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I
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
PHILADELPHIA MEDICAL JOURNAL
AND THE
MEDICAL NEWS
A WEEKLY REVIEW OF MEDICINE
EDITED BY
FRANK P. FOSTER, M. D.,
AND
SMITH ELY JELLIFFE, M. D.
Assistant Editors
FREDERICK T. HANEMAN, M. D.
JOHN M. SWAN, M. D, JOHN S. BILLINGS, Jr., M. D.
SAMUEL M. BRICKNER, M. D. ANDREW F. CURRIER, M. D.
MATTHIAS LANCKTON FOSTER, M. D. De SANTOS SAXE, M. D.
VOLUME LXXXVII
JANUARY TO JUNE, 1908, INCLUSIVE
NEW YORK
A. R. ELLIOTT PUBLISHING CO.
1908
Copyright, 1908.
By A. R. ELLIOTT PUBLISHING CO.
LIST OF CONTRIBUTORS TO VOLUME LXXXVII.
Those whose names are marked with an asterisk have contributed editorial artic les.
Abbott, E. G., M. D., Portland, Me.
Agatston, S. a., M. D.
Albee, Fred H., M. D.
Alger, Ellice M., M. D.
Allen, A. H., M. D., United States
Navy.
Anders, James M., M. D., LL. D., Phil-
adelphia.
.\rm strong, Alfred W., A. B., M. D.,
Canandaigua, N. Y.
*Armstrong, Samuel T., M. D.
AsHroRD, Bailey K., M. D., United
States Army.
.P.ACHMANN, Robert A., M. D., United
States Navy.
Bagg, L. W., M. D., Newark, N. J.
* Bailey, Pearce, M. D.
BAL3WIN, E. R., M. D., Saranac Lake
_N. Y. •
Ballagi, John, M. D., Homestead, Pa.
Ballin, Milton J., M. D.
Barbour, Max, M. D., Philadelphia.
Barrier, L. P., M. D., Louisville, Ky.
Beardsley, John Gillespie, M. D.,
Philadelphia.
Beck, Carl, M. D,
Becker, Henry C, M. D.
BENrDicT, A. L., M. D., Buffalo.
Bernart, William P., M. D., Chicago.
Bierhoff, Frederic, M. D.
*BiLLiNGs, John S., Jr., M. D.
Blackwell, Hugh Burke, M. D.
Blain, Alexander W., Jr., M. D.. De-
troit, Mich.
Boldt, H. J., M. D.
*Bolduan, Charles Frederick, M. D.
Braddock, Charles S., Jr., Ph. G.,
M. D., Haddonfield, N. J.
Brav, Aaron, M. D., Philadelphia.
♦Brickner. Samuel M., M. D.
Bristow, a. T., M. D., Brooklyn.
Brothers, Abram. B. S., M. D.
Brown, Herbert S., M. D.
Brown, Mary Hess, M. D
Bryan, Henry B., M. D., Philadelphia.
Bryant, W. Sohier, M. D.
Buchanan, Mary. M. D., Philadelphia.
Butler, Charles S.. M. D., United
States Navy.
Cabot, Follen, M. D.
Campbell, William Francis, M. D.,
Brooklyn, N. Y.
Cannaday, John Egerton, M. D.,
Charleston, W. Va.
Carling, John, M. D.
Carter, Charles Egerton, M. D.
Chance, Burton, M. D., Philadelphia.
Cohn, Felix, M. D.
Colgan, J. F. E., M. D., Philadelphia.
Cole, Lewis Gregory, M. D.
Collins. Joseph, M. D.
CoNKLiN, W. L., M. D., Dansville, N. Y.
♦Corning, J. Leonard, M. D.
Corson, Eugene R., M. D., Savannah.
Gn.
Cory ELL. C. C, M. D.
CouGHLiN, Robert Emmet. M. D.. Brook-
lyn.
Cnv.iNG, Judge RuFus B.
*Crandall, Floyd M., M. D.
Crispin, Antonio M., M. D.
♦CuMSTON, Ch.\rles Greene, M. D.,
Boston.
♦Currier. Andrew F., M. D., Mount
Vernon. N. Y.
Dana, Charles L., M. D.
De Vries, J. Carlisle, M. D.
Dorrance, George Morris, M. D., Phila-
delphia.
Drennan, Jennie G., M. D., C. M., St.
Thomas, Ontario, Canada.
DuKEMAN, William H., M.D., Los An-
geles, Cal.
Duncan, Harry A., A. B., M. D., Phila-
delphia.
DuNTON, William Rush, Jr., M. D.,
Towson, Md.
'^Edgar, J. Clifton, M. D.
Egbert, J. Hob.\rt, M. D.. Willimantic,
Conn.
Einhorn, Max, M. D.
*Elliott, George, M. D., Toronto, Can.
Emerson, Haven, M. D.
*Ewing, James, M. D.
Faringer, H. R., M. D., Mount Holly,
N. J.
Files, Charles O., M. D., Portland, Me.
Fischer. Louis. ISI. D.
Fitzgerald. R. S., ^L D., Richmond, Va.
Fletcher, Frederick, M. D., Columbus,
Ohio.
Flint, Austin, Jr.. M. D.
* Foster, Frank P., M. D.
"'Foster, jNLatthias Lanckton, M. D.
I-'keenv. L. C, M. D., Pittsville, Md.
Freudenthal. Wolff, M. D.
*Fridenberg, Percy, M. D.
Friedman, G. A., M. D.
Fuller, Eugene, M. D.
GiLBRiDE, John J., A. B.. M. D., Phila-
delphia.
GiNSBURG, Nate, M. D., Philadelphia.
GoLDAN, S. Ormond, M. D.
Gordon, Alfred, M. D., Philadelphia.
Graef, Charles, M. D.
Gregory, M. S., M. D.
Griffith, Frederic, M. D.
Griggs, William C, M. D., Philadel-
phia.
Ha.\se, Charles, M. D.. Elmira, N. Y.
Haim, Leon, E. A. M., Ithaca, N. Y.
■Haneman, Frederick T., M. D.
Hansell, Howard F.. M. D., Philadel-
phia.
H.\rris, Thomas J., M. D.
Hawes, Alfred T., M. D., Lynn, Mass.
Hawkes, Forbes, M. D.
H.\ys, Walter Ennis, M. D.
Herring, Arthur P., M. D., Baltimore.
Herzig, Arthur J.. M. D.
HiBBS, Russell A., M. D.
Hirshberg, Leonard K., M. D., Balti-
more.
Hoffman, William E., Jr., Ph. D., Bal-
timore.
Holmes, E. Burvflle, M. D.. Philadel-
phia.
♦Howard, Tasker, M. D., Brooklyn.
Hopp, George A.. M. D., Philadelphia.
HuBER, Francis. M. D.
HuBER, John B., A. M., M. D.
HuTTON, Paul C. M. D., United States
Arniv.
HvNsox, Lawrence M., M. D., Wash-
ington, D. C.
Hyskell. W. Emory. M. D., Meadville.
Pa.
Ige'.. Richard L., Jr.. M. D., Leaven-
worth, Kan.
Ill.\l\n. G. Mouton, M. D., Philadel-
phia.
♦Jackson, George Thomas, M. D.
Jacoby, George W., M. D.
Jennings. Walter B., Ph. B.. M. D.
^^Jelliffe, Smith Ely, M. D., Ph. D.
Jones, Glenn L, M. D., Washington,
D. C.
Jones. St. Clair, M. D., Jersey City,
N. J.
^^JuDSON, A. B., M. D.
K.\rpas, Morris J., M. D.
Karpeles, M. J., M. D., Germantown.
Philadelphia.
Kaufman, Albert, M. D., Wilkes-
Barre, Pa.
Keating, Emmet, M. D., Chicago.
■'Keenan, Thomas J.
Kensett, W. T., M. D.. Bakerstown,
Pa.
Keppler, Carl R., M. D.
Kinch, Charles A., M. D.
Kirby, Frank B., M. D., Philadelphia.
Kivlin, C. F., M. D., Troy, N. Y.
Klingmann, Theophil, M. D., Ann Ar-
bor. Mich.
Klotz, F. E., M. D.. Lanark, Ontario,
Canada.
Knapp, M.\rk L, M. D.
Knopf, S. Adolphus, M. D.
Konkle, W. B., M, D., Montoursville,
Pa.
KoRSHET, Morris, ^L D., Baltimore, Md.
*Landman, a. J., M. D., London, Eng-
land.
La Pierre, L. F., M. D., Norwich, Conn.
Lathrop, Walter, M. D., Hazelton, Pa.
Le Breton, Prescott, M. D., Buffalo.
Le Roy, Bernard R., M. D., Athens,
Ohio.
LiCKLY, IvA M., M. D., Lima, Ohio.
LiGHTBURN, Richard, M. D., Kansas
City, Mo.
lilienthal, howard, m. d.
♦Lloyd, Samuel, M. D.
Lynch, Jerome M., M. D.
Lofton, Lucien, A. B.. Ph. D., M. D.,
Emporia-Belfield, Va.
Lyons, H. Tucker. M. D., Brooklyn.
McCarthy, D. J., ^L D., Philadelphia.
McCaskey, G. W., M. D., Fort Wayne,
Ind.
McCormick, William S., M. D., Phila-
delphia.
McCuLLAGH, Samuel. M. D.
McIntosh, W. p., M. D.. Portland, Me,
MacKee, George M., M. D.
MacMurrough, F. K., M. D.
Mackay. Malcolm, B. A., M. D., C. IL,
Windsor Mills, Quebec, Canada.
Magruder, E. p.. a. M.. M. D., Wash-
ington. D. C.
:^L\KUEX. G. Hudson, M. D., Philadel-
phia.
M.A.RPLE, Wilbur B., M. D.
Mason, R. D., M. D., Omaha, Neb.
♦Mayo, Caswell A., Ph. G.
Merrill, G. V. R., M. D., Elmira, N. Y.
♦Mettler, L. Harrison, A. M., M. D.,
Chicago.
Meyers, Milton K.. M. D.. Philadelp>.ia.
Miller, James Alex-vxpek, M. D.
Mills, Charles K., M. D.. Philadelphia.
Morgenstern, Adolph, M. D.
Moore. J. Lytle. M. D.. Toledo, Ohio.
MoRo, Ernst, M. D., Munich. Germany
Morse, John Lovett, A. M., M. D.,
Boston.
Murray, Dwight H., M. D., Svracuse,
N. Y.
Nepper, H., M. D., Pnris, France.
IV
INDEX TO VOLUME LXXXVII.
Newmaver, S. W., M. D., Philadelphia.
NuTT John Joseph, M. D.
CRlh-lv, B. R., M. D., Toronto, Can.
O'SuLLiVAN, J. J., AL D., Pittsburgh, Pa.
Oppenheimer, L. S., M. D., Tampa, Fla.
Ostheimer. Maurice, M. D., Philadel-
phia.
Otto, G. Walther. M. D., Dresden,
Germany.
Palier, e!, .M. D.
Palmerlee, G. H., D., Detroit, Mich.
Peck, Charles H., M. D.
Pedersen, Victor C, A. M.. M. D.
Pelton, Henry H., A. M., M. D.
Pennington, J. Raw sox, M. 1)., Chicago.
Penrcse, Clement A.. M. 1)., Baltimore.
Peterson, Frederick, M. D.
Pettey, George E., M. D., Memphis,
Tenn.
^Pii-FARD Henuv G., M. D., LL. D.
Pin-gree, 11. A.. M. D.. Portland, Me.
Plea. -A NT.'.. J. Hall, M. D., Baltimore.
PoLAK, John Ooeorne, M. D., Brooklyn.
PoRCHER, W. Pevre, M. D., Charleston,
S. C.
Porter, William Hexkv, M. D.
PoTTENGEK. F. M., A. M.,' M. D., Mon-
rovia, Cal.
Priest, Howard. M. D., Fort Bayard,
New Mexico.
Proeschek. F.. M. D.. Pittsburgh, Pa.
R.\ndle. William H.. M. D., German-
town. Philadelphia.
RoBBiNoviTz, Samuel, AI. D., Brooklyn.
Roberts, Dudlev, M. D., Brooklyn.
Robinson, W. F.. M. D., Palm" Beach,
Fla.
Rose, Achu.les, M. D.
RosL.xBERG, Lionel, W. D., Brooklyn.
Rosenberger. Randle C, M. D., Phila-
delphia.
Rosewater. Nathan. M. D., Cleveland,
Ohio.
Rovi.xs, Alexander, M. D.
Rowan. Joseph J., M. D.. Philadelphia.
RovsTER, L. T., M. D.. Norfolk, Va.
Ryon, E. William, M. D.. Wilmington,
Del.
Satterlee. G. R.. M. D.
5-\viTZ, Sa.muel a., M. D., Philadelphia.
*Saxe, De Santos, M. D.
Scarlett, B. B., M. D., Philadelphia.
Se.\man, Louis Livingston, A. B. M.
D., LL. B., F. R. G. S.
Sears, Mark H., M. D., Denver, Colo.
*Shaffer, Newton M., M. D.
Shanahan, William T., M. D., Sonyea,
N. Y.
Shelmerdine, E. Kirkland, M. D., Phil-
adelphia.
Sherman, De Witt H., M. D., Buffalo,
N. Y.
*Shively, Henry L., M. D., LL. D.
Shoemaker, Harlan, A. B., M. D.,
Philadelphia.
SiGLER, C. L., M. D., Pinckney, Mich.
Silkworth, W. Duncan, M. D.
Sill, E. Mather, M. D.
Sluder, Green,-^;f.i,i>. M. D., .st. Louis.
Smith, A. C, M. D., United States Pub-
lic Health and Marine Hospital Ser-
vice.
Smith, E. E., M. D., Ph. D.
'■'Smith, E. Franklin, M. D.
Smith, F. H., M. D., Lewisburg, W. Ya.
Smith, Harmon, M. D.
Smith, Oliver C, M. D., Hartford,
Conn.
Sondheim, Sidney J., M. D., Reading,
Pa.
SouTHWicK, Parker F., M. D., Sandus-
ky, Ohio.
Spear, Edmund D., M. D., Boston.
Speese, John, M. D., Philadelphia.
Spence, Thomas Bray, M. D., Brooklyn.
Springer, Harold L., M. D., Wilming-
ton, Del.
Squier, J. Bentley, M. D.
Stalberg, Samuel, M. D., Philadelphia.
Stein, Arthur, M. D.
Stillman, Charles K., M. D.
Stoll, Henry Farnum, M. D., Hartford,
Conn.
Stout, Emanuel J., M. D.. Philadelphia.
Sturmdorf, Arnold, M. D.
Styles, William A. L., M. D., Mon-
treal, Canada.
Summers, J. W., M. D., Chicago.
Sutton, John McGruder, M. D., Kansas
City, Mo.
*Swan, John M., M. D., Philadelphia.
Sweeny, Gilliford B., M. D., Pitts-
burgh, Pa.
Taylor, Fielding Lewis, M. ^v.., M. D.
Taylor, J. Madison, A. M., \ . D., Phil-
adelphia.
Torek, Franz, A. M., M. D.
Tousey, Sinclair. .\. Al., M. D.
Tubby, J. T., Jr.
Tucker, Beverley R., M. D., Richmond,
Va.
Tuttle, James P., M. D.
Vander Hoof, Douglas, A. M., M. D.,
Richmond, Va.
Van Gieson, R. E., M. D., Bro^.-klyn.
Van Slyke, L. L., M. D., Geneva, N. Y.
Veasey, C. a., M. D., Philadelphia.
Verbry'cke, J. Russell, M. D.
VooRHEEs, Irving Wilson, M. D.
Wachenheim, F. L.. M. D.
Walker, J. M.. M. D., Dubuque, la.
Walker, Maurice A., M. D., Dillon,
Mon.
Walsh, Joseph H., M. D., Brooklyn.
Ware, Martin W., M. D.
Wells, William H., M. D., Philadel-
phia.
*Wheeler, Claude L., M. D., Brooklyn.
White, Charles S.. M. D., Washington,
D. C.
White, William Ch.\rles, M. D., Pitts-
burgh, Pa.
Wiener, Joseph, M. D.
Wile, Udo J., M. D.
Williams, Linsly R., A. M., M. D.
Wilson, B. W\, M. D., Youngstown,
Ohio.
Wilson, Frederic H., M. D., Brooklyn.
Wilson, R. L., M. D., United States
Public Health and Marine Hospital '
Service.
Winfield, James M., M. D., Brooklyn.
Wodehouse, Robert E., M. D.
Wolbarst, a. L., M. D.
''■Wood, Francis Carter, M. D.
•^Woodbury, Frank, M. D., Philadelphia
Woodbury, Frank T., United Stares
Army.
*Wright, Jonathan, M. D.
Wynne, S. W.. M. D.
Zemp, E. R., B. S., M. D., Knoxville,
Tenn.
LIST OF ILLUSTRATIONS IN VOLUME LXXXVII.
page.
Accessory Sinuses of the Nose. Five Illustrations 575
Adenoids, Removal of. Six Illustrations 293
Air House. Two Illustrations 1081
Angulations of Colon and Sigmoul l\^n lllu-tr.-itirms. . 479
Apparatus for the .•\dministration df .Xitmns (_)xidc and
Oxygen I97
Association of Tuberculosis Clinics of New York. Two
Diagrams 938-939
Blindness, Sudden. Two Illustrations , 771
Bothriocephalus Latus. One Illustration 1190
Cancer of Stomach. Three Illustrations 628
Carcinomata of GLsophagiis. Four Illustrations 289
Carcinomatosis of Meninges. Three Illustrations 191
A Case of Noma. One Illustration 201
Clamp for Hrcmorrhoids. One Illustration 501
Curette for Treatment of Trachoma S49
Diagnosis of Diseases of the Heart. Three Illu.strations 487
Eye Cases, Unusual. One Illustration 1189
Favus. Three Illustrations 1184-1186
Foot, Restoration of Normal Balance of. Forty-one
Illustrations 875-880, 976-978,' 1070-1073
Frcudcnthal's Modified Bronchoscope 985
Gorgas. Colonel William Crawford. Portrait 1162
Hip, Operation for Congenital Dislocation of. Ten Il-
lustrations 767-771
page.
Intussusception of the Sigmoid. One Illustration 1075
Koch, Dr. Robert. Portrait 74^
Larynx Knife and Silver Nitrate Carrier. One Illustra-
tion 965
Malaria, Pernicious. Eight Illustrations 671
Mucomembranous Enterocolitis. Three Charts 980
Neuralgia. Six Illustrations
Osteomyelitis. Four Illustrations 1077
Pendulum Machine. Three Illustrations 1187-1188
Pylorus, Permcabi.lity of. Nine Illustrations 1179-1183
Radiographic Diagnosis of Renal Lesions. Twenty-four
Illustrations 774
Radiography of Pneumatic Sinuses. Seven Illustrations 579
Rupture of the Heart. Four Illustrations 200
Sarcoma of the Chorioid. One Illustration 675
Sarcoma of the Kidney. Two Illustrations 107
Sigmoidal Factor in Pelvic Diseases. Eleven Illustra-
tions 971-975
Spirocha?ta in Pseudoleucremia, .-Vcute Lymphatic Leu-
c;emia, and Lymphosarcoma. Five Illustrations 9
Study of Sour Milks. Thirteen Illustrations i
Surgery of (iaslric Diseases. Seventeen Illustrations. .95-103
Urethroplastic Operations. Five Illustrations 287
Varicose Veins. Four Illustrations 103
Vision, Defective, in Children. I'our Illustrations. . .880-882
New York Medical Journal
INCORPORATING THE
'Philadelphia Medical Journal r^e Medical News
A Weekly Review of Medicine, Established 184J.
\0L. LXXXVII, No. I. NEW YORK, JANUARY 4, 1908. Whole No. 1518.
(9riiiin;il iLommunifiUions.
A STUDY OF SOUR MILKS*
' ■ Bv Henry G. Piffard, M. D., LL. D.,
New York.
^Man)' }ears ago, when Abraham was encamped
on the plains of Mamre, three strangers approached
and he hastened to welcome them.
They had come to bring him the joyful though
unexpected tidings that Sarah, his wife, although
well stricken in years, would in due time bear him
a son.'
Abraham, with hospitable intent, directed his
servants to prepare food for the visitors ; "and he
took curdled milk and {ordinary) milk, and a
young ox which he had prepared and set {them)
before them — the while he stood under the tree and
they ate." Genesis xviii, 8.
Many years later, when Israel had become a
mighty but a stiff necked people, Moses upbraided
them for their sins and called their attention to
the many bounties the good Lord had showered
upon his chosen people, and among these were :
"Curdled milk of cows and the milk of goats, to-
gether with the fat of lambs and rams — animals
of Bashan and he-goats with the kidney fat of
wheat, and the blood of grapes that thou didst drink
as fiery wine." Deuterorioniy xxxii, 14.'
These passages certainly show that when they
were originally written, several hundred years be-
fore our present Christian era, sour ("curdled'")
milk was held in sufficient esteem to be set before
honored guests, and by Moses to be accounted one
of the good things for which his people should be
thankful.
It is further related in sacred history that
Abraham, after the death of Sarah, procured an-
other wife and several concubines and lived to be
the father of six additional sons by his wife and
several by his concubines, d}ung at the ripe age of
175 years. If these things were the result of a
sour milk diet, it is not surprising that the custom
flourished in eastern countries.
At all events we know that for many centuries
the peoples of eastern Europe, of western and
middle Asia, and a part of Africa have looked on
sour milk as an essential portion of their daily diet ;
for various reasons, preferring it as a rule to fresh
sweet milk.
*Read at a meeting of the Bellevue Hospital Alumni Association,
December 4, 1907.
'The quotations here given have been kindly translated for me by
Professor Richard Gottheil from the accepted version of the Hebrew
Scriptures. They differ somewhat from the authorized English vers-
ion. In choosing between the two versions, I prefer to rely on
modem scholarship rather than that of the times of King James.
In western Europe and in America buttermilk'^
has been, with many, a favorite beverage. The
present writer's knowledge of and fondness for it
extends backward for more than half a century;
and for more than twent}'-five years I have directed
many patients to use it for both dietetic and directly
remedial purposes. I must admit that such use of
it has been largely empirical, rather than based on
any clear notion as to the rationale of its action.
A year or more ago. I read in one of the city
journals what purported to be a declaration by the
present head of the Health Department to the ef-
fect that sour milk w-as a menace to health and
that he would prosecute any one having it in pos-
session and offering it for sale. Later I obtained
a Circular of Inforniafio>i issued over his name
from which I quote the following:
"As bacteria increase in numbers, they gather nourish-
ment from the milk and other substances in which thej
develop, and, like other higher forms of life, transform
what they take into tlieir bodies into useless or poisonous
products. They thus both rob the food of its nutritious
substances and add others to it which are more or les<^
poisonous. When bacteria grow in living things, whethei
they be men, animals, or plants, they excite changes in
them which we know as disease. The bacteria which grow
in de-id things cause them to ferment, rot, or putrefy. Thus
milk becomes sour through the change of its milk sugar
into acid, produced by bacteria."'
In view of the antiquity of the use of sour milk ;
in view of its great prevalence in certain coun-
tries, and in view of the researches of MetchnikofF
as to the extrem.e old age attained by habitual
users of sour milk, the foregoing statement of the
chief sanitary officer of the city is certainly as-
tounding, and especially as that, holding these
views, he permits the present extensive sale of sour
milk within the limits of his jurisdiction or even
allows it to be brought here. As a matter of fact,
sour milk under various names is openly dispensed
from pint and half pint bottles at nearly every drug
store. The large dairy concerns will serve it at
your residence for six cents a quart and the smaller
milk shops commonly serve it over the counter at
three cents a "glassful.
The term sour as used in this connection covers
all milks or parts of milk in which a lactic acid
fermentation has been brought about through the
action of bacteria or other microorganisms. Some
of the sour milks sold are .raw whole milk of which
-I use the terra buttermilk in its -jsually accepted seiise. As de-
fined by Swithinbank and Newman ^Bacteriology of Milk, London.
• 903), "it is the fluid remaining after the fat has been remo'. ed by
churning." I take this occasion to .[uote from the same authors the
following sentence: "Tlie natural curdling of milk is brought about
by the precipitation of caseinoeen, owing to the action of lactic
acid fermentation." It is to be distinguished from coagulation^
which results from the action of reiinin.
Buttermilk: "Milk from which the butter has been removed." — ■
Standard Dictionary.
Copyright, 1908, by A. R Elliott Publishing Company
2
PIFFARD: SOUR MILKS.
kumyss is a type; others are cooked whole milk,
of which zoolak may be taken as an example ; others
are raw skimmed milks, while others again purport
to be sterilized skimmed milk to which living
microorganisms of the lactic acid group have been
intentionally added." Traces of acetic and suc-
cinic acids have been found in milk, but are a neg-
ligible factor so far as regards the present inquiry.
Butyric acid is not found in reasonably fresh milk,
though in very stale milk I have assumed its pres-
ence b}- the odor. It is best known in connection
with rancid butter.
In looking for confirmation of the official opinion
of the Health Department as to the unwholesome-
ness of sour milk, I have been able to find but a
single author who supports him, which he does in
the following words :
"Bacteria when allowed to develop in milk produce fer-
mentation (souring) and render the milk unfit to be used
as an article of food, especially for infants."
I am quite ready to grant that certain changes,
due to bacterial action, may occur in milk that
renders it unwholesome and even actually poison-
ous. Tyrotoxicon has been found in milk, in
cheese, and in stale ice cream and has, on a num-
ber of occasions, led not only to serious but fatal
illness ; but, so far as I am aware, there is ab-
solutely no evidence connecting the ordinary lacta-
cidgenous bacteria with these detrimental changes.
On the contrary, the lactacid bacteria act as
wholesome conservators, and so long as they remain
in control hinder or inhibit the injurious changes
that later may occur in milk. Unforttmately, the
energies of these microorganisms become exhausted
in time, and a totally different class of bacteria
become supreme, rendering the milk alkaline and
unquestionably liable to produce serious derange-
ments. The fresh milk of the cow is ordinarily
amphoteric, that is it will act on both blue or red-
dened Htmus. If kept in a warm place for twenty-
four hours it will give a distinctly acid reaction
only, but if kept for a considerably longer period
it may respond to the well known phenol phthalein
test.
In support of the position I have taken I will
quote the words of a few investigators whose
opinions, it appears to me, merit respect :
"The lactic acid microbes produce large quantities of acid
and so hinder the multiplication of the organisms of putre-
faction. . . . Such facts explain how it is that lactic
acid frequently stops some cases of diarrhoea, and why
treatment with lactic acid is so useful in maladies associated
with putrefaction of the intestinal contents." — Metchnikoff.
"Among the useful bacteria, the place of honor should
be reserved to the lactic bacilli^ They produce lactic acid
and thus prevent the development of butyric and putre-
factive ferments, which we should regard as some of our
redoubtable enemies." — Metchnikoff.
"Sour milk is healthful, and the presence of lactic bac-
teria is not in the slightest degree harmful to those using
the milk; other kinds of bacteria, however, are not harm-
less; manv of them are the cause of diseases of one kind
or another. If the lactic germs multiply rapidly, the other
germs grow scarcely at all ; hence, the lactic bacteria pro-
tect the milk from the growth of other species which would
be more apt to produce trouble and harm." — Conn.
'.•\s there is no short or conveni' r t group name for the organ-
isms that induce the lactic acid fermentation, it occurs to me that
the term laclacidgcns will be a convenient designation. In like
manner we may use the terms acetacidgens for those that excite
the acetic fermentations; bulyractdgens for those that, like the
Oidiiim lactis, tend to cnTender butyric acid, and lastly xtintigeiis
for the class chiefly represented by the various yeasts.
"The bacteria surviving Pasteurization are, for the most
part, the quick growing bacteria of putrefaction which are
inhibited in raw milk by the lactic acid bacteria (italics
mine), but in Pasteurized milk they multiply very fast and
indoubtedly they are capable of generating poisonous sub-
stances."— Jensen.
As to the statement that sour milk is unfit to be
used as food and especially for infants, I can only
say that of late quite a number of articles have
appeared in both the foreign and the American
press strongly advocating its use, • and especially
where there is intestinal disturbance. x\mong these
I note: Acidified Milk in Infant Feeding (Morse
and Bowditch, Archives of Pcediatrics, December,
1906) ; Buttermilk as an Infant Food (Strauch,
Medical Record, March 30, 1907); Ramsay (St.
Paul Medical Journal, September, 1907) ; Judson
and Cook (New York Medical Journal, April 20,
1907) ; Tissier (La Tribune medic ale, February
24, 1906) in the treatment of intestinal infections
uses pure cultures of certain lactacid bacteria
grown in peptone lactose broth.
During the past two or three years there has
been an increasing interest in the subject of sour
milk, excited chiefly by the writings of Metchnikofif,
who urges its consumption not so .much for its
nutritive worth as for its remedial value in dim-
inishing the amount of putrefactive toxins formed
in the large intestine.
In view of the fact that there are nearly one hun-
dred organisms that have been credited with the
power of forming lactic acid in sugar solutions,
and the further fact that there are a goodly number
of acid milks on the market, it seemed to me de-
sirable to obtain further light on the subject. In
furtherance of this, Dr. E. J. Lederle and his as-
sociates kindly placed at my disposal the resources
and conveniences of their laboratories and requested
Dr. Charles E. North, chief of the bacteriological
department, and his assistants, Dr. Anna E. Young
and Dr. O. T. Avery, to aid me in every possible
way. To them one and all I desire to express my
sincere thanks. Dr. Young maintained the neces-
sary cultures and made the required isolations, and
Dr. Avery isolated and cultivated several of the
yeasts that were met with.
Prior to the introdttction of pure bacterial cul-
tures for acidifying potable milk. Christian Han-
sen, of Copenhagen, introduced his so called "lac-
tic ferment" for ripening cream to be used in btitter
making. This was followed by Conn's "bacillus
No. 41," and this in turn by Douglas's "butter cul-
ture," and lastly by a similar product prepared by
Parke, Davis & Co., of Detroit. In January, 1905,
I requested this firm to prepare a pure culture of
some good lactacid organism in tablet form for the
express purpose of souring potable milk. This
they have since placed on sale under the fanciful
and inappropriate name of "lactone."*
At about the same time, or a little later. La So-
cicte le Ferment, of Paris, brought out a tablet under
the name of "lactobacilline," containing a Bulgarian
organism furnished by Metchnikoff. In 1905 also
an American concern placed on the market a milk
souring tablet which they called "kefilac." These
*This naiiie was already in use as the designation of a chemical
product of definite composition and therefore should not have been
applied to an entirely different thing.
January 4, 190S. I
PIPfARD: SOUR MILKS.
3
tablets may be taken direct or used for the domes-
tic preparation of sour milk.
Thirt> or more years ago, Dr. E. F. Brush in-
troduced his well known kumyss, prepared from
cows' milk. In this preparation the fermentation
is induced by yeast aided by such domestic lactacid
bacteria as might be present in Holstein milk pro-
duced under cleanly and sanitary conditions. It
is very mildly alcoholic (i per cent.) and contains
about 0.75 per cent, of lactic acid. It is strongly
effervescent. Dr. Brush's kumyss has been so long
and so favorably known that present comment is
unnecessary.
Shortly after this. Dr. Dadirrian introduced
"matzoon," later changing the name of his special
product to "zoolak." The fermenting organisms
were originally obtained from eastern Europe.
This preparation will be more fully considered
latier.
Among the long known milk ferments, kefir
(kephir. kefyr, kefr) has been the subject of sev-
eral, systematic investigations, notably by Kern and
by Freudenreich. My own studies were commenced
with "kefir fungi" supplied by ]Merck & Co., of
Darmstadt. These consist of light brownish gran-
ular masses of small but varying size, insoluble in
water or other ordinary solvents. Hardened in
alcohol and embedded in paraffin and in celloidin
they defied the efforts of two microtomists. Finally
I succeeded by soaking them in ethylenediamine
in softening them sufficiently to enable me to make
reasonably good spreads. These were fixed and
stained, and on examination yeasts, bacilli, and
cocci were found. Incubated in dextrose broth and
in sterile milk a number of different organisms
were found and isolated and pure cultures obtained.
The first to be studied was a rod form appearing
in dift'erent lengths consisting in reality of links
joined together to form a chain, often without ap-
parent junction points, giving one the impression
that the bacillus was of extraordinary length. If
stained in methylene blue and then dipped for an
instant in alcohol before final washing the junction
points become visible, well shown in Plate I, Fig. i.
In certain stages of its growth clear spots or luci-
doles, two in number, appear in each rod, and on
this account the organism has received from Kern
the name Dispora cancasica. That these are ac-
tually spores has been questioned by later writers,
probably because they are not affected by the usual
spore stains (hot carbol fuchsin, etc). \\"e were
enabled, however, to obtain by culture undoubted
spore formation as shown in Plate I, Fig. 2. It
will be noticed that the spores are arranged in
couplets, thus indicating their origin and justifying
the name proposed by Kern. Authors have indi-
cated the existence of second bacillus in kefir, but
for which I fail to find any name or special descrip-
tion. In these researches it appeared as rods of
varying length, some of them containing points
staining more deeply than the main body, or by a
dift'erent method of preparation not staining at all,
but simply showing a row of clear spaces or luci-
doles as shown in Plate I. Fig. 3. This tempted
me to suggest the name Polyspora cancasica. which
would surely have been appropriate were it not that
when the culture was stained with the cyanide
blue solution' it was found that the long rod ap-
pearance was deceptive, and really consisted of a
chain of short rods each containing a single spore
as shown on Plate I, Fig. 4. The additional ele-
ments found in the kefir grains were streptococci
and yeasts, as noted by previous authors, to which,
however, I paid no special attention. It has been
generally assumed that the production of kefir as
a beverage required the symbiotic action of the
bacilli and the yeasts. However this may be, either
bacillus alone or both combined without the pres-
ence of the yeast'' were capable of souring the milk,
with production of lactic acid never exceeding i
per cent, in the specimens tested. I found the milk
fermented with the kefir bacilli an agreeable and
I believe wholesome beverage. Kefir in potable
form (pint bottles) has been placed on the market
by the Russian Kefir Co.. of Philadelphia.
Bacillac. A sour milk preparation under this
name has been recently placed on sale in this city.
It purported to be made under the supervision of
a presumably competent bacteriologist from steril-
ized skimmed milk, and in accordance with the
directions of Metchnikoft', and activated with a
lactic ferment furnished by him. Advertising
matter states "that its fermentation is not produced
by yeasts which contain harmful microbic flora.'
The name of the bacillus employed is not given,
but I assume it to be the Bacillus bulgaricus. Dur-
ing June, July, and August, I examined several
bottles of bacillac. In every instance I met with
5^easts. not only on direct microscopical examina-
tion, but also in the cultures from which they were
afterward isolated, (^n agar slants, one gave a
white and another a pinkish growth. In every in-
stance also I found the Oidiiiin lactis (Plate I, Fig.
5) and obtained cultures from it.
The pint bottles in which bacillac \Vas sold came
from different molds and resembled those in which
bottled beer is commonly served. The simplest way
of accounting for these results is the supposition
that the bacillac was dispensed in insufficiently
sterilized second hand beer bottles, and that the
milk used was not of the highest quality, and also
imperfectly sterilized. At the price at which this
preparation is sold (25 cents per pint), a better
and more carefully prepared article might have
been furnished.
The acid content of these several bottles varied
from 2.16 per cent, to 2.75 per cent.
The advertising matter that is issued in connec-
^See Xew York Medical Journal, November 23, 1907.
"In cultures from the kefir grains, yeasts were rarely found; Dr.
Young, however, succeeded with some difficulty in obtaining a pure
culture of two different yeasts.
•Melchnikoff in his Xature of Man and in subsequent writings
objects to the use of yeast in the fermentation of milk on account
of the alcohol that is produced. I hardly think this objection is
well founded, for if a quart of milk produced by saccharomycetic
fermentation be taken daily the amount of alcohol would hardly ex-
ceed two or three teaspoonf:;ls. an amount well within the
food limit as ascertained by Professor Atwater. MetchnikofiF
also in Qitelqncs remarques sur le lait aigri, published in 1905, says
that a strongly acidifying bacillus (bacillc bulgare) isolated from
Yaourth is the one to be preferred in the preparation of sour milk.
No biological data are given whereby this bacillus may be identi-
fied other than the bare fact that it is capable of producing a
very large amount of lactic acid, running as high even as 3 per
cent. I have never met with any domestic bacillus capable of pro-
ducing so high a proportion of acid, though Heinemann, of Chi-
cago (Journal of Infectious Diseases. April 6. 1906), has met with
one naturally, soured milk having an acid content of 2.8 per cent,
and another of 3 per cent.
4
I'lfl-ARD: SOUR MILKS.
[New York
Medical Journal.
lion with bacillac may possibly attract the pubHc,
hut I should hardly think it would the profession.
In June last, I sent copies of the advertisements
by registered mail to Professor Metchnikoff, asking
whether he endorsed ail of the statements con-
tained therein. To this communication I have not
as yet received a reply.
Late in October, I examined another recently
purchased bottle of bacillac and found neither yeast
nor oidium.
Maadcouii and Yoghoiirt (Yaourth, Youhourd)
are respectively the Armenian and Turkish names
of the same product, the common sour milk of
southeastern Europe and Asia Minor. For au-
thentic samples of this product, I am greatly in-
debted to Dr. J. H. Kellogg, of Battle Creek,
Alich.. who kindly shared with me some that he
had recently received from Sofia, the capital of
ilulgaria. Jt reached me in two forms — a creamy
liquid and some semisolid, unctuous, cream colored
Hakes. (Jn direct examination by the usual method
( and with the cyanide blue stain) I found a bacillus
morphologically similar to the Bacillus bulgaricus.
a streptococcus and a streptodiplococcus (Plate II,
Pig. 5). There were also two yeasts, one of which
was round, and the other a long oval. The Oidium
lactis and the hay bacillus also were found, prob-
ably as accidental contaminations.
Zoolak { Matrjooii ) . These are both trade names
for the product manu'factured by Dr. M. G. Dadir-
rian & Sons of this city. It is prepared by adding
the eastern ferment (maadzoun) to whole cows'
milk" first thoroughly sterilized. On direct exam-
mation as well as in cultures, it was found to con-
tain bacilli, presumably the Bacillus bulgaricus of
Aletchnikofif, together with yeast cells. Examined
<lirect and stained with methylene blue, I obtained
the picture shown in i'late I, Fig. 6. In dextrose
broth cultures, quite different appearances were
seen, as shown in Plate II, Fig. i. Comparing the
two it will be noted that the bacilli first mentioned
are comparitively short (being morphologically
similar to those found in bacillac), while in the broth
culture there is apparently one long polysporoid
bacillus. In the first, the yeasts all appear nearly
round, while in the second they are oval." Freshly
prepared zoolak is not eflfervescent. but in one speci-
men that was quite old, it was extremely so. The
acid content of recent specimens varied between o.Q
per cent, and l per cent. In the older sample it
was above 1.5 per cent. This is much lower than
the acidity obtainable with the Hiicilhis hnlgaricus.
Assuming the presence of this bacillus, the lack of
acidity mav be due to a partial inhibition by the
other organisms present.
Bv a method of preparation dififering from that
employed by Dadirrian, maadzoun is marketed by
the Russian Kefir Co., of Philadelphia, under the
name Yohourd. This is a soft solid, of about the
consistence of our familiar junket. In New York
it is also found as a customary item in the menu
of some of the Armenian restaurants. I have found
it of agreeable taste, and undoubtedly wholesome
and nourishing.
"Clabbcradc" in bottles has recently appeared on
'A samt)lc of /oolnk .-inalyz»-d at the I.<-<1<tIc Laboratories was
found to iiave a fat content of 3.9'! per cent.
"These evidently corres-ond to the two yeasts found in the Bul-
garian maadzoun to which reference lias already been made.
sale in this city. It is stated by the maker to be a
"predigested milk food, a nourishing fermented
inilk tonic." On microscopical examination, direct
and in cultures, it presents the usual Eastern
microbic complex: Bacilli, cocci, and yeast, as
shown in Plate II, Fig. 2.
In a culture obtained from some tablets of
"lactobacilline" from Paris, that were several
months old, the Bacillus bulgaricus was apparently
dead, but that subtle foe of the laboratory, the hay
bacillus, was rampant.'"
The pure culture of the Bacillus bulgaricus em-
ployed in these studies was a subculture from some
sent by Professor Metchnikoff to a gentleman in
this city. In my cultures it appeared as rods of
moderate length or of very long ones, but by spirit
dipping or the cyanide blue solution were resolv-
able into their separate elements. Milk inoculated
with them developed a very high acidity (Plate II,
Fig- 4)-
Buttermilk. Last but not least, the subject of
buttermilk deserves consideration. We all remem-
ber the celebrated chapter concerning snakes in
Horrebow's Natiiral History of Iceland. It reads :
"There are no snakes to be met with throughout
the whole island." Concerning buttermilk, I can
be equally brief, as I have not been able to find any
throughout the whole Island of Manhattan. I here
refer to the old fashioned country buttermilk ob-
tained when sour cream is churned.
One day a wagon bearing the name of a large
milk distributing concern stood in front of the
laboratory. From it in exchange for six cents, I
received a quart bottle of alleged buttermilk. An
immediate microscopical examination revealed a
number of yeast cells in nearly every field. A
couple of loopsful were then added to a tube of
sterile wort, and placed in the incubator at 37° C.
The following day a loopful of the culture was
spread on a slide, fixed and stained and photo-
graphed, with the result shown in Plate II, Fig.
3. I next obtained a bottle of buttermilk froni
another large milk distributing concern. This too
contained a rich culture of yeast. I then sought
information at headquarters, and an ofificer of one
of the companies gave me the following : "All of
our "buttermilk" comes from our cream station in
• County. The fresh milk, after cooling, is
put through a separator, and the cream comes down
to the city for distribution to our patrons. This
leaves the skimmed milk on our hands. The Health
Board will not permit us to bring sweet skimmed
milk into the city, so the man at our skimming sta-
tion puts in a starter -in order to sour it as quickly
as possible, and when sufficiently soured it is
brought to the city. Here we mix it with some
whole milk, churn it, and after removal of the butter
it is ready for distribution." I know of no reason
why such a product should not be perfectlv whole-
some, Metchnikoflf to the contrary notwithstand-
ing. My informant did not know the naturt
of the "starter" that was employed. From an-
'"The printed matter accompanying packages of "lactobacilline"
contain the following: "It comprises various lactic ferments care-
fully selected and in well defined proportions." There is, how-
ever, no precise indication as to what these "various" ferments are,
and I am therefore in doubt as to whether the presence of the
iubtilis is to be regarded as u contamination or not. i. MetchnikotT
is in a position to throw light on this question, it would certainly
seem "that it was up to him to do so."
PLATE I.
5
Fig. 2. — Clabberade x 2000.
January 4, 1908.]
PIFFARD: SOUR MILKS.
7
other source, I learned that "potato yeast" was
frequently used for this purpose. In my younger
days this product, kept in every farmer's house
as' an adjunct to bread making, was commonly
known as "potato emptins"," "sour emptins," or
simply "emptins." This may not fully account for
the "milk in the coconut," but it certainly does for
the yeast in the buttermilk.
Three facts now appear to be established. First,
the Health Board over the signature of its presi-
dent inveighs against the use of sour milk as dan-
gerous to health. Second, it forbids the entry into
the city of sweet skimmed milk. Third, it per-
mits the entry of sour skimmed milk and its sale
under a name that suggests quite a different prod-
uct. If I am in error as to any of these facts, I
will gladly welcome a correction, or any reason-
able explanation. As I now see it, the Health
Board, if it knows the nature of this city butter-
milk, has placed itself in a rather illogical posi-
tion; if it doesn't know it, why has the fact es-
caped the knowledge of its inspectors, bacteriolo-
gists, microscopists, or others concerned with the
investigation of our milk supply? To me it is
simply one illustration of the imbecile manner in
whicli the entire milk question in this city is being
handled.
But this is not all. Desiring to cultivate Metch-
nikofif's Bacillus htilgaricus (Plate II, Fig. 4) in
raw milk of the best quality, I added a little of
the pure culture to a quart bottle of "certified"
milk of the morning's delivery and placed it in the
incubator at- 37° C. The next day I prepared
some slides for microscopical examination, and
was not a Httle surprised at the result as shown
in Fig. I. The bacilli were of course to be ex-
FiG. I. — Yeast cells in "certified" milk inoculated with a pure
culture of Bacillus bulgaricus. The diameter of the actual field was
68 micra. (Drawn from a photomicrograph by the author.)
pected, but how was the rich yield of yeast to be
accounted for? One explanation is that a yeast cell
or two had inadvertently dropped from the air into
milk before bottling, while another, and I think
more probable one, is that the bottles used had pre-
^^Emptins: "Yeast, especially home made yeast."
Empytings: "The lees of beer, etc., used as yeast." — Standard
viously contained city made buttermilk, and had
not been perfectly sterilized.
Streptococci. A field that urgently awaits inves-
tigation is that of the streptococci, especially as they
are met with in milk.
•For lack of a better means of classification, many
of the bacteria have been arranged in groups based
largely on their morphological peculiarities, and to
these groups what might be termed generic names
have been assigned, such as streptococcus, staphylo-
coccus, etc., and where differences have been
found between different members of the group,
based usually on their cultural peculiarities, they
have received specific names. Now, if any mem-
ber of the group or genus has a known pathogenic
relation, it tends in the minds of many to cast a
slur on the moral character of every individual
member of the genus to which it has been assigned.
This fact may be illustrated by reference to some
of the genera among the higher fungi. Among the
basidiomycetes the Amanita has certainly a bad
name, for we know that the Amanita muscaria, the
Amanita phalloides, and the Amanita verna are
lethal. On the other hand, the Amanita rubescens
is both palatable and wholesome, while the Amanita
ccBsarea comes down to us as a delicious table
luxury from the days of the first Imperator, nearly
two thousand years ago. The man who has once
chewed a morsel of the Lactarius piperatiis is like
the dog that has killed his first skunk — he never
knowingly does it again. On the other hand, the
Lactarius z olenitis is good and wholesome, and the
Lactarius deliciosus is true to name. The Russula
z'irescens well cooked and served is a gustatory de-
light, but if by chance the Russula emetica gains
entrance to the dish, the delight will be exceedingly
brief.
So with the streptococci ; some of them we know
to be pathogenic, some of them can hardly be so,
else the drinkers of the eastern sour milks would
ere this have perished. There are still others of
whose moral characters we are still in dense igno-
rance. It would therefore seem that in the strep-
tococci the research laboratories would find a sub-
ject worthy of investigation.
Bacterial Antagonisms. Throughout the whole
of nature we daily witness the antagonisms that
exist among the different species in the animal
kingdom. Some are created to prey on others —
others to become their prey. It is a question not
of sentiment but of food. In the vegetable king-
dom this condition, though less evident, still holds
good, as some plants prey on others, and even on
the lesser units among animal life. Among the
protozoa there is constant warfare between the
larger and the lesser forms ; and we are therefore
not surprised to find it also true as regards the
protophyta. Among the bacterial species such an-
tagonisms have long been known. Herter was the
first, I believe, to establish the fact that the lactacid
bacteria antagonize those of putrefaction." The im-
mense clinical importance of this fact, however, ap-
pears to have been generally overlooked in this
country, or at least not to have received any ex-
tended practical recognition. On this fact, how-
ever, Metchnikoff has founded a new optimistic
philosophy especially elaborated in his Essais op-
"British Medical Journal, December 25, 1907.
8
I'llU-ARD: SOUR MILKS.
LiNi-w York
Medical Journal.
timistes (Paris, 1907). Brieliy expressed, his views
are as follows : Putrefactive organisms chiefly in
the large intestine lead to the production of cer-
tain toxines, indol, skatol, etc. These tend to im-
pair vitality and shorten life. '1 he bacteria con-
cerned flourish in an alkaline environment, but per-
ish in one that is acid. Metchnikoit believes that
the most convenient and suitable way of supplying
this acid environment 's by the lactacid fermen-
tation of milk, and further, that the bacilli con-
cerned m the fermentation will make themselves
at home in the intestme and, to a certain extent,
colonize it. He especially recommends for this pur-
pose the Bacillus biih^aricns isolated from Bul-
garian soiu- milk.
The experiments in antagonism by Herter,
Metchnikoff, and others suggested the following:
Early in June two broth tubes were inoculated with
an active typhoid culture. One was kept as a con-
trol, the other received two or three loopsful of the
Dispora caucasica. On the second and third days
both were turbid, but a few days later the tube con-
taining the mixed cultures began to clear up. Be-
fore I had an opportunity of making a micro-
scopical examination the tubes were mislaid. On
October 14, five tubes of dextrose broth were
charged aS follows: i, typhoid; 2, typhoid + dis-
pora from kefir ; 3, typhoid + polysporoid bacillus
from kefir ; 4, typhoid + Bacillus bulgaricus; and
5, typhoid + zoolak. After forty-eight hours in the
incubator at 37°C., all of the tubes were turbid.
The tubes were then kept at room temperature.
On October 21 all the tubes were turbid except
No. 2. On microscopical examination I found in
tube I a rich typhoid' growth ; in tube 2, dispora
and typhoid, both rather scanty, with quite a
number of little typhoid bacilli clustering around
nearly every one of the larger disporas, which they
greatly outr.umljcred ; in tubes 3, 4, and 5, rich
growth of the added Ijacilli, with much fewer
typhoids than in No. 2. The behavior of the cul-
ture in tube 2 is mystifying, and reminds one a
little of the Kilkenny cats or of what happens when
the Orange and the Green meet on the 17th of
March.
A single experiment like this counts but little,
but it certainly contains a suggestion, and I leave
it to be followed up by those who may have the in-
clination and proper facilities for so doing.
After considerable ])crsonal use during the past
six months of milk fermented and soured with
pure cultures of the different microorganisms here
considered, I am inclined to believe that the prin-
cipal commercial sour milks for sale in this city
could be improved in usefulness by a slight modifi-
cation in the details of manufacture.
In the effervescent sort, I would recommend the
use of a />ure native yeast with the addition of a
culture of the Bacillus bulgaricus.
In the nonefTervescent sort, the use of pure cul-
tures of the oriental bacilli and yea.sts, with the
elimination of the streptococci.
The necessity of using pure yeasts with the elim-
ination of "wild" yeasts and injurious bacteria is now
fully recognized bv brewers and manufacturers of
sparkling: wines, and I commend the matter to the
consideration of those who are concerned in the
preparation of fermented milks.
Examination of one of the small packages of yeast
sold by grocers tor househuld use revealed the fact
that it was greatly contaminated by the presence of
numerous bacilli as shown in Plate II, Fig. 6. An-
other sample of a dift'erent yeast contained cocci.
In this case, the cocci were mostly grouped about
the yeast cells. Whether they were simply paying
a friendly visit or were present with hostile intent
i do not know, but strongly suspect the latter. At
all events it reminded me of something I once saw
among birds. A large owl that had evidently passed
the night searching for field mice among the corn
shocks found himself stranded and comparatively
helpless when the sun rose. He was at last espied
by a flock of crows, who gathered around and were
busily engaged in bedeviling the poor old fellow to
their heart's conteiit.
The addition of the Bacillus bulgaricus in the case
of the effervescent milks will not lead to undue acid-
ity, as Van Slyke and Bosworth have recently shown
{Bulletin, No. 292, Nezv York Agricultural Experi-
ment Station ) that carbonic acid under pressure re-
strains in a measure the production of lactic acid.
The kefir and other Eastern ferments as they
reach us are, owing to their crude method of prep-
aration, somewhat varied in composition, and it
would be well, I think, for those who are commer-
cially minded to experiment with cultures containing
only the bacilli and yeasts, excluding the oidium,
cocci, and any other accidental organisms that may
be present.
When maadzoun or any similar product is pre-
pared with sterilized milk, it is, of course, an easy
matter to continue it by each day using as a ferment
the milk previously soured, but I must confess a
preference for raw milk as the basis. In this case,
the cultures could be continued indefinitely in sterile
milk or in some suitable laboratory medium, and
added to the fresh milk each day as required.
There are manv who regard good milk at nine or
ten cents a quart as an almost unwarranted luxury
and the best milk at fifteen cents a quart entirely out
of the question. Now. these people certainly can-
not afford any of the proprietary sour milks, which
hardly can be sold at retail for less than twenty
cents a pint. What then are they to do ? A simple
solution of the matter was presented to me one even-
:ng' a few weeks ago at the Academy of Medicine.
Meeting another Abraham, a descendant of the one
already mentioned, I nsked :
"What do you think of sour milk as an article of
food ?" He replied :
"I have it on my table daily in summer; I take a
deep soup plate and fijl it with fresh milk, cover it
and put it in a warm place and the next day it is
sour. Sometimes I sprinkle a little cinnamon or nut-
meg over it. It is good."
This experiment should be tried with fresh raw
milk only, never for obvious reasons with milk that
has been pasteurized.
Conclusions.
I. The assumption by the president of the Health
Department of this city that sour milk is a menace
to health is wholly without scientific foundation, and
is opposed to common experience in many parts of
the world during a period covering thousands of
years.
WHITE AXD FkOESLHER: SPIROcH.ETA LW LEUCAi.iUA.
9
2. Sour milk is wholesome and nutritious and is
probably more easily digested than sweet milk.
3. In certain derangements of health it is an im-
portant direct remedial agent.
4. The present mo>t available souring agents are
special bacteria in common use among certain
European and Asiatic peoples.
5. The essential organisms as they reach us are
frequently contaminated wnth unessential and pos-
sibly undesirable organisms.
6. The proprietary sour milks should be prepared
with laboratory pure (streptococci free) cultures of
the desired organisms.
7. - The proper organisms preserved in some suit-
able liquid or solid mediiun can be readily standard-
ized and administered direct.
8. Whether the bacilli derived from kefir are to
be preferred to those from maadzoun or vice versa
cannot at present be dogmatically asserted.
9. The organisms when placed on the market
should be under their own proper scientific names
and not under a proprietary or trade name. The
guarantee behind them should be the reputation of
the concern that prepares them.
10. They should be advertised to the profession
onl_\- and not to the public.
11. It is more than possible that some domestic
organisms may be isolated in the future that will
prove to be .more desirable than those of foreign
origin.
256 West Fiitv-sevextti Street.
ON THE PRESEXCF OF SPIR0CH.?:TA IN
PSEUDOLEUC.l-.MIA. ACUTE LYMPHATIC
I.EIIC.E^IIA, AND LYMPHOSARCOMA.
By Willi.\m Ch-\';les White, M. D.,
Pittsburgh, Pa.,
Medical Director Pitt^^biirg Tuberculosis Hospital,
.\ND F. Pkoescher, M. D.,
Pittsburgh, Pa.,
Pathologist, .Miegheny General Hospita;.
In the Journal of the American Medical Association
of December 14, 1907. we called attention to our
finding of spirochsetje in cert'iin glands of pseudo-
leucjemia. In a later number of this publication we
called attention to the finding of spirochaetje in the
fluid obtained by aspiration from the glands of a
case of pseudoleuCtTinia and a case of acute lym-
phatic leucc-emia. The fluid obtained from the,=e
glands by aspiration was smeared on the cover
glasses and stained with an eosin methylen tolui-
din blue stain of Dr. Proescher after mordanting
with the old Loeffler mordant. In these sections
spirochsetse varying in length from 20 to 120 mikra
in length were found in each case, stained a pur-
plish blue color.
We wish now to report our finding in fourteen
cases of pseudoleucaemia, acute lymphatic leucaemia,
and lymphosarcoma, in all of which we have found
the same organism. In this group there were
two pseudoleuca?niia glands hardened in formal-
dehyde, furnished by Dr. McCallum. of Baltimore :
one pseudoleuciiemia gland from Dr. Duncan Gra-
ham, of Toronto : one pseudoleucsemia gland from
Dr. Henry Christian, of Boston ; the tissue from
six cases of lymphosarcoma from the material of
Dr. Proescher in the Allegheny General Hospital
Laboratory ; one case of acute lymphatic leucaemia
which was under study during life, and three cases
of pseudoleucsemia which were under study during
life.
In the postmortem tissues and in the extirpated
glands of the living patients we were always able
to find the organism which we describe below
stained by Levaditi's silver method. In the living
cases the organism was found in the aspirated fluid
of the glands in all the smears with Proescher's eosin
methylen toluidin blue stain. In the case of acute
lymphatic leucasmia, the organism w^as seen in the
living state in the fluid pressed from the gland.
From one of the lymphosarcoma cases we were
able to transfer a purely glandular afi^ection to a
guinea pig by subcutaneous injection of an emulsion
Fig. I. — Cheeby mass from pseudoleuc-enna aspiration, showing
mass of spirochsetae; eosin methylene toluidin blue .;taiii.
of one of the sarcomatous glands, ^\'e have now
transferred this to four generations of guinea pigs,
having used in all twelve guinea pigs, and in all of
these we have been able to find the same organism
in the smears by aspiration of glands and stained
by Proescher's method. W'e have been able to see
the living organism in the fluid expressed from these
glands and have found the organism in the sections
of glands .stained by Levaditi's method.
This organism varies from all spirochjetae previ
ously described mainly in its very great length and
in the shallowness of the curves of its body. Both
ends of the organism are pointe l. Its motilitv is
very sluggish, and its translation from place to place
very slight. On account of its high refraction it was
almost impossible to see it. It first became visible on
the cover glass as a fine shining point. Upon watch-
ing this closely for some time one could finally see
the movements of the body similar to those of a fish
worm held by one end in the fingers ; gradually the
body would come up level with the cover glass, and
WHITE AND PROESCHER: SPIROCH.^TA IN LEUC/EMIA.
finally disappear again from the field. When once
seen it was very much easier to again pick out these
organisms in the aspirated fluid in the glands of
future infected guinea pigs. In a silver section, ow-
ing to the great length of the organism, one gets a
Fig. 3. — Spirochsetse from pseudoleucsemia by aspirating the glands
showing spirochjEtse.
great many pictures from the organisms being cut
at different levels.
We think it best to call this organism which we
have found in these cases, and which we look upon
as the astiological factor in this group of cases, the
Spirochicta lymphatica. Our knowledge of this
group of organisms is so limited that future study
may prove that this organism does not belong to the
spirochaeta at all, but for want of a better name, and
from the fact that it is always found in the lymphatic
fluid and tissues, we have chosen this name as the
best at our disposal.
The Proescher method of staining, which we have
found most serviceable in staining these organisms
in the smears made from the aspirated fluid in the
glands, is as follows :
First — Pass once through the flame. Mordant for
one second in the following solution : Loeffler tannic
acid, 2 grammes ; water, 8 c.c. After this is dis-
solved add 5 c.c. of a saturated aqueous solution of
ferrous sulphate ; then add I c.c. of saturated alco-
holic solution of fuchsin.
Second — Wash the smear in water and dry be-
tween blotting paper.
Third — Place for two or three minutes in the fol-
lowing eosin methylen toluidin blue stain. The
stain is made by mixing the two following solutions,
which are only stable while kept apart and must be
mixed fresh for each staining.
Solution I. Eosin solution:
Eosin, 0.5 gramme ;
Water, distilled, i c.c;
Glycerin, pure, 9 c.c. ;
Absolute methyl alcohol, highest purity Merck, 90 c c.
Solution 2. Methylen toluidin blue solution :
Cold saturated aqueous solution methylin blue,
4 parts ;
(Methylene blue medicinale purissimum Hoechst.)
Cold saturated aqueous solution toluidin blue, i part.
("Gruebler" pure zinc chloride free.)
To make the stain ready for use take
Eosin solution, ; 2.5 c.c;
Methylene toluidin blue solution 0.5 c.c.
Mix thoroughly and then allow the cover glass to
float smear side down on the surface of the fluid.
Put one second in 96 per cent, alcohol, wash in wa-
ter, dry, and mount.
In smears of the aspirated fluid from all cases of
pseudoleucaemia, acute lymphatic leucaemia, lympho-
sarcoma, and possibly from the spleen and bone mar-
Fic. 3. — Spirochset.T; from pseudoleucsemia by aspirating the gland;
eosin methylene toluidin blue stain.
row of splenomedullary cases, this organism should
be found as purplish blue filaments similar to those
in the illustrations accompanying this paper. We
have never been able to find it in normal glands nor
in tuberculous glands, in which we have tried re-
peatedly to demonstrate it. We feel that the pres-
ence of this organism could be readily demonstrated
from the fluid obtained by aspiration from the glands
of these cases or from the fluid expressed from ex-
tirpated glands by examination with the Dnnkcl-
feldbelcnchtnng apparatus. We unfortunately had
not one at our disposaj, and could consequently not
complete this part of our search.
The aetiology of this group of diseases (including
acute lymphatic leucaemia, pseudoleucaemia, lympho-
sarcoma, splenomedullan,' leucaemia, chloroma. and
myeloma) is so dark a field of haematology, and yet
their relation to each other is so evident, that in the
light of our finding the organism here described con-
stantly in all cases of this group examined by us,
never finding it in numerous other conditions and
normal cases, and our ability to transfer one type of
the malady to four generations of gfuinea pigs and
recover the organism in each case, and never having
January 4. 'goS.]
F.RDMAXX: BILIARY SURGERY.
II
found it in tuberculous or normal pigs, has led us to
suggest the following classification of these diseases
based upon this supposed aetiology :
Lymphatic spiriUosis.
Acute form, (a) with lymphocytosis; (b) without
lymphocytosis.
Chronic form, (a) benign, without sarcomatous
change or with sarcomatous change ; (b) malign,
with sarcomatous change or without sarcomatous
change.
Bedford Avenue and Wandles Street.
SURGICAL TECHNIQUE IN DISEASES OF THE
GALLBLADDER AND BILIARY PASSAGES.*
By John F. Erdmaxn, M. D.,
New York,
Clinical Professor of Surgery. University and Bellevue Hospital
Medical College.
In preparing a patient for any operation con-
nected with the biliary passages I am accustomed
to have the abdomen prepared high enough to en-
croach upon the extreme limits of the costal arch.
and low enough to do an appendectomy through
the usual site, should occasion demand.
The incision practised by me is one through the
right rectus muscle, either its outer and middle
third, or the inner and middle. This incision can be
extended downward in a direct line. Free expo-
sure of the cystic and common ducts is readily ob-
tained by rotating the liver. This is done by ex-
tending the incision upwards, thereby encroaching
upon the diaphragm to quite an extent, or by the
method of Bevan, or by the additional transverse
rectus incision.
The T incision, made by cutting the fibres of the
rectus transversely about the middle of the original
longitudinal incision, although done once by me,
has never since been found necessary in even the
most difficult deeply seated duct work.
Riedel's lobe should always be remembered, as it
often resembles, or may be mistaken for, an in-
flamed and distended gallbladder.
In cases where atrophy or apparent absence of
the gallbladder exists, it is advisable to find the
main cystic; fissure, and then trace downwards
and backwards toward the transverse fissure. In
these cases, the sand bag or rest as used in duct
work, with free upward extension of the incision
in the abdominal wall so that rotation of the liver
can readily be obtained, is also of great benefit.
In all cases of pericholecystitis accompanying-
cholecystitis, the adhesions of omentum, etc..
should be carefully released. Gauze packing is
then placed between the -bladder and the released
adhesions or viscera before further search is made.
W hen this is done search is made for stones in the
bladder, cystic duct, and finally in the hepatic and
common ducts.
It is often impossible in a fully or over distended
gallbladder that is thickened by either recurring at-
tacks, or by the single acute one, to feel a stone or
stones through the wall. The cystic duct may be
hidden in its upper (bladder) portion by the fact
of elongation or overdistension of Hartman's
pouch. The lower (common duct) portion and the
common duct can usually be palpated when the
foramen of Win slow is patent, although I am never
satisfied with palpation of the common duct in a
jaundice case, or one recently jaundiced, until I
Fig. 5. — Spirochxtse from chronic acute pseudoleucaemia; eosin
methylene toluidin blue stain (White and Proescher).
have opened the duct and palpated its interior. This
interior palpation should be done, as Mayo has so
ably emphasized, with the finger and not a probe,
as stones are often passed by the probe that a finger
'Read before the Medical
w York, November 18, 190;
3f the Greater City of
will reveal
In case the bladder
distended, etc., as men-
12
E RDM ANN: BILIARY SURGERY.
[Ne.v York
Medical Journai..
tioned, I then incise the fundus, empty the contents,
and by so doing the pouch of Jrlartman coUapses,
allowing free examination of the upper extremity
of the cystic duct to be made. This is also a very
decided point to bear in mind when doing a
cholecystectomy, as in tr3'ing to remove the un-
emptied bladder, particularly in the fat, Hartman's
pouch obscures the field of the cystic duct to such
a degree as to render the operation not only diffi-
cult, but dangerous. Formerly I sought for beauti-
ful specimens of full bladders, but now I am more
content to have an operation rendered less danger-
ous and difficult at the expense of my museum.
Cholecystotomy. — When thoroughly satisfied
that no work is to be done on the ducts, proper iso-
lation of the gallbladder is made with compress
gauze instead of sponges. The fundus is then
grasped with two forceps, and a crescent ic section
taken out between these forceps. The assistant
sponges out the leakage of bile, etc., as rapidly as it
appears. As the gallbladder empties itself, more
traction is made by means of the forceps, and a
hand, the left usually, is passed down below Hart-
man's pouch, and the bladder "milked" of its
stones instead of using a scoop in the interior. A
final search is made with the finger in the bladder
for any concretions that may remain, or may be
lodged in the first of Heister's folds.
When the bladder is pronounced empty, a quar-
ter inch calibre rubber tube, fish tailed and with two
perforations, is passed down the entire depth of the
bladder. A suture of iodine catgut No. 2 is passed
through the gallbladder about a sixth to a quarter
of an inch from its cut edge on one side, penetrat-
ing the tube encroaching upon the calibre very
slightly and at a point about one half to two thirds
the distance which it originally occupied in the
bladder. The suture is then passed through the
opposite wall of the bladder and is tied. This step
is often repeated by me on the opposite sides, mak-
ing a crucial suture. A circular suture of the same
material is then placed about a third to a half inch
below the tube fastening sutures, the tube then
pushed down, carrying with it the raw margin be-
low the circular suture. When this is down the
circular suture is tied. Should the bladder be a
deeply seated one, so called extension of the gall-
bladder is made by sewing one or more strips of
gauze about one and a half inches wide to the blad-
der's new fundus, and bringing these strips with
the tube through the abdominal incision.
In case the gallbladder is long enough 1 occasion-
ally take one or two stitches through the bladder
wall and the parietal peritonjEum. A secondary
drain outside of the gallbladder' is used only when
occasion demands.
Cholecystectomy. — .\s a preliminary to this op-
eration I would advise the back cushion or rest as
used in common and hepatic duct work. The in-
cision should be ample to allow of free displace-
ment or rotation of the liver.
When the bladder is exposed, if it is of the con-
tracted variety, no preliminary emptying is called
for ; in fact, in many instances these bladders con-
tain no fluid contents. Removal can usually be
done from below upwards.
In case the bladder be distended or thickened,
preliminary emptying will aid greatly in exposing
the cystic duct, as mentioned in the first part of the
paper. In these cases removal is more readily ac-
complished by attacking the bladder from above.
Nevertheless, a combination of both methods of at-
tack will in all probability be used most frequently.
In attacking from below the first step is to isolate
the cystic artery and duct, clamping them distally
and proximally cutting between and then stripping
the bladder oft' from below upwards.
In attacking the bladder from above the peri-
toneal covering is incised so that a lateral cuflf of
about a half inch is released on each side of the
bladder. This cuff, after cholecystectomy, falls
in upon the raw hepatic surface exposed by the
bladder removal. Cleavage is readily found by the
finger, and the bladder rapidly separated from its
hepatic association. The duct is tied oft" and the
everted mucous membrane edges touched with car-
bolic acid.
Bleeding from the raw hepatic surface may be
profuse, but is readily checked by a few moments'
compression with gauze.
I have closed numbers of these cases without
drain, but have lately come to the conclusion that
a cigarette or simple rubber tissue drain for twenty-
four to seventy-two hours provides better sleep for
the operator, and does not prolong the conva-
lescence of the patient. Where the case is sus-
pected of marked infection drainage is without
question essential.
Cysticotomy. — This operation is only done for a
stone lodged between Heister's folds, and drainage
of the duct, etc. The stone is readily located, and
is usually fixed. Traction is made upon the gall-
bladder, when necessary to bring the duct more
easily into the operator's field, the wall is incised,
the stone removed, and a drainage instituted either
by tube or cigarette method.
Cholcdochotoiiiy. — As a preliminary to bringing
the duct in ready reach the use of the lumbar pad
or rest cannot be too highly recommended. In
addition, free rotation of the liver will bring the
cystic and common ducts in a direct line.
Common Duct. — In addition to stone as a cause,
obstruction may be due to malignanc)' of the duct
itself, or malignancy of surrounding viscera of such
degree as to produce pressure sufficient to prevent
the flow of bile into the intestines. Operative pro-
cedure will then depend entirely upon the extension
of invasion, varying from removal of the diseased
tissue to a cholecystenterostomy or allied anasto-
mosis of the gallbladder and intestines, provided, in
these cases of bladder 'and intestine anastomoses,
the malignancy does not prevent the flow of bile
into the gallbladder. Stone may occupy any por-
tion of the duct. When in the course of the duct,
its removal is accomplished by incising over the
stone, extracting it and then draining the ducts,
or preliminary sutures may be taken over the site
of the stone, cutting between the sutures, and after
extraction tying them so as to close the operative
woinid and prevent leakage.
When there is reason to suspect or know that the
l)iliary passages arc inflamed and infected (cho-
JVARE: rUBEKtULOUS XEPHROlVS 1 1 1 1::,
15
langitis), I sew a tube into the choledochotomy
wound with a No. 2 catgut suture, and close the
remainder of the opening with one or two more
sutures. To guard against leakage infiltration I
then place a cigarette" drain about the size of an
ordinary lead pencil (one third inch in diameter)
down to the duct. This is removed about the third
to the seventh day, while the tube remains till the
catgut sutures absorb. No drainage is replaced, the
sinus being allowed to close spontaneously, which
usually occurs in about ten to twenty-one days after
the operation.
W hen the stone or stones are situated in the dis-
tal quarter to half inch (the pancreatic portion), it
may be necessary to approach them either by the
transduodenal (McBurney) route, or, Jind prefer-
ablv so, by the postduodenal route as described by
C. M. Cooper, who reported, in the Annals of
Surgery, as early as 1903, three cases successfully
(lone by this method.
This method consists of releasing that portion of
the duodenum behind which the duct passes, by
cutting the peritonaeum binding the gut to the back,
then rotating this portion of the duodenum down-
wards and opening the duct, etc.
Operations upon the hepatic duct are performed
with the same preliminary exposure steps as used
in choledochotomy, the duct usually being opened
bv continuing either the cysticotomy or the cho-
ledochotomy Vound upwards, the subsequent steps
being relatively the same as in common duct sur-
gery.
Finallv the technique of closure and dramage is
to be considered. Proper toilet of the peritonaeum,
the surrounding viscera, and omentum are attended
to in the same manner and with the same care as in
all abdominal sections.
In closing my abdominal wounds in this region
I have been in the habit of late years of closing the
Deritonc-eum and transversalis fascia with mattress
sutures, as I can then be assured that my first row
of sutures will not cut out, as is usual when the or-
dinary suture is applied. The second row of
sutures is a simple running suture of the everted
edges of the fascia and peritonaeum resulting from
the mattress suture.
The next suture is that of the anterior layer of
the rectus sheath, and finally the skin closure
suture. If the case has been infected I place a rub-
ber tissue drain in the lower angle under the skin
and fat only.
The drainage tube in cholecystotomy and chole-
dochotomy I leave until the fifth to the seventh day,
when by trial they are usually found loose. Usual-
ly, except in infections of marked evidence, no sub-
sequent drainage material is placed in these chan-
nels. The cigarette and gauze drains are removed
as the conditions warrant.
Bile excretion is often very much increased in the
earlv morning hours, from i to 4 a. m., and is par-
ticularly disagreeable by reason of soiling of dress-
ings and the skin irritation resulting. The flow can
be markedly diminished by giving the patient a
cracker or bit of toast and milk about 11 or 12
p. m., while the skin irritation is overcome by free
use of an ointment of ichthyol. from ten to thirty-
three per cent., or of boracic acid.
It is my habit, and has been for several years,
unless the bile is from a markedly infected cho-
langitis or cholecystitis case, to pinch the tube from
one to eight hours daily after the second postop-
erative day.
In my opening paragraph I stated that the op-
erative field preparation is made low enough to do
an appendectomy should occasion demand, etc. I
have so frequently seen the appendix also involved
that I have been in the custom of removing this or-
gan through the same incision, when possible. This
is to me of such importance that I cannot but tirge,
in considering the technique of biliary surgery, that
this additional procedure, removal of the appendix
when feasible, is not only warranted, but indicated.
I first called attention to the associated patho-
logical conditions in a paper read in December,
1903, before the Passaic City Medical Association
of New Jersey (see Medical News, March 26,
1904), and call attention to an editorial in the
Journal of the American Medical Association, June
29, 1907, in which the association of diseases is
strongly presented to the profession.
60 West Fifty-second Street.
THE DIAGNOSIS OF UNILATERAL TUBERCU-
LOUS NEPHROCYSTITIS, WITH A REPORT
OF SIX OPERATIVE CASES.*
By Martix W. Ware, M. D.,
New York,
.\djunct Surgeon, Mt. Sinai Hosjiital; Surgeon, Good Samaritan
Uisi ensary.
Although I am not able to materially add to our
fund of knowledge on the diagnosis of renal tuber-
culosis beyond that which has already been con-
tributed by able exponents, yet I hope to offset any
disappointment that may be yours in not receiving
anything novel, by the presentation of a critical re-
view of the practical workings in arriving at such a
diagnosis, based in part on a personal experience
of six cases of unilateral tuberculous kidney svic-
cessfully operated on.
Tuberculous nephrocystitis belongs with other
diseases in the borderland of medicine and surgery.
It, therefore, is necessary to pronounce this diagno-
sis on the merits of a strictly clinical and surgical
analysis.
The symptom complex of polyuria, pyuria, slight
hjematuria, pollakiuria (frequency of urination),
painful urination, as present in greater or less de-
gree, and of these the cystitic symptoms predom-
inated. It was, however, the persistence of these
latter symptoms, their rebelliousness, and as often
their intolerance to prolonged therapeutical meas-
ures, mainly unyielding to silver nitrate, that, in
most instances, aroused the suspicions of the phy-
sician that tuberculosis might be an underlying
cause.
Right here, I take it to be opportune to protest
against the laisscz faire attitude of the physician
who rests his diagnosis with "cystitis." This is an^
end result of some other underlying pathological
condition which is the fons et origo of the cystitis.
Were this axiom always borne in mind, fewer cases
of tuberculous nephrocystitis would escape recogni-
*Read, by invitation, before the Hartford Medical Society at the
meeting of November 25, 1907.
14
HARE:
TUBERCULOUS NEPHROCYSTIT IS.
[New Vork
Medical Journal.
tioii at a date when the lesion is one sided and amen-
able to surgical measures.
With the rebellious cystitis, the patient is brought
to the consultant with the request for a cystoscopic
exanunation. much after the fashion that the laryn-
gologist is asked to use the throat mirror to um-avel
the m\stcry of a laryngitis which is called chronic.
The competent laryngologist would furthermore
want to know all physical signs before resorting to
this. Such, also, should be the sequence of events
prior to cystoscopy. The existence of tubercle in
the genital tract, epididymides, testes, vas deferens,
and prostate, have to be sought for and excluded,
and a repeated search for tubercle bacilli are there-
fore to be made.
Authorities diifer widely, and our position is the
same, as to the frequency with which the tubercle
bacilli may be found. These discrepancies, I think,
are largely due to the personal equation of the ex-
aminer, wherefore 1 hold that such examinations
should be left to a bacteriologist. If then, the
tubercle bacillus is not found on a cover slip prep-
aration from ccntrifugattd urine, i c.c. of the latter
should be inoculated, intraperitoneally, into a
guinea pig, known to be free from tuberculous taint
by the absence of reaction after a tuberculin injec-
tion. If the animal does not succumb at the ex-
piration of six weeks, an autopsy is made to search
for tubercles. Bloch has recently recommended a
more rapid procedure, to inject some of the centri-
fugated urine into the cellular tissue of the thigh,
and to massage and bruise the inguinal lymph nodes
which, in the course of a week, become infected
from the urine laden with tubercle bacilli. Nowa-
days the organism is not stamped as the tubercle
bacillus until it has withstood the test of retaining
Its color after prolonged immersion in alcohol and
weak acids. A further precaution to guard against
contamination of the urine with the smegma bacil-
lus is to withdraw the urine by sterile catheter after
the canal has been copiously washed with sterile
water. Young and Churchman assert never to have
encountered the smegma bacillus after these precau-
tionary measures. Smegma bacilli, if present, occur
singly and not in groups as the tubercle bacillus and
to expert eyes the smegma bacillus is thicker than
the beaded organism of tubercle.
Suter has observed that if an agar tube, in-
oculated with pus urine, remains sterile, there is
every reason to suspect that tuberculosis is at hand.
This is, in itself, a justification for culture growtli
of every cystitis.
It is only at this stage, and with these data in
your possession, that cystoscopy is justified. A dic-
tum against the use of the cystoscope has been ven-
tured from the moment we know the cystitis to be
tuberculous ; but the vindication for the use of this
instrument of precision rests upon the basis that
from this moment on, the vesical tuberculosis, as an
end result of renal tuberculosis, is subordinated to
the vital need of knowing which kidney is affected,
and finally, cystoscopy is not exploratory, but con-
firmatorv, and should only be undertaken with the
express intention of an operation to follow, if the
lesion is unilateral.
Cystoscopy. — Never has it been our fortune to
encounter a case so early, that the urine was so
clear as to permit cystoscopy in the bladder dis-
tended with Its own urine, as Fenwick reports. Al-
ways did we encounter pus, and at times bleeding,
necessitating a cleansing of the bladder with re-
peated irrigations of boric acid solution, to make
possible an inspection of the trigonum and the ure-
teral orifices, in the execution of this essential pre-
aminar}- cleansing, we often learned of the dimin-
ished capacity of the bladder, in itself, a finger post
pointing to tuberculosis, and when such contrac-
tion reached the limit of a distensibility of but 60
c.c. and less, examination was barely feasible, and
that only under pyrofound chloroform narcosis.
(.Otherwise,, it is advisable to anaesthetize the entire
urethral canal and bladder with 30 to 50 c.c. of a
2 per cent, cocaine solution or the less toxic surro-
gate, 2 per cent, alypin.
Ulcers were but exceptionally encountered, but
more commonly dark red spots, some with mucous
shreds adherent. The haemorrhagic areas were
very often situated about the ureter and in the in-
traureteric space. Another frequent finding was an
cjedematous translucent appearance of the mucosa
thrown into folds, which is known as oedema bul-
losa. This condition is common to many inflam-
matory conditions in the bladder (Kolischer). At
times these bullae were as small as grape seeds, and
very likely to be mistaken for small tubercles. A
few times upon close examination fine, barley sized,
grayish red, tubercles were found. There is a
pretty constant new formation of blood vessels, and
these often of quite large size, in the vicinity of the
patches. The haemorrhage was more often seen to
come from these patches than from the ureters. An
inspection of the ureteral orifices was the next
order of routine. The one or the other ureteric
meatus was surrounded by the changes enumer-
ated, and if it was visible, discolored urine with
flakes could be seen to dribble from it, in contract
to the forcible jet issuing from the other meatus,
situated in healthy surroundings. At times, the
meatus of the healthy functionating kidney alone
was visible, and the ureteric orifice of the other kid-
ney would be obscured by the extensive vesical
changes, and appear defunct ; yet upon manipula-
tion of the suspected diseased kidney, as suggested
by von Bergmann, some pus or flakes could be
seen to escape from the diseased area. The diseased
ureteric m.eatus when seen, appeared larger, round in
contour, craterized form or golf holed, void of any
peristalsis, and likely to be much displaced, which
deviation could be estimated by the extreme degree
of lateral tilling of the-ocular end of the cystoscope
necessary tn bring the ureteric orifice into view.
These accomplishments of the cystoscope in plac-
ing the stigma of vesical tuberculosis on one or the
other kidney, or both, was epoch making, but the
brilliancy of this epoch was eclipsed with the appear-
ance of the single and eventually the double ure-
teral catheterizing cystoscopes. Any doubt as to
which kidney was now diseased, was to be dispelled
by the possibility of separately withdrawing the ex-
cretion of each kidney. And there arises such
doubt, when the urine is so faintly cloudy that it
cannot be seen in its escape from either ureter, and
January 4, 1908. |
IV ARE: TUBERCULOUS NEPHROL VSTITJS.
when condemnatory changes, though present, have
left the ureters intact, and when associated with
changes in one ostium, the other orifice presents
some abnormal appearance. These, then, are per-
tinent reasons that would seem to mark the indica-
tion for simultaneous catheterization of the ureters.
Catheterization of one or both ureters has Ijeen
practised to advantage by myself numerous times,
as an aid to locating the source of pus, yet upon
consultation of the records of fourteen cases of
tuberculous cystitis, I find that in but three of the
six cases operated on for unilateral tuberculous
nephrocystitis, was it possible to enter the healthy
ureter. Introduction of the ureter catheter into the
diseased ureteral orifice, was foiled in four in-
stances by the free bleeding which haemorrhage, in
turn, was also responsible for failure to enter the
ureter of the accredited intact kidney in three re-
maining cases. Quite recentl}- again, I have had
two more patients with renovesical tuberculosis,
who have not as yet consented to operation, in whom
it was possible merely to enter the healthy ureter.
The urine withdrawn from the healthy appearing
ureteral orifices, in two of the operated cases,
showed some pathological conditions, as casts, al-
bumin, pus cells, epithelial cells, and yet these two
patients who were nephrectomized, made a good
recovery. That such is actually the true working
state oi affairs in the hands of others, you may con-
vince yourself by a persual of cases reported by
Casper, x\lbowan, Fenwick, Newman, Kelly, Willy
Meyer, Tilden Brown, and Kapsammer, who prac-
tise ureteral catheterization, and having learned at
times of the pathological excretion of the other
kidney, none the less advocated removal of the
tuberculous kidney. Konig, Kuster, Lange,
Rovsing, Israel, and Senn, who do not perform ure-
teral catheterization, and see no reason why a to-
tally diseased kidney should not be removed, even
if the opposite kidney is partially diseased, report
successfully operated cases uncler such circum-
stances. \^'e must, therefore, question the real
worth of ureteral catheterization. Furthermore, it
is likely in guiding the catheter into the ureter of
the healthy kidney, via the medium of tuberculous
bladder walls and infected contents, to contami-
nate the urine of that side with tubercle bacilli, and
finding them therein, to impugn this kidney as also
tuberculous. From this transplantation of tubercle
bacilli, the possibility of an infection arising where
none existed heretofore, is but fiction thus far. In
support of this development of the diagnosis of re-
nal tuberculosis by cystoscopic examination alone,
we cite the formidable expert, Fenwick, who con-
siders ureteric meatoscopy paramount for conclu-
sions to operate, and I quote Nitze's words of
warning, in Ins posthum.ous second edition. 'Tf it
is the intention to extirpate one kidney, nothing
should be undertaken which might in any way be
detrimental for the remaining kidney. Wherefore,
I have abandoned double ureteral catheterization,
and recommend the use of the occlusive catheter,
only to be employed on the diseased side. In ad-
dition, a catheter in the bladder will now collect
the urine which comes from the healthy kidney ( ?)
only."
Rovsing has recently drawn attention to two
cases, where a descending tuberculous nephrocys-
titis existed on one side and the intramural portions
of the ureter of the other kidney were (tubercu-
lous) diseased by extension of the infection (as-
cending), and this ureter so stenosed as to pre-
clude catheterization beyond one inch. On bila
teral exploration, which Rovsing often resorts to,
he found the one kidney tuberculous and the other
normal.
At this stage we enter the realm of testing the
efficiency of the kidney to lie left. My experience
from the paucity of material is limited, and I dare
not speak with authority, save to say that all of these
tests are carried out under too artificial conditions.
Two years ago, when interest in this matter was
at its height, my attention was attracted by the state-
ments of Casper, of a lowered mortality of 14.3
per cent., and of Kiimmel, of that of 10 per cent.
From the study of the literature I unearthed these
telling data published by me in the American Jour-
nal of The Medical Sciences, June, 1905: Schmie-
den up to 1902, collected 201 cases of nephrectomy
for nephrovesical tuberculosis, the greater number
of which were diagnosticated without the aid of the
cystoscopy and obtained a mortality of 29 per cent.,
which corresponds to a like mortality of 29 per
cent, in 136 cases reported by Palet. Morris, who
denies himself the use of ureteral catheterization,
reports eighteen cases with a mortalitv of 27 per
cent., which is again exceeded by Konig who takes
the same stand, and also reports eighteen cases, with
a mortality of 33 per cent.
Contrast these figures with those from the advo-
cates of ureteral catheterization : Tuffier, nine cases,
no deaths; Tilden Brown, eighteen cases, 7 per cent,
mortality; Albarran, 12 per cent, mortality; Bangs,
135 cases (collected). 5 per cent, mortality; and
Kuster, seventeen cases, no deaths.
Now, Casper and Kiimmel would have us believe
that their further reduction of the mortality is due
to the still greater precision in the methods for de-
termining operative intervention gained from cry-
oscopic findings; and yet their mortality is 14.3
per cent, and 10 per cent., respectively, two figures
that are surpassed on the one hand by those of
Israel who, in 1896, had but 12 per cent, opposed
to ureteral catheterization at that time, and, on the
other hand, by those of Tilden Brown, whose mor-
tality with ureteral catheterization was 7 per cent,
and the 5 per cent, in the collected cases of Bangs.
This last mortality figure agrees fairly closely with
that of Rovsing, who reports eighty-six cases of
nephrectomy, with a mortality of 8.1 per cent., per-
formed in defiance of the results of cryoscopy.
though often availing himself of the exposure of
both kidneys notwithstanding the accurate uranaly-
sis of the separate urines previously obtained at
times by ureteral catheterization. Some exceptional
cases of haematuria and sepsis will always justify
the risk of the removal of the diseased kidney in
the face of all odds of the conduct and condition of
the opposite kidney.
A very simple way of testing renal integrity and
efficiency, the chromocystoscopy of Volker and
Joseph bids fair to be of success. Following an in-
jection into the buttock of 20 c.c. of a freshly pre-
pared and warmed 0.4 per cent, solution of Mercks
ll'AKE: TUBEKCULOUS N EPH KOCY ST IT IS .
LNi-u- York
Medical Journal.
indigo carmin in physiological saline solution (0.9
sodium chloride), the urine issuing from each ureter
will appear colored in varying degree within six to
twelve minutes. A delay in the appearance of, a
diminution in the intensity of the color, and a slug-
gish delivery of the stream, we are told, indicate
disease of the kidney. Fritz Volcker has drawn at-
tention to a type of stream peculiar to renal tuber-
culosis, in which the colorcfl urine issues after de-
lay as a long continued, slowly moving cloud, in-
stead of the normal, short, (luickly passing cloud.
This phenomena he harmonizes with the polyuria
of the afifected kidney often encountered in renal
tuberculosis.
At the first congress of the Society of German
Urologists, held at Menna, in October of this year,
1907, it was the universal opinion that the indii^n
carmine injection was of value in diagnosis of renal
function. Suter said it is eliminated simultaneously
in six to twelve minutes from both kidneys in health,
and Kapsammer, in thirty-seven cases of renal
tuberculosis, essayed a delay in the appearance of
the stream, and a diminution in its intensity, which
differences grew in direct proportion to the extent
of kidney lesion. Though tried but a dozen times,
I am willing to vouch for its partial value. Nitze
has masterfully sized up the situation by saying
(/. c), that all these tests for renal function are
unavailing, inasmuch as they have nothing to do
with that which the surgeon would know, "whether
the one remaining; kidney afU'r a nephrectomy is
alone capable of eliminating the metabolic products."
Once all the evidence for the diagnosis of nephro-
vesical tuberculosis is in., we try to sustain the ver-
dict by a revision of the palpation of the suspected
kidney. Most times it is enlarged, but more often
it cannot be felt because it is drawn up under the
costal arches by adhesions. In consequence of this
displacement by the contraction of the adhesions,
the kidney loses its characteristic of respiratory ex-
cursions. At times, the opposite healthy kidney
takes on an enlargement because of com])ensatory
hypertrophy, and its excursions with respiration are
more easily appreciated. If, now, the pain is also
referred to this side, an error is very likely. An
examination of the pelvic ureter from the rectum
or vagina may reveal a thickening, and pressure
upon it evoke pain in the penis or side of the af-
fected kidney.
A number of the cases have received an injection
of 0.5 to I milligramme of Koch's old tuberculin,
and the elevation of temperature noted, and also
local reactions in the presence of a tuberculous
lesion, such as swelling of the affected kidney, with
increased pain in it, appearance of blood in the
urine, and at times, tubercle bacilli in greater
amount than heretofore. The absence of a reac-
tion to tuberculin injection does not count against
a tuberculosis being present.
Case of S. G. is one in question, where tlie tnbercnlosis
was grafted upon a gonorrhoea. With a negative reaction to
tubercnlin, and the other means available gone over,
we were bnt able to diagnosticate a unilateral pus kidney.
Even after the kidney was removed, the pus containing
pure staphylococci to culture, our belief was finally only
verified by the finding of the tubercle in sections of the
kidney.
In every way at times renal and ureteral calculi,
in the absence of the evasive tuberculosis organism.
may simulate nephrovesical tuberculosis, but the use
of the X ray will be the final arbiter in these doubt-
ful cases, although in instances of long standing
renal tuberculosis, calcareous deposits may also
show up in radiograms as shadows not as sharply
defined as those from the calculi.
To fasten the stigma of tuberculosis upon a kid-
ney is, therefore, justifiable only from a rigid diag-
nosis per excltisionem in which the tentative clinical
diagnosis is supported by the aids of the laboratory,
radioscopic and cystoscopic examinations.
In support of the facts reviewed in this article, I
herewith append a brief history of the six cases of
unilateral tuberculous nephrocystitis in which I
operated at Mt. Sinai Hospital in the service of Dr.
H. Goldenberg, to whom thanks are due for his
valuable advice and care in the management of the
cases.
Case I. — L. S., aet. twenty-six (Surgical No. 88094).
Antecedent history, family or personal have no bearing
upon the present complaint ; no gonorrhoea.
April 29, 1906. — On October, 1905, patient had a supra-
pubic cystotomy performed elsewhere for suspected stone,
which nas not found. Urination frequency every half hour,
day and night, and bloody and painful as well at that time,
and the urine was cloudy. These symptoms had persisted,
and a small suprapubic fistula remained after cystotomy.
Four months later orchidectomy was performed on the right
testicle for a swelling of the testes the size of an orange,
which had persisted for four weeks. There was no evi-
dence of a sinus. Since then he had to have morphine for
the pain. His chief complaints were frequent micturition,
pain at the end of penis, which increased upon urination.
There was also hsematuria. and loss in weight.
Physical Examination.— Dulness and diminished breath-
ing over right apex.
Rectal Examination. — Tenderness over prostate and thick-
ening of both coruna of the prostate. Urine, acid, gravity,
r,020 to 1,028, but at one time were tubercle bacilli found.
Urine catheterized in sterile manner remained sterile upon
culture. After exhibition of 0.5 increasing to 2 milli-
grammes of the old tuberculin (Koch), the temperature
previously normal, rose to 102° F., attended with pains in
chest and middle and right side of the abdomen. Exami-
nation for tubercle bacilli at this time was again negative.
Cystoscopy by Dr. H. Goldenberg: Right ureteral orifice
was normal. Jets of pus could be seen to come from the
left ureter. There was no difficulty in washing the blad-
der clean. A week later an attempt to catheterize ureters
(Dr. Ware) was abandoned because of pain. The day fol-
lowing the right healthy ureter was catheterized, under
chloroform with 100 c.c. bladder contents. The left was
found to be diseased, and could not be entered : 10 c.c. of
slightly blood tinged urine was collected. Reaction of the
urine was slightly acid. Albumin, in unappreciable quantity,
was referred to the blood from traumatism by ureter
catheter.
Microscopical examinations showed pus cells, epithelial
cells, and red blood cells.
Operation was performed on May nth, nephrectomy.
Slight pyocyaneus infection of the wound followed. This
organism was obtained in" culture from the pus in the kid-
ney. The latter was reported tuberculous. Two weeks
later the supr;ipubic fistula closed. Frequency of urina-
tion persisted somewhat and craving for morphine was un-
abated at the time of discharge, one month after removal
of the kidney.
Case II.— L. K. (surgical No. 84964. 1905). female, ?et.
twelve. Patient had had all the exanthemata and pneu-
monia at six years of age. No menses as yet. Six months
ago she suddenly began to have painful, frequent micturi-
tion and terminal ha^maturia. No benefit from bladder
irrigations was derived. Urine was cloudy, contained pus
cells, epithelium detritus, and tubercle bacilli in great num-
ber. Bladder capacity, 50 c.c.
Cystoscopy.— Right ureter showed small slit, left ureter
large and crescent shaped and many bloodvessels leading to
it. Owing to contracted state of the bladder cystoscopy
was performed under chloroform anaesthesia.
January 4, I9C.1<. |
GORDON
S 1 UMP HA LL ULINA 1 ION.
'7
Catheterization of ureters :
Right Side.
Amber.
Clear.
Albumin, minute trace.
Many pus cells, hyaline
and hyalogramilar casts.
Left Side.
.\niber.
Cloudy.
Albumin, heavy trace.
Loaded with pus cells ;
moderate number of red
No tubercle bacilli in cen- blood cells,
trifugated urine. Centrifugated urine con-
tained tubercle bacilli.
Nephrectomy and resection of two inches of thickened
ureter were performed, and drainage instituted. Specimen
contained a large pus sac communicating with pelvis ; all
of the papilla were seat of smaller abscesses. Wound went
on to healing and a sinus closed after many months. Relief
for six months, then urinary symptoms appeared as before
operation. Cystoscopy and catheterization of the right
ureter now also showed the presence of tubercle bacilli.
Case III. — S. G., September, 1905, set. twenty. Family his-
tory was negative. Patient had had a gonorrhoea seven months
ago, since which time he had had urinary disturbances,
characterized by frequent urination, pain at head of penis
during urination, and hsematuria. A urethral discharge
present contained gonococci. Testicles were normal, and
prostate not tender nor enlarged.
Endoscopy. — Urethra was injected tbroughout the canal.
At one point a polypoid growth was seen, but torn oft' by
manipulations, and was not available for examination.
There was congestion and oedema of urethra. Urine by
sterile catheter was sent to laboratory ; reports stated
staphylococci. Urine continued to contain pus and blood,
and cystoscopy proved a failure. Nothing, in spite of clear
return of water, could be made out because trigone was,
too injected. Patient was complaining of tenderness over
left kidney, and was running a septic temperature. Cysto-
scopy under gas and ether proved again a failure. Blood
culture was negative, also radiograph negative. There was
persistent tenderness over left kidney. Temperature con-
tinued irregular, intermittent and high ; temperatures of
sepsis afTorded indication for operation.
Operation. — Lumbar nephrotomy with vertical incision.
The fat capsule v/as found very much adherent to surround-
ings. In trying to separate the adhesions to free the kid-
ney, the patient collapsed, but rallied under intravenous
saline infusion so that the nephrotomy could be performed
The kidney was found to be riddled with abscesses. Pus
sent to the laboratory w as reported to contain staphylococcus,
and a small section of kidney removed was reported to
show inflammatory changes. The kidney was drained, and
the patient made a recovery within a month. At this time
he was discharged for out patient treatment w ith a lumbar
sinus and ' some frequency of micturition persisting.
Cystoscopy showed a normal bladder. Si.K weeks later,
January 17, 1906, he returned for operation of persisting
renal fistula.
Cystoscopy was performed by Dr. Goldenberg. The right
ureter was seen as a round hole, very velvety in appearance
and no eversion. The left ureter appeared golf holed.
There was eversion of the mucous membrane and numerous
punctate haemorrhages about the ureter.
January 19th. — Nephrectomy was performed by lumbar
route. Kidney on section contained numerous abscesses.
The report of the pathological department stated that the
extirpated kidney was tuberculous. Four months thereafter
the pa:tient had gained fifty pounds, and he stated that he
no longer urinated at night.
Case IV. — M. K., set. fifty, married, four children, Octo-
ber, 1905. Mother had died of tuberculosis ; patient had h^d
at age of thirteen dropsy, but there was no other urological
history. Patient was in one of the hospitals for perineal
abscesses, the sinus persisting.
Cystoscopy by Dr. Goldenberg.— Right ureter was cathe-
terized : contained much pus, while the urine collected from
the bladder contained practically no pus. LVine of right ureter
showed 3 per cent, urea, bladder urine 2.2 per cent. urea,
representing the output of the left kidney. Subsequently,
both ureters were catheterized by Dr. Ware, and the right
kidney showed 0.2 per cent urea, and much albumin ; left
kidney, 2.7 per cent, urea, and trace of albumin. No tu-
bercle bacilli were found.
Operation. — Lumbar nephrectomy. Ligature applied to
pedicle slipped and clamps securing the vessels were left
in situ for six days. Subsequent recovery was uneventful.
Pus from kidney contained pseudoinfluen/a bacillus, and
kidney proved to be the seat of tuberculosis. Revision of
perineal sinus was unsuccessful, leakage at times. Now
(1907) urine was clear, but patient was attacked with tuber-
culosis of the wrist, but gained fifteen pounds.
Case V. — W. N., ?et. fourteen, 1904. Was discharged
from the old hospital upon closing, with diagnosis of tuber-
culosis. He had sufYered from cystitis six months ago, and
tubercle bacilli were found at that time. Small size of
meatus precluded cystoscopy. He returned to the new hos-
pital with original symtoms of frequency of micturition
day and night, with occasional blood, but tubercle bacilli
were not found in the urine.
Cystoscopy, with the children's cystoscope, size 19 F.,
showed pus escaping from the right ureter, while the left
ureter appeared normal. No small ureter catheterizing
instrument was at hand.
Operation. — Lumbar nephrectomy. An uneventful course
thereafter, and the boy discharged cured and free of all
symptoms one month later. He has been in perfect health
since.
Case VI. — L. M., ast. thirty-five, May, 1904. One year
previously operated upon for abscess of the kidney
(nephrotomy) in a hospital of this city, since wfhich time
a lumbar fistula of the left side persisted. Urine was
cloudy, and there was frequency of urination, twice at
night, attended with pain.
Cystoscopy. — Right ureter appears normal ; left ureter
larger than normal, situated on an cedematous papilla, sur-
rounded by much injection.
Operation. — Lumbar nephrectomy. Kidney was found
with difficulty in a mass of dense adhesions under the cos-
tal arch, therefore a rib had to be resected. Clamps were
left on the pedicle in addition to ligature for security.
After six weeks healing was complete, except a small sinus.
Patient was seen subsequently; he had gained in weight
ten pounds. Urine was clear, but contained albumin and
pus; patient complained of dyspnoea and oedema of legs.
Epicrises. — -Of these six cases, all btit Case IV
were in the beginning mistakenly interpreted. One
was treated for a vesical calculus, another was
operated upon (nephrectomy) for a pyonephrosis
grafted on a gonorrhoea, which eventually de-
manded a difficult secondary nephrectomy. A
young girl was treated for six months, in vain, for
a cystitis. After nephrectomy of one kidney in the
face of inflammatory changes of the other kidney
(casts, pus cells by ureter catheter), a tuberculosis
of this remaining kidney resulted, possibly, by an
ascending process. Still another patient operated
upon previously for perineal abscess which did not
heal, nor give relief to his urinary symptoms
(pyuria) was nephrectomized on the basis of find-
ings with the ureter catheter. Two nephrectomies
were performed in spite of pathological conditions
i)f sister organs. No cryoscopy or other tests for
renal sufficiency were applied, and no deaths re-
sulted. But these experiences emphasize anew the
needs of an early cooperation between physician and
surgeon to make possible an early diagnosis.
1 198 Lexington Anenue.
PATHOGENESIS OF STUMP HALLUCINATION
A propos of a Case of Tiventy-scven Years' Duration.*
By Alfred Gordon, M. D.,
Philadelphia,
.\ssociate in Nervous and Mental Diseases. Jefferson Medical Cel-
lege; Examiner of tlie Insane at the Philadelphia Hospital, etc.
It is a common observation that in cases of am-
putation of a limb the sensation of the latter re-
mains a more or less prolonged period of time.
The patient feels every segment of the absent limb
either spontaneously or upon pressure of the stump.
The spontaneous sensation disappears sooner than
*Read and patient exhibited l>efore the Philadelphia County Medi-
cal Society, November 13, 1907.
i8
GORDON: STUMP HALLUCINATION.
[New York
Medical Journal.
the sensation provoked by irritation of the terminal
ends of the resected nerves.
The notion of a Hmb is a synthetic conception
which is made up of several elementary sensations.
Whether the feeling of an amputated limb arises
without or with a local stimulation of the stump,
it is the brain that congregates the old images, tac-
tile, muscular, articular, and osseous of the limb.
In a large number of cases the spontaneous recol-
lection gradually grows weaker so that after a cer-
tain number of weeks or months it disappears
totally. The sensation of the lost limb caused by
peripheral irritation on the contrary persists for an
indefinite time. The question naturally arises. Is
the stump hallucination only of peripheral origin?
While there are ample proofs that the cicatricial
stimulation constitutes the point of departure of the
peculiar phenomenon, the question of its pathogene-
sis has not been entirely settled, as the so called
peripheral view does not explain all the cases. In
favor of that view speak cases in which cocainiza-
tion of the stump removed the hallucination, cases
in which electrization or application of extreme
cold or heat reproduced the knowledge of the
limb. In all of them there was an expansion of
nerve filaments, a neuritis, or a neuroma in the cica-
trix, an excitation of which was transmitted to the
cerebrum, and the old images were reproduced.
That the cerebrum alone without intervention of
the cicatricial irritation plays sometimes an inde-
pendent role in causation of a phantom limb, there
cannot be any doubt. Four examples have been
presented by Reny in 1899 {These de Nancy).
Souques and Poisot {R-evue neurologique, 1905),
report a case of a woman of sixty-three, whose
right arm was amputated two years prior to the
publication of the history. She could see her entire
arm all white with the cicatrices every night.
Cases have been reported where the sight of very
cold water produced a chilly sensation in the ampu-
tated arm. There is a well known experiment which
consists of striking the place upon which the pa-
tient localizes mentally his phantom limb. As soon
as it is done, the stump becomes retracted.
Moreover, spontaneous reproduction of images
of amputated limbs without the presence of an ex-
citing cause is unquestionably in favor of a purely
central origin of the stump hallucination.
If an independent effect of the brain has been
observed in some cases, its participation in the
curious phenomenon is nevertheless constant, as the
brain is the only organ in which hallucinations or-
iginate. Whenever the cicatrix of the stump in-
cludes terminations of nerves or neuromatia,
pressure or any excitations of the latter will trans-
mit the sensory impulse to the cerebrum where
awakening of the old arm image takes place.
The case I am about to report is interesting from
the standpoint of the pathogenesis of the affection.
It tends to prove that while the hallucination is
easily reproduced upon the least irritation of the
stump, nevertheless the phenomenon appears at
times spontaneously.. Since the cerebral haemor-
rhage occurred the neuralgic pain from which the
patient suffers in the absent arm is decidedly worse.
Finally the duration of the malady, viz., twenty-
seven years, shows that instead of losing the habit
the patient is still able tn recall vividly the image
and the sensation of the amputated arm. It is there-
fore a primary cerebral phenomenon.
His history is as follows:
W. S., aged 51, a railroad man without any special per-
sonal or family history, met twenty-seven years ago with a
serious accident in which his left arm was crushed. An
immediate amputation was considered urgently necessary.
Since the operation he had always felt the presence of his
removed arm. At first, he suffered continuous excruciating
pains which were localized, so to speak, mentally in the
absent limb. Gradually, the severity of the pain decreased,
but he has never been free from it. Upon examination the
stump appears to be covered with a cicatrix. The latter is
tender. Pressure upon it causes a sharp pain which ex-
tends downward to the entire absent limb. He feels it par-
ticularly over the ulnar side of the forearm and hand. He
speaks of two lost fingers which are then tingling. The
same phenomenon is observed by him whenever he happens
to strike the stump accidently against a hard object, or if
anyone passing alongside of him would involuntarily press
against the stump. A prick of a pin will also produce pain
in the same area. H cold or hot water is applied to the
stump, a sensation of cold or heat respectively will be
felt by the patient in his phantom arm and hand. Should
electricity be applied to the same spot, a tingling will be
felt by him down the absent limb as far as the tips of
imaginary fingers. So far it can be seen that a peripheral
irritation of the cicatrix, which undoubtedly contains the
ends of the resected nerves, is the exciting cause of the
hallucination.
More remarkable is the spontaneous sensation of the ab-
sent limb which originates in him without any apparent
external cause. In fact, he constantly feels the presence
of the arm. He feels it hanging alongside of the body; he
feels the arrangement of the fingers and sometimes their
movements. But there is a constant unpleasant feeling, a
numbness in the phantom limb. Moreover, he gets some-
times a spontaneous sharp pain of neuralgic character in
that arm, which makes him flinch and double up. This
pain, he says, runs through the ulnar side of the arm.
A few months ago the patient suffered an apoplectic
seizure, following which developed a left hemiplegia. Since
this cerebral disturbance the former stump phenomenon
became aggravated. The spontaneous pain in the absent
arm is more frequent and intense, the numbness causes
him more discomfort than previously, and finally the re-
sponse to stimulation of the stump is decidedly greater.
Conclusion. — The appearance of the hallucination
upon a physical irritation of the cicatrix of the
stump speaks in favor of its peripheral origin. The
spontaneous development of the phenomenon when
the patient is at rest and without external irritation,
aggravation of symptoms after an apoplectic
seizure, are all manifestations which originate pri-
marily in the brain. The question of the pathogene-
sis can not, therefore, be decided in exclusive favor
of one or of the other view. Both elements pla\- an
important role in producing the stump hallucination.
The most interesting feature of the case is the
unusual duration of the hallucination. Cases with
the stump phenomenon persisting for several years
have been reported, but a twenty-seven years' hallu-
cination is very uncommon. The habit of transfer-
ring to the periphery all sorts of sensations is due
to the association of visual, tactile, and motor im-
ages. Normally this habit gets gradually lost : in
home cases at the end of a week or a month, and in
others at the end of several years. When the hallu-
cination persists for a great many years, the cerebral
centres are more or less in a state of an instability.
Such a brain cannot be considered normal. My pa-
tient is alcoholic. For a number of years he used
intoxicating beverages in unusually large quantities
(10 to 12 whiskies and as many beers a day). This
fact illustrates the validity of the view concerning
the cerebral origin of stump hallucination.
T430 r*i.\n Street.
January 4, 190S.
IVALKER: POTASSIUM IODIDE IN INSANITY.
19
POTASSIUM IODIDE IX MENTAL DISEASES.
By J. M. Walker, M. D..
Dubuque, Iowa,
Physician in Charge of St. Joseph's Mercy Asylum for Nervous and
Mental Diseases.
The consideration of this subject is not entirely
new. However, I hope that perhaps it may be of
practical value to the general practitioner, as well
as those practising along special lines. I believe
potassium iodide has a much wider use in mental
diseases, aside from cases due especially to syphilis,
and that in most instances we have not been giving
this drug in sufficiently large doses. My experience
with this drug has been along the lines of special
work, viz., nervous and mental diseases, and I am be-
ginning to feel that it is the one drug, if I was to be
limited to one single drug, which would accomplish
the most good in this class of diseases. I will con-
sider potassium iodide from two standpoints, viz. :
(i) Physiological action and dosage not touched
upon by most of the textbooks, also method of ad-
ministration, and (2) its effect and the possibility of
enormous doses in mental diseases, especially syphil-
itic and alcoholic.
Church in his textbook on nervous diseases ad-
vises 20 gT. doses three times daily and increase
10 gr. daily until in rebellious or critical cases lOO
or even 200 gr. are given at one dose. He also
says it is clinically proved that the syphilitic process
can gain such a tolerance for either mercury or
iodide that their specific effect is lost. I believe the
reason for the supposed tolerance to iodide espe-
cially is due to the comparatively small doses of the
drug, as 200 gr. three times daily is insufficient in
a great number of specific cases. I will also recite
a few cases of specific and nonspecific mental dis-
eases which have tolerated much larger doses of
iodide than recommended by this author.
Pearce in his treatise on nervous diseases speaks
of vigorous and thorough application of antisyph-
ilitic remedies, as potassium iodide, in 20 gr. doses,
increased to 100 or 200 gr. a day. taken in solution.
\'er\- few of the authors of materia medica and
therapeutics, if any, advise more than i drachm
doses of potassium iodide three times daily.
Following is a brief summary of several cases
under my personal care at St. Joseph's !Mercy Asy-
lum for Nervous and Mental Diseases. I will not
deal exhaustively with histor}- and symptomology,
my object being to call attention to the possibilities
of the drug in mental diseases :
Case I. — E. E.. male, single, age forty. Admitted Feb-
ruary 2, 1904. Diagnosis : Cerebral syphilis. His history
showed that he had had syphilis in 1884, twentv years pre-
vious to date of. admittance. He was committed to an
asylum ten years later, 1894. At the time he came under
my observation for the present trouble, he had secondary
and tertiary lesions, showing this was possibly a secondary
infection of syphilis. Mental symptoms were of active type,
religious mania, loud singing and dancing. He was started
on dr. I doses of saturated solution of potassium iodide
three times daily, and increased dr. i daily. Also pills of
protoiodide of mercury gr. three times daily, and in-
creased one pill daily until physiological effect had been
obtained, when the mercury was withdrawn for a short
time, but the potassium iodide was steadily increased until
dr. 15 or 600 gr. were reached, which was on the thirteenth
day. After a rest of two weeks the same treatment was
again instituted. The patient at this time was very much
improved, mentally and physically, and continued to im-
prove until the full effect of potassium iodide was obtained,
when he became stupid for a few days, was also nauseated
and vomited freely. He was at this time getting dr. 18
or 720 gr. per day and was gaining flesh rapidly. After
recovering from the period of stupidity, which lasted four
days, he improved steadily until discharged, which was
two months after the last course of potassium iodide. This
patient was heard from one year later, being under the care
of his family physician for a recurrence of the mental
trouble. His condition was not improved after one month
of treatment with ^ gr. of mercury protoiodide three
times daily and potassium iodide in dr. ^-4 doses three
times daily, advised by his family physician. Large doses
of potassium iodide were recommended as outlined in the
foregoing, and the patient showed improvement almost im-
mediately and made an uninterrupted recovery.
Case II. — F. C, male, single, age thirty-seven. Ad-
mitted Januarj-, 1905. Diagnosis : Cerebral syphilis. He
suffered from very active hallucinations and delusions, re-
ligious mania. I started patient, at once on potassium
iodide dr. i doses three times daily, and increased dr. ^
daily. This man took the drug uninterruptedly until dr. 30
or 1,200 gr. daily were taken, which was the fifty-fifth day
of administration; at this time he was very stupid for
four or five days, vomited a number of times and refused
all food. There was no marked rash, however: conjunctivae
were injected; face was swollen and puffy. After the fifth
day his mental condition became very much improved. He
would converse intelligently and do a small amount of
work, although he was likely at r.ny time to stop his occu-
pation and begin oraying, this feature of his mental dis-
order being the last to disappear. After two weeks' rest the
drug was continued as before and discontinued at the same
quantity as the first course. At this time he was writing
letters to his sister and had gained twenty-five pounds.
After the third course (which was delayed for six weeks,
hoping the patient's mental condition would improve) he
was discharged cured on February 22, 1907, and has been
doing farm work all sum.mer and has been taking dr. i of
potassium iodide three times daily for seven months without
any ill effect, in fact, weighs more and is in better health
than ever before.
Case III. — R. C, male, single, age twenty-six. Admitted
July 25, 1905. Diagnosis : Cerebral syphilis. His physical
condition was fair. On July 30, 1905, the patient was started
on dr. I doses of potassium iodide three times daily, and
increased dr. i daily. Medicine and food, which were liquid,
were administered through stomach tube, as he refused all
nourishment. After the first week he was taking food vol-
untarily, appetite was good, and he gained two pounds ; he
developed rash on face and chest and was slightly nauseated
immediately after taking medicine. As potassium iodide
v.as increased, rash and nausea disappeared, patient's appe-
tie was ravenous, and he had gained eight pounds on the
sixteenth day, at which time he was getting dr. 18 or 720
gr. a day. He continued to improve until the twenty-fifth
day, when he became stupid, refused food, except in small
quantities; conjunctivas were injected; face was puffy and
swollen ; on the twenty-eighth day he was getting dr. 30 or
1,200 gr. per day. The drug was discontinued at this point,
as the patient was vomiting frequently, also had profuse
watery discharge from the bowels. He was kept in bed
four days, allowed liquid diet and bismuthum subnitricum
gr. 30, every two hours, until vomiting and diarrhoea were
checked. On the fifth day. August 27, 1905, his mind was
clear, except slight religious hallucinations. This same
treatment w-as subsequently repeated twice, with a rest of
two weeks between each course. Patient was discharged
cured on January i, 1906. He was afterward employed at
the institution until October 20, 1906, and showed no mental
impairment or effect of the postassium iodide treatment dur.
ing this time, and has been working every day since leav-
ing our employ.
Case IV. — P. O'C, male, single, age twenty. Admitted
August 13. 1906. Physical condition good. Diagnosis :
Raptus melancholicus, due to hereditary influence. Ordi-
nary treatment appeared to have no effect whatever; in
fact, patient's outbreaks seemed to be getting more violent
and frequent ; he had been getting dr. i doses of potassium
iodide three times daily for its alterative effect. I deter-
20
ll'ALKER: FOTASSWM lUDIDE IX IXSAXITY
LNiw York
Medical Journal.
mined to increase the drug. He showed improvement after
dr. 7 or 280 gr. daily had been reached. It was increased
dr. daily until dr. 28 or 1,120 gr. were being taken, which
was the fifty-first day. He had the usual four or five days
of stupidity, when he regained his usual mental vigor and
was discharged cured, March 13, 1907, one month later.
Case V. — Wm. H., male, single, age twenty-one. Ad-
mitted January 14, 1907. Patient's physical condition was
poor. Diagnosis : Cerebral syphilis. Patient had treatment
at Hot Springs two years previous, for syphilis. On Janu-
ary I, 1907, his mgntal symptoms first asserted themselves.
This man was bad, physically and mentally, and required
constant attention, as his habits were filthy. Altogether,
it was one of the extreme cases of this disorder. On Janu-
ary i6th he was started on dr. i doses of potassium iodide,
three times daily, and increased dr. daily until dr. 33 or
1,320 gr. were reached, which was on the sixty-first day.
There was some improvement, mentally and physically.
After a rest of two weeks another course was begun ; he
gained flesh rapidly, and his mental condition had improved
to such an extent that he was doing some light work, viz.,
sweeping, dusting, arranging beds, etc. Drug was stopped
at dr. 28 or 1,120 gr. At this time he weighed more than
ever before, and after recovering from the few days of
stupidity, he wrote letters to his family. Potassium iodide
was given the third time until dr. 28 had been reached. He
was discharged on June 22. 1907, cured. I have kept in
touch with this patient and know that he suffers no ill ef-
fects from the potassium iodide. He has taken dr. i three
times daily ever since his discharge.
Case VI.— F. M., male, single, age twenty-seven. Ad-
mitted December 18, 1906. Diagnosis : Cerebral syphilis.
This case was of the active type rather than the melan-
cholic. Potassium iodide was given as before until the
twenty-fifth day, when he was getting dr. 15 or 600 gr. a
day. This was repeated the second time, and patient was
discharged cured on June 30, 1907.
Case VII. — J. L., male, single, age thirty-eight. Ad-
mitted March 28, 1907. Diagnosis : Depressive melancholia.
His physical condition was fair. Two days after being
admitted he had an attack of acute mania ; temperature was
106° ; pulse 194 per minute. Icebag was placed on his head,
cool sponging used, and dr. i of fluid extract of ergot ad-
ministered every two hours. He recovered from the attack
in thirty-six hours, but was left very much weakened, and
lost twenty pounds in two weeks. He refused all food and
was filthy, rather bestial in habits. As soon as he had re-
covered sufficiently from his acute illness, potassium iodide
was started in the usual size doses, given with milk and
fed through a tube; this was kept up for thirty-nine days.
His physical condition improved very much, and he had
gained ten pounds. At this time he was getting dr. 22 or
880 gr. a day. His mental condition was somewhat better.
After a rest of two weeks, potassium iodide was again
started and reached dr. 28 or 1,120 gr (fifty-first day). He
had added fifteen pounds to his weight, and mental condi-
tion had improved so that he was taking food voluntarily.
After a wait of six weeks, during which time no improve-
ment was noticed, the drug was started the third time and
reached the same as before, dr. 28. He was discharged
October 12, 1907, cured.
Case VIII. — A. K., male, married, age fifty-seven.
Farmer. Admitted June 6, 1907. Diagnosis: Alcoholic
insanity. This man reached dr. 33 or 1,320 gr. a day at
two different times. He has improved mentally and physi-
cally, but is still confined in the institution. He has taken
as large a dose as any of the syphilitic cases.
Case IX. — A. J., male, married, age forty-three. Liquor
dealer. Admitted July 4, 1907. Diagnosis : Alcoholic in-
sanity, also suffering from advanced stage of pulmonary
tuberculosis. Potassium iodide was given after ten days
of other treatment had failed to do any good. He im-
proved rapidly, both physically and mentally. When dr.
15 or 600 gr. a day were reached, he was sufficiently re-
covered to be removed to the hospital ; by reason of this,
five doses of the drug were missed ; the nurse attempted
to make up the amount lost, and in doing so the patient
was made sick and medicine was discontinued. Had this
not happened I am sure he would have taken a much larger
amount. This man was coughing almost incessantly and
raising large quantities of mucopurulent material. Until
300 gr. a day were being administered, the amount of ex-
pectoration was increased markedly: later it ceased almost
entirely, as did also the cough. The patient was gaining
flesh rapidly, two to four pounds per week, and was dis-
charged August 4, cured of the insanity. I saw this man
as late as October 20, 1907, when he had gained, all told,
thirty-seven pounds.
Case X.— Mrs. P., married, age forty. Admitted May
15, 1907- Diagnosis : Puerperal insanity ; very active delir-
ium. After treating three months with ordinary remedies,
it was concluded to try potassium iodide. At dr. 22 or 880
gr. patient became very quiet, talked rationally, and read
the daily papers. When dr. 25 was reached she became
very stupid and vomited freely. After a rest of two weeks
we gave her dr. 3 of potassium iodide three times daily
for a period of thirty-four days, then increased it dr. a
day until dr. 16 were reached, when we were compelled to
discontinue it. Later she became restless and noisy, when
dr. I doses three times daily quieted her; in fact, potassium
iodide administered in this way seems to exert a greater
hypnotic effect in this case than l4 gr. doses of morphine
which I had formerly used. It is the only hypnotic I am
using at the present time in this particular case.
Case XL— E. F., male, single, age nineteen. Farmer.
Admitted _ September 17, 1907. Diagnosis : Depressive
melancholia. This patient had been treated at home for
about one year by the family physician ; during this time
he had been slowly getting worse. Until October i there
was no change noted in his condition. At this time I
started him on potassium iodide. On the twenty-third day
he was taking dr. 14 or 560 gr. daily; his back, face, and
chest were covered with large pustules, which cleared up
as the dosage was increased. When dr. 20 or 800 gr. were
reached, he showed marked improvement mentally; was
eating heartily, playing cards, arranging beds, and doing
some work in the laundry. On the forty-third day he was
taking dr. 24 or 950 gr. daily and was well enough to go
home.
During my observation of these cases, I have no-
ticed several things about potassium iodide which
seemed to be of importance, viz., it is utterly im-
possible in most cases to give enormous doses of
the drug unless the patient is on a full diet and
given immediately after meals. However, I have
divided the doses so as to give a comparative! \-
small dose between meals, but not with the same
tolerance as when given immediately after meals.
I use the saturated solution in water or given in
milk : contrary to the usual custom of considering
dr. I of the saturated solution as containing gr. i
of potassium iodide in computing my dosage. I fig-
ure according to Potter dr. i of saturated solution
as containing 40 gr. of potassium iodide ; hence the
apparent smallness of the dosage in grains as com-
pared with the usual method of computing 60 gr. to
dr. I, which would increase the number of grains
one third of the full amount (as 1,200 gr. usually
considered 1,800 gr.).
I have yet to find a person, especially of the class
of cases cited, who was unable to take very large
doses of potassium iodide. I have also noted in
most every case we have what I may call a primary
eruption, situated principally on the chest and face ;
in most cases this occurs at from 300 to 500 gr.,
also slight nausea ; both of these conditions disap-
pear upon dosage being increased. This seems to
be the rule in nearly every case, and, in so far as
my experience goes, I have found in a good per-
centage of cases of cerebral syphilis, if treatment is
begun within three months after mental impairment
is first noticed, the patient will invariably regain
his normal mental faculties. The eruption and
nausea spoken of seem to be a primary physiologi-
cal effect of potassium iodide, as nausea disappears
and the skin clears up on increasing the dose to its
limit or full physiological action, which is evi-
denced by the patient's face becoming puffy and
swollen, conjunctiva injected, abundant secretion
January 4, 1908.)
rEASEV: GLAUCOMA IN THE VOUXG.
21
from the mucous membrane of the nares and
bronchi, severe vomiting, acne form eruptions cov-
ering nearly all of the body (however, this may
or may not be present) ; diarrhoea, loss of appetite,
and stupidity, which lasts from four to five days ;
during the period of diarrhoea and emesis pulse is
increased ten to fifteen beats per minute, and lasts
for about forty-eight hours, after which it becomes
normal.
I have had some trouble in getting the dose above
300 to 400 gr. in a few cases, but only when it has
been impossible to induce the patient to eat heartily,
and I have a number of patients whom after leaving
the institution have been taking dr. i doses three
times daily for months without any deleterious effect
whatever — in fact, appears to exert a decided tonic
effect and increase the appetite. In Case IX the
effect of potassium iodide appeared to be very
marked, as the tuberculous process was well
advanced and bacilli had been demonstrated in
the sputum ; the man did not get any other med-
ication whatever. Hence I feel that potassium
iodide was responsible for the mental improvement,
also the decided change in the progress of the
tuberculosis. It may have been its alterative ef-
fect alone, or by reason of its being excreted by
mucous membranes a sufficient amount ma}- have
reached the seat of the trouble to exert its antisep-
tic influence. At any rate, I believe it to be worth
a trial in selected turbercular cases.
Griinberg reports cases to sustain his assertions
in regard to the frequently beneficial action of
potassium iodide and of mercury on primary tuber-
culous processes in the nose and throat. Syphilis
could be positively excluded in his cases, and he
thinks that some of those that have been published
as syphilitic affections of the upper air passages
simulating tuberculosis and cured by potassium
iodide or mercury were in reality purely tuberculous
processes.
Stern, of New York, recommends a saturated
formic acid iodide solution in pulmonary tubercu-
losis and alleges improvement or cure in 70 per cent,
of eight hundred patients.
There may be in the minds of some a question as
to whether or not potassium iodide is being digested
or passes directly through the bowels without any
change. As evidence that I think it is. I can point
to the steady gain of flesh, the marked improvement
in the patient's mental condition as the dosage is
being increased, especially the syphilitic cases, also
the urine of every case gives positive tests for
iodine.
GLAUCOMA IN THE YOUNG*
By C. a. Veasey, M. D.,
Philadelphia,
Assistant Professor of Disea'cs of tlic Eye. Jefferson Medical
CoUec-e.
At the December meeting. 1903, I had the honor
of reporting before this section, in conjunction with
Dr. E. A. Shumway, who made the pathological
examination, a case of simple glaucoma in the
young, the history of which was briefly as follows
A. B., an unmarried colored woman, was first seen in
April 1898. No family Jhistory of any ocular disease could
*Read before the Section in Ophthalmology of the College of
Physicians of Philadelphia, November 19, 1907.
'Published in the Ophthalmic Record, January, 1904.
be elicited. A grandmother, aged eighty-three, and a great
aunt, aged ninety-one, were still living and possessed good
vision. At sixteen years of age the patient had typhoid
fever, during which there Vv-as an indefinite history ol a
mild attack of inflammation in both eyes. The patient is
positive, however, that the vision of the right eye began
to fail during convalescence from the attack of fever.
There were at no time any inflammatory symptoms or
pain. The vision gradually diminished until it was finally
entirely lost when she was nineteen years of age, or about
three years from the beginning of the disease. From this
time on there were occasional attacks of severe pain, be-
coming more and more frequent, and located by her in the
eyeball, temporal region, and along the side of the head,
and it was for relief from this condition that she sought
advice.
Examination showed a divergent strabismus of 45°, no
inflammatory symptoms, and a typical complete glauco-
matous cup, the bottom being best observed with — S. 9 D.,
the macular region appearing practically emmetropic.
Ophthalmoscopic examination of the left eye showed a
normal disc of healthy appearance with a small physiologi-
cal cup and pulsating veins. The tension was normal.
The refractive error of the left eye was carefully cor-
rected, and after a year's treatment of the glaucomatous
eye with myotics locally, and sodium salicylate, bromides
and the various analgesics internally, the eye was enu-
cleated. The sections were exhibited at the time of pre-
senting the paper, and showed a very deep kettle shaped
excavation of the nerve, the lens was unusually large, the
epithelial cells markedly pigmented at and beyond the
corneal limbus, and there was also found considerable pig-
nieiitation between the bundles of the ciliary muscle and
around the loose meshed tissue between the canal of
Schlemm and the angle of the anterior chamber.
Here was a ca>e, therefore, in which chronic simple
glaucoma began in the sixteenth year of age, and which
rapidly progressed to total blindness in the nineteenth
year, with no appearance of glaucoma in the other eye
thirteen and a half years later.
Eight months ago. three and a half years after report-
ing the case and seventeen years from the appearance of
glaucoma in the first eye, the patient came to see me com-
plaining of dim vision in the remaining eye, which she
stated had been observed first three months before.
Ophthalmoscopic examination showed a beginning glau-
comatous cup, the vessels being crowded to one side and
the visual field being considerably contracted. The tension
was slightly elevated. Myotics were faithfully employed
locally and strychnine and nitroglycerin internally, but in
spite of this the cup of the optic nerve became more and
more extensive and the field of vision more and more con-
tracted. _ When it was found after some weeks that the
myotics in gradually increasing strengths did not seem to
check the advance of the glaucoma, iridectomy was pro-
posed and respectfully declined. Eight months have now
elapsed, the patient having always declined operative pro-
cedure whenever such was proposed, and although the
myotic treatment, together with optic nerve stimulants, have
been carefully and faithfully employed, the patient is now
almost blind, there remaining but a small amount of eccen-
tric vision, and the field being contracted to a very limited
area.
1 83 1 Che.stnut Street.
TYPHOID FEVER AND TETANUS— A CASE.*
By G. V. R. Merrill, M. D.,
Elmira, N. Y.
Typhoid, as is well known, presents various
phases of onset and progress. Tetany is an uncom-
mon disease and not particularly well defined. Some
authorities consider it akin to hvsteria, others as a
toxaemia, and still others as a disease of nutrition.
Therefore the following case is presented as not de-
void of interest, even if full concurrence is not had
in the diagnosis :
I was called on August ist to see E. H., a boy of decided
nervous temperament, four and one half years of age, who,
*Read before the Elmira Academy of Medicine, November 6, 1907.
22
MERRILL: TYPHOID LEl'ER A^D TETAXUS.
[New Vork
Medical Journal.
five days before, had returned from a week's visit in the
country. He presented the symptoms ordinarily ascribed
to intestinal parasites, and as his mother said he had been
troubled with worms, he was prescribed for accordingly.
There was no headache, no coating on tongue, no evidence
of fever at this time, although his mother said he had been
feverish for two or three nights. There was, however,
marked prostration and irritability, which his mother
thought was due to the child's having played overmuch
the week previously.
I was called again at 2 130 a. m., August 5th. The child
had been feverish and restless all night, and delirious since
12 o'clock. [ found liim tossing from side to side, and
talking incessantly in a voice that could be heard half a
block. His pulse was rapid, full and strong. I did not
get count of pulse or temperature. The medicine given
at my first visit had acted freely on his bowels with ap-
parent benefit, and the child had seemed quite well for the
past two days, except for the continued and progressive
weakness. I quieted his present excitement with chlor-
anodyne. At 9 a. m. he seemed quite well — pulse 88, tem-
perature 99.6° F., but his right eye was strabismic. The
rest of this day, the 6th, 7th, and 8th passed without any
marked symptoms, the depression gradually increasing, the
pulse running from 88 to 96, the morning temperature from
100° to 100.8' F., and the evening temperature from
100.8° to 102.6° F. On the 7tb a diagnosis of typhoid fever
was made.
On the 8th, while passing the house at 7 p. m., I was
called in on account of convulsion. I saw the child within
five minutes of occurrence of a fit and found his body
flexible, but arms slightly rigid, with fingers closed in
palms. His mother stated that the whole body became
rigid. Temperature, 100.2° F. ; pulse, 98 ; respiration, 32.
There was fall in temperature since 5 o'clock of 2.4°. Dur-
ing the night he was very restless.
August 9th. — Temperature ranged from 99.6° to 102° F. ;
pulse, 90 to 100 ; respiration, 30 to 34. Alternating contrac-
tion and relaxation of fingers more marked on the left
side — occasionally affecting the arms, readily induced by
Trouseau's test for tetany. Restlessness continued, with
occasional periods of sleep, from twenty minutes to two
hours duration.
August loth. — Temperature range from 99.6° to 101° F. ;
pulse, 84 to 90; respiration, 26 to 28. Left arm was par-
alyzed, fingers closed in palm, could readily be extended,
but on being released slowly closed into palm again.
Trouseau"s test was positive on muscles of arm, and here
it may be remarked that throughout the disease, even when
in deep stupor, the patient's muscles responded to this test.
Delirious from 11 a. m. to 4 p. m.
August iith. — Temperature range, 101° to 102° F. ;
pulse, 84 to 120; respiration, 12 to 24, It will be noticed
the beginning of the remarkable fluctuations in the pulse
rate. Tlie diminished number of respirations appeared lo
be due to spasm affecting the muscles of the chest, which,
however, was of short duration. At this time the back of
the neck was found to be tender, and head was slightly-
extended. He was delirious by spells. During the night
there was deep stupor.
August I2th.— Temperature range, 100° to 105.6" F. ;
pulse, 94 to 160 ) respiration, 28 to 40. Power of degluti-
tion was lost; whole left side was paralyzed, facial mus-
cles rigid and jaws set; left hand and foot were strongly
adducled. At the morning visit I found right arm inter-
mittingly contracted and relaxed. At noon the whole body
became rigid by spells; intervals of relaxation were few
and short. Blood was now taken for Widal test, whicii
promptly gave positive reaction. Just here I would re
mark the difficulty in getting even a drop of blood. The
lobe of the ear was punctured, then tbe finger tip, then
the ear again several times before a drop of blood could
be obtained.
August 13th. — Temperature range, 102° to 104.4° F. ;
pulse, 120 to 172; respiration, 38 to 56. The whole body
was strongly rigid most of the time. Periods of relaxa-
tion were longer apart and imperfect. Here tbe case pre-
sented the typical features of the complicating disease. The
fingers contracted into the palms; the wrists were strongly
flexed; the forearms flexed and crossed with the elbows
close to the sides ; the toes and ankles flexed and adducted ;
the knees semiflexed; the right vertical and the left hori-
zontal, the facial muscles were rigid, and the head slightly
extended. Towards evening the muscular rigidity was less
marked, and alternating contractions and relaxation were
noticed on the right side.
August 14th. — There appeared to be signs of improve-
ment. Temperature range, 98.6° to 102.4° F. ; pulse, 120 to 178 ;
respiration, 30 to 54. Rigidity of arms and legs was less
marked; he moved head slightly; opened eyes occasionally;
had limited voluntary motion of right leg' and both arms,
and of the left leg in very slight degree. Face muscles
were still rigid, but less pronounced than yesterday.
August 15th was a day of hope. Temperature range.
99.4° to 101.6° F. ; pulse, 120 to 160; respiration, 30 to 56.
All the symptoms improved except the breathing, which
was irregular and catchy. There was general muscular
rigidity; he could open his eyes and mouth a little, and
was sensitive to touch ; he was in a semiconscious state.
August i6th. — Patient was rapidly growing worse, ex-
cept muscular rigidity, which during the day was entirely
relieved. Temperature range, 102° to 104.8° F. ; pulse, 160
to 264; respiration, 28 to 68.
August 17th. — Temperature range, 102.8° to 108° F. ;
pulse, 200 to 260; respiration, 40 to 88. Patient died at
3 :30 p. rn.
In review I have to add that the bowels had been freely
opened at the beginning of the sickness and remained so
throughout. Elimination was sought by frequent high
enemas of normal salt solution, which generally came away
clear. jSTothing given by rectum was retained, and when
endeavor was made to nourish by this route it failed com-
pletely.
The kidneys acted freely and urine was discharged nor-
mally until the 15th, when continuous bed wetting was
noticed, and the bladder thereafter relieved by the use of
the catheter.
His diet consisted of malted milk, junket, and albumin
water administered by mouth until the 12th, and then,
after one day's delay in trying to nourish by rectum, was
given regularly hy nasal route until noon of the 17th.
Remedial measures seemed almost entirely without effect,
except in the temporary relief of certain symptoms. In-
crease in temperature was met by cold or tepid sponging,
according to state of skin and pulse. From the first the
pulse was very weak and various cardiac stimulants were
resorted to without satisfactory results. For the rigidity
the warm pack, and twice the tub bath, were used with
apparent benefit. Time and again difficulties in respiration
were relieved by the use of atropine or sulphuric ether,
but notwithstanding the disease, or diseases, marched
steadily on to lethal issue.
Now several interesting if not partictilarly im-
portant questions present themselves, viz. :
1. Did this child have tuberculous or cerebro-
spinal meningitis ?
2. Was the case one of typhoid with the compli-
cation of cerebral or cerebrospinal congestion ?
3. Were there two separate diseases, distinct en-
tities, complicating and interfering each with the
other?
Regarding the first, there was nothing in the his-
tory pointing to tuberculous infection. The usual
prodromal symptoms of stich condition were ab-
sent. There was no headache, no vomiting except
at the otitset in connection with the operation of
the physic, and no fever except at night. There was
no hydrocephalic cry or anything approaching it.
The only pain complained of was a vague discom-
fort and tenderness in the abdomen. The pulse was
not rapid at first, nor did it stibsequently assume
the character of the tuberculomeningitic pulse. The
pupils were dilated from the beginning. Convul-
sions, tremors, paralyses, and spasms may occur in
tuberculous meningitis, but they are all quite dif-
ferent from those in the case cited.
The ordinary form of cerebrospinal meningitis
may have the initiatory symptoms of headache and
pains in the back, but it is more apt to come on sud-
denly with chill, vomiting, and headache, none of
January 4. 190S. 1
OUR KIlADEKS' DISCUSSIOXS.
23
Avhich occurred in this case. Even in mild cases the
headache and nausea are so uniformly present as to
be regarded almost as essential to the disease.
Spasms also occur, both tonic and clonic, the for-
mer tetanic in their character, and the latter hav-
ing little resemblance to the gradual contraction and
relaxation which marked the case under considera-
tion. In cerebrospinal meningitis, Osier says that
"strabismus is a frequent and important symptom."
It will be remembered that this was an early symp-
tom in my case, manifesting itself on the fifth day.
This, with the active delirium and strong, full pulse
at first, was strongly suggestive of meningeal in-
flammation, but the subsequent course of the disease
was hardl\- consistent with that view. Osier fur-
ther says : "'Of sensory symptoms, headache is the
most dominant and persists from the outset.''
"Delirium occurs at the onset occasionally of a
furious and maniacal kind," and, he adds, "the de-
lirium gives place in a few days to stupor, which,
as the effusion increases, deepens to coma." In this
case there was no time when the patient could be
called comatose. The deepest stupor was on the
eleventh and twelfth days, but even then he gave
evidence of discomfort on being moved or dis-
turbed.
In regard to meningitis as a complication of
typhoid. Osier remarks, "Meningitis is extremely
rare." He did not find it in any of his autopsies,
and it occurred in only eleven of the 2,000 Munich
cases. He further states that he has examined post
mortem three cases with pronounced cerebral symp-
toms, in two of which the diagnosis of cerebrospinal
fever had been made. "In not one of these was
there any trace of meningeal inflammation, only the
most intense congestion of the cerebral and spina'
pia," and continues, "Stokes's dictum that 'there is
no single nervous symptom (in typhoid) which may
not and does not occur independent of any appre-
ciable lesion of the brain, nerves or spinal cord,' is
too often forgotten."
Of tetany with typhoid, he writes, "True tetany
occurs som.etimes. and a number of cases have de-
veloped in certain epidemics. It may set in during
the full height of the disease. This complication is
extremely rare in this countr}-. and Janeway, as far
as I know, has alone reported instances."
As for tetany itself, various causes are ascribed.
In children it is frequently associated with rickets.
It has followed extirpation of the thyreoid gland.
Dilatation of the stomach is frequently found in
fatal cases, and it is stated that any exhausting
disease may be a possible cause. Its pathology
gives no constant or characteristic lesion. T. Madi-
son Taylor in Sajous's Enc\'cIopcedia says: "The
evidences point to the conclusion that tetany is a
disorder of the nerves, somewhat generally dis-
tributed, and of toxic origin."
A slender fishbone lodged in a bronchus will usu-
ally not cast a shadow on the x ray plate. In such
a case bronchoscopy and auscultation are more reli-
able diagnostic measures. In addition to a variety
of moist rales, one may hear, associated with the in-
spiratory or expiratory murmur, or both, a musical
or vibratory note, when a bone or pin lies in the
bronchus. — From Five Hniidred Surgical Suggcs-
tious.
(©ur BeaJjers' §iscussions.
A SERIES OF PRIZE ESSAYS.
Questions for discussion in this department are an-
nounced at frequent intervals. So far as they have been
decided upon, the further questions are as folloivs:
LXIX. — Hoi,.- do yon treat post partum harnorrhage?
(Closed December 16, 1907.)
LXX.~How do yon distinguish alcoholic stupor from
other conditions resembling it? (Answers due not later
than January 15, igoS.)
LXXI. — How do you treat gallstone colic? (Answers
due not later than February 15, igo8.)
IVhoever anszvers one of these questions in the manner
most satisfactory to the editors and their adfisors will
receive a prize of $23. No importance whatever will be at-
tached to literary style, but the award zcill be based solely
on the value of the substance of the answer, /f is requested
(but not reqi ired) that the anszuers be short; if practica-
ble, no one answer to contain more than six hundred words.
All persons Zx.-ill be entitled to compete for the prize,
whether subscribers or not. This prize will not be awarded
to any one person more than once zi-ifhin one year. Every
answ'er must be accompanied by the zvriter's full name and
address, both of zchich zi.-e must be at liberty to publish.
.411 papers contributed become the property of the Journal.
The prize of $23 for the best essay submitted in answer
to question LXl'HI has been azvarded to Dr. Arthur S.
Risser, of Blaclrwell. Oklahoma, whose article appeared
on page I30<) of the preceding volume (l.v.i.vvi, \o. 26).
PRIZE QUESTION NO. LXVIII.
THE TREATMENT OF THE VOMITING OF
PREGNANCY.
(Concluded from page 1216.)
Dr. William H. Wells, of Philadelphia, writes:
The treatment of the vomiting of pregnane}- will
depend on the cause and time of pregnancy.
We have the slight morning nausea caused by a
nervous reaction produced by the growing uterus.
This form is usuall}- seen in the earl}- weeks, par-
ticularly of a first pregnancy. It is felt commonly
in the early part of the day or on rising from the
recumbent position. The blood serum should be
examined so as not to mistake this condition for the
much more serious form to be described later. Al-
low the patient to take her breakfast lying down.
Her diet should be light, easily digested liquids pre-
pared in a dainty manner and always in quantity a
little less than the patient wants. No smell of cook-
ing should be allowed near the patient. The bowels
should be kept open, preferably by enemata. one of
the normal salt solution doing well enough. Minute
doses, say 1/24 to 1/40 grain of calomel with ^
grain cocaine hydrochlorate and 5 grains cerium
oxalate every four to six hours will do for drug
medication. The condition usually passes in from
four to six weeks.
Xausea produced by uterine displacements. — These
usually have pain accompanying the nausea. Other
symptoms characteristic of displacement are usually
found. It is obvious that the correction of the
uterine displacement will cure the nausea. The
uterus must be put back in position ; usually this
may be done by tampons until it is large enough to
ascend out of the pelvis. If the organ cannot be re-
placed vaginally, it must be done by abdominal
section.
Hysterical nausea is often a trying complication
of pregnancy. The diagnosis is often difficult, as it
so much resembles pernicious nausea. The diag-
nosis n-iust be made by a careful study of the case,
in conjunction with frequent examinations of the
blood and urine. The blood will not show the
OUIi READERS' DISCUSSIONS. LNew York
Medical Jouknal.
changes found in the toxsemic form, and the excre-
tion of soUds will be fairly good. Also the excre-
tion of free ammonia nitrogen will be comparative-
ly low. Except in hysteria in an albuminuric sub-
ject there should be no albumin and casts in the
urine, and no oedema. The patient should be put to
bed under the care of a rehable trained nurse. She
should be in a quiet room, away from disturbing
elements of life, and as much as possible with the
nurse alone. All displacements of the uterus should
be corrected if present. Her bowels should be kept
open by small doses of calomel, say i grain in di-
vided doses, if she can retain it, or by aperient
waters, if well borne; otherwise a daily enema of
normal salt solution or magnesium sulphate §j, and
glycerin, gj, in a quart of soap suds. Her diet should
be of liquids — milk or chicken broth or small
quanties of champagne. The chief point in the diet
is to give small quantities of food and at frequent,
regular intervals. Mental suggestion is often useful
in quieting the condition.
The most dangerous form is the tox;emic, found in
patients suffering from the toxeemia of pregnancy,
either of renal or enterohepatic form. This type may
occur at any time in pregnancy, but in my own expe-
rience has been seen most frequently from the fourth
to the seventh and a half months. It frequently oc-
curs earlier. There are usually some blood and urine
changes associated with the condition. In the latter
the solid excretion is decreased, the excretion of
urea and urea nitrogen is less than normal, while
the output of free ammonia and certain other sub-
stances is increased. The patient is constantly nau-
seated, breath foul, temperature somewhat raised, as
is also the respiration and pulse. Frequently the
patient does not seem to lose weight.
The vomitus is composed first of the contents of
the stomach, later bile, and in the late stages the
■'cofifee ground"' vomit. The urine is scanty and
frequently passed in small quantities ; in the earlier
stages it is of lower specific gravity, and usually con-
tains albumin and an increased output of free am-
monia or nitrogen in other combination than urea.
In the latter stages the urine may be concentrated.
The treatment consists in putting the patient to
bed in a quiet room. An attempt should be made
(i ) to feed the patient by the mouth with predigested
milk or broth ; this usually fails; (2) to feed the pa-
tient by the bowel after having thoroughly evacu-
ated all faecal matter. Too much time should not
be lost, as these attempts for rectal feeding are too
often only a slow form of starvation. The subcu-
taneous injection of salt solution may do for a short
time. Usually we are forced to empty the uterus
to save the patient's life, and it should be done early,
as too much time is usually lost in trying other
methods of treatment.
Dr. Ilugenc !<.. Corson, of Savannah, Ga., remarks:
The simpler forms of this trouble require little
or no treatment. The condition may be regarded as
a natural one, to be borne like other disagreeable
features of pregnancy; nor does the general health
suffer from it. When more pronounced, treatment
becomes necessary. Still, up to a certain point,
proper hygienic regulations, a selected diet, suitable
exercise, absence of coitus, a proper psychic sur-
rounding, and the simpler drug treatment, control
the majority of the cases. It is here that cerium
oxalate, nux vomica, ipecac, ingluvin, calomel, hap-
hazard doses of bromide, or what not, relieves the
case, and the successful drug has gained a new
votary. Again, there may be certain local condi-
tions, an unhealthy vaginal mucous membrane, ero-
sions of the OS, an endotrachelitis, or a misplaced
uterus, all of which should be looked to on general
principles.
Yet, while we shall probably see an improvement
from the local treatment in the simpler or ordinary
cases, where the disease assumes the more violent
form, my experience is that we must look for help
elsewhere. The worst forms I have seen have been
without any apparent local trouble. As to the value
of cervical dilatation, a practice made popular for
a time by a very capable man, it may be valuable
in some cases of the simpler type, but I believe it is
precarious and uncertain in the violent forms, cases
which require prompt action in a different way.
And rectal feeding, which has been found valuable
in a few cases, will also fail when most needed. The
bromide sleep makes both these methods unneces-
sary.
Let the condition become more pronounced, let it
pass a certain point, and the problem which con-
fronts us is a wholly different one. Now, any old
thing will not do ; the ordinary drugs not only fail,
but they aggravate, for every additional spell of vom-
iting carries the patient further down stream. Thus
a systematic treatment becomes necessary, with a
keen regard to every possible detail — the trained
nurse, everything by clockwork, and the utmost
vigilance.
I have found but one drug upon which I can
rely, sodium or potassium bromide, and since I
have learned hozv to use it, it has become, to my
mind, the one sovereign remedy. In the simpler
cases it can be given by mouth in 20 grain doses in
plain water, at such intervals as the case demands,
and it is a drug which the stomach stands well. In
the severer form, where everything is vomited, it
can be given by rectum in one or two drachm doses
every two, three, or four hours, and it is a drug
well borne by the rectum. In the majority of cases
the vomiting will cease when a pleasant somnolence
has been induced. In the severest cases this will
not be sufficient, and the regTjlar bromide sleep will
become necessarily a gentle sleep withal, for the pa-
tient is easily aroused and will take her nourishment
without trouble every two, three, or four hours, as
the case may be. To put the "vomiting centre"
asleep we must put the patient asleep.
The food I have found best suited for these cases
is ice cold buttermilk or kumyss, or egg albumen
lemonade. Individual peculiarities may require
some other forms of liquid diet.
Patients can thus be kept gently asleep for sev-
eral days, when they can be allowed to come some-
what out of the sleep, and the vomiting watched.
I have had several bad cases cured by a week of
such treatment. Personally, I have never seen it
fail, while I admit, of course, that there may be
cases where everything fails, and an induced mis-
carriage becomes the only remedy. When this
measure has to be considered do not delay too long.
My practice is to introduce a large leaded bougie
January 4. 190S.1 ijL'K KLADLR^i' DI :i L U :> S 1 u X .
well up into the uterus under the strictest asepsis.
Labor comes on usually in twenty-four hours, and it
is wonderful how the patient's condition improves
immediately or soon after the passage of the bougie.
Before I used the bromide treatment I was
obHged to induce a miscarriage in four cases, if my
memory serves me. Recently in a case complicated
by typhoid fever this treatment acted admirably and
labor came on later spontaneously at the seventh
month.
The patient, of course, is kept flat on her back,
and in some cases the head lowered. I also use an
ice bag on the epigastrium, and I may give ^4 grain
calomel triturates at short intervals to help the up-
per bowel, and increase the flow of urine, so fre-
quently greatly diminished in this trouble. Should
the bowels be loose, I use bismuth subnitrate in
drachm doses. If the pulse is very rapid, a common
cc«idition in bad cases, I use aromatic spirits of am-
monia with the bromide. For drinking water I use
Irish soda or ginger ale, but no form of alcohol.
Other forms of intractable vomiting, due evident-
ly to this same reflex pyloric spasm, are relieved, if
not cured, by this wonderful drug.
Dr. B. W. Wilson, of Youngstown, Ohio, states:
There is no affliction that presents so marked a
variance of symptoms as does the vomiting of
pregnancy. Its cause is mainly reflex from the
growth and dilatation of the uterus and cervix, with
possibly some degree of toxaemia and consequent
irritation of the stomach. Its treatment must be
governed accordingly.
The very mild cases of "morning sickness," with
occasional vomiting, may require little more than a
cup of hot water with a little salt or sodium phos-
phate. This should be taken in the morning, twenty
to thirty minutes before rising. The bowels should
be kept loose, and daily regularity at stool should be
enforced. The diet should contain plenty of fruits
and vegetables, with a liberal supply of water. Cas-
cara should be taken with morning and evening
meals, if there is a tendency toward constipation.
A saline enema may be required if the bowels do not
move freely.
When the weather is favorable the patient should
take daily walks in the open air or ride in a com-
fortable carriage. She should avoid the odor from
the kitchen as much as possible.
With some cases such treatment seems to have no
eflfect whatever. These are the ones that draw upon
our resources and test our ability to allay their suf-
fering, and especially to keep their mental and
nervous systems from running riot.
Cerium oxalate and bismuth, which by many are
recommended so highly, I have found insufficient.
They have never proved satisfactory, except in mild
cases, and then when given in combination with
cocaine. My experience has been similar with wine
of ipecac, nux vomica, creosote, aconite, iodine.
Fowler's solution, the bromides, and others, anv
one of which may be sufficient in mild cases. It is
wise to change drugs occasionally to prevent toxic
or other deleterious effects. Of all the former, ce-
rium oxalate, bismuth, and cocaine in small com-
bination doses shortly before meals or before ris-
ing, give the best results. Quince juice, orange
juice, popcorn, light wines, or whiskey (diluted),
taken moderately at intervals, may assist. Washing
out the stomach gives but temporary relief.
I have obtained by far the best results from the
following drugs in combination : Cocaine, resorcine,
atropine, nitroglycerin, and morphine. The cocaine
and resorcine act locally upon the stomach wall. The
atropine tends to cut off all peripheral nerve end-
ings, while the nitroglycerin acts upon the centres.
The dose of each must be regulated according to
the patient. One powder should be given with wa-
ter from fifteen to twenty minutes before meals. If
the patient is very bad I require her to lie quiet
upon the right side for two hours after meals. The
ice bag over the epigastrium, or a blister over the
fourth or fifth dorsal vertebra, may relieve the
symptoms.
. The cervix should be examined for any ulcera-
tion, which, if present and properly treated, may re-
lieve all trouble. Often a pessary, if properly ap-
plied, performs wonders. A tampon containing a
one or two per cent, solution of cocaine placed
against the end of the cervix may do the same, es-
pecially if the cervix has been kneaded between
thumb and finger.
Should these measures fail, and the patient be-
come weak, I put her to bed, give morphine with
atropine hypodermatically in sufficient doses to con-
trol vomiting, requiring her to eat hearty meals. By
paying attention to the bowels many may be car-
ried in this way until the fourth month, when all
symptoms often disappear like magic. If the vom-
iting does not abate the cervix should be dilated,
even at the risk of a miscarriage resulting, which
is not likely if carefully performed. Rectal feeding
may be necessary to keep up the nourishment. If.
however, in spite of every effort, the vomiting still
persists, and the patient is very weak, with pulse
over 120, possibly vomiting blood, and with some
fever, it may be necessary to bring about a miscar-
riage. We should not wait so long as to endanger
the life of the mother. Such cases, however, are
rare. Yet they cross the path of the physician who
has been long in practice, and his first duty as a
medical man is to the mother.
Dr. A. Ernest Gallant, of New York, states:
The time at which vomiting usually appears is the
third to fifth week of pregnancy; the nausea, with
or without vomiting, on changing from the reclining
to the upright posture, relieved by lying down ; the
similarity to the nausea induced by instrumental di-
latation of the cervix without anaesthesia ; its cessa-
tion when the uterus has risen out of the pelvis and
enlarged sufficiently to be supported by the pelvic
brim ; and the frequent failure of drugs to give re-
lief until the uterus does emerge from the pelvic
cavity; each and all confirm the view that the
'morning sickness" of pregnancy is due to the in-
creasing tension exercised on the internal os by the
growtli of the foetal sac, from within the uterus plus
the additional weight brought about by the physio-
logical congestion and increase in size of the uterus
as a whole.
Treatment. — When tenderness to touch is pres-
ent, place the woman in the left lateral (Simm's)
position, and carefully pack the vagina with tarn--
pons of nonabsorbent cotton, dipped in a mixture of
chloral hydrate, one drachm, in glycerin, one ounce.
20
OUR READERS' DISCUSSIONS.
[New York
Medical Journal.
The cessation of the nausea will confirm the diag-
nosis. After a few days the tampons may be dis-
continued and replaced by a hollow, soft rubber
pessary, which may be left //; situ for a month, if
necessary, removed, cleaned, and replaced, or a new
one inserted.
Whenever, in the vomiting of pregnancy, the ex-
ternal OS uteri can be reached by the examining fin-
ger, the uterus should be lifted up and supported by
tampons or pessary until it rises well above tlie su-
perior straight. Should the vomiting continue later
than the fourth month, if we add rest and quiet,
posture, and diet, multiple incisions of the cervix
or deliberate abortion will seldom or never be indi-
cated.
Persistent vomiting of pregnancy is most fre-
quently caused by displaced uterus, tubes, and
ovaries, incarcerated in the pelvis, held by adhe-
sions which prevent the uterus from emerging out
of the pelvis, or weighted down by tumors, which
sometimes cause the uterus to bulge at the vulva, and
can be, in most instances, gradually released by plac-
ing the patient in the knee chest posture and intro-
ducing small tampons or gauze dipped in a mixture
of ichthyol, two drachms, and glycerin, one ounce,
and renewed every second or third day. Sometimes
the uterus can be elevated in one or two sittings ;
occasionally the treatment will require a few weeks
to accomplish its purpose. Under the solvent action
of the ichthyol glycerin the adhesions soften and
stretch, the organ is supported on the tampons, the
tension is relieved, and the vomiting ceases, and
even where miscarriage seemed inevitable a full term
child has frequently -been delivered. Under these
circumstances jiatients must not be permitted to lie
upon the back, but must be instructed to rest upon
the side, or, better still, upon the abdomen, in order
to facilitate the release of the impacted uterus.
Most patients do better if kept quiet and at rest in
bed. Should the nausea, vomiting, and backache
continue after the fundus is above the brim, the
abdomen must be supported by a tightly fitting
binder or corset, put on while in the recumbent pos-
ture {Joiinia! of the American Medical Associatio7i,
xlviii, J). 1357, 1906). In no instance have we found
it necessary to moderately dilate the cervix, as ad-
vised by Copeman.
General Measures. — The diet must be limited to
fluid or semisolid, light and nourishing food, and at
first it may be well to give nothing by mouth but
six ounces of water every hour, until the stomach
regains its normal status ; sedatives in the form of
sitz baths, moderate doses of bromide and chloral,
avoiding opium preparations (unless a miscarriage
is imminent, as they only upset the stomach the day
after) ; counter irritants, mustard, blister, or cups
over the epigastrium ; mild laxatives, castor oil,
licorice powder, at times olive oil or soap suds
enema to insure free evacuation of the bowel twice
daily.
In a limited number of cases, persistent vomiting,
associated with pregnancy, may be due to malaria,
kidney disease, acute or chronic gastritis, gaslri.-
ulcer, chronic appendicitis, typhoid fever, displaced
kidney, anal fissure, gallduct disease, etc., each of
which must be recognized and appropriate treat-
ment applied.
Dr. H. Tucker Lyons, of Brooklyn, N. Y., observes:
In vomiting of pregnancy the resourcefulness of
the physician will be taxed many times. Although
we know that the ietiology may be sought in one
of the three great avenues, viz., the gastrointestinal
tract, pelvic deformities and injuries, and reflex
irritation, still there remain many cases where the
aetiology is in doubt or unknown.
In gastrointestinal catarrh due to a sluggish cir-
culation, together with an impoverished condition of
the blood and a torpid liver, the administration of
fractional doses of calomel, or in a single dose of
three grains, temporarily relieves the overburdened
organs and allows appropriate treatment in time to
become effective. Where there is a deficiency of the
hydrochloric acid, as evidenced by delayed diges-
tion, flatulence, etc., the administration of five to
eight drops of the dilute hydrochloric acid three
times a day, ten minutes after meals, will prove ef-
fective. Here the alkalies before meals, as the bis-
muth salts, magnesium and calcium carbonate, ren-
der valuable aid. If hepatic torpor is pronounced,
sodium phosphate night and morning should be
given, as well as sodium salicylate and the well
known rhubarb and soda mixture.
Should flatulence be a prominent symptom drop
doses of spirits of turpentine three times a day may
be tried, or the preparations of salol and creosote
carbonate. For the anaemia, which is so often a
pronounced symptom, the various preparations of
iron may be given, provided the bowels are active.
Exercise in the open if possible should be insisted
upon, for it is one of our best stimulants to the gen-
eral well being that we possess. I have seen the judi-
cious use of this treatment give most happy results.
A glass of lukewarm water on arising will often
allay the vomiting when medicinal agents fail. Of
course a regulation of the diet must be insisted
upon, otherwise our best efforts may prove fruit-
less. The preparations of codeine, cocaine, and
drop doses of iodine tincture and dilute hydrocyanic
acid should always be withheld to the last. In many
cases of natural pelvic deformities we are actually
helpless so far as the correction of the same is con-
cerned. Here we must decide the momentous ques-
tion. Can the patient be conducted to a safe moth-
erhood ? and if so act accordingly.
In the multiparous woman prolapse of the uterus,
due to cystocele and rectrocele, with its train of
symptoms, may be an setiological factor ; associated
with the foregoing condition we may have a lacer-
ation of the cervix extending up into the broad
ligament, with its "constant pressure and irritation
upon the uterine plexus, retroversions and retro-
flexions being freely coexistent. In the primipara
a cystic ovary may be at the seat of the trouble or
a uterine ])olyp, many of these patients presenting
an endometritis of recent origin. The treatment for
these cases is purely surgical.
Should the vomiting be unrelieved by an\ of
these measures, the life of the patient in danger,
we must deal with a pernicious state, the question
of emptying the uterus presents itself. This j)ro-
cedurc should be undertaken only after consultatio]i
with colleagues for the best interests of all con-
cerned and for self protection.
January 4, 1908.]
THERAPEUTICAL NOTES.
27
Treatment of Intestinal Hasmorrhage in Ty-
phoid Fever. — E. Hirtz and CI. Simon, in La
Clinique (November 29, 1907), advise the follow-
ing procedure in the treatment of intestinal lijemor-
rhage, occurring in typhoid fever : Every two
hours, or seven times during the day', give a tea-
spoonful of the following mixture:
^ Ergotine, 8.0 grammes;
Calcium chloride, 6.0 grammes;
Distilled water, 150.0 grammes.
M.
In the intervening hours administer one table-
spoonful of a mixture made as follows :
B Extract of opium, o.io gramme;
Syrup of orange peel, 60.0 grammes;
Water 140.0 grammes.
M.
Ice bags should be kept constantly applied to the
abdomen.
Nutritive Soup for Infants. — In Lcs Nouveaux
remcdes a formula for a nutritive soup is credited
to Pierre Lesage. The soup is recommended in
gastroenteritis, being well borne and readily taken
by children of all ages. The soup is composed
thus :
Potatoes, 60.0 grammes;
Carrots, 45.0 grammes;
Turnips, 15.0 grammes;
Green peas,
Haricot peas, dried, aa 6.0 grammes.
These ingredients are added 10 one litre of cold
water contained in a covered casserole or other
porcelain vessel. Heat is applied and the mixture
is allowed to boil for four hours. It is then
strained to reject the peas and beans, and the vol-
ume is made up to one litre with boiling water.
About 5 grammes of table salt is added for each
1,000 grammes of liquid. Infants to whom this
soup is administered may do without milk for from
two to eight hours.
The Therapy of Gold— Professor Grasset
{Province medicale) employs the double salt of
gold and sodium (gold and sodium chloride) in the
treatment of chronic rheumatism as follows :
R Gold and sodium chloride o.io gramme;
Distilled water, 300.0 grammes.
Professor Lemoine prescribes gold bromide in
epilepsy, one or two teaspoonfuls of the following
solution being ordered to be taken at night time :
^ Gold bromide, 0.20 gramme;
Distilled water 500.0 grammes.
M.
Gold bromide is also said to be efficacious in the
treatment of cancer of the stomach and cancerous
affections generally.
The Uses of the Glycerophosphates. — An edi-
torial note in The Prescriber directs attention to
the value of the glycerophosphates in gout, dia-
betes, phthisis, etc. It is shown that while they
do not directly combat such maladies, they assist
the vital powers. Combined with formates they
form a useful tonic, the muscle toning properties
of formic acid assisting the general process of
building up. It is probable, remarks the writer,
that the glycerophosphates act as foods to the
nervous system, their good effects being most
marked in nervous exhaustion from overwork. The
salts most in use are sodium, potassium, calcium
magnesium, and iron glycerophosphates, two or
more of these usually being combined in solution
with formates of sodium and potassium. Quinine
glycerophosphate is usually given alone in doses of
3 to 8 grains in cachets.
Powders for Inhalation in Asthma. — Sawyer, in
Folia Therapcntica. gives the following formulas
for asthma powders :
I.
B Potassii nitratis, 15.0 grammes;
Pulveris anisi, 15.0 grammes;
Pulveris stramonii, 30.0 grammes.
M. et fac pulverem.
Sig. : Ignite a thimbleful of the powder, and inhale as
directed.
Alold with the fingers a thimbleful of this powder
into a pyramid, place on a plate, and ignite at the
pointed top. The plate should then be held near
the patient's face and the fumes inhaled.
II.
B Potassii nitratis, 15.0 grammes;
Pulveris stramonii 30.0 grammes;
Pulveris anisi, 8.0 grammes;
Pulveris lobelia;, 4.0 grammes;
Pulveris these sinensis nig. fol., 4.0 grammes;
(Black tea leaves.)
Olei eucalypti, i.o gramme.
M. et fac pulverem.
Sig. : Ignite a small portion for inhalation, as directed.
III.
Potassii nitratis, 15.0 grammes;
Sulphuris sublimati 2.0 grammes;
Pulveris anisi i5-0 grammes;
Pulveris stramonii, 30.0 grammes.
M. et fac pulverem.
Sig. : Ignite a small portion for inhalation, as directed.
When a pharmacy is not handy for the prepara-
tion of this prescription, "a mixture of one part by
weight of saltpeter and two parts of black tea
leaves, powdered and rubbed together, makes a
good inhalant" in emergency cases.
Picric Acid for Plantar Hyperidrosis. — A 5
per cent, solution of picric acid in absolute alcohol
applied with a swab of absorbent cotton on the end
of a rod is effective in removing the pain, smell,
and sweat of plantar hyperidrosis. Chandeze, who
recommends this (Journal de mcdecine, through
The Practitioner), advises if the feet are in ven-
bad condition, the skin, thin, macerated, and bleed-
ing, that the dressing should be done twice on the
first day of treatment, and then once a day for three
or four days.
Enema in Gout Accompanied with Gastric Dis-
orders.— ]^Iillon (Journal de mcdecine) is credited
with the following enema for use in the treatment
of both acute and chronic gout in cases where medi-
cine is not well borne by the stomach:
B Starch water (5 per cent.) loo.o grammes;
Tincture of colchicum seed, i.o gramme;
Wine of opium, 10 drops.
M.
The lukewarm mixture is used twice daily.
2S
EDITORIAL ARTICLES.
[New York
Medical Journal.
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Review of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, AI.
D.
.Adtlrcs.t all business communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Puhlishcrs,
66 West Broadway, New York.
CurcAGO Office :
IGO Washington Street.
Simscini'TioN- I'luci;:
irnder Domestic Postage Katos, ; undor Foreign Postage Rate
$7 ; single copies, fifteen cents.
Remittances sliould be made by New York Exchange or post
office or express money order payable to the A. K. Elliott Pub-
lishing Co., or by registered mail, as the publishers are not
responsible tor money sent by unregistered mail.
Entered .it the Post Office at New York and admitted for
transportation through the mail as second class matter.
NEW YORK, SATURDAY .JANUARY 4, 1908.
THE COMMAND OF HOSPITAL SHIPS.
More than a year ago a joint board of army and
navy medical officers .was convened by executive
order with instructions to prepare a plan for the uni-
fication of the medical services of the two arms to
as great a degree as possible. This board recom-
mended that hospital ships be put under the com-
mand of medical officers, a recommendation that
received the approval of both the Secretary of War
and the Secretary of the Navy. This recommenda-
tion was recently put into force by President Roose-
velt, who, on the recommendation of the surgeon
general of the navy, gave instructions that a sur-
geon be assigned to the command of the hospita!
ship Relief, which was about to go into commission.
Coincidently with the publication of this order, Rear
Admiral Brownson, chief of the Bureau of Naviga-
tion, through which such orders pass, tendered his
resignation, and it is understood that he did this
as a protest against the appointment. The resigna-
tion has been accepted by the President, the ap-
pointment stands, and a statement by Surgeon Gen-
eral Rixey covering the matter has been made pub-
lic, while Admiral Brownson's letter of resignation,
which presumably presented the objections to the
proposed order, has not been made public.
So far as we can ascertain, the objections which
line officers in the service raise to the appointment
is that it places in command of the vessel a man
who in the nature of the case probably has no
knowledge of navigation or seamanship, and who
therefore cannot accept the full responsibility for
the welfare of the ship. This divided responsibility
will, they say, not only be possibly disastrous in case
of emergency, but will, they argue, require a com-
plete revision of the rules of the service, all of
which are based on the assumption that the com-
manding officer afloat is responsible for everything
which occurs on board the ship. For instance,
when through the laxity of a junior engineer of-
ficer the Bennington was blown up, the officer in
command was court martialed. While this is the
most cogent reason which has been advanced by the
line of the navy against the placing of a medical of-
ficer in actual command, the warmth of feehng
which has been developed in the matter and the
acrimony with which the point is argued suggest
the possibility that the officers of the line resent
what they look upon as a gain of prestige on the
part of the staff and a loss of prestige on the part
of the line even more strongly than they condemn
the proposed change from a purely theoretical point
of view.
In the army this matter was definitely settled
during the civil war when the policy was adopted
of placing medical officers in command of hospitals
and hospital ships and assigning a civilian crew and
sailing master to such vessels. No instance has been
cited where this practice proved objectionable.
The very ship now involved, the Relief, formerly
belonged to the army, and was commanded by a
medical officer when used as a hospital ship. In the
war with Russia the naval hospital ships of the Jap-
anese were placed in command of medical officers,
though when the war opened they had been in com-
mand of the officers of the line. It is said that one
of the factors in determining this matter for the
Japanese was a question as to the status of the
hospital ship under the Geneva and . Hague agree-
ments. If such a ship were in command of a line
officer and manned by a regular navy crew, circum-
stances might arise under which the peaceful status
of the vessel might well be questioned. With a
medical officer in actual command, such question
could scarcely arise.
As a matter of fact, a hospital ship is merely a
hospital afloat, and there is every reason why a hos-
pital, whether afloat or ashore, should be under the
immediate and actual command of a medical officer.
None of the arguments which have so far been ad-
vanced in opposition to this plan will, we think,
prove convincing to any person free from prejudice
who gives the matter careful consideration in all its
various phases. While it is to be regretted that this
incident may cause a recrudescence of the ill feel-
ing between the line and the staff, which has been
allayed to a certain extent by the eflfect of the per-
January 4, 1908. 1
EDITORIAL ARTICLES.
29
sonnel bill, the arguments in favor of the change in
policy seem to us to much outweigh those against
it, and we congratulate the President and the Sec-
retary of the Navy upon their firmness in carrying
out a reform against such pronounced opposition on
the part of the line officers.
FALLING OF THE HAIR IX WOMEN'.
An exceedingly sensible article on this important
subject appears in the Gazette de gynecologie for
December ist. It is by Dr. R. Sabouraud, of the
Hopital Saint-Louis. M. Sabouraud says positive-
ly at the outset that the state of a woman's general
health has nothing whatever to do with the loss of
her hair, save for that which often follows an acute
febrile disease ; the falling of the hair is wholly due
to an abnormal local condition characterized by
overproduction of oily matter by the glands of the
scalp, except of course in cases of a specific nature,
which assume forms easily distinguished from the
ordinary loss of hair.
The onset of baldness, as we all know, varies in
the two sexes as a rule. In men the trouble begins
at the crown of the head, though it may be supple-
mented by recession of the hair from the forehead ;
in women it is in the regions of the forehead and
the temples that it is first conspicuous. The loss
of hair usually sets in when the woman is between
eighteen and twenty-two years of age, but it has
long been preceded by indications that it is about
to occur. At first dry pellicles form on the scalp,
and they are somewhat difficult of removal ; after a
time these are succeeded by a yellowish greasy ac-
cumulation on the skin, and then the hair begins to
fall. The loss may for a time be confined to the
summer months, when the production of oily matter
is more abundant than in winter.
The prime remedy for falling of the hair is the
frequent removal of the greasy accumulation by the
vigorous application of soap, and care must be
taken that the soap employed does not contain
enough potash to prove irritating. It is not the
hair in its entire length that needs to be soaped, but
only about five inches from the roots. After dry
friction of the scalp, the hair should be separated
into plaits and the roots of each plait in succession,
and particularly the portion of scalp concerned,
rubbed vigorously with a tooth brush imbued with
soap and water. The solid cake of soap itself
should not be applied, for then there would be left
on the hair little masses of soap which would serve
only to collect dirt. After the soaping, the hair
and scalp should be rinsed with warm water and
dried with a soft towel, with the aid of gentle heat
if necessary. No attempt must be made to correct
the resulting temporary dryness of the hair by
means of oily applications.
The falling of the hair having thus been con-
trolled, the growth of new hair may to a certain
extent be stimulated, but the applications common-
ly employ ed, especially those of cantharides, should
be avoided. There are a few substances which are
reputed to have some efTect in stimulating the
growth of hair. Among them are pilocarpine, qui-
nine, caft'eine, and camphor, to any of which some
perfume which is agreeable to the patient may be
added. The author suggests the following formula,
though he remarks that the proportions of the in-
gredients should be varied to suit individual cases :
R Pilocarpine hydrochloride, gr. iij ;
Water, sufficient to dissolve the pilocarpine;
Spirit of lavender fl. 5v;
Ether, fl. 3v ;
Ammonia water. fl. 3ss;
Alcohol, sufficient to make fl. ^viii.
M.
When a woman finds that a particular prescrip-
tion proves beneficial in her case, the author re-
marks, she is very apt, in the goodness of her heart,
to pass it around among her friends, but disap-
pointment is almost sure to result, because hardly
any two cases in the circle of her acquaintances
are exactly alike, and it would be as futile to order
one prescription for indiscriminate use as to pre-
scribe the same eyeglasses for all persons with
visual errors.
VIVISECTION IX THE STATE OF NEW
YORK.
Promoters of legislation purporting to be in the
interest of the moral and the humane are prone to
show more zeal than discretion and to close their
eyes to certain grave evils likely to result from the
enforcement of the measures which they advocate.
It was in deprecation of this tendency that in our
issue for October 26th, commenting on an expected
attempt to hamper the work of the Rockefeller In-
stitute, we said: "It is well known to our readers
that we have always condemned cruelty in experi-
ments on animals, and we are quite ready to oppose
the needless repetition of experiments undertaken
simply for the purpose of demonstrating anew such
facts as have been abundantly proved. We do not
sanction the subjection of an animal to discomfort,
to say nothing of actual suffering, for mere show
purposes. But we do insistently advocate noninter-
ference with the full liberty of vivisection done in
the interest of real research — always, of course,
with the understanding that the experiments shall
be conducted with the most scrupulous avoidance of
cruelt\-, and by cruelty we mean the infliction of un-
necessary pain or terror." \\"hile we still hold to
20 EDITORIAL
this view, we are willing to admit that a proper re-
gard for the humane feelings of all right minded
persons would naturally lead to the substitution, to
a reasonable extent, of legal regulation for indi-
vidual discretion.
It is quite probable that the radical antivivisection-
ists, unrestrained by really humane considerations,
will press upon the legislature of the State nf New-
York at its present session certain drastic enact-
ments that would tend powerfully to retard the pro-
gress of medicine in the State, but we are glad to bo
able to add that a number of humane persons have
drafted a bill to which we can give our cordial ap-
proval. It is entitled An Act to Prevent Cruelty by
Regulating Experiments on Living Animals. It re-
stricts experiments on living- vertebrate animals to
those authorized by responsible persons — that is,
representatives of institutions, such as colleges and
hospitals, qualified by their character to grant such
authorization, or of the State or city. It confines
the experiments to licensed places. It prescribes
conditions which will tend to reduce the infliction
of pain to the smallest amount made necessary by
the demands of science, but will ncit interfere with
an experiment seriously undertaken for scientific
purposes. It requires reports to be made to the
commissioner of health regarding such experiments
as are performed. In this synopsis of the pro-
visions of the bill we have employed ver\- largely the
words of one of the chief promoters of the bill, a
man whom we believe to be actuated by entirely
worthy motives and wholly free from any desire to
hamper legitimate scientific investigation.
It is known to us that this bill has met with the
endorsement of many representative members of the
medical profession in the State, and we hope that
the legislature will see the wisdom of giving it the
preference over certain mischievous measures that
are almost sure to be brought before it, and we trust
that, in furtherance of this end, our New York
State readers will exert their influence in favor of
the bill upon the legislators representing them.
STUDIES a^NCERNING CHLOROFORM
ANESTHESIA.
On former occasions we have referred in these
columns to the work of Buckmaster and Gardner
in connection with choloroform anaesthesia {New
York Medical Journal, February 2d and September
7th). In the Proceedings of the Royal Society for
November i8th, their papers are continued. One
communication deals with the fate of the absorption
of chloroform by the blood during anje.sthesia, an-
other treats of the functions of the red blood cor
puscles in chloroform anaesthesia, and the third re-
lates to the rate of elimination of chloroform. It
was found that the chloroform contained in the
blood rose in the initial stages of the anjesthesia with
great rapidity to an amount which approached a
maximum. During this period the chloroform ap-
pears to affect the respiratory centres so that breath-
ing becomes slower and often ceases during the first
few minutes of the anaesthesia. If the animal suc-
cessfully passes this stage of the anaesthesia, on con-
tinuing the administration the amount of chloroform
again rises toward the maximum. Then an equi-
librium is maintained between the amount of intake
and output of the chloroform. This equilibrium
may be n-iaintained for a considerable length of time,
but the margin between it and death is very minute,
and the condition is dangerous. The authors insist
that chloroform kills by failure of the respiration,
succeeded by asphyxia. They have never noticed
a death by heart failure.
They find that chloroform is carried from the
lungs to the cerebral centres by the red blood cor-
puscles, and that the percentage of chloroform in the
blood does not suffer any variation corresponding to
dififerences in the volume of the circulating blood.
The rate of elimination of chloroform is at first
comparatively rapid and subsequently slower. This
is quite in accord with the facts known about the
elimination of other substances from the body.
When the blood contains a relatively high percentage
of material to be eliminated the rate of excretion is
naturally more rapid than when there is a smaller
quantity in the circulating fluids. The elimination
of chloroform is, however, a much less rapid process
than its absorption.
SPURIOUS HENBANE.
Dr. A. B. Lyons, in a recent issue of the Ameri-
can Druggist, directs attention to the appearance in
the American market of a variety of hyoscyamus
which contains practically no hyoscine, but does con-
tain 0.8 per cent, of hyoscyamine, or approximately
ten times the total alkaloidal contents of the phar-
macopoeial drug, which is derived from Hyoscyamus
niger. It is important to guard against the sub.>^ti-
tution of this drug for the official one, both on ac-
count of its greater potency and by reason of the
difference in the character of the effects produced.
Since the Pharmacopeia standardizes the prepara-
tions of the drug on the basis of total contents of
alkaloids, the substitution of the spurious henbane
would not probably be discovered save in the dif-
ference in the therapeutic eflfect. Dr. Lyons says
that the new drug is probably tlerived from Hyoscy-
amus miiticns, which is used in the Orient under the
name of bhang, or hasheesh, and is sometimes used
January 4, 1908.]
NEWS ITEMS.
31
in conjunction with cannabis indica, which is also
known by the same names. From its effects it was
formerly known as Hyoscyavius iiiasus, and is still
called "sakin" (drunken) in Egypt.
DAXGER FROM BROMOFORiAI.
It appears that the use of bromoform as a remedy
for whooping cough is not so free from danger as
has been supposed. Lobl ( Wiener klinische Woch-
enschrift, 1907, Xo. 19; Berliner klinische IVoch-
enschrift, October 28th) reports a number of cases
in which severe symptoms of poisoning occurred, al-
though the usual dose was exceeded by only a few
drops. Unfortunately, he says, the poisonous dose
cannot be definitely stated, for individual suscepti-
bility is very variable.
|[cl\)s Items.
The Geneva, N. Y., Medical Society held its annual
meeting on January 2d, and elected officers for the ensuing
year.
Association of Military Surgeons. — The seventeenth
annual meeting of this association will be held in Atlanta,
Ga., on October 7 to 9, 1908.
A State Sanatorium for the Treatment of Tubercu-
losis is to be established in North Carolina. The State
has made an appropriation of $35,000, and the work will be
started at once.
The Manhattan Clinical Society held a meeting on
Friday, December 27th. The paper of the evening was
read by Dr. Thomas F. Reilly on Some Observations on
Grecco's Sign in Pleurisy with Effusion.
A Research Laboratory has recently been established
m Tananarive, Madagascar. In addition to scientific re-
search work, the laboratory will be used for the analysis
of foodstuff's and for other practical purposes.
Charitable Bequests. — By the will of Mrs. Louisa M.
Bodine, the Kentucky Antituberculosis Association will re-
ceive $20,000, and the Children's Free Hospital and the
Children's Infirmary, Louisville, will each receive $1,000.
The Queens-Nassau Medical Society. — The semi-
annual meeting of this society, which was to have been
held on Saturday evening, December 14th, has been post-
poned till Saturday. January iith, when the same pro-
gramme will be presented.
The Internes of the Mount Sinai Hospital of Phila-
delphia have formed the Alumni Association of the
Hospital. Dr. George Rosenbaugh is the president. Dr.
D. M. Toll is the vice president, and Dr. M. B. Cooperman
is the secretary and treasurer.
Buffalo Medical Union. — At the regular meeting of
the union, held on December i8th, officers for the ensuing
year were elected as follows : President, Dr. Vertner
Kenerson; vice president. Dr. Edward J. Meyer; secretary
and treasurer. Dr. F. B. Rasbach.
Infectious Diseases m Chicago. — During the week
ending December 20. 1907. 127 cases of diphtheria. 97 of
scarlet fever, 55 of measles, 33 of cliickenpo.x, 10 of typhoid
fever, 6 of whooping cough, and 24 of tuberculosis were
reported to the Department of Health.
The Boston Society of Examining Physicians emd
Surgeons will hold its next meeting and dinner at the
Hotel Somerset on Wednesday evening, January 8th. The
meeting will be devoted to a discussion of life insurance
examinations, and the principal speaker will be Dr. Augus-
tus S. Knight, of New York.
Prince George County, Md., Medical Association. —
At the regular meeting of this association, held in Hyatts-
ville on December 14th, the following officers were elected :
President, Dr. John Cronmiller, of Laurel; vice president,
Dr. Harry Nalley, of Brentwood; secretary. Dr. H. B. Mc-
Donnell, of College Park; treasurer, Dr. A. O. Etienne,
of Berwyn.
New Counsel for the Medical Society of the County
of New York. — Mr. Champe S. Andrews, who has been
counsel to the society for the past seven years, has ten-
dered his resignation, which has been accepted, to take effect
on Januarv ist. It is understood that he is to be succeeded
by Mr. Emery C. Weller and Mr. Philip C. McCook, who
have been associated with Mr. Andrews.
Vacation Lectures at the University of Berlin. — The
medical lectures during the coming vacation, held by the
Lecturers' Association of the Aledical Faculty of the Ber-
lin University, will begin on March 2d and will close on
March 28, 1908. A catalogue of the lectures will be sent
free of charge by applying to Dr. Melzer, Langenbeck
Haus, 10 and 11 Siegelstrasse, Berlin, Germany.
Georgetown University Hospital. — A department for
the examination and treatment of patients suffering from
tuberculosis has been opened at this hospital, in connec-
tion with the outdoor department. Dr. W. C. Gwynn has
charge of the clinic, which meets every week on RIonday
from II to 12 a. m. A nurse from the Instructive Visiting
Nurse Society visits patients at their homes to aid them
in carrying out the physician's instructions.
The New York Herter Lectures by Professor Star-
ling.— Dr. Ernest H. Starling, professor of physiology
in the University of London, will give the Herter lectures
of the year on the subject. The Fluids of the Body, begin-
ning January 6th. at 4 p. m., and continuing daily at the
same hour throughout the week, at the Carnegie Laboratory
of the University and Bellevue Flospital Medical College,
338 East Twenty-sixth street. All interested are cordially
invited to be present.
The Seaboard Medical Association, which is com-
posed of physicians from the tidewater sections of Vir-
ginia and North Carolina, have elected the following offi-
cers for the year 1908: President, Dr. Armstead K. Tay-
loe, of Washington, N. C. ; first vice presidents. Dr. E. C. S.
Taliaferro, of Norfolk : Dr. B. F. Halsey, of Roper, N. C. ;
Dr. J. G. Woodward, of Norfolk; Dr. J. R. Harker, of
Tyner, N. C. : treasurer. Dr. Israel Brown, of Norfolk ;
secretary. Dr. John R. Bagby. of Newport News.
Obstetrical Society of Philadelphia.— At the regular
meeting of this society, held on Thursday evening, Janu-
ary 2d, Dr. Edward P. Davis showed a patient with an in-
teresting deformity. Dr. C. C. Norris and Dr. Charlotte
B. Mitchell reported a case of primary ovarian pregnancy.
Dr. Barton Cooke Hirst reported a case of abdominal
pregnancy in which the ovum was implanted in the pelvic
peritonasuni. remote from the tubes and ovaries. He also
exhibited a specimen of unusually large hydrosalpinx.
T3T)hoid Fever in Porto Rico. — We learn from press
dispatches that an epidemic of typhoid fever has broken
out in Caguas, Porto Rico. Governor Post personally in-
spected the town and found one hundred and twenty-five
cases. He has given orders to construct a temporary hos-
pital in which to segregate the sick, and to disinfect or burn
all houses where the fever has been found. All American
school teachers have been ordered to leave the infected
district. It is said that the outbreak is due to contaminated
water.
Dr. Robert Reyburn Honored. — At the regular meet-
ing of the Medicochirurgical Society of Washington. D. C,
a silver loving cup was presented to Dr. Reyburn by the
society, in appreciation of his fifty years of active practice.
After routine business had been transacted, a literary and
musical programme was presented. Dr. Reyburn read a
paper entitled The Prevention of Death During. Anaes-
thesia by Chloroform and Ether, and Professor Kelly Miller
delivered an address on the Allegiance of the Alumni to
the Alma Mater.
Gift to Union Hospital, Fall River, Mass. — The
board of trustees of the new Union Hospital has received
a gift of $10,000 from Miss Caroline A. Dring, $5,000 of
which is to be added to the building fund, and $5,000 to be
used in equipping a library. This gift makes it possible
now to secure other contributions which were given con-
ditionally upon the raising of a certain amount for the con-
struction of the hospital, the largest of these conditional
32
NEIVS ITEMS.
LNeu York
Medical Journai,.
contribulions being that of $45,000 by Mrs. Frank S.
Stevens, of Swansea, $10,000 by the late John D. Flint, and
$7,500 by M. C. D. Borden.
Personal. — Professor Simon Newcomb, of Washing-
ton, D. C, and Professor Emil Fischer, of Berlin, have been
elected members of the Gottingen Academy of Sciences.
Dr. Frederick Montizambert, of Ottawa, Canada, and Dr.
E. P. La Chapelle, of Laval University, Montreal, have
been elected Fellows of the Royal Sanitary Institute.
Dr. Carl D. Camp, of Philadelphia, has been appointed
clinical professor of nervous diseases in the University of
Michigan, in the place made vacant by the death of Dr.
William J. Herdman.
An Operation for Appendicitis in Midocean. — Tht
Cunard liner Pannonia, while on her way from the Medi-
terranean to New York, was stopped for an hour in mid-
ocean to permit the surgeons to perform an operation for
appendicitis on a member of the crew. The operation was
performed by Dr. J. Fraser Orr, ship surgeon, who was
assisted by Dr. Torok, of the Hungarian Government. The
sea was running \cry high and the vessel rolled badly, but
the operation was entirely successful, although it took one
hour to complete it.
The General Practitioners' Medical Society, of Co-
lumbus, Ohio, held a meeting on December loth, and
elected the following officers: President, Dr. Ida Wilson;
\ ice president, Dr. S. O. Griffin ; secretary and treasurer.
Dr. A. B. Davenport. After the business meeting a ban-
quet was held, at which addresses were made by Dr. C. F.
Gilliam, Dr. Emma O. Jones, Dr. Fred O. Williams, Dr.
E. A. Hamilton, and Dr. J. W. Clemmer. Dr. Wilson,
the newly elected president, is also vice president of the
Women's Medical Club of Columbus.
Sydenham Hospital, New York. — The following
members of the medical board of this hospital resigned in
a bodv on December 27th : Dr. Edwin Beer, Dr. Herman
J. Boldt, Dr. C. G. Kerley, Dr. L. La Fetra, Dr. S. Oppen-
heimcr, Dr. G. Seeligman, Dr. A. Strouse, and Dr. A.
Wiener. The following adjuncts have also resigned in a
body : Dr. Richard WeiT, Dr. Richard Lewisohn, Dr. Arthur
Stein, Dr. Joseph E. Field. Dr. De Witt _ Stetten, Dr. A.
Richard Stern, and Dr. Ernst Danziger.
Cortland County, N. Y., Medical Society.— The an-
nual meeting of this society was held on December 20th.
Officers for the ensuing year were elected as follows :
President, Dr. H. C. Hendrick, of McGaw ; vice president.
Dr. S. J. Sornbcrger, of Cortland; secretary. Dr. R. P.
Higgins, of Cortland ; treasurer. Dr. C. D. Ver Nooy, of
Cortland. The retiring president, Dr. F. S. Jennings, de-
livered an address on Tendencies in Medicine. Dr. T. H.
Halstead, of Syracuse, read a paper on CEsophagotomy and
Bronchotomy, and Dr. S. J. Sornberger read a paper on
.Some of the Reflex Neuroses.
Scientific Society Meetings in Philadelphia for the
Week Ending January 11, 1908. — Monday, January, 6th,
Philadelphia Academy of Surgery; Biological and Micro-
scopical Section, Academy of Natural Sciences; West
Philadeli)hia Medical Association; Northwestern Medical
Society. Tuesday, January yth, Academy of Natural Sci-
ences; Philadelphia Medical Examiners' Association. Wed-
nesday. January 8th, Philadclpliia County Medical Society.
Thursday, January ()th, Srciinn Mfciiii!.^ Franklin Insti-
tute; Pathological Socicl\ / ;/.;,(\' Juiiiiarv Jntli, West
Branch, Philadelphia Couniy Mc.lic:il .SMCicty.
The Philadelphia Neurological Society.— At the
regular meeting of this society, held on Monday evening,
December 23d, Dr. Alfred Gordon reported a case in which
the parietal lobe of the cerebrum was destroyed and in
which there was a preservation of the stereognostic func-
tion. Dr. W. B. Cadwalader reported a case of segmental
asteriognosis resulting from a lesion in the parietal area.
Dr. Charles K. Mills and Dr. J. W. McConnell exhibited
two cases. Dr. T. H. Wcisenburg reported a case of
ascending posterolateral sclerosis. Dr. D. J. McCarthy re-
ported a case of ascending paralysis. Dr. Liglitner Witmer
reported some cases requiring a better knowledge of
psychology. Dr. Walter S. Cornell read a paper on The
Backward and Mentally Deficient Children in the Public
Schools. Dr. S. D. Ludhim reported a case of degenera-
tion in the peripherv of the spinal cord.
The Mortality of Chicago. — According to the report
of the Department of Health for the week ending Decem-
ber 21, 1907, there were during the week 592 deaths from
all causes, as compared with 618 for the corresponding
week last year. The annual death rate in 1,000 of popula-
tion was 14.65. The principal causes of death w ere : Apo-
plexy, 8; Bright's disease, 37; bronchitis, 22; consumption,
72; cancer, 26; convulsions, 5; diphtheria, 12; heart dis-
eases, 49; influenza, 4; intestinal diseases, acute, 20;
measles, 6; nervous diseases, 15; pneumonia, 92; scarlet
fever, 13; suicide, 10; typhoid fever, 10; violence (other
than suicide), 48; v.'hooping cough, i; all other causes, 142.
National Association for the Study and Prevention
of Tuberculosis. — The fourth annual meeting of this
association will be held in Chicago on June 5 and 6, 1908.
The organization of the sections has been arranged as fol-
lows : Sociological Section : Mr. Ernest P. Bicknell, of
Chicago, chairman; Mr. Alexander M. Wilson, of Chicago,
secretary; Clinical and Climatological Section: Dr. Henrj'
.Sewall, of Denver, chairman, and Dr. H. W. Hoagland, of
Colorado Springs, secretary ; Pathological and Bacteriologi-
cal Section : Dr. L. Hektoen, of Chicago, chairman ; Surgi-
cal Section: Dr. A. E. Halstead, of Chicago, secretary;
Section in Tuberculosis in Children : Dr. William F.
Cheney, of San Francisco, chairman.
Training in Medical Organization. — The students of
the University of Pennsylvania Medical School have
formed an organization, the purpose of which is to ac-
quaint the undergraduates with the workings of the Ameri-
can Medical Association, after which it is very closely
modeled. The various student societies take the place of
the State organizations and elect members to a house of
delegates which transacts all the business of the associa-
tion. An annual meeting is held, at which papers are read
by chosen members, thus encouraging original research
and a scientific spirit. The organization is named The Un-
dergraduate Medical Association of the University of
Pennsylvania and already has over two hundred and fifty
members.
Infectious Diseases in New York:
ll'c are indebted to the Bureau of Records of the Health
Dcp(irliih-nl jor ilie follozviiig statement of neiv cases and
deaths lehnrted for the tivo zveeks ending December 28,
1907:
^December 21.-., ^Decembvir 28.-^
Cases. Deaths. Cases. Deaths.
Typhoid Fever 35 13 42 18
Smallpox 3 . . 2
Varicella igS . . 123
Measles 517 30 346 26
Seal li t f< \ ' 417 22 426 22
Wh.i . — iQ 2 3 2
"il'l 33S 37 347 30
'I'll' 354 174 308 191
Ccr.N: .1 ^ 7 : 6 6
Totals T.8S8 285 1,603 295
Quarantine Work of the Public Health and Marine
Hospital Service. — The Public Health and Marine Hos-
pital Scr\ ice last year inspected 4,635 vessels, of which 478
were (lisinfected at the forty-three national quarantine sta-
tions in continental United States. Inspection has been
maintained on both the Canadian and the Mexican borders.
.\ train inspection service was maintained during the year
to prevent the introduction of smallpox into the State of
Maine from New P)runswick and Nova Scotia, where it
prevailed in epidemic form. National quarantine has also
been !n:iintained at eight ports in Porto Rico, seven in
Hawaii. .iiiH se\-en in .the Philippines. During the fiscal
year i,jS5 ^4i) immigrants' were inspected under the pro-
visions nf ilic immigration laws and regulations.
The Health of Pittsburgh. — During the week ending
December 14, 1907, the following cases of transmissible
diseases were reported to the Bureau of Health of Pitts-
burgh : Chickenpox, 16 cases, o deaths ; typhoid fever,
112 cases, 17 deaths: scarlet fever, 20 cases, i death;
diphtheria, 12 cases, i death: measles. 68 cases, 4 deaths;
whooping cough. 8 cases, i death ; pulmonary tuberculosis,
20 cases, 10 deaths. The total deaths for the week num-
bered 155 in an estimated population of 403,330, corre-
sponding to an annual death rate of 19.98 per 1,000 popula-
tion. During October there were 567 deaths from all
causes in Pittsburgh, corresponding to an annual death
rate of 15.24 per 1,000 population for the month.
January .j, lyoS.J
XEirS ITEMS.
33
Popular Medical Lectures at Harvard. — A course ot
free public lectures has been arranged by the Faculty of
Medicine of Harvard University, which will be held in the
new buildings of the medical school, Longwood avenue,
Boston, on Saturda} > at 8 p. m. and Sundays at 4 p. m.
beginning January 4ih and ending April 26th. No tickets
are requn-ed. The lecture on January 4th will be delivered
by Dr. Walter B. Cannon on Recent Discoveries in the
Physiology of Digestion; on January 5th, Dr. Edward H.
Bradford will deliver a lecture on the Human Gait ; the
January nth lecture will be delivered by Dr. Elliott P.
Joslin on the I\lodern Crusade against Typhoid Fever, and
the lecture on January 12th will be on Common Salt, by
Dr. Lawrence J. Henderson.
Southern Surgical and Gynaecological Association.—
The twentieth annual meeting of this association was held
in New Orleans on December 17th to 19th, and it is said
that the meeting was one of the largest and most success-
ful i!i tlie history of the organization. The following offi-
cers were elected : President, Dr. F. \V. Parham, of New
Orleans; Tirst vice president. Dr. Willis F. \\'estmoreland,
of Atlanta ; second vice president. Dr. Henr\- D. Fry, of
Washington, D. C. ; secretary (reelected), Dr. \\'illiam D.
Haggard, of Nashville; treasurer. Dr. Stuart AIcGuire, of
Richmond ; council. Dr. George Ben Johnson, of Richmond ;
Dr. Richard Douglas, of Nashville; Dr. Howard A. Kelly,
of Baltimore ; Dr. Lewis A. McMurtry, of Louisville, and
Dr. George H. Noble, of Atlanta. The next meeting will
be held in St. Louis.
The Fifth Pan American Medical Congress will be
held in Guatemala, Central America, the second week in
August, 1908. Guatemala is situated on an elevated plateau
which is comparatively cool, and the weather will prob-
ably not be uncomfortable. The trip from New Orleans
or from New "^'ork bv steamer to Porto Barrios i^ an
agreeable one. The arrangements for the trip will be m
the hands of the chairman of the committee on transporta-
tion. There will be no charges for transport.itinn wiihin
the Republic of Guatemala. The Government and the peo-
ple of Guatemala are taking an active interest in the meet-
ing, and are doing everything in their power to make it a
great success. Further information regarding the cmgress
can be obtained from Dr. Ramon Guiteras, 75 West l-'ifty-
fifth street, New York, who is the secretary of the Inter-
national E.xecutive Commitee.
The Health of Philadelphia.— During the week end-
ing December 14, 1907, the following cases of transmi-^ible
diseases were reported to the Bureau of Health of Phila-
delphia: Typhoid fever. 76 cases, 8 deaths; scarlet fe\-er,
50 cases, 5 deaths; chickenpox, 7.;? cases, o deaths; diph-
theria, 93 cases, 14 deaths; cerebrospinal meningitis,
cases, I death ; measles, 34 cases, i death ; whooping cough.
15 cases, ,s deaths ; pulmonary tuberculosis, 87 cases, 53
deaths; pneumonia, 84 cases, 66 deaths; erysipelas, 6 cases,
2 deaths; septicaemia, 2 cases, o deaths; mumps. 11 cases,
o deaths; German measles, 2 cases, o deaths; cancer, 24
cases, 28 deaths. The following deaths from other trans-
missible diseases were reported ; Tuberculosis, other than
tuberculosis of the lungs, 13 ; puerperal fever, 2 ; dysentery,
i; diarrlirea and enteritis, under two years of age, li.
The total deaths numbered 568 in an estimated population
of 1,500,595, corresponding to an annual death rate of ig.6i
in 1,000 population. The total infant mortality was 112;
under one year of age, 99; between one and two years,
13. There were 37 still births— 19 males, and 18 females.
The total precipitation was 2.17 inches.
Philadelphia Bureau of Health Statistics. — During
the month of October, in the Division of Medical In-
spection 3,792 inspections were made, exclusive of schools ;
632 funiipations were ordered; 48 cases were referred for
special diagnosis ; 6.918 visits were made to schools, and
821 children were excluded ; 420 cultures were taken : 201
injections of antitnxine were given, and 1,308 persons were
vaccinated. In the Division of Vital Statistics 2,126 deaths,
3,086 births, and 960 marriages were recorded. In the
Division oi Milk Inspection 9,028 inspections were made
of 106,101 quarts of milk, of which 775 quarts were con-
demned. Eleven specimens were examined chemically, and
1,088 were examined microscopically. In the Division of
Me?.t and Cattle Inspection 4,367 inspections were made,
of which 240 were found unsanitary ; 147 pieces of dressed
meat were condemned ; 139 postmortem examinations were
made, with 37 condemnations. In the Division of Disin-
fection I fumigation w as done for smallpox ; 139 for scar-
let fever; 326 for diphtheria; 89 for tjphoid fever; 172 for
tuberculosis ; 142 for miscellaneous diseases, and 34 schools
were fumigated. In the Bacteriological Laboratory 1,104
cultures were examined for the presence of bacillus diph-
theria ; 363 specimens of blood were examined for the
serum diagnosis of typhoid fever ; 1,083 specimens of milk
were examined ; 149 specimens of sputum were examined ;
7 disinfection tests were made, and 3,983,600 units of anti-
toxine were distributed. In the Chemical Laboratory 147
analyses were made.
Society Meetings for the Coming Week:
Monday, January 6th. — German Medical Society of the
City of New York; Utica, N. Y.. Medical Library As-
sociation; Niagara Falls, N. Y.. Academy of Medicine;
Practitioners' Club, Newark, N. J. ; Hartford, Conn.,
Medical Society.
Tuesday, January 7th. — New York Academy of Medicine
(Section in Dermatology) ; New- York Neurological
Society (annual) ; Buffalo Academy of Medicine (Sec-
tion in Surgery) ; Ogdensburgh, N. Y., Medical As-
sociation ; Syracuse, N. Y., Academy of Medicine ;
Hudson County, N. J., Medical Association (Jersey
City) ; Medical Association of Troy and Vicinity (an-
nual) ; Hornellsville, N. Y., Medical and Surgical As-
sociation ; Long Island, N. Y., Medical Society ; Bridge-
port, Conn., Medical Association.
Wednesday', January 8th. — New York Pathological Society
(annual); New York Surgical Society; Medical So-
ciety of the Borough of the Bronx. New York; Alumni
Association of the City (Charity) Hospital, New-
York ; Brooklyn Medical and Pharmaceutical Associa-
tion (annual) ; Richmond County, N. Y., Medical So-
ciety (annual),
Thursday, January gth. — New- York Academy of Medicine
(Section in P.-ediatrics) ; Brooklyn Pathological So-
ciety; Blackwell Medical Society of Rochester, N. Y.
(annual) ; Jenkins ^Medical Association, Yonkers, N. Y.
Friday, January lotli. — New York Academy of Medicine
(Section in Otology) ; New York Academy of Medi-
cine (Section in Surgery) ; New York Society of
Dermatolog}- and Genitourinary Surgery; Eastern
Medical Society of the City of New York; Saratoga
Springs, N. Y., Medical Societ}-.
Saturday, January iith. — Therapeutic Club, New York.
The New York Acad^^my of Medicine. — A stated
meeting of the academy, under the auspices of the Section
in Paediatrics, was held on Thursday evening, January 2d.
The following papers on Tuberculosis in Infants and Chil-
dren were read : The Pathological Findings, by Dr. John Mc-
Crae, of Montreal; Recent Diagnostic Methods, by Dr. W.
H. Park, of New Y'ork ; Laboratory Aids to Diagnosis,
by Dr, T, Homer Coffin, of New York; Channels of Com-
niunicatioii. Their Relative Significance, by Dr. S. McC.
Hamill, of Philadelphia ; Management and Treatment, by
Dr. Lovett Morse, of Boston.
The Section in Dermatology will meet on Thursday even-
ing, January 7th. After the presentation of cases, an execu-
tive session will be held.
The Section in Otology will meet on Friday evening,
January loth. The paper of the evening will be read by
Dr. B. Alexander Randall, of Philadelphia, on Do Certain
Ear Diseases Tend to Lateralize to the Right or Left Side?
An executive session will be held.
The Section in Surgery will meet on Friday evening,
January loth. Dr. John F Erdmann will present a patient
with a four ounce brain tumor, Dr. A. Ernest Gallant will
present a case of ureteral drainage through the vagina, and
Dr. A. A. Berg will present six kidney cases showing some
unusual features. A paper, entitled Some Observations
upon the Surgery of the Kidney and Ureter from an
Analysis of 136 Operative Cases, will be read by Dr. George
E. Brewer. Dr. Fielding L, Taylor will report a case of
abscess of the frontal lobe, and Dr. Joseph Wiener will
report three cases of unilateral hasmorrhagic nephritis.
The Section in Public Health will meet on Tuesday even-
ing, January 14th, and the following papers will be pre-
sented : The Care of the Poor, Convalescent from Surgi-
cal Diseases, by Dr. William M. Polk ; The After Care of
the Insane Poor, by Dr. Frederic Peterson ; The Care of
the Convalescent Poor, by Professor Morris Loeb ; Tlie
Need of Care for the Convalescent from the Hospital
Standpoint, by Dr. Samuel T. Armstron.g; The Care of the
Convalescent Poor in Their Homes, by Dr. Lee K. Frankel.
34
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
|itl) of Current |iitcraturt.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
December 26, 1907.
1. The Attitude of the Medical Profession toward the
Psychotherapeiitical Movement, B3' E. W. Taylor.
2. The Use of X Ray Examinations in Pulmonary Tu-
berculosis, By Francis H. Williams.
^ The Results of the Chemical Investigation of Tumors,
By S. P. Beebe.
4. The "Optometrist." A Warning Word,
By John C. Bossidy.
5. Strain as a Causative Factor in Infectious Arthritis,
By John D. Adams.
I. The Attitude of the Medical Profession
Toward the Psychotherapeutical Movement. —
Taylor reviews the past and future of this treatment,
and remarks that the comprehensive knowledge of
the movement, as it exists in the medical profession
would best be disseminated by taking the laity into
the confidence of the profession throtigh poptilar
lectures and the press. He concltides that in our
enthusiasm for the development of a highly signifi-
cant therapeutic advance we shotild not allow the
traditions of the profession to which we belong to
be submerged. Our enthusiasm should not lead to
the antagonism of any reasonable member of the
profession. In our efforts toward what we regard
as progress we should proceed with great delibera-
tion and by recognized logical methods. To this
end we should quote cases and exploit methods
which have stood the test of experience. We should
hesitate in appearing before the public with a de-
tailed expression of our views and theories until we
have secured the acquiescence of the conservative
members of our own -profession. We shoald not
ally ourselves with movements over which we have
no immediate control; we can ill afford m'sinterpre-
tation, especially at the hands of our brother physi-
cians. Our essential aim shotild be to develop a per-
manent interest in the psychotherapeutical movement
within the ranks of the profession, and to do noth-
ing which can in any way retard this effort. To this
end we should urge reasonable but adequate recog-
nition of the assertions of psychotherapy as a le-
gitimate and necessary element in medical education.
Finally, our one object as members of a liberal pro-
fession should be to insist upon the importance of
psychotherapeutical methods with an enthusiasm
which should only be increased by the legitimate
limitations set upon its action.
5. Strain as a Causative Factor in Infectious
Arthritis. — Adams reports several such cases, an
analysis of which shows many common factors,
namely, vocation, seat of disease, sequence of joints
attacked, symptoms, and relief by treatment. In
considering vocation as a factor one must not only
analyze the character of the work but also the con-
ditions under which it is done. Careful investiga-
tion showed that all these patients were tailors work-
ing in dry, well ventilated rooms, not exposed to
drafts and in an even temperature. Their work, ten
hours a day, was chiefly on heavy goods, mostly
men's clothes. The symptoms were first noted in
the thimble finger, and the histories showed a prog-
ressive infection of the joints in the riglit hand
before any symptoms occurred in the left. The on-
.set was more or less insidious and symptoms not
especially acute, but in all the cases, intensified
greatly with use. The pain, intermittent in charac-
ter, was more in the nature of a soreness rather than
the throbbing pain of an infection. The symptoms
were not affected to any extent by sudden changes
of temperature. In all the cases there was abso-
lutely no indication of any trouble in any other joint
in the body. In other words, the trouble was abso-
lutely confined to the hands. The problem con-
fronting one in these cases is a serious one, as we
have a patient otherwise perfectly well but incapa-
citated for making her daily bread. Such a condi-
tion of affairs brings about the most pronounced
type of mental depression. The following line of
treatment was pursued in all the cases : Urinarv
examination shovv'ed a marked hyperacidity in all
the cases. General treatment, omitting all meats,
forcing liquids ; sodium benzoate, gr. v, t. i, d., to
neutralize acidity. Local treatment, baking daily.
This was done entirely by electricity. In the more
acute cases a very intense heat was used, namely,
a ICQ candle power light, applied for a period of
twenty minutes, close enough to be tolerated by pa-
tient over bare skin. In other cases, a small wooden
box, one foot square, was made with two small aper-
tures, large enough to insert hands, in one end.. The
box was lined with asbestos to prevent radiation,
and fitted up with six 16 candle power incandescent
lights. A temperature of 300 degrees F. was main-
tained here for a period of twenty minutes. The
results were most gratifying. The counter irrita-
tion of the heat produced the usual hyperaemia to a
marked degree, and all the cases showed a gradual
dimintition of pain, with a return on failure in s\ s-
tematic baking. The patients pursuing the treat-
ment conscientiously for two months had entire re-
lief from pain, with aSility to return to work.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
December 2B, 1907.
1. Brain Tumor with Jacksonian Spasm and Unilateral
Paralysis of the Vocal Cord and Late Hemiparesis
and Astereognosis,
By John L. Atlee and Charles K, Mills.
2. Tubal Twin Pregnancy, By Charles G. Child.
3. Diverticulum of the Vermiform Appendix,
By Isabella C. Herb.
4. Pathophysiolocjy and Therapeutics,
By George F. Butler
5. Clinical Observations in the Acute Infectious Diseases,
By Louis Fischer.
6. Phlegmonous Gastritis. A Report of Two Cases,
By H. E. Robertson.
7. Ossiculectomy in Chronic Middle Ear Suppuration,
By Frederick L. Jack.
8. The Paravertebral Triangle of Dullness in Subphreriic
Abscess (Grocca's Sign), By K. Heberden Beall
2. Tubal Twin Pregnancy. — Child reminds
us that there are recognized two varieties of multi-
ple extrauterine gestation, where the pregnancy is
tubal. In order to distinguish these two varieties
they may be classified as follows: i. Twin tubal
pregnancy, where each tube contains an ovum. 2.
Tubal twin pregnancy, where one tube contains both
ova. Of the first variety, generally considered to be
the rarer of the two, several cases are reported. Of
the second variety he has been able to find but five
reported cases, to which he adds a sixth case. Tlie
abdomen was opened through the median line in-
January 4, 1908.I
PITH OF CURRENT LITERATURE.
cision ; when it. as well as the pelvic cavity, was
found to contain a great quantity of fluid and clot-
ted blood ; the left tube was ruptured in three places,
a segment two inches in diameter lying free in the
blood clot. Twin foetuses lay outside of the tube,
one attached by its umbilical cord, the other free.
The proximal end of the tube was bleeding pro-
fusely, the distal end was densely adherent to the
ovary, but showed no active bleeding. The tube
and ovary were ligated and removed. The right
tube was intact and adherent to the ovary and poste-
rior face of the broad ligament. The peritoneal
cavity was cleared of blood and clots, the wound
closed, and the patient given an infusion of physio-
logical salt. Death followed tw-elve hours later, wnth
gradually rising temperature and pulse.
3. Diverticulum of the Vermiform Appendix.
— Herb describes her case and thinks that the at-
tack of appendicitis eighteen years ago was respon-
sible for the condition found. The fibrous connec-
tive tissue capsule with deposits of lime salts showed
it was not of recent origin. It is possible that the oc-
clusion occurred at that time ; however, the charac-
ter of the tissue forming the saeptum where the ap-
pendix was occluded rather precludes the possi-
bility of its being as old as the connective tissue
capsule of the diverticulum. The glands still re-
taining their functionating power to some extent,
their secretion by pressure produced a diverticulum
through the muscle undermined by the inflammation,
or enlarged a preexisting one. That the author was not
dealing with a dermoid cyst was proved by the ab-
sence of epiblastic structures. The character of the
wall as well as the content — no booklets or scohces
being found — indicated it was not an hydp.tid cvst.
Enteric cysts extend into the bowel lumen and rarely,
if ever, pass through the muscular coats ; they are
formed by the occlusion of the glands of Lieberkiihn
and do not communicate with the intes'inii Irm n.
Mesenteric cysts can be excluded, as the diverticulum
was situated on the free border ; many mesenteric
cysts, however, are intestinal diverticula, with a con-
stricted base. The possibility of the diverticulum be-
ing an implantation cyst is also to be excluded, as the
ovarian cyst was a simple, benign, unilocular cyst-
oma without adhesions and a fluid content changed
to a greenish yellow by haemorrhage occasioned by
the pedicle being twisted. Cystic malignant dis-
ease is excluded for obvious reasons.
5. Clinical Observations in the Acute Infec-
tious Diseases. — Louis Fischer, of New York,
says he is convinced that an extra careful diet and
absolute supervision, w^ith the aid of a trained nurse,
if possible, will do more good than all medication
combined. The walking convalescent with a weak
heart and low digestive power who is permitted
meat and cake or unwholesome food of any sort
usually invites infection, and thus complications
commence. The desquamation of the skin permits
easy chilling of the surface of the body. In like man-
ner the high fever produces a marked subnormal
condition. Pathogenic bacteria remain dormant in
the nose and throat and in the general circulation,
and these require but one of the factors just men-
tioned to begin an active inflammatory process. It
is wiser to keep a child one week longer in bed,
and two if necessary, than the customary four or
six weeks, rather than be accused of carelessness
and perhaps cause a fatal termination by a com-
plication.
6. Phlegmonous Gastritis. — Robertson ob-
serves that phlegmonous gastritis is a rare form of
gastric inflammation characterized by a diffuse or
focal infiltration of the stomach wall by pus and
serum. It is caused by the entrance into the sub-
muscosa of a virulent organism, usually the strep-
tococcus, through some defect in the gastric mucosa,
though cases are reported in which no defect could
be found. It occurs more commonly in day laborers
of the alcoholic type and at or past middle life. The
clinical symptoms are vomiting, thirst, pain and
tenderness in the epigastrium, fever, rapid pulse,
signs of peritonitis, collapse, and death. The dura-
tion is from twenty-four hours to fourteen days, and
the average is from four to six days. The diagnosis
is usually made at autopsy only. The prognosis is
extremely grave and treatment is of little avail.
Post mortem examination frequently shows, besides
the stomach condition, purulent peritonitis, and
other associated lesions. Bacteriological examina-
tion usually yields the streptococcus in pure culture.
7. Ossiculectomy in Chronic Middle Ear Sup-
puration.— Jack thinks that between 9 and 10 per
cent, of neglected cases of chronic middle ear sup-
puration sooner or later developed symptoms de-
manding surgical interference. Thorough medical
treatment is first to be tried in all cases, excepting
patients having symptoms of intracranial or mastoid
involvements. The result of ossiculectomy has
proved satisfactory in many cases. This operation
avoids some of the dangers of the radical operation.
Curettement of the eustachian tube is of great value
in preventing reinfection of the middle ear cavity.
The mortality of ossiculectomy is practically nil.
MEDICAL RECORD.
December 28, igoy.
1. Some Unclassified Dangers in Anaesthesia,
By Joseph D. Bryant.
2. Environment and Personal Hygiene as Causes of Con-
sumption, By Richard Cole Newton.
3. The Bacteria as Incitants of Malignant Endocarditis,
By Augustus Wadsworth.
4. Skiagraphy in Orthopedic Surgery,
By Frederick H. Albee.
5. Hot Springs, Virginia. By Guy Hinsd.\le.
6. Appendicitis Due to the Presence of Oxyuris Vermi-
rulans By M. Clayton Thrush.
3. The Bacteria as Incitants of Malignant
Endocarditis. — Wadsworth states that malignant
endocarditis develops on the injured or diseased
endocarditim as a secondary localization in the bac-
terisemia or pyaemia of infectious disease. It may
be incited by many different species of bacteria, but
usually the pneumococcus, streptococcus, staphylo-
coccus, or gonococcus is present. It may be associ-
ated with any of the infectious diseases of man,
but chiefly with penumonia or some form of sepsis.
As a complication of previous disease malignant en-
docarditis is of so serious a nature and so often out-
lives or dominates the parent infection that separate
consideration of it is justified. The exceptionally
grave tenor of the prognosis is due to the anatomi-
cal situation of the lesion. The experimental studies
of Rosenbach, Wyssokowitch, and Prudden have
demonstrated the importance of previous injury of
I'll l-i 01- lURKEXT LIl lrajure.
[New York
Medical Journm
the endocardium in determining the secondary lo-
calization of the infection in the heart, a fact of
definite practical significance to both surgeon and
physician in the prophylaxis of the disease. This
stud}- has also shown that the lesions of the endo-
cardium once freed of their mycotic nature tend to
Ileal, and thus recovery, when it occurs, differs in no
essential from that of infection in general, a fact
as yet of little practical value owing to the inade-
quacy of present methods of specific treatment in
tacterisemic disease. Apart from accidents of in-
farction or thrombosis, the course, the prognosis,
and the treatment of malignant endocarditis, as of
infection in other parts of the body, depend primar-
ily upon the balance between the two opposing fac-
tors of infection, the body cells and the bacterial
cells. In this complex mechanism of infection the
difl-'erent processes of immunity in the body tissues,
on th.e one hand, and on the other the development
of the !)acteria, their susceptibility, and virulence,
vary in their relation one to the other with difYercnt
bacterial species and under different conditions.
Since the control of these subtle conditions is be-
yond the reach of modern therapy, the manifesta-
tions of the disease, even the elevation of tempera-
ture, are to -be regarded in general as indicative of
the effort of the body tissues to maintain a favor-
able balance. The limitations of rational treatment
are thus apparent, and departure from a rigid, con-
servative, personal, or physiological hygiene is sanc-
tioned only under exceptional conditions arising in
the individual cases.
6. Appendicitis Due to the Presence of Oxy-
uris Vermicularis. — Thrush describes such a
case. He removed the appendix, which had all the
appearance of an acute infection with marked con-
gestion of the bloodvessels, the only peculiar fea-
ture being a bulb like expansion of the tip into ;i
mass about one inch long and about double the cali-
ber of the remainder of the organ. On incising the
appendix it was found that this mass consisted of a
thick mucoid substance, with a constriction separat-
ing it almost completely from the appendiceal canal,
and in this jelly like substance was a large number
of w orms of various sizes of development, and mov-
ing around freely. Some were quite small, others
of full development. Altogether there were about
one hundred of these wuriiis. Microscopical exam-
ination confirmed the 'li.t-m '--iv of the Oxyuris
vermicularis as being thv \arici\- (jf worm observed.
Rectal examination (jf ihc patient showed, as was
expected, an abundance nf these worms present.
They had spread far up into the colon until th;>\
reached the region of the appendix, where some of
the ova became imprisoned and developmental
changes occurred, causing the attack. The patieni
made an uneventful recovery.
BRITISH MEDICAL JOURNAL.
December 14, i<)07.
1. Prognosis in Relation to Treatment of Tuberculosis
of the Genitourinary Organs (Bradshaw Lecture),
By R. J. GoDLEE.
2. A Note on Nephropexy, By B. Poi,laru.
3. Pericolitis Sinistra with Abscess Formation : Recovery,
By R. DoN.\LDSON.
4. The Part Played by Pediculus Corporis in the Trans-
mission of Relapsing Fever, By F. P. Mackie.
5. A Possible Explanation of Late Return Cases in Scar-
let Fcvir, By W. Habgood.
4. Relapsing Fever and Lice. — Alackie inves-
tigated an outbreak of relapsing fever, occurring in
Bombay, and summarizes the results of his observa-
tions as follows: i. An epidemic of relapsing fever
broke out in a mixed settlement of boys and girls
living under similar conditions. 2. A very high per-
centage of the boys fell victims to the disease in the
course of a few weeks. 3. A much smaller percent-
age of girls fell ill and at infrequent intervals, ex-
tending over three months. 4. The most notable
factor in which the boys differed from the girls was
that they were infested with body lice, from which
parasite the girls were almost free. 5. A well
marked percentage of the lice taken from the in-
fected ward contained living and multiplying spi-
rilla. 6. The stomach of the louse was the chief seat
of multiplication, and this was carried on in the
face of active digestion and after the disappearance
of all other cellular elements. Other organs become
secondarily infected. The secretion expressed from
the mouth of infected lice contained numbers of liv-
ing spirilla, and they also existed in greater or less
numbers in the upper alimentary tract. The ovary
was frequently infected, but spirilla were not found
in deposited ova. y . With the increase of the epi-
demic among the girls, body lice became more in
evidence. 8. With the subsidence of the epidemic
amongst the boys the percentage of infected lice fell.
9. An attempt to infect a monkey by means of lice
failed. These facts are sufficient to throw grave sus-
picion on the body louse as a transmitter of relaps-
ing fever. Many epidemiological facts point to
this mode of transmission as being a likely one, and
the life history and habits of body lice show that
these parasites well fulfill the necessary conditions
for spreading the disease. Thus relapsing fever has
always been associated with poverty stricken, over-
crowded, and half starved communities, and it is
just under such conditions that lousiness is at its
worst. Again, in mixed communities the disease at-
tacks the poor and dirty living in sc|ualid tenements,
to the exclusion of those of cleanl}- habits and bet-
ter conditions of life. Relapsing fever is a "per-
sonal" and not a "place" disea.se, and among stricken
communities the infection spreads from person to
person very rapidly after only a few days' exposure,
and mere contiguity without contact is not sufficient
to carry on the infection. It is probable that the
infected secretion of the louse's mouth is the medium
responsible for transiuission during the height of an
epidemic, but whether the ovarian infection plavs
any part in the linking togelln r of epidemics or in
the carrying over of the discasi. during the off
season it is impossible to say, but the failure to find
spirilla in nits is against this theory.
5. Return Cases of Scarlet Fever. — Habgood
states that of recent years it has been recognized
that where return cases of scarlet fever occur thi:
discharged patient will be found to have some pur-
ulent or mucopurulent discharge. While admitting
the impossibility of being sure that all inflammation
has ceased in the upper respiratory tract, he is in-
clined to believe that cases are occasionally sent out
free from any nasal discharge and not infectious,
but do again become infectious by the occurrence of
an ordinary attack of nasal catarrh, which causes
.some remaining scarlet fever germs to renew their
activity.
January 4. 190S.]
PriH. OF CURRENT LITERATURE.
37
LANCET.
December 14, 1907.
1. Prognosis in Relation to Treatment of Tuberculosis
of the Genitourinary Organs (Bradshaw Lecture),
By R. J. GoDLEE.
2. On Some Gastric Conditions in Wasted Infants, with
Special Reference to Hypertrophic Pyloric Stenosis,
By R. Miller and W. H. Willcox.
3. Two Cases of Congenital Deficiency of the Muscles
of the Abdominal Wall Associated with Pathologi-
cal Changes in the Genitourinary Organs,
By G. Hall.
4. A Case of "Caisson Disease," By F. H. Rudge.
5. Three Successful Cases of Operation on the Labyrinth,
By S. R. Scott.
>. Twenty-six Cases in which Both Eyes Were Operated
on for Senile Cataract, By A. C. Ropek.
. Compensatory Collateral Circulation with "Caput
Medusae" in Cirrhosis of the Liver without Ascites,
By V. X. Brahmacharl
6. The Synchronous Movements of the Lower Eyelids
with the Tongue and Lower Jaw Observed in Cer-
tain Diseases : A Sign of Disease in Connection
with the Lower Eyelids. By H. J. Robson.
1. Genitourinary Tuberculosis. — Godlee in the
Bradshaw lecture discusses prognosis in relation to
treatment of tuberculosis of the genitourinary or-
gans. As regards the most frequent form, tuber-
culosis of the testicles, he has come to the following
conclusions: i. That it is usually a chronic disease
and that a majority of those cases which appear to
be acute or subacute have been preceded by a slow
enlargement of the organ which has escaped the
attention of the patient. And this is based upon the
facts that thickenings of the epididymis are often
discovered accidentally, and that in operations on
the acute or _ subacute cases more extensive cheesy
masses are usually met with than it is possible to
suppose could have been formed since the apparent
onset of the disease. Xo doubt the acute process
does occur, but it is exceptional. 2. That it is so
common as to be almost the rule for the second
testicle ultimately to be affected, whether the first
has been removed or not. The writer has given
up removing every tuberculous testicle, however
quiescent, if no sign of the presence of tubercle
could be found elsewhere, because it so often leads
to disappointment, the patient returning with the
other testicle affected. For the same reason he
deprecates extensive operations upon the vas def-
erens and vesicular seminales. He does not hesi-
tate, however, to remove one testicle which is com-
pletely disorganized, both body and epididymis, if
it is causing much pain or inconvenience, and under
such circumstances takes away as much of tlie vas
as can easily be got at. Thorough curetting of the
epididymis often gives excellent results. If after
orchidectomy the other testicle is subsequently af
fected it should not be removed, but the obviously
diseased portions should be cut away or scraped.
The internal secretion of quite a small portion of
the organ is stiflficient to ward oft the unpleasant
results of complete castration. A very considerable
deposit of tubercle may occur in the prostate with-
out causing any symptoius whatever, and the pro-
cess go on to almost complete atrophy of the gland.
Sometimes an abscess forms, causing retention of
urine, and, if it does not burst in the bladder, ne-
cessitating a perineal opening.
2. Gastric Conditions in Wasted Infants. —
^Miller and \\ illcox suggest that in dealing with
wasted infants we take advantage of the modern
methods of analysis of the gastric contents. As a
result of their investigations they find that differ-
ences exist in the gastric secretion in infantile wast-
ing, corresponding to three clinical groups, as fol-
lows: I. Pure marasmus or atrophic dyspepsia. As
a result of prematurity, immaturity, insufficient or
improper feeding, etc., the infant wastes. There
is a furred tongue, with a tendency to diarrhoea
and vomiting, and progressive wasting, with no
signs of any acute local disease. Post mortem no
changes are found other than atrophy. Examina-
tion of the gastric contents shows a diminished
activity of both acid and ferment secreting glands,
no retention of food in the stomach, and no mucin.
2. Hypertrophic pyloric stenosis. Most usually in
a male child vomiting starts in the first few weeks
of life; the vomitus quickly becomes large in
amount, forcible in character, and is accompanied
by rapid wasting. Constipation is usually marked,
the stools being small and marblelike. The tongue
is generally very furred. The physical signs are
definite gastric peristalsis and a palpable pyloric
tumor. The contents of the stomach show, as a
rule, a marked increase in the ferment activity, to-
gether with excessive secretion of mucin. There
is also very obvious retention of food in the stom-
ach. The total acidity varies, but tends to be below
normal. After regular gastric lavage has been
carried out for a short period, the gastric contents
lose their abnormalities. 3. Acid dyspepsia. Here
the symptoms tend to occur in children three
months of age or over. The vomiting is large in
amount and may be rather projectile in character,
and the bowels are constipated. The wasting is
considerable, but less than in pyloric stenosis. The
tongue is clean, and the abdomen is usually full.
No true peristaltic waves are seen, nor is the
pylorus palpable. The gastric contents show an
increase m their total acidity, the ferment activity
being normal, or below normal. There is no mucin
present, but there is obvious retention of food in the
stomach. In atrophic dyspepsia pepsin and acids
should be given. In acid dyspepsia alkaline gas-
tric lavage, together with the administration of
alkalies, such as bicarbonate or citrate of soda, are
indicated. In pyloric stenosis the best diet is one of
a noncoa'gulable nature, such as a whey and cream
mixture. The smallest practicable doses of food
should be .given, so as to avoid setting up a fatal
diarrhoea in the atrophied intestine.
8. The Eyelid and Lower Jaw Phenomenon.
— Robson discusses the following phenomenon,
which is apparently never present in health : Upon
protrusion of the tongue or depression of the lower
jaw, there is a slight eversion of the lower eyelids,
the lids resuming their normal state when the tongue
is retracted or the mouth shut. The writer regards
it as a new sign of disease witli. some distinct sig-
nificance. Among his general conclusions are the
follov.-ing: i. The phenomenon cannot be detected
unless it is specially looked for, because, as a rule,
the tongue and eyes are not inspected at the same
time. 2. Whenever it is present in chronic cases
some severe asthenic condition will always be fotmd
38
PITH Of CURRENT LITERATURE.
INkw York
Medical JouriNai
to exist, or it will be found that the patient has
been a martyr to pain for many years. 3. The
phenomenon for a time almost disappears after the
tongue has been protruded several times and also
after stroking the forehead or touching the lower
eyelid. 4. In all cases observed but one it was
present in both eyes. 5. In three cases the phe-
nomenon disappeared as the patients convalesced
from their various maladies. 6. In two cases it has
gradually disappeared coincidently with a marked
improvement in the general health of the patients.
7. In two acute cases it disappeared when the
urgent symptoms passed off. 8. In most of the
chronic cases the patients are affected with various
cardiac and abdominal diseases. 9. The phenome-
non is never present in health. It comes and goes
with the onset and cure of disease, and is a clear
index or sign of disease.
LA PRESSE MEDICALE.
November 30,
1. The Reaction of Bordet and Gengoii in Respect to the
Streptococcus in Scarlet Fever,
By C. Foi.x and E. Mallei N.
2. Faradization m Syncope from Chloroform,
By Jean M. Villette.
3. Mercurial Pills, By Alexander Renault.
4. Atoxyl and the Sleeping Sickness, By R. Romme.
1. The Reaction of Bordet and Gengou in Re-
spect to the Streptococcus in Scarlet Fever. — •
Foix and Mallein state that without entering into a
discussion as to the streptococcic nature of scarlet
fever they can give the following as established
facts: I. The serum of persons with scarlet fever
contains antibodies to the streptococcus, antibodies
which they have found ten times out of twelve by
means of the reaction of Bordet and Gengou. 2.
They have found this to be the case as early as the
fourth day, and as late as the thirty-eighth day. 3.
The reaction of Bordet fails in regard to the strep-
tococcus in the other streptococcic conditions. 4.
It remains to be established whether this is a spe-
cific reaction to the streptococcus of scarlet fever,
or a reaction common to all or to many species of
streptococci. 5. This reaction may be utilized as
serodiagnostic.
2. Faradization in Syncope from Chloroform.
— Villette reports some of his experiments on dogs
and alleges that the use of faradization in syncope
from chloroform is of advantage in three ways : It
produces a large and complete respiratory effect,
the procedure is of a true physiological nature, and
it furnishes the adjuvant action of sensory stimula-
tion.
December 4 1907.
1. The Treatment of Appendicitis According to Some
Recent Works, By Amedee Baumgartneu.
2. The Changes in the Terminal Phalanges in Cyanosis,
By E. Jourdran.
Clinical Examination of the Outward Form of the
Neck, By P. Desfosses.
4. Treatment of DeliVium Tremens, By Legrain.
I. Appendicitis. — Baumgartner reviews the
questions which have arisen, as indicated by the
title of his paper, and gives these conclusions: i.
Medical treatment may be permitted in the first at-
tack of acute appendicitis, when no dis(|uicting
symptoms are present, or when, after twelve, or at
the most twenty-four hours, there is a manifest im-
provement which continues. 2. When any serious
symptoms appear, or when improvement is not
manifest after twenty-four hours of temporization,
an operation should be performed immediately. 3.
The operation should always consist of the ablation
of the appendix, except in cases in which serious
difficulties present a contraindication. 4. Every
person who has had a clear attack of appendicitis
should have the appendix removed, even though all
morbid symptoms have disappeared.
2. Changes in the Terminal Phalanges in Cya-
nosis.— Jourdran describes with the aid of radio-
graphs the alterations which took place in the
terminal phalanges of a woman, twenty-two years
of age, who suffered from chronic cyanosis due to
valcular lesion of the heart. The changes in the
bony tissue he ascribes to the lessened nutrition de-
pendent on the trouble in the capillary circulation.
LA SEMAINE MEDICALE.
December 4 1907.
1. What We Should Do in the Ordinary Practice of Ob-
stetrics, By R. liE Bovis.
2. The X Rays as an .'Etiological Factor in Cancer.
MUNCHENER MEDIZINISCHE WOCHENSCHRIFT
November 26, 1907.
1. Concerning the Dangers and Treatment of Placenta
I'rxMa, By Zweifel.
2. Concernnig Appendicitis in Children, By Riedel.
,3 Contributions tc the Treatment of Tuberculous Phthisis
of the Apex of the Lung and of Alveolar Emphy-
sema by Operative Mobilization of tiie Thorax
which Is Stenosed and Rigidly Dilated in Its Upper
Aperture, By Freund.
4. Concerning the Surgical Treatment of Certain Cases
of Pulmonary Emphysema, By Stieda.
5. Acute Fatal Poisoning by Benzol Vapor, By Lewix.
6. Concerning the Use of Solutions of Zinc Chloride in,
the Treatment of Endometritis, By Hofmeier.
7. Successful Transplantations of Proliferations of the
Epithelium of the Lenses of Salamanders Pro-
duced by Ether, By Reinke.
8. Recent Advances in the Field of the Chemical Physi-
ology of the Cell Nucleus, By Steudel.
9. Stumpf's Bolus Treatment, Its Applicability in Diar-
rhoea and Meteorism of Varying Origin, By Corner.
10. The Treatment of Epididymitis and of Buboes with
Hyperemia, By Stern.
11. Support of the Perinjeum, By Mathes.
12. Concerning Narcosis with Warmed Chloroform. Con-
cerning Pubiotomy, By Haun.
13. A Sterilization Apparatus for Laboratory Work,
By Prausnitz.
14. Impressions of America, By MiJLLER.
I, Dangers and Treatment of Placenta Prae-
via. — Zweifel thus Summarizes the principal in-
dications for treatment. Every severe hdemorrhage
in the second half of pregnancy which suggests the
thought of placenta praevia should be so treated,
because of the ver}- great danger that a second
haemorrhage may cost the life of the mother.
To do this the woman should be tamponed for
some time, at least a week, unless the birth takes
place in a less time. For a long continued tam-
ponade nothing can take the place of the colpeu-
rynter. All material used for the tamponade must
be aseptic. The best method to induce labor is the
artificial rupture of the amnion, but this can be per-
January 4, 1908. J
PITH OF CURRENT LITERATURE.
39
formed only in cases in which the membrane bulges
forward, and this is rarely the case in placenta
prsevia. As a rule the haemorrhage is checked most
certainly, and with the best maintenance of asepsis
by version performed' as soon as possible, by the
contbined method of Braxton Hicks when the cer-
vix is faultily dilated. Extraction should not fol-
low until the cervix is nearly or quite dilated on
account of the danger of lacerations of the cervix.
At the same time this delay adds to the danger of
the child and should not be persisted in to its detri-
ment. Where a laceration is not to be feared active
procedures should be taken, and as the lacera-
tion takes place only when the head is being
drawn through it is possible while waiting in
this stage of labor to prevent a laceration and
yet to protect the child from suifocation by
holding his fingers so that the child can draw
air into its lungs by respiration, or by introduc-
ing a catheter into its mouth. In central placenta
prsevia one should first try to displace the flap
of the placenta with the two fingers with which he
performs the combined version, because this pro-
cedure is less injurious to the child than boring
through the placenta. When this cannot be done
the placenta can be perforated at any time, and as
hardly a child survives there is no object then
in hastening the delivery. Very often in placenta
prsevia the question is that of miscarriage, and then
no active treatment should be undertaken, because
this offers little hope of the life of the child and is
more dangerous to the mother. The author depre-
cates the performance of either abdominal or vag-
inal Csesarean section in these cases.
2. Appendicitis in Children. — Riedel states
from a study of the cases met with in the clinic at
Jena during the past twenty-one months that the
mortality among children under fifteen years from
appendicitis was 13 per cent., while that among
adults was 2.9 per cent. The reasons he gives in
explanation of this enormously greater mortality
among children are the carelessness of parents and
their dread to submit their loved children to an op-
eration ; the fact that it is more difficult to diag-
nosticate appendicitis in children than in adults;
that from anatomical causes appendicitis is more
dangerous in children than in adults, .and that very
little children are extraordinarily susceptible to in-
fection from the appendix.
3. Treatment of Pulmonary Phthisis and Al-
veolar Emphysema by Operative Mobilization of
the Thorax. — Freund calls attention to the fact
that he was the pioneer in this operation, that he
performed it as long ago as 1858 or 1859, and as-
serts that if performed by competent surgeons it
is not dangerous, and is able to relieve the condi-
tions of tuberculosis of the apex of the lung and of
alveolar emphysema.
4. The Surgical Treatment of Certain Cases
of Pulmonary Emphysema. — Stieda reports a
case of emphysema in which he successfully per-
formed Freund's operation and concludes that the
operation is sure to be of benefit in certain cases of
chronit pulmonary emphysema which are de-
pendent on a primary rigidity of the thorax caused
by degeneration of the costal cartilage.
5. Acute Poisoning with Benzol Vapor. —
Lewin says that a man may be acutely poisoned by
the inhalation of benzol vapor and recover; that
long persistent sequelae may afflict a man after a
slight acute benzol poisoning; that chronic disease
may be induced by repeated poisoning by benzol ;
that men who inhale a large quantity of concen-
trated benzol vapor may die in from a few minutes
to an hour.
6. Zinc Chloride in the Treatment of Endome-
tritis.— Hofmeier reports a case in which death
from peritonitis followed the injection of a solu-
tion of zinc chloride into the uterus.
9. Bolus Treatment of Diarrhoea. — Corner has
obtained favorable results with the administration
of finely pulverized white clay and considers it par-
ticularly indicated in acute gastrointestinal catarrh.
10. Treatment of Epididymitis and of Buboes
with Hypersemia. — Stern speaks very highly of
the results he has obtained by the use of hyperaemia
in these conditions, and states that he has never
seen any bad after ef¥ects. He produced the hyper-
aemia by means of large suction glass.
12. Pubiotomy. — Haun suggests that a pubio-
pelvioplastic operation might be performed on
young women with narrow pelves at the time of
their first labor which would correct their condi-
tion once for all and render unnecessary a repeti-
tion of a pubiotomy with each succeeding preg-
nancy.
13. Sterilization Apparatus for Laboratory
Work. — Prausnitz describes a sterilizer which he
has used for twenty years in laboratory work. The
sterilization is accomplished by means of steam.
THE PRACTITIONER,
December, igoj.
1. Remarks on Appendix Abscess, By W. H. Battle.
2. Movable Kidney,
By C. M. H. Howell and H. W. Wilson.
3. On the Formation of a Fundal or Suspensory Liga-
ment after Hysteropexy, and its Dangers,
By F. E. Taylor.
4. Malignant Disease of the Testis, By R. Howard.
5. Suppuration in the Region of the Pharynx,
By D. C. L. FiTZ WILLIAMS.
6. Some Remarks on Ascites Associated with Hepatic
Cirrhosis, with Notes of a Case Successfully Treated
by the Operation of Omentopexy,
By A. D. Ketchen and A. E. Thomson.
7. An .Analysis of 832 Cases of Scarlet Fever, with Ob-
servations on the Diagnosis and Treatment of the
Disease, By W. N. Barlow.
8. On the Necessity of Caution in Diagnosing Hysteria,
By B. Myers.
I. Remarks on Appendix Abscess. — Battle
says that a waiting policy is not advisable for this
condition, for a favorable termination can seldom
be prognosticated with assurance. Many dangers
may be avoided by the early evacuation of such an
abscess, for ( i ) it may open into the bladder, large
bowel, or rectum; (2) it may extend to the pelvis
and left side af the abdomen, or into the hepatic re-
gion or even into the pleural cavity; (3) it may
rupture into the peritoneal cavity ; (4) it may cause
general toxaemia; (5) it may be complicated by in-
testinal obstruction. Stress is laid upon the im-
portance of rectal examination, especially in cases
in which the symptoms are indefinite and the local
40
PITH OF CURRENT LITERATURE.
[New York
Mkdical Journal.
signs few. It is thought that removal of the ap-
pendix is not indicated as a routine practice. The
opening of the abscess is without danger if done by
a competent person, but the search for the appendix
in the wall of an abscess may cause serious trouble.
The mortality of appendix abscess from all causes
in a consecutive series is placed at lo per cent., but
if treated surgically from the first it should be un-
der 5 per cent.
2. Movable Kidney. — Howell and Wilson find
that in many cases of movable kidney no symptoms
are present. In cases with pain this symptom va-
ries within wide Hmits. The cases may be acute or
chronic, and the former may be traumatic or ac-
quired. In the acute cases the symptoms are re-
ferable to the mechanical obstruction of the renal
vessels or the ureter, or of both at the same time.
Resemblance to renal calculus is suggested by the
paroxysmal character of the pain, by its frequent
recurrence, by being made worse by exertion and
relieved by rest, and by the presence of blood and
albumen in the urine. An x ray examination will
often assist in clearing up the diagnosis. Hydro-
nephrosis is a possible result when there is rotation
of the kidney. If the renal vessels are obstructed
no tumor will be found in the loin, but the urine
will contain blood, casts, and albumin. In the
chronic cases pain which varies in severity is the
most common symptom. Neurasthenia is often as-
sociated with movable kidney. Treatment in the
majority of cases by the pressure of a well fitting
truss will be satisfactory. In only a comparatively
small percentage of cases is nephrorrhaph}- indi-
cated.
4. Malignant Disease of the Testis. — Howard
states that the diseased testis should be removed as
soon as the diagnosis is made, even though there is
evidence of secondary enlargement of lumbar
glands. No case in which the disease is thus ad-
vanced can be cured by operation, but death from
subsequent recurrence in internal organs is thought
preferable to the undisturbed progress of the pri-
mary disease. In only three of the author's re-
corded cases did recurrence take place in the scar
of the wound. Operation is contraindicated if the
lumbar growth is a large one, or if other organs
are already infected. If the cord is infiltrated, re-
moval of the organ will also be futile, as the growth
will fungate through the wound, and the haemor-
rhage at the time of operation may be very difficult
to control.
5. Suppuration in the Region of the Pharynx.
— Mtzwilliams recalls the fact that this subject has
attracted the attention of many eminent w ritrrs.
He analyzes a series of seventy-five cases nbscrvcd
among children, and divides them into the follow-
ing groups: I. Quinsy or suppuration in and around
the tonsil, the pus being always superficial to the
pharyngeal aponeurosis. 2. Retropharyngeal ab-
scess, in which the suppuration starts in the retro-
pharyngeal space. The abscess is outside the
pharyngeal walls, between the buccopharyngeal
aponeurosis and the prevertebral layer of the dec])
cervical fascia. 3. Postadenoid suppuration, which
is between the lymphoid tissue in the mucous mem-
brane and the pharyngeal aponeurosis. 4. Sup-
puration or caseation in the deep cervical glands.
and extending inward to the lateral pharyngeal
wall. 5. Cold abscess due to spinal caries and lying
behind the prevertebral layer of the deep cervical
fascia. Opening of these abscesses by incision from
the inside is desirable in the majority of cases. # A
general anaesthetic, to a moderate extent, should be
employed, except in very young infants and in
cases in which dyspnoea is urgent.
6. Ascites Associated witih Hepatic Cirrhosis.
— Ketchen and Thomson call attention to the fact
that ascites due to hepatic cirrhosis is now better
treated by surgical operation than repeated tap-
pings. It is desirable, however, to first learn the
cause of the ascites in a given case before sub-
mitting it to operation Two classes of cases are
recognized in connection with cirrhosis of the liver.
In the first free fluid in the abdominal cavity shows
itself when there are few symptoms of general svs-
temic poisoning. Such cases are benefited by tap-
ping. In the second class the ascites occurs in the
late stages of the disease, when there is general
systemic disturbance. The fluid in both varieties
in due to peritonitis. In the first variety the peri-
tonitis is not dependent on changes in the liver, but
the same cause which produces the slow inflamma-
tory changes in that organ also produces the peri-
tonitis. Drainage is effective in such cases, and the
disease may remain stationary for years. In the
second variety the peritonitis is toxasmic; the poi-
sons find their way into various organs, and re-
moval of the fluid is in no way beneficial. If the
patient's general condition is good, and the heart
and kidneys in fair condition, an omentopexic will
usually prove beneficial.
frucwMiigs Sflticttcs.
MEDICAL ASSOCIATION OF THE GREATER CITY
OF NEW YORK.
Meeting of December 16, 190/.
The Vice President, Dr. R. E. Van Giesen, in the Chair.
• Memorial of Dr. Seth D. Close. — 'The report of
the committee on the death of Dr. Sail D. Close, of
the borough of the llronx, who died on October 29.
T907, was presented the chairman, Dr. N. V>.
A' an Etten.
Bile Changes in Infective Diseases. — This pa-
per, by Dr. 11, J'..\rj)wii\, ga\-e the results of an in-
vestigation of 225 autopsies made in various New
York hospitals in the years 1903 and 1904. The
study was conducted in Professor Hcrter's labora-
tory, under a grant from the Rockefeller Institute
for Medical Research, and was undertaken primar-
ily for the determination of cholesterin. In no
fewer than seventy-two instances there were found
marked definite changes from the nonnal condi-
tion, and yet during life the symptoms had been so
mild that cholecystitis had "been diagnosticated in
only two of the cases. The various abnormal
changes detected in the constitution of the bile and
the presence of abnormal elements were described.
In a considerable number of instances infectious
bacteria were found, in seven instances leucocytes,
and in two blood. The results obtained indicated
that in the infectious disease the frequency of bili-
January t. 190S.]
PITH OF CURRENT LITER. ITURL.
41
ary involvement and the danger of the formation
of gallstones was not sufficiently recognized.
Blood Reactions of Inflammation. — In this pa-
per the author, Dr. E. E. Smith, spoke first of
the absolute number of leucocytes, stating that it
was an established fact that often during the active
period of inflammation there was an increase in
the absolute number of leucocytes in the circulating
blood. This increase was known to be a reaction
resulting from the production at the site of the
process of positive chemotaxic substances, which
substances might be derived either from the tissue
cells or from infecting bacterial organisms. As an
illustration of such substances originating from the
first source he mentioned the exudative stage of
inflammation in an active appendicitis, where
it was fair to believe that the chemical substances
calling forth the leucocytes were almost wholly
the product of the defending tissue cells. If, how-
ever, the tissue cells had been so lacking in vital-
ity as to be incapable of defense, the bacterial in-
vasion would have predominated and a degree of
injury to the tissue cells resulted, such as would
produce death of tissue, instead of calling forth the
process of defense. The same result might follow
an unusually virulent bacterial invasion, even
though the initial vigor of the tissue cells v.as not
impaired. Under such conditions the calling forth
of an absolute leucocytosis was less marked than
in an active inflammation. Clinically, there was in
an active process a high leucocyte count in propor-
tion to the degree of activity ; in the less active
gangrene the leucocytes w'ere increased to a lesser
degree. In Considering the increased leucocvtosis
it must be borne in mind that generally there was
an accompanying increase of leucocyte formation
by the blood producing organs. The view, thus
put forth, that leucocytosis w^as proportional to the
active production of chemotaxic substances by the
tissue cells, and that it was not produced altogether
or in most instances largely by the bacteria, the
speaker said, explained some supposed failures of
the absolute leucocyte count in diagnosis. It w-as
occasionally noted that pus failed of recognition by
this means. In such cases it would always be
found that the pus was more or less of the stagnant
variety, and the failure of leucocytosis was not
due directly to the walling in of pus, but to the ab-
sence of active defense, which the walled off prod-
uct no longer aroused.
In the leucocytosis of inflammation there was not
only an increase in the absolute number of leu-
cocytes in the blood, but also, usually, a relative in-
crease in the proportion of those of the polymor-
phonuclear variety. The existence of this relative
increase might be regarded as of even greater diag-
nostic import than the absolute leucocytosis, par-
ticularly as its entire absence was much less fre-
quent in cases presenting conditions which w^ould
be expected to call forth a blood reaction. It
seemed to the speaker that the possible explanation
of the relative leucocytosis, without a correspond-
ing absolute increase, was to be found in two fac-
tors: I. A diminished rate of formation of the
chemotaxic substances. 2. A less active leucocyte
formation. Whatever the cause, the relative poly-
morphonuclear increase was a certain indica-
tion that there was a factor operative in
bringing forth the leucocytes which was not
physiological. Moreover, the greater the relative
increase the more urgent was the call of the dis-
eased tissue; while, again, the less response by an
absolute increase the less was the injured tissue
able to declare its needs.
The conclusion of the paper was devoted to a
third change which the blood might undergo in
inflammation, namely, an increase -in the amount
of fibrin formed when the blood was removed from
the body. This character, Dr. Smith said, was so
marked in certain cases, its detection was so simple,
and its indications were so definite, that it was sur-
prising' that it was not more frequently considered.
Fibrin formation was due to the action of fibrin
ferment on the fibrinogen of the blood. The fibrin
ferment in turn was formed from its inactive
precursor, prothrombin or thrombogen, by the ac-
tion of thrombokinase, which was liberated from
the leucocytes. The throwing into the circul-ition
of thrombokinase not only tended to produce fibrin
m increased quantity at the site of the in-
flammatory process, but gave to the systemic blood
in general the property of forming fibrin in in-
creased amount. This fact afforded a most valu-
able diagnostic feature of the blood, being an index
to the extent and degree of the formation of fibrin-
ous exudate in the body. This being the case, we
should expect to find no increase of fibrin in slight
localized inflammation or in suppuration, and a
great fibrin increase in inflammatory processes in
which there was much formation of fibrinous exu-
date. The value of this observation was not only
to determine the character of the process in a
given case, but also to diagnosticate changes occur-
ring at dift'erent stages of the disease.
Bacterial Vaccines and Curative Sera. — The
author of this paper was Dr. C. F. Bolduan, bac-
teriologist of the Research Laboratory of the New
York City Health Department. Having referred to
the generally acknowledged success of diphtheria
antitoxine, he said it was obvious that such toxine
as had already combined with the cells could not
be neutralized by the antitoxine. Hence, in des-
perate cases, seen late, the antitoxine should be
given in a massive dose intravenously, under
aseptic precautions; and in this wax lives might
sometimes be saved which otherwise would have
been sacrificed. As was well know-n, tetanus anti-
toxine had not proved nearly so successful, and
this was mainly due to tw-o causes: i. In tetanus
the diagnosis was not made until the onset of te-
tanic symptoms, where the specific toxine had en-
tered into so firm a combination with the suscep-
tible cells that no amount of antitoxine would pre-
vent the toxic action. 2. The strong affinity which
the toxine had for the vitally important cells of the
central nervous system. There was, however,
a distinct field for tetanus antitoxine, in which its
use was of unquestioned value. This was as a
prophylactic in cases in which tetanus infection
seemed probable, and here its employment should
become more general than was at present the case.
Considerable work had been done with specific
antisera in cholera, typhoid fever, and other dis-
eases. These sera were bactericidal, killing and
42
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
dissolving the bacteria against which they were
specifically directed ; but clinical trials soon showed
that they had little therapeutic value, while labora-
tory experiments subsequently disclosed many dif-
ficulties in their practical application. Such sera
had, however, been used with some success in im-
munizing against infection, especially when em-
ployed in what was known as the combined method.
In the past few years it had become more and more
apparent that the limitations of serum therapy were,
for the present at least, practically insurmountable,
and therefore attention had again been turned to
treatment by active immunization. The scientific
foundation for this was laid by Pasteur, but, be-
lieving that the production of immunity required
the action of the living virus, Pasteur vigorously
combated the idea that immunity could be brought
about by means of dead virus or of lifeless products
of growth of the virues. To Salmon and Smith,
of this country, belonged the credit of first clearly
demonstrating the possibility of immunization with
dead cultures. Active immunization could, then,
be carried out in several dififerent ways: i. By
means of living cultures (usually attenuated) of
the virus. 2. By means of dead cultures of the
virus. 3. By the socalled combined method — by
first administering a dose of the specific immune
serum and subsequently the virus. This method
had been used in typhoid fever, cholera, and plague.
4. By means of the products of autolysis of the
cultures. 5. By means of various combinations of
these methods.
At first, active immunization was applied only to
prophylactic treatment,, and the first attempt to use
this method in curing an infection already in prog-
ress was Koch's tuberculin treatment of tuber-
culosis. Having presented some explanation as to
how active immunization could accomplish any-
thing in the curative treatment of an existing in-
fection. Dr. Bolduan went on to say that this kind
of treatment of infections had been greatly stim-
ulated by the work of Wright, who had reported
favorable results in a large number of infections.
Richardson, in a recent publication on the treat-
ment of typhoid fever, stated that by using certain
bacterial vaccines prepared after the method of
\''aughan he had found that the typhoid process
was apparently made longer, but milder, and that
l\v continuing the treatment into convalescence the
liability to relapse was diminished. In the use of
bacterial vaccines there should constantly be kept
in mind the nature of the bacterium employed and
the kind of immunity desired to be brought about.
Everything depended on the way in which the vac-
cine was prepared. Having given Koch's methorl
of preparing tuberculin, the author said it was prob-
able that the technique recently introduced by Pir-
quet and by C'aimctte would load to the more ex-
tensive employment of tuberculin in the diagnosis
of tuberculosis in the human subject. Pie then de-
scribed Wright's method of preparing a bacterial
vaccine (for example, a staphylococcus, typhoid, or
streptococcus vaccine), and stated that the doses
to be administered varied with different bacteria,
and also according to the indications, opsonic or
clinical. The ordinary dose for the staphylococcus
vaccine was from 200 to 1,000 million organisms;
for the streptococcus, from 50 to 100 million ; and
for typhoid, from 750 to 1,000 n^illion. All the in-
jections were given subcutaneously, and it was
usually advisable to repeat the injections every
three or four days.
With regard to the yalue of the opsonic index,
which he defined as the relative phagocytic power
of the patient's serum compared with the average
of several normal sera, he said that these determin-
ations were very difficult to make and were sub-
ject to a number of unavoidable errors. His own
experiments had shown that the results of duplicate
or more determinations of the same serum, at the
same time and under apparently identical condi-
tions, often yielded widely divergent results, while
frequently also there was a considerable variation
in the opsonic indices of several normal persons.
Finally, the opsonic index and the clinical course of
the disease did not always run parallel. It would
certainly be surprising, therefore, if the opsonic
power were to prove the real measure of the degree
of immunity, and at the present time he believed it
would be inadvisable to control active immunization
with bacterial vaccines solely by measurements of
the opsonic index. Clinical observations must still
occupy a prominent place in determining results.
Poliomyelitis Anterior as an Epidemic Disease.
— Dr. Hexry W. Berg, who read this paper, said
that during the recent epidemic he had seen some
twenty-five cases, most of them in consultation.
The disease was not limited to any class of society,
and was often found in children living under the
best hygienic surroundings. While some of the
cases were of the character classically recognized as
infantile spinal paralysis, or anterior poliomyelitis,
in many the affection presented itself clinically as
a combination of the symptoms characteristic of
anterior poliomyelitis with those of acute bulbar
paralysis, so that it might well be termed a polio-
myclencephalitis. The patients in' whom there
was a febrile temperature of long duration suffered
from a paralysis of lesser extent than those in
which the duration of the fever was short. From
his eperience in this outbreak Dr. Berg had be-
come impressed with the idea that epidemic poli-
omyelitis was a radically different disease from
sporadic poliomyelitis anterior ; dift'ering, indeed,
in aetiology, pathology, clinical history, prognosis,
and treatment, and it seemed to him that if this dis-
tinction could be maintained, much that was con-
fusing and contradictory in recent clinical and
pathological studies of anterior poliomyelitis, as
compared with the older and equally comprehensive
studies, would be explained. The recent pathologi-
cal observations were almost exclusively studies of
patients dying in epidemics of the disease, while the
older classical conceptions were based upon au-
topsy findings in sporadic cases. In sporadic cases
the permanency of the paralysis was a distinctive
feature, while in the epidemic form of the disease
the paralysis not infrequently disappeared within
two months or less. This and other points would
seem to emphasize the importance of the clinical
study of epidemic cases as contradistinguished from
the sporadic ; and particularly in view of the fact
that the recent epidemic in New York and its vi-
cinity was the largest yet recorded of this disease.
January 4, 1908.J
PROCEEDINGS OF SOCIETIES.
43
It was an interesting fact that epidemics of this
disease appeared to occur in the hot months of the
year, and particularly in seasons when the rainfall
was abnormally small. From reports by the United
States Weather Bureau he- had found that in New
York the total precipitation of moisture during
July, 1907, was only 1.18 inch, of which .55 inch
occurred on a single day of the month ; while the
average precipitation for July for thirty-seven
years past was 4.38 inches. During August, 1907,
the total precipitation was 2.48 inches, against an
average for August for thirty-seven years of 4.53
inches. In MacPhail's report of the large epidemic
in Vermont he noted that the season had been ex-
ceptionally dry. The question of the contagious-
ness, or rather the communicability, of the disease
had been studied in some epidemics, particularly
those occurring in Norway and Sweden, and Dr.
Geiersvold, who reported his investigations to the
Swedish government, had expressed his conviction
that the disease was contagious. Horbitz and
Scheel agreed in this view, although they acknowl-
edged that in the city of Christiania a painstaking
investigation failed to demonstrate any connection
between the cases. In his own experience during
the past summer Dr. Berg did not see more than
one case in any one family. Most of his cases were
seen in the family practice of other physicians, and
these patients, like the great majority of those met
with in the city, were in close contact with other
children. That, under these circumstances, no
cases pointing to direct contagion should have
occurred, was strong, if negative, evidence that this
epidemic disease was not contagious. One peculi-
arity of the epidemic form of the disease, distin-
guishing it from the sporadic, was the fact that it
occurred in older children as well as infants, while
even young adults had sometimes been attacked.
Of the nineteen autopsies in recent epidemic cases
in Norway studied by Horbitz and Scheel, eight
were on adults.
The symptomatology of the epidemic type of the
disease was very different in many respects from
that of the acute stage in sporadic cases. Thus,
the fever was of longer duration and was a more
prominent and constant feature. There was hyper-
resthesia of the entire surface of the body, and in
many cases seen on the first, second, or third day
there was some rigidity of the neck and spine. The
patellar reflexes were absent in most of the cases,
and the initial rigidity of the back of the neck
usually soon gove way to flacidity of the muscles
in this situation. In some of the older children
(from three to eight years of age) there was incon-
tinences of faeces and urine ; symptoms not met
Avith in sporadic cases of the disease. Three of Dr.
Berg's patients had acute bulbar paralysis, and died
of symptoms due to the involvement of the hypo-
glossal, glossopljaryngeal, and pneumogastric nu-
clei. Fortunately, there are now at our command
the records of many autopsies in cases of death from
epidemic (so called) poliomyelitis anterior during
the acute stage, with careful macroscopical and mi-
croscopical findings in the spinal cord, brain, and
other organs. Although such autopsies were ex-
tremely rare, we also had at least four carefully
recorded autopsies in sporadic cases of the disease
terminating during the acute stage. Comparing
these cases with some of those of death in the
acute stage of the epidemic disease, it would be
found that, while in the sporadic cases the lesions
were limited to special parts of the spinal cord, in
the epidemic cases there was a general inflamma-
tory process extending throughout the brain and
spinal cord, as well as the pia mater of both the
brain and cord. No microorganism had as yet
been found for the epidemic disease. The cerebro-
spinal fluid obtained by lumbar puncture had al-
ways proved sterile, cultures made from it were
negative, and animals injected with the fluid suf-
fered no pathological change. From his study of
the affection Dr. Berg thought that it should
properly be termed epidemic meningomyeloenceo-
phalitis. In conclusion, he reiterated his convic-
tion that sporadic ijoliomyelitis anterior was entirely
distinct from this. The sporadic disease was not
infectious, while the epidemic disease was in all
probability infectious, but not contagious.
Dr. Harlow Brooks said that, while he desired
to congratulate Dr. Smith on the best presentation
of the subject which he had ever heard, he could
not but disagree with the author in the roseate view
which he had taken of the importance of leucocy-
tosis. After all, this was nothing but a symptom.
In a great many instances we did not observe it
where we had a right to expect it, and often the re-
verse of this was true. The same was true, he had
found, in regard to the polymorphonuclear increase
also. He must differ, too, in regard to the fibrin
reaction. He had tried this again and again, with
very uncertain results. It did not seem to be the
simple matter that Dr. Smith would have us be-
lieve, and no two men could be found to agree
as to the fibrin formation. Sometimes, indeed, it
was present, but, in his opinion, more often it was
not.
Dr. N. B. Potter said that experience seemed to
show that affections in which there was a localized
infection, as in anthrax, were often' decidedly im-
proved by bacterial inoculation, while the general
diseases were not as a rule so favorably affected.
He referred to six cases of streptococcic infection
reported by Myers in which streptococci were re-
covered from the blood, and said that three of the
patients had recovered, while the other three had
died. In two cases of Dr. Bristow's, of Brooklyn,
he had personally employed streptococcus vaccine,
and both patients had recovered. The same was
true of two cases of puerperal infection in the prac-
tice of Dr. Charles Jewett, and he had had similar
results in other instances also.
Dr. B. Sachs, speaking on Dr. Berg's paper,
said that, while the recent epidemic had been dis-
cussed very fully in many societies, he thought it
would have been very desirable if the discussion of
the whole subject could have been postponed until
a year from now. We were now learning about
the disease, and, with the completion of the system-
atic investigation which was in progress, we should
then know a good deal more about it than we did
at present. He could not agree with Dr. Berg that
the epidemic form of the affection necessarily differed
from the sporadic, any more than epidemic cerebro-
spinal meningitis differed from the sporadic. The
44
PROCEEDINGS OF SOCIETIES.
[New York
JIedical Journal-
only distinction was that when anterior pohomye-
htis occurred sporadically we had very little oppor-
tunity of studying the early manifestations of the
disease. This epidemic had shown us that the dis-
ease as now seen was not at all the affection de-
scribed by Charcot. We must accustom ourselves
to the fact that we had to do with a distinctly infec-
tious disease. In one of the cases which he had
seen all the clinical features of a multiple neuritis
were present, and yet he believed that it was en-
tirely identical with other instances of poliomyelitis
This patient had been taken ill in August, and was
still in the hospital. In another case, that of a boy,
there was hemiplegia and also facial paralysis. As
to the relation of a diminished rainfall to epidemics
of anterior poliomyelitis, this would seem to be a
matter of importance if such felationship could be
established. Learning of Dr. Berg's studies in this
direction. Dr. Strauss had obtained through the
government at AA'ashington some meteorological
statistics from Sweden, and from these it would
appear that the rainfall in the seasons when epi-
demics had occurred in that country did not differ
materially from the average. Great care should be
taken to avoid false inferences in such matters.
Dr. W. M. Leezynsky said that sporadic cases
did not correspond to those seen in an epidemic.
Were it not that an epidemic was present, a large
number of the cases met with would not be classed
as anterior poliomyelitis at all. He described two
illustrative cases presenting peculiar types, and con-
cluded by expressing the hope that when the pres-
ent investigation had been completed the name as-
signed to this epidemic disease would be something
else than anterior poliomyelitis.
Dr. N. B. Van Elten stated that in his practice
he had met with three cases in one family, the chil-
dren being taken ill about three days apart.
Dr. Berg said that in his paper he had expressly
contended that the disease of the recent epidemic
was not poliomyelitis. This, he believed, was fully
established by the series of autopsies he had de-
scribed. In the four recent autopsies in sporadic
cases which were given the conditions found were
entirely different from those met with in the epi-
demic cases.
i00k llfftias.
A Textbook of Clinical Anatomy. For Students and Prac-
titioners. By Daniel F.LSENnRATH, A. B., M. D.. Adjunct
Professor of Surgery in the Medical Department of the
University of Illinois, etc. Second Edition, Thoroughly
Revised. Philadelphia and London : W. B. Saunders
Company, 1907. Pp. 535. (Price, $5.)
Professor Eisendrath, in publishing his book, has
filled a much felt want. The students are taught
anatomy together with physiology and pathology
as fundamental subjects of medicine, during the
first two years of their course of education. Topo-
graphical anatomy is the bridge connecting these
studies with the later ones, given in the clinics and
clinical lectures. While anatomy is taught by post
mortem disection we very often see an entirely dif-
ferent picture in vivo on the operation table or the
sick bed. A textbook of clinical anatomy, there-
fore, will be gladly received l)y both students and
practitioners. The present volume is the second
edition, and is divided into chapters according to
the anatomical region of the body, every chapter
being introduced by an explanation of examination
during life. The index is also of great help. The
text is condensed without disadvantage to clear-
ness, and gives a good description of the material.
It is accompanied by well adapted and advanta-
geously selected illustrations, which are clearly and
distinctly executed. But why use the fig leaf?
This device of prudish censorship may be called
for — though we doubt it — in public places and mu-
seums, but it is out of place in books of art and
absolutely absurd, not to say ridiculous, in medical
works. Eisendrath's otherwise good book would
gain immensely if these devices — which, by the
way, are not even strictly carried through — were
to disappear from future editions.
Principles and Practice of Modern Otology. By John F.
Barnhill, M. D., Professor of Otology, Laryngology,
and Rhinology, Indiana University School of Medicine,
etc., and Ernest de Wolfe Wales, B. S., M. D., Asso-
ciate Professor of Otology, Rhinology, and Laryngology,
Indiana University School of Medicine, etc. With 305
Original Illustrations, Many in Colors. Philadelphia
and London : W. B. Saunders Company, 1907. Pp. 575.
(Price, $5.50.)
A volume entitled Modern Otology, dedicated to
all English speaking students and practitioners of
medicine, and having in view, as the authors state,
among other things, the modernization of the sub-
ject and the correction of certain strangely per-
sistent beliefs in regard to aural ailments, attracts
attention and challenges criticism. The authors
have no reason to be dissatisfied the results of
careful perusal by an impartial reviewer. Tliey
have given a well written and particularly well il-
lustrated presentation of the dio gnosis and treat-
ment of diseases of the ear, and, what is more, have
laid more than usual stress on the subject of proph-
ylaxis. Thus, the influence of nasal and naso-
pharyngeal disease, heat and cold, and of constitu-
tional disorders are fully discussed in their prac-
tical bearing on otology. The operative and diag-
nostic technique is clearly described, and the cuts
illustrative of the various procedures are excellent.
The intracranial complications of otitic disease are
discussed in the light of most recent clinical and
pathological studies. The bacteriology of aural
discharges, the surgery of the facial nerve, the re-
lation of otitic suppuration to life insurance, laby-
rinthine syphilis, lumbar puncture, and the causa-
tion of ear diseases, arc titles of chapters or sub-
divisions indicating the wide scope and complete-
ness of the work.
Pharmacology and Thci apentics. By Reynold Webb Wil-
cox, M. A., M. D., LL. D., Professor of Medicine at the
New York Postgraduate Medical School and Hospital,
etc. Seventh Edition, Revised, with Index of Symptoms
and Diseases. Philadelphia: P. Blakiston's Son & Co.,
1907. Pp. ix-88s. (Price, $3.)
In the seventh edition of this book a good deal of
condensation has taken place as compared with the
sixth edition, which apjicarcd two years ago. It
is a welcome reference book, and every physician
will appreciate its value. Materia Medica and
Pharmacy, by the same author, should be taken as
its second vohmie.
January 4. 190!?. I
Of'l-ICIAL NEirS.
45
gtisffUaiu).
The Tub Bath Treatment of Cystitis. — Run-
ner describes his method of treatment as follows :
The temperature of the water should be kept
at about lOo" F., and the time should be about
eight hours a day. The patient sits or lies on strips
of canvas which stretch across the tub and are held
in position by brass clips. These canvas strips are
about tw-enty-two inches w ide and may be folded if
narrower strips become desirable. The strip at the
head of the tub on which rest the pillows is
stretched as tightly as possible to form a back rest
if the patient is sitting, and if she be reclining this
strip is slackened. The strip at the foot may be
separated a few inches from the middle strip on
which the patient sits, in order that she may easily
pass her feet between them to the floor of the tub
and thus gain a rest by change of position. Light
slats across the tub are covered by a blanket and
mackintosh and these in turn by a white sheet or
spread. This covering serves to retain the heat,
makes a "work table" for the patient, and presents
a neat appearance. If a continuous' irrigation is de-
sired a gallon bottle rigged with a siphon rod and
rubber tubing and set on a box on a table near
the tub will serve as the supply tank. If the patient
is not excoriated about the genitalia, and particu-
larly if she has little or no bladder pain, she does
not require the sitz bath and the tub may be used
without the w^ater. The patient sits on the dry can-
vas strips, two of which are so separated under the
buttocks as to allow the irrigation to run through
to the bottom of the tub. In this manner a con-
stant irrigation can be kept flowing with no other
attention than that requisite for the supply bottle
or tank. The force of the stream entering the blad-
der is regulated by the height of the supply tank,
and the patient can modify the stream at any tiine
by changing the calibre of the supply tubing
through the use of an artery clamp applied to the
side of the tube. The inflow naturally has to be
regulated according to the sensitiveness of the
l>ladder, and to suit the freedom of the outflow^
whether this be through a second tube in the ure-
thra or through a suprapubic or vaginal fistula. —
Journal of the American Medical Association.
Physician and Pharmacist Fined for Faulty
Prescribing and Dispensing. — A case is reported
in L'Union pharniaccutiquc where a physician hav-
ing written a prescription for 50 grammes of
glycerin of carbolic acid (glycerine pheniquee)
wdthout specifying any particular strength, and the
pharmacist having delivered a mixture of equal
parts of carbolic acid and glycerin, which w^as ap-
plied as a wash to a newly born infant and caused
its death, the Tribunal of Nivelles condemned the
physician to pay a fine of 300 francs and the phar-
macist in an equal amount. On appeal the Court
of Appeals of Brussels increased the physician's
fine to 600 francs and allowed the fine of 300 francs
imposed on the pharmacist to stand. The court
criticised the physician for writing an indefinite
prescription and the pharmacist for having dis-
pensed a prescription that was incomplete.
Official gelus.
Public Health and Marine Hospital Service
Health Reports :
llie follo:^'i)tg cases of smallpox, yellow fever, cholera,
and plague luive been reported to the Surgeon General,
United States Public Health and Marine Hospital Service,
during the leeek ending December 2j, igoj:
Cases. Deaths.
Smallt'X—l'nited State
Places. Date.
California — Los Angeles Dec. 1-14 24
California — San I rancisco Dec. 1-14 16
Illinois — Chicago I'fc. 3-14 2
Illinois — Springfield Dec. 6-12 14
Indiana — 7 counties Oct. 1-31
Indiana— Elkhart Dec. 8-21 4
Indiana — Lafayette Dec. 10-16 i
Georgia — Augusta Nov. 27-Dec. 3 i
Kansas — Kansas City Dec. 8-14 i
Kansas — Topeka Dec. 11-17 i
Kentucky — Lexington Xcv. 24-30 i
Massachusetts— Everett Dtc. 8-m 2
Massachusetts — Fall River Dtc. 8-14 i
Massachusetts — Walthani Dec. 15-21 i
Michigan — Saginaw Pec. i-]4 9
Minnesota — Winona Dec. 8-14 i
Missouri- — St. Louis Dec. 8-14 1
New York— New York !>c. 8-14 4
Ohio — Dayton Dec. 8-14 5
Pennsylvania — Harrisburg Dec. 17 i
Imported.
Note — Dec. 6, two cases wi-re erroneously reporttd at Alto
South Dakota — Vermillion Oct. i-Dec. ij 30
Tennessee — Nashville ....Dec. 8-14 12
Texas — San Antonio Iiec. 8-14 i
Washington- — Port "Town^eiid Dec. 7 i
From S. S. Alaskan.
Washington — Spokane Dec. 8-14 9
Washington — Tacoma Dec. 8-14 2
Wisconsin — La Crosse Dec. 8-14 2
Sinc:i.r-:r — Foteign.
Africa — Lorenzo Marquez Oct. 1-31
Belgium — Ghent Nov. 17-23
Brazil— Rio de Janeiro Nov. 4-17 25
Canada — Ne w B ru n - ■. i c k — M 1 1 1 -
town Dec. 14 i
Chile — Iquique To Nov. 20. 'till present.
China — Amoy and Kulangsu To Nov. 9
China — Shanghai Nov. 4-17
Native population.
Ecuador — Guayaquil Nov. 24-30
France — Marseilles Nov. 1-30
France — Paris Nov. 24-^,0 2
Great Britain — Bristol Dec. 1-7 i
Great Britain— Liverpool Dec. 1-7 i
India — Bombay Nov. 13-26
India — Calcutta Oct. 22-Nov. 2
India — Madras Nov. 15-22
Italy — General Sept. 30-Dec. 5 30
Japan — Genoa Oct.
Japan — Kobe Nov.
Mexico — Aguas CaJientes Nov.
Mexico — Monterev Dec.
Peru— Lima '. Nov.
Portugal — Lisbon Nov.
Russia — Moscow Nov.
Russia — Riga Nov. 24-30.
Russia — St. Petersburg Nov. 9-30 3
Spain — Valencia Nov. 25-Dec. 1 32 2
Turkey in Asia — Bagdad Oct. 26-Nov. 2 79 19
Venezuela — Caracas Nov. 22-Dec. 800 cases esti-
mated. 83 in hosi ital.
Clulerc. — i'oieig:i.
Hawaii — Honolulu Dec. 19-21 1 i
India — Bombay Nov. 13-28 S
India — Calcutta Nov. 2-16 267
India — Cochin Oct. ^-25 30
India — Madras Nov. Q-22 11
India — Ncgapatam Oct. i-^o 28
Japan — General Aug. 4-Nov. 27.... 3. 049 1,873
Japan — Kobe Nov. 10-16 4 i
From outbieak to
Nov. 16 472 332
Japan — Shinagawa Nov. 23 Present
on 2 torpedo boat destroyers.
Japan — Nagasaki ken Nov. ii-:7.. i i
Japan — Saseho Nov. 20 — Still present.
Japan — Yokohama Nov. 19-25 7
Philippine Islands — Rocaue Nov. 2
Philippine Islands — Calumpit Nov. 2
Philippine Islands — Manila Oct. 27-Nov. 9 17
Russia — General July 3-Nov. 6 .... 1 1 ,472
Turkey in Asia — Sinope Nov. 27-Dec. 5 68
From S. S. Gregory Merck.
Yclh.-.- Fezer.
Brazil — Rio de Taneiro Nov. 4-17 2
Plagi.c—C r.ited States.
California — San Francisco Dec. 18-23 — Bacteriologically e>
amined. 3 cases and i death.
30-Dec.
1-31. . .
10-16. .
24-30.
Present
Present
S.493
46
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
PliSve-Fureig,..
Brazil — Rio de Janeiro Nov. 4-17 iz
China — Amoy aiid Kulangsu To Nov. 9 — Still present.
Egypt — Alexandria. . . .
Egypt — Port Said
Egypt — Provinces —
Assiout
Minieh
India — General
India — Bombay
India— Calcutta
Japan — Nagasaki kt-n —
Taira Mura. ''.oto Isla
Japan — Osaka
Peru— Caleta Ccloso. .
Peru — Lima
Peru — Ferrenhafe. ...
Peru— Paita
Peru— Tacna
Peru— Truiillo
, .To Nov. 13
Estimated.
.Nov. 21-27
... 13
• • • 3
2
. Nov. 26-Dec. . .
, 8
- • ■ 43
I
. Oct. 27-Nov. 9. .
.17,766
13.210
26
.Oct. 28-Nov. 16, ,
46
.To Nov. 9
22
1 1
... 51
47
1
Present to Nov. .
.Nov. 2-16
■ • ■ 3
Public Health and Marine Hospital Service
Reports :
List 0} Changes uf Stations and Duties of Commissioned
and Noncommissioned Officers of the United States Pub-
lic Health and Marine Hospital Service for the seven days
ending December ?8. IQ07:
Bailey, C. W., Acting. Assistant Surgeon. Granted leave
of absence for seven days from November 21, 1907,
on account of sickness.
Clea\-es, F. H., Acting Assistant Surgeon. Granted leave
of absence for five days from September 23, 1907,
. under paragraph 210, Service Regulations.
Earle. B. H., Passed Assistant Surgeon. Granted leave of
absence for ten days from December 24, 1907.
Gahn, H., Pharmacist. Granted leave of absence for eight
days from December 21, 1907.
Lloyd, B. J., Passed Assistant Surgeon. Granted leave
of absence for four days from November 22, 1907.
Nute, a. J., Acting Assistant Surgeon. Granted leave
of absence for ten days from December 21, 1907.
Oakley, J. H., Passed Assistant Surgeon. Reassigned to
duty at Fort Townsend Quarantine Station, Washing-
ton, effective May 28, 1907.
Parker, H. B., Passed Assistant Surgeon. Reassigned to
duty at Ellis Island, New York, effective December 7,
1907.
Rosenau, M. J., Surgeon. Granted leave of absence for
six days from December 26, 1907, under paragraph 189,
Service Regulations.
Ryder, L. W., Pharmacist. Granted leave of absence for
six days from December 21, 1907.
Stearns, H. H., Acting Assistant Surgeon. Granted leave
of absence for nine days from December 7, 1907, on
account of sickness.
Thompson, W. R. P., Acting Assistant Surgeon. Granted
leave of absence for twenty-one days from December
It, 1907.
Willie, C. \V., Passed Assistant Surgeon. Granted leave
of absence for one month and twenty-two days from
December 22, 1907.
Promotions.
Brown, B. W., Passed Assistant Surgeon. Commissioned
as "iiu-geon, to rank as such from November 9, 1907.
Eaci 1 I \i T' l -I tl \ssistant Surgeon. Commissioned as
iich from November 9, 1907.
Fosi! .Surgeon. Cnminissioned as passed
a- : sinm.jii, t.) rank as such from November 28,
1907.
Robertson, H. McG., Assistant Surgeon. Commissioned as
passed assistant surgeon, to rank as such from Novem-
ber 26, 1907.
Rosenau, M. J., Passed A.ssistant Surgeon. Commissioned
as surgeon, to rank as such from November 9, 1907.
Army Intelligence:
Official List of Changes in the Stations and Duties of
Officers serving in the Medical Department of the United
States Army for the week ending December 38. 1907:
Cole, C. LeR., First Lieutenant and A.-^sistant Surgeon.
Now at Lawrence, Kan., en route to Fort Thomas, Ky..
will proceed to Jefferson Barracks, Mo., for temporary
duty at that post, and upon the completion thereof will
proceed to Fort Thomas. Ky., as heretofore ordered.
Davis, W. T., Captain and Assistant Surgeon. Granted
thirty days' leave of absence.
Snyder, C. R., First Lieutenant and Assistant Surgeon.
Granted five days' leave of absence.
Navy Intelligence:
Official List of Changes in the Medical Corps of the
United States Navy for the week ending December 28,
1907:
Brooks,, F. H., Assistant Surgeon. Detached from the
Adams, when placed out of commission, and ordered
to the Montgomery.
DeLancy, C. H., Passed Assistant Surgeon. Orders- of
December i8th revoked ; ordered to continue duty at
the naval recruiting station, Chattanooga, Tenn.
Hoyt, R. E., Passed Assistant Surgeon. Detached from
the Naval Hospital, Canacao, P. L, and ordered to the
Chattanooga.
Thompson, J. C, Surgeon. Detached from the Chatta-
nooga, and ordered to Washington, D. C, and report
to the Secretary of the Navy.
Zai.esky, W. J., Passed Assistant Surgeon. Detached from
the naval recruiting station, Giattanooga, Tenn., and
ordered to the naval recruiting station. New Orleans,
La.
Married.
Auerbach — MiLLir.AN.— In El Paso. Texas, on Thursday,
November 28th, Dr. Leo B. Auerbach and Miss Lillie Pearl
Miilican.
Deckman — Gantz. — In New York, on Wednesday, De-
cember i8th, Dr. A. C. Deckman, of Boston, and Miss Ethel
St. C. Gantz.
Zinke — Kenney. — In Leavenworth, Kansas, on Thurs-
day, December igth. Dr. Stanley G. Zinke, U. S. Army,
and Miss Beulah Few Kenney.
Died.
BiEGLER. — In Rochester. New York, on Sunday, Decem-
ber 22d, Dr. Joseph A Biegler, aged seventy-five years.
BoDiNE. — In Louisville, Kentucky, on Wednesday, Decem-
ber T8th, Mrs. Laura M. Bodine, wife of Dr. J. M. Bodine,
dean of the Medical Department of the University of Louis-
ville, aged seventy years.
BuTTERFiELD. — tu Manlius. New York, on Monday, De-
cember i6th, Dr. Edward F. Butterfield, aged eighty-one
years.
Covert. — In Itb.aca. New York, on Wednesday, December
i8th, Dr. James L. Covert.
Green. — In Louisville, Kentticky, on Tuesday, December
24th, Dr. James Green, aged eighty-five years.
Hoffman. — In Reading, Pennsylvania, on Thursday, De-
cember 26tli, Dr. John Y. Hoffman, aged forty-nine years.
Hunting. — In Albany, New York, on Sunday, December
22d, Dr. Nelson Hunting, aged seventy years.
Johnson. — In Blairstown, New Jersey, on Monday, De-
cember 23d, Dr. John C. Johnson, aged seventy-nine years.
Jones.— In Pittsburgh, Penn.sylvania, on Saturday, De-
cember 2ist, Dr. ]\L-itthcw O. Jones, aged eighty-six years.
Lassar. — In P>iM-1iii, (~urinany, on Monday, December
23d, Professor LM--;it-, aged fifty-ei.ght years.
Linjer. — In Miniuain 'lis. .Miimesota, on Wednesday, De-
cember nth, Dr ( Jlc I'.dw ard Linjer.
LippiTT. — In FJn.ington, Virginia, on Friday, December
20th. Dr. Charles Edward Lippitt. aged seventy-eight years.
Morrill. — In Assouan, Egypt, on Friday, December 27th,
Dr. F. Gordon Morrill, of Boston, aged sixty-four years.
Peasden. — In Chicago, on Thursday, December 26th. Dr.
Joseph Peasden.
Smith. — In Vincennes, Indiana, on Monday, December
23d, Dr. Hubbard M. Smith, aged eighty-seven years.
Smithey. — In Burkeville, Virginia, on Friday, December
20th, Dr. Frank R. Smithey, aged twenty-five years.
Spooner.— In Republic, Ohio, on Thursday, December
19th. Dr. Harry K. Spooner.
Waters. — In Boyds, Maryland, on Thursday, December
I9t1i, Dr. William A. Waters, aged eighty-one years.
Weaver. — In Syracuse, N. Y., on Wednesday, December
i8th. Dr. Lewis F. Weaver, aged fifty-oiglit years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal ^It Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXVII, No. 2. NEW YORK, JANUARY 11. 1908. Whole No. 1519.
(Original (Communications.
THE VOICE AS AN INDEX TO DISEASES OF THE
THROAT, NOSE, AND EAR.*
By G. Hudson-Makuen, M. D.,
Philadelphia,
Professor of Defects of Speech in the Philadelphia Polyclinic Hospi-
tal and College for Graduates in Medicine; Laryngolo^st
to the Frederick Douglass Memorial Hospital; Laryn-
gologist to the Chester Hospital, Chester, Pa.
Some one has well said that the voice is the mir-
ror of the man, meaning, of course, that it reflects
man's character, his physical and even his moral
and intellectual states. Every physician will agree
with this proposition in so far as it relates to the
physical condition, for who has not noted the weak
and almost inaudible voice of the very ill person
and observed its gradual strengthening during con-
valesence. Indeed, the general physical condition
influences the voice to such a degree as to render
obscure oftentimes certain definite lesions of the
throat, nose, and ear, and this is a fact that should
be kept constantly in mind in dealing with this sub-
ject.
But the moral state of the individual is also re-
flected in the voice. He whose business it is, for
instance, to teach piety will unconsciously and un-
designedly acquire a pious tone or the so called
ministerial voice. The physician, whose function
it is to comfort and heal the sick, will develop a
sympathetic voice, and the lawyer, the colder and
more judicial tones.
Moreover, culture and refinement are reflected in
the voice, and the lack of these acquisitions are no
less apparent. The good man, as a rule, will have
a good voice and the bad man can with difficulty
conceal his badness when he speaks.
The nervous states are also reflected in the voice.
The high, thin voice of the nervous type of man is
in striking contrast to the lower and heavier voice
of the more phlegmatic type.
Good morals and good vocalization, however, do
not come by nature, but they are the results of edu-
cation and training, and this fact has a very prac-
tical bearing upon the subject under consideration.
Skill in the use of the voice may temporarily and
eflfectively render obscure certain abnormal and
even diseased conditions of the throat, nose, and
ear, as it may occasionally conceal the evil in one's
character. For instance, every practitioner of our
specialty doubtless has been surprised at one time
or another to find large tonsils, relaxed palates, and
*Read before the twelfth annual meeting of the American Acad-
emy of Ophthalmology and Otolaryngology, held in Louisville, Ky.,
Sej'tember 26, 27, z8, 1907.
elongated uvulas in the throats of good and even
famous singers, obstructions that have been almost
entirely overcome by skill in the use of the vocal
organs. The question of training, therefore, or
the lack of training, must be considered in studying
the voice as an index to the diseases of the respira-
tory tract.
The various kinds of voice that we think of in
connection with this subject are the hoarse, the
throaty, the tremulous, the muffled, the whispered,
the falsetto, and the nasal voice. The hoarse voice
is always pathognomonic, of either intralarj-ngeal
disease or an intralaryngeal expression of some dis-
ease of the central nervous system. It varies in
degree all the way from the scarcely perceptible
hoarseness of the beginning laryngeal involvement
of a common cold, to the marked hoarseness of an
acute laryngitis immediately preceding the aphonic
stage, when only the whispered voice is possible.
The hoarseness of the various stages of acute laryn-
gitis is due not only to the inflammatory thicken-
ing of the cords, but also to the general tumefaction
of the laryngeal mucous membrane, making it im-
possible oftentimes for the cords to assume the nor-
mal position during vocalization. A common cause
for the characteristic hoarseness of incipient tuber-
culosis is the thickening of one or both of the ven-
tricular bands, which interferes with the normal
approximation and vibration of the cords. An
illustrative case of this condition is one that I ex-
hibited recently at a meeting of the Section in
Otology and Laryngology of the College of Physi-
cians in Philadelphia :
The left ventricular band was about twice the size of
the other normal one. The young woman's hoarseness
was only incidental, in her own mind, to a form of stam-
mering which has annoyed her for years, but it was quite
intractable and did not yield to any form of treatment.
She had a morning cough with slight expectoration, but
there were no characteristic bacilli. The chest signs were
only "somewhat suspicious," to use an expression of Dr.
Eshner, who also examined the patient. The local treat-
ment now in my hands consists in the application of mild
astringents to the larynx, the use of breathing and light
calisthenic exercises, and the usual training and practice
for the improvement of the voice and speech. This par-
ticular patient, in my opinion, can only be saved from the
ravages of the dread disease, tuberculosis, by the strictest
hygienic measures and by the practice of well chosen
respiratory and vocal exercises.
Hoarseness is also symptomatic of intralaryngeal
tumors, both m.alignant and benignant, and the
character of the hoarseness will often suggest to the
practised ear the probable nature and location of
the tumor. A case for diagnosis, however, is a
small boy now under my observation :
He is four years of age and has never used the normal
resonant voice. He is one of twins and of forceps delivery.
Copyright, 1908, by A. R Elliott Publishing Company.
48 HUDSON-MAKUEN: VOICE AND DISEASES OF THROAT, NOSE, AND EAR. ^ INew York
^ Mkdical Tourn
He inherits a nervous disposition, with a history of con-
sumption on his father's side. His tonsils are imbedded
and slightly enlarged, and a satisfactory rhinoscopic or
laryngoscopic examination has not been possible. I con-
fess that I am in doubt as to tl;£ condition of the larynx
that gives rise to this peculiar voice. Whatever it may be
it has existed for several years, and it is only recently,
with some little persuasion and training, that he has used
the resonant voice at all, and even this is very hoarse.
My first thought was of papillomata, but after a further
study of the case I am quite in doubt as to the diagnosis.
In the attempts to get a laryngoscopic image of the larynx
I have found the epiglottis hanging low and folded upon
itself. The use of the mirror seems to give him consider-
able discomfort and some dread of total obstruction to
respiration. There is no history of dyspnoea, but only of
acute colds, during which vocalization is so difficult that he
practically refrains from talking at all. I have not yet
tried direct laryngoscopy, and the symptoms have not been
sufficiently urgent to warrant etherization.
Intralaryngeal ulcers, especially those having in-
filtrated edges with copious secretions, are pro-
ductive of a sort of moist hoarseness which is quite
different from the hoarseness of a comparatively
dry larynx.
The tremulous or broken voice is characteristic
of very old people, but we find it also in those who
are debilitated by overwork, and especially by ex-
traordinary vocal effort. It is the voice of broken-
down and wornout clergymen. I have recently had
two such cases under my care. They are described
in the literature as "disphonia spastica." There is
a nervous element in the condition similar to that
which we find in stammering. The voice wavers in
the glottis most unexpectedly at times, and the pa-
tient knows neither its cause nor its remedy. More-
over, he is in constant dread of its reappearance.
It becomes a nervous habit, a veritable fear neuro-
sis, and it is often accompanied by peculiar psychic
disturbances. The oropharynx and larynx are nor-
mal except for a marked hypersesthesia of the mu-
cous membrane, making a laryngoscopic examina-
tion almost impossible. In one of my cases the
tremulous voice alternates with complete aphonia,
making a most curious admixture. Somewhat akin
to this condition is one illustrated by a young man
now under observation who has a peculiar catch in
his voice, with a hesitation of speech, due to inter-
mittent unilateral paralysis of the abductor laryn-
geal muscles. Although this condition of the larynx
is rarely met with in stammerers, it is one that we
should be on the lookout for and one that may be
very easily overlooked.
The whispered voice is well illustrated in hysteri-
cal aphonia, in which there seems to be a sort of
paralysis of the abductor muscles, and it appears
also in acute laryngitis where there is a mechani-
cal obstruction to the normal action of the cords.
Of course any one of the defective types of the
voice which I have mentioned may be and often is
aphonic. A curious example of this condition is
that of the small boy to whom I have referred. In
the majority of cases of hysterical aphonia there
have been, in my experience, local conditions which
have shared in the sum total of the causal factors.
Acute laryngitis, for instance, may be the original
cause and the hysterical element a subsequent de-
velopment. This emphasizes the importance of a
careful examination of the larynx in all so called
hysterical aphonias. It should be remembered that
hysteria is generally an acquired psychological con-
dition and often the result of a simpler local condi-
tion.
The 'voice of the deaf is particularly character-
istic. It has a high pitch and it is monotonously
throaty. It is an unmodulated voice, owing to the
fact that the deaf cannot hear themselves speak.
The exact degree of deafness in children may be
exceedingly difficult to determine, and the character
of the voice is often our only guide. The child that
is only partially deaf will modulate the voice, while
the totally deaf child will speak, if at all, in high
monotonous and throaty tones. This fact is of
great practical and diagnostic importance. Only the
other day I saw at my clinic a child that had been
at a State institution for the deaf for nearly a year
and sent home again, because it was found that she
had some hearing, a fact that was discovered only
after a considerable experimentation. The child
with a congenital deficiency of hearing will, as a
rule, be backward, speak little, if at all, and that
little will be defective and contain only those sounds
that it happens to hear. On the other hand, the
congenitally deaf child, of course, will not speak or
phonate at all, until it is especially trained to do so.
The adult person who has acquired partial deaf-
ness will generally speak loudly, although he cen-
sures others for speaking too loudly. What helps
him most to hear is distinctness of articulation.
The muffled voice is one that is more or less de-
void of head resonance. It is the voice of those
having faucial and pharyngeal tonsils, hypertro-
phied turbinals, nasal polypi, or other nasal and
pharyngeal growths. The nasopharyngeal resona-
tors are dampened, so to speak, and the voice is
muffled.
The falsetto voice is generally indicative of no
special throat, nose, or ear lesion, and it is due en-
tirely to an erroneous conception of the true tones
and a consequent misplacement of the tones. There
is in it no laryngeal or chest resonance, but the
larynx is markedly elevated and the vibrations are
focused high up in the head.
The nasal voice is due in the majority of in-
stances to inadequacy of the velum palati, which al-
lows too great a proportion of the vibrating breath
to pass up through the nasopharynx, thus giving a
preponderance to the nasal resonance. This is well
illustrated by two patients who have recently come
under my observation — one a woman of twenty-
four and the other a boy of nine years. In neither
case is there a sufficiency of action in the levator
palati muscles during the process of speaking. In
that of the small boy there is no action of these
muscles whatsoever, and they do not respond even
to electrical stimulation. Curiously enough, there
is no history in either case of an infectious disease
to account for the parasis, and the character of the
voice is the only symptom of the condition. The
voice in these patients is strongly suggestive of a
cleft palate.
The purpose of this paper is to demonstrate the
importance of the voice as a factor in diagnosis and
to emphasize the necessity for a more critical study
of the voice, especially in its relation to diseases of
the throat, nose, and ear.
1627 Walnut Street.
January ii, 1908.]
POTTENGER: TUBERCULOSIS.
49
THE ADVANTAGES OF SANATORIUM REGIME IN
TUBERCULOSIS, WITH ESPECIAL REFER-
ENCE TO THE TREATMENT OF
EXTRAPULMONARY LESIONS *
By F. M. Pottenger, A. M., M. D.,
Monrovia, Cal.,
Professor of Qinical Medicine, Medical Department of the Univer-
sity of Southern California.
I shall endeavor to confine my remarks, for the
most part, to the treatment of tuberculous lesions
found in organs other than the lungs. But, inas-
much as many of these lesions exist as complica-
tions of tuberculosis of the lungs, and inasmuch as
tuberculosis is the same disease wherever found, it
will be necessary to discuss the treatment of tuber-
culosis in general to some extent.
In order to have the proper conception of these
extrapulmonary lesions, we must bear in mind that
tuberculosis is the same disease wherever found.
The various manifestations differ only in that dif-
ferent organs are affected ; the cause is the same,
and the result from a pathological standpoint is the
same. The pathology of tuberculosis of the kidney
and bowels is the same as that of the lung and
larynx.
Tuberculosis is a disease produced by a specific
microorganism, and its cure, like that of all other
infectious diseases, is brought about by the estab-
lishment of immunity. I do not mean immunity in
that narrow sense whereby the term is usually un-
derstood as denoting an impossibility upon the part
of an individual, either temporarily or permanently,
of becoming infected ; but immunity in that broader
sense which means a degree of resistance whereby
the organism through a response which is made
upon the part of its tissue cells in reacting to the
stimulation of some toxine, produces defensive
bodies which have as their specific function the de-
struction of that toxine.
The symptoms of tuberculosis are produced, in
part, by the tubercle bacilli and, in part, by the tox-
ines which are produced by the bacilli and poured
out into the circulatory fluids of the body. Its cure
must come from the establishment, upon the part
of the infected organism, of an immunity to both
the bacilli and their toxines.
It has been shown that the action of the tubercle
bacilli and their toxines is different, the former tend-
ing more to the production of fibroid tissue, the latter
more to the production of necrosis. Hence, whether
liealing or necrosis shall occur, the resisting power
of the patient being the same, depends very much
upon the amount of toxine present. An infection
caused by very virulent bacilli or by great numbers
of bacilli pours out into the circulation a toxine
of greater potency and toxine in great amounts
and consequently causes necrosis, while an infection
caused by bacilli of a less virulent strain or by a
smaller number of bacilli is more apt to be fol-
lowed by the formation of fibroid tissue and result
in healing.
In support of this statement I would cite the fact
that dead bacilli which are not producing tox-
ines are more apt to be followed by the formation
of fibroid tissue than the same bacilli when alive;
*Read before the Kings County Medical Society, at a meeting
held at Seattle, Wash., on October 7, 1907.
and the even more convincing experiments of
Stork (Wiener medizinische Wochcnschrift, July,
1907) whereby he has been able to produce fibrosis
in 100 per cent, of pigs by injecting them with a
culture of tubercle bacilli of low virulence.
This, then, gives us the key to the treatment of
tuberculosis, which is to do all we can to lower the
virulence of the infecting bacilli and to counteract
the effect of and destroy their toxines. Anything
which will do this must do it by the production of
specific protective or immunizing bodies. These
bodies are produced by the body cells themselves;
therefore any measure or measures which will im-
prove the nutrition of these cells and make them
capable of producing more antibodies, or any pro-
ducts which will stimulate these cells to the produc-
tion of more antibodies, will aid in bringing about
a cure. It is needless to say that, aside from these,
all distressing symptoms should be treated in the
proper manner.
It can readily be seen, then, that fresh, pure air,
good food, carefully regulated rest and exercise,
hydrotherapy, suitable tonics, and favorable climatic
conditions act by giving the patient well nourished
cells, so that he is capable of responding in such a
manner as to produce a maximum quantity of anti-
bodies when the proper stimulus is afforded. The
stimulus which is required to act upon the cells to
cause them to produce these immunizing bodies is
furnished in all infections by the specific germ caus-
ing the infection, and this can be furnished arti-
ficially as well as by natural infection. The intro-
duction of dead germs or their toxines stimulates
the cells to the production of immunity. In tuber-
culosis, by artificially introducing products made
from the tubercle bacillus we are able to stimulate
the cells to the production of two or three times as
many protective antibodies as they will produce
without this stimulation. The real scientific cure
of tuberculosis, then, consists in building up the pa-
tient, making his cells capable of responding to the
production of as many antibodies as possible, and
then introducing some product made from the
tubercle bacillus, such as tuberculin, bacillus emul-
sion, or bacillus extract, which will artificially stim-
ulate these cells to the production of a maximum
amount of these immunizing bodies.
The cure of tuberculosis is slow. Unlike the
acute infections, which run their course in a few
days or a few weeks, tuberculosis lasts for months
and years. As its pathology^ indicates, it cannot
heal rapidly. This fact adds to the difficulty of
treatment and makes results much less satisfactory
than the disease itself warrants.
Patients suffering from tuberculosis, even in
the advanced stages, feel well a goodly por-
tion of the time. This fact reacts against
them and prevents them from having the
best chance of cure, because during this time
they tax their systems by doing foolish things.
When acutely ill, as with typhoid fever or pneu-
monia, the patient feels so sick that he goes to bed
and sends for his physician ; when afflicted with
tuberculosis, on the other hand, he manages his case
alone or with the advice of a host of friends and
neighbors and perhaps with a few indefinite instruc-
tions from a physician. Thus, the tuberculous pa-
50
POTTENGER: TUBERCULOSIS.
LNeu- York
Medical Jovrnal.
tient is usually badly managed, he goes from bad
to worse, and nearly always dies of his disease.
That such a result should occur when so serious
a disease as tuberculosis is treated in so unscien-
tific a manner is a foregone conclusion ; but such a
result is entirely unnecessary, for tuberculosis is a
disease which yields to rational, scientific treatment.
Does it not seem almost beyond comprehension that
the members of the medical profession should give
careful attention to detail in treating the ordinary
petty illnesses that make up a considerable portion
of every man's practice and then turn the same pa-
tient away to rely on himself or the advice of his
neighbors when he becomes afflicted with one of the
most serious of all diseases? This apparent neglect,
however, springs from and is a monument to the
honor of the medical profession. The members of
our profession have considered tuberculosis as
hopeless, and have felt that they were helpless in
undertaking to treat it, and rather than take money
from patients to whom they felt unable to render
competent service they have told these unfortunate
sufiferers that they could do nothing for them, and
thus they have cast them adrift to find help or harm
for themselves.
It is now time that the honor of the medical pro-
fession demands a change in its attitude. Tubercu-
losis is now known to be a curable disease. During
the past fifty years, but more particularly the past
ten years, favorable reports on the treatment of this
disease have been accumulating, and now we can
say it is the most curable of all chronic diseases.
The most favorable results in the treatment of
tuberculosis have been produced in sanatoria, espe-
cially conducted for the purpose, and the results in
these institutions vary greatly according to the con-
ditions under which treatment is carried on and the
methods employed. Thus the result in early cases
ranges from 65 to 95 per cent, of apparent cures ;
in moderately advanced cases from 10 to 65 per
cent., and in far advanced from none to 20 per cent.
When we compare these results with those ob-
tained in treating tuberculosis in the usual ambula-
tory manner we can see that the results are almost
beyond credence.
It is well for us to inquire, then, why sanatorium
treatment offers such superior advantages in treat-
ing tuberculosis. Why is it necessary to send pa-
tients who do not seem or feel ill to an institution
for treatment? Why especially should those who
are in the early stages of the disease be sent to
sanatoria? A glance at statistics from institu-
tions where all stages of the disease are treated
should answer the question, for these show that
where early cases can nearly all be cured, later
cases are cured with difficulty, and the very late
nearly all die. But figures are not always convinc-
ing and sometimes remain to be explained.
Tuberculosis is a disease which heals slowly, and,
as explained before, one whose healing depends
upon the resisting power of the patient. There is a
constant tendency for the disease to spread to new
areas, and upon this fact, together with the compli-
cations resulting from it, the life of the patient de-
pends. The greater the area of involvement the
greater the opportunity for bacilli to escape and
cause new foci, and the more detrimental the ef-
fect on the system ; hence the more serious the dis-
ease. Whether or not the bacilli which escape from
the foci of infection shall cause a new infection and
whether or not the old infection shall heal depends
upon the resisting power of the patient. A patient
whose resisting power is good — that is, one whose
cells respond to the stimulation of the toxines re-
sulting from the presence of the invading bacilli, by
the production of a large amount of antibodies, will,
unless the virulence of the bacilli be too great, oflfer
a strong resistance to the disease process present as
well as a barrier against the bacilli which attempt to
form new foci. On the other hand, one whose re-
sisting power is low or oscillating between high and
low is offering the disease focus new opportunity to
progress and affording a very uncertain barrier to
the extension to new areas.
The application is obvious to all. The tubercu-
lous patient's resisting power must be kept as high
as possible during the entire course of treatment.
His protective antibodies must be constantly stimu-
lating the old foci to healing and must be ever on
guard to destroy bacilli that may be thrown into the
circulation and go to form new foci in other tissues.
This can only be oft"ered by putting him under con-
ditions which are especially directed to this end.
That it is possible to largely prevent this spread
of infection has been strongly impressed upon me
by my experience in treating advanced cases of
tuberculosis. While about half of those who enter
the institution have an involvement on the part of
the larynx, and while a large percentage have symp-
toms of tuberculosis of the bowels, yet it is rare
for these patients to develop such complications
after they are put upon the hygienic dietetic and
tuberculin treatment, unless it be a part of a termi-
nal general miliary infection.
Our so called civilized methods of living are un-
natural and, from the standpoint of health, barbar-
ous. It is almost impossible for an individual suf-
fering from tuberculosis to live in homes and board-
ing houses, and live a true hygienic life. Well peo-
ple will not put up with the so called deprivations
which are necessary for a tuberculous patient who
is trv'ing to live a hygienic life ; neither, as a rule,
will they allow him to do it. Rather than encourage
him as they should, friends, as a rule, say ''once
breaking the rule will not harm," and urge the do-
ing of those things which carry more or less risk.
The only successful way to keep the resisting
power of these patients at a high stage long enough
for them to overcome the disease is to place them in
the proper surroundings, remove them from tempta-
tion, and then keep them interested in the cure until
it takes place.
It is needless to say that such a method offers not
only greater chances of cure, but the opportunity of
obtaining the result in a much shorter time. Sana-
torium treatment offers about 50 per cent, better
chances of cure than ambulatory treatment and pro-
duces the result in a shorter time.
Another bad feature about treating tuberculous
patients outside of sanatoria is the danger of sec-
ondary infections. Acute colds, bronchitis, la
grippe, and pneumonia, like the poor, we always
have with us. These are dangerous, and often fatal,
enemies of the tuberculous patients; especially when
January ii, 1908. J
POTTENGER: TUBERCULOSIS.
51
they are living in homes and boarding houses and
associating with people in general, there is always
more or less exposure to them, while in sanatoria
such exposure is largely eliminated.
But even aside from these advantages of the sana-
torium treatment the greatest advantage is that this
method brings the patient under the direct control
and constant guidance of the physician, where he can
correct all things which tend to tear down and ap-
ply remedial measures that are of value in the most
advantageous manner. Complications are seen and
treated in their incipiency, accidents are prevented,
troublesome symptoms are relieved, and the coop-
eration of the patient is secured as cannot be at-
tained in any other manner.
For many years medical science has recognized
the curability of tuberculosis of the bones and
joints. To a certain extent the curability of
glandular tuberculosis has been accepted. Gradual-
ly it has been recognized that the pulmonary form
is amenable to treatment, and evidence is forthcom-
ing to show that all forms are sometimes curable
and that many of those which have been considered
hopeless are fairly readily healed by appropriate
measures.
The curability of forms of tuberculosis other than
pulmonary (save those of the bones, joints, and
glands) has been established by sanatorium treat-
ment. Such complications as tuberculosis of the
larynx, upper air passages, urogenital organs, and
even that of the bowels, will yield to appropriate
treatment when carried out as it is done in properly
conducted sanatoria. The cure of these may justly
be said to be the contribution of private sanatoria
to the curability of this disease. Public and philan-
thropic sanatoria have for years refused to take pa-
tients who were suffering with these complications,
but private institutions have taken them and
through persistent effort succeeded in curing many
of them. When I speak of their curability, I do not
wish to minimize the difficulties attendant upon
treating such cases, for they are great ; but the fact
that they can be cured at all is a triumph of modem
medical science. I wish now to discuss several of
the most common forms of tuberculosis as we find
it situated in organs other than the lungs, and en-
deavor to show some of the more hopeful aspects
of their treatment.
Tuberculosis of the Upper Air Passages.
The most common form of tuberculosis other
than pulmonary that we are called upon to treat is
tuberculosis of the larynx. The larynx is involved
much more commonly than is generally supposed.
Careful post mortem observations on patients who
have died of tuberculosis, and careful routine clini-
cal examination of the larynx in patients who are
suffering from advanced tuberculosis, show that
more than 5^0 per cent, of patients in the advanced
stages have some involvement of the larynx.
Unfortunately the tuberculous larynx is not diag-
nosticated early. If the patient presents himself to
the physician complaining of hoarseness and cough,
and, upon examination, the larynx is found to show
thickening with congestion of some portion, either
the cords, the interarytenoid space, the arytenoids,
or the ventricular bands, he is too apt to be treated
for simple laryngitis. A tuberculous nature is not
suspected until there is breaking down with ulcera-
tion.
When we recall our pathology, we remember that
ulceration does not occur as a primary condition.
Only after infiltration has existed for some time
does necrosis occur ; consequently we must not look
for ulceration, but we must learn to diagnosticate
tuberculous laryngeal involvement early, during the
infiltration stage.
The stage of infiltration lasts during a variable
time. It may be a few weeks, in very virulent in-
fections, or it may be months in less virulent infec-
tions, or it may never occur. I have known it to
last for several years without ulceration occurring.
There is one point that should be insisted on in all
cases where such suspicious conditions are found
upon physical examination, and that is the establish-
ment or elimination of tuberculosis elsewhere in the
body and especially in the lungs. A careful expert
physical examination will nearly always settle this
matter very easily, and if there should be any doubt
remaining a tuberculin test will show the local reac-
tion and clear up all doubt.
Tuberculosis of the larynx is perhaps always sec-
ondary to tuberculosis elsewhere and nearly always
secondary to tubercvilosis of the lungs ; and, while
I recognize that all pathological conditions such as
I have mentioned occurring in individuals afflicted
with tuberculosis are not necessarily tuberculous in
their nature, yet facts warrant us in suspecting all
such cases and demand that a diagnosis be made.
Remembering that more than 50 per cent, of
advanced cases of pulmonary tuberculosis show
some infiltration in the larynx, our attention is
called to this as being a very common complication
and one for which we should always be looking.
Routine examination of the larynx should always
be made at frequent intervals in all patients who
are suffering from tuberculosis of the pulmonary
form, and careful examination of the chest should
be made where infiltration presents itself in the
larynx, and if doubt still remains the local tuber-
culin reaction should be looked for.
The administration of the tuberculin test in
laryngeal cases requires a knowledge of the action
of tuberculin and an ability to examine the larynx.
The reaction here nearly always shows early. A
fever reaction is rarely necessary. Following the
injection of the remedy, an increased congestion in
the larynx occurs if the involvement is of a tuber-
culous nature ; if it is not, no change is seen. The
dosage in tuberculous laryngitis should begin with
0.1 to i.o milligramme, the same as is used for the
tuberculin test in general. It is rarely necessary,
however, to give as large doses as are required for
a general fever reaction. One tenth to i, 2, or 3
milligrammes will nearly always decide the diag-
nosis.
When tuberculosis of the larynx has been discov-
ered, what prognosis can we give the patient ? This
depends, like tuberculosis of the lungs, upon the
earliness of the diagnosis and the nature of the
treatment instituted. Another important factor to
be considered is the condition of the lungs. If the
pulmonary condition is not too serious and the diag-
nosis is made early, the chances of cure with proper
treatment are very good.
No doubt many cases of slight laryngeal involve-
52
POTTENGER: TUBERCULOSIS.
[New York
Medical Journal.
ment are healed without either patient or physician
knowing of their presence, but it is not safe to rely
on such good fortune. Tuberculosis of the larynx
calls for skillful, intelligent treatment, and of all
measures which offer chances of cure I believe there
is none equal to the inoculation of the patient with
products made from the tubercle bacillus. In fact,
the cure of this malady has been established by the
use of tuberculin and its allies.
Tuberculosis of the larynx must not be treated
as an entity, but as a part of the tuberculous pro-
cess which affects other organs, nearly always the
lungs.
This is the ideal place for tuberculin treatment,
because the reaction is visible. The dosage should
be so measured that only a slight reaction is caused,
and it should not be repeated until all local signs
have disappeared, and the dose should not be in-
creased in amount until the amount whicii caused
the reaction fails to produce local signs.
Aside from these bacillary products, the patient
should have the benefit of all advantages that the
sanatorium affords, such as open air, good food,
properly regulated rest and exercise, hydrotherapy,
and other tonic measures.
Locally, palliative measures only should be used.
The parts should be kept clean and may be slightly
stimulated by protargol or some such application.
If ulceration is present, these measures are suffi-
cient unless pain be a symptom, when the applica-
tion of orthoform, or if cough is also troublesome,
orthoform with 1/12 to 1/6 gr. of heroine may be
used. The heroine should not be used unless abso-
lutely necesary.
A cold compress to the throat relieves much of
the cough.
Such measures as curettage and lactic acid are of
little value as curatives. In fact, local applications
must not be expected to cure the disease, nor must
the physician flatter himself with a hope that he may
remove all the tuberculous tissue by excision, for
such is almost an impossibility, as has been shown
by the return of the trouble in nearly all cases where
these measures have been employed.
The cure must come about by stimulating the
body cells to the production of sufficient immuniz-
ing elements or antibodies to overcome the action
of the bacilli and their toxines.
Aside from tuberculosis of the larynx, we find
infections of the pharynx, tonsils, tongue, and nose.
All of these are curable in a certain proportion of
cases, but they require constant watching and per-
sistent treatment for a long period of time in order
to accomplish the results. Favorable reports on
such lesions are rarely obtained except in sanatoria,
because it is almost impossible to give the required
attention and impossible to hold the interest and co-
operation of the patient except by the constant in-
timate association of the patient and physician.
Glandular Tuberculosis.
Tuberculosis of the glands is a form that needs
careful consideration. In tuberculosis, the glands
Ijerhaps always play a part. In many instances they
are infected, although they do not break down.
These enlarged glands, however, cannot be looked
upon with unconcern, for they are centres of infec-
tion, and we know not at what time bacilli will be
thrown out into the general circulation and be car-
ried and deposited in some other organ, where they
may start an active tuberculosis.
For years excision has been the recognized treat-
ment for such glands, but it has rarely been em-
ployed until the glands have shown some sign of
breaking down. Such a procedure is irrational, be-
cause in the first place the danger from tuberculous
glands begins before the glands show signs of soft-
ening, and in the second place, by removal, only
those glands which are found at the site of the op-
eration are removed, while, as a rule, others are left
behind, which often go on to softening; or, if they
do not, remain as foci of infection from which the
disease may spread to other organs.
Of the many patients whom I have treated in the
past few years, many have had enlarged cervical
and axillary glands, but in not a single instance has
suppuration occurred. These usually respond to
treatment by becoming smaller and assuming their
normal size, or, if they are the seat of new tissue
formation, they become smaller and remain as
fibroid nodules.
Recognizing the frequency of tuberculosis of the
glands in children, and knowing that tuberculous
infection commonly affects the glands before it
spreads to new tissue, I believe the time will soon
come when we will treat the tuberculosis of chil-
dren while it is still confined to the glands and be-
fore other vital organs are infected. The glands
are the ideal place for the treatment of the disease,
because the lymph, with its antibodies, comes in di-
rect play upon the bacilli and their toxines. It is
better to remove a bomb from under a house before
it is lighted than to patch up the house after the
bomb has exploded.
Tuberculosis of the Genitourinary Trad.
Experience with tuberculosis of the genito-
urinary tract is encouraging. I have seen tubercu-
losis of the kidney heal. The application of tuber-
culin to infection of the bladder and testicle is also
offering good results when properly administered.
We have had a unique experience in the institution
I am connected with, so far as I know, in the way
of an apparent cure of a tuberculous ovary.
The history of the case is as follows :
Two years previously the patient had been operated upon
by a Seattle surgeon, at which time one ovary was re-
moved. This proved to be tuberculous. The surgeon gave
the opinion at the time that the other ovary would require
removal later because it also showed signs of infection.
Owing to a promise to 'the patient that only one would be
removed, the second ovary was left. Immediately before
coming to us the same surgeon examined the patient and
advised removal of the remaining ovary, but instead the
patient preferred to make an attempt to save the organ.
She came to us and insisted that we should treat her. We
informed her that we had never treated such a case, and
could not promise any success; but she urged a trial.
Examination showed the ovary to be much enlarged and
very tender. There was also a slight lesion in the lungs.
The patient was admitted to the sanatorium and treat-
ment was begun. She was put upon the ordinary regime
and given tuberculin. After one year's treatment the pul-
monary condition was apparently cured, the ovary had re-
duced in size, all tenderness had disappeared, and it gave
the impression of being healed. Owing to the inflammatory
January ii, 1908.]
POTTENGER: TUBERCULOSIS.
53
condition present, adhesions formed which at first gave her
some trouble. About six months after leaving the insti-
tution she became anxious about the matter and visited a
physician who gave it as his opinion that the trouble was
active again and that the ovary should be removed. She
again came to the institution for examination, which
showed the result the same as it was upon leaving. She
was given large doses of tuberculin without any reaction
whatever. It is worthy of note that during the course of
treatment large doses of tuberculin often caused conges-
tion with decided pain in the ovary. Her condition re-
mains good and it appears that a cure has been effected.
Intestinal Tuberculosis.
Perhaps tuberculosis of the intestines is the most
serious form of the disease. This is almost always
a complication of the pulmonary form. It is more
common than is generally believed, being found as a
complication in from 50 to 80 per cent, of all cases
of tuberculosis which come to autopsy.
This condition is often present without being rec-
ognized. It is usually thought that tuberculosis of
the intestines manifests itself by diarrhoea. This is
not necessarily true, in fact, whether or not diar-
rhoea is present depends very much upon the loca-
tion of the lesion. There are two principal loca-
tions for tuberculosis of the intestines, one in the
ileum in the region of the caecum, the other in the
lower bowel near the rectum. The former may not
manifest itself at all by diarhoea, but in the latter the
diarrhoea is often intractible.
The diagnosis is not as difficult as is generally
believed. The patient should be cautioned careful-
ly about swallowing sputum, then after forty-eight
hours a sample of faeces should be collected and ex-
amined. Faeces may be examined by making a
smear from a small particle, or a small particle may
be taken, mixed with twenty times its volume of
water, and centrifugalized so as to throw down the
coarser particles. The upper fluid is then poured of¥,
mixed with twice its quantity of alcohol and cen-
trifugalized again, when the sediment is examined.
When tuberculosis of the intestines has been diag-
nosticated, the patient should be treated most care-
fully. A liberal diet should be allowed, but one
which will nourish without throwing extra burden
upon the intestinal tract. Overfeeding should not
be carried out — in fact, it has very little place in
the treatment of tuberculosis of any kind. The
bowels should be kept open and free from irritation.
Where constipation is present, I have found olive
oil, one teaspoonful to one tablespoonful after
meals, to be valuable, with an occasional dose of
castor oil if necessary.
When diarrhoea is present I open up the bowels
at once with castor oil, and put the patient on a re-
stricted diet, consisting of milk and vichy or the
whites of eggs. If after a day the patient's condi-
tion is better, I gradually add milk toast, boiled rice,
scraped meat, and tropon. Applications of hot
cloths to the abdomen, changed every twenty min-
utes and kept up for one or two hours at a time,
gives great relief to the patient and helps to control
the trouble.
If the diarrhoea is intractible, high enemas of hot
normal saline solution or of starch water and bis-
muth, or starch water and opium, may be used to
advantage. In these cases the internal administra-
tion of bismuth from x to xxx grs., either alone
or combined with from v to x gtts. of deodorized
tincture of opium, should be tried if the other mea-
sures are unsuccessful. As a last resort, there is
perhaps nothing better than lead and opium, but I
should not recommend it unless the others have
failed.
By handling the occasional symptoms which are
produced by the less serious infections of the intes-
tines in the manner mentioned and giving the pa-
tient the benefit of rational treatment, as suggested
in the early part of the paper, the disease will some-
times heal. I have seen several cases heal where
the symptoms were pronounced and where diarrhaea
with pain in the abdomen followed tuberculin reac-
tions, thus confirming the diagnosis. While I look
upon this as a most serious complication, yet I think
that we have reason to believe that ere long we will
have evidence enough at hand to show us that this
condition is also occasionally amenable to treatment.
In the preparation of this paper I have simply
given my own experience. The class of patients
that come to us are, as a rule, far advanced in the
disease. They have tried fresh air, and all the usual
remedies, they have given various climates a trial
unsuccessfully, and then when they have arrived at
an advanced condition, with very often complica-
tions on the part of the larynx and bowels, they are
ready for sanatorium treatment. While this has
made our work difficult and precluded the possibil-
ity of obtaining the best results, yet it has afforded
us an opportunity to study these complications,
which have resulted in the evidence which I have
placed before you.
And why should these tuberculous complications
not heal? Tuberculosis has the same cause and
same pathology wherever found. It is cured by the
same measures wherever found. If cured at all it
will be cured by raising the power of the body cells
to the place where they will produce sufficient anti-
bodies to overcome the infection, as I have shown ;
so, we must either assume that these complications
are more virulent than the infection in the lung or
expect them to yield to rational treatment.
I would not counsel delay until these various
complications result, but insist on an early diagnosis
and prompt intelligent treatment ; but the point that
I wish to make is, that a man does not need to be
condemned to death because of some other organ
than the lungs being involved as a complication of
pulmonary tuberculosis, and especially is this true
when the diagnosis of the complication is made
early.
One word about tuberculosis of the bones and
joints before closing. If we may judge from the
after history of these cases we must admit that the
results obtained by the ordinary operative and me-
chanical measures are not quite as good as can be
desired. Very often secondary infection of other
organs follow these primary lesions. The leaders
of thought along this line are now beginning to
suggest that their patients be given the benefit of
sanatorium and tuberculin treatment along with the
other measures. It is certainly rational and will
doubtless add much to the permanency and thor-
oughness of the result.
54
SHAXAHAN: PULMONARY (EDEMA IN EPILEPSY.
LNew York
Medical Journal.
ACUTE PULMONARY CEDEMA AS A COMPLICA-
TION OF EPILEPTIC SEIZURES.*
By William T. Shanahan, M. D.,
Sonyea, N. Y.,
First Assistant Physician, the Craig Colony for Epileptics.
The complication of a grand mal seizure men-
tioned in this short paper is that of a puhnonar}-
oedema which is sudden in onset and produces a
serious condition in all instances and in some cases
a fatal termination. In some cases this oedema is
recurrent. This state is one to which little or no
attention has been called in treatises on epilepsy,
although seen fairly frequently.
Riesman, in an excellent article in the American
Journal of the Medical Sciences, January, 1907,
has given a resume of the literature on the subject
of pulmonary oedema and reports six cases of an
acute recurrent form.
He mentions this oedema as being associated with
arterio sclerosis, Bright's disease, heart disease,
angina pectoris, asthma, acute infectious diseases,
pregnancy, paracentesis of thorax and abdomen,
angeioneurotic oedema, and finally with obscure
conditions of questionable causal relationship, such
as hysteria, etc.
In every grand mal and in many petit mal
seizures there is a more or less marked increase in
the secretion of mucus along the respiratory pas-
pages with the subsequent frothing at the mouth
which is commonly seen in such patients. In some
cases there may be no actual increase, but simply
an accumulation in the mouth of the normal
amount which is then forced from between the lips
during the accentuated respiratory air currents
which accompany the stertorous type of breathing.
In a few cases this great outpouring of mucus
becomes so marked that the patient is in actual dan-
ger of being drowned in his own secretions, this
acute process producing a marked pulmonary
oedema. The acute oedema should not be con-
founded with the frequently occurring terminal
oedema seen in many epileptics, as well as those suf-
fering from the many other diseased states which
have already been mentioned. In a large propor-
tion of the autopsies done on patients who had died
at the colony, a terminal pulmonary oedema has
been found.
The patients observed have been in fairly good
physical condition preceding the occurrences of one
or more grand mal seizures. During the stertorous
period of the isolated seizure, or perhaps the second
or third in a series of seizures, there suddenly ap-
pears an outpouring of mucus, perhaps blood
tinged, from the mouth and nose, with a marked
cyanosis and dyspnoea occurring concomitantly.
/Etiology. — Some of these cases occurred in pa-
tients who had an affection, which in all probability
acted as a predisposing cause, but would never have
been sufficient to have brought about the oedema
unless the circulatory changes accompanying the
epileptic seizure had been added to it. Of the
eleven cases reported in this paper, seven patients
recovered and four died. In three patients the con-
dition recurred, and in one of them the second
period observed was fatal.
•Read at the meetinK of the National Association for the Study
of Epilepsy held at Kichmond, Va., on October 24, 1907.
Dr. William H. Welch's theory of the cause of
pulmonary oedema is as follows:
A disproportion betwen the working power of the left
ventricle and of the right ventricle of such character that,
the resistance remaining the same, the left heart is unable
to expel in a unit of time the same quantity of blood as the
right heart.
An enfeebled action of the left ventricle, rather
than a spasmodic action, is likely to be the cause of
this disproportion under the conditions in which
pulmonary oedema ordinarily occurs. As a conse-
quence of this there is soon a large excess of blood
in the pulmonary vessels. The oedema is one usual-
ly associated with venous hyperaemia. An increase
of the intracapillary pressure is brought about in
the lungs, and perhaps a decrease of the extracap-
illary pressure, or both. The asphyxia accompany-
ing the seizure is caused by the local stagnation of
the blood stream and in turn causes an increase in
the permeability of the endothelial wall of the ca-
pillaries of the lung.
Treatment. — The most important procedure has
been found to be a change of posture so as to aid
in draining the respiratory passages of the great
excess of mucus. If necessary, turn the patient
over the side of the bed, removing all mucus from
the mouth, nares and pharynx. Open the mouth
with a gag or with the fingers protected by a towel.
In addition, much benefit has been obtained by dry
cupping and the use of atropine and strychnine
hypodermatically. Venesection is of value in full
blooded patients. Adrenalin was used without ap-
parent result.
Case I. — M. B. T., female; admitted to the Craig Colony
May 22, 1899; age, twenty-seven years. Onset of epilepsy
at seven years. Had both petit mal and grand mal seizures.
Well nourished woman. At time of admission physical
examination revealed a mitral murmur.
July 13, 1903. — She had a grand mal seizure, following
which a marked acute pulmonary oedema occurred. A
venesection was done and patient quickly improved. Re-
covery uneventful. •
December 6, 1906. — Slight bronchitis had occurred at in-
tervals during past year. General health had been good,
so that slie worked in laundry regularly. At i :i5 a. m.
she had a severe seizure, which was following by a marked
cyanosis of face, dyspncea, and elevation of temperature,
103° F. Examination of chest showed numerous dry rales,
with some moist rales. There was some bloody saliva and
mucus expectorated from time to time. Great restlessness
and fear of death. She was turned on her side with head
hanging over edge of bed, so that fluid would drain from
air passages. Given atropine gr. 1/60 hypodermaticall>
and dry cupped over entire right chest. In half an hour
patient was quieter and dyspnoea much less marked. Pulse
was of good volume, but not of particularly high tension.
Moist rales were present for three days, after which she
returned to her usual state of health.
Case II.— H. J. L.,_male; admitted April 9, 1898; age,
thirty-six years. Evidences of beginning pulmonary tuber-
culosis, but no heart lesion was present. Had both grand
mal and petit mal seizures.
October 4, 1906. — Following serial attacks this patient de-
veloped an acute pulmonary cedema. Loud moist rales
were heard over entire chest, and mouth filled with frothy
mucus. Pulse was full and strong and respiration noisy.
Examination of heart unsatisfactory, owing to noisy breath-
ing, but there was apparently a murmur accompanying sec-
ond sound at apex.
October 5, 1906. — Condition became worse; seizures re-
curred until death occurred at 1 :4s p. m. Temperature
was not above 100.8° F. No autopsy permitted.
Case III.— Lillian S... age, twenty-six years. Onset of
epilepsy at thirteen years. Both grand mal and petit mal.
Patient well nourished. No heart lesion and kidneys
normal.
January ii, 1908.]
SHANAHAN: PULMONARY (EDEMA IN EPILEPSY.
55
June 9, 1906. — This evening patient had one grand mal
seizure, following which she had a very marked pulmonary
cedema. Profuse blood tinged frothy expectoration. Pa-
tient received atropine gr. 1/50, strychnine gr. 1/30 hypo-
dermatically, and was dry cupped over chest. Tempera-
ture 100° F., pulse 120, respiration 68. Foot of bed was
raised. Condition improved rapidly, and patient was in
usual condition in thirty-six hours.
Case IV.— Chas. W. J. ; admitted to the Craig Colony
on March i, 1901 ; age, nine years. Seizures grand mal in
type. No heart lesion when admitted.
September 10, 1906. — Following serial attacks he had
marked pulmonary oedema. Entire chest was dull on per-
cussion, and coarse, moist rales were present in large num-
bers. Given atropine and whiskey hypodermatically, and
mustard paste applied to chest. Temperature 105° F.,
pulse 150, respiration 60. Temperature lowered to 103° F.
by alcohol sponge. Three hours later temperature was
105.4° F'., pulse 140, and barely perceptible at wrist.
CEdema slightly cleared up. Frequent seizures continued.
Patient rapidly became weaker, and death occurred six
hours later. Autopsy, by Dr. J. F. Munson, showed brain
very moist, and on section surface moist and somewhat
foamy. Small amount of fluid in each pleural cavity.
Heart weighed 165 grammes. Left ventricle firmly con-
tracted. Muscle felt firm and good. Mitral valve admitted
forefinger. Mixed clot under mitral valve flapped and ex-
tended up into auricle, making a cast ol their cavities.
Valve edges were thickened, but not hardened. Pulmonary
artery admitted thumb with difficulty. Flaps were nor-
mal. Thymus persistent.
Case V. — H. M. C, female; admitted July i, 1902;
type, grand mal and petit mal. Onset in early childhood.
Note on admission read first sound of heart was not clear.
January 31, 1906. — This patient had some severe seizures
early today, and soon developed a pulmonary oedema.
Temperature (rectal) at 7 a. m. 101° F., pulse 100, respira-
tion 20. At 10 a. m. she was dry cupped on back along
both sides of vertebral column, and was given atropine gr.
i/ioo every three hours. Large and small mucous rales
could be heard oyer entire chest, but especially posteriorly
over left lung. Palpation readily showed fluid in air
passages. Because of large amount of adipose tissue, per-
cussion was unsatisfactory. Heart sounds were rather in-
distinct, but appeared normal ; pulse was of fair volume.
Patient was partially conscious in interval between seizures
and took some milk by mouth. Pupils were even and not
dilated. No evidence of paralysis. Breathing stertorous.
At 2 p. m. temperature 99° F., pulse, 120, respiration 40. At
2:45 p. m., grand mal seizure. At 4 p. m., rales seemed
more numerous. She had another severe seizure at 5 :35
p. m., and was much worse thereafter. Heart sounds were
quite good at 7 p. m., as was also pulse; temperature (rec-
tal), 101-5° F., pulse 132, respiration 40. Condition grew
worse, and death occurred at 8 p. m. Considerable cyanosis
and laryngeal rales were present for some time before
death. Autopsy was not permitted.
Case VL — B. M. J., female ; admitted December 18, 1902 ;
age, eleven years ; type of seizures, grand mal. Onset at
three and one half years. Second sound accentuated. Urine
normal.
January 18. 1906. — At 5 :45 p. m. yesterday this patient
began having severe seizures in rapid succession ; she had
just finished her supper and had appeared as usual. At
6 p. m. rectal temperature was 99.4° F., pulse 118, respira-
tion 34. Patient was unconscious, and facial muscles were
in clonic convulsions, with no interval free from convul-
sions. High cleansing enema ordered to be followed by
enema of chloral hydrate, grs. xx, and potassium bromide,
grs. XXX. Seizures were so severe that after the fourteenth
the physician administered chloroform by inhalation until
seizures stopped. There were marked stertor and increase
of mucus in upper respiratory passages. After seizures
stopped the mucus was so profuse that it poured through
nose, patient became markedly cyanotic and respiration ir-
regular and shallow. She was turned on her side and her
head allowed to hang over the edge of the bed with her
face down. Her mouth was pried open with a spoon and
held so with the handle of a tablespoon ; then the tongue
was grasped with a towel and pulled out far enough to
permit air to pass through larynx. Mucus was expelled
from nose and mouth. Her condition began to improve,
and she began to return to consciousness. Pulse continued
of good volume throughout.
At 7 p. m. rectal temperature was 98.6° F., pulse 120.
At 10 p. m. she was restless, tossing about bed. With
this exception she appeared to be in her usual condition.
The following morning she was up to breakfast and about
as usual.
April I, 1906. — No prostration followed another series
of seizures shortly after the one described. Physical con-
dition was good.
July 31, 1907. — The patient had eleven grand mal seizures
between 7 a. m. and 8:35 p. m. The last seven occurred
in rapid succession between 8 p. m. and 8:35 p. m. Given
chloral hydrate, grs. xx ; potassium bromide, grs. xxx, by
enema. Foot of bed elevated six inches. 9 a. m. atropine
sulphate gr. 1/50 hypodermatically. Mustard paste applied
to chest for twenty minutes. Following the last seizure
patient developed a slight pulmonary cedema. Examina-
tion of chest showed slight impairment of resonance over
entire pulmonary area. Rhonchal fremitus over same area.
Scattered large moist rales over both lungs, but most
numerous over upper and middle lobes of left lung anteri-
orly. Pupils were dilated. Patellar reflexes were very
slight. Tlie remaining reflexes were unobtainable. Patient
was unconscious and slightly cyanotic. Pulse at 11 p. m.
100, regular and full ; temperature 100°, respiration 24.
Normal saline solution, i pint, given by rectum and re-
peated every three hours until patient returned to usual
condition.
August I, 1907. — Patient was bright and wished to get
up. Examination of chest was negative, except a few scat-
tered moist rales over left middle lobe anteriorly and in
left axilla. 8 a. m. temperature 100°, pulse 86, respiration
20.
August 2, 1907. — Examination of lungs was negative and
patient appeared in her usual condition.
Case VH. — C. P., male; age on admission, April 4, 1903,
was twenty-four years. Onset at eight years ; grand mal
and petit mal. Patient was well nourished, and heart and
kidneys were normal.
November 14, 1905. — This patient had had quite frequent
seizures for past few days, having had thirteen in three
days, and this morning he had eleven. He was mentally
disturbed since the day before, was constantly muttering
to himself, and frequently cried out. His temperature
was 102°. He was transferred to the hospital. Exami-
nation showed both lungs filled with loud moist rales,
and some dullness was noted over left lung in front.
Tongue was coated with heavy brownish fur. There was
some congestion of face and neck, which increased during
the evening. Respirations were labored and noisy, ab-
dominal muscles being brought into use. Mouth was filled
with a thick viscid mucus which had to be cleansed quite
often.
November 15, 1905. — He was disturbed during early part
of night, but after 10 p. m. was quiet. Temperature rose
last evening to 102° F., but this morning was 100° F.
Free perspiration last night, and patient could not be
aroused. Saline infusion into both mammary regions this
morning. Pulse was rapid and feeble, the respirations
being less frequent and more shallow, and patient died
at 10:50 a. m.
Case VHL— L M. B., admitted June 21, 1905; age, six-
teen years ; onset at six years ; heart and kidneys were
normal.
October i, 1905. — This patient had four mild seizures
yesterday and complained of pain in her abdomen. At
about 4:45 p. m. she passed into a condition of status epi-
lepticus, seizures beginning by head being turned to right.
When seen by physician she was having a general clonic
convulsion, was markedly cyanosed, breathing, stertorous,
with an unusual amount of mucus in the upper respiratory
passages ; bathed in a profuse perspiration, pupils small and
no reaction to light, corneal reflex absent, reflexes absent
in extremities, pulse 160 ; rectal temperature at that time
was 102.6° F. This morning she was in her usual con-
dition. After convulsion she had a slight lateral nystag-
mus. Right pupil was considerably larger than left, but
both responded quickly to light.
March 12, 1906. — At about 10 p. m. yesterday, night nurse
found this patient in a condition as if she had had a
severe seizure. Patients in same room said she had con-
vulsed for half an hour. She was breathing in a stertorous
manner, with considerable mucus in upper respiratory
tract. Pupils were moderately dilated. Pulse 150 per
minute, but of good volume; rectal temperature 103" F.
56
SHERMAN: FIRST WEEK OF LIFE.
[New
Medical
York
Journal.
Patient semiconscious and very restless. Knee jerks, wrist
jerks, and elbow jerks were active; no ankle clonus;
Babinski reflex present on both sides. At ii p. m. tem-
perature had dropped over two degrees. At 7 a. m. tem-
perature 100.4° F- Tongue lacerated. Patient was pale,
but otherwise in about her usual condition. Later in the
year she had a similar condition develop following seizures.
Recovery.
Case IX. — E. F., female; admitted March 24, 1904; age,
seventeen years. Grand mal. Onset at one year. Ac-
centuation of second pulmonic sound. Urine normal.
May 5, 1905. — This patient had a grand mal seizure last
evening. After the attack she developed a moderate
hemoptysis which gradually became less marked. Ice was
applied over her chest and she was given fragments of ice
to place in her mouth. Morphine, gr. ^, and atropine
gr. 1/150, were given hypodermatically. Pulse was 120.
This morning she was quite comfortable. Temperature
98.8° F., pulse 112, respiration 35. She had very large
tonsils and probably adenoid in nasopharynx. This morn-
ing an examination of the chest revealed many coarse
rales over right lung, especially along border of ensiform
appendix.
CASE X. — J. K., male; admitted March 28, 1905; age,
eleven years. Lungs normal Status with pulmonary
nedema every six to eight weeks. Occasional isolated grand
mal seizures.
August 3, 1906. — Temperature 103° F. Seizures stopped
01! administration of chloroform, morphine, and atropine.
CEdema cleared up in twenty-four hours.
November 25, 1906. — Status controlled by chloroform.
Pulmonary oedema and marked bronchorrhoea, with quanti-
ties of mucus from mouth and nose. Under treatment
cleared up in twenty-four hours.
Case XI. — C. H., female; admitted April 30, 1896; age,
twenty-one years. Grand mal. Onset at fourteen years.
No heart lesion.
March 7, 1905. — This patient had several severe seizures
last night and some today. This morning she was coma-
tose and remained so all day. In the afternoon she had
a slight elevation of temperature; pulse became very rapid,
as did also respiration. . Breathing was noisy, and laryngeal
rales were present. Auscultation showed many rales in
both lungs as a beginning of oedema of lungs. She was
given atropine sulphate, gr. 1/60, and strychnine sulphate,
gr. 1/20, hypodermatically. Latter drug repeated at inter-
vals of two hours for three doses, then gr. 1/40 given every
two hours.
March 8, 1905. — Condition was improved. Very few
rales heard over either lung. Patient coughed occasionally,
but did not expectorate. She took nourishment by mouth,
and was much brighter mentally. She did not answer when
spoken to. When smiling, muscles of right side of face
contracted more than did those of left side. She had a
few mild seizures, which consisted of head being turned
to left; slight lateral nystagmus and chewing movements;
no automatism or stertor ; duration about five seconds.
March 10, 1905. — Patient has much improved, but did not
talk. She took nourishment easily. Lungs were free from
rales. Still some elevation of temperature.
August 10, 1907. — Patient had serial attacks yesterday
morning at 5 :30. In spite of the administration of chloral
and bromide in large doses, and thorough flushing of the
bowels, the seizures continued, and pulmonary oedema
supervened. In the past twenty-four hours the patient
had had forty-one seizures, and was in the morning at 8:00
in a critical condition; temperature 100.6°, pulse 152, res-
piration 48. The oedema of the lungs was increased in
severity and the seizures recurred about every half hour.
Nitroglycerin, gr. i/ioo, administered at 8 :45 a. m. ; copi-
ous enemata of warm water; dry cups. Since last note her
condition had become progressively worse. She had ten
severe attacks between 5:30 a. m. and 12:55 P- rn . and
died at i :o5 p. m.
Autopsy: August 11, 1907. — Froth about nostrils. Hy-
postasis fairly well marked and patchy in character present
on upper chest and neck. Brain, large and soft, very moist,
and congestion marked. Microscopical examination was
negative. Both lungs showed moderate congestion and
oedema. Heart weighed 230 grammes; there was large
chicken fat clot in pulmonary artery ; right heart contained
mixed clot. Examination of valve was negative; endo-
cardium was pale.
Literature.
Riesman, David. Acute Pulmonary CEdema, with Spe-
cial Reference to a Recurrent Form. American lournal of
the Medical Sciences, January, 1907.
Osier. Practice of Medicine. Sixth Edition, 1906.
Meltzer, S. J., M. D. American Medicine, viii, 1904, pp.
19. 59, 151, 191-
CONCERNING THE FIRST WEEK OF INFANT
LIFE.*
By De Witt H. Sherman, M. D.,
Buffalo, N. Y.
The period of life which I have selected to dis-
cuss is one of much more importance than is usual-
ly considered, and really presents a subject too
broad to be covered in its many manifestations in
one paper.
The object of the paper is to recall to the mind
of the busy practitioner some of the often neglected
precautions M^hich can be taken in behalf of the
infant and to impress the necessity of asepsis in
their management. As a class of patients, I do not
suppose there is another one which is handled with
so much carelessness, almost neglect, as the new-
born babe. If it cries after birth, and starts to
functionate, the physician, as a rule, seems to think
his duties toward the child are finished, and it is
turned over to the nurse or attendant without defi-
nite instructions as to its care, or any warnings as
to the dangers which beset it. In its early hours
or days we have appreciated that disturbance of
the equilibrium of its vitality is to be feared, and
we are beginning to appreciate more and more the
dangers of specific morbid processes to which it is
very susceptible.
Only by reviewing the statistics of infant mor-
tality during the first month of life, and studying
the causes of the high death rate, can we fully ap-
preciate the responsibility imposed upon us in their
care. Eross gives the statistics of sixteen large
cities of Europe, which showed 1,439,000 births,
with a mortality during the first four weeks of life
of 9.5 per cent., which means 130,610 deaths. If the
vitality is measured by the weight, it is considered
that pounds shows a fair vitality, 5^/2 pounds
low, and pounds very low. To safeguard those of
low vitality there are a few subjects worthy of con-
sideration, and one of the most important is that of
the body temperature, for it gives definite informa-
tion of the child's ability to endure its new sur-
roundings. In the small or sickly infants, then, the
temperature should be taken every six to eight
hours, for their heat radiating surface being rela-
tively more active, as well as greater, than the
adult, they easily become markedly depressed from
chilling. Refrigeration produces a shock which is
momentous to the newly born.
During the first day or two of life is the only
time the surface temperature may be considered an
accurate indicator of the actual temperature of the
infant. Then, and then only, is the surface tem-
perature at all justifiable; but even then the rectal
temperature is more reliable, and should be the only
one considered by the careful observer.
A. H. Parks, of Chicago, asserts that the g^oin
'Read at a meeting of the Buffalo Academy of Medicine, Novem-
ber 12, 1907.
January ii, 1908.]
SHERMAN: FIRST WEEK OF LIFE.
57
temperature in the normal infant varies only
degree F. from that of the rectum, and for jesthetic
and other purposes is to be preferred. I cannot
elevate myself to this high plane of aestheticism
even in the female infant, and know of no other
poorer or yet better reason than sestheticism for
taking an infant's surface temperature. If the skin
is thoroughly dried, and the one half minute ther-
mometer is left in situ for from three to eight min-
utes, this slight variation of Ys degree F. may be
true in the normal infant, but in the pathological
states one sees the surface temperature often about
normal with a rectal temperature that is very
high. I consequently urge that the surface tem-
perature be always considered misleading. The
temperature per rectum should be kept above 98°
F. The birth temperature is about 99>^° F., and
in one hour is apt to be 96° or 97° F., and not for
a week can the child easily maintain 98° F. or over.
A second fruitful cause of physical depression
which may prove fatal is the disregard of the
amount of food ingested by the very young. It is
put to the breast, draws as strongly as its weak
muscles will allow, and from fatigue falls asleep ap-
parently satisfied, but in reality only having gotten
a teaspoonful or two of nourishment. Soon it
wakens, cries, and is again put to the breast for an-
other almost dry draw, and takes another cat nap.
Bad habits are formed, castor oil is given for sup-
posed colic, and the infant is correspondingly more
depressed and weakened, and the case becomes
more complex. As a remedy all that is needed is
a pair of scales to learn the amount of food the
babe is getting, and to supply this want, if it is
not being sufficiently fed. The stomach of the new-
born holds 25 c.c, almost an ounce, and, like most
human beings, it enjoys having it filled occasional-
ly, especially after a day or two of almost complete
fasting.
A third physical cause of depression is pain aris-
ing from the fact that too little water is g^ven to
the newborn, and too often is there a neglect to add
to this water a small amount of an alkali. It is
commonly known, and almost as commonly forgotr
ten, that uric acid infarction of the kidney of the
newborn is not infrequent. Post mortem exami-
nations show the orange or light red color near the
pyramids, usually due to the ammonium urate,
amorphous urates, or uric acid crystals. They are
easily washed away by water, especially if it con-
tains an alkali, and this simple remedy promptly
produces relief of pain, too commonly treated by
castor oil given in doses for the newborn heroic.
As a routine practice I give all my infants a little
weak sodium bicarbonate water during the first
couple of days of life.
As a fourth cause of physical depression some
criticism is justifiable of the rougher methods of
performing artificial respiration. Because many an
infant can survive low body temperature and lack
of food, so can many stand the rough handling of
some of the methods, such as the swinging ones.
But for the weak these methods are very exhaust-
ing, and in any case should be omitted, if possible.
A simple, not heroic, and very successful method,
called Byrd's method, is to allow the infant to lie
with its back on the palm of one's hand, with two
fingers supporting its head. The thumb encircles
one side of the chest, and the fourth and little finger
the other. The other hand grasps the legs. As the
thighs are bent onto the abdomen, compressing it,
the chest can also be compressed. As the thighs
are extended and the body arched backward, the
chest can be released. It can be performed in a
warm bath, if advisable, and accomplishes good re-
sults with a minimum of fatigue. It compresses the
chest, and by its rhythmical pressure massages the
heart.
In the severe cases the violent methods may be
necessary. In these where the reflexes are wanting
it seems to me there is little avail — in fact, time is
wasted — in resorting to Laborde's tongue traction
method, which is supposed to irritate the superior
laryngeal, the glossopharyngeal and the lingual
nerves.
Sheill, of Dublin, recommends injecting a small
amount of adrenalin through a silver cannula, in-
serted into the umbilical stump, the ligature having
been loosened, to relieve shock and to assist the va-
rious methods of artificial respiration. It is so
much of an operation that it is rarely feasible. The
simpler and gentler the procedure of artificial respi-
ration necessary to produce the desired results the
better. In many of the conditions, such as mal-
formations, injuries during labor, etc., we may be
powerless to accomplish more in saving life than we
are now accomplishing, but in many of the con-
ditions, nervous, pulmonary, gastrointestinal, and
the like, which are of a possible infectious nature,
we may, by strenuous efforts, produce better re-
sults than we are now securing.
Many conditions previously thought functional
disturbances are now considered infectious. To
just what pathogenic bacteria some of them are due
is not now known, for, as the result of a great deal
of research, there is no single germ or series of
germs always present in a given set of symptoms.
If the mortality from septicaemia can be so great-
ly reduced by strict asepsis, as has been done, espe-
cially in maternity hospitals, so can we, in both in-
stitutions and in private practice, help decrease the
infant mortality by similar properly directed care.
In considering the sources of infection of the
newly born we may start with the placenta, which
has been proved to be a fairly reliable filter to pre-
vent infection of the foetus in utero, although the
protection may not be complete. We have the
transmission through it of syphilis, and it may be of
tuberculosis, and some other infections, as well as
the toxines of various diseases. This is a source
we cannot well control, but the vagina, which we
know often teems with bacteria, does come within
our scope, and I see no reason why more attention
cannot be paid, opportunity and time permitting,
to cleanse and disinfect it. With the vagina fairly
sterile we come next to the hands of the attendants,
the careless use of which are undoubtedly the cause
of very many of the conditions, properly considered
infectious, those gastrointestinal and pulmonary in-
cluded. Could the responsibility be definitely
placed, the relief would be promptly aflForded. The
accoucher with hands contaminated from careless
cleansing or from the faecal matter expelled from the
bulging anus, or the nurse who cleanses the anus
58
SHERMAN: FIRST WEEK OF LIFE.
[New York
Medical Journal.
for him or handles other infected articles, either
one may jeopardize the child's life by introducing
some pathogenic germ on the finger inserted into
the child's mouth to remove the mucus or liquor
amnii. Consequently let the mouth alone, whenever
possible, or see to it by previous instructions that
the nurse with sterile hands and a finger incased in
sterile soft gauze be the only one to attend to this
part.
In institutions the opportunity for dissemination
of disease germs is recognized and vigorously met,
but in private practice too little attention is paid to
strict asepsis in the care of the infant. How many
trained nurses are there who are told, after cleaning
the lying-in bed, to sterilize their hands before wash-
ing out the newborn infant's mouth in its first toilet?
They appreciate the necessity for asepsis in the care
of the nipples to prevent inflammation or abscess of
the mammary glands of the mother, but will show
the physician a soiled diaper and soon prepare the
nursing bottle with food or drinking water.
During the first three' of four days the infant
needs water to drink more than most any other time
in its life. If sterile water with soda is given for
the first twenty-four or thirty-six hours, plain sterile
water can later be used, which may, with compara-
tive safety, be allowed to remain in the drinking bot-
tle on the radiator for immediate use. But think of
the bacteria growth we may be administering if the
plain or even filtered Niagara River water be left
comfortably warm for an indefinite number of hours
for this same immediate use. Undoubtedly many an
infant has been made seriously ill by this one pro-
cedure.
In considering the port of entrance of infection it
is often difficult to determine it definitely, but the
mouth, according to Hamill, is probably the com-
monest gateway, the cord, lungs, and other avenues
and parts of the body following in about the order
mentioned.
Let us consider briefly some of the symptoms of
infection often supposed to be other conditions. The
first are the gastrointestinal disturbances. When
pathogenic germs are inserted by mouth the common
set of symptoms are those of intestinal indigestion
or colitis. The child is not anxious for food, cries
from pain, has loose undigested stools, generally con-
taining mucus, and has fever. These symptoms
appear anywhere from the third or fourth day to
the fourteenth or eighteenth, and should, in the large
majority of cases, be considered an infection rather
than an indigestion from improper percentages of
food strength. The breast milk, which may contain
the source of the trouble, or the artificial food should
be stopped for a few hours or a day, and the gastro-
intestinal canal cleansed with sterile water, calomel,
or small doses of oil. Soon other good breast milk
or different artificial food should be used, and used
sufficiently long till the mother's breasts or milk
seem normal, or the return to modified milk seems
perfectly safe. By treating these conditions as in-
fectious rather than indigestions, our measures will
be more prompt, more thorough, more supportive,
and more definitely directed to the point, thereby
checking the disease in its incipiency.
Another class of conditions for which we do not
seem to hold ourselves responsible are the pulmonary
infections. We fairly often hear of inspiration pneu-
monia of the newborn. The diagnosis may be made
from the rapid irregular respiration, cyanosis, high
fever, and prostration rather than from definite
physical signs. In these cases the autopsy reveals
absolutely no pulmonary lesion, showing only that
the condition is an infection through the respiratory
tract, or brought to it from some focal point.
We can in the same manner account for other in-
volvements, such as the skin with its numerous erup-
tions of varied types, the erythema, the ecchymoses,
erysipelatoid eruptions, and the petechise ; or of the
nervous system, such as muscular twitchings, rolling
of the eyes, retraction of the head or convulsions,
symptoms which cannot be accounted for by trauma
or haemorrhage, or pressure inside or outside the
skull cap.
These nervous symptoms may be laid at the door
of the kidneys, but can we say that the kidney in-
volvement is primary and not secondary to some
systemic infection? The kidneys of the newborn
are easily vulnerable and may contribute. Accord-
ing to J. Lovett Morse, the presence of a small
amount of nucleoalbumin in the urine during the first
four days of infant life is constant, and lasts often
for two weeks. This albumin he considers due to
the changes in circulation, to hyperasmia resulting in
excessive metabolism after birth, to renal disease in
the mother, and to uric acid irritation. While there
is evidence that uremia may sometimes be the causal
factor, there is just as much evidence that the kid-
ney involvement is a complication of the general in-
fection. The treatment then includes the removal of
the focal point of infection, as well as overcoming
the symptoms of the nervous condition.
Gallant, in a thorough article on the umbilicus in
the newly born, quotes Cholmogorofl:', who demon-
strated that the cord at birth is free from microor-
ganisms. He differs from Hamill, and considers
that umbilical infections are more common than by
mouth, and refers to i,ooo infants, studied by Eross,
in whom but thirty-two per cent, ran an afebrile
course. Eross concludes that the greatest danger of
infection is through sphacelus of the cord. The
commonest microorganisms causing infection are the
Staphylococcus aureus and Streptococcus pyo_s;e)tes,
and they are probably the exciting cause of four
fifths of the cases, the staphylococcus producing, as
a rule, the milder symptoms. Infection of the navel
from the clinical aspect depends first upon the extent
of the involvement, whether limited to the cellular
tissue, arteries, or the vein, or commencing in one
and extending to the others, and, second, the viru-
lence of the microorganism. When the base of the
stump is infected, the sloughing tissue, moisture, and
warmth give favorable soil for their multiplication.
The toxines eliminated by them are absorbed, caus-
ing toxaemia, with fever and symptoms pointing to
some particularly aflfected part. Through the short
thrombosis of the arteries or vein, which is only an
inch or so in length, the infection reaches the other
parts of the body, early attacking the liver and pro-
ducing jaundice, or carried to the lung producing
pneumonia, or if to the brain purulent encephalitis
or cerebral abscess.
The icterus neonatorum is probably more often
hepatogenous than hjematogenous, especially if asso-
January ii, 1908. 1
SHERMAN: FIRST WEEK Of LI EE.
59
ciated with a mild fever, and occurring on the third
to the fifth day. The point of danger is the attacked
base of the cord, and the period of danger ends noc
with the separation of the cord, but with the cicatriz-
ing of the granulation surface beneath it. The best
dressing then is a dry, sterile gauze or linen without
drying powder, so applied, if possible, as to prevent
air contamination, and taking pains in applying new
dressings not to touch, wipe, or handle the base. Gal-
lant recommends balsam of Peru i part to i6 parts
of castor oil, both sterile, applied to the base with a
thick occlusive dressing of sterile gauze for the cord,
the whole held to the abdomen by adhesive straps.
It is to be changed when soiled, or every third or
fourth day, and by the physician, and only under
aseptic precautions.
A recent fatal case of malsena neonatorum has im-
pressed me with the virulence of the cause, if it is an
infection, and also brought prominently into my con-
sideration the possible effect, as a causal factor, of
maternal intoxication upon the foetus. Let me briefly
relate the case :
This young woman had borne previously two healthy
girls, and was in perfect condition, except for rather un-
usual periodical headaches, occurring about the time of
menstruation. A healthy eight or nine pound boy was
born after a short labor of four hours, during which only
one vaginal examination was made. Immediately after
birth a large amount of liquor amnii ran from the child's
nose, and it ejected from its mouth a large mass of mucus.
Its mouth was gently wiped out with sterile gauze by the
nurse, whose hands had been carefully cleaned numerous
times. The cord, which was thick, was thoroughly tied
after stripping, but in an hour commenced to bleed. Dur-
ing the first day it was tied eight times, all promptly suc-
cessful, but later ineffectual. When nine hours old the
baby vomUed a" little rather bright red blood, and as the
case was suspected as possibly being one of malsena neona-
lorr.m, treatment was commenced at once. Careful physi-
cal examination of the infant at this tim.e revealed nothing
abnormal. As time advanced the cord continued to ooze,
more blood was vomited, there were bloody stools, and
petechial haemorrhages appeared on the left thigh, and later
on other parts of the body. Frequently the child seemed
in great distress, cried out, presenting a typical facies of
pain. Its temperature was never above normal, rather an
unusual condition for ordinary infections, and its pulse
and respiration were not much altered. In spite of ener-
getic treatment, the child died when forty-four hours old,
literally having bled to death.
The treatment of the cord consisted, besides frequent
ligation, of pressure, applications of adrenalin, Monsel's
solution, and the actual cautery, all without avail. The
internal bleeding was treated by means of a 4 per cent,
gelatin solution given by mouth in teaspoonful doses, also
calcium chloride. in gr. J/^ doses, soon followed by ergot
hypodermatically and normal saline hypodermochysis. As
a supportive measure I fed the child on diluted, later
whole, breast milk. The blood from the cord, stomach,
and bowels was taken in sterile tubes and cloths and ex-
amined by Dr. C. A. Bentz. He reports finding the Strepto-
coccus pyogenes. Staphylococcus aureus, and the Bacillus coli
communis. There were no other growths on his cultures.
A post mortem examination was refused and hence further
samples of blood were not obtainable.
Hamill, in discussing this subject, mentions six
different microorganisms isolated, viz.. Bacillus pyo-
cyaneus, Bacilhis lactis aerogenes, Colon bacillus,
Staphylococcus aureus, Bacillus coli immobilis, and
the Streptococcus pyogenes. These are the ones
most commonly found. He also mentions, as found
by others, the pneimiococcus, Pfeiffer's bacillus, the
bacillus of Babes, Bacillus hccmorrhagiciis of Kolb,
bacillus of Gaertner, and the encapsulated bacillus
of Dugern. Of all these the streptococcus, the 5a-
cilhis coli communis, and the staphylococcus are
most commonly encountered.
Almost all writers on this subject consider the
condition due to infection, but there are others who
lay stress upon maternal intoxication. In my case
the symptoms were more those of shock from haem-
orrhage than from infection, and the structural or
anatomical defects possible from maternal intoxica-
tion are worthy of consideration. During the last
two weeks of her pregnancy the mother experienced
two or three headaches, and some pain along the
course of the spinal column. Albumin appeared in
the urine, and the kidneys functionated a little less
actively, though on the whole they behaved fairly
well. These probable urjemic symptoms were not
severe enough to be alarming, and were expected to
be only of short duration, since the date of the ac-
couchement was only a few days off.
The factors we have in this case are maternal in-
toxication, probably of kidney origin, an apparently
healthy infant born in a room thoroughly house
cleaned, attended by persons carefully cleaned. The
infant died of numerous free haemorrhages shortly
after birth, and at no time had had a rectal tempera-
ture over 99.5° F. It is a history and set of symp-
toms which may point to an infection, but also is
very suggestive of a lack of coagulability of the
blood or impaired ability of the bloodvessel walls to
retain the blood, one or both possible conditions fol-
lowing maternal intoxication.
Malaena neonatorum is supposedly a selflimited
disease, commencing in almost all cases within the
first ten days, in many cases on the second day, and
lasting for five to nine days. As a rule, the amount
of blood is not excessive, but is none the less a dan-
gerous condition because the bleeding is continuous.
Townsend, of Boston, found reports of 709 cases
having a mortality of seventy-nine per cent. The
intestinal haemorrhages generally begin early, with-
in the first three days, the umbilical haemorrhages
more commonly coming later, from the fourth to
the seventh day. If the bleeding is from the female
vulva and occurs alone it is generally not danger-
ous. Haemorrhage in the newborn does not appear
to have much relation to haemophilia. McClanahan,
of Omaha, in looking up this subject, mentions
Grandidier's statistics of 576 hasmophilics, and only
twelve of them had any history of early bleeding.
Edward P. Davis made a valuable contribution in
reference to prenatal infection in diseases of infancy
by examining the blood of twenty-six mothers and
infants, and reached the following conclusions, viz. :
The infant's blood is not dependent upon the
mother's plethora or anaemia for its cells or haemo-
globin ; except in acute infections the placenta is usu-
ally sterile ; the faeces of the infant before it has
nursed may contain micrococci ; the mother's milk
before the infant has nursed may contain micrococci.
In conditions of maternal toxaemia the same poison
which affects the mother is transmitted to the child,
in some instances by substances other than bacteria.
There exists in infants a toxaemia of intestinal ori-
gin, mild cases of which are susceptible to treatment,
while severe cases end in multiple haemorrhage and
death. In the latter a germ, resembling that associ-
6o
BIERHOFF: GONORRHCEA IN THE FEMALE.
[New York
Medical Journal.
ated with yellow fever, is capable of transmission
through pregnant animals to their young and has
been isolated.
So far as treatment is concerned, thorough lavage
of the intestines with sterile saline solutions gives
best promise of success. Should the mother's milk
be infected, sterile modified milk or other foods
known to be sterile should be employed.
680 West Ferry Street.
ON THE ABORTIVE TREATMENT OF GONOR-
RHCEA IN THE FEMALE.*
By Frederic Bierhoff, M. D.,
New York,
Attending Physician, Dennatological Department, German Dispen-
sary; Member of the Academy of Medicine; Corresponding
Member of 1' Association fran?aise d'urologie, etc.
By the term "abortive," in relation to treatment,
we mean that form of treatment which brings about
a cure of the disease upon one or two applications.
The term is used in contradistinction to the prophy-
lactic, or preventive, methods, which do not come
imder the scope of this paper. While the lattei
methods seek to prevent the development of a gon-
orrhoea in a person who has been exposed to the pos-
sibility of an infection, the abortive method seeks to
cure an already present gonorrhoea.
In order to be able to abort a gonorrhoea in a
female, the disease must be recognized in its very
earliest stages, and before any structure other than
the urethra itself, or the urethra and vulva, or va-
gina, has become involved. In the early recogni-
tion of this disease we find our greatest difficulty to
the successful accomplishment of an abortive treat-
ment, for women very rarely present themselves to
the physician for examination to determine the pres-
ence of a gonorrhoea.
This disease frequently runs so mild a course, the
infection is of so mild a type, that the women usu-
ally ascribe the very slight symptoms which they no-
tice to a possible urethral irritation or a slight "cold,"
rather than to the possibility of gonorrhoeal infec-
tion. When a woman, whose suspicion of gonor-
rhoeal infection has been aroused, presents herself to
the physician for examination as to the presence or
absence of gonorrhoea, the physician, in by far the
large majority of cases, contents himself with a
physical examination of the parts, and, should he
not find distinct evidence of an acute inflammatory
process, which he recognizes by a reddening of the
vulva and meatus, and by the presence of a more or
less purulent discharge, pronounces the woman to
be free from infection.
Were physicians to rely solely upon the outcome
of a microscopical examination of the scrapings from
the urethral and cervical canal, they would find that
a fair proportion of supposedly healthy women are,
in reality, afflicted with gonorrhoea in a subacute or
chronic form. Since I have based my diagnoses
solely upon the microscopical findings in the cases
of females, I have been surprised to find how many
of them there will be found who, in the absence of
any inflammatory reaction about the urethral orifice,
'Read, in abstract, before the New York County Medical Society,
March 35, 1907.
or in the absence of any visible discharge whatever,
are still found to be infected with gonorrhoea, as
shown by the presence of typical gonococci in the
urethral and cervical scrapings. Were the initial
stage of a gonorrhoea in a female accompanied by
more severe symptoms — that is, more pronounced
distress upon urination, as is the case in the male, so
that the women were led to consult a physician ear-
ly in the disease — and were physicians to rely for
their diagnosis solely upon the findings under the
microscope, I feel sure that a large percentage of the
women examined would be found to be suffering
with gonorrhoea, and an abortive treatment might be
possible in a larger proportion of the cases found in-
fected. Unfortunately, however, in almost all of the
cases of gonorrhoea in females, the patient presents
herself at a time when the process has already got-
ten a deeper foothold in the urethra, or when the
urethral crypts, or the cervix uteri, have become in-
fected. Then, of course, an abortive cure is impos-
sible.
Frequently, too, it is difficult to decide whether
the urethritis is in the early stage of an acute infec-
tion, or whether it is of a chronic character. In the
decision of this point, I have found the following
facts to be of great value to me. In acute urethritis
the condition will be found such as Bumm has so
beautifully described in his report upon gonorrhoea
in the female, as a result of his inoculations with
pure cultures of the gonococcus : "After the inocu-
lations a serous, transparent, yellowish secretion ap-
pears, which contains but few pus cells, but myriads
of epithelial cells. In these, and between them, the
gonococci lie in large numbers, in colonies, and soli-
tary examples." Similarly, in the female as in the
male, Bumm's experiments have shown that these
clinical signs occur about the third day after inocu-
lation. Later on, during the first weeks, the propor-
tion of pus corpuscles increases.
In chronic cases of urethritis in the female, I have
found, in all instances, that we have to deal with
more or less faint traces of mucopurulent secretion,
which is found, upon examination, to consist of bro-
ken down pus corpuscles, epithelial cells, and mucus.
The microscopic organisms are chiefly bacteria other
than the gonococcus, and usually occur in the form
of bacilli and diplobacilli. The gonococci are rela-
tively few in numbers, but, upon careful examina-
tion of the specimen, points will be found where they
have the typical form, and intracellular location. In
the acute stage of the infection the gonococci are nu-
merous, and many lie in the pus cells ; the pus cor-
puscles will be found to be fresh in their appearance,
and to retain their, cell contours and their nuclear
contours much more perfectly than in the chronic
stage of the disease, where the cell bodies will be
found to be broken and degenerated, and the nuclei
very often riddled with vacuoles.
It will be seen from these observations that, in or-
der to effect a cure by the abortive treatment, it is an
absolute necessity to make the diagnosis early, and
that, in order to do this, one must possess the requi-
site degree of bacteriological knowledge to determine
the exact character of the condition to be treated. I
have found that, in making the microscopical exam-
ination, the ordinary watery solution of methylen
blue, or the alkaline methylen blue, is fully sufficient
January ii, .908. | BIERHOFF: GONORRHCEA IN THE E EM ALE. 6l
to enable us to make a clinical diagnosis, where the
question is one of distinction between the gonococci
and other diplococci ; but in the chronic stages it may
become necessary to resort to the Gram distinctive
stain, and where the question becomes one of med-
icolegal importance, the culture experiment must be
resorted to.
The condition, sine qua non, then, of the abortive
treatment of gonorrhoea in the female is, just as in
the male, the microscopical examination. If, now,
the patient presents herself at an early stage of the
disease, and if it be found upon examination that the
gonorrhoeal infection has not extended to the Bar-
tholinian glands, or to the cervix uteri, then the at-
tempt to employ the abortive method is justified, for,
if we do not achieve an abortive result, we do not
injure the patient, nor do we do anything that would
favor the spread of the infection. Where the Bartho-
linian glands or the cervix uteri are involved, an
abortive treatment is impossible.
That the urethra is, in a large proportion of the
cases, the seat of gonorrhoea in the female, has been
determined by careful examinations of competent
observers, and this is in direct contradiction of the
views which were formerly held. Steinschneider
found the urethra involved in forty-seven per cent,
of the cases ; Horand, however, in seventy-five per
cent., and Baum, Luczny, and Wolff in ninety per
cent. The findings of other observers agree, in the
main, with these statements — that, in by far the large
majority of all cases of gonorrhoea in the female, the
urethra will be found to be involved. Where the
conditions for the employment of the abortive treat-
ment are favorable (and I frankly admit that this is,
owing to the circumstances which I have named, in
but a small percentage of the cases of gonorrhcea
coming to our notice), the procedures which I have
employed with success are as follows :
I. A microscopical examination of the urethral se-
cretion, or scraping, and of the secretion showing at
the vulvar orifice.
II. Cleansing of the meatus, and irrigations of the
urethra and surroundings with a solution of one
quarter to one half per cent, solution of protargol.
Either the hand syringe or the irrigator may be em-
ployed, but no great degree of pressure should be
employed. In all about 150 c.c. are used for the
urethra and surroundings, after which about 150 c.c.
of the fluid are injected, through the urethra, into
the bladder, to be later expelled by the patient. In
this latter irrigation, the patient is instructed to relax
the muscles, as though about to urinate, when the
urethra feels distended, whereupon the fluid will be
found to flow easily into the bladder.
III. Cleansing of the vulva with 150 c.c. of the
solution.
IV. A vaginal scraping is now made and exam-
ined, the sterilized platinum loop being passed well
into the vagina for this purpose.
V. The nozzle of the syringe is gently inserted
into the vagina, the stream of the solution, during
this time, passing into the vagina, and the nozzle in-
serted up to the point where the body of the syringe
blocks the outlet. The syringe blocking the outlet to
prevent the escape of the injected fluid, the injection
is continued until the vagina becomes distended with
this solution, which is then allowed to flow out.
About 300 c.c. of the solution are used for this vagi-
nal cleansing.
VI. A sterilized speculum is inserted into the va-
gina— preferably of the duckbill type — and the va-
gina, particularly the fornices and the cervical orifice,
cleansed by gently wiping with little cotton pledgets.
VII. A specimen of the cervical secretion, or a
scraping from the cervical canal, is now made with
the sterilized loop, and a microscopical examination
thereof made. Should this be found to be free of
gonococci, and to contain few or no pus corpuscles
whatever, then the vagina is lightly tamponed with
several yards of narrow, absorbent gauze strips, sat-
urated in one per cent, protargol solution, and the
speculum withdrawn. I employ the tamponade
whether the vagina be infected or not. If it be in-
fected, I employ a five per cent, solution. There is
then an exfoliation of the superficial epithelial layers,
and usually, in from twenty-four to forty-eight
hours, the vaginal secretion will be found to be ster-
ile. If the vagina be not infected, its infection is
prevented by this tamponade.
VIIL A soluble urethral bougie of five per cent,
protargol in cacao butter, made of a length of an
inch and a half, is inserted into the urethra and left
therein.
IX. While the index finger of the left hand main-
tains the urethral bougie in place by pressure of the
finger against the meatus, a pad of absorbent cotton,
saturated with one per cent, protargol solution, is
placed over the urethral and vulvar orifices and kept
in place with a "T" binder. As the patient has uri-
nated in emptying the bladder of the fluid injected
into it, she is now instructed to resist the desire to
urinate, if possible, for several hours, so that the
drug in the melting bougie may be kept in contact
with the urethral mucous membrane for as long a
period as possible. The pad covering the vulva is
also kept moist with the one per cent, protargol solu-
tion.
X. Rest in bed, if possible, is of advantage in the
treatment. Bland diet should be ordered; all in-
toxicating or carbonated drinks avoided, and all
highly spiced articles of food omitted from the diet-
ary. A daily warm sitz bath, in the evening, com-
pletes the treatment. The tampon is left in place for
twenty - four hours, whereupon it is removed by
the physician, and the treatment, as outlined, re-
peated. Should the patient desire to urinate, the
moist pad is simply removed, to be replaced at once
thereafter. Under this treatment, within twenty-
four to forty-eight hours, if the cure is to prove a
success, the urethral secretion must be free of gono-
cocci, as must also the vulvar and vaginal scrapings.
After two such applications, if there be no more
gonococci present, it is my custom to begin the tests
by omitting entirely the urethral irrigation and bou-
gie, and by substituting a vaginal irrigation of bi-
chloride of mercury solution, i in 4,000, or a solu-
tion of one half per cent, zinc sulphocarbolate for the
irrigation with protargol, and the vaginal tampon is
entirely omitted. The warm sitz baths are, however,
continued for a few days longer. Should the test of
the interruption of treatment be followed by no re-
turn of gonococcus bearing secretion, then we pro-
ceed to the alcohol test. Further control examina-
tions must be made at intervals, and only when the
62
IVHITE: CEREBRAL CONTUSION.
[New Yokk
Medical Journal.
urethral and cervical scrapings continue free of gon-
ococci, even after the next following menstruation,
may we discharge the patient as definitely cured.
Should discharge with gonococci reappear during
the tests, then we simply continue with the treatment
until the patient is cured.
51-53 East Fifty-eighth Street.
CEREBRAL CONTUSION.*
By Charles S. White, M. D.,
Washington, D. C,
Superintendent, Emergency Hosi)ital.
An injury to the head sufficient to cause loss of
consciousness for a brief period is the strict lim-
itation of concussion, but the more prolonged coma
or manifestation of cerebral incompetency without
fracture should be defined as cerebral contusion.
It is very probable that so called concussion is but
a slight degree of contusion, but it simulates the
latter condition in its aetiology, pathology, and
symptomatology, and Kocher maintains that there
is no place in a medical vocabulary for the word
■"concussion."
The causative agent is trauma, applied directly
or indirectly. A blow upon the vault or striking of
the head upon an unyielding substance are the
more usual factors, but the force may be trans-
mitted through the spine, as severe falls upon the
buttocks may be followed by severe symptoms of
cerebral contusion. If the object through which
the force is applied is of a yielding nature, con-
tusion of the brain is likely to be a sequence, but
fracture is improbable, 'hence the use of sandbags
and lead pipes as weapons of assault is founded
upon a rational basis.
The pathological changes following cerebral con-
tusion vary from those of microscopic proportions
to tremendous haemorrhages. In the milder types
of the affection the changes are not evident to the
eve perhaps, but section will show minute rents in
the white and gray matter, with here and there a
pinpoint haemorrhage. This would correspond
clinically to the degree of unconsciousness popular-
ly called concussion. In the more severe cases, the
variations in the pathology are of degree rather
than character. The lacerations may be invisible,
but punctate haemorrhages may be seen throughout
the brain, varying in size from a pinpoint to the
size of the lead in a pencil. In those cases which
result in death, the lacerations may be evident to
the eye, and the haemorrhage, either cerebral, sub-
dural, or extradural, may be of great magnitude ;
therefore the term diflfuse cerebral contusion has
been appropriately applied to this condition. While
in the majority of cases the lesion lies immediately
beneath the point where the greatest force was
focused, in many instances it is widespread and no
part of the cerebrum escapes the violent oscillation.
On the contrary, the lesion may be one of contre-
coup, and especially is this true of haemorrhage. In
a personal communication the deputy coroner of
the District of Columbia, Dr. L. W. Glazebrook,
states that in 500 autopsies he found death the
•Read at a nii;eting of the Clinical Society, Washington, D. C,
Novcmher ii, 1907.
result of cerebral concussion or contusion, without
a gross lesion, in seven cases, and in twenty-four
cases there was haemorrhage without fracture.
With haemorrhage of any intensity there is in-
crease of the intracranial pressure, many instances
severe enough to retard the venous outflow; in
other words, a passive congestion. Following this
is an exudate from the vessels, oedema of the brain,
the pressure of which modifies, but does not par-
alyze, the medullary centres, but retards or prevents
the normal cerebration, both psychic and physical.
The centres in the medulla are vital and are the
last to succumb to the increased tension. With the
increased pressure an antemia is the physiological
result, inasmuch as the calibre of the cerebral ves-
sels is reduced by compression. The higher centres
in the medulla feel this loss of arterial blood, and
from the reflex stimulation the heart attempts to
force more blood into the brain ; hence the full
bounding pulse and increased blood pressure. The
cjedema may be temporary or more or less perma-
nent. To quote Osier: "The symptoms of
compression following concussion or contusion, as
shown by Cannon, are frequently attributable to
cerebral cedema due to changes in osmotic pres-
sure. . . . The anatomical changes are not unlike
those of anaemia. (When the anaemia follows pro-
gressive atrophy, the fluid is chiefly in and beneath
the membranes.) The brain substance is anaemic
and moist, and has a wet, glistening appearance
which is very characteristic. In some instances the
oedema is more intense and local, and the brain
substance may look infiltrated with fluid."
The gray matter of the brain does not regen-
erate, once destroyed, and the lacerations which
follow contusions of the brain are permanent gaps
in the communication from cell to cell, bridged
over by fibrous tissue derived from the lymphocytes
or wandering cells of the blood stream. The co-
ordination of ideas or acts may be seriously inter-
rupted by the distribution of fibrous tissue. The
reparative process may seriously interfere with the
circulation and a permanent oedema of the brain be
the consequence.
Symptomatology.- — Following an agitation of the
brain or violent movement from direct or indirect
force, there is a period of unconsciousness immedi-
ately supervening which may last from a few mo-
ments to as many weeks. The face is pale, cold,
and often moist ; the pupils usually dilated, reacting
to light ; the pulse full, compressible, between 70
and 90 ; the respirations free ; the temperature sub-
normal, and the blood pressure below 110. There
is no involuntary evaluation of faeces or urine, and
the patient lies quietly. A period of reaction soon
occurs, the skin becomes warmer, the pulse firmer,
the person may become restless : he can be aroused
by a vigorous shaking and perhaps give monosyl-
labic answers to questions shouted in his ear. In a
case in which the contusion is slight or mild, the
mentalitv is impaired for a brief period, and in an
hour or two he may give intelligent answers and in
other respects appear responsible. Headache and
nausea may be an accompaniment, with mild con-
stitutional symptoms.
The severe contusions are worthy of the greatest
consideration, and the period and degree of uncon-
January ii, 1908.]
WHITE: CEREBRAL COXTUSION.
63
sciousness is the most reliable index of cerebral
mischief. In the severe contusions of the brain,
the coma is profound, pupils dilated or contracted,
usually retaining the light reflex, pulse full, with-
out a great variation from normal, breathing deep
and even stertorous, faeces and urine retained, dor-
sal decubitus and a cool moist skin. Vomiting is
present in the great majorit}' of cases. Bleeding
from the ear is not an uncommon symptom, and
contrary to the general opinion is not sufficient evi-
dence to adduce the presence of fracture of the
base, but more frequently signifies a rupture of the
tympanic membrane only. Bleeding into the con-
junctiva and from the nose is more dependable
as a basal fracture sign. The reaction will be slow,
occupying days. The coma is succeeded by an
active, even maniacal, delirium, lasting from one
to seven days, then a stage of irritation and im-
perfect judgment; later by a quiescent, calm period,
but marked by inability to concentrate, a defective
memor}-, and a lack of original ideas. The con-
joined periods may occupy several weeks, and the
ultimate recovery is" postponed several- months.
The blood pressure is low at first, followed by a
rise. A period of unconsciousness, brief or pro-
longed, after a head injury, followed by coma, in-
dicates plus cerebral pressure due either to haemor-
rhage or oedema, and often can be foretold by the
sphygmomameter. The conscious period may be
a few moments or even twenty-four hours, and a
number of cases have been reported in which indi-
viduals have received cephalic injuries and after-
ward completed a day's work seemingly well, and
shortly after expired from the effects of haemor-
rhage. Traumatic cerebral haemorrhage without
fracture is not uncommon. An excessive rise of
blood pressure is a reliable indication of com-
pression.
Gorin quotes Phelps as sa\-ing : "The loss of con-
sciousness which immediately succeeds a cephalic
injury is always the result of a diffuse cerebral con-
tusion. If unconsciousness is preceded by a con-
scious interval, however brief, or if after restoration
of consciousness to unconsciouness soon recurs, it is
occasioned by some form of intracranial pressure.
... It will be recalled that the recurrence of un-
consciousness after an early interval of sensibility
is indicative of an increased or supervention of
haemorrhage, and that at a later period more or less
conscious intervals in a general unconsciousness re-
sults from lessening from time to time of the
hyperaemia or oedema of a diffuse cerebral con-
tusion."
Symptoms dependent on increased pressure in the
brain are not so frank as those of apoplexy, but a
close examination will probably reveal sufficient
grounds upon which to base a sound diagnosis.
Paralysis may be slight, monoplegic, hemiplegic, or
limited to a group of muscles. Spasticity of a limb
or few muscles is valuable and the comparison of
the tendon reflexes is of much assistance; an in-
crease is likely to be noted in the affected region.
The Babinski sign may be present. Focal symp-
toms dependent of the cranial nerves will likely be
absent, and anaesthesia without paralysis is rare.
The alteration of the steriognostic sense will like-
ly be noted in some cases. The temperature will be
elevated after the initial fall, and a considerable rise
is an unfavorable symptom. A very slow pulse be-
coming rapid or a rapid pulse becoming very slow
are alarming symptoms and often precede dissolu-
tion.
Diagnosis. — The diagnosis rests on the degree of
unconsciousness, alteration in the reflex arc, and
motor nerves, consideration of temperature, pulse,
and blood pressure. The differential diagnosis is
not made easily, and it becomes necessary to ex-
clude opium poisoning, alcoholism, apoplexy,
uraemia, diabetic coma, epilepsy, and hysteria. It
so often happens that an individual suffering from
any one of these conditions may have the odor of
alcohol. Likewise it may be impossible to deter-
mine if the onset of the coma resulted from a fall
or vice versa. Only by a careful elimination, one
by one, can a diagnosis be arrived at. The urana-
lysis is often misleading, as in old persons casts and
albumin are frequently found, and in others after
drinking bouts the amount of urea in a given speci-
men may be 0.2 per cent, instead of two per cent.
Prognosis. — The prognosis regarding life in the
majority of cases is good. Moderate degrees of
unconsciousness are compatible with a perfect re-
covery, and even a comatose state lasting from six
to ten days often has a happy termination. Rise of
temperature, great acceleration of the pulse,
Cheyne - Stokes respiration, irresponsive pupils
point to an unfavorable outcome.
The remote effects may be transient or perma-
nent, and among the most serious is epilepsy, usual-
ly of the Jacksonian type. It is not necessary that
the skull be fractured in order to produce this con-
dition, as noted in a case reported by Starr. Such
cases are not numerous enough to cause great ap-
prehension, but the possibility must ever be borne
in mind, as this deplorable sequela is not always
amenable to surgical interference. The earning
capacity of the individual who has suffered from a
cerebral contusion may be materially lessened.
About five per cent, of men who have had this
lesion are unable to follow their occupations, while
from ten to fifteen per cent, earn less than former-
ly. Seventy-five per cent, return to their trades,
though not entirely free from subjective symptoms.
It has been estimated that fifty to ninety per cent,
of severe injuries to the head, including fractures,
always bear a stigma as the result of such a trauma,
in the form of headache, vertigo, changes in taste
and disposition, alluded to by Bailey as cerebrasthe-
nia, a term denoting a dimininshed functionating
power, without impairment sufficiently to be called
insanity. The prominent symptoms are headache,
dizziness, irritability, insomnia, changes in tempera-
ment, lessened mental activity, and intolerance to
alcohol.
Probably headache is one of the most constant
and distressing symptoms. It may be frontal or
occipital, likely to be dull, and throbbing. Dizzi-
ness upon standing or stooping often compels men
working upon buildings to choose another occupa-
tion. Irritability is especially prone to be present
upon occasions when considerable attentiveness is
necessary. The individual is annoyed by trifles
which previously would have been unnoticed. The
condition becomes plain to his friends. Even the
64
WHITE: CEREBRAL CONTUSION.
[New York
Mel'ICal Journal,
disposition changes, and lifelong habits may be
changed after cerebral contusion. A person of
sunny temperament may become morose, and a
spendthrift may develop miserly habits. The dimin-
ished capacity for intellectual work is noted and
a sense of oppression, both physical and mental, is
common. Fatigue seems not to be limited to the
brain. The intolerance of alcohol sometimes be-
comes striking, and a small amount of whiskey
may make such a person hysterical or even ma-
niacal.
The question of insanity is an important one, but
probably overrated. Much less than one per cent,
of insane cases can be traced directly to cerebral
contusion. We cannot accept each case of insanity,
in which is given a history of a blow some time in-
flicted, as one of traumatic insanity, as there is
scarcely any one who has reached adolescence,
however sane, that cannot recollect having had a
blow upon the head. All in all, the condition of
cerebrasthenia is transient in about seventy-five per
cent, of the cases, but in the remaining twenty-five
per cent, a legacy of some description is seen. It
is conceded that in those persons with a hereditary
taint the occurrence of insanity after cerebral in-
juries is more frequent. The form of insanity is
variable.
Treatment. — The treatment of cerebral con-
tusions must consider the immediate and urgent
symptoms first. Moderate stimulation, preferably
with strychnine, rest, ice cap to the head, and hot
bags to the body are indicated in the shock at-
tendant upon this condition. Should active or ma-
niacal delirium be present, it is best controlled by
hyoscine and the bromides. In the milder cases rest
in bed, purgatives, and sedatives are all that is nec-
essary. In my hands morphine has not given good
results, and is generally contraindicated, as there is
a tendency to produce cerebral congestion. In the
more profound cases, close observation is neces-
sary and symptoms of pressure should be met by
prompt trephining. Should the indications be those
of arterial extravasation, trephination over the mid-
dle meningeal is the course to pursue. Should no in-
jury be found, the use of the trephine on the oppo-
site side is justifiable. The operation is not attend-
ed with rnuch risk. In cases showing no focal
symptoms, with nausea present from the beginning,
rising pulse, and temperature, an opening should
be made in the injured side, the dura opened and
drained. If the appearance is normal, trephine on
the opposite side, following the same technique. It
is not well to postpone operative interference too
long, as this simple procedure may be followed by
the happiest results if practised early. Should the
oedema have become general the outlook is bad.
Comer reports the case of a compound fracture of
the vault ; a week had passed without symptoms,
but at the end of this time the child became drowsy
and finally unconscious. The diagnosis of extra-
dural abscess or meningitis was made. With the
horseshoe flap, the dura was exposed and found
to have been wounded. It was incised, the brain
was bulging, and the trocar did not locate pus.
The brain was pale and a?dematous and not in-
flamed. It was a condition which many did not
.believe in, and to which had been given the name
"spreading oedema." It is not necessarily of septic
or infective origin, and has its analogy in cellulitis
in other tissues. The prognosis is grave.
Bloodletting is of questionable value, as the com-
pensatory high pressure in the general circulatory
system is not present in the cranial cavity. Frazier
states that venesection , is of little avail, as deter-
mined upon animals to overcome cerebral anaemia.
Lumbar punctures may afiford relief in this con-
dition, but after considerable pressure has accumu-
lated in the cranium the medulla is forced down
into the foramen magnum sufficiently to act as a
wedge and cut ofif free exchange of fluid in the
spinal canal and brain ventricles. The efficienc>
of the ice bag can be questioned also. A large pro-
portion of cases of cerebral contusions run a limited
course and will recover without treatment, but in
the severer ones surgical methods are the ones to
be considered curative.
The treatment of cerebrasthenia is along lines to
improve the general health— fresh air, sunlight,
good food, and attention to the bowels. The bro-
mides may be useful. Those cases showing a ten-
dency toward hypochondriasis are often benefited
by resuming work as soon as the physical condition
permits.
The cases I wish to report ai'e but two selected
from a large number, and both of very recent date :
Case I. — D. S., a child of seven years, was knocked down
by a vehicle on October 22, 1907, his head striking the
pavement. He regained his feet, seemed conscious that he
was hurt, and told some one to send for the physician
who generally treated him in his illnesses. He was brought
to the Emergency Hospital in a restless, semiconscious
state. A contusion was found over the right parietal bone,
with no at)parent depression. The child became quiet and
could be aroused with difficulty ; the pupils were regular,
temperature normal, the dorsal decubitus assumed, and
paralysis absent. In view of the approaching coma, trephining
was deemed advisable and performed about two hours after
admission. A flap was turned back to expose the skull
under the contused scalp. A stellate fracture was found
without depression, and a linear fracture extending from
this point over the vault and involved the left parietal to
what extent is unknown, but the line was followed almost
to the level of the left ear. A button of bone was re-
moved from the right parietal, the dura opened and
drained. The amount of cerebrospinal fluid which escaped
was small rnd not bloodstained. The boy reacted ii,
about twelve hours and made an uneventful recovery. I
am convinced trephining relieved an impending oedema.
Case II.— M. W., male, white, seventy years, was struck
by a car November 4, 1907, receiving a lacerated and con-
tused wound of the scalp in the right frontal region. He
seemed unconscious when first attended by the ambulance
surgeon, but before the hospital was reached he was able
to give a fair statement of his name, address, residence,
etc. His general condition was very good. The following
day there was some mental confusion, no paralysis, good
pupillary reaction, pulse between 74 and 80, and tempera-
ture 99° F. or less. On November 6th he was worse ;
there was delirium, followed by a state of lethargy, from
which he could be aroused. No focal symptoms were pres-
ent. His pulse rose to 100, and temperature reached
100° F. in the afternoon. His blood pressure was 200 at
4 p. m. The coma deepened, and he died about 5 p. m.
The autopsy, made under the direction of the coroner,
was typical of cerebral contusion with haemorrhage by
contracoup, as the notes made at the time indicate. In-
spection revealed a small lacerated scalp wound three
inches above the right supraorbital ridge, one inch external
to the median line. Reflection of scalp showed slight
hemorrhage in the immediate vicinity of the wound, and
a small amount of blood oozing from a foramen in the
occipital bone near the vertex. No fracture of the vault
was present, .\fter removal of the upper portion of the
January ii, 1908.]
ROBERTS: HOSPITAL DIETETICS.
65
cranium, a considerable extravasation of blood under the
pia covering the cerebellum and both lower occipital
lobes, decidedly marked, however, over the lower left oc-
cipital region, at a point diametrically opposite the scalp
wound. The cerebellum was covered with plastic lymph.
On section the cerebellum was cut with little resistance
and gave evidence of degeneration. It also exhibited ex-
tensive extravasation of blood into the lobes. At various
levels the cerebrum was the site of numerous punctate haem-
orrhages, very evenly distributed. The ventricles contained
a sanguinous fluid. After removal of the brain, the pres-
ence of blood in the middle and posterior fossa was ob-
served, but no basal fracture was present.
Conclusions.
My general conclusions are:
Cerebral contusions, when fatal, are due to
laceration or haemorrhage.
Prolonged coma is a reliable indication of in-
creased pressure.
A conscious period followed by coma indicates
haemorrhage.
High blood pressure is an early and reliable
symptom of pressure.
Trephining is indicated in plus intracranial pres-
sure from haemorrhage or oedema.
Venesection is of doubtful value.
Fifteenth Street and Ohio Avenue.
HOSPITAL DIETETICS.
By Dudley Roberts, M. D.,
Brooklyn, N. Y.,
Associate Physician, Brooklyn Hospital.
As the standing committee on diet at the Brook-
lyn Hospital ,it has devolved on the writer to make
somewhat of a study of the general question of hos-
pital dietetics in its varied aspects. The systems
in vogue in different institutions vary widely ; there
are those encumbered by a most complicated system
of individual ordering ; on the other hand, many in-
stitutions run their dietetic affairs with no discov-
erable system and about as little consideration of
the scientific aspect of the problem as is given to
the average boarding house table. It is true that
the system must be suited to the equipment and ser-
vice of each institution, but it has seemed to me
many institutions conscious of these difficult prob-
lems may find in our experience a partial solution
of some of their troubles.' '
Were economy unnecessary the ideal plan in the
]jreparation of food for the sick would be the sepa-
l ate preparation of each individual dietary to appeal
to the individual taste while meeting the require-
ments of the condition. Economy of the strictest
kind is usually necessary, and it demands that
kitchens be reduced to a minimal number, prefer-
ably one, and in this one there be a division of labor
suiting the worker to the work with consequent
saving. Waste of material and labor is very evi-
dently proportionately less when food is prepared
on a large scale.
From the standpoint of economy it is important
that the work of food preparation be equally dis-
tributed throughout the day. If the principal meal
of all inmates and workers be served at the same
hour, a larger kitchen force is required at that hour
than at any other time, and the equipment must also
be greater. A simple arrangement in accordance
with this principle has been instituted by Miss
Osborne, the valued executive head of the Brook-
lyn Hospital : Dinner for ward patients and help
is served at 12 noon ; luncheon for private pa-
tients and staff is served at i o'clock; supper for
ward patients and help is served at 5 o'clock, and
dinner for private patients and staff at 6:30
o'clock. Such an arrangement reduces the neces-
sary force to a minimum and makes for better order
in the kitchen at all times.
The arrangement of a comprehensive system of
diet lists is advantageous in many ways. If through
a system we are able to supply proper food to the
majority of patients in need of no especial dietetic
care, our efforts can be spared for those distinctly
in need of the most painstaking attention. The
per. diem cost of food for an institution is a matter
that is very largely under its direct control. The
question resolves itself into just how much it is
possible to expend for food materials, and how
much equipment and labor it requires to prepare
it. By the employment of more competent caterers
and cooks an actual saving may be accomplished,
the more economical foods can be agreeably pre-
pared.
Any system of diet lists must be constructed with
the idea of having one general house diet suitable
for the large proportion of patients. This makes
for economy and obviates the necessity of unneces-
sary individual dietetic ordering. Such a diet list,
then, must be made up of preparations suitable for
the average taste and needs. It must be sufficient-
ly nourishing. It must have no undesirable action
on the gastrointestinal tract or other parts of the
body. It may be said that hospital dietaries are
usually too constipating, and this is entirely un-
necessary. There are natural cathartics cheaper
than drugs. Any diet should be changed from day
to day to avoid tiresome sameness. Finally, its
components should be, in some part at least, suit-
able for those diet lists that may be spoken of as
lighter; this applies particularly to soups, desserts,
and meats.
In arranging the diet lists of lighter grade it is
essential that the importance of regularity in
amount of food and times for its adininistration be
borne in mind. Patients on light diet are not ob-
taining much nourishment, and if such matters are
left to the discretion of the untrained, serious harm
may be done. The diet lists of lighter grade must
have, however, a certain flexibility. It should be
possible to use any one absolutely, or if conditions
demand it should be amenable to changes at the
discretion of those in charge. The natural transi-
tion is from liquid nourishment gradually to more
solid and nourishing preparations.
If any system of diet lists is to meet the purpose
of its construction it is absolutely necessary that it
be understood and adhered to by all responsible
for its preparation, administration, and ordering. I
have often found that those who should be entirely
familiar with the established system are grossly
ignorant of its provisions. A patient ordered on
a certain diet in one ward receives a very different
diet from that given in another. By the use of
66
ARMSTRONG:
CAUSES OF APPENDICITIS.
[New York
Medical Journai..
printed lists on folding cards this difficulty is over-
come; each nurse, each orderly, each executive
head knows the diet of the institution.
For the more definite instruction of the staflf it
has been found convenient to have typewritten
copies of the day's menu in the hands of each head
nurse, while the staff is making house rounds in the
morning. Certain food preparations, as the soups,
the meats, the breads, and desserts, are changed from
day to day, and those which on a particular day
preparations listed are usually well borne. The
meals are all made srriall and frequent. To the
fluids ordered between meals special articles may
be added at the discretion of the staff and attend-
ing physician. By the restriction of certain articles
and the addition of others it is possible to suit this
list to a considerable proportion of patients need-
ing careful attention. The diet list of private pa-
tients is necessarily more liberal and expensive.
The trouble lies often far less in the food than
No. I.
HOUSE DIET.
No. 2.
CONVALES-
CENT DIET.
PRIVATE SIDE.
Breakfast.
Cereal with
cream and sugar
Eggs as ordered
or steak or chops
Toast, hot
bread, butter
Milk, tea, or coffee
Luncheon.
Fruit (fresh or
cooked)
Thick soup
Fish or hash or
eggs or oysters
Either
Potatoes
baked, boiled,
or hashed;
cereal ;
or spaghetti
Bread and butter
Tea or milk
Dinner.
Clear soup
Roast meat or fish
Potatoes
(as above)
Vegetables in sea-
son or cereal
Dessert
Tea, milk, o r
coffee
Breakfast.
7 a. m.
Cereal
with milk, sugar,
and butter
Bread and butter
Coffee or tea
Dinner
12 m.
Thickened soup
Meat stew
Roast meat or fish
Potatoes or
Rice or spaghetti.
Bread and butter
Dessert
Supper
5 p. ra.
Cereal, etc., or
French toast, or
Fried Cereal, with
syrup ,
Baked beans on
order
Bread and butter
Tea or milk
Stewed fruit
Fruit
Cereal
with milk, sugar
and cream or
butter
Toast or bread
with butter
Glass of milk
Coffee on order
Gruel
12 m.
Clear soup
(demitasse)
Meat — beef, lamb,
chicken or fish
Well baked potato
with butter
Bread or toast
with butter
Light pudding
Milk or cocoa
5 p. m.
Cereal, etc.
Eggs on order
Bread and butter
No. 3.
FLUID DIET.
No. 4-
MILK DIET.
7 a. m. Milk
9 a. m. Gruel
II a. m. Milk
I p. m. Soup
3 p. m. Milk
5 p. m. Gruel
7 p. m. Milk
Two kinds of gruel
made daily
MILK GRUELS
Oat meal
Barley
Farina
Corn meal
PUREE SOUPS
Corn
Potato
Split pea
Brown cracker
One kind of soup
daily
56 oz.
On order during
night.
Light Schedule.
6 a.m.
9 a. m.
12 m.
3 p. m.
6 p. m.
9 p. m.
48 oz.
On order through
the night the same
64 oz.
Eight ounces
served hot or
cold as desired.
(If hot, serve in
cup.)
Children, 6 ounces
or less as or-
dered.
No. 5.
FAST DIET.
(1) Beef or
Chicken broth ;
(2) Albumin
water;
the white of one
egg to 8 oz.
water.
(3) Whey— with
or without
lemon juice.
(4) Lemonade;
sweetened with
sugar or saccha-
rine.
One of these flu-
ids as desired
every 2 hours
during the day
and as desired
at night.
Broths should be
served hot in a
cup, other liq-
uids should be
served cold in a
glass.
SPECIAL LIST.'
(On requisition of
visiting physician or
surgeon.)
Lamb chop
Beef steak
Chopped beef
Scraped beef
" " sand-
wich
Chicken — roast
•Chicken — broiled
•Squab
•Sweetbreads —
broiled
creamed
Special change
BROOKLYN HOSPITAL DIETARY.'
'In the original list this special list appears on the other side of the card for convenience
'The author will send sample cards on request.
are found to be unsuitable for a certain patient are
ordered omitted and other preparations substituted
from a list of alternatives. By such a system the
diet of every patient is under the direct daily con-
trol of the proper authority.
Only certain brief comment on these tables is
necessary. Diet No. 5 has been constructed to
meet the dernands of the surgical staf¥ for suitable
fluids to allay hunger and thirst. Nutritive and
consequently fermentable content has designedly
been omitted.
The fluid diet designated No. 3 has much to
recommend it in place of plain milk. It offers some
variety and appeals to some averse to taking milk.
The cereal admixture increases digestibility and nu-
tritive value. So well are these gruels borne that
they may be given at every feeding. They are easily
made by adding the well cooked cereal to hot or
cold milk, salting later to taste.
The convalescent diet has been arranged with the
idea of supplying a highly nutritious diet in concen-
trated form, free from articles of doubtful digesti-
bility. Of course this term is merely relative. The
in the accessories. Attention must largely be de-
voted to the judicious betterment of things mak-
ing an indirect appeal to the gustatory organs.
84 Remsen Street.
THE CAUSES OF APPENDICITIS.*
Bv .Alfred W. Armstrong, A. B.. M. D.,
Canandaigua, N. Y.
It is probable that more has been written on the
subject of appendicitis during the past ten years
than has ever been written concerning inflammation
in any other part of the body. The diagnostic signs
have come to be well known and the treatment dif-
fers, with the best men of the profession, only in
minor details, but there seems to be a wide variation
in the opinion of tho.se who see the most of these
cases in regard to the aetiology of this common dis-
ease.
As predisposing causes of appendicular inflam-
•Read before the Society of Physicians of Canandaigua, November
14. 1907-
January :i, 1908.J
ARM:^ ! RUXG: CAUSES OF APPENDICITIS.
67
mation should be mentioned: i. The degenerate
condition of the organ itself. 2. The structure of
the appendicular walls and their blood and nerve
supply. 3. Its form and direction. 4. Normal
drainage. 5. Diet and chronic constipation. 6.
Mechanical obstruction and stricture of the lumen.
7. Constitutional diseases. 8. Disease of the pelvic
organs.
The list of exciting causes is shorter, including
as it should: i. Traumatism. 2. Intestinal parasites.
3. Enteritis. 4. Direct infection.
The appendix persists as the remains of the
larger caecum of lower animals an anatomical pro-
test against vegetarianism. From the standpoint
of evolution it would appear to be becoming oblit-
erated. It represents a portion of the intestinal
canal which, at an early period of foetal life, was a
contmuation of and differed little from the colon.
At a later period its development ceased, and it
then became merely an appendage of the caecum,
with an inherent tendency to degenerate.
In structure the appendix resembles the other
parts of the intestine in possessing four coats, but
differs in its mmute anatomy. Its mucous lining
is crowded with solitary lymphoid follicles, thus in-
viting infection ; the muscular coat is scanty, and
between its scattered fibres direct communication is
permitted between the submucous and the serous
•coats. Inflammation of the mucous membrane may
therefore spread without hindrance to the peri-
tonaeum. The blood supply is derived from the
ileocolic branch of the superior mesenteric artery.
In the female there is an additional supply from
the right ovarian artery, and this is thought by
(I, 2) some to account for the fact that appen-
dix disease is less common in women than in men
(3). At best the blood supply is poorer than that
of other parts of the intestine, thus making it less
resistant. The nerve supply is derived from the
superior mesenteric plexus. Any conditions which
bring about a change in the blood or nerve supply,
such as kinking or bending of the appendix or
twisting of the mesentery, embolism, or thrombosis
of the vessels, tend to weaken the resistance of the
organ and invite inflammation. In early life the ap-
pendix possesses a canal which is continuous with
that of the caecum, but in later years this connection
is sometimes cut ofif, and in many cases partial or
complete occlusion takes place, this tendency in-
creasing with the age of the patient.
The normal appendix, if such an organ exists,
varies in length from i inch to 93^ inches, in di-
ameter from ^ to 3/2 an inch. Many congenital
variations of form occur. The club shaped, long,
narrow or short, thick, kinked or twisted appen-
dix, is the result of accident or of degeneration of
this rudimentary organ. Hence a person may be
destined from birth to have appendicular inflamma-
tion, if subjected to certain exciting causes. These
irregularities are, like many other minute anatomi-
cal peculiarities, hereditary, and that may explain
the apparent hereditary features of the disease.
Personally, I have observed within a year two pa-
tients, sisters, who had similar attacks of appen-
dicitis in which there was a striking resemblance
between the two appendices, both anatomically and
pathologically. A long appendix is more likely to
become twisted or kinked. As to direction, the ap-
pendix may lie in almost any axis. Authorities do
not seem to agree upon the most common position,
but the (4) four positions, "inward," "behind
caecum," "downward and inward," and "into true
pelvis," will, without doubt, include 90 per cent, of
the cases. The aetiological importance of this rests
in the supposition that appendicular inflammation is
more commonly met with when the appendix is so
placed as to admit material which is with difficulty
expelled — that is, when it is directed inward or
downward.
The mucous membrane of the caecum is continu-
ous with that of the appendix, and the secretions
from the latter are drained into the intestine
through the narrow opening, which may or may not
be guarded by a fold of mucous membrane, known
as the valve of Gerlach. Holmes, in his mono-
graph on appendicitis, places particular emphasis
upon the construction of this valve. He states that
the normal congenital construction of the valve is a
constant menace to health, and believes that any
increase in this narrowing of the lumen, as by ex-
ternal traumatism, unusual activity of the muscles
of the caecum, or injury of these muscles, or con-
gestion by impaction of faecal material and its sub-
sequent dislodgment may bring about a condition
of appendicular inflammation. "An abnormal con-
struction of the valve may admit foreign material
and prevent its exit." This valve was described by
Gerlach in 1847 a "semilunar fold of mucous
membrane guarding the appendicocaecal orifice."
Some present day (5) anatomists declare that it is
"inconstant and unimportant" (6), others deny that
it ever exists (7). Treves does not mention it in
his Applied Anatomy. That which concerns us
most as clinicians is the fact that normal drainage
is essential to the health of the appendix, and any-
thing which lessens the calibre of the lumen may
prepare the way for an acute attack.
Chronic constipation contributes its share to the
causation of appendicular inflammation in a some-
what indirect way. Hesitation in the passage of
faecal matter along the intestinal tract allows more
time for decomposition and the multiplication of
bacteria. The increased pressure in the colon may
force material into the appendix, which, owing to
the position of the organ, the weakened condition
of its walls or resultant swelling from slight trau-
matism, cannot be returned. This condition, pres-
ent within the appendix, is ready to furnish the fuel
for a conflagration when acute conditions demand.
However, statistics do not seem to show that ap-
pendicular inflammation is common among races
who are subject to constipation. In an editorial in
one of the current issues of the Medical Record
(8), the editor quotes statistics to show that in-
flammation of the appendix is very rare among
Orientals, in whom constipation is very common.
One observer, Dr. Naab, reports that out of 6,800
natives of Mesopotamia, who suffered from various
diseases, only two had inflammation of the appen-
dix. This would seem to suggest that constipation
in itself is inadequate to cause the disease. On the
other hand, there are those who believe that there
is an unmistakable relationship between meat eat-
ing and appendicular inflammation. It is stated
68
ARMSTRONG: CAUSES OF APPENDICITIS.
[New York
Medical Journal.
that it is the excessive eating of meat that causes
the white races to lead in the statistics of appen-
dicular disease, and that the increased consump-
tion of meat in Germany has been attended by a
considerable increase of morbidity from appendicu-
lar inflammation. Nothing is said of the way in
which this is brought about, and until the pathology
is explained the mere fact that the increase in the
consumption of meat and the number of cases of
inflammation of the appendix has been constant,
does not make the one the cause of the other.
The presence of foreign bodies within the ap-
pendix may often be looked upon as accidental and
insignificant as regards the causation of inflamma-
tion, but the variety of substances found is interest-
ing. The following are a few which have been re-
corded : Pills and capsules containing medicine,
seeds of various kinds, gallstones, portions of pea-
nut, pins and needles, pips and skins of fruit,
cherry and date stones, hair, bristles from tooth
brush, intestinal worms, fish bones, faecal concre-
tions, and shingle nails. Personally, I have ob-
served many of these substances within the appen-
dix, and one case seen recently through the courtesy
of Dr. Clapper and Dr. Beahan illustrates the va-
riety of seeds which may be stored up in this lit-
tle organ. There were six grape seeds, three to-
mato seeds, three raspberry seeds, several straw-
berry seeds, a tooth brush bristle, and several very
hard masses resembling gallstones, all in a large
amount of faecal matter. The appendix was 53^
inches long, of large diameter, and directed down-
ward. A few haemorrhagic areas were present
along the mucous membrane, where the concretions
were located, and the lumen was large and free
from scars or constrictions.
The coexistence of an ovarian hsematoma brought
up the question of relationship between the two con-
ditions. It is not improbable that the long, heavy
appendix brought about the condition of the ovary.
It seems more likely, however, that there was no
cause common to the two conditions. Out of a se-
ries of 124 autopsies made by Bryant for other rea-
sons than disease of the appendix, 67 per cent, con-
tained abnormal material. One case is reported in
which 150 bird shot were found in an appendix
which was apparently free from disease.
The presence of concretions or of foreign mate-
rial large enough to obstruct the lumen or injure
the walls is without doubt most important. A scar
once formed within the appendix never ceases to be
more or less of a hindrance to the free passage of
faecal matter in and out of the organ. Van
Zwelenburg has reported some interesting experi-
ments upon living dogs, which seem to establish
some facts concerning this subject. He was able
to produce typical inflammation of the appendix in
the dog only when three conditions were met : con-
striction or obstruction, distention, and the presence
of a pathogenic germ. The frequency of necrosis
or gangrene indicates mechanical obstruction. Sim-
ple infection does not produce gangrene. The con-
dition of distention is present in the early history
of every case. If the obstruction is soft or small
enough, the pressure within the appendix may be-
come sufficient to force it back into the bowel, and
the symptoms will gradually disappear. If the
course of least resistance is not in the direction of
the caecum, it is only a question of time when gan-
grene will destroy the wall and a perforation result.
The concretion may form a sort of ball valve which
will admit fluids and prohibit their escape. Once
closed the appendix continues its attempts to empty
itself and appendicular colic results.
It is such a common thing to find appendicular
inflammation as a complication or sequel of various
constitutional diseases that these primary conditions
are often named as causes. They should be men-
tioned as predisposing causes only, for it is not
likely that any one new germ is introduced into the
body for this purpose or that any novel condition
is brought about by any of these diseases, but if the
proper conditions prevail within the appendix, any
one of these conditions, by its weakening influence
upon the entire body, might precipitate an attack.
True it is moreover that (9) measles, la grippe,
rheumatism, typhoid fever, fatigue, digestive dis-
turbances, exposure, excessive physical exertion,
and improper food, not infrequently precede an ap-
pendicular storm.
The frequency with which disease of the pelvic
organs is associated with appendicular inflamma-
tion is interesting, and it is often impossible to say
which is cause and which is result. It is not at all
uncommon to find the appendix firmly adherent to
the falloppian tube, the ovary, or the broad liga-
ment. If it is evident that the inflammation has be-
gun on the outside of the appendix, it would seem
that the pelvic condition originated the trouble, but
if the disturbance is within the appendix it is hard
to understand why the pelvic condition should be
blamed.
Traumatism, whether from a blow upon the
abdomen over the appendix, or brought about by a
strain upon the muscles, which may pinch the organ
and interfere with its circulation, must be dealt with
in this discussion. Pressure upon the intestine, as
by the act of lifting when the body is in a certain
position and conditions are right within the bowel,
might easily force material into the appendix which
could not be expelled. The frequent occurrence of
appendix disease in nurses, waiters, and others who
must do considerable lifting, especially among those
who have given up a sedentary occupation for this
work, is significant.
Intestinal parasites are, without doubt, present in
the intestinal tract more frequently than many
physicians believe, and some of our best men, in-
cluding Dr. Stockton, of Buffalo, hold them to be
a not infrequent cause of appendicular inflamma-
tion. One case reported in tlie Hospital Record for
February, 1906, was operated, at the Canandaigua
Hospital, where it was found that the appendix
contained more than fifty pin worms, which had
without doubt been the exciting cause of the in-
flammation.
Enteritis, especially when it occurs during the
summer months, when indiscretions in diet, espe-
cially along the line of fruits and vegetables, and
the eating of foods, which are, for want of proper
care after coming into market, in an early stage of
decomposition, would be agreed upon, perhaps, as
the condition which is most often present at the be-
ginning of acute inflammation in the appendix. It
January ii, 1908. J
HOfFMAK: BALTIMORE MILK SUPPLY.
09
has seemed to me that the ven^ worst cases are
those which develop while a condition of enteritis
exists. The infection seems to be of a more viru-
lent type, and many cases of general peritonitis are
found, even though the case is operated early. The
condition is more difficult to interpret, and opera-
tion is sometimes delayed beyond the point of
safety, because bellyache has been considered to be
a rather unimportant symptom, constant in enteritis.
It is not uncommon, moreover, to find cases in
which the history will reveal the fact that early in
the attack, with the diagnosis of "acute indigestion"
clearly made, an anodyne has been given to relieve
the pain, and the symptoms have been masked,
while the ravages of the infection have been going
on in the appendix, and the patient's life endan-
gered while he is enjoying the effects of the opiate
which is killing him. Bellyache does mean a great
deal at the present time, and in but few instances
should it indicate the use of the hypodermic of
morphine.
After all this discussion of conditions, real and
imaginary, known and unknown, it remains to be
said, that the presence of a pathogenic germ , is the
one thing constantly necessary to the production of
this condition. Simple necrosis of an organ so
functionally inactive and useless as the appendix
would not be expected to give rise to serious symp-
toms, it must rather become infected. There is no
special germ, however, that can be charged with the
burden of having been introduced into the appendix
for this special occasion — in fact, the germs in-
volved in the process are normally present in the
appendix in health, awaiting the time when some
accident shall bring about a condition suitable for
their work. The Bacillus coli communis and the
ordinary pyogenic cocci are most commonly pres-
ent, and whatever the assigned cause may be it
must be remembered that appendicitis is an in-
fective malady.
REFERENCES.
1. Fowler. Diseases of the Appendix.
2. Maylard. Surgery of the Alimentary Canal, p. 355.
3. Rose and Carless. Manual of Surgery.
4. J. D. Bryant. Annals of Surgery, xvii, p. 164, 1893.
5. Gray's Anatomy, Ihirteenth Edition, p. 1033.
6. Maylard. Surgery of Alimentary Tract, p. 356.
7. Treves. Applied Anatomy.
8. Medical Record, November 9, 1907, p. 777.
9. Butler. Diagnostics of Internal Medicine, p. 782.
10. Annals of Surgery, li. No. 3, p. 437.
THE INSPECTION AND CHEMICAL EXAMINA-
TION OF THE BALTIMORE MILK SUPPLY. .
By William E. Hoffman, Jr., Ph. D.,
Baltimore,
Chemist to the Baltimore Health Department.
During the past year there have been consumed
in Baltimore, as nearly as can be estimated, about
ten million gallons of milk. The supply comes al-
most entirely from the farms and dairies lying
within a radius of thirty-five miles of the city, the
majority coming from the near vicinity of Balti-
more. Until recently there were cows kept even
in the city, but since the introduction of a clause
prohibiting this, there is no longer any such state
of affairs. The physical condition of the cows and
the sanitary condition of the dairy farms outside
of the city limits are under the control of the State
Board of Health and the State Live Stock and
Sanitary Board.
The working force for the examination and con-
trol of this milk supply is provided by the city
through the Health Department, and consists of a
chemist, his assistant, and two inspectors. Each
inspector every morning visits one railroad station,
and there, with a lactometer, examines as much as
is possible of the milk while the cans are being re-
moved from the incoming trains and reloaded onto^
the dealers' wagons. If, in the judgment of the
inspector, the quality of any of the milk does not
meet with the requirements of the law (which are
1.029 specific gravity at 60° F., three per cent, fat,
twelve per cent, solids), he spills it, after having
taken a sample for analysis in the laboratory. He
then marks these empty cans with a conspicuous
tag stating the reason for spilling, and returns them
to the shipper. Also, if any cans are unclean or
if the milk is in any way unfit for use, it is spilled.
In addition to examination with the lactometer,
each inspector collects at least six samples from the
station at which he may have been and delivers
them to the laboratory for analysis.
After having finished the work at the stations,
the inspectors then cover certain districts of the
city, examining the milk at dairies, in wagons, and
at all places where it is sold, and carefully looking
into the conditions under which the milk is kept.
Samples are obtained from these places, when
deemed necessary, and taken to the laboratory for
further investigation. In cases where certain milk
supplies are referred to the Health Department for
investigation, an inspector is especially detailed to
do this work and to make a report on the results.
In the samples which are brought into the labora-
tory by the inspectors, determination is made of the
specific gravity, fat, and total solids, and of the
presence or absence of preservative or artificial
coloring matter.
Since the early summer of 1907, all those cases
in which a preservative was used have been prose-
cuted, and the results have shown that as a rule its
use was without any malign purpose and through
ignorance of injurious effects. During the three
summer months of 1906, fifty per cent, of the sam-
ples of milk analyzed were found to contain pre-
servatives, while in the summer of 1907, after the
publication of the first few prosecutions, less than
three per cent, of the samples analyzed contained
preservatives. Through the cooperation of the Mary-
land State Board of Health with the city Health
Department, prosecutions for this offense have
been rigidly carried out. As a result, the producer
has been shown that it is better policy for him to-,
be particular and to take proper precautions in the
care of milk, than to rely on preservatives and
thereby run the risk of a fine with the attending
publicity.
In the past year, of the ten million gallons of
milk consumed, about twenty per cent, was in-
spected, and five thousand samples were analyzed.
Of course, a vast amount of work remains to be
accomplished before Baltimore can have a pure
milk supply, but toward that end a beginning has.
70
BROIVN: BIER CLINICS.
[New York
Medical Journal.
been made. In previous years very little attention
was paid to the condition of the railroad cars in
which milk was shipped to the city, but during the
past year this phase of the question has been taken
up, and at the present time the sanitary condition
of these cars is fair. In fact, no further improve-
ment can be made in this direction until the rail-
road companies can be induced to provide refriger-
ator cars. Then, too, the sanitary condition of all
the dairies and small stores, where milk is sold, is
being investigated, and the owners are being in-
structed as to the proper way to remedy existing
evils.
The system of inspection and control, in its pres-
ent state of progress, is very imperfect. However,
by a new set of laws and ordinances, which has
been compiled from those of the principal cities of
the United States, and which is soon to come up for
consideration before the city council and State
legislature, it is hoped to overcome in the near fu-
ture the difficulties, and to improve vastly the qual-
ity of Baltimore's present milk supply.
15 South Gay Street.
OBSERVATIONS MADE AT THE BIER CLINIC
IN BERLIN.
By Mary Hess Brown, M D.,
New York.
As this treatment had been the subject of much
discussion in America, at the suggestion of Pro-
fessor Prausnitz, of London, and at Professor Bier's
invitation, I went to Be-rlin the latter part of Jul}
to see the practical demonstrations of Professor
Bier and his assistants, Dr. Klapp, Dr. Schmieden,
and others. Dr. Schmieden speaks English fluent-
ly, so if your German vocabulary is limited, you
still find it worth while to take time to visit the hos-
pital daily and see the patients being treated in the
\\'ards and dispensary.
Case I. — ^One of the first patients seen was an acute case,
a patient with an infected scalp wound, fracture of superior
maxilla, and destruction of right eye. In the very begin-
ning a prophylactic dose of antitetanic serum had been
given. The patient had a high temperature. Passive hy-
peraemia of head was produced by applying a rubber tape
about one inch wide about the neck, an ordinary hook and
two eyes being first adjusted to either end of tape, so that
it could be applied and held steadily in place, yet not with
discomfort to the patient. Gauze pads were placed under
the tape where it crossed the great vessels, so undue pres-
sure would not be exerted over them. The red hyperaemia
gradually appeared and caused no pain or alteration in tem-
poral pulse, and sleep ensued. This dressing remained in
place for eighteen or more hours out of the twenty-four,
the patient always being advised to inform the nurse as
soon as it became uncomfortable. Each succeeding day
the tape was applied for a shorter length of time, as pa-
tient slowly but definitely improved, and in one week the
temperature was normal and the use of rubber tape was
discontinued. Simple aseptic dressings were used for face,
and no strong, antiseptic solutions.
Case II. — The second case was that of a young laborer
who had suffered from a lacerated wound of the forearm.
When the accident occurred the skin was very dirty, and,
of course, an infected wound was imminent. The wound,
however, was thoroughly sutured and a rubber bandage
applied above the elbow, which remained in place for eigh-
teen hours out of the twenty-four. The red hypersemia, of
course, followed the application of the bandage, together
with swelling of the forearm, but as the pain diminshed
the elevated temperature decreased, and pulse was not al-
tered ; the bandage was continued, sometimes being re-
moved and reapplied in a slightly different location. The
discharge from the wound was not drained by gauze or
strips of rubber tissue, but a cup was applied, and by means
of suction all the discharge was removed.
The cup may be applied for four or five minutes,
then removed and reapplied, continuing this pro-
cess for about forty-five minutes, this generally suf-
ficing for twenty-four hours. While the rubber
bandage and cups are applied, a simple, loose, ster-
ile dressing covers the forearm, but no firm dress-
ing.
Each day the condition of forearm improved, and the
temperature decreased, thus avoiding the necessity of open-
ing the wound, which would no doubt have occurred under
the old method treatment. The patient was encouraged to
move his fingers, and when I last saw the case, about two
weeks after injury, the temperature was normal most of
the day, and induration had almost entirely disappeared ;
the function of forearm and hand being perfect.
The cupping is the second hyperaemic method
used by Professor Bier, and thus avoids drainage
by gauze, etc., which no doubt has many times
caused the tissue to become necrotic. The cupping
glass in this way saves the long, free incisions, es-
pecially in cellulitis and mastitis cases, for the dis-
charge can be drawn out throu^ the small open-
ings.
C.A.SE III. — The next acute case, which seemed marvelous
in the light of the old methods of treatment, was a gonor-
rhceal wrist joint, together with involvement of metacarpal
joints, with acute pain, oedema, and redness. A hypoder-
matic injection of morphine had previously been given to
quiet the patient, who was a strong, robust young woman,
but after the application of the rubber bandage above the
elbow all pain ceased, and the patient was encouraged to
use her fingers to some extent, which she did, without
discomfort. The dressing remained on the arm for most
of the twenty-four hours and patient was quiet and happy.
Elevation of temperature gradually subsided, and duration
of application of bandage lessened.
I must not neglect to speak of the acute mastitis
cases, only a stab incision being made when pus
was suspected, and a large cupping glass with the
rubber bulb to exhaust the air and cause suction.
The glass, of course, is boiled before application, so
it is perfectly sterile, and sterile petrolatum is ap-
plied to the edge of glass. The suction is continued
for forty-five minutes, the cup being reapplied ev-
ery five minutes. The application is made general-
ly only once a day, although it may be used twice.
The breast is thus saved from numerous sweeping
incisions, and often the infant can nurse without
any danger whatever.
Large carbuncles, which formerly had always
been incised with a sweeping cut, were stabbed and
a cupping glass applied with most excellent results,
with much less destruction of tissue and less pain.
The chronic conditions were no less interesting,
but, of course, a longer observation would have
been more satisfactory.
Case IV. — A tuberculous knee joint with contractures
was treated first by an extension apparatus to reduce the
contraction, and the application of a rubber bandage above
the knee for one hour, twice a day, which caused no pain
or discomfort and no change in the pulse. The joint was
not immobilized, but passive motion was undertaken to
some degree ; however, old adhesions were not broken up.
for extravasations of blood into the joint would only cause
new adhesions to form. The child was allowed to walk on
crutches, and thus keep the foot from the floor. The
joint was freely movable and the general condition of child
much improved, although I only observed the case for two
weeks.
Prr>fessor Bier's theory is not that tuberculosis
January ii, 1908.]
THERAPEUTICAL NOTES.
71
causes destruction of the joint, with ankylosis as a
result, but treatment by immobilization produces it.
Case V. — A tuberculous elbow with an open sinus was
another case. The sinus was cupped each day for a period
of forty-five minutes, reapplying the cup every few minutes,
with the result that the elbow was improving. The patient
knitted, thus using her elbow joint some, but not tiring it.
The third method of passive hyperaemic treat-
ment was the use of a hot air chamber, which I saw
used in an ankylosed joint after an oM fracture and
-after an old dislocation.
One case of arthritis deformans was very much
benefited by the hot air treatment.
541 West One Hundred and Twenty - third
Street.
Injections of Calomel for Syphilis. — At a meet-
ing of the Societe de therapeutique, held November
10, 1907, and reported in the Bulletin (cliv, No. 21),
M. L. Lafay advocated the use of a 40 per cent, so-
lution of calomel in a specially prepared oily excipi-
ent as a desirable substitute for the grey oil com-
monly used of late for the hypodermatic administra-
tion of mercury in the treatment of syphilitic condi-
tions. The calomel employed must be of the purest
quality in the finest state of subdivision and have
been washed with pure sulphuric ether free from
water. It is important to use a completely dehy-
drated ether ; the ordinary sulphuric ether, or the
alcohol (boiling) used in Italy will not answer the
purpose, according to the author. In the operation
of levigating and washing the calomel care should
be taken to exclude light, which has a reducing ac-
tion on it. The excipient consists of a mixture of
anhydrous wool fat and pure liquid petrolatum (al-
bolene), containing 5 per cent, of camphor. The
author does not add any anaesthetic, since it has been
found that anaesthetics, such as guaiacol and others,
are absorbed and dissipated a long time before the
pain of the injection begins to be felt. The formula
employed by Lafay is as follows :
R Calomel, finely levigated, and washed with ether,
0.40 gramme;
Woolfat, anhydrous, containing 5 per j
cent, of camphor, 3 parts; \ „ g j (. c
Liquid petrolatum (or albolene), contain- T 4' ■
ing 5 per cent, of camphor,... 7 parts. )
Mix and sterilize.
Each cubic centimetre of the oil thus prepared
contains 0.40 gramme of calomel, which represents
the equivalent of 0.34 gramme of metallic mercury.
It has the appearance and consistency of thick cream,
is fluid at ordinary temperatures, and will keep in-
definitely if not exposed to light. The author ad-
vises the use of a specially graduated syringe, the
stem of the piston being spaced into divisions cor-
responding to 0.0 1 gramme of the medicament. The
part into which the needle fits is calculated to ineas-
ure 5 centimetres. The needle should be long and
fine and of just as wide a diameter as will permit
the passage of the oil ; when the calomel is properly
levigated a diameter of six tenths of a millimetre
will be found sufficient. The doses usually em-
ployed were 0.05 gramme, 0.08 gramme, and o.io
gram-me.
x\part from the good results obtained with the
calomel injections, they were found to be better tol-
erated and decidedly less painful than injections
made with the old formula.
Calx Chlorinata Confounded with Calcium
Chlorate.— A note in a recent number of Therapic
der Gegenwart directs attention to a source of dan-
ger in the prescribing of calcium chlorate. For a
case of bleeding haemorrhoids a physician pre-
scribed as follows:
R Calc. chlor. crystallizat. pur., 40.0 grammse;
Aquae destillatse, ad. 200.0 grammes.
M.
The pharmacist committed the error of using
chlorinated lime instead of calcium chlorate, and
the result of the injection of such a solution on the
patient may be imagined. Great pain ensued, which
led to an investigation, when the cause of the trou-
ble was discovered. The prescriber advises physi-
cians to be careful to write out the name of the salt
desired in full, followed in parenthesis by the warn-
ing, "avoid chlorinated lime." [We may remark
that calcium chlorate is not to be found in Amer-
ican pharmacies, but a similar danger to that noted
exists with regard to the possible ignorant substitu-
tion of calx chlorinata (so called chloride of lime)
for calcium chloridum. — Ed.]
For Acute Coryza Boulai employs a solution
of atropine sulphate of a definite strength applied
to the nasal mucous membrane by means of a swab.
According to La Clinique, for September 6, 1907,
he has employed this method in the case of adults
for years with excellent results. The solution is
made according to the following formula:
R Atropinas sulphatis o.oi gramme;
Aquae laurocerasi 20.0 grammes.
Aquas destillatae 20.0 grammes.
M.
Absorbent cotton tightly wrapped around the end
of a match [or wooden toothpick] is soaked in the
solution and swabbed on the nasal mucous mem-
brane, repeating every half hour at first, and then
every hour if necessary, but not oftener than eight
or ten times in the day. It is not advised to use the
treatment where there is obstruction of the nasal
passages.
Treatment of Dyspepsia in Tuberculous Cases.
Renon {La Quinzaine therapeutique, December 10,
1907) advises cutting down the diet and aiding the
digestive functions by the administration of peptic
ferments combined with a mild laxative and bitter
tonic as in the following combination:
B [ 0.30 gramme,
Powdered calumba, 0.25 gramme;
Sodium phosphate, 0.40 gramme.
M. fac cachet i.
Sig. : One after every meal.
Ointment for .Ulcer of the Leg. — An ointment
which has given Danlos better results than all other
means he has tried for the treatment of ulcer of the
leg has the following composition :
^ Ung. ferri peroxid. hydrat.,
Ung. styracis,
01. olivje, aa partes aequales.
M.
This is applied on gauze, or, better still, on silk
protective.
72
EDITORIAL ARTICLES.
[New York
Medical Journal-
NEW YORK MEDICAL JOURNAL
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Entered at the Post Office at New Y'ork and admitted for
transportation through the mail as second class matter.
NEW YORK, SATURDAY, JANUARY ii, 1908,
THE CLINICAL STUDY OF CANCER.
The Fourth Report of the Caroline Brewer Croft
Fund Cancer Commission of the Harvard Medical
School has recently been published, completing the
first volume. The work which it represents was
concerned entirely with the study of spontaneous
and inoculated tumors in mice, and seems to have
been wholly performed by Dr. Ernest E. Tyzzer. A
hopeful view is taken of the possible beneficent re-
sults of the study of such growths. We have not
space for an analysis of Dr. Tyzzer's papers ; it is
rather our present purpose to mention certain re-
marks that are to be found in the introductory sec-
tion, written by Dr. J. Collins Warren.
Dr. Warren tells us that early in their investiga-
tion the commission recognized the importance of
proceeding from an setiological point of view, but
do not wish to be regarded as underrating that of
the study of the disease from the clinical standpoint.
But, he says, "to carry on clinical investigations on
a scale which would bring out new and valuable
data would require resources far beyond what most
commissions have at their disposal." Large endow-
ments, he adds, would enable investigators to "place
the clinical and the laboratory work in close juxta-
position in such a way as to produce results which
it is not possible to obtain either at the hospitals or
with the material of private practice which practi-
tioners of the present day have at their disposal ;"
and he alludes to the large expenditure of money
which would be entailed by special wards for the
study of cancer.
We have in New York two hospitals for the treat-
ment of cancer, in one of which diseases of the skin
also are treated. Something tangible has been ac-
complished in each of them in the way of adding to
our knowledge of malignant disease, but, since they
exist for the prime object of aiding sufferers from
cancer — as many of them as possible and with the
least practicable expenditure of time — it can readily
be understood that for purposes of investigation
they must fall short of the facilities which Dr.
Warren has in mind. The disease should be studied,
he says, "not only in its incurable stages, but at its
very inception, when it is most susceptible to the
action of remedial measures." But the incurable
cases should not be neglected. There may be means
of inducing persons with incipient cancer to seek
for hospital relief in greater numbers than at pres-
ent; certainly it would not be denied them. The
hospitals must do the best they can for the greatest
number of those who have any apparent prospect
of cure or amehoration, and that duty necessarily
restricts the number of advanced cases that can be
kept imder observation. The study of advanced
cases may not be so useful as that of incipient ex-
amples, but doubtless it is of importance, and it
could be pursued in an avowed research hospital
more properly than in one designed solely for
therapeutic purposes, and in conjuction with labora-
tory work.
Such an institution, of course, would involve
great expense, and its funds would have to be sup-
plied rather by persons looking for ultimate results
than by those interested only in the present benefit
of cancer victims. According to Dr. ^\'arren, the
Croft Commission feel that "the investigation of
cancer has now reached a point where it is possible
to take a new departure in this (the clinical) direc-
tion on a far more extended scale than has ever
been attempted and on lines even broader than those
which have been laid down for the study and con-
trol of tuberculosis." It is but human to entertain
the idea that one's own efforts for the welfare of
humanity are not meeting with their fair measure
of support, and therefore we cannot wonder that
Dr. Warren says "A moderate portion of the vast
sums of money which are being used in the crusade
against tuberculosis would be of the greatest value
at the present moment in the attack upon perhaps
the next most dreaded disease of modern times."
Without entering upon a consideration of the com-
parative importance of tuberculosis and malignant
disease as regards the need of investigation, we
heartily express the hope that there may be forth-
EDJIURIAL AKIICLES
73
coming all the funds required for an adequate
clinical study of cancer.
MVISECTION IN THE STATE OF NEW
YORK.
A number of our professional brethren seem to
have misapprehended in some respects the article
on this subject which we published in last week's
issue. It will be remembered that we commended
a certain bill entitled An Act to Prevent Cruelty by
Regulating Experiments on Living Animals, soon
to be introduced into the legislature of the State of
New York. Those of our friends to whom we
now have reference fear that the bill will be so
changed before its actual introduction or so amend-
ed afterward that it will no longer merit whatever
approval it may now meet with at' the hands of the
medical profession. Of course such changes are
quite possible, and we had no idea of giving our
support in advance to unknown alterations. What
we said was with this understanding, not neces-
sarily expressed.
Others of our friends, while under no misunder-
standing as to our view, dissent from it, and we
must acknowledge that their attitude is founded on
reasons which are too cogent to be overlooked.
They say that the bill is speciously drawn and real-
ly intended only as an entering wedge to open the
way. for more drastic and inquisitorial legislation.
In particular, they object to Section 2, relating to
reports required to be made of experiments, point-
ing out that such reports will furnish ad captanduin
material with which fanatics may in the future in-
cite in the public mind a ruthless opposition to all
forms of experiments on animals, as a consequence
of which we shall be reduced to the comparative
impotence which for several years now has ham-
pered our colleagues in England. It may well be
that they are right. ' On the supposition that they
are, we must withdraw our support of the bill and
simply advise our readers to await developments
and the close" discussion that the matter is likely to
draw out.
When the bill was brought to our attention there
was shown to us an endorsement of it bearing the
signatures of a number of medical men of renown
in the profession. On the strength of those signa-
tures we felt that we could not but support a bill
that could command them. It has come to our
knowledge now (since our article was published)
that these gentlemen have revised their opinion and
withdrawn their commendation of the bill. Mind-
ful of the old saying, I'homme conpahle, c'est celui
qui ne change jamais, they have not hesitated to re-
nounce a stand of which they have recognized the
untenability. We cannot, therefore, longer base
an opinion, even in part, on their first judgment;
consequently we must withdraw our support of the
bill. Indeed, we are now convinced that no legis-
lation on the subject is called for, since the law as
it stands is quite sufficient for the punishment of
persons guilty of cruelty to animals.
TWO GREAT SURGEONS OF EDINBURGH.
Within a little more than a fortnight past the
people of Edinburgh have had to join with the med-
ical profession of their town, renowned in medicine
— and, we may truly add, with our profession
throughout the world — in mourning the death of
two of their great surgeons, Mr. Thomas Annan-
dale and Sir Patrick Heron Watson, who, to their
great credit, were commonly known respectively
as "Tommy" Annandale and "Pat" Watson. We
do not speak thus familiarly of men of exalted posi-
tion save as in terms of endearment. Edinburgh,
like Philadelphia and all our southern cities, knows
its medical men and honors and loves them, while
such seething and reckless communities as that of
New York take little, if any, note of personalities
that are not intimately associated with great com.-
mercial, political, or military doings.
Professor Annandale, English by birth, but genu-
inely Scotch by education and in the activities of his
career, was an operator of exceptional skill and
boldness and a diagnostician of almost intuitive per-
ception. He was a man of lively sympathy, always
in close touch with whatever movements made for
the interests of the institutions that commanded his
support, helpful to his students, and gracious and
cheery with the sick, whether their condition was
exalted or of the humblest. It is no wonder, then,
that all Edinburgh mourns for him. His end was
sudden ; he was found dead in bed after a day of
protracted work and an evening spent largely in
making telephonic arrangements for the following
day's duties. He died during the night of Decem-
ber I9th-20th, at the age of sixty-nine.-
Sir Patrick, whose life lasted a few years longer
— he was born in 1832 — was of equal professional
renown, though for a considerable period preceding
his death he was unable, by reason of failing health,
to take an active part in professional work. He
died on December 21st, of angina pectoris. Dur-
ing much of his early professional career he was in
military life. He served with distinction as a med-
ical officer in the Crimean war. For many years
past his name has been of frequent appearance in
the periodical medical literature of Great Britain.
He was knighted in 1903. He is described as of
courtly manners and a military bearing — "an au-
thority in the savoir faire of royal etiquette," says
the Scotsman, but at the same time "a genial com-
74
EDITORIAL ARTICLES.
[New York
Meuical Journal.
panion and not without a touch of humor in his
conversation."
Though not so much resorted to now by students
from various parts of the world as she was a hun-
dred years ago, "Auld Reekie" has by no means
•ceased to implant sound knowledge of medicine in
those who still turn to her as a source of learning.
And so she will continue. She has lost many a
learned and brilliant exponent of our art in the past,
but the ranks are always replenished.
ANAPHYLAXIS AND ANAPHYLAXINES.
One of the most striking and important de-
velopments of bacteriological science has been
the keen stimulus felt in the search for funda-
mental facts concerning poisons in general and
certain organic poisonous substances in particu-
lar. Of recent years, C. Richet, of Paris,
has found in actinians and mussels certain sub-
stances showing peculiar poisonous reactions, to a
mixture of which he has given the name of mytilo-
congestine. In studying the properties of this sub-
stance he has been impressed with certain peculiar
afifmities which it seems to possess with some bac-
terial toxines, and he has been led to a review of the
problem of immunity seen in the light of a new
type of poisoning which he describes.
In a comparatively recent study (Annales de
rinstitut Pasteur, July) he writes that poisons
may be divided into two main groups — the mem-
bers of the one killing immediately or very rapidly,
as chloroform paralyzes circulatory structures,
strychnine destroys nervous structures, curare acts
on neuromuscular terminal organs, mercury de-
stroys cellular metabolism, etc., while those of an-
other group kill, as it were, at a long distance, per-
haps after several weeks, and by a mechanism
which seems dif¥erent from any other which has
heretofore been observed. These poisons are not
immediately operative, but they provoke within the
body the formation of toxic substances of a sort
which, after injection of the poison, develop a true
disease. Or, stated in another way, the disease —
i. e., the ensemble of morbid phenomena which re-
sults from a microbe infection, is a slow intoxica-
tion. It is doubly slow ; in the first place, because
the poison produced by the microbe is slowly and
progressively secreted, so far as, and in the same
manner as, the microbe proliferates, and, further,
because this poison itself acts slowly.
Richet calls attention to the fact that the sub-
stances extracted from actinians, from sponges, and
from mussels have this character of being able to
develop a special morbid state, with an evolution
resembling that of a disease. If one injects this
substance in large doses into the venous system of
an animal (a rabbit or a dog), it will die in from
four to five days ; the injection of doses one fifth as
great, however, brings about a chronic action
which persists from twenty to thirty days at least.
The contrast between tbe action of this type of poi-
son and that of the ordinary crystalloid poison is
very striking, for, as is well known, in the latter
class, strychnine being taken as an example,
amounts of one fifth that of a lethal dose either
cause only nominal symptoms or are innocuous. On
the other hand, Richet's mytilocongestine in
amounts of one fifth of the lethal dose causes a
grave form of chronic intoxication, which frequent-
ly persists for thirty days.
During this period of chronic poisoning, which
Richet has termed anaphylaxis, the body is more
highly sensitive to the action of the poison than it
was before the poisoning. With mytilocongestine,
the sensibility of the body in the greater number of
cases is rendered five times as great, in some in-
stances the sensibility being enhanced at least twen-
ty-five fold. Richet thinks that the presence of a
toxogenic substance is the cause of this increase in
the tdxicity of mytilocongestine. In vitro, the mix-
ture of mytilocongestine with the anaphylactic
serum of dogs is more toxic than this same poison
when in watery solution, and the serum of an
anaphylactic dog, when injected into a normal dog,
can produce anaphylaxis.
Anaphylaxis, then, he argues, is due to the pres-
ence of a sensitizing substance (toxogenine) which,
by reaction with mytilocongestine, develops a poi-
son which acts immediately. Anaphylaxis is estab-
lished only after a certain length of time, and per-
sists for about forty days in the animals used by
the experimenters, for, after this length of time, the
animals become relatively immune, so that injec-
tions of large doses of poison are not followed by
symptoms of poisoning.
The general relations of anaphylaxis to im-
munity, as postulated by the author, are highly sug-
gestive. He considers anaphylaxis as a preliminary
stage to immunity, rendering the latter possible,
for animals react to the injection of toxic sub-
stances of the nature of toxalbumins by producing
sensibilizing substances, or toxogenines, which
create an anaphylactic state, and at the same time
that this state is engendered antitoxines are formed,
but much more slowly. When, in five or six weeks,
the toxogenines disappear, the antitoxines persist.
Anaphylaxis is a sort of rapid defense for small
doses, permitting the organism to rise vigorously to
feeble doses of poison secreted by microorganisms,
and thus to defend the organism so long as the at-
tack is not an energetic one. It is a precursor of
immunity and one of the factors which make it
possible.
OBIJUARY
©bitimri).
NICHOLAS SENN, M. D.,
of Chicago.
This great surgeon died on Thursday, Janu-
ary 2d, after an illness of several weeks' duration in
its acute stage, from a cardiac affection supposed to
have been aggravated by his recent mountain expe-
riences in South America. He was sixty-three years
old. Dr. Senn was born in Switzerland, but was
brought to this country when he was a very young
child. The family settled in \\'isconsin. on a farm.
\\"ith only the advantages of the local schools for
Nicholas -Senn, M. D , of Chicago.
a preliminary education, and eking out his resources
by teaching school, he went through the course in
the Chicago Medical College, where he took his
medical degree in 1868. He served a term on the
house staff of the Cook County Hospital and then
settled in practice in Fond du Lac. He subsequent-
ly practised for twenty 3'ears in Milwaukee, where
he made a national reputation as a surgeon. Then
he moved to Chicago and was made professor of
surgery in the College of Physicians and Surgeons
of that city and subsequently in the Rush ^Medical
College. Early in his career he evinced an apti-
tude for military service, and his services in the
National Guard of Wisconsin, in that of Illinois,
and in the army during the war with Spain won dis-
tinction for him.
It was not only as an operating surgeon that Dr.
Senn was distinguished ; he was the author of many
important additions to our literature. He was of a
frank and martial mien, and his personality made
him liked as well as esteemed in the profession. In
the later years of his life he was able to indulge his
fondness for travel, but in his journeyings he al-
ways kept professional matters in mind and gave
his impressions vividly in contributions to the jour-
nals.
ROBERT WILLIAM TAYLOR. M. D.,
of Xew York.
Dr. Taylor died after a brief illness on Sunday,
January 5th, at the age of sixty-five years. He was
bom in England and brought up in New Jersey,
but came to New York when he was a young man.
Like many other eminent physicians, he began life
as a pharmacist. He studied medicine under the
direction of the late Professor Willard Parker, and
was graduated from the College of Physicians and
Surgeons in the class of 1868. For a number of
years he was professor of venereal diseases in that
institution, and at the time of his death he was con-
sulting genitourinary surgeon to Bellevue and the
City hospitals and consulting surgeon to the French
Hospital.
At the outset of his medical career he was in
general practice for a few years, but even then his
attention was chiefly devoted to skin and venereal
diseases, in which he soon achieved distinction. So
Robert William Taylor, D., of New York.
early as in 1871, only three years after his gradua-
tion, his classic essay on Dactylitis Syphilitica was
pubUsbed in the American Journal of Syphilogra-
phy and Dermatology, and it at once established his
reputation as an acute clinical observer and as a
critic of the writings of others. His contributions
to our literature thereafter were numerous and
weighty, both in the form of journal articles and in
that of books. His published statements were al-
76
NEPVS ITEMS.
[New York
Medical Journal.
ways cogent, and his style of writing was excep-
tionally attractive. In verbal debate, too, he was
remarkably forcible. As a diagnostician in skin
and venereal diseases there was not his superior in
the world, and as a therapeutist he was unusually
successful.
Dr. Taylor had many close friends, and not a
few will be grieved to learn of his death. No
warmer heart than his ever beat in a human breast ;
he was the embodiment of loyalty, and no trouble
was too great for him to take in furtherance of a
worthy cause or in imparting hope to an afflicted
friend. In his death the profession has met with
a loss of the first magnitude.
ALBERT HOFFA, M. D.,
Of Berlin, Germany.
While only of middle age. Professor Hoffa has
been cut off in his successful career. Born in Rich-
nx)nd, Cape of Good Hope, on March 31, 1859, he
studied m.edicine at the universities of Marburg and
Freiburg, and was graduated in 1883. In the same
year he became assistant at the Julius Hospital in
Wiirzburg, and three years later he was admitted
to the medical faculty of the university at Wiirz-
burg as Privatdof:ent in surgery, and in 1897 was
appointed assistant professor. In 1902 he was
called to Berlin as professor of orthopaedic sur-
gery and chief physician of that department at the
university dispensary, which position he held at his
death. From 1886 till 1902 he had a private hos-
pital for orthopaedic patients in Wiirzburg.
Hoffa at the beginning of his career paid special
attention to bacteriology, and his researches in
anthrax should be mentioned {Die Natur des Mils-
brandgiftes, Wiesbaden, 1886), but soon entered
the field of surgery, where he became the founder
of modern orthopaedics in Germany. It was Hoffa
who explored the theory and treatment of scoliosis
and congenital hip luxation and deformities, de-
signing and very often making himself apparatus for
his patients, following and adding to the theories
of Hessing. Later he directed his attention to the
influence of nervous diseases upon orthopaedic
pathology, and to the treatment of joint diseases,
especially the pathology of the knee joint.
During his visit to the United States, in 1904, the
Jefferson Medical College conferred an honorary
degree upon Professor Hoffa.
gftos Items.
Changes of Address. — Dr. William H. Mackinney, to
1831 Chestnut street, Philadelphia.
College of Physicians and Surgeons, New York. — Dr.
George Tiiomas Jackson has been appointed professor of
dermatology to succeed Dr. George Henry Fox, who has
resigned.
The Hospital Saturday and Sunday Association of
St. Louis. — The total collections of this association for
the year 1907 amounted to $.17,841.15, which is $2,783.11
less than the amount collected in igo6.
The Society of Medical Jurisprudence, New York.—
The two hundred anrl tenth regular meeting of this society
will be held at the New York .Academy of Medicine on
Monday evening. January • 13th, at eight o'clock.
Syracuse, N. Y., Academy of Medicine. — A meeting
of this academy was held on January 7th. The retiring
president, Dr. A. B. Miller, delivered an address, and
Dr. F. C. Curtis, of Albany, read a paper on Smallpox and
Diseases Confounded with It.
Food Inspection in New Jersey. — During the month
ending December 31. 1907, 171 specimens of foodstuffs
were examined under the direction of the State Board of
Health in the State Laboratory of Hygiene, 21 of which
were found to be below standard.
Richmond County, N. Y., Medical Society. — The regu-
lar monthly meeting was held at the Staten Island Acad-
emy of Medicine on Wednesday evening, January 8th. The
paper of the evening was read by Dr. W. T. Jenkins on
Disinfection as a Preventive of Dissemination of Small-
pox.
The Jefferson County, Ky., Medical Society held its
annual meeting on December 23d in Louisville and elected
the following officers: President, Dr. Benjamin F. Zim-
merman ; vice presidents, Dr. Charles W. Hibbitt and Dr.
J. Rowan Morrison ; secretary, Dr. Virgil E. Simpson ;
tieasurer, Dr. John J. Moren.
The Northwestern Medical Society, Philadelphia,
held a meetmg on January 6th, when the following papers
were read: Lobar Pneumonia Complicated by Pulmonaiy
Hsemorrhage ; Cancer of the Uterus Treated by Electro-
thermic Hsemostasis, by Dr. A. J. Downes ; Dilatation of
the Parturient Cervix, by Dr. John Cook Hirst.
Two of Scotland's Leading Surgeons Dead. — Pro-
fessor Thomas Annandale, regius professor of surgery in
the University of Edinburgh, died suddenly of heart dis-
ease on December 20th, aged sixty-nine years, and on De-
cember 2ist Sir Patrick Heron Watson died, also from
heart disease, at the age of seventy-five years.
New York Academy of Medicine. — A stated meet-
ing of the academy will be held on Thursday, January i6th.
at 8:30 p. m. Dr. Beverley Robinson will read a paper or,
Laryngeal Phthisis, and there will be additional contribu-
tions on the subject by Dr. Joseph Gleitsmann, Dr. .\.
Jacobi, Dr. Walter Chappel, Dr. S. A. Knopf, and Dr. R.
C. Myles.
Floyd County, Ga., Medical Society. — At the annual
meeting of this society, which was held recently, the
following officers were elected for the ensuing year-
President, Dr. J. C. Watts, of Rome; vice president. Dr.
Isaac Sewell, of Cave Spring; secretary, Dr. W. L.
Funkhouscr, of Rome, and treasurer, Dr. William De
Lay, of Rome.
Buffalo, N. Y., Academy of Medicine. — .\ meeting
of the Section in Surgery was held on January 7th. Dr.
Bransford Lewis, of St. Louis, Mo., read a paper on Prac-
tical Cystoscopy, with a presentation of cystoscopes, ex-
amining, catheterizing, and operative, and Dr. David E.
Wheeler, of Buffalo, gave an exhibition of lantern slides
of skin and genitourinary diseases.
The Fourth Harvey Lecture. — As has been previously
announced, the fourth lecture in the Llarvey Society course
will be delivered at the New York Academy of Medicine
on Saturday. January iitli, at 8:30 p. m., by Professor
Ernest H, Starling;-, of the I'l'iversity of London. The
subject will be The Chemical Control of the Body. All
interested are cordially invited to be present.
Deutsche Medizinische Gesellschaft der Stadt New
York. — A meeting of the German Medical Association
of the City of New, York was held at the Academy of
Medicine on January 6th, when Hie following papers were
read: The Operative Aims in Modern Obstetrics, by Dr.
A. Stein ; Inhalation Therapeutics, by Dr. F. Ruppert, and
the Treatment of Migraine, by Dr. A. Herzfeld.
Charitable Bequests and Donations. — By the will of
Eliza M. Wray the Philad.elphia Home for Incurables
receives $200.
By the will of Mrs. Mary A. Brannon the Carney Hos-
pital, Boston, will receive $500.
The German Hospital. Brooklyn, has received a check
for $7,500 from the Aid Society of the hospital.
American Philosophical Society. — Tlie annual meet-
ing of this society was held on January 3d, and the fol-
lowing officers for the ensuing year were elected : Presi-
dent, Dr. William W. Keen : vice presidents, Mr. George
January ii, 190S.J
NEWS ITEMS.
77
F. Barker, Mr. William B. Scott, and Mr. Simon New-
comb; secretaries, Dr. I. M. Hays, Mr. Arthur M. Good-
speed, Dr. James Holland, and Mr. Amos P. Brown.
The Philadelphia Medical Examiners' Association. —
At a meeting of this association, held on January 7th, the
evening was devoted to a symposium on the Heart and
Life Expectancy. Dr. Robert N. Willson demonstrated the
Physical Examination of the Heart ; Dr. William E.
Hughes spoke on Observations as to Intracardial Lesions,
and Dr. Judson Daland described the Recognition of Ex-
tracardial Lesions.
The Elmira, N. Y., Academy of Medicine held its
annual meeting on Wednesday, January 8th, and elected
officers for the ensuing year. Dr. H. W. Fudge delivered
the presidential address, and papers were read as follows :
The Present Status of Opinion Concerning the /Etiology
of Tuberculosis, by Dr. C. W. M. Brown, and Some Con-
siderations of Systemic Infections Through Diseased Ton-
sils, by Dr. G. M. Case.
The Hospital Ship "Relief."— Dr. Charles F. Stokes,
a surgeon in the United States Navy, has received orders
directing him to assume command of the hospital ship
Relief, which is being fitted out at the Navy Yard, Mare
Island, Cal., with a fv.ll hospital equipment for special duty
with the battleship fleet. It was the issuance of this order
which led to the controversy which resulted in the resigna-
tion of Admiral Brownson.
Consolidation of Two Louisville Colleges. — The com-
bination of the Louisville College of Medicine and the Hos-
pital College of Medicine went into eff^ect on January ist.
Dr. L. S. McMurtry is president of the new college; Dr.
C. W. Kelly is dean of the faculty, and Dr. W. F. Boggess,
associate dean. The institution is known as the Louisville
and Hospital Medical College. Medical Department of the
Central University of Kentucky.
The Philadelphia Academy of Surgery. — At a meet-
ing of this academy, held on January 6th, the following
papers were read : Gunshot Wound of the Stomach with
Posterior Drainage, by Dr. Edward B. Hodge, Jr.; Report
of a Case of Stab Wound of the Diaphragm, by Dr.
Francis T. Stewart ; Report of a Case of Tuberculosis of
the Cfficum, by Dr. John H. Jopson ; Renal Diagnosis and
Efficiency, by Dr. B .A Thomas.
The Medical Society of the County of Ontario, N. Y.
— The quarterly meeting of this society will be held in
Canandaigua, on Tuesday, January 14th, when the follow-
ing papers will be read : A Rare Case of Dermatitis Ex-
foliativa, by Dr. W. A. Howe ; Legal Status of Physicians'
Fees, by W. C. Ellis, Esq., of Shortsville, N. Y. ; Prostatic
Hypertrophy, by Dr. W. B. Jones, of Rochester, N. Y. ;
Treatment of Lobar Pneumonia, by Dr. C. W. Selover.
The Pathological Society of Philadelphia. — At a
meeting of this society, held on January 9th. the follow-
ing papers were re.nd : The Coordination of Gastric and
Intestinal Digestion by the Action of the Pyloric Sphincter,
■by Dr. Walter B. Cannon, of Harvard University ; and
Bacterial Vaccines of Staphylococcic Strains, by Dr. Harlan
Shoemaker. Dr. Judson Daland gave a demonstration of
the Strongyloides Intestinalis from a Philadelphian.
Repairs at Ellis Island. — A bill has been introduced
into Congress providing for an appropriation of $550,000
for urgent repairs and construction at the immigration
station at Ellis Island. The bill suggests that the appro-
-priation come out of the emigrant fund. It provides $35,-
000 for refitting the plant, $125,000 for a steam ferryboat,
$250,000 for completing the wing to the hospital, and $150,-
000 for the completion of the contagious disease hospital.
New York Pathological Society. — The anniversary
meeting of this society was held on January 8th, when
the following papers were read : Tuberculosis of the
Ductus Thoracicus, by Dr. Richard Wei! ; Ureteritis
Cystica, by Dr. Otto H. Schultze; Diphtheritic Laryngitis,
Tracheitis, and Bronchitis, by Dr. Thomas Flournoy, and
Endarteritis Obliterans, by Dr. I. Levin. Officers were
elected and committees were appointed for the ensuing
year.
The Western Surgical and Gynaecological Associa-
tion.— The seventeenth annual meeting of this associa-
tion was held in St. Louis, Mo., on December 30 and 31,
1907, and officers for the ensuing year were elected as
follows : President, Dr. W. ^^^ Grant, of Denver ; vice
presidents. Dr. Willard Barlett, of St. Louis, and Dr. Harry
A. Sifton, of Milwaukee; secretary and treasurer. Dr.
Arthur T. Mann, of Minneapolis. The next meeting will
be held in Minneapolis on December 30 and 31, 1908.
A Tuberculosis Exhibit in New York.— The exhibit of
the Committee on the Prevention of Tuberculosis of the
Charity Organization Society, which was at the Jamestown
Exposition, was opened to the public on January 8th, in a
building in East Twenty-third street. The exhibit con-
sists of photographs and models of hospitals, sanitariums,
day camps, tenement conditions, diet kitchens, sweat shops,
etc. Informal talks will be given each noon on the sub-
ject of tuberculosis, and stereopticon views will be shown
at night.
College of Physicians of Philadelphia.— At the regu-
lar meeting, held on Wednesday evening, January 1st, offi-
cers were elected for the ensuing year as follows : Presi-
dent, Dr. James Tyson ; vice president. Dr. G. E. de
Schweinitz; secretarj'. Dr. Thomas R. Neilson; treasurer,
Dr. Richard H. Harte ; honorary librarian, Dr. Frederick
P. Henry. Colonel W. B. Bannerman, of Bombay, India,
was elected an associate fellow. The honorary librarian
reported an addition of fifty-six volumes to the library dur-
ing December.
The Health of Pittsburgh. — During the week ending
December 21, 1907, the following cases of transmissible
diseases were reported to the Bureau of Health of Pitts-
burgh : Chickenpox, 18 cases, o deaths ; typhoid fever,
103 cases, 17 deaths ; scarlet fever, 13 cases, 3 deaths ;
diphtheria, 20 cases, 5 deaths ; measles, 65 cases,
3 deaths ; whooping cough, 8 cases, i death ; pulmonary
tuberculosis, 7 cases, 6 deaths. The total deaths for the
week numbered 155 in an estimated population of 403,330,
corresponding to an annual death rate of 19.98 per 1,000
population.
A Special Meeting of the Medical Association of the
Greater City of New York was held on Monday, Janu-
ary 6th, under the direction of the chairman for the Bor-
ough of the Bronx. Dr. Thomas E. Satterthwaite, presi-
dent of the association, read a paper entitled Some Phases
of Myocardial Disease ; Dr. Louis Faugeres Bishop read
a paper entitled Instruments of Precision in the Man-
agement of Diseases of the Heart; Dr. William H. Porter
read a paper on the Diagnosis of Diseases of the Heart,
and Dr. Reynold Webb Wilcox delivered an address on the
Use of Drugs in Diseases of the Heart. ■ A general dis-
cussion followed.
The Mortality of Chicago. — According to the report
of the department of health for the week ending December
28, 1907, there were during the week 569 deaths, as com-
pared with 575 for the corresponding week in 1906. The
annual death rate in 1,000 of population was 14.08. The
principal causes of death were : Apoplexy, 8 ; Bright's dis-
ease, 36; bronchitis, 23; consumption, 44; cancer, 30; con-
vulsions, 6; diphtheria, 9; heart diseases, 47; influenza, 6;
intestinal diseases, acute, 32 ; measles, i ; nervous diseases,
23; pneumonia, 103; suicide, 4; scarlet fever, 16; typhoid
fever, 7; violence (other than suicide), 28; whooping
cough, 5 ; all other causes, 141.
Scientific Society Meetings in Philadelphia for the
Week Ending January 18, 1908. — Monday, January 13th.
Section in General Medicine, College of Physicians; Wills
Hospital Ophthalmic Society. Tuesday, January 14th,
Philadelphia Pasdiatric Society ; Botanical Section, Acad-
emy of Natural Sciences. Wednesday. January 15th,
Philadelphia County Medical Society (Business Meeting
open to members only) ; Section in Otology and Laryn-
gology, College of Physicians; Association of Clinical As-
sistants of Wills Hospital ; Franklin Institute. Thursday,
January i6th, Section Meeting, Franklin Institute ; Medi-
cal Society of the Woman's Hospital. Friday, January
17th, University of Pennsylvania Medical Society; Ameri-
can Philosophical Society.
The Mortality of New Jersey. — According to the re-
port of the State Bureau of Vital Statistics for Decem-
ber, J907, there were 2,745 deaths reported in New Jersey
during the month ending December 15, 1907, which was
291 less than the monthly average for the past year. There
were 455 deaths among infants under one year of age, 199
deaths of children over one year of age and under five
years of age, and 862 deaths of persons sixty years of age
and over. Pneumonia caused 216 deaths, an increase of
NEWS ITEMS.
IXew York
Mei'Ical Journ
47 over the previous month, and there were 39 deaths from
tjphoid fever, a decrease of 7 from the previous month.
Among other important causes of death were the follow-
ing: Diseases of the nervous system, 352; tuberculosis
of the lungs, 270; cancer, 112; diseases of the circulatory
system, 318; Bright's disease, 203; infantile diarrhoea, 195.
There were 36 deaths from suicide, which was 7 more than
the average for the preceding twelve months.
Infectious Diseases in New York:
IVe are indebted to the Bureau of Records of the Health
Department for the following statement of nciv cases and
deaths reported for the two weeks ending January 4, igo8:
—December 28.— ^ —January 4.->
Cases. Deaths. Cases. Deaths.
Typhoid Fever 42 18 37 8
Smallpox 2
Varicella 123 .. 98
Measles 346 26 581 32
Scarlet fever 426 22 478 33
Whooping cough 3 2 25 i
Diphtheria 347 30 308 36
Tuberculosis pulmonalis 308 191 344 158
Cerebrospinal meningitis 6 6 n 8
Totals 1,603 -95 1,882 276
Southern Medical College Association. — The annual
meeting of this association was lield in New Orleans re-
cently. Three medical schools were added to the mem-
bership, viz.: the Atlanta College of Physicians and Sur-
geons, the Medical Department of the University of Kan-
sas, and the College of Physicians and Surgeons of Little
Rock, Ark. Officers for the ensuing year were elected as
follows : President, Dr. Christopher Tompkins, dean of
the Medical College of Virginia ; vice president, Dr. W. S.
Rogers, dean of the Memphis Hospital and Medical Col-
lege ; secretary and treasurer. Dr. L. C. Morris, of the
Birmingham Medical College; chairman of the executive
committee. Dr. J. S. Cain, of Sewanee, Tenn.
A Proposed Hospital for Inebriates. — At a meeting
of the Philadelphia County Medical Society, held on Wednes-
day, January 8th, the first steps were taken in a move-
ment to secure for the State of Pennsylvania a hospital
for the treatment pnd care of inebriates and persons ad
dieted to the use of drug.s. The subject was introduced
by Mr. Robert A. Woods, president of the board of
trustees of the Foxboro, Mass., Inebriate Hospital, and
Dr. John B. Carrell, of Hatboro, Pa., read a paper on the
Necessity for the Establishment of an Inebriate Hospital
for the Cafe of Alcoholics and Drug Habitues. A number
of State senators and representatives were present, and
plans were discussed. It is proposed to prepare a bill to
be presented to the next legislature, asking for an appro-
priation to cover the cost of erection and maintenance of
such an institution. The object of the meeting was to
arouse sentiment and interest the medical profession, as
«vell as the public, in the undertaking.
Personal. — Dr. H. Brantley, of Spring Hope, N. C,
is registered at the Philadelphia Polyclinic and College of
Graduates in Medicine.
Miss Annie M. Rykcrt has been appointed superintendent
of the New York Post Graduate Hospital.
Dr. Gordon Wilson, of Baltimore, has been placed in
charge of the medical department of the consumptive hos-
pital at Bayview Asylum.
Dr. William Starr, of Washington, D. C, who recently
celebrated his one hundredth birthday, has been elected a
member of the Confederate Veterans' Association.
Major Charles F. Mason, of the Medical Department
of the United States Army, will deliver a series of lectures
on First Aid, at the Young Men's Christian Association,
Washington, D. C. The first lecture was delivered on
Friday, January lotb, and a lecture will be given each
Friday, at 8 p. m., until the course is completed.
Dr. John P. Moore, head of the Queens Borough Health
Department, has resigned, and will resume his private
practice.
Lectures on Nutrition. — A course of twelve public lec-
tures on nutrition will be given at the Teacliers' College,
I20th street and Amsterdam avenue, for the benefit of
those who are interested in the problem of food in the
home and in institutions. The first lecture will be given
on Monday, January 13th, at 4 o'clock, and the other lec-
tures will follow every Monday at the same time and place
for twelve weeks. There will be five lectures on digestion
and assimilatio:! by Dr. William J. Gics, of the College of
Physicians and Surgeon's ; four lectures on nutritive require-
ments and the selection of food, by Dr. Henry C. Sher-
man, of the School of Chemistry, and three lectures on the
relation of foods in household practice, by Miss Anna
Barrows, of the department of domestic science of the
Teachers' College. The lectures will be illustrated.
Newark, N. J., Medical League.— At the regular meet-
of this organization, held on December 9th, Dr. Willy
Meyer, of New York, delivered a lecture on Bier's Hyper-
aemic I'reatment. In a preliminary talk, Dr. Meyer dealt
with the subject in a general way, and then read two
papers, one on Acute Mastitis, representing the acute dis-
eases in which Bier's treatment may be applied, and the
second on Chronic Tuberculosis of the Knee, showing the
use of Bier's method in chronic diseases. Dr. Meyer ex-
hibited the suction glasses used in acute mastitis, and
showed a mask made of celluloid, to be worn over the
nose and mouth in tuberculosis of the lungs. After the
lecture a dinner was served in honor of Dr. Meyer, after
which he illustrated the application of the rubber band and
cupping glasses on the arm of a member. At the
annual meeting of the league, held on December 23d,
the following officers were elected for the ensuing
year: President, Dr. David A. Kraker ; vice president. Dr.
Herbert W. Long; treasurer. Dr. E. Steiner; secretary,.
Dr. Louis Weiss.
The Health of Philadelphia. — During the week end-
ing December 21, 1907, the following cases of transmissible
diseases were reported to the Bureau of Health of Phila-
delphia : Typhoid fever, 78 cases, 7 deaths ; scarlet fever,
47 cases, 3 deaths ; chicken pox, 56 cases, 0 deaths ; diph-
theria, 106 cases, 10 deaths ; cerebrospinal meningitis, 3
cases, o deaths ; measles, 54 cases, 2 deaths ; whooping
cough, 13 cases, 2 deaths; pulmonary tuberculosis 75 cases,
50 deaths ; pneumonia, 91 cases, 68 deaths ; erysipelas, 12
cases, o deaths ; puerperal fever, 5 cases, 3 deaths ; septi-
csemia, 4 cases, 2 deaths ; mumps, 6 cases, o deaths ; Ger-
man measles, 2 cases, o deaths; cancer, 20 cases, 11 deaths.
The following deaths from other transmissible diseases
were reported : Tuberculosis, other than tuberculosis of
the lungs, 9 ; tetanus, i ; diarrhoea and enteritis, under two
years of age, 14. The total deaths numbered 499 in an
estimated population of 1,500,595, corresponding to an an-
nual death rate of 17.21 in 1,000 population. The total
infant mortality was 104; under one year of age, 86; be-
tween one and two years of age, 18. There were 36 still
births — 17 males, and 19 females. The total precipitation
was 0.05 inch. The temperatures were rather high for the
time of year, a maximum of 47° being recorded on the
2ISt.
Society Meetings for the Coming Week:
Monday, January 13th. — New York Academy of Medicine
(Section in Neurology and Psychiatry) ; Society of
Medical Jurisprudence, New York ; New York Ophthal-
mological Society ; Society of Alumni of St. Mary's
Hospital, Brooklyn ; Corning, N. Y., Medical Associa-
tion ; Waterbury, Conn., Medical Association.
Tuesday, January 14th. — New York Academy of Medi-
cine (Section in Public Health) ; New York Obstetri-
cal Society ; Newburgh Bay Medical Society ; Medical
Society of the County of Schenectady, N. Y. (annual) ;
Practitioners' Club of Jersey City, N. J. ; Medical So-
ciety of the County of Rensselaer, N. Y. ; Buffalo
Academy of Medicine (Section in Medicine).
Wednesday, January 15th. — New York Academy of Medi-
cine (Section in Genitourinary Diseases) ; New York
Society of Dermatology and Genitourinary Surgery;
Woman's Medical Association of New York City
(New York Academy of Medicine) ; Medicolegal So-
ciety, New York ; New Jersey Academy of Medicine
(Jersey City) ; Northwestern Medical and Surgical
Society of New York; New York Society of Internal
Medicine ; New Haven, Conn., Medical .Association
(annual); Buffalo Medical Club.
Thursday, January i6th. — New York Academy of Medi-
cine ; German Medical Society. Brooklyn ; Newark,
N. J., Medical and Surgical Society; ^sculapian Club'
of BufTalb, N. Y.
Friday, January 17th. — New York Academy of Medicine
(Section in Orthopaedic Surgery) : Clinical Society of
the New York Post Graduate Medical School and Hos-
pital; East Side Physicians' Association of the City of
New York : New York Microscopical Society : Brook-
lyn Medical Society.
January ii, 7908.]
PITH OF CURRENT LITERATURE.
79
|it^ 0f Camnt literature.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
January 2, 1908.
1. Renal Tuberculosis and Indications for Operation,
By Lincoln Davis.
2. The Value of Vaccine Therapy to the General Prac-
titioner in the Treatment of Bacterial Diseases,
By Cleaveland Floyd and Arthur M. Worthington.
3. Some Personal Experiences with Specific Vaccines in
the Treatment of Bacterial Disease,
By Mark W. Richardson.
4. Certain Aspects of the Treatment of Infections with
Bacterial Vaccines, By Roger J. Lee.
5. Vaccine Therapy : A Report on Sir Almorth E. Wright's
London Clinic, By Helen C. Putnam.
I. Renal Tuberculosis. — Davis says that abun-
dant clinical experience has shown, and particularly
that of the last few years, that in properly selected
cases nephrectomy gives splendid results in tuber-
culosis of the kidney. There would be little justifi-
cation for nephrectomy if it was true that the renal
disease was secondary to a primary focus in the
bladder, which would remain after the operation to
infect the other kidney. Our present knowledge,
however, that the kidney is practically always the
primary focus, and that the disease secondarily af-
fects the ureter and bladder, not only puts the oper-
ation of nephrectomy on a rational basis, but
strongly indicates an early operation before the sec-
ondary' changes in the bladder have become irre-
parable. In fact, radical removal seems to be the
only treatment for this condition, oflFering hope of
permanent cure. Spontaneous healing of tuber-
culosis of the kidney, unlike tuberculosis in various
other organs, appears to be extraordinarily rare, if
not unknown. Conclusive cases are lacking in the
literature. More light is greatly needed on the sub-
ject. It seems to be pretty generally agreed, how-
ever, that hygienic measures which are so valuable
in treating tuberculosis situated elsewhere in the
body, seem least effective in arresting the process
when in the kidney. Why this should be so is hard to
say. The author quotes Senator, of Berlin, who said :
"When renal tuberculosis is not amenable to opera-
tive treatment, we know of no other termination
than death ; at least recovery must be rare." If this
is true, remarks Davis, the question presents itself
at once in every case. Is operative treatment indi-
cated, and if so, what form of operation is best?
Resection of the tuberculous focus is dangerous on
account of haemorrhage, and uncertain as to re-
moval of the entire disease. Nephrotomy is merely
a palliative measure, and should be followed by a
nephrectomy to obtain a cure, the secondary ne-
phrectomy being as a rule more difficult than a pri-
mary one would have been. Complete nephrectomy,
with removal of ureter when diseased, is the opera-
tion of choice for unilateral tuberculosis of the
kidney.
3. Specific Vaccines in the Treatment of Bac-
terial Disease. — Richardson adds fifty more cases
to his report published October 3, 1907. He has
now 163 routine cases, with thirty -five, or 21.4 per
cent., of relapses, as compared with forty inoculated
cases, with 2 or 5 per cent, relapse.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
January 4, ipo8.
1. Medicine and the University, By William H. Welch.
2. Dentistry as a True Specialty of Medicine. Chairman's
Address in the Section on Stomatology,
By Morris I. Schamberg.
3. The Interrelationships of Medicine and Dentistry,
By Henry C. Register.
4. Dental Education and the Public,
By James McManus.
5. Headache as a Symptom of Local Disorders,
By Frederick Coggeshall and William E. MacCoy.
6. Trichopathophobia, By A. D. Mewborn.
7. The Frequency, Mortality, and Treatment of Placenta
Prasvia, By I. L. Hill.
8. The Effects of Hydrastis and Its Alkaloids on Blood
Pressure, By William Whitridge Williams.
9. The United States Pharmacopoeia,
By Robert A. Hatcher,
id. Evacuation and Depletion of the Tympanic Cavity as
Aids to Drainage in Acute Middle Ear Suppuration,
By Leroy Fridenberg.
7. The Frequency, Mortality, and Treatment
of Placenta Praevia. — Hill observes that among
multipar.T placenta praevia can hardly be called a
rare complication. In i,<Soo cases, of which 87 per
cent, were multiparae and the average number of preg-
nancies 4 plus, he has found the ratio to be i to 225.
The mortality has been understated recently because
of too broad generalization on a few highly favor-
able case reports. There has been very little reduc-
tion in the fcetal death rate, which is still from 40
to 50 per cent. In the presence of haemorrhage in
the last third of gestation the cervix should imme-
diately be dilated sufficiently to allow of a diagnosis
by the finger, and if placenta prjevia is present the
uterus should be emptied without delay. Tampon-
ade of the cervix and vagina is useful as a prelim-
inary step. The Braxton-Hicks version is effective
in controlling haemorrhage and is the safest proced-
ure for the mother, but it does not give satisfactory
results for the child. When the dilatability of the
cervix makes us positive that deliver}- can be ef-
fected with little or no tearing of the cervix we may
elect rapid deliver}' by version or forceps, packing
the utertis and vagina if there is bleeding after the
third stage. In cases presenting long, rigid cervices,
complete praevia and a viable child, if the surround-
ings are favorable, Caesarean section should be
chosen in the interests of the child. The advance in
treatment for placenta praevia has been remarkable
in reducing the maternal death rate even though the
saving of the patients has not been brought so near
to being an exact science as some authors would
suggest. It would seem that progress must be di-
rected to decreasing the foetal mortality.
8. The Effects of Hydrastis and Its Alkaloids
on Blood Pressure. — Williams states that the most
constant and conspicuous effect of the intravenous
injection of hydrastis is a prompt fall of blood
pressure. With small doses the pressure promptly
returns to normal, and there may be a slight rise
above normal. With larger doses (from 0.07 c.c.
to I c.c. per kilogramme of body weight) there is
only partial recovery from the fall of blood pres-
sure or it may remain low. The pressure phenom-
ena are attributable to depression of the cardiac
muscle causing the fall and to stimulation of the
muscle causing the rise. Very large doses depress
8o
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
and paralyze the vagus and vasomotor system ;
otherwise there is no evidence deduced from the
myocardiograms and oncometer that the vasomotor
system plays any important role in the blood pressure
changes. The two principal alkaloids of hydrastis,
hydrastin and berberin, cause qualitatively the
same blood pressure changes, although berberin is
the more active and is responsible for about 85
per cent, of the effect of hydrastis, hydrastin caus-
ing the remaining 15 per cent. Hydrastis given by
mouth or hypodermically causes no change in the
blood pressure, heart rate, or respiration. Hydras-
tinin — an artificial alkaloid derived from hydrastin
— causes a rise of blood pressure above normal,
which is usually preceded by a slight fall when in-
jected intravenously. The rise is well sustained and
is principally caused by stimulation of the cardiac
muscle.
10. Evacuation and Depletion of the Tym-
panic Cavity as Aids to Drainage in Acute Mid-
dle Ear Suppuration. — Fridenberg remarks that
the conditions for free drainage afforded by the ex-
ternal auditory canal are ideal, and any attempts to
improve them are not only illusory but defeat their
own ends. Insufificient drainage is never due to
conditions in the canal but invariably to the state of
affairs in the tympanic cavity, the size, position, or
permeability of the opening in the drum, and it
stands to reason that these conditions can not be
affected by measures which stop short of the mid-
dle ear, and in practice, at all events, do not even
reach the drum. For there can not be much doubt
of the mechanical difficulty, not to say impractic-
ability, of inserting the end of a gauze drain into
the paracentesis opening, and yet this is seriously
laid down as a step in the drainage method. The
drain can, however, be crowded up against the
drum, and here it lies, stopping up the paracentesis
opening and damming back secretions. Immedi-
ately after paracentesis there is a large admixture
of blood with the fluid evacuated. This is apt to
clot, and if a tampon is used retention is still more
apt to occur. This also applies to the sticky se-
cretion which is not only found in the otitis of in-
fluenza, but may be present in the more common
types. The occlusive drain accomplishes two pur-
poses, but they are not those of drainage and anti-
phlogistics alleged for it by its adherents, but
rather act as an occlusive bandage and as an in-
fected poultice. Even if this drain is changed three
or four times a day, which will require the services
of a nurse, there is no guarantee that retention will
be avoided. Secretion from the middle ear is often
so profuse as to render such a reliance entirely
visionary. Syringing is grateful to the patient,
keeps the ear clean and free from discharge for
some time, and can be entrusted to the patient or to
some member of the family after one or two dem-
onstrations. After the acute symptoms have sub-
sided and the secretion has become less profuse and
thick, the antiseptic solution may be changed for a
slightly astringent one, such as zinc sulphate, 0.5
per cent., or a solution made by adding pulvis anti-
septicus (N. F.) one drachm to a pint of water.
This will prevent swelling of the canal and check
any tendency to the formation of granulation tissue
in subacute cases. Eczema of the auricle and ex-
ternal meatus may be caused by irritating secretions,
and possibly by repeated syringing, especially with
too highly concentrated or too hot solutions. This
may be avoided by carefully drying the skin and ap-
plying a little zinc oxide ointment after each irriga-
tion.
MEDICAL RECORD.
January 4, 1908.
1. Poliomyelitis Anterior as an Epidemic Disease,
By Henry W. Berg.
2. Bacterial Vaccines and Curative Sera,
By Charles Bolduan.
3. The Early Diagnosis and Treatment of Pulmonary
Tuberculosis, By John H. Pryor.
4. Some Points in Medical Education Considered from
the Standpoint of the Student,
By Benjamin Michailovsky.
5. The Term "Stauungs-Hyperaemie,"
By Alfred Reginald Allen.
1. Poliomyelitis Anterior as an Epidemic Dis-
ease.— See abstract on page 42.
2. Bacterial Vaccines and Curative Sera. —
See abstract on page 41.
4. Some Points in Medical Education Con-
sidered from the Standpoint of the Student. —
Michailovsky remarks that the present improved
methods of medical teaching fall very far short of the
possible achievements that might be obtained for two
great reasons. In the first place, the student body is but
indifferently prepared for the reception and use of
new knowledge ; the remedy, of course, hes in more
purposeful teaching in the academic courses. In
the second place, those who are to make use of the
means and methods of instruction are not sufficient-
ly conversant with the general fundamental princi-
ples of pedagogics ; the remedy for this lies in indi-
vidual recognition of the fact and attempts to cor-
rect it, or in the establishment of special educational
courses in the universities, of which the medical
college may be a part, and elsewhere. In addition,
the general arrangement of the medical course
ought to be so modified as to allow the greatest pos-
sible opportunities for correlating and harmonizing
the various branches of instruction, thus assisting
in the final end and aim of the work, the adequate
preparation of young men in the art and science of
medicine.
The Term Stauungs-Hyperaemie. — Allen re-
marks that since the advent of Bier's treatment, the
English speaking scientific world has been casting
about in search of a concise descriptive term in its
own tongue, with but questionable success. We find
a number of adjectives used to qualify this hyper-
asmia, such as obstructive, artificial, passive, con-
gestive, and venous, as also the noun, stasis hyper-
aemia. These terms are all open to the same criti-
cism in that they fail to give a mental picture of the
mechanics of Stauungs-Iiypersemie ; stasis hyper-
aemia, besides, conveys a scientifically wrong im-
pression. To the philologist there is nothing more
apparent than the fact that where one language
possesses a single word descriptive of a condition
or thing, another language, in order fully to con-
vey the same idea, may have to use a phrase or a
whole sentence. The Germans at times apparently
avoid this by forming a colossal word by the agglu-
January ii, 1908.]
PITH OF CURRENT LITERATURE.
81
tination of several components. The condition
present in the partial obstruction of venous outflow
with a retained arterial ingress, the amount of blood
thereby being increased in the part, but the circula-
tion thereof never ceasing, is perfectly expressed by
the German term Stauiuigs-Hypercsmie, and but in-
adequately or falsely expressed by the use of any two
word combination in the English language that he
has observed so far in literature. He thinks for
this reason it were well to take over bodily this term
into our language rather than use any of the Eng-
lish terms which but ill portra}- what we desire to
express.
BRITISH MEDICAL JOURNAL.
December 21, 1907.
1. On Tuberculosis in Childhood and its Relation to Milk,
By J. McCaw.
2. Has a Purin Free Dietary Any Special Therapeutical
Value? By C. Watson.
3. A Case of Cerebral Tumor Associated with Subjective
Sensations of Smell, By H. C. Thomson
4. Medical Practitioners and Public Health,
By T. Fowler.
5. A Plea for the Study of Bacteriology by the General
Practitioner, By J. A. Jones.
6. Cremation, By J. VV. Riley.
7. Protection of India from Invasion by Plague,
By J. A. Thompson.
8. Primary Sarcoma of the Vermiform Appendix,
By T. Carvvardine.
9. A Case of Septicaemia with Interesting Reactions to
Treatment and Recovery, By C. F. Fothergill.
10. The Post Mortem Statistics of Middle Ear Disease in
Young Children, By J. Miller.
11. Observations on Blood Films with Special Reference
to the Presence of Haemoconia, By F. Porter.
I. Tuberculosis in Childhood. -McCaw form-
ulates the following rules to protect children from
the ravages of tuberculosis: i. The notification
of all births within twenty-four hours. This would
enable health inspectors to examine into the state of
the child's surroundings; to have the child removed,
or precautions taken, should any case of tubercu-
losis exist in the house, and to give suitable direc-
tions for the care of the child and especially to
encourage breast feeding. 2. Complete control of
the milk supply by the State. This should include
the application of the tuberculin test to dairy cattle,
and the removal of all such as react to this test;
cleanliness in the collection of all milk, and in the
transmission of it from the dairy to the consumer;
the removal of all dairies from the centre of large
towns and cities. 3. Medical inspection of school
children and school premises. First, to detect and
remove children who are actually ill or unfit to at-
tend school ; and, secondly, to ensure proper ventil-
ation and sanitary arrangements in the schools, and
to prevent over crowding. The elementar}' princi-
ples of hygiene should be taught to even young
children ; to older children the principles of domes-
tic hygiene and economy should be added. 4.
Housing reform. Dwelling houses in the poorer
districts should be made more sanitary, especially
with regard to the free access to them of sunlight
and fresh air. A leveling up of the social and do-
mestic conditions of the poor is urgently required,
for of the 1,200,000 children born each year in Great
Britain, fully one fourth to one third of them are
bom to want and squalor. 5. Segregation of ad-
vanced cases. All advanced cases of phthisis
should be segregated as far as possible and treated
in special institutions set apart for that purpose.
Children who are allowed to live in the house with
a consumptive are exposed to serious risk. 6. Noti-
fication of the disease should be compulsory. By
this means health officers would know where the
disease existed, and it would enable them to take
suitable precautions against the spread of the dis-
ease, by disinfection and other means. The large
proportion of tuberculosis in children comes within
the purview of the surgeon to whom the treatment
may be safely left. Our increased knowledge re-
garding the opsonic index has brought treatment
with tuberculin within the realm of safe therapeut-
ics, and the clinical success which has attended the
employment of this treatment has firmly established
its position as a remedial agent of the first import-
ance.
2. Purin Free Dietary.— Watson has studied
the question as to whether a diet, free of purins,
has any special therapeutical value. Purins are sub-
stances constructed on the base C^N*. Those of
chief clinical importance are uric acid, xanthin, hy-
poxanthin, adenin, and guanin. The pathology of
purins centres largely around gout and gouty dis-
orders, that disease being now generally regarded
as a disorder of intermediary purin metabolism.
Many authorities attach special value to the admin-
istration of a purin free diet, but the writer has
come to the conclusion, from practical experience,
that such a diet has no special therapeutical effect.
The benefit that is derived from such a regime in
certain cases would be equally attained by the use
of a carefully planned system of feeding framed
without special reference to purin contents. In
some cases the restriction in amount of animal pro-
tein food is of special value, in others the diminu-
tion in the carbohydrate, and especially the sugars,
is equally efficacious, and in others the restriction
of various alcoholic liquors will suflSce. Very often
complete relief from gouty symptoms follows meas-
ures directed to increase the functional activity of
the liver, kidneys, skin, or thyreoid gland.
9. Septicaemia. — P'othergill reports a case of
septicaemia showing the following interesting fea-
tures: I. The extreme virulence of the infection.
2. The general symptoms became progressively
worse until the use of antistreptococcic serum, which
almost at once acted beneficially. 3. Brandy was,
without doubt, of great benefit in two syncopal at-
tacks, but when the patient was given brandy every
four hours it was found to raise both temperature
and pulse, and made him more restless, and was,
therefore, discontinued. 4. That although the tem-
perature and pulse had been normal or subnormal
for nineteen days after the abatement of the gen-
eral symptoms, yet, when the amputated finger was
examined, it was found that not only had all the
cartilages of the interphalangeal joints been eroded,
but the bone was also eroded into the cancellous
tissue, thus proving that temperature and pulse in
such a case are no guide to active disease, but that
the presence of continuous pain is far more im-
portant. 5. The citric acid mixture proved wonder-
fully efficacious in lowering the abnormally high
coagulability of the blood, and seemed directly re-
82
PITH OF CURRENT LITERATURE.
IiXe'.v Vukk
Medical Journal.
sponsible for improving the character of the pus
and bringing about the rapid and thorough recov-
ery of the wound.
II. Haemoconia. — Porter has studied haemo-
conia, those small micrococcal bodies seen in the
blood, clear and highly refractile, and with the
power of very rapid movement. They are never at
rest and appear to have the power of endless mo-
tion— a swift tremulous movement, scintillating Hke
heat rays. From his observations he has concluded ;
I. Haemoconia are present in all human blood. 2.
Cremated corpuscles and shadow corpuscles are
degenerated cells. 3. certain proportion, if not
all, of microcytes are degenerated cells. 4. Blood
plates are debris of red and white corpuscles. 5.
Leucocytes. Eosinophiles degenerate first ; sec-
ondly, the polymorphs and lymphocytes are the
longest lived (and youngest) of the white cells. 6.
Haemoconia. Some are escaped nuclei of leucocy-
tes, some escaped granules of leucocytes, others are
the result of disintegration or alteration of red cor-
puscles, and all are produced by some change in
the blood constituents.
LANCET.
December 21, 1907.
1. Some Experiences of Intracranial Surgery,
By C. A. Ballance.
2. A Note on Gastric Ecchymosis, Gastrostaxis, and Sim-
ple Gastric Ulcer; Their Possible Relations to
Haemorrhagins and Mucolysins, By E. C. Hort.
3. Three Cases of Intestinal Obstruction,
By R. D. MOTHERSOLE.
4. A Case of Complete Gastrectomy,
By B. G. A. MoYNiHAN and F. C. Moore.
5. The Tuberculin Ophthalmoreaction of Calmette,
By J. W. H. Eyre, B. H. VVedd, and A. F. Hertz
6. Notes on a Case of Bone Abscess Caused by an "In-
termediate" Bacillus Allied to Bacillus Paratyphosus,
By F. G. BusHNELL.
7. The After Treatment of Cases of Suprapubic Cys-
totomy; a New and Economical Method,
By H. Irving.
8. A Case of Poisoning by Potassium Bichromate,
By A. M. GossAGE and J. M. Bernstein.
I. Intracranial Surgery. — -Ballance states that
the more common conditions calling for intracra
nial intervention are: i. Diseased or displaced
bone. These should be dealt with before intradural
mischief has arisen. 2. Efifused blood. The rapid
efifusion of blood into the brain from rupture of a
diseased bloodvessel has not yet been arrested by
an intracranial operation, nor does such an opera-
tion seem particularly feasible. But lumbar punc-
ture would probably, by relieving intracranial pres-
sure, be useful in some cases of apoplexy. The
necessity for surgical intervention in extradural
haemorrhage following blows on the head has, how-
ever, long been recognized. 3. Meningeal inflam-
mation. This takes three forms: (a) Meningitis
serosa, an accumulation of fluid, acutely or sub-
acutely, in the subdural space, the subarachnoid
space, and in the ventricles. The intracranial
serous membranes are excited to hypersecretion by
toxines brought to them by the blood or from a
neighboring infective focus. The symptoms are
fever, a slow pulse, vomiting and drowsiness.
Only two methods of treatment have been success-
ful, intradural drainage and ligature of both caro-
tids, (b) Local meningeal suppurations as a result
of bone disease, and as a localization of posterior
basal meningitis. In the latter the best operation is
one which provides a free bilateral opening and
allows the escape of pus from the subarachnoid
space, (c) Tuberculous meningitis. Exposure of
the disease and drainage of the exudation probably
would modify the evolution of the process, just as
in tuberculosis of the peritonaeum, but how is not
clear. 4. Abscess of the brain should be treated
as abscess elsewhere. 5. Epileptiform neuralgia of
the fifth nerve. Intracranial division of the second
and third divisions of the fifth nerve is the opera-
tion of choice. The foramen rotundum and fora-
men ovale must be closed either with rubber or with
gold leaf, and if the pain returns search must be
made for undivided filaments of the nerve. 6.
Tumor of the brain. The presence of an intracra-
nial tumor is to be inferred from the following-
symptoms : (a) Evidences of disturbance of the
norm.al harmonious and correlated functional activ-
it}' of the various parts of the brain, such as change
of disposition or impairment of mental power, (b)
Symptoms of increased intracranial pressure —
headache, vomiting, optic neuritis, slow pulse and
torpor, (c) Symptoms due to irritation or paraly-
sis of particular nerve centres, or groups of nerve
centres, the so called focal symptoms, such as par-
alysis and disturbances of sensation. Diagnosis and
localization are sometimes assisted by x ray pho-
tography.
2. Gastric Hasmorrhage and Ulcer. — Hort
epitomizes as follows the various views as to the
pathogeny and relations of gastric ecchymosis, gas-
trastaxis, and gastric ulcer: i. Gastric ecchymosis
and gastrostaxis are in no way related to each other
or to gastric ulcer. 2. The causes of ecchymosis
and gastrostaxis are most obscure. 3. Gastric ul-
cer is due to a breakdown of the normal immunity
of the mucosa against autodigestion. The writer,
on the other hand, tries to show (i) that some
forms of gastric ecchymosis, gastrostaxis, and gas-
tric ulcer are but local expressions of a general
blood disease hitherto unrecognized; (2) that ec-
chymosis may be intimately associated with gas-
trostaxis, and both with ulcer; (3) that as a symp-
tom of an unnamed general blood dyscrasia ulcer
may also occur without preceding ecchymosis or
gastrostaxis; (4) that (a) ecchymosis and gas-
trostaxis are due to the presence in the blood of
endotheliolytic and mucolytic bodies, and (b) gas-
tric ulcer itself is due to the presence in the blood
of floating hnemorrhagins, mucolysins. and other
cytolysins, affecting gastric mucosa through one
of two channels^ — either from lymph stream con-
stantly flooding epithelial cells with the specific tox-
ines (mucolysins) or from escaped blood charged
with the same bodies (haemorrhagins, mucolysins).
No other theory as yet put forward brings into line
such apparently incongruous manifestations as ulcer
without haemorrhage, haemorrhage without ulcer,
perforation without haemorrhage, etc. No conclu-
sive evidence as to the cause and eft'ect of ulcer and
haemorrhage can be found post mortem. The pres-
ent day medical treatment of these conditions must
be modified, and the use of surgery in combating a
profound toxaemia must be carefully restricted.
The evidence submitted by the writer in support of
his views is of two kinds: i. Direct evidence of
January ii, 1908. J
PITH OF CURRENT LITERATURE.
83
cytolysis in man in these forms of capillary haemor-
rhage into and from gastric mucosa and of ulcer-
ation afforded by (a) blood examinations, and (b)
the remarkable results of treatment by serum and
by vaccines undertaken with the object of produc-
ing immunity in such cases against the specific
toxins. 2. Collateral evidence of (a) cytolysis in
man in other diseases characterized by gastrostax-
is or other haemorrhagic fluxes or other signs of
cytolysis, such as haemolysis afforded by (i) blood
examinations, and (2) the encouraging results of
serum and vaccine therapy; and (b) cytolysis in the
animal kingdom afforded by (i) the artificial pro-
duction of cytolytic phenomena in certain animals
and (2) the establishment of immunity in such ani-
mals by the preparation of sera and vaccines.
LA PRESSE MEDICALE.
December 7, 1907.
1. What Dangers to the Eye Are Present in the Ophthal-
moreaction? By F. DE Lapersonne.
2. Tuberculines and Vaccines of Carl Spengler. Princi-
ples of His Method, By Andre Bergeron.
3. Medical Treatment of Ulcer of the Stomach, By P. D.
4. The Penial Bone and Partial Ossification of the Penis,
By R. RoMME.
I. Dangers to the Eye in the Ophthalmoreac-
tion.— De Lapersonne concludes that the oph-
thalmoreaction is not of itself a source of danger to
the eye and that the rare cases in which accidents
have occurred simply call for some counsels of pru-
dence. He says that the test should never be made
until after a thorough examination has been made
of the eye of the patient. In ophthmology he thinks
its use will be very limited. It will not serve for the
diagnosis of superficial or deep lesions of the eye-
ball, but it may for the diagnosis of diseases of the
lids, lachrymal passages, and orbits. He does not
think it should be used in old patients.
4. Partial Ossification of the Penis. — Romme
reviews at length the case recently reported by
Frangenheim.
December 11, 1907.
1. E.xamination of Some Stomachs with the Aid of the
Rontgen Rays, By Th; Tuffier and P.\ul Aubourg.
2. Dechloruration in the Treatment of Bright's Disease,
By A. Martinet.
I. Examination of Stomachs with Rontgen
Rays. — Tuffier and Aubourg present plates show-
ing the conditions foimd in the stomach of a ca-
daver, the normal stomach during digestion, stenosis
of the pylorus, neoplastic infiltration of the stomach,
gastroanastomosis for stenosis of the pylorus, at
the beginning of digestion and at the end of the
same, the stomach of a dog on which gastroanasto-
mosis had been performed, and a bilocular stomach.
December 14, 1907.
1. The Treatment of Metritis by the Application of Cup-
ping Glasses to the Neck of the Uterus, the Method
of Bier, By F. Jayle and Robert Loevy.
2. Acute Suppurative Periostitis, By Armand Bernard.
3. The Action of the Sphincter of the Pylorus,
By R. Romme.
I. The Treatment of Metritis by the Method
of Bier. — Jayle and Loevy have devised an ap-
paratus by means of which it is possible to apply suc-
tion to the neck of the uterus and they report seven
cases of various forms of metritis satisfactorily
treated in this manner. Their conclusions are: i.
The application of cups to the cervix uteri results in
the evacuation of the contents, mucus or pus, of the
cervical cavity and causes a hyperaemia of the neck.
If ulcerations are present the hyperaemia produces
a bloody exudation, usually not very abundant. In
some cases in which there are little thin walled cysts
the aspiration causes the rupture of the latter. 2.
After several seances the congestion in the pelvis
becomes lessened, while the symptoms of metritis,
perimetritis, of inflammation of the annexae and of
pelvic peritonitis slowly become ameliorated. Ul-
cerations cicatrise and sometimes disappear entirely,
while one may easily follow the progress of the epi-
thelization. 3. The aspirations are almost always
painful. 4. The application of cups to the neck of
the uterus is a new means in gynaecological thera-
peutics which can be used easily and gives good
satisfaction.
LA SEMAINE MEDICALE.
December 11, 1907.
Intestinal Arteriosclerosis, By L. Cheinisse.
BERLINER KLINISCHE WOCHENSCHRIFT.
November 25, 1907.
1. Concerning a Case of Sepsis Due to Diphtheria Bacilli
and Streptococci, By P. Mahler.
2. Feeding with Ferruginous Cows' Milk, By Schnutgen.
3. Concerning the Electric Response to the Galvanic Cur-
rent in Children with Tetany, By P. Philippson.
4. Concerning the Ophthalmoreaction to Tuberculin,
By S. CoHN.
5. The Forensic Value and the Knowledge of the Joining
of the Complements, By C. Bruck.
6. Cold Abscess of the Larynx, By A. Rosenberg.
7. Operative Treatment of Traumatic Meningitis, .
By A. SCHLESINGER.
8. Concerning the Anatomical Grounds of Weakness of
the Heart, By Beitzke.
2. Feeding with Ferruginous Cows' Milk. — •
Schniitgen uses milk from cows which are fed so as
to make their milk ferruginous, not from the addi-
tion of an artificial chemical preparation of iron,
but by a natural product produced through assimila-
tion in the bodies of the animals. He reports nine
cases of anaemia from different cases which were
benefited by the use of such ferruginous milk. All
of the patients were very sick and all improved re-
markably under the treatment.
3. Response to the Galvanic Current in Chil-
dren with Tetany. — Philippson says that in chil-
dren with tetany there is a distinct local lowering
of the electric excitability after from eight to ten
minutes of constant galvanization. This lowered
action of the current appears to precede a brief
phase of increase of excitability with the associated
degeneration form of cathode contraction.
4. The Ophthalmoreaction to Tuberculin. —
Cohn thus sums up his conclusions: I. The posi-
tive appearance of the ophthalmoreaction after use
of a I per cent, solution of tuberculin indicates
tuberculosis with very great probability. 2. A nega-
tive reaction does not prove the absence of tuber-
culosis, because 50 per cent, of the severe cases of
phthisis fail to react. Slight and moderate cases
of phthisis react only exceptionally. 3. Typhoid
patients exhibit a positive ophthalmoreaction
to tuberculin very frequently, especially during con-
valescence. 4. A subcutaneous injection of tuber-
culin made some time after the instillation is able
84
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
to call forth again the. local reaction in the eye, or
to produce it in case it failed to appear before. 5.
The single instillation induces in nontuberculous
adults, not children, after a sufficient length of time,
a hypersensitiveness of the eye into which the in-
stillation was made; in tuberculous patients this
action is usually extended to the other eye also.
5. Forensic Value and Knowledge of the Join-
ing of the Complements. — Brack says that the
praecipitin reaction retains its old importance in the
distinction of albumin of animal or human origin in
forensic practice. At the same time the method of
complement joining is not only quite equal in value
to the praecipitin reaction, but is superior in fineness
and distinctness of its results, and should there-
fore be used in ever\^ forensic case as the supple-
ment of the praecipitin reaction. The great delicacy
of the reaction forbids the use of too strong immune
sera and necessitates an investigation by one who is
perfectly familiar with the sources of error of the re-
action. The use of weak immune sera enables the
method of complement joining not only to make the
absolutely specific diagnosis of human albumin, but
also renders it possible to distinguish which of the
albuminous fluids of the body produced the spot in
question — i. e., a distinction between blood, pus,
semen, etc., and this should be determined in this
manner in every forensic case.
MUENCHENER MEDIZINISCHE WOCH ENSCH Rl FT.
December 3, igoy.
1. Experiences with Artificial Pneumothorax in Tubercu-
losis, Bronchiectasis, and Aspiration Diseases,
By Schmidt.
2. The Smallest Necessary Supply of Albumin,
By FORSTER.
3. Concerning Passive Hyperaesthesia, By Friedemann.
4. Haemorrhage into the Fatty Capsule of the Kidney,
By Doll.
5. Treatment of Epidemic Cerebrospinal Meningitis,
By TOBBEN.
6. Three Thousand Cases of Ethyl Chloride Narcosis,
By Herrenknecht.
7. Puerperal Fever and the Duty of Reporting the Same,
By VON Herff.
8. A Contribution to the Cases in which at a Herniotomy
the Vermiform Appendix Is Found to Be the Sole
Contents of the Hernial Sac, By GtJNTHER.
9. Old Foreign Bodies in the Upper Jaw as the Cause of
Acute Inflammation of the Conjunctiva Resembling
Blennorrhoeal, By Thorey.
10. An Interesting Case of Foreign Body in the Nose,
By MtJHLENKAMP.
11. A New Apparatus for Vibration Massage of the Pros-
tate, . By GUNSETT.
12. Cotton and Gauze Holders for Use in the Office,
By Grunwald.
13. Impressions of America (Concluded), By Muller.
I. Artificial Pneumothorax in Tuberculosis,
Bronchiectasis, and Aspiration Diseases. —
Schmidt says that one should always try to make
the first infusion of air so as to strike a pleural ad-
hesion ; that among the cases which are fitted ap-
parently for the compression treatment there is a not
small part, 22.7 per cent, of the cases reported in
Germany, in which the production of complete pneu-
mothorax is rendered impossible because of the
presence of pleural adhesions ; that one should not
be discouraged by a failure on the first attempt, but
should repeat the puncture in different places so as
to produce several separated, sacculated pneumo-
thoraces. He has employed this form of treatment
in thirteen cases of pulmonary tuberculosis, eight
of bronchiectasis and three of aspiration disease,
pneumonia, or foetid bronchitis. Involvement of the
other lung he considers a distinct contraindication to
the treatment. On the whole he believes that the
number of cases which are truly benefited by com-
pression treatment is limited.
2. The Smallest Necessary Supply of Albu-
min.— Forster concludes from his observations
that a sufficient quantity of other substances, such
as ash, than albumin, fat, and carbohydrates, are
necessary to the upbuilding and maintenance of
human organs ; that these substances are met with in
the food in combination with albuminous substances,
or at least in relation with albumin, and it is there-
fore to be feared that with a more reduced supply of
albumin nutrition will suffer from lack of these ash
constituents. With the breaking up of albumin in the
body certain necessary materials, digestive ferments,
and other derivatives of albumin, are formed. For
some it is proved, for others it is probable, that the
production is in proportion to the decomposition of
albumin in the body. It is, therefore, to be expected
that with reduced assimilation of albumin slight dis-
turbances of the general condition and diseases
would occur through want of these materials. As
long as the proportions, both qualitative and quan-
titative, are no better understood than they are at
present it is advisable for the purpose of practical
nutrition from the general physiological and hy-
gienic standpoint to maintain a large assimilation of
albumin and not to limit this to the physiological
minimum by which the so called balance of nitrogen
may be maintained in a given case.
4. Hasmorrhage Into the Fatty Capsule of the
Kidney. — Doll gives the clinical picture of this
condition. Vascular diseases which increase the blood
tension, such as arteriosclerosis, chronic nephritis,
syphilis, and alcoholism, form the setiological basis.
Very severe colicky pain recurring at short intervals
in the region of the kidneys, which radiate back-
ward and downward, but not to the scrotum or
penis, soon followed by tenderness on pressure and
on change of position in the region 'where the pain
is located. Then in the region of the kidney, be-
hind the colon, an elongated tumor with indistinct
margins becomes recognizable with increasing clear-
ness by percussion and palpation, tender, tensely
elastic, not moving with respiration. Fever is
moderate, remittent, toward the end appear higher
ranges of temperature, with occasional attacks of
collapse. Symptoms of moderate anaemia, rapid loss
of strength, and bad pulse follow. The diaphragm
presses upward, and symptoms of consolidation of
the lower lobes of the lungs and of exudates in the
pleural cavities are to be seen. Meteorism when
at its maximum renders the tumor indistinct.
Doughy cutaneous swellings appear in the lumbar
region with bluish black efTusions of blood there and
in the scrotum. Two cases are described, one of
which has been reported before.
5. Treatment of Epidemic Cerebrospinal Men-
ingitis.— Tobben speaks strongly in favor of the
results obtained in this disease by the combination
January ii, 1908.]
PITH OF CURRENT LITERATURE.
85
of lumbar puncture and injection of meningococcus
serum.
9. Foreign Bodies in Upper Jaw the Cause of
Conjunctivitis. — Thorey reports a case in which
a man sought relief for a conjunctivitis associated
with a very profuse discharge of pus, that was out
of proportion to the changes in the conjunctiva and
lids. Local treatment for three weeks was without
effect and then close questioning elicited the history
of an injury four years before and a knife blade
was discovered in the nose. The location was per-
fected by means of the x rays and the removal of
the foreign body was followed by an immediate
cessation of the ocular symptoms.
10. Interesting Case of Foreign Body in the
Nose, — Muhlenkamp reports a case in which he
removed a knife blade from the nose of a man who
stated as soon as he saw it that he must have been
wounded with it in a fight two years before.
AMERICAN JOURNAL OF THE MEDICAL SCIENCES.
December, igo?.
1. The Medical versus the Surgical Treatment of Gas-
tric Ulcer, By J. H. Musser.
2. The Indications for, the Methods of, and the Results
to Be Expected from the Medical Treatment of
Gastric Ulcer, By C. G. Stockton.
3. Studies on Arteriosclerosis, with Especial Reference to
the Radial Artery,
By W. S. THA'i'ER and M. Fabyan.
4. The Significance of Tubercle Bacilli in the Faeces,
By R. C. ROSEXBERGER.
5. Acute Intussusception in the Adult,
By G. G. Ross and H. F. Page.
6. Primary Carcinoma of the Urinary Bladder,
By B. H. Brown.
7. Incomplete and Complete Hypothyreoidoea or Myxce-
dema. By R. L. Pitfuxd.
8. A Method of Obtaining Cultures from Human Blood,
By E. C. Schradieck.
9. Observ^ations upon Certain Blood Pressure Lowering
Reflexes that Arise from Irritation of the Inflamed
Pleura, By J. A. Clapps and D. D. Lewis.
1. The Medical versus the Surgical Treat-
ment of Gastric Ulcer. — ]\Iusser affirms that this
is a medical disease, which, with its complications
and sequels, may become surgical. With perfora-
tion it is surgical ; with haemorrhage it is medical,
unless the haemorrhage is frequently repeated. It is
still medical when there is perversion of secretory
function, unless motor disturbances become promi-
nent. It is surgical with signs of retention from
obstruction, dilatation, hour glass contraction, or ad-
hesions. If, in spite of medical treatment, its symp-
toms threaten life, if there are repeated haemorrhages
and consequent anaemia, it is surgical. Surgical
treatment often becomes a necessity on account of
neglect of medical treatment during a long period
of incipiency. The physician for a case of gastric
ulcer should early associate himself with a surgeon
of ability and experience in order to meet with
promptness any emergencies that may arise. After
surgp^cal procedures have been carried out the case
should be treated medicinally for at least four
months, and hygienically and dietetically for several
years.
2. Indications for, Methods of, and Results to
Be Expected from Medical Treatment of Gas-
tric Ulcer. — Stockton summarizes the medical
treatment as follows : The aim should be to secure
a calm mind, a quiet nervous system, and improve-
ment of the general health. A positive diagnosis
should be made, treatment should be begun early,
and its details carefully carried out. Complete rest
should be enforced. In some cases there should be
moderate feeding, in others starvation for a time,
with dependence upon enemata of salt solution. For
haemorrhage, in addition to rest, one should intro-
duce ice water through a stomach tube, and, if neces-
sary, adrenalin solution, followed by gelatine water.
If there is irritating hyperacidity, local general sed-
atives and antacids are indicated. For hypertension
and spasm of the stomach, in addition to proper
drugs, use external applications after von Leube's
method. Continue treatment long after apparent cure,
studying the stools for occult blood.
3. Studies on Arteriosclerosis, with Especial
Reference to the Radial Artery. — Thayer and
Fabyan think the following inferences are justifiable
in the presence of a thickened radial artery : If it
occurs in an old person it represents conditions
which are normal and to be expected, not only in
central but in peripheral vessels. If it occurs in ear-
lier life it may mean (i) that the vessel has been
subjected to unusual and exceptional strain, or that
( 2) it is a vessel which, from inherent weakness or
other individual circumstances, has been unable to
cope with conditions which would ordinarily be re-
garded as normal. In either of these two latter con-
ditions the artery has been obliged to fortify itself
by progressive thickening of its walls, especially by
a connective tissue sclerosis of its intima and media.
When there is marked thickening of a radial artery-
there are usually similar changes in the intima of
the mesenteric artery and the aorta. An unduly pal-
pable, radial artery indicates possible regressive
changes of a dangerous character in other parts of
the body.
4. The Significance of Tubercle Bacilli in the
Faeces. — Rosenberger g^ves the following results
of his investigations in fifty-seven cases: i. No
acid fast bacillus except the tubercle bacillus was
found in the faeces. 2. The presence of this organ-
ism in the faeces means that there is active tubercu-
losis in some portion of the body. 3. In acute mili-
ary tuberculosis the bacillus is always present in the
faeces. 4. In all cases of chronic diarrhoea and in
cases of general glandular involvement the fasces
should be examined for tubercle bacilli. 5. If tuber-
cle bacilli are found in the faeces it does not neces-
sarily signify that there is intestinal ulceration in all
cases. 6. In arrested or healed pulmonary tubercu-
losis no tubercle bacilli will be found in the sputum
or faeces. 7. The faeces should be studied for tuber-
cle bacilli as a part of routine examination, especial-
ly in cases in which no sputum can be obtained.
5. Acute Intussusception in the Adult. — Ross
and Page state that one third of the cases of intes-
tinal obstruction are due to this cause. Its three
varieties of the enteric, the colic and the ileocolic.
The ileocaecal form of the ileocolic is the one most
frequently observed. The condition is due to irreg-
ular action of the intestinal muscular fibres. There
may be spasmodic invagination and parahlic invag-
ination, clinically the former alone being met with,
and in most cases it is descending in its development.
86
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
The causes for this condition may be ptomaine poi-
soning, enteric fever, traumatism, and benign or
malignant growths of the bowel. The onset is usu-
ally sudden, being influenced by the portion of bowel
attacked. The first and most persistent symptom is
pain, which is colicky and intermittent at first, then
moderates, and may cease when gangrene occurs.
When the invagination is fixed the pain is located in
the area of involved bowel. Vomiting occurs at in-
tervals with temporary relief. Muscular rigidity
and abdominal distension are absent in the period.
Diarrhoea and abdominal tenderness are of frequent
occurrence. There is seldom any abdominal tumor
or elevation of temperature. Tenesmus and bloody
stools are of frequent occurrence. Early diagnosis
and operation give the best hope for successful re-
sults.
6. Primary Carcinoma of the Urinary Blad-
der.—'Brown reaches the following conclusions :
I. Intelligent deductions and trustworthy statistics
are to be derived only from the careful and thorough
study of a large number of cases from both the clin-
ical and the anatomical standpoints. 2. The most
frequent seat of carcinoma in the bladder and the
direction of its extension are still matters of uncer-
tainty. 3. Metastasis occurs much more frequentl>-
than many clinicians are willing to admit. 4. A
malignant growth in the bones may occur from a
primary carninoma of the urinary bladder. 5. The
most frequent cause of death in vesical carcinoma is
a secondary infection of the ascending urinary tract.
6. The diagnosis is always difficult, and it is espe-
cially so after complications have occurred.
AMERICAN JOURNAL OF OBSTETRICS
December, igoy.
1. The Best Method of Teaching Gynaecology,
By J. N. West.
2. How to Teach Diagnosis in Diseases of Women,
By J. R. GoFFE.
3. Teaching Methods in Gyna;cology, By C. Jewett.
4. Teaching by Charts and Models and Modeling,
By R. L. Dickinson.
5. On Two Cases of Abdominal Section for Trauma of
the Uterus, By J. B. Sutton.
6. Primary Squamous Celled Carcinoma of the Body of
the Uterus, By C. C. Norris.
7 A Case of Deciduoma Malignum, By A. M. Vance.
8. Intraabdominal Torsion of the Omentum without
Hernia, By R. E. Skeel.
9. Nymphomania as a Cause of Excessive Venery,
By C. C. Frederick.
10. Myofibroma ■ Complicating Pregnancy. Hysterectomy,
By E. J. III.
11. The Conservative Medical Treatment of Salpingitis,
By E. J. III.
12. Consistency in Aseptic Surgical Technique,
By J. E. Sadlier.
13. Deciduoma Malignum, By N. F. Porter.
14. An Unusually Large Dermoid Tuinor in the Ovary,
By W. M. HuMisTON.
15. Nephrocolopexy, By H. W. Longyear.
t6. Large Echinococcus Cyst of the Liver. Operation and
Recovery, By H. E. Hayd.
17. Cotarnine Phthalate in Uterine Haemorrhage,
By O. Maier.
18. Hydramnion Acrania with Spina Bifida,
By J. M. Rector.
19. A Case of Puerperal Eclampsia, By W. E. Lippold.
20. A Telephonic Curette, By A. C. Jacobson.
5. On Two Cases of Abdominal Section for
Trauma of the Uterus. — Bland Sutton narrates
two important cases illustrating the possible dan-
gers of curettage. In the first case a physician
curetted a nongravid uterus for painful menstrua-
tion. The uterus being sufficiently dilated, the op-
erator introduced his finger into the uterus, felt a
soft substance, seized it with forceps, and continued
to pull until a large mass was in the vagina. The
pulling was so vigorous that one end gave way and
the other end was then cut oflF with scissors. The
tissue was found to be small intestine. Eight hours
later Sutton was called to see the patient, who was
in collapse from haemorrhage. The abdomen was
opened and found full of blood. The perforation
in the uterus was closed, and the mutilated ileum
joined to the ileocaecal aperture from which it had
been torn. The patient recovered. In the second
case dilatation of the uterus was performed for
painful menstruation, and the uterus ruptured ex-
tensively, letting coils of intestine pass into the
vagina. There was little bleeding, but much shock.
The abdomen was opened, a large rent found on the
posterior wall of the cervix, and ten ounces of blood
in the pelvis. Supravaginal hysterectomy was per-
formed, the ovaries and tubes being retained. This
patient also recovered.
8. Intraabdominal Torsion of the Omentum
without Hernia. — Skeel observes that this con-
dition is not an infrequent one and that most of the
cases are associated with hernia. He classifies
omental torsion as follows: i. Torsion with hernia
in which the omentum is in the hernial sac and is
there twisted, or twisted both in the sac and in the
abdomen, or adherent to the sac and rotated above
it. 2. Torsion of the omentum in the abdomen,
hernia also being present or having previously ex-
isted, with no apparent connection between omen-
tum and sac. 3. Pure intraabdominal torsion with
no history of hernia. The following theories as to
causation are propounded: i. Causes acting exter-
nally only. 2. Internal force, as intestinal peristalsis,
or external force, as pressure, causing rotation, the
tip of the omentum being readily converted into a
ball. 3. The same forces acting upon an omentum
adherent at the tip. 4. Circulatory changes leading
to twisting of the veins around the more resistant
arteries.
II. The Conservative Medical Treatment of
Salpingitis. — 111 observes that perseverance, judg-
ment, and patience are necessary to make such treat-
ment effective. There are plenty of cases which
are not suitable for such treatment which should
be treated surgically. He divides the cases which
are suitable into three classes, as follows: i. Those
in which the acute febrile condition results from the
extension of a gonorrhoeal vaginitis and endome-
tritis into the tubes and to the pelvic peritonjeum.
Such cases include not only catarrhal salpingitis,
but cases in which suppuration has resulted. 2.
Those in which there is an acute febrile condition
due to a variety of poisons following labor, abor-
tion, and unclean intrauterine instrumentation. 3.
Those which result from inflammatory conditions
following tubal abortion and which have been
neglected for a long time. The treatment consists
essentially of rest in bed, vaginal douches, counter-
irritation at the roof of the vagina, and local deplet-
ing measures.
January ii, 1908.]
PROCEEDINGS OF SOCIETIES.
87
|r0c«Mngs of Sfftieties.
SOUTHERN SURGICAL AND GYNECOLOGICAL
ASSOCIATION.
Tiventicth Annual Session, Held in New Orleans,
December 17, 18, and 19, 1907.
The President, Dr. Howard A. Kelly, of Baltimore, in
the Chair.
Perinephritic Abscess Following Parturition. —
Dr. J. Shelton Horsley, of Richmond, Va., re-
ported three cases in which he had operated, and
called attention to the necessity for early diagnosis
in order to give the patient the benefit of a prompt
operation, as all statistics showed that the mortality
of this disease increased as the operation was de-
layed. He laid stress upon the occurrence of pain
in either flank a few weeks after parturition, even
in cases of comparatively aseptic delivery. The
bending of the body to the affected side, stiffness of
the spine, slight limp in walking, and pain on pres-
sure over the afifected flank were important early
symptoms. Later there was muscular spasm, and a
decided mass could be felt over the region of the
kidney. Constipation was always marked, due partly
to the patient's dread of muscular effort. The usual
constitutional signs of sepsis appeared as the disease
progressed. In all his cases the abscess had been on
the right side. He attributed this to the fact that the
right kidney and perinephritic tissue were lower than
the left, and consequently were more likely to be in-
jured by the bearing down pressure during parturi-
tion. This afforded a point of least resistance in the
perinephritic tissues of the right side, and germs
which were absorbed by the lymphatics of the uterus
might readily gain a foothold here. Treatment
should follow the diagnosis at once, and should con-
sist in a lumbar incision, as in an operation for ne-
phrotomy, and drainage with a tube of large calibre.
Postoperative Complications in Abdominal
Surgery.— Dr. Charles M. Rosser, of Dallas.
Tex., said, among other things, that shock, whether
due to basic inhibition or vasomotor paresis, could
not be overcome by stimulants to an already exhaust-
ed nerve centre, but position for the purpose of re-
lieving cerebral anaemia from haemorrhage, saline
solutions to enlarge the volume of the blood current,
adrenalin to restore the equilibrium of the blood
pressure, and morphine to give balance to the flag-
ging vital forces were the remedies. A rubber band-
age or a suit, by limiting circulatory necessity, might
be used either as a precaution or as a treatment.
Postoperative peritonitis resulted from excessive
trauma or infection. Drainage was the best safe-
guard after asepsis. If required, reopening for
drainage was to be done with the least possible trau-
ma, and the minimum amount of anaesthetic. Ileus
or other obstruction might be treated by an enema
of alum solution, which reversed peristalsis and gas
distention, or by egg turpentine emulsion thrown
high up. Inhalation pneumonia suggested mouth
and pharynx antisepsis, and was treated in the usual
way. Hypostatic pneumonia was not so common,
since physicians did not insist upon decubitus as a
routine.
Some Postoperative Complications of Perito-
nitis.— Dr. R.-VNDOLPH WiNSLOw, of Baltimore,
read a paper on this subject in which he reported the
histories of two cases that had recently occurred in
his practice. One of them was a case of appendici-
tis with peritonitis, followed by intestinal obstruc-
tion from adhesions. A cure was effected b} opera-
tion. The patient was a girl, twenty years of age.
The second case was one of appendicitis and peri-
tonitis followed by extensive adhesions, causing in-
testinal obstruction. Enterostomy was performed,
followed by anastomosis and subsequently by resec-
tion and enterorrhaphy. This patient was a man,
aged nineteen. The operations were successful.
Acute Dilatation of the Stomach as a Postop-
erative Complication. — Dr. C. Jeff Miller, of
New Orleans, said that among the unexpected com-
plications that might arise after surgical operations
no condition was more distressing than acute dilata-
tion of the stomach. This complication was prob-
ably as serious as any that might arise. The latest
statistics, gathered by Simpson, showed that, in 128
cases, in eighty-six the patients had died. Kayser's
collection of sixty cases, quoted by Bloodgood, yield-
ed 71 per cent, of deaths. Conner's exhaustive study
of 102 cases showed seventj^-four deaths, or 72.5
per cent., and twenty-eight recoveries.
The treatment was summed up as follows, namely,
early recognition, prompt emptying and washing of
the stomach, and such posture as might release a
mesenteric compression. To these might be added
any eliminative measure indic^ited, if the emunctory
organs were inactive. Early diagnosis was essen-
tial to successful treatment. Judging from the cases
reported in which an operation had been done with
the idea of relieving obstruction, surgery was not
encouraging. In spite of the high mortality, how-
ever, there was strong evidence to prove that many
patients could be saved by prompt treatment. The
author reported a case in which he had operated suc-
cessfully.
Dr. Henry T. Byford, of Chicago, said that his
experience had been that the longer the anaesthesia
the less nausea there was, and the slower the patient
came out from under the influence of the anaesthetic
the less nausea there was. He had found it advan-
tageous to give from one to two ounces of brand)'
just before giving the anaesthetic, in order to dimin-
ish the amount of anaesthetic necessary, as by so do-
ing there was much less lung irritation. He had
also noticed the good effect of giving an enema after
an operation, putting into the enema one hall or one
ounce of alcohol.
Dr. George Ben Johnston, of Richmond, Va.,
could not agree with Dr. Byford that prolonged an-
aesthesia was prudent. The smallest quantity of any
anaesthetic should be given, and the anaesthesia should
occupy as little time as possible. These conduced to
the welfare of the patient.
As to complications, the most important thing was
the prompt recognition of them. Fatalities from
them occurred because they were not promptly rec-
ognized, and therefore not promptly treated. A
careful study of every postoperative case would en-
able the experienced clinician to recognize an ap-
proaching dilatation of the stomach, and if this con-
dition was quickly recognized and energetically treat-
ed, fully 33 per cent, of the patients would recover.
The stomach should not be washed out in these cases-
88
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
at Stated intervals, but as soon as the condition was
recognized prompt lavage should be practised and
continued as long as there was any indication of
vomiting.
Dr. RuFUS B. Hall, of Cincinnati, speaking of
abdominal distention, referred to the value of the
hypodermic use of eserine in 1/50 or i/ioo grain
doses. Within forty minutes after its administra-
tion the patient would begin to pass gas. His rule
had been to give patients the fiftieth of a grain under
the skin, and within forty minutes, if the patient was
not relieved by passing great quantities of gas, the
dose was repeated. It was rare, however, that he had
had to give a second dose. He had used this rem-
edy for about two years in more than thirty cases,
and in only one had it failed to bring on the. prompt
elimination of the gas.
Dr. W. P. Carr, of Washington, had had good
results from eserine in a number of cases, and where
he had had the stomachs of patients washed out di-
rectly after operation, and had given them a dose of
eserine when they left the table, there had been very
little trouble from distention by gas or in getting the
bowels to move afterward. Washing out the stom-
ach after an operation and giving the thirtieth of a
grain of eserine on the table was very effective as a
routine practice, except where the bowels were open
and where one did not want to cause very much
peristalsis. It was effective only when there was
something in the bowel. If the bowel was empty,
eserine did not seem to have any effect.
Dr. Charles H. Mayo, of Rochester, Minn, re-
ferring to acute dilatation of the stomach, said there
was a great amount of discomfort following opera-
tions in these cases, rnany of the patients dying.
They died because on the second, the third, or the
fourth day they showed a marked condition of re-
gurgitation. These patients would vomit a peculiar
greenish material in large quantities. Two or three
quarts might be vomited suddenly. The lower part
of the abdomen was flat, while the upper part was
distended. The condition would persist for four
days, when there might be a profuse diarrhoea. The
condition could be met successfully in many cases by
lavage as long as the stomach showed a tendency to
refill. Many of these patients, after three or four
washings of the stomach, within the third day would
be entirely relieved ; intestinal peristalsis would be-
gin, and gas would escape. In some of the more
severe cases the patient could be saved by gastro-
jejunostomy done between the fifth and seventh days
as a secondary operation.
Dr. Herman J. Boldt, of New York, did not
think the mortality from acute dilatation of the stom-
ach was so high as had been stated. However, it
was a comparatively frequent and undesirable com-
plication after abdominal section. Whenever there
was the slightest evidence of an inflammatory pro-
cess in the peritonjeum, salicylate of eserine did no
good, so that one must be careful in the selection of
his cases. Early mobilization of the patients would
prevent some of these postoperative complications.
Dr. J. M. Mason, of Birmingham, Ala., mentioned
a patient who had acute dilatation of the stomach on
the day following an operation, but who was entire-
ly relieved by getting rid of the Fowler position, ele-
vating the foot of the bed, and resorting to lavage.
Dr. Hubert A. Royster, of Raleigh, N. C, re-
ported a case of acute dilatation of the stomach fol-
lowing an operation for the fixation of both kidneys.
The patient, however, died on the fourth day after
efforts to relieve her.
Dr. John Young Brown, of St. Louis, had had
twenty-eight cases of diffuse peritonitis, and since he
began the treatment recommended by Bond his mor-
tality had been greatly reduced, whereas prior to that
time, when he irrigated, his mortality was high. It
was not so much the Fowler position as it was in
getting these patients to move about in bed, thus pre-
venting the complications that were formerly ob-
served. Of ten cases treated without the Fowler po-
sition, the results were equally good as in those treat-
ed with it. He contended that by following a sim-
ple technique at the primary operation complications
which would otherwise arise might be prevented.
Dr. I. S. Stone, of Washington, thought that
after doing good surgical work the bowels of the
patient should be allowed to rest. When a surgeon
gave purgatives immediately after operations, he
thought he defeated the very purpose he ought to
attempt to accomplish. He had done quite a num-
ber of operations in the last five years, and had not
had a single case of death from ileus.
Dr. Edward H. Ochsner, of Chicago, said the
sooner surgeons learned to recognize that rest fa-
vored repair, and that motion favored adhesions, the
better it would be for them and for their patients.
Transperitoneal Removal of Tumors of the
Bladder. — Dr. Charles H. Mayo, of Rochester.
Minn., said that a large percentage of early recur-
rences following the removal of bladder tumors, both
benign and malignant, indicated a delayed operation
or imperfect removal. With the increasing interest
in cystoscopy, early operating was becoming more
common. The ineffective operation was due, in part
at least, to imperfect exposure of the operative field.
The transperitoneal operation was advised in cases of
large tumors, benign or malignant, of the bladder.
With the patient in the Trendelenburg posture, the
bladder empty, a long median incision was made over
the bladder, the peritonaeum opened, and the intes-
tines walled off into the upper abdomen by large
gauze pads in the operative field. The bladder was
drawn up into the wound and opened through the
peritoneal covering on its posterior superior aspect.
The cavity was now dried with gauze and the in-
cision enlarged forward or back two or three inches,
the tumor excised, and the area involved treated with
the Paquelin cautery. In some cases large areas of
the bladder, even twp thirds of it, might be resected.
The opening was closed by catgut suture protected
on its peritoneal side by a linen suture of the Gush-
ing type. The abdonimal incision was closed usu-
ally without drainage. In the after care, repeated
use of the catheter for a few days, if necessary, wa^
to be preferred in uncomplicated cases.
Treatment of the Bladder After Suprapubic
Cystotomy for Stone. — Dr. William S. Gold-
smith, of .'\tlanta, said the principles governing thr
treatment of the bladder after suprapubic cystotomy
were: i. The immediate and complete closure of
the bladder and abdominal wound. 2. The institu-
tion of urethral retention catheter drainage. A series
January ii, 1908. 1
PROCEEDINGS OF SOCIETIES.
89
of external urethrotomy cases, in which the reten-
tion catheter method had been used, and following
the closure of the perineal incision, had convinced
him of its efficiency and of the tolerance of the blad-
der for these unusual conditions. Perfect urethral
drainage was such a necessity that failure in secur-
ing successful results was attributed to some imper-
fections of this important factor of treatment. Large
stones could not be removed through small incisions
without seriously lacerating the mucous membrane
and other coats and leaving a ragged, lacerated su-
ture line altogether unsurgical in character, and en-
couraging tissue necrosis with eventual bad results.
Upon the removal of the foreign body the wound
was protected with gauze, the patient turned upon
his side, and the bladder thoroughly irrigated with
the urethral catheter. The wound was closed tight
with interrupted silk sutures, introduced down to
but not through the mucous membrane. The ab-
dominal incision was closed with small chromic cat-
gut and cotton and collodion applied. Elaborate ab-
dominal dressings were not used, for the reason that
they served no purpose other than to interfere with
the freedom of the patient in turning from side to
side. In adults, and particularly men of middle age,
posture was a most important detail. The ability to
turn on either side and the insistence of frequent
change of position stimulated urinary secretions, pre-
vented puddling of urine, and insured a clean, col-
lapsed cavity, which at once began a regeneration of
exhausted anatomical and physiological vitality. The
semierect, and finally the erect, position was rapidly
assumed, and every effort was directed along the line
of forced recuperation and rapid convalescence.
The Treatment of Fibroid Tumors of the Ute-
rus Complicated by Pregnancy. — Dr. Lewis S.
McMuRTRY, of Louisville, alluded to the indications
for surgical intervention in cases of fibromyomata
complicating pregnancy, with special reference to the
time for such intervention, and the plan and scope
of the operative procedure in the varying conditions
presented. Uterine fibromyomata were very com-
monly associated with sterility. The association of
pregnancy with uterine fibromyomata added very
materially to the dangers of this condition ; new dan-
gers would arise from the combination of the two :
and, while the clinical fact that a considerable pro-
portion of the cases came through in safety was in-
disputable, the mortality of the entire number of
cases left to nature was high.
To illustrate the advantage of prompt operative
intervention in properly selected cases, the author re-
ported four cases. These he had selected for the
purpose of illustrating the multiform aspects of ute-
rine fibromyomata complicated by pregnancy as clin-
ically presented. His entire experience consisted of
two more cases, in which an operation was done in
the early period of pregnancy, making six cases in
all, and all the patients had recovered. While indis-
criminate operation in uterine fibromyomata associ-
ated with pregnancy was not to be advised, the mor-
tality of this condition when unaided was so great
as to justify an extension of the field of operative
treatment, both myomectomy and hysteromyomecto-
my ; and every case should receive individual con-
sideration, so that a judicious selection of cases for
operation might be observed.
Dr. George H. Noble, of Atlanta, said that where
the pelvis was impacted completely, as he had seen
in a number of cases, where it was impossible to
make a digital examination, and the upper part of
the uterus was smooth, free from the tumor, the sur-
geon might do one of two things, Csesarean section
or myomectomy. Since Csesarean section was a sim-
ple operation, it would be desirable in the interest of
the mother and of the foetus. Myomectomy could
be carried much further in well selected cases.
Dr. Herman J. Boldt, of New York, said that a
woman in about the third month of gestation had
consulted him as to whether or not she was preg-
nant. She had missed the menstrual period twice,
and the physician whom she first consulted informed
her that she had a tumor which required immediate
removal. Examination revealed a tumor in the
lower anterior segment of the uterus, a fibromyoma
of the interstitial variety ; at the same time, she was
pregnant. At the time she consulted him he advised
noninterference, but added that if any serious symp-
toms were encountered it might be necessary later to
do a Csesarean section in case she could not be dehv-
ered naturally. Myomectomy was decided on and
done to prevent an abortion. The woman made a
perfect recovery. She was now eight months preg-
nant.
Dr. Hexry D. Fry, of Washington, said that, in
addition to the dangers mentioned by the essayist,
we must recognize the increased danger m these
cases from post partum haemorrhage. The retraction
of the uterus was not sufficient at the site of the pla-
cental attachment, and post partum haemorrhage was
likely to occur. Again, if the woman passed through
labor satisfactorily and safely, there might be infec-
tion or necrosis of the fibroids. He had had that oc-
cur twice in his own work, where the women had
been delivered safely, and their puerperium was com-
plicated by septic fever. Supravaginal hysterecto-
my was done. The women got well, but in cutting
down on the tumor it was found to be disintegrated
and necrotic. As to the time of operation for these
fibroid tumors, he thought surgeons ought to tide the
cases along until the child reached the period of via-
bility— got as near the full term of gestation as pos-
sible— and then do a Caesarean section and supra-
vaginal amputation of the uterus.
Dr. Ernest C. Lewis, of New Orleans, men-
tioned the case of a woman, five months preg-nant,
who had a fibroid attached to the body of the uterus
and filling about one half of the pelvis. It was not
suspected until it caused pressure symptoms and
pain. Her family physician sent for him. and a
fibroid which could not be pushed above the brim of
the pelvis was diagnosticated. The cervix was
pressed against the symphysis pubis. The abdomen
was opened, the tumor enucleated from the back
portion of the uterus, the abdomen closed, and the
patient made an uneventful recovery, went to full
term, and was delivered by her family physician
with forceps. He referred to another case in which
the woman was more advanced in pregnancy.
Dr. J. Wesley Bovee, of Washington, thought
there were a great many women who would go to
full term and be delivered naturally with fibroid
tumors of the uterus, so that he thought we could
not lay down any fast rule that would apply to ev-
90
LETTERS TO THE EDITORS.
IXew York
Medical Journal.
ery case. Each case was to be considered indi-
vidually. If any operation was to be done, it was
well to follow the plan Dr. Fry mentioned. The
speaker was loath, however, to do a myomectomy
where the growth was intimately connected with the
body of the uterus, as he felt it would be apt to in-
duce abortion. The case of Dr. Boldt impressed
him as being unique from the fact than an operation
was done to prevent abortion, and abortion did not
occur, although it was threatened before the opera-
tion was done. As a rule, he would expect the op-
posite to be the case, and he doubted whether sur-
geons could follow Dr. Boldt's plan as a routine
measure. In a number of cases he had done myo-
mectomy without interference with pregnancy.
Dr. George Ben Johnston, of Richmond, be-
lieved that when fibroids could be removed early in
pregnancy, this should be done, but unfortunately
many of the cases did not come to the surgeon un-
til a stage of pregnancy had been reached when
this could not be safely done. When a pregnancy
was known to exist and was complicated by fibroids,
such a patient should be closely watched, so that a
prompt operation might be performed if necessary.
In this way the rights of the unborn child could be
respected, and it was not uncommon for such a
pregnancy to go on to the period when the child
was viable. He had had experience in fifteen cases
in which he had operated for fibroids complicating
pregnancy. But his experience had been doleful in
the matter of saving the children. He had not had
a fatality among the mothers, but had been able to
save only one child out of these fifteen cases.
The Treatment of .Dislocation of the Shoulder
Joint Complicated with Fracture of the Upper
Extremity of the Humerus. — Dr. J. M. Mason, of
Birmingham, reported the case of a man who had
sustained a subcoracoid dislocation of both shoul-
ders with fracture of the surgical neck of the right
humerus. The left shoulder was reduced by the
Kocher method, and the right was treated by arthrot-
omy and reduction six hours after the receipt of the
injury. The fracture was wired and primary union
was secured. A perfect result was obtained, and the
patient had neither atrophy, pain, nor weakness in
the arm, and there was no restriction of motion in
any direction. A comparison of the results in the
shoulder subjected to operation with those where
simple reduction of the uncomplicated dislocation
was practised showed no difference.
The author's conclusions were : i . Every dislocation
of the shoulder associated with fracture of the up-
per extremity of the humerus was a grave injury and
was likely to result in serious impairment of function
if not promptly treated. 2. Every such injury should
be subjected to x ray examination for accuracy in
diagnosis. 3. Gentleness should characterize all
manipulative efl!"orts at' reduction, and these should
not be carried to the point of bruising or lacerating
the tissues. 4." Excision should be practised only
where open arthrotomy had failed, where there was
extensive comminution of the upper extremity of the
humerus, or where, in fracture at the anatomical
neck, the condition of the upper fragment did not
justify a reasonable expectancy of its uniting. 5. Af-
ter reduction, the broken greater tuberosity should
be nailed down if the case was recent, and should be
removed if it caused impairment of function in an
old case. 6. In failure to reduce by manipulation,
immediate arthrotomy with reduction of the disloca-
tion, followed by appropriate treatment for the frac-
ture, had given the best results and was the ideal
method of treatment. 7. Rigid asepsis was essential
in securing good results, and these operations should
not be undertaken where this could not be carried
out.
{To be continued.)
PRACTICAL AND SCIENTIFIC NEUROLOGY.
Chicago, December 12, 1907.
To the Editors:
Neurology as a branch of scientific biology and
neurology as a department of medical practice are
still widely apart. This is obvious enough to any
one who follows the literature of both.
Take as a ready, though perhaps not the best,
illustration the book reviews that appear in the
high class journals. Note how sharply separated
are the reviews of the clinical works from those of
the works devoted to pure science. In practically
all of the periodicals devoted to physiology, com-
parative anatomy, and psychology the newer works
upon nervous diseases and phychiatry are wholly
ignored; or, if they are reviewed therein at all, only
those parts of the book are criticised that touch upon
pure physiolog)', anatomy, and psychology. In a
sense, this of course is as it should be; but I, for
one, should like to read now and then a careful and
honest review of a book upon nervous diseases by
a capable critic whose training had been wholly, or
almost wholly, in the pure biological sciences. I
fancy such a one would have some amusing and not
unprofitable things to say about some of the un-
physiological, unscientific, and altogether unwar-
ranted deductions occasionally indulged in by the
teachers and writers trained only in clinical medi-
cine. Some of the crude deductions of the patholo-
gists also would be easily shattered, I am sure, by
such a critic.
On the other hand, "while the magazines devoted
to clinical neurology are more frank to review the
newer works upon neurophysiology and neurobiol-
ogy generally than are the magazines devoted to
pure science to review the newer works upon clin-
ical neurology, such reviews, as a rule, are wofully
flat and inadequate, and reveal often in a most glar-
ing manner the critic's unfamiliarity with the latest
authoritative teachings of experimental and com-
parative neurology." Did space and courtesy per-
mit, one could easily quote from some recent re-
views and authoritative scientific works matter suf-
ficient to make a long series of parallel paragraphs
showing the contradictions and misstatements upon
the part of the reviewer indicative of a lamentable
ignorance in one who pretends to so exalted and
delicate a position as that of critic.
Often have I wondered what the net result would
be if by some miracle the investigators and writers
in the field of pure biology and biophysiology could
be made to study clinical neurology for one year,
and if all the clinicians, pathologists, and writers in
the realm of neurological practice could be forced
to study for the same length of time the pure bio-
January ii. 1908.]
LETTERS TO THE EDITORS.
91
logical sciences, including psychology. I have a
notion that were such a miraculous event to be
brought about, a large part of our present literature
upon neuropathology, clinical neurolog>', and prac-
tical phychiatry would undergo immediate and ex-
tensive revision, if it was not wholly assigned to the
limbo if oblivion.
As there is not the remotest hope of such a sur-
prising event occurring, the confusion and resultant
pessimism that are so prevalent in the rank and file
of the profession in connection with the diseases of
the nervous system, which, in my opinion, are
largely due to the state of affairs intimated above,
might be dissipated to a very considerable extent if
the medical schools would teach more scientific
biology and physiopathology along with practical
neurology. L. Harrison Mettler.
RIDING ASTRIDE BY WOMEN.
Mount Holly, N. J., December i6, 1907.
To the Editors:
In answer to Dr. E. H. Bidwell's inquiry in the
last week's issue, regarding fashion having more
weight than the opinion of physicians, I would say
that it is the general opinion among the physicians
with whom I associate that the fashion of riding
astride has not had its origin in fad so much as it
has in the advice of physicians of our modern type.
That this method caused a greater frequency of
uterine trouble than the side saddle method it
would be hard to explain.
The fact that a person riding astride can have
more freedom from jar and jolt than one riding on
a side saddle should be a point in favor of the
astride method, aside from the facts of it being
safer and easier for the rider. The fact that it
might be considered immodest by those who are
not familiar with the astride method of riding is no
reason why it should be condemned. The main rea-
son why it is becoming more popular is because
physicians in general see its good points' over the
old method and are thus advising it.
H. R. Farixger.
NEUROLOGICAL HOSPITALS.
1909 Chestnut Street,
Philadelphia, December 26, 1907.
To the Editors:
In the issue of your journal for December 21st
there is an editorial on the establishment of a neu-
rological hospital on Blackwell's Island. This arti-
cle is written in the interest of what I believe should
be regarded as one of the most important and most
beneficent movements ever contemplated or consum-
mated by the great city of New York. The writer
of your editorial, however, while showing an ad-
mirable knowledge of what has been done abroad
in the interests of suflrerers from diseases of the
nervous system and for the advancement of scien-
tific neurology, exhibits at the same time an extraor-
dinar}- lack of information of what has been done
in his own country. He speaks of this neurological
hospital on Blackwell's Island as "practically the
first of its kind in this country," while calling atten-
tion to the Salpetriere and Bicetre hospitals of
Paris.
Apparently the writer is entirely unacquainted
with the fact that no less than thirty years ago a
department for the study and treatment of nervous
diseases was established in connection with the
Philadelphia Hospital and Almshouse. It is the
more remarkable that this lack of information
should exist when it is remembered that the neuro-
logical department of the Philadelphia Hospital has
been visited by most of our confreres in New York.
In the Journal of Nerz'ous and Mental Disease
for June, 1904, in a History of Neurology in Phila-
delphia from 1874 to 1904, is given a brief account
of the origin and development of the neurological
department of the Philadelphia Hospital, and in an
article in the Philadelphia Hospital Reports, vol. v,
1902, a more extended history of this department
will be found. To these articles I would refer your
writer and any others who might chance to be in-
terested in the matter. The number of patients in
this neurological hospital is now about four hun-
dred ; it is expected that in a short time this num-
ber will reach five hundred and more. It may be
worthy of note that many of the articles contrib-
uted to the neurological journal above referred to
during the last two decades have been based upon
the study of clinical and pathological material ob-
tained from the wards of this hospital.
The wards of the neurological department of the
Philadelphia Hospital have been visited by neurolo-
gists from all parts of our own country and from
many foreign countries, including Great Britain,
France, Germany, Italy, Switzerland, and Russia;
these visitors in almost every instance have com-
pared these wards favorably with those of the Sal-
petriere and Bicetre.
In Philadelphia there is another hospital for
nervous diseases, which might perhaps have re-
ceived at least passing notice from a writer inter-
ested in the foundation of a new American neuro-
logical institution. This is the Orthopaedic Hospital
and Infirmary for Nervous Diseases, which was
founded in 1867, ten years before the nervous
wards of the Philadelphia General Hospital, and has
now grown into an institution of large proportions,
where all forms of nervous disease, acute and
chronic, are studied and treated. It may be said,
however, that this great hospital and infirmary is
not exactly like that which is contemplated in New
York, which presumably will develop more or less
upon the lines of the neurological department of the
Philadelphia Hospital.
I trust that in your valuable journal, which rep-
resents in its title both New York and Philadelphia,
you will give place for this brief statement of facts,
that neither any of your contributors nor any of
your readers may longer remain in ignorance of the
fact that we have had for more than thirty years in
Philadelphia at least two neurological hospitals
worthy of the name, and that it may not appear that
hospitals, like prophets, are not without honor save
in their own country and among their own kin.
It gives me pleasure, in behalf of my colleagues
of the neurological staff of the Philadelphia Hos-
pital, to extend an invitation to any of those inter-
ested in the establishment of the new neurological
hospital in New York to visit our institution and
study its workings.
Charles K. Mills.
92
BOOK NOTICES.
[New York
Medical Journal.
Surgery: Its Principles and Practice. By Various Authors.
Edited by William Williams Keen, M. D., LL. D.,
Professor of the Principles of Surgery, Jefferson Medi-
cal College, Philadelphia. Volume II. With 572 Text
Illustrations and 9 Colored Plates. Philadelphia and
London : W. B. Saunders Company, 1907. Pp. 920.
(Price, $7.)
In this second volume Dr. E. H. Nichols is the
author of the chapter on diseases of the bones ;
Dr. D. N. Eisendrath has written the chapters on
fractures and dislocations; Dr. R. W. Lovett has
prepared the chapters on the surgery of the joints
and orthopaedic surgery; Dr. J. F. Binnie is the
author of the chapter on the surgery of the mus-
cles, tendons, and bursae ; Dr. F. H. Gerrish has fur-
nished that on the surgery of the lymphatic system ;
Dr. J. A. Fordyce has contributed that on the sur-
gery of the skin ; Dr. W. G. Spiller has written that
on the pathology of the chief surgical disorders of
the nervous system; Dr. G. Woolsey has prepared
those on the surgery of the nerves and the surgery
of the spine ; Dr. F. X. Dercum has contributed
that on traumatic neurasthenia, traumatic hysteria,
and traumatic insanity, and J. C. DaCosta has fur-
nished that on surgery among the insane and the
surgery of insanity.
Each of the subjects is treated admirably, the
text is well illustrated, and the volume is a fit com-
panion to its excellent predecessor.
A Textbook of Mental and Sick Nursing. Adapted for
Medical Officers and Nurses in Private and Public Asy-
lums. By Robert Jones, M. D., B. S. Lond., F. R. C. S.
Eng., F. R. C. P. Lond.; Resident Physician and Super-
intendent of the London County Council's Asylum, Clay-
bury, etc. With an Introduction by Sir William Job
Collins, M. D., M. S., B. Sc. Lond.. F. R. C. S. Eng.,
M. P., D. L., J. P., Vice-Chancellor of the University of
London, etc. London: The Scientific Press, Limited,
1907. Pp. 222. (Price, 3s. 6d.)
The author has had a wide experience in the
treatment of mental disorders, and as superintendent
of one of the largest of London's county asylums is
daily brought in contact with the type of questions
constantly arising in this branch of medicine. While
mental disease is to be considered first, last, and al-
ways as bodily disease, in no wise different in prin-
ciple from any other disease to which flesh is heir,
yet certain features of the nursing of mental cases
make it desirable to issue works of this kind.
This volume is formed of the substance of a series
of lectures delivered by the author at Claybury.
which have from time to time appeared in the
columns of the Hospital. They show the author's
point of view to be that held by leading men
throughout the world, that to be a good nurse or at-
tendant on the insane it is requisite to be a good
general nurse and something more. He empha-
sizes, and wisely so, the fact that certain qualities
of knowledge and character, certain qualities of
mind and of heart, are not less but more essential
than is the case with the general nurse.
To this end he assumes a certain knowledge and
then discusses in some twenty-four chapters the
special features which need emphasizing when one
is called upon to treat the insane, the feeble minded,
and the epileptic.
We can commend it as a convenient and compact
manual, well written and filled with practical sug-
gestions.
The Reduction of Cancer. By the Hon. RoUo Russell.
London and New York : Longmans, Green & Co., 1907.
Pp. 62.
The author believes that the origin and increase
of cancer are to be attributed to the habit of ex-
cessive meat eating, the abuse of alcohol, and the
overindulgence in tea, coffee, and tobacco among
civilized peoples. This view is apparently sup-
ported to some extent by a consideration of the
geographical distribution of cancer and by an in-
genious use of quotations and opinions of medical
authorities which have been in some cases at least
strained to bear the interpretation the writer gives
them. We believe we are quite within the mark
in saying that any competent scientific investigator
would hesitate to draw from such meagre data tht-
sweeping conclusions indicated in the little book.
A Manual of Clinical Diagnosis by Means of Microscopical
and Chemical Methods. For Students, Hospital Physi-
cians, and Practitioners. By Charles E. Simon, B. A.,
M. D., Professor of Clinical Pathology at the Baltimore
Medical College, etc. Sixth Edition, Thoroughly Re-
vised. Illustrated with 177 Engravings and 24 Plates in
Colors. Philadelphia and New York: Lea Brothers &
Co., 1907. Pp. xix-17 to 682.
Dr. Simon has introduced a great amount of new
material into the sixth edition of his Clinical Diag-
nosis. It is about ten years ago that the first edi-
tion was published, and since that time many new
discoveries in medicine have been made and many
new theories advanced. The author has well
adapted his book to the advances of our science. In
this edition we find a new chapter on the opsonins,
with a full description of the technique, in which
Dr. Simon's experience as a pioneer worker will
certainly prove of value. Two appendices have
also been added, the first dealing with the prepara-
tion of culture media, the second representing an
outline of a course in clinical laboratory methods.
The illustrations are well executed. It is usu-
ally a stumbling block for the artist to represent his
objects in natural colors. The difference between
the natural object and the object as depicted in the
illustration is often so great as to make recognition
impossible. Not so in our book. The nuances are
well selected, giving a true gradation of the fine
differences of shade in colors. The author men-
tions Mrs. Simon as the painter of most of the
illustrations.
Fiske Fund Prise Dissertation. No. L. Diet in Typhoid
Fever. By John Benjamin Nichols, M. D. Provi-
dence : Snow & Farnham Company, Printers, 1907.
In his prize essay "the author presents an excellent
historical sketch of feeding in fevers from the
earliest times, and there is a careful analysis of the
entire subject of metabolism in typhoid based upon
the original authorities, with a comparison of dif-
ferent food values, and in conclusion a plea is made
for the adoption of a more liberal diet in typhoid
fever, and to it we give our decided assent.
Synonymik der Dermatologie. Von Dr. Johannes Fick,
Wien. Wien und Leipzig: Alfred Holder, 1906. Pp. 68.
The little pamphlet is a practical reference book
for dermatologists, especially those using the Ger-
man language. It is arranged alphabetically, the
explanations to be found under the Latin name, to
January ii, 1908. 1
OFFICIAL NEWS.
93
which cross references of English, French, and
German nomenclature refer.
Annates de la Societe royale des sciences medicates et
naturelles de Bruxeltes. Soixante-huitieme annee. Tome
xvi, Fasc. i et 2. Bruxelles: Henri Lamertin, 1907.
Pp. 345-
This volume of the Annates contains four inter-
esting essays: i. A contribution to the Study of
Ruptures of the Gravid Uterus and to the Physiol-
ogy of the Trophoblase, by Bouffart and Delporte.
2. The Influence of the Peptones on the Functions
of the Kidneys, by George Hendrik. 3. Experi-
ments with Salts upon the Pancreatic Juice, by
Edgard Zunz. 4. The Action of Camphor and
Oxycamphor upon the Heart of the Turtle after
Extirpation, by Adrien Lippens.
BOOKS. PAMPHLETS, ETC.. RECEIVED.
Practical Anaesthetics. Bv H. Edmund G. Boyle,
M. R. C. S., L. R. C. P., Ass'istant Anesthetist to St. Bar-
tholomew's Hospital, etc. London : Henry Frowde and
Hodder & Stoughton, 1907. Pp. viii-178.
Abel's Laboratory Handbook of Bacteriology. Trans-
lated from the Tenth German Edition, by M. H. Gordon,
M. A., M. D. (Oxon.), B. Sc., with Additions by Dr. A. C.
Houston, Dr. T. J. Horder, and the Translator. London :
Henry Frowde and Hodder & Stoughton, 1907. Pp. x-224.
Die Praxis der Hautkrankheiten. Unna's Lehren fiir
Studierende und Aerzte, zusammengefasst und dargestellt
von Dr. Iwan Bloch, Berlin. Mit einem Vorwort von Dr.
P. G. Unna in Hamburg. Mit 92 Abbildungen. Berlin und
Wien: Urban & Schwarzenberg, 1908. Pp. 698.
Les Homosexuels de Berlin. Par le Dr. Magnus Hirsch-
feld. Paris: Jules Rousset, 1908. Pp. 103.
Schema des Rumpfes. Von Privatdozent Dr. W. Hilde-
brandt, Freiburg i. B. Taschenausgabe. Miinchen : J. F.
Lehmann, 1908.
Les Ferments metalliques et leur emploi en therapeutique.
Par Professeur Albert Robin, membre de I'Academie de
Medecine. Paris: J. Rueff, 1907. Pp. 252.
Traitement de la tuberculose par la parato.xine base sur
Taction antitoxique du foie. Par E. Gerard, professor de
pharmacie et de pharmacologic, and G. Lemoine, professor
de clinique medicale a I'Universite de Lille.
Traite clinique des maladies de I'estomac. Par le Dr.
Lucien Pron (d'Alger). Paris: Jules Rousset, 1908. Pp.
417.
Die tierischen Parasiten des Menschen. Ein Handbuch
fur Studierende und Aerzte. Von Dr. Max Braun, o. 6.
Professor der Zoologie und vergl. Anatomie, etc. Mit 325
Abbildungen im Text. Vierte, vermehrte und verbesserte
Auflage. Mit einem klinisch-therapeutischen Anhang.
Bearbeitet von Prof. Dr. Otto Seifert in Wiirzburg.
Wurzburg: Curt Kabitzsch (A. Stuber), 1908. Pp. 623.
Traite pratique d'hypnotisme et de suggestion thera-
peutiques. Procedes d'hypnotisation, simples, rapides, in-
offensifs. A I'usage des medecins, pharmaciens, professeurs,
instituteurs et^ des gens du monde. Par M. Geraud Bonnet,
docteur en medecine de la Faculte de Paris, etc. Deuxieme
edition. Paris: Jules Rousset, 1907. Pp. 326.
mml Mtm.
Public Health and Marine Hospital Service
Health Reports:
The following cases of smallpox, yellow fever, cholera,
and plague have been reported to the Surgeon General,
United States Public Health and Marine Hospital Service,
during the week ending January 3, 1908:
Smallpox — United States.
Places. Date. Cases. Deaths.
Illinois — Springfield Dec. 13-19.
Indiana — Indianapolis ^. . .Dec. 16-22.
Indiana — Lafayette Dec. J 7-23.
Kansas — Wichita Dec. 15-21.
Kentucky — Covington Dec. i<i-2i.
Maryland — Baltimore Dec. 22-28.
Massachusetts — Boston Dec. 15-21.
Massachusetts — Fall River Dec. 22-28.
Michigan — Saginaw Dec. 15-21.
Minnesota — Winona Dec. 15-21.
Missouri — St. Louis Dec. 15-21.
Nebraska — Nebraska City Dec. 8-21.
New York — New York Dec. 15-21.
New York — Niagara Falls Dec. 15-21.
New York — Syracuse Dec. 15-24.
North Carolina — Greensboro Dec. 15-21.
Ohio — Cincinnati Dec. 21-27.
Pennsylvania — Erie Dec. 20-26.
Tennessee — Knoxville Dec. 15-21.
Tennessee — Nashville Dec.
Texas — San Antonio Dec.
Washington — Tacoma Dec.
Wisconsin — La Crosse Dec.
Wisconsin — Milwaukee Dec.
15-21-
15-21.
15-21-
15-21.
Smallpo
California — Los Angeles Dec. 15-21..
California — San Francisco Dec. 15-21..
District of Columbia — Washington. Dec. 15-21 . .
Florida — Tarpon Springs Dec. 15-21..
Illinois — Chicago Dec. 22-28..
-Foreign.
.Africa — Algeria — Algiers Nov. 1-30 a
.\rgentina — Rosario Sept. 1-30 3
Brazil — Bahia Nov. 2-30 157 ;
Brazil — Para Dec. 1-7 9 2
Brazil — Rio de Janeiro Nov. 18-24 37 5
Canada — Nova Scotia — Halif.ix Dec. 15-21 i
Canada — Ontario Province Dec. 19. Outbreak reported in
several places.
Canada — Belleville Dec. 17-23 4
China — Shanghai Nov. 18-24 j; 11
Cases foreign, deaths native.
Ecuador — Guayaquil Dec. 1-7 4
France— Paris Dec. 1-7 8
Germany — General Nov. 17-23 i
India — Calcutta Dec 1-7 2
Japan — Kobe Nov. 21-27 23 2
Japan — Yokohama Nov. 28-Dec. 3 i
Japan — Malta Dec. 1-7 1 i
Mexico — .\guas Calientes Dec. 9-15 3
Panama — Colon Dec. 8 i
From S. S. Atrato.
Peru— Callao Nov. 20-26 i
Russia — Moscow Nov. 24-30 4 6
Russia — Odessa Nov. 24-30 4
Spain — Cadiz Nov. 1-30 8
Spain — Madrid Nov. 1-30 i
Spain — Valencia Dec. 2-8 3> 2
Turkey in Asia — I'.Mgdatl Nov. 3-16 89 26
Cholera — Foreign.
India— Calcutta Nov. 17-23 108
India — Rangoon Nov. 11-23 '6
Japan — Oshima Isl.ind Dec. 3 5
Japan — Ibaraki Nor. 37 i
Japan — Kanagawa Dec. 1-2 4
japan — Kobe Nov. 18-23 7 2
Japan — Nagasaki Mov. 18-24 ' '
Japan — Tokushima To Nov. 27 27 23
Japan — Yokohama To Oct. 27-Nov. 2.. $ 4
Russia — General Nov. 7-12 403 325
Russia — Kief Nov. 19-23 14 3
Yellow Fever — Foreign.
Brazil — Para Dec. 1-7 16 10
Brazil — Rio de Janeiro Nov. 18-24 2 i
Cuba — Habana Province — Guines .Dec. 23-27 1 1
Cuba — Santa Clara Province — From Balos.
Cieafuegos Dec. 29-31 2 i
Case Dec. 31 from Palmira.
Cuba — Palmira Dec. 31 i i
Ecuador — Guayaquil Dec. 1-7 t
West Indies — Bridgetown Dec 4-14 1 i
Plague -United States.
California — San Francisco Dec. 26-27 ' 2
Plague — Foreign.
Brazil — Bahia Nov. 2-30 »8 18
Brazil — Rio de Janeiro Nov. 18-24 8 a
India — General Nov. 9-16... 8,451 6,308
India — Calcutta Nov. 17-23 22
Japan — Osaka Nov. 17-23 51 57
Peru — Chosica Nov. 21-27 '
Peru — Lima " " 6 5
Peru — Paita " " 3 i
Peru — Piura " " i
Peru — Trujillo " " 8 7
Army Intelligence:
Official list of changes in the stations and duties of officers
serving in the medical department of the United States
Army for the week ending January 4, igo8:
Brown, O. G., Assistant Surgeon. Relieved from further
temporary duty at Jefferson Barracks, Mo., and ordered
to return to his proper station. Fort Robinson, Neb.
CrosbYj W. D., Major and Surgeon. Appointed a mem-
ber of a board of officers to meet at the Army Medical
Museum Building in Washington, D. C., for the ex-
amination of such officers of the medical department
94
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal..
as may be ordered before it to determine their fitness
for advancement or promotion.
Duncan, L. C, Captain and Assistant Surgeon. Granted
four months' leave of absence with permission to go
beyond the sea.
Flagg, C. E. B., Captain and Assistant Surgeon. Relieved
from duty at Fort Creek, Neb., and ordered to the
Philippine Islands for duty on transport to sail from
San Francisco, Cal., about February 5, 1908.
Greenleaf, H. S., Captain and Surgeon. Relieved from
duty in the Philippine Islands, and ordered to proceed
on the transport to sail from Manila, on or about March
15, 1908, to San Francisco, Cal. ; upon arrival will report
by telegraph to the Adjutant General of the Army for
further orders.
McCaw. W. D., Major and Surgeon. Appointed a member
of a board of officers to meet at the Army Medical
Museum Building in Washington, D. C, for the ex-
amination of such officers of the medical department as
may be ordered before it to determine their fitness for
advancement or promotion. Appointed a member of a
board to meet in Washington, D. C, for the purpose of
conducting such experiments as may be necessary re-
garding the efficiency of the Darnall filter for the puri-
fication of water, and its adaptability to the use of
troops in the field.
Morris, E. R., Major and Surgeon. Appointed a member
of a board to meet at Jeffersonville, Ind., for the ex-
amination of such officers of the quartermaster's de-
partment as may be ordered before it to determine their
fitness for promotion.
MuNSON, E. L., Major and Surgeon. Appointed a mem-
ber of board to meet at Jeffersonville, Ind., for the
examination of such officers of the quartermaster's
department as may be ordered before it to determine
their fitness for promotion.
Owen, L. J., First Lieutenant and Assistant Surgeon. Upon
expiration of his present leave of absence, will pro-
ceed to Columbus Barracks, Ohio, for duty.
Powell, J. L., Major and Surgeon. Leave of absence ex-
tended ten days.
Richards, R. L., First Lieutenant and Assistant Surgeon.
Ordered to report in person on January 14, ' 1908, to
Major W. D. Crosby, surgeon, president of the ex-
amining board, Washington, D. C, for examination to
determine his fitness for advancement.
Russell, F. F., Major and Assistant Surgeon. Appointed
a member of a board to meet in Washington, D. C,
for the purpose of conducting such experiments as may
be necessary regarding the efficiency of the Darnall
filter for the purification of water, and its adaptability
to the use of troops in the field.
Shimer, I. A., Captain and Surgeon. Ordered to report
in person on Tuesday, January 7, 1908, to Major William
D. Crosby, surgeon, president of the examining board.
Army Medical Museum, Washington, D. C, for ex-
amination to determine his fitness for promotion. Re-
lieved from duty as attending surgeon in New York
City, and ordered to the Philippine Islands for duty,
to sail from San Francisco, Cal., about February 5,
1908.
Williams, A. W., Captain and Assistant Surgeon. Relieved
from duty in the Philippine Islands, and will proceed
on the transport to sail from Manila on or about
March 15, 1908, to San Francisco, Cal., and upon arrival
report by telegraph to the Adjutant General of the
Army for further orders.
Winter, F. A., Major and Surgeon. Appointed a member
of a board of officers to meet at the Army Medical
Museum Building in Washington, D. C, for the ex-
amination of such officers of the medical department
as may be ordered before it to determine their fitness
for advancement or promotion.
Navy Intelligence:
Official list of changes in the medical corps of the United
States Navy for the week ending January 4, j<)o8:
Dessez, p. T., Assistant Surgeon. Detached from the
Naval Hospilal, Boston, Mass., and ordered to the
naval recruiting station, Kan.sas City, Mo.
Michels, R. II., Passed Assistant Surgeon. Detached
from the naval recruiting station, Kansas City, Mo.
Sellers. F. E., Assistant Surgeon. Detached from the
IVilmington and ordered to the Naval Hospital, An-
napolis, Md.
Married.
Davenport — Mills.— In Rochester, New York, on Wed-
nesday, January 1st, Dr. Howard Irving Davenport, of
Canandaigua, .md Miss H. Helena Mills.
Heimann — Davison.— In New York, on Wednesday^
January ist. Dr. Walter James Heimann and Miss Heloise
Davison, daughter of Dr. David H. Davison.
Lange — Rick. — In Pittsburgh, Pennsylvania, on Mon-
day, December 23d, Dr. J. C. Lange and Mrs. Edith Rick.
Malone — Franzoni. — In Washington, D. C, on Satur-
day, December 28th, Dr. Wilson P. Malone and Miss Edith
Elizabeth Franzoni, daughter of Dr. Joseph D. Franzoni.
Scott — Laycock. — In Bethel, Ohio, on Wednesday, De-
cember 25th, Dr. J. C. Scott and Miss Leona Laycock.
Sellers — Losey. — In Louisville, Kentucky, on Wednes-
day, December 25th, Dr. Harry W. Sellers and Miss Ethel
Losey
Woodford— Croghan. — In Washington, D. C, on Thurs-
day, December 26th, Dr. William G. Woodford and Miss
Beatrice Anne Croghan.
Died.
Austen. — In New York, on Tuesday, December 31st,
Peter Townsend Austen, Ph. D., aged fifty-five years.
Banks. — In Oak Forest, Cumberland County, Virginia,
on Monday, December 23d, Dr. J. L. Banks.
Blake. — In Tampa, Florida, on Thursday, November
28th, Dr. B. F. M. Blake, of Brooklyn, aged fifty-two years.
BoicE. — In Denver, Colorado, on Saturday, December
28th, Dr. John Boice, aged sixty-eight years.
BowEN. — In Buffalo, New York, on Saturday, Decem-
ber 28th, Dr. Clara E. Bowen, aged forty-seven years.
Burgess. — In Huntington, Long Island, on Friday, De-
cember 27th. Dr. Frederick Wells Burgess, aged eighty-six
years.
Cottrell.— In Boston, Massachusetts, on Saturday, De-
cember 28th, Dr. W. J. Cottrell, aged thirty-six years.
Crook. — In Glenwood Springs, Colorado, on Tuesday,
December 24th, Mrs. Olive W. Crook, wife of Dr. W. W.
Crook.
Eager. — In Louisville, Kentucky, on Saturday, December
28th, Dr. Benjamin F. Eager, aged fifty-nine years.
Egelhoff. — In Chicago, on Friday, December 27th, Dr.
William C. EgelhofT, aged thirty-five years.
Hamilton. — In Peoria, Illinois, on Sunday, December
29th, Dr. William R. Hamilton, aged ninety-two years.
Hardenberg. — In Jersey City, New Jersey, on Tuesday,.
December 31st, Dr. Daniel S. Hardenberg. aged si.xty-
seven years.
Hayes. — In Buffalo, on Thursday, December 26th, Dr.
W. Carlos Hayes, aged fifty-six years.
HiGGiNs. — In Glendale, Missouri, on Wednesday. Decem-
ber 2Sth, Dr. Richard M. Higgins, aged sixty-fi\ e years.
Humes. — In Upper Marlboro, Maryland, on Tuesday,
December 24th, Dr. Mareep D. Humes, aged fifty-seven
years.
Jewett. — In Cobalt, Connecticut, on Friday, January 3d,
Dr. Levi Jewett, aged seventy-three years.
Marshall. — In Chicago, on Monday, December 23d. Dr.
David Marshall, of Florence, Kentucky, aged twenty-four
years.
Marshall. — In Bedford City, Virginia, on Friday, De-
cember 27th, Dr. Thomas H. Marshall, aged seventy-twO'
years.
Pierce. — In Newburgh, New York, on Sunday, December
29th, Dr. Louis R. Pierce, aged forty-one years.
Reuling. — In Baltimore, Maryland, on Saturday, De-
cember 28th, Dr. Robert C. Reuling, son of Dr. George
Reuling, aged thirty-five years.
ScnuGENS.— In Bufifalo, New York, on Wednesday, De-
cember 25th, Dr. M. Elizabeth Schugens.
Senn. — In Chicago, on Thursday, January 2d, Dr.
Nicholas Senn, aged sixty-three years.
Smith. — In Frankton, Virginia, on Monday, December
30th, Dr. Charles Smith, aged seventy-two years.
Smith. — In Richmond, Virginia, on Friday, December
27th, Dr. Robert F. Smith, aged sixty-five years.
Taylor. — In New York, on Sunday, January 5th, Dr.
Robert W. Taylor, aged sixty-five years.
Wachendorf.— In Sioux Falls, South Dakota, on Satur-
day, December 28th, Dr. C. C. J. Wachendorf.
Williams. — In Peakes, Hanover County. Virginia, on
Tuesday, December 31st, Dr. Thomas E. Williams.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal ^h' Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXVII, No. 3. NEW YORK, JANUARY 18, 1908. Whole No. 1520.
©riginiil Cffmmunitation.s.
MODERN METHODS IN THE SURGICAL TREAT-
MENT OF GASTRIC DISEASES.*
By Franz Torek, A. M., M. D.,
New York,
Adjunct Attending Surgeon to the German Hospital; Attending
Surgeon to the New York Skin and Cancer Hospital;
Adjunct Professor of Surgery in the New York
Postgraduate Medical School.
The technique of gastric surgery has come more
prominently into the foreground since physicians
have begun to understand that many cases diagnos-
ticated as chronic gastritis were in reahty cases of
mahgnant tumor or of congestion due to mechanical
obstruction by an open ulcer or its resulting cicatrix.
Unless a distinct cause for gastritis can be traced,
such as alcoholism, errors in diet, etc., the other pos-
sibilities should be kept in mind, and proper
measures should at once be taken for making a
correct diagnosis. Many cases will then be found
to be not chronic gastritis, but some malady requir-
ing surgical treatment.
Of the operations uf>on the stomach the most im-
portant are gastroenterostomy and resection ; the
former for ulcer and for pyloric obstruction from
whatever cause, the latter occasionally for ulcers,
but more particularly for the removal of cancer.
Owing to the limitation of this paper I can touch
upon little else than those two operations.
Gastroenterostomy is indicated mainly in ulcer of
the stomach, whether the ulcer is open or whether
the scar of the healed ulcer has, by contracting, nar-
rowed the lumen causing obstruction and motor in-
sufficiency. The indication next in frequency for
the performance of gastroenterostomy is obstruction
at the pylorus from inoperable carcinoma of the
stomach. The operation consists in the formation
of a new communication between the stomach and
the intestine, a loop of jejunum being usually
selected for attachment to as dependent a part of the
stomach as possible. The communication may be
established either at the anterior or the posterior
wall of the stomach, and the operations are accord-
ingly called anterior or posterior gastroenterostomy.
To perform anterior gastroenterostomy the loop
of jejunum is brought forward either around the
transverse colon, so as to he in front of it, or
through an opening established in the transverse
mesocolon. The former of these two methods is
more frequently practised than the latter. In order
that neither the jejunum should press on the colon,
as it passes around it. nor the colon should tug on
the loop of jejunum, this loop must not be too
•Read before the Medical Association of the Greater City of New
York, October 21, 1007.
short. A point about eighteen inches distant from
the duodenojejunal fold is selected for the anasto-
mosis. In performing posterior gastroenterostomy,
on the other hand, a long loop is not needed, in fact
is not desirable, and the anastomosis is made at as
short a distance from the beginning of the jejunum
as is compatible with easy approximation.
As for the method of making the anastomosis,
the majority of surgeons at the present time prefer
the suture to the use of the Murphy button or the
McGraw ligature. For a time the Murphy button
was the favorite among surgeons owing to the
celerity with which it could be applied and the satis-
factory firmness of the union procured by its aid.
But now the number of accidents from the button —
decubital ulcers and perforation, even at a consider-
able distance from the place of its insertion — is
great enough to be no longer a negligible quantity,
showing that there are unavoidable dangers con-
nected with its use. Besides, there are the many
cases of gastroenterostomy in which the button, in-
stead of being voided, fell back into the stomach
and remained there until removed by gastrostomy.
I had one case each of button and McGraw ligature
finding their way into the stomach. The ligature
was vomited after about a month ; the button was
later removed by another surgeon. On the other
hand the method of suture has lately been perfected
very much by the help of instruments which clamp
off only those segments of the stomach and the in-
testine that are needed for the performance of the
operation in place of the former method of tying
or clamping the intestine at two places, one above
and the other below the site for anastomosis. With
the newer method it is easier to do clean work ; the
vessels need not be caught, and the parts to be
united are brought into very satisfactory apposition
before the suture is begun. For all these reasons
the suture can be performed more quickly than was
formerly the case ; so that even in point of rapidity
<-he Murphy button does not lead by as much as it
used to. Anastomosis by suture should be our
choice in all cases except those whose condition is
such that the shortening of the operation through
the use of a mechanical appliance becomes impera-
tive.
The operation of anterior gastroenterostomy is
performed as follows : Median epigastric or left
rectus incision. The stomach and duodenum are ex-
am.ined to ascertain the nature of the disease. Two
fingers then search for the duodenojejunal fold and
grasp the jejunum at its origin. A point at the
jejunum about eighteen inches from its origin is
selected for anastomosis, and this part is brought
forward around the omentum and transverse colon
to be joined to the anterior wall of the stomach at
Copyright, 1908, by A. R. Elliott Publishing Company.
96
TOREK: SURGERY OF GASTRIC DISEASES.
[New York
Medical Journal.
its most dependent portion. It is necessary to carry
in mind which part of the loop is the upper and
which the lower, as it must be attached in such
manner that the peristaltic wave of the jejunum
will travel in the same direction as that of the
Fig. I. — Krause's clamp for anastomosis.
stomach ; in other words, the oral part of the loop
should be on the left side. The anastomosis should
be about three inches long, if possible. It is usually
made nowadays with the aid of long curved clamps
(Fig. i). One of these is made to clasp the seg-
ment of the stomach which is to enter into the an-
astomosis, . the other the corresponding equally
large segment of the jejunum (Fig. 2). These
clamps are closed tightly enough to hold the organs
firmly, but not so tightly as to crush them. The
blades of the instrument are usually covered with
rubber tubes. The clamps are then properly ap-
proximated and tied together so that they may not
change their relative position to each other. In-
stead of two clamps, a single three bladed clamp
may be employed, whicli holds both organs in
proper apposition. The Roosevelt clamp (Fig. 3)
is constructed tn serve tliis purpose. I have used
it quite a number of times and find it very efficient.
In fact, it has advantages over the two bladed
clamps. I''nr instance, in tying the two bladed
clamps together it is necessary to place the handles
of the one on top of those of the other. In con-
sequence of this the segments of stomach and in-
.testine will not be in exactly the same plane, not a
very serious objection, it is true; the three bladed
clamp, however, overcomes this objection and en-
ables one to make the apposition precisely exact.
When the instrument is once in place it requires
no further attention and hence eliminates to some
extent the assistants' hands. The organs being in
Fig. 2. — Two clamps holding segments of stomach and intestine in
place, ready for anastomosis. The clamps are covered with rubber
tubes. The concavity of the clamps does not show in the drawing,
as we stand directly in front of the concave side. The tying to-
gether of the clamps is not represented in the figure.
place, our territory is first well surrounded by
gauze, and then we proceed to the suture, which
consists of an outer, seromuscular suture and an
inner row through all the coats. Some prefer a
triple layer, dividing the inner row into two sub-
divisions, one suture taking mucosa only, the other,
serosa and muscularis.
I shall describe the method of suture in two rows.
Beginning at one end we insert a continuous silk
Fig. 3. — Roosevelt clamp.
suture, which is to be everywhere about one quarter
inch distant from the proposed incisions into the two
organs (Fig. 4). When the posterior half of the
serous suture is completed, a clamp is applied to
January 18, 1908.]
TOREK: SURGERY OF GASTRIC DISEASES.
97
the silk thread close to the viscus to prevent the
meshes of the suture from loosening. Xeedle and
thread are then covered so they will not be soiled
during the next step, when the lumen of the stomach
and of the intestine is opened. An incision is now
made into the stomach and intestine : the cuts in
Fig. 4. — First half of the seromuscular suture inserted. The
suture is represented as beginning on the left, its termination on the
right being secured by a clamp to prevent it from loosening. The in-
cisions into the stomach and intestine are indicated by lines above
and below the suture. Notice that these incisions are shorter than
the seromuscular suture. The two incisions are equal in length.
both organs being exactly equal in length are one
quarter inch shorter at each end than the serous
suture first applied. It is well to incise only the
serous coat at first, because the clean cut into that
layer will enable us to judge very easily whether
the cuts are equal in length and in proper relative
position. The incisions are now deepened down to
the mucosa, which is then incised. In the case of
the intestine the mucosa usually bulges somewhat,
so that some prefer to excise the bulging portion.
It is of the utmost importance for us to be con-
scious that at this stage of the operation our work
ceases to be aseptic and that any instrument or
Fic. 5. — Application of the contiiious niaUress stitch. The knot
is at "a," both ends of the thread being armed with needles. In
the diagram, in order to show how the stitches run, the surfaces are
represented as being separated; in reality, of course, they are
brought into close apposition.
utensil that has come in contact with the mucosa
of the opened organs is not to be used again for
the aseptic part of the operation before being re-
sterilized. The mucosa is wiped clean with a piece
of gauze moistened with saline solution — some pre-
fer a 2 per cent, lysol solution — and then we pro-
ceed to applv the second row of sutures, or, better,
a continuous suture, through all layers, employing
for this purpose either an over and over suture or
the mattress stitch (Fig. 5), the latter having my
preference. In the diagram, in order to show how
the stitches run, the surfaces are represented as
being separated ; in reality, of course, they are
brought into close apposition. This suture is first
applied to the posterior lips of the gastroenterostomy
wound, which are already in perfect apposition, so
that its performance is very simple. The suture is
then continued along the anterior lips of the wound,
where its application is not so easy. With a little
ingenuity, however, and the knowledge that the
serous coats must be brought into apposition, any
one can readily figure out how the thread must run.
Fig. 6. — Continuous mat»ress stitch, ihowing how the corne^ is
turned. To show the method the stitches are represented as being
left loose; in the actual procedure each stitch is at once tightened.
The knot is at "a"; observe that it is not placed at the angle and
that, starting from it, the thread runs in both directions.
Ihe accompanying diagram (Fig. 6) may help
to illustrate the method with the use of the con-
tinuous mattress stitch, showing how the corner is
turned. In the diagram, to show the method, the
stitches are represented as being left loose ; in the
actual procedure each stitch is at once tightened.
Only the last two or three stitches are not at once
drawn close, as otherwise there would not be room
enough to insert the needle at the mucous surface ;
hence, to continue the mattress stitch to the end,
these last few stitches must be left loose till the
sutures are all in place, when they are tightened
and the suture is closed. Some to whom this is too
troublesome finish up by one or two seromuscular
sutures, inserted from the serous side : but a suture
finished in this manner is not so perfect, as it is
not so sure to control haemorrhage. Another point
in the application of the suture is this : Most sur-
geons start the suture at one angle and. having
98
TOREK: SURGERY OF GASTRIC DISEASES.
[New York
Medical Journal.
gone completely around, end up at that same angle.
It seems to me that the adaptation at the angle is
more perfect, if the knot at that place is eliminated.
I therefore begin at some place other than the angle
(compare Fig. 6, where the knot is not at the angle,
Fig. 7. — Diagram showing the condition at the anastomosis in
case a vicious circle is produced. The distended oral loop presses
■upon the anal loop, almost occluding its lumen.
but near it), make my knot, leaving both ends long
and arming each end with a needle, then going
round part of the way with one needle and the other
part with the other needle, the meshes of the first
suture being meanwhile prevented from loosening
by the application of a clamp. Thus I end up, not
at one of the angles, but at the front surface of the
united lips. The advantage of this is that the last
stitches, the correct insertion of which is not quite
simple, are placed at the most easily accessible part.
The anastomosis is now complete with the excep-
tion of the superficial portion of the seromuscular
suture, the posterior half of which was inserted at
the very beginning of the anastomosis and the loose
end of which was held by a clamp to prevent the
stitches from opening (Fig. 4). Before inserting
the anterior half of this seromuscular suture, we
must not forget that now the unclean part of the
operation is completed. We therefore cleanse the
last suture line with saline or lysol solution, remove
the gauze compresses immediately surrounding the
anastomosis, and replace them by clean ones. We
change our gloves or cleanse them, we discard all
soiled instruments, and then proceed with the con-
sciousness that now again we are in position to do
strictly aseptic work. Furthermore, the lumen of
the gut being now closed, we no longer need the
clamps. They are therefore removed, although, if
desired, one blade may be left behind the anasto-
mosis to prevent the organs from slipping back into
the abdomen ; if a strip of gauze has been first in-
serted between the two organs, as is usually done,
this alone is sufficient to prevent slipping back.
Then the anterior half of the seromuscular con-
tinuous suture is applied and knotted at the place
where the first half began.
A complication that is occasionally encountered
after gastroenterostomy is the so called vicious
circle. That is a condition in which the contents
of the stomach, having passed through the pylorus,
the duodenum, and the upper part of the jejunum
to the gastroenterostomy opening, are stopped there,
unable to get down into the intestine beyond the
anastomosis. In consequence of this the intestine
between the pylorus and the anastomosis becomes
distended until its contents are regurgitated into
the stomach and vomited. The obstruction at the
anastomosis opening is usually brought on by the
fact that the spur between the oral and anal loop
is pressed toward the anal loop, closing its lumen
(Fig. 7). This is more likely to occur when the
anastomotic opening is small than when its dimen-
sions are ample ; for, where the attachment of in-
testine to stomach is extensive, the production of a
sharp spur is avoided. Again, the vicious circle
will be observed where the anastomosis is so placed
that the stomach cannot easily empty itself through
it, i. e., if the intestine is attached too high up on
the stomach. In the third place, it is also more apt
to occur when the pylorus is patent than when it is
much con,stricted ; in cases of excessive stenosis at
the pylorus there is very little danger of a vicious
circle being established, as all the chyme must leave
the stomach through the gastroenterostomy opening.
These three causes for the production of a vicious
circle suggest their own remedies. To avoid the
first, the anastomotic opening should be made
larger ; to avoid the second, it should be placed at
as low a part of the stomach as possible ; two de-
siderata which were already mentioned in the
description of the operation. To meet the third con-
dition, that of a well open pylorus, it has been pro-
posed to close the pylorus artificially by a ligature
tied around it. A certain way, however, of pre-
Fic. 8. — Enteroenterostomy added to gastroenterostomy to pre-
vent vicious circle.
venting this complication is to establish an anas-
tomosis between the proximal and distal limbs of
the loop used for gastroenterostomy (Fig. 8). Or
else, as Roux prefers, we may divide the intestine
completely at the place chosen for anastomosis, im-
January i8, 1908. J
TOREK: SURGERY OF GASTRIC DISEASES.
99
planting the distal end into the stomach and the
proximal end, by an end to side anastomosis, into
the intestine below the gastroenterostomy opening
(Fig. 9). The former of these two methods, being
Li
Fig. 9. — Roux's method to prevent a vicious circle. The intestine
is divided completely; the distal end is implanted into the stomach,
the proximal end into the distal portion of the intestine.
the easier to perform, is the one preferred by most
surgeons.
To perform posterior gastroenterostomy the pos-
terior wall of the stomach is exposed by turning
upward the transvere colon and dividing the trans-
FiG. 10. — Finney's operation, modified, showing the use of the
three bladed clamp. The first portion of the seromuscular suture
has been inserted, the organs are shown incised, ready for the
deep through and through suture.
verse mesocolon at a place where the vessels can
be avoided'. In this way the stomach is exposed.
As for the jejunum, instead of selecting a place
about eighteen inches from the duodenojejunal fold,
a place as high up as possible is chosen, so that prac-
tically the short piece of jejunum above the anasto-
mosis does not form a loop at all, but lies close up
against the stomach. If, in posterior gastroenteros-
tomy, this method is adopted and a sufficiently large
opening is established, the vicious circle is effec-
tually avoided. The technique of the operation is
the same as in anterior gastroenterostomy ; but after
the anastomosis is completed, the divided mesocolon
should be attached by a few stitches to the intes-
tine. This serves a double purpose; first, it affords
an additional cover over the suture uniting stomach
Fig. II. — Stump of stomach after pylorectomy. The stomach has
been closed by suture except at its lowest part where the duodenum
is to be joined to it.
and jejunum, and secondly, it prevents the possibi-
lity of an internal hernia through the mesocolon.
Although I have described the operation of an-
terior gastroenterostomy first and more extensively
than posterior gastroenterostomy, I must state that
the latter is my choice and that of most other sur-
geons, for it enables one better to reach a deep
portion of the stomach than the anterior operation,
and the possibility of pressure of the jejunum and
the transverse colon on each other is avoided. It
may, however, be impossible to perform posterior
gastroenterostomy owing to extensive infiltration of
the posterior wall of the stomach through car-
cinoma or otherwise. Again, posterior gastroen-
terostomy may be very difficult if the stomach is
small and the posterior surface therefore cannot
OREK: SURGERY OF GASTRIC DISEASES.
be thoroughly brought forward. It is easy of per-
formance if the stomach is dilated. The operation
of posterior gastroenterostomy will therefore be
found simpler if performed to relieve pyloric ob-
struction than if performed for gastric haemorrhage
without obstruction.
Kocher's gastroduodenostomy must also be men-
tioned as a method of anastomosis between stomach
and intestine. It has the advantage of using the
highest possible portion of the intestine for anasto-
mosis. It should not be performed if there is in-
filtration or immobility of the pylorus or duodenum.
It is also apt to be unsatisfactory in cases of ex-
treme dilatation with atony, because in those cases
Fig. 12. — End to end union of duodenum to stomach after pylorec-
tomy with the -aid of the three bladed clamp. The deep portion of
the seromuscular suture has been inserted.
the anastomotic opening may be considerably higher
than the greater curvature, and drainage would
therefore be imperfect.
The operation for pyloroplasty is much less prac-
tised than formerly, as the functional results are not
as satisfactory as those of gastroenterostomy.
Pyloroplasty should not be performed if the pylorus
is infiltrated or fixed. Of the various methods the
best is Finney's operation, which affords a large
opening, the incision extending so well into the
.stomach and the duodenum that the operation might
well be classed as a gastroenterostomy. Fig. lo
represents a modification of Finney's operation
showing the use of the three bladed clamp. The
first portion of the seromuscular suture has been
made, and the incision into the organs is shown.
[New York
Medical Journal.
ready for insertion of the deep suture through all
the layers.
Resection of the stomach is practised mainly for
the removal of carcinoma and most frequently con-
sists in an excision of the pyloric portion of the
stomach, pylorectomy, much more rarelv of an ex-
cision of other parts of the stomach. 'The condi-
tion which ofl^ers a chance of success is that the
growth is circumscribed; the size of the tumor is
less important. A case of successful removal of a
carcinoma of the pylorus that was large enough to
be distinctly seen through the abdominal wall, which
I reported (Medical Record, June 6, 1906), is an
instance to show that even a large tumor may be
favorable for excision if only it is circumscribed.
This latter point we will often be unable to de-
termine before the abdomen is opened.
The operation is performed as follows : A short
Fig. 13. — Next step after Fig. ]2. Tlirough and through mat-
tress suture. The thread is armed with a needle at each end. .At
the lower portion the corner is being turned.
median epigastric incision is first made for diagnos-
tic purposes. It may appear after opening the peri-
toneal cavity that a resection is impossible. If we
decide to do nothing, the incision is closed again.
If a gastroenterostomy is decided upon, the incision
is lengthened to four or five inches, and if we de-
termine to perform a resection, it may be necessary
to lengthen the incision to six or eight inches. In
that case, the incision is prolonged downward into
the mesogastrium by either going around one side
of the umbilicus or by excising it. The pyloric
portion of the stomach is drawn well forward, and
the extent of the tumor, the extent to which the
lymphatic glands are affected, and the intimacy of
the adhesions are ascertained. At this time the
(juestion has to be decided whether it will be pos-
sible, after resecting amply in healthy tissues, to re-
unite the duodenum with the stomach without caus-
ing undue tension. If this is possible, then Bill-
roth's first method or Kocher's method is performed.
If it is not possible, the duodenum and the stomach
are closed by suture, after the resection has been
TOREK: SURGERY UF GASTRIC DISEASES.
done, and a gastroenterostomy is performed. A
weak point in this latter method of operating is the
suture closing the duodenum. It has not infre-
quently been found that the stomach contents, dis-
charged through the anastomosis, have in part
flowed into the acsending loop and caused so great
a degree of tension that the suture at the duodenum
was not able to withstand it. At any rate, notwith-
standing the assertions of some that the suture is
a safe one, peritonitis due to leakage at the duodenal
suture has been found at autopsies. The accident
could probably always be avoided if an enteroen-
terostomy between ascending and decending loops
were made. According to Mikulicz, the safest
closure of the duodenum is by a purse string suture.
Let us assume that the duodenum and stomach
can be united after resection ; and this is possible
in most cases that are at all suitable for resection,
■especially if we follow Kocher's method of mobiliz-
ing the duodenum by incising the posterior parietal
p"eriton?eum over the right kidney in a line parallel
Accordingly, the duodenum should be resected at a
distance of one inch from the tumor, the stomach
about two to four inches from the tumor, depend-
ing upon the greater or less sharpness with which
the border of the tumor is defined. To prevent the
outflow of the contents of the stomach or intestine,
appropriate clamps are applied at a distance of
about an inch beyond the proposed site of the re-
section at the duodenum and stomach. The clamps
are to compress the organs just sufficiently; they
should not crush the tissues. The ends of the re-
sected portion are also closed by clamps, before the
division is made. The excision having been per-
formed, the stomach is closed again by sutures, ex-
cept at its lowest part, where the duodenum is to be
united to it (Fig ii).
This suture consists of two rows. The inner row,
a continuous silk suture, is applied from within,
beginning at the lesser curvature, going through
all layers and inverting the cut borders, so that
serous coat is in contact with serous coat. The outer
Fic. 14. — Kocher's method of pylorectomy. A continuous mattress suture is applied behind the closed clamp.
to the descending portion of the duodenum, about
one inch to the right of it. Billroth's first method,
modernized, is performed in the following way :
The gastrocolic ligam.ent at the greater curvature
and the lesser omentum at the lesser curvature are
tied oft' and divided to the desired extent, that ex-
tent being determined by the distribution of the
tumor and the involvement of the lymphatic glands.
At the lesser curvature the lymphatic glands are
distributed far up, so that here the resection must
be made quite near to the cardia. In the course of
this step of the operation the main arteries are tied,
viz., the gastric and pyloric above, and the ri^ht and
left gastroepiploic below. Instead of the right gas-
troepiploic, occasionally the gastroduodenal is tied.
The greater and lesser curvatures have now been
liberated, after which the tumor, with the adjacent
parts of stomach and duodenum, i. e.. the part that
is to be resected, is loosened completely around. The
duodenum must be thoroughly liberated.
As a rule, the border of the tumor is quite sharply
marked at the duodenum, less so at the stomach.
row is a seromuscular Lembert suture, likewise
continuous, which still further inverts the stomach
at its cut border and. like the first row, extends
from the lesser curvature to the part which is left
open. This open portion is then united to the
duodenum in a similar manner by two rows of
sutures, the inner one applied from within and
going through all layers, the outer, a seromuscular
suture. The suture is best applied in the same
manner as that described for gastroenterostomy :
in fact, if desired, the three bladed instrument may
be employed (Fig. 12). First, the posterior sur-
faces of stomach and duodenum are united by a
seromuscular suture : then a mattress suture through
all layers unites the divided ends, the same as in
gastroenterostomy (Fig. 13) : finally, the seromus-
cular suture which was first applied" is continued on
the anterior surfaces of the stomach and duodenrm.
The insertion of the seromuscular suture necessi-
tates the invagination, to a slight extent, of the
duodenum into the stomach. As the stump of the
stomach is funnel shaped, while the duodenum is
I02
TOREK: SURGERY OF GASTRIC DISEASES.
[New York
Medical Journal.
cylindrical, there will be a somewhat greater ex-
tent of serous surface on the stomach after invag-
ination than on the duodenum, a condition which,
on inserting the seromuscular suture, may occasion-
ally require a plication of the stomach at some place.
Instead of the suture a Murphy button may be used
to unite duodenum and stomach.
Kocher's method of uniting the duodenum with
Fic. 15. — Next step after Fig. 14. An over and over suture is
placed over the mattress suture.
the stomach is to close the stomach completely and
make an end to side implantation of the duodenum
into the posterior wall of the stomach. The stomach
may be closed in a manner similar to that outlined
in the foregoing description of Billroth's first
method ; Kocher, however, prefers to make the
closure as follows : Both stomach and duodenum
are divided between clamps applied so tightly that
they crush the tissues, the division being made as
close as possible to the clamp attached to that part
of the organ which remains. The tight hold which
the clamps have on the organs facilitates handling
these. The stomach is then sewed up by a con-
tinuous mattress suture applied behind the closed
clamp (Fig. 14). Then the clamp is removed,
while the suture is held on a stretch by making trac-
tion at each end of it; the edges, especially the
mucosa, are trimmed, if necessary, and an over and
over suture is superimposed ov.er the first one (Fig.
15). This closes the stomach securely. A third
row, a continuous seromuscular suture, then com-
pletely buries the preceding, ones. Now, the duode-
num, still firmly closed by a tightly holding clamp,
is brought into apposition with the posterior wall
of the stomach and united with it by sutures in-
serted in a manner similar to that described for
gastroenterostomy. Before opening the stomach
and duodenum to apply the through and through
suture, the outflow of intestinal and stomach con-
tents must be guarded against. This is done, ac-
cording to Kocher, for the duodenum by a gently
compressing clamp or a ligature; for the stomach
by the use of a clamp or the assistant's hands. An-
other way is with the use of the three bladed in-
strument as described for gastroenterostomy, which
grasps in one of its clamps the duodenum in its
entire circumference, in the other clamp that seg-
ment of the stomach which is to enter into the an-
astomosis (Fig. 16). The clamp that closes the end
of the duodenum is removed by closely cutting off
the duodenum behind its grasp. The through and
through suture is then inserted from the mucous
membrane side, and over this comes a seromuscular
suture, the continuation of the first one inserted.
In this operation, the same as in gastroenterostomy,
Fig. 16. — Anastomosis of end of duodenum with posterior surface
of stomach after pylorectomy. The three bladed clamp is em-
ployed. The posterior seromuscular suture has been inserted. The
clamp tliat closed the end of the duodenum has been removed by
cutting oflf the duodenum behind its grasp. The incision into the
stomach has been made.
it is of the utmost importance to be conscious at
what stage the operation ceases to be strictly asep-
tic. Accordingly we protect the peritoneal cavity
carefully by gauze before the gastroenteric tract is
opened. We must also understand that hands and
instruments used at this part of the operation are
not sterile, and that, when the alimentary tract is
closed again, they must not be used at the subse-
quent clean part of the operation without being re-
sterilized. When the intraperitoneal work is com-
KIVLIN: VARICOSE VEINS.
103
pleted, the abdominal wall is closed without
drainage.
Excision of the entire stomach has been per-
formed. It is rare to find a case suitable for this
operation, for in cases where the stomach is so ex-
tensively involved as to require its entire removal
that operation would, as a rule, do no good owing
to the involvement of other organs.
Excisions of parts of the stomach other than the
plyoric portion is indicated in cases of localized
carcinoma and in some cases of ulcer. The exci-
sion in those cases is also performed with the aid
of clamps, and is shaped, if possible, so that the
closure may be made by a linear suture, as any com-
bination of sutures meeting at an angle is less re-
liable.
Of the remaining operations upon the stomach,
the most important is gastrostomy, the construc-
tion of an abdominal gastric fistula. This operation
is performed for obstruction in the oesophagus,
either benign or malignant, and the gastric fistula
Fig. 17. — Diagram of Roux's raethou .if se|iaiatiii- a ImO|i of jeju-
num to replace the oesophagus.
which is established will be either temporary or
permanent, according as the cause of the obstruc-
tion is removable or not. The formation of an
oblique fistula according to Witzel, and of a direct
one according to Kader, are the two methods used
most frequently. They consist essentially in a pli-
cation or an inversion of the wall of the stomach
upon itself in such manner that a canal lined by the
serous coat of the stomach is formed. Whereas for-
merly, after this canal had become firmly united
with the abdominal wall, it was the custom to re-
move the tube and introduce it only for purposes
of feeding, it is now left in situ, as the gastric fis-
tula proved to have a tendency to close, and some
difficulty was frequently experienced in reintroduc-
ing the tube.
One of the most interesting operations for es-
tablishing a new access to the stomach for intro-
ducing food is one which Roux performed upon
animals, viz., to excise a portion of jejunum hav-
ing a long mesentery to which it remains attached.
The anal end of the excised portion is implanted
into the stomach while the oral end is carried under-
neath the skin of the thorax up to the neck, where
it is brought out, the intention being to unite it with
the oesophagus by a subsequent operation (Fig. 17).
The ends from which the jejunal loop has been re-
sected are, of course, united with each other. Roux
ligated a few of the vessels in the mesojejunum to
secure greater mobility, preserving, however, the
peripheral arches, and found that the jejunum re-
mained sufficiently nourished. A stomach tube is
introduced through the transplanted intestine into
the stomach. It is evident that the method is ap-
plicable only under very favorable conditions as to
the vascular supply of the jejunal segment.
When we look over the progress that has been
made in the surgery of the stomach during the last
few years, we find that it consists mainly in an
elaboration of certain details in the technique, in-
cluding improvement in the construction of certain
instruments. Improved technique helps us to guard
our asepsis still more strictly and also enables us to
employ the suture much more frequently, where for-
merly we preferred mechanical appliances like the
button. It is, therefore, in this branch of surgery
the same as in all other branches, the attention to
minute details which is responsible for a great part
of the progress made in the art and the improve-
ment in the results achieved.
59 East Sixtieth Strekt.
VARICOSE VEINS.
Their Treatment by Multiple Sfiort Incisions*
By C. F. Kivlin, M. D.,
Troy, N Y.
Dilated and tortuous veins are spoken of as vari-
ces, or varicose veins. This abnormal condition is
dependent in some way upon an interference with
the flow of blood in the veins. Thus gravity plays
its part, since the trouble is most common in the
veins of the legs and since it is most often seen in
tall people than in short ones. Age and disease of
the heart, producing imperfect valvular action, are
also potent factors. The change is not due to the
atrophy of old age, as it is usually noticed before
the fortieth year, and in a great many instances be-
fore the twenty-fifth year. It is equally difficult to ex-
plain why the veins of one leg should be much dilated
and tortuous while those of the other are scarcely af-
fected, or why in certain persons the large veins are
chiefly affected, and in others the smaller radicles
in the skin. As muscular contraction and muscular
relaxation constitute the chief aids to venous flow, it
is not surprising that persons who are obliged to
stand for hours at a time (washerwomen, car mo-
tormen, etc.) suffer more from this trouble than
those who are constantly changing their positions.
While any of the veins of the lower extremity may
be affected, the trouble is most often found in some
*Read before the Rensselaer County Medical Society at meeting
held on May 14. 1907-
I04
Kir LIN: VARICOSE VEINS.
[New York
Medical Journal.
of the radicles of the internal saphenous vein. The-
tortuous and dilated vessels are easily recognized on
inspection, and if they lie near the surface their blu-
ish color is visible through the skin. If they are not
or have not been inflamed, they collapse under mod-
erate pressure and disappear almost entirely when
the foot is elevated'. In some places their channels
through the skin feel Hke a break in its continuity ;
Fir. I.- — Multiple incisions over interna! saphenous, and one lateral.
while here and there they lie so near the surface that
they seem to be covered with little more than epi-
thelium. The deep veins of the leg may be affected
as well as the superficial ones. If the dilation goes
on to a still greater degree a distinct, thin walled sac
filled with fluid blood is formed.
A.S a result of the dilation many of the valves be-
come insufficient. This can be tested in the follow-
ing manner : After the veins of the lower extremi-
ties have been emptied by elevation of the foot and
stroking the limb toward the body, the thumb is
placed upon the main saphenous trunk, and the pa-
tient is directed to stand. The varicose veins will
fill slowly and only to a moderate degree. The mo-
ment the thumb is removed the column of venous
blood falling into them from above instantly distends
them to their fullest capacity if the valves are in-
competent. Such are the conditions of simple vari-
cosity. Sooner or later one or more complications
are likely to arise, such as thrombosis, rupture, peri-
phlebitis, oedema, eczema, and ulcer.
Complications. — Thrombosis may occur in dilated
veins of the leg, exactly as it may occur in the di-
lated vein- of an external h?emorrhoid. It is accom-
panied by a good deal of pain and tenderness, by
slight redness, and by oedema plainly limited to the
immediate vicinity of the vein involved. Thus if a
not very tortuous vein 's affected for a distance of
five or six inches, its course can be accurately
mapped out as an indurated strip about three fourths
of an inch wide. If the vein is tortuous, the indu-
rated area will have an irregular outline. The nutri-
tion of the parts drained by varicose veins is often
seriously affected, so that a wound may becon^e in-
fected. The result may be erysipelas, cellulitis, ab-
scess, or suppurative thrombophlebitis, although the
last mentioned condition is by no means common.
When the vein lies near the surface it is casilv rup-
tured by a blow from a sharp object, and, as there is
little elastic tissue about the opening, the hremor-
rhage is profuse and may be serious if it is not
stopped by pressure or ligation. A fourth compli-
cation, more often seen in older individuals, is an
extensive oedema. At first this is of the usual t\pe,
revealing itself by pitting on pressure ; but after it
has existed for many months the production of
fibrous tissue may be sufficient to prevent much in-
dentation on pressure: This condition may be due
to other causes than varicosity of the veins ; it great-
ly interferes with nutrition of the parts and espe-
cially with the repair of a chronic ulcer, whether
varicose or not. Eczema is another complication
due to an imperfect nutrition, which is apt to lead
to ulcers starting in the small scratches made by the
patient in the vain attempt to relieve himself from
the intolerable itching.
Not every ulcer occurring in a patient whose veins
are varicose is to be attributed to such varicosity. A
long standing ulcer of the leg of a nonmalignant,
nonsyphilitic, nontuberculous character is better
spoken of as a chronic ulcer. It may be the direct
or indirect result of varicose veins, but it may also
be due to traumatism or eczema or oedema or anae-
mia. It is misleading to call all such ulcers varicose
ulcers. They are all due to poor local nutrition, of
which varicosity of the veins is simply one cause.
When varicose veins have existed for a consider-
able length of time there will often be noted a brown
pigmentation of the skin, occurring more or less in
patches, and due either to small subcutaneous rup-
tures of the venous radicles or to transudattion of
red blood cells through the dilated venous walls. In
either case the blood pigment becomes permanently
fixed in the fibrous tissue of the skin, giving it a
characteristic yellow brown color.
Symptoms. — Varicose veins often give rise to no
symptoms whatever. Such is apt to be the case in
young and healthy persons, and also when the veins
are dilated throughout a small area. The symptoms
in uncomplicated cases are : A sense of weight and
more or less dull aching relieved by elevation of the
affected extremity. The symptoms of thrombosis
are : Marked tenderness on pressure, acute local
pain, which is considerably, but not wholly, relieved
by a recumbent position, and a rise of temperature
of one, two, or three degrees. The symptoms of
Fic. 2. — Same patient, left leg.
the inflammatory complications mentioned are such
as accompany these processes wherever the\- occur
in the body.
Diagnosis. — The diagnosis of varicose veins and
of the different complications which I have enume-
rated is easy for any one who is able to recognize
January i8, 190S.I
Kll'LlN: VARICOSE VEINS.
the different forms of inflammation and ulceration.
The inflamed strip of a varicose vein is broader than
that of infection in a lymph vessel, and the overly^
ing skin is not so red. A sharply localized varix
can hardly be mistaken for any sort of a cystic
growth, as it is so collapsible on pressure, refills
slowly, and has less tension than most cysts. It doe^
not pulsate like an aneurism.
T rcatment. — Palliative treatment of uncomplicated
|.-,c. 3. — Showing incisions ever internal saphenous and incision for
colateral on pcsterior portion of the leg.
varicose veins consists in attention to the general
health ; in the avoidance of such occupations and
such clothing as tend to interfere with the venous
flow: in the "elevation of the feet as much as possi-
ble when the patient is sitting down, and in the wear-
ing, during the day time, of an elastic bandage or
stocking extending from the toes to the knee. Even
though the varicose veins extend well into the thigh,
firm compression of the leg will usually relieve the
symptoms, and it is difficult to apply a stocking or
bandage with comfort above the knee joint.
A woven elastic, cotton or silk web stocking costs
from $2.50 to $8.00. Its advantages are the ease
with which it may be applied and the firm pressure
which it exerts when new. A thin white lisle thread
stocking should be worn next to the skin to protect
the elastic stocking from perspiration. With the best
of care an elastic stocking loses its tone in a few
months, so that the expense is no inconsiderable item
for a poor person. Various kinds of elastic stock-
ings have been devised, such as pure rubber, rubber
webbing, cloth webbing, stockinette, etc., but noth-
ing is more satisfactory than pure, coarse, white
flannel cut on the bias in strips about three inches
wide, a sufficient number of which are sewed to-
gether to make a bandage six or eight yards long.
Such bandages can be washed and ironed as often
as they become soiled, and they will last a long time.
They should be applied before the patient gets up in
the morning. In the beginning this is considerable
trouble, as it is by no means easy to bandage one's
own leg. But most patients soon learn to apply them
in five or ten minutes, and many put them on as
neatly as a professional could hope to do. No one
who has once become accustomed to apply such,
bandages would w illingly exchange them for an elas-
tic stocking, since he can always regulate the pres-
sure according to his own comfort, aside from the
fact that they are cleaner and cheaper.
The radical treatment of varicose veins may be
(i) their multiple ligation, either subcutaneously or
through short incisions; (2) the excision of portions
or of the whole of the dilated veins ; or (3) the dou-
ble ligation of the saphenous vein at its entrance
into the femoral. The injection of substances to
produce clots in the veins
The method of treatment which the accompanying
photographs show is an original operation so far as
I have been able to ascertain, and my only object in
reporting the procedure at this early date is to have
the good or poor c|ualities thrashed out by the pro-
fession, because it is only with an abundance of cHn-
ical proof or postoperative results, good or bad, that
any definite conclusions may be established. The
operation consists of several short incisions starting
about two and a half inches below the knee joint,
more definitely at a point directly over the internal
saphenous vein, where two large laterals are gener-
ally to be found. Cutting down an inch or two in
length, the lateral ligated and liberated, the miin
vein pulled up pncl pulkd upon, ancl where the laL-
eral is given off above or below I u^u illy proceed
upward, the skin will tighten, and with close obser-
vation will show a slight wrinkling. Having thus
determined the lateral, another small incision is
made. The lateral is liberated and the vein picked
up ; this step is proceeded with as far up as it seems
expedient to go. The vein is tied both proximately
and distally. and cut between the two ligatures ; then
going to the next opening lower down, pulling on
the main trunk gr:' dually till it gives wa\' and comes
out free in the (jpeiiing, ihus pulling through subse-
quent openings until the original opening is arrived
ac. Then the step of palling, locating, and ligating
the laterals below the original opening is done as
described for locating and ligating the original open-
ing. When you have proceeded as low as you wish
you simply keep on pulling the vein through till the
lowest opening is reached. When vou have, by sev-
Fic. 4. — Showing incision above and below the knee joint. The
hinge portion of the joint free from scar tissue.
eral small incisions, delivered the entire length of
the vein intact, if any large collaterals need to be re-
moved— and there are usually some — the same prin-
ciple can be and is applied, as shown in photograph
of those incisions awav from the main vessel.
Conclusions. — What is alleged for the operation
is this : It does not take so long to do the opcr?tion
as it does with other operations where the vein is
removed, that it is not so apt to become infected, and
if one incision becomes infected it can be dealt with
LA PIERRE: SARCOMA OF KIDNEY.
[New Vokk
Medical Jolrnal.
more readily and without infecting the others. There
is no scar tissue at the knee joint, tnereby causing
no pain nor limping while walking. There is prac-
tically no blood lost, especially none from the main
vein ; what little blood is lost is from the skin. Con-
valescence is much shorter, a week to ten days' time
being sufficient for the patients to stay in bed ; they
should be up to work by the end of two weeks. But
if it is a case where it was urgent for them to be
back to business, three to five days would be suffi-
cient for to stay in the hospital before returning to
light work. The convalescence is painless and une-
ventful. The style of closure is either interrupted
or continuous. I believe, however, that the continu-
ous silk suture is the best closure.
1826 Fifth Avenue.
A CASE OF SARCOMA OF THE KIDNEY.
By L. F. La Pierre,
Norwich, Conn.
Sarcoma of the kidney is not a common disease.
Many general practitioners of wide experience have
seen only a few or no cases.
The case reported in this paper was diagnosticated
at autopsy, no symptoms relating to the kidney be-
ing noted during life.
About 80 per cent, of sarcoma of the kidney occur
during the first four years of life.
The aetiology is unknown. There are often no
symptoms until the tumor is considerably advanced.
This early period is spoken of as the latent stage of
the disease.
Tumor, haematuria, pain, and cachexia are the
usual prominent symptoms. Later occur emacia-
tion, irritability of the bladder, oedema, jaundice, in-
digestion, constipation, and dyspnoea. All writers
agree that tumor is usually first noted and is the
most constant symptom. Palpable tumor is found
at some time during the disease in 96 per cent, of
cases. It is usually discovered in the loin, but grows
forward toward the median line.
Sometimes it is necessary to give an anaesthetic to
palpate the growth, and it can be felt best by the bi-
manual method. These tumors give rise to a full-
ness, resistance, and roundness in the ileocostal
space. The surface depends upon the nature of the
tumor. It may be lobulated, irregular, or smooth
and firm. In the more malignant round celled forms
it is so soft as to give the sense of fluctuation. It is
movable, but attached posteriorly. The progress of
the growth is often very rapid, so that it may fill the
abdomen in a few months. When this stage is
reached the abdomen may be greatly enlarged, and
presents a peculiar appearance. The veins in the
abdominal wall are distended, the bowels are pushed
to one side toward the median line, except the colon,
which remains in front of the tumor. The colon is
sometimes so tensely distended with gas as to be dull
on percussion. In this extreme condition the child
stands like a pregnant woman.
One author states that tumor was present in 129
out of 133 cases; another in 61 out of 64 cases.
Haematuria is another important symptom, and
occurs in about half of the cases. It occurs when
the tumor has entered the pelvis of the kidney, is
more profuse than in stone or tuberculosis, and is
observed, as a rule, at the beginning of the disease.
It rnay be steady for months or remittent, and final-
ly disappear altogether. The amount of blood passed
may be large and profuse enough to cause death.
Sometimes the blood is voided as clots, which show
as moulds of the ureter or even the pelvis of the
kidney.
It is stated that the haematuria is not diminished
by rest in bed, as is the case with calculus. In some
cases the amount of blood passed is small and is dis-
covered only with the aid of a microscope. Seibert
states that in nineteen out of fifty cases it was ob-
served before the tumor. Certainly haematuria oc-
curring in children under seven years of age should
arouse strong suspicions of renal tumor.
Pain is often absent, is not characteristic, and is
not influenced by movements or pressure. Renal colic
is sometimes caused by coagula or pieces of tumor
obstructing the ureter. In general the harder the
growth the more severe the pain. In children the
growths are usually soft, hence they are usually free
from pain. The pain when present extends to the
lower dorsal or lumbar region and dOwn the thighs.
This is due to the growth extending toward the
spinal column.
Constitutional symptoms are rare until the tumor
has attained a large size. Sometimes, however, as
in the case which I report to-day, generalization may
occur early, when a marked anaemia appears with
rapid emaciation.
Pressure effects are dyspnoea, oedema of the lower
extremities, vomiting, and indigestion.
The growth may soften and break down, ruptur-
ing into the colon, duodenum, or ureter through the
peritonaeum or abdominal wall.
Some cases present an irregular temperature after
the growth is well advanced. They waste steadily,
death finally taking place from exhaustion. Varico-
cele is a symptom in some cases, and is of little im-
portance when on the left side, as it may be normal,
but becomes suggestive when on the right side.
If the tumor is not removed early the patient is
sure to die. He grows progressively weaker as the
tumor increases in size. The duration is variously
stated from three months to two years. Death has
occurred within six weeks. The softer the tumor
the more malignant its character, quicker the
growth, and earlier the end.
As already stated, the presence of haematuria in a
child under seven years of age is suggestive of tu-
mor of the kidney. In early diagnosis lies the only
hope of saving the child's life. In cases without
haematuria the tunjor is the first indication. Rela-
tively small tumors can be palpated in children, be-
cause the subdiaphragmatic space is flat and small
and the kidney less firmly fixed. The conditions to
be considered in the diagnosis are tumors of the
liver, ovary, spleen, retroperitoneal tumors, hydro-
nephrosis, haemophilia, tuberculosis, and stone.
The only treatment is surgical, and in an early
diagnosis lies the only hope of saving the patient's
life by operation.
The primary object of this paper was to report
the following case :
The patient was a female child, fourteen months of age.
Both parents were living in good health, and were de-
scendants of old Connecticut families. The maternal grand-
mother died of tuberculosis, and the maternal great grand-
January iS, igoSI
LA PIERRE: SARCOMA 01- KIDXEY
107
father committed suicide. Otherwise the family history was
negative, there being no further history of tumor, insanity,
or neurosis.
This child was one of three children, and was third in
order of birth. Previous to the present illness she had al-
ways been in good health, being stronger and healthier
than the other children.
February 11, 1907. — During the night the child had had
Fig. I. — Secondary tumors.
a convulsion. A physician was called, and the usual treat-
ment was administered.
February 12, 1907. — Two more convulsions to-day.
February 13, 1907. — Child appeared perfectly well.
February 14, 1907. — Child continued to be well, was
strong and well physically ; no convulsions since the 12th.
April 5, 1907. — The child was brought to physician's office
to-day. It had continued to be well since previous note.
To-day a slight swelling was noted about the outer canthus
of the left eye, extending horizontally backward into the
temporal region. Skin was discolored, and the swelling
had the appearance of a bruise. There was no tenderness
or pain. Temperature was normal. Left eyeball appeared
slightly more prominent than the right. Child was con-
tented, very well nourished, but somewhat anaemic.
April 12, 1907. — The swelling as described increased
steadily and fairly rapidly. Left eyeball had become more
prominent. There was a marked swelling of the tissues
covering the right alveolar process of the superior maxillary
bone. These tissues were spongy and bled easily.
April 14, 1907. — Teeth in the last named mass became
loose and were removed easily to-day. Temperature con-
tinued normal.
April 17, 1907. — All masses were rapidly increasing in
size.
May I, 1907. — Patient had been seen frequently during
past two weeks, and both local and general condition had
grown progressively worse. It was as follows : There was
a marked exophthalmus of the left eyeball. The palpebral
fissure was much increased. The conjunctiva was subject
to an inflammatory process and bathed in a mucupurulent
discharge. The cornea was steany and opaque. Tlie
anterior chamber was partly filled with pus. The pupil
was dilated and immobile. There was a sausage shaped
mass which extended from the outer canthus of the left
eye posteriorly and horizontally. Upon palpation this mass
was smooth, elastic, gave a distinct sense of fluctuation.
Heat, redness, pain, and tenderness were not present. Both
cheeks were abnormally prominent, this being more marked
upon the right side. This made the bridge of the nose ap-
pear depressed. The tissues covering the alveolar pro-
cesses of the superior maxillary bone were greatly in-
creased, especially upon the right side, the surface upon
this side having already commenced to slough. The jaws
cannot be closed, and saliva drools from the mouth. (See
Figs. I and 2.)
Nourishment was taken greedily, but with difficulty.
There were no enlarged glands, and nothing abnormal was
noted in the chest or abdomen upon a rather careless ex
amination. Temperature, 100° F. Child was failing physi-
cally, and was very pale and sallow ; it was restless and
fretful. The urine was not examined microscopically,
but appeared normal. Examination of a stained blood
smear was as follows : The red blood corpuscles were
ring like, stained faintly, and in an irregular manner, show-
ing a fairly well marked polychromaphilia. In size there
was also a marked variation, there being numerous very
small and very large corpuscles.
May 4, 1907. — The various growths continued to increase
in size since last seen. The child died from exhaustion
to-day, after an illness of one month.
May 6, 1907. — Autopsy nineteen hours after death. Body
of a fairly well developed, but poorly nourished child. In
the left temporal region was noted an elongated tumor.
Its anterior end was at the outer canthus of the left eye,
and extended posteriorly in a horizontal direction. It was
five and a half inches in length and two inches in width.
The upper border was represented by a line drawn hori-
zontally backward from the left eyebrow ; the lower border
by the zygoma and a line continued horizontally backward.
In the region of both cheeks below the malar eminences
were tumors the size of a plum. All of these tumors were
soft, elastic, and when palpated gave a sense of fluctuation.
The skm was freely movable over them, but they were
Fig. 2. — Secondary tumors.
loosely adherent to the bone. The skin over the tumors
appeared normal. In the frontal region over the glabella
a small almond shaped swelling was noted. In the mouth
the tissues covering the alveoli and hard palate were enor-
mously increased, the surface was sloughing and haemor-
rhagic in some areas. This swelling was so extensive
that the jaws could not be closed, and the tongue pro-
truded.
Both eyes were exophthalmic, this, however, being more
marked of the left eye. which was at least three quarters
io8
STL RMDORF : McBURNEY'S POINT.
[New York
Medical Journal.
inch anterior to its usual position. The palpebral fissure
of the left eye was increased, and there was a mucopuru-
lent discharge in the eye. There was a small opening one
eighth inch long at the lower margin of the cornea. The
anterior chamber was obliterated, the iris was in contact
with the cornea and the pupil was widely dilated. The
cornea was steany in appearance. The upper lid of the
right eye was ecchymotic, the pupil was moderately dilated.
The remainder of the body showed nothing remarkable,
except emaciation. The superficial lymphatic glands weie
not palpable in any situation.
Chest.— Both pleural cavities were free from fluid and
there were no adhesions. Both lungs were crepitant
throughout. The pleural surfaces of both lungs presented
elevated areas one or two millimetres in height, and from
a few millimetres to a centimetre in diameter. The larger
of these areas were dark red in color externally, and
smooth, the pleura glistening over them. On cut section
they were dark red, soft, and easily scraped away with a
knife.
The pericardial sack contained a small amount of clear
fluid. The heart was in systole and presented nothing re-
markable either externally or internally.
Upon removing the lungs there were noted ring like
enlargements surrounding the ribs, each rib being involved
to a varying extent. Upon examination these reddish
masses were found to be under the parietal pleura and
periosteum. They were dark red in color, soft, friable,
and, although intimately adherent to the bone, were easily
separated from it. They resembled the areas already de-
scribed in the lungs.
The peritoneal cavity contained a small amount of clear
fluid. The peritonaeum appeared normal.
Liver. — Upon the surface of the liver were areas from
a few millimetres to a centimetre in diameter slightly
raised above the surface, presenting a glistening, dark red
appearance. Upon section a few of these areas were noted
scattered through the liver substance. They presented the
same appearance ah-eady described in the lung.
Gallbladder was normal and filled w^ith bile. The spleen
and right kidney appeared normal upon the surface and
•cut section.
On the left side, in the region of the left kidney, was
found a mass. This when dissected out was seen to be six
inches in length and three and a half inches thick. The
•mass was soft and fluctuated on palpation. On cut section
it was found to consist of the kidney which had become
the seat of a new orrowth. The upper third of the kidney
could be distinguished and was fairly normal in appearance.
The remaining lower two thirds was so infiltrated with the
growth that the kidney structure could not be discerned
with the naked eye. The tumor mass contained a cyst
which contained about two ounces of dark red, groumous
fluid. The remaining mass was dark red in color, friable,
of varving consistence, some portions being semifluid,
while other areas were firmer. The whole tumor, however,
was so soft that it did not support itself after section was
made of it.
Head.— Incisions to open the head .began posterior to the
right ear, then upward across vertex to avoid incising
tumor. The anterior portion of the scalp was then drawn
forward over face, and it was noted that the scalp was
not adherent to the tumor, or rather tumors, in any of their
situations. The large sausage shaped mass upon the left
side, already described partially, was found to consist of
dark red, very friable tissue similar to that already de-
scribed in other organs. This tumor was intimately adher-
ent to the bone itself, the periosteum being raised over the
tumor. The bone under the tumor was soft, friable, and
porous.
In the region of the !,d,nbella another small mass was
noted, also in the right temporal region one of considerable
size, all being in consistency and relations to the skull
similar. , , „
The skull cap being removed, the dura was adherent,
hence requiring incision and removal with it. Opon ex-
amination a mass three and a half inches long, three and
a half inches wide and one and a half inches thick was
noted external to the dura matter, but firmly adherent to
it, and very firmly and intimately so to the adjacent bone op-
posite the mass already described on the left side externally.
The brain itself showed nothins^: ahnnrnril upon
the surface or iiiion section, except upon tlie left
hemisphere there was a depressed area, which was
due to pressure from the tumor.
Scattered about the vault of the skull in the same
relations to the dura and skull were smaller masses
from the size of an almond to a walnut. At least
one half of the area of the inner surface of the skull
was covered with these masses.
The horizontal portion of the frontal bone with
its periosteum, especially upon the left side, was ex-
tensively involved, the growth extending through
into both orbits. The globes of both eyes on section
were normal, the exophthalmus being produced by
the growth of the tumor between periosteum and
bone. The growth continued into the face, involving
both antrums, superior and inferior maxillary bones.
The nose and air passages were not involved. These
r.econdary . growths appeared to originate between
the periosteum and bone, the tumor in all cases sep-
arating the two structures.
Microscopically a section of the kidney showed a
reticulum which was scanty and partially supported
large masses of blood and small round tumor cells.
The reticulum was wholly incapable of furnishing
proper support to the tumor cells, which were of the
small round cell type, of fairly uniform size.
The secondary growths in the liver, lungs, ribs,
and skull presented essentially the same structure,
except there was less haemorrhage throughout the
specimens, and the reticulum was more prominent.
The growths all showed fairly uniform, small round
cells.
Anatomical Diagnosis. — Primary, round celled
sarcoma of the kidney, with numerous metastatis
growths in the skull, ribs, liver, and lungs. Com-
pression of brain. Emaciation.
Conclusions.
I. Sarcoma of the kidney may exist without symp-
toms.
IL Generalization may occur early, before the kid-
ney is greatly enlarged.
III. In this case the appearance of the anaemia
and rapid loss of flesh was coincident with its gen-
eralization.
IV'. In this case, had not a complete autopsy been
performed, a correct diagnosis would not have been
made.
THE CLINICAL SIGNIFICANCE OF McBURNEY S
POINT.*
By Arnold Sturmdorf, M. D.,
New York.
In an article, On Appendicitis, published in the
New York Mediccfl Journal, December 21, 1889,
Dr. McBurney wrote as follows:
The exact locality of the greatest sensitiveness to pres-
sure has seemed to me to be usually one of importance.
Whatever may be the position of the healthy appendix
as found in the dead house, and I am well aware that its
position when uninflamed varies greatly, I have found in
all my operations that it lay either thickened, shortened, or
adherent very close to its attachment to the caecum.
This, of course, must in the early stages of the disease
determine the seat of greatest pain on pressure, and I
believe that in every case the seat of greatest pain, deter-
mined by the pressure of oitc finger, has been e.ractly be-
•Rcad before the Section in Surgery of the New York .\cadciiiy
of Medicine, December 6, 1907.
January i8, 1908.] STURMDORF: McBURNEY'S point. 109
tween an inch and a half ^nd two inches from the anterior
superior spinous process of the ilium on a straight line
•flrawn from that process to the umbilicus.
This may appear to be an affectation of accuracy, but as
far as my experience goes, the observation is correct.
Thus announced, nearly twenty years ago, this
■diagnostic dictum, emanating so authoritatively
.and promulgated with such modest dogmatism,
found unchallenged general acceptance, which con-
tinues to dominate clinical discrimination in abdom-
inal disturbances to the present time.
Antedating the adoption of present day methods,
the introduction of McBurney's point marks an
epoch and a phase in the evolution of our mastery
over appendicitis ; nevertheless, while it served to
blaze the path through the mazes of earlier contro-
versies, it has proved an equally potent factor in
leading to error and fruitless nnUilation.
"History repeats itself" ; the accepted dogma of
yesterday becomes tradition to-day and merges
slowly into the obsolete of to-morrow.
McBurney's point, vested with pathognomonic
dignity for almost two decades, nuist be relegated
to the humble rank of a possible contributory diag-
nostic factor.
The pathognomonic validity of a given clinical
sign is proportionate to its constancy in the given
condition ; this essential postulate is not fulfilled by
McBurney's point.
While it is true to-day, as it was twenty years
ago, that a typical McBurney point may be pres-
ent in a typical appendicitis, it is equally true that
appendicitis may exist in the absence of a McBur-
ney point, and, most important, a typical McBurney
point may be present in the absence of appendical
involvement.
To speak concisely, there are three groups of
cases in which operative or post mortem findings-
bear directly upon the point under consideration.
In the first group, a frank appendicitis tends to
substantiate the pathognomonic validity of an exist-
ing McBurney point.
The second group embraces two types of appen-
dical lesion- — one, characterized by a most rapidly
fatal tendency; the other, projecting all of its symp-
toms upon the upper digestive tract, while neither
type manifects a McBurney point during any stage
of its progress.
The third group, the most extensive of the three,
consists of a heterogeneous class of cases that pre-
sent a typical McBurney point in the absence of any
appendical involvement whatsoever.
Any attempt to establish a clinical sign as an in-
dex for operative intervention should be based
upon a thorough understanding of the normal or
pathological physiology of its production.
Unfortunately, such fundamental factors relat-
ing to our knowledge of the sensory manifestations
in abdominal disorders are still undetermined ; nev-
ertheless, there is much information of an empyri-
cal nature, gleaned from the observations of Ross,
MacKenzie, Head, and others — on the distribution
and character of the pain in visceral disease — that
has not found general clinical utilization.
It would lead beyond the scope of the present
communication to attempt a detailed consideration
of these observations, consequently their fundamen-
tal bearings only will be touched upon.
Ross contended that in visceral disturbances pain
or tenderness radiated along the distribution of the
somatic nerves, springing from that segment of the
cord which supplies the sympathetic fibres to the
affected viscus.
Amplifying Ross's work, MacKenzie and Head
defined certain areas, each of which, it is stated,
corresponds to the cutaneous terminals of the pain
fibres, springing from that cord segment involved
by the disturbed viscus.
Whatever may be confirmed or refuted, in the
theory and practical application of these observa-
tions, they have established one clinical fact be-
yond controversy, namely, that any given point of
pai'- may be either the direct expression of a con-
tiguOi.s disturbance, or the transmitted manifesta-
tion of a distant lesion.
In other words, an existing McBurney point may
represent the direct pain focus of a disturbance
zvithin its ozun area or the reflected pain focus of a
distant lesion.
Thus far, then, we find in McBurney's point sim-
ply a clinical sign susceptible of two interpretations
and the problem of its distinctive definition natural-
ly presents itself.
A comparison of Head's instructions for the
demonstration of his "pain points," with those given
by McBurney, reveals two widely different meth-
ods, eliciting- two distinct and characteristic phases
of one and the same subjective sign.
Thus, Head insists upon the gentlest possible
tactile exploration of the cutaneous surface, speci-
fying that "the examination must be carried out
with a round pin head of such a size that it proves,
obviously bltint to all parts of one's own face, and
used in exactly the same manner as in testing for
analgesia."
Compare this most delicate palpatory excursioriL
of a blunt pin head over the cutaneous surface with
"the direct pressure of one finger," according to-
McBurney, and it follows that Head's method can;
elicit superficial areas of pain only, or — more cor-
rectly speaking— areas of superficial hyperalgesia,
while McBurney's method must of necessity elicit
indiscriminately both superficial and deep seated
pain points at the same time according to the in-
tensity of the pressure exerted.
Combining these two methods, by utilizing the
one as complemental to the other, it will be found
that there exist two McBurney's points, one super-
ficial and the other deep.
The superficial pain point, which for practical
purposes we will term the pseudo McBurney's
point, presents all the characteristics of Head's so
called "referred pain points," indicating a disturb-
ance beyond the limits of their own area, while the
deep or direct pain point, when present, will be
found to indicate a local disturbance within its im-
mediate vicinity.
It is not only this variation in the- level of the two
points, but also the marked contrast exhibited in the
character and radiation of the pain, as well as cer-
tain differences in the response of the local reflexes,
which offer distinctive criteria, distinguishing the
indirect from the direct pain focus.
An indirect or transmitted pain focus or pseudo
McBurney's point, as elicited by Head's method of.
no
STURM DORF: McBVRNEY'S POINT.
[New York
Medical Journal.
exploration, is practically a circumscribed area of
cutaneous hyperaesthesia, and, like all such areas, it
is characterized by heightened superficial reflexes
in the presence of apparently normal deep reflexes ;
by the simultaneous existence of concomitant
pain points, radiating backward and upward to-
ward the spine, most marked over the bony promi-
nences encountered in tracing the course of the in-
volved nerve trunks to their exit from the cord.
In the presence of the direct or deep pain focus,
on the other hand, the skin and subcutaneous tis-
sues may be pinched between finger and thumb with-
out eliciting any undue sensitiveness; the deep
muscle reflexes are exaggerated, even to the point
of tonic contraction ; concomitant pains, v -len
present, radiate dounnvard along the anterior
crural nerves and into the perinseum, but never up-
ward and backward.
As noted before, the cases in which operative or
post mortem findings bear directly upon the clinical
significance of McBurney's point resolve them-
selves naturally into three groups.
Applying the foregoing observations to the first
group enumerated, namely, the cases in which a
distinct involvement of the appendix would tend to
substantiate the pathognomonic significance of Mc-
Burney's point, the following is to be noted :
There will be found no superficial area of hyper-
aesthesia, according to Head's method, while deep
pressure, according to McBurney, will elicit a
focus of pain.
There will be present the familiar accompani-
ments, both local and general, of a deep seated in-
flammatory process.
Blumberg's sign is demonstrable in all these cases
— that is, when the appendicular inflammation is un-
accompanied by peritonitis, the deep pain focus in
McBurney's area alone is manifest ; with beginning
peritonitis, the recoil of the abdominal wall follow-
ing the sudden withdrawal of the examining finger
will prove more painful than the original digital
pressure.
The cases in this group represent the acute form
of the adhesive, exudative, or suppurative types of
appendicular inflammation, ^^.'ithout perforation or
gangrene, which latter conditions are found among
the cases of the second group.
This second group embraces two forms of the
disease, neither of which, during any stage of their
progress, present any distinct focus of pain in Mc-
Burney's area.
The first form represents the most rapidly fatal
types of appendicular lesion, presenting themselves
clinically as unfocalizable forms of profound gen-
eral sepsis ; the second form, on the other hand,
manifests but mild disturbances of the upper di-
gestive tract; this latter is the form described by
Ewald as "appendicitis larvata, or masked appen-
dicitis."
In the third group, the most protean, extensive,
and, from the present point, the most important of
the three, are found acute and chronic disturbances
of every degree and many kinds, linked by an ex-
isting McBurney's point over a normal appendix.
It is in this group that operative artefacts, re-
sulting from clamp and ligature applied to an un-
oflfending appendix, supply a pathological consola-
tion for misdirected surgical effort, while the true
source of the disturbance lurks somewhere between
the thorax and perinseum, anywhere but in the ap-
pendix.
In illustration it is but necessary to recall
the abdominal symptoms of thoracic disease, the
distension and the pain over the appendicular re-
gion resulting from right sided pleurisy, empyaema,
and pneumonia, McBurney's point frequently pre-
senting itself, while the physical signs of the
thoracic disturbance are still in abeyance.
Our understanding of the sensory manifestations
of visceral disorders is still incomplete ; neverthe-
less, it is fairly well established that the abdominal
organs are devoid of direct pain sense, and that the
pain of visceral disturbance is located in various
layers of the abdominal parieties.
According to Ramstroem, the lower intercostal
nerves and the lumbar plexus subserve the function
of pain conduction in visceral disorders.
These nerves, after supplying sensory fibres to
the superficial layers of the abdominal parietes, in-
tersect and combine to form a complicated ramify-
ing network between the internal oblique and trans-
versales muscles, dipping down at the edge of the
rectus sheath, they terminate in the parietal peri-
tonaeum.
In this arrangement all sensory manifestations
within the appendical area are dominated by the
iliohypogastric and iliolinguinal terminals, and
when the distribution, ramifications, and anasto-
moses of these nerves is recalled, it will become
apparent that McBurney's point, superficial or deep,
must be interpreted clinically simply as a focus,
upon which may be projected the sensory mani-
festations resulting from disorders in any of the
organs or tissues of the right thorax or abdomen.
The greater the distance between an existing Mc-
Burney point and its causative disturbance, the
more superficial the pain focus, and, conversely,
the more superficial this pain focus the more cer-
tainty of its indicating a distant lesion and a nor-
mal appendix.
The comparative safety of operating in a qui-
escent or chronic stage of appendicular inflamma-
tion has tended probably more than any other fac-
tor to inculcate a reckless confidence in the
surgical indications of an existing McBurney's
point ; there are those who in other conditions ex-
haust every means to establish proper operative in-
dications, yet accept the presence of McBurney's
point as sufiicient justification for appendectomy.
The present communication is intended to be
suggestive rather than exhaustive, and, for obvious
reasons, a detailed enumeration of the manifold
conditions that may simulate a McBurney point
would be out of place.
The relation of prolapsed right kidney to the con-
dition under consideration has been emphasized by
the writer on several other occasions — the other
nephritic, like the ureteral, the gallbladder; the
gynaecological and genitourinary conditions that
naturally force themselves upon our consideration
in connection with this theme are too well known
to surgeons to require more than mention here.
There is one topic, however, the essential rela-
tions of which to our theme warrants more than
January >y..S.l J'LEASAXTS: MEXTAL DISORDERS OF SCJWOL ElJ-E.
allusion, namely, the rehabilitation of primary
typhlitis, acute and chronic.
In the Annals of Surgery for June, 1907, C. A.
McWilliams, treating of the subject of Typhlitis
without Appendicitis, reviews the recorded cases of
the past seven years. He admits that primary
typhlitis is rare in comparison with appendicitis,
but feels justified from the evidence which he has
collected in holding that primary acute and chronic
typhlitis may occur independently of appendicitis,
dysentery, tuberculosis, actinomycosis, or canc(?r,
and that it may be either idiopathic in origin or due
to coprostasis. Numerous autopsy reports and
findings at operations have confirmed him in this
opinion. The disease in the caecum may go on to
ulceration and perforation, with the formation of a
perityphlitic abscess or general peritonitis, while
the appendix remains normal. Howard Kelly alone
has reported fourteen cases presenting primary le-
sions in the caecum, the appendix being normal.
It is well to bear in mind that there is such a dis-
ease as primary typhlitis, especially when dealing
with patients who have been operated upon for
chronic appendicitis and who suffer from a recur-
rence of symptoms. This recurrence may be due to
attacks of typhlitis. Haberer reports ninety-six in-
terval operations for appendicitis, in only fifty of
which were the symptoms entirely relieved by the
operation ; forty patients continued to have more or
less marked symptoms, such as obstinate constipa-
tion and severe pain, from which they had suffered
prior to operation.
The aim of -the humblest scientific effort is the
elucidation of fact. The effort frequently entails
years of multiplied tasks. The facts gleaned may
usually be rendered in a few words. The forego-
ing is a sketchy outline of such an effort, based
upon two hundred and eight cases observed in pub-
lic and private service during a period of three
years.
References.
1. Blumberg. Miinchcner medizinische ]Vochenschrift,
June II, 1907.
2. Head, Henrj-. Brain, xvi, xvii.
3. Korach, .Appendicitis larvata. Mitteilungen aus den
Grenzgehictcu dar Mcdizin und Cliintrgie, xv, part 5.
4. Lennander. Ibidem, xvi, part i.
5. McBurney, Charles. Medical Record, 1889.
6. MacKenzie, James. Brain, xvi, xvii.
7. McWilliams, C. A. Annals of Surgery, June, 1907.
8. Ross, J. i? ram, 1888.
9. Ramstroem. Mitteilungen aus den Grenzgebieten der
Medizin und Chirurgie, xv, part 5.
10. Sturmdorf, A. Medical Record, January 13, 1906.
51 West Seventy-fourth Street.
PREVENTION OF THE NERVOUS AND MENT.AL
DISORDERS INCIDENT TO SCHOOL LIFE*
By J. H.^LL Ple.\s.mvts, M. D.,
Baltimore.
Instructor in Medicine. Joi-ns Hopkins Universily: Associate Pro-
fessor of Meciicine, "College of Physicians aiid Surgeons.
Medical Inspector of .Schools.
The prevention of those disturbances of the nerv-
ous system and of the mind incident to school life is
not a problem which the physician can approach sin-
gle handed, but rather hand in hand with the edu-
cator. Medical iiispccticni of the schools can only be
looked upon as a stepping stone to a more efficient
*Read before the Section in Neurology and Psychiatry of the
Medical and Chirurgical Faculty of ilaryland, October 25, 1907.
and comprehensive system of hyi^^ienic supervision
of our entire system of education, if real and lasting
results in the betterment of the race are to be hoped
for.
Within the past decade great changes in our edu-
cational system have been made, changes which
mean much for the well being of the child, both
mental and physical, but much remains to be done,
and glaring defects vitally aft'ecting the child still
exist in this as in other communities. Home condi-
tions are even worse as regards physical hygiene in
very many cases. The only way we can hope to im-
prove this is by education. The schools have thus a
double function to perform, they should be practical
examples of the best possible hygienic conditions not
only for their direct effect upon the healtli of the
child, but as educational influences which future
fathers and mothers will profit by in the homes of
the next generation.
School life may be said to begin at five years of
age and to extend to about eighteen. It thus covers
the latter years of childhood and the greater part of
adolescence, those periods of human life when mind
and body are passing through their most formative
stage, and are most responsive to mental and phys-
ical environment. The vast majority of the disor-
ders of mind and body incident to this period are
directly attributable to an almost universal disregard
of the simplest rules of mental hygiene in the school
and of physical hygiene in both the school and the
home. As important as are the immediate effects,
the more remote results of this disregard are trace-
able throughout life. The factors most influencing
the physical and mental welfare of the child in school
— for these can in no wise be separated — are, a, the
age at which school attendance begins ; b, the men-
tal demands made upon the child in study ; c, the
opportunities afforded for necessary fresh air and
physical exercise ; and, finally, d, the hygienic con-
dition of the school building and its surroundings.
The age at zclu'ch school attendance should begin
has been much discussed. Individuals vary slighth'
in precocity, but it may safely be said that no child
should enter school, a? now understood, under eight
years, and only exceptionally should school attend-
ance begin under ten. Only too well do I realize the
derision with which this statement will be generally
met, on the ground that it is absolutely impractica-
ble. Let us look for a moment at the grounds upon
which these limits are based.
Life up to the eighth or ninth year is largely an
animal existence. Every instinct demands light, air.
and freedom. Incessant muscular activity resents
all physical restraint. Anabolism is most active,
building up brain and muscle for the demands of the
future. The senses are becoming more and more
alert, and inoiiory increasingly retentive. An awak-
ening interest in the world of nature rivets and de-
velops attciiiioii. All objects in nature otter a fas-
cinating interest, but as yet the mind is but ill pre-
pared for reason or study. Fatigability of mind is
in striking contrast to physical endurance, and at-
tention, if easily aroused, is as easily exhausted.
Physical and mental response to good air. sunshine,
food, and physical exercise is at no age so rapid as
in this period. And how are these imperative de-
mands of nature met ? At the age of five or six we
cut off our children from fresh air and sunshine.
112
PLEASANTS: MENTAL DISORDERS OF SCHOOL Lll-E.
tXi;w V,,RK
Medical Journal.
and confine them for hour? in overcrowded, dusty,
overheated, underventilated, often badly Hghted
rooms, shut off the safety valve of physical activ-
ity, and force their growing brains to undertake
menial processes of which their degree of develop-
ment renders them incapable, and make sustained
demands upon the attention, vvhich it is not able to
endure without damaging strain. And we call this
education.
Now for the remedy. The proper place for every
child is the country, or as near true country condi-
tions as possible, and this is especially true of the
age we are now considering. No child under eight,
or, better, ten, should attend the city school, as it is
now understood, for task study. The child fortunate
enough to live a healthy, outdoor, animal life in
the countr\-, with no definite study routine, but en-
couraged by a conscientious effort on the part of
parent or nurse to take a lively interest in rational
play and nature studies, such as gardening and the
like, thus developing attention, orderliness, and the
power of observation, this child is receiving the best
possible training for future study and progress.
When placed in school, contrary to general belief,
progress will be so rapid and easy it will be seen
within a few years no time has been really lost, and
that much mental and physical capital has been
gained. But, of course, such ideal conditions are
only for the favored few. The great bulk of the
population is crowded into cities and towns, with in-
different or poor home surroundings, and many pa-
rents forced by our industrial sj-stem to spend much
of their time away from home. The school for these
parents is as much a free nursery as a source of edu-
cation. Circumstances require, and poor home sur-
roundings make it desirable, that the community
should, therefore, provide for the care of city chil-
dren five years old and over. The kindergarten was
at one time supposed to be the solution of the prob-
lem, but has not proved so. In the first place, the
kindergarten, as generally found, was only adapted
to the very > uung children — four or five years old —
and too soon were the poor unfortunates pushed into
the miserable old competitive, conventional, leveling,
task study system. Moreover, the kindergarten
classes are almost universally held in the ordinary
public school building. What is needed is a radical
departure from all this. Special schools, kindergar-
ten, or whatever title you choose to give them,
should be established in the suburbs or parks, where
nature studies, or, better, nature observation, could
be followed. The classes slmuld imnriably ])e held
out of doors except in severe weather ; systematized
play and exercise in natural s'-,rroundings should
predominate over assigned tasks, and no attempt
made to educate the child under eight, as is now un-
derstood, in much of the graded work of the mod-
ern elementary schools. What we require are sys-
tematized playgrounds in the broadest sense, in con-
nection with rational kindergarten work, and the
next development in the playground movement, now
so rapidly gaining momentum, \>'ill probably be along
these lines. Nor is the possibility of suburban or
park schools for older children as well as kindergar-
tens a mere dream. In Baltimore the development
of suburban growth and the extension of the park-
system make the scheme entirely practical as regards
new schools. Plenty of elbow room should be pro-
vided along these lines. In the case of the children
in the denser centres of population, free transporta-
tion on the street cars to schools more favorably sit-
uated should be provided by the city. At first sight
this may seem impractical, but a moment's reflection
will show that such a plan does not complicate the
already serious congestion of traffic during the morn-
ing and late afternoon hours, as the school traffic
would be in exactly the opposite direction to the or-
dinary rush. No doubt the street railway company
would be only too glad to fill their returning half
empty cars at a much reduced rate through the sale
of special school tickets.
As regards the effect of the mental demands made
upon the child of suitable school age by the require-
ments of the present system of education, I speak
with some hesitation. Much has been done and
much is being done by the thoughtful educator of
this and other communities to work out a rational
system. The brake upon progress lies more in sla-
vish adherence to the old system and blind ignorance
on the part of parents and the community, than upon
progressive educators, who see light, but are ham-
pered at every turn. Before we can hope to educate
the children rationally we must awaken the parents
to the vital importance of a change.
Shorter hours of classroom work, more frequent
recesses, variety in study to maintain interest, elect-
ive work for the older children, avoidance of home
study, freedom from competitive work, and brisk,
capable, }-oung teachers do much to lessen the men-
tal wear and tear with its train of nervous and phys-
ical evils. The child must be educated as an indi-
vidual, and education not used as a means to grin.l
individuality to the dead level of a school grade.
The opportunities aft'orded for physical exercise
at present are notoriously insufficient in nearly all
the public schools of this city. Such work should
be in the hands of professional physical directors.
Gymnasia properly equipped are a valuable adjunct,
especially for the older children and in inclement
weather, but in general, exercise should be taken out
of doors in playground or athletic field. This is not
possible in our present city schools with their small
yards, but nnist be found in the parks or suburbs.
The younger children can get their exercise in regu-
lated games in the playground, and by movements
under order. Rhythmic movements are not advisa-
ble. In contrast we find, even in our new suburban
schools, a small, high fenced bricked yard, in which
the children are turned belter skelter for fifteen or
twenty minutes, with scarcely elbow room, to play,
fight, or freeze as the case may be — and this is the
physical exercise which we offer all sizes, ages,
sexes, and constitutions to repair the physical and
mental waste our system of education entails, and
to help strengthen body and mind for the tasks of
to-morrow. Of what advantage is our boasted
knowledge of the cause of disease and the so called
preventive medicine of to-day if we do not apply it?
The Greeks understood the secret of a healthy mind
in a healthy body infinitely better twenty centuries
ago.
The hygiene of the present school buildings, or,
rather, the lack of it, is largely responsible for many
of the physical and mental defects of the children.
So much has been written of the deplorable condi-
tion of many of the older city schools that repetition
January ,8, 1908.1 PLEASANTS: MENTAL DISORDERS OF SCHOOL LIFE. 113
"here is unnecessary. The buildings are overcrowd-
•ed, the air space of the room insufficient, ventilation
simply nonexistent, rooms overheated by closed coal
stoves, badly lighted, with improper wall coloring,
desks ill fitting and not adjusted to the size of the
child, toilet facilities unhygienic and inadequate —
these go t o make up a picture in many schools. Apart
from the direct effect of all this upon the health,
what ideals can we expect from children brought up
in such surroundings. I can bring no more con-
vincing argument of the effect upon health of such
conditions than to cite the result of a recent inspec-
tion of a school annex situated over a paint shop.
The children were overcrowded in small, low pitched
rooms, heated by red hot stoves, and without ven-
tilation. These children showed a proportion of en-
larged tonsils of 24 per cent., as compared with 11
per cent, among children of the same age and class
in a new school one block away. If our civilization
compels us to remove our children from the fresh
air and sunshine when their bodies most require
both, to deprive them of the natural outlet to their
energy through unrestricted physical exercise, and
to force their unstable and delicate brains to un-
dertake mental tasks, which, under most favorable
circumstances, involve great strain upon mind and
body, it is certainly our duty to insist that the con-
ditions under which they are housed should be
exemplary.
In the years of childhood we sow most of the
seeds of physical and nervous deterioration. In the
years of puberty and early adolescence this seed,
which in childhood has already sprouted, and in
some cases grown, now springs up and flourishes
with peculiar vigor, and we begin to gather our crop
of neuroses or actual organic degenerations from a
body and mind rendered especially unstable by the
physiological demands of this critical period of life.
Dementia prsecox, hysteria, neurasthenia, the neu-
roses, the psychoses, chorea, the tics and habit
spasms, and impaired mental power are but a few.
Apart from physical defects, which act as a predis-
posing handicap, many of these conditions o>ve their
immediate onset to overstudy, examinations, and thi"
attempt to keep up with the strict grade system,
which tries to fit the child to the task and not the
task to the child. ]\Iany of these children have come
into the world with the additional handicap of bad
heredity, and even under the best conditions have a
tendency to drop on the march.
The physical defects responsible for a diseased or
disordered nervous system as seen in school children
are often of a character which can be remedied or
improved. Their prompt recognition and treatment
is, therefore, all important.
Malnutrition probably stands at the head as a
cause of functional and organic nervous disease.
\"ery many of the children are insufficiently and im-
properly fed. This at once brings up the question
of feeding, not only of children of school age, but
of these same children in infancy, for we must be-
gin at the beginning. Careful observation leads me
to believe that we are less frequently dealing with
actual inability through poverty to supply sufficient
food than with dense ignorance as to what kind of
food should be given. In our work of inspection we
use the school nurse as an educational factor. She
visits the homes of such patients, and as far as pos-
sible makes practical dietetic suggestions to parents.
Eyestrain probably ranks next in importance. Our
Baltimore figures are incomplete, as a routine Snel-
ling test is not made in all cases. As a prophylaxis
to the train of nervous disorders incident to eye-
strain, the number of inspectors should be increased
from five to at least fifteen. Each inspector now has
about 13,000 children under his care, and the impos-
sibility of making a careful examination of the eye
under the circumstances is evident. I am not in
favor of the teacher making examinations of the eye,
as has been suggested. Few are qualified to do so
intelligently, and the mistakes will discredit the en-
tire system. Besides, they are already overworked.
Notwithstanding the incompleteness of this branch
of inspection as now done, very many cases ?.re rec-
ognized and corrected. When examination shows
serious error to exist, children should not be allowed
to attend school until correction is made. This at
once brings up the question. Should the city supply
glasses as it now supplies school books, some parents
protesting that they cannot aft'ord lo buy glasses for
their children? My feeling is that the city should
not do so, for if supplied to one they must be sup-
plied to all. It seems better to rely upon organized
charitable agencies in such cases, as savoring less of
paternalism. While correction of existing defects is
absolutely necessary, much more important is the
prevention of eye disease by improved lighting con-
ditions and properly adjusted desks. In some of the
older schools the rooms are both insufficiently and
improperly lighted. In few of the schools is the
question of wall covering considered at all. The
conditions in some schools beggar description. The
practice of fitting a five year old child and a long
legged boy to the same kind of desk is almost uni-
versal in the older schools. Xot only ocular dis-
ease, but lateral curvature, with their train of symp-
toms and deformities are thus combined. A very
practical difficulty is encountered in some cases in
compelling the children to wear the glasses, when
supplied, as much as they should.
Adenoids are responsible for a definite train of
nervous disorders. The difficulty lies in securing
removal after parents have been notified of their
presence. In New York, if, in aggravated cases, pa-
rents do not heed the notices of the inspectors, com-
pulsory removal in school is performed. Up to the
present time this has not been possible in Baltimore.
Our figures vary, but in two old schools recently ex-
amined by me there were 207 cases of adenoids
among 840 children of all grades. I should insist
upon removal in aggravated cases, referring those
in dispute to the arbitration of a specialist in the
employ of the health department. A very large pro-
portion of backward children suffer from adenoids.
This I feel to be due to several causes, the direct
effect of the condition upon the body and mind, the
frequency of "colds" and catarrhal disorders neces-
sitating absence from school, and the effect of deaf-
ness resulting from Eustachian disease upon the pro-
gress of the child. Some of the most striking cases
of rapid mental and physical improvement, with
astonishing progress in study, are seen after opera-
tion for adenoids.
Enlarged tonsils, unless associated with adenoids,
frequently do not give rise to symptoms. If much
enlarged, however, or if there is a history of recur-
114
PLEASANTS:
MENTAL DISORDERS OF SCHOOL LIFE.
[Xkw York
MtUICAL JoVKXAL.
rent acute attacks of tonsilitis, parents are notified
that they should be removed. Here again comes in
the difficulty of enforcing our recommendations. The
greatest obstacle to the proper operative treatment
of both enlarged tonsils and adenoids is the igno-
rance or indifiference of the average family physician
in certain sections, who usually prescribe a gargle,
and laughingly tell the parents that the condition is
not serious. My school experience has somewhat
modified my views of the significance of tonsillar
hypertrophy. A very large proportion of cases ap-
parently are not subject to attacks of acute tonsil-
itis. On the other hand, hypertrophy frequently
seems to be a response by the body to bad air and
unhygienic surroundings. The figures already re-
ferred to, in which, under such circumstances, the
percentage of enlargement was more than twice as
great as in children better housed, suggest that after
all hypertrophy may be in one sense a conservative
process. It seems probable that enlarged tonsils per
se play a small part in the production of physical or
mental disorders, and that when coexistent, as they
so often are, with adenoids and such conditions as
malnutrition, adenitis, backwardness, etc., may be
an associated symptom rather than the underlying
cause.
Deafness among school children is not uncommon,
but it is interesting to note flow frequently it is over-
looked by the teacher, and the resultant backward-
ness of the child attributed to inattention or impaired
mentality. Several pathetic cases have been set right
when the teacher realized the mistake and the child
was more favorably placed. The frequency of this
condition can be lessened by better control of epi-
demics of scarlet fever and measles. The treatment
of such cases in the rapidly building hospital for
contagious diseases, v^diere the services of experts
can be at once obtained in cases of otitis media,
should do much to lessen ear disease. The compul-
sory removal of adenoids will also do much. Wax
is a frequent and often overlooked cause of deafness
in children.
Epilepsy in the schools presents a difficult prob-
lem. Until very recently epileptics were admitted
to the general classes. The demoralizing effect not
only upon 'the rest of the class, but upon the unfor-
tunate victim of recurrent convulsions in school, can
be imagined. An attempt has recently been made to
segregate the epileptics in special classes, but this
I)resents practical difficulties. It has been definitely
shown that the proper way to manage the disease
nmong the poor is to establish colonies in the coun-
try, where special education and suitable occui:)alion
can be provided. A crying need in this comnnmity
is provision by the State for such an establishment.
Recent investigation of the physical condition of
the mentally deficient, the incorrigiblcs, and the tru-
ants has thrown much light upon the proper treat-
ment of such cases. With the idiots and imbeciles
we are not now concerned. This condition is, of
course, incurable, although much can be done in spe-
cial institutions by proper training to render them
more or less useful and happy. It is a stigma upon
the State that totally inadequate provision is made
for their care, although public opinion is so aroused
that something will doubtless be done by the next
legislature.
What concerns us more in this connection is the
problem of how to better the condition of those chil-
dren who are mentally below par. It has been defi-
nitely shown that a very large proportion of such
children suflfer from physical defects, especially eye-
strain, deafness, adenoids, and malnutrition, and
that when these conditions are corrected or improved
the child at once begins to make more rapid pro-
gress in study. The New York figures prove this
without question. There still remains, however, a
large number of backward and deficient children
whose condition is not dependent upon physical dis-
ease, but an inherited inferior mentality. Special
schools for all such children are impracticable, nor
are they desirable. It seems best for such to mingle
with normal children in study and at play. To rub
up against others better endowed seems stimulating
and of distinct benefit. In class work, however,
such children must be taught individually in small,
ungraded classes. For this purpose teachers of the
highest type are needed. I know of no work which
requires a higher order of tact and intelligence than
the teaching of the so called ungraded classes. The
importance of getting the most out of such children
and encouraging selfreliance is not only humanita-
rian, but economical. If placed in special schools
and separated from other children they fail to de-
velop selfreliance, and when turned adrift on the
world eventually become public charges.
The very high percentage of physical defects
found among truants and incorrigiblcs has thrown
much light upon the causes of truancy. It has been
found that the great majority of such cases sufi:'er
from adenoids, imperfect vision, deafness, or othe'-
defects. Such children have a tendency to fall b ick
in their studies, become sensitive or mortified, then
defiant, and finally drop into truancy. The results
in the so called parental schools where such children
have received proper moral and physical treatment
have been most gratifying. Of course, it is not meant
that all cases can be explained on this ground, for
many are recruited from the congenitally defective
and degenerate.
And, finally, a word in regard to that indefinite but
increasing class of children to whom only the term
nervous can be applied. It is begging the question
to consider their condition as an inevitable result of
our civilization, and to sit by fatalistically and allow
the army of adult weaklings, neurasthenics, psychas-
thenics, and insane to be recruited without protest.
The curse of heredity can only be combated by en-
vironment and education.
We have in the school the opportunity to bring
about better things, if by wise medical supervision
of education we make the school an object lesson of
practical hygiene, and direct the teaching of thi:
school so as to extend the knowledge of healthful
living. In this way not only can disorders of the
mind and of the nervous system incident to school
life be controlled, but the mental and physical wel-
fare of the race can also be placed on a higher plane.
In conclusion, let me summarize certain leading-
points :
1. Children under eight, or, l^etter, ten, should not
attend school if country life and parental attention
are possible.
2. City children between five and eight should Ix^
placed in kindergartens situated in parks or sulitirbs
where nature study and systematized play and Tight
January i8, 1908.J PENROSE: 'PSYCHIC TREATMENT OF NERVOUS DISEASES.
ungraded objective work in the open air can be car-
ried out.
3. Schools for older children should be gradually
removed to the parks or suburbs and equipped w^itli
playgrounds and physical directors.
4. Overstudy and competition among the more
ambitious pupils should be prevented, and the level-
ing of the child to the grade avoided.
5. The hygienic condition of the schools should
be maintained at the highest efficiency, both for the
effect upon the child's health and as educational ob-
ject lessons.
6. Physical defects (usually remediable) at the
basis of many mental and nervous disorders arc
principally :
a. Malnutrition, to be combated at present
largely by the educational influence of the school
nurse.
b. Eyestrain, if of advanced grade or if pro-
ductive of symptoms, to be corrected, and the
wearing of glasses made compulsory.
c. Adenoids and enlarged tonsils to be re-
moved ; in neglected cases the health depart-
ment should have power to enforce removal.
d. Deafness to be prevented by the better
control of epidemics and removal of adenoids.
7. Epileptics to be placed in separate schools, or,
better, in rural colonies.
8. The condition of many so called mental defi-
cients improved or cured by correction of physical
defects.
9. Truancy and incorrigibility in many cases due
to the handicap upon mental work of physical de-
fects.
10. Education of idiots, imbeciles, and the feeble
minded, as far as they are capable, in special insti-
tutions maintained by the State.
11. The education of children slightly below par
mentally in small ungraded classes in the public
schools.
12. Substitution of a broad medical supervision
over education by a board of physicians and edu-
cators instead of mere medical inspection.
16 West Chase Street.
THE PSYCHIC TREATMENT OF NERVOUS DIS-
EASES FROM A PRACTICAL STANDPOINT.*
By Clemext A. Penrose, M. D.,
Baltimore.
Since the address of the Rev. Ellwood Worcester
and Dr. Coriat, of Boston, ^lass., before the Hop-
kins Medical Society, May 20, 1907, it has seemed
expedient that the psychic treatment of patients
should be treated from the standpoint of the gen-
eral practitioner on its practical and everyday side.
There is danger that a man not especially trained
in observation and the study of psychology might,
possibly, take an extreme view- of these methods
and the facts presented to him on that night and in
the literature of the present day.
In the first place, I take exception to the state-
ment that the mass of people w'ho have become in-
terested in psychotherapy have been really driven
into this by the neglect of the profession at large
'Read before the John; Hopkins Hospital Medical Society. Octo-
ber 21, 1907.
in adopting such treatments. I doubt, indeed, if
there is any suggestion more potent than the influ-
ence of the family physician, or the simple admin-
istration of a remedy by one in whom we have such
confidence. I believe that the medical profession
at large have used and uses suggestive therapeu-
tics more than is generally known and as much as
they have dared, owing to the prejudice against
such methods by many patients. That a training
along these lines is most essential I admit, but
whether strictly scientific or no, is questionable
when we see it recommended that such cases be
turned over for treatment, and apparently success-
ful treatment, to men who have not had a scientific
training.
Leaving this point for the moment, the question
of cliief importance is. Why this growing need for
psychic treatment in this country? I hope to show
that this is not due to the neglect of the doctors,
but rather an increase of a certain degenerate type
of mind, fast spreading over our land. We have in
this country every reason for the production of a
class or type of people who, without entering into
any scientific classification, I shall group under the
general heading of the '"mind weary" ; a reaction,
as it were, against the strain and turmoil, the am-
bition and excessive nerve restlessness of the pres-
ent day. I believe that • I can safeh" say there is
scarcely a psychoneurosis that would not come un-
der this general heading. There is no better class
of people in which to study this type than in those
w^ho are led to join the Christian Science Church.
This is a type that has lost the desire to think for
themselves, or, if they must do so, do not care to
use the mind in a way that is hurtful or fatiguing.
How many thousands of these poor mind weary
wretches are on the lookout for some simple, plau-
sible, easy solution of the problems of life that will
cut them out of all its responsibility ! What w-on-
der that a mother, worn out by numerous cares,
should adopt the theory in which she, smiling over
her sick child, can say that "all pain is error, there
is no such thing as pain," and go back to her bed,
free from all the worries of motherhood and safe
in the consciousness of her right doing. People of
this type will accept anything without argument,
proof, or consideration. As an illustration : An
able man and thinker, a personal friend and patient
of mine, attended a meeting at the Mother Church
of the Christian Scientists in Boston some time ago.
He related to me a number of the experiences given
at that meeting, two of which I will repeat, as well
as my memory allows, as an example of what I am
endeavoring to prove.
The first experience cited by one of the mem-
bers of the congregation w-as as follows : A man
on the street was run over by a heavy furniture
van, and suffered a fracture of the thigh, the pow-
dered bone from which could be seen sprinkled on
the streets. While some one was running for a
doctor, another for an ambulance, etc., a majestic
figure appeared, namely, ^Irs. Eddy, who waved
her hand over the man, and in a moment he was
healed, arose, and walked away.
The second experience was told about a little girl
of three years, who, while sewing, drove a needle
through the thumb and bone of the thumb of the
ii6
i'EXROSE
PSYCHIC TREATMENT OF NERVOUS DISEA.'^ES.
[New York
Medical Journal.
left hand. The mother withdrew this, quoted a few
words from Science and Health, the child stopped
crying, and the wound immediately healed.
My friend, being a broad minded and intelligent
man, appreciated at once the utter impossibility of
these two experiences, the powdering of raw bone,
for instance, and the ability of a child of three to
force a needle through the bone of the thumb. He
looked around upon the faces of the fashionable,
well dressed and better class audience to find a
single dissenting look or even a gesture of incred-
ulity, but to his surprise these experiences, with a
dozen more equally ridiculous, were accepted by
all, as a matter of fact, and beyond question. He
asked me for an explanation of this, as he called it,
curious phenomenon. I replied, as I would h^re,
it is because they belong to a mind weary class,
who care not to think or investigate ; they will ac-
cept anything rather than take the trouble to argue
it down or deny it.
I only bring in these cases to show why it does
not seem to me especially requisite that a general
practitioner must have a technical training in
psychology in order to influence such people. Let
us compare the mind weary man or woman, toiling
up the road of life, to a person walking up a hill
with a heavy burden on his back. We can lessen
this burden by taking him into our confidence, re-
lieving his mind of secret griefs, etc., etc., by sug-
gestion and encouragement, telling him that after
all his burden is not so heavy, etc., etc. We can
make the hill seem less steep by giving him assist-
ance in the form of food and money, etc., as our
l^hilanthropic societies d5 and are doing, but we are
making a mistake if we neglect making the man
actually stronger himself, for who knows that in a
few years a heavier burden may be put on his back,
a steeper hill may lie before him, and our assur-
ances cannot be lasting, and we ourselves may not
be on hand to help him. The result of all this is a
still more serious nerve relapse.
Has any one ever seen a perfectly organically
healthy man or woman who could long remain un-
happy? Has any one ever felt quite the same as
when he w'as in what we call the "pink of condi-
tion," as the trained athlete should be before some
trial of his strength? Is not the first duty of the
physician, after all, the strengthening of the body
so it can bear its burdens and nourish the weakened
nervous system? I therefore say, while agreeing
with eminent authorities on the necessity for better
instruction in psychiatry in our medical school, that
it is absolutely necessary, and of more value, that a
thorough training be given in the application of
physical methods. Teach the tailor and the factory
girl how to prevent contractions of the chest, the
crooking of the back — in fact, everybody, better
laws of hygiene ; keep your towns and cities clean,
free of dust and smoke, lessen the hours of work
and increase the hours of recreation, and we will
see how happy the dwellers therein will become,
and how little need physicians will have for psychic
treatment among their patients.
And now, as to the treatment of this mind weary
class already among us and probably doomed to be
with us, at least in our generation ; help them as
suggested in all three ways, but by mental methods
only when they really need it. If a man or woman
is happy in a hobby, let them retain it or even in-
dulge it for the time being, if it does not harm oth-
ers. You will often be unable to supply anything
better to take its place. Why ? For this reason :
Nature has ways of protecting her own ; when the
mind becomes too greatly distressed by eflfort and
worry, it searches around for or oftentimes evolves
a theory that is especially fitted to its own satisfac-
tion at the time, and which allows it to rest and find
repose. Like certain plants or bacteria, it goes into
a resting or spore stage, which the theory allows it
to do, when the environment is against its growth,
and then the harrassed, worried looking, and ner-
vous individual acquires a selfsatisfied, benign, and
placid expression. In some cases restraint is nec-
essary for the protection of society. For example :
The anarchist is a man born with the inability to
work, or at least the disinclination to do so. He
goes restlessly from one vocation to another until
the theory, such a happy one to him, that the rich
man should share with him his wealth and luxuries,
etc., explains the lack he feels within himself for
serious occupation, and he takes up anarchy will-
ingly and happily, works hard, and will even die
gladly for the cause. Anarchy, undobutedly, makes
him happier, and if it did not harm the rest of us
we could leave him alone with his delusion with
possible benefit to himself. The Christian Scientist
or the applicant to the mental healer is one born
with the disinclination to think ; they finally hit on
some simple theory which explains everything to
their own satisfaction. This lets them out of most
of the worries of life, and probably saves a further
degeneration of the mind, and may thus help pos-
terity.
The first stage in the degeneracy of the mind,
then, is the disinclination to think; a later stage
is the inability to think, and at last we arrive at the
various stages of imbecility, dementia, etc.
In conclusion, I would say that it seems to me
a dangerous procedure to turn even the purely func-
tional neuroses over to untrained men for treatment,
even if they can give efficient mental treatment, ow-
ing to the impossibility to determine, often, what is
organic and what is functional, or how dependent
the mental state is on the badly developed or poor-
ly nourished body, I remember very well a case
Dr, Osier disagnosticated as organic trouble, wliich
another very eminent physician said was functional.
After saying everything bad in the calendar about
Dr, Osier the poor patient died a year or so later
of organic disease, .This is a common experience,
and I mention it as showing the impossibility of
distinguishing at once or for years in some of these
cases. There should always be cooperation
throughout the treatment of such cases with a
trained physician ; at least a month's careful watch-
ing and then recurring examinations throughout
the treatment, no matter how long it takes to ef-
fect the cure,
I think our medical schools should have better
courses in psychiatry; but, more important even,
as we can always get a specialist in a pinch, and
manage fairly well without this special training,
would be a thorough knowledge of electrotherapeu-
tics, scientific massage, the administration of heat
Ja»,iiary iS, 1908.]
CRISPIN: CHORIOEPITHELIOMA MALICXUM.
117
and cold, and last, and most important, the prob-
lems of nutrition — which we admit are so important
in paediatrics — and often ignore in adult life. That
fat reduction, if scientifically carried on, will cure
a fat neurasthenic as nothing else will, if you can
substitute good muscle for his poor tissues, is an ev-
ery day experience with those interested in such
matters, and a very important problem for the
consideration of the general practitioner. I be-
lieve, honestly, that gymnastics, outdoor exercise,
proper nutrition, etc., will go much further with
neurasthenics alone than suggestion will alone.
They in themselves are suggestive, and do not
weary the mind with argument, and, as I have
shown, will make the man stronger to bear the bur-
den of his life, which may become greater when
you are no longer at hand to help him. A prize-
fighter, asked why he took up the profession, said
■'he was very nervous as a kid, but when he could
lick any man in the room this all left him."
Beware, without much deliberation, using your
influence in turning a mind, which sometimes is un-
fit for your ideas, from the ones which often, as I
have said, the wornout mind has evolved for itself,
better indeed than you could do for it, and which
in a poor state of nutrition of the body may be its
haven of rest. Build such a body up, and make the
psychic change later. And now, last, but not least,
let us, as American citizens, as well as physicians,
try and prevent this wave of degeneracy which is
spreading over our country, rather than be com-
pelled to cure it after it has fastened itself upon us.
Who can read those two articles in McClure's
Magazine, April and May numbers of this year,
without shame? Who can doubt the genuineness,
from the evidence given, of the statement that in
the midst of one of our greatest cities, in its very
centre in fact, there are over 30,000 people who are
below the par of the most barbarous savages on the
face of the globe? Let us use our influence over
our patients to prevent undue emigration, the cor-
ruption of politics, and see that our cities are kept
clean and hygienic, that proper rules and regula-
tions are carried out in the schools and the fac-
tories, etc. Let us, as physicians, teach the people
how to prevent disease in their children and them-
selves, and if they refuse to be taught, let us see
that the city authorities compel them to keep just
and suitable laws.
It is a great mistake that the building up problem
of the human body is ever turned over to ignorant
people, and who are less trained in their work and
capable of doing more harm than the mental healer
could do with his crude psychotherapy. A doctor
should be able to give massage and baths, or at
least should know whether his employees are able
to do so, and the same thing applies to the vari-
ous physical culture methods, diet, and a number
of other growing necessities. Given a man's age,
height, etc., how few of us know his proper dimen-
sions, the strength of his muscles, their capacity,
lifting power, etc., or, in other words, what a nor-
mal man should be and how to make him so. What
rations should twenty men have for twenty days in
a certain climate, etc., are practical problems which
might and have confronted many a physician most
unexpectedly, to his great embarrassment. The
average medical student reads ten books on psychol-
ogy, or along these interesting and fascinating
lines, to one on nutrition or vital statistics, etc.,.
which are unfortunately dry and not very enter-
taining, but this does not lessen their importance.
This paper is a plea, then, for scientific study along-
the lines of physical needs and physical develop-
ment and the scientific teaching of the same — far
more important, I consider, than that of p.sychiatry
for men beginning their life work and which we feel
the lack of more than anything else when we first
start out in the practice of medicine. I trust that
this paper may serve as a warning and some help'
to men with a medical life before them, and may
restrain their enthusiasm along a very thorny and
hazy path for the beginner— psychotherapy. I re-
member well in 1898, when I used hypnotism in
place of an anaesthetic on some surgical patients in
this hospital, with fair success, how enthusiastic I
was until I found out what limitations my methods^
had, and now I earnestly advise you to learn all
you can first about building your patients up. Your
daily experience will evolve a power for psychic
treatment and develop your powers of influence.
The younger generation of medicine has a great
work before it ; its war cry is prevention rather than
cure, and especially when considering our neuro-
pathic classes.
21 Mt. Royal Avenue, West.
CHORIOEPITHELIOMA MALIGNUM.
By Antonio M. Crispin, M. D.,
New York.
The difficulties of diagnosticating and the com-
parative rareness of these uterine tumors, together
with their clinical and pathological interest, encour-
aged me to report the following case, in which I
operated in April, 1905, thus adding one more to the
scant literature on the subject.
The comparative infrequency of these tumors
can best be judged by reading the masterlv article
by Dr. Robert T. Frank in the Nezv York 'Medical
Journal of April 21, 1906, where, in a most exhaust-
ive and comprehensive study, he found but twenty-
eight cases reported in the American literature. The
nomenclature of these growths has been quite ex-
tensive, and various are the terms applied to desig-
nate this rare form of neoplasm. It has been desig-
nated as deciduoma malignum, malignant bladder
mole, sarcoma decidua cellulare, malignant placental
polyp, and more recently chorionepithelioma and
chorioepithelioma.
The first important study on the subject was pub-
lished by Sanger in 1889 and was followed by Gott-
schalk and Frankel. The concensus of opinion as to
the origin of this growth accepts the theory ad-
vanced by Marchand, that these tumors are of chori-
onic, foetal, or ovular origin. Voight maintains a
contrary opinion, and says that they arise from ma-
ternal tissue and not from foetal ones. Frank in the
article referred to says: ''A chorioepitheliomatous
tumor of pregnancy may be defined as a neoplasm
which arises from some portion of the foetal cover-
ing (ectoderm) invading the tissue of its host, the
mother." It was clearly shown by Marchand what
Il8 I'l^JShy: RUy 1 lIMItAL CHAXUES ()!■ I'ALFEBRAL 1-lSSUkL.
relation the protoplasmic masses of the tumor have
with the syncytium and tlicir relaticjn to those of
Langerhans's layer. It has also been demonstrated
by others that the syncytium and Langerhans's cells
are derived from the ectoderm, and therefore these
tumors are of foetal or ovular origin, causing a ma-
lignant proliferation of the two layers of the chori-
onic epthclium.
These tumors as a rule follow pregnancy, abor-
tion, or a hydatidiform mole. In my case it was the
sequela of an abortion. Metastasis is one of the re-
markable characteristics of these growths, and there
is a decided tendency to early invasion of other vis-
cera. Malignancy is also a marked characteristic of
these tumors. They are usually located in the uterus,
but it has been primarily observed in the vaginal and
in the fallopian tubes, (iencrally it follows preg-
nancy, specially a hydatid mole, but it has neverthe-
less been observed after the menopause in a woman
fifty-eight years old.
The symptoms presented by the patients are usu-
ally as follow-s : After pregnancy, abortion, or the
expulsion of a hydatidiform mole, 58 per cent, of
cases, there is repeated genital hjemorrhages, gener-
ally profuse, although it may be scanty. The haem-
orrhage may be continuous, and in the period of qui-
escence a thin, watery discharge may appear. Anx.-
niia may supervene. \Mien the disease has advanced
the tumor ulcerates, and pieces of necrotic tissue are
discharged, the odor of which may become intoler-
able. Metastases appear in the other organs, ulcer-
ating into bladder or intestines.
The prognosis is extremel}- grave. The only hope
'is early surgical intervention. Medication for the
•control of the bleeding seems not to exert any influ-
ence.
The diagnosis is established by the careful consid-
eration of the symptoms and the physical signs. En-
largement of the uterus, resembling a gravid one.
\arying in size from a five week pregnancy to that
lof full term. The profuse bleeding, and the removal
hy curetting of a piece of tissue for microscopical
examination, will establish the diagnosis.
The treatment of these cases is that of all malig-
nant growth — extirpation. Curetting aggravates the-
condition.
Case. — Mrs. A. S., age fortj'-nine, has no information to
offer about her parents. It may be interesting to know that
one of her brothers had been operated upon by me for a
sarcomatous growth of the right groin. She always en-
joyed good healtli, menstruated when she was eleven years
old, married very young, and has had thirteen living chil-
dren and two abortions. Her present illness began live
months ago, when she aborted at the tliird month of gesta-
tion. Bleeding was very profuse, and as it did not stop
. she consulted a physician who curetted her, but this only
aggravated the condition and the h;cmorrhage was in-
creased. I was then invited to see her. She was a large,
stout woman, very anxmic. On bimanual examination, the
•cervix felt soft and large, the os quite patulous, uterus
globular and about the size of a four month gravid uterus,
uniformally enlarged, and freely movable. Hrcmorrhage
continuous. I advised immediate operation, which was ac-
cepted, and had her removed to the hospital. I performed
a hysterectomy by the combined method on March 7, 1905,
assisted by my friends, Dr. Jacob G. Paepke and Dr. Henry
Kalvin. Flaving first curetted the uterus, which was found
very soft and bled profusely, requiring immediate packing,
1 then opened the abdomen, cutting through enormous
quantity of adipose tissue, which impeded the delivery of
the uterus; this organ was perfectly smooth and large.
After some difficulty, due to the thickness of the abdominal
parietes and the intense bleeding from the tissues which
[.Nkw Vurk
-Mkuical Journal.
tore e:i^'l\- I succeeded in deli\ering it. All went well
until the fourth day, when the patient developed intestinal
paralysis, for which everything was tried, but to no avail,
and she died in the eveiung. The tumor was sent to the
pathologist, Dr. N. Kruskal, and he reported it to be a
chorioepithelioma malignum, with the usual findings.
854 Lexington Avenue.
RHYTHMICAL ALTERATIONS IN THE WIDTH
OF THE PALPEBRAL FISSURE OF BOTH
EYES PROBABLY PRODUCED BY SPASM
OF THE LEVATOR PALPEBR.^
MUSCLES.*
By C. a. Veasey, M. D.,
Philadelphia,
Assistant I'rofcssor of Dise.-.ses of tlie Eye, Jefferson Medical Col-
lege.
At a meeting of this section, held April 15, 1902,
Dr. William Campbell Posey reported a case of
unusual choreiform alterations in the width of the
palpebral fissure of both eyes, occasioned by spasm
of the levator palpebrae muscles, which was ob-
served in a colored boy eight years of age, the pa-
tient complaining only of slight headache and of a
sensation of sand in his eyes, but an examination
showed curious rh} thmical alterations in the width
of the palpebral fissures, the latter widening about
fifteen to twenty times in a minute. The contrac-
tions were choreic and entirely under the control
of the will, the patient being able to initiate them
or stop them when told to do so. The excursions
of both eyes were normal, there was no nystagmus,
and vision and accominodation were also normal.
Atropine was employed, the patient refracted, and
there was no return of the movements after the
patient received glasses.
Posey believed that these curious movements
of the eyelids were due to the contraction of the
levator muscles of the lids, and that these contrac-
tions took place without any assistance of the
frontalis muscles, as the eyebrows remained qui-
escent. There also seemed to be no connection
with the act of winking. He thought that the
widening was occasioned by the contraction of
that part of the levator muscle controlled by the
third nerve rather than by contraction of the small
portion consisting of unstriped fibres which re-
ceives its innervation from the sympathetic. He
argued that if the contractions were due to a spasm
of the muscle of Miiller there would also have been
observed changes in the size of the pupils, as the
iris is also innervated by the sympathetic.
It was thought that the movements were chorei-
form in character, the contraction of the levator
taking the place of the more common manifestation
of habit chorea, namely, the contraction of the orbi-
cularis.
The following notes are of a somewhat similar
case :
T. R., aged seven and a half years, both of whose par-
ents were more or less nervous, was first examined April
12. 1907. The child himself had always been nervous and
very quick in his movements. For some months there had
been observed an upward movement of each upper lid, oc-
curring about twenty times in a minute and sufficiently
great in extent to uncover the cornea and expose the sclera
above. The movements were nuich more marked at times
than at others, but were especially bad when something
• Kead before the Section in Ophthalmology of the CoHegc of
l^liysicians of Philadelphia, November 19, 1007.
THERAPEUTICAL NOTES. ng
occurred to make the child nervous. The movements were
rhythmical in character and were in all probability due to
contraction of the levator muscles. The frontalis was not
involved nor were there any changes in the pupils. Oc-
casionally there were slight contractions of the alae of the
nose. Adenoids had been removed some months before,
and the patient had also been circumcised.
It was thought that we were dealing with a case some-
what similar to that described by Dr. Posey, and the
patient, who had only 6/9 vision in each eye, caused by a
simple hyperopic astigmatism, was refracted under^ atropine
and the "glasses ordered to be worn constantly, this gave
considerable relief, as the contractions of the lids did not
occur so frequently, but the movements did not entirely
cease until the patient was placed upon ascending doses
•of Fowler's solution of arsenic.
In this patient the contractions were probably
largely due to the condition of the eyes, being a
manifestation of habit chorea, but which did not
entirely disappear until after the administration of
arsenic. It is certainly a somewhat unusual mani-
festation, and is here reported because of its in-
frequent occurrence.
1 83 1 Chestnut Street.
f bmjeutital gotts.
Applications for Acne. — According to Ohmann-
Dumcsnil {American Journal of Dermatology), the
general treatment of acne is complicated owing to
the fact that the affection may be caused by so
many conditions. _ For local application it is gen-
erally agreed that sulphur is best. A generally
good applicatiofi is the following :
B Sulphuris pr.-ecip., jss ;
Ung. aqua: rosae 51.
!M. Sig. : Apply twice daily.
As a lotion the following formula of Kumnier-
feld's is stated to be efficient and pleasant to use :
R Sulphuris praecipitati 3iv;
Pulveris camphorae gr. x;
Pulveris tragacanthas 31;
Liquoris calcis, \ " '^'\
Aquae rosae, . .. /
M. Sig. Apply two or three times daily.
[This lotion should be ordered to be shaken well
before applying.]
In cases in which there are old, hard papules the
following will be found useful:
B Hydrargj'ri oleatis (5 per cent.) 5ss ;
Sulphuris praecipitati 5ss ;
Ung. aquae rosae, 51.
Yi. Sig. : Apply thin twice daily.
The Use of Drugs in Cholelithiasis. — In the
Therapeutic Gazette for December, 1907. John H.
Musser. of Philadelphia, discusses the medical treat-
ment of diseases of the gallbladder, and with re-
gard to the use of drugs he has to say that there
are very few that can be administered with any
degree of confidence that results are to be secured,
save those indicated from a careful study of the
gastrointestiiial tract (including the stools and gas-
tric analysis), those that are indicated by a study
of the circulation, and those that are indicated by a
study of the blood. Among the drugs that have
virtue in a general way he places the alkalies first.
^^'here there is congestion or a tendenc}' to stasis
ammonium chloride is of value, as it has an in-
fluence upon the secretions and is said to thin the
bile, allay catarrh, and modify the amount of mu-
cous secretion. The author thinks that after the
establishment of a biliary fistula, the secretion of
bile is increased by the use of the salicylates. The
value of sodium phosphate and other sodium
salts is well known, but whether the result
obtained with them is due to their action as
cholagogues or as purgatives relieving the stasis,
he is not prepared to say. There is no solvent for
gallstones that lie quiet in the gallbladder or in
the bile ducts, and there is no medicinal means of
removing them. Dr. Musser has never seen any re-
lief to gallstones from the use of olive oil, though
it sometimes relieves the syrnptoms in this way:
With gallstones there is usually a hyperacidity,
which gives either simple gastralgia or pyloric
spasin. It is these symptoms that are relieved when
olive oil is administered.
Lotions and Pomades for Alopecia. — From
Schnirer's Taschenbuch der Therapie we take the
following selection of formulas :
I.
B Acidi salicylici, 1.0 gramme;
Tinctitrse benzoini, 2.0 grammes;
Alcoholis, 200.0 grammes.
M. S. Apply to the scalp once or twice daily.
II.
B Resorcini, 5.0 grammes;
Olei ricini, 45.0 grammes;
Isami peruviani, 0.5 gramme.
M.
III.
B Sodii bicarbonatis 3 parts;
Spiritus lavandulae. i , ^
Glycerini. f ^ ^5 parts;
Aquae distillatae .• ad 200 parts.
M.
IV.
R Hydrargj'ri ammoniati, 2.0 grammes;
Unguenti aquae rosae, 50.0 grammes;
Tincturae benzoini, 1.0 gramme;
Olei rosae 5 gtt.
M. S. : Pomade.
V.
B Quininae, 1.0 gramme;
Acidi tannici, 2.0 grammes;
Ung. aquas rosae, 100.0 grammes;
Olei resedae (mignonette), )
Olei neroli, .... j aa 2 gtt.
M. S. : Pomade.
[In this formula the oil of mignonette, which is
difficult to procure in this country, may be replaced
by I drop of oil of bergamot.]
Adherent Cade Ointment. — At the Hopital
Saint Louis, Danlos, makes use {Journal de mcde-
cine, through The Practitioner) , in different skin
affections, especially in psoriasis, of an ointment
which has the advantage of being very adherent to
the skin and which can only be removed by the use
of oil or soap. The formula is :
R 01. cadini 5iss :
Pulv. talci 3ss;
Pulv. zinci o.xidi, jii.
M. F. unguentum.
The preparation of this ointment entails a
lengthy trituration to provide for the complete in-
corporation of the zinc oxide and the talcum with
the oil of cade.
120
THERAPEUTICAL NOTES.
[New York
Medical Journal.
The Contagiousness of Follicular Tonsilitis. —
The contagiousness of follicular tonsilitis is pointed
out by a writer in the Journal of the American
Medical Association, for January 4, who advises
treating it with the same local antiseptics and the
same preventive measures against giving the dis-
ease to others as are used against diphtheria. It
seems to be proved that many attacks of acute in-
flammatory rheumatism begin by the germ entering
the system by way of the tonsils, even if follicular
tonsilitis is not present. On the other hand an ap-
parently typical follicular tonsilitis often precedes
rheumatic symptoms. If there is much general in-
fection from the tonsilitis, as shown by a high tem-
perature, headache, and backache, one of the follow-
ing prescriptions should be given :
I.
B Monobromated camphor, gr. iss ;
Citrated caffeine, gr. iiss;
Acetaniiid, gr. viii.
M. et fac capsulas 5.
Sig. : One capsule everj' three hours, with plenty of
water.
II.
R Acetphenetidin, ) „^
Phenyl salicylate, \ '^^^^
M. et fac chartulas 5.
Sig. : A powder, with water, every three hours.
The local treatment of follicular tonsilitis and diph-
theria is the same, as follows :
R Solution of hydrogen dioxide, 5vi.
M. Sig. : Dilute with three parts of warm water and use
as a gargle every three hours,
and
R Boric acid, , 3i ;
Water, 3vi.
M. et sig. : Use undiluted as a gargle every three hours.
The gargles should be used alternately, each one
every three hours (one or the other every hour and a
half) during the day time, and every three or four
hours at night.
If the patient is debilitated by the inflammation,
a simple tonic is needed, which may consist either of
strychnine sulphate, gr. 1-30; or a mixture of
quinine sulphate, gr. iss and reduced iron, gr.
either to be given three times a day.
Local Applications in Rheumatism. — For ap-
plication to painful joints the following combination
is recommended in The Hospital for November 23.
1907 :
1^ Salicylic acid, )
Oil of turpentine, y aa 3ss;
Hydrous wool fat, )
Lard, q. s. ad jiii-
M. Sig. : Apply to the parts affected on lint, and cover
with guttapercha tissue and a flannel bandage.
In chronic rheumatism and gout the following
may be tried :
R Salicylic acid 5v;
Alcohol, 3iii ;
Castor oil, 5vi.
M.
Lint soaked in this is applied in the same way as
the preceding application.
Treatment of Comedones. — Ohmann-Dumesnil
describes in American Journal of Dermatoloi^y some
of the commoner diseases of the skin. In reference
to acne punctata or comedo, commonly known as
blackheads, -he notes that constipation usually ex-
ists, amounting at times to a veritable obstipation.
Of course, he remarks, it is necessary to overcome
this, the removal of the constipation forming a use-
ful adjuvant to the treatment which may be
adopted. In rectal obstipation he says there is no
better remedy than a pill of socotrine aloes to be
taken every night for several days. The diet should
be regulated. The internal remedy preferred by
him is arsenic in the form of arsenous acid [arsenic
trioxide (U. S. P.)], which he prescribes in the
following combination :
B Acidi arsenosi, gr. ii;
Pulv. piperis nigris, 5ii ;
Ext. gentianas, q. s.
M. et ft. cap. No. 60.
Sig. : One capsule after each meal.
Locally the comedones tnay be covered with the
following paste:
R Acidi acetici dil., 3iss :
Glycerini, 3ii ;
Kaolini, 5iiiss.
M. et ft. pasta.
Sig. : Apply at night.
The Medicinal Treatment of Epilepsy. — During
an attack nothing serves so well as the inhalation of
amyl nitrite. Between the attacks bromide salts in
various coir.binations are of value. The following
prescriptions are adapted from several printed in a
recent number of the Journal of the American Medi-
cal Association:
I. ■ •
^ Ammonium bromide, )
Potassium bromide, |- aa 3ii:
Sodium bromide, )
Syrup of orange peel, ^i:
Camphor water, q. s. ad Jviii.
Ft. mistura. Sig. : Two tablespoonfuls three times a
day after food.
IL
B Potassium bromide gr. Ixxx;
Tincture of belladonna TO'xl-lxxx;
Syrup of orange peel, §i ;
Camphor water, q. s. ad Sviii.
Ft. mistura. Sig. : Two tablespoonfuls to be taken
three times a day after meals.
in.
B Ammonium bromide 5ii;
Tincture of digitalis, TlJ'lxiv;
Syrup of orange peel ji;
Camphor water, q. s. ad 5viii.
Ft. mistura. Sig. : Two tablespoonfuls three times a
day after food.
Boric Acid Instillation in Otitis Media. — F. B.
Richards (Lancet, November 30, 1907, and Le
Bulletin medical, No. 94, page 1049) recommends,
in the treatment of acute and chronic otitis media
and other forms of otorrhoea. the instillation of a
concentrated solution of boric acid in alcohol and
glycerin, as in the following formula :
B Acidi borici 4.0 grammes;
Alcoholis 8.0 grammes;
Glycerini 18.0 grammes.
M.
Twice or thrice daily and. especially mornings
and evenings, the ears are syringed out with luke-
warm water. The head is then held so the affected
ear is uppermost and the drops, previously warmed,
are freely poured in.
EDITORIAL ARTICLES.
121
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Reviciv of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M. D.
Addicsft all 'business communications to
A. R. ELLIOTT PUBLISHING COMPANY,
ruhlishers,
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Philadelphia Office : Chicago Office :
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Entered .it the Post Office at New York and admitted for
transportation through the mail as second class matter.
NEW YORK, S.\TURD.\Y, JANUARY i8, 1908.
INDUSTRIAL ACCIDENTS AND DEPEND-
ENCY.
In the highly intricate relationships of the modern
social fabric there is one feature that comes promi-
nently forward in the life work of many physicians.
This pertains to the alleviation of the suffering of
many who are struck down in the struggle of life for
shorter or- longer periods of time by the numerous
accidents of industrial occupations.
In the quarter ending March 31, 1907, according
to statistics furnished by the Department of Com-
merce and Labor, 45.000 accidents were reported in
this country, which number represents a totally in-
adequate idea of the great total. What compensa-
tion is afforded these sufferers and their families
whereby the necessities of life may be acquired, not
to mention that factor which enters into our lives,
the payment of the doctors' bills? Prophylaxis and
remedial legislation looking toward the diminution
of accidents is one phase of the matter w hich cannot
here be discussed. What are the conditions ?
The lawyers of large corporations will tell us that
the many suits brought for damages are mostly of
the nature of blackmail, but the public at large do
not believe it if jury awards are to be regarded as
expressing the views of the masses ; and we, as phy-
sicians, also know that this is far from being a proper
statement of the case. An investigation of about
400 cases coming to the attention of the New York
Charity Organization Society and reported by Fran-
cis H. i\IcLean in a recent number of Charities and
the Commons, December 7, 1907, affords an illu-
minating glance at what really happens in these
cases, and as such throws considerable light on the
subject, interesting alike to general practitioner,
medicolegal expert^ lawyer, and judge.
About one half of the accidents occurred to men
under forty years of age, that is, in the best part of
their industrial life. About 50 per cent, happen to
workmen in unskilled trades. This includes labor-
ers, drivers, 'longshoremen, and others. Taking 241
of the scheduled cases where the wages were
accurately determined, they find that forty-six,
or 25 per cent., were earning from $5 to $10 a week
only ; and that 144, or about 60 per cent., were earn-
ing less than $15. The tables indicating occupa-
tions also show that this range of wages will run
about the same in the cases where the weekly returns
are not given.
Of the cases scheduled, eighty-two accidents were
in the building trades, seventy-six were in connection
with factories and machinery, and thirty-seven hap-
pened upon the street. This last figure, regarding
street accidents, indicates the range of accidents not
covered by the reports of the State bureau. It should
be stated that, of course, no street accidents w-ere re-
corded unless they happened to workers whose duty
took them upon the streets, that is, drivers and mes-
sengers. Those injured on their way to or from
business were not included. The schedule of perma-
nently injured reads as follows: Ampiitations of
fingers or toes, seven ; amputation of legs, feet,
hands, or arms, twenty; brain permanently injured,
ten ; partially crippled, eight ; paralyzed, five ; blind -
ed, fifty-three; permanently injured by blood poison-
ing, two ; spine injured, two ; internal injuries, three ;
loss of hearing, one ; made deaf and dumb, one ;
hernia, resulting in partial loss of wage earning abil-
ity, at least 250; rendered insane, twenty-one ; killed,
forty-five.
Coming to the question of donations or settlements
by employers, the author limits himself to an analy-
sis of about 200 cases, in which the returns were
fairly complete. Of these, some sort of donation or
settlement was made in forty-seven, so far as
known. Absolute accuracy is not alleged for these
figures, but approximation to the total truth. This
is about 20 per cent, of the total. This table of forty-
seven settlements and donations is a veritable crazy
quilt of absurdities when viewed comparatively. For
temporary injuries the settlements are generally quite
fair. That is, full wages were paid during th^ period
of disability in a number of cases. When more seri-
ous results were present, many incongruities were to
be observed. As a corollary, the facts regarding liti-
gation, as nearly as they could be obtained, are given.
Only the 223 cases which are fairly well scheduled
in this regard are taken. The figures given are mu-
122
EDII OKIAL ARTICLES.
Medical Journal.
tually exclusive — suit begun, nineteen ; suit begun,
but settlement expected, three ; suit begun, with no
probable hope of recovery, two ; suit begun, but com-
plicated by absolute release, two ; suit begun and
lost, four; judgment obtained in two cases, one for
S300 and the other for $200. The $300 one is ap-
pealed, and in the other the lawyer took half for his
fee.
With reference to settlements, it should not be for-
gotten that many elements enter into the individual
settlements as they are now made — the question of
liability, how much the sufiferer was himself to blame,
how much the other employees were responsible, and
the size of the company and its ability to make gen-
erous settlements. These and many personal ele-
ments enter in. The net result, however, is one
which is disgraceful for a civilized community.
In forty-nine cases where the families were pro-
vided with charitable assistance there was a stated
expenditure of charitable relief of $2,646. In many
cases, however, such general entries as "rent paid by
society" or "church," etc., appear. It is, therefore,
a conservative estimate to figure $50 as an average
expenditure in the ninety-two families which wert
in care of New York charitable societies. In addi-
tion, it must be remembered that there were 1 1 1 per-
sons who were given hospital care for periods vary-
ing from a month to a year ; also there must be reck-
oned the cost to various charitable agencies, public
and private, in care of the fifty-three blind. To this
must be added the cost of the twenty insane inmates
of the State hospitals, also the cost of medical atten-
tion in the hernia cases, in many of which the suf-
ferers were provided with free trusses, etc. What
the total figures would be involves so much estimat-
ing that the committee in this statement of facts does
not wish to make the venture. It believes that the
amount of money thus expended in relief, through
public and private sources, during one year would
amount to a good round sum.
But this is not all. In ninety-two cases which
were closely under the observation of trained charity
agents special pains were taken to have them make
returns upon the marked deterioration of the fami-
lies themselves resulting from the accidents and the
conditions which followed. Such deterioration was
decided in at least twenty-six of the ninety-two. The
forms of deterioration may be thus summarized :
Chronic dependency ; intemperance, not before pres-
ent ; lowering of standards of living ; breaking down
in health of widow ; family broken up ; habit of beg-
ging developed ; savings used up ; furniture pawned ;
first experience of being dispossessed. When it is
remembered that these ninety-two cases include only
a small fraction of the cases of permanent disability
investigated, the amount of temporary and perma-
nent deterioration becomes a social debt of great
magnitude. What that social debt is, if one were
able to-day to know accurately the results of the
thousands of accidents which have occurred within
the last few years, is the unanswered question.
SULPHUROUS ACID AND THE SULPHITES
AS FOOD PRESERVATIVES.
The chief of the Bureau of Chemistry of the De-
partment of Agriculture, Dr. H. W. Wiley, has re-
cently issued a report of nearly 300 octavo pages
giving an account of his experiments with sulphur-
ous acid and the sulphites used for food preserva-
tives as regards their effects upon the human sys-
tem. In this investigation Dr. Wiley has had the
assistance of Mr. W. D. Bigelow, Mr. F. C. Weber,
and others. The experiments were performed upon
young men who volunteered for the purpose. The
sulphurous acid was administered in the form of the
gas dissolved in water, and the sulphites were given
in capsules. This inquiry is thought to be perhaps
of even greater importance than the previous studies
of the effects of boron compounds and of salicylic
acid and its salts, on account of the more extensive
use now made of the sulphurous substances as pre-
servatives of food products.
The unequivocal conclusion, is arrived at that sul-
phurous acid and the sulphites, which have no nutri-
ent value in themselves, exert a distinct deleterious
influence when taken in considerable quantities and
for more than a very short time. Particular stress
is laid upon the great probability of the production
of serious lesions of the kidneys, inasmuch as a large
proportion of the drugs in question is eliminated in
the urine after the formation of sulphuric acid. As
a matter of course, these lesions could not be dem-
onstrated, for the young men were not brought to
the post mortem table, but there were unquestion-
able indications of such urinary conditions as could
not but result in the long run in actual structural
changes in the kidneys, probably of an incurable
nature. Dr. Wiley's cautious tepiperament would
naturally compel him to stop short of the infliction
of permanent disease, but enough seems to have been
ascertained to prove the danger of resorting to sul-
phurous acid and the sulphites as preservatives of
food preparations, and to indicate that even the fumi-
gation of wine casks with sulphur may lead to a dan-
gerous contamination of the wine contained in them,
which is said to absorb no slight amount of the sul-
phurous acid generated.
It really seems as if only the old household pre-
servatives were safe, such as salt, sugar, vinegar,
brandy, spices, and smoke, and perhaps some of them
should be used less freely than they are at present.
Recent national legislation on the subject has come
none too soon, and it ought to ha supplemented by
State enactments.
Januao- iS, 1908.]
EDITORIAL ARTICLES.
123
THE .ETIOLOGY OF I'.ERIBERI.
Interest in the aetiology of beriberi continues un-
abated. In two papers in the Journal of Hygiene
for October, Axel Hoist and he and Theodor
Frolich compare ship beriberi, which they consider
to be different from true tropical beriberi, to scurvy,
and they publish some interesting feeding experi-
ments to show the connection of ship beriberi and
scurvy and the relation of diet to the production of
the latter disease. The first experiments were per-
formed on pigeons and chickens. In these animals
a disease was produced which resembled tropical
beriberi more than it did ship beriberi, in that a poly-
neuritis was frequently produced. It was also shown
that many more of the ordinary articles of food
were able to produce polyneuritis gallinarnm than
was formerly thought to be the case : for example,
spoiled canned meats.
The mammalian experiments were done on guinea
pigs. It was found that a one sided diet of various
sorts of grain, groats, and bread produced a disease
that corresponded both in its naked eye character-
istics and in its microscopic appearances to human
scurvy. The disease did not develop, however, when
a one sided diet composed of fresh cabbage or fresh
potatoes was administered. Dried potatoes, how-
ever, did produce a similar disease. This disease
was favorably influenced by remedies known as anti-
scorbutics. The authors have not been able to pro-
duce ship beriberi in guinea pigs in this manner.
Those, therefore, who advocate the setiological rela-
tion of mouldy rice and beriberi seem to have the
advantage over those who believe in the bacterio-
logical nature of the disease. In some recent ex-
periments made on tropical beriberi in Hongkong,
Hunter and Koch (Journal of Tropical Medicine
and Hygiene^ October 15th) have concluded that
the organisms found in their culture media which
were inoculated with the blood of beriberics were
the result of defective technique, and that they have
nothing to do with the disease.
THE BLOOD IN POISONING BY ANILINES.
The number of recorded cases of poisoning by
the constant use of coal tar derivatives in this
country is quite large, but the effects of aniline and
of nitrobenzine and closely allied substances have
not been studied to any great extent. A paper on
the condition of the blood in workers in factories
in w'hich these compounds are produced, therefore,
is of some interest. Maiden (Journal of Hygiene,
October) presents a study of the blood in thirteen
men who were working as aniline dyers and twen-
ty-one men who were employed in the manufac-
ture of dinitrobenzol. In the aniline workers he
found that there was a slight increase of the
erythrocytes, with a decrease in the percentage of
the haemoglobin and in the specific gravity of the
blood, a low color index, and evidences of degen-
eration and imperfect development of the red cells.
The differential count of the leucocytes showed a
diminution in the polymorphonuclear neutrophiles
and an increase in the lymphocytes, the eosino-
philes, and the basophiles. In those men who
worked in dinitrobenzol the changes in the blood
were more marked and the condition appeared after
a much shorter time spent in the factory. The
number of erythrocytes was greatly reduced, and
the haemoglobin and the specific gravity were corre-
spondingly lowered, giving a normal color index.
The occurrence of basophilic degeneration is one
of the earliest phenomena of the poisoning. In
cases of chronic poisoning there is a slight leuco-
cytosis, with an increase in the percentage of the
lymphocytes. It is difficult to demonstrate the
presence of meth^emoglobin in the blood by the
spectroscope, except in the most severe cases. From
a number of animal experiments the conclusion is
drawn that both aniline and dinitrobenzol produce
methaemoglobin and haemolysis, and that the condi-
tion in workers in these substances corresponds to
those in animals artificially poisoned, but is on a
smaller scale. The best treatment for poisoning by
these substances is by the inhalation of oxygen.
A "PFIOBIA" OF THE HOSPITALS.
Apropos of the recent expulsion from one of the
large private hospitals of New York of a patient
under treatment for pneumonia, because tubercle
bacilli were found in his sputum, it may well be
asked if the procedure was really warranted by well
founded apprehension of the spread of tuberculous
disease to the other patients. It is said to be the
policy of similar hospitals to insist on the transfer
of such patients, either to one of the free munici-
pal hospitals or to their homes. We do not suppose
that the exposure incident to the transfer need have
an injurious effect on a patient thus transferred,
but the influence of such an arbitrary and apparent-
ly harsh course of action on the patient's morale,
especially in so severe an illness as pneumonia,
must, we should say, be depressing to the degree of
distinctly reducing the prospect of his recovery.
We can hardly wonder that the hospitals operated
by private organizations decline to receive persons
manifestly affected with certain infectious diseases,
but tuberculous infection, particularly when it seems
to be a mere incident in the course of a grave acute
disease and discovered after the patient's reception,
does not appear to us to justify his summary ejec-
tion.
124
NEli^S ITEMS.
INew Vork
Medical Journal.
getos Items.
Medical Reciprocity. — The State Board of Medical
Examiners of Texas has estabhshed reciprocity with the
State boards of Maine, Missouri, Maryland, and Nebraska.
American Psychological Association. — Professor
George E. Stratton, of Johns Hopkins University, has been
elected president, and Professor A. H. Pierce, of Smith
College, secretary, of this association.
Cincinnati Hospital, — Dr. Louis Schwab has been
elected president of the new board of medical directors
of this hospital. Dr. C. R. Holmes has been appointed vice
president, and Dr. A. B. Isham, secretary;
The Buffalo Academy of Medicine. — At the regular
meeting of the Section in Medicine, held on January 14th,
Dr. Irving M. Snow read a paper entitled The Curative
Value of Rest in Children with Chronic Loss of Appetite.
The Gloucester County, N. J., Medical Society held
its annual meeting in Woodbury, X. J., on Thursday, Janu-
ary 16th. The paper of the evening was on Surgical
Di'agnosis, and was' read by Dr. Joseph Price, of Phila-
delphia.
The CHnical Society of the Elizabeth, N. J., General
Hospital will hold its next regular meeting on Tuesday
evening, January 21st, at g o'clock. Dr. James S. Green
will read a paper entitled Vis Medicatrix Naturae in
Surgery.
Society of Medical Jurisprudence, New York. — At a
meeting held on January 13th. the executive officers of the
society were reelected, as follows: Mr. Mortimer C.
Addoms, president; Mr. John C. West, treasurer, and Mr.
Charles Blanev, secretary.
The Alumnae Association of the New York Medical
College and Hospital for Women held its regular bi-
monthly rpeeting on \\'ednesday, January i8th. The paper
of the evening was read by Dr. Emma D. Wilcox on Pre-
ventive Treatment in Diseases of Women.
The Camden County, N. J., Medical Society held its
annual meeting on Tuesday. January 7th. and elected the
following officers for the ensuing year : President, E. A. Y.
Schellenger ; vice president. Dr. W. L Kelchner ; secretary.
Dr. J. W. Martindale; treasurer. Dr. W. H. Pratt; librarian.
Dr. J. H. Wills.
Public Lecture at the New York Academy of Medi-
cine.— Dr. Louis Livingston Seaman will deliver a lec-
ture at the Academy of ^Medicine on Thursday evening.
January 30th, at 8 130 o. m., on the Civil and Military Medi-
cal Organizations of the South American States. All who
are interested are invited to attend.
Medical Society of the County of Kings, N. Y. — The
Section in Paediatrics held a meeting on Friday evening,
January 17th. Dr. F. A. M'arshall presented a case of
Ichthyosis Hystrix; Dr. J. M. Winfield read a paper entitled
Treatment of Eczema in Infancy and Childhood, and Dr.
L. C. Ager reviewed the French paediatric literature for
1907.
The New York Diet Kitchen Association held its
thirty-fifth annual meeting on Thursday, January i6th. Ad-
dresses were made by the president of the association. Mrs.
Villard ; Dr. Samuel T. Armstrong, medical superintendent
of Bellevue and Allied Hospitals, and Dr. William H. Park,
director of the Research Laboratory of the Department of
Health.
The Hartford, Conn., Medical Society held its annual
meeting on January 6th. and elected the following officers
for the ensuing year:* President, Dr. Frederick S. Cross-
field; vice president, Dr. P. H. Ingalls; secretary. Dr. W. H.
Van Strander: assistant secretary. Dr. Orin R. Witter;
treasurer, Dr. George K. Welch; librarian, Dr. Walter R.
Steiner.
The Military Service Institution of the United States
has made the following awards of prizes for the best essays
on current military topics: Seaman Prize, No. i, $100. to
General A. A. Woodhull. M. D.. United States Army: Sea-
man Prize, No. 2. $50, to Major C. Lynch, M. D.. L'nited
States Army: Ames Prize, $50, to Captain E. A. Helmick,
Tenth United States Infantry, and the Fry Prize, $50, to
Lieutenant F. P. Lahm. Signal Corps.
Illinois State Board of Health.— At the thirty-first
annual meeting, which was held in Springfield on Janu-
ary 7th, Dr. George Webster, of Chicago, was reelected
president of the board, and Dr. James A. Egan, of Spring-
field, was reelected secretary and treasurer. This is the
twelfth time Dr. Egan has been elected secretary of this
board.
The Hayden Medal, offered by the Academy of Natu-
ral Sciences of Philadelphia for the most valuable contri-
bution to the science of geology, was awarded to Dr.
Charles Doolittle Walcott, secretary of the Smithsonian In-
stitution, on Tuesday, January 7th. Professor Persifor
Fraser made the presentation address. The medal is of
gold and is awarded triennially.
The Care of Families in which There Is Tuberculosis
was the subject under consideration at a meeting of the
Charity Organization Society of New York, which was held
on January 13th, under the auspices of the committee on
district work of the society. Brief addresses on the subject
were made bv Dr. James Alexander Miller, Dr. Silas F.
Hallock, and Mr. Edward T. Devine, and a general dis-
cussion followed.
The Society of Regular Physicians of New Britain,
Conn. — At the annual meeting of this society, held on
January 7th, the following officers were elected : President,
Dr. S. Wellington Irving ; vice president. Dr. T. Eben
Reeks; secretary and treasurer, Dr. Arvid Anderson. At
the close of the meeting the annual banquet was held at
the New Britain Club. Dr. Irving, the newly elected presi-
dent, acted as toastmaster.
The Ohio State Board of Medical Examination and
Registration. — At a meeting of this board, held on
January gth, the following officers were elected : President,
Dr. A. Ra\ ogli, of Cincinnati ; vice president, Dr. S. M.
Sherman, of Columbus ; secretary. Dr. George Matson, of
Columbus, and treasurer. Dr. E. J. Wilson, of Columbus.
The board announced that twenty-three candidates had
passed the examination held in December.
The Kansas City Academy of Medicine held its annual
banquet on the evening of January 9th. Dr. Frank J.
Hall acted as toastmaster, and the speakers were Dr. E. L.
Chambliss, Dr. C. Lester Hall, Dr. Thomas C. Holland, of
Hot Springs, Ark. ; Dr. J. E, Sawtell, president of the
Kansas Medical Society ; Dr. Charles Babo, president of
the Oklahoma Medical Association : Dr. C. C. C. Stephen-
son, president of the Arkansas Medical Society, and Dr.
J. Q. Qiambers.
Bequest to the Iowa State University Hospital. — By
the will of Mrs. Helen J. Gifford, of Davenport, la., this
hospital will receive $5,000 which is to be devoted to the
maintenance of a free room in the hospital, as a memorial
to Mrs. Gififord's son, Waite Lowrey Gifford. The will also
provides that about $20,000 more shall be added to this fund,
and if three grandchildren die without issue, a trust of
$75,000. in which they have a life interest, is to go to the
hospital.
The Section in Otology andRhinology of the College
of Physicians of Philadelphia. — At a meeting held on
Wednesday evening, January 15th, the foUow-ing papers
were read : Further Observations on the Value of Lactic
Acid as a Remedy for Certain Conditions of the Nasal
Passages, by Dr. A. W. MacCoy ; Some Applications of the
Rontgen Diagnosis to Disease of the Accessory Sinuses, by
Dr. C. L. Leonard, and Primary Mastoiditis, wnth Objec-
tive Tinnitus Aurium.-by Dr. S. MacCuen Smith.
Ohio Medical Teachers' Association. — The third
annual meeting of this association was held in Columbus,
on December 27th. and was the most successful in the
history of the organization. The programme included dis-
cussions of the details of the entrance requirements and the
curriculum of medical colleges and of the standards of
medical education in general. About seventy-five members
were present and a number of visitors, among whom were
the presidents of several literary colleges of the State,
Section in Ophthalmology of the College of Physi-
cians in Philadelphia. — .\ stated meeting was held on
Thursday evening, January i6th. Dr. G. Oram Ring exhib-
ited a case showing the result of the removal of a foreign
bodv from the iris. Dr. Howard F. Hanscll read a paper
entitled The Subsequent History- of a Case of Acquired
Cataract in Childhood. Dr. Walter L. Pyle exhibited a
■ 9o8.] NEiyS ITEMS.
'case of microphthalmos with double inferior total coloboma.
Dr. G. E. de Schweinitz read a paper on Obstetric Injuries
of the Cornea.
The Health of Pittsburgh. — During the week ending
December 28, 1907, the following cases of transmissible dis-
eases were reported to the Bureau of Health of Pittsburgh :
Chicken pox, 6 cases, o deaths ; t3'phoid fever, 70 cases, 8
deaths; scarlet fever, 13 cases, o deaths; diphtheria, 11 cases,
3 deaths ; measles, 94 cases, o deaths ; whooping cough, 6
cases, I death ; pulmonary tuberculosis, 10 cases, 9 deaths.
The total deaths for the week numbered 170, in an esti-
mated population of 403.330, corresponding to an annual
death rate of 21.91 per 1,000 of population.
Medical Society of Franklin County, Pa.— The regular
quarterly and annual meeting of this society will be held in
Chambersburg, Pa.,' on January 21st, at i :30 p. m. There
will be an election of officers and of new members. Dr.
John W. Croft, of Waynesboro, will deliver the presidential
address on Hysteria, and the following papers will be read :
Diagnosis and Treatment of Diphtheria, by Dr. Guy P.
Asper. of Chambersburg; Uncultivated Acres of the Gen-
eral Practitioner, by Dr. J. Burns Amberson, of Waynes-
"boro, and Gymnastics in Heart Disease, by Robert Oden,
INI. G., of Hot Springs, Va.
Medical Association of the Greater City of New York.
- — The annual meeting of this association will be held in
the Academy of Medicine on Monday, January 20th, at
8 -.30 p. m. There will be an election of officers for the
coming year, and the executive council, the corresponding
and statistical secretary, and the treasurer will present their
reports, after which the following papers will be read :
Newer Methods of Examining the Bladder, by Dr. Frederic
Bierhoft; Ureteral Catheterization, by Dr. F. Tilden
Brown ; Lithotomy versus Lithotrity, by Dr. James Peder-
sen, and Conservative Prostatectomy, by Dr. Follen Cabot.
The Mortality of Chicago. — According to the report
of the Department of Health for the week ending January 4.
1908, there were during the week 665 deaths, as compared
with 673 for the corresponding week in 1907. The annual
death rate was 16.01 in 1,000 of population. The principal
causes of death were : Apoplexy, 10; Bright's disease, 44:
bronchitis, 20; consum.ption, 67: cancer, 30: convulsions, 8:
diphtheria, 23; heart diseases. 56; influenza, 19; intestinal
diseases, acute, 25 ; measles, 6 ; nervous diseases. 32 ; pneu-
monia, 116; scarlet fever. 14; suicide, 13; typhoid fever. 3;
violence, other than suicide, 29; whooping cough, i; all
other causes, 149.
The East Side Physicians' Association of the City of
New York. — A stated meeting of this association was
held on Friday evening, January 17th. Dr. Max Ghertler
presented a case of congenital heart lesion and Dr. George
Dow Scott presented a case for diagnosis. Dr. A. E. Isaacs
exhibited a case of carcinoma of the sigmoid causing acute
intestinal obstruction, also a wired fracture of the patella,
with radiograph. Dr. Abram Brothers presented some in-
teresting gynaecological specimens, and Dr. I. Seth Hirsch
demonstrated "electric sleep" by means of the Leduc cur-
rent. Dr. Leon F. Garrigues read a paper on the Causes
and Treatment of Backache in Women.
The Spokane County, Wash., Medical Society gave a
banquet on the evening of January 8th. in honor of the
Washington State Board of Medical Examiners, at the
close of the semiannual examination ot applicants for li-
censes to practise in the State of Washington. Dr. N.
Fred Essig, of Spokane, acted as toasinia-ter. and addresses
were made bv the following speakers : Dr. D. Mason. Dr.
W, F. Morrison. Dr. Henrv S. Martm. Dr. E. B. Nelson,
Dr. George K. McDowell, Dr. J. G. Cunningham, Dr. N. M.
Baker. Dr. E. D. Olmstead. Dr. M. A. W. Shockley, Dr.
T. L. Catterson, Dr. C. M. Doland. Dr. C. W. Sharpless,
Dr. W. Johnson, and Dr. \\'. J. Munley.
The Bill to Increase the Medical Corps of the Army.
—A bill providing for an increase of the number of colonels
in the medical corps of the Army from nine to fourteen:
lieutenant colonels from twelve to twenty ; of ma.iors
from sixty to one hundred, and of captains and first lieu-
tenants from two hundred and forty to three hundred, has
been favorably reported by the Committee on Military
.\ffairs of the House of Representatives and of the Senate.
The measure provides that contract surgeons may be
permanently appointed to the medical corps, and also pro-
vides for a reserve medical corps to serve in time of war.
The leaders in both houses seem to look favorably upon
the bill, and the probabilities of its becoming a law at this
session of Coongress seem to be quite strong.
Scientific Society Meetings in Philadelphia for the
Week Ending January 25, 1908.- Monday, January 20th,
Northeast Branch, Philadelphia County Medical Society.
Tuesday, January 21st, Dermatological Society ; Academy
of Natural Sciences ; North Branch, Philadelphia County
Medical Society. Wednesday, January 226, Philadelphia
County Medical Society. Thursday, January 23d, Patho-
logical Society ; Entomological Section, Academy of Nat-
ural Sciences ; Section Meeting, Franklin Institute. Fri-
day, January 24th, South Branch, Philadelphia County
Medical Society; Northern Medical Association. Saturday,
January ^jth, Samaritan Hospital Medical Society.
Philadelphia Paediatric Society. — At a meeting of this
society, held on Tuesday, January 14th, Dr. I. H. Jones
presented a case of fibroid nasal polypus in a boy, Dr. J. T.
Rugh showed a case of spondylitis complicated by a psoas
abscess following measles, and a case of Bell's palsy in an
infant three months old was shown by Dr. J. Claxton
Gittings. Dr. Thomas A. Cope gave a demonstration of the
routine methods of differentiating the various fats and
casein in infant's stools ; Dr. D. J. M. Miller reported a
case of empyema and gangrene of the lung complicating
typhoid fever, and Dr. John D. Target reported a case of
spina bifida with other abnormalities. The annual presi-
dential address was delivered.
Improvements of the City (Charity) Hospital. — Plans
have been filed for improvements on Blackwell's Island
and Randall's Island, as follows : For Blackwell's Island,
a four story tuberculosis pavilion, with roof gardens, solar-
ium, and exterior verandas, to cost $180,000 ; a one story
and attic hospital pavilion for the City Home for the Aged
and Infirm, to cost $75,000; a two story pathological labor-
atory, to cost $40,000, and a three story and attic residence
for the medical staff, to cost $80,000. All these buildings
are to be grouped around the Manhattan Hospital, of which
they are to be annexes. On Randall's Island, a four story
home for nurses, to cost $200,000, is to be added to the
plant of the Children's Hospital. The total cost of the
five buildings will be $575,000.
Philadelphia Branch of the American Pharmaceutical
Association. — The January meeting, which was held on
Tuesday evening, January 7th. v.as devoted to a discussion
of the valuation of drugs and assay processes. The follow-
ing papers were read : Recent Progress in the Chemistrj'
of Alkaloid Estimation, by Professor W. A. Puckner ; The
Pharmacopoeia from the Viewpoint of a Scientific Worker,
by Dr. A. Pearson ; The Standardization of the Prepa-
rations of Digitalis by Physiological Means, by Dr. E. D.
Reed ; The Standardization of the Preparations of Digitalis
by Chemical Means, by Mr. Charles E. Vanderkleed ; The
Use of the Compound Microscope in the \''aluation of
Crude and Powdered Drugs, by Professor Henry Kraemer.
An interesting discussion followed.
Infectious Diseases in New York:
We are indebted to the Bureau of Records of the Health
Department for the foUon'ina statement of new cases and
deaths reported for the two iveeks ending January ii, 1908:
--January 4.^ ^January ii.-.
Cases. Deaths. Cases. Deaths.
Typhoid Fever 37 8 SS 6
Smallpox . . . . 2
Varicella 98 . . 199
Measles 5S1 32 691 35
Scarlet fever 4/8 33 562 49
Whooping cough 2^ i 24 i
Diphtheria 308 36 370 * \^
Tuberculosis pulmonalis 344 158 432 171
Cerebrospinal meningitis 11 8 if' 11
Totals 1,882 276 2,351 315
For the Prevention of Tuberculosis in New York.—
On Monday evening, January 27th, a public meeting is to
be held in Albany to inaugurate a general campaign of
education as to the best methods for the prevention of
tuberculosis. The meeting is being arranged by the State
Charities .\id Association in cooperation with the State
Department of Health. The Hon. Joseph H. Choate
will preside and Governor Hughes will be the prin-
cipal speaker of the evening. .'\ddresses will also be
delivered by Dr. William H. Welch, of Johns Hopkins
126
NEIVS ITEMS.
[Niiw York
Medical Journai.-
University; Dr. Eugene H. Porter, State Commissioner of
Health ; Mr. Homer Folks, secretary of the State Chari-
ties Aid Association; Mr. George F. Canfield, vice presi-
dent of that organization, the Lieutenant Governor and
the Speaker of the Assembly.
The Section in General Medicine of the College of
Physicians of Philadelphia held a meeting on Monday,
January 13th, and the evening was devoted to a symposium
on the recent advances in knowledge of affections of the
heart. The programme was as follows : A case of Adams
Stokes diseases was presented by Dr. B. F. Stahl, and Dr.
George W. Norris exhibited pulse tracing from the same
case demonstrating the heart block. Dr. Joseph Erianger,
of Madison, Wis., read a paper on Recent Advances in the
Pathological Physiology of the Heart with Special Refer-
ence to Arrhythmia. Dr. Lewis A. Conner, of New York,
read a paper on the Clinical Study of Heart Cases, and a
paper on the Use and Abuse of Digitalis and Other Heart
Tonics, was read by Dr. Theodore C. Janeway, of New
York. The following formal discussion was held : Dr.
John H. Musser, on the Importance of Instruments of Pre-
cision in the Study of Heart Cases; Dr. Hobart Amory
Hare, on Remedial Measures other than Drugs in the
Treatment of Heart Disease; Dr. Alfred Stengel, on Ex-
tracirculatory Manifestation of Cardiac Failure, and Dr.
Joseph Sailer, on Blood Pressure in Relation to Prognosis
in Heart Disease. After the meeting a reception was tend-
ered to Dr. F,rlanger. Dr. Conner, and Dr. Janeway at the
University Club.
Society Meetings for the Coming Week:
MoND.w, Jannuyy 30th. — New York Academy of Medicine
(Section in Ophthalmology) ; Medical Association of
the Greater City of New York (annual) ; Hartford,
Conn., Medical Society.
Tuesday, January 21st. — New York Academy of Medicine
(Section in Public Health) ; Medical Society of the
County of Kings, N. Y. (annual) ; Triprofessionaf
Medical Society of New York; Buffalo Academy of
Medicine (Section in Patholog)') : Binghamton. N. Y.,
Academy of Medicine ; Clinical Society of the Eliza-
beth, N. J., General Hospital; Syracuse, N. Y., Acad-
emy of Medicine ; Ogdensburgh, N. Y., Medical Asso-
ciation ; Medical Society of the County of Westchester,
N. Y.
Wednesday, January 22d. — New York Academy of Medi-
cine (Section in Laryngology and Rhinology) ; New
York Surgical Society.
Thursday, January 23d. — New York Academy of Medicine
(Section in Obstetrics and Gynecology) ; Brooklyn
Pathological Society ; New York Celtic Medical Soci-
ety; Hospital Graduates' Club, New York (annual).
Friday, January 24th. — Academy of Pathological Science.
New York: New York Clinical Society; New York
Society of German Physicians.
Saturday, January 2fitli. — West End Medical Society, New
York: New York Medical and Surgical Society; Har-
vard Medical Society. New York ; Lenox Medical and
Surgical Society, New York.
Personal.— Dr. William H. Welker, assistant in bio-
logical chemistry at Columbia University, has been ap-
Ijointed demonstrator of physiological chemistry at the
University of Pennsylvania, to succeed Dr. P. B. Hawk.
Dr. Marshall Langdon Price has been appointed secretary
of the Maryland State Board of Health.
Dr. Theobald Smith, professor of comparative pathology
at Harvard University, has received the degree of doctor
of laws from the University of Chicago.
Dr. E. Chapot, i)revost professor of histology at the Uni-
versitv of Rio de Janeiro, died recently.
Dr. James U. Barnhill has retired from the editorship of
the Columbus Medical Journal, in order to devote more
time to his private practice.
Sir Thomas ClifYord Allbutt, M. D., regius .professor of
l)hysics at Cambridge University, was created a Knight
Commander of the Bath on December i6th. A compli-
mentary dinner was given him by the Master of Downing
and the medical men of Cambridge.
Sir William Bennett has been elected president of the
Institute of Hygiene, London, to succeed the late Sir W. H.
Broadbent.
Dr. Nicholas Senn, whose death occurred on January 2d.
had just received the Order of Merit of the Japanese Soci-
ety o<f the Red Cross, by the sanction of the Emperor of
Japan, and had recently been elected an honorary member
of the Royal Medical Society of Budapest.
Dr. Clarence J. Broeman, of Cincinnati, has been ap-
pointed house surgeon of the New York Skin and Cancer
Hospital.
The New York Academy of Medicine. — The Section,
in Ophthalmology will meet on Monday evening, January
20th, at 8.15 o'clock. Dr. J. E. Weeks will present a
patient showing iridectomy in glaucoma after the method
of Lagrange, and Dr. E. B. Coburn and Dr. Mortimer
Warren will present a case of phlyctenular eye disease
treated with tuberculin. The paper of the evening will be
read by Dr. H. \V. Woolton on Final Results of the Ex-
traction of Senile Cataract. There will be an election of
officers.
A meeting of the Section in Medicine will be held on
Tuesday evening, January 21st, at 8.30 o'clock, when the
following papers will be read : The Significance of Acetone
Bodies, with a Clinical Method for Their Quantitative
Determination, by Dr. T. Stuart Hart : Metabolism in
Pneumonia, by Dr. Alexander Lambert and Dr. C. G. L.
Wolf; Experimental Notes on Artificial Nutrition, with:
Especial Reference to the Hypodermic Method, by Dr.
Herbert S. Carter.
The Section in Laryngology and Rhinology will meet on
Wednesday evening, January 22d, at 8.15 o'clock, when the
following progrannne will be presented : Dr. Joseph H.
Abraham will present a patient showing a case of neglected
syphilis, with marked destruction of the nose, nasal cavities,
palate and tongue; Dr. J. A. MacKenty will report
three cases of trichinosis involving the upper respiratory
passages ; Dr. J. E. Newcomb will read a paper entitled
Hrematoma and Al)-ccss of the Sreptnm ; Dr. Sydney Yank-
hauer will show a specimen of a foreign body removed
from the bronchus ; Dr. John McCoy will exhibit a new
tonsil and faucial pillar separator, and Dr. J. Wolff will
present a new method of post nasal tamponade.
The Section in Obstetrics and Gynecology will meet on
Thursday evening. January 23d, at 8.30 o'clock. There
will be a general discussion of the subject of the manage-
ment of febrile conditions after abortion and labor,^and a
paper on Uterine Cysts will be read by Dr. Ulysses Kahn.
Annual Meeting of the Medical Society of the State
of New York. — The progrannne for the one niin 'red and
second annual meeting of this society, which takes place
at Albany on January 28lh, 29th, and 30th. has just been
issued. The sessions will be held in the Common Council
Chamber, City Hall, coiner of Maiden lane and Eagle
street, Albany. The time and place of the sittings follow :
Monday, January 27th. — 8 p. m. : Meeting of Council
in the anteroom of the Common Council Chamber, Cit\-
Hall. 8 :30 p. m. : Meeting of House of Delegates, Super-
visor's Room, City Hall.
TuEsn.w . Juiniary sSth. — Meeting of House of Delegates.
Supcr\i-M!'s k.iom. City Hall. (Time and place to be
selcctc<l at til.- meeting on Monday night.) 11:30 a. m. :
.Scieniitic Ses-ion, Common Council Chamber, City Hall.
2 p. m. : Scientilic Session, Common Council Chamber.
City Hall. 8 p. m. : Section in Cutaneous Diseases, Com-
mon Council Chamber, City Hall. Bp. m. : Section in
Public Health, Court Room, City Hall.
Wednesday, January 29th. — 9:30 a. m. : Scientific Ses-
sion, Common Council Chamber, City Hall. 2 p. m. :
Scientific Session, Common Council Chamber, City Hall..
7 :30 p. m. : Banquet at Hotel Ten Eyck.
Thursday, January jotli. — 9:30 a. m. : Scientific Session,
Common Council Chamber, City Hall. 12 noon : Meeting
of Council.
Arrangements have been made with those in charge of
the State Tuberculosis Exhibit to have this collection set
up in one of the rooms of the City Hall during the meet-
ing, so that those who attend may have the opportunity
of studying this subject from a practical standpoint. An
important public meeting connected with this work will
be held on Monday evening, January 27th. at Harmamis
Bleecker Hall. It will be presided over by the Hon. Joseph
H. Chonte, and addrcses will be made by Governor
Hughes, Dr. William H. Welch, of Baltimore, and others.
.\ reduction of a fare and one third from points in New
York State, on the certificate plan, has been secured for
l^hose attending the meeting.
Dr. Frederic C. C'.irtis, of Albany, is president of the
society, and Dr. Wisner R. Townsend, 125 West Fifty-eighth,
street,. New York, is secretary.
January iS, ipcS.]
FITH OF CURRENT LITERATURE.
127
|it^ flf Current fittrature.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
January g, 1908.
1. Practical Application of Opsonic Therapy (To Be Con-
tinued). By Theodore C. Beebe.
2. Mexican Mining Practice from a Tuberculous Point of
View, By J. S. Kahn.
3. Chronic Dyspepsia, By John B. Deaver.
4. A Method of Obtaining Extension for Fractures in the
Upper Two Thirds of the Humerus,
By Howard A. Lothrop.
2. Mexican Mining Practice From a Tuber-
culous Point of View. — Kahn remarks that a
physician \vith phthisis could liardly find a better
place for practising medicine than a Mexican moun-
tain mining- camp. Labor, says Dr. Kahn, is very
cheap out there, the average Alexican peon drawing
a daily salary of 1/2 pesos or 75 cents in United
States currency, the companies usually furnishing
them "houses" — one room affairs, occasionally made
of adobe (bricks made of mud and straw as in our
western country), but more frequently juicals of
cactus stalks and dried grass. Not infrequently these
houses are merely small caves in the hillsides, with
a front wall of cactus stalks. In addition to homes,
medical care is also furnished them, so that practic-
ally every camp of six hundred or more has its own
hospital or dispensary with a resident doctor paid
bv the company. The drug stores are well stocked,
the doctor being usually given a free hand in the
purchase of drugs and supplies, the companies al-
lowing him more expensive synthetical proprietary
preparations, even plenty of diphtheria antitoxine at
$6.50 gold per 4,000 units. An intelligent Alexi-
can is always given as assistant to do the cleaning,
the simple bandaging, to help dispense medicines,
and to give anaesthetics. Tablet medication is used
as a rule, as far as possible, but tliere is always a
goodly stock of United States Pharmacopoeia elixirs,
tinctures, and fluidextracts to be used when desired.
The doctor is supposed, as a rule, to furnish his own
instruments (these are admitted to Mexico duty
free) : and usually no provision is made for beds in-
side the hospital or for trained assistance. The au-
thor remarks that he receives 50 cents gold for
an office visit, $1 for a house visit, double for ven-
ereal visits, $2 for a house visit or each visit to a
confinement case, $5 to $15 for stab or gunshot
-wounds, and 50 cents a stitch for superficial
wounds. The proportion that he receives is veri-
similar in extent to that of the average doctor north
of the Rio Grande. It amounts to enough in a week
to about meet living expenses, and does not include
the salary. A furnished house is usualh' given to
the doctor, rent free, if married, otherwise the best
room in the settlement, that is, a house or room
furnished from the point of view of a mining camp,
which means, clothes closets, desks, table?, wash-
stands, and chairs, and even at times beds, usually
all built by the mine carpenter. Still, varnish is not
•essential to happiness, and canvas seats and backs
to chairs, while they do not appeal to aesthetic sensi-
bilities, are yet far from uncomfortable. These
rooms or houses are frequently lit by electricity, gen-
erated in the power house for working the mine
■hoists, etc. Another not uncommon luxury is a
shower bath with hot water derived from the air
compressing machines for ventilating the mines,
4. A Method of Obtaining Extension for
Fractures in the Upper Two-thirds of the Hu-
merus.— Lothrop describes his method, which he
used in an attempt to correct a marked deformity in
a case of fracture of the surgical neck. Under ether
union was completely broken up and the follow-
ing apparatus immediately applied : A tin, internal
angular splint was applied, but the short arm of the
splint was adjusted to the patient's forearm and the
long arm was of sufficient length to reach tc a point
a little above the level of the acromioclavicular
articulation. The vertical arm need not reach above
the level of the axilla, provided the coaptation splint
reaches the angle of the tin splint for direct resist-
ance. A stiff felt shoulder cap, suitable in size and
shape for the patient, was selected. This was
padded and placed on the outer aspect of the shoul-
der. Its front portion covered the vertical arm of the
internal angular splint. By means of strapping, the
shoulder cap was fastened to this arm of the internal
angular splint in such a position that its upper
rounded extremity was two inches above the con-
vexity of the shoulder, thus leaving a considerable
space. By means of strapping, the tin splint and the
shoulder cap were made one piece. By means of
one or two rather wide circular strips of adhesive
plaster this apparatus was adjusted firmly to the
upper arm. Downward pressure on the top of the
cap would produce extension in proportion to the
degree of force exerted. Pressure directed back-
ward would carry the upper end of the lower frag-
ment in the same direction. A sling was applied for
support only of the hand and distal half of the fore-
arm, which was thus maintained horizontal across
the chest, A four inch gauze bandage was then ap-
plied. The essential features of this apparatus are,
first, the careful adjustment of the splints, so as to
leave a large free space above the shoulder and
under the upper end of the shoulder cap ; and, sec-
ond, the application of the bandage so as to exert
pressure on the top of the cap downward and back-
ward. The opposite axilla should be padded and a
pad should be adjusted carefully between the front
edge of the cap and the arm at the site of fracture,
if of the surgical neck, the former to protect from
the pressure of the bandage, the latter to help force
the upper end of the lower fragment backward.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
January 11, igo8.
1. The Problems of State Boards of Health,
By Charles D. Smith.
2. The Iinportance of Early Recognition and Treatment
of Rachitis, By Thomas S. Southworth.
3. False Statements Concerning Causes of Oral Pathology,
By S. Blair Luckie.
4. The Signihcance of Changes in the Optic Nerve in Cer-
tain Affections of the Cerebrospinal System,
By William Campbell Posey.
5- Rontgen Ray in Epithelioma,
By William Allen Pusey.
6. Adenomyoma of the Uterus, By Thomas S. Cltllen.
7. The Opsonic Index in Orthopaedic Surgery,
By Charles Ogilvy and T. Homer Coffin.
4. The Significance of Changes in the Optic
Nerve in Certain Affections of the Cerebrospinal
System. — Posey remarks that the classification
of changes in the optic nerve which has been adopt-
128
PITH OF CURRENT UTERATURE.
[New York
Medical Journal.
ed by most opthalmologists is based on the location
of the inflammation according to its site in the axis
of the nerve, the term "papilHtis" being used to
designate all forms of inflammation which affect
the head of the nerve and produce visible ophthal-
moscopic changes, while involvement of the nerve
in its deeper portion is described by the terms "de-
scending" and "retrobulbar" neuritis. In true
papillitis, the swelling of the disc is very great, and
while in the early stages the veins less frequently
present dilatations than in neuritis from meningitis,
the retinal vessels become later greatly dilated and
tortuous, especially the veins. Haemorrhages and
extravasations into the retina are not uncommon.
In descending neuritis, the swelling of the papilla
is never very pronounced, and there is a disposi-
tion for the inflamation to spread to the adjacent
retina. The changes in the disc, too, are often
most intense at the periphery, the centre being but
slightly involved. Hemorrhages and extravasa-
tions are not uncommon, and the vessels are not
kinked as they pass over the edges of the nerve, as
is so often the case in intense degrees of neuritis.
Retrobulbar neuritis may be regarded as a mixed
condition of interstitial inflammation of the nerve
with atrophy. In this variety of neuritis there are
at first either no ophthalmoscopic signs or merely
those of simple congestion. Later, after the disease
has subsided, signs of atrophy usually make their
appearance. Retrobulbar neuritis may occur in
either an acute or chronic form. In the former,
which is induced usually by gout, syphilis, or
sinusitis, there is rapid loss of sight with neuralgic
pain in the temple. In the latter the loss of sight is
very gradual and there is but little pain. Nycta-
lopia is a frequent symptom in this form of neuritis,
the patient declaring that he sees better in a dim
illumination, exposure to an excessive light leading
to a deterioration in vision which may last for some
time. In primary atrophy the disc is gray or
grayish white ; the scleral ring surrounding the
nerve is broadened and the stippling in the lamina
cribrosa is plainly visible. In this connection it
must be remarked that although this form of
atrophy has been described as occurring without
signs of previous inflammation, in the early stages
of the degeneration the nerve sometimes assumes a
dull red tint, due to a superficial overcapillarity.
while the deeper portion of the nerve is gray and
lacking in circulation. The retinal vessels are but
little altered. In secondary atrophy the disc is
usually whiter than in the foregoing and the retinal
vessels are more or less contracted. In consecutive
atrophy the disc is not only pallid, but possesses
also a bluish or greenish tint, from the connective
tissue overgrowth resulting from the previous in-
flammation of the nerve. The head of the nerve
is considerably shrunken and appears as though
filled in by connective tissue, the excavation being
veiled. Finally, the retinal vessels are much con-
tracted, and, if, as may be the case, the neuritis
originating the atrophy was dependent on an in-
flammation of the inner coats of the eye, atrophic
areas and heaps of pigment may be seen in the
retina and chorioid adjacent to the disc.
6. Adenomyoma of the Uterus. — Cullen could
trace the mucous membrane origin of the glands in
fifty cases of uncomplicated diffuse adenomyomata
of the uterus. In six additional cases where squa-
mous cell carcinoma of the cervix complicated
adenomyoma of the body the continuity was estab-
lished in five cases. In two cases of diffuse
adenomyoma of the bpdy the clue as to the origin
of the glands was destroyed by adenocarcinoma of
the body. Thus in only one case out of fifty-six
where he expected to find the glands originating
from the mucosa, if his view as expressed in 1896
was correct, did he fail to find it substantiated. It
will thus be seen that when we include adenomyo-
mata of every kind, whether subperitoneal, sub-
mucous, or dififuse, he has been able in fifty-six
out of seventy-three cases to trace the origin of the
gland element to the uterine mucosa. All ade-
nomyomata of the uterus in which the gland ele-
ments are similar to those of the uterine mucosa,
and are surrounded by stroma characteristic of that
surrounding the normal uterine glands, owe their
glandular origin to the uterine mucosa or to Miil-
ler's duct, no matter whether they be interstitial,
subperitoneal, or intraligamentary, solid or cystic.
7. The Opsonic Index in Orthopaedic Sur-
gery.— Ogilvy and Coffin observe that tuberculin
in small doses at proper intervals is of undoubted
value in the treatment of selected cases of tubercu-
lous bone and joint infections. The rise of the opso-
nic index is accompanied by an improvement in the
local and general conditions of the patient, if no
secondary infection exists. The opsonic index will
prove of value in determining the advisability of dis-
continuing mechanical treatment, and in determin-
ing the prognosis in tuberculous bone and joint dis-
ease. While there are discharging sinuses and
mixed infections the opsonic index ma>- be raised by
the use of tuberculin, without an accompanying im-
provement of the general or local conditions.
MEDICAL RECORD
January 11, 1908.
1. The Plague, By Alvah H. Dotv.
2. The Renal Coniplic:>tions and Sequel?? of Influenza,
By Heinrich Stern.
Influenza of the Nose, Throat, and Larynx,
By W. SoHiER Bry.-\nt.
4. Duchenne of Boulogne. A Biography and an Apprecia-
tion, By Joseph Collins.
5. Relation of Accidents to Functional Nervous Diseases
and Psychoses ; Medicolegal Considerations,
By Alfred Gordon.
6. Fcetid Breath ("Bromopnoea"), By William J. Lederer.
7. Forms of Tubercle Bacilli Which Cannot Be Colored
by Ziehl-Neelsen Stain, By C. A. Treuholtz.
3. Influenza of the Nose, Throat, and Larynx.
— Bryant remarks that the treatment of influenza of
the nose, throat, and larynx is abortive, local and
general, besides the treatment of the complications.
The abortive treatment consists in the local u>-"e of
astringent antiseptics which sometimes abort and
often ameliorate the virulence of the infection if they
are applied immediately on the appearance of the
first sign of local discomfort, pain, or oedema. Silver
nitrate in 10 per cent, solution, painted on the af-
fected area has given nuich satisfaction. Alcohol
99 per cent, with equal parts of glycerin has worked
nearly as well. Local treatment is directed to the
relief of the oedema, assuaging pain and tenderness,
and cleansing and partially sterilizing the mucous
Januaiy iS, 190S.J
PITH OF CURRENT LllERATURE.
129
surfaces. In the nose and throat this may be accom-
phshed with silver nitrate ; a sokition in strength ot
from 2 to 5 per cent, apphed with a swab has given
good resuhs. Argyrol, up to 30 per cent., on a swab
is good. When there is a false membrane, a spray
of hydrogen peroxide is indicated. After the acute
stage is passed and the oedema gone, a spray of
Dobeirs solution seems to facilitate expectoration of
the mucopurulent secretion. When the discharge has
lessened, an alkaline aromatic spray is desirable to fin-
ish up with. Hydrogen peroxide gargle is indicated
for the throat if a purulent condition exists there.
In the larvnx, the applications must be considerably
reduced in strength. Silver nitrate in 2 per cent,
solution can be applied with a swab or spray after
cocainization. Alcohol 95 per cent., and glycerin,
each one ounce, ferric chloride, 15 grains, and water,
two ounces, make a good spray. The general treat-
ment demands absolute rest in bed and light purga-
tion followed by stimulation, especially circulatory,
to keep up the failing strength. Special attention
must be paid to keeping up nutrition. The ingestion
of large quantities of physiological salt solution is
desirable to help the naturally increased diaphoresis
and stimulate diuresis for the purpose of washing
out the toxines. Small doses of salol (gr. iii), calo-
mel (gr. and sodium bicarbonate ( gr. x. ) tend
to keep the alimentary canal in good order. ( ieneral
anodynes and hypnotics are to be chosen w^th care
to avoid the weakening of the heart's action. Do-
ver's powder or codein seems to be satisfactory.
Trional can be used with care. The pains may be
greatl}- relieved by the application of heat or counter-
irritation. The nasal occlusion is best managed
with a 2 per cent, cocaine spray followed by adrenal
powder and an alkaline aromatic spray. The sinus
complications are treated by keeping the nose free
by the method already described. If that is not suf-
ficient, the hot nasal douche should be used ; take
two quarts of salt solution as hot as can be borne
with half an ounce of sodium bicarbonate, and use
a fountain s}ringe at an elevation of six inches, al-
lowing the solution to run into one nostril and out
the other. After the douche use some aromatic spray.
The tonsillar condition can be treated by strong ap-
plications of silver nitrate up to 15 per cent., or by
hydrogen peroxide gargle or spray preceded by a
hot water gargling. If there is an accumulation of
pus an incision is indicated to evacuate it.
5. Relation of Accidents to Functional Nerv-
ous Diseases and Psychoses ; Medicolegal Con-
siderations.— Gordon speaks of his extensive ex-
perience among all accidents and cites cases as ex-
amples for points he wishes to bring out. In con-
clusion he remarks that in cases of railway or other
injuries caused by neglect of those who have in
charge the management of transportation cars, it
is no more than just that the injured person should
be compensated for disability. On the other hand,
simulation or exaggeration of incapacity should be
condemned. The physician is indispensable to the
law. In the name of justice he must be invariably
reserved in his statements. His opinion must be
formed after a thorough study of each individual
case. He must not forget that, while some severe
traumatisms produce mild symptoms, some msignifi-
cant traumata cause marked disturbances of the
nervous system. The degree of the disability and
the prognosis of the affection vary in each individual
case. The recognition of the affection, the recog-
nition of the influence of the accident upon its mani-
festations, finally the discrimination of a genuine
malady from a simulated one— all these elements can
be acquired only when the physician is properly
prepared. In view of the practical importance of
the subject, a continuous study of it is indicated.
7. Forms of Tubercle Bacilli Which Cannot
be Colored by Ziehl-Neelsen Stain. — Treuholtz's
investigations seem to show that the tuberculous
virus frequently exists in some form that cannot be
stained by our usual methods and which is capable
of rapidly developing into the fully grown tubercle
bacillus capable of being stained bv the method of
Ziehl-Neelsen. It is hardly possible that the large
number of bacilli found after incubating the spleen
can be accounted for by rapid division of those that
may be present in the tissue, and moreover single
bacilli were the rule in the incubated tissue ; it was
further found that the spleen which had been incu-
bating three weeks did not show any marked in-
crease in the number over that of four days. In
drawing conclusions from the granules found, says
the author, we are confronted with several sources
of error, namely, the possibility of the presence of
other Gram staining organisms, precipitated stain,
and points of deeply staining chromatin ; these er-
rors were excluded as much as possible by cultural
experiments and staining of control slides of normal
tissue. An interesting point noticed in these investi-
gations was that the Gram staining bacilli showed
a much greater frequency of beading than the Ziehl-
Neelsen stained bacilli. These investigations open
up an interesting field of work and will probably
prove of utility in the studv of negative sputa and
other tuberculous products where the tubercle bac-
cillus has hitherto been very difficult to find.
BRITISH MEDICAL JOURNAL.
December 28, 1907.
1. The Mental Origin of Neurasthenia and Its Bearing on
Treatment, By D. Drum mono.
2. Clinical Remarks on Tuberculous Chlorosis,
By A. J.\MES.
3. The Automatic Rhythm of the Heart,
By A. M. GossAGE
4. Locomotor .\taxia : Its Early Recognition and Gen-
eral Management. By E. A. Dent.
5. An Open Method of Etlier Administration,
By F. W. B.\iLEY.
6. An Open Continuous Drop Method of Administering
Ether, By A. Brownlee and J. L. Thom.^s.
7. Malignant Endocarditis Lasting Over Six Months
Without Bruit, By R. Capes.
I. Neurasthenia. — Druinmond states that ii
neurasthenia the physical symptoms are without
pathological basis. With rare exceptions an estab-
lished nervous temperament has been inherited.
Overwork, mental strain in business, the grief of
bereavement, or some alarming shock do not in
themselves produce neurasthenia and cannot be said
to be its cause, though by lowering health and
weakening mental control they may contribute to
the development of the more serious disturb-
ance. But uncontrolled and bad habits of
thought in early life have a cramping and dam-
I30
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
aging effect on the mind. Among the points indi-
cating the neurotic nature of the symptoms are the
following: Neurotic pains are often described as
constant, as always present during waking hours;
organic pains are seldom so described. The lan-
guage employed in describing symptoms is gener-
ally exaggerated, expansive, and florid. Neuras-
thenic patients usually bring with them some rela-
tive or friend to endorse their story, though thev
may be perfectly well able to describe all their
symptoms in detail. Pari passce with the progress
of the symptoms there is evidence of an ever in-
creasing nervousness. This is valuable, because in
cases of organic disease the functional aspect be-
comes less noticeable as the disease advances. As
regards treatment the point of chief importance is
mental treatment administered under the most fa-
vorable conditions, of which the first essential is iso-
lation under the doctor's control. The mental treat-
ment is, in fact, a sort of education with encourage-
ment. The plan adopted should not be too rigid,
treatment being always directed, in one way or
another, to the one end of leading the patient away
from the constricted, selfcentered habit of mind in
which attention is absorbed in narrow personal feel-
ings, and substituting an interest in the wider af-
fairs of life. To this main object the various helps
of rest, over feeding, massage, etc., can be re-
garded only as subordinate accessories.
2. Tuberculous Chlorosis. — James states that
in cases which present in a more or less marked
degree all the ordinary appearances of chlorosis,
and yet in which the examination of the blood
shows the red corpuscles and haemoglobin to be
norm.al, there is very often found a history of past
or present tuberculous disease. This is the con-
dition called by Trousseau false chlorosis or tuber-
culous anaemia. Anaemia in tuberculosis is now
well recognized, but the possible association of tu-
berculous disease in cases of apparent chlorosis is
often overlooked. The writer suggests that in
these cases there is really an oligaemia — that is, a
diminution in the total amount of blood. This the-
ory explains why on recovery we get associated
with increased volume of blood improvement alike
in the appearance and in the nutrition and vigor of
the patient, and yet the haemocytometer and the
haemcglobinometer show little or no change. In
the treatment of tuberculous anaemia the use of iron
is, as a rule, to be avoided, its place being taken by
arsenic and general therapeutic measures, such as
hydrotherapy, salt water baths, etc.
3. The Heart Rhythm. — Gossage states that
there are two opposing theories as to the origin of
the automatic power of the heart to beat rhythmic-
ally, both of which recognize that the automatic
power of the heart lies in itself, and is quite apart
from the central nervous system or the circulation
of the blood. These are the so called neurogenic
and myogenic theories, implying that the origin of
the impulse lies in the nervous and muscular ele-
ments respectively. The writer thinks that the
complete myogenic theory has the more weighty
evidence in its favor and should be accepted until
stronger arguments are brought against it. It is
not incompatible with any of the known phejiomena
of the heart beat, while it aflfords the best explana-
tion of many of them. It is certain that the muscle
fibres possess the powers of contractility, excitabil-
ity, conductivity, and tonicity, and it is probable
that these are exercised during the normal beat of
the heart without the intervention of the nervous
tissue. It is also certain that all the muscle fibres
are not capable of building up a stimulus for them-
selves, but there is evidence to show that certain
fibres of peculiar structure possess this property.
While certain facts seem to find their readiest ex-
planation in the neurogenic theory, especially the
response of the quiescent heart to the stimulation
of the accelerator nerve, there are others pointing
as strongly to the hypothesis that the heart beat is
purely muscular. This conception does not pre-
clude the possibility of the beat being influenced by
outside nervous impulses. This would give a suffi-
cient explanation of the large nerve supply of the
heart. Attributing the rhythmic power of contrac-
tion to the muscle is, of course, only a very partial
explanation of the cardiac beat, the cause of which
lies deeper in physico-chemical changes in the cells.
4. Locomotor Ataxia.— Dent holds that loco-
motor ataxia is essentially a chronic and progres-
sive disease, and that from a strictly curative point
of view little can be expected. The course is usu-
ally very long — twenty or thirty years. Our aim,
therefore, should be chiefly to relieve the symptoms
and to arrest or retard the degenerative process as
far as possible. Syphilis is responsible for most of
the cases. Fatigue, excesses, cold, trauma, over-
strain, intoxication, etc., are considered to be ex-
citing causes. If syphilis be treated early and thor-
oughly, the probability of tabes is only lessened,
not removed. The earlier the diagnosis, the better
the outlook. Cases showing dyspepsia, neuralgia,
burning sensations and numbness in the hands or
feet, eye and laryngeal symptoms should always be
carefully investigated. A valuable aid in early
diagnosis is examination of the cerebrospinal fluid :
if there is not excess of lymphocytes present,, loco-
motor ataxia (and also general paralysis) can con-
fidently be excluded. The cases may never ad-
vance beyond the preliminary or preatoxic stage.
Retention and incontinence of urine with cystitis,
etc., are common symptoms. Salol and urotropine
here give excellent results, and it may also be nec-
essary to wash out the bladder. Dyspnoea or
laryngeal crises are, as a rule, not serious and may
be relieved by a few whif¥s of amyl nitrite or chloro-
form. Perforating ulcers may form on the foot,
and are to be treated by prolonged rest in bed and
antiseptics. Fractures of the bones are caused eas-
ily, and unite quickly with a great amount of callus,
the condition being akin to the arthropathic changes
seen in the joints where there is rapid eflfusion and
abnormal movement (Charcot's joints), the knee
being the joint most commonly afifected. Frenkel's
exercises are the best form of treatment for the
ataxia, and even the worst cases show improvement.
They should be carried out under the eye of the
doctor and be persevered with for not less than a
month. In certain cases the x rays applied daily
for five minutes to the dorsal region of the spinal
column give good results. Baths in general aid
the circulation and are refreshing and comforting.
Benefit has been noted from the suspension treat-
January iS, igob. |
PITH OF CURRENT LITERATURE.
ment, but it is probably due to suggestion. Both
galvanic and faradic currents have been used, but
without any great result. Cold and damp climates
aggravate the pains. Potassium iodide and mer-
cury are largely given, but have little influence.
Silver nitrate in one quarter grain doses often re-
lieves and lessens the pains and does permanent
good. Aluminium chloride, gold chloride, zinc
phosphate, and arsenic certainly help in some cases.
Strychnine is constantly employed for its tonic ef-
fect. Penacetine and antipyrine are used for the
relief of the pains and morphine should be post-
poned as long as possible. Testicular juice, spinal
cord, brain substance, and spermin have been tried,
but with very unsatisfactory results. Tabetic pa-
tients should not marry.
LANCET.
December 28, 1907.
1. The Personal Factor in Diet, By C. J. Macalister.
2. Constitutional Development and Social Progress of
Boys and Girls from Infancy, By F. Warner.
3. A Series of Four Cases of Infantile Gangrene of the
Cornea in which the Treponema Pallidum Was
Found, By S. Stephenson.
4. Revealed Tuberculosis in Children at School Ages,
from Four to Fifteen Years,
By H. C. Lecky and W. C. Horton.
5. Observations on Cases of Streptococcal Meningitis,
By W. J. Wilson.
6. A Case of Diarrhcea, Erythema, and Asthma Apparently
Due to Nasal Disease, By J. W. Stenhouse.
7. A Note on the Treatment of Pyorrhoea Alveolaris by
Inoculation with a Bacterial Vaccine,
By D. W. Carmolt- Jones and J. E. Humphreys.
8. Appendicostomy in Chronic Dysentery,
By J. A. Pottinger,
9. Nontuberculous Intranasal and Postnasal Abnormali-
ties: Their Recorded Association with Tuberculosis,
By W. C. Rivers.
3. Infantile Corneal Gangrene. — Stephenson
reports the details of a series of four cases of kera-
tomalacia in all of which the treponema pallidum
(spirochjeta pallida of syphilis) was found in scrap-
ings from the necrotic corneae. KeratomaUicia is a
grave affection of the cornea, apt to supervene in
infants whose vital resistance has been reduced by
general illness, such as congenital syphilis, tuber-
culosis, or ileocolitis. It has a distinct seasonal
incidence, the majority of cases resulting from ileo-
colitis. The cases are characterised first by athrep-
sia, and secondly by a sloughing condition of one
or both cornese, associated with but slight symp-
toms of local reaction, such as redness, reflex
blepharospasm, or swelling of the eyelids. Curious,
dry, frothy looking patches of xerosis may some-
times be found in the ocular conjunctivae, but are
not essential to the diagnosis. The necrosis of the
cornea is not due to any particular microorganism ;
any pyogenic microbe may cause it, e.g. the various
staphylococci, the pneumococcus, the colon bacil-
lus, and the xerosis bacillus. Keratomalacia often
leads to destruction of the cornea, and to the death
of the patient, usually from bronchopneumonia.
4. Revealed Tuberculosis in Children. — Lecky
and Horton have examined a number of school
children for the purpose of determining the amount
of revealed tuberculosis among them. Their con-
clusions are as follows: i. The amount of revealed
(or recognizable) tuberculosis in scliool children
is very small. They found but three cases in 806
children. 2. The extremely small percentage of
cases of pulmonary tuberculosis found among un-
selected school children, as contrasted with the rel-
atively large percentage of cases of pulmonary
tuberculosis found among school children specially
referred to a doctor owing to a suspicion of, or evi-
dent ill health, indicate that when pulmonary tu-
berculosis does start in children they quickly show
it by failing health and are removed from school.
The schools cannot, therefore, be considered as
places where much tuberculosis is spread.
9. Nasal Abnormalities and Tuberculosis. —
Rivers has renewed the literature on nontubercul-
ous intranasal and postnasal abnormalities, and
their association with tuberculosis. The common-
est abnormalities are those simple ones leading to
nasal obstruction (such as saeptal deformity, turges-
cence, and hyperplasia of the nasal mucous mem-
brane) and also atrophic conditions. All writers
agree that abnormal intranasal conditions are more
common in consumptives than in the nontubercul-
ous. The oval cavity, or an abnormal nasal mu-
cosa, cannot be expected to perform the complex
physiological functions requisite to prepare the air
for the lungs. Not one writer doubts but that the
intranasal precedes the pulmonary condition. The
evidence seems complete that impairment of nasal
respiration, more probably, perhaps, than any one
of its many sequelae, is a definite predisposing cause
of pulmonary tuberculosis. Most authors pro-
nounce for direct pulmonary infection from inhal-
ation of unfiltered air. So that rhinology should
play an important part in the prophylaxis and treat-
ment of consumption. The simple catarrhal laryn-
gitis common in consumptives is dependent on in-
tranasal conditions and not solely due to the exer-
tion of coughing. Rhinological treatment in such
cases may be the means of averting tuberculous
laryngeal disease. As to prophylaxis the applica-
tion to the physically selected classes and to school
children is obvious.
LA PRESSE MEDICALE.
December 18, 1907.
Opening Lecture. By Professor Prenant.
December 21, 1907.
1. Synergic Action of the Gastric and Pancreatic Juices
upon Faecula, By H. Roger and H. C. Simon.
2. The Functional Action of the Aperture of the Stomach
in Animals with a Permeable Pylorus on Which
Gastroenterostomy Has Been Performed,
By M. GuiBE.
3. Osteomalacia, the Suprarenal Capsules and Adrenalin,
By R. Romme.
1. Synergic Action of the Gastric and Pancre-
atic Juices Upon Faecula. — Roger and Simon as-
sert that the various secretions met with in different
parts of the digestive canal reinforce each other.
Thus the saliva, checked by the acidity of the gastric
juice, the pepsin, checked by the alkalinit}' of the
duodenal secretions, are not deprived of their entire
influence, but aid in the amolytic action of the pan-
creatic juice. If they have lost their zymotic power
they have kept their zymosthenic power.
2. Functional Action of the Aperture of the
Stomach in Animals with a Permeable Pylorus
on Which Gastroenterostomy Has Been Per-
formed.— Guibe presents the following conclu-
132
PITH OF CURRENT LITERATURE.
[New York
Medical Journai
sions: i. In every case of g-astroenterostomv per-
formed upon stomachs in which the pylorus is more
or less permeable a spontaneous obliteration oi the
artificial opening should be expected. 2. If, after a
cure of some duration, the former morbid symptoms
should reappear, medical treatment should be adopt-
ed. If this should fail there should be no hesitation
in having recourse to another surgical intervention,
which mav perhaps demonstrate the closure of th'^
previous anastomosis. 3. In every case, to guard
against this inconvenience as much as possible, the
anastomotic opening should be placed as near as pos-
sible to the pylorus and should be made as large as
possible. The method of suturing is also, without
doubt, of great importance.
December 25, 1907.
1. Opening Lecture. By Professor Nicol.\s.
2. Bismuth Subnitrate in Diseases of the Stoinach,
By Ferxaxd Levy.
2. Bismuth Subnitrate in Diseases of the
Stomach. — Levy alleges that the favorable effects
produced bv bisnnUh subnitrate in certain diseases
of the stomach are not wholly due to its physical
action in coating the surface of the mucous mem-
brane, but that they are partially due to a chemical
action produced in which it is partially precipitated in
the form of the oxychloride. It lessens the phase of
gastric digestion by reducing the hyperchlorhydria
and it tends to suppress fermentation.
LA SEMAINE MEDICALE.
December iS, 1907.
A Case of Adams- Stokes Syndrome without Blocking,
By Professor R. Lepine.
Adams-Stokes Syndrome Without Blocking.—
Lepine's patient was "a woman, sixty-five years of
age, rheumatic, nervous, overworked, who had suf-
fered for nine years from epileptiform attacks, or,
rather, fainting' fits. Her heart was enlarged and
there was a slight mitral stenosis, and her pulse was
very slow. This association of slow pulse with epi-
leptiform or fainting fits forms, in the author's opin-
ion, the syndrome of Adams-Stokes disease, al-
though some authors have used the term "heart
block" as synonymous.
December 25, 1907.
Occlusion Form of Sigmoperisigmoiditis, By F. Lej.\R3.
Occlusion Form of Sigmoperisigmoiditis. — Le-
jars reports a case in which the symptoms of ileus
were produced in a woman, sixty-eight years of age,
by an infl^mination of the sigmoid, which caused
perforation and aperisigmoiditis. Operation failed
to save the patient, who sank and died twenty-four
hours later without pain, vomiting, or the slightest
reaction.
BERLINER KLINISCHE WOCH ENSCH Rl FT
December 16, 1907.
1. Concerning the Development and Present Stand of the
Serodiagnosis of Syphilis, By A. Wasserm.ann.
2. Experimental Contributions to the Morphology and
Biology of Malignant Tumors, By C. Lewin.
3. Concerning the Fibrolysin Treatment of Perigastric
Adhesions By C. Mich.'vei..
4. Perninncnt Cure of Perspiration of the Hands by the
Rc.ntgen Rays By Kromayek.
5. Exophthalmic Goitre and the Sexual Life of the
Woman, By N. Kron,
6. Congenital Stenoses of the Urethra, By A. Hock.
7. Observations on the Human Semen by the Dark Field
Illumination, By C. Posner.
3. Fibrolysin Treatment of Perigastric Adhe-
sions.— Michael reports two cases in which cica-
tricial adhesions about the stomach which were the
results of operations which had been performed
were dissolved by injections of fibrolvsin and thio-
sinamin, made subcutaneously in the neighborhood
of the cicatrix.
4. Permanent Ctire of Perspiration of the
Hands. — Kromayer reports three cases in which
hyperidrosis of the hands was cured in two and re-
duced to a slight degree of perspiration in heat in
the other by exposure of the hands to the action of
the X rays. He believes that the x rays may be con-
sidered, in the true sense of the word, a radical
means of cure of hyperidrosis.
5. Exophthalmic Goitre and the Sexual Life
of the Woman. — Kron reports two cases of
women afflicted with exophthalmic goitre the symp-
toms of which were worse during pregnancy and
improved after confinement. In one the goitre be-
came reduced from 37 to 34 cm. The effect on men
struation is discussed, and the author considers that
we have to deal with in exophthalmic goitre a dis-
turbance of the metabolic processes of the first im-
portance, as in diabetes. Menstrual disturbances
are produced by the chemically changed blood just
as in general disturbances of nutrition, and many
authors are justified in considering these symptoms
as indicative of exophthalmic goitre.
6. Congenital Stenoses of the Urethra. — Hock
reports two cases of congenital stricture of the ure-
thra. The first patient, a luan, seventeen years of
age, came under observation on account of a reten-
tion of urine. The principal evidence that the stric-
ture was congenital came from the statement of the
patient's mother that from his earliest infancy he
had had trouble in urination. He also had nocturnal
and diurnal incontinence and hasmaturia. Extern" 1
urethrotomy proved to be necessary to give relief.
The second patient was a man, forty-seven years of
age, who had likewise had difficulty in urination
from early infancy. In this case, in addition to a
stenosed orifice, there were two strictures, one four
centimetres from the orifice, the other in the pars
bulbosa. The author also refers with less detail t'l
two additional cases of this rare affection which have
come under his observation.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT
December 10, 1907.
1. The Analysis of the Extrasystole in the Picture of the
A.iiricnl'ar Pulsation, By Rautencero.
2. Cylindruria and .'Mbuminuria, By AscH.
3. Investigations Concerning Mendel-Bechterew's Reflex
of the Dorsum of the Foot, By Osann.
4. Decapsulation of the Kidney in Eclampsia, By Franck.
5. Conce'iiing the Pbstoperati\'e Pulnionarj' Complications
and Thromboses after Etherizations, By Otte.
6. Concerning the Worthlessness of the Addition of Prepa-
rations of the Suprarenal Capsules in Lumbar Anes-
thesia, By MiCHELSSON.
7. Epididymitis Erotica, By Walsch.
8. .A Case of Total Extirpation of a Cyst of the Pancreas,
By Schmidt.
Q. A Case of Swine Erysipelas in Man and its Cure by
Means of Sv.ine Erysipelas Serum. By Welzel.
13. Pigmentation of t^ie Nails in Secondary Syphilis.
By Vorner.
11. Sterile Raw Catgiit, By Kuhn.
12. Fibres of the Urtica Nivea as Surgical Threads,
• By Maiieener.
13. A Simple Fermentation Saccharometer. By Basler.
14. Birth' and Death Among the W'asuahcli. By Krai'ss
3. Mendel-Bechterew's Reflex of the Dorsum
January i8, 1908.!
PITH OF CURRENT LITERATURE.
133
of the Foot. — Usann thus sums up the results
pf his investigations: i. The normal extension re-
flex of Mendel arises through direct stimulation of
the extensor brevis digitorum. It is almost con-
stant in health. Its occurrence may be prevented
by external hindrances, such as oedema, changes in
the joints, voluntary tension of the extensor, and
atrophy of the muscles. 2. The absence of the ex-
tension reflex alone is of no special diagnostic im-
portance, but attains a certain value when it can-
not be explained by the mentioned external hind-
rances and is associated with pathological flexor
reflexes. The absence or presence of the extension
reflex serves to a certain degree as a measure of
the Mendel-Bechterew reflex, and in consequence
there can be distinguished a positive and a partial
Mendel-Bechterew. 3. The Mendel-Bechterew re-
flex appears in cases of organic spastic paresis of
the lower extremities. It occurs in many cases in
which Babinski's reflex is present, but is not so
comprehensive. In rare cases there may be a posi-
tive Mendel-Bechterew with a negative or uncer-
tain Babinski. 4. Although these two reflexes are
so frequently associated they have nothing in com-
mon. Babinski's is a purely cutaneous reflex in-
dependent of the muscular tone of the lower ex-
tremities, while the existence of the Mendel-Bech-
terew seems to depend on a hypertonic condition of
the flexor muscles of the foot and toes. \*ery fre-
quently it is associated with foot clonus. 5. A dis-
tinct analogy exists between the Mendel-Bechterew
reflex and the flexor reflex of the finger described
by Bechterew. .
4. Decapsulation of the Kidney in Eclampsia.
— Franck reports a case m which decapsulation of
the kidnev was performed with excellent result in
a desperate case of eclampsia.
5. Postoperative Complications After Ether-
ization.— Otte thinks that he has succeeded in
avoiding the postperative pulmonary complications
which occasionally follow the administration of
ether by such a manner of administration as shall
avoid an overdose of the drug and by prophy lactic
measures, such as clearing up of acute troubles of
the respiratory organs if possible before operation
having the patient's stomach empty at the time of
operation, avoidance of sudden chills during and
after the operation and washing out of tht mouth
with a disinfectant lotion before the operation. In
particular he emphasizes the inhalation of steam for
half an hour before and after the operation.
7. Epididymitis Erotica. — Walsch deals un-
der this name with a distention of the epididymis
dependent on congestion produced by psychical or
mechanical excitation of the sexual organs but in
no way inflammatory.
10. Pigmentation of the Nails in Secondary
Syphilis. — Vomer reports a curious case, in which
a man. twenty-one years of age,_ contracted syphilis
and simultaneously with the appearance of the sec-
ondary eruption black places appeared in the lunula
of the finger nails which grew larger from week
to week. The pigmentation of the nails was not
uniform. On the left hand the fifth finger alone
was strongly marked, and the pigmentation was
not perfectly even.
THE GLASGOW MEDICAL JOURNAL.
December, igoy.
1. Breisky's Kraurosis Valvae; Four Cases, Three of
Them Complicated with Epithelioma,
By John" Ei>g.\r.
2. The Physiopsychology of Hallucination,
By J. H. M.A.cDoN.\LD.
2. Hallucination. — ^MacDonald speaks of hal-
lucinations. He remarks that the student of history
cannot help being struck by the part played by hal-
lucinations in the story of human progress. In the
annals of every nation, even from the remotest pe-
riods, we meet with hallucinatory episodes affecting
the trend of popular thought and belief, and direct-
ing the conduct of the people. In some instances
we find that the hallucinations pertain to a par-
ticular individual, who interprets the hallucination
as a mysterious, divine revelation, an interpretation
which, begetting in its turn the secret belief in a
divine mission, dominates the consciousness, leads
to concentration "of thought, a determination of pur-
pose, and an accumulation of energy that urges on
the hallucinated being to a realization of his dream,
and sometimes makes him a leader of men. Thus,
we find Joan of Arc in the history of France. But his-
tory also furnishes instances of hallucinations affect-
ing masses of humanity. As example the author cites
the hallucinatory epidemics that affected whole com-
munities and armies during the holy wars, and here
also one individual, Peter the Hermit of Amiens.
Biographers relate hallucinator\- episodes in the
lives of many illustrious men of all times, some of
them men of undoubted genius. Martin Luther,
according to the evidence of his own writings, was
undoubtedly subject to auditory hallucinations. So
also was George Fox, the founder of the Society of
Friends. Socrates, the ancient Grecian philosopher,
is judged to have been the victim of hallucinations.
Descartes, after long confinement, was followed by
an invisible person calling upon him to pursue the
search of truth. It is recorded by Lombroso that
Van Helmont declared he saw a guardian angel ap-
pear to him in all the most important events in his
life. Xapoleon was said to have had interviews
with a familiar spirit in the form of a little red man,
and he asserted he saw his star in every great oc-
currence. Oliver Cromwell, while lying tired and
sleepless in bed, had an apparition of the gigantic
figure of a lady who told him he would be tlie great-
est man in England. Johnson when at Oxford one
day heard his mother distinctly call "Sam," though
she was then at Lichfield. Cowper was one day
found by his medical attendant with a penknife
sticking in his side. He believed he had heard a
voice from heaven commanding him to take his
own life. Pope one day asked the doctor attending
him what was the arm which seemed to come out of
the wall. Byron occasionally fancied he was visited
by a spectre, but regarded it as the effect of an
overstimulated brain. Goethe stated that one day
he saw the exact counterpart of himself coming to-
wards him. These are but a few out of many in-
stances in the lives of great men in whom the exist-
ence of hallucinations seems to have been well es-
tablished by the evidence of the facts. Hallucina-
tion should be defended as a subjective perception,
a perception without a corresponding objective
134
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
Stimulus. Hallucinations of hearing are those
which we meet with most frequently among the in-
sane. They vary in character from simple noises,
rumblings, moanings, hissings, whistlings, tinklings,
musical sounds, barks, growis, cries, to the most
complex of words and sentences. Hallucinations of
sight may assume the most diverse forms. The
most elementary appear as mere blurs, clouds,
sparks, flashes of light, while, in the more complex,
faces, persons, every variety of object and scene
may be portrayed in detail. Sometimes they are
very indefinite, colorless, and phantomlike; at other
times they are very vivid, highly colored, and stand
out in bold relief. Hallucinations of smell are not
at all uncommon, and patients often complain that
they smell poisonous gases, chloroform, iodoform,
faeces, putrefying substances, dead bodies, seminal
discharges, etc. Hallucinations of taste also occur,
as when the patient tells us that he detects poison,
blood, fasces, etc., in his food. Hallucinations of
touch may be referred to any point in the body.
They vary in character and intensity from creeping,
pricking, cold, and burning sensations, to electric
shocks, caresses, stabs, blows, bites, and injuries of
all kinds. The author reviews the theories about
hallucination. He believes that the theory of the
peripheral origin of hallucination holds good in
some, but not in all, instances. Even when the
primary stimulus occurs without the cerebrum, hal-
lucinations are produced only after the sensor}' cen-
tres, which are the seat of images, have been stimu-
lated. A hallucination is never an entirely new
creation of the brain, but simply a reproduction of
memory images, and, in cases where the hallucina-
tion seems new, strange, and enigmatical, we have
to deal merely with a new combination of its com-
ponent elements. So also in dreams, which are the
hallucinations of the sleeping state. It is an inter-
esting and remarkable fact that hallucinations vary
in different races and at different periods of his-
tory according to the knowledge and the dominant
ideas of the day and the people. The ancient Greek
who had visual hallucinations saw. gods and
godesses, satyrs, driads, and nymphs. The hallu-
cinated individual of the middle ages had visions of
saints and guardian angels, or saw the devil, after
the manner of that day, with horns, a goat's head,
an arrow headed tail, and a pitchfork. In these
later days visions of heaven or hell are more Mil-
tonic is character, and with the wider diffusion of
knowledge and the practical tendencies of advanc-
ing civilization they are becoming less frequent and
less definite than they used to be. So, too, in the
case of auditory hallucinations. In earlier times the
hallucinatory voices were interpreted as those of
celestial beings or spirits. Then the introduction of
speaking tubes afforded a new explanation, and the
sufferer was convinced that a secret system of tubes
existed in the walls of his apartments. The intro-
duction of the telegraph and then of the telephone
was followed by the transference of the voices to
wires hidden in the walls, while in these days it is
no uncommon thing to find the victim of auditory
hallucinations who declares that he is constantly re-
ceiving marconigrams and wireless messages. The
author concludes that no doubt a hallucination is an
abnormal cerebral product, and if it were possible
to divide mankind into two .categories, those of
sound mind and those of unsound mind, we should
have no option left but to include the hallucinated
with the unsound. Such a division is, however, im-
possible. Sanity and insanity are comparative terms.
Each individual has a normal peculiar to himself,
and applicable to none other. Any attempt to make
a division between sanity and insanity must be arti-
ficial and conventional in the highest degree. The
existence of hallucinations is certainly no criterion
of insanity. We can, however, agree that when
the subject of hallucinations fails to recognize these
as anomalous productions of his brain, and allows
his thoughts to be directed from their ordinary
course, and his conduct to be regulated by the hal-
lucinatory mental content, he is no longer of sound
mind.
f mefMngs a( Sfldeties.
SOUTHERN SURCtICAL AND GYN.^COLOGICAL
ASSOCIATION.
Twentieth Annual Session, Held in Neiu Orleans,
December 17, 18, and 19, igoj.
The President, Dr. Howard A. Kelly, of Baltimore, in
the Chair.
(Continued from page 90J
Fracture of the Femur in Forcible Delivery. —
Dr. Charles R. Robins, of Richmond, 5aid the pos-
sibility of fracture of the femur in the various manip-
ulations of the lower extremities in forcible delivery
was mentioned in medical literature, but he had been
unable to find anything on the treatment. He was
convinced from inquiry that such fractures were
more common than the scant mention would indicate,
and that successful treatment offered serious diffi-
culties. The splint which he presented had been de-
signed for the purpose of treating such a fracture
occurring in his own practice, and the result obtained
had been perfect. In the treatment of such a frac-
ture it was absolutely necessary to adopt some
method that would permit handling of the child for
nursing without disturbing the limb, that would per-
mit changing of napkins, that would prevent soil-
ing, and that would not excoriate the delicate skin.
These indications could not be met by any of the
methods in vogue for treatment in older persons.
The splint he described in detail, also its application.
Some Results of the Hodgen Splint Treatment
of Fractures of the Thigh as Shown by the X
Rays. — Dr. George S. Brown, of Birmingham,
demonstrated by means of sketches the changes he
had made in the original splint of Hodgen as the
latter had modified it from the old Smith's anterior
splint. These changes were : First, he used one
piece of cloth as a hammock to take the place of the
underlapping strips of roller bandage, which were
troublesome about rolling up in strings and other-
wise getting out of order. Again, he had placed
small tent blocks on the supporting cords by means
of which the level and hang of the limb in the splint
could be adjusted in a most satisfactory manner.
Again, he had placed two wire loops at the distal cor-
ners of the wire frame, through which were passed
the traction strips of muslin, which were pinned to
the traction adhesive strips at the malleoli ; these, be-
January i8, 1908. 1
PROCEEDINGS OF SOCIETIES.
ing passed through these loops, were tied together
across the sole of the foot, thus holding the limb
firmly in the frame and doing away with the foot
block which was formerly used, as in Buck's exten-
sion. The loops of the small suspension cords were
hung upon the hook of a spring scales, which in turn
was hung to the sash cord that went over the pulley
wheel in the ceiling.
The writer maintained that while the limb was
swung up from the bed and the suspension cord was
at an angle, the pull was sure to be constant, and
that this splint was the only apparatus so far devised
that would give a constant pull. He asserted that
the principle that should be followed in the treat-
ment of fractures should be that of gradual reduc-
tion by a moderate pull steadily but constantly main-
tained, under which the muscles would entirely give
up their resistance. Reduction under ether was un-
necessary and useless, as the muscles would quickly
recover their resistance and undo all that had been
done in this way ; the old Hodgen splint operated
on the same principle, but owing to its crudeness
would not stay in order, could not be properly regu-
lated as to the pull, could not be properly balanced,
and was not so comfortable. Buck's apparatus was
painful, and for that reason the patient was constant-
ly making efforts to have the weight removed long
enough to allow him occasional relief from the strain
on the hamstring tendons, and this kept the muscles
alive and resistant, and, as long as the muscles were
alive and resistant, it was practically impossible to
overcome the shortening in an oblique fracture-; but
with the Hodgen, the muscles were put completely
at rest in from a week to ten days.
The essayist showed a number of skiagraphs taken
from old patients of his, most of whom had been
treated some years before the discovery of the x ray.
In all but two of the pictures the results were excel-
lent, and these, he explained, had not had the advan-
tage of proper treatment. Two pictures of fractures
through the great trochanters showed union so per-
fect as to leave nothing more to be desired, and the
same could be said of several fractures of the shaft.
In summing up, it could be said of this splmt that
after it was put on a limb it was well nigh automatic
in its operation. It was so comfortable that patients
never objected to it in any way. It made less work
for surgeons and nurses by at least 75 per cent, than
any other means of treatment of these injuries, and
the results were always excellent or fairly good.
Practical Points in the Treatment of Fractured
Femur. — Dr. W. P. C.a.rr, of Washington, said
that numerous surgeons had advocated wiring or
some open operation in all or nearly all fractures of
the femur, and maintained that perfect results could
not be obtained without it. Results could be ob-
tained in nearly all cases of simple fracture that were
both functionally and anatomically perfect, if the fol-
lowing points were carefully observed : Extension
by weight and pulley or other efificient means must
be used daily. The shortening must be absolutely
overcome in the first twenty-four or at most thirty-
six hours, or it could never be entirely overcome.
From ten to twenty-five pounds weight would be re-
quired to do this, and there should be great care to
see that the weight was effective. Shortening was
due to faulty application of the weight or too little
weight. Catching of some part of the apparatus on
the foot of the bed or in the mattress or bed cloth-
ing, and slipping down in bed, were the most com-
mon defects. The traction should be applied so as
to tend to lift the heel and not pull it down against
the mattress, as so commonly happened. Slipping
down was best prevented, not by elevating the foot
of the bed, but by elevating the lower half of the mat-
tress to an angle of twenty degrees. In fractures
just below the lesser trochanter, the elevation should
be thirty-five or forty degrees, flexing the thigh to
that extent, and the limb should be abducted slightly.
Compound fractures should, as a rule, be wired, as
the wound was usually contaminated and the chances
of suppuration were lessened by an open operation
and thorough cleansing of the parts. Children were
best treated by vertical extension. All shortening
could be absolutely avoided by care during the first
few days. Careful measurements should be made,
and skiagrams, when possible. Any fracture not in
satisfactory position at the end of a week should be
wired. If simple rules of mechanics were observed,
a single small loop of soft iron wire was all that
would be needed to prevent shortening, lateral dis-
placement, or rotation. Iron wire was much stronger
than silver. Angular deformity must be prevented
by traction, a plaster of Paris cast, or splints, no
matter what method of fastening the bones was used.
Three instruments were shown that had proved
very useful in resecting and wiring bone : First, a
modification of W yeth's bone saw, much simpler and
more effective than Wyeth's. Second, a bone drill
made like a small brace and bit, to be used in one
hand while the other hand was free to hold the bone.
Third, a very small, thin, grooved director, small
enough to pass through the drill hole and guide the
wire. This was very useful in passing the wire
from within outward through the second fragment,
especially when oozing of blood obscured the open-
ing of the drill hole.
The Relaxed Knee Joint and Its Treatment. —
Dr. Albert H. Freiberg, of Cincinnati, called at-
tention to a group of cases involving the knee joint
which, on account of the absence of manifestations
in the radiogram, the absence of any infectious ele-
ment, and most often the absence of any organic
change in the joint to be appreciated by physical ex-
amination, had for the most part been considered
functional. Excluded from this consideration were
the cases with knee symptoms proceeding from weak
and fiat foot. The complaint of the patient in these
cases was either that of joint pain largely or alto-
gether dependent upon function, with occasional
effusion into the joint after unusual exertion, or else
the occurrence of sudden attacks which were fre-
quently very similar to those resulting from injury
to the meniscus. In the latter cases there was the
sudden onset of very sharp pain, so that the patient
often fell. This was commonly followed by an effu-
sion, which subsided after a few days, leaving the
joint apparently normal. The chief clinical charac-
ters, aside from these symptoms, were atrophy of
the quadriceps extensor of the thigh and diminished
power of extension of the knee consequent thereon.
This atrophy was to be determined by accurate meas-
urement with the tape line. Since the quadriceps
was normally the tensor of the knee joint capsule, its-
136
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
relaxation permitted its falling into folds, and it was
thus subjected to frequent injury by being pinched
between the femur and tibia, and the symptoms were
thus explained. Villous hypertrophy might ensue
in consequence of the repetition of these attacks. In
all the cases reported it was possible to determine a
traumatic origin, although in several the injury ap-
peared to be slight. The theory of reflex atrophy
was favored rather than that of inactivity, because
in several cases the limb was used without any inter-
mission after the injury. The description of this
class of cases as "relaxed knee joint" was advocated
as a distinct syndrome and not simply as a feature
of villous arthritis. The treatment consisted of meas-
ures to restore the volume and strength of the quad-
riceps, such as suitable gymnastic exercise, resisted
movements, massage, and electricity. Tone must be
restored to the relaxed capsule by suitable local meas-
ures, such as hydrotherapy, etc. Often the return to
the normal was so slow that the assumption of dam-
age to the central nervous system seemed justified.
All patients might, however, be expected to recover
with proper treatment and sufficient perseverance.
In summarizing, the author stated that many cases
of so called functional knee symptoms were due to
reflex atrophy of the quadriceps following injury.
The term relaxed knee joint should be reserved for
such cases. The injury might be so slight that its
^etiological relation was overlooked. The atrophy
following injury could in many cases not be ex-
plained by the theory of inactivity. Cure of these
cases would be brought about by the restoration of
the normal volume and strength of the quadriceps
extensor. In some cases recovery was so protracted
as to warrant the belief in material damage to the
central nervous system. While in such cases en-
deavors were necessarily limited to treatment at the
periphery, ultimate recovery might be expected to
follow persevering and well directed efforts.
Abdominal Caesarean Section. — Dr. Henry D.
Fry, of Washington, discussed the management of
labor in minor degrees of pelvic contraction, with
special reference to the relative indications for ab-
dominal Caesarean section. He tabulated eighteen
cases of Caesarean section.
The Treatment of Diffuse Suppurative Perito-
nitis.— Dr. Stuart McGuire, of Richmond, Va.,
reviewed the work of Muscatello, Clark, Fowler,
Bond, Cannon, and Murphy, and stated that the
present generally accepted method of treatment had
not been adopted empirically, but was the result of
deductions from scientific observations. A recent
analysis of the last five hundred cases of operations
for appendicitis in his private hospital gave a record
of twenty-four patients with diffuse suppurative peri-
tonitis. The first six were treated by the old method
of irrigation and multiple drainage, with five deaths ;
the last eighteen were treated by the so called Fowler-
Murphy method, with but one death. The difficulty
he had experienced in carrying out the treatment
was in maintaining the patient in an exaggerated
Fowler position. He found by visiting other hospi-
tals that two principles were in practice, angulation
of the patient and angulation of the bed. The first
was effected by keeping the bed horizontal and ele-
vating the body of the patient by means of a shoul-
der rest : the second by elevating the head of the bed
and allowing the patient to lie flat on the inclined
mattress. The advantage alleged for the semisit-
ting position over bed elevation was that it gave bet-
ter drainage, but this he did not believe to be true, as
it was impossible to maintain the patient in the
proper position on a shoulder rest, while it was an
easy matter to prevent his slipping on an inclined
mattress. The disadvantages of the semisitting po-
sition were that it made it difificult for the nurse to
handle the case, that it was attended by muscular
tension and fatigue, and that the patient would slip
down so that his body would bend at the costal arch
and his abdomen would be on a plane parallel with
the surface of the bed. The advantages of elevating
the head of the bed were that the mattress might be
put at any angle, that the patient lay on the flat sur-
face, often unconscious of his position, and that h*"
was completely relaxed and easily nursed.
Dr. McGuire exhibited a model and photographs
of an apparatus which he had employed for more
than a year to elevate the head of the bed and to pre
vent the patient's sliding down the incline. The bed
elevator consisted of a wooden base and upright
piece, with notches on its side An iron link sup-
ported a block, which received the leg of the bed.
When horizontal, it would slip up or down, but when
oblique would catch in one of the notches. The bed
seat consisted of a board which made a shelf on
which the patient sat. A wooden shaft projected
downward and passed through a second board, which
rested against the footpiece of the bed. In the shaft
were a number of holes, and a peg placed in one of
them would prevent the shaft passing through the
bottom board, and thus transfer the weight of the
patient to the foot of the bed.
Pulmonary Embolism. — Dr. Willard Bart-
LETT and Dr. R. L. Thompson, of St. Louis, went
into the history of the circulation of the blood,
thrombosis, and embolism. They discussed the vari-
ous reasons why thrombus formation took place, stat-
ing that it was most common in neighborhoods rich
in venous blood. An embolus might float off if there
were such thrombi and cause instant death if it
plugged the pulmonary arter\ or one of its main
branches, but if the clot was small and lodged in a
small lung vessel, no symptoms at all might be seen.
Attention was called to varicose veins conducting the
blood from large abdoi^iinal tumors, and the object
of the paper was their recognition and treatment.
Thrombus formation had attended as high as 5 per
cent, of certain long series of operations, while 2 per
cent, of the same were attended with fatal pulmonary
embolism.
The authors reported twenty-two cases, sixteen of
them surgical. An autopsy was performed in the
majority of the twenty-two. Pulmonary embolism
occurred in these cases at intervals varying from one
to twenty-eight days. Two of their patients recov-
ered, but twenty died, the interval between the onset
of pulmonary symptoms and death varying from a
few seconds to twelve hours. The symptomatology
was considered, as was also the prophylactic treat-
ment.
The Diagnosis of Extrauterine Pregnancy.—
Dr. H. J. Boi.DT, New York, read a paper on this
subject. Under the term extrauterine pregnancy he
included all gestations which were situated outside
January 18, ;go8.J
PROCEEDINGS OF SOCIETIES.
137
the uterine cavity. While, anatomically, extraute-
rine pregnancy might be divided into several varie-
ties, from a clinical point of view such a distinction
was not essential. Tubal pregnancy was the most
frequent form of ectopic gestation. Uninterrupted
extrauterine pregnancy was but rarelv recognized,
and then usually by mere accident when operating
for other conditions, or- when examining a patient
for a complaint causing symptoms independent of
extrauterine gestation. He had never palpated in a
case of tubal pregnancy prior to the occurrence of
sj-mptoms due to the pathological implantation of
the ovum, except in one instance, a double tubal ges-
tation. In this case, however, the right tubal gesta-
tion gave rise to symptoms and was diagnosticated.
On the opposite side a tubal enlargement was felt,
the nature. of which was not diagnosticated, but on
operation the tubal distention proved to be dre to a
tubal pregnancy which had not begun to be inter-
rupted by bleeding within the tube or by any inflam-
matory process about the tube. The distension was
limited to the outer two thirds of the tube, which was
freely movable and did not possess the doughy feel-
ing of a pyosalpinx or the tense elasticity of a hydro-
salpinx, which he had supposed to exist on that side.
The symptoms were divided into subjective and ob-
jective, and these were discussed at length.
The absence in the history of the passing of a de-
cidua did not exclude the presence of ectopic gesta-
tion. In the large number of extrauterine pregnan-
cies the author had seen — nearly three hundred — less
than one half gave an affirmative history on this
point. A decidua might be passed unnoticed, or it
might remain in the uterus and eventually be trans-
formed into normal endometrium.
After considering the diagnostic features of early
extrauterine pregnancy, the author pointed out that
after the second half of the gestation period the diag-
nosis depended on one's ability to determine the pres-
ence of a foetus outside of the uterus, which w^as, as
a rule, not very difficult, unless the foetus was located
between the folds of the broad ligament, and the
woman had thick abdominal walls, or the foetus had
been dead for some time and was not in close con-
tact with the abdominal parietes or the cul-de-sac of
Douglas. At this period of gestation the historv
would aid very much, because in nearly all cases, in
addition to the symptoms that were present in the
early stages of ectopic pregnancy, there were also in
the history symptoms which showed that one or more
attacks of local or even general peritonitis had oc-
curred.
A pregnancy in the interstitial part of the Fallop-
pian tube caused bulging of the uterine cornu of the
invaded side. This bulging, being in an upward di-
rection, necessarily made the cornu much higher than
that on the opposite side, and the annexa were given
off at a much lower plane than that of the impreg-
nated side. In the event of rupture, which nearly
always occurred during the first half of the gesta-
tion period, sometimes before the end of the second
month, the haemorrhage was very profuse and re-
quired rapid intervention. The diagnosis was based
upon the determination of pregnancy, with the ap-
preciation of the local findings.
Pregnancy in one horn of a bicornuate uterus
should not cause difficulty in diagnosis if the preg-
nancy had gone to the fifth month or more and the
foetus was still living. During the first half of ges-
tation, in addition to the subjective symptoms of
pregnancy, one should ascertain the presence, along-
side the nonimpregnated cornu. of the impregnated
cornu, which was of a doughy consistency, unless
the foetus was dead. In such event, the impregnated
uterine horn became harder and more globular, so
that it might be mistaken for a pedunculated myoma
or perhaps an ovarian cyst. But if one took all fac-
tors into consideration, the history and the objective
symptoms to be found on bimanual examination, the
diagnosis should not be difficult under ordinary cir-
cumstances. It might, however, be quite difficult if
the patient was corpulent and had rigid abdominal
walls.
The greatest difficulty in making a correct diag-
nosis was in distinguishing an ectopic gestation in
its early stages from purulent inflammatory condi-
tions of the annexa, because in the latter the patients
sometimes gave a history identical with that of ecto-
pic gestation, and objectively the tube was distended
and firm in consistence. Also the change in the ute-
rus and in the vaginal mucous membrane might be
similar. We might have the delayed or omitted men-
struation, or atypical bleeding, and he had seen two
cases where the blood was similar to that described
as t\'pical for the bleeding of interrupted extraute-
rine pregnancy. Furthermore, the character of the
pain was sometimes identical, except that no collapse
ever followed, as in profuse haemorrhage. He frank-
ly confessed that occasionally in such cases he had
been unable to make the diagnosis without surgical
intervention.
The error most frequentlv made by phvsician-; was
that of mistaking ectopic gestation for early abor-
tion. Of his ectopic gestation patients, who had
been curetted by their attendants, more had been so
treated under the impression that they had had an
incomplete abortion than for any other erroneous
diagnosis. In taking the history it would be found
that with abortion cases the pains usually began with
a moderate aching or drawing pain in the lumbar
region, radiating toward the hypogastrium. In tubal
pregnancy the pains were much more intense and
were unilateral in the beginning, and the periods of
intermission were generally further apart.
Appendicitis might sometimes be mistaken for ex-
trauterine pregnancy, or the opposite error might
occur. In an inflammation about the appendix, how-
ever, the exudate, if there was one. would be higher
up in the pelvis, more toward the iliac fossa. Fur-
thermore, there was always a febrile condition in ap-
pendicitis, and none of the symptoms of pregnancy
were found unless pregnancy and appendicitis were
coexistent. Besides, if one was careful in eliciting
a patient's history, there would always be found a
difference.
Renal Decapsulation for Chronic Parenchy-
matous Nephritis. — Dr. J. C. Oliver, of Cincin-
nati, presented a report of the case of a A-oung: man
upon whom decapsulation of both kidneys had been
practised for the relief of chronic parenchymatous
nephritis. The patient received medical treatment
alone for a period of about eight months. At the
expiration of that time his condition was much worse
than it was at the time he began treatment. In fact,
his condition was apparently desperate when a resort
to surgical intervention was determined upon.
[^8 BOOK NOTICES. [New Vork
Medical Journal.
Decapsulation was practised on December 9, 1905.
The first favorable sign following the operation was
an improvement in vision on the sixth day. The
average secretion of urine prior to the operation was
from four to fifteen ounces in twenty-four hours.
He passed nineteen ounces the day following the op-
eration, and by the end of a week this amount had
increased to fifty ounces. The preexisting general
oedema diminished so rapidly that at the end of two
weeks one could notice a very decided reduction in
the amount. A marked increase in the percentage
of urea excreted was associated with the augmented
excretion of urine, but the percentage of albumin re-
mained high. This period of improvement was fol-
lowed by one of relapse. The oedema increased rap-
idly, and repeated tappings were necessary. The
heart exhibited symptoms of gradual dilatation, and
there were almost nightly attacks of severe dyspnoea.
The patient was very ill during January, February,
and March, 1906. It became necessary to aspirate
both sides of the chest six or seven times during this
period. The patient became so desperately ill that
his demise was looked for almost daily. A marked
improvement took place in his condition about the
1st of April. The dyspnoea diminished, the urine
increased in quantity, the oedema disappeared entire-
ly, and the patient was able to get up and walk about.
The amount of albumin in the urine diminished, and
the casts were very much fewer and less granular.
The patient was dismissed from the hospital on June
8, 1906. During the period from June to October he
continued to improve, and he gained in strength to
such a degree that he was able to do some light work.
There was but little further gain in the eyesight af-
ter the primary improvement. The patient was sud-
denly taken ill during the first week in October. He
became comatose, remained in that condition, and at
the end of three days expired. There was no return
of dropsical conditions. The death was in all prob-
ability attributable to the deranged heart.
Inoperable Sarcoma of the Neck.— Dr. Oliver
reported a case of inoperable sarcoma of the neck
which was apparently cured by a combination of the
use of Coley's toxines with exposure to the action of
the Rontgen ray. The treatment extended over a
period of five months, at the conclusion of which the
tumor masses had entirely disappeared. Nineteen
months after the apparent cure a small nodule ap-
peared in the right parotid region. The patient was
now receiving injections of the toxines in the hope
that these newer manifestations might also prove
amenable to the treatment.
(To be concluded.)
Pathologische Physiologic ; ein Lelirbuch fiir Studierende
unci /\crzte. Von Dr. Ludolf Krehl, o. Professor und
Direktor der medizinischen Klinik in Heidelberg. Mit
einem Beitrap von Professor E. Levy in Strassburg.
Fiinfte neii bearbeitete Auflage. Leipzig: F. C. W.
Vogel, 1907. Pp. 649.
We have had occasion to call attention to Krehl's
work on pathological physiology on the appearance
of four of its previous editions. Like many Ger-
man works of this class, a new edition is in reality
a new edition, and additions, corrections, and re-
writing are apparent, making the work one brought
up to date in verity.
The anatomicopathological point of view regard-
ing disease has had its great advantages. It has
systematized our knowledge and brought order out
of chaos. Bacteriological science has added its
quota to a better comprehension of astiological fac-
tors, while chemistry has led to the interpretation
of modifications in the underlying laws that govern
many of the life processes. These combined have
made an enlightened pathological physiology a pos-
sibility.
That a time has arrived when disease must have
a wider interpretation in terms of function is evi-
dent from the great success that Krehl's work has
already had, and for years no work of its compass
has appeared in which the essentials of morbid
physiology have had a more illuminating light
thrown upon them, or a deeper or more comprehen-
sive grasp been shown of the chief factors which
make for disease. It is a book to be most cordially
commended to medical student, general practitioner,
and specialist alike.
Zur Psychologic und Thcrapic neurotischer Syinptome. Eine
Studie auf Grund, der Neurosenlehre Freuds. Von Dr.
Arthur Muthmann, II. Arzt des Kurhauses Bad Nas-
sau, friiherem II. Arzt der psychiatrischen Klinik der
Universitat Basel. Halle a. S. : Carl Marhold, 1907. Pp.
115-
The author gives as his reason for publishing this
small monograph the good results which he believes
he has obtained with the use of the Freud psycho-
analytical method in the Basel Psychiatric Clinic.
He further believes that, as the amount of litera-
ture bearing upon the method is still very sliglit,
his contribution will not fall within the class of dis-
cussions already done to death.
He devotes the major portion of the work to the
setting forth of the histories of a number of patients
who by means of the Freud method are willing or
compelled to unburden themselves of much that has
been kept hidden in their life experiences. Most
of them are hystericals, and the main thesis dis-
covered is truly Freudian, namely, the psychical ef-
fects of the sexual life.
We have always felt that Freud made a partial
if not complete wreck of his scientific craft when
he ran upon the rock of the sexual causation of all
neurotic ills. He still remains upon this isolated
island of interpretation, and his followers are not
few. Muthmann's contribution is an interesting
one on what might be more rigidly interpreted as
a study in the variations and aberrations of sexual
feeling, and it can he alleged for it that it furnislies
another book on that region of psychic life which
has ever challenged the attention of the "Peeping
Toms" of the medical world.
Such analyses are no doubt valuable in obtaining
information, one sided though it may be, of the nat-
ural history of the sexual life, but they err. in our
opinion, and the present volume emphasizes this de-
fect, erroneous in assuming that the ultima Thule
has been reached the moment that sexual doings
have been overturned and exposed to the view of
the curious analyzer.
The part of the work which is specially valua-
ble, however, and taken in its entirety it is a small
January i8, 1908.]
BOOK NOTICES.
139
monograph of real service, is the very able sum-
mary of the various avenues of psychotherapeutic
research which have been developed of late years.
Die Lokalandsthesie, ihre wissenschaftlichen Grundlagen
und praktische Anwendung. Ein Hand- und Lehrbuch
von Dr. med. Heinrich Braun, Direktor des koniglichen
sachsischen Krankenstiftes in Zwickau. Zweite, teilweise
umgearbeitete Auflage. Mit 128 Abbildungen. Leipzig:
Johann Ambrosius Barth, 1907. Pp. 452.
This book has seen two editions in two years,
a circumstance which speaks well for its contents.
The history of local anaesthesia is given in Chapter
I, followed by the physiology of sensibiHty and
pain and local anaesthesia and its methods in Chap-
ter II, while Chapter III and IV treat of local
anaesthesia produced by compression of nerves,
anaemia, and cold. Chapters V and VI lead up to
Chapter VII, dealing with the chemical compounds
used in local anaesthesia. Cocaine, as is only nat-
ural, receives a lengthy discussion, and the subject
is followed by tropacocaine, eucaine, holocaine,
aneson (anesin), orthoform, nirvanin, anaesthesin,
subontin, stovaine, alypin, novococaine, etc. Chap-
ters VIII and IX treat of other methods of produc-
ing local anaesthesia, such as the mechanical, the
use of suprarenin and electricity, medullary anaes-
thesia, etc. The indications, contraindications, and
technique are treated of in Chapter X, while in
Chapter XI to XVII are considered the operations
that can be conducted under local anaesthesia. Very
instructive and giving a brilliant testimony of the
thoroughness of the author is the literature for
the first nine chapters, running in small type over
thirty pages, followed by an index giving the
names of authors and a general index.
Elements of Human Physiology. By Ernest H. Starling,
M. D.. Lond., F. R. C. P., F. R. S., Jodrell Professor of
Physiology, University College, London. Eighth Edition.
Chicago: W. T. Keener & Co., 1907. Pp. viii-716.
(Price, $3.75 ')
Professor Starling's Elements of Human Physi-
ology has been a handy manual for a number of
years. The present edition has been little changed
from the previous one, the seventh, but the book
has been fully brought up to date.
It is a book which will find its proper place, not
only on the desk of the medical student who fol-
lows up the knowledge he has received in the lec-
ture room by reading at home, but also on the
shelves of the practitioner, who will quite often
find it necessary to refresh his memory.
.Atlas and Textbook of Human Anatomy. By Dr. Johannes
SoBOTTA, Professor of Anatomy in the University of
Wiirzburg. Edited, with Additions, by J. Plairfair Mc-
MuRKiCH, A. M. Ph. D., Professor of Anatomy in the
University of Toronto, etc. Volume III, Vascular Sys-
tem, Lymphatic System, Nervous System, and Sense
Organs. With 297 Illustrations, Mostly in Colors. Phila-
delphia and London : W. B. Saunders Company, 1907.
P. 342. (Price, $6.)
This last, third, volume has kept what the first
two promised. As was to be expected, the book is
much larger than the preceding two (vol. I, 258
pages; vol. II, 194 pages; vol. Ill, 342 pages). It
portrays the vascular, the lymphatic, and the nerv-
•ous systems, and the sense organs.
The author also gives his reason for including in
one volume arteries, veins, and nerves, and describ-
ing the heart with the viscera in another volume.
He says : "Long years of experience in the dissect-
ing room have led the author to depict the periph-
eral nerves and bloodvessels as the student is ac-
customed to see them in the cadaver, i. e., the ves-
sels and nerves together in the same region. . . .
(Thus) the student using the atlas in the dissect-
ing room can find upon a single page the descrip-
tion of the great majority of the structures found
in a layer of his dissection, and is not forced to hunt
through the volume and waste much time in unnec-
essary search."
This reason seems to be a good one, although we
still believe that the no pages devoted to the
vascular system added to the second volume would
have given the volumes a more uniform size and
brought this system, with the heart, into one book.
(See Journal, Ixxxv, page 381.)
The coloring of the plates is excellent. The
method of distinguishing the parts of the body has
been carried out systematically, as was done in the
preceding volumes. Thus, the arteries are colored
red, the veins blue, the nerves bright yellow ; in the
brain red illustrates the pyramidal tract, violet the
occipitotemporal cerebropontile, and blue the fron-
tal cerebropontile. A beautiful reproduction is
given in Fig. 623, representing the base of the en-
cephalon.
Two short addenda are added. Appendix I gives
in four pages a condensed account of the regions of
the human body, and Appendix II, in three pages,
gives general remarks concerning the structure and
early development of the human body.
Technischer Fortschritt and seelische Gesundheit. Aka-
demische Antrittsrede gehalten em 25. Juni 1906. Von
Willy Hellpach, Dr. med. et phil. Privatdozent der
Psychologic. Mit einem Geleitwort vom Bildungswert
der Psychologic. Halle a. s. : Carl Marhold, 1907. Pp.
30.
In this lecture Hellpach calls renewed attention
to a question which was eagerly debated by the
Athenians, and if the code of Hammurabi is evi-
dence, by the ancient Babylonians. In it, however,
he sems to deal with the problem as though it were
entirely new and a creation of modern environment
forced upon mankind by the sudden blossoming out
of technical processes in all avenues of enterprise.
Neurasthenia and hysteria are on the increase in
far greater proportion than the natural increase in
population would seem to warrant. Modern ma-
chinery, railroads, electricity, telephone, the cling-
clang, and hustle and bustle of modern idustrial
activity are responsible for the widespread increase
in nervous irritability. This, in short, is the gen-
eral line of argument of the writer. But, while
outlining what he believes are real facts, and their
essential relationships to the causes which he de-
picts, he maintains a fairly conservative and opti-
mistic attitude toward the future and the possibili-
ties of the sound nervous system "to stand the
racket" and to evolve higher and better forms of
nervous stability in the face of the wearing factors
that are bound to increase unless the race has
reached its acme.
He pays a passing compliment to certain "cap-
tains of industry" who reach the top by a ruthless
disregard of all ethics and morality, counting them-
selves above the laws made for the common people
—a point of view quite widely held and displayed
by the robber barons of the feudal times.
140
MISCELLANY.
[New York
Medical Journal.
He makes a final plea for better methods of nerv-
ous and mental hygiene and for the physician mind
healer along rational and temperate psychological
lines. The essay contains little new, but is a care-
ful summary of conditions which must be met by
the neuropsychiater in the present and in the fu-
ture.
BOOKS. PAMPHLETS, ETC., RECEIVED.
Diagnostico y Tratamiento de las Enfermedades de las
Vias Urinarias. Lecciones Elementales. Por Alberto
Suarez de Mendoza, Profesor de Enfermendades de las
Vias Urinarias en la Facultad de Medicina de Madrid,
Cirujano de la Casa de Salud de Nuestra Senora del
Rosario. Madrid : Perlado, Paez y Cia, 1908. Pp. 790.
Jahresbericht iiber die Fortschritte in der Lehre von den
pathogenen Mikroorganismen umfassend Bakterien, Pilze
und Protozoen. Unter Mitwirkung von Fachgenossen
bearbeitet und herausgegeben von Dr. med. P. von Baum-
garten, o. 6. Professor der Pathologic an der Universitat
Tubingen, und Dr. med. F. Tangl, o. 6. Professor der
allgemeinen und experimentellen Pathologie an der Uni-
versitat Budapest. Einundzwanzigster Jahrgang, 1905.
Leipzig: S. Hirzel, 1907. Pp. 941.
Atlas der pathologisch-anatomischen Sektionstechnik.
Von Prof. Dr. M. Westenhoeffer. Hit 34 Abbildungen.
Berlin : August Hirschwald, 1908. Pp. 53.
A Textbook of Diseases of the Nose and Throat. By
D. Braden Kyle, A. M., M. D., Professor of Laryngology
and Rhinology, Jefferson Medical College, Philadelphia, etc.
219 Illustrations, 26 of Them in Colors. Fourth Edition,
Thoroughly Revised and Enlarged. Philadelphia and Lon-
don : W. B. Saunders Company, 1907. Pp. 797.
Atlas and Textbook of Human Anatomy. By Dr.
Johannes Sobotta, Professor of Anatomy in the University
of Win-zburg. Edited, with Additions, by J. Playfair Mc-
Murrich, A. M., Ph. D., Professor of Anatomy in the Uni-
versity of Toronto, etc. Volume IIL Vascular System,
Lymphatic System, Nervous System, and Sense Organs.
With 297 Illustrations, Mostly in Colors. Philadelphia and
London : W. B. Saunders Company, 1907. Pp. 342.
Functional Nervous • Disorders in Childhood. By
Leonard G. Guthrie, A. M., M. D., F. R. C. P., Senior
Physician to Paddington Green Children's Hospital, etc.
London : Henry Frowde and Hodder & Stoughton, 1907.
(Price, $3.)
Thinking, Feeling, and Doing. By E. W. Scripture, As-
sistant Neurologist to Columbia University. London and
New York : G. P. Putnam's Sons, 1907.
Light and X Ray Treatment of Skin Diseases. By Mal-
colm Morris, F. R. C. S., Ed., Dermatologist to King Ed-
ward the Seventh's Hospital for Officers, Surgeon to the
Skin Department of the Seaman's Hospital, etc., and S.
Ernest Dore, M. D.. Cantab., Assistant in the Skin Depart-
ment of the Middlesex Hospital. With Twelve Plates.
Chicago: W. T. Keener & Co., 1907. Pp. 172.
Reflections on Plague and the Methods of Checking It.
(With Letters to the Press.) By Pestonjee M. Kanga,
B. A., LL. B., Solicitor, High Court, Bombay. Bombay :
Bombay Education Society's Press, 1907. Pp. 74.
ilisrdlans.
Resolution on the Death of Dr. Henry P.
Loomis. — The following resolution was adopted by
the Board of Trustees of Bellevue and Allied Hos-
pitals at the meeting on December 31, 1907:
Whereas, The Board of Trustees of Bellevue and
Allied Hospitals has learned with profound regret
of the death of Dr. Henry P. Loomis, fOr many years
one of the attending physicians to Bellevue Hospital,
be it therefore
Resolved, That the board desires to place on rec-
ord its sense of the value of Dr. Loomis's services to
the patients he has treated within the walls of Belle-
vue Ho.spital, as well as his more extended services
to the cause of medical science in general ; and be it
further
Resolved, That copies of this resolution be for-
warded to his family and to the medical journals of
the city of New York. Ja.me.s K. Paulding,
Secretary Board of Trustees.
Report of the Committee on the Classification
and Treatment of Mentally and Physically De-
fective Children. — The committee of the Medical
Society of the County of New York made the fol-
lowing report, classifying the defective children as
physical and mental defectives, which was presented
and adopted at the regular meeting, held on Novem-
ber 25, 1907 :
Physical Dcfcciircs: Under the present system
the Department of Health has medical oversight of
the public schools, especially directed to the detec-
tion of communicable diseases. Physical defects are
noted as they are discovered in the course of the
routine examinations and many defective children
are referred to physicians ; and it is probable that the
physical needs of the children are as well cared for
as could be expected under existing conditions.
These points seem v^orthy of suggestion, however:
There should be an adequate method by which each
child is examined and recorded on admission to
school ; the record should contain a statement of the
condition as diagnosticated by the medical inspector,
(or of the vision, as noted bv the teacher,) the
treatment and its results ; so that it wotild be avail-
able for the principal or teacher and for the medical
inspector in order that the future progress of the
child and his attendance may be controlled. In cases
where children are sent to physicians or dispensaries
for treatment, the medical profession can aid the
school authorities by noting, briefly, on a card
which should be provided for the purpose by the
school authorities, whether the disease is contagious
or not, and such facts as will aid the teacher in show-
ing a proper consideration for the child, as when
hearing or vision is defective. The termination of
treatment should also be noted so that the child may
be readmitted to the school without unnecessary loss
of time. Until a definite census of the physical de-
fects of school children is obtained, with informa-
tion regarding the adequacy or inadequacy of pres-
ent methods of meeting such defects, hasty action
of a paternal nature, by the city or State authorities
is not favored by the committee, but it is the expres-
sion of this committee that there is a proper economic
standard for this work as children who are physic-
ally defective are less liable to be charges on the
community if their physical weaknesses are cor-
rected.
Mental Defectives: The ptiblic school system has
been unable as yet to adequately provide for the in-
creasing number of mentally backward and deficient
children. Such children are unable to benefit by the
regular schoDl instruction and it is an injustice for
the normal children to associate with these mentally
backward and deficient children. In many European
countries supplemental schools arc in si:ccessful
operation.
In view of the foregoing the committee would
suggest :
First. That under the supervision of the Board
of Education a census ^nd record of the mentally
OFFICIAL NEWS.
backward and deficient children in the schools of
New York shall be made.
Second. That a paid Commission or Department
of Mental Hygiene should be formed under the su-
pervision of the Board of Education, to examine and
classify the mentally backward and deficient chil-
dren. This department or commission should com-
prise at least two recognized neurologists. The com-
mission or department shall classify all new pupils
and at stated intervals reclassify them. The com-
mission or department shall be empowered to remove
for institutional care and training all those mentally
defective children who have shown themselves un-
teachable or incapable of such instruction as to ren-
der them ultimately selfsupporting. The commis-
sion or department, as a body should have power to
reinstate in- the regular school for normal children
those pupils of the ungraded classes whose mental
condition has improved sufficiently to warrant the
transfer. The commission or department should
outline the organization, equipment, teaching, per-
sonnel, and general management of these supple-
mental schools for mentally backward and deficient
children. Idiotic and imbecile children should be
regarded as ineligible for these supplemental schools ;
they should be at once transferred to State institu-
tions for this class.
We are aware that these suggestions are in part in
process of being acted upon by the Board of Educa-
tion. The suggestions are made only to assist and
further organize the plan of special schools for the
backward and mentally deficient children in the New
York school system.
Walter Lester Carr, M.D.,
Chairman.
C. E. Atwood, j\I.D.
(Signed) L. Pierce Clark, M.D.
CoLMAN W. Cutler, M.D.
Arnold Knapp, M.D.
Henry Koplik, M.D.
iffinal f elus.
Public Health and Marine Hospital Service
Health Reports:
The following cases of smallpox, yellow fever, cholera,
and plague have been reported to the surgeon general.
United States Public Health and Marine Hospital Service,
during the zaeek ending January lo, igo8:
Smallpox— United States.
Places. Date. Cases. Deaths.
California — Berkeley Dec. 14-21 1
District of Columbia — Washington. Dec. 14-28 2
Illinois — Springfield Dec. 19-26 3
Indiana— Elkhart. . Hcc. 21-28 3
Kansas- — Galena Dec. 21-28 \y
Louisiana — New Orlear.- I H e. 21-28 2
Minnesota — Winona \Kc. 21-28 5
Missouri — St. Louis Dec. 21-28 7
New York— New York Dec. 21-28 2
South Dakota — Sioux Falls Dec. 21-28 i
Tennessee — Knoxville Dec. 21-28 i
Tennessee — Nashville Dec. 21-2S 13
Washington — Spokane Dec. 14-21 2 i
Smallpox — Foreign.
Argentina — Rosario Oct. 1-31 i
Brazil— Para Dec. 14-21 16 11
Brazil — Rio de Janeiro Nov. 24-Dec. 8 31 14
Canada — Winnipeg Dec. 21-28 i
Cape Colony — Cape Town Nov. 16-23 i
China — Hongkong Oct. 25-Nov. 16 i i
France — Paris Dec. 7-14 9
India — Bombay Dec. 3-10 2
India— Madras Nov. S-Dec. 6 z
Italy — General Dec. 5-12 143
Japan — Kobe Nov. 23-Dec. 7 66 20
Japan — Yokohama... Nov. 2-9 i
Java— Batavia Nov. 8-23 3
Malta Dec. 5-12 i
Mexico — Aguas Calientes Dec. 15-29 6
Mexico — Mexico City Nov. 16-30 2
Peru — Lima Dec. 4 32
Portugal — Lisbon Dec. 17-21 7
Russia — Moscow Nov. 30-Dec. 14.... 19 3
Russia — Odessa Nov. 30-Dec. 7 2
Russia— iMga Nov. 30-Dec. 14 5
Russia — St. Petersburg Nov. 30-Dec. 7 30
Spain — Valencia Dec. 8-15 36 3
Turkey — Constantinople Nov. 24-Dec. i.s 5
Venezuela — Caracas Dec. 30 Present.
Yellow Fever — Foreign.
Brazil — Manaos Nov. 23-Dec. 14 9
Brazil — Para Dec. 7-21 23 14
Cuba — Cieiifuegos January 4 i
Cuba — Santa Clara .January 6 i
Guatemala— Chiquimula December Present.
Guatemala — Zacai a " "
West Indies— Trinidad Jan. 6 r
Cholera — Foreign.
China — Hongkong Oct. 28-Nov. 16 3 7
India — Bombay Dec. 3-10 i
India — Madras Nov. i6-Dec. 6 11
Japan — Kobe Nov. 23-Dec. 7 7 3
Japan — Yokohama Nov. 2-9 4 3
Russia — General Nov. 13-19 202 115
Russia — Kief Nov. 24-Dec. 7 24 4
Plai^uc — Foreign.
Brazil — Rio de Janeiro Nov. 24-Dec. 8 17 S
China — Hongkong Oct. 26-Nov. 16 3 3
Egypt — Alexandria .\^ov. 28-Dec. 8 3 i
Egypt — Provinces —
Dakahlieh Dec. 4-1 1 i i
Garbieh Dec. 4-5 3 2
India— Bombay Dec. 4-10 8
India — Rangoon Nov. 8-24 12
Japan — Osaka Nov. 23-30 70 62
Peru — Lima Nov. 2Q-Dec. 4 4 2
Peru — Chosaca " " i
Peru — Matucana " " 2
Peru— Trujillo " " 9 6
Peru— Paita " " 10 7
Peru— Piuia " " 4 2
Straits Settlements — Singapore ... .Nov. 8-16 2
Public Health and Marine Hospital Service:
Official list of changes of stations and duties of cotn-
missioned and noncommissioned officers of the United
States Public Health and Marine Hospital Service for the
fourteen days ending January 8, 1908:
Amesse, J. W., Passed Assistant Surgeon. Temporarily
relieved from Havana, Cuba, and directed to proceed
to Washington, D. C. for assignment to temporary
duty in the Hygienic Laboratory.
Atiles, p. del v., Acting Assistant Surgeon. Granted
leave of absence for thirty days from January 6, 1908.
Barnes, W., Acting Assistant Surgeon. Granted leave of
absence for nine days from January i, 1908.
Bell, J. M., Pharmacist. Granted leave of absence for
eight days from January i, 1908.
Browne, R. W., Acting Assistant Surgeon. Granted leave
of absence for two days from December 23, 1907, under
paragraph 210, Service Regulations.
Francis, E., Passed Assistant Surgeon. Granted leave of
absence for five days from December 31, 1907.
Frick, John, Acting Assistant Surgeon. Granted leave of
absence for five days from January i, 1908.
Frost, W. H.. Assistant Surgeon. Granted leave of ab-
sence for one day.
Gardner, C. H., Passed Assistant Surgeon. Leave of ab-
sence, granted for one month from December 6, 1907,
revoked.
Goldberger, Joseph, Passed Assistant Surgeon. Directed
to proceed to Reedy Island Quarantine Station for
special temporary duty ; upon completion of which to
rejoin his station at the Hygienic Laboratory.
Herring, R. A., Assistant Surgeon. Granted leave of ab-
sence for three days from December 29, 1907, under
paragraph 191, Service Regulations.
Holland, D. J., Acting Assistant Surgeon. Granted leave
of absence for three days from December 26, 1907.
under paragraph 210, Service Regulations.
Krulish, Emil, Assistant Surgeon. Granted leave of ab-
sence for three days from December 9, 1907, under
paragraph 191, Service Regulations.
Lavinder, C. H.. Passed Assistant Surgeon. Granted leave
of nb^ence for one month from January 12. 1908.
Light, S. D. W., Acting Assistant Surgeon. Granted leave
of absence for eight davs from January i. 1908.
Linley, W. J.. Acting Assistant Surgeon. Granted leave
of absence for thirty days from January 2, 1908.
142
BIRTHS, MARRIAGES, AND DEATHS.
[New Vork
MeWCAL JoL'RNAt.
LuMSDEN, L. L., Passed Assistant Surgeon. Granted leave
of absence for six days from December 24, 1907, under
paragraph 191, Service Regulations.
Lyall, R., Acting Assistant Surgeon. Granted leave of
absence for six days from December 23, 1907, under
paragraph 210, Service Regulations.
McCoNNELL, E. E., Acting Assistant Surgeon. Granted
leave of absence for thirteen days from January i, igo8.
NuTE, A. J., Acting Assistant Surgeon. Granted leave of
absence for nine days from December 23, instead of
ten days from December 21, 1907.
Richardson, S. W., Pharmacist. Granted leave of absence
for seventeen days from January i, 1908.
RoBERSTON, H. McG., Passed Assistant Surgeon. Granted
extension of leave of absence for ten days from Janu-
ary 4, 1908.
ScoFiELD, R. B., Assistant Surgeon. Detailed as a member
of the Revenue Cutter Service Retiring Board, New
York, N. Y.
SiMONSoN, G. T., Acting Assistant Surgeon. Granted leave
of absence for two days from January 14, 1908.
Sprague, E. K., Passed Assistant Surgeon. Leave of ab-
sence granted for seven days from December 31, 1907,
revoked.
Stanton, J. G., Acting Assistant Surgeon. Granted leave
of absence for fourteen days on account of sickness.
from December 5, 1907.
Sterns, C. O., Pharmacist. Granted leave of absence for
seven days from January i, 1908.
Stoner, J. B., Surgeon. Leave of absence granted for ten
days from December 31, 1907, amended to read seven
days only.
Thomas, J. N., Acting Assistant Surgeon. Granted leave
of absence for twenty-six days from December 3, 1907.
on account of sickness.
Thompson, W. R. P.. Acting Assistant Surgeon. Granted
leave of absence for nine days from January i, 1908.
Ward, W. K., Passed Assistant Surgeon. Granted leave
of absence for two days from December 30, 1907, under
paragraph 191, Service Regulations.
Wasdin, Eugene, Surgeon. Granted seven days' extension
of leave of absence.
Watkins, McD., Acting Assistant Surgeon. Granted leave
of absence for two days from December 26, 1907.
Wetmore, W. O., Acting Assistant Surgeon. Granted leave
of absence for one day, December 17, 1907, on account
of sickness.
WicKES. H. W.. Passed Assistant Surgeon. Detailed as a
member of the Revenue Cutter Service Retiring Board.
New York. N. Y.
Williams. L. L.. Surgeon. Directed to proceed to Cris-
field. Md.. for special temporary duty ; upon completion
of which to rejoin his station at Baltimore, Md. ;
granted leave of absence for ten days from January 8.
1908.
Wilson. J. G.. Acting Assistant Surgeon. Granted leave
of absence for one day, December 17, 1907, on account
of sickness.
Board Convened.
A board of medical officers was convened to meet at the
Bureau in Washington, D. C, 10 o'clock a. m., Monday.
January 20. tqoS. for the purpose of examining candidates
for the position of assistant surgeon. Detail for the board:
Surgeon D. .\. Carmichael, chairman : Passed Assistant
Surgeon H. S. Mathewson, and Passed Assistant Surgeon
J. F. Anderson, recorder.
Army Intelligence:
Official list of changes in the stations and duties of^
officers serving, in the medical defartment of the United
Stales Army for the weelt ending January 11, igo8:
Ashburn, p. M.. Captain and Assistant Surgeon. Leave
of absence extended one month.
Ford. J. H., Captain and .Assistant Surgeon. Granted
thirty days' leave of absence.
La Garde, L. A., Lieutenant Colonel and Deputy Surgeon
General. Relieved from duty in the Philinpines Di-
vision, and on arrival at San Francisco. Cal., ordered
to report to the Adjutant General of the Army for
further orders.
Raymond, H. L. Major and Surgeon. Granted two months'
leave of absence, with permission to apply for another
month.
Schreiner, E. R., Captain and Assistant Surgeon. Upon
arrival at San Francisco, Cal., will report in person to
the commanding general, Department of California,
for assignment to duty at the General Hospital, Presidio
of San Francisco, Cal.
Shaw, J. H., Captain and First Lieutenant. Ordered to
accompany 14th Infantry from Vancouver Barracks,
Washington, to Sart Francisco, Cal. ; upon completion
of this duty granted ten days' leave of absence.
Navy Intelligence:
Official list of changes in the medical corps of the United
States Navy for the iveck ending January 11, igo8:
Baker, M. W., Passed Assistant Surgeon. When dis-
charged from treatment at the Naval Hospital, New
York, N. Y., ordered home and granted sick leave for
one month.
Jacobson, L. C, Acting Assistant Surgeon. Appointed an
acting assistant surgeon from January 3, 1908.
Spear, R., Surgeon. Detached from the navy, yard. League
Island, Pa., and ordered to the Relief.
Stokes, C. F., Surgeon. Detached from the Bureau of
Medicine and Surgery, Navy Department, and ordered
to command the Relief.
§irtl]$, Iplarriages, an^r i^at^s.
Married.
Baker — Miller. — In Louisville, Kentucky, on Thursday^
December 19th, Dr. Henry H. Baker and Miss Mamie C.
Miller.
Bayliss — Wheatley. — In Syracuse, New York, on Sat-
urday, December 28th, Dr. Frank P. Bayliss and Miss Eva
May Wheatley.
Collier — Smith. — In New York, on Wednesday, Janu-
ary 8th, Dr. Hix Furbush Collier and Miss Janet Birdsall
Smith.
Crawford — Stratton. — In Philadelphia, on Saturday,.
January 4th, Dr. E. Druitt Crawford and Miss Frances J.
Stratton.
Dewar — Stringham. — In Unadilla, New York, on Mon-
day, December 30th, Dr. Bennett W. Dewar, of Albany,,
and Miss Fannie L. Stringham.
Fletcher — Sechrist. — In Cleveland, Ohio, on Wednes-
day, January ist, Dr. Hugh M. Fletcher and Dr. Cora
Sechrist.
Hayes — Canavan. — In Holyoke, Massachusetts, on.
Thursday, January 2d, Dr. Justin E. Hayes, of Chesterfield,
and Miss Josephine E. Canavan.
Laing — McLean.— In Gladstone, Michigan, on Tuesday^
January 7th, Dr. A. L. Laing and Miss Mildred McLean.
Marvin — Swift. — In New York, on Thursday, January-
9th, Dr. Horace N. Marvin, of Dover. Delaware, and Mrs.
Flora M. Swift, of Brookline, Massachusetts.
Wilder — Rothschild. — In Chicago, on Wednesday, De-
cember 2^th, Dr. William H. Wilder and Miss Carrie
Rothschild.
Died.
Austin. — In Bedford City, \^irginia, on Thursday, Janu-
ary 2d, Dr. G. W. Austin.
Baxter. — In Lima, Ohio, on Sunday, January 5th, Dr.
Samuel A. Baxter.
Drummond. — In Calvin, Louisiana, on Monday. Decem-
ber 30th, Dr. E. L. "Drummond.
Gibbons. — In Kansas City, Missouri, on Monday, Decem-
ber 30th, Dr. R. J. Gibbons, aged fifty-four years.
GiDDiNGS. — In Bakcrsfield, Vermont, on Thursday, Janu-
ary 2d, Dr. W. H. Giddings. aged sixty-seven years.
Keirle. — In Baltimore. Maryland, on Suitday, January
5th, Dr. Nathaniel Garland Keirle, Jr., aged thirty-three
5'ears.
Matthews.— In Columbu?. Ohio, on Tuesday, December
24th, Dr. Reid C. Matthews.
Overton. — In Exploit Point. Newfoundland, on Friday,
January 3d. Dr. Henry Rutherford Overton, of New York,,
aged forty years.
Town. — In Spcnccrport, New York, on Thursday, Janu-
ary 2d, Dr. .Arha M. Town, aged sixty-eight years.
Wetmore.— In Catskill. New York, on Sunday, January
I2th. Dr. Calvin \. Wetmore, aged seventy-six years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal The Medical News
A Weekly Review of Medicine, Established J84J.
\"oL. LXXXYII, No. 4. NEW YORK, JANUARY 25, 1908. Whole No. 1521.
Original Comnrnntcations.
THE \ ALUE OF THE SOCIAL WORKER AND
THE VISITING NURSE TO THE DISPEN-
SARY PATIENT.*
Bv LixsLY R. WiLLi.AMS. A. M., M. D..
New York,
Chief of CHnic, Department of Medicine, Vanderbilt Qinic; In-
structor in Medicine, Columbia University; .Assistant At-
tending Physician to the City Hospital.
The population of Greater New York, according
to the State census of 1905, was 4,014,000, of which
the borough of ^lanhattan gave 2,122,000, over one
half. It seems ahnost incredible that during the
year 1905,994,315 patients applied for free treat-
ment at dispensaries in greater New York — that is.
one fourth of the population willingly affirmed that
they were unable to pay for medical treatment. This
statement, however, bears qualification. \'ery few
dispensaries are able to maintain an adequate sys-
tem of records, so that an old patient is always an
old patient, but in many dispensaries the system is
lax, so that an old patient becomes a new patient when
transferred to another department, and often when
the dispensary card is lost he is counted as a new
patient. It is known to dispensary physicians that
many patients rarely continue long at any one dis-
pensary ; they become "rounders," drifting from dis-
pensary to dispensary, not sick enough to be ad-
mitted to a hospital, and thinking, like the well to
do patient, that some new doctor will help him. The
large total, then, is far more than the actual num-
ber of individual patients.
According to the report of the State Board of
Charities, 994,315 patients applied for free treat-
ment in 1905, 869,866 applying for treatment in
Manhattan — that is, 87 per cent. The population of
Manhattan that year was 50 per cent, of the whole.
In other words, Manhattan bore the brunt of the
dispensary work. There are ninety-six dispensa-
ries in greater New York, and sixty of them are
in Manhattan — that is, with half the population, two
thirds of the dispensaries take care of over four
fifths of the ambulant sick.
In the year 1906 the numbers had diminished in
greater New York 9,000 and in Manhattan 17,000.
It does not seem possible that 852,200 of the in-
habitants of Manhattan are so poverty stricken that
they are unable to pay for medical attendance. The
registrar of a dispensary is, by law, also a financial
investigator, but as he is usually the entry clerk he
has no time to investigate, so that in the larger and
•Read before the Section in Public Health, Academy of Medi-
cine, November 12, 1907.
more widely known dispensaries there is practically
no investigation made, and medical relief is given
without investigation ; and in our college clinics the
investigation has been winked at in order to in-
crease the number of patients, for the sake of mate-
rial for teaching purposes. The result has been
that the dispensary classes have grown, and now,
with their enormous numbers, the physicians are
utterly unable to give careful examinations and ade-
quate treatment to the patients. ■
Do not understand that this applies to all dispen-
saries, but it does apply to most of the larger dis-
pensaries. The chief difficulty in the dispensary
situation in New York, then, is too many patients.
In some large clinics the number of patients has
not increased in the last ten years, but the amount
of necessary work for each patient has increased
with modern methods of treatment, so that with
even an increased number of physicians the treat-
ment is unsatisfactor}' and inadequate. This does
not apply, of course, to all our large dispensaries
equally, nor does it apply to all departments. It
applies mainly to the departments of general medi-
cine, which treat from 25 to 35 per cent, of the to-
tal number of patients.
The result of this has been that the physician in
a medical department tries to observe a few pa-
tients interesting to him and to "get rid of" the
others as rapidly as possible. I use the term '"get
rid of" advisedly, for I know that my personal ex-
perience has been that of others, and I do not think
that I am less conscientious than the average dis-
pensary physician.
There has been many a long, hot summer after-
noon when, with no assistants, I have treated from
fifty to eighty-five patients, and my sole purpose on
those afternoons was to pacify the patient, give him
a prescription, and cursorily examine the new pa-
tients, so that I would make no "bad breaks," and
send them all on their way rejoicing. Then I would
go home, feeling that I had done no good to any
patient and harm to some, and, as far as I was con-
cerned, I had gained only physical and mental
fatigue. This, surely, has been the experience of
many.
Let us turn for a minute to the small dispensary,
or to the dispensary where the patients have been
divided into Small classes.
The physician in charge has been able to take a
personal interest in each patient ; he has been able
to study the influence of home and working condi-
tions on the production of disease, the size of the
room, the ventilation, the crowded quarters, the
irregular habits of living, the lack of intelligence in
Copyright, 1908, by A. R. Elliott Publishing Company.
144
WILLIAMS: DISPENSARY NURSING.
[New York
Medical Journal.
the care of the body and in the preparation of food.
He has been able to inquire into the patient's habits
and methods of work, the hours of labor, the kind
of labor ; stop to learn, for example, that "railroad
business" may be driving a horse car, that an op-
erator may use his own feet for power or have
power provided for him — all of which conditions
are factors in the production of disease. Because
there were few patients the physician was able to
do just what a physician would do for his private
well to do patients — find out what should be done
for them, and see that they do it. The first is hard
enough and the latter more difficult still. He would
find out whether his patient needed occupation or
change of it, if he needed a change of air, if he
needed to be moved from the top floor to the ground
floor, or from the basement to the top floor. If he
were in need of special hospital treatment or sana-
torium treatment, or special treatment for baths,
electricity, massage, gj'mnastics, and so on, and
then by a knowledge of where these treatments can
be obtained, he has seen that his patient obtains
them. He has further seen whether relief is needed,
food, rent, clothing, and so on, and he has obtained
it through the proper channel.
In other words, this physician was a social
worker, and in New York this social work was in-
stituted with the beginning of the tuberculosis
classes.
Fully realizing these facts, Dr. Richard C. Cabot,
in Boston, attempted to make the large dispensary
do what the small class for tuberculosis had so suc-
cessfully done. In 1906 Dr. Cabot engaged a
trained nurse, who could act as a social worker and
who could give the necessary information to pa-
tients who needed more than the dispensary physi-
cian could give. This work he called social service.
To see that the patients followed out this advice
volunteers were asked for who could visit these pa-
tients subsequently — that is, follow them up and see
that the advice was taken. The substance of Dr.
Cabot's report was read before the Society of the
Alumni of the Presbyterian Hospital in December,
1906. During the discussion it was -brought out
that at the Vanderbilt Clinic, in New York, plans
had already been formulated for such work, and
that it would be begun as soon as funds were forth-
coming. At the close of the meeting a hospital
manager who was present oflfered to defray all nec-
essary expenses for a year.
The work was begun at the Vanderbilt Clinic in
January, a woman physician taking the position of
social worker. The need is apparent, yet often on
the busiest days, in the desire to get through with
the patients, no cases are referred to the social
worker.
What does this social worker do? This can be
best explained by reading the record of several
cases successfully and several unsuccessfully
treated. ,
Case I. — E. L., Russian Jewess ; three years in United
States ; age, twenty-two years ; operator. Referred to Social
Service February 11, 1907, for change of occupation.
. Patient is suffering from neurasthenia and nervous dys-
pepsia, and says that the confinement and want of ventila-
tion in the shop where she is employed render her fatigued
and nervous. She is a girl of good education, sneaking
French, German, Spanish. Italian. Turkish. Jargon, English,
and a little Russian. She is, however, unable to write
English. Her father was formerly prosperous, owner of a
mill in Russia. At present he has no work, and the family
are dependent upon the wages of the daughter and the
money received from a lodger. Application for employ-
ment has been made for this patient at Macy's, Wana-
maker's, Singer Machine Company, Long Island College
Hospital, Charity Organization Society, Association for
Improving the Condition of the Poor, Joint Application
Bureau, Ellis Island, Special Employment Bureau, and to
the Douglass Phonograph Company. The patient's inability
to write English and her lack of experience as saleswoman
have made all efforts to secure for her a place with ade-
quate compensation unsuccessful.
Case II. — J. W., born in United States; single; age,
thirty-two years ; butcher's helper. Referred to Social
Service March 11, 1907.
Patient is exceedingly depressed, morbid, suspicious, and
apprehensive. Last August he had a severe epileptiform
convulsion, and since tliat time has been greatly worried
in regard to his health. He says that his occupation is
unhealthy ; he works in a slaughter house and in a stooping
position ; spends the workmg day in removing the skin
from animals. He takes large amounts of alcohol. He
imagines that those about him wish to do him harm.
Patient was encouraged and urged to return to the clinic,
but he seemed utterly hopeless, said that he was tired of
life, and the thought of suicide was constantly in his mind.
The patierit was referred to the. St. Vincent de Paul So-
ciety for Friendly Supervision. But the patient was not
found, as he had moved from the address given by him at
the clinic.
Case III. — S. E., born in Russia; Jew; twelve years in
the United States ; married ; age, forty-eight ; cutter. Re-
ferred to Social Service February 6, 1907, for occupation.
Patient is a case of arrested pulmonary tuberculosis who
at the present time suffers from emphysema. He has also
an old trachoma that detracts greatly from his personal
appearance. Patient is almost without education, as he can
neither read nor write. He thinks that he could be a
peddler, but does not know how to get a license.
February 8th called at Bureau of Licenses, but found
that for some time the Mayor has ceased to issue new
licenses.
February loth patient was referred to Special Employ-
ment Bureau. Position was secured for him as assistant
at a news stand. Patient remained a part of one day and
was discharged because he could not write an account of
his sales. Special Employment Bureau then said that they
could do nothing more for patient.
February 2Sth, spoke to United Hebrew Charities about
case. They said that patient was lazy and declined to do
anything for him.
March 13th. gave patient a letter of introduction to
Elevated Railroad Employment Bureau, asking for patient
a position as gateman. Patient's want of education ex-
cluded him from such work. Gave patient a general letter,
stating that he is in need of work, telling him to present it
to Yiddish theatres and other places where a man of his
nationality might find a position.
Patient has had no success in his quest for employment.
He is unable to do heavy work and has no education for
other work.
Case IV. — R. H., Irish; widow; age, twenty-five years;
housewife. Referred to Social Service March 14, 1907, for
change of air and rest. Patient was referred to the Asso-
ciation for Improving the Condition of the Poor, and the
following facts were brought out in the investigation:
Some years ago patient married a West India negro. He
died about three years ago, leaving her with a young child.
She was not strong and succeeded in having the child ad-
mitted to a home, as it was impossible for her to support
herself and the baby. Not feeling well enough to work,
she remained with a colored woman until she was about to
be turned out. At this time a colored man invited her to
become his housekeeper. She accepted this place and since
that time has lived in very vicious surroimdings. She does
not profess much affection for her employer, but says that
she cannot work. The Association for Improving the Con-
dition of the Poor refused to do anything for the case,
and, on a promise of the woman to return to Ireland with
her child, one of the Paulist fathers promised to provide
the money. Pending the making of the necessary arrange-
Jar.uar>' 25, 1908.]
WILLIAMS: DISPENSARY NURSIXG.
145
raents three different homes were applied to for a temporary
shelter. All refused, and finally the Sisters of the Good
Shepherd agreed to take her and the patient promised to
go. At the last moment she changed her mind suddenly
and said that she prelerred to return to her former home
among the negroes. Argument and appeal only met with
the response: vNegroes are as good as any one. I do not
feel like working, i do not want to go to the Sisters, 1
want to go back home."
Case \ . — M. D., born in the United States ; stenographer.
Referred to Social Service February 2, 1907, for investiga-
tion and advice.
Patient was suffering from neurasthenia and gastrop-
tosis. She had spent over one, year visiting various clinics
and physicians. Instruction in hygiene given patient, and,
at the request of attending physician, special arrangements
were made lor her to receive massage for the gastroptosis.
the price being merely nominal. After taking the treatment
for a few times patient failed to appear, either for medical
treatment or for massage, although when last seen she was
somewhat improved.
Case VI. — C. B., born in the United States; guard on
subway ; single ; age, twenty-five years. Referred to Social
Service February 11, 1907, for change of occupation.
Patient was a case of arrested pulmonary tuberculosis,
but losing ground on account of lack of proper air and
sunlight. He had repeatedly tried to secure employment
on the elevated railroad, but had been unable to do so. A
personal letter was given patient to present to one of the
assistant superintendents
April 1st, was given employment as guard on the ele-
vated railroad.
April 20th, patient improving greatly.
Case VII. — K. G., born in Germany; twenty-four years
in United States; domestic; single, age, twenty-six years.
Referred to Social Service April 12, 1907, for a place of
^shelter during pregnancy.
Patient is of a low grade of physical and mental develop-
ment and utterly unable to plan for herself. Her sister is
poor and has a large family and was not in a position to
aid patient. After unsuccessful application to three differ-
ent institutions, patient was admitted on April 3d to the
Margaret Strachah Home.
Case VIII. — W. G., bom in United States; wood pol-
isher ; married ; age, thirty-six years. Referred to Social
Service April 12, 1907, for admission to hospital.
Patient was a case of pulmonary tuberculosis and in so
weak a condition that immediate hospital care was urgently
required. He said that while he saw the necessity of
medical care and proper nursing, he was reluctant to leave
his wife, whose earnings were too small to support herself
and two children. Patient was assured that his family
would be cared for, and through telephonic arrangement he
was admitted to St. Joseph's Hospital on April 12. His
family were visited and the case referred to the Association
for Improving the Condition of the Poor.
Case IX. — E. M., botn in United States : schoolboy ; age.
twelve years. Referred to Social Service February 6, 1907,
for investigation as to cause of extreme nervousness.
A visit to the family revealed the following conditions :
The household consisted of father, mother, and six chil-
dren, the patient the oldest and the youngest twins of six
months. The family lived in three rooms and the patient
shared his bed with two other children. There was in the
place great confusion and disorder — babies crying, children
quarreling. The mother weak and ill. food insufficient and
of the coarsest description. Patient was allowed to drink
strong coffee and beer, and no attention was paid to bath-
ing or to ventilation. Patient was instructed to take a
weekly bath and to join the g>-mnasium of the Neighbor-
hood House. A proper dietary was ordered, and. through
the Association for Improving the Condition of the Poor,
milk and eggs were given the family for patient.
April I, 1907. — Conditions in the household are much
improved, patient is haopier and less nervous, gaining in
strength and weight. The babies have been treated in a
hospital, and the tired mother has had an opportunity to
recuperate.
Case X.— J. H.. black : born in the West Indies : mar-
ried : eight months in United States : age, forty-seven years :
by occupation a porter.
Patient has endocarditis and is without means and un-
able to work. He is unhappy and discouraged, and says
that he would like to return to his family in the West
Indies.
Through the Department for Dependent Adults arrange-
ments were made for deportation, and pending such
arrangements patient was admitted to a hospital.
The social worker thus is a bureau of informa-
tion, who not only gives information to the physi-
cian in the dispensary, but also applies that in-
formation for the benefit of the patient. The family
physician or specialist, with his well to do patient
who needs a change of air, a cure at a water-
ing place, or an admission to a tuberculosis sana-
torium, ascertains for himself all the particulars in
regard to these places and institutions, and is able
to intelligently advise his patients where to go.
This same physician, with his poor patient in the
dispensary, is utterly unable to more than tell his
patient to go on as he is doing, and renew his pre-
scription. Of course there are individual excep-
tions in every dispensary, but what was possible for
a few patients, with one or two doctors, is now be-
ing made possible for a great many patients.
At the Vanderbilt Clinic it is now possible for
any physician working' in the dispensary, by means
of the social worker, to obtain almost everything
that a patient can need. The social worker during
the past eight months has been able to obtain suit-
able employment and change of employment, and
has been largely helped by the work of Dr. T. C.
Janeway, through the Charity Organization So-
ciety Committee for the Employment of the Handi-
capped. Patients have been admitted to homes for
incurables and for convalescents. Patients have
been secured special diets, especially for diabetes
and for constipation. Instruction has been given
to many patients in hygiene, and material relief has
been obtained for a large number of patients.
We have also been fortunate, enough at the Van-
derbilt Clinic to have recently installed a complete
apparattis for the application of hydrotherapeutic
measures under the direction of Professor Simon
Baruch, and are able to give hot baths and hot
packs, tonic baths, douches, and so on.
We have also ptirchased a baking machine for
joints; and have recently secured the cooperation
of IMr. Jacob Bolin, who, with the pupils in his
school of massage and gymnastics, is able to give
massage and gymnastic exercises.
In February, 1903, under the direction of Dr. J.
A. Miller, classes were begun for the treatment of
pulmonary tuberculosis, and a visiting nurse was
engaged. This was the beginning of the "follow
up" work, and it showed what a strong hold could
be maintained upon each individual patient, and
how the nurse could encourage and stimulate the
patient into carrying out the directions given him.
This work of the visiting nurse amongst the tuber-
culosis patients has been primarily educational, and
the nurse has taught all the detail of the care of
the consumptive to the patient and his family, in his
own home.
The tuberculosis work, which at first spread over
a large area, has been limited to a district north of
Fiftieth street and west of Eio-hth avenue. At the
present time two nurses are engaged in the tuber-
culosis work, and each patient in this district is
visited at least once a fortnight.
146
UllAJAMS: DISPENSARY NURSING.
[New York
Medical Journal.
Owing- to a very inadequate history system, we
have been unable to report on the percentage of
tuberculosis cases arrested, but the results have been
similar to that obtained at other clinics. An ex-
cellent history system has just been inaugurated,
and satisfactory reports will soon be able to be
made.
In the winter of 1905 a nurse was engaged to do
actual nursing in the homes of the poor. It is sur-
prising what a comparatively small number of pa-
tients have been referred to the nurse for actual
nursing. The visiting nurses at the Presbyterian
Hospital receive a larger number of patients of this
kind, for convalescent patients from the hospital
are referred to them daily. The nurses from the
Nurses' Settlement do a large amount of nursing in
the home, but from many dispensaries no patients
are referred to the Nurses' Settlement, simply be-
cause it is more red tape for the 'doctor, and in the
dispensary the nurse must be on the spot to receive
the patients.
No part of the outdoor nursing is as valuable as
that amongst the children. A nurse was placed in
the children's department in the summer of 1906,
with most satisfactory results, especially satisfactory
in instructing mothers how to care for and feed
their babies. The nurse sees the mother at the
clinic, and makes an appointment to show her how
to prepare the baby's food. The following cases
reported by the nurse well illustrate the value of
her work:
"A child of five months with indigestion, who had been
fed every time she cried. The mother was at the clinic on
Tuesday, and an appointment was made for 9 o'clock the
next morning, and she was told what was needed to pre-
pare the food. The mother was visited at the appointed
hour. There was no milk in the house, the mother saying
as an excuse that the husband was out of work. Consider-
able time was expended in getting together milk and the
necessary materials. As the mother could not read, she
had to memorize everything that was necessary. Visited
the following morning, the child still having indigestion,
it was found that the mother had forgotten all the instruc-
tions. Reinstructed and visited again on Saturday. Mother
had remembered instructions and had followed them out.
and the child was doing well."
"The feeding of the babies must be done properly, for
with chronic indigestion, which results from improper feed-
ing, the baby quickly succumbs to acute diseases of child-
hood, and is constantly predisposed to attacks of summer
diarrhoea. Education of the mothers, then, is the beginning
of success in our work, just as it is in the care of the
consumptives."
This nursing work ha? steadily grown, and is
now well organized, with five nurses to inspect all
the cases of tuberculosis referred to us in our tuber-
culosis district, but also to do actual nursing in the
homes of the poor, and to instruct mothers in care
vTid feeding of infants and children. For several
years patients were treated who lived anywhere in
the city, the nurses even going to the Bronx and
to Brooklyn, but the extent of the work has been
gradually curtailed, owing to the establishment of
special tuberculosis dispensaries in those boroughs,
so that, in 1905, the nursing work was confined to
Manhattan only.
During that year a special effort was made to
curtail the number of visits upon each tuberculosis
patient. For example : Our nurse would visit a new
patient, and the case would be reported to the De-
partment of Health. They would send an inspector,
who would subsequently send a nurse from the
Department of Health. The case would be re-
ferred to the Charity Organization Society, which
would investigate, and find that the patient had pre-
viously been assisted by the Association for Im-
proving the Condition of the Poor. The Associa-
tion for Improving the Condition of the Poor would
send their visitor to investigate, and by this time
the patient wished that he had never seen a nurse,
or doctor, or social worker. By means of an agree-
ment with the Department of Health, no inspector
or nurse is now sent unless upon our written re-
quest, and all patients are visited until they have
moved or died, when the rooms of the patient are
fumigated. In other words, we keep under observa-
tion every case of tuberculosis in our own tubercu-
losis district that has been referred to us. To elim-
inate the number of unnecessary visits made by
representatives of the charitable societies, I wrote
to the New York Association for Improving the
Condition of the Poor, asking if our senior nurse
could not be made a volunteer visitor of that so-
ciety, and to directly investigate her own patients
and to directly give relief under their supervision.
This the association agreed to do, and this agree-
ment has been carried out for nearly two years with
marked success, and material relief has been given
not only to the tuberculosis patients, but also to the
families of other sick patients who were coming to
the clinic for treatment, so that now, instead of hav-
ing four, five, or six visits from different people, the
patient receives a visit from but one nurse. This
increases his confidence, and enables us to treat the
patient in a more thorough and satisfactory way.
For three years I had the privilege of being ex-
amining physician for the Association for Improv-
ing the Condition of the Poor, and was very much
interested in the examination of the mothers and
children who constituted their fresh air parties. As
result of this work cooperation with fresh air work
was easy, and we were able during the summers of
1904, 1905, 1906, and 1907 to send away for fresh
air vacations, by means of the Association for Im-
proving the Condition of the Poor and other
agencies, a total of 1,565, as shown in the accom-
panying table :
Fresh Air Outings to Members of Families.
Day's outings. Week or more.
In 1904 21 7
In 1905 310 23
In 1906- 1.073 82
In 1907 523 . 152
These were almost all mothers and children.
During July, August, and part of September. 1907.
the New York Association for Improving the Con-
dition of the Poor maintained a day camp for babies
at Junior Sea Breeze at the foot of East Sixty-
fourth street. This institution was an educational
one, to teach mothers how to care for infants and
children. A staff of from ten to twenty-three vis-
iting nurses was maintained from July 15th until
September.
Instead of waiting for patients to come, the
nurses were sent out into the homes of the rich and
poor alike, oflFering instruction in the care of babies
and children.
The Board of Health put the inspectors of the
January 25, 1908.]
WILLIAMS: DISPENSARY NURSING.
147
summer corps in the Nineteenth ward as soon as
the garbage strike was over, and they visited fami-
lies according to the plan of the department's sum-
mer corps work. The. visits of the Junior Sea
Breeze nurses were also confined to the Nineteenth
ward. The Nineteenth ward is bounded on the
south by the south side of Thirty-ninth street, on the
east by the East River, on the north by the south
side of Eighty-sixth street, and on the west by the
east side of Sixth avenue and Central Park.
The nurses visited every dwelling in this ward,
interviewing all who would be interviewed, recom-
mending hospitals, dispensaries, and doctors, parks,
piers, and shady streets, fresh air, cleanliness, and
careful feeding, leaving printed circulars on the
care and feeding of children.
Special cards were filled out for all the sick chil-
dren, and frequent revisits were made.
The care of milk was insisted upon, and instruc-
tions given as to its care, as well as the care of the
baby, its clothing, feeding, and so on. Every ef-
fort was made not to help the mother and her fam-
ily, but to make the mother help herself.
Table of Visits.
Number of tenements visited, 17,261 ;
" " miscellaneous dwellings visited, 8,495 \
"■ " families (visits), 116,601;
" children under two years 34,453 ;
■' " revisits, 2,342;
" " sick treated, 1,062;
" sick placed in hospital or dispensary, . 90 ;
" sick referred to hospital or dispens-
ary 781 ;
" " individual families seen, 101,208.
Instruction given :
In bathing, 20,837;
In feeding, 21,218;
In cooking, 14,350;
In clothing, 19,716;
In fresh air, 35.738 ;
In nursing sick babies, 2,877;
In general care, 35,697.
With this enormous number of visits it may seem
that the work was casual and valueless. The work
of the individual nurse varied considerably, and the
results looked for, while not conclusive, proved
strikingly suggestive.
It was hoped that there would be a reduction of
the infantile mortality in this ward. The Department
of Health gave the Association for Improving the
Condition of the Poor the privilege of going over
the records at the department where Dr. W. H.
Guilfoy, registrar of records, gave much assistance
to a skilled worker. The following table shows the
diminution in mortality :
Manhattan and Bronx, July i to September 14, 1907,
as compared with preceding year :
1906. 1907.
Total deaths, all causes 9,746 9,979 +233
Total deaths from diarrhoeal diseases 2,059 2,084 + 25
Total deaths from diarrhoeal diseases,
under five 1,933 1,989 + 56
Nineteenth Ward, July i to September 14, 1907, as com-
pared with preceding year:
1906. 1907.
Total deaths, all causes 1,022 904 — 118
Total deaths from diarrhoeal diseases 274 236 — 38
Total deaths from diarrhceal diseases,
two years and under 253 221 — 32
Total deaths from diarrhoeal diseases,
under five 254 222 — 32
It cannot be said that this visiting nursing was the
cause of this reduction, but it is certainly sug-
gestive.
There were also three nurses at work, visiting
mothers living in tenement houses, before confine-
ment, teaching them how to care for themselves be-
fore and after confinement, and visiting them after-
ward and teaching them how to care for the baby.
This was done where the mother could not afford a
doctor except for the actual confinement, or where
a midwife was in attendance. In no case did the
nurses deliver any of these patients.
Opportunities for visiting nursing in New York
are enormous, especially on account of their edu-
cational value and their value in the field of pre-
ventive medicine. Cooperation is necessary, and
endeavors are being made to bring the various nurs-
ing associations closer together. The cooperation
between the tuberculosis clinics has been a splendid
object lesson which will bear good fruit.
Arrangements have recently been made with the
Nurses' Settlement so that patients from the Van-
derbilt Clinic who live south of Foiirteenth street
and east of Broadway who are in need of nursing
may be referred to the Nurses' Settlement. Cases
referred to the settlement, living north of Seventieth
street and west of Eighth avenue may be referred
to the Department of Visiting Nursing at the Van-
derbilt Clinic when nurses of the Nurses' Settle-
ment are unable to care for them. Patients apply-
ing for treatment at the Vanderbilt Clinic, living
north of Fifty-ninth street, south of Ninety-sixth
street, and east of the Park, who are in need of
nursing, will be referred to the Presbyterian Hos-
pital Visiting Nursing Association. And if patients
living in the Vanderbilt Clinic Tuberculosis District
north of Fiftieth street and west of Eighth avenue
should apply to the Presbyterian Hospital Dispen-
sary will be referred to the Vanderbilt Clinic De-
partment of Visiting Nursing. At the Roosevelt
Hospital Surgical Out Patient Department a visit-
ing nurse has recently begun work, and it is hoped
that her work will ultimately be confined to the
same area covered by the Vanderbilt Clinic, and
that both this nurse and the nurses from the Van-
derbilt Clinic will work more closely together.
A thorough description of all the agencies in this
city maintaining visiting nurses and social workers
has recently been made by Dr. S. S. Goldwater, of
Mt. Sinai Hospital, in an article entitled Dispen-
sary Ideals. The visiting nurse and the social
worker will not reach their highest state of ef-
ficiency until some of these ideals are reached. Such
ideals as the districting of the city for dispensaries,
the districting of the city for visiting nursing con-
sist in:
The doctrine of small numbers.
No medical relief withoiit previous application,
except in cases of emergency, and more frequent
and thorough financial investigation.
The accomplishment of these ideals will result in
smaller classes at the more popular, large, and over-
worked dispensaries, a more equal division of labor,
less imposition by patients who can afiford to pay,
and infinitely better care of the outdoor sick poor.
839 Madison Avenue.
148 PECK: CHOLELITHIASIS.
CHOLELITHIASIS.
A Study of Twenty-five Operative Cases*
By Charles H. Peck, M. D.,
New York,
Attending Surgeon to the French Hospital; Junior Attending Sur-
geon to Roosevelt Hospital.
In considering the question of diagnosis and
especially the indications for treatment, each clini-
cal group presents certain characteristics and prob-
lems of its own.
Certain cases of undoubted cholelithiasis still be-
long in the domain of internal medicine, e. g., the
cases of biliary colic with the passage of one or more
stones, characterized by paroxysmal pain, vomiting,
and transient icterus, with immediate relief of all
symptoms after the passage of the stone.
Recurrent attacks of pain in the upper abdomen,
without fever, jaundice, presence of a mass or ri-
gidity, and in which tenderness is moderate, slight,
or absent, are typical of another group of cases
which may be said to occupy the border line be-
tween medicine and surgery. Many are treated for
years by the genral practitioner, bearing the ex-
acerbations of pain as best they may, with varying
disability and interference with the routine duties
of life, according to the frequency, severity, and
duration of the attacks. Some become morphine
habitues, as in Case VI of my series. That the op-
eration is not entirely free from danger even in this
simplest of gallbladder conditions is well known,
and is illustrated by Case III with the patient who
died of cerebral embolism four days after operation,
and this fact deters many physicians from advising
and many patients from consenting to operation in
a condition which may exist for years without act-
ual menace to life. Such cases usually have stones
in the gallbladder too large to pass the cystic duct,
which from time to time become temporarily
lodged in a dilated ampulla or at the entrance to
the duct, which is often strictured, causing painful
spasm or temporary obstruction.
Complete obstruction of the cystic duct, with the
development of hydrops, empyema, or gangrene of
the gallbladder, may occur, but is often escaped for
years.
The age, the general condition of the patient,
the frequency and severity of the attacks of pain,
the amount of disability and the effect on the gen-
eral health, together with the necessity for the use
of opiates, are all factors which must be carefully
weighed in the balance in determining as to whether
or not an operation should be advised.
Of the series presented six were of this type
(Cases I to VI), and illustrate some of the indi-
cations for operative treatment, the attacks having
extended over periods varying from three months
to twenty years. Case II, a hard working cobbler
with a large family to support, bore his repeated
attacks of pain for about three months, when the
suffering and especially the interference with his
occupation rendered him only too glad to consent to
an operation, since which he has been perfectly well.
His history in brief was as follows:
Case II. — Patient was forty years of age and had al-
ways been well up to about three months before operation.
•Read before the Society of the Alumni of the City (Charity)
Hospital, December 11, 1907.
Since that time he had suffered from frequent attacks of
severe pain in the region of the gallbladder. No jaundice,
chills, nor fever, but pain had been so frequent and severe
as to interfere seriously with his work, though not ill in
bed Examination was negative, except for moderate ten-
derness on deep pressure over gallbladder. Cholecystec-
tomy was performed August 18, 1906. The gallbladder
was moderately thickened and the ampulla dilated. It con-
tained a single ovoid stone of a peculiar white crystalline
appearance, and a rough mulberrylike surface. The cystic
duct was patent. The patient made an uneventful recovery,
and has remained entirely free from symptoms ever since.
Many such cases are treated for gastric troubles
for considerable periods of time, as illustrated by
Cases I, III, and IV, all three having undergone
prolonged medical treatment, including gastric lav-
age, under the impression that the pain was of gas-
tric origin.
Case III. — A woman, forty-five years of age, had had
repeated attacks of pain in gallbladder region for more
than two years, without jaundice, chills, or fever. The at-
tacks had been more frequent and severe for the six
months prior to operation, requiring morphine hypoder-
matically for their relief, but she felt perfectly well be-
tween the attacks. Gastric lavage was employed for a pro-
longed period without benefit, a diagnosis of gastritis hav-
ing been made. Recently the intervals between the attacks
had varied from a few hours to two or three days, and
she had become very nervous and run down. Examination
was negative, except for tenderness on deep pressure over
the gallbladder. Cholecystectomy was performed on No-
vember 8, 1906. The gallbladder was found to be thick-
ened and distended with grumous bile stained mucus ; the
cystic duct was rigid and its orifice minute. There was a
single rounded, nonfacetted stone of moderate size, and two
fragments which appeared to have been flaked off from
a larger ^toiie. The patient bore the operation, which
lasted fifty minutes, well ; had a moderate reaction tem-
perature and little vomiting. Bowels moved freely on the
second and third days in response to calomel and enemata.
The wound was dressed on the third day; there was no
distension ; no apparent wound infection ; the drain was
not disturbed. Temperature and pulse were practically
normal, and patient seemed in excellent condition. That
night (fourth day after operation), while asleep, her
breathing suddenly became stertorous, she frothed at the
mouth, and became completely comatose. The pupils were
contracted and equal. The coma continued, and she died
within twelve hours, four days after the operation, prob-
ably from cerebral embolism, though no autopsy could be
obtained.
In Case IV both gastric and gallbladder lesions
had undoubtedly been present, the extensive peri-
gastric adhesions indicating the previous existence
of gastric ulcer.
Case IV. — The patient, a woman thirty years of age,
had suffered from attacks of pain in the upper abdomen
for about three years. Had had occasional vomiting, but
ao jaundice, chills, or fever. She had received prolonged
treatment for gastric disorders, including lavage, at a dis-
pensary. Examination was negative, except for slight ten-
derness on deep pressure over gallbladder. Operation per-
formed at Roosevelt Hospital on June 21, 1907. The upper
abdomen was filled with a mass of weblike adhesions. The
stomach, colon, liver, and gallbladder were adherent to each
other, and to the anterior, parieties. The gallbladder was
removed ; it contained three good sized stones ; the cystic
duct was not occluded. No stones found in hepatic or
common ducts. Adhesions binding stomach to anterior
abdominal wall were separated, several bands being ligated
and divided. The anterior wall of the stomach showed old
cicatrices, evidently the sequelae of ulceration. The pa-
tient made an uneventful recovery and left the hospital
well on July 10, 1907, nineteen days after operation.
Patients suffering from this type of cholelithiasis
seldom come to the surgeon until medical means
have been thoroughly tried over a period of months
or years, the mere lapse of time without improve-
ment being often sufficient to determine the neces-
January 25, 1908.]
PECK: CHOLELITHIASIS.
149
sity for operation. Case VI, the widow of a physi-
cian, finally sought operation after having had at-
tacks of pain for more than twenty years, in the
hope of ridding herself of the morphine habit. Her
history was as follows :
Case VI. — She was fifty-eight years of age, and had had
an illness lasting two years, thirty years ago, characterized
by severe attacks of epigastric pain and the passage of
gallstones. Had had repeated attacks of pain in the region
of the gallbladder for about twenty years, without jaundice,
chills, or fever, resulting in the development of the mor-
phine habit. The patient was extremely stout, and this,
in connection with her age, morphine habit, and poor gen-
eral condition, caused much hesitation and careful study
of the case in all its aspects before the decision to operate
was finally reached. Operation was performed on August
19, 1904. The gallbladder was shrunken to such an extent
that it was hardly recognizable. It was surrounded by
adhesions which had drawn the pylorus over to the right.
Cholecystectomy was performed, adhesions- were freed, and
the ducts explored ; no stone was found. Recovery was
slow, but finally complete, with relief of pain, and cure
(for the time under observation at least, up to October 26,
1906) of the morphine habit. A large ventral hernia de-
veloped in the wound, necessitating operation on March
16, 1905.
To summarize the six cases of this type, in three,
single nonfacetted stones were found; one (Case
IV) had three good sized calculi, and extensive
perigastric adhesions; one (Case V) had twenty
or more small, jet black, mulberry like stones com-
posed of bile pigment, of the variety frequently
found at autopsy but which rarely give symptoms,
and Case VI, the history of which included attacks
of coHc followed by the passage of calculi, pre-
sented a diminutive, shrunken gallbladder, with ad-
hesions to the pylorus, but no stone.
Cholelithiasis with Acute or Chronic Cholecystitis
or Empyema of the Gallbladder.
There were nine cases of this type in the series,
and one. Case XII, of acute cholecystitis without
stone.
The symptoms, in addition to pain and vomiting
in the attacks, were fever, sometimes chills, well
marked localized tenderness and rigidity, and
greater disability, the patients always being ill
enough to remain in bed. Jaundice, usually very
slight had occurred at some time during the illness
in six of the ten cases. Attacks of acute inflamma-
tion of the gallbladder are always accompanied by
more or less obstruction of the cystic duct. Resolu-
tion, with reestablishment of the patency of the
duct and natural drainage, may occur, but is seldom
complete. The gallbladder wall remains somewhat
thickened and rigid, the duct narrowed, and sooner
or later the symptoms recur. That patients may
pass through a number of such attacks, however,
with comparatively long intervals of freedom from
symptoms, is a well known .clinical fact. Case IX
gave such a history, having had an interval of fif-
teen years free from symptoms, followed by the
sudden onset of acute suppuration.
Case IX. — The patient was a woman fifty-nine years of
age, who began to have attacks of colicky pain and jaundice
when about thirty years of age. About fifteen years ago
she had a severe illness, with pain, jaundice, fever, and
the passage of gallstones, and was ill in bed for about six
months, and not well for more than a year. Since that
time, except for occasional pain and indigestion, there
was no return of the trouble until the onset of the present
attack, two days ago, with excruciating pain, vomiting,
fever, and prostration; no jaundice. There was extreme
tenderness over the gallbladder and an ovoid mass was
palpated. Temperature on admission, 103° F. Chole-
cystostomy was performed; about six ounces of mucopus
and fifty-eight white, facetted stones were removed. Re-
action temperature reached 105° F., but in a few days fell'
to normal. Slight pocketing of pus in Morison's pouch
at end of second week. Convalescence was slow, but
finally complete. Superficial abscess in wound opened and
drained about three months later.
Instead of resolving, however, many such cases
terminate in perforation or gangrene of the gall-
bladder. Perforation may occur into the colon or
duodenum, with spontaneous subsidence of the
symptoms. It may take place on the liver sur-
face, forming a localized abscess, or into the peri-
toneal cavity, causing local or general peritonitis.
Acute cholecystitis should always be regarded with
suspicion, and early operation is the safest rule. A
damaged gallbladder more or less buried in adhe-
sions, a strictured cystic duct and almost certain
recurrence of the attack is the most favorable out-
come one may expect, while perforation or gan-
grene are possibilities to be considered in every be-
ginning case.
In close relation to the cases of acute cholecysti-
tis with partial or temporary obstruction of the cys-
tic duct are those in which such obstruction is com-
plete and empyema of the gallbladder results, the
course depending largely on the virulence of the in-
fection and the relative resistance of the patient.
My most recent case, XVI, illustrates an extremely
sluggish type, and the enormous distension of tiie
gallbladder which may occur without rupture.
Case XVI. — The patient, a woman thirty- four years of
age, was sent to Roosevelt Hospital for treatment of a
large abdominal tumor which was thought to be an ovarian
cyst. The mass was as large as a child's head and occu-
pied the right side of the abdomen, its greatest prominence
being about opposite the umbilicus. It was spheroidal in
shape, not movable, nor sensitive; no fluctuation could be
made out. There was no fever, and the leucocyte count
was normal. There was a history of an attack of abdomi-
nal pain about three years ago, without fever, jaundice,
or development of a mass ; a similar attack eight months
ago, after which a lump was felt which never entirely dis-
appeared, and a third attack about six weeks ago, after
which the mass rapidly enlarged until it reached its pres-
ent size. Some pain persisted, but there was no fever,
chills, nor sweating, and no jaundice, the chief complaint
being the presence of the tumor. The clinical picture sug-
gested hydronephrosis, but catheterization of the right
ureter drew normal urine. Operation was performed at
Roosevelt Hospital on September 20, 1907. The right kid-
ney was exposed by an oblique incision, found normal,
and the wound at once closed. The manipulation of the
patient in the kidney position dislodged the tumor so that
it became more movable and shifted toward the median
line. The patient was turned on her back and laparotomy
performed. The tumor was an enormous gallbladder, sur-
rounded by dense adhesions. After partially freeing it
from adhesions it was tapped with a large trocar and
canula and about three pints of thick, greenish pus_ evacu-
ated. It was then gradually freed from surrounding ad-
hesions and from the liver and removed. After cutting
away tags of liver tissue the large, raw surface on the
under surface of liver was partially closed by a continuous
suture of heavy catgut. Two large cigarette drains were
inserted, and the wound closed in the usual manner. The
gallbladder walls were greatly thickened, nearly ulcerated
througTi along the right border of its liver attachment,
but not necrotic elsewhere. It contained one small non-
facetted stone ; the cystic duct was occluded. The patient's
condition was critical for about forty-eight hours, after
which improvement was rapid. There was a profuse dis-
charge of gelatinous material, probably necrotic liver sub-
stance, from the drainage tract. Elsewhere the wounds
PECK: CHOLELITHIASIS.
[New York
Medical Journal.
healed promptly, and convalescence has been uninter-
rupted.
I have reported this case in detail because of its
unusual interest in respect to the size of the gall-
bladder, the absence of the usual symptoms and
signs of suppuration, the extremely sluggish course,
and the failure of any of the dozen or more sur-
geons who examined the case to even suspect that
the tumor was of gallbladder origin.
In contrast to this. Case XV presented the typi-
cal symptoms and signs of acute empyema of the
gallbladder, i. e., localized pain and tenderness,
tumor, fever, elevation of pulse, leucocytosis, and
absence of jaundice, the symptoms having steadily
increased from the onset to the time of operation.
The gallbladder was distended with mucopus and
contained many stones. The cystic duct was oc-
cluded and surrounding adhesions were numerous
and dense. Cholecystectomy was followed by a
prompt and uneventful recovery.
Case XII. — Acute cholecystitis without stone was a
rather unusual one occurring in a young girl seventeen
years of age, who gave no history of typhoid fever or any
other previous acute illness. The gallbladder was inflamed,
tliickened, and contained mucopus; the cystic duct was so
strictured that cholecystostomy, which was first performed,
had to be followed by cholecystectomy fifteen days later
on account of recurrence of gallbladder distention as soon
as the drainage opening closed.
Cholelithiasis with Acute Gangrene of the Gall-
bladder.
It is only a step from empyema to acute gan-
grene of the gallbladder, partial or complete, with
ultimate rupture and local abscess, as in Case
XVII, or dififuse peritonitis and fatal sepsis, as in
case XX. Complete occlusion of the cystic duct
is followed by a distension of the gallbladder with
the mucopus secreted by its mucous membrane.
Without exit, the tension in certain cases becomes
so great that the blood supply is cut off and gan-
grene results, just as it does in the overdistended
appendix, from purely mechanical causes. In other
cases it may be due directly to the virulence of the
infecting organism, or lowered resistance, but it is
my belief that it is more often due to the actual
occlusion of the nutrient vessels from intracystic
tension. Once perforation occurs and the contents
of the gallbladder escape into the peritoneal cavity,
a dangerous and often fatal peritonitis results.
Case XX admitted in such an advanced stage of peri-
tonitis that the exciting cause could not be deter-
mined, illustrates the neglected case, allowed to take
its own course until past hope of relief. Case XIX
is typical of the condition operated upon just be-
fore perforation had occurred. An area the size
of a silver quarter near the fimdus was completely
gangrenous and in a few hours would surely have
^ruptured, pouring the contents of the gallbladder
'into the peritoneal cavity. This case also illustrates
the danger signs in acute cholecystitis, i. e., at the
time of operation, sixty hours after the onset of the
attack, the temperature and pulse were steadily ris-
ing and the tenderness and rigidity were becoming
diffused over a wider area. Any attack of acute
cholecystitis in which at the end of forty-eight
hours there is no abatement of the tenderness, or
of the elevation of temperature or pulse, should be
regarded with suspicion. Diminution of the pain
may be an unfavorable symptom, indicating per-
foration and relief of tension. In such cases, how-
ever, the tenderness and rigidity show no abate-
ment.
There were four cases of acute gangrene of the
gallbladder in my series, with one death j one had
perforated on the liver aspect and the process was
localized to the immediate region of the gallbladder.
Her history was as follows :
Case XVII. — A Swedish woman, twenty-nine years of
age, had had numerous attacks of pain in the region of
the gallbladder during the past five days, without jaundice
or fever. Present attack began five days ago with severe
pain, tenderness over the region of gallbladder, and fever,
all symptoms having increased steadily since onset. On ad-
mission to Roosevelt Hospital temperature was ioi.8° F. ;
leucocytes 16,000. Operation was performed on June 16,
1905. The gallbladder was found buried in a mass of ad-
hesions, gangrenous and perforated on the liver aspect:
secondary abscesses among adhesions to the inner side. It
contained pus, eighteen stones, and was completely gan-
grenous, except for a portion of its peritoneal coat. Chole-
cystectomy was performed with difficulty on account of the
great friability of the tissues. Febrile reaction was sharp
after the operation, the temperature reaching 104.4° F.,
but convalescence was satisfactory. Patient was allowed
out of bed on the nineteenth day and left the hospital well
on July 8, 1905, twenty-two days after operation.
Two patients were operated upon before perfora-
tion had occurred, one. Case XIX, being fairly
typical of the condition prior to perforation.
Case XIX. — A woman, forty years of age, had had at-
tacks of gallstone colic without jaundice twelve years ago,
with occasional pain and discomfort in region of gallbladder
from time to time ever since. Onset of severe pain and
tenderness over gallbladder about sixty hours before opera-
tion ; steady increase of symptoms, with rise of tempera-
ture to 103° F., pulse to 120. Diffusion of tenderness and
rigidity in right upper quadrant; some abdominal disten-
sion. Very faint icterus of conjunctivae. Operation July
31, 1906, cholecystectomy performed. The gallbladder was
tensely distended with mucopus, and contained thirteen
stones. The inner coats were gangrenous throughout, and
at the fundus the gangrene had extended to all the coats,
and rupture was imminent. The infection had extended to
the surrounding peritonasum, free turbid serum escaping
on opening the peritonaeum, and recent lymph and adhe-
sions filled the entire region. The usual drainage and
wound closure were adapted. Convalescence was unevent-
ful, except for the development of an abscess at the lower
angle of the wound on the fifth day. Symptoms of sepsis
and peritonitis rapidly subsided, and by the end of the
third week wound was healed and the patient up and about.
This case was on the verge of rupture into the peritoneal
cavity, and twenty-four hours later would have undoubted-
ly had fatal peritonitis.
The fourth case of acute gangrene had ruptured
some time prior to operation and had a generalized
septic peritonitis at the tiine of his admission to
the hospital. Delay in operating until perforation
has occurred is almost sure to be followed by a
fatal result.
Case XX. — The patient, a man thirty-six years of age,
was brought to Roosevelt Hospital in the ambulance on
August 14, igo6, suffering from symptoms of acute general
peritonitis. There was marked distension ; general tender-
ness and rigidity; small, thready pulse. Temperature
101° F., pulse 116, leucocytes 28,500. No history was ob-
tained by the house staff, except that illness had lasted
three or four days. Appendicitis was suspected, and an
incision in the iliac fossa made. Abdomen was full of
seropurulent fluid, but the appendix was not diseased. It
was removed and a soft catheter inserted in stump, allow-
ing quantities of gas and faecal malter to escape to relieve
distention; stump then inverted with pursestring suture.
Palpation revealed a diseased gallbladder and a second in-
January 25, 1908.]
PECK: CHOLELITHIASIS.
cision was made. The gallbladder was completely gan-
grenous, contained three large and many small stones. It
was excised in the usual way, area cleansed, and cigarette
drains placed down to stump. Abdomen thoroughly
flushed with saline solution through Blake tube before
closing. Purulent fluid washed from pelvis and all parts
of abdomen. Patient reacted surprisingly well and for
about twenty-four hours recovery was hoped for. Signs
of peritonitis then increased, and he died at end of forty-
eight hours.
Calculi in the Common Bile Duct.
Movable stone in the common duct presents quite
a different picture, characterized by pain varying
in severity, duration, and frequency of attacks ;
jaundice, which, as a rule, is moderate in degree,
intermittent, but never entirely disappears; ague
like attacks of chills, fever, and sweating; and ab-
sence of a tumor. The course is subacute, or
chronic, as the obstruction is of a ball valve char-
acter and intermittent, the common duct becoming
dilated and thickened as the stone increases in size,
so that at the time of operation it will often admit
the index finger. Case XXI presented a typical
picture of this condition.
Case XXI. — The patient, a man fifty years of age, had
been ill for about three years with intermittent pain in the
upper abdomen, chills, fever, sweating, slight icterus, and
loss of flesh and strength. The attacks occurred fre-
quently but irregularly, the intervals between attacks vary-
ing from a day or two to a week. The chills were often
severe, lasting twenty or thirty minutes. There was in-
creased resistance and tenderness over the gallbladder, but
no tumor. He was operated upon March 30. 1904, at the
French Hospital. The gallbladder was shrunken and
buried in adhesions. A perforation on its under surface
had been sealed by adhesions to the transverse colon.
Cholecystectomy was performed, and the greatly dilated
common duct laid "freely open by incision through the
stump of the cystic duct. Two movable ball valve stones
were removed, and the duct explored with the index
finger and probes. A catheter was passed into the hepatic
duct and secured, and the remainder of the incision in
the duct closed with fine chromic gut sutures. Bile drained
freely, through the tube for three days, when it was re-
moved. All bile leakage ceased on the twenty-second day,
the wound healed kindly, and he left the hospital well on
May 3d, thirty-five days after the operation. He reported
in October, 1906, two and a half years after his operation,
that he had remained perfectly well, and had gained about
forty pounds in weight.
Such cases should invariably be operated on as
soon as the diagnosis is made, as septic cholangitis
is sooner or later sure to occur. The four cases of
this tvpe in the series all recovered promptly after
operation.
Primary Carcinoma of the Gallbladder.
The one case of this type in the series was asso-
ciated with acute empyema of the gallbladder,
which also contained two large stones. The growth
was confined to the region of the fundus, did not
involve the liver, and while very large was not ex-
ceptionally difficult to remove by the usual chole-
cystectomy. The patient made a good operative re-
covery and left the hospital apparently well twenty-
three days after the operation. Some months later
friends reported at the hospital that she was ill
with symptoms which probably meant recurrence in
the liver.
Cases of primary carcinoma of the gallbladder
amenable to surgical treatment must be extremely
rare, and recurrence in the liver is almost certain
to follow within a short time. The case presented,
in which life was prolonged for a few months in
comparative comfort, is the most favorable one that
has come under my observation.
Treatment.
When operation has been determined upon, the
character of the procedure must, as a rule, be de-
cided upon after the abdomen is opened, and ex-
cept in cases of stone in the common duct, resolves
itself into a choice between cholecystectomy or
drainage of the gallbladder after removal of stones,
and cholecystectomy or its complete excision. Ideal
cholecystotomy, i. e., removal of stones, suture
of the gallbladder, and closure without drainage, is
unsafe, and has been practically abandoned. Of
my twenty-five cases, primary cholecystectomy was
performed in twenty-one, with two deaths — Case
III, where the patient died of cerebral embolism on
the fourth day after operation, and Case XX, with
death from general peritonitis, due to acute gan-
grene of the gallbladder and present at the time of
operation. Secondary cholecystectomy was per-
formed in Case XI, the primary cholecystostomy
having been performed by another surgeon two
years before and followed by persistent suppuration
in the gallbladder and adjacent regions. In the
remaining three cases (IX, X, and XII) in which
I performed cholecystostomy, one. Case IX, made
a good recovery after rather prolonged discharge
from the fistula, but in the other two I was obliged
to perform secondary cholecystectomy a few weeks
after the cholecystostomy on account of occlusion
of the cystic duct, and recurring distension of the
gallbladder as soon as the fistula healed.
In the series of twenty-five cases, therefore, I am
able to report only one successful cholecystostomy,
while twenty-two cases of cholecystectomy resulted
in recovery. Undoubtedly other cases of the series
might have been successfully treated by c*hole-
cystostomy, but in the majority of the cases tlie
gallbladder or cystic duct were so damaged that
cholecystectomy seemed, the preferable procedure.
That cholecystectomy is attended by somewhat
greater immediate operative mortality is probably
true, but if the condition present seems likely to de-
mand removal of the gallbladder ultimately to ob-
tain a cure, it is my belief that usually the risk will
be less if the cholecystectomy is made the primary
procedure. Secondary cholecystectomy has seemed
to me an infinitely more difficult and dangerous
operation.
I do not question, however, the value and ef-
ficiency of the simpler operation in certain cases of
the type of my first group, and also in some of the
cases of acute cholecystitis, without distinct stric-
ture or occlusion of the cystic duct.
Cases of stone in the common duct require, in
addition to the removal of the shrunken gallblad-
der, incision into the common duct, removal of
stones and thorough exploration of common and
hepatic ducts to be sure that none are left behind.
Hepatic drainage by rrteans of a tube passed into
the hepatic duct, around which the incision into the
common duct is sutured, should be employed as a
rule. Such a tube is removed in from three to
seven days, the discharge of bile usually ceasing
spontaneously at about the end of the third week.
30 West Fiftieth Street.
January 2$, IQ08.]
PECK: CHOLELITHIASIS.
153
'o
I
m
in
<
154
STILLMAN: POSTDELIRIOUS ALCOHOLIC STUPOR.
[New
ilEDlCAL
York
POSTDELIRIOUS ALCOHOLIC STUPOR.
(Alcoholic Cerebral CEdema, "Wet Brain.")
By Charles K. Stillman, M. D.,
New York.
The peculiar stupor that sometimes follows alco-
holic delirium has been little studied and less fre-
(juently described. In this country it has received
attention from scarcely anybody except Dana' and
Lambert', and although occasionally met with in
private practice, is generally unrecognized by the
profession at large.
Of late there has been manifested an increased
desire for information upon this subject, but the
difficulty of obtaining a sufficient number of cases
for comparative study has operated against the
fulfillment of this desire.
This article, while not pretending to solve the
many pathological problems involved, nor to answer
in sweeping statements all clinical questions that
may be asked, nevertheless represents a certain
amount of first hand study under fairly favorable
conditions and should have a certain value, if for
no other reason than that its rather limited series
of cases and observations may serve as a basis of
comparison for more complete investigations.
The association of stupor with oedema of the
meninges has led many in the past to regard the
transudate as the central, if not the causative, factor
in this interesting postdelirious state, yet it seems
an indisputable truth that the symptoms accom-
panying are merely those of a certain type of cere-
bral irritability, for they not infrequently occur in
conditions where no traces of oedema are found at
autopsy. Thus, in' the low muttering delirium of
typhoid fever and in the last stages of chronic
uraemia is often seen a clinical picture closely re-
sembling alcoholic postdelirious stupor. There are
the same evidences of muscular unrest, the same
vacuous facial expression, the same pupillary
changes, the same hypersesthesias — all pointing to
some profound irritative influence acting upon
brain tissue, but oedema of the meninges is not al-
ways present in the nonalcoholic cases.
It is worthy of note that these cases are in a low
physical state and sufliering from cerebral toxaemia.
Conversely, it is interesting to note that consid-
erable degrees of serous effusion of the meninges
are found post mortem in cases that during life
have given no special symptoms referable to this
condition.
The presence or absence of the oedema apparent-
ly has little to do in the production of the clinical
picture, yet it occurs with surprising regularity in
the alcoholic cases ; its causation had probably better
be looked for among the general conditions under-
lying the stupor.
The occurrence of marked oedema of the men-
inges in advanced alcoholics has been generally
recognized by pathologists the world over. It may
be conceived as beginning in a small way in the
simple chronic alcoholic, and rising with successive
degrees of intensity throughout the various stages
of alcoholism to culm'inate at last in that condition
of which its own presence pathologically is the most
striking feature.
'Dana, Textbook of Nervous Diseases.
'Alex. Lambert on Alcoholism, Osier's Modern Medicine, I.
It is a matter of a good deal of difficulty to ar-
rive at any just estimate of the causes that con-
tribute to the production of the stupor. Perhaps in
view of the undeveloped condition of our knowl-
edge along these lines it may be as well not to the-
orize at all, but merely to lay emphasis on the
probability of a tox:ic factor and to point out the
symptomatic resemblances of this condition to oth-
ers in which toxaemia and exhaustion undoubtedly
play a large part.
The type usually considered in speaking of "alco-
holic wet brain" is a transudate pure and simple,
and not included under the category of the low
grade meningitides. However, there is in alcoholic
oedema a tendency to low grade inflammaton,
changes about the bloodvessels and meninges that
is far more marked than in wet brain of other types.
Transudation takes place from the piaarachnoid
and occasionally from the small bloodvessels pene-
trating the brain substance. About these latter a
small watery zone may sometimes be made out.
The changes in the brain substance and meninges
are those so often described under chronic alco-
holism.
The pathologist should not be too ready to diag-
nosticate wet brain in cases where the oedema may
well have been post mortem. In true oedema the
effusion will be found well distributed, whereas in
post mortem oedema the fluid will be found only in
the dependent areas.
JEtiology.
At the very outset it seems well to lay emphasis
on the fact that the symptoms of this type of stupor
are almost invariably preceded by a greater or less
degree of alcoholic delirium. Dr. Lambert records
a few cases where preceding delirium was not no-
ticed, but in the vast majority of instances the pre-
vious statement will undoubtedly hold true. The
finest examples, naturally, are those in which the
symptoms develop following a simple, delirium, and
it is of these that this paper treats. A second class, in
which the wet brain develops following a delirium
tremens brought on by pneumonia or some other
acute condition, should be worthy of a separate
article.
A study of ninety-eight patients admitted to the
male and female alcoholic wards of Bellevue Hos-
pital shows some rather interesting' results.
From September i, 1905, to September i, 1906.
there were admitted to the female alcoholic wards
of the hospital 2,133 patients; of these but twenty-
two were attacked witli wet brain, which, after de-
ducting a relatively small number of nonalcoholics
from the general total, represents a percentage of
approximately I.
Nationality. — Irish, 10; American, 8; English,
2; Canadian, i ; Scotch, i.
Age. — The youngest was twenty-three years of
age, the oldest sixty, while the majority ran vari-
ously between thirty and forty. There were three
between fifty and sixty.
Mortality. — Of the twenty-two patients, eighteen
died, a mortality of approximately 81 per cent.
Duration. — Among those patients who died, the
duration of life in uncomplicated cases ranged from
one to forty-five days. Of these the three of
longest duration, i. e., twenty-four, twenty-nine,
January 25, 190S.]
STILLMAS: FUSTDELIRIOUS ALcOHULlL STUPOR.
155
and forty-five days respectively, died apparently of
exhaustion. Nine other patients, the balance of the
uncomplicated cases, ran variously from two to
nine days.
Of the com.plicated casefe where the patients
died, the durations were variable. Two contracted
lobar pneumonia, one had lobar pneumonia and
morphinism, another was attacked with broncho-
pneumonia. One died with symptoms of postde-
lirious stupor and pulmonary tuberculosis, but, as
there was no autopsy in this case, the diagnosis
might well have been tuberculous meningitis.
Of those patients that "recovered," one was taken
home unimproved after twenty-eight days. Two
were sent to the Department of Public Charities as
improved, after sixteen and eighty-nine days re-
spectively, and a third was completely cured after
ninety-four days. This young woman, thirty-four
years old, now strong and healthy, presented the
condition in its most aggravated form.
During the same period, that is, from September
I, 1905, to September i, 1906, there were 5,017
admissions to the male alcoholic ward. Among
this number, seventy-six were attacked with symp-
toms of postdelirious stupor, or approximately 1.5
per cent. . After deducting a small fraction for non-
alcoholic admissions, we note that there is still a
relative preponderance of the condition among the
males.
Nationality. — -Irish, 24; American, 30; German,
6 ; English, 3 ; Swedish, 3 ; French, i ; Italian, i ;
Scotch, I ; Bohemian, i ; Hebrew, i.
Age. — The oldest was seventy years of age, three
were between sixty and seventy, fourteen between
fifty and sixty, twenty-three between thirty and
forty, and four between twenty-two and thirty.
Ages of eight others unknown.
Mortality. — Of the seventy-six, sixty-three died,
a mortality of 79 per cent.
Duration of Illness. — Among those that died,
in the uncomplicated cases, the duration was from
less than one day to twenty-two days. The aver-
age duration was a trifle under a week, but this does
not give a correct idea of the condition. As a mat-
ter of fact, out of forty-eight uncomplicated cases,
only fourteen patients were over nine days in dura-
tion, the longest being twenty-two, twenty-one,
seventeen, and fifteen respectively. But twelve
were between five and nine days in duration, while
the greatest number (twenty -two) was less than
five days in duration.
When it is considered that these figures in many
instances represent a considerable portion of the
preceding active delirium as well, a still further re-
duction must be allowed for.
Of the complicated cases where the patients
died, six succumbed to lobar and three to broncho-
pneumonia, either coincident or complicating ; of
these none lived longer than twelve days. One died
of decubital gangrene on the fifteenth day, and two
who were suffering with simple fractures of the
femur on admission died after about a week. In
a case with a fractured tibia, the patient survived
twelve days.
. The thirteen patients who recovered did so in
periods of from two to forty-five days. Five of
these were of long duration, nineteen, twenty-eight.
thirty-four, thirty-nine, and forty days respectively ;
eight recovered in periods of from two to thirteen
days.
The individual mentioned before who recovered
in thirty-nine days exhibited remarkable vitality, as
he had two fractured ribs on admission, and was
attacked with pneumonia while in the ward. The
patient who was discharged after forty days, to-
gether with one other where oedema was of slight-
ly shorter duration, was committed shortly after as
insane.
Of the others, two were sent to the Department
of Public Charities as improved, while the re-
mainder were actual or apparent cures.
Summary. — In studying statistics, particularly of
a small series like the one I have given, great care
should be taken not to be led into erroneous conclu-
sions. However, a number of very interesting
points are apparent.
It would probably be unfair to cite the slight
relative preponderance in males as conclusive,
owing to the rather limited number of cases studied.
The mortality figures for either sex are not far
enough apart to suggest lhat one sex succumbs
more readily than another. Dr. Lambert's records
give a considerably lower mortality than these fig-
ures would indicate, and I am inclined to believe
that the final figures will be found considerably be-
low rather than above the 80 per cent. mark.
The relatively earlier age at which females art-
subject is borne out also by Dr. Lambert's figures.
But there is one peculiar difference that is perhaps
a direct consequence of the drinking habits of the
two sexes. Men unquestionably survive the shorter
attacks better than women, while they succumb
with greater frequency to the longer ones. The
majority of drinking men punctuate their steady
tippling with occasional debauches, which probably
have a tendency to bring on delirium tremens
earlier than it would have occurred if their efforts
had been less spasmodic in character. As a result
the attack is more acute but less fatal, because pre-
cipitated before their vital powers was entirely
used up.
Women, on the other hand, tipple steadily, but
debauch less, and this, together with their more
sheltered life, staves ofif the delirium until it results
as a direct sequence of physical exhaustion. On
these stupor descends with terrible effect, for their
vital processes are verv low, and resistance almost
nil.
In this connection I should like to state that I
have seen in men many cases which for lack of a
better term I will call transitory zvet hrain, in which
the symptoms, manifesting themselves for only a
few hours or during the night, almost escape notice.
In the majority of cases these have occurred in de-
lirium during a pneumonia, although occasional!}
in the simple noncomplicated form.
The most interesting feature of these statistics is
the tendency which they show toward a separation
into two distinct types, the short and the pro-
tracted. The short considerably outnumber the pro-
tracted. \\'omen, by the way, who last long enough
to become protracted cases, show remarkable pow-
ers of resistance.
^.'ULLMAX: PuST DELIRIOUS ALCOHOLIC STUPOR.
LNew Vork
Medical Journal.
Syniptoiiiatology.
There is no set rule as to the time of onset of
stupor in the course of dehrium tremens. When
the delirium tremens eomplicates pneumonia, the
period of greatest susceptibility is about the crisis,
but in general it may be set down that "wet brain" is
likely to make itself manifest at about the third or
fourth day of delirium tremens, and so insidious
and stealthy is its approach that it is hard to deter-
mine where one condition terminates and the other
begins.
Perhaps the first symptom to attract the physi-
cian's attention is the distinct alteration in facial
expression. The marked restlessness and noisy
activity that characterized the delirium tremens have
departed, and his heightened color and exaggerated
play of expression have given place to a gray pallor
and almost cadaveric immobility of countenance.
.\t this time the pupils are observed to be equally
contracted, and there is a moderate degree of stiff
neck present. Soon the picture becomes more com-
plete, as the characteristic symptoms unfold them-
selves. Usually the patient lies flat upon the back
with legs extended, head thrown slightly back and
unobserving glance directed toward the ceiling, to-
ward which the hands reach in a rather character-
istic manner, suggestive of rope climbing. They
are seldom still for more than a few seconds at a
time, and exhibit the weak, wide tremor of cerebral
irritation. The facial expression, aside from its
gray pallor, is rather distinctive, and unique in the
almost total obliteration of the hues of expression.
Dr. Gregory mentions the following points as espe-
cially indicative of. wet brain: "Line of thought
sharply accentuated, yet face totally devoid of ex-
pression. Eyes dead, fishy, and lacklustre. Mum-
bling mouthing articulation in contradistinction to
the muttering of other low deliriums in which the
spoken words are more sharply defined and clear
cut."
Generally the stuporous patients say nothing that
is audible. When they talk, as some of the milder
cases do, the labials are absent, and they appear to
suffer from inability to initiate muscular movements
of the lips. When irritated or hurt, the accom-
panying facial contortion involves the least mobility
of expression consistent with the recognition of
pain. In the majority the eyelids are closed, while
flies gather in numbers unheeded about the eyes,
nostrils, and corners of the mouth. The pupils in
the early stages are often reduced to pin point size
and later dilate, remaining so to the end, but this
is by no means the invariable rule. Some patients
exhibit no pupillary changes whatever, while in
<ine, a case observed in ward 6 in March, 1906, they
underwent frequent alterations in size. At times
it was even possible to see the slow reactionary
changes taking place.
Two, rather constant, early symptoms are mus-
cular rigidity, which is seldom extreme, and hyper-
aesthesia, the latter particularly marked when cir-
culation to any part is cut off. In time both these
symptoms are likely to attract little attention.
.Stiff neck, however, is very persistent. In wo-
men the writer has many times noticed an ulnar de-
flection of the fingers, but it is quite possible that
this may have been due to the multiple neuritis, so
common in alcoholics.
The pulse maintains much the same general
features throughout, being small, frequent, feeble,
intermittent, of low tension, and very variable in
its quality and rate from hour to hour and day to
day ; indeed, it may run 90 to 100 one hour and 120
to 130 the next, the general average being some-
where between these two figures.
Respirations, on the other hand, are not much
disturbed.
Temperature is typically low, 99° to 101° F., and
not seldom it drops to subnormal — in general a low,
irregular temperature curve.
The stupor is typically a quiet one, except for
the muttering movements of the mouth, and the
peculiar and continual activity of the hands.
The coma is a very variable quantity; certain
cases never become comatose until just before
death, when, according to Dana, the filling of the
ventricles induces this result. Cases of this sort
may remain perfectly rational, talking in mouthy
articulation or answering questions until the last.
A second class, passively delirious or comatose,
will comprehend if directly addressed, or even obey
directions, but relapse with closed eyes into in-
coherent muttering, if left alone.
A third class remain oWivious to all external
stimuli.
As to the course of the illness, there is nothing
very definite in the patient's symptoms on which to
base a prognosis ; perhaps all that can be safely said
on this subject is that the cases of short duration
greatly outnumber the protracted ones, but do not
differ from them so far as the clinical picture is
•concerned, except in the matter of muscular wast-
ing.
The hold on life which some of the protracted
•cases seem to have is nothing short of astounding.
Under intelligent care they worry along indefinite-
ly, with occasional periods in which life seems
■completely to be despaired of, periods of weakness
and constitutional depression alternating with pe-
riods of comparative lucidity and apparent gain in
strength until the disease reaches a definite termina-
tion.
It is interesting and worthy of note that in these '
cases gain in strength is sometimes the signal for a
new outburst of delirium.
The termination is by death in the majority of
all cases. Our investigations, already quoted, placed
the mortality at 81 per cent, in females and about
79 per cent, in males.
Exhaustion determines the end of many, while a
large number die of complicating pneumonias, both
lobar and broncho, and bedsores, the latter a most
alarming complication, owing to the patient's al-
most negative vitality and lowered bodily resistance.
Of those that outlast the oedema, a certain pro-
portion develop permanent insanity, while others,
actually cured, suffer for a time from mental or
bodily enfeeblement.
Diagnosis.
This is by no means so simple a matter as might
at first glance seem evident ; unless directly follow-
ing an attack of delirium tremens, the physician
should hesitate about committing himself.
The writer was once so far led astray by appear-
ances as to diagnosticate a case of pernicious ma-
larial fever with meningeal involvement as "wet
KARPAS
GEXERAL PARALYSIS.
brain,'' the picture for a few hours being identical-
ly similar. It is well to remember that any condi-
tion where there is cerebral cedema. or any condi-
tion in which cortical irritability is the same in de-
gree as in wet brain, may produce a picture that
will puzzle the expert. Perhaps the most fruitful
source of error among those who have charge of
the alcoholic service is tuberculous meningitis,
which, while a classic picture in children, may as-
sume in adults more protean forms than almost any
disease except syphilis.
I know personally of three successive cases of
tuberculous meningitis which came to the alcoholic
wards and were diagnosticated "wet brain" by com-
petent and experienced men, who discovered their
mistake only at the autopsy table.
In general, it cannot be disagnosticated from
tuberculous meningitis in atypical form, except by
the presence of a preceding delirium or through
finding tubercle bacilli in the fluid drawn oft by
spinal puncture.
Paretics compensate partially for the reduction
in size of their brain tissue by effusion of fluid into
the unoccupied cranial space, giving rise to a patho-
logical condition in many respects similar to that in
alcoholic wet brain. They, however, die rather
typically by going into a convulsion, with subse-
quent coma, a terminal event which I have never
seen in a simple alcoholic.
Treatment.
Possiblv better results are obtained from a sys-
tem of forced feeding, combined with judicious
stimulation^ than through any other course.
The whole problem seems to be largely one of
vitality and elimination, and happily the stomach ac-
cepts large amounts of nourishment and medicine
without protest. Unfortunately, it is unlikely that
much of this is converted into tissue, owing to the
depressed condition of the body functions.
Enormous amounts of food are required, includ-
ing eggs, egg noggs, liquid peptonoids, and broths,
together with powerful stimulation, when the pulse
flags and the vital processes get low. The patients
do not react to- normal stimulating doses ; it is sur-
prising to see how much stimulation they can take
care of with apparent benefit. The writer has fre-
quently used
B Whiskey, K oz.;
Camphor gr. iii;
Strychnine, gr. 1/30.
M.
ever)' three hours for considerable periods, with
fairly gratifying results.
Of all the drugs, caffeine is perhaps the most
suitable for this class of cases ; it may be given as
citrated caffeine in five grain doses, or, if so de-
sired, as the sodium benzoate in similar amount.
Very good effects are reported as a result of sit-
ting patients up in bed ; it is said to lessen the
oedema. Dr. J. D. Peters, late house physician of
the first division, reports considerable success with
this method.
Tapping the cord produces results for a short
time, say a day or so. The relief of pressure or the
change in circulation incident to the removal of the
fluid seems to cause a temporary accession of
energy, so that a stuporous case may rouse up and
assume for a short time the active movements and
facies of an earlier stage of the disease. Indeed,
there is not infrequently a resumption of active de-
lirium until the fluid reaccumulates.
No permanent results are noted. The fluid re-
moved is usually in increased amount and under in-
creased pressure. Otherwise, it differs in no re-
spect from normal fluid either in appearance or in
the distinctive count.
For criticism and valuable suggestions the writer
would like to thank Dr. Charles Norris and
Dr. A. M. Pappenheimer, of the pathological
laboratory at Bellevue ; Dr. Alexander Lambert ;
also Dr. J. D. Peters, Dr. J. H. Cudmore, of the
medical' staff, and Dr. Paul Waterman, late of the
psychopathic department. Bellevue Hospital, as well
as the many others whose valuable experiences and
observations have added to the material of this
paper.
119 East Twenty-seventh Street.
GENERAL PARALYSIS IN THE SENILE PERIOD,
WITH A REPORT OF TWO CASES, INCLUD-
ING POST MORTEM EXAMINATION.*
By Morris J. Karpas, M. D,,
Assistant Physician, Manhattan State Hospital, Ward's Island, N. V-
Introduction.
It is generally conceded by such eminent authori-
ties as Kraepelin, Mendel, Ziehen, Wernicke, Krafft-
Ebing, Oppenheim, Strumpell, and others that gen-
eral paralysis is very rare at the extremes of life.
The usual run of cases occur from thirty to fifty,
and after the fifth decennium it gradually dimin-
ishes in frequency. Magnau and Serieux consider
the majority of their cases between thirty and forty-
five ; after sixty this malady becomes rare, and after
sixty-five it is exceptional. Arnaud maintains that
paresis after fifty-five is infrequent, and a case of
that kind at this age needs careful and repeated
examinations before the diagnosis as such can be
accepted. Christian is very skeptical about senile
paresis, and he even rejects the idea of the possible
occurrence at this period. ]\I. Dupre is also of the
same opinion.
The statistical data bearing on this subject are ex-
tremely interesting. Of J. A. Hirschl's 202 cases,
7 were between fifty-six and sixty., and only 2 be-
tween sixty-one and sixty-five. Greidenberg found
in his 3,00 paretics 13 over the age of sixty. Rod-
rigues describes 3 cases of general paralysis which
became manifest at seventy. Xeanmoins speaks in
one of his clinical lectures of one subject of gen-
eral paralysis at the age of sixty-five. ^larce ana-
lyzed 300 cases with the following results: 3 be-
tween sixty and sixty-five, and 4 were from sixty-
six to seventy. Bouchereau and Magnau have seen
in two years (1870 and 1871) 173 men and 24
women between fifty and sixty, and 15 men between
sixty and seventy. Christian and Ritti found in
196 cases of paresis 23 whose ages varied from
fifty to sixty.
Alagnau and Serieux observed at Sainte-Anne
*Read before the Section in Neurology- and Psychiatry, New York
Academy of Medicine, December 9. 1907.
K.lkl'A^: GLXERAL PARALy:iIS.
from 1886 to 1892. 2,058 general paralytics, and
furnished these results :
Age. Women. Men.
51-60 67 199
61-70 s 17
71-80 I 2
In the asylum of Comte of Glamorgan, 700 pa-
retics were admitted from 1867 to 1896; 14 women
and 51 men were between fifty and fifty-nine, and i
woman and 8 men above sixty. Serge Soukhanoff
and Peter Gamouchkin at the psychiatric clinic of
Moscow have seen 673 paretics : among them were
1.93 per cent, between fifty-five and sixty, and 0.45
per cent, above sixty.
\''ig"oraux and Laignal T.avastine state that of
259 deaths of general paralysis, 12 occurred be-
tween sixty and sixty-five. Olivier's investigation
in the asylum of Blois showed that out of 139 pa-
retics only 3 were between sixty and seventy. L.
Mongeri in his studies of paresis at Gonstantinople
also furnished analogous results in his 144 cases.
8 at fifty-five, 2 at fifty-seven, and i at sixty.
Picket found 2 males and I female at the age of
sixty out of 113 and 36 general paretics respective-
ly. Only 2 per cent, of Kraepelin's cases appeared
at or beyond sixty.
In Mickel's 2,456 male and 668 female general
paralytics, the ages in the senile period ranged as
follows :
Age. ,M ale. Female.
i 60 ■ 73 26
' 70 19 S
Prina observed 23 cases of general paralysis in
advanced age. Only in 2 of them did the micro-
scope show paretic changes which were suggestive,
but not conclusive. M-erzbacher, in reviewing the
article of Prina, questions the diagnosis of general
paralysis, and is inclined to regard dementia senilis
as more plausible and probable. Alsheimer's anal-
ysis of 173 cases of general paralysis gave these
•data: Eight between sixty and sixty-five years old:
I at sixty-nine ; i at seventy. Obersteiner noticed
4.5 per cent, of his cases of paresis between fifty-six
and sixty-three.
Olivier collected a number of cases from litera-
ture in addition to his o.wn, and he tabulated them
under three headings :
I. — Glinical observations without autopsies. 7
cases from sixty to sixty-three.
II. — Glinical 'observation with autopsies which
were limited to macroscopical examination only. 8
cases from sixty to sixty-six. and 2 from seventy to
seventv-two.
III. — Glinical observations with autopsies embrac-
ing microscopical examination, 4 cases from sixty
to sixtv-five, and i at seventy-two.
The following are complete records of two inter-
esting cases of paresis which came directly under
my observation:
C.\SE I.— Anna H., admitted to the Manhattan State Hos-
pital on May 14, 1904. at the age of sixty-five years; was
an Austrian Jewess; widowed; a midwife by profession.
Family history: No vesanic or neurotic taint could be
tstablisTied in ber consanguinous relations. One son died
from alcoholic excess. Daughter in law is an inmate of
this hospital and suffering from paresis. Patient presents
tvpical features of this disease.
Personal history : The patient was born in .Austria in
1839. Nothing was known of the development of infancy,
childhood, and adolescence. She was an accoucheuse by
profession for forty years. Her diploma was granted by
the University of Gratz. In Austria she held a position as
district midwife. No specific infection could be ascertained
or excluded. In 1901 (three years before admission) the
first evidences of mental alienation became manifested when
she could not attend to her work properly, began to use
alcoholic beverages to excess, stated that the neighbors
wanted to rob her, would wander at night aimlessly, and
complained of insomnia and fatigue. She gradually grew
more restless, delusional, and her commitment to Bellevue
Hospital was necessary.
At the psychopathic ward patient was described as agi-
tated, restless, and confused. She gave expression to the
following: "God keep me. I am dying. I wall give you
twenty dollars to get me out of here. Let me out to see
my son. Oh, oh, oh, oh, I carried him in my arms. You
want my death. Let me out. Let me out. Oh, my !
Oh, my!"
When admitted here physical examination showed fair
nutrition; dilated pupils which sluggishly reacted to light
and accommodation; no sensory disturbances; knee jerks
somewhat diminished; patellar reflexes normal, tremor of
tongue; no tremor of hands; lungs emphysematous; heart
was apparently normal ; varicose veins. A thorough examina-
tion was impossible because patient was too restless and
excited.
Mental status on admission : Patient was resistive, rest-
less, excited, pulled her hair, tore her clothing, talked in a
loud tone of voice, and showed marked prolixity of speech.
The following is a sample of her spontaneous production :
Oh, dear ! I am doing to die ! Send for my son I I am a
good midwife — I have the diploma — Oh, give me my
clothes—Oh, dear ! Oh. dear ! I am going to die — they
took all my money I Oh, Adolph, what have you done to
your mother. Oh, give me a rope — I will hang myself —
Adolph, I had onh- $500. and they took it from me — I will
give you lots of money if you send for my son— I am
going to write to the Kaiser — he knows me well."
Occurrences in the ward attracted her attention. The
orientation zcas deHcient; she knew the month, but did not
know the day or year. She called this place a hospital.
She recognized the physician and nurses as such. The in-
tegrity of her memory was doubtful, although some state-
ments regarding her life were correct. Mood was that of
irritability with frequent outbreaks of uncontrollable temper
She spoke of people who tried to rob her and that they
wanted to send her away on a farm for the rest of her days.
No hallucinations or systematized delusions were ascer-
tained.
For about a year her condition showed practically little
or no change. She was restless, voluble in speech, boasted
of her great ability as midwife, asserted that her diploma
was signed by Dr. Lorenz. and that she was the most skill-
ful accoucheuse in the United States of America. She
stated that she was worth $50,000. Memory was poor and
judgment much enfeebled. Her sleep waa disturbed. Her
general motor unrest was controlled by hydrotherapeutical
measures.
August 21, 1905. She became weak, showed slight ataxia
in gait and station (which was attributed to her general
weakness and poor sight), and vision was much impaired
on account of a double cataract.
August 23, T905. She became totally blind. Examination
at that time revealed marked senile changes, emaciation,
dilated pupils which did not react to light and accommoda-
tion, tremor of both hands, exaggerated knee jerks, but
no speech defect. Mentally, she was restless, tossed herself
on the floor, screamed, .and shouted at the top of her voice,
answered questions irrelevantly, alleged that she had lost
her purse, gold earrings, etc., and was in constant search
for them. Memory and orientation were \ cry defective. Dr.
Ward A. Holden (visiting ophthalmologist to the hospitaH
examined the patient and found left advanced cataract and
right incipient cataract with chorioidal changes about the
disk, but the latter was normal.
In October. 1905, patient was quiet, lay in bed. was con-
fused, could not recognize, her son's voice, misinterpreted
her surroundings, and talked to herself in a low tone of
voice.
On November 5, T905, signs of bronchopneumonia de-
veloped, and she died six days later.
.\fter great diflficiilty an autopsy on encephalon only was
obtained. Post mortem examination was performed by Dr.
G. Y. Rusk, and showed the following: Increase of cere-
January 25, 1908.]
KARPAS: GENERAL PARALYSIS.
brospinal fluid ; pia bagg>-, CEclematous, and diffusely infil-
trated and thickened in the frontal and parietal regions,
and to a much less extent over the temporal tips; the
frontal lobes were moderately adherent ; the membranes of
the sylvian fossce were thick and toughened ; the pia over
the base was slightly infiltrated; convolutions moderately
shrunken, and the corresponding sulci widened; the vessels
at the base were athrematous ; calcarine areas on both sides
were normal.
Microscopical examination: Sections from paracentral
and second frontal and gasserian ganglia showed definite
changes, consisting of pial, cortical, and subcortical pen-
vascular infiltration with plasma cells, among which were
relatively few lymphocytes. There was a moderate peri-
vascular pigment accumulation and moderate pigmentation
of cells. Rod colls occurred in frontal sections. Glia hy-
pertrophy subpially and in depths of tissue was marked, and
particularly in the regions of the second frontal convolu-
tion.
Case II. — This patient was also under the observation of
Dr. L. C. Pettit, Dr. J. R. Knapp, and Dr. J. L. Pomeroy.
The patient, Sarah C, was admitted to the Manhattan State
Hospital on June i, 1906, at the age of seventy. She was a
widow, born in the United States.
Family history: Family history was negative for psycho-
pathic and neuropathic traits. Maternal uncle died from
apoplexy.
Personal history : Patient was born in New York in
1836. Little was known of her early life. She was always
considered, bright, cheerful, intelligent, and sufTered from
no physical ailments except that she was subject to rbeu-
matism. She was married; gave birth to nine children;
three died and six were living and enjoying good health.
Her husband died from pulmonary tuberculosis in 1881.
She did not indulge in alcoholic beverages, led a moral
life, and luetic infection could not be demonstrated. For
the past five years she worried a great deal over domestic
troubles.
There were no manifestations of a mental disorder until
the latter part of November, 1905, when it was noticed that
patient made peculiar motions with her mouth; would put
kittens into the oven, thinking she was roasting turkey ;
would talk in a rambling manner; imagined she had lots of
money; later developed a mania for borrowing a dollar
from her friends, relatives and strangers ; was paticularly
fond of counting her money. On one occasion she fell at
Crotona Park; she was then unconscious and was taken to
Bellevue, where she remained a few days, and subsequently
discharged to the care of her daughter. In February, 1906,
she had an attack of cerebral apoplexy; she was uncon-
scious for two hours. Since then and till the time of her
death she remained a bedridden invalid. The mental symp-
toms remained unchanged until her removal to Bellevue
Hospital.
At the psychopathic ward patient was described as con-
fused, talked in a disjointed manner, reacted to auditory
and visual hallucinations, asserted that she owned elephants
and horses and that an elephant was in her stomach. She
said : "I am too old to work — I have no money — I can
lay my hands on fifty thousand dollars — I played the races
and made lots of money — I paid a thousand dollars for a
white elephant. He goes out every day and I keep him
in Central Park. I paid a thousand dollars for a horse
I have three elephants in my stomach ; they are all in gold.
I own ten houses uptown — I bought them — I made the
money on the horses. Every time I get short I raffle off a
horse."
Upon admission here physical examination revealed poor
nutrition ; unequal, irregular pupils which did not react
to light and accommodation; anosmia, knee jerks not
elicited; ankle jerks diminished; other reflexes not estab-
lished; drawling speech; enlargement of the heads of both
tibias with grating sounds and stiffening of both knee
joints; umbilical hernia; chronic myocarditis; arterio-
sclerosis ; pulmonary emphysema.
Mentally patient was quiet, well behaved, appeared happy
and contented, and talked in an incoherent strain. The
following is a sample: "Since I was a girl I have seen
this policeman — I married him— he owned a house on Cen-
tral Park, and I was a very handsome woman. If yon
knew how sister looks then you know how I look. I have
got my trains which I wore in the theatre when I was a
young girl. I was a school teacher all my life. I get my
pension every year, one hundred and twenty-five dollars, all
in gold."
The answers to questions will fully illustrate her peculiar
trend of thought:
How do people treat you? "First rate — I can't complain."
Anybody annoy you or talk about you? "Nobody ever
talks about me now ; my son-in-law was a drunken bum
and always licked me."
Did you ever hear voices? "No. Sometimes I scolded
ner for living with this man."
Do you ever see strange things? "Yes, I see him often.
He appears to me because I killed him. He was so old he
sat in a chair. I often see him at night time. His name
was Phil Lee. I cut his head off and his belly off, and I
threw him in the river."
Does he ever talk to you? "What I ate to-day was stur-
geon. He ate him up. I get his interest."
Have you any money or property? "Oh, my goodness,
yes. Didn't I tell you I was worth a liundred thousand
dollars? I own the underground railroad from New York
to Albany, from Albany to Boston and to Buffalo, and all
around New York and around the west side. I own Cen-
tral Park. I own Bedford Park. I own that house there
where that policeman is. I will get twenty dollars to-mor-
row ; I am going to give you forty out of it for taking care
of ine all this winter."
Mood showed no variability ; she expressed the feeling of
well being. Orientation was very deficient ; she called the
place New York Hospital; gave the date as 150; year 90;
the month May. Data of personal identification and the
memory for the remote and recent eventb were very much
impaired. Judgment exhibited marked enfeeblement.
June 19, 1906. Lumbar puncture performed; cerebro-
spinal fluid showed chemically serum, albumin in abund-
ance, and microscopical examination revealed a marked
lymphocytosis (100 to 150 in a field). Another examina-
tion of the cerebrospinal fluid was made, and similar re-
sults were obtained.
The patient was examined several times by the writer,
and she practically presented no change in her general
mental attitude. She spoke in a rambling manner, ex-
pressed ideas of grandeur, asserted that she was worth mil-
lions of dollars, owned property, parks, etc. Orientation
and memory were very defective, and in general she ap-
peared to be simple and childish. Physically she showed
diminished knee jerks, articular hypertrophy of both knees,
small, irregular, and unequal pupils which did not react
to light and accommodation, drawling speech, marked
arteriosclerosis, and slight residuals of hemiplegia dextra.
Her physical condition gradually declined. On Novem-
ber 8th, patient had a general convulsion which lasted sev-
eral minutes. After this she remained unconscious and ex-
pired four hours later.
Great effort was exerted to obtain a necropsy, and fortu-
nately a consent was granted, but restricted to the cal-
varium only. Autopsy, performed by G. Y. Rusk, revealed
the following: Increase of cerebrospinal fluid; exp.mina-
tion of the pia negative throughout except for slight niilki-
ness over the vermis of the cerebellum and closely fol-
lowing the principal ramification of the sylvian artery, and
slight diffuse thickening over the mesial aspect of the
frontal lobes ; moderate degree of diffuse atrophy of the
convolutions with slight accentuation in the frontoparietal
and temporal regions ; atrophy was more marked on the
left than on the right hemisphere ; the orbital surfaces of
the frontal lobes also showed atrophy ; two small subpial
cysts occurred at the beginning of the interparietal fissure
between frontal, second, and third, just, above Broca's con-
volution ; frontal and temporal tips were slightly adherent ;
the floor of the fourth ventricle showed a diffuse granular
appearance; the basal artery at its bifurcation was athre-
matous ; carotids and middle cerebral arteries were large
and moderately athrematous. Sections examined from an-
terior and posterior central, first frontal, angular regions,
and cerebellum showed pial and perivascular infiltration
with lymphocytes, plasma cells, and an occasional mast
cell. In all these areas a fair amount of glia overgrowth
with few cells presenting pigmentation was noticed ; the
nerve cells were not excessively pigmented, but there was
an abundant accumulation in the perivascular sheaths. The
walls of the arterioles were thickened and hyaline de-
generation evidenced. Rod cells were seen in the frontal
and angular regions especially.
i6o
MURRAY
HEMORRHOIDS.
.Medical Journau
Remarks.
The mental picture of paresis in the advanced pe-
riod bears a striking resemblance to dementia senilis.
The onset of the psychosis is marked with intel-
lectual enfeeblement. and the delusions are relative-
ly rare. The grandiose ideas are not prominent
(Olivier and Obersteiner). In both of my patients
delusions of grandeur were present, and especially
in Case II they were markedly accentuated. It is
to be remembered that in the latter the usual boast-
fulness, which is so common to paretics of that
type, was wanting. Some of the morbid ideas in
patient Anna H. were analagous to those of senile
dementia. For instance, she asserted that she was
robbed of her property, and was in constant search
of her lost purse and jewels. Each of my patients
presented many stigmata of senile dementia.
Illusions and hallucinations are seldom manifest-
ed, and in my cases these symptoms were not ob-
served.
There are no special somatic signs wdiich stand
out prominently in the disease picture, but they may
be obscured by the usual physical changes common
to senility. Convulsive seizures are not common
(Olivier). In one of Hirschl's cases optic atrophy
was present. My patients manifested no atypical
features except in Case I the speech was fairly well
preserved through the disease.
The duration of the mental malady is relatively
rapid (Obersteiner). However, in my first case
the course was rather exceptionally long, five years.
The diagnosis of general paralysis in the senile
period is very difficult. Quite often such cases are
mistaken for senile dementia, and, indeed, in some
instances the difterential diagnosis between these
two maladies is impossible without the aid of the
cytological examination and necropsy.
My hearty thanks are due to Dr. William INIabon.
superintendent of the Manhattan State Hospital, for
the permission he has given me to publish these two
cases.
References.
Alzheimer. Hislologisclie nnd Histopatliologische Ar-
beiteii.
Ainaud. Quoted by Olivier.
Bouchereau. Quoted by Olivier.
Christian. Quoted by Olivier.
Dupre. Traite de pathologic mentale.
Greidenberg. Neurologischcs Zcittralblatl . 1897.
Gamouchkin. Archives de neurologic, 1902.
Hirschl. Jahrbxtch fiir Psychiatric. 1895.
Kraepelin. Psychiatric, Seventh Edition.
KrafTt-Ebing. Lchrbuch dcr Psychiatric.
Mendel. Leitfaden der Psychiatric.
Magnan. Quoted by Olivier.
Mickel. Paresis.
Mongeri. Centralbtatt fiir Nervenheilkunde nnd Psy-
chiatric, 1906.
Marce. Quoted by Olivier.
Neanmoiiis. Quoted by Olivier.
Obersteiner. Die progressive allgemeine Paralyse, 1908.
Oppenheim. Lchrbuch der NcrvenheUkunde.
Olivier. Revue de psychiatric, 1906.
Prinna. Review in Centralbtatt fiir Nervenheilkunde und
Psychiatric. 1905.
Picket. Paten's Psychiatry.
Rodrigues. Quoted by Olivier.
Ritti. Quoted by Olivier.
Soukhanoff. Archives de iieurologie. 1902.
Striimpell. Spccielle Pathologic und Therapie.
Vignraux. Quoted by Olivier.
Wernicke. Grundriss dcr Psychiatric.
Ziehen. Psychiatric.
SECONDARY H.EMORRHAGE NINE D.\YS AFTER
HEMORRHOIDAL OPERATION. SCIATICA
COMPLICATIONS.*
By D. H. Murray, M. D.,
Syracuse, N. Y.
Case : The patient was an American, 48 years of age,
6 feet, 2 inches high, weight 185 pounds. Previous history
was negative.
Present complaint: Bleeding internal haemorrhoids
which had given him trouble for more than ten years.
For the past two years he had been troubled from time to
time with sciatica, for which he had received various kinds
of treatment, including stretching of the nerve, but he
grew gradually worse, the attacks came on without appar-
ent cause and were worse in the morning on arising.
Six weeks previous to his consulting me, a physician in
his home town gave him special treatment for sciatica.
This was given during three sittings, two days apart. At
the first sitting he was given si.x hypodermatic injections
of atropine 1/150 gr. each, into the sheath of the sciatic
nerve. Two days later he was given seven hypodermatic
injections of atropine, the same amount, which caused in-
tense nervousness. Two days later than this he was given
nine hypodermatic injections of atropine, same amount,
eight of these being into the sheath of the nerve, and one
of these injections was given, or attempted to be given,
into the nerve before it leaves the pelvis. Following this
third sitting he became unconscious and remained so for
fourteen hours ; since the completion of the last sitting he
had been especially nervous, and said his heart had been
very weak. He experienced a little relief at the time, but
occasionally had severe attacks of pain.
On November 24, 1906, he began bleeding profusely,
which had kept up until his visit to me. Examination
showed very large internal hsemorrhoids all around the
pile bearing area, from one of which a large stream of
blood of arterial origin was emitted. Inasmuch as he,
owing to business reasons, could not be operated upon at
once, I tied this vessel. The next day he called at the
office and felt somewhat better, had no pain, slept well.
On December 11, 1906. he entered the Hospital of the
Good Shepherd, where I operated upon him on the 12th.
I dilated the sphincter carefully and removed all internal
haemorrhoids by the cbmp and cautery combined method,
which consisted in dissecting the hemorrhoidal tumor out
3S though it were to be ligated, but instead of ligating,
used the clamp and cautery to complete the removal of
the tumors. Two bleeding \essels were ligated at the time
of the operation. I packed the anal canal with iodoform
gauze and put the patient to bed in good condition, except
that his pulse was slightly weaker than normal. He had
no vomiting, but some discomfort until 6 p. m., after that
he rested quite comfortably. The patient was making a
good recovery -.vith no complications until the ninth day
after the operation.
December 21st, at 10:30. I was called, being told that
the patient had a haemorrhage which had begun at 8 :45.
The internes at the hospital had done what they could to
check the haemorrhage without avail.
I went immediately to the hospital and found .the pa-
tient almost pulseless, gave a small amount of ether, in-
spected the parts, and found that a branch of the superior
haemorrhoidal artery was pouring a stream of blood into
the rectum. The artery was secured, the patient stimu-
lated, to which he responded promptly. The quantity of
blood lost was. by measure, forty-five ounces. The blood
count two days later was 3,270,000 red corpuscles, 7,000
white corpuscles, haemoglobin 70 per cent.
On January i, 1907, he was allowed to sit up, and a
week later to go home.
Since the operation the patient has never had a twinge
of his sciatic pain, which leads me to remark that, as is
well known, many cases of sciatica are symptomatic.
The hypodermatic treatment which this patient re-
ceived may have been a good treatment for some
cases. It is quite evident, however, that in this case
the rectal conditions were paramount.
It is very important that physicians, whether do-
ing surgical work or not. should note all rectal and
•Read before the .\merican Pioctologrical Society, June 4, 1907.
January 25. 1908.]
JENNINGS: DELAYED LABOR.
161
pelvic diseases. It is well known that such condi-
tions often produce symptomatic sciatica and should
be considered in distinctive diagnosis.
To me, it is quite a serious matter that injections
of atropine, in the amount used in this case, should
be given to any patient, when there is a palpable
rectal or pelvic disease existing, that may be the
cause of sciatica, as in this case.
I am not able to explain the cause of so severe a
secondary arterial hjemorrhage as late as the ninth
day after the operation, unless a thrombus or eschar
became dislodged. I have had, three years ago, one
patient with a moderate secondary haemorrhage on
the eleventh day, but in that case pressure controlled
it without trouble. In a speculative way I have
wondered whether the atropine, with its paralyzing
effect on the vasomotors, could have been in any
way responsible for the secondary haemorrhage.
800 University Block.
DELAYED LABOR.*
By W-alter B. Jennings, Ph. B., M. D.,
New York.
The length of normal labor varies within wide
limits, and, while dififerent authorities differ in re-
gard to time, the average duration of normal labor
may be taken as eight hours in multiparae, while in
primiparae the time is usually double that or longer.
Table of average duration of stages of labor
(Spiegelberg) :
First stage. Second stage. Third stage.
Primipara 15 hours, 2 hours, 5'^ hour;
Multipara 8 hours, i hour, >j hour.
Normal labor is longer, as a rule, in the very
young and in old primipara, i. e., extremes of child
bearing life.
What, then, is meant by delayed labor ?
Definition. — Delayed labor may be defined as one
in which the frequency, strength, duration, and ex-
pulsive character of the uterine pain has been so
changed as to prolong the second stage of labor, so
that either the life of the mother or that of the child
is endangered.
In considering this question. Dr. J. F. Moran, of
Georgetown University, Washington, D. C. says
that "It is impossible to separate the cases dependent
upon uterine inertia from those due to many differ-
ent pathological states." In the first stage of labor
one of the most common causes of delayed labor is
a rigid cervix due to old inflammatory conditions,
malignant disease, or cicatrix. These cases, how-
ever, would not be classed with those of delayed la-
bor in the true sense of that term, but are due to
some abnormality of the soft parts. Consequently,
there is reason for classifying delayed labor by itself,
whether complete or partial, as due to some perver-
sion of the normal power concerned in expelling the
foetus. It is the writer's intention to consider briefly
uterine inertia, consequently the many varieties of
pelvic deformities are excluded. While his con-
dition might possibly occur in contracted pelvis,
tetanic uterine contractions are more liable to be en-
countered.
/Etiology. — The causes of ute;rine inertia are local
and general.
*Read before the Section in Obstetrics and Gynaecology of the
New York .Academy of Medicine, November 26, 1907.
Local Causes. — It is generally admitted that the
uterine muscles possess a certain amount of intrinsic
contraction, and any condition causing a disturb-
ance of the uterine muscle would tend to bring about
this condition. Multiple pregnancy causing a loss
of tonicity, uterine tumors, excess of liquor amnii
causing overdistention, are among the local causes
generally given, as well as overdistended bladder or
rectum. Occasionally a soft sagging uterus marked-
ly bent forward, together with a pendulous abdo-
men, will interfere with the action of the uterus.
General Causes. — Among these are general low-
ered condition of the system — rapid child bearing,
anaemias, and wasting disease. Certain psychic and
emotional disturbances may also have some effect
upon uterine contraction reflexly through sympa-
thetic nervous system. Fatty changes and atrophy
of the abdominal muscles or separation of the recti
often lessen the expelling forces and so delay de-
livery.
Very frequently defective abdominal contractions
are due to fear of increased pain on the part of the
patient, and in this way the patient does not bring
her abdominal muscles into full play. In such a case
the administration of chloroform dulls the sensation
of pain, and the patient, unconsciously or semicon-
sciously, use^ her abdominal muscles, with a very
happy and gratifying result. Uterine inertia suffi-
cient to cause delayed labor is of comparatively fre-
quent occurrence. Acconci, from a study of over
2,000 cases, says that it occurs in 6 per cent, of cases.
It has been suggested that uterine inertia might be
the cause of prolonged gestation.
Uterine inertia may be characterized by feeble and
infrequent contractions, or there may be a marked
disproportion between the pain and contractions.
Unfortunately, there is no standard by which the
character of labor pains can be measured.
Clinically, however, the efficiency of uterine con-
tractions may be measured by their effect upon the
progress of labor. In normal labor, the contractions
of the uterus occur infrequently in the early stages
and gradually increase in frequency, intensity, and
duration until labor is terminated.
Many cases of labor begin in the regular way and
give every promise of an early termination. The
cervix is fully dilated and obliterated when the pains
stop and labor comes to a standstill. In many cases
prolonged labor is commonly said to be due to the
undilated cervix, when, as a matter of fact, it is due
to a faulty uterine contraction (primiparae over
thirty-five are exceptions). In other words, the
majority of cases of delayed labor are not due to the
resistance of the soft parts, but to a lack of the vis
a tergo.
Delayed labor is of little importance in the first
stage, if the membranes have not ruptured, but dur-
ing the second stage the life of the child is endan-
gered, and if it occurs toward the end of labor, post
partum haemorrhage may take place. There is nn
fixed and firm rule regarding the duration of labor in
cases of inertia. Cases have been reported when the
liquor amnii has escaped thirty-nine days before la-
bor began, but during the second stage of labor,
with a dilated cervix and the head engaged, delayed
labor is not usually allowed to take a natural course,
two thirds of the cases being instrumental.
BEARDSLEY: INFECTIOUS ORCHITIS.
[New York
Medical Journal.
The writer has collected a series of forty-five se-
lected cases of primiparse, in which twenty-five
cases were instrumental, fourteen cases were in
labor from twenty-four to forty-eight hours, one
case labor was induced, the patient being three
weeks over time, and two cases were breech pre-
sentation. Among the remaining cases, one was in
labor eighteen hours, five fifteen hours, four thir-
teen hours, and eleven ten hours or less. Of the
fourteen cases that were in labor twenty-four hours
or longer, ten were instrumental.
Omitting for the moment the question of uterine
inertia, the writer wishes to call attention to an-
other class of cases, in which labor pains continue
for several hours, progress is comparatively slow,
and the woman is on the verge of exhaustion. These
cases generally occur in the hands of the general
* practitioners. The foetal heart becomes very rapid,
and the life of both mother and child are endan-
gered.
Treatment. — The value of manual dilatation of
the cervix in cases of uterine inertia has been dis-
puted. Playfair recommends sweeping the finger
around within the cervix to separate any adhesion.
Some obstetricians use instrumental dilatation.
During the first stage, quinine, strychnine, and
sugar have been used with varying results. In re-
gard to the latter (sugar), the writer has had no
experience, but that this idea is not a new one is
certain. In looking over an old English transla-
tion, taken from the Latin, Rhodion's De Partu
Hominis (translated as early as 1538), he can hard-
ly refrain from referring to an old superstition. To
quote : "Eating sowre- f ruites, quinces, crab apples,
chestenuts, as well as things of great odour, smel
or savor, hinder byrth."
In regard to quinine, differences of opinion have
long existed among obstetricians as to the value of
this drug as an oxytoxic. A comprehensive summary
of these conflicting views is found in the Deutsche
medidnische Wochenschrift (January 31, 1907),
by Maurer, who reports his experience with quinine
in sixty-three cases during labor and fifteen times in
the treatment of abortion. He found that in 78
per cent, quinine gave results, while in 21.8 per
cent, there was no effect. It was found that the
nature of the quinine preparation was of no im-
portance, and that it might be given by mouth or
hypodermatically.
Pressure upon the fundus of the uterus, as sug-
gested by Krishaber, is of benefit in certain cases.
In the second stage of labor, after full dilatation
and the head in the pelvis, forceps should be ap-
plied, as many hours of suffering to the mother, as
well as danger to the child, will be avoided.
While the writer is a firm believer in conserva-
tion in all things, particularly in obstetrics, and of
the great need in giving Nature a chance, however,
in selected cases (and each case must be studied
separately), he believes in early application of
forceps in the second stage of labor.
Conclusion. — In conclusion the writer wishes to
state that he believes the woman about to become
a mother has the right to demand every alleviation
from suffering which medical science has provided,
such as anaesthesia, asepsis, and rapid delivery.
Given a case of labor with the os uteri fully dilated
and obliterated, ruptured membranes, empty blad-
der and rectum, and asepsis, no abuse is possible.
The time at which forceps should be applied de-
pends upon the conditions that arise in each case.
It is the writer's rule to use instruments when no
progress has been made for two hours. Dr. D. M.
Aitkins, of London, said that cerebral haemorrhage
was more likely to be obviated than caused by the
early use of forceps.
The old idea, and one rather common among gen-
eral practitioners, to wait until signs of danger to
the mother or child were present, was decidedly
erroneous.
157 Lexington Avenue.
A UNIQUE CASE OF INFECTIOUS ORCHITIS.
By John Gillespie Beardsley, M. D.,
Philadelphia.
It is well known that, during or following certain
infectious diseases, orchitis or orchitis complicated
by epididymitis sometimes occurs. The most fre-
quent diseases in which these conditions are seen
are parotitis, variola, typhoid and paratyphoid
fevers, Rocky Mountain or tick fever, and in Medi-
terranean fever, which latter disease is also known
under the names Malta fever, Gibraltar or Rock
fever, or when seen in Italy as Neapolitan fever.
Before the septicaemic condition of the blood in
these diseases was discovered, many different the-
ories were advanced to explain the occurrence of
orchitis in them, and the favorite explanation of the
condition was that because of the lessened resistance
of the individual by the presence of primary disease
there had been a recurrence of a former gonorrhoeal
infection. Other cases were explained by slight
trauma, such as would be brought about by a care-
less orderly in aiding the patient to use a urinal or
bed pan, and still other cases were said to have been
"rheumatic" in origin.
When careful researches and investigations were
conducted to ascertain the condition of the blood in
some of these conditions, notably typhoid and para-
typhoid fever, it was found that in the great ma-
jority of the cases a bacteriaemia existed. Not only
was this true, but study of the excretions revealed
the fact that the germs were being eliminated by
the urinary tract as well as by the intestine, and
thus it became much more reasonable to believe that
the orchitis was caused by the germs of the primary
disease, which were carried to the testicle in the
blood stream, and that because of some lowered con-
dition of resistance in a focus in the testicle inflam-
mation was brought about. In certain cases, also,
there seems at least a likelihood that the infection
may have been brought about by the presence of
bacilluria, with infection of the testicle by way of
the vas deferens.
The case to be reported was so unusual that it
seemed of interest to report it.
Case. — A girl, nine years of age, was under my care for a
well marked case of bilateral parotitis. There was consider-
able constitutional disturbance but no complications, and the
patient soon recovered. During the time of the girl's ill-
ness her mother remarked that a brother of the patient.
January 25, 1908.]
BIERHOFF: HYSTERICAL RETENTION OF URINE.
163
who had been in the country, was on his way home, and
requested me to give him medicine to prevent the disease.
I did not see the boy at this time, but left a prescription
for an antiseptic mouth wash, with directions to use several
times a day and to stay as far removed from the sister as
possible, but as the house was small and the opportunity
for isolation poor, I had little doubt that the youth would
contract the disease. Eight days after the boy's return
home I was called to see him and found a boy, eleven
years of age, with a temperature of 102° F., no pain or
swelling in either the parotid or submaxillary glands, but
a marked swelling of the left testicle, which was extremely
tender to the touch, and the skin of the scrotum over which
was decidedly reddened. The boy recovered completely in
four days, and there was no difference in the size of the
testicles. There had been no urethral discharge or no
history of trauma, and as far as could be learned, no ex-
posure to parotitis until his return home eight days before.
Cases of parotitis have at times been reported, es-
pecially in epidemics, in which the swelling of the
gland was very slight, and among them a few cases
in which the parotiditis became visible only shortly
after the patient was allowed to take fluid, but. as
far as I have been able to find in the literature (if
we grant the possibility of the orchitis being caused
by the infectious principle which causes parotiditis),
this case is unique, although Osier mentions the fact
that such a condition has been seen.^
2030 Chestnut Street.
REPORT OF A CASE OF HYSTERICAL RETEN-
TION OF URINE, COMPLICATED BY
FOREIGN BODY.
By Frederic Bierhoff, M. D.,
New York,
Attending Physician^ German Dispensary. Dermatological Depart-
ment; Correspondine Member, I'Association Francaise
d'Urologie; attenSing Genitourinary Surgeon, West
Side German Dispensary, etc.
While pollakiuria is not at all an unusual condi-
tion to be met with in either neurasthenic or hys-
terical patients, retention of urine of nervous origin
is comparatively rare. Von Frankl-Hochwart
states that in an experience with hysterical cases,
covering a period of eighteen years, he has only
seen this anomaly four times, and reports several
interesting cases of this condition. He further
states that, in cases of this character, he has re-
ceived the impression that masturbatory tendencies
frequently form the basis of the wish to be cathe-
terized, and that, as a result, the rule should be to
delay the use of the catheter as long as it is pos-
sible. Furthermore, that one can do this so much
more easily than in cases of retention of urine due
to other causes, since the unpleasant symptoms
which usually accompany retention of urine are
usually wanting in hysterical retention.
The following case belongs. I believe, to the class
of hysterical retention, even though it was compli-
cated by the presence of calculi, for these I believe
to have exerted an influence only of recent date,
and then not toward retention, while the history of
the nervous disturbance dates back over a num-
ber of years — in other words, I believe the calculi
to have simply complicated the condition, but not
to have been a factor in causing the retention. Un-
>After writing this article I find that Mr. Tereira, of Exeter, :e-
ported in the Lancet of January 12, 1907. four cases of acute or-
chitis or rock parotiditis and with no history of injury nor urethral
discharge occurring during an epidemic of this disease, the conditions
lasting from fourteen to twenty-one days.
fortunately, it was impossible for us to have the
patient's nervous system more carefully examined.
The history of the case is as follows :
The patient. Miss C, aged twent>--six, was sent to me for
examination, by Dr. Greeff, with the statement that, during
the two weeks previous to his sending her to me, she had
been unable to void urine at all spontaneously. She had,
at one time, passed two days without urinating, at the
end of which time she was catheterized. Following this,
she was catheterized daily, large quantities of turbid urine
being withdrawn. Upon one occasion catheterization was
accompanied by the passage of a slight amount of blood.
She stated to me at the lime of examination that she had,
since several years, had similar attacks of inability to void
any urine at all. These attacks were recurrent at intervals
of about three months. She further stated that at times
three to four days would elapse without her being able
to void any urine, at the end of which time she was forced
to seek medical aid for catheterization. Only once or
twice in all had these attacks occurred about the time of
menstruation. In June, 1906, following an operation for
appendicitis, retention again occurred, requiring regular
catheterization for a period of two weeks.
The patient was a well grown female, although of slen-
der build. While in my waiting room she had several at-
tacks of weeping, and even simulated unconsciousness.
The pupils were rather dilated, and the face considerably
flushed. As soon as she recognized the fact that I knew
her to be shamming unconsciousness, she sat up and did
not attempt the deception again during the entire time that
she was in my office. She stated, upon questioning, that she
was subject to frequent attacks of crying, and her brother,
whom I questioned, stated that this had been the case ever
since her childhood; also that she frequently "fainted."
She also complained of pain in the abdomen, particularly
in the region of the umbilicus, and that she had not been
able to pass any urine whatever, in spite of repeated at-
tempts, during the twenty-four hours preceeding her visit.
Examination revealed a markedly distended bladder. The
labia minora were decidedly hypertropied, which condi-
tion led me to decide that the patient was a masturbator.
There were no evidences of discharge, or of inflammation
about the vaginal or urethral orifices, and the hymen was
intact. A catheter was passed, and 1.600 c.c. of turbid
urine of an alkaline reaction were removed. The bladder
was thoroughly cleansed, and a cystoscopic examination
made, which revealed a generalized cystitis of moderate
grade, also the presence of a whitish, foreign body, diag-
nosticated as being of calculous character, situated in the
left lateral bladder pocket
The patient was referred to Dr. Ewald, at the German
Hospital. Through his kindness I was permitted to ex-
amine and operate on the woman at the hospital. A sec-
ond cystoscopy was made under general anaesthesia. Dur-
ing the process of clesansing the bladder and subsequent
thereto, but previous to the beginning of narcosis, in all
during a period of about thirty minutes, the patient re-
peatedly went through movements which were clearly
masturbatory in character, terminating, apparently in each
instance, in an orgasm The insertion of the cystoscope
made it possible to recognize the presence of two foreign
bodies, the larger of which could be easily recognized to
be a button, encrusted with saline deposits, the thread holes
being plainly recognizable. This larger foreign body was
seized with a lithotrite and easily removed. It was a bone
button cm. in diameter. An attempt was then made
to remove the smaller body by means of the evacuator. It
was at first found that the foreign body, or calculus, en-
gaged in the mouth of the evacuator, but would not enter
the bottle. Fragments of calculous nature, however, broke
away. Attempts to seize it with the lithotrite were then
made, but did not succeed. The cystoscope was then
again inserted, and the foreign body was found to be
floating upon the surface of the filling fluid. Being unable
to recognize the character of a calculus which would float,
and recognizing my inability' to seize it with the lithotrite
under those circumstances. I determined to attempt to re-
move the body by engaging it in the mouth of the evacua-
tor. This manoeuvre succeeded, and upon removing the
evacuator with the foreign body it was found that the
latter consisted of a piece of cork, i cm. long by cm.
i64
OUR READERS' DISCUSSIONS.
[New York
Medical Journal.
thick, encrusted with saline deposit. The concretion upon
the button and the piece of cork was found to be of phos-
pliatic character.
The patient was placed upon urotropin, internally, and
the bladder was washed out with a solution of boric acid,
followed by a silver nitrate solution, increasing gradually
in strength from i in 2,000 to i in 1,000. For the subse-
quent report of the case I am indebted to Dr. Ewald.
He states that twenty-four hours after the operation the
patient had no further vesical symptoms ; that she could pass
urines; furthermore, without any pain whatsoever. That
upon the fifth day following the operation the urine, which
had previous to the operation been very turbid, and which
had contained large numbers of pus corpuscles, a moderate
number of vesical epithelia, and large numbers of bacteria,
now showed only a few vesical ephithelia and pus corpus-
cles. On the sixth day following the operation the patient
left the hospital, having been able to pass her urine nor-
mally during this time. Five days later she presented her-
self for control to Dr. Ewald and stated that she had ex-
perienced no further symptoms whatever. Upon inquiry,
she absolutely denied masturbation. Informed of the char-
acter of the foreign bodies discovered in her bladder, she
denied having inserted them, and stated that her only
knowledge of the matter was that, one time, quite a while
ago, she had Scvallou'cd a button.
51-53 E.\.'^T Fifty-eighth Street.
(Bux ^eako' fistitssions.
A SERIES OF PRIZE ESSAYS.
Questions for discussion in this department are an-
nounced at frequent intervals. So far as they have been
decided upon, the further questions are as follows:
LXX. — How do you distinguish alcoholic stupor from
other conditions resembling it? (Closed January 15, igo8.)
LXXI. — How do you treat gallstone colicf (Answers
due not later than Februry 15, igo8.)
LXXII. — Hozv do you treat fracture of the patella?
(Ansivers not later than March 16, 1908.)
Whoever ansivers one of these questions in the manner
most satisfactory to the editors and their advisors will
receive a price of $25. No importance whatever zvill be at-
tached to literary style, but the azvard will be based solely
on the value of the substance of the anszver. It is requested
(but not required) that the anszvers be short; if practica-
ble, no. one answer to contain more than six hundred words.
All persons will be entitled to compete for the prise,
whether subscribers or not. This prize zvill not be awarded
to any one person more than once within one year. Every
anszver must be accompanied by the writer's full name and
address, both of zvhich zve must be at liberty to publish.
All papers contributed become the property of the Journal.
The prise of $25 for the best essay submitted in answer
to question LXIX has been aivarded to Dr. Maurice A.
Walker, of Dillon, Montana, whose article appears below.
PRIZE QUESTION NO. LXIX.
THE TREATMENT OF POST PARTUM HEMOR-
RHAGE.
By Maurice A. Walker, M. D.,
Dillon, Montana.
In the preventive treatment of post partum haem-
orrhage, there are several measures .which are of
vakie. One of the most important is the avoidance
of protracted labor, which by wearing- out the pa-
tient and the uterus tends markedly toward uterine
inertia. If there are weak and inefifectual, l)ut real,
pains, chloral hydrate, gr. xv, repeated, if necessary,
in an hour, will often give the patient a good rest,
and so strengthen the force and add to the effect of
the uterine contractions.
Use the forceps in such a case as soon as the os is
completely dilated, giving as little chloroform as pos-
sible, even none at all, if, as in most multiparse, the
parts are easily distensible, so as to make an easy
median or low forceps operation.
Avoid the use of quinine to stimulate contractions,
as it seems to predispose to inertia after the birth of
the child. Avoid chloroform in slow labors, no mat-
ter how painful. This valuable agent should not be
used simply for the comfort of the patient, but only
in normal or rapid labors.
In very rapid — precipitate — labors, with forcible
contractions, the use of an anaesthetic will tend tc
prevent that form of post partum haemorrhage which
comes from a lacerated cervix, vagina, or perinaeum.
After the birth of the child, the physician should
keep his left hand constantly applied to the fundus
uteri to maintain the contraction of the organ and
to discover if there is relaxation, which tends to
allow haemorrhage into the uterus itself, -concealed
haemorrhage.
If haemorrhage begins during the period between
the birth of the child and the expulsion of the pla-
centa, and without evident relaxation of the uterus,
it may be due to partial separation of the placenta, or
to the fact that the placenta is separated, but still
within the uterus. Slow, rotary kneading or the
more active Crede method of expression of the pla-
centa will usually stop the flow by removing the
obstacle to perfect contraction and directly stimu-
lating the uterus to contract.
Failing to thus remove the placenta, and the bleed-
ing continuing, place the woman across the bed in
the lithotomy position, with hips at the edge of the
bed and a Kelly pad in place. You now have easy
access to the source of trouble. Introduce the sterile
right hand into the uterus and remove the placenta
by peeling it off. In any case, normal or otherwise,
I give a full dose of ergot as soon as the placenta is
delivered, either by the mouth or by the hypoder-
matic use of one of the preparations made for that
purpose.
If there is haemorrhage from inertia of an empty
uterus I give a rapid douche of hot sterile water or
weak creolin solution, and for this purpose always
have prepared, hanging up and ready for use, with
sterile douche tube attached, a four quart fountain
syringe with a solution hotter than can be borne by
the hand, about 120° F.
Bleeding continuing from a contracted uterus may
be due to the presence of portions of placenta or
meinbranes or of clots, which prevent closure of the
uterine sinuses in some comparatively small area.
Remove clots by expression and large pieces of pla-
centa or membranes by the internally placed hand.
All other available methods of treatment failing,
introduce a speculum and pack the uterus and vagina
with sterile gauze, which should be in readiness for
immediate use at all confinements.
Haemorrhage immediately following the birth of
the child may be from the circular artery of the cer-
vix, from a lacerated vagina, or a lacerated peri-
naeum. If this form of haemorrhage occurs, the
specu4um should be used, and with a stream from
the douche bag constantly washing away the flow-
ing blood, apply such local treatment as may be nec-
essary, this meaning, usually, immediate repair of
these lacerations, placing stitches in such a way as
to constrict the bleeding points, which are usually
easily found.
January 25, igo8.J
OUR READERS' DISCUSSIONS.
Dr. Henry B. Bryan, of PhiLuiclphia, remarks:
When in attendance on a labor case, I al\va\s
prepare for a post partum hjemorrhage, having in
readiness beforehand a good syringe, either a Da-
vidson or gravity bag syringe, brandy, sulphuric
ether or chloroform, carbolic acid, ergot, a solution
or morphine, a jar of iodoform gauze, a hypoder-
matic syringe filled with fluidextract of ergot, a
uterine dressing forceps, and dilating- uterine
douche, also bichlorid of mercury tablets, '/}'< gr.
These articles I carry with me. All pitchers,
basins, bowls, slop jars, bed pan, etc., having been
sterilized, plenty of hot water ordered and at hand,
we have practically begun the preliminary treat-
ment.
Of course I always look to the prophylactic
measures during gestation, meeting and treating
any abnormal condition by proper medical, dietetic,
and hygienic measures.
When the haemorrhage occurs I immediately
grasp the fundus uteri through the abdominal wall,
after the method of Crede for expressing the
placenta to secure contraction, while an assistant in-
jects hypodermatically a drachm of flmdextract of
ergot.
Let the nurse give a dose of ergot by the mouth
and put the child to the breast, all of which will
tend to contract the bleeding uterus.
The foot of the bed may now be raised by put-
ting anything which may be at hand under the legs ;
it will tend to carr}' the blood by gravity to the up-
per extremities.
Should the uterus not contract and the hemor-
rhage continue slightly, give a vaginal douche of
hot water or sterile salt solution, 115° to 120° F. If
the bleeding still continues, put the uterine douche on
the syringe and allow a similar solution to flow into
the interior of the uterus, holding on to the uterus
all the time ; if necessary the assistant may use both
hands and strong pressure.
If the haemorrhage still continues, especially if
it is profuse, I grasp the fundus uteri on the out-
side with one hand ; the other hand, without hesita-
tion, I pass quickly and gently into the vagina and
uterus and press the sides of the uterus between
my two hands, gently twisting the hand inside so as
to irritate the womb and produce contraction, feel-
ing at the same time for clots, pieces of membrane,
or the placenta, and remove them.
Failing still to stop the haemorrhage, I perform
the "bimanual manipulation" described in all books
on obstetrics, and usually accomplished by passing
the two fingers of the right hand high up along the
posterior wall, pressing the lower segment and cer-
vix forward toward the symphysis pubis, at the
same time pressing the fingers of the left hand deep
in between the umbilicus and uterus, so that the
hand on the outside, the fundus resting in the palm
of this hand, may be pushed downward and forward
against the pubes, thus forming a sort of temporary
anteflexion, whereby the canal of the neck is closed,
and no blood can escape.
Still failing so far, I next proceed to pack the
uterus with iodoform gauze by means of the uterine
packer, which does not require the use of volsella
forceps, but may be guided by a finger into the
uterus. If the haemorrhage was profuse I would
pack the uterus at once after manual compression
and the use of ergot had failed to work — packing it
completely from fundus to external os.
Having packed the uterus and the haemorrhage
having ceased, the patient should be given plenty
of fresh air from open windows to restore the cir-
culation. To prevent fatal inpending syncope dur-
ing the continuance of the bleeding, stimulants, nu-
trients, and opiates are required.
Dr. IV. P. Mchrtosh, of Portland, Mc, obserz'e.<::
The proper way to prevent haemorrhage after
childbirth, or during the third stage of labor, or to
arrest it when it occurs, is to cause uterine contrac-
tion. Good, firm contraction will prevent post par -
tum hiemorrhage, if, as is generally understood, the
blood comes from the uterine sinuses. In some cases,
however, the haemorrhage is from a lacerated cervix
or rupture of other soft parts, in which case reme-
dies appropriate to the cause should be applied.
In uterine haemorrhage, as in all other abnormal
or pathological conditions, we have first the cause
and then the effect ; remove the cause and the effect
will cease. To properly get at the cause of a re-
laxed or flaccid uterus, we must take the case into
consideration during the months of pregnancy. La-
bor at term without disproportion between the canal
and the body which has to pass through it (dystocia,
maternal or foetal) is generally regarded as a physi-
ological act. Normal labor in itself is a physiolog-
ical process. But the woman having undergone the
strains of pregnancy is not herself, or, rather, her-
organs are not in a condition to perform their physi-
ological functions in a thoroughly normal manner.
The foetal circulation causes an increased pressure
in the maternal vessels (as is shown by the spygmo-
manometer), and puts an added load upon the heart
throughout pregnancy. During the last months of
pregnancy the increased weight and size cause diffi-
culty in taking proper exercise, at a time, too, when
exercise would aid in the elimination of effete prod-
ucts or toxines. It also throws an additional burden
on the respiratory and muscular systems, and these
added burdens cause the expenditure of nervous en-
ergy. "Should one organ or part of the system flag,
an additional load is thrown upon all the others."
"When the maternal eliminative system fails to dis-
pose of all of the products of increased metabolism,
the resulting toxaemia in itself decreases the effi-
ciency of the muscular system, and through the heart
muscles the efficiency of circulation, which latter of
itself impairs anew the efficiency of the eliminative
organs, and so creates a vicious circle." (Reynolds,
Ceesarean Section, Boston Medical and Surgical
Journal.) There is considerable muscular exertion
during labor, and this naturally throws more strain
upon the heart and nervous system. If the labor is
prolonged the woman is exhausted, her muscular
endurance is lessened, *and with it the contractile
power of the uterus, and when its contents are ex-
pelled, and there is no longer the irritating or stimu-
lating effects of the child's body to cause contrac-
tion, the uterus is likely to become flabby and re-
laxed, and if the placenta has become partially or
wholly detached, leaving the mouth of the vessels
OUR READERS' DISCUSSIONS.
[New York
Medical Journal.
open, a serious haemorrhage is apt to occur. Vio-
lent labor witli rapid expulsion of the uterine con-
tents is also likely to cause muscular exhaustion, and
as such labors are attended with great pain, nervous
coordination and control are lessened, the uterus
fails to contract, the mouths of the. vessels remain
patulous, and hemorrhage follows.
The causes of post partum hemorrhage are, there-
fore, those which interfere with uterine contraction
or cause relaxation of the uterine muscles (or lacera-
tion of the birth canal). The causes may be sys-
temic, there may be weakness from existing disease,
weakness from undeveloped uterine muscular fibres,
and fatigue from overstretching, as in twin preg-
nancies. ''Exhaustion from many previou.s labors
or when too suddenly called upon to contract In' a
rapid labor (especially if instrumental). There may
also be mechanical obstacles to firm contraction, as
a retained placenta or clots within the womb : old
adhesions or a distended bladder may interfere."
To ofifset to some extent the untoward conditions
enumerated, Nature makes certain provisions. In
the latter weeks of pregnancy, leucocytes begin to
block the uterine sinuses. There is an excess of
fibrin making elements in the blood of pregnant
women, and this, together with the sluggish blood
current in the sinuses, favors the formation of
blood clots in orifices of torn vessels. As soon as
the uterus is emptied, it contracts so that the blood
channels running through the uterine walls are
closed by the contracting muscular fibres. "What is
thus gained by contraction is held by retraction.'"
In case this does not occur we have hsemorrhage.
Symptoms.— Vost partum haemorrhage may occur
during the third stage of labor or during the first
twenty-four hours thereafter from relaxation of the
uterus. It can usually be readily recognized. Oi
course, when there is a gush of blood, or, as Hirst
puts it, ''when the blood soaks through the mattress
and runs across the floor in a stream," it is easily
recognized. But the bleeding should be detected and
arrested long before anything of this kind can occur.
Usually the first gush of blood is followed in a few
seconds by a further flow of fluid blood and clots.
It is my usual custom to form my hand into a sort
of a cup and hold it at the vaginal outlet. In this
way I catch the blood in the hand and at the same
time I can feel the warm fluid. The other hand is
placed upon the abdomen, and if this hand fails to
find the contracted uterus, there is an absence of the
croquet ball which represents the contracted uterus
and which should fill the hypogastrium. The pres-
ence of blood in any quantity is all the symptom that
is required in acute haemorrhage. Later the ordi-
nary constitutional symptoms of haemorrhage, such
as a rapid, feeble pulse, blanched face, dilated pupils,
sighing respiration, restlessness, and failing vision
may be present.
Treatment. — The only rational thing to do is to
cause the uterus to contract,* close the ves^^els, and
stop the bleeding. My own practice is, as soon as
the child is born, to inject a hypodermatic syringe-
ful of a good fluidextract of ergot into the woman's
thigh. It will cause less pain and prevent any tend-
ency to inflammatory reaction if the ergot be inject-
ed deep into the muscles. If I have special reasons
to fear haemorrhage, I inject the ergot as soon as the
presenting part emerges from the vulva, and I place
one hand on the anterior abdominal wall and grasp
the uterus firmly, the fingers being applied to the
posterior uterine wall, the palm to the fundus, and
the thumb in front. I then compress, knead, and
rub the uterus vigorously. If this does not effect the
desired result it is probable that the haemorrhage is
caused by a partially detached placenta. I there-
fore grasp the uterus very firmly, force it down, and
express tli£ placenta by Crede's method. Then, keep-
ing the hand on the fundus, should the haemorrhage
persist, I introduce the other hand into the vagina,
grasp the cerVix and lower uterine segment with the
fingers, and push upward, and at the same time push
down on the fundus with hand on the outside (bi-
manual compression of the uterus). In this way the
uterine cavity will be partially obliterated, closing
the sinuses and stopping the haemorrhage. Should
this not succeed, pass the hand into the uterine cavity,
remove all blood clots or shreds of membrane there,
double the hand up into a fist, and press down on it
with the hand outside of uterus. While I am doing
this the nurse, who has already received instruc-
tions and has everything ready, passes me the nozzle
of an irrigating syringe. The syringe itself is filled
with sterile hot water — that is, water that has been
boiled and cooled by the addition of cold sterile wa-
ter to 130° F. No time is wasted, however, in tak-
ing the temperature ; water about as hot as the hand
can bear comfortably is used. The nozzle of the
syringe is introduced into the uterus and the water
allowed to flow ; this will wash out the clots, and in
nearly every instance will cause the uterus to con-
tract firmly and the hemorrhage to cease.
In several years' service in a maternity hospital,
where I delivered hundreds of women, I met with
only one or two cases in which this failed to stop the
haemorrhage, and in those cases packing of the ute
rus was necessary.
Another excellent plan is to saturate a piece of ster-
ile gauze in vinegar, carry it up to the fundus of the
uterine cavity, and squeeze it out. Vinegar irritates
the uterine muscles to contraction at the same time
that it acts as an astringent. I prefer to use the hot
water first, as it washes out the cavity and generally
stops the flow of blood ; if not. the gauze soaked in
vinegar can be introduced at once and squeezed.
Hot water and vinegar can be obtained in any house-
hold, and both are safe and reliable. Should these
means fail, I prepare to pack the uterine cavity, and
in making these preparations, ivitJwnt losing any
time, I try two other procedures which often suc-
ceed. First, I grasp the cervix with a volsella
and forcibly pull the uterus down. This will often
stop the flow of blood. Then I either elevate the
woman's buttocks with pillows or place the woman
in Trendelenburg's position over the back of a chair.
The use of pillows is much more convenient and
does not interfere with other manipulations. During
this time the woman has been lying, by preference,
across the bed. The uterus is already drawn down.
The nurse is standing at my side with the box of
gauze and a long placental forceps. Let the
nurse with one hand grasp the volsella and
place the other hand on the fundus uteri. This
gives the operator the use of both hands. Or it may
be better, if only one assistant is available, to allow
January 25, 1008.]
OUR READERS' DISCUSSIONS.
the handles of the volsella to hang down,, and
thus by their weight assist in holding the uterus
down. This allows the nurse to hold the box of
gauze near the vulva. The operator passes the fin-
gers of his left hand into the cervix, and, having
grasped one end of the piece of gauze in the for-
ceps, proceeds to pack the whole uterine cavity firmly
from the fundus down. This absolutely stops the
bleeding, but the external pressure must be kept up
for a time by the hand upon the abdomen.
Before leaving this subject I wish to say some-
thing more in regard to the placenta. In cases of
retained placenta, or those which cannot be ex-
pressed by Crede's method, I introduce my hand
into the vagina, pass it into the uterine cavity, slip
the fingers under the edge of the placenta, and by a
to and fro movement of the fingers gradually peel
the placenta off; at the same time the hand on the
outside of the uterus, on abdominal wall, is holding
the organ firmly, and as soon as the afterbirth is de-
tached the uterus is tightly squeezed and forced
down and the placenta is expelled.
It is not well to hurry the third stage of labor in
every case ; generally fifteen or twenty minutes
should be allowed to elapse before the placenta is
expressed. But in case of haemorrhage it is neces-
sary to empty the uterus in order to get contraction.
Therefore, one cannot wait. Besides, the placenta
is partially detached or there would be no haemor-
rhage.
I do not regard use of the stronger chemicals,
such as Monsel's solution, iodine, or oil of turpen-
tine, as ever justifiable, used inside of the uterus,
and, furthermore, they are not necessary, as packing
the uterus in severe cases of haemorrhage stops the
blood and is cleanly. There is no objection to the
use of the faradic current, though the same is sel-
dom available, and I have found it of little use. If
the woman has lost much blood I always give i,ooo
c.c. normal salt solution by hypodermoclysis. This
is to be given only after the haemorrhage is under
control, but should never be omitted, for the acute
anaemia following haemorrhage is often as dangerous
to life as a continuance of the haemorrhage. And, as
I have shown elsewhere {Nczv York Medical Jour-
nal, June ID, 1905, p. 1 147), the use of the saline
solution by hypodermoclysis causes a decided in-
crease in both the erythrocytes and the leucocytes,
or, in other words, it causes a rapid increase in the
solid constituents of the blood, while it largely takes
the place of serum "itself. It is therefore rational
to replace the blood in as rapid a manner as possible,
as, aside from the acute anaemia, a woman who has
suffered from a serious depletion of the system is in
the worst possible condition to resist the incursion
of disease.
The salt solution should be given warm and may
be given by intravenous injection or injected into
the loose cellular tissue under the breasts or between
the shoulders. It is not alone for desperate cases
that I use this remedy, but in any case where there
has been any considerable loss of blood. I also re-
peat it once or twice during the first forty-eight
hours. An aspirating needle, a piece of rubber tub-
ing, and a small funnel are all the apparatus needed,
or, as I often do, fix the needle on the rubber tubing
of an irrigating syringe. A teaspoonful — about 80
grains — of salt to a quart of warm sterile water, and
all is ready. The needle should be in every obstet-
rical case along with irrigator or tube, and should
be boiled when other instruments, such as scissors,
needles, etc., are boiled.
A hypodermatic injection of strychnine is also
given at once. This stimulates the whole muscular
system through the spinal cord; 1,000 c.c. hot salt
solution may be given by the rectum also, and hot
bottles placed around the patient's body. While these
things have been going on, either the nurse or the
obstetrician has given attention to the uterus, keep-
ing one hand on the abdomen and a clean napkin
over the vulva, in order that any relaxation of the
uterus may be prevented. However, the ergot is
having eft'ect by this time, and the packing, if it has
been used, prevents any further haemorrhage. Then
a large abdominal pad should be laid above the um-
bilicus and a snug abdominal binder applied. The
nurse should be instructed to feel occasionally to see
that the uterus remains firm and contracted, also
to count the pulse and to occasionally look and see
if any haemorrhage is taking place.
"Laceration of the cervix may cause haemorrhage
after delivery, and occasionally dangerous bleeding
may occur from this cause. The diagnosis may be
made by a careful digital examination of the vagina
and cervix immediately after the expression of the
placenta." The haemorrhage may be arrested either
by ligation or tampon. The readiest and safest way
is to pack the lateral vault of the vagina with iodo-
form gauze. This, inserted in form of a half ring,
will always control haemorrhage from a torn cervix.
After forty-eight hours the cervix should be prop-
erly repaired. Lacerations of the vulva, of the ves-
tibule, and of the vaginal entrance may occur. In
this case the haemorrhage is in plain sight and can
be easily controlled by ligation and sutures. Lacera-
tions of the perinaeum should be sutured at once.
All that is needed is a curved needle and some silk-
worm gut. Both should be boiled and be ready in
case of need.
Dr. C. L. Sigler, of Pinckney, Mich., states:
A description of the treatment of puerperal
haemorrhage would not be complete without men-
tioning preventive measures, and this cannot be
done without a word as to the aetiology, which, in
general, may be said to consist of either imperfect
contraction of the uterus, retention of part of the
secundines, lacerations, or haemophilia.
I have found it a wise plan to follow down the
uterus with one hand as the child is expelled, assist-
ing contractions with friction or pressure over
fundus if necessary. After the expulsion of the
child the uterus is first seen to be contracted firmly
on the placenta, then the cord is tied.
I do not immediately express the placenta, but
unless contractions soon follow the birth of the
child I administer a full dose of some reliable fluid-
extract of ergot, and then if expulsive contractions
do not supervene in fifteen or twenty minutes the
uterus is stimulated by friction over the epigastrium
or gently kneading the uterus. As it is felt to con-
tract under the hand, pressure is made, and the
placenta is usually expelled without other assist-
ance. After the expulsion of the placenta the
OUR READERS' DISCUSSIONS.
[New York
Medical Journal.
Uterus is assisted to contract, if necessary, by gentle
manipulation through the abdominal wall.
At no time from the birth of the child until the
uterus is seen to be firmly and permanently con-
tracted after the birth of the placenta does my hand
leave the abdomen for more than a minute or two
at a time. Too rapid emptying of the uterus is apt
to be followed by poor contractions and haemor-
rhage, as after instrumental delivery or removal of
placenta by traction. An atonic condition of the
uterine wall may also, follow prolonged labor, espe-
cially when chloroform has been used through the
third stage. In case of the actual occurrence of
postpartum hjemcrrhage, an examination should be
immediately made to ascertain whether the uterus
is well contracted, and to obtain this result we al-
ways have means which, in the great majority of
cases, is efficient, namely, manipulation of the
uterus either through the abdominal wall or bi-
manually. If contraction does not follow, or if the
contraction does not control the haemorrhage, the
interior of the uterus should be explored to ascer-
tain the presence of clots or placental fragments.
If these are present they should be brought away
by the examining finger, the fingers of the other
hand at the same time grasping the uterus through
the abdomen. While some good hypodermatic
preparation of ergot should be immediately given
in these cases, no time should be lost in waiting for
it to act, as time is precious.
Ice is usually obtainable in most households, and
when applied to the epigastrium or a fragment intro-
duced into the uterus, contraction usually follows.
Hot sterile water, which should invariably be at
hand, may be introduced into the uterus through the
nozzle of an ordinary syringe. If used as hot as
can be borne by the back of the hand it will usually
stimulate contraction.
Vinegar may be introduced by the same means, or
squeezed from a wad of gauze or pledget of cotton,
or, as I prefer, a 2 per cent, solution of acetic acid,
a small bottle of which should be found in the
obstetrical kit, as should either a Davidson or foun-
tain syringe. If necessary to temporarily control
the hfemorrhage while an assistant is preparing the
solutions or other material, the cervix may be
grasped through the vagina with one hand, while
the other grasps the fundus, which can generally
be easily done between the separated recti. By now
approximating the two hands, bringing the fundus
downward and forward, the cavity of the uterus is
mechanically obliterated, and the hjemorrhage tem-
porarily stopped.
The vagina should never be tamponed for post
partum haemorrhage, but when other measures fail
the uterus may be packed with idoform or salicy-
lated gauze.
The small gauze packers are entirely too small
for this purpose, and it may be best done by pull-
ing down a lip of the cervix with a volsella
and applying the gauze with a long uterine forceps.
This procedure will need be resorfed to but rarely,
as the other measures mentioned will almost inva-
riably be successful.
If the blood is found to come from a lacerated
cervix or perina?um, appropriate surgical measures
should, of course, be promptly instituted.
Dr. St. Clair-Jones, of Jersey City, iV. ^03'^.-
Post partum haemorrhage is generally the sequel
of a long and tedious labor.
There is no condition more alarming and, indeed,
more often fatal to the puerperal woman, at the
same time taxing the energy and the practical re-
sources of the experienced physician, to say noth-
ing of the juvenile.
Occurring as it does toward the end of the third
stage of labor, a period which is usually considered
as the end of the woman's pains and trials, every-
thing having hitherto progressed favorably, but
often it proves to be the turning point of imminent
and unforeseen danger.
Post partum haemorrhage offers one of the best
opportunities of making or marring a reputation.
Treatment resolves itself into prophylactic and
actual.
In the first place, too much care and precaution
cannot be exercised in the earlier stages of labor.
Discretion must be used in promoting or retarding
labor, as occasion should arise. Whenever possi-
ble nature should be allowed to take its course ;
rapid delivery is very reprehensible, and in itself is
inducive to uterine inertia and atony, with its
sequelae, especially in women with Brig'ht's disease
and other constitutional dyscrasia.
I have seen the pernicious habit practised by phy-
sicians, everything being normal and favorable, of
"hurrying up labor," i. e., of dilating the partly di-
lated OS, rupturing the membranes, and delivering
under anaesthesia. Such a habit cannot be too
strongly denounced.
Inspection of the vagina and cervix for lacera-
tions, which, if present, should be immediately re-
paired, is the first step, to be followed by removal
of all clots, which act as a mechanical obstruction.
It is of paramount importance that there should
exist an efficient and proper contraction of the
uterus after delivery of the placenta. It is Nature's
safeguard. Plence fluidextract of ergot, oi every
hour, the removal of the pillow, and Credeing for
one half to one hour until proper contraction oc-
curs.
In multiparae, obtaining a history of previous
labors will serve to prepare one for the emergency
should haemorrhage usually exist.
The early application of the child to the breast
serves the twofold purpose of promoting uterine
contraction by reflex action and at the same time the
colostrum acts on the child's bowels.
Lastly, the proper application of an abdominal
binder.
In the actual presence of the contingency, all
practical resources must be brought to bear prompt-
ly and decisively.
Crede's method, previously referred to, must be
vigorously applied, in addition to manual pressure
on the fundus and attempting to grasp the flaccid
organ laterally.
An intravaginal examination should at once be"
made to ascertain the existing condition, for, apart
from the removal of any existing blood clots, the
hand acts as a stimulus to the cervix, promoting
contraction. If the os is wide and patulous, pass the
hand within the uterus.
Januar>- 25, 1908.]
CORRESPOXDEXCE— THERAPEUTICAL XOTES.
169
Combined manipulation by introducing one hand
with a lump of ice into the vagina, sometimes the
rectum, as far as Douglas's cul-de-sac, having the
thighs flexed on the abdomen, and make strong
pressure with the other hand on the uterus. More
often, however, better results are obtained by alter-
nating with hot water, the nozzle of the syringe be-
ing carried into the uterus. Give a hypodermatic
injection of ergot, ITV 30 to 60, into the nates, re-
peated if necessary.
The intrauterine application of vinegar, or the
squeezing of lerrion juice, often proves beneficial.
Syncope must be guarded against ; give strych-
nine sulphate : I prefer the nitrate, up to gr. 1/30,
every hour, with whiskey by mouth, meanwhile ele-
vating the pelvis, lowering the head, and applying
hot water bottles to the feet. Hypodermoclysis,
one quart of a normal salt solution. Cotamine hy-
drochlorate, gr. given hypodermatically. repeated
every two or three hours, often proves serviceable,
producing decided styptic effects with none of the
evils of opium. Tamponing with sterile gauze is
also of service, but great precaution must be taken
lest an external haemorrhage be converted to an in-
ternal.
The patient at all times should receive the bene-
fit of every know^n remedy ; especially is this true in
cases which seem hopeless and desperate. Hence
pressure on the aorta can be practised, but whether
productive of great benefit is doubtful, since the
great volume of blood undoubtedly issues from the
dilated uterine sinuses.
The styptic salts of iron are attended with too
much danger to justify their use. except as a last
resort, all others having failed.
Transfusion of blood in those delicate women
who afterward suffer a protracted convalescence is
advised.
After treatment. — Absolute quiet and rest in the
recumbent position. Precautions must still be taken
against any recurrence of haemorrhage. The de-
pleted system must be aided by good, nutritious, and
easily assimilated diet, gradually introducing stim-
ulants, good port wine, and Ionics, with hygienic
surroundings.
{To be continued.)
Corrfspnknfc.
LETTER FROM KINGSTON, ONTARIO.
The Medical Laboratory Building of Queen's University.
Kingston-, January 20, 1908.
The new medical laboratories building of Queen's
University was dedicated on the afternoon of
January 14th. The ceremonies were held in the
old Convocation Hall, and there were present for the
event, among others, the Hon. Dr. R. A. Pyne, Min-
ister of Education of Ontario, and formerly regis-
trar of the Ontario College of Physicians and Sur-
geons ; Dr. L. F. Barker, of Johns Hopkins Uni-
versity, Baltimore ; Dean Reeve and Professor A. B.
MacCallum, of Toronto University medical faculty,
and Professors Wesley 'SUWs and J. George Adami,
of McGill University, Montreal. There was a large
audience in attendance. The presence of representa-
tives from Toronto and McGill implied that the
three universities were on terms of cordiality, which
should ever be. Dean Connell made a statement re-
garding the history of Queen's medical department,
which was established in 1854, and amid an impos-
ing silence he called the roll of the departed mem-
bers of the medical profession of Kingston by whose
self sacrifice and devotion Queen's medical depart-
ment had been able to exist. The dean commended
the Ontario government for its wisdom in adopting
the principle of State aid for medical education. In
the new building will be accommodated histology,
physiology, patholog)-, biology, and bacteriology.
There will also be rooms for public health work,
which has grown in a few years to be a considerable
tax upon Queen's resources. During the past year
1,505 examinations have been made free of expense
to the public, and specimens have come all the way
from Fort William to Ottawa. Dr. Barker, the emi-
nent Canadian, who succeeded Dr. William Osier at
Johns Hopkins University, delivered an admirable
address upon medical laboratories and their relation
to medical research and discovery, and emphasized
the fact that Canada owed the duty to science of
seeing that its brightest medical students were given
encouragement to take up research work for the
benefit of generations to come.
The Hon. Dr. Pyne, jNIinister of Education, con-
gratulated the medical faculty upon its fine new
building. He scarcely knew how they had managed
to erect such a magnificent stone edifice for less than
$50,000. He would inform Premier Whitney that
he had never seen $50,000 so well expended. Gov-
ernment aid, he said, for research work was money
that could not be better spent. He assured Queen's
medical faculty that it would in future have the sym-
pathy of the government. Short addresses were also
made by Dean Reeve and Professor MacCallum,
F. R. S., Toronto University, as well as by Profess-
ors Adami and Mills, of McGill University, all con-
gratulating Queen's on its advances and the work it
was doing for medical science.
f berapeutital |[fftes.
Medicinal Uses of the Mistletoe. — In olden
times many virtues were ascribed to the mistletoe
( Visciim album), it being regarded as a sacred plant.
In France it is coming into use again, and several
pharmaceutical preparations of it have been intro-
duced into medicine, some under proprietary names.
It is understood to be a component ingredient in a
certain proprietary remedy for epilepsy. An English
practitioner recommends its use in chorea. Ac-
cording to Tlie Prescriber for January, 1908, the
berries are emetic and purgative. The plant has also
an ancient reputation as a cure for postpartum
haemorrhage, a property which has been more than
once confirmed within recent years. Quite lately its
composition and action have been investigated on
the Continent,. where Gaultier, in a communication
to the French Society of Therapeutics, has shown it
to possess the property of diminishing arterial pres-
sure. Plants growing on the poplar and plum have
been found most active, and from these several phar-
170
THERAPEUTICAL NOTES.
[New York
Medical Journal.
maceutical preparations have been made, including
an aqueous extract, a syrup made therefrom, and a
"physiological solution" for hypodermatic and intra-
venous injection. This last is prepared by infusing
the leaves in normal saline solution and sterilizing.
Applications for Chilblains. — The Prescriber
gives two useful prescriptions for the alleviation of
the painful symptoms accompanying chilblains :
I.
To form a protective skin on the surface of the
chilblain apply the following:
3 Tannic acid, 3ii ;
Alcohol 3iv ;
Carbolic acid, ItVxxiv;
Water, enough to make,
Solve. Sig. : Paint on the chilblains night and morning.
II.
The application of a cream of the following com-
position acts as an agreeable and efficient stimulant
to the circulation :
R Menthol, gr. xv;
Methyl salicylate, 3ii ;
Hydrous wool fat 3vi.
M. Sig. : Apply a small quantity frequently, rubbing in
until absorbed.
Potassium Permanganate as a Styptic. — Dzirne
( Vratchebnaya Gazeta and The Prescriber) has suc-
ceeded in checking capillary oozing in operating on
parenchymatous organs by applying to the orifice of
the bleeding vessel a small crystal of potassium per-
manganate held with forceps. If there is general
oozing from the surface he recommends making
pressure with a compress of gauze dipped in crystals
of permanganate. At the point of contact an eschar
is formed upon the wounded surface, and the bleed-
ing stops. The crystals are preferred to the pow-
dered permanganate, because a smaller quantity can
be used to produce the desired effect. The author
has never observed any injurious efifect from the
permanganate.
Depilatory Pastes. — An efficient substitute for
the use of the razor in the removal of hairs from an\-
part of the body, before operation, is recommended
by Bilout, of the French army, who publishes the
formula in the Archives de medecine militaire, from
which it is cited by The Practitioner, for January,
1908, as follows :
R Sodium monosulphide i part;
Lime (unslaked) i part;
Powdered starch 2 parts;
Sufificicnt water to make a paste.
M.
The lime and the sodium monosulphide must be
finely powdered in separate mortars. The monosul-
phide is then well mixed with the starch, and with
this the lime is carefully mixed up. Water is then
added in just sufficient quantity to form a soft paste,
neither a fluid, which is inert and useless, nor a
grumous powder, which cannot be applied. The area
which is to form the field of operation is well
washed with soap and a brush in plenty of hot water,
and all the longer hairs are clipped 'with scissors.
The paste, freshly made, is then applied with a bone
spatula over the area to a thickness of rather less
than one-tenth of an inch. After waiting, for five
minutes, and making sure that all the hairs are de-
tached, the layer of paste is easily removed with a
sterile swab and a small jet of boiled water. The
surface is left completely denuded of hairs, and par-
ticular care must be taken to avoid leaving any of
the paste behind, as it will set up a secondary caus-
tic action. The area is then kept covered with a
sterilized dressing until the operation begins.
In the New York City hospitals barium sulphide
is preferred to sodium sulphide as in the following
formulas, which are taken from The Hospital Form-
ulary of the Department of Public Charities:
1.
^ Barium sulphide, 3 parts;
Corn starch, i part ;
Water, q. s.
M.
II.
R Barium sulphide, 25 parts;
Powdered soap, 5 parts;
Powdered talc 35 parts;
Corn starch, 35 parts;
Water, q. s.
M.
Method of application: Make one teaspoonful of
the powder into a paste with three teaspoonfuls of
water, and apply to the parts with an ordinary shav-
ing brush in a moderately thick and even layer.
After four or five minutes the parts should be moist-
ened with a wet sponge, when after another five
minutes, the hair can be removed by washing off
the mass.
Note.- — The barium sulphide must be as fresh as
possible and not have become oxidized by exposure
to the air.
Lotions for Intertrigo. — Sabouraud {La Qiiin-
aaine therapeutique) prescribes the following:
I.
R Tincture of iodine, freshly prepared, 3iiss:
Eau de Cologne, W\.
M.
II.
I* Alkaline solution of tar, 3iv ;
Eau de Cologne, gvss.
M.
III.
B Ichthyol, 3iiss;
Distilled water, .liii.
M.
Douche in Leucorrhcea. — An excellent douche
in cases of leucorrhcea, according to The Hospital, is
composed of a solution of quinine hydrochloride in
warm boric acid solution, in the proportion of one
grain of the salt to one ounce of the warm saturated
solution of boric acid. The salt may also be pre-
scribed in the fortji of glycogelatin pessaries, two
or three grains in each.
Treatment of Intestinal Flatulence. — In the
Southern California Practitioner, Dudley Felton de-
scribes the treatment adopted by Cohnhcim, of Ber-
lin. Menthol is considered the most efTective medi-
cation and is prescribed in the following combina-
tion :
3 Tincture of belladonna leaves 3i;
Spirit of peppermint, 3i to 3ii;
Tmcture of valerian, 3ss.
M. et sig. : Thirty drops in water, three times a day,
after meals.
January 25, 1908. 1
EDITORIAL ARTICLES.
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Reviezv of Medicine.
Edited by
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and SMITH ELY JELLIFFE, M.
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Entered at the Post Office at New York and admitted for
transportation through the mail as second class matter.
NEW YORK, SATURDAY, JANUARY 25, 1908.
THE MILK QUESTION IN CHICAGO.
As we said some months ago, it is not New York
alone, but every large city as well, that is vitally
interested in the question of the quality of its milk
supply. The matter has recently met with unusual
attention in Chicago, apropos of a committee's re-
port to the Chicago Medical Society. So far as we
have been able to ascertain, not a single Chicago
physician has sought to perpetuate the delusion that
pasteurization is a trustworthy safeguard of the
quality of a milk supply. That is more than can
be said for the profession of some of our other
cities. Pasteurization is at best a makeshift, for it
only works some temporary improvement of bad
milk, leaving even such milk less nutritious than it
was to. begin with and disposing it to changes that
still further impair its value as an article of food
for adults and as the staple aliment for infants.
The discussion in Chicago seems to have turned
largely upon the apparent unwillingness of the peo-
ple to pay a slightly increased price for pure milk
that has been properly handled and promptly de-
livered in good condition. The blame has been
attributed to a very great extent to the thrifty house-
wife, who is said to regard the exaction of an en-
hanced price as "robbery." We doubt if this is quite
fair ; it is generally the father of the household who
pays the bills and does the grumbling. However
this may be, we have no reason to believe that the
people of Chicago will not cheerfully pay well for
good milk when they are really convinced that the
more expensive article is substantially superior to
the product with which they have heretofore been
content. Certainly they will not be willing to en-
danger the health and lives of their children for the
sake of saving a cent or more on a quart of milk.
Our brethren of Chicago are assuredly doing effec-
tive work in bringing their fellow citizens to a real-
ization of the fact that a good article costs more
than a poor one.
It is interesting, but quite in accord with common
observation, to remark that it is the wealthy who
are particularly charged with parsimony in this
matter of milk. The rich woman, it is said, will
soundly berate her milkman for an advance from
seven to eight cents a quart, and then betake her-
self to a fashionable club, where she will unhesitat-
ingly pay ten dollars for a luncheon. Perhaps, how-
ever, it is the satisfaction that she takes in the
denunciation itself, rather than real stinginess, that
prompts her, for the domineering spirit which so
soon takes possession of the rich finds less resistance
among the humble than among those who are but
a few rounds of the ladder lower than the one who
does the scolding. But doubtless the wealthy will
insist on having the best of milk, and they will cer-
tainly have to pay for it.
SUNLIGHT AND THE TUBERCLE
BACILLUS.
There has recently been published in pamphlet
form an important paper, by M. Paul Juillerat and
Dr. Alfred Fillassier, dealing with the hygenic con-
ditions found on inspection of the dwellings in cer-
tain quarters of Paris in which there has been a
large mortality from tuberculous disease. The
paper was presented before the Fourteenth Interna-
tional Congress of Hygiene and Demography, held
in Berlin in 1907. The authors lay great stress upon
the defective arrangements in these dwellings for
exposure of the rooms to the light of day, and we
cannot doubt that they are warranted in so doing.
During the year 1906 the inspectors visited 405
new houses, comprising 20,467 suites, consisting of
43,621 rooms, inhabited by 47,130 persons, an aver-
age of 1.08 to each room. This density of popula-
tion the authors do not regard as excessive. Since
January i, 1894, these houses had shown a mean
annual mortality from tuberculous disease of seven
to each thousand inhabitants. It was found that
3,616 sleeping rooms were practically without air
and light, sixty-three air shafts being so small as
to be absolutely inadequate to the ventilation and
lighting of the rooms opening on them. The pro-
portion of dark rooms was found to be enormous,
rooms into which the sunlight never penetrated.
They were choice places for the lodgment and pre-
172
EDITORIAL ARTICLES.
[New York
Medical Journal.
servation of Koch's bacillus and the almost inevit-
able infection of succeeding tenants.
But the municipality has set on foot measures for
the methodical sanitation of these dark houses, and
the authors are confident that in a few years, when
these murderous rooms have been made to disap-
pear, an improvement will be seen in the tuberculous
mortality returns. They have concluded from the
totality of their observations that tuberculous dis-
ease is the disease of darkness. Once introduced
into dark rooms, Koch's bacillus propagates itself
and maintains an extreme virulence.
It is not to urban apartment houses alone that we
may apply the lesson to be drawn from these obser-
vations ; many a room that the good rustic house-
wife carefully darkens, lest it should become a trifle
warm, or troublesome insects should be admitted,
or the carpet should grow faded, ought to be laid
bare to fresh air and sunlight if it is ever to be oc-
cupied by a human being. It is in darkness and in
stagnant air that noisome germs luxuriate; flush
them with fresh air and the direct rays of the sun,
and we go far toward robbing them of their male-
ficent power. If the "best room" of a farmhouse
•were systematically and persistently flooded with
fresh air and sunlight, instead of being kept in
sepulchral stateliness, the family and their visitors
would reap the reward of vastly increased stability
of health.
COMPULSORY SURGICAL OPERATIONS.
We ruthlessly cut out the testicles of the uncon-
senting bull and stallion, we dock horses' tails, and
.we practise other mutilations of the domestic ani-
mals. These cruelties we perpetrate for purposes
of our own, and nobody calls a halt. Animated by
nobler motives, we subject young children to vari-
ous surgical procedures, and hardly anybody objects.
But it is difficult to conceive that any person, apart
from the dreamers who hope to regenerate the hu-
man race by castrating criminals, should think of
decreeing and carrying out an operation on any sane
adult individual of our species in defiance of his or
her opposition. It seems, however, that such a no-
tion has been broached in the United Kingdom. It
is an outgrowth of the restiveness with which the
new workmen's compensation law is submitted to.
The question has come up in court, as we learn,
irom X\\t British Medical Journal for January nth.
It does not appear that any British court has yet or-
dered a man to be operated on against his will, for
such a course is not held to be warranted by the law ;
but it seems that the courts have the power, and in
some instances have exercised it, of reducing to a
nominal amount the compensation due under the
law in cases in which the pensioners refuse to sub-
mit to an operation fraught with but infinitesimal
danger and holding out the prospect of substantial
repair of a disability resulting from injuries inci-
dental to their work.
There can, we think, be no question of the equity
of such a procedure, whatever may be the final judi-
cial ruling. As human nature is cpnstitute'd, there
will probably always be many persons who will
choose a life of indolence under pay rather than re •
sort to rational means for regaining their legitimate
earning power. Surely there ought to be some way
of curbing this manifestation of parasitism. We
may say that the law under which it is possible
ought never to have been enacted. We do say so.
But there the law is, a piece of iniquitous class legis-
lation. If its tyranny can be mitigated only by re-
sorting to an apparent subterfuge, by all means let
the recourse be had.
Apart from any question of the competency of a
court to compel a man to submit to a surgical opera-
tion against his will, it may well be doubted if any
self respecting surgeon would be willing to carry
out such a behest. When we feel that a procedure
repugnant to a patient is manifestly almost sure to
prove advantageous to him, we urge it upon him
with all our powers of persuasion, but we never pro-
ceed to execute it vi ct armis. In the practice of
medicine compulsion is out of place.
THE SERUM TREATMENT OF EPIDEMIC
CEREBROSPINAL MENINGITIS.
We have already noticed Flexner's preliminary
experiments carried out for the production of a cura-
tive antiserum for Diplococcus intracellulans infec-
tion (New York Medical Journal, May 11. 1907).
The serum has since been prepared on a large scale
and has been used in cases of epidemic cerebrospinal
meningitis by Dr. W. S. Chase, in eleven cases, in
Akron, Ohio ; by Dr. L. W. Ladd, in sixteen cases,
in Cleveland ; by Dr. W. T. Longcope, in five cases,
in Philadelphia ; by Dr. Gushing, in one case, in
Baltimore, and by Dr. Strain, in three cases, in New
York. The serum has also been used in Edinlnirgh
and in Belfast for the treatment of cases of cerebro-
spinal meningitis.-
■ The results of these trials of serum therapy in
this serious disease have been collected by Fiexner
and Jobling and are published in the Journal of Ex-
perimental Medicine, x, i. Of the thirty-six patients
treated in the United States, twenty-six, or 72.22
per cent., recovered, and ten, or 27.77 P^^ cent., died.
We leave out of consideration in this review the na-
ture of the cases, the length of time after the onset
of the disease that the injection was given, whether
the case terminated by lysis or by crisis, etc., al-
though all these facts influence one's judgment of
January 25, 1908.]
EDITORIAL ARTICLES.
the value of the agent. But if a treatment can show
a recovery rate of over 70 per cent, of cases irre-
spective of severity and of the duration of the infec-
tion, in a disease in which, by other methods of treat-
ment, the recoveries form from 20 to 75 per cent, of
the cases, depending upon the severity of the epi-
demic, surely it is worthy of serious consideration
and of careful and extended trial.
This serum is injected directly into the subarach-
noid space after the withdrawal of cerebrospinal
fluid by means of lumbar puncture. The quantity
injected should not at present exceed thirty cubic
centimetres. It seems desirable to withdraw an
amount of fluid equal to that to be injected : the in-
jection should be made slowly and carefully, and the
serum should be warmed beforeitisinjected. Until
it is wanted for use, it should be kept in the refriger-
ator. The injection should be repeated daily foi
three or fcfur days. As in all diseases in which
serum treatment is applicable, the earlier the treat-
ment is begun the better will be the results. The
reasons for this should now be so obvious to physi-
cians that we deem it unnecessary to repeat them
here.
THE TRANSMISSIBILITY AND HEREDITY
OF MALIGNANT TUMORS.
While many observers believe that malignant
tumors may be transmitted naturally from animal
to animal or from man to man, the failure of man\
inoculation experiments to result in the growth of
the transplanted tumor has given rise to well found-
ed skepticism concerning the transmissibility of such
growths in general. Other writers have maintained
that malignant tumors are hereditar}-, and that a
tendency to their production is handed down from
parent to offspring. On the other hand, there are
many instances in which no evidence of heredity
can be obtained, in spite of diligent search.
From a .study of the inoculability of tumors, Loeb
and Leopold {Journal of Medical Research, Decem-
ber) conclude that tumors differ as to whether they
are transplantable or nontransplantable, as to
whether they are transitory or permanent in their
growth, as to whether they grow rapidly or slowly,
as to whether they are infiltrating or circumscribed,
and as to whether or not they give rise to metastasis.
The lymphosarcoma of dogs, according to these
authors, possesses the widest range of inoculability,
as it can be transplanted into other members of the
family Cams. The sarcoma of white rats and the
adenocarcinoma of white mice can be trans-
planted into animals of the same species, but not
readily into those of other species or into hy-
brids. The adenocarcinoma found in the Japanese
mouse cannot be transplanted into other species.
Other tumors, and they form the largest class, can-
not be inoculated even into other animals of the
same species. The majority of human tumors are
uninoculable.
McConnell, however, has recently succeeded in
inoculating an adult white rat with a piece of a
human scirrhous carcinoma of the breast. The
tumor did not grow, but became encapsulated and
showed degenerative changes when examined five
months later. A piece of the same tumor trans-
planted at the same time into a white rat about four
weeks old was entirely absorbed (Journal of Ex-
perimental Medicine, January). As the result of a
series of experiments on mice to determine the in-
fluence of heredity on the inoculability of tumors,
Tyzzer {Journal of Medical Research, November)
concludes that, though the breeding has not been
sufficiently extensive to prove or disprove the influ-
ence of an inherited character on the development
of malignant tumors, the data so far available ap-
pear to favor the view that there is such an in-
fluence.
SPONTANEOUS TUMORS IN MICE.
There are many reports on record of the occur-
rence of spontaneous carcinomata in mice, as well as
in other animals. The original successful trans-
plantation was made by Hanau, who, in i88g, suc-
ceeded in inoculating a carcinoma of a rat into other
rats. The active work in inoculating healthy ani-
mals with pieces of tumors from other animals of
the same species gives new interest to the reports of
inalignant tumors in all animals. It is possible that
some of these tumors will be found to give better
results than those already experimented with for
propagation. Tyzzer {Jotirnal of Medical Re-
search, November) reports sixteen new cases of
spontaneous malignant tumors in mice, giving the
details of their histology. In this series there are
nine cases of papillary cystic adenoma of- the lung,
one case of cystic adenoma of the kidney, two cases
of lymphosarcoma, one in the inguinal region and
one in the mediastinum, and four subcutaneous
adenocarcinomata. As regards the four subcutane-
ous adenocarcinomata, two of the animals had addi-
tional primary tumors in their lungs; in one the
primary subcutaneous growth was in the mammary
gland and in the other it was in the inguinal region.
Six of the tumors of this series were inoculated into
fifty-four normal mice with four positive results ;
two each from two specimens of subcutaneous ade-
nocarcinoma.
174
.\EiyS I 'I EMS.
[New York
Medical Journal.
Changes of Address.— Dr. Charles K. Stillman, to 119
East Twenty-seventh street, New York.
The California State Board of Medical Examiners
will hold its next examination in San Francisco on April
7th.
The Vienna Academy of Sciences has made an appro-
priation of $300 to Dr. Robert Falta for his work on
diabetes.
Kingston, N. Y., Board of Health. — At a recent meet-
ing of this board, Dr. Leonard K. Stelle was appointed
health officer of JGngston, to succeed Dr. J. T. Buckley,
who has resigned.
A Vaccination Bureau in Kingston, N. Y. — A free
vaccination bureau has been established in Kingston, N. ¥.,
and Dr. Frank Keator and Dr. Elbert D. B. Loughran
have been placed in charge.
Health of the Philippine Islands. — According to the
report of Dr. Victor G. Heiser, Director of Health, health
conditions in the Philippines are improving, the popula-
tion is increasing, and the rate of mortality is steadily
declining.
The North St. Louis, Mo., Medical Society has elected
the following officers to serve for the year igo8 : Dr. H.
J. C. Sieving, president ; Dr. A. A. Henske, vice president ;
Dr. H. J. Niebruegge, secretary; and Dr. A. F. Koetter,
treasurer.
The Buffalo Medical Clinic held its regular monthly
meeting on Thursday evening, January 9th, at the resi-
dence of Dr. Edward L. Frost. The paper of the evening,
entitled Complications of the Menopause, was read by Dr.
John Chalmers.
The Sixteenth International Medical Congress. — Dr.
William P. Spratling, medical superintendent of the Craig
Colony for Epileptics, Sonyea, N. Y., has been named as
chairman of a Section in the Public Care of Epileptics at
this congress, which will meet in Budapest on August 29
to September 4, 1908.
The West Philadelphia Medical Association.— The
new officers of this association for the year 1908 are as
follows: President, Dr. Henry D. Jump; vice president.
Dr. Arthur Bogart ; recording secretary, Dr. George Mills
Boyd ; financial secretary, Dr. Charles E. Price ; and treas-
urer, Dr. Edmund L. Graf.
The Obstetrical- Society of Philadelphia.— At the
January meeting of this society the following officers were
elected for the ensuing year : President, Dr. James M.
Baldy; vice presidents. Dr. Daniel Longaker and Dr.
George M. Boyd ; secretary. Dr. Frank C. Hammond ; and
treasurer. Dr. J. W. West.
The Franklin District, Mass., Medical Society held
its regular meeting in Greenfield, Mass., on January 14th.
Sudden Deaths from Natural Causes in Medicolegal Work
was the title of a paper read by Dr. Francis J. Canedy, of
Shelburne Falls, and a paper on Erysipelas was read by
Dr. A. L. Newton, of Northfield.
Infectious Diseases in Chicago. — During the week
ending January iith the following cases of infectious dis
eases were reported to the Department of Health : Diph-
theria, 92 cases; scarlet fever, 102 cases; ineasles, 51 cases;
chickenpox, 35 cases ; typhoid fever, 22 cases ; whooping
cough, 16 cases ; tubcrcidosis, 35 cases.
The Society for the Destruction of Vermin is the
name of a society recently organized in London. The ob-
ject of this society is to bring about a general crusade
against rats wherever found, on the ground that these ani-
mals are dangerous to the public health, and also injurious
to many agricultural and commercial interests.
The New Haven, Conn., Medical Association held its
annual meeting on Wednesday, January istli, and elected
the following officers for the ensuing year: President, Dr.
Edward M. McCabe; first vice president. Dr. A. N. Ailing;
second vice president. Dr. Merriman H. Steele; secretary.
Dr. E. Reed Whitlemore; treasurer. Dr. Robert E. Peck.
The Hartford, Conn., Medical Society. — The annual
meeting of the Surgical Section of this society will be
held on Monday, January 27th. After the election of offi-
cers for the ensuing year a paper on Surgery of the Knee-
joint will be read by Dr. J. E. Root, and a paper on Sur-
gery of the Anklejoint and Foot will be read by Dr. P. D.
Bunce.
Medical Association of the Greater City of New York^
— At the annual meeting, held on Monday evening, January
20th, the following officers were elected : President, Dr.
Robert T. Morris; corresponding secretary, Dr. Frank C.
Raynor; treasurer. Dr. A. Ernest Gallant; and chairman
for the Borough of Brooklyn, Dr. J. Scott Wood.
The New Contagion Hospital in Kingston, N. Y., is
well equipped, and is temporarily under the charge of Miss
Bratton, the directress of nurses at the Benedictine Sani-
tarium, the Sisters very kindly coming to the relief of the
city during the recent smallpox epidemic. Conditions are
beginning to improve under strict quarantine regulations.
The Harvey Society Lectures. — The fifth lecture in
the Harvey Society course will be delivered by Professor
George W. Crile, of the Western Reserve University,
Cleveland, Ohio, at the New York Academy of Medicine
on Saturday, January 2Sth, at 8:30 p. m. The subject is
Shock. All interested are cordially invited to be present.
The Lewis County, N. Y., Medical Society held its
annual meeting in Lowville on Tuesday, January 14th, and
elected the following officers for the ensuing year : Presi-
dent, Dr. F. E. Jones, of Beaver Falls ; vice president. Dr.
O. G. Harrington, of Constableville ; secretary. Dr. H. A.
Pawling, of Lowville; and treasurer. Dr. I. D. Spencer, of
Croghan.
Medical Society of Troy and Vicinity. — At the annual
meeting of this society, held in Troy, N. Y., recently, the
following officers were elected : President, Dr. Hiram
Elliott, of Troy; vice president. Dr. A. Y. Myers, of Bus-
kirk ; secretary and treasurer. Dr. William Kirk, Jr., of
Troy. Papers were read by Dr. R. H. Irish, of Troy; Dr.
Holmes C. Jackson, of Albany, and Dr. J. F. Humphrey,
of Saratoga Springs.
The Pathological Society of Philadelphia.— At a
meeting of this society, held on Thursday, January 23d,
the following papers were read : Interpretation of the Ap-
pearances Seen in a Peripheral Nerve, by Dr. H. H. Don-
aldson; The Diagnosis of Diphtheria by Means of Stained
Smears, by Dr. E. Burville-Holmes ; A Study in Vitro of
Liver Necrosis Produced by Intravenous Injection of
Ether, by Dr. Leo Leob and Dr. M. K. Meyers.
The Hospital Conference of the City of New York.—
The next regular meeting will be held on Wednesday, Janu-
ary 29th, at 8:15 p. m., at the New York .Xc.idcmy of Medi-
cine. The Hospital Committee of the State Charities Aid
Association will present for endorsement the report on the
future hospital needs of Greater New York, and this will
be followed by a general discussion of the subject of Ex-
periences in the Purchase of Food Supplies.
Philadelphia County Medical Society. — The Central
Branch of this society held a meeting on Wednesday,
January 22d. Papers were read as follows ; Wanted —
A Medical Bureau of Publicity, by Dr. J. Madison Taylor;
I'he Importance of an Ocular Examination in Pregnant
Women Manifesting Constitutional Signs of Toxaemia, by
Dr. William C. Posey and Dr. John C. Hirst; Gastro-
enterostomy in Cancer of the Stomach, by Dr. John J.
Gilbride.
Syracuse, N. Y., Academy of Medicine. — The regular
meeting of this academy was held on Tuesday evening.
January 21st, when the following programme was pre-
sented : Dr. J. R. Johnson reported two cases, one of
typhoid fe\er, and one of diabetes; Dr. G. G. Lewis read a
paper on the Pupil in Health and Disease ; and Dr. T. H.
Halsted read a paper on Direct Examination of the
CEsophagus and Bronchus, reporting cases and exhibiting
instruments.
The Triprofessional Medical Society of New York.—
At a stated meeting of this society, which was held in
New York on Tuesday evening, January 21st, a paper or.
the Psychic Phenomena of Intestinal Toxremias and Their
Treatment was read by Dr. J. Carlisle De Vries. and a
paper on Acute Otitis Media in Infants and Young Chil-
dren was read by Dr. Arthur J. Herzig. The officers of
the society are as follows : President, Dr. J. Monroe
Lieberman ; first vice president. Dr. G. Morgan Muren ;
second vice president, Dr. J. Carlisle De Vries; secretary,
Dr. Joseph Gutfreimd ; treasurer, Dr. Daniel E. D. Coleman.
January
XEIVS ITEMS.
A Tuberculosis Exhibit in Louisville. — The tubercu-
losis exhibit, which was held recently in Louisville by the
Kentucky Antituberculosis Association, attracted a great
deal of attention and aroused public interest in a most
satisfactory manner. As is usual in connection with such
exhibits there were various addresses and demonstrations.
On January 14th a measure was introduced into the Senate
of the State Legislature appropriating the sum of $75,000
for the establishment of a State tuberculosis sanatorium.
The New York State Civil Service Commission will
hold examinations on February 15, 1908, for the following
positions : Physician, State Hospitals, $900 and mainten-
ance; Trained Nurse, State Institutions, $420 to $600 and
maintenance ; Orderly, Erie County Hospital, $540 and
maintenance. The last day for filing applications for these
examinations is February 8th. Full information and appli-
cation forms may be obtained by addressing the Chief
Examiner of the Commission at Albany.
Society Meetings for the Coming Week:
MoND.'VY, January 27th. — Medical Society of the County of
New York.
TUESD.A.Y, January 28th. — New York Dermatological So-
ciety; New York Otological Society; New York Medi-
cal Union; Metropolitan Medical Society of the City
of New York; Buffalo Academy of 2^Iedicine (Section
in Obstetrics and Gynjecology) .
Ihursd.w, January 30th. — Brooklyn Society for Neu-
rology.
Improvements in the Metropohtan Hospital. — Plans
have been filed with the building department for the erec-
tion of the following buildings as additions to the Met-
ropolitan Hospital : A four story tuberculosis pavilion with
roof gardens, solarium, and exterior verandas, to cost
$180,000; a two story pathological laboratory, to cost $40,-
000, and a three story and attic residence for the medical
staff, to cost $80,000. It was erroneously reported in our
last issue that these buildings were to be annexes to the
Manhattan Hospital.
Nevy York Academy of Medicine. — A stated meeting
will be held on Thursday, February 6th at 8:30 p. m., under
the auspices of th§ Section in Obstetrics and Gynaecology.
The evening will be devoted to a review of the recent
advances in obstetrics and gynaecology, and the following
papers will be read : The Present Significance of Chorio-
epithelioma, by Dr. James Ewing; Obstetrics, by Dr. Edwin
B. Cragin ; Gyn2ecolog>% by Dr. Herman J. Boldt ; the Prac-
tical Application of Our Recent Knowledge in Obstetrics,
by Dr. Edward Reynolds, of Boston.
The Health of Pittsburgh. — During the week ending
January 4, 1908, the following cases of transmissible dis-
eases were reported to the Bureau of Health of Pitts-
burgh : Chickenpox, 12 cases, o deaths ; typhoid fever,
66 cases, 19 deaths ; scarlet fever, 4 cases, o deaths ; diph-
theria, 15 cases, I death ; measles, 96 cases, i death ; whoop-
ing cough, 12 cases, 0 deaths; pulmonary tuberculosis, 17
cases, 10 deaths. The total deaths for the week numbered
181 in an estimated population of 403,330, corresponding to
an annual death rate of 23.33 in 1,000 of population.
Medical Society of the County of Oneida, N. Y. — At
the annual meeting of this society, which was held in Utica
on January 14th, papers were read as follows : Tubercu-
losis in Cattle, by Dr. W. G. Hollmgsworth ; Extragenital
Chancre, by Dr. G. M. Fisher; Empyema of the Accessory-
Sinuses of the Nose, by Dr. T. H. Farrell. The following
officers were elected : Dr. Earl D. Fuller, president ; Dr.
G. M. Fisher, vice president; Dr. Frank D. Crim, treasurer;
Dr. W. B. Roemer, secretary; and Dr. Smith Baker, libra-
rian. The retiring president, Dr. Conway Frost, presided.
To Reorganize the Navy Department. — Two bills
have been introduced into the House of Representatives
providing for the reorganization of the Navy Department,
one by Sir. Loudenslager and the other by Mr. Dawson.
The latter, H. R. bill No. 12425, divides the work of the
department into two divisions, placing the Bureau of Medi-
cine and Surgery under the division of personnel, which is
to be presided over by the assistant secretary, who shall
be a naval officer. The other division, which is to be known
as the division of material, is to be presided over by a
civilian secretary.
The Manhattan Medical Society.— .\ stated meeting
of this society was held on Friday evening, January 24th.
Dr. S. Strauss renorted a case of Atrophy of the Gall-
bladder, Dr. R. Cronsoii read a paper on Septic Neuritis in
the Puerperitim, and Dr. Dexter D. Ashley reported a case
of Rheumatism Simulating Hip Joint Disease. After the
demonstration of pathological specimens by Dr. J. E.
Welch, there was a clinical conference on the subject of
,\cute Articular Rheumatism. Tlie officers of the society
are Dr. Heinrich Stern, president; Dr. Dexter D. Ashley,
vice president; Dr. Earle Conner, secretary; and Dr. Albro
R. Carman, treasurer.
The Mortality of Chicago. — According to the report
of the Department of Health for the week ending January
II, 1908, there were during the week 726 deaths from all
causes, as compared with 665 for the corresponding week
in 1907. The annual death rate was 17.48 in 1,000 of popu-
lation. The principal causes of death were : Apoplexy,
10; Bright's disease, 52; bronchitis, 25; consumption, 63;
cancer, 33; convulsions, 4; diphtheria, 22; heart diseases.
54; influenza, 31; intestinal diseases, acute, 32; measles, 7:
nervous diseases, 29; pneumonia, 137; scarlet fever, 13:
suicide, 16; typhoid fever, 12; violence, other than suicide.
32; whooping cough, 3; all other causes, 151.
The Scientific Temperance Federation held its annua!
meeting in Boston recently and elected officers for the en-
suing year. The reports of the secretaries showed thai
during the year over a thousand books, pamphlets, etc..
had been added to the collection of data on the alcohol
question. This special library is at the disposal of ali
who desire information on the question of alcohol and nar-
cotics. The headquarters of the federation are at 23 Truli
street, Boston. Among the corresponding members of the
organization are Professor E. Kraepelin, of Munich ; Pro-
fessor A. Aschaffenburg, of Cologne ; Dr. Max Kasso-
w itz. of \'ienna : Dr. Reid Hunt, of the United State?
Hy gienic Laboratory, Washington, D. C. ; and Mr. Walter
X. Edwards, F. C. S., of London.
Infectious Diseases in New York:
]Ve are indebted to the Bureau of Records of the Health
Department for the follozcing statement of new cases and
deaths reported for the tzvo zceeks ending January 18, igoS:
^January ii.-a ^January 18.-
Cases. Deaths. Cases. IDeaths.
Typhoid Fever 5; 6 36 2
Smallpox 2
Varicella igg .. 169 i
Measles 691 35 803 25
Scarlet fever 562 49 585 37
Whooping cough 24 i 14 1
Diphtheria 370 42 406 43
Tuberculosis pulmonalis 432 171 402 181
Cerebrospinal meningitis 16 11 13 i;
Totals 2,351 351 2,428 301
Examination for Physicians in the Panama Canal
Service. — The United States Civil Service Commission
announces an examination on February 19 and 20, 1908, to
secure eligibles from which to make certification to fill
vacancies as they may occur in the position of physician,
at $150 a month, in the Panama Canal Service. It is prob-
able that about fifteen appointments will be made, this esti-
mate being based upon the number of appointments made
during the past year. Applicants must be citizens of the
United States, graduates of recognized medical schools, and
have at least one j-ear's experience as an interne in a gen-
eral hospital. Men only will be admitted to this examina-
tion, and the age limit is twenty to forty-five years on the
date of the examination. Applicants should apply at once
to the L^nited States Civil Service Commission, Washing-
ton, D. C, for application Form 1312,
The State Campaign for the Prevention of Tubercu-
losis.— The tuberculosis exhibit, which was held in Troy
recently, was well attended, and public interest was aroused
in the question of the prevention of tuberculosis. Lec-
tures, illustrated by stereopticon views, were given each
afternoon and evening by the leading physicians and min-
isters of the city, A permanent committee, composed of
the most prominent citizens of Troy, has been appointed
by the State Charities Aid Association, which will en-
deavor to secure compulsory notification and registration
of cases, free bacteriological examinations of sputum,
tuberculosis dispensary and visiting nurses, sanatorium
treatment for advanced cases, the adoption of a building
code which will prevent congestion in housing, and .the
regulation of food supplies. The committee will constitute
a centre from vhich will be conducted a continuous edu-
cational campaign.
70 I'i'^H OF CURRENT LITERATURE. LN^w York
Mkdical Journal.
Special Tuberculosis Dispensaries in Chicago. — Ac-
cording to the Bulletin of the Department of Health of
the City of Chicago, during the first three weeks that the
six special dispensaries of the Chicago Tuberculosis Insti-
uite have been in operation 148 patients applied for treat-
ment. The physicians and nurses attached to this great
bcrvice report that it is their daily experience to find con-
sumptives living in closest relations with their families and
entirely ignorant of the means of preventing infection. In
all such instances the dispensary physicians have instituted
a manner of living that will be safer for the health of the
family and at the same time promote the health of the
patient. It is thought that ' the educatiotjal work of the
dispensaries will be as valuable as the strictly curative
function.
Personal. — Professor Cornil has been retired from
the chair of pathological anatomy and histology in the
L'niversity of Paris, having reached the age limit of seventy
years.
Dr. David Hilbert, of the University of Gottingen, has
been made a member of the Bavarian-Maximilian Order
for Science and Art.
Pofessor Boeckh, of Berlin, died recently at the age of
eighty-three years. He was well known as a medical stat-
istician and emeritus director of the Berlin Statistical
Bureau.
Professor Neisser has returned to London from Bavaria,
where he has been for three years studying syphilis in
apes. A banquet will be given in his honor on February
rst.
Dr. W. W. McMellan, of Mingo Junction, Ohio; Dr. G.
E. Bair, of Braddock, Pa. ; Dr. A. J. Frantz, of Seneca
Falls, N. Y. ; Dr. H. M. Imboden, of Clifton Springs,
N. Y., and Dr. J. S. Goodwin, of Spring City, Tenn., are
registered at the Philadelphia Polyclinic and College for
Graduates in Medicine.
The Health of the Canal Zone.— During the month
of November, 1907, there were in the Canal Zone 2 deaths
from typhoid fever, 33 from malarial fever (clinical), 13
from sestivoautumnal malaria, S froiu hjemoglobinuric
fever, 2 from dysentery, 2 from amoebic dysentery, 7 from
beriberi, 3 from septicemia, 34 from tuberculosis of the
lungs, 6 from other forms of tuberculosis, i from tetanus,
3 from bronchopneumonia, 22 from ptieumonia, i from
abscess of the liver, i from puerperal septicaemia. The total
deaths in the Zone, including Colon and Panama, num-
bered 267 in a population of 111,007, corresponding to an
annual death rate of 28.86 in 1,000 of population. Two
white employees from the United States died of sestivo-
autumnal malaria. The annual death rate of white em-
ployees corresponds to 15.35 '^i 1,000 of population; that of
negro employees corresponds to 22.77 1,000 of popula-
tion. The sick rate for employees was 20.49 in i.ooo of
population. The death rate of the Canal Zone in Novem-
ber, 1906, was 35.76 in 1,000 of population, and in 1907 it
was 28.86 in 1,000 of population — a decided improvement.
Mosquito work continues unabated.
The Health of Philadelphia. — During the week end-
ing December 28, 1907, the following cases of transmissible
diseases were reported to the Bureau of Health of Phila-
delphia: Typhoid fever, 72 cases, 6 deaths; scarlet fever,
51 cases, 3 deaths; chickenpox, 55 cases, o deaths; diph-
theria, 65 cases, 15 deaths ; cerebrospinal meningitis, 3
cases, r death; measles, 34 cases, 3 deaths; whooping
cough, 18 cases, 8 deaths ; pulmonary tuberculosis, 86 cases,
61 deaths; pneumonia, 125 cases, 100 deaths; erysipelas,
5 cases, 3 deaths; German measles, 2 cases, O deaths; septi-
caemia, 3 cases, I death ; luumps, 8 cases, o deaths ; cancer,
25 cases, 33 deaths.. The following deaths from other
transmissible diseases were reported: Tuberculosis, other
than tuberculosis of the lungs, 8; puerperal fever, 2; diar-
rhoea and enteritis, under two years of age, 9. The total
deaths numbered 601 in an estimated population of 1,500,-
595, corresponding to an annual death rate of 20.8 in 1,000
of population. The total infant mortality *vas 12.8; under
one year of age, 106; between one and two years of age,
22. There were 40 still births — 20 males and 20 females.
The total precipitation was 1.62 inches. On the 23d the
maximum temperature recorded was 62° and the same
maximum was recorded on the 28th. The minimtmi for
the week was 30° on the 22d. This high temperature at
a time when the majority of the people were clad for cold
weather is probably responsible for the high morbidity and
mortality from pneumonia.
|itl] M Current f ikraturc.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
January 16, 190S.
I. Vasomotor Relations', By W. T. Porter.
2 The Clinical Importance of the Uneven Distribution
of Hydrochloric -Acid in the Gastric Contents,
By Albert £ Taussig and William H. Rush.
3. An Intracanalicular Papillary Adenofibroma from the
Groin, By E. L. Young.
4. The Problein of Expert Testimony,
By Francis Wayland Anthony.
5. Practical Applications of Opsonic Therapy,
By Theodore C. Beebe and Leon S. Madalia.
6. The "Optometrist." Does He Preach and Practise
Medicine? By John C. BossiDy.
I. Vasomotor Relations. — Porter in his Har-
vey lecture speaks also of shock. There has been
of late renewed discussion as to the cause of the
symptcm coniplex termed shock. Concerning the
symptoms themselves, there is very general agree-
ment— the abnormal fall of blood pressure, the
failing heart, the low temperature, the apparent de-
pression of the nervous system, are frequent tokens
of calamity. It is the apparent depression of the
nervous system tliat has for many years given such
favor to the ide'i that the low blood pressure is the
result of exhaustion of the vasomotor centre. We
forget that the brain is not an organ, but a region,
very large in proportion to the groups of nerve
cells that are scattered through it like settlements
in a wilderness of fibres. It is forgotten, too, that
these cell groups have the most diverse functions.
Thus, as in the writer's experiments, the large
hemispheres may be roughly taken away without
lowering the normal blood pressure and without
affecting the vasomotor reflexes, except to increase
them. The depression observed in shock does not,
therefore, justify any sweeping statements regard-
ing the condition of the many separate nerve or-
gans sheltered by .the cranium and the vertebral
canal. A clear distinction .should be made between
the symptoms of shock and shock itself. The
symptoms of shock form a clinical entity about
which there can be little dispute ; shock, on the
contrary, is a pathological state, the data of which
are at present hypothetical. The hypothesis which
constitutes the hitherto generally accepted defini-
tion of shock declares that the vasomotor cells are
depressed, exhausted, or inhibited by excessive
stimulation of afferent nerves. The fall in blood
pressure and the accompanying symptoms are de-
clared to be the result of this depression. The
vasomotor nervous systein seldom, if ever, dilates
or constricts all the vessels at one time. The same
afferent impulse will cause the vasomotor centre to
dilate the vessels of the face, while it constricts
those of the abdomen. The effect upon the gen-
eral blood pressure depends upon the relative size
of the dilating and constricting areas. Here the
splanchnic nerves, which govern the vessels in the
abdomen, have great importance. Shock must,
therefore, be studied from a local as well as a gen-
eral standpoint. The necessity of studying the
parts, as well as the whole, will be more apparent
when it is remembered that the vasomotor system
is composed of three separate neurons — one in the
bulb, a second in the spinal cord, and a third out-
January 25, 1908.]
PITH OF CURRENT LITERATURE.
177
side the cerebrospinal axis. Experiments under-
taken by the author and Dr. Clark show that the
several neurons are essentially individual in their
action. Were they all of one order, they would
react equally to the same stimulus. In other words,
the sciatic reflex and the depressor reflex should
both be increased or both be diminished by the ac-
tion of the same agent. We find, however, that
they are affected in different way by the same drug.
Curare, for example, affects the depressor reflex
in one way and the sciatic reflex in another. The
experiments seem to establish a specific difference
between the bulbar and the spinal motor cells. The
more the circulation is studied, the stronger is the
conviction that it is not a fixed state, but a sensi-
tive equilibrium, the result of the constantly vary-
ing action of a great number of factors. Hence
the difficulty of the subject and the necessity of
separating the complicated mass problems into sim-
pler problems, capable of answer one by one. Such
a separation can be accomplished only in the labora-
tory, and it is to experimentation upon animals
that we must chiefly look for new knowledge in
this field.
2. The Clinical Importance of the Uneven
Distribution of Hydrochloric Acid in the Gastric
Contents. — Taussig and Rush observe that, when
the stomach contents are expressed and aspirated
in the usual manner as completely as possible, the
patient sitting erect, only a comparatively small
portion of the gastric contents can be obtained.
After any of the usual test meals the acidity of the
portion so obtained cannot be assumed to repre-
sent the acidity of the stomach contents as a whole.
If, after this portion of the stomach contents has
been removed, the patient is made to lie down, it is
usually possible, by means of aspiration, inflation,
and the like, to obtain a further considerable quan-
tity of stomach contents. This second portion often
differs considerably in its acidity from the first por-
tion. Even after this second portion has been re-
moved, the stomach still contains considerable un-
obtainable residue. The amount of this is appar-
ently independent of the total quantity of gastric
contents, and probably varies from one to three
ounces. Of its degree of acidity we can know
nothing; certainly we have no ground for the as-
sumption that it is identical with the acidity of the
contents obtained for examination. The quantita-
tive determ.ination of the acidity of the gastric con-
tents is thus seen to be subject to a grave source
of error. This will be diminished if the contents
obtainable in the prone position are also exam-
ined. It will be further lessened if the acidity of
the two portions does not differ very widely, since
then we may assume that the acidity of the unob-
tainable residue will itself not be very different. It
follows that, in practice, trustworthy results can
be obtained only if the following precautions are
observed : The stomach contents must be obtained
separately in the erect and in the prone posture ;
the acidity of each portion must be determined and
diagnostic conclusions, based upon the degree of
acidity, can be drawn only if the two acidities cor-
respond fairly well, or if the total quantity of gas-
tric contents obtained is so great that the unknown
acidity of the unobtainable residue may be neg-
lected.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
January 18, 1908.
1. A Plea for Early Exploratory Laparotomy in Gastric
Diseases of Doubtful Nature,
By William L. Rodman.
2. Arteriosclerosis,
By George Lincoln Walton and Walter Everard
Paul.
3. The Relation of Upper Respiratory Obstruction to
Oral Deformity, and Simultaneous Treatment by
Expansion of the Dental Arch,
By Francis Ashley Faught.
4. Subacute Polymyositis, with a Report of Three Cases,
By Benjamin T. Burley.
5. A Mixed Tumor of the Parotid Gland,
By A. H. CoRDiER.
6. A Case of Systemic Blastomycosis,
By R. A. Krost, M. J. Moes, and A. M. Stober.
7. Heart Block at Ninety-one. By Charles F. Beeson.
.8. A Clinical Study of the Bromine Compounds, with
Special Reference to Strontium Bromide,
By William J. Robinson.
^. Influence of the Ductless Glands on Metabolism,
By Leo M. Crafts.
10. Acid Autointoxication and Systemic Disease, the Cause
of Erosion and Abrasion, By Eugene S. Talbot.
11. Spme General Reflections on the Psychology of De-
mentia Praecox, By Smith Ely Jelliffe.
2. Arteriosclerosis. — Walton and Paul con-
clude that, while arteriosclerosis is directly product-
ive of apoplectiform attacks and of vertigo and plays
a part in the loss of memory as well as of other fail-
ing powers of involution, it does not produce head-
ache except as the immediate result of apoplectiform
attacks. Arteriosclerosis naturally appears in a cer-
tain proportion of elderly neurasthenics as in any
group of elderly persons, but their observations fail
to establish its causative influence, atid the authors
feel that further study of this branch of the question
is desirable. Renal degeneration is a prominent fac-
tor in the cardiac enlargement often present in cases
of arteriosclerosis. Arteriosclerosis without cardiac
enlargement or renal degeneration is only exception-
ally accompanied by a very high blood pressure. If
either cardiac enlargement or renal degeneration is
present, moderately high blood pressure ; if both are
present, very high blood pressure, is the rule.
4. Subacute Polymyositis. — Burley, in speak-
ing of the pathology of subacute polymyositis, re-
marks that the post mortem findings in these cases
are variable, depending largely on the stage of the
process. A majority of his cases had reached the
later or destructive stage, the early or inflammatory
stage being less in evidence except when a specimen
of muscle was removed during life. The signs of
inflammation, including swelling, infiltration, trans-
udation, and haemorrhage, were found early, affect-
ing largely the connective tissue, in part the paren-
chyma. It was characteristic of the disease that
certain bundles and certain fibres of a bundle were
unaffected by the process. With the progress of the
disease attempts at regeneration were commonly
seen in the great increase of nuclei, including mitotic
forms, while at the same time the anatomical picture
of destruction of fibres was prominently seen. This
appeared as granular, and, later, waxy degeneration
of the fibres ; vacuolation, a great increase of cells
and fat globules, greatly thickened perimysium be-
coming myxomatous or fibrous in structure, in fact
a tendency to the embodiment of the former specific
tissue into a connective tissue structure. The nerves
have been shown to be involved in a number of cases.
1/8
PITH 01- CURRENT LITERATURE.
[New York
Medical Journal.
notably those of Senator, but from their distri-
bution and from the considerable number of nor-
mal fibres found in the sections it seems probable
that the process is not primary in the nerves. The
amount of haemorrhage between the muscle bundles
is variable. It may be very great, predominating in
the sections and giving rise to the name polymyositis
hc-emorrhagica. Of the treatment, he says that at-
tempts to cut short the course of the disease by any
specific form of treatment have heretofore been of lit-
tle avail. Antipyretics and salicylates have somewhat
relieved the pain and soreness of the early stages.
Hot baths and fomentations had been moderately
used before, but in 1903 Oppenheim came forth with
glowing accounts of five cases, which led him to ad-
vocate confidently the systematic use of diaphoresis.
His method was to apply hot air, then wrap in blank-
ets, giving hot drinks and aspirin. The patient was
thus sweated for an hour at least every second day.
Thermomassage was used on the alternate day.
Later simple massage and electricity were used.
Oppenheim considered this treatment a great factor
in the recovery of his cases, though it did not* serve
Burley as well in the one case on which he had an
opportunity to try it. The test of time will alone
determine its value.
8. A Clinical Study of the Bromine Com-
pounds, with Special Reference to Strontium
Bromide. — Robinson thinks that the bromides
are valuable and sometimes indispensable agents.
Potassium bromide is the worst bromide we possess,
its undesirable by efifects by far overbalancing its
therapeutic value. Whoever administers potassium
bromide in large doses for a long time is simply
slowly poisoning his patient. Sodium bromide is a
much milder bromide, and when chemically puce
strontium bromide is not available, sodium bromide
is the salt of choice. Strontium bromide is the best
of all inorganic bromine compounds. It is a posi-
tive anaphrodisiac, and a positive nervous a,nd gen-
itourinary sedative ; it does not upset the stomach,
and does not produce acne, or, if it does produce a
few acne pustules, they are mild and transient ; it
often acts as a mild intestinal antiseptic, does not
irritate the kidne} s — rather the contrary — and has a
tendency to diminish albumin in albuminuria and
sugar in glycosuria. The dose of strontium bromide
ranges from 10 to 60 grains three or four times a
day. Occasionally it may be given in doses of one
or two drachms. It is best prescribed dissolved in
distilled water with the occasional addition of
essence of pepsin, tincture of cardamom, etc. Stron-
tium bromide is incompatible and should not be pre-
scribed with citrates or sulphates, and it is also best
to avoid prescribing it with alkaloids. To obtain
the good results from strontium the salt must be
chemically pure. If contaminated with barium, as
the commercial strontium salts not only frequently
but usually are, its effects will be disappointing and
its untoward by effects may be more severe than
those of potassium bromide.
II. Some General Reflections on the Psychol-
ogy of Dementia Praecox. — Jelliffe, speaking of
the therapeutics, states that many prascocious de-
ments, in fact, the most, are probably doomed from
the very beginning. What with bad structure on
which to build, bad environment, and possibly a
toxic factor (only postulated hypothetically), there
is little opportunity for some prascocious dements.
r>ut a few are worth working for, particularly in
the prasdementia stage. When the diagnosis is
more or less patent the process has been too long
in the making and the opportunities for repair have
usually been neglected. The eccentric, egocentric
child is always a difficult problem from the stand-
point of training. Too many are permitted to go
their own way in the hope that all will be well when
they mature. .A large number of prascocious de-
ments are drawn from this class. The author be-
lieves, in the first place, in teaching the children the
petty conventions of life which make so frequently
the oil that reduces social friction ; the help in per-
mitting an adjustment to unpleasant situations
which thus diminishes the opportunities for af-
fective action. It is simple to say that a child
should be trained to his metier, but extremely diffi-
cult to determine just what individual capacity is.
In an interesting comparison made by Gaupp rela-
tive to the psychoses of urban and of rural com-
munities, it appears that the stress of city exist-
ence bears particularly on the young mind and de-
termines the hysterical and praecox reactions in the
young more frequently, in the city than in the
country. This is a fact worth bearing seriously in
mind if heredity and peculiarity are present in a
child. Schooling work does not seem to make a
marked difiference if it is pursued in moderation.
The brighter, eager brains are more often dam-
aged than those less pushing, and each individual
child's reaction to its school work is worthy of
close observation. If the reaction to intellectual
work is not normal — if fatigue enters as a large
disturbing element — care should be exercised in so
arranging studies as to obviate it. These children
need schools in which outdoor pursuits are culti-
vated and made coordinate with or supplemental
to more intense intellectual efforts. There are a
large number of ideas of primary importance in
the care of this particular type of breakdown.
Many are not hopeless by any means ; they need the
proper type of education, and scientific paedagogy
looks to the physician to indicate the lines of de-
velopment for this class of true mental healers.
MEDICAL RECORD
January 18, 1908.
1. Anorectal Fistula, By Charles B. Kelsey.
2. Schlosser's Alcohol Injections for Facial Neuralgia.
Sixteen Months' Experience with Fifty-five Cases;
Three Failures, By Otto Kiliani.
3. Instruction in Hydrotherapy, By Simon Baruch.
4. The Treatment of Chorea Minor, with Special Ref-
erence to the Dangers of the Arsenic Therapy,
By Henry Kopuk.
5. Medical and Scientific Work in New York State Chari-
table Institutions, By Andrew MacFarlane.
6. Prevention of Death During Anresthesia by Chloro-
form and Ether, By Robert Reyburn.
7. Writers' Cramp; What it Is and How it Can Be
Treated by the Family Physician, By S. H. Monell.
2. Schlosser's Alcohol Injections for Facial
Neuralgia. — Kiliani reports his experience during
sixteen months with fifty-five cases, only three of
which were failures. In all cases he has made
peripheral injections first, even if he expected to
inject into the ganglion. .\11 the injections were
done without any narcosis or local anassthesia. The
January 25, ipok.l
FIJH OF CURRENT LITERATURE.
179
insertion of the blunt needle into the foramen is
rather painful; the slow injection of the alcohol
somewhat more so, but not beyond the endurance
of the patients, who are accustomed to a great deal
of pain. Every successful injection must produce,
within a few minutes, a burning or benumbing
sensation within the region of the nerve injected.
This develops, sometimes after a severe period of
pain for two or three hours, into a more or less
pronounced anaesthesia. Any of the three periph-
eral injections produces a swelling, which in the
first and second branch results in oedema of the
eyelids, and "in the third branch sometimes in a
slight trismus. Nearly every injection into the
second branch through the foramen infraorbitale
produces a slight facial paresis, owing to the con-
necting branch of the ganglion sphenopalatinum.
with the loop of the facial nerve. This paresis dis-
appears within a period of from three days to two
weeks. To reach the part of the second branch
which supplies the roof of the mouth and the roots
of the rear teeth, it is sometimes necessary to in-
ject into the gangiion sphenopalatinum, a pro-
cedure which he has ventured only lately, as he was
afraid of the entrance of the alcohol through the
outer fissure into the orbita, with its possible disas-
trous results on the eye muscles or even the optic
nerve. But a carefully slow instillation has pre-
vented any trouble so far. Injection through the
foramen ovale or rotundum into the root of the sec-
ond or third branch, or the ganglion itself, must at
once produce, if carried out properly, a complete
anaesthesia in the region of the nerve attacked. Only
if gasserectomy has been done before, the effect
may be delayed, owing to the scar tissue resulting
from the former operation. The number of injec-
tions necessary to produce freedom from pain
ranged with the first branch from two to four ; with
the second from four to sixteen; with the third
from two to five. The time occupied to get the pa-
tients free of pain varied from three days to five
weeks. The diagnosis of facial neuralgia rests, to
a large degree, upon the statements of the patients,
although a typical severe paroxysm cannot be mis-
taken for anything else. It is, therefore, only fair
to pronounce a patient cured for the time being
only if the patient says so himself.
7. Writers' Cramp.— Monell states that the
main indications for treatment are, broadly, two:
the elimination of the toxic products which result
from high pressure muscular work and part of
which gradually stagnate in the tissues, and the im-
provement of the nutrition of the affected tissues
so that the powers of recuperation are renewed.
The first of these indications is admirably met by
means of the modern electric light radiant heat cab-
inet bath, and if this is not available for the practi-
tioner he should advise a course of Turkish baths as
the next substitute. The measures of direct treat-
ment are comprised in the resources of electrothera-
peutics. In employing these resources there are
but three requisites to success ; a determination of
the therapeutic actions which must be set up in the
tissues to promote their restoration to normal, the
selection of the means of best setting up the de-
sired actions, and the technical knowledge of how
to make the selected agent do the therapeutic work
that the operator intends it to do. No special skill,
apart from a general command of the resources of
modern electrotherapeutics, is therefore required
to enable the physician to undertake a case of writ-
ers' cramp if he will first acquire an understanding
of the conditions to be treated and the indications
present in the given case. The writer has various-
ly employed with success all the currents. The
galvanic current, currents from fine high grade
faradic coils, the great resources of static elec-
tricity, and high frequency apparatus can all be
made to do the work demanded, provided the given
apparatus has efficient therapeutic resources and
the means of applying them. In most cases it will
be necessary to improve the quality of the blood
as well as the circulation through the affected tis-
sues, for anaemia, if present, retards the regenera-
tive processes. A sedative tonic action is also indi-
cated to allay irritability and remove aches and
pains. Tonic contractions of the affected muscles
are always needed, but must be carefully "dosed''
to avoid the reactions of fatigue. The physician
who is well grounded in the ordinary principles of
current control, actions, and dosage can easily ap-
ply his knowledge to the relief and improvement
of writers' cramp, and in early cases can rapidly re-
store the arm to normal endurance and comfort.
The mental relief to the patient will be incalculable.
BRITISH MEDICAL JOURNAL.
January 4, igo8.
1. Modifications in the Movements of the Knee Joint
Directly Consequent upon Injury,
By Sir W. Bennett.
2. An Operative Demonstration of the Occasional Diag-
nostic Accuracy of the X Ray in Urinary Stone,
By E. H. Fenwick.
3. Cancer of the Ovary, By J. Bland-Sutton.
4. Some Recent Experiences in the Surgery of the Liver
and Gp.llbladder, By J. L. Thomas.
5. Some Recent Developments in Our Knowledge of
Syphilis m Relation to Diseases of the Nervous
System, By F. W. Mott.
6. A Note on Excessive Patellar Reflex of Functional
Nervous Origin, and Especially the "Trepidation''
or "Spinal Epilepsy" Form, By F. P. Weber.
7. Typhoid Carriers,
By A. Ledingham and J. C. G. Ledingham.
8. The Contents of Irreducible Inguinal Herniae in Fe-
male Subjects, and True Hermaphroditism,
By E. Corner.
9. A Note on Nephropexy, By F. Ere.
' I. Knee Joint Injuries. — Bennett discu.sses the
various modifications of movement at the knee
which occur either immediately after an injury or
supervene after an interval without the intervention
of any organic disease of the joint. Complete lock-
ing of the joint immediately after injury is usually
due to some mechanical obstacle. The commonest
cause is displacement of one or both semikmar
cartilages, especially in patients under thirty-five
years of age. Hypertrophied synovial fringes give
rise to obstruction in older subjects. Other causes
are an abnormal flap of sjmovial membrane, under-
lying and adherent to the patella, completely loose
bodies ("loose cartilages"), bodies attached by a
long pedicle, pieces of bone broken off from the
condyles of the femur. Apparently complete lock-
ing of the knee joint, in the absence of anaesthesia,
may be due to muscular spasm, secondary to pain.
In all cases an anaesthetic should be given as soon
i8o
PITH or CURRENT LITERATURE.
[New York
Medical Journal.
as possible, in order to determine how much of the
limitation of movement is due to muscular spasm.
3. Cancer of the Ovary. — Bland-Sutton states
that primary cancer of the ovary is a very rare dis-
ease. The most remarkable feature of secondary
masses of cancer in the ovaries is the large size the)-
sometimes attain, while the primary growth is so
small and inconspicuous as to be overlooked unless
specially sought for. The view that these large
malignant bilateral tumors in the ovaries are sec-
ondary to cancer in other organs rests on the fact
that the structure of the ovarian mass varies ac-
cording to the situation of the primary cancer. Some
of these large tumors may be explained by the fact
that the cancer cells may engraft themselves on a
preexisting ovarian cyst. Primary cancer of the
Falloppian tube is a very fatal disease. Its bad ef-
fects are greatly modified according to the condi-
tion of the ccelomic ostium of the tube. When this
ostium remains open the cancer cells quickly infect
the pelvic peritonaeum ; if it becomes occluded,
which is rare, the infection of the peritonaeum is
greatly delayed. From an operative point of view
these opposite conditions are of great importance.
The removal of a cancerous Falloppian tube with a
patent ccelomic ostium is usually followed by recur-
rence in a few months. The lethal effects of a car-
cinoma are not so much due to the primary tumor
as to the accidents which arise from it. When an
ovary becomes infected with secondary cancer it is
free for a long period from the usual liability to
septic infection, and the cancerous masses may thus
attain unusual size. No case can now be accepted
as primary cancer of the ovary merely on a labora-
tory report ; a primary focus elsewhere must be
most painstakinglv sought for.
5. Syphilis and Locomotor Ataxia. — Mott ac-
cepts the Spiroclucta pallida as the specific virus of
syphilis, and suggests that it ma}- vary in its viru-
lence and toxicity, not every variety producing the
special neurotoxine. Some forms of the protozoon
may be attenuated in their virulence, owing to the
passage of the organism through the bodies of cer-
tain individuals. The writer holds that syphilis is
the essential cause of locomotor ataxia and general
paralysis. Among the facts on which he bases his
belief are the following: i. Erb's statistics. 2. The
cerebrospinal fluid of tabes, general paralysis, and
syphiHtic meningitis invariably contains lympho-
cytes and no polymorphonuclears. This occurs in
no other chronic afifection of the nervous system,
except sleeping sickness. 3. Antisyphilitic bodies
exist in the serum and cerebrospinal fluid of tabes
and general paralysis, the quantity mcreasing in
amount as the disease progresses. 4. Primary
chancres arc exceedingly rare in early paralytics, in
spite of the promiscuous sexual intercourse so fre-
quently observed among them. 5. In 80 per cent,
of forty cases of juvenile general paralysis, the
writer found syphilitic antecedents. 6. The Argyll
Robertson pupil and the irregular pupil are practi-
cally only met with in general paralysis, tabes, and
syphilis : it may be the sole sign of syphilis.
Parasyphilitic disease of the nervous system de-
pends upon two factors: intrinsic, innate, and ex-
trinsic, acquired — the soil and the seed ; the vital
resistance and the specificity of the virus. AH those
conditions, which may be inherited, or acquired,
and which tend to active metabolism of systems,
communities, and groups of neurons functionally
correlated, and which, owing to those conditions of
stress which in one individual would cause spinal
neurasthenia, will, in conjunction with the stimulat-
ing effect of the syphilitic poison, cause the nerve
cells to exercise an abnormal metabolic activity in
the production of the side chain molecules neces-
sary for immunization against the toxic effects of
the virus. The frequent indulgence of abnormally
strong sexual desires, stimulated by many causes,
especially alcohol is, after syphilis, the most im-
portant factor in the production of tabes and gen-
eral paralysis. It acts in two ways: (i) Directly,
by exhaustion of neuropotential ; (2) indirectly, in
the male by the excessive loss to the body of high-
ly, phosphorized nucleoproteids contained in the
sperm. These are biochemical substances possessed
of great specific energy and not easily replaced.
6. Excessive Patellar Reflex. — ^Weber holds
that excess in the patella reflex in functional cases
is due to a peculiar functional condition of the cere-
bral cortex, which, when present in greater degree,
gives rise to the "trepidation" form of reflex and to
"functional ankle clonus." This condition may be
excited or modified by temporary emotional factors,
and a similar state may be induced by toxaemias,
such as urasmia. The signs of this functional cere-
bral condition may be imitated by organic nervous
disease, such as cerebral haemorrhage, disseminated
sclerosis, etc. In "functional nervous vomiting"
we probably have to deal with an analogous func-
tional change in the brain.
7. Typhoid Carriers. — Ledingham and Led-
ingham, in investigating ninety women, found
three of them to be "typhoid carriers" — i. e., while
in good health themselves, they constantly ex-
creted typhoid bacilli in their stools, and so were
dangerous sources of infection. It is probable that
in these cases the bacilli vegetate in the gallblad-
der, from which they are intermittently ejected into
the intestine. No so called intestinal and urinary
antiseptics seemed to have any effect. Such per-
sons should be kept constantly under bacteriologi-
cal supervision. Dehler actually performed chole-
cystostom>- and drainage of the gallbladder on two
asylum carrier cases, though in neither were there
any symptoms pointing to disease of the gallblad-
der. ' In a few months the typhoid bacilli disap-
peared from the faeces, and the blood lost its power
of agglutinating typhoid bacilli.
9. Nephropexy. — Ere advocates a new opera-
tion for performing nephropexy, the principles un-
derlying which are as follows: i. That owing to
the friability of the renal tissue the capsule only
should be used 'for its fixation. 2. That a decor-
ticated surface of the kidney should be brought into
immediate relationship with the quadratus lum-
borum and psoas, on which it normally lies, with-
out the intervention of any connective tissue. 3.
That no suture should be affixed to the capsule of
the kidney in its upper third, as when passed
through the parietes they would, as a rule, fix the
kidney in a position below that which is normal.
January zs, ly-sj PITH OF CURRENT LJTERATUR
LANCET.
January 4, J90S.
1. Human Anatomy in England During the Nineteenth
Century, By A. Keith.
2. The Study of Embryology, By P. Thompson.
3. The Modern Treatment of Cleft Palate,
By W. A. Lane.
4. A Preliminary Note on the Kinematograph in Medi-
cine, By H. C. Thomson.
5. Diabetes Mellitus in Two Brothers, with Necropsies,
By W. C. Bosanquet.
6. A Case of "Diphtlieria of the Skin" of Three Years'
Duration Treated by Antitoxine, By A. B. Slater.
7. An Unusual Pathological Condition of Meckel's Di-
verticulum, By C. H. Turner.
8. Delirium Tremens (Mania e Potu) : Statistical Study
of 156 Cases, By L. N. Boston.
5. Diabetes Mellitus. — Bosanquet reports two
fatal cases of diabetes mellitus occurring in two
brothers. Among the points of interest were the
following: i. The hereditary incidence of the dis-
ease was well shown, no less than four members of
one family being afifected. Alopecia areata also oc-
curred in'three of the cases. 2. In one case the on-
set of the disease was very rapid and accompanied
bv abdominal pain, suggesting an acute alfection of
the pancreas. In the other case the onset was in-
sidious. 3. In one case the patient passed into a
deep state of coma, and yet recovered for a time,
dying comatose eventually, the kidneys showing
acute inflammation. The acetonaemia did not de-
pend on any lack of carbohydrate food. 4. In one
case the amount of sugar in the urine varied inde-
pendently of the diet taken, thus bearing out the
author's views as to the origin of sugar in diabetes,
viz., that some portion of the sugar arises from a
breaking down of the cells of the body, in addition
to that which may be due to some defect in the pro-
cess of absorption of sugar from the alimentary
canal or of its destruction in the body. 5. Secre-
tion failed to act beneficially in either case. Its em-
ployment in diabetes can only be upheld on the prin-
ciple that the formation of the internal secretion of
the pancreas and that of the digestive ferments take
place as a single chemical action, the lining sub-
stance breaking down simultaneously into both
these substances. 6. In both cases the anatomical
condition of the pancreas was striking; in each
there was marked atrophy of the organ without
noteworthy alteration of structure. In both there
were plenty of normal looking islands of Langer-
hans, thus tending to support the view that the
typical condition of the pancreas in diabetes is
atrophy, affecting the secreting cells as a whole. In
both cases there was well marked arteriosclerosis,
which is the most constant feature in the pancreas
in cases of diabetes.
LA PRESSE MEDICALE.
December .28, 1907.
1. Technique of Kraske's Operation, By R. Proust.
2. Spontaneous Rupture of the Aorta,
By Maurice Letulle.
3. Technique and Value of the Microbiological Examina-
tion in Syphilis, By A. Sezary.
4. Method of Measurement of Shortening of the Thigh,
By H. Forestier.
5. Painful Points and Contracture of the Abdominal
V^all, By R. Romme.
I. Technique of Kraske's Operation. — Proust
gives each step ui this opcrrition for the extirpation
(jf cancers situated high in the rectiun, clearly illus-
trated from the exposure of the sacrum to the unit-
ing of the divided ends of the intestinal canal to
bring about its reestablishment.
2. Spontaneous Rupture of the Aorta. — Le-
tulle says that atrophic atheroma of the aorta and
arterial syphilis form the two well recognized varie-
ties of antecedent disease favorable to spontaneous
rupture of the arch, an accident almost unknown to
the aorta in its thoracic abdominal portion. Chronic
atrophic nephritis, acting through the hypertrophy
of the left side of the heart and the arterial hyper-
tension which ordinarily accompanies it, is the usual
active agent in the production of^the rupture of the
internal membrane of the aorta. The commence-
ment of the aorta, above the semilunar valves, is its
weak point and the place of predilection for sponta-
neous ruptures. Every rupture of the arch is not
necessarily fatal.
3. Microbiological Examination in Syphilis.
— Sezary asserts that the microbiological examina-
tion for the Spirochceta pallida can determine ac-
curately the diagnosis of syphilis, and if the technique
is well observed the negative results will be few.
L'nder such rare circumstances, in the absence of a
method of culture and while waiting for a satisfac-
tory method of serum diagnosis, if recourse cannot
be had to experimental inoculation on an ape, reh-
ance must be placed on the histological study, whicli
elsewhere is always very explicit.
4. Measurement of Shortening of the Thigh.
— Forestier places the patient lying face downward
on a table, so that his thighs hang over the edge, in
a vertical position, the legs flexed and supported by
the toes. The pelvis is supported by the iliac spines
resting on the edge of the table, which give.> a fixed
and precise upper point to measure from. A lower
fixed point is readily obtained and exact measure-
ment is easy.
BERLINER KLINISCHE WOCH ENSCH Rl FT.
December .23, 1907.
1. Foreign Body for Two Years in the Left Bronchus.
Direct Extraction. Recovery, By H. von Schroetter.
2. Concerning the Development and the Present Position
of the Serum Diagnosis of Syphilis,
By A. Wassermann.
3. The Technique, Certainty, and Clinical Importance of
Wassermann's Reaction in Syphilis, By G. Meier.
4. Critical and Therapeutic Contributions to the Knowl-
edge of the Quartz Lamp, By R. Ledermann.
5. Concerning Suboccipital Inflammations,
By L. Grunwald.
6. Neuralgia of the Rectum, By A. Albu.
7. A Rare Case of Nervous Eructation, By S. Saito.
8. Exophthalmic Goitre and the Sexual Life of Women
(Concluded), By Kron.
I. Foreign Body in the Left Bronchus. — Von
Schroetter states that, although he has been engaged
in the examination of the upper air passages for
eight years and has seen a large number of foreign
bodies during that time, he has never before met
with a foreign body in the left bronchus. He re-
ports the case of a man, fifty-two years of age, who
inhaled a foreign body in September, 1 905, which
caused difficulty in breathing and cough, followed
by a purulent expectoration, which persisted through
l82
PITH OF CURRENT LITERATURE.
1906 and u)07 up to the time of the removal of the
foreign body. The patient had repeatedly sought
relief from emphysema, bronchitis, and other affec-
tions of the air passages. On August 28, 1907, the
foreign body was discovered by means of broncho-
scopy, and proved to be a fragment of bone, which
was easily removed.
2. Serum Diagnosis of Syphilis. — ^Vasser-
mann asserts to have proved to be diagnostic the
property of the body fluids of syphilitics to unite
with certain lipoids.
3. Wassermann's Reaction in Syphilis. —
Meier gives in detail the technique of the serum
diagnosis of syphilis as practised by Wassermann.
His clinical results were, out of 181 positively syph-
ilitic cases, there \\*as a positive reaction in 148 (81.7
per cent.), doubtful reaction in five (2.7 per cent.),
and a negative in twenty-eight (15.6 per cent.). The
reaction was negative in all of twenty-one cases in
which syphilis was positively excluded. He says
that the reaction may take place in all stages, but is
more marked in the later stages, a point of practical
importance, as in the late stages difficulties in diag-
nosis are often present. In almost every case of
tertiary syphilis the reaction was strong. In a cer-
tain set of svphilitic cases the reaction was negative,
and this needs further investigation. Finally he
holds that Wassermann's reaction is specific for syph-
ilis, which, because of its great certainty, is a true
enrichment of our means of diagnosis, but its com-
plicated technique necessitates the employment of an
experienced investigator in order to obtain unobjec-
tionable results.
5. Suboccipital Inflammations. — Griinwald re-
fers to inflammations in the region of the articula-
tion between the atlas and the occiput and reports
four cases, one of probably syphilitic, the other of
otitic origin.
6. Neuralgia of the Rectum. — Albu describes
two cases of neuralgia of the rectum. In the first
case the neuralgia was occasioned by a developing
carcinoma- of the prostate, in the other it was an ac-
companiment of tabes.
7. Nervous Eructation.— Saito describes a
case of nervous eructation of thirty-six years' stand-
ing which he met with in a woman, seventy-eight
years of age, and cured by forcing her to keep her
mouth open for an hour or two at a time and so pre-
venting her from swallowing air.
8. Exophthalmic Goitre and the Sexual Life
of Women. — Kron declares that if exophthalmic
goitre comes on before or in the early part of preg-
nancv the disease may become worse and tlie devel-
opment of the child will be interfered with, with a
resultant miscarriage, because the thyreoid gland is
insufficient to furnish the needed material to the em-
br}-o, and after the birth the mother regains more
nearly her normal condition because the pathologic-
ally changed gland furnishes sufficient secretion.
But if the disease appears during the second half of
pregnancy it has no influence on the embryo because
it has its own thyreoid. The mother, however, is
still in danger. It is probable that in a woman sexu-
ally mature exophtlialmic goitre is a disease of me-
tabolism.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT.
December ly, igoy.
1. The Technique of the Determination of the Opsonins
and its Use in Tuberculosis of the Lungs,
By Bine and Lissner.
2. Comparative Studies Concerning the Diagnosis of Ty-
phoid by Means of Bacilli Emulsion and Picker's
Diagnosticum, By Schrumpf.
3. Studies Concerning the Functional Behavior of the
Vessels in Trophic and Vasomotor Neurosis,
By CURSCHMANN.
4. The Value of the Negative Result of the Bacteriological
Investigation of the Blood of the Sinus in the Dis-
tinctive Diagnosis between Otititic Sinus Throm-
bosis and Other Not Yet Manifest Febrile Diseases,
By NURXBERC,
5. The Treatment of Tuberculosis of the Kidney by Means
of the X Rays, By Bircher.
6. The Radical Operation of Diverticulum of the CEsopha-
gus, By Gehle.
7. The Treatment of Inoperable Cancer of the Uterus
with Aceton, By Gellhorn.
S. A Serious Complication in Acute Gonorrlicea,
By MuHLiG.
9. Gangrene of the Scrotum after Application of Tincture
of Iodine, By Haxasiewicz.
10. Hypertrophy of Langerhans's Islands of the Pancreas.
By Heiberg.
11. Objects and Methods of Instruction in Gynaecology,
By VON Franque.
12. The Behavior and Reform of Midwives, By Henkel.
2. Comparative Studies Concerning the Diag-
nosis of Typhoid by Means of Bacilli Emulsion
and Picker's Diagnosticum. — Schrumpf says that
in ten cases out of forty-nine in which an infection
with typhoid bacilli was positively present the ag-
glutination test with the diagnosticum was nega-
tive, while with a fresh bacilli emulsion it was pos-
itive. In six of these ten cases agglutination with
the diagnosticum could not be obtained when the
test was repeated on different days of the disease,
in three the agglutination with the diagnosticum
took place, in the later part of the course of the
disease, while in one it was present at first but lost
later. Hence the result obtained with paratyphus
B diagnosticum were faulty, and the method unre-
liable.
5. Treatment of Tuberculosis ot the Kidney
by Means of the X Rays. — Bircher reports two
cases in which he obtained favorable results from
the methodical use of the x rays. He recommends
this form of treatment for those cases which are
not operative, as the patients can lose nothing there-
by but may gain.
6. The Radical Operation for Diverticulum of
the (Esophagus. — Gehle reports a case in which
he successfully removed a diverticulum of the oeso-
phagus from a man sixty-nine years of age. The
condition is rare, and the results of operative re-
moval have been altogether such as might be de-
sired, some patients dying in from one to eight
weeks after operation, a fistula remaining in others.
Hence it would be better for any one who may have
occasion to perform such an operation to read the
details of the technique employed by this surgeon
in his original language.
8. A Serious Complication in Acute Cronor-
rhoea. — Miihlig reports a case in which an acute
gonorrhoea was complicated by a bilateral infarct
of the lungs. He thinks that the gonorrhoea caused
a defercntitis spermatica gonorrhoeica which pro-
January 25. 1908.]
?ITH OF CURRENT LITERATURE.
183
duced a thrombosis of the venae spermaticae internse,
whence emboH were transmitted to the lungs.
9. Gangrene of the Scrotum After the Appli-
cation of Tincture of Iodine. — Hanasiewicz re-
ports the case of a man, nineteen years of age, who
had painted his scrotum with iodine because of a
painful swelling of the testicles of unknown origin.
As a result the scrotum became gangrenous and
sloughed, leaving the testicles exposed. The granu-
lating surface that was left was covertd with
Thiersch grafts with good result. The cause of the
primary epididymitis could not be ascertained. The
patient had no discharge from his urethra, denied
any venereal infection, but acknowledged the pos-
sibility of a traumatism. The author beheves that
the gangrene was the direct result of the applica-
tion of iodine and recommends that such applica-
tions should never be made in cases of acute in-
flammation, but should be reserved exclusively for
cases of chronic or slight inflammation.
ARCHIVES OF P/EDIATRICS.
December, 1907.
1. On the Bacteriology of Meningitis,
By F. S. Chukchill.
2. Proteid in Infant Feeding; the Necessity of a Standard,
By T. S. Allen.
3. Variation in Fat Content of Cows' Milk,
By E. H. Bartley.
4. A Case of Vomiting with Acetonuria and Fatty Meta-
morphosis of the Liver, By A. W. Myers.
5. Estivoautumnal Fever in a Child Two and a Half Years
Old, By R. O. Clock.
6. Sarcoma of the Kidney in Children, with Report of a
Case, _ By W. Shannon.
7. Remarks on the Exudative Diathesis of Czerny,
By A. Heymanson.
8. The Report of a Case of Retropharyngeal Abscess in a
Girl Eleven Years Old, By H. B. Carpenter.
2. Proteid in Infant Feeding; the Necessity
of a Standard. — Allen finds three ways for de-
termining such a standard: i. By determining the
nitrogen waste in the urine of balaies fed first on a
proteid free diet, then the nitrogen excreted with a
]jroteid diet varying in quantity. The difiference
iDetween the proteid ingested and the proteid equiv-
alent of the nitrogen excreted with varying amounts
of proteid will be the minimum proteid necessary
for cell growth. 2. The minimum proteid quotient
may be fixed at 4 and the maximum at 6. 3. By
studying a number of cases in which the babies'
weight, the quantities of milk taken in a day, and
the proteid content of this milk were all recorded.
Having obtained a standard, the minimum daily
proteid may be regarded as supplied by one ounce
of milk for each pound of infant's weight, while
the maximum daily proteid quotient, which is placed
at 6, will be supplied by one and one half ounces of
milk. This application of the maximum and mini-
mum daily standards is available either with whole
milk, skim milk, buttermilk, top milk, or a mixture
of cream with either whole milk or skim milk.
4. Vomiting with Acetonuria. — Myers re-
cords the case of a fairly healthy child of two years
who, without discoverable cause, developed a se-
vere vomiting attack, with acetone and diacetic acid
in the urine. After apparent recovery lasting ten
days, profound intoxication developed, though the
diet had been most judicious, and death quickly re-
sulted, after severe nervous symptoms. The liver
was fatty and the stomach was full of more or less
decomposed blood. Conditions like this are thought
to be frequent in cases in which the food is too rich
or too abundant. Vomiting may also be precipi-
tated by fatigue or over excitement. The author
disagrees with the view that the acetonuria results
from temporary tissue starvation due to persistent
vomiting. The presence of acetone in the urine in
digestive disorders is of value as a sign of liver in-
sufficiency and may be a valuable danger signal
calling for extreme watchfulness.
7. The Exudative Diathesis of Czerny.—
Heymanson refers to Czemy's description of cer-
tain phases of what was formerly called scrofulosis
and which he now terms exudative diathesis. This
condition rests upon a congenital anomaly of the
organism, heredity being an important factor. It
is common during the first year of life. Diarrhoea
inay be present or there may be no gastrointestinal
trouble. There may be a gain in weight, but fat is
excessive, muscle defective. Symptoms which are
prominent are thickening of the lingual mucous
membrane, seborrhcea of the scalp, strophulus,
prurigo, intertrigo with severe itching and gland-
ular enlargements. In older children the mucous
membrane of the nose, throat and lungs is more or
less diseased, and there are usually anorexia, con-
stipation, fetid breath and anaemia. Tuberculosis
in these cases may be excluded. In treatment
Czerny recommends the following brief rules: (l)
Careful feeding, (2) care of the nervous system,
(3) avoidance of intercurrent infection.
THE MILITARY SURGEON.
January, igo8.
1. A Study of Tuberculosis in the United States Navy,
By Presley M. Rixey.
2. The Psychic Phenomena of Intestinal Toxaemias and
Their Treatment, By J. Carlisle DeVries.
3. Ipecacuanha in Amoebic Dysentery,
By Henry I. Raymond.
4. The Treatment of Amoebic Dysentery,
By Robert M. Thornburgh.
5. The Sanitation of the Jamestown Exposition,
By Robert L. Payne.
I. Tuberculosis in the United States Navy.—
Surgeon General Rixey speaks very interestingly
of the achievements and the progress made in treat-
ing tuberculosis patients in the United States navy.
But the main point here, too, is the prophylaxis. In
the matter of recruiting, great pains should be taken
to detect tuberculosis in its incipient form before
the recruits are drafted into active service ; and as
regards enlistment we must insist on a minimum
standard of physical development and age. Until
it is more fully realized that tuberculosis is a dis-
ease of nutrition and until a minimum standard of
physical requirement is more consistently exacted,
we will not have started in a fair way to materially
reduce the tuberculosis in the service. This is par-
ticularly true of the engineer's force, which neces-
sarily has much hard labor to perform below decks
during the short stops in port as well as at sea. The
duties of the engine and fireroom forces represent
the extreme of the different occupations which keep
men below deck and which contribute the greatest
number of cases of tuberculosis. The engineer's
1 84 PROCEEDINGS OF SOCIETIES.
force is particularly subject, moreover, to pulmon-
ary affections consequent upon sudden changes
from a high to a low temperature, or even a cool
one. Frequent and sudden chills from such causes
may be prevented with due and possible care. The
men must be made to understand the dangers in
leaving overheated localities and going immediately
under a ventilation shaft or on deck or into the cold
storage compartments without necessary precau-
tions such as drying the skin of perspiration and
protecting the body by additional clothes, according
to the season or climate. And it should be avoided
as much as possible that the men in the engine and
boiler rooms and other particularly warm places be
called suddenly for duty on deck. In this case, un-
less an emergency is to be met, they should be given
time to dry the body and put on the necessary addi-
tional garments. As regards recreation and exer-
cise, it is a serious mistake to suppose that the vari-
ous athletic sports, exercises, and diversions en-
gaged in by enlisted men constitute all that is re-
quired for their physical development. As a large
proportion of the enHsted force are mere boys not
fully grown, their development requires outdoor
life of a regular, active character in order to make
them vigorous men able to withstand the hardships
of warfare or prolonged physical strain of any kind.
The value of the setting up drill, particularly the
breathing exercise, as a prophylactic measure
against pulmonary tuberculosis in the navy cannot
be overestimated, but it is believed that steps
should be taken to give with more certainty all the
enlisted personnel a larger proportion of time out
in the sun than is secured by virtue of occasional
athletic exercises. Long marches in light marching
order, taking half the crew at a time except those
debarred by sickness, or regularly sending the men
out in sailing or pulling boats are suggested pro-
cedures ; indeed any such practices might meet the
desired end and would not only be of immense ben-
efit to health, but would also be welcomed by the
men as a relief from the monotony of ship life.
Proper rest and food of course have a very decided
bearing upon the conservation of vital resistance in
the prophylaxis against tuberculosis, but these latter
considerations, it is believed, are well met in the
United States navy. The problem of treatment
largely resolves itself into dietetic and hygienic
considerations, with building of sanatoria.
Irocfflriugs at Sffcifttes.
SOUTHERN SURGICAL AND GYN/ECOLOGICAL
ASSOCIATION.
Twentieth Annaul Session, Held in New Orleans,
December 17, 18, and 19, 1907.
The President, Dr. Howard A. Kelly, of Baltimore, in
the Chair.
(Concluded from page 138.)
Thrombosis and Hydrocele in the Inguinal
Canal. — Dr. Joseph Ransohoif, of Cincinnati,
called attention to mild cases of torsion of the cord,
of which he reported three cases following severe
strains. In one there had been a hernia, and the con-
dition followed the use of an ill fitting truss. In
none of the cases did thrombosis occur in the subject
[New York
Medical Journ.\l.
of a varicocele. Under expectant treatment the
thrombosis disappeared. A number of cases of hy-
drocele of the cord within the canal were presented
as a sequence of thrombosis. One was clearly a
hsematocele with thrombus following an injury. In
three other cases the operation showed the throm-
bosed vein and the hydrocele. One specimen pre-
sented was of the rare form of bilocular hydrocele
of the canal of Nuck. The patient was twenty-eight
years of age. After a strain and slight illness a
hydrocele developed, part of which was in the labium
majus, the other properitoneal. The operation, which
consisted in total enucleation of the sac, showed a
thrombosed vein.
The essayist also presented a multilocular hydro-
cele of the inguinal canal without any communica-
tion with the abdominal cavity and without any his-
tory of trauma. He believed that all cystic tumors
within the canal resulted from thrombus and effu-
sion into an unobliterated portion of the vaginal peri-
toneal process. In his paper he alluded only to
cystic conditions of the canal which were secondary
to hernias and resulted from the sequestration of a
portion of the sac.
Traumatic Epilepsy. — Dr. E. Denegre Mar-
tin, of New Orleans, called attention to the impor-
tance of examining all scalp wounds immediately
after an injury, to determine whether or not frac-
tures might be present, and to the need of an opera-
tion at any time that symptoms of cortical irritation
were manifested, whether due to or suspected to be
of traumatic origin. He reported three interesting
cases, in one of which there had been an operation
sixteen years after the injury. The man at the time
of the operation was in such mental condition that he
was not able to transact business and was a care to
his family. He was relieved by an osteoplastic re-
section, and was so much benefited that he was able
to resume business in a short time, and, although he
had had several convulsions after the operation, his
mind was perfectly clear and he felt that he had been
greatly benefited. The third case was one of a child
who had been struck in the head by a plowshare four
years previously. The case had been given up as
hopeless, the child presenting the most peculiar
symptoms, absolutely unmanageable, and a constant
care, with frequent convulsions both day and night.
Removal of a segment of bone in this case at the
seat of injury had resulted in perfect relief and the
mental restoration of the child, who, although oper-
ated on four years ago, had never had any return of
the trouble and had continued to improve.
The Value of Intestinal Exclusion as a Surgi-
cal Procedure. — Dr. John Young Brown, of St.
Louis, after discussing the various surgical methods
in common use for the restoration of intestinal con-
tinuity following artificial anus done for the relief of
gangrenous hernia, reported three interesting cases
in which intestinal exclusion of the afferent and
efferent bowel had been done, followed by end to end
anastomosis.
The first case was one of strangulated umbilical
hernia in which the caecum, the appendix, and the
ascending and transverse colon were found gangren-
ous in the sac. At the primary operation an artificial
anus was made at the umbilical ring. Ten weeks
after this operation the abdomen was opened through
January as, 1908.]
PROCEEDINGS OF SOCIETIES.
185
a median incision, and bilateral exclusion of the
ileum and descending colon was done, followed by
direct anastomosis of the ileum to the sigmoid, anas-
tomosis being made with the Murphy button. The
patient made an excellent recovery, and the pro-
lapsed bowel, which remained after intestinal con-
tinuity had been restored, was removed later under
cocaine anaesthesia by the clamp and cautery.
The second case was one in which artificial anus
was made for a gangrenous inguinal hernia of the
right side, the anus being made at the hernial site.
In this case a similar procedure was undertaken.
The abdomen was opened through the right rectus,
the afferent and efiferent loop of ileum excluded, and
end to end anastomosis made with a button. The
result was exceedingly satisfactory.
The third case was one in which typhlotomy was
done through a gridiron incision, and at the same
time the entire large bowel was excluded, except the
caecum. The operation was performed after faithful
and unsuccessful efforts had been made to relieve
multiple fistulae and ischiorectal sinuses, with necro-
sis of the coccyx. It was deemed advisable to turn
the faecal current, and this method was resorted to.
The turning of the faecal current resulted in healing
of the old sinuses. The intestinal continuity was
later restored by exclusion of the caecum and lateral
anastomosis of the ileum to the ascending colon, the
last operation being done through an abdominal in-
cision through the right rectus muscle.
In each of the cases reported the various steps of
the operation were carried out without difficulty, and
the results were all that could be wished.
Attention was called to the fact that in cases where
artificial anus was made for the relief of the gan-
grenous hernia, the irritation brought about by th'^
constant faecal leakage produced a dense contraction
of the scar, which resulted in complete relief of the
hernia. By opening the abdomen through an in-
cision away from the original wound, the bowel
could be excluded and end to end anastomosis per-
formed with perfect ease, and without impairing the
repair w^ork done by Nature in relieving the hernia.
The paper concluded with a strong plea for the
employment of intestinal exclusion in the treatment
of this condition, the writer believing the operation
to be safe, surgical, and satisfactory.
Haematuria in Pregnancy. — Dr. Edward A.
Balloch, of Washington, surveyed the literature of
so called idiopathic, or essential, haematuria, or haem-
aturia without demonstrable cause. He showed tha:
most of these cases were in the older literature, and
that modern research tended toward skepticism as
to the possibility of renal haematuria without some
lesion in the kidney. The two principle theories of
causation, the angioneurotic and the chronic nephri-
tis theory, were discussed, and the conclusion was
arrived at that the latter had the weight of evi-
dence in its favor.
The influence of nephrectomy upon subsequent
pregnancy was discussed. As a case reported was
the second instance in the writer's experience where
an uneventful pregnancy had followed nephrec-
tomy, he did not consider that the loss of one kidney
had much effect upon subsequent pregnancy.
The cystoscope and urethral catheter were essen-
tial to a proper diagnosis. The existence and func-
tional capacity of a second kidney should be demon-
strated before operative measures were practised. In
the matter of treatment, the author considered that
an analysis of reported cases showed that equally
good results had followed decapsulation and nephrot-
omy as had followed nephrectomy. He advised the
following order of procedure: i. Injection of adre-
nalin solution into the pelvis of the kidney. 2. Ne-
phrotomy or decapsulation. 3. Nephrectomy. Ne-
phrectomy should be resorted to only in cases in-
tractable to other measures, as it was essential to
save as much of the kidney structure as possible.
The Sensitive Short Uterosacral Ligament; Its
Clinical Significance and Treatment. — Dr. Ed-
ward J. Ill, of Newark, N. J., drew attention to the
sensitive short uterosacral ligament as a pathological
entity. Schultz and Burrage liad written of the con-
dition long before this. Schultz gave no special ad-
vice as to treatment, while Burrage recommended
incision of the ligament through an abdominal sec-
tion. Ovaries had been sacrificed under a false ap-
prehension. The condition should not be confounded
with intraperitoneal adhesions or with shortening of
the base of the broad ligament due to scars resulting
from puerperal injuries. Outside of the acute pelvic
exudate, the writer knew of no condition so painful
on pressure as the short and sensitive uterosacral
ligament. During the last twelve years 5 per cent,
of all his operative gynaecological patients had suf-
fered with a short and sensitive uterosacral ligament.
When but one ligament was diseased, it occurred in
73 per cent, on the left side. The disease might be
congenital or acquired either in childhood or during
active sexual life. Because of the short ligament,
fixation of the uterus resulted. The circulation of
the organ became impaired. Catarrhal and metritic
changes resulted in menstrual disturbances. In the
acquired case, when but one ligament was short and
sensitive, the pain was commonly referred to the
sacroiliac synchondrosis or the iliac region of that
side. Menstrual pain seemed to be common to all,
and was produced by metritic and endometritic
changes. The neurasthenic cases offered a bad prog-
nosis. Sterility was a frequent symptom, and abor-
tion sometimes resulted from a very short ligament.
The objective effects, when both ligaments were
shortened, were to elevate the uterus and drag it into
the hollow of the sacrum. Its mobility was much im-
paired. When one ligament was short, the uterus
was elevated and displaced to the side of the short
ligament and retroposed. The short ligament stood
out sharply when the cervix was drawn forward and
downward. Great pain resulted from such a pro-
cedure. The prognosis was bad for those who came
from a neurotic family or where from long standing
conditions the resulting pathological changes had be-
come incurable. The operation suggested by the
writer consisted of a most thorough stretching of the
tense and sensitive uterosacral ligaments, while the
patient was under profound anaesthesia, until the
uterus became freely movable. A free dilatation of
the uterus with graduated steel sounds, curettage,
etc., should be added.
Cyst of the Pancreas. — Dr. Rufus B. Hall, of
Cincinnati, said that true cysts of the pancreas were
retroperitoneal tumors, while pseudocysts were in-
traperitoneal accumulations of fluid. Judging from
PROCEEDINGS 01- SOCIETIES.
[New York
Medical Journal.
the literature, the tail of the pancreas was the favor-
ite situation for the development of these cysts. The
diagnosis of pancreatic cysts should be based upon
the character of the contents of the tumor rather
than upon the supposed demonstration of an ana-
tomical connection. The author reported a case of
cyst of the pancreas in a woman, forty-two years of
age, upon whom he had operated successfully.
Transperitoneal Ureterotomy for. Ureteral Cal-
culus.— Dr. Gerry R. Holden, of Jacksonville,
Fla., reported a case in which he had resorted to this
operation for the removal of a stone in the ureter.
He pointed out the reasons why an abdominal extra-
peritoneal operation was impossible on account of
the thick abdominal walls. He did not believe that
transperitoneal ureterotomy for ureteral calculus was
often the operation of election. He did believe, how-
ever, that it was the best operation when the stone
was impacted at or just above the uterine artery,
provided one was reasonably assured that infection
was either mild or else absent altogether.
The Inconsistencies of the Gauze Pack. — Dr.
Hubert A. Royster, ot Raleigh, N. C, said we
drained before we knew why we drained. A strip
of gauze was simply a means of applying the law of
capillary attraction. Rubber tube and tissue had
been substituted, because the gauze so frequently
failed to drain, acting as a successful stopper to the
outlet. The one thing to be desired was patency of
the wound, but there could be no more efficient plug
than the stereotyped gauze packing. When intended
for a drain, gauze should be inserted after the man-
ner of a lamp wick ; when used for haemorrhage, it
should be packed in like wadding with a ramrod.
There was a field for gauze in packing sinuses, fistu-
lae, and granulating wounds, so that healing might
take place slowly from the bottom. Some would
persist in using gauze drains, and in the event of
disaster would console themselves by believing that
it was better to have drained and lost than never to
have drained at all. The use of gauze to wall off
septic matter in abdominal operations was fraught
with danger and full of inconsistencies. The placing
of large pads or rolls of gauze in the cavity necessi-
tated a long incision and undue handling of the vis-
cera, and almost always uninfected regions were in
contact with pus soaked gauze. When one end of
the gauze was soaked with pus, the other end would
become soiled sooner or later. The common prac-
tice was to. push the gauze packs through pus col-
lections into healthy parts or to wall off around
localized abscesses with pads, which soon became
saturated wath purulent products. Exposure of the
peritonaeum to gauze soaked with pus was just as
dangerous as the presence of pus itself among the
intestines. A glaring inconsistency was seen in the
removal of the packs with contaminated hands. The
surgeon should resolve, first, that he would employ
gauze sensibly, if he could, and not at all, if he could
not. Second, if the using of gauze "maketh our
technique to offend, we will use no more gauze while
the world standeth."
Gunshot Wounds of the Abdomen. — Dr. Le
Grand Guerry. of Columbia, read a paper on th!s
subject, in which he reported eight consecutive cases
of gunshot wounds of the abdomen.
Suppurative Phlegmonous Gastritis. — Dr. J.
Wesley Bovee, of Washington, after going exten-
sively into the literature of this subject, reported a
case of circumscribed suppurative phlegmonous gas-
tritis in which he had resorted to gastrostomy. The
case was complicated by pregnancy of six months
and abortion. Mrs. T., white, thirty-six years of
age, who had had seven children, followed in 1895
by a miscarriage, was admitted to the Columbia Hos-
pital on October 6, 1907. She had suffered irvm
pain in the epigastric region for several years, which
was usually relieved by taking food. Her last men-
strual period occurred on April 13, 1907, and she
considered herself pregnant. On October 3d she
ate heartily of boiled cabbage for dinner and crabs
late at night. In the night she was attacked by
severe pain in the region of the stomach. Morphine
was given for the pain. On the following day the
pain continued and vomiting set in. An attempt to
move the bowels by enemata and cathartics was un -
availing. The temperature was elevated, ranging
from 99.5° to 101.5° F. The pulse was rapid and
weak. The next day croton oil was employed b\
the mouth, but the bowels failed to respond. The
various remedies were not effective in relieving the
pain, constipation, and vomiting. The vomited ma -
terial was first solid and partially digested food.
Later it was watery and frothy, changing to dark
green. She was so enfeebled and appeared to be so
ill that the attending physician secured an ambu-
lance and took her to the hospital on Sunday night,
as mentioned. No chill or sweat was experienced.
Dr. Bovee saw her about 11 o'clock that night. Ar
that time her pulse was thready and her countenance
anxious in appearance. Examination under anaes-
thesia disclosed that the uterus extended to an inch
above the umbilicus, and the epigastrium was dis-
tended, very tender, and tympanitic. A median line
incision above the uterus was made. The intestinal
loops were congested, but not adherent. The stom-
ach was palpated. It was found to be fully three
fourths of an inch thick at the middle of the greate"
curvature, gradually thinning toward the cardiac
end. In the pyloric end and in front was a mass of
nearly the size of a man's fist, that was soft, though
not doughy, to the touch. This gradually thinned
out toward the middle of the stomach. The stomach
was opened at about its middle by a longitudinal in-
cision of about three inches, and the mucosa inspect-
ed. To determine the nature of the enlargement
more definitely, a separate short incision was made
over it, when the nature of its contents was mani-
fest. Gauze was passed around it and it w^as
opened, and two to three ounces of grayish pus
escaped. The long incision was closed and the
pus cavity wiped out. A rubber tube was tightly
sutured into it and brought out of the abdomen.
A light gauze drain was packed about it. She
was fed per rectum for twenty-one days. Five
days after the operation liquids were given by the
mouth, as salt solution by hypodermoclysis and
liquids by the rectum did not quench her ravenous
thirst. The following day the contents of the
stomach came through the wound. A few days
later solid food was given and the tube removed.
Stomach contents ceased escaping in a few days.
January 25, 1908.]
PROCEEDINGS OF SOCIETIES.
187
On the eighth day with little effort she aborted,
the fcEtus living- three hours. With the exception
of infection of the abdominal incision, which re-
quired resuturing, she had made an uninterrupted
recovery.
Harmful Involution of the Appendix. — Dr.
Robert T. Morris, of New York, said that most
cases of stomach and bowel trouble were not cases
of stomach and bowel trouble. Normal involu-
tion of the appendix was often a harmful process
and produced many of the symptoms ascribed to
other organs. Bile tract adheisons, eye strain, loost
kidney, and several pelvic conditions caused symp-
toms similar to the ones produced by involution of
the appendix. The diagnosis was easily made by
two features: First, a persistent or frequently re-
curring sense of discomfort in the appendix region.
Second, supersensitiveness of the right lumbar gan-
glia. This latter point was of definite and constant
diagnostic importance. To find the right lumbar
ganglia, draw a line from the navel to the right
anterior superior spine of the ilium. One inch and
a half from the navel on this line would be found
the diagnostic point on deep pressure. McBurney's
point was six or eight inches away, at the other end
of the line. McBurney's point had reference to
acute inflammatory processes in the appendix it-
self. The point described by Dr. Morris had ref-
erence to reflex disturbances caused by the appen-
dix. If the right lumbar ganglia alone were ten-
der on pressure, the appendix alone was responsi-
ble for disturbances of the stomach and bowel that
were ascribed to other causes. If the disturbance
proceeded from some organ in the pelvis, both right
and left lumbar ganglia were IciTder. If the dis-
turbance proceeded from the 1m le tract or from eve
strain or from some point above the navel, neither
the right nor the left lumbar ganglia were tender.
Dr. Morris referred to the new era of physiologi-
cal surgery, based upon the studies of Metchnikoff
and Wright. The patient would be allowed to do
most of the work in managing his infection, and the
surgeon was to leave him with such a degree of
normal resistance after an operation that he could
elaborate his phagocytes and opsonins. He thought
he stood alone in advocating the doctrine of the
new era, but in a year or two more many surgeons
would be upholding the doctrine. They would stop
doing elaborate work in appendicitis cases with pus,
for instance, and they would not fear spreading
pus over the normal peritonaeum, nor would they
stop to remove the pus, provided they could oper-
ate quickly and with so little disturbance to the pa-
tient that he was left with his normal resistance un-
impaired. The surgeon's function was merely to
turn the tide of the battle between bacterium and
phagocytes, and they left most of the work for the
patient. That was the new principle. Instead of
trying to remove the infection by surgery, the in-
fection would be left to be removed by the patient
physiologically after turning the tide of battle for
him.
The Surgery of the Heart and Pericardium. —
Dr. Rudolph Matas, of New Orleans, described
the recent advances in the surgery of these organs.
According to statistics, the proportion of recoveries
after operations on the heart was 43.83 per cent.
In 134 cases of suture there had been forty-nine
recoveries. In eleven cases the heart had been ex-
posed without suture, and five patients had recov-
ered.
While the value of statistical conclusions must
not be overrated, it might be safely concluded that
heart wounds, far from being invariably fatal, gave
three chances in four for survival long enough to
permit of surgical intervention, one chance in ten
to heal spontaneously, and one in two to be cured
by surgery.
Further progress in cardiac surgery could be ac-
complished only by methods which would diminish
three great factors in the mortality, namely, shock,
haemorrhage, and infection. The writer then dis-
cussed the most recent suggestions which gave
promise of decided progress in at least these three
directions: i. The diminution of shock by simplify-
ing the preliminary thoracotomy, which gave the
operator free access to the pericardium and the
heart. 2. Methods of hsemostasis which controlled
the bleeding from the wounded heart itself, while
the suture of the wound was accomplished. 3.
Methods which would diminish the tendency to fa-
tal postoperative infection (a) by proper attention
to asepsis, usually neglected in emergencies; {b)
by prophylactic drainage of the pericardium and
pleura, and (c) by immediate or early obliteration
of the pleural space and by the expanded lung to
avoid the dead space left by the retracted lung in
pneumothorax.
The Present Status of Gastric Surgery. — Dr. J.
Garland Sherrill, of Louisville, read a paper on
this subject in which he reported three cases illus-
trating different conditions for which an operation
might be done with the hope of materially benefit-
ing the patient's condition.
Case I. — A man, aged thirty-five years. Gastro-
enterostomy done for dilatation, which was causing
great distress, with the result that the patient had
been entirely relieved.
Case 2. — A man, aged fifty. He gave a history
of gastric trouble extending over a period of three
years and a half, with a diagnosis of ulcer of the
stomach, with imperfect drainage. The operation
in this case consisted of gastrectomy, or removal of
the ulcer and the ulcer bearing area. The result
in this case also was very good.
Case J. — A woman gave a history of suffering
from indigestion and various stomach disorders for
a period of six years, with an interval of quiescence.
She had had a number of haemorrhages from the
stomach, had lost in flesh, and began to show a can-
cerous cachexia. A diagnosis of ulcer of the stom-
ach with contracture, probably beginning malignant
change, was made. At the operation, which con-
sisted of a gastroenterostomy, a cancerous nodular
mass was found involving the lesser curvature of
the stomach for three fourths of its length, and the
central portion of the stomach, both anterior and
posterior surfaces for several inches, and the left
lobe of the liver, which was closely bound by the
growth of the stomach. An anastomosis was made
with difticulty, owing to the necessity of making it
quite far to the left, beyond the border of the tumor.
t88
LETTERS TO THE EDITORS— BOOK XOTICES.
[New York
Meoical Journal.
It was possible to complete the operation only after
making an opening through the gastrocolic omen-
tum in addition to the one through the transverse
mesocolon, and bringing the intestine through both
openings and the posterior wall of the stomach
through the opening of the greater omentum and
there making the anastomosis. After this was ac-
complished the operation was completed in the usual
manner. The patient made a good recovery from
the operation, obtained great relief from the gas-
tric discomfort, and had been enabled to take nour-
ishment by the stomach, which was not possible for
some time previously. She had, however, an oedema
of the feet, which made the hope of her final cure
very small.
Officers were elected as foUov^^s : President,
Dr. F. W. Parham, of New Orleans; vice presi-
dents, Dr. Willis F. Westmoreland, of Atlanta, and
Dr. Henry D. Fry, of Washington ; treasurer, Dr.
Stuart McGuire, of Richmond ; secretary. Dr. Wil-
liam D. Haggard, of Nashville.
St. Louis was selected as the place for holding
the next annual meeting, in 1908.
tttUxs to tilt (Bbitors.
VIVISECTION IN THE STATE OF NEW YORK.
Medical Society of the State of Neiv York, Committee on
Experimental Medicine.
64 Madison Avenue,
New York, January 21, igo8.
To the Editors:
On April 8, 1907, "the president of this society
appointed twenty-four members thereof to be a
committee on experimental medicine, in view of
proposed legislation calculated to injure the pro-
gress of medicine by restricting experimentation.
As agitation in this direction has recently been
renewed, in a very plausible form, the imdersigned
have been instructed by the said committee to send
you the following copy of a preamble and resolu-
tion adopted at a meeting thereof held in New
York, on January 15, 1908, and respectfully to re-
quest the publication thereof in the New York Med-
ical Journal:
Whereas, in the State of New York a petition is
being widely circulated among medical men for
signature in favor of a proposed bill entitled An
.•\ct to Prevent Cruelty by Regulating Experi-
ments on Living Animals ; and
Whereas, the said bill contains in its provisions
conditions which would probably seriously impair
the progress of scientific medicine.
Resolved, that the Committee on Experimental
.Medicine of the Medical Society of the State of
New York earnestly requests the members of the
medical profession to refrain from signing the
aforesaid petition, and urges any who may have
signed the same by inadvertence to withdraw their
signatures.
The present laws of this State relating to this
subject have long proved adequate and satis-
factory.
JosEi'ii D. P>RY.\NT, AL D., chairman,
joiix G. CuRTi.s, M. D., secretary.
Functional Nervous Disorders in Childhood. By Leonard
G. Guthme, M. a., M. D., F. R. C. P., Senior Physician
to Paddington Green Children's Hospital, etc. London :
Henry Frowde and Hodder & Stoughton, 1907. (Price,
$3.)
Dr. Guthrie has here collected, in a very pre-
sentable form, a series of lectures and addresses de-
livered by him at various times before learned so-
cieties and students at a postgraduate institution.
Most of them have appeared before, but in the
present volume, appearing as they do as a more
coherent and controlled presentation, added weight
is given to a number of papers which of themselves
are full of suggestion an4 counsel. The neurotic
child is father of the neurasthenic adult is the au-
thor's chief thesis, and it is his aim to develop a
point of view with prophylaxis as its final justifica-
tion.
There are twenty-one chapters, the titles of a few
of which will outline the scope of the work. He
speaks of the Effects of the Emotions on Health,
Nervous System in Childhood, Types of Neurotic
Subjects, Hypersensitiveness of Special Senses,
Mental and Educational Overstrain, etc. Apart
from a few chapters dealing with spasmodic
asthma, tics, chorea, etc., the work is devoted en-
tirely to a study of the nervous system in childhood
in its purely functional aspects. It is a work much
needed in the English tongue, and should be read
by all, for all physicians are interested in building
up a healthy stock. The functional disorders of
the nervous system are bound to increase with the
rapidly increasing complexities of social relations,
and although adaptation is always at work, wear
and tear and strain will claim their victims. Child-
hood is the time when better adjustments may be
planned and dangers perhaps averted. Useful
hints and suggestions are to be found in Dr.
Guthrie's work.
BOOKS, PAMPHLETS, ETC., RECEIVED,
A Textbook on Uric Acid and its Congeners. With
Special Reference to its Physical and Chemical Proper-
ties, its Metabolism, and Accumulation in the Organism.
Together with the Disease Processes Arising Therefrom
and Their /Etiological Therapy. For Medical Students
and Practitioners. By George Abner Gilbert, M. D., Mem-
ber of Local, County, and State Medical Societies of Con-
necticut etc. First Edition. Danbury, Conn. : The Dan-
bury Medical Printing Company, 1907. Pp. 310.
Comparative Electrophysiology. A Physicophysiological
Study. By Jagadis Chunder Bose, M. A., D. Sc., Pro-
fessor, Presidency College, Calcutta. With Illustrations.
New York, Bombay, and Calcutta: Longmans, Green, &
Co., 1907. Pp. 760. .
Medical Diagnosis. A Manual for Students and Prac-
titioners. By Charles Lyman Greene, M. D., Professor of
the Theory and Practice of Medicine in the University of
Minnesota, etc. Second Edition, Revised, with Seven Col-
ored Plates and Two Hundred and Forty-one Illustrations.
Philadelphia : P. Blakistcn's Son & Co.', 1907. Pp. 691.
Transactions of the Fifth Annual Conference of State
and Territorial Health Officers with the United States
Public Health and Marine Hospital Service, held in Wash-
ington on May 29, 1907. Washington : Government Print-
ing Office, 1907. Pp. 47.
An Introduction to the Study of the Infant's Stool. By
Paul Selter, M. D.. Solingen, Germany. Translated by
Herbert M. Rich, B. L., M. D., Detroit. Mich. Detroit:
The Detroit Medical Journal Company, 1907. Pp. 28.
(Price, 30 cents.)
January 25. 1908.]
OFFICIAL NEWS.
Sul processo de riparazione delle perdite di sostanza
nelle cartilagini e pericondrio. Per il Prof. Dott. Giulio
Anzilotti, aiuto e libero docente di i/utologia chirurgica.
Pisa : Orsolini-Prosperi, 1907. Pp. 38.
Ansemii in Puerto Rico. Report of the Permanent
Commission for the Suppression of Uncinariasis in
Puerto Rico for the Fiscal Year 1906-1907. Respect-
fully submitted to the Honorable Regis H. Post, Gov-
ernor of Puerto Rico, September 30, 1907.
Affinal Pftos.
.Dec. 28-J2
Dec. 28-Ja
28- Tan.
Imported
Public Health and Marine Hospital Service
Health Reports :
The follozving cases of smallpox, yellow fever, cholera,
and plague have been reported to the surgeon general,
United States Public Health and Marine Hospital Service,
during the week ending January ly, jgo8:
Smallpox — United States.
Places. Dates. Cases. Deaths.
California — San Francisco Dec. 2:-Tan. 4 16
Illinois — Alton Dec. 23-30 i
Illinois — Danville Dec. 30-Tan. 6 i
Illinois — Springfield Dec. 26-jan. 9 29
Indiana — Elkhart Dec. 28-Ta
Indiana — Muncie
Kansas — Kansas City
Kentucky — Covington
Louisiana — New Orleans Dec. 28-Jan. 4
Massachusetts — Fall River Dec. 28-Jan. 4
Michigan — Grand Rapids Dec. 28-Jan. 4
Michigan — Saginaw Dec. 21-28. . . .
Minnesota — Winona Dec. 28-Jan. 4
Missouri — Kansas City Dec. 28-Jan. 4
Missouri — St. Joseph Dec. 14-28....
Missouri — St. Louis Dec. 28-Jan. 4
Jlontana — Helena Dec. 1-30....
Nebraska — Nebraska City Dec. 21-28....
New York — Schenectady Dec. 1-31....
Ohio — Lorain Dec. 2fi-Jan. 4
Oklahoma — Oklahoma City Dec. 21-28....
South Dakota — Sioux Falls Dec. 28- Jan. 4
Tennessee — Nashville Dec. 2S-Jan. 4
Texas — Laredo Jan. 9
Texas— San Antonio Dec. 21-28....
Washington — Spokane.- Dec. 21-28. . . .
Washington — Tacoma Dec. 21-Jan. 4
Wisconsin — Milwaukee Dec. 21-28
Imported
Sinillpo.r
'gn.
?razil — Pernambuco.
Canada — Winnipeg
China — .^moy (Kulangsu) Nov
-Fore\
Oct. 15
Nov. I
Dec. 28
China — Shanghai .
Nov. 24-Dec. I 2
Cases foreign. Deaths nati
Dec. 14-21 7
France — Paris
Italy — General 160
Tapan — Kobe Dec. 7-14 149
Japan — Yokohama Nov. 30-Dec. 7 8
Java — Batavia Nov. 23-30 3
Mexico — .Aguas Calientes Dec. 28-Jan. 4
Russia — Odessa Dec
Russia— Riga Dec
Russia — St. Petersburg Dec
Siberia — Vladivostok Nov
Spain— Seville Nov
Spain — Valencia Dec
Spain— Vigo Dec
Turkey— Bagdad N ov
Venezuela — La Guaira Dec
■Yellozu Fever— Fo
Jan
7-Jan.
ign.
Cuba — Cienfuegos.
Cuba — Santiago .
In Schr. Mercedita.
S-12.
Cholera — Insular.
Philippine Islands — ^lanila Nov. 8-16.
Cholera— Foreign.
Japan — Osaka Dec. 7-14.
Plague — United States.
California — San Francisco Jan. 7
Plague — Foreign.
Chile — Arica — Vicinity of Dec. 16. . . .
Egypt — Alexandria Dec
Egypt — Port Said Dec.
Egypt — Provinces — ■
Assicut Dec. !!•
Daakhlieh Dec. 10-
Garbieh Dec. 5-
Tapan — Osaka Dec. 7-
Peru — Callao Dec. 7-
Peru — Lima Dec. 7
Peru — Paita Dec. 7
Peru — Piura Dec. 7
Peru— Truxillo Dec. 7
Turkey in Europe — Kavak — In
Quarantine Station Dec. 26
Public Health and Marine Hospital Service:
Official list of changes of stations and duties of com-
missioned and noncommissioned officers of the United
States Public Health and Marine Hospital Service for the
seven days ending January 18, igo8:
Berry, T. D., Passed Assistant Surgeon. Granted leave
of absence for two days from January i, 1908.
Brooks, S. D., Surgeon. Directed to proceed to Rand-
burg, Gal., for special temporary duty ; upon comple-
tion of which to rejoin his station at Los Angeles,
Gal.
Chapin, G. W., Assistant Surgeon. Relieved from duty
at Detroit, Mich., and directed to proceed to Seattle,
Wash., reporting to Passed Assistant Surgeon Gofer
for special temporary duty.
Cheney, E. L., Acting Assistant Surgeon. Granted leave
of absence for fourteen days from January 31, 1908.
Earle, B. H., Passed Assistant Surgeon. Granted leave
of absence for fifteen days from January 14, 1908.
Goodman, F. S., Pharmacist. Relieved from duty at Gape
Charles Quarantine Station and from temporary duty
at Baltimore, Md., and directed to proceed to Tampa
Bay Quarantine Station, reporting to the medical offi-
cer in command for duty and assignment to quarters.
Graham, Earl A., Pharmacist. Directed to proceed to
Stapleton, N. Y., reporting to the medical officer in
command for duty and assignment to quarters.
Keen, W. H., Pharmacist. Relieved from duty at Tampa
Bay Quarantine Station and directed to proceed to
Gape Charles Quarantine Station, reporting to the
medical officer in command for duty and assignment
to quarters.
Ransom, S. A., Acting Assistant Surgeon. Excused from
duty, without pay, for twelve days from December
5. 1907-
Rogers, Edward, Pharmacist. Relieved from duty at
Stapleton, N. Y., and directed to proceed to Fort
Townsend, Wash., reporting to the medical officer in
command for duty and assignment to quarters.
Spratt, R. D.. Assistant Surgeon. Granted an extension
of leave of absence for two days; granted leave of
absence for twenty-one days, from January 14, 1908.
Stevenson, J. W., Acting Assistant Surgeon. Excused
from duty, without pay, for three months from Janu-
ary 6, 1908.
Stoner, G. W., Surgeon. Granted leave of absence for
three days from January 8, 1908, under paragraph 189,
Service Regulations.
Stump, F. A., Pharmacist. Directed to proceed to Chi-
cago, 111., reporting to the medical officer in command
for duty and assignment to quarters.
Thomas, A. M., Pharmacist. Directed to proceed to San
Francisco Quarantine Station, reporting to the medi-
cal officer in command for duty and assignment to
quarters.
Appointments.
Karl H. Graham and Frank A. Stump were appointed
pharmacists of the third class, January 10, 1908.
Reinstatement.
Mr. A. M. Thomas was reinstated as pharmacist of the
third class in this Service, January 8. 1908.
Appointments Revoked.
The appointments of Linn Bradley and F. J. Perusse
to be pharmacists of the third class have been revoked.
Board Convened.
A board of medical officers was convened to meet at
Seattle, Wash., January 16, 1908, for the purpose of ex-
amining aliens suspected of having trachoma. Detail for
the board : Passed Assistant Surgeon L. E. Gofer, chair-
man : Passed Assistant Surgeon M. J. White, and Act-
ing Assistant Surgeon F. R. Underwood, recorder.
Army Intelligence :
Official list of changes in the stations and duties of
officers serving in the medical department of the United
States Army for the zveek ending January 18, igo8:
Baily, H. H., First Lieutenant and Assistant Surgeon.
Will proceed to Columbus Barracks^, Ohio, for duty to
accompany a detachment of recruits to Fort McDowell.
Gal.
Bant.\, W. p.. First Lieutenant and Assistant Surgeon.
• Will proceed in person on February 4, 1908, to Lieu-
tenant Colonel G. H. Torney, deputy surgeon general,
president, examining board at General Hospital,
190
BIRTHS, MARRIAGES, AND DEATHS.
LXeu- York
Medical Journal.
Presidio of San Francisco, Cal., for examination for
advancement.
Bloombergh, H. D., Captain and Assistant Surgeon. Or-
dered to Jefferson Barracks, Mo., for temporary duty.
Craig, C. F., First Lieutenant and Assistant Surgeon. Will
report in person on February 11, igc&, to Major W.
D. Crosby, surgeon, president, examining board at the
Army Medical Museum Building, Washington, D. C,
for examination for advancement.
(MNDY, Charles M., Professor of Military Hygiene. Ap-
pointed a member of a board of medical officers to
meet at West Point, N. Y., February 4. 1908, for physi-
cal examination of the cadets of the first class at the
U. S. Military Academy.
IIanner, J. W., Captain and Assistant Surgeon. Appointed
a member of a board of medical officers to meet at
West Point, N. Y., February 4, 1908, for physical ex-
amination of the cadets of the first class at the U. S.
Military Academy.
Ives, F. J., Major and Surgeon. Retired from active serv-
ice at Fort McHenry, Md., and will proceed to San
Francisco, Cal, taking transport to sail on or about
March 5, 1908, for Philippine Islands.
Keeper, F. R., Major and Surgeon. Appointed a member
of a board of officers, to meet at the General Hospital,
Presidio of San Francisco, Cal., February 4, 1908, for
examination of such officers of the Medical Depart-
ment as may be ordered before it to determine their
fitness for promotion or advancement.
Kendall, W. R., Major and Surgeon. Appointed a mem-
ber of an Army retiring board, to meet at Fort Sam
Houston, Texas, for examination of such officers as
may be ordered before it.
Kennedy, j. M., Major and Surgeon. Appointed a mem-
ber of a board of officers, to meet at the General Hos-
pital, Presidio of San Francisco. Cal., February 4, 1908,
for examination of such officers of the Medical De-
partment as may be ordered before it to determine
their fitness for promotion or advancement.
.Mason. C. F., Major and Surgeon. Appointed a member
of a board of medical officers to meet at West Point,
N. Y., February 4,. 1908, for physical examination of
the cadets of the first 'class at the U. S. Military Acad-
emy.
Xelson, Kent, Captain and Assistant Surgeon. Relieved
from duty at Fort McHenry, Md. ; will proceed to San
• Francisco, Cal., and take transport to sail on or about
March 5, 1908, for Philippine Islands.
'i oRNEY. G. H., Lieutenant Colonel and Deputy Surgeon
General. Appointed a member of a board of officers,
to meet at the General Hospital, Presidio of San Fran-
cisco, Cal, February 4, 1908, for examination of such
officers of the Medical Department as may be ordered
before it to determine their fitness for promotion or
advancement.
Whaley, a. M., First Lieutenant and Assistant Surgeon.
Appointed a member of an Army retiring board, to
meet at Fort Sam Houston, Texas, for examination of
such officers as may be ordered before it.
Navy Intelligence:
Official list of changes in the medical corps of the United
States Navy for the week ending January 18, 1908:
.•\ngwin, W. a., Passed Assistant Surgeon. Detached
from the Naval Hospital, Norfolk, Va., and ordered to
the Philadelphia.
B.\GG, C. P., Surgeon. Detached from the Philadelphia
and ordered to command the Naval Hospital, Puget
Sound, Wash., and to additional duty at that yard.
Riddle, C, Surgeon. Ordered to duty at the marine re-
cruiting station, Philadelphia, Pa., and to additional
duty in attendance on officers not otherwise provided
with medical aid in that city.
Gather, D. C, Assistant Surgeon. Detached from the
naval training station, San Francisco, Cal., and or-
dered to the Lancaster.
De Lancy, C. H., Surgeon. Detacbed from the naval re-
cruiting station, Chattanooga, Tenn., and ordered to
the navy yard, New York, N. Y.
Dennis, J. B., Surgeon. Detached from the Naval Hos-
pital, Puget Sound, Wash., and ordered to the South
Dakota.
Dunbar, A. W., Surgeon. Detached from the Califtirnia
and ordered to the Relief.
Jacobson, L. C, Acting Assistant Surgeon. Ordered to-
the Naval Hospital, Norfolk, Va.
Orvis, R. T., Surgeon. Ordered to the naval recruiting
station, St. Louis, Mo.
P^vrker, E. G., Surgeon. Detached from the Naval Hos-
pital, New York, N. Y., and ordered to the Cali-
fornia.
Russell, A. C. H., Surgeon. Detached from the naval
torpedo station, Newport, R. I., and ordered to the
naval recruiting station, Chattanooga, Tenn.
Spear, J. C, Medical Director, retired. Detached from
duty at the marine recruiting station, Philadelphia,
Pa., and ordered home.
Verner, W. W., Passed Assistant Surgeon. Detached
from the naval recruiting station, St. Louis, Mo., and
ordered to the naval training station, San Francisco,
Cal.
Born.
O'Donnell. — In Detroit, Michigan, on Sunday, January
I2th, to Dr. D. H. O^Donnell and Mrs. O'Donnell, twin
daughters.
M arried.
Allen — Haskell. — In Savannah, Georgia, on Wednes-
day, January 8th, Dr. Frederick Olcott Allen, of Philadel-
phia, and Miss Sallie Owens Haskell.
Basteix — Sheckels. — In Washington, D. C, on Wed-
nesday, January 8th, Dr. F. E. Bastein and Miss Edna
Sheckels.
Harrington — Eliot. — In Washington, D. C, on Thurs-
day, January 9th, Dr. Francis Edward Harrington and Miss-
Maye Llewellyn Eliot.
Kirk — Lambert. — In Kingston, Ontario, Canada, on Wed-
nesday, January isth. Dr. F. James Kirk, of Brooklyn, and
Mrs. A. E. Lambert.
Phillips — Hyde. — In Boston, on Saturday, January iitb.
Dr. John C. Phillips and Miss Eleanor Hyde.
Richmond — Rice. — In Everett, Massachusetts, on Thurs-
day, January 9th, Dr. Fred M. Richmond and Miss M.
Marion Rice.
Williams — Ford. — In New York, on Saturday, January
i8th. Dr. Linsly R. Williams and Mrs. Grace Kidder Ford.
Died.
Atkins. — In Denver, Colorado, on Wednesday, January
8th. Dr. Edward Atkins.
Banks. — In Columbia, Mississippi, on Thursday, January
9th, Dr. M. L. Banks, aged seventy-six years.
Beauchamp. — In Lawton, Oklahoma, on Wednesday,
January 15th, Dr. F. D. Beauchamp.
Coffey. — In New York, on Friday, January 17th, Dr.
Joseph Coffey, aged forty-eight years.
Darrall. — In Washington, D. C, on Wednesday, Janu-
ary 1st, Dr. Chester B. Darrall.
"Gahrer. — In Brooklyn, on Monday, January 13th, Dr.
Robert G. Gahrer, aged sixty-three years.
Haines. — In Philadelphia, on Thursday, January 9th, Dr
Hannah Rodman Haines, aged sixty-four years.
Hebb. — In Randallstown, Baltimore County, Maryland,
on Friday, January joth, Dr. Henry J. Hebb, aged sixty-
six years.
Knight. — In Toronto. Ontario, Canada, on Monday.
January 13th, Dr. John Alexander Knight.
Marill. — In PoiTghkeepsie, New York, on Tuesday-
January 14th. Dr. Joaquim Marill, aged seventy-three years.
Murphy. — In Chelsea, Massachusetts, on Sunday, Janu-
ary I2th. Dr. Stephen N. Murphy, aged thirty-five years.
PoMEROY. — In Springfield, Massachusetts, on Saturday.
January nth. Dr. Stephen F. Pomeroy, aged eighty years.
RoocH.— In St. Louis, Missouri, on Monday, January
13th, Dr. August Rooch, aged eighty years.
Sparrov.. — In Baltimore, Maryland, on Tuesday, Janu-
ary 14th, Dr. Louis Griffith Sparrow, aged seventy-nine
years.
Stone. — In Richmond, Virginia, on Thursday. January
9th, Dr. George L. Stone, aged sixty-three years.
Victoria. — In New York, on Saturday, January nth. Dr.
Jose Lopez de Victoria, aged forty-two years.
Winters. — In Silverton. Colorado, on Tuesday, January
I4fh, Dr, William R. Winters, aged fifty-four years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal ^he Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXVII, No. 5. NEW YORK, FEBRUARY i, 1908. Whole No. 1522.
CARCINOMATOSIS OF THE MENINGES.
Presentation of a Case of Carcinomatosis of the Meninges,
ivith a Consideration of the Diagnosis of Multiple
Carcinomatosis, Tuberculosis of the Nervous
System, Disseminated Syphilis, and
Multiple Sclerosis.
By D. J. McCarthy, M. D.,
Philadelphia,
Professor of Medical Jurisprudence, University of Pen.isylvania,
AND
Milton K. Meyers, M. D.,
Philadelphia,
Voluntary Associate, Pepper Laboratory.
(From the William Pepper Clinical Laboratory. Phoebe A. Hearst
Foundation.)
The case which forms the subject matter of this
paper is worthy of record not only on account of the
rarity of the condition present, but also because the
mistake in diagnosis, made after a careful clin-
ical study, may be of some value in the consideration
of similar cases,.
Multiple secondary carcinomatosis of the nervous
system limited to the meninges is a rare condition.
Only eleven cases were discovered after a careful
search of the literature. In all of the four cases re-
ported by Siefert ( i ) there was a primary tumor of
the brain. In the two cases of Scanzoni (2) tumors
of the brain were secondary to carcinoma elsewhere,
and the meningeal infiltration took its origin from
these. In the case of Lilienfeld and Benda (3) the
meninges of the cord were alone affected.
In some respects our case of secondary carcino-
matosis localized to the meninges is unique. Scholz
(4), it is true, under the title of meningitis carcino-
matosa, reports two cases diagnosticated as menin-
gitis, in one of which the clinical diagnosis was sub-
stantiated by spinal puncture. Westcnhoffer (5)
reports a similar case of carcinomatous meningitis
(confirmed bv autopsy) where colon bacilli were
found in the cerebrospinal fluid during life, and after
death in the bloodvessels of the pia and dura. In
only one of Scholz's cases is there mention of the in-
volvement of the spinal cord or its meninges. In the
other case the spinal meninges were involved, but no
mention is made of spinal roots or ganglia, and the
histological report is meagre. Although Scholz
does not mention specifically the presence of collec-
tions of leucocytes, the case was reported as menin-
gitis carcinomatosa, which Seifert had previously
distinguished from simple meningeal carcinomatosis,
in which signs of inflammation were absent. In
Scholz's and in Westenhofifer's cases, however, the
membranes were tense, the bloodvessels were highly
injected, and the pia infiltrated with turbid exudate
showing here and there traces of blood or clots. On
post mortem examination the conditions could not be
distinguished from simple meningitis.
Of Siefert's cases, one was a case of meningitis
carcinomatosa. Of the others, one shows the mem-
branes adherent to the brain substance at the site of
the tumor. Very careful histological examination
showed that the meninges were extensively involved.
Haemorrhages and collections of leucocytes were
seen. There was penetration of the brain substance
by the columns of cells. In the second case the men-
ingeal changes in the brain were not extensively
studied, but those of the spinal cord showed the pres-
ence of collections of leucocytes and haemorrhages in
addition to the carcinomatosis. In the case of Lil-
ienfeld and Benda there was oedema of the mem-
branes of the brain, infiltration of the spinal men-
inges, invasion of the periphery of the cord by car-
cinoma, and involvement of the roots and of several
cranial nerves. In the cases of Scanzoni the men-
inges of the cord were also principally involved.
The following case reported at the May meeting,
1907, of the Association of American Physicians, by
Dr. Peabody, is evidently a case very similar to the
one here reported, and the only case we have been
able to find at all similar to it. In reporting this
case, Dr. Peabody called attention to the case here
reported from an abstract of the history and clinical
findings published in the transactions of the Phila-
delphia Neurological Society, three years ago, at
which the brain was shown as a card specimen.
Dr. Peabody's case was a woman forty-three years
old. Four years after the removal of the breast for
carcinoma she developed pains, especially marked
ia the lower extremities, back, and shoulders. The
pain was severe and the prostration became intense.
Electrical reactions were normal. Treatment did
not relieve her pains. She slept but little and gradu-
ally became mildly delirious. Lumbar puncture gave
normal fluid. About a week before death she was
attacked with partial ptosis of the right eye, partial
paralysis of the muscles of the right side of the face,
weakness of the right palate muscles, and partial
deafness of the right ear. Diplopia was present in
part of the field of vision. Pain in thighs and legs
persisted, and pain was noted in the lumbosacral
region on attempting to sit upright and on pressure.
There was no other alteration of sensation. The
eye grounds were normal. Urination and defjeca-
tion became involuntary. The muscles of degluti-
tion gradually became impaired, and water regurgi-
tated through the nose. She died of oedema of the
lungs three weeks after coming under observation.
Autopsy showed metastatic carcinoma of the thy-
reoid, of one suprarenal, of kidneys, of one lung, of
Copyright, 19&8, by A. R. Elliott Publishing Company.
192
McCarthy and meyers: carcinomatosis of the meninges. lneu- vork
Mldical Journal.
wall of an old cyst in cerebellum, numerous small
metastatic growths in the pia of pons and medulla,
without lesion of the pons or the medulla. There
was diffuse infiltration, with carcinoma of the peri-
neural lymph sheaths of one trunk nerve of the
Fig. I. — Left prefrontal lobe. sliowiriEr miliary caicinoniUa and tlieir
relation to the cerebral veins.
Cauda equina, and in one place the nerve trunk itself
was similarly invaded. The pia covering the cord
showed small metastatic growths. This case has
since been reported in the literature (6).
In the case about to be presented it will be noticed
upon reading the pathological report that the lesions
were small pin point, and closely scattered like small
grains of sand over the surface of the brain and
cord.
Case. — M. S., colored, age thirty-eight, by occupation
cook, was admitted to- the woman's nervous wards of the
Philadelphia General Hospital, April 9, 1905. She com-
plained of pains in both lower e.xtremities and in the lum-
bar regions. At times the pains extended into the left
chest.
Family history: Mother died at the age of eighty-one
and father at the age of ninety-three, of senility. One
brother died of typhoid fever at ten years of age. The
cause of death of one sister at eight years was unknown
to the patient. One sister died at the age of forty-six, of
aFthma, and one at fifty, of heart disease. There was no
history of tuberculosis in the family.
Previous history : There was a history of the usual dis-
eases of childhood, malaria at thirteen, nettle rash at nine-
teen, acute articular rheumatism nt thirty ; she had been
subject to sick headaches for a long time, and had com-
plained of cough throughout the winter.
History of present illness : Three months ago the present
trouble began with pain in the right elbow and hand, and
headaches in the occipital and temporal regions. Two days
later the pain extended to the left hand. Several days
later she complained of jiain in the lumbar region and in
both lower extremities. Tliere was a persistent cough as-
sociated with pain in the chest and back.
The exainination of the patient on .^pril 9, 1905, revealed
a well developed, well nourished negress. Motion was re-
tained normally in all four extremities, and sensation was
normal over the entire body.
Cranial nerves: F,xaminati<in of the cranial nerves re-
vealed no abnormal symptoms in their distribution, with the
exception that the right pupil reacted sluggishly to light.
The right knee jerk was absent; the left knee jerk was
present, but diminished. The Achilles jerk was present on
both sides and decreased. There was no ankle clonus and
no Babinski reflex. There was flexion of all the toes to
plantar irritation. The superficial abdominal reflexes were
normal. The biceps and triceps jerk of both upper ex-
tremities were exaggerated.
Examination of the chest revealed impaired resonance
over the left chest posteriorly, below the angle of the
scapula. Over this area there was bronchovesicular breath-
ing and moist rales, more marked on expiration. Vocal and
tactile fremitus were increased over the same area.
April 15, 1905. There was severe pain in both legs and
over the lumbar region.
.iVpril 29, 1905. An opthalmoscopic examination was
made by Dr. Sweet. The left pupil reacted promptly, the
right sluggishly. The eye grounds were normal, the nerves
were of good color. The ocular movements were unim-
paired. The visual fields, roughly tested, were normal.
May 10, 1905. The pain in the legs still persisted. There
was a sixth nerve palsy on the left side, and some hyper-
assthesia of the chest posteriorly. There was no Kemig's
sign on either side. The muscles of the left leg were more
flabby than those of the right. While there was still flexion
of the toes to plantar irritation on the right side, on the
left side there was a well defined Babinski reflex.
May 15, 1905. The patient was only semiconscious. There
was partial ptosis of both eyes, and she was unable to
completely close the right eye. .\ttempts to swallow milk
resulted in choking spells. In addition to the physical signs,
there were some moist rales at the base of the rip-ht lung.
May 17, 1905. There was almost complete facial palsy
on the right side, in both the upper and lower distribution
of the nerve. The right eye was held in a third nerve
]iaralytic position with marked dilatation of the pupil. There
was marked ptosis of both sides. The exit points of both
nerves were sensitive to pressure on both sides, with a
well defined paralysis in the distribution of the fifth nerve
on the left side. There was a slight Kernig's sign on the
right side, but none on the left.
The last examination of the urine, made on May 17, 1905,
showed specific gravity of 1.024, an acid reaction, and a
slight trace of albumin. On microscopical examination, a
few red blood corpuscles, a few leucocytes, a number of
hyaline casts, and cylindroids were found.
Pathological Report (Dr. Funke) : Chronic pleurisy,
hi-emorrhagic infarct of the lung, carcinoma of the lung
Fig. 2.— riiotomicroKrapli of miliary tumor of meninvres of brain,
witli extension into the cortex.
(primary), chronic diffuse nephritis, secondary carcinoma
of the liver, primary carcinoma of the pancreas.
The heart, spleen, kidneys, suprarenal bodies, and other
organs not mentioned in detail, showed nothing abnormal.
The left lung weighed 530 grammes. Its upper lobe crepi-
tated throughout and was pinkish red in color with black
mottlings on its anterior surface. Only a slight oedema
l""ebruary i, 190S.]
McCarthy and mevers.- carcixomatosis of the mexi.yges.
193
was present. At the apex of the upper lobe crepitatiuu
was still perceptible, while in the remainder of the lobe
crepitation was absent, and a dull note of percussion was
elicited.
On section, a cavit\- measuring 1.5x2 cm. i;i diameter
was found in the centre of this lobe. Its wall was grayish
white, showing a granular substance. Around the cavitj- was
a cGnsolidatea area made up of quite firm, confluent nodules,
grayish white in color.
The left lobe of the liver contained a nodule 3 cm. in
diameter. This reached the external surface nnd projects.
The centre of the nodule was yellowish gray and granular.
The periphery was granular and pinkish gray in color. To
the right of this was a similar nodule.
On the upper surface of the pancreas were two nod-iles
each measuring one and a half cm. in diameter. They
were firm and were cut with resistance. The cut surfaces
were grayish pink in color. They were apparently asso-
ciated with the pancreas, possibly having taken origin from
that structure. These nodules rested directly below the
columnar type of epithelial cells arranged in cell nests, and
having the appearance of a carcinoma. The nests of cells
were extended in an irregular way into the brain tissues,
without, however, producing any degeneration of the under-
lying white matter as seen by the Weigert and iron haema-
toxylin stains. The cells were of a columnar type with an
irregular deeply stainmg nuclei, and had the appearance
of epithelial origin. Sections of the cortex stained by Mal-
lory's connective tissue stain showed the fibres of con-
nective tissue beginning about the bloodvessels and extend-
ing between, but not into, the alveoli.
There was no degeneration of the spinal cord by the
sheath stains.
Haematoxylin eosin method : The main changes noted
by this method were seen ni the meninges ; the tubercles
scattered here and there over the spinal cord in an irregu-
.^•r fashion, noted in the gross examination, did not follow
a;iy regular distribution. They v.ere widely distributed,
not only over the meninges, but were also seen on the
spinal roots. The sixth cervical seement of the spinal
Fic. 3. — Carcinomatous infiltration of meninges, with secondary carcinoma of spinal, posterior root.
nodules described in the liver. Similar growths were found
along the course of the portal vein.
The uterus showed a large, subserous fibroid arising from
the right lateral surface a few cm. from the superior border
of the fundus. The left ovary showed cysts.
The brain, gross examination : The entire brain was
covered with minute white areas varying in size from a
pin point to a pin head. These areas were most frequent
along the course of the bloodvessels, and occurred in scat-
tered points over the entire meninges. They were most
marked arid occurred in the greatest numbers over the base
of the brain, and especially in the interpeduncular spaces.
Spinal cord : The same condition was present over the
spinal meninges, and most marked over the cervical enlarge-
ment. There was a tumor mass the size of a split pea on
the tenth dorsal root. The second and third spinal ganglia
were increased to the size of a small bean (5x7 mm.),
were of hard consistence, and protruded as tumor masses
on the inner side of the dura. The same miliary tumo:
formation was present on the inner surface of the dura as
far down as the middorsal area.
Microscopical examination : Cerebral cortex : The tu-
bercles of the cerebral meninges were composed of a retic-
ulum of connective tissue containing large masses of a
cord, for instance, showed a tumor mass in the meninges
just within the left posterior spinal root and infiltrating it
and extending to the posterior median fissure. There was
also a miliary tumor infiltration of the anterior root of the
opposite side. The axis cylinders of the roots presented a
swollen appearance, caused by infiltration of the roots by
irregular shaped cells about the size of polynuclear leu-
cocytes. These cells had deeply staining nuclei. The
nucleus varied greatly in size, but in the main made up
a relatively small portion of the cell area. Many of the
cells had a circular, clear, unstained area in the proto-
plasm presenting a vacuolar appearance. These cells were
held in alveolar spaces between the nerve fibres, but pre-
sented nothir:g regular in their arrangement. In the tumor
infiltration of the meninges, the same microscopic appear-
ance was seen in the centre, but towards the periphery
there was a distinct cell nest arrangement. The cells here
took a distinctly columnar type, having much the appear-
ance of cells in adenocarcinoma, composed of columnar
cells.
In the sections stained by Mallory's connective tissue
stain there was no infiltration of the connective tissue
fibrils between the cells. The tumor tissue was surprisingly
free from connective tissue. A small tumor mass the size
McCarthy and meyers: carcinomatosis of the meninges. „ t^'^^' V"'"^
Medical Journ
of a Split pea noted before, on the eleventh dorsal root,
completely surrounded the root, but had a well defined cap-
sule, over which bands of connective tissue extended into
the interior, somewhat after the manner of a lymph gland.
In the alveolar space formed by the connective tissue,
groups of columnar cells were seen here and there, follow-
ing the same arrangement as described before. The
degenerated and infiltrated root occupied the centre of the
tumor mass. As one approached the centre of the tumor,
the columnar shape and acinus arrangement of the cells
was lost. The cells were grouped in an irregular way
wiiliin the connective tissue. The connective tissue fibrils
did not penetrate between the cells. In the lumbar en-
largement the tumor infiltration completely surrounded the
spinal cord and had the same microscopic picture as that
seen in the cervical enlargement. The cord was indented
by the pressure of the tumor mass, but there was no true
infiltration of the white substance of the cord.
Sections stained by the Van Geisen method added noth-
ing to that described by the other methods.
Marchi method : There was a recent marked secondary
degeneration in the posterior columns of root origin. There
was also some degeneration of the direct pyramidal tract
of the left side, and a few scattered dots here and there
in the right crossed pyramidal tract. There was a de-
generation in both crossed pyramidal tracts and also in the
posterior column. There was a degeneration of the
posterior roots and a slight degeneration in the direct
pyramidal tracts. The same was true of the dorsal cord.
Nissl method: In sections from the dorsal cord and
lumbar spinal cord the majority of the ganglion cells of
the anterior horn were in an advanced state of chroma-
tolysis. Only a few of the cells even approached a nor-
mal appearance. In the cervical enlargement, many of the
cells were degenerated. There was a much larger pro-
portion of normal cells than in the cervical or dorsal cord.
Spinal Ganglia. — The nerves in the ganglion cells had
entirely disappeared. There was also marked degeneration
of the nerve fibres. The entire ganglia had been trans-
ferred into a mass composed of a reticulum of connective
tissue, between which were arranged long rows of a col-
umnar type of cell. In niany of the alveolar spaces the
cells had taken a more irregular arrangement, as already
noted in the meninges.
Pathological Discussion.
The gross appearance of the brain when removed
at autopsy, studded closely as it was with small
tubercles, gave the impression at the first glace of a
syphilitic meningitis. The more careful examina-
tion and the finding of the tumor masses in the other
viscera led to a correct diagnosis. The microscopi-
cal examination presented a typical picture of car-
cinoma (see Fig. 2). The involvement of the cor-
tex was unqtiestionably an extension from the men-
inges, and was more a displacement of the cortex,
and could, in no sense, be considered a true infiltra-
tion.
Involvement of the spinal roots is not an uncom-
mon condition, but iiivolvernent of the spinal
ganglia is relatively rare. We have not been able
to find a case in which this condition has been defi-
nitely stated. The pain in the extremities was
probably the result of the tumor infiltration of the
sj)inal ganglia and involvement of the roots.
The peripheral nerves and muscles were not ex-
amined.
The involvement of the cranial nerves is ex-
plained by the presence of miliary carcinomata in
the piaarachnoid, surrounding their points of exit.
There are no tumor masses on the nerves them-
selves.
Clinical Remarks.
A diagnosis of cerebrospinal syphilis was made in
this case, in spite of the fact that the patient pre-
sented no history of syphilis. This negative symp-
tom, if it can be so called, was not given its. proper
value. This is not a matter of surprise when there
is taken into consideration the difficulty in securing
a positive history of syphilis, even when the patient
is aware of it, and, what is more frequently the case
in the class of patients under discussion, who either
never knew or had forgotten such a "trivial mat-
ter." It should be remembered, however, when the
diagnosis is under discussion that too much im-
portance cannot be given to the elements of a care-
fttlly taken history. Ten years of constant effort
has not sufficed to eliminate the Blockley mental at-
titude as to the presumption of syphilis in the diag-
nosis of a doubtful case, quite irrespective of the his-
tory. As as undergraduate student, resident physi-
cian, and assistant physician in the wards of the
Philadelphia General Hospital, an atmosphere of
syphilis of the nervous system in the diagnosis of
obscure cases with multiple manifestations always
led unconsciously to a presumption in its favor.
Multiple syphilis of the nervous system is not
now, nor was it then, a very frequent condition.
By this is meant lesions of the nervous system pre-
senting the histological characteristics of syphilis.
Scleroses, low grade inflammatory processes, and
tract degenerations are present in large numbers,
but it remains to be proved how frequently these are
due to syphilis. Tabes dorsalis, conceded to be a
parasyphilitic disease, does not present the histologi-
cal lesions of syphilis, and is rarely associated with
syphilitic lesions elsewhere in the body. Tabes,
however, is diagnosticated as such, and not as cere-
brospinal syphilis.
In an extensive collection of brains and spinal
cords, obtained for the most part from the Philadel-
phia General Hospital, multiple cerebrospinal syphi-
lis is present in only a very small percentage.
It should be remembered in this connection that
tuberculosis presents the multiple lesions of the
nervous system similar in their character and distri-
bution to those seen in syphilis. Lesions of multiple
sclerosis, being widely distributed, not only present
the multiple symptom group seen in syphilis, but
the reverse may also be true— i. e., disseminated
syphilis may present the classic clinical picture of
multiple sclerosis. Oppenheim (7), and more re-
cently Spiller and Camp (8), have written on this
subject. In a paper recently published by Dr. C.
W. Burr (9), a case of disseminated syphilis pre-
senting the clinical picture of multiple sclerosis was
reported, together with a discussion of the diag-
nosis of the two conditions.
It is conceded that a distinctive diagnosis be-
tween some types of multiple sclerosis and dissem-
inated syphilis is impossible. The importance, there-
fore, of paying attention to a history of syphilis in
order to prevent a mistake in diagnosis is evident.
It will be seen from the clinical history, as given, and
the clinical diagnosis that tuberculosis of the lungs
was diagnosticated. At autopsy, a cavity sur-
rounded by epithelial type of tumor formation was
discovered. In the absence of a history of syphilis,
a natural presumption should have been in favor of
multiple tuberculosis of the nervous system. Had
this patient presented herself at my service, at the
Phipps Institute, such a diagnosis would have been
undoubtedly made, but the Blockley atmosphere in-
February i, 1908.] McCARTHY AND MEYERS: CARCINOMATOSIS OF THE MENINGES.
195
terfered with such a simple logical conclusion. An
important question in this discussion, however, is
why a diagnosis of secondary carcinomatosis of the
nervous system was not made. The patient was
thirty-four years old and in good condition. There
was no cachexia. A careful examination of the dif-
ferent viscera showed no other lesions than im-
paired resonance over the left chest posteriorly, be-
low the angle of the scapula ; expiratory rales in the
right axillary regions and at the base of both lungs ;
in the left axillary regions, an area about three
inches in diameter, over which bronchovesicular
breathing could be heard ; increase in the vocal and
tactile fremitus over the left lung posteriorly. Uri-
nary examination showed some albumin and hyaline
casts, but no other evidence of kidney insufficiency.
The primary growth in the liver and the secondary
growth were too small to give physical evidence of
their existence. There was therefore no evidence of
the presence of carcinoma, and it is questionable
whether such a diagnosis of either the hepatic or
pancreatic lesions was possible.
The predominating symptom on admission was
pain in the low^er extremities. The knee jerks were
absent. On the following day, the left knee jerk
was present. The right pupil reacted sluggishly to
light. On admission, there was pain in the lower
extremities, with headaches from three months pre-
vious. One month after admission, and nine days
previous to death of patient, she first began to show
cerebral symptoms. These began with affection of
the sixth nerve on the left side, and after a few days
were followed by an affection of both third nerves.
On the following day the seventh nerve on the right
side became affected, with an almost similar af-
fection of the fifth nerve on the left side. On the
day before her death, the difficulty of swallowing
indicated an involvement of the ninth or tenth
nerves. One week previous to her death there was
a progessively developing stupor. Such a group of
symptoms, with their progress, irregular distribu-
tion and development, indicated multiple lesions af-
fecting first the spinal cord and later the brain.
For this reason and for no other was the diagnosis
of syphilis of the nervous system made.
In a patient presenting symptoms with an evident
carcinoma elsewhere in the body, or with a history
or evidence of its removal, the diagnosis of multiple
secondary carcinomatosis of the nervous system
could be made. A frank, active tuberculosis else-
where in the body would lead to the diagnosis of
tuberculosis of the nervous system. The history of
syphilis, or distinct evidence of syphilis elsewhere
in the body, would lead to a diagnosis of cerebro-
spinal syphilis. The history of the case with the
rapid development of cerebral symptoms such a
short time before death would practically exclude
multiple sclerosis.
Optic Nerve Involvement. — Optic neuritis is
found in 80 to 90 per cent. (Oppenheim, 10) of
cases of brain tumor and in 15.5 per cent, of cases
of meningitis (Uhthoff, 11). The absence of any
optic nerve involvement, at least within a reasonable
time before death, may be considered as an indica-
tion of a lack of extensive intracranial pressure.
The presence of Kernig's symptom in this case
is a matter of some interest. The general impres-
sion among clinicians, and especially among paedia-
trists, is that Kernig's symptom is diagnostic of
meningitis. Kernig (12) in his original contribu-
tion reports thirteen cases of cerebrospinal (infec-
tious) meningitis, one case of tuberculous menin-
gitis, and one case of purulent cerebral meningitis,
with chronic parenchymatous nephritis, all of which
showed Kernig's symptom. He regrets that he had
not been able to study it in the transitory meningitis
that may usher in typhoid fever, typhus fever, and
recurring fever. He also reports it present in six
other cases, on all of which autopsy was performed.
These were oedema of the pia of obscure origin ;
hsemorrhagic pachymeningitis with intermeningeal
bleeding; circumscribed pachymeningitis and lepto-
meningitis, and thrombosis of the pertosal sinus,
secondary to caries of the petrous bone ; growth of
the dura to the skull and chronic leptomeningitis ac-
companying carcinoma of the brain ; slight haemor-
rhagic meningitis with haemorrhage into the ven-
tricle; slight general hyperaemia of the pia (ques-
tionably tuberculous). On the first day that the
last patient was observed there was no contracture
of the knees; on the second, however, the sign was
present, although modified. Kernig especially notes
this case as affording an instance where his sign
was present, even in the absence of genuine inflam-
mation.
On the other hand, Kernig's sign may be absent
in meningitis (Netter, 13, Morse, 14).. Morse
found it in three of twenty cases of tuberculous
meningitis, but in more than three of twenty cere-
brospinal cases.
It will be noticed that this symptom was not
present in the first and subsequent examinations up
to a short time before death, and then it occurred
only on the left side, and to a limited extent. Mi-
croscopical sections did not show a meningitis in a
strict sense of the term. There was only a tumor
formation. This could, of course, have constituted
the meningeal irritation in the broader sense of the
term.
References.
1. Siefert. Archiv fiir Psychiatrie und Nervenkrank-
heiten, xxxvi, 1902.
2. Scanzoni. Zeitschrift fiir Heilkunde, xiii, 1897.
Reference in Neurologisches Ceutralblatt, 1897, p. 960.
3. Lilienfeld and Benda. Berliner klinische Wochen-
schrift, 1901, p. 729.
4. Scholz. Wiener klinische Wochenschrift, xviii. No.
47-
5. Westenhoffer. Miinchener medizinische Wochen-
schrift, 1903, p. 1902. Also Zentralblatt fiir innere Medizin,
No. 45, 1903.
6. Peabody. Neic York Medical Journal, August 3,
1907.
7. Oppenheim. Die syphilitische Erkrankung dcs
Gehirns, Second Edition, 1903, p. 5.
8. Spiller and Camp. American Journal of the Medical
Sciences, June, 1907, p. 884.
9. Burr and McCarthy. Journal of Nervous and Mental
Disease, xxx, 1904, p. 14.
ID. Oppenheim. Lehrbuch der N erienkrankheiten ,
Fourth Edition, Berlin, 1905, p. 87.
11. Uhthoff. Klinische Monatsbldtter fiir Augenheilkunde ,
xliii, 2 part, 1905, p. 172.
12. Kernig. Berliner klinische Wochenschrift, xxi, 1884.
13. Netter. Twentieth Century Practice, xvi.
14. Morse. An Analysis of Forty Cases of Meningitis
in Infancy. Journal of the American Medical Association,
July 23, 1906.
LE BRETON: ANESTHESIA.
[New York
Medical Journal.
AN.'ESTHESIA BY NITROUS OXIDE, NITROUS
OXIDE AND OXYGEN, NITROUS OXIDE AND
ETHER, CHLOROFORM AND OXYGEN,
AND ETHER ADMINISTERED
PER RECTUM.
By Prescott Le Breton, M. D.,
Buffalo, N. Y.
During the past few years the writer has
anaesthetized over 300 private cases by the
methods cited in the title of this paper for various
operators. Nitrous oxide was given alone eighteen
times, nitrous oxide and oxygen fifteen times, and
ether by rectum six times. ■ There was a large pro-
portion of throat cases, 114 in all, the majority be-
ing given nitrous oxide and ether for the excision
of tonsils and adenoids. In many of the cases the
choice of the anaesthetic and its administration were
of importance, on account of existing conditions —
e. g., myocarditis, endocarditis, nephritis, diabetes,
empyema, a preceding pneumonia, anaemia, etc.
There was one death from the an;esthetic in the se-
ries, of which the following is the history :
Case I. — J. P. W., male, about forty-five years of age;
operator, Dr. M. D. Mann ; June 7, 1906.
A small irreducible hernia in the epigastric region was
the condition necesitaling operation. The patient had had
since youth a rapid pulse, always over 100, and usually
running 106 to 110. There was some increased tension.
The heart sounds were apparently normal. The urine had
showed some time previously albumin and casts, but nephri-
tis at the time was absent. An asthmatic condition had
existed for years, causing the patient to sleep at night in
a chair until early morning, when it was possible for him
to lie down. While asleep he showed Cheyne-Stokes
breathing, there being in the interval a cessation of respira-
tion for thirty seconds. -Nitrous oxide and ether were
chosen, and the patient was fortified by extra feeding,
strychnine, and strophanthus the night, and the morning
before operation. From the beginning of the anaesthesia
the man did not relax well, but remained rigid and some-
what cyanotic. Eight minutes after the nitrous oxide was
started and four minutes after the operation had begun,
the heart suddenly stopped and deep cyanosis and dilata-
tion of the pupils appeared. Artificial respiration, cardiac
massage, and stimulants were of no avail. Ten gallons of
nitrous oxide and three drachms of ether had been used.
I. Nitrons Oxide. — There is a class of cases in
which a short period of narcosis is desirable, yet in
which absolute relaxation is not required. For ex-
ample, the reduction of a dislocation, excision of a
small tumor, the breaking up of adhesions, etc.
Nitrous oxide, continuously administered for ten to
twenty minutes, controls such patients satisfac-
torily, and the after efifects are slight. Women and
children are the most favorable cases, whereas men
and alcoholics are the least favorable. The admin-
istration is started in the usual way by the Goldan
or Bennett apparatus until cyanosis begins to be
evident ; then the valve of the inhaler is closed by
the finger and two breaths of pure air allowed. The
valve is reopened and the inhalation immediately
resumed, while a steady stream of nitrous oxide
gas is allowed to escape into the rubber bag. Very
shortly another breath of air is allowed, and the
anaesthetic continued before the patient can recover
consciousness. In about three minutes the typical
picture is produced ; slight coiistant cyanosis, con-
tracted and not dilated pupils, snoring respiration
with increased expiratory effort, and a pulse of
eighty to ninety of increased tension. This condi-
tion is to be maintained by speedy regulation of the
quantities of air and nitrous oxide gas inhaled. An
increasing cyanosis, stertor, rigidity, and expiratory
effort demand air inhalation, and the opposite con-
dition calls for more nitrous oxide. A little expe-
rience teaches one ho\y to appreciate the quick
changes in the patient. A hypodermic of mor-
phine, one half hour beforehand, although not es-
sential, is of service. There are some cases that
may show muscular rigidity or tremor, or they mav
cry out or move the extremities. One must be
ready for this b_\- having a bottle of ether at hand so
that a drachm or more of this agent may be added.
This changes the method to anaesthesia by nitrous
oxide with a small quantity of ether.
2. Nitrous Oxide and Oxygen for Prolonged
Ancesthesia. — The cut illustrates the apparatus, and
for full details reference may be made to a former
article on the subject {New York Medical Journal,
February 13, 1904). This method is similar to the
administration of gas. Instead of allowing fre-
quent inhalations of air, an oxygen tank is con-
nected by a T shaped tubing and a constant stream
of oxygen is poured into the rubber bag along with
the nitrous oxide. At first the oxygen is allowed
in small quantities, but soon is increased in amount.
The narcosis may often be continued for an hour
or more and major operations may be performed.
As with nitrous oxide alone, ether in small quanti-
ties may in some cases have to be added to insure
smoothness. On account of the increased expira-
tory effort and the rather dark color of the blood,
abdominal operations and procedures requiring fine
dissection cannot well be performed. In operations
on the head also, the anaesthetist has too little room
in which to work. This method is the most trou-
blesome one and often an assistant is necessarv- to
help manage the cylinders and keep the gas from
freezing at the tap by wrapping about the valve
and upper cylinder towels wet in hot water. If the
apparatus is a closed inhaler — i. e., one that has
no expiratory valve, it is essential that the patient
be allowed at occasional intervals a breath or two
of pure air. This method, on account of the ex-
pense, bulkiness of the apparatus, and difficulties
of administration, has a limited use, and is employed
in the larger cities only. A typical case is the fol-
lowing :
Case II. — Boy, ajt. twelve; removal of sarcoma of the
knee by Dr. Gaylord. Time, forty-five minutes; no after
effects. Soon afterwards an amputation at the thigh was
done with the same method for ansesthesia plus one half
ounce of ether. The second day after the operation there
was a trace of albumin in the urine. Administration of
chloroform, some week's previously, had caused haematuria,
which lasted three days.
3 (a). Nitrous Oxide Given Continuously K'ith
the Addition of Small Quantities of Ether. — In
cases where a minimum of anaesthetic and a mini-
mum of after effects are desirable, this method is
of service. Small amounts of ether are added at
intervals, and the disadvantages of the nitrous
oxide alone are obviated. .\t any time nitrous
oxide may be dispensed with and ether pushed for
a short period by the drop method or cone, return-
ing later to the nitrous oxide. About one quarter
as much ether is given in this way as by the u.^ual
February i. 190S.]
LE BRETON: ANESTHESIA.
197
means. It is particularly safe and the method that
the writer prefers. The following is the history of
a typical case :
Case III.— Woman, aet. forty. Plastic operation on the
perinseum by Dr. Hendee. The son of this woman had
died from the effects of chloroform administration. She
herself had chronic nephritis with a high tension pulse.
The urine was clear at the time of operation. The anaes-
thesia lasted two hours, and about sixty gallons of nitrous
oxide and two ounces of ether were used. The second day
after operation a trace of albumin was evident, but immedi-
ately disappeared.
3 (b). Nitrons Oxide or Ethyl Chloride Used to
Precede Straight Ether. — This sequence is largely
employed and is the, method of choice in the large
hospitals. It rapidly induces narcosis, saving time
and material. The ether may then be given by the
ordinary cone or the open drop method. Recent in-
ternes in the hospital are not successful as a rule,
as they make the mistake of pushing nitrous
oxide too far, and then beginning ether in full
doses, which allows the patient to recover in part
.'\pparatus for the administration of nitrous oxide and oxygen for
prolonged anaethesia.
and begin to struggle. The secret lies in overlap-
ping broadly the administration of the two agents ;
a little ether should be run in on the gauze as soon
as the patient begins to lose consciousness, and the
nitrous oxide must be continued in small quantities
until enough ether has been inhaled to hold the case
while a change is made to the ordinary cone. It
may take four to eight minutes to get an adult
thoroughly under the influence of the anaesthetic,
because during the first few minutes very little
ether is inhaled.
For the removal of tonsils and adenoids this
method is safe. Both agents are continued as de-
scribed, the ether in increasing quantity, nitrous
oxide in lessening amount, until the breathing is
stertorous, the pupil contracted, and the eyeball
fixed. The apparatus is removed, the mouth gag
quickly inserted, and the operator begins his work.
He ordinarily has time to finish before the patient
moves. Sometimes a second dose of ether is re-
quired by the time the tonsils arc excised, especial-
ly if the punch has to be used. If the patient has
a very irritable throat, coughs continuously, and
refuses to breathe deeply, the nitrous oxide bag is
discarded and ether is pushed by the cone. Anaes-
thesia is often troublesome in these throat cases be-
cause the existing conditions necessitate a deep
narcosis before the throat reflexes disappear. For
a few nose cases the writer has given nitrous oxide
and ether satisfactorily in a semireclining position.
4. Chloroform and Oxygen. — For certain pa-
tients a minimum of chloroform only is indicated.
A simple method is the following: Empty out the
water in the bottle at the side of the oxygen tank
and partly fill with chloroform. Replace the mouth-
piece at the end of the rubber tubing by a small
glass tubing. Pass this glass tubing through the
upper end of an ether inhaler (the ordinary towel
cone). Turn on the oxygen in a slow, steady
stream and place the inhaler close to the patient's
face, but not quite touching it. The patient at each
inhalation breathes in the chloroform laden oxygen,
and the quantity given is regulated by the speed of
the oxygen stream and the proximity of the cone
to the patient's face. The bottle holding the chloro-
form may be placed in a bowl of warm water, so
that the vapor is warmed to blood heat as it is in-
haled.
5. Rectal Ancesthesia by Ether. — The chief indi-
cation for this method is for cases in which exten-
sive throat operations are to be done, so that the
operator may work uninterruptedly. To Cunning-
ham and Lahey {Boston Medical and Surgical
Journal, April 20, 1905) belongs the credit for de-
vising a new technique. The idea is simple. Air
is forced by a hand bulb through an ether bottle
and then through a rubber tubing into the rectum,
which absorbs the ether vapor. No irritation is
caused in this way, whereas by the old method of
boiling the ether there was condensation in the rec-
tum and great irritation. The writer has given
ether in this way six times so far. In one case with
perfect success, in one case with failure, and four
times with practical success — i. e., in these four
cases a few whiffs of chloroform on a gauze pad
were essential at ten minute intervals to maintain
relaxation. The rectum has a sinall absorbing sur-
face when compared to the lungs, and in case the
quantity of ether absorbed by the rectum is not
quite enough to keep the patient quiet, then an ad-
ditional agent is necessary. The writer at no time
was able to drive the ether vapor beyond the rectum
into the colon, because the sigmoid shuts off the
ascent like a valve. . Perhaps if the colon tube,
used to give a high douche before operation, is left
in situ until the operation, the vapor could then be
absorbed in larger quantity by the colon. Any at-
tempt to push the rectal tube up into the sigmoid
caused the tube to double on itself.
The technique, in brief, is as follows : Two nights
before the operation the patient takes a laxative.
During the next day food is eaten sparingly, and
the next evening a purgative is given. The follow-
ing morning early a colon douche and an hour be-
fore operation a soapsuds enema are employed to
cleanse colon and rectum. One half hour before
operation a full hypodermatic injection of morphine
is given. It is a convenience, but not a necessity, for
198
KLINGMANN: RUPTURE OF HEART.
[New Vokk
Medical Journal.
the anaesthetist to have an assistant. The apparatus
consists of a rubber bulb, such as is attached to the
Paquelin cautery, a wash bottle to hold the ether,
rubber tubing about three feet long, a piece of glass
tubing, and a large, stifiF catheter or rectal tube.
The wash bottle should be of a generous size, about
seven inches high and four inches in diameter. It
has a rubber cork perforated by two pieces of glass
tubing, one of which descends to the bottom of the
bottle. The bottle is more than half filled with
ether and is placed in a wash bowl nearly full of
warm water. The temperature of the water must
not get over 90° F. or the ether will begin to boil,
and yet it must be kept between 80° and 90° F.
or else the ether vapor will not be concentrated.
Starting the narcosis by the rectum is slow and dis-
tasteful to the patient, so the rule has been to have
the rectal equipment close by on a small table in
readiness, and the case is started by inhalation.
A sand bag is placed under the thigh to afford
working space, and the rectal tube is inserted about
ten inches. The rectum is rapidly distended by
compressing the hand bulb. The finger, protected
by a rubber cot, is inserted for a few minutes into
the rectum along the tube to empty the rectum of
gas and provide for the absorption of ether vapor.
Leggett, in a recent article {Annals of Surgery,
October, 1907), suggests a Y shaped tubing fasten-
ed near the rectal tube, which, when opened on one
side, affords escape for the gas in the rectum. Be-
tween the bottle and the rectal tube there is a piece
of glass tubing, which is inspected at intervals to
see that ether is not being forced over in a liquid
form. The rectum is kept well distended by means
of the hand bulb. The' rectal tube needs watching,
as it may slip out of the rectum. In general, from
three to six ounces of ether are used in the course
of an hour. When the operator has finished the
rectum is emptied of gas as at the beginning. The
patient recovers rapidly with little or no nausea and
no proctitis. In fact, constipation is the rule, part-
ly ovv^ing to the thorough cleansing of the alimen-
tary tract before operation.
The chief advantage of this method lies in the
fact that the operator can work steadily and finish
in about half the time ordinarily consumed. A
minor advantag.> is that there is no irritation of the
respiratory tract with excess of mucus. The chief
disadvantage is that if the ether absorbed by the
rectum is not sufficient to hold the patient, the
anaesthetic cannot push the administration any
faster, but an assistant must give an extra supply
by inhalation. The vv'riter has used a little chloro-
form on a gauze pad, held by long forceps directly
over the patient's mouth. This may have to be re-
peated at ten minute intervals.
In the hope of finding a medium better than air,
whereby to hasten absorption, several experiments
were made with nitrous oxide gas, allowing the rub-
ber hand bulb to suck directly from a bag of gas
instead of the open air. The idea was that the
nitrogen of the air was disposed of very slowly, but
that nitrous oxide loaded with ether vapor might
be more rapidly taken up by the circulating blood.
It was found that there was no practical difference
in effect, although the ether was carried over in the
form of vapor just as fast by nitrous oxide as
by the air.
Case IV. — Baby, eight weeks old; preliminary operation
by Dr. Eugene Smith for double hare lip and cleft palate,
October 15, 1906. Castor oil, given the night before, had
had slight effect, and the colon wash was given too near
the time of operation. Consequently, absorption was slow
and fascal matter at times clogged the tube. Chloroform
was necessary at intervals. Time, forty-five minutes, and
one ounce of ether used.
Case V. — The same baby, at a later date. Final opera-
tion by Dr. Smith. The preparation this time was thorough,
and the child was completely anaesthetized at first by inhala-
tion. The operation lasted one hour, and three times dur-
ing that period a few whiffs of chloroform had to be
given. Dr. Smith was satisfied that he had worked' faster
and more comfortably than if inhalation had been con-
tinued throughout.
Case VI. — Woman, jet. sixty-three years. Opening and
draining of right antrum by Dr. Hinkel, October 17, 1906.
Thorough preparation. Ansesthetization was started by
ethyl chloride and ether. Time, thirty-five minutes, and
two ounces of ether used. Complete success obtained, and
the woman moved for the first time when the throat was
swabbed out at the completion of the operation. Rapid
recovery with no sequelae.
Case VII. — Girl, set. twenty years. Opening and drain-
ing of frontal sinus by Dr. Hinkel, November 23, 1906. The
preliminary inhalation was by ethyl chloride only, and she
did not relax when the ether had been continued for some
time. Finally chloroform had to be pushed vigorously and
continuously before the third stage was reached. This
patient, although slight, frail, and anaemic, belongs to that
class occasionally seen who resist the influence of ether
or chloroform until the anaesthetics are used most freely.
She had been well prepared and had had the usual hypo-
dernmtic morphine injection. Catheterization was neces-
sary for some time following the operation.
Case VIII. — Girl, st. nine years, March 7, 1907. Re-
moval of turbinate bones from each nostril and cleansing
the ears of wax by Dr. Hinkel. Time, twenty-five minutes,
and a few whiffs of chloroform given but once during
that period. ■ No after effects.
Case IX.— Boy, set. nine years, March 13, 1907. Re-
moval of tonsils and adenoids and turbinates by Dr.
Hinkel. Time, twenty-five minutes, and additional anaes-
thetic given once. Immediate recovery. These last two
cases were well prepared and were both started by
inhalation.
23 Irving Place.
SPONTANEOUS RUPTURE OF THE HEART.
Report of a Case with Necropsy.
By Theophil Klingmann, M. D.,
Ann Arbor, Mich.
This rare condition was first observed by Har-
vey, and later Morgagni wrote at length concerning
it. Quain called attention to the fact that seventy-
seven of the hundred cases collected by him showed
marked fatty degeneration of the heart muscle.
About, two thirds of the patients were over sixty
years of age.
Deverque asserts* that in every forty cases of
sudden death there is one by rupture of the heart.
Sudden death occurred in 71 per cent, of Quain's
cases. Out of fifty-five cases there were forty-three
in which the rupture took place in the left ventricle,
seven in the right ventricle, three in the righ auricle,
two in the left auricle.
The case which I am about to describe is unique
not only from the fact that the condition is a very
rare one, but also that it occurred in a subject of
unusual good health, at the age of thirty-five years,
without any previous symptoms.
February ,, 1908.] KIJXGMAXN
Case. — On October 23, 1906, the patient in question con-
sulted me on account of a pain in the left cardiac region
which he described as a deep boring pain which was
paroxysmal. He complained of nothing else, and stated
that he had been in perfect health since his childhood days.
His father died suddenly at the age of seventy-nine of
Fig. I. — Showing, a, the epicardial opening of the >.hannel extend-
ing through the outer wall of the right ventricle; b. stnall opening
entering into the descending branch of right coronary artery, which
is closed by a thrombus higher up.
apoplexy, the mother was living at the time of the pa-
tient's death, but I have since learned that she fell over
and died suddenly at the age of seventy-four. There was
no autopsy, but the cause of death was ascribed to organic
heart disease. The personal history of the patient is un-
eventful. He has never had any illness of any kind, except
measles and whooping cough at an early age. His habits
were good, and he denied venereal disease.
The patient was a rugged individual, weighing 180
pounds, five feet nine and a half inches in height, very
muscular. The chest was broad and symmetrical, expansion
equal on both sides, apex beat visible and strongly palpa-
ble in the fifth intercostal space, just inside of the nipple
line. The superficial cardiac dullness was not increased,
the heart's action was regular, there were no murmurs, the
pulse seventy per minute and of good volume, tension
about normal. There was a slight radial arteriosclerosis.
The temporal arteries were somewhat tortuous. There
was some tenderness of the sixth and seventh intercostal
nerves on the left side; deep pressure on these nerves
caused considerable pain radiating to the side of the chest
and back. Aside from the conditions just mentioned the
physical examination was negative. Analysis of the urine
revealed nothing of importance.
I advised the patient to give up his work for a few
days and rest, also directed him to apply counterirritation.
over the tender area, which he did, with the result that he
was entirely relieved from the pain. In fact he told me
that he felt perfectly well on the second day after he saw
me, and undertook to do some light work about the farm
On the morning of the third day he was suddenly taken
TURh UJ- HtART. 199
with an excruciating pain in the cardiac region where he
had previously felt the pain. This was sharp and cutting
in character and continuous. I saw him about half an
hour after the onset of the paroxysm, and found him walk-
ing about the house in great agony. There was apparently
no dyspnoea, and he complained of no shortness of breath,
no dizziness, nausea, or vomiting. On examination I found
the pulse to be 55 a minute, of good volume, and not
easily compressable. Respiration was 20. The apex beat
was visible in the same place where I had located it three
days before. The area of superficial cardiac dullness had
increased considerably since I saw him, and repeated ex-
amination showed a continuous extension of this area.
The apex beat gradually disappeared. I gave the patient
% grain of morphine hj^podermatically, which I was obliged
to repeat in three quarters of an hour, also applied an ice
bag over the heart. The patient became quiet, but he
stated that the pain continued. As time elapsed the pulse
became slower, and was easily compressed. Respiration
was shallow and gradually diminished, death taking place
in one hour from the time of onset of the pain. The area
of dullness in the cardiac region at the time of his death
had extended one inch beyond the right sternal line, two
inches to the left of the nipple line, upward to the lower
border of the second rib and downward below the sixth
rib.
Autopsy. — At the post mortem examination the peri-
cardium was found enormously distended with a haemor-
rhagic exudation in which there were a few small masses
of clot. The myocardium of the left ventricle was firm,
but of a pale waxy color ; some parts of it were covered
with a thick layer of fat. The outer wall of the right
ventricle was less firm, in -onie places spongy; the appear-
ance of the tissues were of a pt'culiar pale color, especially
about the base of the papillary muscles; the tissue had a
Fig. 2. — Showing the endicardial opening of the channel with a
sound passing through into the right ventricle.
grayish, translucent and gelatinous appearance. This ex-
tended in places into the- tissue of the myocardium for a
considerable distance, and \va- especially marked towards
the base of the right ventricle. This pallor and translucent
appearance was in some places associated with hsemor-
200
ROSENBERGER: NOMA.
[New York
Medical Journal.
rhagic infiltration. The condition of the myocardium was
confined almost entirely to the outer wall of the right
ventricle; there was an area 1.5 by i.o cm. situated
near the base where the muscular tissue was substituted
by a pale spongy tissue, in the centre of which was an
opening horizontally oval, 8 mm. by 4, e.xtending
Fig. 3. — Vertical transection tlirough the tissues surrounding llie
rent in the outer wall of the riglit ventricle slightly magnified, a,
Hole through the ventricular wall showing ragged margin, b.
Broken down muscular tissue with infiltration of blood, c, Re-
maining heart muscle in various stages of degeneration, d, Portion
of a bloodvessel showing thickened intima.
obliquely upward through the muscular wall into the right
ventricular cavity, the inner opening being somewhat
smaller and surrounded by a dark brown discoloration.
The channel was empty, the tissues immediately surround-
ing the rent were discolored by considerable extravasation
of blood. One and a half cm. to the right and
I cm. below the opening just described there was another
small opening entering into one of the branches of the
right coronary artery and" extending upward i cm. At
thi.s point there was a complete obstruction of the vessel
by a thrombus. Below the opening the vessel was empty.
The muscular tissue of the heart adjoining the rupture
was undermined, very soft, shredded, and discolored, due
to more or less infiltration of blood. The coronary arteries
appeared diffusely opaque, and were hard and resistent ;
on slitting them open the walls were found to be much
thickened, and the lumen very small in some parts of the
Fig. 4- — Showing fragmentation of the muscular tissue and infil-
tration of blood at the margin of the rent through the ventricular
wall.
larger branches. In others there were aneurysmal dilata-
tions with extremely thin wails. This was the condition
where the obstruction was found, the portion of the vessel
wall surrounding the thrombus was more than double the
thickness on one side that it was on the other; while its wall
was extremely thin below the thrombus, where the rupture
had taken place.
There were no marked changes in the endocardium aside
from those described. In the aortic valves the tissue about
the corpora arantii was somewhat thickened and the
nodules enlarged. There was no marked infiltration in
any of the valves and they retained their translucency.
Microscopical Examination.— Tht muscular fibres of the
anterior wall of the right ventricle showed various de-
grees of degeneration; in the slightest changes they ap-
peared somewhat swollen; diffusely stained, their nuclei
did not take on stain readily or not at all, and in many
places had disappeared. There were frequently large
vacuoles and infiltration of fat throughout the sections.
Surrounding the rupture there was every degree of change
to total necrosis of the muscular fibres, which in-
volved the entire thickness of the wall of the ventricle.
In some areas there was an entire substitution of detritus
and infiltration of blood, with an occasional fragment of
heart muscle for the normal tissues of the heart. Although
the condition of the myocardium was confined almost en-
tirely to the right ventricle, there was considerable fatty in-
filtration throughout the muscular tissue of the heart and
marked sclerosis of the coronary arteries.
Unfortunately the case is not a complete one, as
a post mortem examination of the heart only was
permitted.
In conclusion I may say that the rupture of the
ventricle was a natural consequehce following the
endarteritis obliterans, the cause of which cotild not
be determined.
NOMA.
A Bacteriological Study of Seven Cases.
By Handle C. Rosenberger, M. D.,
Philadelphia,
Assistant Professor of Bacteriology, Jefiferson Medical College; and
Director of the Clinical Laboratory of the Philadel-
phia Hospital.
The question of , specificity of any certain organ-
ism bringing about the affection known as noma
is apparently as far from settlement at the present
day as it was some years ago. To some observers
it seems certain to be due to one organism. A num-
ber of investigators have isolated different bacteria
from the lesion, and each thought the bacterium spe-
cific, but others working along the same line of in-
vestigation have failed to prove these statements.
Numerous investigators have described a condi-
tion similar to noma in calves (Lofller and Lin-
gard), in oxen (Bang), in monkeys (Lingard,
Blackwood, and White), and in rabbits (Schmorl,
Zentralhlatt fitr Bakteriologie, xxi, 1890). As re-
gards the pathology of the affection, most observers
have noted the transition from ulcerative to gan-
grenous lesions, and Kraus (Nothnagel's Specielle
Pathologic und Therapie) mentions that Taupin in
1839 stated that ulcerative and gangrenous stomati-
tis were essentially the same in nature.
Schimmelbusch's work in this connection is well
known, as is also the assertion of Lingard that an
organism isolated by him is specific for this affec-
tion. Perthes (Archiv fi'ir klinische Chirurgie,
1889) sets forth the assumption that noma is a my-
cosis which develops on the basis of some acquired
predisposition, such as measles or typhoid, and
caused by an organism which stands between the
bacteria and threadlike parasites and should be
grouped as a streptothrix. He has demonstrated in
the diseased tissue the "streptothrix" of notna in
February i, 190S.]
ROSENBERGER: NOMA.
enormous threads, which in turn give oft finer fila-
ments, often dichotomously. The projecting fila-
ments have a spirillum form, and the finest mycelia
are found on the boundary line, and in the necrotic
parts only thicker threads are seen and in small
numbers.
Hermann {Archiics of Padiatrics. Xovember,
1905), in dealing with the aetiology of noma and
after analyzing the article of Seiffert and Perthes
(Verhaiidlungcii der inedizmischen Gesellschaft zu
Leipzig, 1897 to 1901), alleges that the threadlike
organisms found in the disease belong to the spiro-
chaetae, which he asserts have such unusual charac-
teristics that it would seem better to consider them
a separate family.
Comba {Jahrbuch fiir Kinderkrankheiten, li, p.
591) believes that noma is always secondary to an
ulcerative stomatitis, and that the process begins
from without. The gangrene is due to the action
of the saprophytes normally existing in the mouth,
and becoming pathogenic under favorable condi-
tions.
Jensen {Handhuch der pathologischen Mikro-
organism, II) fotind a bacillus which he named the
Bacillus 7iecroseos, and which has been found in ne-
crotic processes in the horse, cow, pig, kangaroo,
ape, stag, antelope, and rabbit. This organism, the
Bacillus necroseos, Jensen asserts, is identical with
Salomonsen's Bacillus necroseos, Loffler's Bacillus
diphtherias vibiilorum, Bacillus necrophorus of
Fliigge, and the Streptothrix cuniciili of Schmorl.
Krahn (Mittheilungen aiis den Grenzgebietcu
der Medizin und Chirurgie, VI) found comma
bacilli at the boundary of necrotic and reactive tis-
sue. He was unable to cultivate these comma
shaped bacilli.
Weaver and Tunniclif¥e (Journal of Infections Dis-
eases, January, 1907) summarize their findings in
the necrotic tissue of the cheek in noma as follows :
"There is some leucocytic invasion with fusiform
bacilli and spirilla, similar to those seen in smear
preparations made from the nose and mouth before
death and from the necrotic tissue of the face imme-
diately after death. Both forms are present in
both the necrotic and living tissue, the spirilla
forms apparently being in excess in both places.
The thrombosed vessels contain fusiform bacilli,
filaments, and spirilla. They believe these organ-
isms are the threaded and spiral forms of one or-
ganism which correspond to forms shown by thein
to occur in pure cultures of fusiform bacilli."
Lingard {Lancet, April 14, 1888, p. 159) asserts
that the essential character of the organism of noma
is the same in human, monkey, calf, and horse. It
consists of long threads, the individual threads be-
ing made up of small bacilli of various lengths, and
are found at the line of extension of necrotic
patches in great numbers. The inoculated disease
is characterized by appearances precisely similar to
those seen in the original malady.
Levi and Sailer {Archives of Pcediatrics. 1905, p.
476) report a case of noma following typhoid fever
in which a pure culture of the Klebbs-Loeffler
bacillus was found. Antitoxine did not give any
benefit.
Moser {Medical Record, February i. 1902. p.
170) records finding protozoa in three cases of
noma ; they were small, oval bodies, little larger
than a red blood cell, and were very lively in their
movements.
Bruce {Lancet, October 12. 1907) mentions a
case of \'incent's angina involving the larynx and
trachea, occurring in a man, aged forty-seven. The
patient made no complaint of his throat, but was
suddenly seized with obstruction to respiration.
Laryngotomy was performed, and examination of
fauces showed sloughing of the uvula and the edge
of the soft palate, and later extended to both sides
of the neck. The bacillus of \'incent was present
in large numbers, but no spirilla were observed. (It
might be mentioned that a mild degree of pyorrhoea
alveolaris was present, which might have been the
Illustration from a case of noma, which was bilateral from its
inception.
Starting point of the widespread gangrenous pro-
cess.)
Blumer .ind MacFarlane (American Journal of
the Medical Sciences, Xovember, 1901), in an epi-
demic of measles, at the Albany C3rphan Asylum,
met with sixteen cases of noma. These cases af-
fected the mouth, vulva, rectum, and other parts.
In nine cases studied bacteriologically, the colon
bacillus was found in all. Besides the colon bacil-
Itis was an organism that resembled a leptothrix.
Pus cocci, and occasionally the Streptococcus pyo-
genes, w'ere also present in some instances. These
organisms w-ere encountered in spreads, and sec-
tions of one case studied bacteriologically showed
the same bacteria.
202
ROSEN BERGER: NOMA.
[New York
Medical Journal.
Freynmth and Petruschky {Deutsche ■ medi-
zinische Wochenschrift, 1898, No. 15), in a case of
noma genitalium, found true Klebbs-Loeffler bacilli,
and while stating that all cases of noma are not due
to this organism, it is well to make a careful bac-
teriological examination, as the bacillus producer
necrosis and poisons and associates with putrefy-
ing bacteria.
Grawitz (Deutsche mcdisinische Wochenschrift,
1890, p. 318) reports a case of noma following
typhus, in which a bacillus was the only organism
present. (No specific description of this bacillus
was given.)
Foote (American Journal of the Medical Sci-
ences, cvi, p. 198, 1893) found few long bacilli in
groups which stained by Gram's method in
spreads made from the lesion while in the tissue,
single bacilli often end to end and in filaments were
encountered.
Bruning (Jahrbuch fiir Kinderkrankheiten, Ix,
p. 631, 1904) reports four cases of noma, in which,
in two cases, a cladothrix was obtained in spreads
and also in the tissue. Inoculation into animals
did not produce any lesions whatever.
Walsh (Proceedings of the Pathological Society
of Philadelphia, June, 1901) found true diphtheria
bacilli in a case of noma, and likens the process to
moist gangrene, where a saprophyte produces the
putrefaction and a parasite produces the necrosis.
He concludes that, whenever other pathogenic mi-
crobes capable of producing necrosis are found, it
is possible that they may be the primary excitants.
Fischer (American Journal of the Medical Sci-
ences, April, 1902) mentions a case of noma in
which a nonpathogenic staphylococcus and a pleo-
morphous nonpathogenic bacillus which resembled
the Bacillus diphtheric^ were obtained. Hofman
and Kusser (Miinchener medisi'nische Wochen-
schrift, October 25, 1905) succeeded in isolating a
bacillus 4 to 5 micra long and 0.8 micron in thick-
ness, which in fluid media formed chains up to 40
micra in length. Spores were abundantly devel-
oped in forty-eight hours, and the organism grew
well upon all ordinary culture media.
When noma follows some acute infectious dis-
ease, as typhoid fever, the specific organism of that
disease may be isolated together with other bacte-
ria. Such a case is reported by Ravenna (// Poli-
clinico, May and June, 1904), in which the Bacillus
typhosus was isolated from the blood as well as
from the gangrenous areas. A large number of
observers have isolated bacteria which morphologi-
cally and tinctorially resemble the diphtheria bacil-
lus.' Upon further study of these bacilli, some were
virulent, while most of them were of the pseudo
or nonvirulent type of the organism.
The seven cases collected by the writer include
one following typhoid fever and six following
measles. Spreads were made from all the patients
during life and aftei* death. The bacterial flora
observed in all the cases was so similar that a gen-
eral description will suffice. Foremost and most
abundant was the spirillum and fusiform bacillus of
Vincent ; next in frequency were diphtheria like or-
ganisms, streptococci, staphylococci, and, in a couple
of cases, pneumococci. As just mentioned, the fusi-
form bacillus and the spirillum of Vincent were the
most abundant organisms present in the smears.
In four cases inoculations were made upon agar,
blood serum, bouillon, egg medium (Dorsett). The
tubes were incubated, and the resulting growth con-
sisted principally of an organism resembling the
Bacillus diphtheriic. It, showed granular and bead-
ed forms which were quite pronounced with An-
drade's stain, was Gram positive, and in a few
spreads some few organisms responded positively
to Neisser's stain. Together with this bacillus was
an organism that resembled the pneumococcus and
a few streptococci.
The bacillus was isolated in pure culture and
inoculated into the flank of a guinea pig. Three
days afterward, an apparently painful swelling of
the inoculated part was noticed. The animal did
not move about with its accustomed vigor and was
irritable when handled. On the fifth day the ani-
mal appeared to suffer considerably and got about
the cage upon three legs. Loss of appetite super-
vened, emaciation set in, and the animal was killed.
At this time the swollen area had broken down and
an ulcer, or, more properly, a slough, 3.5 cm. in
length and 2.5 cm. in breadth had formed. Spreads
and inoculations were made from the slough and
from the heart's blood. In the spreads the bacillus
originally isolated was found, together with an or-
ganism resembling the pneumococcus. In the cul-
tures from the slough the same two organisms were
obtained. After obtaining a pure culture of the
bacillus, 2 c.c. were inoculated into the peritoneal
cavity of a guinea pig, but no toxic action was ever
noticed.
The fifth case was interesting principally on ac-
count of the extent of the gangrenous slough and
its bilateral aspect. The following short resume is
from the notes of the case given the writer by Dr.
Frederick Johnson, then assistant chief resident at
the Philadelphia Hospital:
The infection followed measles and was distinctly bi-
lateral from its inception, never showed any demarcation
tendencies ; latent visible signs of gangrene ; apparent free-
dom from pain ; remarkable preservation of strength and
ability to take nourishment until twelve hours prior to
death ; four thousand units of antitoxine of diphtheria
given after first cauterization of the area, without any
benefit ; lungs remaining clear until the end.
At autopsy, inoculations were made upon differ-
ent culture media and the same organisms were re-
covered as during life ; the diphtheria like organism
and in spreads the symbiotic organisms of Vincent.
The sixth case was one following typhoid fever;
in spreads the same bacterial flora was observed,
enumerated in the .other cases. No organism re-
sembling typhoid bacillus was ever demonstrable in
spreads or in cultures.
The seventh case was one involving the groin.
Spreads from this area of gangrene showed enor-
mous numbers of micrococci and long, wavy fila-
ments and spirilla like organisms. Anaerobic cul-
tivations were made, and an organism resembling
the Bacillus nccroseos as well as micrococci were
obtained.
In sections of tissue made from four cases, in
two no organisms were seen except large emboli
made up of micrococci. In the other two cases
SMITH: EUROPEAN SURGICAL CLLMCS.
203
enormous numbers of wavy and spiral, Gram nega-
tive, filaments were present together with micro-
cocci and streptococci. Together with these was a
small number of diphtheria like organisms. • All
these bacteria were best seen in the necrotic tissue,
though a goodly number were seen penetrating into
the healthy tissues.
These studies simply confirm the observations
made by the majority of investigators, that no spe-
cific organism has as yet been isolated in this con-
dition. I prefer to refer to the diphtheria like or-
ganism isolated by me as a pseudodiphtheria
bacillus rather than to call it a true diphtheria
bacillus. The reasons for this are that upon agar
the growth was exceptionally abundant and the
growth lacked the typical cream colored colonies as
are so typical of the true diphtheria bacillus. It
also was wanting in its toxic properties, as well as
the subcultures upon various media. It is well
known that the fusiform bacillus of Vincent is
found in healthy mouths, and it is also a well known
fact that the spirillum of Vincent is also seen in
spreads from healthy persons. In the ulceromem-
branous stomatitis of Vincent both of these bacte-
ria are present and generally in abundance.
It seems to the writer that the affection known
as noma is due to a symbiosis of a number of bacte-
ria, the principal ones of which are the symbiotic
organisms of Vincent. The reasons advanced for
this supposition are that the disease is first evi-
denced by a membranous or ulcerative process ;
that in this stage the fusiform bacillus and the
spirillum of Vincent are present in great numbers;
later, as the process goes on to gangrene, other or-
ganisms like the diphtheria like organism, strepto-
cocci, or other microorganisms, make their appear-
ance, and from this latter invasion toxaemia devel-
ops, and the disease goes on to a fatal termination.
These facts are borne out by the study of these
cases and the bacteriological findings.
In conclusion, I wish to express my thanks to
Dr. Frederick Johnson for the notes of the one case,
together with the illustration of the bilaterial lesion ;
to Dr. J. D. Wilson and Dr. John Funke for one
case each.
2330 North Thirteenth Street.
NOTES ON EUROPEAN SURGICAL CLINICS.*
By Oliver C. Smith, M. D.,
Hartford, Conn.
To the average medical man there is no vacation
more restful and beneficial than a trip to Europe.
The enforced idleness, the fresh air, the cold salt
baths, and good food on a transatlantic steamer fur-
nish the ideal requirements for rest and recupera-
tion.
Most medical men feel, however, that they cannot
aflford to take a long vacation without improving
some of the time in a profesional way. There is
always so much to be learned that it is a natural
temptation to endeavor to combine the requirements
of professional knowledge with rest and pleasure.
Some one has estimated that five thousand Ameri-
*Read before the Surgical Section of the Hartford Medical So-
ciety, September 23, 1907.
can physicians go abroad annually, and that during
the past year the American people have spent $500,-
000,000 in Europe.
It has occurred to the writer that the time has
arrived when a guide book to the European clinics
is an essential addition to the medical man's library.
If Carl Baedeker could be induced to prepare a
careful guide containing the names of hospitals, the
attending physicians and surgeons, the hours for
clinics and operations, and the oportunity at vari-
ous places for courses in various branches, it would
be a great aid to the American doctor who goes to
Europe, especially for the first time.
The American must be prepared to find promi-
nent European physicians and surgeons away on
their vacation during the month of August and
sometimes portions of July and September.
It is expedient, if one has a decided preference
for some operator, to write before leaving America
and learn his plans. It is unwise to travel far with
the hope of finding the operator whom one wishes
to see without previously obtaining information. It
is true that at the large hospitals and clinics the
work must go on, but it is usually conducted by as-
sistants during the weeks before mentioned.
Letters of introduction are a decided aid. In the
absence of these, a card bearing one's name and the
positions, hospital appointments, etc., which one oc-
cupies is a decided help in receiving some degree
of attention at the hands of foreign surgeons.
The route taken by the writer during the past
summer was by Hamburg-American steamer, land-
ing at Hamburg at the end of ten days' delightful
voyage.
Hamburg is a pleasant city, and far from being
a bad place to spend one's vacation/ The Allge-
meines Krankenhaus is a fine, large, modern hos-
pital built on the pavillion plan and well conducted.
Professor Kiimmel and Professor Sich have charge
of the surgical v/ork ; distinguished men in other
lines are also in attendance. A large three story
building is devoted to surgical operations, the
amphitheatre being upon the second floor. The pa-
tients are wheeled from the various pavillions to the
surgical building, thence up an inclined plane to the
operating rooms in comfortable, covered convey-
ances.
As a sample of the amount and character of work
performed in one day, the following list of opera-
tions is quoted : Appendectomy ; pelvic tuberculosis
with removal of both ovaries and tubes; vaginal
hysterectomy under spinal tropacocaine anaes-
thesia; cystic goitre; subdiaphragmatic spondylitis
abscess: resection of knee joint for tuberculosis,
also under spinal anaesthesia.
The work performed at this hospital, to my mind,
fully justifies the favorable comments made by Dr.
Nicholas Senn in an article which appeared in his
interesting series on European travel, published in
the Journal of the American Medical Association.
One could spend a very profitable week or fortnight
at this place, devoting half of the day to the surgi-
cal clinic and the wards of the hospital and the bal-
ance of the day to recreation.
Hamburg is the home of the great Unna, skin
specialist. The writer visited his private hospital.
204
SMITH: EUROPEAN SURGICAL CLINICS.
[New York
Medical Journal.
which is more quaint and antique than attractive,
but the surroundings are impressive when one real-
izes that much of the pathology of the skin was
elucidated on this spot.
From Hamburg to Berlin is a comfortable car
ride of three hours.
Berlin is one of the most rapidly growing, pros-
perous, and modern cities of all Europe. It has
been the home of distinguished surgeons, physicians,
and scientists for many years.
The chair of surgery at the general hospital,
made vacant by the death of von Bergmann, is
now occupied by Profesor Bier, formerly of the
Uni\-ersity of Bonn, who is the author of the hyper-
aemia treatment which bears his name. The writer
was fortunate in finding Professor Bier at his post,
and both heard him deliver clinic lectures and wit-
nessed his operations.
Professor Korter operates at the Krankeiihaus
Urban Mondays, Wednesdays, and Fridays. The
new hospital, only recently built with money left by
Professor Virchow, is some distance from the cen-
tre of Berlin, and was not visted by the writer, but
it is highly spoken of as a modern, up to date insti-
tution, where good work can be seen.
Halle. En route from Berlin to Vienna, the in-
teresting university town of Halle is first reached,
and here Professor von Braman occupies the chair
•of clinical surgery, and is a man well worth meet-
ing. He has a most attractive, kindly face, with
large physique, and lectures fluently and well. It
was the last day of the college term when the writer
visited this clinic, and besides listening to a review
of the work that had been gone over surgically dur-
ing the term, he was" treated to an exhibition of
eighteen postoperative cases, which included a wide
and interesting range of surgery. We were treated
to an interesting lecture by Professor Schwartze,
joint author of the Schwartze-Stacke operation
upon the mastoid. After the lecture he performed
his classical, radical, mastoid operation. During the
college session one could well afford to devote time
to this hospital and observe the work of Professor
von Braman.
Leipsic was next visited : a fine old University
city, the home of Professor Trendelenburg, whom
many of us listened to at the Boston meeting of the
American Medical Asociation. Professor Trendel-
enburg speaks English fluently, is pleased to receive
American guests, and goes out of his way to show
his interesting hospital, his ingenious methods of
teaching, and his operative work. A large collec-
tion of X ray plates are used in the course of in-
struction and thrown upon a screen, the amphithe-
atre being suddenly darkened by automatic sliding
shutters at the ceiling and windows. Specimens and
photographs, as well as Rontgcn ray plates, can be
thrown upon the screen, and api)ear remarkably
clear, lifelike, and distinct.
The writer had the pleasure of witnessing Pro-
fessor Trendelenburg operate on a double hernia,
a multiple suppurative arthritis of traumatic origin :
also a tuberculous ankle, a congenital dislocation of
hip by the open method in a case where the method
of Lorcnz had failed, and an excision of varicose
veins of the lower limbs.
Professor Trendelenburg is a man of large parts.
He is ingenious, bright, and tolerant of others'
teaching, a kindly gentleman and an excellent sur-
geon.
Vienna, the Mecca for the postgraduate in medi-
cine, is reached after a long ride from Leipsic. Many
of you have spent a far longer time at the interest-
ing Austrian capital than the writer.
Certainly there is no one hospital where so many
branches of the profession are taught and prac-
tised with such abundance of material as at Vienna.
The college was not in session, but the surgical
clinics were busy, and the assistants were making
the most of their opportunity.
The work at Professor von Eiselsberg's clinic
was being performed by first and third assistants,
Dr. Clairmont and Dr. Haberer. The former
speaks English and gives excellent courses in sur-
gical diagnosis.
Diagonally across the court is the clinic of Pro-
fessor Hochenegg, made famous during the past
century by the work of Franz Such, Theodor Bill-
roth, and Carl Gussenbauer. Dr. Hans Lorenz per-
formed a large number of operations daily, and gave
place to Dr. Albrecht before the writer's de-
parture. Dr. Lorenz is a remarkably quick and
careful operator. Msitors are welcome to both of
these clinics. A list of the operations can be ob-
tained in the morning, and one can alternate be-
tween the two and witness the procedures in which
he is most interested.
Thorough asepsis is undertaken, and fairly well
executed. Rubber gloves are worn in septic cases
and cotton gloves in the clean cases. The work in
both clinics is accomplished by the surgeons and
assistants and one male steward, no nurses being in
attendance. Silk is almost the universal suture and
ligature material. Continuous sutures are rarely
used. Long incisions are practised, but an apparent
lack of careful exploration in abdominal work after
one lesion has been discovered is occasionally ob-
served. The wounds are never washed after the
operation, it being felt that the blood is a safe seal-
ing agent, and by introducing water contamination
may be invited from the surrounding parts. Anaes-
thesia is usually by chloroform. Local cocaine in-
filtration is practised rather more frequently than
with us.
The following list of operations is a fair sample
of what can be seen at one of these clinics in one
forenoon: i. Cystic goitre; 2. Gastroenterostomy
for tumor of the greater curvature of the stomach ;
3. Aneurysm of the femoral artery ; 4. Radical am-
putation of breast, including cervical, supraclavicu-
lar, and axillary glands and the pectoral muscles,
the large unclosed space being closed by skin grafts,
Thiersch method, taken from the upi)er arm; 5.
Gastrojejunostomy for cancer of the pylorus.
The gastroenterostomies were performed between
the posterior wall of the stomach and the jejunum,
a short distance from the attached portion, this be-
ing performed without clamps, stay sutures being
introduced into the wall of stomach and jejunum to
the gastrocolic omentum. The operation is quick
and simple, but rather hivmorrhagic. the field some-
times soiling from the undamped viscera. The
February i, 1908.]
SMITH: EUROPEAN SURGICAL CLINICS.
205
anastomotic opening made is from one half to two
thirds the size recommended by English and Amer-
ican surgeons.
It is unfortunate for the surgeon that the opera-
tive work comes at the same hour that the autopsies
are being performed in the post mortem building.
Both rooms are so interesting one can ill aftord to
lose either. Professor \\ eichselbaum's official
course during the college year is from twelve to one
p. m., five times weekly. From six to ten autopsies
are performed each morning, it being the law in
Austria that people who die in the hospital come to
autopsy regardless of the station of the patient.
The autopsies are well conducted. All physi-
cians are invited to attend. There is a printed pro-
gramme telling when the post mortems of the re-
spective wards are held. On the desk are the "death
cards," which are numbered. A like number is at-
tached to the great toe of the corresponding cadaver.
The "death card" tells the ward, the name of the
patient, time of admittance, time of death, time
when post mortem will be held, the clinical diag-
nosis, and the name of the clinician. The minutest
pathological changes are noted, and specimens kept
for the gross pathology courses of the afternoon and
for subsequent further elucidation in the laboratory
of Professor Weichselbaum, which is on the same
floor of the post mortem building.
The course in gross patholog}-, conducted four
afternoons each week by Professor Ghon, is most
valuable and interesting. Professor Ghon devotes
his entire time and life to this work. He speaks
rapid Mennese Gemian, but the demonstration of
specimens can -almost be comprehended by one who
does not understand the language.
As many of you know, there is an association
for the American physicians at ^^ienna, which is
most helpful to its members in aiding them to se-
cure what they require in the best and most eco-
nomical manner. The association holds biweekly
meetings, and its members are on the alert to guide
and aid the recent arrivals. The registry is kept
at the "'Cafe Klinik," across the way from the hos-
pital. The round table in the centre of the room is
reserved for American physicians, and one can
gather the information he requires without going
further afield.
At this great Allgemeines Krankenhaus can also
be found Professor Schauter, who, with his as-
sistants, conducts a large gynaecological clinic.
Professor Wertheim's clinic is at the Elizabeth
Hospital, and is most highly commended.
Professor Sukerkandl is found at the beautiful,
new Rothschild Hospital, but a short distance from
the General Hospital. As at other clinics which are
associated with the university, there is more activ-
ity during the college session. It is not always pos-
sible to secure the courses one wishes during the
month of August. For this reason it is better for
those wishing to attend lengthy courses to go at an-
other time, either in the spring, the late fall, or dur-
ing the winter, but by the surgeon or physician on
his vacation enough and more than enough can be
seen daily to repay him for every moment spent at
this institution.
It is to be hoped if Carl Baedeker prepares a
guide for the medical man traveling in Europe he
will add a word of caution and advice as to the con-
duct of the visitor at the European clinics.
It is embarrassing to hear a spectator ask foolish
questions and interrupt the operator, or to see him
crowd closely up to the field of operation without
the prescribed gown and to conduct himself in gen-
eral as if this was his first visit to a surgical clinic.
It is rather surprising, considering the frequency of
such occurrences, that operators are as courteous
to visitors as they are.
The time passes altogether too quickly at \'^ienna.
The balmy atmosphere, the open air gardens, and
the delightful music fill in the time that is not occu-
pied at the hospitals, and round out each day to
completeness.
Switzerland is the ideal country for a summer
vacation. The beautiful scenery, the high elevation,
the clear air, the picturesque lakes, the fine roads
for tramping and motoring are a combination not
found elsewhere in Continental Europe, and the
Swiss are doing excellent surgery.
Berne. The writer for a second time visited the
Kocher clinic at Berne. The elder Kocher was not
at home, but his son was most courteous and will-
ingly exhibited the postoperative cases in the ward
and performed several operations with caution and
skill.
In a case of cholelithiasis, he performed Bernays's
cholecystenditis operation, and remarked that both
he and his father did it frequently, and were sur-
prised that it was not more generally performed.
As a proof of his sincerity he announced that four
years ago this operation had been* successfully per-
formed upon him.
In patients where the gallbladder is not drained
they are allowed to sit up on the fourth and return
to their homes at the end of the tenth day, which
is a decided economy of time, as compared with the
lengfthy course of ordinar}- gallbladder drainage.
The ambulatory treatment for fractures of the
femur was demonstrated, the patients being allowed
to get up within two or three days following the
fracture, the limb encased in plaster, and a thick
soled shoe upon the foot of the well side.
Dr. Kocher reiterated his remarks at the last
meeting of the American Medical Association upon
their thyreoid surgery, and told us that more and
more they appreciated the importance of operating
upon exophthalmic goitre in two or more stages,
ligating the vessels to limit thyreoid secretion be-
fore removing any portion of the gland.
The adage that a prophet is not without honor
save in his own land is exemplified by the fact that
the colleagues of Professor Kocher do not employ
his method in work upon goitre, and it is a matter
of surprise to visitors at the clinics, other than Pro-
fessor Kocher's, to find that his methods are not
carried out.
Geneva. The General Hospital at Geneva is an
excellent institution. Professor Gerard is one of
the most attractive, scientific, and conscientious sur-
geons that it was our pleasure to meet. While there
he was most enthusiastic and courteous in showing
us every detail of the various departments of the
hospital and defining his methods of treatment. He
20,j
SMITH: EUROPEAN SURGICAL CLINICS.
[New York
Medical Journal.
is a strong advocate of postoperative out of door
life. The patients are early rolled out into the gar-
den and there allowed to convalesce.
Tuberculous lesions are treated by the sun's rays,
the af¥ected part being exposed until the skin is
tanned to a dark brown. In no other hospital on
the Continent did we find an operating room so con-
scientiously guarded from the incursion of germs.
Absolutely no one — nurse, operator, assistant, or
visitor — enters the room without gown, cap, and
rubber shoes.
The professor believes this the only way of im-
pressing the importance of such asepsis on the stu-
dent.
One leaves Professor Gerard's company feeling
that he could wisely and cheerfully select him for
his own surgeon.
Geneva now boasts of a remarkably up to date
gynaecological hospital. It is a model in every sense
of the word, scientifically and hygienically, and has
every modern device for the comfort, safety, and
convenience of the patients. The furnishings, espe-
cially the operating theatres, have the latest and
most improved equipments, and are worthy of care-
ful study by one interested in such matters. We
found nothing like it in our travels. It was inter-
esting to know that these excellent aseptic furnish-
ings and appliances were of Swiss make.
To one having the building of a hospital in view,
a visit to this institution would be of great benefit.
Lausanne is the home of Professor Roux, gen-
erally acknowledged to be Kocher's most illustrious
pupil. The writer was disappointed in not finding
him at his work.
Paris. The usual route from Vienna is through
Paris. If one wishes to visit the hospitals or
clinics at this great centre, it is especially desirable
to have a letter of introduction.
There is much excellent, scientific work done at
Paris, but there is some that is not particularly
profitable to witness.
Dr. Fore in gynaecology, Dr. Doyen in general
surgery and gynaecology, and Dr. Albarran and Dr.
Guion in genitourinary work, are all men of great
fame. As a rule, these men are not to be found
at home in the vacation months, but in such a great
centre there is always something of interest.
For instance, at the old I'Hopital St.-Louis there
is a most extensive and interesting museum contain-
ing a collection of wax specimens of cutaneous dis-
eases and Pean's wonderful collection of wax speci-
mens of surgical pathology. One can profitably
spend an entire day at this museum. •
At London, The London Hospital, Whitechapel,
furnishes abundant opportunity for witnessing a
wide range of surgical operations. There are a
dozen operating theatres, mostly in charge of men
of distinction in certain lines, where work pro-
gresses each day in the week except Sunday.
The writer had the privilege of witnessing the
genitourinary work of Mr. Hurry Fenwick at this
institution.
Much may be seen in the same line at St. Peter's,
Covent Garden. It is here that Mr. Frayer per-
forms many of his prostatectomies.
The highest type of brain surgery in Europe is
probablv nerformed by Sir Victor Horsley at the
National Hospital for Epileptics and Paralyzed,
Queen Square, W. C.
At the Children's Hospital, Great Ormund street.
Dr. Lane has an active surgical clinic, and performs
a large number of cleft palate operations.
Bland Sutton can be found at the Middlesex
Hospital, Regent street, W.
Mr. Mayo Robson, well known to us all through
his writings, operates mostly at private hospitals,
and for that reason a letter of introduction is essen-
tial to see his work.
Mr. Hubert V. Paterson, who read a paper in the
stomach symposium at the Atlantic City meeting
this year, operates at the Temperance Hospital. He
does careful, conscientious work, and is very cour-
teous to visitors.
At St. Mary's Hospital, Professor Wright, the
champion of opsonin index theory, may be found.
From what I could learn of his work he is very
much respected by the profession of London.
Liverpool. Probably the most prolific orthopaedic
clinic in England is conducted by Professor Robert
Jones Nelson at Liverpool. The writer did not at-
tend this cHnic, but learned from others who had
that twenty or more operations could be seen each
Wednesday.
Leeds. The visit of the writer to Leeds, a four
hours' ride from London, to witness the work of
Mr. Moynihan, was interesting. Mr. Moynihan op-
erates at the General Infirmary, also at a private
hospital close by. His reputation in biliary and gas-
tric surgery is probably excelled by none in Eng-
land. I think it is fair to speak of him as the Mayo
of his country. He is a dextrous, cool, methodical,
an extremely cautious, and quiet operator. The
contrast between the quiet of Mr. Moynihan's oper-
ating room, where scarcely any one speaks, not even
the chief, to that of some of the operating rooms on
the Continent, is marked, and one is forced to ad-
mire the English habit of speaking softly and work-
ing calmly and quietly.
If asked what is most to be admired and copied
in the work of the European surgeon, the writer
would answer: Their patience in pursuing a long
course of preparation, their accurate knowledge of
anatomy, their familiarity with gross pathology,
their willingness to serve long periods as assistants
before occupying the responsible post of full sur-
geon, and their devotion to the life with but small
compensation.
If asked what features of the work of the Amer-
ican surgeon could be most profitably emulated
abroad, the writer would answer : A more profound
respect for the sacredness of the tissues of the hu-
man body, more thorough explorations in the
abdominal cavity when it is entered, an endeavor at
times to work through smaller incisions, more
prompt haemostasis on the part of the assistants,
more discrimination in the selection of ligature ma-
terial, and greater neatness of technique.
Each may learn from the other ; in years past we
have learned chiefly from them, but at present the
European surgeons are holding us in higher esteem,
and are observing our work with more marked at-
tention and respect than ever before.
44 High Street.
GOLER- MILK AND EDUCATION.
207
MILK AND EDUCATION.*
l-iv (iKOKGE VV. GoLER, M. D.,
Rochester, N. Y.
A woman was complaining on one occasion to Dr. Osier
that Providence had seen fit to take her little child, when
the doctor interrupted with the remark, "Providence had
nothing to do with it ; it was dirty milk." — John Mason
Knox.
Early, very early in the mornini^-, and ac;ain late
in the afternoon in thousands of barns in everv
State in the Union thousands of mileh cattle are
milked every day in the year in order to supply the
millions of people of this great country with milk.
Of these millions of people ten millions are children
under five years of age. In round numbers, down in
New York nearly half a million ; in Boston, 6o,ooo ;
in Philadelphia, 140,000 ; in Chicago, 200,000 babies
under five years of age, all dependent upon milk for
food. Ten millions of babies and many millions of
people, some of them sick, must have this milk pro-
duced daily from the bodies of all these thousands of
animals.
"From these statements one w ould be led to think
that the education and training of those intru.sted
with the production, transportation, and distribu-
tion of milk would be made the subject of the State's
greatest care. For are we not taught that the State
depends upon the physical, mental, and moral wel-
fare of its children for the perpetuation of the
nation ?
Do we see evidences of that care that milk de-
mands by either the producer or the retailer ? Does
the producer handle his milk carefully, care for his
utensils properly, store and transport it carefully,
protect it at the railroad depots and provide for
icing it on trains? Does the producer or the retailer
clean his cans or utensils as they oughi to be
cleansed? Does he keep the milk cold, or does he
substitute pasteurizing or preservatives for ice ? Is
there even provision for determining what percent
age of the milch cattle are subject to tuberculosis?
What man may enter the business of milk produc-
tion? Has he training? Does he enter the hufiness
of dealer in the most perishable of foods with that
education and training which these millions of in-
fants have a right to demand for their protection,
and which we, the State, should demand for them ?
They can neither speak nor vote as we men can
vote or as both men and women can speak.
Inspection of milk and the protection which it
should insure are both sadly lacking.
Is there a model farm where the dairyinan may
see and learn how he ought to produce and handle
his product with financial advantage to himself and
sanitary advantage to you? Is there a model dairy
where the retailers of milk may learn how best to
handle milk and how best to clean and keep clean
milk and milk utensils? The men who work as bar-
bers, the men who cut your corns or bunions, the
/men who bury your dead must all pass examinations
before they can receive licenses to do these things,
but the men who produce or who sell inilk to the
millions of babies in the United States of America
are, as a class, without education or training in the
simplest rules of cleanliness and by a mere declara-
tion and on payment at most of a dollar or two may
•Read before the New York State Sanitary Commission at Buffalo.
purvey food to your children. With this food mil-
lions of germs are frequently found in every tea-
si)oonful. The germs of tuberculosis, typhoid fever,
and diphtheria, the poisons of scarlet fever are but
too often conveyed from the faraway farm or the
family of the retailer to the children of the State.
When will we as a people awaken to the necessity
for clean milk? Not so much because milk may
cause the death of many infants, but because of the
danger of disease in the years of the child's forma-
tive state, when the energies of the body should be
used for growth, and not for resisting disease carried
to it by rnilk.
In the countries of Europe the subject (jf milk as
food for babies has received much attention within
the last decade. Abroad they have begun to realize
that the character of the milk supplied to the babies
is of importance because milk is almost the sole
food of the baby. They have found, as in Berlin,
for instance, that in 1895 45 per cent, of their in-
fants were breast fed, but that in 1905 the number
of breast fed children had diminished to less than
33 per cent. We have in this country to-day, on
the authorities of special workers in children's dis-
eases, less than 25 per cent, of mothers in affluent
circumstances who are able to nurse their children.
Other evidence could be adduced to show that the
number of naturally suckled children is diminishing,
and this being the case, we are compelled to fall back
upon the cow, to make our babies parasites upon a
four footed board faced animal who may furnish
excellent food for a calf, but only at the very best,
indifferent food for a human baby.
Cows' milk, even chemically, is ai best poor food
for a human baby. It clots in larger and more in-
digestible lumps than woman's milk. It has a dif-
ferent fat, albumin, and sugar content than human
milk. With all the skill of the most scientific treat-
ment, it is both chemically and physiologically unfit
for a human baby. Artificial treatment, prediges-
tion, gruel mixtures, make it poor indeed in com])ari-
son with human milk. The only way to make cows'
milk fit for a human baby is to feed it into the diges-
tive tract of the human mother, in whose system it
should be elaborated for her baby into human milk
droplets from her breasts.
But we have before us the ]:)roblem of 75 per cent,
of our nurslings to be fed b\- the cow. We know
the foul, dark, ill ventilated, dirty stables, the dirt\-
cows and cans and utensils, the fiies, the swarms
of bacteria in the artificial food of the baby. We
know of the poor makeshifts, the strainers, the temp-
tation to condense, cook, and pasteurize, and other-
wise "ize" this food, and all the time those of us
who are striving to teach the value of clean milk are
learning the lesson of depopulated France, Germany,
and other European countries, viz., that the most
precious thing in the world is the human baby. We
are learning this lesson, not yet perhaps as the\"
have learned it, because in Europe the mothers bear
children, and, bearing children, attempt to rear them,
but here our native American women no longer
bear children as they once ditl, and so, as we im-
port raw products of other kinds, we are now begin-
ning to import most of our mothers.
But if we have not a large proportion of native
born children, let us tr}- to keep those we have and
208
GOLER: MILK AND EDUCATION.
[Neu York
Medical Journal.
all Other children alive and well. Let us try to- realize
that the bab\- is a future citizen. Let us try to look
upon the protection of the milk supply as one of the
greatest measures of protection for these citizens.
Milk is secondary in importance only to water. All
people may and should join in protecting tliis great
food supply. The physician especially may do nuich
to advance this work if he will acquaint his patients
with the necessity of procuring clean, cold milk, un-
changed by any Pasteurizing or so called concen-
trating process, and for protecting that milk by
cleanliness and by icing, both before and after it
reaches the consumer. The physician can assist in
the establishment of milk stations throughout the
city. Especially should such stations be established
in connection with hospitals, particularly in those
hospitals where clinics are held, so that the nurses
in charge of the work and the physicians and stu-
dents attending- the clinics may observe the value of
clean milk in the artificial feeding of infants. It is
notorious that hospitals, as a rule, have the worst
of milk supplies. It is supposed that their drugs
are pure. Do they pay less attention to their milk
than to their drugs ?" A patient becomes sick, the
physician puts the patient upon a milk diet. How
often docs he know whence the milk comes, and
whether it is clean or dirty? The importance of
•milk as food for older sick people is considerable,
hut of how much greater importance is it when the
rnilk is to become food for infants ! The results
obtained from systematic milk inspection and
through the work of milk stations are remarkable,
hni still more remarkable are the results shown in
the figures taken during the last three months in
Rochester, where all the deaths in infants under one
year of age have been investigated with reference to
W'hether the infants were breast fed or artificially
fed, and if artificially fed, what was the standard of
the milk obtained for their food.
During the months of Julw August, and Septem-
ber, the months of heaviest infantile mortality, there
were 144 deaths in infants under one year of age.
Of these (excluding four less than forty-eight hours
old) twenty-two were breast fed. 122 bottle fed, and
of these 122 bottle fed chidrcn who died during
those three months not one of them receiyed a really
safe milk supply.
It may be fairly assumed that the breast fed in-
fants of the alleys have a far greater chance for life
than their artificially fed brothers or sisters of the
avenues. The children of those i)arcnts in affluent
circumstances, when artificially fed, have a greater
chance for life than the child so fed in the slums,
or the carelessly fed child of a higher social grade.
Artificially fed infants will thrive Ix'tter on clean
cows" milk in hot weather than on dirty milk in hot
weather. They will even do better on home Pas-
teurized or sterilized dirty milk than when fed on
untreated dirty milk, but they will also do far better
if artificially fed on clean, uncooked milk than on the
best kind of commercially Pasteurized or sterilized
•milk.
I*"igures for ten years show that infants do not die
as frequently in cold weather on dirty milk as in hot
weather. Else why do they not die in such great
numbers in January as in July? The infant will
stand dirty milk and cold, and it will endure heat
alone, but it will not endure dirty milk and heat to-
gether. Clean, cold .milk is the great necessity for
the artificially fed baby. How many cities have clean
milk — milk that can be trusted as a food for infants?
Do you know of one city? How many cities have
cold milk? Do you know of one? There are at
least ten such cities. These are the cities that have
a milk ordinance requiring milk to be delivered un-
der 50° F. New York, Boston, Brockton, Los
Angeles, Detroit, Cleveland, Cincinnati, St. Louis,
St. Paul, and Minneapolis have such an ordinance.
Xo city in New York State but New York City.
Why? How many cities are feeding milk from
tuberculous cattle, feeding it to their men and
women with perhaps sufficient power to resist the
disease, but feeding it as well to their infants who
may grow up to become patients in the sanatoria for
tuberculosis that are to be built for their reception
in the future? The only cities buying milk from
tuberlin tested cows are Grand Rapids, Mich ; Min-
neapolis and St. Paul, Minn. ; Montclair, N. J. ; Den-
ver and Colorado Springs, Colo. ; Brookline and
Lynn, jNIass. ; Milwaukee, Wise. ; and Pasadena,
Cal. Why?
It is not until such questions as these have been
answered by the public and until the facts which
the answers to such questions should call forth have
been made known to the public that we shall im-
prove the condition of the milk. The improvement
of the milk supply depends not only upon the educa-
tion of the public, but upon the education of the
milk producer and the milk retailer. The milk pro-
ducer should be a trained dairyman. The State
should have before him as schools of reftrence to
which he may refer a number of model farms.
All the operations of dairying should be carried
on on these farms, and should include the best
method of preparing the soil, planting, gathering,
and housing crops, selection of cattle, the housing,
storing, and transportation of milk. For the further
advantage of the milk producer a system of book-
keeping should be so simplified as to show the opera-
tions of such farms. If the State should tstablish
such farms, it would be unnecessary to provide new
houses and new buildings. It would be a great deal
better to secure old, partly run down places with old
l)uildings, and bring these into the highest state of
efficiency so that the small milk producer could learn
how to iniprove his own place without going to the
expense of new buildings.
Even cities coulcl well conduct model farms with
new buildings in connection with the park system,
where a day nursery might be conducted in the park,
and where the cows might supply milk for such a
luirserv. For the benefit of every producer and re-
tailer every health department should haye a system
of milk inspection so arranged that the premises of
the producer and those of the retailer arc subjected
to regular, quarterly inspections and the result of
those inspections entered upon a score card in trip-
licate so that each record of inspection might be
furnished to the health office, the producer and the
retailer. Upon the score card used for the retailer
all of the data should be gathered necessary to make
a ready reference relating to the retailer's premises,
the score of the producer's premises, the bacterial
count, and a rough diagram of the milk room so that
in conversing with the retailer the inspecting or li-
censing officer might have all the information in his
February i, 1908.]
IVrLE: TUBERCULOSIS IN MEDICAL STUDENTS.
hands at a time in condensed form on a single
sheet.
For the further benefit of the retailer there should
he in every health office a model milk room in actual
operation, consisting of a steam boiler, sinks, with
hot and cold water, and a sterilizing box where the
retailer might see and learn how to adapt the sim-
plest principles of cleanliness and of can and utensil
sterilization to the public needs.
Then, with the. introduction and operation of a
licensing system, the enforcement of a milk ordi-
nance by law that should provide imprisonment for
a second offense, no man should be permitted to send
milk into the city until the licensing authority had
been satisfied with the premises of his producer, the
health of his cows, and the cleanliness of all his ap-
purtenances ; that the cows had been subjected to a
tuberculin test, and that the shipping facilities of
the railway would insure the milk being kept cold.
The retailer, too, should be compelled to show his
ability to comply with the ordinances before being
permitted to sell milk. These are the rules that
must be lived up to if we are to protect the food of
our children.
We live in a great country, the people of which
approach the highest civilization the world has ever
seen. Since the Civil War all the arts and sciences
have attained the most wonderful development.
Everything in this great country of ours is so new
that if we pause and look out upon the achievements
of our people it might almost seem as if we had been
transplanted into a new world, where, fairylike, a
new order of living had been made possible in part
of the cycle of the life of man. New modes of com-
munication at a distance, new modes of travel, the
work of man manifolded by wonderful machines,
new plants, the earth's products quadrupled ; all
these until men, women, and children have become
mere machines.
While we are growing new grains, grasses, fruits,
and vegetables, we are cultivating, weeding, and
protecting them. What are we doing for our chil-
dren ? Are we cultivating them ? Are we doing for
them what the agriculturist does for grasses, fruits,
and flowers? Are we even in their formative state
giving them decent food ?
The subject discussed here is part of a great social
question. Upon the feeding and the training of our
children we must depend for the stability and
strength of the home and of the nation. The chil-
dren of to-day are to be the parents of the future.
To be strong, to be good parents, they must be well
fed. What are you going to do for the protection
of their most necessary food ? Will you leave it as it
is, practically unprotected, or will you insist upon
the enactment of laws for its protection, and the en-
forcement of the laws after they are enacted?
127 East Avenue.
TUBERCULOSIS AMONG MEDICAL STUDENTS
AND ITS POSSIBLE PREVENTION.
By Udo J. Wile, M. D.,
New York.
The prevalence of pulmonary tuberculosis among
medical students and those engaged in the practice
of medicine is a well known and long recognized
fact. The records of private sanatoria for the cure
of tuberculosis show that a very considerable per-
centage of all patients are drawn from these walks
of life. .Setting aside that group of cases in which
there is a previous history of tuberculosis, and that
group in which there may be inherited predisposi-
tion, there remains a large number of cases in which
the infection has been accjuired during the course
of study, and where perhaps it can be traced to di-
rect carelessness or ignorance on the part of the
student, or lack of protection incommensurate with
the exposure to which all students of medicine are
necessarily subjected. This last group of cases,
therefore, would seem justly to be called preventable
cases, and it is the purpose of this paper to point out
briefly the probable sources of contagion in such
cases and to suggest measures whereby .such cases
might be prevented.
During his medical course the student is exposed
to tuberculous infection, as well, of course, to other
infections, in three places, namely, the clinical
laboratory, the post mortem room, and the ward.
I have purposely left out the special dispensaries for
tuberculosis, as here the danger seems to be well ap-
preciated, and elaborate precautions against the
spread of infection are usually observed. Likewise
in the bacteriological laboratories the danger is
probably minimal, for the student in bacteriology,
in order to avoid ordinary contamination, must ob-
serve a technique which of itself does obviate any
possibility of infection from the organisms studied,
if that organism be the Koch bacillus.
Obviously the best time to warn the student
against exposing himself uselessly to tuberculous
infection is early in his course. Therefore, as soon
as the entering classes in medicine are enrolled they
should be gathered together, and some one of their
teachers should address them, explaining the neces-
sary and unnecessary dangers to which they may
be exposed in their ensuing four years of work and
thereafter. They should be strongly advised against
overwork, underexercise, and overstimulation. Too
often these are the causes which break down the
normal resistance and render the student, perhaps
late in his course, a fit subject for infection with
the tubercle bacillus. Secondly, should be pointed
out to the new student the widespread incidence of
slight tuberculous infection among healthy people —
in other words, the German view, '"J^der Mann hat
am Ende ein weinig Tuberculose." To many this
will undoubtedly serve as an added warning against
risking an already infected, although latent, process
to further infection. Thirdly, the proper hygiene
of life, which, after all, is the best prophylaxis,
should be strongly emphasized. Unfortunately in
large cities, where clinical opportunities are good,
proper hygienic surroundings for the student are
not equally good. He should be urged, however,
to spend at least one hour each day in the open air,
to retire and to rise at regular hours, the morning
to be well initiated by the cold tub or sponge.
Using his mind constantly, the student should,
above all things, have good food, and it is indeed
poor economy to frequent, as many of the students
do, the cheap boarding houses usually found in the
proximity of the hospital or college. House infec-
tion is without doubt a factor in some of the cases
2IO
OUR READERS' DISCUSSIOXS.
[New York
Medical Joi-kn-m..
of tuberculosis developing among students, and the
new student should carefully question his landlady
as to his predecessor, and, in any event, before en-
tering it as his own, he should insist upon having
the room fumigated, or at least thoroughly scrubbed
from top to bottom. One evening a week for the
theatre, or any other preferred diversion, is an ex-
cellent rule for the student to follow throughout
his medical course, and if he can be urged to take
Sunday off besides, away from his books, it would
be much better, and, I believe, a real gain in his
working capacity. Having pointed out these things,
the new student should be reminded that, despite all
precautions and advice, a few cases of tuberculosis
will undoubtedly occur in his class, but that these
would probably occur in the same proportion in any
walk of life, and should cause no special alarm.
To return to the places where the student will
necessarily be exposed, we may first speak of the
ward. The chances of contamination are here very
obvious. One patient suffering from tuberculosis
may, through his own ignorance, or the neglect of
those who should know better, contaminate an en-
tire ward with tubercle bacilli. To minimize this
great danger all patieiits who cough, no matter
from what cause, should be instructed to cover the
mouth with a piece of gauze, thus lessening the
chance of droplet infection. These pieces of gauze
should be collected at least once a day and burned ;
furthermore, all patients should have as a sputum
receptacle, not the china cup or mug most often
used, but the regulation tin covered sputum cups,'
which are lined with pasteboard boxes. These
should be covered with sawdust and burned each
day, and the receptacle easily sterilized by boiling
or by immersion in strong carbolic acid. Not in-
frequently the cups ordinarily used are thrown on
the flood and the sputum spilled all over ; the tin
covered pasteboard boxes seldom are spilled, even
when thrown on the floor, owing to the cover and
the small opening in the pasteboard.
With regard to the laboratory, no sputum should
be examined in large bulk. It is obviously a diffi-
cult task to find rice bodies or elastic tissue in two
to four hundred c.c. of sputum. To spread this
amount out on glass plates is to contaminate too
large a surface to be afterward satisfactorily steril-
ized. The proper receptacle for sputum examina-
tion is the wooden screw box, which is painted
inside with black enamel. Into this the patient
should expectorate one or twice only. The black
surface enables one easily to discern the desirable
elements for examination, without transferring the
infectious material to another surface, and the
boxes should then be covered and soon afterward
burned. In all his manipulations in the sputum
room the student should avoid contaminating his
hands, and all sputa should be removed before they
can become dry. Besides this, no room for exami-
nation of sputum is complete unless plenty of soap
and water and some disinfectant is at hand, and no
examination can be complete unless the student
makes use of these, whether he thinks he has con-
taminated his hands or not.
In the post mortem room, possibly more than
anywhere else, is the student exposed to tuberculous
infection. In order thoroughly to understand dis-
eased tissues, whether tuberculous or not, the stu-
dent must feel them. Contact with tuberculous tis-
sue, of course, spreads the infection to the examin-
ing fingers, but the danger from this is probably not
great if the means are at hand for immediate and
thorough cleansing of the hands. Unfortunately,
however, in an autopsy room much used and usual-
ly not overclean, the student may further contami-
nate himself in endeavoring to rid his hands of
infection. The faucets and sinks are probably in-
fected, and even the door knobs may be, by those
who are careless enough to leave the room before
washing. The use of thin rubber gloves in the
autopsy room, or in the examination of pathological
tissue, is, I think, to be recommended. It may be
argued by some that the tactile sense is lost or not
so good, but we have the evidence of the surgeons
against this view. Certainly no measure which may
protect the student, even if its efficacy is a ques-
tion of doubt, should be neglected until shown be-
yond this doubt that it is useless.
It is quite believable that if these briefly outlined
precautions are followed and insisted upon in the
medical school and hospital, a certain number, at
least, of cases of tuberculosis acquired during the
medical student's course may be prevented.
332 W^EST Eighty-eighth Street.
(Bxxx geabm' fiscussions.
A SERIES OF PRIZE ESSAYS.
Questions for discussion in this department arc an-
nounced at frequent intervals. So far as they have been
decided upon, the further questions are as follows:
LXX. — How do you distinguish alcoholic stupor from
other conditions resembling itf (Closed January 15, 1908.)
LXXI. — Hoiii do you treat gallstone colic? (Answers
due not later than February 15, igo8.)
LXXII.—How do you treat fracture of the patellaT
(Anszvers not later than March 16, igo8.)
Whoever ans^vers one of these questions in the manner
most satisfactory to the editors and their advisors zinll
receive a prize of $25. No importance whatever will be at-
tached to literary style, but the award will be based solely
on the value of the substance of the anszL'cr. It is requested
(but not required) that the ans-uers be short; if practica-
ble, no one anszver to contain more than six hundred luords.
All persons will be entitled to compete for the price,
whether subscribers or not. This price ivill not be aivarded
to any one person more than once within one year. Every
anszver )nust be accompanied by the zvriter's full name and
address, both of ivhich we must be at liberty to publish.
All papers contributed become the property of the Journal.
The price of $25 for the best essay submitted in answer
to question LXIX has been awarded to Dr. Maurice A.
Walker, of Dillon. Montana, whose article appeared on page
164 of the preceding number.
PRIZE QUESTION NO. LXIX.
THE TREATMENT OF POST PARTUM HAEMOR-
RHAGE.
(Continued from page i6q.)
Dr. JVilliam H. Randle, of Germantown, Fhiladcl-
jyhia, writes:
Successful treatment of post partum hsemorrhage
depends, first, on prophylactics ; second, absolute cer-
taintv that the uterus is empty ; third, stimulating-
the tired and relaxed uterus (inertia), causing con-
traction.
Immediately after the child is born, the fundus of
]-elmiary i, 1908.J
OUR READERS' DISCUSSIONS.
211
the uterus should be firmly grasped and held for
half an hour, when it should be more firmly grasped
and massaged, thereby expelling the placenta. If
during this thirty minutes (time between the birth
■of the child and expulsion of afterbirth ) excessive
haemorrhage begins, the placenta should be removed
by Crede method, and massage continued. Hypo-
dermatic injections of aseptic ergot and strychnine
1/20 gr. should be given separately.
Should flow continue, the treatment at this stage
is the same, whether haemorrhage began before pla-
centa was removed or after. Patient should be
placed across the bed, buttocks well over the edge.
The left hand should press the uterus well down ;
the right hand, rubber gloved or thoroughh- steril-
ized, be passed quickly into the uterus and every
particle of secundines removed. The uterus should
then be irrigated with normal saline solution at tem-
perature of 115° F. A glass nozzle attached to a
four quart fountain syringe should be carried well
up to the fundus and irrigated slo\vl\- ; at the same
time the left hand should hold the body of the uterus
tightly. If the uterus is well contracted, haemor-
rhage stopped, and pulse good, the patient can be
renlaced in proper position.
If, however, there is doubt of the haemostasia, and
patient shows acute anjemia, and complains of feel-
ing faint, with rapid, weak pulse, grasp posterior lip
of uterus with double tenaculum forceps, draw ute-
rus well down and to either side, and note particu-
larly whether there are any cervical lacerations.
Haemorrhage may be due to laceration of uterine
artery. If so, one or two sutures with chromic cat-
gut, No. I, is the best remedy.
Should exsariguination at this time have reached
an alarming condition, it is best to pack the uterus,
carrying packing (iodoform gauze, 5 per cent.) up
to the fundus (not through the fundus, which can
be easily done), and pack firmly. It is also well to
pack the vagina. Ice cap should now be placed over
lower part of the abdomen, pillows removed from
under the head, and foot of bed elevated about two
feet. Give brandy, half ounce in water, every hour
until two or three doses are given. If indicated at
this time, another hypodermatic injection of ergot,
and another of strychnine sulphate, 1/30 gr., should
be given ; concentrated liquid diet in small quanti-
ties, frequently repeated, and normal saline solution
(enterocolysis) , eight ounces every four hours, and
patient kept at perfect rest, complete the treatment.
Obstetrics being one of the most important
branches of medicine, no physician should assume
responsibilit) of a case without going to his patient
thoroughly equipped for any emergency that may
arise. The armamentarium being so necessary for
successful treatment, so much depending on being
ready and acting promptly, it is quite in order here
to state what the physician should have with him.
His obstetrical satchel should contain a Tarnier
forceps (or the make he likes best) ; a short forceps ;
half a dozen well curved needles ; a needle holder ; a
fountain syringe, a glass nozzle for the.same ; a dou-
ble tenaculum forceps ; a uterine dressing forceps ; a
hy podermatic syringe in good order ; tincture of
veratrum veride : scissors ; two or three haemostats ;
a yard of moist iodoform gauze, 5 per cent. ; six
yards of sterile gauze ; twenty day chromocized cat-
gut, no. I ; a linen bobbin ; bichloride tablets ; tinc-
ture of green soap ; tincture of ergot ; chloroform ; a
can of ether; a pair of rubber gloves; and a glass
catheter. This outfit can be carried in a satchel six
by fifteen inches.
Dr. J. IV. Summers, of Chicago, III., writes:
Post partum haemorrhage, the gravest of all
obstetrical emergencies, is, if properly and intelli-
gently managed, the most amenable to treatment.
Since it is due to multiple causes, there can be no
hard and fast plan of treatment.
In some cases the treatment should begin with
the first visit to the patient. If there is evidence
of anaemia, severe constitutional diseases, degen-
erations of important organs, or history of
hiemophilia, and previous severe haemorrhages,
treatment should be instituted at once for the alle-
viation of the condition. For anaemia judicious diet
with roborant tonics and well regulated exercise
and habits will do good, not only to the blood and
vascular system, but to the musculature of the en-
tire body as well.
The various constitutional diseases, of course,
will call for treatment directed to their alleviation.
If a history of haemophilia or previous haemorrhages
is given, treatment must be directed to improving
the pathology of the blood, and at the time of de-
livery provision must be made for emergencies.
Calcium lactate, calcium chloride, iron, and, in some
caces, small doses of manganese, should be admin-
istered. To gelatin, as food, is sometimes attrib-
uted the power of increasing coagulabihty of the
blood and better fibrin formation.
Prophylaxis during delivery is the next step in
treatment. Care must be taken to prevent too rapid
expulsion of the foetus, which should be extracted
only as rapidly as the uterus will contract firmly.
It is sometimes necessary to hold the child back to
stimulate the vigorous uterine contractions.
After delivery of the child, the uterus must be
encouraged to contraction by mild irritation of the
fundus by massage through the abdominal wall^ un-
til it can be felt as a hard mass low in the abdomen.
Do not hasten to deliver the placenta unless you
feel siu'e contraction is taking place. Then expel
the placenta by Crede's method, which is one of
massage. This, if well done, will stimulate uterine
contractions. After the placenta is expelled the
uterus should still be firmly held and kneaded at
frequent intervals for some time. If contraction
has occurred towels may be tightly folded and
forced under a tight binder in such a manner as to
keep up continuous pressure on the uterus.
But occasionally, with the greatest care in deliv-
ery and previously, the haemorrhage will occur, and
in these cases the alert and self possessed physician
is the one who will succeed. No time is to be lost.
If the patient is conscious give her a good sized
dose of fluidextract of ergot at once, but if she is
under an anaesthetic some of the hypodermatic
preparations of ergot should be given without de-
lay. This can be done by the nurse or some mem-
ber of the family while the physician is giving his
attention to the local condition.
212
OUR READERS' DJSCUSSIO.KS.
[New York
Medical Jourkal.
The first thing to be done in a post partum
hgemorrhage is to introduce the gloved or steril-
ized hand into the vagina and search for vaginal
or cervical tears, and if the cause is not found
there the hand should be introduced into the uterus
and internal and external massage instituted by
placing the other hand upon the abdominal wall.
The cavity of the uterus must be explored while
this is being done, to see if there is still some
placental tissue or membrane attached. These, if
found, must be detached at once, and the walls of
the uterus palpated to be sure there is no rupture
or laceration. If a tear is found it must be rapidly
repaired or grasped with clamps until preparation
can be made for its repair, but if none are found
and the haemorrhage is from the uterine sinuses,
continue the combined internal and external mas-
sage and compression for a reasonable time.
Added to this procedure, a hot intrauterine
douche, temperature iio° to 115°, should be given.
It will sometimes be found that this only serves to
wash the blood away and does not promote contrac-
tion. If such is the case no time should be lost, but
proceed at once to pack the uterus with wet strips of
sterile gauze, or cloth of any kind in case gauze is
not at hand. Tear the cloth in strips and place it in
very hot water to sterilize it, and introduce it into
the uterus tightly. The vagina should be tightly
packed also, in order to prevent expulsion of the
gauze from the uterus, and then a perineal binder
should be placed on tightly, to hold the gauze in the
vagina. These measures are usually sufficient to
stop the flow.-
If adrenalin is at hand, swabbing the cavity of
the uterus with i in "3,000 solution will often do
good, since it is a powerful haemostatic when ap-
plied locally. Should no adrenalin be obtainable,
acetic acid or sterile vinegar will do good.
Ice is an excellent stimulator of muscular con-
traction, and if the hfemorrhage is so unexpected
that no hot water or other measures are ready, a
small piece of ice should be introduced and the cav-
ity of the uterus massaged with it. This is excellent
to promote contraction, but it causes some shock
and even necrosis if allowed to remain too long,
and, besides, ice is not always sterile. However,
it may be used to good advantage in absence of
other measures.
When haemorrhage is so severe as to cause faint-
ing or unconsciousness, the foot of the bed should
be elevated, and in very severe cases the limbs band-
aged, hypodermoclysis or intravenous saline given,
and heat applied. In less severe haemorrhages, high
enemata of normal saline, plain or with a small
amount of whiskey added for its stimulating eflfect.
This acts quickly, and the simplicity of it often
makes it more useful than hypodermoclysis or in-
travenous infusion.
Strychnine, camphorated oil, and other stimulants
should be given if the condition of the patient re-
quires them.
In hospital practice the control of post partum
hajmorrhage and the prevention of sepsis is a fair-
ly easy feat, but in the poorly equipped home it as-
sumes grave aspects and demands the best thought
and selfcontrol of the obstetrician.
Dr. Iva M. Lickly, of Lima, Ohio, remarks:
The most successful treatment of post partum
haemorrhage lies in prophylaxis. An understanding
of its aetiology is therefore necessary.
As soon as the child is born a nurse or assistant
should place her hand upon the mother's abdominal
wall. If it is not unduly relaxed, the uterus will be
felt as a firm, round body. If relaxed and bleeding
occurs, the uterus should be massaged to secure con-
traction. The hand should then remain over the
fundus until the placenta separates spontaneously,
which will be indicated by a rising up of the fundus.
If the patient is watched in this way, one will not be
surprised by a concealed haemorrhage.
Usually the placenta will be expelled spontane-
ously. If not,Crede's method may be used after the
placenta is separated, or if bleeding occurs. Impa-
tience of the obstetrician and too early attempts at
Crede's method often cause retention of portions of
the placenta and consequent haemorrhage.
In rare cases the haemorrhage may be caused by
adherent placenta. Then it may become necessar\
to insert the hand into the uterus to remove the pla-
centa. Strict obedience to the rules of asepsis must
then be observed, for danger of sepsis is great. The
hand should follow the cord into the uterus and the
edge of the placenta found. Then the placenta
should be carefully peeled from the uterine wall.
The hand then grasps the placenta, but should not be
removed at once from the uterine cavity, but should
be slowly withdrawn after the uterus contracts firm-
ly over the hand. As soon as the placenta is ex-
pelled or contracted, it should be carefully examined
for missing portions. If any part is absent, its re-
moval will become necessary. This may be done ac-
cording to method for removal of adherent placenta.
Bleeding, continuing after the expulsion of the
placenta entire, may be due to uterine inertia or to
deep cervical tears. Rarely it may be due to rup-
ture of the uterus or to complete inversion. These
latter, fortunately rare, require surgical treatment.
As soon as the placenta is expelled, the uterus
should be massaged through the abdominal wall to
secure contraction. If it shows a tendency toward
relaxation, fluidextract of ergot 5i may be given by
mouth, or, better, aseptic ergot min. xxx to min. Ix,
may be injected deeply into the muscles of the thigh.
The uterus must be palpated often during the first
hour after the placenta is expelled and massaged
when necessary.
If the haemorrhage is due to deep cervical, vaginal,
or perineal tears, the blood will be bright, the flow
constant, and not stopped by the contraction of the
uterus. In that case a careful examination should
be made and the laceration repaired.
If massage fails to stop the bleeding, an intrauter-
ine douche of hot, sterile, normal salt solution
should be given. It should not continue for over
two or three minutes, for, while the first efi'ect of
the hot water is to cause contraction of the blood-
vessels, if continued too long it defeats its own pur-
pose by causing relaxation.
If this fails it will be necessary to pack the uterus
with sterile gauze, either plain or iodoform. A roll
of sterilized gauze four or five inches wide should
always be carried for this purpose. The f>aticnt
OUR READERS' DISCUSSIOAS.
213
should be brought to the edge of the bed. jjrepared
as for an operation, and a Sims or bivalve ?ptculuni
inserted. The cervix should be brought down with
a tenaculum and the uterus and upper vagina firmly
packed. This packing should be removed in twentx -
four hours by pulling on the free end.
The use of ice. vinegar, ^^lonsel's solution, and
other astringents may be mentioned only to be con-
demned. Ice and vinegar are never aseptic. Any
astringent to be efifective acts by forming a coagu-
lum over the surface. This latter sepaiates by
sloughing. None of these methods are as efifective
as the intrauterine douche or packing the uterus.
Following the latter methods one does not fear puer-
peral sepsis.
The after treatment is the treatment of shock. In
mild cases, absolute quiet, elevation of the foot of the
bed, and hot water bottles to the extremities will be
sufficient. If, however, symptoms of profound shock
occur, if the pulse is weak, of low- pressure, and
thready, and if the patient is restless and shows
signs of "air hunger," more vigorous measures must
be adopted. Strychnine nitrate, gr. 1/30. hpyoder-
matically, repeated until three doses are given, i;
good treatment. Adrenalin extract is evanescent in
its eitects. but may tide the patient over a critical
time until other things have time to act. It may be
given hypodermatically, the dosage depending upon
the preparation used. Brandy and ether may also
be given hypodermatically.
Six ounces of hot coffee and salt solution (tem-
perature 110° F.) may- be given per rectum, or hot
normal salt solution may be injected slowly high
into the colon. , It will be rapidly absorbed and prove
a valuable aid.
In many cases of pronounced shock from haemor-
rhage life has been saved by subcutaneous or intra-
venous injections of hot normal salt solution. If
given by hypodermoclysis, the injection may be given
under each breast, using at least a pint of solution
and repeating as ^oon as absorption has occurred.
If the case is very urgent, the solution should be
given intravenously.
To sum up :
1. Haemorrhage may usually be avoided by proper
treatment.
2. If it occurs, (a) remove placenta; (b) massage
uterus; (c) give ergot hypodermatically; (d) repair
lacerations: (e) use hot sterile intrauterine douches,
and (f j pack uterus.
3. After care : Heat stimulants. Hot normal salt
bv enteroclvsis, hypodermoclysis, and intravenously.
Dr. J. Lytle Moore, of Toledo, O., observes:
After the expulsion of the placenta, normally
there is a loss of a variable amount of blood. In
cases where the uterus does not contract promptly
or sufficiently this haemorrhage may be so severe
that the patient would be exsanguinated in a short
time unless very prompt measures are taken to
stop it.
The causes of post partum hsemorrhage may be
briefly stated as: i. Relaxation or insufficient con-
traction of the uterus. 2. Exertion, which causes
a loosening of the clots in the uterine vessels. 3.
Ruptured uterus. 4. Inverted uterus. 5. Lacera-
tions in the birth canal. 6. Tumors and new
growths.
I. Relaxation of the uterine muscle is by far the
most frequent cause of post partum haemorrhage.
The causative factors of relaxed uterus are those
which interfere with the complete contraction of the
organ, as retained placenta or clots, weakness of the
uterine muscle from overstretching (twins, hydra-
mous, large child, etc.), or debility from general
disease, adhesions around the uterus, distended
bladder or rectum, fatigue from a protracted labor,
rapid delivery, short time between pregnancies, etc.
The treatment of this form of post partum
hsemorrhage divides itself into prophylactic, active,
and after treatment.
Prophylaxis. — If there is systemic weakness or
debility from any cause, this should be treated with
tonics, good food, proper hygiene, etc., to get the
patient in the best condition possible before deliv-
ery. At the onset of labor the rectum and bladder
should be emptied. The physician should not al-
low the patient to become too much exhausted by
a long labor. As soon as the head is born, a hypo-
dermatic injection of ergot should be given and the
fundus massaged to insure contraction. A firm
abdominal binder should be applied to insure slight
pressure.
Active Treatment. — Before giving my favorite
procedure, I would like to mention a number of
methods which are in use by the best physicians for
stopping the bleeding.
a. External stimulation of the uterus. The best
way is to massage the uterus through the abdominal
walls. The fundus is grasped in the hand and
kneaded and irritated. The uterus can also be stim-
ulated to contract by the application of cold to the
abdomen. A little ether can be poured upon the
abdomen, or ice, or a cold compress can be used.
b. Internal stimulation. A comparatively safe and
efficient method is the hot uterine douche. Water
at a temperature of 120° F. should be used.
Pieces of ice are sometimes placed in the uterus.
The chief objection to this is the danger of infec-
tion. Irritating drugs, as tincture of iodine, J\Ion-
sel's solution, vinegar, etc., promptly cause uterine
contraction when introduced into the organ. But
they, too, have an objectionable side. They cause
large clots to form in the vessels, and these are like-
ly to form an embolism. I do not think them as
safe as other methods.
.Another method of internal stimulation is to in-
troduce the left hand into the uterus, and massage
it between the tw^o hands until it is felt to contract
dow-n upon the inside hand. With proper attention
to antisepsis the danger of infection is slight.
Tamponing the uterus. — Sterile gauze is packed
into the uterus and vagina. This will usually stop
all hsemorrhage. The gauze is left in from twenty-
four 10 thirty-six hours. If haemorrhage commences
again after its removal, it should be repacked.
Compression of the uterus.— The fingers of the
left hand are in the posterior cul-de-sac, and the
right hand is over the pubes. The uterus is com-
pressed betw^een the two hands.
Pressure on the abdominal aorta is sometimes re-
sorted to when all other methods fail. Authorities
differ as to the value of this procedure.
214
OOR READERS' DISCUSSrONS.
[Nkw York
Medical Journal.
In addition, ergot should always be given, and
the child placed to the breasts when possible.
The following" is the outline of the way I would
treat a case of haemorrhage arising from lelaxed
uterus: Place patient on her back, with head low-
ered ; then give a hypodermic of ergot. Remove
placenta if attached, correct inversions and mis-
placements if present. By external massage of the
uterus hc-emorrhage is usually controlled. If not,
internal massage. Finally, if this does not control
the bleeding, I resort to tamponing the uterus and
vagina.
After treatment of all forms of post partum
lijemorrhage is the same as ha;niorrhage from any
cause. In the less severe rases, give the patient a
cup of strong, black coffee or some other stimulant,
and keep up the bod\- teni])LTalure 1)\ hot water bot-
tles to the extremities. In severe cases, raise the
foot of the bed, stimulate with a hypodermatic in-
jection of ether, give an enema of hot saline solu-
tion, or a hypodermoc} Isis. After reaction, f|uiet
the patient with morphine, and give stinnilants,
digitalis, strychnine, etc. Keep the patient perfect-
ly quiet, and allow onl\ a liquid diet. Later put
her on tonic treatment.
2. High arterial tension, or exertion on the part
of the patient may cause loosening of the clots.
This should receive appropriate treatment, viz.,
quietness or drugs to lower arterial tension.
3. Inverted uterus. — If the placenta is adherent,
remove it and then replace the uterus. If it does
not contract, the methods given before should be
tried, or it should be packed widi gauze.
4. Lacerations of birth canal. — If possible, pick
up and tie the bleeding: vessels and repair the tears.
If this cannot be done, pack the uterus or vagina,
whichever is necessary. Later, this is to be re-
moved and the rents sewed up.
Haemorrhages from other causes are more rare,
and their treatment is that of the causative factors.
Dr. Parker F. Southzvick, of Sandusky, Ohio, states:
As relaxation and loss of contractile power of the
uterine muscle is the most frequent catise of post
partum hfemorrhage, an)- treatment to be effective
mu.st be directed to these conditions, the object be-
ing to secure firm and prolonged contraction of the
womb. To this end especial care should be exerted
in the third stage of labor.
After birth of the child some little time should
elapse before any attempt is made to deliver the pla-
centa, thus allowing the fatigued and overworked
uterus time to regain its lost nmscular tone. The
placenta having been removed by the expression
method, the hand should maintain this external pres-
sure, and at the same time make gentle kneading
movements over the womb. If the uterus is not
firmly contracted and there is some haemorrhase, 3i
of fluidextract of ergot should be given by mouth.
Then give a hot vaginal douche of sterile water at
a temperature of 112° F. If it produces no effect
•give an intrauterine douche consisting of sterile wa-
ter, normal salt solution, or a 2 per cent, solution of
acetic acid ; if the latter is not at hand, vinegar may
■be used. The use of the hot douche is extremely
valuable, but is not always possible to give without
.trained assistants. During the<e ])rocedures the
mechanical stimulation through the abdominal walls
should be maintained. If haemorrhage continues, re-
peat the ergot and introduce the free hand into the
vagina, carry it up posteriorly to the cervix, and
with both external and internal hands press the ute-
rus firmly up under the symphyses ptibes, always
continuing the kneading movements of the external
hand. If this produces no effect carry the hand up
into the uterine cavity, removing all blood clots and
placental remains. At the same time move the hand
about rather roughly to incite a mechanical stimula-
tion of the muscle, or close the hand in the uterus
and make firm pressure over it with the external
hand. Gauze soaked in vinegar and carried into the
uterine cavity may bring about desired results.
Should all these means fail to incite firm contrac-
tion and check the haemorrhage, the uterine cavity
is to be packed with sterile gauze. With the patient
across the bed the gauze is carried to the fundus and
firmly packed in froin above downward, causing an
immediate cessation of the haemorrhage. Electricity
and local styptics might be tried, but they are usu-
ally not at hand when most needed. Then, too,
styptics are dangerous from the firm clots they pro-
duce in the uterine sinuses.
All of these measures in and about the parturient
canal should be carried out under strict aseptic pre-
cautions, as the uterus is especially liable to infec-
tion at this time.
In cases of mild luemorrhage not controlled by
mechanical irritation and the hot douches, careful
inspection of the vagina and uterus should be made
ilirougli a speculum. ( )ften a tear in the vaginal or
cu lis.-i e may be responsible for the bleeding.
If found, immediate r-.'pair insures the desired result.
The cessation of the luemorrhage is not the only
consideration in these cases, as they are usually fol-
lowed by depression, syncope, and acute anaemia,
which demand immediate treatment.
The patient is to be kept perfectly quiet, with the
foot of the bed raised six or eight inches, and heart
stimulants, strychnine, digitalis, and brandy, admin-
istered as required. An enema consisting of
R Adrenalin chloride, 5j ;
Brandy, . • ■^■5]}
Normal salt solution, 5viij-
M.
acts as a powerful stimulant, besides restoring the
balance of fluids in the system. Normal salt solu-
tion ma\ be given subcutaneously in immediate dan-
ger.
Dr. C. C. Coryell, of Nciv York, says:
The treatment of post partum haemorrhage divides
itself into two divisions — the first prophylactic, the
second curative.
I. Prophylaxis. — Since the causes of post pu tum
haemorrhage are not invariably similar, the prevent-
ive treatment is most important, and should include
a proper regulation of diet and hygiene, especially
during the latter weeks of gestation ; the condition
of overdistention of the uterus, due either to ex-
cessive hydramnios or multiple foetation should re-
ceive attention ; also pregnancy should be terminated
])rematurely if the patient is markedly weakened by
an\ svstemic disea.sc.
February i. 1908. |
OUR READERS' DISCUSSIONS.
215
During labor itself care should be taken, first, to
prevent a too rapid delivery, thereby causing insuffi-
cient uterine contraction or lacerations of the birth
canal, and, secondly, to prevent a too prolonged la-
bor, on account of vv^hich the uterine muscles fail
to contract properly.
Beginning with the end of the second stage of
labor the fundus should be held firmly through the
alxlominal wall and pressure continued thereafter
until there are firm contractions after the termina-
tion of the third stage. However, if the placenta is
not expelled after thirty minutes, the familiar method
of Crede should be employed, this being an impor-
tant adjuvant as a preventive of post partum hjem-
orrhage.
Immediately following the birth of the placenta
fluidextract of ergot should be given bv mouth (or
a smaller dose subcutaneously) to promote uterine
contractions ; the placenta should be carefully in-
spected for possible retained membrane or cotyle-
dons, and, if there is a probability of such being the
case, the fingers (under aseptic precautions) should
passed into the uterus and shreds or clots re-
moved.
II. Curative. — When, in spite of all preventive
measures, there occurs a frank haemorrhage after the
third stage of labor, the following methods of con-
trol should be employed.
Put the infant to breast of mother to promote re-
flex contractions of the uterus ; rub and squeeze the
fundus through the abdominal wall to produce di-
rect contractions ; pass the fingers into the cervix
and remove clots of blood or retained pottions of
placenta or membranes. These procedures failing,
pass the fingers of the right hand into the posterior
vaginal forni, pressing forward the cervix, while
with the left hand seize the fundus through the ab-
dominal wall and press downward and backward in
an effort to bend the uterus upon itself ; as a final
method the closed fist of one hand should be placed
inside the uterine cavity, and with the external hand
squeeze the fundus upon it.
These manipulations, begun early and carried out
rapidly, are invariably sufficient. Then a hot intra-
uterine douche of sterile saline solution should be
given. If there is a tendency for continued uterine
relaxation, the fundus may be packed tigh.tlx* with
strips of sterile gauze, to be removed in twenty-four
hours. Injections of substances such as vinegar,
iron chloride, etc., are mentioned to be condemned.
All manipulations are to be carried out under aseptic
precautions if possible.
Following the control of the hremorrhage, the gen-
eral treatment of the patient must be begun. Ele-
vate the foot of the bed ; give a hot saline enema,
and, ' if considerable blood has been lost, a saline
venous infusion or hypodermoclysis may be em-
ployed ; stimulate with hypodermics of brandy,
strychnine, or Hoffmann's anodyne, as indicated ;
place hot water bottles to extremities ; morphine sul-
phate, gr. 1/4, hypodermatically is a valuable stimu-
lant in cases of collapse.
After the patient has passed two or three days
without haemorrhage, she may be considered out of
danger. ■ Then general tonic and dietetic treatment
must be begun.
Dr. Adolph Morgcnstcrn, of New York, ivrites:
The treatment applicable to a case of post partum
haemorrhage is classed as (a) preventive and {b)
curative.
I shall not consider remote prophylaxis, which
deals with the preparation and treatment of a pa-
tient whose general condition, surroundings, or
family history would warrant suspicions of a pos-
sible post partum haemorrhage. But I must devote
a little space to the immediate or direct prophy-
laxis, i. e., the one pertaining to the proper manage-
ment of the second and third stages of labor. I
firmly believe that the least break in the technique
of managing these two stages enhances some chance
of a post partum haemorrhage. This is especially
true in multiparae, and particularly so where the
patient is exhausted from tardy labor and some-
what prolonged chloroform narcosis. To be more
explicit, I must of necessity give a brief review ot
the rearrangement of the uterine fibres after labor
as well as the methods of aiding this process where
the physiological return to the normal is somewhat
retarded.
After the birth of the child, the hypertrophied
uterine fibres, stretched during the period of gesta-
tion, begin to rearrange themselves, or, in other
words, to tonically contract and relax. The mere
touch of the fingers promotes and stimulates this
tonic action of the uterus. Moreover, as the periods
of contraction lengthen, the periods of relaxation
shorten, and in about twenty to twenty-five minutes
the uterus is usually firm enough to render the
Crede method possible. By virtue of these mus-
cular contractions, which continue after the delivery
of the placenta, the ligation of the uterine vessels
is accomplished. Should the uterus present a boggy
touch, Crede's movements are to be instituted, and
as one or more blood clots are expelled, the uterus
regains its firmness. The hand should, under no
circumstances, leave the fundus for at least one
hour. The -patient remains perfectly quiet, with
thighs together and fiat on the bed. A tight ab-
dominal binder coming up to three inches above the
fundus and reaching about two inches below the
trochanters, is very efifectual, for the reason that it
supports the abdominal muscles, which in turn exert,
a certain amount of pressure on the uterus.
Slight haemorrhages usually originate from a
badly lacerated cervix, vagina, or perinaeum. These
are best controlled by suture. The curative treat-
ment of a post partum haemorrhage proper — that
is, one having its origin at the placental site — I will
discuss more fully. In the treatment of this last
condition various manipulations are employed. In
my experience the ordinary Crede manoeuvre — that
is, grasping the fundus between the hand and the
thumb, and pressing the latter against the dorsum,
simultaneously directing considerable force down-
ward— has been most satisfactory. Breisky's method
is also very efficacious. I have controlled some
moderate haemorrhages by holding the right hand
at a point corresponding to the junction of the
body and cervix, and forcibly antiflexing the uterus
with the left. In these external manipulations a cer-
tain amount of pressure is also exerted on the ab-
dominal aorta. The combined internal and ex-
2l6
THERAPEUTICAL NOTES.
[New York
Medical Journal.
ternal manipulation does not appeal to me, because
of the possible dangers of embolism and infection
consequent upon such a procedure.
To my mind the hot douche of sterile wJter at a
temperature of ii6° to 120° F. is only applicable
in hospital practice. In the tenement houses of this
city it is exceedingly difficult to obtain sterile wa-
ter, and much more so at an optimum temperature.
The styptic effect alleged from a hot i per cent, to
5 per cent, acetic acid douche is too slight to be of
any value, consequently hardly worth while trying.
Uterine tamponade is the most efficient method
for the control of severe haemorrhages following
haemophilia or marked atony of the uterus in con-
sequence of inertia uteri from exhaustion, overdis-
tension of the uterus from any cause, and where
simpler methods have failed. The method I employ
is extremely simple. Strip iodoform gauze one and
one half or two inches wide is carried with a uterine
dressing forceps, or, in emergency, with the fin-
gers, clear up to the fundus, until the whole uterine
cavity is filled with gauze. The fundus is then
grasped with the left hand, while the middle finger
of the right, introduced into the cervix, squeezes
the gauze against the fundus to insure tight pack-
ing of the uterus. The cervix, fornices, and upper
vagina are then tightly packed. This, I find, can
be done more thoroughly with the fingers than with
instruments.
The gauze should carefully be removed after
twelve hours. It is permissible, however, to leave
it in the uterus for twenty-four hours, and, in very
rare instances, for forty-eight hours without the
least untoward effects.
Most standard authors invariably recommend
unmedicated sterile gauze for intrauterine tampon-
ade, but I fail to see its advantages over iodoform
gauze. On the contrary, to my mind, 5 per cent,
iodoform gauze is the safer of the two from the
standpoint of asepsis. Out of about seventy-five
cases packed with iodoform gauze, I only recall one
patient whose urine gave the iodoform test after the
gauze was left in the uterine cavity for seventy-two
hours. The other symptoms of iodoform were so
slight that they entirely disappeared within twenty-
four hours after removal of the cause. It stands to
•reason that in emergency, lacking iodoform gauze,
plain gauze, bandages, or even strips of linen must
be resorted to.
Various textbooks recommend additional mea-
sures for the control of post partum haemorrhages,
such as the application of the child to the breast
as a reflex excitomotor, electricity in the shape of a
faradic current, and swabbing the uterus with
tincture of iodine. In my opinion, they are abso-
lutely useless, for the reason that, considering the
nature of the case, it is imperative to act and not
theorize. All trifling methods must, of necessity,
be discarded and the most efficient ones adopted.
The only effective measures available can be sum-
marized under the following tripod: i. Ergot. 2.
Manipulation. 3. Tampon.
The shock and anaemia should receive attention
in proportion to the severity of symptoms. On gen-
eral principles all pillows should be withdrawn from
under the head, and the foot of the bed elevated.
Hot water bags to the body, and drachm doses of
hot water, with or without brandy, given every few
minutes, tend to keep the patient warm. Rectal
enemata of equal parts of hot decinormal salt solu-
tion and strong black coffee, with one ounce of
brandy or whiskey, are useful for the same reason.
These measures not only stimulate the patient, but
also replace the loss of blood to certain degree.
Hypodermatic injections of strychnine, gr. 1/60, or
digitalin, gr. i/ioo, given p. r. n., are of value. In
very severe cases autotransfusion by means of
Esmarch or muslin bandages, hypodermoclysis, and
intravenous infusions should be resorted to. The
patient must be kept at absolute rest. For the first
twenty-four hours a milk diet, later broths and pre-
digested food should be given. On the third day
semisolid food may be substituted, followed later by
an easily digested general diet. A nutritive diet,
with general tonics, will enable the patient to sit
up in bed on about the fourteenth day post partum.
Fresh air is an important adjuvant m the treatment
of the anaemia. In my opinion, the organic com-
pounds of iron are by far more satisfactory as blood
producing agents than the inorganic combinations.
{To be concluded.)
The Antiseptic Value of Iodic Acid and lodates.
— Calcium iodate employed as a dusting powder, or
as a 4 per cent, ointment with petrolatum, is said to
be an excellent antiseptic for stubborn sores {Jour-
nal pharmaccutique de Liege). It may also be used
as a warm saturated solution in the form of an in-
jection for vaginal and vesical irrigation, and also
as a wash for infantile eczema. It is considered an
economical substitute for iodoform. An aqueous
solution of iodic acid, i in 500, is an active de-
odorant of purulent wounds. Since calcium iodate
is not very soluble, where strong solutions are re-
quired zinc iodate may be used ; bismuth subiodate
is useful as a dusting powder for tuberculous sores.
Gelatin Solution for Hypodermatic Injection in
Haemorrhagic Conditions. — .A. saline solution of
gelatin for hypodermatic injection in haemorrhagic
conditions is made, according to the Pharmac cutis ch
Weekblad, as follows :
^ Gelatin lo.o grammes;
Sodium chloride 70 grammes ;
Distilled water, 500.0 c.c.
M.
Dissolve on a water bath ; neutralize with deci-
noriTial sodium bicarbonate solution, and add dis-
tilled water to make the total volume measure 1000.0
c.c. The solution is sterilized in an autoclave at 110°
C. for ten minutes, is then filtered into sterile flasks,
when each flask is again sterilized for fifteen min-
utes in the autoclave.
Collinsonia Canadensis. — The physiological ac-
tion of Collinsonia canadensis formed the subject
of a thesis presented by M. Abal to the Faculty of
Medicine of Paris for the doctorate degree (Reper-
toire de pharmacie, October, 1907). This pjant
contains a glucoside of the saponin type and a resin.
The alcoholic extract of the root produces in small
Febriiarj' i. igoS.]
THERAPEUTICAL XOTES.
217
doses nervous hyperexcitability. In larger doses
this is followed by a depression, which may lead to
a paralysis of central origin, with circulator}- dis-
turbances and symptoms of irritation of the glandu-
lar system. In moderate doses the glucoside acts as
a feeble cardiac tonic, while the irritant effects pre-
dominate in large doses, giving rise in cold blooded
animals to asystole, alternating with energetic
systole. In warm blooded animals there is a rapid
lowering of arterial pressure, with increased force
of the heart beat. The resin acts less powerfully,
but its action is to augment the action of the heart.
It excites the secretions of the gastrointestinal tract
and provokes a marked diuresis, probably owing to
its action on both the circulation and the renal
epithelium. All the elements of the urine are in-
creased. The chief use of the drug is as a diuretic.
Artificial Sera. — The following formula is pre-
ferred by Netter (Journal de mcdecine de Paris,
Januar}- 5th) :
R Distilled water, 1,000.0 grammes;
Sodium chloride, 7.0 grammes;
Calcium chloride, 0.26 gramme;
Potassium chloride 0.30 gramme;
Sodium bicarbonate 0.20 gramme.
M.
Bouchard employs the formula of Fleig, as fol-
lows :
R Sodium chloride, 6.5 grammes;
Potassium chloride, 0.3 gramme;
Calcium chloride 0.2 gramme;
Magnesium sulphate, 0.3 gramme;
Sodium bicarbonate i.o gramme;
Sodium glycerophosphate, 1,0 gramme;
Glucose, 1.0 gramme;
Sterilized distilled water, 1,000.0 grammes;
Oxygen, sufficient to saturate.
M.
Treatment of Acute Catarrh of the Upper Air
Passages in Children. — In the acute rhinitis of
infants Seiffert {Deutsche medisinische Wochen-
schrift, quoted in The Practitioner, January, 1908)
gives an insufflation, two or three times a day, of
a powder consisting of the following ingredients :
R Boric acid, ' 3iji ;
Bismuth subnitrate, 3v.
M. ft. pulvis.
It is recommended to sprinkle the pillow several
times a day with 10 to 15 drops of Hager's mixture,
which has the following composition :
I* Carbolic acid, "1 -- tjj.
Ammonia water, J
Alcohol, 3iss;
Water, 3iv.
M. ft. lotio.
Older children should inhale the vapor of cam-
phor from a glassful of hot water, on which is
sprinkled a pinch of powdered camphor. The
steam should be inhaled through the nose by the help
of a paper tube, and should be carried out for five
minutes at a time thrice daily.
K)i special value, the author says, is the use three
tiqies a day in a throat spray, or drop bottle, of
twenty minims of the followng solution :
^ Antipyrine, gr. xxx;
Cocaine hydrochloride, gr. xv;
Distilled water, 3iii.
M.
^Menthol vapor is of value in acute inflammation
of the larynx and trachea ; fifteen drops of a 10 per
cent, solution in olive oil should be used in a steam
inhaler.
Correction of Bromopnoea Due to Gingivitis. —
The term bromopnoea is suggested by Lederer
{Medical Record, January iith) to express the
symptom of foetid breath, the term being derived
from two Greek words, bromos, stench, and pnoe,
breath. In foetid breath accompanying mild forms
of gingivitis, Lederer says potassium chlorate or
thymol and benzoic acid are good correctives. The
following formulas are given:
R Thymol, gr. jv;
Benzoic acid, 3ii gr. vi;
Tincture of eucalyptus, 3iv;
Alcohol, 5iii 3iii;
Peppermint oil, Tlj'xv.
M. Sig. : A teaspoonful in a glassful of water four times
a day as a moutli wash (Miller).
If the gtims are spongy, solution of aluminum
acetate, well diluted, may be used as a mouth wash.
Some recommend chlorine compounds, as :
R Chlorine water, ) -- x-
Honey, \ ^iv;
- Distilled water, Jx.
M. Sig. : Use as gargle.
An alkaline saponaceous tooth powder should be
employed, the author recommending the following
combination :
R Saccharin, gr. ii;
Precipitated chalk, ;
Powdered orris root, |
Powdered soap. - aa 3ii;
Sodium bicarbonate, )
Boric acid, 5i ;
Wintergreen oil, \
Peppermint oil, ( ^•
M.
A pleasant deodorizing pellet, which, if slowly
dissolved in the mouth, will mask bromopnoea, is
composed of thymol, menthol, eucalyptol, vanillin,
and saccharin, of each, i milligramme (gr. 1/64).
Powder for Seborrhoeic Eczema and Rosacea
of the Face. — Unna uses the following powder
applied lightly with a piece of old linen :
R Zinc oxide, 5.0 grammes;
Magnesium carbonate, 4.0 grammes ;
White bole, 2.5 grammes;
Red bole, 0.5 gramme;
Rice starch, 8.0 grammes.
M. Sieve frequently to make a very fine powder.
To Allay Vomiting in Cancer of the Stomach.
— Robin {La Quinzaine thcrapeutique, December 25,
1907) gives four to five drops of the followmg mix-
ture in milk before each attack :
R Picrotoxine, 0.05 gramme;
Alcohol, q. s.
Morphine hydrochloride, 0.05 gramme;
Atropine sulphate, o.oi gramme;
Bon jean's ergotin, o.oi gramme;
Distilled cherry laurel water, 12.0 grammes.
M.
Liniment for Ulcerated Chilblains. — The fol-
lowing formula is given in Journal de medecine de
Paris, for December 29, 1907:
^ Purified shellac, )
Purified gum benzoin, > aa 3iiss;
Balsam of tolu, >
Carbolic acid crystals, ^iii;
Oil of cinnamon, 3iss;
Saccharin, 3iss;
Alcohol, enough to make Oii.
M.
2l8
EDITORIAL AKTICLES.
Medical Journal.
[New York .
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal ,
and The Medical News.
A Weekly Review of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M.
Address ail business communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
^^^^Q^^^^P'^ OP'CE : Chicago Office :
3713 Walnut Street. 160 Washington Street.
Subscription Phick :
Under Domestic Postage Rates, .$.3 ; under Foreign Postage Rate
$7 ; single copies, fifteen cents.
Remittances should be made by New York Exchange or post
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nsning .t.0., or by registered mail, as the publishers are not
responsible for money sent by unregistered mail.
Entered at the Post Office at New York and admitted for
transportation through the mail as second class matter.
NEW YORK, SATURDAY, FEBRUARY i, igoS.
THE COMMAND OF HOSPITAL SHIPS BY
MEDICAL OFFICERS.
The controvery aroused by the order assigning a
surgeon to the command of the hospital ship Relief
has resulted in the publication of a series of docu-
ments bearing on the (question which have been laid
before Congress in compliance with resolutions
calling for information on the subject. These docu-
ments show that on August 20, 1904, the medical
ofificers of the navy were authorized to use the term
" in command of." On May 5, 1906, general order
No. 84 of the War Department was issued, publish-
ing the report of the joint board of medical officers
of the army and navy recommending that hospital
ships be placed under the command of medical of-
ficers. This was accompanied by a comment from
Surgeon General Rixey favoring the plan, and one
from Rear Admiral Converse, at that time chief of
the Bureau- of Navigation, disapproving of it. A
later memorandum from Surgeon General Rixey, a
reply by Rear Admiral Brownson, his letter of
resignation, the President's letters accepting this
resignation, communications and orders relative to
the commissioning of the Relief, the President's
letter to the Secretary of the Navy condemning
-Admiral Brownson, and a communication from the
surgeon general replying to the memorandum of
.\dmiral Brownson have also been submitted to
Congress.
.\ new element has been introduced into the dis-
cussion by Dr. Gallinger. a Senator from New
Hamp.shirc. who has submitted to the Senate a
memorandum showing precedents for placing sur-
geons in command of hospital ships. Among these
precedents were a general order, issued February 6,
1865, placing hospital transports and hospital boats
exclusively under the control of the medical de-
partment; five precedents from the Spanish- Ameri-
can war and nine from foreign naval history, while
the Army Regulations are also quoted in which the
command of army hospital ships is placed under the
surgeon general of the army. The citation of these
precedents by Senator Gallinger is most timely, as
it furnishes a complete refutation of the most seri-
ous argument presented by Admiral Brownson
against the order objected to, namely, that the is-
suance of such an order is illegal and contrary to all
precedent in the service. Senator Gallinger's mem-
orandum proves that it is not without precedent and
has not been considered by the authorities as con-
trary to law.
We can scarcely understand the aversion with
which the line officers seem to regard the plan of
placing hospital ships under the actual command of
medical officers, for, as was pointed out by Sur-
geon General Rixey, it is hardly conceivable that
line officers would prefer to serve on a noncom-
batant ship in time of war, and even did they prefer
to do so every one would be needed for active ser-
vice on fighting ships. As a matter of fact, we
have not enough trained officers to command all the
auxiliaries even in times of peace, as there are at
least half a dozen naval colliers now on the naval
register which are manned by a "merchant com-
plement," and a collier, unlike a hospital ship, is a
vital part of the fighting machinery of the service.
An enemy would gain no military advantage by the
capture of a hospital ship, and we should not suf-
fer material loss in efficiency. • But the capture of a
collier might determine a vital point of strategy at
a critical stage of a naval campaign. It would
surely be more important, therefore, that colliers
should be commanded by line officers than that hos-
pital ships should be.
The contention of Admiral Brownson that med-
ical officers would not have authority over enlisted
men and line officers who w'ere on hospital ships as
patients is disposed of by the general order of the
Navy Department No. 61, August 20, 1904, author-
izing medical officers of the navy to use the term "in
command of," and by the universal practice in hos-
pitals afloat or ashore, which places all patients
while in the hospital under the command of the
medical officer, regardless of the rank or station of
the patient. In fact, it would be impracticable to
carry on hospital administration successfully if the
patients were not under the control of the hospital
authorities.
Kebriiary i. 19<),S.1
EDITORIAL ARTICLES.
219
Finally, it is most important that the neutrality
of the hospital ship shall be maintained beyond all
question, and this riiight prove difficult with a line
officer in command of an enlisted crew. In fact, as
pointed out by Surgeon General Rixey, the hospital
ship Solace, while under the command of a line of-
ficer during the war with Spain, forfeited her title
to neutrality on several occasions, and even laid
claim to prize money for having taken part in of-
fensive operations. On the whole we cannot but re-
iterate our conviction that the placing of a medical
officer in command of a hospital ship was a wise
move, and that, moreover, it is particularly desirable
that hospital ships shall be maintained in commis-
sion during peace in order that both the officers and
the men of the medical corps may become familiar
with the details of service aboard such ships.
LONGEVITY AND THE MEDICAL
PROFESSION.
Though length of years is not always an unal-
loyed blessing, many of us prefer to take our leave
of life as the result of the ripening process so charm-
ingly described by the late Sir James Paget rather
than to be launched early upon the unknown waters
of the future. We as physicians see a good deal
of the misery of senility, and, as a consequence of
the dreary contemplation, we are wont to say to our-
selves that we had rather die while yet in possession
of a reasonable degree of our natural powers than
live on to be a burden to those who are younger
than ourselves. But as old age creeps on us this
feeling is apt to weaken, so that we cling to life in
spite of our past sentiments.
Some men, on the other hand, cherish at all stages
of their existence the desire of becoming cente-
narians. A few years ago there was formed in
New York an organization known as the Hundred
Year Club, the avowed purpose of which was to as-
sist its members in attaining to advanced age. The
membership, if our memory is not at fault, included
a goodly proportion of medical men. And of late
the versatile Metchnikoff has glowingly held out to
his fellow professionals the prospect of prolonging"
life very decidedly. But it has long been known
that physicians, as a rule, are not destined to lon-
gevity. Individual instances there are, to be sure,
of medical men who have reached advanced age,
and that, too, without notable impairment of their
faculties. A striking example was the late Dr.
Garcelon, whose venerable figure, still alert, was
conspicuous in every meeting of the American
Medical Association up almost to the time of his
death. On the whole, however, physicians die com-
paratively young — younger, on the whole, than
members of the other learned professions.
An interesting exposition of the subject was
offered at a recent meeting of the Philadelphia
County Medical Society, an account of which we
print in this issue of the Journal. The topic of the
particular diseases to which physicians seem to be
prone furnished the opportunity for many a curious
bit of medical biography. Especially noteworthy is
the number of aneurysms with which Dr. Thomas
King Chambers was afflicted. Addiction to drugs
and the excessive use of alcohol, unfortunately, fig-
ure somewhat prominently among the causes of
early death among physicians. Probably our pro-
fessional brethren are naturally no more disposed
to such dangerous violations of prudent living than
other men are, and they certainly ought to profit by
the many examples of their baleful action which
come necessarily to their notice; but the responsi-
bilities of medical practice, to say nothing of its
almost constant interference with the practitioner's
legitimate expectation of diversion, readily lead to
indulgence for the sake of forgetfulness, and the
narcotic drugs have for him a familiarity that tends
to dull his dread of them.
MINOR MIDWIFERY.
A lecture entitled Obstetric Nursing was recently
delivered before the Canadian Nurses' Association
by Dr. David J. Evans, assistant obstetric physician
to the Montreal Maternity Hospital. It is published
in the January number of the Montreal Medical
Journal, where it would not have found a place had
it not contained hints as advantageous to the young
physician as to the nurse. Indeed, much that is
taught in nurses' training schools is well worthy of
the medical novice's attention. This is not wholly
due to the fact that the physician often has to man-
age even the minor details of a case single handed,
being obliged to forego a nurse's assistance; if he
does not know the nurse's duties as well as his ow n.
he can hardly guide her intelligently when, as will
occasionally happen, she betrays misapprehension or
forgetfulness of some point in her training.
It is' the little things that count in the general run
of obstetrical practice. Real danger rarely attends
childbirth, so a man may take no end of pains to
familiarize himself with the technique of the Ce-
sarean operation, for example, and yet fail to acquit
himself creditably in managing the details of a
simple delivery. We should have almost as keen an
eye for a parturient woman's comfort and peace of
mind as for her safety and that of the child. Not
only is this a duty, but it will conduce most power-
fully to that warmth of regard on the part of
220
EDITORIAL ARTICLES.
[New York
Medical Journal.
patients which is so firm a support to the physician
in his practice. The woman who has been thor-
oughly well taken care of in confinement cherishes
for her physician a gratitude so deep that it arms
"him most effectually in his subsequent professional
relations with the family. It is a hallowed feeling
and a priceless one.
Almost as much may be said of the young moth-
er's attachment to the skilled and conscientious
nurse, and it is much to be regretted that many
trained nurses seem .averse to obstetric work. But
perhaps their dislike for it is not entirely due to
fastidiousness; the, business aspect of an obstetric
•engagement is sometimes quite unfair to the nurse,
she being expected to hold herself for a rather in-
definite length of time in readiness to respond
promptly to a hasty call, though entitled to remun-
eration only from the moment of her actual arrival
on the scene. Such a state of things, as Dr. Evans
points out, is all wrong. A soldier draws his pay
and receives his maintenance in times of peace as
well as when he is on the firing line, and so should
it be with the nurse.
ACCIDENTS OF THE OCULAR REACTION
TO TUBERCULIN.
The instillation of tuberculin into the conjunctival
sac is doubtless a very convenient procedure for
eliciting a reaction indicative of the presence of
tuberculous disease somewhere in the body. It ap-
pears, however, that it is not always wholly free
from danger, though it does not yet seem to have
produced permanent ill effects. At a recent meet-
ing of the Medical Society of the Paris Hospitals
{Bulletins et memoires de la Societe incdicale des
hupitaux de Paris, December 12th), M. H. Barbier
showed a boy, thirteen years old, who had been
under treatment in his service for relapsing nephritis
with anasarca, ascites, double pleural effusion, and
signs of congestion of the apex of the right lung.
On the lOth of August, in M. Barbier's absence,
a one per cent, solution of tuberculin was instilled
into the right eye. On the same day there was an in-
tense conjunctival reaction, with photophobia and
lacrymation, which during the succeeding days was
complicated with keratitis, with superficial ulcera-
tion, sufficiently intense to cause loss of vision in the
eye. Early in September the left eye became af-
fected in like manner, and the trouble remained sta-
tionary during the month. At the end of September
M. Barbier resumed his service and found the child
still the subject of decided lesions of both eyes, with
very pronounced functional symptoms. The right
cornea, completely cloudy, so as to prevent vision,
presented ulcerations and pannus. The ocular con-
junctiva was red and oedematous. In the left eye
there were the same lesions, but they were less
intense.
Until the middle of October the child's eyes re-
mained in about the same condition, with ameliora-
tions followed by relapses. The right eye seemed
to improve and the left one to be the more affected,
though there was hardly any power of vision on
the right side. Leucomatous exudates had appeared
in both corneae. . It was not until the end of October
that the inflammatory phenomena had subsided and
the exudates were beginning to be absorbed. Even
then the right cornea showed diffuse cloudiness,
with a central leucoma, but vision was somewhat
improved. The improvement continued during the
month of November, and the sight was finally re-
stored, only two eccentric spots of opacity remain-
ing. It is added that early in 1906 the child had
had keratitis of a month's duration. M. Barbier is
convinced that the tuberculous disease disclosed by
the ophthalmic reaction is often latent, and he seems
to question the advisability of resorting to the test
in general.
At the same meeting M. Louis Renon reported
that in three instances out of twenty-eight trials of
the tuberculin reaction he had observed accidents,
plainly due to the employment of the test, for the
patients had never before had any trouble with the
eyes. In one of his cases there was intense con-
junctivitis, lasting for forty-five days; in another
there was slight keratitis ; and in the third, twenty
days after the reaction, there was extensive inter-
stitial keratitis, with iritis, that lasted for more than
three weeks, with adhesions which required the use
of atropine and eserine to break them up. Possibly,
he said, the use of a tuberculin solution weaker than
one per cent, would not have been followed by un-
toward results.
THE INOCULABLE TUMORS OF MICE.
The successful inoculation of malignant tumors
from man into the lower animals or from animal to
animal is a necessary step in the solution of an
aetiological problem which is at present attracting
much attention. A great deal of work is being done
at present on the carcinomata of mice, a number of
tumors having been discovered which may be trans-
planted from mouse to mouse. Two of the best
known of these are the Jensen tumor, which was
reported in 1903, and the Ehrlich "Stamm II," re-
ported in 1905, although there have been other
tumors described which grow well upon being trans-
planted into healthy mice. Loeb and Hunter, in the
laboratories of the University of Pennsylvania, have
succeeded in inoculating a tumor, which was spon-
February i, 1908.]
XEIVS ITEMS.
221
taneous in a mouse, into other mice with a good
prcportion of reproductions.
Among recent noteworthy contributions to the
literature of the development of the Jensen and
of the Ehrlich "Stamm 11" tumors is a paper by
E. E. Tyzzer {Journal of Medical Research, Novem-
ber). Tyzzer found that actively growing tumors
developed in seventy three cases, 45.6 per cent., of
transplantations of the Jensen variety in ten gen-
erations of mice. Sixteen per cent, of the actively
.growing tumors, however, disappeared spontaneous-
ly. In a few instances reinoculation of a mouse
which had resisted a first inoculation was followed
by the development of a tumor. There is no con-
stant time ratio for the appearance of the tumor
after the inoculation of the animal.
In the case of the Ehrlich "Stamm 11" tumor
ten transplantations gave fifty-nine actively growing
tumors, 52.6 per cent., among the normal mice in-
oculated. In only one of these tumors was spon-
taneous retrogression observed. The tumors pro-
duced by the inoculation of both strains described
are largely necrotic, because the growth of the
epithelium is more rapid than that of the bloodves-
sels. Certain breeds of mice are found to be more
susceptible to these tumors than other breeds.
Metastases were found in connection with four of
the transplanted Jensen tumors, all in the lung ; and
in two of the successful Ehrlich "Stamm 11" in-
oculations, one in the lung, and one in the lung and
the liver. The metastases are distinctly due to
propagation through the bloodvessels. In no instance
were the adjacent lymph nodes involved, although in
some cases the tumor and the lymph node actually
touched each other.
Petos Items.
American Climatological Association. — The annual
meeting will be held in Boston on June 9 to 11. 1908.
Plague in India. — During the week ending December
7. 1907, there were 4.506 cases of plague in India, with 3.430
deaths.
Changes of Address. — Dr. Joseph Kraner, from Bed-
ford Station to 18 West One Hundred and Fourteenth
street. New York.
The Section in Ophthalmology of the College of
Physicians of Philadelphia, at its meeting held on Janu-
ary i6th, elected Dr. Howard J. Hansel chairman, and
Dr. Edward A. Shumway, clerk.
American Medifcine Comes to New York. — Beginning
with the January number. American Medicine, formerly of
Philadelphia, will be published at 84 William street. New
York, with Dr. Frank C. Lewis as managing editor.
To Practise Medicine in Japan. — It is stated on au-
thority that foreign physicians who wish to obtain the right
to practise medicine in Japan may pass the necessary ex-
aminations in English, French, or German, or may employ
the services of an interpreter.
The Tri-County Medical Society of South Jersey,
comprising the counties of Gloucester, Salem, and Cumber-
land, held a meeting in Woodbury, N. J., on Tuesday even-
ing, January 28th. The paper of the evening, on Gas-
troptosis, was read by Dr. Henry D. Beyea.
New York Academy of Medicine. — At a stated meet-
ing to be held on Thursday evening, February 20th, Dr.
Carlos F. MacDonald will read a paper on the Develop-
ment of the Modern Care and Treatment of the Insane as
Illustrated by the New York State Hospital System.
Boston Society for Medical Improvement. — The an-
nual meeting of this society was held on Monday evening,
January 27th. Dr. Charles W. Townsend read a paper on
Congenital Pyloric Stenosis, and Dr. James S. Stone read
a paper on Some Recent Literature on Intussusception.
Women Graduates from the University of Michigan.
■ — Since the University of Michigan became a coeduca-
tional institution in 1871, 2,832 women have received de-
grees. Of these, 2,168 were from the literary department,
442 from the medical school, and 47 from the law depart-
ment.
The Tuberculosis Campaign in New York State.— It
is announced that the State Charities Aid Association has
received from the Russell Sage Foundation the sum of
$10,000, to be used in carrying on the work of the educa-
tional campaign against tuberculosis, which was formally
opened in Albany on IMonday evening. January 27th.
Fremont County, Colo., Medical Society. — At the
annual meeting of this society, which was held recently,
the following officers were elected : President, Dr. C. H.
Graves, of Canon City; vice president. Dr. W. R. William-
son, of Rockvale; secretary and treasurer. Dr. R. C. Adkin-
son, of Florence; delegate to State meeting. Dr. J. W.
Rambo.
New Training School for Nurses. — It is reported that
a nonsectarian training school for nurses will be established
in connection with the Jewish Hospital, Brooklyn. The
training course will be of two years' duration, and will
be under the guidance of Miss Simonson, superintendent
of nurses, and a corps of well known physicians and sur-
geons.
Buffalo Academy of Medicine. — The regular meeting
of the Section in Obstetrics and Gynaecology' was held
on Tuesday, January 28th. Dr. J. G. Clark, of the Uni-
versity of Pennsylvania, read a paper on Enteroptosis, and
illustrated it by stereopticon slides. Dr. Earl Lathrop read
a paper on the Management of Pregnancy and Some of
Its Disorders.
An Opening for a Young Physician. — We are in-
formed that in the town of Grafton, Rensselaer County,
N. Y., there is no physician, the nearest one being at a
distance of eleven miles from the town. The residents of
Grafton are naturally anxious to have a physician establish
himself in their town, and they believe that a good practice
can be built up.
The Philadelphia Medical Club.— At the election
held on January i8th, the following officers were chosen
to serve for the year 190S: Dr. George McClellan, presi-
dent ; Dr. Wharton Sinkler, first vice president ; Dr. James
B. Walker, second vice president; Dr. J. Gurney Taylor,
secretary ; Dr. Lewis H. Adler, Jr., treasurer, and Dr.
Oscar H. Allis, governor.
The Health of Boston. — According to the report of
the Department of Health, during the week ending Janu-
ary II, 1908, the following cases of transmissible diseases
were reported : Tuberculosis, 41 cases, 28 deaths ; enteric
fever, 3 cases, o deaths ; scarlet fever, 28 cases, i death ;
diphtheria, 60 cases, 3 deaths ; measles, 69 cases, 3 deaths.
There were 229 deaths from all causes in an estimated
population of 560,892.
Scientific Society Meetings in Philadelphia for the
Week Ending February 8, 1908. — Monday, February 3d,
Philadelphia Academy of Surgery ; Biological and Micro-
scopical Section, Academy of Natural Sciences: West
Philadelphia Medical Association ; Northwestern Medical
Society. Tuesday, February 4th, Academy of Natural Sci-
ences; Philadelphia Medical Examiners' Association.
Wednesday, February ^th, College of Physicians: Associa-
tion of Clinical Assistants of Wills Hospital. Thursday,
February 6th, Obstetrical Society; Medical Society of the
Southern Dispensary; Section Meeting, Franklin Institute;
Germantown Branch, Philadelphia County Medical Society.
Friday. February jth, American Philosophical Society ;
Kensington Branch. Philadelphia County Medical Society.
222
XEIFS ITEMS.
[New York
Medical Journal.
Pure Food and Drug Law. — It is reported that Pro-
fessor Ira Remsen, of the Johns Hopkins University, has
been asked by President Roosevelt to head the board of
scientists who are to form a consulting committee on the
enforcement of the pure food and drug law. The other
members of the board will be chosen from Yale University,
Northwestern University, the University of California, and
the University of Virginia.
Charitable Bequests. — By the will of Alexander Craw-
ford, the Northern DispensaTy, of Philadelphia, receives
$2,300, and the Sheltering Arms, of Philadelphia, receives
$1,000. In the event of the death of a nephew without
issue the Episcopal Hospital in Philadelphia will receive
$10,000 for the endowment of a free bed, to be known as
the Ann Coleman Crawford free bed ; the Northern Dis-
pensary will receive an additional $3,000, and the Sheltering
Arms will receive an additional $2,000.
Medical Association of the Greater City of New York.
— A special meeting of the association will be held at the
Staten Island Academy, Wall street, St. George, on Mon-
day, February 3d, at 8:30 p. m., under the direction of the
chairman for the Borough of Richmond. The programme
will include a paper by Dr. Robert Abbe on Radium, and
a paper by Dr. Reginald H. Sayre on the Modern Treat-
ment of Bone Tuberculosis. A cordial invitation to the
meeting is extended to all.
A State Home for Inebriates in New York. — At the
annual meeting of the Medical Society of the State of New
York, which was held in Albany, on January 28th, 29th, and
30th, a movement was inaugurated for the establishment of
a State institution for the care of inebriates and persons ad-
dicted to the excessive use of drugs. A resolution recom-
mending to the Governor and the Legislature the im-
portance of such an institution was introduced by Dr. J. D.
Spencer, of Watertown, and adopted by the society.
Chicago and Suburban Health League. — The first
quarterly meeting of this organization was held on January
nth. The health officers in attendance were first taken to
the isolation hospital for a practical demonstration in the
diagnosis and treatment of smallpox, after which the meet-
ing convened at the laboratories of the Department of
Health. Dr. J. A. Lauer, of Whiting, Ind., read a paper
on the Pollution of Water Supplies, and a discussion of
the typhoid situation in surrounding towns followed.
To Investigate Occupational Diseases in Illinois. —
The Governor of the State of Illinois has appointed the
following physicians as members of the Committee of
Nine, authorized by the General Assembly for the purpose
of inxestigating occupational diseases in the State: Dr.
Ludvig Hektoen, pathologist at Rush Medical College;
Dr. George W. Webster, president of the State Board of
Health, and Dr. James A. Egan, secretary of the State
Board of Health. The committee will submit a report to
the next General Assembly.
Traveling Library for Health Officers. — We learn
from the Monthly Bulletin of the New York State Depart-
ment of Health that for the benefit of health officers in
the smaller communities to whom public medical libraries
are not accessible the department has established a library
from which books can be borrowed for a reasonable period.
The number of books is limited, and on this accotmt, for
the present,' those who borrow books will be restricted to
not more than two at one time. If all copies of a book
desired are out, a work on the same or an allied topic will
be sent.
First Aid Packet. — The method of attaching the first
aid packet issued to the Army, the Navy, and the Marine
Corps, has been criticised as being impracticable. The
metal case has also been criticised as soon becoming bright
and furnishing an excellent mark for the enemy. The
hooks provided for attaching the packet have been dis-
carded by the Army, so that the packet may be slipped into
a canvas pouch or pocket attached to the belt by hooks.
It is tmderstood that a similar change will be recominended
l)y the medical department of the Xavy.
Dr. John Ordronaux's Bequests to Charity. — Dr. John
Ordronaux, who died recently in Roslyn, L. I., left about
half of his estate of $300,000 to charity. Dartmouth Col-
lege, his alma mater, receives $30,000 as an endowment ;
the Nassau, Jamaica, and Flushing Hospitals will each re-
ceive $6,000 for the endowment of beds; the Methodist,
Presbyterian, and Catholic churches of Roslyn, and the
Christ Protestant Episcopal Church of Manhasset will each
receive $3,000. Sums varying from $1,000 to $10,000 were
left to various hospitals, churches, and charities.
Seaman Prize Essays. — The subjects for the essays
in this competition are as follows: The Medical Depart-
ment of the United States Army : Upon What Lines
Should its Reorganization Be Instituted? for which a prize
of $100 is offered ; The Company Noncommissioned Offi-
cer: How Can His Efficiency Be Best Promoted and Hi;
Recnlistinent Be Secured? for which a prize of $50 is of-
fered. The terms of the competition mav be obtained upon
application to the Secretary of the Military Service Insti-
tution of the United States, Governor's Island, New York.
N. Y.
The Associated Physicians of Long Island. — At the
tenth annual meeting of this society, which was held on
Saturday, January 25th, in the library building of the
Medical Society of the County of Kings, Brooklyn, officers
were elected to service during the ensuing year, as fol-
lows : President, Dr. H. Beeckman Delatour, of Brook-
lyn ; first vice president. Dr. Frank T. De Lano, of Rock-
ville Centre ; second vice president. Dr. Frank Overton, of
Patchogue; third vice president. Dr. Thomas R. French,
of Brooklyn ; secretary, Dr. James C. Hancock, of Brook-
lyn ; and treasurer, Dr. Charles B. Bacon, of Brooklyn.
The general subject for discussion was Diseases of the
Stomach and Duodenum, and papers on this subject were
read by Dr. Algernon T. Bristow, Dr. H. Beeckman Dela-
tour, Dr. Richard W. Westbrook, and Dr. Walter C. Wood.
The secretary reported that the membership of the society
numbered 473 and applications were received every day.
.'Kfter the meeting the members adjourned to the Imperial,
where a banquet was served.
The Health of Philadelphia.— During the week end-
ing January 4, 1908, the following cases of transmissible
diseases were reported to the Bureau of Health of Phila-
delphia : Typhoid fever, 96 cases, 13 deaths; scarlet fever.
59 cases, 3 deaths; chickenpox, 51 cases, o deaths ; diph-
theria, T15 cases, 10 deaths; cerebrospinal meningitis, 2
cases, 2 deaths ; measles, 74 cases. 3 deaths ; whooping
cough, II cases, 2 deaths; pulmonary tuberculosis, 74 cases,
72 deaths; pneumonia, 133 cases, 122 deaths; erysipelas.
5 cases, 3 deaths ; German measles, 2 cases, o deaths ; septi-
csemia, i case, o deaths : mumps, 9 cases, o deaths ; cancer.
21 cases, 17 deaths; tetanus, i case, i death. The follow-
ing deaths were recorded from other transmissible diseases:
Tuberculosis, other than tuberculosis of tin- 'u-i»s, 7; puer-
peral fever, i; diarrhoea and enteriti■^. ur<kr tw" years of
age, 10. The total deaths nunihercd in an estimated
population of 1.332.738, corresponding to an annual death
rate of 23.30 in 1,000 of population. The total infant mor-
tality wa.s "125; under one year of age, 9b; between one and
two years of age. 29. Tliere were 50 still births — 27 males
and 23 females.
Medical Society of the State of New York.— At the
one hundred and second annual meeting .if this .society,
which was held in .Mli.any ..n January 28tli, 29th. and 30th. the
following olficers wore elected to serve for the year 1908:
President. Dr. Edward Trudeau. of Saranac; first vice
president, Pt. A. (1. Root, of Albany; second vice presi-
dent. Dr. John Wheeler, of Chatham; third vice president.
Dr. M. C. llawley. of East Randolph; secretary. Dr. Wis-
ner R. Townsend, of New York; treasurer. Dr. Alexander
Lambert, of New York; chairman of the Scientific Com-
mittee, Dr. Leo H. Neumann, of .Albany; chairman of the
Committee on Public Health, Dr. J. L. Heffron, of Syra-
cuse: chairman of the Committee on Legislation, Dr. F.
Van ITcet, of New York; chairman of the Committee on
•Arrangements. Dr. W. J. Nellis, of Albany. The follow-
ing named physicians were appointed delegates to the
.American Medical .Association: For one year. Dr. Robert
F. Weir and Dr. Charles Jewett ; for two years. Dr. W.
R. Townsend. Dr. D. C. Moriarta, Dr. C. B. Angell. Dr.
f. C. Bierwirth, and Dr. .Albert Vander Veer. The follow
ing named physicians were appointed altemate delegates
to the .American Medical .Association: For one year. Dr.
J. .A. Fordyce, Dr. A. H. Terry, Dr. W. T. Mulligan, Dr.
C Ci. Rossman, and Dr. F. A. Burrall ; for two years.
Dr. Thornton, Dr. Brown, Dr. Little. Dr. Glass, Dr. Dun-
ning, and Dr. Stover Mr. J. T. Lewis was reappointed
attorney for the society.
February i. ig^-SJ
A'EIVS ITEMS.
The Philadelphia Paediatric Society. — The annual
meeting of this society was held on Tuesday evening, Janu-
ary 14th. Dr. J. P. Crozer Griffith was elected president.
Dr. Herbert B. Carpenter, Dr. J. Claxton Gittings, and Dr.
Charles A. Fife were elected vice presidents. Dr. Howard
Childs Carpenter was elected treasurer. Dr. Maurice
Ostheimer was elected secretary recorder. The executive
committee will be composed of Dr. D. L. Edsall, Dr.
S. McC. Hamill, Dr. Alfred Hand, Dr. T. S. Westcott,
and Dr. B. Franklin Royer. Dr. William M. Bradley, Dr.
Eleanor C. Jones, and Dr. Frank Crozer Knowles were
elected to the membership committee.
New York Hospital for the Care of Crippled and
Deformed Children. — According to the seventh annual
report of this hospital, which has just been published, in
the hospital at West Haverstraw, N. Y., there were forty-
eight patients on the first day of October. Of the twenty-
two discharged during the year, ten were cured, nine were
sent home much improved, two were removed by parents
in opposition to the advice of the medical staff, and one
died of meningitis. There is a waiting list of two hundred
children. Plans for a new hospital, to accommodate four
hundred patients, have been prepared, and the board of
managers hope to receive an appropriation from Albany to
aid them in carrying on the work.
The Manila General Hospital. — A new general hospi-
tal is being erected in Manila, which is located near the
Bureau of Science. It is to be built on the most modern
plan, and will consist of five two story wards, with a ca-
pacity of thirty beds in each ward, and there will be allow-
ance in some of the pavilions for private patients, giving
a total capacity of about three hundred beds. One special
feature of the hospital will be an obstetrical ward for the
training of medical students and midwives in the science
and art of obstetrics. When this hospital is completed it
is the purpose of the Government to cancel its contract
with private hospitals and to merge the present Civil Hos-
pital into the new institution.
American Pharmaceutical Association. — The Phila-
delphia Branch of this association will hold a meeting m
the hall of the College of Physicians, Thirteenth and Locust
streets, on Tuesday evening, February 4th, at eight o'clock.
The general subject for discussion will be the Responsi-
bility of the Retail Druggist in the Spread of "The Great
Black Plague." This subject will be discussed from the
viewpoint of the sociologist, the physician, and the pharma-
cist. The programme will include the following papers :
The Relation of Medical Practice Acts to Contagious and
Infectious Diseases, by Dr. Henry Beates. Jr.; Gonorrhoea,
Its Nature. Prevalency, Recognition, and Treatment, by Dr.
A. A. Uhlc : The Infection of the Innocent and the Suf-
fering and ]\Iisery that is Entailed, by Dr. E. E. Mont-
gomery; Gonorrhceal Iritis and Its Relation to Total and
Partial Blindness, by Dr. George E. de Schweinitz; and
the More Remote Complications of Gonorrhoea in the Male,
hy Dr. Thomas R. Neilson. Many prominent physicians
and sociologists have signified their willingness to take
part in the discussion, and an interesting and instructive
evening is assured.
The Medical Society of the County of New York.—A
stated meeting of this society was held on Friday evening,
January 31st. The retiring president. Dr. Walter Lester
Carr, and the president elect. Dr. J. Riddle GofTe, delivered
addresses, the subject of Dr. Goffe's address being The
Life and Times of the Great Medical Reformer, Thomas
Wakely, M. D., Founder of the London Lancet. The
scientific session was devoted to a symposium on the recent
epidemic of grippe, the following papers being read : The
Scourge as it Appeared in Pittsburgh, by Dr. John A.
Lichty, of Pittsburgh ; Its Course in Baltimore, by Dr. C.
Hampton Jones, 'of Baltimore ; In New York, by Dr.
Thomas Darlington ; Its General Features and Peculiar
Manifestations, by Dr. Alexander Lambert : Its Course in
Children, by Dr. Charles Gilmore Kerley ; Some Throat
and Sinus Complications, by Dr. C. G. Coakley ; The Ear
Complications, by Dr. Edward B. Dench ; Its Ravages in
the Buccal Tissues, by Dr. William Carr. A general dis-
cussion followed. The officers of the society are as fol-
lows: President. Dr. J. Riddle Goffe; first vice president.
Dr. H. Seymour Houghton ; second vice president. Dr.
John E. Weeks ; secretary. Dr. John Van Doren Young ;
assistant secretary. Dr. J. Milton Mabbott ; and treasurer.
Dr. Charles H, Richardson.
The Southside Virginia Medical Association.— At the
December meeting of this association, which comprises
the counties of Dinwiddie, Brunswick, Surry, Sussex,
Prince George, Southampton, and Greensville, the follow-
ing officers were elected for the year 1908: President,
Dr. Lucien Lofton, of Emporia ; first vice president, Dr.
W. B. Barham, of Newsoms ; second vice president, Dr.
L. H. Moseley, of Ebony; third vice president. Dr. J. G.
Rennie, of Petersburg; fourth vice president, Dr. C. W.
Astrop, of Surry; secretary. Dr. E. F. Reese, of Court-
land; and treasurer. Dr. O. C Wright, of Jarratt. The
association meets quarterly, and the next meeting will be
held in Petersburg on the first Tuesday in March.
The Philadelphia Neurological Society.— At a meet-
ing of this society, held on Monday evening, January 27th,
the programme included the following papers : Unilateral
Ascending Paralysis, by Dr. Alfred Gordon; Frerikel
Treatment of Locomotor Ataxia, by Dr. M. D. Bloomfield ;
Card Specimen of a Case of Cerebrospinal Syphilis, by
Dr. D. J. McCarthy and Dr. Milton K. Meyers ; the Symp-
tom Complex of Transverse Lesion of the Spinal Cord and
Its Relation to Structural Changes Therein, by Dr. A. R.
Allen. Dr. F. X. Dercum reported a case of Aphasia,
Motor and Sensory, without a Lesion of the Third Frontal
Convolution, and exhibited a specimen. Dr. W. G. Spiller
presented a patient with Acquired Bilateral Spasticity and
Athetoid Movements, and reported a case of Encephalitis
with Symptoms of Cerebellar Tumor.
Society Meetings for the Coming Week:
MoND-W, February jc?.— German Medical Society of the
City of New York; Utica, N. Y., Medical Library As-
sociation; Niagara Falls, N. Y., Academy of Medicine;
Practitioners' Club, Newark, N. J.; Hartford, Conn.,
Medical Society.
Tuesday, February 4th. — New York Academy of Medicine
(Section in Dermatology) ; New York Neurological
Society; Buffalo Academy of Medicine (Section in
Surgery) ; Ogdensburgh, N. Y., Medical Association ;
Syracuse, N. Y., Academy of Medicine; Hudson
County, N. J., Medical Association (Jersey City) ;
Medical Association of Troy and Vicinity; Hornells-
ville, N. Y., Medical and Surgical Association; Long
Island, N. Y., Medical Society ; Bridgeport, Conn.,
Medical Association.
Wednesd.w, February ^th- — Society of Alumni of Bellevue
Hospital: Harlem Medical Association, New York;
Elmira, N. Y., Academy of Medicine ; Psychiatrical
Society of New York.
Thursday, February 6th. — New York Academy of Medi-
cine ; Dansville, N. Y., Medical Association.
Friday, February 7th. — New York Academy of Medicine
(Section in Surgery) ; New York Microscopical So-
ciety ; Gynaecological Society, Brooklyn ; Manhattan
Clinical Society; Practitioners' Society of New York.
Saturday, February Sth. — Therapeutic Club, New York.
Philadelphia Bureau of Health Statistics.— During
the month of December, 1907, in the Division of Medical
Inspection 3,670 inspections were made, exclusive of
schools ; 632 fumigations were ordered, 56 cases were re-
ferred for special diagnosis ; 4,312 visits were made to
schools; 482 children were excluded from school; 433 cul-
tures were taken; 167 injections of antitoxine were given,
and 342 persons were vaccinated. In the Division of Vital
Statistics 2,546 deaths, 1,757 births, and 714 marriages were
recorded. In the Division of Milk Inspection 7,678 in-
spections were made of 170.862 quarts of milk, of which
339 quarts were condemned. Seven specimens were ex-
amined chemically ; 924 were examined bacteriologically,
and 924 were examined microscopically. In the Division
of Meat and Cattle Inspection 4,348 inspections; 198 were
found unsanitary, and 128 pieces of dressed meat were con-
demned. Th"ree hundred and three post mortem examina-
tions were made, with 22 condemnations. In the Division
of Disinfection 232 fumigations were done for scarlet fever,
548 for diphtheria, 79 for typhoid fever, 148 for tubercu-
losis, 176 for miscellaneous diseases, and 94 schools were
disinfected. In the Bacteriological Laboratory 1,994 cul-
tures were examined for the presence of bacillus diph-
therije; 268 specimens of blood were examined for the
serum diagnosis of typhoid fever; 924 specimens of milk
were examined; 145 specimens of sputum were examined;
6 disinfection tests were made, and 4,738,600 units of anti-
toxine were distributed. In the Chemical Laboratory 136
analyses were made.
224
PITH OF CURRENT LITERATURE.
[New York
Mebical Journal.
|it^ at Ctrmnt 'giMmt.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
lanuary 2^, igo8.
1. The Significance of Postoperative Acetonuria,
By Ernest Boyen Young and John T. Willams.
2. Extracts from Dr. Alexander Hamilton's Intinerary of
1744, By A. Jacobi.
3. ChyUiria Due to Filariasis. With the Report of a Case,
By Richard F. O'Neil
4. The Rontgen Ray Diagnosis of Urinary Calculus,
By E. W. Caldw ell.
5. Trypsin in the Treatment of Malignant Tumors.
By W. P. Graves.
I. The Significance of Postoperative Aceto-
nuria.— Young and Williams state that acetonuria
is a common accompaniment of a large number of
pathological conditions, where it is the result of dis-
turbances of metabolism. The occurrence of aceto-
nuria seems to bear especial relation to disturbances
of the gastroenteric tract, but possibly many of the
cases of reported acetonaemia following operation
were the results of other diseases, especially sepsis.
The formation and excretion of acetone, and proba-
bly also of its supposed antecedents, diacetic acid,
betaoxybutyric acid, etc., following operation, is the
result of altered metabolism and, in the adult at least,
not the cause of any constitutional disturbance. The
authors have made some observations on fifty-two
patients, of whom only two, or about 3.8 per cent.,
had acetonuria before operation, while following
laparotomy acetone was found in the urine of
twenty-seven, or about 52 per cent. The reaction
lasted in different cases from two to eight days. Of
the two patients whose urine contained acetone before
operation, one was a colored girl, fifteen years of
age, who was operated upon for adhesions follow-
ing an acute attack of pelvic inflammation. The
operation was short and the convalescence excellent.
The other was a woman of twenty-seven, who en-
tered the hospital in very poor physical condition.
A double salpingectomy was performed for pyosal-
pinx. Her convalescence was much prolonged, with
rapid pulse, elevation of temperature, vomiting, and
some mental somnolence, without any abdominal
distention or spasm. She ultimately recovered. Out
of the fifty-two laparotomies five patients died, and
of these four had acetonuria. The duration of ace-
tonuria varied from forty-eight hours in tile major-
ity to ten days. Of these patients, sixteen had sub-
sequent laparotomies. In all but two the ace-
tone had disappeared before the time of opera-
tion. In two others there was acetonuria on
entrance and again after operation. In two a
reaction was present on entrance, but not after lapa-
rotomy. In one of these, however, there was con-
siderable vomiting, with rapid pulse and slightly ele-
vated temperature, but terminating in recovery. In
four there was a reaction after operation, but not on
entrance ; and in the remaining six no acetone was
found either on entrance or after operation. It is
seen that acetonuria occurred most frequently in
those cases where there was more or less disturbance
of metabolism, notably puerperal sepsis, hypcremesis
gravidarum, miscarriages (many of which were sep-
tic), carcinoma, and eclampsia. And in those pa-
tients who may be supposed to have suffered from
no disturbance of metabolism, namely, those admit-
ted for lacerations of the cervix and perinaeum, retro-
version fibroid of the uterus, and extrauterine preg-
nancy, it was found most infrequently. Acetonuria
is much more common in children than adults. In
children metabolism is much more active. The child
has not only to replace the amount of tissue used up
each day, but also to provide for growth. It is nat-
ural, then, that children should be more su.sceptible
to changes of metabolism, and therefore that aceto-
nuria resulting from disturbed metabolism should be
more common in them.
4. The Rontgen Ray Diagnosis of Urinary-
Calculi. — Caldwell remarks that the Rontgen ray
furnishes the most accurate single means we have
for the diagnosis of urinary calculi. It has the ad-
vantage over other methods that it not only indi-
cates the presence or absence of calculi, btit their
size, position, and number as well. When a small
calculus is shown in the ureter, the size and shape of
its shadow will sometimes enable us to predict that
it will be passed, and that operation for its removal
will be unnecessary. Occasionally, conditions other
than lithiasis may be indicated, such as tuberculosis,
abscess, and diseases causing a change in the size,
position, or outline of the kidney, or a fibrous thick-
ening of the lower part of the ureter. The x ray i&
not infallible, and in incompetent hands it may be
very misleading, but under the best conditions it is
exceedingly accurate. The indications given by it
often decide the important question of operation.
Such examinations should therefore not be under-
taken lightly, nor intrusted to careless and incom-
petent persons, nor to those who have not a proper
appreciation of the responsibility involved in decid-
ing a question upon which may depend the health
or even the life of a fellow being.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
lanuary 25, 1908.
1. Factors Which Influence the Permanence of Cure in
Operations for Cancer of the Breast,
By William D. Haggard.
2. The Appearance of Glycuronic Acid in Certain Condi-
tions of Diminished Oxidation,
By C. W. Lewis Hacker.
3. Plea for a More Thorough Course in Practical Phar-
macy and Prescription Dispensing in Our Medical
Schools, By M. Clayton Thrush.
4. Calmette's Ophthalmic Reaction to Tuberculin. Pre-
liminary Report Based on Two Hundred and Forty-
two Cases, By Frank Smithies and R. E. Walker.
5. Some Results from Orthodontia on the Deciduous
Teeth, By E. A. Bogue.
6. The Mutual Development of Upper Air Tract, Jaws,
Teeth, and Face, and Their Economic Importance to
the Human Race, By W. Sohier Bryant.
2. The Appearance of Glycuronic Acid in Cer-
tain Conditions of Diminished Oxidation. —
Haeker remarks that in the first series of his exam-
inations 384 samples of supposedly normal urine of
patients in the hospitals of Albany were examined
in the hope of finding a pseudoreaction, which is
obtained by using a large amount of urine with
Fehling's solution, and of connecting it with the
presence of glycuronic acid or glycuronates. In no
case could there be determined the presence of
these latter compounds in amounts more than the
normal or sufficient to render it of value for diag-
nostic purposes. Fourteen various samples of gly-
cosuric urines were quantitatively examined, with
the following results: Gerrard's and Fehling's
February i, 1908.]
PITH UP CURRENT LITERATURE
225
quantitative methods agreed to within o.i per cent.
The results by the saccharometer were uniformly
lower and usually by o.i to 0.7 per cent. This dif-
ference agreed, however, with surprising accuracy
with that found in the polarization determination
before and after fermentation. The figures obtained
by subtracting the results of polarization before and
after fermentation corresponded to saccharometer
readings to within 0.1 per cent. These facts indi-
■cate that both quantitative copper tests include sub-
stances which are not dextrose and which turn the
plane of polarized light to the left to the extent of
from O.I to 0.7 per cent, (calculated as dextrose j.
The saccharometer readings do not include these
■compounds, hence they are not fermentable. It may
be said that in these urines glycuronic acid or its
salts was not present in excessive amounts. In the
second series of examinations attention was turned
to the postoperative specimens, in the hope that in
the condition of diminished oxidation following
anaesthesia glycuronates might be detected in ab-
normal amounts. All the samples were voided
within twelve hours after operation. In all 273
specimens were examined, of which 261 were voided
after ether anaesthesia, eleven following chloroform,
and one after a mixture of the two. Examination of
the urines previous to the operations showed no
reducing compounds to be present. Subsequent to
the operations eleven samples of urine, voided after
ether, gave positive reductions with Fehling's test,
and on further examination the reducing substance
was shown to be dextrose in amounts from 0.2 to
1.3 per cent. The length and character of the opera-
tion apparently has no effect on the amount of dex-
trose eliminated. The patients were persons from
twenty to thirty-five years of age. Xone of the
chloroform samples or the chloroform ether sample
resulted positively. This is probably to be explained
by the use of oxygen during the operation, thereby
preventing diminished oxidation in the tissues. The
author concludes that dextrose appeared in 4 per
cent, of 261 samples of urine collected after opera-
tions in which ether was employed. Neither glycu-
ronic acid nor its conjugate salts are eliminated in
the urine under conditions of diminished oxidation,
such as occur during diabetes mellitus and ether or
chloroform anaesthesia, when the latter is combined
with oxygen. The pseudoreduction obtained in
about 5 per cent, of normal urines is to be ascribed
to faulty methods of performing the test. It is not
due to an increase in amount of uric acid or crea-
tinin.
4. Calmette's Ophthalmic Reaction to Tuber-
culin.— Smithies and Walker describe their ex-
perience with the Calmette ophthalmic reaction to
tuberculin. They had 185 patients, clinically diag-
nosticated as tuberculous cases; 176 of these gave
positive reactions, nine negative : of twenty-eight
doubtfully tuberculous cases twenty-one gave posi-
tive reactions, seven negative : of 188 persons suffer-
ing from disease not tuberculous, and including a
fair proportion of apparentlv normal individuals, 186
gave negative reactions and only two were positive.
The authors are convinced that the ophthalmic reac-
tion as directed to be practised by Calmette and
others is of undoubted service in the diagnosis of
tuberculosis. In no case where its worth could
be tested clinically by the finding of tubercle bacilli
did they fail to obtain decided ocular manifes-
tations following the instillation of the tuberculin.
This reaction did not follow w-hen instillations
w^ere made in the case of 126 individuals affected
with disease other than tuberculosis. It was not
obtained in sevent_\ -four apparently normal adults.
A proper technique for administration is neces-
sary for the success of the reaction. Whether
or not smaller dosage would produce recog-
nizable effects is not at present fully decided.
Reaciicns have, however, been obtained when sus-
pensions of 0.5 per cent, were used. When positive
reaction follows promptly on the first instillation it
appears that the diagnosis of tuberculosis is reason-
ably certain. The fact that a reaction thus appears
does not mean that the subject is affected with an
active tuberculous process, although the evidence is
strongly in favor of such. Presupposing this might,
in some instances, lead to unnecessary alarm and
much inconvenience. The ophthalmic reaction, as is
the case with every form of tuberculin test, must be
accompanied by complete examination of the sus-
pected focus in order to be judged properly. All
suspicious cases which fail to respond to one instilla-
tion should be reinstilled from two to five times, and
careful examinations, local and general, made after
each instillation. Too little work has as yet been
done to allow conclusions to be drawn regarding the
relative value of the ophthalmic reaction and the
subcutaneous or the skin reactions to tuberlin.
In seven of their cases in which both the sub-
cutaneous and ophthalmic reactions had been tried
positive evidence was furnished in each case. They
have had no experience with the cutaneous reaction.
None of the reactions take the place of thorough
examination of the patient, from every viewpoint.
They are all confirmatory. Properly administered,
they believe that the accumulation of more data will
show that the ophthalmic reaction is quite as valu-
able to the general practitioner as are any of the
others. Its convenience and rapidity of action cer-
tainly commend it. The hypothesis advanced by the
authors is as follows : The inflammatory changes in
the eyes of tuberculous individuals follow-ing the
instillation of tuberculin suspensions is due to the
slight stimulation of the hypersensitive cells form-
ing protective substances, with the production of an
excess of antibodies. These antibodies so produced,
by acting on the tubercle bacilli or fragments of such
enmeshed in the conjunctiva, liberate endotoxines
which are capable of producing the inflammatory-
changes commonly observed.
MEDICAL RECORD.
January jj, igo8.
1. Upon ^^■hat Does the Cure of Tuberculosis Depend?
By F. M. POTTEXGER.
2. The Death Rate of the City of New York as Affected
by the Cosmopolitan Character of Its Population,
By William H. Guilfoy.
3. Report of a Case of Acute Gastrectasis, Following
Typhoid Fever and Premature Birth ; Recovery,
By Albert E. Roussel.
4. Chancroidal Bubo and Its Treatment.
By Henry H. Morton.
5. Syphilitic Fever, with Report of a Case.
By E. D. NEWM.A.N.
6. The Surgical Value of Iodine,
By Walter T. Dannreuther.
7. Carbolic Gangrene, By Isaac Levin.
8. A Case of Ectopic Gestation. Diagnosis and Opera-
tion Before Rupture. By William H. Dukeman.
220
PITH OF CURRENT LITERATURE.
[Nlvv York
Medical Journal.
2. The Death Rate of the City of New York
as Affected by the CosmopoUtan Character of
Its Population. — The conchisions to be drawn from
Dr. Guilfoy's carefully prepared tables show tbat
the natives of Ireland, by reason in great measure
of their living at imfavorable age groups, increase
the general mortality, and this is also true to a lesser
extent of France, Switzerland, and Scotland ; the
natives of Italy, Bohemia, and the United States
are credited with a rate almost the same as that
of the general average of the city, while the
natives of Sweden, Germany, Russia-Poland,
Austria-Hungary, and England affect favorably
the general mortality. On the other hand, the
immediate descendants of the Irish, Italians, and
Austro-Hungarians are instrumental in increasing
the general rate and also the rate from certain pre-
ventable and infectious diseases ; the immediate de-
scendants of most of the other nationalities, includ-
ing Americans, serve to lower the general rate. The
last of his tables shows the death rate per 1,000
from certain diseases and all causes in selected
square blocks typical of some of the nationalities and
races, the population of these blocks numbering
from 1,400 to 5,100 inhabitants, and are situated in
congested areas of the city. i. The Negro block. —
The influence of the negro's presence upon the mor-
tality rates is always cumulative and is clearly shown
in the table; the general rate, 38.56 per 1,000, of
the selected negro block (San Juan Hill) is more
thaq double that of the city at large ; the rate from
pulmonary tuberculosis is three and a half times
that of the average for the city and is only ex-
ceeded by that of the Chinese block ; the mortality
from organic heart, chronic Bright's, pneumonias,
and diarrhceal diseases is also excessively high ;
throughout the greater city the mortality among the
colored population is 27.16 per 1,000, as against
one of 18.19 among the whites, the general death
rate being 18.35, the effect of the negro population
being to increase the rate by 0.16 of a point. 2. The
Syrian block. — The general rate of 35.83 per 1,000
almost equals that of the negro block, and the mor-
tality from cancer, pneumonia, and diarrhceal dis-
eases is greater than that of the negro. 3. The Chinese
block contains about 1,450 Chinamen and is noted as
the block with the highest death rate from pul-
monary tuberculosis, as well as for its unsavory
police record; the general rate is 34.65 per 1,000,
and it also shows a rate from pneumonia almost
as high as that of the Italian block. 4. Irish block
shows a high general death rate and a high
rate in all diseases preponderating at middle or ad-
vanced ages. 5. Bohemian block shows a moder-
ately high general death rate and excessively high
rate from pulmonary tuberculosis and organic heart
disease. 6. Italian block shows a general rate
slightly above the average but the highest rate from
the pneumonias. 7. Russian-Polish block shows a
low general rate with a pneumonia death rate some-
what above the average. The low rates in the Jew-
ish block and throughout the city can be ascribed to
several causes ; although living in densely populated
sections, the Jew, by reason of his temperate habits
and his inherited vitality, is able to resist and over-
come infection ; or, as has been said of the Jew, he is
physically "tough" in its best sense ; again, the pres-
ent status of the Jew as to age distribution is favor-
able at most age periods, with the exception of under
five years. 8. The Austro-Hungarian block makes a
very presentable showing. 9. The German block
shows the lowest general death rate, the only rate
much above the average being that from cancer.
4. Chancroidal Bubo and Its Treatment. —
Morton, of Brooklyn, advocates the following treat-
ment, which was suggested to him by a visit to the
Charite in Berlin: When a bubo first appears,
an attempt should always be made to prevent
suppuration by putting the patient to bed.
The ice bag is no longer used, because it
has been found that resolution will take place
just as well with warm applications. Injection
mto the substance of the gland of antiseptic solu-
tions has also been abandoned as useless. The
bubo is covered with gauze, wet with 95 per cent,
alcohol, and with cotton wadding and perforated
gutta percha tissue to pi event too rapid evaporation.
The alcohol is renewed twice a day as it evaporates.
Another method is fomentation with solution of
ammonium acetate used warm and frequently re-
newed. Tincture of iodine has little or no value as
an absorbent. After fluctuation has begun the
warm applications should be changed for hot ones,
to encourage rapid breaking down of the glands.
The thermolyte bags are useful, as they can be used
with the hot fomentations and serve to retain the
heat for a long time. After the bubo is thoroughly
broken down and full of pus, a small incision is
made with a double edged knife and the pus evacu-'
ated. A 10 per cent, iodoform glycerin emulsion is
then injected into the wound. The injection is made
three times at the first sitting, the first two injec-
tions being allowed to run out and the last one re-
tained. The wound is then bandaged over night with
fomentations of solution of ammonium acetaie. On
the following day the bubo is emptied by squeezing
out and the injection is again made. The wound
is then bandaged and left undisturbed for five or
six days. At the end of that time, in the great ma-
jority of cases the bubo is healed and the patient re-
quires no further treatment.
8. A Case of Ectopic Gestation. — Dukeman
describes such a case and states that his diagnosis
of probable tubal gestation was based on the follow-
ing points: i, The cessation of menstruation the
month previous in a healthy woman ; 2, the character
of the pain penetrating and radiating toward the
heart and the anxious manner in which the patient
described the pain ; 3, slight haemorrhage for a
couple of days, accompanied by the peculiar pelvic
pains, which then ceased ; 4, tenderness over the left
pelvic wall.
BRITISH MEDICAL JOURNAL
January 11, igo8.
1. Hospital Treatment of Morbid Pregnancies.
By J. W. Ballantyne.
2. The Bacteriological Aspects of the Problem of Neu-
rophatic Keratitis, By H. M. Davies and G. Hall.
3. A Plea for the Improvement in the Teaching and an
Encouragement in the Study of Legal Medicine.
By J. J. BuiST,
4. Cancer, Its .^Itiology and Treatment by Trypsin,
By J. .A.LCIKDOR.
I. Morbid Pregnancies. — Ballantyne advocates
February i, 1908.]
PITH OF CURRENT LITERATURE.
227
the establishment of what he calls "prematernity"
beds in ma^ternity hospitals, which beds should be
strictly reserved for the reception of cases of mor-
bid pregnancies. Such beds should be placed in a
ward by themselves and should be in charge of a
nurse or nurses who have had surgical and medical
as well as obstetrical experience. Special attention
should be paid to urine analysis, to examination of
the blood and nervous system, to ophthalmoscopic
investigations, and to a detailed and thorough exam-
ination of the signs and symptoms of pregnancy,
including estimations and descriptions of the foetal
heart and of the foetal movements. Suitable cases
for treatment in prematernity beds are pregnant
patients suffering from albuminuria, heart disease,
intractable vomiting, pulmonary disease, hepatic dis-
ease, anaemia and other blood disorders, and various
nervous maladies, especially epilepsy, hysteroepilep-
s}', hysteria, chorea gravidarum, and paralysis. Dis-
eases of the reproductive organs themselves, such
as retroversion of the gravid uterus, threatened
abortion, pruritus and oedema vulvas, uterine pro-
lapse, cystocele, vulvar inflammation and abscess,
uterine myomata as complications of pregnancy, and
suspected ectopic gestation, might all very properly
be treated in prematernity beds. The same is
true of hydramnies and overdistension of the uterus
(twins), and suspected cases of hydatid mole,
placental haemorrhage, missed abortion, or an-
tenatal death or deformity. Further patients who
have suffered in past pregnancies from "habitual"
abortion, "habitual" foetal death or disease,
"habitual" prematurity or postmaturity, or from
eclampsia, might there be suitably treated in
order, if possible, to prevent the recurrence of these
reproductive disasters. Cases unsuitable for treat-
ment in such a prematernity bed are those of infec-
tious fevers (scarlet fever, measles, typhoid, ery-
sipelas) occurring as complications of pregnancy,
and those of insanity in pregnancy. It is doubtful
whether cases of syphilis should be dealt with, but
patients suffering from gonorrhoeal vaginitis and
vulvitis might be taken in and treated during their
pregnancies. Alcoholism and dipsomania in preg-
nant women might be regarded as suitable for treat-
ment, but actual delirium tremens should find a
home elsewhere until the acute stage has passed ofif.
2. Neuropathic Keratitis. — Davies and Hall
have studied the aetiology of neuropathic keratitis,
paying special attention to its bacteriology. Its in-
timate relationship to disturbances of the fifth nerve
and Gasserian ganglion has led to the eye changes
in all cases being considered as secondary to the
morbid condition or disturbance of the Gasserian
ganglion. Among the various hypotheses may be
mentioned the following : Purely trophic, trophic
with central irritation, trophic with peripheral irri-
tation, vasomotor, vasomotor traumatic, purely trau-
matic, and desiccation. Finally there is the mycotic
hypothesis, looking on microorganisms as an aeetio-
logical factor. This is the one most favored by the
writers. They investigated tv.^enty-one cases of neu-
ropathic keratitis, and found a certain organism,
called by them the Bacillus x, to be present in the
conjunctival sacs of all. The organism could be
demonstrated, together with staphylococci, among
the epithelial cells at the margin of the ulcer of the
excised eye. This same bacillus was found in about
30 per cent, of normal people, but it was not found
in those cases which did not develop keratitis after
removal of the Gasserian ganglion. The writers
conclude that the presence of the x bacillus in the
sac is necessary for the production of neuropathic
keratitis, but that it does not cause it unless there is
an associated lesion of the Gasserian ganglion. Even
in the latter case the disease does not develop if the
eyelids are sewn together, of if the disease is already
present. It tends to heal rapidly after suture of the
eyelids. So that for the production of neuropathic
keratitis three factors must be present: (i) Re-
moval of the Gasserian ganglion ; (2) the presence
of the bacillus; and (3) a factor of undefined nature
dependent on the eyelids and removed by closing
them, (i) and (2) are not adequate alone, as suture
of the lids prevents or cures neuropathic keratitis ;
(i) and (3) are not adequate alone, as keratitis only
occurs after destructive lesions of the Gasserian
gangloin when the organism is present and in the
same proportion of patients as that in which the
organism occurs in normal persons.
4. Cancer. — Alcindor holds that the predis-
posing factor in malignant disease is lowered vital-
itv, whether due to faulty metabolism, alcoholism,
overstimulation, disease of trophic nerves, or the de-
bilities, local or general. Chronic irritation, of no
matter what character, is the determining factor;
the cells of the tissue irritated, unable to respond
normally to the irritant, assume characteristics suit-
able for their environment, thus conforming to a
natural law. Trypsin is of considerable value in
cancer. Cancer of the cervix of the uterus, rodent
ulcer, and epithelioma are eminently suitable for the
treatment. Gout, rheumatoid arthritis, and chronic
rheumatism ought to be treated by injections of
trypsin when other better known methods have
failed. Amylopsin, either alone or in combination
with trypsin, is of no value in the treatment of
cancer.
LANCET.
January 11, jgo8.
1. Certain Bacterial Infections of the Urinary Tract in
Childhood, By C. R. Box.
2. The Infectivity of Cancer, By A. T. Brand.
3. On Anomalous Reactions Obtained in Testing Urine
for Sugar with Fehling's Solution, By H. Ma'^Lean.
4. On Ferments and Their Mode of Action,
By A. Ransome.
5. A Case of Paraplegia Due to an Intramedullary Lesion
and Treated with Some Success by the Removal of
a Local Accumulation of Fluid,
By W. B. Warrington and K. W. Monsarrat.
6. Further Observations on Salts of the Alkaline Earths
.which Affect the Coagulability of the Blood,
By J. B. NiAS.
7. A Case of Echinococcus Disease,
By A. M. SoRABYi.
8. Sudden and Complete Inversion of the Uterus: Its
Probable Causation, By A. Maude.
9. On Blood Coagulability in the Puerperal State,
By R. H. Fox.
I. Bacilluria in Childhood. — Box classifies in-
fections of the urinary tract in children as (i) de-
scending infections, (2) ascending infections, and
(3) infections by contiguity. Descending infection
228
PITH OF CURRENT LITERATURE.
[New York
Medical Jourxal.
is synonymous with infection carried to the kidney
by the blood stream, and is therefore termed "hsema-
togenous." But, while descending invasion does
undoubtedly occur, yet the common cause of uacil-
luria in children is an ascending infection. The
commonest form is that which is due to the colon
bacillus. Although the disease may occur in males,
it is much more common in females, which is strong
corroborative evidence of its ascending character, for
the shortness of the female urethra and the proxim-
ity of its orifice to the anus render infection easy.
In babies infection through the urethra may occur
from soiled napkins or from the passage of stools
over the vulva. Infection of the urinary passages
in childhood may manifest itself as pyelitis, cystitis,
or incontinence of urine without obtrusive evidence
•of local inflammation. Pyelitis may occur as a feb-
rile affection with sudden onset, chills, and pyrexia.
When the course of the disease is protracted emaci-
ation rapidly occurs. Enlargement of the spleen
may often be detected, and sweating may be pro-
nounced. As a rule, the local manifestations of the
■disease are unilateral, and the right kidney is more
apt to be affected than the left. Slight vulvitis is
present in some cases. Incontinence of urine if often
associated with bacilluria, and the organism present
is almost invariably the colon bacillus. The reaction
of the urine is generally faintly acid, never alkaline.
The prognosis of these colon infections must be
guarded, as they may drag on for months. Fre-
quent bathing and the avoidance of urethral con-
tamination from the anus are important preventive
measures. Full doses of potassium citrate combined
with the sedatives of the belladonna group often
act well, but belladonna is disappointing in invet-
erate cases. The writer has tried antibacillus coli
serum in two cases of incontinence. In one the serum
stopped the incontinence, though the bacilluria per-
sisted. In the other the serum had no effect.
2. Cancer. — Brand discusses the causation and
infectivity of cancer. Among the new facts discov-
ered about cancer in recent years are the following :
I. The mitosis of the cells of malignant neoplasms
has been found to be heterotype in character, where-
as the mitosis of all somatic cells with one excep-
tion, and of the cells of benign tumors, is homotype.
The mitosis of normal reproductive tissue is also
heterotype. 2. It has been discovered that cancer is
not restricted to the higher vertebrata, e. g., man
and the domesticated animals, as was at one time sup-
posed, but that it occurs in all vertebrata, with the
possible ■ exception of certain reptilia. The malig-
nant growths occurring in other vertebrata are iden-
tical with those found in man, clinically, patholog-
ically, anatomically, and microscopically. 3. The
transmissibility of malignant new growths from one
lower animal to another of the same species has been
demonstrated. The writer enumerates two final syl-
logisms: I. All diseases which are infectious to the
individual are transmissible to others. Cancer is
infectious to the individual. Therefore cancer is
transmissible to others. 2. All diseases which are
infectious to the individual have an exterm! origin.
Cancer is infectious to the individual. Therefore
cancer has an external origin.
4. Ferments. — Ransome discusses the mode
of action of organized and unorganized ferments
and their relationship to one another. Fermentations
may be grouped under two heads — first, those in
which microorganisms are always present, and, sec-
ondl}-, those in which the specific agent is unorgan-
ized. In the first group are included (i) all the or-
ganisms concerned in the production of fermented
liquors; (2) the microorganisms producing various
eruptive, contagious, and noncontagious diseases,
such as scarlet fever, measles, diphtheria, malaria,
sleeping sickness, and the various epizootics. In the
second group are ( i ) all the physiological ferments ;
(2) those bringing together the components of essen-
tial oils and dyes; (3) those which assist in the
ripening of fruits ; and (4) the unorganized deriva-
tives of living ferments. The enzymes produced by
living organisms have been grouped under the fol-
lowing heads: (i) Proteolytic, (2) .diastatic, (3)
invei'ting, (4) coagulation, and (5) sugar split-
ting. One of the most important attributes of fer-
ments in general is the specificity.
6. The Alkaline Earths. — Nias has studied the
haemostatic action of the alkaline earths, and con-
cludes that none come up to the lactates and chlo-
rides and carbonates if duly assimilated, and that we
should rely on these for the treatment of haemophilia.
For urticaria and conditions of general debility there
is perhaps a larger selection.
g. The Blood in the Puerperium. — Fox records
observations made by him on the coagulation time
of the blood in the puerperal condition. He finds
the coagulation time immediately after delivery is
below the normal, but not markedly so. Under
careful management of labor the hjjemorrhage is less
and the blood coagulability is less altered. In every
case in which two successive observations were taken
the coagulation time increased during the interval.
The excretion of calcium salts in the milk tending to
reduce the coagulability of the blood was probably
one cause of this increase. An observation of the
coagulation time of the blood after delivery might
give useful warning of the risk of thrombosis or em-
bolism if the coagulation time were low, or of post
partum haemorrhage if it were high. Appropriate
treatment — for example, with citric acid on the one
hand or with calcium lactate and salines on the other
— would rectify the condition.
LA PRESSE MEDICALE.
January i, i^ioS.
1. Reflex Troubles of the Pulse in x\ppendicitis (Retarda-
tion, Arythmia Acceleration), By A. Broca.
2. Muscular Physiology. Gymnastics of the Cervical
Region, By Desfosses.
3. Gag and Tongue Depressor, By G. Mahu.
1. Reflex Troubles of the Pulse in Appendi-
citis.— Broca mentions cases of children suffer-
ing from appendicitis whose pulses were very slow
or irregular or rapid, and discusses the probable
causes.
2. Gymnastics of the Cervical Region. — Des-
fosses gives an excellent study of the musculature of
the neck illustrated by many cuts, and then describes
the effects produced by certain gynmastic exercises.
3. Gag and Tongue Depressor. Mahu pre-
sents a description of an instrument he has devised
to keep the mouth open and the tongue depressed at
the same time. It dift'crs only in unimportant details
February i, 1908.]
PITH OP CURRENT LITERATURE.
229
from other instruments that have been devised for
the same purpose.
LA SEMAINE MEDICALE.
January i, igoS.
1. The Abnormal Multiplicity of Cardiac Murmurs,
By L. Bard.
2. A Little Recognized Syndrome Characteristic of a
Family. Multiple Telangiectases with Repeated
Haemorrhages.
I. The Abnormal Multiplicity of Cardiac
Murmurs— Bard pleads for a clearer classifica-
tion of these murmurs, as their number has become
unaccountably multiplied in the descriptions given.
BERLINER KLINISCHE WOCHENSCHRIFT.
December 30, 1907.
1. Oxidation of Sugar, By G. Rosenfeld.
2. Concerning Micrococcus Influenza, Infectious Allor-
rhythmia of the Heart and Nycturia, with Observa-
tions Concerning Pyocyanasis, Quinine, Gas Baths,
and the Action of Acids on the Organism,
By BlEDERT.
3. Experiences with the Meningococcus Serum in Cases
of Cerebrospinal Meningitis, By W. Schultz.
4. Symptomatology of Tumors of the Brain,
By H. HiRSCHFELD.
5. A Case of Diffuse, Foetid, External Otitis in a Tele-
phone Operative, By Hamm.
6. Concerning Suboccipital Inflammations (Concluded),
By L. GRiJNWALD.
3. Meningococcus Serum in Cases of Cerebro-
spinal Meningitis. — Schultz reports a case of
'cerebrospinal meningitis in which he unsuccessfully
injected Kolle-Wassermann's meningococcus serum
and compares statistics he has collated thus: Of
twenty-three patients treated with serum thirteen
died, a mortality, of 56.5 per cent. Of forty-one
patients not treated with serum twenty-two died, a
mortality of 53.7 per cent. Hence he is of the opin-
ion that we are not yet in a position to combat satis-
factorily epidemic cerebrospinal meningitis with
Kolle-Wassermann's serum.
4. Symptomatology of Tumors of the Brain.
— Hirschfeld reports two cases which demonstrate
beautifully the difficulties met with in making a
diagnosis of brain tumor. The first case was one
of a large adenocarcinoma of a cerebellar hemi-
sphere with three smaller, similar tumors, one ex-
tracerebral and two intracerebral, in a woman,
sixty-three years of age, who presented a great mul-
tipHcity of symptoms. The second case was one of
a symptomless tumor of the hypophysis, aneurysm
of the carotid at the sella turcica, and proliferating
endarteritis of the small vessels of the brain in a
woman thirty-six years old.
5. External Otitis in a Telephone Operative.
— Hamm reports a case of diffuse, foetid, external
otitis met with in a telephone operative, which he
is inclined to ascribe to the effect of the electric
current.
6. Suboccipital Inflammation. — Griinwald adds
another case to those reported in the first part of
his paper and then presents the following conclu-
sions: I. Suboccipital inflammation is dependent
not only on tuberculosis of the occiput and vertebra,
but may be induced by other inflammatory pro-
cesses, such as diseases of the ear, traumatic diseases
of the base of the skull, particularly diseases of the
accessory sinuses, also of the teeth, and finally syphi-
lis. 2. The suppuration calls forth various symp-
toms according to the course which it takes and the
organs it involves, but under all circumstances it
causes certain typical symptoms. 3. Among the
most marked, or at least most important, of such
symptoms should be mentioned the more or less ex-
tensive opisthotonos together with the early com-
mencement of the pains localized in the region of the
trigeminus or occipitalis as particularly characteris-
tic. It is, therefore, to be recommended, without
going further into the nomenclature, to unite all
these processes under the title of suboccipital inflam-
mations and to consider more closely only the origin
and course. 4. In the late stage the infiltrate in the
nape of the neck points to the seat of the inflamma-
tion. Perforation into the retropharyngeal space is
less characteristic. 5. The original focus can be
recognized often only from the course of the symp-
toms as regards time and place, because one and the
same localization can have either primary or second-
ary importance. The focus may remain latent for a
long time. 6. The closest attention should be paid
to symptoms of perforation, sudden diminution of
the pain, of the fever, and the motor disturbances,
because these correspond to the extension to a larger
region of the hitherto closely circumscribed process,
and so in any given case, point out the final moment
when, by an immediate operation, an itnlooked for
or even fatal result may be avoided. 7. A careful
study of the temperature is particularly useful not
only to watch the course but also to enable us to
recognize this critical moment in which the exten-
sion commences. 8. Before the development of
marked suppuration the attempt is justified to secure
a retrogression of the process by absolute fixation of
the head.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT
December 24, 1907.
1. Observations Concerning Gastric Digestion,
By COHNHEIM.
2. Cutaneous and Eye Reactions to Tuberculin,
By Mainini.
3. Investigations Concerning the Ophthalmoreaction of
Tuberculosis, By Wiens and Gunther.
4. Critical Remarks Concerning the Clinical Signification
of the Ophthalmoreaction of Tuberculosis,
By Klieneberger.
5. Concerning the Antitoxic Function and Albumin,
By Much.
6. New Experiment Concerning the Demonstration of the
Toxine in the Blood of Patients with Diphtheria,
By Uffenheimer.
7. Concerning Albuminuria and Concerning the Propor-
tionate Excretion of Salicylic Acid from Healthy
and Rheumatic Persons, By Ehrmann.
8. Sahli's Desmoid Reaction, Schmidt's Test Meal and
Siphoning, By Tottmann.
9. Diagnosis of Epidural Hsematoma, By Lindner.
10. Haemorrhage from Vaginal Varix During Pregnancy,
By Gritnebaum.
11. The Medical Service in the Road Construction from
Daresaalam to Morogoro, By Krauss.
12. The Stand Taken by Josef Gossmann in Regard to
Professional Ethics, By Krecke.
2, 3, and 4. Cutaneous and Eye Reactions to
Tuberculin. — Mainini asserts that (i) the cutane-
ous as well as the ophthalmoreaction is positive in
persons with positive tuberculosis with great con-
stancy, with the exception of very advanced cases;
(2) the specificity of this reaction is probable for
many reasons, though not yet proved; (3) in indi-
230
PITH OF CURRENT LlTERAILkE.
[New York
Medical Journal.
viduals not suspected of tuberculosis the cutaneous
reaction has perhaps a six times higher value than
the ophthalmoreaction; (4) under the assumption
that the reaction is specific this contradiction ap-
pears that the ophthalmoreaction points to an
active tuberculosis chiefly, while von Pirquet's re-
action indicates rather a latent focus. — Wiens and
Giinther state that tliey obtained in a number of
cases very serious changes in the eye from the in-
stillation of a I per cent, solution of tuberculin as
recommended by Calmette, and allege that this
procedure is not so harmless and unimportant as
has been supposed. — Klieneberger investigated the
ophthalmoreaction of tuberculin in sixty-one cases,
nine tuberculosis, six suspicious, and forty-six pre-
senting no clinical signs of tuberculosis. All of the
nine tuberculous cases reacted positively to the sec-
ond instillation, even those in whom the reaction
to the first instillation had been negative or doubt-
ful. The second reaction was more severe in the
mild cases than in the serious ones, and was milder
than the first in only one case. Very severe in-
flammatory symptoms appeared in one case of pul-
monary tuberculosis. Of the six suspicious cases
only two reacted positively to the repeated instilla-
tion. These had reacted slightly to the first, but
the second was more pronounced. Of the forty-
six cases in which there was no clinical evidence of
tuberculosis, thirty-six reacted positively to the sec-
ond instillation, 78 per cent. Twenty-eight of these
presented no trace of reaction to the first instilla-
tion, while in the others the first reaction was weak
or questionable. The severity of the symptoms in-
duced by the second instillation was marked, as a
severe conjunctivitis was induced in sixteen of this
group by the repe"ated instillations. In five there
was a considerable swelling of the lids, diffuse
hsematoma, and chemosis of the conjunctiva, condi-
tions which rendered necessary a long course of
treatment. Klieneberger will not grant that there
was latent tuberculosis in 78 per cent, of the per-
sons who presented no clinical signs of the disease,
and hence concludes that reaction from repeated
instillations is of no clinical value. He considers
the reaction to the second instillation as one • of
hypersensitiveness and not serviceable for diag-
nostic purposes.
5. Antitoxic Function and Albumin. — Much
gives a detailed account of his experiments and
suggests three possibilities to account for his re-
sults, the most probable of which he believes to be
that antitoxine is not albumin, but that the separa-
tion of the antitoxic function from the albumin
which cannot be brought about in the test tube is
accomplished in the milk glands.
7. Albuminuria and the Excretion of Salicylic
Acid. — Ehrmann finds that in normal persons
without acute or chronic arthritis the urine remains
free from albumin after a single dose of 5 grammes
of sodium salicylate. In a few cases a very slight
ring of albumin appeared, which disappeared after
a day or two. Repeated doses of 5 grammes usual-
ly produced no albumin. In the few in which a
ring of albumin appeared at first it disappeared as
after a single do.se. In spite of repeated doses. Jn
patients with acute and chronic arthritis the same
was true. In them, likewise, when albuminuria
was caused it disappeared again in spite of repeat-
ed doses. He found also that the period of the
greatest excretion of salicylic acid did not coin-
cide in time with the appearance of albumin. He
finds the duration of excretion to be from thirty-
six to forty-eight hours. The real dangers of treat-
ment with salicylic acid he believes are not to be
found in its action on the kidneys, but in its effect
upon, the brain and spinal cord.
December 31, igoj.
1. Concerning the Antiferment Reaction of the Blood and
its Relations to the Opsonic Strength in Acute In-
fectious Diseases, By Wiens.
2. Withdrawal of Common Salt in Hydrops of Pregnancy,
By Cramer.
3. Concerning Pancreon, By Fischer and Hoppe.
4. Alternating Appearance of Purpura Rheumatica and
Erythema Exudativum Multiforme Hebrae,
By Vorner.
5. Late Appearing Lesion of the Ulnar, By Brassert.
6. Casuistic Contribution to the Question of the Prog-
nosis After Swallowing Foreign Bodies with Un-
favorable Surfaces, By Fischer.
7. Extragenital Infection, By Knauer.
8. Pruritus in Tabes, By Gunzburger.
9. Contribution to the Innovations in the Field of Ob-
stetrical Instruction on the Phantom, By Glockner.
ro. Tamponade of the Nose and of the Nasopharyngeal
Space, By Lennhoff.
[I. Narcosis with Warmed Chloroform, By Rath.
2. Withdrawal of Common Salt in Hydrops
of Pregnancy. — Cramer says that he has obtained
excellent results in hydrops of pregnancy by con-
fining the patient to a diet from which salt was
carefully excluded. Such foods as meat and milk,
which naturally contain considerable salt, were for-
bidden. Wine and beer were allowed in moderate
quantities, and no special limit was placed on the
amount of fluid to be drank. The prescribed diet
is given as tea, coffee, malt coffee, lemonade from
the fruit juice with ordinary water, rice, coarse
meal, sago, potatoes, farinaceous foods, puddings,
green vegetables, lettuce, fresh or cooked fruits,
two eggs a day, bread made without salt, and fresh
butter from which the salt has been washed. Any
addition of salt to the food is forbidden, but any
spice may be added for the sake of improving the
taste. The women are able to attend to their daily
duties during this course of treatment.
3. Pancreon. — Fischer and Hoppe seem to
consider pancreon to be a food particularly well
fitted to meet the needs of patients suffering from
mental and nervous diseases.
4. Alternating Appearance of Purpura Rheu-
matica and Erythema Exudativum Multiforme
Hebrae. — Vorner reports a case in which he ob-
served the alternation of these two conditions at
intervals of fourteen days in a boy ten years old
He believes that the same aetiology underlies both.
5. Late Appearing Lesion of the Ulnar. —
Brassert reports the case of a man, forty-eight
years of age, who came under observation during
the autumn of 1907 on account of atrophy of the
muscles of the right hand, which are supplied by
the ulnar. The elbow joints showed thickenings
and deformities, and could not be perfectly extend-
ed or rotated, a condition which was more marked
about the right elbow. This condition was refer-
able to abscesses about the elbow joints following
scarlet fever in 1875. No other explanation of this
muscular atrophy could be discovered than the in-
volvement of the ulnar nerve in these changes
February i, 1908. J
PROCEEDINGS OF SOCIETIES.
about the joint, the symptoms referable to it hav-
ing appeared at the end of nearly thirty-two years.
6. Prognosis After Swallowing Foreign Bodies.
— Fischer reports a case in which a child, ten
months old, passed per rectum an open safety pin
which had been swallowed about four weeks pre-
viously.
7. Extragenital Infection. — Knauer reports a
case of chancre of the finger.
THE EDINBURGH MEDICAL JOURNAL.
January, 1908.
1. Clinical Observations on Some of the Rarer Varieties
of Vesicular and Bullous Affections of the Skin,
By W. Allen J.\mieson.
2. Some Lessons from the Study of Arterial Pressure,
By G. A. Gibson.
3. The "Energj'-Quotient" in Infant Feeding,
Bj- J. S. Fowler.
4. Chronic Arthritis : A Critical Resume of Recent Views
on the Pathology of Rheumatoid Arthritis, Osteo-
arthritis, Rheumatic Gout, Arthritis Deformans, etc..
By Ch.\lmers W.\tson.
5. A Ten Years' Study of Cupar Water Supply (Clatto
Waterworks), with Special Reference to the Germ
Content thereof, By C. E. Douglas.
5. A Ten Years' Study of Cupar Water Sup-
ply, with Special Reference to the Germ Con-
tent Thereof. — Douglas describes the water sup-
ply of Cupar-Fife, a burgh having about 4,500
p>opulation, which is obtained from a gathering
ground at Clatto, about five miles distant in a south-
easterly direction, 600 feet above sea level and
about 500 feet above the mean level of Cupar. The
supply is an upland surface water, obtained from
numerous "feeders" from the neighboring higher
levels, the land being cultivated, some of it arable,
the rest pasture land. The gathering ground itself
has a water surface, when full, of about 820 acres
of catchment area, and gives a supply of 280,600
gallons per day ; there is. therefore, a supply about
sixty gallons per head of the population. The soil
is of the limestone formation. The water is purified
by sand filtration. The filtering medium consists
of washed quarry clips at the bottom, covered by
clean washed gravel, assorted into five degrees of
fineness from the size of hazelnuts to such as will
pass through a sixteen mesh sieve and be retained
by a sixty-four mesh sieve. Altogether this gravel
bed is two feet in depth. Two feet of clean washed
fine sand overlay this bed. When the filters be-
come clogged the top is scraped of? and laid aside.
This is allowed to weather thoroughly, and is then
well vVashed in a mechanical sand washer acting
under a head of water ; it can be used again indefi-
nitely. Each filter is usually cleaned once in six
weeks, the indication for this being the lowering of
the level in the clear water cisterns into which the
water passes immediately after filtration. When
the slime layer on the surface of the filters becomes
too thick, the water cannot pass through so quickly
as to maintain the level of the water on the filter,
and the filter in question has then to be cleaned.
The total filtration area, when all filters are in use,
is 1214 square yards. With the average daily flow
of water this gives 272.65 gallons per square yard of
filtering area per twenty-four hours, equal to 1.26
gallons per square foot per hour — in other w^ords,
a filtration speed of only 4.848 feet in twenty-four
hours. After filtration, the w^ater passes through
a seven inch pipe to a small reservoir three miles
nearer Cupar, which contains always about a day's
supply, 300,000 gallons or thereby. The author
made a thorough examination of the water and
came to the conclusion, that the water in a catch-
ment area may diflfer chemically from that of the
underlying geological formation. The Glenfield
scraping process is of value in maintaining the out-
put of a supply pipe at its proper figure, and may
even save a community the very large cost of put-
ting down a new supply pipe. The apparatus used
consists of a machine which is driven through the
pipe by the pressure of the water. There are two
distinct portions of the machine, the front portion
carr\ ing a pair of steel scrapers, working one be-
hind the other, and being connected by a swivel
joint with two steel propelling pistons also work-
ing one behind the other. This apparatus is put
into the pipe at a manhole just below the filters,
and driven down by the force of the water behind
it till it emerges at the next manhole situated about
a mile further down. During its passage it has to
be most carefully followed by the men in charge.
They have previously located the line of the pipe
by auscultation through a long iron stethoscope,
and indicated its track by a series of little flags.
If the scraper is travelling, its progress can be de-
tected by the low grinding noise made by it in en-
countering the incrustation. While it is travelling
the detached incrustation goes down before it.
Sometimes it becomes fixed. The increased pres-
sure of the water behind it may overcome the ob-
struction. If not, it has to be cut down upon and
started once more. The range of alkalinity ob-
served in this water supply does not appear to
have any effect upon the germ content. The
mean germ content of this upland surface water is
between 900 and 1,000 per c.c. The method of sand
filtration is capable of removing over 90 per cent,
of organisms when the filters are in good working
order. Filter beds should be cleansed about once
in six weeks, and should be allowed at least a
week's rest after cleansing before being put again
into use. The germ content of a water supply is
distinctly greater at the point of delivery than as
issuing from the filter bed, and this increase is prob-
ably due to the state of comparative rest in the
pipe. In an upland surface water the number of or-
ganisms which wall grow at blood temperature is a
very small proportion of those growing at room
temperature.
grambings of Societies.
COLLEGE OF PHYSICL\XS OF PHILADELPHIA.
Section in General Medicine.
Meeting of December g, 1907.
The "President, Dr. A. O. J. Kelly, in the Chair.
Primary Cancer of the Head of the Pancreas
Causing Obstructive Jaundice. — Dr. Herman B.
Allyx reported the case of a man, sixty-five years
old, who was admitted to the Philadelphia Hospital
complaining of jaundice, epigastric pain, headache,
and weakness. The jaundice had developed two
weeks before admission, and gradually deepened to
232
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
a mahogany tint. The hver was enlarged, and the
gallbladder enlarged and distinctly palpable, but not
tender. The urine always contained bile, and the
faeces were generally alcoholic and contained fat.
No tumor could be felt in the epigastrium. The
patient died of exhaustion and toxaemia. The whole
duration of his illness was less than two months
from the onset of the jaundice. At autopsy there
was found primary cancer of the head of the pan-
creas causing jaundice by compression of the com-
mon duct.
The author discussed the diagnosis of cancer of
the head of the pancreas from stone in the common
duct, from stone in the ampulla of Vater, and from
cancer of the duct and cancer of the duodenum
occluding the orifice of the duct.
With regard to the special tests for pancreatic
digestion, such as Sable's and Schmidt's, the author
had found them uncertain if not misleading. An
excess of fat in the stools was of value in diagnosis,
particularly if there was a small quantity of soaps
in proportion to the neutral fats and fatty acids.
But an accurate estimate of these fats was not easy.
In the work of Robson and Commodge the authors
reported an analysis of the faeces for fats in twenty-
four cases of malignant disease of the pancreas.
The average percentage of total fats was 77, of
neutral fats 50, and of fatty acid 27. But the per-
centage of total fat varied between 93 and 40 per
cent., of neutral fat between 69 and 31, and of fatty
acid between 36 and 3 per cent. Such wide varia-
tions must lessen the value of the findings in any
case. Commodge had also reported upon the result
of his improved pancreatic reaction in sixteen cases
of cancer of the pancreas. It was positive in only
four, negative in twelve cases.
Dr. J. Button Steele believed the estimate of
the fat percentage to be the only accurate means of
determining between jaundice due to obstruction of
the duct and jaundice due to other causes.
Congenital Torticollis. — Dr. Arthur Newlin
reported this case, which was attributed to lateral
fixation of the head in the pelvis during uterine life.
Dr. H. A. Hare inquired whether tests had been
made of the muscles of the opposite side of the neck
to show whether the torticollis might not be due to
lack of power or to palsy of the opposite side.
Dr. Newlix replied that these muscles had been
examined, but not by electrical apparatus. Appar-
entl\- they were normal.
Some Clinical Aspects of Blood Coagulation, —
Dr. Thom.'\s R. Boggs, associate in medicine in the
Johns Hopkins University, presented this paper,
saying that the coagulability of the blood was de-
pendent upon a number of different factors. It
might be varied experimentally in vitro and in vi-z'O
by modifying the physical and chemical condition
of the blood. From the standpoint of the practi-
tioner, it was possible, with a fair degree of accu-
racy, to measure the gross variations in coagulability
and in some cases to modify this coagulability by
therapeutic measures.
For increasing the coagulability the most useful
means was the administration of calcium salts by
the mouth, subcutancously, or by direct infusion.
The salts best adapted to this purpose were the ace-
tate and lactate of calcium. In general, many cases
of haemorrhage from parenchymatous tissue (capil-
lary haemorrhage) after trauma, in purpura haemo-
philia, scurvy jaundice, etc., might be benefited by
calcium therapy.
The treatment was as yet purely empirical, and
not all cases of the same disease would show identi-
cal conditions with regard to coagulabiHty or re-
spond in the same way to treatment. Nevertheless,
the number of cases which were benefited was suffi-
cient to make it desirable to extend the study of
coagulation from a clinical standpoint.
Dr. Hare thought it the experience of all who
had employed the calcium salts in the various con-
ditions in which \Vright had recommended them
had been bitterly disappointed at times, and at other
times had gained results as encouraging as the dis-
appomtments had been discouraging. Possibly 75
per cent, of the employments of the calcium salts in
his hands had been futile, while in 25 per cent, some
good has been observed.
PHILADELPHIA COUNTY MEDICAL SOCIETY.
Meeting of December 11, 1907.
T'he President, Dr. James B. Walker, in the Chair.
Diseases of Physicians. — Dr. Roland G. Cur-
tin presented a resume of his experience in the
study of diseases of medical men, with a tabulation
of the cases and remarks upon the frequency of
diseases, some of which were unusual and some
more common. The probable cause was given, also
the mode of life necessary to preserve health, with
ilirections tending to prolong the practitioner's life,
especially in old age. The statistics given did not
embrace slight ailments or any of the severe forms
of disease in which Dr. Curtin had been called in
consultation. His findings in regard to the drug
habit among physicians difi:'ered from the conclu-
sions of Dr. Crothers, of Hartford. The showing
of twenty-eight deaths from angina pectoris bore
out the appellation of "doctors' disease" for this
afl:ection. Only four cases of Bright's disease had
been noted, all of a severe type. The milder ones
were not mentioned. Ten cases of renal calculus
had been found. The cause of this large number
was difficull to explain. At least half the number
v>'ere in young practitioners.
A general study showed that clergymen had twice
ihc chance to attain the age of sixty-five than the
physician had. This was accounted for by the con-
stant stress attendant upon the physician's life. The
motor car was said to add greatly to the strain of
the nervous system.
The Longevity of Physicians. — Dr. Joseph P.
Tunis showed that the mortality of the medical pro-
fession was higher than that of many other occupa-
tions. According to Dr. Ogle's statistics, the farmer
was the longest lived, and the clergymen enjoyed
Uie greatest longevity of the learned professions.
The late Dr. George M. Beard, in 1866, had said that
the greatest and hardest brain workers of history
had lived longer, on the average, than brain workers
of ordinary ability and industry. Beard had found
that the average age at death of 500 of the greatest
men in recorded history was 64.2. From an insur-
February i, 1908.]
PROCEEDINGS OF SOCIETIES.
233
ance point of view, physicians had shown a slightly
greater mortality than had been expected. Taking
theni as a whole, they were, however, "average
risks. "
Mortality Tabh of Physicians at Different Periods.
No.
Year. Investigated. Investigator. Mortality.
1834 ••• 624 Casper 56.4
1885 3,865 W. Ogle 59.3
1886 8,627 J. M. French 56.47
IQ07 2,000 J. P. Tunis 60.6
The author concluded that statistics proved the
truth of the popular belief that all men lived longer
nowadays than fifty years ago; that the most satis-
factory statisics of longevity could be secured only
by selecting groups of men living under the same
conditions ; that the diseases to which physicians
v. ere especially liable affected the cardiovascular and
nervous systems ; and that the secret of long life
would seem to lie in abstem.iousness, brain work, and
contentment, a sound mind in a sound body being
presupposed.
Diseases of Great Physicians of the Past. — Dr.
William Pepper pointed out the difficulty in draw-
ing conclusions as to the commonest forms of dis-
ease in the physicians whose names were mentioned,
as it was only in those cases in which the men had
suffered from some interesting disease that the cause
of death was given. The cases were, however, class-
ified according to certain loose groups, the most
interesting group including those who had described
diseases and had themselves suffered from the same
disease. Another group included those who had
fallen victims to various diseases in the line of their
duty.
Laennec fell a victim to a disease the nature of
which he had taken pains to describe. Lancisi and
Corvisart died of diseased heart, Boyle sank under
the ravages of the disease of which he had been the
most successful illustrator. Sir Benjamin Brodie, a
great surgeon, died of cancer of his right shoulder
joint. Dupuytren, the most famous surgeon of the
last century, died of an empyema. Refusing to sub-
mit to an operation, he said he "would rather end
his life through God's hand than that of a surgeon."
In more recent times Mikulicz, who wrote on
cancer of the stomach, himself fell a victim to this
disease. Fowler, of Brooklyn, having written on
appendicular inflammation, died of this disease.
Upon the memorial tablet of Dr. Jesse W. Lazear.
who died of yellow fever, were the words : "With
more than the courage and devotion of the soldier
he risked and lost his life to show how a fearful
pestilence is communicated and how its ravages may
be prevented."
A number of distinguished physicians had been
great sufferers from the gout. Sydenham said :
"More wise men than fools are victims of this affec-
tion."
Angina pectoris had claimed its share of the medi-
cal profession, and in this group might be men-
tioned the names of Sir James Y. Simpson, Sir
Charles Bell, and John Hunter.
Instances were cited illustrative of Osier's state-
ment that the profession offered many examples of
good work thoroughly and conscientiously carried
out by men with aneurysm of the aorta. Dr.
Thomas King Chambers first had an aneurysm in the
left popliteal artery, eleven years later one in the
right leg, cured by pressure, and finally aneurysms
of the carotid arteries. Dr. Richard Bright died of
the consequences of extensive and long standing cal-
cification of the aortic valves of the heart, the exit
lor the blood being reduced to a mere chink. Robert
Liston died of an aneurysm of the aorta, which
must have existed for years and been fostered by
his great physical exertions, which characterized his
recreation as well as his work.
Another group was given, including those having
suffered from apoplexy, and still another and larger
group was classified under the heading of miscel-
laneous.
Dr. James C. Wilson said there were two main
groups of morbid conditions to which physicians
were particularly liable — the infectious diseases of
adult life and the general diseases of the period of
involution of life, diseases especially of the cardio-
vascular system, of the kidneys, and of the nervous
system. Neurasthenia, the drug habit, and alcohol-
ism were also to be considered. These were said
to be the result largely of improper living combined
with inherited feebleness of organism. The man
who entered upon the practice of medicine with im-
paired powers of resistance and lack of self dis-
cipline was apt to become neurasthenic or fall a vic-
tim of one of the drug habits.
Dr. James M. Anders, commenting upon the fre-
quency of cardiovascular degenerations among phy-
sicians, thought that the experience of any single
physician or group of physicians even could not
solve the problem, since individual experiences dif-
fered widely. As pointed out by Dr. Tunis, physi-
cians lived under different conditions, pursued dif-
ferent lines of professional work, and their habits
were equally various. E e held, however, that it was
possible to accumulate a sufficiency of data nn which
to base valuable practical conclusions.
An analysis of 115 cases showed tuberculosis to
be present in nearly 15 per cent., while organic
heart disease, gout, obesity, and neurasthenia stood
next in point of frequency. Angina pectoris, dia-
betes mellitus, and nephritic colic, conditions which
appeared to lead in Dr. Curtin's experience, were
less common, although, when compared with their
incidence in general, the percentage among physi-
cians was still abnormally large.
The cases of angina pectoris, nephritic colic, and
diabetes occurred among men who might be counted
as brain workers, but they also led unusually seden-
tary lives and were given to the pleasures of the
table. Of morphinism in doctors there were five
cases, which result agreed with Dr. Curtin's statis-
tics rather than with those of Dr. Crothers. It was
remarked, however, that morphine was often used
in secret by physicians.
Dr. Anders felt strongly that an extensive statis-
tical inquiry would reveal sufficient facts and data
upon which to base valuable conclusions. The sub-
ject was said to be one bringing up the whole ques-
tion of the influence of occupation as a causative
factor of disease, which, whether considered in re-
lation to the professional crisis, brain workers in
general, merchants, artisans, clerks, or laborers even,
was not fully appreciated by the medical profession.
Dr. David Rtesman referred to a feeling pre-
234
LETTERS TO THE EDITORS.
[New York
Medical Journal.
valent among tlie laity that physicians had no right
lo be ill, and regarded it as probably a relic of the
superstition of the barbaric age, when disease was
looked upon as a demon that could be exorcised by
the medicine man, who, naturally, if he could drive
it out of the patient, would drive it out of his own
body. Instances were cited of disease contracted
in the course of the work of physicians. Whether
physicians were prone to certain diseases could only
be learned by statistics. Dr. Riesman's own prac-
tice showed that of some^ diseases there is a rather
large number of cases of physicians. He had had
.'leven cases of appendicular inflammation, two of
tuberculous disease of the lungs, two of pneumonia,
ten of neurasthenia, four of arteriosclerosis, and a
number of others, one and two of a kind. Arterio-
sclerosis seemed to be quite common. Two of his
patients had been under thirty-five years of age and
total abstainers in regard to alcohol. Loss of sleep
and the use of tobacco were considered productive
factors. His experience showed neurasthenia to be
rather profound in the medical profession. While it
could not be said that physicians were exempt from
disease, it was believed that they would work longer
when handicapped than any other class of men, be-
cause of their sense of responsibility and the fact
that no one could take a doctor's place.
Dr. J.AMES Tyson had seen a good many physi-
cians with typhoid fever. He had very often been
consulted for morphinism by physicians who realized
their complete helplessness. He had also known
cases in which physicians had most successfully
overcome the habit. The cocaine habit in his ex-
perience has been a very frequent occurrence among
physicians. This habit was much more easily over-
come than morphinism. Of angina pectoris he had
seen a number of cases. Two cases were cited show-
ing the impossibility of drawing conclusions of a
prognostic character from the symptoms. The pres-
ence of albuminuria and casts in the case of a
physician who had been very much overworked, but
which passed away almost immediately upon rest,
was a condition falling under his observation. Neu-
rasthenia he regarded as almost a doctor's disease,
stating that, after women, doctors came in as a
c lass of neurasthenics.
Dr. Jay F. Schamberg regarded the strain and
stress under which the physician lived and his ex-
posure to contagious and infectious diseases as es-
."^ential factors in the varying incidence of certain,
diseases- in the medical profession compared with the
general population.
He referred to the fact that Dr. Edward Jenner
had been the first to call attention to the pathological
cause of angina pectoris and refrained from pub-
lishing his views on the subject during the lifetime
of John Hunter, because of his intimacy with his
friend and teacher ; and, although he made known
his views to the physicians of Hunter, he was only
given credit for his knowledge after Hunter's death,
when these gentlemen found calcification of the
coronary arteries.
Dr. Albert R. Moulton, from his experience
with cases of drug addiction, was inclined to be-
lieve that the percentages given by Dr. Crothers of
the drug habit among physicians were exaggerated.
Dr. CuRTiN noted that, in fifteen deaths from
angina pectoris among physicians, five had occurred
suddenly after a hard day's work and a hearty meal.
He suggested that the heaviest meal should not be
taken at night and that the physician should rest,
if tired, before and after the meal. After the age
of fifty it was important that physicians gradually
reduce their work; avoiding night work and short-
ening that of the day.
Dr. Pepper said that as the historian of the even-
ing he would simply refer to that good old physician
Rabelais, who, after his study of this subject, said
that "there be more old drunkards than old phy-
sicians."
'^ttttxs t0 tk (tMtflrs.
RECOVERY FROM CANCER.
470 C0MM0NWE.A.LTH Avenue,
Boston, December 31, igoy.
To the Editors:
The writer desires information regarding any al-
leged recoveries or cures of inoperable or recurrent
carcinoma of the mammary gland. If any case or
cases are known to any one who reads this circular
and can be authenticated by facts as to the history
and condition prior to recovery and the length of
time which has elapsed since recovery, such inform-
ation will be much appreciated and duly acknowl-
edged. Any well authenticated reports of recoveries
from carcinoma located in other parts than the mam-
mary gland will be welcomed. Cancer paste cures,
X ray cures, radium cures, or cures as result of sur-
gical operation are not wanted. Hearsay cases are
not wanted unless accompanied by name and address
of person who may give knowledge first hand.
Horace Packard.
MELANCHOLIA.
New York, January 18, igoS.
To the Editors:
In the Journal of October 12th is an editorial on
melancholia in which are reviewed the work and
conclusions of Dr. G. L. Dreyfus, of Heidelberg.
You say in your editorial that Dr. Dreyfus, "after
reviewing all the cases in Kraepelin's clinic, comes
to the interesting conclusion that involution melan-
cholia— the only melancholia in the Kraepelin sys-
tem— is but a phase of manic-depressive insanity.
In my Textbook of Nervous Diseases and Psy-
chiatry, 1904, I distinctly taught this view, and I
argued for its soundness in a paper read before the
New York Neurological Society over three years
ago.
There could be nothing less ambiguous than the
following paragraph (p. 641): "Melancholia,
strictly speaking, is a special disease, and occurs
under three forms: (1) Acute melancholia; (2)
chronic melancholia; (3) manic-depressive insanity,
or manic melancholia. These are all closely allied
types, so much so that the term 'manic-depressive
psychosis' might also be used to include all three."
My conclusions were not guesswork, either, but
based on a study of several hundred cases.
A particular point in my paper was that the
melancholia of involution was not always one of the
later period of life, hut had its rcjiresentation in
Februao' i. 1908.]
BOOK NOTICES.
235
certain usually mild anxious depressions of early
or middle life, and in the hypochondriasis of adoles-
cence and later. There is no clouding of conscious-
ness in those cases, and the depressive ideas relate
usually to subjective or bodily symptoms.
This form of melancholia, in its milder types
called by Meyer "anxious depression," is rather rare
in early life and increases in frequency to the age
of fifty. There is a form of it which is character-
ized by extreme activity of thought, unclouded
brain, great fixity of delusion, and a most persist-
ent impulse to suicide. Here the delusions are
usually self accusatory and do not relate to bodily
conditions.
The most sharply separated form of melancholia
is, no doubt, the depressed phase of manic-depres-
sive insanity. Here there is not so much depression
or actual psychic pain as there is apathy, slowness
and difficulty of thought and action, so that the
patient may become almost stuporous. Yet there
are linking cases which show the relationship be-
tween this and other forms of melancholia. For
purposes of convenience, then, I think we can recog-
nize: I. Acute melancholia, which is represented by
ihe type just described and which may alternate with
a mania. It is often recurrent and occurs oftener
in early life, but it also runs well into old age. 2.
Chronic melancholia, often a melancholia of involu-
tion, but not always, and called as Meyer suggests
an "anxious depression" at whatever period of life
It occurs. A type of this may be called "agitated
depression,"' which takes in the active and suicidal
cases of early and later life, and the "anxious de-
pression" includes most of what is usually called
hypochondriasis. This form is seen with increasing
frequency as age comes on. There are linking cases,
and certain fundamental symptoms appear in each
group.
Charles L. Dana.
Sff0h |[flti«s.
Metabolism and Practical Medicine. By Carl vox
XooRDEN, Professor of the First University Medical
Clinic, Vienna. Volume III. The Pathology of Me-
tabolism, by Carl von Noorden. H. Salomon. A.
Schmidt, A. Czerny, H. Steinitz, C. Dapper. M. Matthes.
C. Neuberg, O. Loewi, and L. Mohr. Anglo-American
Issue, under the Editorship of 1. Walker Hall, Professor
of Patholog>', University College. Bristol, etc. Chicago:
\V. T. Keener & Co., 1907. Pp. xx-527 to 1320.
(Price, $6.)
This, the third and concluding volume of von
Noorden's great work on the physiology and pa-
thology of metabolism, comprises the sections of
greatest practical interest for the physician. The two
preceding volumes, on the physiologv- and general
pathology of metabolism, have already been re-
viewed in this journal. In the third volume are
considered the important relations of the chemical
changes in the body to various specific diseases,
including diabetes mellitus, gout, obesity, diseases of
the skin, cancer, the gastrointestinal diseases of chil-
dren, myxoedema, Graves's disease, acromegaly,
and Addison's disease. There are also valuable and
suggestive chapters on mineral waters, baths, drugs,
and poisons, and the influence of light and the
Rontgen and radium rays. One is impressed by the
enormous amount of patient and minute research
work reported and sifted in these volumes, by the
frank note of scientific candor in the recognition of
the incompleteness and often conflicting nature of
the results obtained by equally competent and un-
biased observers in the same field, and by the
meagreness of the therapeutic applications which
may be deduced in most cases from laboratory con-
clusions alone.
And yet the difficult studies, which are only in
their infancy, have already cleared the ground of
many traditional fallacies and superstitions, and are
the only certain basis for the hope of a therapy
more rational than a blind empiricism. Among the
positive benefits to clinical medicine which may
fairly be alleged for the exact methods of modern
researches in the chemistry of normal and patholog-
ical physiology are the recognition of the role of
the acetone group as a cause of the acidosis pro-
ducing diabetic coma, the part played by the purin
substances in the dietetic management of gout, and
the detection of the rarer derangements of carbo-
hydrate oxidation which result in such anomalies of
excretion as pentosuria and the presence in the urine
of glycuronic acid and laevulose, inosite, maltose,
and other unusual forms of sugar. Studies in met-
abolism have also profoundly changed our views as
to the action of many drugs and as to the thera-
peutic use of mineral waters. On this latter point
von Noorden pertinently and justly says: "Valu-
able scientific work has, however, been published
during the last ten years in spite of the enormous
output of worthless, pseudoscientific writings which
mislead the inexpert. A clamorous jargon has been
invented, which includes apparently learned ex-
pressions about delayed or increased metabolism,
oxidation, assimilation, protein balance, molecular
disintegration, ions, osmosis, radioactivity, and the
like ; without these no twentieth century advertise-
ment is complete. The truth is that so little is
known of the bearing of mineral waters on biological
processes that most of the statements in balneologi-
cal literature may be stigmatized as idle make be-
lieve." This quotation is a fair example of the
author's impatience with pretense, and his demand
for rigorous demonstration can not but have a stim-
ulating and wholesome influence upon the medical
reader, although at times some of his cherished be-
liefs may receive a rude shock. X'othing is more
futile than theory without an adequate basis of
carefully observed fact, and one obstacle to ad-
vancement is removed when we freely admit our
ignorance of what we do not know.
"Eine einziger Zahl hat mehr wahren imd bleibenden
Wert als eine kostbare Bibliothek voll Hypothesen."
Commercial Precedents. Selected from the Column of
Replies and Decisions of the Nezv York Journal of Com-
merce and Commercial Bulletin. An Essential Work
of Reference for Every Business Man. By Charles
PuTZEL, A. B., LL.B., of the New York Bar. Hartford :
American Publishing Company. 1907. Pp. v-776.
This volume presents a compilation of the ques-
tions and answers concerning commercial law and
usages which have appeared in the pages of the Nezir
York Journal of Commerce and Commercial Bulle-
tin. This journal has for seventy-five years been
236
MISCELLANY.
[Neu York
Medical Journal.
the leading authority in the field of commerce, and
the department which has been known in it as
Replies and Decisions has always been regarded as
one of its most valuable features. The publication
is in no sense a law book, the underlying principles
on which the opinions and decisions are based not
being elaborated. The book contains much infor-
mation regarding commercial law and usage which
will be of interest to every one, whether engaged in
professional or in commercial pursuits.
Thinking, Feeling, Doing. By E. W. Scripture. Asfist-
aiit Neurologist to Colvimbia Universitj-. London and
New York: G. P. Putnam's Sons, 1907.
The author, after twelve years, has given us a sec-
ond edition of this excellent little manual. It is one
of the clearest of similar works and introduces the
reader at once into the mysteries of the mechanism
of mind action in a delightful and satisfying man-
ner. It has had a great success as a textbook, and
in its new edition merits all the attention it hns been
paid in the past.
BOOKS. PAMPHLETS, ETC., RECEIVED
Movable Kidney and Other Displacements and Mal-
formations. By David Newman, M. D., ,F. F. P. S. G.,
Surgeon to the Glasgow Royal Infirmary, etc. New York,
Bombay, and Calcutta : .Longmans, Green (S: Co., 1907.
Pp. 233-
Transactions of the American Gynaecological Society.
Volume 32. For the Year 1907. Philadelphia : W. J.
Dornan, Printer, 1907. Pp. 568.
ItisffllHnp.
International Congress on Tuberculosis. — Act-
ive preparations for the International Congress on
Tuberculosis, to be held in Washington, next Sep-
tember, are under way in other countries. The na-
tional committees for France, Germany, Sweden,
Austria, Holland, Greece, Bulgaria, Cuba, Venezu-
ela, Brazil, and Costa Rica have organized and have
forwarded their membership lists to the secretary
general. The French committee has a membership
of over 300 and includes men of prominence in pub-
lic life as well as in the medical profession. The
officers of this committee are : President, Dr. Louis
Landouzy, of the medical faculty of the University
of Paris ; vice presidents, Dr. Faisans, of the Uni-
versity of Paris; Professor Vallee, veterinarian, of
Alfort ; Dr. F. Bezancon, of the University of Paris,
and Dr. Le Gendre ; secretaries, Dr, Triboulct, sec-
retary general of the last International Congress,
which was held in Paris three years ago ; Dr. Nobe-
court. Dr. Leon Bernard, Dr. Dehan, and Dr.
Georges Bourgeois ; treasurer, M. Masson. The sec-
retary of the German committee. Dr. Johannes Niet-
ner, was secretary general of the recent Interna-
tional Congress on Hygiene and Demography. Other
members of the committee are Dr. Gotthold Pann-
witz, secretary general of the International Tubercu-
losis Association ; Dr. B. Frankel, Dr. Ernst von
Leyden, professor emeritus of the University of Ber-
lin, and Dr. Johannes Orth, professor of pathology
in the University of Berlin. Dr. N. P. Tendcrloo, of
Leyden, another well known pathologist, is a mem-
ber of the committee for Holland. Dr. P. K. Pell,
of the University of Amsterdam, is chairman of that
committee, and Dr. W. J. von Gorcum, of The
Hague, is the secretary. Dr. A. Herrera Vegas, the
chairman of the Venezuelan committee, is president
of the Venezuelan Antituberculosis League and a
member of the National Academy of Medicine at
Caracas. Dr. P. Acosta Ortiz, the vice president, is
a director of the hospital at Vargas, and Dr. L. Ra-
zetti, another member of the committee, is vice rec-
tor of the University of \'enezuela, and permanent
secretary of the National Academy of Medicine. All
of the members of the Brazilian committee are act-
ively identified with the antituberculosis movement
in that country. The committee includes Dr. J. J.
Azevedo Lima, of Rio Janeiro, president of the Bra-
zilian Antituberculosis League ; Dr. Oswaldo Cruz,
director general of the Department of Public Health
Dr. J. J. Seabra, and Dr. Cypriano de Freitas, of
Rio de Janeiro. The president of the Cuban com-
mittee is Dr. Guiteras, formerly professor of pathol-
ogy in the University of Pennsylvania, and now at
the University of Havana. Dr. J. L. Jacobsen, the
vice president, is president of the Cuban Antituber-
culosis League. The secretary is Dr. M. G. Lebre-
do. of Havana. Two well known members of this
committee are Dr. Aristides Agramonte, the last sur-
viving member of the famous yellow fever commis-
sion of the L'nited States army, and Dr. Carlos J.
Finlay. Dr. B. Patrikios, the chairman of the com-
mittee for Greece, is secretary of the Department of
Health of Greece, and secretary general of the Greek
Red Cross Society. Dr. Aristote Kouzis, the secre-
tary, is a professor of the University of Athens. Dr.
Constant Savas, a member of the committee, is pro-
fessor of hygiene in the University of Athens ; Dr.
P. Manoussos is the principal medical director of
the Military Hospital at Athens, Dr. Kalliontzis is
professor of surgery, and Dr. Pierre J. Rondopoulo
is professor of pathology at the University of Ath-
ens. The Hon. Otto von Printzkold, the chairman
of the Swedish committee, is the first chamberlain
of the Swedish court. The secretary, Dr. Bertil
Buhre, is the president of the Swedish Antitubercu-
losis League, the largest volunteer association of the
kind in existence. The Costa Rican committee has
named Dr. Louis P. Jiminez chairman, and Dr. Teo-
doro Picado, of San Jose, secretary. Other mem-
bers are Dr. Teodoro Prestinary, Dr. Benjamin Her-
nandez, and Dr. Marcos Zunega, all of San Jose.
Three chairman have been named by the Austrian
committee. They are Professor Leopold von Schrot-
ter, of the medical faculty of the University of Vi-
enna ; Dr. Weichselbaum, and Dr. Richard Paltauf.
of the department of pathology of the LTniversity of
Vienna. The secretaries are Dr. H. von Schrotter,
Dr. L. Teleky, and Dr. J. D. Bartol. Dr. M. R<nis-
sefif, director of the Department of Health of Sophia,
is president of the Budgarian committee; Dr. Ivan
OggnianofY, secretary of the Superior Board of
Health at Sophia, is secretary, and the members in-
clude Dr. Georghi Zolotovitch. Dr. Ivan Theororoff,
and Dr. S. A. Valcovitch.
A Case of Acquired Dextrocardia Associated
with Advanced Phthisis. — J. Hubert Young, of
Boston, places a case on record (Boston Medical
and Surgical Journal, December 12, 1907) whL-h is
unique, as the patient was continually under obser-
vation during the transposition of the heart from
left to right. This displacement was gradual, and.
February i. :90s.]
OFFICIAL NEWS.
237
as it became more marked, signs of cavity were elic-
ited at the right apex. There were no subjective
symptoms referable to the heart, and. except for rare
intervals when the patient was confined to her bed
for a day or two, with slight gastric disturbance, she
was dressed and about the ward all the time without
any discomfort. Nor was there any cHnical evidence
that the heart was not performing its function per-
fectly in its abnormal position. X ray examinations
were made, but, owing to the involvement of the
right lung, the right border could not be accurately
determined. About twenty-five cases of acquired
dextrocardia associated with chronic pulmonary tu-
berculosis, without the presence of fluid or air in the
pleural cavities, have been reported, but in all the
cases, with the exception of four, the displacement
was complete when the case first came under obser-
vation.
The Milky Way.
To boil or not to boil, that is the question :
Whether 'tis nobler, recklessly to swallow
The germs and toxines of raw lacteal blend.
Or to take arms against this sea of microbes.
And by parboiling, end them? To pasteurize —
Xo more, the doctors cry, nor sterilize.
For thus we slay the thousand healthful germs
That milk is heir to ; 'tis a consummation
Devoutly to avoid. Thus would they lull
Our fears to sleep. We dream ; aye, there's the rub.
For in that sleep of dreams, what rude alarms
Awaken us ! The milkman's morning call
Disturbs our rest. There stands the milk,
A bottled menace unto human life.
Yet must we pay for quarts of bev'rage which.
With germs benign, is mixed the contumely
Of rural scorn for hygienic laws,
And city dealers' dash of formalin,
Put in to lower the count bacterial.
Inspection does make cowards of us all ;
And thus the native hue of bovine milk
Is sicklied o'er with the pale cast of doubt.
From Cow to Milch Goat let us turn our thoughts.
To X^anny, late despised, but now the queen
Of rediscovered country, that fair realm
Of capriculture, whence her lacteal yield
Gives health and strength from infancy to age.
— A Caprine Soliloquy by Julia Harries Bull
in Good Housekeeping.
Public Health and Marine Hospital Service
Health Reports:
The following cases of smallpo.v, yeilozc fever, cholera,
and" plague have been reported to the surgeon general,
United States Public Health and Marine Hospital Service,
during the week ending January 24. 1908:
Sinallfox — United States.
Places. Date. Cases. Deaths.
Alabama — Mobile Jan. 4-1 1
Jan. 1-14 10
Alabama — Mobile County .Jan. 1-14 9
California — Oakland Dec. 1-31 J4
California — Los Angeles Dec. 2S-Jan. 4 11
Connecticut — New Britain Dec. 1-30 i
District of Columbia — Washington . Jar. 4-11 2
Illinois — Jacksonville Jan. 4-1 1 3
Indiana — Elkhart Jan. 4-1 1 2
Indiana — Indianapolis Jan. 5-12 2
Indiana — Lafayette Jan. 6-13 1
Kansas — Wichita fan. 4-1 1 j2
Louisiana — New Orleans Jan. 4-11 6
Michigan — Grand Rapids Jan. 4-11 i
Michigan — Saginaw Dec. zg-Jan. 11 23
Missouri— St. Louis Jan. 4-11 3
New York — Niagara Falls Jan. 4-1 1 1
New York — New York Jan. 4-11 2
North Carolina— Greensboro Jan. 4-11 9
Ohio — Cincinnati Dec. 27-Jan. 10 7
Ohio — Dayton Jan. 4-11 3
South Dakota — Sioux Falls Jan. 3-10 9
Tennessee— Kno.>c\-ille Dec. 28-Jan. 11 7
Tennessee — Nashville Ja.i. 4-1 1 14
Texas — HcJuston Tan. i-ii 3
Texas — San Antonio Jan. 4-11 z
Utah — 27 Counties Dec. 1-30 18 i
Washingjton — Spokane Dec. 28-Jan. 4 i
Wisconsin — La Crosse .Jan. 4-1 1 2
Wisconsin — Milwaukee Dec. 21-Jan. 11 4
Smallpox — Foreign.
Brazil— Para Dec. 21-28 10 4
Brazil — Rio de Janeiro Dec. 8-15 33 9
China — Hongkong Nov. 16-23 1 i
China — Shanghai Dec. 1-15
5 cases among Europeans and
17 deaths among .latives.
Ecuador — ^Guaj-aquil Dec. 15-21 2
France — Marseilles Dec. 1-31 .. g
Great Britain — Leith Dec. 22-2S i
India — Bombay Dec. 10-17 5
India — Calcutta Nov. 30-Dec. 17 3
Italj- — -General Dec. 19-20 52
Java- — Batavia Nov. 30-Dec. 7 3 i
Russia — Moscow Dec. 14-21 7 3
Russia — Odessa Dec. 14-21 2
Spain — Denia Dec. 21-28 4
Spain — Vigo Dec. 21-28 2
Venezuela — *Caracas --To Jan. 3...
Venezuela — La Guaira To Tan. 3 . . .
Yellzv Fexer — Foreign.
BrazU— Para X)ec. 21-28..,
Cuba — Habana Province —
Guanamon Jan. 16-19...
Cuba — Santa Clara Province —
Cienfuegos Jan. 17-20..,
Cuba — Palmira Dec. 31-Jan.
Ecuador — Guayaquil Dec. 14-21..,
.3.000 Estimated
Cholera— InsuUir.
Philippine Islands — Manila Nov. 21-28 8 8
Nov. 28-Dec. 7 3 2
Ckolerc— Foreign.
India — Bombav Dec. 10-17 2
India — Calcutta Nov. 28-Dec. 7 262
India — Madras Dec. 7-13 4
India — Rangoon Nov. 28-Dec. 7.... 13
Plagv.e—Fore-.gn.
Brazil — Rio de Janeiro Dec. S-15 6 i
Egypt — Ale.xandria Dec. 13-25 4 3
Egypt — Dianietta Dec. 22-28 1
Egypt; — Provinces — •
Assiout JDec. 19-30 21 15
Minieh Dec. 17-30 i
India — Bombay Dec. 10-17 "
India — Calcutta Nov. 23-Dec. 7 39
India — Rangoon Nov. 28-Dec. 7 5
Turkey in Europe — Kavak
Plague erroneously reported as present on December 26.
*275 cases and 5 deaths rerorted Dec. 13 as yellow fever shoJld
have been included under smallrox.
Public Health and Marine Hospital Service:
OfRcial list of clianges of stations and duties of commis-
sioned and noncommissioned officers of the United States
Public Health and Marine Hospital Service for the zveek
ending January 25, igo8:
Bell, J. M., Pharmacist. Leave of absence granted for
eight days from January i, 1908, amended to read six
days.
Brooks, S. O., Surgeon. Granted leave of absence for four-
teen days on account of sickness, from January 22, 1908.
Cofer, L. E., Passed Assistant Surgeon. Relieved from
duty at Seattle. Wash., and directed to proceed to
Honolulu. Hawaii, assummg the duties of chief quaran-
tine officer at that port.
DE Valtx. H., Assistant Surgeon. Leave of absence granted
for thirty days from December 16, 1907, amended to
read for twenty-nine days only.
FoGARTY. J. N.. Acting Assistant Surgeon. Granted leave
of absence for thirty days from January 15. 1908.
Glover. M. \\.. Passed Assistant Surgeon. Relieved from
special temporar>- duty at Seattle, Wash., and directed
to assume charge of the Service at that port.
Keatley, H. W., Acting Assistant Surgeon. Granted leave
of absence for one day, under paragraph 210, Service
Regulations.
238
BIRTHS. MARRIAGES, AND DEATHS.
[New York
Medical Journal.
Lavinder, C. H., Passed Assistant Surgeon. Leave of ab-
sence granted for one month from January I2th,
amended so as to be effective January 14, 1908.
AIcBride, C. R., Pharmacist. Granted leave of absence for
eighteen days from January 14, 1908.
Troxler, R. F., Pharmacist. Directed to proceed to Nor-
folk, Va., for special temporary duty at the grounds
of the Jamestown Tercentennial Exposition ; granted
leave of absence for seven days, affective upon com-
pletion of special duty at Norfolk.
White, M. J., Passed Assistant Surgeon. Relieved from
duty at Seattle, Wash., and directed to proceed to De-
troit, Mich., reporting to the medical officer in command
for duty.
Board Convened.
A board of medical officers was convened to meet in
Baltimore, Md., 10 o'clock a. m., January 20, igo8, for
the physical examination of an officer of the Revenue Cut-
ter Service. Detail for the board : Passed Assistant Sur-
geon J. T. Burkhalter, chairman, and Acting Assistant Sur-
geon J. LaB. Ward, recorder.
Army Intelligence:
Official list of changes in the stations and duties of officers
serving in the medical department of the United States
Army for the iveck ending January 18, 190S :
Ebert, R. G., Major and Surgeon. Relieved from duty at
the Philippines Division, and will proceed on the trans-
port to sail from Manilla about March 15, 1908, to
San Francisco, CaL, and upon arrival report by tele-
graph to the Adjutant General of the Army for further
orders.
Harris, J. R., Captain and Assistant Surgeon. Ordered to
proceed to the Army General Hospital, Presidio of San
Francisco, CaL, for observation and treatment.
Jones, H. W., First Lieutenant and Assistant Surgeon. Re-
lieved from duty at the Philippines Division, and as-
signed to duty in the Army Transport Service.
Palmer, F. W., First Lieutenant and Assistant Surgeon.
Granted ten days' leave of absence.
Richards, R. L., Captain and Assistant Surgeon. Ad-
vanced to the rank of captain.
Navy Intelligence:
Official list of changes in the medical corps of the United
States Navy for the week ending January 25, 1908:
Allen, A. H., Assistant Surgeon. Detached from duty
with the marine detachment at Lajas, Cuba, and ordered
to duty with the Cape Cruz-Casilda survey expedition,
with headquarters at Martzanillo, Cuba.
FiTTS, H. B., Surgeon. Ordered to the naval recruiting sta-
tion, Indianapolis, Ind.
Iden, J. H., Passed Assistant Surgeon. Detached from duty
in connection with the Cape Cruz-Casilda survey ex-
pedition, with headquarters at Manzanillo, Cuba, and
ordered lo continue other duties.
Mackenzie, E. G., Assistant Surgeon. Appointed an as-
sistant surgeon from December 28, 1907.
RiGGS, R. E., Passed Assistant Surgeon. Detached from
the Naval Academy and ordced to tlie naval station,
Charleston, S. C, for temporary duty, and thence to
Camp Columbia, Havana, Cuba.
Schmidt, L. M., Assistant Surgeon. Appointed an assistant
surgeon from December 28, 1907.
Strine, H. F., Passed Assistant Surgeon. Detached from
the naval hospital, Annapolis, Md., and ordered to Wash-
ington, D. C, January 20th, for temporary duty, and
thence to the Relief.
Wells. H., Medical Director. Ordered to duty at the naval
recruiting station, New York, N. Y.
Wheeler, L. H., Assistant Surgeon. Detached from the
navy recruiting station, Indianapolis, Ind., and ordered
to Washington, D. C, January 27th, for examination
for promotion, and then to await orders.
§irtl]S, Itiirriagts, anJr §tni\s.
Born.
Shaw.— In Santurce, San Juan, Puerto Rico, on Sunday,
January 5th, to Dr. Harry Shaw, United States Navy, and
Mrs. Shaw, a daughter.
Married.
Biggs— NoRRis.— In Rutherfordton, North Carolina, on
Monday, January 27th, Dr. Montgomery W. Biggs and Miss
Mnry Pepper Norris.
Conley— Hinch.— In Wilmette, Illinois, on Wednesday,
January 15th, Dr. B. Conley and Dr. Minnie Agnes Hinch.
Ledbetter— Cowie.— In Annapolis, Maryland, on Wednes-
day, January 22d, Dr. Robert E. Ledbetter, United States
Navy, and Miss Ethel Cowie.
Pekcival— McBurney.— Ill Philadelphia, on Tuesday,
January 21st, Dr. Milton F. Percival and Miss Marv
Beattie McBurney.
Potter— Sargent.— In Brookline, Massachusetts, on Sat-
urday, January 25th, Dr. Nathaniel Bowditch Potter, of
New York, and Miss Mary Sargent.
Reisman— Fleisher.— In Philadelphia, on Monday, Janu-
ary 20th, Dr. David Reisman and Miss Eleanor L. Fleisher.
Russell— Fox.— In New York, on Wednesday, January
22d, Mr. Henry R. Russell, of Pittsfield, Massachusetts, and
Miss Adahne Fox, daughter of Dr. George H. Fox.
Died.
Blakeman. — In Portsmouth. Virginia, on Wednesday,
January 22d, Dr. Robert Silvester Blakeman, United .States
Navy, retired. -aged thirtv-five vears.
Burrall.— In White Plains, " New York, on Tuesday,
January 21st, Dr. Frederick Augustus Burrall, aged seventy-
four years.
Brunner. — In Boyertown, Pennsylvania, on Tuesday ,^
January 14th, Dr. F. R. Brunner, aged sixty-eight years.
Camp. — In Washington, D. C, on Monday, January 20th,
Dr. Herbert M. Camp, aged forty-six years.
Collins. — In Covington, Kentucky, on Friday, January
17th, Dr. J. D. Collins, aged eighty-four years.
Dale. — In Lemont, Pennsylvania, on Tuesday, January
14th, Dr. J. Y. Dale, aged sixty-six years.
Dann. — In Titusville, New York, on Tuesday, January
14th, Dr. James L. Dann.
Eversfield. — In College Park, Maryland, on Monday,
January 20th, Dr. William Octavius Eversfield, aged sixty-
seven years.
Hayes.— In Carrollton, Illinois, on Thursday, January
i6th, Dr. J. B. Hayes, aged sixty-three years.
Heger, — In New York, on Saturday, January 25th, Dr.
Anthony Heger, Brigadier General, retired, United States
Army, aged seventy-nine years.
Kelly. — In Philadelphia, on Monday, January 20th, Dr.
Patrick M. Kelly, aged seventy-four years.
Klock. — In St. Johnsville, New York, on Friday, January
17th, Dr. Charles M. Klock, aged fifty years.
Knife. — In Boyertown, Pennsylvania, on Tuesday, Janu-
ary 14th, Dr. Irwin Knipe.
LopER. — In Philadelphia, on Sunday, January 19th, Dr.
Pero!\al E. Loder, aged fifty- four years.
M( KiTTRiCK. — In Evergreen, Alabama, on Sunday, Janu-
ary 19th, Dr. A. A. McKittrick.
AIathewson. — In Hartford, Connecticut, on Sunday,
January 19th, Mrs. Harriet Silliman Mathewson, wife of Dr.
Arthur Mathewson, of Brooklyn.
Maurer.— In Philadelphia, on Friday, January 17th, Dr.
Emil Maurer, aged forty-two years.
Mayer. — In Boyertown, Pennsylvania, on Tuesday, Janu-
ary 14th, Dr. Charles Mayer, aged fifty years.
Michael. — In Binghampton, New York, on Wednesday,
January 22d, Dr. F. M. Michael.
Ordronaux. — In Glen Head, Long Island, on Monday,
January 20th, Dr. John Ordronaux. aged seventy years.
Painter. — In West Haven, Connecticut, on Thursday,
January i6th, Dr. Henry Wheeler Painter, aged seventy-
six years.
Ross. — In Hearhsville, Virginia, on Monday, January
20th, Dr. C. A. Ross, aged forty-seven years.
Scott.— In Campbellsville, Kentucky, on Thursday, Janu-
ary 16th, Dr. Ben Scott.
Smith. — In New York, on Monday, January 20th, Dr.
A. P. Smith.
Stratford. — In New York, on Friday, January 24th, Dr.
William Stratford, aged sixty-three years.
Turner. — In Boyertown, Pennsylvania, on Tuesday, Janu-
ary T4th, Dr. F. B. Turner.
Wilkinson. — In New York, on Saturday, January 25lh,
Dr. Asa Williams Wilkinson, aged seventy-five years.
Wood-Ali.en.— In Washington, D. C, on Wednesday,
January 22d, Dr. Mary Wood-Allen.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal rt Medical News
A Weekly Review of Medicine, Established 1S4J.
Vol. LXXXVII, No. 6. XEW YORK, FEBRUARY 8, 1908. Whole No. 1523.
Original Cffmmunications.
THE HAND AS A THERAPEUTIC AGENT.
Calling the Attention of Physicians to Useful Auxiliary
Measures Which They May Themselves Employ tcith
Great Advantage by Adaptations of Manual Ther-
apy, Nerve Pressures, Massage, Passive Move-
ments, "Cheirota.ris" Etc.
By J. Madison Ta\-lor, A. B.. M. D.,
Philadelphia.
The hand is an ever present agent of skill for the
physician. It is capable of infinite adaptation. Em-
ployed in a variety of directions by specialists, it is
known to be the chief factor in their personal efifi-
cienc\ . Among primitive peoples manipulations
have always atforded more certain help than crude
attempts at chemical corrections. In the rude sur-
gery of the ancients, and now in many semicivilized
countries, dextrous practitioners often perform feats
well worthy of imitation. In modern medicine evi-
<lence is growing to prove that we should develop
and utilize these hints, always in the hght of advanc-
ing physiological and clinical knowledge. \\'hile
the subject is still in its infancy, the stage of con-
jecture, of early experiment, is past. If half as
much scientific research had been expended on the
principles governing manual treatment as upon
pharmacology, the hand would be esteemed to-day
on a par with drugs in acceptability and power.
Xo single therapeutic agent can be compared in
ei'ficiency with this familiar but perfect tool. Sir
Charles 15ell wrote a book in 1833 on The Hand, its
Mechanism and Vital Endon-ments, etc., calling at-
tention to its marvelous adaptabilities. It is pre-
eminently the instrument of the artist in all de-
partments. Swedish physicians, instigated 'by a
prophetic enthusiast, Ling, have evolved an elab-
orate system of treatment, demonstrating that often
by clumsy, empirical methods great things are, and
greater can be, thereby done. The subject has de-
veloped slowly, but steadily, in the manner common
to other lines of clinical growth. Along with aggre-
gations of incontrovertible facts, there are being
gradually evolved scientific, physiological, as well as
rational, explanations. As was inevitable, such an
easily imitated measure fell early into the possession
of independent handicraftsmen. Many of these,
while more or less competent, protected themselves
instinctively and naturally by secrecy. Methods
were propagated by tradition. The "bonesetters"
of Devonshire, after obtruding their successes upon
the puzzled and disturbed surgeons of England.
gradually contributed much to the science of sur-
gery. Wharton Hood tells the story with valuable
personal contributions ii: a suggestive little book on
Bone Setting.
Few educated physicians themselves employ the
hand in everyday treatments. Those who do are
viewed askance. At least, they are denominated
"cranks." Yet an array of their names makes
creditable showing. In the preface of Kleen's book
on Massage are mentioned a large number of well
known authorities who themselves use what is
called "massage and systematic movements," many
of them distinguished in various recognized lines
of science. Mctzger to-day is overworked minis-
tering with amazing success to the crowned and
coroneted heads of Europe, and not a few "bo-
nanza kings" of America.
To be sure, the utterances of many apostles of
manual treatment are marred by overstatements ;
assertions of exclusive efficacy are often made for
their personal methods beyond the verge of truth.
These vaporings become distasteful to a large pro-
portion of the profession, who, knowing little about
the facts, comfort themselves with sneers or denials.
If, however, the truth is demonstrable in abundance,
even unguessed in its scope, it matters nothing till,
in the fullness of time, all deserving things shall
be made plain. So great is the potency of this mea-
sure that in recent years a vigorous cult is working,
in most communities, cures, or satisfactory- amelio-
rations of conditions, which the "regular profes-
sion" have been unable to relieve. Yet all this po-
tentialit}- is entirely- withni the reach of these
learned gentlemen if they will open their eyes and.
put forth their own hands.
Of course, they will come to make use of it m
due time. Scientific medicine has frequently been
enriched by the adoption, somewhat late, of agencies
intrinsically good, but, unfortunately, discoimte-
nanced. Fashion, convention, ultraconservatism, is
responsible for much delay in adopting many ad-
\'antageous measures. It w as, both amusing and ])a-
thetic to observe how ludicrously reluctant many
physicians, on whom or their families I have worked
"unbelievable iriiracles," were to accept the facts.
The common demurrer is to the effect that the
whole thing is "mere suggestion." But why did not
earlier suggestions compass similar results? Wliat
about the salutarv eft'ects wrought thus upon in-
fants? Why does the alleged suggestion work
against the avowed skepticism of these physicians
themselves? Undoubtedly my own knowledge is
yet too crude to avoid many failures, and lacks^
much of strictly accurate explanations. The physi-
Cniyrisrl't. 1908, by A. R. Klliott Publishing Company.
240
TAYLOR: HAND AS THERAPEUTIC AGENT.
[New York
Medical Journm,.
ologists must do a lot of better work before exact
interpretations of this, or many other functional in-
fluences, are fully explainable. Facts, based upon
the clearest physiological principles, are, however,
abundantly in evidence. A respectable array of
clinical findings are on record to substantiate all
reasonable statements. Many of these are not yet
marshaled in such shape as to corroborate the pos-
tulate that by touch of hand, alternating or con-
tinued, or by distributed pressures, certain curative
results are wrought, though obtainable in no other
way. Yet, rightly interpreted, they contribute un-
erringly to prove our assertions. Many of the ef-
fects produced by heat, cold, faradism, galvanism,
poultices, counter irritants, section, constriction
hypersemia, deep injections of salt solutions, alco-
hol, drugs, and the like, are equaled or surpassed by
the cunningly applied hand and through exactly the
same fundamental physiological principles.
Drug Nihilisms. — The reaction among clinicians
against the use of multitudinous drugs is reflected
with exaggerations upon the laity. Injudicious
condemnation by physicians of medicaments works
more harm to scientific medicine than many con-
crete evidences of failure to afford relief. The
public notices our perplexities and interprets our
candid expressions of conservatism to signify
doubts as to the efficacy of these unimpeachable
agencies. There is a deplorable lack of consistency
in medical teaching, especially in therapeutics. The
cause of this is due largely to unfortunate customs
in teachings, to fanciful explanation, but, above all,
to faulty habits of presenting well attested truths.
Drugs, used with a full knowledge of those princi-
ples which are, or are becoming firmly established,
will always stand first among our keenest weapons
of defense against the havoc of disease. Our lit-
erature would, unfortunately, lead a casual or over-
critical reader to infer that in methods of treatment
we are swayed by whims, fashions, waves of opin-
ion, stupid imitation, or even by emotion. Hence
the public, aware of our candid selfquestionings, in-
terprets all this to signify doubts as to our capabili-
ties. Thereupon they too readily welcome blatant,
ill trained^ assertive irregulars who assume to work
miracles by "drugless methods." The crucial fact is
that to get best results one must be aware of all im-
portant truths, by which alone exact knowledge of
conditions can be attained.
As physiology slowly illumines our pathogenesis
we may form more exact conclusions on the under-
lying potentialities which govern clinical results.
Scientific medicine has repeatedly been compelled to
recognize hints from irregulars which, if useful
enough for adoption, may, when candidly scru-
tinized, be accepted without prejudice, often with
great advantage to our patients. Manipulations
have been increasingly employed by surgeons with-
out criticism, but when a general practitioner un-
dertakes similar methods he is met with condemna-
tion. Why? Originally, i. e., previous to about
1880, whatever manipulation (massage, educative
and corrective exercises, etc.) was deemed advisa-
ble was relegated to handicraftsmen or women. A
certain few of these were (there always are some)
both skillful and wise. Physicians then, as now,
knew personally almost nothing of these measures
except a few vague and fluctuating "rules." They
were, and are, even more ignorant of what should
be expected of "massage" than they are now of the
essential effects of drugs, and no analogue more
emphatic can be cited. Even to-day few physicians
make use of massage except vicariously and inex-
actly.
Ignorance of Physicians on the Subject of Man-
iial Treatments. — In an unclear wa}- the physician
knows that through this agency certain general ef-
fects are usually induced. He has almost never had
personal instruction ; he would be puzzled to dis-
tinguish good work from bad, even if accurately
displayed. A case comes to his mind, e. g., which he
infers might be bettered by this additional measure.
He thereupon selects some one on his list whom he
thinks suitable, and sends him, or her, to the patient.
What instruction is given? Practically none, ex-
cept perhaps some negative directions learned from
books as to the "contraindications." Thereupon the
operator has one of two courses open: i. To apply
for specific instructions to the physician. This is
seldom done. If these are sought they prove so ob-
viously nonhelpful that the second course is open
(and the one that is most generally pursued) : 2. To
go ahead and do whatever seems proper, giving
usually an hour of routine "rubbing."
So important is intelligent, judiciously applied
massage, passive movements, stretching, torsions,
etc., that the laity recognize its utility more clearly
than the profession. Furthermore, irregular practi-
tioners have sprung up, forming a bold, aggressive
body, adopting the best methods taught in Europe,
shrewdly recognizing and utilizing the cruder points
of vasomotor action and reaction whereby vaso-
tonus is influenced, and the public is quick to see
and endorse the excellent results obtained.'
It is well to emphasize the fact that all measures
which influence so powerfully the functions of the
human body should be kept within the jurisdiction
of the educated physician. He it is who must di-
rect and control all remedial measures. He must
keep himself informed as to the principles and
technique, so that he shall be able to use or direct
the precise kind, direction, and amount of auxiliary
measures exactly as he regulates his dosage of
drugs. He must be an expert in the whole field of
theories, practice, scope, and applicabilities, or else
he should not use or countenance measures of which
he is ignorant. If these, or other agencies, are
powerfully influential for good, they are equally
powerful for harm if injudiciously applied; precise-
ly as in the misuse of drugs. It is quite true, as
many will reply, that few instances of harm are
brought to light. That is because expert masseurs
are warned not to do those things which can work
much havoc. When paid for their work they are
often content to do little good, and we should be
happy if they do no harm. Routine massage is,
however, of only moderate efficacy. By it some sur-
face stimulation is afforded, comfort is given, sleep
and rest enhanced, slight nutritive and sensory
quickenings awakened. By the passive movements
ordinarily employed much good is effected in dis-
used or chronically diseased joints. The whole cus-
'See article by the author, New York Medical .Journal, December
II, 1904.
February 8, 1908.]
TAYLOR: HAXD AS THERAPEUTIC AGEXT.
241
tomary procedure constitutes what \\e.\T Mitchell
has classically described as "the equivalent of a five
mile walk without strain upon the heart."
But all these things are as child's play to the
powerful efifects capable of being wrought on the
vasomotor and visceromotor mechanisms if the cen-
tres in the cord, the subsidiary centres, the exposed
points in nerves and ganglia are intelligently op-
erated UDon by an educated physician. Here a
knowledge of these governing mechanisms is re-
quired along with familiarity with the natural his-
tory and phenomena of disease, such as is assumed
to be the possession of the expert clinician.
In trying to teach physicians what I myself know
of the niceties of manipulations. I have been sur-
prised to find so few, even of '"distinguished clinical
teachers," who are possessed of fair motor intelli-
gence. After the plastic age is passed full manual
dexterity is not attainable. Delicacy of touch is
far rarer among physicians than one might assume.
What they cannot perceive through clumsy, ill
trained fingers they are inclined to deny. In per-
cussion and palpation many of our "teachers" dis-
play surprising coarseness of touch. What a per-
son of nice tactile sense may perceive instinctively,
e. g.. the outline of the liver, the spleen, the position
and resistance of the kidneys, the stomach, varying
resistance in tissues, etc., others can only infer in-
exactly by awkward fumblings and gropings.
If space permitted it would be useful to set forth
the significance of those variants in tissue resist-
ance, local infiltrations, tensions, minor alterations
in shape and density, in sensitiveness, tenderness,
etc., especially i-n the erector spinae muscles, which
offer useful corroborative keys to the visceral con-
ditions. We can thereby valuably supplement both
our customary diagnostic as well as therapeutic
measures.
Aids to Diagnosis. — It is my conviction that re-
finements in the education of touch, the perceptive
hand, will form an essential part of clinical diag-
nostic as well as therapeutic teaching in the future.
The laboratory, at its best, is not alone adequate
to reveal many pathological indications. By habit-
ually handling tissues much light is thrown upon
many factors in diasjnosis. The careful clinician
thus not seldom can learn facts which would have
been obvious to former advisers had they ap-
proached the problem in the same way. But sight
and surface touch is a sm.all matter compared to
deeper handling, compression, palpation, estima-
tion of resistances, of mobilitv or waxy compressi-
bility.
Aids to Therapeutics. — The educated hand can
become an exceedingly important instrument in
therapeutics. While at best only auxiliary to other
agents, by its use som.e morbid states can be more
promptly and others more completely removed than
by other known means. In conjunction with judi-
ciously applied hygienic measures, or clearly indi-
cated drugs, or both, the accomplishment of com-
plete cures in certain conditions can only thus be
made certain. Any physician of moderate deftness
can acquire enough skill to greatly enhance his own
usefulness. A few can attain (and many have)
'The most skilful diagnostician of my acquaintance is Dr. Robert
H. Babcock, of Chicago, who is entirely blind and relies largely on
• touch. The late Jacob Da Costa was a marvel of palpatory
skill.
that supremacy of artistic capacity which makes
them welcomed or famous. Variation in result
here is precisely analogous to that in other handi-
craftsmanships. A good equipment in hand skill,
along with brains and education, lifts the few above
the many moderately competent. There is no more
warranty in denying extraordinary results attained
by manual therapy than in legerdemain, in painting,
in sculpture, in violin or piano playing. Herein
feeling, instinctive apperception, must supplement
knowledge.
Conformation also cannot be ignored. Hands
var\'; some are well, others are ill adapted to the
work. Motor intelligence does not always stand on
a par with intellectual gifts. "Each man at arms
naturally prefers to employ those weapons best
fitted to his hand," be they drugs, hygiene, elec-
tricity, or manual dexterity. To omit any one may
be to fail to do our full duty to the patient. The
history of modern medicine exhibits manifold in-
stances of the truth of the assertion, though relative-
ly few failures are candidly recorded. Observant
folk, however, often detect the instances of failures
due to omissions. Hence when varied measures, not
manual, have failed to relieve or cure ; whenever a
skilful craftsman presents and does achieve desired
results (especially where the physician omitted to
advise and direct the agent) confidence in him is
shaken, the potential of the profession is lowered.
This need not be ; should not be permitted. The
remedy is for all physicians to themselves acquire
much Icnowledge, and at least some skill, in manual
therapy.
Massage. — In so condensed a presentation it is
only permissible to describe briefly massage as em-
ployed to-day. For sixteen years I lectured on the
principles of massage at the Orthopaedic Hospital of
Philadelphia, and am familiar with many extensive
and excellent treatises on the subject. To these the
reader is referred for details of how it should be
performed. Suffice it to say that wide differences
of opinion obtain as to the value of general mas-
sage. Those who deny its utility, it is safe to say,
are not familiar with its actual clinical effects or
procedures, hence incapable of estimating the qual-
ity of the product. If a physician, however Teamed
in other departments, prescribes a series of power-
ful remedies of which he knows practically nothing,
but leaves the dosage, etc., entirely to the dispensing
chemist, he cannot expect definite effects. This is
preeminently the situation of most who prescribe
massage.
There is one way, and only one, whereby one can
learn what an individual can do and how do the
work; that is by submitting one's own person, or
part, to be operated upon. It is next in importance
to watch the operation upon a patient and estimate
its immediate as well as remote effects.
The points which the critic should bear in mind
are many, but among the chief of these are: i.
The rate of movements ; of paramount importance
are deliberation, nicety of rhythm, and confident
gentleness ; overrapidity is usually disturbing. 2.
Depth and graduation of pressure ; this should be
nicely adjusted, and increased to the degree and
amount required. 3. Quality of skin touch;
whether dragging on the surface, pulling on super-
ficial structures, hairs, etc.. or (what is correct)
242
TAYLOR: HAND AS THERAPEUTIC AGENT.
(New York
Medical JouRN\r..
firmly lidding the surface tissues, seizing in turn
layer after layer, with increasing grasp, while pro-
ceeding deeper, as the seance progresses, using the
upper tissues to influence those underneath, till the
lowermost are reached. 4. The length of time
consumed. The custoniar\- full hour is often too
much; an adept can do all that is nccde<l in forty to
fifty minutes, often less : more is fatiguing, often ex-
hausting to frail persons. Subjects who "enjoy all
they can get" are welcome to it ; nevertheless, even
then it may readily induce hurtful byeffects. 5.
The kind and degree of exposure of the parts has
much to do with the results. Each part should be
covered immediately after treatment with a warm
faliric. usually a blanket. .SoniL- }icrsons suffer vio-
lent vasomotor reaction after massage, became
chilled, or sweat profusely, or expeiienee an ex-
treme prostration. 6. General massage is exhaust-
ing to many invalids, especiallv to comalcscents
from infection, or to especiallv fragile i)ersons, and
in proportion as subjective overtension is main-
tained. It is an evidence of capacity in an operator,
more often instinctive than acquired, to induce and
maintain complete relaxation in the tissues of the
subject.
It is not to be expected that a physician will him-
self wish to apply general massage or only occa-
sionally. It is more likely that he will have occa-
sion to api)ly localized ])ressures, as for sensory
disorders, or passive iiioi'Ciiiciits of limbs, stretch-
ings, and overstretchings, rotations, torsions, etc.,
which consume only a few minutes, demand little
exertion and induce little fatigue.
These procedures are, to my mind, of almost
equal utility with general massage, often of nuich
greater. As a part of special forms of treatment,
which an ediicaled i)bvsician is best fitted to apply,
c. g., for I lecu] latioii neuroses, "writer's cramp,"
or the ])ariitul stales in joints variously caused
and diverse!} labelled, or to overcome byeffects of
traumata, the milder forms of neuritis, sciatica,
deepseated backaches, etc., these pressures, or pas-
sive, adjusting, elasticizing movements are of the
utmost value.
Jliiifs as to How Passive Movements Should Be
I'cy fanned. — A few words as to how these should
be given are justified. The ]iatient sliould become
completely relaxed; well directed suggestion will
initiate this. Take u]) each limb, move it genii v
about in its normal excursus, bend and turn, then
drop it. repeating until it falls readily with its full
weight, unhindered by any conscious or uncon-
scious tension. So of the head and neck. Next
pull gradually on the limbs in turn till each is
brought out to the full relaxable limit, as of the
shoulder or hip tissues. Xext, holding firmly the
shoulder structures with one iiand, or those of the
hips, supporting and moulding these, haul away on
the limb in its continuity, moving it through its nor-
mal excur.sus. one position after another, until it be
made to describe passively all the attitudes it can
naturally be made to assume. .\fter this is done
the limb may be (if desired to overcome con-
tractures, or to stretch tlie nerves) forced with ad-
vantage a little beyond its customary positions till
a slight discomfort, or ])erha])s moderate pain, is in-
■duced, held for three or four seconds, and carried
hack to a comfortable jxisition. dentle twistings
(torsions j should be also used, often two or three
leverage actions. Finally deep, "distributed pres-
sures" should be made on the tender point "to scat-
ter the lymph" and the pain.
These devices are exceedingly valuable for a
large variet\- of reasons, which could be adduced
did space permit.
The mobility ui the vertebral column should
often come in for education, too. So also of the
thorax.
To induce full mobility of the backbone it is
well to cause the patient to sit on the bed, exaiuin-
ing table, or even the floor. The physician may
force the Ixxlv forward and down, hands on the
shoulders, or the bead, or by exercising traction on"
the arms, lo any degree desired. A number of ail-
ments manifested by rigidities, or parasthesias, in
the back can thus be removed. I have cured peo-
ple of distressing backaches, suffered from for many
years, by this Ireatn.ient. There was often also an
ac(|uireil scoliosis from traumata, and this, too. can
be thus corrected. Sciaticas, especially old ones, can
often be permanently relieved by this means.
While it would carry one too far afield to relate
at length the kinds and qualities of relief the phvsi-
cian can himself afford, through the laying on of
hands, it may be permitted to offer a few final com-
ments. Possessing myself rather more manual dex-
terity than common, ibis tenqited me to become in-
terested in the ])ossil)ilities of hand treatments years
before the public were oxcrsupplied with "special-
ists" professing to "accom])lish wonderful results."
.Occident led me to j)rofit b} tlie teaching of an ex-
cellent Swedish masseur named Rubesam. Much
literature is available, and, if judiciously culled, full
of rewards. Working some years in the physiologi-
cal laboratory trained me to look to the basic sources
of both normal and morbid human actiz'ities in in-
terpreting the natural history and phenomena of
disease. By this means I acquired the habit of
associating effects witJi fundamental causes, and of
looking as deeply as possible for primary i)rinci-
ples of therapeutics. It was early found that a va-
rietv of ])ainful states were amenai)le tc^ trealment
by sim|)le, yet purposeful, manipulations. \'aso-
constriction and vasodilation can be readily thereby
inHu.neei], waste ])roducts hurried into the elimi-
nating cliannels, not so much by direct squeezing
(massage) as by reflex stimulation through the cen-
tral vasomotor substations in the cord.
So many desired effects are attainable by such sim-
ple acts that it is strange the profession has neglected
to observe and make use of the vasomotor reflexes
more constantly. The body is like a piano or haq),
to be played upon at will. .\11 that is needed is to
work out the principles on a i)ractical physiologic
basis. I. have learned from all .sources, and most
from John P. Arnold, who for seven years was
demonstrator of physiology in the University of
Penn.sylvania. For example, he showed me how to
promptly cure- my daughter of a lameness which
iiad resisted the efforts of the best surgeons.
The sphere of api)licability of manual treatment
grows larger all the time ; nevertheless, I hope I am
equally cognizant of the limitations.
For a long time my colleagues and personal
friends adjured me to hold my peace about my con-
victions. I, however, hold and express such defi*
SILL: STERILIZED MILK.
243
nite opinions on the indispensability of drugs that
my sanity suffers no serious challeno-e/
By a five or ten minutes" use of my hands I am
often able to so supplement other remedial agents
as to relieve, often permanently and in a vastly
shorter space of time than formerly, a large variety
of ailments, sufferings, and diseased states, so that
I feel impelled to urge attention to these valuable
measures upon all practising physicians.
1504 Pine Street.
IS STERILIZED MILK A SAFE FOOD FOR
INFANTS?*
By E. Mather Sill, M. D.,
New York.
This question I shall endeavor to answer in the
following paper largely from my own experience,
but sub.stantiated and emphasized by the experience
of others.
Some six years ago my attention was drawn to
this subject from the fact that such a high per-
centage of infants fed on sterilized or pasteurized
milk were found to be diseased or abnormal. In-
vestigations have been closely followed up from that
time to the present.
We are all agreed that upon the proper feeding
of the infants of to-day depends the health of the
succeeding generation and the general physical con-
dition of the nation, for the infant of yesterday is
the child of to-day and the man of to-m'>rrow, and
it lies in a large measure with the profession
Avhether the infants of to-day and of the coming
generations shall be a strong, sturdy, well developed
lot, prepared to resist disease, and physically equipped
for the hardships they will encounter in the world,
or an ill nourished, poorly developed, undersized,
inferior race with little power to resist disease. In
short, it is our supreme duty to find out what is for
their good and our supreme business not to be de-
feated in realizing that good.
Before going farther it would be well to define
just what is meant by sterilized, pasteurized, and
raw milk, as I shall make use of these terms con-
stantly.
To become sterilized, milk is boiled or heated to a
temperature of 212° F., which temperatiu'e is main-
tained half an hour.
To become pasteurized, milk is raised and kept at
a temperature of 160° F. to 170° F. for twenty to
thirty minutes.
By raw milk we mean milk just as it has come
from the cow, unheated.
Observations show that the heating of milk only
moderately alters the constitution of its ingredients
by disintegrating the organic imion of the proteids
^md mineral salts. In this disintegrated state the
nutritious quality and digestibility of the milk are
impaired. Hence starvation and atrophy of the tis-
sues and consequent diminution of cell growth.
If pasteurization made milk a perfectly safe food
it would be universally adopted, but, besides chang-
ing the chemical ingredients and composition of the
milk, it destroys the harmless bacteria, many of
-See the Future Science of Medicine, Sajous's Monthly Cyclopae-
•lia, September, 1907.
'Read at mectinR of the Alumni Association of the City (Charity)
llos;ital. held on January 8, 1908.
which kill off the harmful kind, and thus the milk
is a better culture medium for the virulent or disease
breeding varieties.
We are consuming bacteria in other foods con-
stantly. They are necessary to make our cheese, in
the form of yeast to raise our bread. They are
found in large quantities in the cream which makes
our butter, and in numerous other substances, and
in fact are necessary for the production of certain of
our daily foods. So that the idea of having every-
thing sterile before eating is wrong, impossible, and
unhealthy.
Dr. Freudenreich tells us that fresh raw milk
has germicidal properties, and, according to his ex-
periments, the bacillus of cholera dies in an hour
when put into fresh cows' milk, the bacillus of
typhoid fever in twenty-four hours, while other
germs die at the end of varying periods, and milk
that has been exposed to a temperature of 131° F.
loses these germicidal properties.
Russell and also Freeman, after various experi-
ments, conclude that a temperature of 140° F. (60°
C.) for twenty to thirty minutes is sufficient to de-
stroy the bacillus of tuberculosis, diphtheria, and
typhoid fever.
Recent observations by Spolverini and Hippius
have proved the presence of various ferments, both
in mother's milk and cows' milk, and the weaken-
ing of these ferments by a moderate amount of heat
(145° F.) and their destruction by a slightly higher
degree. According to Spolverini, in sterilizing milk
the following changes take place in the composition
of the milk :
1. Expulsion of carbonic acid gas of milk, which
stimulates the secretion of the gastric juice.
2. Diminution of the amount of lime and free
phosphoric acid, increase of insoluble calcium phos-
phate, which is not absorbed, and precipitation of
the antiscorbutic citric acid.
3. A large part of the lecithin in the nucleon is
destroyed and precipitated as unabsorbable, inor-
ganic compounds.
4. The casein is changed and rendered unabsorb-
able, and the soluble albumin is coagulated.
5. The fat globules unite into larger masses, that
are less easily absorbable.
6. The ferments are destroyed, and thus are lost
antitoxic and immunizing substances, and micro-
bicidal compounds of great value to the child.
These disadvantages result in the child being pale,
with soft flesh, having a predisposition to intercur-
rent diseases and a lack of resistance to ailments,
with rickets, showing disturbances of nutrition.
It has been stated that the germs of typhoid fever,
diphtheria, scarlet fever, and consumption are fre-
quently carried by milk. No doubt this is true in a
few instances, but we all are familiar with the latest
m.ethod of treating consumptives b}- giving several
quarts of raw milk each day, and for years p^.tients
with the other diseases mentioned above have been
fed on raw milk.
If we subject fresh milk that contains germs to
heat, the milk still contains the dead germs and
their toxines. Heat does not purify milk by killing
the germs, and the toxines contained will cause dis-
ease.
\Miat, then, is meant by a "safe" food? A safe
244
SILL: STERILIZED MILK.
[New York
Medical Journal.
food for an infant is one in which all the elements
of the milk have been unchanged as to their organic
union. Heating disorganizes these elements, devi-
talizing the milk and changing it from a live, fresh
food to a dead, preserved food.
It being my privilege to have yearly under my
care some 5,000 infants, I have had exceptional op-
portunities for studying the various methods of
feeding, especially as we have our own diet kitchen .
for the modification, sterilization, and pasteuriza-
tion of milk (nearly two hundred infants being fed
daily). Careful observations have been made for a
period of over five years on all the infants, about
25,000 in number, and accurate knowledge as to the
exact method of feeding was obtained.
Of those infants that were fed on sterilized or
pasteurized milk continuously or part of the time on
one and part of the time on the other, ninety-seven
per cent, developed scurvy or rickets or a combina-
tion of the two, the so called scurvy rickets of the
EngHsh authors. These infants had been fed for a
varying period of from three to eighteen months on
the heated milk ; pasteurized milk was given during
nine months of the year and sterilized milk during
the three summer months. This milk was all care-
fully modified to suit the age and digestion of each
individual infant. About 20 per cent, of the infants
had five feedings a day supplemented by breast feed-
ings. These also had signs and symptoms of
rickets, but in a degree less than those who were
fed exclusively on pasteurized or sterilized milk.
No infants fed on modified raw milk developed
rickets or scurvy or any other disease due to im-
proper feeding, such as anaemia, malnutrition, ma-
rasmus, etc.
According to Koplik, manifestations of rickets
may show in the bones at autopsy when no symp-
toms have shown during life, but these children had
been fed on foods which are known to produce
rickets. I have seen great numbers of infants with
the earliest symptoms of rickets, and spongy or
bleeding gums of varying intensity, but with no
other symptoms of infantile scurvy, and also numer-
ous other infants with purpuric hiemorrhages and
slight sponginess of the gums. The majority of
these infants, it was found, were fed on sterilized or
pasteurized milk, and promptly responded to the use
of raw milk with no other treatment. The greatest
number of my cases of scurvy have been of this mild
type or early stage of the disease, but which were
just as much infantile scurvy as those with more
pronounced symptoms of periosteal haemorrhage,
pseudoparalysis, pain, fever, prostration, etc.
These conclusions based on observations at our
own laboratories are substantiated by investigations
which I have made on infants fed at other labora-
tories and at home. It has been found that every
infant suffering from rickets, scurvy, malnutrition,
etc., that has come to our notice and that has not
been fed on an\' of the patent baby foods has. how-
ever, been fed for varying periods on pasteurized or
sterilized milk.
It would seem, then, that there was a common
cause of disease in these cases, namely the use of
sterilized or pasteurized milk.
Being anxious to know whether sterilization and
pasteurization of milk was the entire cause of these
diseases raw milk was substituted with no other
treatment, whereupon the children immediately be-
gan to improve.
Infants which were in good health when fed raw
milk, were attacked with symptoms of rickets when
sterilized or pasteurized milk was given.
Those who have had a large experience working
among the poor of our city, and know the gross
ignorance displayed by the mothers in the feeding
of their infants, fully realize the fact that the re-
duced mortahty from diarrhoeal diseases of recent
years has been due not to the fact that the milk has
been sterilized or pasteurized, but to the improved
method of feeding by the modification of the milk
to suit the age and wants of the child and putting
the milk up in stoppered nursing bottles that are
kept on ice until the time of using. Also a better
grade of milk has been used.
It might be interesting to note here that T. M.
Price, chemist at the Maryland Agricultural Ex-
periment Station, made a series of experiments on
calves to ascertain the comparative nutritive value
and digestibility of pasteurized, sterilized, and raw
milk. The result of these experiments showed that :
1. More fat and proteid were digested when raw
milk was given than when pasteurized milk was
given.
2. More proteid and fat were digested when pas-
teurized than when sterilized milk was given.
3. More proteid and fat were digested when raw
milk was given than when sterilized milk was given.'
4. Calves gained more when raw milk was fed
than when pasteurized milk v/as fed, and still more
than when sterilized milk was fed.
5. Calves lost on sterilized milk, were stationary
or gained very slowly on pasteurized milk, and
gained rapidly on raw milk.
6. Diarrhoea was set up in calves by the use of
sterilized milk and stopped when raw milk was
fed. Since these experiments show definitely the
effect of sterilization and pasteurization of milk
upon young animals it is natural to conclude a simi-
lar effect upon infants. The most characteristic fea-
ture distinguishing sterilized from raw milk is the
state in which the albumin exists, and Richmond
says that this is changed from a soluble to a col-
loidal form, and not more than i per cent, of albu-
min is found in sterilized milk in a soluble form,
while in raw milk over 4 per cent, is in a soluble
form. The appended table from Richmond's Dairy
Chemistry shows the percentage of soluble albu-
min in milk at various temperatures :
Time of heating. Soluble Albumin in
fresh milk.
10 minutes 60° C. 0.423 per cent.
30 '* " 0.435 "
:o minutes 65° C. 0.3Q5 per cent.
30 " " 0.395 " "
10 minutes 70° C. 0.422 per cent.
0.421 " "
0.380 per cent.
30 . •• •• 0.380 " ■'
10 minutes 80° C. 0.375 per cent.
30 " " 0.37s " "
Soluble Albumin in
heated milk.
0.418 per cent.
0.427 ■' "
0.365 per cent.
0.363 " "
0.269 per cent.
0.253 " "
0.07 per cent.
0.05 " "
None.
None.
Koplik has shown by chemical tests that more
nitrogen is assimilated by the infant from milk that
has been subjected to little or no heat.
There is one apparent exception to what has been
said in regard to raw milk^ namely, I have seen
cases of rickets develop in infants who were fed for
February 8, 1908.]
EMERSON: SOURED MILK.
245
too prolonged a period on poor quality breast milk
or poor quality and much diluted cows' milk, and
here again we have the same or a similar condition
prevailing that we see in the use of heated milk,
namely, deficiency of proteids and salts. When
these infants were given a milk of sufficient strength
for their age immediate and permanent improve-
ment was noted with a healthy, steady growth.
Then it would seem the above mentioned diseased
conditions are brought about by deficiency and
change of the proteid molecule and the alkaline
earthy salts organically combined. This condition
of unabsorbability being caused by superheat.
Landois, in speaking of rickets, says : "The nor-
mal nutrition of muscular tissue can only take place
if sufficient supply of sodium chloride and potassium
salts is provided in the food, as they are integral
•constituents of muscular tissue, otherwise the mus-
cles atrophy and their reconstruction is prevented.
In such conditions the central nervous system and
the digestive apparatus also suffer, and the animals
perish." This, no doubt, accounts for the frequent
occurrence of convulsions in rickets.
Conclusion. — In closing it would seem then, after
careful clinical observation of many cases substan-
tiated by chemical research and bacteriological find-
ings, that the conclusion to be drawn must be that
the advantages of the raw milk, when properly used,
far outweigh any advantages which highly heated
milk may possess. And if milk is heated it should
never be raised above a temperature of 140° F.
for twenty to thirty minutes.
142 West Si:\ i£ntv-eighth Street.
THERAPEUTIC USE OF SOURED MILK.*
By Haven Emerson, M. D.,
New York.
The use of soured milk is based on three distinct
properties :
1. The fact that pathogenic bacteria do not thrive
in a medium that has a marked degree of lactic acid.
2. The process of carbohydrate and proteid disin-
tegration occurring in the souring of milk makes a
softer and more digestible and smaller casein curd,
and a carbohydrate in a state of partial digestion.
3. Lactic acid activates peptic secretion and diges-
tion.
The use of soured milk is indicated broadly as a
preventive against the putrefactive process of proteid
disintegration in the digestive canal. It is useful in
the feeding of infants and invalids who are suffering
from disordered digestion, especially of the fermenta-
tive types. It is safer than unsoured milk where the
supply is not clean enough to be above suspicion.
Its use has been proved valuable, in the dietary treat-
ment of pulmonary tuberculosis and in the modified
food of healthy infants.
Chemically milk may be separated into classes, as :
I, Whole milk; 2, whey, that is, whole milk minus
casein and fat; 3, skimmed milk, i. e., whole milk
minus fat and a small amount of casein ; 4, butter-
milk, really the same as skimmed milk, but usually
a term applied to soured skimmed milk.
*Read at a meeting of the Society of the Alumni of Bellevue
Hospital, December 4, 1907.
Bacteriologically milk may be separated into
classes, as: i, Clean milk, i. e., free from bacteria;
2, pasteurized milk; 3, sterilized milk; 4, putrefac-
tive milk, i. e., milk containing putrefactive bacteria ;
5, pathogenic milk, milk containing pathogenic bac-
teria; 6, lactic acid milk, i. e., sour milk — (a) due to
the presence of lactic acid bacteria with or without
the presence of yeast, free from pathogenic and pu-
trefactive bacteria, and (&) due to the presence of
lactic acid bacteria with or without yeast, but accom-
panied by pathogenic, putrefactive, and harmless
bacteria.
If we want to use soured milk we should demand :
1. Clean, whole milk. This is a necessary prerequi-
site if we wish to avoid the necessity of pasteurizing
or sterilizing the milk before we start the process
of souring. 2. The milk should be skimmed fresh,
preferably by mechanical centrifugal separation im-
mediately after chilling, subsequent to milking or
during the process of chilling. 3. If the milk is not
free from pathogenic or putrefactive bacteria it must
then be sterilized, to put an end to the growth of
pathogenic and putrefactive bacteria, and to enable
us to control the results of our subsequent inocula-
tion without the interference of undesirable organ-
isms. 4. The milk should then be inoculated with
an exact dose of biologically standardized bacteria.
Probably the inoculation with bacteria should be ac-
companied by inoculation with known cultures of
yeasts. The yeast is necessary: i. To inhibit the
overgrowth of pathogenic and putrefactive bacteria ;
2, to add flavor which cannot be obtajned without
it, presumably by the production of aromatic sub-
stances such as esters ; 3, to attack milk sugar after
lactic acid has been formed in the milk, and produce
alcohol and carbonic acid gas, which are valuable
assistants in the digestion and absorption of milk
and in making milk tolerated by irritable and con-
gested mucous membranes.
It is believed that yeast cannot ferment milk by
itself, but needs the preparation of the milk by lactic
acid bacteria before it can itself be effective. Bac-
teria are necessary : i. To prepare for the action of
yeast; 2, to form lactic acid to an amount of, in
some instances (e. g.. Bacillus bulgaricus) , as much
as 2.8 per cent, of lactic acid; and, 3, to break up
the proteid.
The yeasts which ferment milk rarely, if ever,
cause disease processes, and their selection depends
upon the flavors, the carbon dioxide, and the alcohol
which they develop, and their availability for distri-
bution and preservation.
The bacterial flora of the faeces of humans and
all domestic animals normally contains lactic acid
souring bacteria, and the so called natural souring
of cows' milk is due in all probability to the infec-
tion of the milk with the dust from stable manure.
Most pathogenic bacteria will produce lactic acid
souring in milk. Pathogenic and nonpathogenic
cocci produce lactic acid souring of milk. It is ap-
parent then that the bacteria to be used for souring
purposes must be selected from among the nonpatho-
genic varieties, and among these preference is to be
given to those which produce a large and constant
amount of lactic acid. At present the demand is ap-
parent for a distinction between pathogenic and non-
pathogenic cocci appearing in cows' milk, as some
246
SMITH: URIC ACID.
I New York
Medical Journ.
are useful, but all are at present under suspicion of
being pathogenic.
After lactic acid souring or fermentation has pro-
ceeded to a certain point putrefactive processes get
the upper hand, if putrefying bacteria are present in
the milk used for souring. Some of these bacteria
ferment lactic acid and destroy the proteids in the
milk ; thus at the same time we have an injury to the
nutritive power of the milk and a neutralization of
the useful acidity, so it will appear that a milk which
at one time would be valuable and safe, at a little
later date would have lost much of its value and
some of its safety as the result of impure inoculation
or of inoculation of unclean milk.
In inhibiting the growth of harmful bacteria in
the milk there is no positive proof whether the
yeasts or bacteria are more efficient, the important
point being, apparently, a constant and considerable
production of lactic acid to hold other microorgan-
isms in check.
The mere presence of cocci in milk or in the
"starter" or bacterial dose used to sour milk need
not be considered as harmful or necessarily detri-
mental to the usefulness or safety of the milk. The
value of soured milk will depend, then, upon the
purity of the original supply, the promptness and
cleanliness of its subsequent handling, the constancy
of the amount and quality of the dose of the "start-
er," or activating combination of yeast and bacteria,
the limitation of the resultant fermentation at the
proper point, and the subsequent care of the milk at
a constant low temperature.
If we are to introduce soured milk into our house-
holds, as there is good ground for believing would
be of advantage, or if we are to rely upon its use in
the prevention or treatment of disease, we must not
rely upon haphazard infection with undetermined
amounts or kinds of yeasts or bacteria, but we must
demand at least as high a standard of purity as is
expected in whole milk, and as exact a control of the
yeast and bacteria to be used as is maintained in the
production and dosage of diphtheria antitoxine or
tuberculin.
For facts which I believe to be correct as they are
above presented I am indebted to Professor F. C.
Wood, Dr. Hans Zinsser, and Dr. Charles E. North,
who kindly answered my questions and put me right
in matters in which they could speak with authority.
120 Ea.st Sixty-second Street.
URIC ACID; THE FORMATION, ELIMINATION.
AND EFFECT ON THE GENERAL SYSTEM.*
By E. E. Smith, M. D., Ph. D.,
New York.
Professor of Physiology and Organic and ISiological Chemistry in
Fordhara University, School of Medicine.
In directing your attention to the trinity of sub-
jects assigned to me for this evening, I ask you at
the outset that during this presentation you entirely
rid your minds of previous theories, in order that
the views here considered may make their own im-
pressions upon your judgments. The subject has
long suftered and continues to sufTer from un-
founded hypotheses which time will not permit me
to specifically refute on this occasion.
Uric acid is not a product of the catabolism of
proteids in general. It is a product formed by the
destructive metabolism of a particular class of sub-
stances more or less closely related to proteids and
usually found in combination with them ; namely,
those substances into the composition of which
nucleic acids enter. As to what nucleic acids are, I
may explain that they are organic compounds of a
complex phosphoric acid containing in combination
with the phosphoric acid, purin bodies and possi-
bly other organic compounds, notably the pyrimi-
dine and carbohydrate groups. As illustrative of
their nature we have two nucleic acids which have
been successfully studied and the composition of
which is provisionally indicated by the following
formulae :
HO OH
CsHsO.— P— C^HcO.-.
OH
aH.o.
OH
Triticomicleic acid.
HO OH
CiH^N^O— P— O— C3H,
d ~
I
CsH^N.O— P— O— C3H. <
A C=H„0.
0 o — —
V OH
C5H4N5O— P— O— C3H5
I C=H=.0.
o
I
C5H4N.O— P— OH
HO OH
Guanylic acid.
•Read at the meeting on Uric -'Vcii
Society, November 27, 1907.
the New York Urological
Triticonucleic acid has been isolated from the
wheat embryo. The phosphoric acid portion is a
combination of four molecules of orthophosphoric
acid in which hydroxyls are replaced by: (i) Two
molecules of purin bodies; (2) three molecules of
the pentose sugar, 1 — xylose; (3) two molecules of
a pyrimidine body, uracyl ; and (4) one molecule of
an unidentified base, designated x.
In the formula the first, second, and third bodies
enumerated are underlined by one, two, and three
lines, respectively.
Guanylic acid is the nucleic acid obtained from
the pancreas. It is made up of a phosphoric acid
portion, much the same as in triticonucleic acid,
with which are combined : ( i ) Four molecules of a
purin body, and (2) three molecules of a pentose
sugar united to the phosphoric acid by means of an
intervening glyceryl radical. I have underlined the
purin body once, the pentose twice, and the glyceryl
radical three times.
•Nucleic acids, differing in detail, but, so far as
we know, similar in type to these illustrative exam-
ples, exist in the body almost wholly in combination
with simple albuminous substances, forming the
nuclein and nucleoproteid compounds that are pres-
ent in all living cells, and, indeed, make up a large
portion of the cell nucleus. Their interest to us at
this time is that as a result of destructive cell
metabolism, the nucleic acid compounds yield purin
bodies which, as we have seen, enter so prominent-
ly into their composition.
J-obiuary S, 1908. J
SMITH: URIC ACID.
247
The purins are closely related to uric acid, and,
in fact, are transformed in the body into uric acid,
itself a purin. In order to understand these changes
we must consider the structure of the purins. They
are all constructed on a plan most readily under-
stood by considering their relation to the purin
framework, representing the positions of the car-
bon and nitrogen atoms in the purin molecule :
N-C«
I I
i I c.
N,,-C,— Ns
Purin framework.
For convenience of reference, the various posi-
tions in this framework are numbered from i to 9.
Thus, we have the following purin bodies, which
have been obtained from animal substances and
whose structures are built up by substituting in the
positions indicate^ the amino (NH2) group and
oxygen :
HC
C— NH2
I
C — NH
HN — CO
I I
NH..^C C — NH
CH
CH
N — C — N
Adenine (CsH^Ne)
(6 aminopurin).
N — C — N
Guanine (CsHsNbQ)
(2 aminopurin, 6 oxypurin).
HN— CO
n'c C -
HN— CO
I I
OC C — NH
HN— CO
I I
OC C -NH
CH I
CH 1
CO
X _C — N HN— C — N HN— C — NH
Hypoxanthine Xanthine Uric acid
(C»H4N,0) (CaH.N.O.) (C.H.N.OO
(6oxypurin). (2, 6 dioxypurin). (2,6,8 trioxypurin).
The chemical changes by which these closely re-
lated purins are transformed into uric acid consist
of two stages. First, the deamidizing of adenin
and guanin, by which change the amino groups are
replaced by oxygen, and there results, in place of
the adenin and guanin, the closely related hypoxan-
thin and xanthin. Second, the oxidation of the
hypoxanthin and xanthin, by which change these
latter take on oxygen, and are directly transformed
thereby into uric acid.
In order to fully appreciate the formation of uric
acid in the body it is necessary not only to know the
chemical transformations which we have now
traced and which result in uric acid formation, but
also the factors operative in producing these
changes. Recent years have led biologists to the
generalization that the chemical changes which
constitute the activity of living cells are facilitated
through the agency of those catalytic substances
known as enzymes. It has been only in compara-
tively recent time that the name enzyme has sug-
gested to us more than the activities of alimenta-
tion; now, there is good reason to believe that these
agents are concerned in practically all the chemical
changes of the body — in the constructive changes
of metabolism by which the tissues are maintained
and the destructive changes by which they carry on
their work.
In purin catabolism five classes of enzymes may
be concerned :
1. Proteolytic enzxmes, which act upon the pro-
teid compounds of nucleic acid, liberating the latter.
2. Nucleases, which facilitate the breakdown of
nucleic acid with the liberation of purins. Of the
importance and wide distribution in the tissues of
these enzymes there can be no doubt, but specific
knowledge of the nucleases is limited.
3. Amidases, which are concerned in the deami-
dizing of the aminopurins. These enzymes have
been carefully studied. Not only is their existence
known to us, but difference in action and distribu-
tion in various animals has been discovered. They
have thus far been found in the spleen, liver, lung,
muscle, thymus, and suprarenal ; not in the intes-
tines, blood, or kidneys.
4. Oxidases, which facilitate the oxidation of hypo-
xanthin into xanthin, and, subsequently, xanthin
into uric acid. This enzyme is found in spleen,
liver, muscle, and lung. Its action has been repeat-
edly demonstrated.
5. Uricolytic enzymes, found especially in the
kidney and liver, and in lesser amount in muscle
and bone marrow, the action of which is concerned
in the processes by which uric acid, formed by the
chain of chemical transformations which we have
traced, is in turn destroyed — that is to say, oxidized
to simpler products.
In the foregoing presentation of the purin origin
of uric acid I have spoken of its derivation from the
nucleic acid constituents of body cells. Uric acid
from this source is designated as endogenous in
contradistinction to exogenous uric acid, derived
from the purins by changes entirely similar to those
we have considered, but diff'ering in origin in this
particularly, namely, that instead of being derived
from body cells it is formed from the purin con-
tainin"g constituents of the food. This is not only a
possible source of uric acid formation, but a source
in fact, one which under some circumstances may
yield as much, or even more, than the endogenous
uric acid. The distinction of endogenous and
exogenous uric acid is, then, of practical as well as
theoretical importance.
There remains to consider a third possible mode
of formation, namely, the synthesis of uric acid.
We know that in growth nucleic acid and its com-
pounds may originate from purin free material,
such an origin being, of course, necessarily syn-
thetic. Why, then, may not uric acid be regularly
formed in this way in man? The possibility be-
comes more plausible when we realize that such a
mode of origin has been proved in birds. In man,
however," no experimental proof of such origin has
yet been adduced. Certain facts are explicable on
the assumption of this source, but they are equally
so on the basis of the purin source. In the absence
of supporting evidence the view of the synthesis of
uric acid in man remains an unnecessary and un-
substantiated hypothesis. We shall refer to the
matter again in discussing the pathological increase
of uric acid.
While, as we have .seen, the chemical transforma-
tions and the dynamic factors of uric acid forma-
248
SMITH: URIC ACID.
[New York
Medical Journal.
tion are pretty clearly appreciated, it must be ac-
knowledged that it is not so well understood in what
tissues and organs these changes occur. The wide
distribution of the enzymes concerned suggests that
uric acid formation is not limited to any one tissue
or organ. Indeed, the interpretation of experi-
mental observations calls for the recognition of uric
acid formation as a widely distributed occurrence.
Certain facts, however, render it probable that the
formation of endogenous uric acid is especially
abundant in muscle tissue. Thus, increased mus-
cular activity is followed within an hour or two
by an increased output of uric acid, while the per-
fusion of muscle with blood and Ringer's solution
shows an increase of uric acid and hypoxanthin
after exercise. Again, overfatigue is followed by
a very considerable increase of uric acid output. It
is probable, therefore, that ordinarily muscle
metabolism leads to the formation of hypoxanthin,
which by oxidation yields a large portion of the
endogenous uric acid. We must also credit the
muscles with greatest capacity to destroy the uric
acid formed, the kidneys next, and then the liver,
for, while muscle weight by weight is less active
than the kidney and liver in the further oxidation
of uric acid, whereby it is broken down into sim-
pler products, yet the absolute quantity of the tis-
sues in the body seems to give to muscle as a whole
the greatest uricolytic capacity.
Considering the matter of the elimination of uric
acid, it will be appreciated that the quantity that
appears in the urine is not determined by any one
circumstance, but is the resultant of the following-
operative factors:.
1. The formation of uric acid (a) by endogenous
purin metabolism; (&) by exogenous purin meta-
bolism; (c) possibly in a slight measure by uric
acid synthesis.
2. The destruction of uric acid by uricolytic fer-
ments, particularly in muscle, kidney, and liver.
3. The retention of uric acid (o) by deposition
in the tissues; {b) by limited excretory capacity.
In order to reach any conclusion in regard to uric
acid elimination, it is necessary to know the amount
excreted in twenty-four hours. This period repre-
sents the cycle of body changes. At particular
hours such marked variation of the amount of uric
acid excreted normally occurs as to rob such
amounts of any value as indicating the uric acid
elimination as a whole. If we pretend to any
knowledge of uric acid excretion there is no sub-
stitute for accurate information of the quantity
eliminated in twenty-four hours. The acidity of
the urine is of no value as indicating a uric acid in-
crease, since, on the one hand, uric acid is not a de-
termining factor in the production of urinary
acidity, and, on the other hand, the quantity of
uric acid does not even vary directly with the acid-
ity, but is quite as likely to vary inversely with it ;
in other words, the quantity of uric acid eliminated
is in no way related to the urinary acidity. Equal-
ly valueless are the makeshift methods ^of deter-
mining the fact of uric acid increase without accu-
rate determination of the amount present. Such
procedures are indefensible — worse than valueless.
In this day of pretended scientific accuracy and pop-
ular misapprehension as to the significance of uric
acid, the use of these methods certainly partakes of
charlatanism. There is no emergency that demands
such pretense of knowledge, and we owe it to our
profession, our patients, and ourselves not to em-
ploy under the guise of science these or any other
mere vagaries of the imagination.
Moreover, in our discussions of the subject and
especially our presentations of facts as to cases, we
should plainly indicate upon what our statements
of the uric acid elimination are based, whether upon
facts honestly determined or upon statements mere-
ly asserted or not completely established under the
thin guise of clinical privilege. It is only by strict
adherence to this principle that we can hope to es-
tablish the truth and escape the charge of foster-
ing popular misapprehension.
But even the accurate knowledge of the amount
of uric acid eliminated does not assure us of its
correct interpretation. So many factors may in-
fluence the elimination as to call for the exercise
of great caution regarding any conclusion as to the
influence of a given factor. Considering the fac-
tors in the order enumerated, we have, first, the
elimination of uric acid formed by endogenous
purin metabolism. This amount is found to vary
in dififerent individuals from o.i to 0.3 gramme or
perhaps more in twenty-four hours, but in health is
fairly constant in the same individual, due, in all
probability, to individual habits of life and to indi-
vidual musculature. Moreover, within ordinary
ranges of diet, there is no material influence of the
quantity of food on the endogenous uric acid out-
put, although with great reduction of diet the elimi-
nation is reduced.
In certain diseased conditions the production and
elimination of endogenous uric acid may be in-
creased. This is strikingly so at certain times in
leucaemia, but not always. Again, we are apt to
find an increased uric acid elimination, ascribable
to increased endogenous formation, during the
resolution of a pneumonic exudate; likewise,
though inconstantly, in acute hepatic atrophy. In
fact, whenever there is much destruction of the
nucleoproteids of tissues, an increased elimination
of endogenous uric acid is to be looked for, and,
oftentimes, is found.
Variation in the amount of uric acid eliminated
is due more commonly to the quantity of exogenous
uric acid than to any one factor. This, as we have
seen, is derived from the purins, free or in combina-
tion, contained in the ingested food. In man, about
one half of these purins are eliminated as further
oxidized products and one half as uric acid.
In order to allow for the fluctuation of the uri-
nary uric acid, under the influence of the variable
amount of food ingested, clinicians early employed
the ratio of the uric acid to the urea as an index to
the uric acid eliminated, taking advantage of the
fact that the urea varies directly with the amount
of nitrogenous food ingested. Thus, Herter and
Smith, expressing the total nitrogen of the urine as
urea, found that the uric acid urea ratio ordinarily
varies in health from i :45 to i :65. being fairly con-
stant in the same individual. As is expected in the
February 8, 1908.]
SMITH: URIC ACID.
249
light of our present knowledge, the former figure
was obtained with subjects on a purin containing
diet, the latter with subjects on a purin poor diet.
As we now know, the elimination of uric acid may
be increased beyond this limit by the ingestion of
food unusually rich in purins. The ratio, then, be-
comes an index to uric acid elimination only when
the character of the diet is considered. The inter-
pretation of the absolute amount of uric acid not
only calls for consideration of the character of the
diet, but also the exact quantity of purins contained
therein. As will be appreciated, wath diminishing
amounts of ingested food of a given kind, since the
absolute quantity of exogenous uric acid eliminated
constantly diminishes while the endogenous uric
acid remains constant, or nearly so, there is a rela-
tive uric acid increase, seen by an approach of the
ratio to the unusual or pathological limit. This fact
robs the ratio of any pathological significance when
the absolute quantity of uric acid is below a certain
amount. The writer empirically recognized this
amount as 0.4 gramme, a figure which with our
present knowledge of the cause of the limitation has
remained as the lowest limit permitting any inter-
pretation of the uric acid elimination by aid of the
ratio.
Passing for the moment the possibility of uric
acid formation by synthesis, we come to the consid-
eration of the influence of uric acid destruction on
its elimination. Experimental observations have
entirely failed to substantiate the early view of
clinicians that uric acid is a product resulting from
lack of oxygen to oxidize nitrogenous products to
the final, urea, -stage. We now know that if the
limitation of uric acid destruction causes an in-
creased elimination, that it does so through inactiv-
ity of the uricolytic ferments and not through any
deficit in the oxygen supply.
There is reason to believe that this factor is of
very great importance in the production of the uri-
nary increase of uric acid in many pathological
states. This has been established with the greatest
degree of probability by the results which follow the
administration of large quantities of alcohol. Early
experiments by the writer in Chittenden's labora-
tory showed that the ingestion of much alcohol de-
cidedly increased the elimination of uric acid in
dogs; later experiments by Beebe showed that this
only occurred when the ingesta contained purins,
suggesting that the increased elimination results
from a failure of the uricolytic ferments to further
oxidize exogenous uric acid formed, this failure,
most likely, resulting from hepatic or renal uri-
colytic insufficiency from the action of the alcohol.
The same explanation probably applies to the in-
creased uric acid elimination which has been ob-
served to follow the administration of certain other
drugs, notably the salicylates which Herter and
Smith and others have found to increase uric acid
elimination. Moreover, it affords a reasonable ex-
planation of the increased uric acid elimination
observed in the pathological states in which diges-
tive derangements, notably gastrointestinal tox-
aemias, appear. This includes many cases common-
ly classed as neurotic, such as neurasthenia, epi-
lepsy, certain insanities, etc. ; also many cases of so
called chronic rheumatism, arthritis; in fact, cases
of any disease with a gastrointestinal disturbance
and presenting a uric acid increase may find an ex-
planation of such increase at least in part in the
uricolytic failure to destroy the exogenous uric
acid. It is not probable that this failure is in all
instances limited to the uric acid of exogenous
origin. Thus, the uric acid increase following ex-
treme fatigue is most likely derived from diminu-
tion in the destruction of the uric acid formed in
muscle and therefore may be attributed to uricolytic
failure.
Before leaving the subject of diminished destruc-
tion of uric acid by failure of enzyme action, let
me return to the part uric acid synthesis may play
in those cases of increased elimination which we
have just been considering. Peculiarly enough,
these are mostly, and perhaps all, cases in which
the morbid processes concerned afiford products
capable of yielding uric acid formation by synthesis.
We are, therefore, confronted with the question
whether the increased uric acid elimination is in
truth due to diminished destruction by uricolytic
failure or to increased uric acid formation by syn-
thesis. In a former communication the writer ex-
pressed the opinion that the latter process con-
tributes largely to the result. With out present
knowledge of the subject, an hypothesis suggests
itself that is not only consistent with known facts,
but is in keeping with our knowledge of enzyme
action. The last few years have revealed the
fact that enzymes possess a reversible action.
This was first demonstrated with the fat splitting
ferments, which, while they split up fat into glycerin
and fatty acids in the absence of these products or
when present in limited quanity, on the other hand,
when the products of the splitting action are pres-
ent in sufficient amount, the ferment not only fails
to exercise its fat splitting function, but actually
acts in the opposite direction, combining the glyc-
erin and fatty acid to form neutral fat. There is
some probability that the uricolytic enzymes have
an analogous mode of action, the relative quantity
of the products of uric acid destruction, or, what
may be the same thing, products of morbid pro-
cesses which are capable of being built up into urio
acid, determining the rate of action of the uricolytic
enzyme, and, perhaps, if the quantity of such pro-
ducts be sufficient, actually reversing the direction
of action and leading to the synthesis of uric acid
instead of its destruction. If this be so, the pro-
ducts of morbid processes and the overproduction
of lactic acid in extreme fatigue increase uric acid
elimination by limiting uric acid destruction
through a diminution of the action of uricolytic
enzymes and possibly in extreme cases by increased
uric acid formation through synthesis. The accept-
ance of this hypothesis does not prevent the recog-
nition of some degree of limitation to uricolytic
activity by the direct inhibitory action of drugs and
toxines.
It is well established that in a limited number of
diseased conditions there is an excess of uric acid
in the blood and perhaps the tissues. The cause is
uncertain. Diminished renal secretory capacity, ex-
cessive production, fixation in the blood and tissues,
250
McCASKEY:
INTERNAL MEDICINE.
[New York
Medical Journa:-
are all to be considered as possible causes. There
is no proof of diminished renal secretory capacity
excepting clinical facts, which are these : First, a
diminution in the uric acid eliminated at a time
when there is an increase in the blood. This hap-
pens for several days before a gout attack and in
some cases of nephritis. While the evidence is far
from conclusive, it seems to suggest in these cases
retention by limited excretory capacity. Yet the
possibility of the uric acid being held in the blood
in some form that cannot be eliminated must be ad-
mitted. At all events, in these cases the formation
of uric acid is undesirable, because of the tendency
to deposit in the tissue, on the one hand, and the
demand on the kidneys to which these organs are
unable to respond, on the other. It is to be empha-
sized, in this connection, that these cases of uric
acid retention are numerically relatively inconsid-
erable. The disturbances in uric acid metabolism
are in the main due to excessive formation and de-
ficient destruction in the ways we have already dis-
cussed.
The third section of our subject, the effect upon
the general system, can be briefly presented. Uric
acid is possessed at most of a very slight degree of
toxicity. Aside from the instances where it is de-
posited in the tissues, as tophi, infarcts, or as em-
bedded crystals, and produces mechanical injury, it
is not known to cause any pathological condition.
It is eliminated in increased amount in many patho-
logical states, but this is the result of processes al-
ready discussed rather than evidence of its setio-
logical relation to such disease conditions. But as
an infarct or calculus or in the form of irritating
crystals we cannot question its injurious action. As
to the relation of uric acid deposits to the slight
local necrosis which accompanies their deposition
there is reason, though inconclusive, to attribute the
necrosis to the action of the urates. The fact that
joint cartilage has a special affinity for urates seems
established, and it is reasonable to believe that the
deposition results because of this affinity and be-
cause of the excess of uric acid in the blood. The
cause of the excess may be increased formation,
diminished destruction, and, probably most im-
portant, diminished elimination.
26 East Twenty-ninth Street.
INTERNAL MEDICINE: SOME OF ITS PRESENT
ASPECTS AND ACHIEVEMENTS.*
By G. W. McCaskey, M. D.,
Fort Wayne, Ind.,
Professor of Medicine in the Medical Department of Purdue Uni-
versity.
The work of much less than a generation has
wrought a revolution in medicine. Great discover-
ies, fundamental in their influence upon the practice
of the healing art have followed each other in
bewildering succession. The telephone, the phono-
graph, and wireless telegraphy are not more start-
ling in the domain of physics than antitoxines and
vaccine therapy in that of medicine. Amid this
great upheaval of fact and theory many attractive
questions offer themselves for consideration ; ques-
•Address on Medicine before the North Western Ohio Medical
Association at Toledo, Ohio, December 11, 1907.
tions which will continue important until practical
medicine has adjusted itself to its new and ever
changing environment. Instead of selecting any one
particular question for discussion, I have decided to
ask your attention to some aspects of the special
field of internal medicine which has at least kept
pace with surgery in the remarkable advances of
the last two or three decades. If its conquests have
been less dramatic they have been none the less real.
To those whose mental vision can see things in their
true perspective, disregarding for the moment tlie
glamour of the amphitheatre and the flash of the
footlights even the dramatic element is there, al-
though the action is necessarily slow.
An internist, for instance, has to deal with a heart
disabled by toxic or other causes, or a brain, or
a stomach the functions of which are impaired to
the point of disability, or a metabolism in which
chemistry has run riot. These are fairly representa-
tive problems which he has to meet.
Now, if it were a gallstone in the common duct,
or a removable neoplasm anywhere, 'the patient
could be put on the operating table, and the real
battle could be over in thirty minutes, although it
might take thirty days for the smoke to clear awa}-.
But here is an organ that has perhaps suffered from
slowly acting causes, which have produced nutri-
tional changes to all intents and purposes structural
in character. Associated with these changes there
are almost certainly more or less widespread per-
versions elsewhere. Everything must be taken into
account, and a definite plan of campaign marked
out. The patient becomes an ally, more or less re-
liable, and through weeks and perhaps months of
waiting the campaign moves on. The result may
be, as I have repeatedly seen, and as every clinician
of experience has seen, a more or less complete
restoration of function, and return to health. The
clinical picture before and the clinical picture after
present a contrast just as striking as that of any
surgical case, the difference being one of method
and time. These are facts and points of view which
I believe to be worth emphasizing in this connection,
because of the tendency (which is fast disappearing)
to belittle the methods and results of internal medi-
cine, when, as a matter of fact, no such sentiments
should exist on tl^e part of either surgeon or in-
ternist, because each needs the help and should re-
joice in the achievements and triumphs of the other.
The terms internal medicine and internist or in-
ternalist have acquired a new significance within
the last few years. The many scientific discoveries
and appliances which have been given a clinical
application, together with the technical skill and
knowledge required in dealing with the more diffi-
cult problems of diagnosis and therapeutics have
placed internal medicine in the list of specialties.
It is just as impossible for the general practitioner
to master this field as it is for him to become an
expert general surgeon or ophthalmologist. No one
can esteem more highly than I do the splendid char-
acter and sterling qualities of the family adviser. It
is inconceivable that his position can ever be shaken
or his functions usurped. He must ever continue
to be what he is now, the high priest of the domestic
sanctuary across the sacred precincts of which he
should pass with uncovered head and unsullied
February s. 1908.] McCASKEV: IXTERXAL MEDICIXE. 25I
heart. He should know somethmg of all the special-
ties; enough to decide whether or not his patients
need the special diagnostic and therapeutical re-
sources of any one of them. This is very generally
recognized with reference to surgery, ophthalmol-
ogy, larynvology, and a few others, and the time
has certainly arrived when it should be recognized
with reference to internal medicine.
The man who devotes himself exclusively to in-
ternal medicine has a field which will tax his abilities
to the utmost, no matter of how high an order they
may be. This is recognized by the leading medical
men of the world. Professor Osier, for instance,
in the introductory chapter to the first volume of
Modern Medicine, says: "The profession should
learn to recognize the worker in internal medicine
as a man who has to devote so much time to his
studies that it is impossible for him to take general
practice, and in a way he is a specialist, in the broad
sense of the term, like the surgeon." Xo general
practitioner worthy of his calling would think of
letting a patient die of a ruptured extrauterine ges-
tation or lose an eye from an acute glaucoma with-
out endeavoring to secure for the patient the best
skill available. The conditions and results in such
cases as these are so striking that every one, lay-
man and physician alike, recognizes the necessity
of prompt action. The limitations and obligations
of the general practitioner are clearly defined and
fully recognized. Xow, if what I have said is cor-
rect then the limitations and obligations of the gen-
eral practitioner with reference to a small percentage
of cases falling within the particular domain of
internal medicine in its limited sense are equally
plain, and the patient, for instance, with a, stomach,
brain, or heart disturbance of severe and unusual
type; or with an obscure nutritional or metabolic
disorder is fully entitled to the privilege, if he
chooses, of having such advantages as may be de-
rived from such a comprehensive knowledge of the
recent advances along these lines, as is only pos-
sible to the specialist.
To speak of the achievements of internal medicine
is to conjure up the clinical experience of the rges.
out of which it is an evolution, and the entire array
of physical sciences, which internal medicine his
made tributary to its special requirements. To trace
the one or catalogue the other would be impossible
on this occasion, and only a few illustrations can be
oflFered.
Consider, for instance, the liver in its clinical
aspects. One of the jokes which we are fond of
cracking at the expense of our predecessors is that
for them the liver, like a mantle of charity, covered
their ignorance of the real pathology of many of
their cases. This was really true, but it is strange
how close their intuitions or accident led them to
the present attitude of scientific medicine. It is
true that the ground is entirely different. Then it
was empirical ; now it is accurate, scientific knowl-
edge. Taking advantage, for instance, of physio-
logical investigations, we avail ourselves of the phe-
nomena of alimentary levulostiria, to \yhich I will
refer more at length later, as an accurate test of the
very important glycogenic functions of the liver,
which it is believed bears a very close relat'on^hip
to its antitoxic function. The significance of the
last named function is established by a variety of
facts, clinical and e.xperimental. I may mention the
much greater effect produced by almost any toxic
material thrown directly into the general circulation
by the stibcutaneous route, than when reaching it
through the portal circulation and liver ; and espe-
cially the phenomena of the Eck fistula, by means
of which the portal blood is carried past the liver
into the inferior vena cava, thus entirely robbing it
of the detoxicating processes of the liver cells, and
leading in consequence to the most profound auto-
intoxication, as shown by ataxia, epileptiform and
tetaniform spasms, blindness, etc. While these dif-
ferent liver functions (as -well as others of which
we know little or nothing at present) are distinct
entities, yet they must be mutually more or less in-
terdependent because of their anatomical associa-
tions. It has been shown, for instance, that if a
small twig of the hepatic duct is ligated the glyco-
gen disappears from the lobules from which it is de-
rived. The contention, therefore, of von Xoorden
and Straus that jaundice, which is probably always
due to obstructive disease in the biliary passages,
does not interfere with the glycogenic function, must
be received with reservation. It will thus be seen
that, taking advantage of data such as those just
recited, together with other quite familiar facts re-
lating to the biliary and other functions of the liver.
we are able to attack the associated clinical prob-
lems along clear cut lines in a manner which would
have been impossible a generation ago.
The clinical study of the heart oflfers another ex-
ample of the striking progress made in so many de-
partments of internal medicine. From Laennec to
2\Iackenzie, less than a century, reads like a romance.
It was a great advance when the normal sovmds of
the heart could be heard and interpreted, and still
more when pathological variations were recognized
by a combination of clinical study and work in the
autopsy room. Step by step the great work has
proceeded, and is proceeding. The introduction of
graphic methods constitutes the greatest single step,
purely clinical in character, since the time of
Laennec. By means of these methods several car-
diac events can be simultaneously recorded on mov-
ing slips of paper. The rate of motion bemg known,
the absolute time occupied by these events and their
time relations to each other can be accurately deter-
mined. A comparison of these findings in patho-
logical cases with those which normally prevail gives
information of the highest value to the clinician. It
has been found, for instance, that the ventricle
should contract within a certain average time after
the contraction of the auricle. The lengthening of
this. period, which cah be accurately measured when-
ever a recordable pulsation exists in the jugular
vein, may be the first indication of Stokes-Adams
disease, and may probably exist long before the char-
acteristic syndrome appears. These methods are
borrowed bodily from the physiological laboraton-,
as is the determination of blood pressure, variations
in which are not only of great pathological impor-
tance, but have been brought to a greater or less ex-
tent under the direct therapeutical control of the
clinician.
X'eurology of?ers striking examples of the remark-
able progress which has characterized internal medi-
252
McCASKEY: INTERNAL MEDICINE.
[New York
Medical Journal.
cine in recent years. The variations of the elec-
trical reactions of muscles, by means of which we
are able to distinguish between the peripheral and
central location of a lesion of the motor apparatus
which is causing a motor paralysis, may be men-
tioned as a noteworthy application of physical laws
and physiological phenomena to the elucidation of
clinical problems. Such routine procedures become
commonplace, and we lose sight of the profound
scientific knowledge, the laborious research, and the
logical analysis that have made them possible.
In like manner the localization of brain lesions,
which is now possible in many cases, marks another
great triumph of diagnostic methods based upon ex-
perimental and morbid anatomical studies. The ex-
amination of the cerebrospinal fluid obtained from
puncture of the lumbar spinal canal, or general ven-
tricular cavity of the brain, often gives accurate
knowledge of the highest value. The intraventric-
ular pressure can be directly measured, while the
cytology and bacteriology of the fluid may easily
clear up the pathology of an otherwise obscure case.
And so on through chapter after chapter of clinical
research, which has built the imposing structure of
modern neurology, a department of internal medi-
cine large enough and complex enough to easily ac-
mommodate the energies of any one.
The diseases of metabolism form a group the rec-
ognition of which as such would not have been pos-
sible a few years ago. Their importance is indi-
cated by the prevailing view, which appears to be
well grounded, that every function of every organ
and tissue of the body is dependent upon certain
chemical processes, .the correct performance of which
within the range of fairly well defined physiological
variations is absolutely essential for the maintenance
of that state which we call health.
Perversions of these chemical processes constitute
disease, the manifestations of which may vary from
transient languor to a rapidly fatal coma ; from a
fugacious pain in a nerve trunk to a widespread,
multiple neuritis or a myocarditis or a nephritis.
The whole subject constitutes one vast, dark conti-
nent, which has been explored a little here and a lit-
tle there, with most encouraging and even at times
brilliant results. Carbohydrate metabolism may be
mentioned as one of the most important aspects of
the entire subject, because of its essential relation to
the dynamics of the body, and the consequently large
quantities in which carbohydrates are taken. After
absorption their transformation by the liver into
glycogen, and their ultimate oxidation, or, as it is
termed, glycolysis, are the two clinically important
facts. ' The failure of the last named function is the
basal fact in diabetes mellitus. ' It is frequently im-
paired in the absence of the outspoken diabetic syn-
drone, and can be directly tested by the presence or
absence of alimentary glycosuria after giving defi-
nite amounts, usually lOO grammes, of glucose. This
is an important point in the study of chronic nutri-
tional disease.
Within a few years we have solved the problem of
clinically determining the glycogenic function of the
liver by the administration of sufficient levulose to
produce glycosuria. If this function of the liver is
intact the levulose will be converted into glycogen,
which is dextrorotary ; if not, the levulose passes un-
changed through the liver, giving levulosuria, as de-
termined by the polariscope. This is a great ad-
vance in internal medicine, giving us positive infor-
mation of one of the principal functions of this most
important glandular organ.
In nitrogen metabolism I will only mention the
important discovery that creatinin rather than urea
correctly represents destructive tissue metamorpho-
sis ; and the role that the purin bodies, some of which
are undoubtedly toxic, seem to play in morbid
metabolism.
- Reference should here be made to that phase of
metabolism represented by the internal secretions.
The thyreoid, parathyreoid, and adrenal bodies, and'
the pancreas, through their internal secretions, oc-
cupy a position of great prominence in clinical med-
icine, although it is probable that all other glandular
organs in the body furnish similar secretions, with
functions quite possibly of equal importance. The
investigations of the thyreoid bodies has, in the opin-
ion of many, myself included, very nearly cleared up
the pathology of exophthalmic goitre and myxoede-
ma. These syndrones are practically identical with
hyperthyreoidism and hypothyreoidism. The cause
of these changes in thyreoid secretion is of course
the undiscovered factor.
By the light of Ehrlich's brilliant generalizations
antibodies have been produced in the blood of the
lower animals which have a measurably success-
cessful therapeutical application as antidotes for the
excessive thyreoid secretion of exophthalmic goitre.
What an achievement, to thus deliberately produce
a chemical substance in the blood of an animal which
does, without a doubt, combine with and ren-
der innocuous another chemical substance pro-
duced in morbid excess, with disastrous results, in
man. The biochemical law which governs the pro-
duction and operation of an antibody, antidotal to
the active principle of thyreoid secretion, is precise-
ly the same as that which produces on neutralizing
a bacterial toxine. These chemical bodies have
never been isolated, and very possibly never will be ;
and we know therefore nothing of their chemical
constitution, yet we are just as certain of their ex-
istence and can therapeutically manipulate them
with about the same precision as though they were
thus demonstrable. The medical aspects of exoph-
thalmic goitre have been completely changed. In
many cases we are getting striking results, although
in others but little benefit accrues, indicating dift'er-
ences of pathology not yet understood. ■
On the other hand, myxoedema and cretinism
have yielded brilliant results to thyreoid feeding.
Few more striking contrasts are ever seen than
those ofYered by some of these patients before and
after a course of thyreoid treatment.
There is ground for hoping that Addison's, like
Graves's, disease may be made to yield to therapeu-
tical efforts based upon our knowledge of metabo-
lism as influenced by the adrenal secretion. In one
series of ninety-seven patients, about 17 per cent,
were cured and about 32 per cent, improved, in a
disease that is otherwise substantially always fatal.
In nearly one half the cases no effect was observed.
Here again, as in Graves's disease, there are possiblv
diflfcrcnt types presenting unknown i)nt fundanuMital
differences in pathology.
February 8, 1908. 1
BARBOUR: H ATER IN CHILDHOOD.
253
Closely related to metabolic disorders are the
phenomena of bacterial infections, and especially the
defense of the organism against them. As already
indicated, the same biological laws that govern the
defensive operations of the animal organism against
chemical poisons of metabolic or dietetic origin are
concerned in bacterial processes. Antibodies are
formed in response to any chemical poison that finds
its way into the circulation. The very term poison
is, however, open to objection. We know, for in-
stance, that antibodies are formed to neutralize the
secretions of the thyreoid gland. This occurs in
perfect health while the gland secretion is normal
m every respect. Now, it would be absurd to call
an essential secretion the absence of which is the
cause of so terrible a disease as myxoedema, and a
fundamental fact in cretinism, a poison. Yet we
have only to turn to Graves's disease to see how
disastrous its excess may be. The broad fact which
internal medicine possesses as one of its most valu-
able assets, and which is one of the most striking
generalizations of modern science, those of the stel-
lar imiverse not excepted, is that among the bio-
chemical processes of the body provision is made
for the formation of antagonistic chemical bodies
capable of more or less completely neutralizing near-
ly every chemical substance which finds its way into
the general circulation. The therapeutical applica-
tion of these basal laws will widen with our mental
vision.
But this is not all. The scheme is not merely
defensive, but is offensive as w'ell in the case of bac-
terial processes-. Not only are the bacterial poisons
neutralized by. antidotal chemical bodies, but the
bacteria are themselves directly attacked and de-
stroyed in a variety of ways. I will only refer to
one. Ten years ago Denys and Leclef made the
remarkable discovery that chemical bodies in the
serum prepared microorganisms for destruction by
phagocytes. It was recognized as a brilliant scien-
tific discovery but was not supposed to be of clinical
interest. To-day, thanks to the labors of Wright
and his followers, this great discovery is receiving-
daily clinical application all over the world, under
the title of opsonic or vaccine therapy. \\'e are
able at will to increase the efficiency undoubtedly
by increasing the amount of those chemical bodies
that prepare bacteria for phagocytosis, and which,
after Wright, we call opsonins. Its possibilities, es-
pecially in the chronic infections, like tuberculosis,
can scarcely.be overestimated. The techinque will,
we hope, be ultimately simplified so as to place it
on a more practical basis, and permit of its wider
use. ^^'hile it,s limitations have scarcely been ac-
curately defined, it is safe to say that it has taken a
permanent place in the armamentarium of internal
medicine.
Such are a few of the achievements of internal
medicine, which, in its special sense, is simply clini-
cal medicine specialized by a breadth of knowledge
and technical skill, of which that possessed by the
general practitioner forms a larger or smaller part
according to his mental and material equipment. If
time permitted the list could be greatly enlarged,
but these are sufficient to indicate the progress al-
ready made and the character of the work now being
done.
The future is full of promise, and the labor of
those engaged in this fascinating but extremely ar-
duous field of professional work will, there is good
reason to believe, still further broaden both our
knowledge of internal diseases and our therapeutic
resources for their control. This is one of the great-
est advantages of specialism everywhere. It is the
concentration of thought and energy along special
lines that has led to the greatest advances in the
world's history. It is just as true in medical special-
ism as elsewhere.
In conclusion I cannot refrain from reproducing
a paragraph quoted by a contemporary medical
journal from the Nezv York Evening Post. Com-
ing from a lay source it is particularly gratifying,
and shows a keen appreciation of medical affairs.
The writer says: "Some of us forget, too, the de-
velopments in medical science due to the incessant
labors of the specialist. To him we owe the prodi-
gious advances of medicine and surgery in the last
generation, the incalculable alleviation of suffering,
and the saving of life. The perfection of an anti-
toxine may take the best thought and energy of a
specialist for fifteen or twenty years, l^ie resulting
benefits to mankind, as in the case of diphtheria
antitoxine, cannot be reckoned in money. An in-
ventor who should expend half the time and skill
on a contrivance of infinitely less intrinsic worth
might easily win a fortune. But the medical special-
ist reaps no reward whatever, beyond, perhaps, a
slightly increased practice, due to his added pres-
tige. Often, indeed he deliberately sacrifices his
practice, or even his life, to the advancement of
science. For every new discovery in medicine and
surgery, every new specific, every new process or
device is at once offered freely to the whole world.
The doctor who makes a secret of his drugs or
operations is instantly ostracized. Generalizations
are dangerous," concludes the writer, "but it is safe
to say that no one class of men has given mankind
so much and received so little material reward as
the medical specialist. His greatest recompense is
the consciousness that he is the servant of the ideal,"
407 West M.^^in Street.
INDICATIONS FOR WATER IN CHILDHOOD.*
By M.\x Barebour, M. D.,
Philadelphia.
A child is an adult in miniature. All the physio-
logical laws operative in the grownup are similarly
operative in the infant, while most of the diseases
affecting the adult are also affecting the young.
Therefore, all those principles underlying the study
of the proper care and treatment, both in health and
disease, of the adult patient must likewise be ap-
plicable to the study of the care and treatment of the
infant patient.
Barring such conditions to which only children are
subject, we may safely consider this question from a
general standpoint, leaving the particular diseases of
childhood for special consideration.
Physiologists tell us that the animal body consists
of almost 70 per cent, of water. Admitting this to
be true, it would seem plausible to believe that this
*Read before the Eastern Medical Society.
254
BARBOUR: WATER IN CHILDHOOD.
[New York
Medical Journal.
quantity is necessary in order to carry on the nor-
mal pliysic ilogical processes of the animal economy
in proper condition. For similar reasons it would
also appear plausible that should this quantity in any
way be greatly reduced or diminished, either through
normal processes of the body — such as exhalation,
perspiration, and excretion — or through abnormal
processes — such as fevers, diarrhea, or loss of blood
— this lost quantity must immediately be resupplied.
Failure to do so will inevitably disturb the normal
physiological balance and will result in bodily tlisor-
ders of various forms.
Should such a withdrawal of water be permitted
to be unduly prolonged, the disorders wdl assume
such grave dimensions that life itself may ultimately
be terminated. l-"or life cannot be sustained without
a constant renewal of all elements requisite for nor-
mal physiological processes.
The role which water ]:)la_\ s in the animal econo-
m}' is distinct and deiinite and is vitally iirsportant.
It cannot be replaced b\- any other ingredient, and
nuist in itself l)e of sufficient quantity to be utilized
to advantage iius purjjoso. Amoiig its must im-
portant functions may be mentioned that iL enters
into chemical composition with all tissues of the
body ; and all tissue changes depend entirely upon a
sufificient quantity of w^ater. It forms the chief in-
gredient of all the fluids of the body and maintains
a proper degree of dilution. It moistens the vari-
ous serous surfaces and prevents friction and such
other symptoms as will result from drying. It fur-
nishes the blood and lymph with a proper fluid me-
dium by which food may be carried to distant parts
of the bodv and the waste products removed, thus
promoting normal tissue changes.
Elasticity and pliability of muscles, nerves, carti-
lage, tendons, and even bones depend mainly on the
amount of water they contain. Water also serves
as a distributor of bodily heat and regulates the
Ijody temperature by the physical process of absorp-
tion and elimination. In fact, all protoplasmic activ-
itv is greatly impaired and may even entirely cease
when a lack of water becomes felt. And truly has
an eminent author expressed himself that "the cells
of the body are aquatic in their habit." From the
cursory enumeration of facts pertaining to the phys-
iological role of water in the animal economy, it be-
comes evident that its normal percentage must at all
times and under all circumstances be properly main-
tained, so that bodily functions be not materially
interfered with.
Under normal conditions and in a proper degree
of health, this supply is ordinarily furnished partly
by the food and partly by the drink we are daily
consuming. An overindulgence in the use of water
— provided it is not carried to excess — will scarcely,
if ever, be productive of any deleterious conse-
quences. Such excess is ordinarily only of a tem-
porary character and is immediately relieved by the
increased glandular activity. And, instead of ex-
erting an unfavorable efifect, enhances excretion and
metabolism. Should this increased ingestion of
liquid be continued for some time, its favoi'ablc
effect will only be augmented and made lasting. For
a plentiful supply of water increases the volume of
blood, stimulates the activity of the glandular struc-
tures, increases the action of the kidneys, and pro-
motes sweating. Hence the tissues of the body will
be more abundantly supplied with blood and more
readily rid themselves of any dead or inactive tissue
cells. The salivary, billiary, pancreatic, and intes-
tinal juices will be increased, and improved diges-
tion and assimilation will result in consequence.
By an increase in the flow of urine, the kidneys
are washed and cleansed of any toxic substances
that may be found there. ?^Ioreover, by taking
much water into the stomach, it dilutes the "food and
helps digestion, or, if the stomach is empty, it
washes out of it any possible mucus ; and, what is
still more important, by its mechanical pressure, ex-
cites peristalsis, and, passing into the intestinal tract
and acting in a like manner, produces a mild laxa-
tive efifect. The perspiration is increased and a
larger amount of aqueous vapor is exhaled from the
surface of the lung. In consequence of these activ-
ities, the used up material of the body is speedily
removed, and the organism is enabled to take up a
larger quantity of new nutritive substances. Body
weight is thus easily gained. Hence the popular lay
idea that "water is fattening" can well be explained
upon this ground.
Contrasting the results attained by a deprivation
of water and by a liberal supply of same, we find
the following conspicuous facts preponderately in
favor of the latter. An insufficiency of water will
dry up the secretion of the glands, arrest its activ-
ity, and diminish its quantity, thereby inhibiting di-
gestion and other ])hysiological processes ; while a
plentiful supply will engender increased activity and
impart additional tone and vigor. Insufficient water
will diminish the volimie of the bloodvessels, inspis-
sate the quality of the blood, and lessen the quantity,
thereby inhibiting the circulatory power with proba-
ble results of forming thrombi in the smaller veins
of the distant parts of the body, such as the brain or
legs. Should the thrombus lodge in the brain, con-
vulsion will follow, especially in children, and if in
the leg, gangrene is apt to set in. A liberal supply
of water will prevent such calamitous consequences.
Abundant supply of water increases the elimina-
tion of urea and carbonic acid ; relieves the kidneys
from undue irritation and injury; removes the waste
product from the tissue and enhances metabolic ac-
tivity ; while a deficiency of water diminishes the
([uantity of urine, retains the degenerative tissue
products, and causes absorption of ptomain products
from the gastrointestinal tract, kidney, and other
glands. The advantages derived by a plentiful sup-
ply of water cannot, therefore, be overestimated.
Its indications are not only clearly defined, but
perem])torily imperative.
Fortunately Nature has provided a safe guide by
wdiich a deficiency of water is readily detected. The
condition of the system known as "thirst" is an exact
exponent of the dryness of the tissue and a clear in-
dication for the ingestion of liquid. The individual
thus sufl'ering is guided by his personal inconveni-
ence and instinctively supplies the necessary quan-
tity and keeps the body in a normal physiological
equilibrium. But the physiological equilibrium can
properly be maintained only in the grown ups, who
feel their wants and know how to satisfy them. But
the matter assumes an entirely different aspect when
the question of childhood comes to be considered.
February S, 1908. 1
BARBOUR: ll'ATER IN CHILDHOOD.
255
A child cannot in so many words ask for water, nor
does it even understand the pangs of thirst. Yet it
is clearly certain that the child requires water to
carry on the physiological processes of its rapidly
growing system as surely as an adult. In fact, it
needs more water than the adult. According to
Holt and Jacobi, the child requires, proportionately
to its weight, six to eight tmies as much water as
the adult.
Considering the physiology of the child, there are
sufficient data to warrant the administration of in-
fant's food in a very diluted form, even to the extent
of 80 to 90 per cent. According to Holt, such a
percentage of water is normally constituting the
foods of all young mammals. Its ase becomes appar-
ent when we learn that this amount is really needed
to dissolve certain ingredients in the food, such as
sugar and salts ; keep other substances in suspension,
such as proteids ; and also to emulsify fats.
Another and very important consideration, which
is too frequently overlooked, is the child's digestive
power. The child's stomach does not secrete as
plentiful a supply of pepsin as does that of the adult.
And the meagre quantity that is secreted is not al-
ways completely utilized, unless a liberal . quantity
of water is added. This is especially true in artificial
feeding, where the albumin will often remain un-
changed unless the child will be given some acid-
ulated water.
According to Thompson, "One of the most uni-
versal dietetic failures is neglect to take enough
water into the system." I have had many occasions
to observe the correctness of his assertion. The
very frequent occurence of vomiting in children
after having taken the breast I have frequent-
ly alla3'ed with no other medicament than the
administration of a few teaspoonfuls of water. The
water, of course, should, for safety's sake, always
be boiled. The idea is ordinarily entertained that
the milk is in itself sufficiently diluted and requires
no additional dilution. But those who think so for-
get that wlicn th.e milk reaches the stomach it turns
into curd, which is almost a solid, and with the child's
feeble digestive power and with the meagre quantity
of pepsin supplied, digestion will be considerably
hampered unless water be given. And should this
state of affairs continue for some time, irritation
and subsequently inflammation of the gastric nuicosa
will follow.
From these facts we can see the rationality of ad-
vising mothers and nurses who take care of children
to give them water and plenty of it. A glass of
water during the twenty-four hours for an infant
of several months is none too much. This amount
should vary according to season and to certain phys-
ical conditions of the child. During the hot sum-
mer months, the child will require much more water
than during any other time. In a state of perfect
health, the child may receive a little less water, but
during certain morbid conditions the quantity should
be either considerably increased or considerably
diminished.
It is not within the scope of this paper to study
the therapeutical value of water in each particular
disease, but I will only outHne certain indications
in a few diseases, leaving the physician to exercise
his good judgment in the definite case under his
consideration. The morbid states in which water
is particularly indicative are those that are accom-
panied by pyrexia. Fever consumes a great deal of
water from the tissues, diminishes the secretory
power of the various glands and especially lessens
the secretion of the saliva and gastric juice. It also
inhibits the absorbing power of all the mucous mem-
branes. By giving enough water to the child, it will
restore the loss sustained through the fever, en-
hance the glandular activities, and by diluting the
food, the gastrointestinal tract will more readily be
able to absorb the nutriment and maintain the vital-
ity of the child.
In gastrointestinal disorders, a condition very fre-
(luently occurring in childhood, water is of inesti-
mable value. Most of the cases of gastric disorders
are due to overfeeding. The pernicious habit of
giving the child the breast or food whenever it cries
has led to many an ill consequence. Alany mothers
will not appreciate the fact that "a child may be
thirsty without being hungry at the same time."
.Knd if food instead of water is given, the deli-
cate stomach of the child will be overloaded, irri-
tated, and inflamed. The treatment is simple — give
less food and more water.
In the various forms of diarrlKEa, particularly the
summer diarrhea, with stools numbering fifteen to
twenty a day, or in protracted and chronic forms
of diarrhoea, the reason for administering large
quantities of water is selfevident, for watery stools
abstract the fluid from the system, diminish the
blood pressure, and cause a decided depression in the
vital powers. The loss of liquid thus sustained must
of necessity be rectified, either by administering
water by mouth or per rectum.
By imbibing a quantity of fluid we raise the ar-
terial tension, reenforce the bloodvessels, supply
the dried up tissues with the adequate amount of
fluid, enhance metabolism and counteract the de-
pressing effect of the diarrhoea. In cases of gen-
eral inanition or where metamorphosis is very slow,
water will prove a decided benefit by increasing
elimination of waste products and engender greater
ph3'siological activity of the system. In conditions
where the urine is scanty and of a high specific
gravity, water will wash out the kidneys from irri-
tative substances and protect them from undue in-
jury.
In irritability of the bladder due to concentrated
or acid urine, water will prove an unquestionable
beneficent remedy. In laryngitis and bronchitis, in-
gestion of water will moisten the bronchial mucous
membranes, liquefy the viscid expectoration, and act
as a luild expectorant. There are many other con-
ditions where the beneficent use of water is clearly
evident. But they all rest upon the same physiologi-
cal principle, viz., the endeavor to restore the sys-
tem to as close a normal physiological process as
]x)ssible. Upon the same ground and for similar
reasons, the use of water should be restricted in all
such conditions where it will tend to deviate from
the normal physiological process.
Conditions where water in children are contra-
indicated are but few in number. Many more are
found in adults and especially in the aged. Arte-
riosclerosis, aneurysm, cardiac insufficiency, dilata-
tion of the stomach, etc., are certainly conditions
256
POLAK: CONTRACTED PELVIS.
[New York
Medical Journal.
where abstinence from water is highly reasonable, .
but cnildhood being free from such diseases, such
contraindications are out of consideration. There
are. however, certain conditions where the restricted
use of water is clearly advisable. Sucii cases as
cedema or pleuritic effusion where the extravasation
of fluid into t!ic tissues is great, water is certainly
contraindicatcd. in caM.s where there is a high ar-
terial tension with congestion or intfammation in
certain organs, such as the brain in meningitis, or
the lungs in acute lobar pneumonia, an increased
ingestion of water will aggravate the condition by
additiniiallv distending the bloodvessels, and the
withdrawal of water is unc|uestionably the proper
treatment. In fact, in any condition where there is
congestion in important organs as a result of acute
inflammatory processes, the use of large quantities
of water is contrary to good judgment.
Barring such conditions the use of water in chil-
dren, both in health and disease, is certainly under-
rated to the lamentable disadvantage of the child.
Water being so simple and commonplace a drug
that it seems to be below dignity to devote to it
any amount of attention. Hence, its proper treat-
ment in our works on therapeutics is sadly omitted.
Yet if doctors, nurses, and mothers would give "our
little ones" water more often, there would be less
occasion in give drugs so often, lictween the two,
I w^ould rather see the child l^e the reservoir of the
harmless, yet all beneticent, water than a receptacle
for an infinite variety of drugs which at best leave
but an undesirable impression.
J037 SolT!! Fii-th Street.
CONIRACTED PELVIS AS A CAUSE OF
DYSTOCIA.*
Bv John Osbokx Pcl.xk. M. 1)..
Brooklyn. X. Y..
Prof<.'SS<.r_ of ObsU-tncs, h.nluinnll) Medical l ollcw; .Vdjuiicl .'vo-
\ Mi'k,-.'"'iio.i:,i-r'
Actual or relative deh ir,iiil\- (jf the pelvis occurs
with sufficient fre(|uency to make it a common fac-
toi in causing dystocia during labor. All d}-stocice
are due to some defect in the jxjwers, the passenger,
or the passages, and this latter cause is the least
comprehendefl by the i)ractiti()ner, yet actual con-
traction of the pelvis showing from one half to one
inch deficiency in the anterior posterior diameter
occurs in about 6 per cent, of American born women
and a relative contraction is present in a larger ])er-
centagc. Fortunatel\- both for the woman and the
child the degree of contraciion is slight. It is, how-
ever, these slight degrees of contraction which ])ro-
duce tVietal malpositions which result in the dystociic
so commonly met. Marked contraction, though
rare, is more easily recognized, and the physician
is therefore more able to cope with the complication.
The build of the woman, the history of her i)re-
vious labors, the high position of a tumor, some de-
gree of pendulous abdomen, the malposition of the
fcEtus. and the nonengagement of the presenting
part, all point to a disproportion between the pas-
sages and the passenger, and should suggest to the
attendant the necessity of careful investigation.
•Uca.l. iiivit.ition. bt-fori- East Side Medical Society.
The ability to recognize deformities of the female
pelvis by pelvimetry is as necessary an accomplish-
ment for the accoucheur as percussion and anscul-
lation is to the internist.
The practitioner and many teachers are wont to
discredit pelvimetry, failing to appreciate that its
value is relative and suggestive, rather than accur-
ate. For the birth of tlie child depends, not only
on the size of the pelvis, but the size of its head, the
degree of its adaptability, the character of the labor
pains, and the resistance of the maternal soft parts.
The purpose of these remarks is to briefly sum up
our position in the management of labors in con-
tracted or relatively contracted pelves.
Contraction, whether actual or relative, can in
most instances be recognized before labor by ab-
dominal examination, noting the high position of the
tumor, the marked protrusion of the abdomen (a
pendulous abdomen in a primipara is always signifi-
cant of a misfit j. the frequent occurrence of malpo-
sitions, the high position of the presenting part, and
finall} b\- cephalometry and pelvimetry. In mul-
lipane the history of previous labor should put the
attendant on his guard.
When labor has actually begun, the question
wdiich presents itself is. Can this child pass through
this pelvis, and how ?
Before going- into the management of labors oc-
curring in abnormal pelvis, I w ish to take up a few
minutes by directing attention to some simple points
in pelvimetry and cephalometry, both actual and
relative, too often passed over by the attendant as
scientific rather than practical.
The externa^ conjugate or diameter of Baude-
locque simply serves to indicate the probability or
improbability of pelvic contraction. An external
conjugate of 16 cm. or under always means an an-
terioposteriorly contracted pelvis. When this di-
ameter is between 16 and 19 cm., the pelvic inlet
is contracted in more than 50 per cent, of the cases.
When above 21.5 cm., it is almost certain that the
inlet is ample.
This diameter, which is measured from the fossa
below the spinous process of the last lumbar vertebra
to the front of the sxmphysis. about one eighth of
an inch below its upper edge, averages in the normal
pelvis 20.25 cm. The relation of the iliospinal 10
inches or 26 cm. to the iliocristal 1 1 inches or 29
cm. is all important, for the former should always
measure less than the intercristal. in a normal or
generally contracted pelvis, while in a flattened pel-
vis the inlerspinal is often equal to or greater than
the intercristal in length. Occasionally external pel-
vimetry and the suggestive data thus gained is
unavailable for one reason or another, and the prac-
titioner must fall back on the only reliable measure-
ment in the true pelvis, the diagonal conjugate, which
is measured from the summit of the subpubic arch
to the promontory of the sacrum ; from this the con-
jugate vera mav be estimated by deducting from
one half to three quarters of an inch, depending
upon the depth, the inclination, and the thickness
of the symphysis. It is safer, however, always to
deduct three quarters of an inch. A rough, yet
practical, way of estimating the true conjugate is
to estimate the diagonal conjugate by digital exam-
ination, basing such estimate on the case with which
reliruai y S, 1 90S. I
POL. IK: COXTRACriiU PIIIJ'IS.
the promontory can be reached. ( If it cannot be or
can just be touched with the middle finger, the an-
teriorposterior may be considered normal, while if
the promontory can be reached with the index finger
the pelvis is ccntracied, and the contraction is in
proportion to the ease with which the promontory
may be reached.)
W hen extreme accuracy is demanded, as when
U is necessary to decide bet^veen hebotomy during
lai)(:r or an elective C?esarean operation. Hirst's pel-
vimeter for measuring the distance between the up-
per outer edge of the symphysis and the promon-
tory, and then deducting the measured thickness of
the symphysis, seems to leave but little room for
error. The outlet diameters may be accurately
measured.
After determining the size of the pelvis, its rela-
tive capacity must be estimated by noting the size,
compressibility, and malleability of the foetal head,
for an normal pelvis may be an insuperable obstacle
if the child is large. In primipariie when there is a
normal relation between the head and the pelvis, the
presenting part descends into and engages in the
pelvic cavit\' during the last week or two of preg-
nancy, consequently when the head is not engaged
in a primipara at the beginning of labor something
must be wrong. Tliis rule has no exception. Any
of the following caust-s vvill prevent the head from
being found engaged : a contracted pelvis, a large
head, a small child, excessive liquor annul, mal-
positions of the foetus, multiple pregnancy, and
placenta pra;via. \'ertex presentations are lo per
cent, rarer in contracted pelves than when the pelvis
is normal : abnormal presentations increase in fre-
quenc} with the degree of contraction. Face and
transverse presentations possess a peculiar signifi-
cance in primipara, as such a malposition always
suggests disproportion.
Before labor, Stone's method of estimating the
biparietal diameter of the f(etal head is of great
practical value. He measures the occipitofrontal
diameter with a pelvimeter through the abdominal
wall, making no deduction for the thickness of the
])arietes — 2 cm. is subtracted from the occipito-
frontal if this diameter is 1 1 cm. or less — and die
resultant is the biparietal; when the occipitofrontal
is over ii cm.. 2.5 cm. are subtracted.
When labor has begun or is in progress, and the
head remains unengaged — with the occiput to the
posterior in semiflexion or in some degree of exten-
sion, which is always an evidence of dystocia — the
attendant may gain an excellent and accurate idea
of the relative size of the head and pelvis by adopt-
mg the following modification of the so called
Mueller's method :
With the patient on a table, aucnethetized, and in
the Walcher position, her bladder and rectum
empt\, the vulva and the hands of the operator
proper]} cleansed, one hand is introduced through
die \ul\a and passed into the vagina, or, if neces-
sary, into the uterus, the head is seized, flexed, and
rotated in such a way that the sagittal suture is
either in an oblique or the transverse diameter at
the brim. With the head held in this position by the
vaginal hand, the external hand attempts to crowd
it into the superior strait by suprapubic pressure :
if it enters and can be made to engage there is no
disprojiortion ; failure to engage usually signifies
actual or relative contraction.
When contraction of the pelvis is recognized be-
fore labor, the pregnancy may be interrupted before
the fa?tus has attained its full size by the induction
of premature labor, or the pregnancy may be allowed
to go to term, and the labor managed along normal
lines with postural aid until some comjjlication shall
arise to threaten the life of mother or child, or the
pregnancy may be terminated by premeditated in-
tervention for the purpose of protecting mother and
child, ])ractised before or at the onset of labor, as
version, hebotomy, or Ciesarean section.
Every case of labor in a contracted or a relatively
contracted pelvis presents such distinct and definite
indications, that it is difficult to formulate inflexible
rules for its management. The w riter's practice in
this class of cases is briefl\' as follows:
If the conjugata vera measures as low as 9 cm.,
it is a safe plan to induce labor at the thirtv-sixth
week or thereabouts. Such a child has had but little
added risk, and such a procedure is much the safest
plan for the mother, for the induction of labor, if
done properly, should have no maternal mortalitx-.
It will be contended that many women with a con-
jugate of 9 to 9.5 cm. will deliver themselves spon-
taneously at term, and while we know this to be
true, the majority will experience abnormal delay
and difficulty in labor, v. itli added risk to both child
and mother. Even in a pelvis with a conjugate of
8.5 cm. I practise induction at the thirty-sixth week
and consider it the operation of choice. If, however,
ihe conjugate measures 7.5 cm. or less, premature
labor four weeks before term cannot be expected
to assure spontaneous delivery, and the viability of
the child is less as we get further from term.
Qesarcan section, on the other hand, offers the great-
est advantages, done at or shortly before term as
an elective operation.
If the patient is seen for the first time in labor, or
the deformity is not recognized until labor has al-
ready begun, it is well to permit the labor to pro-
ceed, noting the character of the pains, the moulding
and adaptation of the head, and allow, if possible.
lhe engagement of the head by natural forces. It
is permissible in most cases to wait for full or al-
most full dilation of the cervix, noting the woman's
pulse, temperature, her general condition, and the
height of the retraction ring, and the tliining out or
distension of the lower uterine segment, to avoid
the possibility of uterine rupture. Should the head
fail to engage by natural forces while the cervix is
dilating, it is my practice to attempt to fit this head
to the pelvis bv the modification of Mueller's method
already described, taking advantage of the Walcher
position during the manipulation — should this fail
to secure the entrance of the head into the pelvic
inlet. Nature and forceps, in my opinion, should
give place to podalic version, when the conjugate is
not below 8.5 cm.— as the smaller end of the wedge
represented by the child's head is engaged in the con-
tracted inlet, the head may be guided through the
successive diameters with great facility, for not onl}^
is the vault compressible by the overlapping of the
parietal and underriding of the frontal and occipital
bones, but by traction of the body and pressure on
the head, from above, through the abdominal walls
258
DUXTON: SCHOOL LIFE.
Medical Tourxxl.
[New York
greater force in the proper axes can be exerted than
with forceps. If in the judgment of the operator the
danger to the child is loo great by version, either
because of the large size of the child or because the
pelvis is less than 8.5 cm., hehotomx- nr C;esarcan
section must be employed, the latter always in pelves
cf 7 cm. or less, provided, of course, that the child
is living.
Perforation in contracted pelvis has a large field
v.hen the child is dead or dying, particularly when
the woman is exhausted and has a high retraction
ring. The operation simplifies the delivery and
should be elected. It must be remembered, how-
ever, that embryotomy should only be attempted in
pelves above 7.25 cm., and is safer as the anterio-
posterior diameter is larger.
287 Clinton Avenue.
THE NERVOUS AND MENTAL iNIANIFESTATIONS
INCIDENT TO SCHOOL LIFE.
By William Risk Duxton, Jr., M. D.,
Towson, Md..
.Assistant Pliysician, Sheppard 2nd Enoch Pratt Hospital.
So nuich has been written upon the subject under
discussion that it would seem useless to spend any
prolonged time in introducing it, as doui^tless much
of the literature is familiar to you. Less than a
week ago a paper by Dr. Hollopeter appeared.' which
had been read several months earlier, in which he
makes a special plea for the physician to interest
himself in the subject in order to educate the parents
to a proper conduct or oversight of the child's men-
tal and physical health. Dr. Hollopeter makes a
very interesting comparison between the standards
established for certain school grades in 1888 and
the present, showing that there has been a consider-
able advance in the intellectual requirements of
school children. He believes — and I think the ma-
jority of physicians will agree with him — that there
is great danger in advancing the intellectual stand-
ards, as a considerable degree of mental overstrain
may result, with the consequent mental impairment
of the child. In some schools it is possible that the
danger line has been transgressed. Dr. Hollopeter
makes a special plea for the backward child, alleg-
ing that the teacher should bestow greater attention
upon him than upon his more brilliant brother, and,
as a gauge of the capacity of the child for learning.
Dr. Hollopeter suggests that the attention be used,
and in this I heartily concur. There are many
other good papers upon the subject, and I should
like briefly to refer to them, but time does not per-
mit, and it is presumed that a number of them at
least have been read by you.
It must be remembered that for a considerable
part of the child's school life he is passing through
a critical period, that of adolescence, and that over-
strain occurring then will usually be attended by
far more serious consequences than overstrain oc-
curring later.
Concerning teaching, in Adolescence, page xii,
Dr. Stanley Hall says: "Reading, writing, draw-
•Introducing a discussion lield by the Section in Neurology and
Psychiatry of the Medical and aiiriirgical Faculty of Maryland,
October 2";, 1907.
^Journal of the American Medical Association, October 19, 190-.
ing, manual training, musical technique, foreign
tongues and their pronunciation, the manipulation
of numbers and of geometrical elements, and many
kinds of skill have now their golden hour, and, if it
passes unimproved, all these can never be acquired
later without a heavy handicap of disadvantage and
loss. These necessities may be hard for th^ health
of body, sense, mind, as well as for morals, and
pedagogic art consists in breaking the child into
them betimes as intensely and quickly as possible
with minimal strain, and with the least amount of
explanation or coquetting for natural interest, and
in calling medicine confectionery. This is not teach-
ing in its true sense so much as it is drill, inculca-
tion, and regimentation. The method should be
mechanical, repetitive, authoritative, dogmatic. The
automatic powers are now at their very apex, and
they can do and bear more than our degenerate ped-
agogy knows or dreams of. Here we have some-
thing to learn from the schoolmasters of the past
back to the Middle Ages, and even from the an-
cients." I hardly think that the majority of physi-
cians will agree with Dr. Hall in his .opinion, and
personally I feel that it is through just such .means
that the child is subjected to overstrain.
In all probability an inquiry made among this
company for the purpose of determining what is
considered an ideal school life would bring forth
many different opinions, and we should doubtless
have some difificulty in coming to an agreemerit as
to what constitutes the ideal conditions under which
a child should study, but I think that , the majority
of persons who have investigated or thought upon
this subject will agree that attainment of the follow-
ing will go far toward reaching an ideal. In the
first place, after having submitted to, all laws of
hygiene by providing a healthy place in which the
child may study, we must see that the hours of study
are not too long and that they are interrupted by
periods of play, which not only permit a relaxation
of muscles but also a relaxation of the attention.
The child may not be conscious of any feeling of
efTort, but we know that to a greater or lesser de-
gree it is present, and must be ended before it has
gone too far. Second, the manner of learning
should follow as closely as possible the natural
method of thought, and by association "facts and
figures" should be acquired rather than by arbitrari-
ly making memory impressions, as most of us learned
the multiplication table. As an illustration of how
little the child may learn from this arbitrary memory
method I would say that some time sincel was talking
with a teacher in this city concerning the progress
made by a child in whom I happened to be interested,
and who had, up to her thirteenth year, been educated
in one of the public schools of Pennsylvania, and
was told by the teacher that, while the child appa-
rently did fairly well, in reality she did not, and, as
an example of her comprehension of history, he
stated that, while this pupil knew that Sir Walter
Raleigh was one of the courtiers of Queen Eliza-
beth, she probabl\- did not appreciate the fact that
Sir Walter Raleigh was a man. This child was ap-
parently bright and most certainly could not be
classed as mentally defective, so that I am forced to
conclude that the method of instruction in her case
was not what was re(|uired. .\s a third require-
February S, 1908.]
DUNTON: SCHOOL LIFE.
259
ment of ideal study conditions, there should prob-
ably be not n:ore than twenty nor less than ten pu-
pils under the charge of a teacher, although on this
point I do not speak so positively, as I have not had
an opportunity to experiment ; but it seems t ) me
that a teacher cannot well control more than twenty
scholars, and a less number than ten does away with
a feeling of rivalry or of companionship, which may
be made of considerable value. Fourth I would
place the teacher, not because I do not believe he is
most important, but because experience has proved
that, even although he may ha\c mannerisms or
methods which are distinctl}' bad, we fi4id that the
pupils learn despite them. The personal influence
of a teacher is tremendous, and in many cases serves
to make or mar the pupils, but in just as many per-
haps this influence is without any but temporary
eitects. In our list of requirements for an ideal
school life it seems that the teacher occupies a vary-
ing place. If we can have a perfect one he should
be placed first, Init if he has imperfections he may
be placed last.
In this discussion it is hoped that we physician.-
may learn something from the teachers in order that
we may instruct parents, and also that we may bj
able to show the teachers how certain diseases ma\-
have mental effects which interfere with the pupil's
power to acquire knowledge. Besides the introduc-
tion of the subject, my own part includes mention
of the nervous and mental diseases which we may
find in school children, and which have a direct
effect upon the pupil's ability to learn or which may
affect his fellows.
In the first group I would place chorea, which is
undoubtedly the most important of the nervous dis-
eases met with among school children, because it is
so frequent, and because parents and teacners do
not seem to recognize the fact that the subject of
even the mild forms shows defects of memory and
attention which are sometimes interpreted as being
due to sulkiness or ill temper. It is the wisest
course to withdraw the child from school, as his best
interests are thus served, and the other scholars are
not liable to develop tics or habit spasms, as they
ma\ , h\ watching his movements.
This last statement also applies to the subject of
tics and of epilepsy, and probably it is the compan-
ions of the subjects of these last diseases who should
be most considered by the teacher rather than the
individuals themselves. Both the ticer and the epi-
leptic should be so seated that they are not observed
by the other pupils, and if the epileptic has an attack
during school hours he should be laid upon his back,
the clothing loosened about his neck,, precaution
taken to prevent his biting his tongue by the inser-
tion of a piece of wood or some other form of mouth
gag between his teeth, and after the convulsion has
subsided he should be permitted to rest quietly until
consciousness returns and he is able to go home.
The resumption of the interrupted school work as
soon as the convulsion has subsided will go far
toward dispelling the mental shock to the pupils oc-
casioned by the convulsion. Should the epileptic
have frequent attacks, he should not be allowed to
attend the general school, but should be forced to
attend a special school or special class. The teacher
should bear in mind that frequently these patients
have an irritable disposition, and that following the
convulsion there ma\- be a condition of automatism
in which the patient is not responsible for his acts.
It should also be borne in mind that there is usually
mental dulling, which is frequently increased, I re-
gret to say, by the injudicious administration of
bromides b\ the physician, and that the epileptic
must therefore be regarded in many instances as a
backward child.
Hysteria with its multiform manifestations may
be encountered, and the teacher can wield a tremen-
dous influence for good in these cases by inculcating
habits of proper mental hygiene.
Xervous exhaustion, or neurasthenia, may be met
with, and here the most conspicuous symptom may
be the tendency to fatigue, both mental and physical.
These are the principal nervous diseases which
the teacher may encounter, and in all of them the
attention may be used as an index of the power of
the child to learn, although the memory will also
serve as an additional point for observation.
Of the mental diseases but two are commonly
uiet with among school children, and these are im-
becility and dementia prsecox. Of the former there
may be all grades, from the one who is but little
above the idiot to the one who is bright intellectually
but deficient in moral sense, the so called moral im-
becile. It is a condition which is unfortunately
fairly common and easy to recognize, so that it needs
but to be mentioned.
Of dementia prjecox, on the other hand, there is
so much that should be said that I am not going to
make the attempt, as there is not sufficient time, and
instead I am going to recommend that you all read
a paper by Dr. Smith Ely Jellifife entitled The
Signs of Prasdementia Praecox; Their Significance
and Pedagogic Prophylaxis, which appeared in the
American Journal of the Medical Sciences for Au-
gust, 1907 [cxxxiv, p. 157J. and which contains all
that I want to tell }-ou and more. I am sure that
by a perusal of this paper you will be helped more
than you could by any brief resume of the subject
which I would have to give \ou at the present time.
Proposed Chinese College of Medicine. — Con-
sul W. T. Gracey writes to the Department of Com-
merce and Labor from Tsingtau that it is reported
that, according to the wishes of Viceroy Chang Chi-
tung, a college of medicine is about to be opened at
the Chinese capital. Preliminary plans include the
following measures : As the school is to afford the
highest medical training for the young men of the
entire Empire, it shall not emplo\- men on its faculty
who do not come with the highest possible recom-
mendations. In accordance with Chinese ideas the
course is to be divided into three years of old Chi-
nese medical practice and six years of modern West-
ern training. At the end of these nine years there
is to be a thorough examination, and then three more
years of study and trial practice shall be demanded
before the students shall be qualified doctors. This
examination must also be passed by people who are
now practising^ on certificates from existing medical
schools. Xo one who does not hold a literary rank
of a fixed grade (Chii yen) shall be allowed to take
these examinations, regardless of where he studied.
2(M OUR READERS'
i^wx ^Uiibfrs' f istussions.
A SERIES OF PRIZE ESSAYS.
Questions for discussion in this department are an-
nounced at frequent intervals. So far as they have been
decided upon, the further questions are as follows:
LXX. — Hozv do you distinguish alcoholic stupor from
other conditions resembling it? (Closed January 15, igo8.)'
LXXI. — Hoiv do you treat gallstone colic? (Answers
due not later than February 15, igo8.)
LXXII. — Hoiv do you treat fracture of the patella?
(Ansivers not later than March 16, igo8.)
Whoever answers one of these questions in the manner
most satisfactory to the editors and their advisors ivill
receive a prize of $25. No importance whatever will be at-
tached to literary style, but the award will be based solely
on the value of the substance of the answer. It is requested
(but not required) that the answers be short; if practica-
ble, no one answer to contain more than six hundred words.
All persons will be entitled to compete for the prise,
whether subscribers or not. This prise zvill not be aivarded
to any one person more than once within one year. Every
answer must be accompanied by the ivritefs full name and
address, both of zvhich we must be at liberty to publish.
All papers contributed become the property of the Journal.
The prize of $25 for the best essay submitted in answer
to question LXIX has been awarded to Dr. Maurice A.
Walker, of Dillon, Montana, whose article appeared on page
164.
PRIZE QUESTION NO. LXIX.
TMK TREATMENT OF POST PARTUAI H.1£M0R-
RHAGE.
(Concluded from page 3i6.)
Dr. Glenn I. Jones, of Boston, remarks:
\ly experience has taught me that this fonnidalili'
sequel is not so rare as to permit the obstetrician t')
attend a woman in labor without bein^^ fnll\ arnud
to cope with it.
Precluding and Preventative Measures. — .A thor-
ough knowledge of the causes of this most frightful
of obstetrical complications precludes the proper ap-
pliance of preventive measures, which is better than
cure.
The predominating causes tending to post partum
haemorrhage and the conditions that arc treated to
cure the condition are: i. Incomplete separation
of placenta. 2. Retention of cotyledon. 3. Total
absence or deficient uterine contraction. 4. Cervic^d
lacerations. 5. Distension of bladder or rectum
(causing sympathetic uterine inertia). All the othor
jetiological factors are simply prcdisposinsi; c edi-
tions to one of these causes.
A thorough history of jircvious pregnancies and
labors, an accurate, detailed i^yii.eci )I( t^iral and ob-
stetrical examination of ])alient Ijefore impending
labor, and an intelligent consideration of woman's
general physical condition should all be of incalcula-
ble value in the preventive and ])recluding treatment.
The time of occurrence of h<-emorrhage suggests
the cause of bleeding, and I .shall consider the condi-
tion as primary and secondary.
Primary h.-emorrhage occurs before extrusion of
placenta after childbirth, and is due to incomplete
separation of placenta or cervical tears.
Secondary luemorrhage occurs after expulsion of
placenta, and is generally caused by retention of
cotyledon, inertia uteri, or cervical tears.
DISCUSSIONS. [Ne.v York
Medical Jour.val.
A firm and permanent contraction of uterus, with
haemorrhage, occurring immediately after birtlf of
child, before placental delivery, indicates bleeding
from a severe tear. ( )n the other hand, if uterus
does not firmly contract and ntract. bleeding must
be looked upon as due to partial sepnratior, of pla-
centa, retention of cotyleclon, or atony of uterine
niuscnlature.
.Some cases of post partum bkedini;- undoubtedly
occur through the overconhdence df the accoucheur,
who, accustomed to the monotony of normal labors,
overlooks the following minute rules in the manage-
ment of the. third stage :
a. Observe the condition of uterus afti-r liirth of
child.
b. Avoid resorting to Crede's method of expulsion
until condition of fundus indicates complete separa-
tion of placenta.
c. Knead uterus immediately after delivery of
child, to prevent relaxation.
d. Examine placenta immediately after expulsion
to ascertain its integrity. If any defect i-^ observed,
immediate digital exploration of uterine ca\itv with
removal of remnants should be done.
e. lunpty bladder and rectum before labor.
Actual I hvniorrfiage. — HcTmorrhage havmg oc-
curetl it is imperative that it be checked immediately,
since the amount of blood lost is rapidlv dangerous
to life.
1. Before extrusion of placenta, \a) knead fun-
dus firmly; (6) if uterus does not respond, placenta
should be expressed by Crede's method and kn.ad-
ing continued; (r) this failing, manual removal
with digital curettage becomes necessary; (d) have
nurse or assistant make firm pressure over abdom-
inal aorta in region of bifurcation.
2. After extrusion of placenta, ascertain cause
and institute proper treatment. It due to lacera-
tions, ligate bleeding vessel and do primary repair.
If indications point to retention of particles of pla-
cental tissue, remove by digital curettage.
In all cases give fluidextractum ergotse 5j by
mouth and ."ss subcutaneously (in thigh) im-
mediately. Follow this by morphine sulphate gr. ^
subcutaneously. Have nurse or assistant massage
breasts, lower head of bed, and knead uterus vigor-
ously.
If haemorrhage is not controlled, hot intrauterine
douches of dccinormal saline solution or hvdrargyri
chloridum corrosivum 1 in 40.000, followed by sa-
line solution at temperature of 110^ to 115° F,,
should be given until return contains no tinge of
blood. This agent acts most eflficiently, producing
h;emostasis and irritating the uterus to forcible and
permanent contraction.
H;emorrhage persisting after these measures
should be treated by tightly packing the uterus with
-Sterile gauze.
Bimanual compression, producing temporary ante-
flexion, limiting the cavity of the uterus, and stim-
ulating contraction, is sometimes quite efficient in
allaying the haemorrhage. In all manipulations re-
([uiring the introduction of foreign substances into
the uterine cavity the most rigorous ase|)tic tech-
OUR READERS
DISCUSSIONS.
nique should be observed. After haemorrhage is
checked the patient should be kept absolutely at
rest, the foot of the bed elevated, abdominal binder
firmly adjusted to abdomen, and Huidextractum
ergotae 3j administered one hour after (Klivcry.
If the loss of blood is sufficient to cause jilarming
symptoms in patient's general condition, prompt re-
sort to diffusible cardiac stimulants is essential.
Convalescence is always hastened bv the administra-
tion of decinormal saline solution, ij^w with s]Mritus
frumenti f^ij by rectum every three hours. For
the secondary anaemia following the loss of blood,
iron and arsenic should be given in comljination,
such as :
J» Liquoris acidi arsenosi f5 j;
Tr. ferri cliloridi f5 vj ;
Aciili liydroclilorici dilut., f5 iv ;
Ac|. iiK'iith. pip q. s. ad £5 vj.
M. ct .Sig. : A dessertspoonful every four hours.
Dr. li. WaiiaiN Ryan, of ]Vilmington. Del. ob-
I'ost partum haemorrhage is an acute condition,
and must be met, in a majority of cases, by heroic
measures. I will divide the treatment into ])rophy-
lactic and active treatment.
Prophylactic. — If you get the history of a
haemophilic, give calcium chloride for three months
prior to delivery, and be prepared for trouble. If
patient is anaemic, run down, and poorly nourished,
give iron manganese and tonics, advising fresh air.
exercise, and nutritious diet.
If the patient is syphilitic, give the specific treat-
ment all through pregnancy.
During the second stage of labor we should
neither make a rapid delivery nor tedious one, unless
special causes demand otherwise. Be careful to
avoid great tension on the cord, looking out for
cord around neck or body or limbs. Make a slow
and careful deli,very of the after birth by Crede's
method. Don't give too much chloroform or ether.
2. Active Trcatuient. — Mechanical. — Grasp the
uterus from the outside, as in Crede's method, and
run a stream of hot water (120° F.) into the
vagina.
If these measures do not control the haemorrhage
cjuick enough, place the hand into the uterus and
clean it out, removing clots, secundines, etc.. at the
same time running our stream of hot water into the
vagina. Remove hand from uterus during contrac-
tion and introduce our hot sterile water ( 1 20° F. )
into the uterus. While working in the uterine cavity
with the hand and injecting hot water, keep the other
hand over the uterus on the abdomen, as in Crede's
method. Most cases will be controlled by these
measures, but if not, proceed to pack uterus and va-
gina with sterile gauze, removing it in about six
hours. Ice, vinegar, and acetic acid are used as a
styptic and (ice) to promote vascular contraction,
but are not so good in general practice because of
difficulty of being sure of their sterility.
While we are attending to these measures we have
the pillows removed and the buttocks elevated or
foot of bed raised. Also hot water bottles are placed
around patient.
Medicinal. — We should try to give the medicinal
treatment at the same time as the mechanical. ( iive
hypodermatically some reliable preparation of ergot.
.\lso strychnine and atropine hypodermatically, Idc-
ing guided by patient's condition, giving boldly in
urgent cases. Whiskey, camphor, aromatic spirits
of amninnia, calteine, etc.. all have their place, but
we usually use those stimulants we have at hand and
give them hypodermatically, for we have little time
to send out for medicine in most cases.
I have found enteroclysis and hypodermoclysis o£
normal salt solution valuable in nearly all cases.
N'enoclysis and transfusion are excellent in severe
cases, where much blood has been lost and where it
is possible to give them.
The after treatment consists of nutritious broths
and meat juices and other easily assimilable foods;
stimulants in most cases, carefully regulated, and re-
placement of lost blood where great amounts have
been lost. The treatment is prescribed presuming
that we have no great tears or trauma of parts. If
the circular artery uf cervix is torn or other vessels
ruptured, keeping U]) the hcTUiorrhage in spite of
our measures, we should at once proceed to clo.se the
rear by suturing.
( )thcr cases of post partum haemorrhage from ex-
ceeding exceptional causes are hardly frequent
enough to call for discussion in this paper.
Dr. iltred 7'. Haii^'es, Lyiiii. Mass.. says:
The mortality of the third stage of labor is greater
than that of the other two stages. Since haemor-
rhage is probably the most common emergency of
this stage, the physician should be fully prepared,
before he enters the Iving-in chamber, to meet this
emergency with proper treatment.
The most important is the preventative tre;itment.
If the possibilitv of h;emorrhage is kept constantly
in mind, there are many things which can be done
which will make its occurrence less likely. The
labor .should be carefully watched, and the patient
should not be allowed to go too long without as-
sistance. Exhaustion of the patient or of the uterus
is productive of inertia of the uterine muscle.
During the second stage, there may be strong con-
tractions of the uterus, l)ut the patient cries out in-
stead of using her abdominal muscles and bearing
down. The contraction of the uterus, without the
help of the abdominal muscles, may not advance the
head and the condition may tend toward exhaustion.
Relief may be obtained by the administration of an
anaesthetic for a few moments, and as the patient
comes out from the influence of the anaesthetic she
will use her abdominal muscles to good advantage.
As soon as the shoulders are born, one hand
should follow down the fundus and make sure that
the uterus is contracting. While the physician is
tying the cord and attending to the baby, an assist-
ant should keep a firm hold on the fundus. After
the bab\- is born, the quality which is required of the
physician is "patience." ]\iany cases of post partum
haemorrhage occur because the physician is in too
great a hurry to get home.
Gentle pressure only should be made on the fun-
dus before the placenta is born, and unless excessive
bleeding occurs, which requires the immediate de-
livery of the placenta, there may be a wait of one
262
OUR READERS' DISCUSSIONS.
[New York
Medical Journal.
half hour before the placenta is delivered. Great
care should be used in delivering the placenta, since
retained portions of placenta and membranes are
prolitic sources of hemorrhage.
After the placenta has been delivered, the fundus
is to be held for one hour. The fingers are placed
behind the fundus and the thumb in front, and gen-
tle massage should be kept up to stimulate the uter-
ine muscle. The vaginal entrance should be kept in
view, and any increase in the quantity of blood will
call for more vigorous manipulation of the fundus.
As soon as the uterus is empty, ergot sliould be
administered. The tonic contraction of the uterus
produced b}- ergot has four principal advantages :
(i) It prevents post partum hjemorrhage ; (2) it
prevents after pains; (3) it diminishes the danger
of air emboli ; a uterus contracting and relaxing is
apt to suck in air from the vagina: and (4) it di-
minishes the danger of sepsis ; a hrmly contracted
uterus is less likely to become infected than a re-
laxed uterus filled with blood clots and retained
lochia.
After the fundus has been held for one hour and
the uterus has maintained good contraction, it is
safe to apply the abdominal binder. This should be
pinned from above downward in order to make
downward pressure on the uterus. If pinned from
below upward, it tends to lift the abdominal wall
and the abdominal contents away from the uterus,
thus allowing room for it to easily enlarge. The
l)inder should be wide enough to come below the
trochanters of the femur. If it docs not do this, it
always slips up and is useless for support.
As an additional security, a towel made into a
roll may be placed over the fundus, underneath the
abdominal pad. This roll should not be placed
straight across the top of the fundus, as the fundus
may be deflected to one side or the other and the
pad would tend to push it farther to one side. The
■pad should be in the shape of a horseshoe and
should embrace the fundus and sides of the uterus.
If these precautions to avoid haemorrhage are car-
ried out, the physician can wend his way homeward,
feeling reasonably sure that he will not be called
back in haste to attend the patient.
The different causes of post partum h;emorrhage
need not be taken up here, as this paper has to do
with treatment alone. Suffice it to say that any con-
dition which favors bleeding should be avoided or
removed if jjo-sible.
Hut wliauver the underlying cause may be, the
immediate cause of the h.-eniorrhage is "failure of
the uterus to contract tirnily."
The treatment, therefore, may be condensed into
four words, make the litems contract. How can it
be done?
The most efficient stimulant to cause contraction
of the uterus is mechanical irritation.
When an excessive amount of blood is seen is-
suing from the vagina, the fundus should immedi-
atelv be grasped with the fingers behind and the
thumb in front and kneaded vigorously.
If the excessive flow is not controlled by this
method, the next procedure is to give an intrauter-
ine douche of sterile water at a temperature of
1 10° F. If an intrauterine douche tube is not at
hand, CdUtraction may oltentimcs be lirought about
by elevating the douchebag and allowing the stream
of hot water to be injected forcibly against the
cervix.
In cases in which these measures do not suffice to
control the haemorrhage, the operator carefully and
quickly inserts his sterile right hand into the uterus.
The movements of his knuckles on the walls of the
uterus will soon produce firm contraction. At the
same time, his left hand should knead the fundus
and compress the abdominal aorta.
Such measures as carrying oil of turpentine, vine-
gar, ice, etc., into the uterus are not aseptic, to say
the least, and are to be condemned. So, also, the
various styptics which are sometimes recommended
can control only capillary haemorrhage and would
have no effect on the haemorrhage from one of the
larger vessels in the uterine wall.
Let it be repeated that the best stimulant to con-
traction is mechanical irritation, and if he haemor-
rhage is not controlled by the hand in the uterus or
tends to recur when the hand is withdrawn, the phy-
sician should proceed without further delay to pack
the uterus with gauze.
A jar of sterilized gauze should have been previ-
ously prepared, but if it is not at hand, a strip three
inches wide may be torn from a clean sheet, placed
in a dish of water and boiled for twenty minutes and
may then be used as packing for the uterus.
The instruments needed to pack the uterus are the
volcella forceps and the uterine dressing forceps.
The ordinary uterine dressing forceps, on account of
its sharp point, is an element of danger from the fact
that the point may be pushed through the fundus.
Forceps with blunt points are much safer. There is
very little danger that the cervix will contract so
as not to admit the blunt forceps, and they are far
safer than the pointed ones sd generallv used.
After the uterus has been packed, the abdominal
binder and the pad over the fundus should be firmly
applied. The uterine packing should not be left
more than six or eight hours, as it very quickly be-
comes foul. When it is removed, another packing
should be ready to replace it if necessary.
After a severe haemorrhage, the patient may show
signs of the loss of blood, and treatment for this con-
dition should be at once instituted. The pillows
should be removed and the foot of the bed elevated.
The patient should be covered w ith hot blankets and
surrounded with hot water bottles. While the
uterus is packed, there is no danger that the external
heat will increase the haemorrhage.
If the condition of the patient demands it, normal
salt solution should be administered. The general
practitioner, without skilled assistants, is sometimes
at a loss to know how to make sterile salt solution,
but bv keeping in mind the following points, he may
obtain all he needs by using the utensils found in al-
most every household: i. Scrub the inside of a
double boiler with sand soap and rinse it in clean
water, 2. Pour into it two quarts of hot water from
the teakettle and add four small teaspoonfuls of
table salt. Dissolve the salt thoroughly. Add a lit-
tle more water, to allow for evaporation, so that
after boiling for twenty minutes the quantit\ will be
two quarts. 3. In another dish place a handful of
absorbent cotton and a tin fuimel, which is usually
found in ever\ kitchen. This is to filter the salt solu-
February s. 190S.J THERAPEUTICAL NOTES. 263
tion after it is boiled. The rubber douchebag and
the salt solution needle are to be wrapped in a towel
and placed in the dish to boil. 4. After boiling for
twenty minute?, the salt solution should be filtered
through the sterilized cotton in the funnel into the
douchebag, and is then read}- for use. If it is too
hot, it may be cooled by letting cold water run over
the outside of the bag.
The salt solution ma}' then be given in sufficient
quantity under the breast or ma}' be injected slowly
into the rectum.
The rate and quality of the pulse should be care-
fully watched and stimulation given as needed. The
drugs which are of most value in the condition fol-
lowing haemorrhage are adrenalin, digitalin, and
strychnine.
The severer forms of post partum luemorrhage
are fortunately rare, and with the exception of
cases in which there are pathological changes in
the blood, the haemorrhage can be controlled. But
it is necessary for the physician to be constantly on
his guard and to be prepared to meet the emergency
with prompt treatment.
Dr. S. A. Agatston, of New York, says:
Prophylaxis is important. Attend to general
health during pregnancy by improving appetite, if
necessary urging the consumption of plenty of good
food, exercise and tonics if required. If labor is
prolonged, find out cause and remove if possible.
Thus, make sure that the bladder and rectum are
evacuated. Examine carefully to ascertain if pre-
sentation is normal, and if not, correct same accord-
ing to the requirements of the case. If the uterus
simply shows tendency to weakness and relaxation,
give strychnine sulphate, gr. 1/30. If the patient is
exhausted, it is a good plan to give chloral hydrate
15 gr., as we often find that after a good rest the
uterus contracts with renewed vigor. During the
"birth of the child order the nurse to follow the fun-
dus and continue to hold it after the child is born.
Better than Crede's method of expression of pla-
centa after fifteen minutes is to gently massage the
uterus until the latter empties itself after thorough
separation. It takes longer, but is safer. Examine
the placenta carefully to ascertain whether all the
'membranes came away. If, after taking all the pre-
cautions, there still is hii?morrhage with relaxation
of the uterus, massage the fundus vigorously and
express all the clots, and if necessary introduce your
"hand into the uterine cavity and remove them, in-
cidentally feeling for a possible placenta suc:ent'--ri-
ata. If haemorrhage still continues, give hot douche
(water at 116° to 120° F. ) with 2 to 5 per cent,
acetic acid. As a final resort pack the uterus with
•sterile gauze, or in the absence of the latter, with
strips of clean linen or clean towels. The packing
should not remain in longer than twenty-foar
hours. If the uterus is not relaxed and haemorrhage
is present, it is due to the laceration of the cervix,
and it is necessary then to repair the tear, taking
good care not to close the os too much, as that w<nild
cause retention of lochia. If haemorrhage has been
excessive, we may have to make use of saline in-
fusion, hypodermoclysis. and saline enemata. Ad-
minister fluidextract of ergot.
f berapeutifal gotcs.
Vertigo of Gastric Origin is treated by Becker
{Merck's Archives, x, ij by regulating the diet,
putting some patients on an exclusive milk diet,
and encouraging them not to worry. While he does
not deem medication of great importance, he ad-
vises the administration of a simple tonic bitter
before meals, e. g.. ten drops of the tincture of
nux vomica in water, and after eating, at intervals
of one hour, the following prescription :
B Diluted hydrochloric acid, ITI' x ;
Powdered pepsin gr. v ;
Sodium bromide gr. -x;
Peppermint water, ad 51.
M.
As a laxative he prescribes one teaspoonful of so-
dium phosphate to be taken in a glassftil of hot
water before breakfast.
The Use of Sea Water in Medicine. — In a re-
cent number of the Repertoire de phannaeic ( Brit-
ish Medical Journal) Carles gives an interesting ac-
count of the use of sea water in medicine. In addi-
tion to common salt sea water contains many impor-
tant mineral substances, the total solid matter
amotmting to 3.2 to 3.8 per cent. Some of these
substances are present only to an infinitesimal extent,
but in biology the value of a substance is not neces-
sarily dependent upon its actual size or quantity. It
has been shown that various marine plants have the
power of extracting from sea water minute quanti-
ties of compounds of iodine, bromine, arsenic, boron,
manganese, lithium, fluorine, rubidium, caesium, and
other elements. Hence it was not unreasonable to
stippose that the higher animals might derive benefit
from the assimilation of even minute traces of these
physiologically active substances. The employment
of sea water as a remedial agent dates back to the
time of Hippocrates, and modern physiological in-
vestigations have led to its reintroduction into med-
icine. Thus it has been shown that if a portion of
the blood serum of a dog be replaced by an artificial
serum the most suitable serum for the purpose is
sea water, isotonic with the natural serum. Sea
water has been given by the mouth and by injec-
tion with good results in cases of dyspepsia, loss of
appetite, and tuberculosis. In general the appetite
was improved and strength was rapidly regained.
In order to obtain the best and most immediate re-
sults it is necessary to observe certain precautions.
The sea water must be natural, as it is impossible
to imitate so complex a liquid. Indeed, it has been
proved that sea salt, when redissolved in distilled
water, lacks come of the properties of natural sea
water, exerting a tonic action upon a dog when in-
jected subctitaneottsly. It must be freshly collected,
as it loses carbon dioxide on standing, with precipi-
tation of some of its salts. It should be taken from
the open sea remote from rivers and other sources
of pollution. It should be sterilized by filtration, as
lieat dissociates the bicarbonates and destroys the
natural equilibrium of the liquid, ^^'^hen required
for subcutaneous injection it should be diluted
with water to the same concentration as normal
blood serum. Distilled water is not suitable as a
iFIiCTICAL XOTES.
264
diluent, as it soirjtitimes causes pain. It is better to
dilute the sea water with natural potable water in
the proportion of 2 parts to 5. In conclusion.
Carles points out that this method of treatment is
not invariabl} suitable, and that it rests with clin-
ical experience to indicate the cases in w hich it ma\-
advantageously be employed.
Some Applications of Resorcin. — The value of
resorcin in the treatment of certain dermatoses re-
ceives appreciative consideration in an article pub-
lished in La Presse incdicalc for January nth.
IJeing a phenol, isomerous with pyrocatechin antl
hydroquonone, having the chemical formula
GH4(OH):.', its internal use has been abandoned.
Like aristol, chrysarobin, [pyrogallol | , ichthyol, and
sulphur, resorcin acts as a reducing agent b\" uniting
with the oxygen of the tissues with which it is
brought into contact. It exerts a keratolytic action
on the cutaneous surface and hardens the mucosum,
thus hastening desquamation. If the action is pro-
longed an alterant effect is produced on the cells
lying below the rete mucosum, and blistering and
secondary exfoliation may ensue. It is this prop-
erty possessed by it on which is based the kerato-
lytic exfoliative treatment of Unna. In parasitic
diseases of the skin resorcin cures ( i ) by a mechan-
ical removal of the disease germs; (2) by a direct
antiseptic action, and (3) indirectly by its power of
depriving aerobic germs of the oxygen necessary
for their development. In cases of follicular ecze-
ma, seborrhoea of the scalp, pityriasis, etc., the fol-
lowing ointment is applied at night and washed off
with soap and water in the morning :
R Resorcin gr. .x to gr. xv ;
Wool fat ; 3v.
M.
Sabouraud's application is more complex, bceing
composed as follows :
R Resorcin j
Ichthyol, - aa gr. xv ;
Precipitated sulphur, '
Oil of cade gr. Ixxv ;
Wool fat 5viis.
M.
I'nna's exfoliative resorcin paste has the follow-
ing composition :
R Resorcin, 5v ;
Zinc oxide, gr. Ixxv;
Precipitated silica gr. xv ;
Benzoinated lard 3vii.
M.
The paste is allowed to remain in contact with the
skin for a few minutes only.
Another property possessed by reducing agents
like resorcin when applied in mild strengths for any
length of time is to contract and atrophy the ves-
sels of the derma, especially if it is made to pene-
trate the tissue, which is made possible by u.sing
glycerin as a vehicle and abrading the skin. .Ad-
vantage of this is taken in the treatment of nonneo-
pla.stic warty growths in the deep folds of integu-
ment caused by continued local irritation, as for in-
stance the fungous excrescences that dcveloj) in the
labia pudcndi. i)re|)uce, .scrotum, perin.neum, nipples,
uml)ilicus, etc. In these cases the best method of
treatment is to scrape the parts with a bistoury or
curette, and cut away any i)rotruding growths, and
afterwards apply for two or three days a glycerin
solution of resorcin of the following strength :
Resorcm 5iiss to 5iii ;
Glycerin giii.
-M. Sig. : External use.
The resorcin may be also applied as a powder in
the following combination :
Resorcin gr. xv ;
Bismuth subnitrate gr. Ixxv;
Powdered talcum. , 5x.
A solution of resorcin in flexible collodion is use-
ful for application to certain parts of the body, the
following proportions being recommended :
R Resorcin gr. xxx ;
Flexible collodion, 5v.
Sig. : External use.
The Use of Iodine-Formic Acid Solution in the
Treatment of Phthisis. — In a paper ^ntributed
to the Journal of tin- American Medical Association
for February ist. Stern describes the method of prepT
aration and mode of administration of the iodine-
formic acid solution which he uses in the treatment
of chronic ulcerative phthisis. The solution is made
according to the following process :
A. To make the 'mother preparation" 1 10 per cent,
glyceroiodotormic acid) lake:
Iodine, q. s. (an e.xcess, formic acid, taking up a cer-
tain quantity only).
Formic acid, 40 per cent. (sp. gr. 1.200) 25 c.c. :
Glycerin q. j. ad. too c.c.
'i"he dissdUing prdcc-^ niu-t ensue in th.c cold formic
acul and may be hastened by agitatiim.
R. To mai<e i per cent, iodnformic acid, take :
Glyceroiodoformic acid (To per cent.) to c.c;
Distilled water, 90 c.c.
C. To make glyceroiodoformic acid dil. ( fdr internal ad-
ministration) take :
Glyceroiodoformic acid ( 10 per cent.) 10 c.c:
Glycerin go c.c. ;
Distilled water 1.400 c.c.
The iodine formic acid solutions should be kept in dark
colored glass stoppered bottles and scrupulous care should
be exercised to prevent any contamination of the solutions,
especially with organic matter (dust).
The dose of the diluted solution ( C ) given in-
ternally is one tablespoonful, representing one c.c.
of solution B.
For intramu.scular injection the one per cent, so-
lution of iodoformic acid is exclusively employed.
ID drops being injected, half into the left and half
into the right interscapular muscle bundles. This
dose is repeated for three or four clays, after which
the dose is increased to twenty drops for a similar
period. Following this the dose is increased to 30
drops, injecting it every other day for two or three
weeks. A specially constructed syringe is used, the
barrel and piston being of glass. The barrel should
be graduated and. if possible, have a capacity of
three cubic centemetres. Excepting the needle, and
])()ssibly the finger rests, nothing but glass should
enter into the construction of the .syringe. The pis-
ton mu.st be ground to fit snugly mto the barrel. The
injection site is prepared by cleaning with ether and
placing a few drops of the iodine formic acid on it.
Fther in sufficient (|uantity exerts also a local anaes-
thetic effect, which property is of decided value in
intramuscular injections of any solution. The needle,
of course, has to be inserted from above downward
and should meet the body (seen from above) at an
angle of about 75 degrees.
EDITORIAL ARTICLES.
NEW YORK 3IEDICAL JOURNAL
IXCORPORATIXG THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Reviezjj of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M. D.
Address all business communications to
A. R. ELLIOTT PUBLISHIXG COMPANY,
Publishers,
66 West Broadway, Xcw York.
Philadelphia Office : Chicago Office •
3713 Walnut Street. 160 Washington Stieet.
SriiscRiPTiox Peice :
Under Domestic Postage Rates. So : under Foreign Postage Rate
$7 ; single copies, fifteen cents.
Remittances should be made by New York Exchange or post
office or express money order payable to the A. R. Elliott Pub-
lishing Co. or by registered mail, as the publishers are not
responsible for money sent by unregistered mail.
Entered at the Post Office at New York and admitted for
transportation through the mail as second class matter.
XEW YORK. .S.VTURDAY, FEBRUARY 8, 1908.
A XATIOXAL DISGRACE.
Tliere are some articles which we do not yet pro-
duce in the United States of a degree of excellence
equal to that of similar products made elsewhere ;
it may be that there are a few in the production of
which we never shall make a very close approach to
foreign competitors. For example, our textile
fabrics, save those made of cotton, are well known
to be inferior ; we must still resort to older countries
for fine silks, linens, flannels, and the general run
of woolen goods. Xo harm can come from our
frankly acknowledging this.
On the other hand, we make some things that are
superior to those made in other countries, and we
turn out many articles that are almost if not quite
as good as can be found anywhere in the world.
This was amusinglv illustrated by something that
occurred recently in Xew York. A partv of gentle-
men had been dining in a French restaurant and
one of them remarked that it was many years since
he had tasted sparkling Catawba, but that his mem-
ory of that American wine was pleasant. It was
suggested that Catawba was probably to be had in
a neighboring cafe kept by a producer of native
wines. Thereupon the company adjourned to that
resort and called for a bottle of sparkling Catawba.
When the wine was brought it was found to bear
the label "Moselle." It was remarked to the waiter
that he had misunderstood the order. "Oh. no,'"
said he. "this is Catawba, all right." It was found
to be an excellent wine, but probably it was difficult
to sell it to advantage under its own name, so per-
vading is the snobbery which insists that everything
fine must have been imported.
Another incident of like import was the recent
arrival at the port of Xew York of several thousand
empty cheese boxes from France, with their French
labels, designed as receptacles of "Camembert"'
cheese made in the State of Xew York, to i)e em-
ployed to deceive tiie public. We have nothing to
say against such cheese itself : it is of the same type
as the French Camembert, and perhaps it would be
judged by most of us to be quite as good as the
same style of cheese made in France. It might even
be allowable to call it Camembert. but it could not
honestly be marketed under that name without some
qualifying designation to show that it was of Amer-
ican make. To represent it as liaving been made in
France would be fraudulent.
But it is not with the element of commercial fraud
that we are here concerning ourselves. The worst
of the whole misbranding business, apart from the
substitution of injurious for wholesome products, is
its inevitable bolstering up of the disgraceful feeling
that we Americans are not justified in holding any
of our home productions in the highest esteem. That
affectation needs to be rooted out. and in the long
run the process will be powerfully aided by recent
national legislation, but State legislation, not only
in Xew York, but elsewhere also, is needed to sup-
plement that enacted by Congress. Let us freely
admit our shortcomings, but let us at least give our
products the chance to win under their own names
whatever approval they ma}- be found m deserve.
FEED THE FIOSPITAL PATIENT.
Our abhorrence of the slop diet system of treat-
ing acute disease must be well known to our readers,
tor we have harped on it persistently. The prescrip-
tion of low diet stands on no substantial basis of
clinical observation : it is simply a feature, and an
unpleasantly prominent one. of the traditional no-
tion— almost ineradicable, it sometimes seems — that
a sick man can hardly be helped except by making
him as miserable as possible. The old plan was to
rob him of as much blood as he could give up with-
out at the same time giving up the ghost, salivat-
ing him with enormous doses of calomel, nauseating
him with antimony, and forbidding him to assuage
his sufiferings by drinking water, at the same time
seeing well to it that he should get the minimum of
nourishment. The practice is not so old that many
of us do not remember its invariable enforcement.
Fortunately, all these ridiculous measures have been
relinquished save the one relic of starvation. But
this is founded on a sincere if mistaken purpose
2(56 EDITORIAL
to benefit the patient, and it is not our present inten-
tion to speak further of it. What we have to say
now concerns a policy that takes Httle if any account
of the patient's welfare, one of pure niggardliness.
In almost all our hospitals the food provided for
the patients is abominably repulsive. It is furnished
in abundance, and we do not doubt that it is for the
most part nutritious. With a trifling increase of
expense it might be made appetizing, and nobody
will deny that a sick man's inclination to take food
ought t't be encouraged rather than smothered.
With what feelings of repugnance must such a man
spoon intci his nii tulli a lukewarm decoction of tur-
nips, waste his already enfeebled energy in chewing
a leathery steak, or seek to retrieve from his plate
a portion of custard that seems bent on floating away
in the whey that oozes out from it ! W'e are not ad-
vocating green turtle soup, stewed terrapin, pate
de foie gras, plum pudding, and burgundy for the
hospital patient's dinner, but we do insist that the
plain but good material furnished ought to be pre-
pared in an attractive form.
As regards dur hospitals, cookery seems to be
a lost art — at all events one that is ignored. Proper
attention to the marketing will procure unexcelled
roasting pieces of beef at a moderate cost, and the
slices ought to come to the wards in better condi-
tion than that in which they are ordinarily to be
obtained in expensive restaurants, for the patients
all dine at a fixed hour, so that the meat has not
to be kept warm for an indefinite length of time,
whereby the life is steamed out of it. It will not do
to say that the patient comes from the slums and
has never been used to good living ; he is sick, and
it would be the part of wisdom to induce him to
eat heartily during his convalescence, so as to short-
en his necessary stay in the hospital. Moreover, the
story he would tell on returning to his old haunts
would go tar toward dissipating the dislike of tlie
poor to being sent to Bellevue or "the island."
THE ME'i ALLIC FERMENTS l.\
THERAPEUTICS.
As is well known. Professor Albert Robin, of
Paris, has experimented largely during the last five
01 six years with certain preparations of the heavy
metals, gold, silver, platinum, and palladium. These
are apparently in solution, but actually suspended in
a state of minute subdivision. Examined with a
microscope in the usual way, in the preparations em-
l)loyed, the separate metallic particles are invisible,
but if examined by reflected light with the ultra-
microscope, they become clearly evident as minute
bodies less than one two millionth of an inch in
diameter, and endowed with an extremely active
Brunonian movement. Their method of prepara-
tion, their physiological effects, and their therapeu-
tic uses are fully considered in Robin's monograph
{Lcs Fcniiciits inctalliqiics. Paris, 1907). Briefly
Robin passes an electric current ( D. C. 110 v, 3 a)
through chemically pure water, the terminals of the
selected metal being sufiiciently near to permit the
passage of a spark, .\s the sparks pass the water
gradually colors, finally becoming violet in the case
of gold or black if platinum terminals are used.
In carrying out physiological experiments with
the various "solutions" Robin noticed that there was
a striking resemblance between their effects and
those produced by certain ferments of organic
origin, notably an increase of metabolic activity.
And one very remarkable effect of the administra-
tion of these ferments was the great increase of urin-
ary indican, both in normal subjects and in cases of
disease. We can hardly conceive of this being due
to any increase of intestinal indol, and we are
forced to conclude that the substances must possess
some special depurative function in connection with
this body.
Therapeutically, Robin employs his solutions, if
they may be called such, either in intravenous injec-
tions of 5 c.c. or deep intramuscular injections of
10 c.c. The author's most brilliant results have been
in connection with pneumonia, acute articular rheu-
matism, and septicaemia. The immediate effects
were prompt defervescence and rapid recovery. In
chronic affections beneficial results were not so
evident.
THE EPILEPTIC \ OICE SIGX.
The oft repeated declaration that Hippocrates
nearly if not quite completed the clinical descrip-
tion of epilepsy has not wholly prevented further
efforts in this direction. Now and then we note
that not unimportant advances are made to a
clearer understanding of this strange disease. It
may not seem so peculiar as would at first appear
that no study has ever been made of the epileptic
voice, when one realizes that only during the past
few years has it been possible to study the normal
voice carefully by anything like a scientific method.
Our thanks for this latter consummation are due
in greater part to the Carnegie Institution and to
Dr. E. W. Scripture in particular. By what is
known as the air puff method Scripture has found
it possible to study the voice accurately in both
health and disease.
Equipped with this method. Clark. Scripture, and
Pierce have undertaken to study the characteristics
of the epileptic voice.' Many clinicians have noted
•Scripture and Clark: Researches on tlie Epileptic Voice, IVoceed-
ings of the New York Neurologic.-.l Soci.-ty. Nc.vcmbcv 12. 1007.
February S, 1908. |
EDITORIAL ARTICLES.
267
the monotonous, breathy tone of the epileptic voice
without being able to catch exactly another elusive
feature which Clark and Scripture have analxzed.
The method is so novel that it deserves comment.
Briefly stated, it is as follows: The patient speaks
into a mouthpiece that covers his mouth rather
tightly. The mouthpiece is connected with a small
recording capsule that registers the vibrations on a
rapidly revolving smoked drum or kymograph. The
character of the resulting curve can be illustrated
by an example. In the records of the words "most-
ly at night," with the sounds like (m), ( o), (1).
(y) the larnyx vibrates. These vibrations produce
wavy lines in the record. A long wave is pro-
duced by a slow vibration, a short wave by a quick
one. Slow vibrations correspond to low pitch, quick
ones to high pitch. Each w^ave of the record is
measured and the pitch is calculated. For example,
the first six vibrations of (m) measure 1.3, 1.2. i.i,
i.o, 1.0, 1.2 mm. The calculations give a pitch of
110, iig, 130, 143. 143, 119 vibrations to the sec-
ond. That is, the first vibration corresponds to a
tone of no vibrations, the second to a somewhat
higher tone, the third gives a still higher one. A
line connecting the top of the ordinates is termed
the "melody plot." Every vowel in normal speech
has a rising and falling melody. In the epileptic
voice the vowels run along on even tones. It is a
form of "plateau speech," as they have termed it.
The authors say that, when once explained, the
epileptic voice defect may be recognized at once.
In an analysis of cases one can, by a little practice,
they maintain, diagnosticate the disorder by the
voice alone. The authors demonstrated the voice
signs and showed a record of diagnosis in 75 per
cent, of a trial test in 100 cases. There appears to
be no parallel in any other nervous disorder tested
by the authors. Many of the cases were entirely
free from the effects of bromides. All grades of
severity of epilepsy have been under stud\'. It
would appear that the voice sign is dependent upon
the brain deterioration of the epileptic, upon which
the mental stigmata, as shown in slowness, awk-
wardness, and dementia, also rest. The voice sign
ought to be of diagnostic value, and is worthy of
statistical study in the many State colonies and hos-
pitals for epileptics.
THE MEDICAL SOCIETY OF THE STATE
OF NEW YORK.
The one hundred and second annual meeting, held
in Albany last week, marked the continued useful-
ness of this organization. The election of Dr.
Trudeau to the presidency for the coming year
augurs well for a year of efficient work. Dr.
Trudeau is himself an organizer of conspicuous
capacity, and his professional renown in connection
with the present campaign against tuberculous dis-
ease will make his presidency distinguished. The
movement in favor of holding the annual meetings
in each of four large cities of the State in turn was
favored by the committee to which it had been re-
ferred. From every point of view except that of
the tradition which credits the legislature with a
sort of paternal requirement that all the meetings
shall be held in Albany, and during its own session,
the project seems to us highly worthy of consumma-
tion. Surely there is much to be learned in Buffalo.
Rochester, and other large towns of the State of
Xew York, and the accommodations in them aie
ample.
THE "MELODY CURE" FOR STUTTERIXG.
Some weeks ago Dr. E. \\'. Scripture, of Colum-
bia University, explained before one of the medical
societies of Xew York a method of curing stutter-
ing by training the afflicted person to put a varying
intonation into his speech — in other words, to sing
it. He seems to have developed and systematized
this procedure, but we presume that he would be
the last to allege that he had made a "discovery"
of the device, as some of the newspapers declare,
for the principle itself was long ago put into prac-
tice, though the use of it may have been known to
but few persons. It certainly apf>ears to offer a
(lictinct prospect of overcoming an embarrassing
defect.
ABBRE\ lATIOXS OF PHARMACOPCEIAL
XAMES.
In the course of an address recently delivered be-
fore the Xew York College of Pharmacy, Pro-
fessor J. P. Remington, of Philadelphia, chairman
of the Revision Committee of the United States
Pharmacopoeia, made an incidental reference to the
question of abbreviations of pharmacopoeial names
which was in effect a defense of the length}- titles
which have been given in the pharmacopoeia to some
of the newer remedies. The professor said that, as
a matter of fact, the average prescriber never used
the full name of a drug, but prescribed it. and soon
came to know it by some abbreviation, " acetphen"
being the abbreviation which he used for acetphene-
tidin, while hexamethylenamine became in his mem-
ory and in his prescription merely "hex." It seems
to us that the common use of such an abbreviation
may induce the committee to refrain from adding
to the pharmacopoeia any other remedy the name of
which begins with "hex."
268
OBITUAR Y—NE WS I TEMS.
[New York
Medical Journal.
CiEXERAL AX.^:STHESIA WITH SIMUL-
TANEOUS ARTIFICIAL SEQUES-
TRATION OF A PORTION
< )F THE CIRCULATION.
In a recent issue of this journal' we adverted
editorially to the fact that this procedure, advo-
cated a few months since by Professor Klapp. of
Berlin, had been proposed and practically applied
by a New York neurologist. Dr. J. Leonard Corn-
in.<4\ twenty vears before. Coming's papers, as then
stated, were pul)lished in the Xc'zc )'ork Medical
Journal for October 22 and December 24, 1887. It
is a pleasure to note that since the appearance of
our editorial and after reading Coming's papers.
Professor Klapp has puljlished a brief article in the
Tlicrapir dcv Cc^^ciricart for January, 1908, Heft i,
page 47, in which he unreservedly gives Corning
entire credit for the j^riority of the discovery.
A UXH'ORM CATHETER SCALE.
The American Surgical Trade Association has
published cards showing the standard catheter scale
as pre])ared by a committee of that organization.
These cards give the sizes in millimetres and also
g-ive the arbitrary numbers by which these sizes are
indicated. W e congratulate the association upon its
excellent work in the preparation of these cards,
which will undoubtedly be welcomed by physicians
generally, offering a" relief from the uncertainty
which has existed hitherto regarding the method of
designating the sizes in catheters. We understand
that dealers in sm-gic;d instruments will be prepared
to furnish these cards {,> ])hysicians on application.
CARL VON VOIT. M. D.,
of .\fuiiich. Ciermany.
The death of Dr. Carl von Voit, the distin-
guished physiologist, is reported from Munich.
Germany. Born in Amberg, Bavaria, on Oc-
tober 31, -1831. he studied medicine at the uni-
versities of Wiirzburg, (Jottingen, and Munich, and
was graduated in 1854. Two years later he became
assistant to von I'>ischoff at the physiological insti-
tute. Having ])cen ndnutted as I'rivatdnzcnt tn the
medical faculty of his alma mater in 1857, he was
appointed assistant professor in i860, and in 1863
was elected jjrofessor of ])hysiology, when von
Bischoff resigned from this chair, reserving for him-
self the dep-irtment of anatomy. Thus von \'oit
had held the professorshi]) of jjhysiology at Munich
for nearly forty-five years. lie has been one
of the leaders nf this branch of medical S':i( nee in
(jermany. In 1865 he founded, with von Petten-
kofer and von Buhl the Zeitschrift fiir Bioloi^^ic.
'AVtu York McUiCiil Journal, Noviml)fr 23, 1907. p.iBv gSj,
The writings of von \'oit treat especially of the
theor\- of general metabolism and nutrition, and his
theories and teachings have laid the foundation for
the modern conception of the physiology of meta-
bolism.
Although the recipient of many high honors, Dr.
von N'oit always remained unassuming, quiet, and re-
tired. He was equally beloved by his colleagues
and b\- his pupils, to whom he was not only a
teacher, but a friend and adviser. With von Voit
dies the last member of that medical faculty of ]\Iu-
nich which made the Bavarian capital so celebrated,
not only in Germany, but also abroad.
WILLIAM STR.A.TFORD. M. D..
of New York.
Dr. Stratford died on Frida\ , January 24th, at
the age of sixty-four years. He was a graduate of
the Medical Department of the L^niversity of the
City of New York of the class of 1876. He prac-
tised medicine for a number of years, but subse-
quently concentrated his attention on natural his-
tory, of which he was the professor in the College
of the City of X'ew York at the time of his death.
He was active also in the athletic affairs of the col-
lege. He was an attractive gentleman, and those
who knew him well were exceedingly fond of him.
Changes of Address. — Dr. J. B. Rankin, to 177 Onder-
donk avennc. Ridgewood. Brooklyn. N. Y.
The Wisconsin State Board of Health and Vital Sta-
tistics held its annnal meeting on January .'9th. and re-
elected Dr. William F. Whytc. of Watertown, president,
and Dr. C. A. Har|)er. secretary.
Maryland Tuberculosis Sanatorium. — Senator Moore
has introduced into the ALaryland St;ite Legislature a hill
appropriating $173,000 for the Mar>'land Tuherculosis Sana-
torium. Two years ago an appropriation was made, but
this sum has liccn exhausted.
The Sixth Lecture in the Harvey Society Course will
be given by Professor Joseph Jastrow, of the University
of Wisconsin, at the New Yc-k Academy of Medicine on
Saturday, February 8th, at 8:30 p. m. Tlie subject of the
lecture is Subconsciousness.
Surgeons with Experience for Ambulance Duty. — .A
l)ill has been intr >duced iiuo the State Legislature b}
Senator Sohmer which provides that no surgeon in any
hovi n.il !ii {Va: cii\ of \e\v York shall be called upon for
■nnli.'i:;iKe diu\ unless he shall have served at least six
luonths in a hospital.
Kings County Medical Society. — .At a recent meeting
of tills society, the following ofificcrs were elected to serve
for the >ear 1908; Dr. Onslow A.. Gordon, president;
Dr. J. M. Van Cott. vice president; Dr. Henry G. Webster,
secretary; Dr. John R. Slivers, treasurer; Dr. James R.
W-irliasse. diiector of tlie library.
Kentucky Midland Medical Society. — .At the aniu'al
meeting of this society, held recently in Midway, Ky.. the
following officers were elected for the ensuing year: Presi-
dent. Dr. Neville M. Garrett, of Frankfort; vice president.
Dr. Josephus Martin, of Cynthiana ; secretary and treasurer.
Dr. (icorge P. Sprague. of Le.\ington.
Syracuse, N. Y., Academy of Medicine.— .At a meet-
ing of this academy held on Tuesday evening. February
4tb. the programme included tlie following papers: A
Case of Maldevelopment of the L'terus and Vagina, by
Dr. M. D. Bristol; Caloric Value in Infant Feeding, by
Dr. A. C. Mercer; and .XppendicectomN . with Description
of ? Alethod. by Dr. T. L. Dcavor.
AEIVS ITEMS
269
Diphtheria at the Rahway Reformatory. — According
to a report ?ubmitted to Dr. George B. Wright. Commi?-
sioner of Charities and Corrections, there is an epidemic of
diphtheria at the reformator\- at Rahway, X. J. On Feb-
ruary 3d tliere were ninety-nine cases in the institution,
an increa'^e of hfty cases in three days.
Richmond, Va., Academy of Medicine and Surgery. —
At a meeting of this academy, held on January 28th, Dr.
E. C. Levy read a paper on the Importance of the Coopera-
tion of the Medical Professional in Municipal Public
Health Work. Dr. A. W. Freeman read a paper on Pre-
liminary Studies of Typhoid Fever in Richmond.
A New Hospital for New York. — A bill has been in-
troduced ini'j ihe Legislature authorizing the Board of
E.stimate and .Apportionment of the City of New York to
appropriate Si.000,000 for the erection of a new public hos-
pital in New York. The bill also provides for the appoint-
ment by the Mayor of a cominission to obtain the site and
prepare plans for the new hospital.
Rochester, N. Y., Academy of Medicine. — The regu-
lar meeting of the Section in Obstetrics. Gynaecology, and
Pediatrics was held on Wednesday evening. February 5th.
The paper of the evening, entitled The Clinical Significance
of Glycosuria During Pregnancy, was read by Dr. J. Whit
ridge William-, professor of obstetrics at Johns Hopkins
Uni\ersity Medical College.
Buffalo Academy of Medicine. — ^'.A. stated meeting of
this academy was held on Tuesday evening. February 4th.
The programme of the evening, which was furnished b\
the Section in Surgery, included a paper by Dr. Edward
L. Keyes, Jr.. of New York, on the Treatment of .Acute
Prostatitis and Allied Complications of Gonorrhoea, and a
paper by Dr. Vertner Kenerson on Inguinal Hernia.
In Memory of Dr. Senn. — Memorial services in honor
of die late Dr. Senn were held in Chicago on Sunday,
February 2d, under the auspices of Rush Medical College,
the Northwestern University ^ledica! School, the College
of Physicians and Surgeons. Chicago Medical Society.
Chicago Surgeons' Association, and the Nicholas Senn
Club. Dr. Edmund Janes James, of the L'niversity of Illi-
nois, presided.
Scientific Society Meetings in Philadelphia for the
Week Ending February 15, 1908. — Monday. February
loth. — Section in General Medicine. College of Physicians:
\\'i!ls Hospital Ophthalmic Society. Tuesday. February
iith. P'.-.iladelphia Pediatric Society: Botanical Section.
Academy of Natural Sciences. Wednesday. February I2t!i.
Philadelphia Counl\ Medical Society. Thursday. February
13th. Pathological Society: Section Meeting. Franklin In-
stitute. Friday.. February I4tli. West Branch. Philadelphia
County Mer':--'! Society.
Elm'ira, N. Y., Academy of Medicine.— At the regular
meeting of this academy, which was held on Wednesda\
evening, February 5th. the following papers were read :
The Chemical Purity of Drugs, by Dr. S. E. Palmer, of
Elmira ; Backward Displacement. ' with .Abortion, by Dr.
Elliott T. Bush, of Horseheads : Report of a Case, by Dr.
Alfred J. Westlake, of Elmira. The officers of the academy
are as follows: President. Dr. Ross G. Loop: vice presi-
dent. Dr. .Alfred J. Westlake : treasurer. Dr. Charles G. R.
Jennings; and secretarv. Dr. Frank L. Christian.
The Obstetrical Society of Philadelphia.— At a stated
meeting of this society, held on Thursday evening. Feb-
ruary 6th. Dr. Collin Foulkrod read a paper on the Tox
jemia of Pregnancy ; Dr. John B. Shober reported a case
of Nephoureterectomy for Tuberculosis. Hysterectomy. .Ap-
pendectomy ; Dr. Theodore .A. Erck reported a case of
Nephoureterectomy and a ca-e of Resection of the C;ccum
for Tuberculosis : and Dr. E. A. Schumann read a paper
on Tuberculosis of the Uterus with Pyometra. The dis-
cussion was opened by Dr. Charles P. Noble, Dr. Barton C.
Hirst, and Dr. Wilmer Krusen.
The Massachusetts Association of Boards of Health
held its annual meeting in Boston on January 30th. and
elected officers for the ensuing year as follows : President.
Dr. Henry P. Walcott. president of the State Board of
Health: first vice president. Dr. S. H. Durgin, of the Bos
tnn Bo^rd of Health: second vice president. Dr. Charles
V. Chapin. nf the- Providence, R. I., Board of Health: sec-
retary, Dr. James C. Coffey, of Worcester: and treasurer.
Dr. James B. Fields, of Lowell. Rhode Island, having
no State association of its own, has joined the Massa-
chusetts association.
Nassau Hospital.— it was reported recently that the
Nassau County Hospital, Mineola, L. I., would close on
account of financial difficulties, but at a meeting of the
Executive Committee of the Nassau Hospital Association
it was decided to keep the institution open. Tlie com-
mittee has a plan under consideration whereby $130,000
can be raised by bed endowment, and a large sum hag al-
ready been sent in. If, however, the committee finds it
impossible to continue the operation of the hospital on the
new basis, it is said that the Catholic Diocc.-e of Long
Island may take over the property, assuming the mortgage,
the endowment, and all the liabilities.
American Society of Sanitary and Moral Prophylaxis.
— .A r-guiar meetitig of this society will be held at the New
York Academy of Medicine on Thursday, February 13th,
at 8:30 p. m., under the auspices' of the Committee on Edu-
cation. Dr. G Stanley Hall, president of Clark L'niversity.
uill read a paper on the Needs and Methods of Educating
Young People in the Hygiene of Sex. and Mr. Frederick
S. Curtis, principal of the Curti- School for Boys, will
read a paper on Several Year>' Practical Experience in
Edixating Boys in the Hygiene of Sex. .Among those who
will take part in the discussion are Professor Thomas L.
Balliet. Professor Seligman. and Dr. J. P. Warbasse.
Medical Society of the Missouri Valley, — The semi-
annual meeting of this society will be held in Lincoln,
Neb., oil March igth and 20th, and the programme is now
open for contributions. Titles should he sent to the secre-
tary early, as all paper? will appear on the programme 111
the order in ^vllich they arc rtcei\ed, and the number of
papers is limited to twenty-five. The officers of the so-
ciety are : President. Dr. O. Beverley Campbell, of St.
Joseph, Mo. : ilrst \ ice president. Dr. W. F. Milroy. of
Omaha. Neb. : -econd vice president. Dr. C. O. Thienhaus,
of Milwaukee. Wi<. : secretary. Dr. Charles Wood l-"assett.
of St. Joseph. ;\Io. : treasurer. Dr. Donald McRae. of Coun-
cil Bluffs, la.
City and Village Sanatoria in Illinois. — The bill pro-
viding for the establishment of sanatoria for tuberculous
patients in cities and villages of Illinois, which was kno.vii
in the Illinois Legislature as Senate Bill No. 598, has be-
come a law, as we are informed by a telegram from Dr.
J. -A. Egan. secretary of the Illinois State Board of Health.
The bill provides that any municipal government may lev\-
a tax not to exceed four mills on the dollar annually, the
sum collected to be known as the Tuberculosis Sanatorium
Fund, which is to be used for the establishment and main-
tenance of public sanatoria for the benefit of such of the
inhabitants of the city or village as may be afflicted wit'i
tuberculosis.
The Mortality of Chicago. — .According to the report
of the Department of Healtli for the week ending January
18, 1908, there were during the week 715 deaths from all
causes, as compared with 638 for the corresponding week
in 1907. The annual death rate was 17.21 in i.ood of popu-
lation. The principal causes of death were: .Apoplexy,
8: Bright's disease. 45: bronchitis. 28: consumption. 71:
cancer. 29: convulsion-. 3; diphtheria, 15: heart diseases,
51: influenza, 56: intc-tinnl diseases, acute, 28: measles,
2; nervous diseases, 27: pneumonia. 124; scarlet fever, 15;
suicide, 14: typhoid fever. 9: \iolence, other than suicide,
22; whooping cough, 2: all otlier causes. 166.
For the week ending Jamu'.ry 25th there were 687 deaths
from ail causes, as compared \\ irii 735 f-r the correspond-
ing week in 1907. The annual de\th rate in i.ooo of popu-
lation was 16.54. The principal canoes of death were :
.Apoplexy. 8: Bright's disease, 37: bronchitis. 22: con-
sumption, 8r : cancer, 25: con\ ulsions. 8: diphtheria. 7:
heart disease. 53: influenza. 49: intestinal diseases, acute,
35; nervous diseases, 28: pnennii uia. 132: scarlet fever.
r2: suicide. 9; typhoid fe\er. 9: violence, other than sui-
cide, 23: whooping cough, 2: all other causes. 147.
Popular Lectures at Johns Hopkins University. — The
committee on public education of the Medical and Chir-
urgical Faculty of Maryland have made arrangemen:s for
a course of lectures to be delivered at Johns Hopkins L^ni-
versity on Saturday evenings during February and March,
with the exception of Febr-.'.ary 22(1. The lecture on Feb-
ruary 1st was given by Dr. Charles O'Donovati on Ideals
of Flealth in Town and County, and on Saturday evening.
February 8th. Dr. Hiram \\'oods will deliver an address on
Eyesight and School Life. The remainder of the series is
as follows: February 15th. Tuberculosis, 'by Dr. Wilh'am
NEWS ITEMS.
[New York
Medical Journal.
S. Tlia-, cr : February JQtli, Modern School Life and Its
Effect upon Health.' bv Dr. Warren H. Buckler; March
7th, Prc-.onlivc Mcd.cnic. by Dr. William H. Welch;
March 14111. ;\lilk- ,ind its Relation to Disease, b)- Dr. John
Ruhrah ; March 21st, What the City Does in the Preven-
tion of Disease, b}- Dr. C. Hampson Jones; March 28th,
Public Water Supplies, by Dr. Marshall Price.
The Health of Philadelphia.— During the week end-
ing January 11, 1908, the following casr^ of iransniissible
diseases were reported to the Bureau of Health: Typhoid
ivwv. 104 cases, 14 deaths; scarlet fever, 55 cases, o deaths;
eliiclM iipi .\, 62 cases, 0 deaths; diphtheria, 112 cases, 7
(k'aih> ; cerebrospinal meningitis. 6 cases, 2 deaths: measles,
88 cases, 4 deaths : whooping cough, 17 cases, o deaths ;
pulmonary tuberculosis, 121 cases, 69 deaths; pneumonia,
206 cases, 144 deaths; erysipelas, 11 cases, 3 deaths; septi-
cjEmia, 2 cases, i death; mumps, 6 cases, o deaths; cancer,
10 cases, o deaths. The following deaths were recorded
from other transmissible diseases: Tuberculosis, other than
tuberculosis of the lungs, 9: jiuerperal te\'er. ,^ : tetanus,
I ; diarrhea and etiteritis, under t\\ n N cars of age, 14. The
total deaths numbered 705 in an estimated population of
t. 53-738, corresponding to an annual death rate of 23.90
in 1,000 of population. The total infant mortality was 133;
under one year of age, 107; between one and two years of
age, 26. There were 48 still births — 25 males and 23
females. The total precipitation \\as 0.87 inch.
College of Physicians of Philadelphia. — At the regu-
lar meeting, held on Wednesday evening, Februar}' 5tli, the
evening was devoted to a symposium on aneurysm, papers
being read as follows : A Case of Multiple Sacculated
Thoracic Aneurysm Successfully Treated by Wiring, by
Dr, James M. Anders; Sacculated Aneurysm of the Arcii
of the Aorta Rupturcfl into the Superior Vena Cava, with-
out Symptoms of Venous Obstruction, by Dr. Joseph Sailer;
The Pathogenesis of Aneurysm of the Aorta, by Dr. Joseph
McFarland ; The Early Symptomatology of Aneurysm 01
the Aorta, with Special Reference to the Differential Diag-
nosis, by Dr. J. Diitton Steele; The X Ray Diagnosis of
Aneurysm of the Aorta, by Dr. Henry K. Pancoast ; The
Wiring Operation in the Treatment of Aneurysm of the
Aorta, and the Influence of Drugs Before and .^fter the
Operation, by Dr. Hobart .Amory Hall. The honorary li-
brarian announced the addition of fifty-two volumes to the
library during the month of January, and the curator of the
Miittcr Museum announced the addition of one specimen to
the museum. A committee has been appointed to secure a
portrait of the late president. Dr. Arthur V. Meigs.
Meetings of Sections of the New York Academy of
Medicine. — The Section in Neurology and Psychiatry
will meet on Monday evening, February loth, at 8:15
o'clock. Dr. William B. Pritchard will present two cases
of Major Hysteria, and Dr. M. G. Schlapp will present a
case of Unusual Tonic Muscular Spasm and a case of
Hemiatrophy of the Face. 'Professor Joseph Jastrow, of
the University of Wisconsin, will read a paper entitled
Mental Abnormality as Exaggeration of Temperament.
This paper will be discussed by Dr. Carlos F. MacDonald,
Dr. William Mabon, Dr. Smith Ely Jelliffe. and others.
The Section in Public Health will hold a meeting on
Tuesday evening, February nth, at 8:15 o'clock. Dr.
Ceorge A. Soper will read a paper on the Objects of Ven-
tilation; Professor William Hallock, of Columbia Uni-
versity, will read a paper on the Principles of Ventilation ;
and a paper on the Application of Ventilation to Buildings
will be read.
At a meeting of the Section in Pediatrics, which will
be held on Thursday evening, February 13th, at 8:15
o'clock, the following papers will be read : The Indica-
tions for Stimulants in Paediatric Practice, by Dr. Sara
Welt-Kakels ; the Use of Analgesics in Pa^diatric Prac-
tice, by Dr. Le Grand Kerr, of Brooklyn ; the Place of
Hydrotherapy in Prediatrics, by Dr. Friedrich K. W.
Grossc ; the Principles of the Climatic Treatment of Chil-
dren, by Dr. F. W. Wachenheim. The discussion will be
opened by Dr. Henry Koplik.
The following programme has been arranged for a meet-
ing of the Section in Otology to be held on Friday even-
ing, February 14th, at 8:15 o'clock: Presentation of pa-
tients: A Case of Carcinoma Springing from the External
Auditory Canal, by Dr. Emil Gruening; four cases show-
ing the Results of Ossiculectomy, by Dr. W. II. Haskin;
a case exiiibiting Olijcctive Ear Noises, and a case of Re-
current F'ibronia of the Lobule, by Dr. G. B. McAuliffe.
Presentation of speeiiiienN : .\ wet specimen of temporal
bone, by Dr. W. IT. Ha--kin. Reports of L.i^^e?: .\ case-
of Meningitis of Otitic Orioiii, bv Dr. P. D. Kerrison; a
case of Cerebral Abscess with Aphasia, by Dr. B. F.
Knause.
Society Meetings for the Coming Week:
MuxLi.w, I'rbrnary /o//h -Xrw ^'ork Academy of Medi-
cine (Section in Xeur.ilMO\ .ui,] Psvchiatrv) : Society
of Medie;il furi'-pnulrii.T, .V.-u V..rk: New York
Ophthaliiiolomeal S.iciriy; Coniin-, \ Y. ^L-.lical
Association; W:iterl iiiry, C^-iiii., Mcdi.Mi -ijjialioii.
Tl'E.sd.w, Pcbi-iniry iith--Xr\\- Y'.rk X^M^leiny .:if Medi-
cine (Section in Public IKaltli); Unheal Society of
the County of Scheiiectail> . .V. ^■ : I 'ractitioncrs' Club
of Jersey City, N. J.; ^ledieal Society >,f the County
of Rensselaer, N. Y. ; Buffalo Academy of Medicine
(Section in Medicine).
Wednesd.w, February isth.—l<ic\\ York Pathological So-
ciety; New York Surgical .Societ>- ; Mclical .S(^eict>- of
the Borough of the Bronx; .Aliuinn .\-- icuition of the
City Hospital, New York; Brooklyn Medical ;nid
Pliarmacentienl .Association; Richmoiifl County. N. Y.,
Medical Society.
I'hursd.w, February 13th. — New York Academy of Medi-
cine (Section in Piediatrics) ; Brooklyn Pathological
Society; Blackwell Medical Society' r,f Rociu^-rer,.
N. Y. ; Jenkiiis Medical Association, Yonkors, X. A'.
Friday, February 14th. — New York Academy .,f Medicine^
(Section in Otology); New York Society of Derma-
tology and Genitourinary Surgery; Eastern Medical
Society of the City of New York; Saratoga Springs,
N. Y., Medical Society.
Personal. — Dr. Lee K. Frankel, for nine years mana-
ger of the United Hebrew Chaflties of New York, has
tendered his resignation, to take effect on May 1st, in order
to undertake important investigations on ' behalf of the
Russell Sage Foundation.
Dr. Lloward L. Kauclier will hereafter he associated'
in practice with Dr. C. R. P. Fisher, at 224 Somerset street,
Bound Brook, N. J.
Dr. Herbert Leslie Burrell has been appointed John
Homans professor of surgery at the Harvard Medical
School.
Dr. T. A. Williams has taken up his residence in
Washington. D. C. after having spent two years in
the study of nervous diseases in Paris and other Euro-
pean countries. He has been requested to give a course
of instriiction, embodying the more recent researches of
the French school in the diagnosis and treatment of the
psychoiieuroses. The number of pupils will be limited, as
individual attention will be given to each and the whole
day devoted to study.
Charitable Bequests. — l!y the will of Adeline S. Lyon
the Rush Hospital. St. Christopher's Hospital, and the
Kensington Hospital for Women receive $1,000 each. The
Visiting Nurse Society. Gwynedd Home for Convalescing
Children. Northern Day Nursery, Children's Aid Society,
and the Children's Country Week Association receive $500
each.
By the will of William H. Burns the Frankford Flospi-
tal receives $2S.ooo for permanent improvements.
By the will of Lucy Emily Carr, the Sonierville, Mass.,
Hospital recei\cs $5,000,
By the will of FVanccs E. Koons the Haiinemann Hos-
pital Phikidelpliia, will receive $3,000 for the endowment of
a fr.r
r,> il.r \mI1 of :\Irs. Elizabeth S. Folsom the Exeter,
N. Ik. ('otia'_;e Hospital will receive $10,000.
By ilu will of Joseph Hegle. the Little Sisters of the
Poor, of Philadelphia, will receive $500. and St, Vincent's
Orphan .Asylum receives $200.
By the will of Bridget Reilly. her residence is given to
the Philadelphia Protectory for Boys. St. \'incent's Home,
the Maternity Hospital, the House of the Good Shepherd,
St. Joseph's House for Industrious Boys, and the Heme
for Children and Infants. Philadelphia, become reversion-
ary legatees.
By the will of William Jones, the Columbus State Hos-
pital. Columbus, Ohio, receives $3,630.
By the will of James Lambert the Pennsylvania Hos-
pital receives $50,000 and the Free Hospital f - Po.ir Con-
sumptive- at White Haven receives $25,000
February 8, 1908.]
PITH OF CURRENT LITERATURE.
271
|it^ fff tont f iteratuw.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
January so, 1908.
1. An Insidious Type of Nontiiberculous Pyelonephritis,
By Arthur L. Chute.
2. Adenoids and Tonsils. From the Standpoint of the
General Practitioner, with Special Reference to an
Examination of the Throat in Chronic Systemic In-
fections and a Consideration of the Question of
Status Lympliaticus in these Cases,
By Henry Glover Langworthy.
3. Division of the Posterior Spinal Roots for Amputation
Neuralgia, By Philip Coombs Knapp.
4. The Reform of Expert Medical Testimony,
By L. C. Southard.
5. Spina Bifida, By Benjamin Brabson Gates.
I. An Insidious Type of Nontuberculous
Pyelonephritis. — Chute reports two such cases,
whicli represent a class in which infection with a
nontuberculous organism either ascends to the kid-
ney, or if it does not ascend begins as a surface
infection of the kidney pelvis, and in which the
. process of destruction is a slow erosion of the se-
creting tissue. The clinical picture in this type of
pyelonephritis is that of cystitis. As the symptoms
of cystitis persist, but without the great increase
in frequency and pain that is often seen in tuber-
culous cystitis, the patient gets accustomed to the
discomfort, and the process extends insidiously, in
that there is the addition of no new or startling
symptoms until the renal tissue is destroyed to such
a degree that the patient has a deficient power of
elimination. The duration of this insidious progres-
sion may be several years. The failure of the power
of elimination and the appearance of symptoms
that mark the true character of the process occurs
only when both kidneys are involved to such an ex-
tent that they have a combined power of elimination
that is less than that of one normal organ. At this
time it will be too late to attempt operative measures
successfully. The symptoms in these cases, during
the time that it is possible to stay the process, point
to the bladder, though the lesion is of the kidneys.
Cy stoscopy in these cases will be of great help
to make a proper diagnosis. Early treatment by
means of drainage is probably our most efficient
means of treating these cases.
2. Adenoids and Tonsils. — Langworthy re-
marks that there are two points of interest in con-
sidering the question of the status lympliaticus in
these cases. In regard to the first point, whether a
diagnosis can be made during life, the author ob-
serves that it may be stated that a positive diagnosis
is, to say the least, extremely difficult, if not impos-
sible. The diagnosis is certain onh- wlien verified
by a most careful autopsy. Xcverthcless, such a
disorder should be borne in mind, especially if at-
tention is drawn to it by any suspicious circum-
stances. In considering the second point, whether
cases of greatly enlarged adenoids and tonsils are
more likely to fall in this class than individuals who
are not so affected, Langworthy says that it would
seem reasonable to suppose that cases of simple ade-
noid and tonsils should not in themselves present
reasons for doubt or anxiety in this respect. It is
only when they are associated with other stigmata.
as, for instance, absence of pubic hair in an adult,
frequent attacks of syncope, dyspnoea, and laryngis-
mus stridulus, etc., that the possibility of a consti-
tutio lymphatica should be considered. As the list
of fatalities increases we find death from all manner
of slight causes, such as antitoxine injections, bath-
ing, convalescence from acute infectious diseases,
labor, etc., and from both ether and chloroform.
The best method of removal of tonsils and adenoid
in these cases when they are but moderately enlarged
and yet undoubtedly the cause of some disturbance
consists in removing thoroughly the tonsil, includ-
ing the capsule. It is the only method of procedure
which can guarantee immunity from further infec-
tion. The tonsillotome so frequently used will not
answer the purpose. It is about as surgical to leave
large pieces of the tonsil in some part of the sinus
tonsillarus as it is to excise but a portion of the ap-
pendix in an appendectomy. Incision, cauterization,
or partial decapitation does not meet the condition.
The offending organs should be eradicated by scis-
sors, snare, or punch, and even the base curetted if
necessary to secure a sound wall of tissue behind.
The same applies to the adenoid, and, after the re-
moval of the adenoid with whatever instruments are
used, the nasopharynx should be carefully cleaned
out with the finger until smooth and free from all
offending shreds. Adenoids and tonsils rarely recur
after this systematic attention. A so called regrowth
in such instances is usually a fair evidence that the
entire organ was never removed.
THE JOURNAL OF TH E AM ERICAN MEDICAL ASSOCIATION.
February i, igo8.
1. Conservative Operations on Bone Tumors, Based on
tlie Clinical and Pathological Study of Their Relative
Degrees of Malignancy, By Joseph G. Bloodgood.
2. The Conduct of a Plague Campaign,
By Rupert Blue.
3,. Gonorrhoea in Women, By H. J. Boldt.
4. Unrecognized Gonorrhoea in the Female,
By S. W. Bandler.
5. Speech Results of Cleft Palate Operation,
By George V. I. Brown.
6. The Antimicrobic Action of Bromine,
By Guy G. Kinnaman.
7. Landry's Paralysis ; Recovery, Partial Relapse, and
Complete Recovery, By John K. Mitchell.
8. Nervousness : Its Significance and Treatment,
By John Punton.
9. lodoformic Acid in Treatment of Chronic Ulcerative
Phthisis, By Heinrich Stern.
I. Conservative Operations on Bone Tumors.
— Bloodgood remarks that there are two varieties
of bone cysts. The dentigerous cyst is observed
in the jaws. Undoubtedly it arises from an em-
bryonic residue, mesoblastic or epiblastic, of the
dental tissue. This cyst originates within the bony
cavity of the upper or lower jaw, and in its growth
expands the bone, producing a cystic tumor with a
bone capsule. The cyst can be recognized only at an
exploratory incision, when it is found that it usual-
ly contains only clear, viscid serum. In order to ac-
complish a cure, it is simply necessary to remove the
membranous lining. The amount of bone capsule
to be excised should be governed by the extent of
the deformity; resection of the jaw is never indi-
cated. The second variety of bone cysts occurs in
the medullary cavity of the long bones, rarely in the
short and flat bones. It differs from the dentigerous
272
PITH OF CURRENT LITERATURE.
[New York
Medical Journal,
cysts in the absence of a connective tissue capsule.
The fluid is usually haemorrhagic. Islands of carti-
lage may be found in the bone capsule. Clinically
there is a uniform expansion of the shaft, usually
near the joint end, of slow growth. Fracture may
be the symptom of onset. Union may take place, but
the swelling does not disappear. The x ray shadow
does not differ from that seen in any medullary
tumor which produces in its growth bone absorption
and retains a bony capsule. The benign nature of
the lesion can only be ascertained with certainty at
the exploratory incision. Curetting and drainage of
the cyst will accomplish a cure. The adamantine
epithelioma cannot be distinguished clinically from
the dentigerous cyst when it arises within the bony
cavity of the jaw, nor from the so called epulis, when
it begins beneath the mucous membrane of the alveo-
lar border of the jaw. At the exploratory incision
the adamantine epithelioma can be distinguished
from the dentigerous cyst by the coarse, white gran-
ular tissue filiing the single or multiple cavities.
This tumor must be completely excised with its bony
wall, but in the excision one can keep close to the
tumor. When the adamantine epithelioma occurs as
an epulis, local removal with excision of the alveolar
border of the jaw only is necessary. Giant cell sar-
coma usually originates in the medullary cavity of
the long bones, although periosteal growths have
been recorded. It is the most common form of
epulis, which may be looked on as a periosteal growth
from the alveolar border of the jaw. One should
not attempt curetting in these tumors unless there is
a thick shell of bone. When this shell is thin, sub-
periosteal resection should be performed; when the
periosteum and surrounding muscles have become
infiltrated total resection is indicated. For the peri-
osteal giant cell tumor local resection with chiseling
of a zone of bone beneath is sufficient. The pure
myxoma is a very rare tumor. It may occur as a
medullary growth or as a periosteal exostosis. In
the former it is associated with the bone shell ; in the
latter with a partial bony wall. The myxomatous
appearance of the tissue is sufficiently character-
istic to allow a diagnosis. This tumor should be
subjected to the same treatment as giant cell sar-
coma. There is no difficulty in recognizing pure
enchondroma; it is benign, and local resection is
sufficient. In myxochondrosarcoma the cartilage
and myxomatous tumor usually occur together and
most often with sarcomatous degeneration. The
author has observed periosteal fibroma only in the
jaw, when local excision is sufficient. Exostosis bur-
sitis is a benign lesion which clinically may resemble
a rapidly growing sarcoma. The congenital small
exostosis springing from the outer table of the bone
gives no symptoms. The first rapid swelling ob-
served by the patient is due to the filling of the
bursal sac with fluid. Clinically there is a rapidly
growing, tense tumor, apparently of periosteal ori-
gin. Unless x rays are taken from numerous direc-
tions the exostosis may be missed. This lesion is
recognized at once if an exploratory incision is made.
6. The Antimicrobic Action of Bromine. —
Kinnaman divides the results received from his
experiments into two classes. The absolute death
yjoint of the microorganisms, as expressetl in terms
of strength of solution employed and time of expo-
sure to same ; and the power of solutions to inhibit
growth of microorganisms, depending also on
strength of solution and time of exposure to same,
exhibited as a forerunner of absolute death. A very
wide range in efficiency of solutions is found to exist
between Streptococcus pyogenes and Bacillus an-
thracis. The effectiveness of solutions is exhibited
in three main groups: (i) Group i, consisting of
Streptococcus pyogenes and Staphylococcus pyo-
genes aureus, where the antimicrobic power is ex-
tremely well marked, being almost specific for both
microorganisms, but of special importance for its
effect on Staphylococcus pyogenes aureus; (2)
Group 2, consisting of Actinomyces and Blasto-
myces, where less efficiency is shown, but where the
effect is still very satisfactory; (3) Group 3, consist-
ing of Bacillus prodigiosus, Bacillus tuberculosis,
and Bacillus anthracis plus spores, where there is a
very considerable slump in efficiency of solutions.
On the spore forming Bacillus anthracis the effect is
very unsatisfactory. Taking for consideration the
inhibition in growth of microorganisms due to ac-
tions of solutions on them, which depends jointly on
the strength of solutions employed and the time of
exposure to same, the author says that in the cocci
group, the inhibitory sphere, though vigorous and
progressive in character, is very restricted because
of the close approximation of the points at which
inhibition and death occur. In the fungi group,
from the same cause, the sphere of inhibition is again
very restricted, though progressive in character. It
presents a slightly greater range in inhibition than
does the cocci group. In the bacilli group, where,
from the tardy appearance of the death point, we
would expect to find a long and progressive sphere
of inhibition, we find just the opposite. Here, due
to the tardiness of its appearance, we get an inhib-
itory sphere rather contracte4 in character and one
which is markedly irregular in type, giving one the
impression of being highly unreliable. Progressive-
ness in action is strikingly absent. In a solution of
bromine, tlie author thinks, we have a germicidal
agent that presents a peculiar selective action for
certain groups of microorganisms, and then acts
more or less indifferently toward another group. In
other words, on cocci and fungi a i in 300 solution
is effective in a brief time, thus exhibiting a \try
marked germicidal action on them. On the other
hand, on bacilli, especially spore forming, the germi-
cidal effect of solutions is disappointing, a one per
cent, solution having to act for a ytry considerable
period of time before death is produced. It differs
from an ideal antiseptic in that it is hard to prepare,
being extremely irritating to eyes and mucous mem-
branes, and is very unstable, having to be kept in a
glass retainer. Even then it loses its power gradu-
ally, hence fresh solutions have to be made fre-
quently. As it is not markedly penetrating, it has to
act for a considerable period of time to be effective
on all microorganisms, and it coagulates albumin.
Rut it is nontoxic and nonirritating in a strength
that is effective, and docs not produce an appreciable
stain. It is necessary to use a one per cent, solution
for the period of one hour to be effective.
9. lodoformic Acid in the Treatment of
Chronic Ulcerative Phthisis. — Stern, of New
York, nttributcs the primary therapeutic effect of the
February S. i gi S. |
PITH OF CURRENT LIT llRA'l r R li.
273
iodoformic acid in chronic ulcerative phthisis to a
local condition. He bases this opinion on the follow-
ing clinical facts, viz. : The pain in the chest, when
present, is reheved after a few injections ; the cough
soon loses its paroxysmal character when the patient
is under the influence of the drug ; the expectoration,
which may have been profuse, becomes scanty and
attains a "less purulent character, and the bacterial
flora of the sputum (with exception of the bacillus
tuberculosis) becomes perceptibly reduced after ten
or fifteen injections. The elastic tissue fibres and
the tubercle bacilli do not disappear so readily from
the sputum, but in the majority of cases they are no
longer found in it after from five to seven months'
treatment with the iodoformic acid. The one per
cent, solution participates in the removal of the de-
caying material from the lungs and tends to check
ulceration and caseation. Its continued administra-
tion favors sclerotic metamorphosis of the margins
of the ulcerating area and subsequent fibrosis and
calcification of the entire diseased lung tissue. The
mediate therapeutic effect of the drug is constitu-
tional. Iodoformic acid seems to influence assimila-
tion and anabolism in an independent and rather
direct way. which is evidenced by the facts that the
nourishment is better utilized and that the patient
begins to gain in weight soon after the treatment is
instituted and before any appreciable local changes
have been brought about. Such local changes of im-
provement are. of course, preceded by the usually
early relief of the symptoms. (See Therapeutical
Notes, page 264.)
MEDICAL RECORD.
February i, igo8.
1. Classification of Cases of Appendicitis,
By John J. McGrath.
2. A Psychological Study of Hamlet,
By John W. Wain weight.
3. Cutaneous Tuberculin Vaccination in the Diagnosis of
Tuberculosis, By William J. Butler.
4. The After Care of Tuberculosis with Reference to
Employment, By H. R. M. Landis.
5. Treatment of Cancer, By A. G. Henry.
6. The Teaching of Physical Diagnosis,
By O. L. Mulot.
7. Congenital Inderemia with Cataract,
By Edgar S. Thomson.
3. Cutaneous Tuberculin Vaccination in the
Diagnosis of Tuberculosis. — Butler remarks that
the cutaneous tuberculin vaccination commends it-
self because of its simplicity of application, and be-
cause it is unattended by any febrile reaction. The
technique the author describes as follows : Make a
25 per cent, solution of old tuberculin in salt solu-
tion. A similar dilution is used in which one vol-
ume of a 5 per cent, solution of carbolic acid in
glycerin is substituted for one of the volumes of salt
solution. Place two drops, one of each solution,
separated from each other by a space of two inches,
on the outside of the arm, which should be prepared
as is customary for vaccination. A small lancet,
with a dull tip, which is about one sixteenth of an
inch W'ide and placed vertically in a metal handle, is
used to abrade the skin through the vaccine drops
by a rotary motion, removing only upper layers of
epidermis. The tip is then cleaned, and at a point
midway between the vaccination marks a third abra-
sion is made, without any tuberculin being applied.
to serve as a control. If the reaction is positive a
papule, varying in size from 5 to 20 mm. in diame-
ter, at first bright red, later becoming a dark red
with a slight areola, will appear at either vaccination
point, in the first twenty-four hours ; occasionally
they are delayed to the second twenty-four hours.
Sometimes little vesicles with turbid contents, later
becoming confluent, appear over the inoculation site.
These fade and disappear in course of several days,
leaving at times a little pigmentation. In positive
cases in which revaccination is practised similar re-
actions result. In localized tuberculous processes,
as of the glands and bone, the reaction is especially
marked in contrast to the milder reaction seen in per-
sons who have healed foci. At the control point,
and at all three points, in case the reaction is nega-
tive, the slight reddening that follows the scarifica-
tion disappears in twenty-four hours without any
further changes.
5. Treatment of Cancer. — Henry observes
that the germ theory of this disease may be dismissed
as being irrational and pretty thoroughly discredit-
ed. But that it is due to faulty nutrition, assimila-
tion, and absorption we may fairly assume, and
these conditions are brought about by one or more of
a variety of causes. As regards nutrition, we rec-
ognize three ways which make for a departure from
health — overnutrition, undernutrition, and faulty
nutrition. By this last is meant that, while there
may not be too much or too little food taken, the
material composing it is deleterious. In the first
case, that of overnutrition, too much food is taken,
more than the body needs for its proper mainte-
nance. As time goes on and this condition of things
continues, the blood making organs become tired
and manufacture less perfect material from which
the "builders" at some one or more selected places
begin to replace with imperfect or cancer cells the
more normal tissues of the affected parts. As the
eliminative absorbents fail to remove this imperfect
material as fast as it is deposited, we have the grow-
ing tumor. Though less frequently, much the same
conditions obtain in undernutrition. The blood mak-
ing organs themselves are poorly nourished and fur-
nish poor material for the building of perfectly
healthy cells. By material which gives a faulty nu-
trition the author means all flesh foods which, con-
taining toxines and poisons of various kinds, are
totally unfit for human consumption and have much
to do either directly or indirectly in bringing about
a condition of things that goes to the building of
cancers. If cancer is a local disease, it should not
return after removal, as it usually does. On the
theory that there is a general wrong condition of the
blood making assimilative and eliminative functions,
it is readily explainable ; for usually nothing is ef-
fectively done after an operation for the removal of
the growth to remedy the wrongs : and not only
that, but the patient's strength is seriously sapped
by the operation itself, if that operation has been
accomplished by knife or plaster. Thus an early
recurrence is to be looked for. The author thinks
that cancer of the breast, when not too large and
near the suppurative stage, can be treated with the
greatest promise of success with electricity and
massage, both local and general, together with a spe-
cial diet from which all flesh foods are entirely ex-
274
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
eluded The patient should always be under the
physician's immediate care, at his residence or pri-
vate sanatorium, where every detail of the treatment
can be most thoroughly carried out
BRITISH MEDICAL JOURNAL.
January i8, 1908.
1. Note on the Preparation of Catgut for Surgical Pur-
poses, By LoKD Lister.
2. Remarks on the Results of the Operative Treatment
of Chronic Constipation, By W. A. Lane.
1 The Passage of Food through the Human Alimentary
Canal, By A. F. Hertz.
4. On a Special Form of Displacement and Dilatation of
the Stomach, By T. S. Short.
5, Some Physiological Aspects of Gastroenterostomy,
By H. C. Cameron.
•6. Ether Anaesthesia by the Open Method,
By PL B. Gardner.
7, The Conveyance of Whooping Cough from Man to
Animals by Direct Experiment, By H. A. Macewen.
I. Preparation of Catgut. — Lister states that
catgut used for surgical purposes should fulfill the
following conditions: It should, after soaking in
water or blood serum, be strong enough to bear any
strain to which it may be subjected, and should hold
perfectly when tied in a reef knot, it must not be
so rigid as it lies among the tissues as to have any
chance of working its way out by mechanical irrita-
tion. Nor should it be too quickly absorbed, but
should be consumed so slowly by the cells of the
new tissue that grows at its expense that, in the
case of the ligature of an arterial trunk in its con-
tinuity, it may serve sufficiently long as a support
for the substitute living thread in its embryonic
condition. At the same time it is essential that the
catgut be securely aseptic when applied. Chromium
sulphate is an ideal "substance for the prepara-
tion of catgut, with the exception that it is utterly
untrustworthy as a germicide. This defect is easily
remedied by the addition of a little corrosive sub-
limate. The preparing liquid inust be twenty times
the weight of the catgut, and is prepared by mixing
the following solutions: (a) Corrosive sublimate,
2 grains; distilled water, 320 minims, (b) Chromic
acid, 4 grains, distilled water 240 minims, to
which is added enough sulphurous acid to give a
green color. The catgut is kept twenty-four hours
in the preparing liquid and is then dried on the
stretch. But while the substance of the catgut is
antiseptic as well as aseptic, its dry surface is liable
to contamination by contact with septic material,
and it is essential that, before be'ing used, it is
washed with some trustworthy germicidal liquid.
The writer puts the catgut, like the instruments, in
I to 20 solution of carbolic acid about a quarter of
an hour before the operation is begun.
3. Passage of Food Through the Pylorus. —
Hertz, as a result of his studies, concludes that the
passage of food through the pylorus is not regulated
by reflexes from the duodenum alone. When solid
masses in the food are carried against the pylorus,
it closes and remains closed for a time. The result
is that indigestible masses remain in the stomach
until all the fluid and semifluid contents have left,
so that more time is given to the gastric juice to
soften and break up the insufliciently chewed food.
By a similar protective mechanism, fluids at higher
or lower temperatures than that of the body leave
the stomach less rapidly. So that the stomach has
a function which is not generally recognized ; it pro-
tects the duodenum from abnormal stimuli by re-
taining food until it is changed so as to be less-
injurious to the delicate intestinal mucous mem-
branes. Proper chewing will spare the stomacli
most of its work; it will divide the food into fine
particles, dilute it, and bring it to body temperature.
Stasis of food in pyloric ulcer is usually thought to
be due to reflex spasm of the pylorus. More prob-
ably it is due to reflex inhibition of the relaxation
which normally occurs on the arrival of a peristaltic
wave. Indeed, it is doubtful whether spasm of the
pylorus ever occurs.
5. Gastroenterostomy. — Cameron, from a,
study of the physiological phenomena in cases of
gastroenterostomy, reaches the following conclu-
sions: I. On a purely milk diet, in nonmalignant
cases, after gastrojejunostomy, there is a slight but
definite dimmtition in the power of digesting and
absorbing fat. 2. On a mixed diet, rich in fat, for
the most part in the form of butter, this diminution
in power disappears. 3. On a milk diet and on a
mixed diet, rich in fat, the results are the same,
whether there is obstruction at the pylortis or not.
It is, therefore, improbable that the diminution in
power of digesting milk depends upon whether the
duodenum is or is not short circuited out of the
alimentary canal. The cause must be common to
both obstructed and nonobstructed cases, and is
probably to be found in the regurgitation of alkaline
bile and pancreatic jtiicc into the stomach, and in
the consequent reduction of gastric acidity, together
with the inhibition of the rennin. 4. That in cases
of recurrent intractable duodenal or gastric ulcera-
tion, an operation is indicated which will ensure the
complete loss of the acid reaction of the stomach,
while the benefit at present conferred in ulceration
by gastroenterostomy is due to the partial loss of
that reaction. That such an operation would consist
in closing the proximal end of the bowel and im-
planting the distal directly into the stomach. That
where gastroenterostomy is performed, the opening
should be near the cardiac end of the stomach, and
that the anastomosis should be simple, not Y shaped,
nor with enteroentcrostomy. 5. That the complete
digestion of fats on a inixed diet is due to the
specific stimulating effect nn the pancreas of a hor-
mone produced by the fats themselves. 6. A case
of malignant pyloric obstruction, after partial gas-
trectomy and posterior gastrojejunostomy, showed .
complete power of dealing with fats.
7. Conveyance of Whooping Cough. — Mac-
ewen, by feeding a cat on sputum and vomited
material from cases of whooping cough, found that
two weeks later the animal became languid ; after
two weeks more it developed a choking cough which
was always followed by vomiting, and still later a
spasmodic cough with a well marked whoop. The
conclusions drawn are as follows: i. Whooping
cough is beyond doubt an infectious disease. 2. The
specific virus is contained in the sputum, or vomited
material, or both. 3. Infection may take place either
during the process of swallowing or by ingestion of
the infective agent. 4. Cats are susceptible to
whooping cough, and may therefore occasionally be
the means of disseminating the disease.
February 8, 1908. J
PITH Of CURRENT LITERATURE.
275
LANCET.
January 18, 1908.
1. Erythrseniia (Polycythsemia with Cyanosis, Maladie de
Vaquez), By W. Oslek.
2. Tropical Abscess of the Liver, By T. R. Bradshaw.
3. Note on the Preparation of Catgut for Surgical Pur-
poses, By Lord Lister.
4. Excision of the Caecum and Ascending Colon with the
Corresponding Lymphatic Area,
By J. F. DoBSOX and J. K. Ja.mieson.
5. Legal Responsibility and Anaesthetics,
By D. W. BuxTox.
6. Arteritis Obliterans of the Lower Extremity with
Intermittent Claudication ("Angina Cruris"),
By F. P. Weber.
7. A Note on Certain Pupillary Signs in Chorea,
By F. Laxgmead.
8. A Case of Imperfect Development: Acrania,
By A. Yule.
9. Some Cases of Bone Cavities Treated by Stopping with
Paraffin, By A. J. Walton.
10. Electrolytically Produced Fluids Containing Hypo-
chlorites, Their Manufacture, and the Rationale and
Chemistry of the Process for Securing Stability,
By F. W. Alexander.
I. Erythraemia. — Osier reports a case of ery-
thrcemia — a disease characterized by cyanosis, en-
largement of the spleen, and a condition of poly-
cythsemia. The hands, feet, and face are cyanotic
and of a dusky hue. The vasomotor instability is
very ' marked, the hands and feet becoming dark
blue when kept in a dependent position. The skin
shows just the opposite condition to the tache cere-
hralc — along the line of irritation there is a vaso-
motor constriction in the small arterioles, and the
line stands out as a band of anaemia. The spleen is
usually markedly enlarged and its notch can be
readily felt. The blood flows in a large drop from
the finger or ear when pricked, and is sensibly richer
in color and unusually viscid. For the recognition
of the disease a blood count is necessary, not simply
a blood examination, as in leucsemia.. The essential
feature- — the polycythaemia — can be determined only
by counting the number of red corpuscles in a cubic
millimetre of blood. A true polysemia. a plethora
vera, is present. Many other additional symptoms
have been noted, such as pains in the hands and
feet, headache, and constipation. High l)loo(l pres-
sure is the rule and sclerosis of the superficial
arteries and a trace of albumin in the urine have
been frequently observed. . Post mortem, the fol-
lowing anatomical changes are found : A plethora
vera ; intense hyperplasia of the bone marrow, a
myelomatosis rubra ; and enlargement of the spleen,
with histological changes, indicative of chronic pas-
sive congestion, a uniform hyperplasia of all its ele-
ments. It may be that the spleen participates ac-
tively in the process ; neither it nor the lymph glands
lose their power of making red blood corpuscles.
But the essence of the disease is still a mystery, the
over supply of red corpuscles, without any corre-
sponding demand. Very little is known about the
treatment of the disease. As a long experience with
lettcjemia has demonstrated, we have nothing at our
disposal whicli controls the morbid processes in the
bone marrow. When there are fullness of the head
and vertigo, repeated bleedings often give great
relief. Inhalations of oxygen are stated to have
been very beneficial in some cases, relieving the
cyanosis and diminishing the number of red cor-
puscles, which in some cases rises as high as
i2,CKX),ooo corpuscles per cubic millimetre, over
double the normal.
2. Tropical Liver Abscess. — Bradshaw states
that the most noticeable features of tropical abscess,
as distinguished from other forms of suppuration in
the liver, are that it is most often a single abscess,
that it generally attains a large size, and so gives
indications of its presence, that it is not as a rule
associated with general pyaemia, and is not depend-
ent upon any antecedent coarse disease of the liver.
This type of abscess is rarely found except in per-
sons who have lived in tropical or subtropical coun-
tries, and it afYects Europeans more often than
natives. The exact causes which determine its
formation are not exactly understood. Habitual
overfeeding and indulgence in alcohol are credited
with a share in its production, but the cause which
overshadows all others by its frequency is the occur-
rence of dysentery. Whether bacillary dysentery in
tropical regions can give rise to abscess, or whether
the amoebic variety alone can do so, is still suh
judice. While the contents of a large number of
liver abscesses are sterile as regards bacilli, the
majority of abscesses associated with amoebic dysen-
tery do actually contain amcebse. The successful
treatment of tropical abscess by surgerj- depends on
its being single, or at most double. The symptoms
are often indefinite, comprising chiefly w-eakness and
lassitude, loss of flesh, a sallow, muddy complexion,
and sensations of chilliness or actual rigors. Pain
in the right shoulder is a time honored symptom of
abscess in the upper part of the right lobe of the
liver, and is explained by radiation along a small
branch of the sttbphrcnic nerve, which communi-
cates with the nen^e to the subclavius muscle. En-
largement of the liver in an upward direction is
almost pathognomonic of liver abscess, but it is not
easy to recognize. The chief difficulty in diagnosis
in abscess of the liver arises from its simulating
disease of the right Ittng or pletira, or from its
being complicated with actual effusion into the
pleura.
6. Arteritis Obliterans. — ^\"eber reports the
case of a Russian Jew, aged forty-two years, suf-
fering from obliterating arteritis of the left lower
extremity, with intermittent claudication (angina
cruris). His chief complaint was of cramplike
pains in the inner part of the sole of the left foot
(muscles of the instep) or in the calf of the left leg,
which always attacked him after he had walked for
three or four minutes, and obliged him to rest for
a few minutes before going on. No pulsation could
be felt in the arteries of the left foot. The essential
cause of the arterial disease in these cases is un-
known ; possibly it is due to imperfect development.
There is great analogy between the phenomena of
arterial obstruction in the leg and those of angina
pectoris. Just as there are cases of angina pectoris
(pseudoangina) without organic disease of the
coronary arteries, so there are probably also cases
of intermittent claudication of the extremities with-
out organic arterial disease — a dysbasia intermittens
angiospastica, in contradistinction to dysbasia inter-
mittens arteriosclerotica.
276
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
LA SEMAINE MEDICALE.
January 8, 1908.
The Neurites Which Occur in the Course of Cirrhosis of
the Liver, By M. Klippel and J. Lhermitte.
Neurites in the Course of Cirrhosis of the Liver.
— Klippel and Lhermitte allege that peripheral neu-
1 ites may appear at very diverse periods in the evolu-
tion of an alcoholic cirrhosis of the liver. In some
cases they seem to mark the commencement of the
cirrhosis, in others they become manifest in the later
stages of the disease. The two types, very different
in their clinical aspect and in their lesions, are not
of equal interest. In the one case the neurites are
masked as it were by the multipHcity of the cachec-
tic symptoms, while in the other they are from the
first rendered prominent and striking by their inten-
sity. The neurites which appear in the final stage
of cirrhosis are not very frequent and are due to
degenerative lesions, the character of which is strik-
ing as compared with the inflammatory character
of ethylic polyneuritis. In all' other forms of neu-
ritis which are manifested during the course of
cirrhosis the symptoms are extremely severe and the
lesions on which they depend very pronounced. In
other words in most cases of polyneuritis associated
v/ith alcohohc cirrhosis of the liver the neuritis is a
classical alhocolic polyneuritis. Several cases are
described and the literature on the subject is exten-
sively quoted.
January 15, igo8.
Amaurotic Family Idiocy (Tay-Sachs' Disease),
By Apert.
Amaurotic Family Idiocy. — Apert has collated
most if not all of the literature on this subject.
AMERICAN JOURNAL OF THE MEDICAL SCIENCES.
January, 1908.
1. The Diagnosis and Treatment of Cardiovascular Renal
Disease, By J. Tyson.
2. The Treatment of Pneumonia Especially by Outdoor
Air, By W. G. Thompson.
3. The Lenhartz Treatment of Gastric Ulcer,
By S. W. Lambert.
4. The Diagnosis and Treatment of the Gastric Neuroses,
By W. F. Cheney.
5. The Diagnosis and Treatment of Infections of the
Biliary Passages, with Special Reference to Chole-
lithiasis and Cholecystitis, By J. B. Deaver.
6. Rupture of the Kidney, with Remarks upon Conserva-
tive Operative Treatment, By T. R. Neilson.
7. Aspiration Drainage in the Treatment of Empyema,
By W. S. Schley.
8. The Rontgen Ray Treatment of Hypertrophied Pros-
tate, By J. W. Hunter.
9. The Treatment of Psychasthenia from the Standpoint
of Social Consciousness, By J. J. Putnam.
10. The Curability of a Rare Form of Nocturnal Petit
Mai by the Use of Large Doses of Bromide,
By L. P. Clark.
11. The Action of the Nitrites on the Heart,
By W. de B. MacNider.
12. Otitis Media and Its Treatment, By E. C. Ellett.
I. The Diagnosis and Treatment of Cardio-
vascular Renal Disease. — Tyson affirms that this
association of diseased organs is of frequent occur-
rence. The arteriosclerosis or angiosclerosis in-
vades especially the smaller vessels, and the asso-
ciated hypertrophy of the left ventricle (less fre-
quently of both ventricles) is due to effort to over-
come arterial resistance, and to the stimulus of irri-
tating blood. All the chambers of the heart may be
hypertrophied. While general arteriosclerosis may
be primary, it is usually secondary to renal contrac-
tion. Albumin and casts usually appear early in
the primary renal cases. In general arteriosclerosis
there may be hyaline casts, but no albumenuria,
while brain symptoms, anaemic symptoms, retinal
changes, emaciation, and pallor appear early and
are prominent. In the latter condition increase of
blood pressure is less marked than in the former.
The prognosis is more favorable when the heart
disease is primary, even when there is extensive
dropsy. Treatment may be helpful, but not cura-
tive. Sodium iodide, tincture of aconite, nitro-
glycerin, nitrites, and general massage are indicated
for treatment. Rest in bed and milk diet are indi-
cated, though the latter is contraindicated if the tis-
sues are cedematous. Diuretics and hydragogue
cathartics should be given when such a condition
obtains.
2. Treatment of Pneumonia Especially by
Outdoor Air. — Thompson refers to 128 cases of
acute lobar pneumonia treated in the Presbyterian
Hospital in New York in 1906, of which number
forty-seven patients among those who recovered re-
ceived no medicinal treatment. They were either
on the roof or in small rooms in which the windows
were constantly open. The author thinks the only
rational treatment of pneumonia is the symptomatic
one, and that in every case an abundant supply of
fresh outdoor air is the first requisite. He thinks
this method of obtaining oxygen infinitely superior
to obtaining it from a metal cylinder after being
superheated and then blown through stale water
and an unpleasant rubber tube. He thinks the fear
of the draught in the case of pneumonia is due to
prejudice or inexperience. The open air treatment
will not cure all patients with pneumonia, but it will
do more for most of them than drugs. At the same
time there are certain symptoms which call for the
use of drugs, and when such symptoms are apparent
the proper drugs should not be withheld.
4. The Diagnosis and Treatment of the Gas-
tric Neuroses. — Cheney means by gastric neu-
roses those cases of stomach trouble in which there
is constant complaint of discomfort during diges-
tion, but no evidence of organic disease. Neu-
rasthenia is usually an underlying cause. As to
prognosis, one must bear in mind ( i ) that ulcer or
malignant disease may be present, (2) that a cure
depends largely upon change in the patient's mode
of living. The treatment demands simplicity in diet
and habits, slow eating with careful mastication,
resting after meals, and avoiding worry. The
quantity and quality of the diet is to be determined
by analysis of the test meal. Hyperacidity, sub-
acidity, or faulty motility will be revealed by such
an analysis, and the proper diet and drugs will be
formulated in accordance with such findings.
5. Diagnosis and Treatment of Infections of
the Biliary Passages, with Special Reference to
Cholelithiasis and Cholecystitis. — Deaver divides
the surgical treatment of these conditions into (l)
the indications for such intervention, (2) the re-
sults of such intervention, (3) the contraindications.
The indications are (i) repeated attacks of biliary
colic, (2) dropsy of the gallbladder, (3) stone in
common duct, (4) complications, especially the
acute infections. Spontaneous cure of cholelithiasis
February 8, 1908.]
PITH OF CURRENT LITERATURE.
277
is rare, cure by medicines impossible. The same is
true in regard to the adhesions excited by the dis-
ease. The results of surgical intervention in the
author's series of 217 cases show death in thirty
cases from all causes. The contraindications to
surgical intervention are organic lesions of the
heart, lungs, and kidneys, extreme age, anaemia, or
slow coagulability of the blood, and cholasmia.
Surgical treatment is absolutely necessary to a cure
in most cases of chronic biliary infection, and if
undertaken early oilers far greater chances of suc-
cess than when complications have occurred.
6. Rupture of the Kidney. — Neilson reports four
cases in which this accident occurred which were
treated conservatively, rather than by nephrectomy.
He also analyzes the somewhat abundant literature
of the subject, and finds that the advantage lies with
conservative treatment. Surgical interference is
called for to control haemorrhage and prevent ex-
travasation of blood and urine into the tissues and
abdominal cavity, also to treat other organs which
may have been injured simultaneously, and, finally,
to place the injured kidney under conditions which
shall be most favorable for repair, including the
providing of means against the occurrence of infec-
tion. An operation, if indicated, should not be de-
layed. It goes without saying that the injury is
so slight in many cases that an operation is not re-
quired. The conditions must be carefully weighed
to decide between an abdominal or a lumbar in-
cision. The pressure of gauze packing properly
applied will usually control haemorrhage, and drain-
age must be facilitated by the use of 'a sufficient
number of rubber tubes. The injured kidney should
be sutured if possible.
8. The Rontgen Ray Treatment of Hyper-
trophied Prostate. — Hunter notes the failure of
medical treatment to relieve this condition, also the
fact that radical removal of the organ is accom-
panied by high mortality. The application of the
Rontgen ray is suggested in view of its atrophying
action upon glandular tissues. This plan has been
tried with success in a number of cases. The dan-
ger of exciting inflammation in the mucous mem-
brane, which offers slight resistance to the rays,
must not be overlooked. The author thinks the best
results are to be obtained when the hypertrophy is
only of the first or second degree, rather than in
cases in which sclerosis is excessive. He believes
.this method is superior to all others for any except
the oldest and hardest prostates, which must be re-
moved surgically.
ANNALS OF SURGERY.
January, igo8.
1. The Relation of the Mesocolic Band to Gastro-
enterostomy, By W. J. Mayo.
2. Intracranial Abscess Due to the Typhoid Bacillus,
By F. B. GuRD and T. B. Nelles.
3. Isolated Fracture of the Greater Tuberosity of the
Humerus, By H. L. Taylor.
4. A Contribution to the Diagnosis of Renal Tubercu-
losis, By R. P. Campbell.
5. Excision of the Whole Left Lobe of the Liver for
Sarcoma, By G. Torrance.
6. Splenectomy for Lacerated Spleen after Blood Trans-
fusion, By A. H. BoGART.
7. Splenectomy for Gunshot Wound of the Spleen,
By E. H. FiSKE.
8. Splenectomy in Banti's Disease with Report of a Case,.
By G. TORRRANCE.
9. Splenectomy for Carcinoma, By Mary A. Smith.
10. Gangrene of Appendix in a Three Weeks Old Infant,
By C. H. Dixon.
11. Primary Sarcoma of the Prostate, By C. A. Powers.
12. A Systematic Operation for Penile Hypospadias and
Other Defects of the Urethral Floor,
By G. F. Lydston.
13. Simple Fracture of the Carpal Scaphoid,
By W. A. DowNES.
14. Observations on the Treatment of Fracture of the
Neck of the Femur in One Hundred and Twelve
Cases, By J. B. Walker.
15. The Open Method in the Treatment of Pott's Frac-
ture of the Leg, By H.,H. Heath and C. D. Selby.
16. Punctured Fracture of the Skull, By G. G. Ross.
I. The Relation of the Mesocolic Band to
Gastroenterostomy. — Mayo denies that anterior
gastroenterostomy has become obsolete, though its
field of usefulness has been greatly diminished by
the posterior method, by which the intestinal loop
has been eliminated. By the anterior method from
sixteen to twenty inches of jejunum must be looped
around the transverse colon, and regurgitation of
bile is often one of its annoying complications. In
performing the posterior operation the author sug-
gests that the operator locate the peritoneal sus-
pensory ligament or band which extends from the
transverse mesocolon to the upper part of the jeju-
num. Immediately above this band, in the mesoco-
lon, is an area in which there are no important blood-
vessels. The suspensory band having been stripped
away, and a transverse incision made in the above
mentioned area of the mesocolon, the posterior as-
pect of the stomach may be drawn through this
opening and the denuded, jejunum attached to it, the
attachment thus being without strain or loop and
following the normal direction of the jejunum.
4. A Contribution to the Diagnosis of Renal
Tuberculosis. — Campbell analyzes eleven cases
of this condition. In one a circumurethral abscess
was the first objective sign, in three there was epi-
didymitis subsequent to the primary renal symp-
toms, and in one there was pulmonary tuberculosis
when the renal disease was discovered. In nine of
the cases tubercle bacilli were found in the urine.
All but two of the cases underwent nephrectomy,
and the clinical diagnosis was verified. Two of the
cases developed probable tuberculous disease after
the nephrectomy, and another quickly succumbed to
general miliary tuberculosis. The cystoscope aided
in the diagnosis, ulceration, tubercles, or oedema be-
ing observed around the ureteral orifices. The ure-
teral catheter also permitted collection of urine from
each kidney with certainty. With such assistants,
and the possibility of an early diagnosis and a pri-
mary unilateral disease, the prognosis will be much
better for the future than it has been.
9. Splenectomy for Carcinoma. — Mary Smith
states that only four cases of this operation are re-
corded. In her case the points of interest were :
I. The development of malignant ovarian tumors
probably about her thirty-seventh year, during or
following pregnancy. 2. A long period of good
health after the removal of these tumors and the dis-
eased appendix. 3. The entire disappearance of the
sagolike growths observed at the first operation, and
the appearance of a similar growth in the spleen, re-
placing the splenic tissue. 4. Reappearance of the
278
PITH OF CURRENT LITERATURE.
INkw York
Medical Journal.
colloid growth in the abdomen after splenectomy,
having originated from that part of the spleen where
the growth had burst through the capsule. 5. Only
slight variations in the blood before and after opera-
tion. 6. No symptoms pointing to any particular
organ as the cause of rapid emaciation and loss of
strength.
AMERICAN JOURNAL OF OBSTETRICS.
January, igo8.
1. The Role of the Gonococcus in Disease,
By R. W. Taylor.
2. The Treatment of Terminated Ectopic Gestation.
Report of Cases, Including One of Recurrent
Ectopic Gestation, By C. A. Stillwagen.
3. E.xtrauterine Gestation. A Clinical and Operative
Study of Over One Hundred Cases,
By L. J. Ladinski.
4. Management of the Puerperium from a Surgical
Standpoint, By A. Flint, Jr.
5. Care of the Patient in the Puerperium,
/ By F. A. DoRMAN.
6. Treatment of the Puerperium, By S. Marx.
7. In Memoriam. By W. H. S. Wood.
I. The Role of the Gonococcus in Disease. —
Taylor summarizes his exhaustive paper on the
gonococcus as follows: i. It attacks the human
urethra, causing catarrhal and hyperplastic inflam-
mation, which may result in chronic arthritis and
stricture. 2. It invades the testes and their ap-
pendages and thus threatens sterility in men. 5.
Though usually limited to the subepithelial connec-
tive tissue it may invade the venous and lymphatic
radicles of the male and female genitalia and cause
local and general disturbance. 4. The whole or-
ganism may thus be attacked, with much resultant
suffering and disability. 5. It may cause sep-
ticaemia, with serious or fatal result. 6. Arthritis
and rheumatism are constant concomitants, caus-
ing marked changes in joints, tendons, bursae, and
inuscles. 7. After generalized systemic infection
the heart may become seriously involved. 8. The
gonococcus may be destroyed by the antitoxic in-
fluence in the blood serum. 9. The microbe, or its
toxines, may cause serious changes in the cerebro-
spinal system. 10. Invasion of the pleura may oc-
cur, with resultant phlebitis. 11. The spleen may
be attacked. Evidence of liver involvement has
not yet been demonstrated. 12. Many cutaneous
and mucous membrane lesions may be caused by
the gonococcus. 13. Bone lesions may result from
its virulent action. 14. The entire genitourinary
tract in the male may be involved. 15. The mouth,
nares, rectum, umbilicus, and eyes may undergo in-
flammation from this cause. 16. Infection of the
female genitals may menace life and health. 17.
The possible production of an inhibitory serum is
undetermined. 18. The gonococcus causes gonor-
rhoea in the majority of cases. 19. It may be latent,
but may also at any time become potential. 20. l!
is capable of producing the most farreaching in-
fections to which human beings are susceptible.
5. Care of the Patient in the Puerperium. —
Dorrnan considers the .selection of a proper nurse as
a prime consideration in caring for a puerperal
woman. Massage of the uterus for an hour after
delivery should be a portion of the duty of the phy-
sician, not of the nurse. An abdominal binder is
advised and the patient should not be restrained
from moving from side to side if she wishes to do
so. The nurse must be scrupulously clean and not
too fussy, while using all measures conducive to the
comfort and safely of the patient. Fluid diet should
be given for two days. The bowels should be moved
with a mild laxative not later than the third day.
Salines should be used if the breasts become en-
gorged, and heavy breasts should be supported with
a suitable binder. The baby should not be kept too
long at the breast lest the nipple become macerated.
An ice bag to the breast will sometimes avert in-
flammation. Wet dressings of aluminum acetate
are recommended for cracked nipples, and a nipple
shield may be used if nursing is painful. Careful
bandaging of the breast is advised in cases in which
it may be necessary to arrest the flow of milk.
THE PRACTITIONER.
January, igo8.
1. The Diagnosis of General Paralysis, By F. W. Mott.
2. Lupus Erythematous; Observations on its Etiology
and Treatment, By J. M. H. MacLeod.
3. The Urethra:
(a) The Anatomy of the Urethra,
By G. J. Jenkins.
(b) The Causes and Varieties of Urethral Stric-
tures, By A. Edmunds.
(c) The Treatment of Stricture by Bougie,
By H. Lett.
(d) The Treatment of Acute Gonorrhoea,
By J. Pardoe.
(e) Gleet, Some Points in its Diagnosis and Treat-
ment, By C. GiBBS.
4. A Revie\y of Recent Work on Epidemic Cerebro-
spinal Meningitis, By C. B. Ker.
5. The Arrest of Hemorrhage after Labor,
By J. H. E. Brock.
6. Ortljopsedic Surgery, By A. H. Tubby.
7. Subacute and Chronic Middle Ear Deafness,
By M. Yearsley.
8. Ophthalmia Neonatorum, By S. Mayou.
9. Membranous Rhinitis, By F. A. Rose.
3b. The Causes and Varieties of Urethral
Stricture. — Edmunds considers two groups of
causes for stricture. In one, including the congest-
ive stricture and the spasmodic stricture, there is
temporary obstruction in the mucous membrane or
in the muscular tissues surrounding the urethra : in
the other, including organic stricture, there is struc-
tural narrowing in the urethral lumen. The con-
gestive stricture is always due to gonorrhoea, and is
marked by pain and sometimes by spasm. The spas-
modic stricture is due to inhibitory action of the
hypogastric nerve, which not only obstructs the ure-
thra, but diminishes the contractile power of the
bladder. Of the organic stricture traumatism of the
urethra is frequently a cause, including incised
wounds, injuries from falling, kicks in the perin;eum.
fracture of the pelvis, laceration by foreign bodies.
The largest number of strictures include those which
follow gonorrhoeal inflammation. Congenital stric-
ture is of rare occurrence and is due to faulty devel-
opment in one or more of the three portions of the
urethra. Finally the operation of prostatectomy is
occasionally followed by a true stricture, which may
be very troublesome.
3c. The Treatment of Stricture by Bougie. —
Lett observes that in this method of treatment con-
fidence, perseverance, and gentleness are of the great-
February 8, .908.I PROCEEDINGS OF SOCIETIES.
est importance. The urethra is so delicate and sensi-
tive that rough treatment is not usually forgotten or
forgiven. In passing the bougie one should not for-
get that most of the lacunae and follicles in which an
instrument is likely to be entangled are on the floor
of the urethra, and that it is there that the majority
of false passages occur. One is especially reminded of
the point where the urethra turns up into the mem-
branous portion through the triangular ligament. A
false passage can usually be avoided by hugging the
roof with the point of the instrument. Slrictures
vary greatly, not only in their form, but in their tol-
erance of treatment. Dilatation is the treatment
which is to be recomm.ended in the great majority of
cases of urethral stricture. Urethrotomy sb.oakl be
resorted to for impermeable, resilient, nondilatable
ones, and for those in which fevor or rigor follows
any attempt at dilatation.
3d. The Treatment of Acute Gonorrhoea. —
Pardoe considers two methods, the abortive and the
expectant, the choice of treatment, depending upon
the limitation of the infection to the anterior urethra
or its spread along the entire length of tht canal.
The abortive treatment is effective onlv in cases
which arc seen within a day or two after the appear-
ance of symptoms and before the discharge becomes
purulent. It consists in cleansing the urethra, de-
termining the extent of infection with the urethro-
scope (after the application of a local anaesthetic),
and then the free application to the urethra of a 2
to 4 per cent, solution of silver nitrate. This may be
repeated, if necessary, in forty-eight hours. If the
disease has passed the initial stage, urethral irriga-
tion twice daily, for ten days, with a weak solution
of potassium permanganate, will often prevent its
further progress. In the expectant method of treat-
ment cleanliness of the penis and urethra is impera-
tive, antiseptic lotions and plain hot water being fre-
quently applied. The diet should be simple, alcohol
should be abstained from, and the urine should be
made alkaline. When the pain and scalding of mic-
turition are ended the balsams are indicated. Irri-
gation with permanganate of potash solution should
be practised several times a week.
9. Membranous Rhinitis. — Rose thinks that,
notwithstanding the frequent descriptions of this
condition, it is frequently overlooked even b\ spe-
cialists in nose and throat disease. A bacteriologi-
cal examination of a culture from the nasal mem-
brane or the discharge will usually reveal msny diph-
theria bacilli. It usually occurs in children who
may be in fair general condition, running from the
nose, slight bleeding, and nasal obstruction being
pronounced symptoms. The mucous membrane of the
nose is congested and covered with a more or less
dense and tough membrane. The pharynx is usually
normal in appearance. The disease usually continues
four to six weeks. The patient should be isolated as
in well pronounced diphtheria, antitoxin should be
injected, and the nose irrigated. Removal of the
membrane by force does no good, as it will imme-
diately reform. Though this is considered a mild
form of diphtheria and should be treated as such, it
will not communicate to a susceptible person diph-
theria in a severe form, but only a similar rhinitis
or a sore throat with a small patch of exudate.
MEDIC.\L SOCIEIY OF THE STATE OF NEW
YORK.
One Hundred and Second Annual Meeting, Held in
Albany, January 27, 2S, 29, and 30, 1908.
The President, Dr. Frederic C. Curtis, of Albany, in
the Chair.
Meeting of the House of Delegates. — The min-
utes of the last meeting were read and approved
and the roll call answered. The President then
read his report, in which he said that the principal
event of the year had been the passage of the new
law regulating the practice of medicine, and that
the profession as a whole owed much to the society,
and the society, in turn, owed as much to its com-
mittee for its earnest efforts. He called attention
to the excellent work of the society in protecting
its members in malicious malpractice suits. He
earnestly recommended the various county societies
to increase their membership and thus increase that
of the State organization. He recalled its primar\-
object, namely, "to bring together all reputable prac-
titioners of the State once a year," and referred
to the fact that meetings of district branches had
been held for the first time this year. He advocated
cooperation instead of competition and the union of
different districts in their scientific meetings. The
business meetings of course must be held separately.
He advised that a committee be appointed to con-
fer with a 'similar committee of the Bar Associa-
tion to improve the present status of medical testi-
mony, also that another committee be selected to
continue the work in the matter of ophthalmia
neonatorum.
For a century the meetings of this societj^ had
been held at this time and at this place (Albany),
but the winter season was the worst of the year for
physicians to convene, and Albany was not the geo-
graphical centre of the State. He asked if one
permanent meeting place was really desirable. He
recommended that the annual meetings be held in
the fall and at different cities in the State each in
its turn.
The Report of the Secretary, Dr. Wisnek R.
TowxsEXD, showed a total membership of 6,154
against 5,695 last year. During the past year the
secretary had attended all the. branch meetings but
one, and spoke of the high order of scientific at-
tainment shown. He referred to the great possi-
bilities that this district branch system possessed,
the value of the district branch presidents as dele-
gates to the State organization, because he would
be "aware of the local needs and conditions and of
what should or should not be attempted." He
urged each member of the society to try to bring
in at least one physician who was not now a mem-
ber. The secretar)- advised the county societies in
the future to see that registration was properly kept
up and so obliterate the unregistered list, recom-
mended the State society to pay the expenses of its
delegates to the national society, and suggested that
the president be requested to name delegates to the
meetings of societies of adjoining States.
28o
PROCEEDINGS OF SOCIETIES.
[New Yoke
Medical Journal.
The Report of Dr. A. G. Root, Chairman of the
Committee on Legislation, showed that sixty-four
bills had been introduced into the legislature last
year, of which number eighteen had become laws.
Of the sixty-four, twenty-one were general medi-
cal bills, of these, fifteen died in committee, four
became laws, and two did not receive the governor's
signature. Three of the sixty-four were so called
ice bills, referring to the gathering and sale of ice
from polluted sources. All these bills died in com-
mittee. Eight of the sixty-four were labor bills,
referring to the health of factory children and
working women and the general hygiene of the
working classes. Of these, two died in committee
and six became laws. Seven of the sixty-four had
reference to the tenement house legislation in New
York city. Five died in committee and two were
signed by the governor. Twenty-five of the sixty-
four were bills relating to pharmacy, the sale of
drugs, poisons, cocaine, etc. Of these, eighteen
died in committee and seven became laws.
Prize Essays. — Dr. A. Jacobi, chairman of the
•committee, reported that during the past year no
essays had been presented.
The Treasurer's Report, by Dr. Alexander
Lambert, showed a surplus of $10,717.30.
The Committee on Public Health recommend-
ed that a laborator}' be equipped in each county seat
for the examination of secretions and excretions,
■also that the State laboratory at Albany be enlarged
and charged with manufacturing all the antitoxine
and vaccine virus used by the State and that the
State furnish this free of cost to those needing it,
or at least at cost prices ; also that the society active-
ly cooperate with the State Department of Health
in the passage and administration of a law for the
reporting and registration of all cases of tubercu-
losis in the State. The committee called attention
to the necessity of providing special hospitals for
the care of the advanced cases of tuberculosis in
•every centre of population. It also commended the
action of the State making it imperative to cease dis-
'charging raw sewage and other deleterious matter
into streams or lakes or upon the land in the drain-
age area of streams or lakes that could pollute the
waters used as a source of water supply.
The President's Report showed a decrease of
twenty-five per cent, in the number of malpractice
suits, and at the same time the number of paid up
memberships in the society had increased. He said
that the arrest in the number of malpractice suits
was being speedily accomplished. For the past
two years there had never been a single dollar re-
ceived by plaintiffs in suits where the physician had
asked of the society and received malpractice de-
fense.
The Special Committee on Meetings recom-
inended that the State be divided into four divisions,
and that the State society meet in each of these
four sections in its turn. This was referred to a
committee, to report at the next annual meeting.
Officers for the Ensuing Year were elected as
follows : President. Dr. Edward L. Trudeau ; vice-
presidents, Dr. A. G. Root, Dr. John Wheeler, and
Dr. M. C. Hawley ; secretary, Dr. Wisner R. Town-
•send; treasiu-er. Dr. Alexander Lambert: chairman
of the Scientific Committee, Dr. George H. Neuman ;
chairman of the Committee on Public Health, Dr. J.
L. Heffron ; chairman of the Committee on Legisla-
tion, Dr. F. Van Fleet; chairman of the Committee
of Arrangements, Dr. W. J. Nellis ; delegates to the
American Medical Association, for one year. Dr.
R. F. Weir, and Dr. Charles Jewett ; for two years.
Dr. W. R. Townsend, Dr. D. C. Moriarta, Dr. C. B.
Angell, Dr. J. C. Bierwith, and Dr. Albert Vander
Veer ; alternate delegates for two years. Dr. Thorn-
ton, Dr. Brown, Dr. Little, Dr. Glass, Dr. Dunning,
and Dr. Stover; alternate delegates for one year,
Dr. J. A. Fordyce, Dr. A. H. Terry, Dr. W. T.
Mulligan, Dr. C. G. Rossman, and Dr. Burrols.
Mr. J. T. Lewis was reappointed the attorney for
the society.
Scientific Session.
The President's Address. — This was upon
Questions of Broad Consideration Outside of Tech-
nique that Concern the Organized Medical Profes-
sion. He spoke of the significance of the annual
meetings as the mirror of the year's attainments.
He referred to the constantly changing methods of
work and to questions of ethics, policy, and respon-
sibility, as for the most part due to such gathering
as the present one. He spoke of the value of or-
ganization, and said that, while the work done in
the laboratory and college was of great importance,
it was valueless until it was turned into the current
of common life and passed along and became there-
by a stream of influence helpful to humanity. As in
the address to the delegates, he referred to the
primary object of these meetings, "to associate all
the reputable physicians of the Commonwealth and
ostracize the unworthy." He urged that self re-
spect, mutual improvement, and obligation to man-
kind be the actuating and animating motives of the
society. He referred to the Medical Practice Law
as the culmination of earnest and untiring efforts
for the past twenty-five years and to democrac}-
as the chief asset of the organization. He would
bring every reputable practitioner in, simply draw-
ing the line against those who for a very definite
reason were thought unworthy, and so fulfill the
purposes of the fathers. The organization, he be-
lieved, should take in all, give all a chance of ex-
pression, make its floor an open forum and its ex-
ecutive body as free as a New England town meet-
ing; such an association of united men in county
and State would always win good men to its mem-
bership and have its way so long as its purposes
were high.
Obligation, the president stated, was the inevit-
able offspring of capacity, and it was his purpose to
indicate how admirably this society was fitted for
the work which devolved upon it. The public was
dependent upon the medical profession, and the
medical profession was apt to forget its obligation
to the people. The people at large were more apt
to obstruct than aid in the work for their safety.
He emphatically condemned commercialism in med-
icine ; called upon history to bear witness to the
material value of sanitation, and pointed out how
tlie mortality had been reduced one half in diph-
tiieria and one third in diarrhceal troubles. He
viewed it as a function of this .society to direct
[lopular thought, create sentiment, establish county
February 8, 1908.]
LETTERS TO THE EDITORS.
281
health officers and laboratories, and recommend
more teaching in sanitation, for sanitation must
primarily come from the medical profession. He
referred to the question of alcohol as one within
the scope of the State organization, and believed it
one of the most tremendous. Even its therapeutics
he thought worthy of careful scrutiny. He also
touched upon the still prevalent but also prevent-
able disease ophthalmia neonatorum. He believed
active work for its prophylaxis to be one of the
obligations of the society. He lamented the present
status of medicolegal testimony and said that meas-
ures were under way by means of which he hoped
the present deplorable situation would be very much
improved. In closing Dr. Curtis said : "But let us
as a body of a learned profession never be unmind-
ful of the fine old French motto, 'Rank imposes
obligation.' "
Nihilism and Drugs.- — Dr. A. Jacobi believed
that a physician should be judged by his knowledge
and not by his cures, and so bring medicine to the
dignity of a science and not an art. He referred to
the attitude of Oliver Wendell Holmes, who said :
"It is not of the slightest interest to the patient to
know if two or three cubic inches of his lung are
hepatized," etc., and to the more modern William
Osier, who advised students and physicians to be
skeptical of the Pharmacopoeia and counselled
them to study people and learn to manage them,
and said that it was the best doctor who knew the
worthlessness of medicines. Dr. Jacobi expressed
the belief that we owe much to the writings of Dr.
Osier, but that we should be wary of all his sayings
because of their widespread influence. He (Dr.
Jacobi) wished that Dr. Osier had said: i. Be criti-
cal of the Pharmacopoeia. 2. He is the best doctor
who knows the worth of medicines. 3. Study your
* fellow men and learn to serve them.
Dr. Jacobi then showed the impracticability of
the one drug rule. He cited the "mixed treatment"
of syphilis as a striking example of many drug
methods. The cachexia could not be treated by
any one drug, but by a union or combination of
many, such as quinine, ergot, iron, etc. He urged
practitioners not to treat the disease, but the man
or woman. He then referred to the expectant
treatment as practised by many. He cited a case of
spastic encephalitis in which a specialist was called
in and said : "Let me see her in six months." He,
being called in subsequently, advised potassium io-
dide, massage, hydrotherapy, etc., and the child was
greatly improved in six weeks. Thus the actual
treatment of a month with drugs had proved supe-
rior to the expectant treatment of six months.
He regarded the expectant treatment as a sin of
omission which frequently arose to the dignity of
a crime. It was apt, in his opinion, to render men
callous. The expectant treatment of diphtheria was
cited as being especially bad, and drugs, vigorous
stimulation with alcohol, and local antisepsis were
strongly advocated.
As to drugs, he believed cardiac stimulation by
. means of digitalis, strophanthus, sparteine, strych-
nine, ammonia, and musk indispensable in the heart
. failure of pneumonia, and they often were really Hfe
saving. He urged large doses when required. As
to the dose for any particular age, he recommended
giving as much of a remedy as the case demanded.
He considered the injection of morphine over the
seat of pain better than into the arm, but also
deemed it far better in the arm than in the stom-
ach. Contrary to the general opinion. Dr. Jacobi
believed opium to be well borne by children, be-
cause of their indolent nervous systems due to lack
of higher development. Belladonna, too, must be
given in full sized doses to obtain the best results.
The speaker believed no case of chronic tubercu-
losis properly treated unless guaiacol was used.
Whether it acted upon the stomach, improving and
stimulating it, or antigonized the toxine was as yet
unknown, but it did give good results.
In concluding, he referred to Germany as being
the source of much that was good in medicine, but
also of much that was bad.
(To be continued.)
ACUTE POLIOMYELITIS.
Colonial Building,
Boston, January i§, igo8.
To the Editors:
The State Board of Health of Massachusetts has
begun investigations into the aetiology, course, and
treatment of acute poliomyelitis following the ac-
counts of the recent epidemic of this disease in New
York City.
If I had clinical material at hand I would carry
out some experiments to determine positively the
correctness of mv theory that this is an air borne
infection whose port of entry is naturally the first
tonsil.
A.s I have proved to the satisfaction of many, both
patients and physicians, that this is true of many
other air borne infections, such as acute articular
rheumatism, scarlet fever, diphtheria, influenza, etc.,
and that local and direct treatment made at this site
of infection is always positive in results, I am ready
to affirm and would respectfully suggest that, in-
stead of standing helpless by the afflicted patient,
we should attack the disease, which is an infection,
in situ.
Seibert, recently writing of the prophylaxis of
meningitis, advises that the nasopharynx be thor-
oughly sterilized locally.
His evidence had been drawn from reports of
autopsies in which the course of the infection with
the meningococcus was traced from the postnasal
space to the meninges. The process of treatment is
so simple and so direct that it may be readily made
by any one skilled in treating the nose or the ear.
It is preferable to make the applications through the
nose. Edmund D. Spear.
THE ETIOLOGY OF BERIBERI.
Pittsburg, Pa., January 21, 1908.
To the Editors:
Apropos of your editorial article in the Journal
for January i8th on the subject of the aetiology of
beriberi, I beg leave to call attention to a report pub-
lished in the Annual Report of the Supervising
Surgeon General of the U. S. Marine Hospital Ser-
282
BOOK NOTICES.
I N K\v York
Medical Journal.
vice for the Fiscal Year i8p/. on the occurrence
oi" beriberi aboard vessels trading with the ports
of the United States on the Gulf of Mexico.
While at the Gulf Quarantine Station I saw cases
of beriberi aboard ship and was called upon to make
inquiries as to the circumstances attending the origin
of the disease. From the inquiries which I made
in that instance I w^as forced to the conclusion that
the beriberi which I was investigating was a dietetic
disease entirely, and no other explanation seemed
possible ; and I was impressed most of all with a
suggestion made to me by the master of a vessel,
who said that he had never seen the disease until
canned foods were introduced on shipboard. The
canned goods used were often bargain lots which
the vessel had picked up at some port at a very low
price, and in such a case it is to be suspected that
the goods were such old stock that the merchant had
to dispose of them as best he could.
It was suggested, in the report above referred to,
lhat the beriberi as seen at that time was due either
to a chronic ptomaine poisoning or to chronic
poisoning with a metal, dissolved by a slow process
from the cans, in tinned goods.
A. C. Smith,
Surgeon, U. S. P. H. & M. H. S.
A Textbook on the Practice of Medicine. By James M.
AxDrKS, M. D., Ph. D., LL. D., Professor of JNIedicine
and Clinical Medicine at the Medicochirurgical College,
F'hiladelphia, etc. Illustrated. Eighth Edition, Thor-
oughly Revised. Philadelphia and London: W. B. Saun-
ders Company, iqo". Pp. 1.317. (Price, $5.00.)
When a medical work has reached the dignity of
an eighth edilicm its rank aiul u.sefulness lr.i\e !>een
.sufficiently demonstrated and the task of the re-
viewer is an easy one. The qualities which have
distinguished previous editions of Dr. Anders's well
known textbook, orderly arrangement of material,
evincing wide familiarity with the latest literature,
nice discrimination in diagnosis, good judgment in
recommendations as to treatment in which hygiene
and diet receive due consideration, and a concise,
pleasing literary style, are all apparent in this vol-
ume. IVIany of the chapters have been practically
rewritten to keep pace with recent advances in in-
ternal medicine. The sections showing the largest
amount of such revision are perhaps those relating
to the tropical parasitic diseases. Among the new
subjects discussed are the aplastic an.'cmia of Sen-
ator, splenomegaly, the Stokes-.\danis svndrome.
Vincent's angina, chronic appendicitis without
acute attacks, and intestinal autointoxication. Both
lobar pneumonia and acute articular rheumatism
are definitely placed in the group of general infec-
tious diseases. .Accepting the Treponciiia pallida of
Schaudinn, ■ syphilis is classified with the animal
l)arasitic diseases along with infection with trichina,
trenia, echinococcus. and the trypanosomes. The
author's sparing use of illustrations is to be com-
mended. Where they are introduced they really
serve to elucidate the text, and are not used merely
for the pur[)ose of swelling a bulky volume. The
work re])lite with the practical observations of
the great masters of clinical teaching, and is fur-
ther enriched by the author's large personal experi-
ence. The present edition is in every way a very
satisfactory statement of the internal medicine of
to-day, and will be received with the favor which
has been accorded the preceding editions.
Diseases of the Larynx. By Harold B.\r\vell, M. B.
(Lond.), F. R. C. S. (Eng.), Surgeon for Diseases of the
Throat, St. George's Hospital ; Laryngologist, Mount
Vernon Hospital for Diseases of the Chest, etc. London :
Henry Frowde and Hodder & Stoughton, 1907. Pp. viii-
266.
Diseases of the Nose. By E. B. Waggett, M. A., M. B.,
B. C. (Cantab.), Surgeon to the Throat and Ear Depart-
ment of the Charing Cross Hospital, etc. London:
Henry Frowde and Hodder & Stoughton, 1907. Pp. xii-
282.
Diseases of the Ear. By Hunter Tod, M. A., M. B., B. C.
(Cantab.), F. R. C. S. (Eng.), Aural Surgeon to the
London Hospital, Lecturer in Aural Surgery at London
Hospital Medical College, etc. London : Henry Frowde
and Hodder & Stoughton, 1907. Pp. xiv-317.
These little manuals are hardly designed to re-
place any of the standard textbooks, yet each of
them contains something of interest, and all are
worth reading by those who already know the sub-
ject and can appreciate an original presentation of
familiar facts. Barwell has an excellent chapter on
the examination of the larynx, and others on points
of treatment which are valuable. The book is con-
cise and practical, the rarer forms of disease and
theoretical aspects of the subject being treated of
briefly. \\'aggett's pages, as he savs, are intended
to be read as they were written, rapidly, from cover
to cover. He gives a good account of the embry-
ology and comparative anatomy of the nose and a
number of excellent chapters, such as those on
adenoid facies, local treatment, and others. Tod
writes specially for those who have not had the
opportunity of devoting much time to the study o^
diseases of the ear, but his summary will undoubt-
edly be of service in many ways to the more ex-
perienced practitioner. The diagrams showing
modes of extension of inflammation from the tym-
panic cavity, and the cuts illustrating the intracran-
ial otitic complications, are particularly instructive
and novel.
Die Sahsanrctherapic auf thcorctischer uiid t>raktischer
Griindlagc. Bearbeitet von Prof. Dr. Hans Leo in Bonn.
Berlin: August Hirschwald, 1908. Pp. 138.
Professor Leo, of Bonn, has made the hydro-
chloric acid therapeutics the subject of a very in-
teresting little book. Hydrochloric acid, as is well
known, is a compound which is not foreign to the
body; that means, it is found normally in man, and
plays an important role in digestion. It is, there-
fore, necessary to first study the secretion of the
stomach under normal and pathological conditions,
its influence upon the food, and its physiological ac-
tion on the stomach and intestines, so as to give
hydrochloric acid treatment its proper place in
pharmacology, and thus to find out its pharmacody-
namic properties. This, in short, is the disposition
of the subject the author has made in his I)ook. He
also refers to the poisonous properties of hydro-
chloric acid, and gives a full review of the practical
subject of its therapeutics. 'Very interesting and to
the point are his conclusions.
February 8, 1908.)
MISCELLANY.
Ophthalmia Neonatorum, with Especial Reference to its
Causation and Prevention. (The Middlesex Prize Essay
of the British Medical Association, 1907.) By Svdxey
Stephenson, M. B., C. M., Ophthalmic Surgeon to Queen
Charlotte's Hospital, London, etc. London : George
Pulman & Sons, Limited, 1907. Pp. 258.
Stephenson's work is a complete historical and
medical study of a subject which, for practical im-
portance, must appeal not only to the oculist and
obstetrician, but to all physicians who are interested
in the achievements and the possibilities of hygiene
and preventive medicine. The aetiology and bacte-
riology, the symptoms, prognosis, and treatment of
gonorrhoeal infection of the eyes of the new born,
are discussed at length, on the basis of the author's
own experience and on that of aii unusually thor-
ough and complete study of the literature. The
economic side of the question and the relation of
the State to preventive measures are also brought
out. The statistical tables are numerous and will
l)e of great value to future workers in this field.
Stephenson, in ■ conclusion, repeats the admonitory
words of Hermann Cohn, "Die Blennorrhoea neona-
torum kann und muss aus alien civilisirten Staaten
verschwinden.'"
-A Manual of Orthopadic Surgery. By Acgl stus Thorx-
DiKE. M. D., Assistant in Orthop?edics at the Harvard
]\l«dical School. Visiting Surgeon to the House of the
Good Samaritan, etc. With 191 Illustrations. Philadel-
phia : P. Blakiston's Son & Co., 1907. Pp. 401.
Dr. Thorndike has compiled a ver\- handy and
practical manual. The book is divided into five
parts. Part I treats of the foetal deformities and
errors of development of the skeleton and the nerv-
ous system, and the accidents at birth. Part II
comprises deformities due to the action of externa!
forces on growth. In Part III are discussed the dis-
eases and injuries of' bones and joints in postnatal
life. Part IV gives the deformities from acquired
diseases of the nervous and muscular systems. In
Part V is described the technique of plaster of Paris
appliances and apparatus.
From this short synopsis of the contents it can be
seen that the author has given his subject a thor-
ough treatment.
BOOKS. PAMPHLETS, ETC.. RECEIVED.
Diseases of the Heart. By Professor Th. v. Jiirgensen, of
Tiibingen, Professor L. v. Schrotter. of Vienna, and Professoi
L. Krehl. of Greifswald. Edited with Additions by George
Dock, M. D., Professor of Theory and Practice of Medi-
cine and Clinical Medici:ie. University of Michigan, Ann
Arbor. Authorized Translation from the German, under
the Editorial Supervision of Alfred Stengel, M D., Pro-
fessor of Clinical Medicine in the University of Pennsyl-
vani.i Philadelphia and London: \V. B. Saunders Corn-
pan:, 1908: Pp. 848.
Essentials of Modern Electrotherapeutics An Ele-
mentary Textbook on the Scientific Therapeutic Use of
Electricity and Radiant Energy. By Frederick Finch
Strong. M. D., Instructor in Electrotherapeutics at Tufts
College Medical School. Boston. New York: Rebman
Company, 1908. Pp. x-112.
Maternity. By Henry D. Fry. M. D.. Sc. D., Professor
of Obstetrics, Medical Department of the Georgetown Uni-
\-ersity, etc. New York and Washington: Neale Pub-
lishing Company, 1907. Pp. 220.
The Prolongation of Life. Optimistic Studies. By Elie
Metchnikoff, Subdirector of the Pasteur Institute, Paris.
The English translation edited by P. Chalmers Mitchell,
:M. A., D. Sc. Oxon.. Hon. LL. D.. F. R. S., Secretary of
the Zoological Society of London, etc. New York and
London : G. P. Putnam's Sons, 1908. Pp. xx-343.
Formulaire synthetique de medecine. Par le Dr. L. Pron.
Paris: Jules Rousset, 1908. Pp. 601.
Transactions of the American Ophthalmological Society.
Fortv-third Annual Meeting, Washington, D. C, 1907.
Volume XI, Part II. Published by the Society.
Itiscellanj.
The Controversy between Surgeon General
Rixey and Admiral Brownson. — The Army and
A'flc'j' Journal publishes the following letter, sent by
Surgeon General Rixey to the Secretary of the Xavy,
dated January 22, 1908. As this letter covers the
controversy, we publish it in full :
Admiral Brownson's written representations in regard
to the hospital ship have just been brought to my attention,
and as they are of such a character as to lead to serioua
misunderstanding of the matter without further explana-
tion, the Bureau begs to submit the following statement
in answer thereto, and respectfully requests that the same
be transmitted to Congress in connection with the other
papers called for by the resolytion :
First. I have never asked that medical officers be en-
trusted with the navigation of hospital ships. On the con-
trary, I have asked that under the Bureau of Navigation
a sailing master and crew be selected and held responsible
for the navigation and care of the ship. All orders to and
from the sailing master should pass through the senior
surgeon, who will be in command. I asked for the medi-
cal officers of the navy exactly the same status as was and
is given to the medical officers of the army on hospital
ships. The ship now in question, the Relief, as a hospital
ship, was commanded by medical officers of the army.
There can be no question but that the medical officer of
the navy is as well qualified for this work as is the med-
ical officer of the army.
Second. The neutrality of the hospital ship demands
that line officers and a fighting crew should not be put
aboard her except when on the sick list, when they are a
part of the medical corps until discharged from the sick
list and from the hospitals or hospital ship.
Third. I agree with Admiral Brownson that the pilot
age, navigation, and handling of the hospital ship should
be as well done as is that of any other ship, but I contend,
and the facts show, that all of this has and can be done
as efficiently by a merchant master and sailors as by a line
officer and a fighting crew. For example, see Admiral
Brownson's statement in regard to auxiliaries and the his
tory of the transports run by the army at present and
in past wars. Admiral Brownson, citing the difficulties
encountered in the navy with different types of crews
states : "As a result of experience with the various sys-
tems, all in force at the same time and under similar con-
ditions, officers who have had experience with the naval
auxiliaries agree that the most efficient organization is
obtained when these vessels are commanded by a full naval
crew, and it is only the fact that at present there is such
a shortage of officers and men that naval auxiliaries are
not so commanded." In reply to this I wish to call your
attention to the fact that line officers and naval crews
would jeopardize or destroy neutrality in time of war, and
moreover, everj' fighting man of the navy will be needed
for our fighting ships in war. And still further, I wish
to submit that a naval crew who would wish to be on a
hospital ship when there was fighting to be done, would,
to say the least, he most unsatisfactory as naval men of
the fighting branch.
Fourth. Admiral Brownson refers to orders issued and
difficulties encountered in the navy with civilian crews and
masters, and specially cites the cases of the Iris and A^an-
sen. The army transport service is noted for its efficiency,
and it is navigated by a civilian crew and master without
a bureau of navigation to select and equip. How much
better ours should be under such supervision. In the case
of the Iris, she was not saved by a line officer who was
on board, and he was not punished, but the master dis-
284
MISCELLANY.
[New York
Medical Journal.
missed, as he should have been. In the case of the Nan-
sen, cited by Admiral Brownson, the second offcer on
board, who was drunk and disorderly, if she had been a
hospital ship would have been treated as an insane patient,
and he would have been locked up promptly until he could
have been dealt with under regulations governing such
cases.
Fifth. In regard to command in our shore hospitals
and hospital ships, there can be no question as to the
medical officers having all the authority necessary to en-
force their commands. Such authority is exercised every
day in all of our hospitals on shore over line officers and
enlisted men so long as they are on the sick list and in
the hospital ; also over civilian employees and all that come
into the hospitals ; in other words, we absolutely com-
mand in our hospitals ashore. This question was settled
by order of the Department in S. O. dated August 22,
1904, and it was opposed just as earnestly by the Bureau
of Navigation as is now our present request in regard to
command of our hospital ships. This bureau has found
that this sustaining of the bureau in regard to command
in the shore hospitals has been most satisfactory, and just
here I wish to bring out clearly that we are exercising
the right of command according to law in our own corps,
and Admiral Brownson's contention that a line officer on
the sick list in a hospital ship does not belong to that corps
is not well taken. If a line officer sick in our hospital
or on a hospital ship is not under the authority of the
medical officer in command, he would be a most dangerous
person to put in a hospital or aboard the hospital ship.
He might be out of his head or insane ; and as long as he
is on the sick list, it is absolutely necessary that he should
be under the control of the medical officer, and there has
been no question of this in the past, in my thirty odd years
in the navy. A patient going aboard the hospital ship
remains on the sick list until he is discharged from that
ship, and during this time he is absolutely under the con-
trol of the medical officer in charge.
Sixth. The Navy Regulations would be the same on
the hospital ships as in any of our hospitals ashore, and
in any other portion of the navy, and punishment for the
infraction of discipline would be just the same and ac-
cording to regulations. . There is no question of the con-
trol of the paymasters now serving under medical officers
in our hospitals, nor of the enlisted force. Why should
Admiral Brownson fear for the control of them on a hos-
pital ship? In conclusion. Admiral Brownson refers to
the Solace, the only hospital ship mentioned by him, and
the only one that he can find that was ever commanded
by a line officer, whereas I have cited a number of them
in our own and in foreign services which have been com-
manded by medical officers. The Solace, as I have al-
ready cited, destroyed her claims to neutrality on several
occasions, and even laid claim to prize money for having
taken part in offensive operations. The importance of this
contention of Admiral IBrownson does not stop with the
hospital ship. In order to have an efficient personnel
selected to watch over and ever ready to man the guns
of our navy and handle our fighting ships, with the as-
surance that when our men are cut down they will be cared
for, it is necessary that the medical officers must have
authority in their own corps, and further, that medical
officers' authority must be recognized in all matters of
sanitation. There is no question of it ashore, and has not
been since 1904, although the line fought just as hard to
prevent the use of the word "command" in our hospitals
ashore as it is fighting now to prevent the use of the word
"command" in our hospital ships at the present time. In
conclusion, I have to submit that the hospital ship would
be run according to regulations as laid down a year ago
by the Secretary of the Navy, and this should be" done in
time of peace and tried to the satisfaction of the Depart-
ment and the country, so that in time of war the medical
officers may know where they stand in the care of the
thousands that may be entrusted to their care.
The State Charities Aid Association. — The
State Charities Aid Association, which for thirty-
five years has visited the ptihHc charitable institutions
of the State and endeavored in many ways to secure
their improvement, has turned its attention to the
question of the causes of dependence upon the pub-
He. At a meeting of its board of managers, held last
May, the following preambles and resolutions were
adopted :
Whereas, Pulmonary tuberculosis is one of the
leading causes of illness and death, and, therefore,
of suffering, destitution, and pauperism, in this
State ; and,
Whereas, Recent discoveries in medical science
and recent experience in the administrative control
of tuberculosis have made it possible to take prac-
tical and effective measures for the restriction of this
disease ; and.
Whereas, Effective work in this direLtion has been
carried on for several years in this city by the tuber-
culosis committee of the Charity Organization Soci-
ety, and is not carried on as a rule elsewhere in the
State ; therefore,
Resolved, That it is desirable, if sufhcient funds
therefor should become available, without impairing
the income of the association for work to which it is
already committed, that the association should take
up actively, through its comity committees, with the
aid of a paid secretary, the promotion of measures
for the restriction of tuberculosis in the State, out-
side of New York City.
A substantial contribution having been made avail-
able for this work, the association engaged the serv-
ices on October ist of Mr. John A. Kingsbury, a
graduate student at Columbia University, on leave
of absence from the position of principal of a public
school in Seattle, Wash. The State Department of
Health has established during the past suinmer a
traveling tuberculosis exhibit, and the work of the
State Charities Aid Association and of the State
Health Department is being conducted in close co-
operation, the association aiming to secure the larg-
est practical results from the interest aroused by the
exhibit. With Mr. Kingsbury's aid the Oneida
County committee of the State Charities Aid Asso-
ciation has taken up most actively the antitubercu-
losis campaign in Utica, where the ttiberculosis ex-
hibit has been shown for the past two weeks. At a
ptiblic meeting there, addressed by Colonel William
Cary Sanger, president of * the New York State
Branch of the National Red Cross ; George F. Can-
field, vice president of the State Charities Aid Asso-
ciation ; Homer Folks, secretary of the association ;
Hon. Eugene H. Porter, M. D., State commissioner
of health, and Dr. Living.ston Farrand, secretary of
the National Association for the Prevention of Tu-
berculosis. Governor Hughes, who had been invited
to address the meeting, sent a cordial letter, regret-
ting his inability to attend and expressing his deep
interest in the movement. A committee on the pre-
vention of tuberculosis has been appointed by the
local branch of the State Charities Aid Association,
Dr. William M. Gibson, of I'^tica, is chairman of the
committee. A comprehensive program of construct-
ive measures has been adopted by this special com-
mittee as a basis for its work. The establishment of
a tuberculosis free dispensary and the services of a
visiting nurse for a year are already assured. The
Health Department has passed resolutions looking
toward the establishment of a system for the regis-
tration of cases of tuberculosis. Very great interest
has been shown by the citizens of Utica in the ex-
February S, lOoS.]
OFFICIAL NEWS.
285
hibit, which was visited by 4,000 persons in the
course of the fortnight. The outlook for carrying
into effect a comprehensive program is most favor-
able. From Utica the exhibit was sent- to several
cities in the State and finally to New York City.
Luke the Physician. — Professor Adolph Har-
nack, of the University of Berlin, who is known as
one of the most distinguished of living critical his-
torians Of the period at the beginning of the modern
era, has occupied himself not a little with various
points of medical history. He is considered an au-
thority on such matters of philology as throw light
on the details of the history of Greek and Roman
medicine. His historical writing has been taken up
much more, however, with investigation of Chris-
tian origins than with medical matters. It happens,
however, that his last book {Luke the Physician,
translated by J. R. Wilkinson, M. A., New York:
G. P. Putnam's Sons, 1907) is one that unites both
these subjects, and competent critics have declared
it to be one of the most interesting contributions to
history of recent times. While in recent years some
doubt has been expressed as to the authorship of
the writings formerly attributed to Luke, and even
more doubt as to the tradition that their author was
a physician, Professor Harnack has declared his
conviction of the truth of both of these points and
gives incontrovertible arguments for them. These
arguments are drawn chiefly from the words and
expressions which are used in the original version
of the writings attributed to Luke. Careful inves-
tigation of the vocabulary and style of the author
show that the tradition as to his being a physician
is true beyond all doubt. The language of these
writings betrays inevitably the tongue and the mind
of one familiar with the Greek medicine of the time.
Attention has frequently been directed to this be-
fore, but never with so rich a wealth of illustra-
tion and erudition as on this occasion. As has
been well said, the argument from philology has
never received such skillful treatment as is given
it by Harnack. It seems probable, then, that physi-
cians who are interested in this earlier history, es-
pecially from its medical aspects, may still continue
to cherish the old tradition, according to which one
of their number was in that olden time an active
factor in the introduction of the ideas of the frater-
nity of the human race into the world which took
place some 1900 years ago. — From the Journal of
the American Medical Association, November 30,
1907.
The "Cruise of the U. S. S. -flEsculapius, an Op-
era in One Act," was the title of the special en-
tertainment provided for the guests at the annual
dinner at the Gridiron Club, held in Washington on
January 25th. This club, composed largely of news-
paper correspondents stationed in Washington, has
achieved a worldwide reputation owing to the char-
acter of entertainments furnished at its dinners,
which consist of skits or satires based on current
political topics. The controversy regarding the com-
mand of hospital ships furnished the basis of enter-
tainment this year. Among the guests at the dinner
were the President, the Vice President, the Speaker
of the House of Representatives, and many members
of the diplomatic corps and high officials in Wash-
ington. Sailors dressed in regulation uniform ex-
plained that they were part of the crew of the "good
ship ^sciilapius recruited from the Georgetown
Medical College." One of the characters, "Admiral
Trixey,"' informed the audience to the tune of an
air from "Pinafore" that
When I was a lad I served a term
As an office boy to an apothecary's firm.
I filled prescriptions so carefullee
That now I'm an Admiral
In the new Navee.
Another character reported to the captain of the
Aisculapius singing :
Kind captain, I've important inflammation;
Sing hey, the merry doctor and the tar.
Another character, when asked what orders he
had received, said he had received no orders, but had
been given several prescriptions.
Public Health and Marine Hospital Service
Health Reports:
The follozving cases of smallpox, yellozv fever, cholera,
and plague have been reported to the Surgeon General,
United States Public Health and Marine Hospital Service,
during the meek ending January 31, 1908:
Smallpox — United States.
Places. Date. Cases. Deaths.
California — Los Angeles Jan. 4-i"i 15
Illinois — Chicago Jan. 11-18 3
Illinois — Springfield |an. 9-16 14
Indiana — South Bend Ian. 11-18 i
Kansas — Kansas City Jan. 11-18 2
Kansas — Topeka Jan. 4-1 1 3
Kentucky — Covington Ian. 11-18 4
Louisiana — New Orleans tan. 11-18 8
Massachusetts — Fall River Jan. 11-18 4 I
;\Iichigan — Detroit Jan. 11-18 i
Minnesota — Winona Jan. 4-18 3
Missouri — St. Joseph Dec. 7-14 i
Jan. 4-1 1 4
North Carolina — Greensboro Jan. 11-18 i
Ohio — Cincinnati Dec. 31-Jan. 7 3
Oregon — Portland Jan. 4-11 5
Tennessee — Nashville Jan. 11-18 15
Texas — Fort Worth Dec. 1-31 45
Washington — Spokane.... Nov. 23-Dec. 7 5 i
Jan. 4-1 1 6
Smallpo.r — Foreign.
Brazil — Rio de Janeiro Dec. 16-23 24 14
Canada — Winnipeg Jan. 4-11 9
China — Hongkong Nov. 23-30 i 1
Ecuador — Guayaquil Hec. 21-Tan. 4 6
France — Paris Dec. 28-Jan. 4 6 i
Great Britain — Leith Dec. 28-Jan. 4 i
India — Bombay Dec. 17-24 6
India — Madras Dec. 14-20 i
Italy — General Dec. 26-Jan. 2 77
Italy — Catania Dec. 26-Jan. 2 i
Japan — Kobe Dec. 14-Dec. 21 202 36
Mexico — Aguas Calientes Jan. 5-12 4
Peru — Lima Dec. 13 — Cases in Hospital, 18.
Spain — Barcelona Dec. 21-31 3
Spain — Denia Dec. 28-Jan. 4 2
Spain — Valencia Dec. 29-Jan. 5 46 3
Spain — Vigo Dec. 28-Jan. 4 Present
Philippine Islands
Cholera — Insular
-Manila Dec. 7-
Cholera — Foreign
India — Bombay Dec. 17-24...
India— Madras Dec. 14-20...
India — Rangoon Dec. 7-14- • ■
Japan — Osaka Dec. 14-21 . . .
Yellow Fever — Foreign.
Cuba — Santa Clara Province —
Cienfuegos, vicinity Jan. 23-25..,
Ecuador — Guayaquil Dec. 21-Jan.
286
BIRTHS, MARRIAGES, AND DEATHS.
INew York
Medical Journal.
Plague — I'oreign.
Brazil — Rio de Janeiro Dec. 16-23 3 4
Great Britain — Glasgow Aug. 17-31 '
India — Bombay I'ec. 17-24 i
India— Ranpoon Dec. 7-14 6
Tapan — Osaka Dec. 14-21 28 2?
Peru— Callao Dec. 14-21 i
Peru— Catacaos Dec. 14-21 3
Peru — Jequetepeque Dec. 14-21 i
Peru— Lima Dec. 14-21 5 2
Peru— Paita Dec. 14-21 4 4
Peru — Piura Dec. 14-21 3 '
Peru— Trujillo Dec. 14-21 8 6
Public Health and Marine Hospital Service:
Official list of changes of stations and duties of com-
missioned and noncomviissioncd officers of the United
States Public Health and Marine Hospital Service for the
seven days ending February /„ igoS:
Brooks, S. P., Acting Assistant Surgeon. Granted leave
of absence for seven days from January 25, 1908, under
paragraph 210, Service Regulations.
Bryan, W. M., Assistant Surgeon. Granted leave of ab-
sence for seven days, to be taken en route between
Savannah, Ga., and New Orleans, La.
Francis, Edward, Passed Assistant Surgeon, Granted
leave of absence for seven days.
Lloyd, B. J., Passed Assistant Surgeon. Granted leave of
absence for seven days from December 21, 1907, on
account of sickness.
McCoy, G. W., Passed Assistant Surgeon. Directed to pro-
ceed to Sussex County, Va., via Richmond, Va., for
special temporary duty; upon completion of which to
rejoin his station at the Hygienic Laboratory, Washing-
ton, D. C.
Manning, H. M., Assistant Surgeon. Relieved from duty
in the Philippine Islands and directed to return lo the
LTnited States, reporting by wire his arrival in San
Francisco.
Mathewson, H. S.. Passed Assistant Surgeon. Granted
leave of absence for seven days from January 31, 1908.
Robertson, H. McG., Passed Assistant Surgeon. Relieved
from duty at Reedy Island Quarantine Station and di-
rected to proceed to Tampa Bay Quarantine, assuming
command of the Service.
Rodman, J. C, Acting" Assistant Surgeon. Granted leave
of absence for four days from January 28, 1908.
Stoner, G. W.. Surgeon. Granted leave of absence for six
days from January 18, 1908, under paragrajjh 189,
Service Regulations.
Thornton, M. J., Acting Assistant Surgeon. Granted
leave of absence for one day on accoun; of sicl<ness.
Young, G. B., Surgeon. Detailed to represent the Service
at the meeting of the Fourth Annual Conference of the
Council on Medical Education, American Medical As-
sociation, to be held at Chicago, 111.. April 13, 1908.
Army Intelligence:
Official list of changes in the stations and duties of
officers serving in the medical department of the United
States Army for the week ending February i, igo8:
Baker, Frank C, Captain and Assistant Surgeon. Upon
arrival at San Francisco, Cal., will proceed to Fort
Oglethorpe, Ga., for duty.
Cole, Clarence LeR., First Lieutenant and Assistant Sur-
geon. Granted three months' leave of absence, to take
effect when relieved from duty at Jefferson Barracks,
Mo.
Culler, Robert M., First Lieutenant and Assistant Sur-
geon. Leave of absence extended one month.
Hallock, H. M., Major and Surgeon. Having been found
incapacitated for active service, is retired, to take ef-
fect March 20, 1908; granted leave of absence to that
date.
JuENEMANN, George F"., First Lieutenant and Assistant Sur-
geoiL Upon arrival at San Francisco, Cal., will pro-
ceed to Fort McDowell, Cal., for duty at the Depot of
Recruits and Casuals.
KiEFFER, CII^RLEs F., Major and Surgeon. Relieved from
further duty with the Army of Cul)an Pacification ;
ordered to report in person to Brigadier General Fred-
erick Funston, president of an Army retiring board
at San Francisco, Cal., at such time as he may desig
nate, for examination by the board.
Palmer, F. W., First Lieutenant and Assistant Surgeon.
Leave of absence extended twenty days.
Shortlidge, E. D., First Lieutenant and Assistant Sur-
geon. Upon arrival at San Francisco, Cal., will pro-
ceed to Fort Du Pont, Del., for duty.
Navy Intelligence:
Official list of changes in the medical corps of the United
States Navy for the week ending February i, igo8:
Biddle, C, Medical Inspector. Commissioned a medical
inspector, from June 16, 1907.
Brownell, G. DeW., Surgeon. Detached from the naval
training station, Newport, R. I., and ordered to the
Mississippi.
Dessez, p. T., Passed Assistant Surgeon. Commissioned
a passed assistant surgeon, from June 10, 1907.
Donelson, M., Assistant Surgeon. Detached from the
Stringliain and ordered to the Porter.
McDonell, W. L., Passed Assistant Surgeon. Commis-
sioned a passed assistant surgeon, from September 19,
1907.
Mackenzie, E. G., Assistant Surgeon. Ordered to the
Naval Hospital, New York, N. Y.
Porter, F. E., Passed Assistant Surgeon. Commissioned a
passed assistant surgeon, from June 7, 1907.
Russell, A. C. H., Medical Inspector. Commissioned a
medical inspector, from May 7, 1907.
Schmidt, L. M., Assistant Surgeon. Ordered to the Naval
Hospital, Annapolis, Md.
Sellers, F. E., Assistant Surgeon., Detached from the
Naval Hospital, Annapolis. Md., and ordered to the
Naval Academy.
VicKERY, E. A., Passed Assistant Surgeon. Commissioned
a passed assistant surgeon, from October 11, 1907.
Whiteside, L. C, .'\cting .\ssistant Surgeon. Ordered to
tlie Naval Hospital. 'Newport. R. I.^
Married.
1'"lovu — Ma.vi.ev.— In Jacksonville, Florida, on Satur-
day, January i8th. Dr. George M. Floyd and Miss Clara
J. Manley.
Percival — McBuRNEY. — In Philadelphia, on Tuesday^
fanuary' 21st, Dr. Milton Frazer Percival and Miss Mary
Beatty McBurney.
Raguel — Matlack. — In Lewisburg, Pennsylvania, on
Wednesday. January 29th. Dr. George Earle Raguel, of
Philadelphia, and Miss Mary Matlack.
Died.
Arnold. — In Philadelphia, on Saturday, January 25th, Dr.
■John P. Arnold, aged forty years.
Bates. — In Canaan Four Corners, New York, on Sunday,.
J.->.puary 26th. Dr. Milford L. Bates, aged sixty-two year'-;.
Brumbaugh. — In Huntingdon, Pennsylvania, on Mon-
day, January 27th. Dr. .A. B. Brumbaugh, aged seventy-
two years.
Buck. — In Springfield, Illinois, on Thursday, January
23d, Dr. Horatio B. Ruck, aged seventy-five years.
1'ager. — In llarrifburg; Pennsylvania, on Friday, Janu-
ary 24th, Dr. Ciark - P.. Imager, aged sixty-five years.
Griffiths.— in ^'ork, on Friday, January 31st, Dr.
John J. Griffiths, aged forty-eight years. ,
Krausi. — In Brooklyn, on Friday, January 31st, Dr. Wil-
liam J. Krausi, aged forty-nine years.
Marston. — In Light foot, York County, Virginia, on Sun-
day, January 26th, Dr. Thomas P. Marston, aged seventy-
three years.
Ogg. — In Hillsboro, Virginia, on Thursday, January 23d,.
Dr. Charles C. Ogg, aged thirty years.
Peeke, — In Rotterdam, New York, on Monday, Januar>
27th, Dr. Charles Sample Peeke, aged forty-three years.
Reed. — In Philadelphia, on Saturday, January 25th, Dr.
John A. Reed, of Maysviile, Kentucky, aged sixty-four
years.
Riley. — In Omaha, Nebraska, on Friday, January 31st,.
Dr. A. W. Riiey.
SiZER. — In Brooklyn, on Monday. January 27th. Dr.
Nelson Buell Sizer, aged sixty-three years.
Steinmetz. — In Baltimore, Maryland, on Sunday, Janu-
ary 26th, Dr. William R. Steinmetz.
Thomas. — In Quakertown. Pennsylvania, on Tuesday..
January 28tii. Dr. Joseph Thomas, aged seventy-eight yeaii..
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
A Weekly Review of Medicine, Established 1S4J.
\'0L. LXXXMI. Xo. 7. XEW YORK. FEBRUARY 15. 1908. Whole Xo. 1524.
(Original (lommunifations.
ox SOME POINTS REGARDING URETHROPLAS-
TIC OPERATIONS. WITH SPECIAL REFER-
ENCE TO THE DISLOCATION METHOD*
By Carl Beck. :\I. D.,
New York,
Professor of Surgery in the New York Postgraduate Medical Sc'nool
and Hospital: Visiting Surgeon to the St. Mark's Hospital
and the German Poliklinik.
Dislocation of the urethra for hyposp:idi^s. some
types of epispadias, or other urethroplastic opera-
tions are of a more or less delicate nature, especially
so in the case of children. Delicate operations re-
quire delicate instruments, and those commonly used
do not, in my experience, answer this desideratum.
A thumb forceps, as generally used, may tear the
urethral membrane of a child. The retractors hold-
ing the reflected skin flaps must hold the tissues
without injuring them. The knives for dissecting
out the urethra, as well as the bistoury used to per-
forate the glans, must be of a special and delicate con-
struction.
I therefore requested the Kny-Scheerer Company
to construct for urethroplastic operations a special
set of instruments containing all that are needed for
that purpose, viz. : A smaH. short scalpel for the
dissection of the urethra from its bed. a long bistoury
for the perforation of the glans or the penile sub-
stance, two toothed thumb forceps.' delicate blunt
scissors curved on the flat for blunt dissection, a
toothed retractor, two specially adjustable holding
forceps which may serve as retractors at the same
time, two small elastic artery clamps, various thin
needles (sharpened on both sides up to the eye), a
special needle holder, and a rubber catheter provided
with a perforated shield. This set may also be uti-
lized for other delicate plastic operations.
As a rule, my operation for dislocating the urethra
is started by introducing a thick rubber catheter into
the urethra. As soon as the catheter has reached
the bladder, its opening is temporarily closed. Xow
a silk suture is carried through the perforated shield
of the catheter or through the wall of an ordinarv
rubber catheter, as well as the abnormal orifice, with
a thin curved needle, as described. The suture, after
being knotted, is left long, so that it may be utilized
later for fastening the urethral orifice at the tip of
the glans. By pulling the catheter slightly the ure-
thra is stretched to such a degree that the incisio-i
can be made with a greater amount of security and
in the straight direction. If a small, sharp hook is
inserted at the tip of the glans, contraextension is
*Read and demonstrated before the American Urological Associ-
ation at the meeting at Atlantic City, June 5. 1907.
exerted, which facilitates the process nt lifting the
urethra from its bed.
In this position the backward dissection of the in-
tegumental flaps, which are meant to cover the dis-
lodged urethral portion, is also made easier.
For isolating the urethra the catheter serves not
only as a handle, but also as a guide. It can easily
be palpated through the urethral wall — in children
it can even be seen through the somewhat translu-
cent urethral wall. Thus, the surgeon is warned
against incising it. To serve the catheter as a strong
hold, the orificial portion of the urethra should re-
main as thick as possible. If there is any tension the
sutures at the tip of the glans are supported by
placing a relaxation suture of finei^t catgut at each
side of the urethral wall near the sulcus.
In one of the extreme cases of scrotoperineal hy-
pospadias I have modified my method of creating a
new urethra by deep incisions at each side of the
penis, parallel to the existing groove (See YtTi' York
Medical Journal, December 8, 1900). in the follow-
ing way :
After introducing the catheter through the abnor-
mal orifice (Fig. i) the urethra was dissected back-
ward and freed as far as possible. Enveloped in
sterile gauze the dissected urethral portion hung
down, pulled by the weight of the forceps. whi':h
closed the opening of the catheter. After the amount
of tissue needed for forming a urethral tube of suffi-
cient length was measured, a flap of proper propor-
tion was shelled out from the posterior surface of
the penis. Fortunately there was a preformed gutter
lined with the rudiments of a mucous membrane.
Where the base of the dislocated urethral fragment
joined the lower end of the gutter, the inci^it iis were
made especially deep, so as to secure voluminous tis-
sue for better nutrition of the flap, which was sev-
ered from its connection near the glandular portion
of the penis and isolated backward. The whole dis-
sected gutter, which was in broad connection with
the region of the abnormal orifice, was now folded
together over the rubber catheter and thus trans-
formed into a tube which was circularly united with
the tip of the dislocated urethral fragment. The
penis was then perforated in its whole extent by a
double edged bistoury, forming an artificial orifice
at the tip of the gland similar to my ordiuTy pro-
cedure for glandular or penile hypospadias. Through
this newly formed canal the flap, together with the
dislocated urethral portion still containing the cath-
eter, were pulled and fastened at the tip. The bis-
toury must make free excursions by its perforation
of the penile tissue in such cases in order to obtain
sufficient space for the permeation of the combined
tube. At the point of junction between the bridge of
the flap and the orifice of the urethral fragment tor>
much pulling must not be tried, because the nutri-
Copy right. igcS, by A. R. Elliott Publishing Comr.nny.
BECK: UREI HROPLASTIC OPERATIONS.
sibility of utilizing the mucous nienil)ranf of the pre-
formed gutter for a urethra. Its (HsaJvanlage. on
the other hand, is the nuitilation of the penis within
Fig. I. — Scrotopenneal hypospadias before o])erati(in.
trition of the bridge ma\- suffer, Of course tlie de-
fect left at tile "Uhr surface is covered by a flap
taken frum the ^cnituin. The anterior portion of a
by the urethral fragment further l)ack, there is a
sufficient amount of propelling ])o\\rr jiresent.
A decided advantage of this ])rocedure is the pos-
urethra of this kind is not an ideal one. since it lacks
the elasticitv of a normal urethra, l)ut. lieinsr aided
F[<;. 3. — Gauze strip fastened to penis with two sutures.
the extent of the grooved flap. To avoid tlii.>, I have
in another case of the same nature taken the flap
from the scrotum rigin- below the abnormal orifice.
ol)taining a perfect result in a bov of seventeen vcars
of age. There the a1~)normal orifice wa■^ circumcised
after the introduction and fastening of the catheter.
Then the latter was held ui) against the alxicmen in
order to get it out of the field of operation. Xow an
D
□
o
sQ D s
3D OS
1 11.. — liau/e -Inp fur prolcctini) of suturts and opiitinu
\ircthral orifice. L I,, lateral openings for the Kaiizc tail; S S. o]
ings for the knotted stitm-es.
-I^'inal fastcninp of
Fcljruary i;. igob.j
CUMMiXS: LARCIXUMA Of (ESOPHAGUS.
289
incision was made at each side of the raphe and par-
allel to it to the extent of an inch and a half down-
ward, thus forminsT a t1a]). the broad base of which
Avas, after being- dissected and freed, below the ab-
normal orifice. Then the catheter was seized, the
urethra stretched and dissected, as it was done in the
case just described, the scrotal flap folded and trans-
formed into a tube, and then circularly united with
the abnormal orifice. The further steps ot the op-
eration were the same as described above. Great
care is to be taken to estimate properly where the
base of the scrotal flap is to be established, so that
the abnormal orifice, after being: pulled forwird, fits
exactly to it, as it is not wise to put the base itself
under much tension. The fiap operation was much
facilitated in this case by the presence of the extraor-
dinarily smooth surface, which in fact resembled a
mucous membrane alongside the raphe.
In the extreme case described above slight incur-
vation remained, which is gradually becoming less.
In contradiction to the exi)erience of such surgeons
as have observed failures because the\ regarded
some of the minor details of my suggestions as non-
important, or objected for theoretical reasons with-
out actually performing the operation. I may be per-
mitted to say that in m.ne of my balanic or penile
cases has any incurvation lietn left.
As it is difficult to keep an ordinary penile dress-
ing in situ I use a T shaped i)iece of dernntol gauze
with a central opening for the catheter and provided
with a number of lateral openings, which permit of
passing the sutures through them (Fig. 2). The
upper and lower sutures, after being knotted, are
left long for the purpose of fastening the gauze
strip. After the ends of the knotted sutures are
]>ulled through the gauze strip placed alongside the
posterior surface of the penis (Fig. 3) they are tied
and cut short. The two dissected ends of the strip are
now carried around the penis ancl pulled through the
lateral openings and knotted, or held together by
a safety pin ( Fig. 4). This dressing is to be
saturated with a mild solution of bichloride of
mercury several times a day. It must not be re-
moved before a week. Fig. 5 shows result after op-
eration.
SQUAMOUS CELLED CARCIXOMATA OF THE
CESOPHAGUS.
By \V. Taylor Cl'm.mixs, M. D.,
Philadelphia.
(From the Pathological Laboratory of the University of Peiinsvlia-
nia.)
\\'ith regard to the type of cell, carcinomata of
the oesophagus are divided into two classes — the
squamous celled and the columnar celled. The
former is the much more frequently found, for, in
fact, cases of the latter type are rarely encountered.
For the mo.st part the tumor is primary in this or-
gan, but cases are reported in which it is the seat
of metastatic deposits from the pharynx, thvreoid,
and cardia of the stomach. The oesophagus ap-
pears to be invaded but rarely by cancerous growth,
for. out of a series of 722 cancers ( r ) in all parts
of the body, only six were found in the oesophagus.
It seems to enjoy a certain degree of immunity
from neoplasmic invasion in contrast with the or-
gans lower in the alimentary tract. Zenker and
von Ziemssen (2) have collected reports of 5.079
autopsies, of which 0.36 per cent, showed oeso-
phageal cancer and 0.25 per cent, were primary.
The organ may be divided very conveniently into
three segments, viz., an upper. <ir cervical, a middle,
or thoracic, and a lower, or diaphragmatic, portion.
Bland-Sutton (3) believes that the location of the
neoplasm may determine whether it is of the
squamous or columnar celled type, the former elect-
ing the upper two thirds and the latter the lower
third of the tube. This statement must not be made
dogmaticall\' owing to the fact that statistics reveal
many instances in wiiich the squamous celled tumor
primaril\ involved the lower third of the organ.
As to the point of greatest frequency of involve-
ment there seem to be widespread difYerences of
opinion. It is conceded that the points of narrow-
ing of the tube are the usual seats of the new
growth. These are found at the levels of the
cricoid cartilage, the bifurcation of the trachea, and
the diaphragm. Possibly localized trauma at thtse
apparently stenotic areas may incite tumor forma-
tion. Upon making a resume of the statistics at
hand there is revealed the fact that the new
growths, including both types, are somewhat more
frequently found in the lower third of the organ.
Kraus (4) collected 90 1 cases, and of these 397
were found in the lower third, 302 in the middle.
158 in the upper third, and 45 involved more than
one part of the organ.
The oesophageal tumor may be small and defi-
nitely circumscribed, or. on the other hand, it may
be quite large with imperfect demarkation. In some
instances multiple foci have been observed. There
is usually some stenosis of the tube, but in a few
reported cases this condition was absent. Ulcera-
tion and cicatrization are likely to develop, and in
many cases the lumen of the gullet is almost oblit-
290
CUMMINS: CARCINOMA Of (ESOPHAGUS.
[New York
erated. In those cases in which the carcinoma in-
volves the diaphragmatic segment, Bland-Sutton
has explained the forcible ejection of food after
five cases (5) of cc
at St. George's 1
showed metastatic
Fig. I. -^Showing squamous celled carcinoma of the oesophagus at its border. To the left
the penetration of the newly formed epithelium into the underlying tissue manifests itself in
long, narrow columns. "Pearls" are absent.
swallowing by the fact that the tube assumes a
spindle shape on account of the stenotic condition,
and there occurs a hypertrophy of the muscular
walls immediately above, thus favoring a forcible
regurgitation of the (Esophageal contents.
The squamous celled cancer is found much more
frequently in men than in women. liland-Sntton
has observed it four times more fi-e(|aentl\ , while
Makenzie, Zenker, and von Ziemssen iTavx- fi'und it
three times more frequently in men. The distribii-
tion in the se.xes appears comparable to
that of neoplasms of the stomach. Age
seems to be a factor in its production.
The prolific period is between forty and
sixty years, while cases are recorded as
early as the thirtieth year and as late as
the eighty-fourth year. A few excep-
tional cases are on record in which the
disease appeared in the nineteenth and
twenty-first years. Curiously, the fe-
male sex .seems to be attacked earlier
in life than the male.
It has been said that carcinnmat-i of
the (esophagus do not often metastasize.
This has been explained bv the fact tli-t
the disease is often rapidly fatal. ;'nd
metastases have not had the opportunity
to develop. Certain it is that the pa-
tient, in many instances, is not long un-
der observation subsequent to the devel-
opment of localized svmptoms, and
death may take place from inanition,
exhaustion, or septic pneumonia. Re-
ports of metastatic growths are noted
rather infrequently. The posterior me- rarcinonV;.
diastinal glands appear to be afifected
more frequently than any of the other structures, and
tlieir position renders easy access of tumor tissue
from the thoracic segment of the gullet. Of fifty-
)hageal carcinomata recorded
•^pital, London, these glands
posits in twenty-four cases.
Evidences of metastases
were observed in the liver
in ttn cases, in the lungs in
six cases, in the kidneys in
five cases, in the bones in
four cases, and in the adre-
nals and spleen in two
cases each. Widespread dis-
semination of the cancerous
elements is distinctly rare.
In a few cases reported in
literature the tumor had ex-
isted for years without pro-
ducing secondary foci, and
they were generally of the
flat celled type.
Among those who have
reported upon cancer of the
oesophagus with metastases
are Burnet (6), Butlin (7).
Wright (8), Scott (9), and
Eskridge ( lO). Cancer sta-
tistics have been collected bv
eiillies (11) and Moak (12).
Personal Obscri'ations. —
\l\ personal observations have been confined to
a 'review of the autopsx' records on file at the
pathological laboratory ' of the University of
Pennsylvania from 1874 to 1907. The number
of records examined was 1,993. and of these
ten showed .squamous celled carcinnmata of the
tesophagus, distributed as follows: (~)ne in 1891,
one in 1893. four in 1901, one in 1904. two in 1906,
and one in 1907, In regard to the prevailing sex, the
males outnumber the females, eight to two. This
epithelial lu-st" "itli tw.i "pearls." t.iken from another
111. .r-,,i,li,-igns.
conforms with tlie assertions made by the other in-
vestigators that these neojilasms are much more
frequent in men than in women. The ages ranged
cL'.W.U/.\.^.■ i.iRLJXuMA Ob' CE^iOFHAGUS.
from thirty- four to seventy-four years. The young-
est cases, a.tced thirty-four and thirty-eight years,
were females, while the youngest male was fifty.
It appears that the disease may develop earlier in
life in the ft-male than in the male. In but six of
the ten cases was the race noted, and all of them
were white. Xothing conclusive appears in the lit-
erature with regard to the comparative frequency
of the condition in the races. As to the points of
predilection in the oesophagus, as already stated,
there appear to be differences of opinion. In seven
cases onlv was the site of the primary tumor indi-
cated, and four of these involved the lower one
third of the tube. Some of the statistics are based
upon all cancers of the oesophagus, while personal
observations were made upon the squamous celled
tvpe alone. The results are comparable for the fact
that the indift'erent type, the columnar celled, is so
infrequently encountered. All of the tumors of this
series appeared to be primary in the oesophagus,
and involvement of not more than one segment had
occurred. As to the general character of the
tumors, four showed considerable ulceration, three
were fungoid, and one was characterized by dense
cicatrization of the oesophageal walls. In two cases
the ai^pearance of the tumor was not noted in the
records.
The number of cases presenting metastases out-
number tliose without six to four. This surely does
not show a comparative rarity of metastases in such
tumors. For the most part the notes upon the gross
anatomy of the organs were disregarded, and the
diagnosis depended upon the histological findings.
[Metastatic growths occurred in the organs with the
following frequency : Stomach, four times ; liver,
three times ; pancreas, three times ; lungs, twice ;
posterior mediastinal glands, twice : bronchial
glands, twice : hepatic glands, twice : kidneys, once ;
pancreaticosplenic and lumbar glands, each once.
The most widespread metastases occurred in Case
II. in which foci were found in the liver, lungs,
stomach, pancreas, hepatic, pancreaticosplenic, and
bronchial glands. Histologically the primary and
secondarv growths were divided into two groups
dependent upon the presence or absence of "epithe-
lial pearls." In that the keratinous structure of
the squamous epithelium of the oesophagus is poor-
ly developed, the presumption might be that tumors
involving such a tissue would usually show an ab-
sence of the "pearls.'" Such was not the case in
this series, for five showed the presence of pearls
and three showed absence of the same. In two
cases this point was not noted in the records.
It seems plausible that the facts pertaining to the
development of the tumors of the spinal and basal
cellular types of carcinomata of the skin might
readily apply to these tumors, i. e., the tumors in
which the superficial strata of epithelium are di-
rectly concerned, show "epithelial pearls." while
those in which the epithelium of the deeper or
basal strata has proliferated, show no pearls. In
the secondary as well as the primary growths the
nests of tumor cells were much smaller in those
cases showing epithelial pearls than in those in
which they were absent. In several of the meta-
static deposits in the latter group the squamous
character of the cells was ma(le out with some dif-
ficulty. Those cases which showed pearls in the
oesophageal tumor showed the same in the second-
ary tumors. However, there appeared a tendency
toward a diminution in size, and this was well
shown in the tumor of the kidney (Case VII, Fig.
4), in which the "pearls" could with difiiculty be rec-
ognized. It was thought by the author that a com-
parison of the frequency of metastasis in those pri-
mary tumors with and without "pearls" might reveal
that there is less frequent metastasis in those with
"epithelial pearls." Examination of the records re-
veals that of the four cases without metastases
three showed pearls. So limited a number of cases
makes it problematical but at least suggestive.
Several of the tum.or sections presented rather
unusual features. In one, a section of lung ( Fig.
3) there was shown embolism of the smaller radi-
cles of the pulmonary arteries by masses of squa-
mous epithelium. The deposits were confined to
these locations, and but few of them were seen.
In a pancreas there was infiltration of a small lobule
by squamous epithelium with the island of Langer-
hans vaguely evident. In a kidney the cortex
showed a large, irregularly rounded mass composed
of small nests of squamous epithelium, with very
small deeply stained pearls.
Metastasis. — Under this heading a brief descrip-
tion of the lymphatic system of the oesophagus and
neighboring structures is indispensable. The
lymphatics of the oesophagus fall into two groups,
viz.. those in the submocosa and those in the mus-
cular coats. The cervical portion of the organ
drains into the superior deep cervical and recur-
rential nodes. The lymphatics draining the middle
or thoracic segment pass to the posterior mediasti-
nal glands, while those of the lower or dia-
prhagmatic segment pass to the coeliac plexus of
lymph glands. For the most part the efferent chan-
nels of the posterior mediastinal glands pass di-
rectly to the thoracic duct, while a few pass to the
bronchial glands, which in turn drain into the tho-
racic duct. Among the aft'erent channels of the
coeliac plexus, besides those from the oesophagus,
are those from the hepatic, gastric, pancreatico-
splenic. and lumbar nodes, while the efTerents pass
to the thoracic duct. -
It is well known that carcinomata usually metas-
tasize through the lymphatic s\stem. yet there
seem to be very good reasons for the belief that in
some instances dissemination of the tumor tissue
from the primary focus may be eft"ected through
the blood vascular system, and in some instances
it seems possible to take place over mucous or se-
rous surfaces. Let vis discuss the several cases
seriatum.
Case I showed the carcinoma involving the cer-
vical oesophageal segment, but no metastatic
growths were noted. Perforation of the trachea,
however, had occurred. In Case II unfortunately
the autopsy record failed to reveal the segment in
which the primary tumor was found. There was
widespread metastasis as before noted. Case III
showed the tumor in the diaphragmatic portion of
the tube, but no metastases had developed. Case
I\ showed the tumo^ in the lower portion of the
tube -os a very dense fibrous mass, but no metas-
tases. Tuberculous laryngitis was a complication.
CUMMINS: CARCIXOMA OJ' (ESOPH.IUUS.
Mc;:)"lCAL JOURNM-
Case \ showed the growth in the lower segment
of the oesophagus with the development of metas-
tases to the pancreas, liver, and lungs. Ex-
planator'i of the abdominal and thoracic metastases,
it seems reasonable to suppose that dissemination
]-"iG. 3. — Showing lung with masses of squamous epithelium lyin«
in two small branches of the pulmonary artery. The u]i])er embolus
shows apparent organization.
occurred through the blood vessels, for two rea-
sons— an absence of involvement of the coeliac
plexus of nodes and the finding of emboli composed
of masses of squamous epithelium in the blood ves-
sels of the lungs (V\g. 3). The probability is that
the oesophageal veins were effective in disposing of
the cancerous material with the lungs as the pri-
mary seat of deposit. Destruction of pulmonary
tissue by the tumm- process would facilitate its
transmission to the ])ancreas and liver by way of the
arterial system. C'ase \T showed the tuiiKir in the
upper portion of the cesophagus, but no metastases
were noted. Case \TI showed tlu' tunmr in the
thoracic segment of the organ, with metastatic de-
posits in the liver, kidneys, stomach, posterior
mediastinal, bronchial, hepatic, and lumbar glands.
Involvement of the mediastinal and bronchial
glands was naturally direct. The primary tumor
mass had extended to the root of the lungs. In the
stomach it was only in the muscular coats. It seems
mo.st reasonable that in this case dissemination
took place through the vascular .system, with the
root of the lungs as the probable points of entrance
of the cancer tissue into the blood. The involve-
ment of the hepatic and lumbar glands was prob-
ably secondar}' to the involvement of the organs
drained by these glands. Case VHI showed the
cancer in the diaphragmatic segment of the oeso-
phagus, but there were metastases to the posterior
mediastinal glands. It is evident that the tumor
area was drained by the thoracic lymphatics. In
Case IX the location of the cancer was not indi-
cated upon the record. Metastatic deposits were
found in the stomach and are explain.able possibly
by continuitv of structure. Case X showed the
tumor in the thoracic portii 'U of the (esii|)hagus and
secondary growths fnund in the stomach,
pancreas, and l)r(inchi;il L;laiiil-. The presence of the
gastric tumor may Ih' explained as before, while the
tumor of the i)ancrt_;is nrDljaljly developed by con-
tiguity of structure directl}' from the stomach. Cn-
(jucstionably the ])osterior mediastinal glands were
affected to allow extension to the brDucliial glands.
The coiiditidiis liercin brought forth ajjpear suffi-
cient to warrant the statement that the secondary
tumors (levclii])c(l mA only through the channels of
the ]\ni]>liatic system, but also through the blood
\asciilar system. It seems jxissible that metastasis
'iiay also take place over muc(jus surfaces.
In the consideration of the ])reseiU -eries of car-
imimata relative to the frecpiency of the same, the
'■^ulls sIkwv that of 1,720 deaths, eight were asso-
lated with the i es(.iphageal tumor or a frequenc\"
of 0.46 per cent. These embrace the autopsy
records from 1897 IQO/- During this period all
records were filed, and the ])ercentage therefore is
an accurate one. .\nother point revealed is the
preponderance of the squamous celled tumor over
I'lG. 4. — Showing kidney witii very small "epithelial nests" with
two "pearls."
that of the columnar celled type. Vnit one case of
the latter type of tumor was found during the pe-
riod. There is a presumption that the tumor of the
cEsophagus with "epithelial pearls" does not metas-
tasize as frequently as does that without "pearls."
Probably the same condition is true in this instance
as applies to the reason why columnar celled can-
cers metastasize with greater facility than do .squa-
BALL IS
ADLSOll).^
mous celled carreers. A restmblance of the cells
of the basal cellular type to those of the columnar
celled type of tumor is assumed, so that the spinal
cellular type (with "pearls") would appear to be of
all malignant epithelial tumors the least likely to
metastasize. Probably the shape of the cells and a
difficulty in adapting themselves to the lumina of the
smaller radicles of the lymph and blood vascular
s\stems render dissemination more difficult. The
development of secondary tumors appears not un-
usual in squamous celled cancers of the oesophagus.
Referexces.
1. Sajous. Annual and Analytic Encyclopedia for
Practical Medicine.
2. Zenker and von Ziemssen. Cyclopaedia of the Prac-
tice of Medicine. English Translation, viii. 1878; and
Tzucntieth Century Practice of Medicine.
3. Bland-Sutton. Tumors, Innocent, and MaUgna)it,
Fourth Edition, pp. 340 to 342.
4. Quoted by Coplin. Manual of Pathology, p. 694.
5. .\llbutt- Sytsciii. iv, p. 374.
6. Burnet. Stricture of (lEsophagus (Carcinomatous)
with Ulceration and Perforation; Posterior Mediastinal
Abscess Opening into Right Lung and Communicating
with Bronchi : Carcinoma of Stomach, Transactions of the
Pathological Society of London, xxxiii, p. 191. 1881-2.
7. Butlin. Medicochirurgical Transactions. 1893. p.
269.
8. Wright. Primary Cancer of the CEsophagus and
Lower Pharynx : A Stati'^tical Study Rased on the Records
of the Middlesex Hospital. Archizxs of the Middlesc.v Hos-
pital, vii, pp. 143 to 150. London. 1906.
9. Scott. A Case of Cancer of the Oesophagus Simulat-
ing Thoracic Aneurx sm ; i'niz'crsity of Pennsylvania Medi-
cal Bulletin, xvii, pp. 331 [o 335. 1904-5.
10. Eskridge. Carcinoma of Lower End of CEsophagus
and of Mediastinum, the Latter Involving the Heart and
Great Vessels. Philadelphia Medical Times, xii, pp. J4 to
46. 1881.
11. Gillies. Cancer Statistics. Lancet. 1886. i. p. 309.
12. Moak. Cancer Statistics in the 12th Census of the
V. S. American Medicine, v. p. 340. 1903.
1 1 1 1 Spruce Street.
SOME OBSERVATIONS OX THE REMOVAL OF
ADENOIDS.
Bv Mii.Tox J. B.xi.LiN. M. D..
New York.
It ma\ seem superfluous to again bring up a sub-
ject which has so often been the field of discussion.
The writer s apology- for doing so, however, lies
mainly in the fact that one reads of so many vari-
ous methods employed, and sees such a vast number
of implements devised, that he does not consider it
amiss to express his views as to which he regards
the instrument most useful for this purpose, and the
method which yields the best results.
The frequency of adenoid vegetations in children
has of late years, since the publication of W.
Meyer's paper on adenoids in the Archives of
Otology, II, become a moment of importance to the
paediatrist, as well as to the rhinologist, so that the
physician is often confronted with the question
whether it is advisable to have them removed. If
one considers the vast improvement, both mentally
and physically, observed in children following the
removal of these growths it becomes evident that
an operation of this nature is almost imperative in
the great majority of cases. The frequency of
adenoid vegetations in children is a well established
fact, and it would not be placing the average too
high if we wouKi say that eight out of ten children
show, in one wav or other, .syiuptoms indicating, the
presence of these growths in the nasopharyn.x. .Vs.
a rule it is found that wh.en there is a hypertrophic
condition of the adenoid tissue, the process does not
limit itself ti> thi- area alone, but generally involves
the faucal tiiiisiK well, so that we usually see a
combination of hi.th. It does not always say that
where there is an adenoid growth there are tonsils
present, but, on the other hand, if one sees a large
pair of tonsils one can be quite certain that there are
adenoid growths as well.
That adenoid growths are present at birth cannot
be doubted, for one often meets with infaiits only
several weeks old who display all the signs of the
presence ol these growths. As a rule, however, the
fact that these vegetations are present does not be-
come evident until the child has reached the second
or third year, and then through a gradual t-nlarge-
nient, blocking up more or less completely the pos-
terior nares, the child develops all the well known
symptoms of this affection.
The s\ niptoms which one usually ol)serves in the
children may be attributed mainly to the size and.
position of the growths. For, if they are small,
they may pass unnoticed, and as is well known there
are many persons who have adenoids which have
never given them any trouble. Such small growths
may, however, in the cotirse of time, develop in
size, owing to repeated local irritation, and then
give rise to symptoms of nasal Qbstruction. This
is often the case with adults, who never gave any
signs until later life, and also with children who at
first were apparently free.
The growth itself shows manifold forms, so that
one finds it to be either a small, rotnid protuber-
ance, or a large, oblong growth, nearly filling up
the entire posterior nares. The small growths are.
as a rule. soft, small masses, having a granular a\i-
pearance and situated at dift'erent parts of the
pharynx. These need not give rise to any incon-
venience, so that persons may pass through life
without the knowledge of their presence. They are
usually detected only when making a postrhino-
scopic examination with the mirror. The large
growths, on the other hand, are the ones which gen-
erally draw our attention, as their presence gives
rise to the symptoins so well known, The\- are
generally found to consist of one large, solid mass,
sittiated in the meditmi line of the posterior nares,.
more or less occluding the postnasal space, and ex-
tending high up into the vault. On examination,
such a mass is found to be made up of three lobes,
a central one and two lateral, which are separated
by rather deep clefts (Figs, i, 2, and 3), or the
lobes may be subdivided by numerous clefts, as
shown in Fig. 3. These clefts are often the source
of great annoyance, as they act as the receptacle
for cheesy masses which frequently degenerate and
give rise to the foul odor so often observed in chil-
dren, as well as in adults. Then, again, they harbor
bacteria, which keep up a suppurative process, so
that there is more or less of a constant discharge
of noxiotis material in the posterior nares. This
discharge is expelled, giving rise to a constantly
running nose, which is regarded by the parents as a
permanent cold in the head. Then, again, the se-
2()4
cretion is being repeatedly swallowed by the chil-
dren, as a result of which one often observes vari-
ous gastrointestinal disturbances, lirowths of this
character are usually of a solid nature, and are at-
tached to the posterior phar_\ ngeal w all by a broad
base ; they contain masses of secretion as already
stated, and are often spotted with very small super-
ficial hctmorrhagic areas. On microscopical exami-
nation they are found to contain bacteria, giant cells,
and now and then tubercle bacilli. This tuberculous
condition may, how^ever, be merely local, or it may
be a part of a general tuberculous infection.
The small growths may exist, as before stated,
without giving rise to any s\ mptonis, or may cause
only a slight annoyance, which passes away in the
course of time, and especially after the age of
puberty. The large growths, on the other hand,
are not amenable to treatment, do not pass on with-
out notice, and generally get worse as time ad-
vances. These are the growths which give rise to
the symptoms of nasal oljstruction, with the various
sequelae, Avhich can be eradicated only by their time-
ly operative removal.
The writer does not deem it necessary to go into
Is
Pig. 3.
Adenoids, nalnral size.
Pig. I. — :i. lateral lobe: b, cleft: c, central lobe.
Fig. 2.— a, lateral lobe; b, cleft; c. central lobe.
Fig. 3. — a, lateral lobe; b, central lobe, with multiple clefts.
the symptoms indicative of the presence of adenoids,
as they are generally well understood. Yet he would
like to state that in making the diagnosis it is. as a
rule, not necessary to introduce the finger into the
posterior nares. If a child is brought to the physi-
cian with the history of obstructed nasal respiration,
his first duty is to examine the nose anteriorly to
see whether the obstruction may be due to some for-
eign body, or to some physical defect in the sseptum,
or in turbinateds. If the parts present a normal
appearance, while the posterior phar\ngeal wall
shows an uneven, granular condition, and is covered
with secretion, and there are, in addition, the symp-
toms of nasal obstruction, it is perfectly needless to
introduce the finger, as the diagnosis of adenoids is
;self evident.
[NE.V V0K,<
Mi;oic.\L JouitNAL.
In performing the operation for the removal of
tonsils and adenoids, one must ahvays work with
proper illumination. If possible it is always well
to use an electric head mirror (as, for instance,
the Clar light), having a rather powerful lamp. The
current can be supplied with an ordinary dry celled
battery, w'hich is readily transported from place to
place. If electricity is already installed, one can
use the rheostat made b_\- W'appler, which can be
attached to any electrolier, and thus regulate the
amount of current to be used ; where one has no
current, one should use an ordinary head mirror,
taking the light from a kerosene lamj). The illu-
mination of the field of operation is very important,
as one should never operate without a good light.
Operating at a window with direct light is not good
practice, as one can never see properly ; the operator
works more or less in tlie dark, and can never do
justice to himself or to his patient. In the clinic,
where we perform a large number of adenoid opera-
tions, we use the head mirror, taking the light from
a strong fifty candle electric lamp. The great trou-
ble with beginners is that they fail to keep the light
constantly in the field of operation, thus working in
the dark, and thereby failing in their attempt.
Of the numerous instruments devised, the writer
has found the modified square Beckmann curette by
far the best. It is the only instrument now em-
ployed by the writer for the removal of adenoids, as
it has proved most satisfactory. There are three
sizes, a small, medium, and large. The great va-
riety of instruments, such as forceps, pharynx ton-
sillotomes, and the variously devised curettes, have
not prowd \ery satisfactor\-, and it has been the
writer's experience that the successful removal of
the growths depends not only upon a good technique
of the operation, but also upon the proper selection
of the instrument employed.
The forceps, although used by some, is not a very
commendable instrument for this purpose, as one is
never able to remove all the tissue, ' and one is
botind to leave behind small pieces, which, in the
course of time, give rise to a repetition of the old
symptoms, necessitating a second operation. Then,
again, when using the forceps, one is compelled to
introduce it several times. This has its disad-
vantages, inasmuch as one is liable to bring about
infection more readily, create unnecessary trauma
to the vomer, soft palate, and pharyngeal orifices
of the Eustachian tubes, and, lastly, one is com-
pelled to work in a bloody field, thus obstructing the
field of vision. The old fashioned triangular
curettes of Gottstein, etc., are not very practical, as
their shape does not conform with that of the
growth, which is generally broad and oblong, and
therefore do not answer the purpose as well as
the square curettes mentioned aliove. The various
])liaryngeal tonsillotonics, or guillotines, so highly
recommended by some, do not seem to be in great
favor, although they sometimes do their work well.
They are cumbersome, taking up too much room in
the postnasal space, and do not always remove the
entire mass. Even when one has used a guillotine,
one is sometimes compelled to resort to a curette in
order to remove the small particles left behind.
In selecting the curette, one should always choose
the largest one for that particular case, for by do-
ing so you cover almost the entire posterior wall,
BALLIX. ADEXCWS.
February ,5. iyuS.j BALLIX : ADL.XOID:^. 295
whereby the whole growth comes within the grasp
of the instrument, and one is thereby able to re-
move it entirely in one mass. If the proper sized
curette is used the adenoid always comes away in
one steady downward sweep, thereby avoiding the
necessity of reintroducing the instrument. The
great advantage in removing the growth in one
mass lies, namely, in the fact that we can tell by
its contour whether there is any portion of it still
retained in the posterior nares. If, on removal, the
growth is found to be lacking at any portion we can
be almost certain that this corresponding part has
been left behind, and thus necessitates a second in-
troduction of the curette. Then, again, removal of
the adenoid in one piece is proof that all the tissue
has been taken away and that the pharynx is free.
In cases in which the adenoid is removed piecemeal,
as is the case with the forceps, one can never be
certain that the vault is entirely free, and it is usual-
ly found that so called recurrences generally occur
in cases operated in this manner. This mode of
operating, which is rather prevalent, cannot by any
means be regarded as ideal, and the results are not,
as a rule, satisfactory, as all the tissue cannot be
thoroughly eradicated. A recurrence of adenoids
does not take place. It is a mistake to think that
adenoids once removed grow again, as that is not
the case. What does take place is this : When an
adenoid operation has not been properly and thor-
oughly carried out, small pieces of the growth re-
main in the posterior nares. These, through re-
peated irritation, as catching cold, etc., swell up
and become hypertrophied, thereby giving rise to
the same symptoms as prior to the operation. Ade-
noids, when once removed, do not grow any more
than tonsils when once removed. Another point to
which the writer wishes to refer is that the curette
should always be sharp. Some surgeons are of the
opinion that the cutting edge should not cut, but
rather tear through the growth, thus decreasing the
tendency to haemorrhage. The writer does not be-
lieve this to be the case, as he is of the opinion that
one gets less haemorrhage during the operation and
less liability to secondary bleeding when the adenoid
is cleanly cut through. It is frequently observed
that when the curette does not cut well, and a small
piece of the tissue is allowed to remain behind,
there is more liability to secondary haemorrhage
than when the instrument is sharp.'
It has also been the writer's experience that when
a child is seen a day or two after the operation and
complains of pain in the back of the neck, which is
accompanied by more or less rigidity, he has inva-
riabh- found that a piece of tissue has remained
hanging in the postnasal space. This has become
necrotic, thus being the primary source of infec-
tion and the cause of the entire trouble. When this
is removed and some antiseptic lotion sprayed in
the nose and throat for a day or so, the stiffness,
foul breath, and pain disappeared.
The manner in which the curette is held is also
of importance. It has been the writer's practice to
'When secondary haemorrhage does occur, it is not advisable to
pack the posterior nares. as the pacljing is very disagreeable to the
patient, and may set up a secondary infection with all the unpleasant
sequalse. It is a better plan in these cases to reintroduce the cu-
rette, thus clearing away any particles of tisue which have been al-
lowed to remain, and in this way bring about a cessation of the
hemorrhage.
hold the curette as shown in Fig. 4. For, if held in
this way, we get the greatest amount of force neces-
Fic. 4.
sary, and, as experience has shown, quite some force
is required to cut through a large sized dense ade-
noid, especially if operating on older children and
adults. The action in using the curette lies mainly
in the wrist, as it is not necessary to put the entire
arm into play. Another way in which the curette
may be held is shown in Fig. 5. This does not al-
=
Fig. 5.
low US to exercise as much control over the instru-
ment as when held as stated before, but, neverthe-
less, answers the purpose well in some cases. The
writer uses this method, however, when he does not
wish to exercise too much force, as, for instance,
when operating on very young children and infants.
The advisability of employing a general anaes-
thetic depends greatly upon the case at hand. As
a rule, it is more advantageous to give a slight nar-
cosis, especially in children of more advanced years,
as one is able to operate more freely and more thor-
oughly. Older children are often very restless, and
resist, so that the carrying out of the operation
thoroughly without an anaesthetic is often utterly
impossible, as they cannot be properly held. Small
children, on the other hand, can be well held and
ofter little resistance, so that the removal of the
adenoids is readily accomplished, and. as a rule, re-
quires no narcosis. The giving of an anaesthetic is
not free from dangers, so that the writer is inclined
to do without it whenever possible. The danger
lies not only in the administration of the auc'esthetic
itself, but mainly in the fear that particles of the re-
moved tissue and blood may be inspired. In dis-
pensary practice, where one is called upon to per-
form a large number of adenoid removals, it is im-
possible to resort to a general narcosis, as the time
is too limited. In private practice, on the other
hand, one has to give an anaesthetic, as the parents
in the great majority of cases demand one. As to
the choice of the anaesthetic to be used, the writer
generally leaves that to the discretion of the anaes-
thetist, as it is usually found that one can do the
most satisfactory work with that anaesthetic with
which one is most accustomed. Personally, the
writer prefers chloroform or ether, preferably the
former. Nitrous oxide and ethyl chloride answer
very- well, and may be used instead of the former
two. if desired. That the operation is accompanied
by a certain amount of shock is certain : yet. in spite
of the shock, the writer prefers to perform the op-
eration without a general narcosis if possible, as
the sequelae of the shock are less to be feared than
296
BALLIN: ADENOIDS.
I New York
Medical Journal.
the anjEsthetic itself, and this is especially so in very
young- children, with a lymphatic diathesis.
The operation when performed without a general
anaesthetic is caried out as follows :
The operation is carried out in the sitting posi-
tion. The child is taken on the lap of a competent
assistant, who holds its legs tightly between his,
grasps the two hands with one hand, while he
steadies the head firmly with the other hand against
his chest. The patient must be well held, as a well
trained assistant will greatly facilitate the work
of the operator and the successful issue of the
operation. Having the child thus in position the
surgeon seats himself before the patient. A strong
ray of light, as already referred to, is now thrown
ui)on the field of operation, and a mouth gag is then
introduced, which is held firmly in position by the
nurse. The gag which the writer has found most
serviceable is that of O'Dwyer, but when operating
without the aid of a second assistant the selfretain-
ing mouth gag of W'hitehead has proved of great-
est service.
The writer never uses a tongue depressor, as he
deems it only cumbersome and entirely unnecessary,
but finds that the index finger of the free hand is
amply sufficient. A Beckmann curette, the largest
for that particular pharynx, is now selected. This
is grasped as shown in Kig. 4 and introduced side-
wavs into the mouth (Feb. 6) until it has reached
Fig. 6.
behind the soft palate. Here it is turned upright, so
that it comes in contact with the posterior surface
of the soft palate. Our next step is to pull the
palate well forward, directing the curette upward
at the same time, and keeping it directly in the
median line of the postnasal space. This pulling the
palate forward is a very important factor in the op-
eration, as the success of removing the entire
growth depends greatly upon this manoeuvre, espe-
cially in cases in which the growth is very large and
almost fills up the entire posterior nares. Now, if,
in such a case, you introduce the curette, direct it
upward in the median line, and then make one firm
downward stroke, but have neglected to carry out
this important step, you only remove part of the
adenoid, leaving the uj)per portion in situ. This is
due to the fact that you do not get yoiu" curette over
and above the growth, and thereby do not get the
entire mass within the range of the cutting edge of
the instrument. The upper part of the growth is
thereby left behind, which is often the cause of trou-
ble later on, and gives rise to the symptoms of a so
called recurrence. In other words, the entire mass
has not been removed. If, on the other hand, one
follows the suggestion of first pulling the uvula well
forward, one creates more room for the instrument,
and then by directing it upward, always in the me-
dian line, one brings the cutting edge over and above
the growth, so that the entire mass comes within
the reach of the curette. Having followed this pre-
caution you now make one ' steady, downw^ard
sweep, thereby cutting the entire mass from its
base. As the instrument descends you meet it with
index finger of the free hand, whereupon the growth
and instrument are both withdrawn from the mouth.
If these steps are closely followed, the adenoid al-
ways comes away in one solid mass. (Figs. i. 2,
,V ) This is now examined in order to see whether
it is complete, for if not, and part is missing, we can
be certain that that missing part is still in place and
must be removed. If. however, on examination the
growth is found to be symmetrical and complete,
we can be certain that there is no more adenoid tis-
sue retained. In this instance, it is not necessary
to introduce the finger into the postnasal space ; if,
on the other hand, we find that a part of the growth
is lacking, we can introduce the finger to ascertain
its exact location.
The haemorrhage which generally follows the re-
moval of an adenoid en masse is not very copious
as a rule, and ceases within a few minutes. We
then mspect the pharynx again to see that there are
no small pieces hanging down. If a piece is pend-
ing, it should be removed. This is best accom-
plished by grasping it with forceps and cutting it
ofl:' with a pair of curved scissors. It should never
be taken hold of and torn ofif, as one can readily
tear the mucous membrane on the postpharyngeal
wall for several inches. This should be avoided, as
it causes unnecessary after pain and trauma. In-
spection, after operation, should always be carefully
carried out, as one should never allow small pieces
to remain hanging loose. They often give rise to
unpleasant retching, nausea, and vomiting, and,
besides, are usually the cause of secondary haemor-
rhages. Then, again, they undergo putrefaction ;
this often gives rise to the foul odor which is en-
countered after an adenoid operation, and to the
headache, general malaise, and rise of temperature.
The otitis media which now and then follows the
removal of adenoids may be attributed to this de-
composition, inasmuch as the infection spreads
along the Eustachian tubes into the middle ear.
As the writer has already mentioned, when-
ever one meets with rigidity and pain in the back of
the neck after the operation, one is rather sure to
find a piece of necrotic tissue pending in the post-
nasal space; this having become broken down, ab-
sorption takes place through the lymphatics, so that
we have an enlargement of the glands in the neck
with this accompaniment.
It can, therefore, be seen that it is of the great-
est importance that the postnasal space be thorough-
ly cleaned out, and that no small pieces of the
growth are allowed to remain in situ, for these are
usually the disturbing factors which give rise to the
various sequelre detailed above. As soon as these
pending infectious masses are removed, either with
forceps or by introducing the curette again, and an
antiseptic spray is used in the nose and throat, the
source of infection is cleared up and the unpleasant
after effects pass away in a day or so.
(^ne more point to wdiich the writer wisiies final-
ly to refer is. namely, the obstruction which one
often encounters during the operation when making
February 15, 1908.]
( OLLIXS : PSYCHASTHEXIA .
297
the dowmvard stroke. It often happens tliat the
curette is impeded as it cuts through the growth
owing to the marked prominence of the body of the
atlas. This is particularly so in cases in which the
posterior nares is rather narrow, owing to a slight
bulging of the spinal column at that point. In such
a case, even after the removal of the growth, the
results are not always satisfactor>-, as the postnasal
space is still too small to allow proper nasal respira-
tion. If, therefore, one introduces the finger into
the posterior nares and finds a very narrow space
owing to this prominence of the atlas, one must be
guarded as to the outcome of the operation, as the
-liildren often breathe no better after than before
removal of the growths.
If, during the operation, one encounters this im-
j)edin-.ent. it is well to lessen the force used, slightly
i)ulling the instrument forward and continuing the
downward stroke, whereupon the cutting edge of
the instrument glides readily over the obstructing
area.
Conclusions.
To reiterate briefly we find :
( I ) That the operation can be easily performed
without any an?esthetic. taking from one to three
minutes.
(2^ That the growth comes away cn masse, thus
leaving no rests behind which are later the source of
so called recurrences.
(3) That by examining the growth we can ascer
tain if a portion of it is still retained, and its loca-
tion; and in addition we can show the mass to the
parents, thus demonstrating the cause of the im-
paired nasal respiration and pointing out the neces-
sity of operation.
(4) That complete removal leaves no rests be-
hind, which later swell up and become hypertio-
phied. thereby bringing about symptoms similar to
those prior to the operation, or so called recur-
rences.
(5) That by carefully examining the pharynx
immediately after operation we remove pending
pieces which would otherwise become infected, and
lastly.
(6") That these pending pieces of tissue are gen-
erally the cause of postoperative haemorrhages, and
through their breaking down and becoming in-
fected give rise to a secondary suppurating otitis
media, with all its sequels, to the rigidity of the
neck, enlargement of the glands in the neck, nausea,
vomiting, general malaise, and a rise in the tem-
perature.
The operation, as the writer has endeavored tu
detail, has been in vogue for some years abroad,
and he acquired it while working in Hajek's Clinic
in Menna. Being convinced of its thoroughness he
has used it exclusively in all cases of adenoid re-
moval. It is a method which can be readily ac-
(|uired by any one, with a little practice, and will
always yield the best results.
If the removal of adenoids is performed as here
given, it is almost certain that the results will prove
most satisfactor>- and so called recurrences will be
seldom heard of.
57 E.AST Fifty-eighth Street.
PSVCH.\STHEXIA.
Reworks on the I'rcf'riety of Considering It an Individual
Disease.
(First Article.)
By Joseph Collins. M. D..
New York,
Professor of Nervous and Mental Uiseases at the New Vork Post-
graduate Medical School : Attending Physician to the Ciiy
Hospital; Neurologist to the Montefiore Home; Consulting
Neurologist to the Hospital for Ruptured and Cri|>pled,
and the Manhattan State Hospital.
Within the past few years a new word, psychas-
thcnia, has taken its place in medical literature. Dr.
Janet, of Paris, suggested it as the name for a dis-
order characterized by mental, emotional, and phys-
ical symptoms made up principally of obsessions or
imperative concepts, fears, doubts, anguish, uncon-
trollable movement, enfeebled will power, and some
or all of the customary physical symptoms of neuras-
thenia. These symptoms and their associated oc-
currences have long been familiar to pli\ ~icians.
They have been interpreted usually as integral parts
of such diseases as hysteria, hypochondria, neuras-
thenia, and some ill defined insanities of adolescence.
Janet's proposition that they constitute an autono-
mous, constitutional disorder, such as epilepsy and
hysteria, has been favorably received by physicians
concerned with the study and interpretation of ner-
vous and mental disorders. It might be gathered from
reading medical literature, however, that psvchas-
thenia and neurasthenia are one and the same dis-
order, as these terms are apparently used synony-
mously by some writers. This is an unfortunate
occurrence, for, in reality, the two conditions are as
unlike as hysteria and epilepsy. The fact that the
occurrence of neurasthenia is apparently on the wane
and that of psychastheniaon the increase has led more
or less unconsciously to the conclusion on the part
of some that they are the same disorder, to which it
has become the fashion to give a new name.
The reason why neurasthenia is on the wane is not
difficult to explain. In the first place, during the twen-
ty-five years that followed its recognition as a well
defined clinical disorder, the disturbances of function
of various organs or sets of organs, such as the di-
gestive tract, the genitourinary system, the circu-
latory system, etc.. have been carefully studied, and
in some instances the manifestations of their func-
tional inadequacy have been raised to the dignity- of
a disease, which stands in direct relationship to the
symptom complex to which the name neurasthenia
is given. In other words, many of the cases which
but a short time ago were labeled as neurasthenia
are now diagnosticated as disorders of the digestive
s_\-5tem, of the vascular s} stem, of the genitourinary
system, of the mind, etc. For instance, in my clinic
the diagnosis of neurasthenia was made and reported
about 390 times in 1899, whereas in the year 1907
it was recorded only 82 times. During this time the
diagnosis of dementia pnecox. psychasthenia, arte-
riosclerosis, gastrointestinal neurosis, of metabolic
disorder, conditioned originally by disturbance of
the gastrointestinal functions, disseminated sclero-
sis, and general paresis, has been made propor-
tionally oftener. Although the pendulum may be
inclined to swing too far in the opposite direction —
i. e., to the minimizing of neurasthenia — we must
nevertheless admit that it is indicative of progress
298
COLLINS: PSYCHASTHENIA.
[New York
Medical Jou3n\l.
in the realm o£ diagnosis to refuse admission to this
category early or atypical varieties of the above
this category early or atypical varieties of the above
mentioned diseases.
Of these diseases psychasthenia is perhaps the
most important, not so much because of its fre-
quency, for in its fully developed form it is not of
common occurrence, but because of the occurrence
of "allied forms," to use a designation to which the
modern physchiatrist is devoted, of which there are
many. It would be very unfortunate if the belief that
neurasthenia and psychasthenia are the same disor-
der should become accepted. Psychasthenia is quite
different from neurasthenia, although it may be an
important factor in contributing to neurasthenia.
Psychasthenia is a constitutional psychoneurosis that
has its origin in a neuropathic constitution, which
is inherited, not acquired.
A better idea of ])sychasthenia. as it displays it-
self, may be gathered from a typical case than from
any description, which must necessarily be a com-
posite picture. I'he most complete and typical case
that I have ever seen is the following:
A single lady, then thirty-two years of age, consulted me
in 1901. Her family history, or as much as she knew of it,
was interesting and important. She was the daughter of
Irish immigrants of more than average intelligence. The
father's distinguishing cliaracterstics were industry and
peuur}-. He had held a position of some trust for
many years and he saved a considerable amount of money.
Saving money was his passion. Aside from going to work
six times a week and going to church once a week he had
never been known to have any other interest. If he had
ever had much family feeHng there had been no display of
it after matrimony had ceased to be a novelty. He had
every distinguishing feature of the miser, and this makes
the enumeration of them here superfluous. He had some
virtues, but they paled "in comparison with his limita-
tions, and were forgotten and entirely obscured in the at-
mosphere of his ruling passion. The mother was an in-
telligent, kindly, sympathetic, moderately emotional, gentle
woman, who succumbed to diabetes when sixty-six years
old. The parents had h:ifl sc^-en children, four of whom
died in infancy. My patient was the eldest of those that
lived. The second, a sister, a most competent, intelligent,
well balanced young woman is a successful \\age earner.
The third, a young man, is what may be called a dilet-
tante, using that word in Goethe's sense to describe a man
who is always venturing on tasks for which he is not ade-
quately equipped. He studied law and was admitted to the
bar, but was unable to hold a position in a law office. He
undertook mercantile life and was unsatisfactory to his em-
ployers. He espoused a political career, but the organization
with w hich he associated himself soon dropped him. He then
became a follower of Henry George and a student of
philosophy, but he abandoned both interests after a year or
more devotion to them. He was convinced that he had
histrionic talents, but on accoimt of being thoroughly unap-
preciated, misunderstood, and out of harmony with his
environment and his people, he fmally made his displeasure
and inadequate appreciation manifest by taking to a wan-
dering life, and since a considerable time nothing has been
heard of him.
My patient had, when she was twenty-four years old,
symptoms somewhat similar to those for whicli con-
sulted me, but they lasted only a short time. '\ hv\ will be
mentioned later. In order to give a faithful preseniaiion of
her history I shall state it in her own words, the sequence
of occurrence of the symptoms being practically as related.
"About a year ago I seemed to go to pieces. Whenever
I attempted to do anything, such as housework, shopping,
theatres, and the like, I would get used up very quickly, and
the resulting fatigue was so great that I could scarcely sit
up. My hands and. arms, especially the left, would get
numb and powerless after doing any work such as doing
my hair, sweeping, writing, etc. In other words, my grip
would relax on things that I bad in my liand without my
knowing it. With such fatigue there is oftentimes pain in
the back of the neck, specks before eyes, and rings on look-
ing into a bright light. Objects would take on a far away
appearance and everything would lose its proportion. At
times a queer sensation would come on as if I were in a
new sphere. Another evidence of this weakness was that
frequently 1 let things drop that I was holding. Then I
have a great deal of trembling of my hands and occasionally
also of my legs, and I have had twitching of the eyelids
and of the lips and of different parts of the body, particu-
larly after exciteinent or after exertion such as walking and
hurrying. I have a prickling, tingling, stinging setisation in
the head which is sometimes accompanied by throbbing.
At times, after or without exertion, I break into a perspira-
tion."
In addition to the symptoms of this kind, all of which
had somatic reference, .she had peculiar emotional sytnp-
toms. She had days in which she felt restless, discontented,
anxious, without attributable cause. She felt as if she
would like to destroy things, a peculiar feeling which she
was unable to put into words. When she was asked to at-
tempt to do it she said, "It's a feeling as if I wanted to
fly, which I have all through me." She was not emotional
in the ordinary sense of the term, and she has the appear-
ance of being rather a phlegmatic person with more than
the average amount of mental and emotional equanimity.
Nor at this tiine were mental and emotional symptoms
at all conspicuous compared w ith the purely somatic symp-
toms.
In response to the ordinary treatment for the neuras-
thenic state, particularly tonic baths, massage, high fre
quency electrical currents, superalimentation, etc., she re-
covered and remained well until the summer of 1903, when
some of the symptoms returned, and with them a number
of others which had not existed before, or, if they had.
only in a very rudimentary form. She described these as
follow s : "I was at a summer watering place stopping at a
hotel, and one day, just before luncheon, it suddenly popped
into my mind that I could not go into the dining room.
Just why I do not know, but I finally succeeded in persuad-
ing myself to go in, but soon I became so excited and w orked
up tliat I had to jump up and almost rush into the open
air. It was not that I felt the need of air. It was a mix-
ture of fright, excitement, dread, and anticipation, which
disappeared, or at least, abated as soon as I got out."
The only somatic ■ symptom that she had at this tinn.
was pain in the back of tlie head. After a while the domi-
nant idea, viz., that she could not go in the dining room
disappeared, but later other and far more distressing one.;
took possession of her mind, particularly ideas of homicide
Suddenly the thought would flash into her mind : How
easy it would be to kill this or that person. For instance,
she was sitting one evening reading, her sister on the other
side of the table, when, without antecedent thought or
motive she looked up at her sister, and like a flash the
thought came to her how easily she could kill her now h\
just thrusting the sharp end of the scissors into her neck
Again, at night after she had gone to bed, she was seized
with the same thought. It frightened her and made hei
distrust herself, and filled her with a violent feeling to-
wards herself, and although she knew she would not do it,
nevertheless, she felt compelled to get up and go into the
next room that she might not be on the spot pro-
viding an all powerful impulse to slay came to her. More-
over, it distressed her terribly that she should be compelled
to give tenancy to such thoughts. They were so terrifying
that they made her afraid of herself and they were so loath-
some that she despised herself for having them.
A few days ago she received a letter from a friend
who had spent some time with her, and who suggested
that, being on the way to New York, she would visit her
The first conscious thought on reading the letter was.
"How easy it would be to kill her when she comes here","
and for a long time this thought would boimd into her
consciousness without apparent relevancy. Another came
while she was sitting in the park one day. Two boys
of ten or twelve years passed her, and like a flash the
thought came into her mind, "It would be so easy to
kill those boys." The thought was not associated with such
concomitant as to whether or not she might be found out
in her guilt and punished. She was sure that the sentient
associated feeling was one of shame and humiliation. Slu
did admit, however, that in discussing the matter with
herself she thought that possibly she and her sister would
COLLINS : PSYCHAST HEX Li.
299
be quite as well off if they were dead. , Other incontroUable
thoughts that she had were of jumping into the subway,
jumping from the elevated railway, jumping into river, cut-
ting her throat while taking a bath, killing some member of
her family, and suggestions of the "most immoral acts" one
could commit. She might be walking in the street or in
a shop and passing a man, instantly a thought of the "most
awful" nature would pop into her mind, and on occasions
it would be associated with the impulse to say bad words,
but the latter she had been able to keep from saying aloud,
but they came articulately into her mind. It distressed her
terribly that often these thoughts were associated with the
most disgusting looking men, tramps, Italian laborers, etc.
Another was an iriipulse when in church to cry out and
re\ile things always considered sacred, or to get up in
church and swear and blaspheme at some special move-
ment, such as as the elevation of the Host.
So far as could be seen she seemed to be in excellent
physical health : she had no indications of insanity, and
she was concerned quite like a normal person would be
about the dominant thoughts that took possession of her,
and fastening upon her mind crushed out every capacity
for thought save the disgusting and debasing suggestions
\\hich they caused.
She did not have them continually, but she could not
tell when they were going to come nor how long they were
going to sta^-. When she was tired they were more
insistent and dominant. For weeks they would be very
aggravating and then a respite from them would follow.
At other times such impulses were momentary. They
would shoot across her mind like lightning across the
sky and leave no trace. She was not so terror stricken
of them as she was formerly because she had seen that she
did not conform her conduct to them and no one save her
sister whom she told knew of them. After about three
years she began to have other symptoms, particularly a
sensation when sitting as if she were falling off the chair
to the left. This was particularly so wlien she was sitting
at a table, in church, or on a bench in the park. When she
sat in the middle of the seat she felt as if she were going
to fall over because she had no support. This reminded
her of the symptoms she had had a number of years (ten)
ago. Symptoms similar to this and a sensation of strange-
ness, of unreality, used to come over her. It seemed to
her then as though she must have lost consciousness for
there would be a gap in time for which she could not account.
.\t other times she would not get all the dictation that
she was taking, but no one noticed that there was any-
thing peculiar about her. That is, she did not faint nor
seem to become confused. She felt as if some one other
than herself was taking the dictation instead, .After a long
vacation these symptoms disappeared.
Now she has them again and with them sensations of
being in a different world where things have a semblance
of familiarity enly. This sensation seems to last a long
time, but in reality it is very brief. She gets tired some-
times after walking two blocks, and so prostrated that she
feels irritable and tearful. At another time she could walk
a mile without any trouble. She had had one spell of
high temper following a sudden fatigue. She is quite
positive that she is more able to bear the distressing
thougiits and dominant ideas and that she has them less
dominaiitly if she eats often and a great deal. If she
skips a meal (ir takes a small quantity of food she is
sure to feel worse. The consequence of this was that she
had de\eloped a ravenous appetite. She had often noticed
that after menstruation she was weak and she was apt to
have more of these obsessive ideas then. Examination of
the uterine organs showed them to be normal in size and
position. She complained of pain in lower part of abdo-
men when she rested on her abdomen, or when she bent
over without corsets. She was much larger around the
abdomen and hips than she had been. She sometimes
had to pass urine four to five times an hour, and even then
the sensation of desire to urinate was not relieved. She
had noted latterly that statues, and pictures, as well as man
suggested sexual intercourse, especially if she was tired
or m.enstruating. Obsessions of homicide were also very
dotninant at such times.
Later new symptoms, such as twitching of the head, arms,
and legs developed. Perhaps "tw itching" does not describe
the movement she says; it is just a sudden movement of
one part of the body or another. Twitching of her
entire body was often the lasi thing remembered before
falling asleep. Flushing of the face with throb-
bing of the heart and throbbing in the abdomen, especially
when resting, were of frequent occurrence. After meals
she felt similar throbbing and also after exercise. Fear of
falling when going downstairs and when standing and not
having something to lean against was also most distressing
She felt as though she would fall from chair when sitting
at meals. She must have a footstool to brace and steady
herself and must lean on table for support. Objectively
there was no evidence of the slightest insecurity. At the
conclusion of a meal she felt much stronger.
Recently she had the sensation of falling from a chair
and thought that she had lost consciousness or fallen
asleep, for her surroundings seem unfamiliar. She could
not describe them, but like a place which she had seen and
forgotten. After walking a few blocks she felt like falling
and had pain in back and head.
After this she had a long period of respite from the
worst symptoms. Then she sprained her ankle. After she
recovered she began to have weak feelings, a sensation of
falling over to left. If this was very pronounced she had
at the same time numbness in the left arm lasting a few
minutes. All this summer she had marked flushing of face,
more or less constant, and when this was very marked she
felt very excited. Often this came in a sort of an attack.
The patient's intelligence doesn't call for particular com-
ment. She discusses her infirmities with nearly as much
impersonality as if they were those of another. She is
terribly chagrined and distressed at the character of many
of her symptoms, which, however, she discussed with no
one save with her physician, and she made the most com-
mendable efforts to get rid of them. She has no dementia
in the customary sense of the word, though there is un-
questionably enfeeblement of some of the mental processes.
Her capacity for verbal association and her reaction time
are about those of a woman of average intellect. She, how-
ever, has great difficulty in accomplishing things that re-
quire long or close mental effort. And she has lost her
skill as a stenographer.
When we review her symptoms we see that
they practically fall tinder three heads : Obses-
sions, peculiar movements, which she calls uncon-
trollable, twitchings of dif¥erent parts of her
body, agonizing emotions and manifestations of
psychological insufificiency, sentiinents of unreal-
ity, of somatic strangeness, and of depersona-
tion, and finally diminution of will power. The ob-
sessions are involuntary, automatic, and irresistible.
They come into her mind without the slightest warn-
ing and take possession of it. The only relation be-
tween their occurrence and any outside factor is
what has been noted in regard to fatigue. The pa-
tient makes her best effort to prevent them or to cir-
cumvent their dominant operation, but she accom-
plishes little in this direction. She realizes how
strange and morbid the obsession is and how con-
trary to her nature and thought the obsessive ideas
are, and she is able to discuss them in an impersonal
way, but this has no effect upon the tenaciousness of
the obsession, nor can she shut it out b\- effort of
will.
The various tmcontrollable twitching movements,
which are to be interpreted as manifestations of
psychological operation upon the motor areas of the
brain despite the action of the will, seem also to
occur much more severely and extensive!}- when
she is fatigued or when anything has occurred to
lower physical or mental vitality.
Manifestations of psychological insufificiency,
which were the first to develop in this young wo-
inan's case, disappeared for a number of years be-
fore the disorder itself seemed to have fastened upon
300
BliOTHlUiS: PUERPERAL FEJ'ERS.
[Ne'.v Voek
MeDICM- JoURNAt.
her. Later they became the most distressing phe-
nomena of the disease. It is to be noted that in this
case the patient was not of a hesitating, irresolute,
selfdistrusting person, as many psychasthenics are,
nor was there any very conspicuous inclination to
selfdepreciation. which is common in so many of
them. Her lack of self confidence was displayed only
in the attitude which she took toward her obsessions.
She had done her best to overcome them and had
failed, therefore she could not rely upon herself to
cope with them. She did not have many of the
fears which psychasthenics often have, nor was she
a victim of exaggerated morbid scrupulosity.
The feeling of unreality, of disembodiment of per-
sonality, of swaying and falling, are fairly constant
phenomena of fully developed psychasthenia. And
they may be looked upon as a profound exaggeration
of sensations which many so called normal individu-
als have. The sensation that they have of being in
some new atmosphere, in some strange place, and at
the same time of having been there before, is a fa-
vorite topic of the poet,
"I am aware of other times and lands.
Of birth far back, of lives in many stars,"
and it is also that which the modern literary mystic,
such as Lafcadio Hearn, is constantly thrusting be-
fore us. Only in those instances such sensations are
presumably pleasurable, but in the psychasthenic
they are distressing.
The sensation of insecurity, of swaying, and fall-
ing, is a curious one, and it is possible that it may
be interpreted as the cessation of the reciprocal rela-
tionship existing between the will power and the cen-
tres or areas of equilibration.
The efifect which physical and mental effort had
upon her symptoms has often been noted, and pe-
culiar fatigue is one of the stigmata of the disease.
Janet has distinguished six clinical varieties of psy-
chasthenia : I. The doubter, those in whom obses-
sive ideas are not very precise, more of the nature
of a general mental inclination rather than a specific
idea, such as a craze for research, for explanation,
for computing, etc. 2. The scrupulous, those whose
obsessions are of a moral nature. Their manias are of
literalness, of statement of exact truth, of conjura-
tion, of reparation, of symbols, etc. 3. The crim-
inal, those whose obsessive ideas are of homicide,
theft, and other overt acts. It is generally conceded
that in this variety the impulsive tendency is strong-
er than in any of the others, but nevertheless the
individual rarely responds to the obsession, especial-
ly to what may be called the major one, such as
homicide. 4. The inebriates, dipsomaniacs, mor-
phinomaniacs, etc., in whom the impulse seems to be
least resistible. 5. The genesically perverted. 6.
Delirious psychasthenia. a condition in which a de-
lirious state of the mind concerned with the obses-
sions occurs.
Whether such classification contributes to a bet-
ter understanding of the conception of the disease
and its modes of display, it is quite impossible to
say. But that there are cases that fall rather nar-
rowly into each of these categories must be ad-
mitted. And that there is ample justification for
descril)ing a psychoneurosis of deviates, or on a
degenerative basis there can be little doubt.
37 West Fifty-fourth Street.
THE MANAGEMENT OF FEBRILE CONDITIONS
AFTER ABORTION AND LABOR.*
By Abram Brothers, B. S., M. D.,
New York,
Adjunct Professor of (lyna-cology at the Postgraduate Medical
School; Visiting Gynwcblogist to Beth Israel and York-
ville Hospitals.
If one will take the trouble to look over the files
of the medical journals issued during the past five
or ten years, he will find the literature of the puer-
peral fevers so extensive and ponderous that he will
be apt to quit the attempt in a heavy and confused
frame of mind. No sooner will he have formed an
opinion in one direction than the investigations of a
new set of observers will tend to dispel his convic-
tions in another. Take, for instance, the bacteriol-
ogy of the puerperal uterus. One set of competent
observers, investigating more than 500 cases, tell us
that the uterine discharges are ordinarily sterile in
anywhere from 64 to too per cent, of the cases after
childbirth. On the other hand, another set of equal-
ly competent observers assure us that, in some 250
cases examined, the sterility of the uterine lochia
ranged between o to 36 per cent, of the cases. Per-
haps Little — to whom we are indebted for an excel-
lent resume of the subject — may be right when he
attributes the different results to the circumstance
that the observations were made on different days
of the puerperium. when the percentages of sterilitv
varied accordingly. Similarly, in this period of
time, have we witnessed the rise and explosion of
different highly lauded methods of treatment, in-
cluding the injection of chemicals in the blood and
operative procedures of various kinds. So that we
are tempted to put our reading material to one side
and wearily ask ourselves how much further have
we advanced in the management of the puerperal
fevers, and how much of real importance have we
learned in the past ten or twenty years.
I assume that the aetiology, pathology, and bac-
teriology of the puerperal fevers — as taught these
manv years since the time of Holmes, Semmelweis.
Pasteur, and Lister — are today thoroughly under-
stood by every educated physician. When we are told,
for instance, that fifty years ago the mortality from
childbed fever in the Boston Lying in Hospital aver-
aged from 20 to 30 per cent., and grew to such pro-
portions that the service had to be discontinued for
several years, and that today only one woman in
1,100 dies from the same disease, we have indeed
cause for congratulation. It is agreed that sources
of infection occasionally arise from sources inde-
pendent of the accoucheur. Thus vulvovaginal ab-
scesses, chancres, rectovaginal fi.stul?e, pus tubes, or
gonococci transmitted during sexual intercourse may
each be responsible for puerperal fever in isolated
instances. Still, it is a safe assumption that, in by
far tj^t largest proportion of cases, infection comes
from ("without. Although puerperal mortality has
been, almost reduced to nil in institutional statistics
it k nevertheless a fact that in private practice the
mo'rtality remains about the same as it was twenty
years ago. So long as this is the case there must
be no let up in holding the midwife or physician
•Read at a meeting of the Section in Obstetrics of the .Xcademy
of Medicine, held on December 26. 1907-
Februao' '5. '.90S.]
BROTHERS: PUERPERAL FEVERS.
301
morally responsible until results prove that patients
in their homes are surrounded with the same safe-
guards of asepsis and antisepsis as their sisters in
obstetric institutions.
Further, assuming that the medical attendant is
sufficiently able to recognize febrile conditions due
to complicating or coincident conditions — such as
influenza, pneumonia, bronchitis, tonsillitis, typhoid
fever, appendicitis, cholelithiasis, pyelitis, etc. — we
proceed to the consideration of the febile conditii^ns
directly due to abortion and labor.
A slight digression of a personal nature may be
pardoned at this point. Some twenty odd years ago
I had the privilege of a double maternity service at
Bellevue Hospital, under the late Dr. Wm. T. Lusk.
In those days our methods of preparation of patient,
doctor, and nurse were nearly what thev are to-dav.
To be sure, we used vaginal douches more freelv.
we used chemical solutions instead of boiling for our
instruments, and we used no rubber gloves for the
hands, which were otherwise carefully scrubbed and
treated antiseptically. In every respect scrupulous
cleanliness was observed, and our patients — some of
them delivered to us directly from the cit\-"s gutters
— mostly escaped septic infections. Indeed, our re-
sults were so good that the late Dr. Lusk used to
publicly announce that he would rather deliver a
woman in our maternity ward than in the most ele-
gant surroundings of the rich. My first years of
practice were spent among the dirtiest and poorest
inhabitants of the city. In spite of this I was able,
in 1.500 tenement house deliveries, to record but one
death from septicaemia in a selfdelivered woman
who. without my knowledge, had borrowed an old
syringe from a relative and used it for vaginal in-
jections. Of course, I saw numerous fatal cases in
this time, but they were either midwife cases or
cases delivered by colleagues. Since then my hospi-
tal connections and consultation work have provided
me with liberal opportunities for observing and
studying the puerperal fevers, which are still of
common occurrence in the practice of midwives and
those general practitioners who have not yet prop-
erly mastered the secret of surgical asepsis.
Without attempting to dilate on the details of
prophylaxis and prevention let us now proceed to a
consideration of the management of the puerperal
fevers.
Dr. \V. M. Polk, in the course of a clinical lec-
ture, once remarked that the condition of a woman
after an abortion could be compared to an apple
plucked unripe from the branch. At full term the
delivery of the child and easy separation of the pla-
centa could be similarly compared to the dropping
of the apple to the ground after it had fully ripened.
There is. further, a difference' to my mind between
abortions of spontaneous nature and those induced
artificially ; in the latter variety is sepsis from with-
out more apt to be introduced into the uterine in-
terior.
After spontaneous abortions the retention of pla-
cental tissue, etc., only infrequently gives rise to
fever and seems rather to subject the women to ir-
regrular uterine bleeding. I have known cases in
which retained products of conception were carried
for days, \veeks, or months — in one case seven
months — without producing any febrile disturbance.
On the other hand, the cases of sapra^mia. or even
some of the worst varieties of septicaemia, are met
with in women in whom there has been tampering
with the uterine interior of an artificial or criminal
nature.
Abortion, especially the crim.inal varieties, may
give rise to fevers due to sapraemic toxaemia, bac-
teriacmia, parametric exudates, purulent collections
in the Falloppian tubes or peritoneal cavity (usualh-
in Douglas's cul de sac), occasionally to necrotic or
suppurating fibroids, and to varying grades of peri-
tonitis. Often several of these conditions are com-
bined in the same case.
The treatment of retained tissues after abortion
differs somewhat from that employed after labor at
term. Although the principle of cleaning out the
uterine interior is the same in both, I have always
felt that one could be much more thorough in the
operative manipulations of the uterus after abortion
than after full term. After labor the woman is usu-
ally in a much more exhausted state and must be
handled with the greatest gentleness, for every addi-
tional traumatism is associated with the risks of
fresh infection in an already overtaxed and debili-
tated system. I respect the statement of Gilliam
when he says that "to the puerperal woman the man
with a curette is more to be feared than siiot and
shell on the most sanguinary field of battle." I
shall go a step further, and state that only the clear-
est indications should induce the physician to trans-
fer such a woman from her bed to a table for the
purpose of forcibly dragging down the cervix in
tenacula forceps and introducing the Chamberlain
tube or double current intrauterine metal catheter.
Only too often is the subsequent violent chill and
high rise of temperature attributable to these ma-
noeuvres.
But after abortion conditions seem to me to be
somewhat different, and for twenty years I have not
hesitated to use the curette — a semisharp. large
curette — in cases of retained placenta. In such cases
I prefer to begin with placental forceps, then I re-
move adherent placenta with one or two different
curettes, and wind up with intrauterine irrigation of
normal salt solution. If drainage is used at all only
a narrow strip of gauze is left in the uterine interior.
Of course, if the fever, in abortion cases, follows the
perforation of a i:terus the curette, if used at all.
must be handled with the greatest care. In the
presence of pus tubes, pelvic abscesses, general peri-
tonitis, or bacteriaemia the curette is simply harmful.
When called to a patient suffering from fever
after delivery at term I begin with the examination
of the breasts. An early rise of fever is often due
to this cause, and I have known inflammations of
these organs, even to the extent of abscess forma-
tion, to be overlooked in the attempt to locate a pel-
vic origin for the rise of temperature. The term
"milk fever" may be banished a hundred times from
our books, but to my mind it would be far better to
retain this objectionable designation than to have
women unnecessarily and indiscriminately subjected
to the traumation of an intrauterine douche or a
■'scraping" with the omnipresent curette. It is a
difficult matter to prevent the swing of a pendulum
from going to extremes in either direction in the
teachings of our profession.
302
LiKuTIIURS: PUERPERAL f El' EPS.
fXsu- York
Meoi_-.\l Jouknal.
The puerperal fevers proper arc t()(la>- divided
into two main groups : I, the tox;emias, and, II, the
hacteriaeniias.
In toxccmia there is regularly present in the ute-
rine cavity some portion of the products of concep-
tion, usually placenta, disintegrating clots of blood,
or debris. ^Microorganisms feed on these masses,
and give off toxines which are absorbed in the blood
and cause febrile disturbance. Saprjemia in these
cases is the synonym of the toxaemia due to the pu-
trefactive products of the saprophytic bacteria which
are present in all kinds of decaying material. A
second variety of toxaemia in these cases may result
from the absorption of the products of distinct path-
ogenic bacteria.
In bactcricvmia the bacteria themselves circulate in
the blood and usually include ( i ) phlegmasia alba
dokns ; (2) septicjemia, py.-emia, septicopysemia
(sometimes gonococcus absorption) : (3) the peri-
tonitic .types of sepsis. The last varieties, in a sub-
acute form, seen! to owe their origin sometimes to a
toxsemic state, and occasionally include some of the
gonococcus types of puerperal infection ( Wm. S.
Stone).
For practical purposes I beg to submit the clin-
ical classification into four groups which has guided
me these twenty years in the management of the
puerperal fevers.
Group I. Fever dtie to retention of infected
placental debris or blood clots. Between the third
and sixth days post partum these patients usually
manifest their first symptoms with chills and a rise
of temperature. There may be little or no pain, but
the fluor has a decided odor if the canal o^ the
uterus is not prevented from discharging it by a
flexion of the corpus uteri on itself. I pass bv, as
familiar to you all, the associated headache, malaise,
restlessness, backache, or occasional delirium. The
uterus is large, and the exploring finger introduced
gently into the uterine interior recognizes placenta
or blood clot. If the discharges from a little
placental debris are simply pent up because of a
flexed uterus, a simple irrigation after straightening
the uterine canal may be sviflicient. Ordinarily it
will be sufficient to sweep out with the finger or
placental forceps the retained clots or mass of pla-
centa, or even the large, blunt curette may be called
for in some cases, when an intrauterine irrigation
with normal saline solution w ill complete the opera-
tion. I have regularly administered ergot to keep
up uterine contraction. The use of alcohol, as
recommended by Carosso and 111 in this class of
cases, I have no experience with. If the fever does
not drop in a reasonable period of time after this
method of procedure it is usually because one of
two conditions is present — local pelvic inflammation
or bacterisemia.
(jroup II. Fever due to pcli'ic indanunation. These
cases may be associated with or follow the first
group. If present with retained placental debris,
unless the emptying of the uterine contents is done
with the greatest gentleness, the inflammatory pro-
cesses will naturally be aggravated. Hence the
presence of pelvic inflammation is ordinarily a con-
traindication to intrauterine irrigation or curettage
unless in the most exceptional instances and then
only in the hands of experts. The pelvic inflamma-
tions ma\- be in the form of salpingitis, oophoritis,
pelveoperitonitis, or parametritis. Whether these
hiflammations arise from backward continuity of
inflammatory processes or from lymphatic or blood
absorption does not enter into the province of a
practical paper like this. Suffice it to say that they
may all end in spontaneous absorption, but occa-
sionally suppuration supervenes. Long continued
cases of fever after childbirth belong usually to this
group. I have not been able to convince myself
that the usually low grade fever with correspond-
ingly slow pulse rate follows any particular type.
Chills are infrequent or mild, and the facial expres-
sion flushed and hopeful. The addition of localized
pain somewhere about the uterus and the finding
of an exudate or mass to the front, to the back, or
to either side of the uterus usually makes the diag-
nosis very easy. As a rule, these patients recover
under local abdominal refrigeration, prolonged rest
in bed, and hot vaginal douches given at short in-
tervals. In fact, I believe that most cases would get
well if kept simply in bed. The use of the silver
ointments or blisters in the region above Poupart's
ligament and the pubes can certainly do no harm.
It is well to examine the blood in protracted cases,
for I have found pus in a number of cases in which
the fever had apparently dropped to the normal, but
the exudate would not disappear. In such cases
the presence of an increased leucocytosis ranging
between 10 and 20 thousand and a polynuclear
count exceeding 75 to 80 per cent, would induce
me to advise operative intervention with the pros-
pect of finding a pus focus. Of course the clin-
ical manifestation of repeated rigors and marked
fluctuations of temperature, with profuse sweating
associated with a pelvic mass, would lead us to the
same diagnosis and treatment. Where it is possi-
ble to wait for "pointing," this is the best course
to pursue, for then an incision into the fluctuating
tumor in the vaginal roof or over Poupart's liga-
ment ordinarily allows of the easy escape of pus
and the cure of the patient. In one case, however.
I found the abscess dissecting its way upward be-
neath the peritonaeum covering the psoas muscle.
This case necessitated the performance of a lapa-
rotomy before the pus pocket could be reached. In
a certain number of cases abdominal section, which
ordinarily in these patients is not called for before
six or eight weeks have elapsed, will reveal only
thickened and infiltrated tubes. While most of
these patients regularly get well after such opera-
tions. I am satisfied that many of them would have
equally got well under prolonged rest in bed and
under the use of ice applied locally. I cannot in-
sist too much on leaving patients with pelvic exu-
dates alone. Jackson's epigrams teaching us how^
to kill a puerperal woman suffering from sepsis ap-
plv with particular force to this class of cases: "i.
Use all the salts you can persuade her to swallow ;
2. Poison her with strychnine; 3. Use the curette
and intrauterine douche indiscriminately: 4.^ If she
is still alive perform an abdominal section."
Group III. Fever due to baetcriecmia {Sep-
ticemia). Sometimes bacteric-emia occurs before
deliverv, and in my e\])cricnce with a few cases is
a most ominous condition. Ordinarily, however,
a few (lavs elapse after the labor before the
l-"ebruary 15, 1908.J
BROTHERS: PUERPERAL EEI ERS.
303
onset of the symptoms. \\'hile I have seen a few
fatal cases, which began with a pulse range of lOO,
the rule is that from the start the pulse counts 120
or more. Still, in nervous women, the value of the
pulse count only holds good when taken during sleep.
Chills occur once or several times daily, and the
temperature chart shows marked fluctuations. The
facies usually are anxious anl drawn. Intense rest-
lessness, often going on to delirium, characterize
many of these cases, although some of the worst
cases I ever saw were perfectly clear minded up to
a short time preceding exitus. As distingviished
from saprjemia due to retained placenta, the lochia
are diminished or absent and free from odor. There
is usually a complete absence of abdominal pain. In
spite of an absence of local symptoms these cases
may present, on autopsy, gangrene of the uterine
mucosa, abscesses in the uterine wall, pelvic
lymphangeitis, or thrombophlebitis of the pelvic
veins ; also lesions may be found in the more dis-
tant organs, such as abscesses, ulcerative endocar-
ditis, etc.
The few cases in my experience which developed
before the onset of labor died, and it has seemed to
me that the treatment of the future will take into
consideration the earliest possible removal of the
uterus in the hope that the system may still have
sufficient power to fight off successfully the begin-
ning systemic bacterial invasion. After, however,
the blood examination shows the presence of
streptococci or staphylococci the patient's chances
after a hysterectomy seem, to my mind, exceedingly
slim. And even though a patient here and there
may recover after operation, we known that occa-
sionally such patients recover without operation and
in spite of the presence of streptococci in the blood.
At all events, the two patients subjected to hysterec-
tomy by me died, as well as one with unilateral
thrombosis of the pelvic veins on whom I resorted
to ligation of the ovarian and internal iliac veins.
\\'hat the opsonic treatment with bacterial vac-
cines holds forth for these cases is still a matter for
the future to determine. The results of Wright are
not very encouraging ; and, although two out of his
three mild cases got well, Jewett does not seem to
be very favorably impressed with the treatment.
Similarly the use of antistreptococcus serum, which
I employed many years ago and again recently,
have failed to excite any enthusiasm in my breast.
I make this statement advisedly, with the full
knowledge that S. Marx, Hamilton, and others
"have recorded very favorable results. The only des-
perate case which actually recovered ten years ago.
and whom I saw many years later alive, did so after
exhibiting dreadful pyaemic manifestations requiring
wholesale surgery, and this woman was left ulti-
mately with an ankylosed knee joint. It was never
clear to my mind that she did not recover rather in
spite of than because of the heroic treatment insti-
tuted. Another instance which left the same im-
pression on my mind occurred two years ago in m>
service at Beth Israel Hospital, The diagnosis of
pelvic lymphangeitis was made after consultation,
in a septic case", by Dr, Bcldt and myself. After
curettage I opened up the posterior cul de sac and
<lrained the lower pelvis with gauze. She ran a
characteristic fever range just the same, and then
we diluted her blood with saline solution. \\"e used
later antistrepococcus serum without apparent
benefit. She final Iv was attacked with a septic pleu-
risy with efifusion, for the relief of which we drew
off several pints of sanguineous fluid — and the pa-
tient got well ! I may be pardoned if I am often
tempted to leave some of these patients to fight their
own battles for life in the hope that the struggle be-
tween the phagocytes and the bacteria will terminate
in favor of the former. Of course everything in the
way of alcoholic stimulants, cardiac supporters,
nourishment, and careful intelligent nursing should
be prescribed to maintain and conserve the patient's
resisting powers.
The gonococcus type of puerperal infection I
have recognized about a half dozen times. Al-
though the bacteriasmic element is present, these
cases usually run a mild course and terminate in re-
cover}- ; still there are three cases on record b}- Mann
and two cases by Davis which ended in death.
Those cases which I recall developed symptoms of
the pelveoperitonitic type about the second week,
and the patients got well under prolonged rest in
bed. Of course, gonorrhoeal pus tubes require sur-
gical intervention.
Phlegmasia alba dolens is similarly a mild form
of bacteriaemia in which the pathological process
consists of an infected femoral thrombophlebitis.
The fever is of a low grade, and the location of the
pain over the femoral region readily indicates the
natfire of the infection. ^Nly plan of treatment in
these cases has been in the direction of noninterven-
tion ; no rubbing of ointments or liniments, no mas-
sage, no active movements. By keeping these pa-
tients quiet in bed, with the limb elevated until the
fever has subsided and the pain has entirely disap-
peared, the disease usually runs its course in ten
days. There is no objection to the use of an ice
bag over the inflamed area and a flannel bandage
rolled upward from the foot to the thigh during the
period of active symptoms. By following this plan
during a score of years I have never met an embolu.-
as a result of the premature disturbance of the blood
clot in the vein.
Group I\'. Fever due to general peritonitis.
Although clearly a variety of bacteriaemia and char-
acterized by the worst kind of a prognosis, for clin-
ical purposes we can group the cases with general
peritonitis in a class by themselves. In the ful-
minating type of the disease, very soon after de-
liver}-, the abdomen begins to distend ; general ab-
dominal pain is complained of; vomiting and con-
stipation become more and more marked ; the facial
expression (in spite of a clear n-iind) looks sunken,
haggard, drawn, and anxious ; the cheeks have a
hectic flush ; the tongue is brown and dry ; the
pulse — associated perhaps with a low grade of tem-
perature and chills of varying severity — becomes at
an early period small and rapid ; and, often in the
short period of several days, the patient is dead.
The diagnosis is easy if the distended abdomen,
small thready pulse, a'nd facial expression has been
once seen. ' Still, on several occasions, I have
known intelligent practitioners to mistake a condition
of intestinal paresis with exaggerated abdominal
distension for peritoneal sepsis. Of course the
absence of rigidity of the abdominal wall, the
304 BRADIJOCK: rACCINATION JX FAR EAST.
absence of tenderness, the absence of fever and rapid
pulse, should make the distinctive diagnosis per-
fectly simple, and a dose of castor oil or a high
medicated enema containing- oil of turpentine will
equally rapidly cure the patient.
Real acute septic peritonitis presents the same ap-
palling picture familiar to abdominal surgeons
after severe infections. Authorities differ as to the
management of these terrible cases. Unless recog-
nized in the earliest stage I cannot see any benefit
from hysterectomy. That surgical intervention of-
fers some hope in certain cases can be implied from
the statistics of Cyrille Jeannin. published a year
ago. Of 121 cases of general puerperal peritonitis
subjected to surgical treatment this author notes
sixty recoveries and sixty-one deaths. He therefore
advises operating every case of puerperal peri-
tonitis "as soon as diagnosticated." There can be
no doubt that the finding of pus pockets, after
laparotomy, offers the patient a chance for life, al-
though I must record one death in a case in which
I found several pus pockets between the coils of in-
testine. The presence of pus, however, is not al-
ways clear, so that intervention assumes necessarily
the character of an exploratory operation. On the
other hand, if the case is not foudroyante in type,
but assumes a less virulent character, it is possible
for such patients occasionally to get well without
operation. I have met several examples of puer-
peral peritonitis which terminated in spontaneous
recovery.
On the whole, given a positive diagnosis of puer-
peral peritonitis with "the patient in a fair condition,
I think that a laparotomy in proper hands offers her
a better chance for her life than if nothing is done.
As for the opium treatment — as recommended by
the late Alonzo Clark — and which I was taught to
])ush to the extreme, I believe it frequently pens up
secretions and mask.s symptoms. I use it only in
exceptional cases.
If a general peritonitis shows a tendency to rap-
idly subside under the use of ice to the abdomen it
may be well to wait in the hope that the process will
go on to complete recovery or that pus formations
will become localized. I have thus on several occa-
sions, in which peritoneal manifestations seemed to
be quite violent at first, known pus to become sac-
culated in Douglas's cul de sac. In one case, after
vaginal section behind the cervix, a considerable
(|uantity of pus escaped, but the peritonitic mani-
festations continued, and the patient died. In an-
other similar case I resorted to a vaginal hysterec-
tomy, and the patient recovered. I recall one case
seen many years ago in which a po.st partum in-
flated abdomen, with temperature reaching as high
as io6° F., induced Dr. A. Jacobi, who saw the
case in consultation, to suggest the possibility of in-
traperitoneal suppuration. Unable to secure the pa-
tient's consent to an operation she was treated by
the liberal use of ice bags to the abdomen. She
made a good recovery, has had several children
since, but carries as a memento the extensive scar
left from the sloughing of the abdominal wall
which resulted from the too assiduous application of
the ice bags.
In the prci)arati()n of this paper I have endea-
vored to sketch the outlines of the febrile condi-
[New York
Meoical Journal.
tions following abortion and childbirth with few
strokes of the pen. The elaborate descriptions of
detail I have purposely left for the Meisonniers in
our profession or the writers of cold textbooks. If
the essay, brief as it is, can bring forth an in-
structive discussion, the purpose of my writing will
be fully accomplished.
112 East Sixty-first Street.
VACCINATION IN THE FAR EAST.
By Ch.'\rles S. Braddock, Ph. G.. M. D.,
Haddonfield, N. J.,
Former Chief Medical Inspector. Royal Siamese tioveroment.
The history of all nations the world over, whether
in tropical or polar regions, has been only a repeti-
tion of the same dismal tale, that is, the advent of
the white man. He has not only brought civiliza-
tion, but many serious ills in his train, both physic-
ally and morally. Among the diseases traveling in
the train of civilization smallpox is one that easily
leads in its terrible destruction of life and in blind-
ness and disfigurement of the human countenance
that it leaves in its wake.
The average man who lives at home, and does not
have his attention particularly drawn to the mat-
ter, does not realize the terrible loss of life in the
past, and which is still going on in remote parts of
the world.
In the South Sea Islands, in the Far East, in China,
Indo-China, .Siam, the Malay Peninsula, Arabia, Per-
sia, Africa, and many other parts of the world, the
death roll in past epidemics has run into hundreds of
thousands of people who, if they had had protection
by vaccination, might have lived long lives of useful-
ness, not to speak of the thousands of blind and dis-
figured persons. It is no uncommon thing to see in
some cities in the Far East six or eight totally blind
persons being led in one line by a blind leader, each
one with his hand on the shoulder of the one in
front. Literally, as the Scriptures say, "Blind lead-
ers of the blind."
In Siam up to recent years practically ail of the
new cases and the great death rate were among the
children, for all of the older people had had the dis-
ease during successive epidemics.
In 1903 the death rate in Siam and its depend-
encies was 10,000, and this was only one epidemic.
These epidemics have been recurring every few
years. Dr. Peoples, a Presbyterian medical mis-
sionary in the province of Nan, one of the Laos
provinces in the north of Siam, told me that in that
province, which has now a population of 600,000
people, 100,000 had died of smallpox in the past
thirty years. This is only a sample of what
has been taking place all over the Far East with the
exception of the British colonics, where vaccination
has been pushed by the British government. In
Indo-China the French government faces the situa-
tion that the population has decreased 50 per cent,
since they first occupied the country, and efforts are
now being made to vaccinate and instruct the people
in sanitation by government medical men. In 1903
Dr. H. Adamson, inspector general of hospitals, and
myself called the attention of the Siamese govern-
ment to the terrible death rate in Siam from small-
February 15. 190S. J
BRADDOCK: VACCINATION IN FAR EAST.
305
pox and showed the great inroads it was making
among the already sparse population of pure Siam-
ese, who had also suffered so severely from chol-
era, malarial fever, and dysentery, and was to have
bubonic plague added to their troubles. But small-
pox caused more deaths than all of the other dis-
eases together.
Prince Darmong, minister of the interior, a most
able man, sent Dr. Adamson to Manila to study the
American methods there of making vaccine at the
United States Government Laboratory. On his re-
turn active efforts were made to make vaccine in
Siam. The French w^ere making fine vaccine at the
Pasteur Institute at Saigon, but the vaccine spoiled
very quickly in the tropical climate, and long before
it could be used in the interior. The German and
Japanese doctors in Siam had had a try at it, but,
owing to climatic and other conditions, they met
with absolute failure. Dr. Adamson and myself
worked hard, the government giving us every facil-
ity that money could procure, a well fitted up bac-
teriological laboratory, etc. But it was nine months
before we succeeded in making vaccine, nine long
months of failure and disheartenment. But at last
we succeeded and made good vaccine. We were
both proud men when we exhibited to the Siamese
officials a large number of children with well marked
vaccine sores on their arms. All of the physicians
in the Siamese service were put to work, and in two
years we had vaccinated 400.000 people, mostly chil-
dren, without a single death from tetanus. During
this time Dr. Adamson and I inoculated and scraped
every calf with our own hands, made all of the cul-
tures and bacteriological examinations, and super-
vised every detail, as we had no one we could trust
to do it. Dr. Paul G. WooUey. a most able and tal-
ented man, a graduate of Johns Hopkins University,
came from Manila and took charge of the work
finally, and he now fills the position I formerly held,
that of chief medical inspector of the ro} al Siamese
government.
It was only a few weeks after the first successful
vaccine was made that we had a splendid oppor-
tunity to see what vaccination meant. Smallpox
broke out in the town of Tatchin, situated at the
mouth of the Tatchin River. In thirty days 145
'children died of the disease, before we were notified
of the outbreak. This meant about 500 cases, and
we dispatched a fast steam launch with a number of
vaccinators, and in a few days had vaccinated 4,000
people, absolutely stopping the epidemic at once, as
there were no more cases after the period of incu-
bation of those already infected was over, and even
in these it modified the disease. Tatchin has never
knowm smallpox since.
The Presbyterian missionaries in the north, in the
Laos country, heard we were making vaccine, and
at once sent for supplies. As one of them expressed
it to me: "Doctor, I have gone through hell in
years past in seeing my people dying by the score of
smallpox and being helpless to stop it. and now we
can stop it." Dr. McKean, of Chengmai. at once
inoculated calves with the vaccine we sent him and
started the work in the far north, and this year he
has 250 vaccinators at work who will average a
thousand or more vaccinations each, so that he alone
will probabl}- vaccinate 250,000 this year. The work
is going on from the Federated Malay States to, the
Indo-Chinese frontier and from Burma to Indo-
China, so that in a short time smallpox \vill be abso-
lutely a thing of the past in Siam.
The Chinese at once took advantage of the great
demand for vaccination, and it was soon found that
it was necessary for the government to issue an or-
der allowing no one to vaccinate without a govern-
ment permit, as we found that the Chinese doctors,
in their anxiety to make money, vaccinated the peo-
ple with bogus vaccine and were using condensed
milk, gum resin from a tree, and pus from syphilitic
ulcers as well as pus from smallpox ulcers. The
great and unusual death rate among the children
from smallpox was due to the fact that practically
all the adults were the sufferers of previous epidem-
ics and all had had the disease.
Dr. Peoples told me that in the epidemic of 1898
he traveled over a large stretch of country in the
Laos province of Nan, and on investigation found
that in that epidemic alone 75 per cent, of all the
children under seven years of age had died over a
great part of the province, and this in only one epi-
demic. This meant that, of 500 children in a \
l^ge, 375 died of the disease.
One of the most heartrending things was to go
into a village and have the dozens of totally blind
children brought to you to see what could be done
for them, all made blind by smallpox. The poor
people had an idea that the Moh Luang, the king"s
doctor, would be able to give them back their sight.
To-day the great campaign is going 011 among
millions of people, and over hundreds of thousands
of miles of territory Too much praise cannot be
given to the work and selfdenying exertions of the
missionaries, both medical and lay. who have gone
out on tours and have vaccinated thousands and
thousands of children in the past two years. The
great extent of this work was shown by the official
reports sent to me by Dr. Dunlap, Dr. McDaniel,
and Dr. Walker, who vaccinated nearly 10,000 chil-
dren in one season, and of Dr. IMcKean. of Cheng-
mai, who vaccinated 17,500 in one season. They are
all attached to the Presbyterian mission.
The Siamese government fully appreciate the
work the missionaries have done, and the govern-
ment is cooperating with the missionaries. Person-
ally I am proud of the fact that Dr. H. Adamson
and myself made the first vaccine ever made in the
kingdom of Siam, and started the great work which
in now going on to such an enormous extent.
After coming back to America after years of so-
journ in the Far East, I have been utterly astonished
and surprised to read articles in papers deny ing the
protection of vaccination against smallpox, and learn-
ing of so much opposition from parents to have their
children vaccinated, also of the activity of antivac-
cinationists. I wish I could show some of these
people the results of vaccination in the Far East, in
Siam and the Malay Peninsula. It might shame
some of the ultracivilized to see the gratitude shown
by a poor heathen mother when she knows her chil-
dren will not lose their lives or be blinded by this
disease.
In conclusion, it might be interesting to tell what
3o6
KLOTZ: BREATH L\ DIAGXOSIS.
MiDICAL JOURN VL.
the Siamese believe is the origin of the disease. I
quote a translation of a Siamese medical book in my
possession, translated for me by Dr. Dunlap :
"There is a great giant that lives in the sky and
who has seventy-six sons and daughters ; each one
of these is a variety of (Fidat) smallpox. When
the giant sends one of them to earth and he visits
the individual, that individual has that variety of
smallpox, one of the seventy-six the Siamese divide
the disease into."
The book gives no remedy for the disease, but
simply diagnoses the case, and tells how long you
will live, all of which varies from three days to three
weeks, according to the location of the eruption on
the body.
DISEASES OF THE BREATHING APPARATUS
WHICH AFFECT THE BREATH.
The Breath as an Aid in the Diagnosis of These and
Otiier Diseases.
Bv F. E. Klotz, M. D.,
Lanark, Canada.
Just as we draw inferences from the odor of dis-
charges and of pathological tissues in other parts
of the body, let us try to improve on our diagnosis
of afifections of the breathing apparatus by always
taking into consideration the odor carried forth on
the expired air. In addition let us not fail to note
that certain constitutional diseases, septic processes
and drugs, affect the. breath markedly.
I shall enumerate first, the affections of the nose,
throat, mouth, larynx, bronchi, and lungs, which
may be the cause of an abnormal breath, and where
possible, describe in short the character of the odor :
First. — Chronic hypertrophic catarrh of the nose
and nasopharynx causes a breath warmer than nor-
mal, without necessarily any other change; at times
it has a heaviness without any distinct odor ; then
again it may have an odor which is slightly dis-
agreeable, but never markedly so.
Second. — Ethnoidal, frontal, sphenoidal, and an-
trum diseases cause hypertrophic conditions, so that
we have the hypertrophic breath plus that due to the
formation of mucopus, which latter gives forth or-
dinarily a heavy, sweetish, somewhat disagreeable
order. Where an antrum is involved the odor is
.sometimes highly offcn-sive, dense, and penetrating.
Third. — Fibromata of the nose and nasopharynx
produce no odor of themselves. Any odor depends
on mucopus formation.
Fourth. — Mucous polypi, no odor of themselves.
Fifth. — Ozaena, well termed Stinknase in Ger-
man, for this condition produces perhaps the rot-
tenest — to use a vulgar, although in this case most
applicable, word — of all breaths ; it is a conglomer-
ate odor of animal decomposition, fcetid, arid, and
nauseating, and can be detected many feet from the
patient ; once experienced it is never to be forgotten.
The patient with this malady often leads a sad, mis-
erable, and isolated life.
Sixth. — Syphilis of the nose : Gummata produce
an odor only when their surfaces become broken
down ; the odor then depends on the amount of dis-
charge from the deposit on ihe ulcc r surface : gener-
ally only slightly offensive, heavy but rarely foetid.
Mucous placques in the nose, unless large, hardly
affect the breath ; this is not the case in the mouth.
Seventh. — Lupoid ulcerations : No distinctive
odor, though it may cause one to suspect the
chronic formation of pus.
Eighth.- — Tubal discharge of chronic otitis media
may cause a sharp, penetrating odor almost like
Roquefort cheese, and easily detected when necrosis
of bone is taking place in the middle ear. This odor
is periodical in character, due to the varying pa-
tency of the tube and position of the head.
Ninth. — Tuberculous ulcerations which affect the
palate and nasopharynx more frequently than the
nasal cavities proper, produce an offensive breath,
which may be described as heavy, bitterish, and
putrescent.
Ten. — Internal lacerations due to fractures pro-
duce a temporary heavy sweetish "recent pus" odor ;
the blood in the cavities of the nose during the first
few days gives the breath -an additional quality
faintly like burning sulphur.
Eleven. — Atrophy of the mucosa of the nasal cav-
ities produces a light, slightly foetid breath, not suf-
focating, if I may use the term, as that of many
other conditions : moreover, there may be no odor
whatever.
Twelve. — Foreign bodies in the nose may cause
a slight mucopus odor or a highly oft'ensive, steamy,
heavy odor ; it all depends on the nature of the for-
eign body and the length of time elapsed since its
introduction.
Breath as affected by mouth conditions where the
mouth becomes the passage of expired air.
One. — Cancrum oris. — This condition, like manv
others of the mouth cavity, is productive of a
hypersecretion of mucus and saliva ; in consequence,
the breath is superheated, slightly heavv, and
steamy. In addition, we may get the first hint of
gastric dyspepsia.
Two. — Pharyngitis sicca produces no distinctive
odor or one somewhat resembling that of the
atrophic nasal condition.
Three. — Chronic tonsilitis, with constant and
copious secretion of cheesy material, produces a
heavy, cheeselike (limburger), sweetish, offensive
odor, which is fairly easy of diagnosis. The still
more chronic condition in which the cheesy material
is retained and becomes more or less solidified, oc-
casionally forming calculi, is productive of a dis-
tinctive breath, which is present only when the firm
retention masses come to the surface : it may be de-
.scribed as stinking and penetrating, an odor not far
removed from that of the decayed nerve of a tooth.
.\denoids, sometimes, when firm and much enlarged,
give nasal and mouth breathing the characteristics
of chronic tonsilitis, as described.
Four. — Tonsil, pillar, and pharyngeal diphtheria
produce a foul, heavy, superheated and suffocating
odor, dry or steamy, according to amount of fever,
stage of disease, and amount of mouth and bronchial
secretion.
Five. — Tuberculous ulceration, especially of the
tonsil, is always offensive, and may be very sharp
and penetrating, even though no bone is involved ;
(he odor may affect the air of the whole room.
Six. — Soor. or mudget, if e.xtensive. has the odor
February 15, 1908.]
KLOTZ: BREATH IX DJAGXOSIS.
of a rapidly progressive ulceration with necrosis ;
heav}-. though not as highly offensive as the more
chronic tuberculous lesions.
Seven. — Ulcerated gums produce a heavy, of-
fensive breath, with the tainted egg smell added, and
not detected except when very close to patient.
Eight. — Decayed teeth, in which a large portion
of the central pulp is exposed, give to the breath a
light, penetrating, often bitter, odor, though rarely
as offensive as necrosed bone in other parts of the
head. It may resemble the odor of decayed vege-
tables, apples and onions, or of decayed Brazil nuts.
Nine. — Mouth breath following the extraction
of teeth resembles that of diphtheria and tubercu-
lous pulmonary cavities, inasmuch as it will pollute
the atmosphere of a whole room if patient sleeps
with the mouth open. It ma}- be described as ex-
tremely foul and nauseating, not tmlike the smell of
very rotten eggs.
Ten. — Lupus, until ulceration takes place, has no
eft'ect on the breath, differing in this respect from
the warty tuberculous excrescences sometimes found
in the mouth cavit} .
Eleven. — Syphilitic patches are productive of a
heavy, steamy breath, which may or may not be of-
fensive. The odor of gummatous ulcerations has
nothing distinctive, the oft'ensiveness, when present,
being due to the amount of deposit taking place on
the ulcer base.
Twelve. — Salivary and mucous inactivity cause a
dry. hot breath, with bitter sweet characteristics.
Thirteen. — A- furred tongue produces a heavy
odor of decomposing epithelium, which may be
modified by decomposed food, which so readily min-
gles with dead epithelium.
Fourteen. — Hypersecretion of saliva, as in acute
tonsilitis, produces a heavy, steamy, slightly of-
ensive breath, only detected when close to patient's
mouth. Potassium iodide, producing hypersecretion
also, gives the breath at times a certain sharpness
difficult of description.
Fifteen. — After a dietary of strong foods, such as
onions, radishes, and salt fish, the mouth breath
may retain the flavor of these for many hours.
Sixteen. — Pharyngitis hypertrophica has nothing
distinctive.
Seventeen. — The use of tobacco, as pipe or cigars,
produces the well known smokers" breath.
Eighteen. — An alcoholic drink will affect the
mouth breath for a short period ; the same taken in
large quantities will cause an offensive breath hav-
ing the flavor of the liquor taken, but not till some
time after .the liquor has been ingested, and then it
is the alcoholic pulmonary breath which obtains :
this often savors of undigested food, and has a bit-
terish quality.
The breath as affected by larynx conditions :
One. — Lupus in nodular form does not affect
breath, even though obstruction is imminent. Lupus
ulcers of the lar\-nx are rare and hardly worth dis-
cussing.
Two. — Sy philis.- — Onl\- when cartilage or bone is
affected do the ulcerated surfaces give off an of-
fensive odor.
Three. — Tuberculosis of the interarytfenoid space
often begin as a papilomatous growth, more or less
fissured. This condition produces a bitterish odor,
though not penetrating, nor really offensive ; if
ulceration takes place and extends to deeper parts,
the breath becomes quite evil smelling and pene-
trating, and much more oft'ensive than an ulcerated
lupus or syphiloma.
Four. — Diphtheritis of the larynx.- — More oft'en-
sive than the same condition on the tonsils, and very
apparent even when the mouth is closed.
Five. — Lar)'ngitis sicca, singly or associated with
pachydermia laryngis, produces a "thin," acrid, bit-
terish breath of a most penetrating character. In
persons past thirty this breath may be powerful
enough to permeate every room in a small dwelling.
Although different persons, suffering from this
condition, may not have similar breaths, yet the
breaths of all have like characteristics, so that the
cases can generally be easily diagnosticated with-
out the laryngoscope.
Six. — Foreign bodies in the larynx produce a
more or less offensive breath, varying according to
amount of damage and length of time the foreign
body has been retained ; the same applies to foreign
body in bronchus, and I may state that the breath
in one case I saw was highly putrid, though it re-
sembled that accompanying nasal foreign bodies.
Seven. — Malignant diseases of larynx.— One of
the two cases I met with had a very acrid, bitterish
breath.
Eight. — Cigarette smokef's breath. — This can be
detected when three or four feet from the "fiend";
the latter term I apply to one who consumes at
least twenty cigarettes daily, constantly inhaling the
smoke till his larynx and trachea are stained yel-
low, and a chronic, generally desquamating, catarrh
is set up. The breath of the fiend is then heavy,
foul, sweetish, and nauseating, with only a trace of
real tobacco odor to it. The constant smoking of
pipe or cigars produces a characteristic and bad
breath, but it is mild in its offensiveness compared
to that of the cigarette fiend, in whom the breath
acquires its foulness in the trachea, larynx, and lungs.
Among the diseases of the bronchi and lungs
wliich affect the breath I ma}- mention :
One, chronic purulent bronchitis ; two. tubercu-
losis of the lungs : three, abscess of the lungs ; four,
gummata of the lungs; five, asthma in advanced
stages ; six, pneumonia — later stage ; seven ; ma-
lignant diseases of lungs (rare) ; eight, anthracosis
(rare) ; nine, actinomycosis (rare) ; and, ten,
emphysema.
Of these, abscess and tuberculous cavities give
forth the most evil smelling breaths. In the former
it often resembles the odor of moist putrid flesh,
with an acridness added. Tuberculous cavities filled
with glairy pus give the breath, when observed close
to the patient, a most penetrating, nauseating, foetid
odor, the foetor having some of the characteristics
of coal gas. Chronic purulent bronchitis often
gives the breath a sulphuretted hydrogen odor.
This peculiarity is sometimes present in phthisis.
Asthma breath is frequently sourish, but may have
a variety of odors ; rarely is it offensive unless com-
plicated by laryngeal or nasal conditions. Miliary
tuberculosis of the lungs does not impart any odor
to breath except that it might be designated a "fev-
3o8
PELTON:
COLD IN HEAD.
[New Vork
Medical Journal.
erish" breath. The breath of the "kuiger" in the
early stage of the disease is quite distinctive, though
it would be almost impossible to describe it.
I shall not attempt to describe the other pul-
monary breaths, as the}- are subject to much varia-
tion.
Breath as affected by constitutional diseases and
drugs :
One. — Constipation and copr^emia are probably
the commonest causes of bad breath in otherwise
healthy subjects; in the worst cases one would
imagine the lungs were full of faeces, so much does
the breath resemble faecal excretions.
Two. — Diabetes is credited with affecting the
expired air, but I cannot speak from experience.
Three. — Advanced chronic interstitial nephritis
and uraemia give to the breath a urine flavor plus
that of eggs turning bad.
Four. — Febrile conditions produce a hot, dry
breath, bringing to mind pent up excreta and the
value of calomel.
Five. — Septic processes are productive of a vile,
foul breath, often quite characteristic.
Six. — Cachexias are often accompanied by a
breath odor of something dead.
Seven. — Chronic dyspepsia is frequently accom-
panied bv a heavy, sourish breath, and one in which
the odor of undigested food is to be detected.
Of the drugs and poisons which aft'ect the breath
I may mention mercury, arsenic, opium, alcohol,
iodide's, bromides, chloral, oil of turpentine, phos-
phorus, hydrocyanic acid, carbolic acid, creosote,
chloroform, ether, iron, mineral acids, oxalic acid,
nitrobenzme, peppermint, and camphor.
In conclusion, I wish to refer to the rarity with
which reference is made, in clinical work, to the
character and quality of the patient's breath. The
nature of the breath has frequently led me to sus-
pect and discover conditions which, ordinarily,
would have been fairly difficult of diagnosis, and in
manv conditions we may fairly judge of the se-
verity of the disease by the intensity of the breath
^dor.
THE TREATMENT OF "COLD IN THE HEAD."
By Henry H. Pelton, M. A., M. D.,
New York,
riiicf o£ Medical Clinic. Presbyterian Hospital Dispensary; Iiisln.o-
tor in Medicine, New Vork Postgraduate .Medical School.
Cold in the head, while not in itself a serious
ailment, is a most uncomfortable one and one which
may lead to more or les untoward complications,
therefore it would seem that any means which lead
toward the mitigation of the discomfort and the
prevention of the possible complications are quite
worthv of trial.
With regard to prophylaxis it is important that
all intranasal and pharyneal abnormities, particu-
lary adenoid growths and hypertrophied tonsils.
>hould receive appropriate treatment; this, in the
case of the two conditions mentioned, consists in
nothing less than thorough removal. Further pre-
vention of cold in the head may be secured by giv-
ing attention to the hygiene of the nose and throat.
by wearing proper clothing, and by avoidance of ex-
posure in so far as may be possible. The nose and
throat should receive cleansing douches or sprays at
least once daily, for these situations, particularly in
cities where dust and smoke contaminate the at-
mosphere to an excessive degree, gather foreign sub-
stances teeming with microorganisms which cannot
but be prejudicial to the maintenance of their
mucous linings in a health}- condition. The only
drawback to the use of sprays and douches is the
possibility of transferring, by these means, infection
to the middle ear through the Eustachian tube, but
the probability of this untoward occurrence may be,
in great measure, avoided by refraining from blow-
ing the nose for at least five minutes after the use
of the intranasal application, and then performing
this act only in the most gentle manner. A useful
spray or douche for the purpose named is the
liquor antisepticus of the pharmacopoeia diluted i
part to 6 parts of water, or a mixture consisting of
boric acid, 5 grains, sodium biborate, 5 grains,
phenol, '/2 grain, to the ounce of water.
It is often difificult to be certain, before the onset
of distinct symptoms, that one has "caught cold,"'
but if there is suspicion that such is the case the
aft'ection ma}' sometimes be aborted by the adminis-
tration of }^ grain of calomel every 20 or 30 min-
utes until six doses have been given. This is to be
followed on the succeeding morning by a saline
purge such as the effervescing solution of magne-
sium citrate, epsom salts, or a glass of one of the
saline waters, such as Hun}adi Janos or Apenta.
P'oUowing the calomel the patient should take 10
grains of compound ipecac powder and a hot drink
consisting of a half ounce of whiskey and about
eight ounces of water; to this lemon juice and
sugar may be added if desired. In the event of the
patient's objection to alcohol a glass of hot lemon-
ade will often have the same eft'ect. The patient
should now retire and cover himself warmly in
order to induce free diaphoresis. The above pro-
cedure may entirely ward oft' the threatened cold.
When the affection has fastened itself upon the
patient the nasal cavity should receive frequent ir-
rigations of warm (100° F. ) normal 0.9 per cent,
solution of sodium chloride. Each irrigation should
consist of at least a quart of the solution and is best
given from a fountain syringe, the reservoir of
which is held at an elevation of a foot or two above
the patient's head. To the end of the tube a glass
nozzle should be fitted and the latter should be ap-
plied to each nostril in turn, the solution being al-
lowed to flow in at the one and out at the other
while the patient breathes through the mouth and
holds his head forward over the wash bowl or bath
tub. The solution moistens the dry and inflamed
mucous lining of the nasal fossae in the early stages
of the cold and washes away the accumulated
mucus in the later stages, leaving the nasal mucosa
clean to Ix; acted upon by a .spray of 10 per cent.
ac|ueous solution of silver vitellin ; this has a dis-
tinct germicidal, astringent and curative effect upon
the inflammation. Following these procedures a
spray consisting of menthol i grain, eucalyptoi 8
minims, benzoinol i drachm to the ounce of liquid
petrolatum will soothe the intranasal irritation and
KIXCJ-1: TEACH I Mi Of DERMA! OLOGY.
cause a certain amount of contraction of the turgid
tissues. The sprays mentioned above should be
used upon the pharynx as well as in the nose. ( )ily
sprays containing adrenalin chloride are also useful
to lessen the congestion, but appear to have no es-
pecial advantage over the mentholated spray and
possess the disadvantage of being very expensive.
If involvement of the frontal sinuses is present, as
evidenced by pain and a feeling of fullness above
the bridge of the nose and over the eyes, this may
be relieved by the administration of a powder con-
sisting of salipyrine lo grains, and quinine sul-
phate I grain ; this may be taken every 3 or 4
hours, and if there is any tendency to cardiac weak-
ness a grain of citratecl caffeine should be added
to each dose.
The so called rhinitis tablet, consisting of bella-
donna extract ]/?, grain, quinine sulphate Yi grain,
and camphor Y grain, has never proved itself of
any especial value in the hands of the writer, but it
may be prescribed if desired or a tablet or capsule
containing euquinine ^ grain, hyoscyamus extract
14 grain, and monobromated camphor i grain, may
be substituted for it.
In many patients a cold in the head is followed by
a bronchitis of varying severity ; in such the writer
has been able to prevent this sequela by the admin-
istration of pure beechwood creosote in doses of 5
drops, taken in a spoonful of milk after each meal ;
this should be begun at the inception of the nasal
inflammation in these patients and should be con-
tinued for several days after its subsidence. The
appearance of any gastric disturbance or of dark-
ening of the urine is a signal for stopping the creo-
sote, which ma_\- be begun again in a day or two in
smaller dosage. The substitution of creosote car-
bonate in 10 drop doses for creosote will obviate
all possibility of toxic symptoms, but the latter drug
has the disadvantage of being very expensive.
The complication of eustachian tulje inflamma-
tion necessitates the employment of the Politzer bag
for the purpose of inflation, and possibly eustachian
catheterization may become necessary. Should the
inflammation extend to the middle ear, as is often
the case in children, especially in those with ade-
noid growths and enlarged tonsils, the drum mem-
brane should be punctured at the least indication
of bulging of this structure. This operation is a
simple one to the skilled hand, and the provision of
free drainage for the tympanic cavity may ward oft'
mastoid involvement with all the dangerous com-
plications which may follow. Following the para-
centesis the canal of the ear should be loosely
packed with gauze, which should be renewed as soon
as it becomes saturated with the discharge, and free
irrigation with warm 3^ saturated aqueous solution
of boric acid should be employed daily. The inter-
vals of irrigation may be lengthened as the discharge
becomes less, and after a few days two or three
minims of a 20 per cent, aqueous solu.tion of silver
vitellin dropped into the canal may hasten the
cure.
The doses given in this paper are for adults. In
prescribing for children they should be lessened in
accordance with the age of the patient.
781 Park Avenue.
THI-: TE.\CHING OF DERM.\TOLOGY IN MEDICAL
SCHOOLS.
By Ch.\rles a. Kincii. M. D.,
New York,
Dermatologist to New York City Children's Hospitals and Schools,
Clinical Assistant to the Xew York Skin and Cancer
Hospital, New \ ork.
Is a knowledge of the principal facts of dermatol-
ogy and syphilolog}- necessary to the general practi-
tioner ?
"It will be conceded that it is essential that
the physician should be able to diagnosticate the ex-
anthemata, to protect the public by advising quaran-
tine, and to avoid panic : yet to do this it is necessary
to distinguish from them the various forms of eryth-
ema, dermatitis, and syphilis. The gravity and
often unsuspected 'presence of the latter makes it
of the utmost importance to the individual, to the
family, and to the public, that a correct diagnosis
he made and appropriate treatment be carried out.''
(The Need for Higher Requirements in Exam-
inations in Dermatology and Syphilology by Medi-
cal Colleges and Examining Boards, by William F.
Breaky, AI. D.. Ann Arbor. Mich. Read before
the Si.xth International Dermatological Congress,
September 9 to 14, 1907.)
Many affections of the skin are also contagious,
notably scabies, ringworm, and contagious impetigo.
When these gain headway in a group of closely con-
nected families or an institution, energetic and per-
sistent treatment is reqiiired to eradicate them.
In the present four year course of medicine, the
student should begin the study of dermatology in the
third. He should first see cases. He should be
present while patients are examined and discussed
by others. His experience is very slight. His knowl-
edge is poor and perhaps prejudiced. He can say
nothing for himself. But he will learn much that
will be of service in the didactic period. He will
have in store a series of mental pictures which the
words of the textbook will recall. He will not read
blindly. This course of observation may well fill up
one semester. If a tutor can be had or the professor
is willing to give two hours a week for five or six
weeks during the term, instruction may be given in
the special anatomy of the skin, as a secretory and
excretory organ. A study of the lesions may also
follow, to acquaint the student with the language of
dermatology.
The second semester is occupied with a systematic
presentation of the diseases of the skin. Didactic
work is best done along the lines of an authoritative
textbook. Eschew quiz compends and students'
handbooks. Follow a good treatise in which the sub-
jects are discussed with some fullness. A student
can read from forty to fift}' pages in preparation for
a weekly lesson. Recitations will brmg out how
much he has extracted from the book. Skillful
questioning will emphasize the important points, and
judicious comments correct false impressions. The
printed page can never take the place of the voice
and personality of the teacher. The silent hiero-
glyphs convey but a shadowy impression to many
minds. Most people need to be told. They want
to be shown.
The resources of a clinic, even in a metropolitan
3IO
city, fail to furnish examples of some rare diseases.
There are also many typical and atypical conditions
which may be presented in illustration of the text.
No representation in either pictorial or plastic art
can represent exactly the living patient. Yet it must
be acknowledged that the moulages of Baretta are
very lifelike. Wax models, I believe, of equal
merit are made in this country and in England. But
they are not on sale, being preserved in most in-
stances as private records of interesting cases.
Some excellent chromolithographs have been pub-
lished. Xone surpass the atlas of Hebra, but that
book was issued sixty years ago. It is scarce now
and out of print. Crocker's atlas may still be had.
Besides, the teacher will have oil paintings and wa-
ter colors of his own cases.
Photographs show location and peculiarities of the
horny layer, such as disquamation and hyperkerato-
sis. They fail to show color, and show contour but
imperfectly. The lens plays tricks with the per-
spective. Stereoscopic views, when viewed through
a proper binocular, are better. Photomicrographs
are of great value, if the teacher can obtain such ex-
cellent ones as w ere shown by Professor Fordyce at
the .American Medical Association in Atlantic City
last June.
If a stereopticon is available, and especiallv that
form known as the "reflectoscope," time will be
saved and lucidity promoted by throwing the illus-
trations upon the screen, both chromolithographs
and i)hot( 'micrographs. The microscope should be
freel}' used.
By this time the student becomes sophomoric and
thinks he knows it all. He needs another term of
clinical work to take the fall out of him. Here the
lesions of the skin should be minutely described.
The close observation necessary, the enumeration of
the lesions, their character and distribution, will often
suggest the name of the disease, the same as spelling
the letters. Very little regard should be paid to the
histories by patients. The student should be taught
to "look and say." Attention should also be given
to the lesions of the visible mucous membranes.
Will this course take up too much time? Not
very much. For the teacher, one hour a week
throughout the college year ; for the student, one
hour a week through the third and the first half of
the fourth year. The first term is clinical, the seniors
occupying the front seats and taking an active part,
the juniors sitting behind them and looking on. In
the second term, only juniors attend recitations and
demonstrations.
This course is suggested for a college gradiiating
not more than twenty-five or thirty students each
year. Larger classes would need a corps of teach-
ers and division into sections. The course rec|uires
fortj-eight to fifty-four hours of the student's time,
two'thirds of which is clinical. The Association of
American Colleges recommends forty hours as a
minimum.
273 West Seventieth Street.
Tuberculous Bone Disease. — If possibU, drain-
age should be avoided in oi)erating for tuberculous
disease of the bones, as the insertion of drains en-
courages the formation of sinuses. Scruinilous
asepsis will generally render the u.se of drainage un-
necessary.— Intcniathnial Journal of Siiri^cry.
!.N£\v York
Medical Jourxal.
Ilirra))f«tical g otes.
Purulent Rhinitis. — The usual treatment of this
condition as it is observed in children is to syringe
the nasal fossje gently with a lukewarm one per
cent, solution of sodium bicarbonate or a three per
cent, solution of boric acid, the infant's head being
inclined forward and downward in order to prevent
the solution from passing into the throat and larynx.
The application of a two per cent, solution of men-
thol in oil, touching the mucosa lightlv with cotton
moistened with the mentholated oil, is also recom-
mended, but better results can be obtained than
from the methods described by the insufflation of
an antiseptic powder. La C'liiiiqiic, for January
17th, credits the following prescriptions to H. ]\Ien-
del's Memento tlicrapeiitique des maladies des or-
i^ajies resp i rat aires :
I.
R Aristol ' 5i:
lodol gr. xlv;
Sugar of milk, gr. l.xxv.
M.
11.
R lodoftirm gr. xv ;
Gum benzoin, gr. xlv;
Boric acid 3iiss.
M.
III.
R Zinc sozoiodolate, gr. xv ;
Sugar of milk, 5v.
IVI.
If the rhinitis does not yield to some one of these
applications, the nasal fossae should be sprayed with
a weak solution of silver nitrate, as follows :
R Silver nitrate, gr. ii ;
Distilled water ^i.
M.
The External Use of Guaiacol in Pneumonia. —
Cain (Therapeutic Gazette, xxxii, i) uses guaiacol
externallv in the treatment of pneumonia with good
results. The remedy is rubbed into the skin, and
any part of the body may be selected, but it is said
to be absorbed most readily from the abdomen, this
site being selected unless there is pain in the chest,
when the seat of pain is chosen. The average
quantity used for an inunction is twenty minims for
adults and ten minims for a child one year of age.
The drug is dropped slowly from a medicine drop-
]:)er and rubbed in with the end of one finger. It
is usually all absorbed in one or two minutes. The
treatment is never repeated at less intervals than
twelve hours, and the average number of treatments
is four ; no two applications being made in the same
place.
Iodine and Guaiacol Injection for Tuberculo-
sis.— In the treatment of tuberculosis the hypo-
dermatic injection of a solution of guaiacol and
iodine in oil has been used effectively in France,
such a solution of the following composition being
known as Durant's injection:
R Iodine, S""- .^.\' •
1''xprcssed oil of abnond .siii ;
Guaiacol. . 3ii.
M.
Dissolve the iodine in the almond oil by agitation
iti the cold, and add the guaiacol to tlie solution.
THERA PEUTICAL NOTES .
THER.l PE UTICA L N O IHS.
311
The Treatment of Chilblains. — The following
method of treatment is credited to Jadassohn in the
Journal dc iiiedcciuc de Paris, for January i2tli.
Bathe the hands and feet in water as hot as can be
borne three or four times a day for ten or fifteen
minutes at a time. Dry the parts thoroughly, and if
the skin is broken and ulcerated wash with alcohol.
At night an ointment composed of the ingredients
named below is applied b_\' rubbing to the unbroken
skin, the ulcerated parts being covered with a layer
of it applied on linen :
B Ichthyol gr. xv-lxxv;
Resorcin. gr. xv-xlv;
Wool fat 3vii;
Olive oil 3iiss;
Distilled water, 3xiiss.
■
If the ulceration is extensive the ointment may be
applied night and morning.
The Application of Tincture of Iodine in the
Dark. — In the British Medical Journal for Novem-
ber 16, 1907, J. Dunbar-Brunton describes a pecu-
liar property of iodine. If the tinctiu-e of iodine is
painted on the skin in the dark, or is exposed only
to a red light, such as is used in photography, and
is covered immediately without being exposed to a
white ligiit. it will be absorbed with much greater
rapidity than under ordinary circumstances, and it
is said not to discolor or blister the skin, even if
used for long periods.
Fluid Iodoform has numerous uses in medi-
cine. It is a solvent for guaiacol and is miscible
with water, alcohol, ether, chloroform, eucalyptol
and creosote. It is absorbed readily by the cutane-
ous surface. Fluid iodoform may be easily pre-
pared according to the following formula, which is
taken from La Clinique:
R Potassium hydroxide 35 parts;
Water 25 parts.
Dissolve and add —
Oleic acid, 50 parts ;
Alcohol 30 parts.
To the mixture thus formed then add with con-
stant stirring :
Resuhlimed iodine, 30 parts.
When tlie reaction is completed a few drops of
solution of potassa are poured in to complete the
conversion of the iodine, and the whole is allowed
to stand for a few days in the dark, when the fluid
iodoform, which forms the supernatant liquid, is
decanted.
Application for Extensive Burns. — The appli-
cation by means of a camel's hair pencil to the
burned surface of the following analgetic mixture
will, the Journal de mcdeciuc dc Paris says, produce
a cool feeling and form a protective varnish:
B Carbolic acid gtt. xxv ;
White dextrin ^iv ;
Tincture of Socotrine aloes 3ii ;
Spirit of camphor 3i I
Lead acetate gr. xlv ;
Tannic acid gr. xv ;
Cherrv laurel water Jv ;
M.
The dextrin, which has been previously ground
to an impalpable powder, is added in small portions
at a time to the mixture of tincture of aloes and
spirit of camphor and thoroughly incorporated bv
rubbing them up in a mortar : the clierry laurel wa-
ter, containing the lead acetate and tannic acid, be-
ing added lastly.
To Remove Iron Stains from the Teeth. — The
careful application once only of a solution composed
of equal parts of crude hydrochloric acid and dis-
tilled water, is said by Combe (Journal de mcde-
cine ) to remove the stains on teeth caused by cer-
tain preparations of iron. The solution should be
applied by rubbing the teeth lightl\- with cotton
wound around a wooden toothpick which has been
dipped in the solittion.
Method of Administering Arsenic in Chorea. —
J. Gordon Sharp, in The J-racfitiouer, for Februarv,
1908, advocates the administration of arsenic in
fairly large doses to stop the movements of chorea
in children. By large doses he does not mean a
dose of solution of potassium arsenite in excess of
12^ minims, as he has found that when the dose
is increased beyond this, the patient may repeatedly
vomit both food and medicine. For patients of
from eight to fifteen years of age he prescribes the
following :
R Solution of potassium arsenite, . . TIJ^ccxl OT]\y ccc ;
Tincture of capsicum, T^xxv,
Liquid extract of licorice (B. P.), TO' ccxi ;
Chloroform water, 3vi ;
Water to 3xii
M. Sig. : One tablespoonful three times a day immedi-
ately after meals.
As will be observed, 240 minims represent a
dose of 10, and 300 minims a dose of i2j/4 minims.
Since arsenical solution is of the strength of i per
cent., each dose of 10 or l2j/4 minims will represent
respectively about i/io grain (0.0065 gramme),
and grain (0.0081 gramme) of arsenic trioxide,
and, practically speaking, in a week the patient takes
2.40 or 3 grains (0.156 or 0.194 gramme), ac-
cording as the prescription has contained 240 or
300 minims.
When he sees a patient for the first time he pre-
scribes 10 minim doses, but if at the end of a week
no signs of improvement are seen, he increases the
dose to 12^^ minims. The latter procedure is not
often necessar}-, for distinct improvement is more
often than not observed at the end of the first week
on a 10 minim dose. He says it may be laid down,
as a good working rule to follow, that, if arsenic
is going to do good in chorea, it will show its bene-
ficial action within the first fortnight. When the
remedy is doing good, he continues it till the patient
can walk along a straight line, and stand on the leg
of the affected side with steadiness. This, he says,
usually represents a period of three or four weeks,
or, at the outside, six weeks.
The patient is kept under observation for three
or four days after all movement has ceased, and
meanwhile takes the following prescription:
R Sodium bicarbonate, 5ii :
Tincture of capsicum TTJ^xxv;
Liquid extract of licorice (B. P.) 5ss :
Chloroform water, 5vi :
Water to 3xii :
M. Sig. : One tablespoonful three times a day immedi-
atelv after meals.
^,2 EDITORIAL
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Review of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M. D.
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Entered at the Post Office at New York and admitted for
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NKW YORK. S.\TURI).\Y, FKBRU.XRY 15. 1908.
THE (iENESIS OF AMERICAN AlEDICLVE.
In the P^ebruary number of the Bulletin of the
Johns Hopkins Hospital there is pubH.shed an ad-
dress entitled Some of- the Conditions Which Have
Influenced the Development of American Medicine,
Especially During the Last Century, delivered last
June by Dr. William H. Welch, of the Johns Hop-
kins University, at the centennial celebration of his
alma mater, the College of Physicians and Surgeons
of New York (the School of Medicine of Columbia
Tniversity). The address is written in Dr. Welch's
usual graceful style, which is so well known that it
will be read widely, as the importance of its subject
deserves. In these strenuous days we are apt to
overlook the history of our profession, thus not only
neglecting what is due to the memory of our great
predecessors, but also omitting to learn lessons which
might serve as most useful guides in our present
endeavors.
Many of the pioneer physicians of early colonial
times did creditable work, some of which has been
recorded and must ever prove of service, but it was
not until the eighteenth century, and particularly its
latter half, that there was any systematic medical
education in North America, and even then progress-
ive men resorted to Europe for in.struction. This
has ever since been the case, but the need for such
recourse has constantly been growing less. With
the new conditions brought about by the success of
the Revolution and the establishment of a solid re-
public, medical men as well as other citizens became
ARTICLES. „ [Ne«- York
Mepical Jourxai,.
more self reliant, but they still sought for the educa-
tional facilities which Europe alone was capable of
holding out. Edinburgh, London, Paris, Vienna,
and the German universities became in turn the re-
sort of American students. Each of them has con-
tributed materially toward building up that state of
medical knowledge which now seems an earnest that
l)efore long we shall be able to repay in great meas-
ure our debt to older countries.
The system of proprietary medical schools, for the
most part destitute of any substantial connection
with a university, came to us from London, but we
carried it far beyond the conservative English limita-
tions. These schools, though wholly irresponsible,
had the power of granting the medical degree, and
nobody questioned the right of a doctor of medicine,
of whatever pedigree, to practise. Such schools are
still too numerous with us, but in nearly every in-
stance they have been shorn of the licensing power.
The system was vicious, however necessary it may
have been to begin with, but, as Dr. Welch says,
speaking of the early days, "the results were better
than the system,." Strong men grew out of it. or
they grew in spite of it, and Dr. Welch reminds us
that such men as John Warren, Godman, Jacob Bige-
low (whom he regards as the greatest thinker in
American medicine), Dewees, Drake, Torrey, and
the Becks "received their entire training in this coun-
try" ; and we might add many more to that grand
array of names. Common sense largely took the
place of learning, and we hope that common sense
will always lead in our pursuit of medical wisdom.
DERMATOLOGY AND GENERAL
PRACTICE.
The recent sudden death of Sir Thomas M'Call
Anderson, M. D.. regius professor of medicine in
Glasgow University, entails the loss of a man who
was at once a prominent dermatologist and a gen-
eral clinician of renown. We do not recall another
recent instance of the association of the two in one
individual, save that of the late Dr. WiUiam H.
Draper, of New York. In this country we knew of
Dr. Anderson as a dermatologist before we knew
him to have achieved distinction in general medi-
cine ; Dr. Draper, on the other hand, was a well
known consulting physician before he went deep
into the study of skin diseases. Of course, there
have been many physicians who, having arrived at
a commanding position in general practice, have
gradually drifted into a specialty and given up other
work. We think, however, that of late years there
must have been very few men who have kept up
both general and special work. The reason for this
Tebruary ,5. .908. J
EDll OKIAL ARTICLES.
313
"parting of the ways" is perhaps to some extent
what might be termed a commercial consideration,
for probably most men realize that their continuance
in general practice makes their numerous rivals in
that field indisposed to send them patients who re-
quire a specialist. It is the old story, and a ver}-
human one, of the retailer and the wholesaler.
Hence we must look upon the exceptional man who
does not bow to tlie supposed necessity as a man of
unusual strength.
The study of cutaneous pathology seems pecu-
liarly qualified to make a physician unusually profi-
cient as a diagnostician. It is true that diseases of
tiie skin are open to the fullest examination, hardly
any artificial aids being needed for their adequate
inspection and palpation, though, of course, ques-
tions concerning their diathetic connections may be
as knott)- as those that come up in other fields of
practice, and their treatment quite as difficult.
Xevertheless, skill in dermatology is not easily ac-
quired, and there is always something new to learn.
Indeed, there is a playful tradition in the New York
Dermatological Society to the effect that a member
deserves expulsion if he brings before a meeting a
patient whose case can be diagnosticated by any
other member present ; though this is merely a wa\-
of saying that only puzzling cases are brought for-
ward, and dermatology has its puzzles in plenty.
Great diagnostic skill is acquired, however, in course
of time, and that, we presume, is why dermatologists
are so often called upon to make a diagnosis when
there is a suspicion of smallpox, for example, albeit
we do not expect the skin specialist to undertake
or suggest the treatment of the case. \\'e all under-
stand that the exanthematous fevers are not skin
diseases, but perhaps because of the avidity with
which we call the dermatologist into consultation
when we suspect smallpox, not a few dermatologists
have been tempted to include a consideration of the
exanthemata in the textbooks with which thej^ have
provided us. While they have thus been tempted,
they have undoubtedly taught us much in the field
of general practice.
RABIES.
An excellent pamphlet has recently been issued by
the Bureau of Animal Industry of the United States
Department of Agriculture. It is entitled Some
Observations on Rabies, and has been prepared by
Dr. E. C. Schroeder. It is curious that the very
existence of rabies — popularly known by the more
high sounding name of hvdrophobia — should still be
questioned and even denied by some medical men.
But such is the fact. The doubt and denial seem
to rest upon no more substantial ground than the
fact that those who proclaim them have never seen
a case, quite as there are those who maintain that
chloroform is no more dangerous than ether, simpl}-
because they have never observed a death from
chloroform. Fortunately rabies is rare and so are
deaths from chloroform, and this no doubt accounts
for the flimsy basis on which unbelievers entrench
themselves. Rabies is indeed a terrible reality, and
every means ought to be taken to prevent its spread.
The dog is not the only agent by which the dis-
ease may be disseminated, though he is the one that
is most commonly active in communicating it, for
the reason, as Dr. Schroeder points out, that his as-
sociation with mankind is practically unrestricted,
for he is generally allowed to run at large. As a
simple measure of precaution, he should be muzzled.
If all dogs were muzzled when they were allowed
their liberty, no hardship would be inflicted on any
of them, for the muzzled would meet only the muz-
zled in hostile encounters and injury of the defense-
less by their own kind would be done away with.
It is only at first, says Dr. Schroeder, that a dog
finds the muzzle irksome ; he becomes accustomed to
it as a colt becomes accustomed to the bit. This
sort of showing ought to silence the opposition to
muzzling on the part of f)ersons actuated merely bv
humane feeling for the dog, and certainly that of
those who hesitate to humiliate an animal ordinaril\-
so serviceable to man. But, in spite of such oppo-
sition, society has the right to protect itself against
rabies by all known means.
Dr. Schroeder does not touch upon the Pasteur
prophylactic treatment of persons who have been
bitten by animals supposed to be rabid, perhaps be-
cause he thinks, as we do, that the wisdom of it is
commonly held to be res adjiidicafa. Surely enough
experience was long ago accumulated to establish
the almost invariable efficacy of the treatment when
administered under proper conditions. As regards
curative treatment, none has yet been discovered ; an
inoculated person is sure to die a horrible death.
We must therefore be insistent in the matter of pre-
vention. "The dog owner who knows what rabies
is from experience," says Dr. Schroeder, "if he has
the proper consideration for his own welfare and
that of his dogs, will be among the first to demand a
movement for its suppression, even if this should
place restrictions on the freedom of his dogs."
THE PATHOLOGY OF CIRCUS AND
MUSEUM FREAKS.
The announcement from Ansonia, Connecticut, of
the recent death of "the only living skeleton," directs
attention to the entire class of freaks, or human
prodigies, as they themselves prefer to be called.
Thev have for the medical man a more than ordi-
314
nary and passing interest. Most of these humble
and unfortunate individuals, whose sole means of
livelihood is the exhibition of their physical infirm-
ities to a gaping and unsympathetic crowd, are
pathological rarities worthy of more serious study
than they usually receive. Their mortality rate is
high, and many of those recently most famous are
already dead or have been retired from public view
by chronic invalidism. A few days ago there died
in Chicago Maggie Minott, one of the most extraor-
dinary of the nanosomes, or true dwarfs. She was
twenty-seven inches high and weighed but twenty-
five pounds. Most of these pygmies are types of
infantilism and are practically nonsexual. An ex-
ception was the comparatively robust and virile
"Tom Thumb," who had a vigorous and manly
beard, who married, but died without issue. Bass,
the "ossified man," also died several years ago. He
was a man of unusual intelligence, and his condition
was caused by an extreme degree oi polyarthritis
deformans. He was injured by a careless museum
attendant, who let him fall as he was being removed
from a carriage, and he never fully recovered. The
elastic skin man a few years ago contracted tubercu-
lous disease of the lungs from exposure of his
scantily clad body on the drafty stage of dime mu-
seums. His was a case of generalized dermat;olysis,
and he had an amusing trick of drawing the skin
of his forehead down over his face like a veil.
Closely allied to him was the Russian dog faced
man, with features marvelously resembling those cf
a Scotch terrier. He and the bearded lady, who was
wont to convince the most skeptical by a liberal
but chaste display of the matronly charms of her
rounded and well developed figure, were unusual
examples of hypertrichosis. The blonde loveliness
of the Circassian beauty, who delighted our un-
sophisticated younger days, was, of course, a case
of albinoism, and the "wild men of Borneo" and
Barnum's "what is it" we now recognize, in the
maturer years of professional experience, as cases
of microcephalous idiocy, gathered for the most part
from the negro population of our southern planta-
tions.
Most examples of gigantism are cases of acro-
megaly— as was notably Chang, the Chinese giant,
who had the gentle, emotional temperament and, in
his last days, the excessive muscular debility so
characteristic of this disease. The various "human
pin cushions" who have been on exhibition would
doubtless present for the neurologist curious areas
of anaesthesia and analgesia, which he would prop-
erly refer to definite lesions in the spinal cord.
Many .students of the late Dr. E. C. Seguin's will
remember the "blue man" whom he often showed
[New York
Medical Journal.
in his clinic at the College of Physicians and Sur-
geons. He ow^ed hii peculiar caerulean gray hue,
approaching the color - of a Maltese cat, to the
argyria of his tissues produced by the prolonged
administration of silver nitrate — a melancholy victim
of credulity as to the efficacy of this drug in loco-
motor ataxia.
In parts of southern Europe there was formerly
plied a nefarious trade in maiming and mutilating
young children for the purpose of producing dis-
tressing deformities to excite pity and thus induce
alms. An instance of such mutilation is made
romantic use of by Victor Hugo in his story
L'Homme qui rit. In most civilized countries there
are now enacted laws forbidding the public exhibi-
tion of monsters and revolting deformities. A more
refined and a more humane popular taste now
frowns upon such exhibitions, and they are less
profitable to their promoters. The profession of
museum freak is passing. The genuine lusus natura:
is, however, always a valuable subject of study for
the scientific physician, which may add to our
knowledge of development of normal types and may
possibly illuminate many difficult and obscure prob-
lems in pathologv.
BABY'S BEDCLOTHES.
There are few parents who are not annoyed and
even much disturbed by the persistent kicking off
of the bedclothes by the baby and younger children.
The performance is variously attributed, according
to the training of the parents, to a manifestation of
the "old Adam" and to indigestion. The universal-
ity of this infantile objection to bedclothing seems
to us to point to a radical defect in the clothing
itself. It is customary to cover the baby with a
cotton sheet, a blanket or two, and a silkolene cov-
erlet lined with cotton batting. These absolutely
impervious coverings do not permit a particle of
air to pass through, and the respiratory function of
the baby's skin is quite inhibited. We suggest that
a linen sheet be used to cover the baby, although
perhaps a cotton one may be allowed underneath ;
over this nothing could be better than an old fash-
ioned knitted comforter, such as is sometimes seen
on baby carriages in cases where the baby has an
early nineteenth centur}' grandmother who has
learned to knit. Such a comforter will be found
somewhat costly to purchase, but not so costly, after
all, as sundry visits of the physician to take care
of a bronchitis or worse : it will admit air. permit
the skin to "breathe," be light on the baby's delicate
body, and look as well as all genuine homemade
articles look. If the baby has a normal digestion
there will be no kicking ofi^ of such covering.
EDITORIAL ARTICLES.
XEIVS ITEMS
315
"MONGOLIAX BIRTH MARKS."
Certain congenital bluish spots in the sacral
region have been known as "Mongolian birth
marks." When they have been observed in chil-
dren of the white races, there has been the suspicion
of a [Mongolian strain in the ancestry, though per-
haps a remote one. Recently Menabuoni (Monats-
schrift fur Kinderheilkunde, 1907; Berliner klinische
Wochenschrift, September 30th) has observed an
instance in a child, seven months old, born in Flor-
ence, of white parents. Nothing positive could be
ascertained as to the question of a partly Mongolian
ancestry. The author, however, is inclined to accept
its existence.
HENRY NEWTON HEINEMAN. M. D.,
of Paris.
Dr. Heineman died suddenly in Paris on Tues-
day, February nth, at the age of fifty-five. He was
a New Yorker by birth and education, and prac-
tised medicine in New York until about ten years
ago, when he took up practice at Bad Nauheim for
the summer and in Paris for the winter. Long be-
fore he left New York he had achieved the reputa-
tion of an able, physician, and he was very popular
in the profession.
Changes of Address. — Dr. G. W. Stimson, of Phila-
delphia, to St. Charles place and Pacific avenue, Atlantic
City, N. J.
The Portland, Me., Medical Club held a meeting on
the evening of February 6th. Dr. John Allen acted as host,
and the paper of the evening was read by Dr. A. H. Weeks.
The subject was Diet in Diabetics.
Donation to Mt. Sinai Hospital. — The officers of Mt.
Sinai Hospital announce the receipt of a gift of $20,000
from Dr. Adolph Lewisohn. which is to be added to the
endowment fund of the hospital.
University of California. — The chair in psychology
has been gi\ en to Dr. G. AI. Stratton, professor of experi-
mental psychology and director of the Psychological Lab-
oratory at Johns Hopkins University.
The Samaritan Hospital Medical Society, of Phila-
delphia, has elected the following officers for the com-
ing year: President, Dr. Collier H. Martin; vice presidents,
Dr. G. Morton Illman and Dr. William A. Steel ; secre-
tary and treasurer, Dr. Jesse A. .\rnold.
New Nurses* Home for Harlem Hospital. — Plans have
been filed for a five story and basement building to be
erected in East One Hundred and Thirty-sixth street by
the trustees of Bellevue and Allied Hospitals, for the
nurses connected with the new Harlem Hospital.
The Annual Election of the Philadelphia County
Medical Society was held recently and the following
are the newly elected officers : Pres'ident. Dr. Albert M.
Eaton; vice presidents, Dr. Henry W. Cattell, Dr. Frank
C. Hammond, Dr. William Evans, Dr. Robert L. Pitfield,
Dr. Henry G. Godfrey, and Dr. John B. Turner: secretary.
Dr. William S. Wray; assistant secretary. Dr. .\le.xander
R. Craig; treasurer. Dr. Collier L. Bower: censor, Dr.
William M. Welch.
The Medicolegal Society of Philadelphia has elected
the following officers for the ensuing year : President, Dr.
William Ruoff; first vice president, J. Savidge, Esq.; sec-
ond vice president. Dr. S. P. Gerhardt ; secretary. Dr.
W. T. Hamilton ; and treasurer, Dr. G. M. D. Peltz.
The Society of Physicians of the Village of Canan-
daigua, N. Y., held a meeting on Thursday evening. Feb-
ruary 13th. Dr. John H. Pratt acted as host and the
paper of the evening, which was read by Dr. A. L. Beahan,
was on The Treatment of the Neck and Shaft of the Femur.
Buffalo Academy of Medicine. — The meeting of the
Section in Aledicine. which was to ha\e been held on
Tuesday evening, February nth, wa> postponed on
account of the sudden iUness of Dr. Victor G. \'aughan, of
Ann Arbor, who was to read a paper on Proteid Poisons.
The New York Psychiatrical Society has made ar-
rangements for a series of public lectures. The first of
these lectures will be delivered by Dr. Pearce Bailey at the
New York Academy of Medicine, on Saturday evening,
February 15th, at 8:30 o'clock. The subject is Alcoholism.
The Society of Former German Students in America
will hold a meeting on Wednesday, February' 19th, at 8:15
p. m. Dr. Carl Beck, of 37 East Thirty-first street, New
York, will read a paper entitled Pictures from Latin Amer-
ica, a Trip to the West Indies, Colombia, Costa Rica, and
Panama.
The Glens Falls, N. Y., Medical and Surgical Society
held its annual meeting and banquet on Thursday evening,
February 6th. A paper on Hemorrhage in the New Born
was read by Dr. W. J. Hunt, of Glens Falls, and was dis-
cussed by Dr. W. C. Cuthbert and Dr. T. T. Park, of
Sandy Hill.
The Society of Medical Jurisprudence. — The two
hundred and eleventh regular meeting of this society was
held on Monday evening, February lOth. The paper of the
evening was entitled The Constitutional Aspects of Medi-
cal Laws, and was read by Charles A. Boston, Esq., of the
New York bar.
A New Hospital for Rockville, Conn. — It has been
announced that Mr. William H. Prescott has given the sum
of $50,000 to found a hospital in Rockville. Conn. In addi-
tion to this gift, members of the Prescott fainily have pur-
chased a site for the hospital, and will present it to the
trustees of the fund.
Sanitary Officers' Association of Ontario County,
N. Y. — The quarterly meeting of this association was
held in Canandaigua, N. Y., on Tuesday. February nth.
Dr. O. J. Hallenbeck, of Canandaigua, read a paper on
Rabies, and Dr. B. T. McDowell, of Bristol Centre, read a
paper on Typhoid Infection.
Richmond, Va., Academy of Medicine and Surgery. —
.\t a meeting held on Tuesday. February nth, Dr. Beverley
R. Randolph read a paper entitled Tic Douloureux : Neu-
ralgia of the Fifth Nerve from a Medical Standpoint, and
Dr. Charles R. Robins gave an exhibition of a splint from
a fracture of the femur at birth.
Medical Society of the State of New York. — Owing
to the refusal of Dr. Edward L. Trudeau, of Saranac, to
act as president of the society, on account of ill health,
the first vice president in numerical order. Dr. Arthur G.
Root, of Albany, becomes president for the year 1908, un-
der section 2 of chapter 6 of the by-laws.
Rochester, N. Y., Academy of Medicine. — The regu-
lar meeting of the Section in Surgery was held on Wednes-
day evening, February 12th. A paper on the Cause of Pain
in "the Upper Back was read by Dr. C. Wentworth Hoyt,
by invitation, and a paper on Diseases of the Hip Occurring
in Adults was read by Dr. Ralph R. Fitch.
The New York State Civil Service Commission will
hold examinations on March 7, 1908, for the following posi-
tions : Physician, Onondaga County Penitentiary, salary
about $480; steward. State Charitable Institutions, $1,000
to $1,500 and maintenance: woman officer. State Charitable
Institutions, $300 to $360 and maintenance.
Special Sanitation in San Francisco. — The Board of
Health of San Francisco has contributed the sum of
$11,500 towards meeting the expenses of the special sani-
tation campaign now being conducted in San Francisco.
The Public Health and Marine Hospital Service is aiding
the city board of health in carrying on this work.
316
NEI'VS ITEMS.
[Ntw York
Medical Jouit:-i\i..
The American International Congress on Tubercu-
losis and the New York Medicolegal Society will hold
a joint niceling in Chicago, on June ist, 2d, and 3d. The
local committee of arrangements is composed of Dr. Dens-
low Lewis and Dr. Thomas Bassett Keyes, of Chicago, and
Dr. E. S. McKee, of Cincinnati, the latter having been
appointed to take the place of the late Dr. Senn.
The Medical Society of Washington County, Md.,
held a meeting on Thursday evening, February 13th. Dr.
Charles OT^onovan and Dr. A. P. Herring, of Baltimore,
read papers on Medical Organization in Maryland, which
were followed by a general discussion of the question of a
post graduate course for county medical societies. Dr.
\^. M. Reichard, of Fair Play, opened the discussion.
The Pathological Society of Philadelphia and the
Philadelphia Academy of Surgery held a jomt meeting
on Thursday evening, Februar\ 13th. The evening was
devoted to a symposium on the Parathyreoid Gland, papers
on the subject being read by Dr. W. H. Halstead and Dr.
W. G. MacCallum. of Johns Hopkins University. After
the meeting a reception was tendered to Dr. Halstead and
Dr. MacCallum at the University Club.
Appointments in Foreign Universities. — Dr. D. Barry
has been appointed professor of physiology at Queen's Col-
lege, Cork, Ireland.
Dr. S. Berezowsky has been appointed professor of
external pathology at the University of Moscow, Russia,
as successor to the late Professor Sinizin.
Professor Jacobi, of Gottingen, has accepted the appoint-
ment of professor of pharmacology and director of the
pharmacological institute at the University of Tiibingen.
The Tuberculosis Exhibit in Kentucky.— The tuber-
culosis exhibit which was held recently in Louisville and
afterwards transferred to Frankfort, where it was open to
the public from February 3d to February 7th, will be sent
to Lexington for its third and last appearance in Kentucky.
The exhibit in Lexington will lie held on February 21st
to 26th under the auspices of the Lexington Antituberculo-
sis Association. The three exhibits in Kentucky are a
part of the general campaign against tuberculosis, which
is being carried on under the auspices of the National As-
■sociation for the Study aftd Prevention of Tuberculosis.
New York Pathological Society. — The regular meet-
ing of this society will be held at the New York Academy
of Medicine on Wednesday, February 19th, at 8:30 p. m.
There will be demonstrations of a rare case of Multiple
Tuberculous Abscesses of the Spleen, by Dr. Charles
Norris, and a case of Bilateral Renal Tumors, by Dr. J.
Larkin. The following papers will be read : A Study of
Blood Cultures in Typhoid Fever, by Dr. A. A. Epstein;
A New Method for the Quantitative Determination of the
Acetone of the Urine, by Dr. T. Stuart Hart; Tuberculosis
of the Mesenteric Lvmpb Nodes; Infections bv Human
Type of Bacilli, by Dr. A. F. Hess.
College of Physicians of Philadelphia. — The Section
in General Medicine held a meeting on Monday evening,
February loth Dr. L. L. Donhauser exhibited a case of
ricketts.' Dr. Edward H. Goodman read a paper on Levu-
lose as a Test of Hepatic Function, and Dr. G. Gaiiby Rob-
inson read a paper entitled Gallop Rhythm of the Heart.
Dr. William Pepper reported a case of chronic lymphatic
leucaemia. Dr. E. Burville-Holmes reported a case of
fibrinous bronchitis, and a case of pneumococcus arthriti-
was reported by Dr. Alfred Hand, Jr.. and Dr. John H.
Jopson.
An Exhibit Illustrating the Congestion of Population
in New York will be held in the American Museum of
Natural History for a period of two weeks. beginnin.L;
Monday, March Qth. On the opening night Governor
Hughes, Mayor McClellan, the Italian Ambassador to the
I'nitcd States, and several of the commissioners of New
^'ork City will speak, and on the three following days
there will be a general discussion of the various aspects of
the congestion of population. One day will be devoted to
a conference of representatives from the various cities of
New York State. The object of the exhibit is to make
clear the causes of and the evils resulting from the mass-
ing of people in limited areas, and the best methods of
dealing with the problems involved. Much interest is being
shown in the exhibit, and a large number of the city de-
partments and ntlur organizations will participate and
furnisli exhibit-
Philadelphia County Medical Society. — At a meeting
of the Central Branch, held on Wednesday evening, Febru-
ary i2th, the evening was devoted to a symposium on the
Zander Treatment. Mr. Max J. Walter read a paper en-
titled The Zander Gymnastic Method of Treatment by Me-
chanical Apparatus, which he illustrated by a lantern slide
demonstration of the apparatus. Dr. J. Madison Taylor
read a paper on The Field of Applicability of the Zander
Mechanical Gymnastics. Among those who took part in
the discussion were Dr. Hobart Amory Hare, Dr. Judson
Daland, Dr. S. Solis-Cohen, Dr. H. Augustus Wilson, Dr.
J. T. Rugh, and Dr. E. A. Newton.
Mortality of Chicago. — According to the report of
the Department of Health for the week ending February i,
1908, there were during the week 711 deaths from all
causes, as compared with 741 for the corresponding week in
1907. The annual death rate was 17.12 in 1,000 of popula-
tion. The principal causes of death were : Apoplexy, 8 ;
Bright's disease, 42; bronchitis, 35; consumption, 66; can-
cer, 32 ; convulsions, 8 ; diphtheria, 7 ; heart diseases, 55 ;
influenza, 46; intestinal diseases, acute, 43; measles, i;
nervous diseases, 17; pneumonia, 139; scarlet fever, 15;
suicide, 4; typhoid fc\cr, 8; \'iolence, other than suicide,
23; whooping' cough, i; all other causes, 161.
The Mortality of the District of Columbia During
the Year 1907. — According to the report of the Depart-
ment of Health, there were 6,343 deaths from all causes
during the year, an increase of twenty-seven over the pre-
ceding year. The death rate showed a decrease, however,
from 19.35 to 19.25 in 1,000 of population, on account of
an increased population. There -were 750 deaths from pul-
monary tuberculosis, as compared with 781 the previous
year, while deaths from pneumonia increased from 503 to
537. The number of deaths from typhoid fever during
1907 was 114, during 1906, 162. There was also during
1907 a diminished death rate from diphtheria and scarlet
fever.
The Medical Association of the Greater City of New
York. — A stated meeting of the association will be held
at the New York Academy of Medicine on Monday even-
ing, February 17th. The programme will include addresses
by the retiring president. Dr. Thomas E. Satterthwaite, and
the president elect, Dr. Robert Tuttle Morris. The subject
of Dr. Morris's address is Metaplasia of the Appendix
Vermiformis and a New Diagnostic Point. Among those
who will take part in the discussion are Dr. Robert F.
Weir, Dr. Algernon T. Bristow, Dr. Robert Abbe. Dr. Carl
Beck, Dr. Alexander B. Johnson, Dr. Joseph F. Bloodgood,
Dr. Franz Torek. Dr. John B. Walker, Dr. Charles H.
Peck, and Dr. Albert A. Berg.
Something New in the Way of Baths. — The Fleisch-
man Baths, which occupy the three upper stories of the
Bryant Park Building, corner of Forty-second street and
Sixth avenue. New York, were opened to the public last
week, a reception being given to the medical profession and
the press on the evening of February 6th. The establish-
ment is modelled after the baths of Diocletian, but with
many modern improvements, embracing a number of unique
and attractive features. They are fitted up in most elabo-
rate style, and are provided with every kind of bath known
to modern balneology. One particularly interesting novelty
is the solarium, which occupies the entire top of the build-
ing. .Sleeping apartments are also provided in connection
with the baths.
The Hodgkins Fund Prize. — The Smithsonian Insti-
tution, Washington, D. C, announces that the Hodgkins
Fund Prize of $1,500 is oft'ercd for the best treatise 011
The Relation of Atmospheric Air to Tuberculosis, to be
submitted to the International Congress on Tuberculosis,
which will he held in Washington, D. C, on September 21
to October 12, 1908. The treatise may be written in Eng-
lish, French, German, Spanish, nr Italian. The essays
will be examined and the prize will be awarded by a com-
initlee appointed by the secrttar\ of the Smithsonian In-
stitution in conjunction with the officers of the Interna-
tional Congress on Tuberculosis. The right is reserved
to award no prize if. in the judgment of the committee, no
contribution is offered of sufficient merit. The Smith-
sonian Institution reserves the right to publish the treatise
to which the prize is awarded. Further information will be
furnished, on application, by Mr, Charles D. Walcott. sec-
retary of the Smithsonian Institution. Washington. D. C.
February 15, ig^b,A SEIVS 11 l:M . 3I7
Philadelphia Paediatric Society. — A meeting of this
society was held on Tuesday evening. February nth.
Rheumatism in Children was the general subject for
discussion, the following papers being read : The
.Etiolog}- of Rheumatism, by Dr. Warfield T. Longcope ;
The Relation of Rheumatism to Chorea, by Dr. D. J. Mc-
Carthy: Til- Peculiarities of the Symptomatology' of Rheu-
matism in Children, by Dr. Charles H. Dunn, of Boston :
uie v_ ,nipiications of Rheumatism in Children, by Dr. Al-
fred Stengel ; the Cutaneous Manifestations of Rheumatism
in Children, by Dr. Jay F. Schamberg: the Treatment of
Rheumatism in Children, by Dr. J. P. Cozier Griffith. After
the meeting a reception was tendered Dr. Dunn at the
Hotel Stenton.
Insanity in New York State. — According to the an-
nual report of the State Commission in Lunacy, the total
number of committed insane in the State on October i.
1907, was 29,093 — 13,927 men and 15,166 women. The num-
ber of inmates of the two criminal asylums at Matteawan
and Dannemora was 1,104: the number in private licensed
institutions was 977. The net increase for the year was
791. The total number of patients received on original
commitments was 6,105. The maintenance cost during the
year was $3.53 a week. A slight increase in the rate of
recovery is reported, the percentage of cures on the num-
ber of patients received on original commitments being
25.5. The total number discharged during the yezr as
recovered was 1,557, and as improved, 1,236.
The Philadelphia Academy of Surgery held a meet-
ing on Monday evening, February 3d. Dr. James K. Young
presented a case of Excision of the Clavicle with Perfect
Fimctional Results. Dr. Warren Walker e.xhibited a case
of Tumor of the Orbit. Dr. Oscar H. Alli< read a paper
entitled The Nonabsorbable Ligature and Suture. Dr. John
B. Deaver presented a report of the Saturday Surgical
Clinics for Students at the German Hospital During 1906-7.
Dr. Henry R. Wharton reported three cases of Fracture
of the Proximal End of the Fifth ^Metatarsal Bone, a case
of Multiple Fracture of the Lower Jaw Treated with an
Interdental Splint, and three cases of Fracture of the
Patella Treated by Open Operation and Suture. Dr. A. C.
Wood exhibited an instrument for performing Osteoplastic
Resection of the Skull.
Examination for Surgeons in the Public Health and
Marine Hospital Service. — The United States Civil
Service Commission announces an examination to be held
on March 4th to secure eligibles from which to make certi-
fication to fill a vacancy in the position of acting assistant
surgeon. Public Health and Marine Hospital Service, for
duty at St. John's River Quarantine Station, Mayport, Fla.,
and vacancies requiring similar qualifications as they may
occur. For the specific vacancy mentioned applicants must
be expert in the diagnosis and treatment of yellow fever,
and persons who are immune to that disease are preferred.
Applicants must be citizens of the United States and must
be twenty years of age or over on the date of the examina-
tion. Applicants should apply at once to the United States
Civil Service Commission. \\^ashington. D. C, for Applica-
tion Form 1312.
The Health of Philadelphia. — During the week end-
ing January 18, 1908. the following cases of transmissible
diseases were reported to the Bureau of Health of Phila-
delphia: Tj-phoid fever. 115 cases. 21 deaths: scarlet fever.
67 cases, 2 deaths ; chickenpox. 36 cases, o deaths : diph-
theria. 84 cases. 9 deaths : cerebrospinal meningitis. 5 cases,
5 deaths ; measles, 75 cases, 2 deaths : whooping cought. 20
cases, 2 deaths : pulmonary tuberculosis. 128 cases, 70
deaths: pneumonia. 139 cases, 105 deaths: erysipelas, 8
cases, 2 deaths : German measles, 3 cases. 0 deaths : septi-
caemia, 3 cases, o deaths : mumps. 7 cases, o deaths : cancer,
18 cases, 22 deaths. The following deaths were recorded
from other transmissible diseases : Tuberculosis, other than
tuberculosis of the lungs, 13 ; puerperal fever. 3 : diarrhoea
and enteritis under two years of age. 10. The total deaths
numbered 657 in an estimated population of 1,532.738. cor-
responding to an annual death rate of 22.21 in i.ooo of
population. The total infant mortality- was 121 : under one
year of age. 90; between one and two years of age. 31.
There were 44. still births. 26 males and 18 females. The
total precipitation was 1.13 inches. The temperatures were
high, the maximum being 56° on the 12th: the minimum
25° on the 17th.
Personal. — Colonel William C. Gorgas, chief .surgeon
of the Panama Canal Commission, has been elected an
Honorary Fellow of the New York Academy of Medicine.
Sir Thomas M'Call Anderson, professor of medicine in
the University of Glasgow, died on Januarj- 25th.
Dr. Charles S. Crosby, of Columbus, Ohio, is registered
at the Philadelphia Polyclinic and College for Graduates
in Medicine.
Dr. W. J. Collins has been appointed city physician of
Springfield, Mass.
Mr. Malcolm Morris, the well known dermatologist, has
had conferred upon him the title of K. C. V. O. (Knight
Commander of the Royal Victorian Order).
Dr. Charles A. Phillips has been appointed physician at
the new county jail, in Schermerhorn street, Brooklyn.
Dr. Arthur W. de Roaldes, of New Orleans, has been
promoted by the French government to the rank of Com-
mander of the Legion of Honor.
Dr. Howard A. Kelh;, professor of gynaecology at the
Johns Hopkins Medical School, has returned from a six
weeks' trip to Mexico.
Army Medical Bill. — Senator Warren's bill increasing
the efficiency of the medical corps of the Army has been
passed by the Senate. It constitutes the Medical Depart-
ment of the Army of the following corps : Medical, medi-
cal reserve, hospital corps, reserve corps, and dental corps.
The officers are to be a surgeon general, with the rank of
brigadier general ; sixteen colonels, twenty-four lieutenant
colonels, no majors, and 300 captains or first lieutenants.
The medical reserve corps is created by conferring au-
thority on the President to issue commissions as first lieu-
tenants to graduates of reputable schools of medicine. The
rank will carry no rights to promotion. The regular offi-
cers under the proposed law are to receive the pay of offi-
cers of the line of corresponding grade, and the bill pre-
scribes that promotion shall be by seniority. The House
Committee has made a favorable report on the bill but
recommends amendments providing for fourteen instead of
sixteen colonels, twenty instead of twenty-four lieutenant
colonels, and one hundred instead of one hundred and ten
majors. The committee also made other slight amend-
ments, among them being one which makes eligible to ap-
pointment in the regular corps any contract surgeon who
is not over twenty-nine years of age at the date of his
appointment as contract surgeon. The bill has been re-
ferred to the committee of the whole house and its passage
seems assured.
Society Meetings for the Coming Week:
MoxD.w, February jjtlt. — Xew York Academy of Medi-
cine (Section in Ophthalmologj-) ; Medical Association
of the Greater City of New York; Hartford, Conn.,
Medical Society.
Tuesday, February iStli. — New York Academy of Medi-
cine (Section in Medicine) ; Buffalo Academy of Medi-
cine (Section in Pathology' ) ; Triprof essional Medical
Society of New York : Medic.il Society of the County
of Kings. N. Y. : Binghamton. X. Y.. Academy of
Medicine: Clinical Society of Elizabeth. X. J., General
Hospital : Syracuse. X. Y.. Academy of Medicine ; Og-
densburgh. X. Y., Medical Association.
Wednesday. FcbKuary igtli. — New York Academy of Fed-
icine (Section in Genitourinary Diseases) ; New York
Society of Dermatology and Genitourinary Surgery;
Woman's Medical Association of New York City
(New York .Academy of Medicine) : Medicolegal So-
ciety, New York : New Jersey Academy of ^Iedicine
(Jersey City); Buffalo Medical Chib : Xew Haven.
Conn., Medical Association : New York Society of In-
ternal Medicine ; Northwestern Medical and Surgical
Society of X'ew York.
Thursday. February 20th. — New York Academy of Medi-
cine : German Medical Society, Brooklyn ; Newark,
N. J.. Medical and Surgical Society ; .^Isculapian Club
of Buffalo. N. Y.
Friday. February 21st. — New York Academy of Medicine
(Section in Orthopaedic Surgery) : Clinical Society of
the X'ew York Post-Graduate Medical School and Hos-
pital: East Side Physicians' Association of the City of
Xew York: Xew York Microscopical Society: Brook-
lyn Medical Society.
Saturday. February 226. — West End Medical Society,
New York: New York Medical and Surgical Society:
Harvard Medical Society, New York: Lenox Medical
and Surgical Society. New York.
3iS
I'lTH or CURRENT LIT LR.-IT URE.
|ith at Current f iteratoe.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
February 6, JOoS.
1. The Treatment of Sarcoma with the Mixed Toxines ol
Ervfipelas and Bacillus Prodigiosiis,
By William B. Colev.
2. The Treatment of Leucaemia with the Mixed Toxines
of Colev. By Ralph C. Larkabee,
3. General Paralysis as a Menace to Public Safety in
Transportntion, By Philip Coomks Knapp.
4. The Direct Examination of the Larynx and of the
L'pper End r.f the CEsophagus by the Lateral Route,
By Harris Peyton Mosher.
1. The Treatment of Sarcoma with the Mixed
Toxines of Erysipelas and Bacillus Prodigiosus.
— C'ulcy speak> of his treatment which he instituted
sixteen years ago, leased upon the following accept-
ed clinical facts: (i) That inoperable sarcomas,
and even carcinomas, have been known to disap-
pear and the patients to remain well and perma-
nently cured as the result of attacks of accidental
erysipelas. ( 2 j That inoperable sarcomas have dis-
appeared as a result of attacks of erysipelas pro-
duced by inoculation. In all Coley has per-
sonally treated about 430 cases of sarcoma with
the mixed toxines. In forty-seven of these
cases the tumor has completely disappeared ;
and in twenty-eight cases a period of from
three to fifteen years has passed since the dis-
appearance. Twenty-six patients have remained
well from five to fifteen years. These figures cover
a period of fifteen years, and during this period im-
portant improvements have been made, from expe-
rience., in both the preparation of the toxines and the
method of administration. There is no appreciable
risk from this treatment. In only three out of tlie
430 cases death could possibly be attributed to the
toxines. All these three patients were in the last
stages of the disease, with extensive metastases and
very feeble heart action. Two of the cases presented
extensive involvement of the mediastinal glands,
and in both the treatment had only just been be-
gun, for two or three days, and sufficient doses had
not been given to produce any marked reaction. The
patients died suddenly, apparently as a result of an
embolus. The author describes the process of pre-
paring the mixed toxines and cites a number of
cases.
2. The Treatment of Leucaemia with the
Mixed Toxines of Coley. — Larrabee has used the
mixed toxines of streptococcus and Bacillus prodi-
c^iosits in four cases. One showed a degree of im-
l)rovement amounting to symptomatic recovery,
which has now lasted for upwards of four months.
Another showed considerable temporary improve-
ment. A third showed improvement in weight and
general condition only. /V case of the acute lym-
phatic type was uninfluenced. .Although two are
still under treatment there does not appear to be
much hope of permanent cure. In estimating the
value of this treatment, so far as we are justified in
doing so from the limited material at hand, says the
author, we nmst com]nire it with other methods in
common use. particularly with arsenic and the
Rontgcn rays. As to arsenic, it must be admitted
that in some cases excellent results follow its use.
lN.av \okk
Medical Jocr.val.
though these results are never more than temporary
and often fail entirely. In all of the cases under
discussion arsenic had been used alone without
definite results. In the writer's experience it is rare
for arsenic to produce any such prompt and marked
results as in two of the cases described. With the
truly marvellous effects sometimes obtained with the
X rays the writer is unable to say that toxines will
compare favorably. Cases have been restored to
complete health by the x ra}-s, and, though they al-
ways relapse sooner or later, some have remained
well for months. The toxines of streptococcus and
Bacillus prodigiosus are decidedly more painful, and,
in the writer's opinion, decidedly more dangerous.
It is possible that their efifects will prove more perma-
nent. Their great advantage at present is that they
can be used in many cases M-here radiotherapy is not
available. The toxines can be administered by any
physician or nurse of ordinary skill. They need no
costly apparatus and do not require the patient to
leave his bed. The author thinks that the results
have been encouraging enough to justify further
trial. It is in the hope that such further trial may
be obtained that these cases are reported in their
present incomplete state.
3. General Paralysis as a Menace to Public
Safety in Transportation. — Knapp remarks that
if men in responsible positions on our railroads were
subjected to thorough examination by competent
neurologists at regtdar intervals many of these cases
of general paralysis and other brain diseases would
be detected and the dangers attendant upon them
would be averted. Many railroads demand a care-
ful examination of all applicants for employment,
but when this examination is once passed, the man
is not examined again unless some striking disturb-
ance is noted. The average railway surgeon, how-
ever, will inevitably overlook the slight but signifi-
cant symptoms that reveal grave brain disease to
the neurologist, and, even if he were capable of de-
tecting them, it is only by examinations repeated at
regtilar and rather frequent intervals that the on-
set of these diseases can be detected, and the danger
averted. These atfections are not responsible for
all the cases of negligence that cause railway acci-
dents, but they form one factor which can be elim-
inated. The state requires that certain railway em-
ployees shall pass examinations to prove that they
can tell red from green. Is it too much also to re-
quire them to pass periodical examinations to prove
that they can instantly understand the different
meanings of red and green and act promptly on that
knowledge ?
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
February S, igo8.
1. Enforcement of Medical Practice Laws by County
Societies, By Floyd M. Crandall.
2. The Indications for Operation in Elective Surgery,
By Gerry R. Holden.
^. Early and Late Cases of Gastric Ulcer.
By William Fitch Cheney.
4. The .E^tiologv of Epithelioma; .\ Laboratory and
Clinical Study, By .\rthur E. Hertzler.
5. The .Ambulatorv Treatment of Hip Joint Disease,
By E. G. .AnnoTT and H. A. Pingree.
6. The Rontgcn Ravs in Oral Surgery,
By G. E. Pfahler.
7. Sensory Dissociation as a Symptom. With Report of
a Case of Syringomyelia. By Harrison Mettler.
riill OF CURREXT LITERATURE.
8. The ;Major Operative 'I'reatnicm of Middle Ear Sup-
puration and Its Indicatiiius,
B> I'jiW AKi) Bradford Dexch.
9. Indications for Operative Interference in Cerebral
Complications Due to Cb.ronic Suppuration of the
Middle Ear, By Culi.en F. Welty.
3. Early and Late Cases of Gastric Ulcer. —
Cheney observes that' there is an early stage of gas-
tric ulcer, lasting for weeks or months, during
which rigid medical treatment suffices for cure ; but
the clinical pictine of this stage does not correspond
to the classical one presented in the textbooks, and
the diagnosis at this time must be inferred rather
than demonstrated positively. Many cases of
chronic dyspepsia, characterized for weeks or
months by flatulence, waterbrash, burning and dis-
tress after food, where the epigastrium shows ten-
derness and the test meal shows hyperacidity, are in
reality gastric ulcer, even when the faeces show no
occult blood. Such cases cannot positively be diag-
nosticated as ulcer any more than incipient tubercu-
losiscan positively be diagnosticated beforebacilli are
found in the sputum ; yet they deserve routine treat-
ment on suspicion in one instance as truly as in the
other. If these dyspeptic cases are allowed to go
on indefinitely without treatment or with only hap-
hazard treatment, serious symptoms are likely
sooner or later to appear tliat make the diagnosis
clear, but that render the results of treatinent much
more dubious. In the later stage, commonly de-
scribed as gastric ulcer, the symptoms are really-
due to complications rather than to the original
disease; (a) to perigastric adhesions, (b) to pyloric
stenosis, (c ) to gastric dilation and retention, (d)
to localized peritonitis, (e) to the opening of a large
bloodvessel, ( f ) to perforation of the stomach wall;
complications that lie beyond the realm of medical
treatment and have crossed the border line into the
surgeon's domain.
4. The .ffitiology of Epithelioma. — Hertzler
thinks that cancer occurs at that point where irri-
tation and exposure to an alkaline secretion coexist.
When a chemical which has the power of combin-
ing with the acidophilic elements is injected into a
tissue made up of epithelium and connective tissue
the epithelium proliferates and invades the connec-
tive tissue, simulating the process in beginning
epithelioma. The same chemical process which pre-
vents blood from coagulating limits the invasion of
one tissue by another. Epithelium everywhere rests
on a tissue similar to the membrane elastica of the
bloodvessel. It is this layer that confines epithelium
within the normal limit. The aberrant growth of
cells is but the expression of some disturbance in
the chemical relationship of the different kinds of
cells. The results of experiments, based on the
knowledge of tinction chemistry, permits us to state
in general terms the nature of such disturbance of
chemical balance.
5. The Ambulatory Treatment of Hip Joint
Disease. — Abbott and Pingree describe the so
called German, English, Austrian, and American
apparatus and are of the opinion that no one form
embodies all the essential phases of mechanical treat-
ment. In order, then, to apply more successfully the
principles of fixation, traction, and protection, we
are obliged, remark the authors, either to seek
some entirely new form of appliance, or to combine
the requisite features of those in common use, so
that the product will carry the desired treatment into
effect. If we take into consideration the matter of
cost, which is indispensable in a clinic for the poor,
it seems impossible to construct an\- form of ap-
paratus along new lines of different material from
that already suggested without putting it beyond the
reach of most patients. They say that the plaster of
Paris spica bandage aft'ords the best fixation, the ad-
hesive plaster straps the best traction, and the iron
brace which extends beyond the sole of the boot, to-
gether with the high shoe on the opposite foot, and
crutches, the best protection. The cost of this com-
bination amounts to about $5.75 for an average sized
child. The application of such an apparatus is then
described and fully illustrated. The authors have
treated about two hundred children with their form
of apparatus, and come to the conclusion that the
patient is under excellent control, as the apparatus
cannot be removed and replaced by the patient or
family at will. The appliance can be produced at
inuch less expense than anv other that is efficient.
The duration of the treatment may be lessened ;
there is less danger of abscess formation : and the
preservation of the joint structure is inore certain.
The position of the limb can be regulated to a nicety
otherwise obtained only through the use of expen-
sive apparatus accurately adjusted l)y skilletl hands
and kept constantly under the closest observation.
MEDICAL RECORD.
February 8, 1908.
1. Blood Reactions of Inflammation ; and the Diagnostic
Prevention of the Terminal Stages of Infections of
the Appendix and Gallbladder,
By \^■. A. Bartlett and E. E. Smith.
2. Stricture of the Eustachian Tube with Its Baneful Con-
sequences Traced to Adhesions in the Fossa of
Rosenmijller, By W. Sohier Bryant.
3. The Organic Factor in High Blood Pressure,
By Alexander Haig.
4. Incipiency in Tuberculosis from the Standpoint of
Sanatoria. The Safety and the Value of the Tuber-
culin Test when Safeguarded Solely by the Clinical
Method, By Hexrv" B. Dcxham.
r,. Benjamin Rush as a Phthisiotherapist.
By Hexrv Farxl-n[ Stole.
6. The Misuse of the Voice and Its Cure. \'ocal Muscles
and Resonance, By N. J. Poock \"an Baggen.
7. The Favorable Influence of Small Doses of Arsenic
and Bichloride of Mercury in Three Cases of Graves's
Disease, By Leoxard Weber.
2. Stricture of the Eustachian Tube with Its
Baneful Consequences Traced to Adhesions in
the Fossa of Rosenmiiller. — Bryant states that
the fossae of Rosenmiiller are subject to obstructions
and adhesions which interfere with the physiological
action of the Eustachian tube through imperfect
movements of the tubal cartilage, resulting in stric-
ture of the Eustachian tube. This can be demon-
strated by the use of a salpingoscope. Relief from
this impediment allows of more eft'ective treatment
of the middle ear condition. Early treatment of the
obstruction of the fossae is indicated as soon as the
diagnosis is made. The disturbances in the middle
ear, which are caused by the pathological conditions
in the fossae, will tlien yield more readily to appro-
priate treatment. The results are infinitely more sat-
320
I'lTH OF CURKEXT LirEKATL'RE.
[Ni;\v York
ME3ICAI, Journal.
isfactory than when the fossa is neglected altogether,
since an amelioration of the aural condition invari-
ably follows restoration of the function of the tubal
mouth and fossa of Rosenmiiller. The preliminary
treatment of the middle ear condition consists in re-
moving with the curette any lymphoid tissue present.
The adhesions which obstruct the fossa must be
broken down. The more delicate fibres readily give
way to the fingers ; the more resistant ones can some-
times be torn with the finger, but occasionally they
are so dense that cutting is necessary. Often this
process of rupturing adhesions, whether done with
the finger or with the knife, must be repeated a num-
ber of times, and silver nitrate applied until the mu-
cous membrane has healed and is free from adhe-
sions.
3. The Organic Factor in High Blood Pres-
sure.— Haig thinks that high blood pressure may
be due to uric acid or to an organic factor or to both
in varving proportions. In all cases ( if there is time)
the uric acid factor is rcmoval^le ; and the organic
factor, if due to uric acid, is also to some extent re-
movable. The capillary reflux and the blood pres-
sure alter from day to day and hour to hour with the
amount of uric acid passing through the blood ; but
there are undoubtedly other factors which influence
blood pressure, and these may or may not be altere<l
by treating uric acid. By acting on these indications
we can in many cases get an answer to important
problems affecting the causation of circulation dis-
eases.
4. Incipiency in Tuberculosis from the Stand-
point of Sanatoria. — Dunham speaks in favor of
using tuberculin as an agent in diagnosis. He fol-
lows Calmette's method. One drop of a i per cent,
solution, or less at first, of purified tuberculin {Tu-
bercuUn pro'cipitatiiiii) is instilled into the conjunc-
tival sac of the patient's eye. If the patient is tuber-
culous, a decided congestion and a watery and sero-
fibrinous exudate occurs between three and twenty-
four hours later. The percentage of error is prob-
ably a little more than with tuberculin used hypoder-
matically. Until the experience with it covers many
more cases than at present, it would be wise to u.se
tuljerculin in the usnai manner after all negative in-
stillations, when the .symptoms still point to the pos-
sible existence of the disease. When this is done the
initial dose injected need not be as small as would
otherwise be deemed advisable. Opportunities for
inaccuracy • and carelessness in the hypodermatic
method of administration are plentiful, but not more
so than with many, now familiar, painst;dsing med-
ical accomplishments. The mode of measuring as
used in the Massachusetts .State Sanatorium is de-
scribed. In measuring the doses of tuberculin the
greatest care is exercised to insure accuracy. The
tuberculin is weighed and then diluted with sterile
water to make a solution of such strength that each
minim contains one milligram of tuberculin. The
solutions are always freshlv made. A particular
dropper is kept purpo.selv for measuring the pure
tuberculin. With this dropper it was repeatedly
found that five drops weighed 180 mg. and one drop
36 mg. Consequently one drop of tuberculin thus
measured, when diluted to 36 minims with sterile
water, gives a solution of wliich i minim contiins
I mg. of tuberculin. Ten minims of this solution
(measured with a special dropper) is put into an
aseptic glass hypodermatic syringe with enough
more sterile water to make about twenty minims to
be injected. Estimating that nearly one drop of this
might have remained in the needle uninjected, then
the patient receives perhaps one half a milligram less
than was prepared. As the Saranac tuberculin is
always reported as a little stronger or more concen-
trated than Koch's standard, this loss is consider-
ered to have been overcome. The tuberculin used
during the first five years at the sanatorium was fur-
nished through the kindness of the Saranac labora-
tory. Dr. Baldwin describes it as being, if anything,
a little stronger than Koch's standard. Latterly
some imported Koch's tuberculin has been used.
BRITISH MEDICAL JOURNAL
January 25, 1908.
1. Some Misleading- Abdominal Cases, By D'A. Povvek.
2. An Analysis of a Recent Series of One Hundred
Consecutive Operations for Acute Appendicitis,
By A. H. Burgess.
3. Intussusception Due to Polypus, By J. L. Stretton.
4. The Passage of Food Through the Human Alimentary
Canal, By A. F. Hertz.
> Status Lvmphaticus in Relation to General Anaesthesia,
By W. J. McCardie.
6. A Fatal Case of Status Lymphnticus, By H. Hilliard.
2. Appendicitis. — Burgess reports a series of
one hundred consecutive operations for appendicitis.
The results are of great interest in connection with
the question of early operation in appendicitis and
its alleged risks. The cases, forty-five in number,
operated upon within four days, yielded no mortal-
ity as contrasted with a mortality of twenty per cent,
for the fifth day, thirty-three and a third per cent,
for the sixth day. twenty per cent, for the seventh
day, fourteen per cent, for the second week, and
eight per cent, for the third week. These forty-five
cases included exainples of each of the groups of
pathological findings, so that the technique and se-
verity of the operation per sc was the same as in the
latter series. The mortality of the latter, therefore,
cannot be ascribed to the operation itself, but is un-
questionably due to the inferior condition of the pa-
tient at the time the operation was undertaken. The
deaths occurred after the operation and in spite of
it, but certainly nor on account of it. In other words,
the mortality which is so often urged against opera-
tions in the acute stage really represents the mortal-
ity of delay, with the consequent increased toxjemic
state of the patient. The lesson to be dravyn is not,
on account of this mortality, to advise against such
operations, but rather to encourage their perform-
ance before a stage of serious toxaemia is reached.
The .scries here reported would indicate that, pro-
vided operation is undertaken within four days of
the onset, the chances of recovery are exceedingly
good, and in a previou.sly reported series of forty-
seven ca.scs no death occurred after an operation
within four days. The.se results scarcely endorse the
view so frequently advanced as to the great danger
of operating between the second and fifth days. But
even though all these cases recover, yet the earlier
the operation the better the recovery. In all the op-
erations within twenty-four hours, and in the major-
ity of those within forty-eight hours the recovery
was exactly similar to that after an "internal" opera-
tion, without any risk of a weak scar. In most
rn ii Of CURRENT LlTLRA'l L RE.
321
of those on the third and fourth days drainage
was necessary, convalescence was more prolonged,
and the chances of a weak scar greater. Of the nine
deaths in the series five had general peritonitis, two
had dif¥use peritonitis with gangrene of the cjecum
as well as of the appendix, one a local abscess, and
a large abscess extending to the subphrenic region.
Surely these fatalities may be justly ascribed to de-
la}- rather than to operation ; the operation certainly
failed to save, but it cannot be said to have materially
hastened the inevitable end. The great reduction in
the mortality after operations for acute appendicitis
that has followed the policy of "interfering" at an
earlier period points irresistibly to the conclusion
that, were all cases submitted to operation in the
early stages of the attack, appendicitis would cease
to be a fatal disease.
5, 6. Status Lymphaticus. — ]\lcCardie states
that Paltauf was the first to carefull\- study and de-
scribe the so called status lymphaticus. He found
an enlargement of the tonsils, of the l\mphatic gland
system, of the follicles at the base of the tongue, of
the spleen, and lastly an enlarged thymus gland ; in
most cases also there was narrowing of the aorta.
The sudden deaths which occur in patients of this
type are ascribed to cardiac paralysis and acute car-
diac dilatation. The subjects of the condition are
unusually subject to infectious diseases, to death
from shock and fright, and to death during anaes-
thesia. Even comparatively slight lesions in them
may end fatally. The results of autopsies are very
uniform, being characterized by the presence of a
thymous gland of greater or less size, by an enlarged
spleen with varying degrees of prominence of its
follicles, by tumescence and hypertrophy of lym-
phatic glands in various regions (especially of the me-
senteric, retroperitoneal, and cervical), by noticeal)le
prominence and multiplication of follicles at the base
of the tongue and in the pharynx, by enlargement of
the tonsils and swelling of solitary follicles and Pey-
er's patches in the intestine, by a dilated heart (espe-
cially the right ventricle), and extremely flaccid car-
diac muscle. In addition, there is sometimes found
a small heart, contraction of the aorta, and dark fluid
blood in the heart cavities. Less constant features
are great pallor of the skin, enlargement of the
tongue, enlargement of the thyreoid gland, infantil-
ism, oedema of the lungs and brain, fatty changes in
the liver, and alterations in the bone marrow. So
frequently is death during chloroform anaesthesia
associated with status lymphaticus that the question
has been raised whether death under chloroform
ever occurs apart from that condition. The writer
gives detailed reports of five instances of death un-
der anaesthesia in cases of lymphatism. All were
\oung and of the flabby type. They seem to suf¥er
more acutely than ordinary patients from shock, and
the distance between ordinary deep anaesthesia and
danger appears to be shorter. Under chloroform
there is often a tendency to grayness of complexion,
weak heart action, and shallow heart action, and
shallow breathing, so that a chloroform-ether mix-
ture or ether has to be substituted for it, and in most
cases the dose of the drug needed to keep up anaes-
thesia is unusually small. Several members of the
same family may suffer from the condition. In most
cases there is little, or no previous history noted — in-
deed, in many the patient was said to have been well
and strong. In infants and small children there is
frequently stridor causing noisy breathing — "thymic
asthma." Among the conditions sometimes associ-
ated with lymphatism are exophthalmic goitre, epi-
lepsy, rickets, and infantilism. Death in the case of
anaesthesia is always sudden.
LANCET
Javiiary 25, igo8.
1. Wh}' Is Tuberculosis So Common in Ireland? With
Suggestions for Its Prevention and Treatment,
By Sir ]. Byers.
2. The Epidemiology of Plague. With Special Reference
to Its Mode of Spread and the Means by which it
May Be Combated, By C. A. Gill.
3. Graduated Labor in Pulmonary Tuberculosis,
By M. S. Paterson.
4. The Effect of Exercise on the Opsonic Index of Pa-
tients Suffering from Pulmonary Tuberculosis,
By A. C. Inm.\n
5. Note on the Presence and Significance of Certain Rod
Shaped Bodies in the Cells of Carcinomatous
Tumors, By W. F. Robertson.
6. On the Relationship of Cancer Cells to the Develop-
ment of Cancer,
By J. E. Salvin-Moore and C. E. Walker.
7. Note Upon the Effect of Liquid Air upon the Graftable
Cancer of Mice,
By J. E. Salvin-Moore and J. O. W. Barratt.
8. Treatment of Graves's Disease with the Milk of
Thyreoidless Goats, By W. Edmunds.
9. A Case of Acute Suppuration in a Thyreoid Adenoma
Due to the Bacillus Typhosus,
By F. G. Melandri and T. P. Legg.
I. Tuberculosis in Ireland. — Byers assigns the
following causes for the great prevalence of tuber-
culosis in Ireland: i. The damp climate. This is
of relatively slight importance. 2. Dampness of the
soil. While subsoil may be of some importance, yet
other conditions are of much greater potency. 3.
Emigration is supposed to have left behind a physic-
ally inferior population — a race of weaklings, all
very susceptible to phthisis. 4. The susceptibility of
the Irish to tuberculosis. This is denied by the
writer. 5. Poverty and low social condition. 6.
Food and drink. There is reason for believing that
the increased use of tea and white bread instead of
porridge and buttermilk, and the excessive use of
alcohol, have lowered the resistance of the people to
tuberculosis. 7. Manufacturing industries. The in-
fluence of these, as exposing to dust, etc., has been
overstated. 8. Want of sanitary reform. 9. The
domestic or home treatment of advanced cases of
pulmonary tuberculosis. This the writer regards as
the most potent cause which has prevented a lower-
ing of the tuberculosis death rate in Ireland. With
isolation of these advanced or "open" cases in any
country the death rate falls. The measures advo-
cated by the writer are as follows : (a) Compulsory
notification, (b) Institutional treatment of advanced
cases, (c) Education as to cleanliness, sanitation,
and ventilation, (d) Temperance in all things, (e)
Inspection of all meat, (f) State control of the milk
supply.
3, 4. Manual Labor in Phthisis.— Paterson
gives the results obtained in the tuberculosis sana-
torium with which he is connected, of the introduc-
tion of manual labor as a part of the routine treat-
ment of patients suffering from pulmonary tubercu-
losis. The grades of work are suminarized as fol-
322
FlTli Of CURRENT LITERATURE.
INii.v York
Medical Journal.
lows: I. Walking from one half to ten miles daily.
2. Carrying baskets of earth or other material. 3.
I'sing a small shovel. 4. Using a large shovel. 5.
I" sing a pickaxe. 6. Using a pickaxe for six hours
a dav. Patients in grades 2, 3, 4. and 5 work four
hours a day. The various grades are each subdi-
vided into sections. The following points appeared
to be determined : Suitably selected patients can be
gradually trained to do the hardest laboring work
for six hours a day, the result being that their gen-
eral condition is much improved, whilst some lose
both their sputum and tubercle bacilli. Certain pa-
tients who do not improve on light work show
marked improvement on harder work. Patients who
have slightly over exerted themselves and are kept
at rest for the few following days are subsequently
not onlv not worse, but may be in their own opinion
better. The writer therefore concludes that gradu-
ated labor is a definite medical treatment for cases
of pulmonary tuberculosis, and raises the general
health and resisting power of the patients. The
combination of rest, pure air, and overfeeding is not
the onlv treatment for chronic pulmonary tubercu-
losis.— inman studied the effect of the hard work on
the opsonic index of the blood of the patients. His
results show that the exercise supplies the stimulus
needed to produce artificial autoinoculation, and that
- its systematic graduation has regulated this in time
and amount. With the aid of the opsonic index the
stimulus can be regulated with scientific accuracy.
5, 6, 7. Cancer. — Robertson, by using the pal-
ladium methyl violet method of staining, has dem-
onstrated in a number of cases of cancer, one or
more rod shaped bodies somewdiat like tubercle ba-
cilli in the protoplasm "of many of the epithelial cells.
In the examination of thirty-six tumors, these rod
shaped bodies were present in every case of cancer.
They are straight or slightly curved rods about 3
mikron in length and 0.3 mikron in thickness. The
edges are smooth, the ends blunt, and there are no
evidences of flagella. The rods do not stain by
Gram's method or by the methods used for tubercle
bacilli. The writer thinks that there is conclusive
evidence that they are parasitic in nature. They
present features which prove them to be growing
organisms, and they have been cultivated in an arti-
ficial medium. The possibility of their being bacilli
can be excluded at once. It can be shown that they
arise from comparatively large rounded bodies
which arc certainly not Ijacterial organisms. They
have none of the characters of the SpirocJucta iiiicro-
gyrata of mice cancer. The writer believes them to
represent a stage in the life cycle of the protozoan
organisms described by himself and Wade as occur-
ring in certain carcinomatous tumors. It is prob-
able that not one species of protozoan organism, but
several closely allied species, are the pathogenic
agents in the production of carcinomatous tumors.
The forms found in carcinoma of the breast present
certain characters which distinguish them from those
that may be observed in squamous cpitheliomata and
in intestinal tumors, although the life cycles are
essentially the same. — Salvin-AIoore and Walker
have found that exposure to liquid air at a temper-
ature of about — 195° F. does not necessarily de-
stroy the ]i"tentiality of the substance of a mouse
tumor to produce fresh tumors of the same kind in
mice into which such frozen tumor substance has
been grafted. So that the production of new tumors
may not be due to the introduction of the "cancer
cells" at all, but upon the action of a virus which is
independent of these cells, and retains its activity
after being subjected to the temperature of liquid
air. It is well known that a number of bacteria are
not killed by this temperature. So that it is possi-
ble that there exists some such cause as an organized
irritant or parasite acting as an agent in the produc-
tion of cancer. But it is not absolutely certain that
the cancer cells are killed by the low temperature.
LA PRESSE MEDICALE
January S, 1908.
1. Technique of Total .'\bdominal Hysterectomj-,
By F. Jayle.
2. Dilution and Concentration of the Blood, By Chinay.
I. Total Abdominal Hysterectomy. — Jayle
says that total abdominal hj^sterectoni}- is consid-
ered to be more difficult, more serious, and to take
a longer time than partial hysterectomy, and that
consequently the latter operation is recommended
and practised in preference by the majority of sur-
geons. He acknowdedges that the total removal
of the uterus is more difficult and takes longer than
the partial removal, but denies that it is attended
by an}- more serious danger. At the same time the
cervix, which has been left /// situ, is apt to cause
trouble, require subsequent attention, and even
prove the seat of a recurrence of cancer. Hence he
prefers the total operation, wdiich he describes in
detail with the aid of thirteen illustrations. He
divides his description into twent}- steps, the details
of each are given with rather too great terseness to
be perfectly clear to any one not accustomed to
witness the performance of the operation.
January 11, 1908.
1. Gastric Radioscopy. Ptosis and Atonic Dilation of
the Stomach. Maintenance of the Reduction of the
Ptosis by Means of the Pneumatic Hypogastric
Cushion, By Ed. Exkiquez.
2. Cancer Caused by the X Rays, ^ By F. Jayle.
3. Essential Insufficiency of the Heart in "the Child,
By R. Rom ME.
1. Ptosis and Atonic Dilatation of the Stom-
ach.— Enriquez gives a brief account of the utili-
zation of the X rays in the examination of the stom-
ach, together with a description of the technique of
their use, and then passes to the consideration of
ptosis and atonic dilatation of that organ. In every
case of asthenic dyspepsia in a woman which he
has examined he has found the lower border of the
stomach very low, from six to twelve centimetres
below the umbilicus, while radioscopic examination
revealed a very marked ptosis of the stomach asso-
ciated with atony and dilatation of that organ. He
has found to be of great service in the attempt to
keep the stomach in position an air bag bound upon
the surface of the abdomen in such a w-ay as to sup-
port its lower portion.
2. Cancer Caused by the X Rays.— Jayle prac-
tically rei)roduces the twelve observations reported
by Porter and White in the Annals of Surgery in
w'hich cancer developed after an exposure to the x
rays.
February :j. r^. S ]
PITH OF CURREXT LITERATURE.
323
January jj, igoS.
1. The Syndrome Produced by a Lesion of the Optic
Thalamus, By P. Hartexberg.
2. Gonococcus and Meningococcus,
By J. ^IiLBiT and L. Taxox.
3. Parasites of Meat Transmissible to Man,
By X. Gautiek.
4. Pathogenv and Treatment of Alveolodental Cvsts,
By G. Mabe.
I. The Syndrome Produced by a Lesion of
the Optic Thalamus. — Hartenberg presents an
excellent description of the symptomatolog}-. anato-
my, patholog}-. and diagnosis followed by a general
discttssion of the condition produced bv a lesion of
the optic thalamus, a condition first noticed in 1903,
which has since attracted some attention. Briefly,
the symptoms presented are : Hemianjesthesia of or-
ganic character, slightly marked as regards super-
ficial sensibility, but very pronounced as regards
deep sensibility, severe pains in the anaesthetic side
of the face. brow, cheek, orbit, limbs, oftener super-
ficial than deep, slight hemiplegia shown by a little
facial asymmetry, hypotony and diminution of mus-
cular power, without atrophy or contracture and
with reflexes either slighth' exaggerated or nor-
mal, slight hemiataxia not seriously impeding motor
adaptation or locomotion, and choreoathetosic
movements. This syndrome may be produced by a
lesion of the f)Osterior third of the external nucleus,
a portion of the internal nucleus, the median centre
and the pulvinar of the optic thalamus, as well as
in a small number of fibres of the posterior portion
of the internal capsule. The diagnosis may be made
through the presence of a hemiplegia with a maxi-
mum of sensory and a minimum of paralytic troti-
bles. The accuracy of this conception of the syn-
drome produced by a lesion of the optic thalamus is
not tiniversally accepted.
LA SEMAINE MEDICALE
January 22, i<)08.
1. Has Ulcerative Typhoid Inflammation of the Throat
DiagnosLic Value? By Leon Blum.
2. The Method of Permeation and Its Application to the
Exploration of the Digestive Tract and to Treatment
of Diseases of the Same.
I. Has Ulcerative Typhoid Inflammation of
the Throat Diagnostic Value? — Blum states that
the ulcerations of the throat which are met with in
typhoid fever are characteristic in their aspect and
site so that they can hardly be confounded with an}"
other affection of the pharynx. They are usually
seated on the upper part of the anterior face of the
anterior pillars of the fauces, more rarely on the
posterior pillars, on the uvula, or on the velum
palati. Both sides are frequently attacked simulta-
neously and symmetrically : occasionally the lesion is
unilateral. It is not exceptional to see several
ulcerations scattered over the velum and the pillars.
The ulcers are oval, placed obliquely downward and
otitward. following the direction of the pillars, of
variable size, superficial, sharply cut, with red
prominent margins and grayish base, not covered
by a false membrane, but only with a little mucus,
and bleeding readily when touched. They may ap-
pear within a quarter of an hour and disappear
gradually. On the average the^- last about ten days.
In seventy-six cases the author met with these ulcer-
ations in fifty-seven men and nineteen women.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT
January 7, jgo8.
1. Relations of Typhus and Paratyphus to the Bile Ducts,
By FORSTER.
2. The Cutaneous Tuberculin Test (von Pirquet's) in
Children, By Feer.
3. Orthodiagraphic Observations Concerning the Position
of the Heart in Pathological Conditions,
By Dietlex.
4. New Contributions to the /Etiology of the Orthotic
Albuminuria of Children, By Jehle.
5. Concerning Specific Haemolysis Through Isotonic Salt
Solutions, By vox Dungerx and Coca.
6. Concerning a Case of Cholecystitis Paratyphosa,
By Lorev.
7. Concerning the Carriers of Typhoid Bacilli in Lunatic
Asylums, By Grimme.
8. The Typhoid Question in Munich. By Mandelbaum.
9. Modern Methods of Treatment in Gynaecologj-.
By Ruxge.
10. Concerning the Treatment of Lysol Poisoning,
By Feldmaxx.
11. .\ Brief Contribution to the Subject of Foreign Bodies
in the Xose, By Kl.aussxer.
12. The Physician in the Mirror of Poetry, By Salzer.
1. Relations of Typhus and Paratyphus to
the Bile Ducts. — Forster explains the appear-
ance of sporadic cases of typhoid fever, as well as
the endemic and epidemic appearance of the same,
by the chronic excretion of typhoid bacilli in the bile
of chronic typhoid bacilli carriers. The gallbladder
forms the natural place where the bacilli are to be
found in these chronic carriers, and the primary in-
dication of treatment is to so treat patients suffering
from typhoid fever that no permanent diseases of
the gallbladder may be left behind. How this may
be accomplished remains for the future to teach tis.
2. The Cutaneous Tuberculin Test in Chil-
dren.— Feer speaks very highly of this test as an
aid to diagnosis in doubtful cases. The positive re-
sult in young children is rarer and more important
(prognostically more serious) the nearer we come
to infancy, and correspondingly the probability in-
creases that the positive reaction indicates the pres-
ence of an affection which is suspected of being of
a tuberculous nature. The frequent appearance of
phlyctenulse and very unpleasant irritation after the
ophthalmoreaction contraindicates in his opinion the
application of that test in scrofulous children.
4. Orthotic Albuminuria in Children. — Jehle
says that, as nephritis can be excluded in the great
majority of these cases, a milk diet is contraindi-
cated and a strengthening general diet indicated. In
addition, there shotild be physical treatment to in-
crease the general strength, with special attention to
muscles of the lumbar region.
6. A Case of Cholecystitis Paratyphosa. —
Lorey reports a case of cholecy stectomy performed
on a man, twenty-two years of age. two years after
an attack of typhoid fever. Cultures taken from
the mucous membrane of the gallbladder immediate-
ly after the operation developed a pure culture of the
Bacillus paratyphosus alcalifaciens. Some time
after the operation a fistula appeared, from which
there was an abundant discharge of pus stained by
bile. Cultures taken from this revealed no para-
typhus bacilli, but only the Bacillus pyocyaneus.
Before the operation the same typhoid bacilli were
found in the faeces, but could not be found after the
operation.
324
PITH OF CURRENT LITERATURE.
[New York
Medicxl Journal.
7. Carriers of Typhoid Bacilli in Lunatic
Asylums. — Grimme discusses the question of
cliolecystomy for the purpose of stopping the distri-
bution of typhoid bacilli by chronic carriers, with
special reference to the conditions in insane asylums.
10. Treatment of Lysol Poisoning. — Feld-
niann speaks of lysol poisoning as the commonest
form met with at the present time Ijecause of the
ease with which it ma\' Ix' obtained at the drug-
stores. There are three different kinds of Ivsni, the
paralysol,, metalysol, and ortholysol : the most poi-
sonous is a mixture of all tlu'ee kinds. He reports
a case in which the following treatment proved ef-
fective very quickly. The stomach was thoroughly
washed out. the patient placed in a hot bath, and
then packed with hot cloths and hot bottles to pre-
vent a lowering uf the temperature, and two injec-
tions of 0.001 of atropine were given with an inter-
val of ten minutes between them. The patient re-
covered consciousness in a quarter of an hour so as
to be able to answer questions, and made a complete
recovery in a few days.
January 14, jgo8.
1. The Emptying of the Stomach, the Separation of Solids
and Fluids, the Behavior of Fat, By Prym.
2. Concerning the Value of the Ophthalmoreaction for the
Diagnosis of Tuberculosis, By Blum.
3. Concerning the Value of the Ophthalmoreaction as an
Aid inj the Diagnosis of Tuberculosis,
By Schroder and Kauf.mann.
4. Concerning the Ophthalmoreaction, By Wolff-Eisner.
5. Brief Remarks in Regard to the Ophthalmoreaction in
Tuberculosis, By Treupel.
6. Studies Concerning the Ophthalmoreaction in Tubercu-
losis, By Schmidt.
7. Is there a Specific Precipitate Reaction in Syphilis and
Paralysis? * By Plaut, Heuck, and Rossi.
8. The Behavior of the Blood Pressure in Muscle Work,
By Krone.
9. The Influence of the Electric Stimulus upon the Dis-
tribution of the Blood in the Human Body,
By Geissler.
10. The Influence of Mud Baths upon the Organs of Cir-
culation, By Schmincke.
11. The District Medical Ofificer and Infant Mortality,
By Groth.
12. Report Concerning the First Year's Work in the Insti-
tution for the Care of Children in Weissenburg,
By Dorfler.
13. Pathogenesis of Fluor Albus. By Neter.
14. The Physician in the Mirror of Poetry (Concluded),
By Salzer.
1. The Emptying of the Stomach, the Sepa-
ration of Solids and Fluids, the Behavior of Fat.
— Prym learned from experiments on small dogs
that it makes a considerable difference whether
pieces of meat are eaten first and fluid then drunk,
or fluids taken first and meat eaten later. When
the meat is eaten first it is to be found thirtv-five
minutes after the meal in a coherent mass surround-
ed by the fluid, while when the fluid is taken first
the meat is found scattered through it at the same
time after the meal. An hour and a half after the
meal the pieces of meat arc .still together in a mass
surrounded by the fluid and the brownish ]iroduct
of the peptically dissolved meat. Fat is scattered
throughout in fine particles, which tend to unite
and form large drops when the movement of the
wall of the stomach is interfered with.
2. 3. 4. 5. and 6. Ophthalmoreaction. — 151 um
considers that although the ophthalmoreaction may
indicate the presence of tuberculous disease it does
not demonstrate the disease on account of which the
test is made is of a tuberculous nature. — Schroder
and Kaufmann assert that if no reaction follows the
instillation of a drop of a half to a one per cent,
solution of. Koch's old tuberculin into the conjunc-
tival sac, an active tuberculosis can be excluded
with tolerable certainty.— Wolff-Eisner suggests
that the name conjunctival reaction would be prefer-
able to the word ophthalmoreaction, which is incor-
rect and misleading. He then briefly speaks of sev-
eral recent papers, agrees with Mainini, objects to
Klieneberger's conclusions, and protests against ref-
erence to the method as that of Calmette. — Schmidt
is probably right when he says that sufficient evi-
dence has not yet been collected to enable us to de-
cide in regard to the utility of this test.
7. Is there a Specific Precipitate Reaction in
Syphilis and Paralysis? — Plaut, Heuck, and
Rossi answer this question in the affirmative, and
report eight cases in which they have employed this
diagnostic test with satisfaction.
9. The Influence of the Electrical Stimulus
upon the Distribution of Blood in the Human
Body. — Geissler investigated this subject on six
healthy persons and fifteen diseased. Seventeen
investigations were made on the six healthy persons r
twelve of them resulted in an increase of the blood
pressure, two in a lowering, and in three the blood
pressure was not aft'ected. Five of the persons
showed an increase of the blood pressure with two
exceptions at the first exposure ; in these exceptions
the blood pressure remained unchanged, and only
one person always showed a diminished blood pres-
sure. Forty-three examinations were made of the
fifteen sick persons, all of whom suffered from dis-
eases of the heart. The blood pressure was in-
creased during the exposure thirty-two times, sank
three times, and remained unchanged three times.
A rise, followed by depression, was observed twice,
and a depression followed by a rise three times.
These observations prove that the electric stimulus
has an influence upon the heart and vessels.
10. The Influence of Mud Baths upon the Or-
gans of Circulation. — Schmincke says that, on
account of its lesser action upon the temperature,
the mud bath affects the circulatory system less than
a water bath of the same temperature.
13. Pathogenesis of Fluor Albus. — Neter re-
ports a cause of-fluor albus in a child, three and a
half years old, which was demonstrated to be de-
pendent on obstipation.
THE JOURNAL FOR NERVOUS AND MENTAL DISEASE.
January, igo8.
1. A Study in Tactual Localization in a Case Presenting
Astereognosis and .Asymbolia Due to Injury to the
Cortex of the Brain, By Morton Prinxe.
2. Tactile Localization and Symbolia : Have They Locali-
zation in the Cerebral Cortex? By Morton Prince.
3. General Considerations as to the Nature and Relation-
ships of Hysteria, By R. C. Woodman.
2. Tactile Localization and Symbolia. — Prince
remarks that a stereognosis, that is the perception of
form in three dimensions (solidity), is plainly an in-
tellectual ])rocess, and to attempt to localize it is to
do that for which there is no analogy in the scheme
J-Vbruary 15. ^y^^-i I'llt! OF CCKRE.
of cerebral localization. Intellectual judgments are
not thus far, according- to data at hand, localizable
nor likely to be. The nearest approach to such a
scheme is that of Marie's new theor}- of aphasia, ac-
cording to which aphasia is an intellectual defect
and localized in Wernicke's zone. This, to Prince's
way of thinking, is the weak point in Marie's the-
ory. It is true that Marie defines the intellectual
defect as a special intellectual function, but he fails
to define what he means by a "special function."
though holding that it is not one of special sensory
images— visual, auditory, etc. Though Marie may
be quite right, says cur author, in his general the-
ory, and in the localization of his intellectual aphasia
in Wernicke's zone, his denial that the sperial intel-
lectual defect consists of a loss of sensorial images
may be wrong, and does not seem to be warranted
b}- any evidence that he !)rings forward ; and it may
well be. therefore, that if his localization is correct,
it is only a localization of sensorial images. This
denial of sensorial images in the mechanism of
aphasia seems to weaken his theor}- rather than to
strengthen it. Certainly, the localization of broad
intellectual processes does not at present rest upon
any sound basis of fact. The only conclusive evi-
dence for the localization of symbolia must rest
tipon clinical observations in which there is found
to be loss of power to recognize objects by touch,
without loss of the subsidiary sensations and per-
ceptions, and the final demonstration of focal local-
ization in the cortex. Xo such case, e.xhaustively
examined, with or without anatomical findings, has
thus far been reported. In. the absence of such a
case there is absolutely no logical warrant in at-
tempting to treat symbolia as a sense or concept or
function and find for it a localization. Symbolia can
only be spoken of and treated as a function sym-
bolically, as a convenient expression to represent a
complex process, and although it may be legitimate
to do this for purposes of convenience, we are al
once led into error when we atten-ipt to localize the
symbol. In localizing symbolia, we are interpreting
the evidence which in every case involves the im-
pairment of dififerent forms of sensation ; and the
interpretation which localizes the tactual impres-
sions and makes the symbolia depend upon the loss
of sufficient information for judgment fulfills all the
logical requirements of the case.
THE EDINBURGH MEDICAL JOURNAL.
February, 1908.
1. The Symptoms and .Etiology of Mania,
By Lewis C. Bruce.
2. Deaths from Gastric 3nd Duodenal Ulcer after Opera-
tion for Other Condition^. By Alexi? ThomsoV.
3. The Value of Leucocyte Exaniination in Suppurative
Conditions Arising from ^Middle Ear Infection,
By JoHx M. Darling.
4. Plastic Operation on the Renal Pelvis for Intermittent
Hydronephrosis, By Alexaxder Miles.
5. The Value of Novocaine as a Local Ansesthetic for
Subcutanous Use, By J. W. Struthers.
6. Cancer Originating from Bartholin's Gland.
Bv James M. Graham.
I. The Symptoms and .Sitiology of Mania. —
Bruce says in his first lecture that it is a commonly
accepted belief that maniacal states are conditions
of brain toxseniia or brain poisoning, and that it is
.V7- LITERAIL'KE. 325
also commonly accepted that hereditary predisposi-
tion is the chief predisposing cause of all insanities.
As to the exciting causes of mania, there are evi-
dences of bacterial toxaemia: {a) In the blood serum
of over 90 per cent, of patients suffering from
mania one can demonstrate the presence of an ag-
glutinin which agglutinates the red blood corpuscles
of healthy persons. An apparently similar agglu-
tinin is present in the blood serum of many sane
and apparently healthy persons. By infecting rab-
bits with streptococcal and staphylococcal bacteria,
a similar agglutinin makes its appearance in the
blood serum of the infected rabbits. The presence
of such an agglutinin in the blood serum would
therefore apparenth" indicate some form of strepto-
coccal or staphylococcal invasion. As both the sane
and the insane may show this symptom of bacteria!
toxaemia, there must be some further factor in the
production of states of mania, and this further
factor is probably an inherited or acquired tmstable
nervous system. This means that the sane and tiie
insane may suffer from similar toxaemias, but
whereas the brain of the sane man is stable the tox-
ines produce no mental symptoms, while the brain
of the insane man is unstable and readily becoines
disordered by toxic action, (b) Although the bodil\-
temperature shows little evidence of toxic disorder,
a simultaneous observation of the white blcxjd cor-
puscles of the patient demonstrates that a state of
marked toxaemia exists in nearly every case, (c)
The disorders of the alimentar\- tract are such as
one would expect to find in persons suffering from
toxic diseases. Further, the bacteriological flora of
the alimentary tract is altered in at least 50 per cent,
of the subjects of mania, (d) Lastly, the nitro-
genous excretion by the urine in the subjects of
mania indicates an excess of metabolism similar to
that found in known infective diseases.
3. The "Value of Leucocyte Examination in
Suppurative Conditions Arising from Middle Ear
Infection. — Darling has observed a number of
such cases and has made exact examinations of
leucocytes. He remarks that in uncomplicated cases
of acute middle car suppuration, the total leucocyte
count and the polymorphonuclear proportion were
higher than normal in 62 per cent, of the cases. In
cases of acute middle car suppuration with mastoid
complication the total leucocyte cotint was above
normal in 66 per cent., and the polymorphonuclear
cells in 77 per cent, of the cases. Little information
of diagnostic value was obtained, because in a single
examination of the blood the leucocyte count was
in some instances higher in the uncomplicated cases
than in those with mastoid complication. In uncom-
plicated cases of chronic middle ear suppuration,
the total leucocyte count in 33 per cent., and poly-
morphonuclear proportion in 25 per cent, of the
cases, were above normal. In cases of mastoid com-
plication with an acute exacerbation, the total leu-
cocyte count was above normal in every instance,
while the poly morphonuclear proportion was above
normal in 66 per cent, of the cases. In cases of
mastoid complication without acute symptoms, the
total leucocyte count in 44 per cent., and the poly-
morphonuclear proportion in 37 per cent., were
above normal. In cases of acute and chronic middle
ear suppuration with and without mastoid compH-
cation, the leucocyte examination gave information
of a general nature as regards the severity and
progress of the inflammatory condition, but practi-
cally no aid in distinctive diagnosis. In cases of
acute and chronic middle ear suppuration, with
intracranial complication, the total leucocyte count
was above normal in 88 per cent. ; the polymorpho-
nuclear percentage was above normal in all of them.
If the polymorphonuclear proportion is less than 77
per cent., examination of the blood suggests the
absence of an intracranial complication ; when the
polymorphonuclear percentage is above 86 there i.s
strong presumptive evidence of an intracranial com-
plication. In cases of extradural abscess and sig-
moid sinus thrombosis, examination of the leuco-
cytes gave no special features characteristic of the
nature and site of the lesion. In the cases of brain
abscess, the total leucocyte count did not exceed
14,000. In the cases of septic meningitis the total
leucocyte counts were decidedly higher than in those
of brain abscess, being in no case less than 17,000.
'I^lie polymorphonuclear percentage, however, was
only slightly higher. A total leucocyte count of less
than 74,000 suggests brain abscess ; a count of more
than 17,000 suggests meningitis.
|r0ffei(mg5 of Sattftits.
WESTERN .SURGICAL .\ND GYN.I^COLOGICAL
ASSOCIATION.
Srzruti'ciilh Anuiial Meeting. Held in St. Louis, December
30 and 31. 1907.
The President, Dk. Ch.xrles W. Ovi.\tt, of Oshkosh, Wis.,
in the Chair,
.-\fter a brief address of welcome bv Dr. John
YorxG Brown, on behalf of the local profession,
which was responded to by Dr. Ch.'vrle.s E. Bow-
ers, of Wichita, Kansas, the reading of papers was
begun.
The Largest Common Duct Stone on Record.
• — Dr. WiLL.ARii B.\rti.i-:tt. of St. Louis, reported
this case, and exhibited the stnnc. The patient was
a man, forty-six years of age, with a history of .gall-
stone disease extending over twent\- vears, which
was plainly referable to the common duct. The stone
in the duct could be palpated through the ab lominal
wall ; still the man was jaundiced onlv at times. The
stone measured four inches in length 1)\ .nu- inch
and a half in diameter, and weighed two ounces and
a half. The duct was partly sutured and was drained
for a month. Five months later the patient was in
better shape than he had ever been in l>is life l)efore.
The Pathological Gallbladder.— Dr. B. B.
\ is. of Omaha, in a paper with this title, .said that
because a patient had lived through an operation it
did not necessarily mean that he was cured. L'nless
the gallbladder continued to perform its function
normally and painles.sly. the patient was not willing
to consider himself cured. Many patients in whom
drainage was instituted had a recurrence of the
symptoms, and a secondary choUcystcctomv became
necessary. This nsnally produced relief fmni all
s\niptoms.
[Xz',\- York
Mei3i:\l Jour.sai..
The following conditions, in the writer's experi-
ence, called for extirpation: i, Adhesions between
the gallbladder and the stomach, colon, or omentum.
2, Stenosis or even narrowing of the lumen of the
cystic duct, due to old inflammation or pressure
necrosis from an impacted stone. 3, Gallbladders-
with thickened walls due to long continued chole-
cystitis. 4, When external fistulae or fistulse be-
tween the gallbladder and the stomach or colon were
present. 5, When the gallbladder wall was made
up of scar tissue largely displacing the normal mus-
cular coats. 6, Wlien the gallbladder was found
filled with mucus, clear or tarry, and there was no
fresh bile. 7, In gangrene of the gallbladder. 8, In
perforation of the gallbladder. 9, In empyema of the
gallbladder, the mucous membrane being usually de-
stroyed over large areas.
Cholecystostomy in the ])resence of the conditions
given, as a rule, did not relieve, and extirpation had
to be done later. In most cases the cholecystectomy
could be done as a primary operation, without add-
ing to the operative risk. The writer disclaimed tak-
ing too radical grounds, since he believed in the re-
tention of every gallbladder that would not be a
menace to future comfort.
The Diagnosis of Duodenal Ulcer from Gall-
stones.— Dr. W. D. Haines, of Cincinnati, said
that prominent symptoms in common were pain,
vomiting, and accumulation of gas, together with
the deleterious influence which these symptomatic
manifestations exerted on the general health of the
patient. Both complaints were referred to the upper
right quadrant of the abdomen, and while the pain
in cholelithiasis, which was sharp, decisive, and of
sudden onset, was referred to a point opposite the
right ninth costal cartilage, it might radiate over the
entire right side of the abdomen, and not infre-
quently found expression in the right shoulder joint.
Again, the pain might Ije the most intense in the
region of the tenth dorsal vertebra. X'omiting, if
present, was characteristic in that the ejected matter
was bile stained, consisting largely of mucus, and it
af¥orded no relief to the patient. Hot fomentations
might give temporary relief, but full doses of mor-
phine were usually required to allay the terrible suf-
fering. In duodenal ulcer the pain occurred at in-
tervals and was less sudden of onset and less severe
in character. It was described as a burning or gnaw-
ing sensation, which might last a few days or con-
tinue for months after the primary attack. I'^nlike
the lancinating pains of gall.stones, pain in this dis-
ease was markedly influenced by the presence or ab-
sence of food in the stomach. A certain degree of
relief invariably followed the ingestion of a full
meal, lavage of the stomach, or the drinking of a
([uantity of alkaline fluid. The spasm of the pylorus
was a frequent accompaniment of ulcer, but whollv
unknown in early gallstone cases. Spasm of the
diaphragm was evidence of severe pain, which, if
referred to the region under consideration, indicated
gallstones, as ulcer pain, in the absence of perfora-
tion, was not of sufiPicient severity to produce this
symptom, (laseous di.>;tention spoke for ulcer, and
tiie accompanying pain quickly subsided after the
expulsion of the gas by eructations or vomiting.
.Muscular rigidity and local tenderness were present
in both ulcer and stone cases. Pain in duodenal
I'KUL EliLnXGS UI- SOCIE I JES.
I'KUCEEDIXGS OF SUClEi lES
3^7
ulcer was due to the pns>;;o-L- of acid st omacb con-
tents and to di-tcntiMU l)y g-a-. \"oniiting \v;i> ut less
value as a symptom than either pain < ir distention,
but it was well to remember that vomiting was full
and free and followed by marked relief, and ceased
promptly in ulcer cases, leaving little depression and
no nausea. In late or recurrent gallstone histories
vomiting was a prominent feature, and the same
might be said of chronic ulcer. The slight transitory
disturbance of the one and the invalid dealing influ-
ence of the other would materially assist in putting
one right in the diagnosis. Ha;morrhage occurring
during an attack of gallstones was accidental, but it
was prominent as one of the late manifestations in
ulcer. Jaundice, like haemorrhage, was a late symp-
tom and might be present in either of the conditions
under consideration. Jaundice following lancinat-
ing pain of sudden onset, localized in the u]:iper right
quadrant of the abdomen, radiating over the right
chest \\-all or accompanied b}- pain in the right shoul-
der, would warrant a conclusion of the presen.ce of
gallstones. Constipation was one of the early effects
of duodenal ulcer.
In a certain percentage of the chronic and some of
the acute cases of stone and ulcer, the distinction
would have to be reserved for that erstwhile much
used, sometimes abused, method of diagnosis — ex-
ploratory incision.
Peptic Ulcer of the Jejunum. — Dr. F. Gregory
Cox X ELL, of Oshkosh, Wis.. reported one case of this
character in which a secondary gastroenterostomy
was performed three years after anterior gastroen-
terostomy for pyloric ulcer with stenosis.
After a consideration of the subject and an analy-
sis of thirty-nine cases, he concluded as follows: i.
Peptic ulcer of the jejunum was a possible result of
gastrojejunostomy. 2, It was pro])al)l\ nf niMre
frequent occurrence than the thirty-nine rejiDried
cases indicated. 3. It followed the long loop opera-
tion more often than the no loop operation. 4. The
symptoms might be latent until either acute haemor-
rhage or perforation occurred. 5. The symptoms
'might be chronic and simulate those of gastric or
duodenal ulcer. 6. Peptic ulcer of the jejiumm
should be considered in all cases of return of symp-
toms after gastrojejunostomy. 7. A svmi)tomless
period after the operation was necessar\- tei eliminate
a continuation of the condition for which the gastro-
jejunostomy was performed. 8. A di-!gnosi,> could
rarel}- l)e made before an operation, rj. Prophylactic
treatment, aiming to reduce the excess ol' acidity,
should be instituted after gastrojejunostomies for be-
nign conditions, and should be continued for at least
six months. 10. The treatment would be either med-
ical or surgical, similar to that for gastric or duo-
denal ulcer. II. The possible occurren -e iif ulcer of
the jejunum was an additional na- m u r jierform-
ing gastrojejunostomy emh- w here il w a - ji i-itively
indicated, namely, by px loric < iljstriieln )n.
Acquired Atresia of the Common Duct Due to
a Gallstone. — Dr. Johx C. IlAXCorK, of Dubuque,
after referring to the literature, reported the case of
a woman, aged sixty-six, who gave tliis historv in
connection with her illness, which had existed two
years and nine months: Familv historv. negative.
Previous history, also negative except for severe
headaches and occasional palpitation. Her present
illness i)egan in October, i^oi, with sudden and se-
vere pain in the alniomen in tlie region of the ninth
and tenth ribs, vomiting, jmrging, chill, and fever.
The attack lasted from one to two days, and subse-
quent prostration delayed the patient's return to her
home for two weeks. Three w eeks after her return
home she began to experience excruciating soreness
in the same region as before, and extending around
the ribs to the right shoulder blade and shoulder.
This condition, with variations in severity, lasted all
winter. In April, 1903, she experienced a sensation
of pushing and grinding, starting in the right side.
This extended across the back and abdomen, and
lasted two weeks. With this girdle pain the patient
was confined to bed and jaundice set in. This had
persisted. From a weight of 116 pounds the patient
gradually lost 36 pounds, but the loss of strength
was not so great in proportion as the loss of weight.
With the jaundice there were loss of appetite, itch-
ing, dulness of the sensorium, many slight chills, and
once a severe attack with high fever. The stools,
which had been dark, became clay colored. The
urine had been scanty and high colored most of the
time since jaundice set in, and the patient had to
micturate as often as four times a night. In April.
1004, her feet began to swell slightlv, and later the
body. The bowels moved three times in twenty-four
hours, and the movements were accompanied by pain
in the lower abdomen. At present the patient suf-
fered no longer with headaches, but was faint at
times, had enjoyed a fair appetite until the last few
days, was not troubled with belching or heartburn,
had some shortness of breath, without cough, and
occasional palpitation, which, however, antedated the
illness in question. The stools were watery and
cream colored.
Examination revealed a short, jaundiced woman,
with a body spare above the waist, prominent ab-
domen, and slightly oedematous lower extremities ;
pulse 90; temperature 99.2°; respiration lO; sclera
bile tinged; lungs negative: heart apex heat in the
third interspace inside the nipple : and no murmurs.
The liver dulness extended from the fifth rib in the
mammillary line to four fingers' breadth below the
costal margin. Ascites was {jrescnt and j)revented the
examination of other abdominal viscera. Xo tumor
was made out or any tenderness, except near the
costal margin on a line between the ninth rib and the
umbilicus. The circumference of the abdomen at the
umbilicus was 96 centimetres : the urine was high
colored and acid, with a specific gravity of 1.032;
bile was present ; of albumin there was the slightest
possible trace, but no sugar; there were occasional
hyaline casts and some small round epithelial cells,
proba])ly from the kidney ; there were a few abnor-
mal red blood corpuscles, with an abundance of vari-
ous forms of large epithelial cells, probably from the
bladder, and pus corpuscles. The next day six quarts
of ascitic fluid were removed, having a specific grav-
ity of i.oii, and showing a trace of albumin. The
abdomen was now soft and permitted of satisfactory
palpitation. The liver was felt to be hard and smooth
for three fingers' breadth below the costal margin on
the right, and more than halfway to the umbilicus
and thence across the epigastrium transversely,
where the edge could be easily grasped between the
fingers and thumb of the same hand. In the epigas-
FRUCEEVIXGS Of SOCIETIES.
Meoical Jou:tN\L.
trinm. slightly to the right of the median line below
the liver margin, numerous hal^d nodular masses,
slightly tender and movable, were made out. The
liver itself was not tender, but the region of the gall-
bladder was still markedly so. The spleen was en-
larged. The examination of the abdomen otherwise
was negative.
After carefull\- considering the hazards of an op-
eration, in the presence of jaundice and more par-,
ticularly ascites, the patient (lecided upon an opera-
tion. Accordingly, thrdugh a vertical incision
through the right rectus, the abdomen was opened.
The residual ascitic lluid was removed. The viscera
were found cungested, and in addition in the upper
right cpiadrant densely adliercnt. So far the h;em-
orrhage was n.it extraordinary, but upon separating
the adhesiini> llic U\sh surfaces bled freely and con
tinudush, in spite of ligatures and the fact that no
demonstrable vessels were ^-ewred. A hanl, cirrhotic
liver and several enlarged lymidiatic glands were
readily found, and a small contracted gallbladder
was identified. From this stage on, further explora-
tion had to be done almost entirely by palpation, on
account of hjemorrhage. A movable stone, of the
size of an olive, was felt in the common duct, but no
evidence of malignant grow th was made out. Ry
this time the hjeniorrhage had i)ecome alarming and
had so obscured the field that the attem])t to incise
the common duct to allow for bile drainage liad to be
abandoned. The field was packed and the abdominal
wound partlv closed. The patient left the table
showing signs of shock and hfemorrhage, and died
fourteen hours later frcjm complete exsanguination
in spite of calcium chloride, etc.
Shortly after death" a partial autopsy was made.
The abdominal cavity was found entirely free from
clots, although the pelvis contained free blood. The
findings at th.e operation were confirmed. The gall-
bladder was contracted to the size of an olive. The
common and he])atic ducts were greatly enlarged.
At the iunction of the cx stic and connnon ducts was
found a cicatricial contraction of the cystic duct. In
the i)ladder and duct were several small fiat concre-
tions. L'pon removal of the large stone from the
lower end of the common duct the condition of atre-
sia of this duct was discovered. The lower end of
the duct was ])crfcctl\ -nio, tli without a sign of o]>en-
ing into the ihiodunuin ;nid might be likuied to th:
bliml finger end of a rub])cr glove. The bile tract, a
portion of the li\er, the duodenum, and the p incr;,as
were removed cii masse, and examined both macro-
scopically and microscopically. Macroscopic dly, the
liver presented the appearance of hypertro])hic cirr-
hosis, but under the microscope the changes of atro-
phic cirrhosis wen- ] -resent. Macroscopical exami-
nation showed atresia of both the common duct and
that of W'irsung. The duct of Santorini could not
be found, and there was entire absence of the pajjill'i
on the duodenal side. A]icrosco]iically, the ductus
choledochus, that of Wirsung. the pancreas, and the
duodenum showed chronic infiammatory changes,
but no malignant elements. Bile was present in the
common 'duct. The stone was found to be a mul-
berry calculus, composed almost entirely of choles-
terin, and made up, superficially at least, of bile pig-
ment and calcareous salts.
Dr. Cii.xui.Es H. M.\Yo, of Rochester, Minn., said
that he and his brother had done twenty-two hun-
dred operations on the gallbladder and ducts. Of
this number, there were over six hundred cholecys-
tectomies and about three hundred operations on the
common duct. A few years ago they had a leaning'
toward the removal of the gallbladder if there was
any disease of the mucosa perceptiljle, while now
they were inclined to leave the gallbladder if the
cystic duct was open.' The operation, howtver, of
the removal of the gallbladder as a secondary opera-
tion was not so serious as operations on the counmon
duct which might be necessitated later, after the re-
moval of the gallbladder. Thev believed that the
removal of the gallbladder resulted later in the ma-
jority of cases in distention of the common duct.
They had had five cases of the reformation of stones
in the common duct, and three of them after the re-
moval of the gallbladder. In all of the series lie
only recalled two cases in which, after the primirv
operation of removing gallstones from the gallblad-
der, stones had reformed in lliat viscus.
Dr. C. H. W'ai.lau,, ot' St. ]osei)h, 'Slo.. reported
the case of a woman upon w liom he had operated
some two years before for the removal of stones in
the gallbladder. The gallbladder itself was found in
a fairly good condition ; the nnicosa was not dis-
eased, not very much enlarged, and the walls were
not much thickened. A number of stones were re-
moved and drainage was estaljlished. A few weeks
ago this woman began to have attacks again. In the
third or second attack she passed three or four small
gallstones. Tliis was a case in which the question
arose as to wdiether, in doing a second operation, the
gallbladder should be removed or drainage again
tried. He thought surgeon^ got the impression from
those who did a large amount of gallbladder sur-
gery that if in a given ca^e there was a healthy gall-
iDladder, with stones in it, where the mucous mem-
brane was not diseased, if the stones were removed
and the gallbladder was drained, the patient couki
be assured that he or she. as the case might be, would
get well. Occasionally, however, such patients re-
turned, and the guarantee of such a prognosis could
not be given now with as much assurance as in
former years.
Dr. J. !•'. .Sr_MMi i<>. of ( )maha, said that seven or
eight years ago he had reported a case in w hich there
was a tight strictu.re at the lower end of the common-
duct, and also one of the c\siic duct, the common
duct acting as a reser\'oii'. dhe liver was ver\'
nuicli h\ ])ertro])lned. as was also the spleen. The
techni(|ue employed was to open the' common duct
and to make an anastomosis between this and the
duodenum. The patient niade a good recovery after
a long time. Mayo Robson had also reported one
or two of these cases, which Dr. Hancock had not
mentioned in the literature of the subject, and he
thought Dr. William J. Mayo had reported one or
two others.
Dr. J.\MKs E. MooRK. of Minneapolis, .said that
within the past six months he had seen two cases of
gallstones of great interest. One was a case of Dr.
Mayo's and the other a case of his own. Roth pa-
tients had practically the same symptoms. In his
case there were fir.st the ordinary gallstone symp-
toms. The ])aticnt was operated upon, the stones were
removed, and the gallbladder was drnined. Later the
patient had a recurrence of symptoms, and at the
oi)eration gallstones were found and cholecystecto-
my was performed. The interesting feature about
his case and Dr. Mayo's was that thc^e women were
February 15, 190.S. |
PRUCEEDJXGS Of SUCIEIJES
at the present time suffering again from gallstone
colic. What should be done? The only hope was
that there w as a stone or stones in the common duct
that might be reached. He had not yet operated in
a case of that kind. He thought, however, it was
quite possible that these stones might be in the he-
patic duct, because in the case in which he had oper-
ated and removed the gallbladder, the stones \yere
many, small and soft, looked like millet seeds, and
evidently came dow-n from the gallbladder at that
time. He had the feeling that this woman would
surely have trouble some lime in the future. It was
only two years since he did the cholecystectomy, and
now she was having serious symptoms and very
grave attacks, but without jaundice.
Dr. JoHX C. ^iloRFiT. of St. Louis, reported two
cases of bowel obstruction due to gallstones, w hich
had occurred within sixty days of each other in the
last year. A woman of eighty had aciue ( ili^truction
of the bowel, with finally total obstrucii ni w hen he
saw her. The bowel was obstructed at about eigh-
teen inches above the ileocaecal valve by a stone an
inch and a quarter in diamettr and an inch and a half
long, which evidently came from the gallbladder.
She made a very satisfactory immediate recovery
from the operation. Pneumonia, howevtr, devel-
oped on the eleventh day, and she died on the fif-
teenth day after the operation. A post mortem ex-
amination w as not made, but the question arose as to
the pathological anatomy in the region of the gall-
bladder. How did this stone get into the intestine?'
Did it come through the conmicn duct, or did an in-
flammatory anastomosis eiccrr between the gallblad-
der and some portion of the alimentary canal? He
believed that there was, as a result of ])reexisting
inflammation, an ulceration or anastomosis between
the gallbladder and duodenum, or possi1)l\- some por-
tion of the small intestine.
\\'ithin a few weeks tlierLafle-r another woman,
fifty-six years of age. presented herself w ith exactly
the same condition. He- was al:)le to strike a stone in
practically the same situation at once, the stone be-
ing of the same size and consistence. The intestine
was opened by a linear incision, the stone liberated,
and the incision closed, and the patient made an un-
eventful recovery.
Harrington's Solution in the Treatment of
Suppurative Inflammation of the Knee Joint. —
Dr. J. E. ."^r M M i;ks, of ( )maha, said that it had been
proveel ex])eriinentall\ and clinically that Harring-
ton's solution would kill all the common germs
met with in surgical practice in from twenty sec-
onds to a minute, and was not caustic. After thor-
ough washing of the hands in hot soapsuds and then
immersing them for two minutes in this solution, if
cultm-es were taken, there should be an entire ab-
sence of germs. Even when there was no prelimin-
ary washing of the hands before their immersion in
the solution for two minutes, the results were re-
markable. The author rejjorted an interesting case
in which this solution was used, and said that, while
his experience with Harrington's solution was not
great, it could be used very advantageously in in-
fective wounds where it was applicable. After thor-
ough surgical cleansing of a wound or abcess cavity,
the solution was allowed to remain in contact with
all its surfaces for from three to five minutes : it was
then irrigated or sponged away, and the particular
wound clressed as required. Any one who would
trv Harrington's solution wmild like it. It had. be-
sides its established antise])t!c property, the po.ver,
when applied to a raw surface, to produce a copious
discharge of serum, thus aiding the washing away of
noxious elements from the wound.
Dr. Charles H. Mavo emphasized the value of
Harrington's solution as an antiseptic, and said that
it was fjne of the best and least destructive ones we
had in use for suppurating wounds.
The Removal of Gallstones in the Common
Duct through the Lesser Omentum. — Dr. ^1. L.
Harri-S, of Chicago, said that the galll)ladder and
its contained stones might be cnucleited without
much difficulty, but should the common duct harbor
stones, it might be impossible to reach them by the
usual route. He did not now refer to those cases
in w hich a stone was lodged in the ampulla of \'ater,
and could be reached by the transduodenal route, but
to those in which the stone was in the upper part
of the duct or movable within the duct, and which,
owing to the pyloric end of the stomach having-
been drawm to the right by adhesions, lay behind
this portion of the stomach as well as the duodenum.
In two cases of this kind which had come under his
care, after a somewhat prolonged fruitless effort to
reach the common duct in the usual way, he had
succeeded in reaching and removing the stones b\-
following a new route through the gastrohepatic. or
lesser, omentum above the pyloric end of the
stomach. These two cases he reported in detail.
The advantages of this route in these cases were the
great saving of' time over attempting to work one's
way through an aln ost imijossible mass of adhesions
and the lessened dangers of injuring the duodenum
or other structure.
Removal of the Whole or a Part of the Hu-
merus.— Dr. E. M. Sala. of Reck Island, 111., said
that the removal of the whole or a part of the
humerus was a comparatively safe operation, and
one which should be carefully thought of in all cases
where amputations were formerly the first aid to the
injured in serious disturbances of the humerus. He
thought too many arms had been sacrificed in the
past that might have been saved had the surgeon
cared to tr\ an extirpation of only the diseased por-
tion of l)one. .Vlmost any kind of an arm was bet-
ter than none. l!efore the davs of aseptic surgery
there possil)l\- was some excuse for amputating any-
thing in the shape of an arm that looked l)ad, but
to-day, with the aid of aseptic and antiseptic meth-
ods, we were expected to attempt greater feats in
-surgery. That it was possible for a whole or a part
of the humerus to be extirpated, and the patient
given a useful hand or forearm, was beyond doubt.
One third of the upper end of the humerus might
be removed, and the patient appear as though noth-
ing had ever happened to the upper extremity, ex-
cept shortening on that side. The whole humerus
might be removed without serious disturbance to
the hand and wrist, especially if care was exercised
in saving the musculospiral nerve in its separation
from the bone.
Dr. Roland Hill, of St. Louis, to show what
could be accomplished by conservation in the treat-
ment of lesions of the humerus, said that about two
330
LETTERS TO THE EDITORS.
[Ns'.v York
Medical Journal.
weeks ago he presented a case before the St. Louis
IMedical Society, in which the upper part of fhe
humerus was involved and was removed. This man
had been taken ill in 1892, with a septic condition
involving the upper part of the humerus and also
the glenoid part of the scapula. In the winter of
1905 he came to the city and Dr. Morfit opened the
joint and removed some dead bone from the upper
part of the humerus and also from the scapula. The
patient returned home at the end of five weeks in a
much better condition, but in the summer he began
to be septic again. He came back to the speaker in
July, at which time there was a constant discharge
of pus. He opened up the parts freely, removed the
head of the bone, and cleaned out the cavity thor-
oughly and packed it. The patient improved very
much and went home, but the joint did not heal up.
There was a constant discharge, and in March, 1906.
the patient came back with the idea of having the
arm removed. Dr. Hill made one more effort to
save it, opened it up, curetted the diseased tissue,
and found there was some necrosis at the head of
the bone extending down to the medullary cavity,
which was removed. He thoroughly dried it and
sterilized the parts with carbolic acid and alcohol
and then filled the cavity with Moorhof's bone mass.
The arm was not dressed again for a week. In
about six weeks thereafter healing had taken place.
The arm was kept in a sling for four months, at the
end of which time the patient was able to use it and
had been using it ever since.
Dr. W. D. Haines, of Cincinnati, mentioned a
case in which, in 1898, he removed almost the entire
humerus from a boy_, ten years of age, who had a
number of sinuses along the outer surface of the
arm. No attempt was made to save the periosteum ;
the entire bnne was removed down to within two
inches of the condyles. The patient has to-day a
useful arm. He endorsed this method as preferable
to primary amputation, and said that amputation,
if really necessary, could be done later.
The Surgical Treatment of Hallux Valgus with
Bunion. — Dr. Charles H. Mayo, of Rochester,
Minn., recommended for this condition a curved in-
cision, base down, over the metatarsophalangeal
joint. The bursa nf the bunion was preserved and
left attached to the base of the first phalanx. The
head of the metatarsal bone with the greater part
of the bunion was removed. The bursa was turned
into the joint in frorft of the cut end of the bone.
Thus was utilized a ready formed bursa to prevent
joint fixation, a result which was obtained in other
joints with difficulty by turning fatty tissue into a
joint to develop such a bursa. The general function
of the joint was nearly perfect and continued to be
so after many years.
Early Restoration of Function after Excision
of the Elbow in Tuberculous Cases. — Dr. G. G.
CoTTAM. of Rock Rapids, Iowa, related the history
of the case of a young farm laborer who sufifered
from tuberculosis of the capitulum humeri, with
ankylosis of the elbow, in which it was very desira-
ble to secure early use of the arm. Excision b\-
Kocher's incision was used, and through this means
and by radical modification of the after treatment
from that usually employed, together with the fact
that the operation was done before the soft parts
were extensively involved, brought about the desired
result, the patient being able to do the heavy work
of his occupation after the eighth week. The paper
concluded with tl^e following summary of the points
involved in producing such an outcome: i. Early
operation, that is, as soon as it was certain that the
disease was present and not yielding to conservative
treatment. 2, Choice of a method of operating which
preserved the integrity of all the important nerves
and muscles. 3, Removal of sufficient bone to insure
free mobility. 4, Immobilization in the extended
position, with maintenance of the angle of dtfltction.
5, Active motion at the end of three weeks.
{To be concluded.)
fttttxs ta t\)t mtm.
METCHNIKOFF SOURED MILK.
Xew York, January 23, igoS.
To the Editors:
In your issue of January 4th you publish an ex-
tended and very interesting article bv Dr. Henrv G.
Pift'ard, called A Study of Sour Milks, in which he
makes reference to our preparation known as bacil-
lac. Ordinarily I should make no reply to an article
of this kind, but several physicians who have come
to have a friendly feeling toward us through bene-
fits which their patients have derived from our
preparation have urged me to respond, that there
may be no misunderstanding in the matter. It is
for this reason solely that I write >'OU this com-
munication, with the request that you will give it a
place in your columns in answer to Dr. PitTard's
comments on our product.
Dr. Piffard states that in microscopical examina-
tions of our product made in June, July, and August
last he found yeast germs, in the face of the fact
that the papers issued by this company distinctly
state that yeasts are not used in the preparation of
our milk. He also states that he found Oidiitiii
lactis in each instance. As neither of these germs
is pathogenic. Dr. Pittard's discovery becomes of
importance only from the standpoint of purity and
exactness in representation of the contents of the
bottles. He states, too, that the name of the bacil-
lus employed w as not given on the labels, but he as-
sumes that it was the Bacillus bidgaricits. I am
somewhat surjirised that the learned gentleman did
not immediatcl\- recognize the bacillus employed in
implanting this milk, in view of the fact that he so
readily identified yeast germs and Oidiuin lactis.
Our labels state that the milk is sterilized and then
implanted with the bacillus isolated by Metchnikoflf.
In a paragraph following the above mentioned com-
ments. Dr. Pififard accounted for the yeast he found
by saying that the bottles used resembled "second
hand beer bottles" and that they had probably been
"insufficiently sterilized." The milk itself is also
commented on as "not of the highest quality."
This company is the American licensee of La
Socicte le ferment, of Paris, which is conducted un-
der the scientific patronage of Professor Mctchni-
koft", of the Institut Pasteur. Our product of
soured milk is made in the strictest accordance with
Professor Metchnikoft"s directions, and only a pure
culture of the Lactobacillus isolated by him is util-
ized. Yeast is not employed in any way. Every
possible scientific precaution is observed to make
1-ebruary 15. 1908.]
BOOK NOTICES.
331
this milk an absolutely pure product. On the 19th
of August last, for good and sufificient reasons, the
management of this company made a change in the
head of the bacteriological department. Since then
we are confident no one can successfully question
the purity of this milk.
This company has never used "second hand beer
bottles." Last winter the gentleman then manag-
ing the company, desiring to secure quickly a large
quantity of black bottles, made a contract for sev-
eral hundred gross of Dublin stout bottles, which,
properly purified and sterilized, make an excellent
container. A part of this order fell as legacy to
the present management. It may be that at the
time Dr. Piffard states, through improper super-
vision of operatives, some oi the bottles were not
properly sterilized, but such is not the case to-day.
Every container that we u^e is twice washed in
the most approved bottle washing machinery, and is
then completely sterilized. In fact, our bottles are
twice sterilized, once immediately after washing,
and then again on the day on which they are used
for bottling the milk.
Dr. Piffard states that during the month of Octo-
ber he made an examination of this milk, and that
at that time he found neither yeast nor Oidium
lactis. This, I think, is a confirmation of my state-
ment that subsequent to the nineteenth of August
no fault could or can be found with our product.
In reference to the quality of the milk used by this
company, we can only say that we have always used
the best that can be had, furnished by our treasurer.
Mr. L. B. Halsey. the founder of the Sheffield
Farms Milk Company and the principal owner of the
White Clover Farms Alilk Company. To-day, not-
withstanding that we purchase hundreds of gallons
of milk weekly, we pay six cents a quart for our
milk supply. Its quality and richness are well at-
tested by the quantity of cream removed from it by
our decreaming machines.
Dr. Piltard states that in June last he sent the ad-
vertising papers of this company to Professor
Metchnikoff by registered mail, asking him if he
endorsed the statements contained in these papers.
Dr. Pififard's article states that he had received no
reply to his letter. In reference to this, I can only
say that I am glad he sent the papers by registered
mail, as that circumstance leaves no doubt that Pro-
fessor ^letchnikoft received them. Whv no reply
has been made by Professor ^vletchnikoff I cannot
imagine. Perhaps it is because the professor
deemed no reply necessary, the papers in question
so faithfull\- re])resenting his own views and those
of the ilirect'T- '>t Lc Fcnuciit in Paris, with which
lie is uikIi iui)tcill_\ i[U!i:e familiar.
The Lacto-I'.acilmxe Compaxv of Xew York,
W. M. Bates,
General Manager.
COMPRESSED AIR FOR DILATING THE
EUSTACHIAN TUBE.
Charlestox. S. C. February 3. 190S.
To the Editors:
It is quite possible that there may be nothing novel
in this method of dilating the Eustachian tube, but
it is certainl}- new to me. since I have never seen it
used elsewhere, or have heard the suggestion made.
Having long been impressed with the failure of the
Politzer method of inflation, it occurred to me that
an attachment to the cut-off of the compressed air
tube could easily be made and forty or fifty pounds
of pressure be applied for the dilatation of the tube.
This attachment was simply constructed out of the
large end of a rubber Eustachian catheter. This
catheter had the bayonet socket joint so that the
union was firm, and it also accurately fitted into the
mouth of an ordinary Eustachian catheter. I have
been using this method of dilating the Eustachian
tube for some considerable time now, and I have
never injured either the tube or the drum membrane,
even when as much as forty or fifty pounds pres-
sure was used, and its advantage over the old Polit-
zer's bag is so apparent that it has only to be tried
by any one to be appreciated. Of course the use of
any method of inflation presupposes that the tul^e is
intact throughout its course, because if there is anv
abrasion, as occurs after the use of the Eustachian
bougie, emphysema of the neck or face will inevitably
result. W. Pevre Porcher.
The Prolongation of Life. Optimistic Studies. By Elie
Metchxikoff. Subdirector of the Pasteur Institute,
Paris. The English Translation Edited bv P. Chalmers
IMiTCHELL, M. A., D. Sc. (Oxon.), Hon. LL. D., F. R. S.,
Secretary of the Zoological Society of London, etc. New
York and London : G. P. Putnam's Sons, 1908. Pp.
xx-343.
The work before us is a translation of Metchni-
koft's Essais optimistcs published last year in Paris.
W'e can conceive of no good reason for this change
of title except ]30ssibly from a commercial stand-
point. It is not very many years since Metchnikoff
revolutionized patholog\ bv his promulgation oi the
doctrine of phagoc\ tosis. Decried by nearly every
contemporary pathologist at the time, it was soon
found that the facts cited b\- the author were easily
verifiable, and there was no gainsaying the conclu-
sions to be drawn from them. Metchnikoffs next
important work, on Immunity, still further added
to his scientific reputation. His Nature of Man
I English title ) for lay reading is a work that should
be read by every adult, containing as it does a mass
of information not readily accessible to the general
public, and many facts but little known even to the
profession.
Lastly, the volume before us appeals to both the
profession and the public. The author divides his
subject into nine parts, of which the first six are
respectively as follows : The Investigation of Old
Age ; Longevity in the Animal Kingdom ; Investiga-
tions of Natural Death : Should We Try to Prolong
Human Life ; Psychical Rudiments in Man. and
Some Points in the History of Social Animals. The
first three of these are devoted to the causes that
lead to premature decay, and the present unneces-
sary curtailment of existence. Briefly, the chief of
these causes is intestinal autointoxication due to the
development of toxines (indol, skatol, etc.) in the
large intestine through the influence of the putre-
332
MISCELLANY.
[Neu- York
Medical .Iol'RMvL.
f active bacteria. In the fourtli part he indicates the
remedy, to wit : tlie free ingestion of antagonistic
bacteria capahK' 'if iiihi1)iting the growth of the
peccant putrclaciue i>rL;anisnis and especially the
free nse of a certain Ijuli^arian microbe with which
his name has been commercially associated. The
fourth and fifth parts are exceedingly interesting.
The seventh, eighth, and ninth are Pessimism and
Optimism: lioethe and h'aust ; Science and Moral-
ity. We cannot but feel that it would have been
better if these parts had been omitted or rather per-
haps published separately, as we have laid down the
volume with a sense of depression rather than ela-
tion, and in a pessimistic rather than an optimistic
frame of mind.
The trarislalicni is a fairly good one. W'e have
noticed a few crudities of exi)ression and several
evident mistranslations.
Manual •<! Pliv.U"!i>iiii-al and Clinical Clwiuistrv. Bv
F.LiAs li i: \!-TLF^, P,, S., O.. Ph. Ci., Professor o"f
Cht_nu>ir\. T' i.xicMl. . and P;eiH,uric^ in the Long Isl-
and College Hi)>i>iud. ete. Third Kdition, Revised and
Enl.irged. with Fifty-one Illustrations. Philadelphia:
P. Blakiston's Son & 'Co.. 1907. Pp. 202. (Price, $1.)
Dr. F>artle\ "s shnrt manual of medical chemistry
needs no iiitri Hluclion. In its third edition the con-
sideration (if i!ie clinical side tif the subject has been
considerably brnadened atid enlarged. The author
aimed to write a brief } et sufhcientlx' explicit work-
ing textbook tTr students, and he has succeeded very
well. PractisiiiL^ ])l^yvician^ wdio do their own labor-
ator_\- work will uIm' tiiid the book useful as a ])rac-
tical guide. The talnilar statements of manv import-
ant facts add to the -xalue of the book and aid the
student's memory c iisiderablw There are some
minor defects and oiuissiiuis which may i)e over-
looked in view, of the general excellence and i)rac-
tical character of the book.
Materia Medico, Thcraf^cnlics. Pliarniac(>lo;:;y, and Pharma-
cognosy. Inclndni;,; Medical Pharniac}', Prescription
Writing, and Aleilical Patni, P>y W'ili.i.vm Schleif.
M. D., Demonsirai. r . u' Medical Pharmacy in the Medi-
cal Department of the L'niversit\ of Pemisylvania. Series
F.dited by Bern B. G.all.wdet. AF D., Demonstrator of
Anatomy and Instructor in Surgery. College of Physi-
cians and Surgeons, New York. Philadelphia and New
York : Lea Brothers & Co., 1907. Pp. 470.
It is not creditable that this book has seen a third
edition witliout some attempt being made to cor-
rect the many errors of type and of statement that
are to be foimd in its pages. Some of these errors
verge on the ludicrous, like that one on page 28,
where keratin is stated to be "A substance made
from the wing cases of insects." Under the head-
ing Medicated Wines, on page 42, the single pre-
scription printed calls for 15 c.c. of wine of colchi-
cum in 100 c.c. of peppermint water. By an amus-
ing typogra))hical error on page 69 musk root is
represented to contain "volatile oil and resin, in
combination with asafa-dita, ferrous sidphate. and
arsenic trioxide" ; but the printer cannot be blamed
for naming the garden lettuce as the source of lac-
tucarium on the following page ; and it is hardly fair
to teach medical students that "cocaine is the hydro-
chloride of an alkaloid obtained from coca" (page
/()). In ad(h\>ses and papers much has been said
of late of the inadequate knowledge of pharmacol-
ogy possessed b\- the newer graduates of medical
schools, and it is not to be wondered at if the charge
is true, considering the sort of information to be
obtained from textbo<jks of the character of the one
under review.
Itiscellanj.
Deaths of Physicians in 1907. — l)uri;ig 1907
2,013 deaths of ]>hysiciaiis in the I 'nited Slates and
Canada were repurte;!. eipuvalent to an amuial death
rate per 1,000 of lO.i, based on an estimate of 125,-
000 practitioners. This death rate does not dififer
materiallv from those of the previous five years,
which were, respecti \'elv. 1906, 17.2; 1905, 16.36;
1904, 17.14; 1903, 13.73, and 1902. 14.74. The age
at death varied from twenty-one to ninety-seven
years, the average being fifty-eight years, eleven
inonths, and eighteen days. The number of years
of practice of the decedents varied from the first
)ear of practice to the seventieth, with an average
of thirty years, four months, and twenty-one days.
About 1 1 jier cent, of those wdio died were members
of the .\merican Medical Association. One hun-
dred and ninety deaths were attributed to general
infectious, malignant and nutritional diseases and
tuberculosis; 225 to diseases of the nervous svstem ;
107 to diseases of the digestive system ; 243 to dis-
eases of the circulatory system; 181 to diseases of
the resjiiralory s\ stem ; 140 to diseases of the gcni-
tourinar_\- system; 83 tu miscellaneous diseases, and
141 to violence. Chief among the assigned causes
of death were heart diseases, 234 ; cerebral h.-emor-
rhage, 1S4; pneumouia. 147; ne])hritis. 120: tuber-
culosis. ()(); senile deliilitx , 50: malignant disease,
42; ty]ihoid fever, 32; aiJpeiidicitis, 31; septicfemia,
20; diabetes, 18: gastritis, 13, and inlluenza, 11.
Two deaths each are reported from diphtheria,
scarlet fever, and tetanus. The deaths from vio-
lence during the year numbered 141 ; of these 87
were due to accident, 37 to suicide, 16 to homicide,
and I physician expiated the crime of murder in the
electric chair. Falls, and steam and street railways
accidents each were responsible for 25 deaths, poi-
son for 12, drowning for 5, gunshot woimds and
runaways for 3 each, and burns, suffocation, and
automobile accidents for 2 each. The 37 jihysi-
cians wdio are reported to have killed themselves
chose the following methods: Gunshot wounds, 13;
poison. 9, 4 of which were from morphine, 2 each
from carbolic acid and potassiinu cyanide, and i
from strychnine ; 5 cut their throats : 3 hung them-
selves; stab wounds, drowning and jumping from
heights each ' caused 2 deaths, and i was due to
asphyxiation. Of the decedents 85 w-ere between
the ages of twenty-one and thirty, 253 between thir-
ty-one and forty, 247 between forty-one and fifty.
344 between fifty-one and sixty. 404 between sixty-
one and seventy, 331 between seventy-one and
eighty, 172 between eighty-one and nhiety, and 12
more than ninety years of age. One practitioner
had been in practice for seventy years. 50 for from
sixtv to seventy years. 267 for from fifty to sixty
vcars, 558 for from forty to fifty years, 961 for
from thirty to forty years, 1,381 for from twenty to
I'fbruary 15, 190S.]
OFFICIAL NEWS.
333
tliirtv years, and 1.714 from ten to twenty years.
The civil war veterans wlio died during- 1907 num-
bered 332, of whom 231 followed the fedY-ral for-
tunes and lOi the lost cause, 11 saw service in the
S])anish-American war, 5 in the Mexican war, and
17 served in foreign wars. The medical depart-
ment <_>i the army lost 24 by death durino- the year,
the na\-\- l<i<t 14. and the I'uhlic lleallh and Marine
Hospital .Service. S. Twenty-eight were surgeons
in the Xatinnal ( iuard, of whom 8 had attained the
rank of Mirgenn general. — The Journal of the
American Medical Jssocialion, January 4, 1907.
The Late Dr. Isidor Pierce Oberndorfer. — At a
recent meeting of the Metri ipdlitan ]\ledical Society
the following resolution e\pn
death of Dr. ( )berndorfu' wa--
Jl;
'ive of regret at the
fpted :
Piei
mar
ll'hcrcas. Death lia>
valued collenrnie. Isidn
charter members and f'
ropolitan Aiedical Snciety. \vh.
by his lc)\ah\'. his (|ualitie- 'if
by his acti\e iiulilic spirit and
That thi- ex],ri-"i
Resulzrd.
sense of luss
commiinicati.
Committee
all
ed upon our
sympalli}
his faniiU
Percy Fridexijekg, M. D.. Chairman.
Julius Wolff, M. D.
Max RosExr.EKc, M. D.
SiGMuxD Pollitzi:r, M. D.
Resolutions on the Death of Dr. Henry Patter-
son Loomis. — At a meeting of the .Medical lioard
I d' r>elle\ tie fTts])ital. held on Februarv i, 1908, the
|'Tm\ 111- n -Mliitions on the death of Dr. Loomis
In.liana-
Iiuliana-
KaiLsas— Toi,oka
Kans.ns — Wicliita
Louisiana — New Orlenn
Keiituckv — Le-xington. .
Micliigan— Crand Rapii
Michigan — Saginaw. . . .
Missouri — Kansas City
Missouri — St. Louis...
Montana — Butte
( Ihlu- I ull-llo. .
Soutli Dakota—
Tennessee — Knc
Im-.oic, — i'.rist.
hi.!',-!"— I^,.nhav
rtnlv— Ceneral.
[talv— Messina,
.hlr;'!!!— Kobe. . .
Tapan — ^■okollal
Java — lUitavia .
.Dec.
Dec.
Dec.
Outbreak
^Foreign
A\-.v,./7V,/. Tlial llie Mr.l'.-al l',.i:,rd ,.f PdUvue Ifn-pilal
record, wall -..rm-N tlie dr;, ill • <v^ i i.r.iiil ler 22. l.K'7.
late Ci.Hea.Liiu-, I )r, Heiir\ P.ilh'r.'.a l.M.aai-,, tnr
twcatt \<,n-~ w ;i> aciivelv c<«niH-cic.l with the \iMtai- .taft
Mt lledrviir llM.paal. Dann.n thi> peri..d .if scr\ Dr.
Liinmi. \\a- al\\a>-N /calna^ in pri inn )tmtj liu- iii^hrsi niter-
an elticieii! aieniher uf it. xarmu- coiiiinitlee-. Ill-- \\i)id<
as a clnueal teacher did naicli to broaden the latiucnce
of the institution, and. among the many researches which
he coiidacced, la- contrihution^ to the study of tubercu-
losis are especially eonaaendahle.
Resolved. That' till- expre--iiiii of appreciat n ui of the
faifhtfiil work of Dr. Li"nai- fi.r the hn-piLil lu recorded
upon the mittutes of the medical lioarfl. and that copies he
sent to his faniih' and to the trustees of the institution.
■-cua
A-ia- I'.airdacL
UlUl.
I loii'turas — Interior towns.
Tn(li<^ — lioniliay
India — Cochin
Lidia — kanitoon
Russi;
-Foreign,
z. 28-Jan
Public Health and Marine Hospital Service
Health Reports :
The folUneing cases .</ snitillf^o.v, yelhne fez'cr. cholera,
trid plague have been ref^orted to the surgeon general,
United States PuIjUc Health and .Marine Hospital .Seri'ice,
during the zvcek ending Tehrnary 7. i<jo8 :
Smatlp -j.v^l'nitcJ States.
riaces. Date. Cases. Deaths.
Alabama — Mobile Jan. 12-26 7
California — Los Angeles Ian. ii-iS 3
California— San Francisco Jan. n-18 5
District of Columbia — Washington . Jan. 13-25 15
(jeorgia — .\ugusta Jan. 21-28 i
Illinois — Chicago Jan. '16-25 3
Illinois — .Springfield Ir.n. 15-23 7
Indi.ma— Elkhart Jan. 18-25 i
.\rabia— Oi.-ddah.
Arabia— Me lina. .
.\rabia— Mekka. .
liradl— Rio de J
Egypt — .\lcsandr
Egvpt — I )imetta.
Egypt— Province
Fore
"Dec.
.Dec!
Minieh Dec. 17-2^
India — Ponibay Dec. 24-31
India — Rangoon Dec. 14-21
lapan — Ntisbii-na Island Jan. 8...
Japan — Osaka Dec. 28-Ja
Peru— Callao Dec i < =
i'eru — Catacaos I
Peru — I'errenafe I '
Peru — Jequetei)e<iuc I '
Peru — Paita 1 1' > ' - -
I'eru — San Teronimo Dec. iS-j;
Peru— Trujillo Dec. 18-2;
Present.
Increas-
ings.
334
BIRTHS, MARRIAGES, AXD DEATHS.
[New York
Meoijal Journal.
Public Health and Marine Hospital Service:
Official list of changes of stations and ditties of com-
missioned and noncommissioned officers of the United
States Public Health and Marine Hospital Service for the
week ending February 8, igo8:
Blount, B. B., Acting Assistant Surgeon. Granted leave
of absence for thirty days from January 31, 1908.
BoGGESs, J. S., Passed Assistant Surgeon. Relieved from
duty at St. John, N. B.. and directed to proceed to
Qiicago, 111., reporting to the medical officer in com-
mand for duty and assignment to quarters.
Brooks, S. D., Surgeon. Granted an extension of leave of
absence for ten days, on account of sickness.
C.-\RMiCHAEL, D. A., Surgeon. Directed to proceed to Fort
Stanton, N. M., and St. Louis, Mo., for special tem-
porary duty; upon completion of which to rejoin his
station at Buffalo, X. Y., returning via Washington,
D. C.
CoRPUT, G. M., Passed Assistant Surgeon. Directed to
proced to Austin, Tex., for special temporary duty ;
upon completion of which to rejoin his station at Gal-
veston, Tex.
Earle, B. H., Passed Assistant Surgeon. Granted leave of
absence for seven days from February 4, igo8.
Foster, A. D., Passed Assistant Surgeon. Granted leave
of absence for one month from January 10, 1908.
Francis, Edward, Passed Assistant Surgeon. Granted
extension leave of absence for seven days.
Hicks, W. R., Acting Assistant Surgeon. Excused from
duty without pay, December 15 to 23, 1907. inclusive.
Keatley, H. W., Acting Assistant Surgeon. Granted leave
of absence for five days from January 14, 1908, under
paragraph 210, Service Regulations.
McLaughlin, A. J., Passed Assistant Surgeon. Relieved
from duty at Naples, Italy, and directed to proceed to
Manila, P. I., reporting to the Chief Quarantine Officer
for duty.
MoNcuRE, J. A., Acting Assistant Surgeon. Granted leave
of absence for thirty days from February 20, 1908.
Sprague, E. K., Passed Assistant Surgeon. Granted leave
of absence for ten days from February 11, 1908.
Spratt, R. D.. Assistant Surgeon. Leave of absence
• granted Assistant Surgeon Spratt for twenty-one days
from January 14, 1908, amended to read for eleven days
only.
Stoner, G. W., Surgeon. Directed to proceed to Malone,
N. Y., for special temporary duty ; upon completion
of which to rejoin his station at Ellis Island, N. Y.
Walker, R. T., Acting Assistant Surgeon. Granted leave
of absence for four days from February 16, 1908.
W^iCKES, H. W., Passed Assistant Surgeon. Granted leave
of absence for two days from January 28, 1908, under
paragraph i8q. Service Regulations.
WoLr.ENiiERG. R. .\. C., .Assistant Surgeon. Relieved from
duty at Ellis Inland, N. Y., and directed to proceed to
Naples. Italy, for duty.
Young, G. B., Surgeon. Detailed to represent the Service
at the third aiinual convention of the .American Society
of Inspectors of Plinnbing and Sanitary Engineers to
be held at Chicago, 111., February 10 to 12, 1908.
Board Convened.
A board of medical officers was convened to meet at San
Francisco, Cal., February 3, 1908, for the purpose of mak-
ing a physical examination of an officer of the Revenue
Cutter Service. Detail for the board : Surgeon H. T.
Austin, chairman, and Passed Assistant Surgeon C. II.
Gardner, recorder.
Casualty.
Acting Assistant Surgeon Stacy D. Williamson died
January 25, 1908.
Army Intelligence:
Official list of changes in the stations and duties of offi-
cers serving in the medical department of the United States
Army for the week ending February 8, 1908:
Boi kke, James. First Lieutenant and Assistant Surgeon,
Relieved from duty as Surgeon of the U. S. A. Trans-
port Kilpatricli, and ordered to Fort Leavenworth,
Kansas, for duty.
Carter, E. C, Major and Surgeon. Appointed a member
of an Army retiring board at Fort Leavenworth, Kan-
sas.
Miller. E, W., First Lieutenant and Assistant Surgeon.
Relieved from duty, with the Army of Cuban Pacifica-
tion, and assigned to duty as Surgeon, U. S. A. Trans-
port Kilpatriek.
Morse, A. W., Captain and Assistant Surgeon. Appointed
a member of an Army retiring board at Fort Leaven-
worth, Kansas.
Munson, E. L., Major and SurgCDU. Left Fort Sheridan,
111., on ten days" leave <it absence, with permission to-
apply for an extension of twenty days.
Talbott, E, at. Captain and Assistant Surgeon. Relieved
from duty at Fort Leavenworth, Kansas, and ordered
to duty with the Army of Cuban Pacification
Navy Intelligence:
Official list of elianges in the medical corps of the United
States Navy for the z^'eek ending February 8. igo8:
McClurg, W. a.. Medical Director. Commissioned a
medical director from June 16, 1907.
McDonell, W. N., Passed Assistant Surgeon. Detached
trom duty at the Naval Hospital. New York, N. Y.,
and ordered to the naval recruiting station, Chicago,
111.
Orvis, R. T.. Surgeon. Commissioned a surgeon from
Alarch I, 1905.
Wheeler. L. H.. Assistant Surgeon. Ordered to the naval
training station. Newport. R. I.
Married.
Baruch— Emmetaz. — In New York, on Wednesday,.
February 5th. Dr. Herman B. Baruch and Miss Rosemary
Emmetaz.
Cunningham — Treanor. — In San Jose, California, on.
Friday, January 24th, Dr. W. Edgar Cunningham and Miss
Edith Cecelia Treanor.
Kishler — Hollingsw^orth. — In St. Marys, Ohio, Dr. W.
G. Kishler, of Wapakoneta, and Miss Henrietta Hollings-
worth.
McDuffie— Helmer.— In AM.Miry Park, New Jersey, on.
Wednesdav. February ;th. 1 )r. Marshall Williani> Mc-
Duffie, of New York, and Mi- Hattie W. Helmer.
Died.
Allen. — In Cobleskill. New York, on Friday, January-
31st, Dr. Peter A. Allen, aged ^ixty-nine years.
Barron.— In New York, on Thursday, February 6tli, Dr.
Ic>hn Conner Barron, aged sl^-enty years.
Beckham.— In Shelbyville. Kentucky, on Saturday, Feb-
ruary 1st, Dr. Beverly M. Beckham, aged eighty-two rears.
Cedarholm. — In Brooklyn, on Friday. February 7th, Dr.
David L. Cedarholm, aged fony-tive years.
Dee. — In Buckport, New York, on Sunday, January 26th,
Dr. W. H. Dee, aged seventy-nine years.
Dye. — In Philadelphia, on Monday. February 3d. Dr.
Frank Haz^ard Dye. aged tliirty-two years,
Flfwlllijng. — In Sonierxilk. Ala^sachusetts, on Friday,.
January 3T.it. Dr. I)ougl;;s- S. Flewelling, aged forty-six
years.
Fuller.— In Bellefontaine, Ohio, on Thursday, January
30th, Dr. S. W. Fuller, aged ninety-four years.
Grken. — In Pitt^luirtili. Pennsylvania, on Monday, Janu-
ary 27th, Dr. T. T '.i' -1. aged sixty years.
Holcombe. — III i.n.ii 1. irington, Massachusetts, on Sat-
urday. February isi. Dr. Charles Clifford Holcombe. aged
seventy-eight years.
Leckner.— In Detroit, Michigan, on Thursday, January
27th, Dr. Frank P. Leckner. aged forty-eight years.
McCreight.— In Bastrop. Louisiana, on Saturday. Janu-
ary 5th, Dr. William R. McCreight, aged seventy-one years.
Millard. — In Chicago. Illinois, on Saturday, February
1st, Dr, Samuel R. Millard, aged ninety-two years.
Morrison.— In Fort Worth. Texas, on Tuesday. January
28th, Dr. Claude A. Morrison, aged thirty years,
tvIe.\t,— In New Albany, Indiana, on Saturday, February
1st, Dr. Tliomas C, Neat, aged si'xty-scven years.
Paine. — In Oneida, New York, on Sunday. February 2d.
Dr, Ridlev C. Paine, aged titty-nne years.
Roehler.— In Chicago. Illinois, on Thursday. January
30th, Dr. Henry D. Roehler. aged thirty-four years.
Sharp.— In Arcade. New York, on Wednesday, January
29th. Dr. Henry P. Sharp, aged fifty-three years.
Varner— In Evansville. Indiana, on Wednesday. Janu-
ary 20th. Dr. W. T. Varner
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal rlt Medical News
A Weekly Review of Medicine, Established 184J.
\ OL. LXXXVII, No. 8. NEW YORK. FEBRUARY 22. 1908. Whole No. 1525.
Original ^^ffmrnunitatians.
SOME OF THE' TRIUMPHS OF SCIENTIFIC
MEDICINE IN PEACE AND WAR IN
FOREIGN LANDS.
IVith Suggestions upon the Necessity of Important Changes
in the Organisation of the Medical Department
of the United States Army.
By Louis Livingston Se.amax, A. B., M. D., LL. B.,
F. R. G. S..
New York.
Late Major .Surgeon. United States N'olunteer Engineers.
If an}- doubting Thomas questions that the crown-
ing glory of the profession of medicine is the pre-
vention of disease rather than its cure, a visit to the
American tropics should convince him of his error.
For centuries the continents, both north and south
of the equator, have stood in constant dread of dys-
entery, bubonic plague, malaria, and yellow fever.
Terrible epidemics of the latter have ravaged the
coastwise cities in spite of rigid quarantines, for
prior to 1902 the nature of its transmission was not
understood, and effective quarantine w-as impossible
where the stegomyia mosquito thrived. Only a few
years ago, in the harbor of Santos, thirty-one ships
of almost every nationality rode at anchor for
months without a living creature aboard, manv of
their masters and crews having fallen victims to
"yellow Jack," with little possibility of replacing
them.
"Fifteen men on the dead man's chest,
Yo, ho, ho, and a bottle of rum.
Drink and the devil had done for the rest,"
only in this instance the devil was yellow fever,
which was of such frequent occurrence as to scarce-
ly excite surprise. The South American coast was
dreaded by the mariner more than the Spanish main
in the days of the pirate bold and the buccaneer, so
much so that the Llo} ds often refused to underwrite
vessels visiting these hotbeds of infection. But how
is it to-day? Through the brilliant discoveries sug-
gested by Finley. of Havana, and proved b}- the
commission headed by ]\Iajor Reed, the true method
of its transmission was established and its eradica-
tion became a possibility, although in the prosecu-
tion of their experiments the majority of the mem-
bers of the commission fell martyrs to the disease.
What Dr. Wood, Dr. Reed, and Dr. Gorgas accom-
plished in its extinction in Havana and Santiago,
and Dr. Gorgas repeated so effectually in the Canal
Zone— as you heard him so graphically describe at
a recent meeting of this Academy — Dr. Cruz dupli-
cated with even greater success in Bahia, Rio de
Janeiro, and Santos, the most prolific culture
grounds of the disease in the world, because their
sanitary problems were there more difficult. Xot
until the last named scientist was given absolute con-
trol in his own department, however, were his la-
bors crowned with success. A terrible epidemic of
the fever had visited Rio and Santos, the conmierce
of Brazil was paralyzed, the population of the cities
decimated. Foreign capital was deserting, and the
outlook was most gloomy. ^Millions of dollars were
required for its extermination, and, after violent po-
litical opposition, Dr. Cruz was ultimately given con-
trol of his department, with correspondingly for-
tunate results, for in a comparatively short time the
country was free from disease. He established an
admirably equipped department of sanitation, with
a corps of over 2,300 well paid, uniformed men,
whose sole duty was to fight yellow fever and bu-
bonic plague, and who carried out their orders with
almost as much celerity as the members of the
fire department do in this city. Horses stood har-
nessed in their stables, ready to be hitched to ambu-
lances and disinfecting carts, loaded with the neces-
sary equipment for isolating cases and purifying the
surroundings, so that the moment a new case was
reported it was isolated by double screens, and the
spread of the disease was eft'ectually prevented. As
a result, desirable immigration is no longer fright-
ened away, foreign capital is flowing in to develop
the limitless resources of the land, commercial in-
terests have enormously increased, and the material
and financial gains parallel those of humanitarian
character. Brazil demonstrated the axiom that pre-
vention is better than cure; and that, as a financial
proposition, it pays to give the medical officer ade-
(juate authority in his own department.
The splendid work of Cruz in eradicating yellow
fever has been equally successful in his campaign
against bubonic plague, which for > ears had ravaged
the coast with serious mortality. The final extinc-
tion of both these transmissible diseases in South
America will soon be an accomplished fact, if the
present policy of prevention and sanitation is main-
tained. In addition, Cruz established a school of
experimental medicine in Rio, rivaling similar insti-
tutions in Europe and America, which will justly
give Brazil an enviable position in the scientific
world. A large corps of assistants are constantly
occupied in the preparation of the various sera used
in the prophylactic or curative treatment of bubonic
plague, diphtheria, typhoid, and other diseases, and
distributed over the country on the demand of physi-
cians. The stables of the animals used iri the prose-
Copyright, igcS. by A. R. Elliott Publishing Company.
336
SEAMAN: MEDICINE IN PEACE AND WAR.
[New York
Medical Journal.
cution of this work are marvels of cleanliness, and
in the operating room asepsis is observed as faith-
fully as in a modern hospital.
Rio de Janeiro maintains an excellent institution
for the preparation of vaccine virus, also a medical
college, which is to celebrate its centenary during
this coming summer. It is admirably equipped with
laboratories, especially for the study of hygiene and
sanitation. Its Academy of Medicine is a most se-
lect body, and the walls of the lecture rooms of the
college are graced with life size portraits of its lead-
ing professors. Aseptic precautions are observed
so carefully in some of the hospitals that operating
arenas are separated by plate glass partitions from
the remainder of the room, so as to completely iso-
late them from contaminating atmosphere, where the
students are seated.
The most serious defect observed in all the insti-
tutions of South America was the lack of trained
nurses. Many of the hospitals in these old coun-
tries were formerly convents, and the labor of nurs-
ing was performed by the members of the various
sisterhoods. These women, although often inspired
by high motives, lack the skill necessary in the care
of serious diseases, or for obtaining the best results
in the after treatment of operations. And here I
may be pardoned for a moment's digression to pay
a word of tribute to my old traveling companion
and friend, Dr. Nicholas Senn, whose sudden and
lamented death recently shocked the world.
It was my privilege to circumnavigate the conti-
nents of Africa and South America with him, visit-
ing the coastwise cities and hospitals en route, and
penetrating through the jungle to the interior, wher-
ever railway connections permitted.
While crossing the Peruvian Andes in Sej^tem-
ber, near Lake Titicaca. 12,000 feet high, and La
Paz, the highest city in the world, he was seized
w ith the attack of soroche or mountain sickness that
hastened his end. In passing from the Pacific Ocean
through the Cordillerian and Andean ranges, over
the great divide that separates it from the Ama-
zonian slope, we rose to an altitude of nearly three
miles in fifteen hours. The tremendous tension put
upon the circulator)- system in this already rarificd
atmosphere resulted in an attack of acute cardiac
dilatation, with its distressing sequehe, aggravated
by Iironchitis contracted in the Straits of Magellan.
To dwell upon the achievements of tliis great man
would only be to repeat that with wliicli the scien-
tific world is already familiar. Aside from his re-
markable originality in the field of surgery, Senn
was a naturalist of deep learning, well versed in the
flora and fauna of almost every land in the habitable
globe. His fame was world wide. His capacity for
work exceeded that of any man I have ever known.
He was a close ob.server, a conservative operator, an
elfK|uent clinical lecturer, and in the emergency of
war served his country faithfully and well. In his
death America has lost an honored son, .science a
distinguished pioneer, and the world a gentle friend,
whose fame will linger longest in the short and sim-
ple annals of the poor.
You have so recently heard of the brilliant results
attained by Dr. (iorgas in the Canal Zone that a re-
hearsal of them is unnecessary. But the great les-
son to be drawn from his splendid work was not
pointed out at the time of his lecture. It must be
remembered that during the first year of our occu-
pation of the Panama district disease ran rampant,
so much so that at one time the abandonment of the
entire enterprise was considered. It was then proved
that sanitation was the fundamental problem re-
quiring solution, even before the engineering ques-
tion could be solved. The original Isthmian Com-
mission included no member of the medical profes-
sion, but was composed entirely of politicians and
ofificers, ignorant of sanitation and hygiene, who ig-
nored or so limited the authority of the chief sani-
tary officer as to render the enforcement of his regu-
lations and measures impossible. This officer. Dr.
(jorgas, was subordinated to the governor of the
zone, to the chief disbursing officer, to the chief of
the Bureau of Materials and Supplies, to a Mr.
Grunsky, to the commission, to the Secretary of
War — subordinated, in fact, to the seventh degree
from the source of authorit}' — just about as the med-
ical officer of the United States army is, under the
decrepit system under which he is compelled to
serve to-day.
The chairman of the Legislative Committee of
the American Medical Association, Dr. Reed, says :
"Here was Dr. Gorgas, recognized as the foremost au-
thority in the world in the sohition of the pecuhar problems
pertaining to tropical sanitation, subordinated to a series
of other subordinates, all of whom were confessedly igno-
rant of the very question with which he was most familiar."
"The working of this wonderful mechanism," continues
Reed, "is mteresting. Thus, if Major La Garde, superin-
tendent of Ancon Hospital, makes a requisition for sup-
plies, he must make it in due form, take it for approval to
the chief sanitary officer, then to the governor of the zone,
then to the chief disbursing officer ; whence it goes to the
commission nt Washington; then to the Mr. Grunsky as
committeeman ; then back to the commission ; then, if al-
lowed, bids are advertised for; awards are made; the requi-
sition is filled under the supervision of a purchasing agent
notoriously ignorant of the character and quality of medi-
cal and surgical supplies ; the material is shipped to the
Isthmus, consigned to the chief of the Bureau of Materials
and Supplies, who notifies the disbursing officer, who notifies
Colonel Gorgas, who in turn notifies Major La Garde, who
applies to the quartermaster — the boss of a corral — for
transportation, and, so much of the stuff as in the judg-
ment of, first, the governor, next the chief disbursing offi-
cer, ne.\t the commission, next, and more particularly.
Grunsky. the committeeman, ought to be allowed to the
superintendent of Ancon Hospital, finally arrives, or does
not arrive, at its destination, where the necessity for its
use has probably ceased."
This is no fanciful picture ; it is exemplified in
practically every requisition that went forward and
illustrates the tortuous course of the regular mili-
tary channel, as it now exists in the United States
.Army.
And what was the natural consequence of this
wretched system at Panama? A costly epidemic —
the death of some members of the commission and
of many laborers — a stampede of the remainder that
threatened the success of the entire canal scheme
and caused a delay of nearly a year in its comple-
tion, and the loss of interest on its heavy invest-
ment, that would have paid for the sanitation of the
zone for years. Not until the imminence of failure
dawned uix)n the Washington authorities was a
medical officer made a commissioner, with authority
to carry out his sanitary measures. The success re-
sulting from this iK>wer being conferred upon our
honored colleague again demonstrated the wisdom
February 22, 1908.]
SE.4MAN: MEDICINE IN PEACE AND WAR.
337
of making a medical man supreme in his own de-
partment; a truth Congress was for once forced to
recognize.
Foreign governments foster their medical discov-
erers ; ours does not. When Pasteur made his bril-
liant discovery of the microbic origin of disease
and found the magic key that unlocked the secrets
of infection, the French government recognized his
great work by placing him at the head of an institu-
tion under governmental patronage that enabled him
to more successfully prosecute his experiments and
researches. When Koch discovered the bacillus of
tuberculosis, he was a comparatively unknown
country practitioner, but his government placed him
at the head of a department with abundant means
to continue his work : it sent him to Africa to in-
vestigate the rinderpest, and after the successful so-
lution of that problem sent him once more to the
dark continent, where for the past two years he has
been conducting a heroic battle against those
dreaded diseases of the African tropics, sleeping
sickness and malaria.
In Africa I met Dr. Ollwig. Koch's chief assist-
ant, who, in his scientific battle with malaria, is car-
rying out the two policies suggested from an
ietiological point of view : ( i ) The destruction of
the anopheles by ridding the surrounding jungle as
far as possible of its breeding places, and ( 2 ) the
neutralization of the plasmodian parasites by hypo-
dermatic and internal administration of quinine,
continued for many months. Favorable results
have thus been obtained, although the difficulties of
exterminating -the mosquito have not yet been over-
come. The period during which the infected stego-
myia continues as a source of danger in the trans-
mission of yellow fever is limited to fifty days,
whereas the infected anopheles retains its power of
infection for three years, thus making the task of
eradicating malaria far more difficult.
The results of Koch's investigations of tripano-
somiasis are already well known to the medical pro-
fession. The infected tsetse fly is undoubtedly the
most dangerous enemy of man and beast, where it
exists, as up to the summer of 1906 the bite of an
infected fly was invariably fatal. Its ravages in a
belt of territory near X'ictoria Xyanza in the year
we were there resulted in a fatality among the na-
tives of over 200.000. many districts being almost
depopulated. Horses, mules, cattle, antelopes, ze-
bras, and wild buffaloes died in countless numbers.
The zone of these depredations was rapidly increas-
ing, and for that reason the German government
sent Professor Koch to study the habits of the fly
and discover, if possible, a method for its extermin-
ation.
How does the Japanese government look upon
the health of its citizens? When Kitasato. after
careful research and experimentation, discovered the
bacillus of bubonic plague, the government prompt-
ly rewarded him by placing him in charge of a great
institution for the study of infectious diseases, where
the sera are made for the prophylactic and curative
treatment of the most deadly diseases of the coun-
trs-, and where much original investigation is being
conducted.
In England every little town has an officer of
health, appointed by the general government to
guard its citizens against disease.
Lister, Pasteur, and Koch opened the door to
scientific research ; but long before their day, small-
pox had been brought under control by the immor-
tal Jenner. This loathsome disease would long ago
have disappeared from the earth forever, but for
the ignorant attacks of fanaticism. As has been
truly said: "Xothing has tended more to retard the
advance of science than the disposition in vulgar
minds to vilify what they cannot comprehend."
Cholera and h\ drophobia have been conquered by
Pasteur, and Lister and Koch pointed the pathway
to victory over the death dealing microbes of trans-
missible diseases. Through their instrumentality
disease has become the slave rather than the master
of mankind. Xo longer do diphtheria, tetanus, sep-
ticaemia, typhoid, cholera, puerperal sepsis, hospital
gangrene, erssipelas. and wound infection hold the
world in dread.
Xotwithstanding that in 1904 the victims of bu-
bonic plague in India numbered 1,022,000, and in
the first six months of 1907 reached the appalling
number of 1.060.000. a scientific campaign of pro-
phylactive sanitation would soon stamp out the last
vestige of its existence, were it not for the supersti-
tion of the natives which renders such a course im-
possible.
If scientific medicine has won these gigantic vic-
tories over disease, and in methods of its prevention,
in the last twenty-five years, what wonders of dis-
covery may not be divulged in the coming centu-
ries. Let us for a moment see what results have re-
cently been accomplished by an intelligent applica-
tion of scientific medicine in the field of war. Its
last and most noteworthy application was in the
great Oriental conflict just concluded.
General Tarauchi, Japanese minister of war.
stated on X'ovember 23. 1005. in an address before
the Red Cross Society of Japan, that "the total
number of soldiers dispatched to the front during
the war amounted to over 1,200,000. 80,000 of
whom died, and 300.000 fell sick. Of this vast
number only about 9,300 died from wounds, and
20.000 from sickness." This would leave the total
from killed and battle casualties about 60,000 ; and
from disease 20,000, or about one from sickness
to three from casualties of war.
In April, 1906, a \ear after the last great battle
had been fought, and when the totals were com-
pleted. Dr. Lynch (our military attache in Japan
during the war) in his report to our war depart-
ment published the following official figures :
TABLE I.
Killed in battle and died from wounds 58,887
Died from disease 27,158
Total died ; 86,045
or more than twice as manv from battle casualties
than from disease.
The records of extended campaigns for the past
two hundred years, as shown in the Standard
Tables of Longman and elsewhere, are that four
men have died from disease to one from bullets.
These figures of the Japanese army, therefore, con-
stitute the most remarkable series ever published in
33S
SEAM.IX: MEDICINE IN PEACE AND WAR.
I New York
-Mkdical Journal.
the history of wars. Almost simihir figures have
been unwarrantably contradicted by officers of the
United States army, but the report of Major Lynch,
our own medical attache, just published with official
records down to April, 1906, cannot be challenged.
In anotlicr taijle our military attache states that
in the jai)anese war with China, in 1894, for every
man who died from wounds 12.09 fronj dis-
•ease. In the war with Russia, ten vcars later, for
■every man who died from ■woinids. 0.4O died from
•disease, or one twenty-seventh as many.
In their titanic conflict the Japanese kept over
600,000 men in the field for over a year and a half ;
they fought some of the greatest battles of history,
one of twelve days of incessant conflict, and another
of sixteen days ; skirmish fighting went on con-
stantly during the entire period of hostility. In
their campaigns the soldiers had their camp kettles,
water boilers, blankets, and mosquito nets, and
every man was protected by a net d.uring the mos-
quito season. Their casualties have been nearly 40,-
000 in a sing-le battle, or twice the entire number of
soldiers we sent to Cuba, and yet, every man was
promptly, carefully, and scientifically cared for.
They fought through a country where insanitary
conditions prevailed, often camping on the germ in-
fested sites of their enemies, and yet, by the inces-
sant precautions of a numerically adequate medical
corps, with power to enforce sanitation and liygiene,
the army was enabled to make a health showing un-
heard of before in the annals of war.
In contrast to this picture let me for a moment
invite your attention to the Puerto Rican expedition
in that opera bouli'e performance known as the
Spanish-American war, for nowhere in history is
there found a more illuminating instance, a graver
lesson, or a more terrihle warning, than is here por-
traved. For our countrv is the "Mene, mene, tekel
eupharsin," the handwriting on the wall, so easily
decipherable that he who runs may read, and yet,
in the glory of victory, and the enjoyment of pros-
perity, its lesson has passed unheeded.
The story of the expedition is brief. About 20,-
000 .\merican troops landed in Puerto Rico, while
the S])anish on the island numbered about 17,000.
Several skirmishes occurred, in which, according to
the surg'eon general's report, three men were lost
from the casualties of war. The object of the war,
the breaking, of the chains of Spanish despotism and
spoliation, which for centuries had held a race in
shameful moral serfdom, was socn accomplished,
and the war — from the strictly military standpoint
— was over. From our first arrival, the natives of
the island welcomed our battalions with vivas of
applause, strewing our advancing march with flow-
ers, and their masses were ])repared to joyfully
second our efforts for their more complete emanci-
pation.
That is the beautiful story that history presents.
Lest we forg'et, as a nation, and lie supine in the
easy content of this picture, let me invite your at-
tention for a moment to a further study of the re-
port of the surgeon general for that war. It states that
although ///;•('(' men only fell from the casualties of
battle during that entire campaign, 262. or nearly
one hundred times as many, died from preventable
causes. It fails. lu)wever, to state that the number
of hospital admissions nearly equaled the entire
strength of the invading army, and that the camps
of the army from one end of the island to the other,
were pestiferous hotbeds of disease before they had
been occupied a month, so that, had the bugle
sounded for action, only a small percentage of the
units would have been in a condition to respond to
the call. Xor was this state of afifairs confined to
Puerto Rico. In the invading armies of the Philip-
pines and Cuba the same conditions prevailed. The
official figures, as shown on Table II, were fur-
nished by the surgeon general of the army on the
loth day of October, 1905, and cover the vital sta-
tistics of the United States military expeditions for
for the year 1898.
TABLE II.
Deaths from
Battle Casualties Disease.
Ill the Philippine Islands 17 203
In Puerto Rico 3 262
In Cuba 273 567
In the C. S. home camps, etc... .. 2,649
Total (leatiis 293 3,68i
or about one from casualties to fourteen from dis-
ease.
The report further shows that, while the average
mean strength of the army enlisted for the Spanish
war was about 170,000, the total nutnber of admis-
sions to the hospitals was on September 10, 1898,
over 158,000, or 90 per cent. 'This in a war of less
than three months" duration, and in which more than
three-fourths of its members never left the camps
of their native land. The Japanese army for the
same period had about 4 per cent, hospital admis-
sions, or one twenty-second as many.
The vast difference in the Japanese figures illus-
trates the value of a medical and sanitary depart-
ment, properly equipped to enforce practical sanita-
tion, dietary and conservative surgery.
The splendid achievements of scientific medicine
in civil life in the prevention of disease should be
even more effectually obtained in the army, where
only healthy men are accepted, and vigorous out-
door camp life should keep its units, who are sub-
ject to strict militarv discipline, in perfect physical
condition. Health alone, however, is no guarantee
against the insidious attack of the silent foe that
lingers in every camp and bivouac. It is this foe,
as the records of wars for the past 200 years have
proved, that is responsible for four times as many
deaths as the guns of the enemy, to say nothing of
the vast number temporarily invalided or dis-
charged as unfit for duty. It is this dreadful un-
necessary sacrifice of life from preventable disease
that constitutes the hell of war. In every great
campaign an army faces two enemies. First, the
armed force of the opposing foe with its various
machines for human destruction, that is met at in-
tervals in open battle ; and, second, the liidden foe,
alway s lurking in the camp, the spectre that githers
its victims while the soldier slumbers in barrack
or bivouac — the far greater, silent foe, disease. Of
these enemies the history of warfare for centuries
has proved that in extended campaigns the first or
open enemy kills 20 per cent, of the total mortality,
while the second or silent enemy kills 80 per cent.
In otlier words, out of every hundred men who
rebriiary 22. 1908.]
SEAMAX:
MEDICINE IN PEACE AND WAR.
339
fall in war, twenty die from the casualties of battle,
\\ hile eighty perish from disease, most of which is
preventable.
TABLE III.
Battle Casualties. Disease.
In the Russo-Turkish War the
deaths were 20,000 80,000
111 the six months of the Cri-
mean campaign, as is asserted
on eminent authority, the
losses of the allied forces
were _'o.ooo 50.000
In our war with ^lexico the
proportion was i to 3
In our civil war, about the same
proportion i to 3
In the French campaign in
Madagascar, in 1894, of 14.000
sent to the front, twenty-nine
were killed in action, and over
7.000 perished from prevent-
able disease 29 7.000
In the Boer War in South
Africa the English losses
w-ere about i to 10
In our war with Spain fourteen
lives were needlessly sacri-
ficed to ignorance and incom-
petency for every one who
died on the firing line or from
the result of wounds, the fig-
ures being 293 3.681
In the Russo-Japanese War the
figures were 58.887 27.168
or more than two from battle
casualties to one from disease,
thus reversing the records of
all wars for the past 200 years.
The difiference between the martyr and the vic-
tim, between the soldier who falls on the field of
honor and the man who meets a miserable death
from preventable disease, for which his government
is criminally responsible, is as wide as the celestial
diameters. The one meets death compensated in
the thought that his life is given in the protection
of his country's flag and honor ; the other is igno-
miniously forced to his grave through the neglect
of the government that shamefully fails to protect
the life he offered in its defense.
That the monstrous sacrifice of 80 per cent, is al-
most totally unnecessary has been abundantly
proved in the records of the Japanese war, where
1.200.000 men were sent to the front, in a countr\-
notoriously unsanitar\', and only 27.000 men died
from disease, to 59,000 who fell in the legitimate
hue of duty on the field of honor. In the army of
the United States in 1898, 2,649 picked soldiers died
in three months, without leaving the country, in the
pest camps of this, their own native land.
Unless an army maintains a thoroughly organ-
ized sanitary corps, prepared to fight germs and
diseases in advance of the fighting forces, test-
ing the water supplies, and avoiding the dan-
gers from contagion and infection, the medical
clepartment might as well be abolished. If the
Japanese had not realized this before their last
war and taken measures to prevent disease, their
army would never have won their brilliant and un-
interrupted series of victories. If they had sus-
tained the same ratio of mortality from sickness as
in their war with China ten years before, their losses
from disease alone in the Russian war would have
nearly equaled the total of their entire losses from
all causes. This proves the value of the medical
and sanitary corps, and illustrates its importance
as a factor in the winning of the final issue.
The days of operative surgery on the field of bat-
tle or at the front passed with the discovery of asep-
sis and antisepsis. The Russo-Japanese war taught
many lessons and destroyed many ideals in matters
military as in matters surgical, where the hitherto
accepted idea of the duties of the military surgeon
was shown to be erroneous, where asepsis and anti-
sepsis relegated the use of the scalpel to compara-
tive obscurity and demonstrated conclusively that
preservation of the army by prevention of dis-
ease is the surgeon's duty, first, last, and nearly
all the time. In surgical technique, or in the after
treatment of the wounded and sick, the Japanese
taught the foreigner comparatively little, but in the
field of sanitary science and dietetics they demon-
strated, what had never been done before, viz., that
preventable diseases are preventable and can be con-
trolled; and that the great incubus of an army in
the field, the presence of crowded hospitals and the
large and expensive force necessary to equip and
conduct them, can to a large extent be eliminated.
It is a sad reflection on our civilization that, while
we regard as essential separate departments of
State, Agriculture and War, in the executive cab-
inet at W^ashington, and issue bulletins for public
distribution on swine cholera, cabbage culture, and
crop reports, principally used by speculators, we
deliberately ignore the safeguarding of our people
from the horrors of infection and contagion. While
the rest of the world has been making these splen-
did advances in the humanities, America — except in
institutions fostered by private philanthropy — has
stood in stolid indifference, doing little to stem the
tide of destruction. We have allowed the wreckage
and waste to go on, to cripple the energv- with
which we must challenge the future.
The relation of our federal government to public
health has assumed some national importance, and
if the eft'orts of the various medical societies of the
country, the American Association for the Advance-
ment of Science, the American Museum of Safety
Devices, various insurance, accident and allied asso-
ciations, are successful, it may receive a little more
recognition. The paramount want is for a National
Board of Health with a secretary in the cabinet of
the President.
If this cannot be secured, a more liberal policy
toward the National Bureau of Health, connected
with the Marine Hospital Service, is much to be
desired. Through an extension of the services of
this organization the death rate of the country may
be enormously decreased, possibly to the extent of
one third to one half, and the general health of the
community benefited by the eradication or ameliora-
tion of disease from preventable causes. But, as
Dr. Welsh recently stated: "If the millions spent
for the extermination of hog cholera during the
last decade had been spent for the preservation of
the public health, we should be far ahead of where
we are to-day."
In the light of modern and sanitary science there
is little excuse for the enormous losses by illness and
death through typhoid, diphtheria, scarlet fever,
340
SEAMAN: MEDICINE IN PEACE AND WAR.
[New York
Medicai. Journal
cholera infantum, and dysentery, all of which are
preventable. The names of these diseases do not
inspire the same terror as bubonic plague, yellow
fever, cholera, and smallpox, but their victims are
just as dead, and their bereaved are just as desolate.
And these diseases might be stamped out quite as
effectually as the others, with proper enforcement
of sanitary precautions.
It is stated that the appointment of a Secretary
of Health in the President's cabinet and the en-
forcement of regulations for the public health
would interfere with the rights of States, but do
the germs of cholera and yellow fever and tubercu-
losis and bubonic plague and measles respect State
Imes? And do streams polluted with cholera and
typhoid bacilli cease to flow at State borders? In-
terstate commerce is not considered as an interfer-
ence with State rights : then, why should interstate
disease be so regarded?
Prior to the enactment of the pure food laws,
which are now producing such beneficial results in
the preservation of the public health, the same argu-
ment was advanced, but the passage of the act, in-
stead of restricting the States, has induced them to
enact similar or even more drastic laws in the same
line; and no one objects — except the manufacturer
or seller of adulterated products.
The estimation in which the authorities at Wash-
ington hold the only national institution we have
for the preservation of the public health was re-
cently evidenced by the efforts of a late member of
the cabinet to abolish or restrict the work of the
Marine Hospital Service on account of its expense.
Many kinds of fools are required in the making of
a world, but the American who would seriously
advise the abolition of this last named institution
combines in his single self the whole "fifty-seven
varieties."
Disease is an enemy that causes more fatalities
in a year than the combined armies of the world do
in a century. As well might a general in an en-
emy's country abolish his pickets and outposts as
for America with its extensive coastlines, its foreign
commerce, and its enormous immigration to do
without its Marine Hospital Service. I have seen
these zealous guardians of our public health in al-
most every port with which we have commercial
relations, always watchful lest contagious or in-
fectious diseases might elude them and fasten on
our native land, and with a fairly liberal personal
experience and knowledge of our government in its
various departments at home and aljroad. 1 assert
that the United States Public Health and Marine
Hospital Service is the one department of which
Americans have most reason to feel justly proud.
Instead of restricting its powers, they should be am-
plified ; instead of cutting down its appropriation,
it should be increased. In no department of our
government does the nation receive better returns
on its investment, even through some of the men-
tally myopic politicians of the present administra-
tion fail to discover it.
And this argument applies with equal force to
the medical department of the army. We go on
expending nearly half a million dollars a day for
the maintenance of our military schools, the educa-
tion of men in the art of war, and the manufacture
of machines for human destruction, and in the plant
necessary for putting these machines into execution,
while in the study of the equally important subject
of prevention of disease — the foe that kills four
times as many as the enemy's bullets — is left com-
paratively unheeded. .Every death from prevent-
able disease is an insult to the intelligence of the
age; if it occurs in an army, it becomes a govern-
mental crime. The state deprives the soldier of his
liberty, prescribes his hours of rest, his exercise,
equipment, dress, diet, the locality in which he shall
reside, and in the hour of danger expects him, if
necessary, to lay down his life in defense of its
honor. It should, therefore, give him the best sani-
tation and the best medical supervision that the
science of the age can devise, be it German or
Japanese — a fact of which congress will do well to
take cognizance before it begins another war. For
just as surely as the engineer who disregards the
signals, or the train dispatcher who gives wrong
orders, is legally responsible for the loss of human
life in the wreck that follows, so congress, or the
wretched system of the Medical Department of its
army, is responsible for the thousands of soldiers'
lives needlessly, criminally sacrificed — not on the
glorious field of battle, but in diseased camps —
from preventable causes. I believe that, if the Med-
ical Department of the Porto Rican Expedition had
been properly systematized with sufficient numbers,
with supervisory control over the ration, and with
power to enforce sanitary and hygienic regulations,
the units of that army would have returned to their
homes at the close of the campaign in better phys-
ical condition than when they had entered it, im-
proved by their summer outing.
The Medical Department of our army, whose ar-
chaic system almost parallels that of Peking, while
falling far below that of Patagonia (and I am
famiHar with both and speak advisedly), although
miequal to cope with the exigencies of the Spanish
campaign, is to-day, as the surgeon general states,
relatively 50 per cent, worse off in numbers than
at the close of the civil war in 1864, or at the ter-
mination of the Spanish-American campaign. The
theory upon which it is founded, that the cure of
disease rather than its prevention is its objective,
still remains in vogue. Although men of brilliant
attainments and individual merit are found on its
staff, the deplorable system under which they are
compelled to serve, and their lack of authority to
enforce .sanitation and hygiene, render the advis-
ability of the continuance of the department under
present conditions problematical. If it had been
totally abolished during the Spanish-American war.
and the army placed under the control of the Health
Department of this city with such an officer as Col-
onel Waring, or its present incumbent, in charge,
there would not have been such a disgraceful and in-
famous record. And why? Simply because that
dejjartment would have had authority to enforce
the orders respecting sanitation, diet, and hygiene,
and would have assured the safety of the troops.
Under the present system, the same old medical
regulations remain in vogue to all intents and pur-
poses as prevailed before the microbic origin of
disease was discovered and the key to sanitation
found. So that, if another war were to be de-
February 22, 1908.]
SEAMAN: MEDICINE IN PEACE AND WAR.
clared next summer, our government would again
convert the units of its army into hospital patients,
and its veterans into pensioners.
The deplorable collapse of the Medical Depart-
ment in the Spanish war resulted in the introduc-
tion into congress of a measure to increase its effi-
ciency. The essential features of this bill are mere-
ly to increase the commissioned personnel of the
medical corps, thereby abolishing the present sys-
tem of employing contract surgeons, to afford an
adequate flow of promotion and to establish a so
called medical reserve corps, recruited from recent
graduates, who, after examination, may be listed as
available for service in time of war. No provision,
however, is made for the instruction or training of
these reserves.
As a measure of true reform the bill is hopelessly
deficient in most essential features. It makes no
provision for that most important of all adjuncts,
an adequate sanitary department. One keen, up to
date sanitarian, thoroughly skilled in hygienic, di-
etetic, and bacteriological knowledge and armed
with the necessary authority to enforce sanitar\'
measures, is worth a hundred so called surgeons
to an army in the field, restricted, as they now are.
by red tape and lack of authority in matters re-
lating to their special department. Xo provision is
made for an independent transport system, nor are
medical officers given advisory authorit>- over the
Commissary Department or the soldiers" ration. A
regiment may be suffering from diarrhcea or in-
testinal catarrh (and I have seen go per cent, of
an entire command in this condition at one time),
compelled to live on a diet of pork and canned
beans and fermenting tomatoes until they became
hospital cases. Up to this time, the medical officer
has no authority to even order a rice diet, which
would have prevented the men from becoming in-
valided. This was one of the principal causes that
brought our army of 170,000 men in the Spanish
war almost to its knees in the three months, and
sent them home in the shrunken and shriveled con-
dition well remembered b\- many here to-night.
Under the present system the line officer of the
army is under no obligation to accept the recom-
mendation of the medical officer as to the site or
sanitation of a camp. Even in time of peace, he has
no executive power to enforce sanitation, although
he may be convinced that the health of every man
is being jeopardized.
I quote from a letter received last week from a
prominent medical officer in the Philippines ; he
says :
■'Recently a post commander, without the knowledge of
his medical officers, gave permission to a native to dam up
a stream on the reservation. The post had been kept free
from mosquitoes and malaria only by the utmost vigilance.
The medical officers protested personally, officially, and by
special sanitary reports, but to no purpose. Almost every
house soon became infected, one of the surgeons lost his
wife, and there were over forty cases. Finally a new post
commander tore out the dam. The post was Camp
Daraga."
One would suppose that ever}- effort of the med-
ical officers to maintain the health and vigor of the
fighting units would be welcomed, and all the au-
thority necessary to keep them so would be gladly
accorded, by the officers of the line, so in the reality
of battle the men would be in the best physical con-
dition. But this is not the case.
The officers of artiller>', of cavalry, of infantry,
the engineers, and of the signal service, can compel
obedience to their orders, but the medical man,
whose department fights the foe that has killed 80
per cent, in the majority of the great wars of his-
tory, cannot enforce an order, but can only make
a recommendation, which the line officer can accept
or reject at his discretion.
The bill ignores the pressing need for medical
inspectors and contains no provision for the estab-
lishment of a department of pharmacy. This should
have at its head a commissioned officer like the
late Dr. C. C. Rice, of Bellevue, with commissioned
subordinates, as is found in' several of the best or-
ganized armies abroad. It should be charged with
the ptirchase and distribution of all medical sup-
plies, the sterilization and care of all surgical instru-
ments, first aid materials, and the care of hospital
records. This would relieve the medical officer of
the complicated system of bookkeeping, invoicing,
other similar work, that now makes him little more
than a property clerk and decreases his value as a
physician in ratio to the time he remains in service
and wastes the vakiable hours he should devote to
the legitimate duties of his profession. The civil
practitioner gave up the practice of toting his pills
and powder when the scientific pharmacist ap-
peared, but congress, apparently unaware of the
advent of this adjunct to the medical art, still com-
pels the army surgeon to peddle his shop wherever
he goes, and holds him personally and financially
responsible and liable for every item of equipment
of the hospital and drug department of which he
has charge, be it base, field, or post hospital.
Wherein is the fault of the present system ?
First and foremost, in the faulty organization of
the Medical Department. The rank of surgeon
general should be commensurate with the import-
ance of the department of which he is the head.
Under a proper system, this officer should be re-
sponsible only to a National Secretary of Health,
who should be a cabinet officer, to the Secretary of
W'ar, or to the President, and there should be con-
ferred UDon him and his subordinates authority in
all matters of sanitation and hygiene, except in the
emergency of battle, when, of course, all authority
should devolve on the officers of the line.
The importance of the medical, as compared with
the other staff departments, has never been recog-
nized or appreciated. Until it is realized that the
most important function of the medical officer is
in the prevention of disease rather than its cure, the
old custom will prevail. To be efficient the medical
officer must not only be a good physician, but a
sanitarian, a bacteriologist, often a chemist as well
as an administrator. Upon him devolves the duty
of preventing disease, and his part in maintaining
the effectiveness of the units makes him an import-
ant factor in the military establishment. His status
is essentially military, not in the sense of holding
command, but as an integral part of an organiza-
tion, complex in its composition, and whose differ-
ent members should be so organized as to produce
a harmonious and effective whole. Under the exist-
342
SEAMAN: MEDICINE IN PEACE AND WAR.
[New York
Medical Jocrnal.
ing system, he is looked upon simply as a doctor,
whose sole function is treating the sick and wound-
ed— whose duties should be confined to the hospital,
and whose recommendations should be submitted
only when asked for.
In all the wars in which the United States have
engaged, disease has been responsible for more than
70 per cent, of the mortality, more than one half of
which could have easily been prevented, had the
Medical Department been properly organized and
equipped. Preventable disease more than wounds
swells the pension lists. Statistics of the Pension
Office prove that if this unnecessarv' loss had been
avoided the saving in pensions alone would have
paid the cost of the resulting war every twenty-five
years. Aside from the sorrow of the homes made
desolate, consider the economic value of the 70 per
cent, of lives now uselessly sacrificed that might be
saved as breadwinners in industrial pursuits.
The entire appropriation of the Medical Depart-
ment for the fiscal year of 1898 was less than $1,-
000,000 ; this was increased at the outbreak of hos-
tilities with Spain by something over $2,000,000.
Then came the war. As a result of that almost
bloodless conflict, the actual hostilities of which
lasted only less than six weeks, we paid last year
alone $3,471,157 in pensions, with the further as-
surance of an annual increase for many years to
come. The rolls of the Pension Office to-day bear
the names of 24,000 pensioners, over 19,000 of
whom are invalids and survivors of this war, and
over 18,000 additional claims are now pending ; al-
though the total of the. Cuban army of invasion was
only 20,000 men. Last year we paid in pensions a
total of $146,000,000; this year the appropriation
estimated for has increased to $151,000,000. Are
the fatalities of the past to be dismissed from the
equation of the future? Instead of repeating our
own blunders, why not emulate the successes of
others ? Possibly the recent action of the Executive
in placing a medical officer in command of a hospi-
tal, although that hospital chanced to be afloat, may
indicate a ray of hope.
It is far from certain, however, that congress
alone is responsible for the deplorable system of
our Medical Department. Why does not the sur-
geon general demand from congress all that is re-
quired to make the department really eflfective, even
though the- needed appropriation may be increased
tenfold? Why does he not marshal his facts and
figures and present them in illustration of the sui-
cidal policy of allowing this great waste from pre-
ventable disease, thereby demonstrating the value of
the medical man as a financial asset? Why does he
not show that his department could pay for itself
many times over in the annual saving of pensions,
now resulting from its neglect — that statistics prove
this loss amounts every twenty-five years to more
than the cost of the war that caused it ? Why does
he not show the enormous increase in the efficiency
of the army that would result from having fighting
men instead of invalids in its ranks? Also the enor-
mous economic value of the lives of the 70 per cent,
now wasted that might be saved to tlieir families as
breadwinners instead of invalids and pensioners?
Then let congress refuse his demand, if it dares as-
sume that responsibility. The liberality and gener-
osity of our nation to its pensioners proves we are
not always actuated by base or sordid motives ; and
if congress or the American people could be con-
vinced of the necessity for these reforms, there
would be little difficulty in obtaining their enact-
ment.
Permit a moment's digression to narrate the per-
sonal experiences of a soldier, a member of the As-
sociation of Military Surgeons of the United States,
which occurred within sight of the dome of the
Capitol at Washington. He writes:
"My Dear Seaman: — On May i, 1898, my regiment was
sent from our home station to Homestead, L. I., for re-
organization from a National Guard Regiment to a Regi-
m.ent of Volunteers for service in the war with Spain. Our
hospital corps of trained men was taken from us, as well
as our medical supplies and instruments, and the regimental
staff of three surgeons was reduced to one, with the rank
and pay of a first lieutenant — rather short-handed for a
full regiment of 1.333 men. Early in July I was detailed
as Sanitary Inspector of the army corps to which we were
attached, as typhoid fever was breaking out rapidly in every
organization attached to the corps.
"My instructions were to inspect all camp sites, sinks,
water supply, drainage, food, method of cooking, etc., and
report in writing to the chief medical officer of the corps
daily. I assumed the duties with great zeal, for sanitary
problems had long been a favorite study, as I had been
chief medical officer of my home city with its population
of nearly 400,000 for six years.
"There was at that time a yoimg man in my regiment,
who formerly belonged to my hospital corps, a graduate of
Cornell University, who had taken a postgraduate course
in analytical chemistry and was well qualified for chemical
and bacteriological work ; also a private in a hospital corps
detachment, encamped near us, who a few days before his
enlistment had returned from Germany, where he had been
a student and assistant in Koch's laboratory for four
years. A valuable microscope was found in the first divi-
sion of the hospital, which, as it was not used there, we
were assured we could have.
"A list of the required material was prepared, with a
probable cost of less than fifty dollars, and everything
looked favorable for a successful inauguration of my plan.
I accordingly drew up a communication to the chief medi-
cal officer of the corps, outlining the proposed work, show-
ing how we could analyze suspected foods, and water,
make the Widal test, blood counts, etc., and do such other
work as would naturally present itself. I also informed
him that nil details had been arranged, and the only thing
required to inaugurate tlie work at once was the proper
orders from corps headquarters. It is impossible to ex-
press my surprise and disappointment v\'hen my plan was
returned 'disapproved,' giving as the reason that the men
whom I had selected to do the scientific work were not
commissioned officers, but only enlisted men and that 'it
would violate all the traditions of the army to do this work
in this manner,' and that 'it was useless to establish a bac-
teriological laboratory in the field, as it could be of no
practical benefit.' In vain I pleaded the urgent need of
the hour, that the work could be done in my name, or
even in the name of the chief medical officer, but all to' no
purpose. The plan for the scientific work was thoroughly
'sat down on.'
"I then respectfully asked what plan could be substi-
tuted, and was informed that application w-ould be made
for a detail of contract surgeons, especially qualified, who
would aid in the work as outlined. My zeal, acquired as
an old National Guard officer, sulisided. and I plodded on
in my work, looking on and seeing preventable disease
sweeping away our soldier boys, and nothing, absolutely
nothing being done to find the source of the infection or
prevent its spread.
"The summer passed, the war was over, taps had been
sounded over the graves of hundreds of brave boys who
had never heard the hum of a 'hostile bullet, and earlv in
September we were ordered to our home station to be
mustered out.
"It was a beautiful Sunday morning, and the site where
more than 20.000 men had been encamped was practically
Februarj' 2-. 190S. )
METTLER: ART AND SCIEXCE I\ MEDICINE.
343
deserted. I could hear the sound of the drums and bugles
corning faintly through the woods, as the regiment marched
to the railroad. I lingered at the site of the first division
hospital with an ambulance, to bring the last of our sick
away, when my orderly informed me that an officer wished
to see me, and pointed to a man steated on a stump near
b}'. I approached him, and was informed that he was a
contract surgeon, sent by the department to report for bac-
teriological work. I told him that I was glad to see him.
but that the war was over, that sucii of the soldiers who
had not died of disease were now on their way home to be
mustered out. and that I hoped he would stick to his post,
so he would be ready for service when the next war broke
out."
And there is nothing in the Medical Bill now
Ix'fore congress to keep that man on the sttimp. so
he may be ready when the next war does come, or
for his substitute in case he, too, may have joined
the great majority before that time.
Is the great medical profession — a profession that
in one of the bloodiest wars of history has con-
tributed so largely in reducing the mortality of
deaths from disease — to remain subservient to the
dictates of the variety of judgment just cited, or
is its department in our army to be reorganized
upon rational lines, and its personnel empowered
to enforce its mandates, so that the medical and
moral rights of the soldier may be safeguarded and
the country receive the benefit of his protection?
Boast as zve may of our national patriotism and
philanthropy, our altruism in freeing Cuba from the
tyranny of Spain, and in elevating the status of that
bunch of trouble, the Philippines; our foreign mis-
sions, and our great systems of charity at home;
the cold, clammy fact remains that the sons of
Nippon in their war with Russia treated their pris-
oners with far more humanity than our nation does
its own soldiers.
In the great Oriental conflict just concluded, not
once did the Aluscovite win a victory^ but from the
Yalu to Mukden was driven from the field and
often left to his victors the care of his sick, his
wounded, and his dead. Sixty-seven thousand sick
Russian prisoners were brought to Japan from
^Manchuria and nursed back to health. And to the
eternal credit and glory of Japan let it be remem-
bered that from the first aid dressing on the firing
line, to the transport, the subsistence, the medical
care, and the gentle nursing in her home hospitals,
no difference was made between the treatment of
her own soldiers and those of the enemy. There-
fore, without minimizing the splendor of her victo-
ries on land or sea. at the Yalu. Port Arthur. ]\Iuk-
den, Shaho, Laioyang. or with Togo at Tshushima.
the fact remains that Japan's most splendid evolu-
tion and her greatest triumphs have been in the
humanities of war. By careful preparation and or-
ganization, the use of simple, easily digested rations
for her troops, and the application of practical sani-
tation by a fully equipped and empowered medical
department, she almost obliterated infectious and
preventable diseases from her army, and saved its
units for the legitimate purposes of war, to wit, the
smashing of the enemy in the field. She reduced
tlie mortality in her own army by over 80 per cent,
and treated her prisoners with a charity and consid-
eration heretofore unheard of in the history of war.
and established a standard in the humanities which
tlie rest of the civilized world will do well to attain.
Let us hope that the day is not distant when the
true value of the medical man in war will be ap-
preciated in our own land and will be given the au-
thority in his own sphere that will make it possible
for our army in the day of emergency to equal,
if not surpass, this splendid record. Braver men
never served with the colors than the American sol-
diers, as we proved on both sides of the civil war,
where many battles (in one of which, at Cold Har-
bor, ten thousand men fell in ten minutes) exceed-
ing anything known in the Orient, and where it was
conclusively proved that our soldier deserves ever}'
care and protection a generous government can be-
stow.
247 Fifth Avexue.
ART AND SCIENCE AS APPLIED TO THE PRAC-
TICE OF MEDICINE.*
By L. Harrisox Mettler. A. M., M. D..
Chicago,
Associate Professor in Neurology in the !Medical Department of the
University of Illinois.
No sooner had I accepted the flattering invitation
to deliver the address upon this the opening of the
new college year, than I realized how large a moun-
tain loomed up before me in the selection of a
profitable and interesting theme. Before so general
an audience as this a technical discourse would be
quite out of place. In consonance with the occa-
sion it seemed to me that I might speak of the art
and the science of medicine, especially the principles
underlying the broad conception of art and science,
as applied to the practice of healing, and yet not be
wholly unentertaining.
One thing I very promptly concluded not to do,
namely, to retail the history of medicine "from
Hippocrates down."' as is so often and wearisomely
done upon these occasions. The task would doubt-
less have been an easy and time saving one, with
the assistance of a good encyclopaedia and a rapid
stenographer. I have listened to such addresses
and have usually all but gone to sleep. As Bacon
intimates, it was their easy writing that made the
listening to them hard.
Another trite theme which arose in my mind and
about which we are compelled to hear much to-day,
is the wonderful progress of modern medicine.
Tempting as such a theme is. I quickly discovered
good and valid reasons for passing it by. The re-
cent advances of medicine are being iterated and re-
iterated upon evQTv possible relevant and irrelevant
occasion. \'accination, bacteria, serum therapy,
anaesthesia, and surgical technique have become, as
subjects of medical discourse, as platitudinous as
the state of the weather or the condition of the
crops. In most instances the announcement of the
title, modern advances of medicine, foretells for the
audience a very humdrum address and a very poor
speaker to deliver it. To present so self laudatory
a subject, with all its technicalities, attractively de-
mands on the part of the orator a tactful delicacy, a
brilliancy of style, and a versatility of ideas. Few
medical speakers, however, can lay claim to such
*An address delivered at the opening of the College of Physicians
and Surgeons, Medical Department of the University of Illinois,
October i. 1907.
344
METTLER: ART AND SCIENCE IN MEDICINE.
[New York
Medical Journal.
distinction. The advances of medicine, as a matter
of fact, are no greater than are the advances all
along the line of science. This is the age of inves-
tigation and deep research, and medicine is merely
keeping well in the van of progress. Most of my
hearers will know in a few weeks more about these
advances than I could begin to relate in the few
moments at my disposal.
The goodness, charity, and selfsacrifice of the
medical profession is another frequent theme that,
in my judgment, is always ill timed and impertinent
when handled before a lay audience. To pat one's
self on the back and to sound the bugle of one's own
praise is. to say the least, indelicate and a bit hu-
morous. It is childish and tends to make the medi-
cal profession a laughing stock in the eyes of the
rest of the world. I have never been convinced
that physicians, as a class, are more charitable or
kindly disposed to their fellow creatures than is any
other class of worthy and reputable citizens. The
latter, to be sure, have not the advantage that the
])hysicians have in exhibiting personally their be-
neficence and good vv'orks : but with what means
thev do possess, money and sympathy, I think they
do quite as much charitable work as the physicians
do. Much of the so called charity in our profes-
sion, be it said to our shame, is for personal adver-
tisement and self aggrandizement. We must guard
here against adding hypocrisy to the unpleasant
charge of thinking too well of ourselves. It is
pointed out that medical men give their services
freely to the hospitals and dispensaries. True, they
do give their services without salary or direct
monetary return ; but can it be candidly said that
they give those services as a self sacrifice, without
any hope of ultimate benefit? I think not; and I
am entitled to think so, because there is abundant
available proof that they do not. Let us be frank
and have the courage of our convictions, declaring
that in, as well as out of, the profession the laborer
is worthy of his hire. Ability, competition, supply,
■ and demand rule here as eleswhere ; and as to char-
ity and philanthropy, be it said, the medical profes-
sion ranks second to no other. It does vvhat it
can, in the best way that it can, to alleviate the sor-
rows and sufferings of the world. The spirit of
charity is something that belongs to the man
whether he be a medical man or not. It is not an
exclusive endowment, nor is its e.xercise a special
privilege, conferred u])on him by a medical diploma.
Therefore I will have nothing to say upon the
])hilanthropic spirit of medicine. I prefer, if such
a spirit really exists to any superior degree in my
profession, to let my neighbor, the nonmedical man,
speak of that.
And finally I know how pleased you will be when
\ tell you that I do not purpose preaching a sermon
to the students in this audience. There is nothing
so cheap and uncalled for, it seems to me, as the
average talk upon morality and gootl behavior often
doled out at the opening of the medical schools. A
medical man is rarely a good preacher by heredity,
training, or past mo(le of life; and for him to drop
into the giving of monotonous, singsong platitudes
to a body of men who have reached years of discre-
tion and who are about as experienced in life as he
himself is, bespeaks either laziness, mental vacuity.
or on coming old age. Medical students are as
alert, attentive, and eager for knowledge as any
body of men I know of. I am satisfied that a lec-
turer who finds it necessary in his class room to be
incessantly admonishing his hearers, is himself the
source of the trouble, his manner of presenting his
subject being, in all probability, stale, stupid, and
lacking in originality. Science is never uninterest-
ing. It needs no help from sermons, admonitions,
and moral discourses to make it attractive. It is the
labored, flat, inartistic, inconsequential way in which
science is often doled out that makes it seem repul-
sive. The dry rehearsal of mere facts and phe-
nomena is neither brilliant nor illuminating. It is
more often not even scientific, though such is what
it usually is supposed to be in the class room. Ex-
planation, correlation, and illustration are always
fascinating, and when properly presented in con-
junction with the description of facts and phenom-
ena will constitute the attractive element in the sci-
entific lecture. Of this I will have more to say anon.
The terms medical art and medical science are
ever upon our lips. They stand for two separate
and distinct ideas. It is my desire to emphasize
the distinction so as to discover, if possible, how-
near to and how remote from we stand to-day, in
actual medical practice, the fundamental concep-
tions of art and of science.
The Century Dictionary declares that an art is
"the combination or modification of things to adapt
them to a given end; the employment of given
means to effect a purpose." Obviously, then, the
term involves the idea of skill and dexterity.
From the same authority we learn that science is
"knowledge; comprehension, or understanding of
facts or principles ; knowledge gained by systematic
observation, experiment, and reasoning ; knowledge
coordinated, arranged, and systematized." Note
that this definition does not say anything about facts
and phenomena when merely described as being sci-
entific. It affirms that the comprehension and un-
derstanding of the facts and underlying principles
constitute science.
The ultimate aim of both art and science is the
realization of truth.
Wherein they differ is the manner of arriving at
the truth. Science accomplishes it by means of
analysis and criticism ; art by means of synthesis and
reconstruction. As Karslake has well said, "Science
and art may be said to be investigations of truth, but
science inquires for the sake of knowledge, art for
the sake of production."
There is a partial overlapping, of course, of both
art and science, just as there is in all the complex
forms of human activity. There is some art or skill
required in the analyses and criticisms of science, and
there is much science lurking behind all forms of art
expression. The truth aimed at in the art and sci-
ence of medicine is health. The art endeavors to re-
veal that truth in all its physiological beauty and per-
fection by employing the most effective means for the
restoration and maintenance of health. The science
searches for that truth by uncovering the hidden laws
and principles upon which health is founded. Not
wrong are we, therefore, when we speak of the art
of medicine as distinguished from the science. We
are wrong only when we fail to give due recognition
February 22, igo8.]
METTLER: ART AND SCIENCE IN MEDICINE.
345
to both the art and the science, and Hke the quacks
practise the art without the science, or, hke certain
narrow minded laboratory men. emphasize the sci-
ence to the behttling of the vakie of the art.
Let me ask, for a few moments, your considera-
tion of certain characteristics which belong to the
practice of an art ; and then I will request you to
apply those characteristics to the practice of medi-
cine as we see it about us to-day. In doing the lat-
ter you will remark main- things that may prove sug-
gestive and profitable to yourselves.
Art, being synthetic and constructive, the domi-
nant element in the cultivation of it must necessarily
be the personality of the artist. In direct ratio with
the natural endowments of a given individual will
his artistic efforts be. The ability may rise to the
level of talent, even to that of genius. It is some-
thing that cannot be acquired, though by cleverness
it may be somewhat remotely and unevenlv simu-
lated. It depends upon some mysterious and inher-
ent mode of brain action, about which we as yet
know absolutely nothing. It is a unique, special, and
congenital faculty. It is always the cause of much
envy, but it cannot ever be directly acquired any
more than can a desired increase of height. More-
over, it is seldom, if ever, understood by those who
have it not. An old lady once said to Turner, after
gazing at one of his most gorgeous paintings in the
British Museum : "Mr. Turner, why do you use such
brilliant coloring in your pictures ? I never see such
reds and blues and greens as that in nature.'' ''Don't
you wish you, did, madam'" was all the reply he
vouchsafed her. Of the things that the artistic mind
is capable, most of us can only wish that ours were
capable of them too. In medicine a man sometimes
legitimately wins a large practice, obtains a surpris-
ing series of cures, or makes a most happy run of
correct diagnoses. How he does it we cannot tell.
Like the artist, he cannot always tell himself, for of
all men the genuine artist is the poorest of critics and
the least helpful of advisers. His mental mechanism
seems to work instinctively, not through the slow
processes of logic and rational deduction. When
Sir Joshua Reynolds declared he mixed his colors
with brains, he meant the brains of Reynolds and not
the brains of anybody else. No mere knowledge of
rules will furnish one with an artist's mind. Nobody,
perhaps, knew the secrets of the art of painting bet-
ter than did Ruskin and Hamerton ; yet the pictures
of these two great critics were mere daubs beside
those of Turner and Millet. A nobleman once asked
Guido who was the model he sketched his beautiful
Madonnas from. The painter, placing his color
mi.xer, a huge, ugly, and ungainly man, in an appro-
priate pose, said to his visitor, "Count, that is my
model," while at the same time he went on drawing
tlie outlines of a most exquisite female figure.
So instinctive are the workings of the mind of the
true artist, and so unknown are the laws of its mech-
anism, that the possessor of it at times seems to be a
veritable law unto himself. Beethoven was once
sharply criticised for breaking an established rule of
harmony. In a burst of anger he exclaimed : "Rules !
rules! who makes the rules of harmony? I make
my own rules !" Thereafter the composer's alleged
blunder became an accepted musical form. Little
minds, and those not of the true artistic type, often
ape this apparent lawlessness of genius, just as the
gilded youth once imitated the collars of Lord By-
ron. An imitation, however, is always detectable,
because it is always more or less lawless and inap-
propriate. Beethoven did not make his own rules
of harmony, as he angrily exclaimed ; but, by follow-
ing instinctively his own transcendant genius, he
merely revealed the principles of musical beauty
which up to that time had not been portrayed by an\-
one.
The dominance of the personality in the concept
art precludes all possibility of simple imitation being
in any sense true art. Photography is not an art an\
more than is the working of a turning lathe. The
models from which both the camera and the turning
lathe began making their copies may, in some waj-.
have revealed the personality of the artist ; but then
it was the selection and the arrangement of the mod-
els, not the making of reproductions, that constituted
the art. x\s Emerson puts it, speaking of trade and
every mechanical craft, "there is in each of these
works an act of invention, an intellectual step, or
short series of steps, taken ; that act or step is the
spiritual act ; all the rest is mere repetition of the
.same a thousand times." Imitators are never true
artists. As soon, however, as they inject the slight-
est degree of their own personality into their work,
that work at once becomes artistic in the broadest
sense. Art, therefore, modifies, instead of imitating,
everything that it touches. The modification indi-
cates something that belongs sni generis to the art-
ist. "Art has the advantage of nature," says Lub-
bock, "in so far as it introduces a human element,
which is in some respects superior even to nature."
A Webster dictionary can never be regarded as a
work of art ; a Scott novel can never be regarded
as anything else. A Beethoven adagio is beyond
imitation, whereas a Richter exercise in counterpoint
may be duplicated innumerable times. Wonderful
copyists are the Chinese, but their art is of a very
low grade. The accuracy and finish of Boileau's
L'art poctiquc does not make it a work of art : the
personality of the poet is utterly wanting in it. Mere
imitation and accuracy can never alone result in the
practice of the art of medicine. They will reach only
as far as externalities and nonessentials. They are
the cause of much of the quackery both in and out
of the profession.
In this age there is much multiplication of every-
thing, books, railroads, machinery, tall buildings,
shirts, and cigars ; but in the midst of it all there is
comparatively very little genuine art. Lubbock says
that "in art two and two do not make four, and no
number of little things will make a great one." A
physician's practice may be large and yet be as de-
void of the art of medicine as a fourteen story sky-
scraper is of the art of architecture. Diagnosis and
therapeutics, however elaborately practised, do not
alone constitute the art of medicine. The manage-
ment of a single case, revealing a unique degree of
appropriate intelligence, stands more for the prac-
tical art of medicine than do a hundred cases merelv
observed and haphazardly prescribed for. A large
clientele, like a multitude of bales of cotton, may be
very profitable, and in a commercial sense may be
very beautiful to behold. In no way, however, does
it indicate real professional superiority. On the con-
340
MET TIER: ART AND SCIENCE IN MEDICINE.
[Xl'.v York
Medical Journ.
trary, it is more likely to bespeak inferiority ; for in-
crease of quantity is usually synonymous with dimin-
ution of elegance and completeness. In the art of
medicine "two and two do not make four and no
number of little things will make a great one.
Once a nobleman asked Bismarck to place his son
in some high office, urging that the boy was highl)-
educated and well fitted for the position, since he
could converse in a dozen different languages. The
great chancellor knitted his brow and, after reflect-
ing a few moments, replied to the anxious father
that, in his opinion, his son would make a splendid
headwaiter in a cosmopolitan hotel.
Dominant as is the personality of the artist in all
of his work, that personality is further distinguished
by being uniquely initiative, creative, enthusiastic,
and positive, rather than conservative, destructive,
calculating and negative. The artistic temperament
is ever driving its possessor into doing something,
however great or small that something may be. It
leaves him little time or inclination to merely criti-
cise and analyze what already exists. This creative
faculty is far from being a common one. It pro-
vokes astonishment in those who, having it not, be-
hold its strange and unwonted revelations. For this
reason it generally confers upon its owner the lead-
ership among his fellows. Its very wonder working
keeps alive interest and enthusiasm. It is always
positive, believing that affirmation and construction,
however slight, are nobler than mere denial and
annihilation. It holds that Shelley's Ode to the
Skylark is a greater work than are a thousand tomes
of descriptive ornithology. It insists that the Greek
Slave of Powers transcends a whole museum of
human anatomy. It points out that the six hundred
and twenty books of Varro, the most learned of
Romans, are lost, while mere fragments of the
poems of Sappho are still treasured beyond all price.
Man himself being the most wonderful of creations,
it is the exclusion of his personality from science
that gives the supremacy to art. And therefore
Thoreau exclaims : "My friends mistake when they
communicate facts to me with so much pains. Their
presence, even their exaggerations and loose state-
ments, are equally good facts for me."
Novelty constitutes a prominent element of art ;
hence art is always hard to criticise. Very rightly
do we say of a work of art that it is good or bad
according tp one's taste. Being a creation, it is
wholly new and portrays for the first time the
artist's taste, which may or may not correspond
with ours. Hottentot music is not art to us ; and
much less would our music, I fancy, be art to the
African savage. Works of art are always unique
and distinctive.
Art is always most happily cultivated in an artistic
environment. That is the reason why artists live,
singly or in little groups, so much apart from the
world. In the light of the importance of environ-
ment, it is not difficult to understand why Greece
and Italy are the home of art. while Guiana and
Kamschatka are not. The family life of the Bachs
was enough in itself almost to turn out a remark-
able group of musicians. The keeping together of
the Lake poets gave a distinctive touch to their
works. The Preraphaelites showed plainly their
close intimacy with one another. The Elizabethan
age of literature and the New England coterie of
authors owed not a little of their distinction and
individuality to the times and local associations. A
physician who yearns to excel in the art of medicine
dare not Hve apart and away from the influences
that tend toward the best and highest in his calling.
The doctor must dwell in his books, his medical
societies, his intellectual companionships. He must
absorb the best they have to afford him, yield plac-
idly to their highest influences, and feed his mind
upon them every day. But alas ! how often the rich
literature of medicine is neglected for cards and
club gossip ! What arenas for petty squabbles and
cheap politics are some of our medical societies !
What miserable little jealousies are allowed to sepa-
rate men v.ho, as professed practitioners of a noble
art, could be so helpful and inspiring to one another !
Such conditions always betray a lamentable want
of the proper temperament and environment. It
indicates a raw commercial atmosphere ; a dull,
primitive level of barter and sale ; not perhaps neces-
sarily wrong in itself, but oh ! so wearisomely mo-
notonous, cheap, and commonplace. Babies and ani-
mals know very little beyond the desire and struggle
for nutriment, and in the exercise of their incessant
cunning to obtain it they are less despicable than
certain adults who work the medical societies, jour-
nals and hospitals solely as a means of advertise-
ment, whereby they may earn an extra pot of pot-
tage. Such individuals wither and blight the art of
medicine.
Another important fact to be noted in regard to
the practice of an art is the laboriousness of it. Be-
cause the artistic temperament is a natural faculty
the world has usually fancied that its exercise re-
quired no special effort. No greater mistake was
ever made. Indeed genius, which is generally
deemed the exemplar of the highest art, is some-
times defined as merely the capacity for taking infi-
nite pains. I have heard it stated, upon good
authoritv, that Paderewski repeated uninterruptedly
a certain cadenza, during one of his practising
periods, some seven hundred and odd times. "Art
is no recreation," says Ruskin ; "it cannot be learned
at spare moments nor pursued when we have noth-
ing better to do." As Bryant sang :
"Deem not the framing of an immortal lay
The idle pastime of a summer's day."
Yet many students and practitioners play at this
most difficult and exacting art of medicine.
Ruskin further tells us to "remember always that
there are two characters in which all greatness of
art consists — first, the earnest and intense seizing
of natural facts ; then the ordering those facts by
the strength of human intellect so as to make them,
for all who look upon them, lo the utmost ser\'ice-
able, memorable, and beautiful." There are laws
and principles — great truths, if you please — that
underlie all art. Painting without a knowledge of
color, drawing, and perspective is Chinese art.
Music devoid of harmony and rhythm is not even,
as Johnson defined music, "the least objectionable
form of noise."
And now this brings me to the second part of my
discourse, the science of medicine. As I have just
intimated, the art of medicine is a farce unless it is
guided by certain truths and based upon certain
February 22, igoS.J
METTLER: ART AXD SCIEXCL IX MEDICIXE.
347
established principles. These, however, constitute
the science of medicine.
Xo tenn is more misused at the present time than
this term science. Practically nowadays every sort
of silly routine, every systematic form of human
activity, is denominated a science. There is the sci-
ence of pedestrianism and pugilism. Cookery and
haberdashery are said to be sciences. There is a
Christian science, and a scientific Christianity. Ev-
erything, everything, from the mowing of the lawn
to the sleeping in one's bed at night is taught sci-
entitically these days ad nauseam ad infinilum. Se-
riously, however, science is knowledge, and stands
only for the correlation of phenomena whereby
causative factors and underlying laws are discov-
ered. The mere application of principles for the
accomplishment of certain ends is no more science,
in the true sense of the word, than are the mere
observation and description of unexplained isolated
phenomena, ^^'hat is there scientific in eating pea-
nuts for sixty days to prove that life in a certain
individual can be sustained on such a diet? Such
a performance and many like it repeated in our
laboratories is about as scientific as the eating of a
green apple by little Willie to prove that a pain-
less existence is, after all, the happiest. ^Nluch of
what is dignified as modern science is a roaring
farce. It is nothing more, to say the most of it,
than individual experience, and ranks with such
knowledge as that corns on one's toes are disagree-
able and that wintry blasts are apt to be cold. Phe-
nomena and their mere observation are not, as a
rule, very illuminating. They need some explana-
tion, some generalization, possibly even some theory
or hypothesis to raise them to the dignity of scien-
tific facts. \\"hen the Church of Rome forced
Galileo to make his famous retraction in regard to
the movements of the heavenly bodies, it based its
authority upon simple obserA-ation and ecclesiastical
dogma. It knew nothing of, and even denied, the
generalizations and hypotheses that Galileo had
worked out. It was satisfied that the earth stood
still and all other bodies revolved around it, because
such was the testimony of every man of common
sense who had eyes to see. The inevitable soon oc-
curred. The Church was shown to be puerile in
its thinking, Galileo scientific. Tycho Brahe's long
records in regard to the positions of the celestial
spheres did not elevate astronomy to the plane of a
science ; only the generalizing of Kepler, from
those long and laborious observations did that. Mil-
lions of people have watched apples fall. It was
Sir Isaac Newton's enunciation of the hypothetical
law of gravitation, however, that raised the phe-
nomenon and its observation to a position of scien-
tific interest. ^ledifeval alchemy was the poor cul-
mination of the mere observation of certain phe-
nomena. The science of chemistr\- was born when
Dalton and others developed the atomic theory and
related explanatory hypotheses.
There are medical men to-day who publish long
and detailed reports of cases which they have ob-
served. There are pathologists who describe and
depict most elaborately what they behold under the
microscope. There are physiologists who construct
most ingenious apparatuses for recording curious
graphic tracings. There are psychiatrists who
cover reams of paper with mere repetitions descrip-
tive of the actions of asylum inmates. The labors
of every one of these men have, of course, a cer-
tain value. An infant's observation of the moon
has also value. The worth of both sets of observa-
tions falls short of being scientific, until they are
properly correlated and in some way explained.
For the scientific elucidation of phenomena the in-
ductive method of Bacon, when employed alone, is
as faulty as the deductive method of Aristotle. Iso-
lated and unexplained data stand for mere phenom-
ena. Phenomena as such represent mere sensory
reaction on the part of the observer. The observa-
tion is the only thing about them that can be truth-
fully denominated a fact. Observation per se is
always liable to error by reason of the observer's
personal equation and sehsory instability. Such
error can only be eliminated by the correlation of
observations, by their rigid comparison and con-
trast, and this involves and results in the employ-
ment of imagination, reason, and judgment.
Facts, even most so called scientific facts, are not
entiiely beyond the charge of being mere descrip-
tions of our sense organs. The word fact, so re-
vered by the great untrained mind of man, is not
synonymous with truth. It means when so used
by this great untrained mind of man merely sense
observation or phenomenon. It becomes synony-
mous with truth only when it stands for some cor-
related phenomenon, some principle, some law dis-
covered amongst a mass of sense observations-
Redness is a fact to common sense, but it is not a
truth. The same is to be said of sound. The truth
in both instances is a particular form of movement,
vibration. All knowledge is more or less relative,
and a commonly called fact is the most relative
thing of all. This is the reason why the advance of
human knowledge has been borne along on "facts"
that have almost invariably been found later on to
be in need of different interpretation. The newer
interpretations have arisen out of the discovery of
the causes and underlying principles. The latter
and not the so called facts then established the sci-
ence.
This confounding real knowledge with the mere
observation of phenomena explains many curious,
things in the histor}- of science. It renders intel-
ligible, for instance, the fact that science had its
origin in ancient mythology. It accounts for its
long struggle through mediaeval witchcraft, necro-
mancy, and astrology. It affords a raison d'etre for
the modern camp following of science, consisting of
the half informed, semireligious, queer folk.
The origin of life in the sea, typified in .the ocean
born Venus; the panorama of the dawn so poetic-
ally sung in the storv^ of Orpheus and Eur\-dice ;
the growing and moaning of the forests, attributed
to the Dryads : the unceasing flowing of the brooks,
urged on by the sportive nymphs ; the wanderings
of the moon among the stars as Diana chasing the
deer; and the intense brilliancy and creativeness of
the sun. depicted under the form of the glorious
Apollo, are not more fantastic than are some of the
half superstitious, supernatural explanations offered
nowadays for phenomena which, easily observed,
are yet mysterious and unaccountable. ' Clairvoy-
ancy, dream revelations, telepathy, spiritualism.
34«
METTLER: ART AND SCIENCE IN MEDICINE.
INtW V„RK
Medical Journal.
Eddyisni, and all the rest of the innumerable and
rank growing brood that have lately sprung up and
that are bound to recur in the future, represent in
their last analysis the same mode of thinking which
the ancient but more poetical mythology represents.
The etTect of the unscientifically trained mind to
solve the riddle of nature and to explain and cor-
relate appearances is the same everywhere and at all
times. There is never any disagreement as to the
appearances, and hence they are called facts and are
identified with truth. The disagreement always
originates in the attempt to explain these appear-
ances, but here the personal equation, the power of
intellect, enters, and the distinction between the
trained and the untrained mind, between real science
and pseudoscience, is vividly emphasized.
The man of imagination, with the visualizing and
idealizing power developed as highly as the reason-
ing power, is needed in science, for he looks behind
phenomena and reasons logically upon the hidden
forces and principles. If the idealizing capacity
outruns the logical, such a man becomes a mere
dreamer, a dogmatist who assumes that the deduc-
tions formed out of whole cloth, as it were, by his
imagination, constitute the final proof. He is noth-
ing to science but an indolent, tawdry theorizer. If.
on the other hand, he is idealist enough to imagine
some law, principle, theory, or hypothesis lurking
behind phenomena, and if he guards his hypothesis,
both before and after its promulgation, by sound,
logical deduction, reason, and verification, he rises
to the position of a real scientist, such as Newton.
Dalton, and Laplace were. His studies eventuate
in real knowledge and -his work becomes genuinely
scientific.
We thus see that there is not only room for but
actual need of the idealist in science, much popular
opinion to the contrary notwithstanding. Indeed. I
will go a step further and assert, in opposition to
popular opinion, adroitly fostered by certain narrow
minded, drudgelike investigators, that the genuinely
scientific mind exercises its imaginative faculty quite
as much as the genuine poet does, or quite as much
as it does its own reasoning faculty. In his Conver-
sations on Some of the Old Poets Lowell urges the
rationalism of poetry, saying that ''poets are vul-
garly considered deficient in the reasoning faculty,
whereas none was ever a great poet without having
it in excess, and after a century or two men become
convinced of it." Did not the poet Goethe ofTer the
first suggestion out of which arose the greatest of
the biological sciences, morpholog}-? Was it not
intimated clearly in Dante's Inferno, before Newton
was born, that there is a law of gravitation drawing
all things toward the centre of the earth? Is not
Shakespeare really a greater and more subtle souled
psychologist than John Stuart Mill or Herbert
Spencer? Science demands of its devotees the same
creative faculty that the poet possesses. Allow me
to quote here what T have written elsewhere in an
essay upon the Poetry of Science:
When Wordsworth glancc<; into the face of a httle child
and from its happy smile slathers intimations of immor-
tality, his play of imagination is not greater than is that of
Dalton when he ponders upon the subtle phenomena of
chemistry and perceives indications of a vast hidden world
of atoms. When Bnrns beholds the tyranny of man in the
fall of a Mountain Daisy, he is not far from Darwin, who
discovers in the variation of species the cruel law of the
survival of the fittest. When Mrs. Browning reads in the
Dead Rose the lesson of the constancy of love, she differs
not much from Sir Humphrey Davy when he melts two
pieces of ice by rubbing them together and therein detects
the great principle of the conservation of energy. When
Schiller hears in the Song, of the Bell the mutability of ali
thmgs human, his train of thought is not unlike that of
Huyghens when he gazes at a ray of light and beholds it
transmuted into a thousand ever varying undulations. Cole-
ridge once stood at sunrise in the vale of Chamouni and
glancing up at Mont Blanc, exclaimed :
O dread and silent mount, I gazed upon thee
Till thou, still present to the bodily sense.
Didst vanish from my thought ; entranced in prayer
T worshipped the Invisible alone.
Darwin also stood face to face with Nature and witnessing
the evolution of her thousand forms, reverently exclaimed:
"There is grandeur in this view of life witli its several
powers having been originally breathed by the Creator into
a few forms or into one; and that while this planet has
gone cycling on according to the fixed law of gravity, from
so simple a beginning endless forms most beautiful and most
wonderful have been and are being evolved."
Stopford Brooke tells us that Farraday "was al-
ways in the temper of the poet, and, like the poet,
continuously reached that point of emotion which
produces poetic creation." .\s Ryron, himself a poet,
frankly acknowledges :
"There are things whose strong reality
Outshines our fairyland ; in shape and hues
More beautiful than our fantastic sky.
And the strange constellations which the Muse
O'er her wild universe is skillful to dififuse."
Or, as Rhys puts it when speaking of the student's
chamber :
"Strange things pass nightly in this little room,
.-Vll dreary as it looks by light of day ;
Enchantment reigns here when at evening play
Red firelight glimpses through the pallid gloom."
What poem has ever drawn upon the imagination
or glowed with more fanciful idealization than the
theories first put forth by Copernicus, La Place, Dal-
ton, RufYon, Cuvier, Linnjeus, Darwin. Lyell, New-
ton, Davy, Farraday, Thompson, Crookes, Virchow,
Richat, and Waldeyer? Indeed, the writings of
these supreme dreamers of science read more like
])oetic inspirations than does half the versification
which is sometimes denoininated English poetry.
In the light of all this, a moment's reflection will
show how little that deserves to be called scientific is
really found in the elaborate reports from some of
our laboratories, clinics, and post mortem examina-
tion rooms. By way of contrast let me say that T
know a pathologist to-day who. tireless in his obser-
vations and the massing up of data, fondly iinagines
that thereby he is inaking a great name for himself
in science. As a matter of fact, he is only a useful
drudge. He has added absolutely nothing to the
sum total of scientific knowledge. He has merel\
repeated the observations of others. His accumula-
tion of data is about as valuable as the observations
of the starlit firmament by ordinary men are valu-
able to astronomy. Some future pathologist mav
use these data to uncover some great law of cause
and effect, lentil then these disjointed and unre-
lated ob.servations remain valueless as matters of
real and useful knowledge. Ah ! no. science is not
observation, for then everything and every man
would be scientific. Science is comprehension, cor-
Tebruary 22, 1908. J
METTLER: ART A\'D SCIENCE IN MEDICINE.
349
relation, systeinatization, something far more than
the mere accumulation of statistics. Science is
knowledge. As Stanislaus says, "Science, when well
digested, is nothing but good sense and reason."
Alere observation and the accumulation of statistics
do not make very elaborate calls upon either good
sense or reason. Oliver Wendell Holmes gently
satirizes these mere observing, statistical men when
he says, "Science is a first rate piece of furniture for
a man's upper chamber, if he has common sense on
the ground floor. But if a man hasn't got plenty of
good common sense, the more science he has, the
worse for his patient." As Stern intimates, this
form of learning, namely, statistical observation, is
the dictionary, whereas sense is the grammar of sci-
ence. Anybody with drudgelike persistency can
compile a dictionary, but to create or evolve a gram-
mar calls for a rare and superior type of intellect.
This type of intellect is not more common in the
medical profession than it is in any other class of
men. Here, however, we witness much passing un-
der the name of science that is nothing but multipli-
cation of the simplest sort of observation. Long
case reports full of insignificant detail and repeti-
tion, minute pathological descriptions, curious physi-
ological experiments, and elaborate rehearsals of well
known clinical phenomena are doubtless of some
value, even as a child's description of an elephant,
that it may have seen in one of its straying spells
from home, is of value ; but unless some explanation
or correlation is vouchsafed at the same time, some
hypothetical yet well deduced law affirmed for future
approval or disapproval, the value is small. An emi-
nent pathologist showed me some years ago a brain
which he had just received, and which he said was
histologically a most extraordinary specimen. His
tone of dejection I shall never forget when he fur-
ther said that the specimen was all but practically
worthless for scientific purposes because the clinician
who had sent it to him had not attempted to study
the case in all of its symptomatic relationships. The
clinical report could not be correlated with the path-
ological findings, and hence, though much time had
been expended in mere observation in both, no real
scientific knowledge was forthcoming. The lament
of Thoreau voiced itself thus : 'T should say that
the most prominent scientific men of our country,
and perhaps of this age, are either serving the arts
and not pure science, or are performing faithful but
quite subordinate labors in particular departments."
We are living in the age of science. Future his-
torians will devote a chapter to it, as they do now to
the Greek age of art, the Roman age of law and or-
der, the ages of feudalism and of chivalry, of the
Renaissance and reformation, of discovery and po-
litical revolution. This age — and what a glorious
age it is to live in ! — is treading close upon the foot-
steps of the Creator. It is learning the secrets of His
handiwork. It is discovering the forces that He has
employed in sending the planets on their courses
through boundless space, in fixing the rocks and
oceans and streams in their appointed places, in de-
veloping life through all its myriad forms up to that
divine culmination, the human intellect. Wonderful
are the revelations that daily open up before us. We
marvel at our old ignorances and superstitions. We
await in awe the newer light yet to be shed upon us.
So rapid and startling are these scientific revelations
and so wizardlike are their practical applications for
our personal comfort, that, like little children upon a
Christmas morning, we are excited, confused, and
all but paralyzed with ecstasy. Some of us have
utterly lost our heads and grown irreverent and ego-
tistical. Others among us seem to crouch with fear
and fly to newer and more ridiculous forms of super-
stition. Nearly all of us have become prone to laugh
at authority and to stand with hands folded, obsti-
nate and expectant, if not actually sceptical.
This is a transition age we live in. We have left
darkness behind us, with yet many hidden mysteries
in front of us. Xow, if ever, do we need clear brains
and reverent spirits. In an age like this men are
wont always to go to extremes. Stunned by the
magnitude of its discoveries, the\- seek relief in petty
detail or prattle flippantly about that which is still
unknown. Why do we not find the greatest think-
ers of the world of art and literature among us to-
day ? Because of our engrossment in the petty de-
tails of research. Indeed, this age has been face-
tiously called "the age of the little" — the little story,
the little piece of music, the little genre painting, the
little bacteria. While this not strictly true, it is true
that there is much overemphasis of the little at the
present time. Our apparent bigness, as instanced in
our railroads, office buildings, financial transactions,
and commercial corporations, is largely a matter of
mere reduplication. Hence one feels at times like
Berlioz, I think it was, who, after leaving one of
Chopin's most exquisitely soft and delicate piano re-
citals, shouted so loudly upon the street that one of
his companions asked him if the music had, indeed,
made him crazy. "No,'' he replied, "I am not crazy,
but I have been listening to so much pianissimo that
now I want a little fortissimo !"
This tendency to excess of detail, with bigness
consisting of mere reduplication, leads, in this age,
to the dangerous magnification of means with cor-
responding blindness to the end. As a recent writer
in the Atlantic Monthly pointed out, the dominant
fault of the average man is the hopeless losing of
himself in the means. He allows himself to become
immeshed in it like a fly in a spider's web. As the
writer shows, this is preeminently noticeable in the
financial and commercial worlds. Monev making
has become the end here, though every child knows
that money is absolutely useless except for what it
brings or as a means to an end. Many are to-dav
entranced with machinery, telescopes, microscopes,
automobiles, and the other means whereby we are
striving to climb to knowledge and happiness. As
this entanglement in the means results in the monev
world in greed, strife, discontent, irreverence, and
even criminality, so in the world of intellectual ac-
tivity it leads to out and out chicanery and scientific
hypocrisy. That which is not knowledge is fatuous-
ly or fraudulently palmed oft' as knowledge. Truly
Emerson says, "when a naturalist has got all snakes
and lizards in his phials, science has done for him
also and has put the man into a bottle." When thus
engulfed in the little and lost in admiration of the
means, a man is not unlike Socrates when he pro-
claimed that he could never learn anything from the
fields and trees, or like Samuel Johnson when he an-
nounced that, "having seen one green field, you had
350
MUKSIi: TUBERCULOSIS IN CHILDREN.
INew York
Medical Journal.
seen them all." If ever an age were in need of well
balanced idealists, men of broad liberal minds, men
who can distinguish mere agency from finality, it is
this age. \'ery recently I read a long and exhaustive
article, publisl'ied in two mstallments, full of petty
details of description and illustration, at the conclu-
sion of which the distinguished authors stated that
what they had been trying to demonstrate was still a
matter of complete uncertainty. All that paper and
ink for that vapid conclusion ! It doubtless looked
and sounded \cr\ scientific. An investigator, how-
ever, less entranced with mere agencies, would have
saved his readers' time and e\ csight by stating that
he had no information t(j give upon the subject in
question, l.c-l it Ix' repeated, science is knowledge,
not mere statistical accumulations. The greatness
of Goethe's Faust lies partl\- in the fact that it repre-
sents a protest against the iK'littling. detailed science
which is devoid of idealism and intellectual breadth.
The present age is begnming to weary of scientific
co.xcombs. men who arrogate to themselves the name
of scientists but who never add a single grain to the
sum total of human knowledge. It wants men who
can interpret and explain, not merely observe, the
phenomena of the world about us. It has small re-
wards for the mere compilers of the commonplace,
the laborious collectors of dry statistical husks and
irrelevant accumulations.
In conclusion, then, let it be clearly reccignized
that there is an art and there is a science of medicine.
Those who practise medicine as a fine art and as a
real science are far from being numerous. In fact,
they constitute quite a minority in the profession.
There is still abundance of room for him who sin-
cerely desires to develop this noble art and won-
derful science. What Lincoln said about fool-
ing all the people all the time is as true here as else-
where, de])end upon it. An honest and earnest effort
to attain that which is the best, the highest, and the
truest, even in medicine, never goes long unrecog-
nized and unrewarded. I would merely add as mv
final word to you, young men, that you be true to
\-ourselves and to your divine privilege of manhood.
Live up to the full stature of your endowments and
make for the advancement of your chosen profession
along the lines of true art and science, as I have en-
deavored, all too briefly, to indicate them to you.
ICQ St.\te Street.
THE M.^NAGEMENT .\y.V) TREATMENT OF
TUBERCULOSIS IN INFANTS AND
CHILDREN.
Bv John Lovett Morse, A. M., M. D.,
Boston,
>\ssistant Professor of Pediatrics, Harvard Medical School; Assist-
ant Physician, Children's Hospital and Infants' Hospital;
\'isiting Physician, Tloating Hospital.
The general principles of the management and
treatment of tuberculosis in early life are, of course,
the same as in later life. They have to be some-
v;hat modified in their ai^plication, however, becau.se
of the manner in which tulK'rculn.sis manifests itself
in early life and because of the different way in which
children bear exposure and react to climatic condi-
tions.
The chief characteristics of tuberculosis in infancy
;are its malignancy and its tendency to dissemination.
The restriction of tuberculosis to a single organ and
the involvement of the lungs, as it occurs in later
childhood and in adult life, are very unusual. The
fatality of tuberculosis at this age is" so great, there-
fore, that little can be hoped from any form of treat-
ment. In young children the tendency to localiza-
tion is greater. The bones and serous membranes
are much more frequently involved than the viscera,
and there is also a decided predilection for the lym-
phatic system. In older children pulmonary lesions
are more common, the frequency increasing direct-
ly with the age, but they are comparatively rare be-
fore puberty. The course of pulmonary tuberculosis
at this age is more rapidly progressive than later.
.A.t puberty the lesions, course and treatment are es-
sentially the same as in adults.
Children are more rapidly enervated by warm,
moist climates than are adults. They are not, as a
rule, robust enough to bear extremely cold climates,
although there are exceptions. They arc much less
able than adults to bear exposure, and great care
m.ust be taken in "hardening" them, especially if
they are young and delicate.
It is, as a rule, much easier to carry out proper
treatment with children than w ith adults. They do
not have to consider their own livelihood or that of
others ; they are not wage earners : nothing depends
on them. Consequently they can devote their whole
time to their treatment. Their mental attitude is bet-
ter ; they do not worry about themselves or others.
They are more amenable to treatment and almost
always make good patients. It is, however, rather
more difficult to get them to sleep out alone as they
are often afraid. They require, on the other hand,
more attention and amusement. They must have
manual and physical employment ; they must be in-
structed and educated. It is easier to take care of
them because of their small size. They can be car-
ried about more easily ; they require less room. A
small balcony, for example, will do for a child, while
a large one may have to be built for an adult.
Thev accommodate themselves to institutional life
much better than do adults. They are almost never
homesick after the first few days. They are not con-
stantly wishing to get out and go to work. Thev
are not anxious about their own future or that of
their families. They are usually very happy wdth
the other children and take to the life naturally.
Discipline is much easier with them than with
adults
For practical purposes, tuberculosis in children
may be divided into two classes : surgical, including
"scrofulosis" and '"lymphalism." and visceral.
Experience with children suffering from surgical
tuberculosis in the sanatoria abroad shows that, on
the whole, they do better at the seashore than inland,
and that they do better at the seashore if the climate
is temperate rather than cold or warm. Our experi-
ence at the Convalescent Home of the Children's
Hospital, in Boston, however, shows that they may
do well inland and in a cold climate. Experience
also shows that in order to obtain a cure, a stay of
at least a year is neces.sary, and that a few weeks or
months is entirely insuflficieni. Children of the
crithritic type, that is, the delicate, slender, and
neurotic, usually do better, at any rate in the be-
ginning, inland in comparatively niild climates. It
is important not to overdo e.x'ercise with this class
ROBIXSOX: PRECAUTIOXS IX THE SOUTH.
of children. Children of the "torpid" type, that is,
the heavy, coarse and phlegmatic, do better at the
seashore than inland, and in comparatively cold
climates. They bear "hardening" well and can take
a good deal of exercise. If amxloid or kidney dis-
ease develops, both classes do much better in a
v.-arm and dry climate.
This country is far behind many of the European
countries in the establishment of sanatoria for sur-
gical tuberculosis, whether for the rich or poor.
Xew York, as you know, has begun to do something
(iuring the last three years. Boston has for some
years been doing a little at the Convalescent Home
of the Children's Hospital in \\'ellesley. It is ])rob-
able that other cities are also beginning to take
steps in this direction. What is being done, how-
ever, is absolutely insufficient, ^'ery"few children
are being taken care of. and these are not kept near-
ly long enough. ^luch more is being done in the
way of excursions, country weeks, and so on. These
are merely makeshifts, however, and while well
enough as far as the>- go. are absolutely inadequate
to give any permanent results.
Tuberculous peritonitis, while really a form of vis-
ceral tuberculosis, is as regards its climatic treat-
ment and management essentially a form of surgical
luberculosis.
While visceral tuberculosis in adult life means to
all intents and purposes pulmonary tuberculosis, in
the vast majority of instances uncomplicated, this
is not the case in early childhood. At this age pul-
monary tuberculosis is usually not a local disease
but part of a more or less generalized tuberculosis.
The younger'the child, the truer this is. The prog-
nosis of pulmonary tuberculosis in early life is
therefore much worse than in later life, and -much
less is to be expected from climatic treatment. In
young children the disease is usually too far ad-
vanced when recognized to warrant sending them
away from home, as at this time the\- belong, as a
rule, in the incurable class. Children with jnilmon-
ary tuberculosis are even less able to bear extreme
cold than are those with surgical tuberculosis, and
withstand "hardening" and exposure very poorlv.
The dietetic treatment of tuberculosis in early life
is essentially the same as in adult life. INIilk and
eggs are at this age a!s-i the most valuable articles
of food. Much greater skill is required, however, to
feed a child, especially a young child, properly with-
out upsetting its digestion, than an adult.
The drug treatment of tuberculosis in childln'od
is purely tonic and symptomatic. The susce])tibi!ity
to opium in any form at this age must be remem-
bered.
The various forms of tuberculin have been used
much less in children than in adults, and there are
comparatively few statistics on this point. I know
nothing about it from my own experience. There
seems no reason, however, why equally good results
should not be obtained in children as in adults, if
allowance is made for the greater severity of the
disease at this age and the greater tendency to dis-
semination.
Thus far only children with tuberculosis have
been mentioned. Two other classes ought, how-
ever, to be considered. These are the healthy chil-
dren of tuberculous parents, and children with latent
tuberculosis or those who are predisposed to tuber-
culosis by the presence of other diseases or their
])a rentage.
The children of tuberculous parents should, if pos-
sible, be sent away from home. The Society for the
Protection of Children against Tuberculosis in
l-'rance, established by (irancher. is adopting the
proper methods for these children. When they can-
!iot be sent away from iiome much can be done bv
regulation of their life and by guarding them against
infection from the parents.
Children sultering from latent tuberculosis or for
any reason predis]xised to it should, if ])ossil)le. be
given proper climatic treatment or sent to sana-
toria. If this is not possible, every attention should
be paid to their hygiene, food, rest, and care. The
children of the poorer classes should be sent to fresh
air schools, and given the advantages of countrv
vv eeks or seashore air whenever possible.
Finally, the great problem of the management of
tuberculosis in childhood is to prevent its spread,
li is very easy to see what should be done, but very
difficult to carry it out. In the first place, all chil-
(h-en in families in which there is ojien tuberculosis
should be removed and sent to the country or sea-
shore. The schools should be inspected at least once
m six months and those affected with tuberculosis
sent to sanatoria. hVesli air schools should be es-
tablished for the pretuberculous and proper provi-
sion should be made to provide th.em with extra
food. Children suffering from latent tuberculosis
and surgical tuberculosis should be sent to sanatoria
.-eparate from those for open tuberculosis. When
they cannot be sent away they should go to day
camps established for the purpose. Those suffering
from early open tuberculosis should be treated in
camps or sanatoria. The advanced cases should be
treated by themselves in special hospitals. It is very
evident, however, that this course cannot be fol-
lowed at present because of the expense, which is
l)rohibitive. In any case, the matter is too large a
one for private charity and must be taken up by the
municipalities and States. While these plans cannot
be carried out as they should be. there is. however,
no reason why everything that can ])e done should
not be done.
PRECAUTIOXS TO BE TAKEX IX COMTXG
SOUTH.
Bv W. F. RoBixsox. M. D..
Palm Beach. Fla.
.\s an introduction to this article the writer may
-tate that he has been engaged in the practice of
medicine for eight years in hot climates, and that
the statements made in this article are the result of
his experience during this time.
It is often verv amusing to one accustomed to
the Southern countr) to hear the various opinions
held among the laity in the Xorth as to the ad-
visability of coming South from the standpoint of
health. If a person from the North comes to Flor-
ida and contracts an attack of diarrhoea he is apt
to hurry home as fast as the train can carry him
and warn all his friends not to go to that terribly
unhealthy country, as they will be certain to get sick
if thev do go. Another tourist will contract a
35^
ROBINSON: PRECAUTIONS IN THE SOUTH.
[New York
Medical Journai,.
severe cold and hurry home with the same story.
A third will have a severe attack of indigestion, and
he will be inclined to blame the country and think
it a poor place to go to.
These cases occur constantl}', and are very easy
of explanation. First, the journey, like all journeys,
is apt to be tiresome. The travelers perhaps lose
their rest and are forced to go without sufficient
food. As a result they arrive in a strange climate
tired and worn out and with the system in the most
favorable condition to contract disease of any kind.
In addition to this, they often start right out and do
extremely foolish things, either through ignorance
or carelessness. Then they wonder why it is that
they get sick in a climate that they have been told is
so very liealthy.
Let us see now if there is not some way to avoid
illness under these circumstances and what had bet-
ter be done.
First, in view of the inevitable fatigues of travel,
people should be very cautious when arriving at
their journey's end, especially if they arrive just be-
fore or at dark. In hot climates there is apt to
be quite a little fall in temperature about this time.
A person who has traveled through the heat and
dust of a tropical day is naturally tired, hot, and
probably perspiring : he is dressed perhaps in the
heavy clothing which he put on when he started his
journey in the cold Xorth. The sudden coolness
of the late afternoon seems very refreshing, but
before he realizes he has become undulv chilled, and
the next day he may be attacked with a severe cold,
if he is fortunate enough to escape pneumonia or
pleurisy.
The writer sees these diseases constantly, but has
yet to meet the hrst case that was not contracted on
the train or immediately on arriving. Every trav-
eler shrnild hv j^rovided with a good warm wrap
and should be careful to wrap himself up well in
it if he arrives in the cool of the evening.
If the traveler is delicate or perhaps convalescent
from acute disease, it is an excellent plan to go to
bed on. arriving, and if hoi and perspiring, an alco-
hol bath and a stimulant would not hv aniis>. On
waking the next morning, if nut fully rented and
refreshed, it might be \u^i as \\el! to sta\- in bed
during the mornmg or even the ^\■hole day.
In this connection the case of a strong, healthy
man may be mentioned who came to Palm Beach
last winter.. The weather was cold when he left
the Xorth and he got a chill on the train. He
was half sick when lie arrived, but refused to rest
or take any care of himself. Instead, he insisted
upon going out on the beach, where a strong and
cool sea breeze was blowing, and he lay down on
the sand to rest himself and enjoy it. .\s a result
of this indiscretion he was obliged to go to bed with
a severe attack of pneumonia, from which he very
nearl\- died. If this man had taken the simple pre-
cautions which I have mentioned he would in all
probability have escaped the attack, or at least
would have had it in very much milder form. Cases
of this kind could be multiplied by the writer if
there was any object in so doing.
Diet. — Another important matter in this connec-
tion is diet. Just as a change of air is trying at first
lo the throat and hnigs. so a change of diet and wa-
ter is a strain upon the digestive function. In the
first class hotels of the South the food is just about
the same as in the North, so that there is nothing
special to be said in this regard. There are two arti-
cles of diet, however, that deserve special mention,
namely, fish and fruit. Both these articles are spe-
cially fine in the South, and it is just for this reason
that it is necessary to utter a note of warning.
One can go out to the plantations which cluster
around all the resorts and see growing oranges, tan-
gerines, kumquats, guavas, grapefruit, pineapples,
and many other tropical fruits. To a person who
has never seen this before it is a beautiful and won-
derful sight, and the first impulse is to buy a lot of
the luscious fruit and have it sent to their rooms.
Once there they are almost certain to indulge too
freely and bring on an attack of acute indigestion.
When a doctor is consulted they are much surprised
to learn that the fruit is the cause of the trouble. It
should be said in explanation that fruit is an excel-
lent thing to eat and very healthy. If travelers would
begin eating fruit in moderation until the system be-
comes accustomed to the new diet, the)- would re-
ceive benefit instead of harm. It is the sudden and
excessive indulgence that causes the mischief.
As with fruit, so it is with fish. The fish of Flor-
ida is justly celebrated, and lovers of this kind of
food often come South prepared for a great treat.
There are many kinds of fish caught in Southern
waters, and one or another of them are generally
served at every meal, so that the fish lover may eat
his favorite dish three times a day. If he does, the
same result that happened in the case of the fruit is
almost certain to occur, and for precisely the same
reason. After one lesson of this kind the suf¥erer
learns by experience and may cat fish in moderation
all the rest of his stay in the South.
ClotJiiiig. — Just a few words of caution as to the
matter of clothes. People coming South in winter
naturally have on their heavv clothing, and when
they arrive at their destination they find them very
oppressive and are anxious to get rid of them as
soon as possible. This is perfectly right, but it is
very important that the change to lighter clothing
be made in a proper way, otherwise harm may result.
A peculiarity of hot climates is that it is often hot
and close in the early morning, and then later a
breeze will spring up and it will be (juite a little
cooler. Suppose a newcomer gets up in the morn-
ing and puts on fairly heav\- clothes. He goes out in
the sunshine and finds it very hot and uncomfortable,
so that he is glad to come back and exchange his
heavy clothing for much lighter fabrics. He finds
these very much more comfortable and starts out
again, but this time he finds it quite a little cooler,
with a brisk breeze blowing, and before he knows it
he feels chilly and has taken cold. In view of these
facts the writer formulated a rule in the early days
of his practice in hot climates which he has never
ceased to preach to the newcomers whom he meets
professionally or otherwise. The ride is this : Never
change the clothes you have on for lighter ones dur-
ing the day. Look out of your window in the morn-
ing on rising, and if the day is warm and sunny do
not fear to put on the thinnest things you have in
your trunk and go out. If you find them too thin as
the day goes on. then is the time to change to your
Febriuiiy ;9o8.1
BRAV: TREATMENT OF IRITIS.
353
thicker things again, and }ou may find them very
grateful, for sHght changes of temperature are felt
much more in hot cHmati-s than they are at home.
The reader must have noticed by this time that
these suggestions arc addressed exclusively to the
newcomer. After being a certain time in the South
the tourist learns these things for himself, but he
often pays dear for his experience while he is learn-
ing. It is to enable him to avoid the dangers of ig-
norance when he first arrives that this article has
been written.
It may be said in general that in a really warm
climate like Palm Beach the thinner the everyday
clothing the better, and as soon as a person becomes
accustomed to the climate flannel underwear may be
discarded entirely and its place taken by linen or cot-
ton. They are more comfortable than heavier gar-
ments, and ofifer the extra advantage that when a
change is made it is from thin to thick clothing,
which of course is a perfectly safe procedure.
In conclusion the writer would state the following
proposition, of the truth of which he is convinced:
There are many people in the North who decry hoi
climates and state that they are apt to cause diseases
of various kinds. On the other hand, the South is
full of people who know by experience how healthv
a hot climate may be if one takes pains to studv its
requirements and takes care to avoid its dangers.
Thousands of delicate and elderh- people die ever\-
year who might have been spared for years if they
had only known the wonderful qualities of the hot
climate of our Southern States.
As to these wonderful health giving and health
preserving properties, the writer hopes to explain
them more fully in a later article.
Sux.sET Lodge.
THE RATIONAL TREATMENT OF IRITIS.*
By A.^ron Brav, M. D.,
Philadelphia,
Ophthalmologist to the Southern Eye Clinic; Assistant to the Wills
Eye Hospital.
Iritis is a frequent ocular disease. It is rather a
serious disease, often terminating on account of its
sequelc-e in partial, and in rare cases in total, blind-
ness. Usually it yields reaflily to judicious treat-
ment. The success of a cure depencls entirely upon
the prompt application of therapeutic measures. The
disease is of long duration, requiring six to twelve
weeks to bring about a cure. It is subject to re-
missions, excacerbations, and recurrences. In no
other ocular disease is the clinician confronted with
so many problems upon the prompt solution df
which depends the ultimate success of the treatment.
Keen observation, promptness in meeting emergen-
cies, a correct knowledge of the pathologv of the
disease, and especially its complications, are the
essential requisites of the ophthalmologist. Iritis
may be primary or secondary. It mav be of trau-
matic origin, but in the vast majority of cases the
underlying cause is some constitutional disorder.
Among the constitutional conditions responsible for
an inflammation of the iris are syphilis, rheumatism,
*Read hefore the Eastern Medic.il Association of Philadelphia.
tuberculosis, scrophulosis, malaria, anjemia, and the
infectious fevers.
In considering the treatment of iritis we must di-
rect our attention to the following conditions essen-
tial in bringing about a permanent cure : (T ) To
give complete rest to the inflamed organ, until all
the inflammatory signs have subsided. (2j To re-
lieve pain, so as to enable the patient to sleep w-ell,
and allow nature's recuperative powers to exert their
influence. (3) To prevent, as far as possible, any
serious sequelae, such as the formation of posterior
synechise.
Our object can best be accomplished by a combi-
nation of local and general treatment, both of which
should be based upon rational therapeutic principles.
Eye lotions as a matter of routine practice are not
needed, and irritating washes are positivel}' cuntra-
indicated. As soon as the diagnosis has been estab-
lished the eye should be placed at absolute rest.
Even in unilateral iritis the patients should at once
stop from their occupation and not return until after
all inflammatory symptoms have completely disap-
peared. Failure to enforce this rather rigid rule is
often responsible for recurrences, which eventually
destroy the usefulness of the afifected eye. The pa-
tient must be acquainted with the seriousness of his
condition in order to submit to stringent measures.
Iritic patients need not be confined to dark rooms,
but should wear protecting smoked glasses. During
the acute stage of the disease, when the pain is very
severe, it is best to keep the patient at rest in bed, the
window blinds being somewhat lowered so as to
prevent direct sun rays from the patient's eyes ; the
room, however, should be well ventilated. After
the pain has subsided it is best to keep the patient
out of bed and in the open air, except on rainy or
damp days. The diet must be light, easily digest-
ible ; soup, milk, eggs, custard, and mutton are good
articles to be used. No stimulants in the form of
alcoholic drinks should be allowed. It is, however,
advisable to exercise good judgment in the enforce-
ment of this rigid temperance rule. I allow my
patients — those advanced in age and used to alco-
holic beverages — a small quantit}- of whiskey daily.
Smoking should be interdicted. Public places
should not be visited, and all care should be taken
to build up the constitution so as to be able to resist
the inflammatory process.
A good rule to follow is to begin treatment with
a thorough cleansing of the gastrointestinal canal. It
has been observed that patients with iritis feel much
easier after the bowels have been well evacuated.
I am in the habit of using, every morning and even-
ing, if necessary, the following mixture:
R Tinct. cardamomi comp., 5ss ;
Syr. limonis 5ss ;
Sol. magnesii sulphatis, Jiii.
M. Sig. : A tablespoonf Lil morning and evening.
Thorough evacuation of the bowels in the begin-
ning is essential. After depleting the system there
is usually a favorable reaction upon the inflamma-
tory process, lessening the congestion. Emetics,
while advised by some of the older writers, should
not be resorted to. I think they are harmful, for
the straining caused by the act of vomiting increases
the pressure in the eye as well as it causes a sudden
354
BRAr.- TREATMENT OF IRITIS.
rush of blood into the ocular vessels, exercising a
deleterious influence upon the inflammatory process.
The most important drug in the treatment of in-
flammator_\- conditions of tlic iris is atropine, which
should be used energetically and continued until its
physiological effect upon the pupil is manifest. A
complete dilatation of the pupil as well as a com-
plete immobilization of the ciliarv muscles is desira-
ble. The drug should be employed in order to keep
the pupil well dilated until all the intlammatory
symptoms have subsided. Atropine is best em-
ployed in a one per cent, solution and is instilled as
often as occasion requires. In the beginning of the
disease one drop should be instilled every hour until
complete dilatation has been obtained : after that one
drop three times daily in the affected eye should be
used to maintain the mvdriatic eff'ect. Poisonous
effects in adults need not be feared ; in children,
however, symptoms of atropine poison may easily
manifest themselves, so that sometimes the drug has
to be withdrawn and substituted by some other
niA'driatic.
B DuboisiiT: sulphiitc gr. ^ ;
Distilled water .3i.
^^. Sig. : One tlrop in the nffectc d eye three times daily.
B Scopol-iniinc hydrobroniide gr. ^;
Distill-d water 3i].
AI. Sig. : One drop ni the affected eye three times daih'.
Rarely is it necessary to discard with the more
powerful mydriatics on account of poisonous symp-
toms and substitute the less effective drug homatro-
pine imtil the symptoms of poison have disap-
peared. The homatropine must be instilled every
hour and in a 4 per cent, solution.
B Homatropine hydrochloride gr. x;
Distilled water 3ss.
M. Sig.: One drop e\cry hour in the affected eye.
During the course of treatment one should care-
fully watch the tension of the eye so as to be on the
guard against a possible development of secondary
glaucoma. A temporary rise in the intraocular
pressure does not mean necessarily a glaucomatous
condition. This may be observed during the course
of the disease, at certain times lasting several hours.
A good evacuation of the l)owels and absolute rest
will .soon reestablish a normal relation. Tt i>^ best,
however, to stop the atropine for twent} -four hours.
Should the tension not be reduced to its normal c.)n-
dition, eserine may be employed :
B Eserine sulphate gr. ;
Distilled water 5ii.
M. Sig. : One drop instilled in the affected eye every
hour.
One drop of this nii.xture instilled ever\- hour will
soon reduce the high tension. It is not very often
necessary to have recourse to this measure. Still
more rare is the necessity to employ surgical means
in the endeavor to l)ring down the tension of the eye.
The value of atropine in iritis exists in the fact that
it dilates the pupil and thus guards against the de-
velopment of posterior synechije ; it contracts the iris
and thus reduces the congestion, and, paralyzing the
ciliary muscles, it puts the iris in a condition of ab-
solute rest, very essential in the treatment of all in-
flammatory conditions, .\tropine occasionally fails
to dilate the j)upil : it is well then to combine it w ith
[New York
Medical Tourn.\l.
the Other powerful mydriatics, especially scopola-
mine, when its action is enhanced. Not infrequent-
ly it happens that all the mydriatics combined fail to
produce the desired effect upon the pupil luitil some
constitutional remedies have been administered for
their general effect.
The pain in iritis requires special attention. When
the pain is not very severe and is caused by the con-
gestive condition of the iris the instillation of atro-
pine will bring relief. In some cases the pain is
more marked and atropine does not bring the de-
sired relief ; hot compresses applied to the eyeljall
will be found of great value. The best and most
convenient way is the hot, moist compress. The
compress must be changed as soon as the water evap-
orates. In (ierniaiu hoi c:iiiiomile i-^ commonlx' em-
ployed. I'oulticcs uf an\ kind arc not nece--ary. and
they are more difficult to prepare than the r)rdinary
hot, moist compress. During the acute stage of the dis-
ease this compress should be steadily used. If the
pain is not relieved by this method, then it is best to
re.sort to bleeding. In hospitals blood may l)e with-
draw n by ineans of the artificial leech ("Heurte-
loup's); in private practice this instrument is not
practical, and it is best to employ the living leech.
One or two leeches applied to the temporal region
will in the majority of cases relieve the ])ain. If
necessary they may be repeated. Xo bad effects re-
sult from their use, while the pain is always less-
ened, and in the majority of cases the pain is com-
pletely relieved. In some cases, how ever — and es])e-
cially is this the case in rheumatic iritis — riie pain in
the eyeball and the orbital region radiating to the
head becomes intolerable, and all agent- previ')usl\-
mentioned fail to give relief : the patient is very rest-
less, he cannot sleep, and is in misery indeed. L'nder
such circumstances it is best to employ an anodyne
and hvpnotic. Morphine is the best agent. It is
best to use it hypodermatically. It may also be in-
corporated with the other medicaments for the con-
stitutional condition. In rheumatic iritis the mor-
phine may be combined with the silicate.- :
B Sodii salicylatis, .is? ;
Morphin.-e sulphatis jiii ;
Potassii iodidi 5ss ;
Syr. sarsaparill^e conip
M. Sig. : Teaspoonfiil e\ ery four hour<.
Whenever morphine is employed to relieve the
pain it is well to administer an aperient so as to
keep the bowels in good shape. As soon as the pain
subsides the morphine should be stopped, and it
should not be given unless the indication for its use
is manifest.
.\drenalin is a u.scless agent and ma\- be harmful
in some cases.
Darirer employs a combination of tlionin ( ethyl
morphine hydrochloride), cocaine, and atropine lo-
cally.
B Ethyl morphine hydrochloride gr. ii :
Cocaine gr. ss:
Atropine, gr. ss:
Water 3ii.
M. Sig. : One drop in the affected eye six to eight times
daily.
This is a ver\ useful combination.
Di(Miin does not, however, relieve the i^ain. btu is
a usefid agent iti ])romoling the absorptioii of the
l-ebrua.-y
iyoS.l
BRAl-.- TREATMENT 01- IRITIS.
355
inrtammaion- prudiicl. lii some cases it also en-
hances the action of atropine, and thus it becomes
a valuable synerg-etic in our armamentarium in the
treatment of this disease.
I^ypopion complicating iritis does rarelv recjuire
special treatment. Rest, hot compresses, dionin lo-
cally, and a cathartic will usually cause the exudate
to be absorbed. In rare cases surgical interference
( paraceiitlif^is ) may be necessary.
Posterior syncch.ia. As a result of the inflamma-
tor\' exudation very often the iris becomes adherent
to the anterior portion of the lens, either in part, or,
as it rarely ha]i])ens. in total. This, of course, re-
quires our titniost attention. The ideal treatment is
prevention. .~>hould, however, after all the vigilance
of the ph\sician. adhesions develo]) thev nnist have
special care. A few small adhesions do no or ver\-
little harm, and they are, ])erha])s, better let alone.
An effort may be made to break the adhesions b\-
means of a strong mydriatic. ( )ccasionallv it is well
to contract the pupil first with eserine, then followed
l.)y a counteraction with a strong solution of atro-
pine. If no success follows this process it is best
to discontinue the drugs. It must be remembered
that the prolonged administration of atropine mav
give rise to a secondary glaucoma. Large poste-
rior synechi;e. and especially the annular synechia,
are dangerou> to the eyes, not because thev are
responsible for the recurrences, but because the\-
eventually destroy the usefulness of the eve by caus-
ing a secondarx glaucoma. It is advisable to do an
iridectomy, although even the surgical procedure is
not always c'rowned with good result.
When we consider the fact that iritis is only a lo-
cal condition when it is of traumatic origin, that in
the vast majority of cases the causal element is to
l)e found in ■^ome constitutional diathesis, we can
then well a])preciate the necessity of constitutional
treatment. The local treatment is of great service
in giving comijlete rest to the inflamed organ, re-
ducing the congestion as far as possible, but it is
the constitutional treatment that aims at the removal
of the causal factor. In fact, the efficacy of the
drug used for its local effect is made more jjotent
In" the administration of internal medication that
produces a constitutional eff'ect. A study of the con-
stitutional disorder is therefore essential in the sci-
entific application of therapeutic measures. In other
words, the ophthalmologist must be a general prac-
titioner as well, for the local infianimatory process
will not yield to any local application unless a pow-
erful impression has been made upon the constitution.
( )ccasionally w e rind that the iris will not yield to the
mydriatic influence of atropine, or even to a combi-
nation of the most powerful dilators, until by means
of general internal treatment we have been able
to produce a constitutional effect upon the inflamed
organ — in other words, the potency of the local ap-
plication has been enhanced bv the ]ihysiological ef-
fect produced with the constitutional remedies. The
medical treatment, then, of iritis is both local and
general.
liy far the most important constitutional rem-
edies are those employed to coml:)at syjjhilitic aft'ec-
tions. All ophthalmologists agree with Fuchs that
at least 50 per cent, of iritis is caused bv syphilis.
It occurs mostl}- in the secondary stage, and has a
great tendenc_\- to recm". SyhiMlitic iritis usuallv
runs a milder coursi.'. the ])ain being less acute.
Mercur\ is, of course, the remedy par c.vcrllciicc.
It is best administered in tlic' form <'\ ,-111 ointment.
One drachm of the unguentuni ]i\ dr;irgirum
should be nibbed into the skin twice dailv, choosing
dift'erent jxirts of the bod\- at each application.
."Should symptoms of mercurialism manifest itself
the (|uantity of the drug should be reduced, while the
intervals between the applieatiou should be made
longer. During the application of mercury an alka-
line mouth wash should be prescribed and the eft'ect
of the drug should be carefull_\- watched. (Jceasion-
ally it is necessary to entirely w ithdraw the mercurv
on account of poisonous symptoms. The inunc-
tion is ver_\' easily emplo_\ed. The hypodermatic
method, the onlv virtue of which is that it enaldes
us to kn(nv the exact cjuantity of the drug absorbed,
can onl\- be applied b_\- the pb\ sician, is painful, and
patients are not willing to submit to it readily.
When the infiammatorv svmptoms are declining,
potassium iodide is of great value in ])romoting the
absorption of the inflammatorx product. Small
doses of mercury should be given even after the eve
shows no more signs of inflammation. It is the onlv
safeguard against a recurrence, which is so fre-
(juent in syjihilitic cases, and wliich I believe is
often caused by an altogether too early withdrawal
of the constitutional medication. \\'hen on ac-
count of gastrointestinal disturbances the syphilitic
treatment has to be withdrawn for a short time the
syrup of hydriodic acid will be foimd of great value.
The next in frequency, as far as existing causes are
concerned, is rheumatism. Whatever mav be un-
derstood— at the present state of our meagre knowl-
edge of this disease — b\- this term, so much is be-
yond any doubt, that it is a constitutional disease
wdiich very often gives rise to inflammatory concli
tions of the iris.
The iritis being a local manifestation of the con-
stitutional disturbance, it runs a severe course, and
is accompanied by intense pain. Here the salicylates
are of great value. The^■ are best given in powders.
In the beginning of the disease and during the
height of the disease it is best to administer large
doses, while small doses are advisable in the declin-
ing stage of the inflammatory, process. During the
acme of the disease one drachm should be adminis-
tered daily in ten grain doses. At bedtime it is well
to give twenty grains, especially when the pain is
marked. When the patient,, on account of severe
pain, cannot sleep, we ma}- combine with the sal-
icylates morphine. \'ery often by making a pow-
erful impression upon the constitution we find that
the salic^dates not only help to relieve the pain, but
hel]i through general effect to (Hlate the pupil, wdiich
atropine alone could not do.
In the declining stages potassium iodide should
be combined with the salicylates and should be
given in five grain doses four times daily. When
larger doses are prescribed it is well to guard the
action of the heart.
Eliminative waters are useful in the treatment of
iritis. The iron preparations are very often useful.
In ill nourished and anaeiuic patients iron is an in-
35^
CAMPBELL: GONOCOCCUS INFECTIONS.
LNew York
Medical Journal.
dispensable drug. This was best demonstrated in a
case under my care, in which I could not affect a
dilatation of the pupil by all the powerful mydri-
atics known until I administered Blaud's pill. In
scrofulous cases the hypophosphates seem to have
a favorable influence. Good results have also been
obtained by the use of oil of gaultheria in gonnor-
rhocal rheumatism. In malaria quinine is, of course,
indicated. Fresh air, good food, and judicious
medication are essential in building up the patient's
constitution so as to combat with the aid of local
therapeutics the inflammatory process of the iris.
To prevent recurrences it is best to continue treat-
ment after the inflammatory symptoms subside for
a short time. This is very important, for recurring-
iritis al\va\ s reduces the visual acuity, and in a con-
siderable number of cases as a result of the sequelae
the eye becomes a useless organ.
917 Spruce Street.
SOME UNUSUAL EFFECTS OF GONOCOCCUS
INFECTIONS.*
By William Francis Campbell, M. D.,
Brooklyn, N. Y.
It was once thought that certain infectious dis-
eases which manifested in a certain locality were
purely local diseases. Xeiw we know that pneu-
monia is no more a local disease of the lung than
typhoid fever is of Peyer's patches. From more
recent indications it becomes evident that gonor-
rhoea will have to take its stand as a general disease
along with the others". It is true that in 80 per
cent, of the cases gonorrhoea is localized, but with a
margin of 20 per cent, for untoward eftects, it is
evident that affections of such a nature may mani-
fest themselves in numerous ways.
A review of the literature on gonorrh(X'a shows
that there is not a single organ in the body which
at one time or another may not be the victim of
such an infection. Should we add to this the in-
direct effects of gonococcsemia, the disease under
consideration takes on a most serious aspect. It is
because of its very commonness that it is danger-
ous. Beginning with the meninges of the brain and
ending with a felon, the gonococcus has manifested
an ability that other germs would find difficult to
emulate.
Fver smce it was demonstrated by Neisser, in
1879, the gonococcus has repeatedly been shown to
be an inhabitant of places both remote and foreign
from the common site of infection. Thus we read
with peculiar interest the case reported by C. A.
Powers where a diffuse and severe inflammation of
the entire upper extremity of one side was found
to be due to a mixed infection with gonococci and
staphylococci. A little later this author was able to
isolate the gonococcus from the neck, chest, and
parotid gland of the same patient. No less inter-
esting is the case of gonorrhoeal pleuritis, reported
by Mazza in 1894. Here, too, gonococci were
found.
We have become so used to hearing the expres-
sion "gonorrh?eal rheumatism," that from a surgical
'Read before the Brooklyn Medical Club, November, 1907.
Standpoint it has ceased to be the subject of absorb-
ing interest it was some time ago. One peculiar ef-
fect, however, that may be connected with this
outcome of gonorrhoea, is the interesting fact devel-
oped a few years ago by R. Kienbock. According
to this investigator a protracted gonorrhoeal arthri-
tis, especially of the wrist, is productive of a high
grade of rarification of the bones attacked. We can
easily imagine what this means to the bone.
Although not coming directly under the theme of
this paper still because of the bearing it may have,
a few figures in connection with gonorrhoeal arthri-
tis may be cited. From loo cases collected at ran-
dom the gonococcus pure was found in 4 per cent.,
mixed in 13 per cent., and in 83 per cent, no organ-
isms were found at all, the diagnosis being made
from the history, objective and subjective symptoms,
etc. In twenty-four cases mentioning the time of
occurrence of the joint affection, fourteen followed
the first attack, six the second, and of the four re-
maining cases, one occurred after the third, and
three after subsequent attacks. In twenty-one of
these twenty-four cases the disease ran a chronic
course.
In connection with the subject of arthritis the c;ise
reported by Baer is worthy of attraction. His
patient, the subject of acute gonorrhoea, had injured
his wrist, but there was no open wound. After a
short time the wrist swelled and became purulent.
Gonococci were demonstrated in the pu-.
Of further interest may be the statement of some
authors that they obtained no toxine from the con-
tents of joints- the subjects of gonorrhoeal inflamma-
tion. However, once the gonococcus has invaded
the blood, there is no knowing where it will strike,
and the surgeon might just as well be ready for
an abscess of the liver with this germ as the causa-
tive factor, as he is for pyosalpinx or suppurative
prostatitis.
An effect not very common, but by no means
rare in gonorrhoea and where the blood plays the
leading role, is "gonorrhoeal pyaemia." While this
turn of the disease is probably as old as the dis-
ease itself, the first case reported is that by Roswell
Park, who, at a meeting of the Genitourinary Sur-
geons held in Washington in 1888, spoke of a case
under his care where pyaemia followed acute gonor-
rhoea. When two weeks after the infection the dis-
charge ceased, it was followed shortly by swollen
knees, sepsis, a typhoidal condition, and death. At
the autopsy pus was found in the sternoclavicular
articulation in which also there was erosion of bone.
Other joints also contained pus. The mesenteric
gland and the spleen were enlarged. Dr. Park was
not certain whether this was the patient's first attack
of gonorrhoea, and he was not acquainted with the
condition of the urethra before the attack.
Other cases have been reported since then, inter-
esting among which is that of Silverstrim in whose
patient the attack among other things caused great
enlargement of the liver and icterus ; and of T. J
Strong's patient in whom a metastatic -focus formed
and presented a large abscess in the neck.
Strange as it may seem cases of gonorrhoeal peri-
tonitis have also been reported occurring in the male.
Thomas reported two such, but very recently.
February 22. 1908. J
SPEESE. CARCINOMA 01- BREAST CVSTS.
357
A distressing surgical complication in which the
gonococcus plays an important part is that of gonor-
rhccal proctitis. According to Konig the af¥ection
is most frequent in the female sex, the ratio between
the sexes being i to 8. He states that the gonococci
are seldom demonstrable in the excreta and that the
process may extend into the flexure, or by causing
pararectal abscess lead to fistula! He mentions a
case where perforation occurred into the vagina.
Though we are ready to be amazed at his report,
Meyer brings it down to the commonplace when he
declares that in his case of a felon from which the
gonococcus was obtained in pure culture, contact
infection was the responsible factor. This patient
was a woman, twenty-three years of age. affected
with gonorrhoeal vaginitis and multiple arthritis. A
short time previous to admission she had injured the
radial side of the index finger of the right hand by
means of a small iron instrument. Three days after
this accident a blister about the size of a quarter
developed at the point of injury which contained
thick, yellowish pus, and its base presented a ragged
appearance. The skin defect took three and one
half weeks to heal. The tendons and joints in the
immediate neighborhood were not affected.
Less fortunate than this patient was the one re-
ported by Jacobi and Goldman, who, following an
injury of the tendons of the wrist and while the
subject of gonorrhoeal infection, became afflicted
with tendovaginitis, which left a kylosed joint.
The ability of the gonococcus to localize itself at
a point where we would least suspect it, is further
illustrated by the case^of M. A. Gershel. who reports
positive findings in a subcutaneous abscess in a child
two years of age. The child was taken down with
typhoid fever, and two days after admission to the
hospital gave symptoms of gonorrhoea the origin
of which could not be determined. The abscess oc-
curred a week after admission and presented at the
left of the anus. I'hree days later a similar abscess
presented at the right side. Other cases with gonor-
rhoeal abscess of the skin and subcutaneous tissues
have also been reported.
Case. — On January 2, 1907, n male, eighteen years old,
was thrown from a wagon and sustained a compound Pott's>
fracture. He was treated with all aseptic precautions,
drained, md tl.c limb immobilized in splint. Four days
later pus appeared in the wound and continued to spread
up the leg as far as the thigh, requiring extensive incisions
about the leg and thigh to secure adequate drainage. With-
out any reference to the gonococcus, but desiring to find
the germ cause of the extensive suppuration, a culture was
made from the wound discharge a month after admission,
and the gonococcus found. It was then discovered that the
patient was suffering from gonorrhoea, a fact which had
not been obtained on liis admission to the hospital. He
stated that he had acquired the infection three days after
being exposed, about six Aveeks previous to his admission
to the hospital, .\fter four months the patient was dis-
charged from the hospital cured with regard to the frac-
ture, but still having slight urethral discharge. In this
case infection by direct contact was impossible while the
patient was at the hospital, and the cause of the suppura-
tion can only be accounted for in tw^o ways, (a) either the
gonococcus circulating in his blood found a point of low-
ered resistance and there set up a focus, or (b) at the
time of the accident the patient may have become inocu-
lated from the germ in question present on his clothing.
Personally I am inclined to believe the first of these sup-
positions to be the correct one.
394 Clinton .Xvexue.
C.'VRCINOMATOUS DEGENERATION OF BREAST
CYSTS.
By John Speese, M. D.,
Philadelphia,
.Assistant Instructor in Surgery, University of renasylvania;
Surgeon to the Dispensary of the Children's Hospital.
From the Laboratory of Surgical Pathology, Uniiersity of Peniisyl-
: aiiia.
The subject of precancerous conditions in the fe-
male breast is one which is ever of importance to
the surgeon. The recognition of these conditions
along with improvement in diagnosis and the edu-
cation of the laity toward the appreciation of their
significance, has lead to our present success in opera-
tive meastires. \Miile the percentage of cures is in-
creasing, we can hope for further advance only by
careful observation and prompt surgical intervention
in all cases which have any tendency toward malig-
nancy. It is w ell known that the disease commonly
termed chronic cystic mastitis, because of the
marked tendency toward epithelial hyperplasia, fre-
quently undergoes carcinomatous degeneration.
In a recent paper' I called attention to the fact
that this degeneration occurs in a fairly large per-
centage of cases, 12 to 16, and since that series was
collected I have had the opportunity of seeing three
additional instances of malignancy secondary to
chronic cystic mastitis. We find carcinoma likewise
developing secondarily in other benign diseases,
Greenough and .Simmons' asserting from their stud-
ies that 15 per cent, of papillary cystadenomata
undergo cancerous change. Cases have been care-
fully studied in which a malignant process appar-
ently originated in the lining of cysts, a part of the
series of changes observed in abnormal involution.
References to such a transformation in the case of
simple retention cysts are, however, meagre. Be-
cause of this danger and the necessity for its obser-
vance the writer is led to regard the condition as
precancerous and. therefore, one demanding con-
sideration.
The case which forms the basis of this paper oc-
curred in the service of Dr. Edward ^lartin. to
whom I am indebted for permission to report it.
The history of the case is as follows :
The patient, aged sixty-seven, the mother of five chil-
dren, gave an absolutely negative history in regard to
mammary trouble. Nine months before her admission to
the hospital she received a blow over the left breast, the
force being of moderate severity. A short time after this,
she noticed in the outer side of the breast a small nodule
which was tender on pressure. The grow th of the tumor was
very slow- at first, but during the two months before her
admission it had quite perceptibly increased in volume.
Accompanying this change the skin became purple in color,
and there was constant, although not severe pain. On ex-
amination, a mass the size of an orange was detected in the
lower and outer quadrant of the breast. Over its surface
pumerous large veins were seen, and fluctuation w^as elicited
in the tumor which was freely movable on the underlying
structures. There was no retraction of the nipple, the skin
was slightly adherent to the growth, and a few axillary
nodes were found enlarged and indurated.
While the cystic character of the tumor was appreciated,
the possibility of malignancy due to the patient's age, the
adherence of the skin, and the enlargement of the axillary
lymph nodes demanded a radical operation. Accordingly
the entire breast, including the cyst, w as removed, and the
axilla cleaned. The patient made a rapid convalesence,
'Speese, Uni-.ersity of Pcnusyl- aula Bidlcliii. January. igoS.
-Annals of Surgery, February, 1907.
ALLEX: DENGUE. IN CUBA.
Mi:mi.AL Jdluxal.
and Ii,;- remained well for the sixteen nionllis ^iiiee the
time vi operation.
On opening the cyst, which was sitnated directly beneath
the jkiii wdiich it was adherent, a thin, Ijlack tliiid wa^
evacn.-iied. In \ie\v of the history of tranni.i, tlu- olor
of the Imid was believed to be due to degenerated blood.
The wall of the cy-t pre>entcd a peculiar reticulated ap-
pearance, not unlike tli;!l -eeii in the \eiitricles of the
heart. The -emaiiKkr of the brea.-t was in no way differ-
ent from th.it seen in the state of noriiK;! invdlntion, a
fact 0' ninnied by the microscopical e.xaniiii.itinn. The his-
Uik'gic: ! r.xamination of the cy>t wall ^, bowed an inliltra-
t" "1 ' I crlls, epithelial in character. Xiimemu- sections
f.i-e'i ',.i ri\e;il the point from which this nnasion began,
'ii'e p to marked degeiu'ratioii and atropli\- of the
Imiii-^ i!Kii;brane nf ilu' c\st. The circmom.-itous areas
coiisi-ted "{ ciM-rl> eompresM-d rciN arranged in thin pro-
ce-se-, ITU liiikke i scirrhus cancer. The surrounding tis-
tue was aliiKist dexoid of glandular elements and was typi-
cal of .-.n involuting breast. The case represents then the
rather ;uicommon malignant degener.ation of the lining of
a retention cyst of the brea.si The the. rough examination
of the surrounding ni:iiiiinar> ii--nr <, xcluded the possi-
bility of a carcinoma imiltraiing tin- c_\st wall from without.
A discussiiiii (d" the varieties and iikhIo nf forma-
tion Ml' l>rcast c\sLS, is not the object of tiiis i)a]>er.
References are not conunon in the literature con-
cerning'' the formation of a mah^iianl growth in a
preexisting;- c\-st although it is weU known that cyst
formation often results in maHg'nant tumors. At
one tinie it w as denied that a ctincer cinild ])rimarily
arise from a c\st, hut recent sluthes have shown the
contrary to be true. The occurrence of malignancy
in fibroepithelial formations has alrcadv been alluded
to. ( )ccasionally we Hnd a cancerous invasion of
the C} St wall from without, the process developing
primarily in the breast. .Such a case is reportec'
by Sheild. W hile the_ origin of the carcinoma in
many cases is not clear, the retrogressive changes
which the epithelium undergoes :s iargely the cause
•of the malignani degeneration. i'he columnar cells
become compressed as the result of the ])ressure
exerted by the contents of the cyst, and are trans-
formed into ctiboidal or fiat cells, or may undergo
atrophy. In addition, retrograde changes in the
fibrous wall may be detected : these varying factors
having a more or less imi)ortant role in the malig-
nant degeneration which nia\ follow. The actual
origin of the cancer is not so iuiportaut when once
the disease is well estalilishod, i'or a radical opera-
tion is immediatel}- indicated.
The diagnosis according to Slieild dei)ends upon
the age of the patient, the majority lieing fort\- to
fiftv vears of age. Rajiid enlarge nient of the cyst,
especially if followed by the involvement of the axil-
larv Ivmph nodes, should be regarded as very signifi-
cant of be.ginning carcinomatous degeneration. The
cvsts are large, as a rule, round or oval in shaj)e, and
the contents clear, amber colored, or discolored b\
blood. In the majoritv of cases the jjresence of blood
in a cyst, without an intracystic papilloma to exi)lain
the h.tmorrhage can be regarded according to lUoml-
good.* as diagnostic of malignancy. When cysts are
opened at the time of operation the lining should be
carefully examined for thickened or indurated areas,
and papillary projections. The latter in particular
are apt to be overlooked, and even when quite small
mav be the scat of an early but highly malignant
process. A case illustrating this danger was reccnt-
Iv observed. An apparently benign cyst was re-
'Shcilil. Diseases of llie Breast.
*Jolins Hopkins Bulletin, April, 1907.
moved, and only on a second and more careful ex-
amhiation was a suspicious papilloma discovered.
This, on microsco|)ical examination, ]->roved to be a
malignant papillarv cystadenoma, a fact wdiich al-
tered the prognosis and treatment of the case to a
consiflerable extent. Asiuration of e\sl contents as
a diagnostic aid is no longc regarded as a proper
surgical procedure, for if not immediately followed
l)y operation much harm may result.
The treatment of cancerous c\sts ditf'ers in no
way from that of any malignant tumor of the breast.
While in many cases the degree of malignancv is
low, we are not justified in temporizing, but should
resort to the ustial radical removal when on inspec-
tit)n of the cyst contents and its walls, malignancv
is suspected.
328 South Sixteextii Street.
NOTES OX DENGUE IN CUBA.
Bv A, H. Allen. M. D.,
Lajas. Santa Clara, Cuba.
Assistant Surgeon, eniued Stales Navy.
{Published under tlic I mpniiuT. 11 r ilu- liiu-riciii Society of Tropi-
The towns of Laja- ,iiid ."-.into Domingo are situ-
ated about fort\ mile- from ilie- sea coast in the in-
terior of Santa I'laia pro\ince. Aiosijuitoes are
al)undant during the entire \ear, the most frequent
species being the stegomyia, eulicidie, and anopheles,
in the order named.
In August of i<)0~ I ohseryed some cases of den-
gue fever which are reported on account of theii'
mild character and failure to assume an epidemic
form. In all, there were eighteen admissions to the
sick list in two companies of L'uitetl States marines
stationed in the two tow iis mentioned.
J iiciibatioii. — The incuhalioii jieriod in one patient
was three days, in two patients four days, in the
others unknown, but probabl\- not over three or four
days.
PrDdi-oiiics. — There were no prodromal symp-
toms, the first sign of the disease being frontal head-
ache and vertigo, wdiich w ere pronounced. Pain in
the eyeballs was a prominent symptom in every case.
( )nly one patient had severe pain in the joints, al-
though six complained of pain in the loins and I)ack,
and all coin[dained of a ver\ slight rachialgia. ( )ne
])atienl h;id ahtlominal pain with vomiliug and diar-
rhoea, which lasted for twelve hours. In all i)atients
the digestive system showed only the ordiiuuw signs
of the febrile state. In no case was ])ain a prc^ni-
nent feature.
Defervescence started on the first or second day,
without crises of any kind.
h'aslits— 1 he rash appeared on the second or
third dav. The .so called "primary" rash was pres-
ent in five cases. The face was flushed ancl the
mucous membranes of the nose and throat were
somewhat congested. The conjunctiva was slightly
reddened. This condition disappeared in from
twelve to twenty-four hours, either before or during
defervescence, and was succeeded by the typical
rash. This eruption showed a preference for the
dorsal surface of the forearms, internal surface of
the thighs, and the back and chest. It was ])re.sent
February rr, igoS.J
COKRESPONDEXCH.
359
in all cases. Its character was discrete, roundish
maroon, or reddish spots from one (juarter to three
quarter inches in diameter, slightl\- raised. ( )n the
forearms and thighs the spots rajjidly coalesced : on
the back and chest they remained cumparalively dis-
crete. In one case the rash on the arms and neck
gave the appearance of a severe sunljurn. Fading
took place in from twelve to twenty-four hours in
the majority of cases, althoug-h in one the rash per-
sisted for seventy-two hours, and in three for forty-
eight hours. A very slight furfuraceous desquama-
tion succeeded its disappearance.
Glands. — In three cases the superficial cervical
glands were enlarged. In fourteen cases the in-
guinal glands Ijecame swollen without pain, although
the fact that most of these patients had a previous
venereal history nmst he noted.
Temperature and Pulse. — The highest tempera-
ture was 103' F., which occurred on admission, the
average being about T02.2 F. The pulse was uni-
formlv low. With fever of io_v I'- the pulse was
92; with tem])eratures of 102" }■. in six eases the
pulse varied from 80 to 100. The highest pulse rate
was 102.
Blond. — Xo blood examination was ])ossible. as
there was no microscope available, and the I'nited
States Army Hospital at Cienfuegos, Cuba, was con-
tending at the time with an outbreak of yellow fever.
There was no albumininna or an\" tendencx' to
hjemorrhage in any case.
Trans})iissioii. — The theory of (iraham and r)an-
croft. who consider the mosquito the infective agent,
seems to receive some corroboration in these cases.
In previous reports the presence of one case of den-
gue is soon followed hv an epidemic. In these cases
the barracks were fumigated wiih sul])hur dioxide
to destroy all infected insects. and the use (jf the mos-
quito bar was rigidly enforced. The patients were
immediately removed to a screened building and
treated under mosquito nets. One case of a hos])i-
tal apprentice, who nursed the cases and \\:is at-
tacked with a topical seizure of the disease three
days later, was thought to be due to lack of care in
the use of the bar, as another ai")preniice, doing ilie
same work. \ et protecting himself secm-ely at night,
was not attacked with the disease.
Conehisioii. — In summing up, the most noticeable
features of the cases were.tlie uniformity of the rash,
the verv slight amount of pain associated with the
disease, the comparatively low pulse, the mild char-
acter of all cases, and the possibilitv of the mosquitrj
being the transmitting agency of dengue.
LETTER FROM TOROXTO.
TIic Ncz^' Staff of the Toronto General Ho.<;l^ital.
Toronto, Tcbruary 11. igoS.
For r-ver fourteen months the .special committee
of the board of governors of the Toronto Gener d
Hospital have had under consideration appointments
to the staff of that hospital. Their final report has
been made, and it shows very definitelv how la\'men
can. especially when attached to hospitals, stick the
knife ruthlessly tinder the ribs of men who ha\e for
years zealously and faithfully performed their du-
ties. Were it only the older men who liad got it.
one would not grumble that the\- had been laid upon
the shelf as "consulting staff." an honor of verv
doubtful value; but when manv \<iung men. wdio
had done their work well, regularK, and eonstantlv,
are interestedly sacrificed, their sole i';iult l)eing that
they were not w ire pullers, and had not sought any
influence on the board tii Ijack them uj), llu' injustice
is so rank that it is almost sm-prising that even some
of the good and high class ethical men on the new
staft' did not refuse to continue wdien s(>nie of their
late confreres got it so "good and plentv." Of
course, hosjMtal l)oards must cater to the i)roteges
of munificent donors — z'erh. sap.
The three heads of the department of surger\- are
Dr. ( ieorge .V. Uingham. Dr. .Mexander Primrose,
and Dr. H. A. Ilruce. Dr. llingham has under him
Dr. Charles Shuttleworth. Dr.' Wallace Scott, and
Dr. A. I'.. WTight. Dr. I'rimrose has Dr. F. X. G.
Starr. Dr. Stanlev Rver.son. and Dr. S. H. We.st-
man; Dr i;ruce. Dr. VW J. ( ). Malloch. Dr. Warner
Jones. Dr. John .McCollum. and Dr. A. A. Reatty.
.\lr. I. H. Cameron, as professor of surgerv in To-
ronto l'niversit\ , is chief of the surgerv class, and
attached to him is Dr. Clarence L. Starr. There
are three services in medicine, with Dr. Alexander
.McPhedran. Dr. W. \\ Caven. and Dr. (Iraham
Cham])ers as heads, .\ssisting Dr. ^Icl'hedran are
Dr. A. R. Gordon and Dr. William ( ioldie ; Dr.
Ca\-en, Dr. John I'otheringham. Dr. W, !!. Thistle,
Dr. E. C. P.urson, and Dr. loseph S. Graham: Dr.
Chambers. Dr. P. D. Rudolf" Dr. Goldwin Howland.
and Dr. (ieorge W. Ross. In charge of the tuber-
culosis clinic under Dr. ]\lcPhe(lran's clinic is Dr.
11. C. Parsons. In charge of tin- department for the
treatment of functional neuroses, under Dr. (^"aven's
service, is Dr. D. C. Me vers. Dr. J. F. W. Ross is
chief of the gvn;ecological department, and associ-
ated with hiiii' are Dr. V. W. Marlow, Dr. W. P>.
Hendry, Dr. A. C. Hendrick. Dr. Ida Lyn.l. and Dr.
Helen McAIurchy. The obstetrical service is in
charge of Dr. Kenned}- Mcllwraith. with Dr. ITed-
erick b'enton and Dr. J. .\. Kinnear as .assistants.
In the e\"e department are Dr. K. A. Reex'e. chief,
and Dr. C. Trow, Dr. J. M. ^ [ac(, allum. Dr. D. X.
MacLennan. Dr. Colin Campbell, and Dr. W. H.
Lowry. The ear. nose, and throat (le])artmcnt is un-
der the charge of Dr. (iCorge R. .McDonagh, with
Dr. D. J. G. Wishart. Dr. Geofi'rey Royd. Dr. I'erry
("jold.smith. Dr. C. ^] . Stewart. ' and' Dr. Ciilber't
Royce. Dr. Samuel Johnston w ill he the chief an?es-
thetist and Dr. D. ".M. .\nderson assistant. Dr.
Charles R. Dickson will continue to look after the
electrical de])artment, with Dr. (ieorge Ralmer as
assistant. Dr. J. .V. Temi)le and Dr. F. LeM.
Grasett had the cinch on the l)oard, as tluw were life
members of the Rurnside L\ ing-in Department, and
so could not be distm'bi.'d. The\ hax e lieen appoint-
ed life members of the active staff without service.
The committee recommended the following old ac-
tive meml)ers. or active old members, as a consulting
staff, although some of them are not yet entitled to
sit in the baldheaded row : In medicine. Dr. John
L. Davison, Dr. W. H. P.. Aikins, Dr. T. F. Mc-
]\[ahon. Dr. .Allen Baines. and Dr. John Caven; in
surgery. Dr. Luke Teskey, Dr. R. B. Nevitt, and Dr.
36o
THERAPEUTICAL NOTES.
[New York
Medical Journal.
X. A. Powell: in obstetrics, Dr. Adam H. Wright;
in the eye and ear department. Dr. G. Stirling Ryer-
son, and Dr. George H. Burnhani. Whether this
"sop"' will be satisfactor\- in removing any cardiac
ulcerations it is hard to say. Those, liowever, who
were so relentlessly and ruthlessly pole-axed may
lay this flattering unction to their wounded feelings,
which in the process of time, especially tlie lime,
may heal them : The committee expressed its ap-
preciation of the excellent character of the service
rendered by the staff, past and present, and in addi-
tion its grateful acknowledgment of the self sacri-
ficing efforts in the interests of the sick and of med-
ical education on the part of members now retiring
(retiring is good), several of whom have l;een con-
nected with the hospital for long periods, and have
requested to be relieved from further duty — (but
not chloroformed). There is balm in Gilead.
Cocaine in Ointments. — There exists an im-
pression that when cocaine is prescribed in an oint-
ment the alkaloid and not the hydrochloride should
be used, on account of the insolubility of the latter
in oils and fats. The hydrochloride, however, is
more suitable in the majorit}- of cases, for, if the
ointment is to be applied to the eye or to a mucous
membrane, the moisture will dissolve the salt and
cause much more rapid absorption than if the alka-
loid were employed. If wool fat is used as a basis,
the water contained therein will dis.solve the salt
better than the fat will the alkaloid, and absorption
will be immediate. According to Cripps (Tlie Pre-
scrihcr, February, 1908), the pure alkaloid is liable
to decomposition in presence of fats.
To Abort Lobar Pneumonia. — The ciuestion of
the abortion of an apparent first stage of pneumonia
is discussed in the Journal of the Aiiicricaii Medical
Association for February 15. Except in instances in
which the sputun.i lias \)c■:\^ found to contain pneu-
mococci, and, under measures inslilntid, the con-
gested lung has cleared up in a da} or two, we are
not justified in asserting that an attack of pneumonia
has been aborted. On the other liand, with assist-
ance and without assistance, we all see instances of
congestion of one lobe of a lung occur, stop, and be-
come normal in two or three days. Unfortunately,
at this period of an apparent pneumonia there may
be no sputum, and if there is. it is not examined for
pneumococci, and it may not have been a pneumonia
at all, but certainl\- it was a congestion of one lobe
of a lung. Consequently an attempt to abort an ap-
parent first stage of pneumonia should be made. If
the patient is strong, sturdy, and especially if he is
plethoric, venesection will often give good results,
and is positively indicated if there is marked dys-
pnoea, if the heart is laboring, the head full, and the
face congested, even if there is no actual cyanosis.
Life has been saved by venesection done under such
conditions. If the symptoms are not dire enough to
demand venesection and for other reasons it is
deemed inadvisable, which is generally the case, a
full dose of an antipyretic drug, such as antipyrine,
sufficient to cause profuse sweating, is good treat-
ment. The antipyrine may l)e given in fifteen grain
doses combined with calomel, unless there is suffi-
cient pain to require an immediate dose of morphine.
If the pain is severe, morphine should not be de-
layed, but given, if necessar} , hvpodermaticallv, in
a dose sufficient to stop the pain, either 1/8 or 1/6 of
a grain. It is better to repeat the dose of morphine
when needed rather than give as large a dose as %
of a grain, which will, perhaps, procluce more pro-
found sleep than is desired. If morphine is given
for the first acute pain, a saline purgative should be
given on the following day.
Treatment of Biliary Calculus. — A pill of the
following composition is said to be useful in the
treatment of biliary calculus, the formula being
credited by the Journal dc medicine to Gilbert
Davis :
I* Phenolphthaleine gr. Y^;
Sodium oleate gr. i;'
Salicylic acid gr. iss;
Menthol gr. i.
M ft. pil. No. r.
Sig. : One pill two or three time a day.
Thymol Camphor in Abscesses. — -The liquid
produced by mixing thymol and camphor is recom-
mended by Risacher (Journal de medecine de Paris
and The Prescriber) for reducing fungosities of a
tuberculous character. Injected into abscesses it has
two special actions: (i) An immediate action, per-
mitting the rapid evacuation of a fungous abscess,
or at least it relieves its tension and avoids forma-
tion of a fistulous tract: (2) a mediate action, which
it exercises upon the contents of the abscess at the
end of a few days; aspiration, at this time, brings
away a viscid, chocolate colored fluid, of distinct
camphoraceous odor. The injection is not followed
by a fistula ; the tract closes up in a few days and
leaves no induration. In the case of a tuberculous
lymph gland, a few drops of the solution are to be
injected into the interior. After two or three injec-
tions, the gland becomes soft and fluctuates, and can
then be treated like the preceding. In this way it is
possible to remove .'Strumous glands without pro-
ducing a cicatrix, which the patient so much dreads,
and which may become affected with keloid. No un-
pleasant symptoms follow these injections, unless the
liquid should be accidentall\ thrown into a vein.
The proportions recomnu-nded are thymol 16.
camphor, 30.
To Promote Diuresis in Uraemia the following
pills may be given :
B Extract of pilocarpus, 1
Extract (il -(|uill. • aa gr. i.
Extnict r,f i:,!;,,), \
M. ft. pil. No. I.
Sig.: One pill e\cry three hours.
R Pulverized squill. 1
Pulverized scnnimony. |- aa gr. i.
Pulverized digitalis, '
M. ft. pil. No. I.
Sig. : One pill every three hours.
To overcome oedema of the limbs the following
powder is recommended :
Ti Potassium sulphate 5iss ;
Potassium bitartrate 5iss;
Potassium nitrate 3iss ;
Powdered digitalis gr. xv.
M. et divide in chart xx. One to three powders a day,
as needed.
February 22. 1908. 1
THERAPEUTICAL NOTES.
361
Haematuria in Haemophylics. — The treatment
of bleeding- from the kidneys is considered in an
article in the Journal of the American Medical As-
sociation for February 15. In haemophilia various
drugs may be tried. Suprarenal extract may do
good, and thyreoid extract has often been of advan-
tage, although in other instances it tends to increase
the haemorrhage. The exact element in the blood
that is wrong or the exact internal secretion that is
at fault in hasmophilia has not been discovered and
may not be constant, hence the varied results from
the administration of the various organic extracts.
Gelatin has been fed with advantage in such in-
stances, and calcium chloride has often been of bene-
fit. Calcium chloride may be given as follows :
R Calcium chloride, 5iss;
Syrup of calcium lactophosphate, ^\x.
M. et sig. : A teaspoonful. with plenty of water, every
three hours.
To Increase the Flow of Milk. — To increase,
the flow of milk when it is, desired to defer wean-
ing the infant or changing the nurse it is often
recommended to the nurse to take malt beverages
such as light beer or ale and to use additional salt
in the food. Certain aromatic and carminative
drugs are also reputed to be of service, cumin, anise
and fennel seed being used. In the Journal de
medecine de Paris, for January 25. 1908, it is noted
that Professor Del Area, of Buenos Aires, recom-
mends an infusion of the root or a decoction of the
seeds of what is evidently an Argentine plant, tasi,
the botanical name of which is given as niorrenia
brachystcpham. The preparations are .made ac-
cording to the following formulas :
Ijifusio)i of the root:
I* Tasi root, 30 parts;
Boiling water, 200 parts.
Make an infusion and strain. To be taken in doses of
one tnblespoonful during twenty-four hours.
Decoction of the seeds:
R Tasi seeds 40 parts;
Water, 200 parts.
Make a decoction by boiling.
To be given during the day in tablespoonful doses.
In France the following preparations of nettle
and galega (goats' rue) are employed as galac-
tagogues :
I* Galega leaves, 50 parts ;
Make an infusion with
Water 1,000 parts;
And add
Syrup, 100 parts.
The whole of this :s to be given during the twenty-four
hours.
An aqueous extract of galega finds favor, made
as follows:
^ Extract of galega siss ;
Simple syrup Oii.
M. Sig. : Tablespoonful every three hours.
A tincture of galega, made from the extract, is
also employed :
R Extract of galega, Bii ;
Diluted alcohol, Oii.
M. Sig. : Fifty to 100 drops three or four times a day.
Galega may also be prescribed in pill form as
follows :
'^Morrcnia brachystephana Gris is a member of the Asclepiadaceae.
It is a shrub growing in Southern Brazil and Argentine and has
white rotate flowers and spear shaped leaves. — Translator.
R Extract of galega gr. iv ;
Excipient, q. s.
M. ft. pil. No. I.
Sig. : One pill three or four times a day.
Monin recommends the following compound
pill :
B E.xtract of galega, -j
Extract of nettle, I la ^r i •
Extract of ergot. f aa ,r. i.
Calcium hypophosphite, )
Essence of cumin, q. s.
ft. pil. No. I.
Sig. : One to two pills twice or thrice daily with meals.
A tincture and a syrup of nettle are used in the
same dosage, though the nettle preparations are
more concentrated :
B Extract of nettle 5vi ;
Diluted alcohol Oii.
M. Sig. : One to two teaspoonfuls every three hours.
Syrup of nettle:
R Extract of nettle, 5vi ;
Simple syrup Oii.
M. Sig. : Tablespoonful every three hours.
Potassium chlorate in doses of fifteen grains
three times a day has been recommended by Harkin,
of Belfast, but this drug must be used with cau-
tion.
The Treatment of Chilblains is thoroughly dis-
cussed by F. Gardiner in The Practitio)ier. for Feb-
ruary, 1908. He names ichthyol and formaldehyde
as two drugs of preeminent value in the early stages.
Ichthyol reduces congestion. While he has used it
in full strength painted on. an ointment of wool fat
containing ten to twenty per cent, of ichthyol serves
most ptirposes. Spread thi.ckly on linen, and worn
at nights on the affected parts, ichthyol ointment
often dispels a commencing attack after a few ap-
plications. If the odorous character of ichthyol is
objected to, thigenol may be used in its stead. For-
maldehyde requires more care in its application in
consequence of its pungent odor and smarting effect?
on abraded surfaces. In ointment form it ma\- be
used in ten to fifty per cent, strength. Formalde-
hyde may be also applied pure. It is said to be more
effective and lasting in its results, but much harsher
in its action, therefore ichthyol is better suited for
delicate skins. Exposure of the surface to x rays
and high frequency currents have been used success-
fully in severely recurring cases. X rays are said to
have an atrophic effect, this being more pronounced
on unhealthy tissue, hence they reduce inflammation
and remove pain. High frequency currents can be
applied b}- the efifleuve. or by the vacuum electrode.
In the ulcerating stage the following paste forms a
convenient application :
B Ammoniated mercury gr. v;
Ichthyol TD- X ;
Starch, . . . \ _..
Zinc oxide, | ^" =
Petrolatum, 5ss.
M. Sig. : Apply unsparingly on linen and change fre-
quently.
Inhalation for Whooping Cough. — Edson
(Merck's Archives) uses the following:
^ Creosote, 3iii;
Eucalyptol, 5ii :
Spt. chloroform, 5vi ;
Terebene ad ^'i'-
M. Sig. : For inhalation. Fifteen drops on sponge wrung
out of hot water.
362
liDIlORlAL ARTICLES.
[New York
Mel)K-al Jol'kxal.
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Revieiv of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
-:d SMriH ELY JELLIFFE, M. D.
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NEW YORK. S.\TI'R1).\Y. FEURUARY 22. 190S.
SUPRARENAL PREPARATIONS IN
DERMAT( )LOGICAL DL\GNOSIS.
Dr. Winkler, nt (ieniian_\-. has niadc interesling
researches and experiments re^ardiii!^' the intUienee
of adrenahn. hych-ochloride of suprarenine, and syn-
thetic suprarenine upon tlie skin, in w hich he gained
the impression that tlie synthetic preparation did
not act >i) well as the two natural ones.
He reports h\> residts in the M en itslicftr fiir
prahiische Deniuilulogie for b'ehruary 1st, and re-
fers to .\lois\'elich.who described his experiments in
the Wiener inediziiiische Bllittcr, 1897, p. 735, and
to lulius Baum. who wrote about the same subject
in the Archiv fiir Deniiatologie und Syphilis. 1905,
P- 5')-
Tainting of uninjured skin with suprarenal prepa-
rations is hot followed liy any effect. I hit W inkk'r's
method produces results: that is. if a thin la\ er ol
cotton wool impregnated with a suprarenal prepara-
tion is placed upon the uninjured skin and kejjt
there under light pres.sure for ahoul ten minutes,
the area thus treated will remain while for about
thirty minutes to four hours, according to the vaso-
motor excital)ility of the skin, when it gradually
resumes its normal color. Painting with the ])rcpa-
ration makes only injured .skin anjemic, such a lesion
Ix-ing i)roduced by lightly rubbing with fine emery
paper or ether. iHirthcrmore, if a line is marked
with a blunt glass rod u])on a .skin of ready vaso-
motor excitaliility. this line will imtticdiately become
elevated and red, marked on both sides with a white
line; this red elevation, when covered with supra-
renal wadding, will disappear and form with the
white lines a broad white band. If the glass rod is
applied to an area whitened by a suprarenal prepa-
ration in such a manner that uninfluenced skin is
also touched on both sides, then the area will be
surrounded bv red and white lines, while the area
itself becomes onl_\" slightly elevated.
These experiments have been used for diagnoses
in dermatology. Thus, when an area of lupus vul-
garis has been treated in the manner described, the
red nodules will stand out prominently from the
anaemic skin, while the brown red syphilides turn
gray vellow, and in sclerosis a yellow coloring ap-
])ears. Lupus erythematodes is not affected, wdiile
luinis tumidus shows a result. Erythema multi-
forme and erythema nodosum are strongly influ-
enced, the bluish color (]isa]jpearing. In a skin
upon which suprarenal wadding has been placed
and which is then treated with radium, the radium
erythema does not appear, wdiile, wdien it is present,
the skin not having been treated with the supra-
renal preparation, it will disappear on the appHca-
tion. Urticaria blotches pale and the itching stops.
The redness of acute articular rheumati.sm disap-
pears entirely, but that of syphilitic origin turns
grav. In psoriasis the red scales turn white, and,
if there is des(|uamation, can easily be picked off.
Of interest is also the influence of suprarenal
preparations upon eczema, where the rose red nod-
ules in sel)orrh(tic eczema turn yellow, thus dis-
tinguishing eczema from lichen urticatus, where the
entire area is paled. In herpes zoster the vesicles
do not change color, while the surrounding area
pales slightly. Evidently the suprerenal prepara-
tions mav find a place in dermatological diagnosis.
A Ml^SEUM OE SAFETY DEMCES.
The establishment of the American Museum of
Safety Devices and Industrial Hygiene seems to
promise the adoption of many elificient means of
])reventing fatal and cri]:ipling accidents and the
occurrence of disease due to causes now incident to
certain occupations. It appears to us more likely
than the enactment of an employers' liability law to
l)romote the saving of life and health: at all events
it may powerfully supplement such a law and re-
strict the necessity of resorting to its provisions.
.\t ])resent the museum occupies the fifth floor
of a large building at Xo. 231 West Thirty-ninth
Street, near llroadwax. There is no charge for ad-
mission to the disi)lay. which is open to the public
daily from 10 a. m. to 6 p. m., exccjit that on Satur-
days it closes at 1 ]). m. It is announced that special
February 22, 1908.]
EDITORIAL ARTICLES.
363
arrangements can always be made for visitors on
holidays and during conventions and "other events,"
also that competent persons will be in attendance
to explain the devices and processes exhibited. An
"industrial chamber of horrors" is to be made a
feature of the museum, showing the unsuspected
perils to which we are almost all frequently ex-
posed, such as defective pieces of mechanism in
passenger elevators, for example.
Certain prizes are announced. The Scientific
Ainci-rcan offers annually a gold medal for the best
device for the protection of life and limb, limited
for this year to devices pertaining to transportation.
Dr. L. L. Seaman offers a prize of $ioo for the
best essay on the economic waste due to occupa-
tional diseases, and a person wdiose name is nor
given offers a prize of the same amount for the best
essay on the economic waste due to accidents. It
is reasonable to suppose that other prizes will be
open to. general competition, and we may well hope
that beneficent results will folhnv.
The museum is under the patronage of men
whose names are a guarantee that its operation wiU
be free from objectionable features. Bishop Potter
presided at a meeting held in the Cooper Union on
February nth. in furtherance of the work of the
museum. At that meeting addresses were made by
the Hon. Carcoll D. A\'right. Rabbi Stephen S.
^^'ise. Mr. Alfred J. Boulton, the Rev. Percy S.
Grant, Dr. Josiah Strong, and Dr. William H. Tol-
man (the director of the museum). We under-
stand that this undertaking is dependent for its
financial support solelv on the fees received from
e.xhibitors and on contributions, and we hope that
the latter will prove numerous and substantial. The
treasurer is ]Mr. William B. Rowland. A contribu-
tion to the funds of the museum would seem to be
a direct benefaction to the people : not the people of
Xew York alone, but also of the whole country.
AXATOMV .\XD PHYSIOI.OGY A^K )XG
THE CHIXESE.
As we hear only severe criticism of the knowl-
edge of medicine among the Chinese, we wonder
how it is possible that a nation w-hich is so highly
cultivated and possesses such an old civilization
could have been satisfied for many centuries w^ith
ignorant physicians. Dr. Griinhagen. of Schwerin,
Germany, is therefore to be congratulated on hav-
ing published in Janus for January a very interest-
ing and instructive article dealing with this sub-
ject.
\\'e hear from our learned author that since the
seventeenth century the Chinese physicians have not
been permitted to perform autopsies, partly from
religious respect for the dead, partly from the be-
lief that ever}- man should enter the other world
with an uninjured, whole body, that he may lead a
peaceful life in the hereafter and may not disturb
his descendants. The anatomical knowledge of the
Chinese dates, therefore, back to the time before this
period, when post mortem examinations were still
performed, and this knowledge has come to the
Chinese of the present day as a tradition preserved
from generation to generation, partly by word of
mouth, partly in books. Xew investigations and
corrections have not been added.
Su])erstitions have played an important role in
our own medical science, but progress has mostly
overcome this inheritance of the Dark Ages. Such,
however, is not the case with the Chinese ; super-
stitions have with them become a science, and they
have built of them a structure with real Chinese
consistency.
The CTiinese physicians believe that the most im-
portant part of the bod\- is the organ through which
the soul enters it, the testicle in man, the uterus in
woman, or, according to others, the kidneys, for
male and female alike. The body consists of mus-
cles, fat, arteries, skin, and bones. The functions
and importance of the brain were not known form-
erly, while modern physicians classify the organ as
the fir,st of the intestines. The organs are divided
into three classes: i. The liver, the heart, the spleen,
the lungs, and the genitals. 2. The gallbladder, the
large and small intestines, the stomach, the urinary
bladder, the kidneys, the testicles, and the three
body cavities : these two classes constititte the in-
testines. 3, The twelve nerves, si.K to the arms and
six to the legs. Each of these twelve nerves gives
off three ya)ig and three yin, which supply the or-
gans of the body. The nerves consist of fine tubes,
which, leading to all parts of the bod\-, form the
paths of travel for the soul.
The sold travelling from its point of entry to
the centre of the body, which is situated at the
junction of the nose and the upper lip. is some-
times thought to be in a gaseous, sometimes in a
fluid form. From the centre of the l^ody it sup-
plies all parts with power and energy. The soul
flows without interruption througb the body, never
returning to its place of entry. Where it flows more
slowly or where it finds impediments, there will ap-
])ear diseases. Anger makes the soul ascend quick-
ly, happiness slowdy, while fear rrrakes it descend
slowly, terror quickly : cold contracts the soul, heat
expands it, and fatigue evaporates it ( yan'iiing) .
There originate from the centre of the body two
])rincipal trunk arteries, which supply the body and
'limbs with branches, one of the trunk arteries as-
cending vertically upwards to the craniup.1 . and as
3^4
EDITORIAL ARTICLES.
[New York
Medical Journal.
far as the end of the spinal column ; the other ver-
tically downward to the belh-. The pulse can be
felt in six places. Such is the traditional science of
anatomy and phy siology in old China.
LOCO POISONIiNG.
An interest not altogether devoid of mystery is
connected with the loco poisoning of cattle on the
plains east of the Rocky Mountains. The trouble
is popularly attributed to the eating of certain plants
by' the cattle, plants known as loco weeds. The
Bureau of Plant Industry of the United States De-
partment of Agriculture has been investigating the
subject, and Mr. C. Dwight Marsh, of the bureau,
is satisfied that two plants, Aragallns Lainberti and
Asfiiigahis iiioUissiiiuis, are capable of causing the
disease known as loco poisoning. According to Mr.
Albert C. Crawford, also of the bureau, the symp-
toms of loco disease ma}- be produced in rabbits by
feeding them with extracts of these plants. He
attributes the poisonous action to the inorganic con-
stituents, especially barium, at least as regards the
plants collected at Hugo, Colorado.
^Ir. C'rawford remarks that there is a close anal-
ogy between the symptoms and lesions of barium
poisoning and those that follow the administration
of extracts of these plants. Small doses of barium
salts, he says, may be administered to rabbits with-
out apparent effect at first, but suddenly there are
observed acute symptoms analogous to those re-
ported as displayed by "locoed" cattle. Sulphates,
especially magnesium sulphate, may be supposed to
exert an antidotal effect, but it is doubtful how far
they would be of service after the occurrence of
anatomical changes. It seems that loco plants
grown on certain soils contain no barium and are
pharmacologically inactive. In testing loco plants
for poisonous qualities, not only aqueous and alco-
holic extracts should be used, but also extracts ob-
tained by digesting the plants with the gastro-
intestinal ferments.
THE PRESENT STATUS OF THE
XEUkONE DOCTRINE.
The neurone doctrine, as originally outlined by
Waldeyer, like many other doctrines which have
been promulgated by men of science, has led an un-
even life. Alternately attacked and supported, it
has seemed to come through the fierce light of oppo-
sition to gain a better foothold than ])cf()rc.
It is now only about .seven years since .\))athv's
work on neurofibrils seemed to attack the principle
at tlu- very root of its being, and the (inslanglits of
Bethe and Nissl from the morphological side added
weight to the opposition, although it is now well
recognized that these investigators did not make
any serious inroads upon the doctrine. Hensen, in
1903, and Schultze, in 1905, however, to use Ver-
worn's phrase in a recent address {Mcdisinische
Klinik, January 24th) given by him on the neurone
doctrine, "made serious breaks in the wall"' when
they gave evidence tending to show that the periph-
eral nerves might originate from a net or chain of
cells rather than from the neuroblast, as originally
laid down by His.
Swayed by tlic evidence of Schultze, V'erworn's
allegiance to t!u neurone doctrine sufifered, as an-
nounced by him in the Zeitschrift fiir allgeiiieine
Physiologie, vi, 1906, for the nucleus of the neurone
doctrine lies in the conception that the body of the
ganglion cell, with its nervous processes and den-
drites, forms a cellular unit. The nerve prolonga-
tions, with their fibrillar differentiations as well as
the dendrites, must be considered as a growth from
the ganglion cell body and as constituting in their
extension — i. e., the axis cylinder with its fibrillae —
the most important portion of the peripheral nervous
s3'Stem.
Should the cell chain origin be established, a
radical viewpoint is reached that must modify our
present conceptions of the neurone doctrine, but, as
in times past, Ramon y Cajal comes to the rescue
and shows, in a paper on the genesis of nerve fibres
in the embryo {Trabajos del Laboratorio de Investi-
gacioncs biolbgicas dc la Universidad de Madrid,
Tomo iv, Madrid, 1906), that the old conception of
His, which has been one of the most important
foundations underlying the doctrine, is true, and
that Schultze is incorrect in his deductions. Held,
who at times has opposed the doctrine, supports
Cajal in his studies, in a work on the histogenesis
of the nerve fibres (Aiiat. Anseiger, xxix), in
which he traces the development of the neurofibrils
from the protoplasma of the neuroblast, where they
lie in a loose, turning mass, and develop into the
nerve process as it grows out of the ganglion cell.
Finally, from another source, an American investi-
gator, Ross G. Harrison, in a series of studies on
the transplanting of limbs and their bearing on the
problems of the development of nerves {Journal of
B.vperiineiital Zoology, 1907, 4), demonstrates with
great definiteness that the cell chain theory of the
origin of nerve fibres is not tenable. The question,
then, again settles back to the original proposition
that the nerve fibres arc still to be considered as
developments of the ganglion cell. and. in spite of
the attacks of .Apathy. Bethe, and Nissl, the essen-
tial feature of the neurone doctrine remains undis-
turbed.
February 22, 1908.]
NEWS ITEMS.
THE BUREAU OF ANIMAL INDUSTRY.
A modest pamphlet of sixty-nine pages consti-
tutes the report of the bureau's work during the
year 1907. Of course it is only a summary, the
more elaborate reports on special subjects having
been issued separately from time to time. \\"e have
frequently had occasion to mention the bureau's
publications on matters of particular interest to the
medical profession, and we have always found them
commendable. In our opinion, the Bureau of Ani-
mal Industr\- of the United States Department of
Agriculture is one of the most important agencies
in advancing our knowledge of comparative medi-
cine and therefore that of medicine in general.
Jews Items.
Changes of Address.— Dr. Claude L. W heeler, to 418
East Sixteenth street. Brooklyn (residence onh-).
Manhattan State Hospital.— Dr. William Seaman
Bainbridge. of New York, has been appointed consulting
-surgeon to this hospital.
The. Pennsylvania State Board of Medical Examiners.
— Governor Stuart has appointed Dr. Winters D. Hamaker.
of Crawford County, and Dr. M. P. Dickeson, of Delaware
County, members of the State Board of Medical Exami-
ners.
Personal.— Dr. T. Hewson Bradford, of Philadelphia,
has retired from general practice and will devote his atten-
tion to medical insurance.
Dr. L. C. Ahlborn. of Waverly. West \'irginia. is regis-
tered at the Philadelphia Polyclinic and College for Gradu-
ates in Medicine.
The Harvey Society Course of Lectures.- The
seventh lecture in this course will be delivered by Pro-
fessor Otto Folin. of Harvard Medical School, at the New
York Academy of Medicine on Saturday evening. February
22d. at 8:30 p. m. The subject is Problems of Chemistry
in Hospital Practice.
Buffalo Academy of Medicine. — A meeting of the
Section in Pathology^ was held on Tuesday evening, Feb-
ruary 18th. Dr. James A. Gibson read a paper entitled
Some Observations on the Sphenoidal Sinus, and presented
specimens, and Dr. A. L. Benedict gave a demonstration of
a new method of determining urinary acidity.
For the Suppression of Tuberculosis and Typhoid
Fever in New York State.— Dr. Eugene H. Porter. Health
Commissioner of Xew York State, has asked the Legisla-
ture for an additional appropriation of $75,000 to carr}- on
the work of the campaign against tuberculosis, and $30,000
to inspect local water supplies v.ith a view to stamping out
typhoid fever.
The Section in Otology and Larsmgology of the Col-
lege of Physicians of Philadelphia held a meeting on
AVednesday evening. February 19th. Dr. George Alorley
Marshall reported a case of Alveolar Sarcoma Invading
Ethmoid and Sphenoid Cavities and Orbit Operation, and
Dr. J. L. Goodale, of Boston, delivered an address on the
relation of Local Treatment to Acute Inflammation of the
Throat from the Standpoint of Pathology. The discussion
which followed was opened by Dr. D. Braden Kyle.
Hartford, Conn., Medical Society.— The Surgical Sec-
tion will meet on ^Monday evening. February 24th, at 9
o'clock. Dr. A. J. Wolff will present a specimen of ectopic
gestation. Dr. M. M. Johnson will report two cases of
Peritonitis, with Infection from a Ruptured Appendix, and
Dr. M A. Bailey will report a case of Cellulitis Treated
by Scarification. Dr. Oliver C. Smith will give a report of
Dr. Crile's lecture at Xew Haven, and the" latest work of
the Drs. Mayo, and the Chicago hospitals will be discussed
h\- Dr. E. J. McKnight and Dr. E. R. Lampson.
The Northern Medical Association of Philadelphia,
at its semi-monthly meeting, held on Friday, February 14th,
had a symposium on gastric ulcer. Dr. A. O. J. Kelly
spoke on the pathology, retiolngy and symptomatology; Dr.
Albert Bernheim spoke on the medical treatment, and Dr.
William L. Rodman spoke on the surgical treatment.
West End Medical Society, New York.— The first
regular meeting of this society for the year 1908 will be
held at the residence of Dr. Theron W. Kilmer, 165 West
Eighty-fifth street, on Saturday evening. February 22d, at
8:15 o'clock. Dr. Henry L. Shively will read a paper en-
titled The Association of Tuberculosis of the Lungs with
Diabetes Mellitus.
Rochester, N. Y., Academy of Medicine. — The regu-
lar meeting of the Section in General Medicine, which
includes neurology, psychiatry, materia medica, and thera-
peutics, was held on the evening of Wednesday, February
19th. Dr. William S. Ely read a paper on Human Asym-
metry; Dr. Robert G. Cook read a paper on Acute Anterior
Poliomyelitis ; and Mr. John W. Radu gave a demonstra-
tion on the Action of the Valves of the Heart.
Examination for Internes at the City Hospital.— An
examination will be held on March 27th and 28th to secure
internes for the house staff of the City Hospital. The hos-
pital has a capacity of about eight hundred beds, compris-
ing all branches of medicine, and the term of service is
eighteen months. All applications should be addressed 10
the chairman of the Examination Committee, Dr. Smith
Ely Jelliffe, 64 West Fifty-sixth street. New York.
Medical Society of the County of Kings, N. Y.— .\
meeting of the Section in Paediatrics was held on Friday
evening, Februarj- 21st. Dr. R. M. Beach presented a case
of Enlarged Thymus cured by the x ray. and Dr. .A. J.
Sumner presented a case and specimen of foetal rickets.
Dr. Maurice Packard, of Xew York, read a paper on the
Treatment of Pneumonia in Children, and Dr. John I-
Crawford read a paper entitled A Review of Engli-ii
Paediatric Literature.
Syracuse, N. Y., Academy of Medicine. — A regular
meeting of this academy was held on Tuesday evening.
Februarj- i8th. The programme included the following
papers : Ectopic Gestation, by Dr. W. H. Maynard ; Some
Unusual Experiences in Scarlet Fever, by Dr. Robert H.
Phelps, of Norwich : and The Early Recognition of Tuber-
culous Bone and Joint Disease in Children, by Dr. E. J.
Wynkoop. Dr. C. E. Coon illustrated Dr. Wynkoop's paper
with Rontgen ray lantern slitlcs.
Saratoga Springs, N. Y., Medical Society. — A sym-
posium on pleurisy was held by this society at its February
2ist meeting. Dr. A. J. Leonard read a paper on the
.Etiologv and Pathology of Pleurisv. which was discussed
by Dr. G. S. Towne: Dr. E. A. Palmer read a paper which
dealt with the symptoms and diagnosis, and Dr. J. T.
Humphrey read a paper on the treatment. Dr. F. J. Resse-
guie discussed Dr. Palmer's paper and Dr. D. C. Moriarta
discussed Dr. Humphrey's paper.
The Delaware County, Pa., Medical Society held its
regular monthly meeting in Chester. Pa., on Thursday.
February 13th. Dr. John M. Swan, instructor in tropical
medicine in the Philadelphia Polyclinic and College for
Graduates in Medicine, addressed the society on the Diag-
nosis of Malaria. A demonstration of the plasmodium
malariae was arranged The president of the society, Dr.
Frank J. Evans, of Chester, entertained the society at
supper at the close of the formal business.
Assistant Surgeons Wanted for the Medical Corps
of the Army. — It is announced that there are twenty-
three vacancies in the ^Medical Corps of the Army, and
to secure assistant surgeons to fill these vacancies examina-
tions will be held on May 4 and August 3. 1908. at various
points throughout the country where boards can be con-
vened. Applicants must be citizens of the L'nited States,
must be between twenty-two and thirty years of age. gradu-
ates in medicine, of good moral character and habits, and
shall have had at least one year's hospital training or its
equivalent in practice. In order to perfect all necessary
arrangements for the examination of May 4th. applications
must be complete and in the hands of the Surgeon Gene'-al
on or before April ist. Full information concerning the
examination can be obtained upon application to the Sur-
geon General. U. S. Army. Washington, D. C.
NEWS ITEMS.
[Xew Vork
Medical Tol-rxal.
The Medical Society of the Borough of the Bronx
held a nicciing on February iJtli. The c\-L-niiig was de-
voted to a ,syni])osiiiiii on Intltienza, the following papers
l)eing read: The Diagnosis and Treatment of Influenza,
by Dr. Thomas J. Dimn ; Influenza in Children, by Dr. A.
F. Brugman ; the Nose and Throat Complications of In-
fluenza, by Dr. Charles Graef; the I'lar Complications of
Influenza, by Dr. John B. Rae ; and Influenza in Its Rela-
tion to tlie Nervous System, by Dr. William M. Leszynsky.
The general discussion which followed the reading of the
pa])r!> was opened by Dr C;. H. F. Starke.
New York Academy of Medicine. -At a stated meet-
ing to l>i' held on Thursdax', M.ivch 5th. at 8:30 p. m.. im-
der the auspice- iif tin; Secti'iii in Medicine, there will be
a discu^-ion of the -iii'iuct mI Xntritlnii in l"yiihotd Fe\ er.
.N. paper on .MetalioliMn .iiul Diet in Txphoid l'\'\er will
i.e read hv Dr. W.irren Coleman and Dr. P. A. Shaffer,
.-.nd Dr. .Alnrn- .Mange- will read a paper entitled The
Limitations of Liberal h'eeding in T\]>hot(| h'lwer .Kiiumg
tho-e w ho will take part in the (li-cii--ii iii are Dr. (irahaiii
Lusk. Dr. C. G. L. Wolf. Dr. W. CiIiikui Tli.impson. Dr
Fgber. La Fv\ re. Dr. T. C. Janeway. and Dr. Janie- I-wing.
The Eastern Medical Society of the City of New
York held a meeting on hViday. i-'ebruary 14th. the
evening being (le\oted t(.i a syni|iosiuin on Di-ea-e- of the
Bones and Joints. Dr. Leo P)iierger read a paper on Hone
Sarcomata; Dr. Martin W. W.ire gave a stereoptieon
demonstration of radiograms of Syiihilitic Lone Disea-e ;
Dr. P. W. Nathan re.ad a paper on' M ocli.anic.al Treatment
of Bone and Joint rniierculo-,- ; Dr. W^illy Mwr read a
paper on Bier's H_\per;ennc Treatnieiil in ruliercnloiis
Affections of the Joints ; and Dr. Jo-eph Weiner read a
paper on-General Considerations of Bone and Joint ITiher-
culosis.
Scientific Society Meetings in Philadelphia for the
Week Ending February 29, 1908.— Moinlay. Frhniary
24th. .Mineralogical and Geological Section, .Vcademy of
Natural Sciences: Society of Normal and P.iiliological
Physiology, I'mversity of Penn-x K ania. Tiir.uldx. I'rhrn-
ary >yJh, Philadelphia Neurological Society. lI'Vtliirsday.
Pi-bnmry J6th. Philadelphia County Medical Society.
Tliursday. l-'ebnniry j~lh. Pathological Society: Fntomo-
logical Section, .\cademy of Natural Sciences: Section
Meeting, P'ranklin Institute. Friday, l-c-hruary jSfii, South
Branch. Philadelphia Countv Medical SocicU : Xoiilurn
Me.licM .\--ori:.tioii.
Charitable Bequests.— P,y the will of George W.
Wani.T, the Ornlian-' Home and .Asylum for the Aged
and Infirm of the lAangelical Lutheran Church of Ger-
niantown, the Nonlieni Home for Friendless Children, the
Home for .Aged and Inlirm Colored Persons, aiifl the
Pennsylvania Honu for Rlind Women, become contingent
legatees to the extent of $2,500 each. The Pennsvlvania
Hospital, the Episcopal Hospital, and the Pennsylvania In-
stitution for the Instruction of the Blind are also con-
tingent legatees.
Ry the will of Catherine Cullin. St. Joseph's Home for
Homeless Boys and St. Francis's Industrial School. Phila-
delphia, receive $100 each. The Catholic Home for Desti-
tute (Tiildren receixes $50.
The Mortality of Chicago. According to the renout
of ihe Department of Health for the week nuliug Febru-
ary Htli, there were during the week 747 deaths from all
causes, as compared with 783 for the eorres])onding week
in iqO/. The annual death rate was 17. g8 in 1,000 of po|)u-
lation. The principal causes of death were: .Apople.xy, 14:
Rright's disease. 49; bronchitis, 35: consumption, 71:
cancer, .^3; convulsions. 8: diphtheria, 10; heart diseases.
5"; influenza, 43; intestinal diseases, acute. 42: measles, 3:
nervous diseases, 25: pneumonia, 149; scarlet fe\er, 10:
suicide. 7 typhoid fever, 7: violence, other than suicide,
30: whooping cough. 5; all other causes. 149. More than
one-third of the total numbers of deaths were caused by
consumption. i)iienmonia. and bronchitis.
■Vital Statistics of New Jersey. - 'Phe monthlv state-
ment of vita' statistics issued by the Board of Health of
the St.-ite of New Jersey for the month of January shows
that there were 41 1 deaths from pneumonia during that
month, which is an increase of 195 over the preceding
month and 79 f)vcr the corresponding month for last year.
Pulmonary tuberculosis was the cause of 284 deaths, which
is 30 less than the average moiuhly death rate from this
disease. These two disc.iscs are responsil.ile for more
deaths than an_\- other single disease reported. During the
month 1.000 liac.Li lological examinations ha\ e been made.
314 of which were from suspected cases <.if diphtheria, 296
from tul:)erculosis, 171 from typhoid fe\er. and 9 from
malaria. Out of 428 specimens of food and drugs exam-
ined. 89 w ere below the standard. 339 above.
Infectious Diseases in New York:
ll'i- arc indebted to the Bureau of Kecurds of the Depart-
ment of Jleultli for file folloieiir.^ statement of nezv cases
and deiitlis reported for t!ic /:eo zeeel.^s ending February 18,
--February ii.--, —February 25.^
Cases. Deaths. Cases. Deaths.
Tiiberculi-is |iulinonaHs 339 208 340 225
lliphtberia 422 55 371 46
Mi-aslcs 1,063 25 1. 104 26
Scarlet ft\er 744 52 750 55
■s.nallpo.N I .. 4
\';iricilla 162 .. 15?
f.A.r 21 3 26 5
W ^"iigli II I 9 5
I " • lM-s,.n,:,l nu nin.aitis 13 9 7 S
I'l'tals -'.776 353 2,772 370
Society Meetings for the Coming 'Week:
Moxnxx. rehrnarx J4th. — Medical Societv of the Countv
of ^•ork.
Tncsii.w, l ebrnary Jjth. — New York Medical Union: New
\'ork Dermatological Society; Metropolitan Medical
Socieiy of the City of New York; Buti'alo .Academy
of .Medicine ( Section in Obstetrics and Gvn;eeologv).
Wki.xksii.w, yT/>r;/,;;_v New York .\eademy of Med-
icine (Section 111 l.ar\ ugologx- and Rhinology); New
\ ork Surgical Society.
ITiL'R.su.w, Februury _'7//(.- Xew \,,yk .AcadLii;\ ,-f .Med-
icine (Section 111 Obstetrics and (.iyn;ecolo,;y 1 : Xew
York Celtic Medical Society; Brooklyn Pathological
Society: Hospital Gr.aduates' Club. New York; Brook-
l_\n Soeieiy for Neurology.
I'Kin.w, I-'ehruary jSt/r — New York Clinical Society; New
^'ork Society of German Physicians: Academ\- of
Pathological Sciences.
The Medical Jurisprudence Society of Philadelphia. —
The seventy-fourth stated meeting of ihib society, which.
was held on Monday evening. F"ehruary 17th. was devoted
to a symposium on the Public's Gain by State Control of
Medical Practice. Pajjcrs were read as follows : What
People Have Gained Through the Present State Medical
h:xainination Law, hy Dr John P.. Roberts; What the Pub-
lic G.ims by ,1 Single I''x.iinining Hoard System for Law-
yers, l)y rii(jnias W. Ikirlow , l-'s(|, ; Newspaper Publicity
Xeces-ar> to Warn the People as to Insntricient Protection
by the Present MuLiple Medical l{x;iniining Boards Plan,
by Mr. Fdward Sterling: Some I-'acts Relating to Medical
l-".duc:ition in the L'nited States Disco\cred and Demon-
strated hy the Operation of the Act of .Assembly Regu-
lating Practice in Pennsyh ania, by Dr. Henry Beates ;
Consolidation of Multiple Medical Examining Boards into
a Union or One lioard Pl.in Recpiired to Give Full Protec-
iioii. I)\' .Mr, .Vdolpli ImcIioI/. .a general discussion fol-
lowed.
The U. S. Pharmacopoeia as a Textbook in Medical
Schools. — Professor Joseph P. Remington, chairman oi
the Committee of Revision of the L". S, Pharmacopitia.
recently called an informal conference of the medical teach-
ers of Philadelphia, at which the following resolution was
passed :
Resolved, That it is of the utmost imiiortance for accu-
racy in prescribing, and in the treatment of disease, that
students of medicine be instructed fully as to those por-
tions of the U. S. Pharniacopa^ia which are of value to the
]/ractitioner, and that mendiers of the medical profession
lie urged to prescribe the preparations of that publication,
.ind further, that this resolution be forwarded to the medi-
cal and pharmaceutical journals, and to the teachers of
medicine and therapeutics in the L^nited State*.
.Among those who attended the conference were Dr.
lames tvson. Dr. John H. Musser. Dr. fohn Marshall.
"Dr, Horatio C. Wood, Jr., Dr. J. W, Holland. Dr. Hobart
Amory Hare. Dr. James C. Wilson. Dr. E. Q. Thornton.
I")r. John V. Shoemaker, Dr. Seneca Egbert. Or. M. C.
Thrush, and Dr. T. Newton Snively.
February 1908.]
XEIVS ITEMS.
367
The Health of Philadelphia.— During the week end-
ing Janiiar>' 25, 1908, the following cases of transmissible
■diseases were reported to the Biireau of Health : Malarial
fever, 2 cases, o deaths; typhoid fever, 87 cases. 21 deaths;
scarlet fever, 55 cases, 4 deaths ; chickenpox, 57 cases, o
deaths ; diplitlieria, 54 cases, 7 deaths ; cerebrospinal menin-
gitis, 5 cases, 5 deaths: measles, 122 crises, 4 deaths; whoop-
ing cough, 12 cases, o deaths; pulmonary tuberculosis, 141
cases, 62 deaths; pneumonia. 90 cases, gS deaths: erysipelas,
16 cases, 3 deaths; Geiman measles, i case, o deaths;
cancer, 28 cases. 25 deaths: mumps, 10 cases, 0 deaths;
tetanus, i case, i death : hydrophobia, i case, i death :
anthrax, i case, i death. The following deaths were re-
ported from other transmissible diseases : Tuberculosis,
other than tuberculosis of the lungs, 5 cases; puerperal
fever, 2 case^ : diarrhcea and enteritis, under two years of
age, 14 cases ; septicaemia, I case. The total deaths num-
bered 573 in an estim;ited population of 1,532,738. corre-
sponding to an annual death rate of 19.40 in 1,000 of popu-
lation.
A New International Journal of Epilepsy, to be called
Epilepsia, is about to be launched as an international quar-
terly which will be devoted to the study and treatment of
epilepsy. It is announced that this journal will be under
the patronage of Dr, W. Bechterew, Dr. O. Binswanger,
Dr. J. Hughlings Jackson, Dr. L. Luciani, Dr. H. Ober-
steiner, and Dr. F. Raymond. The editorial staff includes
Dr. H. Claude, of Paris ; Dr. A. Turner, of London ; Dr.
L. Bruns. of Hanover ; Dr. W. P. Spratling. of Sonyea ;
Dr. J. Donath, of Budapest, who will be the active editor
for the first year; and Dr. L. J. J. Muskens, of Amster-
darn, who is the secretary. Among the collaborators and
assistants are the following : Apelt. Grainger Stewart,
Lejonne, Maes, Perusini, Southard, Agostini, Aschaffcn-
burg. Alt. Alzheimer, Bastcin, Batten, Brandos, Bruce,
Ferrier. Cowers, Haskovec, Van Hamel, Heboid, Heil-
bronner, Henschen, Horsley, Jelgersma, Jelliffe, Kocher,
Kowalewsky, Krause, Kure, Lewandowsky, Maxwell,
Meyra, Nonne. Oppenheim, Probst, Cajal, Redlich. Stertz.
Jurkel, Voisin, Weber, Salomonson. Wiersma. Winkler, and
Ziehen. The official languages will be English, German,
and French. Further information concerning this new pub-
lication may be obtained from the collaborators or from
the Journal for Nervous and Mental Disease, New York.
Coroners' Cases in Brooklyn During the Year 1907. —
According to the report of the Board of Coroners, the total
number of cases that came within the jurisdiction of the
coroners during the year 1907 was 3,474. Of these 1,810 were
sudden death.s, or cases where medical attendance was lack-
ing, 1,288 were deaths from some form of violence, and 376
w ere still births. The deaths by violence are classified as
follows : Suicides : By illuminating gas. 75 : pistol shot
wound, 64; knife wounds, 14; poison, 34; strangulation, 36;
jump from height, 6; drowning, 3; jump in front of "L"
train, 2; total, 234. Homicides: By pistol shot wounds, 45:
knife wounds, 10; blow from club. fist, etc., iS; poison, i;
illuminating gas, 3; total, 77. Railroads: By trolley, 102:
elevated or motor trains, 26; steam railroads, 19: shock,
third rail. 2: total, 149. By wagons, trucks, etc., 70; auto-
mobiles. 8: falls from windows, stoops, etc., 203; by being
crushed. 60 : kick of horse. 2 ; suffocation, gas, accidental, 83 ;
suffocation, smoke. 7: suffocation, excavation, 5; suffoca-
tion, children in bed, 6 ; accidental shooting. 3 ; accidental
poison, 24; accidental drowning. 114; electricity (live wire).
6; electricity (lightning), i; tetanus, 22: alcoholism, 10:
heat prostration. 16; burns, scalds, 140: miscellanenns, 19.
as follows: Exposure, 7: rallies. 7; \accine poison, 2; ex-
plosion. I, and choked while eating, i.
Vital Statistics of New York State. — During the year
1907 there were 195,735 births reported. Of these 100,495
were males, 95,187 were females, and of 53 the sex was not
stated. There were 193,059 whites, 2,625 negroes, 26
Indians, and 25 Chinese. The a\-crage 1iirth rate for the
State was 20.8, and for New York City 29.3. The total
number of deaths reported was 147,442,' corresponding to
a death rate of- 17.5 in 1,000 of population. There were
76,904 males and 67,476 females. Of the total number
of deaths. 14.406 were from tuberculosis of the lungs, the
greatest number from any one disease. 12.072 were from
heart disease, and 10,990 from pneumonia. There were
1.668 deaths from typhoid fever, an increase of 100 over
the previous year; 995 deaths from measles, a decrease of
374 from the previous \ear : 1.029 deaths from scarlet
fever, an increase of 339 over the previous year; 2,600
deaths from diphtheria, an increase of about 100 over the
previous year. There were 2,372 deaths from influenza,
483 from erysipelas, 225 from cerebrospinal meningitis,
6,400 from cancer, 14,468 from diseases of the ner\ous
system, and 16,893 from diseases of the circulatory sys-
tem. 1 he deaths under one year of age were 27,957 ; from
one to five years of age, 12,142; from five to ten years of
age, 3,249; fiom ten to twenty years of age. 5,206: from
twenty to forty years of age, 24,830; from forty to sixty
years of age, 29,539; from sixty to eighty years of age,
34,516; and over eighty years of age, 9,838.
The Health of the Canal Zone. — During the month
of December, 1907, the total number of deaths in the Canal
Zone was 263, in a population of 110,713, corresponding to
an annual death rate of 28.50 in 1,000 of population. There
were 6 deaths from typhoid fever, i from relapsing fever.
33 from clinical malaria, 2 from malarial cachexia, 3 from
hjemogiobinuric fever, 3 from amoebic dysentery, i from
clinical dysentery. 5 from beriberi, 26 from pulmonary
tuberculosis. 2 from other forms of tuberculosis, 2 from
syphilis, 2 from cancer. 3 from tetanus, 4 from broncho-
pneumonia, 28 from pneumonia, 20 from diarrhoea and
enteritis under two years of age. There were 14 deaths
among the white employees, 5 of which were natives of
the United States. There were two deaths among the white
American women ; one from hyperemesis gravidarum, and
one from capillary bronchitis. It must, of course, be
understood that the annual death rate of 28.50 above
recorded includes the entire population of the Canal Zone
as well as of Panama and (3olon. The death rate in
American territory was 21.67 in 1,000 of population : that
in Panama and Colon, 36 in 1,000 of population.
Meetings of Sections of the New York Academy of
Medicine. — At a meeting of the Section in Ophthal-
mology, held on Monday evening, February 17th. the fol-
lowing papers were read : When and How Shall We Use
Cycloplegics in Refractive Work? by Dr. Alexander Duane ,
Report of a Case of Traumatic Rupture of Descemet's
Membrane, by Dr, E. B. Coburn ; Unguentum Hydrargyri
Oxidi Flavae, Improved, by Dr, T, R. Chambers.
The Section in Medicine held a meeting on February
i8th. Dr. H. W. Berg read a paper on General Phlebo-
sclerosis and Dr. D. M. Kaplan read a paper entitled The
Life History of the Malarial Parasite. Dr. G. R. Satterlee
reported a case of Pernicious Malaria with Autopsy ; Dr.
T. C. Janeway reported a case of Rapidly Fatal Diabetes ;
Dr. L. A. Conner reported a case of Rapidly Fatal Diabetes
with Unusual Cerebral Symptoms ; and Dr. C. N. B. Camac
reported a case of Diabetic Coma under Alkaline Treat-
ment.
The Section in Orthopaedic Surgery met on Friday even-
ing, February 21st. The general topic for discussion was
Fractures Complicating Joints, the following papers being
read : Epiphyseal Fracture of the Hip, by Dr. Royal Whit-
man; Surgery of Fracture Dislocations of the Shoulder,
by Dr. Carleton P. Flint; and Fractures Complicating the
Elbow Joint, by Dr. C. S. Cole. Dr. William C. Lusk pre-
sented a case of Supracondyloid Fracture of the Humerus ;
Dr. Reginald H. Sayre presented a case of Fracture of
the Anatomical Neck of the Humerus ; Dr. Fred H. Albee
presented two cases of Epiphyseal Fracture of the Upper
End of the Humerus, showing the method of reduction ;
and Dr. John Carling presented two cases of Fracture of
the Carpus.
The Section in Laryngology and Rhinology will meet
on Wednesday, February 26th, at 8:15 p. m. The follow-
ing program has been arranged : Dr. Robert C. Myles will
present a case of Osteochondroma of the Saeptum, with
Extensive Absorption of the Cribriform Plate, and Dr. J.
W. Gleitsmann will present a case of Excision of Tuber-
culous Infiltration of the Epiglottis. There will be a sym-
posium- on Atrophic Rhinitis, including Ozaena. Papers on
the subject will be read as follows: A Consideration of
the Herd Theory as an .-Etiological Factor of Ozaena, by
Dr. Clement F. Theisen, of Albany, N. Y. ; The Pathology
of Atrophic Rhinitis, with Ozaena, by Dr. D. Braden Kyle,
of Philadelphia; and The Treatment of Atrophic Rhinitis,
including Ozasna, by Dr. George L. Richards, of Fall River,
Mass., and Dr. Robert C. Myles. The subject will be
discussed by Dr. Francke H. Bosworth, Dr. Clarence C.
Rice, Dr. D. Bryson Delevan, Dr. James E. Newcomb. and
Dr. L. Maidment Hurd.
368
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
February 13, 1908.
1. The Control of the Lymphatics in Injections of the
Extremities, By Herbert L. Burrell.
2. On the Value of Malachite Green Media in Dis-
tinguishing Typhoid and Colon Bacilli, with the
Description of a New Method for Isolating Typhoid
Bacilli from Fseces,
By F. W. Peabody and J. H. Pratt.
3. Observations on Six Cases of Acute Perforating Ulcer
of the Duodenum, By E. G. Codman.
4. The "Optometrist" and His "Colleges,"
By John C. Bossidy.
2. Malachite Green Media in Distinguishing
Typhoid and Colon Bacilli. — Peabody and Pratt
remark tliat tlie cultural methods for the distinction
of the typhoid bacillus from the other bacteria ac-
companying it in f.neces. eartli, and water, may be
divided into two general classes. In those of the
first attempts have been made to produce a charac-
teristic typhoid growth — whether of form or of
color. In the second, the object is to favor the
growth of the typhoid bacillus, and to inhibit the
grow^th of all other organisms, and more especially
of the colon bacillus. Tlie ideal medium for isolat-
ing the typhoid bacillus from the stools would be
one upon which no other microorganism could de-
velop. In 1903, before the AerztHcher X'erein, of
(ireifswald, Loeffler first demonstrated the use of
malachite green culture media. He showed that the
addition of a definite amount of this dye to ordinary
agar favored the growth of typhoid bacilli, but in-
hibited the growth of colon and many other intes-
tinal bacteria. Our authors have made experiments
with malachite green media. The general results of
these experiments has led them to hold the malachite
green media in high esteem. They are not ideal, for
their actinn is not absolutely specific; while they in-
hibit tlic growtli of the colon bacillus, the microor-
ganism most likely to be confounded with the ty-
phoid bacillus, there are other bacteria which flour-
ish in them. Furthermore, as Jorns and Klinger
clearly showed, malachite green checks somewhat
the development of the typhoid bacillus. It is, never-
theless, true that the discovery of the action of mala-
chite green is a step forward in the search for a
perfect differential culture medium. They have
found it comparatively easy to make a medium on
which the typhoid bacillus will grow and on which
the colon bacillus will not grow. While it is true
that various preparations of malachite green dif¥er
in their action, it is a simple process to determine
the strength of solution to be used, and the proper
reaction of the medium for the given preparation.
The malachite green bouillon method is not only
more economical in time and money than that of
Lentz and Tietz, but in the author's laboratory has
yielded better results.
3. Observations on Six Cases of Acute Per-
forating Ulcer of the Duodenum. — Codman gives
the following ])oints which would make him suspi-
cious of duodenal ulcer instead of appendicitis: i.
Onset of pain more sudden and violent and more
initial shock. 2. A contracted concave boardlike
abdomen. This seems to be very characteristic.
though some cases of appendicitis have it, too. 3.
Tympany over the normal area of liver dullness.
This is by no means the rule, but when present
is almost diagnostic. Gas may not always be noticed
when the peritoneum is opened. 4. The vague symp-
toms of duodenal ulcer, elicited by careful Cjuestion-
ing. 5. Most of the patients are males between
twenty and forty years. 6. Location of tenderness
and pain is very deceptive. Of interest are also the
following remarks of the author: If perforated
ulcer is suspected, it is well to be sure that small,
curved, round needles are on hand, for one is much
embarrassed with straight needles in suturing the
perforation. Make high appendix incision and ex-
amine condition of appendix first. Take it out if
necessary, to be sure of the mucosa. If the appendix
is not perforated or gangrenous, carry incision up
rectus high enough to see whether there is fibrin
about the pylorus. If there is, carry incision up to
actual margin of ribs. One needs plenty of room
to do suture quickly. One obtains the best view of
the duodenum by pulling the gallbladder out with
one hand and hepatic flexure down with the other.
Most ulcers are easy of access. Suture the ulcer be-
fore washing out the abdomen. Unless the ulcer is
large and indurated or extends beyond the pylorus
to the stomach, or there is stenosis of the pylorus, or
the history shows severe pain and distress in the
past, gastroenterostomy should not be performed.
iMnally, the author asks the following questions,
which he would like to have answered : Why is
duodenal ulcer a male disease? What evidence is
there to show that these small ulcers are intractable
in heailng? Why may the persistent symptoms not
be due to the cause (duodenal stasis) or the result
(periduodenal adhesions) ? Can perforation into
the pancreas cause a leakage of pancreatic juice into
the intestine at the wrong time ? Why may not the
alkaline duodenal secretions be responsible for some
of the pain attributed to acid gastric secretions ?
THE JOURNAL OF THE AMERICAN M EDICAL ASSOCIATION
February ij, igo8.
1. The Problems of Sanitation, By Edwin O. Jordan.
2. Pregnancy as an .-Etiological Factor in Dental Disease,
By James E. Power.
3. Physical Diagnosis : Urgent Need of Revision,
By J. H. Tyndale.
4. Simultaneous Sphygmomanometric Pressures as Modi-
fied by Postures, By A. H. Sanforu.
5. A Case of Hair Ball in the Stomach, By J. B. Harvie.
6. Polioencephalitis Superior ; Its Causation, Clinical
Course, and 'i'ermination, with a Report of Six Cases,
By W.\RD A. Holden and Joseph Collins.
7. A Report of One Hundred Consecutive Perineal Pro-
statectomies Without a Death. With Remarks on
the General Decrease in the Alortality of Prostatic
Operations in Recent Years, By Hugh H. Young.
8. Experiments on Subconscious Ideas,
By E. W. Scripture.
9. Enuresis Following Prostatectomy. Report and Anal-
ysis of Eleven Cases, with Recommendations as to
Treatment, By Granville MacGowan.
2. Pregnancy as an .Etiological Factor in
Dental Disease. — Power reminds us of the im-
portance to keep the oral cavity in gocHl condition
during pregnancy. He remarks that since the
physician is responsible directly, and the dentist in-
directly, for the salvation of the teeth during the
time the pregnant woman is in their charge, their
1-ebruaiy 2j, 1908. J
PITH OF CURRENT LITERATURE.
369
first duty is to impress on the mind of the patient
how dependent is the entire system on.tlie cleanH-
ness of the oral cavity. The dentist should make a
thorough examination, and should restore all the
diseased teeth to a normal condition, so far as this
is possible. The condition of the patient will regu-
late to a large degree the kind of material to be
used in restoring the teeth. It is the author's cus-
tom to consider very carefully the physical state of
the patient, whether she is irritable or not, how
many months she has been pregnant, etc. He gives
appointments to such patients about noon, as he
found theii- condition is best at that time. The
reservation of time is always short, never longer
than one hour, and many times less, and he relies
on his personal judgment, rather than that of the
patient, as to her capacity for enduring the strain
which is, to some degree at least, associated with
dental operations, especially at this time. He ex-
tracts all broken down roots, after first subjecting
parts to a local anaesthetic. The next important
• step is to clean the mouth thoroughly, and then ar-
range for the patient to make a monthly visit to the
office, or for the dentist to make one to her home.
This accomplishes two important objects: First, it
causes the patient to take good care of the mouth,
because she knows it is going to be inspected, and,
second, one can observe any unlooked for condi-
tions, and correct them immediately, as well as as-
sist the patient in keeping the mouth clean. In his
observation, the degree of morning sickness and
the degree of dental caries are very closely related.
During the day he advises the rinsing of the mouth
with a solution of sodium bicarbonate or milk of
magnesia every four hours, each mouthful of the
solution to be held one full minute by the watch.
In some severe cases he prescribes the use of tablets
whose formula is sodium bicarbonate, with direc-
tions to allow it to dissolve after having placed it
between the cheeks and the first and second molar
teeth, in the region of Steno's duct. There is thus
a remote possibility of any trouble of a dental na-
ture occurring during the most critical period of
pregnancy. The treatment of toothache or of an
abscessed tooth is one of the conditions which the
dentist must consider. In case of toothache he ad-
vocates the extraction of diseased teeth, treatment
of which might be attended with pain sufficient to
affect the life of the embryo and possibly also that
of the mother in this condition. Under anaesthesia,
if possible local, and with modern technique, it can
be safely done. It is advisable to avoid it at times
corresponding to the menstrual period on account
of the greater risk then of abortion. Great care
should be exercised in diagnosticating the source of
dental pain, as often disease in other organs mav
thus m.anifest itself and treatment or extraction of
an apparently aching tooth may complicate rather
than simplify the case.
4. Simultaneous Sphygmomanometric Pres-
sures as Modified by Postures. — Sanford con-
cludes from his experiments that by carefully noting
the changes in the pulse as compression is being
slowly applied, not only the point of obliteration is
noticeable, measuring the systolic pressure in the
vessel, but also the point of diminution in the am-
plitude of the pulse, or the diastolic pressure is to
be observed, and, furthermore, in many instances, a
marked oscillation occurs in the mercury column at
and above the point of diastolic pressure. Posture
affects both systolic and diastolic pressure. There
is an increase of pressure in the arm in changing
from the erect to the sitting, supine, and the head
down positions, and at the same time a correspond-
ing marked decrease in the pressure in the lower
extremity. These changes of blood pressure are at-
tended with a marked decrease in pulse rate. The
pulse pressure, or difference between diastolic and
systolic pressures, increases in the arm and decreases
in the thigh as the body changes from the erect to
the sitting, supine, and Trendelenburg postures. In
the syhygmomanometer we have a convenient
method of applying a known amount of compression
to a limb, and thus may make of it a therapeutic in-
strument in methods of passive hyperjemia treat-
ment.
6. Polioencephalitis Superior.-^Holden and
Collins state that in regard to the aetiological and
pathological contributions to our knowledge of the
disease, the most important are, first, that the same
causes that are responsible for inflammation of the
gray matter in other parts of the central nervous
system are responsible for this disease. Acute in-
fections, such as influenza, pneumonia, and diph-
theria, have all been accused of being the cause of
the disease and a very strong case made out against
them. It is not only infections, however, in whose
wake it follows, for cases have been reported which
seemed to show that lead, oxide of carbon, sul-
phuric acid, etc., were responsible factors. Study
of the central nervous system of many of these
cases in which a post mortem examination was held
has shown that in a number of them the structural
changes are slight and entirely out of proportion to
the severity of the symptoms that existed. Indeed,
in some instances no lesion adequate to account for
the symptoms or the fatal termination of the disease
was found. These cases are looked on as analogues
of aesthenic bulbar paralysis (bulbar paralysis with-
out anatomic foundation), in which it is supposed
that several levels of the different segments of the
central nervous system are so overwhelmed b\'
some toxic agent that they become functionless to
a certain degree, and in some instances wholly so.
It is supposed that the injurious agency, whatever
it may be, is not of sufficient severity to cause dis-
cernible morbid changes in the cells.
9. Enuresis Following Prostatectomy. — Mac-
Gowan, from his experience, is of the opinion that
after removal of extremely large growths bladder
control sometimes comes slowdy, and a condition of
enuresis, either partial or total, will exist for from
six months to a year, and, perhaps, always. This
condition, though lamentable, improves with time,
and is apt to be best at night. There is no surgical
remedy, if the operation has been complete. But
he recommends, w-herever the leakage has lasted for
six months, that careful rectal, urethroscopic, and
cystoscopic examinations be made and if any re-
maining intraurethral or intravesical nodules be
found that they be removed. There are some dense
prostates, not malignant, which cannot be removed.
Such cases should not be disturbed until the com-
fortable use of the catheter becomes impossible.
370
FITH OF CURRENT LITERATURE.
[New York
Medical Journal..
Through these a permanent groove or furrow must
be made, preferably by the cautery apparatus of
Chetwood. They will always leak. Where enuresis
follows the imperfect removal of a small, hard
prostate, the only remedy is the partial section of the
fibrous ring and the prostate on its floor, and re-
moval of the prostate, together with the nonresilient
scar tissue. In such cases patients will then slowly
regain control and be well people. If following a
prostatectomy, usually perineal, and where the
prostate has iDeen only of moderate size, there is
enuresis, and a careful rectal examination fails to
show the presence of an intracapsular growth of
palpable size, overlooked at the time of the opera-
tion, a careful examination of the posterior urethra
and bladder, with suitable optical instruments, has
sometimes revealed the presence of small tumors of
glandular tissue hanging or pressing into the vesical
outlet, preventing its closure, and the removal of
such tumors by' a second operation has resulted in a
cure of the condition.
MEDICAL RECORD.
February is, 1908.
T, What Shall We Do with Far Advanced Cancer of the
Large Bowel? By R. C. Coffey.
2. Sanitation of the Canal Zone,
By Colonel William C. Gokgas.
3. A Method of Milk Production, By Charles E. North.
4. The Importance of Correct Diagnosis in Diseases of
the Eye Is the Chief Reason Why Opticians Should
Not Prescribe Glasses, By A. Edward Davis.
5. Phthisis in Outdoor and Indoor Life and in Isolated
and Cosmopolitan Races,
By NoRBURNE B. Jenkins.
I. For Advanced- Cancer of the Large BoweL
— Cofifey quotes eleven cases of far advanced cancer
of the large bowel operated on by Willy Meyer,
sixteen by Jonas, and eleven by himself. He con-
cludes that far advanced obstructive cancer, not
pathologically extensive, should always be excised,
i-'or extensive growths producing obstruction, ex-
cision may be used in certain cases with hope of re-
lief, if not cure, but a larger percentage are best
treated by some form of enterostomy or colocolosto-
my or colostomy. Extensive growths with marked
cachexia and producing no obstruction should be
treated by meeting the medications with curetting,
late colostomy, etc. In answer to those who say,
"Let these far advanced cases die and get out of
their misery," the author understands our duty to
be : ( I ) Use desperate and radical means to re-
move cancers in all cases where there is a reason-
able hope of cure, either temporary or permanent.
(2) In irremovable cases, perform such operations
as will prolong life or add to the comfort of the
patient.
3. A Method of Milk Production. — North
says that the use of sterile covered pails and sterile
milk cans by the ordinary farmer will immensely
reduce the bacteria in his milk, even though no other
sanitary precautions are taken. The dairy house,
where washing and sterilizing of utensils and cool-
ing and bottling of milk are done, may be at a dis-
tance of several miles from the cow stable without
materially increasing the bacterial count, provided
the milk is delivered at the dairy house within one
hour after milking. Five cents per quart to the
farmer will pay him for his trouble of milking in a
sanitary way and for making two deliveries a day.
In many instances it would compensate him for
keeping his herd free from tuberculosis. Increase
the functions of the creamery, so that it becomes a
\\ ashing and sterilizing plant for all the milking pails
and milk cans of all the farmers contributing milk to
it. Substitute cover milk cans or "pailcans" for the
wide open milking pails now in use. Let the cream-
ery do all the cooling and bottling of milk. Take
the cooling out of the hands of the farmer. Let the
milk dealer pay the farmer five cents per quart for
such milk, and the public pay the milk dealer ten
cents per quart for milk delivered in the city. High
prices for certified milk is due to the expense at the
dairy house. Concentration of operations at the
creamery for a large number of farmers would be
business economy, and would likewise eliminate
many sources of contamination.
5. Phthisis in Outdoor and Indoor Life and in-
Isolated and Cosmopolitan Races. — Jenkins re-
marks that indoor races, in centuries of environ-
ment favorable to tuberculosis, in order to survive
have probably acquired especial aggressiveness
against or resistance to the disease. This immunit\
has been acquired, since individuals and finally
races, favored through variation and by heredity
with resistance would escape or overcome the dis-
ease and in turn leave more strongly immunized
offspring as racial survivors. On the other hand,
individuals without resistance to the disease would
tend to perish without offspring, thus eliminating
the susceptible. In centuries of indoor contact with
tuberculosis, phagoc\tes, enzymes, and opsonins
may have acquired power or become trained to re-
sist and overcome the disease. Again, the body
may have selected superior tissue or certain as yet
undiscovered bactericides with which to resist or
arrest the disease. Such means of defense would be
transmitted to the body's offspring, and thus not
only the body itself, but also its successors would
survive, even in the unfavorable environment of in-
door life. Outdoor races in their natural environ-
ment probably escape tuberculosis without the espe-
cial resistance which indoor peoples require in order
to survive contact with tuberculosis in indoor life.
The agents which destroy, expel, transfer, or absorb
the Bacillus tuberculosis may be partially or entire-
ly absent, may be latent or rudimentary, may be in
inherent or acquired weakness from centuries of
nonuse or may be unable to combat unaccustomed
infection and are inactive when tuberculous invasion
occurs. Outdoor races, when in unchanged envi-
ronment and at the same time exposed to the Bacil-
lus tuberculosis, may resist the disease more suc-
cessfully than when exposed to both the disease and
the more or less unaccustomed environment of civ-
ilization. Biologically speaking, in tuberculosis of
immune races, pulmonary structure and function, as
well as the agents which dispose of the Bacillus
tuberculosis and complicating or parasitic bacteria,
may be in unfavorable variation, in arrest of evolu-
tion, or in reversion ; and while such changes may
allow invasion, they may result from disuse, tuber-
culosis, or other di.sease. In suitable environment
variation would probably tend to evolve to the nor-
mal type and arrested evolution or even reversion
might return to the original type.
l-'ebruary 2z, 1908.]
PITH OF CURRENT LITERATURE.
BRITISH MEDICAL JOURNAL.
February i, igoS.
1. Some of the Medical Aspects of Life Insurance,
By Sir j. Bark.
2. A Second Report on Clinical Experiences with Spinal
Analgesia : With a Second Series of One Hundred
Cases, By A. E. Barker.
3. Inherited Syphilis, By R. C. Lucas.
4. The Medical Inspector of Schools as a Psychiatrist,
By T. S. Clouston.
5. The Critical Solutio'n Point of Urine : A New Physico-
chemical Method of Examination,
By W. R. G. Atkins.
I. Life Insurance. — Barr states that every
insurance company should have at least three classes
of risks — good, average, and moderate or impaired
lives. I. The candidate for insurance in the first
class should live in healthy surroundings ; he should
be physicallv fit for his work, and his occupation
should not be inimical to health. From the list
should be excluded stock brokers and other gam-
blers, and physicians. He should be almost, if not
entirely, a total abstainer from alcohol, and not a
glutton ; overeating kills almiost as many as over-
drinking. He should not be over six feet in height
nor under five feet four inches. He should be in
good health and free from all disease and processes
of disease. Beware of the man who says he has
never been ill a day in his life. Such diseases as
measles, scarlet fever, etc., can be disregarded if
they have left no sequelae. So also with coryza
and' common colds. But repeated attacks of influ-
enza, or a history of such diseases as quinsy, pneu-
monia, pleurisy, bronchitis, rheumatism, gout, all
forms of tuberculous diseases, diseases of the kid-
ney, liver, and spleen, bad teeth and intestinal dis-
orders, developmental defects, and hernia should at
once exclude, applicants* from the first class. The
applicant should ha\'e been vaccinated against sniall-
pox at least twice. 2. The second class would con-
tain the vast majority of the persons who insure at
present. All persons should be excluded who have
a strong family history of insanity and other dis-
eases of the nervous system, consumption, cancer,
rheumatism, gout, and syphilis. Every person with
syphilis should pay a high premium. 3. The third
class would include the derelicts, and yet with care
it should be a large and profitable one. Carefully
selected cases of heart disease are excellent risks,
but great care must be taken to draw a distinction
between lesions follovving rheumatic fever and those
of a degenerative nature. Certain diseases of the
kidneys also run a very chronic course. Frequent
attacks of quinsy or rheumatism should be rated
high, even though no heart disease has supervened,
but glycosuria in a person over forty years of age
need not be a complete bar to insurance. IMyxcede-
ma being very amenable to treatment, mav be ac-
cepted at a moderate rate, but exophthalmic goitre
should pay a high premium. The following condi-
tions should exclude from insurance except at pro-
hibitive rates : Any acute illness with a high mor-
tality until the danger is passed, all forms of active
tuberculous mischief, malignant disease, diabetes in
the young, Addison's disease, leucocythasmia,
splenic anaemia, and lymphadenoma, insanity and all
advanced diseases of the nervous system, advanced
degenerative lesions of the heart and bloodvessels,
all diseases of the lungs where the vital capacity
is reduced below two thirds of the normal, chronic
alcoholism, etc.
2. Spinal Analgesia. — Barker, working with
an injection compound much heavier than the cere-
brospinal fluid, has obtained the following results :
I. The highest analgesias were obtained with the pa-
tient lying quietly on the side before and after in-
jection. 2. The lowest analgesias were found after
puncture in the sitting position, with subsequent
change to the lying. 3. It was not found necessary
to elevate into the Trendelenburg position with the
head low at all, and it is unnecessary, if not posi-
tively dangerous. Further, this position becomes
unnecessary for the convenience of operating, as
the abdominal walls are so relaxed that manipulation
within the peritonaeum becomes easy. 4. The best
results as to high analgesias and absence of after
effects were found where the level of the body had
not been altered after injection, and consequently
the cerebrospinal fluid has been kept in a state of
rest. The volume of the injected compound was about
one c.c. The anesthetic used was stovaine in a five
per cent, solution of glocus.e in water. The specific
gravity of the solution is 1.0230, as compared with
1.0070 of the cerebrospinal fluid. No adrenal de-
rivative of any kind was used, and it is suggested
that some of the ill effects reported may have been
due to the adrenal principle employed and not to
the anaesthetic drug at all.
LANCET.
February i, igoB.
1. Inherited Syphilis, By R. C. Lucas.
2. The Unequal Distribution of Filariasis in the Tropics,
By G. C. Low.
3. A Case of Severe Ecthyma from which the Diphtheria
Bacillus Has Been Isolated,
By A. Eddowes and J. G. Hare.
4. The Value of Cvtodiagnosis in Practical Medicine,
By J. E. H. Sawyer.
5. Acid Intoxication Following Ethyl Chloride Anses-
thesia, By H. H. B. Cunningham.
6. A Note on the Development of Secondary Nodules in
Suture Scars after Operations for the Removal of
Cancer, By C. W. M. Moullin.
7. Two Cases of Ureteropyeloplasty, By A. H. Burgess.
8. Severe Spasmodic Contraction of a Finger Cured by
Stretching the Median Nerve, By J. Adams.
I. Inherited Syphilis. — Lucas objects to the
terms "congenital" and "hereditary"' syphilis, and
prefers "inherited," as implying only something de-
riA-ed from the parents, which is detachable and
more correctly expresses the passing on of the spiro-
chaeta to the offspring. The cause of syphilis,
whether inherited or acquired, is the presence in the
blood of the spirochaeta pallida, which can be dem-
onstrated in the various secondary lesions, in the
blood, and in the internal organs. It is a protozoon
of spiral form from four to twenty micromillimetres
long and one fourth micromillimetre in diameter,
with a flagellum at either extremity. It stains a pale
pink with Giemsa's fluid, while the coarser, highly
refracting spirochaeta refringens. with which it is
often associated, stains dark purple. Inheritance of
the disease from the father alone is entirely out of
the question, and it follows that the infection of a
mother by her syphilitic foetus can never occur. In-
heritance is invariably through the syphilized mother.
This is supported by Colles's law that a syphilitic
3/2
PITH OF CURRENT LITERATURE.
INku- York
Mkiiical Journal.
infant cannot infect its mother's breast. When viru-
lent the spirochseta penetrate the chorion or placenta
and occasion miscarriages, macerated foetuses, or
premature births : but when the virus is attenuated
by time or treatment the placenta forms a complete
protection to the developing fi^etus, and it is the sep-
aration of the placenta at birth which allows the in-
fection to take place througli the umbilical vein.
Hence the regularity of the secondary exanthemat-
ous stage from a fortnight to three months after
birth. In these cases the separation of the placenfa
is the first stage and corresponds to the chancre of
acquired syphilis. Syphilis in a man is generally ad-
mitted to be capable of transmission to a succeeding
generation for a much shorter time than syphilis in
a woman, which supports the view that for trans-
mission it is necessary that the woman be first in-
fected. It is probable that the disease can be trans-
mitted by milk, but not necessarily so. It is obvi-
ous, as the greater cannot be included in the less,
that a spirochseta cannot be carried in a spermato-
zoon ; but this does not exclude the possibility of the
spirochsetae being conveyed by the fluid parts of the
semen. Indeed, it seems almost necessary for the
latter to be so to account for the cases of inherited
syphilis conveyed after the healing of the chancre.
A question open to discussion is whether syphilis
inherited is capable of transmission to the third gen-
eration. The author saw one instance in which the
child of parents, both of whom suffered from inher-
ited syphilis, was free from the disease. Syphilitic
parentage is probably responsible for a greater in-
fant mortalitv than any other single disease or con-
dition. This mortality is greatest in those families
wliere both parents have suffered from chancre
syphilis and obvious secondaries. The trite defini-
tion that syphilis is "a fever diluted by time" is ap-
plicable to the inherited as well as to the acquired
disease. The secondary stage of inherited syphilis
is characterized by eruptions varying from slight
brown luacular syphilides to pompholyx, by snuffles,
stomatitis, condyloma, wrinkled skin, and wasting,
and enlargement of the speen and liver. Then fol-
low changes in the bones — epiphysitis, Parrot's
nodes, craniotabes; and bent bones. It cannot be
too strongly insisted on that the moist eruptions and
ulcerations about the mouth and anus, as well as the
vesicular skin affections, are charged with the spiro-
chaetae and are highly contagious. From the second
to the sixth year there is commonly a rest in the
symptoms, which is quite characteristic. But now
the characteristic physiognomy has been gradually
formed — the flattened nose, the square forehead, the
stunted figure, and the pallid face. During the sec-
ond dentition are to be noted the three signs pointed
out by Hutchin.son — the notched incisor teeth, inter-
stitial corneitis, and syphilitic deafness. A charac-
teristic change occurs in the first molars, as first de-
scribed by Moon. They are reduced in size and
dome shaped through the dwarfing of the central
tubercle of each cu.sp. The eyes may be early affect-
ed by a choroidoretinitis, and the ears are also
often affected. None of the various viscera .seem to
be exempt from the disease. Enlarged .spleen and
liver associated with rickets are almost invariably
of syphilitic origin. When the inherited disease at-
tacks both testicles or both ovaries at an early age and
brings about their fibrosis and atrophy, a condition
known as infantilism is produced at a period when
the sexual characteristics should be pronounced. A
certain proportion, but not a large one, of epileptics,
deaf mutes, and idiots show signs of inherited syph-
ilis. Great care should be taken in diagnosis, in fu-
ture the most certain test of the disease being syph-
ilis will be the presence of spirochseta pallida in the
part affected. This organism has an extraordinary
persistency, producing local symptoms after length-
ened periods. But mercury controls its develop-
ment. Metchnikoff has shown that some hours after
direct inoculation the application of a calomel oint-
ment to the sore is sufficient to kill the organism
and prevent the occurrence of secondary symptoms.
4. Cytodiagnosis. — Sawyer discusses the cyto-
diagnosis of pleural serous effusions, cerebrospinal
fluids, and ascitic fluids. Speaking generally, the
cells found in all effusions and the percentage of each
kind of cell to the total number vary in the same
way in all these pathological fluids, according to the
disease which produces the effusion. In making a
cytological examination it is necessary to obtain the
fluid as soon as possible after it has been removed
from the body, as after a few hours the cells begin
to degenerate. Care should be taken not to centrifu-
galize too long or too forcibly. The cells to be con-
sidered from a cytological point of view are ( i ) the
small lymphocytes; (2) the polymorphonuclear
cells; and (3) the endothelial cells. Very few cells
may be present in serous effusions or cerebrospinal
fluids, especially the latter. As the result of his ob-
servations the writer reaches the following conclu-
sions: I. Effusions of tuberculous origin contain a
large percentage of small lymphocytes, ranging from
59 to 100 per cent. 2. Effusions of acute inflamma-
tion contain a large percentage of polymorphonu-
clear cells, ranging from 64' to 97 per cent. 3. Me-
chanical efifusions contain chiefly endothelial cells,
the highest count being 98.8 per cent. 4. Effusions
due to malignant disease can rarely be diagnosticated
by cytological methods alone, but when such a condi-
tion is suspected to be present the predominance of
endothelial cells would greatly support that view.
LA PRESSE MEDICALE.
January 18. 1908.
1. Urgency Treatment of Wounds of Joints,
By P. Hardouin.
2. Study of the Gastric Secretion without Use of the
Stomach Tube, By Leon Mueniek.
3. Anaphylaxia, By R. Rom me.
1. Urgency Treatment of Wounds of Joints.
— Hardouin says that the knee and the instep are
the two joints which most frequently demand
emergency treatment at the hands of the surgeon,
and in this article he deals chiefly with surgical in-
tervention in these joints. Early and thorough in-
tervention is urged, and in conclusion he says that
a surgeon in the jiresence of a wound of a joint
should reiuembev that if he is to attain success he
must intervene quickly and freely, and that in the
cases in which one becomes hesitant on account of
the necessity of a rather extensive intervention he
should hold to the idea that abstention and hesita-
tion conduce to the worst disasters in this class of
cases.
2. Study of the Gastric Secretion without
Use of the Stomach Tube. — Meunier utilizes the
February 22, 1908. J
PJTH OF CURRENT LITERATURE.
373
following method for the determination of the
length of time required for dissolution in the gas-
tric juice. A capsule of thin rubber tissue, with its
aperture closed by means of catgut and containing
a drop of ether, is swallowed by the patient during
gastric digestion. The catgut is thus submitted to
the action of the gastric juice, and after a certain
length of time it gives way and allows the ether to
escape and come into contact with the contents of the
stomach, with the result that the patient indicates
the precise moment of dissolution of the catgut by a
very characteristic eructation of ether. He describes
two series of experiments, and believes that this
method possesses certain advantages over the usual
method of washing cut the stomach.
January 2^, igo8.
I Protection of the Child. Puericulture in Lille,
By V. BuE.
2. The Inclusion of Parafin at Seventy-eight in the Nasal
Prothesis, By Leroux
3. Latent Nephritis in the Child, By R. Rom me.
2. The Inclusion of Parafin at Seventy-eight
in the Nasal Prothesis. — Leroux alleges that there
are great advantages of his operation over the usual
method of injection of parafin into the subcutaneous
tissues. The essential point of his operation is the
subcutaneous ])rep;iration of a pocket into which
the parafin is introduced and spread so as to pro-
duce the effect desired. He asserts that the aesthetic
results arc better than those obtained from injection,
while the technique is simplified and all danger is
removed.
January 29, 1908.
1. The Bacilli Kiiown as "Paratyphic" and the Diseases
Known as "Paratyphoid,"
By J. CouRMONT and Ch. Lesieur.
2. Paratyphus and Alimentary Infections, By G. Fischer.
3. Alcoholism and Insanity, By Legrain.
4. The Cause of Death in High Occlusion of the Intestine,
By M. GuiBE.
1. The Bacilli Known as "Paratyphic" and the
Diseases Known as "Paratyphoid." — Courmont
and Lesieur discuss the occurrence of these bacilli
and conditions in France, and conclude that the in-
fections called paratyphoid, which have been well
authenticated, seem to be very rare in France j that
to affirm this diagnosis hsmoculture is indispensa-
ble ; seroreaction will not suffice, and that the term
paratyphic bacilli and paratyphoid diseases should
be dispensed with.
2. Paratyphus and Alimentary Infections. —
Fischer says that in the majority of cases para-
typhus is an acute, severe gastroenteritis, often ac-
companied by symptoms of serious intoxication.
4. The Cause of Death in High Occlusion of
the Intestine. — Guibe discusses the idea brought
forward by Maury chat death in high intestinal ob-
struction may be due to the absorption of bile.
LA SEMAINE MEDICALE.
January 29; 1908.
Haemolytic Jaundice, By M. A. Ch.\uffard.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT.
January 2T, 1908.
I. Concerning Haemolysis through Combination of Oleic
Acid or Sodium Oleate and Cobra Venom,
By VON Dungern and Coca.
2. . Cutaneous Tuberculosis among Children,
By Hamburger.
3. Neurology of the Tongue, By Flesch.
4. Eighty Cases of Lumbar .\naesthesia without Failure,
By Holzbach.
5. Treatment by Means of Bier's Hyperaemia,
By Gebele.
6. The Signification of Pentoses in the Fsces and of Their
Quantitative Estimation, By Jolles.
7. Concerning ■ the Action of the Subcutaneous Injection
of Pyocyanasis, By Bermbach.
8. The Transference of Swine Erysipelas to Man,
By Mayer.
9. Psychology and Psychopathology in Police Affairs,
By Uebl.
10. Purposes and Methods of Instruction in Gynaecology,
By Durlacher.
11. Reply to the Above, By von Franque.
1. ?. History and Indications for Oxygen Treatment,
By Galli.
13. Report for the i-"irst Year of the Institution for the
Care of Children in Weissenburg (Concluded),
By Dorfler.
14. Obituary of Moritz Schmidt, By Senator.
2. Cutaneous Tuberculosis in Children. —
Hamburger says that the papulosquamous tubercu-
lides are met with quite frequently in childhood,
and that they are of great clinical interest from a
diagnostic point of view at this age.
3. Neurology of the Tongue. — Flesch has
studied by means of experiments the .conditions pres-
ent with I, isolated paralysis of one genioglossus ;
2, of one styloglossus ; 3, paralysis of both genio-
glossi ; 4, paralysis of the left genioglossus and lin-
gualis ; 5, paralysis of the left genioglossus and stylo-
glossus ; 6, isolated paralysis of the left hyoglossus ;
and, 7, paralysis of the internal muscles. Observa-
tions were made concerning the position and form
of the tongue when at rest, the direction of the
raphe, lateral and vertical motility, touching the mo-
lar teeth with the tip of the tongue, putting out the
tongue, lateral motility of the tongue when put out,
retraction of the tongue, empty swallowing, fibrillarv
twitchings, articulation, and sensibility. He divides
the forms of paralysis met with into three groups,
glossoplegia totalis, in which all of the muscles, both
internal and external, are involved ; glossoplegia ex-
terna ; and glossoplegia interna. The following com-
binations were observed from foci in the cortex: i,
(jlossoplegia bilateralis totalis ; 2, facial paresis or
motor aphasia combined with a monolateral external
paresis of the tongue ; 3, complete motor aphasia
without paresis of the tongue. Hemiatrophy with
tremor, without the reaction of degeneration, has
been observed as the result of a lesion in the semi-
oval centre near the internal capsule. He finds with
regard to the peripheral paralyses of the hyoglossus
that these should be divided into three groups: i.
If the lesion is situated between the base of the brain
and the anterior condyloid foramen there will be a
monolateral atrophic paralysis, glossoplegia totalis
nnilateralis atrophica, with reaction of degeneration,
pain on movements of the head, and noninvolvement
of the lower muscles of the hyoid bone ; 2, if the
nerve is affected extracranially as far down as the
place where the descending branch is given off there
will be a unilateral atrophic total glossoplegia, with
involvement of the lower muscles of the hyoid bone
on the same side ; 3, lesions situated more peripher-
ally cause atrophy, while sensation is preserved, the
lower muscles of the hyoid bone are not involved,
and the movements of the head remain intact.
Spasm as well as paralysis may be the cause of limi-
374
FITH OF CURRENT LITERATURE.
tation of movement in all. The author gives a brief
account of a number of cases of nervous affections
of the tongue which have come under his observa-
tion.
4. Lumbar Anaesthesia. — Holzbacli describes
the method of administration of the mixture of sto-
vaine used for the lumbar anaesthesia in eighty cases
of major operations on women. While the patient
is sitting in her bed a puncture is made in the me-
dian line between the second and third lumbar verte-
brae, the trocar removed from the needle, two or
three c.c. of the cerebrospinal fluid allowed to escape,
and the mixture of stovaine then injected very slow-
ly through the tube, the injection lasting from three
to four minutes. The needle is then removed with a
jerk, which causes the patient to sit upright sharply
and thus prevent any escape of the fluid through the
puncture. Brusque changes of position are to be
avoided, as they cause changes in the level of the
fluid and may cause the extension of the poison to
regions where the vital centres will be endangered.
5. Treatment by Means of Bier's Hyperaemia.
— Gebele reviews the experiences in the surgical
clinic at Munich with this form of treatment of tu-
berculosis of the bones and joints.
7. Subcutaneous Injection of Pyocyanasis. —
Bermbach says that a well marked local and general
reaction follows the injection of pyocyanasis. The
local symptoms are redness, swelling, and pain, the
general fever, with increase of temperature and ac-
celeration of the pulse, headache, dizziness, nausea,
and vomiting. The cause of the reaction is the tox-
ine contained. Treatment should be begun with ver)
small doses, which are to be gradualy increased.
January 28, 1908.
1. Concerning Parabiosis in Artificially United Warm
Blooded Animals, By Sauerbruch and Heyde.
2. Meat Poisoning and Widal's Reaction, By Liefmann.
3. Concerning Modern Seritm Diagnosis, with Especial
Reference to Precipitine and Opsonin, By Fornet.
4. .^Itiology of Chicken Cholera, By Prowazek.
5. Experiences with von Pirquet's Cutaneous Reaction to
Tuberculin, By Gobel.
6. Injury of the Duodenum through Contusion,
By Steinthal.
7. Symptomatology of Exudative Pleuritis,
By VON SCHROETTER.
8. The Limitation of Laparotomy by Vaginal Methods of
Operation, By Lehmann.
9. Concerning the Results as Yet Produced in the Con-
sulting Places of Munich with Propositions for the
Further Extension of These Arrangements,
By Oppenheimer.
10. Concerning Ophthalmoreaction,
By WiENs and Gunther.
11. Treatment by Means of Bier's Hypersemia (Concluded),
By Gebele.
12. Obituary of Professor Wilhelm Nieberding,
By KiRCHGESSNER.
1. Parabiosis, — Sauerbruch and Heyde give
the name parabiosis to the new condition produced
in animals which are experimented upon when they
arc organically connected together in an artificial
manner, and present their observations in regard to
the anatomy and the physiology of this condition.
2. Meat Poisoning and Widal's Reaction. —
Liefmann observed fifty .soldiers taken sick in bar-
racks within a few days of each other with symp-
toms of ptomaine poisoning, ascribable to their food,
and with the Bacillus enteridis Gartner present.
[New York
Medical Journal.
Widal's reaction was positive in all, though no ty-
phoid bacilli could be found.
5. The Cutaneous Reaction to Tuberculin. —
Gobel thinks that in children between the ages of
one and twelve the positive reaction to von Pirquet's
cutaneous test is almost demonstrative of the pres-
ence of tuberculosis, but with adults a conclusion
from the positive reaction must be drawn with care.
A negative result in adults after repeated inocula-
tions makes it extremely probable that that person
is free from tuberculosis.
6. Injury of the Duodenum by Contusion. —
Steinthal reports a case of this nature. A man, eigh-
teen years old, was run over by a wagon and brought
to the hospital. Laparotomy was performed and
lacerations found in the duodenum and elsewhere in
the intestine which necessitated suturing and a gas-
troenterostomy. The patient recovered.
7. Symptomatology of Exudative Pleuritis. —
Von Schroetter describes a nuinber of cases which
illustrate the changes observable by bronchoscopy in
this disease.
8. Limitation of Laparotomy by Vaginal
Methods of Operation. — Lehmann points out
how since 1894 there has been a growing tendency
for the vaginal methods of operation to take the
place of laparotomy in all kinds of gynaecological
operations, and closes with an advocacy of the vagi-
nal Caesarean section.
II, Bier's Hyperaemia. — Gebele finds this
treatment to be not a universal cure, but to be of
good service in acute, fresh cases of inflammation,
better than in cases of tuberculosis.
ARCHIVES OF P/EDIATRICS.
January, IQ08.
1. Three Cases of Typhoid Fever in the First Year of
Life, By J. P. C. Griffith.
2. Case of Hsemothorax, By W. P. Northrup.
3. Myxcedema, with Report of a Case, By .A. M. Davis.
4. Subcutaneous Emphysema following Exploratory
Puncture of the Chest, By J. C. Gittings.
5. Tetanus Neonatorum, Complicated by Pneumonia,
By R. O. Clock.
6. An Examination of Excised Tonsils, By A. F. Hess.
7. Epidemic Anterior Poliomyelitis in Philadelphia,
By R. S. McCoMBS.
8. The Indications for and against Reinoving .\denoids,
and Methods, By S. W. Tiiurber.
9 Ocular Symptoms and Diseases .Accompanying Ade-
noids, ' By C. H. M.\Y.
10. Adenectomy during Acute Middle Ear Disease,
By P. D. Kerrison.
3. Myxoedema, with Report of a Case. — Davis
refers the term to Ord, who proposed it for "an
essential condition in the cretinoid affection occa-
sionally observed in middle aged women." It is
synonymous with the cachexic pachydcrmique of
Charcot, and the cachexia strumipriva of Kochcr.
Whether it follows removal of the thyreoid, as al-
leged by some writers, there is certainly a marked
atrophy of the thyreoid in myxoedema, and the dis-
ea.se at least appears to lie dependent upon loss of
function of the thyreoid gland. It occurs most fre-
quentlv in married women between forty and forty-
five. It mav follow the exanthemata, rheumatism,
erysipelas, malaria, and tuberculosis. One variety
results from the destruction of gland tissue by dis-
ease, while the congenital or infantile form is also
February 22, 1908.]
PROCEEDINGS OF SOCIETIES.
375
known as cretinism. Another variety is that which
follows the removal of the thyreoid gland. If prop-
erly treated it is susceptible of great improvement.
If untreated it lasts from six to twenty years. It is
apt to be confounded with exophthalmic goitre and
chronic nephritis. Suitable climate, baths, and good
hygienic treatment in general are indicated ; also
arsenic, strychnine, ergot, pilocarpin, and thyreoid
extract.
4. Subcutaneous Emphysema following Ex-
ploratory Puncture of the Chest. — Gittings states
that this sequel of pleural puncture has rarely been
reported. Three cases are narrated. The lung is
also punctured, a localized pneumothorax resulting,
and this develops subcutaneous emphysema along the
line of puncture. Another possilale explanation is
that it is due to infection from an air producing ba-
cillus. There may be no ill effects from the emphy-
sema, while a resulting pneumothorax causes dis-
comfort, if not actual danger. In puncturing the
chest one must not forget the possible proximity of
firm and unyielding lung tissue to the chest wall, and
the author thinks the operation is too often under-
taken with disregard of the element of danger, espe-
cially in children. When a small collection of fluid
overlays a more or less consolidated lung diagnosis
by percussion and auscultation is often unsatisfac-
tory, and puncture becomes imperative, but the lung-
must be avoided unless one is searching for an intra-
pulmonary collection of fluid.
10. Adenectomy during Acute Middle Ear
Disease. — Kerrison thinks one should always ask
whether the removal of the tonsils and adenoids is
a necessity, and wdiether the pharyngeal growth will
retard or check tympanic resolution. He offers the
following facts: i. The two operations should be
performed at one sitting, under general anaesthesia.
2. Adenectomy involves risk to the healthy ear. The
acute inflammation is favorable for tlie throat oper-
ation, and if the drum membrane is incised further
damage to the ear may be saved. 3. Free bleeding
accompanying the removal of the adenoids favors
tympanic resolution. 4. In many cases of acute otitis
media recovery is not only tedious and slow, but will
be incomplete until the adenoids are removed. The
drum membrane remains retracted and congested,
and slight provocation will induce recurrence of the
middle ear trouble.
THE SCOTTISH MEDICAL AND SURGICAL JOURNAL.
February, igo8.
1. A Hundred Consecutive Operations for Appendicitis ;
Some Deductions Therefrom, Bv J. W. Dowden.
2. Some E.xperiences with X Rav and" High Frequency
Treatment, By.F. Gardiner.
3. Rheumatoid Arthritis: Its Etiology, Clinical Symp-
toms, and Pathology, By Katherine S. Clark.
3. Rheumatoid Arthritis. — Clark has observed
a considerable number of cases of rheumatoid arthri-
tis in different stages of the disease. She thinks that
the opinion that rheumatoid arthritis owes its origin
to some lesion of the nerves cannot be held. The
bacterial theory is also improbable, because no spe-
cific organism, present in all cases, has been discov-
ered. But she is of the opinion that it is of organ-
ismal origin, the organisms having their seat in some
organ, where they evolve toxines, \\ hich are thrown
into the blood stream. She has found definite
changes in the spleen, liver, kidney, pancreas, skin,
ovary, stomach, and bladder. In the spleen the most
prominent histological change was found in thicken-
ing of the walls of the central artery of the Mal-
pighian body, this thickening being of the nature of
a hyaline degeneration. The capsule and trabeculse
were also more or less thickened with dilatation of
the sinuses of the pulp and some thickening of walls.
In the liver there was increased connective tissue in
the portal tract, with thickening of the walls of
ducts and vessels. The principal changes in the kid-
ney were apparently primarily arterial, and the new
tissue had undergone hyaline degeneration. In some
part the glomerulus was markedly hyaline. Bow-
man's capsule frequently showed fibrous thickening,
and throughout the organs, particularly along the
vessels, were localized patches of fibrous connective
tissue. In the pancreas the pathological changes
were even more marked, increase of connective tis-
sue throughout the organ being very extensive.
There was degeneration of the parenchyma, and
hyaline thickening of the vessels and ducts, with a
proliferation of their lining epithelium. In the skin
sections there were present atrophy of epithelium,
glands, and hair follicles, increase of fibrous tissue
in the cutis vera, with hyaline degeneration in the
deeper layers. The ovary showed little abnormality,
except in the greatly thickened vessels, the coats of
which were markedly hyaline. In one case, the
almost total absence of germinal epithelium and fol-
licles was noticeable, also extensive fibrosis, and
thickening of the hyaline vessels. The hollow or-
gans, stomach and Ijladder, were to the naked eve
markedly thickened, this change being principally
in the muscular coat. Amongst these pathological
changes, perhaps the most remarkable are those de-
scribed in connection with the skin, changes which
are evidently widespread. It is difficult to account
for these otherwise than on the ground of an ap-
parently specific neuropathic origin, and probably,
in addition, they may partly result directly from the
arterial changes. These arterial changes, being so
widespread throughout the body, can only be ex-
plained by the circulation of some chronic irritant
in the blood stream, which, in its course, involves
joints as well as organs. The author is therefore of
the opinion that the joint changes are merely symp-
tomatic and that they are only part of a general
chronic toxjemia.
NEW YORK ACADEMY OF MEDICINE.
Meeting of January 2, igoS.
The President, Dr. John A. Wyeth, in the Chair.
Following the reading of the annual reports was
a "symposium" on tuberculosis in infants and chil-
dren, under the auspices of the Section in Paedi-
atrics.
The Pathological Findings. — Dr. John Mc-
Crae, of Montreal, read this paper. He said that
when one dealt with the pathology of tuberculosis
in children one met with many conflicting statements
376
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
and ventured at once on controversial ground. Much
interest centred about the primary tuberculosis of
young children. Some English pathologists gave a
considerable frequency for this, and he thought that
every one in this country would concur in the rea-
sonableness of Dr. Bovaird's twice in 125 cases and
Dr. Holt and Dr. Northrup's 1.3 per cent. It was
probably the case that the average human being could
overcome an infection by bovine bacilli more easily
than that by human bacilli. The statement that bo-
'vine tuberculosis was less virulent than human tu-
berculosis for human beings rested upon the fact
that the cases so observed had generally been of the
lymphoid form or from cases of slow progression.
To the contrary must be stated the observation that
apes were more virulently attacked by bovine than
by human tuberculosis. There was a slow t>'pe of
infection in children which they called "bovine," viz.,
a slowly progressive tuberculosis, tending to over-
growth and dry caseation, affecting mainly the
lymph nodes. Children were liable to infection by
air borne bacilli of the human, less frequently of the
bovine type, and were liable to infection by ingestion
of bovine bacilli from milk and other forms of food
of which milk was a component part. European
figures, collected in Lubarsch and Ostertag, showed
that, of 396 examinations of milk, 9 per cent, con-
tained bacilli ; and of 244 butter examinations, ba-
cilli were found in 8.3 per cent. This was probably
a greater ])Lrcentage than existed in the United
States or Canada. The exact cultural studies made
in Germany, the Cnited States, and England upon the
bacilli isolated from cases of tuberculosis showed
that, of children under five years of age affected by
tuberculosis, four fifths were probably infected by
air borne human bacilli. One fifth might show the
"bovine" form, and this percentage decreased as the
age progressed. We must admit that in all proba-
bility the bacilli could pass through tissues and
glands without leaving visible traces, and could re-
main in tissues for a considerable time without ex-
citing even so slight a lesion as to be recognizable
only by the microscope. When infection occurred in
children, the first site in air borne infections was in
some part of the lymphoid tissues of the upper air
pas.sages or the lungs, and in intestinal infections the
mesenteric nodes. He asked if it was possible to fix
positively the primary seat of infection as intestinal.
If the mesenteric nodes showed caseous or calcareo-
caseous changes more marked than the thoracic, or
if there was ulceration of the bowel or tubercles of
the mucosa without cavitation, all these in artificially
fed children suggested intestinal infection. Ad-
vanced thoracic lesions should be allowed to weigh
in favor of infection by the respiratory channels.
One must also admit that tubercle bacilli from milk
might stick to the fauces and gain a foothold on the
thoracic lymphatics, but, on the other hand, in.spired
bacilli might go down with food or with saliva, so in
that regard honors were almost even. His personal
experience with foundlings, artificially fed on milk
that was pa.steurized, showed that they were practi-
cally free from tuberculosis. In 747 autopsies, in
which sixty per cent, of the subjects were three
months of age or under, tul)erculosis was found but
five times (0.66 per cent.). He knew that these chil-
dren were of low vitality, that ])asteurized milk
might well contain bacilli, attenuated but not dead,
that the Province of Quebec had a fair amount of
bovine tuberculosis, and that three months of life
was sufficient time to allow an infection to take good
hold. There must surely be less intestinal tubercu-
losis of infants than had sometimes been urged. He
thought the truth was that we had laid too great
stress upon milk borne tuberculosis where the bo-
vine disease was prevalent, and had forgotten that
children were more liable to the human form than
adults, in that, if they did become exposed to a house
or other local infection, they spent less time away
from their dangerous surroundings than their adult
relatives. As to the other forms of tuberculosis,
why in certain cases did the disease manifest itself
in bone and joint and remain there? This phenom-
enon was some expression of the sum total of lower
bacterial virulence and heightened resistance of the
individual tissue. With regard to meningeal tuber-
culosis, he wished to show that in a large percentage
of the cases it was merely a local evidence of a gen-
eralized tuberculosis. It occurred either as second-
ary to a bronchial or other gland infection, without
there being disease elsewhere, or as a local manifes-
tation of the disease that existed in many other or-
gans. The latter was the more frequent.
Recent Diagnostic Methods. — Dr. Willi.\m H.
Park read this paper, and, before touching upon
the technique, spoke on the meaning of the reaction
following inoculation of skin and eye, as recently
proposed. If one took an animal and injected into
it a minute quantity of serum, after ten days that
animal would be sensitized, so that if a fairly large
quantity of serum was injected the animal would
die in convulsions, whereas if the same dose of the
serum was given to another animal not so sensitized
the results would be absolutely harmless. White
of egg would sensitize an animal ; it was also found
that other proteids, as well as bacterial proteids,
would in the same way sensitize animals. Thus, if a
guinea pig, rabbits, or even men, were injected with
dead tubercle bacilli, they would, aften ten days, be
sensitized. This sensitizing would last for a con-
siderable period of time, until the newly formed sub-
stances were eliminated from the body. The im-
portant point was that a minute quantity of suit-
able proteid would thoroughly sensitize an animal
or man to similar proteids, and this sensitization
would last for months or years. When one got a
reaction from the subcutaneous injection of tuber-
culin, it was not a reaction because of the presence
of tubercle poison in the body, but because of the
formation of antibodies due to the body having re-
acted to the tuberculous infection. Therefore, if a
body ceased to produce these protective substances,
the poison in the tissues adjacent to the disease and
in the circulation would not be neutralized, and no
tuberculous reaction would occur. These reactions
were not reactions to bacterial posion, but to the
body products in response to the poison. In ad-
vanced cases, therefore, reactions would frequently
not occur. After referring to the old method of in-
jecting Koch's original tuberculin, he called atten-
tion to the new methods. \'on Pirquet placed tuber-
culin upon the abraded skin, using a i to 4 strength,
one drop of which was rubbed into the abraded
skin. He found thai in tuberculous cases he got a
February 22, 1908.J
PROCEEDINGS OF SOCIETIES.
377
typical reaction. He usually took an arm, and made
a little vaccination mark ; that would be the control
spot. Then two other "vaccinations," or scarifica-
tions, were made, and into them was rubbed a 25
per cent, solution of Koch's tuberculin. In the
course of eight, twelve, or twenty-four hours ap-
peared a papular swelling and redness, of the size
of a dime or larger. So by contrasting the reac-
tion of the two scarifications with tuberculin with
that without the tuberculin, one could judge of the
difiference between a very slight inflammatory reac-
tion due to the abrasion and that due to tuberculin.
Wolff-Eissner believed that he might get the same
reaction without the use of this scarification by ap-
l)lying it to the conjunctiva, and he tried using a
1 to 10 dilution, placing one drop of it on the lower
eyelid. This gave a marked reaction. Calmette, in
order to avoid such a marked reaction or any non-
specific irritation, tried a method of purifying the
tuberculin by precipitating the toxines in 65 per
cent, alcohol. This precipitate was washed and
dried, and a i per cent, solution of it was made
in water. This i per cent, solution was then used
as in the Wolff-Eissner method. The reaction
might develop in from six to thirty-six hours. It
was very important in following up these new meth-
ods to carefully note the amount of reaction that
occurred, and the following scheme had been
adopted by many for the sake of uniformity : Two
solutions Were employed in diagnosis, which con-
tained 0.5 per cent. (No. 1) and i per cent. (Xo. 2)
respectively, and which might be used successively
in each eye if time permitted. In this way un-
necessarily severe reactions might be avoided. The
eyelid should be held down imtil the drop was dis-
tributed about the sac without overflowing on the
cheek. The same eye should not be used for a sec-
ond test, as it appeared to become sensitized to some
degree by one test. The tested eye should be kept
from external irritation by rubbing, wind, dust, and
smoke. The first symptoms of a reaction appeared
in from three to twelve hours in some cases, but
might be delayed twenty-four or even forty-eight
hours, and continued for a week. The presence of
a reaction was indicated by a scratchy feeling or
secretion and redness of the inner canthus, caruncle,
on lower lid, which might increase and include the
entire conjunctiva with redema of the lids. The
following schema was proposed for recording re-
actions: Negative: No difference in color when the
lower eyelids were pulled down. Doubtful: .Slight
difference with redness of the caruncle.
^ = Distinct palpebral redness with secretion.
++ = Ocular and palpebral redness with secretion,
well marked.
+++ = Deep injection of entire conjunctiva with
oedema of the lids and photophobia, and secretion.
Contraindicatious : Any existing disease of the eye
or lids, conjunctivitis, blepharitis, trachoma, kera-
titis, and iritis. Eye strain from errors of refrac-
tion need not prevent the use of the test so far as
had been observed. The objections to the test were
slight. No permanent ill effects had remained. Dr.
Park said it was yet too early to estimate the exact
value of either the skin or the eye reactions. Most
observers believed that the skin reaction was little
less apt to occur than the eye reaction. In young
children the reaction was believed to indicate gen-
erally an active focus of tuberculosis, while in older
children the reaction became less definite, as it
might mean either a present or recently healed in-
fection. In the adult the reaction was present in
such a large percentage of the cases that it was
hard to know whether there was an active or a late
tuberculosis, or whether the bacilli had simply been
absorbed through the mucous membrane, giving no
reaction whatever except .sensitizing the individual.
Negative results were always helpful in excluding
absorbed tubercle bacilli, latent or active tubercu-
losis.
Laboratory Aids to the Diagnosis of Tubercu-
losis.— Dr. T. Homer Coffin considered this sub-
ject in its relation to the examination of the blood,
urine, sputum, faeces, bodily fluids, discharges, etc.
Microscopical examination of the blood in various
forms of tuberculosis of children usually showed a
marked diminution in the haemoglobin and the num-
ber of red cells. There might be a leucocytosis if
the process was associated with suppuration, though
there were some cases of tuberculous suppuration
which showed none. A blood count might in some
cases be of value in distinguishing tuberculous from
other forms of meningitis. Chronic cystitis or a tu-
berculous pyelitis might be a local manifestation of
a general tuberculous process. The bloody or
bloody purulent sediment of the acid urine in uro-
genital tuberculosis contained shredlike or rounded,
sometimes ragged, flocculi, pin head in size, which
upon microscopical examination showed pus cells
and fatty detritis. If smears were made and stained,
tubercle bacilli were found as dense collections
among these cells. In examining urine for tubercle
bacilli one should guard against mistakes with the
smegma bacillus. The method of Findley was ad-
vocated to overcome the difficulty of obtaining spu-
tum in infants and young children. Holt, in sixty-
seven cases of pulmonary tuberculosis in children
under two years of age, had made the diagnosis by
.HI examination of the sputum in eighty per cent, of
the cases when, according to the physical signs, the
disease was not far advanced. A large number of
uninuclears was present in tuberculous exudates ; the
process was usually insidious in development and
was accompanied by slight inflammation. In tuber-
culosis of the cerebrospinal canal and the pleural.
])ericardial, and abdominal cavities the miinuclear
cells did not always predominate in the fluid, for
cases known to be tuberculous had shown the poly-
morphonuclears most numerous at an early stage of
the process, but later the uninuclears predominated.
Therefore the predominating type of cell was more
indicative of the stage and severity of the disease
than of its aetiology. The cerebrospinal fluid in tu-
berculous meningitis was usually clear, and upon ex-
amination of the sediment the uninuclears were
greater in number. In epidemic and pneumococcus
meningitis the fluid was usually cloud\-, and the spe-
cific bacteria were found among or in the multinu-
clear cells. Some writers expressed most sanguine
views regarding the value of the examination of the
fasces in patients with tuberculous lesions. This ex-
amination might be of great value in children with
pulmonary tuberculosis, for the sputum here was
often swallowed. In tuberculosis of the intestine
378
PROCEEDINGS OF SOCIETIES.
[New York
iMedical Journal.
the bacilli were often found in the stools after care-
ful search. Tuberculous affections of the eye, ear,
nose, throat, urethra, or vagina in children might
often be distinguished from lesions due to other mi-
croorganisms by a microscopical examination of the
secretions. Tuloerculous glands were diagnosticated
by examination of sections of hardened tissues from
portions of the excised glands.
Channels of Communication; Their Relative
Significance.— Dr. S. McC. Hamill, of Philadel-
phia, read this paper. He said the question of the
modes of introduction of the tubercle bacillus into
the human body remained at present entirely unset-
tled, more unsettled in fact than a few years ago,
when we accepted it as proved on the basis of post
mortem evidence that infection by inhalation was
the chief if not the only channel. The avenues by
w'hich the tubercle bacillus got into the human body
were the maternal circulation, the skin, the ear, the
conjunctiva, the urogenital tract, and the respiratory
and intestinal tracts. All but the last two of these
were accepted as proved, but considered of such in-
frequent occurrence that they need have no place in
the pre.sent discussion. In the vast majority of tuber-
culous subjects infection occurred either through the
respiratory or the alimentary tract. The experi-
mental results bearing on inhalation tuberculosis
which were the most deserving of consideration in
detail were those of Fliigge. He produced tubercu-
losis of the lungs by inhalation in guinea pigs, rab-
bits, goats, calves, and dogs by means of a very
small number of tubercle bacilli which were floated
in the air in the shape of droplets. From these ex-
periments he concluded: i. That inhalation repre-
sented a mode of infection as efficacious as subcu-
taneous injection, with regard to the very small dose
re(|uired, and that inhalation infection produced a
disease more rapid in course than did subcutaneous
injection. 2. That it might be accepted as proved
by the inoculation of the peripheral parts of the lung
into guinea pigs immediately after exposure to an
atmosphere containing droplets that at least some of
the bacilli inhaled with the air in the shape of drop-
lets were carried to the finest bronchi. 3. That the
quantity of bacilli required to produce manifest
symptoms of disease, when ingested witli the food,
was millions of times larger than when infectiim was
by inhalation, and a fatal termination took place at
a nuich later period. He accepted it as proved, there-
fore, that inhaled tubercle bacilli were capable of
producing tuberculosis directly, and not because
some of them were swallowed and penetrated into
the body from the intestine or throat. The contention
of Fliigge that the floating of bacilli infected drop-
lets in the air was more dangerous than the bacilli
laden dust was not in accordance with the results of
other investigators and was directly opposed to clin-
ical experience. The work of Rartel and Spieler
seemed to indicate that the intestinal tract was the
most common avenue of infection. Infection through
the medium of the intestinal tract has obtained a
great deal of support in recent years. The follow-
ing conclusions were oft'ered : i. That it was im-
possible to gain any know^ledge as to the port of
entry either from the location or the degree of de-
velopment of the tuberculous lesions. 2, That ftrtal
infection was proved, but not common. 3, That in-
fection through the mouth, tonsils, and pharvn.x was
of frequent occurrence and might be produced by in-
halation or ingestion. 4, That primary inhalation
infection through the lungs did occur. 5, That in-
fection through the intestinal tract was definitely
proved. 6, That the bronchial glands and lungs
might be infected through the latter channel as well
as through the lungs. 7, That the relative signifi-
cance of the various modes of infection was very
difficult to determine on the basis of our present
knowledge, since it had been clearly shown that it
mattered not from what point the tubercle bacillus
was introduced — it could eventually reach the bron-
chial glands and lungs without leaving any evidence
of its means of entrance. It was probable, however,
on account of the greater exposure of those por-
tions of the body, that infection through the upper
respiratory and alimentary tracts was the most com-
mon, and next to this, for similar reasons, through
the lower respiratory and intestinal tracts. As to
which of the two latter constituted the more fre-
quen channel, it would seem that the nature of the
exposure should prove a determining factor. If in-
fection occurred when the bacillus was carried in
with the food or to the lips and mouth in kissing, or
by infected hands, nipples, toys, drinking cups, or
the various feeding utensils, it must almost certain-
ly be by the alimentary tract. If, on the other hand,
the bacilli laden dust or droplets were inspired, they
were caught up in large part on the mucous mem-
brane of the upper air passages, whence they might
be swallowed, or they were carried on to the lungs.
Certainly, in infants and children, exposure to the
former group of conditions was much greater than
it was in adults, and, since we must admit that the
greater portion of inhaled bacilli found lodgment in
the upper air passages, from which point they might
be swallowed, and since infection by the intestinal
tract had been absolutely determined in children as
well as experimentally in animals, we could safely
conclude that intestinal infection in earh- life was
more common than in later years, and, with the ad-
ditional support of much experimental work and
much investigation, he was prepared to believe that
infection by the intestinal tract was more common
in infants and children than infection through the
lungs.
The Management and Treatment of Tubercu-
losis in Infants and Children. — Dr. John Lo\ ett
Morse, of Boston, read this paper. (See page 350.)
Dr. David Bovaird, Jr., said it was a question of
great importance to the public, and upon which a
great deal depended in the fight against tuberculosis,
to know the mode of infection and the relation be-
tween bovine and human tuberculosis. He called
attention to the contention of the two ])romincnt
schools, each opposing the other.
Dr. Henry D wight Chapin said that those who
had to deal with disease of childhood recognized the
great difficulties encountered in the diagnosis of tu-
berculosis in its early stages. All clinicians looked
upon laboratory aids with the greatest hopefulness.
The surgical treatment of tuberculous peritonitis was
filled with hope, but the trouble was in getting an
early diagnosis of the condition. He believed that
the danger from milk borne tuberculosis was over-
estimated, and it was a fact that, while tuberculosis
in cattle was on the increase, tuberculosis in man was
on the decrease. If bovine tuberculosis was of sucii
February 22, 1908.]
PROCEEDINGS OF SOCIETIES.
379
importance as a causative factor of tuberculosis in
man, this would not be true.
Dr. Harlow Brooks said that, so far as the
anatomical lesions went in judgins: of the point of
infection, intestinal infection was rare, whereas
respiratory tuberculosis was common. These ana-
tomical lesions, however, were not infallible in lo-
cating the seat of infection. He had had consider-
able experience with infections occurring in ani-
mals, and at one time there had been an outbreak of
tuberculosis in the orangoutang and chimpanzee,
and he had stamped it out by attention to the pre-
vention of its dissemination by respiration, the in-
testinal factor in these cases being negative. It was
wiped out simply by preventing the possiiiility of in-
fection by the respiratory tract.
Dr. William P. Xorthrup condemned the over-
heating of the apartments and houses, especially in
Xew York ; this caused much of the acute and
catarrhal conditions in children and adults. ( )ne of
the best ways to check tuberculosis was by cooling
the houses. It was unfortunate that the trachea
and oesophagus were situated so close together, for
children were so apt to inhale what was regurgi-
tated and swallow what was brought up through the
trachea. He was surprised at Dr. McCrae's state-
ment that tuberculoma in the brain was one fourth
as frequent as meningeal involvement. His experi-
ence was that very little tuberculosis occurred in
the brain itself. The Calmette reaction was a great
aid, and presented a remarkable phenomenon.
Dr. Roland G. Freemax believed that, no matter
what opinions had been held in the past regarding
the channels of inoculation, such opinions must be
modified by the results of the latest researches.
There were many cases seen at autopsy which were
apparently cases of inspiration tuberculosis, but
which were, in fact, cases of intestinal origin, with
little trace of the site of inoculation in the intestine
left, ^lilk from tuberculous cows often contained
no tul)ercle bacilli, or, if it did. they were so diluted
that they might not gain an entrance into the sys-
tem.
Dr. A. F. Hess said that at present one of the
greatest points of variance in different countries and
among various capable observers was in regard to
the relative practical importance of bovine and hu-
man tuberculosis, especially as concerned infants
and children. The importance of the question from
a prophylactic point of view was not open to doubt.
Attempts to solve this matter by means of ascertain-
ing the frequency of tuberculosis in cattle or by en-
tering into the previous history of the child and
considering the question of exposure to bovine or
human tuberculosis were indecisive. It seemed to
him that the only way we could obtain an answer to
this question was by the slow and tedious method
of distinguishing the types of bacilli. It was well
established that by means of morphology and cul-
tural and biological tests the human and bovine
types might be distinguished. This had been done
here, but to a much greater extent by the British
County and the German Imperial Health Depart-
ments. It was only by hundreds of such investiga-
tions of serial cases that we could come to any con-
clusions.
Dr. A. Jacobi dissented from what Dr. Morse
had said regarding the giving of opium to children ;
it was not a rank poison, and might be of great
value when they were subjects of tuberculosis. He
believed the tubercle bacillus could get into the sys-
tem through an intact mucous membrane, and he
cited a case in proof of this statement. Pasteuriz-
ing milk was so carelessly done that Dr. Jacobi ad-
vocated the bringing of the milk to the boiling
point ; one then would be sure to obtain the proper
temperature.
[IV c publish full lists of books received, but zt'e acknoid-
edgc no obligation to reviezv them all. Nevertheless, so
far as space permits, we review those in which zve think
our readers are likely to be interested.]
Modern Medicine: Its Theory and Practice. In Original
Contributions by American and Foreign Authors. Edited
by William Osler, M. D., Regius Professor of Medicine
in Oxford University, England, etc.; Assisted by Thomas
McCrae, M. D., Associate Professor of Medicine and
Clinical Therapeutics in the Johns Hopkins University,
Baltimore. Volume III. Infectious Diseases (Con-
tinued). Diseases of the Respiratory Tract. Illustrated.
Philadelphia and New York : Lea Brothers & Co., 1907.
Pp. ix-17 to 960.
Rather more than half of this volume is required
to finish the consideration of infectious diseases ;
then the aetiological basis of classification is sup-
planted by the anatomical, and pneumonia, for ex-
ample, though undoubtedly originating in infection,
is more conveniently and therefore more properly
dealt with as a disease of the respiratory tract. One
might have expected the same course to be pursued
with tuberculous disease, so overwhelmingly impor-
tant are its pulmonary manifestations, but elsewhere
than in the lungs it assumes a seriousness that is not
to be underrated. We cannot yet classify diseases
.satisfactorily on any one plan, and it is dotibtful
whether a great deal could he gained if we could do
so. Much Gelu'rnschz^riss has been spilled over the
unprofitable subject of classification.
Of the diseases classed as infectious, those treated
of in this volume are: Malta fever (by Colonel Da-
vid Bruce, of the British army), beriberi (by Dr.
[Nla.ximilian Herzog, of Chicago), anthrax, rabies,
and glanders (by Dr. M. P. Ravenel. of Madison,
Wis.), tetanus (by Dr. James M. Anders, of Phila-
delphia"!, gonococcus infections (by Dr. Rufus I.
Cole, of Baltimore), leprosy (by Dr. Isadore Dyer,
of Xew Orleans), tuberctrious disease (by Dr. Ed-
ward R. Baldwin, of Saranac Lake. X. Y., Dr. W.
G. MacCallum, of Baltimore, and Dr. Lawrason
Brown, of Saranac Lake. X'. Y.), syphilis (by Dr.
William Osier, of Oxford, England, and Dr. John
W. Chttrchman, of Baltimore), and infectious dis-
eases of doubtful nature, including febricula, glandu-
lar fever, infectious jaundice, miliary fever. Rocky
^fountain spotted fever, psittacosis, foot and motith
disease, and milk sickness (by Dr. Thomas R. Boggs,
of Baltimore).
Concerning the contention as to the identity of
human and bovine tuberculous disease, Dr. Baldwin
says conservatively : "Out of much strife the truth
seems to be emerging in favor of an intermediate
position between the standpoint of those who hold
the belief in strictly distinct varieties and those who
favor an absolute unity for all." Elsewhere he cites
the findings of Theobald Smith, Ravenel, and the
United States Bureau of Animal Industry as "all
38o
MISCELLANY.
[New York
Medical Journal.
tending- to show that bovine infection is not unim-
portant for man." Dr. Baldwin adduces weighty
reasons for beheving that the direct transmission of
tuberculous disease from parent to child must be
very infrequent and practically always proceed from
the mother. He adds : "Atavistic inheritance of
the bacilli from the grandparents is wholly incon-
ceivable." Dr. Brown thinks that for diagnostic
purposes tuberculin should be used only as a last re-
sort, when the physical signs are indefinite and no
bacilli can be found in the sputum. He regards
Koch's original tuberculin as the best form for use.
He speaks very guardedly of the ophthalmic tuber-
culin test. The pasteurization of milk to prevent in-
oculation, says Dr. Brown, is "much opposed" by
von Behring on the ground that it "alters the im-
munizing qualities of the milk from immunized
cows." If the author has an opinion of his own on
this subject, he does not give it, so far as we have
observed. It seems to us that the following are
words of wisdom : "There is no more important
factor in the treatment of cough than its proper dis-
cipliuc, first advocated by Galen. The patient should
have fully explained to him that it is not necessary
to raise the sputum from the lungs, for cilia are pro-
vided for that purpose, and every cough is an act of
exertion and may further injure the lungs. The
amount of exercise entailed in coughing shoulfcl be
made clear. Cough often begets cough, and a tend-
ency once repressed may mean escape from a vio-
lent attack." The opsonin doctrine seems to be re-
garded as still sub judicc. In the main, the whole
subject of the treatment of tuberculous pulmonary
disease is admirably. handled.
The subject of syphilis is treated of at considerable
length and very judiciously by Dr. Osier and Dr.
Churchman. They accept the existence of parasyph-
ilis and regard tabes as its type, though they do not
appear convinced that tabes is always of syphilitic
origin. The matter of preventing the spread of
syphilis by the regulation of prostitution is consid-
ered in a masterly manner ; indeed, what the authors
say about it is among the most valuable contribu-
tions to the literature of the subject that we have
ever seen.
Part II opens with an admirable chapter by Dr.
Thomas R. Brown, of Baltimore, entitled The Me-
chanics of Respiration and of the Respiratory Dis-
eases. The remaining cha])ters are on diseases of
the nasqpharynx. pharynx, and tonsils (by Dr. Fran-
cis R. Packard, of I'hiladt liiliia ) . ha\- fever (bv Dr.
W. P. Dunbar, of Hamburg; i, disca'^cs of the larynx
(by Dr. H. S. r.irketl, of .MiJiitrcal ) , diseases of'the
bronchi (by Dr. A. McPhedran, of Toronto), dis-
eases of the lungs (by Dr. Hobart Amory Hare, of
Philadelphia), diseases of the pleura (by Dr. Fred-
erick T. Lord, of Boston), pneumothorax (by Dr.
Walter 1>. James, of New York), and diseases of
the mediastinum (by Dr. Henry A. Christian, of
I'oston). These chapters are all good, but we have
not space to go into particulars with regard to them.
We mu.st, however, express our wonder that polan-
tin is invariably printed with an initial capital. This
leads us to remark that the volume contains manv
faults of expression, as they seem to us. and several
verbal errors, such as "intercerebral" injections
(page 87), "epididymes" (page 238), "spirochete
have" (page 484), and "extract of thcbaine" (in a
prescription on page 510). But these are only blem-
ishes ; the substance of the volume is of sterling
value.
Light and X Ray Treatment of Skin Diseases. By M.-kl-
coLM Morris, F. R. C. S.. Ed., Dermatologist to King
I^dward the Seventh's Hospital for Officers, Surgeon to
the Skin Department of the Seamen's Hospital, etc., and
S. Ernest Dore, M. D. (Cantab.), Assistant in the Skin
Department of the Middlesex Hospital. With Twelve
Plates. Chicago: VV. T. Keener & Co., 1907. Pp. 172.
This small book is intended to be a summary of
the methods of application and results of Fin-
sen's Hght treatment, x rays, and other therapeutic
agencies which have been introduced into derma-
tological practice within the last few years. Al-
though it is not indicated by the title, the work em-
braces radiuni and the high frequency currents.
( )nly three pages are devoted to radium, and. al-
though the names of several investigators are men-
tioned, the work of .\bbe, who has done more in
this line than any other physician in America, has
been entirely overlooked. Four pages are given to
the important subject of high frequency currents, in
which the author makes frequent reference to Al-
len's book, but fails to credit the work of previous
.American investigators. The rest of the book is
devoted to x radiation and the Finsen treatment,
and contains the usual report of cases. The por-
traits published in connection with the case reports
are not of a standard to excite admiration in this
country. The book will be instructive and interest-
ing to those who know little or nothing of the sub-
ject, but is of little practical value to those who are
well acquainted with the subject or who desire to
enter this field of practice. It is a well printed
English book, and, with the exception of the title
page, very good paper is used.
BOOKS, PAMPHLETS, ETC . RECEIVED
Hypnotic Therapeutics in rimnx ;liu1 Practice. With
Numerous Illustrations of Treatment Ijy Suggestion. By
John Duncan Quackenbos. A. AT, M. D., Author of Hyp-
notism in Mental and Moral Culture, etc. New York and
London : Harper & Brothers. 1908. Pp. 336.
Surgery. Its Principles and Practice. By Various Au-
thors. Edited by William Williams Keen, M. D., LL. D..
Emeritus Professor of the Principles of Surgery and of
Clinical Surgery, Jefferson Medical College, Philadelphia.
Volume HI. With 562 Text Illustrations and 10 Colored
Plates. Philadelphia and London : W. B. Saunders Com-
pany, 1908. Pp. 1 132.
The Theory and Praetice of Hygiene (Notter and Firth).
Revised and Laryelx Rewritten by R. H. First, Lieutenant
Colonel, Roval .\rni\ .Medical Cori)s. etc. Third Edition.
Philadelphia: P. F.lakistons Son & Co., 1908. Pp. 993-
(Price, $7.)
ItisrellaniT.
An Appeal to the Medical Profession. — The
.Medical .Society of the State of New York pub-
lishes the following appeal, and asks every physician
to write at once to his representatives in the Legis-
lature, both senator and assemblyman, urging oppo-
sition to these measures:
AN APPEAL TO THE .MEDICAL PROFESSION.
There are now in the Legislature not less than three
bills relating to vivisection and one relating to optometry.
The bills, introduced by the .Antivivisection Society, from
which they receive their name, are formulated to prohibit
animal experimentation. The statement is made that all
such experiments are unnecessary and that the various
February iz, 1908.]
OFFICIAL NEWS.
381
discoveries of science made possible by this method of in-
vestigation have not been productive of good to humanity.
This assertion is proved incorrect by a plain statement of
the facts from gentlemen of education, intelligence, and
scientific attainment, professors in our various colleges,
and scientists generally whose very names are synonymous
with honor and integrity. They clearly show to any un-
I)rejudiced mind the inestimable value to humanity of the
work which has been done, and is being done, along this
line. The statement has been made that at present there
is no restriction whatever placed by law on animal ex-
perimentation, whereas the fact is that there is now a law
on the statute books which restricts the work to properly
equipped institutions. If there have been isolated cases of
violation of this law which have gone unpunished, the
blame should be placed on those authorized to secure the
law's enforcement. The assertion that great cruelty is in-
flicted on animals in these scientific experiments is denied
absolutely and entirely by those in charge of experimental
work in this State. There is really no reason for any
enactment of a new law on this subject, and this should be
made very clear to the members of the Legislature.
The optometry bill is the old measure, and should be
defeated. This bill defines the practice of optometry as
the measurement of the powers of vision and the adapta-
tion of lenses for the aid thereof, all without the use of
drugs. This bill gives authority to opticians to do the
work, and at the same time prohibits the employment of the
means necessary to do it. This bill authorizes opticians
to adapt lenses to eyes for defects of vision which may be
due to diseases in other parts of the body, and to diseases
which may be situated in the eyes themselves. The adapta-
tion of lenses to ej'es under such circumstances, while
improving vision for the time, may be the cause of de-
ferring proper treatment until blindness or even death may
be the result. To determine when defects of vision are due
to defects in the eyes, or to diseases, requires the ability
to make a distinctive diagnosis, and this knowledge can
only be acquired, according to the laws of the State of
Xew York, by four years' study in a medical C(^llegc. Pos-
sibly some restrictions ought to be placed on the work
opticians should do. but to give them the power liii- bill
would confer would be to expose the people of this State
to perils the members of the Legislature cannot have know 1-
cdge of unless we inform them.
The members of the Legislature are honest, sincere men.
and their desire is to do what w ill be in the interest of the
State. They listen with great courtesy to the expres>e(l
opinions of the medical profession, and it will require con-
clusive evidence on the part of opticians and others to
convince the Legislature that any of these bills are nec-
essary, or even safe, if we in good faith urge disapproval
of them.
Will you not therefore at once do what you can in aid-
ing us in defeating these measures, by writing the mem-
liers of the Legislature that they ma\- be able to act in-
telligently.
Medical Onomatology. — Dr. H. C. Mtiller, of
I'trecht, Holland, who has written many scientific
works on classical philology and also on and in Liv-
ing Greek, is commencing a series of articles on
-Medical Onomatology in Gciiccskitiidigc Courant
voor Iiet Koningrijk Jcr X cderlaudcn. with the co-
operation of Dr. Rose, the first of the articles of
Dr. Muller, Bijdragen tot Hervorming der Genees-
lamdige Vaktaal (contributions to the formation of
medical technical language) appearing on Novem-
ber 16, 1907. It deals on psychiatrial terms found
in the writings of Kraepelin and Ziehen. Dr. Mul-
ler gives a number of words like psychosis, the
meaning of which has been changed in such a man-
ner that the Greeks must be at loss to recognize
what they shall signify. As a matter of course he
also criticises the use of hastaard ivoordcn (herm-
aphrodite or hybrid or bastard terms). It is highly
interesting and important to study this critic's writ-
ing, because of his point of view, a philologist, a pro-
found scholar of classical Greek and Latin as well
as of living Greek, but who is not a medical man.
In his letter to Dr. Rose he acknowledges the diffi-
culty he experiences to study medical nomenclature
without cooperating with a physician. — Postgrad-
uate, December, 1907.
Public Health and Marine Hospital Service
Health Report's :
The follozcing cases of smallpox, yellow fever, cholera,
and plague have been reported to the surgeon general.
Public Health and Marine Hospital Service, during the
week ending February 14, igo8:
Small fox — United States.
I'iacts. ' Date. Cases. Deaths.
.\labama — Mobile Jan. 26-Feb. 2 2
California — Ixis Angeles Jan. 18-25 13
California — San Francisco Tan. 18-25 16
District of Columbia— Washington.. Tan. 25-Feb. i 6
Illinois — Springfield Tan. 23-30 13
Indiana — In<lianapolis Tan. 26-Feb. 2 2
Indiana — Lafayette Jan. 28-Feb. 3 i
Indiana — South I'.end Ian. 25-Feb. 1 i
Iowa— Ottumwa "lan. 25-Feb. i i
Tojieka Jan. 18-25 3
6-31
Kansas — Wichita Jan
Kentucky — Lexington Tan
Louisiana — Xew Orleans Jan
Michigan — Saginaw Jan
Missouri — Kansas City Tan
Missouri — St. Toseph Tan
Ohio— Cincinnati 'lan
Ohio— Dayton Jan
Oregon — Portland Jan. 18-
I'ennsylvania — Williamsport lan. 25!
South Dakota — Siou.x Falls Tan. i-
Tennessee — Knoxville Tan. 25-I
Tennessee— Nashville Ian. 25-I
Texas — San .\ntonio Tan. 18-I
W'ashington — .Spokane Jan. 18-.
Washington — Tacoma Tan. 8-:
Wisconsin— .\ppleton Tan. 18-:
Wisc.n,>in— La Crosse Tan. 25-I
Wi'^ronsin— Oshkosh Jan. 18-.
Smallpo.r — Foreign
China — Hongkong. . .
Ciicat liritain — Edinbi
(ireat Britain — Leith .
India — Bombay
India — Calcutta
Italv — C.eneral
Italy— C.enoa
Japan — Kobe
Japan — Yokohama. . . .
25-Feb.
25-Feb.
8- Feb.
6 Imported
Ian.
Dtc.
27-Feb. 3...
•• i2
15
7-14
I
11-18
■ ■ I"
I
Dec.
i-Jan. 6
6
Dec.
2
8-^3
• • 4
Dec.
'i-Ian. 4
. .501
138
Dec.
Tan.
■ • 55
13
Cuba — Habana. . . .
Philippine Islands-
Ferer — Foreign.
Feb. 4-6..-
Cholera — Insular.
Manila Dec. 14-21..
Cholera — Foreign.
Dec. 31-Jan.
India — Bombay I
India — Calcutta 1
India — Madras Dec. 27-Jan
India — Rangoon Dec. 21-28.
Plague — Fo reign .
I'razil — Rio de Taneiro Dec. 27-Tan
.\frica— British Gold Coast—
.\ccra Jan. 13....
India — General Dec. 14-21.
India — Bombay Dec. 31-Jan.
India — Calcutta Dec. 14-21..
India — Madras Dec. 21-27..
India — Rangoon Dec. 21-28..
Peru — Catacaos Jan. 4-1 1 .
Peru — Lima Jan. 4-1 1.
Peru — Paita Jan. 4-1 1-
Peru — Piura Jan. 4-11.
I'eru — Trujillo Jan. 4-11.
Present.
2,600
Present.
Present.
Present.
Present.
Public Health and Marine Hospital Service:
Official list of changes of stations and duties of com-
missioned and noncommissioned officers of the United
States Public Health and Marine Hospital Service for the
zccel; ending February 8, 1908:
B.\HRESBURG. L. P. H., Passed Assistant Surgeon. Granted
leave of absence for seven days from January 28,
1908. on account of sickness.
B.MLHACHE. P. H., Surgeon. Directed to report at the
Bureau for special temporary duty; upon completion
of which to rejoin his station at Mobile, Ala.
BIRTHS, MARRIAGES, AND DEATHS.
(New York
Medical Journal.
Bui.LARD, J. T., Acting Assistant Surgeon. Granted leave
of absence for thirty days from February 14, 1908.
Collins, G. L., Assistant Surgeon. Granted leave of ab-
sence for seven days from January 28, 1908, under
paragraph 189, Service Regulations.
Dl ke, B. R, Acting Assistant Surgeon. Granted leave
of absence for twenty days from January 6, 1908, on
account of sickness.
E.\KiNs, O. M., Acting Assistant Surgeon. Granted leave
of absence for thirty days from April 10, 1908, and
excused from duty for a further period of two months,
without pay, from the expiration of said leave.
Earle, B. H., Passed Assistant Surgeon. Granted exten-
.sion of leave of absence for eight days from February
II, 1908.
Foster, M. H., Passed Assistant Surgeon. Directed to
proced to Ponce, P. R., for special temporary duty ;
upon completion of which to rejoin his station at San
Juan, P. R.
Francis, Edward, Passed Assistant Surgeon. Granted ex-
tension leave of absence for seven days from February
8, 1908.
GuiTERAS, G. M., Surgeon. Directed to proceed to Fort
Arthur, Texas, for special temporary duty: upon com-
pletion of which to rejoin his station at Mobile, Ala.
Keatley, H. W., Acting Assistant Surgeon. Granted leave
of absence for one day, February 4, 1908, under para-
graph 2X0, Service Regulations.
Lavinder, C. H., Passed Assistant Surgeon. Granted an
extension leave of absence for ten days from February
14, 1908.
McKay, M., Pharmacist. Granted leave of absence for
thirty days from March i. igo8.
Miller, Charles. Pharmacist. Temporarily relieved from
duty at the Marine Hospital in San Francisco and di-
rected to report to Passed Assistant Surgeon Blue, San
Francisco, Cal., for special temporary duty.
MuLLAN, E. H., Assistant Surgeon. Granted leave of ab-
sence for one day, January 4, 1908, under paragraph
191, Service Regulations; granted leave of absence for
seven days from January 29, 1908, on account of sick-
ness.
Parker, H. B., Passed "Assistant Surgeon. Granted leave
of absence for five days from January 27, 1908, on ac-
count of sickness.
Ramus, Carl, Passed Assistant Surgeon. Granted leave
of absence for three months and twenty-three days
from March i, 1908, with permission to go bcvond the
sea.
Roberts, N., Assistant Surgeon. Granted leave of absence
for six days from February 3, 1908, under paragraph
191, Service Regulations.
Thompson, W. R. P., Acting Assistant Surgeon. Granted
leave of absence for twelve days from January 10,
1908.
Ward, W. K., Passed Assistant Surgeon. Granted leave
of absence for one day from January 3, 1908, under
paragraph 191, Service Regulations.
Warren, B. S., Passed Assistant Surgeon. Relieved from
duty at Chicago. Til., and directed to proceed to St.
Louis, Mo., and assume command of the Service at
that port.
Woli.enburg,, R. a. C. Assistant Surgeon. Granted leave
of absence for seven days from January 2, 1908, under
paragraph 191, Service Regulations.
Board Convened.
A board of medical officers was convened to meet at Fort
Townsend Washington, February 14, 1908, for the purpose
of Piaking a physical examination of an officer <if the
Revenue Cutter Service, to determine his fitness for promo-
tion. Detail for the board: Surgeon W. G. Stimpson,
chairman, and Passed Assistant Surgeon J. H. Oaklev,
recorder.
Army Intelligence:
Offiiial list of changes in the stations and duties of
officers serving in the medical department of the United
States Army for the zveek ending February 15, IQ08:
Davis. W. T., Captain and Assistant Surgeon. Leave of
. absence extended five days.
Flagg. C. E. B., Captain and Assistant Surgeon. Assign-
ment to duty in the Philippine Islands revoked.
Gray, W. W., Lieutenant Colonel and Deputy Surgeoa
General. Relieved from duty as chief surgeon and
attending surgeon. Department of the Gulf ; ordered
to proceed to the Philippine Islands, and upon arrival
at Manila to report in person to the commanding gen-
eral, Philippines Division, for assignment to duty.
Shimer, I. A., Captain and Assistant Surgeon. Orders
so amended as to direct him, on arrival at San Fran-
cisco, Cal., to report for duty as surgeon of the Trans-
port Crook. Upon arrival at Manila, Captain Shimer
to report in person to the commanding general. Philip-
pines Division, for duty as heretofore ordered.
Navy Intelligence:
Official list of changes in the medical corps of the United
States Nai'y for the zveelz ending February 15, igo8:
Brown, E. M., Passed Assistant Surgeon. Detached from
the Naval Hospital, New Fort Lyon, Colo., and ordered'
to report at said hospital for treatment.
Fauntleroy, a. M., Passed Assistant Surgeon. Detached
from the Naval Hospital, Mare Island, Cal., ordered'
home, and granted leave for two months.
Married.
Carr — Ashley. — In Wilkesbarre, Pennsylvania, on Wed-
nesday. February 12th, Dr. Charles D. Carr, of Philadelphia,,
and Miss Sophia E. Ashley.
Culler — Loser. — In Philadelphia, on Wednesday, Febru-
ary I2th, Dr. Robert M. Culler, United States Army, and
Miss Anna E. Loser.
Saxe-Baer. — In New York, on Thursday, February
20th, Dr. G. A. De Santos Saxe and Miss Laure Baer.
Died.
Badger. — In Flushing, New York, on Thursday, February-
13th, Dr. William Badger, aged seventy-four years.
Baldwin. — In Newark, New Jersey, on Sunday, February
9th, Dr. Aaron K. Baldwin, aged sixty years.
Best. — In Brucetown, Fredonia County, Virginia, on
Wednesday, February 5th, Dr. William J. Best, aged
seventy-five years.
BiRKHOFF. — In Chicago, Illinois, on Sunday, February 9th.
Dr. David Birkhoff, aged fifty years.
Dalton. — In Tryon, North Carolina, on Tuesday, Feb-
ruary 4th, Dr. Martin J. Dalton, of Melrose, Massachu-
setts, aged forty-eight years.
Danziger. — In Cincinnati, Ohio, on Friday, I'ebruary
14th, Dr. Leo L')anziger.
Eggleston. — In Worsham, Prince Edward County, Vir-
ginia, on Tuesday. February iith, Dr. Joseph Dupuy Eg-
gleston, aged seventy-six years.
GoLDSBOROUGH. — In Walkersvillc, Frederick County,
Maryland, Thnrs.lay, February 6th, Dr. Charles W.
Goldsborough, aged si\l\ -^i ^ rii years
Gross. — In Piiil.ak Iplii.i. Saturday, February 8th, Dr,-
Willi:ini Dana Gro^-. .i^.l f(iriy-six years.
Hegeman. — In TriiN , New York, on Wednesday, Febru-
ary i2th. Dr. Williaui II. liegeman, aged eighty-one years.
"Heineman. — In Paris, l-'rance, on Tuesday, February
nth. Dr. Henry Newton Heineman, aged fifty-five years.
HuLLHORST. — In Lincoln. Nebraska, on Friday, February
7th, Dr. Charles G. A. llullhorst.
Laidley. — In St. Louis, Missouri, on Wednesday, Feb-
ruary sth. Dr. Leonidas H. Laidley, aged sixty-four years.
Moss. — In Morgan Hill, California, on Tuesday, Feb-
ruary 4th, Dr. Frank Hayden Moss, aged forty-three years.
Porter. — In Wardensville. Hampshire County, West
Virginia, on Thursday, February 6th, Dr. Hampton Porter,
aged seventy-two years.
Putnam. — In Lyons, New York, on Sunday, February
9th. Dr. J. W. Putnam, aged sixty-one years.
Richardson. — In Buffalo, New York, on Wednesday,
February 5th, Dr. Charles C. Richardson.
Schley. — In New York, on Saturday. February 8th. Dr.
Fayette E. Schley, aged fifty years.
Tiefenthaler. — In Washington. D. C., on Thursday.
February 6th, Dr. Benjamin F. Tiefenthaler, aged thirty-
nine years.
W)Li.i.\MS()N. — In Malone, New York, on Wednesday,
February 5th. Dr. Stacy Dwight Williamson.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal The Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXVII, No. 9. NEW YORK, FEBRUARY 29, 1908.
Whole No. 1526.
(Original ^ffmmnnicatiffns.
THE AFTER CARE OF THE INSANE*
By Frederick Peterson, M. D.,
New York,
Ex-President of the New York State Commission in Lunacy; Pro-
fessor of Psychiatry, Columbia University.
In the ten minutes permitted me for the discussion
of this particular type of care of convalescents, I can
only briefly cover what has been accomplished in the
matter of after care of the insane at home and
abroad. At a recent dinner I heard a pessimist say
that in almost everything relating to social organiza-
tion the United States are at least fifty years be-
hind Europe, and in the indignant discussion which
followed I am afraid he had rather the best of the
argument. However, it was generally agreed that no
other country is so quick as ours to remedy its de-
fects when once clearly recognized.
The circumstances surrounding insanity are very
different from those associated with other forms of
illness. Insanity is a protracted malady, and conva-
lescence and cure are matters of months or even
years after admission to hospitals. When the poor
and friendless insane are finally discharged they
come almost as strangers into the community and
are often wrongly regarded, if their history is
known, with some degree of suspicion, even appre-
hension. To have been in a hospital for the insane,
even if now fully restored to health, is unfortunately
looked upon as a handicap. By long sequestration
one loses touch with old associates and feels among
his former haunts like Rip Van Winkle after his
sleep of twenty years. These conditions favor the
recurrence of his malady. Then, too, the number of
convalescent and cured insane is much larger than
we ordinarily realize, and, as most of the hospitals
for the insane are in the country far from civic cen-
tres, few of us know that their total population is
about 27,000 in the State of New York alone. And
when we consider that their mental disorder has
often been the result of conditions of struggle and
stress in the maelstrom of our social life, and that
they must return to a similar or perhaps harsher en-
vironment, less well equipped for the battle because
of the tragic infirmity they have suflfered, we can
readily see that an aid society for the recovered in-
sane must make an especial appeal to our sympa-
thies and take high rank among after care institu-
tions.
I believe that it was nearly two hundred and sixty
years ago that the first after care institution of any
•Read before the Section in Public Health of the New York
Academy of Medicine, January 14, 1908.
Copyright, 1908, by A. R.
kind was established, and this was in France for the
benefit of convalescents from general hospitals. But
it was almost two centuries later before it occurred
to any one that an organization for the care of the
convalescent and recovered insane would be a pro-
ject worthy of our interest and consideration. It was
a German who originated the first society for the
help and protection of the recovered insane in 1829,
followed twelve years later by the establishment of a
similar society in France, and thirty years later by a
Guild of Friends of the Infirm in Mind in England.
Very soon after this there were in existence numer-
ous active societies for the care of the convalescent
insane in Germany, France, Austria, England, Swit-
zerland, and Italy.
The first suggestion for creating societies of this
kind in the United States seems to have come from
Dr. P. M. Wise, formerly president of the State
Commission in Lunacy of New York, in 1893, in a
paper read before the American Medicopsycholog-
ical Association, and in 1894 Dr. Henry R. Stedman.
of Boston, read a paper entitled Management of
Convalescence and the After Care of the Insane be-
fore the American Neurological Association. On
the motion of Dr. C. L. Dana at this meeting a com-
mittee consisting of Dr. Stedman, Dr. Dana, and Dr.
Dercum was appointed to investigate and report
upon some feasible plan for the aid and supervision
of the convalescent insane poor during the first
month or two after their discharge from asylums.
The report of the committee was published in the
transactions of the association in 1897. There was
an interval of several years before the after care idea
had any further development in this country. In
the meantime, Japan, always quick to adopt any-
thing practically helpful from our western civiliza-
tion, established an aid society for the insane in 1902.
Miss Louisa Lee Schuyltr, of the New York State
Charities Aid Association, who has done so much
for the insane and epileptic, may be described as the
founder of the first after care organization in this
country, and it is owing to her efforts, combined with
those of the superintendents of the State hospitals
for the insane, that an organization for after care of
the insane in the State of New York was established
in February, 1906, through the Committee on the
Insane of the State Charities Aid Association. A
subcommittee on after care was created, and the plan
provides for an after care committee to be appointed
by the State Charities Aid Association for each hos-
pital district in the State. Already five of the State
hospital districts have such after care committees,
and the reports of what has already been done are
very gratifying. The cause has been favored and
furthered by the excellent papers of Dr. Richard
Elliott Publishing Company.
384
CABOT: CONSERVATIVE PROSTATECTOMY.
[Ne'.v York
Medical Journal.
Dewey in 1(^05 and of Dr. Adolf Meyer, Dr. William
]\Iabon, and Dr. Robert M. Elliott in 1906 and 1907.
The rather unusual needs of the insane, as com-
pared with the needs of other convalescents, has led
of late to some extension of the functions of an after
care society, so that the qualification "after care"
does not fully represent our present conception of
such an organization. This evolution of a new and
larger ideal of work to be accomplished is due in
great part to the suggestive papers of Dr. Adolf
Meyer. Indeed, the old English designation, (iuild
of Friends of the Infirm in Mind, would better de-
scribe the present trend of combined efforts in this
direction. It is hoped that the hospital physicians
themselves will become members of the various after
care committees, not only for the purpose of follow-
ing up and aiding their recovered patients by wise
counsel, but in order to better study the milieu in
which the mental disorder arose, to better aid in the
fight against the preventable causes of insanity. Take
but one preventable cause, alcohol. How few realize
that 5.400 of the present inmates of asvlums in Xew
York State alone owe their insanity to alcohol !
A guild of this kind composed of hospital physi-
cians, local practitioners, lawyers, clergymen, busi-
ness men, and their wives, as they become familiar
with all matters pertaining to the insane through
their relation to the immediate objects of after care,
will diffuse ideas of prophylaxis through the com-
munity and educate the people in this important de-
partment of public health. Not only will prevent-
able causes thus be more generally recognized and
more strongly combatted. but the public will become
more alive to the need of early treatment and take
advantage of the opportimities now afforded for med-
ical advice in mental fli.sorders at outdoor depart-
ments of city clinics and c<)untr\' asvlums. Fore care
as well as after care of the insane is therefore one of
the new features in comiection with the type of in.sti-
tution under discussion here to-night.
BlBLIOGR.^PHY.
Wise, P. M. Proceedings of the American Medico-
psychological Association. 1^3.
Stedman. H. R. Proceedings of the American Neuro-
logical Association. 1894.
Stedman, Dana, Dercimi. Report of Committee on Aher
Care of the Insane. Proceedings of the American Neuro-
logical Association, 1897.
Dewey, Richard. Editorial in the American Journal of
Insanity, 1898.
Stedman, H. R. After Care nf the Insane. Proceed-
ings of National Conference of Charities and Correction,
1898. Charities Revieiv, March. 1899.
Dewey, Richard. Proceedings of National Conference of
Charities and Correction, 1905.
Schuyler, Louisa Lee. Proceedings of the Neiv York
State Commission in Lunacy, T905. Report of State Chari-
ties Aid Association, 1905.
Meyer, Adolf. The Prol)lem of After Care. Proceed-
ings of the Nczv York State Commission in I unacy, 1906.
Meyer, ."Xdolf. After Care and Prophylaxis and the
Hospital Physician. Proceedings nf the American Neu-
rological Association, 1906. Journal of Nervous and Mental
Disease, 1907.
Mabon, William. After Care of the Insane. Proceed-
ings of the American Medicopsychological Association,
1907. American Journal of Insanity. July, 1907.
Elliott, Robert M. After Care of the Insane. Proceed-
ings of the American Medicopsychological Association.
1907. American Journal of Insanity, July, 1907.
. State Charities Aid Association. First and Second .'\n-
nual Reports of the Subcommittee on .'\fter Care of the
Insane, 1906 and 1907.
4 West FiFrrRTH Strf.et.
CONSERVATIVE PROSTATECTOMY.*
By Follen Cabot, M. D.,
New York.
Attending Genitourinary Surgeon, City Hospital; Professor, Genito-
urinary Diseases, Postgraduate Medical School and Hospital;
Consulting Uiologist to White Plains Hospital.
During the past few years much progress has
been made in the treatment of prostatic hypertrophy.
The advancement has been mainly along surgical
lines. The mortality of 18 to 25 per cent, of ten
years ago has been gradually reduced, till now it
averages about 7 per cent. The results of the opera-
tion as to the urinary function, etc., have also shown
much improvement. In my own series of seventy-
two complete prostatectomies performed in the past
five years I have lost five patients. Two of these
were diabetics and the others were worn out from
long suffering. In looking back over these deaths
I believe, with my present experience and change
in methods, I could have saved at least three of
these men.
I have divided prostatics into three groups.
1. In the first group I have placed the cases
which are beginning to show evidence of prostatic
obstruction. There is usually no appreciable resid-
ual urine, but the force of the stream is somewhat
diminished, mild straining, increase in time of
emptying bladder and some increase in frequency
of urination. The patient probably rises twice dur-
ing the night to empty his bladder. This fact may
be the cause of his seeking his physician. Lipon
rectal examination we find as a rule some increase
in size of the prostate. This change, however, may
not be appreciable even to the trained finger. The
increase in prostatic growth may be entirely vesical.
By the careful employment of clean, flexible cathe-
ters and sounds the urethra may be searched for
stricture. I have, however, never seen a stricture
in a case of prostatic hypertrophy. The use of in-
struments may do harm unless handled with every
care. The general condition of the patients in this
first division is not materially affected.
2. In the second group I have placed those
patients who have two or more ounces of residual
urine, who are straining considerably, and getting
up four to five times at night to empty the bladder.
There is much falling off in the force of the stream
and it may even not go beyond the shoes, but almost
dribble away in some cases. As a result of the
broken sleep and also usually cystitis and pain, the
general health soon Ijecomes involved. Slight ex-
posure to cold, dampness, indiscretion in diet and
use of alcohol will all aggravate the symptoms, and
may even cause retention which necessitates use of
the catheter for its relief. If the obstruction has been
present for some time there is usually cystitis, and
often in addition pyelitis.
Rectal examination nearlv always reveals increase
in size of the prostate. The enlargement, however,
may be almost entirely vesical. The urinary dis-
tance as measured by the catheter is nearly always
increa.sed. In some of my patients a cysto.scopic
examination has been of value in determining the
condition of the bladder, presence of stone, diver-
ticula, and prostatic bulging. On the whole, though.
I have been .somewhat disappointed in this method
•Read before the Medical -Association of the Greater City of New
York, January 20. 1908.
February 29, 1908. J
CABOT: CONSERVATIVE PROSTATECTOMY.
385
of diagnosis and do not use it except in my perineal
cases.
3. In the third group I have placed those pros-
tatics who can no longer be treated by palliative
measures. They are usually very much shattered
in health and will not withstand much surgical
shock. The catheter no longer gives relief, but
often is the cause of haemorrhage, chills, and pain.
The patient is in constant distress, night and day.
The cystitis is of a severe grade, and occasionally
there is stone in addition to the enlarged prostate.
In many cases there will be a steady overflow and
dribbling of urine. Bladder instrumentation is usu-
ally out of the question, and yet some relief must be
given. There is nearly always a pyelitis and often
a pyelonephritis.
By rectum we usually find a large prostatic over-
growth. Manipulation by the finger produces much
pain as the prostate is pressed. This, no doubt, is
due to the additional engorgement of the organ as
a result of straining and inflammation. Haemor-
rhoids, often very large, are common, and even
prolapse of the rectum, as a result of efforts to
empty the bladder.
A man's age really has little to do with his power
to resist operative shock. The circulatory appa-
ratus, kidneys, and general condition must, however,
be carefully studied in every instance.
In the first group of prostatics, those in good
health, with mild symptoms, no operation is advis-
able unless there is evidence of advance in the
obstruction. This is shown by more frequent urina-
tion and straining on passing water. These patients,
therefore, should be carefully watched for any evi-
dence of advance in the process. Their lives should
be carefully regulated. Medicine is usually of no
use except in instances of infection, when urotropin
is of value. The bladder may also be washed out
two to three times a week. If, however, the disease
shows a well marked tendency to advance, an early
operation should be pyerformed. It is much more
conser\-ative to advise it before the machinery has
become impaired. It is easier for the patient and
surgeon. We are now seeing these patients earlier
in their disease, and, as a result, mortality is lower.
This fact, combined with improved technique and
better understanding of preliminary and after treat-
ment, has placed surgery of the prostate in a very
satisfactory state. Formerly no cases were operated
on till the condition was well advanced into the
second and even third group. The mortality there-
fore was necessarily high, and the operation often
done as a last resort.
When a patient sufifering with mild obstruction,
as shown in the first group, presents himself for
an opinion, and my observation convinces me that
an operation will eventually be necessary, I present
the probabilities to the patient and his physician. In
all the cases I have operated in this group I have
"had uniformly satisfactory results. I am also see-
ing more of these cases now.
In the second group we usually have evidence of
cystitis and often a secondary pyelitis. The catheter
"has to be used occasionally or perhaps constantly to
keep the patient at all comfortable. The night is
usually the worst time and although he may wear
a urethral catheter, he is never comfortable.
The broken rest, use of catheter and all it entails
really convert the patient into an invalid. No poor
man can afford it, and for any man except under
peculiar conditions it is most undesirable. There
are exceptional cases where proper use of the
catheter and general care result in comfort and long
life to the patient, but such cases are not common.
There is always danger of infection and other com-
plications which suddenly bring the patient into the
third group. In this third group something of a
surgical nature is necessary in order to preserve
life. It often hapens, too, that there can be no
further delay. The question therefore arises in all
cases in this group and some in those in the second
one, too, what shall we advise? A complete pros-
tatectomy is almost sure to be followed by death.
My friend. Dr. Lilienthal, answered this question in
1896 by suggesting and carrying into practice a two
stage operation. I have done this several times and
believe it to be of the greatest value. In all cases
of the least doubt of the patient's resistive power I
do a two stage operation.
The patient in a state of shock or low resistive
power is quickly prepared for operation. A supra-
pubic cystotomy is done under local or general
anaesthesia. This should not take more than five to
eight minutes. By this means we obtain all the
advantages of a complete operation without its dis-
advantages. The patient is put to bed wearing a
good sized drainage tube. He is made to sit up at
the end of twenty-four to forty-eight hours and
drained in this way till his condition is so good that
a prostatectomy can be quickly performed through
the same cut. This drainage may continue five days
to four weeks. The patient may sometimes wear
the tube indefinitely.
The cystitis gradually disappears, the condi-
tion improves, the engorgement of the prostate
passes away, and the patient, through rest and
forced feeding, regains his lost strength. He then
is given a small amount of chloroform and the pros-
tate is enucleated in a few minutes. The only cut
made at the second operation is the one about the
prostate.
If the patient cannot withstand these two small
operations it would have been useless to perform
a complete operation at one sitting. I believe this
method will be used more all the time, and will
further reduce the mortality.
The suprapubic route is the best one for this two
stage operation, owing to the comfortable position
of the tube.
There has been much discusion as to the best
operative route. In my opinion the perineal is
better in certain simple cases of a small prostate
low down, while in the majority of instances
the suprapubic route is the most satisfactory.
We are better able to control haemorrhage,
dress the wound, and also, I believe, obtain better
urinary results. The convalescence is, however,
somewhat longer, and there is a little more shock
than noted in perineal route. However, with the
two stage method, a divided operation does away
with the latter objection. I believe also it will make
the various cauterizing operations unnecessary.
The question of the result on the sexual power
has also been much discussed, and, I believe, exag-
gerated. I have never had but one man complain
of loss of sexual power in my list of seventy-two
386
FISCHER: MIDDLE EAR SUPPURATION.
[New York
Medical Journau
cases. It is usually much reduced before operation
and causes no particular concern after it. In fact,
I believe, with the operative results otherwise very
satisfactory, we need pay no attention to the sexuzil
side. In one case of perineal prostatectomy the man
said he felt stronger in sexual power.
In closing I will give the history of a case oper-
ated on by the two stage method :
Case. — This patient, referred to me by Dr. Hopke, of
Brooklyn, was operated upon in December, igo6. He was
seventy-five years old and had been suffering from symp-
toms of prostatic obstruction for twenty-five years. Gen-
eral condition was bad; irregular heart; well marked
arteriosclerosis. Digestive system was in fairly good con-
dition, some albumin and few casts in urine showing evi-
dence of renal irritation as result of back pressure. There
was very severe cystitis, alkaline urine with well marked
ammoniacal decomposition. Urinating six or seven times
at night and each hour or less in day till catheter life was
begun shortly before I saw him. Residual urine, 14 oz.
Urinary distance somewhat increased and prostate, by rectal
touch, high up and difficult to reach. It was apparently not
very large and felt smooth and firm. Recently patient com-
plained of chills and had reacted badly to bladder irriga-
tion, but had never passed much blood.
Owing to the patient's enfeebled condition and severe
cystitis it seemed best to operate by two stages, and so I
performed a supracystotomy under light chloroform anaes-
thesia, it being thought best not to give nitrous oxide. The
bladder was opened under air dilatation and a tube of 44
French calibre introduced. The prostate and bladder were
also carefully palpated, all of which took eight minutes.
The third lobe or isthmus was hypertrophied and caused the
difficulty. The rubber drainage tube was kept in place with
a Bang's shield and the patient put to bed.
The old gentleman quickly recovered from the anaes-
thesia. Strychnine sulphate gr. 1/30 each three hours was
administered, also small quantites of soft, uncharged water
were soon taken at frequent intervals. The latter was given
to stimulate the kidneys. While the pulse never went over
100 and the temperature remained at about 99.5° F., there
was considerable prostration the following day. However,
in forty-eight hours the patient rallied well, and on the
third day sat in a chair for an hour or two. Bladder was
washed frequently with boric acid and saline solution.
Cystitis gradually improved with addition of urinary anti-
septics and acids to correct alkaline reaction. In about two
weeks the patient was walking about and going downstairs
to his meals. At the end of three weeks the urine was clear
and free from albumin. He was in much better condition
than he had been for several years. I then, without tell-
ing him that the operation had not been finished, operated
again through same cut under chloroform, and in nine min-
utes removed the prostate. During the enucleation a
catheter was introduced through the penis, hot saline solu-
tion was continually run into bladder and at the end of the
operation several ounces of solution of adrenalin 1/3000
was introduced. There was a very small amount of haemor-
rhage. The congestion about the prostate had disappeared
during the period of rest and so there was less blood in and
about the gland. The enucleation was carried out so that the
whole prostate was removed in one piece. The prostatic
capsule was packed with a strip of gauze which had been
soaked in adrenalin i in 3000. The urethral catheter was
left in place behind the packing to use for adrenalin in case
of haemorrhage and later, after the gauze was removed at
end of forty-eight hours, for inlet to irrigation. The large
tube in the suprapubic wound was for outlet to fluids.
The patient seemed to have less prostration following this
final operation than he did from the preliminary one. I
attribute this fact to his improved condition as a result of
good drainage of bladder, rest, and nursing for three weeks.
In three days he was up and at the end of seven days both
tubes were removed. During the healing of wound a small
catheter was daily passed into the bladder through wound
and the cavity irrigated. In fourteen days the wound had
completely closed and the patient was soon passing urine in
a very satisfactory manner. The control was good from the
first, as it usually is when the operation is performed supra-
pubicaily. After this time no further irrigation was em-
ployed and no urethral sounds passed at any time. It does
not as a rule seem_ to be necessary unless there is some
complicating condition in the urethra which needs it. Stric-
ture, however, in my experience, is rare in prostatics. In.
June the patient reported himself in fine condition, was back
at work, had no urinary symptoms, emptied his bladder
completely and felt better than he had for twenty-five years.
129 East Thirty-first Street.
THE GASTROINTESTINAL SYMPTOMS OF MID-
DLE EAR SUPPURATION.*
By Louis Fischer, M. D.,
New York,
Attending Physician to the Children's Department •£ the Syden-
ham Hospital, and to the Willard Parker and Riverside
Hospitals, etc.
When a child presents gastrointestinal symptoms
one would naturally infer that the stomach or the
intestines are the seat of the trouble. We must re-
member, however, that very many diseases are
ushered in by vomiting, others by vomiting and
diarrhoea, so that a careful distinction of the aetio-
logical factor is demanded.
Vomiting and fever occurring in the preeruptive
stage of scarlet fever has many times been diag-
nosticated as a spoiled stomach. The careful in-
spection of the throat would have solved this mys-
tery. Such serious mistakes may mean an exposure
in school or home of healthy children to one of the
worst infectious disorders of infancy and childhood.
Vomiting is an early symptom in tuberculous men-
ingitis, therefore a symptom that assumes greater
dignity because it may mean an initial manifestation
of any one of several disorders. In like manner an
infection of the middle ear, be it due to the strep-
tococcus or to the pneumococcus, frequently causes
gastric or gastroenteric disturbances. The gastric
symptoms, per se, be they vomiting, anorexia, or
meteorismus, are simply toxic manifestations of the
otic infection, and they are really the result rather
than the cause of the trouble.
Secretions from the rhinopharynx in a young
child are never expectorated, but invariably swal-
lowed. Such discharges may increase the severity
of the gastric symptoms. Kossel found that in a
case of otitis infection due to Bacillus pyocyaneus,
the same bacteria were found in the stomach as were
found in the middle ear.
Pathogenic bacteria lie dormant in the mouth and
in the rhinopharynx. They gain entrance to these
parts first by the air, second through faulty hygiene.
One of the most frequent means of introduction of
pathogenic bacteria is the common nipple used to
soothe the baby while crying.
Prcysing' studied a series of 121 infected ears.
He found a pneumococcus infection in 112 cases, or
92.5 per cent. This alone forced Preysing to be-
lieve that otitis media in nurslings is a specific entity
due to a pneumococcus infection.
Zaufals found that we are dealing with a pri-
mary otitis due, according to him, to the pneu-
mococcus infection, whereas the secondary infections
•Read, by invitation, at a symposium on middle ear suppuration,
before the Eastern Medical Society, January 10, 1908.
iPrevsnig, Otitis Media dcr Sauglinge. 1904.
February ^p, 1908.]
FISCHER: MIDDLE EAR SUPPURATION.
387
are caused by the streptococcus. He then divides
the primarv- conditions into those following ex-
posure to cold and benign catarrh. In secondary
cases, those following scarlet fever, measles, diph-
theria, and typhoid. Influenza is looked upon as
one of the most frequent causes of otitis by Gom-
perz.
Rasch" found the pneumococcus in thirty-three
cases of mucus exudate out of a series of forty-
three examined by him. Leutert' found in a study
of the bacteriology of otitis in small children that
when a tendency to empyema was found, then the
streptococcus was the causative factor, so that it
would seem that the streptococcus was demon-
strated more often in those cases leading to an
empyema, whereas the pneumococcus was found in
the milder type of middle ear inflammation.
Weiss not only studied the superficial bacteria,
but also studied sections of tissue to see how deep
the bacteria penetrated. He found the Diplococcus
^neumonice in 42 per cent., the Streptococcus pyo-
genes in 39 per cent., the Staphylococcus albus in
27 per cent., the Staphylococcus aureus in 12 per
cent. His cases were as young as twenty-five, thir-
teen, eleven, and two days old. Gomperz* believes
that otitis is more frequent following influenza than
it is in any ether infectious disease.
Method of Infection. — Pathogenic bacteria can
enter with air and nasal secretions through the nose
into the Eustachian tube. In like manner an in-
fection can take place from the pharynx or by in-
fectious secretions from the bronchi. During the
act of vomiting it is easy for pathogenic bacteria to
gain entrance through the Eustachian tube in the
rhinopharynx. The act of sneezing, yawning,
coughing, swallowing, and muscular action asso-
ciated with regurgitation of food, especially while
the child is in the dorsal position, are all conditions
which should be remembered in seeking the source
of an infection. The ease with which nurslings
vomit seems to call for especial stress. Fluids will
frequently be expelled through the mouth and nose.
If, therefore, the nose is obstructed by accumu-
lated secretions, and there is a damming back of de-
composed food in the rhinopharynx, bacteria if
present can be forced easily into the Eustachian
tube.
Netter' examined thirty-one cases post mortem
and found that out of these, twenty-eight cases of
otitis were caused by the pneumococcus. Kossel,^
in studying nurslings with special reference to mid-
dle ear inflarnmation, found that out of 108 cases
in the institute for infectious diseases in Berlin,
eighty-five had inflammation of the middle ear;
thirty-eight of these were carefully studied bacterio-
logically ; half of these contained a bacillus resem-
bling Pfeiffer's pseudoinfluenza bacillus. In ten
cases he found Frankel's pneumococcus, in four
-Rasch, Ueber die Hiufigkeit und Bedeutung von Mittelohr-
entzundungen bei kleinen kranken Kindern. Jahrbuch fiir Kin-
derheilkunde. xviii. 1894.
'Leutert, Bakteriologisch-klinische Studien uber complizierte akute
und chronische Mittelohreiterungen, Archiv fiir Orhenheilkunde,
1899, Nos. 46 and 47.
^Gomperz, Mittelohrentsiindungen im Sauglingsalter.
^Frequence des relations des affections aux pneumocoques, 1890.
*Kossel, Ueber Mittelohreiterung bei Sauglingen. Charite An-
nalen, xviii. 1893.
Staphylococcus, in two cases ' streptococcus and
Friedlander's pneumonia bacillus. Once he found
tubercle bacillus, also once Bacillus pyocyaneus.
The same pathogenic bacteria found in broncho-
pneumonia were also found in the middle ear. In
thrombosis of the cerebral sinus he found the Fried-
lander's pneumonia bacillus. In the pyocyaneus in-
fection, the same bacteria were found in the stom-
ach, and thus gave rise to vomiting and diarrhoea.
Diarrhoea may be due to Nature's method of
eliminating poisons stored in the body. If a child
suddenly shows gastric disturbances and if the food
suddenly disagrees, then the temperature should be
taken. In addition to the careful examination of
the stomach and intestines, the nose and throat
should be examined. No diagnosis should be con-
sidered complete until the throat, and especially the
ears, have been examined. The symptoms of an
otic infection may so resemble an acute milk infec-
tion that only careful examination of the ears can
determine the correctness of such diagnosis.
The gastrointestinal symptoms due to the tox-
aemia resulting from a pneumococcus infection or
a streptococcus infection of the middle ear appear
in the following manner:
Breast Fed Infant. — There is usually a history of
some member in the family having had the grippe.
The infant up to this time had been enjoying ex-
cellent health. It is suddenly taken sick. The hu-
man milk causes dyspeptic symptoms, such as vom-
iting, diarrhoea, greenish or curded stools, and
anorexia. The infant turns away from the breast,
and the mother in her anxiety to feed the baby
commits the dietetic error of too frequent, feeding.
Accompanied by these symptoms there is a marked
febrile disturbance. The temperature may be ioi°
F. and rise to 104° F., or even 105° F. The pulse
rate is accelerated and may reach 130 or 140. The
pulse never intermits as it does in tuberculous men-
ingitis. The respiration is also increased, and is
usually between 30 and 40 per minute. There is
no cough present, and there are no distinct evi-
dences of pulmonar)- involvement. The surface
the skin feels hot, and the head is flushed. At
times an erythematous or an urticarial eruption will
be found on various parts of the body, chiefly con-
fined to the face, thorax, and abdomen. This punc-
tate eruption lasts from three to four days. The
infant has a marked apathetic condition and moans
at times as though in pain. The stomach and abdo-
men appear distended, and percussion shows marked
meteorismus. The flatulence is also evident by
frequent eructations as well as by the expulsion of
flatus. The tongue is coated with a whitish fur.
The pharynx and tonsils appear read and congested,
but there are no visible patches. There is a marked
odor of acetone perceptible from the breath. The
cervical glands are not involved.
Bottle Fed Infant. — The clinical manifestations in
an infant, brought up artificially, are usually more
intensified. The same clinical picture of nausea,
vomiting, fever, and gastroenteric disturbances will
also be found. In addition thereto the temperature
may reach 105° F. at the very beginning, and the
symptoms may be ushered in by convulsions. There
388
COHN: PURULENT OTITIS MEDIA.
[New t'oRK
Medical Journal.
may be grinding of teeth. The stools, which until
now have been of a uniform consistency, show evi-
dences of enterocolitis. They are either green or
muddy and contain mucous and undigested particles
of food, and are foul smelling. They are accom-
panied by large quantities of gas. From the irrita-
tion of these acid stools there may be an excoriation
around the anus and the buttocks are usually red
and inflamed. The urine shows a high gravity and
acetone in addition to quantities of indican, the
latter indicating a disturbance of metabolism due to
putrefactive absorption. The gastric symptoms will
continue in spite of careful dieting. So, also, un-
digested particles of food will be found in the stool,
showing the effect of the toxine on the glands of
the stomach and intestines. When intestinal diges-
tion is impaired, in spite of eliminative treatment
and careful dieting, it proves that the seat of the
trouble is located elsewhere. An examination of
the blood in a doubtful case of prolonged fever may
at times reveal obscure suppuration. If the poly-
nuclear percentage is very high then it speaks for
the presence of pus. The fever curve is one that
shows wide variations similar to what we find in tu-
berculous meningitis.
As a rule the symptoms are more pronounced in
the marasmic or atrophic child. It is hardly in the
province of this paper to go into the details of sec-
ondary infections resulting from the acute exan-
themata further than to say that an associated ear
complication must always appeal to the physician,
and hence as a routine method of watching the
urine is demanded, so also must the ear be carefully
supervised by the attending physician or by an
aurist if necessary.
In a normal infant during the act of crying or
screaming the drum membrane appears pink or rose
colored. It is advisable, therefore, to examine the
ear gently and quickly while the infant is asleep to
prevent its waking and crying.
65 East Ninetieth Street.
INDICATIONS FOR SURGICAL INTERVENTION IN
SUPPURATING MIDDLE EAR DISEASES OF
INFANCY AND CHILDHOOD.*
By Felix Cohn, M. D.,
New York.
The first and important surgical intervention, the
performance of which it is our duty to consider in
middle ear disease of infancy and childhood, is the
incision of the drum membrane, or, as it has been
originally designated, the operation of paracentesis.
While we still abide by the old appellation, it is well
to remember that the simple puncture with the so
called paracentesis needle has been laid aside by
most otologists, a thorough incision having proved
to be the more surgical procedure and the one giv-
ing the best results.
Indications for Paracentesis.
In formulating indications for paracentesis of the
membrana tympani, it is necessary to consider the
character of the inflammation from every point of
•Read before the Eastern Medical Society, January 10, 1908.
view, from the pathological, bacteriological, and
surgical.
The pathologist recognizes two main forms of
acute middle ear inflammation, an otitis medin
catarrhalis simplex acuta and an otitis media acuta
mucopurulenta sive purulenta. In the former the
exudate is usually serous or mucous in character;
in the latter the discharge is always mucopurulent
or purulent. The simple catarrhal otitis represents
a lighter form of inflammation ; the latter a graver
one. From the bacteriological standpoint this dis-
tinction does not entirely hold, as we now recognize
a streptococcic form of invasion, for instance, which
may give a serous exudate accompanied by compli-
cations fully as severe as the mucopurulent or puru-
lent types of inflammation. A practical subdivision,
from the surgical point of view, and usually accept-
ed, recognizes a nonperforative and a perforative
form of inflammation.
We speak of a middle ear inflammation as being
perforative if a restitutio ad integrum is impossible
without artificial or spontaneous vent having been
given to the exudate contained in the tympanic
cavity. The acute catarrhal inflammation is usual-
ly a nonperforative form ; the exudate, generally
mucous or serous in character, becomes absorbed ;
in the perforative form, the exudate is usually muco-
purulent or purulent. If we bear in mind these
facts the formulations of our indications for para-
centesis are almost obvious and we can logically
conclude that :
I. — Paracentesis is indicated in every form of
perforative inflammation. — It should be our aim and
it is our duty in this form of inflammation to incise
the drum membrane if possible before spontaneous
rupture can occur, in order to alleviate all symptoms
and establish the most efficient drainage. It fol-
lows likewise that in those cases in which rupture
has occurred, it is our duty to aid Nature by mak-
ing an incision if there are any symptoms pointing
to retention, pressure, etc.
Bearing in mind our classification it follows nat-
urally as an absolute and obvious deduction that:
II. — Paracentesis is not indicated in the nonper-
forative form of inflammation. — The formulation of
these two indications would suffice were it not for
the fact that in practice we meet with a group of
cases in which we unfortunately are perplexed to
determine the character of the otitis, and if we ques-
tion ourselves, therefore, as to the fact whether we
have any absolute guide which enables us to dis-
tinguish between these forms, we must frankly con-
fess that even the most experienced will find it
impossible in every case from its inception to de-
termine absolutely upon the character of the in-
flammation.
We are, therefore, compelled to add as a third in-
dication that:
III. — Paracentesis should be performed in every
doubtful case in which distinction is impossible or
difficidt, and whenever immediate depletion and
diminution of tension in the tympanic cavity appear
advisable. Our aim. however, should be to evolve
a symptomatology which will enable us to distin-
guish between the various forms of inflammation.
February 29, 1908. 1
COHN: PURULENT OTITIS MEDIA.
389
and reduce our third indication — a testiiiioniiiiit pau-
pertaiis — to as few cases as possible.
The fact of the difficulty in distinguishing has
made the subject of indication for paracentesis a
very active and mooted one in the last years, and
has tended to cause a great deal of discord among
otologists ; we might speak to-day of two camps,
those otologists who perform paracentesis too often,
and those who perform paracentesis too seldom. By
carefully evolving the symptomatology in every
case, take cognizance of the otoscopic picture, the
subjective and objective symptoms, and remember-
ing to individualize, a happy medium between these
two violent extremes ought not to be difficult to
find. As a guide to the practitioner, we can state
that for most otologists a trias of symptoms has
been considered as an indication for paracentesis,
namely, a bulging drum membrane accompanied by
pain and the presence of an elevated temperature.
While for most cases this trias occurring simulta-
neouslv may be considered a safe guide for the
diagnosis of a perforative otitis, I have found one
modification of great service in enabling me to dis-
tinguish— of course I am simply outlining in gen-
eral and not any particular case. For instance, ear-
ache not readily controlled by application of heat
and recurring quickly after removal of poultice or
water bag, accompanied by a rise in temperature
and a bulging, usually speaks for the existence of a
perforative form of inflammation. On the other
hand, given a child suffering from intense earache,
on examination you may find a high temperature,
a typically bulging drum membrane, apparently the
complete trias;" if you apply moist heat or a water
bag the child quiets down speedily, and in a few
days you find a complete restitution to the normal, a
type of catarrhal inflammation apparently simulat-
ing a perforative form. If we therefore take into
consideration this fact, that in many cases a diag-
nosis can only be made by a little prolonged ob-
servation and in some cases by the application of a
heat test, if I may so term this symptom, we formu-
late naturally as our fourth indication :
IV. — Not to perform paracentesis too early; un-
less some aggravating symptoms demand such in-
terfa-eiice. Wait until the symptoms have some-
what developed. That, of course, does not mean
waiting indefinitely, but waiting from hour to hour
and possibly from day to day.
There is another disadvantage to paracentesis
made a little too early, before the inflammation has
somewhat progressed, diminution of depleting effect
of operation and tendency to closure of incision be-
fore formation of discharge. In formulating the
indication not to do paracentesis too early, it must
be understood that the term early refers to the
course of the inflammation, rather than to the actual
lapse of time. In one case a paracentesis at the
end of twelve hours may be late ; in another a para-
centesis performed on the second or third day may
be considered in that individual case a fairly early
paracentesis. Usually the time when a paracentesis
should be performed may range from the beginning
of the onset up to the second, third, or even fourth
day ; and a careful consideration of the tout ensem-
ble will enable us to select the suitable time for the
incision of the drum membrane.
I do not wish to leave this subject, which, un-
fortunately, the allotted time does not permit me to
exhaust properly, without warning the practitioner
that occasionally there are cases without any symp-
toms— no trias, a slight history of earache, where
only a pysemic rise of temperature points to the
presence of an exudate — which, above all others, re-
quire immediate paracentesis to prevent unfortunate
and even fatal complications, such as a resulting
otogenic pyaemia, a complicating circumsinous
abscess, etc., the apparently light form of otitis hav-
ing been overlooked on account of the absence of
the subjective earache to which the practitioner so
frequently attaches too much importance.
In the perforative forms, however, the practi-
tioner will rarely find normal or almost nomial ap-
pearance of the drum membrane. In the ordinary
perforative forms, except in those rare cases in
which other dangerous symptoms predominate, a
paracentesis should not be made before such
changes as considerable swelling or partial swelling
of the membrana tympani is noticeable, unless a dis-
tinct exvidate accompanied by febrile symptoms is
present and the exudate visible through the tym-
panum. Exceptions to this are in otitis occurring in
the course of the so called infectious diseases, mea-
sles, scarlet fever, etc. : early paracentesis should be
the rule in order to diminish the eft'ect of the necro-
biotic changes that take place in the tympanic cavity
and drum membrane, thereby mitigating the rav-
ages otherwise caused. Paracentesis should be
made at the earliest indicated occasion ; even a
slight bogginess of Schrapnell, without bulging of
the drum membrane, should be considered enough
indication for paracentesis. The resulting depletion
and reduction of pressure may assist us in prevent-
ing sloughing and destruction of the drum mem-
brane, so often the sad sequelae of morbillic and
scarlatinous inflammations.
Let me emphasize the importance of the practice
of absolute asepsis in our incision. Thorough
cleansing of the canal, removal of cerumen and
scales, and the regular practice of the application
of an occlusion bandage for several hours after
paracentesis may prevent secondary infection in
those cases where discharge or exudate has not yet
made its appearance, and a change of what might
have been a nonperforative form of inflammation
into a perforative form, with source of complicat-
ing dangers to the patient.
Indications for Perforating the Mastoid.
Congestion of the mastoid bone so frequently ac-
companies otitis media, and the otitis media itself
is so often only a secondary or concomitant mani-
festation of a mastoid infection, that we cannot be
surprised to find affections of the mastoid requiring
operative interference an occasional sequel to the
most carefully and scientifically treated otitis. In
fact, congestions of the mastoid cells and the bone
itself have been regular post mortem findings in
children suffering from otitis, where even no symp-
tom.s pointing to these conditions were recognizable
during life. It will be well, therefore, to utilize
these anatomical facts, and right here emphasize
that a congestion of the mastoid, as evinced by ten-
derness on pressure to the touch, or even a greater
degree of inflammation, a periosteal swelling, as
39°
COHN: PURULENT OTITIS MEDIA.
[New York
Medical Journal.
evinced by oedema over the mastoid occurring in the
beginning of an otitis, is no mastoiditis and does not
require an immediate opening of the mastoid. On
the contrary, tliese congestive conditions often dis-
appear, and heal out spontaneously. Mastoid con-
gestion may be readil\- compared to the inflamma-
tion of the accessory nasal sinuses found during at-
tacks of influenza and acute rhinitis, which also
terminate favorably if left to themselves.
The pathological conditions affecting the mastoid
that may interest us from the point of surgical in-
terference are briefly stated as follows: Mastoid
osteitis and periosteitis, empyema of mastoid antrum
and cells, epidural and cerebral abscesses, various
forms of meningitis, circumsinuous abscesses, sinus
phlebitis and thrombosis. For the sake of complete-
ness let me recall the formation of deep and cuta-
neous abscesses of the neck and head, lymphangeitis
and lymphadenitis, general pyaemia, septicaemia, etc.
The bacteriological sources of infection which in-
terest us mainly are the streptococci, pneumococci,
and staphylococci. It is important to elicit the char-
acter of the bacterial infection, as the form of bac-
terial invasion may influence us in the selection of
the time for operative interference, whether to op-
erate a little earlier than even the general symptoms
might otherwise demand.
A notable symptom pointing to the presence of
pathological changes in the mastoid has been al-
ready referred to, namely, sensitiveness of the mas-
toid on pressure. While sensitiveness of the mas-
toid on pressure, in the beginning of an otitis must
not be valued as a diagnostic sign for operative in-
terference, and though even a persistency of the
sensitiveness for a time may be overlooked, provided
it had been present from the beginning of the otitis
and shown a tendency to retrograde, persistency of
the tenderness or a sensitiveness first manifesting
itself in the course of the otitis, after drainage has
been freely established — say, at the second or third
week — is a cardinal symptom in the consideration of
operative interference. A recurring sensitiveness,
after the sensitiveness had already disappeared, is
also an important indication. If besides the pres-
ence of tenderness we find a gradual reddening over
the mastoid, standing ofif of the auricle, cessation of
the discharge, followed by swelling over the mas-
toid, or the presence of an increasing otorrhoea
which becomes gradually more and more purulent,
presenting the character of bone pus, if we find
gradually increasing and exacerbating temperatures
our picture of a mastoid inflammation, requiring
operation, is complete.
Certain points of selection on the mastoid are also
to be looked for, and will aid us in establishing our
indication, tenderness on pressure immediately over
the fovea antri, on the apex, or on the lateral por-
tion of the mastoid in the region of the sinus or
emissary vein.
The otoscopic picture, the quantity and the char-
acter of the discharge, the appearance of the upper
Avail of the osseous portion of the external canal, are
all important guides. At times the character and
quantity of the discharge, with a bare rise of tem-
perature, may be the only symptoms to point to a
mastoiditis, without the presence of any noticeable
changes about the mastoid. Temperatures must be
carefully watched, for in some cases, when the
symptoms are more or less obscure, a sudden rise in
temperature, or gradual rise, will enable us to diag-
nose the presence of mastoid involvement requiring
an operation.
I have already exceeded the time allotted to me,
and therefore cannot enter into the complete symp-
tomatology of more serious and secondary compli-
cations : Let me only refer to the presence of ver-
tigo, headache, neuralgia, convulsions, chills, septic
temperatures, the quality and character of the pulse,
the aid that may be obtained from the bacteriologi-
cal and blood examination, the condition of the
fundus, all symptoms which, if carefully noted, will
enable us to operate on our cases in due time and
also guide us to the extent to which our operations
should be carried, whether a simple and thorough
mastoid operation will suffice, or whether a more
extensive operative interference will be indicated,
such as exposure of an existing circumsinous or a
cerebral abscess, removal of infected thrombi in
sinus thrombosis, the ligation of the jugular, and
so on.
Conclusions.
In conclusion I desire to enumerate briefly the
following indications which have guided me in my
operations, and which were formulated by me in
i8y6 in an article on the Indications for Perforating
the Mastoid.'
I. — The mastoid should be opened in all cases of
diagnosticated osteitis, if under the usual antiphlo-
gistic treatment the inflammation shows no tendency
to resolution.
II. — In pronounced cases of otitis media, compli-
cated by antral empyema, in which the discharge is
purulent, and shows no tendency to evacuate
through the middle ear.
III. — In all cases of prolonged otitis with profuse
otorrhoea which show no tendency to resolve within
a reasonable period, the tiine chosen for operation
depending upon the manifest symptoms, whether,
for instance, retention is present or the mastoid bone
itself is involved.
IV. — In every case of acute otitis, in which there
are dangerous symptoms of resorption, and in
which the drainage cannot be established by para-
centesis or by the natural perforation. In those
cases, even without manifest symptoms of mastoid
affection, the mastoid should be opened in order to
produce more favorable drainage and enable a
thorough cleansing of the ear.
V. — In all cases of mucopurulent otitis, in which
the otitis is evidently maintained by the mastoid
osteitis, the time for operation depending upon the
condition of the patient and the presence or absence
of symptoms pointing to retention or other compli-
cation of a serious nature.
VI. — In cases of protracted otitis, in which there
are symptoms of serious secondary complications
involving danger of extension of the inflammation
inward toward the brain or to the sinus or down-
ward, toward the neck.
VII. — In case of uncomplicated acute otitis, in
which stenosis of the external canal prevents drain-
age and thorough cleansing of the middle ear.
31 East Sixtieth Street.
^Netu York Medical Journal, August 8, 1896.
February 29, 1908.I
ROSEXBERGER: SPIROCHJETA PALLIDA
THE PRESENT STATUS OF THE .ETIOLOGY OF
SYPHILIS.
The Spirochwta Pallida; Its Biology and Etiological
Relation to the Disease*
By Handle C. Rosenberger, M. D.,
Philadelphia,
Assistant Professor of Bacteriology, .TefTerson Medical College; and
Director of the Clinical Laboratory, Philrdelphia Hospital.
Previoti.s to the discovery of the Spirochata pal-
lida, the lesions of syphilis were seemingly success-
fully produced in the lower animals by inoculation
with human virus by quite a number of observers,
among whom ma}- be mentioned Metchnikoff and
Roux, Martineau, Adrian, Hugel, Holzhauer. and
Xeisser (quoted by Flexner, Journal of Experimental
Medicine, ix, Xo. 4, July, 1907).
That the disease could be transmitted was proved
especially in monkeys, but far better in anthropoid
apes. From the lesions produced there seemed to
be no specific organism isolated. Numerous organ-
isms and so called parasites were recognized, and
especially amongst these apparently specific para-
sites was the Cytorrhyctes litis of Siegel (Miinch-
ener mcdizinische Wochenschrift, Hi, pp. 1323,
1384, 1574. 1905), a so called protozoon which he
described as occurring in the blood and tissues of
syphilitics and in rabbits inoculated with the blood
and other syphilitic products. This was followed
by the work of Schaudinn and Hofifmann upon
syphilis, with the result that they observed an or-
ganism constantly in the lesions of syphilis which
they termed the Spirochceta pallida.
The constancy with which the Spirocliccta pallida
is found in primary and secondary lesions of syph-
ilis seems to strengthen the assertion of Schaudinn
and Hoffmann that it is the probable cause of the
disease. The only remaining step seemingly neces-
sary to complete this assertion is the cultivation of
the organism upon some culture medium. It has
been found in the lesions; it has produced lesions
when inoculated into numerous animals (apes, mon-
keys, sheep, dogs, rabbits), and has been recov-
ered from these lesions, and agglutination reactions
have also been recorded by some few observers.
Morphology of Spirochata Pallida.
Schaudinn and HoEm^iXxn ( Arbciten aus dem kaiser-
lichen Gesiindhcitsanitc. xxii. Xo. 2, p. 527, 1905) ;
and Berliner klinischc Wochenschrift, 1905, p. 22)
first describe two forms of spirochaet.-e occurring in
syphilitic lesions, not only in superficial but also in
deep lesions, and in the connected lymph glands.
The Spirochccta pallida is delicate, 4 to 10 mikra
in length, average length 7 mikra, its breadth about
0.25 mikron. The spirals number 6 to 14, are
abrupt, narrow, regular, and deep. It has pointed
ends, progresses by rotating upon its long axis, and
when at rest shows undulatory movements in its
whole length, suggestive of the play of a vibratile
membrane. It stains with difficulty, and with
Giemsa's stain takes on a light purple hue. Schau-
dinn later called the organism the Treponema pal-
lidum.
The Spirochceta refringcns, the second form of
spiroch?etae observed by Schaudinn and Hoi¥mann,
differs from the other spirochgeta in that it is slight-
•Read before the Pathological Society of Philadelphia, at the meet-
ing of December \2. 1907.
ly wider and the spirals are further apart, it stains
more intensely with the dye. The latter organism
is found in other conditions than syphilis.
\'uillemin ( Coin pies rcndns de 1' Academic des
sciences, cxl, Xo. 23. p. 1567, 1905) proposed the
term spironeiiia for spirochsetse with sharp ends.
The Spirochceta pallida would thus become the
Spironema pallidum.
Some observers thought that the organisms
Spirochceta refringcns and Spirochceta pallida were
simply stages of one organism, but this was before
the demonstration of the parasite (Spirochceta pal-
lida) in the blood. Among these may be mentioned
Jesionek {Milnchener mcdizinische Wochenschrift,
1905, Xo. 49, p. 2394), Kiolomeneglon and von
(lube {Ibidem, 1905, Xo. 27).
According to Pfender {American Medicine,
March 10, 1907, p. 350), the generic name spiro-
chaete Cohn, 1872, simply represents an amended
spelling of spirochasta Ehrenberg, 1834. As the
name spironema is preoccupied in zoology, the pres-
ent correct name under the International Code
should be Treponema pallidum. Stiles and Pfender
(American Medicine. December 2, 1905) also pro-
posed the term microspironema.
Minchin {Lancet, September 7, 1907, p. 707)
mentions that the question of considering the spiro-
chgetse amongst the haemoflagellates and not
amongst bacteria is still being debated, but the
weight of evidence was now toward the belief that
they were really protozoa.
Mott (Lancet, September 7, 1907, p. 712) in ex-
hibiting specimens of gummata of the brain, men-
tioned the fact that syphilis "is coming to be re-
garded as due to one form of protozoon, the Spiro-
chceta pallida."
Schaudinn (Deutsche medisinische Wochen-
schrift, 1905, p. 1665), and Hexheimer and Loser
(Milnchener mcdizinische Wochenschrift, 1905, p.
2212), with Loeffler's flagella stain, have demon-
strated flagella upon the Spirochceta pallida. The
latter observers also succeeded with ordinary dyes.
Thesing (Sitzungsberichte der Gesellschaft Xa-
tnrforschender Freunde, Xos. 8-9, 1905) disputes
the propriety of classifying the spirochaetas among
the protozoa,* and denies that the significance of
Spirochceta pallida as the cause of syphilis has been
proved.
Xorris, Pappenheimer, and Flournoy (Journal of
Infantile Diseases. May, 1906) assert that the ab-
sence of any definite indication of long division and
absence of such chromatic particles as justify belief
in the existence of micronucleus and macronucleus ;
the unquestionable occurrence of transverse fission ;
the positive evidence of production of active im-
munity, and, as shown by Xov>-. the formation of
antibodies in sufficient amount to lend passive im-
munity, these facts indicate that the spirochaftae
must not be considered as protozoa. Goldhorn
(Journal of E.vperimental Medicine, 1906, Xo. 8, p.
451') also believes in the transverse division of the
parasite.
Schaudinn places Spirochceta pallida with the
protozoa rather than with spirillar bacteria, allying
it to the trypanosome group.
M. Schiiller (CentralBlatt fiir Bakteriologie,
xxxvi. Xos. 24. 25, 1905) criticises the technique
392
ROSENBERGER: SPIROCHJETA PALLIDA
[New York
Medical Journal.
employed by Schaudiiin, and cannot understand
Schaudinn's i;rounds for placing spirochjetje
amongst animal parasites.
Schaudinn {loc. cit.) alleges that the parasite
may possess, besides flagella, a vibratile membrane,
though this is not yet clearly demonstrable. As
these characters separate Spiroclucta pallida not
only from spirochxtae and spirilla, but from all other
related forms he adopted at one time the name
spironema (of Vuillemin ).
Hexht'imer and Loser ( Miiiichciicr mcdirj.iuische
IVochcnschrift, 1905, No. 46, p. 2212) describe the
presence of granules in the Spirochccta pallida, pos-
sibly of the nature of blepharoblasts, also small free
Ixxlies with nucleus, protoplasm, and membrane,
possibly representing a developmental stage. The}'
think the appearances formerly descrilx^d as a vibra-
tile membrane were artefacts, and confirm the pres-
ence of flagella.
Dalous (Journal dcs maladies ciifaiiccs ct dc
syphilis, xvii, 481, 1905), with a quartz lens and
magnification of from 2,500 to 4,000 diameters,
states that an undulating membrane can be demon-
strated.
Wechselmann and Loewenthal {Mediziiiischc
Klinik., Berlin, i. No. 26) report the appearance of
a nucleus in quite a number of specimens examined
with an ultramicroscope.
Doflein (Fourteenth Internatii mal ( inigress of
Hygiene and Demogogy, British Medical Journal.
October 19, 1907, p. 1075) regards the spirochaeta;
as taking a position midway between the bacteria
and protozoa, and prefers to speak of them as pro-
tiagcllates. They multiplied partly b\- transverse
and partly by longitudinal division ; the former
method was best marked in the smaller forms ; in
some, what he regarded as multiple division could
be seen, and no sexual ])rocesses had been noted.
Levaditi (/bid.) asserts tliat many of the spiro-
ch;et;e had no distinguisliahle morphological char-
acters.
Manson and Sambon (Medical Record, October
5, I9<^7. V- 5^^'>)- i'l table upon the h;emoprotozoa,
classit"\ ^^^r^■(■ genera under ^piroscliaudinniidx ( the
indivi(hiak eliaraclcnzed 1)\ elongating and break-
ing u]) inlii nun'ennis ,s])(.in izoites ) , 4he leucocyto-
zo<jn, s|)ir()sehau('iinnia, and llie treponema.
Krzysztallowicz and Siedlecki [Hulletin del' Aca-
demic dc science de Cracoi ie. Xn. (j, pp. 713-72S,
November. 1905) assert that the body of the .Spiro-
chccta pallida is contractile and can become thereby
much shorter and thicker, with its eur\es less sharp
and at the same time nion- refringent : but the point-
ed extremities remain a distinctive feature. At
some point, generally not far from the middle of the
body, it is seen that for a short distance the body is
straight, or nearly so, and very slightly thickened,
and in this region a clear spot ,can I)e observed
which is regarded as the nucleus. The ordinary
method of reproduction is by fission in a longitudinal
direction. The fission may for a time stop short
of coni])lcteness, with the result that the two sister
individuals may remain connected by their ends. In
addition to the ordinary individuals they also dc-
scrilx' forms which they consider as sexual indi-
viduals. These are thick, spindle shaped forms,
with few bends, which tiie authors consider try-
i:)anosome like and propose to name Trypanosoma
Inis, although the minuteness of the organism makes
it impossible to identify the undulating membrane ;
secondly, minute spirillum like forms with several
nuclei. The former are regarded as macrogametes
derived each by growth of single treponema indi-
viduals ; the latter as microgametes formed by a
process akin to sponilation from an individual with
multiple nuclei. Conjugation between the two
forms was noticed in a single case in "materials
taken from a very large primary ulceration which
was beginning to cicatrize s])ontaneously.'"
Kreibich {Wiener klinischc IVochcnschrift, No.
21, 1907), in staining flagella of bacteria with sil-
ver solutions, noticed attached flagella which were
often spiral and twisted together like braid, and be-
ing pointed at both ends reminded him very much
in appearance of the Spirochccta pallida. He then
questions whether on account of this similarity the
Spirochccta pallida may not l)e a protozoan flagellum
instead of a difhcultly stained individual bacterium,
especially because in the spirocha?ta distinction be-
tween nucleus and membrane has not been estab-
lished. Kreibich answers his own question by say-
ing that the Spirochccta pallida is unlikely to be
identical with a flagellum, because no protozoan
body from which the latter might have come has
vet been discovered.
Occurrence of the Spiroclucta f'allida in the Le-
sions of Syphilis.
Mulzer (Berliner klinischc W ochenschrift . Sej^
tember 4, 1905 ) states that the Spirochccta pallida
is almost always found in the products of infectious
syphilis, and has never been observed in the healthy
or in nonsyphilitic persons.
Levaditi and Petresco [La Pressc mcdicalc. Sep-
tember 30, 1007) l)listered three syphilitic women
and found the parasite in each case.
Levaditi and Salmon {La .Scniaiiie mcdicalc. No-
vember 29, T(;o5, No. 48) found the organism gen-
erallv distributed through all the organs, as lungs,
adrenals, liver, skin, etc. (indicating an acute spiril-
losis), in a stillborn child. The disposition of the
.Spiroclucta pallida in groups around the vessels in
the liver seems to favor the penetration of the mi-
croorganism by the vascular route.
Scholtz (Deutsche niedizinischc W'ochcnschrift .
September 14, 1905) found the Spirochccta pallida
in four cases of syphilis com])rising condyloma
acuminata.
Hurnet and \ incent (La Semaine mcdicalc, No-
vember 29, i<;05, .\'o. 48), in recent syphilitic
chancre (four or five days), found the organism
abundant in the papillary layer of the adjacent skin,
but rarely in the central part. The}- were also suc-
cessful in demonstrating the parasite in the hyper-
tropliicd conjunctival layer and in the lymph spaces.
Levaditi and Manouelian (Ibid.) state that, in a
study of a number of chancres and syphilitic pa])
ules, in all they were able to find the Spirochccta
pallida in the tissues anrl bloodves.sels and endo-
theli-d cells, undoubtedly pla} ing a part in the pro-
duction of iK-riarteritis and the characteristic lesion
or chancre.
\'eillon and dirard (Ibid.. No. 52. December 27.
i<)05) assert that the roseola is not a toxic lesion.
l-'ebiviary 2g. :90s.]
ROSIiXBERGER.
SPIROCHMTA PALLIDA
393
but is caused by a true embolism of the parasite,
wliicli. transported by the blood, becomes fixed in
the terminal capillaries, where it provokes an in-
tense congestion.
Tchlenoff {Roussky I'ratch. June 18. 1903)
studied fourteen cases of syphilis, in wliich he was
able to demonstrate the Spiroclucta pallida in all in-
stances of the secretion of chancres and inguinal
glands. In all cases of hard chancres he found
spirochastae in the specimens and also in the moist
papules, as well as a papule upon the tongue.
Soberheim {Miluchencr medizinischc W'ochoi-
sclirifi, lii, Xo. 39) observed the Spiroclucta pal-
lida in fifty out of fifty-eight cases of certain
syphilis, the positive cases being those with primary
or secondary lesions, while the eight negative cases
were tertiarv. In thirty-four control cases of vari-
ous aflfections the findings were invariably negative.
Schlimpert {Dcuischc iiicdi::.iiiisclic Jl'oclicii-
schrift, 1906, No. 36, p. 1452) found the Spiroclucta
pallida in the conjutictiva, sclerotic, cornea, iris,
choroid, and in the muscles of the eye and lachrymal
sac. It was most frequently seen within the ves-
sels and free in the blood.
Schiitz {Miiuchencr mediziuischc U'ochcnschrift.
liii, Xo. 12), in making comparative >iu(lic> of
Schaudinn's Spiroclucta palluia and Siegel's Cytor-
rhyctcs Inis, mentions the fact that lx)th are always
found together and close to or inside the red cor-
puscles. He thinks it is possible that they repre-
sent merelv different phases in the life cycle of a
single microorganism.
.Sclior {Roitssky I'ratch. September 10. 1905)
exantiiK-d twciitv-five adults and seven children for
the ^pirncluela of svphilis. In twenty-five women
witli condyloma the organism was demonstrable in
fifteen ; in two chancres only one showed the para-
site, and in three roseolous eruptions none showed a
positive result. In thirteen out of fourteen eases of
papular syphilide it was found ; five cases of dry
papules were negative. Xo organisms were found
in the placenta of five women with condyloma, and
in four infants no organisms were found in any of
the organs.
Ravant and Ponselli ( Gaccttc dcs hopitanx. July
13. 1006) found the parasite in the blood of a child
aged two months suffering from severe congenital
syphilis. The blood was taken two hours before
death.
Gi'erke {loc. cit.) reports positive findings in
eleven cases of congenital syphilis. He obtained
])ositive findings in tissues that had been preserved
for years, especially those kept in formol. His find-
ings also prove that the treponema long resists the
effects of maceration.
Xattan-Lanier and Bergeron {La Pressc medi-
cate, January 10, 1906) report three cases of
syphilis in which the Spiroclucta pallida was found
in the blood.
Bandi (Cra:.':ctta dcgli ospcdali c dcllc clinichc.
xxvii, No. 51, 1906) calls attention to the im-
portance of the accumulations of spiroch?et?e inside
the cells. According to him it is not a phagocytic
process, as the organisms seem to be intact, while
the cell seems to liave suffered. He believes that
the condition indicates actual vital parasitism of the
cell.
.MacLennan {British Medical Journal. May 12.
1906) was able to demonstrate Spirochceta pallida
in onl\- eight out of forty cases of syphilis in the
female, but found the Cytorrhyctcs luis in every
case.
Sydney Stephenson {Ophthalmoscope, March,
ic;o6) states that he found the Spirochceta pallida in
the corneal lesions in two cases of keratomalacia in
syphilitic infants.
Alohn {Zcitschrift fi'ir Gcburtshilfc iind Gynd-
kologic. lix, Xo. 2) found the pale spirochceta in
more than 5 per cent, of umbilical cords examined,
and in almost 70 per cent, of the placentae. The
absence of nerves in the placenta shows that the
organisms found cannot be explained away as "sil-
ver stained nerve fibrils," as some have asserted in
respect to other tissues. The fact that the placenta
and membranes are free from external infection also
excludes error from this source. They were never
found in the decidua or intervillous spaces, but they
swarmed in the foetal villi and in the umbilical cord
when the foetus exhibited signs of syphilis — not oth-
erwise. He further maintains that the parasites
find their way into the ovum from the mother or in
the spermatic fluid, or pass from the mother to the
fctnus later. They proliferate in the foetus, acquir-
ing new virulence, and pass thence into the pla-
cental circulation.
Jacquet and Sevin {Aiinales de dermatologie et
dc syphiligraphic. June, 1905) found the Spiro-
chceta pallida in secondary lesions, but failed in
twenty-three tertiary lesions.
Kraus and Prantschoff (Wiener klinische
Jl'ochenschrift, 1905, No. 37, p. 941) found the
Spirochceta pallida in thirty-two out of thirt\ -seven
hard chancres ; and in eighteen ottt of twenty-five
papules. In the lesion of four macaque monkeys
Spiroclucta pallida were foimd.
^Nlulzer {loc. cit.) was successful in observing the
parasite in twenty out of twenty-two cases ; in one
instance he found a mass of organisms of from
tw^enty to forty individuals. He was unable to find
roseoiar blood and syphilis hsemorrhagica neona-
torum.
Scholtz {Deutsche medizinische Wochenschrift,
September, 1905, No. 37) doubts whether the
Spirochceta pallida is of ^etiological significance. In
primary and secondary lesions he had nineteen posi-
tive and eleven negative results and two positive and
one negative result in congenital syphilis.
Rille and X'ockerodt {Milncheiwr medizinische
Wochenschrift . 1905, No. 34) found Spirochceta
pallida in twenty-two different lesions in fourteen
syphilitics. The}' obtained negative results in
roseoiar blood and svphilis hcemorrhagica neona-
torum.
Sobernheim and Tomasczenski {Ibid., 1905. No.
39, p. 1857) were successful in fifty primary and
secondary syphilitics in demonstrating the Spiro-
chceta pallida, but were unsuccessful in eight cases
showing tertiary lesions.
In tertiary lesions Schaudinn {Deutsche medizi-
nische Wochenschrift, October^ 19, 1905) observed
the organism as a granular res'ting form. He also
cites seventy cases of syphilis in which the organism
was constantly found.
Siebert {Ibid., 1905, No. 41) obtained positive re-
394
ROSEN BERGER: SPIROCH^TA PALLIDA
[New Vork
Medical Journal.
suits in fifty-two out of sixty-six cases of primary,
secondary, and congenital syphilis ; negative in le-
sions not syphilitic, and in seven tertiary lesions.
Roscher {Berliner kUnische IP'oelieiisclirift, 1905,
Xos. 44, 45, 46), of 206 syphilitic lesions, obtained
184 positive and twenty-two negative results.
Zaboltny (Roussky Vratch, March 17, 1907) ob-
tained fluid (by means of an aspirator from indu-
rated chancres) which was rich in SpirocJiccta pal-
lida. The addition of physiological salt solution re-
tains the organism in viability for several days. The
presence of serum of those sufiftring from syphilis,
when brought in contact with these organisms, causes
agglutination, which phenomenon is complete within
three or four hours. This fact, the author thinks,
speaks more for the specificity of the Spirochceta
pallida.
Pasini { Giornale italiaito dellc inaUattic veneree e
della pe/le. 1906, No. 5, p. 4). in a child two
and a half years old suffering from hereditary
syphilis, presented two resumptions of the disease. The
first was characterized by exanthematous papules,
and the second time by an eruption of papules and a
mucous patch on the palate. The child was treated
by sublimated baths, by inunctions, and by injec-
tions. It died in two and a half years of tuberculosis
of the lungs and did not present any acute lesions of
syphilis after recovery of the second recurrence. On
tile left leg there was an atrophic lesion resulting
from the first infection, and this was examined his-
tologically by Bartanelli and Levaditi. Pasini found
in this lesion numerous Spirochceta pallida, some in-
tracellular, but for the most part extracellular, some
perfectly preserved, others in a degenerating condi-
tion. He concludes 'that, in the treatment of this
child, though apparent health had been restored, the
S pirocJurta pallida preserved itself during the long
period of latency in the same tissues.
The same observer in a later article {Ibid., 1906,
No. 5, p. 5) asserts that the penetration of the epi-
thelial cells by the Spirochceta pallida is not an ago-
nizing phenomenon, but is followed by the phenom-
ena of degeneration, and that the organism could
well survive in the urine, saliva, and in the perspi-
ration of children with hereditary syphilis, and in
the sperm of an adult.
Wersilowa {Ccntralblatt fiir Bakteriologie, xlii,
pp. 513 to 518, October. 1906) alleges that the trans-
mission of syphilis to the child could be efifected by
the ovum and spermatozoa, sometimes by the pla-
centa. He cites the history of three congenital syph-
ilitics : The first one was macerated, the second
lived only several hours, and the third died one hour
after birth. The mother was apparently healthy.
The first two presented jjlantar pemphigus and nu-
merous papules and the third did not present any
cutaneous manifestations. Examination of spreads
from the umbilical cord, heart, lungs, pemphigus,
and papules revealed SpirochcEta pallida, while sec-
tions showed numerous organisms in the placenta,
umbilical cord, liver, heart, lungs, spleen, pemphi-
gus, and papules. The author has made similar
.studies in twenty-five other cases of hereditary syph-
ilis, but did not confirm the preceding declarations.
Of all these examinations he concludes that the para-
site of syphilis could be transmitted to the mother by
the placenta or umbilical cord, and that he could
verify the spirochaeta in the placenta and cord and
the organs of the children without the mother pre-
senting the least symptom of the malady.
Miihlens and Max Hartmann {Ibid., xliii, Jan-
uary 17, 1907) state that the Cytorrhyctes litis of
Siegel is not a protozoon and that similar bodies ex-
ist in the normal blood, and that these forms are to
be considered as the products of disintegration of
cells, especially the red blood cells.
Miihlens {Ibid., xliii, ^^larch 23, 1907; April 6,
1907) confirms the relation of Spirochceta pallida as
the .-etiological factor of syphilis. In twenty-two
cases of primary lesions and in buboes he found it in
a number of cases. In eighteen syphilitic foetuses
he found the organism constantly, even though the
foetus was macerated. He also emphasizes the fact
that the spirals obtained by Levaditi's method are
true spirochaetas. He concludes by citing the case of
a syphilitic infant that died four hours after birth
and was examined one hour after death. E.xamina-
tion of spreads of dififerent organs, liver, adrenal,
and lung, showed great numbers of motile spiro-
chaetas, fifty to a microscopic field, in the smear from
the adrenal.
Ribadeau-Dumas et Poisot {Comptes rendus dc
la Societc de biologic, Ixii, February 16, 1907), in
an infant presenting diffuse hepatitis with haemor-
rhages and diffuse miliary gummata, showed uni-
form presence of Spirochceta pallida. In the other
parenchymatous organs the parasites were found to
be in such numbers as to constitute emboli.
Bab {Zeitschrift fiir Gcburtshilfc und Gyndkol-
ogic, lix) in fourteen instances of congenital syph-
ilis claims that the biological and bacteriological in-
vestigations gave exactly the same result. Not only
those organs that were free from spirochaetae gave
extracts free from autogens, and organs containing
the parasites gave extracts containing autogens, but
also a great number of spirochaetae corresponded to
a great number of antigens. The contrary was also
true, that a small number of spirochaetae contained
a small number of antigens.
The important problem presents itself, that the
placenta acts like a sponge and stores up the dis-
solved syphilitic toxines, and the granulation tissue
elements act as phagocytes, which also absorb the
dissolved toxines and by this process endeavor to
make them inert. But it is possible that after a time
the barrier becomes incompetent toward the mother
or toward the child and becomes permeable to the
toxines. The placenta seems to correspond to the
foetal liver and spleen, which are sometimes swollen
but contain no spirochaetae.
He examined sixty-four cases of syphilis and
found the spirochaeta most commonly situated in the
vessel wall and in connective tissue. He was able to
detect them in the spleen in 62.9 per cent, and in the
thymus gland 55.6 per cent. In the foetal ovary the
interstitial tissue is especially affected and one illus-
tration accompanying his article shows a spirochaeta
in the ovum itself. This penetration into this struc-
ture proves distinctly that it cannot be nerve or other
tissue fibres. In thirty-nine cases examined, he
found the placenta free from spirochaetas in thirty-
seven. In general the presence of the parasite seems
to end at the navel, while in 50 per cent, the arterial
walls and in 55.6 per cent, the venous walls of the
February 29, igtS ]
ROSEXBERGER: SPIROCHMTA PALLIDA
395
umbilical cord of his positive cases contained the
organism. He also seems to think that one cannot
avoid being impressed with the fact that the spiro-
chsetal masses are disseminated through the body into
dif¥erent organs in the same manner as an embolus
is carried by the blood. He then mentions the case
of a congenitally syphilitic infant from a woman
who had intercourse with a syphilitic at the fourth
month after conception, though herself healthy. The
thymus gland, kidneys, uterus, meninges, and eyes
contained spirochaetae.
Buschke and W. Fischer {Deutsche medizinische
Wochcnschvift, 1906, xxxii, p. 752), Levaditi and
Manouelian {Comptes rendus de la Socicte de biol-
ogie, 1906). Reischauer {Deutsche medizinische
Wochenschrift, xxxiv, August 24, 1905), Oppen-
heim and Sachs [Ibid., 1905, Xos. 29 and 31 ; and
Miinchener medizinische Wochenschrift, 1905, pp.
1507 and 1517). were also successful in obtaining
positive results in the majority of cases studied. The
last observers found Spirochceta pallida in thirty-nine
hard chancres and papules, and failed in twenty-one.
They were unsuccessful in the examination of nine
buboes, twenty-one examinations of the blood, fif-
teen roseolar spots, two mucous plaques, seven gum-
mata, and four cases of congenital syphilis. In
forty-two nonsyphilitic conditions they found no
Spirochcctcc pallida:.
Bertarelli and Volpino {Centralblatt filr Bakteri-
ologic. November 24, 1905) found Spirochceta pal-
lida in twenty-six cases out of forty-two primary
and secondary cases. By the use of Levaditi's
method they demonstrated great numbers of the or-
ganisms in sections of the liver in a congenitally
syphilitic child, and control observations showed that
they had not to deal with elastic fibres, connective
tissue fibrils or nerve endings.
Rosenberger. in fifty-six cases of primary and
secondary' syphilis, as well as the viscera of con-
genitally syphilitic infants, found the Spirochcetce
pallida: constantly. They were, as a rule, few in
number in spreads, though in one chancre as manj^
as forty or fifty organisms could be seen. They
rapidly decreased in number when mercury was ad-
ministered to the patient.
Uhle and ]\IcKinnie {Journal of the American
Medical Association, February 16, 1907) report
upon twenty-four cases of acquired syphilis in which
positive findings were reported in fourteen and nega-
tive in ten. In the patients giving a negative result
seven had received antisyphilitic treatment, the other
three had not. They examined thirty-four pieces of
tissue in all, including seven chancres, nineteen cuta-
neous secondary lesions, apparently healthy skin
from syphilitics. four tuberculous syphilides, and one
gumma of the brain.
Richards and Hunt {Lancet, September 30, 1905)
found the Spirochata pallida in three cases in the
blood taken from the roseolar rash on each of ten
successive days.
Dudgeon '{Ibid.. ]\Iarch 10, 1906) observed the
Spirochceta pallida in six cases of primary syphilis,
two cases of secondary syphilis, one case of tertiary
syphilis, and three cases of congenital syphilis.
Shennan {Ibid.. March 17, 1906) precedes his per-
sonal research with an excellent bibliography of the
subject. He records five hard chancres with positive
results ; in two the results were doubtful, and three
negative. Two nonulcerated papules gave positive re-
sults, two dry papulosquamous syphilides gave
negative results, and two roseolar rashes were also
negative. Of four condylomas examined, three
were negative and one doubtful. Negative results
were also obtained in four glands and one rupioid
syphilide. He concludes that the Spirocha:ta pallida
is found only in hard chancres and in closed pap-
ules ; in other words, in typical syphilitic lesions.
Flexner {loc. cit.) gives the results of sev-
eral cases of acquired syphilis and also of congenital
syphilis in which he obtained positive and constant
results in all cases. In the case of films made from
lesions he was able to demonstrate the parasite sev-
eral months afterward. Fragments of lung tissue
kept in the refrigerator (2° to 4.5° C.) for one
month showed very little if any change in the form
and staining of Spirochcrta pallida, while after three
months no pallida could be stained. The clow
autolysis without putrefaction shows the resistance
displayed by the organism against the autolytic
ferments.
Grouven and Fabry {Deutsche medizinische
Wochenschrift, xxxi, No. 37) observed the Spiro-
ch(£ta pallida in fifteen out of twenty-one cases.
Kraus and Prantscoflf {Wiener klinische Wochen-
schrift, xviii, No. 22) found the parasite in fifty
out of sixty-two examinations of s}-philitics.
Schultz {Journal of Medical Research, xv, p, 363,
1906), reporting upon the distribution of the Spiro-
cha:ta pallida in two cases of congenital syphilis,
says that it is to a marked degree an intracellular
parasite and that multiplication of the organism oc-
curs chiefly in the perivascular lymphatics and
within the tissues themselves ; not within the larger
bloodvessels.
Wiens {Archiv fiir Schiffs- und Tropenhygiene,
X, No. 15, pp. 459-63, 1906) reports six cases of
syphilis in Chinese in which he was able to demon-
strate the Spirochceta pallida. In four cases he ob-
tained it from chancres, in one from serum of a
roseolous eruption, and in one case from juice from
an inguinal gland.
Bab {Deutsche medizinische Wochenschrift. No-
vember 29, 1906, pp. 1945 to 1948) records finding
the parasite in the different structures of the eye;
except the crystalline lens, in a syphilitic foetus. He
thinks that the distribution of the organism in the
different parts of the eye is in accord with the fre-
quency of choroiditis, iritis, and parenchymatous
keratitis in hereditary syphilis. The same observer
in a later article {Miinchener medizinische Wochen-
schrift, November 12, 1907, No. 46) was able to
demonstrate the Spirochceta pallida in the liver,
spleen, testicles, and costochondral articulations in a
congenitally syphilitic child born of an apparently
healthy mother.
Blaschko {Berliner klinische Wochenschrift, No.
12, 1907), in twenty-five chancres studied by the
method of Levaditi, found the Spirochceta pallida in
all cases and observed the organisms most abundant
at the periphery of the lesion,
Menietrier and Duval describe a septicasmic form
of hereditary syphilis evidenced by the presence of
the Spirochceta pallida in the blood and all the vis-
cera, accompanied by congestive lesions. In the
396
ROSENBERGER: SPIROCHJETA PALLIDA
[New York
Medical Journal.
liver the congestion attains an extreme degree, re-
calling the characters of the "asystolic liver."
Renter {Zcitschnft fi'ir Hygiene und Infektions
Krankhcitoi, 1906, No. 49) found typical examples
of Spirochceta pallida in the timica intima of the
aorta in a case of aortitis (Dohle and Heller's va-
riety of aortitis) and also mentions finding the or-
ganism in a gumma of the lung, and in interstitial
pancreatitis of a congenital syphilitic.
Noggerath and Stahelin {Miinchcncr medizi-
iiische JVochciisclirift, August i, 1905) allege to
have observed the Spirochceta pallida in the blood
obtained from the lobe of the ear in three cases of
undoubted secondary syphilis.
Risso and Cipollino (Riforma medica. August 26,
1905) in ten cases of syphilis were successful in
demonstrating the Spirochceta pallida in five out of
seven cases in the gland, juice; also in several mu-
cous patches and one condyloma. They failed, how-
ever, to find the organism m two chancres, ulcerated
gummata, and in a closed gumma of the forehead.
Technique.
In spreads from chancres, papules, and other
syphilitic lesions Schaudinn and Hoffmann origi-
nally recommended Giemsa's azure blue eosin stain,
but very good results have been obtained with
Wright's, Jenner's, Romanowsky's, Leishman's, and
Goldhorn's stains. Many observers recommend va-
rious aniline dyes, a filtered saturated aqueous solu-
tion of gentian violet (Fox), and other modifica-
tions of the various blood stains.
Among those who recommend the anilin dves mav
be mentioned Davidsohn {Berliner klinischc
ll'ochenschrift, xlii, Xo. 31) ; Rille and Vockerodt
{ Miinchcncr nicdi.ziitische Wochcnschrift , Hi, No. 34,
pp. 1620-23); Plocger (Ibid.. Hi. Xo. 29); Hex-
heimer (Ibid.. 1905, Xo. 39) ; Oppcnheim and Sachs
(Deutsche mcdizinische Wochcnschrift, xxxi, July
20); Bandi and Simonelli (Garjcetta degli ospedali
e delle cliniche, 1905, Nos. 85 and 105) ; Moncorvo
(La Pressc incdicalc. 1905, 104-840); Dudgeon
{Lancet, August 19, 1905, p. 522). and Weitlauer
{ Milnchencr medizinische Wochcnschrift, 1905, X^o.
47, p. 2293).
In sections of tissue from svphilitics, it seems that
the best results are obtained l)y impregnating with
silver nitrate in strengths of from i to 3 per cent.
The first investigators to use this method were Ber-
tarelli and \'olpino (Centralblatt fiir Bakteriologie
O., November 24, 1905). Since these observers used
the method numerous others have obtained very
good results, among whom may be mentioned
Buschke and Fischer (Berliner kiinische Wochcn-
schrift, 1906, X^os. I, 6). Gierke (Miinchener medi-
zinische Wochcnschrift, liii. No. 9, 1906), and Leva-
(liti (/Annates de I'Institut Pasteur, No. i, p. 43,
January, 1906). The latter's technique, together with
one which he and A'lanouelian (Comptes rendus
de la Socictc de biologic, Ix, Xo. 3, 1906) originated,
arc by far the best for the demonstration of the
Spirochceta pallida in the tissues. The first technique
is as follows :
The tissue is cut in small masses and fixed for
twenty-four hours in a 10 per cent, .solution of for-
maldehyde ; then placed in alcohol for the same time.
They are then washed in water for a .short period.
after which they are put in a bath of 1.5 to 3 per
cent, freshly made solution of silver nitrate for three
days, changing the solution daily, maintaining the
body temperature and excluding the light. The tis-
sue is then placed in a reducing bath which consists
of a 2 per cent, solution of pyrogallic acid, with the
addition of 5 per cent, formaldehyde. After twenty-
four hours they are dehydrated, cleared in xylol, and
embedded in paraffin.
The method recommended by Levaditi and Alan-
ouelian differs from the plain Levaditi method in
that, just before impregnation with the silver they
add 10 per cent, pyridine to this solution, and for
the reducing bath a mixture of pyrogallic acid, ace-
tone, and pyridine. In the silver solution the tissues
are kept four to six hours at 50° C., or at room tem-
perature two to three hours in glass stoppered
bottles.
Flexner (/or. cit.) prefers and obtains the best
results in films by the use of the direct silver stain-
ing, recommending the technique of Stern (Berliner
klinischc Wochcnschrift, Ixiv, p. 400, 1907), which
is as follows :
The exudation is placed in the incubator at 37° C.
for one hour, then in a 10 per cent, solution of silver
nitrate for one hour in diffuse daylight. A colorless
glass vessel should be used. The preparation grad-
ually takes on a brown color and when it has ac-
quired a metallic sheen it is removed from the silver
nitrate solution and washed in water. In such a
preparation the form of the blood corpuscles is re-
tained ; the) give a strong, dark contour and show
fine granules. There is but little precipitate and it
causes no annoyance in looking for the organism.
The S pirocluctcc pallidcv appear deep black to bright
brown against an almost colorless background. A
reduction of the preparation is neither necessary nor
advisable. Placing it in the sunlight gives the ma-
terial a brown color, which becomes gray black from
a quarter to half an hour later, and finally entirely
black. The S pirocluctcc pallidcp appear almost color-
less against a dark background.
Schmorl (Deutsche medizinische Wochcnschrift.
xxxiii, p. 876, 1907) fixes in 4 per cent, formalde-
hyde, cuts frozen sections, and places in formalde-
hyde or distilled w^ater and stains with Giemsa's
stain (one drop of stain to one c.c. of distilled
water). Great precaution must be observed as to
cleanliness of vessels used. After one hour place in a
fresh staining solution and let it remain from twelve
to twcntv-fnur liours. When sufficiently .stained,
the section 'should be a deep red to violet blue. It is
now placed in distilled water or in a concentrated
solution of potassium alum until it becomes a bright
blue. It requires but a short time in the potassium
alum solution to distinguish the section. It should
then be washed in water for a short period ; too long-
washing is not good for the preparation. It is then
mounted in glycerin jelly, cedar oil, or neutral Can-
ada balsam.
Ravant and Ponselli (loc. cit.) take 30 c. c. of
water and 30 drops of blood added drop by drop.
The haemoglobin becomes diffu.sed through the wa-
ter, and after three hours a fibrinous clot forms. The
clot is withdrawn, washed several times to free it
from water, cut into .sections, and stained b\ Leva-
diti's method.
February zg, 1908.]
ROSEXBEKGER: SPIROCHjETA PALLIDA
397
Levy-Bing (Bulletin medical, xix, No. 49) stains
with an alcoholic (methyl) solution of azur blue and
counterstrains with eosin. The Spirochceta pallida is
stained an orange rose color.
Reitman {Deutsche medizinische Wochenschrift,
xxxi, p. 997) first fixes the spread in absolute alco-
hol, washes in water, places in a bath of phospho-
molybdic acid, again washes in water, stains with
carbol fuchsin, washes in water, then 70 per cent,
alcohol, and alternates with water until no more
color comes away. The spirochseta is stained a deep
red.
Follet (Coniptes rendiis de la Societe de hiologie,
Ixii, p. 667, April 20, 1907) recommends collecting
the saliva some time before a meal and staining with
a mixture of glycerin, acid fuchsin, and carbolic acid,
for the demonstration of spiral organisms. Another
method, using a mixture of glycerin, methylen blue,
and carbolic acid, he says has permitted him to ob-
serve from 00 to 300 spirals, "certainly not all the
Spirochceta pallida." A third formula consisting of
chloroform, methylen blue, acid fuchsin, and carbolic
acid, is more rapid and gives less precipitate and
presents the classic coloration of the Spirochceta
pallida.
Proca and Vasilescu {Ibid., Iviii, p. 1044, 1905)
recommend to fix the preparations in absolute alco-
hol for thirty minutes ; then place in a bath composed
of carbolic acid 50 c.c, tannin 40 grammes, water
100 c.c, fuchsin (2 to 5 per cent, alcoholic solution)
100 c.c. for ten minutes. Wash in water, and stain
for ten minutes with carbol gentian violet.
A'olpino [Rendiconto dellc sessioni dcW Accad-
Ciiiia medica d'i Torino,' July 14, 1905) allows sec-
tions to remain in a solution composed of silver ni-
trate 0.5 grammes in 100 c.c. of distilled water for
twenty-four to forty-eight hours. They are then
washed in water, then transferred to a solution of
tannin 3 grammes, gallic acid 5 grammes, sodium
acetate 10 grammes, distilled water 350 c.c. Allow
them to remain for fifteen minutes, until they are
brownish in color ; wash in water, dehydrate, clear,
and mount in balsam.
Bab [Zcitschrift fiir Gebiirtshilfe nnd Gynakolo-
gic. Ix. Xo. 2, 1907) thinks that the organism pos-
sesses an affinity for mercury equal to that for sil-
ver, and recommends trying mercury phenylate.
Xoggerath and staehlin {loc. cit.) take one c.c.
of blood from a vein, mix with 10 c.c. of V; per cent,
acetic acid in water, centrifugalize, and examine the
deposit in the ordinary way.
McNeal (Journal of the American Medical As-
sociation. February 16, 1907) recommends a mix-
ture of methylene violet, methylene blue, vellowish
eosin, and pure methyl alcohol. The stain is allowed
to remain upon the smear for forty-five to sixty sec-
onds, then immersed in about 10 c.c. of a i in 20,000
solution of sodium carbonate and the mixture stirred
by tilting the dish. After one or two minutes" im-
mersion the cover glass is removed, washed in dis-
tilled water, cleaned, and dried upon blotting paper
and mounted in water and examined with 1/12 inch
objective.
Schereschewsky (Deutsche medizinischc Wochen-
schrift. March 21, 1907, p. 462) fixes one minute in
osmic acid vapor, passes the cover slip three times in
flame, then places in a mixture of i part Giemsa's
solution to 8 to 10 parts water. The preparation is
heated in a Petri dish upon a water bath for ten to
fourteen minutes, and when the cover slip presents
a scum of a reddish color the procedure is at an end.
It is said that by this method the preparations are
so clear that the organisms can be observed with a
dry objective.
Benda (Berliner klinische Wochenschrift. April
15, 1907, pp. 428-432; April 22, 1907, pp. 480-484)
by studying the Spirochceta pallida by the silver pro-
cess of Levaditi, asserts that the parasites are the
same organisms that are found in spreads from or-
gans, and not fragments of tissue elements.
Zabel (Medizinischc Klinik. May 19, 1907, pp.
580-582), in staining sections of organs, fixes in for-
maldehyde and stains with silver nitrate. The or-
ganisms appear larger than those made from fresh
preparations stained with anilin dyes.
Mandelbaum (Mi'mchener medizinischc Wochen-
schrift, November 12, 1907) recommends staining
the Spirochceta pallida in the fresh state by mixing
the scrapings from a chancre or papule with
Loeffler's methylen blue, and examining in the hang-
ing drop with a 1/12 inch oil immersion lens. By
this method the spirochjeta stains pale blue, while
other spiral organs like Spirochceta refringens stain
very heavily. By this method the granules described
by Hexheimer are distinctly brought out. Mobility
can be observed for twenty-four hours, though the
cover glass preparation can be kept for weeks by
sealing with paraffin.
Sabolotni and Maslakovitz (Rousski Vratch. No.
II, 1907) observed the Spirochceta pallida in the
serum (obtained by Biers apparatus applied over the
syphilitic lesions) become attached to one another at
the ends, form star like masses, and eventually un-
dergo granular degeneraation.
Inoculation Experiments Upon Animals.
Metchnikoff (Berliner klinische Wochenschrift.
May 22, 1905) found the Spirochceta pallida in the
glands and chancres of his inoculated apes (twentv-
three out of thirty-one experimental lesions), and
Arnol and Salmon (Annales de I'lnstitiit Pasteur.
July 25, 1904) report upon the features of th-
lesions produced upon chimpanzees, a male and a
female, both showing chancres which were identicil
histologically with those in man.
Piorkouski (Berliner klinische Wochenschrift.
December 19, 1904) injected 5 to 10 c.c. of blood
from a patient under active mercurial treatment into a
horse, intravenously or subcutaneously. Four weci-"s
later a maculopapular rash appeared, which, exa^u-
ined by various experts, was pronounced to be syph-
ilitic in nature. ( No mention of Spirocharta pallida. )
Neisser (Deutsche medizinischc JJ'ochcnschrift.
xxxii, No. 13) has succeeded in inoculating monkevs
with tertiary lesions, provided the lesion is not de-
stroyed by suppuration or necrosis. He was also
successful in producing positive inoculations by
using the nasal secretion, blood and tissues from vn-
rious organs, from children with inherited syphilis.
He asserts the bodies of children with inherited
syphilis are swarming with parasites which can pass
by way of the blood into the organs.
Hoffmann (Ibid.) also reports experiments with
monkeys which have confirmed the contagious na-
ture of the blood during the early stage of syphilis.
398
KOSENBERGER: SPIROCH^TA PALLIDA
[New York
Medical Jourxal.
Metchiiikolf and Roux {Bulletin de I'Acadcmie de
nicdccine, May i8, 1906) report upon the circulation
of syphilitic material into apes and man, followed
by the application of a strong mercurial ointment
applied locally. They found that if this application
was made within one to eighteen hours it destroyed
the syphilitic virus, but if made later than this syph-
ilis developed.
Neisser {Bulletin de la Societe francaise de pro-
phyJaxie sanitaire et morale, Nos. 4 and 5, April and
^lay, 1906) proceeded upon these lines, but without
success. On the contrary, though the mercurial
ointment was applied one hour after the inoculation,
the chancre developed in due course. He came to
the following conclusions : That the chancre devel-
oped in the same manner in a mercurialized subject
as in one not under that treatment, and that the dis-
ease became generalized in exactly the same manner
among animals which had been mercurialized and
those which had not.
Metchnikofif {British Medical Journal, October
19, 1907, p. 1075) a later date experimented
upon the prophylaxis of syphilis, using instead of
mercury, atoxyl. This material was found to pro-
tect the monkeys from the infection, even after a
single dose. It was further found that the injection
of atoxyl could be successfully carried out a week or
even a fortnight after the inoculation. That the
atoxyl had really neutralized the virus was shown
by the fact that the monkeys could be reinfected with
syphilis some months after the atoxyl treatment. He
then spoke of giving atoxyl by the mouth, and con-
cluded by saying that these preventive measures had
been applied to man without any harmful after
effects.
Yancke (Medicitiische KlUiik, April 28, 1907, pp.
486-7) tooks fragments of placenta, liver, kidney,
spleen, and testicle from a syphilitic foetus of six
months, macerated these in distilled water and fil-
tered under pressure through a Chamberlin filter.
The filtrate was inoculated into the superciliary re-
gion of a monkey, and was followed by a slight in-
filtration which reached its height in seven days.
Forty-two days after inoculation he found a lesion
similar to those noticed in primary syphilis. The
long period of incubation was probably due to the
small number of organisms contained in the filtrate.
He attributed the result of this experiment to two
factors : First, to the emulsion, and secondly, to the
high pressure of 2i/^ atmospheres.
Thibiergc. Ravant, and Burnet {La Scmaine
nicdicale. No. 7, p. 80, February 14, 1906) experi-
mented upon macaque monkeys with fragments of
enlarged glands, of papules, and chancre s : inocu-
lated them with a series of other animals, and found
the Treponema pallidum in the secretions and sec-
tions of tissue. They conclude that the experiment
in passage, from the man to the animal, of the para-
site speaks in favor of the organism being the patho-
genic microbe.
.Simonelli and Bandi {Gacaetta degli ospedali e
dellc cliniche. January 7, 1906) inoculated a femaalc
ape with material from a syphilitic perianal hyper-
trophic papule. In due time a chancre developed,
l)Ut the authors were unable to demonstrate the Spiro-
chccta pallida in the lesions. They found certain
masses of very delicate threadlike structures, some
of which were straight, and others wavy.
Metschnikoff and Roux {Annales de I' I nstitut Pas-
teur, November, 1904, p. 761, and Bulletin de I'Aca-
demie de medccine, 1905, p. 468) succeeded in in-
fecting monkeys with syphilis, and in four out of
six cases foiind Spirochccta pallida unaccompanied
by other forms.
Hoffmann and Walter Bruning {Deutsche niedi-
sinische Wochenschrift, April 4, 1907, pp. 553-4)
succeeded in inoculating a rabbit and then to inocu-
late the virus to monkeys. Two dogs were inocu-
lated with the fragments of a chancre, which was
followed in sixteen and twenty-one days by keratitis
of a specific character, with the presence of Spiro-
chccta pallida, and clinically possessing the charac-
ters described in the monkey. By scarifying the cor-
nea they proved that laying bare of the bloodvessels
is not absolutely necessary.
Bertarelli {Ccntralblatt fiir Bakteriologie, April
25, 1907, pp. 790 to 793) has successfully inoculated
a sheep and a dog with virus that passed seven times
through rabbits by inoculations into the cornea. The
cornea of the dog was scarified and smeared with
the virus from a cornea of a rabbit, and sixteen days
later a keratitis, specific in character, was noticed.
In the dog the lesion was more extensive than in the
sheep. The syphilitic nature of the lesions was con-
firmed by microscopical examination, and only two
gave positive results, and the organisms have also
been few in these two cases.
Hoffmann {Berliner klinische Wochenschrift,
xlvi) is said to have successfully inoculated four
monkeys (two Macacus rhesus and two cercopithe-
cus) with syphilitic blood.
Finger and Laudsteiner (quoted by Flexner, Med-
ical Neivs, December 9, 1905) report a successful
transmission of syphihs to the monkey by means of
inoculation of a large amount of gummatous ma-
terial.
Kraus and Prantschoff (loc. cit.) inoculated mon-
keys, Macacus rhesus, with syphilitic material, and
found that the initial lesion produced contained nu-
merous Spirochccta pallida, being identical morpho-
logically and tinctorially with the organism found in
man. They were also successful in inoculating from
one ape to another.
E. Finger and Laudsteiner {Sif::uugsbcrichtc der
Kaiscrlichen Akadcmie dcr Wisscnschaftcn in Wien.
cxv, No. 3, April, 1906, pp. 179 to 199) inoculated
six monkeys with the blood obtained from syphilitics
in full eruptive period, and not one inoculation was
followed by a positive result. These data seem to
show that the blood collects in the cells in the course
of the secondary eruption and is not constantly viru-
lent, and accords with the histological examination
of the blood, which has proved that the Spirochccta
pallida is rarely found in this liquid. The milk of
syphilitic women, and the sperm, did not contain the
active virus, as the experiments upon Macacus
cynomolgus were entirely negative. They inoculated
a "papion" with the ccntrifugalized sediment of the
semen from a person with a chancre of the foreskin,
and lenticular papules of the arms and genital or-
gans. Three weeks after inoculation the monkey
showed an initial lesion. In one other experiment
Febniaiy zg, 1908.]
RUSENBERGER: SPIROCH^TA PALLIDA
399
they used the semen of a person presenting double
interstitial orchitis (syphilis dating back three
years) and the result was more marked than in the
first. They also succeeded in engrafting syphilis
upon inoculated monkeys if they inoculated the virus
five days after the appearance of the primary lesion.
Later than this (five days) immunity begins to
manifest itself in the animal and it is impossible to
obtain positive results. They also find that there is
an absence of absolute immunity of the skin in the
course of secondary and tertiary lesions. They then
inoculated large quantities of the virus in subcuta-
neous pockets and they have seen not only in the
course of the eruption, but also during the tertiary
stage local lesions that were syphilitic in nature.
They made control experiments with heated virus
with negative results. These experiments confirm
the work of Neisser (recent meeting of Congress of
Dermatology, held at Berne) and also the observa-
tions of Metchnikofif and Roux, of Finger and
Laudsteiner, of Kraus, Neisser's collaborators, Hal-
berstadter and Baerman, and Siebert. Among these
last the most important have certainly been those
who have proved that the active virus is in the tis-
sues as the marrow, spleen, lymphatic nodes, and
testicles of the inoculated monkeys. Neisser found
that eight hours after the inoculation, if the scarified
area was extirpated it hindered only the development
of primary syphilis ; as in this short space of time
the microbe of syphilis had invaded the surround-
ing tissues, and infiltrated very rapidly all the or-
gans. He also found that previous to the develop-
ment of the chancre the bone marrow and spleen
contained the active virus of syphilis and it was
inoculable into sensitive monkeys. This seems to
prove the inefficiency of extirpation of the primary
lesion.
Salmon (Comptes rendus de la Societc de bio-
logie, Ixii, p. 254, February 16, 1907) remarks upon
the work of Finger and Laudsteiner upon the re-
inoculation of tertiary syphilitics being followed by
the formation of lesions reproducing the aspect of
tuberculous and ulcerating syphilides. He has ob-
tained positive results in only two out of fourteen
instances, and these were papulosquamous eruptions
of contestable nature. He concludes that ''the im-
munity coexists with persistent infection indefinitely ;
and that the syphilitic possesses an absolute cuta-
neous immunity against reinfection from the out-
side."
Siegel (Ccittralblatt fiir Bakteriologie . liii, March
5, 1907, also March 21, 1907) says he was the first
to show that syphilis could be inoculated into the
rabbit ; that he was the first to show that the organs
of inoculated monkeys contained the active virus ;
he alleges priority for the inoculation of the virus
under the skin, and that he was able to obtain with
great frequency the cutaneous manifestations in the
chimpanzee ; and that the examination of the mter-
nal organs, and especially the liver, should be car-
ried out to consider the infection of a specific
nature.
Hans Bab {loc. cit.) did not succeed in infecting
apes by inoculating them intravenously, intraperitone-
ally, or subcutaneeously, and expresses himself as be-
ing surprised that the intravenous inoculations were
negative, as congenital syphilis offers itself as an
exquisite example of a blood infection. Rubbing
the virus into the femoral vein and into incisions
into the lymph glands also proved without result.
In two instances inoculation into the parenchyma of
the testicle was followed by syphilis in the ape. The
first animal became resistant toward a second attack.
The second ape was killed after thirty-six days, and
with the bone marrow, two other monkeys were suc-
cessfully infected. Those animals inoculated subcu-
taneously showed, without doubt, toxic symptoms,
emaciation, cachexia, and high mortality. The
spirochsetas are by no means always present in the
liver and spleen swelling, and this condition is per-
haps caused by its toxine. He states that the pene-
tration of the virus into the abdominal cavity may
occur through the tubes, and that it is also possible
that the virus may be mixed with the semen in the
prostate or urethra.
Cultivation.
Leuriaux and Celts (Centralblatt fiir Bakterio-
logie, xli, p. 684, 1906) in forty-two lumbar punc-
tures obtained growths of Spirochceta pallida in
three instances. One part neutral bouillon was
added to 2 parts spinal fluid and the mixture placed
at 37° C. for several days; centrifugalized twenty
minutes, and then the sediment spread over coagu-
lated pork serum. An ivory white, moist film was
the result. Smears from young cultures showed
bodies like Cytorrhyctes luis, then a trypanosome,
then a spirochseta.
De Souza, Jr., and Pereira (Berliner klinische
Wochenschrift, 1905, No. 44) tried cultivating the
organism in 5 per cent, each of sodium citrate and
sodium chloride^ but with negative results.
Bertarelli and Volpino {loc. cit.) failed in all ef-
forts to cultivate the organisms, as did Miihleus
{loc. cit.).
Remarks.
From the resume of the literature herein record-
ed, though by no means complete, it seems that the
majority of observers look upon the Spirachceta pal-
lida as the probable cause of syphilis. I have been
able to collect references of 1,210 lesions, including
congenital syphilis, and in this number the parasite
was present in 958. To enumerate still further it
may be mentioned that of 333 chancres examined
positive results were obtained in 299 and negative
findings in thirty-four. Of forty-three papular erup-
tions thirty-five were positive and eight negative ;
of thirty-three mucous patches twenty-three were
positive and ten negative, while of 122 roseola
eighty-seven proved positive and thirty-five negative.
In the lymph nodes, or more properly, the juice of
the nodes, only six positive findings are recorded
of twenty-four examined. Of thirty-five condy-
lomatas, twenty-two were positive and thirteen neg-
ative. Of 435 cases simply described as syphilitic,
not definitely setting forth the lesions, 361 were
positive. Of gummata there were records of only
eleven being studied, two of which were positive and
nine negative ; in forty-seven cases of tertiary syphi-
lis examined negative findings were recorded in all.
By far the highest percentage of positive findings
were in cases of congenital syphilis, for out of 127
instances of this form of the malady, in 123 the
parasite was found.
My own personal observations have convinced me
400
MAGRUDER: AORTIC REGURGITATION AND FLOATING LIVER. [New Vork
Medical Journ\l.
that the Spirochccta pallida is the probable cause of
syphilis. In congenital syphilis though the organ-
ism has been found most constantl}', it is not always
generally distributed in all the organs and tissues,
it may only be demonstrable in one or two organs
as the spleen and liver, or in the kidney, or skin,
and then only in certain areas of these structures.
Anyone who has had histological training should
not mistake the parasite when stained by the Leva-
diti method, for any tissue fibres in the different
organs, while in spreads from lesions or organs it
most certainly takes a practised eye to distinguish
between delicate shreds of tissue and spirochseta,
especially when stained by the anilin dyes or any of
the stains for blood.
Another point must also be borne in mind, and
this is the certain disappearance or diminution in
the number of parasites, when local or general treat-
ment is resorted to. The examination should be
made as early as possible, and I believe that the
I)est stains to use for spreads from lesions or organs
arc Gicmsa"s azure eosin and the blood stain of
either Wright or Leishman.
2330 XoRTM 'l"iiiRTi-:i:xTJi Street.
C.\SE OF AORTIC REGURGITATION AND FLOAT-
ING LIVER.*
Bv E P. MA<;i<riM:u. A. AI., M. 1)..
Wasliington. D. C.
iledical and Surgical Associate at the En.ergency Hosi'ital.
Case. — G. W. R.. male, aged fifly-thrce, laborer, mar-
ried; habits temperate, especially as to alcoholics.
History. — His father • died of pneumonia, aged about
forty-five; mother died at seventy-three, cause unknown;
he had three brothers and two sisters, ail dead; oldest
brother died at fourteen, of diarrhoea; second, at seven, of
-mallpox ; third at thirty, of sunstroke; ouc sister died at
iwenty-five, of sunstroke, the other at fortv-four, effects
of a fall.
The patient had measles and whooping cough in child-
hood; occasional chills and fever at twenty; about sixteen
years ago he had an attack of articular rheumatism, and
four years later another attack of the same disease, neither
of which, he says, occasioned any serious illness. For the
most part he has enjoyed good health, and always worked
hard.
His present illness began November 20, 1905, after a
hard day's work, lifting heavy stones in a quarry, where
he had been working for some nionths. In the evening
as he started homeward he tioticcd for the iirst time an
luiusual sound like the rubbing together of his overalls,
but it camp from his chest. Shortness of breath upon
slight exertion soon followed. He consulted a physician,
who told him he "must be more careful with himself and
not do any heavy work." So far as could be learned he
had been given digitalis.
He consulted the writer at the Emergency Hospital.
Washington, D. C, in May, 1906. Examination.— This
showed at that time a hepatoptosis and cardiac disturlD-
pnces so grave that patient was advised to enter a hos-
pital for treatment. He complained of dyspnoea, anorexia,
bronchitis, broken sleep, loss of weight and strength ; there
were arteriosclerosis, cedema of lower extremities, al-
buminuria 0.2 per cent., brochial blood pressure 228 milli-
metres, great anxiety.
Present State.— Patient is about 5 feet 6 inches in
height, muscnbir, erect, general appearance good; skin nor-
mal, no a'dema or eruption; pulse arrhythmical, about 80;
arteries somewhat tortuous, sclerosed ; sphygmomanometer
registered only 155; pulse strong, at times "Corrigan."
Respiration 22. frequently arrhythmic. The striking symp-
•Keiiorted and imtiriit i)iesented to tlie Medical Society of Wash-
inKton. I). C.
toms are cardiac rather than hepatic. He complained of
palpitation of the heart and a mild soreness upon pressure
over the epigastrium.
He has occasional headache, sleeps well, no disturbance
of sensation or motility. Buccal membranes markedly pig-
mented ; tongue of good color ; circumvallate papillae ex-
traordinarily developed ;. appetite excellent; no thirst or
vomiting; bowels regular, no gastroptosis. Respiration
22, rhythmical ; occasional cough and expectoration ; mi-
croscopical examination of the sputa shows the so called
"heart disease cells" — i. e.. alveolar epithelial cells, con-
taining numerous hrematoidin granules (first observed by
Virchow). Uranalysis is negative.
Fluoroscopic. — No apparent enlargement of the right
heart, but considerable enlargement of the left ventricle.
The usual shadow of the liver is entirely absent.
.•Etiology. — Cardiac : The following may be cited
as conditions contributory to aortic regurgitation:
1 . Acute endocarditis, attended with extensive ulcer-
ation, usually terminating in speedy death. 2. Syph-
ilis, of which there is no history in the case before
us. 3. Chemical irritants, such as uric acid, lead
poisoning, alcohol — none suspected here. 4. Chronic
endocarditis, affecting the aortic valves by direct ex-
tension of aortic endarteritis. We must remember,
however, in this connection, that arteriosclerosis,
present in this case, may be secondary to chronic
valvulitis. 5. Pronounced dilatation in the ascend-
ing portion of the arch near the valve, which is rare ;
or an aneurysm just beyond the aortic orifice — nei-
ther of which could be observed in the fluoroscopic
examination here. 6. Age and sex; much more fre-
([uent in males than females, primarily because a
greater proportion of the former is engaged in occu-
pations causally related to the disease. The great
majority of cases arises in advanced middle life, a
relatively smaller number in still later years than
that found in young adult life. My patient is fifty-
three years of age. 7. Augmented aortic tension
strain. Occupation is more noteworthy than alco-
hol as a cause of aortic regurgitation by increasing
vascular tension. We cannot deny that strong
bodied men at middle life engaged in such occupa-
tions as demand strain — -"not a sudden, forcible
strain," says Osier, "but a persistent increase of the
normal tension to which the segfments are subject
during the diastole of the ventricle — are the most
frequent subjects of aortic regurgitation." This ob-
.servation is of exceeding significance in the history
of the case before us. "T was at Cleveland Park."
says the patient, "engaged in lifting heavy stones."
This work had been kept up for some months, there
was "a persistent increase of the normal tension to
which the segments were subject during the diastole
of the ventricle," and up to that particular hour
when his mental vision became perforce introspect-
ive, when this loud cardiac murmur for the first
time caught his ear, the patient did not know he had
a heart.
Etiology. — Hepatic : Floating liver is very un-
common. So far .as the writer has been able to learn
there have been but eighty cases reported in the lit-
erature. About ten years ago J. E. Graham collected
sevcntv cases from this source. Since then about
ten more have 1x?en added. Nearly all have been
females. The organ moves slightly in the pendu-
lous abdomen of enteroptosis, and in cases of a.scites
repeated. At the posterior margin the organ is so
bound to the inferior vena cava and dia]-»hragm that
fehruaTT :g, igoS.]
MAGRUDER: AORTIC REGURGITATIOX AND FLO ATI XG LIl'ER.
401
little mobility at this point is possible except in case
of a mesohepar or a congenital ligamentous union
of these structures. The suspensory and triangu-
lar ligaments may, however, be subject to consider-
able relaxation, the former three inches, the latter
one and three-fifth inches, and, in the erect position,
permitting the organ's upper surface to lie almost
below the costal margin, as in the case before us.
\\'hen the organ is tilted forward a very large sur-
face of the lobes comes in contact with the abdom-
inal wall, and the error in such instances is by no
means rare to think that the organ is enlarged.
Such, possibly, is the case in point, for the writer is
much of the opinion that the dull soreness upon pres-
sure over the epigastrium complained of by the
patient, and for the relief of which he had been
treated for indigestion, is due almost entirely to
traction upon the suspensory ligament, for no better
reason than that the abdominal bandage recommend-
ed by the writer gives absolute relief, ilie symptom
returning as soon as the patient attempts to go with-
out it.
It will be understood, of course, that in raising
the liver, not only is traction upon the suspensory-
ligament, upon the connective tissue which unites
the uncovered area of the right lobe of the liver to
the. diaphragm,' and, as observed by Faure, the trac-
tion upon the hepatic veins which join the vena cava
— not only are they all relieved, but, what is of in-
finitely more interest to my long sufifering patient
than all this high soimding phraseology, is the fact
that, in elevating the liver the stomach likewise is
elevated, and traction upon the gastrohepatic omen-
tal attachment- to the lesser curvature is prevented,
and the patient is at ease.
Symptoms. — Shortness of breath upon exertion ;
dvspnoea, especially at night; pain over epigastrium: at
tunes, cough ; occasionally, vertigo.
Physical Examination. — Inspection.— His thorax is well
developed and muscular : apex beat displaced one inter-
space below and two and three sixteenths inches to the left.
There is a slight precordial bulge.
Palpation. — There is a forcible, heaving cardiac im-
pulse, a very distinct purring thrill diffused over an area
of three inches square at the base of the heart. Mensura-
tion.— The left thoracic segment is greater than the right
by five eighths inch. Percussion. — This gives consider-
able increase in the area of cardiac dulness, extending
downward and to the left. Auscultation. — There is a
loud diastolic murmur, with seat of maximum intensity
at the sternal border of the second right interspace, trans-
mitted anteriorly and posteriorly over the entire thorax
and abdomen, from the clavicles above to the pelvic brim
Ijelow. clearly heard also in the vessels of the neck and the
femoral artery, completely obliterating the usual myocar-
dial and valvular sounds. It is a loud, long drawn bruit,
almost a moan, and the writer takes it, of course, as caused
by the reflux of blood from the aorta into the ventricle.
Frequently replacing this diastolic murmur is a redupli-
cated or double murmur, iambic in rhythm, the one dias-
tolic, the other exactly presystolic in time. This last the
writer takes for a "Flint" murmur.
The Flint inurmur.as explained by himself, is due
to an extreme dilatation of the ventricle, as a result
of which the mitral segments during diastole are
forced back against the wall, and, therefore, lying
in the blood current, they produce a sort of relative
narrowing, the result of which is a vibratory mur-
mur in character not unlike the presystolic murmur
of mitral stenosis.
Broadbent's theory in this regard is to the effect
that the regurgitant current from the aorta, imping-
ing upon the anterior or aortic flap of the mitral
valve, may set it into vibration and thus produce the
murmur. While Osier observes : "This apex dias-
tolic murmur of aortic insufficiencv occurs in a con-
siderable proportion of all cases," "Tt is variable
and may disappear as the dilatation of the ventricle
diminishes."
Let us look for a moment at our patient's arteries.
There is visible pulsation in the peripheral vessels. The
carotids throb forcibly, the temporals dilate, the brachials
and radials expand with each heart beat. They have a
characteristic jerking quality. The throbbing carotids in
the neck suggested aneurysm, and led to the fluoroscopic
examination. Notice the suprasternal notch and the great
vessels beneath the right sternocleidomastoid ; see the ab-
dominal aorta lift the epigastrium at each systole, and feel
the great prolapsed liver mass pulsate with the expansile
force borrowed from the same source ; look more closely
for the capillary pulse, seen through the finger nails ;
grasp the forearm above the wrist, and, holding it high,
feel the Corrigan or water hammer impulse forcibly strike
the palpating finger with its quick, jerking efTect, and its
immediate recession or collapse ; then observe that short
but appreciable interval between the heart shot and the fall
of the bullet just as it strikes the radial bull's eye — in a
word, observe this symptom complex, and tell me if this is
not aortic regurgitation ?
Abdominal Inspection. — The lower edge of the liver is
seen as a distinct linear prominence, extending transverse-
ly from the right mammary line almost to the correspond-
ing line on the opposite side. Percussion. — Relative dul-
ness of the upper border of liver, right side, is at sixth
interspace in the mammary line, eighth in midaxillary.
eleventh in scapular line. Lower border of hepatic dul-
ness, right side, is on a horizontal line with the umbilicus,
curving an inch above the umbilicus at the median line,
and extending two inches beyond this to the left.
The vertical width of hepatic dulness is as follows : On
the right in mammary line, si.x inches: in midaxillary line,
five inches ; in scapular line, three inches ; in anterior me-
dian line, seven inches : in left parasternal, six and one
half inches.
Palpation. — An extensive hepatic area is easily palpable.
By Glenard's precede du ponce the edge of the organ may
be felt to slip above the fingers with the respiratory move-
ment. Its character is smooth and soft. The organ dis-
tinctly pulsates. It is freely movable from side to side
and from below upward.
The physical signs of the stomach are those of a slight
dilatation ; the spleen is a trifle enlarged. There is no per-
ceptible abdominal tumor except the liver mass. The kid-
neys are apparently in their normal position, and either
may be felt on deep palpation. As stated before, the con-
dition here is not that of enteroptosis.
Diagnosis. — Cardiac. — The diagnosis of aortic regurgi-
tation is based upon a diastolic murmur over the aortic
area, throbbing arteries, the peculiar pulse, hypertrophy of
the left ventricle, and the sphygmographic charts.
Diagnosis. — Hepatic— Floating liver is the diagnosis,
made upon the presence of a large tumor in the abdomen,
in this case easily distinguishable from tumefaction of the
other abdominal organs for the following reasons : I, The
notch is palpable; 2, there is a tympanitic note over the
normal hepatic region ; 3, the unusual mobility of the
tumor; 4, it is possible to replace the organ; 5, its size
and consistency ; 6, the relatively long chest and lax recti
muscles, favorable to the condition; 7, the confirmatory
fluoroscopic examination, showing the total absence of the
shadow as produced by the upper border of the normal
liver.
Prognosis. — Cardiac. — Eventually unfavorable, thoiigb
compensatory hypertrophy may go hand in hand with dila-
tation, and, while subject to sudden death to a larger de-
gree than results from any other valvular lesion, one may.
in the practice of moderation, live for years. This condi-
tion following endocarditis, however, is much more favor-
able than when sequent to arteriosclerosis. This fact,
coupled with the age of the patient. _ makes for shorter
days, for with progressive sclerosis of the arch and en
croachment upon the coronaries, we may expect myocar-
dial degeneration and with it the end.
402
NUTT: ORTHOPEDICS OF ANTERIOR POLIOMYELITIS.
[New York
Me;)ical Journal.
Prognosis. — Hepatic. — Favorable.
Treatment. — Hepatic. — Mechanical support, a snugly fit-
ting abdominal bandage, preferably of linen, and with
straps passed around the buttocks, like a suspensory band-
age, to prevent its riding above the hips.
Treatment. — Cardiac. — The writer protests against digi-
talis as a routine stimulus for cardiac failure. In dila-
tation— when by its use slow regularity supplants the
many ineffective contractions of the overdistended ven-
tricle, this followed by cardiorespiratory rhythm and the
absorption of pulmonary cedema — digitalis produces strik-
ing effect. It is powerless, however, in fatty degeneration.
It disturbs the stomach, and acts on the muscular arte-
rioles as it does on the ventricle, and thus in arterioscle-
rosis increases an already too high tension. Nitroglycerin
will counteract this undesirable vascular effect of digitalis
by dilating the arterioles, avhile it stimulates cardiac
systole.
Strophanthus — almost free from the contracting effect
of digitalis upon the arterioles — is preferred, with strych-
nine sulphate and nitroglycerin as adjuvants.
-A. grain and a half of caffeine citrate is better than
larger quantities, for in some cases long continued admin-
istration of three or four grains occasions cardiac
arrhythmia and distress. Sparteine sulphate in doses of
three quarters or one grain, combined with caffeine and
strychnine, often acts better in aortic regurgitation than
either digitalis or strophanthus.
Since muscular power is directly proportional to the
amount of oxygen consumed, the patient is advised to
spend as much time in the open air as the weather will
permit. Iron, because a great oxygen carrier in the blood
and a preventive of loss as regards the contractile power
in hypertrophied muscles, has been added. Meat, because
of the high tension pulse, has been largely interdicted, and
the value of milk, vegetable diet, and fresh fruit emphasized.
Beans, asparagus, and fibrous vegetables, as - cabbage, tur-
nips, and beets, are denied.
Constipation, raising the tension of the abdominal
arteries, is prevented by the use of magnesium sulphate and
sodium phosphate — one to two teaspoonfuls in a cup of
hot water on rising.
But strong medicines hc^ve been allowed only a secondary
role. Witli sufficient stimulation to keep the heart going,
emphasis has been laid rather upon the importance of
hygiene, diet, and rest.
Under this treatment the patient's blood pressure has
fallen from 228 to 155; he has gained sixteen pounds in
weight ; cedema of the lower extremities has entirely dis-
appeared; no trace of albumin is found in the urine; com-
pensatory hypertrophy seems establislied, and his general
improvement is certainly quite marked.
Discussion.
Dr. ThoiMas a. Claytor said that the hepatoptosis was
very interesting and very rare. He has seen three cases,
including that presented by Dr. Magruder ; one was seen
in Philadelphia and another at the Garfield Hospital here.
Dr. Louis Mackall, Jr., said the case was of great inter-
est, particularly on account of a presystolic thrill at the
apex with no apical murmur, and the presence of the loud
murmur at the base with no basilar thrill. The condition
suggested to him aneurysm of the heart. The heart was
not much hypertrophied, and on that account he did not
think that the aortic regurgitation was of long duration.
He believed fhat the condition of greatest moment was
the hepatoptosis, which by pressure and drag on the aorta
threatened or had already caused aneurism. On that ac-
count he would urge suspension of the liver after the man-
ner described by Le Page. Dr. Mackall believed that such
an operation w^as strongly indicated in this case, in which
the heart was already in bad condition and progressively
growing worse.
Dr. J. D. Thomas said that the conditions under which
he had examined the patient did not justify an accurate
diagnosis. The murmur was a very unusual one, and
though at first it seemed to be systolic, \yhcn compared
with the pulse, it proved to be diastolic in time, or at least
not systolic. Although the sounds did not indicate to his
mind aortic regurgitation alone, that condition was pres-
ent. .\ pathognomonic sign of that lesion is a double
bruit in the large vessels, and that sign was plainly audible
in this case in the femoral artery. Some writers hold that
the sign may also be heard in mitral stenosis. The case
was of great interest, but he did not think that the sounds
were altogether characteristic of aortic regurgitation alone.
Dr. E. p. Magruder, in closing, said that with regard
to the thrill it might be felt at base and apex. He had
referred in his paper to the double vascular murmur men-
tioned by Dr. Thomas., He did not think there was any
involvement of .the right heart. He agreed that possibly
the mitral valve also was affected, producing at times the
reduplicated or double murmur effect described by Flint
as replacing that of simple aortic regurgitation. As to the
time of the murmur careful study had convinced him that
it was diastolic. He had no opinion to offer as to the
relation between the floating liver and the cardiac condi-
tion.
In the course of the last year evidences of arteriosclerosis
had increased. The pulse had also markedly changed in
character, due no doubt to improved mode of living.
The Ashley, Eighteenth and V Streets.
ORTHOP.EDIC THERAPY DURING THE EARLY
STAGES OF ACUTE ANTERIOR
POLIOMYELITIS.*
By John Joseph Nutt, M. D.,
New York,
Instructor in Orthopaedic Surgery, Cornell University Medical Col-
lege; Assistant Surgeon', New York State Hospital for
Crippled and Deformed Children; Surgeon, Ortho-
paedic Department, Cornell University.
Cessation of spontaneous improvement, without
a complete cure of the paralysis, after an attack of
acute anterior poliomyelitis, marks the beginning of
a chronic stage. It is not the treatment during this
stage which it is proposed to discuss here.
Believing, however, that proper and painstaking
orthopaedic treatment, instituted during the more
acute stage, will greatly lessen the extent of the
crippling results, and be the means, in some cases,
of a complete cure, I shall attempt to discuss such
treatment as appears to me to be rational and essen-
tial.
The ultimate disabilities are due to the paralysis
and to the deformities. The deformities result from
unopposed muscular action, from asymmetry in
development, and froin weight bearing in an ab-
normal position while the sustaining tissues have
their motor and trophic centres paralyzed. The
treatment, therefore, before the chronic stage, should
be directed toward: i. Keeping the parts in as
healthy a condition as possible ; 2, the preservation
of the normal range of motion in all the joints ; and,
3, preventing stretching and elongation of paralyzed
and weakened tissues.
I. To keep the parts in as healthy a condition as
possible. The importance of this cannot be over-
estimated. It must be borne in mind that, in these
cases, the paralysis is not only a motor paralysis,
but a trophic paralysis. Not only do the muscle
fibres lose the influence of their trophic centres, but
every tissue, bone, ligament and blood vessel suffers
from this paralysis
The means to be tiscd to combat this condition
are massage, electricity, heat, and hydrotherapy.
•Read before the Society of Alumni of BcUevue Hospital, Janu-
ary 2, 1908.
NUI T: OKI HUF.^UlLS Of ANTERIOR I'OLIOMV ELl'i IS
403
Directions to simply rub the muscles every day are
not sufncient. ihe iailure of most American physi-
cians to appreciate the value of scientihc massage,
and their unwillingness to do it themselves, is a
serious loss to our armamentarium. Massage should
be done daily, conscientiously, scientiiically. Each
seance should occupy from ten minutes to one half
hour, depending upon the age of the patient and
the parts to be massaged. Friction alone is insuffi-
cient. Each paralyzed muscle should be stripped of
its blood supply and its capillaries engorged with
fresh blood.
Electricity is of use in this as well as the later
stage. If there is any response to the faradic cur-
rent it may be used, otherwise the galvanic current
is employed. A very few minutes, perhaps three
or five to a muscle, of skillfully applied electricity,
daily, is undoubtedly of great service toward com-
bating the effects of both the motor and trophic
paralysis.
The local temperature should be maintained.
This is often a difficult matter. Hot water bags and
electric heaters are not to be recommended, as the
lowered temperature is not a temporary condition.
It is best maintained by preventing loss of heat
through radiation and conduction. Extra clothing,
constantly worn, may accomplish this, but, if not,
then wrapping in cotton batting or other means
must be taken.
Hydrotherapy is of value as a stimulant to the
vasomotor apparatus and also as a means of pre-
serving the skin in a healthy condition. On account
of the trophic disturbance to the skin and its conse-
quent liability -to ulceration, care must be observed
in the use of soaps. The alternate hot and cold
douching with sea salt solution is often most happy
m its results. If, however, a reaction is not at once
evidenced, the douching should be discontinued.
2. Normal range of motion at the joints is preserved
by passive movements. These should be carried out
daily from the beginning of treatment. Muscle
shortening begins within a very few weeks. Normal
movements may be impossible, without the use of
force, as early as six weeks after the onset of the
disease, as seen in a case this fall.
This shortening of the muscles and the subsequent
ligamentous shortening is due to the physiological
law enunciated by the late Henry G. Davis, in his
Consen'ative Surgery, page 139:
"Ligament, or any soft tissue, when put under even a
moderate degree of tension, if that tension is unremitting,
will elongate by the addition of new material ; on the con-
trary, when ligaments or other soft tissues remain unin-
terruptedly in a loose or lax state they will gradually
shorten as the effete material is removed, until fhey come
to maintain the same relation to the bony structures to
which they are united that they did before their shorten-
ing."
3. To prevent stretching of paralyzed and weak-
ened tissues : The paralyzing effect of overstretch-
ing a muscle is known to all physiologists, but, I
believe, its importance as a factor in determining
the amount of disability resulting from- infantile
paralysis is not sufficiently emphasized by surgeons.
It has been demonstrated, time and again, that the
application of an apparatus relieving muscles, which
had been classed as paralyzed from the cord lesion,
from a long continued and uninterrupted stretching
force, has produced some return of power. Even
after several years of nonuse from overstretching
muscles may, by proper treatment, be partially re-
stored to their normal functions.
It is to be remarked that of all the groups of
muscles which may be paralyzed after an attack of
acute anterior poliomyelitis, the muscles which re-
ceive the greatest strain, under ordinary circum-
stances, are the ones which, in the majority of cases,
remain as the only reminiscence of the disease. In
paralysis of the anterior tibial muscles, whether the
patient is lying down or sitting up, those muscles
are on a stretch the greater part of the time. Not
only is gravity stretching them, but the calf muscles,
providing they are not paralyzed, are constantly
exerting a stretching force. To avoid this, passive
movements once or twice a day are not sufficient.
The ends of the dorsal extensors of the foot must
be approximated and held in that position unremit-
tently, except for the short time that other treat-
ment is being given. This should be done as soon
as these muscles are found to be paralyzed. The
same precautions should be taken to prevent stretch-
ing of any muscles, such as the peronei, the tibialis
anticus alone, or the deltoid.
To illustrate the importance of preventing this
stretching paralysis, which is so frequently classed
as due to the cord lesion and considered permanent,
I shall briefly relate a case which was recently sent
to me from up the State.
Case I.— L., thirteen years old. Family history was good.
Previous history was negative. Present history: In
August, igos, patient had an attack of what was diagnosti-
cated as acute anterior poliomyelitis. Condition in Septem-
ber, 1907: There was paralysis of tibialis anticus of right
leg, of all the anterior tibial muscles of the left leg, and
probably the intrinsic muscles of the vertabrje, which pro-
duced a lateral curvature. During three months of dailv
treatment of the scoliosis her paralyzed leg muscles re'-
ceived, also daily, massage, electricity, extension of con-
tracted gastrocnemius of left leg, douching with hot and
cold salt solutions, and passive and, where possible, resisted
active motions. A very slight reaction to the faradic cur-
rent was present, at the beginning of treatment, in the mus-
cles of the left leg, but none in the right ' tibialis anticus.
At the present time all the muscles of the left leg, which
had been considered as permanently paralyzed by destruc-
tion of the anterior horn cells, show a return of power.
The right tibialis anticus is probably paralyzed from the
destructive process of the disease.
Another instance, to my mind, of paralysis due to
overstretchins: was the f ollowinsr i
Case II. — Last summer a gentleman consulted me regard-
ing his chauffeur. I found the young man, then twenty-one
years of age, had a paralysis of the anterior leg group of
the right leg. He had had this trouble as long as he could
remember and had been treated at dispensaries in New
York city for a number of years. The treatment had con-
sisted only of braces which he had worn only intermittently.
Operation had been offered and refused. Since becoming
a chauffeur, he had used the foot constantly on pedals and
had found that he was obtaining some use of his toes. The
pedaling, making a forced dorsal flexion, would have tended
to stretch the contracted gastrocnemius and this may pos-
sibly, it would seem, have been sufficient to relieve the
strain on the dorsal flexors, and permitted some return of
power.
Contrary to the opinion of some, prolonged rest
in bed does not appeal to me as the wisest of treat-
ment. After the subsidence of the fever, every
measure which wiU help to restore a normal circula-
404 DORRAXCE: BILIARY FISTULA.
tion to the cord and place the constitution of the
patient in the best possible condition, are to be em-
ployed. When the question of applying a brace,
therefore, arises, serious consideration must be
given as to whether the importance of supporting
a weakened joint or muscle overweighs the con-
comitant conhnement of other joints and muscles.
Functional use of muscle, ligament, and tone arc
to be encouraged. Great care is necessary while
spontaneous improvement is progressing that an
apparatus does not do more harm than good. Hard
and fast rides cannot be laid down. Consideration
must be taken of the age of the patient, his activity,
and the strength of the supporting structures of the
joint. A. child unable to walk, either because too
young to walk or from disability, will need, if any,
but simple apparatus, while an active child, continu-
ously on his feet, and using his legs as I)cst he can,
may need protection while yet his condition is per-
ceptibly improving. In all such cases, the muscles
and joints which are confined shotdd receive exer-
cise by passive and resisted active movements twice
a day, with the brace removed.
"The Seminole," Broadway .vno Sixty-ninth
Strekt.
A CASE OF BILIARY FISTULA BETWEEN TIIIC
GALLBLADDER AND THE STOMACH, WITH
A STONE IN THE HEP.ATIC DUCT.
By George Morris Dorraxce, M. D.,
Philadelphia,
Surgeon to St. Agne^' lIospitaK
In reviewing the literature of biliary fistula one is
struck by the rarity" of fistula into the stonr ch
.\auyn mentions that twelve cases had been reported,
l)Ut only gave the references to nine ( Courvoosicr
eight, Schlorth one) ; Aloynihan records one. the
Middlesex Museum one (No. 1595). ?^layo Robson
one, Oppolzer one, French one, and Jacftreson one.
Undoubtedly many more have been recorded, but 1
have been unable to find them.
The history of my case is as follows :
Patie-nt was seen in consultation with Dr. W. P. and Dr.
E. M. Kistler, of Allentown, Pa. She wa.< a woman, forty-
;,even years of age. Family history was negative; previous
personal history also negative; no history of tvphoid fevct.
History of present illness : Patient had liad three at-
tacks of biliary colic in the past four \ears, ;iccompanied
by jaundice in two instances, but no gastric fhsturliances.
The present attack began with pain in the galll)Iadder region
without lieing transmitted. Jaundice was intermittent for
the past eight days; at the time of operation the patient
was slightly tinged.
Oneration : On opening the alidonien. the .interior wall
'jf the stomach, 6 centimc;tres fmni ilic ;i\l(M-n^, was adher-
ent to the lower surface of the g<-dlljlail'Ur, 1 rentimetre
below th.e apex. Very few adhesions weic i)resent. Witii
the finger in the foramen of Winslow, tlie connnon duct was
found free from stones, while the licpatic duct was ob-
structed by a large faceted stone. The stone was "milked"
down and removed from the hepatic duct. The gallbladder
was opened, and the little finger passed into the stomach
through ilie fistula. The gallbladder was drained with a
rubber tube, and the wound closed, except for a large
gauze drain. The fistula was not closed, but left as T
found it.
Subsequent histf)ry: The wound healed in three weeks.
\'o gastric disturbances have occurred since, and I he jia-
tient reports that she is entirely well.
1716 LoccsT Street.
-OUR READERS' DISCUSSIOXS. [N'-w Vork
(©ur geabirs' fiscussions.
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)nost satisfactory to the editors and their advisors will
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tached to literary style, but the award will be based solely
on the value of the substance of the answer. It is requested
(but not required) that the answers be short; if practica-
ble, no one answer to contain more than six hundred words.
All persons will be entitled to compete for the prise,
zijhether subscribers or not. This prize zeil! )iot be awarded
to any one person more than "iice zeilhin one year. Every
answer must be accompanied by the leriter's fiiil name and
address, both of zvhich zee iini.^t be at lilH-rty to publish.
All papers contributed becuiie tlie property nf'the Journal.
The prize of $23 for .the best essay submitted in answer
to question LXX has been aivarde'd to Dr. Beverley R.
Tucker, of Richmond, Va., whose article appears below.
PRIZE QUESTION NO. LXX.
THE DIAGNOSIS OF ALCOHOLIC STUPOR.
Bv Beverlev R. Tucker, M. D.,
Richmond, Va.
A medical sliuk'nt, cramming for some examina-
tion, learns a long list of distinctive dicfgnoses of
stuporous states arranged for his edification in col-
umns side b\ side. This table he f[uickly forgets
or his impressions become sadly confused. In con-
sequence of this he may thereafter have the em-
barrassing experience of being brought face to face
with some case of unconsciousness and be at a loss
to diagnosticate or treat it. I shall attempt rather to
give only a brief picture of states that may be mis-
taken for alcoholic stupor.
The conditions we will consider are: i, Alcoholic
stupor. 2, Epilepsy. 3, Spontaneous cerebral
haemorrhage ' apoplexy). 4, Cerebral tratima with
stupor. 5, Heat stroke. 6, Uraemia. 7, Shock. 8.
Diabetic coma. 9, Cardiac syncope. 10, Narcotism.
II. Hysteria and hypnotic states. 12, Malingering.
As aids to diagnosis, we should note the time of
day or night when we first see the case, the sur-
roundings, whether or not the patient is alone, and
note the posture, general appearance, and complexion
of the patient. See if marks of violence or injury
are present, and notice if any weapons, bottles, or
papers are lying about. We should feel the pulse
and skin, and note the character of his breathing,
the reaction of his pupils, and whether his limbs are
stiff or relaxed, ancl whether there is any odor about
him. We also nntst bear in mind that in organic
cases the preponderance of .symptoms are on one
side, while in toxic conditions they arc bilateral.
.\11 this will take but a few moments, and then we
begin to classify our case.
I. Alcoholic stupor. — If the odor of alcohol is
])re.sent it is not a reliable sign, but the absence of
this odor is a valuable negative diagnostic jioint.
'l"he patient is tisnally lying on his face or side, and
February Jy. 190S.]
OUR Ri:ADhRS' DISCUSSIOXS.
405
his limbs are llaccid and partly flexed. Pressure
over the supraorbital notch or ammonia inhaled will
arouse him. If the extremities move it proves that
part not paralyzed. He has no convulsions, and his
knee jerks are usually absent. The pupils are di-
lated, but react to strong- light. If cardiac compen-
sation fails his face is pale and pulse weak, but
usually the face is flushed, the skin damp, and the
pulse full and rapid, though of low tension. His
breathing is heavy, he mutters when aroused, and
his temperature we may expect to find subnormal.
2. Epilepsy. — The convulsion itself is not mis-
taken for alcoholism, but the stuporous stage fol-
lowing may be. The history of an immediately pre-
ceding fit. and especially of the past occurrence of
others, is a valuable point. A bitten tongue, froth
on the mouth, and the absence of alcoholic odor
saparate the two conditions. The temperature in
epileptic stupor is usually normal or slightly ele-
vated. The knee jerks are abolished, and the pupils
dilated and immobile, but these reflexes return as
the patient becomes conscious.
3. Spontaneous cerebral hccmorrhage (apoplexy) .
— This occurs most frequently in people past mid-
dle life, who arc high livers and who present evi-
dence of arteriosclerosis, but it may occur when
none of these conditions obtain. The pupils are di-
lated, but, unlike alcohol, do not respond to light.
The blood pressure is increased, and there is
paralysis of one side, the leg on this side being more
flaccid and extended than on the healthy side. The
Uabinski sign is also found on the hemiplegic side.
The knee jerks may be plus, minu^. or absent, but
the superficial -reflexes are decreased. The tem-
])eratnre is subnormal and then rises. The cerebro-
spinal fluid contains traces of blood. If the hjemor-
rhage is pontine the pui)ils are contracted, the symp-
toms bilateral, and there is marked perspiration, al-
though the temperature is high. In cortical hc-emor-
rhage the muscles are spastic and deep reflexes in-
creased.
4. In cerebral trauma zvith stupor the symptoms
of concussion and laceration are similar, compres-
sion is different. In the first two the skin is pale,
cool, and clammy, the pulse weak, the knee jerks
abolished, the temperature sirbnormal. and the
respiration feeble. Concussion may go to cerebral
irritation of the frontal lobes, and the patient be
excited, restless, Iving in a curled up position, and
roll from side to side. In compression the patient
lies on his back, the skin is damp and hot. the pu])ils
vary, the skull may show the depression, and there
may be focal paralysis.
5. Heat stroke. — The atmospheric conditions, the
extremelv high body temperature, sometimes to
112° F., and the very flushed dry skin will usually
be sufficient to distinguish.
6. Urcemia presents all)umin and casts in the
urine, and the face ma\- have a swollen pallor and
the breath be urinous. This condition is usually
preceded by headache, vomiting, and convulsions.
7. Shock. — Get the history of the cause of the
trouble. The face is expressionless and pale, the
temperature subnormal, the skin cool, and the pulse
weak and running.
8. Diabetic coma. — Sugar is found in the urine,
which is of high specific gravit\-, and there is a
sweetish, acetone odor about the breath. If coma
is deep the pupils do not react. The pulse is small
and rapid. Headaches and drowsiness precede.
9. Cardiac syncope. — This condition, known to
the laity as a fainting spell, need be only slightly
considered. The attack is sudden, and lasts but a
short time, the pulse slow and very weak, and the
face pale.
ID. Narcotism. — This embraces too large a field
to be discussed here fully. In opium poisoning the
pupils are contracted and do not react, the skin is
pale, and the respiration and pulse slow and feeble. In
ether and chloroform stupor the odor can be distin-
guished from alcohol. In carbon monoxide and car-
ibou dioxide gas poisoning the surroundings in which
the patient is found help us, together with the weak
pulse and feeble respiration. Stupor from chloral
is marked by a pale, clammy skin, absent deep re-
flexes, subnormal temperature, and sometimes
pupura haemorrhagica. The pulse is slow, then
rapid and weak ; the respiration labored, then weak :
the pupils contracted, then dilated toward the last.
11. Hysteria and hypnotic states. — Hysteria oc-
curs most frequently in young women ; the posture
is that of a pose ; the patients resist having their
eyelids opened : their pupils and pulse are normal,
unless the latter is accelerated from exertion. The
deep reflexes are present. In trance, hypnosis, etc..
the pulse and respiration are slow but regular, the
pupils normal, and the muscles not completely re-
laxed or may be rigid. The temperature and skin
are usually normal.
12. Malingering may be told by the person over-
acting the part, the pupils, pulse, temperature, re-
flexes being in normal condition.
We should try, if possible, to exclude every other
condition before diagnosticating alcoholic stupor,
and I believe that if we make a thorough examina-
tion, picturing the salient features of each stupor-
ous state, rather than trying to memorize extensive
lists of signs and symptoms, and arriving at alco-
holism by exclusion, we will obviate the many dis-
tressing errors that too frequently accompany the
diagnosis of this condition.
Dr. John McGruder Sutton, of Kansas City, Mo.,
says:
The conditions with which alcoholic stupor is
most frequently confounded are ursemic coma, apo-
plexy, and opium poisoning.
In acute alcoholism there is deep flushing, some-
times cyanosis, of the face ; the pupils are evenly
dilated and react to light; the temperature is nor-
mal or subnormal; the pulse is full, regtilar, and
bounding; the breath has a strong alcoholic odor
(which is far from pathognomonic, however) ; the
muscular resistance is equal on both sides ; respira-
tion is slightly accelerated and deep, but not ster-
torous ; there is often twitching of the muscles, but
rarely convulsions ; and involuntary evacuation of
the bladder or bowels may occur, although uncon-
sciousness is rarely complete. Retinal examinations
are negative, and albuminuria, other than of slight
degree, is exceptional. The blood pressure is sel-
dom over 150 mm. Hg. (Riva-Rocci).
The clinical picture is somewhat different in
urremic coma. The pupils vary; they mav be wide-
4o6 OUR READERS' DISCUSSIONS. [Ne«- York .
Medical Jolrnal.
ly dilated or medium in size. The opthalmoscope
shows the presence of albuminuric retinitis. The
coma is deep, and stertorous breathing is the rule.
Oftentimes the breath has a urinous odor. There
is usually marked oedema and puffiness beneath the
eyes, the complexion is pale and "pasty" looking,
convulsions are of frequent occurrence, and a
hemiplegia may be present. A careful examination
of the urine is, of course, the most important of all
procedures here. In fact, it is a wise precaution
to make a brief but exact uranalysis in all cases of
coma from any cause. A portion of the bladder
contents is withdrawn, with aseptic precautions,
using a soft rubber catheter. It is safer to employ
two methods for the detection of albumin. I pre-
fer the one devised by Heller and the magnesium
nitric test. If negative, an examination for sugar,
by Fehling's solution, should follow, in order that
diabetic coma may also be excluded. The blood
pressure in these cases is high, much over 150 mm.
as a rule, and the urine and freces are retained.
Apoplexy is frequently associated with alcoholism
of varying degree, consequently the diagnostician
cannot exhibit too much care in making a positive
differentiation. The face may be cyanotic, but is
often of an ashy gray pallor. Unconsciousness is
profound; the breathing is stertorous, slow, and
irregular at times. The pupils vary. They may be
irregular, and are inactive. During expiration the
cheeks (especially the one on the affected side) are
puffed out, and a blowing noise is made by the lips
as the air is expelled and the cheeks collapse. There
is usually restriction of the thoracic movements on
the paralyzed side. Conjugate deviation is often
present. The affected muscles are commonly
flaccid and nonresisting, although they may show
marked rigidity. The pulse is slow, full, strong,
and of high tension, the manometer showing a
pressure of 175 mm. or more. The temperature, is
normal or subnormal at first, later there may be
fever. The urine is slightly albuminous at times,
but seldom more than a trace. If a fracture of the
base exists, as a complication, it is accompanied by
ecchymoses, especially in the infraorbital regions,
there is escape of cerebrospinal fluid, alone or mixed
with blood, trom the ears, and signs of external vio-
lence, such as bruises and cuts, are present.
The sym'ptoms in a case of opium poisoning are
more typical. Here the invariable presence of the
contracted "pin hole" pupils is of immense aid. The
face is swollen and bluish in color ; the respiratory
movements are irregular, labored, and greatly de-
creased in frequency (six or eight per minute at
times) ; the skin is cold and clammy; the pulse is
slow, weak, and soft, and the unconsciousness is
deeper than in alcoholic stupor. Muscular twitch-
ing is absent. If the opium taken was in the form
of laudanum its odor is imparted to the breath.
At times an epileptic seizure may be mistaken for
the insensibility due to alcoholic poisoning. The
brief duration of the attack, the absence of odor on
the breath, the presence of convulsions at the on-
set, if seen, and evidences of wounds on the tongue
and bruises on other parts of the body will suffice
for differentiation.
Diabetic coma sometimes gives rise to an incor-
rect diagnosis of acute alcoholism, but an exami-
nation of the urine, as suggested under uraemia, will
speedily dissolve any existing doubt.
During the heated season cases of sunstroke and
heatstroke may fail to be recognized, and the con-
dition ascribed to excessive indulgence in alcohol.
The temperature (which should always be taken per
rectum here), the skin, and the pulse will give suf-
ficient information for a correct diagnosis. In sun-
stroke there is a pronounced hyperpyrexia, varying
from 105° to 112° 1^., with a hot, dry skin, and a
strong, bounding pulse of high tension. In heat-
stroke, or heat exhaustion, the temperature is sub-
normal, the skin is pale, cold, and covered with
moisture, and the pulse is thready and weak.
When rendering an opinion in a suspected case of
alcoholic stupor the physician cannot be too cir-
cumspect. If an error is made it should always be
on the safe side, the more serious condition being
given the benefit of the doubt.
Dr. W. Hays, of Neiv York, states:
Stupor, or semicoma, may be defined as an inter-
mediate stage between somnolence and coma. A
partial loss of consciousness, or profound slumber,
is present, from which it is possible to arouse the
patient only with great difficulty and by earnest en-
treaty.
It is exceedingly important in all cases, in which
such unconsciousness obtains, to make a thorough
but rapid examination, and note carefully all physi-
cal signs. Failure to do this may result in egregious
and serious blunders, as, for instance, the diagnosis
of drunkenness, merely because the odor of alco-
hol may be detected on the patient's breath. It is
essential to ascertain the condition of the pupils,
whether contracted or dilated equally or unequally,
the presence or absence of reaction to light or of
the consensual reaction. If the eyelids cannot be
readily raised, no true stupor exists. The face
should be viewed so as to determine whether uni-
lateral facial paralysis be present. Injury to the
head, cuts, bruises, or depressions, must be in-
quired into. The color of the skin may be im-
portant. During extremely warm weather the tem-
perature of the skin should be observed. The
mouth and tongue may show injuries from the
teeth ; froth may be upon the lips. The comparison
of the degree of flaccidity of the limbs on opposite
sides of the body often gives a clue that aids very
materially in diagnosis. If possible, the history of
the past life of the patient should be obtained, to-
gether with a narration of events immediately pre-
ceding the onset of the condition in which found.
The temperature, pulse, and the respirations should
be noted.
In alcoholic stupor, pressure over the supra-
orbital nerve will usually elicit a response, though
it may be with difficulty, and the patient will often
vehemently protest with words or blows. The face
is flushed. An alcoholic odor can be detected on
the breath and in the vomitus, if any. Absence of
this odor will aid in positively excluding alcoholism.
The pupils are equal and either of normal size or
slightly dilated and react to light ; no lateral devia-
tion. The pulse is rapid, full, and strong. Respira-
tions are normal in frequency, but deep and occa-
sionally stertorous. The skin is very commonly cool
February 29, 190S.]
I'M ERA Pli UTICAL NOTES.
407
and moist, and the temperature either normal or
slightly subnormal, unless delirium is present, when
there is a rise in temperature. It is well to hear
in mind that a cerebral lesion may be coexistent
with the drunkenness, and signs of the former con-
dition must be carefully looked for.
• The unconsciousness of apoplexy is usually
deeper than that of alcoholism, taking on more the
character of a coma. The face is suffused, cyanotic,
though sometimes pale. The pulse is full, slow, and
of increased tension ; the artery often shows athe-
romatous changes. The respirations are slow, noisy,
and stertorous, and ofttimes irregular. Cheyne-
Stokes type of breathing may be heard. The
cheeks are blown out with spluttering of the lips,
more marked on one side than on the other if uni-
lateral paralysis of the face is present. The tem-
perature may be normal or subnormal, though in
cases likely to prove fatal fever is noted. The
pupils are dilated, often unequal, and do
not show reaction to light nor the con-
sensual reaction. When haemorrhage occurs
into the pons or the ventricles, the pupils will be
contracted because of the irritation of the nticleus
of the oculomotor ner\'e. Conjugate deviation of
the head and eyes or persistent turning to one side,
the side on which the haemorrhage has occurred,
may be present. Unilateral paralysis of the face is
indicated by the droop of one angle of the mouth,
the eflfacement of wrinkles on the affected side, and
the flapping cheek. Greater flaccidity of the limbs
on one side may be noted by raising them and let-
ting them fall, those on the affected side dropping
as "dead." The skull should be subjected to a
thorough examination for any injury, however
slight it may be. The onset varies in suddenness,
depending on whether the apoplexy is due to cere-
bral haemorrhage, embolism, or thrombosis. Stupor
or coma, with hemiplegia, complete or incomplete,
may occur in the course of pachymeningitis interna
haemorrhagica.
In opium poisoning the patient can be aroused
unless he is extremely narcotized. The face is at
first pale ; later dusky and cyanotic. The pupils are
strongly and equally contracted. The respirations
are slow, and may even drop to eight a minute.
The pulse is slow and full. The temperature of the
body is normal or subnormal. The skin is warm
and moist. If the intoxication is due to laudanum
the smell will be noticed on the breath.
Urtemia is a form of intoxication due to the re-
tention within the circulation of excrementitious
substances normally eliminated by the kidneys. The
patient may be aroused temporarily from the un-
consciousness which may be preceded by or alter-
nate with epileptiform convulsions. The face is
pale, swollen, and oedematous. The breath exhales
a urinous or sweetish odor. Examination of the
urine shows evidence of kidney disease, but that
should not lead the physician astray. The pupils are
equal and usually widely dilated, though they may
be normal and reaction to light be preserved. There
may be twitching and rigidity of the muscles of the
hands and feet. The pulse is rapid. The respira-
tions are frequent and irregular, dyspnoea occasion-
ally being seen, or even Cheyne-Stokes type of
breathing. The temperature is usually normal, but
may at times be subnormal. Convulsions tend to
elevation of temperature. If ophthalmoscopy is
possible, nephritic retinitis may be discovered. Oc-
casional instances of uraemic hemiplegia are met
with, which are unexplainable pathologically and
are often transient.
These conditions are the most common ones in
which a distinctive diagnosis is puzzling, and often,
indeed, baffling. In addition, it is well to bear in
mind that in hysteria, insolation, epilepsy, diabetes,
and gas poisoning, unconsciousness is existent
which may easily mislead the careless observer. In
hysterical stupor the patient will resist opening of
the eyes usuall}-, and the e\eballs are rolled up-
ward. A strong irritant, such as ammonia, held
closely to the nose, will always awaken a response.
Sudden anaemia of the brain causes an absolute
pallor of the face; the respirations are shallow and
almost imperceptible ; the pulse weak and flutter-
ing, and the pupils much dilated, with the eyes pos-
sibly wide open. Thermic fever can usually be dis-
tinguished by the excessively high temperature of
the body and the history of prostration under ex-
posure to the sun. In heat prostration a greatly
subnormal temperature is present, and the uncon-
sciousness may be due to either the sun's rays or to
intense artificial heat. In epilepsy, the froth on the
lips, possible biting of the tongue or lips, the his-
tory of a convulsion, and the gradually subsiding
unconsciousness, will clear away any doubts as to
the condition present. Diabetes is made distinctive
by the discovery of a considerable amount ©f sugar
in the urine and the sweetish, fruity odor of the
breath. In poisoning due to illuminating gas, the
condition is almost always obvious from the circum-
stances under which the patient is found. The
smell of the gas will usually clear up the diagnosis,
though a further criminal aspect may be given to
the case by the discovery of wounds that may ex-
plain the true condition, complicated by the inhala-
tion of the noxious vapor. Stupor may also be asso-
ciated with any organic or inflammatory disease of
the brain. In eclampsia due to pregnancy, stupor,
or coma, preceded by or associated with convulsive
seizures, can be readily diagnosticated. In many of
the acute infectious diseases, such as typhoid,
typhus, and pernicious malarial fever, a gradually
appearing unconsciousness may develop.
Careful attention to all objective signs will usual-
ly lead to a positive diagnosis, but at times the con-
dition seems so obscure that even the most pains-
taking examination will be vain and fruitless.
(To be concluded.)
f btrajfnticiil |lotcs.
A New Treatment for Tuberculosis. — Lemoine
and Gerard, of Lille, read a paper at the Academic
de Medecine upon a treatment of tuberculosis,
based upon the antitoxic action of the liver {The
Practitioner, February, 1908). They point out that
bile and the biliary acids are known to have a true
chemical neutralizing eft'ect upon the venom of the
biles, and that cholesterine, in particular, behaves as
an antitoxic substance. They made a series of ex-
4o8
THERAPEUTICAL NOTES.
[New York
Medical Journal.
periments to determine whether cholesterine and
bile extracts possess any immunizing properties
against the poison of tubercle. Bacilli were injected
into the peritoiiosum of guinea pigs, to which were,
later, given hypodermatic injections of cholesterine
and of biliary extracts, obtained from the bile by
petroleum ether. The injections produced no unfa-
vorable reaction, and a greater resistance to tubercle
was noted in the animals experimented upon. There
was no development of tubercle. In the wards,
Lemoine used the same products for injection, and
found in the patients, submitted to the treatment,
improved general condition, lessening of the night
sweats, of the fever, and of the frequency of the
pulse, increased arterial tension, return of appetite,
and increase in weight. The results obtained in
over 250 patients, treated during the last three
years, have been that in tuberculosis of the first and
second degree, the improvement has been complete,
allowing on an average a return to work in the case
of laborers, in from two to three months. In more
advanced cases, with cavities and profuse expecto-
ration, the results have been moderate. It is best
given hypodermatically.
Pyroligneous Acid for Arthritis Deformans.
— In the treatment of arthritic deformities of the
joints, Kolipinsky is said, according to Journal de
mcdecinc de Paris, for December 29, 1907, to give
])yroligneous acid internally in doses of from one
to two teaspoonfuls, diluted with a small quantity
of water, repeated two or three times a day. Un-
der the influence of this medicament the pain and
tlie swelling are said to subside and the joints to re-
gain their suppleness "in a very short time.
Antiseptic Mouth Wash. — Robin is credited in
Journal de medicine for December i, 1907, with the
following formula for an antiseptic wash for the
mouth and pharynx:
l» Betanaplithol, 0.02 gramme;
Sodium perborate 15.0 grammes;
Peppermint nater, 200.0 grammes;
Boiling water, q. s ad i.o litre.
M.
Heat the .solution on a water bath, when it is
ready for use.
Extract of Brain Substance Hypodermatically
in Tetanus. — According to M. Cspcntjki (Nou-
zrau.v renicdes, December 8, 1907; Pharmaceutical
Journal, February 16. 1908), aqueous or glycerin
extract, obtained by rubbing down brain substance
of any healthy animal with physiological salt solu-
tion or with glycerin and filtering tlirough a T.erke-
feld filter, has given excellent results in tlie treatment
of tetanus with patients ranging in age from >ix to
forty-eight years. The dose given is 15 to 20 c.c. in
twenty-four hours, hypodermatically, in the abdom-
inal region ; more may be given in grave cases. It
is essential that the brain .substance used should be
(juite fresh, and not more than five to seven hours
after slaughtering should be allowed to lapse before
it is used. When thus active, the results obtained
with the injection arc at least equal to those follow-
ing the use of tetanus antitoxine, with the great ad-
vantage that the material is always at hand, procur-
able in a short time, and cheap. The simple method
of injection is also preferable to the more compli-
cated proceeding of subdural injection into the
rachidian region necessary with the antitoxine;
the latter, too, is often followed by complica-
tions. Besides, no pathological elements are intro-
duced into the system by the use of brain emulsion.
Good results have also been obtained, it is said,
with brain emulsion extract in the treatment of
neurasthenia, epilepsy, tabes dorsalis, and in mental
affections.
Abnormal Digestive Fermentations. — Formerly
these were treated by antiseptics, such as benzo-
naphthol, salol, etc.. but Bardet {Bulletin de
thcrapeutique ; The Fractitiouer, February, 1908)
has demon.strated the uselessness of these, and has
returned to the use of special antiferments to in-
hibit lactic or butyric fermentation. For lactic acid
fermentation he gives ammonium fluoride, a sub-
stance currently employed as an antiferment in
breweries and distilleries, in solution, as follows:
R Ammonium fluoride gr. iii to gr. viiss ;
Distilled water,
M. Sig. : Tablespoonful after meals.
For butyric fermentation, the double iodide of
bismuth and cinchonidine is used in combination
with calcium fluoride and prepared chalk.
R Bismuth and cinchonidine iodide, . .gr. Yi to gr. iss ;
Calcium fluoride, gr. Yi to gr. iss;
Prepared chalk, gr. iss.
M. ft. pulv.
Sig. : One powder in a cachet after meals.
Sulphur iodide in a dose of one and one half
grain in a cachet is said to be an effective remedy
for the fermentations which accompany true flatu-
lence, the eructation at intervals of gas produced in
the stomach, as clistinguished from that due to air
swallowing which is almost continuous, and for
which the remed}- is of no avail. Precipitated sul-
phur checks lactic fermentation and stimulates intes-
tinal contractions. It should be given in a dose of
fifteen grains mixed with an equal amount of cal-
cined magnesia in a cachet at each meal. F"eculents
and sugar must be limiterl in the diet. Uncooked
fruit should onl\' be eaten at the beginning of the
morning meal.
A Soothing, Lubricating Application in Cysti-
tis.— Ellice .McDonald, in the Medical Record for
February 22. has found a mucilage of Irish moss of
the follo^xing composition a useful, soothing appli-
cation in ca^es of acute cystitis:
R Chnndrus (Irish moss) .^iss :
Distilled water Oiii.
Wash the clumdrus in cold water, drain: wash again
and drain. To the washed chondrus add three pints of
distilled water and boil for ten to fifteen minutes, stirring
frequentlx. Strain through muslin with expression. To
the strained Irish moss add six pints of boiling distilled
water and filter. Evaporate the filtrate to one fifth by
bulk, cool partially and add gomenol,' one per cent,
by weight, mix well, and strain tlirough fine white flannel
which has been previously boiled.
The author .states that the value of this prepara-
tion consists in keeping the bladder walls apart au'l
lubricating them, so that no friction or irritation re-
sults. The pre])aration is approximately the same
as many lubricating jellies jnit up in tubes for use in
vaginal examination. It is also of use in lubricating
the cystoscope before its introduction into the ure-
thra. In bladder treatment the jelly should be di-
luted with hot water to a thick semisolid consistence,
fit for use in a syringe.
'Oil of cajupiil iil)t.nincd from the leaves of Cajiifuti ■.■iriilifiorn.
'I"lie caiuimf oil of the pharmacopoeia is distilled from Mcialeiicii
Icuci.lc'iulron. ( .Ih.itniclnr.)
February 29, 1908.]
NEW YOKK MEDICAL JOURNAL
INXORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Revieiv of Medicine.
Edited by
FRANK P. FOSTER, .M. D.,
and SMITH ELY JELLIFFE, M. D.
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XEW YORK. S.VTUKDAY. FEllRLWRY .'9. 1908.
THE PHILOSOPHY OF CHARLAT.VXRY.
All educated and experienced physicians are
aware of the fact of the extensive prevalence of
charlatanry throughout the length and breadth of
the development of human culture, from the most
ancient to the most modern of times. ]vlany who
have contemplated the history of mankind have
been tempted to maintain that little or no advance
has been made by the human mind in its attitude
toward charlatanry since the days of Homer at least,
or even perhaps of the early Eg}-ptian civilizations,
glimpses of which are now being obtained with in-
creasing frequency.
The patrons and dupes of what educated physi-
cians call charlatanry are not at the present time
confined to any class of men or of women. Even
those of the highest culture and refinement seem to
follow the lights of false teachers with as much per-
sistence and as little discretion as the most ignorant
of people. It becomes all the more interesting, then,
to analyze if possible the philosophical foundations'
of successful charlatanry, with the view of under-
standing the principles which move so many indi-
viduals along lines which must in the end be the
opposite of self conserving.
In a recent very suggestive article cn this general
subject Dr. D. K. Shute. of Washington {Washing-
ton Medical Annals, January), says he considers
that at least five factors stand fcrth as elements of
stupendous power in cultivating and maintaining
such an extensive field of charlatanry as may be
409
witnessed in any modern state, whether civilized,
l>arbarian, or savage. These are human suggesti-
Ijility, reasoning by analogy, reversions to primitive
modes of reasoning (mostly included in the
former), the assumption that ideal associations have
corresponding material connections, and morbid
imagination. Of these, suggestion, reasoning by
analogy, and morbid imagination are the most im-
portant and fundamental.
Human suggestibility, in some degree at least, is
immeasurable. Dubois has made the computation
that only three per cent, of the human race is free
from the slavery of suggestion. How he arrives at
these figures we do not profess to comprehend, but
the fact will not be gainsaid that the proportion of
the unsuggestible is very small. So soon as one
leaves the cold ground of mathematical reasoning,
difficulties are rnet with in resisting the emotional
elements of suggestibility, and the credulity of the
multitude finds its gratification in this very element
of human suggestibility. Taking it into considera-
tion, the charlatan thrives through unworthy mo-
tives : the true physician must utilize the same
power, but his aim should be and has been to
educate his oversuggestible patients to a healthier
philosophy of living in the battle with the discords
and discomforts of life as they find it.
The omens and signs that sway people's minds
are relics of old usages, customs, and manners.
They derive their power froni tlv.' inveterate habit
of the uneducated of reasoning too much by anal-
ogy. The modern German peasant who says that
meeting a flock of sheep is lucky, but encoimtering
a herd of swine unlucky, and the Cornish miner
who turns aside in horror on meeting a rabbit or
an old woman on his way to the pit's mouth, is no
more illogical than the modern lady of culture and
even a college education who argues the good in
Christian Science on the analogy of certain cures
of incurable disorders. They both exhibit the rad-
ical defect of logic, of reasoning too strictly by
analogy, and are keeping up relics of primitive
types of thought.
And so with tiie factor of morbid imagination in
fostering belief in the myths of ancient times.
\ iewed from the strictly anthropomorphic point of
view, personal will entered into the day and the
night, into the waterfall and into the whirlpool.
Clouds were the great cows of the sky. with full
udders milked l)y the winds : thunder was the roar
of the wild beast : lightning was the serpent darting
at its prey ; zoster was the snake wound round the
body of its victims, and even in the highest of cul-
tures these anthropomorphic conceptions, though
much reduced, still hold sway over the vast number
of minds. \\'e have been able to touch only upon
/zDirORlAL ARTICLES.
EDITORIAL ARTICLES.
[New York
Medical Juurxal.
certain features of Dr. Shute's paper, but are
tempted to point out some of his conclusions, wliich,
although briefly stated, are of great interest.
How can the public be safeguarded against evil
suggestions in medicine, against too much reasoning
by analogy about medical subjects in normal modern
times, and against reversions to primitive methods
of philosophizing when dealing with accident and
disease? It is admitted that mental atavism must
be met with just as is physical atavism, and that no
justifiable faith in the future will preclude this acci-
dent. Reasoning by analogy can best be curtailed
by education ; not by book reading necessarily, but
by fostering a spirit of rational skepticism concern-
ing extravagant and improbable pretensions in med-
ical affairs, especially as expounded in secular publi-
cations.
HYGIENIC FADS.
Though it is for the most part the fate of our do-
mestic animals to come to a violent end, they are not
troubled with forebodings of death, and it may be
([uestioned whether, on the whole, they are not hap-
pier than man. Some of them are condemned to
grievous toil, but in general they are well housed and
w^ell fed, and theirs is not the burden of anxiety.
Their condition, in short, must be delightful in com-
parison with that of the man who is incessantly tak-
ing thought of his health and of the prolongation of
his life. We all know that the number of such men
is very great, and it seems to be continually on the
increase. It really looks as if a large proportion of
the civilized men and women of the world were al-
lowing themselves to be transformed into hypochon-
driacs.
Many are the men who wear out a hand mirror in
inspecting their tongue, who examine their pulse
almost hourly, who take their temperature every day,
and who fret about a little increase of girth. They
are in a perpetual state of fidgets about their health,
and their solicitude is fed by what they read in the
newspapers and on the display signs with which the
public conveyances are adorned, so many philanthro-
pists are there who are ready to interpret every little
irregularity of their bodily condition and put them
on the high road to health and longevity. There are
the numerous cereals, each of which is heralded as
the one article needed to insure good digestion ; there
are the multifarious machines for taking the place of
regular exercise ; there are mysterious agencies for
augmenting vitality ; there are "chest protectors" and
articles of apparel that one cannot do without if he
would preserve his health ; and there is the endless
list of drugs to supplement all such appliances if not
to supplant them.
Learned men there are in abundance, or men as-
suming to be learned — wise, too, above the ordinary
— who write books and magazine articles setting
forth the minutite of the art of prolonging life. They
are clever apostles of the plausible, and they have re-
duced the whole range of hygiene to a faultless sys-
tem—
Till you ask with surprise why anyone dies,
And what's the disorder that kills, my boy.
They prate of proteids and other things mystifying
enough to be impressive, and they all join in the
chorus "We eat too much." Many of them are cham-
pions of the "hardening" process. They tell us of
lurking poisons to avoid as one would shun the wiles
of Satan. A slight drawback to the amount of good
that they might accomplish springs from the fact
that they do not all agree, and meantime there are
some of us who are rash enough to go on under the
more or less complete guidance of inclination, which
in the happy brutes generally answers the purpose.
TYPHOID FEVER TRANSMISSIBLE IN
THE STAGE OF INCUBATION.
We have learned that the subjects of typhoid
fever continue to excrete the germ of the disease
for a long time after the actual illness has ceased.
Such prolonged excretion adds materially to the
difficulty of checking the spread of the infection.
An additional difficulty will be encountered if cer-
tain observations reported by Dr. H. Conradi
{Deutsche medicinische Wochenschrift, October lo,
1907; Semaine mcdicale, January 22, 1908) are con-
firmed. These observations are not only Conradi's
own, but also those of von Drigalski. G. Mayer,
Pietz, and Prigge. Thev find that typhoid bacilli
are eliminated in the faeces and urine of persons
who are still apparently in perfect health and do
not come down with the disease for so long a period,
sometimes, as three weeks.
In an instance that came under Conradi's notice
Eberth's bacillus was found in the blood of a boy,
twelve years old, whose sister lay ill of typhoid
fever. The girl was taken sick early in March, and
on the 24th of that month, while the boy was still
well, the author obtained pure cultures from his
blood. Four days later the boy showed symptoms
of the disease. Therefore, says Conradi, bacilli that
have been swallowed are capable of multiplying and
even penetrating into the circulation while yet the
infection is latent, and at that period there is danger
to those who are associated with the person that is
about to become ill. Epidemiological observations,
says the author, sustain this view, and he has re-
cently reported three cases of the spread of infection
during the period of incubation.
Evidentlv, then, it is not the excreta of the sick
EDITORIAL ARTICLES
411
alone that may disseminate typhoid fever, but also
those of persons who, though they have been ex-
posed to the disease, have not yet shown symptoms
of it. They must all be watched, and measures
should be taken to prevent their contaminating the
drinking water and other articles that may be in-
gested by others. It will be seen that this task sen-
sibly augments the sanitary work necessary in con-
nection with typhoid fever. Inasmuch as individuals
in the stage of incubation may still be engaged
actively in their ordinary vocations and traveling
perhaps for considerable distances, often into dis-
tricts where they are not likely to be suspected of
harboring infectious material, the difficulty of deal-
ing with them in such a manner as to prevent their
spreading the disease will at once be recognized.
OZ^NA DERI\'ED FROM THE DOG.
In La Clinique for February r4th we are remind-
ed by a note signed by Dr. Georges Laurens that last
year, in the Annales des maladies de Foreille. Dr.
Perez, of Buenos Aires, expressed the opinion that
ozaena, declared by Lowenberg twenty-five years
ago to be contagious, might be contracted from the
dog. It seems that Perez had met with twenty cases
in which the disease was probably of canine origin,
and he states that Lowenberg's bacillus is found in
the dog, though he does not inform us that actual
ozjena is observed" in that animal. In view of its
refractory and repulsive character, all possible pains
ought to be taken to avoid ozsena, among them
avoidance of the disgusting habit of allowing a dog
to lick one's face. The practice is known to be dan-
gerous in other directions than that of the risk of
contracting ozaena; for example, it plays a promi-
nent part in the conveyance of • hydatid disease.
Oftener than is generally supposed, the fondling of
pet animals leads to infection, and it is one of the
manifestations of good will toward them that
should be exercised only with the greatest caution.
WHITE PRECIPITATE OINTMENT.
It would seem from incidents that have lately
come to our knowledge that the newer graduates of
pharmacy leave school without that drilling in
the smaller details of dispensing that distin-
guished the pharmacists of an older generation. A
touchstone of the care observed by a pharmacist
in the preparation of galenical compounds is the
white precipitate ointment of the pharmacopoeia, of-
ficially entitled unguentum hydrargyri ammoniati.
As prepared by different pharmacists this ointment
presents varieties of appearance and consistence.
and one is often tempted to ask under which stand-
ard New York pharmacists prepare the official
drugs and medicines. Of course, when white pre-
cipitate ointment is asked for or prescribed, only
the unguent of the pharmacopoeia should be dis-
pensed. This is a preparation consisting of equal
parts of hydrous wool fat and white petrolatum
medicated with ten per cent, of ammoniated mer-
cury. Explicit directions are given in the pharma-
copoeia for the compounding of the ointment so as
to provide a smooth, creamy salve in which the
ammoniated mercury is so evenly distributed as to
make the particles invisible to the naked eye. Since
the eighth revision of the pharmacopoeia became of-
ficial we have been supplied with what was repre-
sented to be ointment of ammoniated mercury,
which consisted of a coarse mixture of gritty lumps
of ammoniated mercury and yellow petrolatum, and
with mixtures of lard and ammoniated mercury,
which in all cases showed a lack of care in prepara-
tion that was most reprehensible. Pharmacists who
would be so indifferent to the requirements of the
pharmacopoeia would not think of the necessity of
using a horn or vulcanite spatula in the preparation
of a mercurial ointment, and one is justified in as-
suming that carelessness in one thing means care-
lessness in others. It is a disturbing thought for a
physician, who is often compelled to depend on the
professional honor of the pharmacist for the prepa-
ration of medicines in strict accordance with the
rules of the apothecary's art. The ointment of am-
moniated mercury is frequently prescribed in the
treatment of the slight eczematous conditions which
sometimes make their appearance on the margins
of the eyelids in young children, as well as in adults,
but good results cannot be expected with ointments
which are hastil}- thrown together without regard
to the elementary principles of pharmaceutical
technique.
"AEROSTATHERAPY."
An enumeration of the therapeutic agencies which
have been advanced for the cure of pulmonary tuber-
culosis would disclose a most varied series of reme-
dial measures. Not the least novel of the list would
be the suggestion recently made before the Aca-
demic des sciences by M. Christian Beck {Bulletin
medical, 1907, p. 1054) that sanatoria be provided
with tethered balloons, in which patients may be
elevated to any heights desired. The arguments for
such a procedure certainly have some basis in fact,
for, as Beck points out, the chemical and biological
purity of the air encountered at a height is far
greater than can be obtained closer to the earth, the
41-'
OBITUARY.— NEWS ITEMS.
[New York
Medical Journal.
dampness so often met with at terrestrial resorts
nf great altitude may be avoided, and the ascent
may be varied to meet the indications for each
patient. He further states that the variation
in the atmospheric conditions obtained by re-
turning to the earth each night is of actual
benefit to the tuberculous patient. Of this we
have some doubt. It hardly seems credible that
a condition so foreign to man's normal environment
and so abrupt in its application can be anything but
harmful to an organism already rendered unstable
by the toxines of tuberculous disease. It seems
probable that M. Beck's suggestion is destined to a
place among the "fads and fancies" of therapy.
FRIEDRICH VON ESMARCH, M. D..
of Kiel, Germany,
In Kiel there recently died the well known Ger-
man surgeon Friedrich von Esmarch. Born Janu-
ary 9, 1823, in Tonning, Schleswig-Holstcin, he re-
ceived his medical education at the universities of
Kiel and Gottingen, and took his degree in 1848,
having been assistant to von Langenbeck since
1846. In the war of independence of Schleswig-
Holstein he took part, first as a line officer, later
as surgeon, and was, in 1849, admitted as Privat-
<locent to the medical faculty of Kiel, where he in
1854 became director of the surgical clinic and three
years later professor of surgery and director of the
hospital. This position he held until his resigna-
tion in 1899. \'on Esmarch took part in the Prus-
sian wars of 1864, 1866, and 1870-71. In the war
against Denmark he served with the army as sur-
geon ; in the war against Austria he acted as gen-
eral superintendent of the hospitals in Berlin ; and
during the Franco- Prussian war he filled the office
of general surgeon.
Von Esmarch's scientific researches were espe-
cially directed to military surgery, to which branch
he made many valuable contributions. iiut he is
best known as the author of Esmarch's band,
a description of which he made public for the
first time in 1873 '^^ the congress of the German
Surgical Society (Volkmann's Sammlung Klini-
.s-chcr Vortrdgc, No. 58).
His son by his first marriage is ICdwin von Es-
march. since 1899 professor of hygiene in the Uni-
versity of Gottingen. In 1872 von Esmarch mar-
ried Henriette, princess of Schleswig-Holstein-Son-
derburg-Augustenburg, aunt of the present Em-
press of Germany. In 1887 he was knighted, and
in i8<)() he received the title of Excellent.
Iltiws Items.
Changes of Address. — Dr. Ralph Francis Ward, to
205 West One Hundred and First street, New York.
University of Michigan. — A chapter of the honorary
fraternity Alplia Omega Alpha has just been established in
this university.
A New Psychoneurological Institute was recently
opened in St. Petersburg. It is under the direction of
Professor Bechterev.
The Tristate Medical Society, of Virginia and the
Carolinas, held its tenth annual meeting in Charlotte, N. C,
on February i8th and 19th.
Iowa State Board of Health. — Governor Cummins
has appointed Dr. Albert De Bey, of Orange City, Sioux
County, to membership on the board, to succeed Dr. F.
W. Powers, of Waterloo, who retired from office on Feb-
ruary 1st.
Philadelphia County Medical Society. — At a special
election, which was held on February 12th to fill vacancies
due to resignation. Dr. Jay F. Schamberg was elected fifth
vice president, and Dr. S. W. Gadd, sixth vice president
of this society.
A Contribution to the Robert Koch Institute Fund.—
It is reported that Mr. .A^ndrew Carnegie has contributed
$100,000 to the fund for the founding of an institute in
honor of Dr. Robert Koch, to be devoted to research
work in tuberculosis.
The Philadelphia College of Pharmacy held a phar-
maceutical meeting on Tuesday evening, February i8th.
Dr. Anna S. Kugler, a medical missionary from India, ad-
dressed the mepiing. Her subject was The Native Prac-
tice of Medicine and Pharmacy in India.
Buffalo Academy of Medicine. — The regular meet-
ing of the Section in Obstetrics and Gynecology was held
on Tuesday evening. February 25th. The programme in-
cluded a paper by Dr. Sigmund Goldberg on The Danger
of Operating in Acute Pelvic Conditions.
A Hospital for Consumptives at Albuquerque. — It is
reported that the Presbyterian Church of the United States
will build in .Albuquerque. New Rlexico. a large hospital
for the treatment of consumption, at a cost of about $t,ooo,-
000. Albuquerque lias donated the site for the institution.
The Floyd County, Ga., Medical Society held its
regular monthly meeting in Rome on Saturday. February
22d. Papers were read by Dr. James P. Ballenger, of
Crystal Springs, and Dr. W. L. Funkliouser, of Rome,
the subject of Dr. Funkhouser's paper being Medical
Ethics.
Contagious Disease in Chicago. — The Bureau of Con-
tagious Disen-ies received nniification of 470 cases of com-
municable disease- dnriii'j llie week ending February 15.
1908, wliich was an increase of seventeen over the previous
V cek, but t wenty-sc\ en less than the corresponding week
in 1907.
The Medical Alumni of the University of Pennsyl-
vania held their annual banquet at the Bellevue-Strat-
ford Hotel on lluirsday evening. February 20th. Dr.
George .A.. Piersol acted as toastmaster. Dr. S. Weir
Mitchell. Dr. Barton Cooke Hirst, and Dr. Charles L.
Dana responded to toasts.
White River, Vt., Medical Association. — A regular
meeting of tliis association will be held at White River
Junction on Wednesday. March 4th. at 1:30 o'clock. Tlie
progranmic will include an address on the Use of the Bio-
graph in Epilepsy, by Dr. Walker G. Chase, of Boston.
The lecture will be illustrated with biograph pictures.
University of Wisconsin.— Dr. .Arthur S. Loevenhart,
of Johns Hopkins University, has been appointed pro-
fessor of pharmacology and toxicology at the recently es-
tablished college of medicine at the tl'niversity of Wiscon-
sin, and Dr. Charles H. Bunting, of the University of
Virginia, has licen appointed to the chair of pathology.
Personal. — Dr. Robert Koch expects to visit the
United States .some time this spring. It is his intention to
take a rest for a year, and consequently has refused all in-
vitations to lecture while here.
Dr. C. M. Pearce. of Sumpter, Ore., is registered at the
Philadelphia Polyclinic and College for Graduates in Mcdi-
February zg, 1908.I
NEWS ITEMS.
415
New Buildings for State Institutions in Minnesota.—
Contracts have been awarded by the Alinnesota State
Board of Control for the following new buildings for State
Institutions : An addition 10 the main building of^ the
Rochester State Hospital, to be known as Ward C; a
contagious hospital building at the Fergus Falls State Hos-
pital ; and a tuberculosis hospital building at the St. Peter's
State Hospital.
Medical Inspection of Schools in Chicago. — During
tlie week ending February 15, 1908, the medical inspectors
of schools examined 7,166 school children, e.xcluding 233
from attendance. Twenty-five were excluded because of
measles, 10 for scarlet fever, 26 for chickenpox, 7 for
mumps, I for tuberculosis, 2 for diphtheria, and 2 for
whooping cough.
Richmond, Va., Academy of Medicine and Surgery.—
A regular meeting of this academy was held on Tuesday
evening, February 25th. Dr. V. M. Reade read a paper
on the Therapeutics of the Salts of Salicylic Acid, which
was discussed by Dr. William S. Gordon, and a paper on
the Sequelae of Grippe was read by Dr. T. A. Parker and
discussed by Dr. jM. D. Hoge, Jr.
Ventilation of the New York Subway. — .\ bill has
been introduced in the Legislature by Assemblyman Eagle-
ton which will give the Board of Health of New York City
authority to compel a proper ventilation of the subway.
The bill empowers the board to prescribe rules and pro-
vides for a penalty of $250 a day for neglect to comply
wiih ihe orders of the board.
The Triprofessional Medical Society of New York
held a stated meeting on Tuesday e\ ening, February 25th.
Dr. Ferdinand C. Valetine read a paper on the Treatment
of Chronic Gonorrhoea, which was discussed by Dr.
Boleslaw Lapowski, Dr. Ramon Guiteras, Dr. George K.
Swinburne. Dr. G. Morgan Muren. and others. Dr. Charles
E. Panoff read a paper on Epididymitis with a Xew Sup-
porting Dressing, which was followed by a general dis-
cussion.
The Mortality of Baltimore. — The report of the De-
partment of Health shows that during the week ending
February 22, 1908. there were 204 deaths from all causes,
as compared with 211 for the corresponding week in 1907.
The principal causes of death were : Typhoid fever, i ;
scarlet fever, 3; whooping cough, i; influenza, 3; con-
sumption, 24: apoplexy, 8; pneumonia, 27; organic heart
diseases, 13; Bright's disease, 18; congenital debility, 14;
old age. 8; accidents, etc., 11.
The Medical Society of the District of Columbia held
a meeting on Wednesday evening, February 19th. The
general topic for discussion was Typhoid Fever. Its Causes
and Prevention. Dr. G. Lloyd Magruder read a paper re-
viewing the various campaigns against typhoid fever and
the work that had been accomplished by the milk commis-
sion. Among those who took part in tile di-cussion were
Dr. H. W. Wiley. Dr. M. J. Rrwenaii, Dr. B. M. Bolton,
Dr. Sternlierg, Dr. \\'ood\vard. Dr. Kober, and Professor
C. B. Lane.
The Pathological Society of Philadelphia held a
stated meeting on Thursday, February 27th. Dr. W^. M. L.
Coplin read a paper entitled Further Remarks on the
Bundle of His. Studied Immediately after Death. Dr.
Howard T. Karsner read a paper on Whole and Differen-
lial Leucocyte Counts Before and .\fter Antitoxine Ad-
ministration. Dr. George Foster read, by invitation, a
paper entitled a Study of the H.xmotopoietic Organs in
Diphtheria and Tuberculosis. A number of card specimens
were exhibited.
The Manhattan Medical Society held a stated meet-
ing on Friday evening. February 28th. Tlie programme
included the report of a case of .\ural Cholasteatoma. by
Dr. F.arle Conner: a paper on Air Borne Infections, Their
Mode of Entrance and Abortive Treatment, by Dr. William
S>hier Bryant; and a paper entitled The True Value of
Cammidge's Reaction in the Recognition of Pancreatic
Disease, by Dr. Heinricli Stern. After the reading of the
ptipers a clinical conference was held on the Treatment
of Habitual Constipation.
A New Anticocaine Measure for Massachusetts has
b^-en proposed by the State Board of Health, Dr. Charles
Harrington, secretary of the board, nppearing before the
Legislative 'Committee on Public Health to present an argu-
ment in favor of the measure. Dr. Harrington said that
he had had numerous complaints from all quarters regard-
ing the illicit sale of cocaine, and that the enactment of
some very stringent restrictive legislation was necessary to
protect the public. He said that the cocaine was sold
mainly in the form of catarrh powders.
The Maine Association for the Study and Preven-
tion of Tuberculosis, which has for its object investiga-
tion into the prevalence of tuberculosis in the State of
Maine, and the dissemination of knowledge concerning the
causes, treatmeijt, and prevention of the disease, has just
been organized. The officers of the association are as
follows : President, Dr. Stephen H. Weeks ; first vice
president. Dr. Seth C. Gordon; second vice president, ^Ir.
.\dani P. Leighton ; secretary, Mr. Nathan Clifford ; treas-
urer, Dr. Irving E. Kimball.
The Mortality of Chicago. — .\ccording to the report
of the Depaitment ^ i 1 lealth for the week ending Feb-
ruary 15. 190S, there were during the week 699 deaths from
all causes, as compared with 698 for the corresponding
week in 1907. The annual death rate was 16.83 in
1,000 of population. The principal causes of death were:
.\poplexy, 15 ; Bright's disease, 42 ; bronchitis, 25 ; con-
sumption, 66; cancer, 24; convulsions, 2; diphtheria, 11;
lieart diseases, 48; influenza. 27; intestinal diseases, acute.
43; measles, 4; ner\ous diseases, 22; pneumonia. 144;
scarlet fever, 12; suicide, 14; typhoid fever, 5; violence,
other than suicide, 28; whooping cough, 4; all other causes,
■ 63.
Changes in the Bureau of He<h of Philadelphia.—
Dr. Seth }il. Brumm has been appointed assistant medical
inspector. Dr. J. Earl Ash has been appointed first assistant
resident physician, Dr. Edward T. Clement has been ap-
pointed second assistant resident physician, and Dr. John
T. Adylote has been appointed third assistant resident
physician at the ^Municipal Hospital. Dr. J. Roy ^Ic-
Knight and Dr. Charles J. Swalm have been appointed
resident physicians at the ^Municipal Hospital. Dr. Henry
D. Jump has been appointed registrar at the Philadelphia
Hospital. Dr. Charles S. Potts has been made a- member
of the advisory board of the Philadelphia Hospital, De-
partment for the Insane.
Rochester, N. Y., Academy of Medicine. — The regu-
lar meeting of the Section in Public Health, which in-
cludes hygiene, climatology, physiology, pathology, bacteri-
ology, and forensic medicine, was held on Wednesday.
February 26th. The programme for the evening consisted
of a symposium on The Systematic Examination and Treat-
ment of Children a First Principle in Maintaining a High
Standard of Public Health and Efficiency. Dr. .Albert C.
Snell read a paper on Ocular Defects, and Dr. Nathan
Davis McDowell r^ad a paper which dealt with Ear, Nose,
and Throat Defects. Dr. S. H. Rosenthal read a paper on
(ieneral Functional and Physical Defects, and Dr. George W.
Goler delivered an address on School Inspection.
A Fellowship in Pathology at Mount Sinai Hospital.
— It is announced that the George Blumenthal. Jr., Fellow-
ship in Pathology has been established at Alount Sinai
Hospital, New York. The object of the fellowship is to
.■lid those who arc anxious to obtain a laboratory training
and to further the scientific work of Mount Sinai Hospital,
the work under the fellowship being carried on in the
hospital or elsewhere under the direction of the patholo-
gist. -All graduates in medicine are eligible. The stipend
is $500 per annum, the term is one year, and the fellowship
cannot be held more than twice b}" the same person. Ap-
plications should be sent to Dr. F. S. Alandlebaum. patholo-
gist to Mount Sinai Hospital, before March 15th.
Medical Association of the Greater City of New
York. — .\ special meeting o\ this association will be
held at the Imperial, 360 Fulton street. Brooklyn, on Mon-
day, March 2d, at 8:30 p. m., under the direction of the
chairman for the Borougli of Brooklyn. Dr. Ransford E.
Van Gieson will read a ptiper on the Comparative Thera-
peutical Value of the Compounds of Iron, which will be
discussed by Dr. Revnold Webb Wilcox, Dr. William H.
Porter. Dr. Henry .\. F?irhairn, and Dr. Gordon R. Hall.
Dr. Albert Martin Jndd will read a paper on the Early
Diagnosis of Cancer of the Uterus, which will be dis-
cussed by Dr. George McNau.ghton. Dr. L. Grant Baldwin.
Dr. Ralph H. Pomeroy. Dr. A. Ernest Gallant, and Dr.
.\rchibald ^Murray. Dr. Joseph Merzbach will read a pa-
per on Experiences in the Field of CEsophagoscopy.
414
XEIVS ITEMS.
[Nkw York
Medical Journal.
Barnes University Merged in the Missouri State Uni-
versity.— Deeds have been filed by the trustees of Barnes
University. St. Louis, conveying the buildings and grounds
of that institution, at Garrison and Lawton avenues, to the
Missouri State University. The Centenary Hospital has
already been transferred to the State. The property is
valued at $250,000 and is free from debt. It is understood
that the medical department of the State University will
be transferred from Columbia to St. Louis and will occupy
the buildings of the Barnes University. The selection of
the faculty for the enlarged institution • is entirely in the
hands of the board of trustees of the State University. It
is reported that the medical faculty will be increased from
forty-two to ninet\- members.
Cornell University Hospital for Cats and Dogs. — This
new institution, which is situated in East Twenty-sixth
street, is an absolutely free hospital and dispensary for the
treatment of the diseases and injuries of pet animals. The
hospital has three floors, and is provided with reception
rooms, isolation wards for contagious cases, a general ward,
a kitchen, a bathroom, and a large well lighted operating
room, equipped with the latest devices in sterilizing ap-
paratus and surgical instruments. Dr. Frederick Gwyer,
professor of operative surgery in Cornell University Medi-
cal College, is at the head of the hospital staft', and asso-
ciated with him, as principal assistant, is Dr. Thomas C.
Sherwood, member of the Royal College of Veterinary
Surgeons.
Medical Society of the County of Ulster, N. Y. — The
February meeting of this society was held in Kingston
on Saturday evening, February isth. Dr. Frederick C.
Curtis, of Albany, delivered an address on the Diagnosis
of Smallpox, which was illustrated by lantern slides. Dr.
H. D. Pease, director of the State Hygienic Laboratory,
delivered a lectm-e on Vaccines and Vaccination, which
he illustrated by means of lantern slides. Dr. Joseph D.
Craig, health officer of Albany, spoke on the subject of the
Management of Smallpox Outbreaks. The officers of the
society are as follows: President, Dr. Aden C. Gates,
of Kingston; vice president. Dr. Thomas Keator, of Ac-
cord; secretary. Dr. Mary Gage-Day, of Kingston; and
treasurer. Dr. Elbert H. Loughran, of Kingston.
Scientific Society Meetings in Philadelphia for the
Week Ending, March 7, 1908. — Monday, March 2d,
Philadelphia Academy of Sugery ; Biological and Micro-
scopical Section. Academy of Natural Sciences; West
Philadelphia Medical Association ; Northwestern Medical
Society. Tuesday, March 3d, Academy of Natural Sci-
ences ; Philadelphia Medical Examiners' Association. Wed-
nesday, March 4th, College of Physicians ; Association of
Clinical Assistants of Wills Hospital. Thursday. March
5th, Obstetrical Society ; Medical Society of the Southern
Dispensary ; Section Meeting, Franklin Institute ; Ger-
man town Branch. Philadelphia County Medical Society.
Friday, March 6th. .\merican Philosophical Society; Kens-
ington Branch. Philadelphia County Medical Society.
Infectious Diseases in New York:
IVe arf indebted to the Bureau of Records of the Depart-
ment of Health for the following statement of new eases
and deaths reported for the two zveeks ending February 22,
1908:
^February 1 5.-^ ^February 22.^
Cases. Deaths. Cases. Deaths.
Tuberculosis lailmonalis 340 225 388 201
Diphtheria 371 46 371 45
Measles 1,104 26 1.252 26
Scarlet fever 75^ 5.S 797 39
Smallpox 4
Varicella 155 . . 133
Typhoid fever 26 5 33 4
Whooping cough 9 s 9 i
Cerebrospinal meningitis 7 8 10 9
Totals 2,772 370 2,993 325
Lectures at the New York Skin and Cancer Hospital.
— It is announced by the governors of the New York Skin
and Cancer Hospital. Second avenue and Ninetecntli street,
that a series of lectures, which will be free to the medical
profession, will be given in the out patient hall of the
hospital, on Wednesday afternoons, at 4:15 o'clock. Dr.
L. Duncan Bulkley will deliver the first lecture in the
course on March 4th. the subject being Pathology in Its
Practical Bearings upon the Treatment of Certain Dis-
eases of the Skin, and on each succeeding Wednesday
afternoon until .\pril 15th Dr. Bulkley will deliver a clini-
cal lecture on diseases of the skin. On April 22d Dr. Wil-
liain Seaman Bainbridge will deliver an address on the
Treatment of Unremovable Cancer, with exhibition of
cases. '
Charitable Bequests. — By the will of Loyal L. Smith
the Champlain Valley Hospital, Plattsburg, N. Y., re-
ceives $225,000.
By the will of Mrs. Arhy Richmond Sheldon the New-
port, R. I., Hospital receives $5,000.
By the will of Levi Schilling the Mount Zion Hospital,
San Francisco, Cal., receives $5,000.
By the will of Mrs. Charlotte Budde, Cincinnati, Ohio,
the German Deaconess Hospital receives $200 and St.
Mary's Hospital $100.
By the will of Mrs. Caroline B. Sears the Industrial
School for Crippled Children, Boston, will receive $1,000;
$200,000 will be divided among various institutions which
are to be selected, and the Boston Lying-in Hospital will
receive $80,000. All of these bequests are conditional on
the death of the husband without issue surviving.
A New Chemistry Building for the University of
Michigan. — At the January meeting of the Board of
Regents of the University of Michigan, architects were
authorized to draw up plans and specifications for a new
chemistry building, which will include two large labora-
tories for general chemistry, two large laboratories for
qualitative analysis, one for advanced general chemistry,
one for beginning quantitative analysis, one for advanced
quantitative analysis, one for beginning organic chemistry,
and one for pharmaceutical chemistry, with smaller labora-
tories for advanced and special work, and private labora-
tories for the instructing staff. In addition to the labora-
tories there will be one large lecture amphitheatre and three
smaller ones. The total cost will be about $275,000,
and it is hoped that the building will be completed by
October i, 1909.
The Health of Philadelphia. — During the week end-
ing February i, 1908, the following cases of transmissible
diseases were reported to the Bureau of Health : Typhoid
fever, 142 cases, 16 deaths ; scarlet fever, 63 cases, 3 deaths ;
chickenpox, 29 cases, o deaths ; diphtheria, 76 cases. 13
deaths ; cerebrospinal meningitis, 2 cases, o deaths ; measles,
142 cases, 3 deaths; whooping cough, 31 cases, 3 deaths;
pulmonary tuberculosis, 121 cases, 62 deaths ; pneumonia,
99 cases, 71 deaths ; erysipelas, 13 cases, 5 deaths ; puer-
peral fever, 4 cases, 3 deaths ; mumps, 19 cases, o deaths ;
cancer, 17 cases, 26 deaths ; tetanus, i case, o deaths. The
following deaths were reported from other transmissible
diseases: Tuberculosis, other than tuberculosis of the
lungs, 7 ; diarrhoea and enteritis, under two years of age, 9.
The total deaths numbered 542 in an estimated population
of 1,532,738, corresponding to an annual death rate of
18.31 in 1,000 of population. The total infant mortality
was 116; under one year of age, 94; between one and two
years of age, 22. There were 41 still births — 22 males and
19 females.
Society Meetings for the Coming Week:
MoND.w, March 2d. — German Medical Society of the City
of New York ; Utica, N. Y., Medical Library Associa-
tion; Niagara Falls, N. Y., Academy of Medicine;
Practitioners' Club, Newark, N. J. ; Hartford, Conn.,
Medical Society.
Tuesday, March 3d. — New York Academy of Medicine
(Section in Dermatology) ; New York Neurological
Society; Buffalo Academy of Medicine (Section in
Surgery); Ogdensburgh, N. Y., Medical Association;
Syracuse, N. Y., Academy of Medicine ; Hudson
County, N. J.. Medical Association (Jersey City) ;
Medical Association of Troy and Vicinity; Hornells-
ville, N. Y., Medical and Surgical Association; Long
Island, N. Y.. Medical Society; Bridgeport, Conn.,
Medical Association.
Wednesday, March 4th. — Society of Alumni of Bellevuc
Hospital : Harlem Medical Association, New York :
Elmira, N. Y., Academy of Medicine ; Psychiatrical
Society of New York.
Thursday, March 5th. — New York Academy of Medi-
cine; Dansville, N. Y., Medical As.sociation.
Friday, March 6th. — New York -'\cadcmy of Medicine
(Section in Surgery) ; New York Microscopical So-
ciety; Gynrccological Society, Brooklyn, N. Y. ; Man-
hattan Clinical Society, New York ; Practitioners' So-
ciety of New York.
February 29, 1908.]
PITH OF CURRENT LITERATURE.
415
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
February 20, igoS.
1. Pendulura Apparatus and an Apparatus for Rotary
Correction in Curvature of the Spine, ■
By Robert Soutter.
2. Mathapan Day Lamp, By David Townsend.
3. A Diabetic Chart,
By Elliott P. Joslin and Harry W. Goodall.
4. The Best Things in Therapeutics,
By Gustavus Eliot.
5 Kallak; an Endemic Pustular Dermatitis,
By John M. Little.
I. Pendulum Apparatus and an Apparatus for
Rotary Correction in Curvature of the Spine. —
Soutter describes two such apparatus ; the first one
he has used for five years, and is adapted to in-
creasing the flexibihty of the spine laterally at any
level by the pendulum motion of the lower spine,
while the upper is held stationary, or of the upper
spine while the lower is held stationary. The
amount of motion can be limited by weights, and
the amount of force to obtain flexibility can be les-
sened or increased. ■ This apparatus consists of a
rectangular frame swung at the middle, inside of
which are two half frames, one swinging above and
the other below, from a point at the middle of the
first frame. The first frame can be allowed to
swing while the lower inside frame is made station-
ary, or the first frame may be fastened and the
lower half frame allowed to swing. In this way
the upper segment can swing and the lower remain
stationary or vice versa. The upper half frame is
used in connection with the large or lower half
frame or for the application of pressure pads or
straps. It can be placed in any position desired,
and pressure pads and rests can be applied at any
level to localize or limit the motion. It is useful in
cases with bony changes, as well as in cases where
the deformity is limited to the soft parts. In simple
curves and round shoulders it has been extremely
satisfactory. In curvature of the spine a twist or
rotation is almost always present in all cases to a
more or less degree. In advanced cases the twist is
very marked, and in a compound curve it may be
on both sides of the spine at the convexity of each
curve. The application of side pressure to correct
the curvature, if not carefully applied, will often
increase the rotation. This apparatus has been de-
vised so that the amount of rotation of the spine
may be increased or diminished to the right or to
the left and at the desired level. Both pressure
correction and active or passive rotary movement
can be utilized in the treatment. This can be done
with the shoulders level, inclined, displaced lateral-
ly, or with the pelvis tilted at any angle so that the
patient may be placed in as advantageous a posi-
tion as possible and the corrective stretching ap-
plied. The patient is placed in position and im-
mobilized up to the point where the twist is de-
sired. The twist may be limited to the right or to
the left, or the amount of rotation limited in either
direction. By a teeter motion the lumbar spine
can be treated, and the muscles going to the lumbar
region strengthened or stretched. The second ap-
paratus consists of a base and a double decked seat.
which twists on the base. The motion is regulated
bv weights and pulleys attached to the arms. The
base is narrower towards the front and broader to-
wards the back to allow for the rotation of the
arms. The seat teeters on a pivot until the side of
the rectangular frame touches the side of the upper
half frame. Blocks keep the rectangular frame
steady when the rotary tnotion is l3eing used.
Should it be advisable to increase flexibility to one
side, one block only may be inserted. .Should re-
sistance to lateral motion be needed in order to in-
crease the muscular work, weights are attached to
hooks below the seat of the rectangular frame.
4. The Best Things in Therapeutics. — Eliot
gives the following drugs as of greatest value, both
to the practitioner and to the patient: i. Mercury in
syphilis ; 2, the salicylates in rheumatism ; 3, qui-
nine in malarial affections ; 4, antitoxine serum in
diphtheria; 5, aconite in the fever of acute diseases;
6, digitalis in chronic heart disease ; 7, alcohol in
cardiac weakness of acute disease ; 8, ergot in
uterine and pulmonary haemorrhage ; g, creosote in
diseases of the respiratory organs : and 10, the bro-
mides in nervousness.
5. Kallak. — Little describes a very frequent
skin disease, endemic pustular dermatitis, so preva-
lent among the Eskimos, and which was seen at the
Moravian mission stations at Makkovic, Hopedale,
Nain, Okak, and Ramah on the East Labrador
coast, and at Killinek, Ungava Bay. When the
Moravians translated the Bible into the Eskimo lan-
guage, they had great difficulty in finding equiva-
lents for many words. Leprosy was one of these.
They had to find some word which would be under-
stood by the Eskimo to represent a contagious, dis-
figuring, chronic disease, and they chose the word
kallak, which was the Eskimo word for the dis-
ease described by Little. Broadly translated, it
means skin disease. The missionaries thought this
disease was scabies, so that to-day in the Eskimo-
English-German dictionary Kallak equals Leprosy,
scabies, skin disease, but as ordinarily used, it
means the one definite thing, the pustular derma-
titis, so common among, and peculiar to, the Es-
kimo. It is not a disease caused by dirt, but it is
peculiar to the Eskimo, and never appears in the
foreigner. The main symptom is the itching, and
it appears as an eruption in the dorsal surfaces of
the hands and feet, and the upper and under sur-
faces of the fingers and toes. At first vesicular, it
almost immediately becomes pustular. In fact, the
vesicular stage is seldom seen. The pustules, of
various sizes from a pin head to a ten cent piece,
are not surrounded by the inflammatory zone which
one would expect. With the appearance of the
eruption, the feelings of malaise disappear, which
preceded the period of eruption, but intense itching
supervenes. The pustules then appear in different
groups in order, on the elbows, knees, and buttocks.
From these centres it spreads. This spreading is
independent of scratching, and takes place when the
part is carefully protected and treated with anti-
septics. Generally, however, the scratching and
rubbing indulged in produce a generalized der-
matitis. Pus is formed. Bleeding takes place.
Crusts and scales appear. It is, however, essential-
ly a dry eruption, and never becomes "weeping."
4i6
riTH OF CURRENT LITERATURE.
[New York
Medical Journal.
Its course is very protracted, and tliickcning and
discoloration of the skin appear. The disease may
disappear, only to break out again on cessation of
treatment. Tliere is no inflammatory area around
the lesions, and the\- are not painful except upon the
buttock, and where a secondary infection has taken
place. Whole houses, and even communities of
Eskimos are affected at a time. The only f:'cts that
seem to have a bearing jetiologically are that while
it may occur at any time of the year, if they have
plent}' of seal flesh to eat they do not have kallak.
Most of the cases, as well as the worst cases, and
the epidemics, occur in the autumn after they have
been living almost exclusively on a fish diet, and
especially after a failure of the berry crops. No
special microorganism is found in connection with
the erujition, nor does it act like an autoinocula-
tive i)rocess, such as impetigo contagiosa. The
author believes it to be a symptomatic reaction to
some toxine elaborated on account of the Eskimo
diet, ])erhaps influenced by his known susceptibility
to suppuration and epidemics of all kinds. As to
treatment, the Eskimos themselves were accus-
tomed to apply seal oil on rags without much ef-
fect. Dr. Hutton has found tlie best treatment to
be the addition of seal meat and berries to the diet,
the ajiplication of protective dressings, with a lo-
tion of lead subacetate. one jjart in 300, and on
adults in the later stages an ointment of zinc oxide
and tar.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
February 22, igoS.
1. Operative Treatment of Cancer of the Rectum,
By EnwARD .\rchib.\ld.
2. The Magnesite Splint. A New Surgical Dressing',
By Raymond Russ.
3. The Value of an Absolutely Vegetarian Diet in
Psoriasis, By L. Dunc.vx Bui.klev.
4. Atypical Typhoid Fever ; Its Part in Preventive Aledi-
cine, and Its Distinctive Diagnosis from Estivo-
autumnal Malaria, By Johx Pelham Bates.
5. ( )l)servations on the Failure of tlie Radial Pulse When
the Arms Are Elevated, By Henry Sewall.
6. h'inal Results of Conservative Surgery of the Tubes
and 0\aries, By Abk.\m Brothers.
7. Report of One Hundred and Seven Cases of Cancer
Treated with Rr)ntgen Ray. with Comments Thereon,
By Exxiox (i. Wii.i.i.\MS.
3. The Value of an Absolutely Vegetarian
Diet in Psoriasis. — Buckley has used li)r a number
of years an absolute vegetarian diet, onl\' allowing
ljutter. but not milk, as treatment for patients suffer-
ing with psoriasis. The effect of this ctitiing oft' the
su])ply of animal nitrogenous food has been very re-
markable and striking in many instances ( a consid-
erable amount of nitrogen is still su])plied by certain
vegetables, as tlie legumes and oatmeal). Patients
continually notice the change in the color and char-
acter of the eruption, it paling and becoming less
scaly, and even entirely disappearing in some weeks,
with absolutely no local treatment. In a number of
instances this diet has been given to ])atients who
had long been under his care, even for years previ-
ously, and thus they were well able to judge of the
result of this radical change in the mode of life, and
liave watched with great interest the often rapid im-
provement in the eruption, under precisel\ the same
treatment as before. This treatment has been given
to patients at all periods of life, from nine to seventy-
eight years of age, and has been carried out with
varying degrees of fidelity. The note has been re-
peatedly made that when there has been a neglect oi
the dietary element there has been a recurrence of
the eruption, which again yielded rapidly when strin-
gent measures were enforced. On the other hand,
there have been a nuiTiber of patients who have faith ■
fully pursued this plan of treatment, in whom a long
existing psoriasis has reinained absent, and who.
having become accustomed to the diet, say that the\-
have lost the desire for animal food and will not
touch it again. In conclusion, the author states that,
while he advises an absolutely vegetarian diet in
psoriasis, he believes that it has its limitations, and
must be directed with care and intelligence ; but that
in proper cases it can control the eruption and pre-
vent its recurrence. But patients with this eruption
at times will require in addition the most varied
treatment, internal and external, in order to accom-
plish the quickest and best results. How interna!
remedies act can not yet be fully stated, but in the
light of our present study they probably have their
action in improving the metabolism of nitrogenous
substances.
6. Final Results of Conservative Surgery of
^the Tubes and Ovaries. — Brothers describes his
personal experience with conservative surgery of
the ovaries and tubes. He states that he has had
only one death out of 160 such cases. In ovarian
surgery cystic ovaries afford an opportunity for con-
servatism, while ovaries that have undergone fibroid
degeneration are seldom amenable to conservative
surgery. Ovaries in jitxtaposition with pus tubes
or purulent pelvic collections can safely be left un-
disturbed, or may be subjected to partial exsection.
These ovaries, if not the seat of the abscess at the
time of operation, seldom give rise to trouble later.
The desirability of applying conservative surgery to
pus tubes is open to question in his mind. He is in
favor of total and complete ablation of pus tubes
down to the horn of the uterus. Experience with
secondary operation for infected stuinps has driven
him to this position. Brothers describes plastic work
on the tubes, mentioning also the exsection of the
tubes for the purpose of inducing sterility, where he
has never seen a new connection formed to perni't
of the union of an ovum with a spermatozo( n.
.Speaking of pelvic peritoneal adhesions with consid-
erable risk of injuring the annexa, tubes, or ovarii s
in ]:)lastic operations, he .says it is wiser to proceed
with their complete extirpation, as the retention of
such mutilated or damaged annexa only too often
threatens the ultimate comfort and health of the pi-
tient, and leads to secondary operations for the r
final removal. The author divides his cases in thr. e
groups: In group i ( con.servative work in twent\-
six patients on the Falloppian tubes) he has note I
unsatisfactory results in two cases. One of these
patients a year later was suffering from a pelvic in-
flammatory mass which could be distinctly felt. In
the second ca.se the patient required a secondary lap-
arotomy for the removal of an infected stump It ft
after the fir.st operation. One of the patients in tlrs
series of ca.ses died suddenly of a cancer of the rec-
tum, which does not reflect on the propriety of tlv
operation previously (lone by him. In group 2 (con-
.servative work on forty-four patients in the ovaries)
February 29, 1908.]
PITH OP CURRENT LPTERATi'RE.
417
six patients had good reason to complain of postop-
erative suffering. A distinct pelvic mass was present
in one case and a secondary operation was required in
another. In group 3 (conservative work in ninety
patients with adhesions of tuboovarian disease)
he has notes of seven unsatisfactory results. In three
cases of this group the patients presented pelvic in-
flammatory masses, subsequent to operation, which
caused much suffering. Four patients required sec-
ondary operations. Although the total number of
secondary operations done in his cases after conser-
vative surgery amounts to only six cases, he readily
concedes that this figure is contestable on the ground
that he has lost sight of a certain number of his pa-
tients after they left the hospital. Some of these pa-
tients possibly required secondary operations else-
where at some subsequent period. As six patients
required secondary operations in the cases which he
was able to follow it may be fairly assumed that six
others were submitted to similar operations in the
other half lost from view. Thus he infers that the
maximum necessity for secondary operations after
conservative annexal surgery does not exceed 7 per
cent. He estimates the postoperative morbidity after
conservative surgery of the annexa to be about 23.5
per cent.
MEDICAL RECORD.
February 22, 1908.
1. Some Notes on the .^Itiology, Prophylaxis, and Thera-
peutics of Laryngeal Tuberculosis. Including Some
Clinical Experiments with Bier's Congestive Hy-
perxmic Treatment,
By S. Adolphus Knopf and Arthur J. Huev.
2. Urticaria, By Edward B. Fixch.
.3. Cystitis in Women. With Report of Forty-five Cases,
Studied Cystoscopicallj'^ and Some Modifications of
Treatment, By Ellice McDon.\ld.
4. The Physical Signs of Incipient Pulmonary Tubercu-
losis, By Aldert Abrams.
5. Carcinoma of the Right Xasal Cavity and of the
Antrum of Highmore, By Louis Klemptxer.
fi. Sudden Death in Penumonia. Its Cause and Prophy-
laxis, By W. P.\rker Worster.
I. Laryngeal Tuberculosis. — Knopf and Huev
describe Kuhn's lung section mask, based on Bier's
(.riginal idea of having the patient inhale in a
slightly obstructed manner, so as to produce nega-
tive pressure in the thoracic cavity. The authors
have studied the results produced by this mask.
They selected six cases of laryngeal tuberculosis
from the various wards in their service at the
Riverside Sanatorium. On reexamination after the
first application of the mask they noted that a
inarked congestion was produced in all the mucous
membranes of the upper respiratory tract. This
was especially noticeable in the membrane of the
soft palate and epiglottis due to the usual pale char-
acter of the membrane in these parts. The anaemic
membrane, characteristic of such cases, was covered
after treatment with a network of small dilated
venulae. proving conclusively the utility of the mask
to produce the desired venous hypersemia. With
this encouraging beginning the masks were worn
fifteen minutes three times daily, and examinations
made from time to time to discover any change in
the pathological condition of the larynx. After a
few days the congestion of the membranes became
more or less permanent, lasting over from one treat-
ment to another, the mucous membranes losing their
characteristic pallor. The cases ranged from the
mildest with only slight infiltration of the cords and
arytenoids with impairment of motion to the se-
verest type with extensive ulceration, and in one
case perichondritis and external abscess. During
the application of the mask very little discomfort
was experienced by the patients, consisting of slight
dizziness and feeling of oppression. This became
less as the patients became accustomed to the treat-
ment. In one case complicated with chronic otitis
media with tinnitus, the dizziness became so severe
as to interfere with the regularity of the treatment.
This was especially true in heavy, stormy weather.
During the two months of treatment all the cases
but one showed some improvement. In the cases
of infiltration without ulceration the improvement
was mainly symptomatic, the hoarseness and dis-
comfort being relieved without any noticeable
change in pathological lesion. Where ulceration
existed the ulcer showed healthier, redder granula-
tions covered by far less secretion than formerly.
5. Carcinoma of the Right Nasal Cavity and
of the Antrum of Highmore. — Klemptner de-
scribes such a case. The patient was operated upon
by the author according to Denker's method. A
horizontal incision in the mucous membrane of the
anterior wall of the right superior maxilla was
made, beginning half an inch to the left of the
frenimi above the sockets of the teeth, and enlarged
upwards to the apertura pyriformis and outwards
to the last tooth. It became evident that destruc-
tion had already taken place of the periosteum and
bony wall in the fossa canina, the size of a quarter
of a dollar, through which opening the tumor was
bulging. The soft parts were pushed back upwards
to the lowest margin of the orbit and inwards, un-
til the lateral and lower margins of the apertura
pyriformis were laid open. The whole anterior wall
of the antrum and the growth which filled it were
then removed. The interior wall of the antrum
was also in great part destroyed by the tumor in
the region of the middle turbinated bone. The nni-
cous membrane of the lateral nasal wall was sepa-
rated from the bone below the inferior turbinated,
and the whole interior bony wall of the antrum re-
moved from the apertura pyriformis, as well as the
inferior turbinated. Then followed the resection of
the middle turbinated, the removal of the tumor
masses from the nasal cavit>- and the nasopharynx,
the removal of all the ethmoidal cells, which were
almost destroyed by the growth. The frontal and
sphenoidal cavities were not affected. The loosened
mucous membrane of the lateral wall of the nasal
cavity was used to cover the floor of the antrum,
and the so formed single big cavity was filled with
iodoform gauze. The wound of the mouth was then
closed. The after treatment was carried out
through the nose. The course after the operation
was ver\- satisfactory. The highest temperature
was loi^ on the third day. On the fourth day the
packing was removed and not renewed ; on the sixth
day the sutures were removed ; the wound of the
mouth healed without complication. After ten days
the patient left the hospital. Four months later
there was no sign of recurrence.
6. Sudden Death in Pneumonia. — ^Worster ad-
vocates cold application in severe cases of collapse
4i8
I'll H 01' CURRENT LITERATURE.
LNt>v York
Medical Joi unal.
in pneumonia. He says that the excitation of cold
is the most powerful and energetic agent for com-
bating such collapse and can be accomplished in the
following manner: A bathtub of water at ioo° F.
to extend just above the patient's hips is prepared
and the patient placed in it or held in a semirecum-
bent position, and several basins of water at 60°
or lower, as the case may indicate, are poured over
his shoulders, chest, and back, the operator standing
on a chair and holding the water as high as possi-
ble so as to get the required force. Such a pro-
cedure, if the patient is unconscious or delirious,
will often arouse him to consciousness and brighten
his eye. and his countenance will wake up from its
apathetic appearance, his shallow respiration will
become deeper, ami the excitation of the cold upon
his bronchial tubes will cause him to cough and ex-
pectorate and free them from mucus and his air
cells from threatened hypostasis, his cyanosed and
marble skin will become ruddier, the capillary cir-
culation will be reestablished, and the heart will
gain in' force and diminish in frequency. This por-
cedure will positively change the whole aspect of
the case, and perhaps only one application will suf-
fice to save the life of that patient.
BRITISH MEDICAL JOURNAL.
February 8, 1908.
1. Clinical Remarks on the Symptoms, Diagnosis, and
Treatment of Tubal Gestation in the Earlv Weeks,
By W. Tate.
2. A Case of Rupuired Ectopic Gestation Occurring in a
Rudimentary Horn of a I'terus Bicornis Llnicollis,
By H. T. Hicks.
3. Rigor Mortis in the Stillborn,
By C. H. W. P.XRKINSON.
4. On the Use of Chemicals in Aseptic Surgery,
By C. B. LocKwooD.
5 On Splenomedullary Leuc.-emia and Splenic Anaemia
(Banti"s Disease), By J. G. Taylor.
6. Some E.xperiences in the Testing of Tincture of Digi-
talis, By S. C. M. SowTON.
7. On Migraine. By T. H. B. Dobson.
8. The Removal of Eoreign Bodies from the Air and
Food Passages. By D. R. Paterson.
I. Tubal Gestation.— Tate states that the
group of symptoms \\hich can be described as typi-
cal of this complaint are as follows: The patient,
who has missed one or two periods, is suddenly
seized with severe pain in the lower part of the
abdomen, which may be accompanied by some
faintness. and is followed by a hjemorrhagic vagi-
nal di.schafge. ■ The patient probably goes to bed,
but, as the pain soon subsides, she may get up in
a day or two feeling fairly well. Soon after get-
ting about again she has a second more severe at-
tack of pain, with signs of faintness, and the nature
of the case becomes evident. These cases may be
divided into two classes : l, Acute fulminating
cases, in which the patient, without any premoni-
tory symptom, is suddenly seized with acute ab-
dominal pain, accompanied by faintness and col-
lapse, together with vomiting. In this class there
is a large eflfusion of blood into the general peri-
toneal cavity. 2. The more common variety, in
whicli the patient has an attack of abdominal pain,
possibly preceded by some irregular haemorrhage ;
there may or may not be a little faintness at the
time. These symptoms, however, subside, though
tlic h;eniorrhagic di.scharge probably persists, and
within a few days, or possibly a week or two, the
patient has a more severe attack, in which the
symptoms of internal bleeding may become more
marked. The physical signs met with in cases of
tubal pregnancy depend on the amount of hzemor-
rhage and the rapidit}- with which the bleeding oc-
curs. Treatment depends upon the conditions pres-
ent in each individual case. In the first class — the
fulminating variety, where the patient is collapsed
and the pelvis and lower abdomen is full of blood
— immediate operation should be advised in order
to save the patient from the risk of further bleed-
ing. It may be contended that operating on a pa-
tient collapsed from haemorrhage is a very serious
undertaking; but as a rule at the time the patient
is seen the hajmorrhage has ceased, and if it has not
ceased there is all the more reason for not delaying
operation. The operation undertaken at this pe-
riod is exceedingly simple, and takes but a short
time. In the second class, where the patient is not
seen till a pelvic haematocele has formed, the treat-
ment, to a certain extent, depends on the time that
has elapsed between the severe attack of pain and
the examination of the patient. If as long as ten
days, the patient having been free from pain, an ex-
pectant treatment can be safely advised. In the
third class, where the patient has repeated attacks
of pain, together with irregular hiemorrhage, and a
unilateral swelling is found in the situation of the
tube and ovary, operation is always advisable. Op-
erative treatment is indicated in those cases where
the hiemorrhage is moderate or severe and of recent
origin, and also where the symptoms and physical
signs indicate that the gestation sac is still con-
tained within the tube. It is safe, however, to wait
and watch the patient in cases where a haematocele
has already formed, and where, after the initial at-
tack of pain, the patient has been free from symp-
toms for a week or more. Under these circum-
stances there is a good chance of the blood becom-
ing completely absorbed, and no serious risk is run
by following an expectant treatment.
3. Rigor Mortis in the Stillborn. — Parkinson
has made a study of the occurrence and significance
of rigor mortis in stillborn children, and reaches the
following conclusions: i. Rigor mortis may set in
under certain conditions before labor, and may pass
ofif while the child is still in utero, and possibly
may delay the birth in these cases until it has
passed away. 2. Rigor mortis may set in when the
child dies during labor, and may either be complete
before or may go on to completeness after birth,
and in those cases increases the difficulty of expul-
sion. 3. The child may die during labor, and be
expelled before rigor mortis can set in, but rigor
mortis may supervene after birth more or less com-
pletely. 4. The attitude produced by rigor mortis
in stillborn children differs from that produced by
cadaveric rigidity under ordinary circumstances,
and by its character enables an opinion to be given
that the child had no separate existence, for in ev-
ery such case the limbs and body generally become
drawn into the position in which it lies normally
in the mother's won.ib. Rigor mortis is not a sign
of live birth, but the character of the rigor mortis
enables one to decide whether or not the child was
stillborn.
February 29, 1908.]
PITH OF CURRENT LITERATURE.
419
7. Migraine. — Dobson states that the word
"migraine" is the shortened form of hemicrania,
and represents a definite entity, and must not be
used for headaches in general. ^Migraine is a func-
tional disease, characterized by paroxysmal attacks
of headache, usually one sided, and which may be
associated with sickness, peculiar affections of
sight, and various m_ental symptoms. ^^ligraine is
looked upon as hereditar}-, but it is probably the
tendency to a neurosis which is inherited. \\'omen
are supposed to suffer more than men, but the
writer holds the contrary. As to the primary cause
of the disease, we can only say there is a hereditary
predisposition to a brain storm. When we come
to the immediate or exciting causes, it is generally
found that mental or bodily fatigue, worry, or eye
strain are responsible. Three classes of migraine
may be recognized: i. Simple hemicrania. topical
in that it is unilateral and responds to every arterial
beat ; it recurs every few weeks. 2. Sick headache,
again periodical : unilateral headache, culminating
in nausea, followed by vomiting and prostration :
hereditarv. 3. Blind headache. Other and more
alarming symptoms which may be grafted on any
case of migraine are tingling of Hps or the arm.
numbness of arm. drowsiness, motor aphasia, and
squint (temporary- paralysis of the third nerve).
The headache is typical in that it responds to even.^
heart beat, is made intolerable by stooping or
coughing, and is in the great majority of cases uni-
lateral. The character of the headache, its peri-
odicity, and usual association with vomiting or
blindness makes- the diagnosis easy. The attack is
one of a large group of nerve storms which are
liable to sweep over the human organism — epilepsy,
spasmodic asthma, tic douloureux, and others. Cer-
tain constitutions seem to accumulate stores of
nervous energ}-, which are liberated by one of these
explosive methods. Treatment consists in: i. To
lessen the tendency to the explosive action in the
nervous centres. Here may be pointed out the ne-
cessitA- for a sufficiency of sleep, nutritious food, but
not excessive in quantity, prevention of intestinal
fermentation, and regular exercise. 2. To avoid the
immediate exciting causes. These are gastric dis-
turbance, constipation, and eye strain. In migraine
there is no deterioration of mind.
LANCET
February 8, 1908.
1. Sleep and Sleeplessness, By A. MoRisox.
2. Some of the Sources of Wound Infection.
Bv C. B. LocKwooD.
3. Is the Death Rate the Best Measure of Severity in
Disease? By F. M. Tcr'ner.
4. Excision of the Rectum for Carcinoma,
By \V. A. Lane.
5. The Methods of Primitive Midwiferj-.
By J. B. Heixier.
6. Observations on Phosphaturia and the Treatment of
Disease by Conversion, By R. Harrison.
7. Hsemopericardium Associated with Svp'hilis,
By J. L. Baskin.
8. A Case of Ariite Ascending Paralysis wi:h Recoverv',
By C. W. VixiNG.
9. A Case of Enucleation During the Seventh Month of
Pregnane}-, of a Uterine Fibromyoma Weighing Seven-
teen and a Half Pounds; Premature Labor Two
Days Later. By H. Williamson.
10. Five Years' Experience of a Reception House for Re-
cent Cases of Insanity. Bv H. C. Mark.
I. Insomnia. — Morison holds that change in
the brain cells themselves is the primary cause of
sleep, and that vascular and neural changes associ-
ated with sleep are effects, not causes, of the condi-
tion. WhzX the essential cause of these intracellular
changes is is unknown, but they undoubtedly exist.
Normally, a moderate degree of exhaustion of the
nerA-e cell from the exercise of function appears to
be the essential cause of sleep. With this there may
be exhaustion of other organs, and more especially
of the voluntary muscular system. But, however the
latter may participate in sleep production, the pri-
mary cause is the need for rest on the part of the
brain cell itself. Temperament is of the greatest
importance in relation to sleep and sleeplessness.
The temperamental differences which influence cellu-
lar excitation, influence also disturbances of sleep
due to afferent neural and to hasmic causes. Sleep-
lessness may therefore be classed in three groups :
Cellular, neural, and haemic. But, whatever the im-
mediate cause of sleeplessness, the effects of it.
though varying in degree, are the same in kind and
the opposite of those observed in sleep. Thus, the
temperature of the body is slightly raised, visceral ac-
tions are quickened, and secretion, especially the uri-
nary secretion, is increased, not diminished. The
latter phenomenon, like all the phenomena of sleep-
lessness, is most evident in the neurotic insomniac
and is due to the higher vascular tension involved,
which causes a larger excretion of urine by the kid-
neys, for the increased output is usually of a limpid
character, i. Cellular insomnia. The majority of
cases of disturbed sleep are referable to this class.
The subjective and objective causes of cerebrocellu-
lar disturbance must be distinguished. Of these the
former, dealing with sensibility and emotion, are
more likely to preponderate than those dealing with
executive overwork, ^^"orry kills and keeps awake
more frequently than overwork. 2. Xeural insomnia
includes all those cases in which sleep is disturbed
by afferent impulses of a more strictly physical kind.
Pain and bodily discomfort originating in whatever
system, be it cutaneous or pulmonary, renal or he-
patic, gastric or intestinal, may rouse conscious ac-
tivity and prevent its dropping into the rh\i:hmical
repose natural to it. This may be caused directlv.
as by pain, or indirectly, as by elevation of the blood
pressure. 3. Haemic insomnia. This is the smallest
group of those into which cases of insomnia fall.
Among its causes, in addition to anaemia, are eleva-
tion of the body temperature without the develop-
ment of localized disease and various intoxications.
The terrible insomnia of the delirious pneumonic,
which frequently hastens death, belongs to this
group. Drug and food agents act through the blood :
also products of defective metabolism acting through
the ner\-ous system on the blood vessels and inducing
a hypertonic state unfavorable to cerebrocellular re-
pose. Vascular hypertonus of a spastic and func-
tional type has its organic expression in the arterio-
sclerotic rigidity of old age so often associated with
defective sleep. The prognosis in cases of insomnia
depends a good deal upon the removability or other-
wise of the cause of disturbance, but on the whole
the prognosis of functional, as apart from organic
insomnia, is good. Of the many hypnotics intro-
duced in recent years, none compares in efficacv in
420
PITH OF CURRENT LITERATURE.
[New York
Medical Journal^
any way with opium and its derivatives. Xo agents,
however, are more apt to produce the drug habit.
In the absence of physical pain and visceral commo-
tion, most of the reliable hypnotics belong to the
methane group — sulphonal, trional, veronal, chloral,
etc. With them may be prescribed bromides and a
derivative of hyoscyamus or cannabis indica. The
writer recommends the use of what he calls an "open
air" pillow — a lightly padded iron frame covered by
a case of smooth webbing and open at both ends, on
which the "head and neck rest comfortably, surround-
ed by air of the same temperature as that of the bed-
room.
6. Phosphaturia and Conversion of Disease. —
Harrison states that it has not infrequently been ob-
served in the treatment of chronic urethritis and
mucopurulent discharges following it, irrespectively
of the internal administration of alkalies, and often
imperceptibly to the patient himself, that the urine
becomes altered in character and assimilated with
that known as phosphaturia. And, further, that
when this change is observed the cessation of the
discharge or gleet, for which the patient original!)
came under treatment, usually soon follows, either
spontaneously or by treatment appropriate to the
phosphaturic state without apparent reference to the
cause which preceded it. The writer suggests that
the artificial production and temporary continuance
of such a state of phosphaturia might be utilized in
the treatment of specific gleety affections following
upon gonococcal infections. To produce a urine hav-
ing the prominent features of phosphaturia bv the
administration of alkalies — potassium bicarbonate
— is not difficult nor detrimental to the patient. The
eflfect on the urine should be sufficient to make it re-
act to the usual tests for phosphaturia — not merely
an alkaline reaction. Further, it is necessar}- to
maintain this condition for some little time, during
w-hich all local applications should be suspended.
After ten days or so, as the phosphaturic condition
passes off under the influence of altered treatment
and diet, it will usual!}- lie found tliat the original ail-
ment has also departed.
8. Recovery in Landry's Paralysis. — Vining
reports a case of severe acute ascending ( Lan-
dry's) paralysis, which, when the diaphragm show cd
signs of paralysis, threatened to be s])i.c(lil\ fatal.
The diagnosis lay between diphtheritic paralysis,
Landry's paralysis, and a toxic paralysis affecting
the anterior cornua or nerves. There was, how-
ever, no evidence of diphtheria, oi- of exposure to
such toxic influences as syphilis, gonorrh(jea, lead, or
alcohol. In this case, strychnine appeared to have a
very beneficial efifcct.
LA SEMAINE MEDICALE.
I'cbruary 5, i()08.
Cystic E|)ilhelioinata of the Ovary, By M. Lejars.
Cystic Epitheliomata of the Ovary.— Le jars re-
ports a case of this kind met with in a young woman,
twenty years of age, in which the right ovary was
involved ; another case in a woman, fifty-seven years
of age, in which both ovaries were cliseased ; and
a third in a woman, fifty-three years old, in which
the left ovary was the seat of the new growth.
AMERICAN JOURNAL OF THE MEDICAL SCIENCES.
February, jgo8.
1. The Clinical and Pathological Distinctive Diagnosis of
Diseases of the Female Breast, By J. C. Bloodgood.
2. Some Fnndamental Principles in the Treatment of
Functional Nervous Diseases with Especial Refer-
ence to Psychotherapy, By J. Collins.
3. The Pathogenesis and Treatment of Neurasthenia in
the Young, By R. N. Wilson.
4. Nervous Manifestations of Arteriosclerosis,
By A. Stenzel.
5. Arteriosclerosis in the Young, By F. Fremont Smith.
6. Lack of Gastric Mucus ( Amyxorrlicea Gastrica) and Its
Relation to Hyperacidity and Gastric Ulcer.
By J. Kaufmann.
7. The -Etiology and Symptomatology of Cerebrospinal
Meningitis, By T. A. Cl.vytor.
8. The Complications and Sequels of Typhoid Fever.
By C. D. Selby.
9. The Laryngeal Complications of Typhoid Fever with
the Report of Two Cases. By W. Rieser.
10. Purulent Cerebrospinal A'leningitis Caused by the Ty-
phoid Bacillus without the Usual Intestinal Lesions
of Typhoid Fever,
By J. N. Heinry and R. C. Rosenberger.
11. Chronic Fibrous ^lyocarditis in Progressive Muscular
Dystrophy, By C. H. Bunting.
12. Certain Unusual Forms of Hepatitis, By D. Symmers.
13. A Case of LTnilateral Mixed Nystagmus Benefited bj--
Treatment, By C. A. Veasey.
1. Clinical and Pathological Distinctive Di-
agnosis of Diseases of the Female Breast. — Blood-
good states that every palpable mass in the lireast
of a woman should be regarded as malignant until
proof is obtained of its benignity. Previous to the
age of twenty-five, lesions of the breast are, as a
rule, benign. They include intracanalicular myxo-
ma, fibroadenoma, and diffuse virginal hypertrophy.
In women over twenty-five every tumor of the
breast should be explored without delay. They ma}-
be malignant or doubtful. The former sliould be
operated (in b\ the extensive dissection devised by
lialsted. In >l(iul>tful cases an exploratory incision
is first made, and if malignancy is apparent the
radical operation is at once performed. If it is
not malignant the extent of the operation will de-
pend upon the nature of the tumor and the condi-
tion of the surrounding breast, the procedures be-
ing excision of the tumor only, e.xcision of the en-
tire I)reast, or excision of both breasts. Clinically,
doul)tful tumors may be either solid or cystic, the
latter being of rare occurrence. Carcinoma of the
breast ma} be divided into adenocarcinoma, medul-
lary, and scirrhus.
2. Fundamental Principles in the Treatment
of Functional Nervous Diseases. — Collins affirms
that the treatment of psychasthenia, like the treat-
ment of nervcnis disease founded on degeneracy,
consists in treating the patient and in treating the
chief factor of the disorder, heredity. The neu-
rasthenic usually yields to treatment when the
cause no longer exists and the general health is re-
stored. The latter usually follows proper rest and
exercise, massage, thermal, and mechanical agen-
cies. The ps} chastlienic will usually require much
more searching psychotherapy. Me will need plain
statement as to the nature of his ailment and the va-
rious data involved in overcoming it. He must de-
velop selfreliance and courage. Treatment by sug-
gestion will be of great importance, though hypno-
tism will ustiall} be unnecessary and inadvisable.
l-'ebruary 29, 1908. J
i^ITH OP CURRENT LITERATURE.
421
Cleans which will improve the general health are of
prime importance, also healthful reading and useful
occupation. Introspection and constant questioning
as to one's acts and thoughts must be overcome by
paternal and pedagogical cooperation.
3. Neurasthenia in the Young. — Wilson nar-
rates a number of cases in which his treatment con-
sisted in first winning the complete confidence of
the patient, then in educating the physical body to
do more than it had ever done to attain perfect
tone, in order that the mind and nervous system
might follow the body in regaining control and bal-
ance. The patient was fed regularly, and then
ample exercise was taken in the open air to consume
the entire intake of food. A thorough evacuation
of the bowels, artificially produced, if necessary, was
always insisted upon, every morning. Exercise
morning and evening to the point of physical tire,
but not exhaustion, was continued, and as the mus-
cles hardened the depression and neurasthenia di-
minished. Gradually selfconfidence w^as acquired,
hopefulness in the possibility of cure became estab-
lished, and after months of such treatment cure re-
sulted. The author recognizes that the close at-
tention and great labor which such cases reqiJire will
not be possible with the majority of physicians.
4. Nervous Manifestations of Arteriosclero-
sis.— Stenzel affirms that various nervous symp-
toms are to be met with in this disease, some of
which are consequences of the disease, while others
are due to associated organic diseases. Those who
sufifer with arteriosclerosis are often afifected at the
same time with" structural disease of the kidneys,
heart, brain, or other organs, and it is always neces-
sary to distinguish the symptoms caused by the asso-
ciated conditions from those which arc directly due
to arteriosclerosis. The error must be avoided of at-
tributing to arteriosclerosis the symptoms which re-
sult from purely accidental organic diseases when
associated with it, but not essentiall}' due to it.
There is great danger of attributing all the obscure
conditions of seniHty and even of the presenile pe-
riod to arteriosclerosis. The aim of the author in
this paper is consequently to point out the certain
results of vascular occlusion or disease, and also the
symptoms associated with arteriosclerosis, which
may be attributable to that condition on account of
their analogy with the symptoms of that disease, anrl
the exclusion of other probable causes.
9. Laryngeal Complications of Typhoid Fe-
ver.— Rieser finds nearly 300 reported cases of
such complications. The following are considered
causative factors: i. Friction and irritation rlue to
phonation and swallowing, together with constant
coughing, all being produced upon a surface which
is part of an organism suf¥ering from general
t\-phoid toxaemia. 2. A mucous membrane itself in
a state of catarrhal inflammation with swollen sur-
face epithelium. 3. Thermic influences, heat or cold,
or both, in rapid succession, including sudden
draughts. 4. Bacteria ; the lymphoid tissue in any
part of the body being subject to primary invasion
by the typhoid bacillus. 5. Extension of pharyngeal
involvement in parotitis, with infiltration of the
arytenoepiglottic folds. 6. The dorsal decubitus.
AMERICAN JOURNAL OF OBSTETRICS.
Ecbniary. 1008.
1. The Influence of the Central Nervous System in the
Causation of Uterine H?emorrhages,
By H. Ehrenfest.
2. Phlegmonous Siginoiditis, Resection, Recovery,
By I. Olmsted.
3. Intrapartum Vaginal Ovariotomy for Ovarian Cyst
Obstructing Labor. Report of a Case,
By K. I. Sanes.
4. Scopolamine Morphine An?esthesia in Gyn;ecologv,
By E. RiES.
5. Vesicouterine Fistula, By W. H. W. Knipe.
6. Obliterating Thrombosis of the Ovarian Artery,
By H. Grad.
7. Normally There Should Be No Haemorrhage from the
Placental Site at the Time of Delivery,
By J. G. Drknnan.
S. A Consideration of Neurasthenia in Its Relation to
Pelvic Symptoms in Women, By E. A. Weiss.
9. Curettage and Puerperal Sepsis, By C. E. Ruth.
10. Cases Illustrating Common Mistakes in Gynaecological
Diagnosis, By W. S. Smith.
I. The Influence of the Central Nervous Sys-
tem in the Causation of Uterine Haemorrhages. —
Ehrenfest states that the end(jmetrium was at first
believed to be the cause of such bleeding. Then
came the theories that the fault was in the uterine
wall. Either it was a thickening of the tunica me-
dia of some of the arteries, or there is relative in-
sufficiency of the uterine musculature with excess
of fibrous tissue, or there is insufficiencv of the ute-
rine elastic tissue. None of these theories include
simple functional disturbance as a cause. The au-
thor then studies the subject from the standpoint of
the nervous system and draws the following conclu-
sions: I. Impulses from the central nervous sys-
tem may alter the normal titerine function both as
to menstruation and labor. 2. Vasomotor anoma-
lies may result, such as amenorrhoea. menorrhagia,
and irregular haemorrhages, or motor disturbances
such as the sudden beginning or cessation of uterine
contractions. 3. The mechanism by which such
nervous influence may cause amenorrhoea or metror-
rhagia has not been clearly explained. With these
facts in view, the effect of increase of uterine tonus
from whatever cause will be passive hyi)eraemia with
local increa.se of blood pressure and dilatation and
rupture of the endometrial capillaries.
4. Scopolamine Morphine Anaesthesia in Gyn-
ascology. — Ries reports the results of this treat-
ment in 185 cases, including all kinds of gynaecolog-
ical operations. He administers 1/50 grain scopola-
mine and j/, grain morphine in three equal hypo-
dermatic injections, two and a half, one and a half,
and one half hour before an operation. Hyoscine
may be substituted for scopolamine. The patient
.should be kept quiet in a dark room while the injec-
tions are being given, the general preparation of the
patient preceding the injections. The operations in
question, in twenty-four cases, were without the as-
sistance of other anaesthetics, the patient being in a
quiet sleep. Vaginal operations by this method are
usually more successfully carried out than abdom-
inal ones. Pulse and temperature undergo little
change during this anaesthesia, but the rate of respi-
ration is sometimes considerably reduced. Verv
young patients should not receive this treatment.
In combination with ether anaesthesia this treatment
produces the best results.
422
PITH OF CURRENT LITERATURE.
Medical
[New
Journal.
York
8. A Consideration of Neurasthenia in Its Re-
lation to Pelvic Symptoms in Women. — Weiss
determined from the analysis of a series of neuras-
thenic patients who required gynjecological exami-
nation and treatment that diagnostic error often at-
tributes to the pelvic organs lesions which do not
exist, that operations have often been recommended
and performed in such cases, and that in the major-
ity of the cases operated upon there was either no
improvement or the symptoms were aggravated by
the operation. He asked that these facts be borne
in mind : ( i ) That neurasthenia may be present
without any pelvic disease, (2) that neurasthenia
and pelvic disease may coexist without causal rela-
tion of one upon the other, (3) that they may coex-
ist with definite relation. The whole class of pa-
tients is very difficult to treat, and requires much
patience and care in dififerentiating real from imag-
inary evils.
ANNALS OF SURGERY.
February, 1908.
1. Liidwig's Angina. An Anatomical, Clinical, and Sta-
tistical Study, By T. T. Thomas.
2. Experimental Surgery of the Lungs, By S. Robinson.
3. Should Cholecystitis and Cholelithiasis Be Any Longer
Considered Medical Affections, and What Are the
Usual Consequences of so Treating Them?
By C. B. G. De Nancrede.
4. The Value of the Differential Leucocyte Count in Acute
Appendicitis, By A. H. Noehren.
5. A New Technique for Dealing with the Appendix
Stump, By C. W. Barrett.
6. Obstruction of the Internal Urinary Meatus by Folds
of Mucosa. By W. Jones.
7. Postoperative X Ray Treatment of Malignant Disease,
By R. H. BoGGS.
8. Endoaneurysmorrhaphy (Matas) in the Treatment of
Traumatic Aneurysm of the Femoral Artery,
By J. M. Elder.
9. Further Observations on the Treatment of Paralytic
Talipes Calcaneus by Astragalectomy and Backward
Displacement of the Foot, By R. Whitman.
ID. The Trough Suspender Forearm Sling,
By W. C. Wermuth.
II. Partial Resection of the Upper and Lower Maxillae for
Congenital Deformity of the Face, By R. T. Morris.
2. Experimental Surgery of the Lungs. — Rob-
inson thinks, as the result of thirty experimental
operations on the lungs and pleura, that a positive
pressure apparatus is better for such work than
the negative pressure cabinet. Further investiga-
tions will show whether disturbances to the pul-
monary and aortic systems are greater than from
negative pressure methods, also the cause of pleu-
ritic effusion and death after pneumectomy of one
side. He also proposes to test different methods of
thoracoplasty, including artificially produced me-
diastinal and diaphragmatic hernise, to obliterate, at
least partially, the unoccupied cavity. He thinks it
has not been proved that interlobular abscesses and
other localized inflammatory conditions of the
pleural cavity may not be approached through un-
involved regions, brought to the wound, walled off,
and drained as in intraabdominal operations. He
then proceeds to answer the eight objections of
Sauerbruch to positive pressure for intrathoracic
o|)erations, as compared with negative pressure.
3. Should Cholecystitis and Cholelithiasis be
any Longer Considered Medical Affections, and
What Are the Usual Consequences of so Treat-
ing Them? — Xancrcdc thinks the importance of
certain biliary conditions and the impossibility of
successfully treating them except with the knife is
not sufficiently recognized. It is not necessary for
a diagnosis of cholecystitis that there be jaundice,
a painful tumor in the gallbladder region, chill, and
fever. The author holds that cholecystitis is an in-
fective process which precedes the formation of
calculi, and implies potential dangers, with or with-
out the formation of such bodies. The most coin-
mon form of the disease is caused by gerins of low
virulence, but one is never sure that there may not
be secondary infection, with virulent organisms,
causing infectious ch.olangitis or suppuration or
gangrene of the gallbladder. There are also possi-
bilities of adhesions inyolving the stomach and in-
testine with permanently serious results. The ab-
sence of gallstones at an operation does not prove
that none have been passed nor that others may not
form.
7. Postoperative X Ray Treatment of Malig-
nant Disease. — Boggs desires to emphasize the
necessity of such treatment early, without waiting
until recurrence has taken place. Radiation should
be used in such a manner that the site of operation
and the adjacent lymphatic glands will be saturated,,
thus producing a physiological result. It must be
remembered that inadequate treatment is useless,
that small doses stimulate growth of tissue, while
efficient radiation retards and destroys new
growths. The treatment with this agent will vary
with the situation, the results for malignant disease
at the surface of the body being far more satisfac-
tory than for its interior. For cancer of the breast
the following suggestions are made: i. The breast
should be removed by the radical operation and be
immediately followed by x ray treatment. 2. If
there is slight glandular involvement, intense x ray
treatment should immediately follow an operation.
3. If the glandular involvement is extensive, intense
radiation daily until axillary glands cannot be felt,
then a radical operation and cautious use of the
x ray.
THE GLASGOW MEDICAL JOURNAL.
February, igo8.
1. Degeneration of the Spinal Cord Associated with Se-
vere Anaemia in a Case of Chronic Gastric Ulcer,
By T. K. Monro and Mary B. Hann.w.
2. Case of Cirrhosis of the Liver in a Boy Nine Years
Old, By Walter K. Hunter.
3. Albuminuric Retinitis with Vascular Qianges :
Aneurysms on Retinal Arteries,
By .\. J. Ballantyne.
4. Three Cases of Severe Injury at the Ankle Joint,
By Alfred A. Young.
5. Mediastinal Cancer, Occurring Ten Years after Re-
moval of the Breast, with Secondary Nodulation
Well Distributed Over the Head and Trunk.
By J. Souttar M'Kendrick.
2. Cirrhosis of the Liver. — Hunter had such a
case in a boy, nine years of age. He remarks that
as to the aetiology of cirrhosis of the liver, we are
still in the dark, but it seems reasonable to suppose,
as a predisposing cause, an undue irritability or sus-
ceptibility of the liver tissue, which may be con-
genital or acquired : and, as exciting cause, a toxine
of unknown composition and origin, which some-
times reaches the liver by the portal and sometimes
by the general circulation. Such a cirrhosis has
been produced experimentally by injecting a certaiii
February 29, 1908.]
PROCEEDINGS OF SOCIETIES.
423
drug into the general circulation ; and it is prob-
able that a toxine of this sort is produced over a
long Dcriod and at times in greater quantity than
at others, for the symptoms show, from time to
time, definite exacerbations alternating with periods
when the patient seems to improve. The enlarge-
ment of the spleen so often met with is probably
also due to a toxaemia, which will be increased as
the liver gets less efficient. Microorganisms and
toxines in the blood tend to collect in the spleen,
from whence they may pass again in the portal
blood stream to the liver, and possibly in this way
add a portal cirrhosis to what may formerly have
been a biliary cirrhosis. Some explanation of this
sort is required to account for the association of
portal and biliary cirrhosis in the same liver.
MEDICAL SOCIETY OF THE STATE OF NEW
YORK.
One Hundred and Second Annual Meeting, Held in
Albany, January 27, 28, 29, and 30, 1908.
The President, Dr. Frederic C. Curtis, of Albany, in
the Chair.
(Continued from page 281.)
Clinical Observations on Vaccines. — In this pa-
per Dr. Joshua M. Van Cott referred to the in-
volved and prolonged technique with which the pro-
duction of vaccines was associated, thus overcoming
most of their clinical usefulness. It was this fact
that had first led him to the manufacture of a vac-
cine composed of enough species of streptococci
and staphylococci to cover all conditio'ns. Follow-
ing the use of this vaccine, he reported no unto-
ward eflfects. On the contrary, the patients seem-
ed to experience a sensation of acceleration. There
was no local reaction except slight hyperaemia. All
the patients vaccinated were in poor general con-
dition and had shown no tendency to improve by
any other treatment. The Bier congestive appara-
tus was used in three of the cases. He reported
eleven cases, all of virulent infections, in which the
patients were vaccinated, with only two deaths. He
believed that the results obtained were sufficient to
warrant a favorable report of this composite vac-
cine, and that we might eventually get rid of at
least some of this elaborate and objectionable
technique.
Report of Four Cases Treated by Vaccines. —
In this paper Dr. Algernon T. Bristow, of Brook-
lyn, began by stating that the organism protected it-
self in two ways — by the blood serum itself and by
phagocytosis. In some cases of infection the serum
had no bactericidal power, and thus phagocytosis
was the only antagonistic factor to infection.
Case I was that of a lady, fifty-eight years of
age, who for some time, at intervals of about three
weeks, had symptoms of infection and rigors. When
she was first seen her temperature was 102° F. She
had a swelling on the side of the neck, moderately
painful upon pressure. The blood count showed
14,000 white blood cells. A few days later the pain
was less, the swelling was more diffuse, and there
was a white count of 10,000. An operation was
done, which consisted of a long incision, parallel
to the sternocleidomastoid muscle. The abscess was
opened and pus evacuated and the abscess drained.
Five days after the operation a culture from the
wound showed a mixed infection with streptococci.
She was vaccinated with 5,000,000 streptococci, ob-
tained, not from her own organism, but from a
stock vaccine. Following this her temperature rose,
she had a convulsion, and she required active stim-
ulation. A second dose of 10,000,000 was then
given a few days later, and from this time the pa-
tient steadily improved.
Case II was that of a girl, aged twenty-one,
brought to the hospital with a history of rheuma-
tism. Her general condition was bad, and strep-
tococci were found in the blood. She had head-
ache, some retraction, and pain in the joints. She
was given antistreptococcus serum for several
doses, but without any beneficial efifect. She sub-
sequently received three doses of vaccine of 5, 10,
then 5 million streptococci. Following the last dose
there was an uninterrupted recovery.
Case III was that of a nurse suffering from
furunculosis. Culture showed staphylococci. A
vaccination was made from her own organism.
Following its administration she remained free for
some months, then a second furuncle developed.
She was revaccinated, and it rapidly cleared up.
Case IV was that of a boy, eighteen years of age,
suffering from gonorrhoeal arthritis. He had a
high temperature, and the joint was swollen and
painful. Seventy-five million gonococci were given
and repeated in four days. In a week the boy was
up on crutches, and a rapid improvement followed.
Dr. Bristow regarded these results as sufficiently
striking to warrant a thorough investigation of vac-
cine therapy upon the part of those who were not
familiar with it.
A Description of the Methods of Sir A. E.
Wright. — Dr. William H. Woglom mentioned
the three elements necessary for the test, viz., the
serum, the washed leucocytes, and the organism.
He described the method of obtaining the washed
leucocytes by dropping the blood into a one and a
half sodium citrate solution, centrifuging, pipetting
ofif the supernatant fluid, rewashing, and recentri-
fuging with a sodium chloride solution, causing the
separation of the leucocytes, which were designated
"washed leucocytes." The collection of the serum
was then explained; the use of the glass capsules,
the sealing in the flame, etc., also how the clot
formed and how the capsule could be broken when
the serum was to be tested.
To make the "bacterial emulsion," a twenty-four
hour culture was advised. Some of this was taken
on a flat loop and mixed with normal saline solu-
tion. The thickness of the emulsion could best be
determined by experience.
Mark off some amount on the pipette and call it
volume. Take one volume of washed leucocytes
and then one volume of the bacterial emulsion, al-
lowing a bubble of air to interpose between them,
then one volume of the patient's serum with a bub-
ble of air between them. Then blow out upon a
slide and mix. The mixed solutions are then
drawn up in a pipette and left for ten or fifteen
424
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
minutes to incubate. Then go through the same
process, using normal serum, which might be ob-
tained from a "pool" of many normal bloods. The
object of this was a control. Blow off a drop from
the pipette upon a glass slide, and smear with a
smearer whose edge was slightly concave. Then
count at least one hundred leucocytes, both those
which had "phagocyted" and those which had not.
The average number of bacteria ' found in the
leucocytes actuated by the patient's serum was then
divided by the average number of bacteria found in
the leucocytes actuated by the serum from the pool.
The result obtained would be the patient's index.
The Value of the Opsonic Index in Controlling
the Use of Vaccines. — In this paper Dr. William
H. Park declared that to Dr. Wright belonged the
credit of causing and stimulating the profession to
use vaccines, and that it would take years to learn
the limits of the opsonic work. He referred to the
fallacies of the technique and the results, not only in
the hands of American workers, but as done by the
assistant of Dr. Wright himself. So he advised that
but little dependence be placed upon only determina-
tion. The difficulties of the work were said to lie in
three main causes: i. The personal equation in
counting. 2. The irregularity with which the leuco-
cytes would take up bacilli. 3. The difficulty of
technique ; one could not always take the same num-
ber of blood cells and of bacilli.
Besides this, he continued that the proper culture
must be obtained, viz., from the individual affected ;
that each day the pool of normal blood must be re-
newed (and this would vary), and that the irregular-
ity of the disease lent its weight in making the de-
termination more difficult. He declared that the op-
sonic power was not the only protective element in
the blood, but one of many.
He reported a series of examinations by ten dif-
ferent laboratories, all of the same specimens of
blood. The results of the laboratories, while very
interesting, showed marked variation, and the results
only emphasized the fact that little dependence could
be placed upon one determination. He recalled his
visit to England and to the hospital in which Dr.
Wright carried on his investigations. He said that
the patients, while not doing as well as Dr. Wright
in his enthusiasm would lead one to suppose, were
on the whole benefited by this method of treatment.
He stated that Dr. Wright himself thought the in-
dex to be of little clinical importance. He concluded
by affirming that the results obtained in England
were no more accurate than those of American work-
ers.
Dr. Rochester asked if a low index to any organ-
ism would warrant a diagnosis of an infection bv
that particular organism, and whether, before using
a vaccine, the cultural method was used, or simply
the vaccine from the germ found in a given case, or
if the vaccine was made from a stock culture.
Dr. BcswELL, of Rochester, wished to know if all
the phagocytes were counted, or if the method of
Sim was employed.
Dr. Park said that Dr. Wright himself used the
index but little for diagnostic purposes. But he as-
serted, if a marked variation of the index to anv
particular organism occurred it usually pointed to an
invasion by that organism. In reply to Dr. Boswell,
he answered that as a rule he counted all the phago-
cytes, though he did sometimes use Sim's method.
The Importance of Examination of Those Who
Have Been Exposed to Tuberculosis. — Dr. John
H. Pryor, of Buffalo, read this paper. He quoted
the annual death rate from tuberculosis in New York
State as being about 14,000, which constituted one
tenth or one eleventh of the total number of deaths
in one year. He declared tuberculosis to be endemic
in its nature and the influence of preventive meas-
ures to be open to discussion. Outside of New York,
he considered the matter of prevention a delusion
and a snare, and the whole system a matter of diplo-
macy between the physicians and the various health
departments. He declared that the solution of this
problem called for rigid laws and an adequate knowl-
edge on the part of health officers before their ap-
pointment. He referred to the utmost importance
of an early diagnosis, and said that the profession
must learn to find the victims early, and that no case
of tuberculosis should be allowed to reach the stage
when the patient could give the disease to another
before preventive measures were instituted.
He believed that thorough and repeated examina-
tions of those who had at any time been exposed to
the disease should be carried out, and that the disin-
fection of apartments after death should be com-
plete, and not done in the slipshod manner in which
it was often carried or not carried out.
He asserted that the physical signs did not always
give an index of the extent of the disease, and that
if earlier haemorrhages were common, the diagnosis
would be easier. In his opinion exposed persons
should be instructed as to the early symptoms of the
disease and kept under constant observation. Un-
derfed persons were especially susceptible, so tuber-
culosis was largely a disease of the poor, and he la-
mented the fact that the practitioner often overlooked
the disease in its early and most favorable stages.
He cited an outbreak in an institution as a strik-
ing example of common and fatal indifference. In
this instance a nurse was found to have tuberculo-
sis. The entire force of nurses with whom she was
associated was examined, and out of thirteen nine
were found to be suffering from the disease ; also a
boy who was employed there proved to be infected.
This only showed the indifference with which most
people regarded this great scourge.
Dr. GooDALL agreed with Dr. Pryor as to the im-
portance of early diagno.ses, and stated that when
tubercle bacilli could be found in the sputum ulcera-
tion had already taken place, and that if the case
could be recognized before ulceration had occurred,
the prognosis would be infinitely better. He believed
also in hunting out the cases.
To emphasize the importance of exposure, he cited
a series of ple\irisy cases. Of those who subsequent-
ly had tuberculosis, sixty-five per cent, had been ex-
posed, and of those who did not have the disease
later only twenty-five per cent, had been exposed.
Pie believed that the mortality record of tubercu-
losis had increased in the last few years, possibly be-
cause of keener diagnoses, and not because of any
greater frequency of the di.sease.
Dr. RocHESTKR congratulated Dr. Pryor upon the
general excellence of his paper. He stated that he
examined the nurses and boy in the institution re-
February 29, 1908. J
PROCEEDINGS OF SOCIETIES.
425
ferred to by Dr. Pryor. and that he recommended
that the boy be sent to the Erie County Hospital and
the nurses" to Ray Brook, but that not one recom-
mendation had been carried out by the trustees of
the institution, and that the boy was retained in its
employ till ^^londay, January 19th. He regretted
exceedingly that it was so difficult to get the people
to carry out the physician's suggestions, or even
orders.
Dr. Prvor in reply to Dr. Goodall stated that the
death record was still probably too low as comp'ared
with the actual situation : many cases of tuberculosis
were entered upon the death certificate as pneumo-
nia or heart disease for insurance purposes.
The Treatment and Prognosis of Suppurative
Cystitis. — In this paper Dr. \'. C. Pedersex said
that there was but little new in the treatment or
prognosis of suppurative cystitis. Inasmuch as the
bladder was never at rest it Avas a difficult organ to
treat, and the treatment would depend upon the char-
acter of the inflammation and the degree of the
efifect. If the functional powers were totally im-
paired, the organ would never return to its normal
condition. He declared that in the treatment the
first step should be the removal of the cause when-
ever it was practicable, such as the dilatation of stric-
tures, the removal of vesical calculi, or treatment of
the prostate. Tuberculosis and cancer being hard
jetiological factors to remove, the prognosis was cor-
respondingly worse.
As to constitutional treatment, he advocated good
hygiene, plenty of sleep, and regulation of the bow-
els, especially in -old people. A change of climate
and avoidance of excesses in food, alcohol, or phys-
ical exercise, vesical fatigue, or irritation from high-
ly seasoned foods, were also advised.
In cases where the urine was alkaline he recom-
mended urotropin given in large doses up to tolera-
tion, as much as a drachm in twenty-four hours.
He believed the balsams to be beneficial, but they
were not to be given if the stomach showed any
tendency to rebel. Irritants, such as cantharides
and oil of turpentine, were to be avoided, but he did
advise irrigation, inasmuch as it stimulated, cleansed,
and soothed the mucosa of the bladder, and was a
mechanical aid in removing mucus, etc. In this pro-
cedure he preferred the soft rubber catheter and a
normal solution of salt or of sodium bicarbonate in-
jected till the return fluid was clear even in a test
glass. The posture of the patient did not make
much difference. The fluid used should be about the
bodily temperature, but the heat might be increased
to 110° or 115° F. From two to four ounces should
be used at a sitting, though in old cases with a di-
lated bladder from eight to sixteen ounces might be
employed. The success of this operation depended
upon the degree of comfort afforded and the lack of
tenesmus.
In chronic cystitis the mucous membrane should
be stimulated, but not irritated. If anv antiseptic
was used in the irrigation some of it might be left in
the bladder. The treatment should be repeated when
the symptoms returned : thus some bladders required
irrigation daily, while others might be quiescent for
five or six days. When tenesmus occurred, he be-
lieved it to be due to too irritating solutions, undue
trauma, or emptying the bladder too rapidly. In
some instances he advised the maintenance of the
knee chest posture during treatment, especially if
there were sacculations in the bladder wall. The in-
dwelling catheter was more applicable to women.
Unless the organ was badly damaged, the prognosis
was usually favorable. 5lany bladders, however,
might recover up to a certain degree, but never en-
tirely.
The Sequence of Pathological Changes in Ap-
pendicular Peritonitis. — Dr. E. McD. Staxtox
presented a study of 1,019 cases. He admitted the
sequence of the patholog}- to be complex, varying
from day to day, and running a definite course
either toward resolution or toward abscess. In gen-
eral it was seen that when peristalsis was arrested,
only a local peritonitis occurred, but, on the other
hand, if cathartics and food had been given, the
infection was disseminated by the movements of the
intestines.
Following inflammation the exudate might be of
two varieties, fibrinous, or dry, and serous or sero-
purulent. The dry variety formed adhesions to the
omentum, the liver, the end of the caecum, the pa-
rietal peritonaeum, and some coils of the intestine,
and these bands of fibrin were later replaced by
granulation tissue which walled off the pus cavity.
Though these granulations were soft and weak at
first, they were usually sufficient to confine the ab-
scess, provided peristaltic movement was effectively
arrested.
In the second variety, with the fluid exudate, it
was shown that there was little or no evidence of
localization, especially in the early stages. ' In cases
of this type operated in upon the first day there
was intense congestion of the peritonaeum, but
otherwise no change. In second day operations the
exudate was found to be more diffuse, with some
few feeble adhesions and slight dullness of the peri-
toneal surface. Upon the third day there was apt
to be a purulent exudate, with more adhesions of
fibrin, but the lesion was so extensive that no sharp-
ly defined abscess cavity could be made out. By
the fourth or fifth day organization was well estab-
lished and definite abscess cavities were then dis-
cernible. Upon the fifth or sixth day there would
be definite evidence of abscess formation. Then, it
was observed, there would be a progressive diminu-
tion in the extent of the area involved, with reso-
lution of the peritonaeum outside of the abscess
cavity; and on the tenth or eleventh day there
would be left but slight, if any, evidence of inflam-
mation in the general peritoneal cavity. Thus three
stages of the disease were said to exist: i. When
there was no marked alteration of the peritonaeum,
requiring only temporary drainage. 2. During peri-
toneal irritation, when an operation was not advisa-
ble. 3. When the peritoneal abscess had formed
and drainage constituted the operation.
The object of his paper was to establish the fact
that the distribution of an intraperitoneal infection
was purely mechanical, due to the movements of the
intestines.
Dr. OcHSXER said that he had looked forward to
the exposition of the living pathology of this con-
dition and especially in a large series of cases. He
believed the paper so complete and that it must
henceforth stand as a basis of our knowledge of the
426
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
pathology of acute appendicitis. Eight years ago
he had brought out the proposition, then heretical,
that the distribution of infection and the consequent
mortality depended not so much upon the primary
disease as upon its dissemination throughout the
peritoneal cavity by the peristaltic action of the in-
testines, and eight years before that he had believed
it possible to limit the infection, provided peristaltic
action could be arrested. This was best accom-
plished by withholding food and by gastric lavage,
possibly adding rectal feeding more for the benefit
of the friends than of the patient. He believed that
quiescent symptoms were often lighted up and in-
fection spread by an abdominal examination or the
administration of food or cathartics. The paper
showed to his satisfaction that if advantage was
taken of the anatomical relations the abscess would
be walled off and the outcome of most cases favor-
able. He believed that the superiority of this treat-
ment had been conclusively demonstrated.
Dr. W. G. Macdonald discussed the paper ad-
versely, and expressed the opinion that no artificial
chronological division of pathology or symptoms
could be made in any surgical or medical disease.
Dr. Monro, of Boston, commended Dr. Stanton
for the high order of his communication, and
agreed with him that the pathology could be identi-
fied day by day.
Dr. Skinner stated that the facts set forth in the
paper coincided with his own observation in cases
where there was no operation. He disagreed with
Dr. Macdonald and referred to the chronological^
cycle of various functions, such as the pulse, respi-'
ration, menses, etc.-, and also to the fact that in
cases of peritonitis treated by this method the
bowels usually moved on or about the tenth day.
Dr. Lake expressed his extreme pleasure in lis-
tening to the paper, because it recalled the early
teachings of Alonzo Clark, and he said that it seem-
ed good to him to hear a surgeon say, "Don't op-
erate ; wait."
Dr. Butler cited his own case as a child, when
he suffered from peritonitis. He stated that he
was kept under opiates for about six weeks. The
unusual feature of the case was that he had a local-
ized abscess, which ruptured into the bladder, and
the pus escaped with the urine.
Dr. A. Vander Veer asked as to whether or not
the disease was progressive as to the number of at-
tacks, and he wished to know the history of the
second and third attacks. He believed that in a
gangrenous and perforative appendicitis the best
chance was given to the patient by an immediate
operation.
Dr. Stranahan cited a series of one hundred
cases treated by Ochsner's method with no deaths,
and he stated that this series included all kinds of
cases.
Dr. Ochsner, in reply to Dr. Vander Veer, de-
clared that every patient seen during the first
thirty-six hours should be operated upon, because
the condition of the peritonjeum was still such that
it would be restored to the normal condition by only
temporary drainage. But on the second, third, or
fourth day an operation was decidedly contraindi-
cated. The procedure he recommended in those
cases was to wash out the stomach, apply an abdom-
inal bandage, and' use rectal feeding, giving along
with the enema lo to 30 drops of the deodorized
tincture of opium. Slow, continuous rectal irri-
gation might be employed if the patient was thirsty,
and if nausea or vomiting occurred he would wash
out the stomach. ,
Dr. Stanton, in reply to Dr. Macdonald, stated
that until he undertook the study of this subject
he too had not believed in any chronological order
of pathology, but he declared that even in the sa-
line treatment a certain attempt at a chronological
order could be made out, and that the death rate
was not one seventh of what it was in cases of op-
eration on the third, fourth, or fifth day. In reply
to Dr. Vander Veer, he stated that recurrent at-
tacks were more severe and more apt to perforate.
Diffuse Peritonitis in Women. — Dr. Ellice
McDonald said in this paper that he believed the
prognosis to depend upon the cause, and it might
be puerperal infection, perforation of a gastric or
intestinal ulcer or the gallbladder, or infections
from the bowel. Peritonitis from appendicitis in
women was much less common than in men, but
women seemed especially predisposed during the
puerperium. The difficulty of diagnosis when it
was associated with puerperal infections of the
uterus was pointed out. In the treatment he con-
sidered raising the general resistance by vaccines
and the leucocytosis by nucleinate of sodium to be
of great importance.
Dr. James N. Vander Veer exhibited a case of
carbuncle on the back of the neck, and showed the
Bier congestive apparatus and its application.
Hereditary Syphilis. — In this paper Dr. G. W.
Wende stated that the symptoms might appear at
birth, about the third week, at the third month, or
even later. The lesions present were more active
than those of acquired syphilis, and they might at-
tack any organ. There was often no room for hesi-
tation, but then snuffles were pointed out to be only
a matter of degree, and might be due to coryza, or
the skin lesion might be closely counterfeited by
eczema. ,
The epidermis was often macerated, and bullae
might be found on the hands and feet. This last con-
dition indicated a serious type of disease, and the
child usually died. Then, again, children might be
born apparently normal and remain so for a few
months, and then show lesions about the lips or a
pustular eruption somewhat resembling that of the
acquired form of the disease.
The tubercular syphilide was not so commonly ob-
served in the hereditary as ih the acquired form, but
it did sometimes occur on the scalp or even on the
rest of the body. He believed syphilis to be responsi-
ble for delayed dentition ; this dental involvement
might include all the teeth or only the incisors.
Huchinson's test teeth were the two upper permanent
incisors, and their outer edges, if continued down,
would meet at a point. This deformity was said to
be due to a stomatitis which had existed in the first
week of life, and if the infant escaped this stomatitis
the teeth would be normal. Teeth when first cut
might not show any notch, but they were usually
friable and the enamel was scaly. If notches exist-
ed they usually disappeared about the twentieth year.
He defined syphilitic pseudoparalysis as an inabil-
February 29, 1908.]
PROCEEDINGS OF SOCIETIES.
427
ity to control muscular movements due to separation
of an epiphysis. It was said to be not a true paraly-
sis, but an atrophy of disuse. The speaker declared
it to be due to a gummatous osteomyelitis in early
childhood. Joint lesions resulting from hereditary
syphilis were practically the same as those resulting
from the acquired form. JThe bones might be large,
globular, and of bony hardness, or might be atrophic
and associated with ankylosis. In hereditary syph-
ilis the bones were said to be more often affected
than in the acquired type, because the bones of young
children were more susceptible to pathological pro-
cesses.
The Clinical and Historical Features of Ac-
quired Syphilis. — Dr. J. A. Fordyce, in this pa-
per, pronounced extragenital initial lesions of ac-
quired syphilis to be relatively common, but often
mistaken for malignant disease,' especially when oc-
curring on the lip, where they were infiltrated and
irregular and resembled a beginning epithelioma. As
a rule, the initial lesions were said to be single, but
they might rarely be multiple, especially about the
nipples of a wet nurse who had suckled a syphilitic
child.
The secondary lesions included a papular and
sometimes a pustular eruption, which could easily
be mistaken for smallpox or vice versa. Pigmenta-
tion might persist in the site of these lesions, espe-
cially in nephritics. On the other hand, the erup-
tion might be scaly and resemble psoriasis.
The circinate form of eruption was referred to as
existing principally in the negro race, and attention
was called to the similarity between the eruption
caused by potassium bromide in susceptible individu-
als and some manifestations of syphilis.
The rarity of gummata of the palm was pointed
out, though they were sometimes present, but they
were apt to develop along the inner side of the leg.
The spreading of a serpiginous syphilide was ex-
plained by the spreading thrombosis of minute ves-
sels. The giant cells met with in syphilis were be-
lieved to' be of vascular origin, because in this dis-
ease the muscular layer of the bloodvessels was
markedly thickened.
The Technique of an Efficient Operative Pro-
cedure in Malignant Disease of the Skin. — Dr.
Samuel Sherwell, of Brooklyn, read this paper.
He said that he did not claim novelty as to method
or absolute perfection as to result for the procedure
to be described, but he had used it for thirty-five
years with good results and relatively few recur-
rences. He recommended simply curettage, but
thorough, deep, and efficient, followed by the imme-
diate and thorough application of an escharotic, pref-
erably a sixty per cent, solution of acid nitrate of mer-
cury. The caustic agent must be neutralized by some
alkaline medium ; he preferred common sodium bi-
carbonate in powdered form. This formed a scab,
which was allowed to remain till it fell or was pushed
off by the process of repair beneath. He said the
scar was relatively insignificant. The knife was per-
haps preferable in pendant and loose portions of the
body, such as the penis, the lips, and the ears, but in
many of these cases even he preferred the method
here described. He objected to the x ray and radium
because of time, expense, and uncertainty of result.
He advised great caution in diagnosis, the slow
growths being often tertiary syphilitic manifesta-
tions. Ulceration of the nasal saeptum where it
joined the lip, or any tumor involving the nasal car-
tilages, was more characteristic of syphilis than of
epithelioma. But sarcoma was appropriately treated
by this method.
He seldom found it necessary to use general anaes-
thesia. The curette used should have a clean wire
edge. He preferred nitrous oxide gas where general
anaesthesia was necessary. Before giving a general
anaesthetic he introduced two or three drops of a two
per cent, solution of cocaine about the edges of the
affected part and at the same time, with the same
needle, gave a hypodermic of about 1/4 to 1/3 of a
grain of morphine, with' or without atropine, in a
distant part of the body. The larger curette was
used with force in, around, and about all parts of the
affected area, so as to remove all morbid tissue.
Smaller curettes could then be used in sinuses and
anfractuosities with energy ; there was no need to
fear hurting sound tissue. He used a Paquelin cau-
tery, a solution of adrenalin, and a ten per cent, co-
caine solution to check persistent bleeding, followed
by acid nitrate of mercury in full sixty per cent,
strength, mopped on with cotton wool mops of the
bulk of a pea. This was the painful part of the pro-
cedure, but the pain was controlled by the anaesthe-
sia. The amount of touching with acid nitrate could
be learned only by experience ; he frequently allowed
it to remain for from ten to twenty minutes before
neutralization. The last step was the introduction
of bicarbonate of sodium into the excavated surface,
pressed firmly down to make an adherent scab. This
turned yellow and later black, and usually came off
in a fortnight or three weeks. It should be kept
dry. He did not use bandages. Inflammation fol-
lowed at the site after a day or two, but no dress-
ing, and particularly no wet dressing, must be used.
It would soon go down.
He considered the chances of recurrence far less
than those that followed the use of the knife, for the
following reason : The less viable cells of which
malignant growths were composed must perish un-
der conditions which would little if at all affect the
normal ; the inflammation itself and the absorption
of the potent alterative escharotic element by the
lymphatics caused the breaking down and destruc-
tion of those cells into innocent waste products to be
cast off by the economy. This was the only way he
could account for the nonliability td recurrence. He
always put his patients on a course of arsenic for a
long time after these operations, intermittently for
months, even years. He was no admirer of arsen-
ical preparations in ordinary skin disease, but did be-
lieve in their inhibitive virtues in sarcoma, and pos-
sibly in epithelioma and carcinoma, and referred to
the beneficial action of arsenic on the economy in the
destruction or prevention of malignant cell life.
He said he had used this procedure for many years
with success, having performed over forty operations
during the past year. Relapses had occurred in less
than ten per cent, of the cases, and he did not hesi-
tate to urge his colleagues to adopt this measure in
appropriate cases.
A Study of Four Hundred Cases of Ejjitheli-
oma. — In this paper Dr. L. D. Bulkley referred
to the many statements regarding the cause of
428
BOOK NOTICES.
[New York
Medical Journal.
epithelioma, and said that none was universally
adopted. He spoke of the striking resemblance that
these lesions had to .syphilitic ulcers, and said that
because of this similarity many were improperly di-
agnosticated and erroneously treated. He believed
the prognosis to be directly dependent upon the wis-
dom with which the lesion was treated from the
time of its inception.
He did not consider heredity to be an important
factor, and declared that epitheliomata might disap-
pear spontaneously or under proper local applica-
tions. He found them to be more frequent in males,
and especially between the ages of thirty-five and
fifty-five.
He made a pathological classification of epi-
theliomata, as those originating from the base-
ment layer of the skin and those developing from
the prickle cells. In those developing from the
basement layer of the skin the progress was seen to
be slower, and they might show evidences of spon-
taneous healing. They did not give rise to meta-
stases, and were amenable to treatment, notably
with the X ray. They occurred most often on the
face.
The second form of epithelioma, growing from
the more superficial layers, showed mitotic figures
and epithelial pearls microscopically. This variety
did give rise to metastases, was more rapid in its
growth, and was apt to occur at a mucocutaneous
junction. Bland ointments had apparently cured
lesions similar to the epitheliomata of the second
variety. He cautioned the general practitioner
against the indiscriminate use of silver nitrate. He
referred to the constant changing of treatment in
the past thirty-five years, but said that the results
depended upon the stage of the disease and the
completeness of its removal. He still thought that
the knife offered the best and surest method of re-
moval. Patients treated with arsenic paste often
recovered, but the process was slow and painful,
and this form of treatment had largely been super-
seded by the x ray. Curetting, combined with other
methods, such as cauterization, was recommended,
but it had to be thoroughly done. The escharotic
which the speaker preferred in connection with the
curette was pyrogallic acid. He believed that the
X ray presented the greatest advantage in the treat-
ment of certain cases of epithelioma. But, as this
agent had been used in this connection only for the
past five years, too much confidence must not be
placed in it yet.
( To be continued. )
[IVe publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, ive revieiv those in which we think
our readers are likely to be interested.]
Poisons: Their Effects and Detection. By Alexander
Wynter Blyth, M. R. C. S., F. I. C, F. C. S.. etc.,
Barrister at Law, Public Analyst for the County of
Devon, etc., and Meredith Wynter Blyth, B. A., B. Sc.,
F. I. C, F. C. S., etc., Public Analyst for the Borough
of Brighton and for the Borough of Eastbourne. Fourtli
Edition, Thoroughly Revised, Enlarged, and Rewritten.
With Tables and Illustrations. London: Charles Grif-
fin & Co., Ltd., 1906. (Through D. Van Nostrand Com-
pany, New York.) Pp. xxxii-772. (Price, $7.50.)
In this new edition of the standard work in the
English language on toxicology the author has by
expansion in some directions and condensation in
others provided much additional information with-
out increasing the bulk of the volume over that of
the preceding edition. The book has been brought
well up to date by . descriptions of several of the
medicinal substances » introduced within the
past decade or so, which have been found
to cause poisonous effects through prolonged use or
excessive doses. Thus, the poisonous effects of and
the antidotes for the sulphones — sulphonal, trional.
and tetronal — receive mention in paragraphs under
the heading Minor Anaesthetics and Narcotics.
Adrenalin, called epinephrin by the author, has a
subchapter to itself under Mammalian Poisons, and
it is further distinguished by being described as the
most powerful of all modern poisons. There is no
work on toxicolog}' more accurate and compre-
hensive in its treatment of the subject than Blyth's
book, and to such as make its acquaintance for the
first time the introductory chapters on The Old
Poison Lore and the Growth and Development of
the Modern Methods of Chemically Detecting- Poi-
sons form very interesting reading, the romance of
the poisons and poisoners of history being finel\-
brought out. The fact that the book has reached a
fourth edition is evidence in itself of the value
which has been placed upon it by succeeding gen-
erations of teachers and students. We are glad to
reiterate our previously expressed good opinion of
the work and commend it as a volume of indis-
pensable value to both students and practitioners of
medicine.
Blood E.raniination and its Value in Tropical Disease. By
Cl.aude F. Fothergill. B. A.. M. B.. M. R. C. S.,
L. R. C. P., etc. With a Preface by Major Ronald Ross.
F. R. S., C. B., Professor of Tropical Medicine, Uni-
versity of Liverpool, etc. London : Henry Kiinpton,
1907. Pp. 34. (Price, 60 cents.)
Dr. Fothergill's essay is intended to show the
value of blood examinations in the diagnosis of
tropical diseases. There are very few tropical dis-
eases in which a blood examination is not the most
important examination to be made. It is always
necessarv to exclude malaria and its influence in all
kinds of disorders of tropical and subtropical dis-
eases. We can as well imagine a physician dttermin-
ing that a patient has fever without using a clinical
thermometer as we can imagine a physician forming
his opinion on a disease of the tropics without study-
ing the blood. We dare say that there are physi-
cians who would undertake to do both. For such
the essay of Dr. Fothergill is especially suitable.
Rejections on Plague and the Methods of Checking it.
(With Letters to the Press.) By Peston.tee M.
Kanca, B. a., LL. B., Solicitor, High Court, Bombay.
Bombay : Bombay Education Society's Press, 1907.
Pp. 74-
It is a difficult matter for an .American to appre-
ciate the obstacles in the way of hygienic advince-
ment in a country like India. It would seem thnt.
now that the relation between the rat and the flo \
and the spread of plague was proved, it would be a
simple matter to rid a comnninity of rats and fleas
and plague. The essay of Mr. Kanga and his let-
ters to the press of Bombay show that this is not so
Mr. Kanga's ideas are sound, and if the govern-
ment and people of India coifld come to some work-
able understanding in the matter of hou.secleaning it
February 29, 1908.]
OFFICIAL NEWS.
429
is probable that plague would cease to exist in epi-
demic form. Laymen, however, are always slow to
apply the discoveries of scientific men, and in India
the adoption of scientific methods of dealing with
disease is further delayed by superstition.
Traite pratique d'hypnotisme et de suggestion thera-
peutiques. Procedes d'hypnotisation, simples, rapides,
inoffensifs. A I'usage des medecins, pharmaciens, pro-
fesseurs, instituteurs et des gens de monde. Par M.
Geraud Bonnet, docteur en medecine de la Faculte de
Paris, etc. Deuxieme edition. Paris: Jules Rousset,
1907. Pp. 326.
For several years the newer works on medical
therapeutics indicate for several disorders, such as
hysteria, incontinence of urine, etc., the advantages
of the use of suggestion, either given in a waking
or a hypnotic state.
The vast majority of physicians, the author con-
tends, neglect this method of treatment, and for the
most part do not know how to apply the method,
nor are they able to recognize the hypnotic state
when they see it. While there is little doubt that
the procedures of the ancient magnetizers, as well
as those of many a modern hypnotizer, are difficult
to understand, yet the author maintains that by
means of the methods outlined in this short man-
ual these difficulties may be reduced to a minimum.
The work of Bernheim, of Nancy, remains
classic, but in spite of this Bonnet finds that he is
not in accord with his teachings, since Bernheim in-
clines too strongly to the exclusive belief in the role
of suggestion. The method of hypnotization by
verbal suggestion, on which Bernheim relies, is not
sufficient for the greater number of patients that one
has to treat.
The author takes up in detail, in successive chap-
ters, although in an easy manner, the general prin-
ciples concerning physiological sleep ; the influence
of body and mind ; nervous force ; suggestion, auto-
suggestion, hypnotism, and hypnotizing ; and sug-
gestive therapeutics, and concludes with a number
of clinical observations.
While there is little new in the book, what is there
is well told and entertaining. The author is not
an advocate of any extreme positions, and fully rec-
ognizes the limitations of the applicability of the
subj ect.
BOOKS, PAMPHLETS, ETC.. RECEIVED
Confessio Medici. By the Writer of The Young People.
New York: The Macmillau Company, 1908. Pp. ix-158.
(Price, $1.25.)
Outlines of Psychiatry. By William A. White, M. D.,
Superintendent of the Government Hospital for the In-
sane, Washington, D. C, etc. New York : The Journal
of Nervous and Mental Disease Publishing Company, 1907.
Vitality, Fasting, and Nutrition. A Physiological Study
of the Curative Power of Fasting, Together with a New
Theory of the Relation of Food to Human Vitality. By
Hereward Carrington, Member of the Council of the
American Institute for Scientific Research, etc. With an
Introduction by A. Rabagliati, M. A., M. D., F. R. C. S.,
Hon. Gynaecologist and Late Senior House Surgeon, Brad-
ford Royal Infirmary, etc. New York : Rebman Com-
pany, 1908. Pp. 648. (Price, $5.)
Studies in Laboratory Work. By C. W. Daniels, M. B.
(Camb.), M. R. C. S. (Eng.), Director of the London
School of Tropical Medicine, etc., and A. T. Stanton, M. D.
(Tor.), M. R. C. S. (Eng.), D. T. M. and H. (Camb.).
Demonstrator, London School of Tropical Medicine. Sec-
ond Edition. Thoroughly Revised, with Many New and
Additional Illustrations. Philadelphia : P. Blakiston's
Son & Co., 1907. Pp. 491.
The Proceedings of the Royal Society of Medicine. De-
cember, 1907. New York, London, Calcutta, and Bom-
bay : Longmans, Green, & Co., 1907.
Morfologia delle arterie dell'estremita addominale. G.
Salvi. Parte I. Origine e significato delle arterie che
vanno all'estremita (selaci, anfibi, retilli, uccelli). Sup-
plemento agli studi Sassaresi, anno v, 1907, sez. II. Sas-
sari : Prem. stab. tip. ditta G. Dessi, 1907. Pp. 53.
Kurzes Lehrbuch der organischen Chemie. Von William
A. Noyes, Professor der Chemie an der Universitat Illi-
nois. Mit Genehmigung des Verfassers ins Deutsche
iibertragen von Walter Ostwald, und mit einer Vorrede
von Professor Wilhelm Ostwald. Leipzig: Akademische
Verlagsgesellschaft M. B. H., 1907. Pp. xxiv-722.
Verhandlungen der deutschen laryngologischen Gesell-
schaft auf der II. Versammlung zu Dresden, Vom. 15. —
18. September, 1907. Herausgegeben im Auftrage des
Vorstandes vom Schriftfiihrer Dr. med. Georg Avellis-
Frankfurt a. M. Mit einem Titelbild und 2 Abbildungen
im Text. Wiirzburg: Curt Kabitzsch (A. Stuber's Verlag).
1908. Pp. xiii-176.
Public Health and Marine Hospital Service
Health Reports:
The folloiving cases of smallpox, yellow fever, cholera,
(Did plague have been reported to the surgeon general.
United States Public Health and Marine Hospital Service,
during the iveek ending February 21, 1908:
Snmtl'po.r — United States.
Places. Date. Cases. Deaths.
Alabama — Mobile Jan. 25-Feb. i 10
Cah'fornia — Los Angeles Jan. 25-Feb. i 5
California — San Francisco Jan. 25-Feb. i 10
District of Columbia —
Washington Feb. 1-8 13
Illinois — Chicago Feb. 1-8 3 '
Illinois — Springfield Jan. i-Feb. 6 10
Indiana — Indianapolis "Feb. 3-9 5
Indiana — South Bend Feb. 1-8 i
Iowa — Sioux City Feb. 1-8 8
Kansas — Kansas City Jan. 25-Feb. 8 3
Kansas — Topeka Jan. 25-Feb. i 2
Kentucky — Lexington Feb. 1-8 6
Louisiana — New Orleans Feb. 1-8 5 Imported
Massachusett.s — Fall River Feb. 1-8 1
Minnesota — Winona Jan. 28-Feb. 8 2
Mississippi — Greenville Dec. 28 — Jan. 18... 3
Missouri — Hannibal Feb. 3-10 2
Missouri — St, Joseph Dec. 28-Feb. 8 32
Missouri — St. Louis Dec. 28-Feb. 8 6
Montana — Butte Jan. 28-Feb. 4 i
New Ycrk— New York Jan. 25-Feb. 8 4
Ohio — Cincinnati Jan. 31-Feb. 7 5
Tennessee — Knoxville Feb. 1-8 2
Tennessee— Nashville Feb. 1-8 18
Texas — Galveston Jtn. 31-Feb. 7 3
Virginia — Richmond Jan. 25-Feb. i i
Washington — Spokane Jan. 25-Feb. i 7
Wisconsin — La Crosse .Feb. 1-8 10
Smallfo.r — Foreign.
Belgium— Ghent Dec. 7-14 i
Brazil— Para Jan. 11-18 5 2
Brazil — -Rio de Janeiro Jan. 5-12 14 13
Canada — Halifax Jan. 25-Feb. 8 2
Canada— Winnipeg Jan. 25-Feb. i 8
China — Shanghai Dec. 22-Jan. 12 14 53
Cases foreign, deaths native.
Ecuador-^Guayaquil Jan. 4-18 13
Kgypt — Cairo Jan. 11-18 i
France — Brest Jan. 11-25 2 i
I'rance — Paris Jan. 11-25 16
Great Britain — Edinburgli Jan. 18-25 2
India — Calcutta Dec. 7-25 ii
Italy — General Jan. 23-30 67
Japan — Nagasaki Dec. 22-Jan. 12 3 i
Japan — Kobe Jan. 5-11 648 218
Japan — Yokohama Jan. 6-13 37 9
Mexico — City of Mexico Dec. 28-Jan. 4 Present.
Yellow Fc-'er — United States.
Texas — Galveston Feb. 16-18 2 2
In Quarantine from S. S. Crt'.t-
pm from Manaos and Para.
Yellow Fever Foreign.
Brazil — Manaos Dec. 2i.-Jan. 11 13
Brazil— Para Jan. 11-18 18 8
Brazil — Rio de Janeiro Jan. 5-12 i i
Cuba — Cardenas Feb. 14 i i
From S. S. Britanmc.
Cuba — Santa Clara Jan. 6-Feb. 18 4
430
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journai..
Cholera — Foreign.
India — Calcutta Dec. 14-28 120
India — Rangoon Dec. z8-Jan. 4 2
Russia — General J)ec. 25-31 28 10
Jan. 1-7 3 4
Russia — Tomsk Jan. 1-8 2
Cholera — Insular.
Philippine Islands — Manila Dec. 28-Jan. 4 31 23
Philippine Islands — Mariquina. . . . Jan. 4 Present.
Plague — Foreign.
Brazil — Rio de Janeiro Jan. 5-12 3
Ecuador — Guayaquil Feb. 13 Present.
India — Calcutta Dec. 7-28 70
India — Rangoon Dec. 28-Jan. 4 2
Portuguese East Africa —
Lorenzo Marquez Nov. 8-Jan. 12 8 5
Public Health and Marine Hospital Service:
Official list of changes of stations and duties of com-
missioned and noncommissioned officers of the United
States Public Health and Marine Hospital Service for the
week ending February 22, 1908:
BahrenburGj L. p. H., Passed Assistant Surgeon. Granted
leave of absence for twenty-one days from February
23, 1908.
Friedman, H. M., Acting Assistant Surgeon. Granted
leave of absence for one day on account of sickness,
February 10, 1908.
Keatley, H. W., Acting Assistant Surgeon. Granted leave
of absence for eight days from February 18, 1908.
McCoy, G. W., Passed Assistant Surgeon. Granted leave
of absence for one month and twenty-one days from
November 28, 1907, on account of sickness.
Miller, Charles, Pharmacist. Temporarily relieved from
duty at the Marine Hospital at San Francisco, Cal.,
and directed to report to Passed Assistant Surgeon
Rupert Blue for special temporary duty.
Parker, T. F., Acting Assistant Surgeon. Granted leave
of absence for two days from March 4, 1908.
Stanton, J. G., Acting Assistant Surgeon. Granted leave
of absence for twenty-one days from February 14,
1908.
Tappan, J. W., Actirig Assistant Surgeon. Directed to
proceed to Douglas, Arizona, for special temporary
duty ; upon completion of which to rejoin his station
at El Paso, Texas.
Thomas, A. M., Pharmacist. Temporarily relieved at the
Angel Island Quarantine Station, Cal., and directed to
report to the medical officer in command of the Marine
Hospital station at San Francisco, Cal., for temporary
duty.
Board Convened.
A board of medical officers was convened to meet at
San Francisco, Cal., February 21, 1908, for the purpose of
making a physical examination of an officer of the Revenue
Cutter Service. Detail for the board : Surgeon H. W.
Austin, chairman, and Passed Assistant Surgeon C. H.
Gardner, recorder.
Army Intelligence:
Official list of changes in the stations and duties of- offi-
cers serving in the medical department of the United States
Army fojr the week ending February 22, 1908:
Craig, C. F., Captain and Assistant Surgeon. Advanced
• to the rank of captain, to date from February 18, 1908.
Dale, F. A., Captain and Assistant Surgeon. Ordered to
Fort Lincoln, N. D., for duty.
Flagg, C. E. B., Captain and Assistant Surgeon. Resigna-
tion as an officer of the Army has been accepted by the
President, to take effect April 15, 1908.
Gray, W. W., Lieutenant Colonel and Deputy Surgeon
General. Granted leave of absence for one month.
Hanner, J. W., Captain and Assistant Surgeon. Granted
leave of absence for two months and seven days, from
February 19, 1908.
McAndrew, p. H., F'irst Lieutenant and Assistant Sur-
geon. Ordered to Fort Slocum, New York, for duty.
Peed. G. P., Captain and Assistant Surgeon. Will pro-
ceed on or before the expiration of his present leave
of absence to Fort Ontario, New York, for duty.
Siler, J. F., First Lieutenant and Assistant Surgeon. Will
proceed on or before expiration of present leave of ab-
sence to Fort Des Moines, Iowa, for duty.
Navy Intelligence:
Official list of changes in the medical corps of the United
States Navy for the week ending February 22, 1908:
Baker, M. W., Passed Assistant Surgeon. Unexpired por-
tion of sick leave revoked; ordered to the Naval Hos-
pital, New York, N. Y.
Belknap, J. L., Assistant Surgeon. Detached from the
IVabash and ordered to the naval training station,
Newport, R. I.
Heiner, R. G., Passed Assistant Surgeon. Detached from
the Wasp when placed out of commission and ordered
to the Pennsylvania.
Kennedy, J. T., Surgeon. Detached from duty with naval
recruiting party No. 3 February 29th, and ordered to
the naval recruiting station, Dallas, Texas, March 2d.
Richards, T. W., Surgeon. Ordered to the Colorado Feb-
ruary 22d, when discharged from treatment at the
Naval Medical Hospital, Washington, D. C.
Schaller, W. F., Assistant Surgeon. Detached from the
Pennsylvania and ordered to the Relief.
Taylor, E. C, Passed Assistant Surgeon. Detached from
the Naval Hospital, New Fort Lyon, Colorado, and
resignation accepted.
Wilson, G. B., Surgeon. Detached from the Colorado
and ordered to the IVabash.
Married.
Barton — Townsend. — In Richmond, Virginia, on Tues-
day, February i8th. Dr. Posey L. Barton and Miss Bessie
Townsend.
Beraux — Maumus. — In New Orleans, Louisiana, on
Wednesday, February 12th, Dr. L. A. Beraux and Miss
Anita M. Maumus.
Justice — Woodruff. — In Philadelphia, on Wednesday,
February 5th, Dr. Crawford Tait Justice and Miss Elsa
Marguerite Woodruff.
Lupton — Woods. — In Charlottesville, Virginia, on Wed-
nesday, February 12th, Dr. Frank Allemong Lupton, of
Birmingham, Alabama, and Miss Mary Watts Woods.
McCann — Bellebaum. — In Louisville, Kentucky, on Fri-
day, February 14th, Dr. Frank E. McCann and Miss
Catherine Crystal Bellebaum.
Magee — Donnelly. — In Trenton, New Jersey, on Wed-
nesday, February 13th, Dr. David M. P. Magee, of Phila-
delphia, and Miss Suzanne C. Donnelly.
Died.
Armistead. — In San Francisco, California, on Thursday,
February 6th, Dr. Cecil Armistead, aged thirty-seven years.
Brown. — In Providence, Rhode Island, on Saturday,
February 15th, Dr. Lucy A. H. Brown, aged sixty-six
years.
Crook. — In Glenwood Springs, Colorado, on Friday,
February 14th, Dr. J. J. Crook, aged eighty-one years.
Graham. — In Denver, Colorado, on Friday, February
14th, Dr. John W. Graham, aged sixty-four years.
Heuchling. — In Evanston, Illinois, on Monday, Febru-
ary loth. Dr. Theodore W. Heuchling, aged sixty-nine
years.
Hodgson. — In Roanoke, Virginia, on Saturday, February
15th, Dr. Wilmer Hodgson, aged sixty years.
Klock. — In Mahanoy City, Pennsylvania, on Saturday.
February ist. Dr. H. A. Klock, aged sixty-four years.
Le Crone. — In Columbus, Ohio, on Wednesday, Febru-
ary I2th, Dr. Thomas W. Le Crone.
Lewis. — In Tip Top, Harden County, Kentucky, on
Thursday, February 13th, Dr. J. C. Lewis, aged sixty-three
years.
Peaslee. — In Schodack Landing, New York, on Satur-
day, February 8th, Dr. John Peaslee, aged fifty-eight years.
Pfeiffer. — In Louisville, Kentucky, on Monday, Febru-
ary 17th, Dr. Robert M. Pfeiffer, aged fifty-one years.
Renick. — In Butler, Missouri, on Friday, February 14th,
Dr. O. F. Renick, aged eighty-three years.
Starr. — In Washington, D. C, on Saturday, February
15th, Dr. William M. Starr, aged one hundred and one
years.
Wood. — In West Chester. Pennsylvania, on Wednesday,
February 12th. Dr. Henry C. Wood.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal rlt Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXMI. No. 10.
NEW YORK, MARCH 7. 1908.
Whole No. 1527.
Original Communications.
PSYCHIATRIC EXPERT EVIDENCE IN CRIMINAL
PROCEEDINGS— ITS lAIPERFECTION
AND REAIEDY.*
By George W. Jacoby, M. D.,
New York.
Every important criminal trial in whicl: the ques-
tion of the insanity of tlie accused forms part of the
defense is followed by a discussion about medical
experts and iriedical evidence in which both profes-
sions, that of law and that of medicine, take part.
The lawyer looks upon medical evidence as an un -
satisfactory kind of testimony and attributes this to
the inexactness of medical science, or to reasons still
less flattering: the physician, on the other hand, sees
the causes in the defects of the law or in the manner
of its application, and reflects in general against the
practice of our- courts.
Certain it is that judges and juries do not re-
ceive this testimony with the respect and confidence
which is accorded to it in other cotmtries, and it
devolves upon us, as alienists and neurologists, as
the ones who arc consulted in the class of cases re-
ferred to, to investigate whether the fault lies en-
tirely in ourselves or only partly so, and to consider
whether a situation which has become intolerable
to all of us cannot be altered.
It has become proverbial that every nation pos-
sesses the government which it deserves, and it may
be said, with even more justice, that an independent
people such as we are possesses the government
which it desires. This is true not only of the gov-
ernment in general, but it also applies to each single
link in the commonwealth, to every disposure of our
legal activity, to each single law, whether the latter
be fundamental in character and of all pervading
import, or insignificant in its activity and immaterial
in its consecjuences.
If we have the law s which we desire, we must also
desire the necessary sequences of the laws which
we have, inasmuch as the laws exist for the purpose
of regulation of our outward life. On the other
hand, are we discontented with the results produced
by the application of our laws, then it follows that
our laws and our will are no longer in unison.
It is often not easy to take the decision to alter
laws under which we have grown up. Our concepts
of what is right and what is good develop with time
and with progress in conditions of existence, be-
coming modified according to the altering conditions '
•Read before tlic New V.irk Xe'.irological Societv. al it^ meeting
March 3. 1908.
of society and culture, whereas the laws themselves
correspondingly change but little or not at all.
Then it may occur that gradually and impercep-
tibly there develops, between the concept of the law
and the law itself, a disparity which at a given mo-
ment, at some special happening, becomes manifest
as a gross discord, and then a law which heretofore
has filled its mission in an approximatively thorough
manner, but has not kept pace with the progress of
the times, nor with us, may appear as a ver\- ques-
tionable fabric.
On the other hand, all of the unsatisfactory- mani- '
festations which evidence themselves under the
workings of a law are not always due exclusively to
inadequacies of this law.
Frequently the cause for disaft'ection is to be
sought in the persons w hn carry out the law, in our-
selves. If the people themselves are reasonable and
just, if they enforce the laws with reasonable wis-
dom instead of making a fetich of the letter of the
law, then even under antiquated law existence may
be thrifty and flourishing.
When, however, as was recently the case in a sen-
sational murder trial, the law's application results in
a monstrosity which obtrudes itself painfull}- upon
the consciousness of every law loving citizen, then
it is our duty to ask ourselves conscientiously, Are
such monstrosities, such excrescences, the lesult of
inadequate laws, or are we ourselves at fault in the
manner in which we apply those laws which we
have ?
Do our existing laws which govern the plea of
insanity in criminal cases constitute in themselves
the chief cause for such occurrences, or would it
have been possible with these san-ie laws t^ have
built up a more harmonious structure, tu have
, avoided the outcry against the medical expert and
therewith against the courts, the laws which govern
them and the methods of their administration?
Whether or no this could have been done in the in-
dividual case here referred to I am not competent
to discuss, but I do say that our method of legal
procedure in such cases does require earnest investi-
gation in order to ascertain whether it to-day still
actually represents that which we desire, that which
we as citizens are in duty bound justified in de-
manding.
My own personal opinion, and I am sure that I
do not stand alone herein, is that in many way s we
do not get from these laws as they are to-da\ what
we ought to have and what we want. This present
writing is undertaken in order to indicate in a gen-
eral way wherein I believe this defect to exist and in
the hope that if a sufficient clan-ior for a change is
raised, such change may ultimately be efliected.
Copyriglit, 1908, by A. R. Elliott Publishing Company
432
JACOBY: PSYCHIATRIC EXPERT EVIDENCE.
[New York
Medical Journal.
In my opinion the prime change needed is an
alteration in the method of giving and taking expert
testimony in our courts.
The aim of every criminal procedure is to answer
the question M^hether the accused is guilty. If there
exists any reasonable doubt as to such guilt, the ver-
dict must be "not guilty."
This verdict of "not guilty" does not, therefore,
without further ado and under all circumstances say
that the accused is in reality not guilty, but that the
guilt has not been proved. For practical life, and espe-
cially so far as the law is concerned, he is then to be
placed on a par with the innocent. This is a demand
of justice and above all of equity and humanity ; but
we see that practically it is perfectly reconcilable
with even the most ideal conception of criminal pro-
cedure that a person who is really guilty may, from
lack of evidence, be acquitted. In so far, therefore,
the task set for a criminal proceeding is by no means
solely the establishment of the truth.
On the other hand, a verdict of "guilty" should be
rendered only if the accused is actually guilty ; to err
is human, but all possible safeguards should be es-
tablished in order to prevent the occurrence of such
an error, and we must strive with all our power
to have only him who is really guilty so pronounced.
Herein the task of the criminal proceeding is at
one with the task of discovering the truth. Inas-
much, however, as it is impossible to say whether a
procedure will end with a verdict of "guilty" or
"not guilty," each individual case must be conducted
from the beginning to the end with but one object —
the ascertainment of the truth. To determine the
truth is the province of the jury ; to point the way to
such determination, the province of the court. From
the contest between prosecution and defense the
truth is to be unraveled, the means at hand for such
disentanglement being the evidence, made up of the
testimony of witnesses and of experts.
Both witnesses and experts serve only one pur-
pose, the elicitation of the truth ; those through truth-
ful evidence of what they have seen, heard, or other-
wise observed ; these by giving their opinion in ac-
cordance with their best knowledge and capability ;
both, no matter how much they may strive to be ac-
curate and truthful, are subject to error, both are
subject to all the influences of human frailty, the
measure of each individual as regards the dcmnnds
which he takes upon himself, his criterion of duty,
etc., being-measurable by no general standard.
It would be a great gain could we select witnesses
in accordance with a certain gauge, but this we can-
not do; we must, as a rule, take. them as we find
them. Not so, however, is it with experts ; these may
be selected. In fact, they are even now selected, but
in an entirely different manner from which I would
have it done. While in a certain sense it is anoma-
lous to speak of witnesses for the prosecution and
witnesses for the defense, inasmuch as all witnesses,
without exception, are supposed to be witnesses for
"the truth, the whole truth, and nothing but the
truth," and should not allow themselves in testifying
to be swayed by the influence which their testimony
may have, one way or another, it is certainly mon-
strous to refer to the experts as an expert for the
prosecution or an expert for the defense.
The expert is in a way the assistant, the aid, of
the court or of the jury ; of course, the ordinary wit-
ness holds, or ought to hold, the same relation, but
the expert does so in quite a special sense. When-
ever there arises a question in regard to things for
the consideration of which the competency of the
jurors, in consequence of the lack of special or tech-
nical knowledge, is inadequate, experts are needed;
where no such extraordinary knowledge is required
the jurors will arrive at the truth by means of their
own faculties, unaided by extraneous elucidation,
without the assistance of experts.-
The expert, whose efificiency also culminates in a
judgment, should, therefore, place himself as far as
possible in the position of a juror, and should draw
himself away as far as possible from the position of
either the prosecution or the defense.
If, then, as already stated, we are able to select
the expert, in contradistinction to the ordinary wit-
ness, whom we must take as we find him, with all de-
fects of mind and character which he happens to
have, we should do this all the more, because it is his
opinion, his judgment, which may be decisive in the
formation of the judgment of the jury, or at any rate
frequently furnishes this verdict with an important
basis. Especially is this so when, in a criminal pro-
ceeding, it is a question of the insanity of an indi-
vidual ; here the matter of opinion stands predomi-
nant, and the value of this opinion will depend much
upon the qualities, educational and otherwise, of the
person giving it.
As already indicated, even to-day a certain selec-
tion of experts takes place, but in such a manner
that the prosecution and the defense enter into direct
competition in order to secure whom they consider
the most available alienist and to obtain his "opin-
ion" for their own side ; of course, always for a fee,
which is rarely a small one.
Against this payment of a fee nothing can be said,
for the physician is certainly entitled to a remunera-
tion for his time, thought, and knowledge, but it
must be clear that the impartiality of expert opinion
would, to say the least, in no wise be affected if the
payment of such remuneration were left to others
than the interested parties. We then have "experts
for the prosecution" upon the one side and "experts
for the defense" upon the other, and it is accepted
that this right to choose and to remunerate an unlim-
ited number of experts -should not be curtailed. Yet
something must be done, if not to curtail, then at
any rate to modify this right, for whereas this com-
petition of the contestants to secure the experts does
guarantee that the most "celebrated" specialists will
appear as acting "personje dramatis" upon the scene,
it does by no means guarantee that the most compe-
tent will be called to this honor ; and when I speak
of competency, I refer not only to scientific attain-
ments, but to that strength of character which will
enable them fearlessly to tread the right road, un-
biased by any attractions whifh ambition may pre-
sent.
Let us be frank with ourselves. Especially in large
cities, the eminence of a specialist is only too often
dependent upon the accidental, upon extraneous fac-
tors which have nothing in common with actual
worth, and is often built up through conditions of
society, so called, which in its turn is supported upoii
a foundation made up chiefly of wealth.
Under such circumstances, what are we to expect
if the accused is, poor? Will these celebrities then
March -. 1908.]
JACOBY: PSYCHIATRIC EXPERT EVIDEXCE.
433
also be obtained to work in his interest? And while
upon no field of justice should the success of either
party be dependent upon money, certainly in the
field of criminal justice the chances of the defense
should not be invalidated by poverty ! This reason
alone should explain why the highest medical au-
thorities call for the abandonment of the present
voluntary experts.
We ought, as a permanent institution, to have a
class of forensic physicians. This institution, w'hich
I am here discussing for psychopathological pur-
poses and which I would premise may be corre-
spondingly developed for all branches of medical
jurisprudence, should, in my opinion, be somewhat
as follows : These physicians are to be public of-
ficials, not city or county, but State officials, so that
they may be as independent as possible of local in-
fluences. The determining factor in their appoint-
ment should be fitness for the specialt}- which they
are to represent. Under no circumstances should
their appointment in any way be determined by po-
litical influences or considerations.
This exclusion of political influences may be ef-
fected by the necessary legal enactments. Most im-
portant, however, would be that these safeguards be
honestly protected. We must elevate ourselves to
a standard which will enable us to realize that there
are certain things which stand so high as to be be-
\ ond the reach of politics, and among these we must
place most prominently the selection of the physi-
cians who are so frequently called upon, by means
of their expert opinion, to exert a strong influence
upon the honor and the life of their fellow citizens.
This choice is not to be made without discrimina-
tion from the general body of physicians, but cer-
tain special qualifications should be legally required.
Firstly, there should be a certain age limit, before
which it is hardly possible to imagine the existence
of the requisite professional and general experi-
ence. Then a special training should be demanded.
This training should start at college with special
courses on legal medicine and legal psychopathol-
og\-, should be followed by clinical psychiatric
work in a State hospital, and terminated with a spe-
cial examination by the State Board of Medical
Examiners. The bestowal of a special degree of
■■physician to the courts," by this board, after proper
examination, would ensure the necessar\- addition
to the curriculum by the colleges, and the acquisi-
tion of the necessary knowledge bv the candidates.
The appointment would then be made hy the
State from the number of successful candidates and
should be a life pt)sition.
The physician to the courts is obliged at call of
the court to give to the court an expert written opin-
ion, and later an expert verbal opinion before the
jury • this, however, is, I repeat, onl\- to be done
upon request of the court. In the composition of
this' opinion the exf)ert is neither to receive or ac-
cept instructions from any one : his responsibility
is one which must lie between himself and his own
conscience. He should not be prohibited from giv-
ing an opinion at privafe request and for private
use, but should be permitted to give an expert opin-
ion for judicial purposes, and to testify in court
only upon call of the court itself. Hereby the
physician to the courts 'will be as little an organ for
the defense as a creature of the district attorney.
This is the only manner in which the absolute im-
partiality and the authoritative respect due to the
purposes of such an institution can be maintained.
For every piece of work which the physician to
the courts does upon call of the courts he should re-
ceive a remuneration apportioned in accordance
with the difficulties of the individual case and the
length of time which he has devoted to its con-
sideration. In addition hereto he should be allowed
to occupy a teaching position and to carry on a med-
ical practice in the same manner as is permitted ev-
er}- physician.
By such or similar means will we 'develop a body
of neurological and psychiatric experts who are so
in the true sense of the w^ord.
The regulation and supervision of this institution
of physician to the courts would, in my opinion, de-
volve primarily upon the State. Whatever super-
vision be exercised, the supervising body must by
law have the power to render its supervision an
active one.
So much about the physicians to the courts, as
such. From their number then the court shall, upon
motion, or upon its own initiative, select and ap-
point the experts for each individual case, it, of
course, being the province of the court in any spe-
cial case to appoint as expert any other physician it
may desire. Capable judges are competent in any
case to say whether the court requires the testimony
of experts for its own information, or for the en-
lightenment of the jury, and also to say who shall
be summoned for this expertness.
The expert being appointed, all material which
may be of even remote use to him in the formation
of a relevant opinion should be placed at his dis-
posal. Only from the entirety of the case can he
form an opinion of value. Particularly in questions
concerning the mental condition of a person may
circumstances which appear irrelevant to a non-.
medical man be of the greatest importance. Par-
ticularly regrettable would be any opposition on the
part of the district attorney to the consideration of
evidence, for instance, communications which the
accused has made to a third party, even where he
has the right to object, sim.ply because he believes
or fears that such evidence would be of injury to
the prosecution.
While it is perfectly true that the relation of the
defense to the prosecution is that of antagonism,
and that, therefore, each side should and must fol-
low out its individual aim, yet this antagonism on
the part of the prosecution should not be overag-
gressive. for the aim of the prosecution should not
be the desire to convict, but the discovery of the
truth, the determination of guilt.
It should, therefore, be the duty of the public
prosecutor to allow to be brought to light, yes, even
himself to bring to light, each and every circum-
stance which may in an}- way be of service in de-
termining the mental condition of the accused, with-
out regard to whether these appear to be of service
to the prosecution or to the defense. And. further-
more, it should be the province of the court in case
either side for one reason or another is dilatory in
434
JACOBY.
PSYCHIATRIC EXPERT EV-IDENCE.
[New Vork
Medical Journal.
this direction, to take upon itself the steps neces-
sary toward bringing out the circumstances which
are being concealed or obscured.
For the determination of the mental condition of
a person all his acts of commission or omission, his
conduct, his mode of life, what he has said, and
what he has not said, may be of importance.
]\Ian is an entity. Our comprehension of him will
be based upon his development up to the moment of
the act which stands in judgment, his personality
during the act and immediately after the act, and
also upon his life in its subsequent course and his
deportment during the investigation. For all this
is part of him ; all serves for the recognition of his
being. The act is a product of his personality ; after
the act this personality does not lose its entity ; the
person after the act is no other than the person be-
fore the act. To attribute such significance to the
act, as to be willing to say: "Everything that was
done, said, etc., by him before, during, and imme-
diately after the act, may be admitted in evidence,
but everything that occurred subsequently is. so far
as possible, to be excluded," is an arbitrary, an un-
scientific, and an unmedical conception.
The science of medicine cannot be other in a
court of law than it is in a sick room, and, there-
fore, the law must conform to the teachings of sci-
ence. If, for instance, the accused, while in prison
has had various conversations with the j^hysicians.
all these conversations may be of significance, and
it would not be right to admit, let us say, the three
first conversations in evidence and not the others ;
but it may be objected, the accused, who knows the
purpose of the conversation, dissembles, simulates,
lies, etc., in order to- influence and deceive the ob-
server in his favor. True, this may all be so; but
all without exception, even the fact of simulation,
assuming this in a given case to be a fact, serves
also for the determination of the being, of the men-
tal state of the accused.
Scientifically there exists no reason why the en-
tire life of the accused after the act should not be
admitted as evidence, without hmitation. Just as the
]5hysician must consider the life before the deed, all
individual occurrences before the act, so he must
do the same for the life, for the details after the
deed. And as the physician must do this in order
to arrive at a relevant opinion, so the jury should
be permitted to do the same in order to enable it to
arrive at a relevant verdict.
The more complete the picture of the accused
which can be unfolded to the physicians, the better
will it be for the performance of their task, and the
court proceedings should be such as to enable them
as far as possible to attain this end.
Allowing that the expert should have at his
disposal the greatest possible knowledge of the
entire case material, in order to be able to
give his expert opinion with the greatest possible
relevancy, then he should also be permitted to give
his opinion as an entity, as a whole. This expert
opinion is a scientific achievement, a decision de-
I)endent upon so and so many conclusions from so
and so many circumstances and particulars of all
kind.
The highest scientific demands may be made upon
the expert, but no obstacles to the production of sci-
entific work must be placed in his \va}-. Above all,
I would demand that he be allowed to deliver his
expert opinion quietly and connectedly. Every sci-
entist, artist, or technician in whatsoever field he
may be active, if his opinion is desired upon any
complicated or difficult matter, would consider it
selfevident that he be allowed to expound his opin-
ion in Jiis own manner, as he is best able to make
it clear to his atidience, and that he be given unin-
terrupted audition. Or if this consideration can-
not be given him, he would decline the imputed
honor ; this he owes to the individualit\' and thor-
oughness of science.
Why should the psychiatrist, in this regard, be
treated difl^erently in a court of justice than every
other scientist is treated outside of the court room ;
and that he is so treated, no one can deny. Often
true equilibristic performances are demanded of
him; not three word? is he allowed to speak with-
out being interrupted by one side or the other, and
questions are all propounded to him piecemeal.
Surely, in this W2.y nothing sensible can be pro-
duced. \\'ere it not, so to say, a special duty, to
serve the courts with expert opinion in cases of
criminal actions, no conscientious and selfrespecting"
psychiatrist could be found who would be willing to
oarticipate in such an "obstacle race." And what
is the practical result of such proceedings? The
expert finally has said all that he wants, or is al-
lowed, to say, in a fragmentary manner, amid end-
less interruptions and deviations, and frequently
amid personal explanations of the most undesirable
nature. Therefore, that much is attained, that he
is unable to expound his opinion in the proper man-
ner, and that the jury has the greatest difficulty in
forging anything serviceable out of this scrap heap.
In this wav the most simple matter may be com-
plicated in a most unwarrantable manner.
Instead of serving the truth, we are strewing sand
in each other's eyes. I can see no reason why the ex-
pert, after having been sworn and after g:iving his
qualifications, should not be asked and allowed to
expound his opinion of the case in continuity. He is
supposed to have been present during the entire trial
before the jury, and, therefore, should be perfectly
conversant with the subject matter of the action ; he
can, therefore, of himself, without outside aid, give
a clear expose of his opinion. If there are special
points, the understanding of which cannot be ex-
pected of a nonjurist, tiiere can be no objection to
the necessary instrnoticm being given. W'e want the
truth, we ask him openly and honestly, we explain
to him freely and directly the special juristic diffi-
culties, and then he will answer just as openly and
honestly, just as freely and directly.
After the expert has finished his exposition in con-
tinuity, there probably will yet remain something
upon 'which the defense, the prosecution, and per-
haps the court or the jury will, from their point of
view, require amplification, explanation or correc-
tion. Let each one iioic ask the questions which he
would like answered. Herein, what is a matter of
course for the court and Ihe jury applies equally to
prosecution and defense, namelv, that the questions
be put simply and honestly with the expressed pur-
pose of arriving at a better understanding of the
truth, and that all 1)\ thought and hidden design —
March 7, 190S.J
JACOBV: PSYCHIATRIC EXPERT El'IDES'CE.
435
technical sophistries for the purpose of confusing the
expert — be foregone.
It should not be attempted to make use of the ex-
pert in order to show that black is white, or that the
one side is the better and the other the worse. Ques-
tions of mental disorder, especially those relating to
borderline states, are in themselves difficult enough
to understand and explain ; it is not at all necessary
that the subject matter be in addition artificially con-
fused and obscured.
Especiall}- do I believe that the hypothetical form
of question is. in general, unnecessary. It is not dif-
ficult to deduce, from a correct expert opinion, upon
what asserted facts or circumstances it is based,
either as a whole or in part. The confirmation of
the facts or considerations is a matter for the jury,
and is, by implication, contained in their verdict.
The expert opinion preceding the verdict, the con-
firmation of the facts, is, in so far as the expert opin-
ion is concerned, of course only hypothesis.
Wherever a misunderstanding may be possible,
this hypothetical character may be emphasized in the
form which is given to the opinion. But to attach
the entire opinion directly to a hypothetical question
does not always make for clarity. Certainly the
question should never be given a monstrous form.
I desire now to refer to another aspect regarding
the delivery of the opinion by the expert. It is nat
only to be given coherently, in continuity, but also
in language which may be commonly understood.
Technical terms, as are used in professional inter-
course among physicians, and which are not under-
stood by the average nonphysician. should not be
used. The psychiatrist is to use simple expressions
and explanations : so far as possible he is to say what
he has to say in plain English, and wherever this is
not possible he must explain his terms without first
being asked to do so. The better qualified, profes-
sionally and generally, the expert, the easier will it
be for him to develop his ideas in simple language,
so that every one with ordinary knowledge and in-
telligence can follow and understand him. A most
peculiar impression is certainly made when, without
rhyme or reason, difficult Greek terms are employed,
in reference to which, then, questions and responses
arise, as in a schoolroom ; again a new means of dis-
traction, of confusion — ostensibly, of course, one of
enlightenment. For an accurate expert opinion it
is furthermore necessary that the expert confine him-
self to such psychopathological exposition as is re-
quired by the case under consideration, and here
allow the essential to stand out prominently. Yet
liow often do we witness an expert going through
almost the ientire field of insanity, with references to
all possible and impossible allied forms of disorder.
This should not be. And this will be avoided, if.
in accordance with the demands already made, the
psychiatric expert be reallv treated as a man of sci-
ence and be allowed to solve his task coherently and
Avithout interruption.
Then he can and will of himself keep to the point
and. endeavor to instruct the jury in simple, inartifi-
cial, truthful manner, instead of blinding them with
sophistical fireworks.
The ideal in expert testimony would be still more
approximated if the expert, at as early a stage in
the proceedings as possible, was permitted the great-
est possible insight into the details and entirety of
the case ; which means that he be not drawn into the
case, as is now done, just at, or shortly before, the
trial itself. The proceedings before the jury are
certainly the essential, but no lawyer, whether he be
for the prosecution or for the defense, and no court
would show any special predilection for occupying
themselves with the case only when the proceedings
before the jury are begun.
The earlier the stage at which the expert ap-
proaches the case, the deeper will be his understand-
ings of it, and the sooner will he become equal to the
task which has been set for him. For this reason, in
every case in which there is a question of mental
disorder, the expert should be called in from the very
beginning. Time spent by him in his own study an.l
in the cell of the accused will be well applied, and
when, thus fortified, he is present at the trial itself,
he will be able in a brief exposition to furnish the
best that could be demanded of a medical expert, and
will be able to instrtict the jury with the greatest
imaginable certainty. In all cases in which it is a
question of the insanity of the accused, not only at
the time of the proceedings, but particularly at the
time of the commission of the deed, it would be of
great importance, not only to have him examined b\
a commission aided by experts, but, in the interest of
personal liberty and acceleration of the proceedings,
to commit him for observation during a limited time
into an insane asylum. In clear cases this would not
be necessary, in doubtful ones, however, of inestima-
ble value.
The scientifically organized and medicalh super-
vised insane asyhmi is the only proper place for such
observation. That, of course, a State asylum is the
only one which could here be considered, must from
the nature of the proceedings be clear. The m^aximum
time of internement for the purpose of observation
could in each case be determined b>- the court : yet a
general maximum which should not be transgressed,
say, perhaps six weeks, which would, in mv opinion,
be ample even in the most difficult cases, could be
established by law. Yes, it is even a question in my
mind whether such internement could not be permis-
sible even before the findings of the grand jury —
that is, before any formal indictment has taken place.
The results of such observation might then occasion-
ally be such that the grand jury would decline to
indict. Then the mental rack of the proceedings
could be spared the patient, treatment be started ear-
lier, his rights of citizenship sooner safeguarded, his
family protected against unspeakable suff'ering. and
last, but not least, the mass of sensation lusting mem-
bers of "society" be robbed of one victim of their
ignoble curiosity.
I have already said what seems to me to be a self-
evident truth, that a surplus of experts acts as an in-
jury to a case. From the moment that the people
have gained actual confidence in the experts them-
selves and in their mode of action in criminal cases,
and have accustomed themselves to look upon and
to appreciate the expert as a leader toward truth,
then the endeavor of the parties to have as many ex-
perts as possible will cease of itself. More attention
will be given to the qualities of the experts than to
their number. The law already to-day empowers the
court to reject superfluous evidence. If the expert
436
J AC O BY: PSYCHIATRIC EXPERT EVIDENCE.
[New York
Medicai, Journal,
system as I have expounded it is once established
and employed, the judge will, even less than at pres-
ent, have any reason to fear that, through the rejec-
tion of such superfluous expert testimony, the pro-
ceedings may be successfully attacked. And what I
have said here about the rejection of superfluous ex-
perts applies also to the rejection of superfluous
questions asked of the experts. If the expert has
given his opinion coherently and exhaustively, and
has supplemented it, so far as necessary, by answers
to the questions asked by the two sides, by the judge,
and by the jury, he can, with a clear conscience, de-
cline to answer any further questions, and the judge
will support him in this refusal, in order that the
court procedure be not turned into a farce. But, as
stated, it is my firm conviction that no side with any
selfrespect will endeavor, by means of unnecessary
questioning, to make a caricature of a serious scien-
tific opinion, which has done justice to all of the cir-
cumstances bearing upon the case. Far be it from
my desire to unwarrantably limit the right and duty
of questioning and cross questioning. I desire only
that the misuse of this right and duty be opposed,
opposed not only in open court in each individual
case, but as a matter of principle through public
opinion. All of which clearly appears justified by
the fact that the refusal by the court to allow really
immaterial questions can in no wise be considered
among the causes for appeal. Herein, therefore, no
change of the existing law is in any way required.
It is merely a question of the manner of admin-
istration. On the other hand, I would lay stress
upon the following innovation. At any stage of a
criminal procedure, the court, whether upon motion
of either side or upon its own initiative, should be
permitted to appoint one or more experts. In which
case the prosecution, regarding its task as it should
be regarded, viz., the ascertainment of the truth,
would very rarely feel called upon to introduce ad-
ditional experts. The defense also will, in the ma-
jority of cases, relying upon the personality, capa-
bility, and integrity of the expert appointed by the
court, be content with such appointment, knowing
full well that its own interests will be completely
])rotected.
I do not conceal from myself that this proposi-
tion will in the beginning meet with manifold ener-
getic opposition. This opposition is voiced by a
judge of . the Supreme Court of New York with
the words: "This idea of official witnesses is total-
ly opposed to all ideas of American and English
jurisprudence. It would be a departure in a di-
rection contrary to the spirit that has given rise to
our free institutions. It may be an improvement,
but it is radically different; and we should consider
that before we determine as to what is the true so-
lution of the problem."
But this proposal tends toward placing the ex-
perts in every way above party lines ; it is directly
interwoven with the high conception which we all
have of the duties of an expert, and which I should
like to see adopted and practically carried out, even
"if the ideas of American and English jurispru-
dence" must adapt themselves to the progress of
the times.
When the experts make such high demands upon
themselves and the people will have accustomed
themselves to see in the expert the real scientific ex-
pert, instead of the medical counsel for the defense
or for the prosecution, then this proposition will
lose all appearance of doubtfulness, and then v^rill,
as I hope, the appointment of the expert by the
court, whether upon motion of the prosecution or
of the defense, or upon its own initiative, become the
rule.
Not one of the least important advantages which
such a procedure would carry with it would be that
the most capable experts would be available, even
in proceedings against the poor and the destitute.
I would advocate still one more change in our ex-
isting criminal law, which, as it now stands, reacts
deleteriously upon our entire expert system. I re-
fer to the part of our penal code, derived from the
old English law, which still exists among us, but
which certain States of the Union, especially certain
New England States, have long ago altered. This
is our right and wrong test of insanity. As is well
known our penal code requires for the irresponsibil-
ity of the accused such a defect of reason that the
accused, in consequence of this defect, at the time
of the execution of the act, did not know the nature
or quality of the act he was doing, or did not know
that the act was wrong. According to this no other
state of mental disorder suffices for the assumption
of irresponsibility. But this is one sided and by no
manner of means just toward the requirements of
medical science.
Scarcely any textbook of insanity, no matter in
what country it is published, can be opened without
finding therein, as a clear and indisputable, practi-
cally proved fact, that there exist a certain number
of mental disorders in which the intellect is not so
influenced that the patient did not know the nature
or the quality of his acts, or did not know what was
right and what was wrong, but in which, neverthe-
less— in full knowledge of the nature of his action
or of the wrongfulness of the act — on account of
a pathologically altered will or emotion, he was not
able to conform his actions to the dictates of his in-
tellect ; in other words, that it is not the knowledge
of the nature of the act or of the right or of the
wrong — in relation to the concrete act — that it is
not the intellect which is of decisive importance, but
much more the question whether the person, in con-
sequence of pathological disorder, was limited or
inhibited in the use of his will.
Most nations have since a long time so altered
their criminal law that it now conforms to this fact
of medical science ; only not in England and in .sin-
gle states of English law. Our New York law has,
up to the present time, in opposition to all scientific
progress, held on to this peculiarity of the old Eng-
lish law ; therefore, to-day, still possesses antiquated
English law. Every expert in insanity, lawyer or
physician, knows this to be a fact. Yet what is the
result of the application of this law in our criminal
proceedings ?
If the accused at the time of the commission of
the act was disordered in intellect to such an ex-
lent that he could not recognize the nature of his
act, or could not distinguish between right and
wrong in relation to it, then, of course, according to
our law, the expert encounters no difficulty what-
soever. He simply gives his opinion that the ac-
ARMSTRONG: CARE OF CONVALESCENTS.
437
cused, as a result of his disease, was unable to rec-
ognize the nature of his act and could not distin-
guish between right and wrong.
But how about the other cases in which the pa-
tient is able to recognize the nature of his acts, and
is able to distinguish between right and wrong, yet
in consequence of disease is deprived of his freedom
of will and thus is prevented to act accordingly?
Here, then, the conscientious expert must declare it
as his opinion that the accused, who, under the in-
fluence of a disordered mind, was deprived of his
freedom of decision, is, in the sense of the law, not
insane. For the honest scientist truly a position
which could not be worse. Under such conditions
the temptations for some may be strong, by means
of subterfuges, by means of all kinds of dissertation
upon all possible and impossible forms of insanity
and symptoms, to rescue justice from the hardship
of the law.
It has seemed to me necessary to go into this
question on account of the close relationship which
exists between it and the attitude of the expert in
court.
In conclusion I would say that my essay upon the
system of expert evidence in criminal proceedings
by no means seeks to introduce a doubtful or dan-
gerous experiment into our legal life. The recom-
mendations here made are those which, in other
places, so particularly in Germany, are in action,
are in accordance with general conviction of the
people, and have proven themselves worthy.
They could be organically woven into our crim-
inal proceedings without creating any difficulty or
causing any disturbance. Thus, the privileges of
the judge would be somewhat extended, but the
fundamental law which governs our courts, that the
trial of the case belongs to the opposing parties,
while only the general direction lies with the court,
would be little, certainly not materially, interfered
with ; nor can I see that, that "nolc me tangere" of
the lawyers, "the law of evidence," is in any way
hereby afifected.
44 West Seventy-second Street.
THE NEED OF CARE FOR THE CONVALESCENT
FROM THE HOSPITAL STANDPOINT.*
By S. T. Armstrong, M. D.,
New York.
In 1899 the surgeon in charge of a general hospi-
tal in Manila deemed it inadvisable to have his con-
valescent soldiers eat their meals in the wards, and
in conformity with military procedure forwarded a
request to the commanding general for authority to
have a messhall constructed. The request was re-
turned disapproved, with the endorsement that sol-
diers who were well enough to go to a messhall were
well enough to be out on the firing line. The gen-
eral's attitude jinpresses one as harsh, unnecessary,
and subject to cohdemnation ; and yet the attitude of
many hospitals||Oithe convalescent is similar, though
it is true that ^§ motives that prompted the general
referred to were not the same as those that have op-
•Read before the Section in Public Health, New York Academy of
Medicine, January 14, 1908.
erated in civil hospitals, because the latter have had
to provide the greatest amount of relief to the great-
est number, and the convalescent has had to be dis-
charged to make room for the acutely ill or for
those in need of operative interference.
In many ways a hospital is a manufactory of
health, a repair shop for mankind ; and like all man-
ufacturing establishments its efficiency is based on a
complexity of organization that has carefully con-
sidered the relation of means to ends in accordance
with the class of patients treated. But, unlike a fac-
tory in which certain mechanical, physical, or chem-
ical procedures will entail certain definite products, a
hospital cannot by certain similar procedures, in ap-
parently similar morbid conditions, produce health.
Many patients attain a normal condition in an aver-
age time, but there are others afifected by similar
diseases who, at the expiration of the average time,
are only more or less advanced in convalescence.
Such patients cannot well be kept, until they have
regained their health, in a hospital intended for an
acute service, without detriment to the purposes of
the institution and to their own convalescence.
Many centuries ago Plato submitted the postulate
■'that in all well ordered states every individual has
an occupation to which he must attend, and has
therefore no leisure to spend in continually being ill.
This we remark in the case of the artisan, but, ludi-
crously enough, do not apply the same rule to peo-
ple of the richer sort." He goes on to say that
"when a carpenter is ill he asks the physician for a
rough and ready cure ; an emetic or a purge or a
cautery or the knife — these are his remedies. And
if some one prescribes for him a course of dietetics,
and tells him that he must swathe and swaddle his
head, and all that sort of thing, he replies at once
that he has no time to be ill, and that he sees no
good in a life which is spent in nursing his disease
to the neglect of his customary employment ; and
therefore bidding good bye to this sort of physician,
he resumes his ordinary habits, and either gets well
and lives and does his business, or, if his constitu-
tion fails, he dies, and has no more trouble."
While the hospital stafif may not ahvavs keep in
mind that their poor patients have no time to be sick,
in general most measures are adopted that w^ill carry
the patient as expeditiously as possible through to
convalescence. Then the patient is discharged to his
home, or permitted to continue in the ward, with such
cursory supervision as seems advisable until he asks
for his discharge, or it is apparent that he has re-
gained his usual efficiency, or it is evident that the
latter cannot be regained. Either of these latter
methods is inadvisable and uneconomic. To send a
convalescent patient home is to relegate him fre-
quently to an undesirable environment, to inadequate
or improper food supply, to the ministration of in-
judicious relatives or friends, to premature work to
earn his support, and each or all of these in the con-
dition of lessened resistance associated with conva-
lescence may divert the latter into a state of perma-
nent invalidism.
To keep such a patient in a hospital intended for
acute diseases is an unnecessary tax on the higher
per diem cost of maintenance in such an institution,
and deprives the patient of those measures of hydro-
therapy, mechanicotherapy. electrotherapy, and aero-
438
.IRMSTRONG: CJRE OF CONI 'ALESCEXTS.
[New York
Medical Journal.
therapy which should be particular features of hos-
pita|« for the care of convalescents and which are
rarely available in general hospitals.
In 1904 the Census Bureau made an important in-
vesti.2:ation of the hospitals in the United States and
found ^.at there were 220 public, 831 private, and
442 ecclesiastical institutions, a total of 1,493 hospi-
tals. At an expense of $28,200,869 these hospitals
treated 1.064,512 patients, of whom 71,530 were in
the hospitals at the end of the year, and therefore
992,982 patients were discharged or died. How
many of these patients were discharged in a state in
which they needed further treatment? The percent-
age may be approximated from the experiences of
Bellevue and Allied Hospitals, which in 1906 dis-
charged 31,334 patients, of whom 13,825. or 44.1
per cent., were discharged improved; that is, they
were not in a condition to resume their usual avoca-
tions.
If, from necessity, they did resume their custom-
ary work, it was done with a more or less impaired
physique, and consequently with proportional dimi-
nution in efficiency. Let it be granted that the four
city hospitals referred to have an exceptional clien-
tele in the destitute poor of New York Cit\-, th?t all
other hospitals transfer t'.i them tb.ose jjatients whosj
diseases entail prolonged convalescence or are in-
curable, and that in turn Bellevue and Allied Hospi-
tals pass these patients on to the hospitals of the De-
partment of Charities, still it is believed to be a mod-
erate statement that more than thirty per cent, of the
patients discharged from hospitals in this country
are in need of further treatment. This would mean
that in 1904 about 300.000 patients had to be dis-
charged who needed hospital care longer.
Great Britain, France, Germany, and Switzerland
have recognized the imi)()rtance of the transfer of
convalescent patients from city to country hospitals.
Indeed, in Great Britain there are 278 such institu-
tions, and thirteen of the London hospitals have their
own convalescent homes. In this country there is
a good example in the .Massachusetts General Hos-
pital, which has 2()i l)e(ls. and which established in
1882, at Waverly, a convalescent home containing
thirty-one beds, at a cost of $50,000. These institu-
tions should give a fair idea of what such a home
may accomplish. In 1906 the hospital treated 5,075
and the home 519 patients ; the average number of
patients in the hospital was 272 and in the home
2j: the average nnmln r <if davs each patient was in
the hospital was i^.d, and in the home was 16.2. A
little more than ten per cent, of the patients were
sent to the convalescent home, and the latter was not
used to its full capacity.
English hospitals find greater need for this con-
valescent relief. The East London Hospital for
Children, having 109 beds and treating 1,587 pa-
tients, has the Princess Mary Convalescent Home
with twenty-eight beds, and treated 317 patients.
The French Hospital, that has seventy beds and
trealed 790 patients, has a convalescent home at
Brighton with sixteen beds, and treated 180 patients.
Victoria Hospital for Children, with 104 beds and
treating 962 jiatients, has a convalescent home at
Broadstairs with fifty beds and treated 663 patients.
Middlesex Hospital has 343 beds and treated 3.147
patient>^. and its convalescent home at the seashore
has sixty-one beds and treated 878 patients. Char-
ing Cross Hospital, with 187 beds and 2,465 patients
treated, has a convalescent home of fifty beds, which
treated 470 patients. These figures might be con-
tinued and would show an accommodation of about
twenty per cent, of the hospital population. And it
is believed that the nuinber that would be helped
would be greater if it were not for the question of
finance.
From the cost of administration standpoint it is
materially more advantageous to provide convales-
cent hospitals. In the latter the cost per patient in
Great Britain is about one half of what it is in a
general hospital ; and in the ^Massachusetts General
Hospital, while the per diem cost in 1906 was $2,062.
it was $1,302 in the convalescent home.
From the standpoint of cost of construction, while
the urban hospital of the present day type will cost
from $3,000 to $5,000 a bed, the convalescent hospi-
tal can well be built at a cost of from $1,000 to
$1,500 a bed.
One of the greatest difficulties that would be met
with in applying the principle of treatment in a con-
valescent hospital to patients whose preliminary
treatment was in a general hospital would be the op-
position of the patient or of his relatives and friends
to his transfer. The administration of the institu-
tion would be subjected to political, financial, social,
and other pressure to exempt certain patients from
the application of the rule. There should be in a
free hospital a nurse in charge of convalescent relief
work who should visit each new patient admitted to
the hospital, and by tactful int|uiry she should learn
the general situation of the individual, and whether
there were dependents left at home who should be
looked after b>- some organization or volunteer
worker. Her professional training and knowledge
of the methods of the visiting physician or surgeon
would indicate those who should be transferred to
the convalescent hospital, and she should represent
to them the advantages in ultimate and perhaps com -
plete cure that would lie gained by a sojourn in such
an institution.
Establishments for convalesi^nts should be located
in accessible places that could be reached by a mini-
mum expenditure for car fare, and that would not
exhaust the patient by fatigue when transferred.
Reasonable provision should be made for the care of
those not distinctly convalescents, but who are de-
pendent on the patient, as in the case of mother and
child.
The following conclusions are submitted :
r. The purpose of hospital treatment should be to
further as expeditiously as possible the return of the
patient to a condition of physical efficiency.
2. Proper hospital treatment for convalescent.^
should be provided to accomplish this end.
3. For economic reasons the treatment of conva-
lescence should be separated from that of acute con-
ditions. But for the same reasons a hospital for
convalescents may be associated witk, one to treat
chronic diseases. rf''»^
4. Crban accommodation for conWUv'^cents is im-
practicable and undesirable, and ac'c*«^SKble suburban
sites should be selected to locate ho<;pitals for con-
valescents.
5. Convalescent hospitals should be constructed at
March 7, 1908.)
IVOLBARST: PROSTATE AXD GOXORRHCEA.
439
moderate cost ; they should provide for patients hke-
ly to require a long as well as a short duration of
convalescence: they should be equipped with all ap-
paratus that will further restoration of tissues and
organs to normal ; the patients should be subjected
to proper medical 'supervision.
6. A committee or society to advocate convales-
cent hospitals should be formed to cooperate with a
charity organization society, or association for im-
proving the condition of the poor, or State board of
charities. Such a society in England has accom-
plished good results.
144 East Thirty-seventh Street.
A BRIEF STUDY OF THE PROSTATE WITH
REFERENCE TO THE CURABILITY OF
GONORRHCEA.*
BV L. WOLBARST. M. D..
New York,
Attending Genitourinary Surgeon. Beth Israel Hospital and West
Side German Dispensaries; Professor of Genitourinary Dis-
eases, New York School of Clinical Medicine.
It is surely not necessary at this late date to quote
from the extensive literature on the subject, in order
to demonstrate that the crucial point in any discus-
sion of the curability of gonorrhoea in the male, is
to be found in the presence or absence of gonococci
in the prostate and its annexa. Experience has
taught us that the genital portion of the genitouri-
narv tract is the most resistant to treatment, and the
last part of the afYected region to recover. It. there-
fore, goes without saying that although the urethra
proper may be entirely cured of the gonorrhoeal
process, the prostate and annexa may still be in-
fected, and that from time to time outbreaks will
occur which owe their being to the latent gonococci
which have not been dislodged by treatment, from
their deep seated hiding places in the prostate and
vesicles.
That the gonococcus may remain dormant in the
prostate and aw^aken months and even years after
the initial infection, has been clearly shown by the
studies pf too many careful observers to admit of
anv serious doubt. Nevertheless, in spite of this
well known fact, and perhaps, just because it is so
plainlv obvious, comparatively slight attention is
usually paid to this subject in actual practice, ant!
it is the purpose of this brief paper to direct atten-
tion to this oft neglected but highly important ele-
ment in the study of gonorrhoea.
We must confess that all of us are not yet alto-
gether agreed on what constitutes a cure in gon-
orrhoea. We have on the one hand the busy general
practitioner, always glad to get rid of his "clap"
cases, and who discharges his patients as soon as the
urine becomes clear and there is no discharge at the
meatus: on the other hand we have the philistinic
specialist who goes to the other extreme and cries
at every breath "once gonococci. alwavs gonococci.''
These men represent the gre^t divergence of opin-
ion which characterizes medical men in the matter
of the curability of male gonorrhoea. The one man
declares that a "clap" is nothing w^orse than a slight
•Read before the .American Urological Association, at Atlantic
Citv. T.n.e 1907.
cold, and is just as easily cured : the man at the other
extreme regards gonorrhoea as a hopelessly incur-
able disease. Who* is right?
It is certainly true that many cases of gonorrhoea
do get well in remarkably short time, with or with-
out treatment, and often in spite of treatment. It is
also true that a considerable number of men who
have been infected with the gonococcus. never get
rid of their disease entirely. So that both extrem-
ists may justify their attitude in the light of experi-
ence. Mv personal preference is to take the happy
medium and say that although gonorrhoea in the
male is often cured entirely, and sometimes spon-
taneously, it very often remains uncured, in spite
of the most enlightened and skilful treatment ob-
tainable. And I would furthermore declare no case
cured until the infectious element, the gonococcus.
has been entirely eliminated from every portion of
the genitourinary tract. So long as a single living
gonococcus remains hidden in any part of this tract
the patient is in danger of an outbreak of his old dis-
ease months or even years after all traces of his or-
iginal attack have passed ofif.
It i? customary \vith many practitioners to exam-
ine the freshly passed urine of a patient seeking a
verdict of "cured," and if it appears clear and spark-
ling, and if in addition they find no gonococci in it.
they send the man on his way home rejoicing that
he is well and cured. Yet I believe it is more than
probable that every man who has had a posterior in-
fection, even if his urine is clear as crystal, has a
prostate that is to a greater or less degree choked
up with gonococci, ready at any moment to spring
into activity and demonstrate their presence by un-
mistakable symptoms.
Several years ago my attention was attracted to a
large number of cases of chronic and recurrent gon-
orrhoea that came under my notice, all of them pre-
senting a common trinity of symptoms, a slight or
moderate discharge, especially in the morning, a
large and tender prostate, and a history of frequent
recurrences under excesses of venery and drink.
^Microscopical examination of the urine or discharge
often showed the utter absence of gonococci. but
with very few exceptions, the massaged urine or.
better still, the expressed secretion of the prostate
nearly ahcays showed the presence of gonococci.
This observation led to a detailed study of fiftv-five
cases and they furnish convincing proof to my mind,
if such proof were necessary, that it is the deep
seated gonococci in the prostate and vesicles that
we have to get rid of before we can hope for a
lasting cure of gonorrhoea. .A. few tvpical cases
will illustrate this point very nicely.
Case I. — L. W., aged thirty-one. clothing cutter, married
two weeks. Appeared for treatment January 20, 1906. pre-
senting a moderate urethral discharge, and complaining of
some pain on micturition of about three days standing.
Positively denied extramarital relations since his marriage,
and for a period of two months before that event. Could
not in any way account for the outbreak, except that such
outbreaks were quite customary with him.
Previous History : First attack of gonorrhcea took place
about ten years ago. when he was treated and pronounced
cured. This attack had been followed with strict and pain-
ful regularity every six or eight months since by an ap-
parently fresh attack, which subsided under local treat-
ment. He could recall about fifteen distinct attacks. Treat-
ment was always directed to the anterior urethra exclu-
sively; his prostate was never examined or treated.
440
WOLBARST: PROSTATE AND GONORRHCEA.
[New Vork
Medical Journal.
Examination : The discharge contained pus and epi-
thelial cells, numerous gonococci (gram negative). First
urine passed was cloud}-, with pus and many shreds ; second
urine, clear ; massaged urine was ' very cloudy. Micro-
scopically, the first urine contained few gonococci ; second
urine none : massaged urine very many. The irrigation
test sliowed the presence of posterior urethritis. The
prostate was fairly large and tender to the touch. Vesicles
the same. No stricture appreciable.
Subsequent History : Under local and internal treatment
the discharge quickly subsided and disappeared, the urine
cleared up w ithin ten days, and the freshly passed morning
urine showed the complete absence of gonococci. On Feb-
ruary 2d the patient expressed himself as feeling entirely
cured. With the present study in mind, I had him call
early the next morning, and he passed two ounces of over
night urine in a sterile flask (glass i). This was per-
fectly clear; I then massaged his prostate and vesicles
vigorously, and he passed two ounces of very cloudy urine
in another flask (glass 2). Microscopical examination of
the .urine gave this result: Glass i, negative as to gono-
cocci ; glass 2, positive ; also much pus and epithelia. These
examinations were made at intervals of three or four days
for three weeks with the same result: Glass i, negative;
glass 2, positive. Meanwhile treatment was continually
■being directed to the prostate and vesicles, with the result
that in April (nearly four months after treatment was be-
■gun) the massaged secretion for the first time gave a nega-
tive rcMih. Thereafter the result wavered from negative
to positive and vice \ersa. until a month later (May) I
succeeded in getting seven consecutive negative results, at
intervals of one week.
The man has. resumed his marital relations, he drinks
as usual, and has had no recurrence of his old attacks. Once
a month he comes for examination, and throughout the
entire year I have been unable to discover any gonococci
in the massaged urines or in the expressed secretion from
the prostate. I consider this man cured.
Case II.— ^A. A. A., cigarmaker, age twenty-three, un-
married, presented himself for treatment on May I, 1906,
with a moderate discharge, and symptoms of chronic
cystitis. Duration one year. First attack was treated by
various physicians, but never declared cured. Prostate
was ne\-er examined or treated.
Fxaniination : The discharge contained gonococci (gram
negative) in moderate amount. Urine passed in three
glasses were all cloud\-. and all contained gonococci. Ex-
aminatinn made the next day by the writer's three glass
catheter te>t' re\ealed an anteroposterior urethritis and
chronic cystitis. Prostate large, hard, and tender in cer-
tain spots. Vesicles moderately congested. No stricture
ai)preciable.
Subsequent History: After two months of treatment
directed at the bladder, prostate, and \csicles, the urine
became qu.ite clear, but not entirely free from shreds and
mucus. A series of examinations similar to that described
in Case I was gone through, with the same result, viz.,
the morning urine passed by the patient was free from
gonococci ; the prostatic secretion contained numerous
gonococci.
This man has been under constant observation and treat-
ment just one year, at this writing. His over night urine
has been clear and free from gonococci since July, 1906 ;
but it is only since March, 1907, that his massaged secretion
gives an occasional negative report. \\'hen I can succeed
in getting from seven to ten negative reports in succession
I shall feel justified in concluding that this man is as thor-
oughly cured as, with our present knowledge, it is possible
for him to be.^
\ Case HI. — E. K. J., aged twenty-eight, unmarried, lawyer.
Presented himself for treatment on May it. 1906, with
moderate amount of discharge, cloudy urine, and some pain
in passing it.
Previous History: First attack, Seplemb r. 1900. Was
treated six weeks and pronounced cured. Since that time
has had repeated attacks at rather frequent intervals,
especially after sexual excesses. Prostate had never been
examined.
Examination : The discharge contained gonococci. The
Jaijassohn-Goldenberg irrigation test .showed the presence
'Dc-scribcd in Medical Record. 21, 1906.
-Since this paper was written this man has had a dozen ex.iniin.n-
tions made, all ncKative as to fjonococci. He has married, and there
have hec n no indications of ^oti ii tIkctI reciinenee.
of a chronic anicroposterior urethritis; both urines were
cloudy and loaded with gonococci (gram negative). Pros-
tate was large, hard, and tender, vesicles the same. No
stricture.
Subsequent History : After four weeks of treatment the
urine became clear and the gonococci were not found after
repeated examinations. The massaged prostatic secretion,
however, gave a positive finding until September (four
months after treatment was begun), since which time re-
peated examinations have given uniformly negative results.
The man has since married, and recent examination failed
to reveal the presence of gonococci.
These three selected cases out of fifty-five thus
studied, illustrate the point I wish to emphas-ize in
this paper, namely, that the mere presence of pus
and gonococci in the urine passed by the patient is
no criterion as to whether or not he may consider
himself cured ; the important point to determine is
whether or not the prostate has been emptied of the
gonococci that infested it. And this can only be de-
termined by the methods described — that is, vigor-
ous massage of the prostate and annexa, and a
careful, examination of the expression urine voided,
or, better still, the secretion obtained by massage
and stripping.
Without wishing to burden this paper with de-
tails of the fifty-five cases studied, a few general
figures and conclusions might not be out of place.
Duration of disease before coming under observation:
6 weeks to 6 months 24 cases
6 months to one year 15 cases
I year to three years (never well) 7 cases
3 years to 10 years (frequent recurrences) 5 cases
12, 15, 19, 26 years (frequent recurrences, of each
one case) 4 cases
Of the fifty-five cases studied fifteen patients are
still under treatment and observation because of the
occasional positive finding of gonoL^occi in the ex-
pressed secretion. Forty have, therefore, been de-
clared cured. Of these forty patients the duration
of treatment before the disappearance of the gono-
cocci from the morning urine, passed by the patient,
varied from ten da> s to eleven weeks ; from the mas-
saged prostatic secretion in the same patients from
nine weeks to ten months. While exact figures can-
not be given, these cases show that the longer the
duration of the infection, the longer it takes to get
the gonococci out of the prostate and adnexa.
Conclusions.
1. The so called "incurable" and "recurrent"
cases of gonorrhoea are those in which the gonococci
remain latent in the prostate and annexa.
2. Every case of chronic gonorrhoea in the mnle
should be thoroughly examined for gonococci in the
prostate and annexa.
3. The morning urine passed by the patient may
or may not contain gonococci ; the massaged urine
passed imtnediately after, or, better .still, if it can
be obtained, the expressed secretion of the prostate,
will most always give a positive finding.
4. The urine passed by the patient may be clear
and sparkling; yet the massaged urine may be full
of pus, and epithelia, which are loaded with gono-
cocci.
5. There is no direct relationship between the
urine clearing up and the disappearance of gono-
cocci from the prostate.
6. Five examinations of the massaged urine may
give a negative result. The sixth may give a re-
verse verdict. TTerc ] ersistence is a cardinal virtue.
March 7, 1Q08.)
STEIN: OPERATIVE OBSTETRICS.
441
7. Before a patient can be declared "cured" and
marriage sanctioned, he should be put on the cus-
tomary tests, and in addition, the massaged prostatic
secretion should be examined at weekly intervals
until at least six consecutive negative findings re-
sult. Thereafter for at least a year, a monthly ex-
amination of the same kind should be made, so as
to make assurance doubly sure.
105 East Xixeteenth Street.
THE OPER.\TIVE TENDENCIES IX MODERN
OBSTETRICS.*
By Arthur Stein, M. D.,
New York.
A study of the development of the art and science
of midwifery during the many centuries up to
modern times shows a decided neglect in the direc-
tion of the evolution of the operative field. In spite
of the fact that operative obstetrics originally was
taught by surgeons and was regarded as a part of
surgery, this branch of medicine drifted far away
from its mother science. In the second half of the
last century, while great strides were being made in
operative gynaecology, chiefly under the guidance
and cooperation of prominent surgons such as Bill-
roth, Simon. Czerny, and Mikulicz, the opinion still
prevailed that operative obstetrics had reached its full
development. Only when modern gynaecologists be-
gan to apply the knowledge they had acquired in the
diagnosis and treatment of the female genital organs
to the functional activity during the period of gesta-
tion, did operations become more frequent in obstet-
rics. And even then the advances were few, for the
gynaecologists were still too wrapped up in their own
subject, so that operative obstetrics only began to
keep pace with the advances in gynaecology during
the last two decades.
Beginning with Sanger's and Kehrer's improved
methods of performing an abdominal Caesarean sec-
tion and the introduction of Porro's operation, we
gradually reach a period in which operative obstet-
rics began to advance along lines hitherto unknown.
Briefly stated, the sentence : ''Every perforation of
a living child is a crime," covers the operative tend-
encies of this period, in which the life of the child
Was given as much consideration as that of the
mother. All the more recent operations were de-
vised to deliver a living child whenever possible
without imperiling the life of the mother. These
operations can be divided into two classes, those in-
volving the maternal soft parts and those involving
the bony pelvis.
At the International Congress of Medicine held in
Berlin in 1890 Bossi and Diihrssen, independently
of each other, suggested an operation on the ma-
ternal soft parts which made it possible to emptv the
uterus in a very short time, with the underlying pur-
pose of delivering the mother of a living child with-
out thereby imperiling her life : the former trying to
attain this end by a bloodless, the latter by a cutting
operation. Bossi's method was at first adopted with
enthusiasm by almost every one, only to be gradu-
*Re id in pp.rt before the Geruisn Medical Association of New
York. January 6, J908,
ally supplanted by operations based on more scien-
tific principles.
Believing that the bloodless methods of dilating
the cervix then in vogue ( laminaria, bags, bougies,
etc.) did not suffice in urgent cases, because they re-
quired too much time. Bossi constructed a dilator
with which he asserted that it was possible during
pregnancy or labor to dilate an unobliterated cervical
canal to such an extent, in from fifteen to thirty min-
utes, that all major operations like forceps delivery,
version, or extraction could be performed without
further delay. The indications set down by Bossi
for his method of dilatation included all cases in
which a rapid delivery was desired in the interest
of the mother or child, thus in cases of eclampsia,
cardiac disease without compensation, grave dis-
eases of the respiratory tract, premature separation
of the normally or abnormally situated placenta, rigid
external os, prolapse of the cord, pernicious anaemia,
prolonged labor, and in cases with signs of decom-
position of the uterine contents or of beginning in-
fection : furthermore, he considered it a new method
of inducing labor. When we consider that the older
methods employed to dilate the cervical canal really
required many hours or even days before complete
dilatation was accomplished, we can readily under-
stand the great advantages of a rapid method of dila-
tation followed by immediate delivery. Bossi's pro-
cedure was therefore very tempting, for it seemed to
satisfy a long felt want : its advantages were, how-
ever, accompanied by such 'great disadvantages that
no conscientious obstetrician could fail to weigh the
latter in his mind before employing the method.
The dilator whose use was chiefly advocated by
Leopold and his school consists of four steel branches
which can be separated eight or ten centimetres from
one another, through the medium of a screw, after
the closed instrument has been inserted into the cer-
vix. The mode of action of the instrument depends
upon whether the cervical canal is still entirely
closed, or whether it is wholly obliterated, with only
an undilated external os. In the latter case, pro-
vided the condition of the soft parts is normal, the
instrument will, as a rule, dilate the os rapidlv, eas'ly.
and without danger. Even Diihrssen, its most zeal-
ous opponent, admits this when he savs : "'In a num-
ber of cases with obliterated cervical can-'l the in-
.strument can dilate the closed or partly dilated ex-
ternal OS of a primapara to such an extent as to
make the extraction of a living child possible." In
other cases of this category it is at times impos=ib)e
to dilate the external os, or the dilatation takes place
at the expense of cervical tears. If this occurs in
cases with an obliterated cervical canal, how must
the instrument act in those cases for which it was
originally recommended, i. e., those where there is
no dilatation of the cervical canal. As a matter of
fact, the most extensive and uncontrollable injuries,
with their disagreeable after effects, have taken place
in these latter cases. Wyder in von Winkel's Hand-
buch der Gcbiirtshilfc says : "There exists the danger
of causing more or less extensive tears of the lower
uterine segm.ent, which may enlarge during subse-
quent delivery. A fact easilv understood, as Bossi's
instrument does not dilate the cervical canal in the
phy.siolos^ical manner, but only pulls its walls apart,
the stretching taking place from the points where
442
STEIN: OPERATIVE OBSTETRICS.
lNi;\v V'oKK
MEintAL JuL'RNAL.
the four branches of the dilator come in contact with
the cervix, and not equally in all directions. It need
hardly be mentioned that the cervical tissue at these
four points is subject to being crushed, and that the
intervening tissue which is put on a stretch is in dan-
ger of being torn." Numerous cases have been re-
ported in which extensive tears occurred in just this
manner, among them those of Knapp. Wagner, and
Lederer. It does not come within the scope of this
article to describe in detail the injuries observed in
their cases, but the general impression gleaned from
their reports and also my own experiences, which
were similar to von Bardeleben's at the Charite in
Berlin, led me to believe that in performing a purely
mechanical dilatation with Bossi's instrument we
do not properly consider the dynamic forces. I
furthermore doubt whether Bossi is right when he
maintains that it is possible to stimulate the dynamic
forces of the uterus during the short time of dilat-
ing the cervix with his instrument. Other disad-
vantages of his method are, an increased liability to
infection and the danger of atonic post partum
lijemorrhage, to which Schatz especially draws atten-
tion. Endometritis and inflammations of the para-
metria as results of deep cervical tears must also be
considered when we discuss the value of Bossi's
method. As was said before, the procedure is con-
nected with little danger when the cervical canal is
entirely obliterated, as the injuries then involve only
the external os, but under such conditions the use of
the dilator is unnecessary, as bags produce a more
complete dilatation when the os yields easily, and as
incisions are more reliable when the os is rigid. The
only way to avoid the dangers and disagreeable after
efifects of Bossi's bloodless method of dilatation is to
abandon it. This we can all the more readily do
since in Diihrssen's cutting operation we possess a
method of dilatation which enjoys all the advantages
of the Bossi method, while it is free from its dis-
advantages.
Diihrssen first described his method under the
name "deep cervical incisions," and finally after im-
provements in technique changed it to "vaginal
Cresarean section," under which name it has at-
tained an undisputed place among modern obstet-
rical operations. lie showed how, by means of four
deep cervical iiicisinns. combined with episiotomy
{Sclieidcu-Daii! Ill incision ) if the vagina was small,
it was possible to deliver even a primipara with
closed cervical canal of a living child, provided, how-
ever, that, the supravaginal portion of the cervical
canal wa.s obliterated. This proviso became unneces-
sary in the vaginal Caesarean section, as the lower
uterine segment was now included in the field of
operation. The introduction of tliis operation repre-
sented a real advance in modern operative obstetrics,
for it was now possible, during pregnancy or labor,
to bring about an immediate delivery if the condition
of mother or child demanded it. even when no part
of the cervical canal was obliterated, and then with-
out imperiling the life of the mother ; the operation
was therefore also a means by which an abdominal
Cesarean section could be avoided. This operation
in my belief is also destined to take the place of the
classical Cjesarcan section in the dying woman. In
this case we operate cntirelv in the interest of the
child.
While this operation possesses only one contrain-
dication, i. e., a true conjugate below seven or eigh*^
centimetres, it possesses very important advantages
over abdominal Ca^sarean section ; in the first place,
the peritonaeum remains unopened, so that it can be
carried out in infected cases, when the abdominal
method is contraindicated on account of the danger
of general peritonitis ; secondly, it is not held in
such horror by the laity, who give their consent to
a vaginal operation much more readily than to an
abdominal one.
This brings up the much discussed question as
to whether the operation should be performed in
a private house. Cases have been reported in
which a general practitioner successfully performed
it -in private with the assistance of a midwife, and
often not under desirable surroundings. Of course,
it is understood that it must be done only by a
physician, who is capable of making a correct diag-
nosis and who has had some surgical training; in
his hands the operation is easy and should be suc-
cessful if he operates according to Diihrssen's rules.
The latter's method, briefly stated, is the follow-
ing: The cervix is grasped with two bullet forceps
and a sagittal incision made through its posterior
lip, extending for four centimetres into the poste-
rior vaginal fornix, when the fold of peritonaeum,
known as Douglas's pouch, is separated from the
posterior wall of cervix and uterus, by blunt dissec-
tion. Then the mucous membrane of the anterior
vaginal wall is divided from the urethra down-
wards, the bladder is pushed back (which is a very
easy matter under normal conditions in pregnancy),
and the anterior lip of the cervix is divided sagittal-
ly. Having exposed the anterior and posterior
uterine walls the cervical incisions are extended
through them for six centimetres, the opening thus
made must admit a fist before the extraction of the
foetus is begun. If there is an atonic haemorrhage
the placenta must be manually extracted and the
uterus packed, but ordinarily the third stage may
take its normal course, after which the wounds are
closed with interrupted sutures, and a small gauze
drain inserted into the antecervical and retrocer-
vical space. To my mind the modifications of
Iktmm, who divides only the anterior cervical and
uterine wall, and of Doderlein, who divides only
the posterior cervical and uterine wall, should be
abandoned, because they do not give us (luite
enough room. At the hands of experienced oper-
ators Diihrssen's operation requires but seven to
fifteen minutes, another advantage over the abdom-
inal method, in which the closing of the uterus
alone takes from fifteen to twenty minutes. Ill ef-
fects of the resulting scars are not to be feared, as
five cases of Diihrssen. Wennerstrom, Jerie. and
von Bardeleben go to show. These cases were all
observed in normal deliveries after a vaginal Cnesar-
ean section had been performed upon these patients
during a previous pregnancy.
From the conservative to the radical vaginal
Cesarean section is only a short .step, the latter be-
ing indicated in those cases in which a carcinoma,
a marked uterine infection, or an uncontrollable
lipemorrhage is present. P. Miiller's method of
hemisectio uteri with subsec|uent hysterectomy is
th'Mi the best mode of procedure.
March 7, 1908.]
STEIN: OPERATIVE OBSTETRICS.
443
As regards the mortality, Diihrssen collected 248
cases of conservative and radical Cassarean section
with a death rate of i per cent., after excluding all
deaths due to causes other than the operation itself.
On the other hand, Olshausen, who has obtained the
best results with abdominal Csesarean section
abroad, reported a mortality of from 6 to 8 per cent.
This marked difference in the death rate should
cause all obstetricians to operate per vaginam rather
than per abdomen. As a matter of fact if we fol-
low the work and writings of obstetricians of note,
we notice that the>- gradually changed their posi-
tion from one of hesitancy to one of enthusiasm for
the vaginal operation. I need only mention Bumm,
Leopold, Zweifel. and von ^^'inckel in Europe, and
Fry and Williams in this country, all of whom have
become staunch advocates of the operation. Fry
even stating that since the introduction of the vagi-
nal method, abdominal Cjesarean section has but
few indications. I do not believe we are going too
far in agreeing with Bumm when he says: "The
value of the operation and the advance which its
introduction into obstetrics represents, lie in the fact
that we are placed into a position to open the uterus
sufficiently to permit a deliver}- along the normal
passages, without loss of time, in a clean cut sur-
gical way, and at any moment during pregnancy or
labor. No other method of dilating the unobliter-
ated cervical canal at our disposal to-day is capa-
ble of accomplishing anything like a vaginal Caesar-
ean section."
W't shall now discuss those operations which
bring about an enlargement of the birth canal by
cutting through some portion of the bony pelvis.
In the beginning of the sixteenth century Severinus
Pinjeus recommended such an operation, but not un-
til 1777 was it performed on the living subject,
when Jean Rene Sigault was the first to do so. The
operations on the bony pelvis may be classified im-
der two heads, symphysiotomy, in which a joint is
divided, and hebosteotomy (also called pubiotomy
or hebotomyK in which one of the pubic bones is
divided.
Symphysiotomy was at first enthusiastically re-
ceived, only to be gradually abandoned on account
of the variable results obtained by it. In Germany,
Siebold, of Wiirzburg, was the first to perform one
in 1778; he was followed by others, and in 1820
Ritgen w^as the last to recommend it for some time
to come. Not until the last quarter of the past cen-
tury was it again taken up, when, due to the im-
provements in technique and asepsis, the operation
was again advocated . by Morisani, Pinard, and
Zweifel, but in spite of their agitation in its favor
it did not gain a permanent place among obstetrical
operations. It is chiefly indicated in contracted
pelves, especially in flat and justominor pelves, but
is contraindicated in the former when the true con-
jugate is under six and one half centimetres, and
in the latter when it is under seven centimetres. Its
disadvantages are so many that it can hardly be
called an advance in operative obstetrics : the fact
alone that a joint is opened and brought into con-
nection with the never aseptic vagina, from where
it is only too frequently infected, is significant. The
real dangers lie in the injuries necessarily inflicted
upon the soft parts, the wound may enlarge during
the subsequent delivery or the urethra may be torn
from its attachments, the bladder and corpus cav-
ernosum clitoridis may be injured, injury of the lat-
ter being likely to be " followed by a retropubic
haematoma, which is often infected ; deep vaginal
tears are also frequently met with. Even when car-
ried out subcutaneously, as recently advised by
Zweifel, the complications become no less frequent,
so that it is not surprising that most obstetricians,
who have a large number' of contracted pelves to
deal with, have abandoned symphysiotomy in favor
of a new operation devised to supplant it, namely,
pubiotomy.
This new operation is not without faults, but of-
fers many advantages over symphysiotomy. Though
recommended in the seventeenth century, its present
\'Ogue is entirely due to Gigli, who advocated it in
the latter part of the last century, when Bonardi
and van der Velde were the first to perform it on
the living subject. They were soon followed by
Calderini, ^lorisani, Caruso, and others. The meth-
ods first suggested by Gigli and van der Velde were
open ones; they exposed the os pubis and then di-
vided it. More recently Doderlein devised a meth-
od, partly subcutaneous, and Bumm, \\'alcher, and
Leopold introduced one entirely subcutaiieous, the
bone being divided either after a moderate or no
dissection of the soft parts. In all the methods the
vagina, urethra, bladder, and corpus cavernosum
clitoridis lie outside of the field of operation ; but
Doderlein's has found the largest number of fol-
lowers and has given the best results. He makes
a small incision along the upper border of the pubes
just internal to the tubercle and large enough to per-
mit the introduction of the finger behind the bone,
where the retropubic tissue and bladder are pushed
away. Under guidance of the fimger a carrier is
passed behind the bone and brought out just external
to the labium majus, where a small skin incision is
made, then the carrier is threaded with a saw, with-
drawn, and the bone divided. From the time that
Doderlein introduced his partly subcutaneous meth-
od, pubiotom)- has been more frequently performed,
especially since Sellheim has demonstrated that the
pelvic enlargement following pubiotomy is the same
as after symphysiotomy. When we consider that
in addition the results following pubiotomy have
been more favorable than those of symphysiotomy,
it is not surprising that the latter has been less
frequently performed.
\Ve may summarize the indications of pubiotomy
by the statement that it is indicated in all cases in
which perforation of the living child was hitherto
resorted to. especially in cases of flat or generally
contracted pelves in which there is a disproportion
between the size of the fcetal head and the size of
the pelvis. From a practical point of view we may
divide them into prophylactic and imperative indi-
cations. Under the first heading those cases of
contracted pelvis are included, in which there was
a previous stillbirth or difficult deliver}- ; then
hebotomy is best performed at the end of the first
stage, and labor permitted to go on spontaneously.
The second heading includes those cases in which
mother or child is in immediate danger, or in which
there has been an unsuccessful attempt at forceps
extraction. Under the latter circumstance it is best
444
HAWKES: GALLSTONE DISEASE.
[New York
Medical Journal.
to perform the hebotomy with the forceps in situ
and then to complete the labor mstrumentally.
Whenever possible one should get along without
forceps, as the cases of hebotomy followed by spon-
taneous delivery have given the best results for
mother and child. According to Baisch's analysis
of 187 cases in which hebotomy was followed by
forceps, the foetal mortality was 4.3 per cent., while
in seventeen cases in which the labor was ended
spontaneously all the children were born alive, the
mortality being o per cent.
After symphysiotomy the average mortality
among the mothers reaches 17 per cent., which
Morisani, Pinard, and Zweifel, who performed the
operation frequently, reduced to 8 per cent. Fol-
lowing hebotomy the mortality is only 4.2 per cent.,
which is reduced to 2.9 per cent, when those cases
which were infected before operation are excluded.
As regards the justly feared bladder injuries, I
should like to mention that they occurred in 2.4 per
cent, of the cases operated on according to Doder-
lein, and in 17.6 per cent, of the cases operated on
according to Bumm. Cases of severe infections,
bladder injuries, and one of fatal hfemorrhage may
surely be attributed to first trials, and will become
less fre(|uent as the technique improves. It cannot
be denied that pubiotomy must be considered as
competitive with abdominal Caesarean section in
certain cases.
As regards the after treatment, it is suf?icient to
dress the wound, and place a few adhesive straps
around the pelvis, in addition to supporting it on
either side with sand bags. The healing in normal
cases goes on quite rapidly, so that the patients can
get up out of bed at the end of the third week, with-
out any disturbances as to function.
It would be going too far were I to discuss such
operations as the removal of large tumors during
pregnancy and labor, the resection of pelvic veins
and hysterectomy for septic conditions during the
puerpcrium ; nevertheless, they are good examples
of the modern operative' tendencies in obstetrics.
Before closing I wish to touch upon the ques-
tion as to which of the operations which I men-
tioned can and should be performed by the gen-
eral practitioner, who so frequently meets with diffi-
cult obstetrical cases. I have already mentioned
that the vaginal Caesarean section, according to
Diihrsscn, gives good results in the hands of the
general practitioner who has had some surgical
training. It is diflferent with respect to pubiotomy,
the result of which in a given case cannot l)e foretold
and concerning which many questions still remain
unsettled. I consider it a risky undertaking for the
general practitioner, and believe the operation
should be confined to the specialist, a man familiar
with pelvimetry, obstetrical diagnosis, and the
technique of the operation — above all, one equal to
the task of meeting any of the complications liable
to come up during and after the operation. Final
judgment has not been passed on pubiotomy, but up
to the present time most obstetricians abroad look
upon it with favor. A definite opinion cannot be
formed imtil the histories of more cases have been
published, and for this reason I hope the operiition
will find more extensive trial in this country in the
future.
From what has been said we cannot fail to draw
the conclusion that a "new obstetrics" has devel-
oped 'in the last two decades, due chiefly to the
adoption of modern surgical principles, and that
obstetrics no longer fails to keep pace with the ad-
vances in other branches of medicine.
References.
1. Baisch. Reformen in der Therapie des engen Beck-
ens, Leipzig, 1907.
2. Von, Bardeleben. Verlctzungen mit dem Bossi"schen
Dilatator. Zcitschrift fiir Gyndkologie und Geburtshilfe ,
xlix.
3. Idem. Spatfolgen des Entbindungsverfahrens mit
schneller mcchanisch-instrumenteller Muttermundserwei-
teriing. Archiv fiir Gyndkologie, Ixxiii.
4. Bossi. Sulla dilatazione meccanica strumentale im-
inediata dell utero, etc. Annali di ostetricia, ginecologia,
e pcdiatria, 1900.
5. Idem. Sulla provocazione arteficiale del parto e sul
parto forcato. Ibidem, 1892.
6. Idem. Ueber meine Methode der schnellen mecha-
nisch-instrumentellen Erweiterung des Uterushalses in der
Geburtshilfe. Berliner Klinik, part 199, January, 1905.
7. Bumm. Ueber die Methoden der kiinstlichen Erweite-
rung des schwangeren und kreissenden Uterus. Report of
the Kongress der deutschen Gesellschaft fiir Gyndkologie
su Kiel, 1905;
8. Diihrssen. Ueber chirurgische Fortschritte in der
Geburtshilfe. Volkmann's Samnilung klinischer Vortrdge
No. 160.
9. Idem. Ueber den Wert der tiefen Cervix- und Schei-
dendammeinschnitte in der Geburtshilfe. Archiv fiir
Gyndkologie, xliv.
10. Idem. 1st die Bossi'sche Methode vvirklich als ein
Fortschritt in der operativen Geburtshilfe zu bezeichnen?
Ibidem, Ixviii.
11. Idem. Der vaginale Kaiserschnitt, Berlin, 1896.
12. Idem. Der vaginale Kaiserschnitt, in von Winckel's
Handbuch der Geburtshilfe, iii, i.
13. Doderlein. Ueber alte und neue beckenerweiternde
Operationen. Archiv fiir Gyndkologie, Ixxii, 1904.
14. Fry. Pubiotomy in America. Surgery, Gynaecology,
and Obstetrics. No. 2, August, 1907.
15. Hammerschlag. Ueber Dilatation nach Bossi. Mo-
natssdirifl fiir Geburtshilfe und Gyndkologie, xvii.
16. Kehrer, E. Symphysiotomie und Pubiotomie. Ibidem,
xxi, 1905.
17. Kronig. Symphysiotomie. Artikel in von Winckel's
Handbuch der Geburtshilfe, iii, i.
18. Leopold. Ueber schnelle Ervv'eiterung mittelst des
Dilatatoriums von Bossi. Archiv fiir Gyndkologie. Ixvi, 66.
19. Williams, Whitridge. Obstetrics. Second Edition,
1908.
20. Wyder, Th. Die kiinstliche Erweiterung des unteren
Uterusabschnittes, in von Winckel's Handbuch der Geburts-
hilfe, iii, I.
36 We.st Fifty-ninth Street.
GALLSTONE DISEASE AND ITS SURGICAL
ASPECT*
By Forbes Hawkes, M. D.,
New York,
Attending Surgeon, Trinity Hospital; Assistant Surgeon. Presby-
terian Hospital; Consulting Surgeon, Nassau and St. Jo-
seph's Hospital, L. I.; Instructor in Surgery, Co-
lumbia University.
When a positive diagnosis of gallstone disease has
been made in a given case, does this condition be
long among those to be treated by medical means or
by surgical ones?
If we exclude those cases where gallstones arc be-
ing constantly passed with slight discomfort to the
patient (I am not at all sure that even these should
•Paper read before the Medical Association of the Greater City
of N.-w York, on November i8, 1907.
March 7. '9c8.1
HAIVKES: GALLSTONE DISEASE.
445
be excluded) and those cases where the risk of any
surgical procedure is very great (e. g., from cardiac,
pulmonary, renal or arterial changes, or from
marked overadiposity) I think that I am voicing the
present day opinions of the greater number of con-
servative surgeons when I say that the remaining
conditions may best be treated by surgical methods,
and the earlier the better.
Early gallstone surgery has been and is still being
opposed by many medical^ men in much the same
way that early surgery of the appendix was opposed.
Xot long ago an article appeared written by a med-
ical practitioner of much experience in this city dis-
cussing the subject of operation in gallstone disease.
He said that many cases had best be treated medi-
cally, boasting that he had carried one patient
through somewhere between ten and twenty severe
attacks of gallstone colic.
That this patient was running a great risk in anv
one of these attacks, and in the interval as well. I
think w-e would all admit.
If we exclude those conditions previously men-
tioned gallstones should i^e removed (and the ducts
drained in many cases), not necessarily just as soon
as the diagnosis is made, but shortly thereafter for
the following reasons : Patients with gallstones are
liable at any time to one or more of the following
serious complications: (a) Abscess of the gallblad-
der: often with (b) subphrenic abscess secondary to
it: (c) gangrene of the gallbladder: with ensuing
(d) spreading peritonitis; (e) perforation of the
gallbladder into the duodenum, stomach, or trans-
verse colon; with occasional (f) intestinal obstruc-
tion from the contents or from subsequent constric-
tion bands ; (g) impaction of one or more of the cal-
culi in the common or hepatic duct, followed b\- ob-
structive jaundice; later by acute ascending infec-
tion along the liver ducts; and resulting in (h) ab-
scess of the liver localized and operable, perhaps, or
diffuse and beyond the reach of the surgeon; (i)
chronic hepatitis; and (j) chronic pancreatitis; (k)
cancer developing in the vicinity of the gallstones ;
and finally (1) changes in the kidneys (chronic ne-
phritis).
Before surgeons could conscientiously recommend
operation as a routine measure to patients with gall
stones, they had to show that the operation per se
was not an extrahazardous one, and that their final
results were better in the cases operated on than in
those treated by medical means alone. This has
now been done by many surgeons the world over.
Gallstones are being recognized more and more as
objects which the surgeon is called upon to remove,
and the disease which has produced them as one to
be treated at the same time by surgical drainage.
Xo one would venture to-day to question the propri-
ety of operating early in appendicitis, because some
patients who have been allowed to run on to diffuse
peritonitis from appendix infection have died fol-
lowing too late an operation. In the same way in
the gallstone case should it be. Patients should be
operated upon early, not late.
The most valuable type of surgery is that which
aims to remove the source of the tfouble, in this
case both gallstones and infection of the ducts, before
dangerous complications arise or permanent harm
has been done. In this way the time that the patient
is kept in bed is shortened, the strongest possible
scar is obtained, and the digestive disturbances soon
disappear.
There are two things that have delayed the recog-
nition of gallstone surgery in its proper value: i,
The attacks of gallstone colic do not at the start
seem to be as dangerous as attacks of appendicitis
often are; and, 2, owing to the situation of the gall-
bladder and ducts the diagnosis is often not made un-
til several attacks have occurred. Marked jaimdice,
we know, is infrequent in cases where the stones
and the infection are located mostly in the gallblad-
der or cystic duct. Attention is therefore often di-
verted to the stomach as the primary seat of the
trouble, and the patient is treated for indigestion for
years, while gallstones are accumulating and sec-
ondary changes are occurring in the bile tracts, liver,
stomach, pancreas, intestines, and kidneys.
I have heard surgeons criticised because in some
of their operative cases they were not able to re-
move all of the calculi at the time of operation.
Many calculi are undoubtedly formed at a late
period of the disease in the ramifications, which
often are inaccessible, of the hepatic ducts in the
liver. They are due to the constantly ascending in-
fection of a mild grade. The best way to have pre-
vented such formation high up would have been to
have removed the preceding gallstones below and to
have drained the ducts at an earlier date. Of course
patients may refuse operation in this early period,
not realizing the serious nature of their trouble, but
the medical practitioner advising operation at this
time will have given his patient the best advice, and
the responsibility for subsequent stone formation
and further duct infection cannot then be laid at his
door.
The well known fact that gallstones are often
found at autopsy in patients dying from other
causes, and that they have apparently been the
source of little or no discomfort is often mentioned,
when surgical treatment is discussed. This fact has
but little bearing on the question, for those that give
rise to no symptoms are not brought to the attention
of medical or surgical practitioner. We are here
considering the cases that present symptoms. What
do medical practitioners say that they can do in the
cases that are not operated on in the way of arrest-
ing the formation of gallstones or of dissolving
them or of helping them through the ducts safely?
As to the prevention of their formation, it is be-
lieved by some that by keeping the bowels thorough-
ly cleared out by saline laxatives — by diluting the
bile by large draughts of water — by giving certain
drugs and adhering to a certain diet, further in-
fection can be arrested. Much good can undoubt-
edly be achieved by these means, and we see the
symptoms often quieted down for a time in this way.
That the stones are not forming during this time,
however, higher and higher in the ducts, we can-
, not say positively. As to the dissolution of stones
already formed no proof has ever been adduced that
such an occurrence can be brought about in the liv-
ing body. As to helping the stones down the ducts
some practitioners feel that the administration of
olive oil over long continued periods has been of
distinct service in this way. While I have seen this
form of treatment followed by cessation of pain in
a certain number of cases I cannot conscientiously
say that stones have passed in greater quantities or
446 Hh'.ll': BENIGN TUMORS OF RECTUM.
with less pain than under other methods of treat-
ment. Many stones are too large to pass through
any of the ducts. Such are apt to cause ulceration.
The small faecal masses passed during the olive oil
treatment have often been mistaken for gallstones.
I am not now dealing with the subject of the sur-
gery of the gallbladder, and I shall not here take
up the question whether the gallbladder should
usually be removed or not. but mv experience justi-
fies me in the opinion that if we are led to exclude
the cases mentioned in the first part of this article
the proper treatment for the others is to remove the
gallstones when they are distinctly diagnosticated,
and at the same time to drain the ducts of their
infection, so that subsequent serious trouble may
be avoided, ft not believed, after the stones have
all come away {mm the gallbladder and from the
drained ducts, that there is any subsequent stone
formation, cxcciit in very rare cases. Stones found
later are usuall> believed to have been either over-
looked or inaccessible.
The conclusions which follow are based on my
own operative records of patients sufifering from
gallstone disease. In all of them gallstones were
found in numbers varying from one to 2,059. I"
the first division are thirteen cases operated on for
gallstones before serious complication had set in.
These are the cases of so called indigestion, dys-
pepsia, gastritis, biliousness, etc., etc. ; no deaths,
no failure of cure. In the second division, nineteen
cases operated on after the development of serious
complications, ten patients cured, three improved,
six deaths. The causes of death in these six cases
were as follows: Septic foci scattered through the
liver (septic cholangeitis from calculi), one case;
carcinoma of bile ducts and of the liver following
old standing gallstone disease, two cases ; septic
peritonitis with septic nephritis following acute in-
fection of a stone bearing gallbladder, one case ;
gangrene of gallbladder with subphrenic abscess,
and perforation into transverse colon, general peri-
tonitis, double septic pneumonia, one case ; calculus
imparted in ampulla, with chronic pancreatis and
chronic cholecystitis, matting parts together in one
cartilaginous mass, with fatty degeneration oi the
liver and chronic nephritis, death due later to
urcxmia, one case.
Conclusions. — Provided the patient is a good sur-
gical risk:
1. Gallstones should be removed al an early date
from gallbladder or ducts; such infection is treated
by drainage of the ducts. Al this time the operation
is comjjaratively safe, convalescence is prompt, and
cure lasting.
2. Serious complications are liable to arise at any
time in patients with chronic gallstone disease.
Long journeys, in which efficient surgical aid cannot
be secured promptly, arc distinctly hazardous. Op-
erations at this time are much more serious, they
are often necessarily incomplete, and the outlook
for permanent cure is less bright.
3. Cancer is liable to develop at any time at or
near the seat of irritation. Operation then is verv
hazardous and the outlook bad.
4. Medical practitioners should familiarize them-
selves with the results obtained by the surgeons to-
day in the early uncomplicated ca.ses.
42 E.\s i T\\ I \ I ^ -sTx i II S treet.
DI.\GNOSIS AND TREATMENT OF BENIGN
TUMORS OF THE RECTUM.*
By H. a. Br.w, M. D.,
Philadelphia,
Proctologist to tlu- American Hospital for Diseases of the Stomach.
In selecting the theme of my paper I was actu-
ated by a desire to present a subject, a discussion of
which would not only be of considerable interest
but also of practical value to every medical practi-
tioner. Since benign tumors of the rectum are
rarely diagnosticated by the general practitioner,
and often overlooked by the general surgeon, it will,
I thought, be of interest to all of us to review this
subject briefly.
Benign tumors of the rectum comprise growths
which, as a rule, have a pedunculated attachment and
a pendulous extremity. These growths are quite
often met with in either six and at any age, but are
more common in women and children. They vary
in size, shape and form, and may be single or mul-
tiple-, and are usually attached by a single stem, but
they may have two or more attachments. These neo-
plasms are also known as polyps on account of the
fact that they are attached to the rectal wall by a
pedicle or stalk. The pedicle consists of a fold of
mucous membrane containing blood vessels which
supply the growth.
The polypoid tumors found in the rectum are as
follows : ( I ) The adenoma or glandular polypus,
(2) the fibroma or fibrous polypus. (3) the vil-
lous tumor or villous polypus, (4) the myxoma or
myxomatous polypus.
I. Of all these varieties the adenoma is the one most
frequently met with. This tumor is very common in
childhood, but extremely rare in adult life. They
are soft when composed of the constituents of the
mucous membrane, while those which are com-
posed of both, the elements of the mucous
membrane and submucous connective tissue, are
generally hard and are spoken of clinically as a
fibroadenoma. Adenomatous .polyps are usual-
ly single, but sometimes two, or even more, may
be encountered within the same patient. They
are generally the size of a large cherry, they may,
however, be a little larger. These growths have the
color of the mucous membrane of the rectum, but
when they protrude at the anus they have a purple
red appearance. They are generally found attached
to the posterior wall of the rectum and at a point
within reach of the finger, but they may arise from
any other part of the rectum and be attached so
high up that the finger alone will not reach it.
When the pedicle is long and not attached high
up in the rectum the polyp will protrude dur-
ing the act of def^ecation and appear at the
anus as a dark red roundish tumor with a bleed-
ing surface. It usually returns spontaneously into
the rectum immediately after defsecation, but some-
times it is neces.sary for the patient to replace it
above the sphincters after each stool. .V small
adenoma may exist for a long time without giving
rise to symptoms of its presence. A a rule, how-
ever, hremorrhage occurs from the abraded surface
of the growth produced by the passage of hard
.scybalous masses over it, it also gives rise to a strain-
ing sensation when caught by the snbincters.
•Read before the Northern Medical .\ssociation. lannary m, iqo8.
^t^rch 7. i9o8.]
BRAV
BEXIGX TUMORS OF RECTLM.
447
The diagnosis is, comparatively speaking, easy.
The passage of blood from the rectum in a child,
usually under ten } ears of age, with or without pain
on defaecation, with or without straining, generally
means the presence of polypus. A digital examina-
tion should now be made in order to locate the
growth. The best way to accomplish this is to
sweep the finger around the whole circumference of
the anal canal as a far as it can be reached when the
growth can be felt or drawn down and sometimes
brought out through the anus. Growths attached
higher up in the rectum can only be located under
an anjesthetic. Owing to the fact that polyp some-
times protrude at stool they are frequently mistaken
for hsemorrhoids and treated for that condition. 1
have a record of several such cases, which have been
treated for piles by the application of astringent and
sedative ointments.
The treatment of polypi consists in their extirpa-
tion under the influence of an anaesthetic. The
sphincters should be dilated and the growth pulled
down with thumb forceps, ligated and cut off as
close as possible to its point of attachment to the
rectal wall. Some surgeons apply a clamp to the
pedicle, sever it, and cauterize with the Paquelin
cautery.
When the pedicle is long and slender and located
in the upper rectum the polypus may be twisted off'
b\- simple torsion. The after treatment consists in
confining the bowels for four days whence they are
opened by the administration of fractional doses of
calomel followed by a saline. After the removal of
an adenomatous polyp in an adult having passed
middle life it is necessary to examine the patient
from time to time, because carcinomatous degenera-
tion has been found to follow some cases. Spon-
taneous cure of polyps sometimes takes place. The
reason for this is that the thin pedicle is torn through
by the passage of hard faeces and the growth passes
out with it. Strangulation of the tumor by the
sphincter muscle will occasionallv cause them to
slough off.
2. The next most common benign tumor found in
the rectum is the fibroma, or fibrous polypus. This
growth consists of fibrous tissue and has a short,
tough pedicle. It is usually situated within the first
two inches of the rectum and varies in size from
that of a hazelnut to a walnut. These growths are
mostly found in adults and are usually multiple in
character. They may protrude during defaecation
and be mistaken for internal piles, especially when
both conditions coexist in the same case. A fibroma
can readily be diagnosticated by a digital examina-
tion when the finger will detect a firm, hard growth
which can sometimes be drawn down the anal ori-
fice and examined. A small fibrous polypus may
exist for some time without any untoward effect,
it will, however, soon bring on spasms of the
sphincter and levatores ani muscles which ulti-
mately become hypertrophied, and indurated. When
the pedicle of a fibromata happens to be
partially torn by the passage of a hard faecal mass,
the patient experiences a burning pain and a slight
loss of blood. The pain, which sometimes lasts for
hours after stool, is suggestive of an anal fissure.
Examination, however, will soon disclose the pres-
ence of a fibrous polypus.
The treatment consists in the removal of the
growth by applying a ligature to its base and cut-
ting off the growth, or by the application of a clamp
cutting it oft", and cauterization of the stump.
3. One of the rarest of all the benign tumors
found in the rectum is the villous tumor. This
neoplasm may reach the size of an orange and has
a bandlike, short, fleshy pedicle. Its surface is gen-
erally lobulated, giving it a cauliflower appearance.
A villous polypus is found only in adults or in old
persons, who, as a rule, complain of diarrhoea on
account of the watery discharge from the bowel,
which makes them go to stool frequently. These
patients also complain of a dull, aching pain in the
rectum radiating to the sacrum. They bleed occa-
sionally, but the haemorrhage generally originates
not from the surface of the tumor but from the co-
existing piles. Patients suft'ering from villous
growths generally lose flesh and strength and have
a cachectic appearance. When completely removed
this tumor seldom recurs, it may. however, become
cancerous and return after extirpation. I have a
case on haitd now which confirms this statement :
Mrs. E. L., aged forty-five years, had a typical villous
growth in the rectum which I completely removed a year
ago. Seven months after the operation the patient came
back to me complaining of a bearing down sensation in the
rectum, straining, mucupurulent and bloody discharge at
stool. She was an-emic. emaciated, and extremely nervous.
A digital examination revealed a narrowing of the anal
canal due to a carcinomatous infiltration of the rectum ex-
tending up the bowel .for about six inches. Slight involve-
ment of the bladder and lymphatic glands were noticeable.
The patient refused another operation whence 1 had to
resort to palliative measures. The stricture, however, grew
so rapidly that a passage by the rectum v. as impossible and
she consented to have a left inguinal colostomy performed.
This operation will probably prolong her life by relieving
her temporarily of distressing symptoms of obstruction.
It is evident that an early diagnosis is impera-
tive in the cure of these cases. The only procedur
necessary to establish a correct diagnosis is a digital
exploration of the rectum. Careftil manipulation of
the finger will detect a growth attached to some
part of the bowel by a broad pedicle. In the major-
ity of cases, however, this tumor will be found at-
tached to the posterior wall of the rectum. The
growth rarely protrudes from the anus, and still
more rarely do we find more than one growth in
the same case. The treatment of a villous tumor
consists in an early removal of it bv operation. Un-
der the influence of an anaesthetic the sphincters arr
dilated and the growth brought down through the
anal orifice. A clamp is then applied on the pedi-
cle which is transfixed and ligatured in one or more
places near its origin from the rectal wall and is
then divided. If there is no distinct pedicle the
growth must be extirpated by resecting the portion
of the bowel to which it is attached, and the result-
ing wound brought together by sutures.
The after treatment consists in rest in bed and
keeping the bowels confined for a few days. On
the fifth day the bowels are made to act bv the ad
ministration of a cathartic. On account of the occa-
sional recurrence of this tumor at the site of the scar
of the pievious operation it is advisable to ask the
patient to call for a rectal examination everv three
months after the operation has been performed.
4. The myxoma or myxomatous polvpus consists
of pure mucous tissue. This growth is verv rarelv
448
LE ROY: ANALYSIS OF SALIVA.
[New York
Medical Jolrn.
encoimtered with, and there is only one case report-
ed by Gant.
There are other forms of rectal neoplasms,
namely, the myoma and lipoma. These, however,
are so rarely met with that they are considered path-
ological curiosities. A description of these would
be of no practical value.
92O XoR'iH Franklin Street.
COLORIMETRIC ANALYSIS OF THE SALIVA,
WITH THE CLINICAL SIGNIFICANCE.
By Bernard R. Le Roy, M. D.,
Athens, Ohio.
The study of the saliva from a pathological stand-
point has been neglected and has not received the
attention it deserves, but from the studies of the few
eminent observers who have given it much thought,
much, very much indeed, may be gathered that is
of interest to the clinician, and if made use of in
diagnostics and therapeutics will result in rapid
advancement in the eyes of the profession, as well
as in the thoughts of the laity, for when applied
intelligently the results more than repay the trouble
taken in the examination.
That all practicians are not in a position to carry
out the necessary laboratory studies is conceded,
yet from the instructions given below any one can
be able, after a few trials, to carry out the labora-
torj- work with ease.
The resulting exactness of the examination will
indicate to the physician the lead or direction in
which he must look and prescribe for the existing
wrong or diseased condition. This will enable him
to prescribe with more exactness and with less of
the "shotgun hit or miss" method, and when once
started the fascinating attraction of the work makes
it intensely interesting and adds zest to one's .study
of disease.
As stated, the literature on the subject is meagre,
and with the exception of Fenwick, Kyle, Kirk, and
a few writers, who only incidentally touch upon the
subject, nothing in the nature of an exact investiga-
tion of the saliva pathologically has been done.
The method of examination is colorimetric and
qualitative in character, and the reagents are to be
used in the smallest quantities compatible with color
reaction, the .commonest error being the use of too
large a quantity of the test solutions.
All test solutions are to be made of 5 per cent,
strength, unless otherwise stated, and are to be
made up with distilled water; other materials needed
are litmus paper and the finest quality of filter paper,
a porcelain tablet with twelve discs, and several
small test tubes.
After securing the saliva note the color, odor,
whether viscid or fluid, note the nature of the sedi-
ment, reaction, and make note of the quantity
secreted dailv.
_ Place a good sized drop of .saliva in each of the
discs of the porcelain tablet, and should the operator
be in normal health he should examine his own
saliva at the same time by placing it in the discs
at the bottom of the plate and testing each in turn.
This will be good practice and will enable him to
soon get at the proper method and also more easily
compare diseased saliva with the normal.
Sulphocyanides. — In the first disc in which you
have placed a large drop of saliva add one small
drop of a slightly acidified solution of ferric chloride ;
if the sulphocyanides are present in normal quanti-
ties there will be a fajnt pink coloration or aura,
which will spread throughout the saliva, starting
from the dark brick red where the reagent is still
unmixed with the saliva. This faint yet decided pink
coloration stands for normality in the sulphocy-
anides and will not be seen in cases where they are
absent ; in cases where they are increased the color
will be deepened into all shades up to a nearly dark
blood red. which is very intense and quickly prevails
throughout the saliva being tested, representing the
varying amounts of the sulphocyanides that may
be present. Or, to the saliva add one drop of solu-
tion of cupric sulphate, then add one drop of a
freshly prepared tincture of guaiac, when a blue
color will indicate the presence of the sulphocy-
anides, but upon the other hand, should the color xbe
green, then it is due to ammonia; in case the color
is green with a few streaks of a dark blue through
it, then it indicates that the sulphocyanides are pres-
ent in small quantities with an increased content of
ammonia.
Ammonia. — In the centre of the next drop place
a tiny drop of Nessler's reagent, when, if ammonia'
is present, a reddish yellow color and precipitate will
result, while around throughout the saliva will be
noticed a faint pinkish color or aura encircling the
reagent. The color will depend upon the amount of
ammonia present and will be shaded accordingly.
Chlorides. — Add a small drop of a solution of
potassium chromate in centre of saliva, then add a
very minute drop of a solution of silver nitrate, and
should the chlorides be present the reddish silver
chromate. being soluble, will dissolve in proportion
to the amount of chlorides present ; add another
drop of silver nitrate and so on until no more is dis-
solved, and thus estimate the amount of chlorides
present.
Oxalic acid. — Add a drop of full strength acetic
acid, then one drop of a solution of calcium chloride :
a precipitate of oxalate of lime takes place if oxalic
acid is present, and the precipitate should be care-
fully examined under a high power micro.scope for
the crystals of the oxalate of lime.
Urea. — Take several c.c. of saliva and evaporate
slowly over water bath to one fifth or less, add alco-
hol, shake well, filter, and evaporate to dryness, dis-
solve residue in distilled water and treat with nitric
acid, set aside .to cool, when nitrate of urea will
separate after a time in characteristic rhombic or
hexagonal plates.
Formaldehyde. — Add a drop of Nessler's reagerit
and a reddish yellow, then black coloration takes
place rapidly with a blackish precipitate at the end
of reaction ; this is not, as some writers have stated,
one of "yellow precipitation," but is very distinct
from the reaction received with ammonia, and is
given here for two reasons, the one just given and
liccause of the common use of formaldehyde.
Aceto-ne. — Add one drop of an alkaline solution of
sodium nitroprusside so dilute as to have only a
slight red color; should acetone be present a ruby
red color is produced, which changes to yellow : add
acid and boil, when a greenish blue or violet color
will result. Or add a drop of solution of iodo-
March 7, 1908.I
LEROY: ANALYSIS OF SALIVA.
449
potassium iodide ; then add a drop of caustic potash
(U. S. P.), let stand; if no more than a trace of
acetone is present iodoform will be precipitated.
Sodium. — -To find the base salt of the saliva, the
saliva is placed in a small test tube and a drop of a
solution of potassium pyroantimonate is added ; if
sodium is present a faint or slight crystalline pre-
cipitate will take place.
Potas.sium. — Place saliva in a test tube and add
an equal amount of alcohol ; this prevents the so-
dium present from taking part in the reaction, and
add one drop of a solution of hydrochlorplatinic
acid when a slight precipitate indicates potassium.
Calcium. — Place a quantity of saliva in a test
tube and add twice the quantity of distilled water,
shake well and add a quantity of solution of am-
monium oxalate (U. S. P.), when if calcium is
present a white precipitate falls which is insoluble
in acetic acid, but is soluble in hydrochloric or nitric
acid.
Silicates. — No known method of producing color
reaction is known to the writer ; the qualititive meth-
od, being rather difficult, will not be given here.
Nitrites. — Take and mix the following: Phenol,
one part ; sulphuric acid, four parts ; water, two
parts; and add small quantity of a potassium hy-
dro>:ide solution. Place a small quantity of this in
a small test tube, then add an equal quantity of
saliva, being careful to not mix them, the saliva be^
ing the upper layer; let stand for several minutes,
and if nitrites are present a deep red colored band
will be present at the line of union of saliva and
reagent, depth "of color depending upon the amount
of nitrites present ; or the following may be used :
Place a quantity of saliva in a small test tube, add a
few drops of Ilasvay's reagent, and gently heat,
when if nitrites are present a red color will develop.
Lactic acid. — To a test tube of water add a few
drops of a solution of iron sesquichloride ; shake, pour
half into another tube, and use this as a control ;
to the first tube add a number of drops of saliva,
when in the presence of lactic acid the test solution
will turn a distinct yellow color, which appears
marked when compared with the control tube. This
test is delicate. (Simon's modification of Kelling's.)
Opium. — The same test is used in opium eaters'
saliva as in the sulphocyanides, producing the same
reaction; now add a drop of a solution of corrosive
sublimate, and if iron meconate is present the color
remains unchanged, but will disappear if due to the
sulphocyanides.
Morphine. — Add one drop of a neutral solution
of ferric alum to the saliva of morphine eaters, and
you will get a dirty green color, which is intensified
by heating the tablet and adding one drop more of
the reagent. Or you may substitute for the alum
a neutral solution of ferric chloride, producing the
same results, but more delicate in action.
These tests are very clever in detecting patients
addicted to the habit of eating these drugs.
The rosolic acid test paper for testing for acids
or alkalies. — Soak strips of extra fine grade of filter
paper in an alcoholic solution or rosolic acid of such
strength as to color the paper a delicate salmon pink
when dry. Now place a drop of saliva on the pa-
per, and if acid the paper will not be aflfected, unless
the saliva is greatly acid, when it will turn an
orange yellow ; but if the saliva is alkaline the paper
will turn or change from a faint pink to a bright
brilliant red, according to the degree of alkalinity
present, making a beautiful contrast to the delicate
salmon pink of the test paper.
Proteids. — Saliva from the submaxillary gland
contains proteids, a nucleoproteid ; place a quantity
of saliva in a small test tube and add a few drops
of a solution of cupric sulphate, mix, and note the
color ; if it has turned towards a blue color it in-
dicates the presence of ammonia, but if it is a pale
green then add a few drops of ammonia, when in
the presence of nucleoproteids it will turn a deep
blue.
The solids of the saliva are the phosphate and
carbonate of lime and silicia ; all are concerned in
the formation of tartar and sordes, and always in an
alkaline saliva. The lime salts have been studied,
but whence comes the silicea? From studies along
this line the writer is of the opinion that silicea is
of fundamental use in the life history of the living
cell, always found in extremely small quantities and
therefore overlooked in the summing up.
Clinical significance. — Fenwick states that the
sulphocyanides bear a relationship to the amount of
sulphur in the bile, and that when the bile is di-
verted from the alimentary canal the sulphocyanides
disappear from the saliva.
The sulphocyanides and ammonia in normal sa-
liva are in about equal proportions and in very
small amounts.
When the sulphocyanides disaj^pear from the sa-
liva we have a condition that needs our careful at-
tention, and if ammonia is increased in quantity we
have a grave condition, indeed, to combat ; this is an
hypoacid condition and accompanies all the graver
forms of disease ; for instance, this is the state of
aflEairs in all diseases of the nervous system, i. e.,
absence of the sulphocyanides with ammonia pres-
ent in large quantities, the larger the amounts of
the latter the more grave the condition. This is
true of epilepsy, paralysis, dementia praecox, and all
forms of nervous diseases resulting from lues.
And when I have been able to detect the sulpho-
cyanides in these cases I always felt sure of a period
of improved state of health, and upon the disap-
pearance of the sulphocyanides from the saliva I
was just as certain that the old attacks would re-
turn. We also have this state of affairs in all forms
of fevers, exemplified in its extreme in the typhoid
state. Here, too, we will notice the appearance of
the sulphocyanides in the saliva in advance of re-
turning health ; indeed, this holds good in all cases
of recovery from any and all forms of disease.
Upon the other hand, when we have an excess of
the sulphocyanides in the saliva, giving a deep dark
blood red reaction, and it continues so for a space
of time, I look for a lesion in the brain, heart, or in
the kidney, and I pay special attention to these or-
gans.
When we have a hypoacid condition the patient
cannot tolerate acids nor iron — that is, these reme-
dies will not agree with the patient ; but change the
ammonia base to potassium and the patient will ask
for acid drinks ! Sodium base will cause the same
changes to take place in the milder forms of dis-
ease.
When the saliva is exceedingly acid examine the
mouth for microorganisms which may produce lac-
450
LE ROY: ANALYSIS Of SALIVA.
[New York
Medical Journal.
tic acid, then examine the saliva for oxalic acid ; in
these cases the saliva upon standing turns a dark
yellowish brown, and the enzyme ptyalin will al-
ways be absent, no doubt having some connection
with the stomach troubles which accompany this
state of affairs. With lactic and oxalic acid present
in small quantities we have caries of the teeth.
When urea is present or combined with the so-
dium phosphate to form the acid sodium phosphate
we have a very irritated condition of the mucous
membrane of the throat and mouth, causing the
parts to become sensitive, the secretions to become
acrid and burning in character, producing rhinitis
and catarrhs. (Kyle.)
When ammonia is in excess there is a diminished
amount of both oxygen and carbonic acid in the
saliva, with a rapid tendency to decompose; this
state of affairs is present in all states of sepsis, and
with acetone present we have a condition of auto-
infection of the system, with indican in the urine.
In all cases of exhaustive discharges from the
bod\- we find the sulphocyanides absent from the sa-
liva, and in case of recovery their reappearance
again heralding a return of health or a period of
improvement.
When we have sulphureted hydrogen, noticed in
the breath, or the patient complains of a rotten egg
taste, the sulphocyanides are absent from the saliva,
and when the proper attention is given the stomach
the sulphocyanides reappear in the saliva, and the
sulphureted odor and taste disappear. In all these
cases where we have the so called rotten egg taste I
have found that it • is not altogether due to sul-
phureted hydrogen, but is in a great measure due to
nitrogen, and that upon carefully analyzing the odor
I have found that it more closely resembles the
odor of burnt feathers than sulphureted hydrogen,
the stench causing one to take snap judgment.
In cases where the reaction for the sulphocy-
anides gives a dark brown color instead of the brick
red to a, dark blood red color, and this reaction is
obtained time and again in the same case, you may
notify the friends of a fatal issue unless you can
produce a decided change, and that within a short
space of time.
Fenwick states that in old people where he per-
ceived the reaction indicating an excess of the sul-
phocyanides with a steady persistence that the case
would develop fatal symptoms.
In heart disease, for instance mitral disease with
dilatation, wherein there is developed a back press-
ure and the sulphocyanides are absent, the case will
terminate fatally ; but if they are present and in-
crease in amount the patient will improve or recover.
In rheumatism, if the sulphocyanides are present
and an increa.'^e is noticed, recovery will be rapid ;
but if present in excessive amounts then recovery
will be protracted.
In most of the chronic skin diseases the sulphocy-
anides are found in excessive amounts.
When we have the smell of hydrogen sulphide in the
breath and ammonia in the saliva, with absence of
the sulphocyanides. we can with a certain degree of
positivenf ss diagnosticate dilation of the stomach
with albuminous putrefaction in the small intestines ;
also that it is from benign causes and that this con-
ditir)n is never present with carcinoma of the stom-
ach, nor is it present when lactic acid is found in
contents of the stomach.
There is in nephritis an increased amount of urea
in the saliva.
As I have stated before, the color indicating the
normal amount of the sulphocy anides ni the saliva
IS a faint yet decided pink color; this fact I have
arrived at from several thousand examinations and
cannot agree with Fenwick when he states that the
normal color is one of a medium dark blood red.
This last color I found to be normal with children
and young people undergoing a somewhat rapid
growth, but not an average for all cases of normal
health irrespective of age.
When the patient complains of a soapy or sappy
taste, look for ammonia in greater or less quantities
in the saliva ; when of a salty taste, look for sodium
as the predominating base ; when of an acid taste,
look for lactic or oxalic acid, should the disease be
in the neck or head ; but if the disease is in the body
or limbs, look for urea with a sodium base; if taste
is of a putrid, horrible nature, look for ammonia
with one or more of the other abnormal contents
found in the saliva.
In looking over the record of several thousand
examinations, several prominent points stand out in
bold relief ; First, that the sulphocyanides, as first
noticed by Fenwick, vary in amount in differ-
ent diseases and in different stages of the same
. disease.
That an excess of the sulphocyanides, or an ex-
cess of urea with a sodium base, will produce an
exceedingly irritative condition of the mucous mem-
branes of the throat, nose, and mouth, as mentioned
by Kyle.
That in all cases of disease the constant presence
of ammonia in greater or smaller amounts, far above
the normal content, is always to be found ; the
greater the amount, the more serious the condition
of the patient.
That in all diseases of the nervous system the con-
tent of ammonia is in excessive amounts ; and in
epilepsy it is greater just before, during, and imme-
diately after the attacks ; in cases where the spells
come at some interval the sulphocyanides will re-
appear in the saliva during the free period, to dis-
appear before the next attack, to be replaced by
ammonia in excess.
That in convalescence the base salt of the saliva
should be one of potassium.
That nitrogen, and not altogether sulphureted
hydrogen, is the gas that arises from benign dis-
eases of the stomach and intestinal fermentation,
and that these gases are not present in malignant
forms of diseases of these organs.
As the saliva contains more oxygen than does the
blood plasma, and a very large amount of carbon
dioxide, it would be interesting to learn the reason
of this and to know why this is the normal condi-
tion. Whence comes the normal as well as the ab-
normal content of the saliva?
In conclusion, permit me to speak of morphine
and opium in this method of diagnosticating: Mor-
phine, no matter how administered, may be detected
in the saliva within three minutes! Opium, no mat-
ter how given, may be detected in the saliva from
within a few minutes to several hours, and in opium
eaters it may be found in the saliva days after tak-
ing the last dose. Chloral may he foimd in the
saliva as chloral or as formates, and thus be
detected.
Maidi 7, 190S.J OVK RilADERS' DlStUSSlUSS. 45 1
^^ur ^eabfrs' discussions.
A SERIES OF PRIZE ESSAYS.
Questions for discussion in this department are an-
nounced at frequent intenals. So far as they have been
decided upon, the further questions are as follows:
LXXI. — //oio do you treat gallstone colic f (Closed Feb-
ruary J 3, 1908.)
LXXII.—Ho'di do you treat fracture of the patella?
(Answers due not later than March 16, 1908.)
LXXI 1 1. —How do you treat seasickness f (Answers due
not later than April 15, 1908.)
Whoever answers one of these questions in the manner
most satisfactory to the editors and their advisors will
receive a prise of $25. No importance zi'hatever unll be at-
tached to literary style, but the award will be based solely
OH the value of the substance of the answer. It is requested
{but not required) that the answers be short; if practica-
ble, no one anszcer to contain more than six hundred words.
All persons zvill be entitled to compete fur the prize,
whether subscribers or not. This prize will not be awarded
to any one person more than once within one year. Every
answer must be accompanied by the writer's full name and
address, both of which we must be at liberty to publish.
All papers contributed become the property of the Journal.
The prize of $25 for the best essay submitted in answer
to question LXX has been awarded to Dr. Beverley R.
Tucker, of Richmond, l a., whose article appeared on page
403-
PRIZE QUESTION NO. LXX.
(Concluded fom page 407.)
Dr. Joseph j. Rowan, of PhiladelpJiia, -writes:
Alcoholism, according to Dr. Tyson, is "the effect
on the human economy of the intemperate use of
alcohol in some one of the forms in which it is used
as a beverage."
Ordinarily, garrulcusness, flushing of the face,
and an excited mien precede the incoherent speech,
staggering gait, and final stupor. If seen in any
stage prior to the stupor, the diagnosis is apparent,
but when seen for the first time after the stupor
supervenes a distinctive diagnosis must be made be-
tween the following conditions: (a) Alcoholic
stupor, (b) apoplexy without fracture of the skull,
(c) apoplexy with fracture of the skull, (d) opium
poisoning, (e) ursemic coma, (f) unconsciousness
preceding acute mania, and (g) unconsciousness in
Meniere's disease.
(a) In ordinary drunkenness the patient lies in
a heavy sleep, from which he can be aroused by
shaking or pinching. He may mumble a few in-
coherent words, but immediately falls back again
into the same heavy sleep. On examining the pupils
of the eyes they will usually be found dilated, and
the odor of alcohol can be detected on the breath.
(b) and (c) In apoplexy without fracture the
stupor is deeper than is alcoholic stupor, but not
so deep as that produced by apoplexy with fracture
of the skull. The breathing is stertorous, but with
apoplexy with fracture the stertor is much more
pronounced. The pupils of the eye will be found
unequal in both conditions. If a fracture of the
skull coexists, slight hemorrhage from either ear
may be detected. In either condition, apoplexy with
or without fracture, sooner or later a paralysis of
one or the other side of the body can be demon-
strated. It was our custom in St. Mary's Hospital,
Philadelphia, to raise in turn the various extremities
of the body and let them fall. The paralyzed side
invariably came down with a heavy, dead, unresist-
ing thud, while the sound side fell with more resist-
ance and more easily.
(d) Ura?mic coma may also be confounded with
alcoholic stupor. In this condition the odor of alco-
hol on the breath is missing, while that of urine may
be present. In the absence of symptoms above men-
tioned as characteristic of these states, the catheter
must be passed, and the urine thus obtained exam-
ined for the presence of albumin and casts. If
found in any quantity, and the symptoms of other
conditions lacking, the diagnosis of unemic coma is
justifiable. The pupils, in uraemia, give us no mate-
rial aid, for they are variable, being sometimes di-
lated and sometimes contracted.
(e) In opium poisoning the pupils are invariably
equally contracted, even to the size of a pin point,
and the face is commonly pale. A pin point pupil
always indicates the presence cf opium.
( f ) The condition of stupor which sometimes
precedes acute mania I mention because while a
resident physician at St. Mary's I was confronted
with a case of this kind. The pupils were equal,
neither dilated nor contracted, the urine contained
no albumin or sugar, there was no paralx sis, and
the patient could not be aroused. The breathing
was not stertorous, nor was the breath alcoholic.
( g) Meniere's disease, or labyrinthine vertigo,
must also be considered. The vertigo, staggering
gait, nausea, and even unconsciousness being suf-
ficiently similar to alcoholism to demand considera-
tion in arriving at a diagnosis.
A final word as to the presence of alcohol on the
breath. Too much reliance must not be placed upon
its presence. The laity are prone to pour alcohol
in some form or other down the throat of every
person suddenly taken ill. and a person stricken
with an apoplectic stroke or otherwise made uncon-
scious is very likely to be dosed with alcohol be-
fore the arrival of a physician.
Dr. J. J. O'Siillhan, of Pittsburgh. Pa., .<;tates:
The conditions which may stimulate and with
which alcoholic stupor is apt to be confounded are:
Opium poisoning, strychnine poisoning, bella-
donna poisoning, chronic plumbism. sunstroke, the
coma of pernicious malarial fever, cerebrospinal
fever, pneumonia, cerebral compression, diabetic
coma, ursemic coma, epileptic coma, apoplectic
coma, disseminated sclerosis, paralysis agitans. tabes
dorsalis, paretic dementia, and hvsteria.
In many of these conditions it is almost impossible
at first to diagnosticate them from alcoholism on ac-
count of the close similarity in symptomatolog\', and
a history of the case if obtainable may materially
aid us in arriving at a diagnosis.
Very often the alcoholic condition is concurrent
with some other distinct pathological process. An
individual may be intoxicated and have either pneu-
monia, sunstroke, cerebral compression, diabetes, or
serious renal trouble. Acute or chronic alcoholism
may be the exciting cause of rupture of a cerebral
bloodvessel. The strain on diesased renal organs
incident to an alcoholic debauch may lead to the
condition of uraemia. Thus it will be seen that alco-
holism may be the exciting cause of a number of
diseased conditions from which it mav be difficult
or impossible to distinguish it.
It is assumed in this article that the alcoholic con-
dition is independent of any other pathological state
452
OUR READERS' DISCUSSIONS.
[New Yvkk
Mkdical Journau
which may exist coincidently in the same indivdual.
The distinctive diagnostic features only are con-
sidered. For convenience of description and the
sake of brevity, the distinctive diagnosis in each case
is outhned in tabulated form.
Alcoholic Stupor.
. Skin cool and clammy.
:. Kespirations normal or slight-
ly accelerated.
. Pulse rapid and feeble.
. Pupils dilated or equally con-
tracted.
. Stupor may be supplemented
or followed by intervals of
wakefulness and is not so pro-
nounced as in opium poison-
ing.
. J resence of vun W edekind'i
the supraorbital ' m.tehcs mav
bring an alcnhulic to lii'^
senses.
Alcoholic Stutor.
. Muscles are relaxed.
. Respirations normal or slight-
ly accelerated.
. Pupils equally contracted or
dilated.
. Examination of urine may not
reveal anything abn^rmaK
. The features I'.aM.- ;i besotted
appearance.
Alcoholic Stupor.
. No paralysis.
2. Tre nors are conlinc
head and arni> .-nul
chiefly in morning;.
3. Face has usually a bloat
jjearance.
4. There is no blue line on
5. There is probably a 1
of an alcoholic debauch
Respirations normal
ly accelerated.
Bodily heat may be
^light-
ered.
. Absence of distinct convul;
movements.
Kxamination of the urine 1
6. I'"ace may present only ■flight
pallor and a besotted ciuin-
tenance.
Alcoholic Stupor.
1. Pulse rapid and feeble.
2. Respirations shallow.
3. Pupils equally ' contracted or
dilated.
4. Temperature may be normal.
5. Stupor may be folic
wakeful moments.
6. Skin is mnist and cool.
Alcoholic Stupor.
1. Temperature normal- or si
ly subnormal.
2. Skin moist and cool.
3. Attacks of shorter dura
and there are intervals
sznity.
4. Kxamination of the li
does not reveal anything
normal.
Alcoholic Stupor.
1. Pulse rapid and feeble.
2. Muscles relaxed.
3. Tremors confined to bead
Opium Poisoning.
. .Skin dry and warm.
. Respirations slow, deep, and
full.
. Pulse slow, strong, and full.
. Pupils extremely small and
contracted (pin point).
. There is profound coma and
it may be impossible to awaken
patient before death super-
Snychntnc Pcsonmg.
1. Mu-cles are in a state of te-
tanic rigidity.
2. There are tonic convulsions
of the entire body, which may
be in a condition of orthoto-
nus, opisthotonus, or rarely
emprosthotonus.
3. Respirations scarcely audi-
ble on account of spasm of
respiratory muscles.
4. Eyes open and fixed, pupils
greatly dilated.
5. Examination of urine may re-
veal presence of strychnine.
6. There is a iietuliar grin, su
called risus sardonicus.
Chronic Lead Poisoning.
I. There may be paralysis of
certain groups of muscles, the
bracliial. carpal (wrist drop),
and sooKtinies the peroneal
limited to mori
iffuse and
. Blue line at margin of gums.
. The knowledge of the indi-
vidual's occuiiation usually
leads to the diagnosis of
plumbism.
Belladonna Poisoning.
Face, flushed and dry, some-
times presents an erythematous
rash.
Respirations extremely de-
pressed.
There is usually a rise in
temperature.
, Presence of convulsive seiz-
"ixamination of the urine may
sho«' presence of belladonna
or its alkaloid atroiiine.
Tlicre are distinct lines of
pallt)r extending from malar
hones to angles of jaw, giv-
ing face a peculiar expression.
Sunstroke.
PuIm- rapid and full.
Res|.irations labored and deen
and .if ( heync-Stokes type.
Pui.ils I xtremcly contracted.
4. Temiierature range is usually
very high.
5. In se.ere cases, there is pro-
found coma lasting from half
an hour to twelve or twenty-
four hours, and followed by
either death or recovery.
6. Skin is flushed and hot.
Coma of Pernicious Malarial
Fever.
1. Temperature high.
2. Skin hot and dry.
3. .\ttacks may last from twelve
to twenty-four hours, and if
patient regains consciousness,
he quickly falls into a coma-
tose condition.
4. Kxamination of the blood
shows the presence of the a;s-
tivoautumnal parasite of ma-
larial fever.
Cerebrospinal Fever.
1. Pulse full and strong.
2. Rigidity of muscles of back
and neck.
3. Tremors more diffuse.
4. Temperature normal.
5. No strabismus.
Alcoholic Slupiir.
1. Pulse rapid and f;-eble-
2. Respirations normal or sup-
pressed.
3. Temperature usually normal.
4. Face moist and cool.
5. Lungs may be normal.
. Eyes dull and apathetic.
Alcoholic Stupor.
. Pupils equally contracted, un-
less patient is aroused.
. No paralysis.
. There may be no head injury
present.
. Unconsciousness incomplete.
Alcoholic Stupor.
. Skin cool and moist.
. Temperature may be normal.
. Pulse strong at first, finallv
feeble.
. .-Vlcoholic odor in breath.
, Patient may be of strong and
robust constitution.
. Stupor not preceded usually
by any special symptoms.
4. High temperature.
5. Strabismus.
Pneumonia.
1. Pulse full and bounding.
2. Resi)irations greatly accele-
rated.
3. Temperature high.
4. Face «arm and flushed.
5. Well marked physical signs
of consolidation may be de-
tected.
6. Eyes bright.
Cerebral Compression.
1. Pupils dilated and fixed, or
unequal.
2. Paralysis.
3. Fracture of some jiart of cra-
nial vault may be detected.
4. Unco'isciousness complete.
Diabetic Coma.
1. Skin dry and harsii.
2. Temi)erature usually abnor-
3. Pulse rapid and thready and
greatly lowered tension.
4. Peculiar sweetish acetone
odor to breath.
5. Extreme emaciation of pa-
tient.
6. Diabetic coma is usually iire-
ceded by extreme dyspnoea,
syncope, nausea, vomiting, and
headache.
Sugar may be absent from 7- Sugar is present in large quan-
irine. titles in urine, also acetonuria,
and acetona;mia.
Uraemic Coma.
Pulse rapid and full, and
Alcoholic Stupor.
1. Pulse rapid and feeble.
2. Respirations may be normal.
3. Pupils equally contracted, un-
less patient is roused.
4. Ophthalmoscopic examination
may not show anything abnor-
mal.
5. Examination of the urine may
not disclose any abnormality
of the renal organs.
6. Only the strong odor of liquor
may be detected in breath.
7. Absence of urea in blood.
8. Dropsy may be absent.
9. Coma not so pronounced and
may be followed by intervals
of consciousness.
10. No paralysis.
11. Temperature may be normal.
Alcoholic Stupor.
I. Face shows slight pallor and
is moist and cool.
2. Respirations nearly normal.
3. Examination of the urine may
not disclose any abnormality
of renal function.
4. There may be no convulsive
seizures.
, Unconsciousness incomplete.
. There may be no frothing at
mouth.
are of longer dura-
.4lcoholic Stupor.
1. Pulse rapid, compressible, and
weak.
2. Skin cold and clammy.
3. Bodily temperature normal or
slightly lowered.
4. Pupils equally contracted.
5. Respirations normal or sup-
pressed.
6. Unconsciousness incomplete.
7. No facial paralysis.
S. No hemiplegia.
/Ilcoholic Stupor.
1. Muscles relaxed.
2. Tremors confined to head and
arms and may he removed by
giving a do.se of alcohol.
3. Speech usually of a brusque
character.
4. No nystagmus.
Alcoholic Stupor.
I. Trem.irs confined to head and
arms.
. Respirations greatly accel-;-
rated.
. Pupils irregular.
. Examination of the eye
ground usually determines the
presence of albuminuric retin-
itis.
. Examination of the urine
demonstrates the presence of
nephritis.
. Heavy, foetid, urea like odor
in breath.
Presence of urea in blood.
Presence of dropsy.
Coma is profound.
10. There may be a monoplegia
or hemiplegia.
11. Temperature usually ele-
vated.
Epileptic Coma.
1. Face, at first pallid, rapidly
develops a dusky or livid hue,
and there is profuse perspira-
tion.
2. Respirations su|)|ircssed and
scarcely audible.
3. Albumin may or may not be
present. There is often ex-
cess of indican in urine.
4. The body assumes a jiosition
of tetanic rigidity, followed by
clonic convulsions which are
succeeded by coma.
5. Unconsciousness complete.
6. There is a frothy saliva which
may be blood stained, due to
patient having bitten his
tongue.
7. Attack is usually of short du-
ration, and paitent returns to
consciousness immediately.
Apoplectic Coma.
1. Pulse full, strong, and bound-
ing.
2. Skin hot and dry.
3. Bodily temperature greatly in-
creased.
4. Pupils unequal.
5. Respirations stertorous and
one sided in lips.
6. Complete unconsciousness.
7. Facial paralysis.
8. Hemiplegia.
Disseminated Sclerosis.
1. Muscles stiff and presence of
contractures.
2. Tremors more diffuse and sub-
side when muscles are at rest,
so called volitional tremor.
3. Scanning speech.
4. Nystagmus.
Paralysis .^igitans.
I. All four extremities equally
affected, and head is not usu-
ally involved.
March 190S.J
OUR RE-iDERS' DISCUSSIOXS.
453
2. Tremors removed by giving
alcohol.
3. Muscles are usually flaccid.
4. Face presents a dull and be-
sotted appearance.
Alcoholic Stupor.
1. No ptosis or strabismus.
2. No .\rgyl Robertson pupil.
3. Reflexes normal or e.xagger-
ated.
4. Waddling gait.
5. No hemiplegia.
Alcoholic Stupor.
1. Delirium is of a restless, noisy
character, and is characteris-
2. Tremors confined to head and
arms.
3. Tremors allayed or removed
by giving alcohol.
4. Attacks of shorter duration,
and are separated by intervals
of sanity.
5. Pupils equally contracted.
6. Jlental condition temporarily
improved by dose of alcohol.
Alcoholic Stupor.
1. Pulse rapid and feeble.
2. Respirations normal or sup-
pressed.
3. Patients are usually males.
4. Unconsciousness more com-
plete, and return to conscious-
ness is slower than in hys-
teria.
5. No paralysis.
6. No contractures.
7. No monocular diplopia.
8. Convulsions uncommon.
Tremors cease during sleep
and persist when muscles arc
3. There is rigidity of all the
muscles of the body.
4. Face is expressionless and
mask like.
Tabes Dorsalts.
1. Ptosis -ind strabismus.
2. Argyl Robertson pupil.
3. Loss of knee jerk.
4. Steppage gait.
5. There may be hemiplegia.
Paretic Dementia.
1. Delirium of grandeur or ex-
altation more marked.
2. Tremors more diffuse.
3. Tremors increased and made
worse by alcohol.
4. Attacks of longer duration.
5. Pupils irregular and presence
of Argyl Robertson pupil.
6. Mental symptoms made worse
by alcohol.
Hysteria.
1. Pulse strong and full.
2. Respirations extremely rapid.
3. Patients are usually females.
4. Unconsciousness is only ap-
parent, and return to con-
sciousness is rapid.
5. There may be paralysis.
6. Contractures present.
7. Monocular diplopia is pathog-
nomonic in absence of struc-
tural eye defect.
8. There may be tonic or clonic
convulsive seizures.
Dr. WiUiam A. L. Styles, of Montreal, Can., ob-
serves:
Stupor is a partial loss of consciousness, a pro-
found slumber" from which it is possible to awaken
the patient only with great difficulty and by im-
portunate solicitations (Butler).
It occurs in many conditions and presents vari-
ous concomitant sxmptoms depending on the setio-
logical factor. Alcoholic stupor is to be distin-
guished from several conditions closely resembling
it ; the diagnosis of this condition per se seldom pre-
senting untoward difficulties, but occasionally mis-
taken diagnoses result, as sometimes upon it is
superadded a much graver condition.
In considering any case of stupor it is well to
follow a certain routine in our method of examina-
tion. The physician should look to the (a) skin
for cutaneous temperature, eruptions, etc. ; (b) head
for evidences of trauma, depressions, etc.; (c) face
for unilateral facial paralysis indicating some uni-
lateral cerebral lesion (haemorrhage, embolism,
etc.) : (d) eyes for bilateral myosis, nonresponsive
on shading the pupil (as, in cerebral lesions or nar-
cotic poisoning) ; if on endeavoring to upraise the
lids there results a quivering muscular resistance
and the eyeballs are directed upwards, suspect hys-
teria; (e) mouth and tongue for bites or froth
(epilepsy) and odor; (f) extremities; look for
spastic, or flaccid, paralysis ; it may happen that
on superficial examination all the extremities are
apparently paralyzed, but closer investigation re-
veals a greater amount of relaxation (i. e., "limp")
on one side.
The history of the case, if procurable, and, at
times, the character of the surroundings in which
the patient is found, will materially assist in the
diagnosis.
In general, we may say that suddenly occurring
stupor is indicative of apoplexy, concussion, hys-
teria, or sunstroke : it must be gradual ; it may at-
tend any of the acute infections. It is also symp-
tomatic of narcotic poisoning, diabetes, uraemia, the
organic brain lesions, and meningitis.
In particular, uncomplicated alcoholic stupor is
seldom difficult of diagnosis. We are all familiar
with the classic picture of alcoholic stupor — the
cold, clammy skin, the feeble, rapid pulse, the heavy
stertorous breathing, the great muscular relaxa-
tion, moderately dilated pupils, subnormal tempera-
ture, oftentimes the alcoholic breath, the staggering;
gait, and incoherent muttering.
From this we must distinguish :
Apoplexia. — We may obtain the history of a
former attack ; we are guided by its usual associa-
tion with arteriosclerosis; the characteristic full,
bounding pulse ; a unilateral paralysis, or aphasia ;
contracted pupils ; slow, stertorous breathing : cyan-
otic mucous membranes: occasional loss of the or-
ganic sphincter control : a valuable negative sign is
the absence of any external trauma.
Thrombosis, — Arteriosclerosis, as a rule ; slow
onset ; characteristic weak pulse ; paralysis depend-
ing on area involved.
Embolism. — Usually in second or third decade of
life ; associated with valvular cardiac disease ; onset
sudden ; course afebrile ; paralysis, as in throm-
bosis.
Concussion. — History is important as to fall, etc. ;:
pupils equally contracted and responsive to light ;
no paralysis ; weak and rapid pulse ; immediate on-
set of stupor.
Compression. — Usually evidence • of fractured
skull ; slow onset of stupor ; paralysis, local or gen-
eral ; pupils irregular, without light reaction.
Uraemia. — Local or general oedema ; cyanosis ;
miosis ; blood pressure high ; no sign of trauma or
paralysis ; muscular twitchings or convulsions ; mi-
croscopic and gross examination of urine is final.
Hysteria, — Usually young female ; stupor may al-
ternate with hysterical cr\ ing ; examine for presence
of hysterical stigmata paresis or paralysis, anaesthe-
sia, or hyperaesthesia, globus hystericus, etc. ; tonic
or clonic spasms; catalepsy.
Epilepsy. — History of former seizures ; bitten
tongue ; frothy moutli ; urinal discharges ; injury
from a fall ; pupil, normal and reactive.
Diabetes. — Suspect this if case is a young person ;
usually "air hunger," preceded by nausea or vomit-
ing; sweetish breath; examine urine for sugar and
acetone.
Sunstroke. — Flushed, pungent skin ; rapid pulse ;:
hy perpyrexia ; dyspnoea.
Heat exhaustion. — Cool skin ; feeble pulse ; no
fever; mild dyspnoea.
Opium. — Extremely slow respirations, four to
the minute ; characteristic "pin point" contracted
pupils ; pallor ; muscular relaxation ; feeble pulse.
Chloral. — Pallor ; cold, clammy perspiration ;
thready pulse ; slow, labored respiration ; muscular
relaxation ; subnormal temperature.
Ptomaine. — History of case is valuable; onset
fairly sudden ; gastrointestinal symptoms leading to
collapse.
Meningitis. — History is important; Kernig's sign
is characteristic, along with the evidence from lum-
bar puncture; paralysis (especially eye); opistho-
tonus ; exaggerated reflexes ; severe headache.
ULR READERS' JJISCL'SSIOXS.
Dr. F. H. Smith, of Lcivishitrg, W. I'a., has prepared the folloi^'ing table, idiich he eniitle.s:
Recognition of Alcoholic Stupor.
Alcoholism
CoCAixE PoisoNisf. Chloral poisn:
Manner o f
Onset, De-
gree and
C h a racter
of Stupor
I It is usually possi- Patient falls into
! ble to arouse patient, heavy sleep, can be
who protests incoher l aroused by efforts,
ently, to drop offl falls back int^. imms-
again into s t u p o r diate sleep, which be-
when undisturbed. I comes deeper and
Police apply ready to deeper, until finally
hand test, tapping on profound coma
ieet with "billv-: if sues, from which he
sd, man
only
be
Delirium and
H a 1 lucii'.a-
tions
3. The Face
1 n c o h c 1- toc
speech, or even active per
delirium and halluci- dist
hearing, common c ■) m :.
symptoms. All o f ;io:~ nin;
these symptoms inten-
sified in delirium tre-
mens; and in chrome
alcoholism more or
less permanent delu-
sions, etc., are com-l
mon. I
L s u a 11 y flushed,! Surius^
often slightly cj-an-i dened :
otic; sometimes (ex-Und cyan
treme cases) pallid.' progressi
I'ullness of vessels of! deepens,
face arid neck. ^ Usu-'and livid
ally evidence of habit
from "bloated" ap-
pearance. Xo sign of'
facial liaralvsis.
There may be ;
1 of pleasant 01
ssiiig delirium
This group rarely More like the bella-! At first normal to At times, a convul-
produces extreme stu donna group than al-, deep sleep; finally sioii precedes, after|
por, though he be un- cohol, so far as stupor' deep coma. w hich coma
symptom. Rarely
true stupor, though
syncope and collapse
may appear, more
often incoherence
Garrulity, incoher- Many patients
ence. uncontrollable come garrulous and
laughter or weeping, incoherent. In chronic
busy delirium, even poisoning, the mental
mania, with hallucina- failure, delusions and
tions and delusions, hallucinations of
are common symp disagreeable nature
torn-. are much like those
of chronic alcoholism
md red- 1 Face flushed, often
1 dusky iscarlatinoform e r u p-
cyanosis ,ion.
as coma
ally pale
suddenly and is pro-
found. Or the stupor]
may develop withouti
I convulsion gradually,
] usually becoming pro-
, found. I
I.
May be present.
May present swol-
len, "doughy," trans-
ucent pallor of renal
disease, especially
about the eyelids. '
1 e r
stage.- an.i nv>.lri-ate
degree^, ratlier rapid,
lull, -strong; later,
rapid, small, feeble.
.Xorinal frequency,
deep, at times some-
wliai stertorous.
I I'sually subnormal.
blow and full: ter-
minal stages of pro-
found poisoning; rap
id. small and feeble.
Quickened, and it; Perhaps, a little Usually very slow,
collapse or stupor en-i slowed at first, thouaji ^.P' \° °iSn ten
12 to 4 aj Slow and full, be-] Quickened;
at first deep coming quicker and lapse, very
•torous; later, shallower, and finally and feeble,
even dyspnoeic.
The Mouth
and Tongue
Usually cool and \N'arm and dry, un-j Dry and h
moist. til sweat of approach- let eruption
ing death. [present.
Conjunctiva; often
congested, pupils
equal, of normal size si;
or slightly dilated.
I'upils equally con- Conjunctivae inject-
to pin point ed. lids reddened and
Not often injured] Odor of opium, or; The odor of the
or frothy. Odor <rf some of its prepara- drug may be recog
alcohol and the sour lions, though not to nized (unless its alka
smell of "drunkard's be perceived when an loid was used). Ex
stomach." (It is to alkaloid is used. treme dryness ol
be remembered that a|
spree may be the ex-j
citing cause of some
more serious trouble,]
this rather than the
alcohol being respon-
sible for the condi.
tion. or. contrarily.
alcohol may h a v e
been given the strick-
man bv a b>'-
standcr. and hence,
the odor of alcohol,
while sucet-<livi-. N
i mouth, tongue and
; throat, an early symp-
|tom.
ign.
very soon rapid, sion; artery hard and
thready, shuttle like. "">'i'<ling and heart
or lost at wrist. may be hypertrophieJ.
Nearly always very
deep, sometimes
quickened, at times
hissing. Cheync-
Stokes' type not rare,
at times, difficult
(uisemic asthma).
if col- At first, slo-w and
shallow labored, later shallow
and feeble.
Usually subnormal. \ Subnormal.
In
cold,
lammy
collapse,
cyanotic
skin Body. especially
Nonconvulsive type,
subnorm. (91° to 95'
I-.): convulsive type,
very high, at times
io8° F. May be chills
followed by fever and
collapse.
General pallor, skin
and forehead and hands, •''"y- QEderaa may be
covered with a coH general, or confined
sweat. to face and limbs.
Pupils,~for a shon Eye grounds should
w hile, contracted: •>« examined (albu-
soon. widelv dilated. mmui'C retinitis^.
Tongue and lips
may li.ave been in-
jured by teeth, if
convulsive. Urinous
or ammonia like odor,
which is strongly sug-
gestive. I
OUR READERS' DISCUSSIONS.
45 S
IJIABETIC COMA
Apoplexy
May ensue without
premonition or be
preceded by drowsi-
ness, and may be of
any degree.
Varies trom shght
confusion to deepest
coma, more often pro-
foundly comatose.
.Mm.
May precede the
De¥num and iucolit-
fest at times in pa-
tients not wholly un
conscious and after
return to conscious-
ness.
•
i-'lushed, or pale, ori
"Concussion,
OR LACERATIOl
OF THE BRAt^
Total unconscious
ness from beginning
o f convulsions ;
rather rapid di
pearancc.
Rarely proloi
patient can usually be
aroused by persistent
efiforts; answers ir
table, monosyllab
or u n i n t e 1 ligible
mumble. Return tc
consciousness f o 1
lowed by deep al
though restless sleep.
(1) DEPRESSOR
fracture;
(2) MENINGEAl
ihere may be wild Jlav
delirium during the! when'
acute attack, later as stupor,
complication, to be "flight'
replaced by
I hap
unity
per-
I. Depressed f r a c
ture: Coma ensues
almost immediately.
2. Haemorrhage — a I
first stupor of "con
cussion," then a peri-
to be followed by
secondary coma due
to pressure of blood.
3. Abscess coma de
velops gradually, i n
the course of weeks,
from a period o f
mental apathy. 4. Tu-
mor, an even longer
period of mental ap-
athy before coma en
, and coma is oft-
itermittent.
be incoherent' Delirium may pre-
aroused from cede coma from ab-
and apt to belscess and tumor,
during sleep
otherwise for
time after ap-
>ai jr. to'
HI 31! •«
■ CMiiintI
ltd; ■h»i*>
Sometimes in-
creased in frequency,
or dyspnoeic (diabetic
asthma).
Ordi
May be
buncles.
should be
for changes
■oils, iris and
of breath,
s h , fruity,
apple," or
chloroform
_he extreme cyan-
cyanotic. One side of osis of the convulsive
face usually paralyzed,. stage graduallv passes
shown by absence of [as the quiet coma
wrinkles, flapping of. after the convulsion
cheek in respirationiis entered upon,
and droop of corner
of mouth.
Very pale.
As
strong.
•, full, I
and
slower than normal;)
artery hard.
Frequent, full and ^
^ 1 o w, stertorous, Stertorous and deep; Labored, deep, oft-i Soft shallow
often arrhythmical, at first, passing to en stertorous,
sometimes Cheyne- normal as coma les-|
Stokes. Lips and sens,
cheeks flapping.
Usually elevated,
ay be very high, as
1 status epilepticus.
erne elevation.
ing hot and
Pupils equal usu- Conjunctivse deeply
ally dilated. Eyes congested,
may be turned to one
act to light; eyes may
be turned persistently
to one side.
One side of mouth Saliva f 1 o w i
and tongue paralyzed] bloody and frothy
and drawn to one I from mouth, tongue
de. and lips having been
bitten during the con-
vulsion.
Color of face varies
and is unimportant;
but it is important to
note that there is usu
.ally unilateral facial
I paralysis.
Slow, full, and ir-
j regular; may become
[more frequent later.
Slow, stertorous,
puffing, or, maybe,
Cheyne-Stokes.
Usually rises pro
gressively as pressure
increases.
Cold and clar
Pupils vary, eithei
moderately contracted
or dilated, possibly
unequally; usually re-
active to light.
Usually warm rath
er than cold, though
body may be covered
Pupils dilated, oft
1 unequally, not re
:tive to light.
Manner o f
Onset, De-
gree and
C h a racter
Delirium and
H a I kicma-
tions
3. The Face
7. The Skin
Surface
The Eyes
9. The Mouth
and Tongue
456
OUR READERS' DISCUSSIONS.
!
Alcoholism
Opium poisoning
Poisoning by some
member of the
belladonna group.
Cocaine poisoning
Chloral poisoning
Uraemia
lo. The Head
May show some
slight injury— a cut
or a bruise — such as
may have been gotten
in a fall or scuffle.
May have struck
head in a convulsion.
II. Paralysis
Absent.
•
At times, a pseudo-
hemiplegia, transient
and inexplicable.
12. Convulsions
Infrequent, though
some muscular
twitching is common.
Rare.
Tremors and slight
common. Later, pow-
erful tonic or clonic
convulsions may su
Initiate one type ot
uraemia, the convul-
sive type, and may re-
cur irregularly during
the cojna.
13. The Urine
and Bladder
In a complicated
case, urine apt to be
concentrated. Blad-
der liable to be dis-
tended by retention
of urine, or bladder
may act involuntarily.
Frequently urine is
voided at early peri-
od, afterward c 0 n -
stant desire to mic-
turate and inability
to do so.
Eliminated with
urine as chloral and
urochloralic acid, giv-
ing the reaction foi
sugar with Fehling's
test.
Urine usually much
diminished, or even
suppressed. Shows
considerable albumin
and casts. Urea elimi-
DUDETIC COMA
.\POPLE.\Y
Grand mal type of
epilepsy
Sunstroke
"Concussion,"
OR laceration
OF THE brain
compression of the
brain, by (i) de-
pressor fracture;
(2) meningeal
haemorrhage; (3)
abscess; (4) TUMOit
10. The Head
iMay have been in-
jured by fall at onset
u f ' convulsion, 0 r
s li 0 u old scars of
mjuries of f<jrmer at-j
tacks. Or, on the
other hand, the cause
tacks mav be discov-,
ercd as 'an old de-
l<i i --sed fracture.
Some part of head
or face will iisually
show sign of injury,
ecchymosis, cut, area
0 f oedema, though
stunning force may
have been indirectly
received.
Usually an injury
to head discoverable
in the first two causes
of compression men-
tioned, though injury
to skull may be basal
and not appear on
the surface.
II. Paralysis
Usually hemiplegia,
as demonstrated by
one side being tossed
about, other remain-
int; motionless; or bv
lifting limb, when i't
will fall more flaccid
than the other.
Sc\eral facts are tu
be noted: (i) Uncom-
plicated idiopathic ep-
ilepsy is not attended
by true paralysis; (2)
there may. however,
appear a transient
pseudoparalysis, due
t 0 exhaustion 0 f
motor centres; (3) the
violence of an epilep-
tic fit may provoke
an a])oplexy, in which
case true hemiplegia
arises from the com-
plication; (4) epilepsy
may be engrafted up-
on case of birth palsy,
the paralysis then
antedating the epi-
l^sy.
Convulsions p r e -
cede coma and are of
tvpical character, i. e.,
first tonic, succeeded
by clonic spasms
whether they be gen-
eral or local.
Paralysis present of
one or more cranial
nerves, one or more
sets of muscles, mono-
p I e g i a, hemiplegia
(usually), or even of
the whole body. Pro-
gressive paralysis is
peculiarly characteris-
tic of compression
from meningeal haem-
orrhage.
12, Convulsions
Violent delirium
may be a part of the
picture, rarely con-
Convulsions rare,
although there may
be convulsive move-
ments of some parts
There may be re-
peated convulsions.
Occasionally, though
by no means the rule.
Quite common to
have one or repeated
convulsions.
13. The Urine
.111.1 m.ndrirr
Considerable amount
of sugar in urine,
which gives also acf
tone reaction.
Apt to show some
abiimin and casts
from coexistence of
interstitial nephritis.
N 0 t uncommonU
urine is voided invol-
untarily.
Bladder often para-
lyzed, hence retention
of urine, until over-
flow causes inconti-
nence.
■March 7, 1908.]
THE RA PE UTICA L XOTES.
457
f lurapeutkal |[otes.
Aphrodisiacs and Antaphrodisiacs, — From
Pron's Formttlaire synthctique dc medccinc (Paris:
J. Rousset) we take the following prescriptions for
aphrodisiac and antaphrodisiac preparations:
Aphrodisiacs:
A warning is given against the use of prepara-
tions of cantharides, which are irritating to the di-
gestive tract and the genitourinary organs.
3 Tincture of benzoin, )
Tincture of can alia, v aa 31.
Tincture of vanilla, )
M. Sig. : Twenty drops to one teaspoonful three times a
day.
B Compound spirit of ether \ aa 5i ;
Tincture of canella, J
Tincture of nux vomica, \ ^
Tincture of vanilla )
M. Sig. : Eight to ten drops three times a day.
B Phosphoric acid / aa gr. xv;
Pulverized cmchona bark. )
Pulverized camphor gr. ivss ;
Extract of cascarilla, q. s.
M. ft. pil. No. xxiv.
Sig. : One to three pills four times a day.
B Zinc phosphide, gr. iss.
Ft. pil. No. xii.
Sig. : One to two pills three times a day.
B Yohimbine (or yohimbine hydrochloride), . . .gr. 1^;
Distilled water, 5iiss ;
Dissolve.
For hvpodermic injection. Five to fifteen minims
to be injected at night in the region of the thigh.
After a few days the treatment should be suspended
for one or two days.
B Solution of yohimbine hydrochloride Ci per
cent), 5ii.
Sig. : Five to ten drops three times a day
(This drug is said to lose its effect after a few
Aveeks of use.)
B Extract of cannabis indica, / - - j^. .
Extract of nux nomica, S ^ ' '
Extract of aloes, gr. xii.
M. ft. pil. No. xii.
Sig. : One three times a day.
Antaphrodisiacs:
B Monobromated camphor, gr. iv.
Fac capsula No. i.
Sig. : One capsule three or four times a day.
B Monobromated camphor, 3iiss ;
Alcohol Biiss;
Glycerin Jiiss.
M. Sig. : One teaspoonful once or thrice daily.
B Aqueous extract of hyoscyamus gr. xii.
M. ft. pil. No. xii.
Sig. : One pill three or four times a day.
R Lupulin, gr. xii.
Ft. cachets No. xii.
Sig. : One cachet to be taken three or four times a day.
B Potassium bromide, 5v ;
Distilled water, adde
Sig. : One tablespoonful morning and evening.
Calcium Chloride in Albuminuria. — Renon, in
a communication to the Societe de Therapeutique
de Paris {Journal of the American Medical Associa-
tion, February 20, 1908). .says that calcium chloride
has proved efficacious in arresting albuminuria of
various origins, without any supplementary meas-
ures or repose. He gives one and one half grain for
five or six days, gradually increasing the dose if
necessary to seven and one half grains, and keeping
up the treatment for a month if the albuminuria per-
sists. A number of patients were cured by this
means after the complete failure of dietetic meas-
ures and prolonged repose. In half the cases treated
the albuminuria vanished entirely. In another
fourth no effect was apparent, or the albuminuria
became aggravated, which occurred in a few in-
stances.
The Treatment of Erythematous Eczema. —
Shoemaker {Medical Bulletin, February, 1908) rec-
ommends as a local application for erythematous ec-
zema the following ointrhent :
B Salicylic acid, 5ss;
Resorcin, Jss ;
Compound tincture of benzoin 3ii;
Zinc ointment, 5'.-
Ointment of rose water, 5'-
Misce, ft. unguentum.
Sig. : Apply locally twice daily.
Internallv the following pill is directed to be taken
for its alterative etfect on the glands and as a diges-
tive corrigent :
B Silver nitrate, 1 ka. sr
Extract of hyoscyamus, J
M. ft. pilula No. I.
Sig. : One pill to be taken half an hour before each meal.
Nervous Palpitation. — As a sedative Lemoine
and Gerard {Lc progrcs medical Beige, January i,
1908) recommend quinine valerianate to be given in
a cachet everv morning in combination with sodium
bicarbonate, or camphor, in the following com-
bination :
B Quinine valerianate gr. iiiss;
Sodium bicarbonate gr. vii.
M.
B Quinine valerianate gr. iiiss;
Camphor, gr. vii ;
Pulverized valerian gr. iii.
M.
Corrosive Sublimate in Pill Form for Syphilis.
— In the treatment of syphilis Guiard {Journal de
mcdecine de Paris) gives corrosive sublimate in pills
of the following composition :
B Extract of opium 3ss ;
Glycerin, 3iTI}'xv;
Pulverized gluten, 3iv;
Corrosive sublimate gr. xv;
Sodium chloride gr. xv ;
Water 5iss.
Dissolve the extract in the glycerin, add the gluten, fol-
lowed by the corrosive sublimate previously dissolved in the
water with the aid of the sodium chloride, and make 200
pills.
Sig. : One pill four times a day.
Medicinal Treatment of Graves's Disease. —
Thomson {American Journal of the Medical
Sciences. IMarch, 1908) favors the medicinal treat-
ment of Graves's disease. He recommends to every
patient thirty grains of sodium- phosphate, to be
taken at the beginning of each meal, and a blue pill
or other mercurial laxative to be taken twice a week.
A course of intestinal antiseptics is then recom-
mended, to be kept up for months at a time. He usu-
ally begins with sodium salicylate and sodium ben-
zoate, of each ten grains, an hour after each meal.
He prescribes for administration at bedtime a cap-
sule containing naphthalene three grains and
sodium benzoate six grains. After a time he sub-
stitutes a capsule containing phenol bismuth and
ammonium benzoate, each five grains, of which two
should be t^ken an hour after meals. The principle
458 NEIV YORK MEDICAL JOURNAL.
of these remedies as intestinal antiseptics being- un-
derstood, every physician can, Dr. Thomson says,
vary the prescription as he finds best.
Lord Lister's Formula for Chromic Catgut.—
The following directions for preparing what is
known as chromic catgut were communicated by
Lord Lister to the Lancet for January 19th :
"The preparing liquid must be twenty times the
weight of the catgut. So for forty grains of catgut
800 grains of preparing liquid are required. It is
made by mixing two liquids — namely, the chro-
mium sulphate liquid and the sublimate liquid.
"The sublimate liquid is :
Corrosive sublimate 2 grains;
Distilled water, 320 grains.
"The sublimate may be dissolved by heat, but the
solution must be used cold.
"The chromium sulphate liquid is prepared
thus :
Chromic acid, 4 grains;
Distilled water, 240 grains.
"Add to this as luuch sulphurous acid (P.B. solu-
tion)'as gives a green color. If more is added, the
color becomes blue, which shows that rather too
much sulphurous acid has been used. It is well to
reserve a few drops of the chromic acid solution,
to be added after the blue color has just appeared
and restore it to green. Then enough distilled water
is added to bring the green liquid up to 480 grains.
Then add the sublimate liquid.
"The catgut is kept for twenty-four hours in the
preparing liquid and is then dried on the stretch.
(X. B. — It is esse.ntial that the chromic acid and
sulphurous acid solutions be mixed before the sub-
limate solution is added).
"Catgut prepared in this way remains actively an-
tiseptic in its substance for an indefinite period, as
was shown by the following experiment : Some
slender hanks prepared three years previouslv,
weighing 207 grains, chopped into short segments,
were placed in a small mortar and treated with
enough distilled water to cover them, 2,000 grains
being required for the purpose. The gut was then
pressed firmly with a pestle and the same was after-
wards done three times at intervals of about three
hours. The gut and water were then transferred to
a stoppered bottle for seventeen hours, when the
liquid was poured off and filtered, being clear and
almost colorless. The germicidal property of the in-
fusion was carefully tested by the late Dr. Allan
]\racfadyen. In spite of the large amount of water
used in preparing it. he found that it destroyed the
Streptococcus pyogenes in a quarter of an hour :
when diminished to half its bulk by evaporation iu
vacuo it killed Staphylococcus pyogenes aureus in
half an hour; and when further reduced by one half
it deprived the resisting spores of anthrax of vitality
in two hours, although the amount of the liquid was
still about twice that of the catgut to which it was
a])plied.
Harrington's Solution. — This solution, which
originated with Dr. Francis B. Harrington, of l!os-
ton, is regarded by surgeons {New York Mciical
Journal. February 15, 1908) as one of the best and
least destructive antiseptic fluids for suppurating
wounds, and for general use in the operating room.
Summers (loc. citat.) says it has been proved ex-
perimentally and clinically that it kills all the com-
mon germs met in surgical practice in from twenty
seconds to a minute, and it is not caustic. Besides
its antiseptic property it possesses the power, when
applied to a raw surface, to produce a copious dis-
charge of serum, thus aiding the washing away of
noxious elements from the wound. The formula for
the solution is as follows :
R Corrosive sublimate, gr. xv :
Hydrochloric acid fl. Siiss ;
Water, fl. 3xii 3vi ;
Alcohol fl. jxxvii.
Solve.
Sig. : Harrington's Solution.
Mixtures for Bronchial Asthma. — Rossbach
( Thcrapciitischc Rundschau) recommends the fol-
lowing mixtures as being efficacious in the treatment
of bronchial asthma, and acute and subacute
iarvngitis :
I.
B Apomorphine hydrochloride gr. J4 :
Codeine phosphate gr. i to gr. ii ;
Hydrochloric acid TU'viii:
Simple syrup 3v ;
Distilled water ad ^vi.
M. et Sig. : One tablespoonful everv three hours.
II.
H Apomorphine liydrochloride gr. iii ;
Codeine phosphate, gr. viii ;
Hydrochloric acid gtt. i;
Hot distilled water, ad 5v.
Dissolve. Sig. : Ten drops every two hours.
Tannic Acid in the Treatment of Dermatitis
Venenata and Eczema Vesiculosum.^ — The drug
which in the hands of Kinnaman (American Jour-
nal of Dcniiatologx, February. 1908) has given
most uniform success in allaying the inflammation
of the skin and checking the serous discharge froin
the ruptured vesicles or blebs in cases of dermatitis
venenata and eczema vesiculosum is tannic acid. It
may be used in either of three ways, i. e., as a dust-
ing powder, as a lotion in aqueous solution, and in-
corporated with a base aS a salve. If the case is
seen early and only a few of the vesicles have rup-
tured he uses one or other of the following com-
binations :
I.
R Tannic acid, 5i ;
Talc, 3ii.
M. Sig. : .^s dusting nowder.
II.
R Tani;ic acid. * -- -jj
Thymol iodide, \ ' " "
M. Sig. : As dusting powder.
The parts are to be protected with cotton and
bandages.
When there is a moderate degree of serous dis-
charge the following applications have proved most
efficient :
I.
^ Tannic acid, 3ss to ,3i ;
Zinc oxide 3i ;
Ointment of rose water 'i.
M.
11.
i: Tannic acid. { -- ,
Thymol iodide, \ aa oss,
Zinc oxide 5ss;
Ointment of rose water, 5'-
M.
.Mauli 7, 1908.J
EDITORIAL ARTICLES.
459
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Review of Medicine.
Edited by
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and SMITH ELY JELLIFFE, M. D.
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Entered at the Post Office at New York and admitted for
- transportation through the mail as second class matter.
NEW YORK, SATURDAY, M.ARCH 7, 1908.
THE PUBLIC HEALTH AND MARINE
HOSPITAL SERVICE.
We have received the Annual Report of the
Surgeon General of the Public Health and Marine
Hospital Service of the United States for the
Fiscal Year Jpo/. It is an octavo volume of 146
pages. For five years now the bureau, formerly
the Marine Hospital Service simply, has been
charged with the great additional duties incident
to its prominent participation in the general san-
itary work of the nation. These duties have been
well performed, and the surgeon general is justi-
fied in saying that "Congress has established a
public health bureau with a broad foundation."
The work, as is well known, extends not only to
our outlying possessions, but also to the foreign
countries from which our immigrants are derived.
Typhoid fever has been profitably investigated in
the District of Columbia, in Savannah, Ga., and in
Charlotte, N. C, and some months ago the bureau
published a voluminous and useful report on this
subject. In conjunction with the Bureau of Ani-
mal Industry and the Bureau of Chemistry of the
Department of Agriculture and the health depart-
ment of the District of Columbia, the bureau has
made a minute investigation of the milk industry,
and we are informed that its report will soon be
published. Surgeon General Wyman assures us
that, as a result of the bureau's supervision of
vaccines and curative serums, the tetanus antitox-
ine now produced is worthy of complete confi-
dence, both as to purity and as to potency, though
before it was weak and variable. An account of
the plague investigation in San Francisco is to be
included in the next annual report.
The other activities of the bureau have been con-
nected with the Jamestown Exposition, making
provision for the investigation of leprosy in the
Territory of Hawaii, the national quarantine, the
medical inspection of immigrants (1,285,349 in-
spections), sanitary conferences with State boards
of health, and, of course, the operation of the ma-
rine hospitals. It will be seen that the bureau's
work is onerous, and it is gratifying to find, as we
do in this report, abundant evidence that it is per-
formed efficiently.
ALBU.MINURIA AND THE ITCH.
Of course, we long ago gave up the old notion
of the "repercussion" of skin diseases and the dire
results of such an occurrence, but it is interesting
to note that it lingered rather late in the nineteenth
century, as we are reiiiinded in an article by Dr.
J. Nicolas, clinical professor, and Dr. A. Jambon,
chief of clinic, of the Antiquaille Clinic for Cutan-
eous and Venereal Diseases of the Universit)- of
Lyons, published in the February number of the
Annales de deniiatologie et de syphiligraphie. But
this is not all that our authors do; they confirm the
observations of a number of modern clinicians to
the effect that albuminuria is a frequent accom-
paninient of scabies, and they discuss in a ver\-
illuminating way the relations of the renal disorder
to the skin disease.
They show that the connection between scabies
and albuminuria is not merely that of coincidence,
that it is not to be explained by the assumption that
the subjects were already affected with renal dis-
ease and the itch was simply a casual acquisition,
though they admit that persons who have been sub-
jected to the ordinary causes of nephritis are more
likely than others to be attacked with it in the
course of scabies. They do not approve of the the-
ory that the kidney disturbance is due to inter-
ference with the cutaneous functions, whereby un-
due work is forced upon the kidneys, as when the
skin is extensively burned or covered with some
impermeable material, for they have found that
albuminuria occurs in many instances in which the
scabies is not widely diffused over the skin.
The theory that the renal affection is due to the
penetration of pyogenic organisms into the blood,
with the production of toxines, does not seem to
the authors adequate to account for what takes
place, because in a large proportion of the cases
observed by them the lesions Avere not pustular;
460
they do, however, admit the possibiUty of such a
mode of production in pustular cases. They look
with favor, too, upon the hyix>thesis that the cutan-
eous irritation may of itself give rise to the kidney
trouble through the mediation of the nervous sys-
tem. There would, however, be nothing peculiar to
scabies in that ; many cutaneous af¥ections are
accompanied by an amount of irritation equal to
that of the itch, and involving as great an extent
of skin. The authors do not altogether reject the
idea that the sarcoptes itself may generate a poison
that gains entrance into the blood. They regard the
question of the manner in which scabies gives rise
to albuminuria as by no means satisfactorily settled.
They announce their intention of continuing their
investigation and of communicating a further arti-
cle on the subject, which is well worthy of study.
UNCINARIASIS IN PUERTO RICO.
The third report of the men engaged in the at-
tempt to reduce or to eradicate infection with
Nccator americanus in Puerto Rico shows that the
infection is most common in persons from fifteen
to twenty-nine years of age, and that all classes of
the population are hosts of the parasite. The infec-
tion is often acquired by cultivating flower gardens.
As in former reports, the commission includes the
results of scientific study of the disease and its
pathology. Dr. Gutierrez, the chairman of the com-
mission, has succeeded in showing that Ankylostoma
duodenale is present in Puerto Rico, as well as
Necator americanus. The opinion is again put
forth that infection takes place through the skin,
the passage of the larvae through the skin produc-
ing a papulopustular dermatitis, called masamorra
by the peasants.
The commission advances the theory that the
anaemia of uncinariasis is due to haemolysis, and not
to haemorrhage, as was formerly believed. Their
reasons for this belief are the facts that bloody
stools are extremely rare and that the intestine of
the parasite contains principally epithelium and very
few red blood cells. They have made no studies of
the stools for occult blood, dismissing the subject
with the statement that should occult blood be
found, it would not explain the severe anaemia, on
account of the small quantity of blood indicated by
that test.
We would point out that the test for occult blood
is not a quantitative, but a qualitative test. It is
quite possible that a considerable amount of capil-
lary haemorrhage, enough when continued for long
periods of time to produce severe anaemia, may
occur high in the jejunum and in the duodenum,
[New \os.k
Medical Jocrnal.
and that by the time the faeces are passed the blood
would be so altered as to be demonstrable only by
the test for its haemoglobin derivatives. Also it is
conceivable that blood taken into the intestine of
the parasite would undergo alterations sooner than
epithelial cells, and so distinct erythrocytes be un-
recognizable with the microscope.
The commission has studied the condition of the
urine in twenty-four cases. Albumin with casts is
found to be common. This is considered to be indi-
cative of a degenerative change in the kidneys and
not of an inflammation. The albumin is present in
very small quantities, requiring the application of
the acetic acid and potassium ferrocyanide test for
its demonstration. It is well known that this test
will give a positive reaction with mucin and with
fibrinogen. In order to infer the presence of degen-
erative or inflammatory changes in the kidney we
believe that serum albumin in sufficient quantities
to be detected by the beat and nitric acid tests, or
by the cold nitric acid test, should be present. It
appears to us that the condition present is one of
renal irritation only, which is sometimes made worse
by the administration of thymol or beta naphthol.
There is much interesting matter in the report, in-
cluding an admirable photomicrograph of the para-
site in situ, made by Dr. W. M. Gray, of the Armv
Medical Museum.
A NEW NEW YORK STATE COLONY.
The march toward organized and comprehensive
care of the dependents in New York State has gone
steadily forward. The State care of the insane and
the gradual coordination of the State hospitals
marked one of the greatest epochs in the
history of such movements in the State. Its
great success, if judged alone from the standpoint
of those cared for, admits of little question, even it
a host of economic considerations press forward and
demand a hearing if not an intelligent readjustment.
It must be acknowledged that defects exist, that
backsliding is not infrequent, that organization car-
ries in its train evils of no small moment, that
small malefactors may remain undisturbed for years
hidden in the meshes of a large system, that laziness
and incompetence may be overlooked in their minor
exhibition in order that greater good may not be
hampered. These we feel are but flies in the pot of
ointment that honest and efficient government and
highminded officials — and the State service has had
a number of such — can remove, and the good work
can go on.
The establishment of the Craig Colony for Epilep-
tics marked another milcnost in this Stnte. v\u\ the
EDITORIAL ARTICLES.
March 7, 1908.]
EDITORIAL ARTICLES.
461
work that the State Board of Charities, the board
of managers, and Dr. W. P. SpratHng have done has
been a credit to our institutions, and the medical
profession has shown itself here, as in the State
Lunacy Commission, capable, conscientious, hon-
orable, and highly progressive. It is only the mind
of small outlook that can think carping criticism of
the management of our insane and our epileptics,
from the economic, humanitarian, and scientific
sides, as exemplified in these two enterprises.
In the State care of its idiots and imbeciles a like
progressive spirit has marked the administration
of the State Board of Charities, and it is with pleas-
ure that we note the announcement that new and in-
creased facilities for the care of the defective and
epileptic are to be offered in a new colony now rec-
ommended, to be called the Haverstraw State Col-
ony, to replace the old and cumbersome title of the
Eastern New York Custodial Asylum.
The report of the commissioners, an able and
thorough document, in recommending to the State
the purchase of a large farm at Shiel, lying just out-
side of Haverstraw, for development into a colony
of the type of Craig Colony, should be received and,
we believe, acted upon favorably. There is need
for such a colony nearer New York, where defect-
ives, idiots, imbeciles, and epileptics may receive the
kind of care which the State is abundantly
able to provide, and which will reflect credit upon its
administrators. The institutions already devoted to
this work are well and favorably known. Craig
Colony has served as a model for philanthropic en-
terprises far and near, and a new one along such
progressive lines should receive the enthusiastic sup-
port of all physicians.
In one matter alone do we feel inclined to ofter
one word of suggestion, and that concerns the nam-
ing of such institutions. We should like to see the
names of our philanthropists and workers for the
betterment of the diseased and afflicted perpetuated'
in an appropriate and honorable manner. No one
has worked more for these ends than Josiah P.
Letchworth, for many years president of the State
Board of Charities. The Letchworth State Colony,
we submit, is, from this point of view, more appro-
priate than the name recommended; or, if as physi-
cians, we would turn to do honor to one in our
ranks who first inaugurated the movement for the
training of defectives, such as are to be cared for in
this new colony, the late Dr. Edward Seguin would
immediately occur to our minds. Let our State insti-
tutions of this nature receive the names of our fore-
most citizens, and so may the community never for-
get those who have been their founders, and after
coming generations be stimulated to the doing of
good work.
THE ROYAL SOCIETY OF MEDICINE.
The Royal Society of Medicine was formed in
June, 1907. by the amalgamation of the following
London medical societies : The Royal Medical and
Chirurgical Society, the Pathological Society, the
Epidemiological Society, the Odontological Society
of Great Britain, the Obstetrical Society, the Clin-
ical Society, the Dermatological Society, the British
Gynaecological Society, the Neurological Society,
the British Laryngological, Rhinological and Oto-
logical Association, the Laryngological Society, the
Dermatological Society of Great Britain and Ire-
land, the Otological Society of the United King-
dom, the British Electrotherapeutical Society, and
the Therapeutical Society.
These societies now form sections of the new
organization, the publication of which is to be
known as the Proceedings of the Royal Society of
Medicine. It is to be issued monthly from Novem-
ber to July. The first number has recently been
received at this office. It is an octavo journal, in
which the proceedings of the various sections are
separately paged, evidently for future distinct bind-
ing. The articles in the initial number are chiefly
clinical reports of cases and the addresses of the
presidents of the various sections. There are a
number of excellent illustrations.
THE PASSING OF THE FERRY BOAT.
With the subaqueous passages already established
for the conveyance of passengers to and from the
borough of Manhattan and the prospect of the open-
ing of other tubes within a short period, it seems
probable that the ferry boats that have so long plied
on the Hudson River and the East River will prac-
tically disappear. For some other than sentimental
reasons, this state of things may not be altogether a
subject for congratulation. The ferries are so ac-
cessible that they have afforded to many a poor
mother a ready means of giving her sick child a re-
viving breath of fresh air. Of course there are
longer sails that may still be taken for that purpose,
and it is to be expected that some of the ferries will
survive, but the reduction of their number will act
as a restriction upon a cheap and readily available
means of moderating infant mortality in the hot
months.
THE TEMPERATURE OF THE SUBWAY.
No New Yorker needs to be told of the oppres-
sive heat of the subway trains in summer, a heat
that persists in spite of the devices that have thus
far been resorted to for its moderation; and few
of them, we imagine, have yet failed to observe that
HEMS.
LXeu Vokk
Medical Journal
ciuriiig the past winter the cars have been unconi-
fortabl}- cold. It seems to us that they have been
colder than in the preceding winters, colder and
more pervaded b}- draughts, and it is the draughts
especially that tend to chill a passenger. Though
much less forcible, they are worse in this respect
than the winds outside the tunnel, intensified as they
are by our ever multiplying "sky scrapers." It is
not the passengers who sufifer chiefly, for their ex-
posure is of comparatively short duration ; the train
hands must often sustain real injury, one would
think. It is clear that better means should be taken
t<i make the temperature of the subway comfortable
at all times.
Changes of Address.— Dr. F. Ward Langstroth, to
156 West Ninety-.seventli .'Street, New York.
A New Nurses' Registry. — We are informed that a new
rcgislr\- for graduate nurses of the New York City Hos-
pital Training School has been opened at 1185 Lexington
avenue, New York.
Wills Hospital Ophthalmic Society, Philadelphia.—
The following officers were recently elected to serve during
iyo8: Chairman, Dr. Samuel D. Risley ; vice chairman,
i )r. William Campbell Posey ; secretary, Dr. Burton Chance.
Resolutions on the Death of Dr. Probasco.— A special
meeting of the Union County, N. J., Medical Society was
held in Plainlield on Thursday afternoon, February 27th,
at which resolutions were adopted expressive of regret at
the death of Dr. John B. Probasco.
The Philadelphia Academy of Surgery has elected the
following officers for the year 1908: President, Dr. William
J. Taylor; vice presidents, Dr. Robert G. -Le Conte and
])r. G. G. Davis: secretary. Dr. John H. Gibbon; treasurer.
Dr. James P. Hutchinson; and recorder. Dr. John H.
Jopson.
The Harvey Lectures. — Professor Ross G. Harrison,
of ^'ale University, will deliver the eighth lecture in this
course at the New York Academy of Medicine on Sat-
urday, March "th, at 8:30 p. m. The subject of the lec-
ture is Embr\onic Transplantation and the Development
of the Nervous System.
College of Physicians of Philadelphia. — At a meeting
held on Wednesday evening, March 4th, Dr. Joel E. Gold-
thwait, of Boston, read a paper entitled Our Present Un-
derstanding of the Nontuberculous (Rheumatic) Diseases
of the Joints. Dr. James C. Wilson. Dr. G. G. Davis, and
Or. Charles fl. Frazier took part in the discussion.
Nova Scotia's Children's Hospital. — We learn from
Charities and the Commons that a children's hospital is t<-
he established in Halifax, N. S., in order to care for the
children of the province. The sum of $25,000 has been
collected toward a building fund, and the committee will
jirocccd at once with the plans for the new institution.
Cincinnati Academy of Medicine. — .\t the annual elec-
tion, which was held on March 2d, the following officers
were elected to serve for the ensuing year: President.
Dr. William Gillespie ; first vice president, Dr. R. B. Hall :
second vice president. Dr. Stephen C. Cone ; secretary. Dr.
Mary Keytc Isham : treasurer. Dr. .\. G. Drury ; and libra-
rian. Dr. A. 1. Carson.
Medical Society of the College of Physicians and Sur-
geons, Baltimore.— .\l a meeting of this society, which
was lirld un Thursday evening, February 20th, Dr. Hans
Rcitze, of the Virschow Hospital, Berlin, delivered a lec-
ture on a .New Cure for Gout and Rheumatism. Dr. \. M.
Forster, of the Eudowood Sanatorium, spoke on the Sana-
torium Treatment of Tuberculosis, and Dr. H. S. Beck
and Dr. J. J. O'Malley read papers which dealt with the
.^nbjcct of tiic pituitary gland.
Obstetrical Society of Philadelphia. — Xt a meeting
of this society, which was held on March 5th. the following
papers were read : Synctioma Malignum of the Placenta,
by Dr. E. P. Da-\ is ; Sarcoma of the Round Ligament, and
Fibroid Tumor of the Anterior Abdominal Wall, by Dr.
Wilmer Krusen ; .\denoma of the Cervix Associated with
Fibroma of the Uterus, by Dr. George Erety Shoemaker.
Syracuse, N. Y., Academy of Medicine. — .\ regular
meeting of this academy was held on Tuesday, March 3d.
Diabetes waN the general topic for discussion, and papers
were read as follows : The Skin in Diabetes, by Dr. H.
C. Baum ; the Surgical Aspect of Diabetes, by Dr. Nathan
Jacobson ; and the Treatment of Diabetes, by Dr. J. L.
Heftron. The discussion was opened bj' Dr. F. P. Knowl-
ton.
Rochester, N. Y., Academy of Medicine. — The Sec-
tion in General Medicine, which includes neurology,
psychiatry, materia medica, and therapeutics, held a regu-
lar meeting on Wednesday evening, March 4th. The pro-
gramme included a paper on Acute Anterior Poliomyelitis,
which was read by Dr. Robert G. Cook, and the presenta-
tion of a case of Tuberculous Hip Disease Occurring in the
Aged, by Dr. L. A. Whitney.
Elmira, N. Y., Academy of Medicine. — At a meeting
of this academy, which was held on Wednesday evening.
March _|cli, the following papers were read: Some Points
in Hygiene Well to Remember, by Dr. H. D. Wey. of
Elmira; An Odd Case in Obstetrics, by Dr. J. C. O'Brien,
of Elmira; Chronic Interstitial Nephritis, by Dr. O. J.
Bowman, of Horseheads ; The Diagnosis and Clinical Sig-
nificance of Peritonitis, by Dr. H. B. Smith, of Corning.
National Congress of Mothers. — Preliminary announce-
ments have been sent "out by this organization for a con-
ference to be held in Washington, D. C, on March loth
to i6th. The announcement states that the members of the
congress have studied the needs of children for a number
of years, and at these conferences, which are annual, inter-
esting discussions are held on the question of the best
methods to adopt to bring about the highest development
of the coming race.
The Health of Pittsburgh. — During the week ending
February 15, 1908. the following cases of transmissible dis-
eases w ere reported to the Bureau of Health : Smallpox.
I case, o deaths; chickenpox, 9 cases, o deaths; typhoid
fever, 41 cases. 12 deaths : scarlet fe\-er, 25 cases, o deaths ;
diphtheria, 18 cases, 2 deailis ; measles, 317 cases, 11 deaths;
whooping cough, 20 cases. 2 deaths ; pulmonary tubercu-
losis, 17 cases, 17 deaths. The total deaths for the week
numbered 244, corresponding to an annual death rate of
31.46 in 1. 000 of population.
New York Academy of Medicine. — The following pa-
pers will be read at a stated meeting of the academy, which
is to be held in Hosack Hall on Thursday, March 19th, at
8:30 p. m. : Tbe Psysiological Mechanism of Vasocon-
striction and Vasodilation, by Dr. George B. Wallace; The
Therapeutics of Vasoconstriction and \"asodilation, b\- Dr.
Egbert Le Fevre : The Present Status of Experimental
Arterial Disease, by Dr. L Adler; and Toxic Arteritis,
\^ith Report of a Case of Prolonged Use of Adrenalin, bv
Dr. Harlow Brook> and Dr. D. M. Kaplan.
Scientific Society Meetings in Philadelphia for the
Week Ending March 14, 1908. — Monday, March gth.
Section in General Medicine. College of Physicians; Wills
Hospital Ophthalmic Society. Tuesday. March joth, Phila-
delphia Pediatric Society : Botanical Section, Academy of
Natural Sciences. Jl'edncsday. March iith, Philadelphia
County Medical Society. Thursday. March 12th. Patho-
logical Society; Section Meeting, Franklin Institute. Fri-
day, March 13th, Northern Medical .Association ; West
Branch. Philadelphia County Medical Society.
Conference on the Congestion of Population. — .At thc
opening session of this conference. Monday evening, March
gth, at the American Museum of Natural History, Dr.
John H. Finley. president of the College of the City of New
York, will preside. Among those who will make addresses
are Governor Hughes. Commissioner Darlington, Commis-
sioner Hebbcrd, Mrs. Vladimir G. Simkhovitch. His Ex-
cellency Baron Mayor des Planches, and the Italian .Am-
bassador to the United States. Reserved seats for this
meeting may be obtained by addressing the committee, 105
East Twenty-second street. Three sessions will be held on
Tuesday, two on Wednesday, and two on Thursday.
March ;. igcS.J
XEIVS ITEMS.
463
The Medical Society of the Missouri Valley will meet
in Lincoln, Neb., on March 19th and 20th, on the invita-
tion of the Lancaster County Medical Society. The ad-
dress of welcome will be made by Dr. Frank Brown, mayor
of Lincoln, to which Dr. R. C. McDonald, of Fremont,
Neb., will respond. Dr. Charles H. Hughes, of St. Louis,
will deliver the oration in medicine, and Dr. William Jep-
son, of Iowa, will deliver the oration in surgery. Pro-
grammes may be obtained from the secretarj- of the so-
ciety, Dr. Charles Wood Fassett, of St. Joseph. Mo.
Buffalo Academy of Medicine. — The Section in Sur-
gery held a regular meeting on Tuesday evening. March
3d. Dr. F. Whitehill Hinkel gave a demonstration of di-
rect bronchoscopy and oesophagoscopy. Dr. ^larshall Clin-
ton and Dr. Hermand Hayd reported cases of echinococcus
cyst of the liver. Dr. Prescott Le Breton read a paper
entitled Spinal Sprain : Its Complications and Conse-
quences, with Report of Twenty-six Cases, and Dr. Roland
Mcisenbach read a paper on Flat Foot. Dr. James A.
Gardner is chairman of the section and Dr. Lawrence
Hendee is the secretary.
The Mortality of Minneapolis. — We learn from the
report of the Department of Heahh for the month of Janu-
ary, 1908. that during the month there were 325 deaths
from all causes, corresponding to an annual death rate of
S.46 in i.ooo of population. Of the total number of deaths,
81 were from pneumonia. 33 from tuberculosis. 31 from
heart diseases, 17 from Bright's disease, 9 from diarrhcea
and enteritis, 5 from typhoid fever, 14 from cancer, 6 from
suicide, and 13 from accidents. There were 69 deaths in
public institutions. There were 464 births during the month
— 238 males and 226 females.
Philadelphia County Medical Society. — At a meeting
of the Central Branch of this society, which was held on
Wednesday. February 26th. the following papers were read :
Ether Anaesthesia, by Dr. Colin Foulkrod ; Congenita!
Absence of the Ulna, by Dr. Francis D. Patterson : The
Frequent Necessity of ^lultiple and Consecutive Opera-
tions for Renal Calculi, by Dr. W. Wayne Babcock. Dr.
Ross H. Skillern gave a lantern slide demonstration of the
Anatomy of the Accessory Sinuses of the Nose, with
Especial Reference to Their Suppuration, and Dr. John J.
Gilbride exhibited a specimen of hour glass contraction of
the stomach.
The Mortality of Chicago. — According to the report
of the Department of Health for the week ending Feb-
ruary 22d. there were during the week 616 deaths from
all causes, as compared with 707 for the corresponding
week in 1907. The annual death rate was 14.83 in 1,000
of population. The principal causes of death were : Apo-
plexy. 8; Bright's disease. 47; bronchitis. 25; consumption.
63; cancer, 26: convulsions. 2; diphtheria. 10: heart dis-
eases, 42; influenza, 23: intestinal diseases, acute. 37:
measles, 3; nervous diseases. 21: pneumonia. 117: scarlet
fever, 10 ; suicide, 8 ; typhoid fever. 2 ; violence, other than
suicide, 22 ; whooping cough, i : all other causes. 149.
Opportunity for a Bacteriologist in Savannah.— The
Board of Sanitary Commissioners of Savannah, Ga., an-
nounce that an examination to fill the position of City Bac-
teriologist will be held simultaneously at the Research
Laboratory of the Department of Health. New York: the
U. S. Marine Hospital. Chicago ; the Hygienic Laboratory.
Washington. D. C. ; the U. S. Marine Hospital Service
Office, New Orleans: and the City Hall. Savannah. The
term of office will be five years and the salary $3,000 per
annum. Further particulars regarding the examination are
published in our advertising pages, or may be obtained from
Dr. W. F. Brunner. City Hall, Savannah. Ga.
Association of Seaboard Air Line Railway Surgeons.
— At the sixth annual meeting of this association, which
was held in Tampa. Fla.. February i8th. 19th, and 20th.
the following officers were elected : President. Dr. L. S.
Oppenheimer. of Tampa. Fla. ; first vice president. Dr.
J. G. Dean, of Dawson, Ga. : second vice president. Dr. H.
M. Wilder, of Charlotte. N. C. ; third vice president. Dr.
E. H. Terrell, of Richmond. Va. : secretary and treasurer,
pr. J. W. Palmer, of Ailey, Ga. The executive committee
is com.posed of Dr. James R. Rogers, chairman, of Raleigh,
N. C. : Dr. Southgate Leigh, of Norfolk. Va. : Dr. J. W.
Corbett. of Camden. S. C. : Dr. John M. Blair, of Monroe,
N. C. : and Dr. John W. Miller, of Crossbill, S. C.
A Dinner in Honor of Dr. Ostrander. — The Brooklyn
Medical Society ga\o a dinner on the evening of Saturday,
February 29th, in honor of Dr. George A. Ostrander, to
celebrate his completion of fifty years' practice of medi-
cine in Brooklyn. About seventy-five of the leading physi-
cians and surgeons of Brooklyn were present, among whom
were four physicians who also had completed fifty years
in the profession. Thev were Dr. A. N. Bell. Dr. J. T.
Burdick, Dr. William McCollom, and Dr. J. S. Prout.
-Addresses were made by each of these physicians, the
subject of Dr. Ostrander's talk being the progress of medi-
cal science during the past fifty years.
The Medical and Chirurgical Faculty of Baltimore
Purchase Building Site. — A lot. having a frontage of
>ixty feet on both Maryland Avenue and Cathedral street,
just south of Preston street. Baltimore, ha- been purchased
by the ^Medical and Chirurgical Faculty of Baltimcjre on
which will be erected the new building which is intended
to furnish quarters for a medical library, the State Board
( f Health, the State Board of Medical Examiners, and the
local association of pharmacists, the tuberculosis commis-
sion and the State veterinary board. A building fund of
$200,000 is to be collected, of which some $50,000 has al-
ready been pledged. The legislature will be asked to ap-
propriate Sioo.ooo towards the library.
Charitable Bequests.— The will of Charles E. Wood
provides for the establishment of a sanatorium at Atlantic
City, N. J., at a cost of about $300,000.
By the will of Elizabeth Kuntz the Wernie Orphans'
Home, of Richmond. Ind., receive- $2,000. The Society to
Protect Children from Cruelty-, the Lutheran Home and
Asylum for the Aged and Infirm, and the Home for Crip-
pled Children are reversionary legatees.
By the will of Thomas P. Dillon the Little Sisters of
the Poor, Philadelphia, receive $500.
By the will of Cyrus Detre the Samaritan Hospital.
Philadelphia, receives $500.
By the will of Mrs. Mary E. Ives the General Hospital
Society of Connecticut recci\ es $5,000 for the establishment
of a free bed in memory of Mr. Hoadley B. Ives, and
Grace Hospital. New- Haven, receives $5,000 for a free bed
in memory of Mrs. Mary E. Ives.
Infectious Diseases in Pittsburgh. — The following
cases of transmissible diseases have been reported to the
Bureau of Health of Pittsburgh :
Week ending. Tan. 4. Jan. 11. Tan. iS. Tan. 25. IVb. i. Feb. 8.
Chickenpox 12 o 12 o 14 o 13 o 10 o 10 o
Typhoid fever 76 22 119 14 117 9 86 16 78 10 84 7
Scarlet fever 7 o 25 3 22 i 23 i 22 i 18 i
Diphtheria 20 2 24 3 19 4 19 4 14- 3 11 4
NTeasIes 117 5 282 9 355 13 476 15 468 21 493 20
Whooping cough. 12 011 3 5 iii o 4 3 10 0
Pulmonary tuber-
culosis 17 13 22 17 23 12 13 8 II !4 if) 10
Total deaths . . 238 330 271 263 246 242
.\nnual death rate
in I.ooo of popula-
tion 30.43 42.54 34.94 -33-91 31.71 31.20
( Estimated population. 403.300.)
The Health of Philadelphia. — During the week end-
ing February 8. 1908. the following cases of transmissible
diseases were reported to the Bureau of Health : Typhoid
fever. 114 cases. 18 deaths: scarlet fever. 55 cases. 4
deaths: chickenpox, 44 cases, o deaths : diphtheria, 88 cases,
II deaths: cerebrospinal meningitis. 2 cases, 2 deaths;
measles. 125 cases. 3 deaths ; whooping cough, 33 cases. 5
deaths: pulmonary tuberculosis. 70 cases, 77 deaths; pneu-
monia, 56 cases, 71 deaths : erysipelas. 21 cases. 5 deaths :
tetanus, 2 cases, i death ; puerperal fever, 2 cases. 4 deaths :
mumps, 17 cases, o deaths: cancer. 15 cases. 23 deaths.
The following deaths were reported from other trans-
missible diseases : Tuberculosis, other than tuberculosis of
the lungs. 8: diarrhoea and enteritis, under two years of
age. 13. The total deaths number 598 in an estimated pop-
ulation of 1,532.738. corresponding to an annual death rate
of 20.21 in I.ooo of population. The total infant mortality
was 133; under one year of age. tc6: between one and two
years of ase. 27. There were 35 still births — 26 males and
9 females.
464
NEWS ITEMS.
INi-A- York
Al uiCAL Journal.
Infectious Diseases in New York:
IVe are indebted to the Bureau of Records of the Depart-
ment, of Health for the following statement of nei<u cases
and deaths reported for the two weeks ending February 2g,
1908:
^February 22.^ ^February 29. -^
Cases.
Deaths.
Cases.
lieaths
Tuberculosis pulmonalis
388
451
204
373
44
Measles
26
1.554
39
39
924
39
Varicella
180
33
45
9
20
I
Cerebrospinal meningitis
10
9
16
8
Totals
2.993
325
3.563
344
Personal. — Dr. Walter E. Whitney, of Waterville,
J\le., and Dr. Frank J. Vankirk, of Bellinghani, Wash., are
registered at the Philadelphia Polyclinic and College for
Graduates in Medicine.
Dr. Jacob Frank, of Chicago, has received from Count
Matsukato, president of the Red Cross Society of Japan,
a medal made from weapons actually used on the battle-
field, in recognition of the service rendered by him during
the Russo-Japanese War.
Dr. Mortimer J. Lampson has been appointed superin-
tendent of the Jersey City Hospital.
We learn from the Canadian Journal of Medicine and
Surgery that Dr. George Elliott, of Toronto, has been ap-
pointed provincial medical examiner for the Royal Ar-
canum in Ontario.
Dr. Charles D. Aaron, of Detroit, has been appointed a
member of the Committee of One Hundred on National
Health.
Dr. William H. Taylor, of Cincinnati, was tendered a
dinner at the Queen City Club on the evening of March
2d, in honor of the fiftieth anniversary of his graduation
in medicine.
Dr. Elizabeth Blackwell, of Hastings, England, who is
the first woman to take a medical degree, was eighty-six
years old on February 3d.
The Grand Legion of the Red Cross is the name
given to a trained volunteer army of first aid, which is
being organized by the American National Red Cross. The
Grand Legion is made up of four or more legions, each
legion has four relief columns, each column four detach-
ments, and each detachment four .squads. The first relief
columns were formally organized on January 22, 1908, in
Brooklyn, under the direction of Dr. Glentworth Butler,
who was assisted by Major Charles Lynch, of the Medical
Department of the U. S. Army, who has been specially de-
tailed by the Surgeon General to aid in the work. The
members of the Legion will be taught to give first aid
under all conditions, and will be prepared to serve as a
body in time of need. They will not be obliged to serve
in the Army hospital corps in time of war, but may do so
if they wish. The chief work of the Legion will be, both
directly and indirectly, a crusade against preventable acci-
dents, and it is estimated that about two thirds of the
10,000,000 accidents a year in the United States are pre-
ventable. The Grand Legion will not be composed of men
alone; each relief column will eventually have attached to
it a relief corps of women trained in first aid and home
nursing. Further information concerning this work may
be obtained at the New York State Branch of the American
National Red Cross, 500 Fifth avenue. New York.
Philadelphia Bureau of Health Statistics.— During the
month of December, IQ07, in the Division of Medical In-
spection 3,952 inspections were made, excluding schools;
715 fumigations were ordered; 64 cases were referred for
special diagnosis ; 4,624 visits were made to schools ; 556
children were excluded from school ; 418 cultures were
taken; 132 injections of antitoxinc were given; and 208
persons were vaccinated. In the Division of Vital Statis-
tics 2,143 deaths, 2,600 births, and 196 marriages were
reported. In the Division of Milk Inspection 8,304 inspec-
tions were made of 190,172 quarts of milk, of which 984
quarts were condemned. Thirteen specimens were exam-
ined chemically and 989 microscopically. In the Division
of Meat and Cattle Inspection 3,897 inspections were made;
286 were found unsanitary ; 207 condemnations were
■ordered. Fifty-nine post mortem examinations were made,
of which 8 were condemned. In the Division of Disinfec-
tion 271 fumigations were done for scarlet fever, 501
for diphtheria, 91 for typhoid fever, 173 for tuberculosis,
290 for miscellaneous diseases, and 36 schools were fumi-
gated. In the Bacteriological Laboratory 1,714 cultures
were examined for the bacillus diphtheriae ; 416 specimens
of blood were examined for the serum diagnosis of typhoid
fever; 973 specimens of milk were examined; 156 speci-
mens of sputum were, examined ; 3 disinfection tests were
made; and 3,716,400 units of antitoxine were distributed.
In the Chemical Laboratory 119 analyses were made.
Society Meetings for the Coming Week:
Monday, March gth. — New York Academy of Medicine
(Section in Neurology and Psychiatry) ; Society of
Medical Jurisprudence, New York; New. York Ophthal-
mological Society; Corning, N. Y., Medical Associa-
tion ; Waterbury, Conn., Medical Association.
Tuesday, March loth. — New York Academy of Medicine
(Section in Public Health) ; New York Obstetrical
Society ; Newburgh Bay, N. Y. ; Medical Society ;
Medical Society of the County of Schenectady, N. Y ;
Medical Society of the County of Rensselaer, N. Y. ;
Buffalo Academy of Medicine (Section in Medicine) ;
Practitioners' Club of Jersey City.
Wednesday, March iith. — New York Pathological Society;
New Y9rk Surgical Society; Medical Society of the
Borough of the Bronx, New York ; Alumni Association
of the City Hospital, New York; Brooklyn Medical and
Pharmaceutical Association; Medical Society of the
County of Richmond, N. Y.
Thursday, March i.slli. — New York Academy of Medicine
(Section in Ptediatrics) ; Brooklyn Pathological So-
ciety ; Blackwell Medical Society of Rochester, N. Y. ;
Jenkins Medical Association, Yonkers, N. Y.
Friday, March isth. — New York Academy of Medicine
(Section in Otology) ; New York Society of Derma-
tology and Genitourinary Surgery ; Eastern Medical
Society of the City of New York ; Saratoga Springs,
N. Y., Medical Society.
Saturday, March J.^f/i.— Therapeutic Club, New York.
Meetings of Sections of the New York Academy of
Medicine. — The Section in Pediatrics will meet on
Thursday evening, March 12th, at 8:15 o'clock. The meet-
ing will be devoted to the presentation of patients and a
discussion by members, of the section.
The Section in Otology will hold a meeting on Friday
evening, March 13th, at 8:15 o'clock. Dr. G. H. Cocks
will present a patient showing recurrent keloid of the
scalp and lobule of the ear, and Dr. Frederick Whiting will
read a paper entitled The Toxaemia of Latent Erysipelas
in Its Relation to Otitic Serous Meningitis.
A meeting of the Section in Public Health will be held
on Tuesday evening, March loth, at 8:15 o'clock. Dr.
Simon Baruch will read a paper on Public Baths. Their
Need and Usefulness, and a paper on Public Comfort
Stations will be read by Frederick L. Lord, City Engi-
neer, Hartford, Conn. -The discussion will be opened bv
Dr. S. A. Knopf.
A meeting of the Section in Surgery was held on Fri-
day evening, March 6th, which was devoted to a general
discussion on aneurysm. Papers on the subject were read
as follows : The Treatment of Popliteal Aneurysm by the
Reconstructive Method, by Dr. J. F. Binnie, of Kansas
City; Personal Experience with the Modern Treatment of
Aneurysm, by Dr. Robert Abbe ; A Report of Two Cases
of Aneurysm, by Dr. Joseph A. Blake; The Serous Coat
of Blood Vessels Compared with the Peritonaeum, by Dr.
Robert T. Morris.
On Monday evening, March 9th, the Section in Neu-
rology and Psychiatry will hold a meeting, for which the
following programme has been arranged : Dr. William B.
Pritchard will present two patients showing progressive
muscular dystrophy ; Dr. John Hartwell will report two
cases of suture of the ulnar and median nerves, and a gen-
eral discussion on the subject will follow: Dr. Charles N.
Dowd will report cases of tendon transfer for paralytic
deformities of the foot ; Dr. John A. Bodine will read a
paper entitled Injection of Alcohol for the Cure of Tri-
geminal Neuralgia ; and Dr. R. H. Dawbarn will read a
paper entitled The Shortening of All Sensory Nerves an
Essential Step in ,\11 Amputations.
March 7, 1908.,
PITH OF CURRENT LITERATURE.
465
|it| of (tmtxd f itfraturf.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
February 37, igo8.
1. The Bennett Fracture of the First Metacarpal Bone,
Diagnosis and Treatment, By Samuel Robinson.
2. The Treatment of Trophic Nerve Lesions: A Study
Based on a Case of Mai Perforans ; of Ischaemic
Paralysis, and of Erythromelalgia,
By William C. Quinby.
3. Pulmonary Embolus Following Operative Interferences,
By Charles Greene Cumston.
4. Psychologj- in Medicine,- By Arthur H. Bing.
I. Bennett Fracture of the First Metacarpal
Bone. — Robinson remarks tiiat ihe tirst and nitn
metacarpal bones are most frequently fractured.
Sixty-four per cent, of fractures of the first meta-
carpal are of a less obstinate transverse type.
Twenty-eight per cent, are oblique fractures into the
joint, with or without subluxation of the metacarpal
(Bennett type). Certain forms of the Bennett
lesion are difficult of treatment and render all in-
juries to the base of the thumb worthy of a ski-
agraph for their early detection. For transverse
fractures without much deformity any simple immo-
bilization splint is sufficient to produce imion. Such
methods of fixation have also proved adequate in
certain oblique fractures into the joint where sub-
luxation had not already occurred, and owing to
ligamentous support remained in position until
maintained by bony or cartilaginous union of the
fragment to the shaft. For the Bennett fracture w-ith
fracture and subluxation, different methods have
been employed. Our author regards the method
of Miles, Struthers, and Bennett inadequate. He
describes his method as follows : Two narrow strips
of adhesive plaster are first applied to the lateral sur-
faces of the thumb with free ends about six inches
long. These strips are held in position by circular
turns of the adhesive. In preparation for the spica.the
thumb, metacarpal region, and w'rist are bandaged
with cotton sheet wadding. To provide space be-
tween the thumb and plaster spica in which the
thumb may be later extended, two narrow pieces of
splint wood, such as are used as tongue depressors,
are laid laterally against the cotton. They should
extend an inch beyond the tip of the thumb in order
that the circular turns of the plaster spica may
continue the extension cylinder beyond the tip.
With the thumb w-ell abducted a plaster of Paris
bandage, cut to width of two inches, is then firmly
applied as spica from the wrist. As the plaster
hardens, extension should be maintained with trac-
tion on the adhesive plaster strips. At the same
time pressure should be applied over the proximal
end of the subluxated fragment. A second layer of
plaster bandage should then be applied for added
support and for the incorporation, if so desired, of
two buckles. The splint wood is then withdrawn
through open end of cylinder. Traction is exerted
on the adhesive extension strips which are turned
backward over the now firm edge of the extension
trough, and held in position bv the buckles, or. if
the latter are not available a circular turn of ad-
hesive around the hand outside the spica will answer
the purpose. The following day the pull on the
extension strips should be increased to make up
for stretch in material, for yielding in the grip of the
strips on the thumb and for muscle relaxation. This
should be repeated every two days for at least a
week. Four or even five weeks is none too long a
time for the maintenance of this apparatus. At the
end of three weeks to make, up for reduced swell-
ing the spica may be carefully removed and a new
plaster spica restored with the same moulding over
the seat of fracture but without the extension
apparatus.
2. The Treatment of Trophic Nerve Lesions.
— Quinby remarks that the so called trophic nerve
lesions of the skin, bones, and joints are due to a
break in the neurovascular mechanism of the part
involved. This break may be situated centrally or
on the neural side, or on the vascular side. Hence,
rational treatment of such conditions will be directed
toward modification of the blood supply; or the
nerve function of the part. For modification of the
blood supply, we have active and passive hyperaemia
increasing it. and positive pressure by bandaging,
pneumatic cabinet, or the immersion in mercury,
decreasing it, while for modification of the nerve
function, we have nerve stretching, neurolysis and
nerve disassociation, and electricity. Nerve stretch-
ing is probably to be condemned, similar results
being obtainable by the simpler passive hvpersemia.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
February 2g, 1908.
1. Intestinal Tuberculosis: Tuberculous Intestinal Neo-
plasms and Tuberculous Ileocecal Tumor,
By John C. Hemmeter.
2. Some Studies of the Endogenous Uric Acid Moiety in
Pathological Conditions,
By Robert E. Peck and Frank W. Thompson.
3. Operative Procedure as a Therapeutic Measure in the
Cure of Epilepsy, By Matthew Woods.
4. Psychasthenia : Its Semeiology and Nosologic Stat is
Among Mental Disorders, By J. W. Courtney.
5. The Relations of the Diaphragm as Revealed by the
Rontgen Ray, By Sidney Lange.
6. The Choice of a Vasodilator and the Indications for
Vasodilation, By Henry Wireman Cook.
7. Prostatic Calculi. With the Report of Two Cases,
By G. L. ROHDENBURG.
8. The Heart's Action Preceding an Epileptic Seizure,
By J. F. Munson.
9. Sterile Hands Secured by Abstinence from Infection ;
the Essential Factor in Successful Surgery,
By J. H. Carstens.
10. Tuberculosis and the Medical Schools,
By David R. Lyman.
2. Some Studies of the Endogenous Uric Acid
Moiety in Pathological Conditions. — Peck and
Thompson summarize their investigation as follows :
A certain number of patients show-ing nervous and
other symptoms are suffering from disturbances of
metabolism of such nature as to lead to an abnor-
mally low^ output of endogenous urinary purins.
Just what these metabolic abnormalities are the
authors can not at present state, because of ignor-
ance of the exact physiological processes concerned
in the formation of the endogenous moiety, but that
they are, in a measure at least, responsible for some
of the symptoms is shown by the relief of these same
symptoms on increasing the elimination of the urin-
ary purins. The best method of bringing about this
result is not by trying to dissolve the uric acid, as
has been our endeavor in the p?)st, but to increase
the activity of the metabolic processes. This latter
466
PITH OF Ci RRENT LITERATURE.
[New York
Medical Journal.
;ui.-()ni])lishment is best attained by exposing the
naked bodv to the direct rays of incandescent electric
lights.
5. The Relations of the Diaphragm as Revealed
by the Rontgen Ray. — Lange remarks that the
(Haphragm functionates in an analogous manner
to the other muscles of the body. Its excursion is
greatest when its points of origin and insertion are
most widely separated, and it acts more forcibly
against resistance than when acting unopposed. The
practical application of the study of the diaphragm
by means of the x ray will be possible perhaps only
in the larger hospitals where the Rontgen equipment
is complete. But its importance as a routine method
of examination is not an inconsiderable one. In
feeble patients where auscultation is difificult because
the lireathing is weak and suppressed and percus-
sion is unsatisfactory because of the inadvisability
of turning and lifting the patient, this method is
especially valuable, for the examination may be con-
ducted in the recumbent position without in anv wa}-
disturbing the patient. The high convex position
of the diaphragm is dependent on the combined ac-
tion of two forces. When either fails the dome
drops downward. One factor is the elasticity of the
lungs, maintaining a constant suction in the pleural
sac. The other is the pressure of the abdominal
contents. This abdominal pressure is of a hydro-
.static nature, in that it is equally distributed over
the entire lower surface of the diaphragm. This
pressure is due, in the upright posture, to the com-
pression exerted by the abdominal musculature on
the abdominal viscera, while in the recumbent posi-
tion the abdominal contents influence the diaphragm
by gravitating against it. That these forces support
the diaphragm is shown in phrenic paralysis where
the diaphragm stands at a high level and rises dur-
ing inspiration and sinks during expiration, al-
though its own tonus is lost. That there is an up-
ward suction and an upward pressure on the dia-
phragm is shown in phrenic hernia where the
stomach enters the thorax through a rent in the dia-
phragm. When the elastic suction of the lung is-
removed, as in emphysema, the diaphragm stands
low. \'ariations in the pressure from below arc
shown by variations in the phrenic level, dependim:;-
on whether the individual is lying, standing, or sit-
ting. The phrenic level is highest when the patient
is recumbent, in which position the abdominal con-
tents, acted on by gravity, push against the dii-
phragm. When standing the diaphragm is slightly
lower than when lying down. The force here is the
rigidity of the abdominal walls exerting pressure
on the viscera, which force is partly counteracted
by gravity pulling tlie abdominal contents away
from the diaphragm. In the sitting position the
diaphragm is lowest, for in this attitude the abdomi-
nal musculature is partly relaxed, and the force of
gravity acting on the abdominal contents less op-
posed sucks the diaphragm downward. But notwith-
standing this pressure, its excursion is greater than
the opposite unopposed half. This upper hTlf, fur-
thermore, acts very peculiarly. It .stands compara-
tivel\- low, and instead of sweeping up and down
with its fellow of the lower side it remains almost
motionless, swinging in a sort of pendulum fashion
about an axis which runs through its middle point.
In other words, its excursion is decreased because
its points of origin and insertion are approximated
and because its action is unopposed.
6. The Choice of a Vasodilator. — Cook says
that sodium nitrate is the best vasodilator ; it has the
most enduring effects ; is most stable and depend-
able ; and gives rise to fewest unpleasant symptoms.
Vasodilatation may be indicated with low or normal
tension, i. e., all uncontrollable haemorrhage, either
during operative manipulation, typhoid ulceration,
gastric ulcer, pulmonary phthisis, other internal
hasmorrhage uncontrollable by surgical methods,
aneurysm, thrombus, etc. High tension is abnor-
mal, and is either the accompaniment of organic dis-
ease, or else presages its onset ; in either case it
demands treatment ; first, by general hygienic meas-
ures ; second, when necessary, by venesection or
vasodilatation with drugs — preferably sodium
nitrate.
8. The Heart's Action Preceding an Epileptic
Seizure. — Munson has made observations on the
heart's action preceding an epileptic seizure. Look-
ing over the cases reported it will be seen that the
condition common to all but one was an acceleration
of the pulse preceding the seizure and lasting through
the onset stage to the moment of the first recorded
convulsion. This acceleration was never great. The
absence of a time marker prevented exact state-
ments, but the increases seemed to be in the several
cases, from eight to nine, or from twelve to fifteen
or seventeen beats. In all the cases the pulse was
entirely regular. For this group of c^ses one can
conclude definitely : Cardiac arrest does not occur ;
except for slight acceleration, and in one case slight
slowing, the heart does not take part in the con-
vulsion.
MEDICAL RECORD
February 29, igo8.
1. Chronic Sigmoiditis, By Heinrich Stern.
2. Cardiac Hydrothorax. Report of a Case Aspirated 311
Times, By W. Tr.wis Gibb.
3. Acute Bulbar Paralysis, with an Unusual Symptom,
By Alfred GoRnoN.
4. Significant Features of Middle Ear Suppurations in
Infancy and Childhood, By S. J. Kopetzky.
5. Dangers .Attending Operative Intervention in Gonor-
rhrel Salpingitis. Report of a Case, By J. S. Price.
6. Ether .-Anrestliesia, By De.\n Loree.
I. Chronic Sigmoiditis. — Stern reports eight
cases of chronic sigmoiditis, forming about the sixth
part of all the cases of that affection which have
come under his observation. Xaturally. extent and
intensity of the inflammatory processes were of
manifold degree in the various instances. That an
inflammatory condition may he limited to the sig-
moid flexure there is no question. That such an in-
flammatory condition may be idiopathic, at least in
a proportion of cases, we have to assume on logical
grounds. However, we will not be far out of the
wav when we maintain that a goodly number of the
pertaining instances are deuteropathic in character;
that they are. in other words, the consequence of
a preexi.sting condition. The direct local condition
predisposing to inflainmation of the sigmoidal mu-
cosa is habitual obstipation and long continued drug
catharsis, the more mediate cause acting as predis-
ponent for sigmoiditis being an adequate or perverse
nerve impulse in the descending and especially in
Marcli 7, tpoS.]
riTH OF CURRENT LITERATURE.
467
the signioidal segments of tlic colon. In every in-
stance of chronic sigmoiditis which came to his
notice, there prevailed obstipation or a tendency
thereto, and the characteristic lethargy of the large
intestine, which is directly attributable to the cus-
tomary ingestion of purgatives. Stagnation of the
faeces occurs mostly in the lower portion of the
descending colon and in the sigmoid flexure, the
peculiar anatomy of which virtually invites the
retention of fasculent material. Inflammatory pro-
cesses of the colonic and sigmoidal mucosa may
thus be set up readily, to some extent, by mechan-
ical injury on the part of the accumulated excre-
mentitious substances, to some extent by chemical
irritation of the products of secondary fermentation
evolved from the impacted faeces. Intestinal s])asni,
atony, or paresis, by giving occasion to obstipation,
may be the more remote causes of chronic inflam-
matory processes of the sigmoid flexure. The great
majority of all intestinal aftections which are due to
insuflicient or perverse innervation arise in the sig-
moid. An initial intestinal spasm is almost in every
instance confined to the sigmoid ; intestinal atony or
paresis, as a rule, starts in the sigmoid ; seventy
per cent, of all cases of volvulus — due primarily in
almost every instance to fascal impaction, and in-
duced forced peristalsis, that is, perverse innerva-
tion— occur in the sigmoid flexure. Chronic sig-
moiditis may be associated with numerous concom-
itants and complications. Its occurrence, in fact,
favors the production of other, especiallv functional,
disturbances of the alimentary canal. Functional
disorders of the caecum, for instance, are often due
to a chronic pathological condition of the sigmoid.
The synchronous occurrence of cjecal derangement
and the syndrome of chronic sigmoiditis often pre-
sent the clinical picture of chronic appendicitis.
Again, we know that in the .nstiology of appendicitis
itself, chronic obstipation (and consequently sig-
moidal disease) plays an important r(31e. Further-
more, perisigmoiditis may be due to the same cause
which gives occasion to endosigmoiditis, or it may
be the direct consequence of the latter, and inflam-
matory processes in other parts of the peritonaeum
may be engendered by chronic sigmoiditis or its
most frequent immediate precursor, obstipation.
4. Significant Features of Middle Ear Suppu-
rations in Infancy and Childhood. — Kopetzky
finds the significant features of middle ear suppura-
tion in infancy and childhood to lie in the existence
of the purulency without perforation : in the pres-
ence of a discharge from the Eustachian tube to the
pharynx ; in the exhibition of temperature, early
facial paralysis and marked disturbance of stomach
and bowel ; in the advent of periosteal abscess : in the
rapid progress of destructive processes in the pet-
rous bone ; in the tendency to intracranial complica-
tions ; in the possibility of early primary bulbar
thrombosis : in the existence without thrombosis of
otitic pyaemia, and in the relatively serious sequlae of
certain forms of ear disease in the child, who is ex-
posed to the danger of deaf mutism by the loss of a
special sense so intimately related to the function of
speech.
6. Ether Anaesthesia. — Loree states that in
the past the mere selection of ether over chloroform
has been deemed sufficient precaution without at-
tempting a study of the possibilities of the latter.
The profession seems to be awakening to the fact
that proper etherization calls for experience and
that, within certain limits, a maximum dosage must
be established. Aluch is being written concerning the
difi^erent forms of apparatus, and tliis or that
method calls for much or little commendation,
whereas the true lest is the anaethetist him-
self, and that mode of administration is su-
perior which in his hands permits him to
employ the smallest quantities of ether. The
drop method has done more for ether in gen-
eral than any one thing since its discove r} . .\ver-
ages of five ounces of ether per hour nia\ Ije ob-
tained with the Allis inhaler slightly modified. .\i-
trous oxide gas preceding ether is unnecessary ; the
former is valuable in selected cases, not only for
minor but, if properly given, may be prolonged for
major operations. Primary anfesthesia with ether is
valuable in many short operations, viz. : extraction
of teeth, incision of abscesses, urethral dilatations,
etc. The average amount of ether required per hour
is four ounces, when complete unconsciousness must
be continuous. The longer the operation is pro-
longed the less ether is necessary for any given per-
iod of time. The longest period of ether anaesthesia
that has come under his observation was five and
one half hours, in the case of a radical mastoid
operation with exploration of the brain and ligation
of the left common carotid ; the amount of ether
used was fourteen ounces. Proficiency in future will
require the minimum amount of ether instead of the
promiscuous "soaking" of the past. When this is
made obligatory, vomiting is the exception, not the
rule ; the excitement stage is wanting ; the intense
irritation of bronchial mucous membrane is never
experienced, and the capillary circulation is as good,
sometimes better, than before administration.
BRITISH MEDICAL JOURNAL.
February 75, igo8.
1. Chorea of Aggravated Type with Certain Unusual
Phenomena, By R. W. Philip.
2. Chronic Bronchitis. By A. G. Auld.
3. Surgical Aspects of Subphrenic Abscess,
By H. L. B.^RNARD.
4. Preliminary Note on the Existence of an Acute Tu-
berculous Fever in India Which Has Been Con-
founded with Continuous and Remittent Fevers,
By J. R. Roberts and P. R. Bh.\ni).\rkak.
5. On the Spread and Prceention of Tuberculous Disease
in Pondoland, South Africa, By J. G. Millar.
6. The Prevention of Tuberculosis : A Suggestion,
By A. R. Grx.v.
7. The Treatment of Epidemic Cerebrospinal Fever by
Intraspinal Injections of Fle.xner and Joblfng's Anti-
meningitis Serum, By A. G. Rop.b. '
I. Chorea. — Philip reports a case of chorea of
an aggravated type occurring in a youth aged eigh-
teen years, and which ended fatally. Among the un-
usual phenomena observed was the condition of hip-
pus, i. c. the pupil of the eye was alternately dilated
and contracted in extraordinarily rapid fashion. The
age of the patient was unusual, in that the great ma-
jority of cases occur between the ages of five and
fifteen years. The family history in cases of chorea
often reveals a hereditary tendency to rheumatism or
to a nueropathic condition. The ultimate causation
of chorea is still a mystery. The varjnng character
of the symptoms and their extreme violence in some
468
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
cases arc much in favor of the disease being due to
irritation. In particular, various toxines are a(huit-
ted as irritants, especially that associated with rheu-
matism. The disease follows other infective condi-
tions besides rlieumatism — scarlet fever, measles,
small pox, diphtheria, typhoid fever, and many other
conditions. Shock, fright, etc., are probably merely
predi,sposing influences which determine the direc-
tion in which the eft'ects of intoxication ma}' show
themselves. Up to the present there is no certain,
constant post mortem appearance which can be pred-
icated as the anatomical basis of the disease. The
prognosis is grave in the severer types. The patient
should be on a water bed, and his larger joints
wrapped in cotton wool. Of drugs the most ser-
viceable are the bromides and chloral.
2. Chronic Bronchitis. — Auld discusses the
causation and treatment of chronic bronchitis. Three
drugs have a specific action on the epithelial and
glandular tissues ; they are potassium iodide, bal-
sam of Peru, and turpentine. Of these the balsam
of Peru is the most efficacious and the most gener-
ally applicable. When the expectoration is already
free, begin at once with the balsam in doses of ten
to twenty minims, given disguised in an emulsion.
If the expectoration is scanty and difficult to expel,
begin with five to eight grains of potassium iodide,
and, having obtained a free expectoration, follow up
with the balsam of Peru.
4. Acute Tuberculous Fever. — Roberts and
Bhandarkar call attention to the existence of an
acute fever, due to the tubercle bacillus, and which is
often confounded with typhoid and malarial fever.
The fever is of a remittent or intermittent type, last-
ing from a week to four weeks ; the liver is often
enlarged, the spleen not so. Vomiting and nausea
are marked, but not continuous. The most distin-
guishing feature is pain and tenderness in the epi-
gastrium, on which stress is laid in diagnosis. Some
cases have acute exacerbations of pain, others only
tenderness, which, if it is associated with hepatic
enlargement, makes the diagnosis from liver abscess
very difficult ; but the detection of tubercle bacilli in
the urine clears up all doubt. The mind is clear,
generally remarkably so. The tongue is furred, but
not coated as in typhoid fever. This fever is com-
pletely recoverable from, but it marks the launching
of the patient on a tuberculous career — the begin-
ning of a long period of ill health of an indefinite
kind. This general malaise is not continuous.
Another set of cases develop obvious tuberculosis —
tubercle of the lungs, kidneys, etc. The initial acute
tuberculous fever has been by that time completely
forgotten. In this fever the abdominal symptoms
point to probable invasion through the alimentary
canal. It is not to be confounded with tuberculous
peritonitis. The mortality is low, and the condition
does not drift into acute miliary tuberculosis. The
direct evidence is supplied by the detection of the
tubercle bacillus in the urine. The technique is that
given in the books ; attention is called to the impor-
tance of a good centrifuge, the washing of the de-
posit in distilled water once or twice to insure fixa-
tion, and the use of egg albumin to facilitate this.
The Ziehl carbol fuchsin method of staining was
the one used. The writers arc convinced that there
exists a tuberculous cachexia, not only as the
sequela of acute tuberculous fever, but coming on
gradually, and manifesting itself by indefinite mal-
aise. Its detection depends on the examination for
tubercle bacilli in the urine. This stage is prob-
ably the precurscr of an evident tuberculous disease,
such as affections of the lungs, kidneys, bones, or
abdominal organs. This cachexia exists along with
a low opsonic index, and it is important to raise this
to eft'ect a cure.
6. Prevention of Tuberculosis. — Gunn sug-
gests that the problem of tubercle free milk can be
solved by taking those members of the herd of cat-
tle which are immune to tuberculosis, and breeding
from them and them alone.
7. Serum Treatment of Cerebrospinal Menin-
gitis.— Robb reports a series of thirty cases of
cerebrospinal meningitis treated with Flexner and
Joblmg's antimeningitis serum. Eight patients
died, a mortality of 26.6 per cent. Of thirty-four
cases treated at the same time without the serum,
twenty-nine patients died, a mortality of 85.2 per
cent. The general mortality in Belfast of the dis-
ease was 72.3 per cent. These results are encourag-
ing. Three cases were of the fulminant type, four
of the ordinary type, and one was already "chronic."
LANCET.
February 15, 1908.
1. Ovarian Teratomata (Erasmus Wilson Lecture),
By S. G. Shattock.
2. The Treatment of Tuberculosis by Different Kinds of
Tuberculin, By N. Raw.
3. On a Case of Acute Poliomyelitis Associated with a
Diplococcal Infection of the Spinal Sac,
By W. Pasteur, A. G. R. Foulerton, and H. Mac-
CORMAC.
4. The Therapeutic Uses of Normal Serum,
By E. C. HoRT.
5. Plastic Bronchitis in a Girl, Aged Eleven Years, the
Seventh Attack in Four Years, the First Occurring
at the Age of Seven Years : Extreme Displacement
of the Heart and Mediastinum, Produced by Collapse
of the Lung, Disappearing with Expectoration of the
Cast, but Recurring as Each Fresh Cast Formed.
By S. West.
6. An Artificial "Airway" for Use During Anaesthetiza-
tion. By F. W. Hewitt.
7. The "Early" Operation in Acute Appendicitis : The In-
dications for Its Performance and Its Advantages,
By F. A. SouTHAM.
2. Tuberculin Treatment. — Raw holds that
human and bovine tubercle bacilli are divisible into
two distinct types of a common species, ( i ) typiis
liitnianns; and (2) typus bovinus. Man, from feed-
ing for centuries upon cattle products — milk, cheese,
etc. — has become tolerant to the bovine bacilli.
Tubercle bacilli of the typus hiimanus produce
phthisis pulmonalis, ulceration of the intestines, and
tuberculous laryngitis ; and tubercle bacilli of the
typus bovinus produce tuberculous peritonitis, tuber-
culosis of the lymphatic glands, tuberculous joints,
meningitis (probably), and lupus. Acute miliar>-
tuberculosis is probably also of bovine origin. In
the author's experience, Koch's tuberculin R. has
little or no healing effect in phthisis pulmonalis.
He has therefore prepared from bovine sources a
special tuberculin for the treatment of pulmonary
tuberculosis, the results from which have been most
excellent. Working on corresponding lin^s, he has
treated over seventy cases of surgical or bovine
tuberculosis with Koch's tuberculin R. The results
March 7, 1908.]
PITH OF CURRENT LITERATURE.
469
have been beyond anticipation : enlarged glands,
joints, and lupus have been immensely improved,
while discharging sinuses have cleared up, and the
symptoms of meningitis have disappeared (in two
cases).
3. Acute Poliomyelitis. — Pasteur, Foulertoii,
and MacCormac report that after having identified
a micrococcus in the spinal fluid withdrawn during
life from a boy with symptoms of acute poliomyelitis,
they succeeded in producing an ascending motor
paralysis in a rabbit, after a prolonged period of in-
cubation, by inoculating this fluid into the subdural
space. On the death of the rabbit a micrococcus
could be demonstrated in the cerebrospinal fluid
similar to that seen in the fluid from the human
case; and by similarly inoculating another rabbit
with an emulsion of cerebrospinal substance and
fluid from the first experimental animal they again
succeeded in producing a motor paralysis again as-
sociated with the presence of the micrococcus in the
spinal fluid. The evidence is bacteriologically in-
complete, however, as it was not possible to cultivate
the organism on artificial media. The writers hold
that the investigations of Geirsvold and others have
established beyond question the existence of a spe-
cific infective disease of which acute poliomyelitis
is a frequent and prominent, but not essential, fea-
ture. This specific disease has apparently no clearly
distinctive primary features to enable one to dis-
tinguish it by its clinical symptoms from many
other febrile conditions of probably infective origin.
And so while the serious complications of acute polio-
myelitis when it has occurred has been at once recog-
nized, the primary disease has not been distin-
guished hitherto, but has in fact usually been alto-
gether overlooked. But there is not sufficient reason
for assuming that acute poliomyelitis is always a re-
sult of this particular diplococcal infection. The
symptoms by which acute poliomyelitis is recognized
are the consequences of a constitutional alteration of
certain cells of the central nervous system, which
causes an impairment of their functional efficiency.
It is probable that these cell changes may be caused
also by the toxines produced in other infective pro-
cesses.
4. Therapeutics of Normal Serum. — Hort has
treated with the most encouraging results a number
of morbid conditions by the administration of nor-
mal blood serum. Among the diseases treated in
this way are gastric and duodenal ulcer, with and
without haemorrhage, chlorosis and other forms of
anaemia, haemophilia, purpura haemorrhagica, tuber-
culous peritonitis, haemoptysis, ulcerations of all
kinds, pulmonary oedema, pneumonia, etc. What-
ever value normal serum therapy may prove to have,
it does not seem obviously connected with supplying
fibrin ferment. It is conceivable that the administra-
tion of normal serum may effect the production of
autoanticomplement, or in some unknown way cor-
rect a disturbance of the regulating mechanism. It
is not impossible that in all the conditions mentioned
there is a common basis of autocytolysis, character-
ized by destruction of epithelial, endothelial, haemic,
or other cells — which autolysis can be inhibited by
normal serum.
7. "Early" Operation in Appendicitis. — South- '
am is a strong advocate of the early operation in ap-
pendicitis. The temperature and pulse rate bear no
constant relation to the severity of the attack. A
rapid pulse is also' suggestive of serious mischief
and points to a probable termination in suppuration.
The same applies to a high temperature. A subnor-
mal temperature, especially if the fall has been sud-
den, oftai indicates perforation. A high temperature
and a slow pulse, or vice versa, are always unfavor-
able, the same being true of an initial rigor, urgent
vomiting, acute pain, and painful rigidity of the ab-
dominal wall. Another important early symptom,
pointing to the onset or the presence of the destruc-
tive form of appendicitis, is the absence of abdomi-
nal respiration, the breathing being mainly or
entirely thoracic. The advantages of surgical inter-
ference in the early stage of acute appendicitis are
as follows: i. The infective centre, i. e., the appen-
dix, can be removed in many cases before suppuration
has taken place, and if it has not perforated or be-
come gangrenous the operation is practically an
aseptic one. 2. If pus has formed, even though not
encysted and surrounded by a barrier of lymph, it
will usually be found to be localized as yet to the
neighborhood of the appendix and small in quan-
tity. In these circumstances, its evacuation, to-
gether with the removal of the appendix, if followed
by free drainage, will usually check the spread
of the suppuration which otherwise so often tends
to become general. 3. The operation being per-
formed before the onset of general toxaemia ( the
common cause of death in fatal cases) is usually
well borne by the patient. 4. The risks of the later
complications of acute appendicitis, viz., subphrenic
and hepatic abscess, empyema, parotitis, and phle-
bitis, and infections in other parts of the body, are
greatly minimized. 5. In the early stage the appen-
dix— unless bound down by adhesions the result of
a previous attack — lies quite free, and is therefore
easily removable. In the later stages, especially in
the less acute cases, it is often surrounded and im-
bedded in a deposit of lymph, which may form part
of the wall of an abscess when the pus is encysted.
Under these circumstances it is often not easy to
recognize the appendix, and its removal is frequently
difficult or impossible without breaking down this
barrier of Ivmph, and thus running the risk of in-
fecting the general peritoneal cavity.
LA PRESSE MEDICALE.
February 5, IQ08.
Opening Lecture, By Professor Barr.
February 8. IQ08.
1. Infantile Splenic Infection by the Leishmann-Donov'an
Bodies. Its Relations to Kala ■ Azar and Infantile
Splenic Anaemia, By C. Nicoi.le and E. Cassuto.
2. Cancer and the X Rays, By AIally.
X -Apropos of Conjugal Diabetes, By R. Rom me.
I. Infantile Splenic Infection. — Nicolle and
Cassuto state that under the name Kala Azar, trop-
ical splenomegaly, dumdum fever, etc., the physi-
cians in India describe an infection which is distinct
from paludism, with which it is sometimes con-
founded, and characterized by irregular fever, pro-
gressive anaemia, extreme emaciation, digestive trou-
bles, great hypertrophy of the spleen, some hyper-
trophy of the liver, transient oedemas, petechial
eruptions, bronzing of the skin, rheumatic pains, and
470
PITH Ob- CURREKT UTRRATURE.
LNew York
Medical Journal.
an always fatal termination. The infection is by the
bodies, discovered by Leishmann and also by Dono-
van in IQ03 and described by them in the British
Medical Jounial. Nicolle and Cassuto describe a
case which came imder their observation in a child
of French parentage born in Tunis in 1905, to-
gether with the findings at autopsy. Several other
cases have been observed which go to show that this
disease is to be met with about the Mediterranean
as well as in India.
February u. i<jo8.
1. Diagnostic and Therapeutic Value of (Escii)hagf)scop\ .
Study Based on 300 Personal Observations,
By GuiSEZ.
2. I^isinfection of the Uterine Cavity in Puerperal In-
fection, By A. Schwab.
I. Diagnostic and Therapeutic Value of
CEsophagoscopy. — Guisez urges the invaluable
aid afforded in diseases of the oesophagus by oesopha-
goscopy as well as in the case of application of
rational treatment. Particularlv he insists that the
method is not dangerous or painful. Injury is pos-
sible to the walls, which are sometimes very friable,
as in cases of cancer and ulcer, or an aneurysm of
the arch or of the thoracic aorta may possibly be •
ruptured, but nevertheless harm is not done in this
way, and since its introdtiction it has been jjossiblc
to treat successfully certain lesions previoush inciu"-
able, such as spasius, idiopathic dilatations, cica-
tricial strictures, and congenital obstructions.
LA SEMAINE MEDICALE.
February u. 1008.
.\nibulatory Treatment of Patients on Wliom Laparotomy
Has Been Performed, By Phoi-kssok R. de Bovis.
MUENCHENER MEDiZINISCHE WOCHENSCHRIFT.
February ii. igoS.
1. The Electric Treatment of Cancer, By Czerny.
2. Immunization by Mouth, By Wolf.
,i Concerning Polycyth.neniia. By Lommei,.
r.xperinicntal Contril)utions to tlie fCxphtiiation of the
Manner of Working of liier's .Stasis, -
By VON Graff.
5. Serum Studies in 'I'hyreoid Cases, By Hoffmann.
6. Lysol and Keesol Soap. By Schottei.tus.
7. ,1s Tiiere a Specific Precipitate Reaction in Syphilis and
Paralysis? By Foknet and S( herkschevvsky.
8. The Separation of Cholestcrinc in the I'.ilc and Its
Sifinificance in the Pathogenesis of flallstones
(Coiuinncd), By B.xrMEisxER.
Q. Fnriher Studies Regarding Electricity and Magnetism
of the Skin in Man (Concluded) . By I I.\i<.\AtK.
10. Obituary of Adelbert von Tobold, "I'.y P'kanck.
1. The Electric Treatment of Cancer. — C/.ern^
.speaks very highly of the method of treatment which
he calls fulguration, the application of the high fre-
quency current and of fulguropuncture, in the treat-
ment of cancer. The detailed results certainh seem
to be excellent.
2. Immunization by Mouth. — Wolf has show n
by his experiments that it is not difficult to imnumi/re
white mit^ against mouse ty])hus by means of a kind
of paratyphus given by mouth. Whether it is pos-
sible that immunization may be obtained in this wax-
in man against any disea.se the primary seat of which
is in the intestinal canal is not certain, but the nu-
merous mishaps and the impossibility of an exact
dosage render it imi)robable.
3. Polycythaemia. — Lommei rejjorts a case of
polycytli.-emia, said to be called Osier's disease in
.\merica, and discusses at length the clinical picture
of the disease, its pathology, pathogenesis, and treat-
ment.
4. Manner of Action of Bier's Stasis. — Vou
( iraff has arrived at the following conclusions as the
result of his experiments: i. The component of the
stasis which is fatal to bacteria does not depuul on
a pure humoral action of blood serum and cedema ;
2, an antidotal action against poi.soning with strych-
nine or the toxines of tetanus and diplitheria is not
l^roved ; and, 3, the oedema, although it possesses in
itself only a slight and inconstant bactericide power,
accelerates phagocytosis very markedly.
9. Electricity and Magnetism of the Skin. —
Harnack has established the following results by his
observations; i. By stroking a nonconductor with
the finger tips a person becoiues charged with static
electricity, and in some individuals with a markedly
strong tension after a comparatively very slight ex-
ertion of force : 2, with such persons iron and steel
objects which the}- carry with them and frequentl}
take in their hands become to a fairly high degree
permanently magnetic ; 3, the unrubbed skin ma}-
e.xert an eflect upon the magnetic needle and other
easily movable objects to which it is approached in
which the finger behaves neither exactly like a
rubbed varnished object, nor exactly like an iron
magnet ; the signs of this change rapidly ; 4, the
influences of the living skin in different individuals
are of different strengths and are independent, in
any individual, of the physiological conditions at the
time, i. e., of a full or empty stomach, holding of the
i)reath, or movements. X connection with the in-
ternal vital processes is doubtless present.
ARCHIVES OF PAEDIATRICS.
February, igo8.
I. Pneumohydrothorax in a Boy Two Years Old. Re-
covery, By F. HuBER.
J. Blood Pressure in Children, By W. L. Stowele.
,1. Hysteria in Children. By G. E. Price
4. The Rest Treatment in Chorea, By J. Ruhk-ah.
5. Report of a Case of So Called Cyclic Vomiting with
Hepatic Insufficiency, By E. W. Saunders.
6. Report on the Milk Supply of Ne-w York City, with
Recommendations, By L. E. Holt and Others.
7. Digital Methods of E.xtubation, By J. R. Clemens.
8. A Fatal Case of 1 fiemophilia Neonatorum,
By H. F. Lange-Ziegel.
<). An Automatic Bottle Warmer, By R. G. Freeman.
I. Pneumohydrothorax. — Huber states that
the view formerly held that gas is secreted by the
pleura is now considered improbable, except in rare
instances, as from dccomjiosition or the action of
the gas bacilli. The almost invariable cause of this
condition is perforation from disease of the chest
organs, or through the thoracic wall. The most fre-
(]uent cause is an ulcerative tuberculous focus be-
neath the pulmonary pleura. It may also be due to
l)erforation of an empyema into a bronchus, giving
way to gangrene in the lung, rupture of a pulmon-
ary abscess or hydatid cyst, bronchial ulcerations,
and rupture of subpleural emphysematous vesicle.
The condition may be precipitated by coughing,
vomiting, or any severe strain, or it may come on
(juietly, even during sleep. From without it may be
produced by trauma of various kinds. It is very
rare in children, and is usually followed by pleurisy.
There is a serofibrinous effusion in most cases. Two
MaicI) 7. 1908 J
PITH OF CURRENT LITERATURE.
471
plivsical signs are absolutely distinctive of this con-
dition : ( I ) a horizontal upper line of flatness, what-
ever the patient's position; (2) an immediate
change of this level with every change of position.
3. Hysteria in Children. — Price states that,
while there is no organic change in hysteria, its
phenomena may result from an increase of motility
in the neuroses. The condition is a very common
one among children, especially after the age of six,
and among females. Predisposing aetiological fac-
tors are heredity, faulty environment, and educa-
tional influences, also any condition which lowers
the vitality or causes continuous irritation of the
nerve centres. The symptoms in children are essen-
tially the same as in adults. The diagnosis is more
difficult than in adults, especially in hysterical con-
vulsive seizures. The condition may also be asso-
ciated with serious nervous disease. The prognosis
is usually good. The treatment should consist in
suggestion, remembering that there may be an un-
derlying neuropathy, good hygiene, good food, per-
haps iron and bromides. Cases are narrated illus-
trating hysterical tremor, hysterical joint, hysteria
of the psychic type, and of the visceral type.
4. The Rest Treatment in Chorea. — Ruhrah
states that various writers believe that drug treat-
ment* in this disease is more effective in the fifth or
sixth week than at earlier periods, perhaps because
the really serious part of the disease is over by that
time, and because drugs are not believed to have
any profound influence on the conditions which pro-
duce the disease. The author believes that a mod-
ified ^^'eir [Mitchell rest treatment is the best means
now at our command, and is less likely than other
measures to be followed by recurrence. The two
ends to be reached are ( i ) rest for both body and
mind, (2 1 increase in the body weight. Daily
baths, massage, abundant milk diet, with subsequent
m.eat diet, are the principal measures. Medicines
given are castor oil, hydrochloric acid iron, and de-
rivatives of salicyl. This plan was curative in a
large number of cases in from ten to seventy-two
days.
THE PRACTITIONER
fcbruary. i(joS.
I. A Clinical Lecture on the Causes ami Operative Treat-
menr of Umbilical and Ventral Hernia,
By A. E. B.\RKEK.
Tlie ^lode of Production of the Presystolic Murmur
in Mitral Stenosis, By E. H. Coi.hf.i k.
3. Infantile Paralysis, By G. Rankix.
4. The Radical Treatment of Cancer of the Prostate,
By J. W. T. Walker.
5. Metastatic Affection of the Pancreas in Mumps,
By W. Edgecombe.
6. Ophthalmia Neonatorum. By S. Mayou.
-. The Contracted White Kidney, By W. M. Robson.
S. Review of Tropical Diseases, By R. T. Hewlett.
9. A Review of Diseases of the Blood and Blood Forming
Organs. By H. B. Shaw.
ID. The Treatment of Chilblains. By F. Gardiner.
II. A Statistical Inquiry into the Cases of Cancer Occur-
ring at Twickenham for Twenty-one Years from
• 1882 to 1902, with Observations and Remarks,
By J. R. Leeson.
12. Chorea and a Convenient and Trustworthy Method of
Exhibiting Arsenic Therein, By J. G. Sharp.
I. The Causes and Operative Treatment of
Umbilical and Ventral Hernia. — Barker attrib-
utes to the great expansion of abdominal surgery the
great frequency of ventral hernias. Their occtir-
rence is due not merely to faulty closure of the
wound and to suppuration, but to the inherent weak-
ness of scar tissue, and to the unfavorable condi-
tions in which the healing of such wounds often
takes place. The cause of umbilical hernia is virtu-
ally the same as that of ventral hernia, for it is the
weakness of a physiological scar. The protrusion,
having once begun, exercises distending force in all
directions. In operating for such conditions simple
apposition of the edges of the ring will not result in
permanent cure. In large hernije the contracted
condition of the abdominal cavity will also militate
against permanent cure. If there are large masses
of omentum in the hernia they should be excised.
The sac having been cttt away close to the ring, the
edges of the ring are united, the stitches including
the cut edges of the sac. The author thinks that
then a wire filigree should be introduced under the
anterior layer of the sheath of the recti and secured
by sutures passed through the overlying sheath ; a
final layer of sutures should then close the skin. A
small opening at the lower angle of the wound will
facilitate drainage and ensure better results in tho.=e
who are obese.
3. Infantile Paralysis. — Rankin follows La-
borde in dividing this disease into (i) an initial
stage not exceeding a week; (2) a stationary stage
of a week to a month; (3) a regressive stage, from
one to six months ; and (4) a chronic stage, with
atrophy and deformities. He takes for its pathology
the summary of Byrom Bramwell. as follows: i.
The lesion is acute inflammation of grey matter in
the anterior horn. 2. It is ttsually confined to this
part of the cord. 3. It involves chiefly the lumbar and
cervical enlargements, some or all its segments be-
ing involved. 4. The lumbar enlargement is the
more frequently involved. 5. The inflammation may
be very slight or very severe and destructive to the
multipolar cells. 6. The inflammation temporarily
arrests or permanently destroys the function of the
nerve elements, with paralysis to the muscles which
they supply. 7. A destroyed nerve cell is never re-
stored. 8. Degeneration and atrophy of the axis
cylinder process in the motor nerve endings follow
destruction of a nerve cell in the anterior horn, and
also the muscular fibres with which the nerve end-
ings are connected.
4. The Radical Treatment of Cancer of the
Prostate. — Walker finds such treatment favor-
able from some points of view and unfavorable in
others. It is favorable if used early, as the disease
in this location progresses slowly. It is unfavor-
able from the fact that when symptoms arise the
disease is usually far advanced and has invaded the
bladder or rectum, or both. If an incomplete opera-
tion is done in the latter class of cases, e^rly recur-
rence is almost invariably the rule. The methods
which have been used are pararectal, prerectal, lat-
eral perineal, median perineal, and suprapubic. The
suprapubic and perineal routes are most frequently
followed, the latter the more frequently and with
less disastrous results. The most promising cases
are those in which there is a precancerous adenoma-
tous period. L'nfortunately the true nature of these
472
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
growths is often not determinable until after opera-
tion, when the tumor is submitted to microscopical
examination.
5. Metastatic Affection of the Pancreas in
Mumps. — Edgecombe states that it has long been
known that the pancreas may be involved in the in-
fection of mumps. Various writers have affirmed
that parotitis occurring in connection with pancre-
atic disease is always secondary to the latter. Miiller
is quoted as stating that mumps may occur in con-
nection with the pancreas, thyreoid, thymus glands,
and other organs. The author records an epidemic
of thirty-three cases of mumps occurring in a boys'
school. The disease was mild in type, constitutional
symptoms being slight or absent. Orchitis was pres-
ent in two cases, both the boys having attained pu-
berty. In five of the cases there were symptoms
which pointed to metastatic involvement of the pan-
creas.
6. Ophthalmia Neonatonim. — Mayou finds
the organism causing this disease occurring in the
following order of frequency : (i) Gonococcus. (2)
pneumococcus, (3) Koch-Weeks bacillus, (4) diplo-
bacillus of Morax-Axenfeld, (5) bacterium coli, (6)
Klebs-Loffler bacillus, (7) pneumobacillus, (8)
common pyococci, (9) streptococci, (10) micro-
coccus luteus. There are three classes of the dis-
ease : ( I ) The severe, with profuse discharge and
danger to the cornea; (2) the moderate, with Koch-
Weeks conjunctivitis; (3) the mild, with very little
discharge. Infection may take place : ( i ) Before and
during the act of birth, before birth through the un-
ruptured membranes, the eyelids being separated as
early as the fifth month. During the act of birth the
infectious discharge may be communicated from the
cervix or vagina, or by means of the forceps, or the
finger of the accoucheur. Infection from the faeces
is rare. (2) Immediately after birth, hence the ne-
cessity of carefully wiping the eyes with bichloride
solution and instilling nitrate of silver. (3) Some
time after birth, through the medium of the nurse,
the diapers, etc. The period of incubation is very
short, and the severer the attack the shorter the in-
cubation period.
THE JOURNAL OF NERVOUS AND MENTAL DISEASE.
February, igo8.
1. The Functions of the Corpora Striata, with a Sugges-
tion as to a Clinical Method of Studying Them,
By Charles L. Dana.
2. General Considerations as to the Nature and Relation-
ship of Hysteria, By R. C. Woodman.
I. The Functions of the Corpora Striata. — Dana
remarks that the corpus striatum is an early de-
velopment from the wall of the anterior vesicle,
and its cells are more of the associative and sen-
sory type than motor. It is most closely linked to
the optic thalamus and the subthalamic ganglia.
It is a ganglion which is present in the lowest of
the vertebrate orders, and seems to have functional
importance in fishes and reptiles when the pallium
is nothing but a layer of epithelial cells. We may
suppose it, therefore, to be an older portion of the
hemispheres than the cerebral cortex of man. As
the cerebral cortex grew in importance, in higher
vertebrates, the corpus striatum became less im-
portant relatively, and while it, no doubt, has some
functions in man, they are probably of an associa-
tive and automatic character, rather than independ-
ent and specialized. The author has the notes of
four cases, from which he concludes that the corpus
striatum has not any independent or specific motor
function. It probably has some supplementary
motor function, and especially in connection with
articulation. It may have some control over the
bladder (double lesions), and seems to have some
control over vasomotor and trophic conditions of
the skin (and lungs?). It has no thermic centre,
but it may have some supplementary and associa-
tive psychic function, so that lesions afifect memory
or initiative. It is an organ of less importance rela-
tively in the higher vertebrates. In severe gas
poisoning there is a double softening of the lentic-
ular nuclei due to thrombosis of "the artery of cere-
bral thrombosis," and there result vasomotor and
gangrenous conditions of the skin, so that these
conditions in connection with a history of coma
from gas poisoning form a group of symptoms
called "the syndrome of the corpus striatum."
WESTERN SURGICAL AND GYN.5;C0L0GICAL
ASSOCIATION.
Seventeenth Annual Meeting Held in St. Louis, December
30 and 31, 1907.
The President, Dr. Charles W. Oviatt, of Oshkosh, Wis.,
in the Chair.
(Continued from page 330.)
Anaesthesia Fatalities in Iowa. — Dr. L. W.
LiTTiG, of Iowa City, Iowa, said he had sent a cir-
cular letter to 3,500 physicians practising in Iowa.
Eight hundred replies had been received, many of
them containing information which led to reports
of fatalities by men who did not reply to his first
letter. He had rejected reported chloroform fatali-
ties occurring from two to four days after anaes-
thesia, because he did not think it was possible to
secure anything like reliable data in this class of
cases. He had rejected ether fatalities occurring at
the close of a long and difficult operation ; he had
excluded cases in which he thought that the opera-
tion itself was of sufficient magnitude to cause death
on the operating table or soon after the patient's re-
moval from it. He had excluded obstetric fatalities
in which placenta praevia or severe haemorrhage com-
plicated delivery. He had excluded cases in which
pneumonia or other lung complications followed
gallbladder or other abdominal work. The report
dealt with sixty-three chloroform fatalities. Of
these, ten occurred in dental practice. One fatality
was due to choking during an.xsthesia. There were
five fatalities in confinement in which chloroform
was used and in which the reporters blamed the
chloroform. There was one confinement fatality in
which ether was used and in which the reporter
blamed the ether. There was one H. M. C, ether,
chloroform sequence, and one chloroform ether se-
quence. There was one late chloroform fatality with
jaundice.
The author concluded: i. That chloroform was
vastly more dangerous than ether, and especially in
March 7, 1908.]
I'RUCnHDIXGS Ur SOCIETIES
473
minor work and at the beginning of the administra-
tion. The chloroform ether sequence was especially
bad. 2. That in the class of work mentioned chloro-
form was so much more dangerous than ether that
its use should be emphatically condemned, and that
''the surgeon (quoting H. C. Wood, writing sixteen
years ago or earlier) is not justified in using chloro-
form except under certain circumstances and for
very definite reasons." 3. That chloroform was es-
pecially dangerous in dental work and should not be
used. 4. That chloroform was not free from dan-
ger in obstetric practice.
The Abdominal Incision. — Dr. Clifford U.
Collins, of Peoria, III, read a paper on this subject
in which he drew the following conclusions : i. Ab-
dominal incisions should be placed so they would
pass through both aponeurosis and muscle. 2. The
incision- of the aponeurosis and the split in the mus-
cle should run in different directions. This could
be done in a large majority of abdominal operations.
3. A longitudinal incision should not be made
through the linea alba or the sheath of the rectus at
a right angle to the combined pull of the three side-
muscles when it was possible to avoid it. 4. For
very large tumors, in cases where the character and
situation were in doubt, the longitudinal incision
was probably necessary. 5. If the longitudinal in-
cision was necessary, the split in the rectus should
not be continuous with the aponeurotic incision, but
should be placed to one side and preferably extend
through its inner half to avoid the intercostal nerves
which entered the outer half. 6. It would take
longer time and more experience to demonstrate the
correctness of these conclusions.
Arthrodesis and Tendon Transfer in Paralytic
Club Feet. — Dr. John Prentiss Lord, of Omaha,
advised arthrodesis and tendon transfer in cases of
paralytic club feet for the following reasons : i . To
prevent the return of the deformity, which so often
occurred where braces alone were used. 2. To
avoid loss of time, during which the child became
confirmed in the habit of deformity. 3. Because
younger children learned to walk anew much easier
than those of more advanced years. Where the pa-
tient was financially unable to meet the expense of
prolonged treatment with braces. 5. If a return of
deformity was prevented, the parents did not fall
into the habit of thinking nothing could be done. 6.
It utilized to best advantage the remaining muscu-
lar power, and gave the best possible results to be
obtained in these cases.
The degree of work done depended upon the
amount of deformity. Ordinarily, removal of the
articular surfaces from the tibioastragaloid, astra-
galoscaphoid, and calcaneccuboid was done to effect
arthodesis. In addition, transfer of the tibialis an-
ticus to the common extensor for toedrop was done,
while in extreme equinovarus astragalectomy with
removal of the joint surfaces from the calcaneo-
cuboid articulation, and even suturing the tibialis
anticus to the periosteum on the outer side of the cu-
boid, might be demanded. In some cases, even the
flexor longus hallucis was brought through the in-
terosseous membrane and sutured to the common
extensors. In the rare cases requiring muscle split-
ting, he said, we should avoid severing the trans-
verse nerve fibres in the body of the muscle. Dr.
Lord had used catgut sutures, except where the ten-
sion was heavy, when he used fine silk, boiled in bi-
chloride, dried and reboiled in paraffin before the
operation. In more than forty consecutive cases
cigarette drainage was used to take away oozing.
This was gradually removed, no suppuration taking
place. Heavy casts were kept applied as long as six
months, the use of the foot being gradually in-
creased after three or four months. The results had
been very gratifying, the majority of patients hav-
ing been able to discard braces or crutches within a
reasonable time.
The President's Address. — President Oviatt
did not deal with any concrete surgical problem,
but his address consisted of a few thoughts bearing
on the practice of surgery that naturally came to
one who had spent the most active years of his life
in the work. No attempt was miade to take up the
history further than to show that previous to the
year 1800 but few discoveries were made that
marked any distinct advance. The evolution of
surgery in the past century had kept pace with the
development of science along other lines, wonderful
as this had been. With the perfected technique of
antisepsis and asepsis, it seemed that the acme of
surgical science had been reached ; but in the light
of discoveries it would be rash to attempt to place
a limit to the future of surgery.
The ambitious medical student did not usually
get far into his college work before he decided to
become a surgeon. This decision was brought
about largely through what he saw in surgical clin-
ics and from his observation of the position held
by the surgical leaders of the profession. Young
men who elected to become surgeons should make
sure that they possessed the special aptitude and
then be willing to devote a long period to prepara-
tion for the work.
Attention was called to the fact that there was
much that passed under the name of surgery being
done 'by incompetent and ill trained men. Some of
it was honest and well intended, but much was for
purely commercial ends. A spirit of "graft" had
pervaded the profession that was undermining
morals and ethics. A partial explanation for the
existence of this condition was found in the fact
that this was an age of commercialism. We were
known to the world as a nation of dollar chasers.
This and the overcrowding of the profession with
men from inferior schools were in large part respon-
sible for fee splitting and the commission evil. The
existence of this class of medical colleges was less
excusable when it was considered that the better
schools ranked with the best in the world, and that
they were ample to afford instruction for all who
should enter the profession. Enough well prepared
men of character were entering the field to insure
the upholding of the lofty ideals that had character-
ized the profession in the past. V\t might, there-
fore, take a hopeful view of the future. Another
aid in the elimination of the "graft" evil was coming
from the people themselves. The public mind was
especially active at this time in combating; "graft"
in all forms.
The normal standards set for professional men
and men in public life were going to be higher in
the future, and with the limelight of public opinion
474
i'KUCtEUiNGS OF SOCIETIES.
IXew York
Medical Journal.
turned upon the medical and surgical "grafter " the
evil would cease to exist. Hand in hand with this
reform it was hoped that an established standard
of qualilication would be established for those who
assumed to do surgery.
The Significance of Abdominal Tenderness in
Locating Lesions of Viscera. — Dr. T. C. Wither-
si'oox, of Butte, ^^lontana, referred to the physi-
ology- of the sensory nerves of the abdominal vis-
cera, and discussed at length the effect of lesions of
the viscera in the production of pain. The somatic
areas of pain referred from the viscera and their
significance in diagnosis were pointed out and expa-
tiated upon : likew ise the character, of the visceral
pain. He spoke of disturbance of the sensory func-
tion of the somatic nerves, with coincident disturb-
ance of visceral function. Lastly, he called atten-
tion to those pains of central origin which were
referred tci the abdomen. Pott's disease, tabes, and
tumors in the spinal canal illustrated this class.
Usuallv the subjective pain was not accompanied
by tenderness, at least not of any acuteness.
The .ffitiology of Epithelioma. — Dr. Arthur E.
Hertzler. of Kansas City, Mo., began with the
hypothesis that the limitation of epithelial cell devel-
opment was set by the chemical dif¥erence in the
basement membrane and epithelial cells. Experi-
ments proved that those chemicals which united
with ( stained I connective tissue in zivo caused an
atypical epithelial cell proliferation resembling
closely a beginning epithelioma. The development
of atypical cells was limited because the action of
the chemical upon the connective tissue was limited.
This resulted in constancy for stains having these
characteristics. It" was negative for connective
tissue stains which did not stain in z'iz'o or for
nuclear stains. In areas in which atypical cell pro-
liferation had been brought about by such means
the fibres, after fixation, did not stain with the ordi-
nary fibrous tissue stains, while the fibrous tissue in
regions not so treated stained in the characteristic
manner.
Applying facts so deduced clinically, the general
statement was ventured that epitheliomas occurred
in those regions where alkaline secretions were per-
mitted to come in contact with the fibrous tissue by
irritation, thus producing the resistance of the con-
nective tissue to the invasion of epithelial cells or
to some exposure to leucocytes, as in chronic inflam-
mation, or to some overstimulation of the epithelial
cells. Either of these conditions would lead to a
disturbance of chemical balance and permit the
invasion of the epithelium.
Preparatory and Postoperative Treatment. —
Dr. J.\MEs E. Moore, of l\Iinneapolis, said that as
a rule preparatory and postoperative treatment,
aside from the sterilization of the operative field
and the dressing of the wound, had more to do with
the comfort of the patient than with his recovery,
for emergency patients very commonly did well and
surgeons frequently performed successful opera-
tions away from home and left the after treatment
to a physKrian little skilled in the care of surgical
cases. In all but exceptional cases, where some
organ — the bladder, for example — had to be pre-
pared for operative procedures, prolonged prepara-
tory treatment was unnecessary and inadvisable. It
was not in keeping with modern surgery that sur-
geons should operate upon their patients off the
street, but it was sufficient to have the average
patient enter the hospital on the day preceding the
operation. In weak patients and where a very
severe operation was to be performed, a hypodermic
of 1/30 of a grain of strychnine just before the
operation was helpful. The operative field should
be shaved and thoroughly disinfected and a sterile
dressing applied the evening before the operation.
Every operating room should have an experienced
anaesthetist, because it added to the patient's com-
fort and safety, and allowed the surgeon to give
his undivided attention to the operation. He pointed
out the many things pertaining to the operation
itself which had a decided bearing on the after
treatment. The patient always thought the stitches
and bandages were too tight, and it was very im-
portant that the surgeon should know that they
were not. Most stitch abscesses were caused by
tight stitures, and tight bandages were the cause of
untold suffering. Thirst was the greatest source of
suffering after an operation, and in the management
of this symptom many mistakes were made. His
patients all got water after an operation, and they
got well much more comfortabh- than those who
were deprived of it. "All surgeons agreed that the
patient was better without food for a time after
an operation, for they did not suffer from hunger,
and an effort to force feeding would surely disturb
the stomach. Aside from opiates and mild cathar-
tics, medicine had very little place iu postoperative
treatment. His patients got it only to meet definite
indications. Attention should be given to the relief
of pain after an operation. The proper care of the
bowels had much to do with the patient's comfort.
In every case the question naturally arose. When
shall, the patient get out of bed? AU were agreed
that old people should get up at the very earliest
period possible, for reasons well understood, but
there was still a great diversity of opinion as to
when a younger patient should get up, Everv ab-
dominal operation was of sufficient importance to
justify the patient in remaining in bed for from one
to three weeks, according to circumstances, and he
was usually content to do so. There was no crying
need of getting the patient out of bed on the day
after an abdominal operation. He was safer and
more comfortable in bed for a few days at least.
The author had recently operated upon a colleague
for chronic appendicitis, and he made the statement
that he intended to get out of bed on the day after
the operation, saying that staying in bed for a week
after such a simple operation was all nonsense, to
all of which the speaker readily acceded, with a
mental reservation. On the first day the patient
quietly curled upon his side, and Dr. Moore smiled
without comment. On the second day he was still
in bed, and when he asked him why he was not up,
he mildly suggested that he go to a warmer climate,
and very emphatically stated that his viewpoint had
changed.
The Appendix in a Femoral Hernia. — Dr.
Chart. Es .S. J.\mes, of Centerville, Iowa, reviewed
the literature, after which he reported the case of
a woman, aged seventy-seven years, who for four
days had noticed a painful lump in the right groin.
She had been in her usual health previously, but
had noticed a small \\\mp at this jKiint for several
March 7. 1 908. 1
BOOK XOTICES.
475
years. The symptoms were negative, except that
the pulse was 96 and the temperature 102''. The
abdomen was not distended. There was nothing
noted indicating an intraabdominal lesion. There
was a prominent brawny swelling, three and a half
to four inches in diameter, indurated and semi-
fluctuant, presenting the characteristic appearance
of a suppurative gland over Poupart's ligament.
There was no impulse. A diagnosis was made of
a local suppurative process, with probable femoral
hernia. An operation was performed at the Center-
ville Hospital an hour later under spinal anaesthesia,
using 10 centigrammes of 10 per cent, stovain solu-
tion. The abscess cavity was dissected up with
difficulty and the appendix was found to extend
through the femoral hernial opening. A separate
abdominal incision disclosed an incarcerated loop of
ileum, gangrenous, and two perforations. He re-
sected five inches of the intestine and resorted to
end to end anastomosis with suture. The appendix
was ligated, severed, and removed, with the closure
of the stump in the usual manner. Both incisions
were closed with continuous catgut suture. The
time of the operation was an hour and a quarter.
The patient was conscious, but suffered no pain
throughout the operation. Convalescence was pleas-
ant and recovery excellent. He presented photo-
graphs and the specimen.
(To be concluded.)
§ffok llotitts.
[ll'e publish full lists of books received, but icr acknov-'l-
cdgc no obligation to reviezu them all. Nevertheless, so
far as space permits, zee reviezv. those in zvhich zve think
our readers are likely to be interested.]
The Operating Room and the Patient. Bv Russell S.
Fowler, ^.1. D.. Professor of Surgery. B'rookl>-n Post-
graduate Medical School, etc. Second Edition. Revised,
and Enlarged. Philadelphia and London: W. B. Saun-
ders Company, 1907. Pp. 284. (Price. $2.)
This book appeared for the first time a little over
a year ago, when it was well received and appre-
ciated by the medical profession. The author now
places a second edition before his confreres, in
which he has added a chapter on the general con-
sideration in the after treatment and another on
complications of wound infection. The book con-
tains twelve chapters, and treats the subject in the
following way: The operation room and its per-
sonnel ; the instrument and supply room, giving also
a full list of instruments and dressings cofnmonly
employed: amesthesia : the patient; after treatment;
aseptic wounds : infections : complications. The
book can be well recommended, as it contains man\-
useful hints and instructions.
Textbook of Organic Chemistrv for Medical Students. Bv
Dr. G. V. BuxGE, Professor of Physiological Chemistry
in the University of Basel. Translated with Additions
by R. H. Aders Plimmer. D. Sc. (Lond.). Assistant
Professor of Physiological Chemistry and Fellow of Uni-
versity College, London. London and New York : Long-
mans. Green, & Co.. 1907. Pp. viii-260.
As indicated by the title, this book is intended for
the equipment of medical students with a working
knowledge of the science of organic chemistry. In
the series of seventeen lectures which make up it?
contents, almost every branch of organic chemistrv
that has the slightest application in physiology,
patholog}-, pharmacology, or hygiene is included,
and the author points out in which branch "t medi-
cine the selected facts of the lectures find applica-
tion. The value of the book is much enhanced by
the additions and transpositions which have been
made by the translator, and though the subject as
presented in the lectures may wear a formidable look
to medical students and others who enter on the
study for the first time, it is yet ideally adapted to
its purpose and is well calculated to fulfill the hope
of the translator that by its study organic chemistry
may be brought nearer to physiological chemistry.
The arrangement and general plan of the lectures
are attractive and the subject matter is readable
enough, but we fear that a little too much elemen-
tary knowledge of the science of organic chemistry,
on the part of the average medical student, is pre-
supposed by both author and translator.
A Textbook of Diseases of the Xose and Threat. By D.
Br.adex Kyle. .\. M.. ^1. D.. Professor of Laryngology
and Rhinolog>-. Jefferson Medical College, etc. 219 Il-
lustrations. 26 of Them in Colors. Fourth Edition. Thor-
oughly Revised and Enlarged. Philadelphia and Lon-
don: W. B. Saunders Company, 1907. Pp. 797.
On its first appearance we recommended Kyle's
textbook as particularly well suited to students, and
called attention to the excellence of the chapters on
examination, diagnosis, and anatomy. These have
been revised and amplified. The whole subject of
local disease and of operative methods, has been
brought up to the latest standpoint, and there are a
number of entirely new chapters, among which the
most important are those on the surger}- of the
larynx, bronchoscopy, the physiology and pathology
of the voice, speech defects, and the relation of the
voice to hearing. Radiography has not received
from the author the attention it deserves as a
diagnostic measure, only cursory mention of it being
made. The x ray is a valuable aid in many cases in
which bronchoscopy shows nothing or cannot be
employed. It should be made a routine m'.asure
where a foreign body is suspected. and in all obscure
and long continuing cases, as well as invariably be-
fore operative procedures on the accessory sinuses.
The curative effects of this agent might also have
been mentioned, considering the results obtained by
its application in rhinoscleroma, epithelioma, and
other serious affections of the upper respiratory
tract.
Diseases of Children for Xurses. Including Feeding,
Therapeutic Measures Employed in Childhood. Treat-
ment for Emergencies. Prophylaxis. Hvgiene. and Nurs-
ing. By Robert S. McCombs. :M. D., A ssistant Phvsician
to the Dispensary and Instructor of Nurses at the Chil-
dren's Hospital of Philadelphia, etc. Illustrated. Phila-
delphia and London : W. B, Saunders Companv. 1907
Pp. 431- (Price, S2).
The scope of this work is well defined by its title,
and a reading of it shows that the author has ad-
mirably fulfilled his purpose. It is strictly a book
for nurses. Short descriptions of the various dis-
eases of infants and children are given, and should
aid in rendering, a nurse intelligent regardinq- her
cases. It is certainly desirable that a nurse should
have a sufficient knowledge of disease to know what
symptoms are to be expected and what complica-
tions are to be guarded against. A sufticient knowl-
edge of treatment is also necessary to explain to
4/6
MISCELLANY.
[New York
Medical Journal.
her the reasons for the measures adopted and to
render her intelligent in their application. Follow-
ing this section of the book is special instruction
upon the nursing of various diseases or classes of
diseases. The subject of infant feeding is, on the
whole, very satisfactorily presented, and is well
adapted to the nurse's use. The chapter on thera-
peutics must prove one of practical value to the
nurse. The portions devoted to the methods of ap-
plying the various measures used in the treatment
of children are well managed and must also prove
valuable. The book, on the whole, is an excellent
work for the use of nurses, and in some particulars
covers a field which has not been heretofore writ-
ten upon.
BOOKS, PAMPHLETS. ETC. RECEIVED.
The Production and Handling of Clean Milk. By
Kenelm Winslow, M. D., M. D. V., B. A. S. (Harv.),
Formerly Instructor in Bussey Agricultural Institute and
Assistant Professor in the Veterinary School of Harvard
University, etc. New York: William R. Jenkins Company,
1907. Pp. 207. (Price, $2.50.)
Diseases of the Breast. With Special Reference to Can-
cer. By William L. Rodman, M. D., LL. D., Professor
of Surgery in the Medicochirurgical College of Philadel-
phia, Professor of Surgery in the Woman's Medical Col-
lege of Pennsylvania, etc. With • Sixty-nine Plates, of
which Twelve Are Printed in Colors, and Forty-two Other
Illustrations. Philadelphia : P. Blakiston's Son & Co.,
1908. Pp. 385- (Price, $4.)
Healthy Boyhood. By Arthur Trewby, M. A. With an
Introduction by Sir Dyce Duckworth, M. D., LL. D., Con-
sulting Physician to St. Bartholomew's Hospital, etc., and
a Foreword by Field Marshal Earl Roberts, K. G., K. P.,
V. C, O. M., P. C, G. C. B., G. C. S. I., G. C. I. E.,
D. C.L., LL. D. New York: Longmans, Green, & Co.,
1907. Pp. 63.
Practice of ]\Iedicine for Nurses. A Textbook for
Nurses and Students" of Domestic Science, and a Hand-
book for all Those Who Care for the Sick. By George
Howard Hoxie, A. M., M. D., Professor of Internal Medi-
cine in the University of Kansas, etc. With a Chapter
on The Technic of Nursing, by Pearl L. Laptad, Princi-
■pal of the Training School for Nurses of the University of
Kansas. Philadelphia and London: W. B. Saunders Com-
pany, 1908. Pp. 284.
Report of the Commissioner of Education for the Year
Ending June 30. 1906. Volume 2. Washington : Govern-
ment Printing Office, 1908. Pp. 1308.
La Lutte contre les microbes. Cancer, tuberculose, mala-
die du sommeil, tetanos, enterite et microbes intestinaux,
variole et vaccine: L'CEuvre de Jenner. Par Dr. Etienne
Burnet, de ITnstitut Pasteur, chef du service de la vaccina-
tion de la Ville de Paris. Paris: Armand Colin, 1908.
Pp. 318.
Die Entzimdung; eine monographische Skizze aus dem
Gebiet der pathologischen Physiologic. Von Dr. Rudolf
Klemensrewicz, o. 6. Professor u. Vorstand des Instituts
fiir allgemeine Pathologic an der Universitat in Graz, etc.
Festschrift der k. k. Karl-Franzens-Universitat in Graz aus
Anlass der Jahresfeier am 15. November 1905. Jena:
Gustav Fischer, 1908. Pp. vii-120.
Klinische Semiotik. Mit besonderer Beriicksichtigung
der gcfahrdrohenden Syniptome und deren Behandlung.
Von Dr. Alois Pick a. o. Universitatsprofessor, k. u. k.
Oberstabsarzt, und Dr. Adolf Hecht, Kinderarzt. Wien
und Leipzig: Alfred Holder, 1908. Pp. 969.
Hsematological Atlas. With a Description of the Technic
of Blood Examination, By Priv. Doz. Dr. Karl Schleip,
Scientific .Assistant in the Medical Clinic University of
Fn-iburg i/B. Engli.sh Adaptation of the Text by Frederic
E. Sondern, M. D., Professor of Clinical Pathology, New
York Postgraduate Medical School and Hospital, etc. With
Seventy-one Colored Illustrations. New York : Rebman
Company, IQ08. Pp. 256. (Price. $io.)
.Milk and Its Relation to the Public Health. By Various
Authors. Bullciin No. 41, Hygienic Laboratory,. Public
Health and Marine Hospital Service of the L'nited States.
Washington : Government Printing Office, 1908. Pp. 757.
Resolution on the Death of Dr. Robert W.
Taylor. ■ — The following obituary notice was ap-
proved at the meeting of the Dermatological So-
ciety, held on February 25, 1908:
ROBERT W. TAYLOR.
Born August ti, 1842. Died January 5, 1908.
Dr. Taylor was one of the founders of the New
York Dermatological Society, the oldest derma-
tological association in existence. Since its organ-
ization in 1869, to the meeting held shortly before
his death, and at which he was present, he has al-
ways been one of its most zealous members. An
indefatigable student, an earnest and convincing
teacher, and a brilliant and prolific writer, his death
will not only be keenly felt by those who had the
opportunity of working with him and profiting by
the example of his energy and enthusiasm, but will
be regarded as an irreparable loss to the medical pro-
fession. Among the eminent names which have been
inscribed upon the muster roll of our society Dr.
Taylor's name will ever rank high. No member has
been more faithful in the discharge of his duties,
and no one, by his professional achievements, has
shed greater lustre upon its membership.
In our grief at the thought that he will meet with
us no more, we feel that we have lost not only a very
distinguished colleague, but a most estimable friend.
George Henry Fox,
Hermann G. Klotz,
Edward B. Bronson,
Committee.
Symposium. — Dr. A. Rose writes in a letter to
the editor of the Medical Reviczv of Reviezvs: "Will
you kindly permit me to call your readers' attention
to the wrong interpretation of the word 'symposium,'
which we find so frequently on programs of medical
writers? Synnposium (rd GvtnroSioi') is a banquet, a
feast, and one of the features of such banquet or
feast is drinkingtogether((3t;yuiriVw-5i';',7r/»'w) 'Svuirorj/i
{6vv, iror/;?) is One with whom we drink in company.
I know very well that in English language is under-
stood by symposium a collection of opinions or
essays, but this is incorrect. Incorrectness of such
kind may creep in every living language, but in all
civilized countries there are men of taste — in Ger-
many and France there are even patriotic societies —
who exert themselves to eliminate from the language
whatever has been found incorrect."
Illumination of the Battlefield for the Search
of 'Wounded. — Dr. Willcox has translated an arti-
cle of Dr. Fluteau, of the French army, which ap-
pears in The Military Surgeon of December, 1907.
Several lights were tried and it was proved by these
trials that the Bleriot acetylene lamps produced a
light fully equal to the easy discovery of the
wounded, hidden as well as they could have been
on the battlefield. The second lantern constructed,
that gave a more brilliant light than the first, is a
trifle too large, but it is a fault it would be difficult
to remedy without injuring its qualities. It also
presents certain defects in construction, such, for
example, as the employment, for closing the ap-
March 7, 1908.]
OFFICIAL NEWS.
A77
paratus, of a rubber washer that can be changed in
length. It will be possible, according to the maker,
to replace this with a beaten out leather plate. The
Brenot-Mareschal lamp is simple, light, not cum-
Tdhous, but it presents one great fault. To put it in
operation it requires, as does the Paquelin thermo-
cautery, the working of a rubber bulb by hand.
There results a fatigue that does not allow it to be
used sufficiently long for the purpose that it is
meant for. Moreover, the inflation of the rubber
iDulb is a difficult task, and it is liable to alteration
in spite of the precautions adopted for apparatus of
this kind that form part of the sanitary service ma-
terial in the field.
The Relation of Upper Respiratory Ob-
struction to Oral Deformity. — Faught observes
that the aetiology of the general subject of dental
irregularity, and particularly the interrelation of
such deformity and chronic respiratory disturbances,
is still lacking a definite basis. This matter should
receive particular attention at the hands of every
dentist. Dental irregularity in the vast majority of
instances is associated with, if not dependent on,
upper respiratory obstruction. Dental practitioners
should be more familiar with the common forms of
tipper respiratory obstruction, their symptoms, diag-
nosis, and treatment. The comparative study of the
changes brought about through corrective proce-
dures should be more carefully studied, and more
accurate methods of measuring and recording them
devised. The rational treatment of dental irregu-
larity should include preliminary examination and
treatment of the nasal chambers and pharynx. The
result of the ordinary expansion operation on nasal
conditions is more dependent on vital tissue in the
nasal region than on mere mechanical movement.
Operations designed mechanically to increase the re-
spiratory capacity of the nasal passages are practi-
cally valueless unless the intermaxillarv suture is
separated, as shown by increase of space between
the central incisors. It is impossible to relieve steno-
sis due to adenoids or sosptal irregularities by expan-
sion methods. Adenoids and deviations of the ssep-
tum should receive the usual treatment at the hands
of the rhinologists prior to the correction of dental
irregularity. The stimulation of vital forces and re-
newed growth in the nasal chambers, together with
the restoration of normal conditions in contiguous
parts, are the chief causes of improvement following
the expansion operation. — Journal of the American
Medical Association.
Public Health and Marine Hospital Service
Health Reports:
The folloz^'ing cases of smallpox, yellozc fever, cholera,
and plague have been reported to the surgeon general,
United States Public Health and Marine Hospital Service,
during the week ending February 28. 1908:
Smallpox — United States.
Places. Date. Cases. Deaths.
California — San Francisco Feb. 1-8 3
Illinois — Springfield Fdi fi-i ; 6
Iowa— Ottumwa Ftb. S-i'; i
Kansas — Kansas City Feb. 8-1 = 11
Kansas — Topeka Feb. 1-8. 2
Michigan — Saginaw eb. 1-8 6
Ohio — Cincinnati Feb. 7-14...
Ohio— Warren Feb. 8-15...
Oregon — Portland Feb. 1-8
South Dakota — Sioux Falls Jan. 25-Feb.
Tennessee — Nashville Feb. 8-15...
Texas — San Antonio Feb. 1-8. .. .
Washington — Spokane Feb. t -8 . . . .
-25-
Smalll'o.v — Foreign.
Cape Colony — East London Jan. 4-1 1
Japan — Kobe Jan. 11-18
Japan — Nagasaki Jan. 1-23
Japan — Yokohama Tan. 18-25
Java — Batavia Dec. 21-Tan. 18..
Mexico — Aguas Calientes Jan. 26-Feb. 2...
Mexico- — Mexico City Jan. 4-11
Netherlands — Rotterdam Jan. 18-25
Portugal — Lisbon Tan
Dec.
Russia — Batoum Tan.
Russia — Libau Feb.
Russia — Moscow Jan.
Russia — Odessa Tan.
Russia — Riga Jan. :
Spain — Denia Jan.
Spain — Valencia Jan.
Straits Settlements— Singapore .... Dec.
Venezuela — Caracas Jan.
Venezuela — La Guaira Jan. 4-Feb.
Yellow Fe. er — Foreign.
Barbados- — Bridgetown, vicinity of. Jan. 29. . . .
Cuba — Habana Feb. 20-2_>.
Cuba — Santiago Feb. 20. . .
Cliolc ra — Foreign.
India — Madras Jan. 4-10..
India — Rangoon Jan. 4-1 1..
Plague — Foreign.
Australia — Brisbane Jan. 3
Australia — Cairns Nov. 23-30.
•783
ii-Feb. I.
^y^b.-.
8-Jan. 4.
Australia — Sydney. . .
Chile — Valparaiso. . . .
China — Hongkong. . . .
Egypt — -Assiout Prnvir
Egypt — Garbieh Provi
Egypt — Minieh Provir
India — General
Dec.
• Jan. 4
Dec. 21-28.
Jan. 16-22.
.Jan. 19-22.
Tan. 12-22.
Dec. 22-28 3.725
Dec. 28-Jan. 4 4.402
Peru- — Callao Jan.
Peru — Catacaos Jan. 18 7 4
Peru — Chosika Tan. 18 i
Peru— Eten Jan. 18 9 1
Peru — Ferrenafe .Ian. 18 i
Peru — Lima Jan. 18 5 3
Peru — Paita Tan. 18 10 o
Peru — Piura Jan. 18 2
Peru — San Geronimo Jan. 18 4
Peru— Trujillo Jan. 18 29 9
Public Health and Marine Hospital Service:
Official list of changes of stations and duties of com-
missioned and noncPiumissi'Vicd officers of the United
States Public Health and Marine Hospital Service for
the seven days ending February 26, igo8:
Delg.^do, J. M.. Acting Assistant Surgeon. Granted two
days' leave of absence on account of sickness from
February 7, 1908.
H.\LLETT. E.' B.. Acting Assistant Surgeon. Granted leave
of absence for thirty days, on account of sickness,
from January S. 1908. and seven days' leave of absence
from February 7. 1908.
Keatley, H. W.. Acting Assistant Surgeon. Granted leave
of absence for seven days from February 11, 1908,
under paragraph 210, Service Regulations.
Roberts, Norm.\n, Assistant Surgeon. Granted leave of
absence for three days from February 24, 1908, under
paragraph 191. Service Regulations ; granted leave of
absence for twenty-three days from February 27, 1908.
SiMONSOx. G. T.. .\cting .\ssistant Surgeon. Granted leave
of absence for one day. February 21. 1908.
Walker. T. D.. Acting Assistant Surgeon. Granted leave
of absence for two days from February 25, 1908.
Army Intelligence:
Ofncial list of changes in the stations and duties of
officers serving in the medical department of the United
States Army for the week ending February 29, igo8:
CowPER, H. W., First Lieutenant and Assistant Surgeon.
Resignation of commission as an officer of the Army
accepted, to take effect March 18. 1908. and granted
leave of absence to and including above date.
Morris, E. R.. Major and Surgeon. Left Fort Thomas,
Ky., with troops en route to San Francisco, Cal.
Muxsox, E. L.. Major and Surgeon. Leave of absence
extended twentv davs.
4/8
BIRTHS. MARRIAGES, AND DEATHS.
[Nev. York
Medical Tournai.
Melson, Kent, Captain and Assistant Surgeon. Ordered
to proceed to Fort Thomas, Ky., for duty to accom-
pany the Fourth Infantry from that post to San Fran-'
Cisco, Cal.
PuRNELL, H. S., Captain and Assistant Surgeon. Ordered
to accompany First Battalion, Fourth Infantry, from
Fort Mackenzie. Wyo., to San Francisco, Cal., and
then to return to his proper station.
Talbott, E. M., Captain and Assistant Surgeon. Granted
ten days' leave of absence.
The following named medical officers are detailed as
members of boards of officers, to meet at the posts desig-
nated, on April 14, 1908, or as soon thereafter as practi-
cable, to examine such applicants for commission in volun-
teer forces as may be authorized to appear before them :
AsHDURN, P. M., Captain and Assistant Surgeon. Fort
Banks, Mass.
Baker, F. C, Captain and Assistant Surgeon. Fort Ogle-
thorpe, Cal.
Banister, J. M., Lieutenant Colonel and Deputy Surgeon
General. Fort Riley, Kan.
Davis, W. B., Lieutenant Colonel and Deputy Surgeon
General. Fort Crook, Neb.
De Shon, G. D., Oilajor and Surgeon. F'ort Logan H.
Roots, Ark.
EwiNG, C. R., Major and Surgeon. Fort Oglethorpe, Cal.
Ford, J. H.. Captain and Assistant Surgeon. Fort Mac-
kenzie. Wyo.
Freeman, P. L., Lieutenant Colonel and Deputy Surgeon
General. Fort Riley, Kan.
Grissinger, J. \V., Captain and Assistant Surgeon. Fort
Banks, Mass.
Hansell, H. S., Captain and Assistant Surgeon. Fort
Crook, Neb.
Harvey, P. F., Colonel and Assistant Surgeon General.
Fort Sheridan, 111.
Huntington. P. W., Captain and Assistant Surgeon. Fort
Rosecrans, Cal.
Keeper, F. R., Major and Surgeon. Fort Rosecrans, Cal.
Kendall, W. P., Alajor and Surgeon. Fort Sam Houston.
Texas.
KiRKi'ATKiCK, T. J., Captain and Assistant Surgeon. Fort
McPherson, Ga..
Lewis, W. F., Captain and Assistant Surgeon. Fort Logan
H. Roots, Ark.
MoN( KJEF. W. H., First Lieutenant and Assistant Surgeon.
Fort McPherson, Ga.
MfNsoN, E. L., ?iIajor and Surgeon. Fort Sheridan, 111.
PuKNELL, H. S., Captain and Assistant Surgeon. Fort
Mackenzie, Wyo.
Whaley, A. M., First Lieutenant and Assistant Surgeon.
Fort Sam Houston, Texas.
Navy Intelligence:
Official list of changes in the medical corps of the United
States Navy for the i^'cck ending February 2g, IQ08:
Allen, A. H., .AsMstant Surgeon. Will stand relieved from
duty in Cuba upon arrival at Lajas, province of Santa
Clara, of Passed Assistant Surgeon R. E. Riggs, and
will comply with orders from the Navy Department.
Brown, E. W., Assistant Surgeon. Ordered to the Naval
Medical School, Washington, D. C.
Clifford, A. B., Passed Assistant Surgeon. Detached from
the Naval Medical School Hospital, Washington, D. C,
and ordered to the Xaval Hospital, New Fort Lyon,
Colo., March 12.
Downer. J. O., Assistant Surgeon. Unexpired portion of
leave revoked ; ordered to the Relief.
Means. V. C. B.. Surgeon, Retired from active service
February 22, 1908, under the provisions of Section 1453,
revised statutes.
MoRAN, C. L.. Assistant Surgeon. Appointed an assistant
surgeon from February 10, 1908.
MuNSON, F. M.. Passed Assistant Surgeon. Ordered to
the Barry.
RiGOs, R. E., Passed Assistant Surgeon. Will proceed from
Camp Columbia, province of Havana, to Lajas, Cuba,
for duty.
Stanley. A. C, Assistant Surgeon, Appointed an assistant
surgeon from February 10. 1908,
Sprite, C. E., .Assistant Surgeon. Dctadu-d from the
Barry and ordered home.
Sirt^s, Parriagts, anb ftat^s.
Born.
De Witt. — In Whipple Barracks, Arizona, on Saturday,
February 15th, to Dr. Wallace De Witt. United States
Army, and Mrs. De Witt, a son.
Married.
Culler — Loser. — In Philadelphia, on Wednesday, Feb-
ruary I2th, Dr. Robert M. Culler, United States Army,
and Miss Anne E. Loser.
DiLMORE — Mines. — In Philadelphia, on Wednesday, Feb-
ruary 26th, Dr. George S. Dilniore and Miss Sarah Hall
Mines.
Faller — GiMBEL. — In St. Louis. Missouri, on Monday,
February 24th, Dr. Albert Faller and Miss Hortense
Gimbel.
Farley — Lumley. — In Philadelphia, on Wednesday, Feb-
ruary 26th. Dr. Joseph Farley and Miss Lillian E. Lumley.
Longmore — Dalgleish. — In Ottawa, Canada, on Wed-
nesday, Februarv 26th, Dr. Tohn Alva Longmore, of Brook-
lyn, and Miss Lillian Llewellyn Dalgleish.
Price — Francis. — In Brooklyn, on Tuesday, March 3d,
Dr. Wiliam Harrison Price and Miss Anna Francis.
Ringland — Snedecor. — In Brooklyn, on Friday, Febru-
ary 2ist, Dr. Robert Finley Ringland, of Bloomfield, New
Jersey, and Miss Elizabeth Van Buskirk Snedecor.
Smith — Ressler. — In Philadelphia, on Saturday, Febru-
ary 22d, Dr. Frank W. Smith, of Passaic, New Jersey, and
Miss Florence M. Ressler.
Died.
Avery. — In Chicago, Illinois, on Tuesday, February i8th.
Dr. Samuel J. Avery, aged eighty years.
Bedel. — In Norfolk. Nebraska, on Monday, Februarv
17th, Dr. Marshall D. Bedel.
Boone. — In Frederick, Maryland, on Saturday, February
22d, Dr. Jermingham Boone, aged eighty-seven years.
Coverly. — In Brooklyn, . .n Monday, Februar>' 24th, Dr.
John Henderson Coverl>, ~ixty-ti\e years.
Dodge. — In Tacoma. Washington, on Saturday, February
22d, Dr. Maurice M. Dodge, aged sixty-six years.
Fitzgerald. — In New York, on Thursday, February 27th,
Dr. Charles F. Fitzgerald, aged thirty-five years.
Halsted. — Newark, New Jersey, on Sunday, February
23d, Dr. Alfred T. Halsted. aged' forty-five years.
Ingram. — In Murphysboro, Illinois, on Thursday, Feb-
ruary 20th, Dr. \\')lliani I . Ingram, aged seventy-eight
years,
Kramer. — In Louisville. Kentucky, on Sunday, February
23d, Dr. William F. Kramer, aged forty years.
McMaster. — In Toronto. Canada, on Thursday, Febru-
ary 20th, Dr. John AIcMaster. ■ aged forty-nine years.
Mangum. — In New York, on Sunday, F'ebruary 23d, Dr.
Joseph Young Mangum.
Miller. — In Needhani, Massachusetts, on Saturday, Feb-
ruary 22d, Dr. Vesta D. Miller.
Nettleton. — In Roclu-tcr. New York, on Friday, Feb-
ruary 2ist, Dr. H. R, Wttleton. aged sixty years.
Probasco. — In Plainfulil. Xcw Jersey, on Tuesday, Feb-
ruary 25th, Dr. John P. I'r.ilia-co. aged sixty-six years.
Rice. — In Newmarket, \"iri;inia. on Saturday, February
22d, Dr. F. E. Rice, aged seventy-four \ears.
Robinson. — In St. Augustine, Florida, on Saturday, Feb-
ruary 22d, Dr. George A. Robinson, of Sayville, Long Isl-
and, aged fifty-seven years.
Ross. — In Madisonvillc, Kentucky, on Wednesday, Feb-
ruary 26th, Dr. W. S. Ross, aged seventy-eight years.
Saunders, — In Memphis, Tennessee, on Monday, Feb-
ruary 23d, Dr. Dudley Dunn Saunders, aged seventy-three
years.
Sonnenschmidt. — In Washington, D. C. on Friday, Feb-
ruary 28th, Dr. Qiarlcs W. Sonnenschmidt, aged seventy-
six years.
Trimble. — In Baltimore. Maryland, on Monday, Febru-
ary 24th, Dr. Isaac Ridgeway Trimble, aged forty-eight
years.
Urquhart. — Tn Orange. New Jersey, on Thursday, Feb-
ruary 20th, Dr. WilliTUi Mnrri^ Ur(|uhart. aged thirty-four
years
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal The Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXMI, No. ii. NEW YORK, MARCH 14, 1908. Whole No. 1528.
(©ripnal Comiiuinttatious.
ACUTE FLEXURES OR ANGULATIONS OF THE
SIGMOID AND COLON.
By James P. Tuttle, M. D.,
New York.
The role in tlic [jroduction of disease whieh is
attributed by internisls at the present time to the
absorption of toxiiies ircm retaiiied, fermenting-, or
putref3'ing LTcal matter, renders any stndy which
throws hght upon the causes and rehef of these con-
ditions both interesting and important. Without
minimizing the importance of other factors. I would
call attention to the intluence of acute flexures or
angulations of the colon and sigmoid in the causa-
tion of constipation and f;ecal retention. The term
acute is used here in the geometrical sense as the
obverse of obtuse, and not in the medical, for acute
flexure or angulation is usually a chronic condition
of slow origin. The term itself describes the con-
dition, a sudden or shar]) bend of the gut upon
itself, such as in all hollow tubes narrows or obliter-
ates the calibre according to its degree. These an-
gulations are anatomical throngliont the colon, and
all will recognize the terms Itcpnlic thwiirc. splenic
flexure, sigiuoid flexure. reet'<.\e^uiuitl(il llexuie. In
noamial conditinns these flexures retard tii a slight
degree the f;ecal current, and when through dis-
placement or any other cause the bend is exa rger-
ated the obstruction is proportionately increased.
Thus, in gastroenteroptosis the transverse colon is
carried downward in the abdominal cavity and un-
less the ligaments give wa\-, the normal hejiatic and
splenic flexures become more and more acute and
obstructive as the colon .descends. ( b'ig. <)). This
accounts for the distention and tenderness over the
caecum in such cases. In many instances of this
kind the right kidney and hepatic flexure descend
along with the transverse colon, and then only the
splenic flexure is accentuated. (Fig. 2).
Causes.
These two flexures are no doubt physiological,
and are produced by a short mesentery and retain-
ing band, the ligament, at the angle and a more or
less long mesentery on either side of it. Now, this
throws some light upon the causation of alinormal
and pathological flexures elsewhere. A shortening
of the mesentery by inflammation or adhesion or
the fixation of the gut by adhesion may either or
both together cause angulation which will narrow
or even obliterate the intestinal calibre. The sig-
moid flexure is so irregular in its anatomical con-
formation, and in the length and attachment of its
mesentery, and it is so liable to inflannnation aris-
ing in itself or extending to it from the pelvic organs
with which it is in constant apposition, that it is
the most frequent seat of all exaggerated flexures,
both congenital and acquired. It is with these that
I have had chiefl}- to deal, and I shall not theorize,
but briefly describe only those conditions which I
have seen and operated upon.
History.
It was before the American Proctologic Society,
in 1809, ^^'^^^ I fii'^t publicly called attention to
acute flexures of the sigmoid as a frequent cause
of constipation. In i()Oi, I described the condition,
(^International Journal of .Surgery), and again in
my work on Diseases of the Anus. Reetum. and
Pekic Colon, first edition, 1902, the subject is re-
ferred to several times and the technique of treat-
ment is detailed. Delatour {.-inimis of Suj-gery,
xlii, p. 678, i<)05j, and Laroque, (Ibid., xliv,
p. 678, 1906 ) evidently not having seen my descrip-
tions, have published five interesting and descriptive
cases, which they thought were the first recognized.
Delatour even says: "Angulation of the intestinal
canal at the sigmoid is a pathological condition
which we believe exists, but it has not been de-
scribed." Niles, {Journal of the Ameriean Medical
dissociation . September 15, 1906), refers to acute
and tempi rar-,- angulatinn- the residt of ulcera-
tion of the sii^inoid. He rejjorts and depicts two
cases in which acute angulation of the sigmoid with
the descending colon was caused by ulceration at
this point; and states that tlie l)owe] walls gave way
on attempts to restore them to ])osition. Reis, (. /;;-
nals of Sur_(;ery. 1904), ni a most interesting article
on jMesosigmoiditis in Its Relation to Recurrent
X'olvulus, relates a case which appears from his
description to be one of recurrent angulation rather
than volvulus. It woukl be s]ilitting liairs to argue
the point whether a volvulus always consists in a
twist, or whether it may not be an acute angulation
or flexure. The fact which he pro\ es, viz : that in-
flammation in the mesosigmoid may produce a thick-
ening and contraction which will cause such twists
or angulations as will partialh- or completely ob-
struct the passage, is most interesting and instruc-
tive.
^lEtiology.
These flexures may be congenital or acquired.
The congenital type are all, with one exception
so far as I have observed, due to tlie turning of the
rectum to the left at its upper end and thus bringing
the two fixed ends of the sigmoid in such close
apposition that the long loop in itetween is neces-
Copyright, 1908, by -\ R. Elliott Publishing Comi any.
48o
TUTTLE: ANGULATION OF COLON.
[New York
Medical Journal.
sarily acutely flexed, either when it rises up into the
abdominal cavity, or drops down into the pelvis,
or folds over upon itself, as is shown in Figs. 2, 3,
4. The case of congenital angulation which differed
Fig. I. — Ivxtciisive adhesions of the sigmonl to the vertebral col-
umn, transverse and (k-scending colon, causing acute flexures at two
points.
from this, consisted in the fixation of the sigmoid
on the right side of the pelvis, and its sudden turn
backward along the promontory of the sacrum to
join the descending colon. These malformations
are. T believe, the origin of most of the cases of
hypcrtr(:;])hicd and distended sigmoid and colon so
often seen in children. Sigmoiditis and perisig-
moiditis are the chief causes of acquired angulation.
Ulcers of the sigmoid, as has been so well described
by Xiles. may cause angulation either by their cica-
tricial contraction or b_\- the inflammation extending
to the peritonjeum. and causing adhesion or fixation
of the gut at some abnormal point. (Fig. 7).
Perisigmoiditis ma\- alsn arise from traumatism b\-
the action of the iliacus and psoas muscles, as has
been pointed out by BryfJii Robinson, and in this
state the gut may become adherent to almost any
point in the abdomen, thus causing an acute flexure
with partial or complete obstruction. Mesosigmoid-
itis as described by Reis may also account for the
condition through shortening of the mesentery and
thus causing abnormal fixation of the gut. Inflam-
mation of the ])clvic organs, oophoritis, salpingitis,
etc., mav extend to the sigmoid and cause adhesions
and angulations of any degree, (bi.g. 9). These
are, I believe, the most frequent causes, and they
account for the so much greater frequency of the
condition in women than in men. Local or general
peritonitis of anv type may brin? about the condi-
tion when there is no disease in the sigmoid itself.
A marked illustration of this was found by the
writer in the green room some years since. ■ .\d-
hesions between the appendices epiploicae may cause
acute angulation with most distressing symptoms
(Fig. 7). I have observed this condition twice.
Chronic appendicitis, if not a cause, is at least a
comparatively frequent complication of acute flex-
ure on the right side. (Fig. 9).
Symptoms.
There is always constipation or faecal stasis ; dis-
tention and more or less tenderness over the cxcum.
often leading one to suspect chronic appendicitis.
The latter may be the cause, and it may have caused
the angulation, (See Fig. 6) ; but the removal of the
appendix alone will not cure the patient. The flex-
ure must be straightened out at the same time or
there will still be fecal obstruction. May this fact
not account for some of the cases of fatal obstruc-
tion after appendicectomies ? As to the other symp-
toms, they are local, constitutional, and include the
whole category of reflex phenomena associated with
obstructed bowel movements. In the congenital
t\pc, which the specialists rarely see in early life,
there is always a history of colic, distended abdo-
men, constipation, and indigestion. As the child
grows up it is called anaemic or chlorotic, but is
really toxic from absorption of the products of re-
tained faeces. If a girl, there is usually delayed or
irregular menstruation, imperfect development, and
often intractable leucorrhoea. The constipation,
flatulence, and colicky attacks persist.
In one such case the girl at seventeen years of
age weighed only seventy-eight pounds, and though
her menstruation appeared at twelve years of age
and was always painful, it had never been more
than a few drops. Two years after operation this
function was normal, and the patient weighed 105
pounds. In this case the deformity was due to too
Fio. 2. — Acute flexure of the sigmoid, due to adhesion of two ap-
pendices epiploicsc, causing almost complete faical obstruction.
close approximation of the fixed ends of the sig-
moid. (Fig 2). Sigmoidoscopy here showed that
the rectum turned markedly to the left at its upper
end and at about eight inches from the anus the
TUTTLE: ASGULATION OE COLON.
instriiiiient impinged upon the blank gut wall. By
the aid of a long flexible bougie passed through the
sigmoidoscope, I was able to pass the latter into a
large distended sigmoid, which extended almost up
I"lG. 1. — Acute flexure of the sigmoid, due to too close apposition
of its fixed points with luns; niosentery to its intervening loop, this
to the diaphragm, and contained manv l)alls of hard,
mucus coated fa?ces.
In another supposedly congenital case the rectum
turned just as markedlv to the right, and I was
unable to pass the sigmoidoscope beyond the flexure.
Operation here revealed the sigmoid attached to the
right side of the pelvis, where it is so often found
in infancy, by a short mesentery and bending sharp-
ly back along the promontory of the sacrum to join
the descending colon.
I do not mean to assert that all the cases with
such symptoms as these are afflicted with acute flex-
ure ; but I do believe that the large majority of them
owe their poor health and lack of development to
faecal stasis and autotoxaemia. Procidentia, or as
Gant calls it "chronic invagination," of the sigmoid
into the rectum, or any other condition which pre-
vents the bowel from emptying itself thoroughly and
sufficiently often may bring them about: but the
possibility of acute flexure should always be borne
in mind in making the diagnosis.
In the acquired angulations there is usually, in
addition to the constipation and distended csecum,
a history of dysentery, typhoid, acute colitis, sig-
moiditis, pelvic peritonitis, or inflammation of the
pelvic organs. Following these, sometimes at long
intervals, increasing constipation or irregularity of
l)Owel movements appear with crises of colic, with
nausea and vomiting, followed or not by passages
of mucus ; in some the symptoms are so severe that
volvulus is suspected. In the majority, however,
they are not so violent. The patients are consti-
pated, muddy complexioned, have furred tongues,
flatulence, bilious attacks, and pass more or less
481
mucus with their stools. The latter is often the
most disturbing symptom. Examination may or
may not show haemorrhoids, hypertrophy of Hous-
ton's folds, or other disease of the rectum; but it
always shows, if there is an acute flexure, some point
in the sigmoid in which the instrument instead of
passing upward into the calibre of the gut comes
squarely against the wall ; atmospheric pressure nor
pneumatic inflation neither open the gut in front of
the instrument, and twist it about as we will, we
cannot get the tube past this point. Sometimes by
pressing as firmly as one dares to one side or the
other, or downwards and forwards, we may pass the
obstructing fold onl}- to come squarely against the
wall of the other leg of the flexure, or getting past,
may lift up and stretch the binding adhesion or
short mesentery so as to carry the instrument higher
up : but this is a dangerous experiment ; rupture of
either the mesentery or adhesion, or of the gut wall
would prove disastrous. Sometimes the mucous
membrane prolapses through the narrowed calibre,
looking like a prolapse, or, as Laroque says, like a
sessile growth. Often there is abrasion or ulceration
at the angulation. Another symptom of which many
complain is incomplete evacuation. They may go
to stool four or five times to pass what amounts
to an ordinary stool. This does not vary between
hard and soft stools. They even have to go several
times to relieve themselves of a high enema. I have
often made a provisional diagnosis upon this symp-
tom occurring after an enema given in my ofiice.
Treatment.
The treatment of these cases is both palliative and
radical. In some instances of the acquired type I
Fig. 4. — .\cute fle.xure of the sigmoid, due to too close apposition
of its fixed points with long mesentery to its intervening loop, this
loop folding over upon itself and causing symptoms of volvulus.
have been able to give great and lasting relief by
pneumatic inflation, and passing long rectal bougies
through the flexure and leaving them inserted for
fifteen to twenty minutes. The theory of this is that
482
TUTTLE: ANGULATION OF COLON.
[New York
Medical Journ^kl.
the hou.^io in its tendency to straighten itself grad-
uall}- stretches the hinding tissues and thns straight-
ens the llexnre. 'I'he bongie shodld never be passed
alone, however. The sigmoidoscope shonld first be
Fig. 5. — .\cutc flcNiir.' uf tli. ■~igmnifl, due to too close apposition
of its fixed points with Imii; r,ir-. ntci \ to its intervening loop. The
flexure at both its points i- . lee .i^mned by accun'.ulation of gas and
lifting up of the long loop into tile abdominal cavity.
passed up to the flexnfe, and the bongie passed np
through this. ( )n]y in this way can we be snre that
the tle.xiblc instrument passes beyond the angulation
and does not double np. its- If. liefore the liouQie is
removed there should be injected through it an oil
or watery enema to wash out the bowel thoroughlw
No doubt some will say that much of the relief ^iven
my patients has been due to these injections. Tn
reply 1 can only say they had all tried iniections
and lavage before they consulted me. In some cases
the inflation alone and applications to abraided or
ulcerating surfaces have given relief. When such
])alliative measures fail, however, < >r where the cnu-
dition is clearly due to malformations or firm fixa-
tion, operative interference should be resorted to at
once. The operation, however, varies in each in-
dividual case. In some it is sufficient to l)ieak uji
the adhesions, cover up the raw surface-, .m l tuni
the sigmoid loose, while in others it i- in cs ar.
to fix the sigmoid to the abdominal wall and thus
prevent the flexure from recurring. In general one
may say sfraii^litcii out the Hcxurcs. cover in thc
rai<.< surfaces, and if necessary Hx the hoivel so it
cannot resume its old position. How to accomplish
these ends can best be shown by exliibiting the
drawin^/s and giving the details of .some of my cases.
Case Histories.
Cask I.— I'lxtcnsive adhesions of the sigmoid to the verte-
br;c coluiii ; the descending ;ind transverse colon (Fig- 6)
shows a marked scries of adhesions of the sigmoid, witli
acute fle.xnres at its junction witli the descending colon and
at its adhesion to ilie transverse colon.
This specimen was found at an autopsy, and 1 could gain
no history of the case. Tt simply shows to what extent the
sigmoid may rise and at what various points it may becoine
adherent; it als<.) illustrates how^ easily one may produce
a flexure at the juuctiou of the descending colon by sutur-
ing the sigmoid loo high in the abdominal cavity.
Case II. — Acute flexure of the sigmoid with obstipation
from adhesif>ns between two appendices epiploicas.
Mrs. M., age thirty-five, consulted me on November 20.
1895. I'aniily history w as negative. She had suffered from
peritonitis two years previous; for some months had suf-
fered from obstinate constipation, with crises of acute pain;
abdominal distention, iiausci, and vomiting; had been losing
tksh and unable to an adeciuate amount of solid food;
flatttlence o\'er dcscciidino colon and left iliac region, with
some tenderness at this joint: decided diilness to the right
(if the medium line and three inches below the umbilicus.
Temperature 100° F'., pulse no. Enemas had been used,
only giv ing partial relief. The proctoscope showed nothing-
abnormal in the rectum, but the ttibe was arrested in the
second loop of the sigmoid, about eight inches from the
anus, by a sharp bend and apparent contraction in calibre;
mucous membrane protrtided through the narrowing, simu-
lating a prolapse.
Operation was perfdniiefl (jii Xoxeniber 23, 1805. Tucision
in medium line, i)eriii iiia-iiiii sdtncwhat thickened: sp.4ntoid
flexure was found well tip in the abdominal ca\Uy and ad-
herent to the abdominal periton;eum just to the right (if the
medium line. Dragging it out of the wound, two granulse
epiploicae were found united together by strong adhesions,
thus folding the gut at a very acute angle. (Fig. 2.) The
ob-truction, howexcr, did not seem to Ite- at the flextirc, but
at the point of attachment of the two epiploic;e. The de-
scending colon was distendcl liy ;t large amount of semi-
solid fiEcal matter: ihc -.pit lielow tlic :;iii)endices col-
lapsed; the appendices w ere lied (iff at their t);isc, some very
slight adhesions between tlie tw. 1 kgs ,,i the flexure were
broken up, and then, li\ siioht jires-nre. the fietal matter
could be mo\ed along intu the cavity nf the rectum. In
the wall of the gut there were ni\riads ,,f litile lumps al:)OUt
the size of goose shot; they did imt seeni in prdtrtide, how-
ever, upon the peritoneal surface: pri)li:djly they were in-
flamed follicles ; ihere was no ex idence of diverticula.
The gut was carried back upon the left side to its normal
position and the abdomen closed. Eight hours after the
Fin, 6. — Acute flexure of the sigmoid upon the right side, with
chronic appendicitis and adhesion. Short mesentery.
operation the patient had a large semisolid movement, from
the rectum. Convalescence was nneventfid; bowels were
washed out daily with high enemas, and laxatives adminis-
tered as the. occasion required. The patient was seen six
years later; she had gained thirty pounds in weight, and
Marcli 14, 1 90S. J
TUTTLE: ANGULATION OF COLON.
483
the bowels move regularly without uicdicine, although she
occasionally had a little mucus in the stool ; she had had
no more crises, and considered herself perfectly well.
Case III. — Acute fie.xure with prolapse, due to too close
apposition of the two fixed ends of the sigmoid, with a long
mesentery of the inter\-ening loop.
Miss v.. age tw entv ye:ir~. c: moulted nie , -11 ^(arcli 10.
Fig. 7. — Acute flexure of the sisnioid upon tlie rectum, due to
short mesentery and old pelvic adliesion.
189S. Family and personal history clear. German h\- birth.
She had suffered from constiri'Uion c\cr since she was a
child: was pale and an;eniic, with iieriodicd attacks of grip-
ing pain, followed by diarrhoea; at times her abdomen
swelled up yery large and went down when ga-^ was passed.
The chief pain seemed to be in the left side and low down;
during these atfcks there was aching and a feeling of
weight in the back: -he -aid that someliuies m hen -he went
to stool she felt like the whole bottoui of lu r peUis was
dropping out: there w:r- no |)i-olai)>e, Iml t'lv .nitirior wall
of the rectum btilged backward mto ilie centre of the sa-
crum when lying upon her back or side. Hard f;ecal hunp ;
were easily distinguished with the finger in Douglas's cul-
de-sac. The htmps disappeared and the rectum ballooned
easily under atmospheric ])re>snre. The valves were highly
liypertrophied, but no f'lt.al matter rests above them. The
sigmoidoscope was arve-ied at about the end of the first
loop of the sigmoid by a vaKelike fold juttin.g out into
the calibre: wdien this was passed to one side the instnt-
meiit could be carried a little farther, where it came in
contact with a large mass of hard fietal matter. Hydrogen
peroxide, one half oinice. wa< introdnce<l through the tube.
The patient i),'s>e(l 'ai-L;e ([tiantities of f.Tcal matter, and
some lumps since introduciiig peroxide. The weight in the
back seemed less; no lnm]>s could be felt by the finger
in Douglas's cnl-cle-sac, riie sigmoidoscope showed a com-
plete circle of mucors meinlirane jutting through the jitnc-
tnre of the recttun with the sigmoid, which was bright red
and congested. Under pneumatic pressure this disappeared,
and with some manipulation the proctoscope could be car-
ried upw ard to a distance of nine inches, although there was
a decided pain in the back and in the left side.
Diagnosis: Prolapse of the third degree, with contrac-
ture or adhesions it- the first fold of the sigmoid.
Operation was performed on March t8, 1898. Abdomen
was opened to the left of the medium line, through the
rectus muscle. Sigmoid \yas found prolapsed in Douglas's
cul-de-sac, the loop with the long mesosigmoid falling down
between the two fixed ends, and causing two flexures, one
at the distal and one at the proximal portion, as sbiown in
^ Fig. 3. It could be easily lifted up, and upon doing so the
proximal llexure was obliterated; the distal, however, re-
mained more or less .acute on aecomit of the very short
mesentery and some slight .adhesions to the walls of the
sacrum. The adhesi(]ns were broken up, and the perito-
nrcuin of the inesentery incised so th.at the flexure could
be straightened out. In this case it seetned almost impossi-
ble to draw the perilon;euni together, and there was some
ra\> surface left. The sigiiKjid was sntitred to the trans-
\ ers,ilis fasci.T of the imlerior .abd( niiin.al w.all to the extent
ii two ,ind a half inches, nuimng (Jiuward and upward with
enough on the lower -c-nunt to hold the acute
1- scraight ; antl with no t-n-ii^n on the proxmi.al loop,
>. • ;t\-oid a flexure at the junction watli ibe dcscend-
\\'itl!:);-i -oing into detail. I may say that this patient
sutTei'ei! from some traumatic peritonitis, but was never in
an>- d.-'.ng.r of lur life. Slu' reco\-ereil in about six weeks;
her bowels mo\-ed well enon^h :ifu r the uci\lv nillaimnation
had passed, rind 1 was .-iMe to p:is- iiie siL;nioidoscope to the
extent of ten im-lii s \',itlioiii .lirih-iil.\ or pain. Prac-
tically all her suiii)ioni- -li- lo;.. . o -1, aihl lor fixe years her
health impriivcd >tva.iii> : •■fi-T .iit- I Im>i smlu of her.
C-\SE 1\^ — .\notlier e o! o,is type is shown in h'ig. 4.
This patient snt'fered with acnie attacks of intestinal ob-
stipation, with gre:it jciin in the left iliac region, l)ut none
in ihe !nck. The sigmoidoscope c<iiild be introduced its
full length without obstruction, or an>- e\-idcnce of disease.
(.)pi.r;iiion here sliowed the same close apposition of the
li.xed ends with the long interxening mesentery; the sig-
moid prolapsed down into the Kft pelvis, making a sort
of twist or fold just below its lunction with the descending
colon. Tiiere were no ;i(11k spins .-md no narrowing of the
gut that could be made oni, ami >et. when the gut was
dropped back into the ikIms the twis! or llexure immedi-
ately recurred. The siuinoid was f.isteiied to the ah lominal
wall, ne;irly ;it the centre and almost up to the umbilicus,
with more tension on the proximal loo]) than on the distal.
There were iv) coirnllcitioii ., .and the crises of pain and
cTstruction ha\ e ne\ er recurred,
C.\SE V. — Mrs, Al.. ,i_;e fori) se\en, consulted me on Janu-
ary I, 1905. h",'ni;l\ hist :r\ w,is clear. Patient had had
malaria in carh' life; c>>:i%li|>aU-.l since chiidliood ; early
Fig. 8. — Acute flexure in the u]'pi r loop of the sigmoid, due to ad-
hesion of the gut iust below the crest of the ilium on the left side
(Dr. Wyeth's case).
and irregular menstruati' n ; complexion never clear. She
complained of increased .onstipation ; much flatulence; some
itching around the amis after stool, and passage of con-
siderable mucus ; had had no severe crises. There was a
tympanitic note over cnecum ; dulness over left inguinal
484
TUTTLE: AXGULATION Of COLON.
[Ntw York
Medjcal Journal.
region; pain on deep pressure in right inguinal region and
also on taking a large enema, two or three attempts were
necessary to relieve her of the fluid; a small tender mass
could be felt through the vagina and abdominal wall just
below the promontory of the sacrum; it did not feel like the
ovary or tube ; she occasionally lost blood at stool. Exami-
nation showed small internal hasmorrhoid, spasmodic sphinc-
ter, and obstruction apparently due to an acute flexure at
the right sacroiliac junction. No ulceration could be seen
and there was no evidence of growth.
Operation was performed on January 28, 1905. An in-
cision was made just outside the right rectus muscle, the
small intestine being lifted up out of the pelvis; the sigmoid
flexure at its junction with the rectum was found to bend
sharply over to the right of the pelvis, where it was held
by adhesions to the sacrum ; the appendix passed down
over the brim of the pelvis and was adherent to the convex
surface of the sigmoid; it was thickened and contracted at
one or two points and contained three small faecal stones ;
this organ being released from its adhesions was extirpated,
the adhesions of the sigmoid broken up, and the gut lifted
up mto the abdominal cavit\-, thus straightening the flexure
on the rectum, as well as at its first and second folds. The
Fie. 9. — flastrotntcroptiiMS with di sc( r,t ot the transverse colon,
acute .nngulation at the splenic flexure, together with adhesion and
angulation of the sigmoid flexure, due to old tubal and ovarian in-
flammation.
sigmoid v.as sutured to the abdominal wall, the suture em-
bracing one inch abtn c and one inch below the point of
flexure, ilm- b.^ldinu' this part of the gut straight out
agaiii-i il The abdomen was then closed,
h,Tni(.i I ii' I'i- i^ iiin\e<l. and the patient removed to her
room.
February isth. Convalescence was uneventful; bowels
moved without pain in the sigmoidal region by oil enemas ;
the usual amount of pain at the field of h;emorrhoida!
operation.
February 20t_h. Convalescence was uneventful until to-
day. Dermotitis or erythema developed about the rectum,
simulating erysipelas. So far as constipation and pain in
the right side were concerned the patient never had another
complaint, and is lo-day having regular movements of the
bowels without laxatives; her di.gcstion is perfect. The
ery.sipelas complication was one worthy of mention. The
erythema spread from the buttocks and anal region all over
the bod}-. 'I emperature was as liigh as 106° F. and never
below 102° F. for three weeks. Numerous consultations
with specialists revealed no actual cause or pathology for
the same: blood examination shorved no streptococcus and
no marked increase in leucocytes. We were forced to con-
tent ourselves with an uncertain diagnosis of obscure
toxremia, which gradually wore itself out or was cured
through diet and intestinal antiseptics.
Case VI. — Acute flexure due to shortened mesosigmoid.
Miss D., age seventeen, consulted me on October 25,
1902. Patient was pale, anaemic, of dull complexion; had
sufi^ered all her life from constipation and dyspepsia ; men-
struation irregular ; she had never grown as other children,
weight only seventy-eight pounds. Abdomen was rather
distended ; marked tympanitic notes over caecum ; dulness
over left iliac region ; on palpation one could feel a nodular
mass extending from the median line out to the crest of
the iliurn. Rectal examination showed nothing abnormal ;
the sigmoidoscope was arrested just beyond the rectosig-
moidal junction, the cavity of the gut could be seen dipping
down forward into Douglas's cul-de-sac ; but the sigmoid
could not be inflated or lifted up so as to introduce the tube.
A long soft rectal tube was introduced through the sig-
moidoscope, and by the aid of a stream of water this was
carried up into the sigmoid. It was covered with faecal mat-
ter and mucus w hen withdrawn ; this examination and in-
jection was followed by a large discharge of faecal matter.
The bowel was again washed out in the same manner as
before, and with a large return of faecal material. Exarni-
nation afterward showed practically normal resonance over
the left iliac region ; palpation, however, showed a thick-
ened sausage shaped tumor extending from the median line
over to the sacroiliac junction.
Diagnosis: Congenital stricture or malformation of the
sigmoid, with possible neoplasm.
Operation was performed on October 27, 1902. Abdomen
was opened to the left of the rectus muscle; sigmoid found
in the upper pelvis, very thick and inelastic, but not ad-
herent at this point ; it dipped down into Douglas's cul-de-
sac, and just at the left of the rectum it was found by a
mesentery which held it almost against the sacral wall,
thus causing an acute flexure with the rectum and also with
the loop above. Any dragging upon the upper loop of the
sigmoid increased the flexure; it was impossible to lift this
up without increasing the flexure. Tlie danger of cutting
the bloodvessels and destroying circulation by incising the
mesentery through and through was apparent. In order to
overcome the flexure and stricture I made a longitudinal
incision in the peritonaeum extending about one inch to
either side of the flexure ; this was done on the right and
left, the cellular tissue not being involved. I was then
able to lift the gut up and unfold the flexure, breaking up-
the adhesions between the first loop of the sigmoid and the
rectum. The peritoneal wound was sutured transversely,
thus lengthening the mesentery, so that the flexure was al-
most obliterated. The second loop of the sigmoid was then
drawn up and attached to the abdominal wall, thus straight-
ening out the flexure and holding it in this position. The
abdoininal wound was closed.
November 10. 1903. The patient suffered from severe
dragging pain for about a week ; in the mean time, her
bowels were washed out daily with i in 500 carbolic solu-
tion. After this time she began to improve ; her digestion
became much better, and her bowels acted freely with small
doses of cascara. I have heard from her within the last
ten days ; her bowels now act without medicine, and she
has gained nearly forty pounds ; she is teaching school, and
is a very grateful patient.
This case is very instrtictive, showing the futility
of siinply drawing the sigmoid up in such cases of
acute angulation. Had the sigmoid been drawn
up without loosening it at the point of angulation,
the flexure would have been increased, tlie faecal
obstruction made worse, and the patient would prob-
ably have suffered from acute obstruction of the
bowels.
C.^SE VII. — Faecal stasis with acute flexure of the mid-
dle loop of the sigmoid.
Mr. F., age forty-two, of pale, flabby, anaemic appearance.
I'amily and personal history clear. Patient had suffered
from constipation for five years; this came on after an
attack of acute inflammation of the bowels, which followed
a long bicycle ride. Tympanites over the head of the
cecum; more or less distention of the transverse and de-
•icending colon ; flatulence in the left iliac region. Local
examination showed the anus and rectum normal. The tube
March 14. ipoiS.]
T UTILE: AXGULATIOX Of CO LOS.
485
passed readily into the sigmoid, but it had to be directed
forward to the left ; at about eight and a half inches it was
arrested by coming squarely against the wall of the gut.
Inflation did not lift up the sigmoid, but by carrying the
tube as much forward as possible a glimpse of the open-
ing through the flexure could be obtained, with a mass of
hard faeces pouting through the same.
December 5, 1906. dperation revealed an acute flexure
of the sigmoid, wirh adhesions over the left iliacus muscle
low down (Fig. 7). Fhe adhesions were incised, raw sur-
face closed in, and the pelvis filled with saline solution.
As soon as the adhesions were broken up the sigmoid rose
so easily into position that it was not thought necessary to
suture the gut to the abdominal wall. A long Wales bougie
was passed into the rectum daily, beginning three days after
the operation. The constipation and other symptoms dis-
appeared very rapidly.
"C.\?E MIL— Air. G., age forty-four, referred by Dr. John
A. W'yeth, on March 24, 1906. Patient had been operated
upon for haemorrhoids five years previously and had his
sphincter stretched, with a view of overcoming obstinate
constipation. So far as the relief of this symptom was
concerned the operation was ineff^ectual. Constipation had
been aggressive, and it was now almost impossible to obtain
a movement of the bowels with any amount of laxatives ;
he complained of desire to go to stool, but inability to have
a satisfactory movement ; had a bearing down pain in the
left inguinal region, extending upward to the splenic flex-
ure; dulness over ascending colon: markedly tympanitic
note over the caecum. Proctoscope passed seven inches
into the sigmoid, beyond which I was unable to advance on
account of an acute flexure, with probable adhesions, as the
sigmoid could not be lifted up into the abdomen.
Patient was operated upon on March 31st by Dr. Wyetli.
The second loop of the sigmoid was found adherent over
the iliacus muscle just above the brim of the pelvis; thus
forming an acute flexure or angulation, with a mechanical
constriction of the calibre (Fig. 8) : there was no cicatricial
narrowing of the canal. As soon as the adhesion was di-
vided the constriction was relieved. The raw surface left
by this division was closed over, both on the gut and ab-
dominal wall, and the sigmoid lifted well up into the abdo-
men. No attempt was made to fix the gut. as this seemed
unnecessary. The patient made an uneventful recovery, and
his constipation disappeared in about three weeks.
C.\SE IX. — Mrs. L., age thirty-fiver, had suffered for year?
from constipation, flatulence, and hemorrhoids. Hereditary
antecedents were negative. Digestive disturbance came on
three or four hours after eating; bowels never moved with-
out a large laxative ; she had had an attack of pelvic peri-
tonitis with salpingitis some six or seven years ago. Physi-
cal examination showed distended cxcum and transverse
colon ; stomach had prolapsed one inch below the umbilicus,
and the transverse colon dipped down almost to the pubes.
Operation revealed general gastroenteroptosis with the
transverse colon and omentum prolapsed into the pelvis,
the omentum being adherent; there was considerable disten-
tion of the transverse colon ; the sigmoid in its second loop
was adherent to an old inflamed tube ; an acute angulation
of the gut at the splenic flexure, also in the sigmoid, but
not so marked as above (Fig. 9). The adhesions of the
omentum to the sigmoid were incised and the raw surface
of the latter closed by sutures. The stomach and transverse
colon were lifted up. and the colon sutured across the ab-
dominal wall one inch above the umbilicus, thus relieving
the angulation at the splenic flexure. The sigmoid was
turned loose and lifted up into the abdomen, but not
sutured. The pelvis was filled with saline solution, and
the abdominal wound closed.
This patient made an uneventful recoxery, improved in
health and bowel movements for nine months, at which
time she was in the country, and after eating a lot of green
fruit and corn was seized with an acute attack of enteritis,
which lasted several weeks. At this time she also had a
recurrence of salpingitis, and there now appeared to be a
readhesion of the sigmoid in the neighborhood of the left
ovary. The transverse colon, however, remained in po^^i-
lion and there was none of the pain in the left side, and
much less flatulence and digestive disturbance than for-
merly.
It would probably have been wise to have fi.xed the sig-
moid to the abdominal wall at the first operation, but I
"hesitated to fix the gut at so many points at .one time.
Hocal treatment by the bougie and sigmoidoscope give a
the present time much relief, and it is possible an operation
for the new adhesion may be avoided.
Case X. — On December 6. 1904, Mrs. R., age thirty-five,
consulted me. She had two children. Complexion clear,
in fairly good flesh, i-amily history negative. Had a
severe attack of dysentery at mne years of age, otherwise
no serious illness. After the birth of first child she had
suffered from childbed fever ; following this had nervous
trouble, with flashes of heat, violent headaches, and in-
creasing constipation. Xow suffered from severe constipa-
tion, hard, lumpy stools ; weight and pain in the left iliac
region; very slight tenderness over the appendix; much
flatulence and digestive disturbance; pain in the left side
was increased by stool. Examination of the rectum showed
nothing abnormal ; the sigmoidoscope passed into the sig-
moid without difiiculty; tube deflected markedly to the left,
at about three inches, the upper wall of the gut impinged
upon the mstrum.ent and even with pneumatic dilatation it
was difiiculi to pass the instrument farther on account of
pain in the left side, although there seemed to be no
diminution of the calibre.
Diagnosis : Adhesions of the sigmoid to the left tube
and ovary.
Treatment: Hot douches, introduction of a Wales
5
Fig. 'o. — .\cute flexure of the sigmoid, also of the ilium. Chronic
appendicitis and multiple fibroids of the uterus.
bougie every other day. with a hope of stretching out the
adhesions and allowing the bowels to move freely. This
treatment was carried out by the physician in attendance.
1905. The patient was improved by the treatment some-
what, but returned still suffering more or less from the
same condition and was made so nervous by the treat-
ment that she asked for radical relief. An operation was
therefore performed in June. 1905. The abdomen opened
in the median line ; appendix drawn out. and being found
chronically inflamed, was removed. The sigmoid was
found closely adherent to the left tube, ovary, and broad
ligament, causing quite an acute flexure when the proximal
loops were lifted up. The :idhesions were dissected off,
and the rav\- surface in the pelvis covered as well as pos-
sible by suturing; the sigmoid v.'as drawn up into the abdo-
men, and the loop which had been adherent down below
was sutured to the transversalis fascia to the extent of
about two inches, thus straightening out the flexure.
The abdominal would was then closed. There followed
uninterrupted convalescence. The patient's bowels were
moving without la.xatives. she still had some pain at the
menstrual period, otherwise felt quite well. On October
T, 1906, patient reported herself entirelv well.
C.\SE XI. — Miss McG.. age forty-four, very thin, of
486
PORTER: DIAGNOSIS OF HEART DISEASES.
LN'Ert- York
Medical Journal.
muddy complexion. Family history negative. Twelve
years ago patient had had an attack of intense pain over
the lower abdomen, with high temperature. Pain and irri-
tation continued more or less all summer ; after this con-
stipation had always been present. Eight years ago she
had a severe pain in the abdomen, with fainting spell,
which was followed shortly by a passage of a large mucous
cast. Since this time she had had periodical mucous crises,
passing mucus all the time ; required enemata usually to in-
duce a HMN cnicn! 'riuTc was ])rc~-i.-iU tenderness oxer right
ili.ic I'll presMirc (lisUiUmn i.if the c:ecuni and
,1-c.j idiiiL; ciil(jn; aiius w"a;3 ucjrnKil ; rectum stiuiewhat
congested ; sigmoid tender upon toucli, turned sharply to
[he right and could not be lifted up, acute flexure at about
six inches from the anus, thick cord like mass could be
felt with the hnger high up in the rectum and running up-
ward toward the crecum.
Diagnosis : Inflamed appendix in the pelvis.
Patient was operated upon on January 30, 1908. Ap-
pendix enlarged to the size of one's little finger, very tor-
tuous and running down the iliosacral line ahnost into
Douglas s cul-de-sac. The sigmoid was attached to its tip
and held lirnily in •,he pelvis, acutely tlexed at the point of
attachment. At the angulation of tlie appendix the ileum
was caught and adherent, thus producing an acute flexure
of this organ (Fig. 10). The sigmoid w;is released, as was
also the ileum, and straightened out by breaking up the
adhesions. The appendix was then freed and removed;
the raw surface covered up as well as possil)le by sutures.
The object to which the sigmoid had been adherent having
been removed and its raw surface coxered up, it w^as not
thought necessary to suture the gut to the abdominal wall.
At the present writing, three weeks after the operation,
the patient is apparently perfectly well ; her bowels move
w ithout enemata ; digestive symptoms have disappeared,
and mucus in the stool is no longer seen.
These cases represent some types of flexure or
angulation such as may be found in the sigmoid and
transverse colon. The methods of dealing with them
have been largely justified by the results; but no
doubt some of my readers will devise different and
better technic in the future. I should now with
wider experience proceed differently with some my-
self; but working along original lines one cannot
always select the most direct and smoothest paths.
I have reported the cases with as little detail, but as
accurately as possible, and trttst they may excite
a wider stud\ of this interesting condition.
42 West Fiftieth Street.
THE DIAGNOSIS OF DISEASES OF THE HEART.*
By Willi.\m Henry Porter, M. D.,
Xew York,
Professor of I'atliol _ \>. .lu. In, ,,i iLe Xuw York Post-
graduate Medical - ital; Au. inling Physician
to the NcA I. -ii.i.lualr llt.spital, etc.
The subject which you have asked me to discuss
at this meeting is a very large one ; and one the
elucidation of which, in the time at my disposal, will
be most incomplete. Therefore, the most that can
be accomplished will be a very brief consideration
of a few of the most important points and questions
in diagnosis that we are called upon to decide almost
daily.
One of the most important points to be consid-
ered in conection with the diagnosis of cardiac af-
fections is, how to recognize and correctly interpret
the so called valvular murmurs. This is especially
true in view of the fact that we have well defined
murmurs, when there is no endocardial lesion of the
•Rrad before the Medical Association of tfic (Ircater City of Nt'w
York, at a special niectinR held in the Bronx. January 6, 1908.
valves, and where at the necropsy all the valves are
found to be practically normal.
in order to accurately diagnosticate these valvular
aif'ections of the heart, it is absolutely essential to
understand precisely the anatomical position of the
organ, and also the physiological niecliaiiism of the
action of the heart. This is especially true of those
mtirmurs that are located at the left auriculoven-
tricular orifice when there is no organic lesion of the
valve segments. ,
if, as is usually the case, the anatomical position
of the heart is taken from frozen section.s of the
body, it will appear to be located upon a lower plane
than actually occurs during life, hence great errors
in diagnosis are easily made unless due cognizance
is taken of this fact. During life the heart cavities
and the great blood vessels are distended with blood,
which naturally catises the \iscera to occupy a
higher position in the chest than i.s the case when
empty in death. While the individual is alive, there-
fore, the long axis of the heart occupies a triple
ol)lique position in the chest cavit_\-, or one corre-
sponding to a line drawn from right to left, from
above downward, and from behind forward — a po-
sition that has for its central axis a line represented
by one transfixing the body from behind forward,
starting posteriorly, at the sixth dorsal vertebra,
passing through it and the cavity of the chest and
emerging on the anterior surface of the thorax,
through the fifth intercostal space 1.34 centimetres
(3.5 inches) from the midsternal line.
The base of the heart corresponds to a line drawn
obliquely across the anterior surface of the chest
wall, from the first intercostal space on the left side
to the second intercostal space on the right side.
The apex of the heart is located just within the an-
terior or chest wall, behind the fifth intercostal space
of the left side, at its junction with the sixth ril).
1.34 centimetres (3.5 inches) from the midsternal
line.
The left heart is the most posterior ; this is espe-
cially true of the left attricle, which is also the most
inferior portion of the organ, as it lies deep down in
the space between the vertebra and diaphragm.
As a result of this posterior and inferior position
of the cavity of the left atiricle, the current of blood
discharged I'vom ii into the left ventricle naturally
flows frnni lichiiid forward, from riqht to left, and
slightly from liclow tipwanl. or directlv across the
chest cavity, hut never from ahow downward. The
directiou of this current corresponds to the line
already given, as transfixing the body, and to which,
many years ago. T gave the name left auriculoven-
tricular axis. From this description it is clearly
apparent that the bicuspid or mitral valve is located
well to the posterior limit of this left auriculoven-
tricular axial line. All nmrmurs, therefore, that
occur at the mitral orifice are produced and trans-
mitted by the current of blood flowing in one or the
other direction of this axis.
When sttidying these conditions, we should al-
ways remember that a common law governs the seat
of production and transmission of all cardiac mur-
murs, to wit, that the abnormal sound called a mur-
mur is heard with greatest intensitv just bevond
the point of its development, and that the .soimd is
March 14. igo.s.J
PUR'lER: UIAGXOSIS Of HEART DISEASES
487
transmitted from the point of its productiim lorward
or backward in the direction of the current of blood
whicli, together with the valvular defect, is the cause
of the nnuniur.
W here there is an organic narrowing of the bi-
Fm. I. — Professor Porter's skeleton scheme. -Iiowini; position of
the heart in the chest cavity; also circular jjrcas at which points
the different niurnnirs can be heard with yvcatc^t iiutn^ity. The
arrows indicate the direction in which tlie iiunimn- :i!e 1 1 a.ismittcd.
King Ml), a mitral, direct, .'■iiriciilar. stcnota. 01 ir.i-\-inlic mur-
mur. Ring -MI. a mitral, iii-lirect, u-surgil.inl. . t -.t.ilic murmur
at the mitral orifice. Ring .\D, an aortic. <lircct. sKiictic. or sys-
tolic murnuir at the base of the heart. Riut; .\I, an aortic, indi-
rect, regurgitant, or diastolic murmur at the base of tlie heart.
cusjiid orifice an ainiormal sound i.'- produced in the
line i:f this left auriculoventricular axis, liy an ;)b-
structioii to the normal incoming current nf Idood
from the left auricle to the left \cntriclc. This
murmur has often been called pnesystolic, which is
true so far as the ventricle is concerned, hut in
realitv it is a systolic murmur of the left auricle
It occurs at the height of or just at the end of the
auricular contraction and just as the ventricle is
])eginning to contract. If. for any reason, the
auricular and ventricular power become- enfeebled
so that there is no counter resistance in the currents
of blood, the murmur often entirely disajipears ; the
same is true if the auricle alone becomes very much
enfeebled. In both instances with a resumption of
muscular power the murmur will be recstalilished.
A mitral direct murmur is heard with greatest
intensity just in front of and over the left ventricle,
at a point where the left auriculoventricular axis
strikes the anterior surface of the chest wall, over
the junction of the fourth rib and its adjoining cos-
tal cartilage, or within the ring marked MD, in
Figs. T and .This murmur is, as a rule, high
pitched, of short duration, and limited in area. The
intensity of the murmur will vary with the degree
of ol)struclinn and the strength of the auricular
contractinii.
An uh.slructive murmur, hjcated at the left
auriculovenlriLular onhcc, without alteration in the
structure of the segments of the mitral valve, is not
un frequently heard in connection with considerable
leakage at ilie aortic orifice. 1 he explanation for
this murmur is that the rapidly regurgitated blood
from the aorta into the left \ eiitncle fill- the apical
portion of the left ventricular ca\ u\ , and li_\- so doing
crowds one segment or the other of the bicuspid
\alve quicklv against the incoming current of blood
from the left auricle and thus, for the time being,
produces an obstruction to the incoming curreiit of
blood. This undue pressure of the .segments of the
valve toward the auricular cavity at the height of
the auricular contraction gives rise to a short but
(|uick. sharp, and decided obstructive murmur. This
murmur is distinguished from one due to positive
organic narrowing at this orifice by its frequent dis-
ain)earance when the physiological action of the
heart, acting as a mechanical pump, is improved, so
that the regurgitation of blood from the aorta back
into the left ventricle becomes very much less, so
nnich so that the valve is not pushed up against the
incoming current of blood from the auricle.
When th.ere is an organic incompetency at the left
auriculovt nti icular orifice, the abnormal sound or
murmur is produced b_\- the blood being forced back
into the auricle by the contraction of the left ven-
tricle at the time of its systole,, the blood being
forced into ihe auricl" ai.>air=t the incoming current
of blood : the murmur in all probability being pro-
duced by the opposing currents having an unequal
pressure against each other. The murmur is pro-
duced bv the current of blood that is running from
left to right, from before backward, and slightly
from above downward. This murmur is distinctly
heard at the apex region or within the circle lettered
MI in Figs, i and 3. It is transmitted to the left
and is, as a rule, lost at the anterior axillary line,
but it is heard posteriorly with equal intensity at a
point midway between the inferior angle of the
scapula and the eighth dorsal vertebra on the left
side. According to the ordinary law governing the
production and transmission of cardiac murmurs
already given, this mitral indirect murmur should
iinl\- be heard |:)Ostcriorly ; but occurring, as it does,
at the same time of and as the result of the ventricu-
lor contraction, or when the heart becomes, as it
were, a solid body, and impinges against the an-
terior bony chest wall, which is also a dense body,
they together obey the general physical law of trans-
mission of sound by dense bodies, and thus bring the
abnormal sound or mitral indirect murmur distinctly
to the anterior surface of the chest, so that it is
heard most distinctly within the circle lettered MI
in Figs. I and 3.
When I was a student in medicine it was com-
monly taught that a systolic murmur heard at the
apex region, within the circle marked in the figures
MI, and transmitted from this point to the left as
far as the anterior axillary border, and heard be-
hind, as already noted, always indicated -an organic
lesion of the mitral valve. This assertion, in the
light of our ever advancing knowledge, is frequently
found to be incorrect at the necropsy, and still more
frequently it proves to be false 'at the bedside.
488
PORTER: DIAGNOSIS OF HEART DISEASES.
[New York
Medical Journal.
Therefore, a dififercnt interpretation has to be placed
upon the murmur in many instances.
This regurgitation at the mitral orifice, without
organic changes in the valve segments, unquestion-
ably produces a mitral indirect murmur, and one
A hich is of the greatest importance. First, because
of its frequency ; second, because it is so often mis-
taken for a sound due to positive organic changes
in the valve segments. From this it is readily seen
that it is not the leakage that is questioned, but the
interpretation put upon the murmur. If we stop
and consider for a moment the anatomicophysiologi-
cal mechanism of the heart, acting as a pump, the
explanation and diagnosis in this class of cases are
quite simple. The ventricular wall of the heart is
composed of seven distinct anatomical layers of
muscle fibres, or for simplicity they may be consid-
ered as four. There are connected with these layers,
in the left ventricle two sets of papillary muscles,
one springing from the anterior and the other from
the posterior wall of the ventricle. To these papil-
fect action just described, one set of muscles con-
tracts more forcibly or more quickly than the other,
and as a result one papillary muscle shortens more
than the other. As a natural sequence, one segment
of the valve is pulled a little too far into the ven-
tricle, while the other segment of the valve floats
too far out into the auricle, thus preventing com-
plete closure of the mitral orifice and permitting an
escape of blood from the ventricle to auricle. In
this manner a complete gap is produced, the same as
if there was an organic lesion. This is well illus-
trated in the schematic drawing as seen in Fig. 2, b.
Through this opening, which has resulted from
the incomplete coaptation of the two segments, there
is a positive escape of blood and one that gives rise
to all the physical signs of an organic insufficiency
with regurgitation. The temporary results are the
same as if there existed positive and irreparable
defects. The physical signs are the same in both
instances.
This condition is very frequently diagnosticated
Fig. j — Cn) Xormal liear'
mcnts. (h) Functional dc-rnnj
also conpcnilal ncrforations in
pulmonary semilunar Rc(rnients
sure of the
erfect closui
segments.
lary muscles the segments of the bicuspid valve are
attached by the corda tendinse.
When everything is working in unison, the two
segments of the bicuspid valve which are in the
ventricular cavity float outward toward the auricu-
lar cavity. At the height of the ventricular con-
traction, the margins of the bicuspid segments are
approximated at just the right point, and held there
by the equal and synchronous contraction of the two
sets of papillary muscles and their attached chord.ne
tendincse (Fig. 2, a). By this peculiar mechanism
the auriculoventricular orifice is perfectly closed,
and regurgitation from the left ventricle to the
auricle is prevented. When for any reason the in-
nervation of the heart is unequally distributed to the
different papillary muscles or the muscular layers
become unequally notirished, the unity of contrac-
tion is apt to be disturbed, and, instead of this per-
ral valve, and normal aortic and pulmonary semilunar valve seg-
if mitral val\e, but without organic changes in the valve segments;
Diagram illustrating the congenital perforations in the aortic and
as an organic lesion, and later the necropsy reveals
a perfectly normal valve. My experience has been
quite large in connection with heart lesions both at
the bedside and at the necropsy table. At the latter,
I have heard some very good diagnosticians declare
that they were very much in doubt as to the value
of physical signs in connection with cardiac disease
on account of this contradictory evidence between
the living and the dead subject. The difficulty,
however, is not so much with the rational and physi-
cal evidence as it is with the interpretation placed
upon the signs and symptoms presented. On the
other hand, when the signs and symptoms are cor-
rectly analyzed and interpreted our diagnosis will
be correct in the vast majority of cases, and we can
feel sure that it will be confirmed at the necropsy.
When this is not the result, the fault is with the in-
terpretation placed upon the symptoms presented in
JMarch 14, 190S.]
PORTER: DIAGNOSIS OF HEART DISEASES.
489
■each case, for each case must be analyzed by itself.
These cases are of great interest from a practical
standpoint, both to the patient and practitioner.
Organic and the so called functional insufficiency
at the left auriculoventricular orifice can easily be
distinguished during life, not by their rational or
physical signs, however, but by an appropriate line
of treatment. If the cause of the so called func-
tional murmur be a deficient innervation, by giving
such remedies as will restore the ner\-e power, the
signs and symptoms will quickly disappear, all re-
gurgitation be prevented, and the patient relieved
from all the unpleasant symptoms.
On the other hand, when due to defective nutri-
tion, with incomplete innervation and irregular mus-
cular action, a building up of the cardiac muscle, as
can be done with proper diet and therapeutic reme-
dial agents, will cause the murmur to disappear.
When the physical signs are due to positive lesions
in the valve segments, then the physical signs will
not disappear, but will usually become more pro-
nounced under treatment, even though the general
condition is improving.
Having settled accurately which of the two classes
of murmurs we have to deal with, and having de-
cided whether they are due to organic changes or
not, if one has spent considerable time in the study
of neci'opsy findings, it is easy to determine what
the nature of the lesion is. Without a large ex-
perience, however, in the post mortem field, there is
absolutely nothing upon which to rest the certainty
of the diagnosis made. Unfortunately, however, too
many of our profession are compelled to go through
their whole medical career without ever having had
much opportunity to get personal and practical train-
ing in this most important branch of medical science
— the combined clinical and necropsy work. The
more frequently one can be placed on record as to
the diagnosis, and have it confirmed or overthrown
by the result of the necropsy, the greater will be the
skill in diagnosis.
If now, upon auscultation of our patient, we find
within the circle or mitral indirect area, which is
lettered MI in Figs, i and 3, instead of the normal
first sound of the heart, that there is an abnormal
blowing sound, there is present a mitral indirect or
regurgitant murmur. Further, if we find that this
sound is transmitted to the left along the fifth and
sixth ribs, that it is lost as we approach the anterior
axillary region, and that it is heard quite distinctly
posteriorly, we are positive that regurgitation is
occurring at this orifice. Under these conditions
we are justified in saying that there is a leakage at
the bicuspid orifice. We are not, however, justified
in saying that there is an organic damage to the
valve structures until we have had the patient under
treatment for a reasonable space of time. Then by
the disappearance or intensification of the murmur a
positive diagnosis can be made.
When there is also a faint abnormal sound or direct
mitral murmur heard with greatest intensity within
the limited area or circle MD, as indicated in Figs.
I and 3. and this sound or murmur is of very short
duration and not transmitted, there is an obstruction
to the incoming current of blood to the ventricle.
Therefore, some difficulty may be experienced in de-
tecting this murmur, as it is often masked to a cer-
tain degree by the aortic and mitral indirect mur-
murs. But if one listens intently there will be heard
a distinct abnormal sound, which is distinctly lim-
ited to the circle lettered MD. If the chest piece of
the stethoscope is moved outside this limited area,
the murmur is at once entirely lost, and it is ob-
served that its character is entirely different from
the transmitted soiind of the aortic or mitral mur-
mur, with which it might at first be confounded.
Thus we are enabled to decide that a certain amount
of obstruction is offered to the current of blood as
it flows from the left auricular cavity into that of
the ventricle. As before stated, a course of treat-
ment will enable us to distinguish between true
obstruction or one due to overfilling of the ventricle
secondary to aortic insufficiency.
There is also a double set of murmurs to be con-
sidered at the aortic valve as well as at the mitral.
The abnormal sounds developed at this aortoven-
tricular orifice are best divided into three general
classes : First, those due to organic changes in the
valve segments and the aorta, or in the substance of
the ventricular wall as a whole ; second, those due
to congenital perforations of the segments of the
aortic and pulmonary valve, and which may be
classed as functional when compared with the truly
organic changes that are acquired ; and third, the
so called hsemic murmurs.
At the aortoventricular aperture we have an axial
line upon which all murmurs are developed and
transmitted similar to that for the mitral. The di-
rection of this axis is through the centre of the
aortoventricular outlet from below upward, from
left to right, and from before backward, following
Fig. 3. — Chest of natient with irv:r~ mark: 1 r,n the anterior sur-
face, illustrating where the different imirniurs can be heard most di.^-
tinctly; arrows indicating direction of transmission of abnormal
sound. Ring MD, mitral, direct, stenotic, obstructive, praesystolic,
or true systolic murmur of the left auricle. Ring MI. mitral, in-
direct, regurgitant, or systolic murmur of the left ventricle, heard
most distinctly at point of apex beat of heart, transmitted to the
left and heard posteriorly. Ring AD, aortic, direct, stenotic, ob-
structive, or systolic murmur, heard at the base of the heart; trans-
mitted up into the great vessels, when loud, heard posteriorly at
fourth and_ fifth dorsal vertebrse. Ring AI. aortic, indirect, regurgi-
tant, or diastolic murmur, heard most distinctly at the base and
transmitted downward.
490
PORTER: DIAGNOSIS OF HEART DISEASES.
[New York
Medical Journal.
the natural course nf the hXood stream. AU mur-
murs, therefere, which originate at the aortic valve
must necessarily he produced l)_v the current of hlood
flowing through the now al^normal opening, either
in the direction of the normal blood stream, or at a
right angle to a line drawn ohli()ueiy across the
sternum opposite the third costal cartilage, as slinwn
between the rings AD and Al in Figs, i and 3. The
position of the aortic valve being posterior to the
sternum very nearly behind the obHque bar as seen
in the figures referred to, all abnormal sounds de-
veloped at this outlet will be due to an obstruction
to the current of blood, as it is thrown from the left
ventricular cavity through the aorta, or to a failure
of the aortic valve to close tightly and prevent any
leakage back into the ventricle, which must of neces-
sitv follow incomplete closure.
Having developed the lesion, obeying the com-
mon law of production and transmission of cardiac
sounds, if there is a stenosis or obstruction to the
current of blood as it normally leaves the ventricle
to reach the aorta, a murmur will be produced and
heard just be} ond the seat of its development, which
is at the aortic aperture, or in the second intercostal
space on the right side at the sternal margin, as in-
dicated by the circle, lettered AD in Figs, i and 3.
It is transmitted along the course of the great ves-
sels, and is heard with almost equal intensity over
the subclavian, and the common carotid arteries in
the neck. When it is loud at the seat of develop-
ment it will also be heard posteriorly where the aorta
begins to impinge against the spinal column or over
the fourth and fifth dorsal vertebra. In some rare
instances it will be trajismitted all the way down the
spinal column, being heard as low down as the
sacrum. On the other hand, if there is an incom-
plete closure of the aortic valve, the arterial tension
forces some of the blood back into the ventricle, it
causes an indirect or regurgitant murmur. This
abnormal sound, according to the common law of
production and transmission, is heard just below and
to the left of the location of the aortic valve, or at
the junction of the third intercostal space of the left
side with the sternum, as indicated by the circle let-
tered AI in I'igs. I and 3. The natural course of
the transmission of this murmur is primarily gov-
erned by the direction of the blood stream which
causes its production and would be downward and
forward toward the apex. This is true in part, but.
develnpcd as it is, when th.e ventricle is exjianding
against the sternum, which is a dense structure, the
common physical law of transmission of sound is
obeyed, and the murmur is distinctly transmitted
down the sternum, and is often heard with the same
intensity over the xyphoid appendi.x as it is at the
point of origin.
In the second variety, or those due to congenital
perforations in the cusps of the aortic and pulmon-
ary valves, there are often heard the same well de-
fined physical signs, the same as occtiT in a well
established case of aortic insufficiency due to more
positive lesions, which produce incomplete closure
of the aortic valve. T have frequently diagnosticated
these congcnitnl perforations and later confirmed the
correctness of the diagnosis at the necropsy. Aortic
regurgitation from incomplete closure of the aortic
valve can be distinguished from regurgitation due
to congenital perforations by observing the follow-
ing distinctive points :
Aortic regurgitation from
incomplete closure. congenital perforations.
1. Physical signs almost the Physical signs almost the same
same except marked car- except no uniform enlarge-
diac enlargement of tlie nient of the heart.
J. Marked Milicl^ixian jjulsati ui. Xi^ snbclax'ian ijvilsation.
3. Shot or biad like pulbe. Pulse normal.
4. Marked dxspnu^a. No dyspnoea.
5. Cardiac niterstitial pneunio- No ijrown induration of the
nia. lung.
0. ilav have |iulmonary hiemor- No pulmonary lisemorrhages.
riiages,
7. Cough with considerable
sputum.
8. Dropsy usually marked. No cough or sputum.
g. Great general discomfort. No dropsy.
10. Physical signs may change No general discomfort.
under treatment. .Not artected by treatment.
In consequence oi these facts a positive diagnosis
in cardiac lesions should only be given after several
examinations and after suitable treatment has been
instituted.
third, so called hjemic murmurs are produced at
the aortic and mitral orifice in very anaemic sub-
jects; they may be of the direct or indirect variety.
.\ direct murmur may be produced both at the
mitral and aortic orifice in very aiic'emic cases. More
frequently, however, there is an incomplete closure
of the mitral valve and an indirect murmur is heard,
which is due to a dilatation of the ventricle brought
about as a result of the an?emia and imperfect nour-
ishment of the muscular structures. The hasmic
murmurs will be heard and transmitted in the same
manner as the murmurs already described as occur-
ring at the mitral and aortic orifices. They are dis-
tinguished from the other forms of murmurs by the
associated antemia, and the rapid disappearance of
the murmur under suitable treatment.
In this discussion the right side of the heart will
be largely omitted. The reason for this is, that dur-
ing a period of more than twelve years of almost
continuous work in the dead house, during which
time I made and observed a very large number of
necropsies, only one case was met with in which
there was a primary lesion of the valves of the right
side of the heart, and that was a case of congenital
inei inipeteiicv of the pulmonary valve. This state-
ment refers to cases of a chronic nature, and not to
the acute infective or malignant type. During the
life of this patient just referred to. although exam-
ined very carefully by several noted and exceedingly
competent diagnosticians, all regarded the case as
one in which the lesion was primary in the aortic
valve, with secondary changes on the right side of
the heart. Whereas, the aortic valve was found at
the necropsy to be perfectly normal. • Pulmonary
and tricuspid leakage always gives rise to marked
jugular pulsation which is synchronous with the
systolic action of the ventricles. When this occurs
there is also an associated general venous engorge-
ment. Therefore, it is easy to say that there is leak-
age on the right side, but almost impossible to say
that it is primarily located on the right side, and
that it is not secondary to changes of the left side.
A tricuspid direct or indirect murmur is practi-
cally an impossibility, owing to the almost negative
blood pressure on both sides of the valve. A leak-
age may occur at the tricuspid valve as a secondary
sequence to a pronounced mitral and pulmonary in-
sufficiency, but never as a primary condition so long
March 14. 190^)
M.ICKEE:
IXDICAXURLI
491
as the pulmonary valve closes perfectly. W'e are,
therefore, justified in omitting the right side of the
heart from the diagnosis of prnnary affections of
this organ, except in those cases in which there is
an infective or malignant endocarditis.
The murmur, which is often described as a tri-
cuspid regurgitation during life, is usually found at
the necropsy to be due to a leakage of blood through
congenitally perforated aortic and pulmonary cusps.
According to the general law of development and
transmission of murmurs, if a tricuspid indirect
murmur is to be heard, it would l)e posteriorly and
not anteriorly, because at the time of its produc-
tion the right heart is rolling away from the anterior
wall of the chest, which would tend to carry the
soimd back into the chest rather than to bring it
forward to the anterior surface of the chest. There-
fore, it seems reasonable to exclude murmurs of the
right side of the heart from this discussion, for they
are of Httle practical value to the diagnostician.
Enlargement of the heart, either a? the result of
hvpertrophy or degeneration with dilatation, is de-
termined by an increased area of dulness on auscul-
tatory percussion. The hypertrophy from degen-
eration is determined by auscultation and a careful
studv of the muscular tone. If the muscular con-
traction is firm and strong we know that there is a
hypertrophic condition of the organ. If, on the
other hand, the muscular contraction is soft and
feeble, we know that there is an atrophic or decided
degenerative change in the muscular tunic of the
heart.
.\ careful determination of the nutritive tone of
the heart miiscle is one of the most important facts
to be ascertained in connection with the diagnosis
of cardiac disease, because upon it depends the prog-
nosis not only in purely cardiac aflfections but also
in all the infectious diseases.
1674 Broadway.
INDICANURIA: .ETIOLOGY, DT.^GNOSIS.
P.\THOGENY. AND TRE.\TMEXT.*
Bv George M. MacKee, M. D.,
New York,
Clinical Instructor of Dermatology at the New York University and
Bellevue Hospital Medical College.
The demonstration of blue coloring matter in the
urine has been recorded as far back as the time of
Hippocrates (i), but it was not until 1840 when
Prout (2) discovered a blue substance in the urine,
to which he gave the name of indigo, that much
attention was directed to the subject. For a con-
siderable period this substance w-as thought to be
identical with the indigo of plant life, which, ac-
cording to Hartley (3) is a glucoside, but in 1879
Baumann and Breiger (4) proved that urinary in-
dican w'as a combination of a conjugate sulphur of
a hydroxylated indol with an alkali.
In the last thirty years we have had many im-
portant contributions on this subject, and we now
possess a fairly clear knowledge relative to the
origin of indol and the formation of indican. There
is, however, at present, a rather one sided argu-
ment regarding the origin of the indol which is rec-
*Read at a meeting of the Passaic, X. J., City Medical Society-.
February 13. 1908.
ognized by the presence of indican in the urine.
Slowtzow (5), for instance, divides indicanuria into
three forms : First, that due to intestinal fermenta-
tion and putrefaction . second, that due to suppura-
tion in some other part of ihj body, and, third, that
due to the formation of indol in the cells of the
body tissues. He terms them intestinal, septic, and
metabolic. respecti\ cly. In the intestinal form he
alleges that the indican reaches its maximum four
or five hours after the ingestion of food, is dimin-
ished by a milk diet ami by tlic administration of in-
testinal antiseptics, and increased Lv the (h-inking of
alkaline waters. In the SL'[)tic type the indican is
increased in the evening, is not intluenced by the
before mentioned measures, and is relieved by re-
moving the septic focu>. In the metabolic type the
indicanuria is moderate, occurs uniformly through-
out the twenty-four hours, is diminished by a milk
diet, but is not influenced b\ intestinal antisejjtics,
although it may be diminished by drinking alkaline
waters. Confirmatory evidence tending to establish
the existence of the metabolic type of indicanuria
is scanty, and such evidence is considered to be very
unsatisfactory. It is undoubtedly the concensus of
opinion at the present moment that the indican of
the urine depends exclusively upon the production
and absorption of indol from the intestinal tract,
excepting in those cases in which pathological pro-
cesses, such as a putrid abscess, putrid bronchitis,
pulmonary tuberculosis with cavity formation, the
retention of a dead fa-tus. gangrene, etc., are asso-
ciated with the formation of the base.
Owing to the fact that indol is a product of pro-
teolytic cleavage it has been stated by Flint (6) and
others, that it may be formed by the action of the
tryptic ferment of the pancreatic juice upon proteid
food. In fact. Flint asserts that indol may be pro-
duced in this manner outside of the body. It is,
however, quite possible that the indol of these ex-
periments was the result of an unrecognized or-
ganic ferment. In this connection Herter (7, p.
260) states that "such a phenomenon could onlv oc-
cur in the intestines in the presence of excessive
amounts of proteid food, combined with greatly de-
layed absorption. Ordinary absorption occurs in
the peptone and aminoacid stage of proteolytic diges-
tion, and it is hardly conceivable that in the absence
of putrefactive bacteria a rapidly proteolyzed meal
should lead to the formation of indol. ' Further-
more, marked and persistent indicanuria has been
observed in dogs from which the pancreas has been
removed and also in people in whom autopsy or op-
eration show-ed both the biliary and pancreatic duct
to be occluded." These observations, combined with
recent experiments with intestinal antiseptics, with
the organized and unorganized ferments, would
seem to prove beyond any reasonable doubt that
indol owes its origin to the action of certain bacteria
upon the proteid food in the intestines.
Regarding the action of the individual members
of the intestinal flora upon the formation of indol
considerable knowledge is still wanting. Extensive
investigations into this perplexing problem are now
being made, and although considerable light has
already been shed upon the subject, other important
findings undoubtedly will soon be reported. It might
be stated in a general way that the colon group of
492
MACKEE: INDICANURIA.
[New York
Medical Journal.
bacteria are unable to break down native proteids,
but act only upon the peptones and other products
of proteolytic cleavage. On the other hand, there
are certain putrefactive bacteria (probably both
aerobes and anaerobes) which possess the ability to
act both upon the native proteids, the peptones, and
the carbohydrates. It appears that some species
are able to only partly digest proteid food, and the
production of indol left to the action of the colon
bacilli, while others continue the splitting process
and form indol without the aid of the colon group ;
furthermore, this action under varying conditions
may take place in either the large or small intes-
tines. The fact that certain butyric acid forming
bacteria are able to attack the carbohydrates with
the formation of toxic and irritating substances has
led Herter (8) to divide chronic excessive intes-
tinal putrefaction into three types : First, the indolic
type, marked by striking indicanuria and probably
due to members of the Bacillus coli group; second,
the saccharobutyric type, which seems to be insti-
tuted chiefly by anaerobic forms ; in its simplest ex-
amples there is very little indol in the gut and very
little indican in the urine ; third, combined types, or
cases cornbining the characteristics of groups one
and two. He not only separates these types by dif-
ferences in the analysis of the urine and faeces, but
also distinguishes certain interesting clinical varia-
tions.
A consideration of the aetiology is hardly com-
plete without at least a superficial review of the syn-
thesis of indol in the body and the reason for the
abnormal bacterial activity in the intestines. Grant-
ing that indol is formed in the digestive tube, as
stated before, it is next absorbed, combined with
sulphuric acid and potassium, and appears in the
urine as the indoxyl potassium sulphate or indican.
Just where and when this pairing off process oc-
curs is not as yet positively determined, but the
trend of recent investigation is to consider that this
process takes place very largely, but not entirely,
in the liver. In this connection Herter and Wake-
man (9) have shown that the body cells, especially
those of the liver and kidneys, but also the epithelial
cells of the intestines possess the power of oxidizing
and pairing off these substances. Petrone and Pa-
gano (10) are of about the same opinion, for as a
result of extensive experiments they conclude that
the body depends largely upon the liver for protec-
tion against the enterogenic poisons. They think
the epithelial cells in the walls of the intestines of-
fer the first barrier. Toxines that escape the in-
testines and liver are acted upon by the lungs, and
finally the circulating leucocytes play an important
part. Besides these tissues and organs there is lit-
tle doubt but that the muscles and skin also enter
into this process of oxidation and elimination. The
nature of the enterogenic toxines and the exact
manner in which they exert their deleterious action
upon the organism is not well understood. It must
be remembered that besides the aromatic products
of intestinal putrefaction we have other known
bodies, such as the basic substances, the sulphur
compounds, etc. From evidence recently advanced
it would seem that we have also to deal with the
formation of certain ptomaines and other toxic
bodies, some of which appear to possess haemo-
lytic powers, while others seem to act mainly upon
the nervous system. That indol itself is toxic to the
organism has been amply proved by the experiments
of Richard, Howland, and Lee ( 1 1 ) , and also by
observations to be mentioned later.
It was thought by students of the earlier school
of physiologists that certain bacteria, through their
ability to do the work of some of the unorganized
ferments, were a necessity to health, l)ut this theory
has been largely negatived by experiments upon
animals conducted by Nuttall and Thierfelder
(12), and others, who found no difficulty in keep-
ing these animals alive under aseptic conditions in
the alimentary canal. Metchnikoff (13, p. 211)
cites many observations upon human beings, both
children and adults, placed upon aseptic food for
long periods, but who remained in perfect health.
Such observations would tend to show that the in-
testinal flora is not essential to life, but they do not
prove that certain bacteria existing in the intestines
are not beneficial. Indeed, it has been shown by
Herter and others that under normal circumstances
the Bacillus coli group may be of considerable ben-
efit to the organism. As stated by Metchnikoff,
"when man enters the world his intestines are practi-
cally free from bacteria, but contain a good culture
medium for the bacteria, which soon gain entrance
by means of air, water, and food." From a theo-
retical standpoint it is not impossible that if a per-
son always throughout life obeyed the laws of Na-
ture the intestines would soon adjust themselves to
the presence of bacteria, and under favorable con-
ditions the harmless and protective species would
predominate and defend the individual against the
invasion and injurious action of the undesirable
microbes. One can hardl\' help but think that
primitive man suffered very little from gastrointes-
tinal disturbances, but with the advancement of civ-
ilization, the crowded conditions of city life, the
lack of physical exercise, the hurried eating, the
worry, hurry, and excessive loss of nerve energy
associated with the gaining of a livelihood, together
with the inferior character of the food obtainable,
it is no wonder that a suitable soil is prepared for
the growth of harmful organisms in the intestines.
An extremely long large intestine has, for various
physiological reasons, always been considered a
necessary part of human anatomy, but very recently
Metchnikoff ( 14, p. 70) has advanced the opinion
that a large j^art of the large intestine is rudimen-
tary, that it has acquired in common with other
rudimentary organs a lowering of vital resistance,
thereby forming one of the many disharmonies of
the human race in its present stage of evolution.
He cites many experiments and observations to
verify and fortify his interesting hypothesis, which,
if found to be true, will certainly help one to un-
derstand why people of to-day are so susceptible
to diseases of the gastrointestinal tract.
Diagnosis.
Although the rapid or slow aI)sorpti(>n of the en-
terogenic toxines may produce a more or less typi-
cal picture of intestinal autointoxication or entero-
toxismus, a positive clinical or symptomatic diag-
nosis can, for obvious reasons, only be made in a
limited number of cases. > But in the absence of
putrid processes elsewhere in the body the presence
March 14. 1908.]
MA CKEE : IXDl CA .V URIA .
493
of indican in the urine is positively indicative of in-
testinal putrefaction. There are several methods of
testing for indican, the most of which are adequate-
ly described in the textbooks. The accurate quan-
titative methods are extremely difficult, and fall
within the domain of the analytical chemist. Such
procedure, however, is hardly necessary, for, if
conducted in a methodical manner and especially
if frequently performed for the purpose of obtain-
ing the average reaction for the individual, the
qualitative tests will give a very fair idea of the
variable amount of indican voided, and in many
cases will indicate the intensity of the intestinal
putrefaction and the amount of absorption of toxic
substances. Certain important exceptions must be
considered. In negative reactions, for instance,
the possibility of injurious types of saccharolytic
fermentation must be considered. Again, the quan-
tity of indican in the urine, although indicative,
cannot be taken as a criterion of the amount of
harm being done, because so much depends upon
the nature of the toxines produced, upon the abil-
itv of the system to properly oxidize, pair off, and
eliminate these substances, and also upon the
amount of absorption from the intestines. It is de-
sirable, therefore, to consider not only the presence
of indican, -skatoxyl. sulphuric acid, and ethereal
sulphates in the urine, but also the severit\- and
character of the symptoms presented. Further-
more, in considering individual cases where it is de-
sirable to establish the relationship between the
symptoms presented and the associated indicanuria
it is essential that one take advantage of diagnosis
by exclusion." In other words, one must exclude to
the best of his ability all other aetiological factors,
or if other possible causes are present, to estimate
the probable significance of the indicanuria, which
may be accomplished by careful study and by the
aid of therapeutical measures.
In testing for indican it is advisable to decide
upon one reagent, and always employ it in a definite
manner. The following modification of Ober-
mayer's test has given me great satisfaction : The re-
agent consists of a stock solution, composed of a
0.3 per cent, solution of C. P. ferric chloride in pure
hydrochloric acid. Five cubic centimetres of this
reagent are added to the same volume of urine in
a test tube : i c.c. of chloroform is added to this
mixture, and the tube inverted several times. If
indican is present the chloroform, which rapidly set-
tles to the bottom of the tube, will assume a blue
color, the intensity of which depends upon the
'amount of indican in the urine. Occasionally the
splitting of the potassium indoxyl sulphate is de-
layed, so in all negative cases it is advisable to al-
low the mixture to stand for several minutes be-
fore venturing an opinion. In mild reactions better
contrast can be obtained by replacing the urine
with water, leaving the chloroform at the bottom
of the tube, or the urine may be clarified by filtra-
tion after the addition of a few drops of a saturated
solution of lead acetate. Occasionally one will ob-
tain a purpHsh or red, instead of a blue, reaction.
This is probably due to the presence of skatoxyl
compounds. The significance is the same, provid-
ing the patient has not been taking potassium
iodide, which will give a red reaction with this re-
agent. Any doubt can be cleared up by the addi-
tion of a few crystals of sodium hyposulphite.
Pathogeny.
Physicians are frequently at a loss to know how
to interpret their indican findings. They will no
sooner arrive at the conclusion that certain diseases
or disturbances are always associated with indi-
canuria than their calculations will receive a set-
back by the demonstration of large amounts of in-
dican in apparently normal beings, or the disease
usually associated with more or less indicanuria
will be found to exist without any reaction to the
Obermayer test. The proper interpretation of in-
dicanuria is not easy, and depends upon the recog-
nition of several important factors. In the first
place, it is necessan,- to determine if the indicanuria
is temporary or permanent. If temporary one
would hardly expect more than mild, febrile dis-
turbances associated with lassitude and signs of
gastrointestinal irritation, depending, of course,
upon the severity of the attack. If permanent then
one must look for evidence of systemic disturbance,
and in a majority of cases such evidence will usual-
ly be demonstrated by the presence of various local
or general manifestations of disturbed metabilism.
It has already been stated that the effect of in-
testinal putrefaction depends largely upon the ab-
sorption, oxidation, and pairing oft' of the toxic ma-
terial. As long as the tissues entering into this pro-
cess are nonnal and able to cope with these sub-
stances no harm other than an increased amount of
work for important organs will be produced. But
just as soon as these tissues become impaired by
overwork or disease, then various local or general
symptoms of toxaemia are likely to manifest them-
selves. The question of idiosyncrasy is possibly no
more than a question of synthesis. However this
may be, we observe the same relation between cause
and eff'ect in the case of indicanuria as we do in
the case of many of our important drugs. Quinine,
the salicylates, the iodides, and bromides, all pro-
duce very distressing symptoms in certain individ-
uals, while others may partake of them with im-
punity.
In cases of chronic, persistent indicanuria, where
no deleterious eff'ect is observable, it must be re-
membered that relatively small doses of poison are
being absorbed into the circulation for a peHod of
months or years, and in many of these individuals
the evidence of disease may not manifest itself un-
til the age of fifty or sixty. We are accustomed to
use the inappropriate word toleration to account for
such phenomena, and the same picture is portrayed
in many cases of chronic alcoholic indulgence and
by the long continued use of any one of many
drugs. It is largely this effect of chronic intestinal
autointoxication that has led Mctchnikoft" tr) write
his latest book, Essais optijiiisfes, which, like
Nature of Man, is a study in optomistic philosophy.
In these works he considers the phenomenon of old
age, and concludes that the autointoxication de-
rived from chronic intestinal putrefaction is one of
the most important causes of premature senility,
chiefly through its influence in inducing arterio-
sclerosis.
It is possible to divide the effect tipon the system
of the enterogenic poisons into acute and chronic.
494
HACKEE: INDICANURIA.
[New York
Medical Journal.
The acute cases represent the sudden abs()r]:)tion of
large (juantities uf toxic substances from the intes-
tines in individuals, who, as a rule, are free from
indicanuria. (Jr the acute symptoms ma\- occur as
an e.\acerbati(.)n in the course of a chronic intes-
tinal autointoxication. ]!oth forms are common.
The cause of these attacks is usually some indis-
cretion in diet or perchance to hygienic disobe-
dience, but in many cases it is impossible to ascer-
tain the cause. The svmptoms of acute exterotox-
isnui.- a.rc fairh' tvpical, the most usual of which
ma_\' be grouj^ed under the term of biliousness.
Mental and ph\sical fatigue, anorexia, vertigo, and
similar manifestations are usually prominent. Oc-
casionall\- one meets with a very severe case, pre-
senting gastric pain and \oniiting, with or without
diarrhcea. For some time i ha\ e noticed the inter-
esting fact that man}- indivi<luals are able to fore-
cast with a surprising degree of accuracy the out-
come of the lest for indican. These patients appear
to be able to distinguish between nuiscular fatigue,
the weariness fri:-.ii insufficient sleej), certain
hygienic incliscre: ii m.s, and the "dopy feeling," as
the_\- express it, which is ])roduced b\- a mild intes-
tinal autointoxication.
In the chronic tyi^e of intestinal autointoxication
we have to deal with the \\\>n\- or Ivss slow absorp-
tion 'if relativel\- small amounts of iiidol and other
toxic substances. The clinical i)icture is totally dif-
ferent from that portrayed in the acute type — in
fact, the svmptoms, diseases, or conditions pro-
duced depend largely upon the nature of the toxines
generated and the idiosxncrasy of the individual as
a whole and the resistance oft'ered by the local tis-
sues. It is, therefor,t. , jiractically impos.sible to
classifv the symptom- <if chronic excessi\e intes-
tinal putrefaction, InU inasmuch as its elTecl^ arc-
now being seriously considered in all l)ranchLS of
medicine it will be i)roiital)le to gi\e a S'lmewhat
superficial review of the more im])orlant recent lit-
erature.
It has long been known that gingivitis, Rigg's
disease, and other similar affections could be
caused b\ \arioiis nutritional disorders and bv cer-
tain toxic snbvi.iiu ( It is, however, onh' within
the last few \ear>. tint the dental profession has de-
voted attiiitiiiii to intestinal autointoxication in re-
lation to the^c diseases. \' . \ .. Stanton (15), of this
city, was ])robabl\- one of the first dentists to recog-
nize the possil)i]ity of an iiucsiinal autotoxic factor
in pN'orrhcra alveolaris. In CMllaboriiiion with Dr.
R. il. Potter, he examined ;i large iiuniber of pa-
tients, and found an excess of indican in .about 98
per cent, of the cases. Talbot (16}, of ( liicago,
has devoted considerable study to this sul)|i ct. Al-
though recognizing all forms of autoinl< iMcat i(jn
as well as local ;etiological factors, he consiik rs that
intestinal putrefaction deserves very careful consid-
eration. He is of opinion that toxines in the cir-
culating blood act chiefly upon the end organs, of
which the gums and alveolar processes are exam-
ples, and that the injurious effects are pnjduced by
their action upon the bloodvessels. Fossune (17),
of New York, is also an enthusiastic believer in the
constitutional origin of Rigg's disease, and consid-
ers the constant presence of an excessive indi-
canuria as being very significant.
Taking the advice of Sabaroud, to the effect that
the dermatologist should- devote more attention to
diseases of the superficial mucous membranes and
being interested in the subject,! have, in collaboration
with several dentists, treated a few cases of Rigg's
disease. In some of these cases it was possible to ex-
clude diabetes, syphilis, nephritis, acidosis, alcohol-
ism, etc. \\'ith(nit .going into details these patients
all presented an intense indicanuria, and many of
them, besides their Rigg"s disease, had attacks of
vertigo, gastrointestinal disturbances, anremia, skin
eru])tions, etc. As a result of a careful study of
these cases I believe that as a result of treatment
they are not only in better health, but that their
mouth condition improved with a greater degree
of rapidity under local surgical measures insti-
tuted by the dentist than had been the case previ-
ously. It is too soon to predict the ultimate effect
upon this disease by treatment directed at the indi-
canuria. but evidence so far at hand would indicate
that a considerable addition to permanency might
be expected.
The neurologist finds indicanuria to be asso-
ciated with man\ I'isorders of the nervous sys-
tem, particularl\ with neurasthenia and various
forms of neuritis. Cleghorn (18), in a report of
six thousand cases of neurasthenia, finds that
among the causative factors the disturbances of the
gastrointestinal tract and the autointoxication
therefrom -tand ont as conspicuous examples.
Combe ( m h, ! b ' ler (20), and others place consid-
erable importance upon the relationship existing
between neurasthenia, and intestinal putrefaction.
Herter, for instance, considers the state of
debility that we call neurasthenia as being
one of the clearest clinical signs associated
with certain tNpes of intestinal putrefaction.
During the ])ast \ e ir >e\-eral general ])ractitioners,
at my suggestion, ha\e studied this question, with
the result that a marked indicanuria was found to
be present in a large iiercentage of the cases. The
achievements of treatment in these cases were ex-
ceedingly interesting and instructive, and as a con-
sequence c)f these observations I am of opinion that
intestinal i)ut refaction is the cause of many, a means
of exaggerating the symptoms in some, and possi-
l)ly the elfect rather than the cause in other cases
of neurasthenia. Among other diseases of the ner-
vous system, neuritis, progressive muscular atro-
])hy, and various reflex disturbances are thought
to be (hie to the enterogenic toxines. Mennella
(2ij, for instance, in an article dealing mainly with
the question of autointoxication and neurasthenia,
not only believes intestinal putrefaction to be the
cause of most cases of this character, but is of opin-
ion that many cases of obscure reflex nervous
syinptonis, cephalagia, various neuroses, and
psychoses are of autotoxic origin, and especially
from intestinal putrefaction.
Among the diseases lying mostly within the do-
main of the general practitioner and thought to be
occasionally caused, or at least greatly exaggerated
by intestinal autointoxication, may be mentioned
certain types of chronic arthritis, muscular rheu-
matism, anaemia, c>stitis, renal irritation, etc. In
fact, it is now generally considered that the recov-
ery from many diseases can be retarded by the
I)resence of an excessive indicanuria, for the sim-
ple reason that the tissues have to deal with an ad-
March .4. i9"S I
MACKEE : I NDIC ANURIA.
495
ditional toxaemia. Landers (22) has resurrected
the old idea of giving intestinal antiseptics in cases
of typhoid fever, asserting that the good results ob-
tained are due to the lessening of intestinal autoin-
toxication, thereby overtoming the battle of the
body tissues against these toxines. In this connec-
tion it might be stated that there are cases of intes-
tinal putrefaction, which possess many of the
symptoms of typhoid. Through the courtesy of a
professional friend I recently had the opportunity
of observing such a case. In this patient the at-
tack was preceded by a severe vertigo, which lasted
a month, at the end of which he had a temperature
of 103° F.. and presented many of the clinical
manifestations of typhoid. The blood failed to re-
spond to the \Mdal test, and the urine to the diazo
reaction, but it did show a very marked indi-
canuria. The most curious feature was an erup-
tion upon the abdomen closely resembling the well
known rose spots. This eruption later developed
into an extensive and typical erythema multiforme.
The patient made a rapid recovery, both from his
symptoms and his indicanuria when placed upon
salol and a milk diet.
It is the opinion of several investigators that
through the haemolytic effect of certain intestinal
toxines profound grades of secondary ansemia may
be produced. In fact, it has been asserted that in-
testinal putrefaction may have an important bearing
upon the production of primary anremia. In this
connection Olin (23) reports a case of simple
anaasmia with the haemaglobin reduced to 30 per
cent, and associated with a persistent indicanuria.
Measures taken to overcome the intestinal putre-
faction restored the patient to comparative health.
Several attempts have recently been made to as-
sociate indicanuria with renal irritation. Williams
(24), for instance, reports six hundred urinary ex-
aminations in which he found one half the oases of
albuminuria had an associated indicanuria, which
apparently increased in severity with the increase in
the albuminuria. He also found that in manv of
these cases the albuminuria rapidly subsided when
attention was directed to the intestinal putrefaction.
Daremberg and Perroy (25) found that in 95 per
cent, of the cases in which the urine contained a
great excess of indican there was likewise an al-
buminuria. Houghton (26) mentions three inter-
esting cases of interstitial nephritis in which the ad-
ministration of intestinal antiseptics was of the
greatest value. It is quite reasonable to suppose
that the excessive work demanded of the kidneys
in eliminating such poisons may weaken these im-
portant organs. At any rate, there is sufficient evi-
dence at hand to show that indicanuria represents
a serious obstacle to the recovery of a diseased kid-
ney. It is a well known fact that indicanuria is fre-
quently, if not always, associated with increased
arterial tension, and the proper attention to this
indicanuria will not infrequently alleviate the strain
placed upon the kidneys, circulatory system, and
other important organs and tissues.
In recent literature one finds frequent mention of
intestinal putrefaction in connection with diseases
of the organs of special sense. De Schweinitz (27)
in a very interesting paper devotes considerable at-
tention to intestinal autointoxication as an setiologi-
cal factor in the various diseases of the eye. He re-
views the literature to some extent, and concludes
that although the heterogeneous autointoxications
mav not be the sole cause of certain ocular disturb-
ances they are at least contributory, and frequently
are the means of a continuance of symptoms after the
more commonly accepted ?etiological factors have
ceased to be active. The interesting discussions of
this article by Wood, Bull. Marple, Posey, Weeks,
and others were remarkably enthusiastic and
strongly fortified the author's contentions.
In paediatrics considerable attention has been
given the subject of indicanuria as bearing upon the
gastrointestinal complaints and malnutrition of in-
fants. \'eitch (28), for example, reports the cure
of a child which appears to warrant the adoption of
suitable means to overcome intestinal putrefaction
in most cases of infantile malnutrition when asso-
ciated with such process. Dunn (29) distinguishes
between infectious diarrhoea and that produced by
intestinal fermentation and putrefaction. Judson
and Clock (30) mention several cases of marasmus
successfully treated by the use of buttermilk, which,
as will be seen later, is one of the most important
means of combatting intestinal putrefaction.
Combe, in his various writings, recites experiments,
observations, and investigations which strongly
fortify these findings. Herter ( 7. p. 284). in col-
laboration with Holt, has investigated the group of
cases that are characterized by the marantic, large
belly type of chronic intestinal indigestion in chil-
dren. To use Herter's words: "All physicians
agree that this form of digestive trouble is extreme-
ly obstinate to ordinary methods of treatment. It
is usually manifested by a distinct retardation of
growth, muscular weakness, distension of the abdo-
men by gas, and voluminous, light colored, usually
gray, and fatty stools. The urine of such cases
usually contains an excessive amount of indican,
phenols, and ethereal sulphates. Regulation of diet
and hygiene in accordance with our knowledge of
the action of bacteria in the intestines has been of
considerable service in the treatment of these
cases."
Although there is a very close relationship exist-
ing between the cutaneous diseases and intestinal
autointoxication the scope of this article is too gen-
eral to allow but a few words on this interesting
subject at the present time. Engman (31) who has
studied the significance of autointoxication in der-
matological disorders, pays particular attention to
the presence of a marked and persistent indicanuria
in cases of pompholyx and dermatitis herpetiformis,
and is of opinion that the toxines derived from in-
testinal putrefaction may be an important aetiolog-
ical factor in many of these cases. Johnson (32)
has considered the evidence of an autotoxic factor
in eczema, and particularly in the bullous diseases,
and concludes as a result of routine urine examina-
tions, the clinical manifestations of these diseases,
as well as the therapeutical results obtained, that
autointoxication in relation to dermatolog}- should
receive careful attention. He believes that the auto-
intoxication in many cases has its origin in the
failure of proteid metabolism, and while placing
considerable importance upon the various toxic sub-
stances found in the urine, together with the esti-
496
MACKEE: INDICANURIA.
[New York
Medical Journal.
mation of the total nitrogen output, he also consid-
ers the presence of an indicanuria as very signifi-
cant. Personally, I have never failed to obtain a
marked indican reaction in cases of pompholyx or
dermatitis herpetiformis, although in this connec-
tion it might be stated that Schuyler Clark, at a re-
cent meeting of the dermatological section of the
Academy of Medicine, January 7, 1908, reported a
very severe case of dermatitis herpetiformis which
had never presented an indicanuria. Indicanuria
is not infrequently associated with eczema, psoria-
sis, urticaria, erythema multiforme, pruritus, etc.,
and although a definite relationship between these
diseases and intestinal autointoxication has not as
yet been established, there is little doubt but that
some such cases may be produced in this manner,
while in others the indicanuria represents a possible
contributory cause. Clinical oTDservation of indi-
vidual cases certainly tends to confirm such opinion,
and, furthermore, as a result of such observations, I
believe that intestinal autointoxication may possi-
bly have an influence in establishing individual sus-
ceptibility to various cutaneous irritations. In con-
cluding this subject I am of the opinion that supe-
rior average results are obtained in many cutaneous
eruptions when proper attention is directed to an as-
sociated indicanuria.
Treatineut.
Diet. — Inasmuch as indicanuria is caused by the
action of certain bacteria upon the proteids, it is es-
sential in most cases to restrict the amount of this
type of food. I think it is a good plan in these pa-
tients to limit animal food to one meal a day. In
some instances it is necessary to abstain, for a time
at least, from all nitrogenous food. Occasionally,
however, one encounters a case that appears to be
unable to tolerate a farinaceous diet. Both Herter
(20) and Porter (33) have also found this to be the
case. The latter objects to a vegetarian diet, be-
cause he considers such food hard to digest, while
the former asserts that under certain conditions the
growth of the gas bacillus is favored by an excess
of the carbohydrates. It is obvious, therefore, that
no absolute rule can be given regarding dietary
measures, for each case is a law unto itself. A very
important desideratum is the promotion of prompt
absorption, which may be accomplished by the use
of such vegetable foods as rice, or, in certain cases,
an exclusive milk diet may be advised with bene-
fit. Thorough mastication is also very important,
and I have seen excellent results follow an adapta-
tion of the rules of mastication as formulated by
Horace Fletcher in his A. B. Z. of Nutrition. The
entrance into the stomach of putrefactive bacteria
must, as far as possible, be avoided. If the gastric
secretions are normal, most of these bacteria are
destroyed, but when defective, and especially when
considerable mucus and desquamated 'epithelium
is present, such organisms are not only able to sur-
vive, but may actually find a favorable medium
upon which to multiply. In such cases this
object may be attained by the proper cooking of
food, by thorough mastication, and by attention to
the teeth.
Hygiene. — Plygienc in many cases is of as much
importance as diet. Proper exercise and bathing
will aid metabolism, elimination is increased, and
the digestive functions strengthened. The preven-
tion of worry, anxiety, etc., must be avoided if pos-
sible, for the efllect of enthusiasm, suggestion, or
by whatever term it may be called, upon metabolism
is not well understood, but very likely it has been
underestimated.
Medicine. — The digestive mixtures may, for
obvious reasons, be of service when indicated. The
so called intestinal antiseptics have been and are
still being employed to control intestinal putrefac-
tion. Although such drugs as salol, dermatol, etc.,
may reduce the urinary indican, it is hardly advis-
able to use such preparations for protracted periods.
In the first place, we do not know what deleterious
effect such drugs may have when taken indefinite-
ly. Again, it is possible that such measures influ-
ence the protective members of the intestinal flora
as well as the harmful invaders. In any event, it
has been found that patients fail to do as well as
expected when treated in this manner. This opin-
ion receives confirmation by the published observa-
tions of Herter (7, p. 329), IMetchnikofif (13, p.
204), Steele (34), Conner (34), and others. It is
an opportune moment to say a word regarding con-
stipation. Although cases of obstinate constipation,
without an associated indicanuria, are to be met
with, the opposite condition of affairs is more fre-
quent. It is advisable to overcome the sluggish
action of the bowels by other than medicinal means,
but not infrequently it is necessary to resort to
laxative measures. In this connection it is interest-
ing to note the observation of Maberly (35), who
finds that sodium sulphate in small doses acts not
only as an aperient, but also as an intestinal anti-
septic through the liberation of oxygen during the
process of chemical decomposition. Intense and
persistent indicanuria is sometimes met with in
cases of chronic diarrhoea, and not infrequently the
diarrhoea, flatulence, etc., will continue after the in-
dican has been reduced. In such cases it is possi-
ble that certain bacteria are acting upon the car-
bohydrates with the production of irritating acids.
In these patients, if other means fail, the temporary
use of bismuth subnitrate may be of service. In
passing I might call attention to the fact that lav-
age of the colon and stomach in both adults and
children has been of benefit in disturbances of these
organs when associated with intestinal putrefac-
tion and autointoxication.
Bacterial antagonisms. — Through the possibility
of the formation of specific antibodies by the influ-
ence of putrefactive bacteria in the intestines some
work has been done in hopes of obtaining a specific
bacterial vaccine or specific bacterial sera. Such
investigations, although to be commended, have not
as yet been attended with laudable success. Tis-
sier (36) by analyzing the bacterial contents and
determining the special bacillus causing the dis-
turbance has been able by modifying the diet and
infecting the individual with microbes antagonistic
to the one at fault to obtain very good results. Rut
as stated by Combe (37) : "It is very difficult to in-
dividualize an intestinal infection, and in the ma-
jority of cases it is only possible to determine
whether the flora is saccharo or ploteolytic. This
is sufficient to indicate the regime and the nature of
the antagonistic bacteria. When it is possible in
March 14. 190S.]
MACKEE: INDICANURIA.
497
every case, as Tissier does in some, to determine
exactly the individual germ which is at the bottom
of the' trouble, it will be feasible to find its direct
antagonistic microbe. The method of individual-
ized intestinal infections is still a laboratory method
which cannot enter into general practice."
Sour milk. — That sour milk is of benefit both in
health and disease has been known since the earliest
biblical times. For many centuries the inhabitants
of Eastern countries have employed it as an article
of diet. Passing from antiquity to modem times we
find that buttermilk, or sour milk, is a favorite ali-
ment among the people of many countries. The
medical profession has long recognized the value of
sour milk in disease. Pilfard (38) has, for the past
twenty-five years, directed many patients to use it
both "for dietetic and directly remedial purposes,
and for the past thirty years many physicians have
advised the use of certain fermented milks as an aid
to digestion and nutrition. IMetchnikoff (13, 14)
has noted the interesting fact that individuals who
have existed largely upon sour milk and vegetable
food have attained a very old age and were remark-
ably well preserved both mentally and physically.
Furthermore, he is of opinion that such milk, by
preventing the deleterious effect of intestinal auto-
intoxication on the circulatory system, will greatly
aid in prolonging life, and if this is found to be true
we have indeed, in sour milk, the nearest approach
to the long sought elixir of life. In 1892 Rovighi
(39), an Italian physician, drank daily a litre and a
half of milk subjected to lactic acid and alcoholic
fermentation. He found that in a few days the pro-
ducts of intestinal putrefaction in his urine were
greatly reduced. In 1897 Herter (40) reduced the
amount of indican in dogs by injecting pure cul-
tures of lactic acid bacilli into the small intestines.
In 1902 Bienstock (41) and Tissier and Martelly
(42) proved the existence of certain bacteria in
milk that prevented its putrefaction. Such observa-
tions explain why sour milk is of such value as a
medicine. They also show why lactic acid will con-
trol certain cases of infantile diarrhoea. In any
advent, the writings of Herter, Combe, Metchni-
koft'. and others have stimulated interest in a much
neglected subject, and in recent months several in-
structive articles have appeared testifying to the
efiicacy of sour milk as a medicine. Dunn (29),
\>itch (28). Batten (43), Morse and Bowditch
(44), Judson and Clock (30), and Strauch (45)
have found buttermilk of considerable service in
certain forms of infantile diarrhcea, intestinal auto-
intoxication, and malnutrition. As a result of per-
sonal observation I can state that sour milk will
control the majority of cases of indicanuria, but is
this effect the result of the lactic acid contained
therein, or the colonization of the lactacid microbes
in the intestines? As has already been mentioned
Herter succeeded in modifying the indicanuria in
dogs by the use of pure cultures of lactacid organ-
isms. Tissier (46, 19) obtained good results in
cases of intestinal putrefaction by employing pure
cultures of certain lactic acid forming bacteria
grown in peptone lactose broth. Combe (37) states
that the bacillus of IMassol (Bacillus bulgarictts of
Metchnikoft'), which is one of the organisms found
in Bulgarian curdled milk, may be demonstrated in
the fasces of patients taking such milk. He also
cites many favorable results obtained with both
soured milks and with pure cultures of .the various
lactacid organisms. On page 223 of the Essais
optimisies, Metchnikoff, as a result of numerous
experiments, conducted by himself and others, is of
the opinion that certain lactic acid forming organ-
isms are able to colonize in the intestines, and that
sour milk is of benefit not alone through its lactic
acid, but also on account of the large number of
desirable bacteria contained therein.
I have found that although lactic acid will con-
trol indicanuria to some extent, the indican will re-
turn to its original degree very soon after the acid
is discontinued. Buttermilk and milk soured by
means of native bacteria will, in many instances,
completely control an indicanuria, and in some of
my patients who have taken such milk for a con-
siderable period and especially when placed upon a
diet favorable to the growth of the lactacid organ-
isms, there has apparently been a complete cure
effected, making a continuation of the milk unnec-
essary. It has also seemed to me that milks fer-
mented by certain foreign bacteria are more pow-
erful and produce a more permanent eft'ect than is
the case with the native organisms. In experiment-
ing with pure cultures I have utilized the lacto-
bacilline tablets from Paris, the lactone tablets from
Detroit, the yogurt capsules from Battle Creek, and
some cachets which were specially prepared for Dr.
Piffard. When employing these preparations it
must be remembered that we are giving only rela-
tively small numbers of bacteria, and they must, in
some cases at least, be given over an extended pe-
riod of time and combined with a favorable diet be-
fore their eft'ects become clearly manifest. On the
whole, I believe I have noticed good results from
the use of these preparations, especially with the
ones containing foreign organisms. Piffard (47)
has also experimented with pure cultures, and finds
that they control the indican output. Although
a more rapid and positive action may be obtained
by the use of soured milk, the cultures given direct
are especially convenient for those individuals who
cannot or will not tolerate any form of sour milk.
Although these observations would seem to ver-
ify the contention to the eff'ect that under favorable
circumstances certain lactacid organisms are able
to colonize in the intestines, such a theory requires
further fortification before it can be said to rest
upon a firm scientific foundation. In this connec-
tion it might be stated that Herter (20), in his latest
communication, is inclined to doubt the ability of
lactacid organisms to permanently colonize and dis-
place the putrefactive bacteria. He finds that in-
testinal putrefaction may continue in spite of the
free or even exclusive use of fermented milk. Fur-
thermore, he asserts thai- there is no evidence what-
ever that the lactacid organisms are able to restrain
specifically the growth of Bacillus aerogoies capu-
latiis. He considers that any limitation in the
growth of the putrefactive anaerobes depends upon
the absence of carbohydrates in the fermented milk
and in the presence of lactic acid. He admits that
fermented milk possesses certain advantages over
498
MACK EE; I NDIC ANURIA.
fresh milk, but considers this to be due chiefly to
the ability of the bacilli to make lactic acid freely
from the soluble carbohydrates and to subdivide
and transform the casein in such a way as to render
it more readily absorbed than that of ordinary
milk. It is to be hoped that further investigations
will soon be made in this line, not only in the case
of Bacillus acrogenes capulatus, but with other pro-
teolytic anaerobes and in the case of the overactiv-
ity of the members of the Bacillus coli group. Such
investigations are desirable, because we have thus
far depended largely upon clinical observation,
which is notoriously uncertain unless conducted by
a number of different men over a protracted period
of time.
For the lack of time and space it will be
impossible to enter into a discussion regarding the
relative value of the various sour milks and the
preparations made therefrom. I respectfully refer
those who are desirous of studying this important
phase of the question to an excellent article recent-
ly published by H. G. Pififard (38), in which is re-
corded the result of an exhaustive bacteriological
study of sour milks, and also to an article by Combe
(37), who gives the method of preparing and tak-
ing of yoghourt and other products used as an arti-
cle of food in eastern Europe.
I desire to state, however, that considerable cau-
tion must be exercised in selecting from among the
artificially soured milks recently placed on the mar-
ket, for one or two of these preparations have pro-
duced very untoward results. In choosing these
products one should always consider the reputation of
the firm making them. I am of the same opinion as
Dr. Pififard in respect -to the wholesomeness of most
of the soured milks sold in New York City under
the name of buttermilk. Finally, if one desires to do
so, a good grade of whole milk may be soured at
home by infecting it with a culture of suitable lact-
acid organisms and the product consumed daily.
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26. Houghton. American Medicine, October 7, 1905.
27. De Schweinitz. Autointoxication in Relation to the
Eye. Journal of the American Medical Association,. Feb-
ruary 9, 1907. With discussions.
28. Veitch. Malnutrition in an Infant Due to Excessive
Putrescence in the Alimentary Canal Successfully Treated
by Lactic Acid Bacilli. British Medical Journal, August
10, 1907.
29. Dunn. On the Use of Living Lactic Acid Bacteria
to Combat Intestinal Fermentation in Infancy. Archives
of Fwdiatrics, April, 1907.
30. Jndson and Clock. Modified Buttermilk in Infant
Feeding. Nciv York Medical Journal, April 20, 1907.
31. Engman. A Preliminary Note L'pon the Presence of
Indican in the Urine of Those Afflicted with Dermatitis Her-
petiformi. Journal of Cutaneous Diseases. May, 1906. The
Significance of Indican in the Urine of Those Afflicted with
Certain Diseases of the Skin. Journal of Cutaneous Dis-
eases, April, 1907. Pompholyx in Those Afflicted with In-
testinal Intoxication. Medical Review, November 11, 1889.
32. Johnson. Evidence of the Existence of an Autotoxic
Factor in the Production of Bullous Disease. British Medi-
cal Journal, October 6, 1906. Eczema — A Sketch of the
Process and Its Management. Neiv York Medical Journal,
October 20, 1906.
33. Porter. Indicanuria, Its .Etiology and Practical Sig-
nificance. Medical Record. June 15, 1907.
34. Steele and Conner. Experimental Observation upon
the -Action of Intestinal .Antiseptics. A paper edited by J.
D. Steele before the .Association of .American Physicians,
held at Washington, May 7, 1907. Discussion by L. A.
Conner. Society Proceedings, Medical Record, May 18,
1907.
35. Maberly. Sodium Sulphate as an Intestinal .Anti-
septic. Lancet. November 10, 1906.
36. Tissier. Cited by Combe (37).
37. Combe. The Treatment of Intestinal .Autointoxica-
tion by the Introduction of .Antagonistic Microbes to Com-
bat Proteid Putrefaction in the Bowel. Journal de mede-
cine de Paris, No. 9. Reprinted in Modern .Meii^ine.
December, 1907.
38. Piffard. A Study of Sour Milks. Neiv York Medi-
cal Journal, January 4. 1908.
39. Rovighi. Zeitschrift fiir physiologische Chemie. xvi,
p. 43, 1892. Cited by Metchnikoff (14), p. 255.
40. Herter. On Certain Relations between Bacterial
Activity in the Intestines and the Indican of the Urine.
British Medical Journal, ii. 1897. P- 1847-
41. Bienstock. Archiv fiir Hygiene, xxxix, p. 390, 1902.
Cited by Metchnikoff (14), p. 255.
42. Tissier and Martelly. Annalcs de ITnstitut Pasteur.
p. 865. Cited bv Metchnikoff (14). p. 255.
March ,4. '9o6.iCHANCE: ACCE^i^URY SIX US DISEASE.—SHELMERDINE: WISJEK DIARRHCEA.
43. Batten. Lactated Milk in Infantile Diarrhoea. The
Clinical Journal, December 19, 1906. Abstracted in the
Journal of the American Medical Association, February 2,
1907.
44. Morse and Bowditch. Acidified Milk in Infant
Feeding. Archives of Pediatrics, December, 1906.
45. Strauch. Buttermilk as an Infant Food. Medical
Record, March 30, 1907.
46. Tissier. Ea Tribune medicale, February 24, 1906.
47. PifTard. Correspondence, Medical Record, June 22,
1907.
616 Madison Avenue.
A CASE OF ACCESSORY SINUS DISEASE WITH
THE SYMPTOMS OF AN OSSEOUS TUMOR
OF THE ORBIT.*
By Burton Chance, M. D.,
Philadelphia.
The subject of this report was a lad of fourteen who
a year previous to his coming under m}" observation
had noticed a reddened swelling at the inner side of his
right orbit. He had been told at a local dispensary that this
was caused by "tear duct trouble." The swelling was soft
at hrst, but in eight months it became hard, and began to
increase in size and density, though without pain. Later,
the eye became slightly displaced, and the patient grew
anxious because of a very annoying diplopia.
When I examined the boy for the first time, in January,
1905, the inner half of the orbit was occupied by a bulging
mass, and the eye was pushed outward and downward, and
could not be rotated inwardly. The mass was dense and
appeared to have its base at the nasal and lacrimal bones
and along the inner orbital wall. It extended laterally into
the orbit about a half inch, and it could be palpated for
three quarters of an inch horizontally backwards. It was
irregularly nodular in shape, and projected forward to
about the vertical plane of the cornea. It was not sensitive
even to deep pressure. The tear ducts gave free passage
to small Bowman's probes.
The patient was active and wiry, a member of a boys'
choir and inclined to pay much attention to his personal
appearance. He had never been annoyed by colds in his
head, and had never received any injury to his orbital or
facial bones.
There were no obstructions in the nasal or faucial pas-
sages, nor were there discharges on their membranes.
The accessory sinuses were not examined as there was no
symptom of such importance to lead me to believe they
might be diseased. I did not express an opinion upon the
probable cause of the swelling in the orbit. The patient
was instructed to use an alkaline nasal douche daily and
he promised to return to my office in two weeks.
He returned in ten days because of marked conjunctival
congestion and he said he could not see so well with the
right eye. The acuity of vision was 5/15. The optic disks
were pale, though the retinal veins were engorged. I be-
lieved then that a bony tumor had invoh-ed the inner wall
of the orbit, and, because it appeared to be pressing upon
the ocular structures, I advised the boy's mother to have
the tumor removed, but I requested her to consult a general
surgeon before she accepted my opinion. She took the
boy to Dr. Gwilym Davis, and he gave an independent ver-
dict that it was an exostosis of the orbit, and urged the
immediate excision of it.
On February 4, 1905. with Dr. Davis assisting me. I
undertook the operation at the private building of the Ger-
mantown Hospital. The incision was begun along the up-
per orbital margin, carried in a semitircle down over the
tumor, and ended at about the' middle of the lower margin.
The soft parts were separated deep into the orbit. Rather
free hjemorrhage followed. The tumor was circumscribed
and projected irregularly. In the dissection of the peri-
osteum the instrument suddenly penetrated the bone, and
a bead of thick tenacious mucus exuded. This opening was
at once enlarged to the full size of the tumor. An almost
incredible amount of thick mucus was removed before the
cavity could be exposed ; then it was found that the eth-
*Read at a meeting of the Section in Ophthalmology of the Col-
le.ge of Physicians of Philadelphia, February 20. igo8.
moidal sinus had been entered. The cells had been ab-
sorbed so that exploration was carried on easily. The
cavity extended back to the sphenoid, up to the frontal
sinus, and the inner concavity to beyond the median line,
while the outer wall projected far into the orbit. The walls
were scraped; and as there was no opening into the nose,
one was made with the curette. Two rubber drainage tubes
were inserted, one far back into the cavity, the other up-
wards and forwards, and brought out through the nostril.
The soft tissues were placed over the orbital opening, and
the wound was closed by several silk sutures. The dress-
ings included the tubes.
The patient recovered promptly, and no untoward events
occurred. The cavity was douched daily with solutions
of hydrogen dioxide. After six days the tubes were with-
drawn ,and the sutures were removed, so that in eight days
the boy was able to come to my office for treatment. The
aperture in the ethmoid allowed free drainage to continue
mto the nose.
For about four weeks the external cicatrix remained
prominent, but it became reduced when the osseous apper-
ture began to be filled in. Two months later the sinus
was draining satisfactorily, though a plug of mucus was
held in the opening ; and, when deep pressure was made
over the orbital opening a bubbling sound was emitted
as though there was an accumulation of mucus. The boy
stated there was no noticeable discharge from his nose. He
had great comfort. The eye had become straight again ;
he was relieved of the diplopia, and the vision had returned
to normal. The optic nerve had lost its pallor, and in all
respects the fundus appeared to be as healthy as that of
the other eye.
On November 16, 1907, nothing but the cutaneous cicatrix
and a rather broad nasal bridge gave external signs of the
former state, while the visual and ocular conditions were
normal, and the nasal cavities were healthy.
The case is interesting on account of the question
of diagnosis. Had the tumor been soft and painful,
or had there been discharge from the nose, the eth-
moidal origin of the trouble would have been sus-
pected. But all these were absent, and the extreme
hardness of the tumor, with lack of tenderness or
pain or nasal trouble, caused one to regard it as a
possible osseous tumor. The characteristics were
explained by the fact that the bone was bulged for-
ward, and the enlargement was really beneath it in-
stead of above it.
235 South Thirteenth Street.
WINTER DIARRHCEAS IN INFANT FEEDING. '
By E. KiRKL.\ND Shelmerdine, M. D.,
Philadelphia.
Extreme cold in winter as well as the extreme heat
of the summer has its influence upon the progress
of an infant who is being artificially fed. The
diarrhoeas which the physician is called upon to
treat in summer are well known, but the diarrhoeas
which arise in the winter months are more puzzling
as to their origin.
I must confess that up to recently I laid the main
cause of winter diarrhoeas to other reasons than the
true one. I always blamed the cause to a too high
percentage of fat. some carelessness in the prepara-
tion of the food, or to soine accidental infection of
the gastrointestinal tract due to the swallowing of
microorganisms taken into the mouth from an un-
clean nipple, a teething ring, or some such object
given to the baby to put into its mouth.
In my own household my four months' old in-
fant was attacked by a diarrhoea during a spell of
cold weather which had all the symptoms of the
diarrhoea which occur in the summer months from
500
H AX SELL: TUERCULOSLS OF CONJUNCTIVA.
LXew Vokk
Medical Journal.
impure and contaminated milk. He was being fed
on a certified cream and milk mixture; when the
diarrhoea assumed the proportions of from eight to
twelve stools a day I accused the mother of a lack
of care in the preparation of the food, and volun-
teered to prepare it myself until conditions improved.
Both the cream and the milk were left early in the
morning before any of the household were out of
bed, and when they were brought into the house
both were frozen. After thawing out the milk and
cream and making the mixture, I noticed that there
were fine particles floating on the top ; if the mix-
ture was allowed to stand there would be quite a
number, which would rise to the top. I came to the
conclusion that the milk was not good, and tele-
phoned the dairy, accusing them of leaving old
milk, informing them of what I had found. They
indignantly denied that old milk had been left at my
place, and asked me if the milk had been frozen; I
replied that it had. They informed me that if that
was the case, the freezing was responsible for the
small curds ; and said, furthermore, that it was a
well known fact among milkmen that freezing milk
spoiled it. As it was not convenient to procure a
fresh supply of milk, I strained the mixture through
cotton and removed all the curds ; this strained mix-
ture was fed to the infant, find his diarrhoea disap-
peared by night.
By making arrangements to have the milk left
at a later hour in the morning and thus preventing
its freezing from being left out in the cold, and hav-
ing the milkman take precautions to keep it from
freezing en route, there was no further trouble on
the score of minute curds in the milk. After pre-
venting the milk from freezing there was no further
trouble with diarrhoea. Since my attention was
called to the cause of the diarrhoea in my own in-
fant, I have found it also to be responsible for what
was formerly pvizzling diarrhoea in other infants
under my care ; precautionary measures adopted to
prevent the milk from freezing brought about
prompt relief.
When the milk is frozen, the water in it is con-
gealed into ice, the perfect solution of the casein in
the water is disturbed, and there results a clump-
ing of the proteid molecules which lose their solu-
bility ; on the reduction of the frozen mass to a
liquid, the curds, through some chemical change
brought about by the freezing, are incapable of ac-
quiring the solubility which they formerly pos-
sessed. These minute curds cannot be broken up
by pouring the milk from one jar into another, by
agitation, or by heating, and are present in the final
mixture.
Certified milk, as a rule, contains very few bac-
teria when compared with ordinary milk ; yet it has
some, enough under favorable conditions to multi-
ply into immense numbers. This clumping of the
casein carries with it the majority of the bacteria
suspended in the milk. These clumps in the gas-
trointestinal canal of the child are difficult to digest ;
the digestive juices do not break them down into
assimilable forms, the rennet in the child's stomach
is not capable of bringing about the molecular
changes necessary for the proteolytic action of the
gastric and pancreatic juices— in other words, tough
curds are ingested which are difficult to digest.
These curds undergo decomposition in the intes-
tines and are excellent foci for the multiplication of
the bacteria with which they are loaded, as well as
for the omnipresent microorganisms normally in the
intestinal tract.
The diarrhoea caused by frozen milk is not as se-
vere nor as debilitating as that of the summer sea-
son ; neither are the number of stools as great. Six
to twelve stools a day is the average. There is dis-
tressing colic. The stools are green, acid, watery,
and contain small cheesy masses of undigested
casein ; the buttocks are generally excoriated from
the irritative effects of the acid stools.
Treatment consists in taking the child off the
milk diet for twenty-four hours, cleaning out the
bowels, and giving barley water in the interim. If
the condition is recognized early, correction of the
underlying cause will produce a prompt subsidence
without the necessity of stopping the food.
6135 Germantown Avenue.
A CASE OF ACUTE DOUBLE MILIARY TUBERCU-
LOSIS OF THE CONJUNCTIVA.*
By Howard F. Hansell, M. D.,
Philadelphia.
A Lithuanian, aged thirty-seven, having successfully
passed the physical examination, was admitted to the
United States through the port of New York in June, 1906.
He stated that he had been healthy all his life and had
had no trouble with his eyes until nine weeks ago, jive
weeks before he applied at the Out-Patient Eye Department
of the Jefferson Hospital. At this time he presented to
superficial external examination the characteristic appear-
ance of trachoma, so common among the Russians who apply
at the clinic. The skin of both upper lids was discolored,
and the lids were swollen and drooping. On the palpebral
surface the resemblance was equally marked. Scattered
over the conjunctiva of both upper and lower lids were
numerous yellow, isolated swellings that might at first
glance be mistaken for trachoma follicles. Close inspec-
tion showed that the yellow patches were not granulations
or enlarged follicles. They were round or oval, the size
of a grain of wheat, circumscribed and sharply separated
from the adjacent membrane, yellow in color as though
they contained pus or caseous matter, slightly raised above
the surface of the membrane and covered by epithelium.
They were shallow, not penetrating as far as the tarsus.
I had never seen a similar case and was uncertain as to the
diagnosis. Dr. Rosenberger, of the pathological laboratory.,
collected some of the material from the surface of the con-
junctiva by gently scraping and reported the presence of
numerous tubercle bacilli. Examination of the contents
of one of the little caseous like elevations had been com-
menced, but not completed. No signs of general tubercu-
losis could be detected by examination of the lungs, sputum,
or urine by Dr. d" Apery, of Dr. Cohen's medical clinic.
The preauricular or cervical glands were not enlarged.
The eye grounds were healthy, V. = 6/6 with — .75s.
Tuberculosis of the conjunctiva is usually ac-
quired from sources external to the body, such as
the dried sputum of tuberculous patients, a previous
traumatism, and, as Fuchs has shown that, since
many cases originate in the small fold of mucous
membrane near the inner canthus, it may arise from
the lodgment there of minute foreign bodies carry-
ing the bacilli. Tschemolissow .speaks of a case in
which tuberculosis of the conjunctiva was implant-
ed by the tongue of a tuberculous woman who at-
•Read before the Section in Ophthalmology, College of Physicians,
December 17, 1907.
]\Iarc'.i 14, iyo8. 1
MURRAy.- CLAMP FOR HEMORRHOIDS.
tempted to remove a foreign body from the con-
junctival sac of a friend, and Birch-Hirschfeld of a
man who for months had milked a tuberculous cow.
It may also be due to extension from neighboring
parts of the lids or from the lacrimal gland. That
tubercle of the conjunctiva is not more frequently
seen in tuberculous individuals seems to prove that
the disease is seldom metastatic, and that the con-
junctiva is practically immune to contagion from
within. Its frequency varies from i in 1,500 to
none in 14,000, according to different observers.
Groenouw says the conjunctiva is but little suscep-
tible, as proved by the rarity of tuberculous disease
in places where general tuberculosis is common. It
appears in several forms, the miliary, ulcerative, dis-
seminated, trachomalike tubercles, polypoid and as
lupus. The symptoms are those of a mild form of
chronic conjunctivitis. Its sequels are as disastrous
as those of trachoma — entropion, ulcers, opacities,
and pannus, perforation of the sclera, and extension
of the destructive process to the lacrimal sac or to
the interior of the ball.
Samisch describes the usual appearance and pro-
gress of tuberculosis of the conjunctiva thus : "It
consists in the beginning of an ulcerative pro-
cess and then the development of small nodules (tu-
berculous) in a thickened conjunctiva in which the
papillae are hypertrophied." He adds: "But not
always is the ulcerative stage present, but the tuber-
culous growth assumes the form of disseminated,
small, deeply placed, irregularly defined nodules,
which show but little inclination to become necrosed.
In rare cases they appear as circumscribed, polyp-
like prominences covered by a smooth surface, each
one projecting above the level of the moderately in-
jected and thickened conjunctiva.
The recent literature on ocular tuberculosis is vol-
uminous. A small proportion only of the articles
deals with tuberculosis of the conjunctiva. Samisch's
comprehensive article (Graefe and Samisch, second
edition) includes the references from 1864 to 1903.
The writers have agreed on the clinical signs and
the diagnostic tests, but have differed as to the prog-
nosis. Some patients recover spontaneously, many
lose both eye and life, and a few have recovered
after tuberculin injections. An example of the last
is the case reported before this Section on October
17, 1905.
On August i8th the patient received in the arm 2 mm.
of Mulford's tubercuHn which was followed in thirty-six
hours by prolonged general and local reaction. On Sep-
tember 2d a second injection with a still more marked and
rapid improvement in the condition of the eyes. Five in-
jections in all were given and on October loth the nodules
had disappeared and the eyes were quite well.
A positive opinion as to the value of tuberculin
diagnosis and treatment cannot at this time be given,
but I believe both to be of great service. Calmette's
suggestion of applying the tuberculin directly to the
conjunctival sac and then determining by the reac-
tion the presence of tuberculosis is not in my limited
experience dependable. It was tried in the case
cited with negative result ; also in fifteen or twenty
individuals known to be suff'ering with general tu-
berculosis the reaction was present in only one
fourth.
1528 Walnut Street.
CAUTERY CLAMP FOR HAEMORRHOIDS.
By Dwight H. Murray, M. D.,
Syracuse, N. Y.
The use of the clamp and cautery in performing
rectal operations for haemorrhoids and other growths
is so popular with surgeons that improvement in
mechanism is always in order.
A haemorrhoidal clamp should embrace the fol-
lowing qualifications in order that the work can be
done securely and rapidly: i. The most convenient
form for most surgeons is shaped like a pair of scis-
sors. 2. It is necessary that the clamp should have
parallel jaws in order to securely hold all the tissues
to be cauterized. 3. The clamp should be so con-
structed as to admit of rapid work. 4. One that can
be easily taken apart for the purpose of sterilization.
5. A clamp that locks securely and automatically as
it is closed. 6. It should be so made that the tissues
can be released immediately. The fifth and sixth
necessities mentioned are great time savers in an
operation.
I feel that my clamp combines all of these quali-
fications for an instrument with which to work se-
curely and rapidly. I claim originality only for the
improvement this clamp embraces. The principle of
the Goodell dilator reversed is used, and the same
principle was used by Dr. Linthicum, of Baltimore,
in his clamp six years ago. My improvement does
away entirely with the thumb screw, which takes
much time to close and open. I published the de-
scription of a clamp six years ago which was par-
allel jawed and scissors shaped, but find the new one
to be a distinct improvement. ,
800 University Block. ' " ;
CAUSE OF PREMATURE SEPARATION OF THE
PLACENTA.
By Samuel Robbinovitz, M. D., '
Brooklyn, N. Y.
A number of times I have come across statements
made by various contributors in the columns of the
Neiv York Medical Journal that the cause of pre-
mature separation of the placenta, in certain cases
which they had reference to, was. not known, or
could not be definitely ascertained.
Now, I do not mean to imply that the cause of
premature separation of the placenta in a given case
can be determined with ease, nor that / can do so.
Such a statement would seem absurd, and I would
not venture_ to make it, considering the great num-
ber of predisposing and exciting causes enumerated
in standard works on obstetrics. But having given
this matter a thought I came to the following con-
502
ROBBIX'OVITZ: PREMATURE SEPARATION OF PLACENTA.
[New York
Medical Journal.
elusion : I find that the most frequent and pre-
dominating cause that may be assigned to the pre-
mature separation of the placenta with more cer-
tainty is traumatism, in the form of cither direct or
indirect violence. To corroborate my statement, I
beg to be permitted to relate my experience concern-
ing this subject. During mv obstetrical practice
which I received since student life heretofore I have
not observed such a number of cases where a too
early separation of the placenta took place as I
chanced to see during the past half a year. This is
due to the fact that I was appointed, six months
ago, a physician to a Woman's Confinement
Society, in Brooklyn, the object of which society is
to furnish gratis a physician or an accoucheur to all
poor women who are to be confined, and apply for
such aid, but have not adequate means requisite for
the engagement of such an attendant. Hence, so
far, in every case, without exception, where I found
accidental hremorrhage either before labor directlv
or during the last month of gestation I could elicit
by close investigation (all such cases having been
furnished me by the society) a history of traumat-
ism as a cause. To make this more explicit I wish
to maintain the fact, in support of my opinion, that
several of the patients presented a history of hav-
ing been beaten bv their husbands — addicted to al-
coholism, and being at the time under th.e influence
of liquor — during the last trimester, or during the
last month, because they refused to go to v/ork for
their husbands and furnish them with sufficient
means for drink as they wero able to during the
earlier period of pregnancy. Again, others stated
that they were thrown to the floor violently or had
been pushed with their abdomen by their cruel hus-
bands against a hard or solid object during the last
period of pregnancy. Other such poor women told
me that they fell from a flight of stairs, or met with
some accident in the workshop or factor}, where
they were employed during pregnancy.
In conclusion I will state, therefore, that all these
facts go to prove what an important part traumat-
ism plays as a cause of accidental h?emorrhage or
premature separation nf ihe placenta, especially so
when the woman is subjected to trauniatism during
the last month or two of the gestation period.
71 A Sumner Avenue.
ACUTE PURULENT OTITIS MEDI.^ IN INF.\NTS
AND YOUNG CHILDREN.*
By Arthur J. Herzig, M. D.,
New York,
Surgeon in Chief, Harle-n Dispensary, Eye and Ear DepartiiiciiT .
and Beth Israel Hospital Dispensary. Eye Department.
Before proceeding with my subject I wish to re-
port a few statistics of the prominence and fre-
quency of the occurrence of acute otitis media dur-
ing or following the acute exanthemata. Duel's re-
port in 1904 shows that there appeared in 6,000
cases of otitis media, about 10 per cent, in diph-
theria, about 20 ])cr cent, in scarlet fever, and about
5 per cent, in measles.
Dovvnic. of Glasgow. rei)orts 500 cases, of which
acute purulent otitis media originated during simple
"Read, by invitation, at a meeting of the Triprofessional Society
.on January 21, 1908.
catarrh 29.4 per cent., measles 26.1 per cent., denti-
tion 20 per cent., scarlet fever 12.6 per cent., per-
tussis 3 per cent., mumps 0.6 per cent., syphilis 1.6
per cent., and doubtful were 6.7 per cent.
Craiger (1891) reports 125 cases of acute puru-
lent otitis media occurring in 1,000 cases of pneu-
monia.
Kerley in 1905 reports seventy-seven cases, one
occurring with rubella, two with scarlet, seven with
measles, and fifty-eight with influenza.
Of 248 cases examined and treated by me in five
years in private practice there originated acute
purulent otitis media during simple catarrh in 56
per cent., during measles in 14 per cent., during
dentition in 2 per cent., during scarlet fever in 20
per cent., during pertussis in 1.5 ]:icr cent., during
mumps in 0.5 per cent., and dcuhlful were 6 per
cent. Eight_\'-nine cases, or 31) ].)er cent., originated
from the exanthemata : 230 cases, or 93 per cent.,
had adenoids ; forty-eight cases, or 20 per cent., had
hypertrophied tonsils: twenty-eight cases, or 11 per
cent., had acute coryza, and twelve cases, or 5 per
cent., had follicular amygdalitis.
Proportion of symptoms in 248 cases: i. Rise of
temperature was present in 248 cases, or 100 per
cent. ; 2, pain, and 3, tenderness in 114 cases, or 46
per cent. ; 4, extreme restlessness in 236 cases, or 95
per cent. ; 5. refusal of the child to rest its head upon
the affected side in 125 cases, or 50 per cent.; 6,
glandular enlargement in 189 cases, or 76 per cent. ;
7, nasal discharge in 136 cases, or 54 per cent.; 8,
gastroenteric symptoms in 69 cases, or 28 per cent.,
and 9, convulsions in 40 cases, or 16 per cent.
In these cases 50 per cent, showed the absence of
pain or tenderness, which fact proves how uncertain
the symptom of pain or tenderness is in infants and
young children.
.■Utiology. — The following conditions may cause
acute purulent otitis media: i. The exanthemata; 2,
adenoids ; 3, hyperthophied tonsils ; 4, acute coryza ;
5, nasopharyngeal catarrh ; 6, follicular amygdalitis :
7, hypertrophies of the turbinals, and 8, deflected
sjepti. These causes act by either blocking the
Eustachian tubes directly or by causing a congestion
and thus closure of the tubes.
Closure of the tubes results in a disturbance of
circulation in the middle ear and acts also as a good
nidus for infection. I forget to mention that a fre-
quent cause is the introduction of fluids into the
tube by the use of the old fashioned nasal douche
Symptoms. — These vary in infants and older chil-
dren, hence I will describe them separately.
Infants. — These symptoms may be divided into
Objective and Subjective. Objective symptoms
are: i. A red, angry, bulging drum membrane is
seen upon careful examination. I also wish to state
that very often one sees a bulging of the posterior
portion of the tympanic membrane, or only the con-
gestion of the upper third, and sometimes one onlv
sees a congestion of Shrapnell's membrane alone.
.Ml of these lead to a diagnosis of acute otitis media.
\'erv frequently a physician examines an ear and
finds what appears to him a white membrane, which,
if carefully and delicately swabbed, will reveal an
angry, red, bulging ear (Irum. Tiiis while coating
is caused bv drugs used by the parents or doctor
or bv the secretio:is of the ear. Infiltration of the
Marcu 14. 1 906. J
HERZIG: OTITIS MEDIA.
canal wall occurs in infants, so that it is often im-
possible to introduce a small speculum, and so fail
to see the ear drum.
Subjective symptoms are: i, Temperature; 2,
pain ; 3, extreme restlessness : 4, refusal of infant to
rest head upon affected side; 5, tenderness; 6. en-
largement and tenderness of the glands under the
angle of the jaw; 7, a nasal discharge; 8, symptoms
of gastroenteritis, and 9, convulsions.
1. The temperature is one of the most reliable
and constant symptoms that we have. If during
the convalescence of an infant from one of the in-
fectious fevers the temperature suddenly rises ex-
amine the ear, and you very frequently find the
cause of the trouble here. Also in gastroenteric
diseases, when the patient is improving, but the tem-
perature remains high, examine the ear, and in 95
per cent, of the cases you will find an acute otitis
media the cause of the temperature.
2. Pain is the most inconstant symptom we have
in acute otitis media in infants. Kerley. 1901. re-
ports seventy-seven cases, of which number there
was a total absence of pain and tenderness in 69
per cent., and yet these infants all suffered from an
acute otitis media. In cases where pain is present
it is shown by the short, spasmodic cry of the in-
fant, which is increased by pressure upon the auricle
and in the angle of the lower jaw.
3. Extreme restlessness is a very constant symp-
tom in infants, being present in over 90 per cent,
of the cases. In cases of gastroenteritis we often
see extreme restlessness as the only symptom of an
acute otitis media.
4. Refusal of the child to rest its head upon the
aflPected side was brought to notice by Dr. Alarsh in
1897. This is not a constant sign, as it only appears
in about 50 per cent, of cases.
5. I have already described tenderness upon pres-
sure.
6. Enlargement of the glands under the angle of
the jaw is fairly constant, as I have been able to
collect 248 cases in my own experience where the
glandular enlargement was present in 189 cases, or
76 per cent.
7. -\ nasal discharge was present in 136 cases of
the 2-1 8 cases I have seen, or 54 per cent. This
discharge is generally of a glairy mucoid character,
but oftentimes mucopurulent.
8. Gastroenteric symptoms, such as diarrhoea and
vomiting occur.
9. Convulsions occur in a small percentage of
cases, and take the place of the chill, which we get
in older children and adults.
Symptoms in older children are the same as those
enumerated for infants, except that the element of
pain plays a greater role than in infants, and is a
far more constant symptom. Xausea is also a
symptom often seen in older children. These chil-
dren complain frequently of a fullness of the head.
Anorexia is present in most of the cases in older
children. In older children the gastroenteric symp-
toms are more marked than in infants. Headaches
are also complained of.
Types of Cases.
Case I. — A child, aged three years, was brought to me suf-
fering from pain in the head. This child had been treated
by her family doctor for summer complaint as the mother
described it, but did not get well, the child being restless
at night and eating poorly. The child also complained of
pain in the ear, which the doctor told the mother was neu-
ralgia. I asked the mother whether the doctor examined
the child's ear and she told me "No. he did not think it
necessary." Upon examination I found a bulging drum
which I incised. There was an immediate relief of the gas-
troenteric symptoms, and the child was relieved of its
summer complaint by an ear specialist as the mother
termed it.
Case II. — A child, six years of age, was brought to me by a
physician for a running ear. He had treated the child for
ten days for an enteritis, and suddenly on the eleventh day
was surprised to see a discharging ear. The doctor tells
me that the child complained of a stuffy feeling of the head,
but he thought it was only a cold in the head, which the
child contracted. The child had no pain whatsoever and
this fact misled him. I am happy to say that the doctor
now examines the ears of every child he has occasion to see.
These cases are only a few of the many that I
have had tlie opportunity of seeing, and I always
hear the same remark : "There was no pain, and I
never thought of looking in the ear."'
Case III. — A typical case in an infant. An infant, three
months old, did not nurse well, was restless at night, rested
on one side continually, and cried when laid upon the op-
posite side. Rectal temperature 103° F. showed there was
a slight discharge from the nose, and slight congestion of
the pharyn.x and tonsils. After two or three days these
symptoms subsided, but the infant continued to be restless
and awoke frequently at night with a start. The child
seemed quite ill, but no definite symptom.s were present.
Sometimes there was marked tenderness about the ear, and
the child screamed when the ear was touched. After a
few days a discharge was found in the external auditory
canal and the symptoms subsided.
In some cases we get a rise in temperature and no
other symptoms until the ear discharges, this being
the first sign of the trouble in the ear. In other
cases in older children the child hangs its head for
several days, eats poorly, and does not sleep well ;
the child may complain of nausea, but no sign of a
pain or a rise of temperature beyond 100° F. Dur-
ing the night the child is restless, and all of a sud-
den falls asleep, and the next tnorning we find a dis-
charging ear and the child feels better and is
brighter. Such is the general rim of cases, and un-
less a physician examines the ears of such patients
he will be misled very often as to the cause of
the child's illness.
Treatment. — The treatment of acute purulent
otitis media is summed up in three words, namely,
Remoz e tlie cause. The treatment may be prophy-
lactic; remove any postnasal obstruction, e. g., ade-
noids, hypertrophied tonsils, or treat the postnasal
catarrh, which is present in a great number of chil-
dren. A thorough examination of both ears in all
children will become necessary. At the time the
bulging drum is seen a paracentesis may be per-
formed. After treatment consists in keeping the
ear free from accumulated debris, by douching the
ear with a hot normal saline solution every half
hour. I prefer to have the people use a four ounce
syringe. The Eustachian tube should never be in-
flated, as is the custom with a great many of our
aurists. ^^'^hen I open the ear drum I make a good
free incision in the posterior quadrant, and carry
my cut not only through the drum, but also well
into the periosteum of the tympanum. A good free
incision ought to relieve a patient in from one to
three hours.
Keep your patient in bed on a fever diet until all
the acute symptoms have subsided. Douching with
504
CORRESPONDENCE.— THERAPEUTICAL NOTES.
a normal saline solution is all that is necessary, as
the ear drains itself, and all we need to do is to
remove the retained secretion which collects in the
external auditory canal. A running ear will, under
favorable conditions, be self limited in its course.
The attack usually lasts from fifteen to thirty-six
days. Keep the bowels open is an axiom to be fol-
lowed in all febrile conditions, and so in purulent
acute otitis media.
Complications and Sequela need only be men-
tioned, as my paper treats of acute purulent otitis
media in infants and children. They may be: i,
Mastoiditis ; 2, meningitis ; 3, cerebral abscess ; 4,
thrombosis of the lateral sinus ; 5, labyrinthine in-
volvement, and, 6, facial paralysis.
Conclusion. — In summing up, I- wish to state that
my paper was not written with the idea of giving a
complete resume of this subject, but rather to bring
to your notice the extreme importance of examin-
ing the ears of infants and children frequently, espe-
cially during the various exanthemata. The physi-
cian should not be satisfied with one examination of
the ears, but make frequent and thorough examina-
tions at short intervals. If I have made this clear
to you this evening my purpose in presenting this
paper shall have been fulfilled.
2040 Seventh Avenue.
Cflrrcspiikiuc.
LETTER FROM OTTAWA.
A Department of Public Health for Canada. — The Canadian
Medical Association.
Ottawa, Ont., March g, 1908.
On the 3d of March an important delegation of
medical men, consisting of the medical members of
the Canadian House of Commons, the medical men
of the Senate, and the Special Committee on PubHc
Health of the Canadian Medical Association, wait-
ed on Sir Wilfrid Laurier, the Prime Minister, and
members of his cabinet to lay before them the va-
rious resolutions and reports which for the past six
years have emanated from the Canadian Medical
Association, as well as a memorandum on the sub-
ject of a Department of Health for Canada. At
the present time the medical services in the Do-
minion government are administered from five sep-
arate departments, and the object is to have these
consolidated into one department under one of the
existing ministers of the crown. In the Depart-
ment of Agriculture there are national quarantine,
leprosy, etc. ; in the Department of the Interior, dis-
eased immigrants ; in the Indian Department, sick
Indians ; in the Department of Marine, marine hos-
pitals and sick seamen ; in the Inland Revenue De-
partment, the analyses of drugs and foods. The
delegation was introduced by Dr. Black, M. P., of
Windsor, N. S., and at his suggestion the Prime
Minister called upon Dr. Lachapelle, chairman of
the Quebec P>oard of Health and the convener of
the Special Committee of the Canadian Medical
Association on Public Health, to present a memo-
randum on the subject. This memorandum, in ad-
dition to calling for a consolidation of the above
mentioned services, also advocated a national
laboratory for Canada, for the examination of vac-
cines, sera, etc. Dr. George Elliott, the general
secretary of the Canadian Medical .Association,
came down from Toronto, and also addressed the
cabinet, particularly as to what had been done by
the national medical body in this direction. Dr. R.
W. Powell, of Ottawa, who for five years was con-
vener of this special committee, advocated the sub-
ject strongly, as did Lieutenant Colonel Carleton
Jones, M. D., director general of the Canadian
Army Medical Services; Dr. Schaffner, M. P., of
Manitoba, and others. The Premier and the Hon.
Minister of Agriculture were much impressed
with the delegation, and considered the project
feasible, but the Hon. Minister of Agriculture saw
some difficulties in the way of bringing it to a suc-
cessful issue. The matter is to be again debated in
the House of Commons shortly, on the resolution
proposed by Dr. Black a few weeks ago.
A very successful organization meeting was held
in this city on the afternoon of the 3d of March,
looking toward perfecting arrangements for the
forty-first annual meeting of the Canadian Medical
Association in this city on the 9th, loth, and nth
of June. Dr. Montizambert, the Director General
of Public Health, the president, called the meet-
ing in his office in the Langevin Block, and a good
representation of the physicians of Ottawa was
present, as was the general secretary from To-
ronto. Dr. R. W. Powell, the chairman of the
Committee of Arrangements, was in the chair, and
after considerable discussion it was decided to fol-
low out the arrangements provided for in the new
constitution and inaugurate different sections for
the meeting. There are to be general sections in
medicine and surgery, and one session for each of
the following sections : Eye, Ear, Nose and
Throat ; Obstetrics and Gynaecology ; Military Sur-
gery ; Public Health ; Mental and Nervous Dis-
eases.
f Irerapnttiral Jiote.
Chronic Sigmoiditis. — Stern {Medical Record,
February 29, 1908), in discussing the causal treat-
ment of chronic sigmoiditis, says that sigmoidal
spasm is readily amenable to atropine administered
hypodermatically in repeated doses of i/ioo grain
until relaxation of the affected parts has ensued.
When the spasm is less pronounced, but occurs on
the slightest provocation, lupulin should be given for
its mild, enteric nervine sedative effects. In the
motor neuroses of the sigmoidal segment of the
colon, lupulin in the following combinations may,
the author says, be found of service :
I.
B Lupulin, { ^1
Strontium bromide, )
M. ft. caps. No. 1.
Sig. : Two capsules three to five times a day.
n.
B Lupulin 3iss;
Pulverized ipecacuanha gr. vi.
M. ft. cap. No. XX.
Sig. ; One capsule four to six times a day.
NEW YOKK MEDICAL JOURNAL
IXCORPORATIXG THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Reviezi' of Medicine.
Edited by
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and SMITH ELY JELLIFFE, M. D.
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Entered at the Post Office at New York and admitted for
transportation through the mail as second class matter.
XEW YORK, SATURDAY. MARCH 14. 1908.
MILK AND THE PUBLIC HEALTH.
Last week, in an article entitled The Public Health
and Marine Hospital Service, we mentioned that the
bureau's report of its investigation of the milk in-
dustry was announced as soon to be published. We
fiave now received the report, a volume of 758 pages,
styled Milk and Its Relation to the Public Health.
\'arious writers have taken part in its production,
and the result of their associated efforts is a most
notable contribution to the literature of hygiene.
The volume opens with an introductory article by
Surgeon General Wyman. "It has been the object,''
says Dr. Wyman, "to include in this volume all
available data showing the influence of milk as a car-
rier of infection, its chemical composition, the con-
taminations found therein, their influence upon it as
an article of food, and the measures necessary in its
production and handling to prevent such contami-
nation." The surgeon general is conservative in his
brief remarks on pasteurization. While he admits
that it is "not the ideal to be sought," he declares
that "practically it is forced upon us by present con-
ditions." He goes on to say: "It prevents much
sickness and saves many lives — facts which justify
its use under proper conditions." These statements,
it will be seen, do not justify the demand that has
been made in some quarters for wholesale and indis-
criminate pasteurization.
Passed Assistant Surgeon John W. Trask treats
of milk as a cause of epidemics of typhoid fever,
scarlet fever, and diphtheria. While perhaps the
505
text of the article tells us nothing new, it is written
in a convincing and very readable style, and to it
are appended about a hundred pages of tabular mat-
ter setting forth the facts with regard to epidemics
believed to liave been caused by milk. This statis-
tical material, intelligently classified, must prove of
great value. The milk supply of cities in its relation
to the epidemiology of typhoid fever is treated of
specifically by Passed Assistant Surgeon Leslie L.
Lumsden, who considers not only milk itself, but
also buttermilk, butter, cheese, and ice cream. His
article is a short one, but it contains many useful re-
minders. Passed Assistant Surgeon John F. Ander-
son follows with a short report on the frequency of
tubercle bacilli in the milk supplied to the city of
Washington. He properly holds that all dairy cows
should be tested with tuberculin, and those that re-
spond to it so disposed of as to prevent their con-
tributing to further milk supplies. Dr. Anderson
furnishes us also with an interesting article on the
relation of goat's milk to the spread of Malta fever.
Milk sickness, an affection apparently confined to
the United States, is lucidly described by Passed As-
sistant Surgeon George W. McCoy. Dr. Charles
Wardell Stiles treats briefly of the relation oij^cow's
milk to the zooparasitic diseases of man. Under the
title of Morbidity and Mortality Statistics as Influ-
enced by Milk, Assistant Surgeon General J. M.
Eager treats in rather a sketchy way of various
points relating to milk and disease. He appears to
believe implicitly in pasteurization, and he leaves the
reader to infer that the diminution of mortality
which followed the installation of a pasteurizing
plant on Randall's Island in 1898 resulted solely
from pasteurization. Dr. Harvey W. Wiley, chief
of the Bureau of Chemistry of the Department of
Agriculture, with the collaboration of Dr. George
W. Stiles, of Washington, and Dr. M. E. Penning-
ton, of Philadelphia, contributes an interesting and
instructive article on ice cream. It has the crispness
and directness of all of Dr. Wiley's writings. The
great subject of the chemistry of milk is handled by
Dr. Joseph H. Kastle, chief of the Division of Chem-
istry, and Assistant Surgeon Norman Roberts. It
covers not only the chemistry of normal milk, but
also the changes due to ferments and bacteria, milk
poisoning, the chemical standards for the control of
the sale of milk, and the adulterations of milk, to-
gether with a section devoted to the Washington
milk supply.
Bacteria in milk receive the special attention of
Dr. ]\Iilton J. Rosenau, the director of the Hygienic
Laboratory, and the same author, in conjunction
with Dr. McCoy, contributes an article on the germi-
cidal property of milk. One of the conclusions is
that "this so called germicidal property of milk oc-
i:.Vj I uRiAL AkIItLL.:>.
EDITORIAL ARTICLES.
[Xea- York
Medical Journal.
curs only in the fresh raw fluid." It seems to us
rather important to bear this in mind in connection
with the consideration of pasteurization. It is in-
sisted that the action is rather "restraining"' than
truly germicidal. The significance of leucocytes and
streptococci in milk is treated of by Assistant Sur-
geon William Whitfield Miller, and his essay, though
brief, is full of interest. Dr. John R. Mohler, chief
of the Pathological Division of the Bureau of Ani-
mal Industry of the Department of Agriculture,
treats briefly but satisfactorily of the conditions and
diseases of cows which affect their milk injuriously.
Sanitary inspection is dealt with by Mr. E. H. Web-
ster, chief of the Dairy Division of the Hureau of
Animal Indu.stry. His article, which is freely and
eflfectively illustrated, brings out sharply the con-
trast between good and bad methods in the care and
milking of cows, in the storage of milk, and in its
transportation and distribution. The allied subject
of sanitary water supplies for dairy farms is well
handled by Dr. B. Meade Bolton, of the Bureau of
Animal Industry, with a separate section on the wa-
ter supplies of dairies supplying the District of Co-
lumbia. Dr. A. D. Melvin, the chief of the Bureau
of Animal Industry, contributes a very short article
on the classification of market milk. He thinks that
all milk which comes from other than certified or in-
spected dairies should be pasteurized, though he ap-
pears to regard the process as onl}- a substitute for
more radical measures. Certified milk and infants'
milk depots are succinctly described by Assistant
Surgeon General John W. Kerr.
Pasteurization is particularly treated of by the di-
rector of the Hygienic Laboratory, Dr. Milton J.
Rosenau, who balances the advantages and disad-
vantages of the procedure fairly. An excellent arti-
cle on infant feeding is contributed by Passed As-
sistant Surgeon Joseph W. Schereschewsky. The
volume concludes with an instructive article on the
municipal regulation of the milk supply of the Dis-
trict of Columbia by Dr. William Creighton Wood-
ward, the health officer of the District.
As in all variorum works, there is an unavoidable
overlapping of subjects in this volume, but the col-
lection as a whole is one that gives a renewed assur-
ance of the efficiency of the Public Health and Ma-
rine Hospital Service, and must prove of great value
in the final solution of the problems involved.
CALCIUM METABOLISM AND THE
PAR.\THYREOIDS.
Of the many advances that have been made in
medicine in the past twenty-five years, those con-
cerned with the relations of specialized structures
and metabolism have been the most striking. The
discovery of thyreoid insufficiency as a determining
factor in myxoedema and cretinism was but the
first of a long series of. observations that have
served to unravel a large number of disorders de-
pendent on thyreoid inadequacy and thyreoid ex-
cess.
The regulating effect of the adrenals in carbo-
hydrate metabolism is a further illustration in the
line of progress, and now we would call attention
to a preliminary announcement of what promises
to be a very important discovery by Dr. W. G.
MacCallum and Dr. C. Voegtlin (Johns Hopkins
Hospital Bulletin, March) that the parathyreoids
stand in close relation with the calcium metabolism
of the body.
It will be recalled that Loeb and J. B. MacCal-
lum showed that calcium salts had the property of
reducing the irritability that caused twitchings in
muscles rendered superactive by the application of
other salts, notably those of potassium, and, fur-
ther, that certain well recognized disorders, such
as osteomalacia and rickets, usually associated with
a defective amount of calcium, were frequently ac-
companied by a muscular irritability sufficient in
many cases to cause what is clinically grouped as
tetany.
With these general facts in mind, and further
recalling that an abundant milk diet, which is
rich in calcium, served to either prevent the tetany
reaction in parathyreoidectomized dogs, or to
greatly mitigate its severity, the authors were led
to a study of the calcium metabolism in animals in
which tetany had been produced by removing the
parathyreoids.
They tell us that all the violent symptoms pro-
duced by extirpating these glands — muscular
twitching and rigidity, tachypnoea, fibrillary
tremors, increased rapidity of the heart beat, etc. —
may be almost instantly cured by the intravenous
injection of a calcium salt. They use the acetate
or lactate for the purpose by hypodermic injec-
tion, or, acting more slowly, by the stomach. Mag-
nesium salts are also efificient, but they introduce a
toxic action, while potassium salts make things
worse. It is significant that an anal3'sis of the blood
taken from a dog during tetany shows an amount
of calcium which is only about half that of a nor-
mal dog on the same constant diet.
The authors suggest the hypothesis- that the para-
thyreoids control in some way the calcium metab-
olism, so that upon their removal a rapid excretion,
possibly associated with inadequate absorption and
assimilation, deprives the tissues of calcium salts. The
certainty and rapidity with which the symptoms of
tetany are dispelled by the administration of cal-
cium salts make it .seem probable that this observa-
tion will have some therapeutical importance, not
only in postoperative tetany, but also in the vari-
March 14. 1908.]
EDITORIAL ARTICLES.
507
ous forms of tetany which occur spontaneously in
children and in connection with infectious diseases,
pregnancy, and lactation. They suggest that it is
possible that the tetany of lactation may be due to
the great drain of calcium in the production of milk
rich in calcium, especially in individuals in whom
there is parathyreoid insufficiency.
The analogies of the modifications ^ of carbo-
hydrate metabolism by the destruction of the isl-
ands of Langerhans, with the pro luotion of dia-
betes mellitus, suggest the term diabetes calcareus
for this type of phenomena. The work is not with-
out immense significance when one views the en-
tire group of motor anomalies, the choreas, cata-
tonias, tics, and it may be even epilepsy, which may
have some light thrown on them through this new-
ly opened door.
THE CRIPPLED AND DEFORMED CHIL-
DREN OF THE STATE OF NEW YORK.
In West Haverstraw there is an old wooden Co-
lonial mansion which has been remodeled as thor-
oughly as was practicable to serve as the New York
State Hospital for the Care of Crippled and De-
formed Children. The old building happened to
stand on a tract of land, fifty acres in extent, which
the State bought in 1904 as a site for a large new
hospital which it evidently intended to build, and in
the interest of economy it was thought expedient to
use the building as a temporary hospital. But it is
not well adapted to the purpose. In the first place,
it is too small, for it will accommodate only forty-
five patients, though at times there have been forty-
eight within its walls. It cannot be enlarged to ad-
vantage, but there is a crying need for more exten-
sive provision for the cure (which is often possible)
of children who, but for such an institution, would
either die or grow up more or less incapacitated for
work and become a burden to the State for life.
Therefore a bill has very properly been introduced
into the present legislature to appropriate $100,000
for building and equipping on the ^^^est Haverstraw
site a modern hospital with accommodations for two
hundred patients, the ultimate design being to en-
large it to double that capacity.
In the mean time the Medical Society of the State
of New York has passed a resolution, apparently not
very well considered, approving of a project to con-
vert into a similar hospital certain unoccupied build-
ings in Rochester formerly used by the State as a
custodial and correctional asylum for boys. But it
is pointed out that the Rochester buildings also are
unsuitable for the purpose, and that to carry out the
proposed plan would be to scatter forces which ought
te be concentrated. The West Haverstraw institu-
tion already has the special appliances for the work
in hand, and to duplicate them in Rochester would
be to spend money unnecessarily. It seems better to
establish and support one adequate hospital for the
relief of deformity than to start two that will still
fall short of answering the purpose, though doubt-
less in years to come others will be needed. The ob-
jection that West Haverstraw is not easily reached
by the poor of the entire State is met by the state-
ment that the railway companies whose lines lead to
that point have heretofore shown themselves willing
to furnish free transportation to children accepted
as patients, and would probably continue to do so.
It appears to us, therefore, that in the interest of
economy the State would do well to perfect the hos-
pital already in existence rather than to establish
another imperfect one. The action taken by the
Medical Society of the State of New York shows
that the profession recognizes the need of a suitable
provision for the treatment of crippled and deformed
childjen , but its specific recommendation hardly
seems wise in view of the situation which we have
outlined.
THE CONGESTION OF POPULATION IN
NEW YORK.
On last Monday night an exhibit illustrating the
congestion of population in New York and its moral,
intellectual, and physical effects was opened in the
American IMuseum of Natural History with a for-
mal address by the governor of the State. Many
who attended were surprised to find that the large
auditorium of the museum was filled, a fact which we
should like to construe as being a hopeful indication
of the attitude of the public on this most important
question, though it is quite possible that an oppor-
tunity to hear the governor had some bearing on the
size of the audience. Such as had the privilege of
attending the conference cannot but have been im-
pressed with the grave responsibilities which rest
upon the shoulders of the executive authorities in
dealing with a problem which is so full of seriou.s
import for the future, not only of the city and State
of New York, but of the republic. Governor Hughes
might well be both oppressed and depressed, as he
admitted, by the exhibit, for there are shown in
graphic manner the density of the congestion in vari-
ous parts of New Y^rk and the pitiable results aris-
ing from it, results which, as Governor Hughes
rightly said, "are intolerable. They cannot last."
This exhibit is the first step in a systematic study
of the evils of congestion, and should furnish a basis
for suggestions as to the means of combating these
evils. The committee which organized the exhibit
is to be congratulated upon its wisdom in refrain-
ing from the elaboration of definite plans to remedy
the evils which they point out. The function which
the committee has assumed is that of making clear
5o8 EDITORIAL
the need for the amelioration of the congestion of
population and its attendant evils. There naturally
will be differences of opinion as to the best means
of preventing the continuance of these conditions,
and if the committee had come before the public at
this juncture with a full fledged plan of reformation,
their energies would probably have been dissipated in
the discussion of details of such plans. Instead of
doing this, the members have wisely restricted their
efforts, so far as this conference is concerned, to a
presentation of the facts, with a view to so arousing
the public conscience to its responsibilities in the
matter as to lead the way to a systematic study of
ways and means of changing these conditions.
The physician is necessarily interested in this
topic, for so long as these densely congested areas
of population exist in our large cities, just so long
will it be impossible to give protection against infec-
tious disease and insure the normal, healthy growth
of the children of the slums, who in the near future
will constitute the men and women of the republic.
A child reared under such conditions as are por-
trayed in some parts of this exhibit is almost fore-
doomed to ill health and immorality. Physicians
more than the people of any other class are keenly
alive to the degrading influences, both physical and
moral, incident to living under the unhygienic con-
ditions to which the very poor of the city of New
York are condemned^ and if this exhibit can stimu-
late the physicians who may visit it to a keener ap-
preciation of the responsibility under which they
rest for the creation of public sentiment against such
abuses as are shown, it will have done good work,
bearing fruit in improved conditions of living and
higher types of manhood for our future citizens.
Every physician who can do so should visit this ex-
hibit, which will be open for two weeks, and should
use it as a means of stimulating public interest in a
question which is one of the most vital importance
to the future welfare of the community and of the
nation.
A PUERILE ATTEMPT AT HUMOR.
On Friday of last week, under the subheading of
Hospital Ship Will Join Fleet Fully Equipped, the
New York Times published a special dispatch from
Washington, of which the following is the sub-
stance :
With its magazines stored with pills, and high explosive
seidlitz powders in its handling room, within easy reach of
the ammunition hoists, the hospital ship Relief will set sail
from San Francisco under orders from the Navy Depart-
ment to join Admiral Evans's fleet at Magdalena Bay.
. . . The Relief will take part in the target practice at
Magdalena Bay. In consequence Rear Admiral Surgeon
Stokes will steam south with the muzzles of his medicine
bottles uncapped and his crew of internes in readiness for
whatever may arise.
This precious piece of puerility could not be held
ARTICLES. , [New York
Medical Journal.
back for the mail ;• it had to be telegraphed ! We
congratulate the Times on the humor of its corre-
spondent.
THE BUREAU OF ANIMAL INDUSTRY.
The Tzuenty-third Annual Report of the Bureau
of Animal Industry for the year 1906, recently is-
sued, is cliiefly devoted to matters of interest from
the agricultural point of view and from that of per-
sons concerned with meat products, but it contains
also much that will prove valuable to medical men.
We have had frequent occasion to cite the bureau's
publications, nearly all of which are of the greatest
scientific or economic value.
DANIEL B, ST. JOHN ROOSA, M. D., LL. D.,
of New York.
Dr. Roosa died suddenly on Sunday, 2\larch 8th,
lacking less than a month of the age of seventy years.
He had appeared to be in his usual good health, but
it is now understood that he had trouble with the
kidneys and with the heart. Soon after his morn-
ing bath he fell to the floor and was dead almost at
once. He was a native of Bethel, Sullivan County,
N. Y. He received his medical degree from the
Medical Department of the University of the City
of New York in i860. After taking the full course
of two years on the surgical house staff of the New
York Hospital, he made a special study of ophthal-
mology in Vienna and Berlin. Returning to New
York, he entered upon ophthalmic practice and soon
won distinction in that field, both as a practitioner
and as a teacher.
Dr. Roosa was a born leader of men. Had he
chosen a purely political career, he would undoubt-
edly have climbed very high. As it was, he was
able to move the general body of the medical profes-
sion almost at will by the earnestness and precision
of his oratory. His was the central figure in the
movement which led to the abolition of the old Code
of Ethics in the State of New York. And it was
not in speechmaking alone that he made himself
felt; he was a skilled organizer, as was shown by
his establishment of the New York Postgraduate
Medical School and Hospital, the first institution of
its kind. Almost everybody looked for the failure
of the scheme, but Dr. Roosa carried it through tri-
umphantly. He was a man of great mental and
moral strength.
H.'\L C. WYMAN, M. D.,
of Detroit.
This distinguished surgeon died at his home, in
Detroit, on Monday. March gth, after a short illness.
He was fifty-six years old. He was a native of In-
diana, but had practised in Detroit for many years.
He was a frequent contributor to medical literature
and a well known authority on abdominal surgery.
He was an attractive man personally and a highly
successful practitioner.
March 14, 190b.]
NEWS ITEMS.
509
Changes of Address.— Dr. Henry Mitchell Smith, to
64 Montague street, Brooklyn, N. Y.
The Franklin Institute of Philadelphia has received
$50,000 from Mrs. Anne Weightman Walker Penfield as
a memorial to her father, the late William Weightman.
Portland, Me., Medical Club. — At a meeting of this
organization held on Thursday, March 5th, Dr. Willis B.
Moulton read a paper entitled Laboratory versus Clinical
Diagnosis.
Dr. R. V. Wagner, of Chicago, inventor of apparatus
for the therapeutical application of electricitj-, and head of
the firm of R. V. Wagner & Co., died on Thursday,
March 12th.
Gloucester County, N. J., Medical Society. — The next
meeting of this society will be held in Woodbury, N. J.,
on Thursday, March 19th, at i :30 p. m. A full attendance
of the members is desired.
Donations to Charities. — Mrs. Anne Weightman
Walker Penfield has given $20,000 to the Society to Protect
Children from Cruelty in Philadelphia and $20,000 to the
Society for the Prevention of Cruelty to Animals in Phila-
delphia.
A Hospital and Medical School in Manchuria. — The
Chmese authorities have announced their intention of estab-
lishmg in Kirin, Manchuria, a medical school and hospital,
with graduates from the Medical School of Formosa as
teachers.
The Frankford Hospital, of Philadelphia.— The new
buildings of this hospital were dedicated on the afternoon
of Tuesday, February 25th. Dr. B. F. Walters and Dr.
Samuel Bolton made addresses. Donation Day was also
observed.
Society of Medical Jurisprudence, New York. — The
two hundred and twelfth regular meeting of this society
was held on March 9th. The paper of the evening was read
by A. Delos Kneeland, Esq., of the New York bar, on Hon-
esty in Our Professions.
The Pennsylvania State Board of Pharmaceutical Ex-
aminers has issued certificates to 8 registered pharma-
cists and 49 qualified assistants, as a result of the exam-
inations held in Harrisburg on February 15th. One hun-
dred and thirteen persons took the examinations.
The Clinical Society of the Elizabeth, N. J., General
Hospital will hold its next meeting at the hospital on
Tuesday, March 17th, at 9:00 p. m. Dr. T. N. McLean
will read the paper of the evening on Epidemic Influenza.
Dr. Russell A. Shirrefs is the secretary of the society.
Rochester, N. Y., Academy of Medicine. — At a meet-
ing of this academy, which was held on March nth, the
evening was devoted to general .observations and conclu-
sions after a visit to Dr. William J. Mayo and Dr. Charles
H. Mayo, of Rochester, Minn., by Dr. Zimmer and Dr.
Eisner.
St. Catherine's Hospital, Brooklyn.— At the annual
meeting of the medical board of this hospital, which was
held recently, the following officers were elected : Presi-
dent, Dr. Maurice Enright ; vice president. Dr. Peter
Hughes ; secretary and treasurer, Dr. E. J. Carroll ; and
member elect to executive committee. Dr. J. C. Kennedy.
New York Pathological Society. — The regular meet-
ing of this society was held at the New York Academy
of Medicine on Wednesday evening, March nth. The pro-
gramme included a paper by Dr. Leo Buerger, entitled
The Pathology of the Vessels in Cases of Gangrene of the
Lower Extremity, due to So Called Endarteritis Obliterans.
Buffalo Academy of Medicine. — The regular meeting
of the Section in Medicine was held on Tuesday evening,
March loth. The programme included the report of a case
of paranoia, by Dr. Sidney A. Dunham, and a paper on Specific
Infectious Arthritis, by Dr. J. Henry Dowd. Dr. A. L.
Benedict is chairman of the section, and Dr. Thomas J.
Walsh is the secretary.
The Pathological Society of Philadelphia.— At a meet-
ing of this society held on Thursday, March 12th, Dr.
Allen J. Smith and Dr. Herbert Fox presented a paper on
a Ciliate Organism in the Mammalian Liver, a Prairie
Wolf; Dr. R. S. Lavenson read a paper on Acute Lympho-
penic Lymphatic Leucsmia ; and Dr. J. L. Donnhauser read
a paper on Splenomegaly.
A Physicians' Protective Association in Gloucester
County, N. J. — The physicians of Woodbury, Mantua,
Wenonah, and Westville have organized a protective as-
sociation, the members of which embrace all practising
physicians in the towns named. The association meets on
the first Wednesday evening of each month at the residence
of the members in turn.
Societe de Pathologic Exotique is the name of a new
medical society which has just been organized in Paris
which will meet at the Pasteur Institute. The principal
object of the society will be the study of tropical diseases
in man and animals, and the sanitary measures that will
best prevent the spread of epidemics of diseases of exotic
origin. Dr. Laveran is the president of the society.
The Long Island Society of Anaesthetists will hold
its spring meeting on Saturday evening, March 14th, in the
building of the Medical Society of the County of Kings,
1313 Bedford avenue, Brooklyn. The evening will be de-
voted to a consideration of modern European methods of
surgical anaesthesia, and all members of the profession who
are interested in the subject are invited to be present.
College of Physicians of Philadelphia.— On Monday
evening, March 9th, a meeting of the Section in General
Medicine was held, and the following papers were read:
The Resistance of Diabetics to Bacterial Infections, by Dr.
J. C. Da Costa, Jr., and Dr. J. G. Beardsley ; Some Cases
of Fever of Obscure Origin, by Dr. J. Dutton Steele ; and
A Case of Typhoid Fever Ushered in by an Attack of
Urjemia, by Dr. R. Max Goepp.
The Northern Medical Association of Philadelphia
held a meeting on Friday evening, February 13th. The gen-
eral subject for discussion was gonorrhoea, and papers were
read as follows : The Symptomatology and Treatment of
Gonorrhoea, by Dr. H. M. Christian ; The Symptomatology
and Diagnosis of Complications of Gonorrhoea, by Dr. Al-
exander A. Uhle ; and The Treatment of the Complications
of Gonorrhoea, by Dr. William H. MacKinney.
Richmond, Va., Academy of Medicine and Surgery. —
A regular meeting of this academy was held on the evening
of March loth. The programme included a paper on Brain
Lesions secondary to Diseases of the Eye, Ear, and Nose,
by Dr. Clifton M. Miller, and a paper entitled An Improved
Operation for Mastoid Disease, by Dr. D. A. Kuyk. Dr.
Miller's paper was discussed by Dr. John Dunn, and Dr.
Kuyk's paper was discussed- by Dr. William F. Mercer.
Geneva, N. Y., Medical Society. — At the regular
monthly meeting of this society, which was held on Thurs-
day evening, March 5th, the general subject for discussion
was constipation. Many interesting papers were read, and
at the close of the meeting refreshments were served. The
officers of the society for the present year are: President,
Dr. J. H. Knickerbocker; vice president. Dr. C. C. Lytle;
treasurer. Dr. C. F. Nieder; and secretary. Dr. j' A.
Spengler.
Meetings of German Medical Societies. — The seventh
annual congress of the German Society for Orthopaedic
Surgery will be held in Berlin on Saturday, April 2Sth ; the
fourth annual congress of the German Rontgen Ray So-
ciety will be held in Berlin on Sunda}', April 26th, and the
thirty-seventh annual congress of the German Surgical
Society will be held in Berlin on April 21st to 24th. Ex-
hibitions of instruments and apparatus will be held in cou;
nection with these congresses.
Philadelphia Neurological Society.— At a stated meet-
ing of this society, which was held on Monday evening,
February 24th, cases were exhibited as follows: A case
of Paralysis of Associated Upward Movement with Pres-
ervation of Isolated Upward Movement of Eyeballs, by Dr.
Alfred Reginald Allen; a case of Tabes Dorsalis with
Psychoses, by Dr. W. B. Hawk; a case of Aphasia, by Dr.
W. B. Cadwalader; a case of Bilateral Involvement of the
Cochlear and Vestibular Branches of the Eighth Nerve,
by Dr. T. H. Weisenberg; cases of Retardation Requiring
Psychological as Well as Medical Examination and Treat-
ment, by Dr. Lightner Witmer ; the Pathogenesis of Tabes,
by Dr. T. A. Williams, of Washington, D. C. ; and a case
of Hemiplegia with Rigidity of the Muscles of the Neck,
with Necropsy, by Dr. W. G. Spiller.
NEWS ITEMS.
The Diisseldorf Postgraduate Medical School.— Pro-
fessor Witzell, president of the new Postgraduate Medical
School at Diisseldorf. Germany, has issued an interesting
prospectus showing the course of instruction given. The
corps of teachers includes several men of prominence in the
'medical world, and, as the course is particularly intended
for postgraduate students, it may interest our readers to
know that foreign physicians, including those from Amer-
ica, of course, are admitted to this school without any fee
except the registration fee of $i each.
The Medical Society of the Borough of the Bronx
held a stated meeting on Wednesday, March iith. Dr.
Ralph Waldo read a paper entitled The Indications and
Contraindications for the Use of the Uterine Curette, and
Dr. Malcolm McLean read a paper entitled A Consideration
of the Foetal Envelopes in Obstetrics. The officers of the
society for the current year are : President, Dr. William
McChristie ; first vice president. Dr. Edward Broquet ;
second vice president, Dr. Charles Graef ; secretary. Dr.
Clarence H. Smith ; and treasurer, Dr. William H. Meyer.
Medical Society of the County of Richmond, N. Y. —
The regular monthly meeting of this society was held at the
Staten Island Academy of Medicine on Wednesday evening,
March nth. Dr. Carl Keppler, of Manhattan, read a paper
on the Treatment of Infantile Paralysis, which was dis-
cussed by Dr. Sprague and Dr. Johnston, and Dr. A. P.
Voislawsky, of Manhattan, read a paper on Oral and Nasal
Troubles in General Practice, which was discussed by Dr.
Coonley and Dr. Jessup. Dr. C. E. Pearson, of 32 Central
avenue, New Brighton, S. I., is the secretary of this society.
Vacancies in the House Staff of the New Harlem
Hospital. — A competitive examination to fill vacancies
in the house staff, of the new Harlem Hospital, which is
situated at the corner of Lenox avenue and One Hundred
and Thirty-sixth street, will be held at the hospital on Sat-
urday, March 21st, commencing at id a. m. Applications,
stating the natrie, address, academic education, place and
date of graduation or expected graduation !n medicine, of
the applicant, and accompanied by at least three letters of
endorsement from regular physicians in good professional
standing, should be sent by mail to Dr. R. Van Santvoord,
10 West One Hundred and Twenty-second street.
Philadelphia County Medical Society. — The Central
Branch of this society held a meeting on Wednesday,
March nth, the general subject for discussion being nos-
trums and nostrum prescribing. Papers were read by mem-
bers of the pharmaceutical profession, as follows : Nostrum
Prescribing: Its Cure, by Prof. Joseph P. Remington;
Nostrutus in Dosage Form, by Mr. M. I. Wilbert ; The
Relative Frequency in the Prescribing of Proprietary Medi
cines, by Mr. Ambrose Hunsberger; and The Legal Safe-
guards Surrounding U. S. P. and N. F. Preparations, by
Mr. W. L. Cliffe. The discussion was opened by Dr. Jame^
M. Anders and was participated in by many prominent
members of the medical profession.
Eastern Medical Society of the City of New York. —
At a meeting of this society, which was held on Friday,
March 13. Dr. D. A. Singer presented a case of acetonuria
bradycardia. There was a further discussion of the papers
on diseases of the bones and joints which were read at the
previous meeting of the society, and Dr. A. J. Hcrzig gave
a short resume of the commoner conjunctival and corneal
diseases, which was discussed by Dr. Ervin Jorcik and Dr.
Martin Cohen. Dr. Henry S. Stark read a paper entitled
Diabetes and the Food Factor, which was discussed by
Prof. Lafayette B. Mendel, of Yale University; Prof.
Graham Lusk, of Bcllevue; Dr. Max Einhorn, Dr. W. Gil-
man Thompson, Dr. J. Kaufmann, Dr. Ph(rbus A. Levene,
and Dr. Morris Manges.
Statistics Desired on Gallstone Surgery.— Dr. Hans
Kehr, of Halberstadt, Germany, has been designated as re-
porter on the surgery of gallstones at the International
Congress of Surgeons, which will be held in Brussels next
September. He wishes to collate as complete statistics as
possible, and to that end requests that all surgeons who
have had any experience in this direction will send him
complete statistics of their own cases covering the live
years from 1903 to 1907, inclusive. He would like to have
the cases arranged in three classes: ist, pure stone cases;
2d, complicated, benignant and reparable cases; 3d. com-
plicated, malignant and irreparable cases, the statistics re-
garding sex and results being given. He also would like
10 learn from surgeons who can furnish such statistics what
their view s are regarding the various operative methods.
Entertainment for Women Physicians Attending the
Chicago Meeting of the American Medical Association.
— The Women's Aluninre Committee, the Women's j\Iedi-
cal Society of the State of Illinois, and the Women's Medi-
cal Club of Chicago, announce that a banquet and
entertainment will be given on the evening of June 2d. to
which all women physicians who are in Chicago at that
time are cordially invited. Each of these organizations de-
sire to entertain the visitors, but as the session is very
short they have decided to join forces. At the banquet a
special feature will be the reunions of the alumnre of the
different colleges. The College Club in the Fine .Arts
Building, 203 Michigan avenue, will be at the disposal of
the ^\omen physicians exclusively during the meeting.
Philadelphia Paediatric Society. — At a regular meet-
ing of this society, held on March loth, the following pro-
gramme was presented : Dr. James K. Young exhibited a
case of tuberculous dactylitis; Dr. James K. Young re-
ported a case of streptococcic dactylitis; Dr. C. F. Judson
and Dr. H. L. Carncross reported a case of encephalitis ;
Dr. E. Burville-Holmes read a paper entitled Lumbar
Puncture, its Technique and the Value of Cytodiagnosis in
Differentiating the Tuberculous from the Epidemic Form;
of Meningitis : Dr. C. H. Muschlitz read by invitation a
paper on Congenital Unilateral Hypertrophy; Dr. B. F.
Royer and Dr. J. D. Wilson reported a case of incomplete
heterotaxy with unusual heart malformations; and Dr. C.
F. Judson and Dr. W. N. Bradley presented a case of
sporadic cretinism.
Scientific Society Meetings in Philadelphia for the Week
Ending March 21, 1908:
Monday, March j6^/i.— Northeast Branch Philadelphia
County Medical Society.
TuESD.w, March i/th. — Dermatological Society ; Academy
of Natural Sciences ; North Branch. Philadelphia Coun-
ty Medical Society.
Wednesd.-\y, March iSth. — Section in Otology and Laryn-
gology, College of Physicians ; Association of Clinical
Assistants of Wills Hospital; Franklin Institute.
Thursday, March igth. — Section in Gynrecology. College
of Physicians; Section Meeting, Franklin Institute;
Medical Society of the Woman's Hospital ; Section in
Ophthalmology, College of Physicians.
Friday, March 20th. — University of Pennsylvania Medical
Society ; American Philosophical Society.
Infectious Diseases in New York:
IVe arc indebted to the Bureau of Records of the Depart-
ment of Health for the folloiving statement of new cases
and deaths reported for the tzvo zveeks ending March 7^
1908:
^February 29.-^ , March 7. ,
Cases. Deaths. Cases. Deaths.
Tuberculosis pulmonalis 451 204 426 200
Diphtheria 373 44 • 379 48
Measles 1.554 39 i>465 26
Scarlet fever 924 39 901 56
Smallpo-x . . I
Varicella 180 .. 215
Typhoid fever 45 9 26 7
Whooping cough . ■ . 20 i 9 i
Cerebrosuinal meningitis 16 S 10 12
Totals 3,563 344 3,432 350
Personal. — Surgeon General Baron Sato has been ap-
pointed president of the Great Korean Hospital, attached
to the Japanese Residencv-General in Seoul.
Dr. W. C. McKechnie, of Portland. Ore., Dr. John
J. Snyder, jmd Dr. George C. Thomas, L'. S. Navy, are
registered at the Philadelphia Polyclinic and College for
Graduates in Medicine.
Dr. Roswell P. Angier, of the Medical College of Yale
University, has been promoted to an assistant professorship
of psychology.
It is reported that Dr. August Martin, professor of gyne-
cology at the University of Griefswald, will visit the United
States during the summer, and will attend the meeting of
the .Xmerican Medical Association.
Dr. R. C. Kemp announces that he has moved from Echo,
La., to Baton Rouge, La., where he has an office in the
Reymond Building.
March 14, 1908.]
NEIVS ITEMS.
The Mortality of Chicago.— According to the report
.if the 1 )ci)arlmein tif Health for the week ending February
_"nli. ilvrc were during the week 677 deaths from all
cause.-. a> cunipared with 786 for the corresponding week in
1907. The annual death rate was 16.30 in 1,000 of popula-
tion, as compared with an annual death rate of ig.45 for the
corresponding week in 1907. The principal causes of death
were : Apoplexy, 10; Bright's disease, 43; bnmchitis, ;
crinsuniplmn. 71; cancer, 2(1; c uunl mi m-, 4; <li|iliiluTia, 15:
heart disease-, 73; inlluenza. -'4; intestinal dise.ise-. acute.
39 ; measles, (.) ; nerxous diseases, Ji; pueumnnia. loO; scar-
let fever.. 9; suicide, 8: typhoid fever, 6; violence, other
than suicide, J5 ; w hooping cough, 4; all other causes, i6j.
The Health of Philadelphia. — During the week ending
l'eliruar>- 22. 1908, the following cases of transmissible dis-
eases were reported to the Bureau of llealth: Typhoid
fever, 1X3 cases, 32 deaths; scarlet fe\er, 80 cases 4 d'eaths ,
chickeiipo.x, 41 cases, 0 deaths; diphlhenri, 78 cases, II
ileaths; measles, 17J cases, [ ileath- ; wliM,,piii- enugh, 36
cases. () deaths; pulmonary tubeiciilosis, i,Si cases, 76
deaths; pneumoni.a. 113 cases. 77 deaths; erysipelas, 17
cases, o deaths ; puerperal fever. 2 cases, 8 deaths ; mumps,
27 cases, o deaths; cancer, 14 cases, 17 deaths. 'Jdie follow-
ing deaths were reported from other transmissible diseases:
Tuberculosis, other than tuberculosis of the lungs, 5; ma-
larial fe\ er, I ; dysentery, I ; diarrbiea and eiitei'itis, under
two years of age, 15. The total deaths numbered 590. in an
estim.iied population of 1.532,733, corresponding to an an-
nual death rate of 20.00 in 1,000 of population. The total
infant mortality w.as irS; under one year of age, 95; be-
tween one and two years of age, 23. There were 43 still
births; 30 luales, and 13 females.
Society Meetings for the Coming Week:
.\lo.\D.\v. Marih New York Academy of Medicine
(SectiDU in Ophtlialuiologv ) ; Medical Association ol
the Greater City of Xew York; Hartford, Coiui., Med
ical Society-.
TuESiiAV, Marili ijlh. — New ^'ork Academ> of Medicine
(Section in Medicine); jMedical Society of the County
of Westchester, N. Y. ; Buffalo Academy of iMedicine
(Section in Pathology); Triprofessional Medical So-
ciety of New York; Medical Society of the C<iunty of
Ivings N. Y. ; Binghamton, N. Y., Academy of Medi-
cine ; ("linicnl Society of the Eliz.abcth, N. J., (jcneral
Hospital: S\ractise, 'N. Y., Academ\- of Medicine; Og-
deiisliuijii, ,V, Y.. Medical Association.
\VKD.xhsle^, Morcli ifil Ii .—New York Acadeni\ of Medi-
cine (Section in Genitouriutiry Diseases): New Yori<
Society of Dermatology and Genitourinary Surgery;
Woman's Medical Association of New York City (New
York .\cademy of Medicine) ; Medicolegal Society,
New York; New Jersey Academy of Medicine (Jersey
City): Buffalo Medical Club; New Haven. Conn.,
Medical Association; New York Society of Internal
^ledicine : Northwestern Medical and Surgical Society
of New York.
Thl'ksd.vy, March jgth. — New York Academy of Medicine;
German Medical Society, Brooklyn ; Newark, N. J..
Medical and Surgical Society; ^sculapian Club of
Buffalo, N. Y,
Friday, March 20tJi. — New York Academy of Medicine
(Section in Orthopredic Surgery) ; Brooklyn Medical
Society ; Clinical -Society of the New York Postgrad-
uate i\ledical School and Hospital ; East Side Physi-
sians' Association of the City of New York; New York
Microscopical Society.
The Medical Association of the Greater City of New
York will hold a stated meeting in Du Bois Flail, New
York Academy of Medicine, on Monday, March i6th, at
8 :30 p. m. The evening will be devoted to a consideration
of the subject of progressive locomotor ataxia, and papers
vyill be read as follows: The Relations of Tabes and Pare-
sis, by Dr. J. Ramsay Hunt; Laryngeal ln\-olvemeut in
Tabes, by Dr. W. Freudenthal ; The Bladder in Tabes, b\-
Dr, J. Bentley Squier, Jr. ; Present Methods of Treatment,
Tjy Dr. S. Wachsmann. Among those who will take part
in the general discusion are Dr. A. D. Rockwell, Dr. Fred-
erick Peterson. Dr. W. B. Pritchard, and Dr. Joseph
Fraenkel. The officers of the society for the present year
are: President, Dr. Robert T. Morris; vice president. Dr.
Ransford E. Van Gieson ; recording secretary. Dr. P. Bryn-
berg Porter ; corresponding secretary. Dr. Frank C. Ray-
nor; treasurer, Dr. A. F>nest Gallant; chairman for the
Borough of Manhattan, Dr. J. Bl;ike White; ch.airman for
the B<jrough of the I'.ronx, Dr. Nathan P.. Van Etten ;
chairman for the Borough of I'.rooklyn, Dr. J. Scott Wood;
chairman fcu" the I'.oroii.oh of ( hie, us. Dr. Neil (Jrrin h'itch ;
chairman for the Morou.^li oi ki.huiond, Div Henry C.
Johnston.
Scholarships and Fellowships at the Rockefeller In-
stitute.— The I-iockefeller Institute for .Medical Research
.announces that for the \ear 1908-1909 a linuied number of
sch.ohirships :uid fellowships will lie :iw;irded for work to
be C'irned on in the l;d)or,'ilori,-s cjf the institute in New
York Cit_\-, under tlie follow in- conditions ; The scholar-
ships and fellow ships w ill he uiMiitcd to tissist im estigations
in experimental paili,Jo<_;y. 1 ,:icii nology, medical zoology,
physiology and pharm:icolo;.^\ , pli\ siological ;uid pathologi-
cal chemistry, and ex]ieriiiiein,'il surgery. They are open
to men and women who are ])ro|)erly fjuahhed to under-
take research work" in an_\' of the :il)o\ e iiienlioued subjects,
and are granted for one vear. The value of these scholar-
ships and felliiwship- ranges from $800 to ,$r,200 each. It
is expected ilial holders of the scholarshijis and fellowships
will devote their eiiiire time to research work. Applica-
tions accompanied by proper credentials should be in the
hands of the secretary of the Rockefeller Institute not
later than April ist. The announcement of the appoint-
ments is made about May 15th. The term of service begins
preferably on October ist, but, by special arrangement, maj'
be begun at another time. Dr. L. limmet Holt, 44 West
Mfty-fifth street. New York, is the secretary.
The Congestion of Population in New York. — The
exhibit of congestion of population in New York, which
will be shown for two weeks at the American Museum of
Natural Flistory, Seventy-seventh street and Columbus ave-
nue, was formally opened to the public on Monday evening,
March 9th, by a series of addresses, the principal speaker
of the e\ening being the Governor of the State. Governor
Hughes's address was devoted to an accentuation of the
importance of the work being done by the conference and
of the need of ;i c;ircful, systematic survey of the field in
just the way in which it was being carried on by the Com-
mittee on Congestion of Population. He said that the ex-
hibit was a most depressing one, and a study of it would
be helpful in arousing public sentiment to the need of
proper legislative regulation of the various and complex
problems involved and the need of proper enforcement of
such legislation. He took a hopeful view as to the pos-
sibility of eradicating; the evils incident to this congestion,
now that they are being carefull_v and scientilically studied.
He said that he felt coniident tb;it with the immense mass
of facts and statistics which had been colhited through the
agency of the committee, it would be possible eventually
to devise some means of ameliorating the (wiK which ar.?
so vividly portrayed in the exhiliit. The nieeling was
opened by Mrs. Vladimir G. Simkovitch, chairman of the
Committee on Congestion of Population, who, after a briel
address, introduced Dr. John FI. Finley, president of the
College of the City of New York, who presided during the
meeting. The speakers included Count Massiglia, the Ital-
ian Consul General, who spoke on behalf of Baron des
Planches, the Italian Ambassador, who was unable to at-
tend ; Dr. Baker, representing the Commissioner of Health
of New York ; the Hon. Robert W. Hebberd, Commissioner
oi Public Charities of New York, and Mr. Jacob A. Riis.
Further conferences were held throughout the day and
evening of Tuesday, Wednesday and Thursday. The speak-
ers at these meetings include the following: Mr. Gavlord S.
White. Dr. George W. Goler, of Rochester, N. Y. ; Mr.
Joseph Lee, of Boston; Mr. Howard Bradstreet, Mr. Rob-
ert Briiere, Dr. Arthur Shoemaker, Mr. Robert Watchorn.
Dr. Lee K. Frankel, Mr. Leonard B. Robinson, Dr. Antonie
Stella, Mr. Gino C. Speranza, Miss Amy A. Bernardy, of
Smith College; Professor Morris Loeb, Mr. Eugene A.
Philbin, Dr. Felix Adler, Dr. E. R. L. Gould, Dr. Henry
M. Leipziger, Mr. Homer Folks, Mr. Mornay Williams,
Miss Mary Van Kleek, Miss Julia Richman, Dr. Edward
P. Devine, Mrs. Florence Kelley, Dr. Henry R. Seager.
Dr. Walter Laidlaw, Mr. John F. Tobin, Mr. George Neu-
bert. Dr. M'llliam FI. Allen, Professor L. H. Bailey, of
Cornell University; Dr. Abraham Jacobi, Mr. C. W. Lar-
nion. Professor Jeremiah W. Jenks, of Cornell University ;
Mr. Charles Mulford Robinson, of Rochester, N. Y. ; Mr.
Lawson Purdy, and the Rev. Stephen S. Wise.
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
March 5, 1908.
1. The Surgical Treatment of Various Conditions as In-
fluenced by Pregnancy, By Malcolm Storer.
2. A Case of Acute Dilatation of the Stomach and Duo-
denum (in a Moribund Phthisical Patient) Simulat-
ing a Terminal General Peritonitis,
By Thomas Ordway.
3. The Boston Medical Library. Its Past, Present and
Future, By James F. Ballard.
I. The Surgical Treatment of Various Condi-
tions as Influenced by Pregnancy. — Storer con-
siders the view, held universally until comparative-
ly recently, and still having much weight in the
minds of most general practitioners, that pregnancy
is a condition of noli me tangerc, in which opera-
tions of all kinds are to be avoided, chiefly from
fear of interrupting pregnancy. That the organism
then has quite enough to do without being sub-
jected to the additional strain of a surgical opera-
tion, of whatsoever nature, that can just as well
be deferred is selfevident. From a critical survey
of much of the wealth of material bearing on this
subject, some 700 papers, it is evident that nearly
all operations have practically no influence upon
the course of pregnancy, except to favor its con-
tinuance, provided that they are not followed by
a septic process which, by reason of continued high
temperature, may cause the death of the foetus and
abortion. A glance at the following list of report-
ed operations, by which pregnancy was not inter-
rupted, will make this evident: External genitals:
Incision of hsematoma, extirpation of hypertrophied
clitoris and labia, extirpation of Bartholin's glands,
extirpation of labial abscess, sarcoma of labia and
vagina, perineorrhaphy, prolapse operation, peri-
urethral sarcoma, fistula in ano, hasmorrhoids.
\'agina and cervix : Excision of cicatricial stenosis
vagina, curettage of cancer of cervix, scarifica-
tion of cervix, cauterization of cervix. Uterus:
l<"or incarcerated retroflexed uterus, adhesions,
curettage of uterus septus (at three months).
Miscellaneous : Curettage of bladder, ex-
ploratory laparotomies, fibrosarcoma of ab-
dominal parieties, nephrotomy for pus, nephrotomy
for stone, nephrectomy, nephorraphy, other kidney
operations, extirpation of spleen, cholecystotomy,
resection of pylorus, resection of sigmoid, Cornell
thyreoidectomy, amputation of breast, inguinal and
umbilical hernia, general peritonitis, tuberculous
])critonitis, dermoid of mesentery, hydrosalpinx. In
the next group of reported cases abortion has fol-
lowed more or less closely upon operation :
Labial polyp, carcinoma of vulva in which blad-
der was injured, cervical polyp, amputation of
cervix, vesicovaginal fistula, removal of stones
from bladder, tumors of pelvis, cancer of
rectum, echinococcus cyst, ileus, crural hernia,
I)yo.salpinx, cysts of vagina removed, appendicitis,
ovariotomies, myomectomies. In many of these
cases in which abortion followed it was at so appre-
ciable an interval that it may be questioned with
propriety whether it was caused by the operation ;
in fact, some writers hold that in no case is the oper-
ation the direct cause of miscarriage, but merely de-
termines a miscarriage that is bound to come any-
way. An examination, then, of the foregoing li.st
will show that operations of the most varied nature
can be performed with very little danger of inter-
rupting pregnancy, with two exceptions : In g op-
erations for vesicovaginal fistula abortion followed
in four, and in 25 operations for crural hernia it
took place six times.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
March 7, igo8.
1. Symptomatology and Diagnosis of Acute Articular
Rheumatism, By Philip Kixg Brown.
2. Cardiac Complications of Acute Rheumatism,
By Alexander Lambert.
3. The Vaccine Treatment of Gonorrhceal Vulvovaginitis
in Children, By William Butler and J. P. Long.
4. The Common Ground of Medicine and Dentistry,
By F. L. FossuME.
5. Subphrenic Abscess as a Complication of Appendicitis,
By Daniel N. Eisendrath.
6. The X Ray and High Frequency Treatment of Exo-
phthalmic Goitre, By Finley 'R. Cook.
7. Local Arteriosclerosis, By F. Fremont-Smith.
8. Perinephritic Abscess Following Parturition,
By J. Shelton Horsley.
1. Symptomatology and Diagnosis of Acute
Articular Rheumatism. — Brown summarizes his
article thus: Diseases with acute joint symptoms
which resemble each other in the character of the
joint involvement and in the accompanying com-
I)lications belong to a definitely infectious group.
The nature of the infection is clear in the following
group: Group i. — Septicaemia, pyaemia, puerperal
fever, typhoid, pneumonia, epidemic meningitis, in-
fluenza, dysentery, gonorrhoea. The character of
the disorder is established as definitely infectious
in: Group 2. — Scarlet fever, smallpox, dengue. An
infectious origin is presumed on good analogical
evidence in: Group 3. — Acute articular rheu-
matism, acute arthritis deformans. Still's type, and
the erythema group. When the infectious diseases
with acute joint s\ mptoms and known aetiology and
also those infectious diseases with established iden-
tities but still doubtful aetiology have been taken
out, there remains another group which contains
acute articular rheumatism, acute arthritis de-
formans, and the erythema type of lesions. That
specific toxic agents are responsible for these con-
ditions seems a matter of no doubt, and that these
agents difi^er from each other seems likely. The
final diagnosis of acute articular rheumatism can
be made only when Groups I and 2 have been ex-
cluded and when there are clinical distinctions
clearly separating the diseases in question from the
other members of Group 3. There are cases in all
groups which can be diagnosticated only by the
lapse of time, and some which cannot at present be
differentiated at all.
2. Cardiac Complications of Acute Rheuma-
tism.— Lambert ub.scrves that it can not be reit-
erated too often or emphasized too strongly that
the cardiac affections of rheumatism occur in all
their intensity without any ratio to the extent of the
joint manifestations, and the intensity of the car-
diac involvement in both children and adults is not
necessarily in any ratio to the intensity of the other
sypmtoms. Many of the symptoms which we have
heretofore believed due to endocarditis occur with
the myocarditis and must be considered as equallv
due to this condition. After the acute joint symp-
toms have subsided, it is often noticeable that the
March 14, 1908.]
PITH OP CURRENT LITERATURE.
513
patient's temperature does not come down to nor-
mal and remain there ; there is a continued run of
temperature from subnormal to subfebrile. from
97^^ or 98'" to about 100°. and it may rise as hii^h as
101°. This invariably means an actively continuing
endocardial or myocardial inflammation. The
pulse may range near normal or be slightly above.
In the subacute forms, in which the degeneration
of the nuiscle is more common than in the acute
inflammatory condition, and in the chronic condi-
tion, the pulse rate may be distinctly below normal.
Heart disease, in the early half of life, is mainly of
rheumatic origin, and we hive come, in late yenrs.
to realize that the treatment of heart disease has
more and more become the treatment of the car-
diac muscle. We have now reached the position
where we must realize that our knowledge of rheu-
matic endocarditis is still fragmentary and very in-
complete. Heretofore our knowledge has . been
chieflv focused on the endocardial and pericardial
involvement to the exclusion of the m>-ocardial. but
to-day we realize that the cardiac involvement of
rheumatism includes endocarditis, pericarditis, and
myocarditis, and the most serious is myocarditis.
3. The Vaccine Treatment in Gonorrhoeal
Vulvovaginitis in Children. — Butler and Long re-
port twelve cases treated with vaccination of
gonococcus serum and twelve cases treated locally.
Thev came to the conclusion that vaccine therapy
has a place in the treatment of gonorrhoea in the
female, that it appears to be far more efficient and
at the same time scientifically more tenable than
local antiseptic treatment.
4. The Common Ground of Medicine and
Dentistry. — Fossume, in speaking of the common
ground of medicine and dentistry expresses his opin-
ion as follows : The dentist must appreciate the fact
that the mouth is a part of the whole body, an im-
portant part, but only a part. He must think in
terms of interchangeable scientific expressions of
thought, so that his findings, observations, and de-
ductions are easily interpreted by the physician. He
must keep pace with the best in medicine, for only
those physicians who stand for what is best in medi-
cine can and will appreciate what is best in dentistry.
The mediocre man in either profession will of neces-
sity stick to his own particular line, but if the dentist
will record and read his daily findings correctly he
will find that his experience must more and more
elucidate some of these problems of medicine, his
work will be of double interest to himself, and he
will open up fields hitherto undreamed of. The
physician, on his part, must recognize that the mouth
as a seat of disease is often overlooked, and that the
logical consultant in many cases is the dentist, who.
by virtue of his constant clinical experience of the
normal in the mouth and teeth, must acquire the
knowledge that is necessary for the unraveling of
symptoms pointing to the mouth as a seat of trouble.
Let the physician choose his consulting dentist with
the same care that he does his consulting surgeon,
for all his patients will have to visit a dentist, while
only a small proportion will need surgical interven-
tion. Let him keep abreast to a small extent of
dental literature, not necessarily the most technical,
but the general literature. Let the dentist think and
work in terms scientifically interchangeable with the
physician ; then, and then only, will the common
ground need no defining.
5. Subphrenic Abscess as a Complication of
Appendicitis. — Eisendrath saj's that there are five
methods of draining a subphrenic abscess: (a) By
an incision in the epigastrium ; (b) by an incision
along the costal arch; (c) by an incision in the
lumbar region; (d) by the transpleural route; (e)
by pushing the pleural reflection upward and open-
ing the abscess cavity through an incision in the
diaphragm without opening the pleural cavity. The
first three methods are indicated when there is
bulging in the epigastrium along the costal arch
or in the lumbar region. A simple incision will
suffice to evacuate the abscess. If, however, sup-
puration continues and septic symptoms reappear,
it indicates either an accompanying empyema or
insufficient drainage, or, finally, a persistence of the
original focus. Such conditions require more ex-
tensive operations. The ideal method of opening a
subphrenic abscess, no matter what its origin may
be, is by one of the last two methods, viz., resection
of ribs over the area of suppuration with or with-
out opening of the pleural cavity. If it is neces-
sary to open the pleural cavity several. methods can
be employed. If possible, the diaphragmatic pleura
should be sutured to the costal pleura. If there is
much bulging of the diaphragm it is best to aspirate
some of the pus lying beneath it before suturing.
If it is impossible to bring the diaphragm to the
chest wall the general pleural cavity can either be
walled off with gauze or a larger portion of the
ninth and tenth ribs can be resected.
7. Local Arteriosclerosis. — Fremont-Smith
remarks that arteriosclerosis is frequently in its in-
ception, a local disease dependtnt on acute or chronic
infections. Its final lesion is controlled by the ex-
tent of primary vessel injury and the success or fail-
ure of natural reparative processes. Arterial hyper-
tonus exists in some instances independently of arte-
riosclerosis, and may or may not produce or be asso-
ciated with causes which produce cardiac vascular
phenomena. Arteriosclerosis exists independently of
arterial hypertonus as both a general and a local'dis-
ease, and the absence of hypertension must not be
regarded as security from dangers arising from ar-
terial degeneration.
MEDICAL RECORD.
March j, igo8.
1. The Opportunities of a Great Medical Society,
By Thomas E. Satterthwaite.
2. Report of Three Years' Work at the Sea Breeze Hos-
pital for the Treatment of Surgical Tuberculosis in
Children,
B}^ Leonard W. Ely and Brainerd H. Whitbeck.
3. Some New Facts Regarding Heart Disease,
By Wachenfeld.
4. - "The Flowers that Bloom in the Spring"' — With Varia-
tions and Digressions. By W. B. Konkle.
5. A Plea for the Correction of Uterine Displacements,
By Frank H. Hancock.
3. Some New Facts Regarding Heart Dis-
ease.— -Wachenfeld says that it has been stated
that the general tone of a normal heart can be in-
creased through a course of gymnastics, and that
this would improve the strength of the contractile
514
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
elements of that organ. This appHes also to the body
muscles, and against it the following may be said :
Every human being is endowed at birth with a max-
imum ability to develop his musculature. The mus-
cles, including the heart, can develop only to the ex-
treme limit of this ability. The condition necessary to
a healthy maximum muscular development is normal
metabolism; this simply means the conveyance of
normal nutrient substances to the muscle cell, and
normal removal of waste. This is important, as not a
single cell in the entire body receives its nourish-
ment other than through the lymi)li channels. The
Ivmphatic clefts reach directly ever_\- cell of all the
organs in the economy. The cajjillaries, however,
reach only to the clefts. W'c must, f(jr this reason,
and for many others which do not come within the
scope of this work, regard the l\ niphatics as the car-
riers of cell nourishment. The force which propels
the Ivmph within the closed system of channels is
mainiv derived from muscular energy. For these
reasons active muscular work, or passive, massage,
is necessary to healthy metabolism. Absorption of
the nutrient moving material within the lymphatics
can take place properly only when muscular relaxa-
tion and contraction normally alternate. Excessive
muscular exertion causes congestion of lymph. The
author has in mind, in making this statement, the
lymph stagnation often seen in the muscles of the
legs after long marches, and the same condition in
the arm after protracted fencing bouts. The heart
performs always as much work as the nutrition of
its cells will allow. Overstraining of the heart —
and each muscular act intensifies and accelerates its
work — must lead not only in the normal, but particu-
larlv-in the diseased organ, to congestion of its lymph
channels. We can, however, stimulate metabolism
of the diseased heart if we increase to a maximum
the period of rest between the contractions and re-
tard its action. For these reasons digitalis, rest in
bed, and thermal baths act invigoratingly upon the
diseased heart, whereas it is always, and in any case,
harmed or damaged by gymnastics.
5. A Plea for the Correction of Uterine Dis-
placements.— Hancock remarks that statistics
show that the fecundity of the American woman is
below that of any other woman of the world, the
average number of children being as low as 2.5 per
marriage. Discounting the large number that insist
upon defeating nature's great purpose, there are still
a multitude seeking relief from sterility. Flexions
do not cau.se sterility by mechanical obstruction, as
formerly supposed. Spermatozoa will pass any point
that will permit the exit of menstrual blood, but the
attending endometritis is a factor. Sims found fifty
per cent, of his cases of sterility were associated
with dysmenorrha>a, or really en<lometritis. In
cases not due to infection endometritis results from
interference with the circulation, with its attendant:
phenomena, proliferation of the glandular structures,
and Icucorrhoca. The epithelium that develops is of
poor quality and embryonic in character, on account
of venous congestion occurring in place of the arte-
rial blood that supplies the normal endometrium,
giving a shaggy, thickened, mushy surface, which
the villi of the impregnated ovum cannot readily
penetrate, as they must do if the ovum is firmly
planted and properly nourished. Again, the ex-
cessive secretion pouring from the utricular glands
is apt to wash away the ovule, just as it often sweeps
out of the uterus the spermatozoa ascending to the
distal end of the tube. Nature arranged that the
spermatozoa should be deposited in the vaginal vault
and that the cervix should be immersed in this sper-
matic fluid, and any alteration of this arrangement
is at least, as Bissell observes, "discouraging to fe-
cundation" and should be corrected.
BRITISH MEDICAL JOURNAL.
February 22, iqoS.
1. Some Abdominal Tumors Simulating Malignant Dis-
ease, and Their Treatment, By A. W. M. Robson.
2. Surgical Aspects of Subphrenic .\bscess,
By H. L. Barnard.
^. Observations on the Incidence and Spread of Cancer,
By G. L. Che.\tle.
4. A Form of Oral Filter to Be Worn During Operations
by all Persons Inside the Operating Room,
By G. E. Duncan.
5. Appendicitis at Sea : With Remarks on the Surgical
Equipment of the Mercantile Marine,
By A. E. Johnson.
I. Pseudomalignant Abdominal Tumors. —
Robson, from a considerable experience of abdom-
inal tumors that have simulated malignant growths,
but which, arguing from the sequel of events and the
ultimate complete recovery of the patient, must prob-
ably have been inflammatory, concludes that such tu-
mors are much more common than is generally sup-
posed. Guarded prognoses should more frequently
be given in the case of abdominal tumors having the
appearance and feel of cancer, and even having the
clinical signs and symptoms. The writer cites a
number of instances of inflammatory tumors of the
colon in which resolution occurred. The pathology
of the cases was probably a chronic infiltrating coli-
tis, possiblv associated with pouches lodging faecal
matter, or niav be simply due to infection spreading
througli the intestinal walls. Two forms are com-
monly described, chronic adhesive colitis, in which
the onset is usual)}- acute, and chronic infiltrating
colitis or oroctitis, in which the onset is insidious
and the progress slow. Both are associated with pro-
gressive constipation and with great loss of flesh
and strength. The fact that cancer is complicated
with inflammation makes a positive diagnosis ex-
tremely difiicult and at times impossible, but fortu-
nately the treatment of securing physiological rest
by operation is curative if the disease fortunately
turns out to ];e a jirimary inflammation and not sec-
ondary to growth. Chronic tuberculous disease of
the ca?cum may closely .simulate cancer. The liver
is not infre(|uently the site of simple tumors sus-
pected to be malignant, and if they are associated
with rapid loss of flesh and more or less jaundice,
the diagnosis of cancer is very apt to be made. The
urili r re|)orts a number of cases of simple abdom-
inal tumor simulating malignancy, all going to sup-
port the proposition that, if the diagnosis is doubt-
ful and the patient is at all in a condition to bear
operation, exploratory laparotomy should be per-
formed. Not only may a removable cause of the
jaundice be discovered, but it may fortunately hap-
pen that, even if the diseases appear to be incurable
on exposure, the operation per sc may have some
hitherto unexplained influence leading to recovery.
March ,4. 1908.] PITH OF CURRENT LITERATURE. 515
Such exploratory operations, if undcrtatccn with
proper care and skill, are almost devoid of danger,
so that, even if no real good can be done, no serious
harm can follow.
2. Subphrenic Abscess. — Barnard has ana-
lyzed seventy-six cases of subphrenic abscess, and
among his findings are the following: About one
third the cases were due to perforating gastric and
duodenal ulcers. In the majority of the cases due to
giistric ulcer the perforation was on the anterior
wall of the stomach and near the lesser curve. The
septic matter escaped direct into the left anterior in-
traperitoneal space and the abscess was localized
there. About one sixth of the cases were due to appen-
dicitis, which may infect the subphrenic fossae in four
ways : i. As a part of an acute general jx-riti mitis. 2.
By a more or less slow and direct extension uj) the
lumbar peritoneal fossa;, from the pelvis. 3. Through
the medium of the portal vein, as a part of iivlcphle-
bitis. 4. By lymphatic extension fa) up the right
retroperitoneal cellular tissue, or (b) up the lym-
phatics aroun^l the deep epigastric arter\ to the fol-
ciform ligament. Another one sixth of the cases
was due to h}-(latid and tropical abscesses of the
liver. As a liver abscess enlarges it tends to thin
out the liver substance over it and comes to the sur-
face. In the majority of cases the right anterior in-
traperitoneal space is infected, the layers of the cor-
onary ligament being pushed aside until the dia-
phragm forms a considerable part of the up])er
boundary of the abscess. The diagnosis of a sub-
phrenic abscess is not really difficult if the examina-
tion is conducted in an orderly and complete man-
ner, as follows: i. (a) History. In manv of the
CTses due to gastric ulcer there is a characteristic
history of dyspepsia and h;ematemesis, in those due
to appendicitis of previous attacks, and in the case
of tropical abscess of the liver of foreign residence
and of having suffered from dysentery, malaria, or
typhoid fever. The duration varies from one day to
sixteen months, but averages eight weeks, (b) On-
set. The great majority of intraperitoneal subphre-
nic abscesses begin with an acute perforation into
the peritonfeum, whilst extrai)eritoneal collections of
pus below the (li;i])hragni result from a spreading
cellulitis and are tliereforc slower in their begin-
nings. Pain is nearly alwaxs the first svmptom of
the onset of a subphrenic abscess, and is referred in
every case to the situation where the abscess forms.
In perforative cases it is sudden, severe, and stab-
bing. Vomiting is the next sxmptom in point of
frequency and time, and is almost restricted to those
subphrenic abscesses which originate in a perforative
peritonitis, and especially to gastric and duodenal
cases. Nausea, hiccough, collapse are occasionally
observed at the onset, which may also be preceded
by a period of obstinate constipation. When the ab-
scess becomes well localized septic diarrhrea nearlv
always appears. Hfematemesis and meheria are usu-
ally due to hjemorrhage from a gastric or duodenal
ulcer, but occasionally they arise from a chronic and
insidious subphrenic abscess which has ruptured into
the stomach and has then become acute in its pro-
gress. 2. General signs and symptoms. In ncarlv
all_ cases an examination of the general symptoms
points to the presence of a collection of pus below
the diaphragm. The tongue is dirty and dry, the
face pale and muddy. In most cases there is pro-
fuse sweating, with weakness, d\s])n(ca, and no ap-
petite. Wasting is a ver\ constant n-n, and there
is usually a profuse si])tic diarrhd-a. I'V'ver is al-
ways present, but may l)e slight in amount. Chills
occur in about one se\entli of tlte ca^-s, and are a
verv fatal sign. Leucoc\ tosis is presi^-nt in all cases,
the polymorphonuclear leucocxles bring greatlx in-
creased. In two out of three caso due to hydatids
of the liver, eosin ophilia was n<jte(l. 3. Abdominal
signs and symptoms. An abdominal swelling is
present in the great majr^rity of the cases. This
swelling does not descend on respiration, because it
is adherent. The part formed by adhesions is rigid,
tender, and dull on percussion : thai formed by pus
in contact with the abdominal wall is scarcely ten-
der, bulges and fluctuates, and is dull on percussion.
Where gas is present a tympanitic area is formed, high
up in the epigastrium as a rule, and over the liver
dulness, amphoric and coin sounds can be obtained,
and the tympanitic area travels around the chtst as
the patient is rolled over. In onl\- a very few of the
cases is the liver dulness lost. 4. Thoracic signs and
symptoms. These are present in most cases, the
conditions indicated being those of compression, and
inflammation of the base of the lung and pleura,
namely: (a) Displacement of the lung upwards and
obliteration of the lower pleural angle. ( b ) Dry
pleurisy, (c) Pleural ef¥usion. (d) Compressiori
of the lung. (e) Consolidation of the lung. ( f )
•More or less bronchitis at the base. The most fre-
quent association of signs is dulness, with diminu-
tion or absence of breath sounds, vocal resonance,
and tactile vocal fremitus. 5. Local signs. These
are found over the abscess and encroaching upon
the thorax or abdomen or both. In many cases the
abscess causes a visible bulging of the thorax or a
definite swelling in the abdoinen. The circumfer-
ence of the thorax may be greater on the side of the
abscess, and deep tenderness is sometimes present.
In the only case in which the x rays were used, the
abscess showed as a deep shadow. The proper use
of a good aspirating needle on the operating table
and under a full anaesthetic is the most certain means
of diagnosis we possess. The onlv safe rule in tho-
racic operations is to follow the needle : it is useless
to make a large opening and admit air to the pleura
unless pus is present. Xeedling should never be
abandoned until it is certain that no pus is present,
but a promiscuous search for pus with an inefifective
syringe is dangerous and deceptive. Of the seventy-
six cases investigated forty patients lived and thirty-
six died, a case fatality of 47.4 per cent. Twelve
patients were not operated upon and all died, a fa-
tality of 100 per cent. Of the sixty-four operative
cases, 24 patients died, a fatality of 37.5 per cent.
Posterior operations gave the best results. Half the
avoidable deaths could be attributed to the fact that
the condition was not diagnosticated, the other half
to the absence of exact and detailed knowledge of
the localization and character of subphrenic ab-
scesses on the part of the surgeons. With a perfect
opportunity, knowledge, and technique the seventy-
six cases might have been treated with an ideal fa-
tality of no more than 16 per cent.
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
LANCET.
February 22, igo8.
1. The Pyogenetic Activities of the Pneumococcus (Eras-
mus Wilson Lecture), By J. W. H. Eyre.
2. Considerations Concerning the Functions of the Stom-
ach and the Operation of Gastroenterostomy,
By H. M. W. Gray.
3. Night Blindness, By J. H. Parsons.
4. A Case of Aneurysm of the Femoral Artery in a Man,
Aged Seventj'-eight Years, in which Suppuration
Took Place from Pneumococcal Infection: Recovery,
By H. H. Clutton and L. S. Dudgeon.
5. Three Cases of Poisoning by Carbonic Oxide; One
Recovery, By R. S. Pearson.
6. A Method of X Ray Examination in Cases of Urinary
Calculus, By C. J. Morton.
7. "Dammed Circulation" and "Interrupted Circulation."
A Note in Nomenclature, By W. Ewart.
2. Gastric Function and Gastroenterostomy.
— Gray sums up his conclusions as follows: i.
The cardiac and pyloric portions of the stomach
are distinct in development, stntcture, function, and
pathology. 2. During the early stage of gastric di-
gestion the pyloric portion is normally empty and
tonically contracted. When food has attained a
proper chemical reaction in the cardiac enlarge-
ment it passes iiito the p\'loric portion. 3. Bearing
this in mind, care should be taken in performing
gastroenterostomy to make the opening in the stom-
ach wall within the pyloric portion as near the
pylorus as possible. This will then, if the stomach
■ has not irremediably lost its muscular power, pro-
vide against an "imcontrolled escape of the acid
gastric contents," which is asserted to occur in
cases of gastroenterostomy. If pyloric spasm is
present the stomach will act as a safety valve and
remove the spasrn. If pyloric stenosis exists the
natural condition of things will be most nearly ap-
proached and the "regulating action" of the
pylorus, so necessary to perfect digestion, be most
nearly approximated.
3. Night Blindness. — Parsons states that com-
plaint of inability to see in the dusk or foggy
weather at once suggests the disease commonly
known as retinitis pigmentosa. In this disease
there is comparatively little disturbance of central
vision. Examination of the fundus shows in the
early stages in young patients a zone of character-
istic retinal pigmentation in the neighborhood of
the equator ; both peripheral or central to this zone
the retina looks almost or quite normal. The pig-
mentation shows characteristic spots shaped like
bone corpuscles, and aggregations along the peri-
vascular sheaths of the retinal vessels. The pro-
gress is usually slow, and central vision is seldom
lost by direct extension of the disease, as before this
happens a posterior cortical opacity usually appears
in the lens. Another chronic form of night blind-
ness is met with which differs from retinitis pig-
mentosa in that it is stationary. This form is al-
ways hereditary, and shows no gross changes in
the fundus. Syphilitic pigmentary retinitis consti-
tutes a group of cases intermediate between idio-
pathic retinitis pigmentosa and congenital night
blindness. Malnutrition occasionally causes night
blindness, it having been observed in alcoholism,
scurvy, malaria, and nephritis, most of the patients
having reflex blepharospasm (photophobia) in
bright snnlight. Another group of cases are those
associated with jaundice; it may be noted that bile
salts are a solvent of the visual purple.
6. X Ray Diagnosis of Urinary Calculi. —
Morton, in order to diagnosticate urinary calculi by
means of the x rays, tests the efficacy, quantity, and
penetrating quality of the rays, uses a set of cal-
culi of known composition and size as a means of
testing the actual effects of the rays while they are
passing through the patient. If the rays are of
sufficient strength, shadows of the individual cal-
culi will appear on the fluorescent screen, and can
be readily recognized. If no shadows can be seen
it means the rays are inadequate.
7. "Stauungshyperamia." — Ewart suggests
that the term "dammed circulation," introduced by
Thomas thirty years ago, be used to express in
English the German Sfauungshyperdmie — the con-
dition produced by Bier's method of treatment.
"Passive congestion," "passive hypersemia," and
"stasis hypera-mia" are all unsatisfactory.
"Dammed circulation" is even more strictly inclu-
sive than the German term, for it implies the
manoeuvre and covers the entire field of its opera-
tions, arteries, veins, capillaries, plasma, and lym-
phatics.
LA PRESSE MEDICALE.
February 75, igo8.
1. The Lower Segment of the Uterus. General Idea of
Its Anatomy, Physiology, and Patbology,
By Cyrille Jeannin.
2. Do the X Rays Produce Cancer? By G. Haret.
3. Palpation of the Normal Stomach, By G. Fischer.
4. Artificial Parabiosis in Cold Blooded Animals,
By R. RoMME.
I. The Lower Segment of the Uterus. — Jean-
nin studies the lower segment of the uterus during
pregnancy, during labor, and during involution.
The term lower segment is obstetrical rather than
anatomical 'or surgical ; the puerperal uterus is di-
vided into three zones, the body, the lower seg-
ment, and the neck, and these correspond in the
nonpregnant uterus to the body, the isthmus, and
the neck, hence the lower segment or intermediate
portion corresponds to the isthmus. The ana-
tomical study is followed by a brief glance at the
physiology and pathology of the lower segment.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT
February 18, 1908.
1. The Experiment on Animals in the Diagnosis of Tu-
berculous Disease, By Weber.
2. Concerning the Frequency of Tuberculosis and the Two
Principal Points of Time of Infection in Infancy,
By Sehl3.\ch.
3. Comparative Valuation of the Tuberculin Reactions in
Childhood, By Reuschel.
4. Influenza Bacilli in the Bronchi, By Wohlwill.
5. Zinc Chloride for Carcinoma, Carbolic Acid for Endo-
metritis, By V. Herfk
6. Concerning the Value of .Arthrodesis, By Vulpius.
7. Carbonic Hand and Foot Baths, By Pototzky.
8. A Case of Vaginal C?esarean Section Performed on Ac-
count of a Rare Indication, By VoiGT.
9. Concerning a Case of Qiolesteatoma, By Beyer.
ID. An Improved Nozzle to the Irrigator for Washing Out
the Vagina, By Scheunemann.
Ti. Two Cases of Tetanus after Gynrecological Operations
Treated with Antitoxine, By Zaciiarias.
12. The Separation 'of Cholesterine in the Bile and Its Sig-
nification in the Pathogenesis of Gallstones {Con-
cluded), By Bacmeister.
13. Obituary of Eduard Buchner, By Gruber.
March 14, 190S.]
PITH OF CURREXT LITERATURE.
14. The Royal Gynaecological University Poliklinik at
Munich, By Klein.
15. Medical Support of Quackery, By Kantor.
1. Experimental Diagnosis of Tuberculous
Disease. — Weber considers that the finest and
most positive demonstration of tuberculosis is the
experiment in which supposedly tuberculous mate-
rial is injected beneath the skin of the abdomen of
an animal. If the material is tuberculous the lym-
phatic glands in the neighborhood of the injection
can be felt at the end of from ten to sixteen days,
and if these glands are removed the presence of
tubercle bacilli within them can be easily demon-
strated. This experiment is of special value in dis-
tinguishing bacilli found in the urine, smegna, and
tubercle, a? these resemble each other in their
staining and morphological properties.
2. Frequency of Tuberculosis and the Two
Principal Times of Infection in Infancy. — Sehl
bach comes to the following conclusions: i, The
frequency of tuberculosis in infancy does not in-
crease from month to month, as has been assumed
heretofore, but a retrogression takes place toward
the ends of the first and of the second years. 2.
Correspondingly there are two principal points of
time of infection, (a) in the first three months of
life, crade infection; (b) creeping, or dirt, or smear
infection about the turn of the first year ; the possi-
bility of an infection at any other time cannot be
excluded. 3, In general, artificially fed children
fall victims to tuberculosis most quickly, those par-
tially breast fed next, and those nursed wholly at
the breast latest. 4. This shows the great pro-
tective power of the mother's milk against tubercu-
losis.
4. Influenza Bacilli in the Bronchi. — Wohl-
will. on account of the pandemic of influenza, insti-
tuted a bacteriological examination of the smallest
bronchi in 158 cadavers. Seventy-five of these had
suffered from phthisis, twenty-six from acute in-
fectious diseases, and fifty-nine from various other
diseases. The bacteriological examination re-
vealed the Streptococcus pyogenes sixty-eight
times; the Staphylococcus pyogenes aureus thirty
times ; albus six times ; the Diplococcus lanceolatus
forty-six times; the Bacillus pncumonice Fried-
laender seven times; the Bacillus coli communis.
the Bacillus pyocyaneus, the Bacillus diphtheria.
each twice : the Bacillus influensa twenty - nine
times ; influenza like rods five times ; and three
kinds of not identified germs. In ten cases no mi-
croorganisms were found. Further analysis showed
that the influenza bacillus was present in 22 per
cent, of the cases of pulmonary tuberculosis, in
both of the patients that had died of measles, and in
the six patients that had died of whooping cough,
but in only one of the adults that had died from
various other diseases.
6. Arthrodesis. — Vulpius deals with the indi-
cations for this operation in the various joints, and
then pictures some remarkably good results which
he has been enabled to obtain in this manner.
8. Vaginal Caesarean Section on Account of a
Rare Indication. — Voigt reports a case in which
he performed this operation because of a severe
bronchial asthma with secondan,- cardiac insuffi-
ciency and pulmonarj^ oedema, aggravated by the
physiological compression due to the nine months'
pregnant uterus, which imminently threatened the
life of the mother.
9. A Case of Cholesteatoma. — Bey.er reports a
case of cholesteatoma which varied from the usual
in several of its characteristics. The patient was
a soldier under observation, who was seized with
an acute suppurative inflammation of the middle
ear, on account of which parecentesis was per-
formed, and later, as the suppuration proved not
amenable to treatment, a radical mastoid operation.
This final operation revealed the cholesteatoma,
which may therefore be said to have run a symp-
tomless course.
THE MILITARY SURGEON.
March, igo8.
1. Plague in India, By Arthur Hexry Moorhead.
2. Benjamin Rush's Directions for Preserving the Health
of Soldiers, with a Note upon Surgeon Ebenezer
Alden, By Hexrv Pelolze de Forest.
3. Notes and Statistics of the Year's Service at the United
States Marine Hospital, San Francisco, Cal.,
By H. W. Austin.
4. Instruction in the Physiology of the Circulation,
By Robert S. Woodsox^
5. In Memoriam : The Necrologj- of the Association for
1907. By Samuel C. Stantox.
6. Heat Exhaustion on Men-of-War,
By Middletox Stuart Elliott.
I. Plague in India. — Moorhead remarks that
the future outlook and likelihood of the spread of
the plague to Europe and America is a ver\- serious
problem. The disease in eleven years has spread
through the whole of India, and will no doubt next
infect Afghanistan and Persia. These countries lie
in the northwest frontier and are adjacent to Rus-
sia in Europe, and they are not likely to adopt more
vigorous measures than have been done in India.
Wherever the plague carrying rat and its flea, the
Pnlex Chcopis, can travel and live the disease is sure
to spread to, and it will reach Europe overland. He
describes his method of treatment as follows : All
plague patients were removed to plague hospital on
the boundary of cantonment. This hospital con-
sisted of several grass built huts with open doors
and very free ventilation. The sick attendants, hos-
pital assistants, and staff of servants lived in tents
close by and were never changed. A guard over
this hospital prevented all communication and per-
mitted only the medical officer to enter it. All con-
tact cases were isolated in a camp for ten days and
daily inspected, and their clothing disinfected in
perchloride of mercury lotion and placed in the sun
for four hours. A medical inspection of the whole
regiment and followers was made daily, and an airing
of all kit, clothing and bedding in the sun for four
hours daily. All the barracks occupied by the men
and followers' huts were disinfected by swabbing
floors and walls with strong perchloride of mercury
or carbolic, and later were all lime washed. All
huts in which cases of plague had occurred had the
roofs removed and remained in this state for a cou-
ple of months. All dead rats found were burnt with
kerosene oil and special disinfection of places in
which they occurred. Inoculation was not carried
out. Rat destruction was not employed, and the
importance of the flea not then known. Buboes
which mostly were in the groin were opened and
dressed antiseptically. The present treatment is to
5i8
PROCEEDINGS OF SOCIETIES.
[New Vokk
Medical Journal.
open and drain tliese at a very early date and pre-
vent the pciscin entering the s}'steni. The strength
of the patient was kept up by suitable diet, and stim-
ulants were freely given. He also tried internally
large doses of carbolic acid freely diluted. Doses
as large as eight grains twice or thrice daily were
given. The rest of the treatment was symptomatic.
l~(_ir the \'ery high fever, ice to head, cold packings,
and iced water enemata were employed, and stimu-
lants freely .given in the event of cardiac failure.
The result, the author says, was very satisfactory,
as the mortality was only 65 per cent. .\ curious
after effect in many patients was an affection of
speech and difficulty in articulating words.
'§xamVmp at ^atutm.
MEDICAL .ASSOCIATION OF THE GREATER CITY
OF NEW YORK.
Special! .17. ■,•/;;,.<;, Held in the Borou-h of the Bronx.
January 6, igoS.
Dr. N. B. Van Ettex in the Chair.
On Some Newer Aspects of Cardiac Pathology.
— The first paper of the evening was read l)y the
president, Dr. Tiiom.\s 1-'.. S \ i 1 F.R tiiw.\iTE, on this
subject. The first i)o>iti\v a(h-ance in cardiac
l)atho!ogy, he s;ii(l, was made in 1826, when
Laennec announced his discovery of fatty degen-
eration as a nuocardial disease: but it was not until
a qtiarter of a eenUir\ later th;il the matter was
turned to ])racticrd account. in Ouain's classical
monograph, published in 1850. Laennec's fatty de-
.generalion was distinguished clinically from the
fatt\- deposition of the fat heart, and five years
later Stokes elaborated still further the topic of
myocardial diseases, being the first to recognize the
fattv hearts ,,|" inl"een'\-e disease, especially typhus
and tvphoid. Ikuing referred to the discoverv of
the svphilitic heart bv Ricord and the "irritable
heart" by Da Costa, he stated that in 1876 Bristow
showed that the interstitial cardiac tissue, as well
as the muscle tissue, of the hearl, might also be
implicated, so as to cause a diffuse myocarditis. .V
further advance was made when Romberg, in 1891,
traced myocardial disease to diphtheria and scarlet
fever, while Huchard, in 1891, showed that the
source of the interstitial inflammation might be the
coronar}-. vessels.
.\s a result of these pioneer discoveries and of
still later investigations, we had now reached a
point where it could be said with confidence that
all tox.-emias, whether acute or chronic, some dys-
crasias and hyperpyrexias, if long continued or se-
vere, and some other conditions which would be
mentioned later, produced definite morbid changes
in the heart walls, evanescent or permanent, as the
case might be. To the j)rofession at large these
matters were comparatively new, since attention
hitherto had been mainly directed to diseases of the
endotardium and pericardium ; yet the condition
of the heart substance was always of paramount
importance. .\s regarded the term myocarditis,
however, we had to face the fact that its use had
led to some misa[)prehcnsion. It had been and was
still employed somewhat indiscriminately for vari-
ous myocardial diseases, and to most physicians
myocarditis implied an inflammatory process, and
did not therefore include the degenerative afJections
of the heart. The speaker then offered a new
classification of these diseases, as follows: i. Acute
parenchymatous -myocarditis. 2. ' Acute diffuse
myocarditis, including the tuberculous, syphilitic,
and suppurative forms. 3. Chronic myocarditis, in-
cluding all the diffuse inflammatory changes men-
tioned. 4. The fat heart. 5. The fatty heart. 6.
Hypertro])hies, whether due to severe exercise,
vascular diseases, blood disorders, neurotic dis-
turbances, or possibly pregnancy. Dilatation could
not be called si disease, being an incident which
might occur at times in any of the varieties
enumerated.
Some such classification as that now given, he
thought, was essential to a clear conception of myo-
cardial diseases, thou.gh many of the pathological
phenomena mentioned might be interconnected in
any single instance. A parenchymatous myocar-
ditis might be but die first indication of the dif-
fuse form, even though the character of the paren-
chymatous change was not fully understood. It
might, however, be presumed, from what we knew
of similar processes elsewhere, that parenchy-
matous changes might produce not only necrosis of
the muscle cells, but, in addition, fatty degenera-
tion, leading to dilatation and possibly rupture of
the heart. Harlow lirooks had recently published
statistics showing that, of 457 cases of which he
had persi)nal ])ost mortem records, where death was
the result of cardiac lesions. 330 showed evidences
of diseased heart walls, while in many others myo-
cardial (liseases figureil as additional subsidiary
factors. Vet these diseases, which were largely re-
sponsible for the fatal endings, were not recognized
during life in a ver\ considerable number of in-
stances. Of these -| 57 cases, in 214 there was
chronic endocarditis, in 31 acute endocarditis, and
in (\(> ])cricardial diseases; so that, throwing entire-
ly out of account the myocardial affections which
complicated endocardial and pericardial disease —
which might of themselves have been the cause of
death in many and possibly most instances — 12(^
out of the 427, or al)out twenty-eight per cent, were
believed to have been due to uncomplicated degen-
eratixi ilisease of the heart walls. From his own
clinical records. Dr. .Satterthwaite would say that
in fort\ -fi\ e per cent, of his deaths in heart cases
degenerative cardiac changes were the principal
predisjmsing causes of death, though at the end
in very many uraemic poisoning was an active con-
trolling factor. The statistics gathered by Roemer
in Liebermcister's clinic corresjionded very closely
with these figures. Tlie later statistics of Romberg
showed that chronic cardiac insufficiency (by
which he meant chronic myocardial disease) was
the most common heart affection, and if we added
to the chronic forms the uncomplicated acute myo-
cardial forms associated with infections, dys-
crasias, anfemias, etc., it could readily be seen that
myocardial diseases were very much more common
than valvular disea.ses. Moreover, as other organic
heart diseases were comparatively rare, and as
myocardial disease was apt to complicate valvular
March 14, 1908.]
PROCEEDINGS OF SOCIETIES.
disease, it could well be asserted that myocardial
diseases were more common than all other forms
of heart diseases combined, in the sense that they
entered as a factor.
The speaker then took up in detail a number of
the forms of myocardial disease, as given in his
classification, and some of the statements made were
as follows: P'arench}mat()us alteration was the
earliest form of muscle metamor])hnsis. Schmalz,
whose experience was ver}- large, had sometimes
found acute myocarditis within a few days after the
inception of an attack of diphtheria, and myocardial
disease occurred in sixteen per cent, of his diph-
theria cases. Diphtheria was now held to be the
most frequent cause of chronic myocarditis, .\cute
myocarditis occurred also in rheumatism, tubercu-
losis, amygxlalitis, measles, lobar pneumonia, erysip-
elas, epidemic influenza, gonorrhcca, and septic pro-
cesses, and according to present o])inion the ])athn-
logical changes noted were due either to the tnxines
of the diseases named or to the continued high tem-
perature. In alcoholism a similar condition had been
noted, though in this instance the alcohol itself was
probably the poison to which the myocarditis was
due. We could not dissociate these parenchymatous
changes clinically from those of that acute myocar-
ditis which was a somewhat later event in the patho-
logical chain. This, however, presented a different
microscopical picture, and what we were ])lcased to
call acute myocarditis was found, from the micro-
scopical appearances, to consist of a diffuse inflam-
mation in which the muscular tissue was onl\ one of
the several elements involved. Occasionally abscess
resulted, usually causing death ; but the acute form
of myocarditis might pass over into the chronic
form. When hypertrophy of the muscular tissue oc-
curred, more or less dilatation was likely to follow.
Clinically speaking, if the left margin of the heart
did not extend beyond the nipple, it was not regard-
ed as an alarming sign, but if an inch bexond that
point, the prognosis was unfavorable. Tn mild cises
the dilatation (as shown b\' the apex beat) would
not reach to the nipple. If, now, in the course of
or following typhoid, diphtheria, or any of the acute
or chronic toxcemias referred to, the pulse became
weak and irregular, no matter what its rapiditv, nt-
tention should be directed to th.e probability of the
occurrence of some myocardial affection. If there
were prjecordial distress or cyanosis, dvspnciea, and.
in extreme cases, anginoid attacks, the dii gnosis of
acute dilatation could be made with a reasonalilc de-
gree of probability: which would amount to cer-
tainty if it was found that the heart's dimensions had
suddenly become enlarged. While the parenchy-
matous change might result in acute diffuse myo-
carditis, and possiblv terminate in fatty degenera-
tion, it was found that in most cases the condition
disappeared with convalescence, and that, so far as
could be determined by clinical tests, the patients
wholly recovered.
Among the prominent causes of cardiac hyper-
trophy were arteriosclerosis, congenitally small ves-
sels, scoliosis, Graves's disease, and the neurotic
heart of hysteria. During the first stage of h\-per-
trophy there was a gradual increase in the several
tissues of the heart walls, with increase of the size
of the muscle cells and perhaps increase in the num-
ber of cells. This stage was completed when the
hypertrophy had become suflicient to propel the
blood column with the recjuired amount of force, and
the second stage was marked by a return of the ac-
tion of the heart and pulse to their normal condition.
This condition, so f;ir as we knew, might continue
indefinitel\-, Init if the heart l)egan tn dilate further
the afl'ection then entered upon the third stage, a
period of failing compensation, temporary or perma-
nent. In many cases a further access of dilatation
would mean cardiac failure, and, if no relief was
given, sudden death. The heart of the athlete was
more apt to suft'er from excitement or sudden strain
than the normal heart, so that he must always be
put upon his guard against sudden dilatation.
The two terms, fat heart and fatty heart, implied
some semblance in intimate structure, and while it
was true that, pathologically speaking, thev were
closely allied, there was in micomplicated cases little
clinical resemblance between them as to natural his-
tor\', diagnosis, prognosis, and treatment. In the
fat heart there was a deposition of fat between the
muscle fibres or bundles, wdiile in the fatty heart
there was a fatty degeneration of the muscle fibres
themselves. The character of the conditions exist-
ing in cardiac syphilis was now prettv fully under-
stood. The disease might aff'ect any part of the
heart, and also the pericardium. The gumma or
some tertiary infiltration was most often found, and
might occur as late as ten or twelve years after the
primary lesion. Cardiac syphilis was also one of
the manifestations of the hereditary form of the dis-
ease. The condition \-ielded promptly to treatment
if recognized before destructive changes had taken
place.
Instruments of Precision in the Management
of Diseases of the Heart. — This paper (to be pub-
lished ) was read by Dr. Louis F. Bishop.
On the Diagnosis of Diseases of the Heart. —
This paper was read by Dr. Willi.vm H. Porter
(sec page 486).
On the Use of Drugs in Diseases of the Heart.
— Dr. Reynold Webb Wilcox, to wdiom this topic
had been assigned, said that the wave of therapeutic
nihilism wdiich had of late years affected the profes-
sion was happily now passing awav. Substitution
and failure to observe the requirements designated
by the pharmacopoeia were punishable by severe
penalties, so that reliance could be placed on the
qualities of the remedies at our disposal. The work
of the heart w. as determined to a verv large extent b\-
th.c condition ( 1 ) of the \essels, (2) of the cardiac
walls, and (3) of the vahes, the last named being
of less importance than the others. Having referred
to the value of the h^emoglobinometer and the
sphygmomanometer, he expressed the opinion that
the question of the blood pressure was as yet only in
its infancy.
We could regulate the rapidity and the force of
the heart's action, and there were three groups of
remedies at our command for accomplishing this. As
long ago as in 1783 Withering had correctly laid
down the indications for the use of digitalis as a
rapid low tension pulse, with venous congestion.
This drug was indicated, in general, when the car-
diac action was rapid and feeble, with low arterial
tension, and contraindicated when the cardiac action
520
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
was strong and arterial tension high. DigitaUs,
however, had its defects, and the principal of these
was the pronounced vasoconstriction which it pro-
duced. This had led to the study of strophanthus
as a substitute for it in suitable cases. Strophanthus
was found to be less of a vasoconstrictor and to have
a more rapid action, and experience had shown that
it should be used in place of digitalis in children and
the aged. Dr. Wilcox had personally worked out
its efifects in the laboratory and in his clinics with
the sphygmograph. Convallaria was untrustworth\',
and adonidine, another drug of the digitalis group,
which was now official, was objectionable on account
of the renal irritation which it caused. Erythro-
ploeum, or sassy bark, the last of the five drugs of
this group, was a remedy which slowed the pulse
and raised the tension, just as digitalis did. He had
made a careful study of its effects, and the results
obtained in the laboratory were confirmed by clin-
ical observations. As compared with -digitalis, it
was decidedly more active in slowing the pulse, but
it was irritating to the stomach. As a vasocon-
strictor it had a greater effect than digitalis ; in fact,
as great as digitalis and ergot combined. While it
was less cumulative than digitalis, it was also rather
less reliable. Its use, he thought, should be con-
fined to those cases of fairly competent heart with
low vascular tension, in which it would show its
effects more markedly and rapidly, and to those
cases in which digitalis had lost its usefulness or had
entirely failed. In the most recent revision of the
pharmacopoeia the tincture of strophanthus and all
potent tinctures had been placed at the uniform
strength of ten per cent.
Then came the class of drugs which weakened the
heart's action and slowed its rate, such as aconite
and veratrum. Both these were of great value in
appropriate cases. Veratrum was especially esteemed
by the obstetricians, and the danger from its use had
been much exaggerated, since it always gave ample
warning when it was being carried too far. There
was only one drug which both increased the force
and frequency of the pulse, and that was cactus. It
was especially useful in the neurotic heart and the
slow heart. If an active preparation (and such
was readily found in the shops) was used, in ap-
propriate cases, brilliant results might be obtained.
In pulmonary oedema with heart failure the speaker
did not know of any remedy so good as hot coffee
given I)y high rectal injection. By combining with
each dose half a grain of caffeine sodiobenzoate, we
could get along with nnich less digitalis than other-
wise. Strychnine was sometimes of service in car-
diac disease, but one difficulty with it was that pa-
tients readily became habituated to its use. As to
cardiac syphilis, he had himself seen three cases of
gumma of the heart wall, proved to be such in the
dead liouse. In this disease he had found that arse-
nic iodide had sometimes proved efficient in cases in
which the usual antisyphilitic remedies had entirely
failed.
Dr. Robert E. Coughlin, of Brooklyn, said that
he was interested in the subject of Dr. Satterthwaite's
paper, l)ecause for a number of years he had given
some time and thought to the subject as related to
athletes and the strain put upon their hearts in ath-
letic contests. As medical men we were not par-
ticularly interested in the professional athlete only
so far as his life might become an example to the
growing young, many of whom sought oilr advice
when about to enter into athletics. The subject was
very important when we considered that young
schoolboys were at present put into contests by the
public school instructors where their hearts were put
to a very severe strain, as in sprinting and running
a distance. There was great chance of injury being
done to the heart by violent exercise in competitive
games. His opinion was that the young exercised
probably too much, and those over forty and fifty
years not sufficiently. Take, for instance, he said,
the case of the oarsman, Edward Hanlon, who died
a few days ago. It was said that he was the most
graceful oarsman who ever pulled an oar, and that
he lost only six races out of 200. He also held the
record for a four mile row. This man died at the
age of fifty-two, after a two days' sickness, of pneu-
monia. It was known to be a fact that he took no
exercise for ten years preceding his death. Was it
not reasonable to suppose that, after an interval of
inactivity, no exercise being taken for this period,
myocardial disease was really the cause of his suc-
cumbing to pneumonia, in which the heart was
markedly taxed? Twenty years ago Richardson, of
London, pointed out a white spot on the heart, or
myocarditis, in connection with the deaths of ath-
letes. It was interesting to note that the reader of
the paper described very well the pathology of this
condition. Persons over forty ought to try to keep
up their cardiac muscle, so that no degeneration
should take place. Especially was this so in men
who had overdeveloped their cardiac muscle. Take
the instance of Weston, who at the age of sixty-nine
walked from Portland, Maine, to Chicago, a re-
markable feat for a much younger man to perform.
Weston had kept up his cardiac muscle development
uninterruptedly, as in an interview he professed to
have taken regular exercise every day of his life.
The great thing was to maintain our cardiac muscle
and not allow degenerative changes to take place. A
young man could map out his life's work in this re-
spect, and it was our duty to explain to him what he
should do to keep up his cardiac muscle once he en-
tered into the athletic life.
Dr. Edward E. Corxw.vll, of Brooklyn, thought
the water sphygmomanometer of Dr. Bishop very
ingenious, but unlikely to be of much practical use
on account of the height of ceiling required, to say
nothing of the step ladder. The sphygmomano-
meter which he preferred for general use was the
Kaplan. This he found convenient and portable,
though it frequently spilled out mercury, which,
however, could he easily replaced if one carried a
small bottle of mercury with him and a medicine
dropper. .\s for the therapeutic nihilists to whom
Dr. Wilcox referred, he was inclined to doubt if
they existed to any important extent among regular
physicians. He was inclined to believe that thera-
peutic nihilism was a bugaboo invented by those
who were in the habit of using drugs excessively
and without clear indications. These, who he
thought constituted a very numerous class, he sus-
pected of stigmatizing the advocates of conserva-
tive and rational therapeutics as therapeutic nihil-
ists in order to distract attention and criticism
March 14, 1908.]
PROCEEDINGS OF SOCIETIES.
from their own prejudiced therapeutics. He was
much pleased with Dr. Wilcox's remarks on stro-
phanthus, and remembered reading in Wilcox and
White's Materia Mcdica Dr. Wilcox's account of
the action of that drug, which was the best descrip-
tion of it he had ever seen. He had used that drug
extensively, and had learned to value it at least
equally with digitalis. He thought its range in
cardiac therapeutics was greater than that of digi-
talis, and, though not exactly coextensive, its ac-
tion included much of the range of digitalis. He
had found by clinical experience that for restoring
lost compensation in valvular diseases in children
it was better than digitalis, and in conditions of
high blood pressure and in dilated hearts with
greatly weakened myocardium he though there was
no question of its superior value. He thought that
failure to get good results from its use were often
due to the fact that it was given in too large doses,
and that the doses advised in the textbooks were
too large. He had also observed clinically that,
while it was generally much less irritating to the
stomach than digitalis, there were a few people who
seemed to have an idiosyncrasy in regard to it,
who got less therapeutic benefit from its use and
more irritation of the stomach than they did from
digitalis. A preparation of digitalis which he had
found useful in bad cases and for which he wished
to say a good word was the soluble digitoxin re-
cently put on the market. In regard to cactus, of
which Dr. Wilcox spoke favorably in spite of the
investigations on the action of this drug and ad-
verse conclusions recently reported in the Journal
of the American -Medical Association, he felt that
he could say little, not having had sufficiently ex-
tensive experience with it. He was inclined to be-
lieve, however, that it was a cardiac sedative of
value in functional disorders of the heart. Conval-
laria he had found so vastly inferior to digitalis and
strophanthus that he seldom used it. He was
pleased that Dr. Wilcox omitted to make mention
of sparteine, if, indeed, his silence was not meant
for assent, for he thought we could well afford to
ignore sparteine as a heart stimulant when we had
so many better ones.
Dr. Satterthwaite said he would like to ask
Dr. Wilcox's opinion of the value of adrenalin in
cardiac failure.
Dr. Wilcox said that Dr. W. H. Bates was the
first to demonstrate the effect of suprarenal ex-
tract on the eye and the larynx. He himself had
been the first to make sphygmographic tracings un-
der the use of suprarenal extract, and these cor-
responded very closely with those obtained with
adrenalin later. Adrenalin should be employed for
shock, he thought, only when this was due to dila-
tation of the bloodvessels of the splanchnic area.
Unless it was used with great caution, a weakly
acting heart might be overwhelmed.
Dr. Satterthwaite said he had heard of cases
in which death was caused by adrenalin. Under
its use the pulse ran up very high at first, but soon
sank below normal, and he therefore regarded it
.as a very dangerous remedy. On the other hand,
he had found the ordinary suprarenal extract dis-
tinctly useful at times, and was accustomed to em-
ploy it in his practice in appropriate cases.
Dr. William H. Porter thought there could be
no doubt that the heart muscle underwent fibrinpus
degeneration after an individual accustomed to tak-
ing active exercise stopped this. In affections of
the heart, as in other diseases, the object of drugs
in all cases was, not to cure the disease, but to en-
able Nature to continue the functions which had
been interrupted. We should first seek the cause
of the trouble, and then direct our remedies toward
the removal or modifying of existing conditions.
As regarded drugs, in many cases of cardiac dis-
ease he had come to place special reliance upon
benzoic acid and caffeine.
WESTERN SURGICAL AND GYNECOLOGICAL
ASSOCIATION.
Seventeenth Annual Meeting Held in St. Louis, December
30 and 31, 1907.
The President, Dr. Charles W. Oviatt, of Oshkosh, Wis.,
in the Chair.
{Concluded from page 473.)
The Association or Confounding of Appendi-
citis with Other Diseases in the Female Pelvis. —
Dr. A. E. Bexjamix, of Minneapolis, said that any
inflammatory disease within the abdomen primarily
involving one organ might from continuity or con-
tiguity result in other tissues or organs being in-
volved. The blood supply of the abdomen and pel-
vis was such that infectious microorganisms might
be carried from one diseased organ to another,
thereby starting a similar disease in a part through
which this infected blood flowed. The lymphatics
mig-ht also convey disease to organs in the line of
their distribution. The nerve supply of the organs
of the lower abdomen and pelvis and their sym-
pathetic relationship were such that pain might be
referred to localities not affected. It was possible
for more than one form of disease to exist within
an abdomen simultaneously, and the symptoms to
become quite complex in consequence. Besides ac-
tual disease, there might exist a misplaced position
of one or more organs, thereby changing the symp-
toms considerably, or resulting in contiguous organs
being affected because of this displacement. Also
the misplaced position alone might cause distress
which resembled some actual form of disease. The
character of the disease, the variety of each form of
disease, the number of organs involved, the asso-
ciated displacement of organs, the temperament, en-
vironment, and vocation of the individual were all
factors to be considered in summing up the case. A
careful personal history, a thorough physical exami-
nation of the individual, with the aid of chemical
and bacteriological investigation, and a searching ex-
amination with all the apparatus at command, i. e.,
the cystoscope, proctoscope, microscope, and x ray,
would clear up the majority of cases. In certain
cases, if no positive diagnosis could be made, there
might be clear indications for operative interference
to cure the disease. In complicated cases a thorough
search through a proper sized opening should be
made to terminate the symptoms complained of, and
a record of all findings made for future reference.
Torsion of the Omentum. — Dr. W. W. Grant,
522
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
of Denver, reported an interesting case of torsion of
the omentum, and said that in view of the most
common association of this diseased condition with
hernia, it liecanie a matter of unnsnal interest in this
particul;ir case as to its possible connection with
hernia in earliest childhood. He was positive, from
the nature and character of the adhesions, the con-
dition of the intestine, and the absence of any indi-
cation of disease, past or present, of every other
organ or i)art, tliat it was of long standing. It
seemed ])nssil)le tli;it it could have dated from the
existence m hernia in childhood without causing in-
testinal obstrnclion or torsion at an earlier date.
The vonnting might have been due to a momen-
tary ( »l)struction from volvulus due to the adhesion
and intestinal peristalsis.
In reviewing the literature, Dr. Grant found that
sixty-one cases had been reported. He agreed with
Richardson, of Los Angeles, that strangulation of the
omentum from pressure or adhesions did not con-
stitute torsion and should not be classed as such.
Onl}- seven cases were entirely intraabdominal. His
own made eight. The torsion might be single or
double, but usually the former. In the intraabdomi-
nal cases the symptoms closelv resembled those of
acute appendicitis, and up to the present time there
had ])rol)abl\- ];)een a diagnosis of the latter. Even
in h( rnia the abdominal symptoms were pronounced
in most cases. The tenderness and dulncss at an
early period covered a wider area than in appendi-
citis; yet, if on the right side, both subjective and
objective symptoms simulated those of acute ap-
pendicitis. If hernia existed, one should especialh'
be on guard as to the diagnosis. The historv of tor-
sion of the greater omentum justified this precau-
tionary statement, and he hoped that these sugges-
tions might l)c accepted as timely. He bjclieved this
case was unicpie in the fact of a portion b^ing com-
pletely amputated l)y torsion from the body of the
omentum and fixed by adhesion to one point of in-
testine and to nothing else.
Lymphatic and Portal Infections Following
Appendicitis. — Dr. Rdlaxd Hili,, of St. Louis,
reported an interesting and unique case illustrating
these infections, and said that in the present stag -
of surgical knowledge we were almost absolutely
helpless in the presence of some of the severe forms
of infection when the infecting organism had once
passed into the general circulation. It went without
saying that earl\' removal of the appendix should be
the keynote in all case.^, togctlier with an attack,
whenever possible, upon any fo.us that might form.
Considering what had been acconi])lished along the
lines of serum therapy, the remarkai)lc effects of
antitetanic serum as a ]irophylactic of tetanus, and
the miraculous results of dii)htheria antitoxine, it
did not seem too much to hope and expect that ex-
perimental medicine would soon offer specific agents
which would nullify the effects of the various patho-
genic organisms when once they had been intro-
duced into the blood.
Extrauterine and Intrauterine Pregnancy of
Five Months, with Operation and Death. — Dr.
D. C. Hkoc K.MAX, of Otlumwa, Iowa, reported the
case of a woman, five months pregnant. An attempt
was made to remove the ectopic sac by abdominal
section, lint the parts were so vascular that he was
obliged to desist. Futhermore, the patient was so
debilitated from vomiting that he did nothing-
further. But in ten days he opened the sac from
below, removed the fcetus, and packed the cavity
with gauze, intending to remove the placenta later.
Lterine h;emorrhage and pains occurred on the third
day, and the woman died two days later from ex-
trauterine and uterine h;emorrhage. He asked
whether a better method could be suggested.
Dr. D. W. Bash.nm, of A\'ichita, Kan., reported
a case of hernia of the appendix, wdiich w-as compli-
cated with appendicitis, and reviewed the literature
on the subject.
Sexual Perversion as an Accompaniment of
Prostatic Hypertrophy. — Dr. J. F. Percy, of
Galesburg, 111., believed that the old prostatic, who
show ed aberrant sexual activity, was in a large pro-
portion of cases suffering from a ps3'chosis rather
than senile dementia, to which the symptoms were
usually atlriljuted. Under the influence of the irri-
tation from his enlarged prostate he might commit
all forms of sexual crime, and after removal of his
prostate his functional sexual aberration disap-
peared and he remained cured. This phase of the
diseased prostate opened up the possibility of a
more rational study of the pelvic environment of
the prostate gland m the sexual perverts among
men, old and yotmg. Many old prostatics were in
insane asyltuns and many of them were in the Gov-
ernment and State soldiers' homes, as well as in
the various county almshouses. The strain of sex-
ual excesses from early life until old age, the inti-
mate connection maintained between the prostate
gland and the sympathetic and the cerebrospinal
nerves, the tmknown secretory functions of the
prostate gland along physiological lines — these all
made prominent the fact that with the hypertrophied
prostate could be had a class of symptoms referable
to the sexual system wdiere the mental life of the
sufferer carried him close to the border where in-
sanity had its dominion, and which could be cor-
rected by the aid of surgery.
Intestinal Obstruction. — Dr. B. Merrill Rick-
i-:tts, of Cincinnati, contributed a paper on this sub-
ject, in which he defined obstruction as the stoppage
or blocking of a canal or opening in the body, due
to any n\ the numerous causes. The symptoms,
such as vomiting, ]jain, distention (symmetrical or
asymmetrical), sweating, collapse, rigid parietes,
and toxaemia, one or all, might be present in any
form of obstruction in the large as in the small
bowel. These being facts, why should exploration
be delayed, when simple incision through the ab-
dominal wall was done without mortalitv? Should
exploration and direct digital and ocular examina-
tion of the abdominal viscera be delayed in intes-
tinal obstruction, because experiments, reports,
"symposia," and discussion had failed to explain
.satisfactorily its aetiology, symptoms, and treat-
ment? Intestinal obstruction probably had a higher
immediate mortality, with or without surgical inter-
vention, than any of the surgicopathological dis-
eases. The nonmechanical type without operation
had a supposed mortality of ninety per cent, when
not complicated with general peritonitis, and from
sixty to eighty-four per cent, with operation. This
mortality in postoperative obstruction exceeded that
March 14, 1908.]
BOOK NOTICES.
523
of preoperative obstruction of the same degree,
whether of the mechanical or nonmechanical or
septic type. This increased mortahty was <kie to
the added surgical trauma, and especially to the
anjesthetic. In the mechanical type the mortality
was given as one hundred per cent, without opera-
tion, and from fifty to eighty per cent, with opera-
tion. This difference was probably due to the
advantages of palpation and the Rontgen ray in
detecting neoplasms and foreign bodies, which v>-ere
Its most common cause ; hence earlier surgical
meastires might be resorted to. In the septicc^peri-
tonitic type without operation the mortality was
generally given as one hundred per cent., while
with operation it was somewhat less. There were
certain forms of obstruction with or without infec-
ti(jn that had been considered invaria])ly fatal. Ii
this was so. there was nothing to be lost ni upeni.ig
the abdomen. If, after opening the abdomen, an
imperfect mechanism within could be made perfect
withotit destruction of the nerve or blsml su))pl_\ .
in the absence of infection, surely many more
patients would recover ; even with many forms of
infection this was probablv so. But if the patient
became exhausted from vomiting, pain, or want (.;t
nourishment, with cr without infection of any kind,
the nil rtalit} v > ul 1 l)e proportionately high. Pain,
distention, and \ ur.iting were always alarming, and
the majoritv of patients went on to death in spite
of every effort to relieve them. Intoxication had
not \et been proven to be the cause of death in any
given case of obstruction. If patients with olistruc-
tion indicated by one or more sym])tc:ms were
opened at the onset, under crdinary jirecantions, the
mortality would be less than if the\- were ^qxTated
upon late in the attack. The element of dela\ in
surgery was more serious than the element of ag-
gressiveness. In no other surgical condition was
this statement more fully verified. The most skilled_
operators had many times opened the abdomen for
a condition made apparently certain by one or m. ire
symptoms, and found one entirely different. If this
was sanctioned in other lesions of less importance
within the abdominal cavity, why could not explora-
tion for obstruction based tipon one or more symp-
toms be undertaken ? This would determine the
character and degree if obstruction was present. If
it was not present no special harm wotild ensue. If
the character or degree or both were believed to be
fatal, the remedy should be applied, regardless of
its character, because that verdict was onlv an opin-
ion, not an established fact.
Dr. A. A. Kerr, of Salt Lake City, contributed
a paper in which he discussed obstructions of the
common bile duct, and reported a case in which he
performed cholecystostomy, partial gastrectomy
with posterior gastrointestinal anastomosis, chole-
cystenterostomy, and enteroanastnmnsis.
The following officers were elected ior the ensu-
ing year: President, Dr. Grant, of Denver;
vice-presidents. Dr. Willard Bartlett, of St. Louis,
and Dr. Harry A. Sifton, of ^lilwaukee : secretary-
treasurer. Dr. Arthur T. Mann, of IMinneapolis :
executive council. Dr. C. H. Mayo, of Rochester,
Minn., and Dr. J. F. Percy, of Galesburg, 111.
Minneapolis was selected as the place for holding
the next annual meeting, on December 29 and 30,
1908.
[IVe publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers- are likely to -be interested.]
Maternity. By Harrv D. Fry, M. D., Sc. D., Professor of
O'ostetrics, Medical Department of the Georgetown Uni-
versitj', etc. New York and Washington : Neale Pub-
lishing Company, 1907. Pp. 220.
This book seems to be intended primarily for the
laity. Its teachings are sound in the main, and the
author's style is agreeable; consequently, it is likely
to be of real service to many women, provided they
do not accept it as embodying "the truth, the whole
truth, and nothing but the truth." as the laity are very
apt to do. Such implicit acceptance of any medical
writing is ajit to make tlic reader think he knows all
about the subject and to render him contentious in
his intercourse with the physician. .\ general pre-
cept has often to be fitted to the ca.se in hand, and
this the laity rarely comprehend.
The book treats of hygiene in its particular appH-
cation to the female sex. with special attention to
menstruation, pregnancy, and childbirth, dealing
also with the care of infants. .
Outlines of Psychiatry. By Willi.xm .\. White, M. D..
Superintendent of the Government Hospital for the In-
sane, Washington. D. C. etc. New York : The Jour-
nal of Nervous and ^Mental Disease Publishing Compam-,
1907.
In publishing this book the author disclaims any
intentirin of .ittering a >uli->titute for larger and more
l)retentiou> works, lie will have it that he is merely
providing a "hel]3ful guide" for his stttdents and a
\\( irking knowledge for young physicians. This is
modest, but we believe that, whatever his conscious
purpose ma\- have been, the author has wrought
more deeplv than he thought. To give a working
basis for the student of mental diseases, that is, to
provide him with such matter and manner of
thought as will lead to the acquisition of the power
of independent observation and logical interpreta-
tion is scarcely a light undertaking. To a science
like morbid psychology, involving at every turn a
comparison of pathological mentalization with the
normal operations of the mind, the task of laying
down adcfpiate principles is beset with manifold diffi-
ctilties ; and. furthermore, when it isborne in mind that
many who read are by nature inejjt, being but poorly
provided with the faculty of subjective analysis, the
wonder is that any can be found among us with suf-
ficient powers of exposition to reach the comprehen-
sion of the average mind. Yet we believe that Dr.
White has succeeded ; that he has written a book of
manifest helpfulness to those desirous of going about
the study of mental diseases in a systematic and ra-
tional manner, and that no student can read his book
thoroughly without gaining a point of view which,
with the aid of subsequent cultivation and experi-
ence, will confer a sense of capacity — more or less
according to original endowment — for independent
and useful observation.
The author prefaces his treatise with a brief chap-
ter on the nature of the human mind. This is sat-
isfactorily done ; but we believe that the account of
psychical operations could have been appreciably
lengthened without detriment or interference w^ith
the general plan of the book. Upon this follow out-
524
CORRESPONDEKCE.— THERAPEUTICAL NOTES.
York
M ..)KAL Journal.
givings on the definition of insanity ; classification
of mental disorders ; the causes of mental disorders
and their treatment ; and then two rather lengthy
chapters on symptomatology and the examination
of the insane. The last named chapter is admirably
done ; and even though all the tests are not always
applicable, and a few of them perhaps debatable,
most of them are well conceived and obviously in-
forming.
Likewise to be commended are the chapters on
Dementia Prjecox, Paranoia and Paranoid States,
and Manic-Depressive Psychoses.
The author acknowledges his indebtedness to Dr.
Smith Ely Jelliffe for valuable hints and to Dr.
Shepherd Ivory Franz for the preparation of the
substance of Chapter VII — that on the examination
of the insane, to which wc have already favorably
adverted.
Notwcndige Reformcn der Unfallversiclicrnngsgcsetze.
Nach einein auf der Wanderversammlung der siidwest-
deutschen Neurologen und. Irrenarzte in Baden-Baden
am i. Jiini, 1907, erstatteten Referate. Von Prof. Dr.
A. HocHE, Freiburg, i. Br. Halle a. S. : Carl Marhold,
1907.
The (jerman laws referring to accident insurance,
which force every employee to be insured and every
employer to insure his help, was made the subject of
a dissertation by the author at a meeting of the So-
ciety of Southwest German Neurologists, held in
Baden-Baden on June i, 1907. He points out sev-
eral features of the laws which should be changed
from the viewpoint of the neurologist.
BOOKS. PAMPHLETS, ETC.. RECEIVED.
Die Schuppenflechte (Psoriasis vulgaris) und ihre Be-
handlung. Von Dr. S". Jessner, Konigslierg i. Pr. Zweite
Auflage. Wiirzburg: A. Stuber, 1908. Pp. 39. (Price, 70
marks.)
Annual Report of the Board of Trustees of the German
Hospital and Dispensary in the Cily of New York for the
Year 1907. Pp. 100.
Geschichte der Laryngologie in Wiirzburg. Von Pro-
fessor Dr. Otto Seifert, Wiirzburg. Wiirzburg: A. Stuber,
1908. Pp. 68. (Price, 3.50 marks.)
Fourth Annual Message of John Weaver, Mayor' of the
City of Philadelphia, with the Annual Reports of the Di-
rector of the Department of Public Health and Charities
and Chief of the Bureau of Health, for the Year Ending
December 31, 1906. Issued by the City of Philadelphia,
1907. Pp. 236.
Textbook of Otology for Physicians and Students. In
Thirty-two Lectures. By Fr. Bezold, M. D., Professor of
Otology at the University of Munich, and Fr. Siebenmann,
M. D., Professor of Otology at the University of Basle.
Translated by J. Holinger, M. D., of Chicago. Oiicago :
E. H. Colgrove Co., 1908. Pp. 314.
Bericht iiber den XTV. internationalen Kongress fiir
Hygiene und Demographic, Berlin, 23-29 September. 1907.
Band I. Berlin : August Hir'-rliw ald. iqdS. Pp. 314.
Persona] Hygiene in Tropicil .ind .Seniitropical Coun-
tries. A Popular Manual Written for the Use of For-
eigners Residing in the Philippines. Cuba, and Other Por-
tions of the Tropics. By Isaac Williams Brewer, M. D.,
Member of the American Society of Tropicil Medicine.
Philadelphia: F. A. Davis Company, 1908. Pp. 130.
The Diagnosis and Treatment of Pulmonary Tuberculo-
sis. By Francis M. Pottcnger, A. M.. M. D., Monrovia,
('alifornia. Medical Director of the Pottenger Sanatorium
for Diseases of the Lungs and Throat. Professor of Clini-
cal Medicine, Medical Department, University of Southern
California, etc. New York: William Wood & Co., 1908.
Pp. .377.
A Textbook on Prescription Writing and Pharmacy.
With Practice in Prescription Writing, Laboratory Exer-
cises in Pharmacy, and a Reference List of the Official
Drugs Especially Designed for Medical Students. By
Bernard Fantus, M. D., Professor of Materia Medica and
Therapeutics, College of Physicians and Surgeons of Chi-
cago, etc. Second Edition, Thoroughly Revised and
-Adapted to the Eighth (1905) Edition of the L^nited States
Pharmacopoeia. Chicago: Chicago Medical Book Com-
pany, 1906. Pp. 404.
' 'SlistfUans.
The Plan of the Campaign Against Tuberculo-
sis.— Much has been said of late in the press con-
cerning the campaign for the prevention of tuber-
culosis which has been inaugurated by the State
Charities Aid Association. The press has indeed
been, as it always is, most generous in giving to
this movement the full and complete publicity
which is indispensable to any effective work of a
broad educational nature. Some few misconcep-
tions, however, have become current. Chief among
these is the fact that people have been led, through
a misinterpreted newspaper report, to believe that
a million dollars has been donated for the purpose
of conducting this campaign, and that therefore the
localities in which the educational campaign is be-
ing conducted are to assume no responsibility so far
as financial support is concerned. In the light of
this report it may be well to state definitely the plan
and method of the State Charities Aid Association
in this movement. The associatioir is not merely
spending mone\' in arousing a wave of sentiment
without a permanciu basis in fact. On the con-
trary, the educational movement in any given local-
ity is not begun until the facts concerning the dis-
ease are well known. This knowledge is obtained
by means of an extended and thorough investiga-
tion : First, of the vital statistics, in order to de-
termine the exact death rate and the prevalence of
the disease : second, as to the provisions for relief
and care of needy consumptives ; third, as to the pre-
ventive measures llial are in force ; fourth, as to the
means which are em])loyed for acquainting the
wage earners and the people in general with the
present knowledge as to the treatment of pul-
monary tuberculosis ; fifth, as to general hygienic
measures having special value in the prevention of
tuberculosis, such as the adequacy of the building
code, of supervision of food supplies, of supervision
and regulation of public lodging houses, etc. It
is not until after the investigation has revealed all
the facts touching u];on these points that the active
part of the educational campaign in any given lo-
cality is undertaken. It is then that the series of
public meetings is held, in connection with the
tuberculosis exhibition of the State Department of
Health and the facts concerning the means of pre-
vention, treatment, and cure of this terrible dis-
ease are as widely disseminated as possible, and
sentiment aroused through the aid of the press.
And all this is done only for the purpose of directing
the interest and enthusiasm thus aroused into defi-
nite channels of action, which will result in a mate-
rial saving of life in each community. At the close
of this active educational campaign a local commit-
tee of the State Charities Aid Association is formed
for the purpose of continuing the work of educa-
tion and securing the adoption of definite measures
for the prevention of this dread disease. Thus, a
OFFICIAL NEWS.
5-5
permanent organization is formed and a definite
programme is adopted, and from this moment the
burden of the expense rests upon the locality. The
fund under which the State Charities Aid Associa-
tion is operating is available onl\- for the purpose
of initiating the movement in the various localities,
and the impression which has been given out. to the
effect that the permanent movement is to be sup-
ported by the association, has unfortunately done
some harm. For example, in the city of Troy,
after the erroneous million dollar announcement
had gone out, the permanent local committee when
it attempted to raise money was confronted with
the impression that nothing whatsoever was ex-
pected of a locality. In order to dispel this erro-
neous impression, Robert de Forrest, the vice presi-
dent of the Russell Sage Foundation, made the
statement that the mone}' for starting the campaign
against tuberculosis had been contributed from the
Sage Foundation, "but that it was expected that
the war against the disease would be supported in
future by voluntary contributions from the difller-
ent localities to be benefited." In order that the re-
sults of this campaign may really be fruitful, the
localities in which it is to be waged must awaken
to the fact that the lesponsibility rests upon them,
and each community must prepare to shoulder it,
as doubtless it will if the situation is made perfectly
clear. — From a publication of the State Charities
Aid Association.
Buried Sutures and Ligatures. — Chase says that
it is demonstrated by practice and by bacterio-
logical tests that catgut can be uniformly rendered
sterile and such treatment need not impair its
proper tensile strength. A wise selection of plain or
chromicized catgut will secure bloodvessels and
pedicles and maintain proper approximation of sur-
faces for an ample period in which permanent union
is established. Unabsorbable material for buried
sutures and ligatures has no superiority over cat-
gut and its use subjects the patient to avoidable
and frequently serious complications. The over
tense tying of ligatures and sutures is a serious and
not an imaginary evil. The only advantage that
fine silk has over catgut, if such really exists, is in
intestinal suturing, and that of very delicate tissues.
Simplicity of application and safety of use lead me
to urge on all operators the use of absorbable ma-
terial for buried ligatures and sutures, within the
limitations heretofore expressed. — The Journal of
the American Medical Association, Xovember 30,
190;.
Paraffin Tumor. — In the Deutsche Militccrccrzt-
liche Zeitschrift Dr. Goldenberg remarks that while
the number of devices and, methods adopted by
European soldiers for the purpose of freeing them-
selves from the military service are too numerous
to mention, yet a new method which is pathological-
ly very interesting deserves to be reported. The
patient, a Russian Pole, twenty-two years of age,
came to his clinic for the extirpation of a tumor the
size of a goose egg, located on the left jaw. The
hard irregular outline of the tumor, firmly adherent
to the skin and bone, would have led one to the
-diagnosis of sarcoma had the patient not given the
liistory that seven months ago a physician had made
repeated injections of paraffin to produce a tumor
in order to render him unfit for military service.
An attempt to remove the tumor had been made
before, but was abandoned on account of haemor-
rhage. The enucleation of the paraffin was difficult
because it was not sharply defined, and was sur-
rounded by an induration rich in bloodvessels. It
was intimately connected with the skin. Micro-
scopically the tumor presented a meshwork of
strings, the meshes of which contained small gran-
ules of paraffin, small cell infiltration, and a few
giant cells showing an attempt of the tissue to ab-
sorb the foreign substance. The kind of paraffin
could not be ascertained. Two other patients had
paraffin injected into the scrotum and were rejected
as unfit for military service on account of scrotal
elephantiasis. Paraffin may produce total blindness
and cause infarcts of the lungs. Quacks and physi-
cians of low mental calibre can only be credited
with such practices. It would seem that a govern-
ment relying on conscription for the public defence
would be fully justified in taking the most severe
measures against alleged physicians of this class. —
Through TJie Militarx Surgeon. Xovember, 1907.
Public Health and Marine Hospital Service
Health Reports:
The following cases of smallpox, yellow fever, cholera,
and plague have been reported to the surgeon general,
United States Public Health and Marine Hospital Serz'ice,
during the zecck ending March 6, 1908:
Smallpox— I' nited States.
Places. Date. Cases. Deaths.
Jan. 26-Feb.
.Feb.
.\rizona — Bisbee
California — Los Angeles..
District of Columbia —
Washington Veh.
Illinois — Chicago Feb!
Illinois — Danville Feb.
Illinois — Springfield Feb.
Indiana — Klkhart Feb.
Indiana — Indianapolis Feb.
Indiana — La Fayette Feb.
Indiana — JIuncie Feb.
Kansas — Kansas City Feb.
Kansas — Topeka Feb.
Kansas — Wichita Feb.
Kentucky — Covington Feb.
Kentucky — Georgetown Feb.
Kentucky — Lexington Feb.
Louisiana— New Orleans Feb.
Maryland — Baltimore Feb.
Massachusetts — ilelrose Feb.
Michigan — Saginaw Feb.
Minnesota — Winona Feb.
Missouri — Kansas City Jan.
Montana — Butte Feb.
North Carolina— Charlotte Feb.
North Dakota — Fessenden Feb.
Ohio — Cincinnati Feb.
Ohio — Dayton Feb.
Pennsylvania — Merian Tan.
Pennsylvania — Pittsburgh Feb.
Tennessee — Knoxi'ille Feb.
Tennessee — Memphis Dec.
Tennessee — Nashville Feb.
N'irginia— King William County ... Feb.
Virginia — Richmond Feb.
Washington — Spokane Feb.
Washington — Tacoma Feb.
Wisconsin — La Crosse Feb.
Smalltox — Foreign.
9- 23 4
10- 24 2
8-22 2
Brazil — Bahia Dec.
Brazil — Para Jan.
Brazil — Rio de Janeiro Jan.
Canada — Winnipeg Feb.
Cape Colony — East London Jan.
China — Hongkong Dec.
China — Shanghai -Tan. 12-19.
Egypt — Cairo Jan. 21-28.
Egypt — Suez Dec. 31-Tan
France — Brest Jan. 25-Feb
28-Feb.
18- Feb.
19- 26. .
I- I5- . ■
II- 18. .
526
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
Jan. 25-Feb. 8.
l-'eb. i-S
Dec. 25-Feb. 8.
Jan. 14-28
z8-Jan. 1 1
-Feb.
France — Paris
Great ISritain — Edinburgh.
Great ISritain — Leith
India — ISombay
India — Calcutta Dec
India — Madras Jan,
Italy — General Jan
Japan — Kobe Jan. i8-Feb.
Japan — Nagasaki Jan. 19-26.
Japan — Osaka Jan. 25-Fcb
Japan — Tokyo Feb. 4
Japan — Yokohama Jan. 25-Feh
Manchuria — Dalnv Jan. 18-25 •
Mexico— ARua-caiirntes Feb. 2-16..
Mexico— Monte rey Feb. 9-16. .
Russia — Moscow Jan. i8-Feb
Russia — Wari-aw Nov. i6-Dec
Spain — Denia Jan. 25-Feb
Spain — \'alencia Feb. 2-9. . .
Turkey— Con-.tantin(iple Jp.n. 27-Feb
Brazil — ilanaos l.iii. i8-Feb
Brazil — Para ,hin. jj-i-'eb.
Ecuador — Iluifira l'\l). 4-1 1 . .
Venezuela — Ciudad liolivar Jan. 1-31..
603
, . 46
• • 3
Cholera- Insular.
Philippine Islands — Manila
Philippine Islands- — Mariqv
India — Bombay .
India — Calcutta .
India — Rangoon
Plagh
Hawaii — Hilo.
Jan. 11-18..
Insular.
Feb. 24
Plague — Foreign.
Brazil— Bahia Dec. 28-Feb.
Brazil — Rio de Janeiro Jan. iq-26..
China — Hongkong Dec. 28-Jan.
Egypt — .Mexaiidria Jan. 19-Feb.
Egj'pt Provinces —
Assiout Jan. 25-Feb.
Fayoum Jan. 29-Feb.
Gurgeh
Minieh Jan. 28-Feb. 2.
India — General Jan. 4-11
India — Bombay Jan. 14-28
India — Calcutta Dec. 28-Jan. 11
India — Madras Jan. 11-24
India — Rangoon Jan. 11-18
Jaiian — Osaka
Turkey- Bagdad
Feb. 4-6 20
"Dec. 28-Jan. iS
Public Health and Marine Hospital Service:
;/(/ ilulics of com-
>j the United States
•';'iic for the seven
1 report to Passed
rman of a board of
Official liM nj Juiiii^r:; ,1/ .v/,//j..«.n- ,
niissiciicd oiid wnicfiniinssvincd nHiccrs
Public Health and Mannc Ilosfilal Sc
days cndiiiii March 4, i(jo8 :
Com FORI , X. C, Pharmacist. Directed
.Assistant .Snriicon V. Ci. Ileiser, cha
exaniiiKr-., tn (Ictcrniinc liis fitness for promotion to
tlie .tirade nf pharmacist n[ the second class.
E.AKI.F.. !!. !!.. I'assed .Assistant .Surgeon. Granted leave of
absence for live days, from .March 2, [90S.
Foster, M. H., Pa.ssed Assistant Snrgeon. Leave of ab-
sence granted for two montiis and eleven days, from
October 9, 1907, amended to read two months and nine
days.
Ke.\tlev, If. W., .'\cting Assistant Surgeon. Granted leave
of absence for five days from February 26, 1908.
Keex, W. n.. Pharmacist. Granted leave of absence for
twenty, days, from March 6, T908.
ScoFiELD, R. B., Passed .Assistant Surgeon. Granted leave
of absence for three fiMin Ferbuary 23, 1908,
under paragraph 191, Sm-\u .; Regulations.
Board Convened.
A board of medical officers was convened to meet in
Manila, P. I., upon the call of tlie cliairman, to e.\amine
Pharmacist N. C. Comfort for promotion. Detail for the
board: Passed Assistant Surgeon V. G. Ilciscr, chairman;
Passed .^ssistant Surgeon T. B. McClintic, recorder.
Army Intelligence:
Official list of changes in the stations and duties of officers
serviuji in the medical department of the United States
Army for the iveek ending March 7, igoS:
Banta, W. p.. Captain and Assistant Surgeon. Advanced
to the rank of captain, from February i.S, 1908.
BiRMiNGHA.M, H. P., Major and Surgeon. Now on duty
as medical inspector, Army of Cuban Pacification, will
report in person to the commanding general of that
Army for duty as chief surgeon, relieving Lieutenant
Colonel Blair D. Taylor, deputy surgeon general.
LeGakde., L. a., Lieutenant Colonel and Deputy Surgeon
General. Upon arrival in the Lhiited States will pro-
ceed to Denver, Colo., and report in person to the com-
manding general, Department of the Colorado, for
duty as chief surgeon of that department.
^L\BEK, J. L, First I-ieutenant and Assistant Surgeon. Or-
dered to report in person on Tuesday, March 24, 1908,
to Lieutenant Colonel George H. Torney, deputy sur-
geon general, president of examining board. Presidio
of San Francisco, Cal., for examination to determine
liis fitness for advancement.
Sc'OTT. G. H., Captain and Assistant Surgeon. Ordered to
report in person on Tuesday, March 24, 1908, to Lieu-
tenant Colonel George H. Torney, deputy surgeon gen-
eral, president of examining board. Presidio of San
h'rancisco.
Scott, G. H., Captain and .Assistant Surgeon. Relie\ed
from further duty at Fort Duchesne, Utah, and as-
signed to permanent station at Fort Logan, Colorado.
T.v\i.ou, B, D., Lieutenant (".ilmiel and Deputy Surgenn
General. Relieved t
Navy General Hns,
his relief fnim (hil>-
Pacification, will im
the commaiidinL; gei
duty as chief si
1 fiirtlier chit)- at tlie .\rmy and
. Il'it Springs. .Ark., and uijon
chief surgeon. .Army of Cu\a.i
d to Atlanta, Ga., and report {o
il. Department of the Gulf, fov*-
)f that department.
Van Du.sen, J. W., Cajitain and Assistant Surgeon. Now
on leave of absence at Xorwalk. Ohio, will proceed o\\
or Ijefore the expiration of said leave to Fort Crook,
Neb., fur duty.
Navy Intelligence:
Official list of chan^<:cs in Tlie medical corps of the United
States Xary for the leeel: ending March 7, 1908:
G.VRDNEu, J. E., Medical Inspector. Ordered to the marine
recruiting station, Boston, Mass.
Hull, N. F., Passed Assistant Surgeon. Commissioned a
passed assistant surgeon from April 12, 1907.
McDoNELL. W. N,, Passed .Assistant Surgeon. Detached
from the n<i\ al . recruiting station, Chicago, 111., and
ordered to the Hancock.
Puck, R. F. S., Pharmacist. Appointed a pharmacist from
February 24, 1908.
Thompson, J. C, Surgeon. Ordered to report at Washing-
ton, D. C, to the Secretary of War, for special duty.
Wheeler, L. H., Passed Assistant Surgeon. Commissioned
a passed assistant surgeon from April 22, 1908.
Married.
P.MiiMAX l,i;ssi(,, — In Pottstown, Pennsylvania, on
Wedn.-da\. I'eljniary _'()ih. Dr. Morton V. Bachman, of
Philaiii l]iliia, and .Miss Caroline Bleim Lessig.
1 1 A \i \i i:i;[ I Wui F. — In Stillwater, Minnesota, on Wed-
ne>da\, l ilirnarx jdth. Dr. Ambrose Louis Hammerel and
Miss Anna Al.artlia Wolf.
SciiKSLER — CHii'Fin-. — In St. Louis, Missouri, on Mon-
day. February 24th, Dr. Kdwin J. Schisler and Mrs. Lily
Chiplev.
Died.
Chamberlain. — In Aladanapalle, India, on Monday,
March 2d, Dr. Jacob Chamberlain, of New Brunswick, New
Jersey.
DuFLOO. — In New York, on Saturday, February 29th, Dr.
.Armand L. F. Dufloo, aged seventy-five years.
Eaton. — In Des Moines, Iowa, on Thursday, February
27th, Dr. Charles W. ICaton, aged tifty-two years.
GuEENWALt). — In Philadelphia, on Wednesday. February
26th, Dr. Daniel F. Greenwald, aged fifty-five years.
Hughes. — In New Rochelle, New York, on Thursday,
March 5th, Dr. Oliver John Davis Hughes, aged fifty-
five years.
LuEPEKiNG. — In St. Louis, Missoiu-i, on Saturday, Feb-
ruary 29th. Dr. Robert Lucdeking, aged fifty-four years.
M.\i LAV. — In Chambersburg, Pennsylvania, on Tuesda>.
March 3d, Dr. David Maclay, aged fifty-six years.
Ring. — In Olcott, New York, on Saturday, February 29th.
Dr. Charles A. Ring, aged fifty-four years.
Roos.\. — In New York, on Sunday, March 8th, Dr. Daniel
Bennett St. John Roosa, aged sixty-nine years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal rlt Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXVII, No. 12. NEW YORK, MARCH 21, 1908. Whole No. 1529.
Original Cffmmitnitatifliis.
PROGRESS IN GYNECOLOGY FROM A CLINICAL
VIEWPOINT.*
By H. J. BoLDT, M. D.,
New York.
While the advances made in gynaecology during
the last few years are not so numerous as in some
other departments of medicine, yet they are of suffi-
cient importance to be noted.
Time was, not so many years ago, when it was
a common occurrence to have an abundant number
of uterine appendages that were practically normal
presented at medical meetings and exhibited by the
operator as trophies of his skill. Most of the pa-
tients recovered from the operation, it is true, but
what was their physical condition subsequently?
The greater number were not benefited at all : many
of them were made much worse, while onl\' a com-
paratively few were made better. When we seek
for a reason for these unsatisfactory results, we are
inevitably brought to the conclusion that the indica-
tion for the operation was based upon poor judg-
ment; that in reality it did not exist at all. Physi-
cians of many years' experience have passed the
operating furore, and their judgment has been im-
proved by experience, although it has not become
perfect. In those days fifty per cent, of the cases
of pelvic pain without gross palpable lesion in the
pelvis were ascribed by the operating gyn;ecologist
to an inflammation of one or both ovaries, the re-
moval of which was deemed necessary to effect a
cure. The tubes were said to be inflarned, whereas
in reality, from a strictly pathological viewpoint,
they were normal or very nearly normal.
Following the period of indiscriminate extirpation
of the pelvic organs, there comes a period of ultra-
conseWatism, and though conservative procedure
sometii.-'es acts to the detriment of our patients, it
has even then this advantage over radical surgery,
that if the conservative operation does not bring
about a symptomatic cure, a radical operation may
subsequently be done.
Let me illustrate by an example : Take a patient
with bilateral pyosalpinx of the chronic variety.
Nearly all such patients have a chronic metroen-
dometritis, and it is safe to state that they are
sterile. From a theoretical point of view, such pel-
vic organs are useless to the patient. Tf she is
advanced in years, near to the climax, and if the
symptoms arising from the diseased local condi-
tion indicate surgical intervention, then the only
*Read at the February meeting of the New York Academj' of
Medicine.
correct procedure is to do a radical operation —
that is, remove the uterus with its annexa. If,
however, the patient is in her thirties, or even
younger, the psychical effect of such an operation
is likely to be very severe. In the latter case, then,
it is better to exsect the Falloppian tubes, and if a
zone of seemingly normal ovarian stroma is still
present, to exsect also the diseased area of ovarian
tissue, and to implant the apparently normal part
into the uterine cornu, from which the interstitial
part of the tube also should have been excised.
Subsequently, the cure of the metroendometritis
by means of local treatment may be attempted.
With such operation psychical disturbances are
avoided. Should it be shown, after a sufficient
time has elapsed, that the patient is not cured, then
we may resort to a radical operation.
The greater conservatism of operating on the
pelvic organs is also exemplified when operating
for tubal pregnancy. While most operators still
follow the old method of removing the entire an-
nexum of the affected side, a considerable number
have given that up and are content to remove only
the Falloppian tube, retaining the ovary ; while
under favorable circumstances, some operators are
still more conservative, and content themselves
with splitting open the affected tube and depriving
it of the conception product.
On this kind of conservatism of the pelvic or-
gans I think most of the gvn:ecological operators
of experience are agreed. It is not so. however,
with conservative operations in multiple myomata.
While the procedure has been tried frequently, the
results are so far from satisfactorx- that we are
still on the line of experimentation. With pedun-
culated tumors and single interstitial tumors of
moderate size, we have pas-^ed the period of ex-
perimentation, -nnd can with safety do a myo-
mectomy.
With regard to myomatous tumors, we are learn-
ing more from year to year, and are realizing that
they are not so innocent as we formerly thought
them to be.
In operations for cancer of the ivterus we have
done much to advance the curability of the disease
by doing the operation more radically, not relying
upon the extirpation of the affected organ alone,
but going beyond the boundaries of the organ and
exsecting the parametria and the glands, and, in
some cases, even a part of the ureter.
Whether the longevity of patients afflicted with
carcinoma of the cervix is increased by such pro-
cedure, has not yet been settled. It does not seem
possible to remove all the pelvic and retroperito-
neal glands. While I have done the operation a
Copyriglit, 1908, by -'\. R. Elliott Publishing Company.
528 KLATIXG: EARLY DIAG.^
number of times, I am not yet favorably impressed
with it, both because of the magnitude of the sur-
gical intervention, and because, in my opinion, it
is impossible to remove all the invaded glands.
About five years more of work in this direction
should determine the mooted point.
Our knowledge of chorioepithelioma may be
classed among the late achievements in gynaecol-
ogy-. The first description of this malignant dis-
ease was given by the late Martin Saenger. Since
he called the attention of the profession to this oc-
casional transformation of conception product
structures, many exhaustive and valuable articles
on this comparatively new disease have appeared,
and we have learned to recognize it sufficiently
early to save many lives by immediate radical sur-
gical intervention.
\'ery marked progress has been achieved in the
treatment of purulent peritonitis. It has been
proved bv those who have tried the more modern
method of extensive nonintervention that the rate
of mortality is much lower. After the primary
cause of the peritonitis has been removed, no at-
tempt should be made to rid the abdominal cavity
of the purulent secretion by flushing and sponging,
because to remove it all is impossible, and the time
consumed in flushing and sponging is too long
and the traumatism too great. One should content
himself with placing a drain in the cul-de-sac of
Douglas, without any flushing or sponging. Rapid
work is essential. When the patient is put to bed
she should be placed in a semisitting position, the
position suggested by the late Dr. George R.
Fowler.
From that time on, continuous instillation of sa-
line solution should be used, a method advocated
by Dr. J. B. Alurphy. It is certainly marvellous
what a large quantity of fluid is absorbed. I have
found that the best technique consists in taking an
ice water C(H)ler of two <>r three gallons' capacity,
filled with hot saline solution ( 0.9 per cent.). This
is kept at a temperature of about 110° F. by adding
more verv hot solution as needed. The quantity
so added shr)ul(l be noted, so that we may know
how much the patient absorbs. The container is
placed alongside the bed and the rubber tube, with
a small-sized rectal point, is attached. The flow is
regulated by the faucet, and should not be more
rapid than a quick dropping. The nozzle is in-
serted into the rectum, an(J the instillation is con-
tinued steadily, day and night. In one of my cases
fourteen quarts were absorbed in twenty - four
hours.
We have also learned by experience that, in in-
stances of cystocele associated with descent of the
anterior vaginal wall, a simple operation on the
vaginal mucosa, such as some form of anterior
colporrhaphy, does not suffice to cure a patient of
the cystocele, but that it is necessary to separate
the bladder from its cervical attachment and dis-
place it upward, and then attach the vagina to th:it
part of the cervix to which the bladder had been
previously attached.
It would take more time than that allotted on
this occasion were I to consider also the strictly
scientific progress made in gynaecology, and to
consider in detail all of the clinical advances. I
have, therefore, limiteil myself to those achicve-
)S1S OF TUBERCULOSIS.
Medical Journal.
ments which I consider most imf)ortant and bear
strictly on gynaecology.
39 East Sixty-first Street.
POINTS IN THE EARLY DIAGNOSIS OF PUL-
MONARY TUBERCULOSIS.*
By Emmet Keating, M. D.,
Chicago,
Clinical Assistant, Department of Medicine, Rush Medical College;
Physician to the Swedish Baptist Home for the Aged,
Morgan Park.
Medical society discussions of the subject of pul-
monary tuberculosis indicate that it is difficult for
many physicians to erase from their minds the clin-
ical picture of what was formerly conceived to be
an early diagnosis of this disease. Teachers in
medical schools soon learn that students are least
proficient in those subjects of which they have
heard most, prior to their routine consideration. It
seems that the exhaustive studies and discussions
of the subject, that have filled the medical jour-
nals, while they have been of immense profit to
those who are especially interested, have failed to
impress the majority, who mistakenly infer that
there is nothing more to be learned of a disease of
which so much has been said and written. The
Bulletin of the Chieago Department of Health
states that for the v/eek ending December 7, 1907,
seventy-four people died from pneumonia, and sev-
enty-seven died from various forms of tuberculosis.
These figures do not indicate very startling progress
in the prevention and cure of tuberculosis.
Although the pathologists have been demonstrat-
ing- the almost universal prevalence of tuberculous
lesions in adults that come to autopsy, we are slow
in understanding that it is not the presence of tuber-
culous foci that should be cause for alarm, but the
manifestation of the infection that should demand
prompt and decisive action. When it is fully appre-
ciated how slowly the disease progresses in its in-
cipiency, how grudgingly the organism yields to the
invasion and with what readiness favorable reac-
tion occurs, the number of cases of quick consump-
tion will dwindle to a small minority, and we will
find little solace in the thought that death in these
cases is inevitable.
The mistaken belief that the tubercle bacillus
must be found in the sputum before a diagnosis can
be made is responsible for lack of care in clioical
examination, errors in diagnosis, and unnecessary
delay in the institution of proper treatment. It is
quite true that if the patient recovers there is no
positive evidence that the illness was due to tuber-
culosis ; but if sufficient care has been exercised to
rule out other diseases such a diagnosis is justifi-
able.
Clinical ability is largely proportionate to a knowl-
edge of pathology, but the ambition to have diagno-
ses confirmed at the autopsy table is not always con-
ducive to close and careful study of patients, nor to
the making of efforts to eft'ect a cure. If sputum
can be obtained it should be examined in all cases,
but the examiner should keep in mind that a nega-
tive sputum may be demonstrated from a victim of
•Read before the North West Suburban Branch of the Chicago
Medical Society, Norwood Park, 111., December 9, 1907.
March ^i, 190S. I
KEATING: EARLY DIAGXOSIS OF TUBERCULOSIS.
529
pulmonary tuberculosis, as well as a negative urine
from a case of nephritis. Bacteriological studies
have made possible the diagnosis of pneumococcus
infection, when lung symptoms are wanting; but
as it is seldom convenient to make the cultures to
prove its existence, the clinical diagnosis is made.
If the sputum examination offered as many difficul-
ties as the recovery of the pneumococcus from the
blood, more skill in the way of clinical recognition
would be developed. Dr. Herrick has told us that
"the physician has no right to throw the entire re-
sponsibility of an important decision upon the
laboratory" (i). The value of the laboratory find-
ings in any disease process should not be minimized,
but these findings are but a part of the evidence,
and the correlation with the clinical picture is a ne-
cessity in arriving at a correct conclusion. It is en-
tirely possible to make a diagnosis of pulmonary
tuberculosis before the condition is suspected by
either the patient or his associates. The prospect of
cure and the difficulties involved in the treatment of
fairly well advanced cases do not admit of delay in
recognizing the disease.
"Cammidge found bacilli in the sputum of 866
cases out of 925 (63.6 per cent.) ; and Lawreson
Brown, who frequently made more than one exam-
ination for the same patient, found them in forty-
two out of ninety incipient cases (46.7 per cent.) ;
and in eighty out of eighty-seven moderately ad-
vanced cases (92 per cent.) ; Turban found tuber-
cle bacilli in the sputum in 325 out of 408 patients
(79.9 per cent.), during the course of the disease;
and, according to stages, in thirty-seven out of nine-
ty-seven cases (-37.5 per cent.) in the first stage; in
184 out of 205 cases (89.9 per cent.) in the third
stage. Julius Nagel found tubercle bacilli in 161
out of 1,081 female patients (14.9 per cent.); in
eleven out of 762 cases (1.4 per cent.) in the first
stage; one hundred out of 264 cases (38 per cent.)
in the second stage ; and in fifty out of fifty-five
cases (91 per cent.) in the third stage. Nagel as-
serts that on account of the weaker muscular ex-
piratory mechanism in women the chance of finding
tubercle bacilli in the sputum of women is less
than it is in men. They are also said to swallow
their sputum more than men. From statistics of
several different German sanatoriums, from records
made on admission, I find that out of 3,429 patients
with expectoration, 1,351 (39.4 per cent.) showed
tubercle bacilli; 438 out of 1,555 (28.2 per cent.)
in the first stage; 225 out of 705 (31.9 per cent.)
betwee."' the first stage and second stage; 302 out
of 612 (49.3 per cent.) in the second stage; 176
out of 2/^ (63.3 per cent.) between the second and
third stage; 209 out of 276 (72.1 per cent.) in the
third stage ; and out of three in which the stage was
not recorded" (2). It is to be presumed that care
was exercised in obtaining the sputum for these sta-
tistics, and that the compilers were skilled in the
use of the microscope. They are in accord with
the experience of any physician who has kept rec-
ords of his patients, and has had the opportunity to
follow the subsequent history of those in whom he
suspected pulmonary tuberculosis at the first ex-
amination.
A careful and searching history should be ob-
tained (3). Fear of the incurability of the disease
has been so firmh^ impressed upon the minds of
most persons that admission of the disease in mem-
bers of the family is evaded. If the patient sus-
pects the presence of the infection in his own case
he not infrequently becomes reluctant and aggres-
sive if the line of questioning suggests that the ex-
aminer has in mind the possibility of tuberculosis.
Denial of facts and conditions is not uncommon.
Diseases of childhood are easily overlooked if the
offhand thoughtless disclaimer of the patient is at
once accepted. The occurrence of these infections
are important in that conditions are established that
render .the tissues of the child susceptible to the im-
plantation of the tubercle bacillus, which may be-
come a menace in after years. Of importance is
the past and present association with others suffer-
ing from tuberculosis. The occupation may be a
causative factor, but no trade or profession is ex-
empt. Inquiry should be made as to the manner of
living, worry, overwork, or a too zealous devotion
to social duties, which results in a nervous break-
down. Does the bedroom receive fresh air? Is the
window kept open at night, and how much? An
inch or two is not enough. How does the patient
eat? Is it coffee and rolls for breakfast, a starva-
tion lunch at noontime, and a fifteen cent dinner in
the evening? Flas the patient, misled by the stom-
ach symptoms, been indulging in a light diet, which
further impairs the nutrition and serves to aggra-
vate the distressing hyperchlorhydria that is often
present? These are common conditions found daily
in clinic and office, and merit more attention than
they have received. Slight haemoptysis may have
occurred months and even years before the patient
comes under our observation. Night sweats are
found to have occurred at different times in many
cases. It has been stated that those children whose
heads sweat profusely when they are asleep are al-
most always subjects of tuberculous infection (4).
Patients who have pulmonary tuberculosis tire easi-
ly, especially in the afternoon.
The 'expression of the face is often significant,
sometimes worried and anxious, sometimes dis-
couraged and apathetic. A slight degree of de-
spondency is generally apparent. The feet and
hands are cold and clammy. Emaciation is not a
feature of an early case. The red line of the gums
at the margin of the teeth was noted fifty years
ago. A number of decaying teeth may be consid-
ered both as a cause and a result of tuberculosis. In
many cases the tonsils are chronically inflamed, and
the larynx presents a pale and anjemic appearance.
If emaciation is not present, the chest will not have
the phthisical appearance described in the textbooks.
When this condition is found, no other disease pro-
cess being present, it may be generally set down
that the case is well advanced. Subclavicular re-
traction will be noted in many cases, but may be of
slight degree. Expansion is apt to be limited, as
many of these patients are shallow breathers. Un-
due prominence of the scapulae is not seen in those
patients who have lost but a small amount of
weight. Changes in vocal fremitus cannot be ex-
pected where the involvement of lung tissue is so
slight as to make it difficult to know from the chest
findings that tuberculosis is the disturbing factor.
When the infection first becomes apparent it is
530
UlN FIELD: ECZEMA IN CHILDREN.
extremely difficult in many patients to determine
the existence of the process by the chest findings
alone, or to decide wliether we are dealing- with a
simple bronchitis, a slight bromopneumonia, or a
healed lesion. With a simple bronchitis of small
degree there is not apt to be any disturbance of
other organs that are manifest either to the patient
or to the ])hysician. When tuberculosis is present,
the examiner will he ai)Ie to find pathological or
functional changes iri other nrgaus, |)rn(luced by the
lung infection. Earl\ in the infection the lung find-
ings can onl_\- be considered as confirmatory evi-
<lence of pulmonary tu!)erculosis. Tkurisy has been
considered positive evidence of tuberculosis, but I
do not believe it to be an initial sxniptom, as I have
not found s\ ni])toniatic or i)hvsical evidence of it
in beginning cases, I'ain in the region of the heart
is often the onh one of which the patient com-
plains.
When the process is sufficiently advanced to pre-
sent physical signs, a slightly higher percussion note
is detected, which extends from the apex to the
upper border of the second rib. In slight variations
of the percussion note the examiner should strike
t'lghteen or twenty blows with the percussion ham-
mer instead of the customary three or four. Not
infrequently the patient will complain of pain with-
in the chest beneath tlie area being percussed.
Over this area the stethoscope will show an in-
spiratory sound that is sometimes harsh and some-
times jerking in character. Care in listening will
demonstrate slight prolongation of the expiratory
murmur. Rales, either dry or moist, are seldom
heard. Rales that are difficult to elicit can be
heard more plainly if the patient is instructed to
breathe deeply several times in succession. If it is
desired to demonstrate bronchial breathing, rather
sliallow, rapid breathing is most efTective.
Posteriorly, the higher percussion note will be
found as low as the spine of the scapula. The ab-
normal breath sounds heard beneath the clayicle are
here more pronounced, and pectoriloquv mav be
noted as low as the fourth rib. In uncomplicated
cases no change in size or position of the heart can
be demonstrated. There is always a degree of
tachycardia present, and an increased force to the
contraction of the organ. Aside from the pain
caused by a gas distended stomach, there is noth-
ing eithe.r clinically or ])athologicallv to account for
the pain in the he;irt region compLained of bv the
patient. The examination of the abdomen mav be
entirely negative, but pressure over the stomach
will, in the majority of cases, elicit pain. In more
advanced cases almost the entire abdomen may be
sensitive to pressure ; and in the female the tubes
and ovaries will be fuund (|uitc sensitive. Men-
struation is not often affected; if the function
should i)e altered it seldom has any bearing on the
case, as the flow not infrecjuently continues until a
short time before death. The pulse and tempera-
ture are important features, the afternoon tempera-
ture of most significance being 99° Y. ; a pulse rate
of 80 or a trifle higher will be found Ipoth morning
and afternoon.
References.
I. Ilerrick. Journal of the American Medical Associa-
tion, June 8, 1907,
2. Montgomery. Third Annual Rcj^oit of the Henry
Phipps Institute.
Keating. Medical Record. July 20, 1907,
4. Bunuughb. E.xaniincr and Practitioner, November,
igo6.
34 W.\.SHiNGTOx Street.
THE TREATMENT OF ECZEMA IN INFANTS AND
YOUNG CHILDREN.*
Bv James M, Winfield, M. D,.
Brooklyn, N, Y„
Professor of tlie Diseases of tlie St<iii in ttie Long Island College
Hospital, etc.
It is with considerable hesitancy that I present
this paper before a society composed of members
skilled in the treatment of diseases of children. For
the subject of eczema is so vast, and so many points
require consideration, that it is difficult to choose
which ones to touch upon in a paper that must be
limited by lack of time.
Of all the cutaneous diseases, eczema is the most
important, for it, in some of its protean forms, con-
stitutes about one third of all of the skin diseases
treated in the dermatological clinics of the world.
It is of common occurrence among infants and
young children, and often proves extremely difficult
to handle ; many factors must be taken into consid-
eration before one can expect to accomplish a cure.
Eczema is a catarrhal dermatitis, and if the typi-
cal symptoms of redness, swelling, vesiculation, and
exudation are marked the diagnosis is a comp-.ira-
ti\ely eas\ matter; but if there should be any varia-
tion from type the diagnosis may become difficult.
It. is unfortunate for any one who is not a cuta-
neous specialist that writers upon skin disease have
seen fit to multiply adjectives in attempting to de-
scribe the clinical t\pes of eczema; the essential
point to remember is that the treatment must be
appropriate for a catarrhal skin disease that may be
acute, subacute, or chronic.
These terms, acute, subacute, and chronic, should
be understood to indicate the grade of inflammation,
rather than the length of time the eruption has ex-
isted.
• Infantile eczema is usually aciite or subacute;
when acute it is attended with redness, heat, and
swelling; when chronic these conditions have, to a
great extent, subsided, and the skin is considerably
thickened.
Acute eczema frequently runs a typical course of
three stages. h'irst, the stage of congestion,
er} thema, and vesiculation ; second, weeping and
crusting; and, third, the stage of resolution by
desquamation.
Owing to the thin and sensitive epidermis of the
young, the vesicular stage may not be present, or
if it is it is very transitory, and the picture first
seen by the physician is the raw, red, exuding, and
crusted surface. This condition is brought about
by an intense effusion of serum underneath the
epidermis, which washes it away in mass.
It occasionally iiappcns that the effusion is verv
slight, and the congestive stage is rapidly followed
by the squamous.
•Read bcf.orc tl-e Section in I'wcliiilrics of the Medical Society of
tin- ( unnty of Kinijs. T.Tnitary i;. igo8.
.March 21. .908.]
IVINI-IELD: ECZEMA IN CHILDREN.
The four types of eczema that are of special in-
terest to those who treat diseases of children are the
erythematous, the papulovesicular, pustular, and
squamous.
Erythematous eczema is usually dry, and is the
mildest form that children have; it is often de-
scribed under the name of pityriasis ; it is more fre-
quently seen upon the face and hands, appearing, in
some instances, as a simple chapping of the skin.
It is also quite common to see erythematous eczema
occur, in small rounded spots, scattered over differ-
ent parts of the body. Although, in the adult, this
variety is characterized by intense itching, in chil-
dren this subjective symptom is comparativeh
slight.
1'he papular variety, eczema papulosum, the
lichen simplex of the older writers, is observed in
childhood ; it usually appears on the flexor surfaces
of the body as discreet, or numerous, irregular
groups of bright red, accuminate papules, which,
.from the scratching, are tipped w^ith minute blood
crusts ; if the disease becomes at all chronic the
groups run together and are converted into thick-
ened, scaly, or crusted patches.
The vesicular variety, eczema vesiculosum, is the
most typical expression of the disease, and in in-
fants is generally seen upon the face.
In the vesicular form the duration of the vesicle
is usually so short that the physician sees the patient
after the vesicle has ruptured, and there is a 'red
exuding surface. The exudation is sticky or gum-
my in character and stiffens the hair and linen.
In children and infants the inflammation is usual-
ly intense, and the skin is swollen and red. This
is the infantile eczema rubrum of the textbooks.
Pustular eczema is this type when it has become
infected by the pus organism; then instead of ex-
uding clear serum, the discharge becomes purulent
and dries into brownish, or greenish crusts ; instead
of the thin, yellowish, friable scales of a serus
exudate.
Postular eczema is more frequently seen on the
head and face of strumous and ill nourished children
(ir those whose skin and clothing have not been kept
clean. It is also the sequel of pediculosis capitis ;
then the eruption is found on the scalp, especially
over the occipital region and the back of the neck.
Squamous eczema, eczema squamousum. may fol-
low any of the other types, and as it indicates that
the attack is declining, it might be termed the type
of resolution.
The greater the amount of previous inflammation
the greater and more persistent the scaling and
vice versa.
/Etiology. — It is difficult to discuss the aetiology
of eczema in infants and young children in a limited
paper, for so many factors must be considered. The
exact cause or causes are perhaps still obscure, but
we do know that the great majority of cases seen in
the very young are due either to external irritants
or reflexes from the gastrointestinal tract.
Heredity plays but a small role in its causation.
Children who have inherited delicate skins are espe-
cially subject to eczematous outbreaks, provided
there is any irritation either external or constitu-
tional. Males seem to be slightly more subject to
eczema than females.
In the true definition of the term, eczema cannot
be said to be contagious or parasitic, unless those
cases of catarrhal dermatitis that are the sequel of
ring worm or scabies are included under the head of
eczema.
The diet has considerable influence in producing
the disease in small children ; over feeding has as
great an aetiological bearing as the kind of food
given.
A great deal has been said about the influence of
dentition in the production of eczema ; dentition is
a physiological process and never causes eczema
or any other skin disease ; but reflexly, through di-
gestive di'sturbances, it may cause an eruption on the
face of children, the so called tooth rash, which
can readily become eczematous. Intestinal parasites
may cause an outbreak of eczema in children so pre-
disposed either through reflex impression, or by
their disturbing influence upon the digestive func-
tions. A tight foreskin, or adhesions of the hood
of the clitoris may produce a reflex eczema, but it
should be remembered that every male infant who is
the victim of eczema is not the possessor of a tight
foreskin, nor does every child with a tight prepuce
develop eczema. In short one thing alone, be it
dentition, a tight prepuce, or a disturbed digestion,
is not capable of producing an outbreak of eczema
in young children ; there are usually many factors
that enter into the sum total of the aetiology of the
disease.
External Causes. — Among the external causes of
eczema should be mentioned the animal parasites
(pediculi and the scabic louse) and diseased, or
more properly speaking malformed skin, as illus-
trated by ichthyosis, over clothing and improperly
placed clothes and binders, woolen underclothing,
and sometimes, in older children, the presence of
irritating dye stuffs in the clothing that comes in
contact with the skin.
Diagnosis. — In infantile eczema, as in other dis-
eases, the correct diagnosis must be made before the
proper treatment can be instituted.
There are certain diseases that bear a transitory
resemblance to eczema, and to distinguish them
seems to be a difficult task to many practitioners.
In making a diagnosis the physician should place
before his mind the picture of a catarrh of the skin,
with its attendant erythema, vesiculation, papula-
tion, exudation, and crusting ; the exudations being
of a sticky, mucilagenous nature. If this picture
is remembered, then the distinctive diagnosis and
treatment become a comparatively easy matter.
The principal skin diseases which might occur in
infants and young children, that could be mistaken
for eczema are : Scabies, impetigo, erythema, and
syphilis. The distribution of scabies is so pathog-
nomic that even when aggravated by maltreatment
and scratching it assumes an eczematous character
it should be easily distinguished. It would seem
that the eruption produced by head lice could be
easily diagnosticated and not mistaken for eczema ;
the characteristic location on the occipital region is
enough to stamp it pediculosis and not eczema.
Impetigo. — If the eruption is composed of closely
aggregated pustules it might easily be mistaken for
impetiginous eczema, providing the diagnostician
forgets that impetigo always begins as discreet pea
532
iriNfJELD: ECZEMA IN CHILDREN.
[New York
Medical Journal.
sized blisters, containing serum, which soon be-
come seropurulent, and not as pin point or pin head
sized papules or vesicles, which exude a sticky,
serous fluid. The impetiginous lesion dries into a
brownish crust, while the eczematous vesicle gen-
erally ruptures spontaneously.
Erythema.— In infants and children this is easily
■distinguished from eczema, but if a mistake is made,
the erythema can readily become a true catarrh of
the skin.
The symptoms of inherited syphilis in infants are
so well marked that, to an audience of this character,
it is only necessary to mention it in passing.
The other diseases which are frequently mistaken
for eczema are erysipelas, miliaria, dermatitis, her-
petiformis, ring worm, and favus ; time will not al-
low me to enter into their discussion.
The symptoms of eczema in young children are
constipation or loose movements indicative of intes-
tinal irritation, some febrile disturbances, restless-
ness caused by itching, and the acute or subacute
eruption which assumes one or more of the types
previously described.
Treatment. — The treatment of eczema in infants
and young children must be divided into two parts :
First, the care of the child ; and second, the treat-
ment of the disease proper. The first division is the
more important, for if the child is properly and hy-
gienically cared for the treatment and cure of the
cutaneous disease proper is often an easy matter.
Clothing. — The clothing of the child should be as
light as possible ; heavy flannel underclothing should
"be avoided, in fact, many children have an inherited
idiosyncrasy to woolens ; in these cases all the cloth-
ing that comes in "contact with the skin should be
of either linen, cotton, or silk. Most mothers and
nurses make the mistake of keeping the babv too
thickly covered ; the clothing and coverinp' should
he just sufficient to protect the child, and not great
enough to stimulate the cutaneous glands.
Care should be taken not to have the binders or
bands of the clothing too tight upon children with
sensitive or tender skins.
It would, perhaps, be better for the cutaneous in-
tegrity of the infant if water for bathing could be
avoided, and some bland oil, such as olive or al-
mond, be substituted ; but it is almost impossible to
properly remove crusts, soiled secretions, and
debris without water, yes even soap and water!
The water should be soft, rain or spring water, but
if this is unattainable, water that has been boiled
and cooled will be found quite as good ; bran baths
to which a small quantity of sodium bicarbonate has
been added will often be found usefifl ; castile. or the
superfatted soaps, can be used when soap is indi-
cated, but it is better to use as little soap as possible,
for even the mildest will irritate some skins. After
the child has been thoroughly dried, the body, dis-
eased portion and all, should be thoroughly in-
nuncted with some bland grease, such as cold cream
or almond oil. The physician should be careful to
prescribe a perfectly fresh oil or the best cold cream,
for it is a fact of common observation that much of
the olive or almond oil procured from the drug store
is apt to be rancid, and the cold cream so badly
made that it acts injuriously on sensitive skins.
I think that dermatologists as well as psediatrists
make a mistake when they impress upon the minds
of the mother or nurse the dangers of using water
on an eczematous skin ; proper bathing at stated in-
tervals, every third day or once a week or longer as
the case requires, is not only noninjurious but bene-
ficial, for, as stated above, water is the best medium
for removing soiled cutaneous secretions and other
deleterious material. After the bath the child should
be thoroughly inuncted with cold cream or dusted
with some bland powder, preferably of mineral
origin, because the vegetable, such as lycopodium,
rice powder, or starch, take up the secretions, be-
come rancid, and readily serve as culture mediums.
Most mothers and nurses use talcum powder for
dusting; the only objection to this is that it is apt to
roll up in lumps ; this can be prevented if the powder
is thinly and evenly distributed. The oxide or
sterate of zinc with or without bismuth is useful.
A commercial powder called pulvola, which is said
to be a zinc preparation, fills the requirements of a
dusting powder better than thos'e mentioned.
Among the vegetable powders, lycopodium stands
at the head, although in some cases either rye or
buckwheat flour has a more soothing effect.
It seems needless to say that a child with eczema
should be handled as little as possible, but it is a
fact that is constantly disregarded by mothers and
nurses.
Feeding. — The feeding of infants is a matter that
tries the skill of the medical profession ; and the
difficulties are multiplied when the child is suflfering
from eczema.
It is a matter of common observation that the
majority of eczematous children have been or are
fed on artificial foods ; these starch compounds have
so upset the intestinal tract of the child that after
repeated insults the skin becomes reflexly irritated,
and eczema is the result.
The proper food for an infant, especially one with
a sensitive skin showing a predisposition to eczema,
is human milk. If this mode of feeding is impossi-
ble, cow's milk, either plain or properly modified, is
the best substitute.
I have found that children fed upon sterilized or
pasteurized milk are more subject to reflex eczemas
from disordered digestive organs than those fed the
plain or modified milk, and if pasteurized or steril-
ized milk IS given to infants already suffering from
eczema the dise'ise is aggravated. The possible ex-
planation of this is expressed by a remark of Jen-
sen, quoted by Piiiard in i:n article on milk in the
New York Medical Journal. January 4. 1908. "The
bacteria surviving pasteurization are. for the most
part, the quick growing bacteria of putrefaction
which are inhibited in raw milk by the lactic acid
l)acteria. but in pasteurized milk they multiply very
fast, and undoubtedly they are capable of generating
poisonous substances."
T have found the best modification of milk for
children with eczema is the one formulated by Pro-
fessor Bartlev, and with his kind consent it is given
in full :
"Siphon ofT from the bottom of a bottle of fresli milk of
good quality three fourths of its contents, leaving the cream
and upper part of milk undisturbed in tlie bottle. This may
be easily done with a piece of small rubber tubing, previ-
March 2:, 1908.]
\V IX FIELD: ECZEMA IX CHILDREN.
533
ously filled with water, to start the siphonage. Pinch one
end of the rubber tube and hold it firmly, while the other
is thrust through the cream and to the bottom of the bot-
tle. Lower the outer end into the inner vessel of an ordi-
nary double boiler, and release it when the skim milk will
run out, provided the latter vessel is kept lower than the
milk in the bottle. To the milk thus drawn off add a tea-
spoon and a half of Fairchild's essence of pepsin, or one
junket tablet, and warm slowly in the double boiler to blood
heat, or until the milk is well curdled. Now continue the
heat with rapid stirring, until the thermometer indicates
150'' F., when the curd should be well separated. Remove
from the fire and strain, dissolve in the whey a heaping
cablespoonful of sugar of milk. When cold pour the whey
back into a milk bottle, and mix thoroughly with the top
milk. In hot weather the mixture can be pasteurized, but
it is not necessary in cold weather. If the food should
prove too laxative reduce the quantity of milk sugar. It
is well to add from one to two teaspoonfuls of lime water
to each meal. As the child increases in age the amount of
bottom milk siphoned off may be diminished.'"
After the child has cut its teeth milk should still
constitute the bulk of its diet, with the addition of
beef juice, cream, dry bread, and zwieback, and in
the strumous cases benefit cn be derived from the
judicious administration of oils and fats; orange
juice and baked apple can also be added to the
dietary ; it is often necessary to direct the mother to
give the child frequent and liberal draughts of either
soft or boiled water, this assists in the elimination of
waste material.
Constitutional Treatment. — Most eczematous chil-
dren are constipated ; and various formulas have
been devised for relief, but there can be no definite
prescription given that will suit all cases. Occasion-
ally a dose of castor oil is indicated; calomel in
from one half to" one grain doses either alone or
combined with small quantities of rhubarb or castor
oil wnll be found useful, this can be followed by mag-
nesium milk or magnesium citrate ; cascara sagrada
in one of its various combinations is commonly em-
ployed by many physicians : while this drug is of
undoubted benefit after awhile a tolerance is estab-
lished and then recourse must be had to other reme-
dies. Phenolplithalein, a recently advised prepara-
tion for the relief of constipation, is rather uncer-
tain in its effects ; in some instances a quarter of a
grain dose will regulate the bowels, and again a
much larger dose is necessary, while it often hap-
pens that even a small dose will cause intestinal dis-
comfort and even pain.
I have found that malt sugar seems to work well
in certain cases : this can be conveniently given in
the shape of malted milk, one or two feedings in the
twenty-four hotirs being sufficient to overcome and
control the constipation. I know the use of malt
sugar is against the teaching of paediatrists, on the
statement that sugar will cause fermentation and
acid stools : while this may be theoretically true, I
personally have never noticed any bad eflFects either
upon the disease in question or upon the digestive
functions of the child to whom it has been given.
No laxative should be given in large enough doses
or for a sufficient length of time to cause purgation ;
the dose should be just large enough to relieve the
constipation and regulate the bowels, except in those
children that are heavy feeders and poor eliminators
then an initial dose of either calomel or castor oil
can be prescribed to rapidly relieve and clean out
the intestinal tract.
If the child is .~til! at the breast some of its con-
stitutional treatment can be given through the
mother. In the strumous eczema codliver oil and
the iron iodide is indicated ; if the eczema should
be a manifestation of inherited syphilis, minute
doses of calomel or bichloride of mercury will often
effect a cure when other measures have failed. Calo-
mel, or mercury and chalk in small doses is indi-
cated for eczema in children of the flabby, lymphatic
type.
The most troublesome symptom of eczema is pru-
ritus ; this can usually be relieved by external appli-
cations, if not, small doses of bromide or chloral can
be given, but when these drugs are used their action
should be closely watched, for the bromides are
capable of caitsing a seriotis looking dermatitis, and
when the skin is already diseased this drug should
be most judiciously employed.
The routine administration of arsenic in infantile
eczema should be most strongly condemned, for it
does little or no good to the cutaneous disease and
is apt to disturb the digestive processes ; this drug
is only indicated when its tonic effect is desired.
The important rule regarding internal medication
-is to give as little medicine as possible ; for if the
child is properly bathed, clothed, and fed, its con-
stipation relieved, and the proper external aplica-
tion is used, little else will be required to effect a
cure.
External Treatment. — The external treatment
should be protective ; the cardinal principle is not to
apply anything to the skin that will irritate it, so,
therefore, all ointments, lotions, or powders should
be bland and protective.
All scales and crusts must be removed before any
medicinal application is used; the scales can be
softened with olive or almond oil, to which can be
added one to three grains of resorcin or carbolic
acid to the ounce. The oil can be used for a few
days or until the scales are softened, then the parts
should be thoroughly washed with soap and bran
water, or water to which a small quantity of sodium
bicarbonate has been added ; the washing should be
repeated as often as is necessary. During the in-
terval between the water baths the parts can be
cleansed with oil.
For the erythematous type, where there is little
or no vesiculation, the application of some simple
protective ointment, such as cold cream, petrolatum,
or wool fat. will be all that is necessary ; the petro-
latum should be the refined white petrolatum, and it
is not prescribed with an idea of a medicinal eiTect,
but as a simple protective covering for the skin.
If the child is much exposed to the outer air. it is
sometimes advisable to cover the unguent with some
bland dusting powder.
In eczema rubrum, if there is not much inflamma-
tion, benefit can be derived from dusting the dis-
eased part with zinc oxide or bismuth, either sep-
arate or combined. If the diseased surface is much
irritated and inflamed a mild boric acid lotion can
be used tmtil the inflammation subsides, and then
an ointment composed of zinc oxide, ammoniated
mercury, and cold cream will be found useful.
The physician is cautioned against prescribing the
commercial zinc oxide ointment, as it is either too
strong for the individual case, or the fatty base has
become rancid. Cold cream is a much better ornt-
534
BURV ILL-HOLMES: DIAGNOSIS OF DIPHTHERIA.
[New York
Medical Jour:
ment base than benzoated lard. While it is not the
purpose of the paper to give any prescription, the
following combination will serve as an example of
prescriptions when used —
R Ammoniated mercury, lO to 15 grains ;
Zinc oxide, 10 to 25 grains ;
Cold cream, 5j-
M. S. : Externally.
If there is much pruritus carbolic acid or some
tar preparation can be combined. If the disease has
become chronic oil of cade or beta naphthol in from
ten to thirty grains to the ounce of an ointment will
assist the cure. In prescribing the tar preparations
physicians should use discriminating judgment, for
the tars do not act well in all cases ; in fact, they
frequently aggravate the existing inflammation, and
sometimes produce a tar dermatitis. Occasionally
cases of eczema resent any fatty applications, then
lotions, such as the calamine lotion, must be re-
sorted to.
The physician should examine the genitals, and if
any adhesions are found they should be removed.
If the attack of the skin disease appears for the
first time during the eruption of the teeth, or if the
skin condition seems to be aggravated, appropriate
measures should be instituted to assist dentition.
In concluding it is only necessary to reiterate
what was said in the beginning, that it is ex-
tremely difficult to lay down any fixed rules for the
treatment of eczema; for the remedies, be they in-
ternal or external, must meet the exigencies of the
individual case and condition.
47 H.\T,SEY Street.
THE VALUE OF STAINED SMEARS IN THE
DIAGNOSIS OF DIPHTHERIA.*
By E
JURVILL-HOLMES, M. D.^
Philadelphia,
Formerly .Assistant Chief Resident Physician of the Municipal Hos-
pital; Bacteriologist of the Henry Phipps Institute,
I think that it is undoubtedly the opinion of men
who are conversant with diphtheria, both in its clin-
ical and bacteriological aspect, that in no case is the
specific organism absent from the parts involved.
True, there are a few men — fortunately, very few —
who still have a tendency to deride or consider of
little moment the findings of the bacteriologist, and
who insist that mere inspection of the throat, etc., i?
sufficient for diagnosis, the aid of the microscope
not being essential. These men either cannot or will
not accept what are facts, not theories merely, and
that is that organisms other than the Klebs-Loeffler
bacillus can produce pseudomembranes identical
with this later organism, and I think mainly because
they know little about, and have worked less in.
bacteriology. That this has been and can be proved
beyond the peradventure of a doubt must be appar-
ent to any one who has kept abreast of the litera-
ture or has made investigation for himself. Klebs
(i) observed a whole family epidemic of false diph-
theria which was caused by a large monococcus of
the group of monades. Ballouche (2) has shown that
typical diphtheritic pseudomembrane can be pro-
duced by the streptococcus, as also by the staphylo-
•Read bcforr the I'hiladelphia Pathological Society, January 23,
1908.
coccus and pneumonococcus. Moreover, according^
to Bourges and Futterer, paralysis identical with
that which often follows in the wake of a diphtheria
intoxication has been seen as a sequelae of a pure
streptococcus angina. Again, Frankel's pncumo-
bacillus can be responsible, and at times is, for errors
of diagnosis. The, symbiosis of Vincent's spirilla
with the fusiform bacillus gives rise to an exudate,
a pseudomembrane, call it what you will, which on
more than one occasion, to my knowledge, has
caused an individual unfortunately so afflicted to be
sentenced to an enforced sojourn in a ward of the
diphtheria pavilion. Another organism, which of
late years we have been led to strongly believe is
the aetiological factor of syphilis, the Spirochceta pal-
lida, has been, while not to the same extent, guilty
of the same thing. To quote from a report of the
local Government Board of London (3), "It must be
remembered that membranes produced by bacteria
other than the Klebs-Loeffler bacillus may appear
in the throat, and that in many cases the clinical
phenomena prove it to be of little assistance ; in
these cases a careful bacteriological examination
should always be made." Filatov (4) says: "In the
diagnosis of the throat, clinicians are guided, not by
the anatomical changes of the mucous mambrane,
but by the aetiological causes, namely, diphtheria of
the throat is an inflammation of its mucous mem-
brane produced by the Klebs-Loeffler bacillus. It is
immaterial whether the throat be aflfected by a croup-
ous exudation or a catarrhal one ; as soon as we find
that in a given case the cause of the sore throat is
Loeffler's bacillus, we should regard such morbid
process as diphtheritic and should so characterize
it. Since not only Loeffler's bacillus is liable to pro-
duce diphtheritic inflammations of the mucous mem-
branes, i. e., membranous exudations, but other
microbes may also have similar action, it is obvious
that the presence of a membranous coating alone
on some of the mucous membranes does not prove
that we have to deal in any given case with a case
of diphtheria."
Personally I had the privilege and opportunity
while at the Municipal Hospital of observing both
clinically and bacteriologically many cases in which
the inspection of the throat alone was responsible
for errors in diagnosis, and I am certainly convinced
that without a bacteriological examination one is not
justified in saying that this case is one of diphtheria
and that one is not. Let me here cite two cases as
examples :
Case I.— Miss C, a trained nurse, while caring for one
of her associates who had been ■^ent to the hospital suf-
fering from scarlet fever, was taken ill with headache,
rise of temperature, and angina. When her throat was first
examined some slight whitish exudate was noticed on both
tonsils, which 'ater spread. It was considered a case of
diphtheria and particularly in view of a report, by one of
the resident physicians who, in my absence, examined a
smear, that the Klebs-Loeffler bacillus was present in very
large numbers. The patient was transferred to the diph-
theria pavilion and antitoxine was administered. On my
return to the hospital I was requested to e.\amine the
smear, and although it was carefully gone over not a single
diphtheroid organism could be found. The first examiner
had made the mistake, singularly so conunon with the un-
experienced, of confounding the Streptococcus lanccolatus
with the diphtheria germ, this organism being in the smear
exclusively, and substantiated by culture control. Although
repeated cultures were made, the Klebs-Loeffler bacillus
was never found. Twenty-four hours or thereabouts after-
March 21. 190S.]
BuRl'ILL-HOLMES: DIAGNOSIS OF DIPHTHERIA.
535
ward the patient developed a cough with some dyspnoea,
and while examination of her chest showed little or noth-
ing, her subjective sj-mptoms and her subsequent tempera-
ture reading made a diagnosis of central pneumonia more
than probable. I may add that two days after the adminis-
tration of the antitoxine she developed violent pains with
swelling of her joints, and later a marked pericarditis with
effusion. Whether the pneumococcus was responsible for
the entire train of troubles, I am not prepared to say
definitely. I believe that it was. A blood culture remained
sterile.
Here then is a case where the pseudomembrane
was indubitably pneumococcic in origin. It certain-
ly was not diphtheritic, since as I say after repeated
cultures the specific organism of that disease was
never found.
C.'VSE II. — \V. J., a young male, was admitted to the
diphtheria ward, suffering from malaise and angina. Ex-
amination of the throat showed a dirty white membrane on
both tonsils and to a slight extent also on the uvula. Diag-
nosis other than diphtheria was not entertained at first,
and he was, and properly, so treated. However, repeated
negative cultures with the persistence of the membrane
prompted the physician in charge to look further into the
cause of the trouble and accordingly he was sent to the
laboratorj- with a request that a smear be made and ex-
amined for the Stifochwta pallida. This was done, that
organism found, or what was thought to be the organism,
appropriate treatment was adopted, and the exudate
promptly disappeared.
And so case after case might be recorded if time
and space permitted. To repeat, then, I say that
every case of diphtheria, providing the throat be
properly swabbed and cultured, the culture incu-
bated at the proper temperature — an important fac-
tor— and examined by a competent bacteriologist,
will invariably demonstrate the bacillus. Con-
versely, and I cannot do better than quote Professors
Kathnack and Hardy (5) : "From the investigations
made all over the world, we must refuse to call any
lesion diphtheria unless it is associated with the
bacillus. The bacillus asserts itself with an author-
ity which mtist put aside any preconceived notions.'"
There are those, of course, who will argue that the
bacteriological investigation in a given case is not
necessary, because if so suspicious as to be distin-
guished with difficulty, it should be for the welfare
of the patient, as also for those with whom he might
come in contact, that the treatment and precautions
against contagion should be in accord with the as-
sumption. Conceded : until the diagnosis can be
clinched, as it were, by the microscopist, all this
should be done, and promptly. If, however, the sub-
sequent treatment-is to be carried along logical and
scientific lines : if that chaos in households which a
wholesale disinfection entails is to be eliminated ; if
the perturbed mind of a parent consequent upon
the knowledge that her child has diphtheria is to be
set at rest, and lastly, and by no means the least, if
statistical records are to be open to less criticism
than they unfortunately are at the present time, then
it is essential that bacteriological studies shotild be
made in every case of exudative angina. Again, the
argument has been advanced that since diphtheria
organisms are found in healthy throats, a case in ac-
cordance with smear and cultural finding may be
deemed one of diphtheria, when, as a matter of fact,
that organism may be taking little or no part in the
diseased process. This leads us to the question as
to how many well persons harbor the organisms in
their throats. According to a report of a commit-
tee of the Association of the Massachusetts Boards
of Health (6) persons not exposed to the contagion
revealed the germ on culture in 3 per cent, of cases.
In the eastern part of the United States the per-
centage was lower, or 1.39 per cent. On the other
hand, their report says that in the exposed the per-
centage was from 8 to 50. If this latter is correct,
then my experience must be somewhat unique.
Smears and cultures from the resident physicians
and nurses on duty in the diphtheria wards were
taken at the various periods, and of the eighty or
ninety so .studied, only two gave positive results, or
2.2 per cent. Both were nurses, and singularly new-
comers, having been in tlie hospital but four da}s.
one of whom went down with the disease the day
following the issuance of the report. To obviate
any prejudice in the matter the cultures were made
by one of the resident physicians and sent to the
laboratory with those from the patients and under
fictitious names. At any rate, the number of, well
persons whose throats contain diphtheria organisms
are so comparatively few that, when found in dis-
eased throats, we are justified in the inference that
the case is one of diphtheria.
The Value of Smears. — Early diagnosis of pseu-
domembranous anginas is imperative, firstly, so
that prompt remedial measures can be instituted,
and secondly, if contagious, immediate isolation or
removal of the patient to the hospital eft'ected. That
diphtheritic anginas frequently present the typical
textbook pictures of follicular tonsillitis is a recog-
nized clinical experience of many practitioners. In-
deed, more than one life has been sacrificed because
the clinician failed to appreciate this fact. It is not
so many years ago that in an orphan asylum on the
outskirts of this city such an error cost the loss of
five lives and the expenditure of about four thou-
sand dollars. In the following cases the Klebs-
Loefiler bacillus was undoubtedly responsible for
the trouble, although the clinical picture was that of
follicular amygdalitis :
Case III. — A girl of ten years was sent to the hospital
from her suburban home, with a request that she be ad-
mitted, as she was supposed to be suffering from diphtheria.
On admission inspection of her throat revealed two much
enlarged and congested tonsils, each having thereon a small
circumscribed dot of yellowish pultaceous exudate. Her
condition was considered to be one of tonsillitis and not
diphtheria, and certainly the appearance of the parts justi-
fied such a diagnosis. However, before discharging her
to her home, as it was the intention to do if the smear
should prove negative, it was deemed advisable to make a
smear from the exudate, which was done. This showed
an exceedingly large number of diphtheria organisms, and
culture made from the same swabbing showed on the fol-
lowing day a pure culture of the bacilli. Furthermore, a
guinea pig test proved the germs to be virulent.
Case IV. — F. K., a druggist, presented all the clinical
symptoms of a follicular tonsillitis, prostration, high tem-
perature, and considerable angina. The tonsils were very
large, reddened, and small dots of yellowish, soft exudate
were to be seen filling the crypts. It was considered by the
attending physician, a larj'ngologist, as a case of tonsillitis,
although to give the patient the benefit of any doubt, anti-
toxine was administered. A smear and culture were made,
and both showed the bacillus almost exclusively. These
organisms were also virulent.
Case V. — B. A., a boy of seven years, presented all the
symptoms of a follicular tonsillitis, and it was so diag-
nosticated. Twelve hours later the small yellow dots of
exudate had coalesced, but there was nothing in the appear-
ance of the parts to prompt the attending physician to alter
536
BURl ILL-HOLMES: DIAGXOSIS OF DIPHTHERL-i
I. New York
Medical Journal.
his initial diagnosis. Only when it was too late did he
realize what he had to deal with, and the child died.
The following case was one in which a diagnosis
of diphtheria was made but which smear and cul-
ture proved undoubtedly to be staphylococcic infec-
tion :
Case VI.— Miss H., a trained nurse, was sent from one
of the local hospitals where she was on duty with a diag-
nosis of diphtheria. On one tonsil was a small, white patch
of exudate, about five millimetres in diameter. The ton-
sils were not markedly congested or enlarged. There was
slight dysphagia. A smear was made, but no diphtheria
organisms were found after a long and careful search. She
was immediately discharged, and the next day, without any
treatment whatsoever, she was entirely well, at least to all
intents and purposes. The culture made from the same
swab from which the smear was made showed on the fol-
lowing day a pure culture of the Staphylococcus pyogenes
aureus.
We see that in Cases III, V and VI where
smears served a good purpose. Had inspection
alone been relied upon, it is easy to see how disas-
trous might have been the results, and particularly
as regards Case III, where the child would have
been sent home, there to mingle with other children.
To have awaited the results of culture would have
meant detention in the hospital for at least seventeen
hours. Removal of Case IV to the Municipal Hos-
pital was consummated one hour after the visit of
the physician, in lieu of being deferred twenty-four
hours had culture alone been relied upon, thus ob-
viating the dangers of contagion, as the patient was
a resident in an apartment house. The smear saved
Case VI from being subjected to antitoxine treat-
ment and forced detention in the diphtheria pavilion
unnecessarily. Had a culture or smear been made in
the case of the small boy a life might have been
saved.
Being desirous of ascertaining the value of smears
compared with cultures made and examined, a con
siderable number of smears were made from the noses
and throats of patients admitted to the diphtheria
and scarlet fever wards. My conclusion is that they
are of great value, indeed, in experienced hands as
valuable as cultures, because even the latter, owing
to careless culturing for the most part, do not al-
ways reveal the true state of afifairs. Of special value
are they when an immediate diagnosis is required.
The experience of Welch and Schamberg (7),
who examined a large number of smears also at the
Municipal Hospital, is much in accord with my own.
It would be a mistake for me, however, to leave the
impression that it is easy to positively identify the
organisms in smears without some experience, as is
demonstrated by the smaller percentage of errors as
this experience is augmented. Smears obtained
from the nose in particular are ofttimes difficult to
interpret. But then I do not believe that either
smears or cultures are of much value in diagnosti-
cating nasal diphtheria without the clinical evidence
or guinea pig tests, because the nose is a frequent
habitat of an organism the morphology and cul-
tural characteristics of which — to the exclusion,
perhaps, that it renders bouillon slightly turbid
— are identical with those of the Klebs-Loeffler
bacillus. It does, however, lack virulence. From
the nose, also, even in culture, I have observed
that virulent organisms only rarely .show polar
staining or granules, as is so frequently seen
in those from the throat. As a matter of fact
polar staining and granules are often absent in or-
ganisms from throats as examined by smear The
grouping of the bacillus, rather than their actual
morphology. I consider the more valuable in recog-
nizing their presence. In "looking over a smear con-
taining the bacillus, they will be found in most part
lying together in groups of two or more, paralleling^
each other or radiating from each other like the
spokes of a wheel. This is most characteristic both
in smears and cultures.
Of 529 smears examined, only in thirty-one did
they fail to correspond with the cultures, and in
every instance the smear was made from the same
swabbing as the culture. This is a difference of 5.8
per cent. In twelve of these cases the report on the
smears was positive when the culture showed no
diphtheria organisms, although the case was one of
diphtheria, as subsequent cultures proved. In three
instances I can account for this as owing to a gas
regulator which refused to regulate, and being a
warm night in summer the temperature of the in-
cubator rose to 52° F., a degree of heat we know to
be prejudicial to the growth of the Klebs-Loeffler
bacillus. In the remaining cases the discrepancy
was due to the fact that other organisms doubtless
predominated and choked out the diphtheria bacillus.
Whatever the reason, it showed that here at least the
smears were more reliable than the cultures. This,
then, leaves twenty-four cases in which the error
was on the wrong side, or 4.1 per cent. Six of these,
again, were from the nose, a site from which, as I
remarked before, it is at times difficult to interpret.
In two of these six cases a long search of the smear
failed to show any organisms whatsoever, and quite
recently I was asked to examine a nose smear from
a yoimg physician which showed, and then only after
considerable hunting, a single pair of organisms,
lying side by side, on which finding he was isolated
and later sent to the Municipal Hospital. The cul-
ture made from this latter patient showed the organ-
ism solely. Withal then, with these results — because
even cultures, depending upon personal equation, in-
cubator troubles, or the choking out of the diph-
theria bacilli by more rapidly growing organisms,
will show a degree of error of at least 4 per cent. — I
do not think it is without the pale of consistency to
give a value for smears almost as great, if not as
great, as cultures. I would suggest, nevertheless,
that cultures as controls 'ought always to be made,
and it would be time well spent if. every young clin-
ician would make himself conversant with this means
of diagnosis.
Conclusions.
No pseudomeinbranous angina should be consid-
ered as one of diphtheria if, after careful and proper
culturing and competent examination, the Klebs-
Loeffler is absent.
Cidtures and smears should be made in every case
irrespective of the appearance of the parts involved.
Typical pictures of follicular amygdalitis frequent-
ly show large numbers of virulent bacilli.
When in doubt, and until smear and culture can
be examined, all cases should be treated as diph-
theritic in origin.
That without clinical evidence or guinea pig tests,
smears and cultures from noses are not of much
value.
The grouping of the bacilli, rather than the
March 21. iQoS.l
VANDERHOOF: SYMPTOMS AND DIAGNOSIS OF NEPHRITIS.
537
morphology, is the more valuable aid in the identi-
fication of the bacillus in both smear and culture.
For immediate diagnosis smears are of great value ;
indeed, from the results obtained in the cases men-
tioned, it would tend to show that on the whole they
were as valuable.
References.
1. Klebs. Realcncyclopsdie of Professor Eulenburg,
article Diphtheria.
2. Boiillouche. Les Angincs a fausses tiiembranes, pp.
142-153, Paris, 1894.
3. Report of London Government Board for 1904.
4. Filatov. Diseases of Children, i, pp. 126 and 127.
5. Alb"trs System of Medicine, article Bacteriology of
Diphtheria.
6. Jour. Massachusetts Associated Boards of Health.
July, 1902.
7. Welch and Schamberg. Acute Contagious Diseases,
p. 677.
2030 Chestnut Street.
SYMPTOMATOLOGY AND DIAGNOSIS OF
NEPHRITIS.*
By Dougl.\s VanderHoof, A. M.. M D..
Richmond, Va..
Adjunct in Medicine, Medical College of Virginia.
;More than one hundred years ago Nicholas Co-
tungo discovered a coagnlable substance in the urine
of persons afflicted with dropsy. To Richard Bright
(1827), however, is due the credit of having pro-
duced the first evidence of the association of dropsy
as a symptom, albuminuria as a sign, and altered
kidney structure- as a cause. Any one who has had
the good fortune to have examined a copy of
Bright's original monograph cannot fail to be im-
pressed bv his remarkable appreciation of the rela-
tionship of diseased kidneys to albuminuria and the
clinical features of the affection which now bears
his name. Equally wonderful are the beautiful col-
ored plates illustrating lesions of the kidneys as he
saw them at the post mortem table. Since Bright's
time a certain knowledge of organic and functional
disturbances of the kidney has been acquired, but
were he to return to-day he would find us deeply
perplexed over many of the same problems that con-
fronted him.
It is generally conceded that the term "nephritis"
includes certain diseases of the kidney associated
with, or dependent upon, an altered state of metab-
olism and a defective condition of the blood, so that
the disease is always bilateral. It is characterized
by inflammatory changes in the various tissue ele-
ments which do not, however, lead to suppuration :
and is manifested clinically by various features in
which albuminuria, dropsy, and cardiovascular
changes are prominent.
A satisfactory classification of nephritis to include
the different clinical forms as well as the various
pathological pictures of the disease has never been
made. The subdivisions proposed by Senator, how-
ever, ofTer a working basis for both clinician? and
pathologists.
I. Acute nephritis: (a) parenchymatous: (b)
diffuse.
•Read at a Symposium on Nephritis, at the Twelfth Semiannual
Meeting of the Southwest Virginia Medical Society, held at Ro-
anoke. Va., January 16 and 17. 1908.
2. Chronic diffuse nephritis, zmthotit induration
("chronic parenchymatous nephritis").
3. Chronic indnratizc nephritis: (a) secondary
induration (secondary contracted kidney) ; (b) pri-
mary indurative ("chronic interstitial") nephritis:
(c) arteriosclerotic induration.
I. Acute Nephritis.
Acute nephritis is a simple inflammation which
mav only involve the parenchyma, or functional ele-
ments, of the kidnev ( tubular and glomerular epithe-
lium) ; or it may be difTuse, so as to involve the in-
terstitial as well as the parenchymatous tissues,
a. Acute Parenchymatous K'ephritis.
Symptomatology. — This form of nephritis not in-
frequently exists without any distinctive clinical
manifestations, either in the urine or elsewhere, as
has been so graphicall}- demonstrated by Cabot (R.
C. Cabot, Clinical Examination of the Urine, Jour-
nal of the American Medical Association, March 18
and 25, 1905).
In many instances only the epithelium of the tu-
bules is affected, while the glomeruli are not in-
volved to any extent. In the mildest cases the only
lesion found is a cloudy swelling and degeneration
of the epithelium, such as is common in the infec-
tious diseases accompanied by "febrile albuminuria."
The urine contains only a small amount of albumin,
and usually presents the characteristics of "fever
urine," is scanty in amount, deep amber in color,
strongly acid in reaction, of high specific gravity,
with little or no sediment, in which only an occa-
sional tube cast is found. This usual textbook pic-
ture of the urine in febrile conditions is not seen so
commonly now as heretofore, however, because of
the hydrotherapeutic measures with increased fluid
intake that are instituted in our treatment of fevers
at the present day. Dropsy and uraemic symptoms
do not occur, and the only subjective symptoms are
those due to the primary intoxication or infection.
The albuminuria usually disappears with the sub-
sidence of the fever.
b. Acute Diffuse Nephritis.
In acute difTuse nephritis the changes in the tu-
bules are accompanied or followed by changes in the
glomeruli and interstitial tissue which are more
frankly inflammatory in character, and symptoms of
renal insufficiency appear that are wanting in acute
parenchymatous nephritis. Acute difTuse nephritis
is seen most commonly during or following infec-
tious fevers, especially scarlet fever, after the inges-
tion of soluble poisons such as corrosive mercuric
chloride, etc. It is the usual form of nephritis which
characterizes the "kidney of pregnancy." Some-
times, particularly in those cases following exposure
to cold, acute diifTuse nephritis may rank as a dis-
tinct clinical entity, having the character of an acute
infectious disease, with the only symptoms referable
to the kidneys.
Symptomatology. — The onset is often abrupt, but
may be gradual when the kidney lesion develops
during the course of an acute infectious disease.
The most prominent symptom is dropsy, which is
often the earliest evidence of the renal condition. Its
appearance is usually coincident with the alterations
in the urinary secretion. The oedema first appears
about the eyes and ankles, but may rapidly progress
538
i ASDEKHOOl-: SYMPTOMS AND DIAGXOSIS OF XEPHRITIS.
[New York
Medical Journal.
to a condition of general anasarca, associated with
eiYusion into the various serous cavities of the body.
In severe cases, particularly in children and in preg-
nant women, the first symptom may be a uraemic
convulsion.
With the exception of dropsy, no other symptom
is constant or characteristic in acute dif¥use nephri-
tis. \^ery often a pronounced anaemia develops
quickly, with the low color index of a typical sec-
ondary anaemia. General constitutional symptoms
are more or less marked. The patient looks ill, is
often apathetic, if not somnolent. Fever, associated
with a polynuclear leucocytosis, is often present.
The condition of the cardiovascular apparatus
varies. In many cases the pulse tension is much in-
creased, and, according to observations reported by
Riegel, the rise in blood pressure in acute nephritis
occurs early. This may be followed by a distinct
hypertrophy of the left ventricle as shown by the in-
creased area of cardiac dullness to the left and the
accentuated second aortic sound. In other cases,
especially severe ones, in which the strength of the
myocardium is impaired by the toxic agent, the right
ventricle becomes dilated, and the blood pressure
may not be increased. This may be a factor in the
occasional occurrence of acute cardiac dilatation.
Pulmonary oedema may follow upon a gradual cardiac
insufficiency or may be associated with a rapid effu-
sion of fluid into the pleural sacs. As has been well
said, the only vessels which do not leak are those of
the skin, kidneys, and the intestines. The skin is
dry and harsh, the urine scanty or suppressed, and
the bowels constipated.
Gastrointestinal disturbances are inconstant, but
the occurrence of nausea and vomiting always makes
one apprehensive of approaching uraemia. Visual
disturbances and retinal haemorrhage may appear
with the development of uraemia, but are rare as
compared with their frequent occurrence in chronic
nephritis.
The urine in acute nephritis is characterized by a
diminution in the amount of the twenty-four hour
secretion, the presence of albumin and tube casts,
and usually red blood cells. But this usual urinary
picture does not invariably obtain, however, as is
well shown by the statistical reports of Emerson (C.
P. Emerson, Cylindruria, Journal of the American
Medical Association, January 6 and 13, 1906) and
Cabot (loc. cit.).
The scanty urinary flow is sometimes the first
symptom that attracts attention, and this is often
coincident with the appearance of dropsy. In severe
cases anuria may occur at the beginning. The total
amount in twenty-four hours is commonly less than
500 c.c. and the specific gravity is normal or distinct-
ly high. Albumin is almost constantly found, occa-
sionally only in traces, but often in larger amounts,
although it rarely exceeds i per cent. Tube casts
are practically always present, and may be of any
form, including epithelial, blood, and leucocyte casts.
The urine occasionally contains much blood, and
some red blood cells are almost constantly found on
microscopical examination. The solids of the urine,
particularly sodium chloride and phosphoric acid,
are reduced, and the nitrogen excretion is said to be
diminished.
Dia}^nosis. — The existence of an acute nephritis
can be positively affirmed in only a certain propor-
tion of cases. When this renal condition is depend-
ent upon an already existing acute infectious disease
the symptoms of this complication may be entirely
masked iDy those of the primary condition, especially
if dropsy is absent. The urine will show the pres-
ence of albumin, it is true, but unfortunately this
does not prove that morphological changes have
taken place in the kidneys. If, in addition to the
albumin, the urine (catheterized in females) con-
tains more than the occasional epithelial cell, and a
moderate number of red blood cells and leucocytes,
additional data are present on which to base the diag-
nosis of nephritis. The occurrence of even slight oede-
ma about the eyes and ankles is strong corroborative
evidence.
In some cases the diagnosis is only too apparent.
Other causes of albuminuria or of dropsy have to
be excluded. hoVever. such as chronic passive con-
gestion of the kidney, amyloid disease, cachexia, and
anaemia. A considerable degree of oedema of the
ankles is very commonly noted when a patient who
has been bedridden for several ^ xeks, as with ty-
phoid fever, first begins to walk. This is generally
referable to the weakened state of the cardiovascu-
lar apparatus, and is only of a few days" duration.
The question whether the symptoms are due to an
acute nephritis or to an acute exacerbation of a
chronic kidney lesion is not always easy of solution.
The clinical history may ofifer the most valuable data,
while the absence of marked cardiovascular changes,
together with normal eye grounds, speak for an
acute process.
A difficult problem is presented in many cases of
haematuria. Aside from such conditions as calculus,
neoplasm, and tuberculosis of the urinary tract, and
malaria, blood in the urine may be present in acute
and chronic nephritis — so called hsemorrhagic ne-
phritis— or occur idiopathically as an acute renal
haemorrhage — renal epistaxis. The diagnosis of ns-
phritis cannot be made from the examination of the
urine, as the presence of the blood not only makes
the urine albuminous, but also causes any casts that
may have been present to disintegrate because the
specimen becomes alkaline so rapidly. The diagno-
sis will rest on the history, symptoms and the phys-
ical examination of • the patient — dropsy, fever,
changes in the heart and bloodvessels and eye
grounds, and uraemic symptoms. Renal haemorrhage
is very apt to be intermittent, so that a bloody urine
may alternate with one entirely free from blood and
albumin. Very often the diagnosis cannot be reached
until a specimen entirely free from blood cells is ob-
tained, when chemical and microscopical examination
will tend to show whether we are dealing with a nor-
mal secretion, or one from a pair of diseased kid-
neys.
The distinction between acute parenchymatous
and acute diffuse nephritis is not easy. In typical
cases the former condition is characterized by ab-
sence of cedema and a smaller percentage of albumin
in the urine, while dropsy and more or less marked
albuminuria indicate the more severe diffuse process.
If albumin persists after the fever becomes normal
we cannot be said to be dealing with a simple case of
febrile albuminuria, and such an occurrence may be
our only criterion of more or less extensive damage
to the kidneys.
March 2:
,908.]
]-A\DERH00r : SYMPTOMS AXD DIAGNOSIS OP NLl'HRl I IS
539
2. Chronic Diffuse Nephritis, -without Induration.
Chronic diffuse nephritis was at one time consid-
ered to be the "second stage of Bright's disease" and
so to form a connecting link between acute nephritis
and the chronic indurative forms of the disease.
While the careful study of the aetiological factors,
course, and termination has shown that the different
varieties of nephritis cannot be so arranged, yet in
many respects, both clinical and pathological, chronic
diffuse nephritis does occupy a position intermediary
between the acute and chronic indurative types of
nephritis.
Symptomatology. — The onset of chronic dift'use,
or parenchymatous, nephritis is always insidious.
While the one dominant symptom of this lesion, as
in acute diffuse nephritis, is dropsy, yet prior to its
appearance the patient usually suffers from a train
of indefinite symptoms such as frequent headache,
vertigo or "blind staggers," persistent gastrointes-
tinal disturbances which do not yield to appropriate
medication, a gradually increasing anaemia which is
more or less uninfluenced by iron and arsenic, or re-
curring attacks of bronchitis. Not infrequently the
lesion is discovered when the individual applies for
life insurance, and in many cases only a general feel-
ing of ill health associated with weakness and slight
shortness of breath, causes the sufferer to consult a
physician.
In a well developed case the appearance of the pa-
tient is most typical. The more or less widely spread
cpdema, the striking pallor, the mental hebetude, and
the dyspnoea on slight exertion combine to form a
clinical picture that suggests the disease at a glance.
Other symptoms are inconstant and not at all char-
acteristic. The heart is often enlarged, but here the
factor of dilatation is of about equal importance with
that of hypertrophy, and this so called eccentric hy-
pertrophy differs from that form which occurs in
indurative nephritis. The pulse is not character-
istic, as it may be rapid and weak at the height of
the disease when oedema is marked, while in other
cases the tension is distinctly increased, which leads
us to suspect that indurative lesions are developing
in the kidney. Digestive disturbances are often the
most distressing symptom early in the disease and
quite apart from ursemic conditions, being dependent
in all probability on an redematous infiltration of the
gastric and intestinal mucous membranes. Diar-
rhoea is not uncommon. Albuminuritic retinitis and
cerebral h:emorrhage do not occur early in the dis-
ease, but are not so infrequent toward the end. At
any time oedema of the brain or meninges may occur
and give rise to many of the symptoms of uraemia.
A papilitis, which may be confined to one eye, occa-
sionally develops, or a condition of so called con-
gestive neuritis and dropsy of the optic sheaths. In
typical cases of chronic parenchymatous nephritis
acute uraemic symptoms are not prominent except
at the terminal stage of the disease. A certain num-
ber of the symptoms of chronic uraemia (see below),,
however, are as common as in chronic interstitial
nephritis.
The urine is generally diminished in amount, al-
though not necessarily so, as an increased secretion
may accompany the rapid disappearance of dropsical
effusions, or develop gradually coincident with in-
durative changes in the kidney structure. The spe-
cific gravity, while usually high, varies with the daily
(luantil}- oi' urine excreted. The urine becomes am-
moniac'al very quickly on standing owing to the
ready decomposition of its increased albumin con-
tent." Albumin is a constituent that is rarely absent
in this form of nephritis. Except in those cases in
which the lesion approaches the indurative type, the
quantity of albumin is large, often ranging from 0.5
to I per cent. The sediment shows about the same
constituents as in acute nephritis, but red blood cells
are not so numerous unless there is a special tend-
ency to haemorrhage, or an acute exacerbation oc-
curs. Casts are usually abundant, especially the
coarsely granular, waxy, and fatty casts, but the
urine must be examined promptly on voiding, as the
casts go to pieces quickly in an alkaline urine.
Diagnosis. — In the majority of instances chronic
dift'use nephritis cannot fail to be recognized, and, as
Cabot says, the success in the diagnosis of this type
of case is in striking contrast with the large percent-
age of failures in other forms. He further calls at-
tention to the fact that the diagnosis may depend as
much on the clinical features as on the urinary ex-
amination. From acute dift'use nephritis it is distin-
guished chieflv by the history of onset and clinical
course, as w ell as by other points mentioned in dis-
cussing that lesion. Amyloid di.sease of the kidney
may be very difticult to distinguish from chronic
parenchymatous nephritis, and in some cases this
cannot be done. The absence of causes which usu-
ally lead to amyloid degeneration is against the as-
sumption of that disease. An acute exacerbation of
a chronic iaterstitial nephritis may simulate a case
of the parenchymatous form very closely, and only
the history of the case, or possibly the cardiovascu-
lar condition, or often the subsequent course, may
allow us to speak with any degree of assurance on
this point. Chronic passive congestion of the kidney
due to cardiac insufiiciency, emphysema, etc., can
usually be distinguished by discovering a cause for
the congestion, but not infrequently we have equally
good reasons to suppose that the heart condition may
be of the nature of a relative insufiiciency secondary
to the kidney lesion. In such a dilemma we have to
be satisfied with the diagnosis of a "cardiorenal"
case.
3. Chronic Indurative Nephritis.
"Dift'use indurative nephritis may develop either pri-
marily as the product of a protracted, or oft repeated,
extremely insidious inflammatory irritation, or it may
follow acute, subacute, or subchronic so called paren-
chymatous inflammatory states and represent then-
terminal stage — i. e., as so called secondary indura-
tion or contracted kidney. The primary form again
may be either the result of some irritant acting di-
rectly on the renal parenchyma on account of some
abnormality in the blood, or indirectly through the
mediation of arteriosclerosis. The former is desig-
nated 'genuine (primary) renal cirrhosis' or simply
'chronic interstitial nephritis' ; the latter is known as
'arteriosclerotic contracted kidney' or 'sclerosis of
the kidney.' " (Senator.)
Symptomatology. — The onset of chronic indura-
tive nephritis is always gradual, except in the small
proportion of cases that are secondary to acute ne-
phritis. The patients experience difficulty in de-
scribing either the time or the nature of the earliest
540
VANDERHOOl- : SYMPTOMS A\D DIAGXOSIS OF NEPHRITIS.
[New York
Medical Journal.
symptoms that may be attributed to the ahered kid-
ney function. I am in the habit of asking them
when they were last perfactly well, but the informa-
tion so obtained does not really give the exact dura-
tion of the process for the reason that the earliest
evidence of the disease may be found in the urine for
a certain period of time before symptoms manifest
themselves.
As has been well demonstrated, there are two
stages in the development of primary chronic indu-
rative nephritis ; the first, aside from certain variable
and inconstant s}mptoms, is characterized only by
changes in the urine, while the second has to do with
the more characteristic clinical symptoms, chiefly
referable to the vascular and nervous systems.
In arteriosclerotic indurative nephritis symptoms
on the part of the cardiovascular apparatus are the
first to appear, and definitely precede the changes in
the kidneys and the appearance of abnormal constitu-
ents in the urine. So here, also, two stages may be
distinguished, occurring in reverse order to those of
primary indurative nephritis. While this arrange-
ment of the symptoms is convenient for purposes of
clinical or pathological distinction, yet it must be re-
membered that it applies only to typical examples of
the two processes, and that many transitional or in-
termediary forms occur.
The changes in the heart and bloodvessels are in
many respects the most important, both from the
standpoint of diagnosis and prognosis. " It is this
very fact that makes the examination of the eye
grounds of such great value, for in many cases
the actual condition of the vascular apparatus is
depicted more clearly by the ophthalmoscope
than by any other available means of examina-
tion. In a clinically doubtful case I know of no
greater comfort than the absolutely negative opin-
ion of a competent eye specialist, while I certainly
would hesitate to give anything Init a most gener-
ally worded prognosis in the chronic disease of in-
terstitial nephritis without the ophthalmoscopic re-
port before me.
The ordinary subjective symptoms on the part ot
the cardiovascular system are dyspnoea, palpitation,
and general precordial distress, vertigo, tinnitus
aurium, and interference with vision. The objective
features are hypertrophy of the heart, increased
pulse tension, and ha-niorrhage.
The frequent occurrence of cardiac hypertrophy,
without valvular lesions, in chronic nephritis was
first insisted on b\ Richard P.right, although his
views were much contested until put on a firm basis
in the classic treatise by Traube, in 1856. It is now a
well estal)lished fact that the enlargement of the
heart does not appear until after the urinary changes,
particularly polyuria and albuminuria, have alrearly
existed for .some length of time ; and, furthermcre.
that the hypertrophy exists for some time without
dilatation, and that it afiPects the left ventricle pri-
marily and exclusively, or, at least, more than any
other chamber.
The rise in blood pressure, which has now become
of such importance in the diagnosis that progressive
insurance companies have seen fit to include the
manometric readings in the examination of all risks
over fortv years of age, apparent! v develops par'
passu with the hypertrophy of the heart. The at-
tempts to explain the real cause of the increased
pulse tension and cardiac hypertrophy have led to
the promulgation of a great number of theories.
While this problem still remains unsolved, yet it may
be said, in short, that the various theories based on
physical considerations are not tenable in view of
the experimental studies on animals, and that the re-
maining theories either rest upon the assumption of
unproved physiological factors, or an altered state
of the blood which acts as an irritant to the vascu-
lar endothelium. Senator concludes that in primary
chronic interstitial nephritis, owing to the insidious
onset and slow course, the irritation of the vas-
cular apparatus is no doubt more feeble than in par-
enchymatous nephritis. Accordingly the injury to
the vessels in interstitial nephritis is not, as in the
parenchymatous form of the disease, severe enough
to allow the transudation of serum and dropsy ; but
that the persistent irritation eventually results in con-
traction of the vessels. The result is increased pres-
sure in the whole aortic system and hypertrophv of
the left ventricle. Further discussion of this phase
of the subject will only lead us to theorize as to the
yet unknown cause of nephritis in general, and serve
to bring up the question as to whether the source of
this supposed irritant is in the kidnev, liver, or other
organ of the body.
A very important group of symptoms refer-
able to the vascular system is due to hemor-
rhage. Cerebral haemorrhage is, of course, the most
serious form, and statistics show that it occurs in
from 6 to 18 per cent, of cases. Retinal haemorrhage
is probably the most common lesion that we can dem-
onstrate, and is therefore of special significance in
diagnosis. Haemorrhage from the kidnev may be a
feature of some cases of chronic interstitial nephritis.
Epistaxis is not very uncommon. Rarer forms of
haemorrhage are metrorrhagia, haematemesis, hem-
optysis, and haemorrhage into the intestine, tympanic
cavity, pharyngeal and laryngeal mucous mem-
branes, haemorrhages into the skin, and lastly a con-
dition of hasmorrhagic diathesis. These vascular fea-
tures of nephritis are well set forth in a valuable
paper by Riesman (David Riesman, Haemorrhages
in the Course of Bright's Disease, etc.. American
Journal of the Medical Sciences, November, 1907,
page 709).
Symptoms on the part of the digestive system are
not prominent in chronic nephritis except when due
to passive congestion of the intestinal tract, or when
associated with uraemia. The same may be said for
the respiratory apparatus, except that patients are
often subject to catarrhal inflammations of the upper
air passages, or attacks or "renal" asthma, and that,
with the general lowered resistance, the terminal
event in chronic nephritis is not infrequently a pneu-
monia. When cardiac insuflficicncy develops there
is passive congestion in the lesser circulation, with
all its attendant symptoms.
Subjective symptoms referable to the nervous sys-
'tcm are very common, such as headache, insomnia,
neuralgia, retinitis, and papillitis, etc. Some of these
.symptoms assume special importance in regard to
their relation to uraemia (see below).
The organs of locomotion, the skin, and the gen-
ital organs .show no noteworthy changes that are" not
due either to haemorrhage or uraemia.
The general state of the health may remain fair-
March 21, 1008.)
VASDERHOOF: SYMPTOMS AXD DIAGNOSIS OF XEPHRITIS.
ly good for some length of time, and no pronounced
alterations in metabolism are noted early in the dis-
ease. With the advent of chronic passive conges-
tion of the intestinal tract, and in chronic uraemia,
malnutrition becomes manifest and results in dis-
tinct loss in weight and strength and of the gen-
eral resistance of the organism to various acute in-
fections. The blood shows no important changes that
are at all constant or characteristic.
The urine in chronic indurative nephritis, in the
great majority of cases, shows characteristic
changes which may be readily explained. The first
change is the appearance of small quantities of albu-
min. This albuminuria for some length of time is
distinctly intermittent, and the albumin may be en-
tirely absent in the urine voided in the morning after
a night's rest, but be found in a specimen passed in
tiie evening after the ordinary physical exertions of
a day's routine. This slight and distinctly periodic
excretion of albumin later becomes more persistent,
although it is never large in amount. More or less
coincident with the albuminuria hyaline casts begin
10 appear, but they are often scanty in number and
difficult to find. This intermittent albuminuria and
cylindruria may occur for months, or even years, be-
fore subjective symptoms are noted. The first of
these is a slowly developing polyuria, which grad-
ually becomes more marked until the patient has his
attention directed to the increased frequency of
micturition, which is especially conspicuous when
he finds that he is compelled to get up once or twice
during the night to empty the bladder. When the
nephritis is well developed the daily secretion of
urine amounts to two to four litres or even more.
The urine is pale, clear, definitely acid, with a con-
stantly low specific gravity varying from 1.005 t°
1. 010, the albumin is seldom more than a distinct
trace — 0.05 per cent. — and casts are few.
The urinary changes in arteriosclerotic indurative
nephritis differ from those in the primar>- interstitial
form in that the polyuria is the earliest change, and
an increased secretion of urine having a low specific
gravity is the most constant sign of this disease.
Albumin and casts may never be found until the
kidney lesion, as well as the clinical symptoms, be-
come marked. In other instances a slight trace of
albumin may be found in the evening urine, and
only prolonged search will reveal one or two hya-
line casts.
At any time during the course of a chronic ne-
phritis an acute exacerbation may occur with cor-
responding changes in the urinary findings. Also,
when the heart begins to fail, the broken compensa-
tion gives rise to chronic passive congestion of the
kidneys and other viscera, and distinct deviation
from the usual urinary picture is found. Particular
attention has been directed to these anomalous
urines, because very often the patient only consults
a physician when an acute exacerbation has caused
the appearance of slight dropsy, or the failing heart
brings about an unusual degree of dyspnoea. It is
only after these transitory conditions have cleared
up that the typical urinary findings reappear.
Other qualitative or quantitative changes in the
urine are either inconstant or not necessarily char-
acteristic of chronic indurative nephritis. The ques-
tion of the urea excretion shall be referred to in
discussing the diagnosis of this affection.
The reasons for the changed character of the
urinary secretion can be understood when the ana-
tomical and physiological alterations in the kidney,
heart, and bloodvessels are considered. It is a well
accepted fact that the kidneys are. generally speak-
ing, the first to suffer from any injurious substance
circulating in the blood. Now, the action of the
irritant, which is supposed to be the underlying
cause of nephritis in general, first manifests itself
in slight damage to the parenchyma, or secreting
portions, of the kidney, and this accounts for the
early albuminuria and cylindruria. The further ac-
tion of this irritant, as has been already pointed
out, brings about a general rise of blood pressure in
the systemic circulation accompanied by hyper-
trophy of the heart. It is then quite conceivable
that the increased pressure and velocity of the blood
flow through the kidneys may be the cause of the
increased urinary secretion, particularly water, char-
acteristic of chronic indurative nephritis.
Chronic Urce>nia. — The careful examination of
the cardiovascular system and of the urine usually
suffices tp establish the diagnosis of chronic indura-
tive nephritis. In spite of this it may be safely
stated that a large proportion of cases are not diag-
nosticated, and this is often due, I believe, to the
failure on the part of the physician to fully appre-
ciate the various symptoms that are due to chronic
uraemia, so that he does not have his attention di-
rected to the renal insufficiency as the cause of the
patient's ill health.
Chronic uraemia is a toxaemia which occurs to a
greater or less extent in all cases of chronic ne-
phritis and with a symptom complex of considerable
diversity. Most of the disturbances to which it
gives rise are on the part of the nervous and di-
gestive systems.
The motor symptoms, convulsions, etc., which are
so prominent in acute uraemia, are replaced to a
certain extent by psychic manifestations in this
chronic toxaemia. The patients are for the most
part apathetic, and frequently somnolent. Restful
sleep, however, is not assured to these sufferers, and
pronounced insomnia is a feature of some cases.
Some patients, who have believed themselves per-
fectly well, may suddenly lapse into a condition of
mental confusion, so that they experience difficulty
in remembering their names or recognizing familiar
faces. I saw such a case not long ago in a man
of fifty-six. who was suddenly seized with severe
gastric symptoms, to be followed by the mental con-
dition just described ; his blood pressure was 210
mm., and the ophthalmoscope revealed a unilateral
papillitis. His symptoms slowly cleared up in about
two weeks' time. In other cases distinct mental
symptoms develop, such as profound melancholia, or
mental depression, with delusions of persecution.
Headache, recurring and persistent, is undoubt-
edly the commonest symptom of chronic uraemia.
It is an early feature, and may continue, with short
periods of freedom, for many months. While it is
frequently occipital, yet it varies in different cases,
and also in the same one from time to time. A pa-
tient under my care at present describes his pain,
542
I 'AXDERHOOl' : i,yMFIUM^ AND DIAGA'OSIS Of NEPHRITIS.
[Xew York
Medical Journal.
Avhich is limited to the vertex, as if an object the size
of a lead pencil were boring into one particular spot.
This same patient complains of attacks of sharp
pain in the "bones" of the arm and leg, about three
inches above the wrist and ankle, which are severe
enough to wake him up at night. Headache is often
so predominating a symptom that patients state that
they would feel perfectly well if they could only be
relieved of it. This symptom is of special impor-
tance when it develops in an individual who ha?
not been subject to headache.
Tonic contractions of ditterent groups of mus-
cles are prominent in some cases. Most conmionly
one sees cramps in the calves of the leg, especially
at night, but a not infrequent symptom in some
cases is severe and recurring abdominal colic. In
one interesting case of mine this symjiidin caused
the patient, a day laborer, to stop work and seek
medical advice. During the four months he has
been under treatment directed to the renal insuffi-
ciency this symptom has entirely gone, and he has
insisted on resuming his usual occu|)ali(jn.
Among the eye SNiiiptoms of chronic uraemia
myosis is commonly ohscr\e(l. altlicnigh in acute
unemia the pupils are usually dilated. Retinitis is
a relative common finding, and in some cases is as-
sociated with an optic neuritis, but many of these
changes may be partly attributed to lesions of the
bloodvessels of the fundus. Sudden and transient
amaurosis may occur without visible changes in the
nerve.
Disturbances in the sense of hearing are rather
rare, except tinnitus, which is probably vascular
rather than urjcmic in nature. \"ertigo, however. i>
a frequent complaint, and may be due to disturb-
ances in the inner ear. •
Other nervous phenomena consist of various
forms of palsies which are associated with the
uraemia state, but their character points to a focal
brain lesion. In view of their transitory nature,
they are probably due to fedema of the brain rather
than cither uraemia or h:emorrhage. These palsies
include strabismus, monoplegia, and hemiplegia,
paralyses of the bulbar type associated with diffi-
culty in speech and in mastication, etc. Numbness
and tingling in the extremities is sometimes ob-
served.
Chronic uraemia very frequently manifests itself
in disturbances of the gastrointestinal tract. Dis-
tinct indigestion is an early sign, and proi)ably ranks
only second to headache as an important symptom
of renal insufficiency. Loss of appetite is a feature
of some cases of chronic nephritis, and the patients
usually state that the slightest indiscretion in diet
upsets the stomach very promptly and often induces
nausea and vomiting. These early gastric symp-
toms, like the headaches, are usually periodic, as on
some days the food is relished and retained without
difficulty, while at other times the patient has abso-
lutely no desire for food, and attempts to eat bring
on nausea and vomiting. The tongue is often heavi-
ly coated, and much com])laint is made of the foul
taste in the mouth. Such symptoms as these oc-
curring in persons of the age at which chronic in-
terstitial nephritis is common should always direct
attention toward this lesion, and the presence of in-
creased pulse tension, accentuated second aortic
sound, and the history of increased frequency of
urination make the diagnosis very probable even
before the urine is examined. I remember just such
a case as I have described which I saw last summer
in a woman, sixty years old, who had been under
the successive care of three physicians, and had
probably been given digestive mixtures ad nauseam
(literally). Under appropriate medication directed
to the kidney condition her improvement was most
prompt and striking, and when I last heard of her
she considered herself practically well. I have a pa-
tient in the hospital at present with well marked
interstitial nephritis. He is unable to definitely fix
the onset of his ill health, but it is very instructive
to note that he consulted a physician in the spring
of 1906 for "stomach trouble," and that he was
referred to a specialist for a gastric analysis, etc.
The bowels are regularly constipated, and this is
often so marked that one of my former teachers
used to declare that a patient will not die of uraemia
as long as one can keep his bowels open. It is
said, however, that severe diarrhoea may be a fea-
ture of uraemia, but I rather believe that this oc-
currence is of the nature of a terminal infection of
the bowel, as the dysenteric symptoms may be
marked, and on post mortem are often found to be
associated with ulcerative processes in the intes-
tines.
Respiratory disturbances dependent on uraemia
are rare, as they are due to the associated cardiac
insufficiencv and consequent passive congestion in
the lesser circulation. The occurrence of Cheyne-
Stokes respiration is likewise due to insufficient
aeration of the blood and its direct effect on the
respiratory centres.
1 he skm is usuall}' dry, but this does not indicate
that the patients cannot be made to sweat profusely.
Intolerable itching is said to be a frequent symptom,
which is sometimes attributed to overloading of the
blood with urinary constituents, so that the sensory
nerves are irritated. I have failed to observe this
.sxniptom in chronic nephritis, except in patients
who were receiving morphine.
, Diagnosis. — There are three essential points to
be considered in the recognition of chronic indura-
tive nephritis: First, the physical examination of
the patient, with special regard for the condition of
the cardiovascular apparatus ; second, the examina-
tion of the urine, bearing in mind the apparently
slight variations from normal early in the disease,
or even after it is well established ; and, lastly, the
full appreciation of the significance of the symp-
toms that may characterize the condition of chronic
uracil ia.
The cardiovascular features of chronic interstitial
nephritis, while not the earliest signs of the disease,
are, nevertheless, prominent and important from the
diagnostic standpoint. Increased pulse tension is
usually indicative of a kidney lesion, though not
necessarily so. Even in the absence of dyspnoea
the tongue often shows a distinct cyanotic tint, and
the second heart sound over the aortic area is found
to have a sharp, ringing, accentuated tone. The
apex beat is displaced downward and to the left, and
is strong and heaving. If any degree of dilatation
March 21. 190S. |
VANDERHOOl=: SYMPTOMS A\D DIAGXOSIS 01- SliPIIRITIS.
543
has occurred the relative insufficiency of the mitral
valve is denoted by a swstolic bruit over the mitral
area. The condition of the radial and temporal
arteries may suggest the arteriosclerotic basis for
the nephritis.
The ophthalmoscope may reveal most important
evidence in the diagnosis of nephritis, and the large
number of cases that are first recognized by the
eye specialist will always stand to the general prac-
titioner's discredit. Chronic nephritis should cer-
tainly be diagnosticated before retinal hremorrliagc
has occurred, although in some few cases interfer-
ence with vision may be the symptom that first seri-
ously afifects the patient, so that hfe consults an ocu-
list rather than his family doctor. In any doubtful
case the eye picture may settle the question, and it
would be well for every medical man to be suf-
ficiently versed in the use of the ophthalmoscope so
that he can recognize the grosser retinal lesions.
The instrument that is equipped with an electric in-
candescent light is a most convenient one to use, as
it requires very little dexterity in its handling, and
the patient can be examined while l} ing flat in bed
in a room not necessarily darkened. Slight degrees
of nenroretinitis are, of course, more safely left to
the judgment of the specialist. As I have stateil
before, I regard the retinal changes as being of spe-
cial value not only in the recognition of the disease,
but also in enabling us to give a more definite prog-
nosis in many cases.
The most important features of the urine in
chronic indurative nephritis are the total amou'it in
twenty-four hours, the specific gravity, and the
presence of a, small amount of albumin and a few
tube casts. Are we justified, however, in making a
positive diagnosis in view of such findings? Most
certainly not. L^rines presenting just such charac-
teristics may occur in other conditions, and it
should be emphasized that the urinary examination
IS only of value when considered with the clinical
history and physical findings. Just by way of illus-
tration, the urine from a patient with typhoid fever
who is drinking large quantities of water will be in-
creased in amount, of low specific gravity, show
febrile albuminuria and often a few casts.
Polyuria is a constant feature of chronic intersti-
tial nephritis, and is usually most marked during the
night. A certain amount of discretion should be
used in placing valuation on this symptom, as the
patient must not be on a forced water consumption.
If physicians would insist on having the twenty-four
hour amount recorded in all their urinary examina
tions, early cases of chronic interstitial nephritis
would not be overlooked. The low specific gravity
is associated with the polyuria, but it is al\va\ s ad-
visable to determine the weight of a mixed specimen
of the twenty-four hour secretion. A low specific
gravity — 1.005 to i.oio — of the early morning urine
is especially suggestive, as single voidings at other
times may show greater density.
The albuminuria of chronic interstitial nephritis
is distinctly intermittent or periodic in the verv earl\-
stages of the disease. When subjective symptoms
first begin to appear the albumin occurs more con-
stantly, and will be found in nearly all cases, I feel
certain, just in proportion to the care with which it
is .sought. Contrary to the teaching in many text-
books, I do not regard one of the most commonly
employed tests — Heller's reaction when nitric acid
ancl the urine are brought into contact — as at all suf-
ficient to demonstrate the small, but distincl. traces
of albumin in the urine of chronic interstitial nephri-
tis. Only a short time ago a physician bn^ught me
a specimen of urine from a woman in whose eyes an
oculist had discovered an albuminuric retinit-> He
was rather inclined to question the eye s]Kcialist's
judgment, for the reason that he could nni find the
albumin ring by Heller's test. I could not, either, even
by making use of the horisniascope. \\\ boiling the
upper part of the urine in a test tube three fourths
filled, however, a slight but distinct cloud appeared,
which persisted on the addition of a few tlrojjs of
five per cent, acetic acid. In addition, the urine was
of low specific gravity, and the sediment obtained bv
centrifugalization showed the presence of a few hya-
line casts.
In the heat and acetic acid test the albumin is ])re-
cipitated by boiling as coagulated albumin. The
cloud that is produced can be easily recognized by
comparing the upper boiled urine with that in the
lower part of the tube which is held in the hand.
The cloud may be due to phosphates or carljonates.
but these are immediately dissolved on adding ;i few
drops of the acetic acid. The acid should always be
added after boiling, even if no cloud has appeared,
as the urine may not be sufficiently acid for the pre-
cipitation of the albumin until the acetic acid is
added. Any great excess of acid should lie a\-oidcd.
as it produces soluble acid allnimin. WJ-i n tliis rloud
is faint enough .so as to become doubtful we are
probably dealing with a normal urine, and this
"faintest possible trace" is due to the so called nu-
cleoalbumin. This substance is equally well precipi-
tated in the cold by dilute acetic acid, how ever, and
does not often occur in sufificient amount to cause
the very distinct cloud that albumin produces. Hast-
ings ( t. W. Hastings, Albuminuria, Medical Rec-
ord. July 7. 1906) advises that there lie added to the
urine one fifth to one sixth its \ .)liime of saturated
sodium chloride solution before it is heated. This
procedure not only serves to bring nut the serum
albumin in a urine poor in neutral salts, but also
holds in solution any nuckoalbumin that ma\ be
present.
It is ver\ important that the urine to be tested for
albu mm should be ])crfectl\ clear. It is best to ex-
amine only a' comparatively fresh specimen, but if
the urine is at all turbid from the presence of bac-
teria these c-in be mechanically removed bv mixing-
the urine with Kieselo-iihr. or infusorial earth, and
then filtering. The presence of any (juantity of pu-i
or blood in the urine always makes the urine albu-
minous, and may be very (lisconcerting, as no satis-
factory method has been devised by which we can
estimate how much of the albumin in such a speci-
men c^n be attributed to these formed elements.
The urinary sediment is very scanty in chronic in-
durative liephritis. and none may be thrown down
even on centrifugalizing. Casts mav be found in
most cases, chiefly of the hyaline and finely granular
varicty, but are rarely numerous. Cast.s', of them-
selves, have but little diagnostic importance, as
544
IIAIM: SOUR MILK.
[New V.,kk
Medical Joirnai^
the lesion causing cylindruria may be a slight
or temporary irritation of the renal paren-
chyma. The continual presence of casts is
of far greater importance. In discussing the
significance of casts, lunerson, in his excellent pa-
per on Cylindruria, already referred to, says :
"Casts . . . are of nnich importance in following
a case of nephritis or other renal disturbance. For
them t(i l)e present temporaril_\- and then to disappear
entirel}- means, no matter how alarming their num-
ber and variety may have been, a temi)orar\- and
probabh harmless disturbance; for them to continue
for days, weeks, or months, no matter how few and
how insignificant the onset of the trouble, means
chronic nephritis: and for them to remain two years
means, it is ^aid, an incurable case." In order to
find casts the urine should be as fresh as possible, a^
they g'> to pieces more or less rapidly, and in an
alkaline urine the search for casts is time thrown
away, for they will not be found.
The estimation of the amount of urea excreted in
twentv-four hours has been shown to be not only
fallacious, but also useless in the diagnosis of nephri-
tis. To refer to the latter contention first, it has been
well demonstrated that the urea is not constantly
reduced in the urine of chronic interstitial nephritis,
but that its excretion is subject to ])erio(lic altera-
tions, I have not infrequently found a total excre-
tion of over 40 grammes per t\\cnt\ -fonr hours in
well developed cases. As a ride the uren excretion
is below normal, but such a finding by no means in-
dicates the functional power r>f the kidney to ex-
crete tlii> substance. The amount of urea that is
carried in the blood for excretion is the imj)ortant
factor, and tliis depends on the amount of nitrog?n
ous food absorbed, and on many other factors, such
as presence or absence of fever, \-oniiting, and diar
rhoea, the amount of exercise and sleep, and, in fact,
the general catabolism of the whole body. It is only
by the most elaborate experiments, with due regard
to a large number of conditions, that urea estima-
tions of any value at all can be made.
Attempts to estimate the fiuictional activitv of the
kidneys by cryoscopy, the degree of glxco^uria after
the use of phloridzin, and the rapidity of the excre-
tion of methylene blue, cannot be said to have made
for themselves a place of value among our diagnostic
aids for the recognition of nephritis.
The relative value of the different urinary features
of nephritis, as well as the relative importance of the
urine compared with the other signs and svmptoms
of this disease, demand nuich studv and considera
tion. In the main, one nuist agree with Caboi
when he says: "In my opinion the mi - ro-c i] i al
and chemical examinations of the urine are (<\ nuu li
less significance than the physical. Microscopic and
chemical changes arc relevant rather to temporary
alterations in function than to alteration in anatomi -
.structure. When we are concerned chiefly with the
rjuestion Has this patient a nephritis or not? what
we need most to know is simplv how much urine
does he pass, by day and by night, and wfiat is the
weight of that urine? These facts, together with the
presence or absence of dropsy, retinitis, cardiac hv-
pcrtrophv. and uncmic manifestations, constitute
nearly all the evidence at otu" disposal."
119 XoRTii Finn Siui-.tCT.
THE QUESTION OF SOUR MILK.
By Leon H.aim, E. A. M. (France),
Ithaca, N. V
From the Cornell Vniversitx, Ulluicn. A'. )'.) Dairy Bacleriotog\
L.l!>,jr„torx.
History of Sour or Curdled Milk.
Xothing is older than curdled mik or sour milk,
and nothing seems newer than the application wdiich
has been made of it.
It is to be noted that civilized people are the only
ones to drink milk fresh or boiled, while fermented
milk is almost the only kind used outside the pale of
our civilization. The use and origin of curdled
milk are older than liistory. Thus, at the time of
the patriarchs, whose longevity was remarkable,
mention is made in tlie I'.ible of sour milk: "W'hen
Abraham saw three men approaching he invited
them to enter and oft'ered them some sour milk and
some sweet milk and some veal that had just been
brought." ( ( ienesis, xviii. 8.)
Later the Greeks and Romans also recognized the
strengthemng and tonic effects of sour milk, and
they ])er formed veritable cures with the special kind
of curdled milk called "schiston."
In our time fermented milk is in common use as
a daily diet in eastern countries. The writer has
seen in I£g\ pt. the Holy Land, and Syria a kind of
sour milk called "leben" ; in Anatoly, Turkey in
Europe, and Greece a 'kind of sour milk called
"yaghourt." I'nder the name of raiel, he found a
kind of SOU!' milk in use in North Africa. He vis-
ited in Tunis, North Africa, the bacteriological ex-
periment station under the supervision of the
French govermuent. where the preparation of sour
milk is scientificallx conducted, in order to pro])a-
gale this wholesome product.
It is said that a kind of sour milk under the name
of ■■yaghourt" is used in Bidgaria ; of "leben" in
.\rabia ; of ■"matzoon" in Armenia ; of "gioddu" in
.Sardinia: of ■' jM-ostokvasha" and of V'arrnetz in
Russia. .\lr. 1 lernian \ . R. Ande, from Denmark,
wrote to the writer that in Denmark, Norway, and
Sweden tlie jteopK enjoy a dish of sour milk called
"tyk moelk. ' translated, thick milk. The milk is put
away in dishes to sour a;id curdle: then it is eaten
usuall\ with r\ e bread cnunbs and sugar.
The following reference has been given by K'Ir.
Chacravarty, of Dacca, Hindustan: "The 'dabi" is
a kind of sour milk used as a beverage in India.
There are various kinds, and the bacteria bringing
about these fermentations have not been studied in
det 'il. It is usually sour, used as a cool beverage,
and is sup[»sed to help digestion. Sometimes,
ludirm and I^uropean jihysicians recommend it as
a diet for persons suffering from diarrhoea." Ex-
plorers say that sour milk is used by numerous tribes
of negroes in Africa.
In almost all these countries, besides being used
as a food, sour milk has played and still plays a
great part in empirical medicine. The use of fer-
mented milk as food among these people must be
♦^he result of judicious observations and experience
of munerous generations. This empirical observa-
tion may have a scientific explanation, for it is well
known how fpiickly foods decay when exposed to
tropical ln'at. When ingested, germs of putrefac-
:Marcli -'I. TyoS.I
HAIM: SOUR MILK.
545
tion enter with them, which may continue to develop
in the large intestine. Unwittingly these people
have used for many centuries, in order to combat
intestinal putrefaction, the best and the most effi-
cacious method which is known to science for only
a short time.
It is only w'ithm a few years that the question of
sour milk, as a wholesome food, has attracted the
attention of the physicians : and since many studies
on the different kinds of fermented milks have been
made by various peoples ; and on account of satis-
factory results of numerous investigations and ex-
Ijeriments these wholesome product.-, came into use
again.
The first investigations had to do with the "kefyr"
and "'kumyss." which were highly recommended for
their great digestibility and tonic effect. Since other
similar beverages are known to contain no alcohol,
these latter are preferred in most cases.
Sour milk, after being recognized as a whole-
some food possessing medicinal properties, has been
proclaimed by some people as a remedy for pro-
longing human life. In connection with this, we shall
quote the following few lines, resuming the opinion
of Metchnikoff. one of the greatest authorities on
the subject:
The fact that many people in all countries and in all
ages have consumed large quantities of sour milk, and are
so much benefited by its use, is a testimonial to its value.
The distinguished African explorer, Xegueria. in a letter
to me has described his astonishment upon beholding the
well preserved appearance and absence of senility among
the natives of Massamedes, whom he had not visited for a
period of many years. Dr. Lima affirms that among the
natives of the region south of Angola there is to be found
a very large number of individuals noted for their extraor-
dinary longevity, and although they are thin and dry, the
old people are active and capable of making long voyages.
Grogoroff, a Bulgarian student, has reported an astonish-
ingly large number of centenarians encountered in a region
of f?ulgaria where sour milk constitutes an essential ele-
ment of diet. A long list of centenarians has been col-
lected by chemists in many countries using sour milk as an
article of daily diet. etc.
For many years these sour milks have been prepared by
first sterilizing milk and afterward inoculating it in a pure
culture of lactic acid microbe. I have taken a liberal ration
of this sour milk daily and have been exceedingly gratified
with the results that I have experienced. After this long
trial, I feel justified in expressing a favorable opinion.
Man}- of my friends, among them some who suffered from
gastrointestinal troubles and serious kidney diseases, have
followed my example. In view of all that has been stated
I am naturally led to the opinion that in the struggle against
intestinal putrefactions the lactic acid producing bacteria are
undeniably serviceable. Finally to proclaim that in this
specially prepared sour milk, we possess a remedy against
old age, or a means of prolonging human life we must let
time, experience, and observation answer this question.
Sour Milk ill Therapeutics. — The antiseptic action
of the lactic acid ferments is a fact commonly known
for a long time, and numerous applications of it
have been made. Thus, evervbody knows the sim-
ple process used in many countries since the most
remote time of preserving vegetables such as cab-
bage, cucumbers, beets, fresh beans, olives, etc. The
vegetables are placed in jars or other receptacles full
of water, to which is added a little salt, and they are
kept well sealed. After some time these vegtables.
which exposed to the air would have decayed and
become unfit for food, undergo by this process no-
ticeable modifications in color, smell, and taste, in
their digestibility and preservation, all appreciable
qualities. These products in order to acquire these
qualities have undergone a fermentation ; and it is
proved today that the principal agent of this fer-
mentation is lactic acid ferment. The salt is used
only to check temporarily the growth of injurious
bacteria w^hich may be present, until the lactic fer-
ments are able to develop freely and in sufficient
number to carry on their useful action. The writer
has seen in certain Eastern countries and in North
Africa people using the same process for preserving
lemons, green tomatoes, etc. In the preservation of
beets in silos, lactic acid is, in this case too. the prin-
cipal agent of the process of fermentation. W'htn.
for some rea.sons, the lactic acid fermentation does
not take place, the silage has a very disagreeible
odor, which causes the cattle to reject this food. "The
animals feeding on a product of this kind show
symptoms of gastric troubles. The continued feed-
ing of such food may cause serious troubles and even
threaten the health of the animals.
Metchnikof? tells us that in many countries in
which they use sour milk the latter is used for pre-
serving meat. In ^America older people often sweeten
tainted meat by the use of buttermilk, as well as
using it for preserving meat for a short time. All
these facts, although empiric, are nevertheless sig-
nificant of the antiseptic power of the lactic fer-
ments.
It is to-day proved that lactic ferment causes the
preservation of all these products by preventing the
development of the germs of putrefaction. First by
the production of lactic acid from hydrocarbohy-
drates substance, and thus rendering the medium
unfavorable to the growth of many species of bac-
teria preferring neutral medium : second, by its high
power of growth, capable of checking and combat-
ing the development of other germs.
One of the simplest and most easily demonstrated
experiments showing the antagonistic action of lac-
tic acid fermentation towards harmful germs has
been made by Dr. Ed. de Freudenreich. Following
is his own account :
When sterilized milk is inoculated simultaneously with
one platinum loop of cioddu (a kind of sour milk used in
Sardinia and one of typhus and cholera cultures, the latter
do not develop; the microbes of the cioddu (lactic acid bac-
teria) rapidly invade the entire field.
Along the same line Conn has made an analogous
experiment, which we quote. If sterilized milk is
inoculated with putrefactive bacteria it will be badly
decomposed and putrefied in a few days. If, how-
ever, lactic acid bacteria are present, the putrefac-
tion of the milk by these peptonizing bacteria is pre-
vented.
Industrial Applications. — Certain industries, as
the manufacture of beer, butter, and cheese, have
been the first to profit by these discoveries and by
their successful application. Thus, Ducaux in his
reputed w-ork. Microbiology, iii. expresses himself as
follows in speaking of the role of the lactic acid fer-
ments in the manufacture of beer :
We know that nearly neutral liquids are easily invaded
by countless germs in the raw materials employed. The
question is how to give in this mass of various germs the
predominance to the lactic ferments which in making the
liquid acid protect it against other ferments that might
produce undesirable changes. The lactic acid fermentation
thus becomes an antiseptic fermentation.
The application of the use of pure culture of lactic
546
HAIM: SOUR MILK.
Medical Journal-
acid to the manufacture of butter has contributed to
regulate the ripening of cream, to obtain a product
uniform throughout the year and capable of being
kept longer.
Application in Medicine. — It has only been since
investigations on the human intestinal flora were be-
gun and the existence of their useful bacteria was
recognized that scientists asked themselves whether
the beneficial action of sour milk was not due to the
presence of lactic acid ferments. Experiments have
been conducted by bacteriologists and physicians in
order to know whether the presence of lactic acid
organisms in the intestine is capable of preventing
the development of putrefactions. I shall now give
a general summary of these experiments. Before tak-
ing up this (|nestion. however, I should like to quote
the following passage from a work of Metchnikof¥ :
We ought to try to transform the wild intestinal flora of
man into a cultivated flora represented by species that are
useful or at least harmless. Numerous attempts are being
made to regulate different fermentations by the aid of pure
. cultures and to improve the manufacture of beer, cheese,
' butter, etc. It is high time to apply similar methods to
perfect the intestinal fermentations of man.
The same learned professor of the Pasteur Insti-
tute, in his researches in the problems of old age, un-
dertaken in 1889, observed that the birds which live
to be old have no large intestine. His observations
had to do with birds which live more than fifty years
and with one parrot who died at the age of eighty-
four years. By this fact he was led to study the
action of the microbes of the large intestines of the
human organism. He was struck by the direct anal-
ogy existing between the deterioration produced by
the toxines of certain hannful microbes of this or-
gan with that produced by alcohol, lead, or mercury.
He performed experiments upon young chickens and
frogs, and demonstrated conclusively that there ex-
ist harmless and harmful intestinal microbes, and
that it is necessary to fight the latter and multiply
the former. He further proved that young chickens
brought up without intestinal microbes waste away
and die.
After establishing this point, he showed that the
microbes of the human large intestines constitute, in
general, a harmful flora. These microbes, by the
poisons they secrete and pour into the system, cause
various troubles, such as intestinal intoxication and
others. At the time of Metchnikoflf's experiments
gastrointestinal troubles were being treated bv anti-
septics. But this treatment had the disadvantage of
depriving the large intestines of useful microbes and
was, therefore, useless or injurious. The problem
to be .solved, then, was to check the intestinal putre-
factions, together with the microorganisms which
cau.se them, without introducing poisonous products
into the system, and to leave the useful microbes in
the intestine.
While in Ikilgaria, Metchnikoflf had his attention
arrested by the extraordinary longevity of the Bul-
garians and the diet of the.se robust mountaineers,
which consisted almost exclusively of curdled milk.
After ten years of experiments, Metchnikoflf came
to the conclusion that the lactic ferments are the
most powerful antagonists of the harmful microbes
which infest f)ur intestine.
An important point is that these bacteria pass
through the stomach, and the gastric juice does not
affect their vitality. It will be seen, therefore, that
the result of using this food containing these fer-
ments is the inoculation of the intestinal mucous
membrane. Dr. Cohendy (Coniptcs rendus dc la
Socictc dc biologic, C.) has demonstrated that in case
of a person under treatment the lactic acid bacteria
is found in the intestine from the third to the fifth
day after ingestion ; and its presence has been ob-
served there from the twelfth to the twenty-fourth
day after the last taking of the ferment.
The practical application of this treatment in
cases of intestinal intoxication has produced the re-
sults to be expected from the theory. And in cases
of infantile diarrhoea, where putrefactive microbes
are the cause of troubles, this treatment by inocula-
tion of the large intestine with the lactic acid fer-
ments has met with great success {Annales dc I'ln-
stttiit Pasteur, 1905). One more happy application
of the use of sour milk as a healthy diet has been
made by Hayem, Dujardin Beaumetz in feeding
their typhoid fever patients almost exclusively with
fermented sonr milk. Lately Dr. Lietchfield, a noted
physician of Pittsburgh, Pa., had. from his own initi-
ative, made some conclusive experiments and ac-
quired valuable experience in the same line. An in-
teresting pai)er on his experiments has been read
before the meeting of Pennsylvania State Medical
Association.
We shall set forth the result of Ed. de Freuden-
reich's studies {Rcvuc gcnerale du lait, 1905) on
the gioddu, which he has propagated in Italy. In
this connection he has made some conclusive experi-
ments on animals. In inoculating guinea pigs with
culture of Bacillus prodigiosus he saw that these
are found in great numbers in the faeces. He fed
gioddu to these animals while still continuing to in-
troduce the bacillus, and gradually the latter became
very rare in the faeces. He found that the viru-
lence of the Bacillus coli in his own intestines was
diminished so long as he made use of gioddu. These
facts confirm the. opinion of Metchnikoflf, Huchard.
Hayem, and other authors that lactic acid bacteria
are the most powerful antagonists of the harmful
flora which infest our intestine.
Sour Milk and Similar Products. — In this chap-
ter I shall endeavor to define sour milk and to ])oint
out the dififerences between it and similar products.
Spontaneous Sour .Milk. — l^verybody knows that
milk kept in a moderate temperature for a short
time (longer in winter than in summer) becomes
sour and takes a consistency more or less dense.
This is spontaneous. Sour milk curdles by natural
agents, with a disagreeable taste and smell. More-
over, this i)r(uluct, in the absence of any control in
its fernuiitations, may contain toxic poisons and
may present serious dangers of autointoxications.
Dr. Bufour de la Rochelle cites such a case (Bulle-
tin general de tlicrapentiquc, 1907, Xo. 8) occurring
in a convent where thirty-three out of forty-one
nuns were rendered suddenly ill by the use of spon-
taneous sour milk, .'^o much ma\ be easilv under-
stood. The milk when left to itself requires one
to one and a half days in summer, and two to three
days in winter to sour and curdle. This long time
is required because lactic acid bacteria are not
usually found in milk freshly drawn from the cow,
but appear later. So, before their appearance in
March 2:. 1908.]
HAIM: SOUR MILK.
547
the first period, other species of germs, from the
liav, dust, air, body of the cow, etc., appear, some
of which in their development secrete toxic poisons,
but most of them contain substances which alter the
taste and odor of the milk. When lactic acid bac-
teria appear they find a medium already badly cor-
rupted and in which they cannot carry on any use-
ful action.
Sour Milk zi'itli Pure Culture. — Sour milk, as it
is recommended at present, possessing salutar}-
properties which have been proved, is milk which,
-after having been freed of all living germs by ster-
ilization, is started with a. pure culture of specific
ferments. I may add, in connection with this, that
there exist numerous bacteria, some even patho-
genic, which can produce lactic acid with the hydro-
carbon and proteid substances, especially the Bacillus
coli communis, bacillus of fowl cholera, bacillus of
Friedlander, Bacillus prodigiosus, etc. The specific
lactic acid ferments include a great number of spe-
cies, dift'ering from each other not only by their
morphology, cocci, diplococci, streptococci, rods,
but also by their physiological properties. Although
there are some which may convert all of the sugar
lactose into lactic acid, there are others which can
convert but a small quantity. Some render milk sour
without curdling it, while others render milk acid
and at the same time curdle it by means of an en-
zyme analogous to rennet. Others, after having cur-
dled the milk, partly liquefy it by another enzyme,
discovered by Euclaux, which he called casease.
There are some which liquefy gelatin, produce gas.
aromatic flavors, etc. Add to this all of the natural
factors capable -of influencing the work of fermenta-
tion, even for one single bacterium such as the
kind of milk, its richness, climatic conditions, adap-
tations, selection, and we may understand why there
exist so many varieties of sour milk. This fact is
not peculiar to sour milk ; there are as many dififer-
ent wines as countries that manufacture them.
In general specific lactic acid ferments, in their
work of fermentation, act as follows on the three
elements of milk:
a. The casein is coagulated in minute particles,
which adhere together, and a certain part of it is
dissolved. The following, according to M. Tousart,
chemist of the Pasteur Institute, are the quantities
of casein and soluble calcium phosphate produced
during the fermentation, 5.54 amount of casein in
ICQ grammes of product.
Test of casein soluble during fermentation :
Quantity of casein
soluble in 100 Relation of
Time. grammes of product. casein soluble.
2 hours 2 grammes 02 37, 81 per cent.
8 hours ........ 2 " 08 38. 95
24 hours 2 " 24 41, 94 "
48 hours 2 " 49 47, 19 "
54 hours 2 " 64 49. 43
0.38 amount of phosphate calcium in 100
grammes of product. Test of the phosphate cal-
cium soluble during the fermentation :
Quantity of phosphate Relation of the
calcium soluble in 100 phosphate cal-
Time. grammes of product. cium soluble.
2 hours 0 grammes 26 68, 42 per cent.
24 hours o " 27 71. 08
48 hours o " 28 73. 68 "
54 hours o " 30 78, 94 "
His experiments have to do with the ferments of
theyagiiourt. The casein coagulated by the lactic acid
ferment is entirely uiflferent from that coagulated
by any other acid ; in the latter case the casein is
in the form of large lumps, sharply separated from
the serous portion. And this diflference is even
more distinguishable by taste and microscopical ex-
aminations. Casein coagulated by lactic acid fer-
ment does not assume a compact mass, nor does it
precipitate in lumps even with the addition of acids.
The casein in this case, we may say, has under-
gone, by the action of the lactic acid ferment, a
partial digestion, and this will explain why sour
milk does not curdle in as large masses in the stom-
ach as raw or boiled milk does.
b. In sour milk, one part of the fat is saponified
under the action of lactic acid ferment. Thus, in
sour milk under certain conditions, the cream does
not rise to the top, and its presence is only perceived
by the taste, more or less unctuous, according to
richness of the milk in fat. A drop of such sour
milk under the microscope shows very plainly the
number of fat globules to be much less than that
of whole milk under any other form. We know
that the fat, in order to be assimilated, must imder-
go the action of pancreatic juice, which saponifies
it, and we see that in sour milk one part of the fat
is already in an assimilable form.
c. By means of one lactase discovered by Biich-
ner, the sugar of the milk is converted into lactic
acid, a product which does not need any previotis
digestion in order to be assimilated into the bod\-.
It will be seen from, the preceding that the modifica-
tions of the elements of the milk during fermenta-
tion give us a product quite different from the milk
with which it is made. The changes will explain
the high digestibility of sour milk, a well known
fact recognized by all experimenters. Dr. Mon-
treius says in regard to this "that sour milk has the
advantage over fresh milk in that it has a stimulat-
ing eflfect on the intestine, and thus prevents incon-
veniences, and I should say even dangers of a milk
diet." While raw or boiled milk needs six to seven
hours to be digested, sour milk needs only three to
five hours. Besides this high digestibility sour milk
is not only free from harmful bacteria, but is in the
meantime a pure culture of the lactic acid. One
c.c. of sour milk may contain 500,000,000 of bac-
teria and more.
Role of Yeast in Sour Milk. — Analysis in almost all
kinds of sour milk, as they are found in their orig-
inal countries, shows, besides the lactic acid bac-
teria, which may be of one or more species, the pres-
ence of yeasts. The yeasts, according to the mode
of preparation of the sour milk, are utilized for the
aromatic products, or, still more, for the alcohol
they are able to produce. Thus in the gioddu, leben,
yaghourt, besides the lactic acid bacteria, there are
yeasts ; and these sour milks under usual conditions
contain only traces of alcohol, practically we may
say none at all.
These quantities of alcohol vary between 0.0 1 and
0.014 per cent. The same is true for the zoolak
when freshly made. But they all possess a sui
generis flavor with an agreeable taste, due mainly to
the individual qualities of the yeast.
548
EGBERT: TRACHOMA.
[New Vork
Medical Journ \l.
The flavor of the zoolak is distinctly different
from that of the yaghourt, and this difference de-
pends on the species of yeast. The fact is well dem-
onstrated when these two different yeasts are iso-
lated and started separately in milk or in any other
medium, the flavor of the zoolak can be perceptibly
changed by taking out its original yeast and re-
placing it by that of the yaghourt. This has been
done in the laboratory.
Sour Alcoholic Milk. — In some sour milks the
yeasts, which are found with the lactic acid bacteria,
are mainly utilized for the alcohol they are able to
produce from the lactose, or from any other sugar
previously added to the milk. These beverages, ac-
cording to the mode of preparation, may contain
from 0.5 to I per cent, of alcohol ; they are fresh,
sour, effervescent, have a biting taste due to the
presence of carbon dioxide, which is in solution.
These beverages are much enjoyed by some people.
This is the case with the kefir used by the mountain-
eers in the Caucasus, and the kumyss used by the
Tartars and other tribes of eastern Russia and Asia.
It has been alleged that in the grains used for the
preparation of kefir are found some undesirable bac-
teria and that nothing could be done to make these
grains pure, i. e., including only the bacteria neces-
sary and indispensable for the work of fermentation.
In his experiments in the Dairy Bacteriology Labora-
tory of Cornell the writer has prepared kefir without
using the original grains sold for this purpose. We
proceeded in the following manner : After milk
previously boiled and inoculated with pure culture
of lactic acid was sour, a pure culture of yeast was
added in order to develop the alcoholic fermenta-
tions. With this process there was no chance of in-
oculating undesirable bacteria and we could have the
kefir ready in a shorter time.
Medicinal Sour Milk. — Some authors have rec-
ommended for hospitals and medicinal purposes a
kind of sour milk made with a pure culture of lactic
acid, excluding all yeasts. This is the case with the
gioddu which Dr. de Freudenreich has popularized
in Italy. There are in this original product a lactic
acid bacterium and a species of yeast. He has iso-
lated the lactic acid ferment and prepared with this
his special sour milk, which is in use to-day in many
hospitals in Italy. The same has been done with the
bacillac by Dr. MetchnikofT. These products are
undoubtedly as wholesome as the originals, but they
do not possess the particular flavor and agreeable
taste of the .original sour milk from which they are
derived. In trying in the laboratory to prepare zoo-
lak from which all yeasts were excluded, we meet
the same difficulties. We do not think it worth
while to deprive these original sour milks of the
appreciable qualities in taste and flavor, for at no
time — as far as we know — have traces of alcohol in
any food been considered detrimental to health.
Frauds. — Unfortunately the public, unfamiliar
with the different kinds of fermentation which milk
can undergo, is incapable of distinguishing the qual-
ities of the numerous products put upon the market.
In consideration of the interest taken by the people
in those products, especially in Europe, it has been
attempted in many ways to manufacture certain bev-
erages which would more or less resemble sour milk
in ta.ste. Such beverages as the following have been
placed upon the market : Milk to which a sufficient
quantity of any acid has been added to coagulate
it, and afterwards, as it is practised in soda water
drinks, adding carbonic dioxide under pressure of
I to 2 atmospheres. In another case a similar
beverage was obtained by adding to milk some
sugar and baker's yeast and keeping until fermen-
tation had occurred. In order to prevent such un-
desirable practices, the public ought to be very care-
ful in their choice and preference should always be
given to those possessing the guarantees necessary
in such cases. No matter whether the product is
manufactured by or under the supervision of a
physician, the product should be registered with
guarantee of a definite chemical standard and stand-
ard of bacteriological compositions, according to the
regulation of the pure food law.
TRACHOMA— CLINICAL ASPECTS AND SUCCESS^
FUL TREATMENT.
By J. HoBART Egbert, A. M.. M. D.,
Willimantic, Conn..
Oculist and Aurist to St. Joseph's Hospital, Willimantic. Conn.;
Assistant Surgeon, Eye Department, Cornell University
Medical College Dispensary, New York, etc.
In view of the facts that trachoma is a contagious
and not imcommon disease ; that recently collected
statistics show that about 75 per cent, of untreated
cases of trachoma result in blindness' and that in
some localities (European) 60 per cent, of all cases
of blindness result from trachoma' ; that among
cases treated absolute and satisfactory cures have
heretofore been altogether too infrequent, and that
in many cases long under treatment by approved
methods pannus. xerosis, trichiasis, and entropion,
with concomitant permanent reduction of vision,
have supervened — in view of these facts, it seems
entirely unnecessary to offer any apology for call-
ing attention to improved methods of treatment —
or, at least, modifications of technique in the ap-
plication of recognized methods — that are capable
of yielding better results than have heretofore gen-
erally been attained.
A discussion of the history, aetiology, and general
aspects of trachoma is foreign to the' purpose of the
present paper. Available literature pertaining
thereto is already voluminous. Before considering
the treatment of the affection, however, we desire
to urge consistency and simplicity in classification.
Trachoma has been described as acute and chronic :
as simple and complicated ; as papillary, miliary, and
diffuse; as follicular, granular, and mixed;. as true
and vesicular ; as inflammatory and noninflamma-
tory, etc., etc., and has been referred to by dift'erent
writers under a variety of names, as: Egyptian
ophthalmia, granular ophthalmia, granular conjunc-
tivitis, trachomatous conjunctivitis, syndesmitis
granulosa, granulated lids, etc. Thus have differ-
ent observers and teachers endeavored to express
their conception of the stages and aspects of the
disease ; but it is more than a conjunctivitis, it is
more than a syndesmitis, and while it niay be an
"ophthalmia." this word has justly fallen into disuse
(or. rather, retained to apply to a definite acute
'Schereschewsky ; ibid.
'Clark: U. S. Public Health and Marine Hospital Report, 1907.
.March .i, igoS.j
EGBERT: IRACHOMA.
549
infectious disease which, when occurring in the new
born is called ophtlialniia nconatonim and, other-
wise encountered, gonorrhoeal ophthalmia), and
even though it be not always "rough" ( r/juxo'^ ),
the term "trachoma" is both distinctive and con-
venient, and by this simple term this affection should
be universally known. Whether the granules be
large or small; crowded, conduent, or diffuse;
whether they arc in the retrotarsal folds or overly-
ing the tarsus ; whether fhere is present connective
tissue hyperplasia or cicatricial contractions — the
disease is .still one and the same, whatever the varia-
tions in clinical aspect resulting from duration and
activity of the morbid process, or attributable to
idiosyncrasy, racial peculiarity, age or environment
ui the patient. There is no "acute trachoma" — it
is always a chronic affection, though it may, and
frequently does, present symptoms peculiar to acute
inflammatory processes. Cases of "acute trachoma,"
resulting in spontaneous cure, are reported, though
our own experience — covering hundreds of cases of
the disease — would suggest that at least some of
the cases thus recorded have been cases of acute
follicular conjunctivitis or simple adenomatous con-
junctivitis, and not trachoma. Trachoma is alwa\ s
"true" — always .seriously real. 'It is a distinct, local
disease, and while its clinical aspects may, in a
measure, call for variations in the details of treat-
ment, its successful cure, like that of other definite
local pathological conditions, requires the institu-
tion and execution of a certain, quite distinctly de-
fined plan. There is unquestionably a tendency on
the part of Nature to overcome the disease, and
time alone will doubtless effect a termination of the
active process in many cases of trachoma, but at
what a cost! The low grade of inflammation in-
duced by the disease itself operates so slowly and
in such a diffuse manner that, ere the absorption of
the products of exudation is eff'ected, serious con-
nective changes have taken place and the destruc-
tive process has extended not only to the hyperplas-
tic material but also involved the proper tissues of
the lids, occasioning contraction and deformity in
these appendages and irreparable damage to the
eyeball. Thus, in its natural course, the disease
presents three characteristic stages which merge
more or less into each other, to wit: (i) a stage of
exudation and granulation, (2) a stage of hyper-
plasia, with connective tissue formation, and ( 3 ) a
stage of sclerosis and cicatrization.
The treatment of trachoma has long embraced
both therapeutical and mechanical measures— the
end in view always being to occasion or hasten ab-
sorption, destruction, or removal of the products of
exudation and hyperplasia. To this end, inflamma-
tory action has generally to be stimulated rather
than retarded, and while the usual method is to
stimulate persistently and guardedly, decidedly he-
roic measures have at times been adopted — as the
inoculation of an aft'ected eye with secretion from a
purulent ophthalmia or gonorrhoea, or the local use
of jequirity or similar active irritant. Bluestone
(copper sulphate), directly applied to the granular
conjunctiva, has been used, perhaps, the longest and
most widely of all chemical agents in the treatment
of trachoma, though just why is difficult to under-
stand. Theoretically, it would seem to be an ideal
remedy, being both actively stimulating and astrin-
gent, but practically — and we have observed its reg-
ular and persistent use on many, many cases for
periods of year.s — we cannot recall a single satis-
factory cure resulting from its use. jNIoreover, our
own personal observation and experience with this
remedy is b}' no means exceptional. Nearly thirty
years ago a famous Glasgow ophthalmologist wrote :
"Sulphate of copper used to be, and I sup])ose is
still, considered the ^tandard remedy for granula-
tions, for in every case of Egyptian ophthalmia, out
comes the bluestone, mechanically, as it were.' 1
have seen patients rubbed with bluestone for eight
or ten years, until no trace of transparent cornea
was left ; and I have never seen any satisfactory re-
sult accruing from the use of argentum nitras, or
any other caustic.'" In spite of such facts the use
of the bluestone goes on, as does the use of other
caustics and astringents. There is one ciciiiL]it of
benefit — though an entirely indirect one and largely
buried beneath the injurious eff'ects of such treat-
'W-g ^
ment — that does accrue from the rubbing of tracho-
matous lids with smooth crystals of bluestone. alum,
etc., and that is a mechanical stinnilation to absorp
tion from the tissue massage. This mechanical
stimulation to absorption and restoration is a fea-
ture of the rational and successful treatment of
trachoma which we are about to present, but it is
much more wisely and satisfactorily accomplished
by other agents than copper sulphate crystal or al-
lied substance.
Ordinary lotions and collyria are, alone, utterly
inefficient in the treatment of trachoma, though hav-
ing a definite sphere of u.sefulness in conjunction
with other methods of treatment.
Operative (mechanical) procedures have long-
been employed by various oculists in the treat-
ment of certain cases of trachoma. The following
methods have been practised : Linear scarification
of the conjunctiva with subsequent squeezing out
of the granules; grattagc of the conjunctiva, with
or without preliminar\- sacrification ; crushing the
granules and expressing their contents by means of
special forceps, rollers, etc. : excision of the superior
cnl-de-sac ; removal of tarsus and retrotarsal folds,
fn addition to these operations upon the lids might
be mentioned penectomy and peritomy — operations
tipon the eyeball' for the relief of pannus.
Rubbing the granular and hyperplastic conjunc-
tiva with cotton or soft brushes dipped in certain
solutions has been found beneficial in the treatment
of trachoma, and a i in 500 solution of bichloride
of mercury is being thus employed by not a few
practitioners with more or less satisfactory results.
The stimulation from the medication employed is
doubtless of benefit, though we are quite certain
that the manipulation is the most important factor
of the treatment— having obtained excellent results
in certain long standing cases (cases in the second
nVolfe: Diseases au.l Injuries of the Eye, London, 1SS2.
550
I'k.lXZL: I IJM nuXAL POli hk 01' HliART.
(Nkw Vokk
Medical Journal.
and third stages of the disease ) from massage of
the tissues of the Hds by ruhbino- tlie conjunctiva
with a smooth, glass spatula. In carrying out this
procedure, it is our practice to thoroughly irrigate
the conjunctiva with warm boric acid solution — tak-
ing care to include the superior cul-de-sac — and
everting the lids, rub the involved portions of con-
junctiva— both over the tarsi and in the retrotarsa!
folds — with the glass spatula, after which the con-
junctiva is again thoroughl_\- irrigated. Previous
to this treatment, however, most cases re(|uire oper-
ation for the opening and emptying of all granules
and the removal of hyperplastic material. For ac-
complishing this, we iiave desised a special curette
— or, rather, two curettes, one sharp and one blunt
— which are herewith illustrated. Iliese curettes
are so constructed that all portions of the involved
conjunctiva, including the superior fornix and re-
trotarsal folds, can be reached, and the edge is so
fashioned that while all granular and hyper])lastic
material can be readil\ remowd, there is little danger
of injuring smooth, health}' tissue. The edge n\ the
-shari) instrument ])oints downward and backward
(toward the handle) t<> an angle of about 45° and.
when the instrument is drawn by the handle, read-
ily engages and removes the abnormal tissue. On
the sides of the s])oon the edge merges into the flat
metal, so as to prevent side cutting or laceration.
Tn using these curettes, the Uj)per lid is
everted over a horn or metal spatula and the
sharp curette, the handle of which is held be-
tween tlie thumbs and the first and second
fingers much as an ordinary spoon is held,
with edge upward, is pushed over the eyeball well
up into the superior cul-de-sac and then drawn
downward fmm all directions of a segment of a
circle similar to that outlined b\- the brow. I'irm,
though gentle pressure, is necessarv, aiid the curet-
ting must be thoroughly done. I'he blunt curette
is now substituted for the sharp (jue, and the ])ro-
cess repeated with slightly more pressure, til! the
tissues feel smooth under the instrument. The u])-
turned jjortion of the conjunctiva is ne.xt similarly
treated — the edge of the curette now, of course, be-
ing turned downward. The lower lid is then like-
wise freed from all granules. The eye is then thor-
oughly irrigated with boric acid or normal salt
solution, and th.e other eye operated on — or that
may be left until inflamm'atory reaction in one eve
has subsided. Light, iced conii)resscs should be
applied to eyes thus operated on during the suc-
ceeding twenty-four hours. Iluse should, ol
course, be intermittently applied lest freezing of the
cornea occur. Their continued application for
periods of fifteen or twenty minutes every hour will
answer well. The lid spatula is not essential, though
it will be found of value in many cases, esi)ecially in
obtaining pro])er pressure with the blunt curette.
The operation of curetting with the sharp instru-
ment, when done thoroughly, will seldom require
repetition, though stimulation through rubbing with
the blunt instrument is fre(|uently called for at in-
tervals to promote resolution in the diseased area.
This rubbing and massage may often, however, be
advantageously carried out by means of the glass
spatula.
Local merlication i'> of doiibtful value, as alreadv
stated, in the treatment of trachoma. The bichlor-
ide of mercury solution (i in 500) may be applied
to the conjunctiva at the time of massaging, and a
collyrium of zinc and boric acid given the patient
for daily use, to limit and control the general con-
junctivitis.
748 M.AiN Street. ,
HOW TO ESTIMATE THE FUNCTIONAL POWER
OF THE HEART.
Rv P.\UL C. Franze, M. D., L. S. A. (London).
Bad Nauheim, Germany.
If the functional power of the heart sinks below
a certain luinimum necessary for overcompensat-
ing to a certain degree all the resistances to the
circulation, then cardiac failure ensues. Thus
proph\ la.xis, eflieient therapy, and prognosis of car-
diac disease (Ie])end on the estimation of the func-
tional power of the heart. Can this be done, and
how? Tile answer is: Only approximately', and by
taking into account all different factors that give
evidence as to the heart's capacity for its work.
1. BIddd /pressure. — The height of pressure in the
arterial system depends on the total of driving
forces and resistances. The former are constitutecl
by the contractions of the ventricles and the elas-
ticity of the arterial walls. The conclusion, there-
fore, is: in absolute insufficiency of the heart blood
pressure must fall. Facts, however, show that this
is the rule, but not one without exception. .A.nd
yet mere fall of the blood pressure is, on the other
hand, no criterion of cardiac weakness. T'^ar less
is high pressure a sign of a strong heart. The rea-
sons for this are that the former may be due to un-
dertension, the latter to undertension in the arte-
rial system. So far, therefore, the value of blood
presstire is minimized as a means of judging the
cardiac power. Nevertheless, Griiupner has man-
aged to develop a method of using the changes in
blood pressure after specialized exercises in cer-
tain grou])s of muscles (extensors, flexors of the
up])er and lower extremities) as an aid to estimat-
ing the heart's power.
2. Pulse. — I''re(|nency, rhythm, and volume of
the pulse are (|uite useless in themselves as crite-
rions of the heart's strength, for they are subject
to nervous influences.
3 Respiration. — Dyspnoea in rest speaks for car-
diac failure. Hut the reverse, its absence, is no
guarantee for a sound heart.
4. Urine. — Scant*\- urine, liigh specific gravity,
and albuminuria arc signs of a weak heart, if other
sources are excluded. I'.ut the absence of these
signs is. no proof of a sound heart.
5. Cyanosis. — This, in a person with sotmd Itnigs.
is a valuable adjunct to the diagnosis of a weak
heart.
6. The sice of the heart. — .\s a rule a heart of
sufficient functional capacity is nondilated, and
when incompensation sets in begins to dilate. So.
naturally, the size of the cardiac diagram is in
some degree a means of forming an opinion as to
the organ's functional capacity. P>ut for this pur-
pose, of course, only the most exact measurements
can be relied ui)on. Such ones can only be made
March 21, 1908.]
THERAPEUTICAL NOTES.
bv X rays, viz., by "orthodiagraphy." or. of late, by
'"telorontgenography."
Of all methods and signs .which I have men-
tioned. Graupner's method, and those by x rays, are
the most valuable in themselves. Yet, in my opin-
ion, even in taking all symptoms and methods into
account, there is no absolutely exact way to arrive
at an opinion regarding the functional power of
the heart; it can only be estimated with more or
less accuracy.
Clurapfatical |lotes.
Ointment of Yellow Oxide of Mercury. — It it
is desired to prescribe the ointment of yellow oxide
of mercury so as to insure the use of a freshly pre-
cipitated oxide it is recommended to order that it be
made according to the following procedure :
R Corrosive sublimate gr. xxvii .
Fused sodium hydroxide gr. x.
Dissolve the corrosive sublimate in two ounces of
warm distilled water and filter. Dissolve the so-
dium hydroxide in cold distilled water, and into this
solution pour slowly, with constant stirring, the mer-
curial solution. Set the mixture aside in a warm
place until the precipitate all subsides. Then decant
the supernatant clear liquid, and wash the precipi-
tate by. decantation, or on a linen filter, until the
washings cease to give any reaction for chloride.
Mix the moist precipitate with a sufficiency of a
mixture of hydrous wool fat ( i ) and white petro-
latum (3) to make ten drachms. Each drachm con-
tains two grains of yellow oxide of mercury.
Methods of Administering Salicylic Acid and
Sodium Salicylate. — Salicylic acid is seldom used
alone because of its insolubility and its irritant prop-
erties, remarks Pouchet in La Quinsaine therapeii-
tiqnc. Internally it is best given in solution as
follows :
I.
R Salicylic acid gr. xv ;
Glycerin 5ss ;
Distilled water ,iiiss.
Ft. solutio.
Sig. : One tablespoonful three times a day.
II.
B Salicylic acid 5ii 3ii;
Potassium citrate, • Jss ;
Glycerin .^ii ;
.\romatic elixir (U. S. P.), q. s. ack 3iv.
M. Sig. : One t-^aspoonf ul three times a day.
(The foregoing is supplied when "'elixir of sali-
cylic acid, X. F.," is ordered.)
It is mostly in antiseptic applications for external
use that salicylic acid is used nowadays, as in the
following :
R Salicylic acid 5ss ;
Starch, 3iss ;
Talc, 5ii-
M. Sig. : Dusting powder.
Other topical applications are :
I.
B Salicylic acid, 3ss ;
Alcohol. 90 per cent 5i ;
Wool fat 5v.
M.
Dissolve the acid in the alcohol and incorporate
with the wool fat.
II.
R Salicylic acid 3ss;
Absolute alcohol, Siiss;
Castor oil 5v.
III.
Oil of turpentine is combined with salicylic acid in
ointment form when quick absorption and irritant
and hyperc-emic effects are desired at the same time :
R Salicylic acid, \
Oil of turpentine, \ 5i ;
Wool fat, )
Benzoinated lard, 5vii.
M.
IV.
For the abortive treatment of boils salicylic acid
is used in combination with soap and diachylon plas-
ter as follows :
B Salicylic acid, / 55 •
Soap plaster. (
Diachvlon plaster, 3ii.
M.
Sodium salicylate is the ])reparation of salicylic
acid that is most commonly prescribed for internal
use. It is absorbed very rapidly and circulates in
the blood in an unaltered condition. According to
the British rharmaccutical Codex, when taken in-
ternally it increases tissue breakdown, and the nitro-
gen (urea, uric acid, etc.), sulphates, phosphates,
and chlorides in the urine arc all increased, but the
uric acid is increased out of all proportion to the
urea. It is so rapidly absorbed that it is useless as
an intestinal antiseptic, and a less soluble form, such
as salol, is therefore preferred. Sodium salicylate
is usually given in solution in mixture form, as
elixir of sodium salicylate. X. F. Pouchet (loc.
citat.) says the disagreeable and persistent taste of
the salt is masked in the following formulas :
B Sodium salicylate 3ii;
Rum (old^ 3ii;
Syrup of oiange peel, ( --
Distilled %vater, ( ^m.
M. Sig. : One tablespoonful every hour.
In combination with extract of licorice it is better
tolerated by the stomach :
B Sodium salicylate, 3i to 3ii ;
Extract of licorice 3i to 3ii ;
Distilled water, jiii-
M.
The Value of Antimony in Bronchial Catarrh.
— In The British Medical Journal for February 29_th,
page 488, Eustace Smith directs attention to the
value of tartarated antimony in the treatment of
bronchitis and bronchial catarrh. In catarrhal states
of mucous membrane, antimony, he says, is of pre-
eminent value. Because in full doses it produces
profound discomfort and depression it does not fol-
low that the drug, if given in more moderate and
prudent quantity, is not of the utmost efficiency.
According to his way of thinking the most errone-
ous views regarding the treatment of bronchitis pre-
vail among the younger generation of medical prac-
titioners, and he illustrates his point as follows : "A
young house physician will order a patient who is
suffering from a severe pulmonary catarrh a mixture
552
THERAPEUTICAL NOTES.
[New York
Medical Journal.
containing ammonium carbonate and other stimulat-
ing expectorants as a matter of course and in total
disregard of the stage of the derangement or the char -
acter of the symptoms. But in the management of a
bronchial catarrh each class of remedy has its own
time for serviceable action and is useless or worse
than useless if given out of its due season. The
whole treatment of this derangement consists in un-
loading the congested vessels and setting up free se-
cretion as a first and indispensable step before any
attempt to reduce the amount of expectoration can
be made. To give ammonia, squill, paregoric, and
other stimulating and antispasmodic drugs in the
early stage of the catarrh is to make the cough harder
and the chest tighter, and greatly to aggravate
the discomfort of the patient, if not to produce worse
ill consequences. By such means I am convinced
that what should have been- a mild indisposition has
often been aggravated into a serious illness by
driving the catarrh further and further into the
minuter tubes, and that in children a moderate bron-
chitis has not seldom been turned into a broncho-
pneumonia. The use of these remedies should be
reserved strictly for the later stages of the catarrh
when the cough is perfectly loose from a free secre-
tion of mucus. The earlier remedies have then fin-
ished their work, and the time has come for stimu-
lants and astringents to take their place and begin
their task of bracing up the relaxed mucous mem-
brane and guiding the complaint to a satisfactory
issue." Tartarated antimony acts most efficiently
when given in small doses frequently repeated. The
most convenient form is the vinum anthnonialis, of
which a dose of from two or three to ten or fifteen
iriinims, according to the age and condition of the
patient, may be given -every hour or two hours as
long as the symptoms are acute. The drug may be
combined advantageously with potassium nitrate,
ammonium acetate, spirit of nitrous ether, or simi-
lar diaphoretics.-
Paste for Soft Chancre. — Balzer {Journal de
medccine de Paris, December 2Q, 1907) uses the
following combination :
R Zinc chloride, i part;
Zinc oxide, 9 parts ;
Water, q. s.
M.
Use sufficient water to make a paste, which is al-
lowed to remain in contact with the ulcer for
twenty-four hours, when it is renewed if necessary.
For Asthenic Dyspepsia. — The following aro-
matic bitter tonic is recommended in Bulletin gen-
eral dc thcrapeutiqiie:
B Tincture of cardamom, 3ii ;
Compound tincture of rhubarb 3ii ;
Sodium bicarbonate, 3i ;
Infusion of calumba, ad .^iv.
M. et Sig. : Dessertspoonful three times a day.
Harrington's Solution. — From Dr. Francis 1!.
Harrington, of Boston, we are in receipt of a com-
munication in which he disclaims credit for the in-
troduction of "Harrington's solution," attributed to
him in a note on the subject published in this col-
umn on March 7,. 1908. He advises us that this val-
uable solution was first brought to the notice of sur-
geons in general by Professor Charles Harrington,
of the Harvard Medical School, and refers us to
The Transactions of the American Surgical Asso-
ciation, 1904, vol. xxii, pp. 41 to -51, asking at the
same time fur a correction of the credit, which we
gladly make.
Local Applications for Orchitis. — The follow-
ing local applications are cited in Bulletin general
de thcrapentiqne: (i) During the first six days
apply the following ointment, rubbing it in gently,
and covering the parts afterward with a layer of
charpie :
R Guaiacol, 3iiss ;
Lard, Jii-
Envelop the testicles in cotton and support them
in a suspensory bandage.
' " ( 2) At the end of the first w^eek apply the fol-
lowing ointment :
R Mercurial ointment,
Belladonna ointment, I -- t-
Ichthyol, f
Wool fat, J
M.
Haemoptysis, according lO Hirtz and Simon
( Thcrapentiqne medicine d'urgence ; La Tribune
niedicale, February 22. 1908), is treated best by com-
plete repose in bed in a well aired room, with appro-
priate medication for the relief of cough and to
check the haemorrhage. H the haemorrhage is se-
vere solid food should be withheld and the diet con-
fined to cold liquids such as milk, clear soups, etc.
Opium may be given in small doses to allay cough-
ing, according to the indications, as in the following :
R Syrup of codeine. \_ - - .
Syrup of belladonna, ) '
Orange flower water, / -- -
Distilled water, S ^
M. Sig. : One teaspoonful as needed.
To control the haemorrhage ergotin may be given
either hypodermatically (ten to fifteen minims of
ergotin Yvon) or by the mouth in the following
mixture :
R Ergotin .31;
Syrup of rhatany 5viiss ,
Orange flower water, 3iiss;
Cinnamon water, ad. ^iv-
M. Sig. : One tablespoonful when required.
Ergotin may also be given in combination with
calcium chloride, as in the following mixture :
^ Ergotin. I -- 5i
Calcumi chloride, J
Orange flower water,- 3ii_ss ;
Cinnamon water, ad. 5iv.
M.«
If the haemorrhage continues as at first at the end
of three or four hours recourse may be had to
adrenalin, which is given hypodermatically in doses
of five to eight minims of a i in 1,000 solution of
the chloride repeated three times a day.
To allay the coughing that sometiines comes on
after the haemoptysis is stopped, the following pill is
prescribed, to be taken night and morning:
R Tartarated antimony. ) j, .
Extract of hyoscyamus, / ^ ' '
Dover's powder gr. v ;
Confection of roses q. s.
M. ft. pil. No. xii.
Particularly ob.stinate cases are treated with doses
of ipecac sufficient to cause slight nausea, and by in-
jections of gelatin serum.
EDllOKIAL ARTICLES.
553
NEW YORK MEDICAL JOUKNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Reviezv of Medicine.
Edited b>-
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M. D.
Addrcsx all husincss communicatiom to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Philadelphia Office: Chicago Office:
^^\^ Walnut Street. 160 Washington Street.
SUISSCKIPTION Pbice :
Under Domestic Postage Rates, $3 : under Foreign Postage Rate
$7 ; single copies, fifteen cents.
Remittances should be made by New York Exchange or post
office or express money order payable to the A. R. Elliott Pab
lishing Co., or by registered mail, as the publishers are not
responsible for money sent by unregistered mail.
Entered at the Post Office at New York and admitted for
transportation through the mail as second class matter.
NEW YORK. S.XTURD.'XY. M.XRCH ji. iqoS.
A VALUABLE MODE OF TEACHING.
To interrogate a student at a clinic is doubtless a
very efficacious way of compelling him to take in
the features of- a case to the limit of • his capability.
Hardly less effective frc/iii the point of view of en-
forcing observation — such observation as Sherlock
Holmes always insists upon — while allowing more
time to be taken by the student for reflection, is a
method set forth in the March number of the Cana-
dian Practitioner and Review. Professor Adam
Wright, of the Medical Faculty of the University
of Toronto, presented the fourth year students of
a clinical class with the following extract from
Smellie's Textbook of Midzvifer\, and directed them
to criticise the treatment recorded as having been
employed in the case :
I was .sent for to see a woman, aged forty, who had
borne several children before, in 1749. When 1 came I
found the head e.xpellcd. I slipped up my fingers and
found the os tineas contracted about the neck of the child
(which w^as dead), and endeavored to pull it away, but in
vain. I then sent for Dr. L., and I desired him to see
what he could do, as my fingers were numbed. He first
got one hand in the uterus, and then slipped up the fingers
of the other and brought away the child. The woman's
pulse before delivery was strong, and she had little flood-
ing ; but we had not been gone a quarter of an hour when
we w-ere sent for again. They told us that immediately
after we went away, which was five minutes after de-
livery, she was seized with a shivering and a vomiting, and
liad fainted. We found her in a swoon, and held spirits
to her nose, but she could not swallow, and died in about
lialf an hour after delivery.
As was manifestly due to Smellie's memory. Dr.
Wright informed the class that the case was not one
of Smellie's own. I)ut had been reported to him by
another practitioner, whose account he was simply
quoting. .\ student's criticism is appended. For
the most i)art it is judicious, but in the treatment
suggested the student wrote : "On arrival, give
antesthetic. dilate the os, and then remove the child."
In his remarks Dr. Wright said : "AVhile the admin-
istration of an anaesthetic would have been very de-
sirable, this case occurred in 1749." This simple
comment should have been quite enough, and doubt-
less was, to recall the student from any confusion
into which he may have fallen as to whether he was
expected to suggest what the eighteenth century
practitioner should have done in the conduct of the
case related or to intimate what he himself would
think it proper to do in a similar case occurring at
the present time. We venture to say that the
student will remember the remark for the rest of
his life, and by reason of it will grow to be a
better thinker and a better physician than he might
otherwise make himself. Retrospective practice, if
we may use such a tenn, has its uses, and the mate-
rial may come from another man's experience almost
as well as from one's own.
THE GRAND LEGION OF THE RED CROSS.
It is not creditable to us as a people that, whereas
the Japanese Red Cross has a membership of 1,300,-
000, our own has only 10,000 members, and that
number is said to be thirty times as great as the-
membership was three years ago, when th^ Amer-
ican society was reorganized and placed under gov-
ernment supervision. Perhaps this enormous dis-
l>arity is due to the great war in which Japan has
l)ut recently been engaged. Our own organization
seems to have done better in the matter of obtain-
ing money than in that of enlarging its numbers,
for we are informed that since the year 1905 it has
raised $4,000,000 and spent that sum in relief work.
There 'has now been initiated an included organi-
zation which appears likely to aid materially in in-
creasing the membership of the Red Cross while
doing its own beneficent work in the community.
It is known as the Grand Legion of the Red Cross.
As a grand legion is made of ''four or more
legions," we presume there will be a number of
grand legions, for each legion consists of only 256
men and 104 officers. Multiplying these numbers
by four, we have 1.024 men and 416 officers, or
1.040 all told, in a grand legion — a pitiful number
to serve "in the succor of the sick and injured ev-
erywhere and in the prevention, by education, of
death by accident and disaster." Perhaps, how-
ever, the circular from which we are drawing our
554
EDITORIAL ARTICLES.
[New York
Medical Journal.
information pertains only to the State of New
York and its branch of the National Red Cross, but,
even at that, what can 1,040 men do "in the succor
of the sick and injured everywhere"? They can
do much, of course, but not a tithe of what ought
to be done. Therefore, we repeat, there will prob-
ably have to be many grand legions, even in the
State of New York, though the statement that a
grand legion is made up of "four or more legions"
gives us the hint that a great number of legions
may be included in a grand legion.
The objects of the organization are said to be :
To help the sick and injured when physicians are
not at hand, and also to assist the latter; to help
care for those sick or injured in great public cele-
brations ; in time of war to serve under the Army
Medical Department in field, hospital, and camp; to
spread a knowledge of simple hygiene and assist in
the struggle against tuberculous disease; to teach
ordinary care and forethought for the prevention of
accidents ; to teach what to do in moments of dan-
ger in order to prevent injury or loss of life, as in
panics and street crushes ; and to help establish a
higher regard for human life. Each legion is com-
manded by a director in chief, and each relief col-
umn (of which there are four in a legion) by a di-
rector, and these officers must be physicians.
The objects stated are certainly such as all good
citizens have at heart, and we hope that enough
legions will be organized to assure their accomplish-
ment, also to swell the membership of the National
Red Cross, for every member of a legion must also
be a member of that body.
IRON IN CHLOROSIS.
To those who would vieV chlorosis in the light
of a severe anicmia and nothing more the hypo-
thesis that it is in reality a specific disease, due to
a mechanism differing essentially from others
which lead to a condition of grave anaemia, will
come as something new. Yet such is the point of
view adopted by a number of modern students, the
most recent expression from whom comes to us in
a study by F. W. Warfinger, formerly director and
senior physician of the Sabbatsberg Hospital, of
Stockholm (Nordiskt medicinskt Arkiv, 1907, 3).
For years chlorosis has been grouped with the
grave constitutional disorders, due to fundamental
luitritional disturbance, and formerly often asso-
ciated with tuberculous or leprous processes. Ac-
cording to this view, the derangements of the func-
tion of nutrition lead to the grave anaemic changes
which are present in this disorder. The present
author, on the contrary, says that chlorosis should
not be included among the chronic anaemias, with
which it has been allied, and to which it has few
resemblances, save that of a modification of the
constitution of the blood, but that it is to be con-
sidered as an entirely specific, independent disease,
arising spontaneously, particularly in young women,
without any apparent cause, and presenting a defi-
nite clinical picture. This view of the nosological
position of the disease is of the utmost importance
from the standpoint of treatment.
Inasmuch as it is a matter of clinical knowledge
that the disease appears very frequently in persons
of good nutrition, and that experience shows that
the best of dietetic means are usually inefficient, it
would appear that chlorosis, as has been held in so
many quarters, is not to be regarded as an inanition
anaemia. Neither is the author disposed to accept
the idea of its being of nervous origin, or Roki-
tansky's hypothesis that it is due to an insufficient
development of the circulatory and genital systems.
For other good and sufficient reasons he rejects
heredity and digestive disturbances as essential
ietiological factors. Clinically, true chlorosis is
characterized by certain very striking features. Its
appearance practically only in young women about
the period of puberty, a peculiar whitening of the
skin and of the mucous membranes, the lack of
alteration in the nutrition of the body, a cardiac
murmur, and a striking change in the constitution
of the blood are the most marked symptoms.
The cause of the lowering of the haemoglobin
percentage and of the diminution in the number of
red cells is still unknown, but the author believes
that his study has demonstrated that there is a de-
fect in the internal composition of the plasma of
the red blood cell by which an interference takes
place with the assimilation of the necessar)'^ amount
of haemoglobin. This change in the constitution of
the plasma is due to a poison of some nature which
reduces the catalytic power of the protoplasm of
the red blood cell, in which is brought about the
formation of haemoglobin from the haematogens of
the food. This poison, according to the hypothesis
of the author, arises as a consequence of an acute
infectious disease, probably of parasitic origin, since
the disease is characterized by a febrile course, a
tendency to recurrence, and epidemic features.
The therapeutic efficacy of iron he adduces as an
argnment in favor of his hypothesis. Its action is
not local, and hypodermic injections are as efficient
as its internal administration. Organic as well as
inorganic preparations arc valuable, but only when
thev give a distinct chemical reaction of iron. The
pharmacological action of iron takes place in the
fluids of the body, and only after dissociation of the
iron ions, which ions act as catalyzers, hastening
Match 21, 190S.J
EDITORIAL ARTICLES.
555
the reduction of the already existing toxic sub-
stances which hinder haemoglobin formation. The
iron should be given for at least six weeks in order
to counteract all the poison thoroughly, and, in the
author's opinion, should be administered in large
doses, since by far the greatest amount passes
through the gastrointestinal canal unabsorbed.
THE ESSENTIAL IDENTITY OF TUBERCLE
BACILLI.
In rather a long article on the variability of the
tubercle bacillus, published in the February number
of the Revue dc la tuberculose. Professor S. Arloing
argues in favor of its essential identity, however
great may be its temporary variations in mor-
phology, virulence, and other characters. He re-
minds us that in the year 1884 he maintained the
variability of human tuberculous disease in vir-
ulence, and that his contention was opposed more or
less vigorously until 1902, when the bacteriologists
suddenly became agreed on the mam question, dif-
fering only as to the limits of variation beyond
which the bacilli ought to be arranged in distinct
groups. Were there, for example, it was asked, a
human type and a bovine type, rigorously defined,
among the tubercle bacilli of the mammalia, and
were there also-special types for birds and for fishes,
impossible of inclusion under either of the others?
Arloing now declares himself more and more con-
vinced that the tubercle bacillus is a single entity,
that the species or types recognized and insisted on
b\- many observers are only temporary strains or
varieties, and that their apparent lack of change lasts
no longer than the conditions in the matter of media
under which they were formed. In effect, he says,
the facts now adduced by him demonstrate the
greater or less facility with which the types admitted
by many authors are modified in ever}- particular,
and at what point types at first distinct come to re-
semble each other in many respects under the in-
fluence of natural or experimental modifiers.
In conclusion, he thinks it must be admitted: i.
That types arc rarely perfect in distinguishing
features. 2. That they are accompanied by an al-
most indefinite series of individuals which, by their
growth, their form, and their virulence, are capable
of passing the one into the other. 3. That natural
variability is sufificient to explain the usual charac-
ters of virulence in the bacilli of mammalia and in
those of birds. 4. That there would be positive
danger, from the medical and the hygienic points
of view, in basing principles to be applied in the
prtvention of tuberculous disease upon differences
that are essentially changeable.
If M. Arloing is correct in his contention, the
inference can hardly be avoided that the tubercu-
lous disease of human beings may be conveyed to
cattle and that of cattle to the human subject.
Such an inference, coupled with the growing evi-
dence to support the view that human infection is
incurred more commonly through the digestive
tract than was until lately supposed, must accentu-
ate our endeavors to eliminate tuberculous meat
and milk from our food supplies, and that elimina-
tion, indeed, ought to be effected as a mere matter
of precaution, quite apart from final solutions of
the problems of bacteriology.
I'LAGCE INVESTIGATIONS IN INDIA.
In our issue for September 7, 1907, we called at-
tention to the special, number of the Journal of
Hygiene devoted to the report of the India Plague
Commission. The December number of the same
journal is devoted to further reports of the Plague
Commission. The first article is a digest of the
recent observations on the epidemiology of plague.
Then follows the original work of the India Plague
Commission. They first describe the epidemiologi-
cal observations in the city of Bombay ; then they
report observations made in the villages of Sion,
Wadhala, Parel, and VVorli, suburbs of Bombay ;
then follows a discussion of the manner of the
spread of the infection in Bombay and of the in-
fectivity of houses; and, finallv, there is a descrip-
tion of epidemiological observations made in the
villages of Dhand and Kasel in the Punjab. .
The entire work is, of course, done from the
viewpoint of the epizootics in Mus decmnanus and
in Mus rattus and their conversion into human epi-
demics by the agency of the rat flea, Pulex cheopis.
The methods of the examination of rats are similar
to those described by Kitasato in a paper published
in the Neiv York Medical Journal for July 7, 1906.
• The method of collecting fleas for examination is
ingenious and original.
The names of the writers of the reports are sup-
pressed, most unjustly, we think. It appears to us
that the important points are these : First, there are
distinct Miis decumanu^ epizootics and Mus rattus
epizootics, which are followed by distinct human
epidemics. Second, these epizootics are followed by
the epidemics in from seven to ten days. Third, the
rat flea is the agent of spread of the epizootic from
Mus decumanus to Mus rattus, and of the conver-
sion of the latter epizootic into a human epidemic,
b'ourth, the way to stop plague is to exterminate
rats.
These facts are those that are guiding our own
authorities in their efforts to stop the spread of
556
NEIVS ITEMS.
Medical Joi rn.
bubonic plague on the Pacific coast. While no cases
of human plague have been discovered there for
more than a month, the work of exterminating rats
goes on at the rate of seven thousand a week in
San Francisco alone. Rats continue to be found in-
fected with Bacillus pestis (Public Health Re-
ports).
•'DR. MAGNUM."
"Dr. Magnum," it may be allowed, has a festive
sound, but to see it substituted for Dr. Magiiaii, of
the Ste.-Anne, in a Paris press dispatch "by tele-
graph to Clifden, Ireland, thence by wireless," as
it was in one of the newspapers last Sunday, inclines
one to wonder whether the error is to be imputed
to the cable or to the Marconi system. From the
sul)stance of the dispatch it is to be gathered that
Dr. Magnan's jubilee was to be celebrated on Mon-
day, but throughout he is called "Dr. I\[agnum."
MR. DANIFX SIDNEY APPLETON,
of London.
Mr. Appleton died on Wednesday, March i8th,
at his residence, in London, at the age of forty-
seven years, of cardiac disease. He was a member
of the firm of D. Appleton & Co., and during the
latter years of the many that the New York Med-
ical Journal was published by that house he was
particularly devoted to its interests. He was of
the third generation of those Appletons who were
engaged in the publishing business. Some seven
years ago he became the London representative of
the firm, and he also entered upon a publishing
career of his own in that capital. With the ready
adaptability of our countrymen he took kindly to
life in London, where he made many friends. The
deceased gentleman was a wise man of business,
and. above all, he was personally most attractive
and amiable.
Petos Items.
Changes of Address.— Dr. Thompson J. Trueman,
to 2Q9 Bridge street, Brooklyn, N. Y. ; Dr. B. Franklin
RoycT, to 35 Sonth Nineteenth street, Philadelphia.
The Society of Physicians of the Village of Canan-
daigua, N. Y., held a meeting on the evening of March
I2tlr Dr. (). J. Hallcnheck read the paper of the evening
on Spinal Injuries.
The Franklin District, Mass., Medical Society.— At
the March meeting of this society, which was held in
(ireenfield on Tuesday, March loth. Dr. Clara M. Green-
oiigh read a paper on Functional Dysmenorrhoea.
Buffalo Academy of Medicine. — The regular meeting
of the Section in Pathology was held on Tuesday, Marcli
17th. The programme inchided a paper on Gangrenous In-
flammation of the .Appendix with Spontaneous Discharge
into the Small Intestines, by Dr. A. L. Benedict, and a
paper on Epithelial Tumors of the Skin and Exposed
M ucous Aletnbrancs, by Dr. A. H. McGlantian, of
Baltimore.
American Urological Association.— The New York
Society \\ ill hold a stated meeting at the New York Acad
emy of Medicine on Wednesday, March 25th, at 8:30 p. ni.
The paper of the evening will be read by Dr. Ramon
Guiteras on Tuberculosis of the Kidney.
Rochester, N. Y., Academy of Medicine.— .A meeting
of Section III, which embraces obstetrics, gynecology, and
paediatrics, was lield on Wednesday evening, March i8th.
Dr. C. S. Starr reported a case of chorea at term, two
cases of eclampsia, and an alleged case of abortion.
Hartford, Conn., Medical Society. — The Surgical
Section of the society will meet on Monday, March 23d, at
8:30 p. m. Dr. Roswell Park, of Buffalo, will deliver an
address on the Modern Aspect of the Cancer Problem,
which will be followed by a general discussion. At the
close of the meeting a reception will be tendered Dr. Park.
American Medicopsychological Association. — The
sixty-fourth annual meeting of this association will be held
in Cincinnati, Ohio, on May 12th to 15th. The programme
includes a long list of papers by eminent neurologists, and
the meeting promises to be one of especial interest. Dr.
Charles W. Pilgrim, of Pouglnkeepsie. N. Y.. is the secre-
tary of tlie association.
Statistics of Operations for the Cure of Aneurysm. —
Dr. Rudolph Mntas. of No. 2255 St. Charles avenue. New
Orleans, writer tliat lie is compiling the statistics of opera-
tions for the cure ni aneurysm by the intrasaccular method
(endoaneurysmorrhapliy), and will be obliged to all sur-
geons who have had experience with this operation for
brief reports of their cases.
Syracuse, N. Y., Academy of Medicine. — A meeting
of this academy was held on Tuesday evening. March
17th. Dr. J. C. Palmer read a paper on the Inspection of
Schools in Syracuse, Dr. Jesse Heiman read a paper en-
titled Personal Experiences in School Inspection, and Dr.
D. M. Totman read a paper on Milk Inspection. The gen-
eral discussion, which followed the reading of the papers,
was opened by Dr. Nathan Jacobson.
Charitable Bequests. — By the will of William B.
Scott, of Bryn Mawr, Pa., St. Christopher's Hospital, of
Philadelphia, receives $25,000 for a permanent fund. The
Children's Seashore Home, of Atlantic City, the Bryn
Mawr Hospital, and St. Christopher's Hospital are re-
versionary legatees.
By the will of Mrs. Sarah E. Thomas, the Presbyterian
Eve, Ear. and Throat Charitv Hospital, Baltimore, receives
$i'oo.
The Norfolk, Va., Antituberculous League. — At a re-
cent meeting of the board of directors the plan of establish-
ing a separate hospital for tuberculosis patients at the city
almshouse was endorsed, and it is believed that the neces-
sary appropriation will he made by the council. Clinics are
held daily under the auspices of the league, and are conducted
by Dr. J. W. Hunter Dr T. J. Miller, Dr. W. P. Smith,
and Dr. Charles R. (irand>. each taking a turn in regular
order.
Medical Society of the County of Kings. — At a meet-
ing of the Section in Pediatrics, held on Friday evening,
March 20t1i, the programme included the following papers :
A Review of English P;ediatric Literature for 1907, by
Dr. John F. Crawford ; A Review of the German Pediatric
Literature for 1907, by Dr. .A.lexander Spingarn ; Chronic
Intisiinal liifcction in Infants and Young Children, and
Report ni a Case of Rudimentary Fingers, bv Dr. F. H
Bartle\ .
The Mortality of Connecticut. — According to the
Monthly Bulletin of the Connecticut State Board of Health
for the month' of February, 1908, there were during the
month 1,511 deaths from all causes, a decrease of 44 from
the preceding month, and an increase of 8 over the same
month in 1907. The annual death rate in 1,000 of popula
tion was 17.5 for the large towns. 18.6 for the small towns,
and 17.7 for the whole State. There were 282 death- rc
])orted from infectious diseases.
Alumnae Association of the New York Medical Col-
lege and Hospital for Women. — The regular sprni..:
meeting of this association was held on Wednesda> . March
i8th, in Brooklyn, at the residence of Dr. J. V. II Baker.
512 Bedford avenue. Dr. Clarice J. Parsons, of Spring-
field, Mass., read a paper on Women Physicians in Small
Cities, which was followed by a general discussion. Dr.
March 21. 190?.]
A'EIVS ITEMS.
557
Sara D. Smalley is the president of this association, and
Dr. Sophie B. Scheel, 970 Park avenue. New York, is the
secretary.
The Health of Pittsburgh. — The following cases of
transmissible diseases were reporte-l to the Bureau of
Health of Pittsburgh for the week ending February 29,
1908: Typhoid fever, 44 cases, 12 de.iths; scarlet fever, 22
cases, 2 deaths; diphtheria, 12 cases, 1 death; measles, 258
cases, 3 deaths; whooping cough. 23 .^-ase-, 5 deaths; pul-
monary tuberculosis, 27 cases, 15 deaths. The total deaths
for the week numbered 207. in an estimated population of
403. ,300, corresponding to an annual death rate of 26.68 in
1. 000 of population.
Vacancies in the Staff of the Hudson Street Hospital.
— \\'e are informed that there are several vacancies in the
staff of the Genitourinary Section of the House of Relief
(Hudson Street Hospital), 67 Hudson street, Tlie section
luects e\ery Tuesday and Friday, from 8 to 10 p, m., and
any one who is interested in genitourinary work and is
willing to pledge regular attendance and faithful perform-
ance of duty is invited to send an application, together with
references, to the chief of the clinic. Dr. Victor C, Peder-
scn, 45 West Ninth street. New York,
The Glens Falls and the Saratoga Medical Societies
held a joint meeting in Saratoga, N. Y,, on Friday. March
6th. The evening was devoted to a general discussion on
epidemic and tuberculous cerebrospinal meningitis. Papers
on the subject were read as follows: The .-Etiology of
Cerel.Tospinal Meningitis, by Dr. E. B. .Probasco, of Glens
Falls; The Pathology of Cerebrospinal [Meningitis, by Dr.
S. A. Downs, of Saratoga ; The Symptor.is of Cerebrospinal
jMeningitis, by Dr. A. McKee, of Glens Falls; and the Treat-
ment of Cerebrospinal Meningitis, by Dr. G. S. Towne, of
Saratoga.
The New York Academy of Medicine. — A stated
meeting will be held on Thursday-. April 2d. at 8:30 p. m..
under the auspices of the Section in l.nrxngology and
Rhinology, The general subject for (li-cn~-iiiii will be the
diagnostic value of symptoms in ihv uppi r ri.--piratory
tract in general disease, Dr, Thomas J. Ham- will read
a paper dealing wjth the subject in its relatiim Ui nerxcus
diseases; Dr, Francke H, Bosworth will read a [);iper im
its relation to syphilis and tuberculosis ; and Dr. Fniile
Mayer will read a paper on its relati(in to rheumatism,
gont, and diabetes.
Scientific Society Meetings in Philadelphia for the
Week Ending March 28, 1908. — Monday. March .23d.
Mineralogical and Geological Section, Academy of Natural
Sciences ; Society of Normal and Pathological Physiology,
University of Pennsylvania. IVcdiic.uhiy. Miircli Jj/Zi, Phil-
adelphia County Medical Society, 7 ,'!/( ' ,w/<'v. Morch 26th.
Pathological Society: Entomological SeLiwui, .\cademy of
Natural Sciences : Section Meeting, f ranklin Institute,
I-riday. March jjtli. South Branch, Philadelphia Count\
Medical SociecN : Northern Medical .Association; Phila-
delphia Neurological Society.
The Mortality of Chicago. — According to the report
of the Department of Health for the week ending March
7th, there were during the week 669 deaths from all causes,
as compared with 650 for the corresponding week in 1907,
The annual death rate was t6.io in i.ooo population. The
principal causes of death were : .\]ioplex\-. 1 1 : P.right's
disease. 48; bronchitis. 25: consii!ni)ti. t,, ,s;3 ; cukxt. 29:
convulsions, 3; diphtheria, 16; heart di-^:i-r,. 4(1; mlluenza.
20: intestinal diseases, acute, 28; niea.-i>.~, 1: iui\Mtis dis
eases, 26; pneumonia, 100; scarlet fe\er, it: suicide, 9:
typhoid fever. 15: violence, other than >uicide. 37: wl>oop-
ing cough. 5: all other causes, 153,
The Mortality of New York City.— During the week
ending March 7, 1908, there were reported to the Depart-
nient of Health 1.622 deaths from all causes, as compared
with 1,647 for the corresponding period in 1907. The an-
nual death rate was 19.14 in i.coo of population. The prin-
cipal causes of death were: Apoplexy. 45: Bright's disease
and nephritis. 124: bronchitis, 15: cancer, 58; cerebrospinal
meningitis, 12 ; diarrhoeal diseases. 77 : ' diphtheria and
croup, 48; influenza. 16; organic lieart diseases. 135: [)neu-
monia, 168; bronchopneumonia, 129: typhoid fever, 7:
measles, 26; scarlet fever, 56; pulmonary 'tuberculosis, 200:
tuberculous meningitis, 23; other forms of tuberculosis. 9:
suicides, 18; homicides, 6; accidents. 6^. There were 133
stillbirths.
The Cartwright Lectures of the College of Physi-
cians and Surgeons will be given this year by Professor
James Ewing, of Cornell Medical College, on March 25th,
27th, and 30th, at 5 p. m., at the Nev\- York Academy of
Medicine. Acidosis and Associated Conditions is the sub-
ject, which will be divided as follows: On March 25th the
lecture will be on The Experimental Basis of the Doctrine
of .Acid Intoxication — Diabetic Acidosis ; on March 27th,
the lecture will be on the Physiological Chemistry of
.Acetone Compounds; and on March 30th the subject of
the lecture will be Clinical Forms of .Acidosis, Pathological
.Anatomy, and Classification.
The Medical Jurisprudence Society of Philadelphia. —
The >cvent.\-lifth stated meeting of this society was held
on Monday evening. March i6th. The evening was de-
voted to a discussion of the question of the protection of
the public against medical frauds and criminals, Mr.
Thomas W. Barlow read a paper on The Prevalence of
Medical Fraud and Crime in Philadelphia. Mr. Alexander
R. Craig read a paper on The People's Lack of Defence
.Against Medical Criminals and Quacks in Previous and
Present Medical Practice .\cts. Mr. Charles Mclntyre, of
Eastoii. Pa., rtail, hy in\'itation, a paper on Difficulties in
the of Correct Legislation. .A general discussion
followed the re:L(Iiiig cf the papers.
Infectious Diseases in New York:
]Vc arc indebted to the Bureau of Records of the Dej'art-
nient of Health for the folknving statement of neic cases
and dratlis reported for the tzva weeks ending March 14,
190S :
March
, Mai
Cases.
Deaths.
Cases.
Deaths.
'Pubercuiosir-
434
191
Diphtheria , ,
370
"48
322
55
Measles
.. 1,46s
26
1.643
27
Scarlet fever
901
56
942
44
18;
Typhoid fcve
26
37
9
\\'liooiiing CO
'gl<
20
2
Cerebrospinal
12
J.59S
340
Medical Society of the County of New York. — A
stated meeting of this society will be lield on Monday,
March 2311. at 8 :i5 o'clock. The programme w ill include the
following p;iper^ : The Correlation of Clinician, Path-
ologist, tind Laity, by Dr. Bond Stow, which will be dis-
cussed 1)\- Dr, John Van Doren Young and Dr. Beverley
Robinson : The Public Hospital System of New York
City, by the Hon. R. W. Hebberd, Commissioner of Pub-
lic Charities : The Relation of the Seniiprivate Hospitals of
the City to the Public Hospitals, by Dr. S. S. Goldwater;
The .Ambulance System of Public and Private Hospitals,
by Nathan Bijur. Esq. The papers on hospital manage-
ment will be discussed by Dr. W. Gilman Thompson, the
Hon. Homer Folks, Dr. Theodore Janeway. Dr. John Win-
ters Brannan, and Mr, Ludlum. superintendent of the
New York Hospital.
Personal. — In a recent issue of one of our contem-
poraries it was stated that Dr. Ern>t J. Lederle had re-
turned front an extended trip abroad on February 21st.
This statement, we are advised, was incorrect, as Dr, Led-
erle did not sail from Naples until Fcbruarv 21st. arriving
ni New_ Y.irk on Alarch 5th.
Dr. (niy .A, Geherick. of Lelianon, Pa., is registered at
the Philadelphia Polyclinic and College for Graduates in
Medicine.
Dr. Reginald Herbert Fitz, llersey professor of the
iLeory and practice of physics at the Harvard Medical
School, has resigned, and will retire from active work on
September ist.
Dr. John B. Watson has been appointed professor of ex-
perimental and comparative psychology at the Johns Hop-
kins University.
Dr. Robert Boyd, of the New York College of Physicians
and Surgeons, has been appointed instructor in vertebrate
zoology at the College of the City of New York.
The Health of Philadelphia.— During the week end-
ing February 29. 1908. the following cases of transmissible
diseases w ere reported to the Bureau of Health : Malarial
fever, i case, o deaths: typhoid fever, 92 cases, 27 deaths;
scarlet fever. 75 cases. 5 deaths: chickenpox. 51 cases, 0
deaths; diphtheria, 77 cases, 13 deaths; cerebrospinal men-
ingitis. 4 cases. 2 deaths; measles. 209 cases, 6 deaths;
558
.\FJVS ITEMS
LNevv York
Medical Journal
wliooping cough, 19 cases, 4 deatlis; pulmonary tubercu-
losis, 137 cases, 77 deaths ; pneumonia, 98 cases, 67 deaths ;
erysipelas, 10 cases, 3 deaths : puerperal fever, 5 cases, 2
deaths; cancer, 13 cases, 18 deaths; mumps, 15 cases, o
deaths; tetanus, I case, o deaths. The following deaths
were reported from other transmissible diseases: Tubercu-
losis, other than tuberculosis of the lungs, 12; diarrhoea
and enteritis, under two years of age, 14. The total deaths
numbered 562, in an estimated population of 1,532,738, cor-
responding to an annual death rate of iQ.oi in i.ooo of
population. The total infant mortality was 115; under one
year of age, 92; between one and two years of age. 23.
There were 36 stillbirths ; 22 males, 14 females.
Society Meetings for the Coming Week:
MoND.AV. March jjd. — Medical Society of the Countv of
New ^'ork.
TuE.SD.w, March J4th.—Nt;w York Otological Society;
New York Medical Union ; New York Dermatological
Society ; Metropolitan Medical Society of New York
City; Buffalo Academy of Medicine (Section in Ob-
stetrics and (jyna'cology).
Wed.\i:.si)av, March jf,th. — New York Academy of Medi-
cine ( Section in Laryngology and Rhinology) ; New-
York Surgical Society.
Thi-r.sd.w, March ?6th. — New ^'ork Academy of Medicine
(Section in Obstetrics and Gynaecology) ; Brooklyn
Pathological Society; Hospital Graduates' Club, New-
York; New York Celtic Medical Society; Brooklyn
Society for Neurology.
Frid.w, March jjth. — New York Clinical Society; Acad-
emy of Pathological Science, New Y'ork ; New York
Society of German Physicians.
Satiikday, March 28th. — New York Medical and Surgical
Society ; Harvard Medical Society, New York ; Lenox
Medical and Surgical Society, New York ; West End
Medical Society.
College of Physicians of Philadelphia. — At a meeting
of the Section in Otology and Laryngology, held on
Wednesday evening, March r8th, the following papers were
read: Tertiary Syphilis of the Pharynx, Tonsil, and Soft
Palate, Epiglottis and Vestibule of the Larynx, w ith Mem-
branous Formation Simulating Vincent's Angina, by Dr.
D. Braden Kyle; Position of the Patient in Operations on
the Nose and Throat, by Dr. yVrthur A. Bliss ; Some Lar
yngeal Complications of Typhoid Fever, by Dr. Joseph S.
Gibb.
The Section in Ophthalmology held a meeting on Tinirs-
day evening, March igth. The programn-ie was as follows :
Dr. Howard F. llansell read a paper on Burn of Both
Eyes by Electricitv, :i,i<l rxliil.iled a i)atient ; Dr. William
Campbell Posey rejiorled a ease of paralysis of the ex-
traocular muscles ill ex. )i)hth;ilmic goitre, and a case of
homonym<jus b.emianopsi:i in the ma.eular regions. Dr. S.
D. Risiey reported two eases of uiter^tilial keratitis asso-
ciated with cretinoid conditions; Dr. Wendell Reber read
a papei entitled .X FVobable Conmniial Circumscribed
Defect in the Choroid with Anomalous Pigmenl .'Xrrange-
ment ; and Dr. William Zentmayer read a paper entitled
Restoration of the Contracted Socket.
Over Seven Thousand Dollars in Prizes for Exhibits
and Essays Relating to Tuberculosis. — Five prizes of
$1,000 each and seven of $100 each are offered by the Tn-
ternational Congress on Tuberculosis as f(jllows : ist. Vor
the best evidence of effective work by a voluntary associa-
tjon for the prevention or relief of tuberculosis; 2d, for the
best exhibit of a furnished house for a family, or a group
of families of the working class; 3d, for the best exhibit of
an existing sanatorium for the treatment of tuberculosis
among the working classes; 4lh, for the best exhibit of a
tlispeiisary or kindred institution for the treatment of
the tuberculous poor; sth, for the best exhibit of a hospital
for advanced pulmonary tuberculosis. The Congress also
offers prizes of $100 each for seven educational leaflets of
from one to two thousand words, addressed to (a) adults
generally, (b) teachers, (c) mothers, (d) indoor workers,
(e)dairy farmers, (f) grammar school children, and (g)
primary school children, the latter to be pictorial in charac
tor. 'i he Smithsonian Institution offers a prize of $1,500
for the best treatise submitted on the Relation of .\\.-
mospheric Air to Tuberculosis. Numerous medals are also
offered for exhibits in allied lines. Full details i-egarding
the forms in which essays are submitted will be furnished
by Dr. Thomas G. .A.shton, 1814 South Rittenhouse Square,
Philadelphia, secretary of the Committee on Prizes.
The American Society of Tropical Medicine. — The
fifth annual meeting of this society will be held at the Johns
Hopkins Hospital, Baltimore, on Saturday, March 28th.
At the morning session Dr. James M. Anders, of Philadel-
phia, will deliver the presidential address on a Brief Review
of the Year's Progress in Tropical Medicine ; Dr. Joseph
McFarland will read a memoir of the late Dr. Jatnes Car-
roll; Dr. Charles Wardell Stiles, of Washington, D. C, will
read a paper, the subject of which is not announced; Dr.
Bailey K. Ashford, of Washington, D. C, will read a paper
entitled Puerto Rico as a Field for Research in Tropical
Medicine; and Dr. R. H. Strong, of Manila, will read k
paper on Vaccination against Plague. In the afternoon the
election of ofificers and members will be held, and the fol-
lowing papers on the prophylaxis of malaria will be read:
Quinine Prophylaxis, by Dr. William S. Thayer, of Balti-
more; Mechanical Prophylaxis, by Dr. Charles F. Craig,
of Fort Leavenworth, Kansas; Mosquito Extermination, by
Dr. L. O. Howard, of Wasliington, D. C. ; Stroiigyloides
Intestinalis in Philadelphia, by Dr. Judson Deland, of
Philadelphia; Twenty Years' Experience with the Hypo-
dermic Use of Quinine and Urea Hydrochloride in Malarial
Infection, by Dr. .S. Solis-Cohen. The following papers
will be read by title : A Biographical Note of Dr. Louis
Beauperthuy, by Dr. Aristides Agramonte, of Havana ,
Some Notes on a Collection of F.ntozoa Made by Dr. F.
Creighton Wellman in Portuguese West Africa, by Dr.
Henry B. Ward, Lincoln, Neb.; The Pathogenesis of
Pernicious Malaria, by Dr. William H. Deaderick, of Mari-
anna, Ark. ; Clinical Charts of a Case of Quartan Alala-
rial Fever Observed in West Africa, by Dr. F. Creighton
Welln-ian, of Breyuella ; and a History of a Case of Malarial
Fever, Algid Form, Choleraic Type, by Dr. R. H. von
Erdorf, of New- Orleans.
Meetings of Sections of the New York Academy of
Medicine. — A meeting of the Section in Ophthalmology
was held on Monday excning, March i6th. The paper of
the evening was read by Dr. P.. S. Thomson on the I^iag-
nostic Value of Tenderness in the Ciliary Region.
.^t a meeting of the Section in Medicine, which was held
on Tuesday evening, March 17th, Dr. Lawrason Brown, of
Saranac Lake, read a paper on Cardiac Complications in
Pulrnonary Tuberculosis; Dr. Thomas B. Futclier. of Bal-
timore, read a paper on the Cerebral Complications of L'l-
cerative Endocarditis; and Dr. .Mfred Stengel, of Philadel-
phia, read a paper on the Clinical Features of Myocardial
Disease. The discussion which followed was participated
in by Dr. W. Oilman Thompson, Dr. .A.lexander Lambert,
and Dr. Henry Koplik.
The Section in Genitourinary Surgery held a meeting on
Wednesday evening. March i8th. Dr. Eugene Fuller read
a paper entitled A Reminder that Fatal or Serious Results
May Follow Operative Treatment of Bubo, and Dr. L.
Levin read a iiajier entitled Renal Pyuria Without .Ap-
parent Lesion in the Kidney.
A i-neeting of the Section in Orthop.-edic Surgery was
held on Friday exening. March 20th, and papers were read
as follows: Some Obserx atioiis on Suppurative Conditions
in the Joint Regions in Infancy and Young Children, by
Dr. Linnaeus E. La Fetra; Serotherapy in Infectious
.Arthritis, by Dr. John Torrey ; and the Diagnosis of Joint
Infection, by Dr. P. William Nathan.
The Section in Obstetrics and Gynaecology will meet 011
Thursday evening, ]\Iarch 26th. The following programme
has been prepared for the meeting: Dr. Eden V. Delphey
will present a imique specimen of an asexual monster, Dr.
H. J. Boldt will present a specimen of tubal abortion, and
Dr. C. C. Sichcl will present a specimen of carcinoma of
the uterus complicated by pus tubes and adherent appendix.
Dr. Eugene C. Savidge will read a paper entitled The
Problem of Uterine Cancer, and the following reports of
cases will be given : Inverted Appendix, reoperated, w ith
microphotograph, by Dr. H. D. Furniss ; .Amputation of the
Cervix under Hypnosis, by Dr. C. F. .Adams; Right
Ovarian Cy.st Complicated by .Appendicitis and Distended
Gallbladder, by Dr. C. C. Sichel ; Serous Fluid (Pelvic)
encapsulated two months after Supravaginal Hysterec-
tomy, by Dr. Le Roy Broun ; and Small Ovarian .Abscess
Rupture while Rem iving, by Dr. Le Roy Broun.
March 21. 190S.]
PITH OF CURRENT LITERATURE.
559
THE BOSTON MEDICAL AND SURGICAL JOURNAL,
March 12, igoB.
1. The Genesis and Nature of Hysteria: A Conflict of
Theory, By J. \y. Courtney.
2. Some Clinical Observations on the Diagnosis and
Treatment of Exophthalmic Goitre,
By James Marsh Jacksox and Louis Gray Mead.
3. Strictures of the CEsophagus Dilated through the
QEsophagoscope. Report of a Case.
By T. Paysox Clark.
4. A Case of Gastric Symptoms of Reflex Origin.
By Richard F. Chase and Johx T. Bottomlev.
I. The Genesis and Nature of Hysteria: A
Conflict of Theory. — Courtney reviews the theo-
ries of Freud, Babinski, Janet, Prince, and PuUier.
and gives the definition of hysteria put forward by
these authors. He states his own ideas as follows :
He believes that hysteria is the clinical expression
of a simple adynamic condition of the brain, and
that in our part of the world we rarely see more
than a forme frustc of the classical picture. By
this he means that the somnambulistic phenomena
(which, Janet says, constitute more than half the
so called accidents of hysteria ) . the complete
abulias, the deliria, the paralyses, and contractures,
even the absolute hemianaesthesias and amauroses,
are genuine rarities. In view of these observations
he is firmly convinced that the generally unfavor-
able prognosis laid down by American writers on
hysteria represents the teaching of the French
school rather than an independent conviction based
on their own experience. He is also satisfied that
in environment and psychotherapy we have two
agents that are absolutely adequate for the cure of
practically ever\- case we meet in our dail_\- work.
His conception of psychotherapy is based on this
fact, that the infusion of force and activity into
brain cells is by no means a purely endogenous pro-
cess. This truth was obvious to the mind that first
conceived the idea of placing a band of music at
the head of a regiment of soldiers ; and we are all
familiar with the tremendous dynamogenic capa-
bilities of a patriotic tune. A waltz measure, for
some of us, possesses the same energizing quality ;
for others the spoken or written word, the personal
example, are all sufficient. Psychotherapy stands
for anything and everything that acts upon the in-
tellect and the emotions in a way to recharge de-
pleted brain cells. As to the aetiology of hysteria
he held that it is logical to assume that from a re-
mote period in historj-, even as far back as the time
when the misbegotten term "hysteria" was con-
ceived in the medical mind, human beings of both
sexes have been the victims of bodilv injuries, and
that these injuries have been incurred under cir-
cumstances quite as harrowing to the emotions as
any which obtain today. In the face of this logical
assumption, it seems to him nothing short of mar-
velous that medical history should be so absolute-
ly barren of reference to trauma as a cause of hys-
teria, up to the time when corporate bodies began
to direct the great commercial enterprises of the
world and were held responsible by law for the
safety both of those in their employ and of those
whom they undertook to convey from one place to
another. There is to our author a sinister signifi-
cance in the rapid growth in importance attached
to bodily injuries in the causation of hysteria from
that time to the present, and a sinister significance
in the facility with which bodily injuries of the
most trivial sort appear to be capable of producing
this untoward result in persons previously unemo-
tional and whose family history is so universally
free from everything that might suggest nervous
or mental deviation.
2. Some Clinical Observations on the Diag-
nosis and Treatment of Exophthalmic Goitre. —
Jackson and Mead are not in favor of sending early
cases to the surgeon. The results of medical treat-
ment are too favorable, from 70 per cent, to 80 per
cent, of the cases being cured by it. This is espe-
cially true in the rudimentary forms; better in the'
form which develops gradually than in the form
which develops suddenly with full force; better in
the old than in the young. But notwithstanding
the good results from medical treatment there will
always remain a certain number of cases for the
surgeon, viz.. when the thyreoid gland becomes so
large that it produces symptoms of compression or
when the patient gets rapidly worse on medical
treatment. Organic heart changes and bad general
condition are surely contraindications to operation.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
March 14, 1908.
I. Tlie Chemical Control of the Body,
By Ernest H. Starling.
J. Passive Hypersemia by Means of the Cupping Glass of
Bier and Klapp, By B. M. Bernheim.
3. The Frequency and Significance of Endometritis from
the Standpoint of Treatment,
By Brooke M. .\nspach.
4. Delirium During and After Tetanus,
By Charles W. Burr.
5. A Typhoid Fever Epidemic from Infected Milk,
By Charles Nahum Haskell.
6. Removal of a Subcortical Cystic Tumor at a Second
Stage Operation Without Anaesthesia,
By H. M. Thomas and Harvey Gushing.
7. American Mineral Waters in the Light of Recent
Analyses, By James K. Crook.
8. The Oatmeal Diet in the Treatment of Diabetes
Mellitus. By James B. Herrick.
9. The Importance of an Ocular Examination in Pregnant
Women Manifesting Constitutional Signs of Tox-
Kmie,
By William Campbell Posey and John Cooke Hirst.
10. The L'se of .A.nthracite Coal Ash as a Surgical Dress-
ing. • By W. Irving Clark, Jr.
II. Fistulous Tracts, Tuberculous Sinuses, and Abscess
Cavities. A New Method of Diagnosis and Treat-
ment by Bismuth Paste. By Emil G. Beck.
I. The Chemical Control of the Body. — Star-
ling, of London, observes that, as a result of recent
investigations, we may assert that in the employment
of drugs we are but imitating, although perhaps in a
very imperfect manner, the method employed by
Xature herself, and, indeed, that a large share in the
wonderful coordination of the activities of different
parts of the body, which determine their mutual co-
operation for the common weal of the organism, is
played by the production and circulation of chemical
substances which are strictly analogous to the drug.s
employed during countless ages by mankind in the
56o
PITH OF CURRENT LITERATURE.
treatment of diseases. As an illustration of this fact
he cites secretin, a chemical substance that excites
pancreatic reaction. This body can be regarded as a
type of a whole group of chemical messengers,
which, formed in one organ, travel in the blood
stream to other organs of the body and effect cor-
relation between the activities of the organs of ori-
gin and the organs'on which they exert their specific
eflfect. For these chemical messengers the name of
"hormone" has been suggested. Ehrlich divided the
chemical agents which act on the organism into two
classes, the toxines and the drugs. There is one
marked distinction between the two groups : The
toxines cause the formation in the organism of anti-
bodies, tending to produce immunity, while in the
case of the drugs, though with some a limited de-
gree of tolerance may be produced, there is no evi-
dence of the production at any time of antitoxic sub-
stances in the treated animal. The hormones, acting
constantly as chemical messengers from one organ
to another by way of the blood, cannot produce anti-
bodies that would abolish their function, and must
necessarily, therefore, belong to the class of drug
substances. Their action must also, in all probabil-
ity, be ranked with the purely chemical processes,
rather than with those mixed chemical and physical
processes which determine the formation of absorp-
tion compounds and distinguish the interaction of
one colloid with another, as well as of toxines with
the animal cell or with their corresponding anti-
toxine.
7. American Mineral Waters. — Crook com-
pares the analyses of American commercial mineral
waters, recently published in Bulletin pi of the
Bureau of Chemistry, of the United States Depart-
ment of Agriculture, "with those of the advertised
analyses. He comes to the conclusion that a great
majority of the advertised analyses of our mineral
waters were made many years since when methods
were not so exact as they are at the present day.
Some mineral springs are sensibly influenced by the
wetness or dryness of the season, both in strength
and in volume ; the greater the volume of the water
the weaker it is in mineral ingredients; examinations
of such springs at different stages would undoubt-
edly yield dissimilar results. While many springs
are of deep origin and show no apparent fluctuations
in their rate of flow, we have no positive proof that
even these have not become more or less modified
in character during the long period since the old
analyses were made. The subterranean aqueous
current, which constitutes a spring when it reaches
the surface, cannot be counted on continuously to
come in contact with earth strata which yield a uni-
form product to its solvent power. Underground
streams, as well as those on the surface, are liable
to change their course, and, while losing certain of
their former contents, may acquire new ones. The
fact must not be overlooked that the government
analyses were made in each case from samples pur-
chased in the open market. It is, therefore, possi-
ble that some of the waters examined by the bureau
chemists w^erc spurious or adulterated. All of our
medicinal springs should, therefore, be submitted to
analysis at least once in ten years until we are able
to arrive at a correct estimate of their potency, and
whether they are gaining or losing in strength. No
enterprising mineral spring proprietor, animated by
a desire to put forth a reliable product, can object
to the expense, repeated at intervals so widely sepa-
rated. The decennial revisions of our works on ma-
teria medica and pharmacy should present a brief
account of the mineral waters conforming to ethical
rules, so that the medical practitioner may be in
possession of as authentic and authoritative a source
of information regarding these as he has in case of
other therapeutic agents.
8. The Oatmeal Diet in the Treatment of Dia-
betes Mellitus. — Herrick confirms von Norden's
statement for the oatmeal diet. While occasionally
the stomach will rebel and refuse to tolerate this
food for any great length of time; while the diet
is not suited to all cases, being of least avail in the
milder forms ; while it fails even in some of the
severer types, and while no claim for a cure of dia-
betes can be made, this diet still remains a most
valued therapeutic agent for the warding off of im-
pending coma in the severer types of diabetes and
for assisting in the establishment of a tolerance for
carbohydrates. In the milder types of diabetes he
has so far seen no ill effects follow its use, but the
benefits have been trifling. His experience in using
it in the diabetes of moderate severity has in general
been favorable, it being of especial help in establish-
ing tolerance for carbohydrates. In the diabetes of
children, if employed early, it seems to exert a
usually favorable influence.
ID. The Use of Anthracite Coal Ash as a Sur-
gical Dressing. — Clark has made experiments
with anthracite coal ash pads as surgical dressings.
He concludes that in cases where gauze cannot be
obtained or the expense is too great, ash pads form
a good substitute. In freely discharging sinuses
and suppurating- wounds the discharge will be well
taken care of. When the discharge is thick and
gummy, or where weight or bulk of dressing is con-
traindicated, they should not be used. They are
particularly applicable to discharging wounds of the
axilla, popliteal space, and palm of the hand, be-
cause they fit snugly and tend to splint the part.
They are also well suited to varicose ulcers and dis-
charging sinuses of the abdomen. The ash pad is
made in the following manner : The ash collected
from the furnace is placed in a flour sifter and
thoroughly sifted. It will be found to fall on a
sheet of paper as a soft, brownish, floury powder.
This is all the preparation necessary. A piece of
old sheet or well washed linen is cut in rectangular
shape and of any desired size. The square is
placed on a table and a small pile of the ash is placed
in the centre. The sheeting or linen is then folded
over it, as in making a poultice. Such a pad can be
made rapidly, and when examined will be found
soft, compact, and absorbent. It can be nicely ad-
justed to any part of the body with adhesive piaster
straps, .'\fter an ash pad has been applied to a dis-
charging wound for some time it becomes moulded
to the part, as the ash loses its powdery consistency
owing to absorption. It has then the consistence of
dough, and acts as a partial splint, being more com-
fortable than otherwise.
March 21, 1908. J
PITH OF CURRENT LITERATURE.
MEDICAL RECORD.
March 14, 1^08.
1. Some Observations on the Effects of Tobacco in Surgi-
cal Practice, By L. Boltox Bangs.
2. Preliminary Report of a Case of Cerebrospinal Menin-
gitis of Streptococcus Origin Apparently Cured by
Subdural Injection of Antistreptococcus Serum,
By George L. Peabodv.
3. Sjeptal Haematoma and Abscess,
By James E. Newcomb.
4. Renal and Ureteral Calculi Complicating or Simulating
Appendicitis, By John" F. Erdmaxn.
5. Retrodeviation of the Uterus and Treatment by Short-
ening the Round and Sacrouterine Ligaments,
By C. F. KrvLiN.
6. Traumatic Rupture of the Spleen with Report of a
Case, By V. E. Watkixs.
7. Relapsing Fever with a Report of Two Cases,
By Samuel J. Goldfarb.
I. Some Observations on the Effect of To-
bacco in Surgical Practice.— Bangs cites some
such cases and thinks that, as the heart has become
accustomed to, and dependent upon, the tobacco,
sudden withdrawal should not be counselled. These
observations strengthen the opinion that the rest-
lessness, depression of vital force, aiid melancholia
of some of our ward patients may be due to the
deprivation of their accustomed stimulant. Dr. Lar-
rabee, of Harvard University Medical School, says
that emotional strain, overexercise, insufficient or
improper food, and indulgence in alcohol will pre-
dispose to some of the ill eiTects of tobacco, and
states that a series of cases of angina appeared on a
French man of war where the men, debilitated b\-
scurvy and poor food, smoked to excess in a small,
close apartment. It is possible that some of these
predisposing influences may, and they probably do.
exist in many of our hospital patients, but neverthe-
less the relation of tobacco to the individual ought
to be considered more than we are in the habit of
doing.
3. Saeptal Haematoma and Abscess. — New-
comb, in speaking of the treatment of saeptal haema-
toma and abscess, says that it is simple in case of
hsmatomia alone. The usual cold applications may
be made over the nose and its interior kept clean. If
the contents seem fluid they may be aspirated and
firm bilateral pressure made by some form of tube or
tampon, preferably the former. Serous cysts should
be incised and their cavities scraped. The incision
should be a generous one. In case of abscess the
sooner and the more freely the incision is made, the
less liability to destruction of cartilage and deform-
ity. At times it is extremely difficult to keep up
proper drainage. Strips of gauze or tubes inserted
through the incision will not stay in place. Ernest
Waggett has suggested the thrusting through the in-
cision of a knotted loop of horsehair. A seton may
also be employed. The abscess cavity should be thor-
oughly flushed with peroxide solution followed by
some alkaline antiseptic, but it should never be
packed. In some instances of pus reaccumulation
he has opened the cavity with the galvanocautery.
In case of unilateral abscess it is of value to tampon
the mucosa against that of the opposite side, rubber
protective being placed in contact with the mucosa.
The cavity is thus obliterated by pressure.
4. Renal and Ureteral Calculi Complicating
or Simulating Appendicitis. — Erdmann describes
his mode of operation thus: When, as most usual.
the stone is in the ureter, it is a decidedly simple
matter to approach it either by the transperitoneal
route through a Deaver or Kammerer incision, re-
moving the appendix, palpating the course of the
ureter, and finding the location of the stone. Then by
a narrow extraperitoneal dissection from the outer
margin of the incision one rapidly reaches the site of
the stone, the ureter and stone being held transperi-
toneally and pushing upwards. Then through
the retroperitoneal dissection the ureter is incised
over the stone, the stone expelled, and the ureteral
wound sutured or not, a small drain put down to the
trauma in the ureter. The peritonaeum is then su-
tured and the muscles and skin sutured to the emer-
gence of the drain. There is no necessity of sutur-
ing the wound in the ureter. The author prefers
the transperitoneal localizing method, as it is rapid :
one can hook the fingers under the ureter and push
it up without contusing it, as is done with the usual
instruments required in the retroperitoneal method.
In the retroperitoneal method one must make a very
long incision and dissect up a large amount of the
pelvic and abdominal anatomy before arriving at the
site of the stone. When the stone is situated high
in the abdomen or is in the hilum of the kidney, the
incision is either the oblique lumbar or the incision
of Israel. One need not hesitate in either of these
operations, provided the renal association is not in-
fective, to explore the appendix through a nick in
the peritonaeum, and remove it. as it is readily found
even in the usual incision of Edebohl for nephror-
rhaphy.
6. Traumatic Rupture of the Spleen, with Re-
port of a Case. — A\'atkins describes the symp-
toms as follows : They are essentially those of an
abdominal injury associated with internal haemor-
rhage. The shock is pronounced, as evidenced by
the anxious facies, the pallor, feeble and rapid pulse,
and collapse. Consciousness is usuallv retained in
all abdominal injuries. The pain is severe and may
be more pronounced in the splenic region. If the
case is seen early, before the eflFusion of blood fills
the peritoneal cavity, the dulness can be localized in
the left flank, otherwise it will be general over the
abdomen. An unusually pronounced contraction of
all the abdominal muscles has been reported as a
diagnostic sign, but it does not occur in all cases and
cannot be considered pathognomonic. In fact, it may
not be more marked than in other abdominal condi-
tions. Vomiting may or may not occur. From this
resume of the symptoms it will be seen that they are
essentially those of internal haemorrhage, and the
diagnosis is usually not made until after abdominal
section. The symptoms are obscure so far as ena-
bling us to distinguish whether the spleen or some
other abdominal viscera is ruptured. However, there
should be no difficulty in diagnosticating the exist-
ence of haemorrhage into the abdominal cavity, and
when this condition is recognized, abdominal sec-
tion is indicated. The incision should be made over
the region of greatest dulness. if this can be deter-
mined. If percussion elicits a note of higher pitch
in one flank than in the other, a valuable hint as to
the source of haemorrhage has been obtained.
Should the haemorrhage be sufficiently severe to give
a percussion note of equal dulness in all regions the
indication is to make the incision in the middle line.
502
PUH OF CURRENT LITERATURE.
[Ne-.v York
Medical Journal.
The treatment is essentially snrgical, the object be-
ing the control of h;em<jrrhage, and all authorities
are agreed that this end is most certainly accom-
plished by splenectomy. The mortality following
removal of the healthy spleen for rupture is about
40 per cent., whereas that of nonoperative treatment
is probabl} J 00 per cent. Ligation of the bleeding
vessels has been recommended, but is invariably fol-
lowed, in animal experiments, by necrosis. Control
of the haemorrhage by suture has been advised and
has succeeded in some cases, but in the large major-
ity the sutures have failed to control the haemor-
rhage and the patients' have died. Tamponade is
certainly a quicker and better method than suture,
according to the results thus far published, yet some
authorities reject this treatment as suitable only
when the tear is small, or in cases in which the con-
dition of the patient necessitates a speedy ending of
the operation, or in those in which extensive adhe-
sions make the removal of the spleen too long an
operation.
BRITISH MEDICAL JOURNAL.
February 2g, igo8.
1. Multiple Serositis : Illustrated by a Case in wliich the
Abdomen Was Tapped Seventy Times,
By W. H. White.
2. A Plea for a Neglected Remedy, By E. SMrrH.
3. Sudden and Unexpected Deaths, By W. W. Westcott.
4. An Unusual Case of Suicide by Suffocation,
By J. M. Renton.
5. Case of Remarkable Striae Atrophicae Due to Cachexia,
By H. D. RoLLESTON.
6. On the Production of Pseudoarthrosis of the Hip with-
out Disarticulation of the Head, By R. Jones.
7. Scarlatina Associated with Pyrexia in Apparently
Healthy Contact Cases, By B. Thornton.
8. Note on the Treatment of Experimental Trypano-
somiasis, ■ By A. Castellani.
9. An Unusual Deformity of the Foot,
By B. KlLMlGTON
10. A Note on Dr. Mulligan's Paper, "The Treatment of
Chronic Suppuration of the Middle Ear without
Resort to Radical Mastoid Operation," By O. Klotz.
11. A Fatal Case of Infectious Jaundice in the Federated
Malay States, By W. B. Orme.
12. Experiments Towards the Prevention of Malaria in the
Federated Malay States. By M. Watson.
I. Multiple Serositis. — White reports a case
of this remarkable affcclion occurring in a woman,
thirty-one years of age when she first came under
observation, complaining of swelling of the abdo-
men, due to ascites, and for which she had then been
tapped some thirty times. The first tapping took
place in 1902. There was no disease of heart,
lungs, or kidneys. She died in 1906, having been
tapped in all nearly seventy times, and nearly two
thousand pints of fluid withdrawn in all. This
chronic affection of the various serous membranes
has had many names given it — polyorrhomenitis,
multiple serositis, polyserositis, progressive sero-
sitis, and Concato's disease. The periton?eum,
pleurae, and pericardium are chronically inflamed
and thickened. The serous membrane may be-
come centimetres thick; it has a dense opalescent
appearance, and consists of several stratified layers.
It can always be peeled ofif the subjacent organs.
No case should be regarded as an example of mul-
tiple serositis unless, after careful examination,
neither tubercle or growth, can be discovered. The
disease may occur at any age. It is equally com-
mon in men and women. iThere is often a history
of previous acute infectious disease which strongly
suggests that the serositis is bacterial. Out of four-
teen cases the peritonaium, pericardium, and both
pleura; were all afifected in seven cases ; one or
more of these serous membranes, but not all, were
afifected in the remaining seven cases. Perihepatitis
is always present, and perisplenitis nearly always.
In the great majority of cases the disease begins
in the peritoii;eum : in a few the pericardium is the
first menil)rane involved; in these cases there is apt
to be indurative mediastinitis, the lungs being
bound in one mass to the pericardium, and there
being no cirrhosis of the liver. The kidneys are
often granular. The prognosis is very bad, but
cases may last for years. The ascitic fluid contains
a large amount of albumin. The histology of the
thickened membrane clearly shows it to be inflam-
matory. Little can be done as regards treatment ;
diuretics hardly seem to restrain the accumulation
of the fluid. The only thing seems to be to re-
move the fluid frequently.
2. Antimony. — .Smith puts in a plea for anti-
inony and jiotassium tartrate, a remedy of great
value, which has been strangely neglected of late
years. With our present views we should not pre-
scribe the salts of antimony with any desire to pro-
duce a profound sedative effect upon the vascular
and muscular systems, but should limit our efforts
to obtaining free secretion from the mucous sur-
faces and the skin. For this purpose antimony re-
mains preeminent, but it should always be pre-
scribed in small doses given frequently, for it is
only b}- this means that its full efifect can be ob-
tained without any danger of lowering the patient
and giving rise to unwelcome signs of depression.
In cases of bronchial catarrh and bronchitis there
is no drug to take its place. Great severity in the
attack is no bar to the use of the drug. In the
early stage of bronchoi^neumonia in children it is
of undoubted value, being most useful at the period
when the consolidation is still in patches. Bella-
donna is also of value at the same period, and the
two remedies may be combined. Laryngitis stridu-
lus is another disease in which antimony is of great
benefit ; it should be given as wine of antimony in
(l(5ses of 15 to 20 drops, so as to induce a slight feel-
ing of nausea. Hot fomentations to the throat aid
materially. \"ery small doses of antimony act as a gas-
tric sedative, and arc also of value in inflammatory
conditions of the skin, especially in eczema. To its
quality as a hepatic stimulant antimony owes its
inclusion in "riuiiinK r's pill," where it is combined
with calomel and guaiacum.
3. Sudden Death.— Westcott holds that in
cases of sudden death, sixty per cent, are of car-
diac, thirty i)er cent, of cerebral, and ten per cent,
of pulmonary origin. Among the causes of cardiac
syncope are haemorrhage (external and internal),
perforation of the bowel in typhoid fever, valvular
disease of the heart, angina .pectoris, rupture of the
heart, sudden changes in pressure on the bloodves-
sels (as in paracentesis, etc.), severe burns, simple
fatty degeneration of the heart muscle, etc. Men-
tal impressions, sudden violent pain, sudden blows
on the testis or epigastrium are also occasional
causes of sudden death from cardiac syncope. As
regards pulmonary causes of sudden death, the im-
March -:. -.goS.] PITH OF CVRREt
portant ones are the arterial hjemorrhage of
phthisis, diffuse pulmonary apoplexy, and compli-
cations of pleurisy. Asphyxia may also be due to
oedema of the lungs, to pulmonary embolism, to
overdense or overrarefied air, to illuminating gas
poisonini;, etc. Persons may die asphyxiated from
In dniplmbia, tetanus, and strychnine, or other poi-
soning. Sudden deaths accompanied by coma are
mostly due to diseases of the brain or to apoplexy.
Kidney disease has no fourth type of death to sup-
plement syncope, asphyxia, and coma. Sudden
death in convulsions may occur in epilepsy.
5. Cachectic Striae Atrophicae. — Rolleston re-
ports the case of a boy, aged sixteen years, suffer-
ing from malignant disease, in which extraordi-
narily well marked lineae atrophicae began to appear
on the back about ten days before death. The fac-
tors concerned in their production were (i) mal-
nutrition, due to cachexia, which disposed the der-
mis to rupture on slight provocation; and (2) trac-
tion exerted on the dermis in the process of turn-
ing the patient in bed. Osier divides lineae albi-
cantes into three groups: (i) Those due to disten-
sion— the ordinary lineas gravidarum; (2) the post-
febrile, especially those occurring after typhoid
and scarlet fever; and (3) the idiopathic form.
7. Scarlatina Without Eruption.— Thornton
states that in a community affected with scarlatina,
in addition to those showing definite signs of the
disease, there are others affected by the poison to
a minor extent, as shown simply by an elevation of
temperature. It might be a useful precaution to
take the temperature of contacts, with a view to
keeping under -special observation those who, while
otherwise quite well, show a moderate degree of
fever.
LANCET
February zg, igo8.
1. Acute and Chronic Infections of the Urinary Tract Due
to ihe Bacillus Coli (Erasmus Wilson Lecture),
By L. S. Dudgeon.
2. The Radical Cnre : Certification of Inebriates,
By T. C. Sh.wv.
3. A Case of Acid Intoxication Following the Administra-
tion of Chloroform, By H. Thorp.
4. Three Cases of Delaved Chloroform Poisoning,
By E. D. Tklford.
5. A Report on Two Cases of Delayed Chloroform Tox-
aemia, By T. M. Bride.
6. A Fatal Case of Delaved Chloroform Poisoning,
By H. C. Wilson.
7. Three Cases qf Fracture of the Lower End of the
Humerus, ' By F. C. Wallis.
8. The Pathology and .-Etiology of Intussusception from
the Study of 1,000 Cases,
By D. C. L. FiTzwiLLiAMS.
9. Two Cases of Anthrax, By J. S. Clarke.
10. Tausini Method for the Cure of Cancer of the Breast,
By F. Purpura.
I. Colon Infection of the Urinary Tract. —
Dudgeon .states that in most acute infections of the
urinary tract due to the colon bacillus, the onset is
sudden, a chill being the first indication. The fever
may reach 104° to 105° F. There is frequency of
micturition, with pain, and the passage of small
quantities. Nausea and vomiting are often present.
Tenderness of both kidneys may be detected, usu-
ally much more marked on one side. In some cases
the spleen is definitely enlarged, which, with the fe-
ver, may lead to a diagnosis of typhoid fever. The
v7 LITERATURE. 565
urine is acid and turbid from the presence of bacilli.
In the chronic cases the symptoms may vary from a
few apparently unimportant facts to a condition of
considerable severity. In women the bacillus coli ■
mav multiply in the urine, causing bacilluria and
sometimes pyuria, without causing any symptoms
pointing to an infection of the urinary tract. When
fever occurs in such cases the diagnosis is apt to be
malaria, tuberculosis, or influenza. In men such
cases are less common. So called gouty urethritis
may be due to an infection of the urine and urethral
mucous membrane by the bacillus coli. Incontinence
of urine in children is sometimes associated with the
presence of bacilli in the urine. In by far the larger
nimiber of cases the urine is acid. The presence of
colon bacilli in sufficiently large numbers to give
rise to turbidity causes a characteristic "shimmer-
ing" appearance. A nucleoproteid substance is pres-
ent in the urine in most cases, usually albumin.
Casts do not occur in uncomplicated cases. That
the colon bacillus is often present in apparently nor-
mal urine is shown by its being found in the urine
of ten out of forty-five cases of pregnancy, in four
out of twenty cases of peritonitis, and in five out of
fourteen cases of prostatic enlargement. These
facts serve to explain how infection of the urinary
tract mav occur. There is no evidence that the urine
in these cases contains either an excess or a defi-
ciency in opsonins — the substances which render the
bacilli more or less susceptible to phagocytosis. That
there is little systemic immunity is shown by the
fact that it is extremely rare to obtain a well marked
agglutination reaction of the colon bacillus with sera
obtained from all classes of cases of bacillus coli in-
fection. Indeed, in most instances patients suffer-
ing from an infection of the urinary tract due to the
bacillus coli. whether it is acute or chronic, show a
low opsonic and phagocytic index. The prognosis
of the acute cases is usually excellent, as long as the
infection remains uncomplicated. As regards treat-
ment, medicinal treatment is of little, if any, avail.
Urotropin, which produces such wonderful results
in other classes of cases, is useless here. Cure, when
it occurs, is usually spontaneous. Good results have,
however, been obtained in the acute cases with anti-
colon bacillus serum. In five out of twelve cases
the results were rapid and permanent, while in four
more considerable benefit ensued. In the subacute
cases the serum is also useful, but not as much so' as
in the acute cases. Twenty-five cubic centimetres of
the serum should be given each day for three days.
Calcium lactate in doses of twenty grains three times
a day will diminish the objectionable eft'ects of the
serum, such as joint* pains and rashes. In chronic
cases the Wright treatment by means of vaccines
should be tried. Unfortunately the cases due to the
colon bacillus do not give as satisfactory results as
are obtained in the case of staphylococcus aureus
and albus.
3, 4, 5, 6. Delayed Chloroform Poisoning. —
Thorp reports a fatal case of delayed chloroform
poisoning or acid intoxication, occurring in a boy
aged three years and ten months. The child was
operated upon for phimosis and was given chloro-
form for seven minutes; about two drachms being
used. Thirteen hours later symptoms of acid intoxi-
cation set in, and the child died about twenty-four
PITH OF CURRENT UTERATL'RE.
[New York
Medical Journal.
hours later. No antiseptics were used such as might
contribute to the cause of death. Telford reports
three cases, two in boys, aged two and a half and
one and three-quarters years, respectively, and in a
girl aged eight years. The operations were for tu-
berculous epididymitis, right inguinal hernia, and
double genu valgum. The younger boy recovered.
We do not seem any nearer to a solution of these
cases — why certain children will develop a state
of acid intoxication after the administration of
an anaesthetic and die with fatty degeneration of the
liver, kidneys, and heart. The condition is not rare,
as the writer has seen four deaths out of 1,500 cases
of chloroform anaesthesia in a children's hospital.
It is not sufficient to seek for a cause in a tabulated
Hst of the diseases for which the children are treat-
ed. There must be in such children some common
predisposing cause which we are not yet able to rec-
ognize. The fatty changes which are found on post
mortem examination are probably due directly to the
anaesthetic and do not represent an antecedent con-
dition. The naked eye change in such an organ is
merely the total of its cellular changes, and such
changes may well happen in the last two or three
days of life. The writer has never seen the fatty
kidneys present in these cases in children dend from
other causes, and holds that it is in the highest de-
gree unlikely that such grave alterations could exist
in the kidneys without yielding obvious clinical signs
of their presence. In a previous paper he has re
ferred to the dangers of anaesthetics in children suf-
fering from rickets. Rickets in an active condition
was present in each of the three cases here reported.
He has not been able to satisfy himself that the treat-
ment of cases of delayed chloroform poisoning by
alkalies or by intravenous saline infusion is of the
least value. Bride reports two cases, both occurring
in girls, aged three years and fourteen years, re-
spectively, the latter case recovering. The opera-
tions were for congenital talipes equino-varus. and
for genu valgum. The points of interest were: r.
The absence of any possibility of poisoning by anti-
septics. 2. In both cases the operation wounds were
surgically clean. 3. Stress has been laid on the fact
that codlivcr oil has been given in such cases. One
of the patients had never taken it, and the other onlv
at intervals. 4. Both children were markedly rick-
ety. Wilson reports a fatal case in a girl aged six
and a half }ears, who was operated on for tubercu-
lous disease of the right hip. While acetone was
early present on the breath, it did not appear in the
urine until three days later. A history of cyclic
vomiting prior to admission supports the view that
cases subject to that affection are alsojiable to post-
anaesthetic poisoning or fatty acid intoxication. All
that can be said at present is that a general anaes-
thetic must interfere with fat metnbolism in such a
way that complete oxidation of fat does not tnke place
and the intermediate products of fat metabolism,
betaoxybutyric acid and diacetic acid, pass into the
circulation and give rise to the .symptoms of fattv
acid intoxocation. Fatty liver is a constant phenom-
enon in all post mortems on these cases. Some con-
nection exists between this and the .symptoms, but
the exact relationship is obscure.
10. Tausini's Method in Cancer of the Breast.
— Purpura states that Tausini's method for the cure
of cancer of the breast consists, first, in removing all
the skin of the breast, compensating the loss of sub-
stance by the provision of a perfectly nourished flap,
which makes it possible to approximate the skin
edges in the region whence it is taken by a lineal
suture ; the flap is formed from skin rarely invaded
by cancer, and with its large pedicle abundantly cov-
ers the loss of skin of the axilla. The flap allows the
arms to move freely.
LA PRESSE MEDICALE.
February ig, 1908.
The Diatheses. The Personal Factor in Disease,
By Sir Dyce Duckworth.
The Personal Factor in Disease. — Duckworth
protests against the tendency of modern times to
neglect the personal factor, which the clinician
must ever face in the treatment of disease. He be-
lieves the present tendency to adopt new revelations
and to ignore or condemn the old to be a danger-
ous error, and that the diatheses, which cannot be
studied in the laboratory, and cannot be attributed
to the presence of infectious microbes, deserve
careful study and attention. He discusses particu-
larly subjects of arthritic, scrofulous, and nervous
diatheses.
February 22, IQ08.
1. The Action of Glycolytic Ferments Injected into Man,
By R. Odier.
2. Therapeutical Action of Radium in Cutaneous Tuber-
culosis, By Louis WiCKHAM and Degrais.
3. Poliomyelitis and Ventral Pseudohernias,
By R. Rom ME.
1. The Action of Glycolytic Ferments Inject-
ed into Man. — Odier endeavors to make clear the
difference in the effect produced by the injection
of trypsin and of the glycolytic ferments in the
treatment of cancer. Trypsin is injected in the
vicinity of the tumor in order to produce a local re-
solvent, digestive, or destructive action upon it. The
injection of the glycolytic ferments, on the con-
trary, produces a general eft'ect wherever in the
organism may be the point of inj'ection and wher-
ever may be the seat of the tumor. He speaks high-
ly of the results obtained in cases of cancer by the
injection of these ferments, and quotes a case in
point. He describes more than one way in which
these ferments may be prepared.
2. Therapeutical Action of Radium in Cutane-
ous Tuberculosis. — Wickham and Degrais speak
of the effects produced by radium on several forms
of tuberculous skin disease, and conclude that, in
their opinion, radium can render good service hi
every form of cutaneous tuberculosis, and that it
deserves a place in the treatment of granulations,
tuberculous ulcerations, lupus of the conjunctiva, of
the vicious cicatrices which follow lupus erythema-
tosus.
February 26, IQ08.
1. Removal of tlic Thyreoid Gland in Exophthalmic
Goitre, By Professor Garr^.
2. The Transplantation eu Masse of the Two Kidneys,
By J. P. Langlois.
I. Rernoval of the Thyreoid Gland in Exoph-
thalmic Goitre. — Garre reports that he has oper-
ated in thirty-five cases of exophthalmic goitre, five
men and thirty women. Partial exsection of the
thvreoid gland was performed in thirty, ligation of
March 21, 1908. J
PITH OF CURRENT LITERATURE.
565
vessels in eight, resection of the sympathetic with
enucleation of the intraglandular nodules in two.
In every case the thyreoid was very vascular and the
vessels very friable'; the veins in particular had ex-
tremely thin walls. Almost all the operations were
performed under ether ; in a few cases under local
antesthesia. The immediate results were invariably
a diminution in the frequency of the pulse and an
improvement in the general feeling of the patients.
The exophthalmos was little influenced. The re-
sults after five years are thus given : The exophthal-
mos had disappeared in a third of the cases; in a
quarter it persisted in the same degree as before
operation ; in the balance it was present to some de-
gree. The tachycardia persisted without modifica-
tion in four cases. In two thirds of the patients
the pulse was maintained below 92 ; in the remain-
ing third it did not descend below 100. The ner-
vous troubles persisted in two thirds of the cases,
and traces were present in the other third. The
general condition was said to be excellent in fifty
per cent, of the cases ; in some the weight had great-
ly increased. So large a percentage of success and
such a small mortality as attends the operation
seems to the author to urge the adoption of the
surgical treatment of this disease.
3. Transplantation en Masse of the Two Kid-
neys.— Langlois practically gives a translation
of Carrel's article Transplantation in Mass of the
Kidneys in The Journal of Experimental Medicine,
January, 1908. That author successfully transplant-
ed the kidneys from one cat to another.
LA SEMAINE MEDICALE
February 26. 1908.
The Reality and the Mechflnism of the True Reduplica-
tion of tlie First Sound of the Heart,
By Professor L. Bard.
Reduplication of the First Sound of the Heart.
— Bard reports a case of reduplication of the first
sound of the heart met with in a man, twenty-five
years of age, sufTering from stenosis of the pul-
monary artery and tuberculosis of the apex of the
left lung, who died of tuberculous meningitis.
These diagnoses were confirmed by autopsy, and
from the findings at autopsy Bard works out the
mechanism by which the reduplication of the first
sound of the heart was produced.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT.
February 25, 1908.
1. Concerning Hypertrophy and Organ Correlation,
By RossLE.
2. Development of X Ray Diagnosis,
By RiEDER and Kastle,
3. Bacteriocidine in Perhydrated Milk, By Much.
4. Embryological Analysis of Hyperdactylia,
By Braus.
5. Rheumatismus Tnberculosus Poncet, By Esau.
6. The Arrangement and Problems of the New Pavilion
for Prostitutes of the Dermatological Clinic of the
City Hospital at Frankfort a. M.. By Hubner.
7. Concerning a Breech Presentation at the End of Preg-
nancy in a Uterus Bicornis, By Jacoby.
8. Punctured Wound of the Abdomen. Laparotomy
After Seventy-three Hours. Recovery,
By Hartleib.
9. New Zinc Gelatine Bandage, By Betz.
10. A New Wall Arm for the X Rays, By Pflugradt.
11. Comparative Valuation of the Tuberculin Reactions in
Childhood (concluded). By Reuschel.
12. Obituary of Josef von Mering, By Zuntz.
13. The Centenary Fund of the Society for the Relief of
Widows and Orphans of Bavarian Physicians, and
the Benevolent and Insurance Methods in Bavaria,
By Neuberger.
14. Suction Treatment in the Aliddle Ages, By Schuster.
I. Hypertrophy and Organ Correlation. —
Rossle points out that there are diflFerent forms of
hypertrophy that are induced by different forces.
First, there is such hypertrophy as the increase in
size of the milk glands durmg pregnancv induced by
a chemical stimulant. Such may also be the expla-
nation of hypertrophies which are of correlative ori-
gin and produce a diffuse enlargement of an organ,
such as the hypertrophy of the thymus. But local
hypertrophies of certain parts of organs or of the
vessels cannot be explained in this way. The com-
mon factor for all kinds of hypertrophy is to be
found in the mechanical and chemical action of hy-
pera?mia in strongly working tissue and the regen-
eration in excess after replacement of the used tis-
sue. Only one form does not fall under this law.
the congenital hypertrophy of organs and parts of
organs through excessive formation. While all
other forms of hypertrophy originate functionally
from the work of the organ and are in a sense corre-
lative, this form is a malformation which occupies
the border land between hypertrophy and tumor.
5. Rheumatismus Tuberculosus. — Esau re-
ports a case met with in a child six and a half years
old, in which acute and subacute attacks of pain fol-
lowed each other in both knees and ankles, the right
hip joint, and the cervical segment of the vertebral
column. From time to time there was a high fever,
and the general condition became markedly impaired
as these attacks went on. Part of the joints showed
a tendency to great contracture in flexed positions,
and under correcting appliances the disease healed
partly in the form of a firm, fibrous ankylosis, the
knee, partly in perfect restoration of the functions
of the joints, in the ankles and the vertebrae, and in
a bony ankylosis in the hip joint. The author be-
lieves this to have been a case of tuberculous rheu-
matism, although he cannot ofifer further absolute
proof of its tuberculous nature. Hequotes freely from
the writings of Poncet and Leriche, giving their de-
scription of this disease and their belief, founded on
their investigations, that it is the result of the action
of the tuberculous toxine. The diagnosis is difficult,
the prognosis not very good. The most favorable
form of treatment seems to be that with hypersemia.
particularly that produced by a large suction ap-
paratus.
7. Breech Presentation at the End of Preg-
nancy in a Uterus Bicornis. — Jacoby reports a
case of this nature, the second child of the mother,
and remarks that completed pregnancy in a uterus
bicornis is very rare.
8. Punctured Wound of the Abdomen. — Hart-
leib reports a case in which a boy, seven years of
age, was stabbed in the abdomen with a table knife,
came under observation fifty-three hours later with
normal temperature, pulse 104, no meteorism, and
no positive indications that the intestine had been
injured. Some hours later the appearance of me-
teorism was taken to indicate that the intestine had
been injured, and laparotomy was performed sev-
enty-three hours after the receipt of the wound, and
566
PROCEEDINGS OF SOCIETIES.
[New Vork
Medical Journal.
the intestine- was found to have been cut in two
places. This case shows that it is not always easy
to distinguish between those wounds of the abdo-
men that demand surgical intervention and those
which do not.
II. Comparative Valuation of the Tuberculin
Reactions in Childhood. — Reuschel presents the
following summary of his long article: i. We have
in the tuberculin reactions a means which points out
to us any form of tuberculosis, active, inactive, or
even healed, because, generally speaking, the reac-
tions are produced by antibodies, which, so far as
our present knowledge goes, are produced only after
the engrafting of tuberculosis. 2. Pirquet's cutane-
ous reaction is handy and deserves to be used in
practice. The positive result always shows a tuber-
culous infection ; the negative is not as certain. 3. A
good method of retesting when the Pirquet reaction
is doubtful is the injection for observation of Esch-
erich's puncture reaction in the way recommended.
At the same time this calls forth a desirable sensibil-
ity in inactive tuberculosis. 4. These two methods
should not be looked upon as rivals of the older
Koch's method, but the three should be considered
supplements each of the other, because there are
cases in which the calling forth of a local reaction
must be aimed at. 5. It still remains to be deter-
mined whether the sensibility mentioned, which is
an indubitable result, demonstrates antibodies to the
tubercle bacilli material, or, what is very improbable,
to the albuminous bodies of the bouillon.
ANNALS OF SURGERY
March. 1908.
1. Tracheobronchoscopy, By C. Jackson.
2. Trichinous Infection of a Carcinoma of the Lip,
By E. A. Bahler.
3. Ludwig's Angina, By T. T. Thomas.
4. Studies in Technique of Cancer of the Breast Opera-
tion, By R. H. M. Dawbarn.
5. Rupture of the Lung Without Costal Injury,
By R. G. Le Conte.
6. Acute Dilatation of the Stomach and Arteriomesenteric
Ileus, By W. B. Laffer.
7. Unilateral Renal Haematuria Due to Pyelitis Cystica,
By I. S. Haynes.
I. Tracheobronchoscopy. — Jackson states that
upper bronchoscopy by means of the slide specu-
lum is usually easy under general anjesthesia. The
bronchoscope is inserted at the first inspiratory
movement without difficulty and without injury to
the larynx. The operation is more difficult in most
cases, under local anaesthesia, the resistance and
rigidity of the muscles being such that the exposure
of the laryngeal aperture for the insertion of the
bronchoscope is not easy. This is especially the
case in presence of the results of inflammatory ac-
tion in the trachea and larynx, whether recent or
remote. With the author's instruinent no gag is
necessary until the bronchoscope has passed the
glottis. With this instrument it is not necessary to
wait for an inspiratory movement or for the sub-
sidence of the glottic spasm. Neither is it neces-
sary to expose the anterior commissure, as its point
can be started between the posterior ends of the
vocal cords. The mouth of the tube will not catch
over the arytenoids, while the point of the slanting
extremity can be used as a retractor in the bronchi.
The author has performed seventeen tracheobron-
choscopies for foreign bodies below the larynx, in
fourteen of which the body was removed.
3. Ludwig's Angina. — Thomas defines this as
a rapidly spreading cellulitis beginning in the re-
gion of the submaxillary gland and extending to
the floor of the mouth and pharynx. It may origi-
nate from a carious tooth, a tonsilitis, or an ulcer
in the mouth. The infecting organism is the
streptococcus, either alone or combined with
staphylococcus, pneuriiococcus, or bacillus of ma-
lignant oedema. Death usually results from inva-
sion of the larynx, the lungs being frequently in-
volved also. The path of invasion is the opening
in the muscular buccopharyngeal wall through
which , the submaxillary gland projects into the
floor of the mouth. If the phlegmonous process
begins in the pharynx or larynx, the danger is very
great, as the tissues cannot be properly inspected,
disinfected, and incised. Modern surgical treat-
ment has somewhat reduced the extreme virulence
of the septic phenomena. The most favorable in-
cision is over the submaxillary triangle and parallel
with the lower border of the jaw. If this does not
reveal the abscess, the mylohyoid muscles must be
divided and the sublingual tissues exposed. Local
anaesthesia is preferable when performing the op-
eration.
4. Studies in Technique of Cancer of the
Breast Operation. — Dawbarn thinks the great
number of relapses after cancer operations signi-
fies that further study is to be encouraged. He urges
caution in operating' when the diagnosis of cancer is
not absolutely determined, and narrates a case in
which he performed a radical operation only to find
that the lesion was a thick walled abscess. He also
recommends the procedure of Gerster, who attacks
the armpit first and the breast last. By this means
the lymphatic communication with the body is sev-
ered at the very beginning of the operation and the
danger of squeezing infective material into the
lymph stream at least lessened. It is also a means
of lessening the haemorrhage. An advantage in
subsequent use of the arm will be gained by anas-
tomoting a small segment of the deltoid with the
stump of the pectoralis major. Finally he recom-
mends the use of a triangular splint at the patient's
side, in abduction, to favor the subsequent use of
the hand in the necessary movements to raise it
above the head.
MEDICAL SOCIETY OF THE STATE OF
NEW YORK.
One Hundred and Second Aunual Meeting, held in Albany,
January 27. 28. 2Q. and 30, j8o8.
The President, Dr. Frederic C. Curtis, of .\lbany. in the
Chair.
(Continued front page 428.)
Diseases of the Pancreas. — This subject was
presented in a paper by Dr. Wii.li.xm J. ^Iayo. of
Rochester, Minn. He referred to the pancreas as
the great abdominal salivary gland with but a single
defect, that being the association of its excretorv
duct with that of the liver. In 6.1 per cent, of al!
biliary operations the pancreas was involved, and 81
per cent, of cases of pancreatitis wore due to gall-
.stone disease. The secretion of pancreatic juice was
Mc. ch 21. 1 90S.]
PROCEEDINGS OF SOCIETIES.
567
due to the presence of chyme in the small intestine,
stimulating its mucous membrane ; fluids were ab-
sorbed froin the large intestine and solids from the
small ; thus we ate with the small and drank with
the large intestine.
Pancreatitis was always due to infection or to
chemical irritation, as from the action of bile which
found its way up the pancreatic duct after an ob-
struction at the papilla of Vater. The weight of
this last cause was materially increased by the state-
ment that 62 per cent, of cases of pancreatitis were
associated with jaundice of an obstructive nature.
But, on the other hand, a large percentage of the
simple catarrhal jaundice cases were due to an in-
flammation of the pancreas similar to mumps.
Pancreatitis, if acute, was said to be usually asso-
ciated with haemorrhage ; if more chronic in nature
it was apt to be purulent. The fat necrosis, he be-
lieved, was not due to the action of normal pancre-
atic juice, but of that which had been called forth by
bile or duodenal secretion. Furthermore, he did
not believe this fat necrosis to be so fatal as was or-
dinarily supposed.
This disease, he declared, usually attacked people
of about middle life, rather obese, and often patients
who had been intemperate in the use of alcohol. The
symptoms were seen to come on suddenly with nau-
sea, vomiting, etc., resembling intestinal obstruction
high up.
He classified pancreatitis as of two varieties — the
interlobular, often associated with gallstones and to
the "feel" resembling a malignant growth, and the
interacinous, often associated with glycosuria, in
which the pancreas was large and smooth. The
first type might go on to the development of the sec-
ond, and the disease extend over a period of years
with almost continued jaimdice, emaciation, and
large pasty stools containing fat or undigested mus-
cle fibres.
He advised clearing out all calculi at an operation
and freeing the hepatic ducts thoroughly by the pass-
age of a large probe through the common duct.
Duodenal and Gastric Ulcers were the subject
of a paper by Dr. J. J. Oehsner. He believed the
joint consideration of duodenal and gastric ulcer to
be proper, inasmuch as they were developed from
the same embryological structure, the foregut, iii
utero, and often intimately associated pathologicall}-
in the adult. The duodenum was shown to be an
extension of the stomach, furthering the processes
of digestion, but in an alkaline medium.
He believed the aetiology of gastric ulcer to be :
I. Injury from within. The pyloric end of the stom-
ach had the hardest work to perform, and injuries
were most apt to occur there. 2. The lack of pro-
duction of certain antibodies whose function it was
to prevent the digestion of the mucous membrane bv
the gastric juice. 3. Anaemia. Duodenal ulcer was
caused by extension from an ulcer of the stomach,
by the irritating action of the acid gastric juice upon
the mucous membrane of the duodenum, burns of
the skin, or by thrombi of the bloodvessels of the
duodenum.
He referred to the sphincter muscle in the duo-
denum, from 7 to 10 cm. below the entrance of the
common duct, and to the frequency of relapses after
apparent cure, but declared that, if the digestion
could be restored to the normal without the inter-
vention of surgery, it was far better for the patient.
He emphasized the facts that even after a so called
cure the patients must be careful as to their diet and
that, of the patients operated upon, only one third
were comfortable unless they were careful in this
respect later. The most serious complications he
thought to be perforation, haemorrhage, emaciation,
adhesions, and implantation of malignancy. While
some cases responded better to surgical treatment
and others to medicinal, it was not possible to dis-
tinguish between the two types until medicinal treat-
ment had been instituted, and he believed all cases
surgical that were not amenable to medicinal treat-
ment.
The pain found in this disease he had observed to
come on after eating, especially if the uhcer was
at the pylorus, and it might be referred to the
middle of the sternum or to the back. In gallstones
the pain referred to the back was at a lower level.
In duodenal ulcer the pain might come on some little
time after taking food or even before, from the
escape of acid gastric juice into the intestine due to
a relaxed pylorus. Blood in the stools would often
help in the diagnosis. The large amount of mucus
was believed to act as a protecting coat against the
action of the irritating gastric juice, but this would
also cover the food ingested and render its diges-
tion slower.
In the early stages of pyloric stenosis the muscu-
lature of the stomach was seen to undergo hyper-
troph}' to force the food through the contracted ori-
fice, but this musculature weakened after a time and
dilatation followed. In the meantime the ulcer might
have crowded a bloodvessel and a haemorrhage oc-
cur, and perforation was not an infrequent compli-
cation.
After dilatation had occurred there was usually
residual food in the stomach, and even when fresh
and wholesome food was ingested it would soon be
contaminated and decompose : hence the indication
for frequent gastric lavage.
The objects of the surgical treatment were drain-
age and rest, and the results would vary with the
skill of the operator and the strict adherence to good
hygiene and dietetics afterward. The directions
given were : Inflict as little injury upon the tissues
as possible. Expose the other intraabdominal or-
gans as little as possible. Have the patient assume
the sitting posture as soon as possible after the oper-
ation. The direction of the sutures should be such
that the contraction of a subsequent scar will not
cause an obstruction. Excise any neighboring lym-
phatics in case of complicating malignancy. Choose
the lowest point for anastomosis. Have no tension
upon the sutures. Except in complete gastrectomy,
always preserve the coronary artery. In acute dila-
tation following an operation, introduce a stomach
tube and wash out the stomach with about half a
pint of water. In an operation use the simplest
technique without any unnecessary mechanical trau ■
matism. Control the patient's habits and diet as long
as possible afterward.
The Surgery of the Liver and Gallbladder. —
This paper was read by Dr. J. C. Monro. First,
he begged permission to ask the question if syphilis
of the liver was a surgical disease. He stated that
568
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
nonoperative cases of liver disease often showed a
marked specific liistory. Gummata were the most
common syphiUtic lesions of the liver ; they might
vary in size from that of a pinhead to that of an
egg. They might undergo fatty degeneration, be
absorbed, and only a scar remain ; they might cal-
cify, or they might become infected and form ab-
scesses. He declared that the liver was often af-
fected, but gave rise to no symptoms whatever.
When the peritonaeum was involved, pain, limited
respiration, ascites, loss of weight, evidence of in-
fection, and jaundice might be found, though the
last symptom was not common. The most common
site for syphilitic lesions was seen to be near the
suspensory ligament. Thus the resemblance to
malignant disease could be readily seen. Diarrhoea
had beeii observed by some, but in the writer's ex-
perience constipation was the rule. He stated that
a tumor might often be felt, and any associated
pain was frequently relieved by vomiting, and final-
ly pointed out the conditions which might resem-
ble the present lesion, such as cirrhosis, abdominal
tumor, functional dyspepsia, malignancy, chole-
cystitis, biliary colic, and chronic intestinal ob-
struction.
Another question that he wished to ask was as
to the proper treatment that might have been given
to patients that died a few hours or days after an
operation, from complete suppression of the liver
function. He cited such cases and said that the
symptoms usually began much like those of sep-
ticaemia or severe haemorrhage.
He believed that surgeons were coming more and
more to consider the question of the preservation
of the gallbladder in an operation, because at any
subsequent operation which might be necessary the
dangers were materially increased by absence of the
gallbladder.
Nonparasitic Cysts of the Liver and Congen-
ital Cystic Liver. — In this paper Dr. W . G. ^NIac-
DOiV.ALD, of Albany, spoke of the low mortality as-
sociated with the abdominal surgery of to-day, and
stated that when death did occur it was usually the
result of an incorrect diagnosis or the exploratory
incision. The best surgical training afforded no
adequate preparation for the unexpected in sur-
gery. A false diagnosis destroyed the continuity
of an operation, hasty preparation had to be made
for a new operation with the patient under the
anaesthetic, and the surgeon wandered aimlessly
about until compelled to desist, either from haemor-
rhage or from some other complication, or went
ahead with an original procedure upon general sur-
gical principles. He referred to the many valua-
ble aids in diagnosis that modern medicine afford-
ed, such as examination of the gastric contents,
physiological chemistry, the Rontgen ray, the gas-
troscope, etc.
He presented the histories of three cases of cys-
tic liver. In the first the patient had been treated
for ascites, as the abdomen was full of fluid. Un-
der local an.'csthcsia he opened the peritoneal cav-
ity and evacuated about eight (|uarts of a clear
fluid. Upon the lower surface of the liver he then
found a fluctuating tumor. He aspirated it and
drew oflF fluid f about 500 c.c) of the consistence
of glycerin. The ascites did not reappear for some
weeks. The patient subsequently died.
The second case was one of cyst of the liver. In
this case the incision was made in the usual situa-
tion for a gallstone operation, and the cyst attached
to the abdominal wound and drained. Before the
operation the diagnosis had been made of a dis-
tended gallbladder, but the gallbladder was found
to be normal and the tumor to be a large liver cyst
filled with about 6,500 c.c. of clear mucin. It was
drained for about three weeks and the patient made
an uneventful recovery.
The third case also simulated gallbladder dis-
ease. Drainage was used, and recovery followed.
The difficulty in the diagnosis of this condition
was pointed out, and the possible reason given was
its rarity. The object of this paper was to show
that in tun-iors of the upper abdomen, nonparasitic
cysts must be kept in mind. In the three cases
above cited the pathological report showed these
cysts to be nonparasitic in origin.
Gastric Neuroses. — In this paper Dr. D. D.
Roberts began by saying that, the treatment and
cure of disease being the primary end of all the
branches of medicine, a study and classification of
functional disturbances was also desirable. He be-
lieved neuroses gave rise to more symptoms than
actual diseases themselves, and the essential ques-
tion was not ivhat function was abnormal, but why.
He referred to the two schools in the treatment of
gastric neuroses, one advocating a meat diet and
the other vegetables. Some patients were unduly
conscious of any pathological condition, and hys-
teria varied according to the degree of suggestibil-
ity. When the physician failed to spend time in
investigating and studying a patient's environment
he sent him to seek relief in all sorts of creeds and
therapy. The function of the normal and abnor-
mal stomach had been studied well, but in treating
it the average practitioner seemed to consider it
by itself and not as but a part of an intricate mech-
anism, the disturbance of any element of which
might cause its derangement.
The Diagnosis and Treatment of Gastric Ulcer.
— Dr. D. RuciiFSTER, in this paper, reported a case
the clinical symptoms of which were characteristic
of gastric ulcer. A haemorrhage occurred, and the
case was treated medically. A few days later an-
other profuse haemorrhage came on. As soon as
the patient rallied sufficiently an operation was per-
formed by Dr. Roswell Park. No ulcer was found
on the anterior surface of the stomach. The stom-
ach wall was opened and inspected from within,
but still no ulcer could be demonstrated. Since
then he had been more skeptical as to the advisa-
bility of an operation in gastric ulcer, resorting to
it only when there was evidence of perforation. In
cases similar to the one cited above he believed the
cause to be reflex or some nervous taint.
The symptoms were epigastric pain increased by
food and often referred to the back; however, food
might relieve the pain for a time. A definite ten-
der spot might be elicited, and sometimes the area
of hepatic dulness was decreased. The patients
might show a tendency to anaemia, due probably in
part to loss of blood from hremorrhage, which might
often be demonstrated in the stools.
The treatment could i)e divided into three differ-
ent stages — ^the treatment of haemorrhage, the
treatment of the patient to cure the ulcer, and treat-
March 21. 1908.]
PROCEEDINGS OF SOCIETIES.
569
ment of perforation. For ihc haemorrhage he ad-
vised physical and mental rest on the part of the pa-
tient and functional rest for the stomach. This
could be best accomplished by a full dose of mor-
phine and atropine, cold to the epigastrium, and
possibly a I to i.ooo solution of adrenalin. With-
hold ever\-thing by the mouth but possibly cracked
ice. The subgallate of bismuth in milk of mag-
nesia might be given. Food by the mouth was be-
Heved to be harmful at anv time during the first
forty-eight or seventy-two hours, and even by the
rectum for the first twent\'-four, because it would
cause the secretion of gastric juice.
In the attempt at curative treatment he advised
the physician to examine carefully the eyes, ears,
pelvic organs, urine, etc.. and to correct any abnor-
mity found. Constipation and colonic toxaemia
must be treated ^f found to exist. Then rest,
graded exercise, and hydrotherapy were advised.
As to the direct medication of the stomach, he or-
dered the exclusion of all coarse meats, liquors,
strong tea, coffee, and fruits that did not agree with
-the patient. Carbonized waters, malted milk,
chicken, fresh fish. rice, sago, and tapioca (the last
named to be taken with no salt and but little sugar).
Three or four hours after each meal he advised
drinking about half a pint of diluted milk. He
recommended slow eating, thorough mastication,
and mental rest at meals.
Good results could be obtained from strontium
bromide, sodium bicarbonate, charcoal, and bismuth
subcarbonate, all suspended in milk of magnesia.
This treatment must be continued for a long time,
and in all cases he advised a thorough search for
and thorough 'correction of any reflex nervous dis-
turbance.
The Modern Conception Regarding Chemical
Regulation of Function. — Dr. Graham Lusk ob-
sers'ed in this paper that there was much in the
nervous system below the threshold of conscious-
ness. The cause of death in animals after the ex-
cision of the adrenals was the removal of their in-
ternal secretion from the system and not the shock
incident to the operation. The active principle of
this secretion was not a ferment, because it could
not be heated to boiling without destroying its ac-
tivity. In tuberculosis of the adrenals, the
thymus, spleen, etc.. might become secondarily en-
larged, thus demonstrating a very complicated and
involved problem in physiology at present unex-
plainable. He referred to the great number and
general uselessness of the theories brought forward
by fanciful observers anxious of recognition.
He stated that solid substances introduced into
intestine which had been cut off from its nerve sup-
ply would still cause secretion due to the mechan-
ical stimulation of the plexuses of Xeisser. When
food was taken into the mouth there were impulses
which traveled along the yagi and thus produced a
reflex secretion. A secondary secretion might take
place even if both vagi were cut. if partly digested
food was placed in the stomach.
He believed that the secretion of the gastric
juice depended upon a substance absorbed from the
region of the pylorus and taken into the blood.
This stimulated the gastric secretion. Hydro-
chloric acid was stimulating to the duodenal mu-
cosa, causing a secretion of the pancreatic juice.
and he cited experimental work of Popeelski prov-
ing that fact.
As to the formation of the pancreatic juice, the
acid gastric juice from the stomach activated a pro-
secretin there. This prosecretin was absorbed into
the blood and then caused the secretion of pan-
creatic juice. Xerve reflexes were not necessary,
simply the chemical stimulant being absorbed into
the blood stream. If portal blood was diverted from
the liver, the symptoms of toxaemia resulted, and
this was shown to be due to the fact that certain
toxines and deleterious substances were rendered
innocuous in the liver.
Experiments had shown that if an extract was
made of a rabbit's foetus and injected into the blood
of a virgin rabbit, the mammae would develop. Also
in the human .species, it was pointed out, if one kid-
ney was extirpated, the blood pressure was raised
and hypertrophy of the left ventricle occurred, which
went to prove that ordinarily certain substances were
excreted by the kidneys in a definite amount : one
kidney could not excrete as well as two, so part of
these substances were retained, and by their pressure
caused a rise in blood pressure.
In fevers, the xanthine bases were present in
amounts corresponding to the height of the fever :
therefore the administration of xanthine free milk
in febrile patients was declared to have scientific
justification.
The Effect of Alcohol upon Secretions. — Dr.
H. C. Jacksox, in this paper, said that no other sub-
stance taken into the human economy had such a
variable effect upon digestion. Its effects were di-
vided into that upon the activity of the hydrochloric
acid and pepsin, that upon the amount of secretion,
and that upon the motion of the stomach. Inas-
much as it was rapidly absorbed from the stomach,
its influence was soon removed from the site of activ-
ity. In the beaker, alcohol was shown to retard di-
gestion in a direct proportion to the amount present.
In the stomach the malt liquors in small amount had
no influence upon digestion, but in large amount
they retarded it. With liquors containing less than
ten per cent, of alcohol its effect was declared to de-
pend upon the solids in solution and not upon the
alcohol present. Strong alcohol rendered the pepsin
less active and might even coagulate albumin. Ex-
periments upon animals were cited in which the food
was introduced through a fistula without the knowl-
edge of the animal, in order to obviate the psychic
effect. In the first stage, while alcohol was present
in the stom.ach, pepsin was diminished. In the sec-
ond stage, when the alcohol had been absorbed, the
hydrochloric acid was increased. In these experi-
ments alcohol left the stomach in from twenty to
thirty minutes ; the short time that spirit of less than
ten per cent, strength remained in the stomach did
not materially affect digestion. If the strength was
over ten per cent, a tremendous increase in the secre-
tion of mucus occurred.
Then the process was shown to be little aft'ected
or possibly slightly improved by a single dose of a
solution of less than ten per cent, strength. In
strength greater than- ten per cent, the digestion was
retarded, pepsin decreased, mucus increased, and
motility lessened. The secondary effect of dry wines
was stated to be to form insoluble substances by rea-
son of the union of their tannin with the food, and
570
BOOK NOTICES.
[Ne«- Vokk
Medical .Ioirnal.
SO the}- exerted a marked inhibitory eftect. Alcohol
was seen to affect the secretory mechanism of the
pancreas by being absorbed into the blood, and by
means of the circulation stimulating the secretory
centres in the medulla. The digestion of fat by
lipase was enhanced by alcohol given in any strength.
The pathological chemistry of the liver had received
much attention, but up to the present time was neg-
ative as to results. Alcohol appeared in the bile
much sooner than in the urine. Alcohol in the stom-
ach would increase the formation of bile from 50 to
360 per cent. The prolonged irritation of the alco-
hol exerted in the liver was probably the cause of
cirrhosis. The conclusions were that a single dose
of an alcoholic beverage of less than ten per cent,
strength might benefit the process, but that addi-
tional doses were wasteful.
Dr. Stockton, of Bufifalo, believed that there
could only be assent to the conclusions set forth in
Dr. Mayo's paper as to the association of pancreatic
and biliary disease. He believed that chronic pan-
creatitis was a more common disorder than was usu-
ally supposed, even with no biliary involvement.
He considered the paper of Dr. Ochsntr impor-
tant because it took up the treatment of gastric ulcer
both before and after an operation.
As to Dr. Roberts's paper, he believed it of great-
est importance that these nervous diseases of the
stomach should be well studied, inasmuch as at
present they were but poorly understood. He de-
plored the tendency of the average physician to give
so little attention to disturbances the basis of which
was known to be functional.
{To be contuiued.)
gook llotias.
[We publish full lists of books received, but we acknowl-
<^dge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
Cancer of the Womb. Its Symptoms, Diagnosis, Prognosis,
and Treatment. By Frederick John McCann, M. D.
(Edin.), F. R. C. S. (Eng.), M. R. C. P. (Lond.),
Physician to In-Patients, Samaritan Free Hospital for
Women, London, etc. London: Henry Frowde (Oxford
University Press) and Hodder & Stoughton. Pp. x-172.
In spite of the small array of its numbered pages
this is a fairly thick book, for there are forty-six
full page inset plates in addition to a colored front-
ispiece, and' we may remark at the outset that the
pictures are excellent.
The volume opens with an Anatomical Introduc-
tion, rather unnecessary, we think, though very
well worked up in the main. An exception to the
general clearness of the author's style, as it seems
to us, is this sentence : "The ringlike attachment
of the vagina is very oblique, having a much lower
level in front than behind, and thus the posterior
vaginal wall is longer than the anterior."
.•\ general consideration of the subject of ma-
lignant disease comes next. As regards the aetiol-
ogy, "the trend of modern opinion," says the au-
thor, "is against the parasitic theory," and in sup-
port of that statement he quotes from the Third
.hitiual Report of the Harvard Cancer Commis-
sion, which, he says, "tends to the demolition of
the parasitic hypothesis." He thinks that heredity
has a certain influence, but regards the question as
not yet decided.
As to the diagnosis of uterine cancer, apart
from the local signs, the author remarks that wast-
ing is frequently absent. The one symptom of
greatest significance is haemorrhage, though it is
not usually so severe as the bleeding- produced by
fibroids. "Any loss of blood after the menopause,"
he says, "is a sign of the greatest importance, and
in every case a thorough investigation of the con-
dition of the pelvic organs should be made."
A chapter is devoted to the modes by which
cancer of the uterus spreads and to its recurrence
after an operation, and the chapter is an exceed-
ingly good one. In includes a consideration of the
modes of death from cancer, the chief of which, the
author thinks, is by uraemia resulting from changes
such as hydronephrosis and pyonephrosis produced
in the kidneys in consequence of involvement of
the ureters by reason of invasion of the pelvic cel-
lular tissue.
Appropriate operations are advocated for the re-
moval of the various forms of uterine cancer, and
they are well described. The author is very hope-
ful of a virtual cure by operations done sufficient-
ly early. Abdominal hysterectomy, for some vears
past practically supplanted by the vaginal opera-
tion, has again been introduced, he says, and he
justly adds that the improvements in the operation
are "really all modelled on the original plan adopt-
ed by Freund." The transverse suprapubic in-
cision, he thinks, offers considerable advantages in
providing more working space and better exposure
of the pelvic contents in cases of involvement of
the parametrium, but he doubts the advisability of
an operation in such advanced instances.
Palliative treatment and the management of in-
operable cases are duly considered, though we find
no mention of the ernployment of the Rontgen
rays or of radium. In the section dealing with the
treatment of the patient after an operation there
is no discussion of the length of time for which
confinement to bed is judicious. Some of the
terms employed are a little puzzling at first — for'
example, "Brom alcohol" (with a capital B, page
103), though this, without the capital-, is said on
page 105 to be composed of one part of bromine
and five parts of rectified spirit. "Bortannin" does
not seem to be explained.
On the whole, the book is a solid addition to the
literature of a most important subject, and one of
a very practical character. As we have intimated,
its usefulness will not be confined to operating sur-
geons, but will extend to all practitioners.
A Manual of the Practice of Medicine. Prepared Espe-
cially for Students. By A. A. Stevens, A. M., M. D.,
Professor of Theraeiitics and Clinical Medicine in the
Women's Medical College of Pennsylvania, etc. Eighth
Edition, Revised. Illustrated. Philadelphia and London :
W. B. Saunders Company, 1907. Pp. 558. (Price, $2.50.)
The first edition of this book appeared fifteen
years ago. New material has been added, and miny
articles, especially in the section dealing with dis-
eases of the nervous .system, have been rewritten. The
nomenclature in the prescriptions has been changed
according to the new (eighth) revision of the pliar-
macopcTcia. It is one of the very few books in which
the author has taken the trouble of revising the
March Ji, J 508. J
BOOK XOTICL:)
pharmacological terms in his new edition. The book
has thus been brought up entirely to date.
Dr. Stevens's book has always been well known
for the practical hints it gives in the treatment of
diseases and the great number of good prescriptions
it contains. Thus it has become a valuable adjuvant
for the senior student and a welcome compendium
for the practitioner.
Diagnostico y Tratamiento de las Enfermedades de las Vias
Urinarias. Lecciones Elementales. Por Alberto Suarez
DE Mendoza, Profesor de Enfermedades de las Vias
Urinarias en la Facultad de Medicina de Madrid. Ciru-
jano de la Casa de Salud de Nuestra Senora del Rosario.
Perlado, Paez y Cia, 1908. Pp. 790.
This volume presents a series of lectures on
urology delivered to the medical students at Madrid.
As might be expected, the author follows largely
the French school, that of the Xecker Hospital,
where Guyon taught so long and where Albarran
now holds his clinical courses. The subject is
handled with great completeness and thoroughness,
and the book will make interesting reading for
those who wish to familiarize themselves with med-
ical Spanish and who desire to practise urinary
surgery in a Spanish speaking country. In other
respects the book offers nothing special' to those
w^ho have works in French, German, or English on
the same subject in their libraries.
Abel's Laboratory Handbook of Bacteriology. Trans-
lated from the Tenth German Edition, bv M. H. Gordon
U. A., M. D. (Oxon.), B. Sc., with Additions by Dr. A. C.
Houston, Dr. T. J. Horder. and the Translator. Lon-
don: Henry Frowde (Oxford University Press) and
Hodder & Stoughton, 1907. Pp. x-224.
Bacteriology, has become an indispensable aid in
correctly diagnosticating infectious diseases, and
while every physician is required to have a general
knowledge of the subject, medical officers of cities
or States must be thoroughly conversant with this
branch of the medical sciences. The present pocket
edition, an abbreviated and condensed translation,
provides those studying bacteriology with a guide
for practical laboratory work. But not only will
medical men find it very instructive, but the veter-
inary surgeon, the druggist, and the chemist will
liave in this compendium a handy assistant.
The translation has been well done, so far as we
can judge, and several chapters contain revisions
and amplifications by the English authors.
The book may be divided into three parts : Intro-
duction and general methods of staining (pp. i to
81, chapters i to v) ; special staining and culture
methods for certain bacilli (pp. 82 to 159, chapter
vi) ; chapters vii to xii, pp. 160 to 218, containing
synopses of methods of obtaining material from the
body for bacteriological examination, methods of
examining^ blood in relation to immunity, inocula-
tion and post mortem examination of animals, meth-
ods of preserving preparations, bacteriological ex-
amination of water, milk, shellfish, sewage, soil,
dust, air, etc.
Auscultation and Percussion. By Samuel Gee, M. D.,
Fellow of the Royal College of Physicians, etc. London :
Henry Frowde (Oxford University Press) and Hodder
& Stoughton, 1907. Pp. xvi-287.
This is the fifth edition of a very useful and prac-
tical book. Although chapters on auscultation and
percussion of the chest are to be found in every
textbook of medicine, the methrxis of physical
examination are of such importance that the subject
well deserves, as it has amply received, complete
treatment in books devoted especially to them. The
author has excluded x ray examinations, as he
thinks the necessary apparatus is too expensive to
be within reach of every practitioner.
The book is divided into two parts. Part I treats
of the physical signs in abstract, giving the pure
science, while Part II considers these signs in their
subservience to the discovery of disease, giving thus
the applied science of these signs.
Laboratory Guide for the Modelling of the Human Bones
in Clay. By Vilray Papin Blair, .\. M., M. D., Asso-
ciate Professor of Anatomy, Medical Department, Wash-
ington University. St. Louis : Cooperative Association
of the Medical Department of the Washington Univer-
sity. Pp. 69.
This book is a very interesting (inc. although we
doubt if this new system of teaching osteology will
find a place in the already overcrowded curriculum
of junior medical students. The method itself
seems to be very advantageous, as the student will
receive a good idea of the shape and form of the
bone he is modelling. Names and descriptions can
be easily memorized, and will answer for a theo-
retical examination. But the old saying non scholce
sed ritcc discimus is so often forgotten that this
practical course of osteology will be of great help
in remembering the normal shape of a bone. But
not every medical .student can become a modeller,
and it needs the skill and the eye of an artist to
imitate nature. The medical student will hardly
find time to adapt himself to the necessary technique
of handling clay and producing models which will
really answer the requirements.
The Treatment of Fractures. With Notes upon a Few
Common Dislocations. By Charles Locke Sci^dder,
M. D., Surgeon to the Massachusetts General Hospital ;
Lecturer on Surgery in the Harvard University Medical
School. Sixth Edition, Thoroughly Revised and En-
larged. With 856 illustrations. Philadelphia and Lon-
don : W. B. Saunders Company, 1907. Pp. 628.
In this, the sixth edition of Scudder's well known
book on fractures, special attention has been paid to
obstetrical fractures of the skull in the new born
(chapter i) ; fractures of the zygoma, malar bone,
and superior maxilla (chapter ii) ; of the head and
neck of the radius (chapter x) ; of the neck of the
femur (chapter xii), etc., and to the nonunion of
fractures. A few illustrations have been added,
especially those referring to x ray examinations.
The new edition will add to, the well merited renown
of the book.
Hospital Training School Methods and the Head Nurse.
By Charlotte A. Aikens, late Director of. Sibley Mem-
orial Hospital. Washington, D. C, etc. Philadelphia
and London ; W. B. Sauhders Company, 1907. Pp. 267.
(Price, $1.50.)
This is a very interesting book, written by an au-
thor who has had much experience in the training
of nurses and superintending of hospitals. She very
rightly remarks in her preface that "in the begin-
ning of the era of trained nursing in America we
were satisfied with a rudimentary training. Little
by little this has been added to until at the present
time a hospital which admits a pupil to its training
department is expected to start her in at the kinder-
572
MISCELLANY.
[New York
Medical Journal.
garten stage in nursing, and conduct her by a swift
high pressure system clear through the university
stage all in the short space of two or three years."
Out of her great store of knowledge Miss Aikens
discusses the training school problem, speaks about
plans that have stood the test, and advises teachers
and superintendents of hospitals. Of textbooks on
nursing we have a goodly number, but very few, if
any, books on the method of teaching and superin-
tending.
The book is divided into two parts : Hospital
Training School Methods, and the Head Nurse.
Some of the chapters have appeared in the Canadian
Nurse and the National Hospital Record, but are
here collected for the first time. Both parts are
well constructed and contain interesting material.
The author represents the proper viewpoint and is
opposed to the new method, which seeks to make a
graduated nurse know as much as a graduated phy-
sician. The hospital training school should certain-
ly teach nursing from its very foundation, while
postgraduate training schools should go beyond
these essentials.
Surgical Applied Anatomy. By Sir Frederick Treves,
Bart., G. C. V. O., C. B., LL.D., F. R. C. S., etc. Fifth
Edition, Revised by Arthur Keith, M. D., F. R. C. S.,
Lecturer on and Senior Demonstrator of Anatomy at the
London Hospital, etc. Illustrated with 107 Figures, Li-
cluding 41 in Color. Philadelphia : Lea Brothers & Co.,
1907. Pp. 640.
Some sections of this revised edition have been
entirely rewritten, while to others much new matter
has been added. The illustrations are clear and to
the point. A very complete index and the size of
the book make it a very handy compendium. Al-
though mainly intended for the use of senior stu-
dents, it will prove of value to the general practi-
tioner.
BOOKS, PAMPHLETS. ETC., RECEIVED.
Lectures on Medical Jurisprudence and Toxicology as
Delivered at the London Hospital. By Fred J. Smith,
M. A., M. D., F. R. C. P., F. R. C. S., Physician to and
Lecturer on Forensic Medicine at the London Hospital,
etc. Second Edition. London: J. & A. Churchill, 1908.
(P. Blakiston's Son & Co., Philadelphia.) Pp. xiv-463.
Woman. A Treatise on the Normal and Pathological
Emotions of Feminine Love. By Bernard S. Talmey,
M. D., Gynaecologist to the Yorkville Hospital and Dis-
pensary, etc., New York. For Physicians and Students
of Medicine and Jurisprudence. With Twenty-three Draw-
ings in the Text. Second Enlarged and Improved Edition.
New York: Practitioners' Publishing Company. iqo8.
Pp. x-258.
Vorlesungen uber Diatbehandlung innerer Krankheifen
vor reifercn Studierenden und Aerzten. Von Dr. H.
Strauss, in Berlin. Mit einem Anhang "Winke fiir die
diatetische Kiiche" von Elisc Hannemann. Berlin : S. Karger,
1908. Pp. 340.
A Textbook of Surgical Anatomy. By William Francis
Campbell, M. D., Professor of Anatomy, Long Island Col-
lege Hospital, etc. With 319 Original Illustrations. Phil-
adelphia and London : W. B. Saunders Company, 1908.
Pp. 675. ^ Price, $5.)
Sprachstorungen und Sprachheilkunde. Beitriige zur
Kenntnis der Physiologic, Pathologic und Therapie der
Sprache. Unter Mitwirkung von E. Bloch, Boodstein. M.
Bresgen, Briihl, Panconcelli-Calzia, F. FrcnzeJ, H. Knopf,
O. Laubi, E. Maschke, Hudson-Makuen, A. Mielecke,
Xadoleczny, Oeconomakis. W. Oltuszewski, H. Piper,
Georges Rouma. A. v. Sarbo, K. L. Schaefer, H. Soder,
H. Stern, E. Stotzner, E. Winckler, and H. Zwaardemaker,
heransgegeben von Dr. med. II. Gutzmann. Privatdozenl
an der Universitat Berlin. Mit 15 .Abbildungen im Text
und cincm Ponrrit. Berlin: S. Karger, 1908. Pp. 189.
Transactions of the College of Physicians of Philadel-
phia. Third Serie'^, Volume XXIX. Philadelphia, 1907..
Pp- 159-
lliscaians.
Resolutions on the Death of Dr. Daniel B. St.
John Roosa. — The following resolutions were
adopted at a regular meeting of the Alumni Asso-
ciation of the New York Postgraduate Hospital,
held Tuesday evening, March 10, 1908:
We meet to-night under the shadow of a great
afifliction, so sudden, so unexpected, that we have-
not yet realized how great it is. It will not be easy
to fill the position Dr. Roosa's death has left vacant.
It probably never will be filled. The work will con-
tinue. The medical school his mind conceived has
become an established fact, an integral part of the-
educational system of the State, while the hospital
he founded and over whose destinies he has presided'
for the past twenty-five years has become an impor-
tant factor in the charitable work of New York. No
one else occupying the position of president will
ever be able to hold all those connected with the in-
stitution to their duties through sheer loyalty to the
president. This Dr. Roosa has done most success-
fully, binding all together in a determination to
carry on the work of our institution, no matter what
disappointments were met, no matter what obstacles
were put in the way, simply because he wanted it —
not for himself, but to attain the great object that he
had in view.
Dr. Roosa was a strong man, a man of broad edu-
cation and culture, and his great success as a teacher,
as an administrator, as a practitioner of his spe-
cialty, came from the force of his intellect and the
power he had of presenting facts clearly and cogent-
ly. This made him a natural orator, and led him to-
take an interest in af¥airs outside of medicine. He
was a national man, a cosmopolitan man.
He will ever be remembered as the founder of sys-
tematized postgraduate instruction for medical men.
His was the original conception of the idea which
has since been copied throughout the world.
We who have served on the house staff of the
New York Postgraduate Hospital during the past
twenty-five years feel his loss the more keenly be-
cause we were made to feel throughout the years of
our association with hirti that he was especially in-
terested in our welfare, not only during our service
in the hospital, but during after life. We have all
felt his kindly sympathy, and we will all miss the
cordial tone with which he used to meet us and in-
(|uire of our successes or sympathize with our fail-
ures.
Of him we cannot speak as we would. It is said
of Sir Christopher Wren, the architect of St. Paul's
Cathedral, London, that he did more to beautify the
city than all the architects of a hundred years. He
lies in a vault in .St. Paul's, and above his sleeping
dust is a simple slab bearing this inscription : "Here
lies Sir Christopher Wren, architect. Would you
see his monument? Then look about you." So Dr.
Roosa has built his monument in the New York
Postgraduate ]\Tedical School and Hospital, and in
every other institution, the world over, devoted ex-
March 21, iqoS. 1
OFFICIAL NEWS.
573
clusively to the systematic instruction of graduates
in medicine. He has put his time, his energy, his
brain, his heart, himself into the great work. The
powers thus set in motion for the upHfting and edu-
cation of the medical profession and the ameHoration
of the ills of suffering humanity are as far reaching
and immeasurable as eternity.
We thank God that Dr. Roosa lived. We thank
God that we have had our medical training under
the influence of his precept and example.
To Mrs. Roosa and his family we offer not the
perfunctor}- sympathy of a medical society, but the
sympathy of those who loved, admired and rever-
enced him.
His memory will live with us as long as any of us
may survive.
For the association,
Franklix a. Dorman,
Edward W. Peterson,
Douglass W. C.mrns,
Samuel Llovd, Chairman.
Vivisection. — The subjoined letter was recent-
ly forwarded to each member of the Judiciary Com-
mittee of the Senate and Assembly of New York by
Dr. J. Leonard Corning, of Xew York :
Dear Sir — The undersigned respectfully requests^ that
you will use your influence as a member of the Judiciary
Committee of the Assembly to prevent the recommendation
or passage of any bill in restraint of the liberty of physi-
cians to conduct experimentts on living animals with the
purpose of augmenting medical knowledge, and thereby
conducing to the welfare of the public.
My reasons for putting forward this request are as
follows :
1. Experiments on animals, vivisection, as it is sometime^
called, are absolutely indispensable e.xpedients to physi-
ologists, pathologists, pliysicians, and surgeons. By their
aid physiologists are able to discover the nature of the vital
processes; pathologists to determine the effects on the dif-
ferent organs and on the organism as a whole of various
disease breeding agencies, and devise means for the coun-
teraction of such agencies : physicians to test the effects of
remedies on the animal organism before venturing to pre-
scribe them for their patients, whether in hospitals or in
private practice: while surgeons are cnahleil t<> ilevise and
perfect new and salutary operations, and tlirs insure the
success of the latter before performing thcni on human
beings
2. By virtue of the knowledge derived largely by experi-
ments on the lower animals it is now possible to prevent or
abort epidemic diseases that formerly swept on to death,
whole populations ; among such diseases are cholera, and
yellow fever.
,3. Thanks to experiments on animals, a serum is now
prepared that enhances the prospects of recovery from
diphtheria enormously. This is proved by the astounding
fall in the percentage of fatalities from the disease in all
the great cities of the world where the serum has been
consistently and generally applied.
4. To prepare a serum of this kind and to discover new
ones applicable in other diseases, experiments on animals
are absolutely indispensable.
5. All new remedies should be, and usually are, tried on
animals before finding an application in hospital and pri-
vate practice. By such trials it is possible to ascertain how
they act in different doses used in proportion to the weight
of the animal, so that when applied in human beings, scien-
tific accuracy may be substituted for guess work which, in
many instances, might result in death. Again, by experi-
ments on animals, it is possible to ascertain the effects of
different remedies on the individual organs, and so deter-
mine under what conditions and for what purpose the rem-
edy shall be given, or whether, because of a hurtful, poison-
ous influence on one or several organs, it shall be discarded
altogether.
6. Through the instrumentality of experiments on ani-
mals, discoveries of such transcendent importance have
been made thut, were we to-day bereft of them, inedical
science would be thrust back into the barbarous ignorance
that characterized it during the Dark Ages.
7. An impartial and thorough analysis of medical his-
tory by competent criticism cannot fail to reveal the fact
that exerime.itation on animals has to a large degree served
to advance medical science more in the last fifty or sixty
years than in the previous five hundred.
8. That physicians should be urged to continue experi-
mentation on animals is of vital importance to the present
and future well being of the public. Restrict their privi-
leges in this regard ; dampen their zeal by ill considered,
galling regulations, and you drive to apathy and cynicism a
kind of intellect that, if encouraged to go on, would, as in
the past, add achievement to the resources of a profession,
the conservation of whose ideals and whose advancement
upon the road of reason are of vital importance to the
moral and physical well being of every civilized community.
9. The following are a few of the more striking results
achieved by vivisection : The discovery of the motor cen-
tres in the brain ; discovery of the functions of the sympa -
thetic nervous system ; the demonstration of the difference
in function between the anterior and posterior roots of the
spinal nerves ; important discoveries in the physiology of
the spinal cord ; demonstration of nervous influence on
secretion : discovery of the nervous mechanisms of the
heart ; discovery of transcendent facts in the physiology of
digestion ; implantation of bone, i. e., the removal of bone
from an animal to a human being; patching of bloodves-
sels ; working out of important operations on the intestines ;
working out important operations on the brain ; suture of
nerves — these are but a fraction of the results obtained by
resort to the only method b\- which their accomplishment
could have been made possible.
53 West Thirty-eighth Street.
Public Health and Marine Hospital Service
Health Reports-
rits folloii'ing cases of smallpox, ycllon' fever, cholera,
and plague have been reported to the surgeon general,
United States Public Health and Marine Hospital Service,
during the Xi'eek ending March ij, igo8:
SmaHfo.c—Unitcd States.
Places. Date. Cases. Deaths.
("alifornia — Berkeley Feb. 8-15 i
California — Los Angeles Feb. 15-22 11
California — San Francisco Feb. S-22 11
District of Columbia— Washington. Feb. 22-29 ^
Illinois — Springfield Feb. 20-27 3
Indiana — Indianapolis Feb. 22-Mar. i 3
Indiana — La Fayette Feb. 23-Mar. 2 i
Indiana — Muncie Feb. 22-29 i
Indiana — South Bend Feb. 22-29 ■
Iowa — Ottumwa leb. 22-29 2
Kansas — Kansas City b. 22-29 11
Kentucky — Covington Feb. 22-29 4
Louisiana — New Orleans Vvh. 22-29 13 " Im-
ported.
Massachusetts— Fall River Jan. 4-11 i
Michigan — Saginaw Feb. 15-22 6
Missouri — Kansas City Feb. 15-29 26
Missouri — St. Joseph Feb. 15-22 17
Montana — Butte Feb. 18-25 1
New York- Buffalo Feb! 22-29 i
Ohio — Cincinnati Feb. 22-2 S 25
Ohio — Toledo Feb. 15-22 2
Tennessee — Knoxville Feb. 22-29 "8
Tennessee — Nashville Feb. 22-29 8
Texas— San Antonio Feb. ,^-22 6
Washington — Spokane Feb. 15-22 14
Wisconsin — La Crosse Feb. 22-29 9
Wisconsin — Manitowoc Feb. 15-22 i
Smallpo.r — Foreign.
China — Amoy Jan. 4-25 Present.
China — Hongkong Jan. 11-25 3" 33
India — Bombay Jan. 28-Feb. 4 8
India— Calcutta Jan. 11-18 8
Italy — General Feb. 6-13 iiy
Jaran — Nagasaki Feb. 6 2
Japan — Tolcyo Feb. 12 300
Japan — Yokohama Dec. 28-Feb. 12 197 63
)'cllo'v Fezer — Foreign.
Barbadoes —
Bridgetown and vicinitv Ian. 29-Feb. 18 4 2
Cuba— Santa Clara Feb. 28 i
Venezuela — Ciudad Bolivar Feb. 26 i
574
BIRTHS. MARRIAGES, AND DEATHS.
[New York
Medical Journal-
-Cholera— Insular.
Philippine Islands —
Manila Jan. ii-Feb. i 127 106
Zambales Province To Feb. i 158 108
Cholera — Foreig 11 .
India — Calcutta Jan. 11-18 27
India — Madras Jan. 25-31 7
India — Rangoon Jan. 18-25 3
Plague — Foreign.
China — Hongkong Jan. 11-18 4 4
India — Bombay Jan. zS-Feb. 4 35
India — Calcutta Jan. 11-25 '.3
India — Rangoon Jan. 18-25 ^
Peru — Catacaos Jan. 23 8 6
Peru — Chepen Jan. 23 2 1
Peru — Lambayeque Jan. 23 2 3
Peru — Lima Jan. 23 5 3
Peru — Paita Jan. 23 2 i
Peru — San Pedro Jan. 23 i i
Peru— Trujillo Jan. 23 iS 5
Public Health and Marine Hospital Service:
Official Hit of changes of stations and duties of cofti-
missioned and noncommissioned officers of the United
States Public Health and Marine Hospital Service for the
seven days ending March 14, 1908:
CuMMiNG, H. S., Passed Assistant Surgeon. Directed to
proceed to Kobe, Japan, for special temporary duty,
upon completion of which to rejoin his station.
De Valin, Hugh, Assistant Surgeon. Granted leave of
absence for two days from March 3, 1908, under para-
graph 191, Service Regulations.
Duke, B. F., Acting Assistant Surgeon. Granted leave of
absence for seven days from March 10, 1908.
Fkost, W. H., Assistant Surgeon. Granted leave of ab-
sence for two days from February 29, 1908, under
paragraph 191, Service Regulations.
Oakley, J. H., Passed Assistant Surgeon. Directed to
assume temporary charge of tbe Marine Hospital at
Port Townsend, Wash., during the absence of Sur-
geon W. G. Stimpson.
'Pettus, W. J., Assistant Surgeon General. Granted leave
of absence for three days from March 9, 1908.
Stanton, J. G., Acting Assistant Surgeon. Granted an
extension of leave "of absence for seven days from
March 6, 1908.
Stimpson, W. G., Surgeon. Directed to report to the
commanding officer of the revenue cutter Thetis for
temporary duty.
VoN EzDORF, R. H., Passed Assistant Surgeon. Directed
to proceed to New Orleans, La., for special temporary
duty, upon completion of which to rejoin his station.
Wetmore, W. O., Acting Assistant Surgeon. Granted
leave of absence for eight days in February, 1908, un-
der paragraph 210, Service Regulations.
Army Intelligence:
Official list of changes in the stations and duties of
officers serving in the medical department of the United
States Army for the week ending March 14, igo8:
Bratton, T. S., Captain and Assistant Surgeon. Upon
arrival at San Francisco, Gal., will proceed to Fort
Des Maines, la., and report in person to the command-
ing officer of that post for duty, and by letter to the
commanding general, Department of the Missouri.
Cakswell, R. L., Captain and Assistant Surgeon. Granted
two n7onths' leave of absence, with permission to apply
for an extension of one month.
CoRULSiER, W. n., Lieutenant Colonel and Deputy Surgeon
General. Relieved from further duty as chief sur-
geon, Department of the Columbia, and will proceed to
his home, where, for his own convenience, he is
authorized to await retirement from active service.
Davis, W. B., Lieutenant Colonel and Deputy Surgeon
(jeneral. Appointed a member of an Army retiring
board, to meet at Omaha, Neb., for the examination
of such officers as may be ordered before it.
Reaso.nek, M. A., First Lieutenant and Assistant Surgeon.
Relieved from further duty in the Philippines Division,
and assigned to duty in the Army Transport Service,
with station at San Francisco, Cal.
Shortlidge, E. D., First Lieutenant and Assistant Sur-
geon. Granted leave of absence for three months.
Van Dusen, J. W., Captain and Assistant Surgeon. Ap-
pointed a member of an Army retiring board, to meet
at Omaha, Neb., for the examination of such officers
as may be ordered before it.
Wilson, W. H., Major and Surgeon. Detailed to accom-
pany the Thirty-fifth Company, Coast Artillery Corps,
from Fort Monroe, Va., to San Francisco, Cal., pro-
ceeding at the proper time to Fort Monroe, Va., re-
porting upon arrival to the company commander ;
upon completion of this duty, ordered to return to
Fort Hamilton, N. Y.
Navy Intelligence:
Official list of c flanges in the medical corps of the United
States Navy for the zveefz ending March 14, 1908:
BoGERT, E. S., Jr., Surgeon. Detached from the Pennsyl-
vania and ordered to the Naval Academy.
Brown, E. M., Passed Assistant Surgeon. Granted sick
leave for three months, when discharged from treat-
ment at the Naval Hospital, New Fort Lyon, Col.
Moran, C. L., Assistant Surgeon. Ordered to duty at the
Naval Hospital, Norfolk, Va.
Richards, T. W., Surgeon, Detached from the Colorado-
and ordered to the Naval Hospital, Mare Island, Cal.,
for treatment.
Stanley, A. C, Assistant Surgeon. Ordered to duty at
the Naval Medical School Hospital, Washington, D. C.
Urie, J. F., Surgeon. Detached from the Bureau of Medi-
cine and Surgerj', Navy Department, and ordered to
the Pennsylvania.
girtlis, gtarrisps, anb i^at^s.
Married.
Borst— Bryant. — In Framingham, Massachusetts, on.
Monday, Marcli 9th, Dr. Theodore F. Borst and Mrs. Sara
Cone Bryant.
Dagg — McGee. — In Kansas City, Missouri, on Tuesdaj',
February 25th, Dr. G. R. Dagg and Miss Maud McGee.
Maverick — Baxter. — In Philadelphia, on Thursday,
March 5th, Dr. Augustus Maverick and Miss Elizabeth
A. Baxter.
Rosenheck — Gotsdanker. — In New York, on Sunday,
March 8th, Dr. Charles Rosenheck and Miss Leonora
Gotsdanker.
Died.
Brannen. — In Washington, D. C, on Wednesday. Marcli.
4th, Dr. Dennis J, Brannen, of Flagstaff, Arizona.
Du Bois. — In Hyde Park, New York, on Monday. March
2d, Dr. Mary Du Bois.
Dunlop. — In New York, on Friday, March 6th. Dr. Clark
W. Dunlop, aged sixty-three years.
Giberson. — In Beverly, New Jersey, on Saturday, Feb-
ruary 29th, Dr. William H. Giberson, aged forty years.
Harlow. — In Tyngsboro, Massachusetts, on Tuesday^
March loth. Dr. Granville A. Harlow, aged fifty years.
Holden. — In Paris, France, on Friday, February 28th, Dr.
Francis M. Holden, of Philadelphia, aged fifty years.
Kennedy. — In Springfield, Massachusetts, on Wednes-
day, March nth. Dr. Charles Francis Joseph Kennedy,
aged forty-one years.
Richardson. — In Belair, Maryland, on Saturday, March
7th, Dr. E. Hall Richardson, aged forty years.
Sadler, — In Montgomery, Alabama, on Saturday,
March 7th, Dr. John M. Sadler, aged fifty-eig^t years.
Sammons. — In Chicago, on Thursday, March 5th, Dr. E.
H. Sammons. aged fifty-eight years.
Samuels. — In St. Joseph, Missouri, on Monday, March
2d, Dr. Reuben 1. Samuels, aged eighty-two years.
Semple. — In Philadelphia, on Thursday, February 27th,
Dr. William H. Semple, aged forty-three years.
TiBBETT.s. — In Newville, New York, on Wednesday,
March nth. Dr. William Tibbetts, aged seventy years.
White. — In Lancaster, New Hampshire, on Sunday.
February 23d. Dr. A. Campbell White, of New York, aged
thirty-nine years.
Woodhull. — In St. Augustine, Florida, on Sunday,
March 8th. Dr. E. D. Woodhull, of Monroe, New York.
Wyman. — In Detroit, Michigan, on Monday. March gthj
Dr. Hal C. Wyman. aged fifty-six years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal rlt Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXVII, No. 13. NE^^■ YORK, ^lARCH 28, 1908.
. Whole No. 1530.
^Briginal Communications.
THE ACCESSORY SINUSES OF THE NOSE FROM
AN OPERATIVE STANDPOINT.*
Bv IIarmox Smith, M. D.,
New York,
Surgeon, Manhattan Eye, Ear, and Throat Hospital ; Instructor in
Clinical Laryngology. College of Physicians and
Sur.geons, Columbia University.
In the following paper I shall take up the subject
of sinusitis where operative measures of a more
radical nature are imperative, either to save life
or because palliative treatment and minor surgical
measures have failed.
When empyema of the maxillary sinus has ex-
isted for a long time, and irrigation through the
ostium, or through an ill advised opening in the
alveolar process, or through a small opening in the
inferior nasal fossa, has failed to make favorable
headway against the disease, a more radical pro-
cedure is necessary.
The CaldweJl-Luc operation has been employed
successfully for a number of years, and with the
drainage taking place into the nose it has many
features to recommend it. However, it now ap-
pears unnecessary to enter the sinus externally in
the majority of instances, for sufficient drainage is
obtained and complete recovery accomplished by
entering the sinus in the following maimer :
Inject into the mucous membrane over the an-
terior half of the inferior turbinate and into the
mucous membrane over a corresponding area of
the inferior fossa one half of one per cent, solution
of cocaine, and sufficient adrenalin solution of i in
5.000 strength to bleach the parts. The anterior
part of the inferior turbinate is then removed. A
tongue shaped flap of mucous membrane can be
detached from the bone at the site of the desired
entrance into the antrum by cutting two vertical
parallel lines, the first one from a point just anterior
to the cut end of the inferior turbinate downward
to the floor of the nose, the second about half an
inch farther forward and parallel to the first.
These two are connected by a third cut between
their upper extremities. With a small periosteal
elevator, such as Freer's, the mucous membrane
can easily be detached from above downward and
turned back into the floor of the nose for subse-
quent use. Then with Abraham's pyramidal punch
easy entrance may be made into the' antrum at the
upper extremity of this denuded area. After en-
trance has been gained with this punch. Abraham's
•Read before the Waterbury Medical Association, January, 1907.
Copyright, 1908, by A. R.
olive pointed burr is introduced, and with a back-
ward and forward movement the original entrance
may be enlarged to the full width of the denuded
bone and also lowered to the floor of the nose,
which opening should be sufficiently large to per-
mit of removing from the antrum most of the
polypoid material therein.
After this procedure the haemorrhage is con-
trolled by packing the antrum with gauze soaked in
adrenalin or pure alcohol. This packing should
then be removed and the tongue shaped flap of
mucous membrane turned into the antrum and held
in position on the floor by dry boric acid gauze
packing. This packing should be fed into the
antrum so that it will run in layers from the floor
to the roof and can be withdrawn gradually from
above downward, beginning on the second day.
This method of removal permits the mucous mem-
brane to become attached before the removal of
gauze immediately in contact with it tends to tear
it from its place. I think, however, that the impor-
tance of this mucous membrane flap is overesti-
mated. In persistent cases, tight packing is neces-
sary for a period of many weeks. Just as tight
packing facilitates the healing of a radical mastoid
operation, so does it act in keeping down granula-
tions in the antrum.
In cases where no polypi exist in the antrum, the
free drainage and frequent irrigation with hot
normal saline solution will readily overcome the
purulent condition. If for any reason, such as
carious bone, a pocket of pus out of reach of the
packing, or the root of some decayed tooth, this
operative method should not succeed, then recourse
may be had to the more extensive one of Caldwell-
Luc, in which case that part of the operative pro-
cedure which connects the antrum with the nose
will already have been performed.
The Sphenoidal Sinus— Tht surgery of this
sinus has been greatly developed by rhinologists
during recent years, so that it is no longer regarded
as a part of orbital surgery. Natural drainage here
is difficult, owing to the elevated position of the
foramen of exit, so that the escape of the secretions
must be due largely to the ciliary motion of the
epithelial lining. Therefore an empyema here not
only produces difficulties per sc. but also endangers
the cranial cavitv by contiguity, meningitis of the
base being readily set up by extension of infection
through the blood and lymph vessels. In investi-
gating the sources of intracranial suppuration, not
a few are found to be due to pus in the sphenoidal
sinus, as is demonstrated by the forty-two cases
cited by St. Clair Thomson. Such cases are natn-
Elliott Publishing Company.
SMITH: ACCESSORY SINUSES OF THE NOSE.
[New York
Medical Journal,
rally difficult of diagnosis, being both obscure in
character and insidious in course.
The method of entering this sinus through the
nose is as follows : The middle turbinate is first
removed and the anterior and ni^-.st cf the posterior
Fig. I.— u. The flap of mucous membrane detached from the lateral
wall of the nasal chamber under the inferior turbinate; b, the re-
maining portion of the inferior turbinate after the removal of the
anterior third; c. the approximate size of the opening into the
antrum Highmori necessary to evacuate the products of chronic
suppuration.
ethmoidal cells curetted away. The anterior wall
of the sphenoidal sinus may then come into view.
A small sinus lamp should be employed in the
examination. ^Measurements should be taken, when
the results will be about as follows : The anterior wall
of the sphenoidal sinus is about eight centimetres
from the vestibule. A sinus probe, slightly curved,
follows the vault of the nasal fossa, and should then
enter the sphenoidal sinus through its ostium. A
curette should be introduced along the probe into
the sinus, whereupon the anterior wall of the latter
may be broken down by drawing the instrument
downward and backward. Elongated forceps, such
as Kerrison's. are used to enlarge the opening, frag-
ments of bone tissue being pinched away. When
the cavity is thoroughly exposed drainage is not
only established, but polypi, purulent mucosa, etc.,
may be scraped away, tf necrntic l>nne is present
it should also be curetted, but this operation is very
dangerous when the roof of the sinus is necrosed,
on account ' of the close proximity of the brain.
Trephines, saws, etc, are used to enter the sphen-
oidal sinus, although they are more dangerous than
the curette.
The sinus should be cleansed and packed with
iodoform gauze, which is removed the next day. Tt
is well to apply strong silver nitrate solution to the
cavity, or at least its border, after a few days, in
order to cut down granulations,
Trendelcnbur<r position : This has both advan-
tages and disadvantages, although in the main
it is essential to operative success. Its advantaces
are obvious, while its drawbacks include the diffi-
culty of choosing the proper route for curettement.
The operator must be careful not to direct the in-
struments too high up, as there is danger of enter-
ing the cranial cavity. The maxillary route is by
far the easiest and safest, provided a Caldwell-Luc
operation on the antrum has been necessary,
fronlal Sinus. — When convulsions, coma, chill,
followed by high temperature, or the evacuation of
pus into the orbit occurs in the course of frontal
sinus suppuration, radical procedures are clearly
indicated. Comparative comfort may be experi-
enced by the patient for a number of years by the
removal of the anterior end of the middle turbinate
and careful opening into the "hiatus semilunaris,"
giving drainage to the sinus.
The internal operation upon the frontal sinus is
usually condemned because of its dangers, but
Ingals, of Chicago, has devised a small guarded tre-
[;hine which is directed by a probe along a proper
and safe course into the cavity. I have never used
this mstrument. but it appears to be the safest for
all intranasal measures. This method, however,
would serve only to give drainage, and would by
no means tend to overcome the numerous foci of
infection walled ofif by sajpta of bone, such as are
frequently fmmd in a sinus. Numerous operators
have devised and advocated special methods for
gaining entrance externally into this sinus without
]iroducing sul)sec[uent deformity. The first of these
was Callisen, in 1798. The modern idea, as advo-
cated by Jansen, Killian, Coakley, and others, is to
thoroughly cleanse the sinus, remove the ethmoid
cells, enlarge the nasofrontal duct, and minimize
deformity. For a small sinus showing no bony
s?epta upon the skiagraphic plate, Jansen's opera-
KiG. 2. — From Keen's .Surgery, iii, \\ 436, l"ig. .'69 (Killian's
Operation). First Step — .Showing line of initial incision with slight
transverse cutaneous cuts. The initial incision is made through the
soft structure to the periosteum.
tion may well be advocated, and, briefly described,
is as follows :
A curvilinear incision is made just above and
parallel to the eyebrow, beginning at the external
March 28, 1908.]
SMITH: ACCESSORY ShWUSES OF THE NOSE.
577
orbital angle and terminating at the mdidle of the
root of the nose. The soft tissues and periosteum
are then detached from the roof of the orbit, which
is the floor of the sinus, by the use of the periosteal
elevator. The roof of the orbit is then removed
Fig. 3 —From Keen's Surgery, in., p. 437, Fig. 270 (Killian -
Operation). Second Step — Showing soft tissures retracted, an^',
lines of periosteal ipcisinns.
with a curette. The sinus is curetted and the naso-
frontal duct is enlaroed. A drainage wick of gauze
is introduced from the sinus into the nose through
the duct, and a second drainage wick is placed in
the lower internal angle of the wound. The orbital
fat is supposed to fill the excavated sinus. If the
sinus is large and has numerous saepta, proper
cleansing is impossible. If it is small and undi-
vided, good results will be obtained both surgically
and cosmetically.
The operation which now recommends itself to
most operators and which is being pursued with a
minimum of evil results is that of Killian, of Frei-
burg.
First step. — The brow is not shaved, but clipped,
and the incision is made through the hair line of the
brow from the temporal extremitv of the orbit to
the root of the nose, dividing the nasal section of
the musculus quadratus in the centre of the frontal
process of the superior maxilla. This incision end.s
in an oblique curve outward below the base of the
nasal bone. The line of incision is marked by slight
transverse cutaneous cuts, which enable the op-
erator to properly coapt the wound after operation
and thus lessen the tendency to deformitv. After
this primary incision is made through the soft parts
to the periosteum, the soft tissues are lifted away
from the periosteum, uncovering the external plate
of the frontal bone above the arch and the roof of
the orbit below, and the nasofrontal suture beyond
the median line
Second step. — Periosteal incisions. — (a) An in-
cision is made through the periosteum parallel to
the supraorbital margin and five to six millimetres
above, extending from the temporal end of the eye-
brow to the beginning of the root of the nose at
its central point, (b) A second periosteal incision
is made, beginning just internal to the attachment
of the pulley of the superior oblique muscle and fol-
lowing the line of the cutaneous incision to its ex-
tremity. The perio-steum is then elevated from the
superior incision over the entire anterior frontal
wall and from the inferior incision downward, ex-
posing the inner and superior third of the orbit.
These elevations leave a strip of periosteum cover-
ing the site of the bony arch left for the purpose of
sustaining the soft tissues after closing the wound
and giving nourishment to the bone beneath.
Third step. — Enter the sinus by means of a gouge
and mallet just above that piece of bone included
between the periosteal incisions.
Fourth step. — With a probe ascertain the extent
of the sinus.
Fifth step. — By means of a gouge and mallet ex-
FiG. 4.— (Killian's Oi.eratiun). Third Step— Showing, i, the bridge
of bone with its periosteal covering left in place for upholding the
soft tissues upon closure of the wound; 2, the entrance through the
OS planum into the ethmoidal tract extending back into the sphenoid:
3, the size of the sinus in this case with its irregular outlines and
deep sulci: 4, the little nicks in the initial incision which must be
approximated in closing the wound to preserve the integrity of the
parts.
cavate a groove through the external table from the
first opening into the sinus to the external extrem-
578
SMITH: ACCESSORY SINUSES OF THE NOSE.
[New York
Medical Journal.
ity of the sinus. This groove will then permit the
free use of the chisel in removing the remainder of
the bony covering of the sinus, without endanger-
ing the arch, which it is desirable to retain intact.
The entire bony covering of the sinus is thereby re-
moved, and considerable care exercised to uncover
properly the angles of the sinus.
Sixth step. — Thoroughly remove all contents of
the siiuis and its mucous membrane, also break
down all existing bony scepta, so that free inspection
of the sinus may be made throughout. Haemor-
rhage will frequently be profuse until all granula-
tion tissue is removed.
Seventh step. — Remove the floor of the sinus
without injury to the supraorbital ridge, which en-
ters into the arch of bone left standing. This pro-
cedure ma\- best be accomplished by the op>erator
standing behind the patient's head and chiseUng
Fin. s. — (Killian's Operation). Lateral apiiearance after dividing
the liead. a, Entra ice through os planum and orbit into the eth-
moidal tract, b. The ethmoidal tract, c, Sphenoidal sinus, d. Line
of attachment of middle turbinate, e. Inferior turbinate.
from above downward. The bone is thin and can
easily be removed without endangering the con-
tents of the orbit. '
Eighth step. — Remove the frontal process of the
superior maxilla and the remaining part of the sinus
floor.
Ninth step. — Remove the ethmoid cells, both an-
terior and' posterior, if diseased, and the middle tur-
binate bone. Likewise remove the anterior wall of
the sphenoid and curette this cavity if it is involved.
Griinewald's forceps are serviceable in performing
this operation. In order to reach the posterior
ethmoidal cells, and the sphenoid, it is frequently
necessary to chisel away part of the nasal bone on
the side involved. This does not complicate mat-
ters in the general healing of the wound.
Tenth step.- — Irrigate the wound with salt solu-
tion and dust with iodoform. Run a gauze wick
from the temporal extremity of the frontal sinus
into the nasal chamber through the frontonasal
canal and terminate at the nasal vestibule. The in-
cision is then sutured with the expectation of pri-
mary union. Care is exercised in the coaptation of
the wound, and the little cuts previously made
across the first incision materially aid in this matter.
After treatment. — Place the patient on the
healthy side. Give strict orders that he shall not
blow his nose, but must aspirate the secretions flow-
ing from the wound. Dressing must be done daily,
but no irrigation must be used. The gauze packing
is removed on the second day, and the sutures on
the fourth to the fifth day. Care of the wound in-
ternally must be continued over a period of two to
six months. This after treatment is tedious, and
the after granulations springing up must be cut
down with a strong silver nitrate solution. Even
fused silver nitrate on a probe is necessary in many
instances.
Deformity frequently results from this opera-
tion, in the form of a depression above the bony
arch, which is left to support the tissues. This de-
pression has been filled in by the subcutaneous in-
jection of paraffin, which overcomes the deformity.
For a long time after the operation a soft, mushy
condition may be felt in the angle of the orbit, and
sometimes a fistula forms at this point.
Dangers. — Many deaths have followed these op-
erations, in which the operator could in no wise
hold his technique responsibile ; and fatal termina-
tions have been reported by such eminent operators
at St. Clair Thomson, Herbert Tilley, Burghard,
Lambert Lack, Milligan, and Logan Turner. I
have seen most excellent results from operations by
Thomson, Tilley, and Lack, and firmly believe that
no fault of theirs contributed to the fatal results. I
would emphasize the importance of serious consid-
eration before attempting the radical operation :
1. Consider the close proximity of the brain.
2. The many avenues of infection opened up by
the exposure of such an extensive area.
3. The limited knowledge of the sphenoidal sinus
and the posterior ethmoidal cells obtainable by di-
rect observation, and the necessity of relying almost
entirely upon one's knowledge of the anatomy of the
parts for operative measures.
4. The possibility of an already existing menin-
gitis; for not infrequently cases are sent in for op-
eration with a high temperature, some mental
aberration, perhaps delirium, choked disc, and other
symptoms which could be attributed either to pus
under pressure or to an existing meningitis.
5. The lowered vitality and resistance of the pa-
tient, which predisposes to both infection and pneu-
monia.
Before leaving the subject I would emphasize the
material aid offered by skiagraphy, not only in diag-
nosticating empyema of the sinus, but in outlining
the probable extent of the operation. In the frontal
sinus particularly it is important to know the size
of the cavity, whether it is multilocular or presents
an orbital recess, and, finally, whether the sinus is
diseased. The last factor is determined by the
milky appearance of the sinus in contrast with the
dark appearance of the unaffected side. The skia-
graph also demonstrates the width of the ethmoid
cell area and its relation to the frontal sinus. Just
as it is essential to become acquainted with the
ophthalmoscope and its readings in the eye, so is it
necessary to study a number of skiagraphs and fol-
low their teachings by operative demonstration, in
order to become proficient in deciphering the shades
rOUSEY: RADIOGRAPHY OF PNEUMATIC SIXUSES. 579
March 28. 1908.]
and shadows exposed in the plate. One familiar
with this subject can deduce many truths from a
skiagraphic plate which an unaccustomed eye could
never perceive.
In closing I would advise against too much ag-
gressiveness in radical operation upon either sphe-
noidal, ethmoidal, or frontal sinuses — the maxillary
is farther removed from danger — for I believe that
a great many suppurative conditions can be cured
by securing perfect drainage. I also believe that it
is of vital importance that one should be perfectly
familiar with these areas before attempting to
curette in such close proximity to meningeal tissues.
Even when the operator is perfectly familiar with
the anatomy he may induce meningeal infection by
stirring up infected areas adjacent to venous and
lymph channels which lead directly to the base of
the brain.
44 West Forty-xinth Street.
THE RADIOGRAPHIC TOPOGRAPHY OF THE
FRONTAL SINUS AND OTHER PNEUMATIC
SINUSES OF THE FACE.
By Sinclair Tousey, A. M., M. D.,
New York,
Surgeon to St. Bartholomew's Clinic.
The use of the x ray in making examinations of
the frontal sinus,' the antrum, and the ethmoidal
Fig. I. — Topography of the antrum in an anteroposterior radiograph.
and sphenoidal cells divides itself, naturally, into
two methods : First, that by which a lateral view
'A series of radiographs illustrating this subject were exhibited
at a meeting of the Section in Laryngology and Rhinology, New
York Academy of Medicine, December 18, 1907.
Fig. 2. — S<'1k:-oi.., .i-r radiograph.
of the face is taken, and. second, an anteroposterior
picture in which the tube is placed behind the head
and the plate in front. This is by far the more dif-
ficult, and results are only possible, as far as the
frontal sinus is concerned, with the very best ob-
tainable apparatus and technique. In the latter
case, however, it is not so much a matter of terribly
powerful currents or long exposures as it is of the
proper adjustment of the x ray tube and the other
apparatus. The author's radiographs of this char-
acter have been made with an exposure of only
thirty seconds and with a twelve inch induction
coil and a primar\- current of eighteen amperes.
The lateral radiographs are much easier, be-
cause there is only a small fraction of the amount
of tissue to be penetrated by the x ray. An ex-
posure of fifteen seconds with a primary current
of eighteen amperes is amply sufficient. The dis-
tance from the tube to the plate has a great deal
to do with the success of the radiograph in either
case. The anticathode should be twenty-five inches
from the plate for an anteroposterior picture, and
about seventeen inches in making a lateral picture.
The author has made two kinds of radiographs
of the pneumatic sinuses : one set has been made
from an empty skull in which the different air
spaces have been filled with lead shot, which is en-
tirely opaque to the x ray, and the other set of
radiographs shows the condition of these air spaces
in living patients. The radiographs of the air
spaces in the empty skull furnish a set of accurate
charts showing the topography of the sinuses in
X ray pictures of the head. The author has found
them valuable in the exact localization of disease
TOUSEY: RADIOGRAPHY OF PNEUMATIC SINUSES.
[New York
Medical Journal.
Sphenoidal cells, lateral radiograph
and sometimes in distinguislnng a shadow due to
pus or a solid substance in one of these sinuses
from the normal shadows due to neighboring bony
structures. The radiographs of living patients
have proved a valuable means of diagnosis, and it
can be confidently stated that this method has greai
advantages over ordinary transillumination.
The anteroposterior radiograph ( Fig. i ) , showing
the antrum full of shot, gives the comparative appear-
ance of the side on which the antrum is empty and
that on which it is full of the opaque substance. It en-
ables us to recognize the normal location of the an-
trum in patients. The same picture
shows the frontal sinus, which in
this skull was a small unilocular air
space on one side of the median
line, not reaching over the orbit to
any extent. The alse of the sphe-
noid bone may be seen forming the
upper wall of the orbits ; and the
bony saeptum of the nose and the
turbinated bones form distinctive
landmarks. . All the bony outlines
are more distinct than in the actual
patient, but, as will be seen later, dif-
ferent portions in pictures of nat-
ural patients can be recognized.
The lateral radiograph of the
antrum full of shot shows the size
and position of this air space, and
it also shows the frontal .sinus in
profile, showing the separation l)e-
tween the external and internal
bony walls of this cavity. The
malar bone sometimes forms an im-
portant landmark in such a picture.
The anteroposterior radiograph
(Fig. 2) of the sphenoidal cells
filled with lead is valuable be-
cause it enables us to recog-
nize at a glance in a similar
picture from a living patient
the position of these particular
cells.
The lateral radiograph (Fig.
3) of the sphenoidal cells filled
with shot is especially valuable
as a topographical chart.
There arc certain shadows in
radiographs of the living pa-
tient m this region which it is
important to distinguish be-
tween— those due to bony
structures and those due to a
collection of pus in the sphe-
noidal cells. By comparing a
lateral radiograph of a pa-
tient's head with this ex-
perimental radiograph it
has been found easy to
make this distinction at a
glance.
Radiographs of the anterior
middle and posterior eth-
moidal cells, respectively, have
been made upon an emptv
skull in which these different
air spaces have been filled
with shot. The ])ictures are anteroposterior and also
lateral. Thcv furnish valuable information as to the
exact position of these diliferent cells.
Radiographs of the Pneumatic Sinuses in Actual
Patients.
One of these radiographs (Fig. 4) is that of a
patient in whom the antrum and the other pneu-
matic sinuses proved to be normal. It is an an-
teroposterior picture made with the tube behind the
head and the plate in front. It shows a large fron-
tal sinus with a number of sjtpta. It shows the
Maroh 28, iqog.l
TOUSEY: RADIOGRAPHY OF PNEUMATIC SIXUSES.
581
ethmoidal cells someu-hat msre distinctly on one
side than on the other. This is due to the diffi-
culty experienced in producing an abso-
lutely median application of the x ray.
Another picture is an anteroposterior
radiograph of a patient referred to me by
Dr. Alleman. The left antrum shows as
a completely opaque mass, contrasting
sharply with the normal air space on the
right side. This picture was made with
the X ray tube at a lower level than would
be suitable for radiography of the
frontal sinus, and the latter air space
therefore does not show in the radio-
graph.
Another lateral radiograph (Fig. 5) is
that of a distinguished physician, who had
all of his upper teeth extracted for pain,
and upon whom subsequent minor opera-
tions were performed for the abstraction
of spicuLx of bone from the jaw. All
these treatments failed to relieve his suf-
fering, and he was unable to wear a set of
artificial teeth for more than an hour at a
time. The radiograph showed that the
antrum was absolutely opaque, and an op-
eration was performed by Dr. Cryer, re-
sulting in a complete cure. The antrum in
this case was full of pus and swollen mucous mem-
brane.
Fig. 6 is an anteroposterior radiograph of a case
referred to the author by Dr. Joseph Abraham. It
shows the frontal sinus in normal condition, but
the left ethmoidal cells are opaque. The left an-
trum presents a small translucent area at its centre
surrounded by a zone of opacity. This is the ap-
pearance to be expected in cases of suppuration in
the antrum, where the pus has been evacuated, but
where the mucous membrane is still swollen and
unhealthy.
Fig. 7 was made of a patient of Dr. Gleitsman be-
fore operation. It shows a frontal sinus with a
little less than the normal translucency, but still
with an outline and s;epta which are readily seen.
The mucous membrane may be swollen, but the
radiograph does not show the opacit}' which would
be found if the sinus were full of pus. The
ethmoid cells do not show opacity, and the antrum
presents a clear centre with surrounding moderate
opacity. This also indicates a polypoid mass or
swollen mucous membrane, not the presence of a
mass of undrained pus.
Disease of the frontal sinus may show itself as
opacity in one or more of the spaces into which
the saepta divide this cavity, and in some cases it
ma\- even look as if the frontal sinus was absent
upon one side.
A case which the author examined for Dr. Phil-
lips showed a great area of opacity, extending out
to the side of the forehead, and upon operation
the frontal sinus upon this side was found to con-
tain a very large amount of pus.
Examination of the Radiograplis.
Anteroposterior pictures of the head seldom
>how as well in the print as they do in the original
plate or negative, and the best means of studying
the latter is by transmitted light in a negative ex-
FiG. 6. — Chronic antrum and ethmoid inflammation; a, frontal sinus; b
cells opaque; d, normal ethmoid cells; c, antrum showing opacity; e, normal an-
trum.
COXKLIX:
MEXTAL ATTITUDE AND BODILY fUXCTIOX.
[New York
Medical Journal.
amining- box. Details may be readily discovered
in this \va}- which are entirely lost in the process
of rei)roduction as seen in the prints illustrating
this article. ,
The frontal sinus has been shown by Cryer's
Anatomical Studies and by the radiographs of
Some one describes one organ of the body thus:
"The human eye is the most wonderful piece of
mechanism in the world. It has eight hundred dis-
tinct contrivances. It opens and closes auto-
matically its curtains thirty thousand times a day.
It is selfafljusting to all degrees of light from mid-
FiG. 7. — Anteroposterior radiograpii of case with chronic antrum and ethmoid inflammation without much
retention of pus; a, frontal sinus; b and d, ethmoid cells; c and e, antra.
Caldwell and Coakley to present a great diversity
in size, shape, and position and in the number of
saspta which subdivide it. It follows, therefore,
that the diagnosis of disease cannot be based mere-
ly upon a deviation from any particular appearance
which might be considered typical. The radio-
graph must show sufficient detail to afiford proof
in itself of an abnormal condition.
59 West Forty-sixth Street.
THE RELATION OF MENTAL ATTITUDE TO
BODILY FUNCTION.*
By W. L. Conklin, M. D,,
Jackson Health Resort, Dansville, N. Y.
Of the many complex problems which have chal-
lenged the reasoning powers of man, and sometimes
baffled his best ef¥orts, man himself is the most
complex, the most difficult of solution. A great
grammarian is said to have remarked that if he
had his life to live over again he would spend it in
the study of the dative case. If there are such
possibilities for study and research hidden away in
one leaf of the science of man's language, it is lit-
tle wonder that a lifetime may be spent in the
study of man himself without a complete solution
of the problem which he presents.
The anatomist and physiologist study the struc-
ture and function of the various organs of the hu-
man body, and for 3,000 years there has been
increasing evidence that David was right when he
said, "I am fearfully and wonderfully made."
'Read at the annual meeting of the MedicaJ Society of the
County of Monroe, Rochester, N. Y., December 17, 1907.
day to midnight. Its retina is a highly sensitive
plate. Its lenses are normally perfect, with micro-
scopic power to see the point of a cambric needle,
and telescopic power to gaze upon the sun, ninety-
five millions of miles away, and it is the mirror of
an inward occupant. It can flash with the fire
of anger, burn with enthusiasm, melt with tender-
ness, stare with fright, leer with villainy, twinkle
with mirth, or beam with love."
While the eye is an optical instrument of such
marvelous construction and power, it is but the
servant of the mind, obeying the behests of volition
and giving expression to emotion. Without its aid,
moreover, intellect may grapple with the great
problems of life, and imagination "give to airy
nothing a local habitation and a name."
But while the psychologist, the anatomist, and
the physiologist pursue their investigations, the
physician must study man as man, not body alone
or mind alone, but a complex being. He must take
carefully into account this twofold nature, and I
think there are but few who will dissent from the
assertion that he must go further than this, even,
and recognize a third factor in the problem of hu-
man life. Call it spirit, if you will; a something
at least which transcends the mind in its ordinary
workings as the mind transcends the body. A
something of which it has been said:
"Birthless and deathless and changeless remaineth
the spirit forever ;
Death has not touched it at all, dead though the
house' of it seems."
I am aware that it may be objected that this is a
realm beyond the ken of scientific investigation.
This mav, to some extent, be true, but it has, nev-
March 28. i9"8.l CONKLbN: MENTAL ATTITUDE AND BODILY Tl'XCllOX. 583
ertheless, its bearing upon the complex problem
which confronts the physician — the problem which
he must work out many times over in his efforts to
guide back to normal, healthful activity the man
or woman who is "out of commission" because of
disease" in some of its many manifestations.
Whether we believe in the identity of mind and
matter or not ; whether we assert with the material-
ist that everything, from a dissertation to a diatom,
is the result of a "fortuitous concourse of atoms,"
or dissent from the assertion, or even if for the
moment we dismiss the subject with the humorist's
cogitation :
"What is mind? — no matter.
What is matter? — never mind,"
we must still look upon mind and body as so close-
ly related, so intimately associated, that a condition
of health and activity in one tends to produce a
like condition in the other ; while if one is in a
marked degree abnormal the other is almost sure
to suffer in one or more of its functions. The ex-
ceptions to this rule, in which there is associated
with a weakened and diseased body a mind of un-
usual power and scope, are rare and suggestive of
the innate superiority of mind over matter.
Alienists have long found abundant evidence
that abnormal physical conditions are capable of
producing mental disease. Indeed, the general
practitioner has learned that mince pie and melan-
cholia not infrequently bear the close relatiouship
of cause and effect. But do we place sufficient
emphasis upon ,the correlative truth that mental
attitude and bodily function \ bear to each other a
relationship quite as close?
I will not weary you with illustrations of this
intimate association. Medical \Uterature abounds
in them, and indeed they are freqit^tly brought to
the attention of every physician. Th^ medical stu-
dent is very likely, early in his careef, tO' observe
the effect of imagination upon his own bodily func-
tions as he suffers a sudden twinge of pain on the
McBurney's point side of his anatomy just after a
lecture on appendicitis, or finds himself consulting
the long suffering professor of practice ,the dav
following a lucid description of valvular diseases
of the heart.
Tuke quotes from the Spectator of .March 29,
1 7 10, a humorous account of the effect upon the
writer of the perusal of medical books : He said
that as a result "he found his pulse irregular, and
scarce ever read the account of any disease that
he did not fancy himself afflicted with. Dr. Suy-
denham's learned treatise on fevers threw him into
a lingering hectic, which hung upon him all the
while he was reading that excellent piece. I then,"
he continues, "applied myself to the study of sev-
eral authors who have written upon phthisical dis-
tempers, and by that means fell into a consumption,
till at length, growing very fat, I was, in a man-
ner, shamed out of that imagination. Not long
after this I found in myself all the symptoms of
the gout, except pain, but was cured of it by a
treatise upon the gravel, written by a very in-
genious author, who (as it is usual to convert one
distemper into another) eased me of the gout by
giving me the stone."
If the imagination produced only temporary
functional disturbances its effects would be of lit-
tle importance, but there can he no doubt that long
continued interference with function, and even or-
ganic changes sometimes result.
Dr. J. M. Buckley says tliat "so long ago as the
time of John Hunter it was established by a va-
riety of experiments and by his own experience
that concentration of attention upon any ])art of the
human system affected first the sensations, then
produced a change in the circulation, next a modi-
fication of nutrition, and finally a change in struc-
ture."
Not only has the imagiiiafioii a powerful influ-
ence over sensation and organic function, both vol-
untary and involuntary, but the intellect, the emo-
tions and the will have, or may have, an influence
qtiite as potent.
Indeed is it not true that thought, either con-
scious or unconscious, precedes and gives direction
and character to bodily function ?
There may be no immediate result growing out
of disregard, first in thought, then in act, of the
laws of health, but sooiicr or later so called involun-
tary bodily functions w ill suffer as a consequence.
The title of a recent book, JVhy the Mind has
a Body, suggests an important truth of which
we sometimes lose sight, aamely, that the intangi-
ble something, which for want of a better name we
call mind and spirit, is deserving of first and most
important place in all our estimates of man as man.
I am not in the least in sympathy with Mrs.
Eddy and the so called Christian science princi-
ples which she so zealously advocates. Indeed, it
has always seemed to me that her teachings con-
tained little of Christianity and less of science and
have resulted in incalculable harm. The same in-
dictment might be brought against the "new
thoughters" in general. If a little knowledge is a
dangerous thing and the danger is in proportion to
the littleness of the knowledge manifested, then
they are indeed a dangerous company. Truth must
be considered in its relationship to other truths,
and with due regard to its relative importance,
otherwise it may be so distorted and overworked
as to lose its fair character and pose as a legitimate
offspring of the father of lies himself.
It is profoundly true that mental attitude has
much to do with bodily function and is capable of
producing changes in nutrition and secretion. We
may go a step farther and say that healthful and
hopeful habits of thought do much to put the body
on the defensive against the assaults of disease, but
to give absent treatment instead of antitoxine to
a case of diphtheria or to treat cancer with the
assurance that all is well, is fanatical, if not homi-
cidal.
No one will deny the superiority of mind over
matter. No one will gainsay the assertion that
mind and spirit are or should be the controlling ele-
ments in the maketip of any human being. But to
ignore, in our present state of existence, the physi-
cal in man is to cast reason and common sense to
the winds and substitute an idealism, the adoption
of which leads to results and conditions which are
anything but ideal.
Having made clear, as I hope, my position in re-
gard to the so called "new thoughters" in general,
and the so called Christian scientists in particular,
I beg to assert the belief that as physicians we give
584
SHOEMAKER: VACCINES OF STAPHYLOCOCCI.
[New York
Medical Journal.
too little attention to the subject of psychotherapy.
I do not refer to the employment of hypnotic sug-
gestion, which, it seems to me, has a very limited
field of usefulness as a therapeutic resource, but to
the practical application of the plain, common sense
fact that right thinking, a normal, healthful men-
tal state or attitude, is conducive to continued
bodily health and a potent remedial agent when
bodily health is below the normal standard. I wish
to place emphasis on the fact that just as bodily
attitude does not mean the position of the head or
an arm, but of the body as a whole, so mental at-
titude refers, not to the will or the emotions, but to
the mind in its entirety. What is the trend of a
man's thought? Can he use his intellect and as
a rule reach conclusions which are definite and rea-
sonable? Are his emotions and imagination under
control and is his volition strong? Has he an ob-
ject in life and some sense of personal responsibil-
ity or is he aimlessly drifting? These are ques-
tions which have a distinct bearing upon the bodily
function and health of any individual. No doubt
the subject has been brought into disrepute
through the mistaken zeal of faddists, but the sci-
entific man should not be prejudiced against or fail
to recognize the importance of truth simply because
it has been distorted and mixed up with error.
The alienist would be but poorly equipped for the
treatment of diseases of the mind if he had no
knowledge of the structure and function of the
bodily organs. Is it not equally important that the
physician in general practice should be conversant
with the phenomena of normal and abnormal men-
tal processes and their relationship to bodily func-
tion ? To this end it would seem that psychology and
psychotherapy should be given a place in the cur-
riculum of our medical colleges.
An intelligent recognition and application of the
principles involved in the relationship of mind and
body is, I am convinced, of great value in the scien-
tific treatment of disease. It is not so easy as to pre-
scribe veronal and valerian, but more lasting results
may be looked for. Moveover, the patient who has
been taught something regarding the importance of
mental attitude in its relationship to health will be
less in danger of a repetition of his present pain-
ful experience, and preventive measures nutst al-
ways be regarded, both from a scientific and from
a philanthropic standpoint, a long step in advance
of those which are palliative or curative only.
BACTERIAL VACCINES OF STAPHYLOCOCCI
STAINS, A TECHNIQUE FOR THEIR
PREPARATIONS.*
By H.'VRL.iiN Shoem.\ker, A. B., M. D.,
Philadelphia.
I have been enabled to make the following ob-
servations while at work on the immunization of
cases of furunculosis, acne, and- sycosis in Pro-
fessor J. F. Schamberg's clinic for diseases of the
skin held at the Polyclinic Hospital. The work has
been done in the laboratories attached to the hos-
pital with the kind permission of the registrar, Miss
Kirkbride.
•Read at a meeting of the Pathological Socictv of Pliilacklphia,
January 9, 1908.
The experimental evidence of phagocytosis by
Metchnikoff and of bacteriolysis by Pfeiffer as a
chain in the mechanism of immunity has been elab-
orated by the French and German schools; and
Wright and his followers have placed the former
theory well before the profession.
It is my pleasure to bring before this society for
discussion a statement, as to the effects produced by
the application of heat upon the bacterial body, as
to degree of intensity, duration of exposure, and
the relation this bears to the immunity conferred
by inoculations of bacterial suspensions so pre-
pared.
A number of the workers in this country and
abroad have dismissed this subject with a word.
They allege that their bacterial suspensions are
"killed cultures" rendered incapable of further
propagation.
Sir Almoth E. Wright {Lancet, 1902) first kill-
ed his cultures at 149° F. for twenty minutes. One
patient, of a series of six reported in this paper,
developed a localized inflammatory reaction at the
point of inoculation. Wright asserts that this re-
sult occurred from staphylococcic matter already
in the system of the patient, while all six patients
showed evidence of pronounced local reaction, as
well as constitutional symptoms. Subsequently
Wright {Proceedings of the Royal Society of Lon-
don, July 26, 1904, p. 154) evidently found it neces-
sary to keep the suspension of bacteria in the in-
cubator twenty-four hours after heating at 140° F.
for thirty minutes. The suspension is then cultured
and at the same time enumerated. Twenty-five to
seventy-five million bacteria are used. Should the
culture media show evidence of bacterial growth,
the technique is repeated imtil the organisms have
lost their power of further multiplication.
E. H. Schordor, of the Rockefeller Institute,
makes a reference to the use of killed cultures of
streptococci, employing twenty-five to one hundred
million in number. Dr. Simon, of Baltimore {Ex-
perimental Medicine, September 21, 1907), in a
paper read before the Association of American
Physicians last assembled in Washington. D. C.
makes the most remarkable statement that he can
see no difference in the reaction of a patient to his
vaccine whether twenty-five millon or a million mil-
lion staphylococci are given. . And Wright and
Reed, when emplo}ing the colon bacillus for im-
munization in cases of cystitis, make use of a ster-
ilized vaccine containing two hundred million or-
ganisms.
Since we find such a variety of ideas and con-
clusions among the workers, apparently the elab-
orate experiments in immunity present the only
analogy to the effects of heat on a bacterial body.
Here one is confronted by a great diversity of
terminology, and finds, on the other hand, a mar-
vellous unanimity of results.
Regarding the various theories elaborated from
the standpoint of temperature alone, there has been
found in the blood a thcrmostabile substance at
140° F., and a thermolabile substance at the same
temperature. Ehrlich and the German school ex-
press an amboceptor stabile at 140° F.. and a com-
plement labile at 140" F. liortlet and the I'-rcnch
school designate their thcrmostabile and tlier-
Marcii 28, 19.8.J
SHOEMAKER: VACCINES OF STAPHYLOCOCCI.
585
molabile products as A'xatcur and substance seitsi-
bilisatricc respectively.
Bordet {Annalcs dc I'liistitiit Pasteur, xii, 10)
has recently shown the analogy between hjemo-
lysins and bacteriolysins. Both substances are
thermolabile, and if they be destroyed by heat the
serum will still be found to contain a thermostabile
substance, which has the power of agglutinating
either the blood corpuscles or the bacteria as the
case may be. This substance of a thermostabile
nature in the serum he terms 3 iixatcur.
Wright and his followers determine an incitor
stabile at 140° F. and an opsonin labile at the same
temperature. Wright {Proceedings of the Royal
Society of Loudon, Ixxvii, Series B) invents the
term incitor to explain the phenomena of phago-
cytosis of bacteria by washed leucocytes in the
presence of blood serum which has been heated for
ten minutes at 140° F. Although the opsonin has
been removed from the serum by heating, there yet
remains a substance of a thermostabile quality which
unites with the bodies of the bacteria. They are
rendered capable of phagocytosis by the incitor
without the presence of opsonin or any other ther-
molabile product in the serum. Wright does not
admit the presence of any new body in the blood
serum, notwithstanding his use of the term incitor,
and alleges that the thermostabile substance does
not exist, there being instead but an opsonin at-
tenuated by heat, thereby disprovirfg any possibility
of spontaneous phagocytosis.
Dean (Proceedings of the Royal Society of Lou-
don, July 8, 1905, Series B) produced an active
phagocytosis of bacteria specially treated, in which
the presence of an immune serum was displaced by
a physiological salt solution. The bacteria used in
the experiment were centrifuged through a heated
immune serum, and thoroughly washed frpe of the
serum before being used. It was found \that the
organisms selected something from the immune
serum which rendered them capable of being en-
gulfed by the white blood cell. This scrum is quite
incapable of producing phagocytosis in the usual
way with the species of bacteria used, although it
is active in opsonizing any other species of bac-
teria.
Two years later Cowie and Chapin (Journal of
Medical Research, xii. No. i, 1907), in experiments
similar to those of Dean, and independent of any
knowledge of his work, arrived at the same conclu-
sions, and Wright (Lancet, November 2, 1907)
adds a beautiful confirmatory analogy to this work
when he demonstrates the dififcrence between the
opsonic power in the normal blood serum and in
the serum obtained from the focus of infection. The
latter is very deficient in opsonin.
Regardless of the attempts of the German school
to explain immunity by a multiplicity and speci-
ficity of each Amboceptor and Couipleincut, or
those of the French school to confine all serum re-
actions to a duplex role, the various experiments
conform alike to heat exposures. Wright does not
accept this, although he readily admits the modi-
fication of the blood serum by heat, while, judged
by the variety of their terminology, his technique
in the hands of competent observers in this country
and abroad shows opsonin to hold the same rela-
tions to temperature as those which are expressed
in their experiments.
Substances in Substances in
blood serum blood serum
thermostabile at thermolabile ?t
140° F. 140° F.
Ehrlich and the German
school amboceptor complement
Bordet and the French
school fixature substance
sensibilisatrice
Wright and tlic English
school incitor opsonin
Summary of Observations.
(a) Opsonin in the serum is modified by heat.
(b) Bacteria are incited to phagocytosis by serum
from which the opsonin has been removed by heat.
(c) Bacteria unite with a substance in heated
serum which prepares them for phagocytosis.
(d) Bacteria remove a substance from the serum
collected at the foci of infection which reduces the
opsonizing power of this serum for this species and
no other below that of the patient's blood serum.
These observations deduced from actual experi-
mentation do not prove the presence of a thermo-
stabile and a thermolabile substance in the bacterial
body, but they suggest it. The bacterial bod\- dif-
fers from the blood serum, perhaps, in the molecu-
lar arrangement of its elements and in its inherent
ability to reproduce itself. This difference presents
a step from an unorganized organic substance in
the serum toward an organized organic substance
in the bacteria.
In the spring of 1907 Gildersleeve, of the Uni-
versity .of Pennsylvania, successfully inoculated
two cases of sycosis in the clinic. Both patients
had constitutional and well marked local reactions.
An abscess developed at the site of inoculation in
the second case, while only a cellulitis appeared
upon incision of the local tumefaction in the first
case. Both patients recovered completely from the
sycosis.
When I first prepared a vaccine, taking 176° F.
as the thermal death point of the staphylococcic
strains, the constitutional reaction upon inoculation
was mild. No local reaction occurred at the site
of injection, and very little activity was demon-
strable by Wright's method of estimating the pha-
gocytic power of the blood. In all sixteen cases
were determined. In these the failure of Wright's
method to yield results was attributed to poor
technique and insufficient experience.
Subsequently, during the preparation of a vac-
cine for the use of the clinic, the water bath in
which the cultures were killed attained a tempera-
ture of 194° F. One of the vaccines in this brew
was used upon a physician suffering with furuncu-
losis. Forty million staphylococci at 176° F. had
caused him some symptoms of constitutional reac-
tion, such as thirst and restlessness at night, accom-
panied by irregular fluctuations in the opsonic in-
dex; 0.75 to 1.3 were noted. If previous inocula-
tions of bacterial suspensions prepared at 176° F.
were insignificant and but mildly effective, one at
194° F. would do no harm. This vaccine contained
four hundred million staphylococci. According to
the patient, who was a competent observer, this in-
586
SHOEMAKER: VACCINES OF STAPHYLOCOCCI.
[New York
Medical Journal.
ociilation produced no more clinical effect than the
injection of so much coagulated egg albumen;
neither did the opsonic index fluctuate, but re-
mained at O.8.
This shows how it might be possible for Dr.
Simon, or any one for that matter, to give in a sus-
pension a million million bacteria, subcutaneously
inoculated, without untoward effect.
Now began a gradual reduction in the tempera-
ture applied to the water bath. The inoculation of
a bacterial suspension, heated at 158° F. for one
half hour, gave evidence of fluctuation in the pha-
gocytic index ; at 149° F. for half an hour, pro-
duced more pronounced constitutional symptoms ;
at 140° F. the cultures had to be maintained in the
water bath one hour before the thermal death point
inhibiting the reproduction of the species was
reached. Upon inoculation with this suspension a
violent constitutional reaction was observed. Three
strong men who had received injections not only
felt feverish and restless the next day, but remained
in bed more or less prostrated. Only a few phago-
cytic counts were made in these cases. They
showed that the positive and negative phases in
Wright's experiments were well marked by a
fluctuation from 0.5 to 3.5, i.o being the normal or
control index.
W'e see that the clinical reaction and laboratory
phenomena exhibit an increased intensity as the
temperature applied to the bacterial suspensions is
reduced. The duration of the application of heat
is also an element to be considerecl.
Further reduction of the tem])crature to 138.2°
F. and then to 136.4° F., used in the preparation of
the vaccines, was followed by disastrous results.
Five people were unconsciously inoculated with
living cultures of bacieria, of autogenous strains,
twenty to forty million strong, pasteurized for one
hour at 13O.4" 1'". All were attacked with a local
tumefaction of brawny induration, with a sensation
of deep fluctuation in each case. In three of these
cases the local reaction disappeared, while two pa-
tients were attacked with an abscess at the site of
inoculation. One of the latter showed a pronounced
rise and then a depression of the phagocytic count ;
the other, at two different readings of several days'
interval, exhibited a continued depression of the
phagocytic power of the blood. .A. third patient of
this series, having relapsed clinically, was reinocu-
lated with a bacterial suspension treated in a water
bath for one hour to 138.2° F. A small abscess
developed at the site of injection. One reading
subsequent to the evacuation of the abscess showed
a ver\ high ind(!x. From all three patients there
was recovered the same organism which had been
introduced.
The following is a technicjue recommended for
the purpose of producing the highest "positive
phase" of Wright: Prepare, 1, sterilized glass
pipettes : 2, sterilized test tubes, each containing
small glass beads or sand ; 3, a twenty-four hour
culture of bacteria of autogenous strain (not neces-
sarily a pure strain) on a nutrient agar slant; 4. a
sterile salt solution, 0.85 per cent., .sodium chloride ;
5. a water bath ; and, 6, a thermometer.
With a sterile gum attached to the pipette, draw
up about I c.c. of the salt solution. This solution
is played over the surface of the agar slant culture
media until the tvvent>-four hour old growth of
bacteria has been washed free from its surface.
The bacterial suspension is then drawn up into
the pipette and immediately transferred to the test
tube containing the glass beads. The tube is now
stoppered with its cotton plug and agitated freely
in order to disintegrate the colonies and clumps of
bacteria. Having previously heated the water bath
to the desired temperature the bacterial suspension
is inserted into it. The surface of the water in
the bath should be above that of the salt solution
containing the suspended bacteria, or, better still,
if the vaccine is sealed in a glass receptacle, com-
plete submersion in the bath is desirable. The
thermometer should be kept in the bath under the
same relative conditions as those surrounding the
bacteria. For example, the bacteria being in a cer-
tain quantity of solution in a test tube, the ther-
mometer should also be similarly placed. Both
tubes should then be kept in the closest contact in
the water bath. A temperature of 136.4° F. to
138.2° F., or the lowest possible point required to
destroy the reproductive activity of the germ, is
maintained for one hour. It is then subcultured
and enumerated, when the suspensions are placed
in the incubator at 98.6° F. for the remaining
twenty-three hours. Prior to a repetition of this
technique, which is advised for at least three suc-
cessive days, a daily subculture following the pas-
teurization is made from the bacterial suspension.
If at the end of the fourth day there is no growth
upon the subcultures, and especially the last one,
the vaccine may be used for subcutaneous inocula-
tion.
A suspension containing five to ten million of
bacteria, prepared at this low temperature, is equal
to a four hundred million bacterial suspension pre-
pared at a higher temperature.
At some point, between the temperature neces-
sary for greatest bacterial growth and that for re-
productive death of the, germ, lies a substance
which is active in producing immunity. This sub-
stance may be entirely inactivated by heat, or it may
evidence marked activity just above the degree of
temperature where the reproductive powers of the
organisms cease.
The ultimate chemistry of the i)rotei(l lx)dy re-
mains for the future. Our object is a bacterial pro-
duct of efificiency which may be injected with im-
punitv. Perhaps this problem may best be solved
without heat at all. Digestion by an active ferment
and precipitation of the globulins, albumoses, and
other cleaveage products of the bacterial body will
help to elucidate this subject. ( Holliburton, Pro-
ceedings of the Pathological Society of London.
Ivi, p.^158, 1905.)
When we consider that every surgical wound
made for the relief of infected i)arts gives rise to
inoculation of living bacteria and their products,
uncontrolled and unlimited ; that every massage,
active or passive, of diseased areas produces much
the same result with absorption of fixed tissue cells
and tissue juices in addition, there may be some
extenuation for these unusual experiments.
March 28. 1908.]
SWEENY: ANIMAL THERAPY IN TUBERCULOSIS.
587
Conclusions.
A thermolabile and a thermostabile substance is
found in the bodies of the staphylococcic strains of
bacteria, which substances, in the organic bacterial
bodies, are of the nature of an amboceptor and a
complement.
The activity of the thermolabile moiety of the
bacterial body varies, inversely, as the degree of
heat and its time of application.
1618 Spruce Street.
THE INFLUENCE OF ANIMAL THERAPY UPON
THE OPSONIC INDEX IN TUBERCULOSIS.
By Gilliford B. Sweeny, M. D.,
Pittsburgh, Pa.,
Formerly of the Pasteur Institute, Paris.
In an article recently published in the Nezv York
Medical Journal' the clinical results obtained in tu-
berculous patients, following the administration of a
lymph derived from the bullock, which had previous-
ly been rendered immune to tuberculosis, were de-
scribed.
It is the purpose of this paper to briefly describe
the influence of this treatment upon the opsonic
index.
While Wright, Metchnikoff, Ehrlich, Neufeld, an.l
other scientists differ in their opinions as to the
sources whence the defensive properties of the blond
are derived, upon this point they all agree, that
phagocytic activity follows any manifestly stimulat-
ing influence, however exerted, upon the blood.
Also that the ability to withstand or overcome in-
fectious processes is proportionate to the\ degree of
this activity. \
We shall not describe the technique of obtaining
the opsonic index, as this is available in theXlitera-
ture.
The following five cases were carefully selected
from a larger list of fifty-two patients treated, in
which systematic observations of opsonic indices
were recorded every thirty davs. All the cases de-
scribed are among those in which tuberculous ba-
cilli were found in one or more of the secretions.
C.\SE I. — Male, aged twenty-two year.s, bookkeeper by
profession. After losing in weight and vigor for four
months applied for treatment. Patient was very anaemic.
Temperature in morning subnormal, in evening 99.5° to
100.5° F- Respiration was shallow and hurried. There
was a moderate cough, with mucopurulent expectoration.
Pleuritic pains were present upon left side of thorax.
Marked dulness over upper lobe of left lung, with moist
rales. Right lung was not perceptibly involved. Tubercle
bacilli were found in sputum. Opsonic index 0.76. Patient
had ID minims antituherculous lymph daily, omitting every
seventh day for thirty days. At the end of that time morn-
ing temperature was very slightly * subnormal or normal.
Evening temperature did not exceed 99.5°. Opsonic index
0.84. Decrease in amount of expectoration and number of
bacilli present. Anaemia was less marked, and general nu-
trition was much improved. Opsonic readings at the end
of sixty and ninety days' treatment showed 0.91 and 0.97
respectively, with corresponding improvement in all symp
toms. A fourth month's treatment was administered, the
opsonic index remaining at 0.97. Patient was allowed to
return to work as solicitor for his firm, spending most of
time out of doors. Observation made sixty days later showed
opsonic index still 0.97. General condition of patient was
very good.
C.\SE II. — Married woman, age twenty-six years. Brother
•Animal Therapy in Tuberculosis. New York Medical Journal,
December 7, 1907.
died at same age of phthisis florida. Patient had diarrhoea
with severe abdominal pains. Mesenteric glands were per-
ceptibly enlarged. Tubercle bacilli were abundant in faeces.
There was no perceptible pulmonary in\ olvement. Tempera-
ture varied from subnormal morning to 101° F. evening.
Pulse 95 to no. Patient suffered from insomnia. Appe-
tite was capricious. During three months indisposition
patient lost hfteen pounds. Opsonic index 0.82.
Daily injections of antituherculous lymph were used for
three months. A normal temperature was gradually ap-
pro.\imated and maintained after two months' treatment.
Diarrhoea disappeared entirely before the end of treatment,
decreasing doses of Epsom salts being administered daily
until dose was infinitely small, and then discontinued. Op-
sonic index at end of first month was 0.95. Second read-
ing one month later showed 1.02. Final observation made
innnediately after treatment was discontinued showed op-
sonic index 0.985. Later observation could not be made
owing to patient's moving to a neighboring state, but she
reported continued improvement.
Case III. — Patient was a boy, seventeen years old. Sev-
eral inembers of his mother's family had died of pulmonary
phthisis. Patient applied for treatment for "chronic sore
throat." Voice was clear and full, left tonsil much en-
larged, with ulcer covering one fourth its surface. Cervi-
cal lymphatics were enlarged, especially on left side. Pa-
tient complained of pain under sternum, during deep in-
spiration. There was diffused infiltration over both upper
lobes. Expectoration was scanty and showed no tuber-
cle bacilli. The tonsillar ulcer was curetted and examina-
tion showed tubercle bacilli in large numbers. This boy
had lost probably ten pounds in weight. Temperature
readings showed slight evening rise. Opsonic index 0.89.
Antituherculous lymph administered for three inonths.
Tonsillar ulcer treated with x ray through a tube. Tlie
cervical glands, as well as anterior aspect of the thorax,
were also rayed every third day during first half of
treatment. At the end of this time the tuberculous ulcer
had entirely disappeared and the patient complained of no
pharyngeal or other discomfort. Improvement in vigor
and weight was gradual but continuous. Opsonic readings
at end of each month's treatment showed 0.95, 0.92, and
0.985 respectively. Observation inade two months later
showed 0.975. Patient's condition is seemingly normal.
C.\SE IV. — Patient, single woman, thirty-three years of
age, of distinctly anaemic type, presented herself for treat-
ment, complaining of extreme bodily weakness. There was
a marked hepatization of upper half of left lung, with
scanty expectoration, showing limited number of tubercle
bacilli. Temperature seldom subnormal and frequently run-
ning 103° in the evening, with rapid pulse. Opsonic index
0.68.
Antituherculous lymph was administered for four months,
10 ininims daily, omitting every seventh day. Collateral
treatment, which seemed suited to the exigencies of the
case, was also instituted. This case is of interest chiefly
because at no time during treatment did there seem to be
the slightest improvement. The temperature was not re-
duced and the opsonic index readings remained practically
the same for some time, while the lung involvement and
emaciation increased. At the present time, two months
since treatment was discontinued, the patient is bedfast and
failing rapidly.
C.-\SE V. — Patient was a bright boy of fifteen years. Tu-
berculosis of hip joint, following similar attack four years
previous, involving the same joint. Temperature, pain, and
swelling were characteristic. Pus from a discharging sinus
contained tubercle bacilli in abundance. Temperature was
slightly above normal. Opsonic index 0.92. No appreciable
lung involvement. An extension apparatus was applied, pa-
tient being confined to bed for four weeks, after which he
was allowed to go about, continuing to wear the regulation
apparatus during the three months that antituherculous
lymph was administered. The results in this case w ere dra-
matic. The opsonic index at the end of first month was 0.975.
One month later 1.2, and at the end of third month 0.985.
The patient was the possessor of a voracious appetite, which
it was next to impossible to satisfy or control. Three
months have elapsed since treatment was discontinued.
Patient walks with a cane without apparent discomfort.
The sinus has entirely closed, and patient has gained per-
ceptibly in weight.
For my own part I am strongly disposed to at-
tribute the benefits observed in these cases as much
588
BIERHOFF: EXAMINATION OF BLADDER.
[New York
Medical Journal.
to the invigorating influence of the lymph upon the
phagocytes as to its specific antitoxic action upon
the tuberculous bacilli.
Tn my monograph" upon this subject, among other
preliminary propositions laid down, is the follow-
ing: "Tuberculous infection takes place in the hu-
man subject only when the normal ratio of resist-
ance is lacking or disturbed." I am fully convinced
.that a defensive attitude upon the part of the human
organism towards infectious agents can be estab-
lished and maintained only through influences ex-
erted upon the living, active cell. It is true that this
view of the subject has not been particularly popr.-
lar during the past year. It will be interesting to
the reader to know the present attitude of Professor
j\Ietchnikof¥, the leading exponent of the doctrine
of phagocytic defense, upon the subject. In a per-
sonal letter, received very recently, he writes :
"I see no reason for in'odifying my views upon this sub-
ject, as expressed in my essay upon Hygiene of ^ the Tis-
sues.^ There can be no doubt that, under artificial condi-
tions and outside the body, the phagocytes are weakened,
and cannot show their functional activity to such advantage
as inside the body. It is therefore quite natural that under
such unfavorable conditions the phagocytes more readily
attack the microbes already impregnated with preparatory
substances than the quite intact microbes. When they
have been deprived of this favoring influence the phagocytes
can only fulfil their duties with more or less delay. That
is exactly, in reality, what takes place. Left to themselves
in a liquid, deprived of all opsonic substances, the phago-
cytes nevertheless surround the microbes ; only instead of
doing this in a quarter of an hour, it takes them longer,
perhaps an hour to two. In the experiments conducted by
Dr. Lohlein, of Leipzig, who was at that time working in
my laboratory, it was proved that the absorption of the
bacilli by the phagocytes often occurred quite as early in
normal saline solution as in the sera, and thus the im-
portance of the opsonins is still further diminished. I do
not wish, however, to depreciate the utility of the opsonic
index in determining the defensive resources of the blood.
For this purpose it is invaluable, and it is to be deplored
that the difificulties encountered in rendering it available
to the general profession are so great."
I wish to express mv thanks to Dr. Edward T.
Smith, of Bufifalo, N. Y. ; Dr. H. G. Walcott, of
Dallas, Tex., and Dr. T. E. Courtney, of Indian-
apolis, Ind., who rendered me valuable assistance in
making systematic observations upon the work
which I have briefly described above.
519 Smith Block.
THE NEWER METHODS OF EXAMINING THE
BLADDER.*
By Frederic Bierhoff, M. D.,
New York,
Attending Surgeon, Urological Department, German Dispensary; .At-
tending Surgeon, Department of Genitourinary Diseases,
West Side German D ispensary; Fellow, New York
Academy of Medicine; Corresponding Mem-
ber of I'Association Fran<;aise d'Urologie.
The methods of examination of the bladder which
are at our disposal are : Inspection, percussion, pal-
pation, exploration with the sound, exploration with
the catheter, digital exploration, exploratory inci-
sion, examination by the x ray, and examination by
direct illumination.
Of these methods all, with the exception of
''Animal Therapy, its Relation to Immunity, in the Treatment of
Tuberculosis. 1907.
•Translated by E. R. Lankaster. Harbcn Lecture before tbe
Royal Institute of Public Health. 1906.
•f{cad, by invitation, before tlie Greater Xew York Medical .Asso-
ciation on January 20, tgoS.
examination by the x ray and examination by
direct illumination, have been in use for a great
many years, and give us comparatively little, and
usually unsatisfactory, information concerning dis-
eases of the bladder. The last two mentioned are
the more modern developments in the line of bladder
examination, and of these examination by direct il-
lumination, by means of the cystoscope, is the most
exact and most satisfying. Each, however, of the
methods enumerated gives us some information, and
in order that none may be slighted I shall take them
up in the order named.
Inspection. — This gives us no further inform^ition
than to allow us to know at times — in thin individu-
als, that the bladder is distended. Under such cir-
cumstances we may, when the bladder is full, notice
the elliptical or oval prominence in the hypogastric
region, which reveals to us the presence of a dis-
tended bladder.
Percussion. — This method makes it possible for
us to determine the degree of distention of the blad-
der by revealing to us the presence of an area of
dullness in the hypogastric region. It is not positive
either. Intestines, distended with gas, may overlie
the bladder and interfere with the perception of dull-
ness, or, if distended with fjeces, may simulate a dis-
tended bladder.
Palpation. — Palpation may be performed by either
the simple or combined (or bimanual) method. It
gives us more information than the previously men-
tioned methods. By the simple meth.od, perfonned
by the use of both hands upon the surface of the ab-
domen, we may make out the form of the bladder,
its degree of distention, the character of the bladder
wall with regard to irregularities, and its degree of
sensitiveness. In thin individuals it is sometimes
possible to determine the presence of calculi, if large,
particularly in children. We may also, at times,
diagnosticate the presence of pericystitis and para-
cystitis. It should be carried out with the patient
lying upon the back, the shoulders being slightly
raised, and the knees and hips flexed and properly
supported. The bimanual tnethod of palpation is
carried out with the patient in the same position as
for simple palpation, one hand examining the abdo-
men, and one or two fingers of the other hand being
passed into the rectum, or vagina. This method is
best carried out with an einpty bladder. By means
of it we may diagnosticate prostatic hypertrophy,
hard tumors of the bladder wall, calculi, and decided
infiltrations of the vesical wall. In females we may
also diagnosticate vesicovaginal fistuhe.
Exploration xi*;//; the Sound, or Searcher. — This
examination should be carried out with the patient
in the same position as in the former methods, and
the bladder should contain a moderate amount of
fluid. The sounds used may be either of metal, or
of elastic material — rubber or silk or linen weave —
covered with an elastic mass. The stone searchers
are of various familiar models. It is assumed that
the readers know all about the indications and con-
traindications for tlie passage of instruments, as well
as the proper method of passing these. The beak of
the instrument must enter into the bladder cavity,
and the investigator must assure himself, before pro-
ceeding further, that it is freely movable in all direc-
tions. He may then measure the size of the bladder
March 28. igoS.l
BIERHOFF: EXAMINATION OF BLADDER.
589
by pushing forward the searcher in the middle line
until it is arrested, and then noting the distance be-
tween this point and the bladder outlet. The sensi-
bility of the bladder wall may also be noted. In
some spinal diseases, notably locomotor ataxia, the
vesical wall is singularly aneesthetic. In cases of
ulceration it is very sensitive. The character of the
bladder wall must also be noted — whether smooth,
or rough, as in columnar bladder. It is also possi-
ble, with the sound or searcher, to palpate the pro-
trusion of an enlarged prostate. Foreign bodies may
be discovered by means of the sensation imparted to
the instrument. It is often, but not always, possible,
in cases of stone, when using a metallic instrument,
to get a distinct click. When using an elastic in-
strument it. however, often occurs that a sensation
as of the catheter's grating upon a foreign body is
experienced, which, upon investigation, proves to
have been due only to the spasmodic gripping of the
catheter by the sphincter muscle. Experts in the
use of the searcher, or lithotrite, may even deter-
mine the presence of multiple calculi by using the
lithotrite and seizing the stones separately. In some
children, too small for the use of the cystoscope. a
small metallic catheter may be used as a searcher.
The use of the sound, or searcher, leaves us entirely
in the lurch in determining the presence or absence
of tumors.
Exploration zvith the Catheter. — The chief use of
this method is in determining the power of the blad-
der to fully empty itself, and in measuring the
amount of residual urine. It is of value in cases of
retention, suspected to be of prostatic origin, in
w^hich there is no hypertrophy palpable pbt; rectum,
and particularly in the examination of casesNof sus-
pected tabes, where. in_the absence of any discover-
able organic obstruction in the urethra or bladder,
the patient has a large amount of residual urine,
with a perfectly capable detrusor. I have been able
to make the diagnosis of tabes in the early stage, in
a number of instances, through the discovery of
large amounts of residual urine in the absence of or-
ganic obstruction of the urethra. This diagnosis
should, however, never be made without the corrob-
oration of cystoscopy. The catheter is also of value
in determining the amount of intravesical pressure.
Digital Exploration. — This may be of value in
women. In such cases preliminary dilatation of the
urethra is necessary. It is possible, by means of
this method, to explore the interior of the bladder,
and to determine the presence of foreign bodies or
calculi, and the presence of tumors, if large. It is
very unsatisfactory, however, in all cases except the
determination of foreign bodies.
Exploratory Incision. — By means of the supra-
pubic incision it is possible to get a clear view of the
entire interior of the bladder. Owing to the nature
of the operation, however, it should never be em-
ployed until a satisfactory cystoscopic examination
proves to be an impossibilitv.
The X Ray. — By means of this we arc able to de-
termine, when employed by a competent operator,
the presence of foreign bodies and of calculi, in
some instances. After filling the bladder with a ten
per cent, bismuth mixture in water, we are also en-
abled to discover sacculations or lobulations. It is.
however, of no value in the determination of inflam-
matory conditions, new growths, etc.
All of these methods, however, when all is said
and done, are uncertain and unsatisfactory, with the
exception of the exploratory incision, and this is a
procedure of so grave a nature that, as stated before,
it should onlv be emploved when all other methods
fail.
Cystoscopy — The certain method of examination
of the bladder is, and must remain, the method of
direct illumination, by means of the cystoscope, for
no other method gives us so much information as
this. Where any stiff instrument can be passed at
all into the bladder, the cystoscope may be employed.
I have examined with it children as young as four
years, and I feel confident that, were the need to
arise, I should be able to examine even younger chil-
dren with it. While cystoscopy is not free from dan-
gers, particularly in the hands of inexperienced or
careless operators, it offers, w'hen properly and c?.re-
fully employed, the minimum of danger and the
maximum of utility.
There are two methods of examination — or rather
two types of instruments — those for direct vision and
those for indirect. The instruments of the direct
vision type are all modifications of the principle first
laid down by Bozzini. who, in 1806, first proposed a
method for examining the various canals of the bodv
by means of his so called "light carrier." Of the
instruments in use at the present day those of Paw-
lik-Kelly and Brenner, with their modifications, are
the representatives of the direct method. The indi-
rect method is that of Xitze, and the instruments
employed are all modifications of Xitze's original
prismatic cystoscope.
We are all sufficiently familiar with the instru-
ments, so I may pass over the descriptions thereof,
and content myself with the statement that, while
the straight telescopic instruments have the advan-
age that they do not invert the image, they suffer
from the disadvantage that there are parts of the
bladder interior which cannot be seen when such in-
struments are used. By means of the prismatic cys-
toscope, however, every part of the bladder wall
may be brought into the field of vision, and to the
experienced cystoscopist the inversion of the image
forms no obstacle whatever to correct examination
and interpretation. Recently Jacoby, of Berlin, has
devised an attachment which screws on to the ocular
end of the cystoscope, by means of which the invert-
ed image may be restored to its original position.
In other words, the inversion is corrected. The in-
struments of the Pawlik-Kelly type may be dismissed
with few words, ^^'here these instruments may be
used, those of either the straight vision telescopic, or
the prismatic types ma)- be employed, and whereas
the Pawlik-Keily are of utility only in the female,
those of the other two classes mav l)e employed in
both sexes. The knee elbow position, also, required
for the employment of the Pawlik-Kelly cystoscope,
is distasteful to most patients, and uncomfortable to
all ; while, by the employment of the other two types
of instruments, the comfort of the patient is much
more easily possible. Certainly, those females w^ho,
after having been previously subjected to the Paw-
lik-Kelly method, have been cystoscoped by me, by
590
BIERHOFf: EXAMINATION OF BLADDER.
[New York
Medical Journal.
the Nitze method, have invariably expressed a great
preference for the latter.
In order to successfully cystoscope a patient,
whether male or female, there are several conditions
which are requisite. In the first place, the operator
must understand the construction of his instrument
and the accidents to which it is subject. Nothing is
more distressing or disturbing to both operator and
patient than the frequent removal and insertion of
an instrument which has met with some accident.
The instrument must always be thoroughly tested,
both as regards its electrical and its optical appa-
ratus, before it is inserted into the urethra of the
patient, and whatever may be at fault must be reme-
died. Lamps should be tested slightly beyond the
limit at which they are going to be employed, in or-
der that they may be less likely to burn out after in-
sertion into the bladder. The electrical source also
must be examined, in order that there may be no
trouble with this. Either the storage battery, or the
wet cell battery, or the street current, cut down to
the proper strength by means of a controller, may
be employed.
The urethra of the patient to be examined must
allow of the easy passage of the instrument to be
used at the examination. For the examination of
children, the specially small cystoscope, made par-
ticularly for this purpose, should be employed. In-
struments of this type may be had of a calibre as
small as Xo. 14 Charriere, and it is a good plan for
the cystoscopist to have instruments of various cali-
bres. In the presence of stricture of the urethra,
where an immediate examination is not possible with
the use of the smaller sized instruments, which, of
necessity, have a smaller field of vision than the
larger instruments, preliminary dilatation of the
stricture must, of course, be employed. The meatus
may, in males, also have to be enlarged by incision.
In females I have never had any difficulty in exami-
nation, as a result of obstructive urethral conditions.
Another requisite is that the bladder shall be capa-
ble of a sufficient degree of distention to make free
excursion of the beak of the instrument possible. It
has always been my practice to use as large an
amount of filling fluid as the patient would tolerate
with comfort. In males, whenever possible, I em-
ploy 300 c.c. ; in females as much over that as the
patient will tolerate with comfort. In infants I have
had to examine with as little as 50 to 75 c.c, al-
though one is frequently surprised at the degree of
distensibility of the bladder of the infant. Opinions
vary as to the minimum of fluid which may be em-
ployed with safety. I have repeatedly had to cysto-
scope adults with as little as 60 to 75 c.c, although
I must confess that I do this with trepidation. It is
a safe rule to follow that in those cases which do not
tolerate at least 75 to 100 c.c. of fluid, it is wiser to
postpone the cystoscopy until such a time as treat-
ment of the bladder has made such a degree of dis-
tensibility possible. Where vesical sensitiveness is
pronounced, the use of cocaine solution will fre-
quently suffice to make safg distension possible. Only
where an immediate cystoscopy is urgently indicated
should one venture to cystoscope with less than 75
c.c, and then it must be done by interrupting the
illumination at intervals of two to three seconds —
in other words, the light is turned on for from two
to three seconds, and then at once turned ofif, this
manoeuvre being repeated at intervals of about 10
seconds, in order that the lamp may have a chance
to cool off, and cauterization of the bladder wall be
avoided.
The bladder must be filled with a transparent me-
dium, and to this end must be irrigated until the
fluid used to cleanse the bladder returns perfectly
clear. This is, at times, a very tedious process, and
one which taxes the patience of the operator and pa-
tient to the utmost. Any bland, nonirritating fluid
which is perfectly transparent may be employed,
such as sterilized water, or sterilized normal saline
solution, boric acid solution, oxycyanate of mercury,
etc. It is a matter of great importance to have the
fluid perfectly clear, for even a slight macroscopic
turbidity may be just enough to render hazy the pic-
tures seen with the cystoscope.
In cleansing the bladder, I have found it of service
to note whether the fluid steadily clears, remains tur-
bid,orclears andthen suddenly again becomes turbid.
If it steadily clears the operator need only persevere
in the simple cleansing. Should it remain steadily
turbid with blood, then it is wise, at times, to post-
pone the further irrigation and examination until
after the employment, for a time, of a solution of
adrenalin chloride. I have found this of great value
in checking the haemorrhage from vesical ulcers, or
bleeding tumors. Where the fluid clears temporari-
ly and then again becomes turbid, with either pus or
blood, we are almost certain to have to deal with a
suppurative, or bleeding process, of renal origin. In
cases of this sort I have repeatedly had to examine
with slightly turbid fluid. In such cases it has been
my custom to cleanse, as far as possible, and when
the fluid returned relatively clear, to insert the cysto-
scope and examine only the ureteral orifices at that
sitting. At a later sitting the examination may be
completed.
Air has also been used to fill the bladder, and has
its supporters still. Most cystoscopists, however,
prefer to fill with a fluid medium.
Another requisite is that the light shall be suffi-
ciently powerful to clearly illuminate the bladder
wall. In my examinations I have been wont to fol-
low the directions given by Nitze, who stated that
the light must be such as to have a dazzling white
brilliancy outside of the bladder, and to be of suffi-
cient strength to penetrate the filling fluid, and clear-
ly and distinctly illuminate the bladder wall. As a
result I have been forced to have stronger lamps
than are usually furnished us in this country con-
structed for me, my lamps requiring 8 volts and 3/2
ampere. These are not of the so called "cold" type,
and must be used with caution, so as not to burn the
bladder wall ; but the degree of illumination possible
by means of them, and the clearness of the picture
obtained with them, are such as to amply repay the
additional care required in their use.
When a cystoscopy is to be performed my method
of procedure is as follows : The patient is instructed
to divest himself or herself of sufficient clothing to
make it possible easily to reach and cleanse the gen-
ital organs. The patient is then placed upon the ex-
amining table in such a position as to give him or
her the greatest possible comfort. I have found
that a fully supine position is not desirable, since the
Mjrch 28, 1908.]
MICHAELIS: OCCIPITOPOSTERIOR POSITIONS.
abdominal muscles are not sufficiently relaxed. The
back rest is, therefore, raised at a slight angle, and
the head and back made comfortable with pillows.
The buttocks are approached as near as possible to
the edge of the table, and the knees and thighs sup-
ported by the knee rests which I have devised. The
thighs are then well separated and the external gen-
itals thoroughly cleansed. The urethral canal is then
irrigated with 'a solution of i in 20,000 bichloride
(about 150 c.c. in amount) and a sterilized catheter
inserted. Where necessary, in the male, the posterior
urethra is anesthetized by the injection into it of a
few c.c. of I per cent, solution of cocaine. In draw-
ing off the urine in the male, I prefer to employ,
where possible, a metallic catheter of about 22
French, since, if this passes easily, there is no longer
any doubt concerning the passage of the cystoscope,
which has a calibre of 21 French. The character of
the urine is determined, as also its turbidity, or clear-
ness. Should the urine be clear I at once proceed
to the filling of the bladder. Should it be cloudy
then the bladder is washed out until the fluid returns
clear. A similar procedure is employed in the fe-
male, except that the ordinary female catheter suf-
fices. The bladder having been distended, the cysto-
scope is now gently inserted. After assuring myself
that the beak is really within the bladder cavity,
which fact may be determined by rotating the in-
strument gently upon its axis, so that the beak is
rotated within the bladder cavity, I proceed, in the
female, to get an idea with regard to the size of the
bladder, by employing the unlighted c}stoscope to
get the measurements of the bladder cavity. T^e
beak of the cystoscope is pushed forward in the mid-
dle line until it is arrested, and the distance between
this point and'the vesical orifice noted. Thereupon I
proceed to inform myself concerning the measure-
ments, in a lateral diagonal direction, and. having de-
termined these measurements, proceed with the ex-
amination. In the male, however, owing to the
greater length of the urethra, these manipulations
are impossible.
A regular routine is of value in the examination
of the bladder. The margin of the sphincter and
its surroundings should first be examined. The up-
per vesical wall comes next. The lateral walls fol-
low upon this, and then the inspection of the poste-
rior wall, and the trigone, as well as the postero-
lateral portions. Last comes the inspection of the
ureteral orifices, and I usually end the examination
b\ watching these orifices to determine the charac-
ter of the urine which is discharged therefrom. We
may, however, particularly where we suspect the
ureters or kidneys, reverse this routine.
By means of the cystoscope we are able to deter-
mine whether the sphincteral margins are normal or
diseased — that is, whether inflammatory changes,
papillomatous formations, or defects, etc., are pres-
ent : whether the bladder wall is the seat, at any
point, of inflammatory conditions, varying in degree
from simple hypersemia to ulcerative, or hjemor-
rhagic changes : whether there are nodules, vesicles,
new growths, diverticula ; whether the bladder cav-
ity is encroached upon by tumors from without :
whether it is the seat of hypertrophied muscles, or
whether it shows the scarlike contractions of peri-
cystitis, or the vesicles of oedema bullosum, which
denote that a perivesical process impedes the circu-
lation in the vesical wall ; whether foreign bodies or
calculi are present ; whether there is prostatic hyper-
troph}- or cystocele ; whether the trigone is normal
or the seat of inflammations or new growths ;
whether the ureteral orifices are both present ;
whether they are normal in location, in shape, in
condition : whether they are singly or both discharg-
ing urine, or blood, or pus ; if foreign bodies are
present or tumors exist, the character and nature of
the foreign body, the size and shape, dnd the prob-
able character of new growths, and of ulcerations.
The iniection of indigo carmine into the buttocks
and the internal administration of methylen blue
have been employed to serve as aids in locating the
ureteral orifices in cases where their location is not
otherwise easy. By their use the injection of a
stream of colored fluid from the ureteral orifice
serves to determine the presence, or absence, of a
ureter, or functionating kidney. Of the two meth-
ods the former is preferable, since its result shows
after a much shorter period of time than is the case
when methylen blue is employed.
Recently there have been devised a cystoscope for
the demonstration of the image to two observers at
the same time, for use in teaching cystoscopy, one
for stereoscopic presentation of the image, and one
for retrograde examination, by means of which
those parts just behind the vesical orifice, or behind
an enlarged prostate, may be examined more easily
and perfectly than is possible with the ordinary ex-
amining instrument.
None of these, however, has a broad field of use-
fulness. The prismatic type of cystoscope, as orig-
inallv presented by Xitze, in 1879, is and will remain
the instrument par excellence for the satisfactory
examination of the bladder.
53 E.\ST FiFTV-KIGHTH StREF.T.
SOME REMARKS ON OCCIPITOPOSTERIOR
POSITIONS.*
By L. M. MiCHAELis, M. D.,
New York.
Recognizing 'the obstetric importance of poste-
rior positions of the occiput, and also the fact that
the older textbooks were much too conservative in
their estimates of the frequency of the occurrence
of this position, the profession has of late years
been pac ing more and more attention to the sub-
ject, as evidenced by the number of papers written
on it, as well as by the interest shown in their dis-
cussion. Because the remarks I am about to make
are the result of personal experience, I venture to
add another paper, even though it be sketchy in
character, to this growing list ; for, to my mind, the
fact cannot be too often reiterated that much ma-
ternal suffering, an^l. at times, danger, and also
much foetal mortality can be avoided by the earl}-
recognition and prompt treatment of this obstetric
annoyance.
\'ery many women have the occiput lying poste-
riorly at the very commencement of labor, but the
position is rectified almost immediately, and hence
these cases do not enter into consideration here.
*Read before the Harlem Medical -Association, February 5, 1908.
50^
MICHAELIS: OCCIPITOPOSTERIOR POSITIONS.
[New York'
Medical Journal.
What the proportion of such cases is I will not
venture to estimate. Let it suffice to state that the
number is unquestionably very large. As for those
in which the diagnosis is made, I find that in my
own practice the number amounts to 30 per cent,
in the last 100 cases which I have had, and I do
not think that my experience diiTers materially
from that of others interested in obstetric work.
We were taught that the reasons for the occiput
being situated posteriorly were disproportion be-
tween passenger and passageway, excess of liquor
amnii, and abnormal mobility of the child. In ad-
dition, I find that either combined with, or caused
by these factors, or very often entirely independent
of them and in their absence, incomplete flexion of
the head is the underlying causative element. This
latter, rather than the others mentioned, has been
the cause in the large majority of my own cases,
and its action in producing the posterior position is
readily understood when one reflects on the im-
proper adjustment of head to pelvis caused there-
by, with the resulting tendency of the occiput to im-
pinge on the posterior pelvic plane, and to be thus
rotated toward the back, where it can more read-
ily accommodate itself.
In many cases the diagnosis is easily made by
examination, for the anterior fontanelle is found
in front, while on palpation of the abdomen the
depression between chin and chest of the child and
the presence of small parts instead of the foetal
back are plainly to be established. The position of
the point of maximum intensity of the foetal heart
sounds further confirms the diagnosis, for it lies
quite off in the flank, well toward the mother's
back. Yet where we find a case in which none of
these points can be made out, where owing either
to slight moulding or 'to a naturally small anterior
fontanelle it is indistinguishable from the posterior,
and where, in addition, the foetal heart is heard in
the usual position for anterior occiput cases, and
where neither depression nor small parts can be
felt through the abdomen, we are apt, on having
the child born looking up into our astonished faces,
to feel deeply the uncertainty of things mundane.
How, then, are we to arrive at a correct diagnosis?
Here the general behavior of the case is of great
assistance to us. In vertex presentations the early
rupture of the membranes speaks for a posterior
occiput in an overwhelming majority of cases.
When this happens in anterior positions it is due
either to excess of liquor amnii or to specially
strong uterine contractions, thus putting an undue
strain on the membranes, or to the fact that the
membranes themselves are inherently weak. In
posterior positions the undue strain is caused by
the maladjustment between head and pelvis, for
thereby neither the uterine contractions nor the re-
sulting intrauterine pressure arc equally distributed,
while at the same time the bag of waters has not
the regular globular shape which it should have
normally. Thus, I always regard with suspicion a
case in which rupture of the membranes precedes
or is synchronous with the onset of labor. Owing
also to the unfavorable mechanical conditions un-
der which the uterus must act, due not only to this
same maladjustment, but to the absence of the wa-
tery wedge as well, dilatation of the os is mark-
edly retarded, the first stage being, as a rule, un-
duly prolonged. This means that the woman suf-
fers more than ordinarily from the trying pains of
the first stage, with the not uncommon result of
more or less complete maternal exhaustion before
the OS is fully dilated. Some observers mention a
decided increase of the pain in the back in these
cases. Personally I have never been able to con-
firm this symptom. Therefore, in the absence of
any other complication, the man who makes the
diagnosis of posterior position of the occiput from
these two symptoms, early rupture of the mem-
branes and slow dilatation, will seldom go far
astray. Of course, if on vaginal examination an ear
can be felt and its position positively learned, the
diagnosis is easily and surely established.
If after full dilatation of the os the position of
the vertex is not rectified, the tardy progress of
labor continues on into the second stage, for the
relation between the head in the posterior occipital
position and the pelvis, and, frequently, an incom-
pletely flexed head as well, is a decidedly unfavor-
able one mechanically. Naturally -this is extremely
apt to lead to further exhaustion on the part of the
mother, and also to danger to the life of the child,
because of the prolonged pressure on the head. In
all cases, since the head is forced down on the
cervix early in labor without the protective inter-
position of the liquor amnii, danger to that part of
the uterus from grinding is greatly increased, while
in those in which the posterior position persists
throughout labor, perineal laceration is the almost
invariable sequel. That there is grave danger of
rupture of the uterus after long continued expul-
sive efforts in cases of impacted posterior occiput
goes without saying, but as my object is to speak
of the ordinary uncomplicated cases of this condi-
tion, I will not enter further into the discussion of
these complicated ones here.
In regard to treatment, our efforts are at first
directed to rectifying the malposition, converting
it, if possible, by both postural and manual meth-
ods into an occipitoanterior position. This happy
outcome is frequently obtained by having the pa-
tient lie on that side of the body toward : which
the occiput is directed. As she does this the fundus
falls forward, to the side, and slightly upward, and
the child's body consequently tends to be flexed on
the head, and at the same time its back is thrown
anteriorly, carrx-ing the occiput with it, while the
head, raised slightly out of the pelvis, can, and fre-
quently does, impinge on the anterior plane during
subsequent uterine contractions, and rotation is
thus promptly and satisfactorily effected. As a
substitute for this position the patient may kneel
on the floor with a pillow under her knees, which
is placed a little distance from the bed on which
she rests her head and arms, while at the same
time she advances the side toward which the occi-
put points somewhat more than the opposite one.
This position acts exactly as does the lateral one,
except that as the angle at which she leans away
from the perpendicular is increased, the fundus is
thrown further forward, augmenting the tendency
to anterior rotation. The drawback to this kneel-
ing posture is its discomfort ; yet even though it is
very uncomfortable for the woman in pain kneel
March 28. 1908. J
DRENXAX: BLOOD CONSERVATISM OF XEUROTICS.
593
at her bedside, it is decidedly preferable to the con-
dition which it tends to obviate. For the matter
of that, the lateral posture is frequently a source
of discomfort to the patients, and I therefore let
them alternate one with the other. The success
of this treatment is marked, and the desired result
is attained in a large number of cases. Unfortu-
nately, this is not true in all. and in those in which
it has failed I then proceed to attempt manual rec-
tification, provided the os is sufficiently dilated to
permit the necessary manipulation — in other words,
that it is at least the size of a quarter of a dollar.
The first step is the attempt to flex the head and
then to keep it flexed during several successive
pains. This in itself is often sufficient to cause an-
terior rotation, as mentioned before. If it is not.
the next step is the effort to rotate the head man-
ually. Two fingers are introduced, and, after the
head is flexed, pressure in an anterior direction is
made by them on the occiput w^ith the object of
bringing it to the front of the pelvis, while at the
same time the other hand is used to assist rotation
through the abdominal wall by pressing the trunk
of the child upward and forward. This is most
often successful when the head is just at or above
the brim : when it is firmly wedged in the pelvis
it is hardly necessary to say that this procedure is
futile, except in very exceptional instances, until
the ischial spines are passed. At this point in the
pelvis, however, rotation is more readily effected
with the forceps than with the hand.
In the presence of maternal or foetal exhaustion
it is necessary to anaesthetize the patient carefully,
complete the dilatation manually if indicated, and
then, after thorough flexion of the head has been
obtained, apply the forceps. It frequently happens
that in the presence of good flexion, the head plus
the forceps will rotate anteriorly ver\- soon after
traction is commenced, provided the application is
made with the head just engaged in the brim.
This, of course, necessitates the removal and read-
justment of the instruments. If anterior rotation
does not occur then, it will, in most cases, when the
ischial spines are passed and the head impinges on
the pelvic floor. Rotary axis traction as described
by ;Marx, in which the deliberate attempt is made
to rotate the head with the forceps while making
traction, is an operation which gives brilliant re-
sults, but it calls not only for operative skill on the
part of the accoucher, but for absolute certainty in
regard to the diagnosis and accurate knowledge of
the mechanism involved as well. In the absence
of these prerequisites it should not be undertaken,
for it is then fraught with danger to the mother
and vastly greater danger to the child.
As for podalic version in preference to the use
of the forceps I have but a few words to say. Nat-
urally, the indications for this operation, other than
the position of the head, obtain here as elsewhere,
but when it is thought of as a remedial measure
for the malposition alone, I feel that the indications
for its employment are extremely limited. \Mien
the head is absolutely free above' the brim and op-
erative interference is called for — a condition very
rare indeed — then and then only, to my mind, is
version indicated. Such an entirely uncomplicated
condition, by which I mean uncomplicated by any
of the ordinary accidents of labor, would be the
very exceptional one of early maternal exhaustion,
or the equally exceptional one of essential uterine
atony. In the vast majority of cases the liquor
amnii has drained away, the uterus is more or less
firmly contracted on the body of the child, and the
performance of version, or rather, forced version,
in such cases endangers both mother and child.
Therefore, except in these few, rare cases, when-
ever operative delivery is called for, the forceps is
indicated.
In all cases, but especially in those in w^hich in-
strumental delivery has been performed, means for
the resuscitation of the child should always be at
hand, for the probability of its being born in a state
of suspended animation is a complication with
which, almost invariably, we are called upon to
contend.
1090 Lexixgtox Avexue.
THE BLOOD CONSERVATISM OF NEUROTIC
INDIVIDUALS.
By Jexxie G. Drennax. M. D., C. M.,
St. Thomas, Ont., Can.,
Medical Superintendent of the Amasa W^ood Hospital.
\\'e frequently notice the extreme pallor ,of cer-
tain persons, and noting it wonder how in the
world they can .exist and accomplish what they do,
for frequently they are exceptionally active. The
popular answer is: "O ! they are living ^on their
nerve." And we rest content with acknowledging
that neurotics never die, while apparently healthy
looking people easily succumb to disease and in-
jury. "Never despair of a neurotic" ought to be as
familiar a phrase as "never despair of a sick child."
It has been scientifically demonstrated that the
blood of these same neurotics is not the blood of an
anaemic person, howsoever much in other respects
they may resemble one another ; but the pallor of
the one is not the pallor of the other; that of the
neurotic is due to the absence of blood in the capil-
laries of the skin, and not as in the anaemic due
to the presence in them of a blood poor in cor-
puscles. This blood circulates in the superficial
capillaries of his skin and gives him the typical
pasty, sometimes rosy, puffy appearances of the
anaemic ; while, on the other hand, the neurotic has
empty capillaries in his skin. It has been scien-
tifically demonstrated that if his skin is pricked
with a needle no blood issues from the puncture,
showing that there is an absence of blood in the
capillaries of the skin, while in the case of the
anaemic a thin, watery, reddish fl.uid issues, denot-
ing the presence of a poor quality of blood. The
neurotic is a shrewd individual ; whether conscious-
ly or unconsciously so one cannot perhaps say,
though my experience of him is that in many re-
spects he is consciously so : though probably in this
one respect I must admit that it is unconsciously
that he regulates his blood supply for his own best
interests. Nature wisely attempts to make a good
use of the small amount of blood which such a
person manufactures, normal in quality, but sub-
normal in quantity, and therefore not sufficient for
all the requirements of the body. To thus econo-
594
OUR READERS' DISCUSSIONS.
[X--.V York
Medical Journal.
mize she restricts the flow to the skin, allowing
merely sufficient to maintain the skin in a condi-
tion of living, not of health, however, for the skin
is tough and leathery, due to poor vascular supply ;
but it furnishes a covering for the body, even if
its other functions are not performed. The bulk
of the small blood supply of the body in these cases
is sent to the most vital structures, and they are
maintained in a fair degree of health, and to all
appearances the person performs the ordinary and
sometimes extraordinary duties of life as well as
his more robust looking brother. Very often con-
siderable of this scant supply goes to the brain
and spinal cord, and a well nourished nervous sys-
tem, even if it be in a neurotic person, regulates
the other systems. His efforts may be spasmodic,
but generally they are fit for the occasion. Never
despair of one of these pallid workers flunking his
duty, when necessity or ambition make demands upon
him. The proverbial pallor of the hard student is
accounted for in this same way ; the bulk of his
blood supply going to nourish his brain.
There is,' on the other hand, the rosy neurotic,
less often seen, who is also anaemic, and to whose
skin considerable blood is supplied ; there is not in
this case the conservatism of the other, nor is the
blood of such good quality. The skin in the pallid
case is rather a foreign covering and not the true
covering of a human body.
(0ur gcabers' iiscussions.
A SERIES OF PRIZE ESSAYS.
Questions for discussion in this department are an-
nounced at frequent intervals. So far as they have been
decided upon, the further questions are as follows:
LXXII.—Hozv do you treat fracture of the patella?
(Closed March i6, igo8.)
LXXIII.—How do you treat seasickness? (Ansivers due
not later than April 75, igo8.)
LXXIV.—Hoiv do you treat sunstroke? (Anszvers due
not later than May 15, 1908.)
Whoever anszvers one of these questions in the manner
most satisfactory to the editors and their adz'isors zvill
receive a prize of $25. No importance n'liaicrrr z^'ill be at-
tached to literary style, but the award will hr hascd solely
on the value of the substance of the ansz^'cr. ll is requested
(but not required) that the anszvers be short: if practica-
ble, no one anszver to contain more than si.v littiidred zi'ords.
All persons zmll be entitled to coiiipele for the price,
whether subscribers or not. This priae :eill not he awarded
to any one person more than once z^'itlnn one year. Ezwy
anszver must be accompanied by Ihe zvnter'.^ full luinie and
address, both of which zve must be at liberty to publish.
All papers eoiitnhiited become the property of the Joitrnal.
The price of for the best essay submitted in answer
to question l.XXI has been azvarded to Dr. Frank B. Kirby,
of Philadelphia, whose article appears belozv.
PRIZE QUESTION NO. LXXI.
HOW DO YOU TREAT GALLSTONE COLIC?
By Frank B. Kirby, M. D.,
Philadelphia.
A case of gallstone colic demands immediate
anodyne treatment. I give at once chloroform in-
halations or a hyi)odermic injection of morphine
sulphate grain and atropine sulphate i/ioo
grain, repeated in half an hour if necessary; exter-
nally the hot turpentine stupe or mustard plaster
over the gallbladder. However, if the case is mild
in character, with slight pain, it will be relieved by
R Strychnine sulphate, 1/60 grain ;
Hyoscyamine sulphate, 1/250 grain ;
Nitroglycerin, 1/200 grain.
with hot water, repeated every ten minutes to ef-
fect, usually three or four doses.
After pain the next most urgent symptom may be
vomiting, although this may be slight or absent. If
slight, it tends to ovei^come the spasm of the mus-
cular structure of the duct, and if severe the drugs
already used will tend to correct this trouble.
A third concomitant symptom is jaundice; this
also may be absent. Jaundice is corrected by the
use of the hot pack and fractional doses of calo-
mel, say 1/6 grain for eight to ten doses to aid
the emunctories, skin, kidneys, and intestines, with-
out the usual subsequent saline, as the liver needs
what bile is in the intestines to be absorbed for fu-
ture use. The saline would cause a diarrhoea, and
deprive the body of the valuable bile salts.
We determine the gravity of the situation after
relief of its most urgent symptoms. Should we get
a hectic temperature with leucocytosis and physi-
cal signs of distended gallbladder, all pointing to
pus formation, we urge early cholycystotomy and
removal of the stone. Should we decide on its
benign character we give palliative treatment.
This in effect is prophylactic as well.
Realizing its pathology we recognize no danger
from the concretion per se, any more than a bullet
encapsulated in the tissues. But as a possible cause
of future trouble we determine on ( i ) the solution
of the stone, and equally as important, (2) com-
parative intestinal asepsis. These we accomplish
by the use of sodium glycocholate mass in three
grain doses four times daily, with five grain doses
of sodium succinate during several months. The
former is one of the few true cholagogue drugs,
the latter has distinct value as an antiseptic and sol-
vent for the concretion. Sodium succinate may be
replaced by salol or sodium salicylate in the same
dose.
The foregoing deals directly with the stone al-
ready formed. But true prophylactic treatment will
not only prevent the hepatic colic of existing
stones, but prevent the formation of other stones.
Gallstones are chemically, cholesterin and calcium
bilirubinate, which are only precipitated from bile,
to form stones, by being in excess over their nat-
ural solvents, the glycocholate and taurocholate of
sodium. This change is probably due to hepatic
torpor and intestinal toxaemia, due to constipation
and the sedentary habit.
1 have never seen good results from the use of
olive oil, and, in fact, restrict fats in the diet, also
meat, substituting fruits and vegetables. It is also
best to omit tea and coffee, and advise the free use
of water. Walking in the open air is of value.
Exercise, correct diet, intestinal antiseptics with
cholagogue drugs form the keynote in the prophy-
laxis of gallstone colic.
5525 Woodland Avenue.
Dr. Nathan Rosewatcr, of Cleveland. Ohio, says:
Diagnosis of gallstone colic being established,
immediate treatment of the colic with a hypoder-
matic injection of 1/6 to 1/4 grain of morphine
sulphate, preferably combined with 1/150 to i/ioo
grain of atropine sulphate, will usually relieve the
March 28. 1908. J
OUR RHADliRS' DISCUSSIONS.
595
pain, control spasm, and correct the nausea and
vomiting if reflexly present. Chloroform or ether
may be used internally in small doses (5 to 10
drops), or by inhalation, if immediate relief is de-
sired before the hypodermatic injection can be ef-
fective, or, in very mild attacks, these may answer
alone.
When the pulse is intermittent and rapid, or the
tension high, amyl nitrite by inhalation or nitro-
glycerin hypodermatically will aid in relieving
spasm of the ducts as well as improve the circula-
tion, provided the heart is strong. If not, 1/30
grain strychnine sulphate can be given. Hot appli-
cations or fomentations over the hepatic area are
preferable to cold for quick relief. In extreme
cases, with symptoms of shock, weak pulse, and
cold extremities, hot applications to the extremities
and entire body should be kept up. The colic may
subside after the first dose of morphine and not
recur, or more doses may be needed every few
hours or hourly to relieve pain and induce sleep
if needed. Be watchful lest you are not one of sev-
eral physicians called in quick succession, each in
turn administering a hypodermatic injection of mor-
phine, unaware of previous dosages, with final fata!
result, as is said to have occurred in the case of an
ignorant patient thus treated for some painful
malady.
Recurrence of attacks. — Gallstone colic can re-
cur so long as irritating stones are present to pro-
voke them, to prevent which, as well as to relieve
the immediate attack if severe and threatening life,
the immediate or remote removal of the gallstones
must be seriously considered by all concerned, best
of all, including a clinician and a surgeon, thus
giving due w-eight to both surgical and nonsurgi-
cal advantages. In spite of urgent advice to submit
to operation, the family or patient may refuse and
prefer to temporize. This forces on us the ques-
tion, have we a nonsurgical or medical treatment
for gallstone colic recurrence, aside from the imme-
diate relief? My answer is, yes. The history of
large numbers of cases of permanent recoveries
after medical treatment, by cautious observers, is
not to be ignored. Surgical treatment, though far
oftener positively preventive, is not in every case
so, so that while medical treatment has its limita-
tions and may result in a history of prevention
which is debatable, let us not forget that absolute
proof of prevention of anything is impossible, so.
too, even after no recurrence of gallstone colic for
years following any treatment, not even the post
mortem examination can prove an actual prevention
of gallstone colic. Xo removal of the stone, with-
out the knife, can be expected where stones are too
large to pass the ducts or where contractions or ad-
hesions or other mechanical obstructions exist, un-
less by some solvent action on the stones. These
cases of almost inevitable failure of medical treat-
ment may cast ridicule upon such treatment in
general, but should not lessen our ardor and confi-
dence in the ever widening field of medical thera-
peutics, and if these causes for failure are frankly
stated in advance to the patient he will the more
readily give his consent for final operation.
Medical treatment to prevent recurrence of gall-
stone colic must consider the coexisting factors in
its production, to determine what means are applica-
ble in preventing recurrence.
The coexisting factors are: ist, the gallstones,
which of themselves can remain dormant through
life and not give rise to colic : 2d, the conditions that
are said to produce the stones, of which we know
nothing positive ; 3d, the vulnerability and sensitive-
ness of the area involved — here we may have con-
stitutional and local conditions, luetic, lithsemic,
toxic, local inflammation, etc. : 4th, a study of the
conditions that provoke an attack, such as drag, mo-
tion causing friction, spasm, passage of stone, tem-
peramental conditions, diet, habits, acute infection,
etc. Thus, removal of gallstones, as also preventing
gallstone formation, prevents attacks, so, too. render-
ing the involved area invulnerable or insensitive to
pain would also do so, and, again, if the conditions
can be sufficiently modified, as by dilating the ducts
or softening or dissolving enough of the surface of
the stones to make them smaller, or lubricating their
path enough to make them slip onward, or by re-
lieving a spasm which is holding them too tightly,
each of these would thus act as an agent for inhibit-
ing attacks.
Motion during an attack and even afterward
should be limited, as it tends to increase local irrita-
tion and colic. During the attack this is best fa-
vored by the recumbent position, with legs flexed, or
changed to any position affording relief ; elevation of
the foot of the bed will also be useful, especially to
the obese, in overcoming traction upon the gallblad-
der and ducts, and still more so if adhesions aid iit
causing the colic or in cases of enteroptosis and hep-
atoptosis. By partially immobolizing the epigastri-
um, and especially the gallbladder region, lifting up
and supporting the belly by means of 3 inch wide
strips of zinc oxide adhesive plaster, which method
I have fully described in Dr. Rose's Atonia Gastrica
(pp. 96-120), I prevent traction upon the irritated
bladder and ducts, and my patients sometimes secure
great relief, one patient thereafter doing her house-
work and a large washing for a number of months,
although tenderness and pain on pressure repeatedlv
showed that the gallstone condition, though present,
was absolutely relieved by the supporting bandages,
subsequent operation revealing a large number of
small stones in the gallbladder. This supporting
bandage gives relief not alone from traction upon
adhesions, but it prevents elongation and consequent
narrowing of the ducts and bloodvessels by gravi-
tating drag, enables some stones that are too large
to pass the narrowed ducts to escape more readily
because such support restores the ducts to greater
and more nearly normal calibre, and renders them
less irritable and sensitive to the passage of stones.
While the Gallant corset or the abdominal belts also
give similar support, they are not so effective. Rest
from irritation, friction, and spasm can be given by
antispasmodics and lubricants. Possibly stones are
held by spasm in the ducts, just as a sound is held
in the oesophagus or urethra. Relief of the spasm
by morphine, atropine, ether, chloroform, etc., may
be the means of allowing such stones to pass. So,
too. local applications of heat, fomentations, etc..
counter irritants such as mustard, relieve not onlv
the colic, but also the irritability and local conges-
tion. Lubricants, including oils such as olive oil.
596
OUR READERS' DISCUSSIONS.
[New York
Medical Journal.
oleate of soda (castile soap), have been reported bv
many careful observers as aids in expelling the
stones, acting by mechanically overcoming spasm, as
oils do in pylorospasm. Probably the oil reaches the
ducts in a circuitous route through its property of
rising above its normal level in its containers or
through antiperistalsis.
The origin of gallstones from infection is urged
by some, and suggests studying in each case the na-
ture of any possible infection that could render this
area vulnerable, and any traceable, constitutional, or
infectious cause should be treated, be it of a mala-
rial, colon, typhoid, luetic, rheumatic, or tubercu-
lous origin. The benefit derived from salicylic acid
and its alkaline salts in so large a number of cases,
and its usefulness in various infections accompany-
ing rheumatism, whether as cause or complication,
may be accredited to its antimicrobic action locally
and constitutionally. So commonly have I observed
rheumatic symptoms accompany as well as precede
gallstone attacks that I have found in just such
cases, both during and following the attack, very
great satisfaction in the use of sodium salicylate in
doses of lo to 15 grains dissolved in a half glass of
water every three hours for the first day of the at-
tack, and later one or two hours before meals and
at bedtime. I cannot recall a case in which it dis-
agreed with the patient. At the hours named there
should be no undigested food in the stomach, so that
it can scarcely inhibit gastric digestion, while it in-
hibits fermentation and putrefaction, until later on it
is absorbed by the villi into the blood. Its prolonged
use I have never seen followed by albuminuria or
by any toxic effect, nor have I, as a very heavy pre-
scriber of it, used any of the so called salicylates
made from oil of wintergreen. Its action as a sol-
vent of uratic deposits may also explain its virtues
in these cases.
Serum therapy may be useful when perfected, and
we are able to more accurately diagnosticate those
cases due to a specific infection.
The value of mercury in many infections is well
established, and many have recommended it in the
preventive treatment of gallstone recurrence, its ef-
fect as observed being due to its local antiseptic as
well as to its constitutional effect, and no doubt in
luetic and other infections it may be preferable
These and other drugs, by inhibiting or destroying
infection of the irritated area, and by thus limiting
inflammatory processes if present, have a special
place in rational treatment.
Cholagogues. — Whatever tends to increase the
fluidity and volume of bile may aid in flushing out
small concretions ; for this purpose plenty of water,
sojourn at watering places such as Vichy, Carlsbad,
etc., are reputed of special benefit. Constipation be-
ing an acknowledged etiological factor, the drink-
ing of quantities of laxative and cathartic waters,
the long stay and constant use of these at watering
places, keep the intestinal canal flushed and prevent
stasis in the portal circulation, thus favoring a nor-
mal hepatic circulation and a free flow of bile, fac-
tors tending slowly toward restoration to the nor-
mal of the involved area. The cholagogue action of
sodium sulphate, sodium pho.sphate, and alkaline
salts generally may explain their reputed efficiencv
in such cases. To this list of cholagogues mav be
added sodium cholate and fatty oils such as olive oil ;
the latter — acting also as a lubricant, perhaps too as
a solvent — is worthy of trial in doses of one ounce
before meals and at bedtime.
Diet also plays a part, and in certain cases, espe-
cially the lithaemic and autotoxic, on whom it is a
most important element in treatment, also in the
strictly gastric cases with digestive disorders, and in
nephritics.
During paroxyms of colic withhold all food and
give what is safest, water, preferably hot, and as
much as can be tolerated, returning to usual diet bv
slow degrees. Gastric cases must be treated along
individual lines.
In cases with a rheumatic, lithasmic, or nephritic
history I give a diet, allowing onl)' meats freed from
their extractives (purin freed) by removing the first
two, soups, and then preparing the meat for the
table suitable to the culinary art. I allow no meat
soups, nor tea, coffee, cacao, or chocolate, while
sugar, starch foods, and fruits are restricted. Alco-
hol must be curtailed or prohibited, since its toxic
action on the liver taxes this already overstrained
organ. Well cooked vegetables are allowed, and
those foods not specially interdicted. Avoidance of
worry, cheerfulness of mind, pleasant surroundings,
diversions of travel, etc., aid, especially when, as an
setiological factor, the mental and nervous influences
act as deranging or exciting causes.
Dr. IV. Emory Hyskell, of Meadznlle, Pa., re-
marks:
In view of the fact that gallstone colic is caused
by the acute impaction of one or more gallstones in
one of the large bileducts and is associated with in-
tense pain, faintness, and more or less nausea and
vomiting, the first thing to do in all severe cases
is to give the patient a hypodermatic injection of
Ya to y2 grain morphine sulphate, combined with
i/ioo grain atropine. This anodyne will have to
be repeated often enough to give the patient a
comparative degree of comfort. If the colic is very
severe, it is well to give a few whiffs of chloroform
to ease the pain till the morphine has time to act.
The morphine decreases the agonizing pain, and
in conjunction with the atropine relaxes the spasm
of the muscular layers of the biliary ducts. Fre-
quently this relaxation allows the impacted stone
to pass without further trouble.
Six or eight ounces of olive oil or one ounce of
glycerin should be given during the attack of pain,
as this aids in relaxing the spasm of the bileducts
and has a good aperient action on the bowels. Hot
fomentations or hot turpentine stupes should be
placed over the liver, as they are soothing to the
patient and also have a relaxing effect.
In severe cases give a laxative enema ; in mild
and in subacute cases give calomel in small fre-
quently repeated doses until there is a free move-
ment of the bowels ; then watch the f.neces to see
if any gallstones pass.
Keep the patient at rest in bed, and if the colic
is very .severe do not gi\;e any food or any water
by the mouth, except in small amounts to relieve
thirst, as it would excite peristalsis and increase any
existing inflammation or local peritonitis that
might be present. Give nutrient enematn instead.
March 28, 1 908. J
OUR READERS' DISCUSSIONS.
597
As soon as the pain is lessened enough to permit
you to do so, take a full history of the case, not-
ing especially if the patient has ever had any sim-
ilar attacks, and make a thorough examination of
all the thoracic and abdominal viscera, thus making
sure of your diagnosis and ascertaining if there is
any other diseased conditions present with which
you have to deal. Also get a specimen of urine
and examine it for bile and for any existing dis-
ease of the kidneys.
If the severe pain lasts more than a few hours,
if there is much enlargement or tenderness of the
gallbladder, or if there is high or irregular tem-
perature, call in a surgeon in consultation, with view
to operating if it becomes necessary.
In order to carry out the farther treatment of
gallstone colic intelligently, it will be necessary to
study the causes of gallstone formation and adapt
your treatment according to the indications of each
individual case. The following are the most usual
predisposing causes :
1. Cholangeitis and cholecystitis. — The inflam-
mation produces an excess of mucin and diminishes
the alkalinity of the bile. This allows the calcium
salts and the cholesterin to combine with the mucin
and form a nidus for gallstones.
2. Gouty and allied diatheses.
3. Infection. — Bacteria gain entrance into the
bileducts and gallbladder by way of the common
duct, the bloodvessels, or the lymph channels, keep
up the inflammation, and sometimes form nuclei for
gallstones.
4. Stagnation of bile.
5. Digestive disturbances. — These produce in-
flammation, which often extends to the bileducts
and gallbladder.
6. Circulatory disturbances. — Congestion of the
liver interferes with biliary secretion and causes
stagnation of bile.
The following treatment is adapted to patients
after the severe pain of the first stage of gallstone
colic is passed and to subacute and chronic cases.
As no drugs can be given that will dissolve gall-
stones, the aim in our treatment should be to re-
pair the damage already done and relieve all con-
ditions that have a tendency to aid in the formation
of others.
To those cases with inflammation of the biliary
passages give sodium salicylate or sodium succinate
10 grains three times a day. This relieves inflam-
mation, increases alkalinity, and checks infection.
Phenolphthalein. 3 to 5 grains, can be combined to
advantage with the salicylates. Oil of turpentine, 5 to
10 minims, in capsules, three or four times a day,
gives brilliant results with some patients. Phenyl
salicylate is a useful intestinal antiseptic. Ammo-
nium chloride acts well in cholangitis.
Pure nitrohydrochloric acid, 3 to 5 minims, well
diluted in water after meals, aids digestion and
stimulates hepatic secretion.
Hepatic congestion should be relieved by the
remedies that are indicated by the conditions pro-
ducing the same. Heart tonics and stimulants may
be indicated. If there is a tendency toward vis-
ceroptosis, a well adjusted abdominal binder often
gives relief.
A dose of eflFervescing sodium phosphate in a
glass of cool water, taken slowly each morning be-
fore breakfast, is a valuable adjunct to our other
treatment. The phosphate stimulates the hepatic
cells, acts as a laxative, and aids in the elimination
of the byproducts of metabolism.
The Spa treatment often gives good results, and
should be recommended in suitable cases. The al-
kaline laxative waters are very useful if taken
properly and faithfully kept up.
All gastrointestinal troubles should be corrected.
The food should be limited in amount, eaten slow-
ly, and thoroughly masticated. It should contain
plenty of green vegetables and fresh fruit, while
the carbohydrates, hydrocarbons, fried foods, sweet
cakes, all rich foods, and alcoholic beverages
should be avoided.
Even.- patient, when at all able, should have
plenty of well regulated exercise in the open air
and sunshine. Exposure to wet should be inter-
dicted. Horseback riding is the best exercise for
patients with hepatic torpor, as it jolts the liver and
causes the stagnant bile to flow on more freely,
gives exercise to nearly all of the muscles of the
body, affords pleasant diversion for the mind, and
keeps the patient out in the open air and sunshine.
Dr. Frederick Fletcher, of Columbus, Ohio, writes:
The victim of an agonizing paroxysm of gall-
stone colic demands quick relief. And the physi-
cian invariably meets the emergency by instituting
a time honored treatment. The suffering incident
to an attack of colic may last from a few seconds to
a week or longer. It is for this reason that the per-
sistent treatment and variety of applied therapeutic
measures are in keeping with the remissions and ex-
acerbation of the symptoms.
Theoretically, the subcutaneous use of morphine
and atropine, or the inhalations of chloroform, are
indicated for the relief of the pain and spasm. And
when this treatment is supplemented with rest in
bed ; a hot bath, the local use of dry heat, or poul-
tices over the hepatic area ; the giving of an enema,
or the ingestion of olive oil or a large quantity of
hot water, we not infrequently relax the muscular
spasm, and, with the dislodgment of the stone, cure
the patient. But this treatment is purely sympto-
matic, and takes cognizance of nothing other than
the stone as the exciting factor. Again, the large
amount of morphine necessary to produce quietude
has the efifect of obstinately constipating a patient
whose bowels should move regularly, so that it be-
comes necessary for the physician to actively disturb
the entire astrointestinal tract in an attempt to
empty the stagnant bowel.
It is of practical importance to know that digestive
disturbances are symptomatic of cholelithiasis, and
that any indiscretion of diet is prone to excite an
attack of gallstone colic. It has been pointed out
that the spasmodic contractions of the gallbladder
occur synchronously with the contractions of the
stomach. This physiological facts suggests a rational
method of treatment, namely, the "removal of the
irritating gastric contents by lavage.
Treatment.
During the passage of a gallstone the chief meas-
ures to be carried out are: (a) Rest in bed. (b)
The stomach should be rested, and not insulted bv
59«
OUR READERS' DISCUSSIONS.
[New York
Medical Journal.
the administration of nourishment or liquids. Thirst
can be controlled by the rectal use of normal salt
solution, (c) The stomach should be irrigated with
a large quantity of hot water, preferably a solution
of sodium bicarbonate, one drachm to the pint of
water. If the pain and vomiting persist, the irriga-
tion should be repeated at the end of an hour, or at
any time the taking of nourishment excites a par-
oxysm of colic. Vomiting is not a factor when the
stomach is relieved of its irritating contents.
This form of treatment will cure the average at-
tack of gallstone colic without recourse to opium.
However, it may be necessary, in the exceptional
case, to give a single dose of morphine and hyoscine,
or to keep the patient submerged in a tub of hot wa-
ter. Lavage can be practised with the patient in a
tub. Collapse is met with the use of stimulants.
Good results follow the intelligent administration
of olive oil. It is the lavage effect of the quantity of
oil used in the stomach, rather than a direct thera-
peutic action of the drug upon the hepatic appa-
ratus, that effects the cure. The oil should be ad-
ministered through 0 stomacJi tube — it should be
warm, and given in a quantity of not less than one
and a half pints.
For the prevention of gallstone colic attention to
'diet and hygiene is most essential. Cholecystotomy
is the rational prophylaxis.
Operative treatment is not advisable during the
attack of colic. However, if there are indications
of a permanent lodgment of the stone in either the
cystic or common ducts, or symptoms suggestive of
a perforation or suppurative process, prompt sur-
gical interference should be advised.
Dr. Hozi'ard Priest, of Fort Bayard, Nczv Mexico,
ohserz'es:
The treatment of gallstone colic resolves itself into
three factors, namely, prophylaxis, medicinal relief,
and surgical intervention.
These three methods will be considered in their
respective order.
Firstly : Prophylaxis. This is the treatment be-
tween attacks, for an attack must occur to demon-
strate the existence of biliary calculi. Possibly the
Carlsbad treatment ranks foremost ; certainly the
springs take precedence over the bottled waters or
the natural or artificial salts. A teaspoonful of so-
dium phosphate dissolved in a tumblerful of hot
water and taken three times daily, a diet directed to
be taken regularly thrice daily, the heaviest meal at
middav. and the meals consisting of easily digestible
nourishing, food, excluding fats, excess of carbo-
hydrates and alcohol, combined with judicious exer-
cise, bathing, and thorough regulation of the bowels,
continuing for a period of from four to six weeks,
probably approaches as near to the ideal as does tlie
Carlsbad method. Sweet oil as a solvent is men-
tioned, but not recommended.
Secondly : The medicinal treatment during the
attack. There are two ends to be accom])lished in
this. The relief of the pain and the correction of
the inflammation. The usual resort is to hypo-
dermatic injections of morphine, Y4 grain and atro-
pine i/ioo grain, combined. The inflammation is
best combatted by a few days' rest in bed, light diet,
external applications of hot water, poultices, and
stupes, and the internal administration of bella-
donna, hyoscyamus, and cannabis indica. The pain
may be so severe as to call for inhalations of chloro-
form or ether.
Thirdly : The surgical intervention. In view of
the comparative low mortality attending such pro-
cedures this should appeal to physician and sufferer
alike. Results are usually permanent, while the
nonoperative measures, more than frequently, con-
stitute a continuous performance. The nature of
the operation, a cholecystotomy, a cholecystostomy,
or a cholecystectomy, is determined by the patho-
logical conditions present.
Certain contraindications to the operative treat-
ment occur, such as diabetes, chronic pulmonary and
cardiac diseases, arteriosclerosis, and excessive adi-
posity ; but in the main the surgical treatment gives
more satisfactory and lasting results.
Dr. Walter E. Hays, of New York, states:
The treatment of an attack of gallstone colic re-
solves itself into chiefly the alleviation of the special
symptom of pain, since there is no means b\' which
we can directly reach the seat of the trouble. The
attack begins with agonizing pain in the region of
the gallbladder and thence radiates to the right shoul-
der usually, though it inay be felt in any part of the
trunk or even radiate to the extremities. It often
seems very pronounced in the epigastrium. The
pain is produced by the passage of a biliary calculus
through the cystic or common bile ducts, or both,
into the duodenum. Consequently, our ultimate
effort should be directed toward aiding in the expul-
sion of the stone into the bowel.
Nothing will suffice to relieve this intense agony
but opium in full dosage. If there is no vomiting,
powdered opium, grs. ii, combined with extract of
belladonna, gr. should be given by mouth and
repeated as often as necessary. Or, if nausea and
emesis are present, morphine sulphate, gr. ^4 hypo-
dermatically, with atropine sulphate, gr. 1/150,
should be administered. The belladonna or its de-
rivative will offset the nausea often produced by the
opiate, especially the morphine, and also acts as an
antispasmodic. Oftentimes a few whiffs of chloro-
form will deaden the pain in a very severe paroxysm
until the opiate has had time to work. After the ini-
tial dose of the anodyne, the patient should be placed
in a bath as hot as can be well borne by him for at
least ten minutes. He should then be put to bed
and hot fomentations applied to the entire upper ab-
domen. Allbut says that at times the drinking of a
pint of water, as hot as can be taken, will aid in
assuaging the pain. In the case of inflammatory
processes going on in the gallbladder, however, the
hot applications are not so well borne. In such
cases leeches or cold compresses will often relieve
when placed over the painful area. The former are
serviceable in plethoric individuals and may allevi-
ate the spasms. Antipyrine, acetphenetidin, and
other coal tar derivatives have been recommended,
but frequently their use has to be supplemented by
the administration of opiates. Consequently, it is
much more satisfactory to employ the opium first.
All these measures not only allay the pain due to the
passage of a biliary calculus in the cystic or common
ducts, but also relax the spasm of their musculature
March 28. 190S.]
THEK.lPIii TJCAL NOTES.
599
and thus permit the escape of the stone into the
larger common duct or into the duodenum, as the
case may be.
The nausea and vomiting of gastric contents, and
later, frequently, of bile, usually leaves the patient
in a temporarily exhausted condition and produces
relaxation of the pylorus. This favors the onward
movement of the stone. If, however, retching con-
tinues, the administration of olive oil will often quiet
the spasm of the pylorus. Olive oil, ether and oil of
turpentine have been much lauded because of their
solvent ef¥ect on the gallstones, but, as they cannot
in any way be brought into contact with the stones,
their use is barren of results. Musser maintains that
olive oil acts well in relieving the hyperacidity of the
gastric juice, usually associated with gallstones, and
causing simple gastralgia or pyloric spasm.
It is advisable, during the attack, to secure a good
evacuation of the bowels, or as soon as possible
after the attack begins. For this purpose, epsom or
rochelle salts, magnesium citrate, castor oil, etc., in
full dose, or a pill composed of podophyllin, gr. l4-
and extract of belladonna, gr. ^, are useful, but
they are frequently vomited. It is then necessary to
employ enemata. Simple hot or cold soapsuds ene-
mata may be tried, or injections of olive oil in case
the stools are very hard. Or, if these avail not, a
purgative enema consisting of magnesium sulphate,
glycerin, olive oil, of each an ounce, oil of turpen-
tine 2 drachms, water to make six ounces, may be
tried, and will usually be found very efficacious,
though it may have to be repeated in two or three
hours.
It is doubtful whether a chill can occur or fever
be present in an uncomplicated case of gallstone
colic, though 'some authorities maintain that such
cases have been observed. With the expulsion of
the stone, however, this pyrexia disappears, though
it may return with further pain.
Jaundice will be observed when the stone lodges
in the common duct and completely blocks its lumen.
This disappears with the dislodgment of the stone.
This medical treatment is chiefly palliative. After
an attack, care should be taken to prevent a recur-
rence. The regulation of the diet is important.
The amount of lime salts ingested should be kept
down by the eating of small quantities of farina-
ceous foods. The nitrogenous food elements should
be increased in amount, as cholesterin, the chief con-
stituent of biliary stones, is precipitated when there
is a deficiency of solvents in the bile, these solvents
being the glycocholate and sodium taurocholate, de-
rived from the metabolism of nitrogenous food (Ail-
but). Exercise and proper attention to the bowels
will also prevent stagnation of the bile in the gall-
bladder. The dress should be regulated by women
to avoid pressure on the liver and gallbladder. Zins-
ser likes the use of ammonium chloride where thero
is congestion or a tendency to stasis of bile, as it has
an influence upon the secretions and is said to thin
the bile, allay catarrh, and modify the amount of
mucous secretion. The use of sodium phosphate or
other sodium salts is of value, but whether they act
on the liver itself or as purges is not known.
If consent of the patient can be obtained, relief
from the gallstones should be permanently secured
by surgical procedure. Thus these severe and peri-
odic paroxysms of pain can be obviated.
The Nonspecific Treatment of Diphtheria. —
In the absence of diphtheria antitoxine serum, De-
learde, Minet, and Bricout, of Lille, recommend the
following method of treatment (Revue frangaise dc
iiicdcciiic ct dc chirurgic, February 25, 1908; L'Echo
medical dit nord, October 6, 1907) :
Thrice daily, morning, noon, and night, daub the
throat with a mixture of the following composition :
B Menthol 3ii ;
Camphor, 3i.
M.
[Mixed in these proportions menthol and cam-
phor form a liquid. — Abstractor.]
If it is required the mouth may be washed out
with a five per cent, solution of chlorinated soda, or
a two per cent, solution of hydrogen dioxide water.
Thrice daily drop in each nostril a teaspoonful of
the following:
B Menthol gr. ivss ;
Camphor gr. ii ;
Kesorcin 3ss ;
Olive oil. sterilized and washed with alcohol, . .Jiiiss.
M.
The patient should be bathed in lukewarm water
every morning :
If there is bronchitis mustard plasters should be
applied twice a day.
When the laryngeal exudation loosens up its elim-
ination is accelerated by an expectorant mixture of
the following composition :
R Sodium bcnzoate gr. xxx ;
Oxymel of squill Jiiss ;
Syrup of tolu, 5x ;
S\rup of acacia q. s. ad ^iv.
M.
Dose : One teaspoonful to a tablespoonful, ac-
cording to the age of the patient, every four hours,
in a little warm milk.
The Treatment of Warts. — The following top-
ical applications for warts are cited in Bulletin gai-
cral dc thcrapcutique for February 23d :
I.
R Extract of cannabis indica, gr. viiss;
Salicylic acid gr. xv;
Collodion 3v.
M. Sig. : Paint the warts nightly with the mixture.
II.
(Blakko"s Ointment.)
B Potassium bichromate gr. iss ;
Lard, or petrolatum jss.
M.
III.
(Mantelin's Paint.)
R Cliloral h.\(lrate gr. xv;
Salicylic acid 3i ;
Acetic acid TTtxv;
Ether 3i :
Collodion 5ss.
:\i.
Nutmeg Poisoning. — In an address to the
Therapeutical and Pharmacological Section of the
Royal Society of Medicine, at a ineeting on Janu-
ary 28th ( The Prescribe)-. March, 1908), Professor
Cushny dealt with the subject of nutmeg poisoning.
It had been found that cases of poisoning occurred
exclusively from the use of crude nutmeg or mace.
Xutmeg does not appear to have any abortifacient
6oo
THERAPEUTICAL NOTES.
[New York
Medical Journau
action, although it has been used for this purpose.
The symptoms generally resemble those of cannabis
indica, and include drowsiness, stupor, diplopia, and
sometimes delirium and burning pain in the stom-
ach. He considered that the symptoms were to be
attributed to action on the central nervous system,
which was depressed, but exhibited some indications
of stimulation in the form of restlessness, slight con-
vulsive movements, and tremor. The oil had a
marked local irritant action, whether given by the
mouth or hypodermatically. The stomach wall was
found red and injected, and the urine often con-
tained albumin. Dr. Power said he had found the
chemistry of oil of nutmeg to be of a very complex
nature. It was significant that the quantity of nut-
meg required to produce symptoms of poisoning rep-
resented a very small amount of myristicin, and he
had doubts as to whether this body was really re-
sponsible for these symptoms.
Antimony as a Hepatic Stimulant. — By its in-
fluence in promoting secretion from the intestinal
mucous membrane, antimony, says Eustace Smith
(The British Medical Journal, February 29, 1908),
is a useful addition to the aperient in cases of chronic
constipation where the stools are exceptionally dry
and hard. It was to its quality as a hepatic stimu-
lant that it owed its inclusion in the old pharma-
copoeal preparation known as "Plummer's pill," in
combination with calomel and guaiacum. Smith
suggests the following combination in pill form for
use in cases of chronic constipation :
R Tartarated antimony, gr. 1/25 to gr. 1/20;
Podophyllin, gr. % ;
Compound extract of colocynth, gr. ^2 ;
Extract of belladonna, gr. J/^ ;
Extract of mix vomica gr.
M. ft. pil. No. i.
Sig. : One pill to be taken each evening before dinner.
Draught for Alcoholic Intoxication. — Pouchet
is credited in La Qidnsainc therapeutiquc with the
following prescription for overcoming the symptoms
of alcoholic intoxication :
R Ammonium acetate, 3i ;
Sea salt, gr. Ixxv ;
Infusion of coffee, Siss ;
Simple syrup, 5'-
M. Sig. : Give in two doses, fifteen minutes apart.
Aperient Salt. — The composition of the aperi-
ent salt, commonly known as Harrogate salts, and
which is a favorite purgative in gout, rheumatism,
etc., is given in the British Pharmaceutical Codex
as follows :
R Potassium bitartrate, 3i ;
Sulphurated potash, gr. xii ;
Magnesium sulphate, exsiccated, 3vss.
M. Dose, 3i to 3ii.
Fluoroform for Whooping Cough. — According
to Tissier (/o»r;;a/ dc pharmacic et dc chimic; Phar-
maceutical Journal, February 8, 1908), a saturated
aqueous solution of fluoroform which contains 2.8
per cent, of fluoroform is odorless, colorless, almost
tasteless, and less toxic than bromoform solution.
It is a specific for the treatment of whooping cough.
It has been given during the past four years in 117
cases without a single untoward symptom, even
when large doses were administered. After the sec-
ond or third day the number of paroxysms is less-
ened, and in a week they disappear. No broncho-
pulmonary complications occur ; if these already
exist they are speedily cured. Fluoroform should
be given in sufficient doses, or it will not act. For
infants up to two years of age one drop of the sat-
urated solution may be given after each paroxysm,
and two drops on the second day, three drops the
third, and so on, progressively, not exceeding a total
daily dose of 100 drops. From two to four years
the doses may be increased to 75 to 150 grains (50
to 100 drops) in twenty-four hours. Above this age
half an ounce of the solution may be given in sub-
divided doses in twenty-four hours, and adults may
take twice as much. The fluoroform solution may
be taken in milk, or water, or alone. Its administra-
tion causes no gastric disturbance. Larger doses
than above indicated may be given, but they serve
no useful purpose.
Enema After Abdominal Section. — After ab-
dominal section cathartics cannot be given by the
mouth on account of nausea. In such cases when it
is desirable to secure bowel movement the following
enema, high into the rectum, may be given (Amer-
ican Journal of Clinical Medicine, March, 1908) :
B Epsom salt, 50 per cent, sol., ^ii ;
Oil of turpentine, 3ii;
Glycerin, ^ii ;
Water, 5vi.
M.
The injection is to be held in the bowel as long as
possible by the patient. It is well to anoint the inner
surface of the thighs and the buttocks in order to
prevent irritation of the parts should they come in
contact with the turpentine by any mischance.
For Taenia Solium. — ^The following formula is
taken from Bulletin general dc thcrapeutique for
February 29, 1908 :
R Oleoresin of male fern, 3i ;
Rectified oil of turpentine, gtt. xx;
Chloroform, gtt. xv;
Mucilage of acacia 3i.
M. Sig. : One half to be taken at night, and the other
half the following morning.
Suppository for Dysmenorrhcea. —
R Morphine hydrochloride, gr. ;
Extract of hyoscyamus gr. l4>;
Cacao butter, gr. xxx.
M. ft. suppositorium No. i.
Inhalation for Catarrhal Pneumonia.— Marfan
(Journal de mcdecine de Paris, December 29, 1907)
advises the inhalation three or four times a day
from a teapot or steam kettle a teaspoonful of the
following mixture added to eight ounces of water:
R Creosote, 5i;
Tincture of benzoin, 3iiss;
Oil of turpentine, Jiii.
M.
Glyceroboric Ointment. — The following oint-
ment is said by Nouveaux remcdcs to be superior
to boric ointment as an antiseptic. It has a con-
sistence like cold cream, and is an agreeable substi-
tute for iodoform or carbolic ointment:
R Boric acid 3ii ;
Glycerin, 3iii ;
Wool fat, hydrous 3iv;
Petrolatum 3ii.
M.
March 28, 1908.I
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Review of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
■ and SMITH ELY JELLIFFE, M. D.
AdOuss all business communications to
A. R. ELLIOTT PUBLISHING COMPANY,
PiihlisherSj
66 West Broadivay, New York.
Philadelphia Office : Chicago Office •
3713 Walnut Street. 160 Washington Street.
SDnscRiPTiON Price :
Under Domestic Postage Rates. $5 : under Foreign Postage Rate.
%1 ; single copies, fifteen cents.
Remittances should be made by New York Exchange or post
office or express moner order payable to the .\. R. Elliott Pub-
lishing Co.. or by registered mail, as the publishers are not
responsible for money sent by unregistered mail.
Entered at the Post Office at New York and admitted for
transportation through the mail as second class matter.
NEW YORK, SATURDAY, MARCH 28, 1908.
"A MIXD THAT FOUND ITSELF."
No one can read the stirring introduction of an
autobiography of '\lr. C. Beers in a recent work,
A Mind that Found Itself (Longmans, Green, &
Co., New York") , without being tempted to do some-
thing. 'T am not telling the story of my life just to
write a book," says Mr. Beers. "I tell it because it
seems my plain duty to do so. For what purpose
was my life spared? That question I have asked
myself, and this book is, in part, an answer." This
is the author's introduction to a human document
which constitutes one of the most fascinating chap-
ters in the psychology of insanity that have been
written for many years.
]\Ir. Beers calculates that there is about one in
every eighty of the population of the United States
suffering from some form of mental disease — a high
estimate, if the statistics of the Census Bureau are
at all reliable : and the great pity is that so little, he
says, "is being done to combat the present ifresisti-
ble advance of insanity." While we feel that the
author's outlook as to what »s being done is lamenta-
bly narrow, and that he would not really have us
"combat" the "irresistible," yet we are at one with
him in the feeling that we are neglecting opportuni-
ties that lie about us in trying to withstand this
marked increase in mental breakdown. We welcome
the harshest criticism from the outside, feeling that
our own words fall on dead ears.
The author's early life, his graduation, his train-
ing, his early illness, his attack of manic-depressive
601
insanity, and his recovery, are all told in a simple
)et striking manner that compels attention. Even
the chapters dealing with the abuses to which he was
subjected have more interest in them than tlje usual
run of asylum abuse descriptions, because the au-
thor's insight into his condition was so well pre-
served, and his literary quality betrays a humor that
is a saving grace.
We feel that this work should be read far and
wide, for through it we hope may come the remedy-
ing of certain drawbacks that prevent the insane
from receiving the care that should be their portion.
We recommend this work, not that we feel at one
with the author throughout, but because he has put
his finger with precision upon those very things for
which asylum superintendents have been working
for years. The unheeding public look upon our large
asylum structures and wonder why such palaces
should be built. The unheeding used to wonder in
the same way at Bedlam two hundred years ago;
they feel that too much money is spent on the insane,
and the legislators skimp and save and cut down —
and where? In food and in attendants, the two
most essential features in the care of the mentally
disordered. The same legislators allow one physi-
cian to about two hundred patients ; one nurse or at-
tendant to fifty, to thirty, to twenty, under the best
of circumstances; and (sometimes) such attendants!
We can feel with Mr. Beers that they have been
chosen for their physical prowess rather than for
their intellectual capacity. How much are they
paid? The answer to this question will go a long
way in explaining the preponderance of brawn over
brains.
We can sympathize with the author's dissatisfac-
tion in not obtaining proper redress, but we feel that
he is ill prepared to speak of the real reasons why
control of the attendants is not the simple matter
that he supposes. It is not over a year now since a
well known medical director in one of our better in-
stitutions for the treatment of the insane actually
had to compel a district attorney to prosecute an at-
tendant who had assaulted a patient. This superin-
tendent was not content to dismiss the attendant, he
had him indicted and punished, and largely on the
evidence of so called insane patients. We should
like to see a recognition of this feature of the situa-
tion in Mr. Beers's book, but, apart from the fact
that a more general reading of this work would tend
to make it easier for other superintendents or med-
ical directors to deal more efifectually with brutal at-
tendants and careless and incompetent medical as-
sistants, we also feel that it may help to bring about
an advance in the treatment of '"disturbed" patients.
While our modern institutions have progressed :i
great way in the better care of all classes of the men-
EDITORIAL ARTICLES.
6o2
EDITORIAL ARTICLES.
[New York
Medical Journal.
tally sick, the care and treatment of the acutely vio-
lent have seemed to have been benefited little since
the days of Julius Caesar, when the use of poppy an4
of henbane was advised for the violent, and it was
said that only those who would hurt themselves or
others should be kept in chains. Plenty of space,
enough attendants, good food, frequent baths, and
constant medical supervision ; these are reforms for
which psychiatrists have been striving for two hun-
dred years, and toward the bringing about of which
we believe that Mr. Beers's book, even with its obvi-
ous defects, may contribute.
AN IMPROVED BIRTH RATE IN
NEW YORK.
For many years the death rate of the city of New
York, both the old city and the present enlarged
territory included under the name, has been higher
than it ought to be, and it has not been offset as it
should have been by a high birth rate. There is
some reason to hope, however, that the ratio is
destined to become approximately normal. One
swallow, indeed, does not make a summer, but the
lone bird is promising, for all that. A straw be-
tokening what may turn out to be a favorable wind
is to be found in the birth rate reported to the State
Department of Health for the month of January
of the present year, as we find it set down in the
February number of the board's Monthly Bulletin.
During the month of January 11,853 living chil-
dren were born in the entire city. The population
is estimated as 4.244,411. Therefore there was a
calculated annual birth rate of 33.5 to each thou-
sand of the population. In two of the five borouglis,
indeed, the calculation gives figures somewhat
larger still, the rate set down being 34.0 in the
borough of Manhattan, and 33.9 in the borough of
the Bronx. It is given as 33.0 for the borough of
Brooklyn, 33.2 for the borough of Queens, and 28.7
for the borough of Richmond. The populations of
the five boroughs are estimated as follows : Man-
hattan, 2,21^,294; the Bronx, 300,078; Brooklyn,
1,435,530; Queens, 216,336; Richmond, 75,173.
The most populous borough, then, shows the
highest birth rate and the least populous shows the
lowest ; but beyond this there seems but little tend-
ency of the birth rate to bear a definite ratio to the
population. If there were such a ratio established,
it would be interesting to speculate as to the fecund-
ity of the boroughs when, as must come to I)c the
case within a few years, the density of population
goes on increasing in all but Manhattan, which, let
us hope, may at the same time be partially relieved
of the "congestion" that is now meeting witli the
earnest consideration of many of our philanthropic
citizens.
The boroughs of Brooklyn and Queens must soon
become full under the influence of new facilities of
travel to and from Manhattan ; so also must those
portions of New Jersey which are within easy reach
from the city of New York after the Hudson River
has been passed, but the latter, of course, though
virtually a part of the city, will probably never be
included within its limits. In the Bronx, too, the
population is rapidly increasing in density, and there
are the contiguous municipalities of Yonkers and
Mount Yernon, constantly growing more and more
like integral portions of the metropolis. In the bor-
ough of Richmond (Staten Island) we may pre-
sume there will not soon be seen a vast growth of
population, unless additional means of transporta-
tion are brought into operation earlier than at pres-
ent seems probable. That boro'ugh, however, in
spite of its distance from the chief seat of business,
is properly made to figure in the vital statistics of
the metropolis, and the same treatment might logi-
cally be applied to those districts of New Jersey
and Westchester County which we have mentioned
did not diversity of jurisdiction interfere with such
a course.
THE TACHYCARDIA OF TUBERCULOUS
DISEASE.
In an interesting article published in the Gazette
uicdicale de Nantes for March 7th, Dr. Joseph
Lequyer remarks upon the frequency with which
the subjects of tuberculous disease are aflfected with
a form of tachycardia which does not correspond
to a rise of temperature and has no apparent con-
nection with the particular course of the tuberculous
affection. It is observed very often in both the
acute and the chronic forms of the disease. It
occurs at the very onset and even during what may
be called the pretuberculous stage, while yet the
clinical signs are at the minimum. In other in-
stances it is not until a very advanced period that
the pulse becomes very frequent. In many cases
the temperature is normal or hardly above the
normal point, but the pulse ranges from 100 to no;
if the temperature rises to 100° or 102°, the pulse
reaches 130 or 140. There is no invariable rule
about this, says the author, but he calls special atten-
tion to the discrepancy between the pulse and the
temperature. In spite of its acceleration, the pulse
generally preserves its perfect regularity ; it is ex-
ceptional for arrhythmia to exist, though it does
occur frequently in the last stages of the disease,
also in tuberculous meningitis.
March -8, 1908.I
EDITORIAL ARTICLES.
603;
The author then discusses the causes of this
tachycardia. He thinks that the patient's nervous-
ness plays a prominent part. Often, too, the accel-
eration of the pulse is a reflex effect due to excita-
tion of the accelerator nerves. The pulse betrays
the suffering of the organism before the pulmonary
lesions are much advanced. Tuberculous inflamma-
tion of the pneumogastric nerve, which very rarely
exists alone, is almost always an accompaniment of
peripheral neuritis; then the cause of the tachy-
cardia is clearly apparent. Moreover, there is the
action of the tuberculous toxines on the circulatory
apparatus ; in all tuberculous persons there is a
more or less pronounced vascular dilatation, and
that of itself is enough to cause tachycardia. If
there is, in addition, a slight degree of myocarditis,
the heart no longer contracts with its normal force,
but endeavors to make up for lack of strength b}-
rapidity of action. In 1889 Maurice Klippel main-
tained that cardiac amyotrophy was frequently pres-
ent in tuberculous subjects, and that the consequent
overexcitability of the muscular structure of the
heart would give rise to tachycardia.
As an early diagnostic sign, when auscultatory
signs are wanting, acceleration of the pulse should
not be neglected. Lasegue insisted upon it as a
distinguishing mark between chloroanaemia and
incipient tuberculous disease. Often, he said, the
diagnosis would be confirmed when one repeatedly
found the pulse above 90 without a febrile tempera-
ture. However, the importance of the sign must
not be exaggerated. Tachycardia is a frequent
symptom, it is due to very diverse causes, and a
diagnosis of tuberculous disease is not necessaril}-
to be taken for granted when it is met with. Car-
diac affections are often accompanied by tachy-
cardia, and in particular we should bear in mind
chronic myocarditis, but the accompanying symp-
toms will distinguish it. Acute endocarditis is
accompanied by dyspnoea and cyanosis, and auscul-
tation will disclose abnormal bruits. In angina pec-
toris, precordial pain and its radiations are almost
constant. Aortitis manifests itself by special souf-
fles. Tachycardia, then, is not the sole sign of these
affections.
In prognosis, too, the tachycardia of the tubercu -
lous is often of very great value — not early in the dis-
ease, but at an advanced period. Then it indicates
intense systemic intoxication, and is particularly
observed m patients with extensive lesions ; it in-
creases with the advance of the lesions and often
attains its maximum in the last stage of the disease.
Tachycardia is not simply a diagnostic and prog-
nostic index ; it may predispose to ver\- grave com-
plications, such as asystolia. Tuberculous persons
with tachycardia often die like the victims of heart
disease ; their enfeebled myocardium is forced, their
right cavities become distended, and acute asystolia
appears. In other cases, in consequence of the
tachycardia and the lowering of arterial pressure,
cardiac collapse takes place. The pulse, always very
rapid, can no longer be counted.
As regards the treatment of this tachycardia, M.
Lequyer remarks that it is very often futile. Rest
is the first thing to be recommended. Cold com-
presses and ice bags applied over the heart are not
so often efficacious as they are for the relief of
palpitation. Alcoholic and other stimulating drinks
must be interdicted, also overeating, for they in-
crease the frequency of the pulse and predispose to
cardiac erethism. In the open air treatment of con-
sumption the tachycardiac patient should not be
exposed to high winds or to prolonged action of
the sun.
THE ETIOLOGY OF YAWS.
In 1905 Castellani discovered in smears made
from yaws papules an organism which had a mor-
phology closely resembling that of Treponema pal-
lidum. His observations were published in the /o»r-
nal of the Ceylon Branch of the British Medical
Association for June 17, 1905. The organism,
which he named Spirochceta pertcnuis, he says, is
14 to 20 micra long, is pointed at both ends, and pre-
sents a variable number of walls. The name of this
organism is now accepted as Treponema pertenue.
The observation was confirmed by Wellman, work-
ing independently in Angola {Journal of Tropical
Medicine, vol. viii, p. 345).
Ashburn and Craig {Philippine Journal of Sci-
ence, October, 1907) began the investigation of this
organism soon after its first description, having had
the good fortune to have some cases referred to
them by a native physician. Since the discovery
of these cases, yaws, which was formerly thought
to be a rare disease in the Philippine Islands, has
been found to be common in certain districts on the
islands of Luzon and Mindanao. Ashburn and
Craig agree in the opinion that Treponema pertenue
is the cause of yaws. They have found it con-
stantly present in the serum from yaws lesions.
From experiments made on monkeys they find that
the inoculation of serum from human yaws lesions
containing Treponema pertenue causes yaws in the
former animals, and that the organism can be easi-
ly demonstrated in the lesions. They further assert
that this treponema is dift'erent from Treponema
pallidum.
Yaws was originally considered to be a variety of
syphilis, modified by climate and by racial pecul-
iarities. In vol. ii of the Transactions of the
6o4
NEWS ITEMS.
[New York
Medical Journ\l.
First Pan-American Medical Congress there is an
interesting description of yaws, or framboesia, by
Dr. George Edmund Pierrez, of Antigua, in which
the cHnical differences between that disease and
syphilis are mentioned. The discovery of an organ-
ism which has certain morphological differences
from the organism now held by the majority of ob-
servers to be the cause of syphilis is an interesting
commentary on the accuracy of purely clinical meth-
ods. Pierrez, however, considered the disease to
be due to a bacterial infection.
THE HISTOLOGY OF THE YAWS PAPULE.
Specimens of yaws papules have been sent by
Ashburn and Craig to Dr. Harry T. Marshall
(Philippine Journal of Science. October, 1907),
who describes their histology. He finds that the
lesions are primarily degenerative changes resem-
bling colliquative necrosis, which affects the epithe-
lial structures. This degeneration leads to ulcera-
tion. Following the degeneration there is an irreg-
ular new formation of epithelium in the form of
down growths, and they, in turn, often degenerate.
Accompanying these changes, vascular dilatation,
oedema, and leucocytic infiltration occur in the
corium, with a minor deg'ree of new formation of
capillaries and connective tissue. There is no
endarteritis, and there are no other changes sug-
gestive of syphilis. At an early stage of the lesion
the infiltrating cells are polymorphonuclears and
mononuclears in about equal proportions, with many
of the latter of the plasma cell type. Sometimes the
plasma cells outnumber the polymorphonuclears.
Eosinophile cells are abundant. The lesions from
monkeys have practically the same histology as
those from human sources.
|iftos Items.
Changes of Address. — Dr. H. M. Carey, from Retreat,
Pa., to St. Georges, Del. ; Dr. William Campbell Posey, to
nortlieast corner of Twenty-first and Chestnut streetb.
Philadelphia.
Brooklyn Hospital. — A department of diseases of the
stomach and intestines has been opened at this hospital,
with Dr. Dudlc\- Ruhcrts as chief of the service, and Dr.
James T. PilclKr as his associate.
Cuniberland County, Me., Medical Society.— At a
meeting of this society, held on Thursday, March 26th, the
principal paper of the evening was read by Professor Wil-
liam D. Hard, of tlie University of Maine.
The Northern Medical Association of Philadelphia.—
At a stated meeting of this society, held on Friday evening,
March 27tli, Dr. Jay F. Schambcrg read a paper on the
Diagnosis and Treatment of the More Common Diseases of
the Skin, which was illustrated by lantern slides.
Buffalo Medical Clinic. — At the regular monthly
meeting, which was held on 'I'hursday evening. March 5th.
at the residence of Dr. Hofifman. the principal paper of the
evening was read by Dr. F. .\. Drake. The subject was
Psychotherapy — the Emmanuel Church Movement.
The Third Cartwright Lecture will be delivered by
Dr. James Ewing, of Cornell University Medical College,
on Monday evening, March 3t>th, at the New York Acad-
emy of Medicine. The subject will be Clinical Forms of
Acidosis, Pathological Anatomy and Classification.
Richmond, Va., Academy of Medicine and Surgery. —
At a meeting of this academy, held on Tuesday evening,
March 24th, Dr. St. George T. Grinnan read a paper en-
titled Rheumatic Cycle in Childhood — Tonsilitis, Chorea,
Arthritis, and Carditis, and Dr. M. O. Burke read a paper
on the Uses of the Stomach.
The Bill for a New State Hospital for the Insane.—
An act appropriating $119,250 has been introduced into the
Legislature to provide for the purchase of the site of eight
hundred and four acres at Congers, Rockland County, N. Y.,
upon which will be erected a new State hospital for the
insane, with a capacity of probably 2,500.
Association of the Surgeons of the Southern Railway
Company. — A meeting of this association will be held
in Birmingham, Ala., on April 28th, 29th, and 30th. A long
list of papers and subjects of interest to railway surgeons
is shown on the preliminary programme, and the meeting
promises to be one of special interest.
A Banquet in Honor of Dr. Robert Koch will be
given at the Waldorf Astoria on Saturday evening, April
nth, under the auspices of the German Medical Society of
New York. The price is $7 a plate, which includes wine.
Admission cards may be obtained from Dr. George Mann-
heimer. No. 60 East Fifty-eighth street, New York.
Saratoga Springs, N. Y., Medical Society.— At a meet-
ing of this society, which was held on Friday, March 20th,
the general subject for discussion v.as lobar pneumonia.
Papers were read by Dr. Bently on the aetiology and
pathology, by Dr. Resseguie on the symptoms and diag-
nosis, and by Dr. Ledlie on the treatment of lobar pneu-
monia.
The Mortality of New Orleans, La. — During the month
of February, 1908, there were reported to the Board of
Health of New Orleans 736 deaths from all causes, 462
white, and 274 colored. The annual death rate in 1,000 of
population was 21.48 for the white population, 35.35 for the
colored, and 25.16 for the total white and colored
population.
An Antituberculosis League has been organized in
Lawrence, Mass. Antispitting signs have been placed about
the town by the board of health, and an efTort will be made
to keep the streets cleaner. A class for instruction in the
cause and prevention of tuberculosis has been formed
which meets once a week. The league is planning to es-
tablish a day camp in the near future.
Medical Inspections of Schools in Chicago. — During
the week ending March 7tli the medical inspectors exam-
ined 6,828 school children, excluding 313 on account of
contagious diseases. Of the total number of exclusions 58
were for measles, 12 for scarlet fever, 7 for whooping
cough, 6 for diphtheria, 3 for chickenpox, and 7 for mumps.
Vaccination was performed on 890 pupils.
The Mortality of Portland, Me. — During the four
weeks ending March 7. 1908. there were reported to the
Board of Health 98 deaths from all causes, as compared
with 108 for the corresponding period in 1907. The annual
death rate in 1,000 of population was 21.23. Of the total
number of deaths, 23 were from contagious diseases, 17
from pneiunonia, and 7 from tuberculosis.
The Manhattan Medical Society held a stated meet-
ing on Friday evening, March 27th. Dr. Louis Fougeres
Bishop reported several cases of early liver symptoms in car-
diac diseases, and after the reading of a paper on Post Mor-
tem Findings in Cases of Eclampsia, by Dr. John Edgar
Welch, a clinical conference was held on Icterus, Its Sig-
nificance and Treatment. .\ general discussion followed.
Vacancies in the Staff of the West Side German
Dispensary.- There arc two vacancies in the staff of the
trenitourinary clinic of the West Side German Dispensary,
which meets on Tuesday, Thursday, and Saturday even-
ings, from 7:30 to 8:30. There is a large general service
at this clinic, and it offers a good opportunity for special
work in cvstoscopy, urethroscopy, and urethral catheteriza-
tion. .Applications .should be sent to Dr. .Abraham L.
Wolbarst. 105 East Ninetcentli street. New York.
March 28, igoS.]
NEWS ITEMS.
605
Buffalo Academy of Medicine.— A stated meeting of
this academy was held on Tuesday evening, March 24th,
under the auspices of the Section in Obstetrics and Gyne-
cology. Dr. James E. King read a paper entitled Trans-
verse Abdominal Incision in Pelvic Surgery, Its Advan-
tages and Limitations, and Dr. Frank 2^IcGuire read a
paper entitled The Treatment of Diffused or Spreading
Peritonitis.
The Middleton Goldsmith Lecture of the New York
Pathological Society will be delivered by Professor Frank
B. Mallory, of Harvard University, at the New York Acad-
emy of Aledicine. on April 4th, at 8:30 p. m. The subject
will be The Results of the Application of Special Histologi-
cal Methods to the Study of Tumors. The lecture will be
illustrated, and all who are interested in the subject of
tumors are invited to attend.
Hickman County, Tenn., Medical Association.— At a
recent meeting of this association Dr. Robert P. Wilson
read a paper on Nematodes, and Dr. Andrew Norris
read a paper on Parasitic Diseases. The officers of the
association for the current year are : President, Dr. Ken-
neth I. Sutton, of Centerviile ; vice president. Dr. J. W.
Thompson, of Centerviile : secretary and treasurer. Dr.
John S. Beasley, of Centerviile.
The New Hampshire State Board of Health an-
nounces that it has issued a new compilation of the
public health laws of the State, chiefly for the use of health
officers, physicians, town clerks, undertakers, and all who
have specific duties to perform under these laws. If anj
interested person fails to receive a copy, one will be for-
warded upon application to the board. Dr. Irving A. Wat-
son, of Concord, is the secretary of the board.
Scientific Society Meetings in Philadelphia for the
Week Ending April 4, igoS.—U'cditcsday April ist. Col-
lege of Physicians : Association of Clinical Assistants of
Wills Hospital. Thursday, April 2d, Obstetrical Society:
Medical Society of the Southern Dispensary ; Section Meet-
ing, Franklin Institute: Germantown Branch, Philadelphia
County Medical Society. Friday, April 2d, American
Philosophical Society: Kensington Branch, Philadelphia
County Medical Society.
The Pathological Society of Philadelphia held a stated
meeting on Thursday evening. March 26th. A number of
card specimens were presented bv Dr. E. M. L'Engle. Dr.
T. C. Kelly, Dr. A. J." Smith, and Dr. John Funke, and the
following papers were read : A Study of the Colon Aero-
genes Group of Bacteria, by Dr. David Bergey; A New
and Improved Method in the Presumptive Test for Bacillus
coli communis, by Dr. D. Rivas ; Periarteritis Nodosa, by
Dr. William T. Longcope : Cysts of the Gallbladder Ducts,
by Dr. R. S. Lavenson.
A Special Tuberculosis HospitJil for Oneida County,
N. Y. — The Board of Supervisors of Oneida County,
N. Y., has passed resolutions providing for the establish-
ment of a hospital for advanced cases of tuberculosis. An
appropriation of from $65,000 to $85,000 will be made for
the building of a general county hospital and a special
tuberculosis hospital, to be erected on the same grounds,
but entirely separate from each other. The tuberculosis
hospital will have a capacity of twenty-five beds for men
and fifteen beds for ^\-omen.
Philadelphia County Medical Society. — The Central
Branch of this society held a meeting on Wednesday,
March 25th. The evening was devoted to a "symposium'
on psychotherapeutics, and papers were read as follows :
Dr. Charles K. Mills, Psychotherapeutics, Its Methods.
Scope, and Limitations : Dr. Charles W. Burr, The Use of
the Mental Element in the Treatment of Disease : Dr. F. X.
Dercum, An Analysis of Psychotherapeutic Methods. The
discussion was opened by Dr. John K. Mitchell, Dr. Wil-
liam G. Spiller. and Dr. Charles S. Potts.
A Congress on Physiotherapeutics will be held in
Paris during Easter week, under the auspices of the French
Society of Electrotherapy and Medical Radiology, and the
Kinesithcrapeutic Society. The general subject for dis-
cussion will be the use of such physical agents as electricity,
massage, gymnastics, light, x rays, etc., in the diagnosis
and treatment of articular. and bony traumatism, and in the
treatment of neuralgia and neuritis. Information regard-
ing the congress may be obtained from the general secre-
tary of the organizing committee, Dr. Lequerriere, 2 rue de
la Bienfaisance, Paris.
The Health of Pittsburgh. — The following cases of
transmissible diseases were reported to the Bureau of
Health of Pittsburgh for the week ending Alarch 7, 1908:
Chickenpox, 6 cases, o deaths ; typhoid fever, 25 cases, 7
deaths; scarlet fever, 19 cases, 4 deaths; diphtheria, 9 cases,
o deaths; measles, 221 cases, 10 deaths; whooping cough,
19 cases, I death ; pulmonary tuberculosis, 21 cases, 13
deaths. The total deaths for the week numbered 205, in an
estimated population of 403,300, corresponding to an annual
death rate of 26.43 i" 1,000 of population.
Rochester, N. Y., Academy of Medicine. — The Sec-
tion in Public Health, which includes hygiene, climatologi',
physiolog}-, pathology, bacteriology, and forensic medicine,
held a meeting on Wednesday, March 25th. The general
subject for discussion was the investigation of medicolegal
cases. Dr. E. B. Angell read a paper dealing with the ex-
amination of the nervous system ; Dr. E. W. Mulligan pre-
sented a paper dealing with the surgical aspect of the
question; and Dr. W. J. Herriman read a paper on The
Detection of Malingering. Dr. F'ranklin W. Bock is chair-
man of the section and Dr. Bradford A. Richards is the
secretary.
The West End Medical Society of the City of New
York — The second regular meeting for 1908 will be
held at the Belleclaire Hotel, on Saturday evening, March
28th, at 8:15 o'clock. Dr. Theron W. Kilmer will read a
paper on The Ambulatory Treatment of Cases of Pneu-
monia in Infants and Yoimg Children, which will be dis-
cussed by Dr. Charles Gilmore Kerley, Dr. W. B. Hoag,
and Dr. Floyd M. Crandall, and a general discussion will
follow. The officers of the society are : President. Dr.
Le Roy Broun ; vice president, Dr. Frank S. Fielder ; sec-
retary. Dr. William H. Morrison ; and treasurer. Dr. E. V.
Hubbard.
Vital Statistics of New Jersey. — During the month
ending February 15, 1908, there were 3,528 deaths reported,
an increase of 147 over the previous month. The principal
cjiuses of death were: Typhoid fever. 39; measles, 11;
scarlet fever, 50; whooping cough, 24; diphtheria, 67; ma
larial fever, i ; pulmonary tuberculosis, 375 ; other forms of
tuberculosis, 47; cancer, 126: cerebrospinal meningitis, 24;
di.seases of the nervous system, 434: diseases of circulatory
system, 420; diseases of respiratory system (pneumonia
and tuberculosis excepted), 275: pneumonia, 516: infantile
diarrhoea, 52; diseases of digestive system. 174; Bright's
disease, 220; suicide, 22: all other causes, 651.
The Philadelphia Neurological Society held a stated
meeting on Friday evening, IMarch 27th. Dr. Alfred Gor-
don presented a case of superior and inferior polioencephal-
itis. Dr. S. D. Ingham presented a case of syringomyelia.
Dr. Moore presented for Dr. Spiller an atypical case of
Friedreich's ataxia. Dr. Lightner Witmer presented a case
of aphasia and read a paper on Certain Cases in which the
Psychologist May Assist the Neurologist. Dr. William G.
Spiller read a paper on Hemiplegia with Rigiditv of the
Neck Caused by Cervical Myelitis. Dr. Samuel 'Leopold
read a paper on Osseous Plaques of the Spinal Pia Arach-
noid and Their Relation to Pain in Acromegaly.
The Gloucester County, N. J., Medical Society.— At
the meeting of this society, held on Thursday, March 19th,
Dr. John M. Swan, instructor in clinical pa"tholog\^ in the
Philadelphia Polyclinic and College for Graduates in Medi-
cine, made an address on the Diagnostic Significance of
Leucocytosis. The address was supplemented by a micro-
scopic demonstration of specimens showing leucocjtosis of
varying extent. Dr. Pfeiffer, of the German Hospital,
Philadelphia, reported an interesting case. There was a
discussion on medical legislation as affecting the State of
New Jersey. The scientific business was followed by a
dinner at Paul's Hotel. About thirty-five members and
guests were present.
Society Meetings for the Coming Week:
Wednesday, April j^f.— Society of Alumni of Bellevue
Hospital, New York; Harlem Medical Association;
Elmira, N. Y., Academy of Medicine.
Thursday, April .^rf.— Ne\v York Academy of Medicine;
Dansville, N. Y., Medical Association.
Friday, April sd.—'Nev/ York Academy of Medicine (Sec-
tion in Surgery) ; New York Microscopical Society ;
Gynaecological Society, Brooklyn, N. Y. ; Manhattan
Clinical Society; Practitioners' Society of New York.
6o6
NEWS ITEMS.
LNlivV VORK
Medical Journal.
The Mortality of Chicago. — According to the report
of the Department of Health for the week ending March
14, 1908, there were during the week 639 deaths from all
causes, as compared with 684 for the corresponding week
in 1907. The annual death rate was 15.38 in 1,000 of popu-
lation. The principal causes of death were : Apoplexy, 1 1 ;
Bright's disease. 31; bronchitis, 20; consumption, 78; can-
cer, 15; convulsions, 7; cerebrospinal meningitis, 3; diph-
theria, 11; heart diseases, 53; influenza, 10; intestinal dis-
eases, acute, 50; measles, 16; nervous diseases, 16; pneu-
monia, 120; scarlet fever, 8; suicide, 9; typhoid fever, 7;
violence, other than suicide, 44; whooping cough. 2: all
other causes, 139.
Vital Statistics of New York. — According to the re
port of the Dep'artnient of Health of the City of New York,
there were during the week ending March 14, 1908, 1,604
deaths from all causes, as compared with 1,670 for a cor-
responding period in 1907. The annual death rate was
18.92 in 1,000 of population. Of the total number of deaths,
826 were in the borough of Manhattan, 125 in the Bronx,
557 in Brooklyn, 69 in Queens, and 27 in Richmond. The
death rate for the borough of the Bron.x was 19.91, which
was the highest for the tive boroughs, and Brooklyn wa>
second with a death rate of 19.47. The death rate of Man-
hattan for the week was 18.79, of Richmond 18.37, and of
Queens, 15 48. There were 578 marriages recorded during
the week, 2,317 births, and 132 stillbirths.
Personal. — Dr. Frederick L. Benton, a surgeon in
the United States Navy, is the first American physician to
receive a degree in medicine and science at the University
of Havana. Dr. Benton is now regimental Nurgeon of the
marine regiment in Cuba. The examination was in
Spanish.
Dr. Arthur Keith, lecturer on anatomy at the London
Hospital Medical College, has been appointed conservator
of the Museum of the Royal College of Surgeons.
Mr. Peter White, of Marquette, Mich., has given $1,000
to the library of the University of Michigan, to be used in
purchasing rare medical books.
Dr. Ennion G. Williams, of Riclimond, has been ap-
pointed health commissioner of the State of Virginia.
Infectious Diseases in New York:
!/■(• are indebted to the Bureau of Rrenrds of the Depart-
ment of Health for the folUneiinj, statement of nei^' eases
and deaths reported for the tzeo leeeks ending Mareh .21,
1908 :
, March 14. , , Marcli2i. ^
Cases.
Deaths.
Cases.
Death;
Tuberculosis pulmoiialis . . .
■ ■ 434
191
507
168
. . 322
55
397
53
Measles
. ■ 1.643
27
1,607
33
44
961
37
... .87
2i8
37
9
27
3
Cerebrospinal meningitis . .
9
Totals
. ...3.598
340
3.748
307
The Health of Philadelphia.— During the week end-
ing March 7, 1908, the following cases of transmissible dis
eases were reported to the Bureau of Heallli : Malarial
fever, i case, o deaths ; typhoid fever, 85 cases, 9 deaths ;
scarlet fever, 74 cases, 5 deaths ; chickenpox, 32 cases, 0
deaths ; diphtheria, 85 cases, 18 deaths ; measles, 228 cases,
7 deaths; whooping cough, 19 cases, 5 deaths; pulmonary
tuberculosis, 139 cases, 73 deaths; pneumonia, 94 cases, 93
deaths ; erysipelas, 12 cases, O deaths ; puerperal fever, 8
cases, 7 deaths; cancer, 23 cases, 23 deaths; German
measjes, 3 cases, o deaths ; mumps, 28 cases, o deaths. The
following deaths were reported from other transmissible
diseases: Tuberculosis other than tuberculosis of the lungs,
4; diarrlicta and enteritis, under two years of age, 17;
cerebrospinal meningitis, i. The total deaths numbered
571, in an estimated population of 1,532,738, corresponding
to an annual death rate of 19.31 in 1,000 of population. The
total infant mortality was 119; under one year of age, 87;
between one and two years of age, 32. There were 35 still-
births. 21 males, 14 females.
Benedictine Sanitarium and Hospital, Kingston, N. Y.
— The annual meeting of the board of directors and the
staff of this institution was held on Friday evening. Feb-
ruary 28th. Dr. Charles Phelps, of New York, was re-
elected president of the staff, and Dr. Mary Gage-Day was
elected secretary, to take the place of Dr. Robert R Thomp-
son, deceased. The out of town consulting staff remains
the same as last year, and the local staff will be composed
of the following: Attending surgeons. Dr. Mark O'Meara,
Dr. James L. Preston, Dr. E. E. Norwood, Dr. Alexander
A. Stern, Dr. W. J. O'Leary, Dr. L. K. Steele; attending
physicians. Dr. George H. Van Gaasbeek, Dr. B. W. Maben,
Dr. Harvey C. Keator, and Dr. Adelbert H. Mambert ;
consulting physicians. Dr. W. E. E. Little, Dr. C. F. Keefe ;
attending physician and surgeon for the eye, ear, nose, and
throat. Dr. Aden C. Gates ; attending bacteriologist. Dr.
Charles W. Crispell ;, and attending gynaecologist. Dr. Mary
Gage- Day.
An Antituberculosis Campaign in Rochester, N. Y. —
The I^ublic Health Association of Rochester, N. Y., has
made arrangementts for a series of meetings to be held
during the week of March 30fh for the purpose of discuss-
ing the question of tuberculosis. The traveling tubercu-
losis exhibit of the State Department of Health will be
open to the public daily from i to 10 p. m. at Convention
Hall, where the meetings will be held, and illustrated lec-
tures will be delivered daily at 3 and 8 p. m. The campaign
will be opened on Monday, March 30th, by a joint meeting of
the Public Health Association with the medical and dental
societies and the ministerial associations of Monroe County.
Dr. Lewis Gregory Cole, of New York, will deliver an il-
lustrated lecture on Radiography in the Diagnosis of Tuber-
culosis, and Dr. John B. Huber, of New York, will deliver
an address on The Diagnosis of Incipient Tuberculosis.
Among those who will deliver addresses during the week
are Dr. C. W. Dodge, city bacteriologist of Rochester, Dr.
J. Franklin Bock, Dr. Albert C. Snell, Dr. Francis E.
Fronczak. of Buffalo, Dr. Arthur G. Root, of Albany, and
Dr. S. A. Knopf, of New York.
Meetings of State Medical Societies for the Month of
April, igo8:
Medical Association of the State of Alabama, annual
meeting at Montgomery, April 21st.
Arizona Medical Association, annual meeting at Tucson.
April 20th.
Medical Society of the State of California, annual meet-
ing at Coronado, April 21st, 22d, and 23d.
Florida Medical Association, annual meeting at Ocala,
April 15th.
Medical Association of Georgia, annual meeting at Fitz-
gerald, April 15th.
Louisiana State Medical Society, annual meeting at
Alexandria, April 28th, 29th, and 30th.
Mississippi State Medical Association, annual meeting at
Natchez, April 14th.
Medical and Chirurgical Faculty of Maryland, annual
meeting at Baltimore, April 28th, 29th, and 30th.
South Carolina Medical Association, annual meeting at
Anderson, April i6th, 17th, and i8th.
Tennessee State Medical Association, annual meeting at
Knoxville, April 14th.
Philadelphia Bureau of Health Statistics. — During
January, 1908, in the Division of Medical Inspection of the
Philadelphia Bureau of Health, 3,902 inspections were
made exclusive of schools: 654 fumigations were ordered;
43 cases were referred for special diagnosis ; 4,422 visits
were made to schools; 349 cjiiidren were excluded from
school; 311 cultures were taken; 133 injections of anti-
toxine were given ; and 412 persons w ere vaccinated. In
the Division of Vital Statistics 3,165 deaths, 2,921 births,
and 1,178 marriages were reported. In the Division of
Milk Inspection 8,561 inspections were made of 196,634
quarts of milk, of which 315 quarts were condemned.
Seven specimens were tested chemically and 984 micro-
scopically. In the Division of Meat and Cattle Inspection
3,695 inspections were made; 83 places were found unsani-
tary; 214 pieces of dressed meat were condemned; and 868
postmortem examinations were made with 44 condemna-
tions. In the Division of Disinfection 312 fumigations
were done for scarlet fever, 440 for diphtheria, 135 for
typhoid fever, 222 for tuberculosis, 545 for miscellaneous
diseases, and 17 schools were fumigated. In the Bac-
teriological Laboratory 1,396 cultures were examined for
the presence of bacillus diphtheriae; 510 specimens of blood
were examined for the serum diagnosis of typhoid fever ;
984 specimens of milk were examined, 208 specimens of
sputum were examined; 5 disinfection tests were made;
and 3,224,500 units of antitoxine were distributed. In the
Chemical Laboratory 97 analyses were made.
March 28, 1908.]
PITH OF CURRENT LITERATURE.
607
|it^ at Cnrnnt f ittratun.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
March 19. 1908.
1. Opening Address of the President before the New
England Psediatric Society,
By Thomas Morgan Kotch.
2. The Serum Treatment of Epidermic Cerebrospinal
Meningitis, By Charles Hunter Dunn.
3. The Use of Fat Free Milk in Infant Feeding.
By Charles W. Townsend.
4. The Use of the Rontgen Ray in the Study of Diseases
of Children, By Arl^l W. George.
2. The Serum Treatment of Epidemic Cere-
brospinal Meningitis. — Dunn has used Flexner's
antiserum, since Xovember. 1907, in fifteen cases of
epidemic cerebrospinal meningitis, in all but one of
which the diagnosis was confirmed by the finding
of the diplococcus intracellularis in the cerebrospinal
fluid. Of these patients eight have completel}- re-
covered, two died, and five are still under observa-
tion. The eight patients who recovered are all
perfectly well, having been left with no sequelae of
anv kind, an unusually favorable result in this dis-
-ease. The two fatal cases were both chronic cases,
in which the disease had run considerable time
before coming under his observation. Of the five
cases which are still pending, four patients are now
convalescent and will undoubtedly recover : the
other is a chronic case, in which the outcome is
dubious. The eight patients, to whom the serum
was given early in the disea.se. showed a very
marked, even startling, improvement immediately
following the giving of the serum. In four of these
cases there was an immediate and permanent fall
of temperature, exactly resembling the crisis of a
pneumonia, which was accompanied by a complete
and permanent return of the mental condition to
normal, complete and permanent disappearance of
headache, and followed by rapid disappearance of
rigidity of the neck and all other signs. Two of these
cases, in twelve hours after the first dose, returned
from a condition of complete tmconsciousness to
one of absolutely normal mental condition. In the
other four cases, the temperature fell to the normal
by a fairly rapid lysis, accompanied by rapid im-
provement in the mental condition and disappear-
ance of symptoms and signs. In two of these, there
was a rapid change from a condition of active, al-
most violent, deliritim to one of normal mentality.
The conclusions he reaches are that the use of the
antiserum does no harm. Our author states that
he has tised it in larger doses than any of the other
investigators. In no case was there any sign of
bad effect, and in two cases he injected it into the
spinal canal without the previous withdrawal of
fluid withotit any sign of bad resttlt from increased
intradural presstire. He would not recommend the
use of this procedure without great caution. He
has never seen nor heard of a case proved by lumbar
puncture to be true epidemic meningitis which
aborted or terminated by sudden crisis at an early
stage. The recovery by crisis and the rapid im-
provement followed by recovery immediately fol-
lowing the giving of the antiserum, in so large a
proportion of this series of cases, is. he believes
strong evidence of the favorable specific eltect of
this treatment. The completeness of the recovery
of the cases in this series is another very important
feature. The most important point suggested by
the results of the tise of the Flexner serum, in this
series of cases of epidemic cerebrospinal meningitis,
is the advantage to be gained by giving it early in
the course of the disease. Not only did all the pa-
tients to whom it was given early recover, but all
those cases in which its use was followed by a
marked immediate improvement were cases in which
it was given within the first few days of the disease ;
and in two of these earlier cases, the disease was
apparently completely aborted by one dose of the
antiserum. He thinks the results of the Flexner
antiserum in these cases are stifficiently good to af-
ford a very strong basis of hope that this treatment
will prove of great value in the treatment of cere-
brospinal meningitis, a value commensurate with
that of antitoxine in diphtheria,
3. The Use of Fat Free Milk in Infant Feed-
ing.— Townsend thinks that, while fat is very
necessary to the normal infant, it is more often
given in excess than is generally supposed. Excess
of fat may cause one or more of a number of symp-
toms, as, for example, constipation, white and
"curdy" stools, a ravenous appetite with atrophy,
convulsions. In gastrointestinal disturbances it is
desirable to exclttde fat. The proteids of undiluted
fat free milk appear to be remarkably well borne
even by young infants, and there is an absence of
so called curds from the stools.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
March 21, J908.
1. Some Neglected Facts in the Biology of the Tetanus
Bacillus. Their Bearing on the Safety of the So
Called Biological Products. By Theobald Smith.
2. The Home Treatment of Pulmonary Tuberculosis,
By Orville Harry Brown.
3. ^Management of the Sexual Factor in Tuberculosis, and
Its Relation to the Home Treatment,
By W. H. Peters.
4. Traumatic Pneumonia, By Jaaies Joseph King.
5. Injuries of the Spinal Cord, with the Study of Nine
Cases with Necropsy. By Alfred Reginald Allen.
6. The Endemic Occurrence of Cancer in Fishersville.
Va., and Vicinity. By A. L. Tvnes.
7. "'Cactin" and "Cactina." An E.xamination into Their
Physiological Actions, By S. A. Matthews.
8. A Breach of Trust ; The Physician's Use of Secret
Remedies. By John B. Roberts.
2. The Home Treatment of Pulmonary Tu-
berculosis.— Brown says that in the treatment of
tuberculosis a proper regulation of rest and exer-
cise is the most important point. Absolute rest must
be enforced during and for some time after the ex-
istence of toxaemia. The exercise must begin after
nearly normal weight is gained, and very gradually,
so as not to prodtice toxaemia. It is best that the
exercise be begun so that there is an interval of a
week or more between two exercise periods. The
second important factor is good air. Fresh country
air. or a* climate which is not too warm, and at an
tltitude of not more than 1,000 to 1.500 feet, is de-
sirable. Air should be circulating through the pa-
tient's room all the time. It is of some benefit, per-
haps, in some instances, for the patient to live out
of doors. This is of little importance, however, when
compared with the significance of the rest and exer-
cise. The third important factor is good food. The
patient should have three good meals a day. and be-
tween each two meals a lunch of eggs and milk.
6o8
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
Forced fee.ding is not necessary, but good feeding is
essential. It should also be repeated that consump-
tives are curable, and that it is being demonstrated
every day. The tuberculous patient must, however,
be treated as though he were really sick, just as sick
as if he had some acute disease, as scarlet fever,
typhoid, or pneumonia. In tuberculosis, where there
are signs of progress of the disease, it is of far more
importance to keep the patient quiet than to force
him to eat unusually large quantities of food, or keep
him out of doors all' the time, or give him large quan-
tities of codliver oil, creosote, or other drugs.
3. The Management of the Sexual Factor in
Tuberculosis. — Peters remarks that the problem
of how to regulate sexual intercourse is one of the
most difficult in phthisis therapy, and that it is cor-
respondingly important. Some physicians think it
is erroneous to hold that consumptives are more
prone to sexual excitement than healthy individuals ;
that we are impressed in rather a disproportionate
way because the erethism which some consumptives
admit is surprising and grotesque, when this disease
is, in itself, so enervating and so exhausting. At the
other extreme are those physicians who consider the
phenomenon a very prevalent one. The latter view
is apt to be held by those of our colleagues who do a
great deal of dispensary work among the poor in
large cities, and among the victims of alcoholism
and prostitution, which factors are so often either
predisposing to or coexisting with consumption. Be-
tween these two extremes of opinion, however, are
ample data to show that the tendency to abnormal
sexual excitement is so frequent among consump-
tives as to require the careful attention of the physi-
cian. What are the reasons for such abnormal ere-
thism in consumptives? There is, first, the lack of
occupation, which is" either enforced by the phvsicinn
as one of the fundamental principles of phthisis ther-
apy, or which has naturally come about through the
patient's weakness and hesitancy of employers to en-
gage a sick man. Enforced idleness follows, and
this oftentimes leads to unwholesome introspection.
Then, the temperature in consumption, no doubt,
excites erethism. The toxines generated bv the tu-
bercle bacillus and in the mixed infections have a
similar influence. Then, there is the forced feeding
essential to the cure ; the eating of raw eggs and
rich red meats; also the stimulating life in the open
air and sunshine, and the tonics — such as strychnine
— which we find adjuvant to the cure. Besides, some
con.stimptives feel that their disease dooms them to
an carl}- death, and "Drink and hf merry, for to-
morrow y'ou die," becomes their life philnsnphv. The
physician should represent to the patient that the
treatment which is emphasized, rest, nourishing
food, outdoor life, and the u.se of tonics and stimu-
lants, is essential, in order that the exhausted or-
ganism may fight and destroy the forces o^f disease
which so grievously beset it ; and that if the body be-
comes enervated by excesses and acts tending to de-
plete the strength, recovery can not be hoped for.
We must appeal to the fair mindedness of the con-
sumptive, stating to him that the spermatic fluid
contains the fructifying sperm up to the day of
death ; that children have often been born long after
the death of consumptive fathers ; that such children,
because of the physiological poverty of tlieir sick
progenitors, come into the world with the most un-
fair and cruel handicap of an abnormal heredity.
The well husband of a consumptive wife should
have his honor and real aflfection for her appealed
to, not to make her pregnant ; since in such cases
the saddest of all deaths is deplorably frequent.
Finally, consumptives who consult physicians with
regard to their marriage prospects should be most
earnestly counseled not to take the step until they
are entirely cured.
6. The Endemic Occurrence of Cancer in
Fishersville, Va., and Vicinity. — Tynes states
that there has been an endemic of cancer in Fishers-
ville and vicinity for a number of years. At one
time there was a high mortality from cancer among
those who lived in the community, by no means con-
fined to families, succeeded by a period in which
there was comparative immunity to the disease. This
period is followed by a decade in \vhich there is a
recurrence of the disease, causing a higher mortality
in his own practice than that of any other disease.
In a nearby city, within an area a little larger than
a city block, twelve cases have developed during the
last seven years, and this in a city in which the phy-
sicians inform the writer they have seen very few
cases of cancer. He believes sufficient evidence has
been submitted to show that the high mortality from
cancer in Fishersville and vicinity is not due to a
fortuitous occurrence, but is due to an infectious
organism transmitted directly or by means of a host.
Such a theory does no violence to the views of those
who believe in a hereditary predisposition to cancer.
MEDICAL RECORD.
March 21, igo8.
1. A Study of Four Hundred Cases of Epithelioma, in
Private Practice, with Remarks on Treatment and
Resuhs,
By L. Duncan Bulkley and Henry H. J.vneway.
2. Acute invasion of the Kidneys by the Bacillus Coli,
By W. Hanna Thomson.
3. Arnctli's Method in the Clinical Study of Pulmonary
Tuberculosis,
By G. E. BusHNELL and C. A. Treuholtz.
4. The Diagnosis and Treatment of Early Ectopic Gesta-
tion, By Aeram Brothers.
5. Treatment of Hyperphonia (Stuttering and Stammer-
ing) by the General Practitioner,
By E. W. Scripture.
6. Freud's Method of Psychotherapy,
By L. Pierce Clark.
I. A Study of Four Hundred Cases of Epi-
thelioma, in Private Practice, with Remarks on
Treatment and Results. — liulkley and Janeway
observe that the most frequent form of cancer which
the dermatologist is called on to treat is, both patho-
logically and clinically, quite a dif¥erent growth in
its relatively benign course from the usual concep-
tion of cancer. It occurs chiefly about the face, in
places where radical operative measures are apt to
produce serious deformities, which very materially
add to the patient's discomfort, Wliile the experi-
ence of thirty-five years demonstrates that many
cases can be permanently cured by caustic pastes,
these are at times disappointing and may lead to an
aggravation of the trouble. The curette cannot be
depended on alone, but requires additional destruc-
tive agents to the base left after operation. By the
proper use of the x ray we have a safe, and, in
cases that have not been grossly neglected or mal-
March 28, 1908.]
PITH OF CURRENT LITERATURE.
609
treated, a sure method of cure, with the least amount
of deformity. In cases where knowledge and ex-
perience show that these lighter measures are not
likely to avail in checking the course of the disease,
recourse should certainly be made to complete sur-
gical removal, as this has been shown to be perma-
nently successful in a reasonable proportion of cases.
4. The Diagnosis and Treatment of Early
Ectopic Gestation. — Brothers observes that in
the attempt to make a diagnosis of ectopic gestation
a careful previous history is desirable. The age of
the patient, period of married life, nature of menses
previous to and since marriage, the number of chil-
dren or abortions, including their nature and post
partum ailments — all should be inquired into. The
possibility of gonorrhoea! or puerperal infections, of
endometric or annexal disease should be sought for
in such previous history. Previous operations — es-
pecially curettages — should be noted. In taking
note of the present illness, the mode of onset — par-
ticularly if an attack of syncope is referred to — •
should be analyzed. Symptoms pointing to the pos-
sibility of an early pregnancy and an impending or
an incomplete abortion are of peculiar value in the
history of the case. The three original subjective
symptoms are, irregular uterine bleeding, cramps,
or pelvic pains, and fainting spells, and should direct
the attention of the physician to the possibility of
ectopic gestation, the diagnosis of which can then
be substantiated or negatived by the physical exam-
ination. Besides these there are minor symptoms,
such as rectal and bladder symptoms, etc. Dis-
tinctive diagnosis must take into consideration or-
dinary uterine pregnancy with the usual symptoms
of impending or. incomplete abortion. Diagnosis
has been made of choletithiasis or appendicitis : a
fibroid uterus can usually be distinguished by the
history, and the stone like hardness of the one or
more tumors present. Cystic ovarian tumors and
intraligamentary cysts sometimes lead to errors,
particularly when they are complicated by uterine
pregnancy, or are wedged in the pelvis, or are
twisted on their pedicles. The cystic feel, the globu-
lar contour, the lateral situation, and the mobility
of ovarian cysts suffice ordinarily to distinguish
them. Pelvic abscess may at times strongly simu-
late an ectopic gestation. In case the presence of a
febrile movement, exquisite tenderness over the
mass, a markedly increased leucocytosis and poly-
nuclear count fail to clear up the diagnosis the intro-
duction of an aspirating needle will definitely settle
the matter.
5. Treatment of Hyperphonia (Stuttering and
Stammering) by the General Practitioner.—
Scripture remarks that the general therapeutic indi-
cations include treatment of any. nose or throat
trouble that may be present, building up the gen-
eral health, etc. It sometimes does occur that an
operation for adenoids, for phimosis, or for anything
else is followed by complete cure of the stuttering,
but this is purely a result of the patient's belief that
the operation was intended for his disease. Everv
case of hyperphonia requires special therapeutic pro-
cedures. His own experience has slwwn the follow-
ing ones to be most effective : Introducing melody
into the voice, developing expressiveness, distrac-
tion from the compulsive idea. The author explains
his methods of procedure, and asserts that they
will permanently cure three quarters of the stutter-
ers and stammerers, if practice is given at first as
often as possible and then at steadily increasing in-
tervals. The treatment should last for fifteen min-
utes to half an hour. At first it should be given at
least three times a week, then twice a week, then
once a week, then once in two weeks, and so on.
The patient should be warned that if he stops sud-
denly his trouble will probably return. The care of
the general health and the examination of the mind,
nerves, and breathing organs are so important that
only a physician can be considered competent to
advise. For a case of stuttering the parent should
send the child directly to the doctor. Unfortunately
the doctor is very likely to prescribe a tonic and to
say that t"he trouble will pass away in the course of
time. Sometimes it does ; generally, however, it
steadily becomes worse, and the child's companions
and parents by their taunts or nagging or scolding
make his life a condition of torture to which Hades
would be a relief. Hyperphonia is a serious disease.
The patients do not die of it directly, but their lives
are so filled with suffering that most of them wish
they could. That some of them are cured by out-
siders does not alter the fact that most of them
are not.
BRITISH MEDICAL JOURNAL.
March j, 1908.
1. Clinical Rem.^rks on Pulmonary Tuberculosis in In-
fancy and Childhood, By R. A. Young.
2. The Modern Treatment of Surgical Tuberculosis,
By V. W. Low.
v A Case of Actinomycosis (Streptotrichosis) of the
Lung and Liver Successfully Treated with a Vac-
cine, By W. H. Wvxx.
4. A Case of Abscess of the Lung Cured by Incision and
Drainage, By C. H. Cottle and J. R. Edward.
5. A Case of Phlegmonous Gastritis.
By A. J. Hall and G. Simpson.
6. A Successful Case of Thoracoplastj- for the Relief of
Chronic Empyema. By J. R. LuxN.
7. A Typhoid Carrier of Twentv-nine Years' Standing.
By G. Dean.
I. Pulmonary Tuberculosis in Children. — ■
Young states that the various authorities differ wide-
ly as to the frequency of pulmonary tuberculosis in
infancy and childhood. French observers assert that
fifteen per cent, of school children have tuberculosis
in some form, while English and German observers
make it less than two per cent. Of 337 children
with cough and wasting examined by the writer,
only forty-five showed signs of definite tuberculous
involvement of the Itmgs. As regards the manner
of infection of children with tuberculosis, there are
five possibilities — (i) transmission from the mQfher
to the foetus in utero ; congenital or hereditarv tu-
berculosis: (2) inoculation of wounds > inoculation
tuberculosis: (3) inhalation of tubercle bacilli , in
dust: aerogenous or inhalation tuberculosis; (4) by
swallowing bacilli in food, especially milk : inges-
tion or enterogenous tuberculosis; and (5) infection
through the ear. Eustachian tube, or tonsil. The
first two and the last of these may be dismissed as
exceedingly rare, and the problem is narrowed down
to the relative frequency of aerogenous and enterog-
6 10
PITH OF CURRENT LITERATURE.
(New York
Medical Journal.
enous tuberculosis. The question is not yet settled,
but it seems probable that the first is more common.
As regards predisposing causes, the condition of in-
fancy itself is one of high susceptibility, the resisting
power being low, and only a very short exposure
being required to produce, the disease. As regards
the sites and distribution of the lesions, attention is
called to the great frequency with which in children
the bronchial or tracheobronchial glands are in-
volved, either primarily, or secondary to pulmonary
infection. Again, the lesions in the lungs do not, as
a rule, follow the well known laws of spread from
apex downward, they being usually dififuse and very
often most marked at the root of the lungs. The
cases may be classified as follows: (a) Tuberculo-
sis of the tracheobronchial glands; (b) acute mili-
ary tuberculosis; (c) acute caseous tuberculosis;
and (d) chronic or fibrocaseous tuberculosis. Fibroid
tuberculosis does not exist in children. Cavities,
while difficult to recognize clinically in children, are
not uncommon ; usually they are small and of recent
origin. They may contain a sequestrum of broken
down lung tissue. Pleurisy is common and may lead
to parietal and interlobular adhesions. The diet
should be liberal, but children do not stand over-
feeding well. Drugs are but little needed. Tuber-
culin should only be used where the disease is strict-
ly localized, and then in very small doses. The aims
of the practitioner should be in the first instance to
prevent infection ; failing this, to establish the diag-
nosis as early as possible, and to employ every avail-
able means of improving the general health of the
child, with the object of improving its protective
powers. Under such conditions the outlook in a
considerable proportion of the cases is distinctly fa-
vorable.
2. Surgical Tuberculosis. — Low sums up the
modern treatment "of surgical tuberculosis as fol-
lows: I. In all cases "open air treatment" should
be organized to meet the circumstances and require-
ments of the particular case. 2. The patient's pow-
ers of resistance to the disease should be periodically
measured by suitable blood examination. 3. Where the
resistance is found to be low and there is no evidence
of excessive autoinoculation, use should be made of
inoculations of Koch's new tuberculin, in doses that
are accurately controlled, both as regards their
amount and repetitions, by examination of the blood.
4. For patients in whom there is evidence of excess-
ive autoinoculation, absolute rest with, in the case of
a limb, absolute fixity of the diseased part, should
be prescribed. 5. In the cases of circumscribed tu-
berculosis, efforts should be directed to increase the
circulation through the infected area. 6. Operative
procedures should be directed to the removal of the
inert material, whether caseous glands, carious bone,
or SDllections of pus, and allowing the access to the
infected area of healthy lymph. The necessary op-
erations should be conducted with the most scrupu-
lous asepsis.
7. Typhoid Carriers. — Dean reports the case
of a man who had typhoid fever twentv-nine years
ago, and who still has living typhoid bacilli constant-
ly present in his stools. Our conception of typhoid
fever has been materially altered by the ob.scrvations
of Forster. It is now held that the bacilli are pres-
ent in the blood during the incubation period, and
even before they can be found, antibodies are pres-
ent. The bacilli only appear in the faeces during the
first and second weeks. The bacilli therefore do not
multiply when first taken into the alimentary tract,
but find their way through its walls into the blood.
At a very early stage they gain entrance into the
liver and bile, and set up inflammation in the bile
ducts and gallbladder. Normal bile is not a good
medium for their growth, but when the albuminous
secretion due to the typhoid inflammation is added
to it, it becomes an excellent medium, and the bacilli
grow freely in the gallbladder and pass out in large
numbers, but intermittently, into the small intestine.
This explains the irregular occurrence of the bacillus
in the faeces. In most cases, with recovery the in-
flammation in the bile ducts and gallbladder also
ceases. But in about two per cent, of the cases this
cholecystitis typhosa becomes chronic, and the bacil-
lus continues to multiply in the gallbladder for
months or years, and to be thrown out into the gut.
and on out with the faeces. The gallbladder is then
a normal habitat of the typhoid bacillus. These
cases are the so called "typhoid carriers" — constant
sources of danger to the public. They account for
the sporadic cases, the origin of which has been so
puzzling. Gallstones occur in many cases, and, just
as three fourths of the cases of biliary calculi in gen-
eral occur in women, so three fourths of the typhoid
carriers are also women. In most of the cases the
blood serum possesses marked agglutinating prop-
erties. This may be useful as a means of detecting
such cases in a community. There is an enormous
reduction in the total number of microorganisms
present in the faeces, the normal inhabitants having
l)een altogether or largely replaced by the typhoid
bacillus.
LANCET.
March 7, igo8.
t. The Surgery of the Spinal Cord and Its Memliranes
(Hunterian Lectures, I), By D. J. Armour.
2. Tlie Diatheses : The Personal Factor in Disease,
By Sir D. Duckworth.
3. A Case of Aortic Aneurysm with Extensive .Arterial
Disease, By S. Taylor.
4. A Case of Wertheini's Hysterectomy for Advanced
Carcinoma of the Cervix, By A. H. N. Lewers.
5. Hernia of the Iliac Colon, By R. A. Stoney.
6. The Pathology and .■Etiology of Intussusception from
the Study of 1,000 Cases (concluded).
By D. C. L. FiTzwiLLi.\MS.
7. Seven Years' Experience of the Finsen Treatment,
By J. H. Sequeir.\.
8. A Case of Egg Poisoning, By A. T. Schofield.
9. Motoring Notes, By C. T. W. Hirsch.
I. Surgery of the Spinal Cord. — Armour, in
the first of the Hunterian lectures on the above
mentioned subject, discusses the congenital mal-
formation knowii as spina bifida. Under the terms
"rhachischisis" and "spina bifida" are included the
principal forms of congenital defects of the spine.
I')Oth are characterized by a deficiency in the verte-
bral arches, but distinguished by the presence or
absence of a well developed spinal cord. Total
rliachischisis includes all cases in which the verte-
bral canal is open from end to end ; the cord is al-
ways rudimentary or atrophic, split open or bifid.
It may be entirely absent (amyelia). This form
March 28. 1908.)
FITH OF CURREXr LITERATL RE.
611
occurs much more often with anencephalv. I'ar-
tial rhachischisis includes cases in which the de-
fective development affects only a part of the col-
umn. It ma}- or may not be associated with the
presence of a hernia, the condition being then
known as meningocele, meningomyelocele, or
syringomyelocele, according to the relation of the
spinal cord to the sac. In spina bifida occulta there
is no external evidence of the defective develop-
ment of the vertebral column, normal skin covers
the affected area of bone, and no cyst projects
through the bony defect, which is usually closed in
by a thick fibrous membrane. Spina bifida may be
accompanied by other malformations of the spinal
cord, and clubfoot, double or single, is a common
complication. Congenital dislocation of the hip.
hare lip, cleft palate, etc., also occur. Spina bifida
occurs about once in i.ooo births, and both sexes are
equally affected. While it may appear in any por-
tion of the spine, the lumbosacral region is most
frequently aft'ected, the sacral being next in order
of frequency. This is probably due to the fact
that the medullary groove is latest in closing here
to form the neural canal. The diagnosis is usually
easy, except where the tumor makes its exit
through a defect at the sides of the spinal column
and forms an intraabdominal cyst. Here it may be
impossible to distinguish it from other abdominal
cystic tumors. It is often impossible to distin-
guish clinically between the various forms of spina
bifida, myelocystocele, meningomyelocele, and
meningocele. The treatment of rhachischisis, or
complete lack of union, is hopeless. Spontaneous
cure in spina bifida does take place occasionally :
cure may also follow rupture and ulceration, but
these processes are also the most common causes of
death. Protection against rupture and abrasion
should be maintained in all cases. Simple tapping
should never be resorted to as a curative pro-
cedure : the fluid returns quickly, and sudden death
sometimes occurs. The only forms of treatment to
be recommended are palliation or excision. Pal-
liation is obtained by the use of some form of
shield used in conjunction with a broad abdominal
belt. But excision is now universally adopted, ex-
cept in absolutely inoperable cases. The indica-
tions to be met are the removal of the sac and the
closure of the cleft. The simplest and quickest
technique is the best ; no drainage should be used,
and special attention paid to asepsis. The opera-
tion should be done as early as possible. The chief
contraindications are marasmus and hydrocephalus.
The prognosis without operation is absolutelv
bad.
5. Hernia of the Iliac Colon. — Stoney states
that hernia of the iliac colon may occur in at least
three distinct ways: i. It may be drawn into or
through the inguinal canal by an extra attachment
of the gubernaculum testis. 2. It may be drawn
down by a protrusion of the peritonaeum covering it
in the formation of the sac of an ordinary hernia.
3. There may be a giving way or lengthening of
the supporting apparatus of this portion of the in-
testine and a subsequent protusion of it by the ex-
pulsive action of the abdominal muscles and dia-
phragm. The operative treatment varies accord-
ing to the condition of the sac ; where this is com-
plete it will not differ from the radical cure of any
other inguinal hernia ; but where the sac is incom-
plete the difficulties in the way of a radical opera-
tion may be great. The two main points to be at-
tended to in the operation are, first, not to interfere
with the blood supply of the loop of intestine, either
while trying to separate adhesions or while dissect-
ing up the posterior wall of the sac above the loop
of intestine from the surrounding tissues, for this
would mean almost certain gangrene of the gut ;
and, secondly, an attempt should be made to stitch
the cut edges of the peritoneum after the main part
of the sac has been cut away and the gut and re-
mainder of the sac together have been reduced in-
side the abdominal cavity.
6. Intussusception. — Fitzwilliam's paper is
based on a study of one thousand cases of intus-
susception. In the first part he brought forward
arguments to prove that the so called ileocolic va-
riety of intussusception is nothing more than an
enteric invagination which has commenced in the
lower part of the ileum and passed through the
valve. In the second he deals with the classification
of intussusception, the relative numbers of each va-
riety, and gives a short account of some of the
rarer forms. The seasonal incidence of the condi-
tion is marked. The number is low during Jan-
uary and February, and then suddenly rises to the
maximum in March. From April to September
the fall is gradual, w-ith a slight rise in October
and November, and a sharp rise in December. The
remarkable thing is the steady fall in the number .of
cases during those months in the summer and early
autumn when the intestinal disorders of infants
are most marked. The rise during December is
probably connected with the dietary peculiar to
Christmas time. The marked rise during March is
associated with ^Easter, at which time older chil-
dren are accustomed to take candy and other indi-
gestible food, a share of which is given to the in-
fants. Of 788 cases, sixty-eight per cent, were
boys and thirty-two per cent, girls. This dispro-
portion between the two sexes becomes still better
marked in children under twelve years of age, the
ratio between boys and girls being then three to
one. \\'hatever may be the explanation of this, it
is probably not due to any difference in anatomical
relationships, since the preponderance is most
marked during the early }ears of life before any
sexual dift'erences become marked. Indeed, the
sex incidence rather favors a dietetic origin of the
affection : male children, being larger and stronger,
are given more food than those of the opposite sex.
Want of coordination of the intestinal movements
may be an important factor in the production of in-
tussusception. It is only a factor, for it cannot be
the sole cause. From the diminution in the num-
bers of intussusceptions during the months when
epidemic diarrhoeas are at their height, it may be
supposed that the more violent forms of intestinal
stimulation are so potent that any invagination
which has taken place is reduced by the rapidity of
the intestinal movements long before it has become
really established. The age incidence, the effect
of the seasons, and the disproportion between the
sexes all seem to point to a dietetic rather than to
an anatomical causation of the disease.
6l2
PITH OF CURRENT LITERATURE.
[Xkw York
Medical Journal.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT.
March 3, 1908.
1. Opsonins as a Means of Distinction and Identification
of Pathogenic Fomis of Bacteria,
By ScHOTTMULLEK and AIucH.
2. Hasmolytic Action of Anchylostoma Duodenale,
By Preti.
-5. Concerning the Relation of Cobra Poison to the Red
Blood Cells, By Sachs.
4. The Use of Phlebotomy and. of the Local Abstraction
of Blood in Neuroses and in Gynsecological Diseases,
By Theilhaber.
5. Blood Serum Studies in Carcinoma of the Stomach
and Intestines, By Rosenbaum.
6. Graphic Registration of Blood Pressure in Man,
By JAQUET.
7. Standard Conditions for the Basis of the Dosage of the
X Rays, By Hessmann.
8. Concerning Inhalations of Saponin in Diseases of the
Upper Air Passages, By Zickgraf.
9. Contribution to the Causes of Death After Lumbar
Anaesthesia with Stovain, By Birxbaum.
10. Concerning a Case of Tuberculosis of the Liver with
Large Nodules Cured by Operation, By Bunzl.
11. Pathology of Laryngocele, By Scheven.
12. Casuistic Contribution to the Importance of tbe Radio-
logical Investigation of the Colon, By Wiesner.
13. Concerning Treatment of Placenta Prjevia by Vaginal
Cfesarean Section. by RiJHL.
14. Concerning a Case of Traumatic Lu.xation of the Rignt
Ulnar Nerve. By Quadflieg.
15. A Glass Bulb Filled witli Physiological Salt Solution
Ready for L^se as an Infusion. By Brenner.
16. Tlie Restriction of Laparotomy by Vaginal Methods of
Operation, By Flatau.
17. Are the Objections to the Legal Regulations Concern-
ing Sexual Perversions Scientifically Tenable?
By Weygandt.
18. Obituary of Oskar Lassar, By Jesionek.
19. The New Regulations as to Board in the City Hospital
in Dresden, By Schanz.
I. Opsonins as a Means of Distinction
and Identification of Pathogenic Forms of Bac-
teria.— Schottmiiller and Much state that the
honor of the discovery of o]jsonins belongs to Rus-
sia at the hands of Aletchnikoff, but acknowledge
the indubitable service of Wright and his followers
in the discovery of a practicable method for then-
determination. They now advance the theorA- that
if several kinds of bacteria are to be found in a sick
man and yet only one of them is influenced opsonic-
ally by his serum it is extremely probable that this
microorganism is alone the originator of the sick-
ness. When several kinds of bacteria are thus influ-
enced the case is one of mixed infection. They pre-
sent first the results of their investigations in cases
of acute gastritis, gastroduodenal catarrh, and gas-
troenteritis, then a case in which the bacillus coli
communis played a passive role, then cases of epi-
demic cerebrospinal meningitis, in all of which the
offending microorganisms seemed to be pointed out.
3. Cobra Poison and the Red Blood Cells. —
Sachs disagrees with the conclusions recently pub-
lished by von Dungern and Coca to the effect that
the cobra venom contains a constituent rendered
specially active by serum complement which unites
with the red blood cf)rpuscles.
6. Graphic Registration of the Blood Pres-
sure.— Jacjuet describes an instrument which he
has devised and named the sphygmotonogmoh that
is to be applied to the wrist of the patient in such a
way that the pulsations of the radial artery will be
transmitted to a registration needle, which will re-
cord the blood pressure at the time.
8. Inhalations of Saponin in Diseases of the
Upper Air Passages. — Zickgraf states that he has
obtained excellent results in nasal conditions vary-
ing from rhinitis sicca to ozsena from the inhalations
of the fumes of saponin dissolved in hot water to the
strength of one or two per cent.
12. Radiological Investigation of the Colon. —
Wiesner reports a case in which an interval opera-
tion for appendicitis was successfully performed, but
was followed in about four weeks b)- attacks of acute
colitis occurring about every three weeks. Radio-
logical examination revealed the fact that the caecum
and a portion of the descending colon were bound
down by adhesions, and that a small blind pouch had
become formed in this portion of the intestine. This
condition was relieved by another operation, and a
radiological investigation three months later showed
that the intestine was in good position. There had
been no recurrence of the attacks of acute colitis five
months after the operation.
13. Treatment of Placenta Praevia by Vaginal
Caesarean Section. — Riihl reports two cases of
placenta praevia, in which he performed Caesarean
section through the vagina. He strongly advocates
this method of treatment, although formerly he was
inclined to condemn Caesarean section, either ab-
dominal or vaginal, as not indicated in such cases.
14. Traumatic Luxation of the Right Ulnar
Nerve. — Quadflieg reports a case of luxation of
the ulnar nerve in a man, thirty-five years old, who
had received an injury to the arm. The nerve was
laid bare and attached with silk threads to the tendon
of the triceps, the sutures passing through the peri-
neurium. The pain and other symptoms, which are
graphically described, disappeared immediately as the
result of the operation. This method of fixation of
the nerve seems to have worked better in this case
than the method of resection of a part of the nerve
on the assumption that it has been overstretched.
LA PRESSE MEDICALE.
February 29, igo8.
r. The Previous Condition of Victims of Railroad Ac-
cidents, By V. Balthazard.
2. Fulguration in the Treatment of Cancer,
By R. Rom ME.
I. Previous Condition of Victims of Railroad
Accidents. — Balthazard discusses the influence
that should be exerted by the previous condition of
the victim upon the indemnity for injuries received.
March 4, igo8.
1. Electrolysis in the Treatment of Angeiomata. Particu-
larly of Angeiomata of the Parotid Region,
By P. Redard.
2. Evolution. Forms, and Treatment of Bronchointc^tinal
Autoinfectiou in the Newly Born, By P. Londe.
I. Electrolysis in the Treatment of Angeio-
mata.— Redard reports with illustrations a case
of angeioma of the parotid region in a child of eleven
months which he successfully treated by means of
electrolysis. Five sittings only were required, and
the author declares that this is not an isolated case,
that he has cured in the same way many angei-
omata of the face which appeared to be serious. He
describes his technique very fully. When the pa-
tient is not docile, or when the angeioma is large,
arterial, or situated in a dangerous region, general
anaesthesia is necessary. Local an.xsthesia is insnf-
March 28, 1908.]
PITH OF CURRENT LITERATURE
613
ficient. The sittings should not be frequent. After
the first sitting from two weeks to a month should
elapse before the second, and the time between the
subsequent sittings should be determined by the effect
obtained.
2. Bronchointestinal Autoinfection in the
Newly Born. — Londe classifies these affections
as: I, Combined forms; (a) with coincident local-
ization; ( b) with alternate localization, acute, sub-
acute, and chronic, slight, serious, and very serious.
2, Disassociated forms; (a) with the respiratory
manifestation isolated, but not primary ; (b) with
the gastrointestinal manifestation primary and iso-
lated, each either acute, subacute, or chronic, slight,
serious, or very serious.
LA SEMAINE MEDICALE.
March 4, 1908.
1. Retrodeviations of Young Girls and Retrodeviations of
Young Women, By Professor R. de Bovis
2. Blepharoplasr\' b.v Means of a Pedicled Flap Taken
from the Xeck.
2. Blepharoplasty by Means of a Pedicled
Flap Taken from the Neck. — The writer describes
briefly the well known operations by means of pedi-
cled flaps for the formation of new eyelids, and de-
votes much space to a consideration of the operation
recently brought forward by Sn} dacker. of Chicago.
This operation is described in full, an evident trans-
lation from an American journal, the name of which
has been omitted, probably on account of a lapsus
memoriae.
AMERICAN JOURNAL OF THE MEDICAL SCIENCES
yiarcli, 1908.
1. Graves's Disease and Its Treatment.
By W. H. Thomson.
2. Adiposis Tuberosa Simplex, By J. M. Anders.
3. The Choice of Operation in Pvloric Stenosis,
'By J. M. T. Finney.
4 The Occurrence of Congenital Adhesions in the Com-
mon Iliac Veins, and 1 heir Relation to Thrombosis
of the Femoral and Iliac Veins.
By J. P. McMuRRicH.
5. Acute Glandular Fever, By G. I. Jones.
6. Epidemic Cerebrospinal Meningitis in HartforcJ, Conn.,
During 1904-1905. with Special Reference to the
Cases Treated at the Hartford Hospital,
By W. R. Steiner and C. B. Ingrah.\m.
7. Tumors of the Cauda Equina and Lower Vertebr.ne. A
Report of Nine Cases, Seven with Necropsy. Three
with Operation, By W. G. Spiller.
8. Morbid Sonmolence, By D. O. Hechi.
9. A Fatal Case of Pontile Haemorrhage, with Autopsv,
By T. DiLLER.
10. Chorioepithelioma of the Uterus. Report of a Fatal
Case, with Operation and Autopsy.
By B. M. .Ansp.xch and H. R. Alburger.
11. Specific Immunity and X Ray Therapeutics.
By A. W. Crane.
I. Graves's Disease and Its Treatment. —
Thomson states that no disease shows so many signs
of a universally acting toxaemia. Its many derange-
ments may be extreme, though no organic change
accompanies any of them. He thinks the symptoms
prove that one agent produces all the eft'ects. and
that the disease cannot be confounded with anything
else. The nature and origin of its specific poison
are wholly unknown. The chief cause of this igno-
rance is a want of knowledge concerning the phvsi-
ology of the thyreoid and its associated structures.
The nature cf the disease is complicated by the oc-
currence of two serious conditions which follow re-
moval of the thyreoid, namely, hyperpyrexia and
tetany. The view that the disease is due to hyper-
secretion of thyreoid juice is questioned. Proper
medical treatment furnishes the best chance for re-
covery in severe or mild cases. Rest from both
physical and mental exertion is the first requirement.
Dark meat and shell fish must be avoided. The
standard article of diet must be milk either ferment-
ed or peptonized, but never raw. Certain vegetables
and cereals are permissible and most of the fruits.
Medical treatment consists mainly in the persistent
use of intestinal antiseptics.
2. Adiposis Tuberosa Simplex. — Anders de-
fines this condition as constituted by the presence of
a larger or smaller number of fat nodules, ranging
in size from, a bean to a hen's egg. in the subcutane-
ous tissue of the abdomen or the extremities. They
do not fuse together, are not elevated above the
surface, and are usually painful to the touch. The
cause is the same as that of general obesity, and they
are removable by the same treatment which will re-
move obesity. They are not associated with any
glandular, mental, muscular, or nervous trouble.
That they are caused, like adiposis dolorosa (Der-
cum's disease), by disease of the lymphatic struc-
tures, of the thyreoid, or of the hypophysis, is
deemed improbable on account of the mildness of
their symptoms and the readiness with which they
yielded in the four cases reported by the author to
careful dietetic and regiminal treatment.
3. The Choice of Operation in Pyloric Steno-
sis.— Finney limits his discussion to the consid-
eration of organic strictures, surgical treatment be-
ing always presupposed for such conditions. Pyloric
stenosis in the adult usually originates from an ulcer.
The choice of operation should depend partly upon
the patient and partly upon the ability of the oper-
ator. If the condition is due to incipient cancer an
attempt at extirpation should be made by the Billroth
Xo. 2 method. If the obstruction is of benign ori-
gin the choice of operation will lie between gastro-
enterostomy, pylorectomy, pyloroplasty, and gastro-
duodenostomy. The clinical results which have fol-
lowed gastroenterostomy by the "no loop" operation
cf Mayo have been very good, the object being to
obtain good drainage of the stomach. The advan-
tage of pyloroplasty is that it preserves the ana-
tomical and physiological outlet of the stomach, and
it is indicated in the author's experience in connec-
tion with dilatation of the stomach, dense adhesions,
hypertrophy and cicatricial thickening of the stom-
ach wall, acute and chronic ulceration, and pyloro-
spasm. In forty-five cases the author has had very
good results, and he prefers the operation to any
other.
5. Acute Glandular Fever. — Jones defines this
condition as an infectious disease, developing usu-
ally without premonitory signs, and characterized by
slight redness of the throat, high fever, and swell-
ing and tenderness of the lymph glands of the neck.
Most of the reported cases have been in Germany
and France, Pfeffer having described the disease as
Dri'iseiifieber. It may be endemic or sporadic. Eighty
per cent, of the cases are in children. Exposure to
cold and damp favors its development. Some writ-
ers suppose it is a peculiar form of influenza. Its
6i4
PITH OF CURRENT LITERATURE.
[Ne'.v York
Medical Journal.
incubation is five to seven days. Its onset is sud-
den, with headache, abdominal pain, anorexia, chills,
constipation, coated tongue, pulse from 90 to 130,
temperature 102° to 104° F. The enlargement of the
glands begins from the second to the fifth day and
persists, v^nth more or less tenderness, two or three
weeks. The spleen, liver, and mesenteric glands are
also enlarged in many cases. Convalescence is usu-
ally uninterrupted. The dififerentiation must be
from leucaemia, pseudoleucaemia, tuberculous ade-
nitis, and syphilis, also from typhoid fever and
influenza. The presence of Pfeffer's bacillus deter-
mines the diagnosis.
7. Tumors of the Cauda Equina and Lower
Vertebrae. — Spiller states that the diagnosis of
these tumors must be between hysteria, multiple
neuritis confined to the lower limbs, intrapelvic
tumor, tumor or caries of the lumbar vertebrae or
sacrum, lesions within the vertebral canal but external
to the dura tumor or other lesion of the conus, and
the condition which is under consideration. The
pain with these tumors may be unilateral or bi-
lateral. The functions of the bladder and rectum
may be greatly impaired. Digestive disturbances
and emaciation are late symptoms. Both anterior
and posterior roots may be involved, and paralysis
of motion and sensation ultimately ensue. The
symptoms develop very slowly, but may be entirely
disproportionate to the size of the tumor. With
regard to surgical treatment, the operable tumors
are those of the membranes that have not implicated
the cord and are lipomata, fibromata, psammomata,
echinococci, and exostoses.
II. Specific Immunity and X Ray Therapeu-
tics.— Crane draws the following conclusions :
I. Such treatment may require sufficient intensity
to set free in the tissues the equivalent of an auto-
genous vaccination. 2. The duration of exposure
and extent of diseased tissue exposed should be so
regulated as to induce a small negative phase or
none at all. 3. The repetition of exposures should
be governed by the duration of the negative and
positive phases. If the disease producing agent in
a given case is undetermined, one should follow the
analogy of cases in which opsonic estimations can
be made. The advantages of x ray over opsonic
therapy are: i. The immunizing substance set free
by the x ray is autogenous, being formed from the
actual microbe strain which is producing the dis-
ease. 2. Many of the difficulties and mistakes of
a bacteriological diagnosis are eliminated. 3. If the
bacteriological cause is undetermined or the disease
producing agents arc not bacteria, the x rays are
still applicable.
THE SCOTTISH MEDICAL AND SURGICAL JOURNAL
March, igoS.
1. Notes on Immunity to Disease,
By W. F. Harvey and Anderson McKendrick.
2. Some Experiences with X Ray and High Frequency
Treatment, By F. Gardiner.
.1. The Recognition and Treatment of Incipient Mental
Disease, By T. C. Mackenzie.
I. Notes on Immunity to Disease. — Harvey
and McKendrick review our vaccinotherapy. The
applications are numerous. Some have been more
successful than others. A tubercle vaccine — Koch's
tuberculin — has been used for the cure of lupus, tu-
berculous glands, tuberculous sinuses, and genito-
urinary tuberculosis. It has been also used in early
cases of phthisis. A staphylococcus vaccine has been
used for boils, acne vulgaris, sycosis, malignant en-
docarditis, certain cases of pyaemia, and other such
affections due to this organism. A bacillus coli vac-
cine is useful in some cases of appendicitis, cystitis,
and cholecystitis. It is quite possible that an efficient
gonorrhoeal vaccine may be found which will be use-
ful in chronic cases. We may hope for a dysentery
vaccine, Malta fever vaccine, and pneumococcus
vaccine.
THE EDINBURGH MEDICAL JOURNAL.
Ma3-ch, igo8.
1. Remarks on Empyema Based on a Series of One Hun-
dred Consecutive Cases, By Albert E. Mori son.
2. The Symptoms and Etiology of Mania {continued),
By Lewis C. Bruce.
3. A Resume of the Report of the Royal Commission on
Human and Bovine Tuberculosis, By J. S. Fowler.
4. Tumor of the Cauda Equina Removed by Operation :
Recovery, By R. C. Elsworth.
5. A Review of Recent Work on Spinal Anaesthesia,
By J. W. Struthers.
6. Tropical Diseases: Notes on Some of the More Inter-
esting Cases Recently Under Treatment in Edin-
burgh, By D. E. Marshall.
I. Remarks on Empyema. — Morison con-
cludes from his obseivation of one hundred con-
secutive cases of empyema that pleuropneumonia is
the most frequent cause of empyem.a, while it rarely
follows pleurisy with effusion. In adults empyema
is more likely than in children to be secondary to
serious lung disease. The diagnosis of empyema is
not always easy, for it may be ushered in by symp-
toms pointing more to the abdominal than the tho-
racic cavity, and the physical signs resemble close-
ly those of consolidation. The exploring needle
should be used in all doubtful cases, and, if needful,
in more than one place, as there is no danger in
using the needle with proper care. The immediate
prognosis of an uncomplicated empyema treated by
incision and drainage is good. It is worst when al-
lowed to burst through the chest wall. The remote
prognosis is excellent. No deformity follows re-
covery, and no sequelae are to be anticipated. The
best prognosis can only be given in cases where an
aseptic condition of the pleural cavity can be as-
sured by antiseptic operation and antiseptic after
treatment. The anaesthetic should be carefully ad-
ministered, and the patient not turned over during
its administration ; in adults it is safer to do the op-
eration without general anaesthesia. Aspiration is
disappointing as a curative agent, but is useful in
some cases temporarily, while incision and drain-
age with antiseptic i>recautions may be trusted to
cure all cases of curable empyema, but irrigation
is unnecessary and dangerous. Rib resection is
needful in some neglected cases, but in the general-
ity of cases it is meddlesome surgcr>'.
3. A Resume of the Report of the Royal Com-
mission on Human and Bovine Tuberculosis. —
Fowler reviews the rcjiort. The exact reference to
the commission was to incjuire and report : ( i )
Whether the disease in animals and man is one and
the same; (2) whether animals and man can be
reciprocally infected with it; and (3) under what
conditions, if at all. the transmission of the disease
from animals to man takes place, and what are the
March 28, 1908.]
PROCEEDINGS OF SOCIETIES.
615
•circumstances favorable or unfavorable to such
transmission. In the seven years which have
elapsed since the commission was appointed, inter-
est in the tuberculosis problem, so far from fading,
has spread among all classes, and the observations
and conclusions of the commission are of great im-
portance in their bearing upon one of the practical
questions of the day. The commission has not
answered the first question referred to it, but
it IS able to give an affirmative reply to the sec-
ond. The principal points drawn attention to in
the conclusion of the report are: (i) That a cer-
tain amount of tuberculosis, especially in children,
is directly due to infection with the bovine bacillus.
(2) That tuberculous milk is clearly a cause of
tuberculosis, and fatal tuberculosis, in man. (3)
That a verv large proportion of tuberculosis con-
tracted by ingestion is due to bovine bacilli. (4)
That more stringent measures are required to pre-
vent the sale or consumption of milk from tuber-
culous cows.
IrocetHngs at ^at'ntm.
PHILADELPHIA COUNTY MEDICAL SOCIETY.
Meeting of Wednesday, January 22, 1908.
The President, Dr. A. M. Eaton, in the Chair.
Cancer of the Stomach. — Dr. John J. Gilbride
exhibited a specimen of cancer of the stomach taken
from a woman seventy-two years of age. The en-
tire stomach was involved and was reduced to about
one third the size of the normal organ. It was firm-
ly adherent posteriorly. The pancreas was also in-
volved as well as the transverse colon. Metastases
were distributed throughout the great omentum.
The woman had been under treatment by various
physicians and at dispensaries and clinics for a pe-
riod extending over four years. The various diag-
noses given were gastritis, nervous dyspepsia, kid-
ney disease, nervousness, etc. The case was illus-
trative of the lax methods of examination too often
employed in such cases, since the woman, according
to her own statement, had never been thoroughly
examined, and her disease had not been recognized
until within a few months of her death.
Wanted, a Medical Bureau of Publicity, Espe-
cially for County Medical Societies. — This was
the title of a paper presented by. Dr. J. IMadisox
Taylor. The profession of medicine, he said, was
essentially an educational agency. It was still held
by its nobler traditions to a dignified position of reti-
cence. It was governed by ethical principles some-
what restricted and vague. Nevertheless, the ques-
tion should be fairly met, "Did these ethical limita-
tions accomplish the objects for which they were
originally devised?" By not one jot or tittle would
he assail the spirit in which they were conceived or
mar the purity of those principles of right conduct,
of conscientious protection of the home, or of mu-
tual relationships between advisers and family long
maintained. There was, however, ground for fear
that in the wider field of relationships between the
profession and the great world movements gross
misapprehensions had arisen. These misconceptions
had long been a source of injustice, not alone to us,
but to those who needed our counsel. Much harm
resulted.
The central aim of the profession of medicine was
radically different from all other professions, call-
ings, organized activities. Only a few individual
representatives failed to adhere conscientiously to
this aim. We stood as a unit sworn to use all the
powers we possessed and could acquire to prevent
the very causes of conditions which made our call-
ing necessary. A secondary purpose was to cure or
remedy with the utmost promptitude the baneful
eft'ects of these causes. In short, whereas all busi-
ness enterprises endeavored to increase a demand,
we strove to prevent, to check its growth. So much
for the basis of our professional ideals, to which,
with rare exceptions, all its exponents adhered.
Not so, however, with that immense force of com-
mercial auxiliaries grown up alongside, viz., the
purveyors of articles which we used in our work,
drugs, remedial agents, waters, various appliances,
and lately special foods, et id omne genus. The
watchword of these men was not only to supply all
demands, but to apply progressive business princi-
ples to their enterprises and keep the demand not
only active, but overactive, to create a demand, legit-
imate or artificial. They assumed to teach us and
form opinions for the public. Here was a grave
peril for which we were partly responsible by omit-
ting to insist upon needful precautions.
It is most difficult to compete with shrewd mer-
chants in distinguishing between statements based
on truth and those which were adroitly cited to sus-
tain fictitious demands or to encourage excesses of
supply. Above all, we should aid in promulgating
right conceptions of the advances in medical science.
The agency we must use was the public press. Here,
upon this recognized arena, with the great body of
thinking people as an audience, must we stand to
win or lose on truth as our inspiration, on ethical
principles as rules of the competition, on our sincer-
ity of purpose to benefit our fellow man as the ban-
ner of our cause.
In his opinion it was necessary to meet modern
conditions by adopting modern methods. Every
form and kind of opponent to the purposes and ef-
forts of the profession made use of the newspapers
to reach the attention of the people. The whole
crew of fakirs, grafters, panderers to evil amuse-
ments, venders of disguised poisons, and all the dis-
seminators of hurtful influences employed vast sums
of monev through press agents of one kind or an-
other. The one available means of combating these
destructive agencies was for organized medical
bodies to establish bureaus of publicity, safeguarded
by competent committees, through which informa-
tion, opinions, action should be accurately and sys-
tematically supplied to the papers. The public were
made fully aware of every tempting method of do-
ing themselves harm. We. as a profession, failed to
exert the counterinfluences which ought to impres.^
the consciousness of those who needed our protec-
tion. Every large daily should have a medical ed-
itor, to whom matters of polity should be referred.
He had better be a busy practitioner, too, not one
whose professional activities had ceased.
The author would propose the establishment of
medical bureaus of publicity in connection with all
6i6
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
county medical societies. A reliable press agent
should be retained. Many and varied reasons could
be adduced why these were absolutely essential to
secure a correct presentation of facts bearing upon
the integrity of medical science and the best inter-
ests served by the conservators of public and private
health. Among the most important of these was the
well known fact that all those interests which were
diametrically opposed to medical ethics did employ
press agents. With them it was a question of busi-
ness. Good business methods demanded that the
public should be made acutely aware of the more at-
tractive phases of the proposition offered. These
fakirs had goods to sell, advice, or whatever they
wished to barter for money. The chief avenue of
dififusion was the daily press, through the ordinary
channels of advertisement or shrewdly placed news
items. For example, it was well known that the
great nostrum vendors expend many millions of dol-
lars annually, and through the intelligent coopera-
tion of professional press agents. These constituted
practical bureaus of publicity for quackery. No or-
ganized medical body in the world spent one cent
for popular education, to "put the people wise" on
questions it was their desire and duty to have cor-
rectly understood. Yet a large and increasing group
of irregulars did spend vast sums to mislead the un-
wary, thereby causing incalculable damage to mo-
rality and health.
Teaching mankind systematically and accurately
how to know good from evil, right interpretations of
current facts, advancements in scientific knowledge
of hygiene, correct living and acting, should be the
undivided purpose of the profession of medicine.
The first step was to get the real facts known, to
teach the people correctly what we were doing for
their welfare, to furnish information of a kind cal-
culated to advance the best interests of the race.
The form and character of such bureaus of publicity
should be carefully formulated. Rules to govern
methods, however, should be revised repeatedly and
promptly, until, by intelligent evolution, consonant
with experience, they became perfected.
Dr. John G. Clark, chairman of the Board of
Public Education of the American Medical Associ-
ation, spoke of the plans being formulated by the
board in the matter of educating the public upon
medical matters. Educators and editors generally
had taken the most enthusiastic view of the ques-
tion. A large number of subjects really required
public exploitation, and efforts were being made to
have the large magazines and the agricultural and
other papers publish articles bearing upon such sub-
jects. It was the aim of the board that all the arti-
cles published for lay people should be bound to-
gether or in pamphlet form. In the event of an out-
break of typhoid fever, if necessary, a certain dis-
trict might be flooded with literature drawing atten-
tion to the necessity of disinfection of water and
bearing upon general principles, but not upon treat-
ment. For advice as to treatment any person would
be referred to his family physician. It was the ob-
ject of the board to take up the broader phases of
medicine-; possibly the history of medicine would be
considered. All articles would be unsigned.
Dr. A. B. HiRSH felt that the proposition of Dr.
Taylor" to have the Philadelphia County Medical
Society name a Committee on Publicity should take
practical form, and referred to similar work done
by one of the other county medical societies of the
State.
Dr. Jay F. Schamberg believed that medical
bodies should have publicity or press bureaus, that
the work could be done in such a manner as to pre-
vent any abuse, and that it would result in a vast
amount of good to the public. He gave credit to
Dr. Taylor for his courage in braving the attitude
of the medical profession by the publication over
his name of articles in the public press which he
thought were for the public welfare. It seemed to
Dr. Schamberg feasible to have a bureau of pub-
licity composed of prominent men in the society
who could revise reports given out to the press for
publication.
Dr. Charles A. E. Couman endorsed the paper
of Dr. Taylor, but thought that, since such work
was to be done by the American Medical Associa-
tion, it seemed unnecessary that each county so-
ciety in Pennsylvania should have such a commit-
tee or bureau working independently. He would
favor a plan whereby the State society should have
the general control of all the subsidiary bureaus in
the State, with the committee of the State societ}-
working in connection with that of the American
Medical Association. He believed there should be
such a bureau of publicity, but that the profession
should work together, thereby making its power
felt.
The Importance of an Ocular Examination in
Pregnant Women Manifesting Constitutional
Signs of Toxaemia. — Dr. William Campbell
Posey and Dr. John Cooke Hirst referred in this
paper to the value of an ocular examination, not
only in pregnant women who had albumin in the
urine, but also in cases of toxaemia where the urine
showed no traces of albumin. This happened when
the liver or other organ apart from the kidney was
unequal to the task put upon it by the excessive
tissue changes, or when the kidneys, though dis-
eased, had not as yet excreted albumin. They
pointed out that the quantitative estimation of
urea was not always of value in proving a toxic
state of the system, careful studies of which were
made upon groups of patients at the Maternity of
the University of Pennsylvania showing that the
urea varied from o.i to 3.5 per cent, in patients
each of whom received exactly the same amount of
food. They insisted that obstetricians should ap-
preciate two facts ; first, the changes in the fundus
of the eye which had been occasioned by renal dis-
ease, and were almost certainly diagnostic of renal
disease, might precede the presence of albumin in
the urine ; and, second, that the ophthalmoscope
might give evidence of disease other than of the
kidneys which has been excited by the toxaemia of
pregnancy.
While the renal condition which arose in preg-
nancy was an acute condition, it was not unlikely
that chronic nephritis might have existed in many
cases prior to pregnancy. An examination of the
fundus under these conditions revealed in most in-
stances disease of the retinal vessels, and served to
put the obstetrician on his guard. The writers re-
ported all the cases found in literature of ocular
March 28, 1908.]
PROCEEDINGS OF SOCIETIES.
617
changes which had been noted in women who were
pregnant, but whose urine did not contain albumin.
They pointed out that, the diagnosis of toxaemia
once made, the question of saving the Hfe of the
mother must be considered. Silex concludes that
when retinitis developed in the first months in cases
in which chronic nephritis had previously existed
in a latent form, but had been set into activity by
pregnancy, labor should be at once artifically in-
duced, for not only was the life of the mother
jeopardized, but there was present the possibility
of blindness. In the acute nephritis of pregnancy
he considered the prospect for sight during the pro-
gress of pregnancy none too favorable. The prog-
nosis for sight in cases in which the ocular changes
had been induced by the renal toxaemia of preg-
nancy had been well established, Culbertson's fig-
ures recording blindness in 24.99 per cent., partial
recovery of sight in 58.31 per cent., and recovery
of sight in 16.66 per cent, of the cases. Silex's
tables showed blindness in twenty-five per cent.,
partial recovery of sight in forty-seven per cent.,
and recovery of sight in twenty-nine per cent.
The writers reported a case of toxaemia during
pregnancy where the ocular symptoms, which were
the only demonstrable signs of the disease, also the
general symptoms, disappeared promptly after the
artificial induction of labor. The urine was free
from albumin at all times, and the general symp-
toms were few, and had the ophthalmoscope not re-
vealed the malignancy of the toxaemia, it was prob-
able that labor would not have been interrupted,
and it was not unlikely that the patient would have
died of eclampsia. Active eliminative treatment
gave no relief.. Dr. Hirst then induced labor arti-
ficially. The general symptoms disappeared at
once and the ocular changes after some weeks. A
year had elapsed since the termination of the preg-
nancy. The general condition of the patient was
somewhat abnormal, and though there had been no
recurrences of the retinal travasations, the retinal
vessels appeared unhealthy, being unduly full and
tortuous, awaking the suspicion of a disease of
their walls. Nothing abnormal had been found in
the urine, and the patient's physician was inclined
to regard the toxaemia as a result of the failure of
the liver to perform its functions properly, the pa-
tient's father having died of hepatic cirrhosis, and
there having been great tenderness over the whole
liver until after the expulsion of the foetus.
Dr. George E. de Schweinitz said that the re-
cent work of Berger and Loewy stated that the
ocular complications of pregnancy might arise: {a)
from pressure of the gravid uterus on the circum-
uterine nerves, causing reflex symptoms; {h) from
qualitative changes in the blood; (c) from autoin-
toxication, which in its turn might arise from fer-
mentations in the intestinal tract, or from new toxic
substances which came from the foetus, the placenta,
insufficiency of the kidneys, or atony of the blad-
der. Finally, the cessation of menstruation during
the pregnant period, according to Charrin and
Roche, was capable of originating metabolic pro-
ducts which otherwise would be eliminated, added
to which there might be an insufficient action of the
antitoxic active glands, especially of the liver. It
was, therefore, evident that the pathways were
numerous, and the statement of Winckel that in
1.6 per cent, of pregnancies some disorder of the
visual organs could be found was well within the
possibilities. Naturally, the most important ocular
complication was the development of the albu-
minuric retinitis of pregnancy, to which the paper
of the evening did not specially refer, and which
was so sure a sign of serious disorder that the ques-
tion of inducing premature labor must immediately
be seriously discussed, if the eyesight of the patient
was to be saved. An equally important matter,
however, was to determine whether or not there
were other ophthalmoscopic signs which might be
of service to the obstetrician if widespread retinal
lesions were absent, and if frequent examinations
failed to show albumin in the urine. Dr. de
Schweinitz observed that thus far there was no
ophthalmoscopic ^picture which is diagnostic, al-
though, as the essayist had pointed out, neuritis
and neuroretinitis, retrobulbar neuritis, and retinal
haemorrhages might develop without the presence
of albumin ; and if they were present, they fur-
nished potent reasons for the most searching inves-
tigation and for a discussion of the necessity of in-
terference with a view to terminating the preg-
nancy. He believed it probable that certain types
of autointoxication, although the whole subject
was surrounded with much uncertainty, played an
important role in the production of those ocular
complications which were not directly the result of
a kidney lesion. He felt that ophthalmologists
and obstetricians should work together in order
that one might be helpful to the other, and, if pos-
sible, the ophthalmoscope be utilized to detect
changes which the ordinary clinical examinations
failed to reveal.
Gastroenterostomy in Cancer of the Stomach,
with Reports of Two Cases; also a Third Case
Diagnosticated by Examination of Shreds of
Tissue which Came Away During the Use of the
Stomach Tube. — Dr. John J. Gilbride described
three types of onset of cancer of the stomach, and
emphasized the very great importance of employing
every method to make an early diagnosis, stating
that even the suspicion of cancer justified an ex-
ploratory laparotomy. Three cases were reported.
One was of six months' duration, in which an-
terior gastroenterostomy was performed. The pa-
tient lived for four months after the operation and
had been able for two months to do light work. Of
the two other patients, one gave a history of indi-
gestion extending over a period of fourteen years.
This disturbance the author attributed to ulcer. Pos-
terior gastroenterostomy was done in this case on
August 27, 1907, and, although the patient died in
the latter part of October, there had been no further
stomach symptoms. She ate her food well, but did
not recover her strength. The third case reported
illustrated three points: i. Diagnosis of cancer by
examination of a piece of tissue that came away in
the wash water during the use of the stomach tube.
2. Absence of lactic acid. 3. A clear history of ulcer
of the stomach dating back twenty-eight years. This
patient declined an operation. In this case the diag-
nosis of cancer of the stomach would not have been
made without the use of the stomach tube, since
there were a floating kidney and conditions which
6i8
LETTERS TO THE EDITORS— BOOK NOTICES.
[New York
Medical Journal.
would readily have accounted for the stomach symp-
toms.
Dr. Gilbride pointed out that lactic acid was never
present in the early stages of the disease, and that
in many instances the presence of cancer was not
suspected until there were bloody vomit and a tumor.
The method of choice in the performance of gastro-
enterostomy was said to be the posterior no-loop
method with a double row of sutures, with the jeju-
num continuing its normal course to the left. When
adhesions and other conditions did not permit of the
posterior operation the anterior anastomosis should
be done. In the presence of the anterior operation
enteroenterostomy should be performed. The anas-
tomotic opening in the stomach should be so far dis-
tant from the line of apparent invasion of the dis-
ease as to prevent the early involvement of the stom-
ach by the disease. Contraindications to operation
were involvement of the supraclavicular lymph
glands, particularly of the left side, other extensive
involvement, and advanced cachexia and ascites.
Dr. John B. Deaver agreed with Dr. Gilbride
that the results were very good if an operation was
done early, but very bad if it was resorted to late in
the disease.
fetters ta tl|e mtm.
A PROBLEM IN APPLIED ETHICS.
To the Editors:
Dr. A. was engaged to attend a confinement in
the family of a farmer who had recently moved sev-
eral miles out from the village in which he resided
to a place about halfway between the village and a
neighboring borough. • Dr. A. bespoke the services
of Dr. B., of the borough, as alternative, to the
entire satisfaction of the family. Dr. B. had perma-
nent arrangements with Dr. C. to visit certain cases
in his absence, being an established physician with
hospital appointments. Dr. C. was a recent grad-
uate.
When the day came Dr. A. was in a distant State
after big game, and Dr. B. was in the great city
attending to operations. By a rapid interchange of
telephone messages Dr. C. was promptly put on the
road. He was an utter stranger and unwelcome.
The case was tedious and complicated, being that
of a primipara of above thirty. Anaesthesia, help,
and an operation for laceration were required. Dr.
C. secured the aid of Dr. D., another stranger, and
the two gave the day to the requirements of the
case. Mother and child did splendidly.
Here is the problem: Who should send the bill
for service? Who should pocket the fee? Who
should ultimately share it?
While I have my pen in hand let me add a few
facts relative to the financial and the ethical, or the
nonethical, sequel of this case. According to an
agreement between Dr. B. and Dr. C, the latter
sent a bill, expecting to compensate his assistant.
Both needed it, and had nobly merited what was
asked. The farmer had employed Dr. A. and looked
to him for the bill. He would have no dealings with
Dr. C. Dr. A. spoke hot words against the doctor
who dared bill a family of his! Just before they
lighted the candles to adorn the birthday cake on
that child's fourth birthday Dr. A. produced the bill
and quiet payment was made.
The writer was merely an interested onlooker.
What is good ethics in such a case? I ask not to
puzzle, but to learn. Reader.
iek |[0tires.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
The Diagnosis and Treatment of Pulmonary Tuberculosis.
By Francis M. Pottenger, A. M., M. D., Medical Direc-
tor of the Pottenger Sanatorium for Diseases of the
Lungs and Throat, Monrovia, Cal, Professor of Clinical
Medicine, Medical Department, University of Southern
California, etc. New York : William Wood & Co., 1908.
Pp. xiv-377. (Price, $3-50.)
Our readers are well aware of Dr. Pottenger's
title to write on tuberculous pulmonary disease, for
he has contributed valuable material concerning
the subject to our columns. In this work he has
treated of it very thoroughly and in a most sci-
entific manner. There are, however, some ques-
tions of interest which he hardly discusses — for
example, that of the relations between bovine and
human tuberculous disease, that of the comparative
frequency of infection by the air passages and the
alimentary canal, and that of Dr. John B. Murphy's
proposal to give prolonged rest to a diseased lung
by keeping the pleural sac distended with nitrogen.
The author does well, we think, to call particu-
lar attention to the fact that a long time may elapse
between infection and the appearance of frank
signs of tuberculous disease. Concerning heredity,
he says: "Since the overthrow of the theory of
heredity as the cause of tuberculosis, the impor-
tance of the family history has declined. While it
seems well established that there are very few in-
stances in which tuberculosis has been transmitted
directly from parent to offspring, nevertheless,
family history is important as an index of resist-
ance to disease, and as it bears upon the longevity
of the patient." This seems to us judicious teach-
ing.
The necessity of an early diagnosis is urgently
insisted on. the author intimating that it is little
short of criminal to wait until bacilli are found in
the sputum, and especially to keep back the truth
from a patient, so that time is wasted in a false
sense of security. There should be perfect frank-
ness, he says, between the physician and the pa-
tient. The matter of diagnosis is considered almost
exhaustively, and the author is at great pains to set
down the minutije of the physical signs. Excessive
carefulness, it seems to us, is shown in this sen-
tence: "When the mouth is used, the temperature
should not be taken for at least a quarter of an
hour after drinking or eating; and, if the patient
has been drinking anything very hot or very cold,
the temperature of the mouth may be influenced
for a still longer time." However, it can do no
harm to wait to the extent recommended. The use
of tuberculin as a diagnostic test is squarely advo-
March 28, 1908.]
BOOK NOTICES.
619
cated, but he thinks that the practical value of the
conjunctival reaction to tuberculin "needs further
confirmation."
The establishment of immunity is regarded by
Dr. Pottenger as the keynote to the curative treat-
ment, and he handles in a masterly way such mat-
ters as the action of fresh air, the influence of diet,
rest, and exercise, climate, hydrotherapeutics, sana-
.torium treatment, and even Bier's hyperjemia. He
deals, too, most instructively with the subject of
prophylaxis. He takes a very favorable view of
the careful therapeutic use of tuberculin, and re-
gards Wright's work under the guidance of the
opsonic index as having done more than everything
else to establish the efficiency of the tuberculin
treatment. The treatment of individual symptoms
and the management of complications are well set
forth ; so also are the results of treatment and their
permanence.
In short, we do not see how more valuable teach-
ing in regard to a disease that is now meeting with
the earnest attention of the whole civilized world
could well have been given within the moderate
compass of Dr. Pottenger's work.
Textbook of Otology for Physicians and Students. In
Thirty-two Lectures. By Fr. Bezold, M. D., Professor
of Otology at the University of Munich, and Fr. Sieben-
MANN, M. D., Professor of Otology at the University of
Basle. Translated by J. Holinger, M. D,, of Chicago.
Chicago: E. H. Colgrove Company, 1908. Pp. 314-
In the form of a series of clinical lectures Bezold
presents the developments of the last twenty-five
years in otology. The volume is naturally more
suited to students and general practitioners, as the
author intended it should be, than for the aural sur-
geon. Most stress is accordingly laid on the anat-
omy and physiology of the organ of hearing,
clinical examination of the ear, functional tests, and
the pathology of otitic disease. The operative pro-
cedures and the details of surgical technique are
limited to those which the general practitioner might
be called on to perform. Major operations are to
be studied practically. The volume is an interesting
and instructive one for those who wish to familiarize
themselves with the principles of otology and with
the routine of scientific examination of the organ
of hearing. It is hardly a textbook of otology in
the sense of presenting the entire field. Holinger's
translation is adequate, but rather crude.
Les Ferments metalUques et leur emploi en therapeutique.
Par Professeur Albert Robin, membre de I'Academie de
medecine. Paris : J. Rueff, 1907. Pp. 252.
In this volume Robin presents a resume of the
studies he has made on the therapeutic action of
certain metals which have been administered in a
highly divided condition. The results of these in-
vestigations have been published from time to time
since igoi ; and, as Robin alleges in his introduc-
tion, have been received with considerable incred-
ulity, which, it may be remarked in parenthesis, has
not been allayed in many quarters even at the pres-
ent time. This incredulity, however, has attached
itself more to the methods announced than to the
general factors of the problem since these latter
have received so much more thorough study from
the laboratories of other students.
Robin then takes up in a sketchy fashion the re-
lation of the ferment action of metals to that type
of action seen in the organic enzymes. Then he
develops the physiological and therapeutic indica-
tions of the metallic ferments and medicinal serums.
The treatment of pneumonia, bronchopneumonia,
articular rheumatism, acute meningitis, and various
infections, acute and chronic, are then taken up,
and therapeutic optimism throws caution and even
good sense to the winds. His results and conclu-
sions often show the attitude of the special writer
on a Sunday edition of a metropolitan journal, and
the reviewer feels that the author's conclusions
should be taken cum grano salts.
Diseases of the Genitourinary Organs and the Kidneys.
By Robert Holmes Greene, A. M., M. D., Assistant Pro-
fessor of Genitourinary Surgery, Medical Department of
Fordham University, etc., and Harlow Brooks, M. D.,
Assistant Professor of Pathological Anatomy, University
and Bellevue Hospital Medical School, etc. With 292
Illustrations. Philadelphia and London : W. B. Saun-
ders Company, 1907. Pp. 536.
A surgeon and a pathologist have joined efforts
in producing this newest textbook on genito-
urinary diseases. In some ways the book of Greene
and Brooks does not diflfer materially from the
older works, but in other respects it marks perhaps
a step in the evolution of urology in this country.
In the first place, much more space is devoted in it
to purely urinary diseases, and far less to sexual
or venereal conditions. This is in accordance with
the tendency of urology to ascend higher in the
tract, from chancres and gonorrhoea toward the
kidneys. In this respect and in some others the
present volume is distinctive among American
genitourinary treatises. It is perhaps the first work
which gives space to a marked extent to the ideas
and views of the new French and German, particu-
larly the German, schools of urology. Frisch and
Zuckerkandl's great work, HiDidbuch der Urologte,
has evidently been freely used in the composition
of the text, without, however, any suggestion of di-
rect translation. One might say that the authors
had "caught the flavor" of the German work rather
than that they had imitated it.
We are sorry to find that some of the plates are
not credited as they should have been, such, for in-
stance, as those showing cystoscopic images, which
bear a close resemblance to the plates of Nitze and
of Frisch and Zuckerkandl. In dealing with func-
tional renal diagnosis but two methods are men-
tioned, the phlorrhizin test and the methylene blue
test. Nothing is said of Voelcker and Joseph's
indigo-carmin test, which, according to Kapsomer,
has practically superseded the methylene blue test
since 1903. Albarran's method of "experimental
polyuria," a most important one, is also not men-
tioned. Nothing is said of the fallacy involved in
the methylene blue test, owing to the fact that the
dye is often excreted as a colorless "chromogen" or
"ieuko" product. This section needs revision, and
its contents should be made more intelligible to the
average student.
The surgical and the pathological aspects of the
subject are well handled. The illustrations are
clear cut, simple, and helpful. The text is well ar-
ranged, and the style is not cumbersome or pro-
lix, but adapted to the comprehension of beginners.
As a whole the book is one of the most satisfac-
620
MISCELLANY.
[New York
Medical Journal.
tory and useful works on genitourinary diseases
now extant, and will undoubtedly be popular among
students and practitioners.
Der Abstineniismus und seine Bedeutung fiir das Indi-
viduuin und fiir die Gesellschaft. Von Dr. Gustav
Kabrhel, a.o. Professor der Hygiene, Vorstand des
hygienischen Institutes der bolimischen Universitat und
der staatlichen Untersuchungsanstalt fiir Lebensmittel
in Prag. Miinchen und Berlin: R. Oldenbourg, 1907.
Pp. 69.
The alcohol question, which was hardly known in
central and northern Europe about twenty-five
years ago, lately has come very much indeed to the
foreground. Leading in this respect was Norway,
to be followed by Sweden, Denmark, Germany, and
Austria.
Professor Kabrhel speaks in his book of the
influence of alcohol upon the human body ; the
dependence of this influence on the method and
form of using alcohol, on the power of resistance
of the body, on the muscle activity, and the climate ;
and finally describes facultative and absolute tem-
perance. He thinks that absolute abstinence is not
unconditionally necessary. The only safeguard
against the evil sequelae of excess in eating and
drinking is the use of simple foodstufTs ; alcohol
does not belong to the simple foods, and should
therefore not, be included in the daily fare. If one
wishes to change the monotony of such simple fare
he should partake moderately of a richer meal with
some wine or beer. But this breaking of the rule
should only be an exception.
But, concludes the author, the best results are
obtained in countries where no concessions are
made by the enemies of alcohol, and where the prin-
ciple of absolute abstinence is carried out.
BOOKS, PAMPHLETS, ETC.. RECEIVED
Rotunda Midwifery for Nurses and Midwives. By G. T.
Wrench, M. D., Late Assistant Master of the Rotunda Hos-
pital. With Introduction by the Master of the Rotunda
Hospital. London: Henry Frowde (Oxford University
Press) and Hodder & Stoughton, 1908. Pp. xiv-324.
The History of the Study of Medicine in the British
Isles. The Fitzpatrick Lectures for 1905-6, delivered be-
fore the Royal College of Physicians of London. By Nor-
man Moore, M. D. Cantab., Fellow of the Royal College of
Physicians, etc. Oxford : The Clarendon Press, 1908.
Pp. vi-202.
Bericht uber die Thatigkcit des temporaren Lazareths
am Golitzyn-Hospital in Moskau wahrend des russisch-
japanischen Krieges (18. Juni 1904-10 April 1906). Von
Dr. S. Deruginsky, Chefarzt des Golitzyn-Hospitals in
Moskau. Mit 6 photographischen und 37 Rontgen-Auf-
nahmen. Herausgegehen auf personliche Kosten der
Fiirstin Anna Alexandrovvna Golitzyn. Moskau : S. P.
Jakowlew, 1908. Pp. 159.
Medical Lectures and Aphorisms. By Samuel Gee, M. D.,
Fellow of the Royal College of Physicians, Honorary Phy-
sician to H. R. H. the Prince of Wales, etc. London:
Henry Frowde (Oxford University Press) and Hodder &
Stoughton, 1908. Pp. viii-308.
Clinical Lectures and Addresses on Surgery. By C. B.
Lockwood, Surgeon to St. Bartholomew's Hospital. Lon-
don: Henry Frowde (Oxford University Press) and Hod-
der & Stoughton, 1907. Pp. viii-307.
The Mellin's Food Method of Percentage Feeding. Bos-
ton : Press of the Mellin's Food Company, 1908. Pp. 183.
Applied Physiology. A Manual Showing Functions of
the Various Organs in Disease. By Frederick A. Rhodes,
M. D., Professor of Physiology and Embryology, Medical
and Mental Departments of the Western University of
Pennsylvania, etc. Pittsburgh, Pa. : Medical Press, 1907.
Pp. 206.
A Textbook of Physiological Chemistry. By Olaf Ham
marsten. Late Professor of Medical and Physiological
Chemistry in the University of Upsaia. Authorized Trans-
lation, from the Author's Enlarged and Revised Sixth Ger-
man Edition, by John A. Mandel, Sc. D., Professor of
Chemistry in the New York University and Bellevue Hos-
pital Medical College. Fifth Edition. First Thousand.
New York : John Wiley & Sons, 1908. Pp. 845.
Syphilis. A Treatise for Practitioners. By Edward L.
Keyes, Jr., A. B., M. D., Ph. D., Clinical Professor of Gen-
itourinary Surgery, New York Polyclinic Medical School
and Hospital, etc. With Sixty-nine Illustrations in the
Text and Nine Plates, Seven of Which are Colored. New
York and London : D. Appleton & Co., 1908. Pp. xxix-577.
A Textbook of Minor Surgery. By Edward Milton
Foote, A. M., M. D., Instructor in Surgery, College of
Physicians and Surgeons (Columbia University), Lec-
turer on Surgery, New York Polyclinic Medical School,
etc. Illustrated by Four Hundred and Seven Engravings
from Original Drawings and Photographs. New York and
London: D. Appleton & Co., 1908. Pp. xxvi-7S2.
A Mind That Found Itself. An Autobiography. By
Clifford Whittingham Beers. New York and London :
Longmans, Green, & Co., 1908. Pp. viii-363.
The Functional Inertia of Living Matter. A Contribu-
tion to the Physiological Theorv of Life. By David Eraser
Harris, M. B., M. D., B. Sc., R R. S. E., Lecturer on Phy-
siology and Normal Histology in the University of St.
Andrews, etc. London : J. Sz A. Churchill, 1908. (Through
P. Blakiston's . Son & Co., Philadelphia.) Pp. 136.
(Price, $2.) ^
ilisallang.
An Appeal to American Physicians. — During
the year 1907 over 200 papers, lectures, and pam-
phlets were ptiblished in Europe and America, pre-
senting difTerent phases of alcoholism and inebriety,
purely from a scientific point of view. Many of the
authors complain that these papers were not widely
read and were practically lost, becavise they did not
reach medical men interested in the subject. The
Federation Bureau of this country, organized nearly
two years ago, for the purpose of collecting and dis-
seminating all facts concerning the alcoholic prob-
lem, in connection with the International Bureau m
Europe having the same purpose, proposes to secure
a list of medical men and scientists interested in the
scientific study of the alcoholic problem. This list
is to be made available for authors and students who
write on this subject, and who wish to address a
special audience of physicians, not only to increase
their interests, but to stimulate further studies of the
subject. Such a list will enable the bureau to extend
its work of accumulating facts from the most reli-
able sources, and keep both authors and readers in
close touch with all that is done. This is a practi-
cal ef¥ort to group and concentrate the experience
and observation of medical men, and make them ac-
quainted with what is being done in the scientific
study of the alcoholic phenomena. All physicians
who are interested in the scientific literature, re-
search work, and studies of medical men at home
and abroad are urged to send their names and ad-
dresses for registration, and also to receive copies
and abstracts from authors and persons who may
wish to have their work read and examined by inter-
ested parties. As chairman of the board of direct-
ors of the Federation Bureau, I urgently request
every physician interested in this subject to send me
not only their own names, but lists of reputable
Marcli 28. 1908.]
OFFICIAL NEWS.
621
physicians who would care to receive some of this
most important Hterature coming from the press, and
hear what is said in the scientific world concerning
this problem.
(Signed) T. D. Crothers, D., Chairman,
Hartford, Conn.
Affinal ims.
Public Health and Marine Hospital Service
Health Reports:
The folloicing cases of smallpox, yellow fever, cholera,
end plague have been reported to the surgeon general.
United States Public Health and Marine Hospital Service,
during the leeck ending January 20, igo8:
allfo.v
-Ciiitecl States.
1 )ate.
Place*
Alabama— Mobile Feb. i-3
I-eb. 22-29..
California — Los Angples Feb. 22-29..,
California — .San Francisco Feb. 22-29..
Illinois — Chicago Feb. 29-Mar.
Illinois — Springfield Feb. 27-Mar.
Indiana— Elkhart Feb. 29-Mar.
Indiana — Marion Feb. 1-29...
Iowa — Cedar Rapids Feb. 1-29...
Kansas — Kansas City Feb. 29-Mar.
Kansas — Wichita I-'cb. i-NIar.
Kentucky — Covington I"eb. 29- .Mar.
Kentucky — Lexington l-"eb. 22-29..
Louisiana — Xew Orleans I'eb. 29-Mar.
Michigan — Detroit I'eb. 29-Mar.
Minnesota— Winona i-eh. 22-29 . .
Missouri — Kansas City Feb. J9-^lar.
Montana — Butte F>b. 25-Mar.
New York — Buffalo Feb. 22-29..
New York— New York Feb. 29- .Mar.
North Carolina— Charlotte Feb. 29--Mar.
Ohio— Cincinnati Feb. 28-Mar.
Ohio — Toledo l"eb. ag-.Mar.
Oregon — Portland Feb. 1-15...
Tennessee — Kno.xville Feb. 29-Mar.
Tennessee — Nashville Feb. 29-Mar.
Texas — San .\ntonio. I'eb. 22-Mar.
Virginia— Norfolk Feb. 22-Mar.
\'irginia — Richmond I'eb. 29-Mar.
W]ashington — Spokane I'eb. 22-29 • • ■
Wisconsin — Milwaukee Feb. 29-Mar.
Hawaii— Horolulu
Smallpo.r—lns
Feb.
Smallpo.\-—For
Arabia — .\den .'Jan.
-Argentina — Rosario Dec.
Brazil — Para Feb.
Brazil — Rio de Janeiro Jan.
Canada — Halifax F'eb.
Canada — Hamilton Feb.
Canada — Toronto Dec.
Canada — Winnipeg Feb.
China — \moy (Kulnagsu) Dec.
China — Foochoo Jan.
China — Hankow Ian.
China — Shanghai Jan.
China — Hongkong Ian.
Ecuador — Guayaquil Feb.
Egypt — Cairo Jan.
France — Brest Feb.
France — Paris Feb.
Gibraltar Feb.
Great Britain — Edinburgh Feb.
Great Britain — Leith I'eb.
India — Bonibav Feb.
India— Madras I'eb.
Italy — General Feb.
Italy— Naples Feb.
Japan — Kobe Feb.
Japan — Nagasaki Jan.
Japan — Osaka F'eb.
Java — Batavia Jan.
Malta Ian.
Manchuria- — Dalny Tan.
Mexico— .\guas Calientes Feb.
Mexico — Mexico Tan.
Mexico— Monterey Feb.
Portugal — Lisbon Feb.
Russia — Libau Feb.
Russia — Moscow Feb.
Russia — Odessa Feb.
Russia — Riga Feb.
Russia — St. Petersburg Jan.
Spain — Almeira Jan.
•igii.
28-Feb.
28-Feb. 29.
1 1-18
18-25
i8-Feb. 9. .
eign ant:
25-Feb. 9-
1-8
28-Feb. II
13-28
8-22
16-23
>5 deaths native.
-Feb.'
.65_7
!l26
25-Feb. 15 20
25-Feb. 8 7
i6-Mar. i
8- Feb. 8
16-23
8-25 3
ii-Feb.
I-3I--
. . 109
• ■ 9
■ • 3
.. 76
Spain — Barcelona Feb. 11-20. .
Spain — Denia Feb. 2-14...
.Spain — Malaga Dec. 1-31...
Spain — \'alencia F'eb. 8-21...
Turkey— Bagdad Jan. i8-Feb.
Yellow Fever — Foreign.
Barbados — Bridgetown March i...,
-Manaos Feb. 1-15...
Brazil— Para Feb.
Ecuador — Guayaquil Feb. 1-8
Chole ra — Fo reign.
India — Bombay Feb. 4-1 1
India — Madras Feb. 1-7
India — Rangoon Jan. 25-Feb. i..
Flag 11 e — F or eign.
.\frica — .Accra March 9
Brazil — Rio de Janeiro Jan. 25-Feb. i..
Chile — -Antofagasta Jan. 22-Feb. 5..
China — Hongkong Jan. 26-Feb. i..
Eg>'pt — .\ssiout Province Feb. 7-11
Egypt— Fagoum Province Feb. S-13
Egypt — Guirgueh Province Feb. 7-11
India — Bombay Feb. 4-1 1
India — Rangoon Jan. 25-Feb. i..
Japan — Kobe Feb. 11
Japan — Osaka Feb. t-8
Peru — Catacaos Jan. 30-Feb. 13.
Peru — Chosika Jan. 30-Feb. 13.
Peru — Eten .Tan. 30-Feb.
Peru — Lima Jan. 30-Feb.
Peru — Paita Jan. 30-Feb.
Peru — Piura Jan. 30-Feb.
Peru — Santa Eulalia Jan. 30-Feb.
Peru — Trujillo Jan. 30-Feb.
,..Ja
18-25.
.Straits Settlements — Singapore.
Public Health and Marine Hospital Service:
Official list of changes of stations and duties of commis-
sioned and noncommissioned officers of the United States
Public Health and Marine Hospital Service for the seven
days ending March i8, igo8:
.Amesse, J. W., Passed Assistant Surgeon. Granted leave
of absence for ten days from March 19. 1908.
n.\HREXBrRr,, L. P. H., Passed .Assistant Surgeon. Granted
nn extension of leave of absence for fourteen days from
?^Iarch 15. igo8.
Hlolxt, B. B.. Acting Assistant Surgeon. Excused from
duty without pay for a period of ten days from March
16, 1908.
Bkowx, S. E., .-Acting Assistant Surgeon. Granted leave of
absence for fourteen days from March 15, 1908.
Cle.wes, F. H., Acting Assistant Surgeon. Granted leave
of absence for one day, March 13, 1908, on account of
sickness.
G()ODM.\x, F. S., Pharmacist. Directed to proceed to
Tampa, Fla., not oftener than once in each month, for
special temporary duty.
McCov, G. W.. Passed .\ssistant Surgeon. Relieved from
duty in the Hvgienic Laboratory, and directed to pro-
ceed to San Francisco, Gal., reporting to Passed As-
sistant Surgeon Blue for special temporary dut}'.
Rosex.au, M. J., Surgeon. Detailed to represent the service
at a meeting of the American .Association of Pathol-
ogists and Bacteriologists at Ann Arbor, Mich., on
April 17 and 18, 1908.
S.\FF0RD. AL v.. Acting .Assistant Surgeon. Directed to
proceed to Portland, Me., for special temporary duty,
rejoining station upon completion of same.
ScoFiELD, R. B., Assistant Surgeon. Granted leave of ab-
sence for seventeen days from April i, 1908.
Spr.\gue, E. K., Passed Assistant Surgeon. Order granting
leave of absence for ten days from February 11, 1908,
revoked, and leave of absence granted for ten days
from March 20, 1908.
Stiles, C. W., Chief Division Zoology, Hygienic Labora-
torj-. Detailed to represent the service at the annual
meeting of the .Alabama State Medical Association,
Montgomery, Ala., .April 21, 1908.
White. J. H., Surgeon. Directed to proceed to Puerto
Barrios, Guatemala, for special temporary duty, upon
completion of which to rejoin station ; granted leave of
absence for seven days.
Appointment.
Dr. Eugene W. Hill appointed an acting assistant surgeon
for duty at Malone, N. Y.
Board Convened.
A board of medical officers was convened to meet at
Seattle, Wash., March 16, 1908, to examine an immigrant
622
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
reported to be afflicted with trachoma, detail for the
board : Passed Asiistant Surgeon M. W. Clover, chairman ;
Assistant Surgeon C. W. Chapin ; Acting Assistant Surgeon
F. R. Underwood, recorder.
Army Intelligence:
Ofhcial list of changes in the stations and duties _ of
ofUcers serving in the medical department of the United
States Army for the week ending March 21, 1908:
Birmingham, H. P., Major and Surgeon. Having reported
in compliance with paragraph 2, S. O. 54, War Depart-
ment, March 5, 1908, is announced as chief surgeon,
Army of Cuban Pacification, relieving Lieutenant
Colonel Vlair D. Taylor, deputy surgeon general.
Roberts, W. M., Captain and Assistant Surgeon. Ordered
to Fort Hancock, N. J., for duty.
ScHREiNER, E. R., Captain and Assistant Surgeon. Ordered
to report to the commanding officer. Headquarters
Band, First and Third Battalions, Twenty-fourth In-
fantry, San Francisco, Cal., for duty to accompany that
command en route to Madison Barracks, N. Y., and
upon completion of this duty to return to his proper
station.
Shepard, J. L., Captain and Assistant Surgeon. Now on
leave of absence, will proceed on or before the ex-
piration of said leave to Fort Sam Houston, Tex., for
duty at that station.
Navy Intelligence:
Official list of changes in the medical corps of the United
States Navy for the iveek ending March 21, igo8:
Bacon, S. Detached from duty at the Naval Medical School,
Washington, D. C, and ordered to report to the presi-
dent of the naval examining board, Washington, D. C,
April I, 1908, for examination for appointment as an
assistant surgeon, and then to await orders.
BiELLO, J. A., Acting Assistant Surgeon, Detached from
duty at the naval medical examining board, Washing-
ton, D. C, and ordered to report to the president of the
naval medical examining board, Washington, D. C,
April I, 1908, for examination for appointment as an
assistant surgeon, and then to await orders.
De Lancy, C. H., Passed Assistant Surgeon. Detached
from the Navy Yard, New York, N. Y., and ordered
to duty in connection- with fitting out the Neivark, and
to duty on board that vessel when commissioned.
Garrison, H. A., Assistant Surgeon. Detached from the
Naval Medical School, Washington, D. C, and ordered
to the Naval Hospital, Philadelphia, Pa.
Haines, B. F., Acting Assistant Surgeon. Detached from
duty at the Naval Medical School, Washington, D. C,
and ordered to report to the president of the naval
medical examining board, Washington, D. C, April i,
1908, for examination for appointment as an assistant
surgeon, and then to await orders.
Higgins, M. E., Assistant Surgeon. Detached from the
Naval Medical School, Washington, D. C, and ordered
to duty at the Naval Training Station, San Francisco,
Cal.
Holeman, C. J. Detached from the Naval Medical
School, Washington, D. C, and ordered to duty at the
Naval Training Station, San Francisco, Cal.
Hough, F. W. P., Acting Assistant Surgeon. Detached
from duty at the Naval Medical School, Washington,
D. C, and ordered to report to the president of the
naval examining board, Washington, D. C, April i,
1908, for examination for appointment as an assistant
surgeon, and then to await orders.
McGuire, L. W., Acting Assistant Surgeon. Detached
from duty at the Naval Medical School, Washington,
D. C, and ordered to report to the president of the
naval examining board, Washington, D. C, April i,
1908, for examination for appointment as an assistant
surgeon, and then to await orders.
Mei.horn, K. C, Acting Assistant Surgeon. Detached
from duty at the Naval Medical School, Washington,
D. C, and ordered to report to the president of the
naval medical examining board, Washington, D. C,
April I, 1908, for examination for appointment as an
assistant surgeon, and then to await orders,
MiLi.ER, J. T., Assistant Surgeon. Detached from the
Naval Medical School, Washington, D. C, and ordered
to the Franklin.
Morgan, C. R., Acting Assistant Surgeon. Detached from,
duty at the Naval Medical School, Washington, D. C,
and ordered to report to the president of the naval
medical examining board, Washington, D. C, April i,
1908, for examination for appointment as an assistant
surgeon, and then to await orders.
Ohnesong, K., Surgeon. Detached from duty at the Naval
Hospital, Philadelphia, Pa., and ordered to the Navy
Yard, League Island, Pa., for duty in connection with
fitting out the New Hampshire, and for duty on board
that vessel when placed in commission.
Plummer, R. W., Passed Assistant Surgeon. Detached
from the Naval Recruiting Station, Chicago, III,
March 30, 1908, and ordered to Washington, D. C,
April I, 1908, for examination for promotion, and then
to await orders.
Rhoades, G. C, Acting Assistant Surgeon. Detached from
duty at the Naval Medical School, Washington, D. C,
and ordered to report to the president of the naval
examining board, Washington, D. C, April i, 1908, for
examination for appointment as an assistant surgeon,
and then to await orders.
Snyder, J. J., Passed Assistant Surgeon. Detached from
the Naval Hospital, Philadelphia, Pa., and ordered to
instruction at the Naval Medical School, Washington,
D. C.
Verner, W. W., Passed Assistant Surgeon. Detached from
the Naval Training Station, San Francisco, Cal., and
ordered to duty in connection with fitting out the
Wisconsin, and to duty on board that vessel when
commissioned.
Williams, R. B., Passed Assistant Surgeon. Detached
from the Franklin and ordered to the Naval Hospital,
Philadelphia, Pa.
Born.
Kierulff. — In San Francisco, California, on Friday, Feb-
ruary 28th, to Dr. H. Newton Kierulff, United States Army,
and Mrs. Kierulff, a daughter.
Married.
Carey — Miller, — In Philadelphia, on Tuesday, February
i8th. Dr. H. M. Carey, of St. Georges, Delaware, and Miss
Minnie E. Miller, of Pomona, Kansas.
Died.
Bryant. — In Boston, on Friday, March 20th, Dr. John
Bryant, aged forty-seven years.
Bysfield. — In St. Louis, Missouri, on Monday, March
i6th. Dr. Frank B. Bysfield, aged sixty years.
Cannon. — In Lawrenceburg, Kentucky, on Wednesday,
March nth. Dr. F. M. Cannon, of Oxford, Scott Coimtj-,
aged seventy-six years.
Devi.in.— In Denver, Colorado, on Saturday, March 14th,
Dr. James B. Devlin, aged fifty-six years.
Eaton.— In Philadelphia, on Tuesday, March 17th. Dr.
William Bradford Eaton, aged thirty-nine years.
Lamb. — In Chicago, on Wdenesday, March nth. Dr. Orin
C. Lamb, aged sixty-eight years.
Langrehr. — In Philadelphia, on Sunday, March 15th, Dr.
Hiram Langrehr, aged sixty-eight years.
Nickels. — In Sellersburg, Indiana, on Thursday, March
I2th, Dr. John M. Nickels, aged sixty years.
Ninde.— In Colonial Beach, Westmoreland County, Vir-
ginia, on Tuesday, March loth. Dr. Frederick F. Ninde.
Pettit — In New Orleans, Louisiana, on Monday, March
i6th. Dr. Absalom Pettit, aged sixty-eight years.
Rogers. — In Charlottesville, Virginia, on Sunday, March
15th, Dr. William G. Rogers, aged eighty-six years.
Rowland, — In Atlanta, Georgia, on Tuesday, March loth,
Dr. Anak A. Rowland, aged seventy-four years.
Scarff. — In Govans, Maryland, on Wednesday, March
nth. Dr. John H. Scarflf, aged fifty-seven years.
Scheppkrs. — In Chicago, on Wednesday, March nth. Dr.
D. Q. Scheppers.
Totten, — In Cleveland, Ohio, on Monday, March i6th.
Dr. Roy O. Totten.
Wilson. — In Washington, D, C, on Friday, March 13th,
Dr. Anne A. Wilson.
Wyckoff. — In Trenton, New Jersey, on Thursday, March
19th, Dr. William A, WyckofT, aged seventy-one years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal it Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXVII, No. i.
NEW YORK, APRIL 4, 1908.
Whole No. 1531.
C©riginal Cffmntttnirations.
WHAT WE HAVE NOT DONE FOR THE INSANE.*
By Frederick Peterson. M. D.,
New York,
Former President of the New York State Commission ii; Lunacy;
Professor of Psychiatry, Columbia University.
It is a wonderful catalogue of achievement for
the welfare of the insane that Dr. MacDonald has
outlined this evening. New York now leads the
States in its provisions for the insane. I, too, bear
witness to how much has been accomplished in less
than twenty years by the Lunacy Commission, the
superintendents and managers of the hospitals, and
the State Charities Aid Association.
But, as with most human undertakings, there is
still a higher standard to which we must aspire.
Let us not be too easily satisfied. There are de-
fects to remedy, and ideals to attain, and I feel it
my duty to point out as briefly as possible some of
these defects and these ideals. We could fill a
book with praise for what has been accomplished,
but we might also fill a book with criticism of con-
ditions as they are. The people having assumed the
burden of State care are bound to be interested in
all that pertains to it, in the conditions that lead to
the asylum, in prophylaxis, in the care of the pa-
tient before admission to the hospital, in the hos-
pital conditions themselves, and in the after care
of the convalescent and recovered insane.
What are we doing for prophylaxis? There are
several preventable causes of insanity. It has been
estimated that nearly 20 per cent, of the insane un-
der State care owe their insanity to alcohol, a pre-
ventable cause. That is nearly 6,000 patients in
this State in round numbers. Dr. MacDonald has
just told us that one insane person means an ap-
proximate loss to the State of $400 per annum.
Surelv the people of the State have an interest in
this $2,400,000 annual loss to the State through al-
coholic insanity. The asylum physicians in each
hospital district should be the leaders in a campaign
of education for the regions round them. They
could preach prophylaxis understandingly, and they
are able to open outdoor clinics in connection with
each hospital, where free advice and treatment
might be extended to the poor insane in the early
stages before commitment becomes necessary.
Owing partly to the prisonlike plan on which
the older asylums were built, and partly to the
complicated judicial procedures necessary for the
•Discussion on the Care of the Insane at the meeting of the
Academy of Medicine, February zo, 1908.
Copyright, 1908, by .\. R.
commitment of patients, there still exists among
the people an ancient legacy of feeling about an
asylum, and they pass it as they do a prison or a
cemetery, with mixed dread and mistrust. Out of
this, too, they must be educated. Though we ex-
changed the word asylum for the word hospital, we
have not yet succeeded in instilling into the minds
of the public that the insane are sick. They must
learn that insanity is an illness, a preventable and
curable one. When this is once learned they will
never again permit the acutely insane to be taken
to jails and station houses, as they are at the pres-
ent time frequently all over this State, pending
commitment to a hospital for the insane. They
will provide psychopathic hospitals in all of our
larger cities or pavilions in connection with gen-
eral hospitals (as at Bellevue Hospital in New
York, Kings County Hospital, Brooklyn, and the
General Hospital, in Albany), to which all emer-
gency cases of insanity can be taken for observation
and treatment before transfer to hospitals for the
insane. The period of detention in such general
hospitals or psychopathic hospitals should be at
least ten days, instead of five days, and without
any magistrate's or judge's order whatever. This
is a purely medical and not a legal matter. It is
a question for a board of health to regulate, not the
courts. As Dr. Meyer has suggested to me, it
should fall altogether under the rules of quaran-
tine. An insane person is sick, and is a menace to
himself and the public while thus sick. If we can
restrain a person of his liberty without commit-
ment papers when he has diphtheria and other con-
tagious or infectious diseases, why have recourse
to a judicial proceeding in emergency cases of in-
sanity? If physicians unite in demanding the rec-
ognition of insanity as a disease this point will be
gained. Of course for longer stays in hospitals
and retreats for the insane a regular form of com-
mitment is necessary for the protection of the sane.
But chartered general hospitals should be per-
mitted to receive and treat cases of insanity for
whatever length of time is expedient, and all hos-
pitals and retreats for the insane should be per-
mitted to receive, on the recommendation of any
physician or relative, emergency cases of insanity
for a ten day period for observation and treatment
pending commitment.
After the patients have been admitted to the hos-
pitals what conditions do they find there that are
unsatisfactory? In the first place, I should men-
tion overcrowding. The Lunacy Commission re-
ports overcrowding every year. The responsibility
for its continuance rests with the legislature, and
Elliott Publishing Company.
624
PliTERSON:
CARE OF INSANE.
[New York
Medical Journal.
there responsibility is so finely divided that it is
practically nothing at all. It is like some of the
smaller currency of India, which Mark Twain says
is so attenuated that you can give nothing and get
nothing for it. With an addition of nearly one
thousand patients a year it means that we ought to
build practically a new hospital for the insane an-
nually. It means an expense of at least $600,000
annually for new accommodations. Only one new
hospital for the insane has been established and
constructed by the State in eighteen years. Some
additions are made every year, but they are never
adequate, and such additions are made to existing
asylums until they are growing unwieldly. Three
of our asylums are already probably the largest in
the world. In the report of the Lunacy Commis-
sion for October, 1906, the excess of patients in
the hospitals over the estimated capacity was 1,812.
But the estimated capacity in itself has always been
forced far beyond what it ought to be. It is
forced some 20 per cent, above what it ought to be.
To estimate such capacity every available space for
a bed is utilized. Hallways, day rooms, and cor-
ridors are used for dormitories. Single rooms in-
tended for one patient are made to accommodate
two or even three. Beds are placed side by side
in dormitories, so that patients are compelled often
to climb over the foot of the bed to get into it.
Even were the 1,812 excess not there, there would
still be overcrowding. The overcrowding on
\\'ard's Island is said to be 30 per cent, above ca-
pacity, and some 2,000 of New York city's insane
are scattered about the State in various other hos-
pitals, even as far oflf as Buffalo and Gowanda.
Of course the first remedy for this state of af-
fairs that suggests itself is that the money be
appropriated at once for the construction of new
asylums. But there are other ways of reducing
the hospital population. .\ great part of the ac-
commodation in the asylums is due to admission of
old people. Some 16 to 17 per cent, of the admis-
sions are people between sixty and one hundred
years of age. A considerable proportion of these
are not insane. They are physiologically senile
or dotards. In the struggle for life among the
poor, old people are a burden, especially when they
become decrepit and feeble in mind. When the
State Care Act went into effect, the relatives soon
found that the State hospitals were better by far
for the aged and infirm dependents than the noto-
rious almshouses. Hence by all manner of sub-
terfuge the senile have been certified as insane, and
help to swell the hospital population. Doubtless if
the State could help the sons or daughters to the
extent of paying the actual cost to the State of the
board of such patients, now about $172 per year,
a very large proportion of these aged people would
be taken back to their own homes. This would not
only be better in some respects for the senile pa-
tients, but more satisfactory to the relatives. It
would be, in a way, inaugurating the boarding out
system, which has been so successful in Scotland,
where nearly 3,000 patients are boarded out in pri-
vate families, a considerable proportion with their
own relatives. If it were begun with the senile, the
system would doubtless be extended to other
classes. The scheme has been in successful opjera-
tion in Massachusetts for many years.
Besides being overcrowded, the State hospitals
are inadequately supplied with physicians. Many
years ago the physicians were in the proportion of
I to 128 patients. Since the State undertook the
care of the insane, the proportion has fallen, partly
for economy's sake (the cost of all physicians' ser-
vices being $8 to $16 a year, or 3 cents a day
for a patient) and partly through difficulty in se-
curing medical men to fill vacancies, to the present
figure of I to 174. The proportion should be much
larger, at least i to 150.
The number of nurses and attendants is also in-
adequate, and there is great difficulty in obtaining
even a sufficiency of inferior individuals to fill va-
cancies in some of our asylums. The wages should
be made high enough to attract a better class, and
the training school system, which has done so much
good, needs extension, and ought to be put under
some competent superintendent of nurses as in gen-
eral hospitals.
While recreations and occupations for patients
have been multiplied and improved upon to a great
degree in the State hospitals, this is still a form
of psychotherapy that is far from sufficiently de-
veloped. It is probably the most important form
of therapy for the vast majority of the patients,
yet it plays a very small part, after all, in the hos-
pital regime. Each hospital should have several
employees whose sole duty should consist in keep-
ing patients occupied in various recreative exer-
cises, industries, and handicrafts. The exercise and
occupation cure nowadays so extensively applied to
various neuroses, both here and abroad, as at the
Craig Colony, at Dr. Hall's place at Marblehead,
and at Dr. Sharp's at Katonah, should be carried
out quite as elaborately, and really with more rea-
son, at every hospital for the insane.
Thus far I have been discussing conditions in the
State hospitals. When we take up the matter of
the twenty-two private retreats for the insane in
the State of New York, we find that while there has
been some advance on the whole in the methods
and manner of care, there is still much to be de-
sired. In fifty per cent, perhaps of the twenty-two
institutions the standard of care is scarcely equal
to that of the State hospitals. There is not the
same painstaking, scientific study of the cases, not
the same alert medical spirit, not the same ambition
to excel and progress, and no systematic occupation
of patients, such as would be easily possible in an
institution of small size with considerable income.
One would think that with such abundant leisure
and select material, substantial contributions to sci-
ence might emanate from these smaller institutions,
and that instead of lagging behind the great State
institutions they would be in the van, in the lead,
and point the way to further advance in psychiatry
and in methods of treatment and care. This has
been possible to one private institution in America
at least, the INTcLean Hospital at Waverley. Mass.
.A.nd now a few words as to the after care of the
convalescent and recovered insane. Within two or
three years, chiefly through the efforts of Miss
Louisa Lee Schuyler, of the State Charities Aid
April 4, 1908.]
WIENER: JOINT AND BONE TUBERCULOSIS.
625
Association, an after care organization has been
founded, and already some good work accom-
plished in connection with several of the State hos-
pitals. This work should be extended to all parts
of the State, and it should include among its func-
tions forecarc or prophylaxis as well as after care.
The hospital physicians themselves should be the
most active members of such a body, because of the
opportunities thus afforded for the better study of
the conditions under which the mental disorders
have arisen, because they may thus secure fuller
histories of their patients, both before admission
and after discharge, and in order to more clearly
understand and disseminate the facts in relation to
prophylaxis.
4 West Fiftieth Street.
GENERAL SURGICAL CONSIDERATIONS OF
JOINT AND BONE TUBERCULOSIS,*
By Joseph Wif.xer. M. D..
New York,
Adjunct Attending Suigecn, Mt. Sinai Hospital.
Diagnosis. — The diagnosis is made from the fam-
ily history, the previous history of the patient, the
examination of the entire body, and the use of the
X ray. In doubtful cases tuberculin may be inject-
ed, both for the local and for the general reaction.
In children, the new method of dropping tuberculin
in the eye, by which we obtain a local reaction within
-eight hours, is free from danger of lighting up an
old focus [Calmette reaction]. Occasionally the
aspiration of a joint, together with animal inocula-
tion, will be, of service. The distinctive diagnosis
must be made from lues, acute octeomyelitis, and
arthritis. In acute octeomyelitis the sudden onset,
high fever, marked prostration, and high leucocyte
count will make the diagnosis. In lues, antiluetic
treatment will clear up the diagnosis. Tuberculo-
sis of the joint may, secondarily, infect the shaft of
the bone; and, conversely, the primary infection of
the bone may secondarily infect the joint. Some-
times, especially about the knee, it is difficult, even
at operations, to determine where the primary focus
was.
The hip and knee make up forty per cent, of all
■cases of bone and joint tuberculosis. These joints
must carry the weight of the body, and they are
more prone to injury than other joints. As in other
tuberculous lesions, predisposition plays a great role.
To this must be added poor housing, poor nourish-
ment, and debilitating sickness of any kind.
Advanced tuberculosis of the joint may lead to
subluxations ; at times, especially in the hip, a dislo-
cation may result from a slight injury. Owing to
disuse of a joint, the neighboring muscles atrophy,
and there is often a contracture of the musL^l, s, part-
ly cicatricial, partly nutritive. In advanced cases,
where an entire extremity falls into disuse, all the
muscles of that extremity are thus affected. Even
the bloodvessels are involved. Lannelongue has
pointed out that the femoral artery and its large
tranches are often decreased in diameter in cases of
tubercular hip.
Prognosis. — The prognosis varies with the joint
*Read before the Eastern Medical Society, as part of a Symposium
on Bone and Joint Tuberculosis.
that is aft'ected, and with the degree of infection.
In the hip a cure, so called, will often be followed,
after years, by tuberculosis in other parts of the
body. There is usually some shortening remaining
after hip disease. In the knee there is almost al-
ways some limitation of motion and some stift'ness
resulting. This is found in most cases, be the treat-
ment expectant, palliative, or radical. There often
remains a condition of genu valgum. The growth
of the limb is often interfered with, partly' by de-
struction of the epiphyseal centre by the disease or
by operation, and partly through disuse of the limb.
The amount of shortening varies with the amount
of bone destroyed and with the age of the patient.
Treatment. — This may be divided into three
parts : First, general hygienic ; second, prevention
of further involvement ; third, direct treatment of
the lesion.
1. General Flygienic. — Patients should receive
fresh air day and night ; they should sleep out of
doors, if possible. A change of air is very benefi-
cial. Everything possible should be done to improve
the general condition, and in that way the local con-
dition will be improved. A quiet, regular mode of
living is one of the great advantages of sanatorium
treatment.
2. Prevention of Further Involvement. — The sine
qua non is absolute rest. This can be accomplished
by an immobilizing dressing or by a suitable ortho-
poedic apparatus.
3. Direct Treatment of the Lesion. — We will not.
in this paper, take up the operative treatment. The
palliative treatment includes rest, orthopoedic treat-
ment, the Bier hypersemic treatment, the use of
iodoform injections, and the use of tuberculin.
Iodoform glycerin in ten per cent, solution or iodo-
form oil will, without any other treatment, often
bring about a complete cure.
Technique of iodoform injection. — After rigid
sterilization of the skin about the joint, a trocar and
canula with a rubber tube attached are plunged ob-
liquely into the joint in such a way that the skin
opening and the opening into the joint do not
directly overlie. In this way the skin overlying the
joint is left intact. After evacuating the contents
of the joint, the iodoform emulsion is injected
through the tube attached to the canula. In young
children three to four grammes, in older children
eight to ten grammes, may be injected. By gentle,
passive motion of the joint the emulsion can be
brought into contact with the entire synovial sur-
face. Following the injection there is generally a
smart local reaction, pain, redness, swelling, and
some fever. No further iodoform should be in-
jected until all inflammatory symptoms have sub-
sided. This will usually be in eight to ten days. A
few such iniections, with rest of the affected joint,
will often bring about a permanent cure. Any local
tuberculous abscess may be treated in this way.
Fistul?e may also be injected with iodoform. It may
sometimes be well to follow the suggestion of
Wendelstadt. and inject the iodoform into the tis-
sues around the fistula. Carbolic acid, cynnamic
acid, and other similar agents have not proved as
efficacious as iodoform. It is not always easy to
decide in which cases to advise the iodoform injec-
tion. Their greatest field of usefulness is in chil-
dren. In them an operative procedure about a joint
626 WIENER: JOINT AND BONE TUBERCULOSIS. [New York
Medical Journal.
is only too prone to interfere with the further
growth of the affected bone. And it is in children
that we obtain the most brilliant functional results
by the conservative treatment of bone and joint
lesions. So that, in the early tuberculous joint dis-
ease the injection of iodoform is usually to be ad-
vised. However,, valuable time should not be lost.
If in three to four weeks there is no improvement,
then some operative procedure must be undertaken.
If there has not been too much delay this proced-
ure will usually not be a severe one.
In some cases the iodoform will bring about a
cure of the lesion in the joint, but there will still be
some pain and tenderness around the joint. In
such cases the x ray will render valuable assistance
by showing a small bone focus which the iodoform
could not reach, but which can be rapidly cured by
a minor operation.
There is a difference of opinion as to the impor-
tance to be attached to small sequestra in bone
tuberculosis. According to Riedel they occur very
frequently, and he advises in all bone abscesses
incision and curetting, as he believes the sequestra
will prevent healing. On the other hand, Mikulicz's
experience taught him that small sequestra need
not be removed, as they do not interfere with the
healing process.
Mikulicz regarded the Bier treatment as an adju-
vant of the conservative iodoform treatment; If no
improvement takes place in four weeks and the
process is spreading, then an open operation is indi-
cated. But in children we should be as conservative
as possible, as we often get surprisingly good func-
tional results without extensive operations.
Hip.
Pain and disability are the cardinal symptoms.
The former is usually the first symptom. The pain
may be spontaneous or occur after prolonged exer-
cise. In many cases the pain is chiefly nocturnal.
Children in the early stages of the disease often
awake at night with a sudden cry, complain of pain
in the joint, and go to sleep again. The pain is
probably elicited by a sudden muscular contraction.
Frequently the pain from an affected hip is referred
to the knee, especially on its inner side. Errors in
diagnosis may thus occur. The second early symp-
tom of hip disease is the limp. It is often the first
striking symptom. The patient involuntarily drags
the afifected limb in order to favor the diseased
joint. The limp may be constant or intermittent,
usually the latter in the early stages. Besides the
two cardinal symptoms of pain and limp, there, is
one other of great importance. If the affected limb
is passively abducted or rotated ever so carefully,
there will be a distinct contraction of the hip mus-
cles. This symptom will be found present even in
patients that are still able to walk quite well. By this
time also the inguinal glands will usually be found
enlarged. In all doubtful cases an x ray picture
should certainly be taken, for, as we have mentioned
above, small bone foci may be present without giv-
ing anv symptoms. The x ray picture, which
should include the opposite joint, will also show the
presence of an exudate in the joint.
In the early stages the child favors the affected
limb by bringing into play the joints of the pelvis
and spine, and by not standing on the limb more
than absolutely necessary. At this time there is
pain and tenderness on pressure over the joint. In
the fully developed stage the limb is usually held
in abduction and outward rotation and at the same
time kept slightly flexed. In doubtful cases rectal
examination should always be made. The exam-
ining finger will often find tenderness about the
affected joint, or swelling, or even fluctuation.
Swelling of the joint is due to the exudate in the
joint and to a periarticular inflammatory process.
A typical location of the swelling is p>osteriorly
above the trochanter. In some cases pus develops
early in the disease, in others not until the later
stages. The abscess may perforate and a fistula
develop on the anterior or the posterior aspect af the
joint. Often the pus burrows along the abductors
and perforates on the inner aspect of the thigh.
Posteriorly the abscess often points at the lower
border of the gluteus maximus. There is usually
with the development of an abscess some rise of
temperature. In most cases we cannot distinguish
between a primary synovial and a primary osseous
tuberculosis. Crepitation in the joint points to bone
destruction, and in this stage there will usually be
some shortening of the limb.
Healing can take place at any stage of the disease.
In the early stages complete return of function may
be expected. In later stages there will be some
contraction and some limitation of motion. Still
later, there will be healing, with more or less anky-
losis and with shortening of the limb.
Distinctive diagnosis must be made from arthritis
deformans, fracture of the neck of the femur, con-
genital dislocation, coxa vara, hysteria, neuralgia,
articular rheumatism, spondylitis, osteomyelitis,
syphilis, or gonorrhoeal infection. For some of
these the x ray will help us materially in making
the diagnosis. For others the distinctive diagnosis
can be made from the history and general examina-
tion of the patient, and by instituting specific treat-
ment.
Treatment. — Some form of extension is always
indicated. This relieves the pain and prevents the
limb from assuming a pathological position. For
children five to fifteen pounds, for adults twenty
pounds and more will be indicated. The extension
separates the two ends of the bones and puts the
joint at rest. Immediate relief of the pain often
results. Many excellent orthopaedic splints have
been devised. These, while carrying out the idea
of extension, enable patient to walk about. Plaster
of Paris also has a wide field. Iodoform injections
are of great value. The Bier treatment is not
applicable. The details of orthopaedic treatment will
not be touched upon.
Knee.
The synovial and osseous forms occur with equal
frequency. The bone focus gives only slight symp-
toms, slight pain increased on pressure. It is the
synovial form that we diagnosticate readily. There
are three manifestations: (a) Hydrops of the joint;
(b) granulation tissue formation (fungxis form) ;
(c) cold abscess of the joint.
(a) Hydrops. — The symptoms are similar to
those of serous synovitis. The simple synovitis oc-
curs in adults, the tuberculous in children. The
spontaneous afebrile occurrence or after a slight
April 4, 1908.]
WIENER: fOIXT AXD BONE TUBERCULOSIS.
627
trauma, the chronicity of the exudate in spite of
treatment, or the continued recurrence of the exu-
date, point to tuberculosis.
(b) Fungus /orwi.— Accordmg to Konig, this is
always preceded by hydrops of the joint. But in
some cases the amount of exudate was so small as
hardly to be appreciated. The thickening of the
capsule is most marked in the upper part of the
joint. This, together with the atrophy of the mus-
cles, especiallx- the quadriceps, gives the joint the
characteristic " spindle shape. The skin becomes
thin and glossy, and the subcutaneous veins are
visible. Motion of the joint becomes limited and
contractures in the flexed position take place.
(c) Cold abscess of the joint. — This is compara-
tively rare, and is not to be confounded with suppu-
ration in the fungus form. It is rarer in the knee
than in the hip. Swelling of the capsule is mod-
erate, but the synovial membrane is riddled with
miliary tubercles and is lined by a pyogenic mem-
brane which secretes a thin, purulent exudate.
There is no tendency to perforation of the capsule.
In doubtful cases a puncture of the joint should be
made.
Prognosis. — Recovery can take place at any stage.
The disease may last for years, and complete recov-
ery with full mobility is very rare. We must usu-
ally be satisfied with some limitation of motion,
often with ankylosis. The contractures often inter-
fere very much with the usefulness of the limb. In
children the growth of the limb is often interfered
with.
Treatment. — The general tendency of all sur-
geons is toward conservatism. Any contracture
should first be overcome, if necessary under anaes-
thesia. The limb should then be put up in plaster
of Paris. If complete extension is not obtained
the process may be repeated in two to three weeks.
If the limb cannot be straightened in this way,
permanent extension for two or three weeks will
usually overcome the contracture. The child can
wear an orthopaedic splint which allows the weight
of the body to rest on the pelvis. The knee should
be kept immobilized until all pain and swelling have
disappeared. For several months longer a remov-
able splint should be worn in walking. After this
long period of immobilization the joint will be quite
stiff. But it is very important not to break up
these adhesions too soon or too suddenly, for fear
of lighting up a new inflammation. The patient
will accompHsh much by using the Hmb, and after
a few months a little passive motion will help. To
keep up the nutrition of the muscles massage will
be found useful. Ft'sfina lente should be our motto
in these cases.
During the period of rest of the joint, iodoform
injections will be found very beneficial. WTiere
iodoform fails. Konig has had good results by wash-
ing out the joint with two per cent, carbolic acid
and then injecting five per cent, carbolic acid. The
Bier treatment is also a valuable aid.
Joints and Bones of Foot.
They are ver\' frequently affected, usually the os
calcis and astragalus. The disease seldom starts in
the synovial membrane. The process may spread
anteriorly or posteriorly, and fistulae may form on
the dorsum of the foot or on either side of the
tendo-Achillis. The first symptoms are usually a
little local pain and some limp. On examination,
one or more tender areas will be found. Somewhat
later we find swelling around the ankle. Very sel-
dom does the disease start with an infection of the
synovial membrane.
Treatment. — At the onset this should be con-
servative. If much bone is affected, and here the
X ray helps, an open operation will be necessary.
Many cases, especially in children, will get well with
rest, fixation, elevation of the limb. Bier treatment,
and iodoform injections. If the foot is fixed, it
should be at a right angle, half way between prona-
tion and supination, so that if ankylosis takes place,
the foot will be in the best possible position for
walking. An ambulator}' splint of plaster of Paris,
similar to the one used in fracture of the leg, is
very useful. Even where abscesses have developed
in young subjects a cure can often be obtained
without operation. If, however, the child is losing
weight, or if there is a secondary infection of the
soft parts, or extensive bone involvement, then an
open operation is imperatively demanded. In adults
we cannot hope for much from conservative treat-
ment. The older the patient, the earlier will opera-
tion be necessary-.
Shoulder.
In the shoulder joint tuberculosis occurs very
rarely. The age varies from fourteen to twenty
years ; usually the right shoulder is aflFected. and
usually the process starts from the head of the hu-
merus. In forty per cent, of the cases there is pul-
monary tuberculosis. The disease usually spreads
very slowly. As the process is chiefly in the bone,
palliative measures are not of much avail. It is
often necessary to remove the diseased focus in the
bone or to resect the head of the humerus. But it
should not be forgotten that even purulent joint in-
fections may heal without operation and even leave
a movable joint.
Elbow.
Primary synovitis in the elbow is rare, the dis-
ease usually starting in the olecranon or in one of
the condyles. The usual course is slow. Small
bone foci remain localized for some time without
giving symptoms. The diagnosis can often not be
made until perforation into the joint has taken
place. Such a perforation often follows a slight
trauma, and the trauma is thus looked upon as a
causative factor of the disease. The x ray will find
small bone areas, and is, therefore, a valuable aid
to early diagnosis. When the joint becomes af-
fected there is an exudate formed which distends
the capsule. To this is soon added periarticular
oedema, the muscles of the arm and forearm
atrophy, and we have, then, the characteristic
spindle shape. After the synovial membrane be-
comes aflFected, motion of the joints is painful. In
the majority of cases abscess followed by fistulae
result. The ligaments may become so destroyed
that abnormal mobility results. Many cases do not
come for treatment until late in the disease, owing
to the very gradual onset. Naturally the prognosis
varies with the extent of the disease. In early cases
it is very good.
Treatment. — Owing to its accessibility, the injec-
tion treatment of iodoform is of great value. The
628
I.ILBKIDE: L ANCER Of STOMAL H.
Medical Journal-
Bier treatment is also useful. If a fistula is pres-
ent, the iodoform can be injected directly into it.
Sometimes there will be marked improvement for
several weeks, and then no further progress can
be made by this treatment. An x ray picture will
show a small bone focus, which, after scraping out,
will be followed by a rapid cure. Especially in chil-
dren should we be ultraconservative, and we will
often be rewarded by surprisingly good results.
But we must individualize, not work by rule, and,
above all, watch our cases very carefully during the
whole course of treatment. Often when we are in
doubt, the x ray will point out to us the next step
in the treatment. Advanced cases with multiple
fistulse and much destruction of joint will, especial-
ly in adults, require resection of the joint.
Wrist.
We must distinguish between a lesion in the
joint and a lesion in the tendon sheaths. The dis-
ease can extend from the tendon to the joint. It is
rare in children, commoner in adults, but usually
associated with other tubercular processes, especial-
ly of the lungs. There may be a serous exudate, a
dry necrosis of bone, or general involvement of the
entire joint. There is frequently a history of in-
jury preceding the symptoms. The disease often
starts in the radius or metacarpal bones, although
much oftener in the carpal bones. Frequently the
disease starts in the synovial membrane. There is
swelling, disability, and atrophy of the foreann.
We seldom find much bone pain unless the process
remains localized to one focus. Here again we find
the spindle shaped swelling. There is doughy
oedema of the skin, increasing disability of the fin-
gers, and fistulae often develop. Owing to the ease
with which x ray pictures can be taken, they are a
valuable aid, not only in making the diagnosis, but
also in locating the various foci.
Treatment. — In children, again, we should be
very conservative.- In adults, especially if other
lesions are present, the treatment should be opera-
tive. The details of the conservative treatment are
similar to those referred to in tuberculosis of the
elbow.
46 East Seventy-eighth Street.
GASTROENTEROSTOMY IN CANCER OF THE
STOMACH.
With Report of Two Cases; Also a Third Interesting Case
Diagnosticated by Examination of Shreds of
Tissue which Came Away During the Use
of the Stomach Tube*
By John J. Gilbride, A. B., M. D.,
Philadelphia,
Instructor in Diseases of the Stomach and Intestines, Philadelphia
Polyclinic; Assistant Demonstrator of Anatomy at the
Medico-Chirurgical College.
Charles Kingsley in his book Westward Ho says
of the cider Leigh of Burrough that he was one of
those men, moreover, who possessed almost every
gift except the gift of the power to use them.
Might not this be applied to the position of many
of us in reference to cancer of the stomach. The
signs, symptoms, and laboratory methods for diag-
•Read before the Philadelphia Ccunty Medical Society, January
32, 1908.
nosticating this disease early, while of value, are un-
satisfactory, and of no value whatever, unless the
possessor of this knowledge applies it. Too often
in the early stages of the disease no ef¥ort is made
to use these means of diagnosis ; the result is that
the disease has already passed into an advanced stage
before being recognized, and either no operation can
be performed, or the palliative operation of gastro-
enterostomy is all that can be applied.
Gastroenterostomy was introduced into surgery of
the stomach by Wolffler (Die Resection des carcino-
matos erkrankten Magens ; JVieiier mcdizinische
Wochcuschrift, 1882, No. 14), who performed this
operation in cancer of the pyloric end of the stom-
ach, ill which complete resection of the diseased
pylorus was no longer possible.
Unfortunately, in nearly 80 per cent, of the cases
of gastric cancer submitted to operation the disease
is too far advanced to permit of a radical operation.
Out of 313 cases of cancer of the stomach operated
on up to February i, 1906, by the Mayos { Journal
of the American Medical Association, April 7, 1906,
p. 1006) only 26 per cent, were early enough to
permit of radical operation.
Widespread adhesions, metastases, and great loss
of strength are contraindications against resection.
Extensive adhesions between the growth and sur-
rounding structures not only render radical opera-
tion more difficult of performance, but they alsO'
form channels along which the spread of the disease
is apt to occur. The Mayos state that they have dis-
sected into the superficial surface of the pancreas a
number of times without that fatality to which Ha-
berkant (76 per cent.) and Mikulicz (74 per cent.)
have called attention. Moynihan reports a case in
which the involved transverse colon was also re-
moved, together with the stomach, with the patient
living at the time of the report, two years after the
operation. It is true that in the great majority of
cases the growth will recur either locally or gener-
ally, but the advantages of gastrectomy as compared
with gastroenterostomy are that it prolongs life about
ten months longer, it affords a greater degree of
comfort to the patient, and the patient has a chance
of complete recovery. There are also a number of
surgeons who advocate resection as a palliative op-
eration, even in those cases where lymph glands are
irremovable or an early secondary deposit in the
liver has occurred.
The advances made in the surgical treatment of
gastric cancer have gone beyond all expectations, as
the mortality following both radical and palliative
operations has been a gradual 'but continuously di-
minishing one, so that at the present time, according
to the Mayos, the mortality is not over 10 per cent.,
and in selected cases the death rate is as low as 5
per cent. Of course, cases operated on in the late
stages of the disease will continue to show a high
percentage of mortality. Again, it must be remem-
bered that all the cases treated medically die. Mayo
also reports 25 per cent, of the operative recoveries,
after resection, as living for more than three years.
Other cases are reported as living a longer time,
some of which are believed to be cured : One living
five years, the Mayos : one living eight years, and
one living thirteen years. Kocher ; a woman living
and well nearly six years, and a man living and well
April 4, 1908.]
GILBRIDE: CANCER OF STOMACH.
629
nearly ten years after resection, Berg. (Hygiea.
Stockholm, No. 307, through the Journal of the
American Medical Association, December 14, 1907,
page 2048.) While the radical operation is the one
of choice, if, after opening the abdomen, it is found
that resection cannot be applied, and that stenosis of
the pylorus, or stagnation of the stomach contents, be
present, a gastroenterostomy should be performed.
There is usually a stenosis of the pylorus, as about
80 per cent, of gastric cancers occur at the pylorus
and lesser curvature.
In cancer involving the curvatures without stag-
nation of contents nothing is accomplished by doing
a gastroenterostomy. However, with the perfection
that has been attained in the technique of these oper-
ations it is not unreasonable to expect that a greater
number of cases of cancer of the stomach will be
subjected to early operation at a time when complete
removal of the growth and involved lymphatics may
be accomplished. There is no doubt about the ad-
visability of performing a gastroenterostomy if in-
dicated, because it may be possible in some cases to
do a radical operation when nothing more than a
palliative one was intended. There is generally con-
siderable improvement in the health and well being
of the patient after gastroenterostomy. Vomiting
ceases, the appetite returns, and the weight remains
stationary or improves for a time. The stomach is
more quickly emptied and there is a lessening of the
irritation caused by the food passing over the sur-
face of the growth. Katzenstein (Deutsche medi-
sinische Wochenschrift, xxxiii, No. 4, through the
Journal of the American Medical Association, March
16, 1907) is of the opinion that the pancreatic juice
passing over the surface of the cancer after gastro-
enterostomy checks the growth, the surface of which
it presumably digests.
The prolongation of life after gastroenterostomy
is usually from three to six months, and after resec-
tion is on an average of fourteen months.
Now that surgery has definitely shown that it has
something to offer sufferers from cancer, the next
thing is to create a favorable public opinion by let-
ting it be known that cancer has been cured and can
be cured by early operation. The education of the
people on this point would, to my mind, give a most
wholesome impetus to the proper treatment of this
disease.
The delay in bringing these cases to the operating
table is not only due to our unsatisfactory means of
diagnosis, but to the lack of enthusiasm among
many members of the profession, as well as among
the laity. An early diagnosis is difificult, sometimes
impossible ; however, if the methods of diagnosis
which we now have were more generally applied
many more cases should be recognized at a time when
radical operation might be performed. These meth-
ods are neglected, except by a comparatively few ;
even the simpler forms of physical examination, and
this notwithstanding the pleading of the best men of
the profession for early diagnosis and early opera-
tion. He who has made an examination of hi? pa-
tient and tried to make a diagnosis is doing his duty,
but he who has kept a patient under treatment and
made no effort to diagnosticate the case until the pa-
tient says he has "black vomit and a tumor" is per-
forming the function of a patent medicine. "Coffee
ground vomit" and a tumor arc frequently only ante-
mortem signs.
Until recently the onset of gastric cancer had been
considered to be usually of one type, that is, it oc-
curred most frequently in individuals past forty who
had been previously free from dyspepsia, and that if
the symptoms had persisted for more than eighteen
months or two years the disease was probably not
cancer. However, we now recognize two other dis-
tinct types of onset ; one, where the cancer develops
on an ulcer that may have caused symptoms at either
a recent or a remote date preceding the cancerous in-
vasion, and it was formerly believed that this change
occurred in only from six to ten per cent, of cases,
whereas we now know the change happens in a
nnich greater number of instances. According to
the Mayos {Journal of the American Medical Asso-
ciation, April 2, 1906), 56.4 per cent, of their last
thirty-nine cases of cancer of the stomach operated
on showed direct evidence of carcinoma developing
on an ulcer. Moynihan (British Medical Journal,
February 17, 1906) gives 72.1 per cent., and some
writers even a higher percentage of cancer develop-
ing on an ulcer. This knowledge has been gained
from operations performed for gastric ulcer, its com-
plications, etc., and could not have been obtained
from post mortem examination. The other and
third type of onset is in cases that give a history of
dyspepsia extending over a period of from two to
fifteen years, and, in some few instances, even a
longer time. The presence of lactic acid in the
stomach contents is a valuable sign in diagnosticat-
ing this disease ; however, it should be thoroughly
understood that lactic acid is usually, I believe it is
always, absent in the early stages of gastric cancer,
and one should not, therefore, wait until lactic acid
is present to diagnosticate cancer.
The presence of a tumor, if small and movable, is
not a contraindication to radical operation, for the
reason that the majority of tumors occur at the py-
lorus in the most accessible part of the stomach to
examination, and the fact that there are usually
symptoms of stenosis which direct the attention of
the patient more forcibly to the disease and lead
him to seek medical advice earlier than he otherwise
would.
In the performance of gastroenterostomy in gas-
tric carcinoma the posterior no loop method with a
double row of sutures is the method of choice, with
the jejunum continuing its normal course to the left.
When adhesions are too extensive and do not per-
mit the performance of the posterior operation, the
anterior anastomosis should be performed, the jeju-
num being raised in front of the transverse colon,
and the anastomotic opening in the jejunum made
at a distance of from ten to fourteen inches from its
commencement, sufficient distance being allowed, so
that the transverse colon will not be obstructed. In
the employment of either method the anastomotic
opening in the stomach should be made at a point
far enough away from the diseased area to avoid
the probability of an early involvement of the stoma
by the extending disease, with a return of symptoms
of obstruction. If the anterior operation is applied
this should be followed by the performance of an
630
GILBRIDE: CANCER OF STOMACH.
[New York
Medical Journal.
enteroenterostomy between the afferent and efferent
loops of intestine comprising the anastomosis. The
double row of suture method is here, too, preferable.
The cases that I have to report are the following :
Case I.— J. V., male; white; age sixty-five years; born
in the United States ; bricklayer ; consulted me June 28,
1906, six months after the onset of symptoms. (See Fig. i.)
Family history : Father died of consumption of the
bowels at sixty-two years of age.
Previous history: While in the army during the civil
war he had suffered from intermittent attacks of diarrhoea.
Fig. I.— Cancer of the pylorus (Case I).
He also had had inflammatory rheumatism at that time, and
had had influenza in 1891. Otherwise he was perfectly well
and in good health up to Christmas time, 1905, when_ he
began to have a dull pain in the epigastrium after eating,
lasting about two hours. The pain would then disappear
to return after the next meal. There was also some full-
ness and distress after meals. He has been gradually get-
ting worse. Vomiting began in May, 1906, occurring about
once a week and consisted of probably a quart of a black,
tarry material. His appetite began to fail about six weeks
before consulting me, and food had no taste recently. He
belched considerably, and the bowels were constipated.
He felt very weak and tired easily. Weight at the time of
onset of symptoms was 205 pounds ; at the time of my
examination he' weighed 155 pounds— a loss of 50 pounds.
Sleep was restless ; no cough or headache.
Physical examination : Patient was a large, strongly
built man; there was some wasting, but no cachexia. Color
was good; mucous membrane slightly pale; examination
of eyes was negative : teeth showed to be defective ; tongue
was slightly coated; there was no pulsation in the neck or
palpable lymphatic glands. Chest was emphysematous;
lungs and heart examination proved negative; radial pulses
were equal; arteries were atheromatous. Liver dulness be-
gan at the sixth rib ; lower border not palpable. Inspection
of abdomen : Abdominal wall flat and relaxed with slight
distention and a globular swelling in the epigastrium to the
left of the median line extending under the left costal
border, and corresponding in size, shape, and position to a
distended stomach, the greater curvature of which was not
below the normal position. Peristaltic waves were passing
slowly and at regular intervals from left to right. An
oblique inguinal hernia of the right side was also present.
Palpation of the epigastrium showed an increased fullness
and resistance, but did not at first reveal the presence of a
definite mass. However, the peristaltic waves indicated
conclusively the presence of stenosis of the pylorus, and by
laying my hand almost flat upon his abdomen, with a little
deeper pressure exerted by the tips of the fingers over
the epigastrium up beneath the liver, and gently stroking
the abdomen downward during deep inspiration, holding
the parts during expiration, I was able to bring down below
the liver a tumor of the pylorus which was about nine
centimetres in its transverse diameter by six centimetres
vertically. It was hard and nodular. The finger tips could
be placed between the growth and the liver, to which it
seemed to be strongly united, as the mass could not be held
down during expiration. This I attributed to a densely
involved gastrohepatic omentum and to the fact that the
growth was also adherent posteriorly, both of which con-
ditions allowed but a slight mobility of the growth, and
the operation which followed a few days later showed this
supposition to be correct. The epigastrium was only slight-
ly tender, and the growth could be handled without causing
pain or discomfort, except a little nausea. Gastric tympany
began at the sixth rib in the left nipple line and the greater
curvature e.xtended two and a half inches below the left
costal border. Gas could be heard escaping through the
pylorus. Kidneys or spleen were not palpable. Webster's
and Stiller's signs were absent. Left supraclavicular lymph
glands were not palpable. Physical examination was other-
wise negative. Urine examination was negative. Analysis
of gastric contents after an Ewald test breakfast: Aspirated
100 c.c. of a black "coffee ground material" ; contents fairly
well digested ; slight amount of mucus present ; reaction to
Congo negative; total acidity 0.30; free hydrochloric acid
absent. Lactic acid test showed a positive reaction. Blood
positive. Microscopical examination of the gastric con-
tents was not made. Occult blood also in the faeces, using
the aloin test.
The diagnosis of gastric cancer was made, and an opera-
tion was advised which I performed at St. Joseph's Hospi-
tal on July 5, 1906. On opening the abdomen the stomach
presented showing the growth as described and involving
the whole pyloric end of the stomach, also extending more
along the lesser curvature. The gastrohepatic and gastro-
phrenic ligaments were thickened and the lymph glands en-
larged ; one lymph gland overlying the cardia was the size
of the distal phalanx of an adult's thumb. Adhesions were
so extensive posteriorly as to render it impracticable to
do a posterior gastroenterostomy, therefore, an anterior
one was performed without doing an enteroanastomosis.
The abdomen was closed in the usual manner, and the pa-
tient recovered from the operation w-ithout a bad symptom.
He was up in a chair at the end of five days and had his
clothes on, and out upon the floor at the end of eight days,
leaving the hospital in three weeks. His appetite was ex-
cellent and he relished his food ; he resumed light work
during September and October, and died November 26,
igo6. No autopsy.
This man had been under treatment for dyspepsia from
the time of onset of symptoms and he said he had not been
examined even in so far as to show his tongue. The man
was an admirable patient and anxious for anything which
might save his life, but alas, too late!
C.A.SE II. — (See Fig. 2.) L. S., female, age forty-seven,
housewife, born in the United States, was seen in consul-
tation with Dr. James L. Hornbeck, of Catasauqua, Pa.
Family history: Father, seventy; mother, sixty-eight,
both living and well.
Previous history : Married twenty-five years ; eight chil-
dren living and well. Patient had had measles when a
child ; malaria eighteen years ago.
Present condition began fourteen years ago by vomiting
off and on at variable intervals of from once a day to
once in two weeks or once in two months ; no blood was
vomited ; there was belching, regurgitation of sour liquid
at times. She had been gradually getting worse. Four
years ago she had a rather severe attack of stomach dis-
turbance which lasted between three and four weeks, con-
fining her to bed. She had had similar attacks about once
a year since the one mentioned. She vomited blood during
an attack that occurred about a year ago. Constipation
had pain during attacks only. The present and last spell
began March 11, 1907, by loss of appetite, fullness, and dis-
tress after eating, vomiting every few days, the quantity de-
pending upon the interval between each vomiting spell ;
bowels constipation alternating with diarrhoea; complained
April 4, 1908.]
GI LB RIDE: CANCER OF STOMACH.
631
of thirst and weakness; was gradually getting worse. She
alternated with diarrhoea. Appetite was usually good in
the intervals between attacks. Patient slept soundly and
had been confined to bed from the middle of June until
the first week of July, 1907: was then up and about for
two weeks when she again took to her bed, where she
had been for five weeks when I saw her, August 22, 1907.
Fig. 2. — Cancer of the stomach, gastroptosis, with dilatation
(C.^SE II).
Physical Examination : A large boned woman who was
very much emaciated. The skin was dry. brownish, and
shriveled. Tongue was dry. red. and slightly coated, show-
ing that she was suffering from a toxaemia : lips were dry ;
teeth defective. Supraclavicular lymph glands were not
palpable. Examination of lungs was negative ; pulse was
small, hard, and accelerated. ^Myocarditis and arterio-
sclerosis were present. Inspection of abdomen showed con-
siderable prominence in the imibilical region and scaphoid
above and below. This bulging was the dislocated and di-
lated stomach, the greater curvature being midway between
the umbilicus and symphysis pubis, and the lesser curva-
ture was midway between the xiphoid cartilage and um-
bilicus. Peristaltic waves were passing from left to right ;
succussion splash was present over stomach. There was a
diffuse thickening of the stomach wall at the pyloric end.
Gas could be heard passing through the pylorus at delayed
intervals of from 30 to 40 seconds. The normal tone of
peristaltic sounds at the pylorus was. according to Cannon,
at intervals of about nineteen seconds, which observation I
have also noted. The pylorus could also be felt to alternately
contract and relax under the palpating fingers. Examination
of liver, kidneys, spleen, etc.. were negative. There was but
slight tenderness over the stomach on palpation. A right
femoral hernia was present The woman was almost a skele-
ton, the muscles as well as the panniculiis having wasted
away. Aspiration of the stomach contents : It was not as-
pirated in truth, as the contents were so thick as to obstruct
the tube and the patient vomited about two quarts of a thick,
brownish, fairly well digested materia! of a sour odor.
This on examination showed a total acidity of 0.58; free
hydrochloric acid to Congo positive : free 0.02 : lactic acid
negative. Blood present : some mucus.
Diagnosis stenosis of pylorus probably malignant: gas-
troptosis with dilatation: arteriosclerosis and chronic in-
terstitial nephritis.
Operation upon the stomach was advised so that in the
event of the pyloric stenosis not being malignant she would
be given a chance for recovery. Dr. Hornbeck had ex-
hausted all medical means, including belts, drugs, diet, etc.,
and to his credit be it said he had had the patient under
observation only a few months. Operation was consented
to and she came to Philadelphia on August 27, 1907. I
operated upon her at St. Agnes Hospital the following day,
doing a posterior gastroenterostomy, as pylorectomy was
out of the question on account of the emaciation, weakness,
etc. There was a diffuse thickening of the pyloric end of
the stomach, almost complete stenosis of the pylorus, which
was hard and indurated, the glands at the pylorus along
both curvatures were large and hard. The patient re-
covered nicely from the operation, getting up in a chair
at the end of five days. Nourishment was begun early and
forced. She had a good appetite and relished her food.
The urine went as low as ten ounces a day for two days
following the operation, and never above twenty-four
ounces during the four weeks she remained in the hospital,
although treatment against this condition was begun before
the operation and by filling the abdomen with saline solu-
tion before closing, this was followed with saline by the
rectum (Murphy's method), diuretics, including sparteine
sulphate in two grain doses hypodermatically as the occa-
sion required.
She had no further trouble with the stomach following
the operation and returned to her home four weeks later.
Her bowels continued loose off and on as before. Appe-
tite was good. She ate her food well, but never gained
strength, nor did the kidneys increase their function. She
died the latter part of October, 1907. Dr. Hornbeck wrote
me after her death that following the operation she did not
suffer at all from her stomach and complained only of
weakness. The cancer in this case, I also believe, in all
probability, followed a chronic ulcer which was the cause
of her long continued dyspepsia.
I will cite one other case, becattse it illustrates
three points : ( i ) Diagnosis of cancer by examina-
tion of a piece of tissue that came away in the wash
water while using the stomach tube: (2) absence of
lactic acid ; (3) a clear historj' of ulcer of the stom-
ach dating back twenty-eight years. Lactic acid
was also absent in the other case above reported.
Case III. — (See Fig. 3.) A. B., female, white, age forty-
five years; born in Germany; housewife: came from Con-
necticut. Seen in consultation with Dr. Edward F. Menger,
632
FETTEV: CHRONIC ALCOHOLISM.
[New York
Medical Journal.
of Philadelphia, Novemher 5, 1907. She had been married
twenty-two years ; had had five children and one miscar-
riage.
Family hi.story : Mother died of cancer of the stomach
at forty-tivc \-ears of age. One brother died of tubercu-
losi-s of the lungs at the age of twenty-five years.
Previous history: Vonfited blood at seventeen years of
age, belie\cd to have had gastric ulcer and was kept in bed
about twtiity weeks.
Present cimdition: Regan four years ago by failing ap-
petite, fulness and distress after eating, belching, vomiting
at variable intervals of fnun .nice in two weeks to once a
day or once in two days. The (|iiantity of vomitus was
about a quart when she xcmiited every day. and may have
been a little more when the inter\als between \omiting at-
tacks were longer. Soiiietinies her appetite improved off
and on for a few days at a time : she then ate a little
more and this was again followed 1)\- vonfiting; but she
felt better when she ate least. Pain had been present in
epigastrium more or less all the time for the past several
years. It was relieved by \omiting or by lying down. No
iieadache : bowels were regular; there was burning sensa-
tion occasionally in the epigastrium ; regurgitation of some
liquid at time-. Patient had lost about thirt\- pounds in
weight in the last year ; sleeplessness and palpitation ; no
swelling of the feet.
Physical exanfination : .\ medium sized, fairly well built
■woman showing some wasting, but not cachectic or emaci-
ated: teeth \ery defective and tongue coated; examination
of luntis and heort were negative; supraclavicular lymph
glands were not palpable.
Inspection : .Abdominal wall w as relaxed and there was
a prominence about the width of a hand extending frotn
"beneath the left costal margin downward and to the right
parasternal line. The centre of its vertical diameter was
at the umbilicus. Below the xiphoid cartilage tenderness
on palpation was quite marked. Splashing was present over
the stomach, which was dislocated downward; no peristaltii;
waves were visible, nor was there any mass palpable, the
right kidney and stomach, of course, being excepted. The
right kidney occupied the third position of dislocation, as
the tips of the lingers cmild be placed above the upper po'.e
of that organ. I.iwr, left kidney, or spleen, were not
palpable. W eli-iei '^ and Stiller's ^igns were not present,
no tenderness ali.mg the left side of the spine posteriori)-
(Boas sign of gastric ulcer). Exanfination of gastric con-
tents following an Ewald test breakfast : Time forty-five
minutes: aspirated 20 c.c. of fairly well digested contents;
some blood streaked mucus, and a few drops of bloody
liquid dangled from the end r,f the tube on withdrawal.
Total acidity 0.50. l-"ree liyilrochlnric acid to Congo po vo-
tive; by analysis o.io. lUocid was macroscopically present.
On examining the wa.sli water 1 nnticed a few small pieces
of supposed mucus which reseniMed tiiucous membrane and
which I had examined hy -Dr. W ieder at the Aledico-
chirurgical College and by Professor Joseph McFarland,
of the same institution. It was pronounced by them can-
cerous.
An operation was advised, but the woman, who had re-
turned to her home in Connecticut, refused her consent to
operation.
Kverv patient who in middle cir advanced life is
sufferin_£( from d\spc])sia .should have the stomach
contents examined, not once, but several times, if
necessary. This can be readily carried out bv giv-
ing an Ewald test breakfast on a fasting stomach :
two small slices of bread and about a pint of water
are given. Aspirate the stomach contents in fortv-
five minutes and examine. If the attendant is un-
able to examine the contents himself, he should
shake it up. pjiit some or all in a bottl<\ seal, and
send it to some one for examination and report.
Suspicion of the presence of malignant disease
of the stomach calls for an exploratory lai)arotomy.
Contraindications to any operation on the stomach
are involvement of the su])raclavicular lymph
glanrls, particularly those on the left side, other ex-
tensive involvement, advanced cachexia, and
ascites.
One hears the statements rhade on every side, by
the uninformed, of course : "We have nothing that
will cure those cases, and what can we do until we
know the aetiology?" These are but lame excuses
for inactivity.
Let those who ofter these statements arouse from
their lethargy, and when a diagnosis has not been
made until the life of a dear one is ready to pass
over the river beyond, not console themselves w'ith
the thought that the disease was incurable anyway.
Why sit idly by when men like Billroth. Kron-
lein. Mikulicz. Robson. ^^loynihan. Deaver, the
Afayos, and others have carried or are carrying the
light and showing us that some of the cases sub-
jected to early radical operation are cured? We
have a remedy, the only one at present — surgery.
.Apply it promptly and judiciously, and when the
last shades of the twilight of life will have fallen
around the chamber of those afflicted with this dis-
ease, let us be able to feel and say, even though we
fail at times, but not always, that we have done our
duty, we did our best to save our patients from
death by this disease.
2412 XoRTH Sixth Street.
CHROXIC .ALCOHOLISM:
What Can and U'liat Cannot Be Accomplished by
Treatment.
Bv George E. Pettey, M. D.,
Memphis, Tenn.,
Jlcinbcr, Aiiicricaii .\ssociation for the Study of Inebriety, etc.
The question is frequently asked : "What can be
done b\ treatment for those who are enslaved by
alcoholic liquors — can they be cured?" To this
question both an affirmative and a negative answer
can be made, and each would be correct when re-
ferring to a certain class of cases. Chronic alco-
holism is not only a disease itself, but in many in-
stances it springs fremi nther diseases. These dis-
eases may be either physical, mental, or moral. To
cure any disease the cause must be removed. In
some cases of alcoholism this can be done by treat-
ment, while in others it cannot : then the question
naturally arises, what class is curable and what is
not? In endeavoring to answer this question it is
necessary to consider the type of the addiction as
well as the influence which led to its formation. In
doing this it is well to first divide the drinkers into
two classes, the regular drinkers and the periodical
drinkers, then to study very carefully the influences
and causes that led to the formation of the addic-
tion. It will be found in many instances that these
differ materially in the case of the regular drinker
from those of the periodical drinker.
Regular Drinkers.
Probably 80 per cent, of all persons who drink
whiskey regularly, day by day and week by week,
got into the habit inadvertently, unintentionally.
They were persons of .sound bodies and minds, good
habits and high aims, who began to use liquors in
a social way.' or i)robal)ly with the idea that their
effects would protect them from malaria or other
l)revalent disease. They continued this course
without mature thought as to its consequences and
certainly without any ])urpose to go to excess or
April 4, 190S.]
PETTEV.
CHRONIC ALCOHOLISM.
633
dissipate in any way. The use of a stimulant grad-
ually grew more frequent, finally leading to the
daily consumption of considerable quantities of
some alcoholic beverage. For a time the effects
of this beverage seemed to improve the healtli, to
impart greater mental and physical vigor, and to
generally promote the well being of- the subject, but
these benefits w-ere more apparent than real, and
all this time there was being created in the system
a demand for the cf¥ects of alcohol, and this pro-
gressed until the user felt more comfortable when
under the influence of the stimulant than when not.
Thus, gradually, and almost imperceptibly, the de-
mand for the stimulant grew, and the victim be-
came more and more dependent upon it, until
larger and larger quantities were required to meet
this demand. The daily consumption of these con-
siderable quantities of liquor necessarily brought on
such changes in the system as to create an impera-
tive demand for the continuation of their effects.
After reaching this stage the victim felt that he
could not begin his day's work without his morn-
ing drink; there was a degree of lassitude and lack
of vigor that he was totally unable to throw off ex-
cept by the aid of a stinuilant. As these disorders
progressed, one drink was not sufficient to give him
the necessary support, and two, three, or more were
taken in close succession, and this bracing process
was continued throughout the day and from day to
day and from week to week. The effects of this
prolonged and free use of alcohol wrought serious
impairment of the digestive organs;, the appetite
became variable or absent altogether unless fresh-
ly stimulated by an extra drink, and if, at this or
any subseque,nt stage the victim made an ef¥ort to
discontinue drinking, such a state of nervousness
would result as to drive him to resume the stimu-
lant. The entire system had by this time become
so thoroughly saturated with toxic matter, of such
an extremely irritating kind, that a condition of in-
tolerable nervousness would arise whenever the
system was allowed to get out from under the iiozc
sedative influence of liquor, and no matter how
acutely conscious the victim may become to his
slavery or how heroically he struggles to throw ofif
the yoke he finds himself unable to do so by his
own efforts. The prolonged free use of alcoholic
stimulants brings about such disorders of the sys-
tem as to lead even the best of men, when in its
grasp, to continue to seek relief from the suffer-
ing incident to these disorders by increasing the
quantity of alcohol consumed. Whether that course
is imperatively necessary or not, it appeals to them
as being the one readily avadable and efficient rem-
edy, the panacea for every ill, and it is so used.
A majority of all habitual users of alcohol in
this country belong to this class, and many of them
would gladly quit drinking if they could ever get
the poison out of their systems, and reach a condi-
tion in wdiich they could live in comfort without it,
bvtt they seem never to be able to do this. The\-
never get entirely sober, and their systems are
never clear from the products of tissue waste.
They are always in an extremely toxic condition,
and are only comfortable when the paralyzing' ef-
fects of alcohol blunt their sensibilities to the ])rcs-
ence of this poison. In habitues of this class the
addiction has a purely physical basis, due to the ef-
fects of alcohol alone, a combined chronic auto-
toxsemia, and drug toxaemia, and as both of these
elements are susceptible of being removed by treat-
ment, cases of this class are curable.
In the second division I would place a small per
cent, of regular drinkers who were born with, or
who from disease in carl\- life acquired, a defective
physique and an unbalanced nervous system, per-
sons who, because of such defects, have never been
normal either in nervous or physical organization.
When such persons, in seeking something to over-
come their habitual discomfort, experience the ef-
fects of alcohol the\- readily fall a victim to its se-
ductive influences, h'or a time this stimulant seems
to be the one thing lacking in their lives ; it over-
comes that discordant nervous condition which they
so much dread, and they feel that they have found
a panacea for all their ills, but this relief is only
temporary. The den.and for the effects of alcohol
grows very rapidly in such cases, and its contin-
uous use brings on the same pathological conditions
that it does in others. The system soon becomes
extremely toxic, and this irritating matter greatly
aggravates their former nervousness, so tliat the
two conditions together now make such an impera-
tive demand for liquor that the victim camiot in any
wise resist it, and he keeps himself constantly sat-
uated with alcohol — in fact, after reaching this
stage he must do so to enjoy the least degree of
comfort. In this class of cases but little can be
expected from treatment, unless it is found that
the original discordant nervous element can also be
removed b}' treatment. \Mien these causative con-
ditions are found to be such as to be amenable to
treatment, anrl the treatment for the addiction em-
braces not only such treatment as would be neces-
sary to give relief in an ordinary case, but also such
other well directed measures as may be required
to restore the primarily unlialanced nervous system
to a normal condition, nnich benefit may be de-
rived from treatment even in these unpromising-
cases, provided a reasonable degree of moral fibre
was originally present.
In a third division I would place another, but
relativelv small, proportion of regular drinkers. To
this class belong those who drink as a pure dissi-
pation, persons who are deficient in moral fibre,
lacking in purpose, supremely selfish, willing to
gratify the present moment at any cost to them-
selves or others, without a nornial sense of re-
sponsibilit'^- : those who arc simph drifting through
the world without rudder, conqjass. or objective
point. These defective traits of character may be
due either to inherited tendencies or to early envi-
ronment. .Such persons as these drink because they
prefer to do so. and would return to the use of
liquor even if some one took them U]) and gave
their systems a thorough renovating and removed
all physical necessity for the .stinndant. In cases
of this class more than human agency would be
necessary to effect a cure. Xot only would it be
necessary to renovate their bodies and put them in
normal condition, but it would be necessary to ef-
fect a most radical change in their moral natures,
a complete transformation of their purposes in life,
and nothing short of the grace of God is sufficient
634
PETTEY: CHRONIC ALCOHOLISM.
[New York
Medical Journal.
for such a work. Human agency will not avail.
Fortunately only a small proportion of the regu-
lar drinkers belong to this class ; the great ma-
jority are of the class first described in this paper.
They are men or boys of good families, of excel-
lent traits of character, of high aims, chivalrous,
generous to a fault, truthful, and honest — in fact,
men with whom no fault can be found except this
one weakness, and that due to the lamentable fact
that they have drifted into the clutches of this mon-
ster. Victims of this class only continue to drink
because their willpower and selfcontrol have been
so undermined by the effects of alcohol that they
cannot extricate themselves from its clutches ; they
cannot retrace their steps. When such men as
these are once freed from the domination of alco-
hol and are put in a normal condition they will
maintain themselves and almost invariably remain
permanently free from its thraldom.
Failure to permanently benefit such men as are
described in the second and third division should
not be allowed to discourage us or to make us less
enthusiastic in our ef¥orts to rescue the more
numerous and really noble army of enslaved ones.
Periodical Drinkers.
These should be divided into four classes, and
probably some of these classes should be still fur-
ther subdivided in order to get a clear conception
of each class. There are at least four sets of
causes that lead to periodical drinking among men
who are entirely sober between such sprees. These
should be enumerated as: Dipsomania, real and
symptomatic ; moral cowardice ; environment with
lack of stability of character ; environment with an
ever present but resisted appetite.
Dipsomania. — Dipsomania is defined to be "an
uncontrollable desire for strong drink," but this
term should be restricted to those cases in which
this desire or impulse springs from a real mental
disorder, a true mania, and should not be applied
to those cases where the desire for drink only be-
comes uncontrollable when it is excited or intensi-
fied by some general physical derangement, or
where the desire is continuous. A better definition
would be "periodical insanity taking the form of
an uncontrollable desire for strong drink." Real
dipsomania is very rare, but that it does exist can-
not be denied. Most writers leave the impression
that such attacks are due entirely to some obscure
structural brain lesion or inherited mental defect.
It is doubtless true that there are persons in whom
a real mania of this type occurs because of an in-
herited mental bias, or perverted nervous organiza-
tion independently of the general physical condi-
tion, but, in my judgment, such cases are extremely
rare. In a large majority of cases which are thus
classified the attack only occurs when excited by
an added general systemic derangement, an acute
autotoxsemia. The irritating effects of this toxic
matter serves as the exciting cause of the outbreak,
and in most instances these attacks may be warded
off or prevented altogether by keeping the system
free from toxic matter. Where outbreaks of this
kind occur as the result of an inherited or acquired
mental defect, entirely independent of the physical
condition, treatment cannot be expected to be of
permanent benefit, but in cases in which such at-
tacks only occur when an exciting cause, such as
autotoxsemia, contributes its influence, then treat-
ment will be of real benefit, provided it embraces
such instruction in the manner of living as to en-
able the victim to avoid the occurrence of such
toxic states.
Moral cozvardice. — Another and probably the
most hopeless class of' periodical drinkers are those
who drink as an expression of moral cowardice.
These are men who have no particular craving or
appetite for liquor, and who will say at almost any
time that they do not particularly care for the taste
or primary effects of alcoholic drinks, but who have
learned from experience that the effects of alco-
hol will bring them surcease of cares and worries
which they have not the moral courage to take up
and bear, and from time to time they seek forget-
fulness in the effects of liquor. A man of this class
will quarrel with a friend or his wife and go off
and get drunk for spite, or he may have some busi-
ness experience which to other men would be
trivial, but he, not having the moral courage to face
it, runs from it and seeks oblivion in the effects of
alcohol. Little if any good can come from treat-
ment of patients of this class. Therapeutic meas-
ures cannot remove these incumbrances from
their lives, or impart to them that degree of
moral courage that is needed to fit them to fight
the battles of life in the open and to resist the ad-
verse current which drifts them from a safe and
sober mooring.
Instability of character zvith bad environment. —
In another class of periodical drinkers the sprees
are due to "bad environment coupled with lack of
stability of character." These are the social drink-
ers of the type who lose control of themselves as
soon as one drink is taken. Many of these are men
of estimable qualities, amiable, chivalrous, good
hearted, kind, and in every way lovable men. but
they are deficient in selfcontrol, fixed purposes, and
positive traits of character. They are good na-
tured fellows who drift with the current and allow
others to dictate their course. These men, when
away from the drinking associates and out of
temptation, remain entirely sober, and would not
think of going alone and deliberately beginning to
drink ; they have no craving or appetite for liquor
that they are not fully able to control, but they are
negative characters, and when thrown with drink-
ing associates they do as others do. They are of
the type of social drinkers who lose control as soon
as they are slightly under the influence of alcohol.
When once started, such men continue to drink un-
til some one takes control of them and gets them
out of the adverse current. Then a period of en-
tire sobriety follows, only to end in another spree
when they get into the current which drifts in that
direction.
Treatment in such cases can only be successful
when followed by an entire change of environment.
The old associates must not only be given up, but
the one seeking to reform his life nuist be thrown
with sober and moral people whose p(5sitive influ-
ence for good over him will be sufficiently strong to
enable him to stand firmly in his new position, not-
withstanding his defective traits of character.
Bad environment zvith an ever present but re-
April 4, 1908.]
PETTEY: CHRONIC ALCOHOLISM.
635
sisted appetite. — Another type of periodical drink-
ers are those who have an inherited or acquired
thirst or craving for Hquor which is ever present
with them, but who, from strong convictions, con-
tend against this weakness with a courage that is
in many cases really heroic, and, under favorable
circumstances, they succeed in controlling them-
selves, but when thrown with drinking associates
or when brought under other strong temptation
then they find themselves unable to resist both the
ever present thirst and the temptation. Under these
circumstances they begin to drink, and as soon as
one drink is taken their resisting poiver is gone,
and they throw themselves into the spree with a
vigor and abandon that is not known to the more
timid or. less resolute. They continue to drink un-
til the stomach rebels and will no longer retain
the liquor : then they go through a period of ex-
treme distress and remorse, and finally get back on
their feet.
Periodical drinkers of this type are more amen-
able to treatment than any other form of periodical
drinkers, because the craving, the thirst against
which they contend, can be overcome — in fact, en-
tirely destroyed. In addition to this their attitude
toward liquor can be so changed as to render the
taste small, and the effects of liquor repulsive to
them. Wh&n men of this type are given this much
aid they find themselves quite able to successfully
contend against the influence of drinking asso-
ciates and to resist other currents of influence
which, when associated with their former craving,
would have been sufficient to cause them to fall.
Principles of Treatment.
Before undertaking to treat any disease we
should endeavor to ascertain the nature of the con-
dition to be met : whether such a condition has a
real, structural pathology or is only functional de-
rangement, and whether it is a physical or a mental
disorder. That the prolonged use of alcoholic
stimulants does cause serious structural lesions of
the brain, liver, stomach, and other organs cannot
be denied, but such lesions are not the only or prin-
cipal reason for the continuation of the habit. In
some cases, as we have seen in the preceding, the
use of liquors are continued from preference, or
because of some mental or moral defect, but in the
great majority of cases alcoholic drinks are con-
tinued because of a strong demand in the system
for their effects. The habit has a real physical
basis. This demand for the effects of alcohol is
due to the extremely toxic condition of the system.
Alcohol blunts the sensibilities of the nervous sys-
tem and retards the excretion of the products of
waste. The life of the human organism is a con-
tinuous process of waste and repair. When the ex-
cretion of this waste is retarded, even to a slight
degree, day by day, the system finally becomes so
saturated with poisonous matter as to cause serious
functional derangement of almost ever)- organ in
the body. One in this condition finds it necessan,-
to keep the nervous system constantly blunted with
the effects of alcohol or other narcotic to enable it
to carry on the work necessary to support life and
promote a reasonable degree of comfort. While
it is true that alcohol has caused these disorders,
still its effects relieve the acute distress springing
from them more promptly and in a manner more
acceptable to the sufferer than anything else wnth
which he is familiar, therefore he continues to seek
what comfort he can get by taking more alhohol,
and thereby burns the taper at both ends.
In endeavoring to bring about such a change in
this condition as to render the further use of al-
cohol unnecessary^ the first and most important
step is to thoroughly cleanse the system from the
products of waste which the effects of alcohol have
forced it to retain. In doing this the bowels, kid-
neys, and skin should all be made to do their full
share — in fact, for a time these should be made to
do many times their ordinary duty. Just in pro-
portion as the excess of toxic matter is eliminated
will the nervous system become quiet and the
urgent demand for the effects of alcohol disappear.
As a rule, in the course of three or four days the
system may be so cleansed of toxic matter as to
permit the withdrawal of alcohol without risk
or discomfort to the patient. I do not consider
it safe or at all advisable to abruptly withdraw al-
coholic stimulants from one who has been using
them in large quantities without first preparing the
system for such withdrawal. After the system is
properly prepared for the withdrawal it may be
made with perfect safety and without discomfort,
but I cannot agree with the arbitrary rule of cut-
ting oflP the alcohol as soon as the patient is taken
in hand.
Up to this point the treatment of the several
classes of alcoholic cases is practically the same, as
all of them require elimination of the toxic matter
and the withdrawal of alcohol, but from this point
on the several classes of cases will require radically
different lines of treatment. The particular nature
of the treatment required to complete the cure will
depend upon the cause, or set of causes, which orig-
inally led to the formation of the habit, as well as
those which have had an influence in its continua-
tion. If these were purely mental, then treatment
calculated to overcome a mental disorder should be
given ; if they were moral or social, then those influ-
ences should be looked into and every effort made to
direct the patient's future life so as to protect him
from these damaging influences and prevent a re-
turn to his old haunts and habits.
If the patient belongs to the more promising class,
the regular drinkers, in which the habit was con-
tinued because of the usual mental bias favorable to
the use of alcohol, and because of the deranged
physical condition resulting from its effects, then
the succeeding step in the treatment should be to
neutralize the remnant of alcohol remaining in the
blood, to overcome any appetite which may remain
for it, and to supplant the mental bias favorable to
alcohol with a dislike or complete disgust both for
its taste and effect. The means available for these
purposes are so numerous and their application so
varied that they do not admit of detailed discussion
in an article of this kind. In addition to the well
known therapeutic agents, static and other forms of
electricity, vapor, shower, or neutral or electric
baths, suggestion, and in some cases even hypnotic
suggestion, discipline and physical training can be
used to advantage.
While these corrective measures are being em-
636
EMERSON: CARIOUS TEETH.
[New York
Medical Journal.
ployed active therapeutic measures calculated to over-
come the catarrhal condition of the stomach should
also be employed. This condition is the remaining
disorder which would exert the greatest influence
toward a return to the old habit, because of its effect
in impairing digestion.
Fortunately catarrh of the stomach yields readily
to treatment in these cases after alcohol has been
discontinued, but active treatment for this disorder
is essential, and it should be continued until all
trace of it has disappeared and the patient's diges-
tion is perfect. He should be able to eat and enjoy
three good meals a day. Patients of this class need
the strength derived from the digestion of a hearty
breakfast in order to prevent them from feeling the
need of the support they formerly received from
alcoholic stimulants. No part of the treatment is of
greater importance than this, since, if it is not suc-
cessfully carried out, the patient will not be as secure
from relapse as he should be. Impaired digestion,
with its attendant lack of strength, operates as an
ever present influence suggesting the need of some
stimulant, some outside supportive, and this amounts
to an autosuggestion to take a drink. This is a
dangerous condition for the patient to be left in.
The conditions to be met in a majority of cases of
alcoholism are simple, and the treatment can be easi-
ly carried out, while in others they are so compli-
cated tliat the resources of the best equipped institu-
tion as well as the skill of the most resourceful physi-
cian will be taxed to the uttermost ; but with the aid
afforded by a well equipped institution a competent
physician can effect as large a percentage of perma-
nent cures in cases of chronic alcoholism as can be
effected in any other serious ailment. The most
skilful physician cannot treat them successfully at
their homes. The disadvantage due to their home
surroundings and to lack of perfect control of his
patient will defeat his best efforts. Even a general
hospital docs not assure the physician such control
and protection as this class of patients require.
I do not feel that I should close this paper with-
out a warning against any institution or physician
offering to send a home treatment for alcohol or
drug cases. Such an undertaking is worse than
folly, and when a proposition of that kind does nor
.spring from entire ignorance of the conditions to be
met, it is prompted by criminal avarice. Especially
fraudulent is the offer to send a rcmedv that can be
administered in coffee, etc., without the patient's
knowledge, and thus overcome tlie desire for liquor
and break up the habit.
In undertaking the treatment of alcoholic cases
the physician should take a comprehensive view of
the patient and his surroundings, and endeavor to
correctly estimate every influence which has in any
way contributed to his enslavement, and to so man-
age the treatment of the case, and" to so direct the
life of the patient thereafter, as to r-emove everv one
of the hurtfid influences as far as it is pos>--ible to
do so. The y)hysical man must be completely reno-
vated, and every function of his body restored to
normal activity. The mental, bias favorable to the
use of alcoholic liquors must be eradicated, and in
its stead a positive aversion to alcohol be established.
The patient is to be given a new chance in life bv be-
ing put back on his feet with a clear head, in full
control of all his faculties, and free from the domi-
nating influence of alcohol. The consummation of
such a work is certainly worthy of the best efforts
of any man.
958 South Fourth Street.
CARIOUS TEETH IN, THE TENEMENT POPULA-
TION OF NEW YORK CITY.*
By Haven Emerson, M. D.,
New York.
From June to September, 1907, I had the oppor-
tunity of examining the teeth of 2,301 applicants for
the Sea Breeze Health Home at Coney Island, under
the auspices of the New York Association for Im-
proving the Condition of the Poor. In each instance
the mouth was examined in the usual manner with a
tongue depressor, for evidences of contagious dis-
ease. The moment of this examination was used to
note the number of teeth decayed as well as to count
those lost, and the number replaced by artificial teeth.
The data acquired in this manner are the basis of
this report.
It is to be noted that none of these people, adults
or children, were suffering from any acute diseases.
The applicants were mothers and daughters over fif-
teen years, and children of both sexes from three
weeks to fifteen years.
They had been invited to apply for a two weeks'
stay at Sea Breeze, because they were known to need
an outing, often owing to sickness during the pre-
vious winter, but in the majority of cases because
their general health was failing, or they were giving
evidence of lowered vitality, in various forms of mal-
nutrition, anaemia, and general debility. As they
presented themselves for examination, they appeared
rather above the poorest class of tenement dwellers.
None had suffered from hunger, and all were suffi-
ciently clothed.
The rapidity with which the examinations were
made, and the lack on the part of the examiner of
technical skill in observing dental defects, are re-
sponsible for at least a very conservative estimate.
Only such cavities or distinct evidences of destruc-
tive decay in a tooth as were plainly visible on direct
inspection were taken in the count as decayed teeth.
Of the 2,301 applicants examined, 189 were in-
fants under one year, 1,478 were children from one
to fifteen years, and 634 were women and girls over
fifteen years.
Of the 1,478 children, 278, or 18.8 per cent., had
no defective teeth, leaving 1,200, or 81.2 per cent.
Among these 1,200 children I found 5.996 decayed
teeth, almost five apiece, or an average of 4.7 de-
cayed teeth for each one of the 1,478 examined.
Of the 634 applicants over fifteen years old, only
19, or 3 per cent., had no defective teeth, leaving
615, or 97 per cent., in whom 4,022 teeth were found
to be decayed. Tliis makes an average of 6.5 de-
cayed teeth for each of the 634 examined. There
were also found in this group 1,655 t«-"<?tb missing,
and, in addition, 1,444 artificial teeth, making a total
of teeth which had been removed presutuably for
advanced caries of 3,099, or an average of 4.8
"Read at a meeting of llie Institute of Stomatology, on Ueorin-
brr 8, 1907.
April. 4, 1908.]
NEWMAYER: MEDICAL INSPECTION OF SCHOOLS.
637
for each one of the 634. Combining the num-
bers of those removed and those at present de-
caved, we have an average of 11.3 teeth decayed,
or'28.8 per cent, of all the teeth of 634 adults severe-
ly enough diseased to be more or less permanently
ineffective. It also appears that 7.2 per cent, of the
entire number of teeth of these 634 adults were re
placed by artificial teeth. Inquiry elicited the fact
that only in the rarest instances were the toothbrusli
or even mouth rinsing used, and, as far as I could
find out, no means of cleansing the mouth and teeth
were considered to be worth while until the perma-
nent teeth liad appeared.
To those who are familiar with the conditions ot
patients who frequent the public medical dispensa-
ries, these figures will probably seem moderate, and
I do not doubt that an examination by a dentist
would reveal a material increase in the number of
carious teeth. These figures are. however, suffi-
cienlv striking to emphasize my point, that this de-
fect in the teeth of the tenement dwellers must be
corrected before we. ps physicians, can remedy some
of the serious evils of health and development which
these people suffer from. I refer especially to the
errors in digestion wdiich originate in incomplete
mastication and salivary digestion, with constipation
as an almost universal accompaniment. The ad-
vanced results appear as malnutrition, underdevelop-
ment, and lowered general resistance to infectious
disease.
That mouth infections involving the fauces and
tonsils are more common in individuals with many
carious teeth. I have no figures to prove : but the
condition of the soft tissues which come in contact
with carious "teeth, at the gum margin or upon
the buccal or lingual mucous membranes, certainly
suggests that there is a pretty constant source of sep-
tic or putrefactive bacteria in the crj-pts of the de-
cayed teeth.
Wadsworth (Journal of Infectious Diseases, iii.
No. 5, October, 1906) says : "From the hygienic
standpoint, the secretions of the mouth constitute
the chief, if not the only, source of respiratory in-
fection, and the infectious material is transferred
from one person to another in some instances
through the air, as from sneezing or coughing, but to
a much larger and more serious extent directly by
personal contact, or the use in common of the vari-
ous accessories of life."
I venture to suggest that one way in which the
prevalence and increasing incidence of respiratory
disease may be checked will be by a prevention and
correction of dental diseases, supplemented by the
use of bland alcoholic solutions as mouth washes,
which Wadsworth found to be the only mouth dis-
infectants of practical value.
To summarize my ideas upon this subject I may
say that carious teeth are so numerous among the
tenement population of New York, and the manifest
results of digestive disturbances caused thereby are
so far reaching in their effect upon the welfare of
the individual and the state, and the danger of com-
munication of infectious disease is so much increased
by the presence of unclean mouths, that prophylaxis
and treatment of decayed teeth should be undertaken
on a comprehensive scale as a public necessity.
The economics of public hygiene occasionally de-
mand considerable present burdens to avoid certain
increasing difficulties and expenses in the future.
I believe the dentists of this city would be doing
a work of great value to the public health, a work
which they alone can do, and a work of immediate
importance, if they would undertake the betterment
of existing conditions in the present sufferers from
decaying teeth, and so spread the knowledge of the
needs and means of caring for the teeth that the
children of the poor will not continue to grow- up
under a handicap, which, aside from the physical
suft'ering often entailed, stunts their mental and bod-
ilv development and renders them alike disseminators
of infection and fit subjects for infectious disease.
120 E.\ST Sixty-second Street.
A PRACTICAL SYSTEM OF MEDICAL INSPEC-
TION WITH TRAINED NURSES, ADAPTED
FOR PUBLIC SCHOOLS OF LARGE CITIES.
By S. W. Newmaver, M. D.,
Philadelphia.
After studying the various systems of medical in-
spection, with the aid of trained nurses, as employed
in several large cities of the United States, and elim-
inating the useless and unpractical features. I de-
vised the following system, which seems to give the
best results. The chief factors to which I gave con-
sideration were: i. The elimination of useless cler-
ical work. 2. Methods which would assure cooper-
ation between medical inspector, nurse, principal and
teacher, and parents. 3. The unnecessary exclusion
of pupils, and. when excluded, their return in the
shortest possible time. 4. Each party concerned as-
sumes his or her share of the responsibilities, and
errors can easily be traced to their source. 5. Rec-
ords and reports are few and can readily be referred
to for practical purposes.
Various bad features are noted in the systems em-
ployed in the different cities. One city is hampered
by a law which admits of the doctor and nurse su-
pervising only contagious diseases. This prevents
them from ^recommending or treating some of the
most important ailments of school chiklren, such as
defective vision or hearing, enlarged tonsils, and
adenoids. Some cities have too few doctors and
nurses to attend to the work, or the allotment of
territory is poorly arranged. Consideration must be
given to the distances between schools, and the kind
of and not number of population in a district. A
nurse or doctor can attend to more schools in a sec-
tion of a city inhabited by the higher social classes
than the doctor who attends to schools among the
congested foreign element. In some schools the
physician may see no more than a half dozen pa-
tients a month, whereas in the district of poorer peo-
ple each school may send each day from twenty to
fifty patients. School population is not a safe guide
by which to allot the work. Sometimes a small
annex with one hundred children takes as much time
to inspect as a school of one thousand pupils.
Through a lack of understanding of the duties of
the doctor and nurse, in some schools there is a
waste of valuable time disposing of trifling w'ounds,
etc., when the same time could be used for most im-
portant examinations. Again, there is no necessity
638
NEW MAYER: MEDICAL INSPECTION OF SCHOOLS.
[New York
ilEDICAL Joi.'RNAL.
of a teacher sending to the inspector the same child
with the same aihnent each day. The nurse should
judge when she desires the doctor to again see the
patient.
Instead of examining and re-examining normal
children, every new child should receive a thorough
physical examination on being enrolled, such as is
performed in the schools of Philadelphia.
The blanks and system of keeping records seems
to be the most difficult problem. Any system which
requires writing a half dozen times the same name
of school, patient, disease, recommendation, and
treatment for each case is faulty. Aside from the
enormous expense of printing large quantities of
index cards and blanks which serve no purpose, one
third of the time is wasted in recording and rere-
cording, with the result that it is difficult to again
refer intelligently to the records. These facts should
be written once, and arranged and filed so they can
be referred to at a moment's notice. The blanks are
the medium to give the cooperation between the
teacher, nurse, and doctor, so they can closely
follow each other's work without friction. The
work has many responsibilities, and each should
assume his part. The teacher is to recognize
each day the pupils who require the attention
of the attending physician. A contagious dis-
ease, whether diphtheria, scarlet fever, or a con-
tagious skin disease like scabies or ringworm, should
not remain in the class several days before it is sent
to the doctor for diagnosis. The doctor can bring
the teachers in closer contact with his work by an
occasional talk when they hold their monthly teach-
ers' meeting. Before beginning the day's exercise
the teacher should go through her class and note
which pupils she is to send to the doctor.
The following systehi of medical inspection with
trained nurses is based on using but one card and
one blank. Some of these index cards are in each
classroom. Each morning the teacher fills out for
each pupil she desires examined by the inspector
that part of the card above the dotted line. This
may seem as though more clerical work is being
shifted on the already overworked teacher. But a
moment's reflection will prove it saves her time,
trouble, and responsibility. ]\Iany of the younger
pupils do not know their name, address, and number
of classroom, much less why the teacher sent them
to the doctor. This necessitates the return of the
pupil to his class with a note requesting the desired
information, which is eventually written on any
scrap of paper, to again be copied by the doctor, and
a third time by the nurse. I have heard teachers
say, "Who wishes to go to the doctor?" There are
a few shiftless pupils who are only too ready to ac-
cept such an invitation to get out of the classroom.
With the teacher answering the question, "Whv sent
to medical inspector?" this imposition is avoided.
In schools having a system of bells, the physician
on visiting the school rings the bells on each floor a
number of taps, which informs the teachers of his
presence. Immediately the children are sent to him
with their respective cards. In schools having no
bells, each morning the teachers send to the princi-
pal's office the cards of children to be examined, and
the inspector sends to the classes for these pupils.
The diagnosis and disposition of the case are written
on these same cards, which are then kept in the office.
Each pupil sent to the inspector for examination re-
ceives one of the following slips to take back to his
teacher :
To Teacher : —
This child is referred for treatment to
NURSE
DISPENSARY
FAMILY PHYSICIAN.
This child is excluded from the class room
until you receive notice for his (her) return.
S. W. New MAYER,
Medical Inspector.
School, Jas. Campbell. Teacher, R. E. Saunders, Room No. 7.
Name, William Broivn. Address, 732 Bainbridge Si.
Date, Jan. 8, 1908. Sent to Med. Insp. for sores on face.
Diagnosis — Impetigo.
Referred to physician — Dispensary — Nurse.
Excluded — date Returned
Treatment by nurse — at home — at school.
Antiseptic ointment.
{3) Dates of treatment — 1/8, //p, i/io.
Results — Cured, 1/10/08.
Improved.
Not improved.
S. W. Newmayer,
Medical Inspector.
A. L. Stanley,
Nurse.
On these slips the doctor underscores whether the
pupil is to go to the nurse, dispensary, or family
physician for treatment, or whether excluded from
the class. This admits of no mistake by the teacher,
and aids her in knowing the exact nature and dispo-
sition of each case. The child cannot go home for
the remainder of the day, when he was instructed to
wait for treatment by the nurse, and, again, a child
excluded cannot return to his seat in the classroom
and the teacher remain ignorant of his exclusion by
the inspector. It admits of the principal having a
full written record of the disposal of all cases sent
to the doctor.
When the case is referred to the nurse, the doctor
specifies on the card if the child is to be treated at
home or at school, or both ; also the treatment rec-
ommended. This concise written report makes mis-
takes impossible, and may prove valuable if legal or
other questions arise. These cards are filed in the
office in a box with three compartments : i . New
cases ; 2, unfinished cases ; and, 3, cured cases. Each
of these compartments is arranged according to the
number of classrooms.
The nurse, on visiting the school, first takes all
cards in the compartment of new cases, and sends
for each pupil individually. The information on the
card makes it possible for her to perform all her
work without troubling the principal or teachers.
After attending to the new cases and recording on
them the date of treatment, she replaces them in the
cabinet, in the compartments of unfinished or cin"ed
cases. She now looks over the unfinished cases and
sends for those requiring treatment, again recording
the date. She so proceeds each day until the child
is cured or disposed of, when she records the date of
cure, when the card is filed in the third compartment.
Once a month all finished cards are sent to the
Bureau of Health or Bureau of Education, where
they are filed in a cabinet according to school and
April 4, 1908.]
MACKAY: PRACTITIOXERS' CLINICAL LABORATORY.
639
disease. One can readily see how easy it would be
to refer to these records. For example, should one
desire to know how many cases of defective vision
were treated and obtained the necessary glasses, or
the average number of treatments required at school
to cure a certain skin disease, these facts can readily
be obtained.
The following are copies of weekly reports of thf
nurse which are successfully used in the city of
Philadelphia :
A. A. CAIRNS, M. D.,
Dear Sir .—
The follo^ iag is a t^ eekly report of Nora* of Schools of Fourth
Section.
1
1
I
s
s
2
*
I
>
If! ! ! I i !il.y 1 1 ! I |JI
I'll i:!?!-^! . I
I I I I0ii,»-»|0ij|»«»l II
I' M M M ! I ! : I I I I I I !l
CASES TREATED AT HOMES
CASES TAKEN TO DISPENSARY
THE CLINICAL LABORATORY OF THE GENERAL
PRACTITIONER.*
By M.alcolm M.^ckay. B. A., M. D., C. 'SI.,
Windsor Mills, Quebec, Canada.
"A room fitted as a small laboratory, with the necessary
chemicals and a microscope, will prove a better investment
in the long run than a static machine or a new fangled air
pressure spray apparatus."— Oj/er.
That a laboratory is needed in the daily work of
a general practitioner no one will deny, but the ideas
of what should be attempted and what omitted in
routine work vary greatly with the individual physi-
cian.
Some go so far as to state that they prepare and
cut paraffin or celloidin sections, and make micro-
scopic slides. Some that they do not even venture
to stain "for the all pervading tubercle bacillus.
Others, alas, will acknowledge that they do not look
through a microscope from one year's end to the
other.
I believe that one reason for the lack of attention
to this most important branch of our work is that
•Read at the January meeting of the District of St. Francis
■Medical Society, Province of Quebec, Canada.
the majority of books speak of tests and reagents in
an abstract way and do not give definite methods for
keeping the laboratory in good working order, ready
for instant use, without any delay for the purpose
of making up new stains and reagents which have
gone bad since they were last used. It is therefore
with no apology for my subject that I bring before
you one man's idea of a practical laboratory well
within the reach of every one, together with a few
words on the actual manipulations.
If there is any who is not convinced of the use of
such a laboratory I confidently refer him to an arti-
cle by Dr. R. X. Willson, which appeared in the
Xew York Medical Journal of September 28, 1907,
and which takes up this side of the question in a
very convincing way.
In the first place, a microscope is essential. No
analysis of any of the secretions or excretions is
complete without a microscopical examination, and
no man can consider himself to be carrying on a
modern practice unless he is able to intelligently
carry out such an investigation. One would think
that at the present stage of development of medical
science that such a statement would be unnecessary,
but when one sees time and again offices and dis-
pensaries guiltless of such an instrument, except pos-
sibly one kept for show, the fact cannot be too
strongly insisted upon.
Two objectives, say a 3 and a 6 or 7, will give
fair results, but if bacteriolog}- is to be attempted an
oil immersion lens will be required.
Taking up, in the first place, the examination of
blood, we find that for its detection in small quanti-
ties few tests are more satisfactory than the hasmin
test, for which all that is required is common salt
and glacial acetic acid. Frequently the guiacum test
is more convenient, and it is best to keep it in the
form of gum and make up the tincture as required,
using a fresh preparation of hydrogen peroxide to
complete the test. The microscope will of course
reveal blood, provided that the corpuscles are not
disintegrated. Slides, and perhaps cover glasses as
well as Canada balsam, will be required for the mak-
ing of smears. In order to fix the blood before
staining, the old method of using equal parts of alco-
hol and ether for several hours will give excellent
results, but I have found that a few drops of wood
alcohol poured directly on the slide will fix within a
minute and give a perfect picture. The eosin stain-
ing may be taken up along with this process by add-
ing the stain to the wood alcohol. I have never seen
this method of fixing in any textbook, although
doubtless the principle is the same as that upon
which Wright's modification of Leishman's stain, or
Jenner's stain, is based, methyl alcohol being the fix-
ing agent. Fixing by heat has in my experience to
be very carefully done in order to get any satisfac-
tory results. For staining purposes an aqueous or
alcoholic solution of eosin will keep indefinitely, and
I have found that Ehrlich's acid haemotoxylin,
R Haematoxylin 2 grammes;
Absolute alcohol, 60 c.c;
Ghcerin, 60 c.c;
Water _ 60 c.c. ;
Glacial acetic acid, 3 c.c;
Ammonia alum q. s. ad saturandum.
thus prepared, the solution will keep almost in-
definitelv, and this can hardlv be said even of Dela-
640
field's lisematoxylin, which keeps better than the ma-
jority of such preparations.
Methylene blue may be used as a nuclear stain,
and I have found it convenient to keep a saturated
solution (alcoholic) in stock, to be diluted as fol-
lows :
Loffier's blue :
Saturated alcoholic solution, 30 ex.;
Solution I in 10,000 caustic potash in water, . . 100 c.c.
Kiihne's blue :
Saturated alcoholic solution, 10 c.c;
5 per cent, carbolic acid water, 90 c.c.
Ordinary staining:
Saturated alcoholic solution, i part;
Water 9 parts.
To examine for hemoglobin there is no doubt
that Dare's instrument is the neatest and quickest of
the translucent methods, and with a little experience
results soon become consistent, but the Tallquist
haemoglobin scale is by far the easiest and cheapest
of all ordinary tests, and is almost, if not quite, as
accurate as any of the others. It simply consists of
a series of colored plates with which the blood,
.sucked up on a specially prepared absorbent paper,
is compared. *
Wetherill's scales are similar in design, but contain
plates for the comi)arison of urine, faeces, moisture
(perspiration), and post mortem blood.
For counting the blood cells the Thoma-Zeiss ap-
paratus is probably the most popular, and is accurate
when the technique is good. But it must be remem-
bered that the count cannot be relied upon until the
procedure has been carried out for a number of
times. The solutions, which can easily be made in
the laboratory, are as follows :
Toison's solution for. counting the red cells:
Distilled water, 160 c.c;
Neutral glycerin, 30 c.c;
Sodium sulphate, 8 grammes;
Sodium chloride i gramme;
Methyl violet 5 B., 0.025 gramme.
This must be filtered before use, as a mould quick-
ly grows in the solution.
For counting the white cells :
Glacial acetic acid, . ..0.5 per cent, solution in water;
Methylene blue, q. s. to color.
The physician omits one of his greatest aids in a
doubtful diagnosis when he neglects to make a blood
count, for when compared with a blood slide and
diflferential count it will often turn a possibility into
a certainty. Yet how often men outside of the hos-
pitals make a practise of carrying out this compara-
tively simple procedure?
The Widal test, as performed with dead cultures,
has given fair satisfaction, and the test can easily be
obtained through .some of the pharmaceutical houses.
It may be performed in bulk or microscopically,
and saves one taking a culture from a stock tube and
using an incubator.
The examination of urine requires litmus paper,
a urinomcter, a pipette, test tubes, alcohol lamp or
Bunsen burner ; nitric and acetic acids for the ordi-
nary tests for albumin ; and Esbach's albuminometer
and solution (picric acid, i gramme; citric acid, 2
grammes; water, too c.c.) for the quantitative esti-
mation.
[New York
M'l.UCAL JoURN.AL.
Fehling's solution for detecting sugar should be
kept in the form of two solutions, keeping the cop-
per apart from the alkali. A yeast saccharometer
gives a fair estimate of the quantity in a given speci-
men.
For the quantitative determination of urea the
Doremus ureometer is generally used. The sodium
hydroxide solution (6 ounces to I pint water) should
be kept in a rubber stoppered bottle separate from
the bromine until the test is actually being made.
Then it is poured into the apparatus until it reaches
the mark, wlien 0.1 of its volume of broinine is
added. The addition of water to fill the tube is fol-
lowed by the introduction of i c.c. of urine by means
of the pipette, the resulting nitrogen being read off
as the index of the amount of urea.
Acetone is most easily detected by adding potas-
sium h} drate solution to a distillate of the urine and
adding a few drops of a solution of iodine in potas-
sium iodide, the result being iodoform when the re-
action is positive.
Bile may be considered to be present when, placed
alongside a drop of nitrous acid on filter paper, the
urine shows the play of colors so often described.
Ehrlich's diazo reaction is easily performed by keep-
ing in stock two solutions ;
I. Sulphanilic acid, i part;
Hydrochloric acid 50 parts;
Aq. destil., 1,000 parts.
II. Sodium nitrite, i part;
Aq. destil., 200 parts.
In addition, there is required some liquor ammo-
nia. Personally I never obtained much satisfaction
with this test in the early diagnosis of typhoid fever.
For one year it was carried out daily in 166 cases.
Less than forty per cent, showed the reaction at any
time, and it practically never appeared before the
second week. Others have had better results than
this ; but few authorities show much enthusiasm at
the present time.
Indicanuria is detected most surely by taking 10
c.c. of urine. 10 c.c. of hydrochloric acid (c.p.), and
shaking up with 25 drops of 0.5 per cent, solution of
potassium permanganate. Adding 5 c.c. chloroform
and shaking will bring down a purple coloration
followed by a blue deposit, provided that indicanuria
is present.
A centrifugal machine is a very useful instru-
ment to have in the laboratory, but, contrary to the
opinion of some, it i'; not essential to the study of
urinary sediments. Use a conical glass, keep the
urine cool, take plenty of it, and let it stand for
from six to eighteen hours, and very little will be
missed. A little salicylic acid will in summer time
be found a useful addition to prevent decomposi-
tion.
Looking for tubercle bacilli is at the best a tedi-
ous affair, and w-ithout a centrifuge is desperately
slow, but by letting the urine stand for a day, then
pouring off all but the sediment, adding distilled
water to the original volume, shaking, and repeat-
ing the process several times, one can get a good
slide, but one must be very careful of the technique
and beware the deceitful smegma bacillus.
The gastric contents present a field explored by
surprisingly few general practitioners, considering
MACK AY: PRACTITIONERS' CLINICAL LABORATORY.
April 4, 1908.]
MACKAV: PRACTITIONERS' CLINICAL LABORATORY.
641
that the apparatus and reagents required are but
few, and the methods simple. Once the contents
are removed, a glass funnel with filter paper soon
gives a clear solution, which should be tested at
once with litmus paper. A burette filled with a
decinormal solution of sodium hydrate {4 grammes
in 1,000 c.c. distilled water) when carefully titrated
into a given volume of stomach contents contain-
ing a little phenolphthalein (one per cent, alcoholic
solution) gives the total acidity.
Congo red paper will detect free acids, though
a large amount of combined h}drochloric acid also
gives this reaction.
To test for free hydrochloric acid a 0.5 per cent,
alcoholic solution of dimethylainidoazobenzol is very
simple and delicate, and as it is used in the quanti-
tative examination of free hydrochloric acid it is
to be preferred if but one reagent is used.
The tests for acetic and butyric acid require no
special reagents, while lactic acid may be detect-
ed by the old carbolic acid and ferric chloride meth-
od or by the new technique described by J. L. Mc-
Phedran, of Toronto.
The microscopical examination of gastric con-
tents as well as of f;eces requires no additional ap-
paratus, and often gives a clue to an obscure diag-
nosis.
A glance at the sputum is at times sufficient to
point to a diagnosis in certain pulmonarx condi-
tions, but a microscopical examination is infinitely
more satisfactory and indeed is most conclusive
when we get a positive result — and most aggravat-
ing when we do not. After pouring out the
sputum into a Petri dish and separating it with
hat pins or a platinum wire, it will often be found
useful to spread it out on an ordinary pane of win-
dow glass and examine it with a hand lens. An-
other plan is to pour it out upon the black paper
which is wrapped aiound photographic films or
plates. The peculiarities of the specimen can be
easily seen on this background, and the whole can
"be thrown into the fire to insure complete destruc-
tion of any bacilli which may be present.
Make a satura-ted alcoholic solution of methy-
lene blue and one of fuchsin as stock ready for dilu-
tion to stain the slides. In staining for tubercle
bacilli the solution of fuchsin is diluted one in nine
in a solution of carbolic acid (20 per cent.). While
staining, heat to boiling, decolorize with 25 per
cent, sulphuric acid, and counterstain with methy-
lene blue. It is often important to use absolute al-
cohol as a decolorizing agent in addition to the
above, as it renders the distinction between the
tubercle and smegma bacillus rather more certain.
In staining for other organisms aniline gentian
violet must be used, but in order that it may keep
it is best to have a saturated alcoholic solution of
the gentian violet in a separate bottle. When re-
quired for use, add to four parts of the alcoholic
solution twenty-one parts of aniline water (5 per
cent, solution of aniline oil in water shaken and
filtered). It is well not to use this solution for
several hours on account of precipitation. Gram's
iodine is easily made by adding to 100 c.c. distilled
water one gramme iodine and two grammes of
potassium iodide. Safranin keeps well in a satu-
rated solution, and is one of the best counterstains
we have.
In regard to the detection and classification
of ordinary pathogenic bacteria it is wonderful
what satisfactory results can be obtained by cul-
tures in bouillon, gelatin, white of egg, and potato,
incubated in a plate warmer of a kitchen range or
some similar contrivance. It is not very often that
such an examination need be carried out by the
general practitioner, but the identification of diph-
theria bacilli by the method of culture on the white
of an egg may be accomplished by anybody, and
will give most satisfactory results. Its main
feature is its simplicity, nothing being required but
a hard boiled egg and an egg cup. Take the swab
from the throat in the usual way, and after break-
nig off the shell at one end of the egg, make a
smear for incubation. Place the egg inverted in
the egg cup, and put it in a warm place, and in nine
to fourteen hours a diagnosis can be made from the
culture, as no other germ grows with such rapid-
ity in this medium. If left over twenty-four hours
it is likely to be overgrown by other bacilli or
cocci. A slide from one of the colonies will show
vast numbers of the bacteria if stained with
Lofler's blue or some distinctive stain. For a coun-
try practitioner this method is simply invaluable,
and much time is saved by making a smear from
every suspicious throat at the first visit.
For the study of transudates and exudates as
well as cystic and cerebrospinal fluid, the reagents
I have mentioned are generally sufficient, though
possibly a saturated alcoholic solution of Sudan iii
may be of use in detecting fats. It is well in these
cases to stain at least one slide for tubercle bacilli,
one with eosin and haen-.otoxylin, one with methy-
lene blue, one by Gram's method, and one with
Sudan iii. This series of stains will show practical-
ly everything bacteriologicall\- and cytologically
that can be seen in such slides.
In conclusion there should be a day book on the
laboratory table ready to receive notes of tests as
they are made, whence they may be transcribed to
the case reports at leisure. In addition, all perma-
nent slides should be labelled and stored away in
boxes made for the purpose, where they will in
time form a valuable collection for reference.
A laboratory such as I have described will clear
up the diagnosis in at least 50 per cent, of the cases
which puzzle the man who does not think of doing
anything more than testing the urine for albumni
and sugar, and will save a great deal of time for
the country practitioner, who anxiously waits, pos-
sibly for days, for the report on the sputum, blood,
or smear he has sent for examination to the board
of health, a hundred miles away.
References.
1. Miisser. Medical Diagnosis.
2. Boston. Clinical Diagnosis.
3. Hensel, Weil, and Jelliffe. Urine and Faeces in
Diagnosis.
4. Saxe. E.vaminafion of Urine.
5. Mallory and Wright. Pathological Technique.
6. Eyre. Bacteriological Technique.
7. Mace. Traite pratique de bacteriologie.
8. Willson. N^ezi' York Medical Journal, September
28. 1907.
9. Porter. The Postgraduate, October, 1907.
642
CARTER: LACTACID MILK.
[New York
Medical Journal,
LACTACID MILK IN INFANT FEEDING.
By Charles Edgerton Carter, M. D.,
New York,
Instructor in Medicine, Department of Paediatrics, Postgraduate Medi-
cal School.
The problem of duplicating Nature's formula is
the point about which the whole subject of infant
feeding has centered even before the time that
Rotch first presented percentage methods of milk
modification. Quantitatively it may be possible to
dilute, add, and combine until the product is sim-
ilar to that of Nature's laboratory, but chemically
and bacteriologically the problem is far more com-
plex ; in consequence of which attempts have failed
to produce a milk food identical with or even sim-
ilar to the natural product in its enzymic activity
and nutritional value. Following the investiga-
tions of Rotch, Holt, Caille, Chapin, Winters, and
others in our country, practical clinicians admit
that in modifying cows' milk for infant feeding we
are merely producing the best practical substitute
which conditions permit. That we fall far short
of Nature's human product is frankly granted.
Past experiences with buttermilk feedings have
proved equally unsatisfactory. On account of the
difiliculty in procuring, as well as the extreme
variability in bacterial content, no system of ex-
tended buttermilk feeding has been elaborated.
Therefore, in advocating a system of feeding based
upon the modification of cows' milk, which has
been fortified by the lactic acid ferment, we oflfer
of necessity still a substitute, but not an attempted
reproduction of human milk. We are dealing with
a natural milk augmented by microscopical life, in
place of an inert medium loaded with its sterilized
dead. To suggest that by this method we may
have at hand a means of most effectually overcom-
ing certain difficulties in feeding and of preventing
intestinal malassimilation and intoxication, is the
purpose of this necessarily diagrammatical paper.
For the purpose of condensation, the term
"lactacid milk" is adopted as a name for fresh
cows' milk, which has been artificially impregnated
with the "Bacillus bulgaricus" and has become in
consequence a fermented product with definite
parasitic inhibitory properties and an easily assim-
ilable casein curd. The detailed method of acquir-
ing this artificial product, as well as the process of
its final adaptation to the infant's requirements,
will be elaborated later in this article. For the
present we may consider lactacid milk as an entity
in substitute feeding.
The literature available on buttermilk feeding,
corroborated by personal observation, discloses its
following shortcomings, viz.: i, Commercial but-
termilk contains little or no fat ; 2, it varies in the
amount of its component elements on account of an
equally variable degree of dilution ; 3, it presents a
food teeming with extraneous germs of filth or
disease ; 4, it is impossible to procure, at stated in-
tervals, in required amounts; 5, finally, it is an in-
exact, unhygienic base for even temporary milk
substitution.
On the other hand, the vital factor in buttermilk
which has made it seem desirable as a food, and
which has rendered it efficacious as a remedy, is
found in the lactic acid ferment. This ferment to-
day has been isolated, cultivated, and, like the
housewife's yeast, is available in convenient form
for household use. Thus it is possible to give our
difficult feeding cases, infant or adult, food not
alone efficient in itself, but augmented by an active
agent for overwhelming the pathogenic bacteria
that may inhabit the intestinal tract. Like the
blood stream, which carries not only food for the
tissues, but also manifests the defensive phago-
cytic function, we have in lactacid milk a food me-
dium inimical to all undesired fermentative pro-
cess and possibly prohibitive of pathogenic growth.
From what evidence do we infer that lactic acid
may inhibit pathogenic germs in the intestinal
tract? Herter {British Medical Journal, Decem-
ber 25, 1907) writes that lactic acid bacilli notably
decreased intestinal putrefaction due to Bacillus
coli, or Bacillus proteus; M. Cohendy reported (in
Archives de la Societe de biologic, November 17,
1906) that, from personal ingesta of pure bacilli
lacti, intestinal putrefaction was markedly de-
creased, and, furthermore, these results persisted
for seven weeks after cessation of the daily aug-
mentation from the ingested cultures. Pochou, of
Lausanne, reports similar results. His urine
analyses showed great diminution of indol and
phenol substances, which are accepted as certain
indices of intestinal putrefaction. Metchnikoff
concludes "that lactic acid bacilli prevent multipli-
cation of other microbes, but are incapable of de-
stroying these pernicious microbes." Should con-
tinued clinical results demonstrate the accuracy of
such observation when applied to lactacid milk, it
is rational to hope that the natural powers of re-
sistance may more frequently win in their struggle
against typhoid or even tuberculous infection of the
intestines ; provided we are able to decrease to any
appreciable degree the fermentative and putrefac-
tive processes of the digestive tract.
Heim states that typhoid bacilli succumb after
forty-eight days when the culture is impregnated
with lactic acid bacilli. Piffard has also found that
the Bacillus bulgaricus (from Bulgarian sour
milk) inhibits the growth of typhoid bacilli on
dextrose broth, markedly so within one week's
time. Considering the acknowledged vitality and
longevity of the typhoid germ, this possibly inhib-
itory value of lactic bacilli in the intestine is obvi-
ous. More than that, Cohendy 's comment upon
their persistence seven weeks after ingestion, shows
that the lactic acid bacilli in all probability adapt
themselves to the anaerobic habitat of the intestine
and feeding upon the carbohydrates digested, may
further preserve organic matter from putrefaction.
As to the tolerance of lactic acid which the human
organism exhibits, it has been found that twelve
grammes can be taken by mouth daily, without un-
toward efifect. While experience has shown that
moderate use of lactic acid is not provocative of
rhachitic changes in bone and muscle, as formerly
taught, yet possible individual idiosyncrasies may
occur. On the contrary, Tigersted (Physiology,
p. 297) states that lactic acid is normally elaborated
in the human metabolism as a result of the action
of pancreatic juice and bacteria, upon carbohy-
drates in the small intestine.
April 4, 1908I]
CARTER: LACTACID MILK.
t»43
To contrast with the persistence and elaboration
of lactic acid in the intestine, M. Copelan's has
found that the bactericidoinhibitory property of
fresh milk becomes inactive after four hours. This
bactericidoinhibitory property of strictly fresh milk
is of such short life then that it may be ignored
absolutely as an aid in fortifying against infective
invasion. On the other hand, the inhibitory fea-
ture of lactacid milk may well be considered when
we realize that 72 per cent, of all herds in New
York State is infected with tuberculosis, according
to V. A. Moore, of Cornell University. With an
annual mortality of children under one year of
16,500 in New York city, we need to utilize" every
rational, available method to better these condi-
tions.
In seeking to adapt lactacid milk to a practical
utilization it is desirable to avoid what Chapin so
well calls "freak or random feeding," and yet that
need not be such a difficult matter when we recall
the complexity of some percentage feedings. Test
tube and laboratory estimates must be verified by
long clinical observation before any method of
body building can graduate from the awkward
squad of "freak feeding," and lactacid milk may be
diluted or adapted to the basis of percentage feed-
ing according to the requirements of existing con-
ditions.
It is appreciated that sufficient proteid of assim-
ilable form is required for normal infant growth.
That perfect digestion does not necessarily mean
complete assimilation is also recognized. There-
fore, an important argument in favor of lactacid
milk feeding lies in the easily assimilable casein
curd of the proteid. Since an excess of proteid in
the intestinal tract, whether that be in excess for
the type or for the individual, can be determined
only when putrefactive processes ensue, the intro-
duction of lactacid milk carrying an antiputrefac-
tive enzyme, robs excess proteid ingesta of its dan-
gers. Further, from this fact, it also follows that
in pathological conditions of uric acid excess, with
the accompanying faulty metabolism, a diet that
includes lactacid milk is indicated both as an anti-
fermentative and antacid.
The technique and detail of lactacid milk modi-
fication may be given best, perhaps, by reproducing
the printed leaflet used in my clinical work at the
Postgraduate Hospital. This may be taken in three
steps, namely : First, the preparation of lactacid
milk; second, the modification of this prepared milk
to any desired formula : and, third, number and
quantity of daily feedings:
TO PREPARE LACTACID MILK.
1. Pour one quart fresh bottled milk into clean pitcher.
2. Add .... glassfuls of hot water.
3. Crush one tablet and stir with clean spoon into milk.
4. Add pinch of salt.
5. Cover wifh clean napkin and set in warm (not hot)
place for twenty-four hours.
6. After twenty-four hours keep on ice or, in cold
weather, out of doors.
N. B. — Enough for two days. Prepare fresh every other
day.
TO PREPARE DAILY FEEDINGS.
1. Stir lactacid milk with clean spoon and mix feedings
for day as follows :
2. Pour .... oz. of lactacid milk in clean quart bottle or
pitcher.
/ Barley water \
\ Oatmeal " |
3. Add .... oz. < Rice " >to this milk.
I Lime " i
^ Albumin " /
5. Stir well and put on ice until needed.
6. Feed of this mixtture .... oz. every .... hrs. heated
to body temperature.
N. B. — Enough for one day.
Resume.
1. Lactacid milk is obtained from clean, fresh
cows' milk, fermented by the lactic bacillus, iso-
lated by Cohendy in 1903, and which he describes
as "not growing under 35° F. nor above 63° F."
The degree of acidity is limited by the time allowed
for the activity of the bacilli.
2. Buttermilk feeding and lactacid milk feeding
are absolutely distinct. The former afifords an un-
certain and temporary expedient always, and being a
spontaneously sour milk contains, besides the lactic
ferments, generally yeasts which produce alcohol.
3. In infant feeding the frequent desideratum of
high proteid percentages may be found not only
possible, but also safe, with lactacid modification
of milk.
4. The digestive enzymes of natural milk are not
killed as in the unnatural processes of sterilization
or even in Pasteurization^ but are augmented by
the Bacillus bulgariciis.
5. Lactacid milk is logically indicated in chil-
dren : a. In difficult feeding cases ; b, in fermenta-
tive diarrhoeas ; c, in specific enteric infections of
typhoid or tuberculous bacilli.
6. From the extremes of the scientist and the
enthusiast, from Herter and from Metchnikoflf
come corroborative evidence that lactic acid inhib-
its intestinal putrefaction.
7. Promulgation of the general desirability of
undiluted lactacid milk as a beverage can but lessen
the ills that flesh is heir to, even if it cannot accom-
plish, as Metchnikoff hopes, the prolongation of
man's alloted span.
8. The writer presents this as a preliminary
communication, and will later submit a series of
results obtained in indicated cases of lactacid milk
feeding.
54 West Fifty-second Street.
Gunshot Wounds. — In Der Militdrartz, Dr. Ker-
chenberger gives a study of gunshot injuries on
post mortem cases and also on the healed injuries
of attempted suicide cases. He calls attention to
the action of powder gas and discusses its action in
general and more specifically when shot into the
mouth and into the jaw. The action of the projec-
tile alone is not so destructive. The blowing out
of the brain from the cranial cavity he attributes
to the action of powder gas. The powerful
rushing in of the air behind the projectile may also>
play a part. The action of the gas is especially im-
portant in shots of the mouth. As signs of powder-
gas having entered the bullet wound, Kerchenberger
gives the following: i. When the bullet wound is.
larger than the caliber of the gun. 2. A widespread;
destruction of the tissues. 3. Fractures of several:
ribs. 4. Blackening of the internal organs by smoke
of the powder. — The Military Surgeon.
644
OUR READERS-
DISCUSSIOXS.
IXtvv York
^ur ^^fakrs' fistussions.
A SERIES OF PRIZE ESSAYS.
Questions for discussion in this department are an-
nounced at frequent intervals. So far as they have been
decided upon, the further questions are as follows:
LXXIL—How do you treat fracture of the patella?
(Closed March i6, 1908.)
LXXIII.—How do you treat seasickness? (Answers due
not later than April 75. igo8.)
LXXIV. — Hoiv do you treat sunstroke? (Answers due
not later than May 13, igo8.)
Whoever answers one of these questions in the manner
most satisfactory to the editors and their adv'sors will
receive a prise of $^5. No importance zvhatevcr w^ll be at-
tached to literary style, but the an'ard ivill be based solely
on the value of the substance of the anszvcr. It is requested
(but not required) that the anszvers be short; if practica-
ble, no one anszver to contain more than six hundred zvords.
All persons will be entitled to compete for the price,
whether subscribers or not. This prise zvill not be azvarded
to any one person more than once zvithin one year. Every
anszi'er must be accompanied by the ziriter's full name and
address, both of zvhich zee must be at liberty to publish.
All papers contributed become the property of the Journal.
The prise of $25 for the best essay submitted in anszver
to question LXXl has been azvarded to Dr. Frank B. Kirl^v.
of Philadelphia, zvhose arlicU- appeared on page 59-/.
PRIZE QUESTION NO. LXXI.
HOW DO YOU TREAT GALLSTONE COLIC?
(Concludrd from pa.^e 599.)
Dr. Richard Lightburu. of Kansas City, gives Jiis
opinion as follozi's:
In ri^alLstone colic treatment is instituted for two
purposes, the relief of pain and the removal of the
cause.
The sufifering- is best combatted by the hypoder-
matic administration, every half hour, of small
doses C/s grain) of morphine sulphate, together
with strychnine sulphate ( 1 '120 grain). At the same
time a tablet of am(M-i)li()Us hyoscyamine ( 1/250
grain), in an ounce of hot water, is given by the
mouth, to be repeated in thirty minutes.
As a rule the patient rests comfortably after the
second dose, and the remedies need be repeated
onlv cverv three or four hours. A few whiffs of
chloroform will serve to lessen the pain while the
initial doses are being absorbed.
This combination, in my hands, has proved more
efficient and satisfactory than the heroic amounts of
morphine, alone or with atropine, so frequently em-
ploved. The disagreeable, sometimes serious, after
effects of the heavy dosage are avoided, and, if the
attacks are of frequent occurrence, the risk of con-
tracting the drug habit is materially lessened.
Fomentations, locally, or hot baths, the water be-
ing at as high a temperature as can be borne, will
often prove valuable adjuvant measures.
The second condition, the removal of the cause,
is most satisfactorily met by cholecystotomy. In
competent ha.nds the danger is slight and relief
practically certain.
In case the i)atient refuses to undergo an opera-
tion the only course open is the administration of
remedies which will aid Nature in getting rid of
the concretions. Here the alkalies are of greatest
. value. Of these, sodium phosphate, a drachm dis-
solved in hot water and taken before breakfast,
daily, is the best. I also give sodium succinate,
five grains after each meal, continuing ft for sev-
eral months.
Starch}', fatt\-. and saccharine foods are to be
avoided, and plenty of outdoor exercise is of great
importance.
Dr. Mark H. Sears, of Denver, Colorado, says:
The pain and nausea of gallstone colic varies all
from a hardly noticeable uneasiness to the par-
oxAsms of a choked, or partially choked, duct,
through which Nature is endeavoring to force a
stone that frequently is too large to pass. It will
usually be located in the right hypochondrium or in
the epigastric region.
\'ery often there accompanies a decided yellow
tinge of the skin, the sign of bile absorption, which
may have preceded the attack for several days, or.
as frequently happens, this symptom mav be con-
spicuous by its al3sence.
Between these two extremes of severity, slight in
the one instance, or the agony of the other, we
must seek for and apply a remedy, which will re-
lieve the symptoms of irritability, assuage the un-
bearable pain, and give rest and comfort to the
suft'erer. Be sure of your diagnosis. Do not con-
found the colic of the gallstone with the nephritic
stem or other varieties of abdominal distress. loca-
tion, severity, history, palpation, the presence or
absence of elevation of temperature, or any other
symptom, which may throw light upon the condi-
tion, should be considered 'carefully. Nor should
the masking symptoms of a neoplasm growing at
or near the pyloric orifice of the stomach or at the
head of the pancreas be overlooked. They should
be carefully considered and excluded. A growth
of this kind very often causes symptoms much re-
sembling the distended gallbladder of a closed duct,
especially if accompanied with pain and jaundice.
If the call for aid is very urgent, nothing has
thus far been used which affords the relief given
by the hypodermatic administration of morphine.
It should be given in quarter, third, or, in very se-
vere instances, half grain doses. The effect of the
remedy should be carefully watched, and not re-
peated without good reason. If it is necessary to
relieve the awful suffering, until various methods
of medication have time to act, if for any reason
they are slow in doing so, equal parts of chloroform
and water poured on a flat sponge and applied over
the seat of the pain will give a grateful, although
only temporary, relief until more efficient and per-
manent remedies can be used. .A. few whiffs of
chloroform itself will often bridge a crisis.
Great comfort will be experienced from the use
of the hot bath, as hot as can be borne, but not
to be continued so long as to act as a de])ressent.
The hot water bottle is a valuable remedy also.
Steaming the region of the liver is another method
of applying heat, and any home which affords a
tea kettle will be amply provided with apparatus.
Hot fomentations, notably the flaxseed, poppy leaf,
or hop stupe, will often abate the pain, and give the
gallstone the opportunity to either proceed into the
intestine or recede into the gallbladder.
i _i)
April 4. >908.]
OUR Rll.lDERS' D/SCUSSIONS.
645
The use of olive oil in large doses, accompanied
by laxatives, has also found favor in the past, and
is still used more or less, but is of doubtful utility.
It was formerly thought that by using certain rem-
edies it would be possible to dissolve gallstones,
and sulphuric ether and oil of turpentine in proper
dosage have long enjoyed this reputation, but they
have proved disappointing and of little or no perma-
nent value.
Sodium sulphate and sodium phosphate, the lat-
ter in saturated solution, and given in drachm
doses, have shown a distinct remedial action. It is
believed that they prevent in some way the forma-
tion of bile concretions by modifying the concen-
tration of that fluid, or perhaps allaying catarrhal
conditions in the bile cyst or ducts. For the intol-
erable itching that occurs in some cases, alkaline
baths have been used. Sodium bicarbonate and so-
dium biborate have entered largely into this form
of medication. Powdered starch applied to the
skin is another remedy. It is soothing and val-
uable. An ointment containing menthol and
ichthyol has afforded much relief in the writer's
hands. These forms of medication can be extend-
ed indefinitely. Wool fat should always form the
base of ointments likely to ferment.
The diet in these cases should be simple. .Sac-
charine and starchy foods should be taken in mod-
eration, while meats should be boiled. The bowels
should be kept free by the use of the laxative alka-
line mineral waters, moderate depletion of the por-
tal circulation being the aim. The habits of life
should be simple and regular, and the daily mus-
cular exercise sufficient for the bodilv needs, but
in no way exhausting. It should not be forgotten
that each individual case will present characteristics
peculiar to itself. These should be met by modi-
fications of treatment which will meet the condi-
tions. In this manner recurring attacks of gall-
stone colic may be successfully passed, and much of
a. lifetime spent, with only an occasional attack.
The bile passages are very tolerant, and the gall-
stone may exist in large numbers, without causing
any symptoms whatever. The case will be very dif-
ferent and much more serious when constantly re-
curring attacks of colic render the life of the suf-
ferer miserable. In this event surgical interfer-
ence should be seriously considered. When, how-
ever, the cystic or common ducts become clogged
surgical rehef becomes imperative, and an opera-
tion should be undertaken immediately by a com-
petent surgeon. The results of this operation are
very satisfactory, and when practised with careful
attention to the technique, which the operation de-
mands, they are secured at once, with a minimum
of danger. Any recent textbook will give the de-
tails.
Dr. Samuel A. Savitz. of Philadelphia, remarks:
The treatment of gallstone colic depends on the
severity of the attack, which, on the one hand, may
l;c mild and last only a few hours, while, on the
other hand, it may continue anywhere from a few-
days to a week or more.
It is well to commence with a hypodermatic in-
jection of morphine, 1/4 grain, accompanied by 1/100
grain atropine. The mor])liine relieves the pain and
the atropine relaxes the muscular coats of the gall-
bladder and the appendages tlureof, thus aiding the
stone to escape. 1 repeat this dose three or four
times, at intervals, until the pain ceases. In addi-
tion, I give a few whift"s of chloroform inhalations
until the effect of morphine takes place, and this in-
variably gives the patient relief. A very \-aluable
adjunct is hot applications over the he])atic region.
The applications should be a little above the tem-
perature of the normal body, and continued lung
i-nough until the rigidity of the muscles of this region
is well relaxed. The writer finds that gratifying
results are obtained with hot turpentine stupes.
Some lay great stress on hot baths. I, however,
. find that it not only 'fails, but instead i^ an incon-
venience to the patient. In one case where 1 resort-
ed to this measure the heart action became so de-
pressed, the pulse so weak, that I was compelled to
use vascular stimulants to restore the heart's action.
( )live oil in some cases is very beneficial. U is
best given in one large dose, two to four ounces. It
increases the flow of bile, and thus aids materially
the escape of the calculi.
If the patient complains of nausea and vomiting-
it is best not to give the oil, for the gallliladder at-
this time is no doubt very nuich irritated and in-
fiamcd, and the strain in producing the vomitus may
cause rupture of the organ. Xausea and vomiting-
may be relieved by administering brand\- with
cracked ice. If this fails I give the following with,
happy results :
Cerii oxalatis gr. xxiv ;
Bismutlii subnitratis gr. xxxvi ;
Sodii bicarbonatis .3ii.
Mix. Chartae No. xii.
Signa : One every hour tinlil relieved.
If the case is mild it is unnecessarv to re-ort to
the afore mentioned measures, and in such cases very
often the attack will yield to codine and acet])heneti'-
din in ca])sule form.
Regarding purgatives and cholagogues in gall-
stone colic, I cannot too strongly en-iphasize tint the\
should not be thought of during an acute attack.
The\ not only increase the severity and duration of
the attack, but may in their strong action upon the
gallbladder (the time when it is most inflamid and
least resistant) cause rui:)ttu-e of same. If, however,
the liver is very torpid, calomel in small divided
doses nia\- be given.
The question of surgical interference during an
acute attack should not l)e considered until the period
of quiescence.
Conclusions. — I will terminate mv brief remarks
by stating :
r: Keep the patient at perfect rest in bed.
2. Make subcutaneous injections of n-iorphine and
atropine, followed by chloroform inhalations.
3. If there is nausea and vomiting present, relieve
.same by nieasures indicated.
4. .Vpply hot applications with counter irritation
over the hepatic region.
5. Avoid purgatives and cholagogues. They
should be given between the attacks with the hope
that the irritation of the gallbladder will be dimin-
ished.
646
OUR READERS' DISCUSSIONS.
[New York
Medical Tocrxal,
6. Take into consideration the prophylactic meas-
ures after the acute attack is over, for much can be
accompHshed to prevent the formation of biliary
calculi.
Dr. Lazvrence M. Hynson, of Washington, D. C,
observes:
The treatment of simple cases of gallstone colic
presents at first sight no striking difficulties, but in
prolonged and severe cases it ma}- be necessar}- to
direct the treatment of the colic to the treatment of
the general condition of gallstones (cholelithiasis),
for the colic is only a symptom of an existing con-
dition.
When the patient experiences the severe par-
oxysmal pains produced by biliary calculi, mor-
phine, hypodermatically, in doses of one quarter
grain each, should be given without hesitation.
Morphine so given relieves the severe pain, pro-
duces comfort of the patient, and allows the mus-
cular structures of the bile duct to relax, thus per-
mitting the calculus to pass on. Care should be
taken to see that just enough morphine is given to
keep the patient free from pain, for too frequently
large doses of this 'drug might mask the symptoms
resulting from the possible rupture of the common
bileduct, with a discharge of the gallstone into the
peritoneal cavity. The inhalation of chloroform, if
at hand, may produce relief from pain in the mildly
acute cases, but where the pain is severe and con-
tinuous morphine, hypodermatically, is indicated.
Rest in bed during the attack is necessary, and
hot applications, hot water bags, should be ap-
plied over the liver region. Where the patients
icannot bear the weight of a water bag, owing to
tenderness, I have found the Japanese hand stove
to be very useful in that it is very light in weight
and supplies an intense dry heat.
In protracted cases it is of the utmost importance
to keep the bowels thoroughly open. Daily rectal
irrigations with artificial Carlsbad salts, two
drachms to one quart of warm water, allowing the
fluid to run in slowly and encouraging the patient
to hold it as long as possible before releasing it, has
an effect of producing a reflex action on the bile-
duct through the peristaltic motion of the lower
bowel. This treatment can be enhanced by the
drinking, each morning, of one glass of water con-
taining one drachm of the artificial Carlsbad salts.
When the bowels are unusually sluggish give rec-
tal injections of glycerin, one ounce, at bedtime.
Where a series of attacks of colic have occurred
and the patient anticipates another, relief from pain
has been observed by administering camphorated
oil (Pharmacopceia of the United States), five to
eight drops on a lump of sugar, every fifteen min-
utes.
In regard to the diet the only change to make is
to restrict heavy and rich food, as, for instance,
salads and desserts. The eating of reasonable
quantities of green vegetables, stewed fruits, stewed
chicken, and chopped meat is of advantage in has-
tening the passage of the calculus. The drinking
of a glass of hot water morning and evening will
do much to overcome the gastric irritation usually
accompanying such attacks.
The patient should be cautioned against vomit-
ing when it is evident, as such exertion may pro-
duce rupture of the bileduct Should the stone be
large and firmly impacted. The hypodermatic in-
jection of morphine given for the" pain will also
minimize this tendency to vomit.
In those cases in which the attack of colic lasts
for several days, and when the pain is not too se-
vere, the patient may be allowed (provided there
is no fever) to walk about the house, care being
taken to prevent undue pressure or tension being
made over the liver region.
In cases resisting this treatment, and where great
prostration, weakness, elevation of temperature,
and marked jaundice occurs, the treatment of the
colic can be found only in surgical intervention.
Dr. R. S. Fitzgerald, of Richmond, Va., states:
During the attack of gallstone colic the indica-
tions are to relieve pain and spasm, which are very
severe. Hot oil of turpentine stupes are at once ap-
plied and changed every fifteen minutes, using wa-
ter as hot as patient can stand, with only two or
three drops of turpentine applied to side of towel
next to skin ; of course these stupes are applied over
the region of the livfer. A few whiffs of chloro-
form may be necessary for dulling the pain until
the morphine, 1/6 grain, repeated if necessarv, has
time to get in its work.
Then I use the following formula : Sodium
chloride, 5i ; sodium sulphate, 5i ; sodium phos-
pate, 5i; sodium bicarbonate, 5i. Give this in a
glass of water at one dose, and repeat the dose
every three hours. Keep up this treatment for two
or three days, and after the trouble is over put your
patient on granular efifervescent sodium phospate,
oii in water be'fore breakfast, and at bedtime, or
as often as necessary to keep the bowels open.
Give a good tonic of hydrargyri chloridum corro-
sivum, gr. i; tincture nucis vomicae, "^ixss; elix.
gentian, q. s., and '^w. Teaspoonful in water be-
fore meals.
If this does not relieve take him to the hospital
and remove the cause surgically.
Dr. William S. McCormick, of Philadelphia,
ivrites:
In this condition the object is to secure quick re-
lief from the severe pain. In my experience noth-
ing has served better than to give, subcutaneously,
morphine in doses of grain to 54, guarded with
atropine, and then give inhalations of chloroform
until the effects of the morphine are noticeable.
This plan usually gives ease in a few moments.
The colic can also be relieved by the hot bath and
hot applications over the liver. The temperature
of the bath should be from 98° to 102° F., and con-
tinued for about fifteen minutes unless cardiac de-
pression results and pulse becomes weak. Oil of
turpentine stupes over the hepatic area are also
valuable.
During the interval the patient should have a
well regulated diet, mostly vegetable ; svstematic
exercise ; mineral waters ; sodium phosphate in
regulated doses to keep the bile flowing.
Proper attention should be given to relieve the
catarrhal condition of the ducts, in order that the
stones can pass without causing such severe pains.
April 4, 1908.]
THERAPEUTICAL NOTES.
647
f jrerajeutical gates.
Formulas for Skin Applications. — From Die
Praxis dcr Hautkrankheiteu. a collection of the
teachings of Professor P. G. Unna. by Dr. Iwan
Bloch, we take fhe following selection of formulas :
Lassar's Paste:
Salicylic acid 5ss ;
Petrolatum 3iss;
Zinc oxide, / 5= i
Starch, i
M.
Zinc Paste:
Zinc o.xide 5vi ;
Precipitated silica, ^5i;
Benzoinated oil, 5in ;
Benzoinated lard Bii.
M.
Zinc Sulphur Paste:
Zinc oxide, , oiiiss;
Precipitated sulphur, Siiss;
Precipitated silica, 3i;
Benzoinated oil, 5iii ;
Benzoinated lard 5ii.
M.
Red Zinc Sulphur Paste:
Zinc sulphur paste, 99 parts;
Cinnabar, i part.
M.
Unna's Bole Paste:
White bole, I .- ~-
Linseed oil, f ■
Zinc oxide 3v;
Solution of lead subacetate 3v.
M.
Unna's Lead Paste:
Rice starch, 5iiss;
Litharge, ( - .
Glycerin, i •
Vinegar 5ii.
M.
Unna's Caustic Paste-
Potassium hydroxide,
Quicklime.
Green soap.
Distilled water, of each equal parts.
M.
Exfoliative Zinc Paste (Pasta Lepisinatica) :
Zinc paste, / 35
Ichthvol, ( _..
Petrolatum, \
M.
Soluble Adhesive Paste:
Zinc o.xide. 1
Starch, >■ aa 5v;
Glycerin. '
Mucilage of acacia, 5x.
M.
Ichthyol Dextrin Paste:
Ichthyol, gr. xv to gr. xlv;
Water, |
Glycerin, ^ aa 5iiss.
Dextrin, •
Mi.x over a water bath with moderate heat to form a
paste.
Mild Zinc Paste:
Precipitated calcium carbonate. ) -- z
Zinc oxide. (
T.'nseed oil, ) - ..
Lime water, /
M.
Gelanth Film:
Gelatin, hydrated, \ -- , .
Tragacanth, / aagr. xl.
Glycerin ti]<.1xxv;
Distilled water, 5iii ;
Benzoic acid, artificial gr. v;
Rose oil, gtt. i.
M.
Gelanth Cream:
Zinc oxide gr. l.xxv,
Petrolatum, 5iiss;
Gelanth film, 5iiss ;
Ft. emulsio, adde. :
Extract jasmin, |. ..
Extract synnga, J
M.
The Treatment of Acute Bronchitis. — [Martinet
(Presse viedicale, Januan.- 11, 1908) outlines the
method of treating acute bronchitis in the earlier
stages of the disease. He overcomes the inflam-
matory condition by the application of sinapisms
and poultices to tlie chest, the limbs being envel-
oped in cotton wadding. Warm baths (100° F.)
are given after an acute congestive attack. To allay
the cough and assist expectoration the following-
mixture is given :
B Tincture of aconite, gtt. xl ;
Cherry laurel water,
Sodium benzoate, aa 5ii ;
Syrup of codeine,
Syrup of senega.
Syrup of tolu aa Jiss.
M. Sig. : One tablespoonful every three hours.
To overcome the general infection and fever a
saline purgative is given, followed by antipyretic
treatment, the following cachet being prescribed :
R Quinine dihydrochloride,
Antipyrine aa gr. v.
M. ft. cachet No. 2.
Sig. : One cachet to be given on the first and second daj'
at 2 o'clock p. m.
Mercurous Bromide in Syphilis. — It has been
found, after several trials, that the following is the
best solution for use as an intramuscular injection
in syphilis :
B Mercurous bromide, gr. viii;
Sodium bromide, gr. vi ;
Distilled water, sterilized, 5i.
M. ft. inject.
In doses of fifteen to thirty minims this injection
is said to be painless and effective in action.
Hypophysial Opotherapy. — The part played by
the hypophysis in the economy seems to have great
importance. It appears to influence nutrition to a
certain degree, as shown by the changes in it in
acromelagy-, and it is this function of which use has
been made in infectious diseases by Louis Renon
and Arthur Delille. The results obtained by these
observers in twenty-four cases of grave infectious
diseases were recently communicated to the Societe
de therapeutique in a thesis by Jean Azam, accord-
ing to an abstract from the Journal de medeciue ef
de chirnrgie pratiques in The Practitioner for
^larch, 1908. In enteric fever, particularly, the
therapeutic effect has been most evident ; eight cases
were treated, and they all recovered. Si.x of the pa-
tients were not bathed, and among those must be
noted two cases of exceeding gravity. In one. myo-
carditis gave cause for a gloomy prognosis, and in
648
the other a miscarriage occurred at the outset of her
enteric disease, to be followed later by a puerperal
infection, associated with her typhoid infection. In
both these cases the hypophysial treatment was fol-
lowed by an almost simultaneous rise in the arterial
tension ; from 12 to 14 the tension rose by degrees to
20. The pulse, which in several patients was as high
as 130 to 140, fell gradually to 90 and 84. The tem-
perature, in both these cases, fell from one to two
degrees, but went up again when the hypophysial
treatment was stopped. Diuresis was well marked
in all the patients ; in some the quantity of urine was
three to four litres. In all the cases convalescence
was very quick. In all eight cases the diagnosis of
enteric was confirmed by the serum test. In pneu-
monia the effect was less favorable, but the cases
were of extreme gravity. Pituitary gland substance
was given in influenzal pulmonary congestion, cere-
brospinal meningitis, etc. In all there were four
deaths in the twenty-four cases. The daily dose
given was 43/3 to 6 grains of the powdered hypo-
physis of bullock. At the end of his thesis Azam
gives a resume of the effects of hypophysial inade-
quacy, and the influence of hypophysial opotherapy.
Inadequacy is characterized in toxine infectious dis-
eases by (I) a fall in arterial tension, (2) quicken-
ing of the pulse. To these two principal symptoms
are added secondary eft'ects, including insomnia, loss
of appetite, frequent sweat, and painful heat flushes
Under the influence of hypophysial opotherapy in
toxine infections are to be noted: (i) Increase oi
arterial tension, (2) decrease in the rate of the pulse
with increase in the force and amplitude of the beats.
(3) increased diuresis, (4) increase of weight, (5)
suppression of the secondary symptoms of hypo-
physial inadequacy, (6) a favorable influence on
convalescence. It is conceivable that this form of
opotherapy will be able to rank beside specific treat-
ment of toxine infections when the quickness of the
pulse and the low tension suggest a functional in-
sufificiency, or an actual lesion of the hypophysis.
Erythema Annulare. — The subjective symp-
toms of erythema annulare are said to respond
quickly to the following treatment recommended by
Cocks" (Medical Record, March 28, 1908) :
R Sodium salicylate, 3v ,
Rhubarb and soda mixture 3iii-
M. Si^'. : 5i in a wineglassful of water every three hours.
The objective symptoms are relieved by the ap-
plication of the following lotion :
R Powdered calamine, 5ii ;
Zinc oxide, 5ii ;
Carbolic acid, xxx;
Rose water, 5iv.
M.
Equisetum Arvense in Suppression of the
Urine. — This plant, popularly known as horsetail,
and which was at one time reputed to have diuretic
properties, has again come into use in the treatment
of suppression of the urine where the ordinary thera-
peutic methods have proved ineffective. lireiten-
stein (Correspondenz-Blatt fiir Schzceicer Acrtze)
cites the case of a patient suffering from heart dis-
ease and extensive cedema. wlio, after taking six
ounces of a concentrated decoction of equisetum
twice daily for six weeks, was quite cured of all
[N'ew York
Melical Journal.
swelling, the urine being raised from 53 ounces to
165 ounces daily {sic) by the simple and old fash-
ioned treatment. .Vn infusion of the dry powdered
plant, obtained by infusing a tablespoonful of the
powdered herb in a cupful of boiling water, and de-
canting after fifteen minutes, has been recommended
as an internal remedy for various haemorrhages, such
as epistaxis, haemoptysis, menorrhagia, metrorrha-
gia, and bleeding haemorrhoids. The dose is a cup-
ful, repeated, if necessary, twice or thrice daily.
Mistura Ferri Acida. — In the Journal of the
American Medical Association, for March 28th, F.
A. Faught comments on the various formulas that
have been published for the combination bearing the
name, Mistura ferri acida. He gives the formula
employed at the Philadelphia Polyclinic during the
time he served there as follows :
R Iron sulphate, gr. xxxvi ;
Magnesium sulphate 5ii
Diluted sulphuric acid, 3ii ;
Compoimd iiifusion of gentian, Jvi.
M. Sig. : A tablespoonful in water before breakfast, or
two tablespoonfuls in water after each meal.
Spray in Asthmatic Attacks. — The following
spray is recommended in Journal de nicdecine de
Paris for February 22, 1908, for the alleviation of
the distress accompanying the paroxysin in asthma :
R Cocaine nitrite gr. xv ;
Atropine nitrite, gr. viiss ;
Glycerin, ^i ;
Water, ad ^iii
M.
The spray is applied on the approach of the attack
and repeated one half hour or an hour after it. In
severe cases the spray is applied night and morning.
Treatment of Scabies or . Pediculosis. — Babies
and adults aft'ected with scabies or pediculosis
should, says Cocks {Medical Record. March 28.
1908), be wathed in warm water, to which borax
and tincture of green soap have been added, and al-
lowed to soak for half an hour. After drying a two
per cent, ointment of ammoniated mercury applied,
night and morning for a week will effect a cure.
Lactic Acid for Alopecia. — Lactic acid is said
by The Preseriber to have a specific action in alo-
pecia areata. The following prescription has been
given, accf)r(ling to the authority cited, in a number
of cases with complete success :
R Lactic acid 5ii ;
Castor oil 5ii ;
Alcohol (90 per cent.) ad .^iv.
M. Sig. : To be painted on tlie patches night and
morning.
Ointment for Tinea Tonsurans.— In a note on
the cure of tinea tonsurans by Cocks (Medical
Record, March 28, 1908), it is remarked that long
and persistent treatment is necessary. The patient
should wear a muslin night cap and be isolated. The
hair is to be clipped, thirty or more hairs to be
epilated daily, and the following ointment rubbed in
with a stencil brush twice a day :
R Ointment of red mercuric oxide, .3i_ss ;
Sulphur ointment, 5ii ;
Ointment of rose water 5i.
M.
THERAPEUTICAL NOTES.
April 4, 1908.]
EDITORIAL ARTICLES.
649
NEW YORK MEDICAL JOURNAL
IXCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Review of Medicine'.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M. D.
Addresx ail husiness conimiinications to
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NEW YORK, S.\TURD.\Y, .\PRIL 4. 1908.
PREVEXTIX E ^lEDICIXE AXD THE
GOX'ERXMEXT.
Two bills affecting the Public Health and Marine
Hospital Sen-ice have been introduced into Con-
gress, and their enactment would inaugurate a very
important movement in the interest of preventive
medicine in this country. The functions of this
service have been enlarged so often, in response to
the growing demand for more active participation
by the government in the prevention of disease, that
it is Jiecessary from time to time to provide by legis-
lation the authority and facilities required by the
service to meet its new responsibilities. The bill
entitled "A bill to further protect the public health,
and imposing additional duties upon the Public
Health and Marine Hospital Service" (H. R. 18792.
S. 6101) does this, but, in addition, it provides for
the broadest investigation by the service into ^he
prevalence, the conditions influencing the spread,
and methods for the prevention and suppression of
"tuberculosis, typhoid fever, rabies, and other dis-
eases affecting man.'"
This bill, if it becomes a law, will mark the be-
ginning of aggressive action by the government in
the prevention of those diseases which cause the
greatest waste of life, and in entrusting the first
organized campaign to the Public Health and
Marine Hospital Ser\-ice. assurance is given that
Congress has been aroused to the necessity of assum-
ing, within its constitutional limits, its important
share in the w^arfare against disease. Besides pro-
viding for the investigation of the preventable dis-
eases, the bill authorizes the widespread dissemina-
tion, by means of bulletins, exhibits, and reports, of
the results obtained as well as of practical informa-
tion as to the control of infectious diseases. Provi-
sion is made for the estabhshment of a school of
hygiene under the administration of the Public
Health and Marine Hospital Service, in which in-
struction may be received by accredited health offi-
cers of States, counties, and municipalities, and for
the detail of commissioned officers of the service,
upon request of the proper health authorities, to
cooperate in the sanitan,- work of States and terri-
tories. In accordance with recommendations made
by Surgeon General ^^'yman in his last annual re-
port, certain additional administrative officers are
provided for in the bill. These include an assistant
surgeon general, to have charge of a new division
(that of water supplies and sewerage), a sanitary
engineer of high attainments, and a solicitor con-
versant with general and local laws and regulations
relating to the public health.
The growth of the Public Health and Marine
Hospital Sen-ice illustrates the beneficial effect of
rewarding the efficient performance of one task by
the imposition of a more difficult one. From the
professional and administrative success with which
the marine hospitals were conducted, and the famil-
iarity with quarantinable diseases which the care of
sick seamen involved, came the administration by
the Marine Hospital Service of the national mari-
time quarantine and the control of the earlv yellov,-
fever epidemics of the south. The confidence in-
spired by the devotion and ability of the officers of
the service in the performance of these duties re-
sulted in the assignment of new tasks, one by one.
until the activities of the service now include the
control of epidemics too serious for the resources of
local health authorities or which threaten interstate
communication (examples fresh in the public mem-
ory being the epidemics of yellow fever in New
Orleans and of bubonic plague in San Francisco),
the administration of the Federal quarantine system,
not only in the United States and its possessions,
but in every infected port in the world, the investi-
gation of diseases of peculiar local interest, like that
of leprosy in Hawaii and of the hook worm disease
in the south, the supen'ision of the production of
vaccines and curative serums, the medical inspec-
tion of immigrants, and the operation of the marine
hospitals.
In the performance of these diversified duties, the
Public Health and Marine Hospital Sen-ice has
been engaged in public health work of the widest
scope, and. with its well organized and disciplined
corps of trained officers, is fully equipped to take
650
EDITORIAL ARTICLES.
[New York
Medical Journal.
up the new obligations which the bill before Con-
gress imposes upon it. The place in the public con-
fidence which this service holds was well expressed
recently by Dr. L. L. Seaman, who said: "I have
seen these zealous guardians of the public health
in almost every port with which we have commercial
relations, always watchful lest contagious or infec-
tious diseases might elude them and fasten upon
our native land, and with a fairly liberal personal
experience and knowledge of our government in its
various departments at home and abroad, I assert
that the United States Public Health and Marine
Hospital Service is the one department of which
Americans have most reason to feel justly proud."
The other bill affecting this service (H. R. 18794,
S. 6102) makes belated provision for pay, allow-
ances, and retirement in conformity to that enjoyed
by the medical officers of the army. If the same
pay, allowances, and opportunities for advancement
which exist in the other medical services of the gov-
ernment are not provided, it will be difficult, if not
impossible, to attract to the Public Health and
Marine Hospital Service young physicians of the
type needed as commissioned officers or to obtain
men with the training and ability needed to carry on
the highly specialized work of some of the divisions
in the Hygienic Laboratory. An efficient and con-
tented personnel, satisfied to devote their lives to the
work of the service and trained to the highest de-
gree of usefulness, is the factor absolutely essential
for the successful performance of the future work
of this service.
The course of these two bills through Congress
will be followed with interest by all those who have
at heart the development of preventive medicine in
this country, and their enactment will go far toward
removing the stigma that this government does
more for the preservation of swine and cattle than
for the protection of human life.
THE MOTHER OF MODERN NURSING.
If Hippocrates was the father of medicine — and
it is customary so to designate him — ^surely Miss
Florence Nightingale may justly be called the
mother of such nursing as has now, over practically
the whole civilized world, happily supplanted the old
style of nursing, almost always worthless and often
truly abominable. The nurses' training school of
to-day is her creation. Probably it would have
come eventually in any case, but it was her marvel-
ous career in the Crimean war, backed by the con-
science of the British people, that endowed her with
the prestige required to carry out her lofty purposes
in the face of foolish and fussy officialdom.
Miss Nightingale's extraordinary services to man-
kind have met with universal acknowledgment, but
it is well that in her declining years she has received
such a tangible and distinguished token of the fact
as the freedom of the city of London, "one of
whose most graceful functions it is," says the
Lancet, "to 'act as a mouthpiece for the nation in
honoring those who have deserved well of their
fellow countrymen." The ceremony took place on
Monday, March i6th. It is quite in keeping with
Miss Nightingale's higher regard for the general
welfare than for her own gratification that she
should have declined the ofifer of "a golden casket
to inclose the address presented to her, choosing
rather," says our contemporary, "that the money
thus saved should be spent on some work of char-
ity."
The Crimean w^ar occurred many years back, more
than half a century, and Tennyson, who gave the
world the other good thing that came out of it. The
Charge of the Light Brigade, has been several years
at rest. It was high time, therefore, that the crown-
ing reward of Miss Nightingale's lifelong labors
should come. The prolongation of her most useful
life for many years yet is heartily de^sired for her
by public spirited people all over the world, and we
are all glad to believe that her memor}' will be im-
perishable.
OUR PRESENT KNOWLEDGE OF
CANCER.
Dr. James Ew-ing, of New York, delivered, on
November 16, 1907, a very interesting lecture before
the Harvey Society, at the New York Academy of
Medicine, which lecture has now- appeared in print
in the Archives of Internal Medicine, i, No. 2, In
this lecture the author gives a very good synopsis
of the cancer question as it presents itself to-day.
He states that our knowledge of cancer must be
reviewed from three points : The parasitic theory,
the theory of cell autonomy, and the modern bio-
logical and biochemical study of tumors.
"The search for the cancer parasite has been a
chaotic chapter in medical research." It was only
natural, remarks the author, that, after the discov-
ery of specific agents in many infections, especially
in infectious gummata, researches for a specific
cancer parasite should be instituted. But at the
present day it cannot be said that these researches
have been successful. Although certain irritants
and parasites may be effective in producing tumors,
no specific parasite has so far been discovered.
In reviewing the theory of cell autonomy Dr.
Ewing thinks that it seems to explain sufficiently
the enormous and quick growth of tumors. Nor-
mally, the organization controls the growth of tissue
April 4, I90».]
EDITORIAL ARTICLES.
651
cells, the regenerative powers of which are greatly
in excess of ordinary needs, so that if called upon
the cells may meet extraordinary requirements; if,
therefore, tlie proper external condition or stimulus
should arise, the cells will exhibit a phenomenal
grade of proliferation. But can such a stimulus be
the result of a parasite, not necessarily a specific
parasite ? Dr. Ewing answers this question by say-
ing that when the theory of a stimulus is accepted,
the existence of such a parasite, and even of a spe-
cific parasite, must be admitted. But he shows that,
to make this theor}^ acceptable, the parasite must
invade minute groups of cells in protected organs,
even in the embryo of an immune parent, infecting
an embr}-onal cell, but not attacking its immediate
neighbor, lying dormant for years and awaking
suddenly, doing its destructive work in a very short
time.
The third theory is of very recent date. In a bio-
chemical sense, efforts to demonstrate specific qual-
ities in tumor cells have not been very successful.
The experiments made show that tumors grow read-
ily in young dogs, rats, and mice, although such
tumors seldom or never develop spontaneously in
these j'oung animals. From these experiments the
theory of cell autonomy becomes important.
Dr. Ewing thinks that in the clinical observation
of the general and local conditions of the early
stages of cancer, such as can be made only by the
physician, lies the chief hope for the present gene-
ration of a reduction in the mortality from cancer.
DRIED SPUTUM AND THE SPREAD OF
CONSUMPTION.
At a recent meeting of the National Society of
Medicine, held in Lyons (Presse medicate, February
29th), M. Cadeac made some remarks in which he
reminded his hearers that he had been one of the
first to deny that tuberculous disease was contracted
by inhalation, his experiments and communications
concerning the matter dating back to 1887 and 1888.
He had now made additional experiments tending
to show that the disease was not usually spread by
dried tuberculous sputum, even by absorption from
the alimentary canal. He had mixed dried sputa,
taken indiscriminately from all the sp>ecial recep-
tacles in a hospital service, with the food given to
guinea pigs. It was only in very rare instances that
the animals had become tuberculous, and then only
after they had been made to ingest enormous quan-
tities of the dried sputum. These experiments, he
said, were all the more valuable when they were con-
sidered in connection with the fact that, to infect a
guinea pig with tuberculous disease, it sufficed to
touch the tip of its tongue with a stirring rod dipped
in a ten per cent, solution of fresh tuberculous
sputum. If the author's experiments are confirmed,
and if, at the same time, as is plainly the tendency,
we come to regard infection by the digestive canal
as more common than infection by inhalation, we
shall have to lay much less stress than we do at
present on the danger of inhaling tuberculous dust.
However, it will be well to pause before acting on
such a deduction.
A NEW STATE HOSPITAL.
The members of the medical profession in the
city of New York have long been convinced that
the only temporary solution of the problem of over-
crowding in the hospitals for the insane in New
York State could be reached by the erection of a
new hospital in the southeastern part of the State.
It is a matter for congratulation that a bill was
introduced into both^ houses of the legislature last
week to provide $119,250 for the purchase of a site
in Rockland County upon which a new hospital for
the insane is speedily to be erected. The tract
selected by the State Commission in Lunacy com-
prises 408 acres, and is situated at Congers, on the
West Shore Railroad. Almost all desirable features
are found in this site, and the price is low if one
considers the certain appreciation of values for land
within twent\^-nine miles of New York, now that
the tunnel under the Hudson River to Hoboken has
been completed.
The overcrowding of the State hospitals is due
almost entirely to the large increase of the insane
population in New York city. From Manhattan,
Kings Park, and Central Islip State hospitals trans-
fers have been made to all the ten other hospitals in
the State, except those of Buffalo and Long Island.
In fact, none of the hospitals of the districts in the
nonhern part of the State, with the exception of
Buffalo and Utica, would be filled were it not for
these transfers. The certified capacity of the thir-
teen institutions is much overstated at 23,525. The
number of patients actually housed in these hospi-
tals has reached nearly 26,000. The only solution
of this problem lies in the speedy erection of a new
hospital in this part of the State. The question of
other hospitals at different points is entirely inde-
pendent of this prime consideration and secondary
to it. It is without doubt a fact that a much larger
proportion of our insane population can be cured or
can be rendered at least partially self supporting
when the great overcrowding now existing is at an
end and more individual care and attention is ren-
dered possible. This can best be done by the erec-
tion of small hospital groups rather than by putting
OFFICIAL NEWS. [New York
Medical Journj
652
up buildings so enormous that no one head can carry
the necessary details of administration and medical
care.
AN ANNUAL OF PARASITOLOGY.
We learn that a new annual, to be called Para-
sitology, is soon to make its appearance as a supple-
ment to the Journal of Hygiene. Dr. George H. F.
Nuttall, F. R. S., is to be the chief editor. It is
announced that each volume will contain 400 or 500
pages of text, together with the necessary plates for
elucidating contemporary studies of the structure
and life history of the pathogenic organism and of
the intermediate host or hosts in the case of such
diseases as are carried from one vertebrate animal
to another by mosquitoes, biting flies, ticks, etc. The
new periodical is to be issued by the Cambridge
L^niversity Press, which has a representative, Mr.
C V. Clay, in Fetter Lane, London, E. C.
getos Items.
The Second International Conference on the Sleeping
Sickness met at the Foreign Office, London, during the
week of March 9th. Lord Fitzmaurice presided and dele-
gates from seven countries were present at the conference.
The Pathological Society of Philadelphia will hold its
annual conversational meeting on Thursday evening, April
22d. Dr. Richard M. Pearce will deliver an address on the
Theory of Chemical Correlation as Applied to the Pathol-
ogy of the Kidney.
The Dorchester, Mass., Medical Society was organ-
ized on March 25th, with the following officers for the
first vear : President, Dr. Madison T. Thurber ; vice presi-
dent," Dr Robert M. Merrick; secretary and treasurer. Dr.
H. F. R. Watts.
Emergency Hospital, Washington, D. C— The resig-
nation of Dr. Charles S. White as superintendent of the in-
stitution has been accepted by the board of directors, to
take effect on April isth. He will be succeeded by Dr. E.
P. Magruder, of Washington.
A Gift to the Maine General Hospital.— It is reported
that Mr. William Deering, of Evanston, 111., has made an
unconditional gift of $25,000 to the Maine General Hos-
pital, Portland. In doing so he anticipated a clause in his
will bequeathing that amount to the institution.
The Harvey Society Lectures. — The next lecture in
the course will be delivered on Saturday evening, April
i8th, at the New York Academy of Medicine, by Professor
A. E. Taylor, of the University of California, on The Role
of Reversed Ferment Reactions in Metabolism.
Medical and Surgical Society of the District of Co-
lumbia.— At a meeting of this society, which was held
in Washington, D. C, on Thursday, March 19th, Dr. F. A.
King read a paper on The Pleasures and Advantages of
Functional Reversion to Antecedent Conditions of Life,
and Dr. Joseph Taber Johnson read a paper on Abdominal
Surgery.
Arkansas Medical Society. — The annual meeting of
this society will be held in Little Rock, Ark., on May 13th,
14th, and 15th. Tlie chairman and the secretary of the
Section in the Practice of Medicine are preparing a pro-
gramme which promises to be one of especial interest, and
every effort is being made to make the meeting a success
in every way.
The Army Medical Reorganization Bill. — This bill,
with its amendments, has been passed by the House of
Representatives, but the Senate failed to agree with the
amendments of the House, consequently the bill is now in
conference. A compromise will probably be arrived at bc-
tweeii the Senate and the House, and the bill, as finally
modified, will then become law.
Baltimore Medical Society. — The semiannual meeting
of this society will be held on Tuesday, April 7th. The
general subject for discussion will be Expert Testimony,
which will be considered from both the medical and the
legal points of view. Among those who will take part
in the discussion are Dr, George J. Preston, Dr. N. G.
Keirle, and Dr. Joseph C. Bloodgood.
American Society of Sanitary and Moral Prophylaxis.
— A regular meeting of this society will be held at the New
York Academy of Medicine on Thursday evening, April
9th, at 8 :30 o'clock, under the auspices of the Committee
on Education. The following papers will be read : The
.Etiology, Prophylaxis, and Treatment of the Social 111, by
Dr. S. Adolphus Knopf ; Prostitution in New York City,
by Frank Moss, Esq.
Elmira, N. Y., Academy of Medicine. — The regular
meeting of this academy was held on Wednesday evening.
April 1st. Papers were read as follows : Dr. PI. R. Ainsworth,
of Addison, N. Y., Measles and Its Quarantine ; Dr. Anna
Stuart, of Elmira, N. Y., Carcinoma of the Breast; Dr.
Abraham Lande, of Elmira, N. Y.. Cardiac Insomnia. Dr.
Ross G. Loop is the president of the academy, and Frank
L. Christian is the secretary.
The Rockavsray Tuberculosis Hospital. — Plans have
been prepared for the seaside hospital and sanitarium for
tuberculosis patients which is to be built in Rockaway, Long
Island, by the New York Association for Improving the
Condition of the Poor. The association has raised $250,-
000 for the purpose, one half of this amount having been
contributed by Mr. John D. Rockefeller. The city has fur-
nished the site. According to the plans the hospital will
accommodate two hundred patients.
A Department of Public Health in Canada. — Dr. Jud-
son B. Black, member of Parliament for Hants, Nova
Scotia, has proposed a resolution in the Canadian House
of Commons asking the government to establish a Depart-
ment of Public Health, whereby all matters relating to
public health will be under one responsible head, instead of
being scattered through several departments, as is the case
at present. All the medical men in the house spoke
strongly in favor of the resolution.
Vital Statistics of Minneapolis. — During the month of
February, 1908, there were reported to the Department of
Health of Minneapolis, Minn., 269 deaths from all causes,
corresponding to an annual mortality rate of 9.80 in i,ood
of population. Of the total number of deaths, 55 were
from pneumonia, 29 from pulmonary tuberculosis, 21 from
Bright's disease, and 10 from cancer. There were 2 sui-
cides, and 7 deaths from accidents. There were 194 mar-
riages and 436 births registered during the month.
The Anglo-American Society of Vienna is the name
of a society recently organized. ' with headquarters at the
Imperial Hotel. Vienna. The object of the organization is
to facilitate the visits of English and American students in
Vienna, and to make known in England and the United
States the artistic and scientific resources of the place. H.
H Princess M. A. Lubomirska is the president of the so-
ciety. Dr. G. de Griez is the honorary secretary, and Mr.
O. S. Phillpotts, the English vice consul, is the treasurer.
The Health of Pittsburgh.— The following cases of
transmissible diseases were reported to the Bureau of
Health of Pittsburgh for the week ending March 14. 1908:
Chickenpox. 4 casi s, o deaths: typhoid fever, 25 cases, 6
deaths; scarlet fe\er, 12 ca^es, 2 deaths; diphtheria. 0
cases, 2 deaths; measles. 229 cases, 11 deaths; whooping
cough, T3 cases. 3 deaths: pulmonary tuberculosis, 32 cases,
16 deaths. The total deaths for the week numbered 181, in
an estimated population of 403.300, corresponding to an an-
nual death rate of 23.33 in 1,000 of population.
The Health of Philadelphia.— During the week ending
March 14, 1908. the following cases of transmissible dis-
eases were reported to the Bureau of Health : Typhoid
fever, 97 cases, 17 deaths; scarlet fever. 86 cases. 6 deaths:
chickenpox, 39 cases, 0 deaths ; diplitheria. 72 cases. 7
deaths; cerebrospinal meningitis, 2 cases, o deaths; measles.
222 cases, 5 deaths ; whooping cough. 17 cases. 2 deaths ;
pulmonary tuberculosis. 95 cases. 71 deaths: pneumonia. 73
cases, 69 <leaths; erysipelas. 7 cases, i death; puerperal
April 4, 1908 J
Ori'ICJ.lL XHUS.
653
fever. 2 cases, 5 deaths; cancer. 15 cases, 21 deaths; tetanus,
2 cases, I death; mumos. 29 cases, o deaths. The tollownig
deaths were reported' from other transmissible diseases :
Tuberculosis other than tuberculosis of the lungs. 9;
diarrhcea and enteritis, under two years of age, 11. The
total deaths numbered 527, in an estimated population of
1,532,738, corresponding to an annual death rate of 17.81 in
i.ooo of population. The total infant mortality was 118;
under one year of age, 88: between one and two years of
age, 30. There w^ere 34 stillbirths, 16 males, 18 females.
University of Pennsylvania Alumni Election. — The
Philadelphia Alumni Society of the Medical Departmeni of
the University of Pennsylvania held its annual meeting
on :\larch 21st and elected' the following officers: President,
Dr. J. Allison Scott ; honorary vice president. Provost C.
C Harrison : vice presidents Dr. Richard C. Xorris, Dr.
Howard Sipple. and Dr. De Forest Willard : treasurer. Dr.
H. B. Carpencer; secretaries. Dr. B. F. Stall and Dr. Wil-
liam S. Ray; executive committee. Dr. Louis Adler. Dr.
C. F. Franklin, Dr. David Parrish, Dr. George B. Wood,
and Dr. Louis Saladi.
Women Physicians in Japan.— The Japanese medical
law recognizes the existence of women physicians, but there
is no medical school for women in Japan, and the schools
which admit female students are not recognized by the
medical law. The establishment of a medical technical
school for women has been proposed, but the authorities
are not in favor of the suggestion, and think it preferable
to create departments for women in two or three of the
leading medical schools. Regulations to that effect are be-
ing drawn up and will be submitted to the conference of
medical technical schools.
Scientific Society Meetings in Philadelphia for the Week
Ending April 11, igo8:— Monday. A(^ril 6th. Philadelphia
Academy of Surgery ; Biological and Microscopical Section,
Academy of Natural Sciences ; West Philadelphia Medical
Association ; Northwestern Medical Society. Tuesday.
Ahr'il jth. Academy of Natural Sciences: Philadelphia
Medical Examiners' Association. Wednesday, April Sth,
Philadelphia County Medical Society. Thursday, April gth,
Pathological Society ; Section Meeting. Franklin Institute.
Triday. April lotfi. West Branch. Philadelphia County
Medical Society l Northern Medical Association.
The Mortality of Chicago. — During the week ending
March 21. 1908, there were reported to the Department of
Health 623 deaths from all causes. 335 males and 28S fe-
males. The annual death rate in i.ooo of population was
15.00, in an estimated population of 2.107,620. The principal
causes of death were : Apoplexy. 5 ; Bright"s disease, 32 ;
bronchitis, 31; consumption. 72; cancer. 26; convulsions. 5:
diphtheria, 5; heart diseases, 50; influenza, 9; intestinal dis
eases, acute, 38: measles. 5; nervous diseases, 23: pneu-
monia, in: scarlet fever. 5; suicide. 12; typhoid fever. 6;
violence, other than suicide, 24; whooping cough. 2; all
other causes. 162.
College of Physicians of Philadelphia. — At a meeting
held Wednesday evening. April i^t, papers were read as fol-
lows : Dr. George W. Norris. Cardiac Arrhythmia from a
Practical Standpoint in the Light of Recent investigations ;
Dr. William R. Nicholson and Dr. Joseph S. Evans. The
Bacteriology of the Puerperal L'terus : Dr. Jay F. Scham-
berg. The .Vpplicability of the Lumiere Process of Color
Photography in Medicine : Dr. Milton B. Hartzell. Photo-
r.^icrographs and Portraits of Diseases of the Skin Obtained
by the Lumiere Process of Color Photography. Dr. Scham-
berg also gave a demonstration of color photography with
the Ives Kromskop.
Infectious Diseases in New York:
IVe are indebted to the Bureau of Records of the Depart-
ment of Health for the folloiuing statement of neiv cases
and deaths reported for the two weeks ending March 28,
1908:
, March 21. , , March 28. >
Cases.
Deaths.
Cases.
Ueath^i.
Tuberculosis pulmonalis .
• ■ 507
168
539
200
l'!->htheria
• • 397
53
405
58
3'easles
. . 1,607
33
1,813
3S
961
37
1,113
40
135
27
22
3
3
Cerebrospinal menigitis . .
9
8
. . 3.748
307
4,059
351
New York Academy of Medicine. — At a stated meet-
ing which will be held on Thursday, April i6th. at 8:30
p. m., the general subject for discussion will be exophthal-
mic goitre. Papers will be read as follows : The Pathologi-
cal Changes in the Thyreoid Gland as related to the Vary-
ing Symptoms in Graves's Diseases, Based upon the Patho-
logical Findings in Two Hundred and Seventy-five Cases
of Exophthalmic Goitre, by Dr. Louis B. Wilson, of
Rochester, Minn. ; The Surgical Aspects of Exophthalmic
Goitre, by Dr. W. S. Halsted, of Baltimore: The Consid-
eration of Exophthalmic Goitre from the Medical Stand-
point, by Dr. Alfred Stengel, of Philadelphia.
Rochester, N. Y., Academy of Medicine. — The Sec-
tion in General Medicine, which includes neurology,
psychiatry, materia medica, and therapeutics, held a meet-
ing on Wednesday evening, April 1st. The evening was
devoted to a discussion of the subject of pneumonia, and
papers were read as follows : The Bacterial Origin of Pneu-
monia and the Factors Entering into Its Causation, by Dr.
John R. Williams; The Blood in Pneumonia, by Dr.
Charles O. Boswell ; The Treatment of Penumonia. by Dr.
J. R. Culkin ; The Specific Treatment of Pneumonia,
Nuclein and Serum Therapy, by Dr. C. E. Darrow. Dr.
Edward G. Nugent is secretary of the section, and Dr. T.
A. O'Hare is the chairman.
The Medical Association of the Greater City of New
York. — A special meeting of this association will be
held on Monday, April 6th, at 8:30 p. m., at the Demo-
cratic Club, Long Island City, under the direction of the
chairman for the Borough of Queens. The programme
which has been prepared for this meeting includes the fol-
lowing papers : Personal Observations in Scarlet Fever, by
Dr. Charles G. Kerley ; Must the General Practitioner Use
the X Ray Method in the Treatment of Fractures? by
Dr. Carl Beck; The Differential Diagnosis of Meningococ-
cus Cerebrospinal Meningitis from Other Types of Cere-
brospinal Meningitis, by Dr. Henry W. Berg. Dr. Beck's
paper will be accompanied by lantern slide demonstrations.
Vital Statistics of New York City. — During the week
ending March 21, 1908. there were reported to the Depart-
ment of Health 1,480 deaths from r.ll causes, 544 marriages,
2.509 births, and 170 stillbirths. The annual death rate in
I.ooo of population was 17.46, in an estimated population of
4,442,685. In the Borough of Manhattan there were 767
deaths; in the Bronx, 126; in BrookljTi, 491: in Queens.
66; and in Richmond, 30. Of the total number of deaths
reported 168 were from pulmonary tuberculosis. 127 from
pneumonia, 127 from contagious diseases. 99 from broncho-
pneumonia, 97 from diarrhceal diseases. 56 from cancer, 116
from Bright's disease and nepliritis. and 138 from organic
heart diseases. There were 16 deaths from suicide, 5 from
iiomicide. and 56 from accidents.
The Obstetrical Society of Philadelphia. — At a meet-
ing of this society, which was held on Thursday evening,
April 2d, the following programme was presented : Dr.
Alice Weld Tallant reported a case of labor complicated
by ventrofixation of the uterus, and the following papers on
the subject of ectopic gestation were read: Dr. Stephen E.
Tracey, Report of a Case Operated Upon for Advanced
Ectopic Gestation Associated with Fibromyomatic Uteri ;
Dr. Theodore A. Erck. Report of a Case of Ectopic Gesta-
tion Cornual in Type : Dr. Collin Foulkrod. Report in Out-
line of Two Cases of Ruptured Extrauterine Pregnancy Il-
lustrating one of the Dangers of Expectant Treatment ;' Dr.
John A. McGlinn. Treatment of Ectopic Pregnancy with
report of Cases including one of Death from Hasmorrhage.
Personal. — Dr. Carl E. Seashore, professor of psychol-
ogy at the Graduate College of the State University of
Iowa, has been elected dean of the faculty.
, Professor S. E. Chaille, professor of physiology and
comparative anatomy, and dean of the medical department
of Tulane University, New Orleans, has been awarded a
retiring pension by the Carnegie foundation.
Dr. S. J. Meltzer, of New York, will deliver a lecture at
the Toronto .\cademy of Medicine on Tuesdav, April 7th,
on the Nature of Shock.
Mr. Cullen A. Battle, president of the firm of Battle &
Co.. of St. Louis, Mo., died on Monday, March 23d.
Dr. S. A. Knopf's prize essay on Tuberculosis a Disease
of the Masses and How to Combat It is to he translated
into Chinese. It has already been translated into twenty-
one languages.
OFFICIAL NEWS. [New York
Medical Journal.
Samaritan Hospital, Philadelphia, Medical Society. —
An interesting progrannne was presented at a meeting of
this society, held on Saturday evening, March 28th, which
inchided the following reports of cases: A Case of Sar-
coma of the Choroid, by Dr. Wendell Reber; Glaucoma
following Thrombosis of the Central Retinal Vessels, by
Dr. Joseph Clothier ; Hydrophobia, by Dr. H. C. Grof? ;
Pleurisy followed by Pneumonia and Pulmonary Abscess,
by Dr. Paul F. Bremer ; Acute Nephritis, by Dr. I. Newton
Snively ; Some Cases from the Neurological Dispensary, by
Dr. S. F. Gilpin ; Thirty Cases from the Opsonic Clinic, by
Dr. Harry A. Duncan and Dr. G. Morton lUman ; Mitral
Regurgitation, by Dr. Rae S. Dorsett ; Preliminary Report
on Normal Saline Enteroclysis in Febrile Cases, by Dr. W.
H. Pope ; Preliminary Report on Blood Pressure Observa-
tions During ]\Iajor Operations, by Dr. Charles S. Barnes.
Dr. H. F. Ptieuger read a paper entitled The Treatment of
Whooping Cough, Dr. Edward B. Finck read a paper en-
titled Some Practical Therapeutic Measures in Skin Dis-
eases, and Dr. D. J. Kennedy read a paper on the Thera-
peutics of Varicose Ulcers and Eczema Rubrum. The gen-
eral discussion on the papers and the reports of cases ^yas
opened by Dr. Samuel VVolfe.
Discussion on the Sanitary Aspect of Milk. — The
New York i\lilk Committee has made arrangements for a
series of five meetings to be held in Assembly Hall, 105
East Twenty-second street. New York, for the purpose of
discussing the various questions connected with the milk
supply. Among those who have been invited to participate
in the discussions are representatives of the Department of
Health, milk dealers, representatives of railroads bringing
milk to New York, the editors of the New York daily news-
papers and of agricultural papers published in New York
State, representatives of the State Department of Agricul-
ture, physicians, bacteriologists, and other individuals in-
terested in the sanitary aspect of milk. The meetings will
be conducted as private conferences and no reporting will
be permitted. The general subjects for discussion at these
meetings are as follows : Saturday afternoon, April 4th, at
2 -.30 o'clock, The Need for Improving New York's Milk
Supply; Saturday afternoon, April iith, 2:30 o'clock,
Tuberculosis ; Saturday afternoon, April i8th, at 2 :30
o'clock, Methods for Improving the Milk Supply ; Saturday
afternoon, April 25th, at 2:30 o'clock, Pasteurized Milk;
and Saturday evening, April 25th, at 8 o'clock, Certified
Milk and Other Clean Raw Milks.
American Gastroenterological Association. — The
eleventh annual meeting of this association will be held in
Chicago on June ist and 2d. The preliminary programme,
which has just been received, includes the following papers:
President's Address, by Dr. J. P. Sawyer of Cleveland; A
New Method of Ascertaining the Permeability of the
Pylorus, by Dr. Max Einhorn, of New York ; Ischochymia,
by Dr. F. H. Murdoch, of Pittsburgh; An Explanation of
the Motor Activities of the Alimentary Canal in Terms of
the Myenteric Reflex, by Dr. Walter B. Cannon, of Bos-
ton ; The Chemical Coordination Existing Between the
Salivary Glands and the Secretion of the Stomach, and the
Effect of Splenectomy on the Gastric Secretion, by Dr. J.
C. Hemmeter, of Baltimore; Cholec.vstitis, by Dr. H. W.
Bettmann, of Cincinnati ; Progress in Gastroenterology, by
Dr. A. L. Benedict, of Buffalo ; The Nervous Influence on
the Production of Sugar in the Body, by Dr. J. J. R.
MacLeod, of Cleveland ; The Behavior of Some Indigesti-
ble Carbohydrates in the Alimentary Tract, by Dr. Lafay-
ette B. Mendel, of New Haven, Conn. ; A Comparison of
the Guaiac and Benzidin Tests for Invisible Haemorrhage
in Diseases of the Digestive Organs, by Dr. Franklin W.
White, of Boston ; Intestinal Sand, by Dr. Jesse S. Myer
and Dr. Jerome E. Cook, of St. Louis ; Gastric Ulcer, by
Dr. William Gerry Morgan, of Washington. D. C. ; Pathol
o^y of Malignant Growths, by Dr. W. T. Howard, of
Cleveland ; Gastromyxorrhoca. by Dr. Julius Friedenwald.
of Baltimore.
The Health of the Canal Zone.— During the month
of January. 1908, the following deaths in the Canal Zone,
including the cities of Colon and Panama, were recorded :
Typhoid fever, 2; a?stivoantinnnaI malaria, 13; clinical ma-
laria, 24; malarial cachexia, 3; hajmoglobinuric fever, 3;
amoebic dysentery, 4; clinical dysentery, 6; beriberi, 2; sep-
ticsemia, 3 ; pulmonary tuberculosis, 22 ; general tubercu-
losis, 11; cancer, 5; bronchopneumonia, 7; pneumonia, 28;
uncinariasis, i. The total number of deaths from all causes
on the isthmus was 249, in a total population of 112,062,
corresponding to an annual death rate of 26.66 in 1,000 of
population. The death rate among the employees of the
Canal Commission, both black and white, was 12.72 in 1,000
of population; among the whites the death rate was 11.48
in 1,000; among the blacks 13.16 in 1,000. This death rale
is much less than that for January, 1907, when it was 13.01
in 1,000 for the whites, and 30.06 in 1,000 for the blacks.
The death rate in the cities of Colon and Panama has also
been reduced. The best index of the value of the sanitary
work of the Commission is in the malaria incidence. In
January, 1907, 1,813 cases of malaria were admitted to the
hospitals ; in January, 1908, only 642 cases were admitted.
During the year the number of employees had increased
by 12,000, so that the incidence of that disease is really
one fifth of what it was in January, 1908. Both yellow
fever and bubonic plague are present both north and south
of the isthmus ; but no case of either has occurred in the
Canal Zone during the year. The morbidity among the
employees for the month was 332.69 in 1,000 of population.
Meetings of Sections of the New York Academy of
Medicine. — A meeting of the Section in Dermatology
will be held on Tuesday evening, April 7th. After the
presentation of cases previously shown, the following new-
cases will be presented : Results of the Treatment of Pig-
mented Njevi by Liquid Air (two cases), and Prurigo of
Hebra (two cases), by Dr. Trimble; Xanthoma Tuberosum
(two cases,) and Pityriasis Rubra of Hebra (two cases), by
Dr. Howard Fox; Keloid Treated with the X Rays, and
Lupus Vulgaris Treated with the X Rays, by Dr. Clark;
and a number of miscellaneous cases.
The Section in Pjediatrics will meet on Thursday even-
ing, April 9th, at 8:15 o'clock. After the presentation of
patients, Dr. Eli Long will report a case of Status Lymphat-
icus. The paper of the evening will be read by Dr. A. F.
Hess on The Distribution of Bacteria in Bottled Milk:
Its Application to Infant Feeding.
The Section in Otology will meet on Friday evening,
April loth, at 8:15 o'clock. Dr. Edmund P. Fowler will
exhibit a suction bell ear douche, and the following reports
of cases will be presented: Unusually Atypical Case of
Sinus Thrombosis, Importance of the Blood Culture in
Diagnosis, by Dr. Seymour Oppenheimer ; Cases of Mas-
toiditis in Elderly People with Unusual Conditions, by Dr.
H. A. Alderton ; Case of Mastoiditis Complicated by Puru-
lent Meningitis, Encephalitis, Phlebitis of Sigmoid Sinus,
Jugular Bulb, and Internal Jugular Vein, by Dr. J. F.
McKernon ; Case of Sinus Thrombosis Following Removal
of Granulations from the Middle Ear, Excision of Internal
Jugular Vein, by Dr. E. B. Dench.
Society Meetings for the Coming Week:
Monday, April 6th.— German Medical Society of the City
of New York ; Utica, N. Y., Medical Library Associa-
tion; Niagara Falls, N. Y., Academy of Medicine;
Practitioners' Club, Newark, N. J. ; Hartford, Conn.,
Medical Society.
TuESD.\Y, April yth. — New York Academy of Medicine
(Section in Dermatology) ; New York Neurological
Society; Buffalo Academy of Medicine (Section in
Surgery); Ogdensburgh, N. Y.. Medical Association:
Syracuse, N. Y., Academy of Medicine: Hudson
Countj', N. J.. Medical Association (Jersey City) ;
Medical Association of Troy, N. Y., and Vicinity; Hor-
nellsville, N. Y., Medical and Surgical Association
(annual); Long Island, N. Y.. Medical Society;
Bridgeport, Conn., Medical Association.
Wednesday, April 8th.— New York Pathological Society;
New York Surgical Society ; Medical Society of the
Borough of the Bronx ; Alumni Association of the City
Hospital, New York ; Brooklyn Medical and Pharma-
ceutical Association; Medical Society of the County of
Richmond, N. Y.
Thursday, April gth. — New York Academy of Medicine
(Section in Pediatrics) ; Brooklyn Patiiological So-
ciety; Blackwell Medical Society of Rochester, N. Y. ;
Jenkins Medical Association, Yonkers, N. Y.
Friday, April loth. — New York .Academy of Medicine
(Section in Otology) ; New York Society of Derma-
tology and Genitourinary Surgery; Eastern Medical
Society of the City of New York ; Saratoga Springs,
N. Y., Medical Society.
Saturday, April ////;.— Therapeutic Club. New York.
April 4, 190S.J
PITH OF CURRENT LITERATURE.
655
|it| of Cnmnt f itfraturt.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
March 26, 1908.
1. Dental Cases as a Factor in the .^^tiology of Other
Diseases, By Lawrence \V. Baker.
2. The People's Disease: How to Prevent It,
• By William R. Woodbury.
3. Idiopathic Dilatation of the Colon, with Report of a
Case in a Man of Fifty-six, By Emil H. Stone.
4. Notes on X Light, By William Rollins.
I, 2. Dental Caries. — Baker reminds us that
diseased teeth are a cause of other diseases of the
human body, and that the control of these dental
diseases is a factor in preventive medicine, worthy
of attention. Citing authorities on this question and
illustrating it by cases, the author concludes that
dental caries is the most prevalent disease that at-
tacks man, and is a preeminent factor in the causa-
tion of other diseases in the human body. This
initial disease is the cause of great physical suffer-
ing, to check which many millions of dollars are
annually spent in this country. Thus, to prevent
dental caries would be a great financial saving and a
very great step in preventive medicine. Since this
disease is a problem of the civilized world, it should
be further investigated ; and to aid investigation
money should be provided to secure the most emi-
nent men in research work. In the present state of
scientific knowledge, the most adequate means of
combating dental caries and oral sepsis is by the en-
forcement of hygienic measures. In order to make
his hygienic fight successful, the physician and the
surgeon should cooperate with the dental practi-
tioner, for this branch of hygiene requires a thor-
ough knowledge of the teeth and their adjacent tis-
sues. Skilled dentists, therefore, should be placed
upon the various hospital staffs to treat this infected
area which so materially hinders both surgical and
medical treatment. Dentists should give the nurses
instruction in the hygienic care of the teeth. Dentists
should also be placed upon the staff' of medical in-
spection of the public schools, for the condition of
the child's mouth is just as important to its health
as the condition of its throat and nose. — Dr. \\'ood-
bury is in favor of a movement which would create
in Boston an organization that would help encour-
age and promote better care of the teeth by : i. Put-
ting into wider circulation the leaflet on the Care
and Use of the Teeth. 2. Furnishing literature on
dental hygiene, and information and assistance in
promoting the cause. 3. Providing popular exhibi-
tions— charts, photographs, instructions, literature
— for settlements, schools, and institutions. 4. Giv-
ing practical talks on the care of the teeth, and pop-
ular and timely articles to the newspapers, country
and city. 5. Providing lists of registered skilled
dentists who will work for nominal fees for deserv-
ing and worthy persons. 6. Discouraging the sale
and use of dental preparations injurious to the
teeth.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
March 28, 1908.
1. Importance of Ocular Lesions and Symptoms,
By Edward Jackson.
2. Infant Mortality m the Summer ' Months. Methods
Adopted at Yonkers for Its Reduction and the Re-
sults, By S. E. Getty.
3. Adiposis Dolorosa, By Julius B Fraxkenheimer.
4. Epididymitis and Orchitis Complicating Typhoid,
By John Gillespie Beardslev.
5. Foreign Bodies in the Larynx. By F. E. Fkaxghere.
6. Using the X Ray Without Burning,
By Albert C. Geyser ; Addendum by Bexjamix P. Riley.
7. Treatment of Diffuse Suppurative Peritonitis,
By Stuart McGuire.
8. Mixed Xarcosis, By James T. Gwathmey.
9. A Suggestive Plan for a Modern General Metropolitan
Hospital of Five Hundred Beds.
By Bayard Holmes.
10. Xerve Bridging. Report of One Successful Case,
By Alfred S. Taylor.
2. Infant Mortality in the Summer Months. —
Getty states that the problem of reducing infant mor-
tality from digestive diseases in cities can be summed
up in a few words. Clean milk, properly propor-
tioned, for those infants and young children who
cannot be fed on the breast, and intelligent care and
feeding by the physicians and parents. To produce
these results he suggests the following as the neces-
sary means: i. Rigid State or municipal inspection
of all milk from the producer to the consumer. 2.
!Milk dispensaries properly to modify clean milk in
feeding bottles ready for use. The milk may be pas-
teurized if it is to be used in the tenements. 3. Cam-
paign of education to instruct both physicians and
parents in the art of infant feeding and urge on the
officials the necessity and economic. value of clean
milk. 4. Employment of trained nurses in the sum-
mer months to follow up cases of digestive disturb-
ances in infants and to aid physicians in their work.
5. The continued improvement of tenement houses
so that the dwellers may have the benefits of proper
sanitation and plenty of fresh air and sunlight.
4. Epididymitis and Orchitis Complicating
Typhoid. — Beardsley observes that epididymitis
or orchitis, occurring during typhoid fever or dur-
ing the convalescence from this disease, are com-
paratively rare complications, and in the majority of
cases are due to infection by Eberth's bacillus. These
complications may be caused by other ptis produc-
ing bacteria, but this is unusual. The conditions
may also be caused by phlebitis and thrombosis of
the testicular veins, the aetiological factor being the
same (Bacillus typhosus). These complications
may occur during the course of the disease, but they
are far more likely to occur during convalescence.
Although the lesion, as a rule, is unilateral, it may
be bilateral, and it may involve either the epididymis
or testicle, or both, and not infrequently the cord
as well. Eff'usion into the tunica vaginalis testis
is seen occasionally, and there may be a urethritis
with urethral discharge. Localized necrosis and
suppuration, with extrusion of the testicular sub-
stance, is an uncommon termination, the usual
termination being resolution, in a week to ten days.
5. Foreign Bodies in the Larynx. — Franchere
deducts from his observations that in every case of
aphonia search for a foreign body should be insti-
tuted. There is great variation in the symptoms
and pathological results of foreign bodies in the
larynx. A careful report of every such case should
be made for the next few years, in order that a
more extensive literature on the subject may be
built up. The great majority of laryngeal forceps
now in use are ill adapted for the uses to which they
are to be put. Laryngotomy is a safer and more
conservative procedure in the hands of a competent
656
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
surgeon, in many cases, than bungling attempts on
the part of an inexperienced laryngologist to re-
move a foreign body by way of the mouth with im-
perfect instruments and technique.
7. Treatment of Diffuse Suppurative Periton-
itis.— McGuire says that the bodv of the patient
.should be elevated to an angle of 50 degrees to per-
mit gravit\ drainage of the flanks. To accomplish
this there are two princii)Ies in practice, angulation
of the patient and angulation of the bed. The dis-
advantages of the semi-sittinti' position are: (i) It
makes it difficult for the nurse to place the bedpan
properly : (2) it is unnatural and subjects the patient
to mental and muscular tension; (3) he will slip
down when relaxed by weakness or sleep, so that
his body will bend at the costal arch and his abdo-
men will be on a plane parallel with the surface of
the bed. To prevent the tendency to assume this
false position some surgeons use axillary straps at-
tached to the shoulder rest ; some a double inclined
plane to support the legs ; and others go so far as to
elevate the foot of the bed. None of these methods,
however, satisfactorily corrects the trouble. The
advantages of elevating the head of the bed are : ( i )
The mattress may be put at any angle; (2) the pa-
tient lies on a flat surface, often unconscious of his
position; and (-3) he is completely relaxed and easi-
ly nursed. The difficulty experienced in managing
this position has been to get a simple device for rais-
ing or lowering the head of the bed, and to devise a
means to prevent the patient from sliding down the
incline. The author describes his method. The bed
elevator consists of a wooden base and upright piece.
There are a number of notches on the side of the
upright, into which fits an iron link which supports
a block to receive the leg of the bed. The link, when
horizontal, slips up or down, but when oblique fits
into a notch, just as does the lock of an ordinarv
needle holder. The bed seat consists of a board
which, either bare or padded with a pillow, makes a
shelf on which the patient sits. A wooden shaft pro-
jects downward and passes through a second board
which rests against the footpiece of the bed. In the
shaft are a number of holes, and a peg placed in one
of them will prevent the shaft from passing through
the bottom board, and thus transfer the weight of
the patient to the foot of the bed. The advantages
of the bed seat over a hammock or swing are its
rigidity and consequent sense of security given the
patient ; the ease with which it can be removed and
replaced by the nurse when it is found necessary to
do so ; and also by the fact that there are no straps
or ropes on either side of the patient's head or body
to embarrass the nurse or alarm the relatives. Both
of the devices described can be made by any carpen-
ter at a cost of a few dollars, and will securely main-
tain the patient at any angle for any time without
discomfort.
10. Nerve Bridging. — Taylor thinks that the
literature of nerve surgery is not well indexed : case
reports give results in very general terms, often be-
cause of the difficulty of tracing cases and making
systematic examinations over the long periods of
time necessary. Much experimental work is still
necessary to determine the best technique for the
solution of the various problems in nerve surgery.
Nerve defects can be bridged. Judging from the
material at hand, suture 0 distance offers the sim-
plest and most successful method. The younger the
patient and the better the general condition, the more
hopeful is the result. Results come only a long time
after operation, and depend for completeness on
massage, passive motion, electricity, etc. Probabili-
ties are against the bridging of gaps greater than
4 cm., although a few cases are reported. For de-
fects larger than 4 cm. resection of bone or lateral
implantation of nerve ends may be used. Good
muscle power with bone deformity in an extremity-
is much to be preferred to complete or serious
paralysis.
MEDICAL RECORD.
March 38. 1908.
T. Grave Chorea and Its Relation to Septicnemia.
By B. S.\CHS.
2. Theoretic Considerations Relative to Immunization Iiy
Means of the Tubercle Bacillus and Its Products.
By WiLLARD J. Stone and E. C. I. Miller.
3. How Much Gynaecology and Abdominal Surgery
Should the General Practitioner of Medicine Know?
By W. A. Newman Borland.
4. The Diagnosis and Treatment of the More Common
Diseases of the Skin,
By Edmund Ltndley Cocks.
5. A Rational Method of Treatment in Chronic Endo-
metritis. By Joseph M. Rector.
6. Examples of Chronic Productive Inflammations in
Early tife, By Rolfe Floyd.
I. Grave Chorea and Its Relation to Septi-
caemia.— Sachs is of the opinion that the search
for a single specific organism as the cause of chorea
is fruitless, and in vie\v of what has already been
discovered, entirely illogical. Some forms of chorea
are evidently the expression of an acute general in-
fection. There may be a number of different mi-
crobic agents giving rise to this condition, but it
seems reasonable to suppose that certain bacteria
have a special predilection for the motor neurones,
while others exert their baneful influence over the
sensory elements of the central and peripheral nerv-
ous system. The infection may be due directly to
those microorganisms or to a toxine formed by
them. The author thinks that the microbic origin
of the septicemic chorea has been established. The
study of tox;emia and of general infection looms up
big in the future study, not only of chorea, but of
syphilis of the general nervous system, in the stu'd\-
of meningitis as well as in the researches now in pro-
gress on acute anterior poliomyelitis. The prog-
nosis of septicsemic chorea would seem to be ex-
tremely grave, but he is not willing to believe that
every such case must necessarily prove fatal. As
far as the treatment is concerned, it has been un-
availing to the present time. Salicylates, sedatives,
hypnotics, and the usual forms of hydriatric treat-
ment have been employed. The good results that
have been obtained in other severely toxic and in-
fectious disorders by the use of appropriate anti-
toxines, leaves us sotne hope for the future. Mean-
while we nuist endeavor to eliminate, if ]>ossible,
toxic products circulating in the body.
5. A Rational Method of Treatment in Chronic
Endometritis. — Rector places his i)atient in the
dorsal position and the disijersing (positive) elec-
trode uiK)n the abdomen, a speculum is inserted in
the vagina, with its blades gciiefously separateil.
This brings into view the servix and the adjacent
April 4, 1908.]
PITH OF CURRENT LITERATURE.
657
parts. The active (negative) electrode is intro-
duced into the uterus and a constant current of five
to fifteen niilhamperes turned on. Stronger cur-
rents are not to be used, for fear of the soft lique-
faction and stricture which may follow its caustic
action. The surrounding muscular tissue softens,
by reason of abstraction of water from the tissues,
bubbles of hydrogen gas will be seen issuing from
the OS uteri, and a copious watery or mucoid dis-
charge flows readily from about the now loosened
electrode. After an application of five to ten min-
utes the sounds are removed, and the irrigator,
which is also an electrode, is inserted in their place.
While the current is still passing the cleansing solu-
tion is allowed to flow. Upon withdrawal of the
irrigator, the canal will be found softened, patulous,
and free from discharge. The dilatation will re-
main a sufficient length of time to allow any addi-
tional application to be made to the cavity of either
uterus or cervix and without any muscular interfer-
ence. But the source of supply and class of cur-
rent must be perfect and absolutely under control,
positively free from any interruptions of current,
sudden stoppage, or increased milliamperage. The
milliami>ere meter must register accurately the
amount and constancy of the current passing. The
wires, binding posts, and electrodes must be prop-
erly insulated. The current must not be turned on
until the electrode is in position, and must then be
raised slowly to the required strength. The cur-
rent must be slowly reduced before the electrode
is removed. These precautions are advised because
of the adverse mental effect that any disturbance will
have upon the apprehensive patient. If the woman
suffers any ccHisiderable amount of pain, burning
sensation, or sudden electric shock, she will become
frightfully nervous and insist upon ending the treat-
ment, in begiiniing the dilatation, the size of
the uterine electrode is selected which will readily
pass into the canal without giving any pain ; in the
same gentle manner and with the same aseptic pre-
cautions as one would pass a uterine sound for diag-
nostic purposes. The electrode, which is best made
of copper, and properly insulated, is passed onward
until the collar which marks the beginning of the
insulation presses against the external os. . The
length of the exposed electrode is shorter than the
canal, as he has found that when the ti]) '"f the
electrode rests against the fundus of the uterus, the
patient often experiences a disagreeable ( temporary)
attack of painful uterine contractions. As tlie canal
gradually dilates and softens, electrodes nf increas-
ing size are used, until the entire canal i> sufficient-
ly dilated to admit freely the irrigating electrofle.
As soon as the irrigator is in proper position and the
desired current is passing, the cleansing fluid is al-
lowed to flow and freely wash the active mucous
surface. One half to one per cent, solution of the
tincture of iodine acts best as such cleansing agent.
BRITISH MEDICAL JOURNAL.
March 14, 1908.
1. The Treatment of Pneinnonia, By S. West.
2. The Diagnosis of Organic from Functional Affections
of the Nervous System (Purvis Oration"),
By J. S. R. Russell.
3. Some of the Commoner Symptoms of Cerebellar Ab-
scess, By W. Trotter.
4. The Colony and Bromide Treatment of Epilepsy,
By A. J. McCallum.
5. A Case of Hysterical Somnambulism Showing Abnor-
mal Acuity of Vision in the Somnambulistic State,
By J. W. Russell.
6. A Case of Merycism, By H. F. L. Taylor.
3. Cerebellar Abscess. — Trotter's paper is
based on the study of two cases of cerebellar ab-
scess recently under his care. Cerebellar abscess
may produce (i) general evidences of an infective
process, (2) evidences of a lesion in the substance
of the brain, spreading with variable rapidity, but
as a rule subacutely, (3) evidences of a lesion in the
lateral lobe of the cerebellum. 1. General evidences
of infection. When the case is seen from the be-
ginning there will practically always be a period of
onset, during which the symptoms are those of arr
acute infective process — chill, high fever, headache,
loss of appetite, and wasting. There may be no
evidence calling attention to the brain, and occa-
sionally the patient may succumb in this stage with-
out any suspicion of the seat of the disease having
been aroused. This septicasmic type is the rarest
and most puzzling of the clinical forms under which
cerebellar abscess presents itself, and almost always
escapes diagnosis. Like other infective processes
elsewhere, suppuration in the brain is apt to undergo
a spontaneous arrest or quiescence after the acute
onset. Thus arises a second important clinical type
— the latent abscess. Usually, however, some evi-
dence or other of impairment of function will be
present. The clinical behavior of these cases is very
similar to that of pneumonia followed by empyema.
2. General cerebral signs. The three familiar signs
of increasing intracranial tension are optic neuritis,
vomiting, and headache. Of these, optic neuritis is
the most significant when it is present, but it is
often absent in cases of abscess, so that its absence
is of no diagnostic significance. Vomiting is a much
more common symptom, so that its complete absence
throughout would be distinct evidence against cere-
bellar abscess. The headache is by far most com-
monly occipital and practically never lateral, so that
the substitution of occipital headache for the lateral
headache so common in acute mastoid disease should
lead to the suspicion of the development of intra-
cranial suppuration. Giddiness is a sign both of
intracranial pressure and of cerebellar disease, but
in cerebellar disease objects during the attack seem
to always move in a definite direction. Causeless
wasting is also suggestive. The mental state is one
of the most important of this group of symptoms.
All stages of impairment of consciousness, from
the slightest to profound coma, may be seen, the
latter, however, usually only in very advanced cases
or in the very ^cute fulminating varieties. The
earliest change is a very slight dullness — a disap-
pearance of spontaneity. But as long as the patient
can respond, the intelligence is quite normal. It is
unusual for any true delirium or confusion to de-
velop. 3. Localizing cerebellar signs. This is the
most important group of signs, as they may be
present in latent cases when the first two groups
may be absent. They may be divided into extrinsic
signs, due to the involvement of the structures out-
side the cerebellum, and intrinsic, due to the involve-
ment of the cerebellum itself. Among the struc-
658
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
tures the involvement of which produce the extrinsic
signs are the fifth and sixth cranial nerves, with
corresponding changes in the area of the trigeminal
and paresis of the external rectus on the same side
as the abscess. The latter is the commonest isolated
sign of cranial nerve involvement in cerebellar
lesions, but its diagnostic value is small, as it is not
uncommon in acute mastoiditis. Pressure on the
pons and bulb may cause hemiplegic exaggeration
of the reflexes, etc. The intrinsic signs or motor
effects of a cerebellar abscess may be classified as
follows: I. Ocular signs. Nystagmus, weakness of
conjugate movements, skew deviation. 2. Signs
affecting the limbs. Incoordination, paresis, hypo-
tonicity. In cerebellar abscess, as in any case of
increasing intracranial tension in the posterior fossa,
the need for operation is urgent, quite as much so
as in perforated gastric ulcer or ruptured spleen.
4. Epilepsy. — McCallum holds that epilepsy
must be regarded as the result of a disease or the
perpetuated sequel of one, a vicious habit of brain
having been established. For practical purposes the
so called predisposing causes may be ignored. In
the writer's experience the only constant factor in
infantile convulsions has been the evidence of pain
and unrest. Pain and nerve tension seem to so dis-
turb cerebral harmony that there is a furious out-
burst of energy, giving rise to a display of sensory,
vasomotor, and motor function constituting the fit.
The fit is so obviously an outcome of cortex func-
tion that idiopathic epilepsy is usually regarded as a
disease of that area. Add to this the fact that epi-
lepsy lasts for years, is \ery prevalent, and has been
w^idely studied by pathologists, yet no constant,
unvarying condition has been found. The author
holds that only two factors are necessary for epilepsy
— healthy brain and sufficient stimulation. A healthy
brain bursts out into fury owing to its overstimula-
tion by sensory impressions poured into it from one
or more varying sensory areas, the pain and tension
of teething acting like the electric stimulation of
■experimental observation. The brain gets teased,
less tolerant, almost vicious in its habits, so that it
will reply, long after teething has passed away, to
other sensory disturbances with an epileptic fit.
Epilepsy thus becomes a reflex act in its origin and
a cerebral vice in its fuller development and per-
petuation. The treatment of epilepsy is to remove
the cause where this can be done, and where it
cannot, to render it inoperative. Some patients are
hopeless — developmental cases, those arising in im-
beciles, in the microcephalic, in inoperable tumor
cases, and probably the confirmed epileptic. But
peripheral, traumatic, emotional, and toxic causes
give rise to about sixty to seventv per cent, of all
cases in childhood and youth, and are curable if
treated early and long enough. P>romide treatment
is necessary and curative in these cases. Epilepsy
being due to severe, prolonged, or repeated sensory
stimulation of the brain, that amount of bromide
must be used that is necessary to stop the sensory
stimulation. The amount in boys varies from 60 to
130 grains a day. Larger doses interfere with the
equilibrium, swallowing, and, organic reflexes. The
toxic action of potassium salts on the heart is prob-
ably a myth ; it is the bromide that is harmful.
Pirnmidc rashes may be ignored. In the few cases
due to absorption of toxic products from overeating,
from unsuitable food, or from constipation, diet is
of importance, but for the bulk of the cases diet may
be summed up in : Three meals a day, everything
fresh, everything limited, and meat not oftener than
once a day, three times a week being ample.
LANCET
March 14, 1908.
1. The Surgery of the Spinal Cord and Its Membranes
(Hunterian Lecture, II), By D. S. Armour.
2. The Clinical Symptoms of the Cases of Epidemic Cere-
brospinal Meningitis Admitted to Belvidere Fever
Hospital, Glasgow, During the Recent Epidemic,
Together with a Short History of the Disease in
Scotland, By W. Dow.
3. A Remarkable Case of Persistent Ingestion of Needles
and Their Removal from Different Parts of the
Body, Especially from the Organs of the Abdominal
Cavity, by Laparotomy Several Times Repeated,
By A. NicoLL.
4. A Study of Five Cases of Appendicostomy,
By J. L. Stretton.
5. Congenital Hypertrophic Stenosis of the Pyloris and Its
Medical Treatment, By G. Carpenter.
6. A Suggestion for Treatment in Delayed Chloroform
Poisoning, By A. P. Beddard.
7. A Case of Cystic Disease of the Maxillary Antrum,
By R. Lake.
8. Lymphangeioplasty : A New Method for the Relief of
the Brawny Arm of Breast Cancer, and for Similar
Conditions of Lymphatic CEdema,
By W. S. Handley.
9. Portal Obstruction without External Evidences of
Portal Caval Anastomosis : Its Prognostic Sig-
nificance, By G. H. C. Lumsden.
10. Note on a Case of Compound Depressed Fracture of
the Vault of the Skull : Operation and Recovery.
By H. R. Beale.
I. Surgery of the Spinal Cord. — Armour, in
his second Hunterian lecture, divides cases of in-
jury to the vertebral column into two main classes —
those in which the functions of the spinal cord are
not interfered with and those in which there is more
or less interference with the ftmctions of the spinal
cord, with or without obvious injury to the vertebral
column. The qtiestions that arise in discussing the
subject of operation in cases of fracture-dislocation
of the spinal cord are, in order of importance :
I. Will any benefit to the patient result from the
operation? 2. Will his life be endangered by the
operation ? 3. Will he be made worse as a result
of the operation? It is essential, in order that an
operation should be perfectly successful : ( i ) To
remove enough laminae to be absolutely sure that
there is no remaining pressure on the cord; (2) to
remove any projecting bone, whether it be a portion
of the vertebral bodies or one or more articular
processes ; (3) to remove all blood clots, even though
laminae of unaffected vertebrae have to be removed
to do so; (4) to open the dura mater to ascertain
definitely the condition of the cord; and (5) to see
that the cord dilates to its full extent again, and that
pulsation returns (this is only possible where the
cord has not been completely destroyed). The
operation may be expected to relieve pressure, or,
at any rate, remove any doubt as to whether con-
tinued pressure exists. Degeneration as a result of
pressure appears within four days. If the spinal
cord be not completely destroyed, continued pressure
may succeed in completing its destruction. There-
fore, operation is indicated (i) to relieve pressure
April 4, 1908.]
PITH OF CURRENT LITERATURE.
659
from depressed or displaced fragments of bone; (2)
to relieve pressure from blood clot or from extensive
haemorrhage, either extradural or intradural; (3) to
relieve pressure and to prevent further destruction
from oedema by enlarging the constricted bony
canal; and (4) to remove the future danger of
pressure from exudate and inflammatory thickening.
No operation will restore a cord in which complete
transverse section has taken place. But there are
tio symptoms by which we can in a reasonable time
determine beyond a doubt the presence of a complete
transverse section of the spinal cord. So that we
should feel compelled to give the patient the benefit
of an operation which does not endanger his life,
but which does lessen his pain.
6. Delayed Chloroform Poisoning. — Beddard
is inclined to favor Rosenfeld's view as to the nature
of delayed chloroform poisoning. He believes that
when cells are poisoned by chloroform their metab-
olism is so altered that whilst they can utilize
carbohydrates well they can oxidize proteids but
imperfectly and fats even less well. Consequently
as soon as the cells have used up their meagre store
of carbohydrate, their hungry condition causes a
"breaking down of tissue proteid and a transfer of
fat to them ; but since neither of these foodstuffs,
and especially the fat, is properly utilized, the cells
remain in a condition of severe starvation which
may rapidly lead to their death through lack of
energy. But if an animal poisoned with chloroform
is fed with dextrose, the transfer of fat is prevented
because it is no longer necessary, and recovery is
much more likely to take place than when the
animal is starved. Feeding with carbohydrates does
not prevent the poison from damaging the cells, but
it does provide the cells with the source of energy
which they can most easily utilize, and may prevent
their dying from acute inanition and so give them
time in which to recover. The writer therefore
suggests that patients suffering with delayed chloro-
form poisoning be fed with dextrose — either by
mouth, by continuous rectal infusion, or even by
intravenous infusion of a six per cent, solution.
8. Lymphangeioplasty." — Handley states that
among the complications of breast cancer none is
more terrible than the brawny swelling of the arm
coming on in the later stages of the disease. The
pain is so excruciating that amputation has been
performed for its relief. It is in all probability due
to a destruction of the lymphovascular system of
the arm. Bearing this in mind the author, having
such a case under his care, introduced into the sub-
cutaneous tissue of the swollen arm a number of
Juried silk threads, running longitudinally upwards
from the wrist to terminate in the loose and healthy
areolar tissue in or beyond the axilla, and spaced
out at convenient intervals around the limb. The
operation was analogous to the drainage of a
marshy field by means of buried pipes ; for stout
silk threads, if not under tension, remain unab-
sorbed for some years, and the absence of organiza-
tion and coagulation in their interior insure the
retention of their capillary power. The result was
immediately beneficial, the swelling going down,
the pain disappearing, and the power of motion
returning. In another similar case the same results
were obtained.
LA PRESSE MEDICALE,
March 7, 1908.
1. The Liver in Diseases of the Kidney. Study of Ex-
perimental Lesions,
By Leon Bernh.\rd and L. Laederich.
2. Pyocyanasis in Therapeutics, By R. Rom me.
I. The Liver in Diseases of the Kidney. —
Bernhard and Laederich state as the result of a
series of experiments that, i, sudden and absolute
suppression of the renal function, by bilateral ne-
phrectomy, ligature of both ureters, or total necrosis
of the kidneys, produces in the liver a congestion,
usually intense, resulting in an extravasation of
blood corpuscles or in the formation of little hsemor-
rhagic foci, habitually generalized about the ves-
sels, but frequently presenting its maximum of in-
tensity in the centre of the lobule. The intracapil-
lary leucocytosis is very marked. The cellular mod-
ifications are various. Some cells have a grumous
appearance due to the condensation of the pro-
toplasm. The glycogen has disappeared, and con-
sequently the protoplasmic granulations, larger than
usual, are conglomerated and mask the cytoplasmic
reticulum. Other cells show vacuolization. These
cellular modifications change the appearance of the
lobules. 2, Partial suppression of the renal func-
tions by nephrectomy, ligature of one ureter, or by
the direct production of a nephritis, produces an en-
tirely different set of changes in the liver. Hyper-
trophy of the liver is frequent, at times considerable,
due to the multiplication of cells. Under the mi-
croscope the hepatic cell presents an aspect which
the authors have denominated etat clair, a clear
state, which they find to be constant, sometimes
generalized in all the cells, sometimes localized in a
portion of a lobule. The conclusion from these ex-
periments is that renal insufficiency may induce cer-
tain lesions in the liver, and is to be looked upon as
the true cause of complex lesions of that organ
which are to be observed following renal disease in
man.
March 11, igo8.
The Previous Condition in the Victims of Railroad Acci-
dents, By V. Balthaz.^rd.
BERLINER KLINISCHE WOCH ENSCH Rl FT.
March 2, 1908.
1. A Skeleton of the Thorax for the Purpose of Demon-
stration of the Position of the Levels of the Valves
of the Heart, By H. Virchow^.
2. Concerning an Aneurysm of the Ascending Aorta
Fixed in Situ, By H. Virchow.
3. Traumatic Appendicitis, By Adolf Ebner.
4. Concerning Gummatous Disease of Both Nuclei Cau-
dati, By Campbell.
5. Use of von Pirquet's Method for Diagnosis of Glan-
ders in Man, By H. Martel.
6. The Question of Myeloid Leuchaemia,
By Heinrich Lehndorf and Emil Zak.
7. Concerning the Development of Balneology During the
Past Decade, By Frankenhaser.
8. The Discussion Concerning the Cutaneous and Con-
junctival Tuberculin Reaction, By C. von Pirquet.
9. Reply to von Pirquet's Article, By A. Wolff-Eisner.
I. Position of the Valves of the Heart. — Vir-
chow says that the pulmonary valve is at the level
of the third cartilage, the aortic at the level of the
upper border of the fourth cartilage, the mitral at
the level of the lower border of the fourth cartilage,
and the tricuspid at the level of the end of the fifth
66o
intercostal space at the margin of the sternum. The
tricuspid is in the mesial plane, the pulmonary 25
mm. to the left, the aortic almost exactly in the
mesial plane, the mitral 37 mm. to the left. The
pulmonary is situated 40 mm. from the anterior
surface of the thorax (not the skin), the tricuspid
45 mm., the aortic 55 mm., and the mitral 85 mm.
rhese measurements and levels apply to the middle
]X)ints of each valve mentioned ; the measurements
and levels of other parts of the valves, as well as
of other parts of the heart, such as the ssepta between
the auricles and the ventricles, the Eustachian valve,
the opening of the sinus venosus, etc., together with
the positions of the various parts, are carefully
worked out.
2. Aneurysm of the Ascending Aorta. — Vir-
chow describes in minute detail a specimen of
aneurysm of the aorta which began at the aortic
valves, so as to involve the sinus of Valsalva, and
was so extensive that the innominate and left carotid
arose from it, while the left subclavian arose from
the aorta beyond the aneurysm. At the left end
of the aneurysm there was a sharp angle in its lower
wall.
3. Traumatic Appendicitis. — Ebner reports a
case in which symptoms of appendicitis followed a
contusion of the abdomen. Operation two months
later revealed an abscess cavity containing a fjecal
concretion which was removed. The author con-
siders that in this case the contusion of the abdomen
was the actuating cause of the inflammation of the
appendix, to which the latter was predisposed by the
presence of the fjecal concretion.
4. Gummatous Disease of Both Nuclei Cau-
dati. — Campbell describes the case of a man,
twenty-two years of age, who came under his ob-
servation with a siibnormal temperature, a small
pulse, 50 to 90 per minute, scarcely to be felt. He
lay still in bed, hardly spoke of his own accord,
showed no interest in his surroundings, appeared
stupid, and had no control over his urine and faecal
movements. Finally he was attacked with broncho-
]>neumonia and died. Autopsy showed that both
nuclei caudati had l)een destroyed by gummata.
This case shows that lesions of the nuclei caudati do
not produce paralysis, affect the reflexes, or the
sensation of pain. The other perceptive qualities of
the skin could not be ascertained because of the
mental condition of the patient, but the impression
was given that no disturbance of this kind was
present.
5. Pirquet's Method for Diagnosis of Glan-
ders.— M artel reports first the case of liimself, in-
fected with glanders in 1894, and reaction obtained
from mallcin applied to cutaneous ulcers, though no
reaction was obtained in ten control persons, the
skin of whom was scarified and mallein applied.
Tlien follow several other cases during the past year
in which mallein has obtained a distinct reaction in
ca.ses of glanders, though not in the controls. In
one case a positive reaction was obtained l)v means
of mallein through the conjunctiva.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT.
March 10, 1908.
1. Concerning the Behavior of the Heart .\ftcr a I.on.^
Continued and Strenuous Wheeling,
By DiETi.EN and Mokitz,
[New York
Medical Journm..
2. Studies Concerning the Resorption of Fat in Infants,
By SCHELBLE
3. Studies of Opsonines, By Much.
4. Concerning the Bactericide and Haemolytic Efficiency
of the Material of Leucocytes and Blood Plaques,
and of CEdema Lymph and Vessel Lymph,
By Schneider.
5. The Method of Complement Union,
By LoDER and B.\llnek.
6. Skin Reaction .\fter Inoculation with Diphtheria
Toxine, By Schick.
7. Concerning the Clinical Importance of the Difference
Between the Temperatures in the Rectum and the
Axilla, Particularly in Peritonitis, By Propping.
8. Lumiere's Color Photography and Its Use for Clinical
Demonstration, Bj' Wilms and Eggenberger.
9. Concerning Cholesterine Exudates in the Pleura! Cav-
ities, By RUPPERT.
10. A Sarcoma in a Stump Twenty Years After Ampu-
tation, By C.'VP.^LDi.
11. Extensive Avulsion of the Mesentery in Abdominal
Contusions, By Autenrieth.
1.2. A New Medicine Glass. By SxRiiBE.
13. Concerning the Fulguration of Cancer. By Gorl.
14. The History of the Discovery of Zymase, By H.\hn.
15. Comparative Studies Concerning the Diagnosis of
Typhoid Fever by Means of Bacilli Emulsion and
Ficker's Diagnosticum. By L.\nd.m.\nn.
16. Obituary of Alphons Laveran, By Marti.\l.
17. The Suaheli Physician, By Krauss.
I. Behavior of the Heart After Long Con-
tinued and Strenuous Wheeling. — Dietlen and
Moritz state as the result of their investigations
that they did not find a single case of dilatation of
the heart ascribable to this cause, but that the hearts
of wheelmen showed a tendency to diminution after
an excessive strain, or, in practiced riders, after an
unusual and exiiausting tour. This tendency dif-
fered in degree in different persons, but seemed to
be present in all. In many cases this acute diminu-
tion did not a])pear at once, but gradually, after
the elapse of hours or days.
4. Bactericide and Haemolytic Efficiency of
the Material in Leucocytes and Blood Plaques
and of Lymph. — Schneider sums u]) hi,-^ conclu-
sions in the following manner : The leucocytes with
polymorphic nuclei contain bactericide material,
which they can excrete in vitro or during life un-
der the influence of certain stimulations. These
"leucins" are not identical with the alexins circulat-
ing in the blood. They belong rather as material
sni generis to the natural antibacterial protection a])-
paratus of the animal organism, together with the
alexin of the blood and the phagocytes. The bac-
tericide action of the lymph in inflammatory cedenia
rests in great part upon extracellular leucocyte ma-
terial, while the vessel lymph contains alexin. The
haemolytic action of the extract of the lymphatic
glands is to be ascribed to other material than that
which produces the haemolytic action of the blood.
The blood plaques do not coine into consideration
as distributors of alexin.
6. Skin Reaction After Inoculation with Diph-
theria Toxine. — Schick has show n tiiat the human
skin reacts to the inoculation of diphtheria toxine :
he asserts to have shown that the reaction is spe-
cific ; he hopes to obtain in this way an e.xact and
rational dosage of the seriun to be used, and thus to
secure an advance in the treatment of that disease.
7. Clinical Importance of the Difference Be-
tween the Temperatures in the Rectum and Ax-
illa.— l'ro])ping says that the abnormally great
difference of temjjerature between the rectum and
PITH OF CURRENT LITERATURE.
April 4, 1908.]
PITH OF CURRENT LITERATURE.
axilla is due to reduced axillary temperature in both
healthy and feverish organisms. The difference of
temperature is inversely proportional to the heat
production in the muscles. The great difference of
temperature is present in all febrile diseases ;' in
peritonitis in about one fourth of the cases at the
height of the disease. The great difference of tem-
perature is of serious prognostic importance in peri-
tonitis.
8. Lumiere's Color Photography. — \\ ilms and
Eggenberger describe the method of color photog-
raphy in detail, including the development and fixa-
tion of the negatives.
9. Cholesterine Exudates in the Pleural Cav-
ity.— Ruppert reports a case in which cholesterine
was present in such quantity in the pleural exudate
as to be noteworthy, and attempts an explanation
of its presence other than a transformation of the
elements of the exudate.
10. Sarcoma in a Stump. — Capaldi reports the
case of a man, fifty-five years of age. whose fore-
arm was amputated in 1886. In February. 1907.
he struck a piece of wood against the stump, and
not long afterward a sarcoma appeared in the scar.
Capaldi does not think the traumatism was re-
sponsible for the appearance of the tumor.
11. Avulsion of the Mesehtery in Abdominal
Contusions. — Autenrieth reports a case of severe
contusion of the abdomen in a child, four and a half
}ears old. Laparotomy was performed because of
the symptoms of internal hjemorrhage. and a verv
extensive laceration and avulsion of the mesentery
was found which necessitated the excision of a con-
siderable portion of the small intestine that had been
deprived of its nutrition. The child recovered.
12. A New^ Medicine Glass. — Striibe has de-
vised a rather complicated glass and tube for the
administration of medicines without injury to the
teeth. It consists of two globular vessels, one large
and one small, each with a tube. 'The tube of the
smaller enters that of the larger, so that fluids com-
ing from the two vessels mingle. The medicine is
supposed to be put in the smaller vessel, while the
larger is filled with some indiff'erent fluid such as
water or milk. The tube is introduced far into the
mouth, when the fluid can be drank without appre-
ciation of the bad taste or injury to the teeth.
THE GLASGOW MEDICAL JOURNAL.
March, igo8.
r. Consumptive Sanatoria: Are They Worth While?
By David Lawson.
z. Case of Injury to the Motor Area of the Brain,
By G. BcRXsiDE Buchaxax.
3. Case of Multiple Exostoses in a Rachitic Subject.
By A. YouxG.
4. Operative Procedures in Relation to Disease of the
Frontal and Sphenoidal Sinuses. By W. S. Svme.
5. Preliminary Note on Quinine Sulphate as a Factor in
the Causation of Blackwater Fever. By D. McCav.
I. Consumptive Sanatoria: Are They Worth
While? — Lawson shows on the base of statisti-
cal material that the fact that eight years after dis-
charge from sanatoria so large a number as seventv-
three per cent, of persons treated were still capable
of work, and of these over sixtv-one per cent, en-
joyed full working capacity, must effectually reftite
the contention of those who assert that the clinical
results of sanatoria do not justify their existence
He then takes up the commercial objection, and cites
the city of Glasgow. There is good reason, says our
author, for stating that not less than 700 males died
of pulmonary consumption in the city of Glasgow in
the year 1906. The average age at which these
deaths took place was roughly thirty-one years, and,
taking the ascertained average wage earning capac-
ity for England and Wales, 30s. per week is a fair
average wage earned by those sufferers when in
good health. Insurance companies inform us that,
dying at thirty-one years, those who then suc-
cumb had their life and rate paying term curtailed
by twenty years. It is thus merely a matter of arith-
metic to ascertain what the mortality from consump-
tion is yearly costing the city of Glasgow in ultimate
wage earning capacity. Calculated on this basis, the
annual loss amounts to over ii, 000.000 sterling. If
it pays insurance companies to preserve their clients'
lives for the premiums they then continue to pay
them when so restored, does it not seem probable
that if — with a view to lessening the enormous an-
nual drain upon her resources, in addition to the
heavy claims made by that section of survivors who,
deprived of their breadwinners, become chargeable
to the poor law rates — the corporation of Glasgow
were to provide one or more consumptive sanatoria,
and maintain them as they do the other infectious
fever hospitals out of the rates, their experience
would prove here, as it has done elsewhere, that such
expenditure is worth while ^
THE JOURNAL OF NERVOUS AND MENTAL DISEASE
March, 1908.
1. A Case of Recurrent Autohypnotic Sleep, Hysterical
Mutism, and Simulated Deafness: Symptomatic Re-
covery with Development of Hynomania.
By Berx.\rd Oettixger.
2. A Xew Diagnostic Sign in Recurrent Laryngeal Paraly-
sis, By Alfred Reginald Allex.
3. A Case of Matricide and Attempted Suicide, with Brief
Psychological Analysis. By W. K. Walker.
4. General Considerations as to the Nature and Relation-
ships of Hysteria, By R. C. Woodman.
4. General Considerations as to the Nature
and Relationships of Hysteria. — W oodman re-
marks that the mechanism of the production of hys-
teria is better known than that of the other mental
disorders. The origin of its salient features in divi-
sions in consciousness has been repeatedly shown.
The cause of its more characteristic symptoms is
found in thought. Few workers seek its cause in
this or that unknown toxine. We can see that it is
functional in the same sense that normal thought is
fimctional, and that we have no more reason to look
for a poison in the system or a change in the struc-
ture of the cells upon some given day, when a patient
has become hysterical, than we have to look for them
after any other change in opinion or point of view.
We believe that some change in the physiological
chemistry of the brain occurs with every thought
and emotion, just as some change accompanies every
movement of a muscle, and the change in hysteria
at the moment of its inception seems purely a mentai
change. This does not alter the fact that mental
stress, whether it be hysterical or not, sets up nutri-
662
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
tive disorders, and secondarily extensive changes in
the tissues and fluids of the body. With the func-
tional nature of hysteria in mind, it is possible to
regard the mental disorders from a new point of
view, and to inquire to what extent they may be
thinking disorders as well, and functional in the
same sense. Our knowledge does not suffice to
answer the question raised, but such a query de-
serves consideration along with the hunt for bac-
terial poisons and cellular degenerations. Perhaps
in this may be found the explanation of the surpris-
ing amount of old knowledge and opinion to be had
from almost any long standing dement, if we can
by any means temporarily overcome his lethargy,
and of the improvement which comes when the
patient's interest can be aroused. It seems in part
at least as if such patients had merely fallen into
bad habits of thought. The recognition of hysteria
as a psychosis the author thinks tends to bridge the
gap which has been allowed to grow between dis-
eases of the body and diseases of the mind, and to
give a wider outlook and a new point of view
from which to regard the other insanities. It makes
it possible to correlate the insanities with what most
physicians in their practice and thought regard as
nervous diseases, and through them the physician
and the patient's friends can come to some conception
of whdt goes on in the insane person's mind, and of
how such insane thoughts can arise and be enter-
tained. It need not be supposed that the hysterical
process is the only one through which mental aber-
rations occur. Rather in the past its role has been
almost totally overlooked. The studies in hysteria
should be applied to the problem of insanity, and
the functional element sought in every mental dis-
order, and its mechanism be made clear if possible,
whether it be hysterical or some other as yet un-
named type of reaction. Thus we may hope to
attack psychically in a rational way the psychic ele-
ment of psychic disease.
NEW YORK ACADEMY OF MEDICINE.
Meeting of February 6, 1908.
The President, Dr. John A. Wyeth, in the Qiair.
This meeting was held under the auspices of the Section in Ob-
Sterics and Gynaecology and was devoted to a review of
RECENT ADVANCES IN OBSTETRICS AND GYN.T:C0L0GV.
The Present Significance of Ghorioepithelioma.
— Dr. James Ewing said that he was firmly con-
vinced that this group of tumors could be sub-
divided and different prognoses established on their
histological structure. Briefly, the conclusion was
reached that chorioepithelioma included three rather
distinct tumors, which were distinguished by their
gross appearance, histological structure, prognosis,
and indications for treatment. Very uncertain and
contradictory opinions were at present maintained
regarding this. In 1895 Marchand pointed out that
there were two types of chorioepithelioma, one typi-
cal, the other atypical. Yet, while Marchand had
stated that the atypical variety, composed chiefly of
giant cells, was comparatively benign, and he and
another author had stated that it was a crime to
remove the uterus for this varietyr because it was-
benign, all writers had not agreed as to the position
of the atypical chorioepithelioma.
The typical choriomata of Marchand had shown
extreme variations in structure and clinical course.
While some had proved very malignant, Schlagen-
haufer in 1899 had pointed out that recovery might
follow after ( i ) spontaneous extrusion of the tumor
from the uterus, (2) removal by curetting, (3) par-
tial removal with the knife. Six cases were on
record in which recovery had followed where pul-
monary metastases were believed to have occurred.
On the other hand, some of these tumors were ex-
cessively malignant, and Schmauch had said that
it was a crime to remove the uterus, because of the
bad results following. Here, then, was a tumor
with which hard words met the ill advised surgeon
who ventured to operate, because it was so benign
and because it was so mahgnant. There were no
histological signs by which the different prognoses
could be determined. Here was a unique situation
in tumor diagnosis, in which there was no relation
between histological structure and prognosis. The
following classification and nomenclature were sug-
gested ;
1. Syncytioma, the atypical chorioma of Mar-
chand. This tumor produced a more or less diffuse
infiltration of the myometrium, or there was a large
intrauterine tumor, leading to marked enlargement
of the uterus, but not tending to perforate the organ
and not giving rise to metastases. Histologically
the tumor was composed of large syncytial wander-
ing cells in the walls of sinuses and in the mus-
culature. Haemorrhage, cachexia, suppuration, and
perforation by the curette might prove fatal. In the
early stages the prognosis was good.
2. Chorioadenoma destruens, malignant placental
polyp. This tumor tended to infiltrate the sinuses
of the uterus, considerably enlarging the organ, but
not splitting it by a compact growth. Metastases
occurred in the kings and vagina, but recovery might
follow, certainly after vaginal metastases or after
partial removal, possibly after pulmonary metastases.
Histologically the growth showed villi.
3. Choriocarcinoma. This tumor was a relatively
small, circumscribed growth in the musculature,
tending rapidly to perforate the uterus without
greatly enlarging it, and to cause local and pulmon-
ary metastases. Histologically villi were absent.
Langans's cells and syncytium were present in
masses. Morphological signs of anaplasia and
malignancy were always marked. The atypical and
diffuse-growth of cells yielded a structure to which
the term carcinoma was commonly applied. Tumors
of this structure were probably always fatal. An
operation sometimes seemed to accelerate their
course. The uterus should be removed as soon as
possible. Infraction of the lines laid down in this
classification might result in inability to determine
the true position of the tumor, from insufficient
curettings, the occurrence of intermediate types of
tumors, or differences in structure in different por-
tions of the same tumor. Dr. Ewing then illustrated
the different types of these tumors by lantern slides.
Recent Advances in Obstetrics. — Dr. Edwin B.
Crac^i.v said that marked advances had been made
along three lines, a better knowledge of obstetric
April 4, 1908.]
PROCEEDINGS OF SOCIETIES.
663
pathology, a better knowledge of the mechanical
problems of delivery, and better procedures. Distinct
advances had been made in the toxaemia of preg-
nancy, as shown, in pernicious vomiting on the one
hand' and eclampsia on the other. In the pernicious
vomiting of pregnancy the chief pathological lesion
was a fatty and dropsical degeneration of the liver,
and, if the' condition existed long enough, the lesions
were practically identical with those of acute yellow
atrophy. There was more or less degeneration of
the .renal epithelium of the convoluted tubules. The
urine contained acetone, diacetic acid, beta oxybu-
tyric acid, indican, and perhaps a trace of albumin
and a few casts. These cases, as a rule, showed a
high amount of ammonia nitrogen, high amido acid
and undetermined nitrogen, and a low urea nitrogen.
The hepatic and nephritic types were recognized
clinically. In the hepatic type, aside from the con-
vulsions, there was vomiting, with little oedema, lit-
tle albumin and casts, often jaundice, tenderness
over the liver, and ascites. In the nephritic there
were headaches, disturbances of vision, high tension
pulse, nervous irritability, marked albuminuria, and
casts. These two types were often combined. In
the livers studied by Dr. Cragin there were three
varieties of lesions. In the nephritic type the cells
near the periphery of the liver showed a moderately
fatty and dropsical degeneration, without necrosis.
In the hepatic type the fatty and dropsical degener-
ation at the periphery of the lobules was very
marked ; the cells had lost their nuclei and were in
fact necrosed cells. There were necrosis at the cen-
tre of the lobule, a zone of fatty and dropsical de-
generation near the periphery, and a few normal cells
at the periphery along the portal vessels. In the
third variet\' there was an area of degeneration of
the liver cells with haemorrhage, the so called haem-
orrhagic hepatitis. The lesion was situated at the
periphery of the lobule. In eclampsia the myocardium
often showed degeneration, and the brain oedema
and haemorrhage. In the nephritic type of eclampsia
two classes of patients were recognized, those who
had previously suffered with nephritis, and in whom
the eclampsia had developed from an acute exacer-
bation of the old trouble, and those whose kidneys
had been previously free from disease. Figures pre-
sented by him showed a marked resemblance be-
tween the hepatic type of eclampsia and the perni-
cious vomiting of pregnancy, i. e., ammonia nitro-
gen, amido acid, and undetermined nitrogen above
normal, and urea nitrogen below normal.
We now had a better knowledge of the mechan-
ical problems of delivery. We recognized earlier
the posterior positions of the vertex and anterior ro-
tation of the occiput was performed by the obstetri-
cian relatively early when Nature failed to accom-
plish this. In pernicious vomiting cases one did
not feel that he had done his duty by his patient un-
less the urine had been examined and the nitrogen
partition determined, and the presence or absence of
acetone, diacetic acid, beta oxybutyric acid, indican.
etc., ascertained. The laboratory findings should be
studied in connection with the clinical picture. In
pernicious vomiting of pregnancy the best results
were obtained by colon irrigations, rectal feeding for
a short time only, and early emptying of the uterus.
Prolonged menorrhagia and metrorrhagia following
labor, abortion, or an operation for hydatidiform
mole should be looked on with suspicion, and early
diagnosis should be made and early hysterectomy
performed in case it was chorioepithelioma, for that
operation alone gave hope. The induction of labor
two weeks before term would often secure a rela-
tively easy and safe birth for a child which other-
wise would be lost. The improved methods of in-
ducing labor at the proper time for a child to pass
the given pelvis, and the low mortality of Caesarean
section, had largely reduced the number of cases in
which craniotomy was considered justifiable. The
operation of pubiotomy was still sub jndice. A well
trained man might repair a lacerated cervix imme-
diately after labor, but a note of warning should be
sounded, that the morbidity if not the mortality of
the patients was markedly increased, and the old
rule for the general practitioner was a good one —
immediate trachelorrhaphy for haemorrhage only.
Advances in Gynaecology. — Dr. Herm.\xx J.
BoLDT presented a paper on this subject Tsee page
527).
The Practical Application of Our Recent
Knowledge in Obstetrics. — Dr. Edward Reyn-
olds, of Boston, read this paper. The methods of
practice which he wished to present were based upon
the belief that the mortality of the Caesarean section
varied greatly in accordance with the period of labor
at which it was performed ; that the mortality of the
section late in labor was too great to permit of its
performance in the interests of the child alone ; that
the maternal mortality of the section performed even
so early as the end of the first stage of labor was
greater than that of an ordinary high forceps opera-
tion or version ; and that the mortality of the section
done at the time of election, in advance of labor or
at its very beginning, the primary section, was so
low that it was a safer operation for both patients
than a difficult high forceps operation or version
when performed for mechanical obstacles. His own
experience with section now comprised thirty cases
without mortality. He divided the operations into
three classes : Those done before labor, or the pri-
mary ; those done early in labor, or the secondary ;
those done late in labor, or late sections. His com-
pleted tables contained 289 cases of operations by
twenty different operators ; of these. 82 were pri-
mary, 158 secondary, and 49 late. The late cases
allowed a mortality of over twelve per cent. ; the
secondary cases, four per cent. : the primary cases,
slightly over one per cent. He offered the proposi-
tions that a section undertaken under every surgical
advantage in advance of labor was less dangerous
than one performed after even a few hours' endur-
ance of the exhausting physiology of labor, and un-
der the technical conditions incident to such work ;
that the section, performed after a full test in labor
had demonstrated the approaching failure of the
natural forces, was an operation favorable to the
child, but more dangerous to the mother than the
intrapelvic methods of extraction with forceps or by
version. There could be no plainer or more obvi-
ous deduction than that, when the Caesarean section
was necessary, it was desirable that it should be de-
termined upon in advance, and performed as a pri-
mary operation. He ruled out secondary section as
an operation of choice. To attain accurate results.
664
PROCEEDINGS OF SOCIETIES.
LNe.v York
MeDic.ai, Journal.
w e should estimate with equal care the pelvis, the
passenger, and the probable maternal power as a
propelling engine. To estimate these in difficult
cases, it was usually necessary to see the patient re-
peatedly during, and when possible before, preg-
nancy. The whole matter of the size and shape of
the pelvis was as yet in its infancy.
In conclusion, he believed that, to avail ourselves
of all the resources of our art in the management of
difficult labor, we should see the patient at intervals
during pregnancy, and, where the circumstances
permitted, before pregnancy ; in cases where the un-
fortunate history of previous labors or the existence
of evident deformity had brought the question of
the safety of labor into consideration before another
pregnancy had occurred. Such a detailed observa-
tion of pregnancy, and such painstaking investiga-
tion of the mechanical conditions, would be mani-
festly impracticable and unnecessary in the routine
practice of midwifery in multiparse. It was applica-
ble only in cases in which difficulty could be reason-
ably expected. He believed the general practitioner
should be taught how to select the cases in which
danger threatened, but might be forestalled by an
early and accurate comprehension of the circum-
stances. All primiparse ought really to be examined
for determination of the mechanical conditions dur-
ing pregnancy, and this procedure was growing in
repute. The following should have a determination
of the mechanical conditions during pregnancy : i ,
All primiparse of very small stature. In this type of
women the symmetrically small pelvis, the pelvis
nana, was to be looked for. 2, All primiparae who
had done heavy muscular work during the period of
development, and more especially those who pre-
sented a short, squat, short legged appearance. In
this class of women the flat pelves were particularlv
frequent. 3, All primiparae with the narrow hipped,
long, straight legged, flat backed, boyish type of fig-
ure. In this type of women we found the true justo
minor, or neutral, type of pelvis so frequent. 4, All
primiparse with bandy legs, protuberant buttocks,
prominent abdomen, and an unusually hollow lumbar
region. These women were often rather wide
hipped, markedly feminine in figure, and at first
suggested favorable labor ; but it was in such women
that the pelves with excessive inclination of the brim
and exaggerated curvature of the pelvic axis were
mostly found. 5, All primiparse of delicate health.
Many of these women had easy labors, but in them
even moderate mechanical difficulties assumed im-
portance. ■ 6, Multiparae who had had even one diffi-
cult or disastrous labor. Few men would doubt the
wisdom of these propositions when placed before
them on paper, but to effect their present adoption
in practice was quite another thing.
Dr. William M. Polk said the ordinary practi-
tioner was not in a position to enter into the niceties
of laboratory work. The only way to anticipate a
(lire calamity was to keep a very close watch upon
the women whose uteri had not undergone proper
involution. He regretted that Dr. Cragin had failed
to tell them of the advantages of a slow forceps de-
livery. There had never been anything so potent
for good as the obstetric forceps, but all realized
that, when used with a rush for the purpose of termi-
nating labor quickly, it was capable of causing clan-
ger which was not limited to external passages ; but,
apart from the dangers of sepsis and lacerations, it
was responsible for the great number of sad cases
of procidentia. The fact that forceps delivery could
be extended over an hour or longer, until such a time
as the uterus was coaxed to do its duty, seemed to
him to be worthy of earnest consideration. Disor-
ders in young women were very frequently the
groundwork of many of the after conditions, such as
diseased ovaries, which ultimately led to those
wretched cases of neuroses which revolved around
ovarian pains. There was an immense number of
yoimg women beginning menstruation under condi-
tions which were far from hygienic ; this function,
carried on under conditions of ignorance as to its
true significance and true pathological conditions,
laid the foundation in girlhood of subsequent ail-
ments. Time and time again the treatment of sim-
ply removing adenoids that grew in the uterus had
been sufficient, not only to relieve the condition of the
sexual organs, but to improve the condition of the
patient. He also wished to emphasize the vast ad-
vantage of early and prompt incision and drainage
by the cul-de-sac in those cases of pelvic peritonitis
associated with septic infection of the uterus.
Dr. J. Clifton Edgar agreed with Dr. Cragin in
the main as to the statements made about the toxae-
mias of pregnancy, and he was grateful to him for
!)ringing out the value of the nitrogen ratios as diag-
nostic factors. He believed that to-day we could
draw a line more sharply between the pure nephritic
and hepatic cases of eclampsia than ever before. At
the Manhattan Maternity Hospital the internes often
made the diagnosis of the nephritic or the hepatic
varieties before urinary analysis. There was a small
class of cases in which the urinary findings often
flew^ the red flag, giving out the danger signal be-
fore the clinical condition and picture w^ere particu-
larly well marked. Suture of the cervix should be
confined to those cases in which there was a haemor-
rhage following labor. The keynote of the obstetric
papers was prophylactic obstetrics. It was Utopian
to believe that we had arrived at a condition of
affairs where dystocia would be prevented weeks be-
fore labor set in. In institution work the mortalitv
from puerperal sepsis was one tenth of one per cent,
or less. The morbidity was exceedingly low. This
was not so in private practice.
The reason for this diminution in the mortality
and morbidity rate in institutions was the introduc-
tion of asepsis and antisepsis in midwifery. The in-
ference was plain. Ophthalmia neonatorum in in-
stitution work gave a mortality that was practically
nil ; but this was not so in private work. In Eng-
land, in 1894, thirty-four per cent, of the cases of
total blindness were due to ophthalmia neonatorum.
Twelve years later, in New York State, in 1906,
twenty-six per cent, of the cases of blindness were
found to be due to this cause. Examinations in
pregnancy, especially in the primigravida, were of
value in determining contracted pelves or large chil-
dren ; this was carried on only in institutions.
In speaking of the advances in midwifery he said
he could merely refer to a box on the table before
the academy, the property of Dr. Bedford, who died
in his sixty-fourth year in 1870 or thereabouts. He
would simply state that the top tray contained eleven
April 4, 1908.]
LETl liRS TO THE EDITORS.
665
instruments; of these eleven, ten were designed to
mutilate the child, or break it up, and only one was
for the delivery of a living child.
Dr. Charles Jewett said that in the toxaemia of
pregnancy, whether of the vomiting or eclamptic
type, the general condition of the patient must still
remain the principal guide in the treatment. As
Ewing and Wolf had stated, any material departure
from the normal nitrogen ratios spoke for an un-
stable condition of the organism that might end in
disaster. Eclampsia sometimes occurred explosive-
ly with scant clinical premonition. The end might
come unexpectedly in pernicious vomiting. An elab-
orate analysis of the urine at short intervals during
pregnancy, in the latter months, and in all cases of
pregnancy vomiting, might save many lives, but this
required the services of a practical chemist, so that
this was expensive and not generally available. He
would like to have heard more said regarding the
nitrogen coefficient as a clinical guide; the objection
had been made against it that an increase in the pro-
portion of ammonia nitrogen might be due to starva-
tion rather than pregnancy toxaemia. Experimental
liver necrosis in animals, so long as the animals
could be fed, was attended with very little increase
in the ammonia excretion, while in the hyperemesis
of pregnancy in the human subject, even with com-
paratively little pathological change in the liver, the
percentage of ammonia nitrogen often was in great
excess. Pubic section, whether median or extra-
median, had a limited field, and it had grown more
so with the improvement in the status of the Caesar-
ean section. It was difficult to select cases before
labor which we could be sure would properly fall
within the scope of symphysiotomy or hebotomy.
The principal objection to immediate suturing of the
cervix was the danger of sepsis. The cervix was
perhaps the seat of less resistance than other parts
of the birth canal, because of the traumatism it suf-
fered even in spontaneous delivery. The cervix
should not be sutured at the end of labor except
when it was necessary for haemostasis.
Dr. George L. Brodhead said that cases would
be met with from time to time in which the clinical
picture suggested that the uterus be not emptied, in
spite of the fact that the urinary findings indicated
the termination of pregnancy. We were becoming
more and more accustomed to doing craniotom)' in
cases where the child was dead, rather than to sub-
ject the woman to a difficult forceps operation or
version. Lacerated cervices should be repaired im-
mediately after delivery only in cases of haemor-
rhage. Caesarean section might be done too often.
Many patients might be delivered at the eighth
month safely and well. After Caesarean section tlie
danger of rupture occurring at the site of the scar
in subsequent labors should be borne in mind. There-
fore the induction of premature labor oflEered an ad-
vantage over.Cassarean section. Too much attention
could not be given to the details of obstetric work.
Dr. F. A. DoRMAN emphasized the clinical evi-
dences of toxaemia, so often overlooked by the gen-
eral practitioner. The excretory and digestive func-
tions, the circulatory system, and the nervous mani-
festations, neuralgic or mental, should be carefully
investigated. The operation of instrumental rota-
tion of the head was a valuable method and tech-
nique in occipitoposterior positions, and was in-
creasing in usefulness. Rubber gloves should be
used as a prophylactic measure. The induction of
premature labor had a large field, and very success-
ful results might be obtained by starting labor while
the child was smaller.
Dr. W. Gill Wylie said that it had been his prac-
tice for over twenty-five years to make a close study
of all these cases from the beginning, and it was
amazing how often cases of toxaemia and septic
troubles could be averted. The prevention of disease
ofifered great future advances.
Dr. James Ewing said that the estimation of the
nitrogen partition was not presented to supersede
other and older methods, nor was it intended to tell
when to empty the uterus ; it only told when metab-
olism was not right. The estimation of the nitrogen
partition should be made the basis of treatment to
prevent the necessity of empt} ing the uterus.
Dr. Edwin B. Cr.\gin believed that the elective
vaginal Caesarean section had but a small field.
Dr. Hermann J. Boldt said that the adenomatous
t3-pe of chorioepithelioma might sometimes be as
dangerous to Hfe as the carcinomatous type. In his
opinion it was in the interests of the patient to do
radical work on the basis that we were dealing with
a malignant form of disease.
Dr. Edward Reynolds, speaking of the mortality
of Caesarean section being raised in proportion to
the length of labor, made the simile as follows : If
one hundred strong men started to do a twenty-five
mile Marathon run, and a certain proportion pulled
out at the end of one mile and subjected themselves
to an operation, say an appendectomy, would they
not expect that mortality to be less than if done on
those who struggled in at the finish ?
f atm t0 \\t mm.
MANUAL THERAPEUTICS.
1504 Pine Street, Philadelphia, March 21, 1908.
To the Editors:
Will you permit me to reply to the large number
of inquiries concerning my article in the February
8th issue, on The Hand as a Therapeutic Agent?
I am asked : "How can a physician learn what is
necessary to make use of the hand in securing the
results alluded to?"
First of all, it is essential to have a working
knowledge of the physiolog\' of circulation, espe-
cially the vasomotor mechanisms.
It would undoubtedly be best for any one desir-
ing to attempt this form of auxiliary treatment to
know the art of manipulation practically. It would
be well to secure as teacher a graduate of the Royal
Institute of Stockholm if possible ; if not, then the
best masseur obtainable.*
There are many excellent books dealing with the
subject of massage, and from which much can be
learned, by Douglas Graham, J. H. Kellog, Thomas
Stretch Dowse, Hartvig Nissen, Professor Lan-
derer, Kleen, etc. John P. Arnold, who died recent-
*I am informed there are only seventeen graduates of the Royal
Institute of Stockholm in this country. They are not appreciated
at their true worth.
666
BOOK NOTICES.
[New York
Medical Journal.
ly, had nearly completed a book on Clinical Physi-
ology, which contains data to elucidate the vaso-
motor reactions necessary to a comprehension of the
principles involved. There are a number of books
by reputable authors, dating back as far as 1834,
notably the one by the two brothers Griffin, pub-
lished in that year, in which are analyzed 148 cases.
My friend Dr.' Seymour D. Ludlum (of 1728 Chest-
nut street, Philadelphia) read an admirable paper
before the American Medical Association last June
(just now passing through the press), which gives
further information on history and physiology.
We must be prepared to learn from irregular, as
well as regular sources of knowledge. Some of
these practitioners attain excellent skill, and they
oftentimes get admirable results. I do not find that
they difTer materially in their physical methods from
those of the high class Swedish masseurs. All this
utility, however, is entirely within the province and
capacities of a properly educated physician, pro-
vided he possesses dexterity.
It is by no means necessary to assume, as many
do, that much time or strength is demanded in ac-
complishing desired effects. I am able to materially
relieve and oftentimes to cure ailments, not other-
wise relievable, by a two or three, or possibly five
or ten minutes' procedure, requiring exceedingly
little efifort, yet valuably supplementing whatever
knowledge I possess of the use of hygiene, drugs,
electricity, moral suasion, and other commonly em-
ployed therapeutic measures.
The important point is that physicians should
learn, by practice, enough of these procedures for
their own use. They cannot fail to prove of inesti-
mable value, fitting them to form standards whereby
they can select and direct those who shall apply the
treatment. Furthermore, it is well to remember that
one cannot learn to play the violin without employ-
ing thought, study, and considerable experience.
Finally, unless physicians recognize the truth, as
I hope I have set it forth in my paper, they will con-
stantly be annoyed by losing the confidence of their
patients, and, worst of all, omit to supply that meas-
ure of resourcefulness, leading up to satisfactory re-
sults, which is entirely within their powers if they
will give the subject a moderate degree of personal
attention. J. Madison Taylor.
iMk 'gatm.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
Lectures on Medical Jurisprudence and Toxicology, as
Delivered at the London Hospital. By Fred. J. Smith,
A. M., M. D. Oxon.; F. R. C. P. Lend.; F. R. C. S.
Eng.; Physician to and Lecturer on Forensic Medicine
at the London Hospital, etc. Second Edition. London :
J. & A. Churchill, 1908. Pp. xiv-463. (Price, $3.40.)
Though this comparatively small book does not
purport to be anything like a complete treatise, it
expounds the gist of the subject very satisfactorily,
and we do not wonder that a second edition has
been called for. The principal additional matter is
in the form of three new lectures — The Examina-
tion of the Person Alive and Dead, Death Certifica-
tion, and y\naesthetics. The entire volume teems
with common sense and with the desire to smooth
out difficulties for the practitioner of medicine in
situations where he may come in contact with the
law. It contains much spicy material, especially in
the running commentary on the Coroner's Cate-
chism, a set of questions drawn up by coroners for
routine use in cases of death imputed to the ad-
ministration of an anassthetic. We can heartily
commend the book.
A Textbook on Prescription Writing and Pharmacy. With
Practice in Prescription Writing, Laboratory Exercises
in Pharmacy, and a Reference List of the Official Drugs,
Especially Designed for Medical Students. By Bernard
Fanjus, M. D., Professor of Materia Medica and Thera-
peutics, College of Physicians and Surgeons of Chicago,
etc. Second Edition, Thoroughly Revised and Adapted
to the Eighth (1905) Edition of the United States Phar-
macopcjeia. Chicago : Chicago Medical Book Company,
1906. Pp. 404.
Nu.meroiis are the books which have been com-
piled with the object of supplying medical students
with the knowledge they are supposed to acquire
of the art of prescription writing and the com-
pounding of drugs during their college course, but
few are found to fulfil their purpose. The failure
does not always spring from a lack of acquaintance
with correct methods on the part of the authors, but
is the result in most instances of a faulty arrange-
ment of the subject matter which is confusing to
the student. Of the lack of what the Germans call
Gefiihl for the study of pharmaceutical principles
in teachers of materia medica and therapeutics, a
feeling which cannot be developed in students ex-
cept by teachers who possess it themselves in a
sensitive and trustworthy form, it is mentioned here
only to emphasize the fact that textbooks which do
not give evidence of the possession of this feeling
by their authors are usually unsatisfactory guides.
In the work by Dr. Fantus indications are plentiful
of the author's intimacy with the technique of the
dispensing pharmacist, and he makes use of and
exhibits his intimate acquaintance with the drugs
and medicines of the pharmacopoeia in a manner
that is admirably adapted, we think, for the training
of medical students along well ordered lines. The
design and scope of his work are such as to make
for orderly and systematic study, and a multiplicity
of details, which is apt to be so confusing to the
student, is avoided, without, however, any sacrifice
of essentials. The form, language, and composi-
tion of prescriptions are dealt with in the beginning,
prescription ethics being also considered in chapters
on the repeating, ownership, and cost of prescrip-
tions, in which useful hints are given regarding the
customs of both prescribers and dispensers. The
chapters in which the products of pharmacy are de-
scribed impress the reviewer as being eminently
practical, and the student who masters them should
never be at a loss to know what is required in the
origination of a prescription for any single drug or
combination of drugs. Laboratory exercises are
outlined, the numerous problems in prescription
writing and compounding being calculated to form
excellent drilling in these subjects.
As a textbook of materia medica the book is thor-
ough, yet concise. Nearly one half of it is taken up
April 4, 1908.]
BOOK NOTICES.
667
Nvith descriptions of drugs, arranged in a form to
facilitate memorizing by the student. First is given
the official Latin name of the drug, printed in
Gothic capitals, and followed by ( i ) the pronuncia-
tion, (2) the genitive case, (3) the official English
name, (4) synonyms, (5) the origin of vegetable
drugs, (6) a' description, (7) solubility, (8) active
constituents, (9) incompatibles, (10) uses, (11)
doses, (12) official preparations, and (13) forms of
administration. It only remains to add that the vol-
ume is in accord with the latest revision of the
United States Pharmacopoeia, and is a manual of
prescription writing and pharmacy that can be un-
qualifiedly commended for use as a textbook of
these subjects in medical colleges. Although it is
dated 1906, it is only within a few weeks that we
have received it.
Schema des Rumpfes. Von Privatdozent Dr. W. Hilde-
BR.\NDT, Freiburg i. B. Taschenausgabe. Miinchen : J. F.
Lehmann, 1908. (Price. 1.20 mark.)
This booklet, in the form of a pad, consists of
about twenty-five pages, each of which can easily
be detached and used as a memorandum, taking the
place of a written case history. Each of the pages
contains a diagram of the skeleton of the trunk, with
landmarks, drawn similar to the Mercator projec-
tion map of the earth. The physician is to mark in
this schedule certain hnes and arrows indicating the
situation of the viscera as found in the patient under
examination, together with the results of ausculta-
tion and percussion depicted in graded shading, and
using certain forms of lines and cross hatchings
which are explained on the fly leaf of the pad.
The Practice of Gyncccology, in Original Contributions.
By American Authors. Edited by J. Wesley Bovee,
M. D., Professor of Gynecology, George Washington
University, Washington, D. C. lUustrated with 382 En-
gravings and 60 Full Page Plates. New York : Lea
Brothers & Co. Pp. xii-836.
This volume, one of three to cover the subjects of
paediatrics, obstetrics, and gynaecolog}-., is an emi-
nently characteristic contribution to American
g}-naecological literature. An incomplete list of the
authors and their contributions will substantiate this
view. Thus, Dr. Bovee has written of develop-
mental anomalies and the diseases and affections of
the urinary system; Dr. X. O. Werder has contrib-
uted articles on the examination of patients and on
extrauterine pregnancy; Dr. J. Riddle Goffe has
written on menstruation, uterine displacements, and
the vaginal method of operating ; Dr. G. H. Xoble
has written of faecal and urinary fistulje and lacera-
tions; and Dr. Benjamin R. Schenck and Dr.
Thom.as J. Watkins have divided the diseases of the
Falloppian tubes between them. Dr. G. B. Miller
has taken the tumors and inflammations of the
uterus for his subjects.
The book is remarkably free from the repetition
and overlapping that one usually finds in composite
works. While it is not possible in a short space
to review each series of contributions, the general
conservative attitude of the authors is to be com-
mended. Thus, the avoidance of unnecessary in-
strumental manipulation of the uterus is advised, as
well as the nonoperative treatment of acute infec-
tions involving the uterus and appendages. The
chapter on postoperative treatment and the compli-
cations of abdominal operations is unusually good.
The vaginal operations are, too. very well described,
as are the various methods of repair of vaginal and
perineal tears. Among other features, the details
of plastic operations on the tubes may be mentioned
with commendation.
Altogether, much care and toil have gone into the
preparation of this book. Not only textually. but as
far as the illustrations are concerned as well, can
the volume be heartily commended as a practical
work on gynaecology from the standpoint of the
American gynaecologist of to-day.
Skin Affections in Childhood. By H. G. Ad.-^mson, M. D.
(Lond.), M. R. C. P., Physician for Diseases of the Skin,
Paddington Green Children's Hospital etc. London :
Henry Frowde (Oxford University Press) and Hodder
& Stoughton, 1907. Pp. xvi-287.
Although the skin affections in children are es-
sentially the sam.e as those in adults and should be
taught as an intimate part of the whole subject of
dermatology, there are many advantages in consid-
ering them apart. Many affections of the skin are
far more prevalent in childhood than in adult life,
nhile others are peculiar to the child, or. when oc-
curring in childhood, are so modified that they
present entirely special appearances. This book is
therefore a useful addition to our compendia in
dermatology.
The author treats his subject from the clinical,
diagnostic, and therapeutical points of view, and
divides it thus: Affections of congenital origin;
eruptions due to local physical causes, animal and
vegetable parasites, local microbic infection, or toxic
origin ; tuberculous disease of the skin ; affections of
nervous origin ; and, finally, unclassified affections.
On pages 280 to 284 will be found a very handy
list of the principal remedies for external applica-
tions. The illustrations are good selections and are
well executed.
Die chirurgischen Untersuchungsarten. Einfuhrende Vor-
lesungen iiber allgemeine chirurgische Diagnostik von
Dr. Otto Maxz. Mit 38 Abbildungen im Texte. H.
Teil. Jena : Gustav Fischer. Pp. vii-257.
The object of these lectures is the instruction of
the student in the methods of examining surgical
patients. They are simple and very complete, omit-
ting unnecessary and unimportant facts in order to
emphasize the essential features of surgical diag-
nosis. In other words, it is a work on surgical
physical diagnosis. The author has sensibly avoided
long descriptions of technical processes, such as
cystoscopy and oesophagoscopy. but has contented
himself with the laying down of broad general prin-
ciples.
The book is worthy of study, and will prove val-
uable to moderately advanced students as well as to
teachers in the preparation of their lectures. The
illustrations are particularly well chosen.
Atiiiokausis und Zestohausis, die Behandlung mit hochge-
spanntem Wasserdampf in der Gynakologie. Von Dr.
LuDwiG PiN'cus, Frauenarzt in Danzig. Zweite verbes-
serte Auflage mit 33 Textfiguren und 5 Tafeln. Wies-
baden : J. F. Bergmann. Pp. xiv-369.
There is no doubt that, within the past five years,
Pincus's method of spraying the uterus with super-
heated steam has, within its recognized limitations,
668
MISCELLANY.
[New York
Medical Journal.
been widely accepted by the profession as a valuable
therapeutic measure. Especially in the treatment of
uterine hiemorrhages has this procedure seemed to
be of benefit. Thus, in haemorrhages preceding the
menopause, in hsemorrhagic endometritis, in bleed-
ing due to haemophilia, and in cases of uterine
fibroids (except of the submucous variety), the use
of atmocausis is almost invariably attended with
success. Pincus, in this edition, advises that the
procedure be preceded by curetting, sufficient time
being allowed for regeneration of the endometrium
to take place. In ordinary endometritis atmocausis
seems to be of no benefit, and in septic cases, too, it
has shown little favorable result ; but in the condi-
tions mentioned and in menorrhagia or metrorrhagia
depending upon postabortive subinvolution, chronic
uterine atony, as well as for the production of ster-
ility, and for the cure of chronic gonorrhoeal endo-
metritis, it is of the greatest value.
Pincus is careful to urge a selection of the cases
in which atmocausis should be used. The book rep-
resents a thorough and careful clinical and patho-
logical study.
BOOKS, PAMPHLETS, ETC., RECEIVED.
Life Insurance and General Practice. By E. M. Brock-
bank, M. D, (Vict.), F. R. C. P., Honorary Assistant Phy-
sician, Royal Infirmary, Manchester, etc. London: Henry
Frowde (O.xford University Press) and Hodder & Stough-
ton, 1908. Pp. xiv-288.
Darwinism To-day. A Discussion of Present Day Scien-
tific Criticism of the Darwinian Selection Theories, To-
gether with a Brief Account of the Principal Other Pro-
posed Auxiliary and Alternative Theories of Species Form-
ing. By Vernon L. Kellogg. Professor in Leland Stanford,
Jr., University. New York : Henry Holt & Co.. 1907. Pp.
xii-403.
Diseases of the Lungs. Designed to be a Practical
Presentation of the Subject for the Use of Students and
Practitioners of Medicine. By Robert H. Babcock, A. M.,
M. D., Author of Diseases of the Heart and Arterial Sys-
tem, Consulting Physician to Cook County Hospital, etc.
With Twelve Colored Plates and One Hundred and Four
Text Illustrations. First Edition. New York and London :
D. Appleton & Co., 1907. Pp. xix-8og.
Gonorrhoea. Its Diagnosis and Treatment. By Frederick
Baumann, Ph. D., M. D., Professor of Genitourinary Dis-
eases in the Reliance Medical College, and Instructor in
Dermatology and Venereal Diseases in the College of Phy-
sicians and Surgeons. Chicago. Fifty-two Illustrations in
the Text. New York and London : D. Appleton & Co.,
1908. Pp. xii-206.
An Introduction to Vegetable Physiology. By J. Reynolds
Green, Sc. D.. F. L. S., F. R. S., Fellow of Downing Col-
lege, Cambridge, Late Profes.sor of Botany to the Pharma-
ceutical Society of Great Britain, etc. Second Edition.
Philadelphia : P. Blakiston's Son & Co., 1907. Pp. xx-459.
Die Funktionen der Norvenccntra. Von Prof. Dr. W
V. Bechterew, o. .Akadeniikcr, Dircktor der psychiatrischen
und Nervenklinik der niodizinischcn .\kademie, Prasident des
psychoncurologischen Institutes in St. Petersburg. Deutsche
Ausgabe, in Verbindung mit dcm Vcrfasser redigiert durch
Dr. Richard Weinberg. Professor der Anatomic in St.
Petersburg. Erstes Heft: Einleitung. Untersuchnngsmeth-
oden, Rijckenmark und Verlangertes Mark. Mit 96 Ab-
bildungen im Text. Jena : Gustav Fischer, 1908. Pp. 691.
The Bacteriology of Diphtheria. Including Sections on
the History. Enidemiology, and Pathology of the Disease,
the Mortality Caused bv it, the Toxines and Antitoxines,
and the Scrum Disease' Bv F. Loeffler, M. D., LL. D. ;
Arthur Ncwsholme. M. D., F. R. C. P.; F. B. Mallory,
M. A., M. D. ; G. S. Graham-Smith, M. A.. M. D., D. P. H. ;
George Dean, M. D. : William H. Park, M. D., and Charles
F. Boldiian. M. D. Edited by G. H. F. Nuttall, M. D.,
Ph. D., Sc. D.. F. R. S.. Quick Professor of Biology in the
University of Cambridge. Fellow of Christ's College, and
G. .S. Graham-Smith, M. A., M. D., University Lecturer in
Hygiene, Cambridge. Cambridge: University Press, 1908.
London: H. K. Lewis. Leipsic: F. A. Brockhaus. New
York : G. P. Putnam's Sons. Bombay and Calcutta : Mac-
millan & Co., Ltd. Pp. xx-718. (Price, $7.50.)
Bier's Hypersmic Treatment in Surgery, Medicine, and
the Specialties. A Manual of Its Practical Application. By
Willy Meyer, M. D., Professor of Surgery at the New
York Postgraduate Medical School and Hospital, etc., and
Professor Dr. Victor Schmieden, Assistant to Professor
Bier, University of Berlin, Germany. Illustrated. Phila-
delphia and London: W. B. Saunders Company. 1908. Pp.
209. ( Price, $3.)
Proposed State Custodial Institution at Haver-
straw, N. Y. — The foUoAving resolution was
unanimously passed at a regular meeting of the
Medical Society of the County of New York, held
on March 23. 1908; submitted to the members by
Dr. E. Eliot Harris, chairman of the Committee on
Legislation :
To the president and members of the Medical Society of
the County of Nezsj York:
The Committee on Legislation voted unanimously to
actively support Senate Bill No. 636 and Assembly Bill
No. 1215, and requested its chairman to prepare suitable
resolutions to be submitted to the society for its action.
Whereas, the commission appointed by his Excellency
Governor Hughes, pursuant to an act of the last Legisla-
ture, has investigated and reported on a suitable site for the
Eastern New York State Custodial Asylum, and has offi-
cially published that there are at least 20,000 feeble minded
and epileptic persons in this State ; that the existing State
custodial institutions located at Rome, Syracuse, Newark,
and Sonyea are now overcrowded ; that they house 3,250
persons while their capacity is authoritatively reported for
only 3,183 incates, making an excess of 67 persons, which,
added to 1,000 applicants who are now on the waiting list
of these institutions, and 1,808 patients improperly confined
in almshouses of the State, make a total of 2,875 patients
needing immediate State custodial care — to say nothing of
the much larger number of 20,000 persons in private homes
who require State custodial care for the protection of them-
selves and for the protection of the best interests of the
Commonwealth.
Whereas, the site selected is admirably suited for the
purposes of the colony, as shown in the report of Mr.
Kuichling, the consulting engineer; the options on the
property were secured at a time which gives the State a
remarkable opportunity to be possessed of a tract of land
at the lowest possible cost; its value will rapidly enhance
with the improvement in the financial conditions of the
county : that the proposed colony will be locjited near
Haverstraw, Rockland County, 22 miles north of New York
City, is a great blessing to these unfortunate poor as well
as being of great economic value to the State, as it may be
readily and cheaply reached by train or boat ; the round
trip being one dollar by train and much less by boat ; that
more than fifty per cent, of the inmates and over sixty-one
per cent, of those on the waiting lists of the distant State
institutions are from the vicinity of Greater New York
accounts for the many instances where it seems cruel to
send these poor patients so far from their family relations
and friends, who plead pitifully for their retention in the
city institutions which arc accessible to them, for they know
full well that the time and the expense of the journey will
in most cases prohibit them from ever seeing their dear
ones again, which becomes evident when we consider that
the round trip railroad fare alone is fourteen dollars to the
Craig Colony for Epileptics at Sonyea — the present cost to
the Department of Public Charities of this city to send a
patient with an attendant to the colony is over twenty-five
dollars. If a colony was established at Plaverstraw then
the regular boat of the Department could make the trip
easily and without cost to tlie visitors entitled to permits.
Therefore, be it resolved, that this society earnestly re-
quests the finance committee of the senate to report favor-
April 4, 1908 ]
OFFICIAL NEIVS.
669
ably Senator Armstrong's bill Xo. 636, which provides for
an appropriation of one hundred and eighty-eight thousand
five hundred and seventy-five dollars for the site near Hav-
erstraw, Rockland County. The members of the Senate
are also urgently requested to vote for the final passage of
the bill which haS already passed the assembly unanimously
as Assembly Bill Xo. 1215.
Resolved, that the Committee on Legislation be empow-
ered to use these resolutions in cooperating with other
committees working for the enactment of the bill to pur-
chase the site of the Eastern Xew York State Custodial
Asvlum.
Cases. Deatlr
Public Health and Marine Hospital Service
Health Reports:
The follou'mg cases of smallpox, yelloiv fever, cholera,
and plague have been reported to the surgeon general.
United States Public Health and Marine Hospital Service,
during the z^-eek ending March 27, 1908:
Smallpox — United States.
Places. Date.
Alabama — Mobile March 1-8 5
California — Los Angeles Feb. 29-March 7 10
California — San Francisco Feb. 29-March 7.... 12
District of Columbia — Washington . March 7-14 13
Florida — De Funiak Springs March 7-14 4
Florida — Jacksonville March 7-14 1
Illinois — Chicago March 7-14 6
Illinois — Rockford March 7-14..' i
Illinois — Springfield .March 5-12 16
Indiana — Fort Wayne Feb. 29-March 7.... 5
Indiana — Indianapolis March 1-15 10
Indiana — Muncie March 7-14 4
Nebraska — Nebraska City March 7-14 2
New Jersey — Newark March 7-14 i
New York — New York March 7-14 i
North Carolina — Charlotte March 7-14 i
Ohio — Cincinnati March 6-13 14
Ohio — Dayton March 7-14 i
Ohio— Sanduskv Feb. 29-March 7 i
Ohio — Toledo March 7-14 2
Oregon — Portland Feb. 22-March 7 6
Iowa— Ottumwa t >'arch 7-14 i
Kansas — Kansas- City March 7-14 12
Kansas — Topeka. . . .' Feb. 29-March 7.... i
Kansas — Wichita March 7-14
Kentucky — Lexington .March 7-14
Louisiani — New Orleans March 7-14
30
Michigan — .Saginaw. . .
-Minnesota — Winona. . .
Missouri— Kansas City
Missouri — .^t. Joseph.
Missouri — St. Louis..
Tennessee — Knoxville.
Feb. 22-29
.Feb. 29-March
.March 7-14...
Feb. 15-March
March 7-14. . .
.March 7-14...
Tennessee — Nashville March 7-14. .. .
Texas — Galveston Msrch 6-13....
Texas — San Antonio March 7-14....
Washington — Spokane Feb. z^-March
Wisconsin — La Crosse March 7-14....
S,:i,nhox—I»
Philippine Islands — Province
Pangasinan — San Fabian...
Smallpo
Feb. 2
— Foreii
Jan.
26-Feb.
11-25. ..
Brazil — Rio de Janeiro Feb. 2-23
Canada — Halifax March 7-14. . . .
Egypt— Cairo Feb. 11-25
Formosa Tan. 26-Feb. i.
France— Marseille Feb. 1-29
France — Paris Feb. 22-29.'. • . .
Great Britain — Glasgow . Feb. 22-\farch
Honduras — Tegucigalpa March 1-8
India — Bombay Feb. 1 1-18
India— Madras Feb. 8-14
India — Rangoon Feb. 8-14
Italy — General Feb. 20-iIarch
Japan — Kobe Feb. 1 5-22
Japan — Moji March 16
Japan — Osaika Feb. 8-15
Japan — Shimonoseki March 16
Japan — Tokyo Feb. 25
Japan — Yokohama Feb. 15-22
Java — Batavia Jan. 26-Feb. 8.
Mexico — Mexico City Feb. 5-12
Mexico — Monterev Feb. 1-8
Russia— Batoum J?n. 13-Feb. 1,1
Russia — Moscow Feb. 15-22
Russia — Odessa Feb. 15-22
Russia — Rig'j Feb. 22-29
Present
63
Present
Present
t6
Spain — I'.arcclona JIarch i-io
Spain — Denia Feb. 22-29
Spain — Malaga Jan. 1-3 1
Spain — Valencia Jan. 25-March i.
Turkey — Constantinople Feb. 9-March i.
Venezuela — Maracaibo Feb. 18
Yellow Fe-.cr — Foreign.
Brazil — Manaos Feb. 15-22
Brazil — Para Feb. 22-29
Ecuador — Guayaquil Feb. 8-15
Cholera— I, isular.
Philippine Islands — Manila r<.I). 1-8
Cholera — Foreign.
India— Madras Feb. 8-14
Plague — Foreign.
.\ustralia — Brisbane Jan. 18-25
.\ustralia — Cairns Jan. 23
.\ustralia — Sydnej- .'an. ii-i8
Brazil — Para I'eb. 22-29
Brazil— Rio de Janeiro Feb. 2-23
Egypt — Alexandria Feb. 23
Egypt — Provinces •
Assiout Feb. 22 26
Beni Souof Feb. 24
Garbeih Feb,
Keneh Feb.
Mcnu6ch Feb.
Minieh Feb.
India— General Jan.
India — Bombay Feb.
India — Rangoon Feb,
Japan— Osaka Feb
Present
6
26-27 .
24-27.
7,208
70
8
Army Intelligence:
Official list of changes in the stations and duties of
officers serving in the medical department of the United
States Army for the weelz ending March 28, igo8:
B.vxiSTER, \V. B., Major and Surgeon. Appointed a mem-
ber of a board of officers, to meet at the call of the
president thereof at Manila, P. I., for the examination
of such officers of the Medical Department, ordered be
fore it to determine their fitness for promotion.
Borden, W. C, Major and Surgeon. Appointed a member
of a board of officers, to meet at the call of the presi-
dent thereof at Manila. P. I., for the examination of
such officers of the Medical Department, ordered be-
fore it to determine their fitness for promotion.
Brownlee, C. Y.. First Lieutenant and Assistant Surgeon.
Relieved from duty at the Pacific Branch, U. S. Mili-
tary Prison. Alca'traz Island, Cal., and ordered to
Manila, P. L. for duty on transport to sail from San
Francisco. Cal.. about May 5, 1908.
DeLoffre, S. M., First Lieutenant and .Assistant Surgeon.
Leave of absence extended seven days.
DeWitt. \\'.. First Lieutenant and .Assistant Surgeon. Or-
dered to Fort Yellowstone. Wyo., for duty upon ex-
piration of present leave of absence.
GiBXER, H. C. First Lieutenant and .Assistant Surgeon. Or-
dered to report at the Army General Hospital, Presidio.
San Francisco, Cal., for temporary duty.
Glenx.xn, J. D., Major and Surgeon. Appointed a member
of a board of officers, to meet at the call of the presi-
dent thereof at Manila. P. L. for the examination of
such officers of the Medical Department ordered before
it to determine their fitness for promotion.
Greexle.\f. H. S.. Captain and .Assistant Surgeon. Granted
four months' leave of absence with permission to go
beyond the sea.
Grissixgek. J. \V., Captain and Assistant Surgeon. Granted
two months" leave of absence.
Kend.\ll, Willi.\m P., Major and Surgeon. Relieved from
duty at Fort Sam Houston. Tex., and will proceed to
Fort Ethan .Allen, Vt.. for duty at that post.
Schreixer. E. R.. Captain and Assistant Surgeon. Granted
leave of absence for fifteen days, to take effect upon his
arrival at ^Lidison Barracks, N. Y., with troops from
Sam Houston. Cal.
Stark. .A. X.. Major and Surgeon. In addition to his other
duties at Vancouver Barracks. Wash., will assume
temporary charge of the office of the Chief Surgeon,
Department of the Columbia.
^VooDBUKY, F. T., Captain and xAssistant Surgeon. Re-
lieved from duty in the Philippine Division, and will
proceed on the transport to sail from Manila, P. I.,
about June 15th. to San Francisco. Cal., and upon ar-
rival will report to the .Adjutant General of the .Army
for further orders.
670
BIRTHS. MARRIAGES, AND DEATHS.
[New York
Medical Journal.
Navy Intelligence:
Official list of changes in the medical corps of the United
States Navy for the week ending March 28, 1908:
Alderman, C. G., Assistant Surgeon. Detached from the
Naval Medical School, Washington, D. C, and ordered
to the South Dakota.
B.\KER, M. W., Passed Assistant Surgeon. Detached from
the Naval Hospital, New York, N. Y., and ordered to
the Colorado.
B.'iRBER, G. H., Surgeon. Detached from the Naval Hospi-
tal. Boston, Mass.. April loth, and ordered to instruc-
tion at the Naval Medical School, Washington, D. C.
Blackwell, E. M., Passed Assistant Surgeon. Detached
from the Naval Academy and ordered to instruction at
the Naval Medical School, Washington, D. C.
Bogert, E. S., Jr., Surgeon. Orders of March loth modi-
fied ; ordered to course of instruction at the Naval
Medical School, Washington, D. C.
Boland, M., Assistant Surgeon. Detached from the Naval
Medical School, Washington, D. C., and ordered to the
naval recruiting station, Detroit, Mich.
Bunker, C. W. O., Assistant Surgeon. Detached from the
Naval Medical School, Washington, D. C, and ordered
to the Naval Academy, Annapolis, Md.
Clayton, J. C., Acting Assistant Surgeon. Detached from
the Naval Medical School, Washington, D. C, and or-
dered to report before the naval medical examining
board, that city, April ist, for examination for ap-
pointment as assistant surgeon, and then to await orders.
Cole, H. W., Jr., Assistant Surgeon. Detached from the
Navy Yard, Charleston, S. C, and ordered to instruc-
tion at the Naval Medical School, Washington, D. C.
DuHiGG, J. T., Assistant Surgeon. Detached from the
Naval Medical School, Washington, D. C, and ordered
to the naval recruiting station, Des Moines, la.
Fauntleroy, a. M., Passed Assistant Surgeon. Detached
from the Naval Medical School Hospital, Washington,
D. C, and ordered lo instruction at the Naval Medical
School, that city.
FiSKE, C. N., Passed Assistant Surgeon. Detached from
the Naval Hospital, Mare Island, Cal., and ordered to
course of instruction at the Naval Medical School,
Washington, D. C.
Freeman, G. F., Passed Assistant Surgeon. Detached
from the Naval Hospital, Portsmouth, N. H., and or-
dered to instruction at the Naval Medical School,
Wasliingtcn, D. C.
Hale, G. D., Assistant Surgeon. Detached from the Naval
Medical School, Washington, D. C, and ordered to
the Idaho.
Hayden, R., Assistant Surgeon. Detached from the Naval
Medical School, Washington, D. C, and ordered to
duty with the marine detachment at Camp Columbia,
Cuba, sailing from New York, N. Y., about April 4th.
Hermesch, II. R., Assistant Surgeon. Detached from the
Naval Medical School, Washington, D. C, and ordered
to the naval recruiting station, Cincinnati, Ohio.
Huff, E. P., Assistant Surgeon. Detached from the naval
proving ground, Indian Head, Md., and ordered to the
naval station, Olongapo, P. I., sailing from San Fran-
cisco, Cal., about May 5th.
Huffman, O. V., Assistant Surgeon. Detached from the
Naval Medical School, Washington, D. C, and ordered
to the New Hampshire.
Lando, M. E., Assistant Surgeon. Detached from the naval
station; Tutuila, Samoa, and ordered home to await
orders.
McDonald, P. E., Passed Assistant Surgeon. Detached
from the Connecticut and directed to await orders.
McLean, A. D., Passed Assistant Surgeon. Detached
from the naval recruiting station, Detroit, Mich., and
ordered to the Navy Yard, Portsmouth, N. H.
Peck, A. E., Passed Assistant Surgeon. Detached from
the naval station, Olongapo, P. I., and ordered home to
await orders.
Randall, J. A., Passed Assistant Surgeon. Detached from
tlie naval recruiting station, Denver, Col., and ordered
to the Denver.
Smith, F. W., Assistant Surgeon. Detached from the
Naval Medical School, Washington, D. C, and ordered
to the Wisconsin.
Smith, G. T., Surgeon. Detached from the Maryland,
April 1st, and ordered to instruction at the Naval Med-
ical School, Washington, D. C.
Spear, D. A., Assistant Surgeon. Detached from duty at
the Naval Medical School, Washington, D. C, and or-
dered to the Naval Hospital, New Fort Lyon, Col.
Stepp, J., Passed Assistant Surgeon. Detached from the
Denver and ordered home to await orders.
Stibbens, Assistant Surgeon. Detached from the Naval
Medical School, Washington, D. C, and ordered to
the Naval Hospital, Mare Island. Cal.
Stuart, M. A. Assistant Surgeon. Detached from the
Naval Medical School, Washington, D. C, and ordered
to duty at Camp Elliott, Isthmian Canal Zone, sailing
from New York, N. Y., about April 7th.
Taylor, J. L., Assistant Surgeon. Detached from duty
with the marine detachment at Camp Columbia, Cuba,
and ordered to instruction at the Naval Medical School,
Washington, D. C.
Tkible, C. B., Assistant Surgeon. Detached from the Naval
Medical School, Washington, D. C. and ordered to
the Naval Hospital, Mare Island, Cal.
Valz, E. v., Assistant Surgeon. Detached from the Naval
Medical School, Washington, D. C, and ordered to the
Mississippi.
WiCKES, G. L., Assistant Surgeon. Detached from the
naval recruiting station, Omaha, Neb., and ordered to
the naval .recruiting station, Denver. Col.
Wilson, G. B., Surgeon. Detached from the IVabash and
ordered to instruction at the Naval Medical School,
Washington, D. C.
Woodward, J. S., Passed Assistant Surgeon. Detached
from the naval recruiting station. Cincinnati, Ohio, and
ordered to the Naval Hospital, New York, N. Y.
The following medical officers were detached from the
Naval Medical School, Washington, D. C. and ordered to
duty as specified below :
HiGGiNS, S. L., Assistant Surgeon. To the Naval Hospital,
Canacao, P. I., sailing from San Francisco, Cal., about
May 5th.
Kelley, H. L., Assistant Surgeon. To the Naval Hospital.
Canacao, P. I., sailing from San Francisco, Cal., about
May 5th.
Lawrence, H. F., Assistant Surgeon. To the naval station,
Tutuila, Samoa, and to additional duty on board the
Annapolis, sailing from Vancouver, B. C, about
April 24th.
Rose, M. E.. Assistant Surgeon. To the naval recruiting
station, Omaha, Neb.
Short, W. H., Assistant Surgeon. To the naval recruiting
station, Oklahoma City, Okla.
Straeton, R. J., Assistant Surgeon. To the naval station,
Guam, L. I., sailing from San Francisco. Cal., about
May 5th.
Died.
Baker. — In Philadelphia, on Friday. March 20th, Dr.
George Linville Baker.
Barrett. — In Louisa, Virginia, on Tuesday. March 17th,.
Dr. R. L. Barrett, aged seventy-five years.
Burleigh. — In Braintree, Massachusetts, on Saturday,.
March 21st, Dr. Robert F. Burleigh, aged forty-six years.
Butman. — In Somerville, Massachusetts, on Sunday,.
March 22d, Dr. George F. Butman, aged seventy years.
Cook. — In Chicago, on Saturday, March 21st, Dr. John
C. Cook, aged fifty-eight years.
Dewey. — In Chicago, on Monday, March 23d, Dr. Frank
Jones Dewey, aged fifty-seven years.
Ford. — In Washington. Connecticut, on Friday, March
27th, Dr William J. Ford, aged fifty-eight years.
LiTTUELL. — In Rve. Colorado, on Mondav, March i6tb.
Dr. R. S. Littrell. '
McConnei.i..— In Ludington, Michigan, on Tuesday,
March 24th, Dr. A. P. McConnell, aged eighty-two years.
Morse. — In Boston, on Tuesday, March 24th, Dr. Edward
G. Morse.
Pease. — In Springfield. Massachusetts, on Monday,
March 23d, Dr. Herbert Owen Pease, aged fifty-one years.
Teetzel. — In Cleveland. Ohio, on Wednesday. March
i8th, Dr. William McQueen Teetzel.
Venn. — In Chicago, on Monday. March 2--(\ Dr. Clement
Venn, aged forty years
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal rlt Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXVII, No. 15. NEW YORK, APRIL ir. 1908.
Whole No. 1532.
Original (^ffmmwnicatiflnis,
A CASE OF PERNICIOUS MALARIA WITH
AUTOPSY.*
By G. R. Satterlee, M. D.,
New York.
This case is interesting because of the in fre-
quency of tropical malarial fever in the northern
part of this country and the still more infrequent
reports of autopsies on these cases.
The patient, a Finn, twenty-six years old, was admitted
to the wards of Gouverneur Hospital, New York, on Octo-
ber 15, 1907, at 9 p. m., in the service of Dr. Francis Huber.
His condition was so grave and his knowledge of the Eng-
lish language so poor that a very imperfect history only
was obtained. He was a sailor and had spent the last si.K
months traveling around South America (in places the
names of which were unobtainable) and had been in this
city for nine days following his return from the last trip
south. He had been a heavy drinker, but denied any
severe illnesses. He gave no distinct malarial history
with the exception that he stated that he had, a week before
admission, loss ol appetite, headache, chilly sensations, gen-
eral malaise, fever, some localized pain in the epigastrium
and diarrhrea. He was brought to the hospital during a
chill in a state resembling alcoholic delirium. On admis-
sion his temperature was 105.4° F-> pulse 120, and respira-
tion 42. His temperature dropped rapidly to 99° F., his
condition improved, and although he was semidelirious,
seemed to understand questions (see temperature chart).
He was a well developed and well nourished man, with
a slight icteroid hue to the skin. Slight epigastric tender-
ness was present, the liver could not be felt, and the spleen
was just palpable.
The blood examination on the second day after admission
showed 24,000 leucocytes per c.mm. with 56 per cent, poly-
nuclear, II per cent, large mononuclear leucocytes, and 32
per cent, lymphocytes. No red blood cell count nor esti-
mation of haemoglobin was made.
The blood examination for malaria, sixteen hours after
entrance, showed an excessive number of signet ring forms
of Plasmodia. The urine contained no albumin, blood, nor
casts. The diagnosis of malarial fever and alcoholism was
made, and quinine sulphate was administered in large doses
by mouth.
On the morning of the second day the temperature rose
rapidly to 103° F. and remained there all day. His mental
condition during the afternoon was that of apathy and
gradually merged into coma. Shortly before midnight of
the third day under observation he had a chill lasting
twenty minutes, followed by a rise of temperature to 105.8°
F., pulse of 140, and succumbed.
Blood smears were examined sixteen hours, twenty-four
hours, and forty hours after entrance chill and just after
death.
The blood taken twenty-four hours after the entrance
chill showed in the red blood corpuscles an excessive num-
ber of signet ring forms of the aestivoautumnal malarial
parasite (see Fig. i).
•Presented before the New York Pathological Society, November
13. 1907. and before the Section in Medicine of the New York
Academy of Medicine, February 18, 190S.
The rings were small, occupying about one sixth of the
area of the erythrocyte ; in the early stages with thin bodies
and a small amount of fine pigment and one nucleus ; in
the later stage with thicker bodies, more pigment, and
occasionally two or more nuclei. Many of the parasites
were near the edge of the cell with the nucleus protruding
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Temperature chart. .Xestivoautumnal fever, pernicious type.
into the cell wall. Nearly 75 per cent, of the erythrocytes
contained parasites, very many with two. many with three,
and some with four organisms. The infected cells were
small and shrunken, their cytoplasm dark and many cre-
nated, and there was a marked absence of granular degen-
eration.
Fig. 2 shows the organism of simple tertian malarial
fever in a pale enlarged erythrocyte which can be con-
trasted with that of the pernicious type.
The blood examined eight hours before death or forty
hours after entrance showed but few plasmodia in the
forms of well developed signet rings and schizonts. occur-
ring from one to four in a cell. There were numerous
macrophages containing large amounts of black pigment,
and some polynuclear leucocytes containing fine pigment
along their rim (see Fig. 3). Macrocytes, microcytes. and
a few nucleated corpsucles were present in this specimen.
A few crescents with pointed extremities were seen, demon-
strating beyond a doubt the restivoautumnal form of the
fever (see Fig. 4).
The blood examined at the time of death (following the
Copyright, 1908, by A. R. Elliott Publishing Company.
672
SATTERLEE: PERNICIOUS MALARIA.
[New York
Medical Journal.
second chill or about forty-eight hours after the entrance
chill) showed an excessive number of ring forms, often
three or four in one corpuscle, crescents, ovoids, and
nucleated red cells, signs evident of dissolution.
An autopsy was performed fifteen hours after death.
The body was slightly jaundiced but showed no pigmenta-
tion of the skin or mucous membranes. The lungs showed
a moderate congestion with cedema at the bases. The
d
hours before derth. Stained with Wright's stain. Oil immersion
lens 1/12, ocubr 4. Camera lucida. a, Erythrocyte containing one
well developed ring form; b, one with two; and c, one with three
ring forms; d, ring form containing three nuclei. There is no
granular degeneration of the corpuscles nor increase in their size.
pleural cavity was free from fluid. Microscopical examina-
tion demonstrated an intense congestion of the pulmonary
capillaries, which contained numerous organisms in all
stages, numerous macrophages, and free pigment. There
^vas no general consolidation ; some of the alveoli were free
Ktn. 2. — Simple tertian malarial fever. Wright's stain. Oil im-
ttiersion 1/12, ocular 4. Shows corpuscle infected with pigmented
tertian organism. Note the enlargement of the cell.
from exudate, others contained quite a few leucocytes, pig-
mented epithelium, macrophages, and a small amount of
■fibrin.
The heart muscle was pale and flabby, the valves normal.
The coronary arteries were normal. The aorta had a
slight fatty infiltration of the intima. The arteries in
^leneral throughout the body showed very slight indications
of arteriosclerosis.
The stomach showed a chronic atrophic gastritis with
flattened rugae raid congested mucosa. There was marked
congestion of the large intestine.
The spleen was enlarged, weighed one pound, and had a
Fig. 3. — Blood from a case of pernicious malaria, taken eight
hours before death. Tenner's stain. Oil immersion 1/12. ocular 4.
Camera lucida. a. Erythrocyte containing one well developed ring
form; b. erythrocyte with one full grown schizont; c. one with two
full grown schizonts; d, macrophage Note the small size of the in-
fected corpuscles and the lack of granular degeneratio;i.
moderate old interstitial splenitis with a few old cicatrices
on the surface. The section revealed a small amount of
interstitial conncclive tissue, and a pulp of moderately soft
<
KiG. 4. — Blood from a case of pernicious malaria, eight hours be-
fore death. Jennei s stain, a, Crescent; b, erythrocyte containing
four schizonts.
consistency and of a deep red color. Tlie organ did not
indicate any severe long standing chronic malarial infection.
Smears from the spleen will be described later.
The liver was much enlarged and weighed six and three
quarter pounds. The surface and section showed marked
congestion of the veins and the lobules were well mapped
out. Microscopical examination showed cloudy swelling
of the liver cells with brown pigmentation. The capillaries
were markedly congested and contained numerous malarial
organisms and masses of black pigment. Hremosiderin
reaction was absent.
April II, 1908.]
SATTERLEE: PERNICIOUS MALARIA.
673
Smears from the fresh liver showed marked pigmenta-
tion of the liver cells, and in the erythrocytes numerous
ring forms, fully developed schizonts, and segmentation
bodies. Numerous micro- and macrogametocjtes are pres-
ent. The liver was evidently an organ in which an active
development of the malarial organism took place.
The kidneys presented the appearance of acute congestion
with a pale parenchjTna and no gross interstitial changes.
Microscopical examination revealed a quite marked cloudy
swelling of the epithelium of the convoluted tubules, with
some granular degeneration and breaking down of the cells.
The capillaries of the glomeruli as well as the larger blood-
vessels, especially the veins, were acutely congested and
contained numerous intracellular parasites.
The pancreas on gross appearance was normal, but on
microscopical examination showed deficiency of zymogen
granules in the epithelium. The congested bloodvessels
contained numerous organisms, macrophages, and black
pigment granules.
The brain was apparently normal except for a moderate
cious type of organism that the ring forms are very
small, and often occur as two or more in one cor-
puscle. When full grown they occupy up to two
thirds the volume of the cell, which shows a ten-
Fic. 5. — Smear from the bone marrow in a case of pernicioui
malaria. Wright's stain. Oil immersion 1/12, ocular 4. Camera
lucida. a, Microgametocyte; h, erythrocyte containing moderately
developed schizont; f, intracellular segmenting bodies with twenty
merozoites; d, free pigment.
congestion of the bloodvessels. Microscopically there was
a moderate congestion of the capillaries and small arteries,
which contained a proportionate number of organisms and
pigment.
Smears from the bone marrow of the ribs showed a
large number of microgametocytes, numerous ring forms
and segmenting bodies and a large aniount of free pigment
in masses (see Fig. 5).
Smears from the spleen were stained with Wright's and
Jenner's stain (see Figs. 6, 7, and 8").
Every stage in the asexual development of the parasite
can be demonstrated (see Fig. 6). Here can be seen the
early and late signet rings, schizonts. rosettes, and segment-
ing forms. The latter contain from fifteen to twenty-five
merozoites. Many er>'throcytes contain two, three, and four
parasites.
Microgametes and microgametocytes were very numer-
ous (see Fig. 7) and less numerous macrogametocytes.
These are evidenced by their larger size, finer pigment, and
more distinct vacuolization near the rim of the cell (see
Fig. 8). Macrophages are especially numerous. Some
hyalin bodies are also present.
;Max Braun (i) says of the malignant or pemi-
FiG. 6. — Smear from the spleen in a case of pernicious inalaria
Jenner's stain. Oil immersion 1/12, ocular 4. Camera lucida. <j
Microgametocyte; b, segmenting bodies with from twenty to twenty
five merozoites: c, erythrocyte containing two signet ring forms
d, same with three; and e, one with four ring forms; /, macro-
phages. J
dency to shrinking and is darker than normal. ^ The
number of merozoites varies from eight to tw'ent}-
four, the average between twelve and sixteen. In
Fig. 7. — Smear from the spleen in a case of pernicious malaria.
Wright's stain. Oil immersion 1/12, ocular 4- Camera lucida.
a, Microgametocyte; b, erythrocyte containing a fully developed
signet ring; c, segmenting form with eleven merozoites.
674
HERZIG: SARCOMA OF CHORIOID.
[New
Medical
York
Journal.
south European and in tropical malaria, the or-
ganisms are very numerous in the circulating blood,
but seldom so in a west African pernicious fever.
C. W. Daniels (2) says that sporulation in malig-
nant malaria occurs almost
exclusively in the internal
organs. That in fatal
cases, with cerebral symp-
toms, the sporulating and
full grown forms can be
observed in enormous
numbers in the brain and
in other organs, lungs,
suprarenals, liver, etc., but
rarely in the kidneys. He
says that the pigment in
cases of short duration is
in fine granules only ;
cloudy swelling and fatty
degeneration are the prin-
cipal changes that occur
in the viscera ; and that
the blood stasis in the ca-
pillaries in the brain causes the large part of the
headache, drowsiness, and coma of the disease.
Conclusions.
( 1 ) This was a case of acute malignant or per-
nicious malarial fever of the sestivoautumnal type
(tertian form, according to Dr. Charles F. Craig,
U. S. A.) (3).
(2) Death was caused by the overwhelming in-
vasion of the blood by the parasite, and due pos-
sibly to the toxines evolved and not to acute cere-
bral congestion and thrombosis.
(3) The sporulation of the organism took place
principally in the inner organs, especially in the
spleen, liver, lungs, pancreas, bone marrow, and to
a less extent in the kidneys.
(4) Alcoholism played a small part as a fac-
tor in the man's death.
(5) The gametes may not be seen in the per-
iplieral circulating blood until just before death.
(6) The diagnosis of pernicious malaria can be
made on the small size, dark cytoplasm, and shrink-
ing of the cytoplasm of the infected corpuscles.
References :
1. Max Braun. Die tierischen Parasiten.
2. C. W. Daniels. Studies in Tropical Medicine.
3. C. F. Craig. In Osier's Modern Medicine.
60 E.^ST Seventy-eighth Street.
REPORT OF A CASE OF SARCOMA OF THE
CHORIOID.
By Arthur J. Herzig, M. D.,
New York.
I deem it of sufficient interest to the profession to
report this case of sarcoma of the chorioid, not that
the malignancy of the case is important or rare, but
that the case is unusual in that it has run an unusual
course. The case is as follows :
Mr. H. struck his head against an iron pipe about March
24, 1907. .About a week afterward he complained of a sud-
den diminution of vision, and consulted his family physi-
cian, Dr. H. Goldman, who referred the patient to me for
examination. I first saw the patient on .\pril 12, 1907.
Family and Personal History. — There is no history of
rheumatism, tuberculosis, gout, diabetes, or syphilis. Pa-
tient has always been a healthy man, active in work, leading
an out of door life. His business is real estate, age fifty-
six years.
Examination of the right eye revealed the following:
Media clear. Pupillary reaction normal to light and con-
vergence. Pupils of normal size and equal. The lens
Fig. 8. — Smear from the spleen in a case of pernicious malaria. Sta
Oil immersion 1/12, ocular 4. Camera lucida. a, Macrogametocyte ;
segmenting form with sixteen merozoites.
ed with Wright's stain.
I, microganietocyte; c,
showed several opacities in the periphery, but was clear in
the center. Indirect examination showed a slight oedema,
just below the region of the disk. In the lower and nasal
portion a marked detachment presented itself which was
ill defined and whose outlines were irregular. The veins
larger and fuller than normal and arteries of normal size.
There was no arterial sclerosis. The detachment could not
be seen by the objective examination. Tension of the eye
was normal. Range of vision was lost in the upper and
outer portions. Chorioidal vessels could not be seen over
the detachment. Muscle balance normal. Sclera white and
tense. Vision 20/200. Not improved. Near vision negative.
Examination of the left eye revealed the following: A
normal fundus with normal vessels and normal disk. Pupil-
lary reaction normal to light and convergence. Some slight
opacities were present in the lower lens. Cornea was
clear. Pupil of the same size as that of right eye. Tension
normal. Muscle balance normal. Sclera white and tense.
Range of vision normal. 20/50-0.75 sphere equals 20/20.
Near vision add plus 2.00 to the above for Jaeger No. i.
Diagnosis.— Detachment of the retina due to subretinal
haemorrhage or tumor.
Course. — The patient was ordered to bed in a dark room
on plentiful nourishing diet. His eyes were bandaged, as a
precautionary measure to exclude all light, with a black
bandage over a white bandage. I put the patient on in-
creasing doses of the saturated solution of potassium
iodide, starting to give him 10 drops three times a day in
water. I increased this to 60 drops within a week. Two
drops of atropine sulphate i per cent, were dropped into
the right eye three times daily. This was later increased to
ever}' two hours. I enforced absolute quiet. The vision
at the beginning of the treatment was 20/200. His range
of vision was almost entirely lost. The patient complained
of severe pain over the right eye during the entire week.
These pains seemed especially severe at night. Examination
of the eye on April 19th showed a distinct mass in the
lower and inner portion of the globe. This was seen by
direct objective examination. Examination with the oph-
thalmoscope revealed a dark mass. Range of vision was
entirely lost and vision reduced to fingers at 2 feet. Ten-
sion was minus i. From April 19th to April 27th the pa-
tient's vision gradually increased until it reached 20/100
and he could tell the time of a watch easily. Tension during
this time was normal. I made daily examinations of the
patient and noticed a gradual disappearance of the tumor
during this time until my original detachment could be
seen. The mass gradually disappeared so that it was im-
possible to see it by the objective method. The pain in the
head during this time became gradually less, and the patient
rested fairly comfortably and only complained of a bad
taste in his mouth and a spoiled stomach, whicTi was prob-
ably due to the lying on his back and the potassium iodide.
During this time the patient complained of severe itching,
which annoyed him considerably. I forgot to mention that
April II, 1908.]
PEDERSEN: VIVISECTION.
675
the patient was freely purged by Epsom salts during this
«ntire treatment.
There was no circumcorneal injection during any part of
the time, the sclera remaining perfectly white; the patient
having only a slight catarrhal conjunctivitis. This was
relieved by dailv applications of i per cent solution of silver
nitrate. From' April 19th to April 27th the patient was
taking 80 drops of potassium iodide three times a day. On
the 27th of April the patient suffered considerable pain in
the right eye and also itching. I w-as sent for, and upon
examination I found a large mass in the lower nasal por-
tion of the globe. This mass had made its appearance over
night, as it was not present on the 26th of April, when the
patient's vision was 20/100. On the 27th of April his vision
had suddenly decreased to fingers at i foot. At no time
during the entire illness were choroidal vessels seen pass-
ing over the tumor.
At the time of my examination on the 27th of A.pril, I
pronounced the case one of sarcoma of the chorioid and
advised immediate enucleation. This the people objected
to without a consultation. Dr. Born was called in consul-
tation, and after a thorough examination fully agreed with
my diagnosis, and also advised immediate enucleation. The
people not being satisfied still, asked for a third consulta-
tion, and Dr. Gruening was sent for, who, after an exam-
ination, also agreed with our diagnoses. The patient was
immediately sent to the hospital, and on the 28th of April
I removed' the right eye. The patient after remaining at
the hospital for six days went home. During the patient's
stay at the hospital his temperature rose suddenly to 102° F.
the day following the operation, but upon the administra-
Sarcoma of the Chorioid.
tion of Epsom salts promptly dropped to normal. Aside
from a catarrhal conjunctivitis, which usually follows an
•enucleation, the patient felt perfectly well.
Microscopical examination showed a round cell melano-
sarcoma. Macroscopical section showed a tumor about the
size of a large pea lying in the lower portion of the eyeball
between the retina and choroid, and raising the retina con-
siderably. The tumor was round and sharply outlined. It
was completely surrounded by a fibrous pigment layer.
Above the tumor was a large detachment, beneath w-hich
there was considerable exudate. Below the tumor was an
exudate also, causing a detachment which was probably a
haemorrhage. The tumor was not attached to the optic
nerve. The detachment in the lower portion reached nearK
to the insertion of the ciliary body. The insertion of the
ciliary bodies were exceptionally well presented in this
specimen, the lens showing several opacities and the iris
showing its two layers clearly.
In conclusion, I wish to thank Dr. Braiin
and Dr. Dixon for the painstaking efforts they
have taken in the preparation of the micro-
macroscopical sections. The pecuHar retro-
gressive course of the sarcoma at first seemed un-
usual, as it misled me in feeling that I had a case
of haemorrhage which was being absorbed : then,
suddenly assuming its original size, it plainly showed
its malignant character. The gradual improvement
of vision from the 17th to the 27th of April also led
me to believe I had a case of haemorrhage to deal
with. The absence of chorioidal vessels running
over the tumor was another factor, and. lastly, the
malignant character, showing itself by its sudden
enlargement, accompanied with marked detachment
of the retina. Socket of the right eye during Janu-
ary, 1908, showed no recurrence of any tumor, the
patient being contented and wearing his glass eye.
He still has a chronic conjunctivitis, which is being
treated by the usual methods.
2047 Seventh Avenue.
VIVISECTION FROM A STUDENT'S STAND-
POINT.*
By Victor C. Pedersen, A. M., M. D.,
New York.
It is certainly a privilege and an honor to come
before you on this occasion, and I sincerely thank
you in the name of the Medical Society of the State
of New York, which I represent through the Com-
mittee on Legislation. I do not utter the slightest
reflection upon the purity of motive, the loftiness of
aim, or the inspiration of kindliness which are be-
hind the antivivisection movement. There are.
however, many misrepresentations which physicians
hear by word or read in pamphlets which are mis-
leading and unfair, the correction of which is only
the just due of those who practise the noble science
of vivisection, a term which I use to embrace all
forms of experimentation upon animal life. As a
matter of fact, the reverse would be a better ter-
minology, as vivisection is only one form of experi-
mentation. As, however, this movement is called
an antivivisection movement, one is temporarily
compelled to make the term vivisection the more
generic of the two terms. The word suffering is
used in its broadest sense to mean exactly what its
derivation means from sub. under, and fero, I carry,
that is to say, "to undergo." and it therefore applies
to any form of animal experimentation with or
without the perception of pain. The phrase "per-
ception of pain" means conscious or partially con-
scious pain in the animal. If we stand in common
upon the ground of these definitions, misunderstand-
ing will be impossible.
As a premise for beginning, I may repeat the
words of the lady who honored me with the invita-
tion to appear before you, namely: "It is unthink-
able that physicians who spend their lives in the
service of human suffering and disease should be
really guilty of wanton cruelty to animals." An-
other premise is the fact that pain is perceived less
and less as the scale descends from higher to lower
warm blooded animals and from warm blooded to
cold blooded animals.
The text for my remarks will be furnished by a
letter which I have written to the members of the
Committees on the Jtidiciary of the Legislature, in
answer to which several have written that it has
furnished them with exactly the kind of informa-
tion which they need in brief form. That part of
the letter which concerns my object to-day is as
follows :
Physicians are not, as the antivivisectionists be-
lieve, indifferent to animal suffering and pain, but
they recognize that the amelioration of human suf-
fering and the cure of human diseases are ends
which transcend all other considerations. If forty
*An address delivered by invitation, March 23, 1908, before the
National Society of Ohio Women, with the approval of the Com-
mittee on Legislation of the Medical Society of the State of New
York.
676
PEDERSEN: VIVISECTION.
[New York
Medical Jocrxal.
years ago, in 1867. when the present law regarding
vivisection was passed, vivisection had been forbid-
den or greatly restricted, the following well known
elements of medical knowledge might not to-day be
established. I am neither gray haired, bald headed,
nor the holder of a professorial appointment. How-
ever, having been graduated only ten years ago, I
come before you with the standpoint of a student
\\ho may perhaps make clear the value of well
known vivisection demonstrations. This I trust to
do in the simplest and most comprehensible terms.
I cannot burden my discourse with scientific detail
lest it confuse and weary you. The following, how-
ever, are ten points of importance gained for man-
kind through vivisection :
1. The knowledge of the parts of the brain and
spinal cord which govern various parts and func-
tions of the body.
2. The fact that one kidney, the whole .spleen,
about one third of the intestines, the whole stomach,
the womb and the ovaries, as examples, may be re-
moved without death of the individual necessarily
ensuing. Nearly every one has had friends or rela-
tives upon whom such operations have been per-
formed successfully.
3. The life sustaining value of normal salt infu-
sions in cases of haemorrhage, shock, and poisoning.
4. The possibilities of resuscitating the victim of
electrical shock by hanging his head downward and
performing artificial respiration.
5. The modern treatment of diphtheria with anti-
loxine serum. Similar sera are now available in
other diseases of which typhoid fever and meningi-
tis are types.
6. The amelioration. and cure of certain forms of
goitre, founded upon observations by Victor Hors-
ley on monkeys many years ago.
7. The comparative safety and dangers of various
anaesthetics singly, in sequences, and in combina-
tions.
8. The possibilities of skin grafting in burns and
other accidents.
9. The absolute understanding of the mechanics
of the circulation, both as to the heart itself as a
muscular pump, and as to the bloodvessels as vastly
important, elastic and muscular auxiliaries of the
heart.
10. Sera as antidotes for snake bites. The British
government estimates that 20,000 human beings
each year die in India of the cobra bite alone. When
the present successful serum shall have been effi-
ciently distributed so that some of these people may
be saved, of what possible value will be the guinea
pigs and other numerous animals used in developing
the serum? This work was begun twelve years ago
by Professor Stewart, of Edinburgh.
Modern teaching is founded on the principle that
the pupil shall perceive an entity as such, remember
and reason from that and not trust to mere memory
of printed statements for his supply of knowledge.
In illustration, the child of to-day is taught his spell-
ing not from a long list of words selected from a
dictionary, but as an act of perception of words as
wholes as he reads. Likewise he is taught his nat-
ural history not by picture and' printed page, but by
excursions into the fields and woods with his teacher,
where he watches the spider weave its web, the bird
make its nest and rear its young, and the caterpillar
eat its special food and pass into the cocoon and
then the butterfly stage. Later on, the boy and
girl are taught their physics and chemistry in high
school and college not as bare printed statements,
but as the results of actual experiments in the labor-
atories. All these things are as they should be, and
will in the future produce and train minds probably
superior to our own in acumen of perception and
validity of reasoning.
Why then should the medical student be denied
by law the value of the same kind of instruction in
the laboratory through vivisection of animals ? The
medical man deals with vital forces which cannot
be weighed or measured, but whose action can be
estimated only by the study of the processes of life.
Thus it is that the medical student must make ob-
servations upon animals in order to grasp the mean-
ing of scientific facts which cannot possibly be
learned from the printed page with equal certainty.
In illustration of what I mean and as a matter of
personal experience as a student fourteen years ago,
let me go back to the headings already enumerated
and briefly give you illustrations under each.
1. I learned beyond all possibility of mistaking
or doubting the general plan of the principal .warm
blooded animals as to the control of the brain over
the muscles and other organs of the body from the
following demonstration : A dog was put under an
anaesthetic, and the top of its head removed, thus
exposing the brain. While still under the anaesthetic
various points of the brain were gently touched
with an electric pole carrying a weak current of
just strength enough to provoke slight reaction in
various parts of the dog's body in turn. After the
demonstration the dog, while still under an anaes-
thetic, was killed. No death could have been more
merciful and no means of teaching as adequate, fit-
ting, or lasting. Could this dog possibly have ful-
filled the purpose of its being better than by teach-
ing several hundred medical students these all im-
portant facts? Does any pet dog, no matter what
may be his money value as such, ever contribute
to the cause of human knowledge and benefit what
this cur did under the anaesthetic followed by death?
2. From animal vivisection it is now known that
nearly one third of the intestinal tract may be re-
moved without death. This shows the injustice and
unwisdom of requirmg the death of all animals
vivisected, because after many of these operations
effort must be made to keep the animal alive in
order to study the effect of the operation upon the
economy.
The application of this fact was illustrated in
the case of a Dublin boy who was run over by a
truck, but who, instead of being allowed to die as
he would have been fifteen years ago, underwent an
operation for the removal of several feet of his in-
testines. The child recovered and showed exactly
the same differences which are found in animals after
such vivisections, namely, that he had to make up
for the shortening of his intestines by a vast in-
crease in the amount of his food. This boy may
some day be prime minister of England ; even if
he is not, of what possible importance compared
with his life are the distress and the deaths of ani-
mals used in developing this point of knowledge?
April II, 1908.]
PEDERSEN: VIVISECTION.
^77
Primarily through observations upon animals it
is now known that one kidney may be removed;
and more than that, parts of both kidneys may be
sacrificed without death of the subject provided the
remaining portions are heahhy.
Diseases of the spleen are in some patients now
cured by removal of the spleen. Years ago these
victims would have been allowed to die unaided.
Through animal vivisection it has been learned that
the bone marrow becomes the substitute of the
spleen in producing the corpuscles of the blood.
The fact that the womb, and the ovaries, may be
sacrificed without material harm is a matter of the
commonest knowledge to-day, and yet much of the
detail of that knowdedge was gained at first through
operations upon animals.
It may be almost needless to add that all these
operations are done under an anaesthetic and the
animals treated thereafter exactly as though they
were human beings in the effort to make them re-
cover. Most of them are as happy . in the labora-
tories during their recovery as are human beings in
the hospitals, and recognize the doctors w-ho work
upon them with wags of the tail and laps of the
tongue.
3. The fact that the infusion into the veins of
C.6 of a I per cent, solution of common salt will
sustain life in cases of shock, haemorrhage, and poi-
soning, was very largely developed through vivisec-
tion. We now know within very reasonable limits
of accuracy how much blood by weight an animal
may lose and not die, provided the salt solution is
quickly substituted for the blood. Through animal
observations it has also been proved, and later ap-
plied to the human being, that a failing heart in
shock may be brought back to life sustaining con-
dition by such infusions. From the same source,
namely, vivisection, it has been abundantly estab-
lished, and later employed for man, that, in some
cases of poisoning, blood letting followed by a salt
infusion will save life. Remembering the human
beings saved by scores each year in the civilized
world by these means, of what significance are the
animals which underwent vivisection, either with or
without unavoidable perception of pain, to prove
these things?
In illustration I remember a man who died after
an amputation of both legs due to a railway acci-
dent eleven years ago when I was an interne in one
of our large hospitals. Two years ago I saw a
woman survive the same operation because with
better knowledge she was first gently infused until
her heart improved and then after just enough
anaesthetic had been given to stop pain, and no more,
the amputation was quickly done. Part of this skill
was gained from vivisection.
4. From time to time one hears of cases of elec-
trical shock in the human being followed by recov-
ery due to inverting the patient and giving artificial
respiration and stimulation. The fact that within
certain limits electrical shock need not necessarily
be followed by death was first demonstrated upon
animals. Are the lives of the animals which suf-
fered, or the actual misery they underwent, any-
thing in comparison with the human being of to-day
who may be saved?
5. In the days before the diphtheritic antitoxine
had been developed nearly eighty per cent, of all
children, victims of the disease, died. Mortality has
been reduced now to less than ten per cent., if the
children be seen early, the disease correctly diag-
nosticated, and the antitoxine quickly administered.
Yet this serum was produced at the cost of some
animal suffering in various creatures until finally
the horse was found to be the best source of the
serum. Can we stop to consider this loss of animals
when we remember the safety of our own children
thus cured? Compare, for example, two cases
within my own experience. In 1873 ^ had a cousin
die of diphtheria of the larynx in forty-eight hours,
just as she w-as reaching young womanhood. Two
years ago I saved the infant son of a comrade, the
victim of diphtheria of the larynx, by a timely in-
jection of antitoxine. In less than four hours after
receiving it the child's condition began to improve ;
he passed a quiet night for the first time in several
days, and, in tw^o days, instead of being dead, was
practically symptom free. It is needless, of course,
to say that in this baby no membrane had as yet
formed, but it was sick enough to get up on all
fours at night to breathe, at times also ran a high
temperature, and had a poisoned look.
The Board of Health in 1907 reports 15,276 cases
of diphtheria. If eighty per cent, of these had been
lost, the deaths would have been 12,221 as against
the actual number of 1,740. This fact is without
reference to the violent epidemic which would have
ensued but for the preventive value of serum treat-
ment. No distinction is inade in the number actual-
ly lost due to cases complicated with scarlet fever,
Bright's disease of the kidneys, pneumonia, and the
like, and last and most important, due to ignorance
and neglect on the part of parents, whereby serum
was omitted or given too late.
6. Goitre or enlargement of the thyreoid gland
was first explained by Victor Horsiey, about twenty
years ago, through vivisection of monkeys in Eng-
land. His results have made it possible to rescue
from a life of idiocy and uselessness children who
are born without a thyreoid, known technically as
cretins. They are dull of eye, with at best slow
minds, or practically deprived of intellect, thick
tongued. sallow, heavy skinned, and on the whole,
revolting and disgusting in appearance. Thyreoid
extract given to these individuals will commonly
work miracles. I remember as a student seeing a
baby changed in eight months from a useless and
disgusting specimen to a playful and interesting
child by just this form of treatment.
Another form of goitre is characterized by rapid-
ity of the heart, causing breathlessness, extreme
nervousness, and a terrifying prominence of the
eyes. Horsley's observations have also served to
demonstrate the best way of returning these un-
fortunates to perfect or reasonable health.
In speaking of goitre before our class Professor
Starr said that vivisection needed no apology; if it
did, the experiments of Victor Horsiey as to goitre
would for all time be the only apology necessary.
Applause, in which you ladies would have joined
if you had been present, followed these remarks
upon our seeing the human beings who proved the
truth of this assertion by their cures and improve-
ments.
6-8
PEDERSEN: VIVISECTION.
[New York
Medical Journal.
7. In general terms it is known that ether and
cliloroform are the best anaesthetics we have, yet
animal experimentation involving the death and suf-
fering of some animals has shown that chloroform
depreciates the value of the circulation from ten to
thirty per cent., a fact which must be reckoned with
in choosing between the two at all times. Yet, on
the other hand, it has reasonably been proved, simi-
larly with sacrifice of animals, that if the fumes of
these anaesthetics are given warm the dangers are
almost divided by two. When after years of obser-
vation in the human being these facts become thor-
oughly recognized, where will the animal loss stand
in summing up the usefulness of the results ob-
tained ?
8. Skin grafting is now a matter of common
knowledge, yet some of its principles are born of
the sufYering imposed on animals, proving the fact
that in certain instances living parts of the body
may be rapidly transmuted to other parts and sur-
vive.
9. The actual mechanics of the circulation, as to
the heart itself as a muscular pump were shown by
the following experiment before about five hundred
medical students in college when I was there.
A calf was thoroughly anaesthetized and its heart
widely exposed through the chest wall. While the
animal was kept alive and breathing by artificial
means, it was possible to watch the course of the
blood with great accuracy as it flowed into the heart
and out again.
Through this animal demonstration under an
anaesthetic, the medical student of to-day is shown
how the blood, returning to the heart from the sys-
tem at large and from the lungs, rushes into the
upper part of the heart, technically called the auri-
cles, passes, by a contraction of both auricles to-
gether, into the lower or heavier part of the heart
called the ventricles, and by contraction of these in
uni.son into the lungs from the right ventricle for
purification and from the left ventricle into the
main blood channels for nourishment of the body.
This demonstration is so graphic that no human
being of ordinary perception and understanding can
ever after it have any confusion in his mind as to
what the heart is doing when he listens to it in the
chest of the patient. The characteristics of change
of blood pressure by contraction and dilation of the
bloodvessels and many other wonderful features
of the circulation of the blood are also shown in a
similar way. Since all these matters of knowledge
are for later practical application in the treatment
of disease among human beings, of what possible
matter is it whether a certain number of animals
perceived some pain perhaps, or even in many in-
stances lost their lives? All the animals used for
such purposes are under anaesthetics, and after the
lesson is over are destroyed before they come out
of the anresthetic. To deny the right of the medi-
cal student as he comes and goes generation after
generation to see these same demonstrations repeat-
ed would be like a professor stating to new classes
of mechanical engineers something like the follow-
ing: "This is a complicated and high speed engine;
ten years ago my class took it aj^art and put it to-
gether again in working order. These men have
since then become the leading engineers of the coun-
try ; you cannot, however, take the engine apart, but
will have to accept on faith what we learned about
it at that time."
There is certainly no cruelty whatever, directly
or indirectly, in employing animals for such pur-
poses. Each medical student is entitled to know
from his own personal observation and perceptions
exactly what these processes of life mean, exactly
as each student is entitled by actual experiment to
know the facts of other sciences, such as chemistry,
physics, electricity, and the like. To deny to medi-
cal students this right would be stepping backward
in their instruction thirty or forty years.
Which of the following two calves fulfils in the
higher degree the purpose of its being for man's
benefit — one which is slaughtered, its body con-
sumed as food, its skin as shoes, its skeleton ground
up for chicken food, and its entrails employed as
fertilizer, or a calf used for such as the foregoing
demonstration before five hundred medical students
vcho may in their lives through the knowledge thus
given easily benefit one hundred thousand human
beings? The .skin, flesh, skeleton, and entrails of
the second calf could well be emploved exactly as
those of the first, or its skeleton might be set up in
a museum of comparative anatomy to show the
beauty and the order of the animal kingdom, to lay-
men, medical, and veterinary students alike.
We have already spoken of antidiphtheritic serum.
Other important sera have been developed and ap-
plied as follows. They are all developed from pains-
taking animal experimentation, sometimes with suf-
fering, usually without perception of pain to the
animals. I am indebted to Dr. Simon Flexner, chief
of the Rockefeller Institute of Medical Research,
for the following authentic list of sera:
(a) Sera of wide application and great success
in diphtheria, dysentery, tetanus (as a preventative
measure), and antivenin (employed with great re-
sults against the cobra bite).
(b) Sera partially successful are employed in
meningitis, scarlet fever, typhoid fever, and against
the rattlesnake bite in animals. Cases of rattle-
snake bite in human beings are rather rare, and no
observations are at present recorded.
(c) Sera that are successful in treating animal
diseases are now available in anthrax, rinderpest (a
tropical disease common in cattle), and hog cholera.
(d) Protective inoculation of animals is now suc-
cessfully carried on in tuberculosis by serum obtained
from the human tubercle bacillus. Also in anthrax,
blackleg (quarter evil), and chicken cholera. Thus
is man handing back to his bovine friends (cattle)
protection from tuberculosis by inoculation. This
is the .same order of wonderful phenomena as is
vaccination itself in smallpox from cow to man.
Permit me to digress one moment to say that, if vac-
cination needed any argument to support and war-
rant it, that argument is found in the medical books
written at the time Jenner made his wonderful dis-
covery, that is. about 1700. Statements are met
with like the following: Three quarters of the en-
tire population of London have had the smallpox.
If London at this time was a citv of four hundred
thousand, three hundred thousand of these gave ob-
vious proof of having had the disease, a statement
which does not include any reference to the deaths
April II, 1908.]
I'UDERSEX: I 'II 'ISECTiOS.
679
from sniallfKDx at that time. Last year in New York
City the Board of Heahh reported fifty-eight cases
in a population of fully three million five hundred
thousand or four million during 1907. In Germany,
where vaccination is absolutely compulsory, the dis-
ease is almost extinct, excepting in the seaports,
where occasional cases arrive. Again in the
Franco-Prussian War. the French army, which had
no compulsory vaccination, lost by death from small-
pox vastly more soldiers than were even stricken
in the German army, the ratio being given by some
authorities as more than 10 to i. In the German
army all were vaccinated.
(e) Sera for establishing diagnosis in animals
are now available in tuberculosis and glanders re-
spectively called tuberlin and mallein.
(f) Among drugs of remarkable value proved by
animal experimentation is atoxyl. which is a won-
derful means of curing African sleeping sickness,
of which doubtless some of you have read. The
value of this, too, was developed by animal experi-
mentation.
(g) Rather satisfactory results have also been
obtained up to the present in the matter of cancer
experiments in rats and mice. When the day comes
for fully developed means of combatting this dread-
ful scourge in the human being, which one of you
will stand up and object to the possible suflfering
of the animals in developing that truly miraculous
product — because it will be truly miraculous?
To the foregoing ten illustrations of actual and
lasting benefits conferred on man by vivisection. I
could add many others, but time forbids, moreover
these ten elements of human knowledge thus gained
and proved from vivisection, are fully ample for our
purposes.
These remarkable and more or less familiar il-
lustrations of some of the results of well balanced
vivisection will prove my contention at the outset,
that this science is not a disgusting but an ennob-
ling sphere of human study.
A few words should be added as to the appa-
ratuses pictured in the lay press which are used in
vivisection. Kindly bear distinctly in mind the fact
that animals' backs are round and will not rest mo-
tionless upon a fiat table while they are under anaes-
thetics. It is therefore necessary to fix two boards
at right angles to each other to make a gutter like
pocket in which the rounded back of the animal will
not shift. Motion may mean failure of the whole
operation, and sacrifice of another animal.
Straps and other devices are required to keep the
paW'S of the animals away from the sterilized hands
and instruments. Similar methods are necessary
even in human beings under anaesthetics, because as
unconsciousness ensues frequently the arms and the
legs get into the surgeon's way and greatly impede
rapidity, precision, and surgical cleanliness of the
work. In man and in animals this apparatus is
beneficial, merciful, and well intentioned. and not
harmful, cruel, and malicious, as the pictures are
meant to imply.
For example, I saw one picture of a dog with
its mouth gagged wide open by an apparatus. No
screw or bar bore anywhere upon the dog except
that across its mouth and teeth. Had dogs the same
tooth plan as horses, namelv. had thev a space be-
tween the grinding teeth behind and the biting teeth
in front, this bar would have been resting in that
space and the dog could have closed its mouth.
This apparatus is no more an instrument of tor-
ture than are the mouth gags employed in man,
pictures of which almost made me faint when a
\oung man contemplating the study of medicine
and caused me to doubt my fitness, until I realized
that real sympathy lies not in the fainting but in
helping and in doing.
Let us turn now to the proposed Acts before our
Legislature limiting vivisection, with a brief criti-
cism of their shortcomings.
First the Cobb-Johnston Bill. It may very well
work a hardship to require that vivisection shall be
done only in certain institutions. For example, a
friend of mine practising in a mining town in Penn-
sylvania saw that miners who were tlie victims of
crushing, scalds, and other accidents, very frequent-
ly died if put under a general anaesthetic for treat-
ment. The thought occurred to this medical genius
that perhaps a local anaesthetic, of which cocaine
is the type, injected into the spinal canal might per-
mit life to continue during the early treatment of
the case. He therefore took thirteen dogs and
subjected them to various injuries similar to those
suft'ered by the miners. The question may arise,
why did he not anaesthetize them? This was be-
cause he had to repeat in the dogs the same condi-
tions found in the miners. The miners were not
under an aut-esthetic v.-hen injured, therefore the
dogs should not be. The miners died under anaes-
thetics while being treated : it was therefore neces-
sary to see how dogs would act under the two meth-
ods of anaesthesia. He proved that the dogs, too, died
under a general anaesthetic, but afterward found
that, if a local anaesthetic was employed, many that
previously would have died, lived. In the same
article in which he published these observations he
also published the reports of several cases of miners
who, under the influence of cocaine thus used, did
not die, but lived. C)f what value were these thir-
teen dogs in the face of these facts? If this doctor
had been compelled to go to New York or Phila-
delphia to carry out his experiments they might
never have been performed, for perhaps he could not
have afTorded to leave his practice for the purpose.
It is unfair to withdraw from the physician a
decision as to whether or not an anaesthetic is de-
sirable. The whole point of the observation may
rest upon not giving an anaesthetic, as for example
in the foregoing instance. If we are to unravel the
mysteries of the nervous system we must be al-
lowed free hands in deciding the best methods for
reaching the truth.
It would prove a hardship to require that animals
after the operation or experiment shall be killed,
because the result of the study may rest absolutely
upon whether or not the animal may be kept alive.
For example, consider the operations on various
organs, such as removal of the kidneys and the like,
followed by survival of the animal in good health.
It will deprive the modern medical student of his
best source of knowledge to require that facts al-
ready known shall not be demonstrated again to
each class by animal experiment. It would be
equally unwise to say that all chemical laboratory in-
68o
ROSE: MALARIA IN GREECE.
[New York
Medical Journal.
vestigatioiis shall cease so far as the proof of facts
already established is concerned. Knowledge can-
not possibly be gained so wisely and well as by see-
ing real, natural processes in the course of their
action. This necessarily includes the vital forces
of animal life with which the doctor has to deal
throughout his practice. As you have perhaps
noted already, one or a very few animals a year are
usually enough for a given demonstration in each
medical school.
Physicians are entitled to demand that their
scientific researches shall not be inspected by lay-
men and shall not be inspected under the direction
of lay societies, perhaps largely composed of mis-
informed and hostile persons. In other lines of
human activity the similar demand is made and ap-
propriately conceded, namely : The boilers of our
engines and factories are inspected not by layman
but by competent engineers. Our electrical instal-
lations are inspected not by laymen but by suitably
trained electrical engineers. To impose upon medi-
cal men any new principle is unwise, unfair, and
contrary to human experience through ages of civil-
ization.
I doubt very much whether any of you present
would honestly and honorably consider herself com-
petent to pass upon the validity of any animal ex-
periment, either from the standpoint of its pain giv-
ing or its results, even though she might stand be-
fore the law as the accredited representative of some
humane society. Such a requirement in this law
is against human experience in other lines of human
knowledge, and no new principle may fairly be ap-
plied to the form of human knowledge which we
are discussing.
Next, the compulsion of annual reports is another
objectionable requirement whereby scientific re-
search may very well be greatly hampered, inter-
rupted, and interfered with.
Certainly nothing but good to humanity has in
the past come from vivisection as conducted under
the present laws, and in virtue of these facts there
is truthfully no need of any new law. The Davis-
Lee Bill also imposes a number of injurious, vexa-
tious, and needless limitations upon the work of
men whose only idea is the amelioration of man-
kind.
The allegation is made that a similar law is of
advantage in England. Permit me to state the fol-
lowing facts : This law has in the past driven Sir
T. Lauder Brunton from London to Paris to per-
form experiments. Upon Brunton's work depends
much of our knowledge of the action of modern
drugs obtained by the improved methods of modern
chemistry. He is one of the greatest observers
of drug action in the world. Is it not hardship
and injustice that a man of his nobility of purpose
should ever have been driven out of his country in
order to perform experiments to the results of
which humanity is honestly entitled?
In closing let me allude to an incident which has
created a good deal of comment, namely, a memo-
rial erected in Battersea Park. London, by Stephen
Coleridge. The monument caused bitter hostility
among vivisectors, resulting in a riot, according
to Life, which also states that the inscription reads:
"In memory of the l)rown terrier dog done to
death in the laboratory of University College in
February, 1903, after having endured vivisection
extending over two months and havmg been handed
over from one vivisector to another until death
came to his release. Also in memory of the 232
dogs vivisected in the same place during the year
1902. Men and women of England, how long shall
these things be?"
Part of the fallacy of this monument lies in the
fact that many of these experiments upon this dog
must have been of a very simple nature and with-
out pain. Time does not permit me to illustrate
some of the valuable observations for teaching stu-
dents which may well have been carried out upon
this dog. Instead, however, of a riot ensuing, how
much better it would have been if another monu-
ment had been erected, a duplicate of the first, but
surmounted by the statue of an infant, and bearing
the following inscription :
"Sacred to the memory of the countless children
of tender years who in the past died of diphtheria
before the noble science of vivisection had given to
"men the knowledge of immunity, and of the serum
treatment of diphtheria, through observations on
animals. Sacred also to the memory of other human
beings who have died of diseases whose cure will
one day be discovered through vivisection. Sacred
also to the memory of the animals who in fulfilling
their purpose of existence in the service of man
have given up their lives for the establishment of
important facts in medical knowledge. And finally,
sacred to the honor of the noble men who with
singular honesty of purpose in the past and pres-
ent have, and in the future will, through well pur-
posed animal vivisection, bring to human knowledge
the present undiscovered mysteries of life."
In tl'te past much that is incalculably useful has
been accomplished, in the present much that is of
inestimable blessing is being attained, and in the
future more still will be given to man in knowledge
gained through purposeful vivisection. It behooves
the misinformed layman to be thankful and appre-
ciative, and not ungrateful and obstructive.
45 West Ninth Street.
MALARIA IN GREECE.
By a. Rose, M. D.,
New York.
At the annual international competition at the
Academy of Medicine of Paris the prize, a silver
medal, was awarded this year to Dr. John P. Car-
damatis, of Athens, Greece, for his work On Elono-
sia (Malaria) in Athens. In this monograph is
given the history of the disease in Athens from the
prehistoric times to the present day.
Dr. Cardamatis is the founder of a syllogos which
has for its object to combat malaria in Greece, and
stands under the protection of the king of the
Hellenes. Our distinguished Greek colleague hon-
ored me by sending me the report of his syllogos.
a large octavo volume of 653 pages for the years
1905 and 1906. written in Greek' by him and Pro-
^'H'EXoyoiia iv'EA.X({Si xai rd Tltirpayniya rov'S^'XXo-
yov 'EHSiSorat 'ETrtjaeXfi'a Ku>y6r. F. ^dfSfia uai 'luar.
n. Kapfitrfidr^ 'Eto? irfidarov xal Sfvrepov,^ ev 'ASi}ai?,
/907.
April II, 1908.]
ROSE: MALARIA IN GREECE.
681
fessor C. G. Sabba. of the University of Atlicns.
Presuming that much of the contents will be of in-
terest and value to American physicians, I will give
an extract of the same.
According to the statistics in this report Greece
is perhaps of all countries in the world the most
afflicted with malaria. This is also the opinion of
Ross, who has studied the disease in East India and
Africa, but it is contrary to Celli's view who gives
to Italy this unfortunate first place.
Malaria has been prevailing in Greece from the
remotest period all through its entire history. In
the Orpheus poems, assumed to have been written
about the year 1000 B. C., the different types of
malaria are most exactly described. The descrip-
tion of the disease by Hippocrates is well known to
all who are familiar with history of medicine. The
writers of the classical period in general describe
its existence during this time, only from the epoch
of the downfall of ancient Greece exact informa-
tions are lacking. Under Turkish rule cultivation
of the soil was neglected in Greece, and mostly so
during the War of Independence, which lasted seven
years. The little Greek nation had fought until
her land had been devastated and her race deci-
mated. The sword, famine, and disease had reduced
the population to about one third of its original
number, and this third to a state of most complete
destitution. Vegetation was destroyed, especially
the forests, by fire. On account of the bareness of
the mountains after the destruction of their forests,
torrents of water would overflow the fields and be-
come converted into marshes, the favored places
for the development of mosquitoes. After the war
was over, order began to be restored, the popula-
tion increased again, and the cultivation of the soil
was taken up anew, especially drainage of marshes.
But how much is left to be done yet will be seen
from the description of conditions existing at the
present time.
Official statistics about the spread of malaria in
Greece exist only since the year 1899, and even
these are as yet confined to the statistics of the
board of health of the twelve larger cities of Greece,
of those which have a population of ten thousand
and more. From these statistics we learn that dur-
ing the period from 1899 to 1906, that is in eight
years, there were 2,174 deaths in the large cities
from different forms of malaria, a yearly rate of
272. From ten thousand city inhabitants in Greece
9.7 die from malaria ; in 100 deaths 4.36 are due to
malaria. The details of these statistics regarding
the months of the year, the ages of the deceased,
the distribution over valleys, the immunity of the
altitudes over 800 metres, and all the details which
we expect to find in ofificial statistics are given.
While in Greece, according to the investigation
of the syllogos. among 100,000 inhabitants 12,848
are afflicted with malaria, the number in Italy is
only 4,058 among 100,000. While the Italian popu-
lation of thirty-four millions consumes yearly twen-
ty thousand kilogrammes of quinine, the Greek
population of two and one half millions (fourteen
times less than the Italian) consumes five to eleven
thousand kilogrammes.
There are one million acres of marshes in Greece.
A great deal of drainage has been done by two com-
panies, an English and a Greek company.
The syllogos, similar to the one established in
Italy, was formed by Dr. Cardamatis in the year
1905, who commenced his work on May 4, 1905.
It has the hearty support of distinguished physi-
cians, clergymen, politicians, in fact of the whole
population ; has been recognized by royal decree and
stands, as mentioned, under the special protection
of the king, who takes personally the warmest in-
terest in the vital question here involved, and, as
we shall see, promotes in many ways the work of
this patriotic society.
One of its first objects is to make popular the
information about malaria among all classes in all
cities and villages of Greece. To this end com-
mittees have been formed which are headed by the
highest in rank, the archbishops, mayors, physicians
of distinction, in fact all influential men. The next
object of these committees is to study all concern-
ing malaria in their respective districts, the existence
of marshes, the means and ways for the drainage of
such marshes, to destroy mosquitoes, to provide
quinine either free or at the smallest price for the
poor, as therapeutical as well as prophylactical
measure, to elicit the interest of the priests, the muni-
cipal authorities, the physicians, the teachers, to col-
lect money destined to promote the purpose of the
syllogos. In order to facilitate this work, the syllo-
gos has issued brief instructions, printed in form of
hand bills similar to those published in Italy, and
distributed them everywhere. They were sent out
by the Department of Public Instruction to the
teachers of the public schools with the request to
propagate the contents through the pupils to the
families. In order that the knowledge about malaria
becomes more clear among the population, pictures
of Plasmodia, of the development of the mosquito,
and other illustrations about the genesis of the fever
have been added. These illustrations are distributed
now to be hung on the walls not only in all public
schools, but also in the shops, the railway stations,
the coffee houses, etc. It is contemplated also to
put postal cards with illustrations concerning ma-
laria into circulation, and finally a kind of decalogue
corresponding with the Italian malarian decalogue,
commandments of precaution against malaria. It
is intended to give discussions with demonstrations
by means of the stereopticon not only in medical
societies, but also for teachers and the general pub-
lic in the cities. This has been considered as prom-
ising to be an effective mission for physicians who
will go from place to place, welcomed by the coun-
try practitioners, who will learn the most advanced
modern views.
The syllogos has addressed himself privately to
every one of the wealthy landlords, sending them
instructions about the measures of drainage of the
little marshes in their states.
The daily press and the literary magazines have
greatly contributed in disseminating the ideas of the
syllogos by publishing articles and pictures relating
to precautions against malaria.
Simultaneously with popularizing all these meas-
ures the syllogos collected information about loca-
tion of marshes everywhere and to make maps on
which they were marked.
For the destruction of the larvae of the mosquito
olive oil, petroleum, and lime are recommended.
Olive oil is abtmdant and often cheaper than petro-
682
FRIEDMAN: CAMMIDGE'S REACTION.
[New York
Medical Journal.
leum ; it can be used either alone or mixed with the
very popular oil of turpentine. A greater amount
of olive oil is required to cover a certain surface
of water, but on the other hand it is conserved for
a longer time than petroleum, which latter is quick-
ly evaporated. A special advantage in Greece is
that olive oil is always on hand, every peasant has
it in the home, and a further advantage is that it
has no odor and does not make the water unfit for
various purposes in the house, for the animals to
drink from, and for watering the garden. Besides
it has to be taken into consideration in Greece that
extensive distribution of petroleum is dangerous
where forests are near, and this danger must not be
overlooked on account of the great dryness which
exists in Greece in summertime, the many dry
bushes and that kind of tree, the pine tree, which
is especially combustible.
As the syllogos has under consideration the drain-
age of the great marshes, the surface of which
amounts to about a million acres, as told, and which
is most difficult and requires long time and exces-
sive costs which the budget of the government can
bear only gradually, the members directed their at-
tention to the drainage of the little marshes in the
neighborhood of cities and villages, the drainage of
which is easy by means of the well known methods.
To this end the syllogos recommended the drainage
of the little marshes, asking the government to pass
laws forcing the proprietors of every estate to make
the necessary drainage, public lands to be drained
by funds provided in the state budget or the com-
munities, or to oblige inhabitants to work personal-
ly. The government is also asked to form brigades
for special duty, corresponding to the Ross mos-
quito brigade.
126 East Thirty-fourth Street.
CAMAIIDGE REACTION IN PANCREATIC DIS-
EASE, WITH NOTES OF A CASE.
By G. A. Friedman, M. D.,
New York,
Visiting Physician to Yorkville Hospital and to the German Poly-
clinic.
VVliile our knowledge of the pliysiology and
pathology of the pancreas has greatly increased
(luring the past twenty-five years, no corresponding
advance has been made in the symptomatology or
the diagnosis of the lesions to which the gland is
subjected. Nearly thirty-three years ago Friedreich
wrote : "No single symptom which may occur in
pancreatic disea.se is pathognomonic, and even the
combination of several symptoms does not always
lead to a positive diagnosis." Little can be found
to aid one in diagnosis in either textbooks or mono-
graphs written since then. Even in diseases of the
head of the pancreas, where the signs are more
marked, it is often hard to exclude affections of
other organs with similar signs, as, for instance,
gallstones, cancer of the papilla of Vater. In most
of the cases where a correct diagnosis has been
made, this was done by the process of exclusion.
The character of icterus described by many authors
•Rcarl before the Kast .Side Physicians' .Association, with demon-
str.Tlinn of a specimen. Tebruary 21, 1908.
as being very deep in pancreatic lesions will hardly
help any one to make his diagnosis certain, as the
so called deep icterus may be present in affections
of the biliary tract just as well.
Should a mass be palpated in the supposed pan-
creatic region, which occurrence is very rare, its
proper connection with the gland is not always dis-
cernible. Pain in pancreatic affections is one of the
most unreliable symptoms on which to base our con-
clusions. Visible fat in the stools, marked amount
of neutral fat crystals under the microscope (steator-
rhcea), the presence of striated muscle fibres in the
stool (azotorrhcea), these are the findings which
may suggest a pancreatic lesion. This becomes ob-
vious by taking into consideration the fact that the
pancreas produces ferments for the purpose of
regulating normal digestion. In a diffuse affection
of the gland the power of secretion is either reduced
to a minimum or abolished altogether, the latter
happening very seldom. In obstruction of the duct
of Wirsung from certain causes, the flow of pancre-
atic juice is dammed off.
In such instances the reaction of Sahli may yield
negative results. This test is based upon the ob-
servation of Sahli that salol, a compound ether of
salicylic acid, is decomposed through the action of
pancreatic juice in the small intestines into phenol
and salicylic acid. A violet color is produced by
adding a small amount of ferric chlorid solution to
the urine, due to the presence of saliciluric acid
eliminated through the kidneys.
In assuming a normal motility of the stomach, or
nearly so, the pancreatic juice had not entered the
bowel if, after taking 2 grammes of salol, the urine
of the patient does not show the above mentioned
reaction after a lapse of twenty-four to fort\-eight
hours.
Of greater importance is the quantitative estiina-
tion of nonutilized fat and nitrogen in the stool.
For this purpose it will sometimes suffice to place
the patient on a inixed diet. But to obtain correct
results a standard diet, as the one proposed by
Schmidt, must be resorted to for at least three
days, viz.: In the morning — One glass cocoa (pre-
pared from J/3 of an ounce cacao powder, J4 of an
ounce sugar, 2 ounces milk, 6 ounces water), and
2 ounces zwieback. In the forenoon — ^Two glasses
of oatmeal gruel (from ly^ ounce of oatmeal,
ounce butter, ^ ounce milk, 10 ounces water, and
one egg strained). At noon — 4 ounces chopped beef
(raw weight), broiled rare with ounce butter.
In addition, 8 ounces potato brotli (made of 6
ounces mashed potatoes, ounces milk, and
ounce butter). In the afternoon — As in the morn-
ing. In the evening — As in the forenoon.
With the first breakfast a five grain carmin cap-
sule should I)e given to the patient, for the purpose
of demarcating the stool resulting exclusively from
this test diet. The first red colored stool is used
for the quantitative analysis. This method, though
correct, is inconvenient for the physician, as definite
results cannot be obtained before three days.
Normally, according to Schmidt, the percentage
of fat in the dried fjeces ranges between 21.5 and
26.61. If we find a percentage of 40 or over, a
pancreatic lesion may be suspected. \ high per-
April II, 1908.]
FRIEDMAN: CAM MIDGE'S REACTION.
683
centage of nonutilized nitrogen may also be found
in affections of the pancreas.
The presence of sugar in pancreatic disease is
very rare. This is a fact acknowledged by most of
the authors. According to the studies of Weichsel-
baum, Stangel, and Opie, mellituria is apt to be
found only when a considerable number of the
islands of Langerhans are affected. Hence it is
obvious that pancreatic lesion may be present with-
out glycosuria.
As the object of this paper is not to give all
signs which may help to form a positive diagnosis
in pancreatic disease, we shall make a short critical
review of only those more prominent ones as already
pointed out.
Let us assume a given case, in which steatorrhoea
has been noted. The history and present findings
exclude tuberculosis of the intestines, tuberculosis
of mesenteric glands, and a retroperitoneal tumor
( which may press upon a portion of the small intes-
tine and interfere with the absorption of fat). In
this case, a pancreatic lesion could be diagnosticated
if icterus is absent.
The presence of fatty stool, if noted, can also be
due to obstructive jaundice, without pancreatic
affection, since we know from Schmidt that 50 per
cent, of nonutilized fat may be found in the faeces
of patients with affection of the biliary tract. Fur-
thermore, Miiller stated that when bile was excluded
from the intestine, 52.2 to 75 per cent, of the fat
contained in food was passed unabsorbed, as against
7 to II per cent, (the latter being the normal
amount, according to his investigations).
Further studies showed that in the stools of pan-
creatic patients there is a predominance of neutral
fat over fatty acids. The reverse condition holds
true for biliary obstruction without changes in the
gland. Mayo Robson, in his work, came to the
same conclusions. But there are instances of pan-
creatic lesion where the ratio between neutral fat
and fatty acids is not so conclusive.
The next prominent sign in pancreatic lesions is
azotorrhoea. If we find undigested striated muscle
fibres in a large number of microscopical prepara-
tions, we must first be certain that the motility of
the stomach and intestines is normal. Since, in the
derangement of the stomach, atonic or hyperstalsis
of the bowels is present, the azotorrhoea may point
to these conditions.
On the other hand, a number of cases are on
record where neither steatorrhoea nor azotorrhoea
were present, and nevertheless pancreatic lesions
were found at autopsy or operation.
These possibilities are explicable by recalling a
few facts concerning the physiology and pathology
of the gland. We know that the pancreatic juice
may enter into the duodenum by way of the duct
of Santorini when the duct of Wirsung had been
occluded by calculi or inflammatory swelling ; hence
pancreatic lesion may be present without disturbance
in the flow of pancreatic juice. Even if the duct of
Santorini be deficient or occluded from the same
causes, an accessory pancreas may furnish its fer-
ments to the bowels.
Assuming by a concurrence of favorable condi-
tions that a positive diagnosis of pancreatic lesion
had been arrived at, still we are sometimes at a loss
to determine the nature of the same. It is of little
importance for the patient whether we are unable to
diagnosticate his condition in acute pancreatitis.
The onset in this affection is acute, even fulminant.
In spite of the fact that the symptom, pain, can be
referred to different abdominal organs, yet the
physician ought to recognize the condition as not
a medical one, and the patient ought to be turned
over to the surgeon with a diagnosis of gallstones,
abscess of the liver, acute intestinal obstruction,
appendicitis, etc. An exploratory laparotomy will
be performed, and the patient will often be saved.
A cyst of the pancreas may be diagnosticated pre-
vious to an operation. Should this not be the case,
however, exploration of the patient on account of
an indefinite abdominal tumor will often clear up
the situation. In the same manner a patient with
pancreatic calculi may be helped by an operation,
following exploratory incision.
Entirely different is the question with two affec-
tions of the pancreas — chronic or subacute pancre-
atitis and carcinoma of the gland. We are not only
unable to distinguish these two conditions during
life, but we are often unable to do so even after a
laparotomy. Shotjld a microscopical examination
of an extirpated piece of the pancreas show evi-
dence of chronic pancreatitis, still we are not abso-
lutely certain, since an examination of the whole
gland had not been made. How desirable it would
be to have means of making a positive diagnosis of
one or the other condition !
If we could exclude carcinoma, and if medicinal
treatment for chronic pancreatitis should have failed,
we then all the more have to refer our patient to the
surgeon, as the results of the operation in this con-
dition are very encouraging indeed (about 4 per
cent, mortality, according to statistics of Robson).
Sometimes a simple exploratory incision may suffice
for recovery, as in a case quoted by Chambers and
Friedenwald.
If a malignant growth of the pancreas is present,
the condition should mean a noli me tangere to the
surgeon.
In this way we arrive at the reaction of Cam-
midge, or pancreatic reaction in the urine. Thanks
to this author (Cammidge), we are not only able to
confirm our diagnosis in suspected pancreatic lesion,
but also are able to distinguish carcinoma from in-
flammatory processes.
As the basis for his reaction was the condition of
fat necrosis, a brief description of this pathological
phenomenon should be given. Ponfik first described
the process of fat necrosis in the bone marrow.
After him., Balser observed about the pancreas of a
number of bodies small, opaque, white areas, often
surrounded by a hasmorrhagic zone. These areas
were shown to be composed in great part of necrotic
fat cells.
Fitz offered the suggestion that fat necrosis is
consequent upon a lesion of the pancreas, and sup-
ported this conclusion by numerous instances in
which the two conditions had been associated.
Though the condition is met with in the majority
of cases in acute haemorrhagic and gangrenous pan-
creatitis, the process of fat necrosis has also been
684
FRIEDMAN: CAMMIDGE'S REACTION.
[New York
Medical Journal.
detected in other lesions of the pancreas micro-
scopically, when no evidence of the same had been
noted by gross appearance of the gland.
Cammidge looks upon punctate haemorrhages,
which frequently occur in lesions of the gland in
the absence of necrosis, as an early stage of this
condition. According to him, similar but less
marked changes may be present in all instances of
pancreatic lesion. Sometimes the process of fat
necrosis may be overlooked by the operating sur-
geon or at the autopsy table.
It has been shown by Langerhaus, Flexner, and
others that the changes taking place within the fat
cells of the gland or the abdominal viscera are asso-
ciated with the splitting up of the fat molecule into
fatty acids and glycerin, through the fermentative
action of pancreatic juice. Fatty acids are deposited
as needle like crystals within the cell, which has lost
its nucleus and is necrotic, while the soluble glycerin
is absorbed by the blood. The fatty acids soon com-
bine with the calcium of the blood plasma to form
salts, which remain in the necrotic foci.
At first Cammidge experimented with the blood
of patients affected with various diseases of the
pancreas. As this method did not seem to him to
be practicable, on account of the small amount of
blood available at bedside, he turned his attention to
the urine.
Notwithstanding the fact that glycerin brought
into circulation is oxydized by the elimination of
carbon dioxide, yet Cattilon showed that 50 per cent,
or 60 per cent, of the same can be detected in the
urine of dogs who had been given this per mouth.
Cammidge is certain that even higher percentages
may be obtained in urines of pancreatic patients,
since, in the latter, the process of oxidation is
diminished.
It is a well known fact that glycerin, on being
boiled with nitric acid, gives rise to glycerol, which
can be recognized by the ozazone which forms with
phenylhydrazin. Experience showed him very soon
that clearer preparations could be obtained with
hydrochloric acid. Finally, two reactions were
worked out by Cammidge, called "A" reaction, and
a distinctive reaction, called "B."
The "A" Reaction. — The specimen of urine to be
examined is filtered. 10 c.c. of the filtrate are
poured into a small flask, i c.c. of hydrochloric
acid (sp. gr. 1.16) is added and a funnel placed in
the neck to act as a condenser. The flask is set up
on a sand bath and gently boiled for five to ten
minutes after the first sign of ebullition is detected.
The flask is afterward cooled in running water.
After cooling, the mixture is filtered. To 5 c.c. of
the filtrate is added 5 c.c. of distilled water. The
excess of acid is now neutralized by slowly adding
4 grammes of lead carbonate, and, after standing
for a few minutes to allow the completion of the
reaction, the urine is filtered through a well moist-
ened filter paper and the flask is washed out with
5 c.c. of distilled water on to the filter. To the clear
filtrate arc now added 2 grammes of powdered
sodium acetate and 0.75 grammes of phenylhydrazin
hynrochloradc, and the mixture is boiled from three
to four minutes on the sand bath. The hot fluid is
tlien poured into a test tube and allowed to cool
undisturbed. .After the lapse of a period varying
with the severity of the case from one to twenty-
four hours, a more or less flocculent yellow deposit
is found at the bottom of the tube. The precipitate,
when examined under the microscope, is found to
consist of sheaves and rosettes of golden yellow
crystals.
Sugar when present must be freed by fermenta-
tion and subsequent heating for removal of the
formed alcohol. Albumin is removed by acetic acid
and boiling.
When the "A" reaction is positive the "B" reac-
tion has to be made.
The "B" Reaction. — 20 c.c. of filtered urine is
mixed with 10 c.c. of saturated solution of perchlo-
ride of mercury. Carefully filtered and after stand-
ing a few minutes, to 10 c.c. of the filtrate is added
I c.c. of strong hydrochloric acid. The mixture is
then boiled for ten minutes on a sand bath, and
subsequently to 5 c.c. of the urine is added 10 c.c.
distilled water. After cooling, it is neutralized with
4 grammes of lead carbonate. The remaining stages
of the reaction are like those of the "A" reaction.
The "B" reaction is a differential one, based upon
the observation of Cammidge that in inflammatory
conditions of the pancreas the crj'stals obtained are
destroyed by the action of perchloride of mercury.
A large number of examinations showed Cammidge
that the crystals in malignant disease are broader
and coarser, while in inflammatory processes they
are smooth and slender. The solubility of the crys-
tals in a 33 per cent, solution of sulphuric acid is
different according to the nature of the affection.
The crystals obtained from a specimen of acute pan-
creatitis are soluble in from one-half to one-fourth
of a minute : in chronic pancreatitis, in from one-
half to two minutes ; in carcinoma, in from three to
five minutes and longer. In pneumonia and in
adenitis crystals have been noted which were soluble
in one minute.
Negative results with these reactions have been
obtained by Cammidge and also Robson in normal
urines in icterus catarrtalis, in gallstones without
pancreatitis, in ulceration of the stomach, and in
various other conditions.
In support of the pancreatic reaction of Cam-
midge may be added that Felix Eichler has lately
experimentally produced acute pancreatitis in three
dogs, and in the urine of all he fouiid the character-
istic crystals of this condition, while in the urinary
specimens of dogs in good health the results were
negative.
The folloAving cases well illustrate the diagnostic
value of the pancreatic reaction in the urine :
C.^SE I. — Reported by Mayo Robson. Woman, sixty-one
years old. gave a history of biliary colic for three to four
years. No jaundice had been noted in the first year of her
illness. In the last two and one half years the attacks of
pain were alwa\s accompanied by icterus, by rigor, and by
deepening of the jaundice. During the short time that the
patient was under his observation. Robson noted that she
lost considerably in weight, and her symptoms became ag-
gravated. Therefore the question of cancer arose. But the
pancreatic reaction in the urine pointed to inflammation and
not to carcinoma, .^t the operation Rob<nn found the pan-
creatic portion of the common duct packed with large gall-
stones, and the head of the pancreas markedly swollen. On
passing the scoop through the opening in the common duct
down to the pancreatic portion, a stone the size of a cherry
was extracted, covered with oflFensive pus. This stone,
according to Robson, was lodged in a cavity of the head of
April 11, 190S.]
FRIEDMAN: CAMMIDGE'S REACTION.
685
the pancreas. A diffuse discharge of bile and offensive
pancreatic fluid with pus continued for a week, after which
the discharge became gradually less. The patient made a
good recovery, and a year later was still well.
Case II.— Reported by Mayo Robson. No less than six
eminent physicians had advised operation in a woman of
forty-eight, who had jaundice for five months, although
her condition was much better than could be expected if
the cause was a malignant growth. As the pancreatic re-
action pointed to cancer, Robson did not have the slightest
hesitation in advising nonoperative treatment.
Case III. — Reported by Moynahan. Patient fifty-seven
years old, female. lu operating Moynahan found a calcu-
lus in the duodenum about the size of a French bean.
This turned out to be of pancreatic origin. His diagnosis
of pancreatitis had been confirmed previous to the opera-
tion, as the pancreatic reaction in the urine was positive
for this condition.
Case IV. — Reported by Agabekoft'. Patient, si.xteen
years old, male, entered the hospital complaining
of pain in the abdomen. Loss of flesh had been
well marked. A physical examination revealed dif-
fuse nodules in the abdominal cavity, slight ascites,
and enlarged glands in the neck. He presented the
clinical picture of tuberculous peritonitis, the more so
as the age was in favor of this condition. Diarrhoea had
been present and vomiting absent. Pancreatic reaction
was positive for cancer. The autopsy showed that almost
the whole gland had been affected by cancer originating
from the greater curvature of the stomach.
We add to this series our case, in which we were
able to arrive at a positive diagnosis of the head
of the pancreas by the aid of Cammidge's reaction :
Case V. — R. L., female, sixty years old. Was seen by
us with Dr. Sturmdorf on October 12, 1907. Patient be-
longed to a neuropathic family. She had always been
melancholic. Had never had any attacks of gallstone colic,
nor had she ever been troubled by indigestion. Six months
before our examination she began to complain of a loath-
ing for meat, and four months later jaundice had come on
at once. In addition to jaundice, indefinite pains in the
abdomen were complained of. The stool was said to be
clay colored, and the urine dark in color.
Physical examination showed the visible mucous mem-
branes and the whole skin icteric. The icterus could not have
been considered as a deep one. Liver was palpable, gall-
bladder not palpable. Spleen not enlarged. By deep
pressure high up in the right hypochondrium, patient felt
tenderness more pronounced than in the right paraster-
nal line, two fingers above the navel, where some tender-
ness could also be detected. A tumor mass could not be
felt by either of us.
As there was no history of gallstone colic, and the physi-
cal examination did not reveal an enlarged gallbladder (as
is usually found in malignant disease of the biliary tract or
carcinoma of the head of the pancreas), and' also as
cachexia at that time had not been noticed at all, the pos-
sibility of a diagnosis of a chronic pancreatitis arose in
our minds. The examination of the f.-eces, which were
bile free and offensive in odor, showed a strong acid reac-
tion. Under the microscope fatty needles and fat droplets
were detected, but no crystals of neutral fat. Urine of
dark brown color showed traces of albumin, hyaline, and
granular casts, but no sugar ; indican was not in excess.
The urine was freed from albumin by acetic acid and
subsequent boiling. The "A" reaction showed, in about
five hours, a bulky yellow deposit. Reaction "B" gave the
same deposit. From both reactions, broad crystals in the
shape of rosettes were seen under the microscope. Treated
with a 33 per cent, solution of sulphuric acid, they disap-
peared in about si.x minutes. The examination with fresh
urine was repeated on two subsequent days with the same
results.
The diagnosis of carcinoma of the head of the pancreas
was made, though we had no other positive symptoms
pointing to this condition. The idea of operation was then
given up.
The patient died in about six weeks after our examina-
tion. The autopsy was performed by Dr. Satterlee, whose
findings follow :
Body was that of a woman of medium height, consid-
erably_ emaciated, especially about the face, chest, and ex-
tremities. The skin was of a sallow, greenish yellow hue,
the sclera? were only moderately jaundiced. The post
mortem examination was confined to the abdominal con-
tents. The abdomen was moderately distended, but the
abdominal walls showed a panniculus, thicker than normal
but pale. The striae on the skin made it apparent that a
considerable amount of flesh had been lost.
On opening the abdomen, an enormously distended stomach
filled the entire anterior portion of the peritoneal cavity, ex-
tending from the ensiform almost to the pubes. On
opening the stomach it was found to contain a very large
amount (about one and one half quarts) of dark, ochre
colored fluid of the consistency of ordinary mockturtle
soup. The walls of the stomach were tliin, the pylorus
practically obliterated because the distention extended
through the duodenum to the tumor in the head of the
pancreas. The ruga were obliterated, the mucosa con-
gested.
The colon was very small, narrow, and empty. The
small intestine was almost empty and contained but little
gas.
The head of the pancreas contained an extremely hard
nodular growth about one and one half inches in diameter,
extending for about the same distance into the pancreas
and into the duodenum, which it constricted, sur-
rounding the splenic artery. On section of the growth, it
was found to be tflcerated on the surface in the duodenum ;
deeper in, it was white, extremely firm, and fibrotic. The
portion to the left was haemorrhagic. A very small cal-
culus in one of the larger pancreatic ducts was found. The
remainder of the pancreas was extremly thin and atrophic.
The splenic artery had a slight degree of atheroma.
The common bile duct was patent. No enlarged lymph
nodes in this vicinity could be seen or felt. The bile duct
was enormously distended with dark greenish viscid bile,
but contained no calculi. Apparently the obstruction to the
flow of bile had been purely mechanical.
The liver was small, flabby, and elongated from above
down; the left lobe was very long and pushed over to the
right of the median line. The liver tissue was normal in
consistency but very deeply stained with dark green bile,
and the bile capillaries were very well marked out. The
gallbladder was remarkably distended and tense, showed
no evidences of inflammation, and contained about 150 c.c.
of dark green bile, but no calculi. The spleen was normal.
The kidneys showed chronic parenchymatous nephritis,
were bile stained, contained a few areas of fibrosis ; capsules
were nonadherent.
The bladder and internal genitalia were apparently
normal.
Anatomical Diagnosis. — Tumor head of pancreas; intes-
tinal obstruction with dilatation of the stomach ; obstructive
jaundice, chronic nephritis.
Cause of Death. — Intestinal obstruction with dilatation
of stomach due to malignant disease of the pancreas (car-
cinoma), which caused also obstructive jaundice; chronic
nephritis.
Histological examination of tissues from autopsy. — Tu-
mor of pancreas (a) from the head. Carcinoma with
marked myxomatous degeneration, fibrosis and infiltration
with polynuclear leucocytes; (b) from the tail. Marked
fibrosis and atrophy of glandular tissue. Kidney tissue.
Marked chronic parenchymatous degeneration of epithelial
cells of convoluted tubules, the tubules distended and con-
tained hyalin casts. Obliterating endarteritis, no increase of
connective tissue. Liver tissue. Chronic parenchymatous
hepatitis, fatty degeneration and interstitial hepatitis with
marked bile pigmentation of liver cells. Obliterating en-
darteritis.
Tn conclusion it may be said that the Cammidge
reaction has been obtained by us in a few more
instances which are also likely to be affections of
the pancreas. As in all these cases no confirmatory
proof could be given either by an autopsy or an
operation, we shall withhold all the material, there-
fore, for a future paper, when more cases of posi-
tive reaction in suspected pancreatic disease may
be at our disposal.
References.
1. Cammidge. The Chemistry of the Urine in Diseases
of the Pancreas, The Lancet, March 19, 1904, p. 782.
2. Robson. Mayo. The Pathology and Surgery of Cer-
tain Diseases of the Pancreas, Tlie Lancet. 1904, p. 773.
3. Robson and Cammidge. The Pancreas. Its Surgery
and Pathologic, Philadelphia and London, 1907.
686
STOUT: POISONING WITH TANSY.
[New York
Medical Journai-
4. Friedreich, v. Ziemssen's Handbuch der speciellen
Pathologie und Therapic, 1875, viii, 2, p. 234.
5. Opie. Disease of the Pancreas, Its Cause and Na-
ture, Philadelphia and London, 1903.
6. Ad. Schmidt und T. Strassbiirger. Die Faces der
Menschen im normalen und krankhaften Zustande, Ber-
lin, 1905.
7. Miiller, Friedreich. Zeitschrift fUr klinische Medicin,
1887, xii, 45-
8. Ponefik. Zur Pathogenese der abdominalen Fett-
iiecrose, Berliner klinische Wochenscrhift, 1896, No. 17.
9. Fitz. The Symptomatology and Disgnosis of Dis-
eases of the Pancreas, Transactions of the Congress of
American Physicians and Surgeons, 1903, vi.
10. Flexner. The Pathology of Pancreatitis, Diabetes,
and Fat Necrosis, Ibidem.
11. Moynihan. On Pancreatic Calculus, with Notes of
a Case, The Lancet, August 9, 1902, p. 355.
12. Eichler. Experimentelle Beitrage zur Diagnose der
Pancreaserkrankung, Die Camidgesche Pancreas Reaction
im Urin. Berliner klinische Wochenschrift, 1907, No. 25.
13. Chambers and Friedenwald. A Case of Chronic
Pancreatitis, Its Diagnosis, Operation, Recovery, Ameri-
can Medicine, July 9, 1904, p. 65.
14. Agabekoff. Russky Vratch, 1907, No. 35.
123 E.\ST Ninety-fifth Street.
A CASE OF POISONING WITH TANSY (TAN-
ACETUM).
By E. J. Stout, M. D.,
Philadelphia.
The author deemed the following case worthy of
record, as it adds another forcible illustration to
the long list of the pernicious habit of counter pre-
scribing, improper, unskilled dispensing, and conse-
quently dangerous use of drugs, and affords an ex-
ample of the toxic properties of tansy.
Talleyrand, I believe; is credited with the saying:
"Language was invented to conceal thoughts," and
it would appear that laws regulating the sale of
drugs have been made to be circumvented. It is
not the writer's intention to accuse the druggists
indiscriminately — for- happily we have thoroughly
reliable and honest men in that profession — but to
call attention to the evil referred to above, which
has become so common and has been discussed by
the medical journals and even by the magazines ad
nauseam. It is difficult to understand how any con-
scientious pharmacist can place a dangerous rem-
edy in an individual's hand without a proper pre-
scription and assume the responsibility and run the
risk of a possible death, as a result of his cupidity.
Virgil's lines, Qtiid non mortalia pectora cogis
auri sacra fames, are as applicable at the present
day as thousands of years ago. We have daily ex-
amples of this tendency in the human breast when
reading the high sounding and misleading adver-
tisements of nostrums in medical journals, unfortu-
nately allowed to appear in the advertising col-
umns, a subject that has been frequently alluded to
in print and in the meetings of medical societies.
Well might we ask in righteous indignation, Quo
usque abutere patientia nostra? Mere moralizing,
however, will not change the present condition of
things one iota ; drastic measures are required. If
Hercules had stopped to moralize when he under-
took to clean the .Augean stables, his task would
have remained unaccomplished. Could we apply
Zeus's heroic treatment, meted out to his son Vul-
can {Ilias A, line 590) :
i'fS}] ydp HE Hal aAAor' aXe^euEvat HE^omra
IJlipE, itoSoilTETOtyoov, (XTTO firjXov 8E6wE6tOlO.
■KcLv 8^rjnap q)Epofiriv , ana 8''r)EK.i(ip ^araSiijTZ
HatrirEQov Ir Arfjuvaj, oXiyoi S^eti dvj^oi tvijEv ,
to this genus homo, what a great benefit it would
be to the human race !
Trusting this somewhat flowery preamble ma}^
not prove too tedious, the author would refer to
the drug as it appears in the materia medica.
"Tanacetum, or tansy, is described as the leaves
and tops of tanacetum vulgare, a perennial, her-
baceous plant of the natural order compositas. The
flowers and seeds are also endowed with medicinal
properties. Tansy is indigenous to Europe, but is.
cultivated in our gardens, and grows wild in the
neighborhood of old setlements. It bears yellow
flowers, arranged in a dense terminal coryrmb. It
exhales a strong, penetrating, but not unpleasant,
odor when fresh, and its taste is bitter and aro-
matic. These qualities depend mainly on an essen-
tial oil which is most abundant in the flowers and
seeds, etc. (Stille.)" The same author describes
the action of the drug as follows: "Tansy, in mod-
erate doses, acts as a gentle stimulant to the diges-
tive organs, and when more freely given produces
some general excitement, augments the urine and
perspiration, and may bring on nausea, vomiting,
and diarrhoea. In overdoses the oil acts as a fatal
poison, producing unconsciousness, flushed cheeks,
dilated pupils, hurried, stertorous respiration,
strong spasms, a full and frequent pulse, repeated
convulsions, and then a failing pulse and death."
Given in decoction in overdose it does not appear
to give rise to convulsions, as noted byPendleton
(quoted below) in a fatal case, differing in this re-
spect from cases of poisoning with the volatile oil.
The drug was formerly employed as an emmena-
gogue, and has diuretic and anthelmintic proper-
ties. There are no officinal preparations, but a
fluidextract may be prepared according to the gen-
eral rule and administered in doses of TQ- x to gi- The
dose of the volatile oil (oleum tanaceti) is i to 5
drops. An infusion (tansy tea) may be made in
the proportion of 3i to the pint and used in doses
of §i-ii.
On January 17, 1907, the writer was hurriedly called to
attend the following case at 9 p. m. The patient, a young
married woman, twenty years of age, presented the follow-
ing symptoms: Pulse 160, rapid respiration (40), dilated
pupils, clammy skin, more or less rigidity of the muscles
of the jaw and legs ; she was in a semistupor and unable to
answer questions intelligently. Upon questioning the hus-
band, he informed me that his wife, acting upon the advice
of a married sister, had taken 3ii of oleum tanaceti for the
purpose of bringing on menstruation, at half-past 8 o'clock
in the evening. About thirty minutes later, while in
the act of disrobing, he heard her fall on the floor. A
hypodermatic injection of apomorphine hydrochloride
(gr. i/io) was promptly given, and in the vomit the char-
acteristic odor of the drug could readily be detected. This
was followed by a liberal dose of spir. ammonii aromatici;
in an hour's time the symptoms had improved, respiration
becoming less frequent, the pulse more regular, and the
patient could respond satisfactorily to questions. Three
days later the woman called at my office and stated that
the muscles of the jaw still felt stiff and sore, and com-
plained of similar sensations in the muscles of the legs.
Judging from the alarming symptoms, it is very probab/e
that the patient would have died, had an emetic not been
administered promptly. There was good reason to believe
that the drug was not taken with criminal intent, and the
woman was entitled to the benefit of the doubt. Careful
April II, 1908.]
VAX GIESON: IRON.
687
uestioning elicited a history of irregular menstruation,
he began to menstruate at fourteen years of age, but quite
irregularly, and there had been amenorrhcEa for several
months when sixteen years of age; during the last eight
months the menses had been entirely suppressed. She had
been married tor six months; there were, however, no
symptoms indicating pregnancy. Four days later the woman
informed me that she had commenced to menstruate, prob-
ably due to administration of tinct. ferri chloridi. The
writer managed to obtain the bottle from which the medi-
cine had been taken and which still contained about 5ii of
the oil of tansy; the absence of a proper label and direc-
tions and of the pharmacist's name on the bottle aroused
suspicion. The patient admitted that she had been in-
structed by the druggist furnishing the medicine not to
mention his name, and she could not or would not remem-
ber the place where she had bought the drug.
Tansy appears to be a favorite remedy with the
laity in suppressed menstruation, and is regarded
popularly as an abortifacient, although it does not
possess this power, as has been demonstrated in
cases of poisoning with the drug, in which doses of
various size, although followed by convulsions and
in some instances by death, did not cause abortion.
In looking over the literature on the subject, the
writer has found several instances of poisoning,
following the administration of tansy, which are
briefly given.
Dalton (John C, Jr., the American Journal of
the Medical Sciences, January, 1852, p. 136) de-
scribes a case of poisoning with oil of tansy, in
which death resulted at the end of three hours and
a half, and the quantity of the drug taken was about
3i and 3iii, in a young girl, about twenty-one years
of age. The case presented the following appear-
ances : Total unconsciousness, cheeks flushed, of a
bright red color; eyes open and very brilliant;
pupils of equal size, widely dilated and immovable ;
sclerotics injected; skin warm, not remarkable as
to moisture. Respirations hurried, labored, ster-
torous, and obstructed by an abundance of frothy
mucus. The breath had a strong odor of tansy ;
pulse quite full, forcible, 128; at intervals of five to
ten minutes the body was convulsed by strong
spasms, in which the head was thrown back, the
respiration suspended, the arms raised and kept
rigidly extended, the fingers contracted. This gen-
tleman quotes a case, coming under the notice of
Dr. Dalton, of Lowell, of a girl, who took a quan-
tity of oil of tansy just before dinner. After din-
ner she vomited and immediately fell down insensi-
ble and convulsed. She recovered after remaining
a long time unconscious. Dr. Dalton (Jr.) speaks
of another fatal case of poisoning with oil of tansy,
occurring in Boston, under the care of Dr. C. T.
Hildreth, which was published in the American
Journal of the Medical Sciences for May, 1835. In
this instance a woman took of the drug and
did not lose consciousness entirely till three quarters
of an hour afterwards, though she was convulsed
at intervals before that time. After unconscious-
ness became complete, she did not again recover it,
and died rather less than two hours after taking the
poison. He concludes by calling attention to the
fact that although all the muscles, both of the body
and limbs, were for three and one quarter hours
subjected to a succession of the most violent con-
tractions, there was no sign of abortion, and after
death the ovum was found in the uterus entirely
undisturbed.
. In Dr. Hildreth's case also, pregnancy existed but
a few weeks advanced, and the drug was undoubt-
edly taken for the purpose of producing abortion,
but nothing of the kind took place. The general
symptoms in that case were similar to those de-
scribed in the foregoing, the most remarkable dif-
ference being the more gradual loss of conscious-
ness, and the more rapid death after a much smaller
dose. Dr. Chapin {Boston Medical and Surgical
Journal, 1858, p. 383) describes another occurrence
of poisoning in a married woman, who was found
in bed, partly conscious, and in paroxysms. The
quantity of oil of tansy taken was §3/2 ; the woman
was four months pregnant, and took the oil to bring
about abortion. In an hour the mind became clear
and the woman recovered.
John E. Pendleton {American Medical Times, ii,
177, March 16, 1861) reports fatal poisoning by
decoction of tansy in a negro girl, twenty-one years
of age, who had taken a large quantity of strong
decoction, for the purpose of producing abortion.
She died twenty-six hours after taking the drug.
There occurred delirium, slow and laborious
respiration, contracted pupils ; paralysis of the
muscles of deglutition and of all the voluntary
muscles ensued. There were no spasmodic or con-
vulsive movements of the body through the whole
progress of the case, as has been observed in cases
of poisoning by the volatile oil of the drug; abor-
tion did not occur.
It will be seen from the foregoing that a drug
with whose properties the laity are but improper-
ly acquainted and whose use may be followed by
the gravest consequences should under no circum-
stances be allowed to be sold promiscuously and
without a prescription.
O judgment, thou art fled to brutish beasts,
And men have lost their reason !
Unless energetic measures are taken to suppress
the evil, similar cases will continue to occur.
1538 North Fifteenth Street.
THE COMPAR.^TIVE THERAPEUTICAL VALUE
OF THE COMPOUNDS OF IRON.*
By R. E. Van Gieson, M. D.,
Brooklyn, N. Y.
As introductory to this topic I wish to invite your
attention to a brief survey of the present state of our
knowledge of haemoglobin and the metabolism of
iron. Somewhat over a half century ago Dr. George
B. Wood, in writing of the existence of iron in the
blood, stated : "The probability is, that it is united
with some peculiar organic principle, having for it
an affinity beyond any other body in nature, and
capable of being overcome through chemical agency
only by the destruction of that principle." It is ver>'
remarkable to note that this ''probability" of that
able clinician expresses very concisely and truly
nearly all that we know in regard to this important
element at the present day. Long considered as a
combination of hjematin and globulin, it is now
known to be a definite nitrogenous element of the
blood not separable without destroying its molecular
constitution. Haematin is a product of destructive
analysis. Haemoglobin is a proteid unit. It is the
•Read before the Medical Association of the Greater City of New
York at a special meeting, held in the Borough of Brooklyn, March
3. 1908.
1
688
FAX GIESON: IRON.
[New York
Medical Journal.
basic, essential element of the red blood corpuscle
and carries literally the breath of life. Its necessary
molecule is iron.
The total albumin of the blood is about four per
cent. The quantity of iron is less than o.i per cent,
a surprisingly small amount when we consider the
enormous energy developed in carrying oxygen to
the remotest tissues of the body, the average adult
consuming about eighteen cubic feet of that gas in
twenty-four hours. The microscope reveals com-
paratively few facts as to the structure of the red
corpuscle, and physiological chemistry does not add
materially to our knowledge, since the chemist can
only describe the constituents of dead cells.
We may infer from our present knowledge that
the blood corpuscle, inasmuch as it contains normally
from eighty-four to ninety-six per cent, of haemoglo-
bin, is mainly made up of that substance, and that
the remainder is an apparently structureless stroma
with which the haemoglobin is united.
Coming now to the metabolism of iron, either as
a food or drug, we approach, a field which, in spite
of the enormous amount of careful research that has
been made, is confessedly, a terra incognita.
Living matter is essentially unstable. Construct-
ive metabolism leads us into a maze of myriads of
cells incessantly changing, wherein no fabled thread
of Ariadne is found to lead us securely on. A single
sentence from Chittenden's Nutrition of Man ex-
presses the magnitude and despair of the problem :
"Regarding the process of anabolism, as in the con-
struction of living protoplasm out of inert food ma-
terials, we can say nothing. This is altogether be-
yond our ken at present, and doubtless will remain
so, since it involves a chemical alteration or change
akin to that of bringing the dead to life." Neverthe-
less, work in this direction has not been entirelv
futile. We have learned that nearly every foodstuff
that enters the human laboratory, with the excep-
tion of water, suffers change, and that this is spe-
cially true of iron, considered either as a food or me-
dicinal remedy. Melzer, speaking of the metabolism
of iron and the changes of ingested iron into haemo-
globin, .states : "The normal animal body commands
a large reserve fund of iron, which is far in excess
over its immediate requirements. The liver, bone
.marrow, and especially the spleen, are the main de-
positories for the reserve iron, which is reserved in
the form of resistant organic compounds. (This con-
firms the observation of Carpenter, made some sixty
years ago, that the spleen, besides regulating blood
pressure, was also an organ of sanguification.) "All
ingested and absorbed iron, no matter of what char-
acter and origin, goes first to one of these depots,
where it becomes converted into organic compounds.
The first function of absorbed iron is to increase
the iron reserve.
The ingested iron, no matter of what character, is
never utilized directly for the construction of haemo-
globin."
Bearing in mind these important statements so
closely connected with our subject, we are better pre-
pared to estimate the comparative value of iron com-
pounds. For practical purposes we can divide them
into the ferric and ferrous official preparations, the
nonofficial preparations, of the dispensatories and
national formulary ; the so called organic com-
pounds — albuminates, peptonates, caseinates — of
which the formulas and methods of preparation are
given ; and a final class which may be called com-
mercial, in some of which an atomic formula is
given, but the method of preparation is known only
to the manufacturers. Their names are supposed to
indicate their composition. In estimating their com-
parative remedial value I shall only refer to their
use in the tractable forms of anaemia and neuras-
thenia, where deficiency of haemoglobin forms the
prominent indication for their use.
Direct, primary anaemia from loss of blood is not
benefited by iron unless convalescence is retarded.
In such cases it is not the lack of red blood corpuscles
that makes the real element of danger, but the fall
of blood pressure to a point where circulation fails.
If the circulation can be maintained there still re-
mains a sufficient number of red blood corpuscles to
carry on respiration, and the immediate treatment is
to raise the blood pressure within the vessels. Even
here, transfused blood from a healthy donor pos-
sesses no direct nutritive value, and it is doubtful,
at least not proved, that the transfused blood per-
forms the same functions as the original blood of
the recipient. A 0.75 per cent, solution of salt, ster-
ilized, injected into the veins, gives all the advan-
tages that can be obtained from the transfusion of
blood. If the patient recovers the question of iron
comes later on.
At the threshold of our inquiry, the question meets
us. Which are to be preferred, the ferric or ferrous
compounds ?
Ferric salts are supposed to produce insoluble al-
buminates with the stomach juices, while the ferrous
salts give soluble albuminates. But it is contended
that the soluble ferrous albuminates are converted
into ferric albuminates before absorption takes place.
There is, then, practically no real difiference, and our
choice may be guided more by the palatableness and
acceptability to the stomach than by these theoret-
ical suppositions.
It would be foreign to the purpose to attempt to
describe each official preparation, the object of this
paper being only to consider those that have been
and are now in common use. Among the oldest and
n.iost useful is the ferrous carbonate in its various
forms, which, unless freshly prepared and immedi-
ately taken, always contains a variable proportion of
sesquioxide.
Dr. George B. Wood, in his Treatise on Thera-
peutics, commends this "both for its gentleness and
efficiency. I am in the habit of using it, and calcu-
late with the utmost certainty upon the desired eflFects
from it. In the Pennsylvania Hospital there is a
constant succession of patients, especially in the au-
tumn, in the most pitiable state of anaemic debility,
often complicated with oedema of the limbs, to whom
a dose of this medicine three times a day, with a lit-
tle quinine and nutritious diet, in the course of from
two to four weeks, and sometimes even a shorter
period, restores healthy color and strength." Its
only liquid preparation is the mistura ferri compo-
sita, a modification of the antihectic mvrrh mixture
of Dr. Griffith.
Personally I think I have obtained better effects
from iron carbonate by giving it immediately after
mixing, and having the ferrous sulphate and potas-
April II, 1908.]
J -AX GIESON: IROX.
689
sium carbonate in separate bottles. So prepared and
taken the precipitated carbonate is not long enough
exposed to the air to produce the sesquioxide. The
water used in making the two mixtures should be
boiled so as to expel the air. In this way we get
nearly the full equivalent of unaltered ferrous car-
bonate.
\'allet's mass, prepared according to the German
pharmacopceia. contains about fifty per cent, of fer-
rous carbonate. Prepared according to the French
pharmacopoeia, it contains some forty-one per cent.
Ferrum oxydatum saccharatum solubile contains
three per cent, of metallic iron. According to Hager
it is not a mere mixture, but a definite compound, in
which sugar plays the part of an acid and the iron
that of a base. Its solution gives no reaction with
potassium ferrocyanide or sulphocyanide ; with tan-
nic acid, a very slight opalescence, but no violet or
blue black color. To borrow Dr. Wilcox's most ap-
propriate word, the iron seems quite thoroughly
"masked," although it is not ''organic." Hager states
that its introduction into the German pharmacop-xia
is of the greatest importance. It is mild, but highly
efficient. It never irritates even in larger doses, and
does not discolor the teeth. It can be added to food
without in the least altering the normal taste of the
latter. I can only say from personal experience that
I can fully testify to the truth of all that Hager has
said in its favor, and it should be incorporated in
our pharmacopceia. It is especially useful in pre-
scribing for children, as they rarely know that they
are ''taking medicine." In these cases it is best given
in a little weak chocolate or cocoa.
Ferrous sulphate, usually dispensed in pill form,
is recommended by Warfinge, of Stockholm, and no
doubt is a favorite form of iron with many. I have
never used it, on account of its highly astringent and
slightly corrosive action on the mucous membrane.
Its solution is excessively disagreeable and cannot
te disguised by any form of adjuvant.
Ferric phosphates. — Of these the best are the sol-
uble ferric pyrophosphate, official in the pharmaco-
poeia of the United States, and the ferrum pyrophos-
phoricum cum ammonio citrico {Hager Pharmaceu-
fische Praxis, i, p. 1081). The author states: "This
preparation, which has the misfortune to possess no
empirical or shorter name, is imconditionally a
splendid iron remedy, and deserves a more exten-
sive consideration." It differs advantageously from
most of the scale salts of iron in being nonhygro-
scopic, keeps well, is nearly tasteless and easily sol-
uble. It contains on an average 16.6 per cent, of
iron.
The ferric salts with the vegetable acids. — Ace-
tates, citrates, tartrates, mallates. and their double
salts, in my own experience rank very high. Iron
tartrate and potassium, long ago recommended by
Ricord in his lectures, is one of our best remedies
in postsyphilitic anaemia. The following mixture I
have used for manv years with good results :
R Ferri et ammonii citratis, 5v;
Aquae cinnamoni, / -- 5 •• .
Vini angelicx, \ '
M. S.
Two teaspoonfuls of this equals about 5 grains.
It is agreeable to the taste, acceptable to the diges-
tive organs, and rarely fails to produce the hoped
for results.
Iron acetate in the form of Basham's time hon-
ored mixture is too well known to need more than
a passing allusion. It is official as the liquor ferri
et ammonii acetatis.
Dialyzed iron. — Liquor ferri oxychlorati is offi-
cial in the German pharmacopceia. It has been dis-
carded from the British pharmacopoeia. It may be
prepared by dialysis or by mixture. Hager states
that, prepared by either method, the resulting prepa-
rations are chemically identical. It has been ob-
jected to because, in contact with the stomach juices,
it becomes insoluble, but this is only a transitory
condition. It soon becomes soluble and enters rap-
idly into the intestinal fluids. It is palatable and
can be diluted to any extent with distilled water.
According to German authorities it should be
ranked with the best of iron preparations. The idea
of many physicians that the stomach is a dyalitic
apparatus and therefore must be indifferent is with-
out foundation. Chittenden truly says that dead
parchment and the living membrane of the intes-
tines are not to be compared with each other. The
Hving cells that stand as guardians of the portals
modify the rate of passage and control absorption.
Reserving one of the best for the last, we take up
ferric chloride, the oldest of them all. The official
tincture is about the most disagreeable compound
of this most valuable salt of iron that could well be
devised. A better form is the simple dilution of the
official liquor ferri perchloridi to the strength of the
tincture and the addition of glycerin. A good
formula which I have used for a long time is :
R Liq. ferri perchlor 35 parts;
Aquas distillatae, 65 parts;
q. s. ad 3x ;
Glycerini, 3ii.
M.
The strength is slightly less than that of the
tincture. It is to be noted that iron perchloride
solutions, when added to proteid substances, form
albuminates, as may be proved by adding it to albu-
min solutions or with milk. The preceding solution,
when given with milk, 10 to 30 drops in 10 to 30
drachms of milk, makes a palatable mixture, does
not attack the teeth, and undoubtedly, from the
strong affinity of the perchloride for proteids, con-
tains some "masked" or changed iron difTering from
the perchloride. As a general remedy for anaemia
thus administered it will give excellent results, and
for the anaemia following or attending rheumatism
it is the remedy par excellence.
Organic iron, iron albuminate, caseinated lactate
of iron, peptonate of iron, extractum sanguinis
bovini. — This group is the result of efforts to attain
some form of nitrogenized iron, under the suppo-
sition that in such combination they would be more
readily absorbed, and consequently more effective
as remedies or foods. The formulas for all these
can be found in the dispensatories and the National
formulary, and can be prepared by any competent
pharmacist. Dr. Jackson, of Philadelphia, in 1852
prepared a dried blood from bullocks, and for some
time it was considered as Nature's remedy for
anaemic conditions. The blood is the life. Ergo.
fresh or dried blood should make blood. Many of
us can recall the dangerous practice of drinking
the fresh, warm blood of bullocks at the slaughter
house. The results did not justify the ver\- logical
690
VAN GIESON: IRON.
[New York
Medical Joukkal>
inference. The iron was certainly true organic iron,
but it pursued the same path as other forms of iron,
and gave no better results, either as a food or tonic.
The last group, comparatively small, are those
"organic" preparations that are asserted to be better
than those we have long used. In some the atomic
formula is given, but their method of preparation
is known only to the manufacturers. In the dis-
cussion of this class it is hardly possible to be
entirely impersonal. I have no ethical prejudice
against them, I welcome them with unreserved
mental hospitality and cheerful expectancy, I take
them experimentally, I prescribe them fairly and
with proper judgment as to favorable cases for iron
treatment; but thus far I have obtained no better,
no quicker results than from the official prepara-
tions.
Dr. Laspeyres, of Bonn (Journal of the American
Medical Association, Literary review, p. 340, 1907),
comparing inorganic and organic iron, states: 'Tn
the desire to approach the supposed method of
Nature there has been a tendency to take up the
complex organic preparations to the neglect of those
simple preparations which were estimated so highly
in the past. The modern preparations cannot be
recommended as economical, as the percentage of
iron is small and the doses necessarily large." His
conclusion is in favor of the official preparations.
Dr. F. W. Warfinge, of Stockholm (Journal of
the American Medical Association, Literary review,
p. 1409, 1907), records results from fifty cases of
chlorosis. He states that in chlorosis the effect of
iron is not felt unless given in a compound which
shows the iron reactions with the ordinary tests.
Dr. Wilcox, in his paper, "Modern Iron Ther-
apy," arrives at a directly opposite conclusion, stat-
ing that :
"In determining the form of masked or organic iron for
oral administration one should be selected which (i)
should be of definite chemical composition ; (2) does not
precipitate with a silver nitrate solution; (3) does not give
the blue black color with MacCallum's test; (4) is not
decomposed by the hydrochloric acid of the gastric juice;
and (5) it must show definite results in (a) an increase
in the number of red bloodcorpuscles, and (b) in the
amount of contained haemoglogin. These requirements are
evidently the most rigorous which can be devised, and in
meeting them modern iron therapy will be placed upon a
secure foundation."
These widely divergent opinions of competent
observers must be due to the fact that the older
and the more recent preparations in properly
selected cases give equally good results, and it is
apparent that the rigorous requirements suggested
in Dr. Wilcox's paper are not essential to successful
treatment.
It is germane to this subject to recall to mind
the fact that hjemoglobin percentage when below
the normal may be raised without giving iron in
any form except as it occurs in the food. Rest in
bed, with milk diet and unfermented grape juice,
with massage, increases haemoglobin. The influ-
ence of light is favorable in preserving normal
haemoglobin percentage. In animals well fed but
deprived of light it falls below the normal. Prison
pallor is doubtless due to some extent to reduction
of haemoglobin from deprivation of light. Static
electricity is an important aid in improving the con-
dition of impoverished blood. In answer to my in-
quiry on this point. Dr. J. Herman Branth has
kindly sent me the following notes :
I have not personally conducted examinations of blood
counts, or haemoglobin percentage, but have read in my
medical journals that static electricity elevates the per-
centage of haemoglobin. I believe that this is the commonly
accepted opinion. I adhere to it, and practice accordingly.
To me personally the principle involved in the cure of
anaemia and neurasthenia by the proper form of electricity
seems plausible and the results attained confirm the theory.
It is generally accepted that protoplasm is stimulated
(when below the normal) to greater activity by static elec-
tricity, this means improvement in metabolism or the in-
take of nourishment, and the casting of? of waste prod-
ucts. In neuralgia and neurasthenia this process is be-
low the normal, the tissues are underfed, and the accumu-
lated waste acts as toxins to the cells. We know the
nerves have no blood vessels, but get their nourishment
from the blood vessels in the nerve sheath, and when the
blood is impoverished there rises a cry for nerve cell food.
This cry we may call neuralgia or a local neurasthenia.
In genera] neurasthenia the whole organism is implicated
in this defective metabolism. The concomitants of this
condition are general restlessness, undue excitability, loss
of sleep, constipation, anaemia, vulnerability to atmospheric
changes and to microbic infection, or in general to a re-
duced resistance to the inroads of disease.
In such a condition, what will the administration of iron
do? Will it be absorbed if the organism is suffering from
lowered and defective metabolism, and as iron is contained
in nearly all our foodstufifs, why does not the organism
abstract and assimilate it? We know that under just the
conditions described iron in any form frequently passes
out of the system without producing any appreciable efTect.
Now, let us see what happens when we give a case of this
kind the static electric bath. In a few minutes it produces
unconscious perspiration, sometimes profuse perspiration.
In some cases the secretion has such an offensive odor that
the room requires ventilation. This certainly indicates the
elimination of waste material. Pat-i passu we notice in-
creased heart action. Applying now sparks and spray to
the abdomen, we find the peristaltic action of the intestines
decidedly increased and evacuations soon follow. Now, if
in these forms of defective metabolism we have in elec-
tricity a means of eliminating waste products and increas-
ing the heart's action, it is certainly reasonable to expect
improved nutrition, and as a result the assimilation of iron
given as a remedy is more likely to ensue. I believe most
emphatically that electricity in these cases is a most valu-
able synergist to the favorable action of iron preparations.
Defective metabolism, with its attendant evils of
autointoxication and constipation, are very serious
impediments to the favorable action of iron com-
pounds. If we give iron in such cases perfunc-
torily and indiscriminately, we fail to attain the full
benefit of the remedy. There may be a temporary
improvement, but the conditions which are causa-
tive of the anaemia are not controlled, and unfor-
tunately in many cases cannot be, as the circum-
stances of the patients will not permit them to lose
the time and incur the expense of proper prepara-
tory treatment.
To sum up :
A careful study of iron metabolism shows that the
official preparations of iron so long useful in the
past will increase haemoglobin.
The ferrous carbonate ; the soluble oxide with
sugar ; the double salts with the vegetable acids ;
the solution of the perchloride given in combination'
and largely diluted with milk, are the forms most
likely to produce good results.
Directly conflicting views as to the value of the-
modern proprietary preparations exist among com-
petent observers.
In all iron medication the question of defective
mctalmlism is important.
April II, 1908.]
CANNADAY: SURGICAL TREATMENT OF APPENDICITIS.
691
Cases must be individualized and preparatory
treatment is essential.
Rest m bed, massage, milk diet, unfermented
grape juice, and static electricity are valuable ad-
juvants preparatory to or during the administration
of the iron compounds.
94 Kent Street.
THE SURGICAL TREATMENT OF APPENDICITIS.*
By John Egerton Cannad.\v, M. D.,
Wheeling, W. Va..
Surgeon to the Reynolds Memorial Hospital.
The surgical treatment of appendicitis resolves
itself into the treatment of chronic cases, acute
cases, and pus cases.
In the first and second class of cases I believe in
the unqualified removal of the appendix, first, last,
and always. In the third class of cases 1 simply in-
cise and drain, removing the appendix, provided the
condition of the patient warrants the interference
and provided that the appendix can be secured with-
out breaking down the wall of adhesions tliat has
been formed between the abscess cavity and the gen-
eral peritoneal cavity.
To successfully cope with the many and sundry
shadings, intricacies, complications, and combina-
tions of these three more or less arbitrary classes
will at times tax the skill and ingenuity of the most
accomplished operator. The chronic cases, unless
there are numerous adhesions, can be dealt with
through a small incision. When the adhesions are
numerous and many difficulties stand in the way of
locating, much less removing the appendix, a larger
incision with its added room will be required.
Again, the skilled surgeon can accomplish through
a short incision that which the tyro could only ac-
complish through a long incision. The incision pre-
ferred is a short gridiron ; this when closed by tier
catgut and healed primarily should never result in
hernia. When used for drainage and a small drain
used hernia will seldom follow.
When more room is needed, as, for instance, in
the dissection of dense adhesions, an incision of fair
length in the rectus is more desirable. The muscle
fibres should be separated without the division of
nerve trunks so as to avoid subsequent muscular
atroph)- in the abdominal wall.
Pick up the appendix, apply a haemostat about its
middle, ligate its mesoappendix with catgut, includ-
ing the entire meson in tha grasp of the one liga-
ture; an artery forceps is placed on the mesoappen-
dix between the appendix and the ligature for the
protection nf the latter when the appendix is being
freed. A forceps is clamped on to the appendix flush
with the ciecum. a second haemostat is placed just
above the first and gradually worked upward for
about one quarter of an inch, forcing the contents
of the appendix before it. The appendix is now
amputated with knife or scissors, flush with the
jaws of the forceps applied next the caecum, and the
cut surface touched with the thermocautery or a
little carbolic acid on a cotton tipped applicator, fol-
lowed by alcohol. I invert the appendix by the
purse strino- method with ten day chromic catgut
*Reafi bv title before the Kentucky State Medical .Association.
T.ouitville, October. 1907.
of medium size threaded on a round pointed needle.
Beginning at the point of attachment of the meso-
appendix, the needle is carried under the artery sup-
plying the appendix and again under this vessel for
the second tiine, obliterating the vessel as if it had
been tied ; two or three turns of the needle are taken
into the caecum on either side of the base of appen-
dix. When the handle of the artery forceps is
reached the ligature is carried over instead of under
in such a manner that when the ligature is drawn
taut and the handle of the forceps raised a ring of
the caecum is readily drawn up over the amputated
stump of the appendix with much ease. This
method is described by me in detail with cuts in the
Journal of American Medical Associatian of June i,
1907, XLVI II, page 1865.
The inversion site is reinforced by a few Lembert
sutures of ten day catgut.
Drainage is not used unless it is deemed abso-
lutely necessary. In my own practice I have re-
versed the old dictum, "When in doubt, drain," and
when in doubt I do not drain. In a number of
drainage cases it is an advantage to carry the drain
through a small stab wound, so that the operation
wound may be closed in the usual manner by layer
sutures.
At times pus cases are so situated that postperi-
toneal drainage can be used, but this does not hap-
pen very often. Some of the postcaecal abscesses
can be appropriately drained through the loin ; when
an abscess cavity has to be drained remove the
appendix, provided it can be gotten out without
breaking down the abscess wall; otherwise leave it
until after the abscess and its resultant sinus have
closed, then do a secondary operation for its
removal.
I believe that all patients with appendicitis should be
operated upon irrespective of the stage of the trouble.
When the case is one of general peritonitis or ex-
tensive local peritonitis a small incision should be
made and a cigaret drain inserted, no more, no less.
Irrigation, sponc'ing, and mopping out, breaking up
adhesions, etc., in such a case, would be murderous.
Postural drainage is undoubtedly of some value in
these cases. I greatly favor having the patient lie
on the side in which the drain has been placed for
a few hours at least immediately after the insertion
of the drain. The administration of normal saline
enemata to the patient who is weak or exhausted
gives valuable support.
Register FSuilding.
REPORT OF A CASE OF CEREBRAL ABSCESS
WITH MASKED SYMPTOMS.*
By Robeut Emmet Coughltn, M. D.,
Brooklyn, N. Y.,
.\ssociate Physician to the Norwegian Hospital.
The following case was admitted on October 14,
1907, to the Norwegian Hospital, medical division,
under the service of Dr. Edward P. Cornwall:
Mrs. I. A., age t\\enty-five years; occupation, housewife;
birthplace, Norway.
Family history : Mother, sister, and two brothers died of
nulmonary tuberculosis ; one brother has some form of
kidney disease.
Past history: No disease of childhood that she remem-
*Read before the Long Island Medical Society, January 7, 1908.
692
THERAPEUTICAL NOTES.
[New York
JIedical Journal.
bered. Except for two attacks of rheumatism she had
always been perfectly healthy. Two years ago she had
a severe earache in her right ear, which was relieved by a
sinipism applied to the back of lier neck; discharge was not
present. Menstrual life began at fifteen; twenty-eight day
type, lasting from two to three days ; rather painful ; mod-
erate in amount. Patient had one child, seven months old,
no miscarriages. She took an occasional glass of beer, no
tea ; coffee, three or four cupfuls a day.
Her present trouble began two months ago, commencing
in a constantjSharp headache, slightly worse at night ; always
located in the right occipital and parietal regions. She
vomited occasionally ; the same had no reference to meals.
Once or twice the vomiting was rather forcible. She had
attacks of vertigo, also visual hallucinations, but never any
paralysis or epileptic attacks. Her control of bladder and
rectum was perfect, bowels were constipated.
Examination : Patient looked poorly nourished ; complex-
ion was fair; lips and conjunctivae were anaemic, tongue
slightly coated. Teeth were in fair condition. Pulse was
regular, small, of low tension, vessel wall was not thick-
ened. Pupils were equal and reacted to light. Heart and
lungs were normal. Abdomen and extremities were
normal. Uranalysis : On October 17, 1907, showed specific
gravity 1,018, urine straw colored, triple phosphates pres-
ent, very fine trace of albumin present, no sugar. There
were present a heavy sediment, mucous and debris, epithel-
ium and white blood cells.
Diagnosis : Held in reserve.
Treatment: Purely symptomatic.
Epitome of family history, past history, and present con-
dition. Family history of tuberculosis very strong. No
diseases of childhood'. Pain in right ear two years ago.
Occipital headache on right side of head constant and
worse at night. Forcible vomiting. Vertigo. Poorly nour-
ished patient. Anaemic. Small low tension pulse.
On October 20, 1907, eyes were examined by the con-
sulting ophthalmologist and found to be entirely normal,
not even a congestion of the vessels of fundus.
On October 21, 1907, the consulting physician examined
his patient and thought the condition due to anaemia, mal-
nutrition, and decayed teeth.
On October 31, 1907, the consulting neurologist examined
the patient and did a lumbar puncture, but a dry tap was
obtained. On the same dny an aurist examined ears and
only a congestion of right drum was found.
Blood count: On October 31. 1907. showed white blood
cells. t8,doo: polynuclear cells, 86 per cent.; lymphocytes, 11
per cent; eosinophiles, i per cent.; mast cells, 2 per cent;
haemoglobin (blotting paper method"), 90 per cent. _
On November i, 1907, the attending surgeon decided that
patient could not be operated upon until something more
definite could be localized.
On admission tlie temperature w as 99.6° F. ; the highest
temperature being 101° F. ; lowest temperature 97.2° F.
The average morning temperature was about normal; the
average evening temperature was 99.4° F. Five days prior
to- death a normal temperature was present.
The pulse rate ran from 82 on admission to 145 before
death. Lowest pulse rate 68.
The respirations never varied from 20 to 24 throughout.
In spite of all treatment the headache continued until
November 2d, when patient became stupid but answered
questions rationally. Suddenlv at 5 p. m. breathing became
verv slow and shallow. Pulse kept fairly strong, later be-
coming thready and slow, until death occurred at 6 p. m.
Necropsy: Upon opening the calvarium an irregular,
burrowing abscess in the left hemisphere just external to
the lateral ventricle could be made out. Thi'^ burrowing
pus could be traced to a small opening entering the right
ear. The base of brain was covered with exudate. A com-
plete post mortem examination was not performed, by re-
quest of family.
Conclusions— Buef\y stated, here was a case of a
young woman with a strong family history of tuber-
culosis ; a historyof pain in her riglit earwithottt any
discharge of pus two years previously; a pain in
right occipital and parietal region coming on two
months before her admission to the hospital, this
pain l)eing constant and unrelieved by treatment and
worse at night ; forcible vomiting : vertigo : anaemic ;
a leucvtosis of rS.ono: a low tension pulse: patient
d}ing after ail apparent means had been employed
to locate her disease ; and the necropsy showing the
diseased condition in the left hemisphere of the
brain, where there had never been the slightest sign
to indicate the location of the abscess in this situa-
tion. Had the consulting surgeon operated over the
site of trouble as indicated by the symptoms he never
would have reached the diseased area.
Operative evacuation of the abscess is the only
treatment that can be considered, yet how impossible
it is to operate when the symptoms bear no relation
to the location of the abscess, as in this particular
case. Without such an operation the disease is, of
course, fatal.
The statistics of Korner show that there is hope
in many of these cases by operation. Of seventy-six
cases in the cerebrum, forty-two patients were
cured, thirty-four patients died ; of sixteen cases in
the cerebellum, nine patients were cured, seven died,
i. e., 56 per cent, of each were cured by operation.
Greene, in the International Textbook of Surgery,
says: "To wait till a complete diagnosis of the pres-
ence and situation of an abscess is in the majority
of cases to lose the only opportunity of saving life,
for the full development of symptoms necessary for
such a diagnosis in most cases show themselves only
in the latest stages, just before death, when the vital
forces are so reduced that operative procedure is not
justifiable. For a fair chance of success the opera-
tion must be done early ; and the fact already stated,
that in 92 per cent, of otitic abscesses of the brain
the bone is diseased directly to the dura, justifies
and demands an exploration of the bone, even on
slight suspicion of brain disease. If this is done by
exposing the ear cavities by the so called radical op-
eration, the disease can be followed inward from its
source to the brain."
428 Forty-seventh Street.
The Local Treatment of Diphtheria.— J. T.
Maclachlan contributes to TJie British Medical
Journal, for March 21, 1908. a note on a case of
diphtheria in which recovery followed the applica-
tion of a paint consisting of a sohition of equal
pans of liquor hydrargyri perchloridi and glycer-
inum acidi tannici, of the British Pharmacopeia.
He was called to see a child on January 5, 1908,
and found it was sufifering from diphtheria, there
being considerable patches of membrane on both
tonsils. The face was pale and puffy, and the pulse
was soft. He ordered the paint to be used every
two hours, telling the mother the object was to kill
the germs in the throat. The mother, in her anxiety
to get the child well, actually painted the throat
cverv hour, and in thirty-six hours all trace of
membrane had disappeared and the child seemed
well again, except that she was weak and anjemic.
The paint was continued for several days, at longer
intervals, and then stopped and an iron tonic pre-
scribed. On January 20th a bacteriological exam-
ination was made and the bacillus of diphtheria was
found. The paint had been stopped too soon. The
lesson which Maclachlan derives from this experi-
April II, 1908.]
THERAPEUTICAL NOTES.
693
ence is to paint hourly, day and night, until mem-
brane is gone, then continue the application at suit-
able intervals for a week or longer, or until the swab
test is negative. The following is his form of pre-
scription : :
J"^ Liq. hydrarg. perchlor, Bi ;
Glycerini acidi tannici, 5i.
M.
The author says he has used this paint for many
years, ordering it to be applied every two hours,
unless during sleep, and has found it only fail on
one occasion to clear up the throat, when he used
antitoxic serum.
Sprays for Laryngeal Tuberculosis. — ^The fol-
lowing formulas are credited Lemoine and Mendel,
respectively, in Journal de medccine de Paris, for
March 14, 1908 :
I.
R Boric acid, Siiss;
Sodium borate, Siss ;
Cocaine, gr. ii ;
Glycerin,
Boiling distilled water, Bvi-
M.
II.
R Balsam of Peru, TiJtviii;
Tincture of eucalyptus aa 3i;
Tincture of quillaja, Tttlxxv;
Distilled cherry laurel water Siiss ;
Distilled water 5xvi.
M.
Sodium Nitrite in Therapeutics. — Sodium ni-
trite has been used for some time in therapeutics.
It is a drug which requires to be used with caution,
because it is poisonous in comparatively small doses,
and fatal cases" of poisoning are recorded. It is a
white salt, readily soluble in water, and it is ordi-
narily prescribed in aqueous solutions, in doses of
two to five grains during twenty-four hours. It is
of value in cases of chronic arterial hypertension,
according to M. Vaquez {Archives des maladies du
cceiir, des z'aisseaux, et du sang, January, 1908),
who prescribes the following syrup :
R Sodium nitrite, 3ss ;
Tincture of melissa, W Ixxv ;
Distilled water, Siiss;
Simple syrup ad ^v\.
M. Sig. : One teaspoonful three times a day, th^ patient
taking the medicine for five days and suspending treatment
another five days, when the medicine is resumed.
M. Raymond {loc. citat.) recommends the hypo-
dermatic administraton of sodium nitrite in the
treatment of the lightninglike pains of locomotor
ataxia. He uses a ten per cent, solution, injecting
fifteen minims during the day [ ? in divided doses]
for six days, then suspending treatment for ten days,
after which it is renewed for a fresh period of ten
days, thirty minims being administered daily in
divided doses. The treatment is again suspended
as before, and renewed after the interval of rest in
doses of forty-five minims a day.
American Wormseed Oil for Ascaris. — The
value of the oil of xA.merican wormseed {oleum
chenopodii anthelmintici) in the treatment of as-
caris is attested by Briining, of Rostock {Pharma-
seutischc Zcntralhalle, March ig, 1908, p. 234), who
gives it in from eight to fifteen drop doses, accord-
ing to the age of the child, every hour for three
hours, in sweetened water, followed by a laxative.
If it is not retained readily, or gives rise to colicky
pains, when given in this way, it should be taken in
a draught of warm milk.
[American wormseed oil is distilled in this coun-
try, in the neighborhood of Baltimore, from the en-
tire plant, Cheiiopodiiiin ambrosoides L. var. an-
thelminticum Gray. — Abstractor.]
A Middle Ear Inspirator. — In a communica-
tion to the Journal of the American Medical Asso-
ciation for March 28th, Percy R. Wood describes
an instrument he has devised for the inflation of the
middle ear by the patient
at his home. He first
calls attention to the fact
that tinnitus auriuin,
\A hich is frequently an an-
n o y i n g and persistent
sequel to acute and
chronic Eustachian and
middle ear catarrh, is
often permanently re-
lieved by inflation of the
middle ear for a pro-
longed period. A pro-
longed course of office
treatment is, however,
denied to many patients
on account of lack of
time or means, and for
the benefit of such he hit
upon the construction of
the instrument illustrated,
which consists of a glass
tube bent on itself. One extremity is shaped for
insertion into one naris, while the other retains the
medicament and is inserted between the lips. When
charged and in place a sudden expiration forces the
medicated vapor into the middle ear. The author
says that persistent application of this instrument
for weeks or months permanently relieves tinnitus
and morbid conditions of the Eustachian and intra-
tympanic membranes in a large percentage of cases.
The following solution is used to impregnate the
cotton and supply the medicated vapor :
^* Chloroform ^ii;
Ether •
Alcohol \ . ! .3i;
Oil of rose enough to scent.
M.
Zittmann's Decoction. — In The Journal of
Cutaneous Diseases, for April, 1908, Professor
Montgomery, of the University of California, re-
vives an old and greatly neglected remedy, animad-
verting at the same time on the present day sub-
serviency of clinicians to chemists. Montgomery
believes it is just as erroneous to conclude, because a
drug has certain chemical properties, that it must
necessarily be of value in a given disease, as to assert
that, because a medicament does not answer to cer-
tain chemical requirements, it is valueless. Zitt-
mann's decoction at one time enjoyed a great and
deserved popularity in the treatment of syphilis, but
because the chemistry of the day asserted that the
mercury used in it was insoluble, and therefore
could never reach the patient, it fell into disuse.
Now, through chemistry, it is known that mercury
Middle ear inspirator. A. medi
cated cotton; B, oakum; C, rub
Ler tip for insertion into naris.
694
THERAPEUTICAL NOTES.
[Neu York
Medical Journal.
is present in the finished decoction, and in a very
digestible form. He admits that chemistry has done
infinite good to the practice of medicine and believes
that the hope for future advance lies largely along
chemical lines ; but "what is objected to is subservi-
ency to chemistry, and often to men who never saw
a patient." The author gives a minute description
of the old way of making Zittmann's decoction, and
he emphasizes the necessity of seeing that the in-
structions are implicitly followed by the druggist
who is entrusted to compound it, even if it becomes
necessary to "sit over him with a cocked pistol in
your hand while the necessary steeping and boiling
is being carried out." It is especially difficult to get
the instructions fulfilled, Montgomery says, "if the
apothecary is over clever and enterprising." The
formula of the original preparation is cited by him
as follows :
R Sarsaparilla root loo.o grammes ;
Water, 2600.0 grammes.
Then add well mixed up and in a linen bag:
White sugar, 6.0 grammes;
Powdered alum, 6.0 grammes;
Calomel, 4.0 grammes;
Cinnabar (mercuric sulphide), i.o gramme.
Allow to stand over night in a covered porcelain
or earthenware vessel. The next morning simmer
gently for eight hours. Then add :
Fennel seed 4.0 grammes;
Anise seed, 4.0 grammes;
Senna leaves, 24.0 grammes;
Licorice root 12.0 grammes.
The leaves should be first brac ed in a mortar and
then cut fine.
Allow the mixture to stand for three hours and
then strain oflf 2,500 g;-ammes.
This should be labeled Zittmann's decoction
(strong).
The weak decoction is made as follows : Take
the dregs left after straining off the .strong decoc-
tion, and add to them :
Sarsaparilla root, 50.0 grammes;
Water 2600.0 grammes.
Boil gently as before for three hours, stirring fre-
quently, and add :
Lemon peel,
Cassia bark,
licorice root,
Short cardamom seeds, aa 3.0 grammes.
Allow to stand for three hours and strain ofif
2,500 grammes.
Bottle and label Zittmann's decoction (weak).
The dose of the decoction varies. A wineglassful
each of the strong and of the weak is a moderate
dose. If it proves too laxative, less may be given.
Sometimes large doses are ordered, as a pint of the
strong in the morning and a pint of the weak at
night, but this is unusual. If the patient is kept in
bed, and the decoction is taken warm, it is said to
add to its efficacy.
Montgomery says that the decoction may be given
also as a mild alterative between courses of inunc-
tions or injections of mercury, or after the prolonged
administration of potassium iodide.
Thymol in Whooping Cough. — Berger {Thera-
peuHsche Rundschau, March 22, 1908) says he has
met with astonishing success in the treatment of
whooping cough by the use of a one tenth of one
per cent, solution of thymol given as an inhalation
every three hours, in the following prescription :
^ Thymol, gr. viiss ,
Absolute alcohol nklxxv;
Distilled water, 3xvi.
M.
The thymol will not remain in solution unless the
bottle is kept in a warm place at a temperature about
68° F., and it may be necessary to place it in warm
water before using, in order to redissolve the thymol.
Mistura Ferri Aperiens. — -The Philadelphia
Hospital Formulary (edition of 1899) does not list
a preparation bearing the name Mistura ferri acida,
but under the heading Mistura ferri aperiens the
following is published :
R Iron sulphate, gr. xvi;
Magnesium sulphate 3ii»
Diluted sulphuric acid 5ii;
Syrup of ginger, Jii;
Infusion of quassia, q. s. ad 5viii.
Dose : Tablespoonful.
It will be perceived that the quantities of mag-
nesium sulphate and diluted sulphuric acid in this
formula are identical with those prescribed in the
formula for Mistura ferri acida printed in the pre-
ceding number of the Journal on page 648, but the
amount of iron sulphate is reduced and the mixture
is made up to eight ounces.
For Gastric Hyperasthenia. — The following
prescription is attributed to Robin {Gazette mcdi-
cale de Nantes, March 14, 1908) :
R Tincture of cocrulus, Siiiss ;
Tincture of hyoscyamus,
Tincture of belladonna, I -- V
Tincture of cannabis indica, |
Tincture of opium, J
M. Sig. : Ten drops at noon and night before meals, and
five drops before breakfast.
Another prescription, said to be more effective, is
the following:
I* Atropine sulphate, gr. 1/7;
Picrotoxine, gr. 1/2;
Alcohol sufficient to dissolve ;
Distilled water, 3x.
M. Sig.: One tablespoonful twice daily, before meals, at
noon and evening.
Gargle for Chronic Pharyngitis. — The follow-
ing is credited to Eudler in Journal de medecine de
Paris, for March 14, 1908:
R Zinc sulphate, gr. iii;
Peppermint water, Jii-
Sig. : Use as a gargle three or four times a day.
Application for Pruritus Ani et Vulvas. — A
paste of the following composition may be applied
to the parts affected :
^ Salicylic acid, gr. xxx;
Phenol, gr. xv ;
Tartaric acid gr. xlv;
Glycerite of starch, 5iii;
M.
To be followed by the free use of a dusting
powder :
R Powdered talc, 3vii;
Zinc oxide .3i.
M.
Application for the Prevention of Bedsores. —
The following, applied as a varnish twice daily to
the parts menaced, will act as a preventive of bed-
sores :
Guttapercha,
Chloroform .^i ;
Balsam of Peru gtt. xv.
M.
April II. 1908.]
EDITORIAL ARTICLES.
695
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Review of Medicine.
Edited by
FRANK P. FOSTER, .M. D.,
and SMITH ELY JELLIFFE, M. D.
Address all business communications to
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Entered at the Post Office at New York and admitted for
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NEW YORK, SATURDAY, APRIL 11, 1908.
THE STATE CHARITIES AID ASSOCIA-
TION'S WORK IX THE CAMPAIGN
AGAINST TUBERCULOUS DISEASE.
The State Charities Aid Association is playing
a very commendable and efficient part in the effort,
undertaken jointly by itself and the Department of
Health of the State of New York, to curb the in-
roads of pulmonar>' consumption on the public
health. Not the least praiseworthy of its activities
is the maintenance of a "press bureau," by means
of which authentic information is furnished weekly
to about 500 newspapers, principally in the State of
New York.
We are indebted to the association for a recent
issue of its publication, dated March 24th, in which
attention is called to the advantage likely to accrue
to the Chinese by the forthcoming translation into
the Chinese language of Dr. S. Adolphus Knopf's
famous prize essay, which we have already an-
nounced as about to appear. To some extent, it
seems, the preparation of the translation is a result
of the association's "press bureau." It is stated in
the issue before us that, in reply to an inquiry
recently sent out for the purpose of ascertaining
whether or not it was the opinion of the editors
who received the association's publication that such
service was worth while, a letter was received from
Mr. Charles M. Fahs, a missionary editor, stating
that he thought the service extremely valuable, add-
ing that he often sent the material to medical mis-
sionaries, and that one of them, Dr. George A.
Stewart, connected with a number of farm missions
in China, having received from Mr. Fahs a copy of
Dr. Knopf's essay, had written to Dr. Knopf for
permission to have it translated into Chinese. Dr.
Stewart wTOte also that the people of China suffered
severely from consumption and knew nothing about
hygienic methods of combating it.
THE AMERICAN SOCIETY OF TROPICAL
MEDICINE.
The fifth annual meeting of the American Society
of Tropical Medicine, which was held in Baltimore,
at the Johns Hopkins Hospital, on Saturday, March
28th, was a notable one. In the five years of its ex-
istence this society has provided a centre for the
distribution of information about tropical diseases
and has acted as the rallying point for the increas-
ing number of medical men returning from the trop-
ical climates of the world. Not only are the activi-
ties of this body of men of interest to physicians and
sanitarians returning from the tropics, but they are
or should be of interest to all the practitioners of
medicine in the lower austral zone of the United
States, which comprises the Carolinas, Georgia,
Florida, Alabama, Mississippi, Arkansas, Louisi-
ana, Texas, Arizona, New Mexico, and southern
California. In all these districts, with the possible
exception of southern California, malaria is present
in greater or less amount. There is still much to be
learned by original investigators about this disease ;
but there is much more to be learned about it by the
general practitioner. In this region also intestinal
parasites are more common than in the more tem-
perate climate found above the thirty-sixth parallel
of north latitude. The study of the faeces in all
cases of chronic gastrointestinal disorder is rapidly
producing results which make all the inconvenience
of the process well w'orth while.
While it is quite likely that kala azar and try-
panosomiasis will never be found in our own home
territory, except as imported diseases, as plague and
cholera are occasionally imported, still there is
enough work, which is properly classifiable as trop-
ical, to be done to interest an increasing number of
medical men.
The programme of the society was carried out in
the main as indicated in the news columns in our
issue of March 21st. Mr. D. E. Lantz, of the United
States Department of Agriculture, gave a very in-
teresting account of the habits of rats, and described
the best methods of catching them. Dr. F. F. Rus-
sell, of the Army Medical Museum, read a paper on
the comparative morphology of Treponema pallidum
and Treponema pertenue. Dr. Terry, of the Rocke-
696
EDITORIAL ARTICLES.
[New York
Medical Journal-
feller Institute, gave a demonstration of living and
stained trypanosomes and spirochsetas. The sessions
of the meeting, one held in the morning and one in
the afternoon, were attended by about a hundred
members and guests.
THE GOLITZYN HOSPITAL.
The Russian physicians' accounts of the casualties
of their armies during the Russo-Japanese war are
now being brought to the notice of their foreign
confreres. We have received a report of the work
of the temporary structure of the Golitzyn Hospital
in Moscow, edited by Dr. S. Deriiginsky, chief
physician of the hospital.
The charity of the Russian nation during the war
was boundless. Rich and poor alike contributed
funds for the care of the wounded, for the improve-
ment of the condition of the soldiers at the front
and on the march, etc. The Golitzyn Hospital was
founded and is supported by the princely family of
Golitzyn. The present chief of the family, Prince
Sergius Michailovitch Golitzyn, gave the building
for a temporary war hospital and provided twenty
beds ; Mr. Nicolaus Dmitrievitch Selesnev, ten beds ;
and the Teamsters' Guild of Moscow, twelve beds.
Thus the temporary hospital contained forty-two
beds and was equipped with a full armamentarium,
including a Rontgen ray apparatus provided by
Prince B. D. Sidamon^Eristov. Dr. Deriiginsky
supervised the hospital and attended to the surgical
cases and operations. Dr. G. J. Pribytkov took
charge of the nervous diseases, and Dr. V. N.
Spassky treated the other medical cases. Besides
these three regular physicians at the Golitzyn Hos-
pital, there were engaged four gentlemen as assist-
ant house physicians at a nominal fee of eighteen
dollars a month. Five women volunteered as nurses.
Thus it was made possible that the cost of each bed
was only one ruble (about sixty-five cents) a day.
From June 18, 1904, to April 10, 1906, 210
wounded and seventy sick soldiers were received,
having been sent from the front, which circumstance
meant a long and tedious trip. The wounded had
certainly received some treatment, not merely "first
aid," at and near the battlefield.
Of the 210 wounded, four died, one after an
operation for tuberculous coxitis, one from internal
haemorrhage (a haemophiliac), and two from sepsis,
having arrived at the hospital very septic. Of the
seventy sick, seven died, one of carcinoma of the
stomach and six of tuberculous disease of the lungs.
Of the sick soldiers, twelve suffered from septic
middle ear inflammation, four from emphysema and
bronchitis, two from pleurisy without exudation,
fifteen from pulmonary tuberculous disease, two
from subacute enteritis, one from perityphlitis, two
from typhoid fever, two from syphilis, one from a
sequela of gonorrhoea, three from sciatica, three
from traumatic nervous disturbance, and two from
epilepsy. Eleven were classified as neurasthenics.
Among the wounded, there were seventeen in-
juries of the cranium, twenty-seven of the brain,
and seven of the spinal cord. Three successful tre-
phinings were performed. Ten soldiers were treated
for paralyses of peripheral nerves, and in six cases
bone sutures were applied for ununited fractures
(two in soldiers who afterward died from septis).
Two operations for aneurysm were performed with
good final results. Bullets and metallic splinters
were taken out in eighteen cases, while in eight cases
the foreign bodies were left in place. The lung was
injured in sixteen cases, the abdominal cavity in six,
and the spinal column in seven. Simple injuries of
the long bones and joints by bullets were treated in
thirty-eight Avounded, multiple injuries in six. Nine
cases presented injuries to other parts of the body,
while twenty-eight patients were operated upon for
diseases which were not contracted in the field. This
short synopsis shows the great variety of cases.
Some of the wounded soldiers arrived at the hos-
pital a year and a half after the injury.
CARRIERS OF TEIE MALARIAL
PARASITES.
Two years ago there were only six mosquitoes
which had been definitely settled to be capable of
transmitting malarial disease from man to man.
These were Anopheles maculipennis, Anopheles
bifnrcatus, Mysomyia fimesta, Pyretophorus cos-
falis, Cellia argyrotarsis, and Cellia albipes. Others
were suspected, but there was a doubt. In the sec-
ond edition of Tropical Diseases, by Sir Patrick
Manson, 1907, there is a list of twenty-six other
members of the family Anophelincr which have
"been shown with more or less precision to be effi-
cient hosts of the malaria parasites." The notable
species included in this list are Myzorrhynchus Lutzi
for Brazil and Myzomyia Rossii and Myzorrhynchus
sinensis for India (the latter also for Japan). In
the December number of the Philippine Journal of
Science there is an interesting article by Mr. Charles
S. Banks, entomologist in the Biological Laboratory
of the Bureau of Science of Manila, describing the
methods by which he succeeded in showing that
Myzomyici Lndlozvii should be added to the list.
Mr. Banks's work was done at the navy yard at
Olongapo and at the marine rifle range at Maqui-
naya, where malarial fever of a very pernicious type
was prevalent. Among other interesting facts ob-
served in the course of the study, the development
April II. 1908.]
EDITORIAL ARTICLES.
697
of Myzomyia Lndlozdi larvae into pupae and imag-
ines in salt water was not the least in importance.
The development of the gametocytes into the
ookinete and into the sporozoites has been definitely
traced in this mosquito, and one person has been ex-
perimentally infected by the bite cf an infected
insect.
THE COUXTRY DOCTOR.
This is a well worn theme, but it puts on fresh
attractiveness under the touch of Dr. X. A. Powell,
of Toronto, professor of medical jurisprudence and
associate professor of clinical surgery in the Medical
Department of the University of Toronto. His ad-
dress on the subject was published in the March
-number of the Canadian Journal of Medicine and
Surgery. It was first delivered in 1890 before the
students of Trinity Medical College, and it is so
good that we do not wonder that it was repeated
by request seventeen years later, in 1907, before the
Medical Society of the University of Toronto.
Dr. Powell tells us that for ten years he was him-
self a country doctor, but that it is not his own story
that he recounts. He evidently had other country
doctors under observation, and the composite pho-
tograph which he carries in his mind, and of which
his address is an impression, is a well deserved
tribute to the country doctor in general. There may
be an occasional black sheep in the ranks, but the
average country doctor is such as Dr. Powell de-
picts him. 'The glory of optimism pervades his
life." "He is the best friend a community can have.
He is the confidant of lovers, and helps to make
up their quarrels. He brings together again the
husband and wife, whom differences have separated.
He is father confessor to half the country, and
keeps his trust with knightly honor. His sym-
pathy is deep and genuine, and is not worn upon his
coat sleeve. Xo one more than himself feels con-
tempt for a 'gusher' in or out of his profession."
The address overflows with humor. The author
quotes Father Faber as having once said : "There
is no greater help to a religious life than a keen
sense of the ludicrous." He tells us that "an evan-
gelist at one time got into the habit of calling his
audiences 'Dear souls.' Laboring in Ireland, he
used to say with effect, 'Dear Belfast souls,' 'Dear
Dublin souls,' but when he said "Dear Cork souls'
it did not seem quite so appropriate."
A grand man is the country doctor as portraved
by Dr. Powell, but he is not perfect. "To be per-
fect," he saySj "'an ideal doctor, he would need to
have the wisdom of Solomon, the patience of Job.
the strength of Samson, the bravery of Joshua, the
eloquence of Paul, the meekness of Moses, the
faithfulness of Abraham, the charity of Dorcas, and
the executive ability of Jezebel. He would have to
hunt like Ximrod, fish like Peter, climb like Zac-
cheus, and drive like Jehu. He would have to keep
clear of the gout of Asa, the melancholia of Saul,
the gastric infelicity of Timothy, and would still fall
short of perfection if he had not the tireless perse-
verance of the devil himself."' We have quoted Dr.
Powell's own words freely, feeling that any attempt
to paraphrase them would detract from their ex-
pressiveness. We hope that many of our readers
will be fortunate enough to obtain the entire text
of the address.
EXPERIMEXTAL \'AL\"ULAR LESIOXS.
The old method of damaging the valves of the
heart, in experimental patholog}-, by introducing
instruments into the heart through the vessels of
the neck, was of some value, but it was impossible
to regulate the nature and degree of the damage
with any degree of certainty. Recently Dr. Cush-
ing and Dr. Branch, of Baltimore {Journal of
Medical Research, February), taking advantage of
McCallum's improved valvulotome, which is in-
serted directly into the chamber through the heart
muscle, have evolved a technique whereby they can
induce either regurgitation or stenosis at will. The
respiration is controlled by direct inflation through
a tracheotomy tube, and the heart is exposed by a
muscle splitting operation, the sixth rib being re-
sected. The valvulotome is then inserted into the
heart and the valve cusps or chordae tendineae
divided if it is desired to bring about regurgitation.
To induce stenosis a suture is passed around the
chordae tendineae or through the cusps. Lesions in-
duced in dogs in this manner give rise to signs and
symptoms closely resembling those found in human
patients with corresponding valvular defects. Of
twenty-five dogs subjected to this experiment,
eleven recovered, while eight died during the opera-
tion and six died later from infection, to which dogs
seem peculiarly liable after operations about this
part of the body.
The authors not only believe that much may be
learned from such studies, but they regard it as
possible that the technique may be so improved
that it will be feasible to divide a stenotic mitral
\ alve in the human subject, a procedure which, they
state, was conceived by Sir Lauder Brunton six
years ago (Lancet, 1902, i, p. 352). In certain
cases it might be justifiable to subject a patient to
considerable risk in order to relieve him of the pro-
gressive results of a contracting mitral valve. Cush-
ing and Branch do not consider that our present
knowledge would justify such an attempt. The one
698
NEWS ITEMS.
[New York
Medical Journal.
dog on which they had an opportunity of putting
their theory to test certainly upheld them in this
position. Not only did the animal die during the
oj>eration, but the post mortem disclosed no sign
of stenosis, notwithstanding the fact that the diag-
nosis had been made by eminent clinicians.
DR. STANFORD E. CHAILLE'S JUBILEE.
It is singularly appropriate that the alumni of
the Medical Department of Tulane University, as
well as his many friends, purpose to celebrate the
fiftieth year of teaching service of Professor Chaille,
the celebration to take place on May 19 and 20,
1908, in the form of a jubilee.
It is further proposed that a fund be created to
preserve the memory of the occasion of Dr. Chaille's
retirement from the medical department and to per-
petuate his name. This fund is to be employed to
establish a chair of physiology or a chair of
hygiene in Tulane University, to be named after
Dr. Chaille. The alumni and friends of Dr. Chaille
are requested to send their contributions to Dr.
Isadore Dyer, secretary and treasurer of the Chaille
Memorial Fund, P. O. box 778, New Orleans.
Changes of Address. — ;Dr. William Edwin Park, from
Sunbury, Pa., to New Milford, Susquehanna County, Pa.
Geneva, N. Y., Medical Society. — The regular monthly
meeting of this society was held on Thursday, April 2d.
The general topic for discussion was Tuberculosis.
The Glens Falls, N. Y., Medical and Surgical Society
held its regular meeting on Thursday evening, April 2d.
The paper of the evening was read by Dr. J. S. White, of
South Glens Falls, on The Borderline of Insanity.
The Iowa State Sanatorium for the Treatment of
Tuberculosis was opened on February ist, with six pa-
tients. The sanatorium has accommodations for eighty
patients and is under the direction of Dr. H. E. Kirschner.
Charitable Bequests. — By the will of Dr. John Or-
dronaux, who died recently at Glenhead, L. I., the Mary
Hitchcock Hospital, of Hanover, N. H., receives $6,000
for a free bed, and the Norton Hospital, of Taunton, Mass.,
receives $6,000.
Philadelphia Medical Examiners' Association. — At a
stated meeting held on Tuesday evening, April 7th, Dr. G.
G. Davis delivered an address on A Consideration of Her-
nia from the Viewpoint of Life Insurance. The discus-
sion was opened by Dr. L. J. Hammond.
Buffalo, N. Y., Academy of Medicine. — The regular
meeting of the Section in Surgery was held on Tuesday
evening, April 7th. The principal paper of the evening was
read by Dr. Robert W. Lovett, of Boston, on Acute Trau-
matic and Chronic Synovitis of the Knee.
Union County, N. J., Medical Society. — The annual
meeting of this society was held on Wednesday, April 8th.
at the General Hospital, Eli;^abeth. Officers were elected
for the ensuing year, and Dr. H. R. Livengood, the retiring
president, read a paper on Abdominal Pain.
Philadelphia Municipal Hospital Changes.— Dr. Sam-
uel S. Woody has been appointed chief resident physician.
Dr. Edward K. Mitchell has been appointed third assistant
resident physician, and Dr. Charles J. Swalm has been pro-
moted to be second assistant resident physician.
The Medical Society of the Borough of the Bronx. —
A stated meeting of this society was held on Wednesday,
April 8th. The principal paper of the evening was read by
Dr. William Seaman Bainbridge on The Diagnosis and
Treatment of Cancer — Some Practical Suggestions.
The Portland, Me., Medical Club held a meeting on
ITiursday, April 2d. Dr. R. F. Goodhue presided, and Dr.
W. H. Bradford read the paper of the evening on Varicose
Veins of the Lower Extremities with Resulting Varicose
Ulcer. Dr. P. W. Davis is the secretary of the club.
The Hospital Ship "Relief," under the command of
Surgeon Stokes, joined the fleet at Magdalena Bay on
March 27th, where a number of sick men from different
vessels were transferred to her. The Relief will remain
with the fleet during the remainder of the cruise around
the world.
National Volunteer Emergency Service. — The annual
meeting of the National Volunteer Emergency Service
Corps was held in New York on Tuesday evening, March
31st. Major General James Evelyn Pilcher is the director
general of the service and Brigadier General Franclyn El-
bert Davis is adjutant general.
New York State Hospital for the Care of Crippled
and Deformed Children. — The bill recently introduced
into the legislature providing an appropriation for the
erection of a new building at West Haverstraw, N. Y., has
been approved by tlie finance committee of the senate. It
has already passed the assembly.
No Yellow Fever in Cuba. — Governor Magoon has
received from Major Jefferson R. Kean the reports of
twenty-six army surgeons in different parts of Cuba saying
that there is no yellow fever in Cuba and that there is no
need of further quarantine. The reports add that the health
of the island generally is excellent.
The Michigan State Society for the Prevention and
Cure of Tuberculosis. — This society was organized on
February 21st at a meeting held in Detroit under the
auspices of the National Association for the Study and
Prevention of Tuberculosis, for the purpose of carrying
on active work against tuberculosis.
The Pathological Society of Philadelphia held a
stated meeting on Thursday evening, April 9th. The pro-
gramme included the following papers : The Production of
Decidnomata, b\' Dr. Leo Loeb; The Interpretation of the
Venous Pulse, by Dr. George Bachman ; Volume and Spe-
cific Gravity of Organs Removed at Autopsy, by Dr. Syd-
ney L. Olsho.
Medical Society of the County of Richmond, N. Y. —
The regular monthly meeting of this society was held on
Wednesday evening, April 8th, at the Staten Island Acad-
emy of Medicine. Dr. Eugene J. Callahan read a paper on
Malignant Growths in the Spleen, and Dr. Carl R. Keppler.
of Manhattan, exhibited an apparatus used in the treatment
of deformities.
A Portrait of Dr. Packard Presented to the Pennsyl-
vania Hospital. — The former resident physicians of the
Pennsylvania Hospital presented to the hospital a portrait
in oil of the late Dr. John H. Packard, for many years
chief surgeon of the institution. The presentation was
made on March 27th in the presence of the entire staff of
nurses and physicians now connected with the hospital.
The Lake Keuka, N. Y., Medical and Surgical Asso-
ciation.— The ninth annual session of this association
will be held at Grove Springs, Lake Keuka, N. Y., on July
Qlh and loth. The membership of the association includes
physicians from the counties of Allegheny, Chemung. Li\-
ingston, Monroe, Ontario, Steuben, Schuyler. Seneca,
Tioga, Wayne, Wyoming, and Yates. Dr. Lewis W. Rose,
of Rochester, is the president of the association.
Craggs's Research Prize. — The London School of .
Tropical Medicine announces that a prize of £50 will be
awarded to the student, past or present, of the school who.
during the current year (October to October), makes tlie
most valuable contribution to tropical medicine. If the
work has already been published it will not be disqualified
on that account. All contributions must be in English, and
must be sent in on or before October i, 1908. Further
information may be obtained from the Medical Superinten-
dent of the London School of Tropical Medicine, Royal
.Mbert Dock. F. , London.
April II, 1908.]
NEl'VS ITEMS.
699
The Northwestern Medical Society, Philadelphia. —
At a stated meeting of this society, which was held on
Monday evening, April 6th, the programme included the
following papers : Dr. David L. Edsall, Our Present Knowl-
edge of Autointoxication ; Dr. John T. Carpenter, Ocular
Complications of Toxaemia; Dr. Barton Cook Hirst, The
Toxaemias of Pregnancy and the Puerperium ; Dr. Alfred
Stengel, The Treatment of Constitutional Toxsmias.
The Detroit Academy of Medicine celebrated its for-
tieth anniversary on February 25th. Five of the original
thirteen members are still alive, and one of them, Dr. A. B.
Lyons, was present at the meeting and gave a brief ad-
dress on the early work of the academy. Dr. Leartus
Conner reviewed briefly the life and work of each of the
deceased charter members, and personal reminiscences of
the eight deceased members were given by members of the
academy.
Northern Medical Association of Philadelphia. — At a
meeting of this association held on Friday, April loth, the
evening was devoted to a "symposium" on diseases of the
rectum. Dr. Ernest La Place read a paper on the Diagnosis
and Treatment of Malignant Diseases of the Rectum. Dr.
Collier F. Martin read a paper on the Diagnosis and Treat-
ment of Hasmorrhoidal Disease. Dr. J. Coles Brick read
a paper on the Diagnosis and Treatment of Ischiorectal
Abscess and Fistula.
Contagious Diseases in Chicago. — According to the
weekly bulletin of the Department of Health, the following
cases of contagious diseases were reported during the week
ending March 28, 1908 : Diphtheria, 105 cases ; scarlet fever,
84 cases; measles, 295 cases; chickenpox, 56 cases; typhoid
fever, 20 cases ; whooping cough, 39 cases ; tuberculosis, 56
cases. Diphtheria showed an increase of 30 cases over the
preceding week, measles showed an increase of 73 cases,
and scarlet fever a decrease of 15 cases.
The German Rontgen Society. — In connection with
the fourth congress of this society, which is to be held in
Berlin on April 26th, there will be a Rontgen tube exposi-
tion. This exposition will demonstrate the historical de-
velopment of the Rontgen tube and will give an exhibit of
the various kinds' of tubes in use at the present time, but
will not show any of them in action. Further information
concerning the exhibition may be obtained from Dr. Melzer,
Langenbeck Haus, Berlin N., Germany.
Syracuse, N. Y., Academy of Medicine. — At a meet-
ing of this academy which was held on Tuesday evening,
April 7th, the programme included the following papers :
Resection of the Humerus Following Gunshot Wounds, by
Dr. F. H. Flaherty ; Sporadic Cretinism, by Dr. W. H.
Maynard ; Tumor of the Pituitary Body, by Dr. F. W.
Marlow ; Puncture of the Heart with Suicidal Intent, by
Dr. H. L. Eisner. Dr. Frederick W. Sears is the president
of the academy and Dr. Clarence E. Coon is the secretary.
Personal. — Dr. A. A. Michelson, professor of physics
in the University of Chicago, has been elected an honorary
member of the Royal Irish Academy.
Dr. Theobald Smith, professor of comparative pathology
at Harvard University, has been elected an honorary fel-
low of the Society of Tropical Medicine and Hygiene of
London.
Dr. M. G. Varian, of Coram, Cal., is registered at
the Philadelphia Polyclinic and College for Graduates in
Medicine.
The Philadelphia Academy of Surgery held a stated
meeting on Monday evening, April 6th. Dr. A. P. C. Ash-
hurst reported a case of nerve anastomosis and several
cases of tendon transplantation for infantile paralysis. Dr.
J. |. A. Van Kaathoven read a paper on Twenty-five Hun-
dred Cases of Gas Ether Anasthesia Without Complication.
Dr. Charles H. Frazier read a paper entitled The Surgical
Treatment of Trifacial Neuralgia, including a Series of
Nineteen Intracranial and Fourteen Extracranial Opera-
tions, with One Death.
The Medical Association of the Greater City of New
York. — A stated meeting of this association will be held
in Du Bois Hall, New York Academy of Medicine, on
Monday, April 20th, at 8 :30 p. m., for which the following
programme has been arranged : Dr. Robert Coleman Kemp
will read a paper on Various Clinical Types of Acute Dila-
tation of the Stomach ; Dr. Samuel G. Gant will read a
paper entitled An Efficient Method of Irrigating the Small
and Large Intestines ; Dr. H. Beeckman Delatour will re-
port three cases of perforating ulcers of the alimentary
canal ; and Dr. A. Ernest Gallant will give a demonstration
of a corset for visceral ptoses. Among those who will par-
ticipate in the general discussion are Dr. William H.
Thomson, Dr. Max Einhorn, Dr. Joseph Merzbach, Dr.
Jacob Kaufmann, Dr. Martin L. Bodkin, and Dr. Ludwig
W. Kast.
The Health of Pittsburgh.— During the week ending
March 21, 1908, the following cases of transmissible dis-
eases were reported to the Bureau of Health of Pittsburgh :
Chickenpox, 13 cases, o deaths; typhoid fever, 31 cases, 6
deaths ; scarlet fever, 18 cases, i death ; diphtheria, 9 cases,
2 deaths; measles, 172 cases, 3 deaths; whooping cough, 26
cases, 2 deaths; pulmonary tuberculosis, 27 cases, 13 deaths.
The total deaths numbered 182 in an estimated population
of 403,330, corresponding to an annual death rate of 23.46
in 1,000 of population.
Rochester, N. Y., Academy of Medicine. — The regu-
lar monthly meeting of the Section in Surgery, which in-
cludes anatomy, orthopjedic surgery, ophthalmology, otology,
laryngology, dermatology, and genitourinary surgery, was
held on Wednesday evening, April 8th. Dr. Floyd S. Wins-
low reported a case of retention of urine complicating
pregnancy, and two cases of tuberculous peritonitis, and
Dr. Milton Chapman reported a case of skin gratfing. Dr.
J. W. McGill is the chairman of the section and Dr. Cur-
tiss Jameson is the secretary.
New York Academy of Medicine. — A public meeting
will be held in Hosack Hall on Thursday, April 30th, at
8:30 p. m. The Hon. Rufus B. Cowing will deliver an
address on the Value of Medical Expert Testimony, based
on an experience of twenty-eight years on the bench. He
will be introduced by Dr. John A. Wyeth, president of the
academy, who will make a brief introductory address. At
this meeting the president and the members of the State
and New York City Bar Associations will be invited to
meet the fellows o; the academy and the medical profession
at large.
Registration of Tuberculosis Cases in the District of
Columbia. — A bill has been passed by the House of
Representatives providing for the registration of all cases
of tuberculosis in the District of Columbia, for the free
examination of the sputum of suspected cases, and for
other measures that will aid in preventing the spread of
tuberculosis in the district. This bill will in all probability
become a law, and Washington will then have a very com-
prehensive ordinance covering the question of the registra-
tion of tuberculosis.
The Medical Society of the County of Ontario, N. Y.
— The quarterly meeting of this society will be held in
Canandaigua on Wednesday, April 15th, at 2 p. m., in the
Y. M. C. A. building. The tuberculosis exhibit of the
State Department of Health will be in the building and
will be open to the public all day. The programme includes
the following papers : The General Practitioner in the
Fight Against Tuberculosis, by Dr. F. L. Stebbins ; Myo-
cardial Changes with Fleeting Physical Signs, by Dr. H. L.
Eisner, of Syracuse; Tuberculosis, by Dr. H. D. Pease, of
Albany. Dr. C. P. W. Merritt, of Clifton Springs, is the
president of the society, and Dr. D. A. Eiseline, of Shorts-
ville, is the secretary.
Infectious Diseases in New York:
We are indebted to the Bureau of Records of the Depart-
ment of Health for the follozcing statement of new cases
and deaths reported for the two lueeks ending April 4, 1908:
, March 28. ^ , April 4. ,
Cases. Deaths. Cases. Deaths.
Tuberculosis pulmonalis 539 200 531 171
Diphtheria 405 58 390 44
1,813 38 1,778 37
Scarlet Fever 1,113 40 997 53
Smallpox
Varicella 135 .. ,66
1 yphoid fever 22 4 28 8
Whooping Cough 15 3 29 4
Cerebrospinal meningitis ly 8 9 12
Totals 4,059 351 3,928 329
700
NEWS ITEMS.
[New York
Medical Journal.
Scientific Society Meetings in Philadelphia for the
Week Ending April i8th.—Al ondav, April 13th. Section
in General Medicine, College of Physicians ; Wills Hospital
Ophthalmic Society. April 14th, Philadelphia, Pediatric
Society; Botanical Section, Academy of Natural Sciences.
April 15th, Philadelphia County Medical Society (business
meeting for members only); Section in Otology and Lar-
yngology. College of Physicians ; Association of Clinical
Assistants, Wills Hospital; Franklin Institute. Thursday,
April i6th, Section Meeting, Franklin Institute; Medical
Society of the Woman's Hospital; Section in Ophthal-
mology, College of Physicians. Friday, April 17th, Uni-
versity of Pennsylvania Medical Society; American Phil-
osophical Society.
The Mortality of Chicago.— According to the report
of the Department of Health for the week ending March
28, 1908, there were during the week 660 deaths from all
causes, 381 males and 281 females, corresponding to an an-
nual death rate of 15.89 in 1,000 of population. In the cor-
responding period for the year 1907 there were reported
744 deaths from all causes, and the annual death rate was
18.40. The principal causes of death were: Apoplexy, 19;
Bright's disease, 37 ; bronchitis, 25 ; consumption, 83 ; can-
cer, 28; convulsions, 6; diphtheria, 8; heart diseases, 51 ; m-
fluenza, 5; intestinal diseases, acute, 34; measles, 4;
nervous diseases, 33; pneumonia, 104; scarlet fever, 8; sui-
cide, 8; typhoid fever, 7; violence (other than suicide),
2,2 ; whooping cough, 4 ; all other causes, 164.
The Health of Philadelphia.— During the week ending
March 21, 1908, the following cases of transmissible dis-
eases were reported to the Bureau of Health of Philadel-
phia: Malarial fever, 2 cases, o deaths; typhoid fever, 96
cases, 15 deaths; scarlet fever, 89 cases, 6 deaths; chicken-
pox, 36 cases, o deaths; diphtheria, 103 cases, 13 deaths;
cerebrospinal meningitis, 3 cases, i death; measles, 292
cases, 5 deaths; whooping cough, 13 cases, 5 deaths; pul-
monary tuberculosis, 115 cases, 65 deaths; pneumonia, 77
cases, '76 deaths; erysipelas, 11 cases, i death; puerperal
fever, 7 cases, 7 deaths ; tetanus, 2 cases, 0 deaths ; mumps,
23 cases, o deaths; cancer, 21 cases, 25 deaths. The fol-
lowing deaths were reported from other transmissible dis-
eases: Tuberculosis, other than tuberculosis of the lungs,
10; diarrhrea and enteritis, under two years of age, 12. The
total deaths numbered 531 in an estimated population of
1,532,738, corresponding to an annual death rate of 18.00 in
1,000 of population. The total infant mortality was 115;
under one year of age, 87; between one and two years of
age, 28. There were 38 stillbirths ; 19 males, and 19 females.
Meetings of Sections of the New York Academy of
Medicine.— The Section in Neurology and Psychiatry
will meet on Monday, April 13th, at 8:30 o'clock. Dr.
Wolff Freudenthal will present two patients showing pecu-
liar paralytic affections of the larynx. Dr. H. W. Frauen-
thal will report eleven cases of anterior poliomyelitis with
involvement of the face, and will exhibit photographs of the
patients. Dr. William B. Noyes will report a case of an-
terior poliomyelitis, with blood examination showing ma-
larial parasite'. Dr. Robert H. M. Dawbarn will read a
paper on End Bearing Stump Comfort by the Aid of Short-
ening all Sensory Nerves at Amputation. Dr. Smith Ely
Jelliffe will read a paper entitled The Psychiatrists and
Psychiatry at the Age of the Caesars.
A meeting of the Section in Public Health will be held
on Tuesday evening, April 14th, at 8:15 o'clock. The Hon.
Robert W. Hcbberd, Commissioner of Charities of New
York, will read a paper entitled The Need of Additional
Facilities for the Care of the Tuberculous Sick in This
City. Among those who will take part in the discsussion
are Dr. John S. Billings, Jr., Dr. Alfred Meyer, Dr. C. M.
Cauldwell, Dr. J. A. Miller, Dr. Henry L. Shively, and
Dr. L. F. Frissell.
American Therapeutic Society.— The ninth annual
meeting of this society will be held at the Bellevue-Strat-
ford Hotel, Philadelphia, on May 7th. 8th, and 9th. The
preliminary programme, which has just been issued, shows
a long list of papers covering a wide range of subjects, and
the meeting promises to be one of unusual interest. The
presidential address will be delivered on Thursday morn-
ing by Dr. John "V. Shoemaker, on Therapeutics in the
Light of Oology. The Thursday afternoon session will be
devoted to a "symposium" on diseases of the vascular sys-
tem, and in the evening a joint meeting of the American
Therapeutic Society and the Philadelphia Branch of the
American Pharmaceutical Association will be held, which
will be followed by a reception. The morning session on
Friday will be taken up with a discussion of the treatment
of tuberculosis, and for the afternoon session the pro-
gramme shows a list of thirteen papers on subjects of in-
terest to the general practitioner. On Friday evening the
president's reception will be held. On Saturday the general
subject for discussion at the morning session will be Ront-
gen ray therapy, and the afternoon session will be devoted
to routine business. The annual banquet of the members
will be held on Saturday evening. The officers of the so-
ciety are: President, Dr. John V. Shoemaker, of Philadel-
phia; first vice president. Dr. Joseph E. Janvrin, of New
York; second vice president. Dr. Frederic H. Gerrish, of
Portland, Me. ; third vice president. Dr. Howard Van Rens-
selaer, of Albany; secretary. Dr. Noble P. Barnes, of
Washington, D. C.
The Regulation of Lying-in Hospitals in Ohio. — A
bill has been passed by the Ohio State Legislature regulat-
ing the establishment and maintenance of private lying-in
hospitals, boarding houses for infants, and similar institu-
tions. According to the provisions of the bill, particulars
of which we glean from Charities and the Commons, no
one is allowed to receive women for childbirth or board
two or more children without a license from the State
Board of Health. The application for the license must
bear the approval of the local board of health. The license
shall be for a term not exceeding one year. It must specify
the number of women and infants who may be received.
The State Board of Health and the local board of health
may inspect the premises at any time, and may revoke the
license at any time. All patients in such licensed institu-
tions must be attended by legally qualified physicians. Com-
plete records of all women or children received must be
kept by each person holding the license. No child under
two years of age from any such place shall be given out for
adoption, except with the consent of a charitable organ-
ization, society, or institution having the care of children,
duly incorporated, or by a juvenile court. No parent or
guardian shall give an infant under the age of two years to
any person for the purpose of placing it under the permanent
care and control of any person for hire, gain or reward,
but this provision shall not apply to any charitable institu-
tion, society, or association, or to its agents. No person
holding a license shall advertise that he will adopt children
or hold out inducements to parents to part with their off-
spring. Violations of the provisions of the act are mis-
demeanors, punishable by a fine of not more than $500, or
by imprisonment for a year, or both.
Society Meetings for the Coming Week:
Monday, April 13th. — New York Academy of Medicine
(Section in Neurology and Psychiatry) ; Society of
Medical Jurisprudence, New York ; New York Oph-
thalmological Society ; Society of Alumni of St. Mary's
Hospital, Brooklyn : Corning, N. Y., Medical Associa-
tion ; Waterbury, Conn., Medical Association.
TuESD.w, April 14th. — New York Academy of Medicine
(Section in Public Health) ; Medical Society of the
County of Schenectady, N. Y. ; Practitioners' Club of
Jersey City, N. J. ; Medical Society of the County of
Rensselaer, N. Y. ; Buffalo Academy of Medicine (Sec-
tion in Medicine).
Wednesd.vy, April 13th. — New York .Academy of Medicine
(Section in Genitourinary Diseases) ; New York So-
ciety of Dermatology and Genitourinary Surgery;
Woman's Medical Association of New York City
(.Academy of Medicine) ; Medicolegal Society, New
York; New Jersey Academy of Medicine (Jersey
City); Buffalo ^Icdical Club; New Haven. Conn..
Medical .Association; New York Society of Internal
Medicine : Northwestern Medical and Surgical So-
ciety of New York.
Thursday, April i6th. — New York Academy of Medicine:
German Medical Society, Brooklyn ; Newark, N. J..
Medical and Surgical Society; .^sculapian Club of
Buffalo, N. Y.
Friday, April 17th. — New York Academy of Medicine
(Section in Orthopaedic Surgery) ; Clinical Society of
the New York Post Graduate Medical School and
Hospital; East Side Physicians' Association of the City
of New York ; New York Microscopical Society :
Brooklyn Medical Society.
April II, 1908.]
PITH OF CURRENT LITERATURE.
701
|itfe at dvixxtnt f iUrature.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
April 2, 1908.
1. Intussusception : A Review of Some Recent Literature,
with a Report of Cases, By James S. Stone.
2. Remarks Upon Intussusception, with a Suggestion for
a New Method of Operation Upon Cases in Which
Reduction is Not Possible, By E. A. Codman.
3. Anomalous Folds in the Nasopharynx,
By J. Paysox Clark.
2. Intussusception. — Codman observes that
all cases in infants and children, in which the diag-
nosis can be made and which are not already very
feeble, should be given one forcible oil enema under
an anaesthetic on the operating table. This should
be followed by laparotomy, whether the tumor dis-
appears or not. Before using efforts at reduction
forcible enough to cause increased shock, the sur-
geon should, if he does decide on it, make up his
mind to carry out reduction up to the limit of the
patient's strength. If reduction is considered too
doubtful, resection with double enterostomy is the
choice when (a) the mass is wholly composed of
small intestine; (b) when it is wholly composed of
large intestine and the mechanical conditions make
resection easy. If reduction is abandoned and the
mass is wholly composed of large intestine, and re-
section cannot readily be performed, excision of the
intussusceptum is indicated by Barker's or Miku-
licz's method. In irreducible cases in which the
small intestine is invaginated into the large, simple
enterostomy without resection and resection of the
mass should be abandoned and replaced by ligation
of the impacted mesentery and enterostomy. In in-
fants where there is already evidence of severe ex-
haustion, ligation and enterostomy could probably
be done very rapidly and with less operative shock
than even a successful reduction, provided the oper-
ator from the beginning abandoned any idea of re-
duction. The essential object of the operation which
is here suggested is to produce gangrene of the
intussusceptum in a convenient manner, so that
within a few days enough softening of the con-,
stricted portion will have taken place to allow of its
ready reduction by gentle traction. When the arte-
rial supply is cut off it cannot be long before the
blood and cedema in the intussusceptum will be
squeezed out b)' the peristalsis of the intussuscipiens,
leaving the submucosa still strong enough to stand
a gentle pull. The suggestion is offered particularly
for desperate cases to replace resection and hopeless
effort at reduction. It would be easier, quicker, and
produce less shock than any other form of operation.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
April 4, igo8.
1. The Ethics of Surgery, By Charles W. Oviatt.
2. The Treatment of Iritis, By E. C. Ellett.
3. Treatm.ent of Ulcers of the Cornea,
By H. Bert Ellis.
4. Alimentary Intoxication. By William J. Butler.
5. Restoration of the Pelvic Floor, By Howard Hill.
6. Subacute Combined Cord Degeneration with Report of
Cases, - By Julius Grinker.
2. The Treatment of Iritis.— Ellett recalls to
our mind Brailey and Stevenson's words in refer-
ence to the treatment of iritis, that the object of
treatment of iritis should be : To dilate the pupil, to
relieve pain ; to treat any constitutional condition
that may be present as a cause. To dilate the pupil
we must use a mydriatic drug, and atropine, four
grains solution to the ounce, would be the best. In
patients presenting themselves for treatment with
adhesions already formed, it may be necessary to
increase the strength to eight grains to the ounce
for a few instillations in order forcibly to break up
the adhesions. On the other hand, in children, and
in those susceptible to the drug, a weaker solution
may be expedient. Under some circumstances a
small solid crystal of atropine may be introduced. In
general four instillations in twenty-four hours, with
the patient at rest, and under favorable surround-
ings, will suffice to keep the pupil dilated. When
the patient is first .seen it is well for the surgeon
to instil the drops until the pupil is dilated, but we
frequently see that ver\' little dilation is procured
in one hour, while a continuation of the drops for
twenty-four hours may break all the adhesions and
give a round pupil. Even if this has not happened
by the end of the twenty-four hours, it does not mean
that the adhesions are permanent, for continued use
of the drug may result in the continued rupture of
synechia for as long as four or five days. When
full dilation is secured, the frequency of the instilla-
tion should be reduced until the minimum dose
which will maintain the mydriasis is ascertained.
Briefly, this should be continued until the eye is
free from redness. The state of the pupil and the
comfort of the patient together guide us in forming
an idea of how satisfactor}' is the progress of a case
of iritis. The use of the mydriatic, cocaine, dionine,
rest, protection from light, and the application of
heat or cold, all contribute to the patient's comfort
and freedom from pain, and while pain persists im-
provement is not imminent. Special consideration
should be given to one or two of these measures.
Dionine is much used as an ocular analgesic. In
many cases the instillation of a 5 per cent, or 10
per cent, solution will relieve ocular pain for sev-
eral hours, and it mav be repeated as often as neces-
sary. Continuous dry heat of lesser degree is often
soothing. Cold applications seem to be of the most
value in traumatic cases, with threatened or feared
suppuration. In such cases the application should
be continuous as long as it is needed at all. It occa-
sionally happens that a patient with ordinary plastic
iritis prefers the effect of cold to that of heat, in
which case cold may be used continuously or in-
termittently. \\'e must often give anodynes inter-
nally. The various preparations of opium are most
effective, but unpleasant by reason of the systemic
disturbances to which they give rise. A mixture
of antipyrine and sodium salicylate in moderate doses
is a very efficient anodyne, five grains of the former
and seven and one half of the latter in simple elixir
being a convenient form and dosage. Constitutional
treatment is essential and includes attention to ever)'
constitutional condition that can in any way retard
the cure or interfere with the action of remedies.
Aside from its relation to cause, internal treatment
is of importance, and mercury and the salicylates
are of great vakte in other forms than the syphilitic
and rheumatic. Ellett has not had a very favorable
702
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
impression of the value of the iodides except in
chronic cases or in cases associated with chorioditis
and running a slow course ; nor does he find sweats
so effective as in chorioiditis and general uveitis,
though they are of decided value, as Woodruff and
Woods have shown. Burnham"s "combined meth-
od" of the use of mercury, iodides, and pilocarpine
is considered by him well worthy of a trial.
4. Alimentary Intoxication. — Uutler says of
the treatment that it consists in combating the col-
lapse, cutting short the intoxication, and slowly
bringing the child back to a diet commensurate with
its caloric requirements. The first indication may
be met by hypodermoclysis of salt solution, using
50 to 100 c.c, and repeating as is deemed necessary.
The second indication is met by withdrawing the
food entirely and allowing water only for twenty-
four hours. With the subsidence of all symptoms,
begin feeding as follows : As exceedingly small
quantities of fat are injurious, begin with centrifu-
^ated breast milk, if possible, given in teaspoonful
closes, five times a day, or an equal quantity of but-
termilk, to which neither sugar nor meal has been
added ; or, if this is not at hand, fat free milk may
be used. As a diluent, and to supply the liquid
necessary, water and a thin cereal gruel may be
used or given separately. After an interval of
twenty-four hours, provided treatment has been well
tolerated, without any evidence of return of the
intoxication, the separate quantities of milk may be
increased to two teaspoonfuls, which, after two or
three days may, under the circumstances mentioned,
be doubled, and so on, until they are gradually
brought to a diet (free of fat in artificially fed
infants) that will temporarily meet their needs from
a caloric standpoint, having added, in the meantime,
with their increased tolerance of the buttermilk
(where employed), 30 grammes of sugar, prefer-
ably maltose, and 15 grammes of flour to each litre
of buttermilk while boiling. The child should not
be kept on the buttermilk diet longer than six weeks.
After this time whole milk dilutions will be neces-
sary to meet its needs. In case the infant was at the
breast, after four or five days of careful feeding
with contrifugated breast milk, it may be returned
to the breast, the amount of milk being carefully
controlled. During the treatment slight relapses arc
common where the food toleration has been passed.
More efifective and permanent results are accom-
plished by proceeding slowly, allowing forty-eight
hours for judging the efifect of a food increase be-
fore again adding to it. Cathartics and intestinal
antiseptics are unnecessary, unless constipation ex-
i.sts, as sometimes occurs in the soporose form, when
a laxative is indicated. There is little doubt that
injudicious dieting and constant or frequent admin-
istration of laxatives in convalescence are respon-
.sible for the persistence of varying temperature rises
in the first instance, and slimy green stools in the
second instance, which are wrongly interpreted as
manifestations of an cnterocolonic catarrh, or a
bowel infection with repeated reinfections, etc.
MEDICAL RECORD.
April 4. IQ08.
I. The Deep Intraocular Lesions of Infantile Inherited
Syphilis and Tardy Inherited Syphilis, from the
Standpoint of General Patholopy. Prognosis, and
Treatment, By CH.^RI.ES Stfuman Bull.
2. The Treatment of Intraperitoneal Haemorrhage from
Rupture or Abortion of Tubal Pregnancy,
By Hiram N. Vineberg.
3. Acute Lobar Pneumonia — A Study in Inflammation,
By G. K. Dickinson.
4. Notes on Chronic Rheumatism and Its Treatment,
By J. Dardel.
5. Obstruction of the Duodenum by Gallstones. Pre-
operative Localization ; Operation ; Recovery,
By G. A. Friedman.
6. Treatment of Epithelioma and Carcinoma of the
Mucous Membrane, By W. D. Witherbee.
I. The Deep Intraocular Lesions of Infantile
Inherited Syphilis and Tardy Inherited Syphilis.
— Bull, in speaking of therapeutics, remarks that his
question is a broad one and beset with difficulties,
which vary with the age of the patient, and espe-
cially when we come to consider the question of
subinitting the parents to continued observation and
treatment. In the case of the patient, the indication
for specific treatment seems to exist in all cases
where there are lesions of possibly syphilitic origin,
especially if one or more undoubted stigmata are
present. In infants and very young children a
proper dietary is very necessary, especially of the
supporting kind, for these children need soups or
meat extracts at an earlier age than other young
children. A mild mercurial ointment acts very well
in the cases of infantile iritis, in promoting absorp-
tion and assisting to break up the adhesions to the
lens capsule. The prognosis as to resulting vision
will depend largely on the possible existence of
chorioretinitis, vitreous opacities, and lesions of the
retina and optic nerve. But these cases of syphilitic
lesions of the deep structures of the eye promise
much more to persistent and careful specific treat-
ment than is usually supposed. Dr. Bull cites Four-
nier, who lays down four propositions: i. Specific
treatment is indicated in all cases in which the pa-
tients are actually aflfected by lesions or symptoms
which might be due to syphilis, and who show at
least one of the stigmata mentioned. 2. If a patient
shows one or more of the stigmata mentioned, he
should be subjected to specific treatment as a pro-
phylactic measure, even if there be no actual lesion
present. 3. In a recognized syphilitic family, if a
child has recently been born who presents one or
more of the stigmata, the parents should be sub-
mitted to prolonged specific treatment, in order to
prevent, if possible, the transmission of the inherited
taint to any future births. 4.. In case a woman be-
comes pregnant in a family in which the children
previously born show some of the stigmata above
mentioned, she is to be subjected to rigid specific
treatment during her entire pregnancy. In view of
the many serious, even disastrous, lesions which
have come under his observation. Dr. Bull adds a
fifth proposition to the four of Fournier, viz., that
it should he tnade a penal offense for any syphilitic
to marry.
3. Acute Lobar Pneumonia. — Dickinson re-
marks that the time necessary for the formation of
sufficient opsonin, agglutinin, and antibodies to en-
able the phagocytes to accomplish their result is the
length of the disease process proper. The crisis of
the disease occurs at that time when these sub-
stances obtain the upper hand. Such is Nature's
method of cure, and without this process, without
the opsonins, or the agglutinins to assist the phago-
April II, 1908.]
PITH OF CURRENT LITERATURE.
cytic action and the antibodies, the crisis does not
occur and death may and probably does follow. As
soon as the crisis has occurred, as soon as the bat-
tle has been fought and won by Nature, then comes
the process of elimination of the different toxoids
ni the blood and the absorption of the pneumonic
exudate and its elimination. This process of ab-
sorption is heterolysis — that is, the mutual fer-
mentive action of one extraneous product upon
another in the presence of leucocytes and elec-
trolytes leads to their softening and the gradual
passage through the lymphrtic system into the
blood. During pneumonia the . odium chloride out-
put is diminished and often absent, because of its
retention in the system, no more in the lung than
elsewhere ; nevertheless, its presence in the lung is
of vast importance. Sodium chloride is an active
electrolyte and easily becomes ionized. The elec-
trolytes put life into the proteids, and without their
presence active tissue changes would not occur.
As soon as the crisis has passed we have the nitro-
gen output increased and sodium chloride in propor-
tion, while the leucocytes promptly diminish in
number. In addition to the local effect of the germ
mighty influences are brought to bear in various
ways upon the economy in general. After one or
two days' intubation, tissue and microbic poisons, of
amount sufficient to produce fever, rapidly accumu-
late. The sudden influx into the system of these
materials produces a vasomotor reflex disturbance
so severe that the peripheral capillaries contract and
the volume of blood is largely thrown into the ab-
dominal cavity. This condition is clinically known
as the chill or rigor. Although it is the first symp-
tom ordinarily recognized, a careful study of indi-
vidual cases, where possible, will show minor respira-
tory lesions, tonsillitis, indicative of pneumococcus
invasion through the tonsil ; tracheobronchitis, often
induced by the pneumococcus, gastroenteritis sug-
gestive of entrance by this means, or conditions of
malaise, with rise in temperature. The supreme fac-
tor in treatment is the serum. Leucocytes, except
in the very pathogenic types of pneumonia, do not
fail, but the ferments peculiar to the serum, though
present in the normal individual, require several
days for their sufficient elaboration. All treatment
therefore should be directed towards the prompt
formation of these substances. The opsonins in
particular are easily influenced by various condi-
tions. Sleep and mental and physical comfort ma-
terially assist in their formation. A quiet, sympa-
thetic, and attentive nurse, congenial surroundings,
and the assurance of recovery are not unimportant
factors for their formation. Vaccination after the
plan of Wright with dead pneumococci obtained by
culture from the pharynx is a logical procedure and
has been reported as successful. It has been shown
that several drugs ordinarily administered during
the course of this disease are potential for harm.
Alcohol, for instance, will quickly reduce the op-
sonic index. Another action of alcohol is that it
is quickly absorbed from the stomach without be-
ing acted upon by the digestive fluids, and, passing
into the liver, inhibits that organ's function as a
toxine destroyer. Our best clinicians do not re-
sort to it until the crisis, but even then it may be
harmful, for, if there remain any pathogenic germs
in the lung with the opsonic ir .cx cut down too
promptly, relapses may O' cur Opium, aconite, and
large doses of quinine n'^ .oit the ameboid move-
ments of the white bl >' J corpuscles. Small so
called "tonic" doses of '^jinine, however, have a con-
trary effect. Water ^nould be given liberally for
its flushing effect. As the pneumococcus brings
about the formation of acids in the lung and catab-
olism of body acid i in the tissues, some alkaline is
valuable through tl - entire course of the disease;
the ammonia prepara ions are perhaps the best type.
They further tend to forestall heart clot.
BRITISH MEDICAL JOURNAL.
March 21, 1908.
1. Visible Signs of Visceral Disease, By J. Galloway.
2. An Analysis of Two Hundred and Fifty-three Cases
of Tabes, By B. Bramwell.
3. Remarks on the Treatment of Syphilis by Intramuscu-
lar Injections, By J. E. Lane.
4. A Case of Syphilis, Phthisis, and Locomotor Ataxia,
By H. G. Sutherland.
5. On Extragenital Syphilitic Infection, By H. Bayou.
I. Signs of Visceral Disease. — Galloway's
article deals with the cutaneous signs of liver dis-
ease, which signs he classifies as follows: i. Erup-
tions of the type of erythema exudativum, occurring
in cases of disease of the liver with portal obstruc-
tion, such as cirrhosis. Cutaneous manifestations
of the erythematous type occur during the course
of diseases of the liver, especially in those cases in
which the portal blood passes into the general and
therefore into the cutaneous circulation without
being subjected to the normal cleansing action per-
formed by the liver, (a) Urticaria. This is quite
uncommon in liver disease, the circulating toxines
tending to produce the allied eruptions of the er^'-
thema multiforme type, (b) Erythema exudativum.
This is not uncommon in cirrhosis of the liver, oc-
curring most profusely on the trunk as discs or as^
segments of circles. The irritation and pruritus
may be intense. The attacks do not usually last
more than ten days, but are apt to recur. The erup-
tion is frequently complicated by jaundice. (c).
Hasmorrhagic exudative erythema. Erythematous-
eruptions occasionally become purpuric, var)'ing
from a slight amount of blood staining to intensely
hsemorrhagic lesions, occurring as elevated spots or
patches having the color of a superficial hsematoma.
(d) Erythema leading to atrophy of the skin. This
so called "lupus erythematosus" is entirely distinct
from lupus vulgaris ; there is no distinct relation-
ship, and possibly only in some cases a remote con-
nection with tuberculous diseases of other organs.
The inflammation and exudation are of a peculiar
type, leading to atrophy of the connective tissues and
alterations in the character of the epithelium. 2.
Dilatation of superficial blood vessels as an indica-
tion of diseases of the liver. Several forms of dila-
tation of the superficial veins occur: (a) A very-
striking type is the enlargement of the subcutaneous-
veins of the abdomen, forming collateral channels
for the return of blood, with a general course from
the groin upwards to the intercostal veins and even
towards the axilla. These enlarged veins are evi-
dences of obstruction to the vena cava rather than
to the portal circulation, (b) Dilatation of venules-
is usually noted in one of two situations : First,
those radiating from the umbilicus and permitting
704
riTH OF CURRENT LITERATURE.
[New York
Medical Journal.
blood to pass backwards from the liver through its
round ligament into the subcutaneous veins of the
abdomen. This occurs in cases of obstruction to
the portal circulation arising in the liver itself, and
permits of the passage of portal blood directly into
the general circulation. The condition is known as
"caput medusae" or "cirsomphalos." Second, en-
largement of the "costal fringe of venules" along the
lower border of the thorax. This is not specially sig-
nificant of hepatic disease. Third, indications occur-
ring in the course of the lymphatic vessels. An early
sign of cancer of the bile ducts and of the gall-
bladder is the appearance of an indurated patch in-
volving or in the immediate neighborhood of the
umbilicus. Fourth, primary new formations in disease
of the Hver. Xanthoma. The majority of cases of
the widely spread form of xanthoma are accom-
panied by important morbid changes of metabolism,
especially associated with the functions of the liver.
Fifth, anomalies of pigmentation as signs of vis-
ceral disease, (a) Haemochromatosis. This is due to
the destruction of red blood cells, with the formation
and deposition of abnormal pigment throughout the
body and in the skin. Most of the cases are asso-
ciated with disease of the liver, and often with glyco-
suria, (b) Jaundice. This, of course, is the most
common and most important of the indications of
disease of the liver.
2. Locomotor Ataxia. — Bramwell has tabu-
lated 263 cases of locomotor ataxia with the follow-
ing results : 192, or 73 per cent., were in the ataxic
stage, and 71, or 27 per cent., in the preataxic stage
of the disease. 239, or 90 per cent., were males. In
73 per cent, of the cases the disease began between
the ages of thirty and fifty years. In one case it
began as early as at twenty-one years, and in an-
other as late as at sixty-six years. One patient,
aged seventy-three years, presented many symptoms
of the disease, but had no lightning pains. 159, or
60 per cent, of the patients were married. In 155,
or 61 per cent., the patients admitted having had
syphilis, and in 12 per cent, more syphilis was
doubtful. (No attempt was made to discriminate
between "hard" and "soft" chancres.) In 45 per
cent, of the syphilitic cases, the locomotor ataxia
developed within ten years after infection. In only
10 per cent, did it develop more than- twenty years
after infection. In a few of the cases marriage
seemed to have a decided influence either in pro-
ducing or aggravating the disease. Alcoholic ex-
cess was admitted in about 10 per cent. Among the
other causes assigned may be mentioned injury, ex-
posure to cold and wet, lying out at night, mental
worry, infectious diseases and lead poisoning. The
first symptoms, as stated by the patient, were light-
ning pains in 51 per cent., diplopia in 7 per cent.,
dimness of vision in 7 per cent., and ataxia in 6 per
cent. Lightning pains were by far the most fre-
quent of all the symptoms and signs of the disease.
Visceral crises of some form or another were pres-
ent in 13 per cent, of the cases, the gastric being the
most frequent form. Trophic lesions in the bones
and joints occurred in 6 per cent, of the cases. In
11 per cent, of the cases general paralysis of the
insane developed in the course of the loconiotor
ataxia. Seventy cases proved fatal, the most fre-
quent cause of death being general paralysis of the
insane. The average duration of the fatal cases
was 8.2 vears (shortest under one year, longest
twenty-two to twenty-three years).
LANCET.
March 21, igo8.
1. Tuberculosis of the Kidney and Malignant Disease of
the Caecum (Lettgowian Lectures, I),
By C. J. Symonds.
2. The Surgery of the Spinal Cord and Its Membranes
(Hunterian L'ectures, III), By D. J. Armour.
3. Acquired Diverticula of the Sigmoid Flexure, Consid-
ered Especially in Relation to the Secondary Patho-
logical Processes and Their Clinical Symptoms,
By W. H. M. Telling.
4. Preliminary Note on Some Aspects of Splenic Anaemia,
By G. A. Gibson.
5. A Case of Obstruction Caused by Sarcoma of the Small
Intestine, By A. C. D. Firth.
6. Deaths Under Anaesthetics, By F. J. Waldo.
3. Acquired Diverticula of the Sigmoid. —
Telling reports three instances of acquired diver-
ticula of the sigmoid flexure. Diverticula may occur
in any part of the intestine and are divided into two
kinds, congenital and acquired. Meckel's divertic-
ulum is the most familiar example of the first kind,
but they may occur anywhere. Acquired diverticula
are also found in almost any situation in the gut.
They are generally thought to be most frequent in
the large intestine, and especially in the lower part
of the descending colon and the sigmoid flexure. In
the latter location they are usually multiple, have
fairly constant anatomical features, and are particu-
larly liable to undergo secondary pathological pro-
cesses, with a symptomatology peculiarly their own.
The diverticula, apart from such secondary pro-
cesses, do not give rise to symptoms or cause
trouble. In the sigmoid flexure they occur niainly
in two rows, either at the side of the gut or close
to the mesenteric attachment, more rarely on the
convexity. The commonest situation is into the epi-
ploic appendices. In many cases they are confined
to them, and then generally present a double row of
symmetrically placed, hollowed out "pockets." The
special favoring of the epiploic appendices is
ascribed to the fact that the point of their attach-
ment to the gut is a point of least resistance. In a
majority of cases the affected appendages are or
have been filled with a large amount of fat. The
diverticula vary in size, usually from mere macro-
scopic visibility to that of a hazel nut. A larger size
is rarely attained, owing to secondary changes,
which lead either to detachment, ulceration, abscess,
or peritonitis, ^^'hen small they are semiglobular.
and as they increase they become more flask shaped.
The following are the views held by various observ-
ers as to their etiology: i. The generally advanced
age of the patients. In eighty cases the average
age was sixty years. 2. Sex. In eighty-one cases
fifty-three were men. 3. Obesity. Certainly many
of the patients have been fat. 4. Cachexia and ab-
sence of fat. Many subjects, on the other hand, are
thin, after having been fat. The loss of fat is sup-
posed to weaken the wall of the intestine. 5. The
normal structure of the large intestine, which readi-
ly lends itself to local yieldings of its walls. 6. The
physiological role of the sigmoid flexure — fseces are
retained longer in this part of the gut, and conse-
quently the pressure is greatest. 7. Pressure from
within the bowel, due to the accumulation of faeces
April II. 1908.]
PITH OF CURRENT LITERATURE.
or gas, or both, constipation and flatulence. 8. The
relation of the diverticula to the points of entry of
the vessels through rhe gut walls. 9. The variations
in size of tjie vessels. 10. The connective tissue
around the vessels. 11. Muscular deficiency of the
gut wall. As the diverticulum enlarges, the earliest
pathological change is an atrophy of the muscle
layers, with the following serious results: (i)
Thinning of the diverticulum wall. (2) Perforating
action of the retained concretion. (3) The pres-
ence of microorganisms and thv'r toxines. (4) In-
flammatory reaction of varying type and degree.
The secondary processes to w.iich sigmoid di-
verticula are liable may be summed up as follows :
(a) Infection of the general peritoneal cavity from
thinning of the sac walls, without perforation, (b)
Acute or gangrenous inflammation — -"diverticulitis."
(c) Chronic proliferative inflammation with thick-
ening of the gut wall and stenosis of the bowel.
(d) The formation of adhesions, especially of ad-
hesions to the small intestine and to the bladder.
(e) Perforation of the diverticula, giving rise to
general peritonitis, general abscess, submucous fis-
tulse of the gut wall, and fistulous communication
with other viscera, especially the bladder, (f) The
lodgment of foreign bodies. (g) Chronic mesen-
teritis of the sigmoid loop. (h) Local chronic
peritonitis. (i) Metastatic suppuration. (j) The
development of carcinoma, (k) Perforation into a
hernial sac.
6. Deaths Under Anaesthetics. — W aldo has
endeavored to ascertain the exact facts regarding
the mortality in Great Britain due to anjesthetics,
and has examined the methods whereby statistics
of the kind are officially presented to the registrar
general. His conclusions are as follows: i. That
present available data as to deaths during anaesthe-
sia are so imperfect as to be useless for the purpose
of formal investigation. 2. That the returns of
such deaths are for the most part obtained from
coroners' returns of deaths occurring in hospital
practice. 3. That only a small proportion of deaths
under anaesthesia in private practice ever come to
the notice of registrars or coroners. 4. That im-
perfect as are the returns for England and Wales,
those of Scotland and Ireland are still less trust-
worthy. 5. That with such imperfect data it is im-
possible to form any trustworthy conclusions as to
the absolute rate of fatalities to administrations, or
to the relative proportions of deaths to deaths in the
case of particular anaesthetic deaths. 6. That it is
highly desirable to arrive at satisfactory conclusions
as to the precise facts of all deaths under anaesthesia,
both for the safety of the public and the further-
ance of scientific knowledge. He therefore recom-
mends: I. That no general or local anaesthetic shall
be administered by any but a duly qualified medical
man, except in most exceptional circumstances,
which shall be duly reported to some recognized of-
ficial authority. 2. That full details be kept by the
anaesthetist of all administrations of anaesthetics,
whether in hospital or private practice, including
date, name, and address of patient, of operator and
of administrator, nature of operation, the drug used,
and other pertinent details. 3. That a register of
all administrations of anaesthetics be kept in all med-
ical charities, poor law infirmaries, asylums, and
other public institutions. 4. That so far as possible
special skilled anaesthetists be appointed to all hos-
pitals and infirmaries, and that resident anaesthetists
he provided in all the larger institutions. 5. That
when the administration of an anaesthetic is intrust-
ed to a junior qualified man, he should be supervised
by a skilled anaesthetist, except where he can pro-
duce a certificate of special skill and experience as
an administrator, or where a skilled anaesthetist is
not available. 6. That notification be made to the
coroner of all deaths occurring at any stage of gen-
eral anaesthesia by the anesthetist and other con-
cerned. 7. That coroners be required to hold a
public inquiry into all cases of death during anaes-
thesia, and that they make a detailed report to the
registrar general, together with the verdict. 8. That
a commission might with advantage be appointed to
inquire into the present facts of deaths under anaes-
thesia, so far as may be ascertainable.
LA PRESSE MEDICALE.
March 14, 1908.
1. Laryngostomy, By S.\rgnon and Barlatier.
2. Late Ocular Lesions After the Ophthalmoreaction with
Tuberculin,
By Paul Van Durme and Evariste Stocke.
3. Compensatory Hypertrophies and Vicarious Actions,
By R. Romme.
I. Laryngostomy. — Sargnon and Barlatier. in
a brief historic sketch of this operation, say that
it was first performed, to the best of their
knowledge, by Professor Ruggi in January,
1898, but its merits were prominently brought
forward by Killian in 1906. They de-
scribe the operation, which they divide into, i,
the operation itself : 2, the dilatation and the
dressings; 3, the autoplasty; and, 4, the watching
and the maintenance of a tracheal orifice. Two va-
rieties are named, the typical tracheolaryngostomy
and the total or partial laryngostomy. The indica-
tions for laryngostomy are laryngotracheal stenoses,
in order that they may be dilated, and when there
are no stenoses to permit inspection or treatment,
such as dressings, caustics, phototherapy, radio-
therapy, or curettage. The latter cases include those
of malignant tumors in their early stages, certain
forms of glottic and subglottic tuberculosis, certain
forms of laryngeal paralysis, and recurrent papil-
lomata of the larynx. It is specially indicated in
cicatricial strictures. The contraindications are not
numerous. The operation should not be performed
when there is pus in the trachea, when there is
fever, when there is a severe bronchitis, or when
there is an obstacle in the trachea below the place
where the canula would be, a papilloma, for ex-
ample. The inconveniences are slight. After the re-
moval of the canula the vocal troubles clear up, and
they state that many of their patients sing. The
results of the operation they consider very encour-
aging, and they believe that it furnishes a certain
and definite cure for serious cicatricial stenoses oth-
erwise incurable.
March 18, 1908.
T. Opening Lecture on the History of Medicine at the
Faculty of Medicine of Paris,
By Professor Gilbert B.\llet,
2. Sporotrichosis of the Buccopharyngeal Mucous Mem-
brane. Clinical and Pathological Diagnosis,
By M.'VURiCE Letulle.
7o6
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
2. Sporotrichosis of the Buccopharyngeal
Mucous Membrane. — Letulle pictures the condi-
tion of the mucous membrane of the mouth and
pharynx produced by the S porotrichum Beurmanni
as well as the microscopical appearance of the
spores. He alleges that the disease, both clinically
and pathologically, is an affection siii generis, dis-
tinct in all points from any other ulcerative affection
which has yet been described. It does not appear
to be related even indirectly to tuberculosis or
syphilis. If it should appear coincidently with one
of these diseases in the same patient the differentia-
tion would always be absolute and precise.
BERLINER KLINISCHE WOCHENSCHRIFT
March g, 1908.
1. What Is the Cause of Death? By Johannes Orth.
2. The Theory and Practice of the Serum Diagnosis of
Syphilis, By Fleischmann.
.3. The Action of Sodium Oleate in Wassermann's Reac-
tion of Syphilis,
By Hans Sachs and Karl Altmann.
4 Concerning a. Bilateral Isolated Luxation of the First
Metatarsal Bone, By Alfred Stieda.
5. The Varieties of the Skeleton of the Human Foot,
By W. Bocker.
•6. Hvpersemia in the Treatment of Internal Diseases,
By A. Lewandowski.
1. What is the Cause of Death?— Orth dis-
cusses this subject from the medical, scientific, and
legal standpoints, but presents little, if anything,
new.
2. Theory and Practice of Serum Diagnosis
in SyphiUs. — Fleischmann studied the effects
produced by serum in 230 cases, 192 syphilitic, 38
nonsyphilitic. The thirty-eight control cases in-
cluded cases of nonsyphilitic brain tumors, tubercu-
lous meningitis, typhoid fever, pneumonia, sepsis,
myelitis, apoplexy, and carcinoma. In all of these
the reaction was negative. The syphilitic cases were
divided into four groups : i , Positive s}T5hilitics,
with positive syphilitic Symptoms manifest at the
time of investigation, eighty-nine cases ; 2, positive
syphilitics, without manifest symptoms at the time
•of investigation, sixty-four cases ; 3, patients with
symptoms suspiciously like syphilis and questionable
former infection, thirty-two cases ; 4, positive syph-
ilitics. who presented symptoms of disease which
could scarcely be ascribed to the former syphilis,
seven cases. The eighty-nine patients who com-
posed the first group presented at the time of inves-
tigation primary, secondary, tertiary, or the so called
metasyphilitic symptoms. In these the serum gave
a positive result in eighty-three, 93.5 per cent. ; a
negative in six, 6.5 per cent. The six negative cases
were a case of tabes dorsalis of several years' dura-
tion, which had been repeatedly treated ; another
case of tabes dorsalis which had been under treat-
ment for years, an untreated case of tabes dorsalis
with a syphilitic history of twenty-eight years' dura-
tion, an ulcer of the nasal sa^ptum that had been
treated for three years with inunctions and injec-
tions, an old syphilitic chorioiditis, and secondary
papules in a patient during treatment. The first five
were therefore cases in which the process had becMi
long existent or exhausted, and in four had undcr-
gonc .specific treatment. The second group was
composed of sixty-four patients, who presented no
-manifest symptoms, though conceded to have been
infected with syphilis. A positive reaction was ob-
tained in thirty-three, 52 per cent. ; a negative in
thirty-one, 48 per cent. A comparison of these re-
sults with those obtained in the first group shows
that the presence of symptoms is of considerable
moment in the production of the reaction. The author
suggests that in certain of these cases the presence
of the reaction may be an indication for the rehewal
of treatment of the disease. In three of the cases
that gave a negative result fresh syphilitic symptoms
appeared some months later, and then the reaction
was positive. The negative reaction tells us noth-
ing. In the thirty-two cases of the third group one
half gave a positive reaction, one half negative. No
positive conclusion can be drawn as to the value or
lack of value of the reaction in these cases, but in a
considerable number the positive reaction was con-
firmed by the results of specific treatment, and the
negative by the course of the disease. The fourth
group comprised seven syphilitics who were suffer-
ing from probably nonsyphilitic skin affections.
The reactions obtained were positive in one, neg-
ative in six. The author concludes that in
spite of our ignorance in regard to the theoretical
basis Wassermann's reaction has an extensive clin-
ical application in the hands of careful investigators
experienced in serological work. Its chief domain
is in the cases in which suspicious symptoms appear
while infection is denied or is uncertain. A posi-
tive reaction may be considered diagnostic in such a
case, and a negative result, particularly in the ab-
sence of former treatment, may, under certain cir-
cumstances, be of value. In the second place the
test may have a certain value in old cases which
have presented no symptoms for a long time, and
the question needs to be determined whether to re-
new treatment or not. A positive reaction might be
an indication for such renewal of treatment, even
though a negative result would not contraindicate it
when suggested otherwise. The reaction does not
appear to be useful for the diagnosis of cured syph-
ilis.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT.
March 17, igo8.
1. The Fluid in the Sound and the Diseased Conjunctival
Sac, By Schirmer.
2. Destruction of Blood Plaques, Blood Clot, and Muscle
Clot, By BURKER.
3. A New Stethoscope for Measuring the Subjective
Strength of the Heart Beat, By Bock.
4. The Treatment of Eclampsia, By Osterloh.
5. Comparative Studies with the Conjunctival Reaction of
Wolff-Eisner and the Ointment Reaction of Moro,
By Heinemann.
6. Concerning Disinfection of the Hands with Chirosoter,
By Becker.
7. More Favorable Experiences in the Treatment of Blen-
norrhoea of Adults with Blenolenicet Ointment,
By Adam.
8. Concerning the Relations Between Infant Mortality,
Infant Nutrition, and Fitness for Military Duty,
By Hahn.
9. Concerning the Ability to Live of Infants with Very
Large Congenital Umbilical Hernias,
By Durlacher.
10. Concerning X Ray Momentary Exposures with the
Apparatus Used, By Grodel and Horn.
11. The Problem of Skin Electricity, By Haknach.
12. Fulguration According to Keating Hart, By Wiesnek.
13. Lysol and Creosol Soaps, By Ahlfeld.
14. Yearly Report of the Out Door Department of the Sur-
gical Clinic at Munich, By Gebele.
15. Studies in Opsonins (concluded) . By Much.
16. Obituary of Professor Ferdinand Petersen, By Pfister.
April II, 1908.]
PITH OF CURRENT LITERATURE.
707
2. Destruction of Blood Plaques, Blood Clot,
and Muscle Clot. — Biirker says that his experi-
ments show that the material that prevents, or at
least delays, the destruction of the blood plaques
and the coagulation of the blood is irritant to the
muscles at a temperature of 20° C, the more so the
greater the degree to which the destruction of the
blood plaques and the coagulation of the blood is
prevented. This material influences in like grada-
tion the muscle rigidity at 40° C, in that the
muscle contract much earlier and more energetically
than the control muscles. But the most striking
circumstance is that the muscles, although they
finally exhibit all other signs of rigidity, remain
transparent, while the control muscles always be-
come whitish and completely opaque. All solutions
used to preserve the transparent muscles remained
clear, while the control solutions always became
slightly cloudy. A final peculiarity mentioned is
that these muscles remained transparent when
placed in alcohol or formalin. The author finally
draws two conclusions from his experiments: i,
That the lime salts are of importance not only for
the destruction of the blood plaques and the coagu-
lation of the blood, but also for the normal passing
ofif of the coagulation of muscle; 2, that cloudiness
of the muscle is not a necessary criterion of muscle
rigidity.
3. New Stethoscope. — Bock describes a stetho-
scope with an apparatus connected with it for the
purpose of registering the strength of the heart
beats. The instrument is complicated and difficult
to describe briefly.
5. Comparative Studies with the Conjunctival
Reaction of Wolff-Eisner and the Ointment Re-
action of Moro. — Heinemann finds that Moro's
reaction is as useful in making the diagnosis in
tuberculosis as Wolff-Eisner's, and has certain ad-
vantages over the latter. After the conjunctival
test he observed conjunctivitis, which often afflicted
the patient for two weeks, while the ointment reac-
tion was always harmless and afiflicted the patient in
no way whatever. This he considers a noteworthy
practical advantage.
9. Large Congenital Umbilical Hernia. — Dur-
lacher reports a case in which a child was born with
a very large inoperable umbilical hernia, and was
still living at the end of two years and four months.
The treatment given was the application of moist
warm compresses. He discusses other reported
cases, the natural tendency to contraction of the
aperture, the prognosis, and treatment, but adds
little if anything new.
10. X Ray Momentary Exposures. — Grodel
and Horn present some beautiful x rays — teleront-
genograms, they call them — produced by exposures
of 1/15 of a second, i second, and 2 seconds.
LA SEMAINE MEDICALE.
March 18, 1908.
Systematic Drainage as a Prophylactic Measure Against
Postoperative Phlebitis, By F. Motv.
Systematic Drainage as a Prophylactic Meas-
ure Against Postoperative Phlebitis.— Moty re-
fers to the phlebitis that sometimes follows abdom-
inal operations, such as appendectomy, hysterec-
tomy, ne]-)hrorrhaphy, or the radical cure of hernia.
AMERICAN JOURNAL OF OBSTETRICS.
March, igo8.
1. Recent Advances in Obstetrics, By E. B. Cragin.
2. The Diagnosis of Early Pregnancy,
By E. McDonald.
3. High Rectocele After Perineal Repair,
By R. L. Dickinson.
4. Fistula Between the Fundus of the Uterus and the
Upper Portion of the Intestine; Operation, Cure,
By W. P. Graves.
5. Value of Blood Observations in Gynaecological Cases,
By H. A. Duncan.
6. Dystocia from Ventral Fixation,
By O. P. HUMPSTONE.
7. The Hymen, Anatomically, Medicolegally, and Histori-
cally Considered, By E. S. McKee.
8. Some Experiences Relative to the Causation and Treat-
ment of Certain Forms of Metrorrhagia,
By A. P. Clarke.
9. Puerperal Haemorrhage, By J. N. Bell.
10. Personal Observations and Conclusions on the Treat-
ment of Fractures, By D. C. Moriarta.
1. Recent Advances in Obstetrics. — Cragin
states that advance has been most marked along
three lines: (i) Better knowledge of obstetric
pathology, (2) better knowledge of the mechanical
problem of delivery, (3) better procedure. Knowl-
edge of obstetric pathology has made most distinct
advance in the toxaemia of pregnancy, as shown by
pernicious vomiting on the one hand and eclampsia
on the other. In pernicious vomiting there is
fatty and hydropic degeneration of the liver, which
may be diffuse, while the kidneys show degenera-
tion of the epithelium of the convoluted tubules. In
eclampsia there are two clinical types, one in which
the liver is greatly involved and the kidneys slight-
ly, and the other in which the kidneys are chiefly
affected and the liver slightly. Three varieties of
lesions were found in livers which were studied, the
area of degeneration in the lobules varying in each
type. The nephritic type of eclampsia included ( i )
those who had suffered with nephritis, the eclampsia
liaving aroused the old trouble; (2) those whose
kidneys were previously healthy. Better knowledge
of the mechanics of labor consists in noting care-
fully the relation between the foetal head and the
maternal pelvis in the later months of pregnancy,
also in the early correction of occiput posterior pre-
sentations. Better procedure is based upon better
pathology and better mechanical knowledge.
2. The Diagnosis of Early Pregnancy. — Mc-
Donald divides the signs and symptoms of preg-
nancy into (i) those from the history, (2) breast
signs, (3) signs on vaginal examination. Absence
of menstruation may or may not be a significant
sign. It is frequently present from other causes
than pregnancy. On the other hand, a bloody dis-
charge may occur during the first three months of
pregnancy. Nausea and vomiting are common
symptoms, but neither are they limited to early
pregnancy. They are present in about half the
cases of pregnancy. Sensitiveness in the breasts is
usually felt within two months of conception, and
by the end of that period the enlarged papillae, and
the changed areolae of the breasts are manifest. The
vaginal signs are purplish hue of the cervix, soften-
ing of the cervix, compressible isthmus, alterations
in the size, shape, and consistency of the uterus, and
intermittent contractions of the uterus. The last
of these are present or may be excited throughout
7o8
PITH OF CURRENT LITERATURE.
[New York
Medical Jourxai.^
pregnancy. None of the foregoing signs are con-
stant. Their value chiefly consists in the confirma-
tory evidence which they add to other signs.
3. High Rectocele After Perineal Repair. —
Dickinson states that the factors in the production
of rectocele are: i. Laceration or lack of tone in the
fascia and muscles of the pelvic floor. 2. Injury to
the muscular layers of the rectal wall, or defective
activity of such layers. 3. Defects in conformation
of the rectum, or in the axis of the rectal canal, or
both. 4. Obstruction from rigor or irritability of
the sphincter. The methods of study of the form
and direction of the rectal and anal canals upon the
living are as follows: i. The rectum is distended
with air, and viewed with specula in the knee chest
or in the lithotomy posture with lowered head. 2.
By digital touch. 3. By tracing tape or wire, the
measurements and angles being plotted on a full
size sketch. High rectocele after operation is to be
prevented (i) by digital rectal examination of saep-
tum before anaesthesia, (2) by identification of the
structures at operation, and high apposition, (3) by
after care. Precautions after operation for bad
ca.ses are (a) three or four weeks in bed, (b) a daily
soft movement of the bowels, (c) low intraabdom-
inal tension for three months, (d) overcoming irri-
tability or sensitiveness or undue rigor of the
sphincter, and watchfulness against constipation.
THE PRACTITIONER.
March, igo8.
1. The Aortic Incompetence of Later Life,
By J. F. H. Broadbent.
2. Appendicitis, By E. S. Bishop.
3. Valvular Disease of the Heart, By R. Crawfurd.
4. Simple Nasal Obstruction, By W. S. Syme.
5. The So Called Adenomata of the Palate.
By T. P. Legg.
6. Rupture of the Genital Canal During Labor,
By H. T. Hicks.
7. Ophthalmia Xeonatorum, By S. Mayou.
8. A New jMethod of Intestinal Anastomosis Suitable for
Cases of Gangrenous Intussusception,
By A. Edmunds.
9. Future Lines of Treatment : Their Effect on the Pro-
fession, By W. J. Tyson.
10. A Review of Some Recent Work on Gout,
By A. W. SiKES.
11. A Review of Diseases of the Blood and Blood Form-
ing Organs, By H. B. Shaw.
12. A Case of Retroperitoneal Endothelioma Simulating
Malignant Disease of the Pancreas,
By A. W. Falconer.
13. Open Method of Ether Administration Combined with
Chloroform, By H. R. Phillips.
I. The Aortic Incompetence of Later Life. —
Broadbent mentions as causes of degenerative lesions
producing aortic regurgitation in old age ( I ) senile
degenerative change, (2) high arterial tension or
constant strain on the valves and arch of the aorta,
(3) severe intermittent strain on the valves from
frequent and violent fluctuations in the blood pres-
sure, (4) syphilitic aortitis, (5) rupture of a valve.
The physical signs are sudden, short, and forcilile
pulse wave, high blood pressure, hypertrophy of the
left ventricle with a diastolic murmur at the aortic
cartilage, the aortic second sound being also pres-
ent and indicating dilatation of the aorta. If the
lesion is due to intermittent strain in an arduous oc-
cupation, mitral incompetence quickly follows, with
cough, dyspnoea, cyanosis, enlarged liver, fullness
of the veins of the neck, oedema of the legs, and
death from heart failure. Aneurysm is one of the
possible consequences. Urgemic symptoms and an-
gina pectoris may also be present. The prognosis
is always unfavorable, sudden death being of fre-
quent occurrence. When uraemic symptoms are
present mercurial purgatives, diuretics, and iodides,
with a purin free diet, are indicated. With anginoid
symptoms the nitrites and morphine should be ad-
ministered. Digitalis is indicated only in some of
the cases in which compensation has failed.
2. Appendicitis. — Bishop thinks the wide-
spread opinion that the usual symptoms of an acute
attack of appendicitis should be the signal for an
immediate operation is entirely erroneous, and he
protests against such an opinion. The opinion that
every surgeon or practitioner who does not at once
attack it surgically is criminally negligent is simi-
larly erroneous. If there is a history of two or three
previous slight attacks, gangrene and perforation
may be excluded. If acute perforation has occurred
into a protected cavity and not into the general cav-
ity of the peritonaeum it had better be let alone. The
rage for speed in operating is responsible for much
bad work, and the rash and hasty breaking up of
protective adhesions often leads to infection of the
general peritonaeum. During the acute stage the
virulence of the microorganisms is at its highest, the
development of opsonins and antitoxines is at its
lowest. In cases in which there have been previous
attacks it is therefore wise to defer operating until
a quiescent period. In cases without a history it is-
frequently, but not always, best to operate at the
earliest possible moment.
3. Valvular Disease of the Heart. — Crawfurd
says of pulmonary stenosis that it is a rare lesion
and may be congenital or acquired. Rheumatism,
syphilis, and bacteria are causative in the congenital
variety, rheimiatism and other acute infective dis-
eases in the acquired variety. It may exist (i) at
the situation of the orifice and valves, (2) in the in-
fundibulum of the ventricle, (3) in the artery of it?
main subdivisions. It quickly causes hypertrophy
and dilatation of the right ventricle. Clinically one
observes in such cases pallor, dyspnoea on exertion,
and general debility. Some of the cases present
marked symptoms of circulatory sepsis. The visi-
ble signs may be pulsation over the front of the
heart and in the epigastrium, and in some cases
prsecordial bulging. The diagnosis rests upon the
presence of a systolic murmur in the second left
interspace, moving upward and outward, accompa-
nied by a thrill. The second sound is diminished
or reduplicated, and the right ventricle shows hyper-
trophy or dilatation. Sufferers with this condition
are very susceptible to tuberculosis. As to treat-
ment, bronchial catarrh must be avoided, a dry and
warm climate must be selected, and great exertion
must be avoided. In general, the treatment must be
symptomatic, on the lines applicable to cardiac fail-
ure.
6. Rupture of the Genital Canal. — Hicks thinks
this accident should be classified as intra and cxtra-
peritonaeal, rather than as complete and incomplete.
The latter is simple as to treatment and prognosis
compared with the former. Intraperitoneal rupture
may be (a) spontaneous and without delivery of the
foetus, or (b) with delivery of the foetus and fol-
April II, 1908.]
PROCEEDINGS OF SOCIETIES.
709
lowing version or otlier forcible manipulation. The
former is usually unavoidable, rupture occurring at
the point of greatest pressure, its direction being
transverse to the line of greatest tension. It is gen-
erally behind and vertical in the vagina and oblique
or transverse in the lower uterine segment. It is
almost always at the cervicovaginal junction, ex-
tending upward and downward. The abdomen must
be opened if foetus and placenta have entered the
peritoneal cavity. The rent should be sutured, the
peritoneal cavity shut ofif from the uterine cavity,
and the latter drained. Bleeding must be checked
by ligation of bleeding vessels or the tissues through
which they are passing. Wounds of the bladder
should be ligated. In cases in which suturing of the
uterus is inadvisable a gauze drain should pass from
the rent to the vagina. Internal version and trans-
verse presentation cause most of the ruptures in
which the foetus has been delivered. The rent may
not be discovered for hours after its occurrence.
Irrigation and drainage with gauze constitute the
treatment. One must not forget the possible devel-
opment of abscess in the torn and bruised tissues.
THE MILITARY SURGEON.
April, igo8.
I. The Purification of Drinking Water for Troops in the
Field, By Carl R. Darnall.
-2. An Efficient Method of Disposing of Garbage and
Kitchen Refuse by Incineration Under the Camp
Spider, By Herbert A. Arxolu.
3. Tea as a Beverage for the Military Service,
By George F. Mitchell.
4. A Case of Lumbar Hernia,
By James Raymond Hurley.
5. The United States Naval Station, Olongapo, Philippine
Islands; Its Location, Climate and Diseases,
By C. P. Kindleberger.
I. The Purification of Drinking Water for
Troops in the Field. — Darnall describes his ap-
paratus. It cotisists of a galvanized iron tank or
can 24 inches high with an oval section measuring
7 by 16 inches ; two cylindrical water cans 7 by
22 inches, with a mark indicating the three-gallon
point ; and a filter consisting of a cylindrical metal
framework, connected to a siphon of one half inch
galvanized water pipe. The short limb of the pipe
is closed at the end, but communicates with the in-
terior of the framework of the filter. The long arm
is provided with a stopcock. Over this cylindrical
framework the filtering medium is wound and fast-
ened in such a manner that water must traverse the
filter to gain access to the short limb of the siphon.
The filtering material is a cotton fabric known as
"outing flannel," and is quite closely woven. About
twenty-eight thicknesses are used after being folded
into a suitable size and sewed together. This ma-
terial met the requirements better than any other
that was tried. It gives a large flow of water, is
easily sterilized, and does not shrink. Such a siphon
weighs about twelve pounds and will deliver about
fifty-five gallons of water per hour. To start the
siphon action, a small pump somewhat like a bicycle
pump is used. The apparatus is so constructed that
all parts may be packed in the large oval can. which
is then placed in a light wooden crate. This crate
is also used for a stand for the filter. This filter
complete weighs about thirty-five pounds without
the crate, which, on occasion, may be dispensed with.
By leaving out the water cans, the weight may be
further reduced to twenty-six pounds. By distribut-
ing the parts among several men it can be easily
transported by marching troops. In operating this
form of apparatus "hydroxid powder" is used, a
one-pound tin of this being sufficient for 500 gal-
lons of water. The powder consists of alum and
soda, mixed in the form of a powder. The method
of operation is simple. The filter cloths, of which
there are several, are all sterilized by boiling in the
morning before starting and one is put on the filter
ready for use. At the end of the march the ap-
paratus is set up in a few minutes ; the cans or
camp kettles are used to measure the water, to which
a sufficient quantity of the powder is added by means
of the small measure furnished with each container.
After stirring, the water is poured into the filter can
and the filter is then started. Within ten minutes
after halting filtered water may be delivered to the
troops. A larger apparatus is more elaborate, being
furnished with a pump and means of automatically
supplying the solutions of alum and soda to the
water. This model with all its accessories crated
for transport weighs about 390 pounds. Its
capacity is 400 gallons per hour. As regards effi-
ciency it may be said that in a series of experiments
conducted by a board of officers of the army it
was found that this filter removes about ninety-nine
per cent, of the contained bacteria. Since the filter-
cloths are sterilized daily by boiling, bacteria can-
not multiply in them. The filter also removes all
organic coloring matter, and all mud and clay, leav-
mg the water clear and palatable.
MEDICAL ASSOCIATION OF THE GREATER CITY
OF NEW YORK.
Annual Meeting, Held January 20, 1908.
The President, Dr. T. E. Satterthwaite, in the Chair.
Election of Officers. — The following officers
were elected : President, Dr. Robert T. Morris ;
corresponding and statistical secretary. Dr. Frank
C. Raynor ; treasurer, Dr. H. Ernest Gallant ; chair-
man for the borough of Brooklvn. Dr. J. Scott
Wood.
Report of the Corresponding and Statistical
Secretary.— This report showed that during the
year thirty-one new members had been elected, and
that the total membership of the association was
now 647.
Ureteral Catheterism. — In this paper Dr. F.
TiLDEN Brown expressed his gratification at the
increasing appreciation shown by the profession at
large for the accurate diagnosis of urinary disor-
ders and abnormities of the urinary tract, which
was only afiforded by this dififerentiating practice.
He then proceeded to give a demonstration of his
combined cystoscopic and radiographic table, as
well as one connected with the development of the
cystoscope since Nitze and Leiter first made their
wonderfully advanced presentation in 1879. The
speaker said that since 1894, when after a success-
ful and comparatively easy application of the un-
appreciated Brenner catheterism cystoscope, in a
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
case of urinary tract tuberculosis (where the re-
sult served to decide an all important question as
to surgical interference), he had been interested in
testing the relative merits of the different catheteriz-
ing instruments existing at that period ; and he was
satisfied that for this purpose, in general, the direct
vision cystoscope was possessed of more advantages
and fewer disadvantages than the prismatic, or in-
direct, type. Hence his adoption of the Brenner
pattern for his first efforts in development of the
cystoscope. Dr. Brown's remarks were directed
more particularly to instruments and methods with
which he had himself had to do, and were supple-
mented by wall drawings and photographs to dem-
onstrate the various developmental forms, since
1900, of his original "composite cystoscope," the
identical instrument which a St. Louis cystoscopist
had recently appropriated, and had been presenting
as his own "universal cystoscope." This compo-
site cystoscope, made by the Wappler Company, of
New York, was a vastly more useful instrument
than its immediate predecessor, the author's double
catheter direct vision cystoscope, which Leiter, of
Vienna, made for him in 1898, and which was the
first telescopic cystoscope, of any form, to provide
for two catheters and effect synchronous catheter-
ism of the ureters. But this Vienna instrument had
no reserve channels for irrigation. It was with
the end in view of finding a way to add such irri-
gation channels to the already practicable double
catheter direct vision cystoscope, while, at the same
time, not increasing the circumference of the shaft
beyond 24 French, that the Brown-Wappler efforts
were first directed, in 1900. With what initial suc-
cess these efforts had met and what constantly
added improvements he expected, the present pre-
sentation was intended to fully demonstrate. It
should be here added that the speaker's first double
catheter instrument was but a modification of the
then existing Brenner single cystoscope, whereas
his subsequent instruments involved a wholly novel
departure from all the preexisting types. The first
essential change lay in getting rid of the old time
terminal window at the vesical end of the sheath,
and this was followed by the use of different kinds
of interchangeable telescopic tubes for the same
common sheath. Up to the present time its devel-
opment on this basis had resulted in giving us at
least three complete cystoscopes for different pur-
poses, adjustable in one sheath. Still another tube,
of paramount value, to go with this common sheath,
was all but completed, in the shape of an indirect
vision double catheter telescope, which would be
welcome to those who preferred this method of
ureter catheterism to the direct one, and which here
in America had been gaining constantly in favor
since the first introduction of the composite cysto-
scope.
As to the uses of ureteral catheterism. Dr. Brown
said these might come under two heads — diagnostic
and therapeutic. The latter, in his belief, were quite
limited, and it was also his opinion that those en-
thusiasts over kidney lavage of a few years ago
who, missing the diagnostic resources of this pro-
cedure, professed to meet with so vast a number
of patients with pyelitis as to astonish others who
had long been studying such conditions with intel-
ligence, and by the aid of this same differentiating
means — not only had they discovered that pyelitis
was ver}- common, but, furthermore, that it was a
leading factor in the causation of Bright's disease.
From such original deductions, regarding both the
prevalence of pyelitis and their new aetiology of
Bright's disease, it was not difficult to foresee what
a marked change the future mortality statistics, in
connection with such forms of renal disease, when
treated by their medicated lavage of the pelvis,
would show ! The speaker said that he could ap-
preciate the fact that there were exceptional cases
of pyelitis which would be advantageously treated,
at least in part, by this method, but that for the
great majority internal medication, together with
climate, hygiene, and diet, would be much more ef-
ficient and vastly safer.
The therapeutic use of the ureter catheter, on the
other hand, in cases of stones lodged in the ureter
was, from the speaker's experience, one of consid-
erable importance. In not a few the descent of
such calculi had been determined at once or in inter-
mitting stages, by the stretching incidental to the
introduction of the catheter. Besides this mechan-
ical effect of the catheter it was of undoubted ser-
vice in such cases, when the eye of the catheter
had reached a point above. the lodged calculus, either
to use warm gomanol oil or add to the existing
urinary hydrostatic pressure by the guarded and
gradual injection of warm boric or saline solution.
The efficacy of the ureter catheter for the imme-
diate relief of some cases of acute hydronephrosis
by carefully insinuating the eye of the catheter past
the mechanical barrier (whether this was stricture
of the ureter, angling of the ureter, or impaction of
a calculus) was self evident. Where, in such cases,
the catheter was successfully used, it was at once
appreciated as being a therapeutic and diagnostic
resource of the greatest value.
The last therapeutic purpose of the ureter
catheter referred to by the speaker was that of
serving as a tubular splint for a partly or com-
pletely severed ureter, whether such was the result
of accident in abdominopelvic surgery or of any
compression trauma of this tube incidental to acci-
dents. Not only would extravasation be prevented
by draining the urine past such laceration, but the
presence of the catheter also served as a mandrel
during the suture of the ureter.
The second, or diagnostic, class of uses of the
ureteral catheter was altogether too numerous and
too well recognized to require comment, even if
time permitted. Upon only one, as yet not well
appreciated, field of value the speaker said he would
dwell for a moment. This was the combined use
of radiography with ureter catheterism. It was
a well known fact that many plates of the bony
pelvis revealed shadows which, as regarded shape
and position, it was impossible for even the most
expert interpreters of x ray plates to say whether
they represented a calculus in the ureter or some
simulating body in the immediate vicinity. When
these shadows were found in patients giving a fair-
ly typical clinical history of lodged ureteral stone,
the only nearly absolute safeguard for the surgeon,
as well as the patient, against an unnecessary op-
eration was to be had from this practice of first
April II, 1908. J
PROCEEDINGS OF SOCIETIES.
711
passing a ureteral catheter to a distance beyond the
site of this previously recognized questionable
shadow, then inserting a metal stylet (preferably of
platinum) into the catheter, and again making an
X ray picture of both. Of course when the ques-
tionable former shadow was seen to be in the same
anteroposterior plane as the shadow of the metal
stvlet — in other words, when these were apparently
in direct contact — the diagnosis was materially
strengthened. On the other hand, if an appreciable
space existed between the two shadows, the diag-
nosis was almost negatived. A double ureter or en-
cvsted calculus would need to be involved if the di-
agnosis was still to be maintained. The speaker
showed photographic prints from x ray plates illus-
trative of all these conditions. It was because
of the great value of this diagnostic resource that
Dr. Brown had had made a table where this en-
tire procedure could not only be carried out in the
specialist's office, but wOiere no essential change or
movement of the patient's body was necessary after
insertion of the stiletted catheter. In conclusion, he
said that this and closely allied branches of x ray
work were so essentially within the province of the
genitourinary specialist that an office could not be
said to be complete in its appointments without
them.
On the Newer Methods of Examining the Blad-
der.— This paper was read by Dr. Frederic
BiERHOFF (see Journal, pp. 588, et seq.).
Notes on Overtreatment of the Urethra and
Bladder. — In this paper Dr. James Pedersen pre-
sented reports of several cases which illustrated the
bad effects of injudicious management. In one of
these the patient, a young man of twenty-tw^o, re-
ported a slight urethral discharge to his physician,
who told him there was no infection, and proceeded
to pass a full sized sound. This gave him pain and
caused some haemorrhage, and on the following day
he had a chill, foUow-ed by fever. There then de-
veloped an increasing frequency of urination, with
progressive obstruction, and on the twentieth day
after the passage of the sound complete retention
occurred. It was then that Dr. Pedersen first saw
the patient. With a rubber catheter, which was
passed without difficulty, twenty-four ounces of
chocolate colored urine was drawn from the over-
distended bladder, and catheterism was repeated ev-
ery eight hours. In two days fluctuation in the
prostate made its appearance. The pus present was
evacuated through a median vertical perineal in-
cision, and at the end of eight days systematic treat-
ment of the urethrocyslitis and dilatation of the
stricture were instituted.
In another case the patient, twenty-five years of age,
had frequency of urination about five months after
the disappearance of a urethritis lasting six months.
About a month later he noticed a redness about the
meatus, and shortly afterward there appeared a
urethral discharge, which gradually increased. In
a week's timejt became greenish yellow in color,
and by the end of another week he was suffering
from very frequent and painful erections. Under
the use of daily irrigations of the penile urethra
by his family physician the discharge was reduced
in six or seven days to an occasional morning drop,
but although the irrigations were kept up regularly
for two months the one drop still continued. Dur-
ing this time, however, no attention was paid to the
patient's adverse mode of life, the correction of
which would no doubt have greatly aided recovery.
The physician then gave an instillation of a ten per
cent, solution of silve.'- nitrate, and the consequences
were disastrous. This patient was seen in consul-
tation four days later by Dr. Pedersen. and the dis-
charge, which promised to continue indefinitely, was
tiien thin and purulent.
Another case was that of an nnmarried man of
thirty who had suffered much from ungratified sex-
ual excitement, and one year previously had had a
short attack of urethritis. This case, the speaker
said, afforded a striking example of a total disre-
gard of the patient's general condition and lack of
recuperative power, for the man was anjemic and
poorly nourished, and had undergone two opera-
tions (eight years apart) for osteomyelitis. Three
months ago he began to suft'er from pain and ten-
derness in some of his joints and bones, a scanty
urethral discharge, frequent desire to urinate, loss
of appetite, and general ill health. After three
weeks' treatment by intravesical irrigation, sounds
were passed every third day, as it w^as discovered
that he had a stricture. The patient then went
south for three weeks, and came back greatly im-
proved in every respect. Dilatation was now re-
sumed and practised more frequently than before,
and the result was a return of the frequency and
urgency of urination. The point which Dr. Ped-
ersen said he wished to make was that, allowing for
errors of judgment and in diagnosis, and for acci-
dents from the use of instruments, there remained
a fair 'number of cases of faulty treatment (chiefly
overtreatment), in which a correct, or nearly cor-
rect, diagnosis had been made, but in which over-
zeal or overconfidence had led the physician into
doing the patient an unwitting injustice.
Conservative Prostatectomy. — Dr. Follen
Cabot read this paper (see Journal, pp. 384,^/ seq.).
Dr. Parker Syms said that Dr. Brown was cer-
tainly to be congratulated on the admirable work
which he had done. By his ingenious apparatus
and technique he had added no little to the resources
of surgery. He conceded freely that ureteral cathe-
terism had a legitimate field, but this was a some-
what limited one. In hands as skilful and careful
as those of Dr. Brown the procedure was an entirely
safe one, but it seemed to him that the time had
come when a note of warning should be given
against its too promiscuous use. It should be lim-
ited, he thought, to cases in which other measures
had failed and in which it was imperatively de-
manded for diagnostic purposes. With it there was
danger of infecting the ureter, and if, from this,
one kidney became infected, it might lead to disease
of the other also. When infection was already
present in the urinary tract, he thought ureteral
catheterism should be avoided. Under any circum-
stances this procedure should be practised only by
those specially skilled in its performance.
In speaking on Dr. Bierhoff's paper he said that
the cystoscope was unquestionably of very great
value. But, while this, too, had its dangers and
limitations, and while the positive proof which it
afforded was indisputable, its negative proof was
7X2
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
not conclusive. Because the cystoscope did not
reveal a certain condition in the bladder, it did not
follow that that condition was not present. Taken
all together, the evidence which this instrument af-
forded was not so exact as he wished that it was.
In regard to prostatectomy, we had now gone so far
that surgeons were pretty generally agreed as to the
propriety and indications of the operation, though
differing more or less as to methods. Personally,
he preferred the perineal route. He believed that
the mortahty was less with this than with the supra-
pubic— not the immediate mortality alone, but also
that during the period of convalescence. One great
advantage of the perineal operation was the short
duration of confinement required. As a rule, he
allowed his patients to get out of bed at the end of
forty-eight hours, or certainly within three days.
Suprapubic prostatectomy not only necessitated a
longer confinement, but involved more danger in the
subsequent convalescence. He was glad to learn
that by conservative prostatectomy Dr. Cabot meant
an operation in two stages. In selected cases he
himself had followed this plan for the past ten years,
and at times he had found it very useful. He re-
called one case particularly in which the patient was
almost moribund, and where he believed that to
complete the operation at one sitting would certainly
have proved fatal. Here he first drained the blad-
der, and later, after the patient had become much
stronger through the relief thus afforded, he re-
moved the prostate through the same incision. In
all cases where a slightly increased loss of blood or
a sHghtly longer anaesthesia would in all probability
turn the tide against recovery, he now made it a
practice to adopt the two operation plan.
Dr. G. Morgan M-uren, of Brooklyn, said he
agreed with Dr. Syms that at present the cystoscope
was resorted to too often, and he believed that other
useful means of diagnosis had been neglected by
those who were enthusiastic cystoscopists. The pa-
tient's welfare was thus jeopardized by the too fre-
quent resort to this instrument, although it was, in
its legitimate place, one of great practical value. As
regarded prostatectomy, he said that frequent refer-
ence had been made to selected cases, but no one
had spoken about the unselected cases, those of old
men whose general condition was such that any
radical operation was likely to prove fatal. He had
seen such patients die after suprapubic and after
perineal prostatectomy, as well as after the two
stage operation described by Dr. Cabot. In this
class of cases Dr. Muren preferred the method of
permanent suprapubic drainage of the bladder,
which he said he had employed in a number of
instances, making the incision required for the pur-
pose under local anaesthesia. It was here most im-
portant to prevent the leakage of urine, and for this
purpose he exhibited an apparatus with a plug
attachment which he had devised and which he had
found very serviceable.
Dr. Martin W. Ware said that the papers pre-
sented this evening had made it clear that, after all,
the cystoscope was an instrument of precision. We
should look upon it, he thought, in the same light
as the microscope, on the findings of which we sel-
dom relied solely, to the exclusion of other factors.
Although the cystoscope was an instrument of pre-
cision, however, its proper use required a good deal
more care than was generally supposed to be the
case. Its employment was never a procedure of
exigency. After paymg a tribute to the achieve-
ments of Dr. Brown in the field of ureteral cysto-
scopy, and extolling the value of his instruments,
the speaker said that certain cases were met with in
which the conditions were such that direct illumina-
tion of the ureteral Orifices was impossible, and in
which it was therefore necessary to resort to the
Nitze cystoscope. While the possibility of infect-
ing a healthy kidney by ureteral catheterism should
be borne 'in mind, the danger of infection from this
source, and particularly in tuberculous conditions,
had no doubt been exaggerated. The proof was
still entirely lacking that through this agency the
opposite kidney had become infected, and he be-
lieved that any such contention was largely a myth.
Cystoscopy in children constituted a field' which was
as yet not thoroughly opened up. In those under
five years of age the calibre of the urethra was so
small that the instruments thus far devised for the
purpose of exploring the bladder had not proved
satisfactory, on account of the small size of the
prism which had to be used. He thought it might
be of interest to know that the salpingoscope, an in-
strument which rhinologists used for exploring the
orifices of the Eustachian tubes, had been employed
with success by some operators in the case of young
children. It was of the Nitze type, and the prin-
cipal objection to it was the shortness of the shaft.
This was one, however, which could be readily ob-
viated.
Dr. Brown said that, while he believed that in
the vast majority of cases requiring ureteral cathe-
terism the direct instrument could be used, and
while he believed that method preferable for a vari-
ety of reasons (among them being the saving of
time and the diminished risk of haemorrhage), he
fully appreciated the value of the indirect instru-
ment in atypical cases. As to the supposed dangers
attending ureteral catheterism. Dr. Ware had very
well answered some of the criticisms made, and
personally he was not aware of any accident having
occurred in the cases he had examined. He had
refused to take up this procedure, or even simple
cystoscopy, imtil he had become convinced that it
was possible to have all the apparatus employed
completely sterilized. It would not do to resort to
boiling for this purpose, but by repeated experi-
ments he had proved that the vapor of formalde-
hyde was thoroughly efficient. He therefore did not
think that his tools were dangerous, and, as he was
equally careful to have the urethra and bladder
properly cleansed, and to perform the operation
under strict aseptic precautions generally, he be-
lieved the danger of infection was minimized. Even
if the tip of a catheter which had become accident-
ally infected was introduced into a healthy ureter,
he doubted whether the kidney would become in-
volved, for it was now recognized that an ascending
infection was apt to become less and less potent as
it advanced. It was descending infection of the
kidney which we had most to dread. There was a
good deal of injury involved in the turning about
of a searcher in cases of stone in the bladder ; yet
there was very little danger of infection from this
source.
Dr. BiERHOFF said that his own preference was
April II, 190S.J
FROCEEDiXGS OF SOCIETIES.
for the indirect vision cystoscope. and he had been
perfectly satisfied with the results obtained with
this. He could not agree at all with Dr. Muren.
If an examination was to be made, he did not think
it was fair to the patient to experiment with an
insufficient method. It was the duty of the surgeon
to resort at once to the scientific procedure, cysto-
scopy. This, in the speaker's opinion, offered the
maximum of information with the minimum of risk.
The cystoscope was certainly not a safe instrument
in the hands of an incompetent operator, but he had
never seen a case in which complete asepsis was
observed, and burning of the bladder wall avoided,
which was followed by a reaction. In order to
determine the existing condition, it was sometimes
necessary to have two sittings, or even more. He
said that negative evidence did show something,
and cited an illustrative case in which the diagnosis
of hsematuria of renal origin was made out. In
reply to Dr. Ware, he said that it was not necessary
to resort to the salpingoscope in the case of young
children, for at present there were to be had special
children's cystoscopes, which were longer than the
salpingoscope and which, notwithstanding their
small calibre, were perfectly satisfactory as regarded
the results afforded.
Dr. Pedersen said that from his own experience
he could confirm Dr. Brown's statement that calculi
were sometimes more quickly got rid of after the
passage of the ureteral catheter. He had also seen
a stone lodged at the orifice of the ureter disengaged
by the passage over it of the searcher. Radiography
with a stiletted catheter in the ureter for the diag-
nosis of ureteral calculus he thought a matter of
great interest. In a case of Dr. Forbes Hawkes's
the shadow supposed to represent the calculus was
at some distance from the catheter, and it seemed
probable to him that this was one of those instances
of bifurcated ureter which were sometimes met with.
Therefore there was some danger of being misled
by the evidence aflForded by the x ray. Cystoscopy
he believed to be absolutely safe when performed
with proper precautions and under proper condi-
tions. As to prostatectomy, he was convinced of
the usefulness of the two stage operation in certain
cases, and he thought that he had saved a patient's
life last spring by means of it. In reply to Dr.
Syms, he would say that perineal drainage after the
first step was not always safe.
MEDICAL SOCIETY OF THE STATE OF
NEW YORK.
One Hundred and Second Annual Meeting, held in Albany,
January 27, 28, 2g, and 30, igo8.
The President, Dr. Frederic C. Curtis, of Albany, in the
Chair.
{Continued from page 570.)
Dr. Morris, of New York, stated that the subject
was too large to be properly discussed at that time,
and that if he were called upon to give advice to be-
ginners in the profession he would say : "Keep out
of debt and remember that all cases of stomach and
bowel trouble are not cases of stomach and bowel
trouble."
He considered such names as hyperchlorhydria as
high sounding but useless as to the expression of a
pathological entity, and thought its only value lay in
the impression the high sounding title made upon
the patient, so that the doctor's directions would be
more faithfully carried out. In nervous disease of
the stomach he deemed it necessary to eliminate eye
strain and the normal involution of the appendix.
Dr. Dunning, of Orange County, asked for a rea-
sonable explanation of the development of duodenal
ulcer after extensive burns, also for a satisfactory
method of diagnosticating cancer in its early stages.
She asked if the injection of trypsin in people not
affected with malignancy would never give the tryp-
soglycogenic reaction, and if it was always present
in patients so affected.
Dr. Jacobi believed that neuroses of the stomach
usually meant nervous exhaustion. The diagnosis,
he thought, between hyperchlorhydria, ulcer, and
disease of the colon could be reached by the fact that
in hyperchlorhydria the pain was often relieved by
the taking of food. In ulcer it was increased soon
after or even while eating, and in disease of the
colon it came on two or three hours after the food
had been taken. He never admitted so many arti-
cles of diet as Dr. Rochester had allowed, but his
programme was "milk, milk, milk, with rarely a lit-
tle stale bread." A small quantity of rice w^as also
allowed at intervals, and bismuth and magnesia were
administered. A cure might be hoped for in five or
six weeks, and while this treatment was being car-
ried on the patient would often take on flesh.
Dr. BuLKLEY cited the case of a woman who ate
her breakfast as usual, though she was to have an
operation that day, but she did not eat any lunch.
In the afternoon, when she was anaesthetized, she
vomited up the breakfast unchanged. He concluded
from that that it was the nervous condition of the
patient which retarded the digestion, and that ner-
vous conditions from any other cause might also
have the same effect.
Dr. Collins, of New York, believed the involved
classification of gastric neuroses upon a thoroughlv
theoretical and hypothetical basis to be highly unde'-
sirable and to denote a retrogression of about fifty
years. He defended the term hypochlorhydria as
legitimate and signifying something.
Dr. Angell, of Rochester, wished to back up Dr.
Collins in every particular. He considered the dis-
cussion of gastric neuroses as highly speculative.
Dr. Wayne stated that in his experience, especial-
ly in the early stages of ulcer, the administration of
food did not increase, but, on the contrary, relieved
the pain.
Dr. Mayo wished to express his gratitude to Dr.
Stockton for his excellent discussion. He stated
that he always liked to discuss a question with Dr.
Stockton because he believed that he as a surgeon
rnight overestimate the surgical importance of con-
ditions and not give the medical side of the question
its proper consideration. While eighty-one per cent,
of the cases of pancreatitis had been associated with
gallstones, he hoped that the discussion would stim-
ulate the medical department of the profession to
investigate the cause of pancreatitis when no gall-
stone disease coexisted.
Dr. OcHSNER believed all cases of ulcer, when
714
LETTERS TO THE EDITORS.— BOOK NOTICES.
[New York
Medical Journal.
they cannot be cured by a reasonable trial medically,
to be surgical. He stated that when these cases did
come to operation secondary changes, such as py-
loric obstruction, dilatation, or adhesions to other
organs, had occurred. The cause of ulcer of the
duodenum following burns was purely theoretical,
as was also the trypsin diagnosis of cancer, though
he was very glad to have had it brought up.
(To be continued.)
'gttttxs ta t\t mtm.
A CATECHISM FOR PHYSICIANS.
Lanark, Ont., March 31, 1908.
To the Editors:
As an old subscriber and ardent admirer of your
journal, allow me to make a suggestion pertaining
to the personal side of our fraternity, in the shape of
questions which thousands of the subscribers would
willingly answer. The answers could be tabulated
according to their frequency and importance.
1. Is it your ambition to earn enough in a certain
time limit to be able to live at ease without prac-
tising the profession ?
2. Are you desirous of municipal or political
honors plus what they may bring in a financial way ?
3. Would a good property (your business loca-
tion) and a good life insurance, in keeping with
vour income, satisfy your money ambitions?
4. Do your poor patients get as good attention as
your well to do ones ?
5. Do you read medical works and magazines,
besides other up to date literature, daily?
6. Do you strive to. keep in touch with and on
friendly terms with your professional neighbors?
7. Do you belong to the local medical association
or any other?
8. What are your intellectual and physical hob-
bies (if any) ?
9. Are you of a mechanical nature as regards the
use of your hands and head ?
10. Are you prepared and capable to attack nine-
■ ty per cent, of surgical difficulties?
11. What is vour present ambition?
J. E. Klotz.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we retnew those in which we think
our readers are likely to be interested.]
Essentials of Modern Electrotherapeutics. An Elementary
Textbook on the Scientific Therapeutic Use of Electricity
and Radiant Energy. By Frederick Finch Strong,
M. D., Instructor in Electrotherapeutics at Tufts College
Medical School, Boston. New York: Rebman Company,
1908. Pp. X-112.
This little book contains in a very handy form the
elements of the scientific therapeutic use of elec-
tricity and radiant energy. The author does not
presuppose much elementary knowledge in his
reader, and introduces him immediately in medias
res. He speaks of the modern theories of matter,
force, and the fundamental laws and principles of
electrophysics (Chapters I and H). After physi-
ology has been considered from the electrical stand-
point in Chapter HI, galvanism and faradism are
treated in Chapters IV and V. Electrodiagnosis is
the subject of Chapter VI, while in Chapters VII,
VIII, and IX are mentioned the types of static ma-
chines, high frequency currents, and Rontgen rays.
Phototherapy is spoken of in Chapter X, and the
therapeutic use of ozone in Chapter XI.
The illustrations which accompany the text are
well executed and will be of great help in under-
standing the subject. The book will be welcomed by
every practitioner who is not an expert or specialist
in this branch of medicine, and by every student.
A Textbook of Surgical Anatomy. By William Francis
Campbell, M. D., Professor of Anatomy, Long Island
College Flospital. etc. With 319 Original Illustrations.
Philadelphia and London : W. B. Saunders Company,
1908. Pp. 675.
Scattered through the pages of this book there
is indeed a good deal of what may properly be called
surgical anatomy, but essentially it deals with de-
scriptive anatomy from the regional point of view.
The author speaks of it as an "applied anatomy,"
and in so doing he appears to us to be correct, for
he makes his anatomical teaching apply quite largely
to medical as well as to surgical practice. On this
account the book will prove of value to practitioners
in general. The pictorial illustrations are numerous
and clear. In one respect some of them are strik-
ingly different from the lugubrious pictures of the
older anatomical works ; where the face is shown,
it is usually a living and cheerful face, not that of
a corpse. This is particularly true of Fig. 89 (page
174), which depicts a young woman from whom a
generous slice of flesh has been removed so as to
show the proximal ends of the subclavian vessels,
which have been cut through. In spite of this mutil-
ation, the girl's face shows no sign of distress.
The History of the Study of Medicine in the British Isles.
The Fitz-Patrick Lectures for 1905-6, Delivered before
the Royal College of Physicians of London. By Norman
MooRE, M. D. Cantab., Fellow of the Royal College of
Physicians, etc. Oxford : The Clarendon Press, 1908.
Pp. VI-202.
This book consists of four lectures. In the first
of these lectures the author, after a short introduc-
tion in which he also mentions Dr. Thomas Fitz-
Patrick, in whose honor the Fitz-Patrick lectures
were founded by Mrs. Fitz-Patrick, speaks of medi-
cal study in London during the Middle Ages, ex-
emplifying it with the description of the life of John
Mirfeld, who lived in London and died about 1258.
He also mentions among others a medicus Grim-
baldus, who witnessed in T105 the signatures to a
grant. A copy of this document faces the title page,
while the text itself will be found in the appendix.
The second lecture treats of the education of
physicians in London in the seventeenth century.
Here are described the lives of Nicholas, of Casa.
Dr. Thomas Linacre, the founder and first president
of the College of Physicians (founded in 1518), and
others. But the representative of this period is
Dr. Edward Browne, who died in 1708.
The third and fourth lectures give the history of
the study of clinical medicine in the British Islands.
The first part is given over to Sir Theodore Tur-
quet Mayerne (died in 1655), who reported on the
death of King James T and Queen Henrietta Maria.
April II, igcS.]
BOOK NOTICES.
These documents are well translated in the text,
and the Latin originals are to be found in the ap-
pendix. Several letters from the royal personages
to their body physician are given. Sir Theodore
was also a friend of William Harvey. Mayerne's,
Harvey's, Glisson's, Sydenham's, and others' influ-
ence upon the study of medicine in England is men-
tioned, and Boerhaave's upon Scotland and Ireland.
The appendix contains also a note of Harvey on
Galen. A very complete index is of great advan-
tage.
The book has been marvelously compiled and ar-
ranged ; the labor and researches of Dr. Norman
Moore must be greatly admired ; and the Royal Col-
lege of Physicians is to be congratulated on having
entrusted the Fitz-Patrick lectures to such a scholar.
We can recommend the book to every physician
as a recreation after the duties of a strenuous day.
Jahresbericht iiber die Leistungen und Fortschritte auf
dem Gebiete der Erkrankungen des Urogenitalapparates.
Begrundet von Prof. Dr. M. Nitze und Dr. S. Jacoby,
Berlin. Herausgegeben von Priv. Doz. Dr. Albu, Ber-
lin; Prof. Dr. R. du Bois-Reymond, Berlin, etc. Und
unter Mitwirkung von J. Albarran, Paris ; A. Bier,
Berlin; H. Fenwick, London; A. von Frisch, Wien; H.
KUMMELL, Hamburg; H. Young, Baltimore. Redigiert
van Prof. Dr. A. Kollmann, Leipzig, und Dr. S. Jacoby,
in Berlin. IL Jahrgang, Bericht uber das Jahr 1906.
Berlin: S. Karger, 1907. Pp. 452.
This second volume of the yearbook of urology
represents the advances made in this branch during
the year 1906. It does not differ materially from
the first volume, issued for 1905, which we reviewed
here last year. The death of Professor Nitze in
1906 necessitated a change in the editorial manage-
ment, and Professor Kollmann, of Leipsic, took up
the work of the distinguished cystoscopist. Dr
Hugh Young, of Baltimore, and Dr. Krotoszyner,
of San Francisco, represent this country on the
editorial staff of the yearbook. In this volume there
is a slightly diminished tendency to quote principal-
ly German authorities and authors, so that the year-
book is gradually assuming a more international
character. It presents a very fair collection of ab-
stracts on every subject pertaining to urology, and
will prove very useful to compilers of literature and
to writers and students who follow the progress of
urology from year to year.
Clinical Therapeutics. A Handbook on the Special Treat-
ment of Internal Disease. By Alfred C. Croftan, Au-
thor of Clinical Urology. Second Edition, Revised. Chi-
cago: Cleveland Press, 1907. Pp. 626.
The first edition of Dr. Croftan's very useful
book has been rapidly exhausted, and within a few
months this second issue has been launched. There
have been no great advances in therapeutics within
that short space of time, but the book has under-
gone careful revision. It represents undoubtedly
not only one of the most practical, but also one of
the most readable and convenient works on the
treatment of disease that have appeared within re-
cent years. There is nothing in the book that sug-
gests the old textbooks on materia medica and
therapeutics. It is purely a clinical work, dealing
with diseases, symptoms, and complications as they
occur in every day work and giving precise direc-
tions, with the reasons therefor, for treatment.
Numerous useful prescriptions appear in the text,
but the author has made it a point to include all
the modern methods of physical and dietetic treat-
ment. Accurate, detailed directions are given for
the carrying out of these methods, so that with this
book alone on hand a practitioner can follow out
the treatment of disease in all its phases. We
strongly recommend the book, being convinced of
its value, and satisfied by practical experience with
it, that it will prove acceptable to practitioners.
The Operative Treatment of Prolapse and Retroversion of
the Uterus. By J. Inglis Parsons, M. D., M. R. C. P.,
M. R. C. S., Physician to the Chelsea Hospital for
Women ; Late Surgeon to the Royal Maternity Charity
Hospital ; Fellow of the Royal Medical and Chirurgical
Society, etc. London : John Bale, Sons, and Daniellson,
Ltd. Pp. viii-90.
The purpose of this little monograph is to ex-
ploit the author's operation for prolapse of the
uterus. Briefly, this consists in the injection into
each broad ligament of a solution of quinine, which,
producing an effusion, brings about the deposit of
fibrous connective tissue, and that, in turn, gives
firm support to the uterus. The author alleges,
among the advantages of this procedure, painless-
ness and absence of shock and haemorrhage. His
own experiences in 105 cases have been entirely sat-
isfactory to him. The uterus expands easily during
pregnancy, and is not placed in abnormal positions.
The technics of the operation are fully described
and illustrated.
Diseases of the Male Generative Organs. By Edred M.
Corner, M. A., M. B., B. Sc., F. R. C. S., Surgeon to
Out-Patients, St. Thomas's Hospital, etc. London :
Henry Frowde (Oxford University Press) and Hodder
& Stoughton, 1907. Pp. x-279.
This little manual forms a part of a series of
monographs. It deals with diseases of the gen-
erative, as distinct from the urinary organs, and
therefore includes a brief description of the diseases
of the testicle and its envelopes, of the epididymis,
the spermatic cord, and the seminal vesicles. Some
of the diseases of the penis, prepuce, and scrotum
bearing upon the generative function have been in-
cluded. The diseases of the prostate are considered
in another volume of the series. It is a rather odd
notion, to deal with diseases of the genitourinary
organs in their relations solely to the generative
function. We do not, for our part, see the special
need of dealing with .strictures of the urethra, for
instance, from the point of view of their influence
upon the sexual function. However, the book is
one which it is a pleasure to read, and it will prove
very useful to students taking special courses in
this particular line of work. It is compact and
convenient to carry in its flexible cover. Its con-
tents represent rather informal talks in the style of
a clinical lecture than formal essays.
Essentials of Obstetrics. By Charles Jewett, A. M., M. D.,
Sc. D., Professor of Obstetrics and Gynaecology in the
Long Island College Hospital and Obstetrician and Gynse-
cologist to the Hospital, etc. Assisted by Harold F.
Jewett, M. D. Third Edition, Revised and Enlarged.
Illustrated by Thirty Illustrations and Five Colored
Plates. Philadelphia: Lea Brothers & Co., 1907. Pp.
vi-17 to 413.
The popular success of Dr. Jewett's little book is
made evident by the appearance of the third edition.
As an introduction to more extensive works and as
7i6
MISCELLANY.
[New York
Medical Journal.
a guide to lectures, it fulfils its purpose admirably
by bringing before the student the essential facts of
the subject. While the illustrations are mainly
schematic, they are well adapted to their didactic
purpose.
The Medical and Surgical Uses of Electricity, Including the
X Ray, Phototherapy, the Finsen Light, Vibratory Thera-
peutics, High Frequency Currents, and Radioactivity. By
A. D. Rockwell, A. M., M. D., Neurologist and Electro-
therapeutist to the Flushing Hospital, etc. With Two
Hundred and Fifty-nine Illustrations. New York: E. B.
Treat & Co., 1907. Pp. xvi-676.
The present edition, which is practically the elev-
enth of Beard and Rockwell's standard work, has
been thoroughly revised. Many chapters have been
rewritten and much new material has been added.
Especially is this the case in the chapters on high
frequency currents, on x ray diagnosis and thera-
peutics, on phototherapy, and on radioactivity.
It has been the aim of the author to present in
book form the results of his own labors and of the
researches of all other investigators in electrothera-
peutics. He has well succeeded, and the summary
thus obtained, which he places before his readers, is
practical and exhaustive, and the book can well be
recommended.
Lehrbuch der speziHschen Diagnostik und Therapie der
Tuberkulose. Fiir Arzte und Studierende. Von Dr.
Bandelier, dirigierendem Arzte der Lungenheilstatte
Cottbus, und Dr. Roepke, dirigierendem Arzte der Eisen-
bahnheilstatte Melsungen. Mit 18 Temperaturkurven,
auf S lithographischen Tafeln. Wiirzburg: A Stuber,
1908. Pp. 113.
Bandelier and Roepke have collected data from
their experience, and have thus written a book from
practice for practice. The book is divided into
three parts : The specific diagnosis of tuberculosis,
the treatment of tuberculosis of the lungs, and the
treatment of tuberculosis of other organs. A gen-
eral introduction precedes the main body of the
work, and a conclusion follows it. The bibliogra-
phy comprises seventy-three reference books and
articles, of which number three are French, one is
English, and one is Italian, the rest are German
and Austrian.
The authors wish to call the attention of the pro-
fession to the use of tuberculin. They speak of
old tuberculin, new tuberculin, and new tuberculin
bacilli emulsion ; Denys's tuberculin ; Klebs's tuber-
culin ; Beraneck's tuberculin ; Spengler's bovine tu-
berculosis tuberculin therapy ; von Behring's spe-
cific remedy ; other tuberculins following Koch's
method ; the immunization methods following Jen-
ner and Pasteur's theories ; and nastin. These they
classify as active immunizing remedies, while the
passive ones are Maragliano's serum; Figari's
liaemoantitoxine ; Marmorek's antituberculosis
serum, and streptococci sera. The book contains
also very interesting statistical material.
BOOKS, PAMPHLETS, ETC., RECEIVED.
Medical Gynecology. By Howard A. Kelly, A. B.,
LL. D., F. R. C. S. (Hon. Edinb.), Professor of Gyne-
cological Surgery in the Johns Hopkins University, Gynae-
cologist to the Johns Hopkins Hospital, Baltimore, etc.
With One Hundred and Sixty-three Illustrations, for the
Most Part by Max Broedel and A. Horn. New York and
London : D. Appleton & Co., 1908. Pp. 662.
Transactions of the American Climatological Association.
For the Year 1907. Volume XXIII. Pp. 330.
ilistdlang.
George Sand and Her Lovers. — An interesting
problem in literary clinics is discussed in Mr. Fran-
cis Cribble's new book, George Sand and Her Lov-
ers. What was the nature of the illness through
which the novelist nursed Alfred de Musset when
she was living with him at Venice? Dr. Pagello,
who, while attending the patient, supplanted him in
the affections of his mistress, writes : "I diagnosti-
cated a nervous typhoid fever." That, of course, is
nonsense. Nervous typhoid fever is a complication
unknown to medicine, and typhoid fever itself was
unknown to medicine in the year 1834. Typhoid and
typhus were at that date confounded and called
"continued fever." It follows that the alleged diag-
nosis was really an afterthought ; and the record of
the symptoms indicates that the afterthought was
due, not to increased pathological knowledge, but to
a desire to protect the poet's reputation by tamper-
ing with the truth. "When," as Mr. Gribble writes,
"we find the delirious patient seeing 'phantoms'
round his bed, needing to be held down by two
strong men, warned by his doctor during his con-
valescence to avoid strong drink, suspected of obtain-
ing it surreptitiously, and relapsing, we know pretty
well what to think." What we feel compelled to
think is, of course, that the disorder from which
Musset was suffering was delirium tremens. We
feel as certain of that as it is possible to be of the
malady of any patient whom we have not actually
had under observation. The fact — a "new fact" in
literary history — may perhaps in some measure ex-
plain the facility with which George Sand trans-
ferred her affections from the sufferer to his med-
ical attendant, though it certainly cannot be said that
it makes Pagello's conduct in kissing her behind the
screen, as Musset averred that he did, any the more
excusable from the point of view either of morality
or of professional etiquette. — From The Practi-
tioner, March, 1908.
Sugar in the Soldier's Ration. — In the April
number of the Archives de medecine et de phar-
macie militaires, Major P. Joly presents the results
of a series of experiments on sugar in the field ra-
tion of the foot soldier, in the 94th French In-
fantry Regiment during the autumn manoeuvres of
1906, from which he concludes that: i. Two com-
panies, respectively, of 142 and 149 men, without
any previous selection, were able to absorb, during
twenty or seventeen days, a daily dose of sugar
varying from 60 to 165 grammes without any di-
gestive trouble or other signs of intolerance result-
ing therefrom. 2. A hundred grammes of fresh
meat may be replaced in the daily ration by a hun-
dred grammes of sugar without the men perceiving
the diminution in the amount of meat. They ac-
cepted readily, and most of them with great plea-
sure, the addition of sugar in the form of sweet-
ened drink — coffee, wines, or water. 3. The sub-
stitution of 120 grammes of sugar for the hundred
grammes of fresh meat resulted in improvement in
the physiological condition of men subject to mus-
cular exertion, decreasing the number of heart
beats, the respiratory rhythm, and the weight of the
body consecutively ; augmenting the physical re-
sistance and decreasing the sick rate. 4. The over-
April II, 1908.]
OFFICIAL NEWS.
717
alimentation with sugar acted especially upon the
prophylaxis of accidents attributable to heat and
fatigue on the march and in manoeuvres. 5. It was
possible, without in any respect diminishing the
vigor of the subjects, to replace for three days the
entire food ration by 300 grammes of sugar on five
volunteers, who made the last stages of the
manoeuvres without any fatigue. — Through the
Military Surgeon, January, 1908.
Japanned English. — In an entertaining article
on "Japanned English" {The Outlook, December
14, 1907) Mr. George Kennan discusses the ludi-
crous mistakes which the Japanese make when they
essay to advertise their wares and show their
erudition by a smattering of English. The medical
reader finds much to interest him. For example,
"FuUish Milk," "Fluish Milk," and "Fulish Buttr"
represent the endeavors to spell phonetically the
word "fresh" as it sounds to the Oriental ear, the
letter "r" giving the Japanese a lot of trouble. All
sorts of drinks are described in Japanned English
as "nourishing." For instance, over a shop in
Tokio a sign board bore the words "Nourishing
Drugs." Mr. Kennan says that he did not ascertain
whether the proprietor sold cocktails or cod liver
oil. In a daily newspaper a dealer in cofifee de-
clared, "More men is not got dropsy of the legs
who use this coffee, which is contain nourish." One
cannot deny that some definite idea is conveyed, at
any rate. A Tokio druggist advertised for months
"Invaluable, Fragrant, and Nice Pills." The quali-
ties are all desirable, we admit, but the druggist
did not inform the public for what the pills were
to be used. In this country it is the custom for
manufacturers superabundantly to inform the pub-
lic and physicians what certain pills will "cure."
The advertisers of our sanatoriums and health re-
sorts might receive suggestions from the artistic
writer of a pamphlet, "A Guide on Hakone," pre-
pared for the use of visitors to this beautiful sum-
mer resort on the eastern coast of Japan. "Wind
proper in quantity, suits to our boat to slip by sail
and moonlight shining on the sky shivers quartzy
lustre over ripples of the lake. The cuckoo singing
near by our hotel, plays on a harp, and the gulls
flying about to and fro seek their food in the waves.
All these panorama may be gathered only in this
place. Forty-five houses among whole machie are
the hotels for the cessations of travellers. Breads,
fleshes of fowls and animals satisfy the relish of
people. The milk is distributed to the hopers by
the branch store in Hakone. Streams of water is-
suing forth in the southeastern valley of Hakone
machi are used by whole people. Transparent
and delicate liquid is constantly overflowing from
the vat and its purity free from defilement so values
on the applause of visitors as it is with the air."
"Who," Mr. Kennan asks, "after reading this de-
scription, would lose a moment in packing his
trunk and starting for Hakone? The moonlight
shining with quartzy lustre on the gulls, and the
cuckoo playing a harp, would alone pay for the
journey." Mr. Kennan calls attention to the fact
that however ludicrous may be the mistaken use
of words. Japanned English is almost invariably in-
telligible. For instance: "This hot spring is beau-
tiful perspective and a delightful freshness in the
air. It is raise up 4,640 foot up the sea surface and
the temperature within 75 degrees. Therefore it is
most able to everybody sheltering the hot in the
summer season. This hot spring is not special vir-
tue that will give the pure and healthy to human
heart. Because it is the carbonic acid spring to
comprehend many iron. There build the several
bathroom to reserve for some person. Half and 6
miles for Tanaka Station at Shinetsu Line." In
many parts of Japan, says Mr. Kennan, men and
women have been accustomed to bathe together in
the same hot spring. When the Japanese found
this practice shocked foreigners, the proprietor of
a hotel, in advertising a certain bath resort, said:
"We have complete separation for ladies and gen-
tlemen so that the disorder is improbable." Mr.
Kennan calls attention to the admirable precaution
and prudence shown in the word "improbable." —
Through the Journal of the American Medical As-
sociation.
Public Health and Marine Hospital Service
Health Reports :
The foUozving cases of smallpox, yellow fever, cholera,
and plague have been reported to the surgeon general.
United States Public Health and Marine Hospital Service,
during the week ending April 3, igoS:
Smallpox — United States.
Places. Date. Cases. Deaths.
California — Los Angeles March 7-14 4
California — ^^.San Francisco March 7-14 5
Illinois — Chicago March 14-21 2
Illinois — Jacksonville March 14-21 .
Illinois— Rock Island March 14-21.
Illinois — Srringfield March 12-19 .
Indiana — Elkhart March 14-21.
Indiana — Indianapolis March 15-22.
Indiana — La Fayette March 16-23.
Indiana — JIuncie March 14-21.
Indiana — South Bend March 14-21.
Iowa— Ottumwa. . , March 14-21 .
Kansas — Kansas City March 14-21.
Kentucky — Covington March 14-21.
Louisiana — New Orleans March 14-21.
Michigan — Detroit Feb. 14-21 . . .
Michigan — Port Huron March 14-21.
Michigan — Saginaw March 7-14. .
Montana — Butte March 10-17.
Nebraska — Nebraska City.. March 14-21.
New Jersey — Newark March id-21.
Ohio— Cincinnati March
Ohio— Cleveland March
Ohio— Dayton March
Tennessee — Nashville March
Texas — San Antonio March 14-21...
Washington — Spokane March 7-14. .. .
Washington — Tacoma March 7-14. .. .
Washington — Whatcom County ... Feb. 15-March
Wisconsin — La Crosse "....March 14-21...
Wisconsin — Manitowoc March 14-21 . . .
Wisconsin. — Racine March 14-21 . . .
Smallpox — Foreign.
Brazil — Bahia Feb. 1-29
Canada — Halifax March 15-22...
Canada — Winnipeg March 14-21...
China — Hongkong Feb. 1-8
Ecuador — Guayaquil Feb. 15-29
Great Britain— Edinburgh Feb. 22-March
Great Britain — Greenock Feb. 29-March
Great Britain — Leith Feb. 22-March
India — Bombay Feb. 8-25
India — Calcutta Jan. i8-Feb. 8.
Italy— General March 3-12
Japan; — Kobe Feb. 22-29
Japan — Osaka Feb. 15-26
Japan — Yokohama Feb. 22-29
Malta Feb. 22-29
Mexico — ManzaniTlo March 7-14....
Mexico — Monterey March 8-15....
Peru — Lima Feb. 15-22
Russia — Moscow Feb.
Russia — Odessa Feb.
Russia — Riga.
Russia — St. Petersburg Feb.
Russia — Warsaw Dec.
Spain — Valencia
13-20.
22-29 40
22-March 7.... 2
,Feb. 29-March 7.... 2
'5-29 33
[4-Jan. II
March 1-8 10
Yellow Fever — Foreign.
Ecuador— Guayaquil Feb. 15-29
India— Calcutta Jan. i8-Feb. 8
India — Madras Feb. 15-21
India — Rangoon Feb. 8-15
7i8
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Jourkal.
Plague — Foreign.
Brazil— Bahia Feb. 1-29 5 •
Chile- -Antofagasta ■ Feb. 23 14 '
Chile — Arica Feb. 19-26 6 i
Chile — Iquique Feb. 25 Present
Chile — Valparaiso Dec. 14-28 2 i
Ecuador- — Guayaquil Feb. 15-29 4 9
India — Bombay Feb. 18-25 125
India — Calcutta Jan. 18-25 40
India — Rangoon Feb. 8-15 17
Peru— Callao Feb. 22-29 ' '
Peru — Catacaos Feb. 22-29 12
Peru — Chepen Feb. 22-29 9 4
Peru — Eten Feb. 22-29 15 10
Peru — Lima Feb. 22-29 9 4
Peru — Mansefu Feb. 22-29 7 4
Peru — Mollendo Feb. 22-29 3 -
Peru — Paita l"eb. 22-29 i 2
Peru— Santa Eiilalia Feb. 22-29 6 6
Peru — Trujillo Feb. 22-29 32 16
Public Health and Marine Hospital Service:
Official list of changes of stations and duties of commis-
sioned and noncommissioned officers of the United States
Public Health and Marine Hospital Service for the fourteen
days ending April i, igo8:
Amesse, J. W., Passed Assistant Surgeon. Relieved from
temporary duty in the Hygienic Laboratory, Washing-
ton, U. C, and directed to rejoin his station at Havana,
Cuba.
Andersox, J. F., Passed Assistant Surgeon. Directed to
proceed to Asheville, N. C, for special temporary duty,
upon completion of which to rejoin his station in the
Hygienic Laboratory, Washington, D. C.
Bryan, W. M., Assistant Surgeon. Temporarily relieved
from duty at New Orleans, and directed to proceed to
New Orleans Quarantine Station, reporting to the
medical officer in command for duty.
Carmichael, D. a.. Surgeon. Granted leave of absence for
ten days, from March 25, 1908, on account of sickness.
DE Valin, Hugh, Assistant Surgeon. Relieved from duty
at New Orleans Quarantine Station and directed to
proceed to Savannah Quarantine Station and assume
charge at that port.
GusTEfTER, A. L., Acting Assistant Surgeon. Granted
leave of absence for four days, from March 3, 1908, on
accoimt of sickness.
FiSTEk, S. B., Acting Assistant Surgeon. Granted leave of
absence for fifteen days, from .^pril 6, 1908.
Jackson, J. M., Jr., Acting Assistant Surgeon. Granted
I'eave of absence for seven days from April 14, 1908.
Kalloi H, P. C, Surgeon. Directed to proceed to Bradford,
Me., for special temporary duty, upon completion of
which to rejoin his station at Portland.
Keatley, li. W., .'\cting Assistant Surgeon. Granted leave
of absence for one day, March 10, 1908, under para-
graph 210, Service Regulations.
SiMONSoN, G. T., Acting Assistant Surgeon. Granted leave
of absence for two days, from March 31, 1908.
Tarbell. B. C., .^cting Assistant Surgeon. Granted leave
of absence for thirty days, from April i, 1908, and ex-
e.xcused without pay for a further period of two weeks
from expiration of leave.
Warren, B. S., Passed Assistant Surgeon. Detailed to
represent the service at the annual meeting of the Okla-
homa State Medical Association at. Sulphur, Okla., May
14-16, 1908.
WiGHTMAN, W. M., Assistant Surgeon. Granted leave of
absence for seven days, from March i, 1908.
Board Convened.
A board of medical officers was convened to meet at Bos-
ton, Mass.. April 9, iyo8, for the purpose of making physical
examination of an officer of the Revenue Cutter Service.
Detail for the board : Surgeon R. M. Woodward, chairman ;
Assistant Surgeon T. W. Salmon, recorder.
Resignation.
Resignation of Assistant Surgeon R. B. Scofield accepted,
by direction of the President, to take effect April 17, 1908.
Army Intelligence:
Official list of changes in the stations and duties of
officers serving in the medical department of the United
States Army for the zveek ending April 4, igo8:
Clayton, J. B., Captain and Assistant Surgeon. Will re-
port in person to Major William C. Borden, Surgeon,
president of the examining board at Manila, P. L. at
such time as may be rcqiiired by the board for exam-
ination for promotion to the rank of major.
Dean, E. A., Captain and Assistant Surgeon. Will report
in person to Major William C. Borden, Surgeon, presi-
dent of the examining board at Manila, P. I., at such
time as may be required by the board for examination
for promotion to the rank of major.
Harris, J. R., Captain and Assistant Surgeon. Relieved
from further treatment at the General Hospital, Pre-
sidio of San Francisco, Cal., and ordered to return to
station. Fort Worden, Washington.
Heinzman, C. L., Colonel and Assistant Surgeon General.
Retired from active- service, upon his own application,
after forty years' service.
Kieffer, C. F., Major and Surgeon. Retired from active
service on account of disability, to take effect June 24,
1908, and granted leave of absence to include that date.
Navy Intelligence:
Official list of changes in the medical corps of the United
States Navy for the weefz ending April 4, igo8:
Baker, M. C, Assistant Surgeon. Detached from duty on
the Midway Islands and ordered to the Navy Yard,
Mare Island, Cal.
Leach, P., Surgeon. Ordered home to await orders, when
discharged from treatment at the Army and Navy Hos-
pital, Hot Springs, Ark.
KoLTES, F. X., Assistant Surgeon. Detached from the
Naval Medical School. Washington, D. C, and ordered
to the Navy Yard, Mare Island, Cal.
Puck, R. F. S., Pharmacist. Ordered to the naval training
station, San Francisco, Cal.
Married.
Anderson — Hunt. — In Birmingham, Alabama, on Satur-
day, March 21st, Dr. J. Henry Anderson and Miss Daisy
Hunt.
Doll — Russell. — In St. Louis, Missouri, on Tuesday,
March 24th, Dr. Joseph Doll and Dr. Libby Russell.
Stein — Bedford. — In Scranton, Pennsylvania, on Thurs-
day, March 26th, Dr. James Stein and Miss Sadie May
Bedford.
Died.
Bailey. — In San Francisco. California, on Tuesday, March
24th, Brigadier General FJislia I. Bailey, L^iited States
Army (retired), aged eigiity-three years.
Cannaday. — In Jacks Mills, Floyd County, Virginia, on
Friday, March 20th, Dr. Asa H. Cannaday.
Carter, — In Meridian, Mississippi, on Tuesday. March
24th, Dr. N. G. Carter,
Chandler. — In Cornwall, New York, on Saturday, March
2ist, Dr. Daniel Henry Chandler.
Crump. — In Millersburg, Ohio, on Thursday, March 19th,
Dr. A. A. Crump, Sr,, aged eighty-eight years.
DwiGHT. — In Philadelphia, on Wednesday, April ist, Dr.
Henry E. Dwight, aged seventy-five years.
Fassett. — In New York, on Tuesday, March 24th, Dr.
Bryant Sloat Fassett, aged twenty-eight years.
Gillett. — In Detroit, Michigan, on Thursday, April 2d.
Dr. Wilbur Gillett.
Healy. — In New York, on Sunday, March 29th, Dr.
James Redmond Healy, aged fifty-eight years.
JuDD. — In Philadelphia, on Wednesday, March 18th, Dr.
Leonardo D. Judd, aged sixty-six years.
Orr. — In St. Louis. Missouri, on Saturday, March 28th,
Dr. Charles J. Orr. aged forty-four years.
Penni.mgton. — In Brooklyn, N. Y.. on Monday, March
30th, Dr. William J. Pennington, aged forty-one years.
RoiiiNsoN. — In Boston, on Sunday. March 29th, Dr. Al-
bert Brown Robinson, aged seventy-three years.
Spea«, — In Norristown, Pennsylvania, on Friday, April
3d, Dr, John C. Spear, L^iited States Navy (retired).
Thibodaux. — In Napoleonville. Louisiana, on Sunday,
March 22d, Dr. O. J. Thibodaux. aged forty-two years,
Thomson, — In Belchcrtown. Massachusetts, on Sunday.
March 29th, Dr, Kdnnuul San ford Thomson, aged forty
years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal rlt Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXVII, No. 16. NEW YORK, APRIL 18, 1908. Whole No. 1533.
Original Cffmmanitations.
A COLONY S.-VXATORIUM FOR THE NERVOUS
AND NEURASTHENIC; A MUCH NEEDED
WORK OF PHILANTHROPY.
By George W. J.\coby, M. D.,
New York.
Whether those statistics which show an increase
in functional nervous diseases are correct or not. is
a question which 1 should not care to discuss, but
it is certain that we are constantly hearing and
reading of the alarming manner in which neuroses
and psychoses are augmenting, while nowhere can
we find any statement that either the former or the
latter are diminishing in frequency. Nor should
we be astonished if such an increase were proved to
be a fact, for the present day life makes constantly
growing demands upon the nervous system of ever\-
individual ; modern educational requirements, the
ever extending competition in business and profes-
sional life, the rapid popularization of the use of
new inventions, are all factors which put an addi-
tional stress upon a brain which has not as yet
adapted itself to the conditions with which it has
to cope.
If we admit the fact that there is such an in-
crease, as it seems we must, then we cannot avoid
asking whether the progress of these diseases, affec-
tions which constitute a menace to the welfare and
happiness of many individuals and families, which
destroy the economic worth of many people, which
annually deprive the state of many of its best work-
ers, cannot in some way be opposed.
Before answering this question, it will be neces-
sary to review briefly some of the causes which
produce these troubles, and to give thought to the
conditions under which they occur.
In so doing, as well as in discussing their prophy-
laxis and contravention, much will necessarily be
said which is elementary, and which has been said
time and time again, but these things do not lose
in weight through repetition and reiteration, and
they cannot be said too often.
The confines of the various disorders called neu-
rasthenia, hysteria, and nervousness intertwine and
overlap at many points, so that no sharp line of
demarcation can be drawn between them.
Nevertheless, an effort should be made to dis-
tinguish between neurasthenia, which is always
pathological, and the nervousness which may exist
within physiological limits; at least, we must in a
way specify what we mean by these expressions.
for the terms nervousness, nervous prostration, and
neurasthenia are used by many physicians as ex-
pressive of one and the same condition.
Popular opinion here seems to draw a more dis-
tinct line, and we find our patients speaking of ner-
vousness and neurasthenia with the understanding
that the former is a more or less temporary condi-
tion, and that the latter is an actual disease. And
we physicians must admit that this is correct ; for,
while neurasthenia is an affection which consists of
a premature exhaustion and an untimely inhibition
or arrest of function, occurring usually in a neuro-
path, frequently in a psychopath by birth, nervous-
ness, on the other hand, is a condition which may
be produced in anyone, even m the most robust.
The expectant attention caused by portending
events, the effects of sickness with its physical and
psychic drain, all produce a condition which we call
nervousness and which passes away with its pro-
ducing cause. In contradistinction to this transi-
tory nervousness, there is still another form which
is more or less permanent, frequently congenital,
and found among all classes of people.
Persons so afflicted appear perfectly healthy, but
are the possessors of a nervous system which reacts
differently to external impressions from that of a
normal person. Slight excitations produce unusual-
ly strong sensations ; disordered equilibrium, pain,
and emotions of an ultrapositive kind are produced
by inadequate causes ; this nervous person can exert
himself, can, under pressure, do even more than cir-
cumstances require of him. and never is there a
question of the occurrence of more than physiologi-
cal fatigue.
Neurasthenia, on the other hand, is characterized
mainly by an abnormal exhaustibility. The neuras-
thenic is at the end of his forces, he is unable to go
on any longer, he is tired out ; even under pressure
he cannot force himself, and this exhaustibility im-
plicates not only the somatic processes, but first and
foremost the psychic ones. It would seem as though
the entire exhaustibility was primarily of psychic
origin.
Associated and going hand in hand with this ex-
haustibility there is always a more or less constant
uniform excitability and irritability of all sensory
apparatus, with the result that normal sensory im-
pressions, as well as the physiological performance
of the functions of internal organs, are abnormally
perceived and create feelings of distress.
Just as no distinct line of demarcation can be
drawn between nervousness, neurasthenia, hysteria,
and other allied affections, so the causes of all of
these aft'ections may fittingly be discussed together.
Copyright, 1908, by A. R. Elliott Publishing Company.
720
JACOBY: SANATORIUM FOR THE NERVOUS.
[New York
Medical Journal.
Neither condition comes on suddenly, like lightning
from a clear sky, but each requires time for its de-
velopment. While neurasthenia frequently makes
its appearance with an apparently sudden onset —
and such a state has been called "acute neuras-
thenia"— the fact remains that such an acute onset
is merely the culmination of a series of events, the
climax in a tragedy. Even when this al¥ection
occurs in young children — and Oppenheim says
that he has seen the severe form occurring in a
child two and a half years old, and has treated many
children between the ages of three and five years
suffering from this trouble — it is always a result of
accumulated previous causes.
Of such preceding causes, the most important is
heredity. Precisely as in infectious diseases a cer-
tain soil is necessary for the growth of the virus,
so here there is frequently inherited a predisposition
which renders the individual less resistant to cer-
tain noxious influences to which everyone is more
or less exposed.
While such a disposition may be an acquired one,
in the vast majority of instances it is congenital,
i. e., inherited, and due to the same troubles or to
other nervous affections in the ancestors. The
greater such predisposition, the more easily will the
influences to which everyone is exposed exert their
action in a causative way and bring about the
troubles of which we speak.
First and foremost among the actually excit-
ing ones are those which act psychically. • Emo-
tional excitations of all kinds, whether single
and severe or repeated and mild, are the most potent.
Thus we find that the struggle for existence among
the conditions of modern life, especially among
those found in the large centers of industrial and
scientific activity, and the steady, persistent work
with its attendant sorrows, deprivations, and over-
anxiety for success, are among the most prolific
causes : causes which are the results of conditions
from which, for the large mass of people, there has
been no possibility of escape.
Especially here in America are people forced into
surroundings for which they have never been fitted,
and especially here are premature demands made
upon their nervous system before they are mature
and properly qualified. This lack of proper train-
ing deprives many of the workers, in all branches,
of the best protection against functional nervous
diseji'-cs. which any person can have, namely, a well
trainc'l nervous system.
This straggle for existence by the congenital
neur(;])ath or the educationally unfit forces many
to the use and then to the abuse of stimulants and
excitnnts, and herein v.-e have another important
exciting cause.
This early and excessive use of coffee, tea, al-
cohol, and tobacco is especially deleterious in its
action upon the nervous system of those very ones
who are most prone to go to excess in their use.
Therefore, predisposition, aided by the storm and
stress of active competition and abetted by the use
of stimulants, must be looked upon as the main
cause for the premature collapse of nerve force
which we call neurasthenia : so it will l^e found that
the majority of neurasthenics are between twenty-
five and fifty years of age, and that their occupa-
tions are those which are attended by worry, undue
excitement, uncertainty, excessive wear and tear,
and thus we find mentally active persons more easily
afifected than those whose occupation is solely physi-
cal. Authors, actors, schoolteachers, governesses,
telegraph and telephone operators are among those
most frequently aftected, and the increase of neu-
rasthenia among women dates from the modern era
which has opened to them new channels of work
and has admitted them more generally into the so
called learned professions. But whatever may be
the occupation in which persons have broken down,
it is never the occupation alone which has been the
cause.
This cannot be too often repeated. The emo-
tional fitness or unfitness of an individual for his
occupation is of the utmost importance as a causa-
tive factor, and overwork alone, without any emo-
tional cause and without any errors in mode of life,
will never act to produce such a collapse.
It is, therefore, not astonishing that this class of
functional nervous diseases is not confined to the
wealthy, and that the rich and the poor are indis-
criminately affected. But certain causes are of
greater influence in the one class, while different
ones obtain in the other. Poverty in itself, with its
limitations of proper rest and recuperation, is a very
positive cause. Years of neurological dispensary
work among the poor have convinced me that
nervousness, neurasthenia, hysteria, etc., are quite
as prevalent among the indigent as among the well
to do.
Other factors which are prominent in the pro-
duction of neurasthenia are those which are caused
by family environment, and which are intimately as-
sociated with the entire atmosphere of the home.
Here the very causes which have made themselves
felt in the sowing of the hereditary seed continue to
exist and act as a fertilizer upon the very soil which
they have helped to produce.
Each year the endeavor to attain satisfactory
prophylactic measures in all fields of medicine be-
comes more and more pronounced. This very
prophylaxis is the chief end of hygiene, and the
enormous progress which this branch of bionomy
has attained must merit the recognition and appro-
bation of every worker in every branch of clinical
medicine. We, who see a great deal of functional
nervous disorders, cannot but express the hope that
prophylactic measures, which have accomplished so
much in the direction of infectious diseases and give
promise of the ultimate eradication of typhoid fever
and tuberculosis, may in some way also aid in pre-
venting, or in counteracting, the spread of those
affections which we are now considering.
When it is remembered that neurasthenia impli-
cates the productive stage of life, and incapacitates,
not only for days and weeks, as do .so many epi-
demic diseases, but for months and years, and even
for an entire lifetime: and when we also consider
the social and material impoverishment of the indi-
vidual and of his family caused by this and anal-
ogous affections — then we can appreciate how great
a saving of suffering and deprivation for the indi-
vidual and how great an economy for the State, in
a material way, such prophylaxis would carry with
it. When once it is generally recognized that
April 1 8, 1908.]
JACOBY: SANATORIUM FOR THE NERVOUS.
neuroses, even of a mild kind, in one's ancestors,
may give rise to the most severe psychoses in the
descendant, that the neurosis in the former is sim-
ply the formative stage of the psychosis in the lat-
ter, and that the prevention, or, if not this, the cure
of the one may mean the interception of the devel-
opment of the other, then the community and the
State will be forced to busy themselves with the
problem of the prophylaxis of functional nervous
affections, and, failing in this, to give their support
to means which promise relief from the existing
conditions.
Unfortunately any direct prophylaxis is only part-
ly in our power. The demand made by certain
writers that we wage war against hereditary influ-
ences, and that we attempt to modify the seed of a
neuropathic disposition, is futile, except in so far as
has already been indicated and also in so far as
treatment in itself is a prophylactic measure for
future generations. Thus the questions of natural
selection, of limitation of the spread of disease by
regulation of marriage, of the care and mental
hygiene of children with neurotic family histories,
are to a certain extent Utopian and too distant to be
discussed in the present connection.
Yet, we physicians can do much to promote a ra-
tional rearing of children, to instruct parents and
educators in regard to the noxious influence of cer-
tain external circumstances in the family and the
school, to disseminate teachings on the deleterious
influences of stimulants and excitants upon the de-
veloping nervous system, to promulgate correct
ideas in regard to improper and premature sexual
tendencies, and to establish a correct adjustment be-
tween the environment and the individual. Of most
importance in the latter connection is the correct
choice of an occupation, of the life work of an indi-
vidual, because here, even with all due consideration
for individual tendencies and proclivities, too little
attention is often given to the nervous predisposi-
tion of such a person.
While, after all, it must be admitted that the ques-
tion of the prevention of functional nervous diseases
is intimately bound up with, and can hardly be sep-
arated from, that of their treatment and cure, it
must also be admitted that in this prevention or cure
of functional nervous troubles lies, to a great ex-
tent, the prophylaxis of insanity. Precisely at this
developmental period of insanity, the existence of
neurasthenia in one generation or another, at this
most important period in the life history of a psy-
chosis little or nothing is done. And this is so be-
cause our hands are tied ! There is no place for
patients with imperative concepts, for patients who
are not insane, but who without proper care may
easily become so, while with proper care they may
be reclamied and become useful members of society.
No institution exists which will receive the neuras-
thenics, hysterics, or psychasthenics.
The correct treatment of a neurasthenic patient
is the most difiicult problem in clinical neurology.
How much can be done for such a patient can be
realized only when we have at our command all
the therapeutic resources which study and experi-
ence have given us. Unfortunately, these resources
have not received the attention from either state or
society which they merit. The direct therapeusis of
neuroses of varied kind has been disregarded by
them, in order that the treatment of psychoses might
receive the immediate attention which its impor-
tance demands. The care of other affections also —
such, for instance, as tuberculosis — is occupying the
attention of the public to an extent which leaves but
little room for the just therapeutic consideration of
functional ner\'ous disorders. This is so because
the actual menace to society and state by insanity
and tuberculosis has been popularly recognized.
When it is equally well understood that the large
and increasing group of functional nervous affec-
tions is causing great injury to the masses and to
the health of the nations, then the public will demand
as its right the proper care of the broken down and
nervous invalid.
This proper care must, ,as can easily be under-
stood, consist primarily in the opp>ortunity for rest
and recuperation. While the treatment of neuras-
thenia should, so far as is possible, be a causative
one, we all know that no cure can be effected with-
out attention to the details of everyday life. The
main principle of any successful treatment must be
sought in the regulation of all activities, and not in
the use of any single remedy or method. Occupa-
tions must be interrupted or adjusted. Activity and
inactivity must be duly apportioned, the bodily func-
tions must be regulated, habits of life must be super-
vised and methodized, and to hydrotherapy, electro-
therapy, psychotherapy, etc., must be allotted the
share which each or all combined may deserve.
Above all, however, we must realize and acknowl-
edge that no specific medicinal treatment is known
and that the use of drugs can have but a symp-
tomatic value.
Everyone of any experience whatsoever will admit
that, in order to carry out the principles of treatment
which here have been merely sketched, the prime
requisite is the removal of the patient from his
habitual surroundings, surroundings in which there
exists no appreciation of the patient's condition, in
which the recognition of the existence of actual
disease is wanting, in which the constant admoni-
tions to "brace up," to "exert your will power,"
force the patient to mental and bodily overexertion,
and in which the worries about a livelihood are
always dominant. Still, such a change alone will
help but few.
It is being recognized more and more that these
functional diseases of the nervous system can receive
satisfactory' treatment only in institutions especially
arranged for this purpose. The majority of these
nervous disorders require for their treatment such
an amount of constant attention as can be obtained
only in a well regulated institution, with its expert
supervision and trained attendants.
Yet, we are being constantly asked, cannot the
advice and the teachings which are given in an
institution be written down? Cannot patients be
instructed to lead the proper life, if not in their own
homes, at any rate away from an institution? The
answer to this cannot be too categorical. Certainly
not ! Teachings in ■ advance as to how the patient
should employ each moment of each day are entirely
out of the question.
There can be no question about this, and every
neurologist has long recognized the boon which a
722
JACODY: SANATORIUM FOR THE NERVOUS.
[New York
Medical Journal,
well regulated sanatorium represents in the treat-
ment of these affections ; and this is true for all
classes of patients, for the f>oor and the indigent as
well as for the well to do and the rich.
In the case of the nervous or neurasthenic patient
who is well to do, relaxation and supervision can
usually be obtained without difficulty and for a suffi-
cient length of time; for them there exists in all
countries a large number of sanatoria, in which ap-
proximately proper care may be obtained. But the
question of what is to be done for the poverty
stricken patients who suffer from these same affec-
tions still remains, for this country at any rate, an
unsolved problem.
Such needy patients are unable, even for a brief
period of time, to meet the pecmiiary demands of
the cheapest of the existing sanatoriums ; their
earning capacity has gradually been reduced by pro-
longed inadequacy, and has finally become ex-
hausted ; they have sought and obtained medical
counsel of all kind, but still they have at no time
been relieved of their irritating surroundings, with
their attendant insalubrious conditions, nagging
influences, the hard work of to-day and the worry
for the morrow. Is it a wonder that the treatment
of neurasthenia among the poor is a heart sore to
the conscientious physician ?
The conditions here outlined have for a long time
been recognized and their existence deplored by
every neurologist and psychiatrist. Bender, Cramer,
Determan, Erb, Forel, Fiirstner, Jolly, Kraepelin,
Krafft-Ebing, Laehr, Moebius, Neumann, and
Peretti have in their excellent writings called atten-
tion to the necessity for relief in this direction, and
but recently, in a presidential address before the
American Neurological Association, Stedman, of
Boston, has pleaded for early and efficient action.
There can to-day be no question that there is a cry-
ing need for the establishment of a proper form of
sanatorium for the nervous poor.
Statistical proof of the urgent need for such sana-
toria has, for Germany, been furnished by Hoff-
mann and Peretti, who have clearly shown that such
an institution would at once be filled to its utmost
capacity. Such a sanatorium, in order to fulfill its
mission and actually to cure a large percentage of
cases, must be established upon totally different lines
from, those of the existing institutions for the
wealthy, for it must be conceded that, with few ex-
ceptions, our present sanatoriums for nervous dis-
eases do not produce results which are in any way
adequate. Sanatorium care, as at present carried
out, only too often tends toward the demoralization
of the patient on account of the listless life which
he is obliged to lead.
The principles which should govern the establish-
ment and management of a sanatorium for the needy
neurasthenic are those which long ago were laid
down by Mcxibius and others, and which have since
been shown practically to be correct. These prin-
ciples, briefly stated, call for the proper application
of rest and occupation. This rest must be physical
and psychical, must be furnished by the location of
the in.stitution in the country, away from the turliu-
lence of the city : the institution must be, as Laehr
expresses it, "a harI)or for those who. in the strife
and stress of the world's activities, have become ship-
wrecked."
But rest alone, while of the utmost importance
at the opportune time, becomes an obstacle to fur-
ther improvement when persisted in beyond its use-
ful period. Then it is that the second element
enters into consideration, that the weakened organ
requires strengthening, and that action and activity
must be superadded. '
Moebius demands the "exclusion of false, harm-
ful, or useless activity, the incitation to good, satis-
factory work alternating in the proper way with
rest." Even if others before Moebius have dwelt
upon the value of work as a therapeutic adjunct
in the treatment of neurasthenia, no one has stated
so clearly as he has done that it is the proper work
or the correct regulation of activity which must be
the chief remedy. In an introduction to Schwartz's
book he specifies his ideas as follows :
The nerve sanatorium (Nervenheilstdtte) must be a
school. The patients must learn how to live. I do not ask
for a hospital, but for a school of life If work-
shops are erected in a hospital and the patients are sent
into them for an hour in order to let them do any super
fluous work, then the work is prescribed in the same
mechanical sense as bathing, massage, and anything else.
That is not the way I meant it to be. The nerve sana-
torium should be an organism appropriately devised and
supported by the activity of all its parts, and at this useful
and necessary work the patient, so far as his strength will
allow, should be placed. This aim can be attained only if
the sanatorium is a large landed seat, in which the work is
not artificially provided, but is proffered of itself in all its
manifoldness, and in which a sensible supervisor is able to-
give to each his own.
Thus those patients who have become nervously
exhausted through overactivity or in consequence
of the unsuitability of their occupation will have
their new life adapted to their tastes and their
capacity ; they will, by means of the organization
and discipline of the institution, learn what is best
for them, the one being taught a trade, the other
some simple ofiice work, and the third being occu-
pied in some agricultural or horticultural pursuit.
Determan asks for still more ; he wants the new
profession, of whatever nature it may be, to be
drilled into them until they become adepts, until
they are able to compete, to some extent at least,
with the healthy, and until they have thus become
partially if not entirely self-supporting.
These demands may seem high, but they are prac-
tically realizable. This is shown by the history of
such institutions, of such colonies.
There is still another side than the mere practical
one, one which Cramer calls the "imponderable."
and that is the entire social and human question
which is touched by the establishment of these col-
onies. As Cramer justly says, such an establish-
ment means the drying of many a tear and the re-
lief of many a family from worry and anxiety.
This plea for work, the demand for occupation for
our neurasthenics, will not seem new to those of
us who for years have been sending many of our
patients to a ranch or to a farm, farming them out,
so to say; but we shall all admit that the "proper"
occupation, the "proper" work, was never found
under those conditions. This plan has in my hands
proved to be very troublesome and quite as ineffec-
tual as the insufficient supervision of hygienic and
April .908.]
JACOBY: SANATORIUM FOR THE XERl OL'S.
723
medical matters would lead one to expect. For the
nervous or for the constitutional or acquired neu-
rasthenic this plan is a failure.
Nor is the demand for work new to those who
know what has for many years been done in this
direction in asylums for the insane. Indeed, it
seems strange, considering that our sanatoriums for
nervous diseases are developmentally an outgrowth
of the asylum, that the idea of occupation as ap-
plied to patients in the asylum should not sooner
have been transferred to those in the sanatorium.
Yet, notwithstanding the many arguments and
appeals to the public, it was not until 1897 that any
practical result could be attained. In that year the
fruition of Moebius's writings became apparent in
the donation by a few charitable persons in Berlin
of a tract of land and about $60,000 for the purpose
of founding a sanatorium for impecunious nervous
patients. Hereupon an appeal was issued to a
larger circle, and Haus Schonow^ was founded as
the first institution in the z<:orld devoted to this
special purpose.
Dr. Max Lahr was chosen director, and the first
patient was received in October. 1899. Since then
the movement has progressed. "Kolonie Friedau"
is being organized in Switzerland ; in Sachsen
Weimar and Hessen negotiations for similar founda-
tions are far advanced ; in the Rheinprovinz such
an institution is going up ; in 1903 the "Rasemiihle,"
near Gottingen. was organized through the efforts
of Professor Cramer; most recently the city of
Frankfort on the Main has resolved to organize a
villa colony for nervous diseases, and has set aside
400,000 marks for this purpose, and, finally, other
countries have taken up the efforts of Germany to
provide for the care and cure of the needy neuras-
thenic by the establishment of proper sanatoriums
or colonies. Sweden is contemplating the founda-
tion of a sanatorium upon Schonow's model, and
at the Second International Congress for Assistance
to the Insane, held in Milan in 1906, the following
resolution was adopted :
"The congress expresses the desire to see organ-
ized popular sanatoriums for the nervous, erected
in, propitious locations, open to all without prelimi-
nary formalities, as is now being done in Germany.''
The principles of treatment and of life in such
sanatoria may best be practically studied in Haus
Schonow and in the Rasemiihle. and have been de-
scribed accurately and in detail by Determann as
"well as by Grohmann.
It has been my good fortune to witness the daily
regime in both of these institutions, and it affords
me pleasure on this occasion to express my thanks
to Professor Lahr, director of Haus Schonow, and
to Professor Cramer, director of the Rasemiihle,
for their courtesy and extraordinary amiability in
giving me free access to all parts of their institu-
tions and in supplying me with much of the literary
and practical material which forms the basis of the
present writing. The aim of such sanatoriums is,
above all, the cure of the patient, not only in the
hospital sense of the word, but also in an economic
one, and the result which is sought for the patient
is stable health with capacity for work and self
support.
Whether this can be done or not, or whether it
can even be approximated, may be a moot question,
but all plans for organization, construction, and
management must be laid with this one aim in view.
While the choice of a suitable location for our colony
sanatorium should in a way be governed by consid-
erations of climate, atmospheric conditions, and
scenic attractions, these factors will, after all, remain
secondary to the more imminent and practical ones
of adaptability to the requirements as already de-
scribed. For this reason a tract of land should be
chosen which is made up of farm and woodland,
upon which the various agricultural and horticul-
tural pursuits to which we shall refer presently may
be carried on, and which will furnish proper sur-
roundings for the buildings which are necessary for
administrative and therapeutic purposes. This land
should be located upon a railroad and near a large
city, not only for the purpose of convenience of
access, so as easily to obtain supplies and to dispose
of the products of farm and workshop, but also in
order that trained assistance of a medical, technical,
and pjedagogical nature may be obtained, and that
diversion of a suitable kind may be easily furnished.
So also should the water supply not only be ade-
quate for all hygienic purposes, but, if possible, be
ample to furnish power for mills and to serve as a
source of supply for the production of all the elec-
tric current that may be required.
The size of the grounds must be sufficient to fur-
nish patients with opportunities for occupation,
recreation, and treatment in the open air, in addition
to offering facilities for raising products for home
use, such as milk, fruit, vegetables, and a portion at
least of the meat to be consumed. The acreage cf
the land will, of course, also be governed by the
nimiber of patients destined to be received in the
institution or colony.
The number of patients thus to be received was
determined by the committee appointed for the
organization of Haus Schonow. and their decision
was that a beginning should be made with not fewer
than seventy to eighty patients ; that with a smaller
number classification became impracticable, the divi-
sion of sexes became difficult, and the cost per capita
became prohibitive. On the other hand, if too large
a number of patients were to be admitted, the super-
vision would become more complicated and the entire
organization to a certain extent unwieldy. Yet
Grohmann. as well as Determann, on account of the
easier apportionment of the work as well as on
account of the reduction of the proportionate cost of
maintenance, favors the admission of from 100 to 150
patients, and experience would seem to show that
this number is the one which from all points of view
can be most practically and most economically cared
for. It must be evident, in view of the amount of
individual attention required by each neurasthenic,
and in consideration of the time which must be
devoted to the psychic as well as to . the physical
instruction and care of each patient, that the medical
superintendent, no matter how many assistants may
be given him, will be unable to supervise more than
this number of patients satisfactorily.
The question of economy will, of course, be an
important one, for no matter how or from w-hat
source the money for the establishment of the colonv
is obtained, we should never lose sight of the fact
724
JACOBY: SANATORIUM FOR THE NERVOUS.
[New York
Medical Journal.
that the purpose of the institution is the care of the
needy and relatively impoverished ; that, even if it
is designed to receive such patients as are able to
pay a certain amount, in addition to those who are
received gratuitously, the viewpoint is hereby in no
wise changed, for the amount which such patients
should pay must, under no circumstances, be so
large as to mvalidate the character of the colony as
one designed for the care of the needy or to curtail
the sojourn of those whose spirit of independence
impels them to pay something. We should never
forget that in many cases, notwithstanding all ad-
vantages, prolonged care presents the only hope of
recovery.
In view of the fact that the class of patients to
be admitted is made up primarily of the needy and
destitute, we are at once confronted with the ques-
tions: What kind of patients, aside from their
financial distress, should be admitted into such a
colony? What kind may be admitted, what kind
must be excluded? From a medical point of view
there seems to be unanimity of opinion as to what
classes of cases are specially suitable for reception
into such a sanatorium. The proper patients are
those with the numerous functional neuroses, par-
ticularly those suf¥ering from neurasthenia, nervous-
ness, and hysteria with its diverse manifestations.
There seems to be no reason why persons with other
functional nervous affections, such as certain vaso-
motor neuroses, migraine, chorea, etc., should not
also be admitted, but it may be a question of doubt
whether patients with mild hypochondriasis, melan-
cholia; and other nervous affections belonging to the
border line between neuroses and psychoses should
be accepted. Certain it is that persons with
developed insanity, epileptics, and those addicted to
drugs cannot be received. They should be placed
in separate institutions, and can under no circum-
stances be treated together with the subjects of
functional neuroses.
Other factors than that of pure medical diagnosis
also enter into the question of acceptance or rejec-
tion, and the large class of morally irresponsible
degenerates, those who would prove to be a social
and moral canker to the other inmates, and who
are so easily recognized by the experienced observer,
must not be received.
Huber has summed up this question well by
formulating these rules : Patients suitable for recep-
tion must enter voluntarily, with the expressed de-
sire for medical treatment ; they must have full con-
sciousness and recognition of their illness, and have
perfect control of their own actions, in order to be
able to follow medical instructions ; they must not
require watching, and must not appear abnormal to
their fellows or infringe upon their rights.
The admission of patients suffering from organic
diseases of the nervous system may be deemed in-
advisable, on account of such patients' requiring
essentially hospital treatment ; at the same time such
hospitalization of the patients afflicted with organic
disease could easily be effected in conjunction with
the colonization of the sufferers from functional
affections, to the benefit of \K>th classes, the one
receiving their hospital treatment together with
light, air, and the advantages of out of town life,
while the other would thus receive the moral teach-
ings which the presence of organic disease must
have upon the minds of those afflicted with func-
tional troubles. While the entire institution might
become unwieldy through this double purpose, no
objection could be raised if the two institutions were
associated in location, yet remained under different
management.
The question has been discussed of whether both
sexes should be received in one and the same colony,
and, if this is done, whether they should be sepa-
rately nursed and cared for. Inasmuch as the insti-
tution is to be a working one, one in which work
of all kind is to be done so far as practicable by
the patients, there will be plenty of work which can
be done only by one sex or the other, and that
would make the presence of both sexes desirable.
Grohmann also believes that the association of the
sexes adds to the facility of treatment, that the men
especially become more tractable, more inclined to
work and exert more self control. What has been
found to be the case in Haus Schonow and in the
Rasemiihle will probably apply to all similar institu-
tions ; this experience has been that the association
of the sexes has added much to the congenial tone
of the sanatorium ; men and women are more care-
ful of their demeanor and pay more attention to
their clothing and appearance when under the influ-
ence of the other sex. While in the Rasemiihle
there is only separation of sleeping and toilet apart-
ments, in Haus Schonow the sexes have been sepa-
rated as to house, meals, and work, and partially
even in their entertainments and recreations.
The question of which building system is to be
adopted and what buildings are essential is of im-
portance, yet it would go beyond the scope of the
present article to enter upon these details. Certain
principles of general planning must, however, be
alluded to.
Thus, the system of large buildings, such as are
used for asylums and hospitals, is entirely out of the
question. Each building designed for the living
apartments should in outward appearance and inner
furnishings bear a great resemblance to a home, for
the psychic effect which such surroundings exert
upon our patients must not for a moment be lost
from sight. The buildings must be comparatively
small, should not be too near together, and should
be constructed to give the impression, as Deter-
mann says, of a villa colony. He also has desig-
nated the following buildings as necessar)' :
1. A main building, for administrative and thera-
peutic purposes, containing a laboratory, living room
for physicians, amusement halls for patients, etc.
2. Dwelling houses for patients.
3. A building for workshops and occupations of
varied kind.
4. A central building for heat, electricity, hot
water, steam, etc.
5. Agricultural buildings — farm buildings, dairy,
granary.
In addition to these, a special hospital building,
perhaps also one for a training school for nurses,
and some sheltered promenade corridors with open
front, so that patients may exercise and rest in the
open air in all kinds of weather, must be considered.
'Fhesc corridors might be so made as to connect the
various buildings.
April 18, 1 908. J
JACOBY: SAXATORIUM FOR THE NERVOUS.
725
The great advantages of such a colony system
would be that a few essential houses could be
erected, and these then be supplemented by others
from time to time, as the institution grew in size,
much of the work being done with the aid of the
patients. All details of construction, elaboration of
building plans, etc., must be left for discussion upon
some future occasion, for the question to which we
desire to give consideration now pertains more
directly to actual treatment.
The' treatment as carried on in such a colony will
of necessity have to be of the broadest possible
nature, and the principles which are to govern it
must rise to the requirements set by Moebius, who,
as stated, demands a school and not a hospital.
Accordingly, no method of treatment must cast its
exclusive impress upon the whole, and, to cite
Moebius again : "That which most surely distin-
guishes the quack from the true physician is the
one sidedness of the former. Every one who cures
with a method, may he swear by water, or massage,
or by electricity, or by nature as such, or by any
other thing, is a quack or becomes one. The whole
world acts so as to influence people ; everything
possible may be injurious, and in the same way help
may come from the most varied sides."
So the chief essential of success is to find a
proper head for the institution, the "true physician,"
who is broad "minded and efficient, for ever}thing
will depend upon him ; he must have a gift for im-
parting knowledge, must be able to teach the cor-
rect and healthy mode of life, and to bring about a
reversal of ingrained habits, to recognize what the
individual patient can do and what he cannot do,
and to select for him the proper occupation — in
short, to regulate his every action. In addition to
all this, he must be a disciplinarian of the highest
order.
Can such a man be found? Certainly it is no
easy task, but Haus Schonow owes its success to
having found such a one in Professor Lahr. and,
with the example which he has set, the administra-
tion of such a colony should not be overdifficult.
In addition to the psychic influence' which such
a superintending physician will exert upon the pa-
tients, he must have at his command all the physical
appliances which are even now found in all well
regulated sanatoria, facilities for hydrotherapy,
medicinal baths, electricity, massage, gymnastics, air
baths, etc. ; in fact, all apparatus and appurtenances
for scientific and medical use. So everything which
has proved of value in the old sanatoriums will be
taken over into the new one. Opportunities for
diversion of all kind, for summer and winter, for
outdoor and indoor, must exist. Even,- factor by
which health can be influenced will have to receive
consideration in forming the atmosphere of the
institution.
While the dominant difference between the colony
which is being considered and the existing sana-
toria is the spirit of occupation and of work which
permeates the entire place, the colony being a work-
ing colony in the ideal sense of the term ; "rest
cures" will have their place and are by no means to
be discarded. Even,^ neurasthenic is, as we have
stated, exhausted ; he requires rest and feeding, and
the more acute the breakdown, the more the symp-
toms of exhaustion and irritability outweigh the
others, the greater will be the need for physical rest,
for freedom from physical and psychic concentra-
tion. Yet only for a time. Soon the general prin-
ciple of alternate rest and activity asserts itself, and
the time comes in all cases when rest alone is detri-
mental; then active work, or the "work treatment,"
"work cure," is put into force. Here it may be said
that the appellation "work sanatoriums" is'a mis-
nomer and misleading. Moebius calls it "hideous,"
and it should never be employed.
To this question of work we will now give closer
attention ; the principles as laid down and practically
applied by Grchmann in Ziirich, by Lahr in Haus
Schonow, and b}- Cramer in Rasemiihle are those
which m.ust serve as a basis.
It is hardly necessary to ask what work is. Yet
it would seem as though many of the advocates of
this therapeutic auxilian,- looked upon it merely as
the direct use of the muscles, as an output of
mechanical energ}-. While this element of work, in
so far as its action upon physical processes, circula-
tory, respiratory, digestive, and metabolic, is con-
cerned, certainly bears an important part in the pro-
duction of therapeutic results, no one can gainsay
that the most important factor in beneficial work, as
applied to the treatment of the nervous and the
neurasthenic, is the psychic one, or deny that this
factor exerts its influence not only through the
negative quality of causing distraction from morbid
concepts and obsessions, but also by means of its
very positive qualities of producing concentration
of mental processes, restoring disordered emotional
equilibrium, strengthening the will, and increasin.^
self confidence.
Too much stress cannot be laid upon the psychic
effect produced in these patients bv work, and for
this reason the work which each person is called
upon to do should have in view an ultimate object
which will appeal to him, one which will be other
than that only of effecting a cure. While the recog-
nition of this curative action will exert a salutary
influence, this knowledge, if unextended, would tend
toward the increase of introspective and egotistical
emotions ; if. however, it is supplemented by the
knowledge that all work has a broader object, that
the work which is being done has a certain future
value, and above all that this work is of actual use
to the small community of which the patient is for
the time a part, that the present and future welfare
of the colony depend in a way upon his work, then
an interest in the work will be incited and continued
in many a patient upon whom purely selfish reason-
ings would be lost. The psychic influence here
spoken of extends even to the nonworkers, and the
patient who is too ill to work will profit by the
atmosphere of occupation with which he is sur-
rounded.
It has been the experience of all institutions in
which work has been introduced as a therapeutic
measure that most of the patients, independent of
class or former p>osition in life, will grasp at the
opportunity for habitual regular occupation, and
that the selection of the kind of occupation for each
group of patients should be governed by that factor
726
JACOBY: SANATORIUM FOR THE NERVOUS.
IXew Vork
Medical Journal.
through which work exerts its greatest therapeutic
effect, namely, its psychic action, the latter being-
effected by means of the allurement of novelty, the
recognition of the curative influence, the pleasure
in accomplishing and executing new things, the in-
terest aroused by the use of novel apparatus, and,
last but not least, the ethical and altruistic emotions
already referred to. These considerations apply not
(.nly to the selection of the suitable work, but to the
niamteHance of the patient's interest in the work
after it has once been aroused. While change of
work may be called for occasionally and variety of
work at different periods of the day may be neces-
sary, the experience in Haus Schonow has been
that it is not so much a question of variety in work
as it is one of systematization and thoroughness. Of
greatest import will always remain the correct in-
struction and the constant incitation with the most
careful supervision.
The organization of the work must be begxin by
the selection of proper paid and trained supervisors.
I'hese supervisors, who must have the necessary
knowledge, tact, and adaptability, will act as assist-
ants in the various fields of work, will, so to say,
lie the leaders. They will give instruction in the
manner of carrying out the technical work and will
also give instruction in the general utility of work,
the value of cooperation, etc. In short, technical
and ethical instruction will have to go hand in hand.
It will not be long -after such a colony has been
in operation before these assistants and leaders can
l)e selected from among the older patients. This
stimulus of advancement is of great value, and in
the course of time paying positions can be n-iade for
such patients as have shown themselves to be spe-
cially qualified and interested. In this way gradu-
ally a staff of competent instructors will be estab-
lished.
The psychic aspect of treatment by occupation
being of such great importance, the entire institu-
tion must be organized with the end in view of
gaining and maintaining the patients' interest. The
institution must bear the impress of contented work
brought about by the establishment of bright, cheery,
and hygienic workshops, well equipped with the
necessary tools, and clean and orderly throughout.
These workshops should be sufficiently large to
enable a number of patients to work with ease at
one and the same time, for the comradeship of work
is an important factor in gaining results. Occupa-
tion of whatsoever nature should always be carried
out in company, and no patient should be put to
work in a room by him.self. We have already stated
that most of the patients will be glad to join in an
cKCupation which dispels the tediousness of inac-
tivity, and it is a fact that after a prodromal and
necessary period of rest, nearly all will, of them-
selves, ask to be allowed to work. Ihit this !)egin-
ning cannot be left to the will of the patient ; when
once the decision has hocn reached that the proper
time for work has come, the proper occupation must
be selected and the work mcdicallv imposed. Lahr
savs that in ITaus Schonow but few ])aticnts were
uninfluenced by the recognition of the value of
work, and most of them went at it with pleasure,
at first perhaps only upon medical orders; and I
myself am satisfied that in Schonow, as well as in
the Rasemiihle, the majority of patients work regu-
larly, earnestly, and successfully.
Schwartz, who spent five months as a patient in
Schonow, says that during the time of his stay he
knew of but one patient who refused to work.
Occasionally there were complaints about the work
being obligatory, but every one lauded the oppor-
tunity for work. Of forty male patients in the
colony in that early part of its career there were
once thirty-four at work, gardening, at one and the
same time ; the six not working were too ill. He
was astonished at the enthusiasm and perseverance
which the patients at all times showed in their work.
Schwartz, who, together with Moebius and Hoff-
mann, is against the obligatoriness of work, cer-
tainly does not fortify his opinion by his experience
at Schonow. There any patient absolutely refusing
to work when ordered to do so is at once discharged,
and it appears to me reasonable, inasmuch as the
work is prescribed as part of the treatment, and
may be modified or omitted only in accordance with
the judgment of the physician in each individual
case, so that the refusal to work must be viewed as
an act of insubordination to medical orders, which
cannot be condoned unless the discipline of the place
is to be allowed to suffer.
The selection of the kind of work best adapted
to the need of each patient is not an easy matter, but
can usually be properly made by the application of
the principles already described. Before such choice
is made the decision must, however, be reached as
to whether manual occupation or some form of
brain work is preferable. It has been said that this
choice will depend upon the nature of the work
which has led to the breakdown ; that in the case of
brain workers brain activity is to be reduced or ex-
cluded and muscular work substituted, while the
manual worker is to be interested in a more or less
psychic way.
We, who believe that the chief therapeutic value
of work, whether of brain or of body, lies in its
psychic influence, cannot accede to this view with-
out modification, for it must appear to us that in
the vast majority of cases preference is to be given
to some form of manual work, regardless of the
previous habits of the patient. This is so because
manual work carries with it a direct action upon the
somatic processes, in addition to its psychic influ-
ence, and because most patients, whether head
workers or hand \\-orkers, have been accustomed to
some form of manual occiipation from early life,
and it will be easy to accustom them again to do
that which they did in their childhood : in addition
to this, there can be no question that manual work
can be more easily organized, supervised, and con-
trolled.
The fear expressed that purely mechanical work
would be devoid of interest to the head workers,
from which class the majority of patients are re-
cruited, has been controverted by practical experi-
ence. This has shown thai in the existing colonies
the most enthusiastic workers in the shop and
garden l)clong to the intellectual class.
On the other hand, when manual work is chosen
for former Innd workers, the patient ought not at
ACOBY: SAXATORIUM FOR XERrOUS. 727
once be put to work at that which has constituted
his own trade. As soon as that is done the entire
psychic ei¥ect of the work is lost ; the work with
which he is so famihar, and which has been a factor
in his breakdown, will to him be nothing but
"work," and counteracting suggestions of manifold
nature will neutralize the suggestion which we had
hoped to impart.
Care should, of course, be exercised lest the pa-
tient overdo, for, aside from the fact that in all
neurasthenics there exists a pronounced exhausti-
bility, those patients who have hitherto done noth-
ing but brain work, and have led a more or less
sedentary life, have no gauge for their physical
capacity and are apt to overexert themselves. Care-
ful supervision, especially under proper observation
of the pulse rate, will here be the chief protection
against exhaustion.
Under no circumstances should physical exercise
be looked upon as a substitute for physical rest. The
evil effects of mental overexertion can never be
counteracted by muscular activity, and bodily work
as such is no remedy for fatigue of any kind. The
practise of recommending physical w:ork as a neu-
tralizer of mental fatigue can only be characterized
as pernicious.
The choice of the special kinds of occupation to
be used in the colony will be met by the principle
of the greatest good to the greatest number, and the
result of experience has been that this requirement
is best met by two kinds of work — these are carpen-
tering and gardening. Both of these combine the
psychic and mechanical factors essential to success-
ful therapy in a greater measure than any other
kinds of work.
Carpentering especially is of very great value ;
in no other occupation are mental interest and mus-
cular activity combined as they are here ; according
to the kind of work done, sawing, planing, or ham-
mering, all movements of the body may be obtained
in any relationship and to any desired extent.
At the same time the result of the work soon
becomes manifest, for in a relatively short space of
time some useful object may be produced; the work
is concrete, it may be surveyed from beginning to
end, and thus psychic interest be maintained.
To gardening, as Grohmann has shown, must be
given second place ; its disadvantages lie in the psy-
chic reason that it is not sufficiently concrete to be
sur\-eyed and learned in a few months. The period
of growth of most plants is too long to enable
patients to obtain a general view of the connection
between their daily task and the total result. But
the factors which go to make up gardening as a
whole, the digging, hoeing, raking, cutting, etc.. are
all of inestimable value. For this reason the simpler
forms of gardening are of greater service than those
of higher grade.
While carpentering, gardening, or agricultural
work will constitute the chief sorts of occupation,
other forms must also be employed. For those pa-
tients in whom no interest can be aroused in car-
pentering or gardening, or who for one reason or
another cannot or may not take part in these pur-
suits, some supplementary work must he furnished.
Bookbinding, scroll sawing, pyrography, drawing,
modelling, wood carving, designing, photography-
decoration of pottery, or clerical work will serve as
the means to our end. in Haus Schonow, book-
binding has proved to be a suitable occupation for
many patients and is utilized for an hour each day,
under the supervision of a patient who has been
specially taught and with the assistance of a pro-
fessional bookbinder who does not live in the colony.
Thus, in 1903, 124 books were bound by patients for
the colony's library.
Typesetting and printing are also done there, and
upholstering in all its branches has, by its diversity
and evident results, given pleasure and occupation
to many patients. Basket making and analogous
occupations, which have been recommended by
many and which are much employed in colonies for
other classes of patients, are justly characterized by
Grohmann as "stupid."
Female patients will also find fruitful sources of
activity in the necessar)- household duties and
kitchen work of varied kind. It would be futile to
enter here upon the details of all of the various
kinds of work which may prove serviceable' or to
attempt to plan too much ahead of the actual estab-
lishment of the colony; much will develop of itself,
much will show itself during development and
growth which cannot be foreseen and which will be
adapted particularly to the individual colony which
has been organized.
Above all, however, let us bear in mind that the
work as planned and carried out in institutions for
the insane should not, as has been advised, be trans-
ported as such into the colonies for neurasthenics.
Xo matter what the nature of the work made use of,
we should always remember that every treatment
by means of occupation has its limitations, and that
the indiscriminate use of such treatment necessarily
carries with it the dangers attendant upon indis-
crimination of every nature.
If new colonies are to be established upon the
aforesaid or similar lines, and of the crying need
for their existence in every State of the Union there
can be no question, we must ask ourselves the prac-
tical question, Who is to furnish the means for their
organization and support?
That the State would profit greatly by the estab-
lishment of such colonies has already been shown,
and that State prophylaxis and State hygiene are
rights which the people can demand has been ac-
knowledged by the State through its work in every
other direction. The State must aid in maintaining
the physical and psychic availability of the indi-
vidual, for the assets of a nation are made up of this
physical and psychic productivity of its individuals.
On the other hand, the State can hardly be ap-
pealed to for aid until the practical proof of the
necessity and benefits has been furnished, and it is
even questionable whether it would be wise to seek
State support in the beginning. The institution be-
ing essentially a charitable one. it will be found that
the impressible neurasthenic will be more willing to
place himself under treatment, and will do so with
greater freedom of mind, if the colony is the out-
come of private charity than of a State charity. In
the latter case the parallel between asylums and
workhouses would be verv close.
Private charity will here, as it has so often done
before, once again have to lead the wav. I know
728
TAYLOR: MOST USEFUL SPECIALTY.
quite well that the demands made upon such private
charity are enormous, and that individual donors
are appealed to for aid from all sides and for all
purposes ; yet, when once the worthiness of such an
institution has been proved, there should be no
difficulty in obtaining even more than the necessary
support from all classes of society. The history of
the European colonies shows that we should have
no misgiving as to the possibility of obtaining the
necessar)' hnancial support. What has been done
abroad with difficulty should be accomplished here
w ith ease.
In conclusion, I would say that any description of
the entire organization and equipment of such a
people's sanatorium for functional nervous afifec-
tions would give one the impression of great compli-
cations and unwieldiness of management. This im-
pression is, however, at once dispelled by a personal
inspection of the existing colonies. It is entirely a
question of initiative, growth, and development.
References.
Bender, Th. Oeffcntliche N ervcnheilanstalten? Berlin,
1891.
Cramer. A. Die Heil- imd Unterrichtsanstalten fiir
psychische una Nerven-Kranke in Gottingen. Klimschcs
Jahrbuch, .xix, Jena, 1904.
Determann, Dr. in St. Blasien. I'olkshcUstdltcn fiir
Nervenkranke. ihrc Nothwendigkeit. Einnchting iind Aus-
fUhrung, Wiesbaden, 1900.
Idem. Die Badische Volksnervenlieilstatte. Psychia-
trisch-neuroloaische Wochenschrift. No. 35. 1904.
Fiirstner. C. IVie ist die Fiisnrgc fiir Gciniithskranki von
Acrzicn iiiid Laicii -ju siclit'ni .' Rcrliii. 1899.
(,rulnn;inn, A Iliitwtfri riiiri -ni ^ssrusclhiftlichcn
Musti-ranslalt jiir U ntc rhriitoniig iiiid Hcsrhdflignug von
Nervcnkrankcn. .Stuttgart. 1899.
("ircihniann. A. I'cclituschcs mid psycliologisclics in der
Bcs. Iiiift'guiig. l oii Nervenkranke II. Stuttgart. 1899.
IlotTmann. .-Vug. l^eber Nothwendigkeit imd Einrichtung
von Volksheilstatten fiir Nervenkranke. Zeitschrift fiir
Psychiatrie. h i.
jacoby. (icurge W. Die staatliche Fiirsnrge fiir Epilep-
tikcr. New Yorker niedicinische Monatsschrift, October,
1894
Jacoby, George W. Sanatorium Care for the Impe-
cunious Neurasthenic. Monthly Cyclopccdia of Practical
Medicine, i.x, p. 289, 1896.
Von Krafft-Ehir.g. Nervositat nnd neurasthenische
Zustande. Nothnagel, Specielle Patholngie und Therapie.
xii, Part 2, 1895.
l.ahr, Max. Bemerkungen zur .Arhcitsbehandlung Ner-
vc'ikranker. Zeitschrift fiir klinische Mcdezin, liii.
Idem. Wie sicbern wir den Heilerfolg der Anstalten
fiir Nervenkranke? Archiv fiir Ps\chiatrie, xl. p. 212,
1905-
Idem. Annual Reports of Hans Schiinoiv.
Moebius, P. J. Ueher die Behaudlung von Nerven-
kranken und die Einrichtung von N ervenheilstdtten. Ber-
lin. 189ft.
Idem. Vermischte Aufsatze. Neurologische Beitrdge,
part 5. Leipzig, 1898.
Idem. Introduction to Schwartz's book.
Idem. Foreword to the Besehiiftigung von Nervcn-
krankcn of .\. Grohmann.
( )p|)cnhcini, H. LclirbucJi der Xcr^'cnkraukhciten, ii, p.
iio<). 4th r-^d., Berlin, 1905.
I'crctti. J. Ucbcr den Stand der Fragc dor Errichtung
von Xcrvenheiistatten. <-lc. Zeitschrift fiir Psychiatrie,
Reports, Annual, of llaus Sehiiiiow: lleilstdtte fiir Ner-
venkranke in Zehlendorf bei Berlin. Berlin. 1899, et seq.
Report of a conference Ziveck's (iriindung einer ha-
disrhen Volksheilstdtte fiir Ner-venkranke. Karlsruhe, 1904.
Stedman, Henry R. The Public Obligation of the Neurol-
ogist. Journal of Nervous and Mental Disease. August,
1906.
Schwartz, Georg Christian. Ueher Nerveuheilstdtien und
die Geslaltung der Arbeit als Hanptniittel. Leipzig, 190.?.
44 West Sr;vi£NTV-si-coNn Stuf.kt.
THE AIOST L-SEFL'L SPECIALTY IN MEDICINE
To Estimate tlie I 'Hal Status and Enhance Efficiency 63
Eliciting Contributory Agencies in Reestablishing
A utoprotcctive Equilibrium.
Bv J. M.xDiso.N- T.WLOR, A. M., M. D.,
Philadelphia.
No form of medical specialisiu can accomplish sc
much as one which aims to reinforce inherent ener-
gies, to perfect latent or iiupaired powers. It is
but a limited conception of professional duty to be
content to merely repair damages or injuries, to
overcome the effects of disorders, or even to cure
actual disease. In the field of restoration large in-
dividual abilities are exhibited by the exponents of
restricted specialisms. The best ^effects are, even
there, due to the measure of wisdom show n in deal-
ing with the broader factors involved in supplying
constitutional needs. The solution of most of these
problems often lies in estimating the exact status
of the grosser mechanisms and in correcting many
contributory disabilities not ordinarily recognized
as significant.
Every person, voung or old, is capable of a nota-
ble increase in vital status by revising modes of life.
This is particularly demonstrable as middle age ap-
proaches and tissue elasticity subsides. Some of
these deviations merge into serious retrograde
changes, often shown by rigidities, densities, caused
by faulty habits or vitiated automatisms, due to
omissions of suitable variety in both impulses and
movements, whereby alone symiuetrical action and
reaction are assured. The factors involved are
both psychical and physical. The deadening effects
of routine, of monotony, are well known. Stiiuuli
should be varied : suggestion or autosuggestion is
rarely adequate to preserve rhythm. Individual
resourcefulness is seldom large, or only exhibited
in restricted and s])ocializc(l lines. Hence it is of
value to invite skilled direction from one w'ho has
achieved a well rounded familiarity with huiuan
perfectibility, needs, and derangements, and can
judiciously particularize.
Human health, con.«;tituting, as it does, the basis
of economics, is steadily coming to be recognized at
its true commercial \alue. Bread winners especial-
ly are awakening to this fact, and beginning to ap-
preciate expert professional aid in perfecting and
maintaining bodily efficiency. That physician is
most wise and useful who omits no opportunity to
estimate the fundamental factors in any problem
presenting. Not only should he meet imme-
diate exigencies, deal correctly with confronting
difficulties, but search out and correct under-
lying and contributory causes, which may keep
the individual on an inferior plane of poten-
tiality. He should do luuch more : luake occa-
sions, seek earliest possible opportunities to learn
all rcvelant facts bearing upon the vital status of
those in his charge. To accomplish this the pub-
lic requires constant and varied education. The
tendency is for each good citizen to make the best
of his condition, to treat lightly unobtrusive ail-
ments, to forge energetically ahead, ignoring slight
symptoms, especially psychical phenomena, so that,
too often, serious states are otilv revealed when far
advanced or loo late. This disregard of aihuents
is comin. iidalile ; it makes for renown, for cliaracter
TAYLOR: MOST USEFUL SPEtTALTY
729
April 18, 1908.]
building, for success. Through such pertinacity
only are the highest ends achieved. Carried to its
logical limit, however, it lures the ignorant opti-
mist to a state of perilous monism. Conversely, to
err by overmuch selfsearching leads to hypochon-
driasis, timidity, inefficiency. Most physicians are
aware of this, but there are different degrees of
awareness. Some impressions, even some convic-
tions, are cloudy, inexact, or, worse, fail to act
as stimuli to right action. A nicety of judgment is
needed in solving such problems. For instance, it will
prove a boon to a man complaining of a slight dys-
pepsia for the physician consulted to discover and
rehabilitate an organism never brought to that de-
gree of vigor and stability which, if attained, would
have enabled him to become a power. Hitherto he
may have been held by removable limitations to
some petty, hireling post.
Numberless men and women often courageously
and intelligently undertake ventures well within their
inherent powers, who are yet not able alone to bring
them to full fruition. They may be handicapped
by physical defects, wasteful in method, underde-
veloped, lacking in some essential particular, or all
these combine to keep them low in the economic
scale. Unwarned, confident, they often assume in-
creasing burdens and press on to, or beyond, the
limit of their working powers. There then ensues
some minor or major accident, and a useful Hfe
is vv-arped, mind and body are distorted, perhaps
thereby alsa complicating important collateral do-
mestic or financial interests. All this dwarfing
could have been avoided by adopting one of two
courses of action: (i) Had the family physician
been observant, wise, and, above all, dominant, cor-
rective measures could have been instituted' suf-
ficiently early; or (2) had the individual been duly
alive to his economic needs, advice would liave
been sought capable of establishing full working
efficiency.
It is true that the general practitioner, hampered
as he too often is by a multitude of fatiguing ex-
actions, harassing exigencies, may not be expected
to accomplish more than he does. Too frequently,
however, his interest is exhibited rather in the im-
mediate than in the basic problems.
Admitting the force of the proposition suggest-
ed, there would seem to be ample work in any
communitv for specialization in systematic ampli-
fications of efficiency. The chief difficulty, as in all
specialisms, is the petty distrust and jealousy which
discourages frank consultation, cooperation, except
in departments of professional effort rigidly de-
fined.
Another serious difficulty is the supineness of the
profession in omitting to compel recognition of the
high pecuniary value of expert advice in the con-
duct of life. The general public are not slow to
realize the value of first class working efficiency,
however blind individuals may be to their own ulti-
mate advantage. For the relief of actual disease
or damage, even more so for fancied ailments, they
are often willing to consult a physician. When people
arrive at the conviction of a need for general or
special betterment, they are usually prepared and
willing to spend time and money on measures con-
fidently endorsed. Hence much capital is invested in
various medical enterprises, good and bad, legitimate
and quackish. If, however, they would realize that
the best, the most complete, plan is to promptly and
frankly consult a physician, or to seek advice peri-
odically as to how they may retain their health, im-
prove their powers, achieve a relative perfection,
by far the greatest gains in efficiency would follow.
Furthermore, should objection be raised to this
unusual course of action, practical analogues can
be shown to obtain in many other lines of profes-
sional activities as in manufacturing, engineering,
or mercantile lines. Specialists flourish, earning
large sums, who are employed to revise exist-
ing business methods, suggest improvements,
promising the enhancement of organization,
economics, and earnings. I know one gentle-
man, a mechanical engineer, who in early mid-
dle life adopted this improvement specialty
much to his own financial advantage. There are
many such in other lines. This form of specializa-
tion is preeminently a practical one, and within the
capacity of many. It requires thorough technical
knowledge and a broad grasp of details and poli-
cies. Lesser business specialists there are in plenty,
competent in narrower lines ; experts in mechanics,
in chemistry, in labor saving devices, in advertising
methods, in the search for markets, etc. These are
the analogues of our specialists in diseases of the
eye, ear, throat, skin, heart and lungs, kidneys, rec-
tum, etc. Busy they become, satisfactory earning^
do they make, valuable services do they render.
Yet wherein does this detail service compare to that
of one who, having all these and other resources at
command, shall, with their aid when needed, esti-
mate the organic index, the structural, the circu-
latory balance ; ascertain the significance, by expert
estimation, of developmental faults, of significant
maladjustments, of the phenomena and effects of
vitiated physical habits, motor, sensory, psychic,
and the like?
One of the most important points is to determine
and adjust the kind and quality of mental impulse,
present or needed ; the capacity for psychical right
direction and persistence.
In the process of enhancing vital powers there
are diverse, well known, excellent resources, often
wisely employed. These embrace such familiar
measures as regulation of life on a hygienic basis,
including all those factors which contribute to
physical economies, to normal activities, as by open
air life, dietetic care, correction of functional or
constitutional errors by well chosen drugs and the
like.
These are efficacious in proportion t6 (i) the
judgment and care exercised by the adviser in
searching out causes, and (2) to the degree of co-
operation- supplied by the individual. Success de-
pends upon a thorough estimation of the specific
needs of each person.
The possibilities of such specializations may be
rendered clearer by one or two illustrations, outlin-
ing certain supplemental measures which have
often contributed materially to my own successes,
viz., the correction of conditions which may be de-
scribed as deformities, but which really constitute
730
TAYLOR: MOST USEFUL SPECIALTY.
[New York
Medical Journal.
the foundation of many metabolic disorders and
demand orthopaedic treatment.
A long experience in and many consistent en-
deavors to solve the complex problems of patent
but indefinitely lowered health, to get that uplift
so desirable whereby we may make efficacious
previous efforts, has impressed me with the im-
portance of securing greater elasticity of the tissues
and promptitude in the reaction times between con-
trolling centres and outlying motor parts. This
constitutes a key to vascular competence, by en-
hancing vasomotor reflexes throughout the whole
system. The grosser mechanisms often need even
more attention than is afforded by customary meth-
ods of organic regulation, because without first
achieving elasticity therapeutic results are not so
readily secured. Full organic competence is not sus-
tainable unless the supporting structures are main-
tained in normal degrees of mobility. The lungs,
heart, etc., for instance, cannot do their perfect
work in a contractured thorax. The abdominal
viscera are unable to perform their full duties unless
their supporting structures are adequately strong
and elastic to exercise normal counter pressure. The
hollow viscera both above and below the diaphragm
need to be held poised in the normal interrelation-
ships, so that vital hydraulics, connecting tubes
large and small, suffer no interference from undue
compressions. Poisons, endogenous and exogen-
ous, work greater harm unless local stasis is re-
lieved. No amount of salutary passive conditions
can accomplish much if the normal stimuli to cir-
culation lack something of necessary impulses and
responses. The most powerful drugs can do little
for ultimate restoration of capacity if the great
oxygenating laboratories, the muscles, cease to do
their essential cooperative part.
The subsidiary centres in the spinal cord, regu-
lating vasomotor action, require that the paraverte-
bral tissues shall continue to receive normal stimu-
lation. So simple seeming a measure as making
more flexible the backbone is followed in my expe-
rience by extraordinary betterments. There are
thus provided structural normalities in the reflex
cycle to motor stimuli through the vasomotor cell
bodies in the corresponding segments of the cord.
Hence the ebb and flow of fluids is encouraged.
The physiological factors in this reflex process I
have often outlined ; the clinical proof is daily seen
in my work.
Parenthetically let me say that the benefits which
we know to follow physical activities are explain-
able upon this same principle of responsive-
ness to reflex motor stimulation through
vasomotor subcentres. For those who are
unwilling, unable, or organically unfit to avail
themselves of open air sports, muscular activi-
ties, as much or even more can be accomplished by
brief but exact education in the cycle of motor im-
pulses and responses, along with correction of local
rigidities in the skeletal structures, direct or col-
lateral. There is needed a precise estimation of
what is amiss in the particular person, by whatever
means the individual taste, opportunities or organic
competence makes practicable, and correcting, in
so far as is feasible, the observed shortcomings.
By securing greater elasticity of the less used
structures u'e can accomplish improvements in
many unexpected directions, among the chief of
which is securing harmonious interreactions
through systematic motor stimulations. The body
is dependent upon wholesome motor stimulations
for the maintenance of diverse nutritive processes.
The paravertebral tissues are, as has been said, in-
nervated by the posterior primary divisions of the
spinal cord ; mechanical stimulation of these
structures causes salutary reflex vasomotor effects,
through the cell bodies in the segments inducing
pronounced circulatory quiescence or enchance-
ment. Derangements in organic or other peripheral
tissues always induce alterations in the nutrition
of the cell bodies from plus or minus afflux of
blood. These are almost always recognizable
through alterations in the gross morphology of the
erector spinae muscles and of the ligaments. By
encouraging activities in these paravertebrce
muscles, and securing elasticity in the liga-
ments in the back, there follozvs, in my
experience, a corresponding and correlated en-
hancement of all organic activities. This can be
readily accomplished by systematic posturings, tor-
sions, bendings, etc., alone or along with exten-
sions of the limbs ^aid systematic forced respira-
tory acts, whereby the junctures of the ribs and
backbone are made more mobile.
Indeed, oftentimes a larger benefit follows from
a ten minutes daily practice of such stretchings than
from hours of ill directed "physical culture" stunts.
Take an instance, oft recurring, where the chest
has become rigid, usually contractured, the neck
tissues also. It is a principle evolved by my expe-
rience that }iormaUt\ of posture is essential to or-
ganic competence. Erectness is compounded of
vertical and horizontal lines from which diverse
other lines may depend. While curving lines make
for grace they tend to impair the power of sup-
port. The weaker the person the greater are the
ciu-ves exhibited. Much bodily weakness is condi-
tional upon that exaggeration of dependent lines
which evidences incompetence in the supporting
structures. These supporting structures may be at
fault, both at origin and periphery. For example,
the visceroptosia, as I have repeatedly emphasized,
arise in central defects which can and should be
radically corrected by enhancing the vital index
through attention to the inherent fountains of force."
A secondary cause is loss of integrity in those
agencies exercising support which is supplied by
collateral and external structures. Where these
are voluntary muscles their vigor must be enhanced
by all means, among the most definite of which is
suitable use by exercise.
The key to erectness, hence of skeletal ef-
ficiency, hence of visceral interrelationships,
hence of an important factor in organic
competence, lies in the maintenance of a normal
posture of the thorax. This assumes the mainte-
nance of a relatively straight backbone and horizon-
tality of ribs. When the ribs remain relatively hori-
'The principles of organic action are made plain for the first time
by Chas. E. de M. Saious in tlie Internal Sfcrelions. The domi-
nant agencies are the ductless glands— the adrenal system.
April iS. igoS.]
BIERHOFF: PALLIATION OF PROSTATIC HYPERTROPHY.
7Zi
zontal and are easily held well up to their normal
levels, there is thereby afforded adequate support to
the diaphragm, the external and internal abdominal
muscles, and to all those structures combining to
afford visceral support. There is thus afforded
surprising degree of improvement in organic com-
petence.
To secure this thoracic normality requires intelli
gent motor education. By the simple device of
training a patient to clasp the hands behind, pulling
apart strongly and pushing the arms forcefully down,
at the same time thrusting up the chin vertically,
these contractured tissues are forcefully stretched,
perhaps for the first time in years. This act repeated,
and with steady increments of force, widens the
front of the thorax, educates the down pull of the
erector spinae muscles, and overcomes the common
and damaging habit of stooping. Stooping always
induces undue compression of the larger viscera.
By this procedure I have been able frequently to
rid patients of limitations caused by adherent
pleurae ; to improve the power and sonorousness of
the voice ; to restore in a measure chronicallv im-
paired hearing: to relieve many of the evil eft'ects of
chronic heart disease : to mitigate asthmatic states,
etc. The increased respiratory capacity induced
also makes for many aesthetic as well as essential
betterments. By adding to this (the most efficient
known "'setting up" device forced expiratory- action,
the lower ribs being made to forcibly contract, the
abdominal - contents are raised toward the dia-
phragm, hence a varied train of advantagements en-
sues. In short, by a close study of the minor con-
tractures and their economic corrections, it is prac-
ticable to achieve that symmetry and elasticity of the
body, at any age, which constitutes the index of
working capacity.
One eminently satisfactory and unexpected result
has followed in a dozen instances from voluntary
elasticizing of tissues, viz., improvements in pro-
gressive deafness. The description of one case will
serve to illustrate :
A lady, sixty-nine vears of age. had steadily lost acuity
of hearing, being told by the best otologists that it was due
to inevitable senile changes aggravating catarrhal pro-
cesses. She was a vigorous, massive woman, over red. pre-
senting distressing phenomena due to passive congestion of
the head. In my eftorts to relieve the obvious tissue water-
logging. I trained her in neck stretchings, torsions, forcible
chin elevations, etc. Also I adopted hints from a Vien-
nese larvngologist, in an article on treatment of chronic
catarrhal conditions, to forcibly open the mouth, simulating
the act of yawning, all with the purpose of so stretching
the stiffened tissues as to invite afflux of blood to impov-
erished muscles and adjacent structures.
To my surprise and gratification the hearing steadily
improved. Now. at the age of seventy-seven, this lady can
hear about twenty-five per cent, better. Many similar re
suits have followed like efforts, success being in propor-
tion to intelligent cooperation and persistence.
Such a careful study of individual defects, inhe-
rent or acquired, as are here instanced, and their
judicious correction, using resourcefulness in not
only restoring but enhancing the existing status by
rational auxiliary measures, aft'ords full scope for
a specialty to which none other can be superior.
1504 PixE Street.
THE PALLIATIVE TREATMENT OF PROSTATIC
HYPERTROPHY.*
By Frederic Bierhoff, M. D.,
New York,
Attending Surgeon, Urological Department. German Dispensary:
Fellow, New York Academy of Medicine; Corresponding
Member of TAssociation frangaise d'urologie, etc.
When our president invited me to address this so-
ciety, he suggested that I take, as a topic which
would be of interest to the general practitioner, the
palliative treatment of prostatic hypertrophy. In ac-
cepting his invitation, I accepted also his suggestion
regarding a topic, for the reason that I have long
felt that the possibilities of palliative treatment in
cases of prostatic hypertroph}- have been rather over-
shadowed by the enthusiasm felt by the general sur-
geon for radical operation in this disease condition.
I do not wish to be misunderstood. There comes a
time in the history of almost every case of true pros-
tatic hypertrophy when a radical operation is de-
manded ; but I also feel certain that the indications
for operation and the contraindications forbidding
operation are not sufficiently studied by the general
run of surgeons, and that they often lose sight of
the not inconsiderable risk which always accompa-
nies so grave an operation as the extirpation of the
prostate in their enthusiasm over a certain type of
operative procedure. Some of the cases which I
have seen and examined, after a considerable lapse
of time following radical operations, have made me
think that they would have been better oft' bad the
means employed been palliative rather than oper-
ative. I firmly believe that the true statistics of
radical prostatic operations have not, as yet. been
written. The temptation to class cases as cured,
when, a short time after the operation the patient is
free of symptoms and discards his catheter, is very
great.
We must not forget, on the other hand, that there
is a large percentage of cases in whom, for various
reasons, it is an impossibility for the patients con-
scientiously to carry out the various measures neces-
sary for a successful palliative treatment, and that,
in these instances, radical operative treatment should
be the choice, as being the lesser of two evils.
Leaving aside any consideration of the question
as to whether true hypertrophy of the prostate is of
inflammatory origin, or of true neoplastic character,
we mav pass to the classification of the stages of
prostatic hypertrophy as we see them in practice.
The first stage — the premonitory, or develop-
irental — is characterized by the conditions that the
bladder is still able to empty itself, practically com-
pletely, and that the patient complains, chiefly, of an
increased desire to pass water, and increasing tenes-
mus, which develop into an imperative desire to
urinate, and, finally, of a difficulty in passing water.
The first svmptom which usually affects a patient
and draws his attention to the fact that his bladder
is not normal is the development of a desire tc uri-
nate frequently during the night. He must get up
once or twice during the night, or oftener. As this
stage is seldom complicated by cystitis, the tenesmus
is not marked. The patient usually promptlv falls
asleep, after having emptied his bladder, and his gen-
*Read. by invitation, before the Iladem Medical .Association,
January 8. 1908.
732
BIERHOFF: PALLIATION OF PROSTATIC HYPERTROPHY.
[New York
Medical Journal^
eral condition is little impaired. Usually the amount
of urine passed at each micturition is rather small,
but there may be a true nocturnal polyuria. A fre-
quent symptom during this stage is that the patients
complain of a burning pain, which they locate a
short distance behind the glans penis. The ability to
start the stream of urine is also somewhat impaired,
and the stream itself is rather smaller than formerly,
■and weaker. These symptoms are, in great part, due
to congestive conditions of the prostate and prostatic
urethra, and we frequently meet with sphincteral
spasm, which shows itself by an interrupted jet of
urine, a few drops, or a teaspoonful being ejected
during each act of micturition. The fact that the
symptoms are more pronounced during the night is
ascribed to an increased congestion, or hyperaemia
of the prostate, while the patient is in a recumbent
position. This condition also explains the frequent
occurrence of painful erections during the night.
During this stage any conditions which tend to in-
crease pelvic congestion increase the symptoms, par-
ticularly the dysuria, very much. If we examine
patients in this stage, we are frequently si^rprised ^t
the comparatively slight degree of hypertrophy pal-
pable upon examination per rectum. The prostate
is only slightly enlarged, and is of a moderately elas-
tic consistence. The insertion of a catheter usually
meets with a distinct sensation of obstruction when
it enters the prostatic urethra, and its passage is usu-
ally accompanied, at this point, with considerable
pain. The amount of residual urine in this stage is
usually small, 15, 25, or 30 c.c. being a fair average.
Examination with the cystoscope reveals but slight
hypertrophy of the gland, with, in almost all in-
stances, little or no evidence of hypertrophy of the
bladder muscle, and no inflammatory changes. I
have, however, repeatedly seen unusually prominent
veins just at and about the vesical neck.
It is during this stage that most can be done by
palliative measures. The patient should be carefully
instructed concerning his mode of life, and the neces-
sity for his bearing in mind the fact that his prostate
is not normal, and that he must regulate his life and
his habits to conform with the needs of his condi-
tion, is imperative. It must be borne in upon his
mind with emphasis that whereas, with care upon his
part, he may live in comfort for many years, his
prostate and bladder are his points of least resist-
ance, and that every indiscretion or carelessness of
which he is guilty will show itself in the increased
symptoms from which he suffers. Such patients
should be instructed to avoid,, above all things, sit-
ting for long periods, long drives, or long rides in
railway carriages ; horseback riding, in particular,
must be avoided. I have made it a rule to advise
men whose work is of a sedentary character, under
such circumstances, to use an air ring upon their
chairs or seats. They must avoid excesses in eating;
avoid alcohol, spices, or highly spiced foods, expo-
sure to cold and wet, and must attend to the condi-
tion of the bowels, and arrange for regular evacua-
tions daily. Where cathartics are necessary, milder
medicaments, such as cascara, ep.som salts in moder-
ate doses, castor oil, or some of the mild aperient wa-
ters are preferable. The patient should dress in such
a manner that sudden changes in temperature may
not bring on chilling of the body. I advise patients
of this class to wear natural wool underwear, in dif-
ferent weights, during the entire year, and also to
avoid wetting of the feet, or sitting down upon cold
or wet ground. Sexual intercourse, in moderation,
is not harmful, but all sexual excesses are strictly
contraindicated. These patients should be instruct-
ed, also, that should complete retention occur, at any
time during the course of their trouble, they may
employ a hot sitzbath, of from five to ten minutes'
duration, and attempt to urinate while seated in the
bath. In fact, I have found the hot sitzbath, used
at night, just before the patient retires, a routine
measure of great help in lessening the prostatic con-
gestion, and have frequently been surprised to note
the marked relief which such a simple measure pro-
cured for the patients during the night. They should
also be instructed that in case of sudden, complete
retention, they must not delay long before sending
for their physician, but that if the attempt to urinate
while seated in the hot bath fails, they should at once
send for their medical attendant and permit him to
draw off the urine by the catheter.
Where the compressor and sphincter cramp is pro-
nounced, the careful passage of a metallic instrument
is advisable. Many authors speak of the passage of
a metal sound in these cases. Personally, I prefer
to use a metal catheter, of a size corresponding to
the sound, because of the lessened danger of making-
false passages. The manoeuvre which I always em-
ploy in such cases is as follows : The glans penis and
prepuce are thoroughly cleansed with a solution of
bichloride of mercury, i in 4,000. The anterior ure-
thra is then irrigated with a solution of i in 20,000
bichloride of mercury, after which the attempt is
made to inject a small quantity, the amount of which
is noted, through the posterior urethra, into the blad-
der. Where the compressor cramp is pronounced, 8
c.c. of one per cent, cocaine solution is now injected
into the urethra, and the urethra gently manipulated
in such a manner that the solution is forced into the
posterior urethra. After superficially anaesthetizing
the posterior urethra in this manner, a cleansing fluid
may be injected through into the bladder. The cathe-
ter, sterilized by boiling, is now gently passed into
the bladder, and the appearance of fluid, escaping
from the catheter, is positive proof that the instru-
ment is in the bladder. The bladder is now thor-
oughly cleansed with tepid one per cent, boric acid
solution, and the catheter allowed to remain in place
for a few minutes and then withdrawn. Some au-
thors advise the use of posterior urethral dilators in
cases of this sort. My personal preference, how-
ever, is for the metallic catheter, as before men-
tioned, for the stated reasons.
The most frequent complication of this stage of
the disease is complete retention of urine, following,
usually, some breach of the before mentioned regu-
lations for the general conduct of the patient. This
may be treated by rest in bed, and by intermittent
catheterization ; but .should it persist, I believe the
preferable treatment to be the catheter a demcure.
This may be left in place for .several days, under
a.septic and antiseptic precautions, and its use is gen-
erally quickly followed by relief of the acute reten-
tion.
April 18, 1908.]
BILRHOFf
PALLIATION OF PROSTATIC HYPETUROPHV.
733
Out of this first develops the second stage, or stage
of vesical insufficiency, due to the gradual weaken-
ing of the muscle fibres of the bladder wall. This
stage is characterized by a chronic, incomplete reten-
tion of urine. The symptoms which present them-
selves during this stage are, in the main, exaggera-
tions of those present in the first stage. Added to
this are the symptoms resulting from the accompa-
nying cystitis, which, sooner or later, develops in all
of these cases. I have been surprised, however, in
many cases, to find how long a period will pass dur-
ing which men, with marked retention, will maintain
urine which is practically normal. The intervals of
rest between the imperative desires to urinate grow
shorter. During the day the patients urinate at in-
tervals, frequently as short as an hour. The sensa-
tion of burning and of tenesmus is increased. The
stream of urine grows weaker and smaller, even at
times flowing merely in drops. The patients also
complain of an increasing pain in the region of the
glans penis, and of an uncomfortable sensation, as
of a foreign body, in the rectum. Obstipation is in-
creased. The patients pass stool which is thinner
than the normal, and sometimes flattened, and pro-
lapse of the rectum or the formation of haemorrhoids
are not of infrequent occurrence as a result of the
severe straining to evacuate the urine. During the
night, particularly, the frequency of urination is in-
creased, the intervals being even so short as a half
hour. During this period also the patient's general
condition suffers ; digestive disturbances result, and
mild febrile movement may occur. Owing to these
various general disturbances, and, in great measure,
to the disturbance of the night's rest, the patients
grow weaker, and are less able to ward off compli-
cations. Here, too, vesical or urethral haemorrhages
may occur ; cystitis is very likely to result, and an in-
fection of the kidneys or pelvis mav occur. Poly-
uria is not an infrequent development during this
stage. This second stage develops either suddenly,
as the result of an acute retention of urine, or it may
come on slowly. Palpation of the prostate now reveals
a rather markedly enlarged gland, and the cystoscope
shows a prominence of the lateral lobes, or the mid-
dle lobe, or a combination of these. The lengthen-
ing of the prostatic urethra is also more pronounced.
In addition thereto, the cystoscope usuallv reveals a
condition of columnar bladder — more or l^ss marked
hypertrophy of strands, or bundles of bladder mus-
cle, with spaces of weakened bladder wall between
them. We also here frequently note the develop-
ment of diverticula. There is usually, also, an ac-
companying hypersemic or inflammatory condition
of the bladder wall, which is more marked in the
region of the trigone and the vesical neck. Here,
too, we frequently see a varicose condition of the
vessels at the bladder neck. The most important re-
quirement of treatment during this second stage is
systematic and regular emptying of the bladder by
catheterization. The tendency toward too frequent
catheterization, however, must be combatted. Where
the patient has a residual urine of between 150 and
200 c.c. it is usually suflficient to empty the bladder
once during the course of the dav. The time for this
catheterization is preferably at night, just before the
patient retires to bed. In this manner he is insured
a longer period of rest during the night.
Catheterization, whether performed by the patient
or by the physician himself, must be done with the
greatest care and gentleness. It should be borne in
mind that the powers of resistance of these patients
are diminished, and that any lesion of the urethral
canal or of the bladder is, almost invariably, fol-
lowed by a reaction, which only tends to further sap
the patient's vitality. It is a good rule to keep the
catheter out of the patient's hands until this is no
longer possible, unless he is a man of sufficient intel-
ligence to fully appreciate the need for the greatest
possible care.
In the choice of a catheter I am usually guided bv
the presence or absence of resistance in the posterior
urethra. I prefer not to manipulate long with a soft
rubber catheter, but usually at once pass to the flexi-
ble silk, or linen catheter, with the single Mercier
beak. Care must be taken that the catheter has a
smooth exterior, that it is sufficiently flexible, and
that the catheter eye has no rough or sharp edges.
It should invariably be boiled for at least two to
three minutes before being used. Boiling in this
way, in plain water, does not hurt catheters which
are properly made. Many of mine have been boiled
fifty to eighty times or more without injury. A
catheter should never be inserted until after a pre-
liminary irrigation of the anterior and posterior ure-
thras, with I in 20,000 bichloride solution, and until
the glans penis and prepuce have been thoroughly
cleansed with i in 4,000 bichloride solution. The
catheter should always be passed with the patient in
a recumbent or semirecumbent position. The hands
of the person handling the instrument should be
thoroughly cleansed, and the catheter seized at a
point close to the outer end, so that that part which
is to enter the urethra and bladder may not become
infected through handling. A sterilized lubricant
is used to anoint the catheter, and it is a wise pre-
caution to express and wipe away the most superfi-
cial layers of lubricant in the tube, and to cleanse the
mouth of the tube containing the lubricant before
applying it to the catheter. It is well, too, to pass
the mouth of the container through an alcohol flame
a few times. The catheter must now be gently in-
serted, the left hand of the operator steadying the
penis, and the catheter gently pushed forward until
the urine flows off, care being taken to keep the point
of the beak directed upward. If, upon emptying the
bladder, bleeding occurs toward the end of the act
care should be taken not to let the bladder empty
itself fully, but to replace some of the urine with
sterilized boric acid solution, until the fluid flows off
clear, and to allow about 50 to 100 c.c. of boric
acid solution to remain in the bladder, according
to the amount of residual urine it contained. The
urine should never be withdrawn from the bladder
without a subsequent irrigation with sterilized bo-
racic acid solution, no matter how frequently, dur-
ing the course of the day, catheterization is resorted
to. Where cystitis is present, the cleansing irriga-
tion may be followed by the use of a solution of
silver nitrate, beginning, usually, with i in 2,000
and increasing, gradually, to i in 1,000, or even i
in 500. Although this may cause some tenesmus,
it is usually of short duration, and is, in most in-
stances, quickly followed by marked relief in the
inflammatory symptoms. In addition, the hot sitz-
734
BlERHOFf: PALLIATION OF PROSTATIC HYPERTROPHY.
[Nhv V„uk
Medical Joirxal.
baths, previously mentioned, are of service. Inter-
nally, urotropin, helmitol, formin, or any other of
the reliable formaldehyde combinations, should be
employed, in order to diminish, as far as possible,
the bacterial contents of the urine. Where tenes-
mus and rectal discomfort are pronounced, a rectal
suppository of opium and belladonna, or a small
enema of hot water is frequently of benefit. Fre-
quently patients may be carried over years, in great
comfort, by carefully carried out and consistent
catheterization, with the accompanying measures of
treatment. Particularly is this the case in those pa-
tients in whom some contraindication to operation
exists, such as marked atheroma of the vessels.
The third stage is that of complete retention,
with, in some cases, ischuria paradoxa. In this
stage the desire to urinate reaches a frequency, in
many instances, of five to ten minute intervals, both
day and night. All the symptoms previously men-
tioned are increased in their severity, and the pa-
tient, in spite of persistent attempts to urinate, is
unable to pass any urine whatsoever. It is during
this stage that toxic symptoms are likely to develop,
owing to resorption, and to involvement and dilata-
tion of the ureters and kidneys. Polyuria is also
pronounced during this stage of the illness, and five
to six quarts of urine during the twenty-four hours
may be passed. This is usually due to secondary
degenerative changes in the kidneys. The gastroin-
testinal symptoms are increased, and febrile move-
ment, accompanied by chills, is not of infrequent
occurrence ; cerebral symptoms pointing to a
urgemic condition are not unusual, and haemorrhages
are frequent. Even here, in many cases, regular,
carefully carried out catheterization, combined with
proper general treatment, may serve to tide the pa-
tient over the grave condition and make him com-
paratively comfortable. Particularly is this true
of the use of the catheter a doiieiire.
In addition to the measures previously mentioned
in the consideration of the different stages of pro-
static hypertrophy, general tonic treatment is indi-
cated during the entire course of the illness. The
condition of the skin, also, must be kept good by
regular bathing, such patients doing well to use
warm body baths twice a week, followed by brisk
friction over the entire body. These baths are best
taken just before retiring at night. Attention must
be paid to all intercurrent disturbances, particular-
ly those of the digestive tract.
Of direct measures, not radically operative in
character, numbers have been suggested. Direct
electrolysis of the gland, the negative electrode be-
ing inserted, through the rectal wall, into the sub-
stance of the prostate gland, the postive pole being
placed upon the abdomen, gave little, or no, benefit,
and was, in a number of instances, followed by un-
pleasant complications. Injections of drugs, direct-
ly into the perenchyma of the gland, have been sim-
ilarly unsatisfactory. Faradization has been tried
without success. The x ray has also been em-
ployed without much benefit. Massage of the gland
itself has been of little benefit, except in such cases
as were due to chronic congestive causes. In sev-
eral cases of this latter type, however, I have felt
that my patients obtained much benefit therefrom.
Naturally, where we are dealing with a fibrous
prostate, massage of the prostate can be of no value.
General massage, however, particularly when ap-
plied to the lower abdomen, the thighs, and the pel-
vis, has been reported as being of distinct benefit
in many instances. Organotherapy, which has been
tried in a number of instances, has been without
any benefit.
Where haemorrhage results, as not infrequently
happens in cases of prostatic hypertrophy, and
where an acute retention develops, or where a pro-
nounced cystitis, or a pyelitis, or pyelonephritis is
present, the patient should at once be put to bed. and
a permanent catheter inserted. This should be,
preferably, a soft rubber catheter, and should be,
approximately, of the largest size that the meatus
will permit to pass. It should not, however, be be-
low 1 8 French. If the meatus will not allow the
passage of an instrument of this calibre, it should
be enlarged sufficiently to permit such an instru-
ment to pass. There are a number of appliances
which enable us to fasten the catheter in place, but
a very simple one can be made with a safety pin,
which penetrates the upper wall of the catheter,
just beyond the meatus, to which silk, or strong
linen threads are attached, these threads passing
back, along the sides of the penis, and being kept
taut and in place by a zinc oxide plaster strip, en-
circling the organ, but making no pressure. Such
a permanent catheter, which must, of course, be in-
serted under the strictest aseptic precautions, should
be removed daily and resterilized, by boiling, care
being taken, at such times, to thoroughly irrigate
the urethra and bladder in the manner before men-
tioned. It is a surprising thing to note how well
the permanent catheter is tolerated by the majority
of patients, and how quickly the complications for
the treatment of which it is used respond thereto.
A not infrequent complication, where the patients
catheterize themselves, or where the catheter is
carelessly used, is epididymitis, or orchitis, or a com-
bination of both. Usually it is not severe in charac-
ter, although it may go on to suppuration. Under
such conditions the patient should at once be put to
bed, and, where the vesical symptoms are at all
pronounced, the permanent catheter be inserted, in
order to avoid the danger of frequent catheteriza-
tion. All patients suffering with prostatic hvper-
trophy should drink freely of water, and many are
benefited, particularly in the presence of cystitis, by
Wildungen, or some of the similar waters.
When the patient's local condition is such that
it does not respond readily any more to palliative
treatment, and when no complicating conditions ex-
ist which forbid operative procedure, then radical
measures must be emplox ed. I do not believe that
any patient's chances of recovery are impaired by
palliative treatment, so long as the symptoms re-
spond thereto ; but I do not believe that one is
justified in delaying radical operation where pallia-
tive treatment fails to achieve tangible results.
While our aim as physicians must be to save our
])atients any unnecessary risk, we should recognize
the fact that when the risk must be taken, there
must be no unnecessary delay.
53 East Fiftv-eiciitii .Stkket.
April 18, 1 90S. J
• CHANCE: REPAIR OF LIDS.
735
ATTEMPTS TO REPAIR THE EFFECTS OF GREAT
DESTRUCTION OF THE LIDS AND ORBITAL
TISSUES CAUSED BY DISEASE OF
THE ANTRUM *
By Burton Chance, M. D.,
Philadelphia.
The earlv history of this case, without which I
could not liave understood the cause of the awful
conditions present when I first saw the patient, was
given me by Dr. Beaman Douglass, of New York,
and I now express my obHgation to him for the in-
formation. The young woman had had a disease
of the left antrum which had been caused probably
by infection from a decayed molar tooth. The dis-
ease spread into the orbit after necrosis of the roof
of the antrum. Orbital cellulitis followed, and later
the evelids became the seat of numerous abscesses.
In a short time panophthalmitis occurred, and the
eyeball had to be rem.oved.
Dr. Douglass opened the antrum, which he found
filled with infected granulation tissue. After thor-
oughly curetting this cavity he removed all of the
necrotic? bone, fhus enlarging the opening into the
orbit and establishing communication into the mid-
dle nasal meatus. The abscesses in the lids were
opened and drained ; other incisions were made to
ascertain the state of the frontal and the ethmoidal
sinuses. Here all the osseous tissues and spaces
were healthy, and the_\- were left undisturbed.
Drainage tubes were placel in the opening be-
tween the orbit and the antrum, and these cavities
were drained. Further treatment consisted in fre-
quent cleansing and of the removal of redundant
granulations. Dr. Douglass viewed this as one
of the most interesting accessory sinus cases he had
ever had, and he could hardly believe it possible for
so great destruction to follow disease of the
antrum.
The patient was a well developed young woman. Over
her left orbit she wore a thick black silk patch. On her
cheek were several scars ; one as though it were the cica-
trix of an incision, others as though from excoriations,
while along the superior orbital ridge were those from the
exploratory incisions over the frontal and ethmoidal re-
gions. The globe had been removed. The orbit was par-
tially filled in by soft tissues adherent to the muscular
pyramid. There was sufificient movement of the mass to
justify the assumption that the ocular muscles had not been
entirely destroyed. The upper lid, which was greatly dis-
torted and stretched, was firmly adherent to the roof of the
orbit. The inner two thirds were without lashes or ciliary
horder; the outer third was puckered, and from the edge
projected distorted cilia. The lower lid had been drawn
downwards, and with the skin and facia had become firmly
adherent tr, the orbital border. Here, surrounded by nu-
merous radiating cicatricial bands, w-as a sinus leading from
a pocket in the orbit and discharging on the cheek. The
antrum was drained by a small opening into the nasal
cavity, and through the socket of a molar tooth into the
mouth. FcEtid pus exuded from all these sinuous tracts.
The whole aspect was most pitiful. The young woman
besought me to stop the annoying discharges, and expressed
the hope that some prosthetic eiTect might be obtained by
repairs to the orbit.
My first efforts were directed towards thorough cleansing
of the cavities and the maintenance of drainage. The pa-
tient was most wilful and unmanageable. She persisted in
wearing the patch which created a brood oven out of the
orbital cavity and excited irritation of the surrounding skin
surfaces.
I sent her to Dr. John B. Roberts for suggestions as to
*Read before the Section on Ophthalmology of the College of
Physicians of Philadelphia. Thursday. February 20, 1908.
restorative plastic operations, but even to one so experienced
as he the conditions were formidable and discouraging.
The patient was entirely willing to submit to a series of
operations without demanding my assurance of definite
results. Accordingly she was admitted to the Germantown
Hospital. After complete ether anaesthesia I examined the
orbital cavity in a way in which I could not have done it
before. The lids were not united to the floor and to the
roof of the orbit throughout their whole extent, but only
here and there, the contiguity being interrupted by sinuous
tracts which led to the deeper conjunctival sacs, where the
mucous membranes were apparently preserved. The tarsal
cartilages had been damaged by the suppurative processes.
Bands of adhesions had formed between the lid margins
and the orbital tissues which had retracted so greatly as to
draw the lids far into the orbit. The inner third of the
lower tarsal border had been destroyed. There were no
signs of the lacrimal punctum or caruncle, nor of the sac
of the inner fornix. The apex of the orbit was fi'lled with
the remains of the extraocular tissues. The sinus opening
into the cheek communicated with several pockets contain-
ing putrid secretion.
After this survey I determined on a plan providing for
a series of operations, some of which had been suggested by
my friend Dr. Roberts. In the performance of the opera-
tions I was given much help by Dr. Charles Plank, the
senior resident of the hospital, and here I wish to express
my obligation to him for his patient care of the woman
while she remained in the wards.
The first operation consisted in carefully dissecting the
lids free from all adhering bands so that they hung over
the orbit like loose flaps. Greater mobility of the lids was
gained by an external canthotomy, and more space was ob-
tained in the orbit by the severance of the larger distorting
bands. As the lacrimal punctum could not be found, a
stout conical probe was forcibly pushed through the soft
tissues and entered into the duct. A thick lead style was
inserted after\\ards and passed down into the floor of the
meatus and left in the duct, the upper end of it bent and
embedded in the soft tissues of the orbit. The sinus into
the cheek was not disturbed, but was left to drain the ex-
cessive secretions from the orbit.
A piece of sheet lead was fashioned and placed over the
base of the orbit. This plate fitted into the angles corre-
sponding to the retrotarsal space. Then, with the hope of
effecting an anchyloblepharon, the lids were drawn over the
convex surface of the plate, and. their edges freshened,
they were-.united by interrupted sutures.
The reaction following these procedures was intense ;
great oedema of the lids persisted and the patient com
plained greatly of pain. In a week, because the sutures
broke loose, the lead plate was withdrawn and a ball of
bird paraffin was inserted in the cavity. Simple dressings
were used rnd firm pressure applied. The sinus in the lid
was swabbed with pure carbolic acid. After a week the
paraffin ,\as remo\ed. There was decided healing of the
raw surfaces, the discharge had lessened, and it was noticed
that the orbital mass could be moved more freely than was
the case before the operation. The skin on the cheek w-as
l;eginning to heal. In general terms a di-tinct benefit had
been gained.
An attack of quinsy supervened and in a few days the
patient asked to be allowed to go to her home. In a fitful
way she applied for treatment of the antrum to Dr. Carle
L. Felt to whom I had recommended her.
When the parts were examined three weeks later much
of the raw surface was found to be healed, and there was
considerable retraction and distention of the tissues. Again
the adhesions were broken and another lead disk was in-
serted over which the eyelids were united by silk and cat-
gut sutures. Only slight reaction ensued and in ten days
the results were more satisfactory than at the earlier opera-
tion. The eyelids were not united in their entire extent,
yet they covered the orbital outlet. The fistulous tract into
the cheek was closed and the site of it had become adherent
to the inferior orbital margin.
There were reasons for believing that the patient had
received a luetic infection two or three vears previously.
Because of this, and because of the great value I believe
mercury has as an antiseplastic, applications of mercurial
ointment were made daily for several weeks. The woman's
health improved rapidly; the .antral discharges diminished
and lost their foetid odor.
.\fter an interval of three weeks attempts were made to
736
LOFTON: DISLOCATION OF NECK.
[New
Medical
York
Journal.
repair the distorted upper lid. Adhesions were broken, and
exuberant granulations were removed. An incision was
made in the lid above the point in the border where the
distorted portion joined the natural. Again a lead style
was inserted into the lacrimal duct. An ordinary glass
shell was placed in the orbit and the lids were sewed to-
gether over it. Iced bichloride compresses were applied
without interruption for three days. But little swelling or
discharge followed, though the parts were tender and the
patient complained of considerable pain.
At the end of a week the sutures were removed. There
was firm union in the inner third, but less firm in the outer.
In spite of the great mutilation that had taken place in the
tarsal cartilages there was a noticeable, indeed even marked,
movement of the two lid flaps. The low er flap was com-
posed of the cutaneous and subcutaneous tissues of the
facial region, together with the inner fibers of the orbicular
muscle. The upper flap included similar tissues in the
inner portion and contained a very much distorted tarsal
cartilage in the outer.
At the end of another week the tissues conformed quite
regularly over the temporary glass shell. The tarsal border
had become more extensive ; the canthoplastics had in-
creased the general dimensions of the fissures, and the dense
cicatrization in the tissues at the lower border had favored
the eversion of the lower flap.
One month later a gold sphere was inserted beneath the
muscular cone of the orbital mass. The metal conformer
excited pain and induced considerable discharge, so that
by the end of a week it had to be removed, at which time
the sutures were withdrawn.
The patient was discharged from the hospital on Novem-
ber 15, 1904. After another month of irregular attention,
she disappeared and has'not presented herself again. When
I saw her the last time the lower lid had become adherent
to the orbital mass, but the sphere had so molded it that
the upper lid had become decidedly convex and overhung
the lower lid. There was at that time a resemblance to a
tarsal border along the upper lid. The cavity was drained
perfectly by the nasal duct, and the antral discharge had
ceased. '
Mr. Joseph Ferguson contrived a pair of spectacles con-
taining large periscopic lenses, the left having ground sur-
faces, which greatly obscured the disfigurement; but the
lady discarded them for the black patch of earlier days.
235 South Thirteenth Street.
DISLOCATION OF THE NECK WITH RECOVERY.*
By LuciEN Lofton, A. B., Ph. D., M. D.,
Emporia-Belfield, Va.,
Coroner and Health Officer to Greensville County, Va.
Traumatic injuries of the cervical vertebrae and
spinal cord are declared by many able surgeons as
being invariably grave ; a majority of such condi-
tions are said to be usually followed by an early death
or permanently bad results. A fevi^ cases, however, are
on record where a satisfactory recovery has been
observed.
Boswell mentions a man of sixty whose fourth
cervical vertebrae was subluxated and who recovered
within two weeks. Lazzaretto reports a case of a
seaman whose atlas was dislocated and who made
an uneventful, though somewhat tedious, recovery.
Vanderpool describes a fracture of the odontoid pro-
cess, but death ensued about six months after injurv.
Ashhurst, Phillips, the elder Cline, Willard Parker,
Bayard, and Stephen Smith have reported partial
and complete recoveries after fracture of the atlas
and axis. Doyle in 1896 attended a woman patient
with a dislocated neck who made a fairly good re-
covery within seven months, and who was enabled
to follow her daily vocations around her farm.
X, '".''i before the Seaboard Medical Association of Virginia and
North Carolina, at Norfolk, Va., December, 1907.
Ashhurst especially refers to the condition of dislo-
cated neck and says the mortality is always high.
His experience with three hundred and ninety-four
cases no doubt justifies this conclusion. Barney Bald-
win, the erstwhile Louisville and Nashville railroad
switchman, who exhibited himself throughout the
country several years ago, suffered from a disloca-
tion of the neck in the cervical portion of the spin-^.I
column. It is not generally known that the Earl
of Minto, Viceroy of India, is- one of the few nota-
bles who ever survived a broken neck. This acci-
dent befell the viceroy thirty-one years ago and was
reported by the distinguished English surgeon, Sir
James Paget. This famous physician declared after
his patient recovered '"that in the whole of his ex-
perience it was the only instance he knew of the
vertebrae going back into the place after being
stretched." A few other interesting examples of
this character could be enumerated which have ap-
peared in the medical journals of which every sur-
geon has easy access.
The case of dislocated neck the writer desires to report
is that of William N., white, age twenty, of Emporia, who
at the time of accident was employed as a daily laborer on
the Tidewater Railroad.
The writer was summoned at i p. m. to attend this man
in July, 1906, at Rural Bower, a distance of fourteen miles
from Emporia. I reached the injured boy about three
hours after the accident had taken place. Upon examining
the condition of the patient complete motor and sensory
nerve action were found to be absent from the chin down-
ward, barring a slight movement from the right index
finger, which could be feebly flexed.
Before proceeding further I desire to briefly describe the
origin of the dislocation. The young man while assisting
in adjusting an "idler" chain beneath a steam shovel was
caught around the neck by this powerful linked rope and
drawn up against the floor of the machine and securely
held there for several seconds. The engineman above, mis-
taking the signal, started the machinery below, and thus
was the unfortunate youth drawn near his doom. The left
side of the boy's head was pressed directly against the
under surface of the steam shovel, and when released the
body fell limp and, to all eye witnesses, apparently lifeless
to the ground. A number of intelligent observers, after
removing the body, pronounced life extinct, but for-
tunately, within a few seconds signs of resuscitation were
observed. When the young man awoke, as it were, he
asked for water, which he could not then swallow after
repeated attempts during a period of an hour.
At the time I reached the young man his condition was
improved to such an extent that, upon off'ering a liquid, he
could with great difhculty use some of the muscles of
deglutition. Practically no pain was complained of other
than that his ''neck was sore." The respiration was fourteen
to the minute, and the heart showed a count of fifty-eight
beats. The paralysis mentioned was absolute; likewise
necessarily complete loss of function of the bladder and
bowels. The patient talked intelligently, would whistle,
expectorate, protrude the tongue, and rendered any facial
contortion requested of him.
A more minute exammation of the boy's injury revealed
the fact that his neck muscles and ligaments had stretched
approximately one and one-half inches beyond normal
conditions. Upon manipulation the ventral arch of the atlas
was found resting upon the odontoid process of the axis.
The man had been placed upon a flat ground surface
where, in the following manner, I reduced the luxation.
Summoning four men, I directed two to grasp a low^r ex-
tremity, that the patient might be held evenly in proper
position. The other two assistants rested their hands upon
the thorax to steady the trunk. Then firmly grasping the
occiput with my right hand, I placed the left under and
around the chin, when by lifting the head backward, up-
ward, and forward upon the chest the atlas was replaced
to its normal position. Each step of the manipulation was
deliberately and slowly accomplished, owing to the fact I did
not know to what extent trauma had entered into the
WALHEXHEIM: CLIMATIC TREATMENT OF LHILDREN.
717
proposition. 1 felt reasonably certain that the cord or its
meninges were in a measure lacerated. During the reduc-
tion of the dislocation no anaesthetic was used for fear of its
direful results, and much pain was complained of by my
patient, especially in the region of the throat, and as ex-
pressed by him "felt as if about to choke.'" No immediate
sensory or motor improvement was noted upon reducing
the displacement other than a desire to micturate.
With one inch surgeon's adhesive strip, I firmly fixed
the neck and head in as normal position as possible. The
man now requested that his bladder be relieved, which was
done three times within three hours, voiding each time ap-
proximately from three to four gills, of deep amber color.
In an improvised ambulance I moved the man to Emporia
over one of the roughest public highways in the State.
Upon arrival at destination the pulse was 76 and respira-
tion 19. At no time did he become delirious after originally
regaining consciousness. The patient arrived home in
fairly good condition, about eleven hours after being hurt.
He was placed in bed, with the head of bed elevated about
eight inches. An additional bandaging of the neck and
head reinforcing the adhesive strip was thought necessary.
After a teaspoonful dose of a narcotic the boy fell into a
restless sleep which lasted for three hours, at which time
the narcotic was repeated and brought on the desired ef-
fect. The pulse and respiration continued practically nor-
mal for three weeks. At no time did the temperature rise
above 99.6 from the traumatic condition.
On the fourth day the paralysis began to clear in the left
lower extremity and in the right forearm. On the seventh
day the right foot began to be used, provided the boy
would direct and concentrate his mind upon this spot.
Then followed gradually the use of the muscles of degluti-
tion, the erector spinal muscles and the entire general mus-
cular arrangement, including the bladder and bowels.
The patient did not at any time suffer any mental dis-
turbance. He did not attempt to assume other than the
•dorsal decubital position for ten days, but after this time,
when I began massage, hot sponging, and the faradic cur-
rent from twice to five times daily, he would change his
position with only partial assistance.
On the fifteenth day the boy contracted measles, which
ran the usual course. The young man had tonics and al-
teratives for two months along with the treatment as
■described. A light but nutritious diet was given during his
illness and confinement to bed, and was increased to a full
diet upon leaving it.
On the twenty-ninth day after the injury the boy was
able to sit up and walk a few steps, but it was sixty-three
days before he ventured out of his chamber. The massage
and electrical stimulation was conscientiously applied for
five and a half months, with the result that the only evi-
dence of the original injury is a partial atrophy of the
deltoid muscles covering the shelf of the left shoulder. I
have purposely avoided going into the minutje of the nerve
structure herein involved, for I feel assured the distribu-
tion is generally known and any attempt upon my part to
describe the neural complications would prove unprofitable
to the reader.
THE PRINCIPLES OF THE CLIMATIC TREAT-
MENT OF CHILDREN*
By F. L. Wachenheim, M. D.,
New York.
Climatic treatment is often recommended for va-
rious subacute and chronic ailments of infancy and
childhood, but few authors have cared to lay down
the general principles which must be our guide in
ordering a change of air for our young patients.
As a rule, our recommendations have been largely
empirical, with a resulting uncertainty as to what
can actually be accomplished in applying climatic
treatment to this or that group of cases. I may,
therefore, be pardoned for taking up the time al-
lotted to me with a brief outline of the underlying
•Read before the Section in Padiatrics of the New York Academy
■of Medicine, February 13, 1908.
principles of climatotherapy, particularly as applica-
ble to early life.
The three most important climatic elements
which we have to consider are the temperature, the
various phases of atmospheric moisture, and the
pressure of the air, the last chiefly as modified by the
elevation above sea level. We may commence with
a discussion of the general therapeutical principles
applicable to all of these, and then take them up
severally.
We have two methods of applying physical
therapeutics of all kinds, including climate ; one
consists in training or developing the diseased body
or organ by exercise, the other in aiding the re-
storative powers of nature through reduced func-
tional activity, or what we may briefly call, in the
German fashion, a rest cure. The former is indi-
cated when the body or any of its organs suffers
from imperfect development or functionate poorly
from disuse. A course of training, likely to be in-
effectual or even dangerous in advanced life, is al-
most certain to yield excellent results in childhood,
if applied with judgment to patients affected with
such diseases as, for example, rickets or scrofu-
losis ; it is very generally agreed that removal to
a stimulating climate is of the greatest benefit to
these cases. When, however, the body or any of
its parts is already overstrained and for that rea-
son unable to cope with the work that normalh
falls to it, a rest cure is called for. Here, like-
wise, the indication is more urgent in childhood
than later, for in the young subject overwork en-
tails far more danger of permanent impairment
than in the adult, and, on the other hand, there is
a much better chance of complete, or at least satis-
factor}', restitution if appropriate measures of rest-
ing be applied, a sedative climate being one of the
very best of these. Climatic rest cures are especial-
ly indicated in such affections as nephritis and un-
compensated cardiac lesions.
In applying the diversities of temperature in ac-
cordance with the outline just given, our first object
must be to ascertain that indifferent temperature
which feels neither warm nor cool, and is there-
fore most restful. In the normal adult the indif-
ferent temperature stands at about 75° F. in sum-
mer clothing and 65° F. in heavy winter garments,
but is reduced about ten degrees by such moderate
exercise as walking. In children the indifferent
temperature ranges higher, only a few degrees to-
ward puberty, five or more in early childhood,
varying considerably according to individual
robustness, rising rather rapidly to near the body
temperature in earliest infancy. Thus the indiffer-
ent or restful temperature varies greatly according
to age; the average July afternoon temperature at,
for example, Atlantic City, namely, 78° F., is de-
cidedly bracing for young infants, indifferent for
children who are just able to run about, too warm
for older and very active children. It must be re-
membered, in this connection, that temperatures
above the indifferent point are not at all sedative,
but involve a continuous, stimulation that is most
harmful if prolonged, leading to exhaustion of the
type called enervation ; in physical therapeutics in
general, the belief in the sedative effect of warmth
is a common error.
738
STOLL: RETROSPECT IN PHTHISIOTHERAPY .
[New York
Medical Journal.
It is evident, from what I have said, that we have
within our reach some very dehcate gradations in
applying the cHmatic rest cure, if we balance care-
fully the factors of temperature, age, and exercise.
When, on the other hand, we desire to employ
measures of climatic training, the matter is ex-
tremely simple, as we need only recommend a
climate averaging ten degrees or so below the in-
difiFerent point for subjects who should m.ove about
freely, and a somewhat milder region for children
under three or four years of age, or such as suffer
from a disabling disease of the lower extremities
like chronic rheumatism, tuberculosis, or a trau-
matism.
The practitioner unfamiliar with climatic details
will, of course, be obliged to look up climatic tables,
besides sizing up his patients carefully. It is also
w'ell for the paediatrician to remember that young
children stand severe cold badly, so that a transfer
to the very frigid winter climate of the Adiron-
dacks, for example, is neither necessary nor even
advisable before the age of ten or twelve years.
Furthermore, it is evident that temperatures above
the indifferent point are not to be employed under
any circumstances ; the stimulation of cold can
readily be checked, if undesirable at any time, by
resorting to extra clothing and artificial heat, but
the effects of heat cannot be counteracted by any
known method. In applying any course of physi-
cal training, the chief danger is from excess or un-
due prolongation of our treatment, with the re-
sultant exhaustion which is invariably injurious.
As to the atmospheric moisture, I can speak
more briefly. Rain is useful in moderation, especial-
ly if it falls in brief showers to lay the dust; a
permanent winter snow sheet is of inestimable
value for the same reason, but the alternation of
frost and thaw, rain and snow, met with in our
Eastern .States from Massachusetts to New Jersey
in ordinary winters, is objectionable as causing
sloppiness underfoot and interfering with outdoor
exercise. The proportion of aqueous vapor in the
air, known as the relative humidity, is important in
that it checks the evaporation of body moisture and
consequent reduction of body temperature in pro-
portion to its own percentage. A low relative hu-
midity is extremely valuable in lowering the sensi-
ble temperature, or, what amounts to the same
thing, raising the indififerent temperature. Thus
the sensible temperature in summer is eight degrees
lower at Denver than at Atlantic City, though the
dry thermometer registers the same. The latter lo-
cality is somewhat enervating for older and fairly
robust children, whereas the former is bracing, on
the whole, in spite of pretty high afternoon tem-
peratures. At temperatures below the indifferent
point the relative humidity has no practical im-
portance, not being physiologically perceptible ;
thus our northeastern hills are popularly credited
with a dry winter, whereas observations show that
it is damper there than on the coast ; the truth of
the matter is that we cannot feel any difference
whatever. Clinically, the relative humidity at mod-
erately high temperatures is important for such
cases as call for tree transpiration, where we desire
to relieve the kidneys by causing diaphoresis; here
a warm and moist climate is indicated as being the
best mild diaphoretic known. Such localities as the
middle Atlantic coast in summer, the south Atlantic
coast in winter, and the southwest California coast
at all seasons are sure to be of value in chronic
nephritis or albuminuria.
As to great altitudes; we know that they cause a
hypertrophy of the red blood cells in proportion to
the elevation, and, as a necessary consequence, a
general stimulation to metabolism ; they are there-
fore admirable as a general tonic in torpid states,
but contraindicated in severe organic disease, where
rest is indicated. Elevations below i.ooo feet may
be disregarded ; those up to 3,000 feet are most
generally useful where a moderate toning up is de-
sired ; the higher levels are only to be resorted to
where a course of physical training is distinctly
called for, as in older children who have become
enervated from excessive warmth or lack of exer-
cise. The anaemias of young subjects do best at the
moderate elevations of our Eastern mountains, and
the same is true of the victims of general malnu-
trition, rickets, scrofulosis, and chronic tubercu-
losis. Greatly debilitated children are indeed bene-
fited most by elevations of 500 to 1,500 feet, and in
their case some such alternation as Xew York or
New England in summer and the Carolinas in win-
ter will be found to produce the best results.
I regret that the time allotted has been sufficient
only for a broad outline of a few generalities ; on
the other hand, I feel that a clear comprehension
of the fundamental principles of the climatic treat-
ment of children is calling for special consideration
at the present time.
1 1 1 West Eightv-fifth Street.
A RETROSPECT IN PHTHISIOTHERAPY.
Showing Some Curious Ideas as to the Treatment and the
Development of the Modern Method.
By Henry F.\rnum Stoll, M. D.,
Hartford, Conn.
Since centuries tuberculosis has been recognized
as the greatest scourge the human race has ever
known. Described with great accuracy h\ the fathers
of medicine, Hippocrates, Galen, Celsus. and others,
each generation has brought forth physicians who
have assiduously devoted themselves to conquering
this disease, yet it is only within recent years that its
cure has been thoroughly established. In ignorance
of the aetiology, knowing but little of its pathology,
yet eager to stay its ravages, it is not strange that
many "cures" were announced from time to time
which proved unworthy of the name. And it is the
memory of these bitter disappointments that is re-
sponsible for the iconoclasm with which each new
announcement in phthisiotherapy is received.
Many centuries ago the contagiousness of tuber-
culosis was attested to by Arostotle and Isokrates.
and later Avicenna, the father of Arabian medicine,
recognized its infectiousness. While its contagious-
ness was appreciated by "all the inhabitants over the
levant" (t) as early as the eighteenth century, the
Italians were the chief promulgators of this doctrine.
It is said (2) that Valsalva, who had a consumptive
tendency, would leave the autopsy whenever the
lungs of a person dying from consumption were dis-
sected. In 1757 Cocchi furnished the Florentine au-
thorities with certain directions to prevent its spread,
which are surprisino^ly hke the circulars issued by
our boards of health to-day. Consumptives were
urged to avoid living in small, stufTy rooms, choos-
ing rather large, airy ones exposed to the sun's rays.
The edict states (3) that "the sick should only spit
into vessels of glass or dried porcelain, which should
be frequently and thoroughly cleansed," and physi-
cians who failed to report their cases were fined 300
ducats for the first offense and exiled for ten years
for the second.
In the north of Europe, however, where supersti-
tion was rampant, where monarchs were "touching"'
for scrofula, where all sickness was either an evi-
dence of divine displeasure or of evil spirits, this in-
fectious theory was slow of adoption. Dr. Heberden
considered his experience as hardly sufficient to jus-
tify an opinion, yet he had seen "too much appear-
ance of it to be sure that it is not so." The things
which we recognize as secondary or contributing
causes — excesses, overwork, exposure, overcrowd-
ing— were considered by some as the primary or
real causes. Then as now the dress of the gentler
sex was severely criticised, one waiter remarking
that "the scant, light, and flimsy attire of our modish
females very much increase the liability of the com-
plaint." w-hile another stated that "the nakedness of
women is the clothing of the physician."
Laennec. the father of auscultation, observed the
very high mortality from consumption in the re-
ligious orders of women. This Laennec accounted for
by the depressing influence of the "ascetic spirit"
which regulated their lives. During ten years he
witnessed two or three renewals of the society by
admission of new members to replace the loss of old
ones, and that ''the only ones who withstood its de-
pressing influence were the superior, the gatekeeper,
and the sisters who had charge of the kitchen, the
garden, and the infirmary. These latter had occa-
sionally to visit the city" (4). Could a clearer case
of house infection and a more eloquent plea for the
outdoor life be imagined? It would seem that Laen-
nec would have been persuaded of the infectiousness
of the disease from this example alone, but as Walsh
truly remarks. "Even genius makes but one step into
the unknown" (5).
Some idea of what the treatment was two hun-
dred years ago is obtained from Robinson's Xeu'
Method of Treating; Consumption, published in 1726.
It will be recalled that at that time the scientists
were divided into two schools, the iatrophvsicists
and the iatrochemists, and to the former belonged
Robinson. He tells us that this "new method" is
based upon an endeavor "to account for all the phe-
nomena's attending consumption, from the laws of
attraction, motion, and division. These are the three
grand principles on which the several springs of the
constitution turn, and to which all the symptoms of
health and disease are referable" He gives a
dozen propositions, which contain frequent reference
to '".solids." "fluids." "elastic spring," "balance of
Nature." "tenuity of fluids." etc. It is explained
that these proposition? are founded upon "a kind of
mathematical reasoning without numbers." He re-
fused to accept the teaching of those who asserted
that the disease was due to "acid, sharp corroding
humors; putrid, sharp blood: sharp saline, volatile
lymph ; worms or animalculse's fretting or gnawing
the vessels of the stomach, lungs, liver, etc." ( 7).
It was much simpler to consider it occasioned by
"obstructions and tumors in the viscera" which were
caused by "a collection of juices" as the results of a
"depression of the solids" (8). The symptoms
were directly referable to "the force of the heart not
decaying in a simple proportion to the resistance of
the other parts" (9). Notwithstanding this remark-
able theory as to the aetiology of consumption. Dr.
Robinson appears to have been a rather close ob-
server and a man possessed with a good bit of com-
mon sense. He speaks of the poor digestive powers
of those w^ho are "inclinable to consumption.'' and
gives some excellent advice concerning the "cough
that paves the way to decay." "This. methinks. should
make all people, but especially those of weakly con-
stitution, exceedingly careful, that they sufl^er not a
cough to continue ; for it is a dangerous enem>' to
play with, and several — I speak it of my knowledge
— have greatly endangered their lives by neglecting
in the beginning an indisposition of such seeming
slight consequence" (10). He considered "a light,
thin, clear air, not too sharp." an easily digested diet,
and proper exercise, with '"a command of the pas-
sions." as the essentials in the treatment. Bleeding
was not favored, but "gentle vomits" w^ere advised
and "cheerful and innocent recreations" were
thought highly of. This treatment was augmented
by "a few of the most choice and generous medi-
cines." He prized the juice of turnips very greatly
after seeing improvement follow its use in a certain
case where "whole pailfuls of ass's milk and vipers'
broth" have been unavailing. As a "constant drink"
he recommended a preparation made from pure milk
and egg albumen. Dr. Robinson shared the popular
belief that the night air was harmful. In fact, he
thought that night was "more than a privation of
light, for it consists of particles (whatever they mav
be) that are capable of abating the air's spring''
(11), and in substantiation of this he quotes, "and
there was darkness in all the land of Egypt, even
darkness that might be felt." Exercise he recog-
nized as very important, but just wh}- it was neces-
sary he frankly states is "above his philosophy to de-
termine." yet he thought that its necessity occurred
coincident with the fall of man. "for they that will
not labor, that is, exercise, seldom have an appetite
to eat, or at least a true relish of the meats and
drinks they take for the support of nature" (12).
Some rather startling therapeutic measures were
advocated by one John \\'esley. M. A. (13). who in
the middle of the eighteenth century wrote a book
which "was intended more especially to aid the
clergy in meeting the frequent demands of their
flock in cases where physicians were not easilv ac-
cessible. The seeming ease with which he cured his
patients with the simplest of remedies must have
won for him great popularity :
One in a deep consumption was advised to drink
nothing but water and to eat nothing but watergruel.
without salt or sugar. In three months' time he was
perfectly well. Or. take a pint of skimmed milk, with
half a pint of small beer. Boil in this whey about
twenty ivy leaves and two or tliree sprigs of hyssop.
Drink over night half, the rest in the morning. Do this if
needful for two months daily. This has cured a desperate
740
STOLL: RETROSPECT IN PHTHLSIOTHERAPV.
[New York
Medical Journal.
case. Tried. Or, take a cowheel from the tripe house
ready dressed, two quarts of new milk, two ounces of isin-
glass, a quarter of a pound of sugar candy, and a tract of
ginger. Put all tliese in a pot, and set them in an oven
after the bread is drawn. Let it continue there till the
oven is near cold, and let the patient live on this. I have
known this to cure a deep consumption more than once.
Or, every morning cut up a little turf of fresh earth, and
lying down, breathe into the hole for a quarter of an hour.
Tried. Mr. Masters, of Eversham, was so far gone that he
could not stand alone. I ad\ ised him to lose six ounces of
blood each day for a fortnight, if lie lived so long, and
then every other day, for the same time. In three months
he was well.
The popular treatment at the beginning- of the
nineteenth century was the sd called "antiphlogistic,"'
which, as the name signifies, was directed against
the inflammation rather than its cause. To this end
emetics and cathartics were freely employed, bleeding
was performed, and the diet was meagre. The in-
troduction of bleeding- in the treatment of this dis-
ease is attributed to Dr. Dover, whose name has been
perpetuated by the well known "Dover's powder.'"
He recommended that it be performed at first daily
and in small amounts ; after the second week it was
to be done every second or third day for a consider-
able period of time. "Cases are on record in which
before the disease proved fatal, blood letting had
been performed upward of fifty times" (14).
The popularity of emetics is attested to by Rich-
ter (15), who tells of a woman aged forty years
Avho took 600 emetics in ten years! And Dr. Witt,
physician to the Infirmary of IBedford, said, concern-
ing the treatment of incipient cases, "When I have
been successful I have in my own n-iind attributed
these successes mainly to the unsparing and persever-
ing use of emetics" (-r^)). "Could phthisis ever be
cured," said Dr. I'arr, "it would be by the joint ac-
tion of emetics and blisters"' (17). These latter
were shifted hither and thither over the chest with
the idea of "preventing the tubercles from proceed-
ing to suppuration." Dr. Simmons, an Englishman,
extolled the hano de tierra, or earth bath. His pa-
tients would spend considerable time in pits which
had been freshly dug in the earth. The efficacy was
supposed to be due to "the antiseptic powers of the
exhalations from the earth," which were thought to
be absorbed by the body.
In 1787 an extraordinary plan of treatment was
published by Salvadori (18), who claimed to have
evolved the treatment by combining the methods of
Hippocrates, Bennett, and Sydenham. Discarding
medicine and all exactness of regimen, he directed
his patients to climb, in the morning, some high emi-
nence as (juickly as possible, till out of breath and
bathed in sweat. He then was to plnce himself near
a large fire in order to increase the perspiration.
.Afterward the linen was changed and the patient
gradually withdrew from the fire to partake freely
of salted meat and wine.
The demonstration of oxygen by Priestley about
the middle of the eighteenth century was followed
by an attempt to cure disease by this "vital air."
Other gases were discovered, and these two were
tried in the treatment of disease. Pearson, of Bir-
mingham, administered ether for the relief of con-
sumption in 1795 (19). Thomas Beddocs advocated
the inhalation of oxygen, hydrogen, and other gas in
the treatment of consumption, and in the latter part
of the eighteenth century he founded a medical pneu-
matic institution at Bristol for the treatment of this
disease (20).
While the treatment of tuberculosis was not ad-
vanced by this institution, it was here that Hum-
phry Dav}- began and carried on his notable re-
searches on nitrous ox:ide, and it was here that he
inhaled that gas while sufifering from a toothache,
and discovered, to his great delight, that it relieved
the pain. This led to his writing in 1800: "As
nitrous oxide in its extensive operation seems capa-
ble of destroying physical pain, it may be used with
advantage during surgical operations in which no
great efi^'usion of blood takes place" (21).
This same Thomas Beddoes was loud in his praise
of digitalis as a cure for consumption. "I daily see
many patients in pulmonary consumption," he says,
"advancing toward recovery with so firm a face that
I hope consumption will henceforward as regularly
be cured by the foxglove as ague by the peruvian
bark" (22). This worthy gentleman advocated one
of the most unusual of the numerous methods of
treatment. He believed that a steady warmth dimin-
ished one's chances of contracting the disease, and,
if already its victim, would bring about a cure. Dif-
ficulty seems to have been experienced in obtaining
what he describes as "an atmosphere permanently
modified, of a regular temperature, and at all times
likely to improve the conditions of pulmonary
ulcers." After trying many plans he tells us that
"residence in a cow house (as first recommended by
Bergins) (23) seemed by far the simplest, safest,
and least disagreeable." Strange as it may seem, the
public did not take altogether kindly to the idea, for
the doctor adds : "Nor is it without extreme regret
that I now look back upon the number of instances
in which my recommendations failed. Not infre-
quently did I forfeit the good opinion of my pa-
tients" (24).
The persuasion of the patient appears to have been
but half the battle, judging from the accoimt of the
trials of a certain Irish lady. This estimable person
"went to considerable expense in fitting up a cow-
apartment. But a mob of females who could by no
ineans bring themselves to fancy the scheme, having
unhappily got intelligence of the time when the cows
were to be driven through a certain passage, assem-
bled at its mouth and scared the animals so much
that their passionate owner, notwithstanding the ex-
travagant price for which he had bargained, refused
the patient their u.se on any terms." As the cows'
horns were apt to be noisy at night, young cows \vere
desirable, and the use of halters rather than chains
was advocated for a like reason. A patient of a Dr.
.Saififert, who employed this same treatment in
France, describes her experiences in a letter to a
friend as follows : "My bed was placed upon planks
about one foot from the ground. These planks were
purposely ill joined, that the vapors might penetrate,
and it was so strong that everything white which
was brought in became reddish in a very short time."
That she was a person of distinction is evinced by a
reference she makes to a visit from the Duchess of
Orleans, and by her stating that her physician for-
bade her playing on the harp because it cau.sed short-
ness of breath (25).
In one case, where, we may presume, Dr. Bed-
does's elocjuence was not sufficient to carry out the
April 1 8, 1.J08.J
STOLL: RETROSPECT /.Y PHTHISIOTHERAPY.
cow house treatment, he tells ns that "double doors
and double windows were added to a bedroom. The
fireplace was bricked up round the flue of a cast iron
stov" for giving out heated air." And. almost in-
credulously, we read that the poor patient lived near-
ly a year and a half. Dr. ]\lichael Peter descril^es
such a room as a place "hideously foetid
where both air and hope are alike forbidden to en-
ter" (26). The belief in the baneful effect of cjld
air was very generally shared by the physicians of
those days. Andrew Duncan, physician extraordi-
nary to the King, said that the consumptive should
"confine himself to the house dtiring the coldest
months in the winter and never allow the atmos-
phere of his room to be under 48° F.." and another
writer explains that "tubercles are evidently induced
and accelerated in winter and retarded in summer."
The treatment of Dr. Francis H. Ramadge ( 28 )
is of interest in connection with the inhalation mask
recently devised by Kohn (27), which, by obstruct-
ing inspiration, increases the negative pressure with-
in the thorax, causing air hyperjemia. Ramadge,
who was a pupil of Laennec. practised medicine
during the early part of the eighteenth century in
England. One of his patients, who was a consump-
tive, was attacked with a sw-elling above the sternum
and so situated that it made a great deal of pressure
on the trachea, "almost causing suffocation." At
the end of some weeks a marked improvement was
apparent in the pulmonic condition, and by the time
the swelling subsided, the consumptive appeared to
l3e cured. In another case he placed a silver band
about the patient's neck, to which was fastened an
ivory ball which pressed firmly against the trachea.
This case also showed improvement, and, acting on
this principle, he had constructed an inhalation tube
four feet long, whose calibre was manv times smaller
than that of the windpipe. Later he constructed a
tube with a valve, so that expiration took place
through a much smaller opening than inspiration.
Fitch (29) in this country was an ardent advocate
of this tube.
The prognosis of this malady at the beginning of
the nineteenth century was distinctly bad. Dr.
Young, of St. George's Hospital, saying: "It is
probable that without assistance not one case in a
thousand of the disease would recover, and, with the
utmost power of art, perhaps not more than one in a
hundred will be found curable" (30). "Follow
Laennec." said Dr. Davis. "I can give you no better
guide : but do not go straight to the work with him
and attempt to cure consumption. Stop short and
be warned by me — for I have enjoyed a liberal al-
lowance of failure — that it cannot be cured" (31).
Less than a hundred years ago an eminent divine
told Fitch that it was blasphemy to assert that the
disease was curable, "for God Himself had made it
incurable" (32).
There was. however, a smaller class of physicians
who maintained that the malady was amenable to
treatment, and, discarding the popular antipblo2:i?t'C
regime, thev strove to support the patient's strencjth
by tonics, fresh air. and a liberal amount of food.
"The stimulating plan of treatment," said Sir James
Clark, consulting physician to the king and queen
of the Belgians, and phvsician to the Duchess of
Kent and the Princess Mctoria. "I do not consider
deserving of mention" (33). One of the pioneers
to advocate this method was Benjamin Rush, who
practised in and about Philadelphia during the lat-
ter part of the eighteenth and the beginning of the
nineteenth centuries. Except for his use of the
lancet, he treated his patients along much the same
lines that we employ to-day (34). "It is vain," he
asserted, "to depend upon internal or external medi-
cines. The whole system must be strengthened or
we do nothing" (35). He was a firm believer in
exercise, but he urged that it be not prolonged tO'
the point of fatigue. He sums up the treatment in
lliis concise fashion: "If it were possible to gradu-
.ate the tone of the system by a scale, I would add
that, to cure consumption, the system sho.ild be
raised to the highest point of the scale" ( 36).
The first physician to advocate sleeping out —
which we are apt to fancy is quite a "new idea" —
appears to have been Nicholas Way. of Quaker ori-
gin, who was born about 1750 and graduated from
the University of Pennsylvania in 1771. He prac-
tised skilfully in Wilmington, Del., and took an act-
ive part in the yellow fever epidemic of 1793. Aftei
his removal to Philadelphia in 1796 he was appoint-
ed president of the mint.' Concerning him Rush
says: "Dr. Way, of Wilmington, informed me that
a certain Abner Cloud, who was reduced so low bv
a pulmonary consumption as to be beyond all relief
from medicine, was so much relieved bv sleeping in
the open air, and the usual toils of building a hut
and improving a farm, in the unsettled parts of a
new country in Pennsylvania, that he thought him
in a fair way to perfect recovery" (37).
In England, Andrew Stewart seems to have been
one of the first to see the fallacies in the popular
antiphlogistic treatment, and interwoven with his
practice is a very pretty romance. In 1796 he re-
ceived his license to preach from the University of
Edinburgh, and six years later his medical degree
from the same institution. It was while attending
the lecture of an eminent physician who was advo-
cating the antiphlogistic treatment that he first ques-
tioned its validity. "Why." he reasoned, "should an
entirely dift'erent method be adopted for treating
ulcers of the lungs than for ulcers on the surface of
the body?" His first charge was at East Lothian,
where he established a reputation for curing con-
sumption. In 1804 he was presented to the parish
of Bolton, Haddingtonshire, by Lord Bantyre. Now,
it so happened that his lordship had a daughter.
Margaret Stuart by name, who was a consumptive,
and it is possible that he had heard of this young
medical preacher who cured tuberculosis, and de-
sired that she be under his care. Be that as it may.
we know that she became a patient of Dr. Stew-
art's, and the good doctor cured her. So grateful
was she that she consented to become his wife, and
"they lived happily for many years afterward." The
only description we have of his method of treatment
is contained in a letter (38) written by one of his
patients. The writer first tells us that Dr. Stewart's
treatment was "founded upon everv principle of
common sense" ; that he "supported the constitution
and enabled it to throw oft' the disease by its own
rallying powers." and that, as "the climate cannot
"Through the kindness of Dr. John W. Jordan, of the Pennsyl-
\ania Historical Society, I was enabled to obtain the information
concerning Dr. Way.
742
STOLL: RETROSPECT IN PHTHISIOTHERAPV.
[New York
Medical Journal.
be brought to suit the constitution, therefore the
constitution must be hardened to bear the climate."
He favored rubbing the body with cold water and
vinegar, believing that it hardened one, and allowed
a liberal diet, though he did not favor the "cram-
ming method." "It is Dr. Stewart's urgent wish,"
the letter continues, "that the patients should be for
many hours daily in the open air — cautiously, how-
ever, avoiding fatigue — either on horseback, or on
foot, or in an open carriage, which last he relies
more upon as least likely to tire the patient." Can
one conceive of more sound advice ?
As might be predicted, such views aroused a storm
of protest. He was "keenly opposed by the leading
practitioners, both in Scotland and England." The
following, abstracted from the minutes of the meet-
ing of the Glasgow Medical and Chirurgical Society
of February 17, 1825, shows how bitter was the
feeling. A Mr. Campbell read a paper advocating
the tonic treatment, but the majority present favored
the antiphlogistic. "The society, in discussing this
subject, naturally adverted to the chief promulgator
of this practice — a medicoclerical gentleman of con-
sumptive notoriety — who, by means of nourishing
diet of the most substantial kind, with occasional use
of wine and ardent spirits, aided by cold and tepid
sponging, with as much exercise a:s the patient can
bear, has effected so many wonderful cures and ren-
dered his name famous over three kingdoms. If his
practice has been so strikingly successful, he ought
long ago to have sacrificed every feeling of personal
aggrandizement to the public good, and, by publish-
ing an account of his experiences, illuminated the
darkened intellect of his medical brethren, removed
those prejudices which -many of the best informed
entertain against it" (39).
\Mien we consider that Dr. Stewart was serving
in the dual capacity of physician and parson, we do
not wonder that he did not find the time to "publish
an account of his experiences."
Stewart died in 1838, and two years later George
Bodington, a country practitioner of Sutton Cold-
field, Warwickshire. England, read a paper before
a medical society which was entitled "The cure of
pulmonary consumption on principles natural, ra-
tional, and successful," in which he extolled the
value of fresh air, restricted exercise, and an abun-
dant diet. Although he made no reference to Stew-
art, it is more than probable that he had heard of
him, for, as we have seen, his name was "famous
over three kingdoms." Their views in the main
were in accord, although Bodington allowed seda-
tives, which Stewart withheld, while the latter fa-
vored the em])loyment of cold sponging and the use
of vinegar, which the younger man did not refer to.
Dr. Bodington established a sanatorium at Sutt' n,
and for several years he treated consumptives with
apparently considerable success. But the publicT-
tion of his paper proved his downfall, for so bitter
was the ridicule and so high did public opinion run
that his patients left, and Bodington turned his insti-
tution— the first of its kind in the world — into an
asylum for the insane (40). It would be of more
than ])assing interest to know how many of his med-
ical hrctlircn he subscr|uently had as patients.
Although Bodington was forced to close his s'lna-
torium, his efforts can scarcely be said to have re-
sulted in a complete failure, for a young German.
Herman Brehmer, was much impressed with the pa-
per and he determined to found a sanatorium in Ger-
many where the new treatment could be carried out.
He encountered stubborn resistance, but he tri-
umphed, and in 1854 established a magnificent sana-
torium at Gorbersdorf; And, as a result of Breh-
mer's success, we have sanatoria to-day all over the
world.
In Ireland Graves enjoined his patients not only
to walk and ride, but to sit out of doors quietly for
several hours each day, thereby inaugurating the
rest cure years before Dettweiler advocated it (41).
The importance of rest is at the present time quite
generally appreciated, and such exercises as moun-
tain climbing and horseback riding are only recom-
mended to those patients in whom all signs of activ-
ity have subsided. But the time was, a few years
ago, when the most common advice given to the
consumptive, irrespective of his condition, was "go
west and ride horseback." Sydenham was one of
the strongest advocates of horseback riding. "I sin-
cerely assert," he says, ''mercury in the French pox
and Jesuit's bark in ague are not more effectual than
the exercise above mentioned in curing consumption,
if the sick be careful and the sheets be well aired,
and that his journeys are long enough" (42). Stoll.
on the other hand, about the middle of the eighteenth
century, solemnly stated : "If a consumptive patient
mount his horse he will ride to the bank of the
Styx" (43).
The only son of Louis XV died of tuberculosis in
1765, and shortly after his death his wife developed
the same disease. Throughout the greater part of
her illness she was closely housed in the palace at
Versailles and treated along antiphlogistic lines.
When the malady had reached an advanced state
Tronchin, a pupil of Boerhaave, was called in, and
his substitution of a regime of fresh air and bounti-
ful diet brought about a temporary improvement in
her condition. But, the disease being far advanced,
she soon succumbed to it. Tronchin had made many
enemies by his radical change in the treatment, and
when his royal patient died he was called "the worst
of charlatans," and his treatment was designated as
being "as fantastic as murderous" (44).
This backward glance into the treatment of tuber-
culosis would be incomplete were no reference made
to the man who is the father of the sanatorium move-
ment in this country — Dr. Edward L. Trudeau.
r)roken in health, he went into the Adirondacks in
1874, and while "taking the cure" through the long
winter days he conceived the idea of a sanatorium
where those of limited means might regain their
health. The story of his struggles, his sore disap-
pointments, his perseverance, and at last his success,
is familiar to the profession. It is a tale of rare in-
terest, and therein is depicted a lifelong devotion to
a noble case that is rarely equaled.
References.
T. Duncan. Ohscrvatioiis on tlic Disliiiguisliing Symp-
toms of Three Different Species of Pulmonary Consump-
tion. 1816.
2. Rnsh. Medical fiiqiilrirs and Obscr'Lations, ii. p. 57.
.3. Huber. Consumption and Civilization, p. 44.
4. Fitch. Six Lessons on the Use of the Lungs, and
Causes. Pre-Yiition. and Cure of Consumption, p. 210. Also
R-imadge, op. cit.
April 1 8. ipcS.J
WOODBURY : URETHROTOMY.
743
5. Walsh. Bulletin of the Johns Hopkins Hospital,
-Kvii, No. 186, p. 301, September, 1906.
6. Robinson. A Nezv Method of Treating Consumption,
p. II.
7. Idem, op. cit., vol. 1, p. 109.
8. Idem, op. cit., p. 17.
9. Idem, op. cit., p. 17.
10. Idem, op. cit., p. 71.
11. Idem. op. cit., p. 188.
12. Idem. op. cit., p. 202.
13. Hill. Bulletin of the Johns Hopkins Hospital, xvii.
No. 186. p. 312. September, 1906.
14. Duncan, op. cit.
15. Clark. Treatise on Pulmonary Consumption, p. 258.
16. Idem. op. cit., p. 263.
17. Idem. op. cit., p. 257.
18. Salvadori. Dr/fr nim-bo tisico. Quoted by Young,
■on Consumption, p. 329. referred to by Morton in Illustra-
tions of Pulmonary Consumption, p. 144.
19. Anon. Aiia-sthctics. Ancient and Modern, p. 30.
20. Idem, op. cit.. p. 33.
21. Idem, op. cit., p. 33.
22. Beddoes. Observations on the Medical and Domes-
tic Management of the Consumptive, 1801.
23. Berzins. Neue scliwedische Abhandlungen, 1782,
part iii, p. 298. Referred to by Good. The Study of Med-
.icine, 1829, ii, p. 225.
24. Beddoes. op. cit.
25. Beddoes. op cit.
26. Hnber, op. cit., p. 132.
27. Meyer. Medical Record, Ixxii, No. 19, p. 757, 1907.
28. Ramadge. Consumption Curable, 1839.
29. Fitch, op. cit., p. 92.
30. Ramadge. op. cit., p. 34.
31. Idem., op. cit., p. 24.
32. Fitch, op. cit., p. 120.
33. Clark, >:jp. cit.. p. 397.
34. Stoll. Benjamin Rush as a Phthisiotherapist. Med-
dcal Record. ■
35. Rush, op. cit., ii. p. 43.
36. Idem, op. cit., u, p. 43.
37. Idem, o'p. cit., ii, p. 40.
38. Finlayson. British Medical Journal, 1905, i, p. 960;
Ibidem. 1899, i^ PP- ISI4, 1587. 1709: Ibidem, 1899, ii, p. 1435
39. Huber. op. cit., p. 281.
40. Walsh, op. cit.
41 Pechey. Works of Thomas Sydenham, 1740, p. 326.
42. Morton. Illustrations of Pulmonary Consumption,
1834, pp. 42 et. scq. Al-o Cnod, op. cit., ii, p. 223.
43. Shattuck. Bfst.'H Medical and Surgical Journal.
730 North C.\scapi£ Avenue.
EXTERNAL URETHROTOMY FOR ACUTE RETEN-
TION OF URINE CAUSED BY IMPACTION OF
A VESICAL CALCULUS IN THE PENILE
PORTION OF THE URETHRA.
By Frank T. WnoDBURY, M. D.,
Captain and Assistant Surgeon, U. S. Army,
Camp Jossman. Philippine Islands.
A. M. V,. of the Island of Guimaras. aged thirty-five,
presented i^iniielf at the Camp Hospital for treatment,
about 4 p. m. on October 27. 1907, complaining of having
had difficulty of urination, intermittent in character, for sev-
eral months. He stated that during the previous week it
had been almost impossible to pass urine, except by strain-
ing, and that he was suffering continually with an agony of
desire to evacuate his bladder.
At the time of the onset of this urgent symptom, he also
noticed a small, hard lump in the perinneum. which grad-
ually passed forward until w ithin two inches and a half of
the meatus, where it could tb.en be readily felt apparently
imbedded in the urethra.
Through n misunderstanding, he went to his home to get
some clean clothing, and did not return to the hospital until
the follow ing morning, when he appeared very weak, with a
cold, clanuny skin, a rapid pulse, and a facial expression of
acute suffering.
He was immediately placed upon the operating table.
After cleansing the parts, the urethra was flooded with nor-
mal salt solution, followed by an injection of four per cent,
solution of cocaine. Finally an injection was given of olive
oil. An attempt to dilate the urethra with sounds and to
deliver the calculus by external expression failed ; as did
also attempts to withdraw or crush it by means of long
armed nasal forceps introduced through the meatus.
The patient was given ether, and when fully anaesthet-
ized, a medium external urethrotomy was made directly
over the foreign body. The stone was very irregular and
jagged in shape, and was firmly imbedded in the urethral
mucosa, forming a pouch from which it was extracted,
piecemeal only, by much force and manipulation. Several
smaller granules were found more deeply imbedded, and
were also removed.
The wound was irrigated freely with hcl nor-
mal salt soltttion, and a metal catheter was then
passed through the meatus into the bladder, whicii
had in the meantime emptied itself throitgh the
wound. Using the catheter as a sound, it was im-
possible to detect other calculi in the bladder. The
urethra was closed over the catheter by two fine
silk sutures, prepared in the tmcture of iodine.
The outside wound, which passed partly through
the rhaphe of the scrotttm, was packed with gauze,
soaked in alcohol, and a large gauze and cotton
pad was applied.
Hexamethylenamine (urotropin), 65 centi-
grammes, was administered four times a day for
a week. Magnesium sulphate was given several
times to keep the bowels open. A light diet was
maintained. The temperature was very irregular,
being between normal and 101° F. for three days,
when it finally became normal. The urine escaped
in part through the wound until the eighth day.
The presence of the catheter caused, at first, fre-
quent emptying of the bladder. The fragments of
the stone were very sharp, irregular, and were
found to be phosphatic in character. Its full size,
when impacted in the urethra, was about that of a
very small hazel nut.
The patient made a stead\- and rapid recovery.
The metal catheter was replaced by a soft rubber
one, on November loth, and the patient was dis-
charged well on November 22d.
A CASE OF MULTIPLE TAPEWORM INFECTION.
By R. L. Wilsox. M. D.,
New Orleans, La.,
Passed Assistant Surgeon, United .Stat&s Public llealtli and Marine
Hospital Service.
Patient, male, age thirty-nine, was admitted to the United
States Marine Hospital, New Orleans, La., December 26,
1907, suffering with pain in the right side of chest. There
was no rise of temperature.
December 28. Pain in side improving. No fever. Pa-
tient said he had had tapeworms for some time, having
passed segments by rectum. He lived in the eastern part
of Germany until 1905. Frequently ate fish from fresh
water lakes. First noticed segments of worms in 1903.
These would always be in chains one foot or more in
length. The separated segments were not noticed. Appetite
had been poor at times, uncomfortable feeling in abdomen
with digestive disturbance was frequent. He had been
ofteii restless at night. The passage of parts of worm hud
continued to the present. Physical condition was fair. No
noticeable an?emia.
December 29. Light supper and thirty grammes mag
nesium sulpli;ite. No breakfast for the next day.
December 30. Eight cubic centimetres oleoresin male
fern in emulsion at 11 a. m. : forty grammes magnesium
sulphate at I p. m., patient not taking dinner. Patient to
744
WILSON: MULTIPLE TAPEWORM INFECTION. -THERAPEUTIC AL NOTES. C^ew York
Medical Journal.
defaecate into a vessel containing water at about body tem-
perature. At 3 p. m. a large mass of worms passed.
December 31. Examination showed thirteen heads and
319 measured feet of worms. Dibothriocephalus latus. On
account of the tangle in the worm mass and its having
been immersed in water for several hours, no individual
worm could be extricated complete. The longest unbroken
length was seventeen feet.
January 2, 1908. Patient eating, sleeping, and feeling
much belter. Discharged, recovered.
The identification of the worms was based on the
appearance of the heads, the size and shape of seg-
ments, the rosette uterus, and the appearance of the
eggs. This finding has been corroborated by the
pathological laboratory of the medical department,
University of Texas, where specimens were depos-
ited.
United St.\tes M.^rine Hospital.
Intramuscular Injections in Syphilis. — After a
trial of the soluble salts of mercury, J Ernest Lane
{The British Medical Journal, March 21, 1908) has
abandoned them for the insoluble preparations,
using almost exclusively calomel. The dosage of
the calomel is % grain of the sublimed powder sus-
pended in 17 minims of sterilized olive oil, each in-
jection being prepared separately and introduced
into minute flasks hermetically sealed. The deposit
of calomel seen in the small flasks at once disappears
on heating them over a spirit lamp, when the pow-
der assumes a milky appearance, and the powder is
in a state of perfect siispension. He has also used
gray oil, a term applied to a large number of prep-
arations of different strengths and compositions, but
consisting essentially of metallic mercury suspended
in some fatty vehicle. He gives the following as
the formula of a preparation which is employed by
the army medical stafi^ :
R Mercury ^i ;
Wool fat, 3iv;
Liquid petrolatum (carbolized 2 per cent.), . ..ad
M.
One grain of metallic mercury is contained in 10
minims, and a suitable weekly dose for an adult is
from 10 to 15 minims.
The Purification of Drinking Water. — Simple
methods for the rapid purification of potable water
continue to be published. French chemists have de-
voted much attention to the subject, and various
means have been suggested of sterilizing the water
of the Seine, which is greatly contaminated, being
notable for the number of bacteria which it contains.
Mention has been made in this column previously of
a simple method, consisting of the addition to each
quart of water of one grain of potassium perman-
ganate, followed, after standing ten minutes, by the
addition of two grains of manganous sulphate,
which has the effect of precipitating all germs and
impurities to the bottom of the vessel. Water treat-
ed in this way is freed from microbes and forms a
limpid, colorless fluid of pleasant taste, which is
richer in oxygen than ordinary water. A more effi-
cient method of treating suspected water is described
by M. Celestin Hy in the Union pharmaceutique.
The process is based upon the fact that potassium'
permanganate in an alkaline solution oxidizes or-
ganic matter and destroys microorganisms, just as
in the preceding formula. The method is based
on that originally devised by M. Girard and
M. Bordas. The water to be purified is first treated
with a powder consisting of one equivalent of potas-
sium permanganate and sodium carbonate and
slaked lime, of each seven equivalents. After an
interval of five minutes eight equivalents of dried
ferrous sulphate are added. Any calcium sulphate
that may exist naturally in the water is precipitated
by the sodium carbonate, while calcium bicarbonate
is thrown down by the calcium hydroxide, the addi-
tion of ferrous sulphate removing any excess of
permanganate in the form of a dense precipitate.
Carefully decanted water treated in this way is said
to be very pure and limpid and to contain a small
amount only of the sulphates of potassium and so-
dium, the presence of which is not at all objection-
able.
lodotannin Mixture for Tuberculosis. — The fol-
lowing mixture is credited to Arthaud in Journal dc
mcdcciiic dc Paris for February 22, 1908:
R Tincture of iodine, .' 5i ;
Tannic acid, 5vi ;
Glycerin, 5v ;
Alcohol, 5x.
M. Sig. ; One teaspoon ful three times a dty.
Application for Neuralgic Headache and Inter-
costal Neuralgia. — An application used by Solis-
Cohen, and which he has found of special value in
neuralgic headache and intercostal neuralgia, is
quoted by the Journal of the American Medical As-
sociation from Merck's Archives, as follows:
R Oil of wintergreen,
Guaiacol, aa iik xv ;
Menthol, gr- x ;
Hydrated wool fat.
Cerate, aa 5ii.
M. (Dispense in a tin tube.)
Sig. : A small quantity, about the size of a pea, to be well
rubbed in over the seat of pain night and morning.
Tonic Mixture for Phthisical Patients. — To in-
crease the appetite, control the fever, and overcome
the cachexia, it is recommended in Therapentische
Rundschau, for March 29, 1908, to administer the
following mixture :
R Quinine hydrochloride, 5ss ;
Calcium hypophosphite, 5i ;
Tincture of nux vomica, 3iiss;
Glycerin, 3ii ;
Distilled water q. s. ad 5xvi.
M. Sig. : Two tablespoonfuls three times a day. half an
hour before meals.
The Administration of Calcium Lactate. — Ac-
cording to The Prescribcr, this salt should not be
prescribed as powders or tablets, since, though solu-
ble in water when freshly prepared, it rapidly be-
comes insoluble. The best method of administra-
tion is in solution as follows :
R Precipitated calcium carbonate 31;
Lactic acid cxxx ;
Water, enough to make 5vi.
Solve. One tablespoonful contains fifteen grains of cal-
cium lactate.
April i8, 1908.1
EDITORIAL.
ARTICLES.
745
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Revieii' of Medicine.
Edited by
FRANK P. FOSTER, .M. D.,
and SMITH ELY JELLIfFE, M. D.
Addicsa all business eonimiinicalions to
A. R. ELLIOTT PVBLISHIXG COMPAXY.
Publishers,
66 West Broadway, AVtc York.
Philadelphia Office : Chicago Office :
3713 Walnut Street. 160 \^ashlngton Street.
SuBscKirTiON Price :
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%~ ; single copies, fifteen cents.
Remittances should he made by New York Exchange or post
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llshing Co., or by registered mail, as the publishers are not
responsible for money sent by unregistered mail.
Entered .it the Post Office at New York and admitted for
transportation through the mail as second class matter.
NEW YORK, SATURDAY, APRIL 18, 1908.
A PROPOSED INCRE.ASE IN THE RANK
AND PAY OF OFFICERS OF THE
ARMY MEDICAL DEPARTMENT.
We print in our Miscellany department the text
of a measure providing for the reorganization of
the Medical Department of the United States
Army which has been approved by a conference
committee of the two houses of Congress, and
which it therefore seems reasonable to suppose will
become a law. The measure has been before two
sessions of Congress, and was passed by the Sen-
ate at a previous session. The main features of
the bill are an increase in the number of medical
officers and the provision for a medical reserve
corps. The bill is eminently conservative, and was
evidently drawn with a careful view to avoidance
of arousing antagonism by the introduction of
radical changes.
Another measure now before Congress which is
of material concern to the medical officers of the
Army and likewise of the National Guard is the
Army pay bill, which provides for an increase in
the rate of pay, both for enlisted men and for of-
ficers. This measure is also in the hands of a con-
ference committee, and, as the principal difference
between the bills passed by the Senate and by the
House is in the form in which the increase of pay
of the officers is stated, it seems reasonable to hope
that the conference committee will come to an
'agreement, and that the bill as agreed on in con-
ference will become a law. The Senate measure
provides that the present pay of officers of the Army
shall be increased as follows : "Of brigadier gen-
erals, 15 per centum; of colonels, lieutenant
colonels, and majors, 20 per centum; of captains,
first lieutenants, and second lieutenants, 25 per
centum." The measure passed in the House of
Representatives, known as the Nelson Amend-
ment, has the advantage that it disposes of the
controversy over mounted and dismounted pay,
giving in each case the actual amount of pay to be
given to the officer in each particular grade, in-
stead of stating this by means of a percentage in-
crease. In most of the grades named the pay pro-
vided is the same in both bills, and where any dif-
ference exists the difference is small.
It is much to be hoped that both the pay bill and
the reorganization bill will become laws, as it may
then become possible to secure something like an
adequate number of medical officers for the Army.
Even had the reorganization bill passed, we doubt
whether it would have been possible to secure as
many medical officers as are provided for in that
measure without some increase in the rate of pay,
and this increase is provided in the Army pay bill,
which thus becomes a very important factor in the
contemplated reorganization of the Medical De-
partment. The combination of an increase in the
number of commissions in the higher grades in the
department, which is provided for in the reorgani-
zation bill, and of an increase in the pay of officers
of all ranks, provided for in the Army pay meas-
ure, may prove sufficiently attractive to induce the
right kind of men to enter the service in sufficient
numbers to meet the requirements of the Army.
THE FRENCH SPEAKING PHYSICIANS
OF NORTH AMERICA.
We long ago expressed our satisfaction at the
establishment of the Association des medecins de
langne francaise de I'Ameriqne dn Nord. It is an
organization that has a very legitimate place, and
we are sure that it is doing good work. It is to be
supposed that the French language is more exten-
sively employed in the ordinary affairs of life in the
Province of Quebec than elsewhere in North
America, and in Quebec there are published sev-
eral ven,- creditable medical journals printed in
French. The tercentennial of the founding of the
city of Quebec is to be marked by a series of fes-
tivals beginning on the 20th of July. It is fitting,
therefore, that the association is to hold its meet-
ing at the same time in that old and picturesque
city. The sessions will be held in the buildings of
Laval University on the 20th, 21st, and 22d of the
month mentioned.
746
EDITORIAL ARTICLES.
[New York
Medical Journal.
There is a goodly number of French physicians
in the United States — French by descent if not by
birth — and they are among the most respected of our
profession. Many of them will doubtless deem it
almost a pious duty to betake themselves to Quebec
on the occasion of the celebration, and not a few
of our physicians who are not of the French race
are sure to be attracted to the romantic city at the
.same tnne. Those of us who have ever visited
Quebec preserve the memory of the geniality of our
confreres resident in that region, and we always
feel tempted to renew our acquaintance with them.
It is not mere fondness for sight seeing that draws
so many American visitors to Quebec ; it is a gen-
uine interest in the affairs of the people of the
province and sympathy in their aspirations. All
these things taken into consideration, we cannot
doubt that the association's meeting this year will
be a notable event.
XEW YORK'S TRIBUTE TO
ROBERT KOCH.
It is granted but seldom to a man to "read his
history in a nation's eyes." Too often those who
have given their lives in some work of humanity
have known only a few friendly words among the
jibes of many, and it has been reserved for another
generation to honor their tombs. Again, those
who have won the acclamation of the crowd, rid-
ing victorious from the fields of battle, have been
followed by the lamentations of the conquered, the
requiem of the slain. We can conceive of no honor
greater or more soul satisfying than that which
was brought to Dr. Robert Koch at this first public
appearance in New York, though under the con-
ventional tribute of a dinner given by the German
Medical Society. From the head of the German
nation and the leader of American industry, down
to the humblest laborer who had suffered and been
saved by some one of the 500 physicians present,
there was a tribute of more than admiration, some-
thing very like worship, for the modest man of
genius.
The abstract scientist, who follows the call of in-
quiry, is led into fascinating by paths, that may
or may not lead to practical results. But Dr. Koch
has had the genius of a philanthropist as well as
a scientist. He has applied himself to the scourges
of man and of animals that man depends upon.
Humanity recognizes vaguely the value of thought,
but thought that begets action, science that cul-
minates in deeds — this they know to be the flower
of civilization.
As Dr. Koch himself said, in answer to the
words of praise and thanks that made the tribute
of our nation as represented by its physicians, he
has never done anything more than all the doctors
present were doing every day. He did his duty,
they did theirs. That was all there was to it. And
yet all the doctors present, cheering him, in their
hearts knew the general who had led them, knew
better far than the masses who have been brought
back to health the infinite patience and courage
necessary to surmount the difficulties that stand
between a scientific discovery and its practical ap-
plication. The appreciation of the scope of Dr.
Koch's work, as shown in the speeches of such
men as Dr. Welch, who studied under Cohnheim
in the early days when Dr. Koch was working upon
his germ theory, and of Dr. Jacobi, brought out the
facts that Dr. Koch had shown the mind of a
genius in his youth, and had unswervingly devoted
this genius to science on behalf of civilization. He
has had a heaven born quality that is not always
combined with genius, that of inspiring other men
to work with him. Many of the most distinguished
bacteriologists of our country have been students
of Dr. Koch's in bacteriology, and there is not a
laboratory the world over that does not owe some
of its enthusiasm and power to men who have been
guided by him.
From the days of miracles, how few the years,
how great the progress ! When plagues raged, a
pilgrimage with a saint's relics at its head marched
to a shrine, sowing disease through the country as
it went. To-day, holy men — for the primitive
form of the word holy meant bringing health,
safety, happiness — men consecrated to a life of
work, withdraw from the diversions and gratifica-
tions of life, and after years of labor, endeavoring
to penetrate the mystery, their high priest steps
forth, and reads a riddle of the ages, not in
oracular words, but in the plain language of the
people. In the emotional period of civilization's
development, the masses would have rushed forth
with hozannas, to greet the savior who healed
them. None the less are they now saved, and none
the less are they grateful, though to the high
priest of science in this more moderate age no fur-
ther demonstration is made than the hearty hand
clasp and the word of thanks from the men who
know.
NEW ENGLAND AND THE SOUTH
SHOULDER TO SHOULDER.
The president of the Society for the Protection
of New Hampshire Forests, in a communication
which he has had the courtesy to send us. asks us
to help in securing national legislation for the
preservation of some of our forests by calling at-
April i8, 1908.]
EDirORIAL ARTICLES.
7-\7
tention to the apparent unwillingness of Congress
to act upon House bill No. 10457, entitled the
White Mountain and Appalachian Forest Reserve
Bill. He incloses a circular addressed to the mem-
bers of Congress from the New England States,
signed by the representatives of twelve great manu-
facturing concerns having their headquarters in or
near Boston, in which we find this passage : "We
beg to say that we believe the future welfare and
prosperity of the eastern part of the United States,
and especially of New England, to be dependent
upon the adoption of the policy set forth in this
bill, and that, if such policy is not adopted now, it
will be necessary to adopt it at a future time and at
vastly increased expense, and that in the mean time
great injury will be done New England."
President Rollins reminds us that the bill has
been endorsed by the entire country, and been
urged for five years by lumbermen, paper makers,
farmers, business men, and the press. He adds
that at a recent hearing before the present Commit-
tee on Agriculture the governors of Georgia and
New Hampshire, together with official delegates
from the governors of twelve other States and a
group of two hundred business men and citizens
from all but four of the States that lie east of the
Mississippi River, presented evidence that the tim-
ber supply was disappearing, that water powers
were affected, that navigation was crippled, and
that agriculture in the low lands, particularly in the
South, was in many cases being ruined by floods.
"When," say^ Mr. Rollins, "six New England
States, and eight Southern States unite in asking
prompt action by Congress, do the men who guide
that body propose to turn the matter calmly down?
What do the . representatives from the South and
from New England intend to do about it?"
We believe that Mr. Rollins is ^juite warranted
in using this strong language. W^e have always
advocated legislative measures for the protection
of our forests, and we now again adjure Congress
not to disregard further the necessity of enacting
House bill No. 10457. The sanitary advantages of
the primaeval forest are appreciated by the medical
profession, and its necessity to great industrial en-
terprises is clearly understood. We cannot con-
ceive of any good reason that can be entertained by
Congress or its committees for standing in the way
of such conservative and beneficent measures as
this one for which the people of New England and
the South are urgent. It is easy to destroy a for-
est, but it is a difficult and protracted task to re-
store one. Let not Congress delude itself with the
notion that the advocates of the bill are actuated
solely or even chiefly by aesthetic considerations,
powerful as such considerations are and ought to
be. The reasons which impel them are practical
and vital. Surely Congress should not adjourn
without enacting the bill.
THE SIGNIFICANCE OF INTRACELLULAR
TUBERCLE BACILLI IN THE SPUTUM.
Since the publication of Lowenstein's observations
on the occurrence of tubercle bacilli in the pus cells
of certain specimens of sputum {Zeitschrift fiir
Tuberkiilose, x, p. 47), this phenomenon has been
generally regarded as a sign of favorable prognostic
portent, as it was supposed to indicate phagocytic
activity. A recent report by Pfeififer and Adler
{Zeitschrift filr Tuberkulosc , xii, p. 89). however,
tends to discredit this supposition. In an examina-
tion of 844 specimens of sputum these authors
found intracellular bacilli in forty-eight, from forty
patients. The great majority of these patients were
jn an advanced stage of the disease, thirty-two pre-
senting evidences of cavity formation, and in most
of them the disease progressed rapidly to a fatal
issue. All the sputa in which were found intra-
cellular bacteria contained very numerous extra-
cellular organisms, and Pfeifter and Adler came to
the conclusion that no more could be inferred from
the presence of tubercle bacilli within the pus cells
than from a great abundance of these organisms in
the sputum.
THE OCULAR SYMPTOMS OF SCLERO- .
DERMIA.
Observations of abnormities of the muscles of
the eye associated with generalized sclerodermia
seem to have been recorded in but few instances,
for M. Raymond and i\I. Guillain (Bulletins et
memoires de la Societc medicale des hopitaux de
Paris, March 12th) declare that they have found
paretic eye symptoms mentioned by Logetchnikov
alone among recent dermatological writers. They
themselves have observed two instances. They de-
scribe the paresis (sometimes amounting to absolute
paralysis) as aflfecting the extrinsic muscles of the
eye indiscriminately, but as being most decided in
the external recti. EflForts to move the eyeballs are
apt to be associated with oscillatory movements re-
sembling those of nystagmus.
It is well known, the authors remark, that mus-
cles are prone to become paretic as the result of
sclerodermia, and it is not those muscles alone that
underlie the sclerotic skin, but .others also that are
situated at some distance. The fault, they think, is
in the muscles themselves rather than in the cen-
tral nervous system. The paresis has been observed
to disappear in cases of recovery from the sclero-
dermia.
748
A DINNER TO DR. ROBERT KOCH.
I New Vork
iMEDicAL Journal.
A DINNER TO DR. ROBERT KOCH.
Robert Koch received a rousing welcome at a
banquet arranged in his honor by the Deutsche
medizinsche Gesellschaft der Stadt New York at
the Waldorf-Astoria on Saturday evening, April
II, 1908. Dr. Carl Beck, as president of the Ger-
man Medical Society, presided at the dinner, in
which about 450 admirers of the German savant
took part. On the right of the guest of honor sat
Mr. Andrew Carnegie.
Robert Koch's career is too well known to be
mentioned in detail. Born at Clausthal on Decem-
ber II, 1843, he received the usual medical educa-
tion, and was county physician at Wollstein from
1872 to 1880. In his little town, removed from all
the centres of medical science, he became interested
in bacteriological studies, and discovered the
anthrax bacillus in 1876. Thus, without a uni-
versity career, he became soon a prominent figure
in the medical profession. In 1880 he was called
to Berlin as a member of the Imperial Department
of Health. Two years later he published his dis-
covery of the tubercle
bacillus, and in 1883
that of the com m a
bacillus, while he was
chairman of the German
Cholera Commission in
Egypt. At the same
time he found also the
bacillus of Egyptian tra-
choma. In 1885 he was
appointed professor and
director of the Hygienic
Institution at the Uni-
versity of Berlin, and in
" 1891 director of the In-
stitution for Infectious
Diseases. In the same
year he published his
first report on tuber-
culin. In i8g6 the Cape
Colony called him to
southern Africa, where
the rinderpest was
threatening to destroy
the cattle. He de-
vised a virus suitable
for protective inocu-
lation. From there he
nung, die Sie mir zu Teil
werden lassen, in Betracht
ziehe, so entsteht in mir
das Bedenken, ob ich auch
wirklich berechtigt bin, mich
so feiern zu lassen. Manches
von dem, was mir Riihm-
liches nachgesagt wird, kann
ich, wie ich glaube, mit
gutem Gewissen accep-
tieren. Aber ich habe nichts
Anderes gethan, als was Sie
jeden Tag thun, namlich
ich habe gearbeitet was ich
konnte, und meine Pflicht
und Schuldigkeit gethan.
Wenn etwas mehr dabei
herausgekommen ist, so
liegt das daran, dass ich auf
meinen Wanderungen
durch das medizinische Ge-
biet auf Strecken stiess, wo
das Gold noch auf dem Wege
liegt. Es gehort allerdings
Gluck dazu, das Gold von
dem Unedlen scheiden zu
konnen, das ist aber kein
besonderer Verdienst.
great distinction conferred
by you upon me, I must
necessarily ask myself, Am
I really entitled to such
homage? I believe that I
can accept, indeed, with a
clear conscience many of
the laudatory things said
about me. But I have done
nothing else than what you
are doing every day. I have
worked as hard as I could
and have fulfilled my duty
and obligation. If the success
really was greater than is
usually the case, the reason
for it is to be found in the
circumstance that I came in
my wanderings through the
medical field upon regions
where the gold was still
lying by the wayside. For-
tune is necessary to be able
to distinguish gold from the
base metals, but that is no
great merit.
DR. ROBERT KOCH
went to Bombay to in
vestigate the plague, and again to Africa, study-
ing the cattle plague in German East Africa. He
also began there his researches on malaria,
which he continued in Italy, the Dutch East Indies,
and New Guinea. Returning to Berlin, he took up
the typhoid fever question, and was called back to
Africa in 1903, and again in 1906, to study the
sleeping sickness, which he definitely attributed to
a trypanosoma. From that expedition he returned
only a short time ago. He is now enjoying a long
deserved rest, making a tour around the world.
Such are the labors of Robert Koch ! Modestly he
said in his speech at the dinner :
Wenn ich Alles zusam- Were I to review every-
menfasse, was zu meinem thing that has been said to-
Lobe heute gesagt worden day in my praise, and also to
ist, und die grosse Auszeich- take into consideration the
But to come back to
the banquet. Professor
Beck, as president,
speaking in German,
introduced Professor
Koch. Among other
things he said: "What
your achievements in
science have been, men
who are capable of
judging will tell us to-
night. It will not be an
easy undertaking, for
what you have accom-
plished will hardly find
its equal in medical
history. With admira-
tion and deep wonder
we ask ourselves : How
could one human brain
succeed in creating so
much? We stand be-
fore a building firmly
erected and resting
upon a soHd founda-
tion, an immense mon-
ument in its simplicity
and greatness, so similar to your own character.
The tempest of time will sweep over it and may
leave here and there superficial scars, but
its foundation is unassailable, and will never be
shaken." . . .
A "hoch" to Professor Koch concluded the chair-
man's address, and he then introduced Professor
W. H. Welch, of Baltimore, who spoke of Koch as
investigator and teacher. "His work," he said, "is
a combination of discovery for science and comfort
for mankind. While Dr. Koch has always shown
the stamp of a scientist in his work, he has never
allowed his view to wander from what would be
most practical for the benefit of men. His work has
been a triumph for the experimental method in sci-
ence. . . ."
Dr. Beck then read a letter of regret from Dr.
April i8, 1908.]
NEWS ITEMS.
749
Trudeau, and upon motion of Dr. Koch, seconded
by Mr. Carnegie, a telegram was sent to Dr. Tru-
deau.
Professor Abraham Jacobi was the next speaker.
''The nineteenth century," he said, "gave to medi-
cine four epoch making men — Bichat, Virchow, Pas-
teur, and Koch ; three for its clinical department :
Virchow, Pasteur, and Koch ; two for the modern
knowledge of serum theory and prophylaxis: Pas-
teur and Koch. . . . We have the honor of hav-
ing with us the only survivor of these four great
men. . . ."
Professor Beck then read a letter from the German
Ambassador in Washington to Andrew Carnegie,
who was the next speaker. Mr. Carnegie said : "In
viewing the progress of the world in its various
phases, no profession has made and is making
greater progress to-day than the art of healing.
. . . In the list of the heroes of civilization our
honored guest occupies a high position. The world
has always been devoted to hero worship, ever prone
to worship physical force as displayed in its heroes.
These heroes, from the days of Homer, have been
men who had become celebrated for the number of
their fellow men they had butchered. . . . Our
true hero of to-day is he who can count the number
of men, women, and children he has saved. Jenner,
Lister, Pasteur, Reid, Carroll, Lazear, Agramonte,
and Koch are such heroes. . . ."
. The last speaker of the evening was the guest of
honor. His speech culminated in the following very
interesting remark: "We have achieved all we
could in our fight against tuberculosis. We have
come to a point where we can hardly hope for more
success. The idea of building sanatoria will not ac-
complish much ; such sanatoria will only benefit cer-
tain localities. We must make new researches. Such
researches will become possible in the Robert Koch
Institute for Tuberculosis in Berlin, a foundation
which Andrew Carnegie has so munificently en-
dowed. In this institution investigations will be
made which will open new fields, new theories, new
modes and possibilities of fighting the old enemy,
tuberculosis. It will be an international aft'air, bene-
fiting all mankind. And we have to thank ^Nlr. Car-
negie for placing this institution upon a sound finan-
cial basis. Herr Carnegie lebe hoch!"
Professor Beck then closed the proceedings by
proposing the health of Mrs. Koch, who had accom-
panied her illustrious husband to Africa, and is now
with him on his trip around the world.
The company included between four and five hun-
dred persons, of whom the following had been as-
signed to seats at the main table :
Professor Dr. Rodert Koch, Excellenz, Berlin, guest
of honor, •
The President, Dr. Carl Beck.
Dr. J. George Adami, Montreal ; Dr. Isaac Adler ; Dr. Her-
mann M. Biggs ; Mr. George Blumenthal ; Dr. Vincent Y.
Bowditch. of Boston ; Consul General Biinz ; Professor J.
W. Burgess : Mr. Andrew Carnegie ; Dr. Thomas Darling-
ton; Dr. Francis Delafield : Dr. Simon Flexner ; Dr. Law-
rence F. Flick, Philadelphia; Dr. Frank P. Foster; Dr.
William S. Halsted, Baltimore; Mr. R. W. Hebberd ; Dr.
Abraham Jacol^i ; Dr. Edward G. Janeway ; Dr. Howard A.
Kelly, Baltimore ; Dr. S. Adolphus Knopf ; Geheimrat A.
Martin, Berlin; Dr. Alfred Meyer; Mr. Henrv Phipps,
Philadelphia ; Dr. William M. Polk ; Dr. Eugene H. Porter,
.\lbany ; Dr. Theobald Smith, Boston : General George M.
Sternberg, of the Army; Dr. Victor C. Vaughan, Ann Ar-
bor, Mich.; Dr. Leonard Weber; Dr. William H. Welch,
Baltimore ; Dr. John A. Wyeth ; General Walter Wyman,
of the Public Health and Marine Hospital Service. ^
^tias |Ums.
Changes of Address. — Dr. S. A. Bienenstock, to 1542
Madison avenue, New York; Dr. J. E. Cannaday, from
Wheeling, W. Va., to 1012 Virginia street, Charleston,
W. Va.
Medical Society of New Jersey. — The annual meeting
of this society will be held in Cape May on June i8th, 19th,
and 20th, instead of June 2^^d, 24th, and 2Sth, as originally
announced.
Society of Physicians of the Village of Canandaigua,
N. Y. — At a meeting of this society which was held on
Thursday evening, April 9th. Dr. H. I. Davenport read a
paper entitled Pathological Physiology.
Richmond, Va., Academy of Medicine and Surgery. —
At a regular meeting, held on Tuesday evening, April 14th,
Dr. Karl von Ruck, of .\sheville. N. C, read a paper en-
titled General and Specific Resistance to Tuberculous
Infection.
The Middlesex County, Conn., Medical Association
held its annual meeting on Thursday, April 9th, and elected
the following officers for the ensuing year: President, Dr.
James Murphv ; vice oresident, Dr. M. D. Murphy ; clerk.
Dr. Arthur B' Coleburn.
Hudson County, N. J., Medical Society. — At the an-
nual meeting of the society, which was held recently, the
following officers were elected for the ensuing year: Presi-
dent, Dr. John J. ]Mooney ; vice president, Dr. Arthur Ras-
kins ; treasurer. Dr. H. Brinkerhoff.
Emanuel County, Ga., Medical Association. — At the
annual meeting of this association, which was held in
Swainsboro on April 8th. the following officers were
elected: President, Dr. J. W. Bowie, of Summit; secretary
and treasurer. Dr. J. H. Chandler, of Swainsboro.
The Society of Medical Jurisprudence, New York. —
At a meeting of this society, held on Monday evening.
.\pril 13th, Dr. Daniel Lewis, former Commissioner of
Health of the Slate of New York, delivered an address on
The Sanitary Protection of New York Bay.
Buffalo, N. Y., Academy of Medicine. — A meeting of
the Section in Medicine was held on Tuesday evening,
.\pril 14th. Dr. John D. Bonnar read a paper on Apo-
plexy, and Dr. Julius Ullman read a paper on Psycho-
therapy. Dr. James W. Putnam, of Boston, opened the
discussion.
The Philadelphia Medical Club held its regular quar-
terly reception on the evening of April loth. Dr. Samuel G.
Dixon, Commissioner of Health for the State of Pennsyl-
vania, and Dr. Louis G. Pilcher, of New York, were the
guests of honor. About three hundred members were in
attendance.
The Pennsylvania Society for the Prevention of
Tuberculosis held its annual meeting on Wednesday.
April 8th. Dr. Charles J. Hatfield was elected president of
the society, Dr. James M. .Anders, first vice president, and
Dr. Ward Brinton. ^ecretarv. During the year contribu-
tions amounting to $4,595.86 were received.
The Harvey Society Lectures.— The ninth lecture in
the Harvey Society course >\ ill be given at the New York
.Academy of Medicine on Saturday evening, April i8th, at
8 130 o'clock, by Professor Alonzo E. Taylor, of the Uni-
versity of Califoriiia. The subject will be The Role of
Reversed Ferment Reactions in Metabolism.
Windham County, Conn., Medical Association.— The
one hundred and fifteenth annual meeting of this society
will be held in Putnam. Conn., on Thursday, April 23d, at
II o'clock. The programme includes the following papers:
Diagnosis of Impetigo Contagiosa, by Dr. J. L. Gardner,
of Central Village; an address on Bacteriology', by Pro-
fessor H. W. Conn., of Middletown University ; The
Present State of Stomach Surgery, with Special Reference
to Gastric and Duodenal Ulcer, by Dr. John B. Boucher,
of Hartford. The officers of the society are : President,
Dr. C. J. Le Claire, of Danielson ; vice president, Dr. Rob-
ert C. Paine, of Thompson ; secretary. Dr. James L. Gard-
ner, of Central Village.
NEl^yS ITEMS.
Rochester, N. Y., Academy of Medicine.— The regular
monthly meeting of Section III, which embraces obstetrics,
gyn.Tcology. and paediatrics, was held on Wednesday even-
ing,' April 15th. The principal paper on the programme was
read by Dr. William M. Brown on Obstetrical Haemor-
rhages; Causative Factors and Methods of Control.
Philadelphia Paediatric Society.— At a meeting of this
society, which was held on Tuesday, April 14th, Dr. A.
Parkt'r Hitchens read, by invitation, a paper on Anaphy-
laxis; Dr. B. F. Boyer read a paper on Hypersusceptibility
to Horse Serum in Man; and Dr. F. C. Knowles
read a paper entitled Syphilis Extragenitally Acquired in
Childhood.
Hornell, N. Y., Medical and Surgical Association.—
At the nineteenth annual meeting of this Association, which
was held on the evening of April 6th, the following officers
were elected : President. Dr. Leon M. Kysor ; vice presi-
dent. Dr. J. G. Kelly; secretary. Dr. B. R. Wakeman. At
the close of the meeting the members adjourned to the
Hotel Sherwood, where the annual banquet was served.
Physicians Wanted for State Hospitals and Institu-
tions.— The Xew York State Civil Service Commission
will linld an examination on Ma\- inli ir<r the position of
physician to State hospitals and ni-iitutirm--. with a salary
of $010 ;in<! maintenance. ApiilicatKMis nuist be filed on
or before May 2(1. l-"ull inforniatK m and application forms
may be obtained by addrc^sinu Air. Charles S. Fowler, chief
examiner oi the conunission, .\lban\-, X. Y.
A New Laboratory for Clinical Pathology. — The
Saxe Laborator\' was opened recently at 72 West Forty-
fifth street. Xew York, under a charter granted by the
State of Xew York. The object of tiiis laboratory is to aid
physicians m the diagnosis of disease. A course in clinical
microscopy will be given to practitioners, and special re-
searcli work in clinical pathobigy will be carried 011 under
the supervisi'in rif the director, Dr. De Santos Saxe.
Contagious Diseases in Chicago. — During the week
ending April 4. 1908, there were 57 cases of diphtheria re-
ported to the Department of Health, a decrease of 48 cases
from the preceding week. Scarlet fc\-cr cases showed a
slight increase. 98 cases lia\int; lit en reported, as compared
with 84 for the preceding w eek' There were 309 cases of
measles reported during the week, and 80 cases of tubercu-
losis. Only one case of smallpox wa^ reported.
The Medicolegal Society of New York will meet in
joint session with the Psvcholnoiral Session of the s ciet^-
at the \Val(l..ri" .X^turia on We.huMlay, April 22,1, at 8:30
p. m. Mr. Aii'lrew McConnel! will leiul a pajier on The
Electrical .Action of the Organs nf the Human Body.
Margaret Higgins. of Xew York, will read a paper on
Psychotherapeutics in F.iu-opcan Capitals. There will be
a general discussion on Alcohol .ts a Diet or a Medicine,
and Medical Expert Testitnony.
Medical Society of the County of Kings. — .\ meeting
of the Section in Prediatrics was held on Friday evening.
April 17th. The programme included the follow ing : Re-
port of a case of hereditary syphilis treated with intra-
muscular injections of mercurv. by Dr. B. Van Wart;
a paper entitled Results of the Use of Antistreptococcus
Serum in Scarlatina, by Dr. Henrv U. Robinson, of Man-
hattan ; A review of German paediatric literature for the
3'ear 1908. by Dr. Alexander Spingarn.
Prize for Essay on Occupational Diseases. — Dr.
Louis Livingston Seaman has offered a prize of $too for
the best essay on The Economic Waste Due to Occupa-
tional Diseases. In the original announcement the time
limit was specified as April ist. but we are informed that
the time has been extended to June T5th. Each essay
must u'-'t contain more than 5,000 words. It must be signed
by a uoiii de plume, and the real name and address sent
in a sealed envelope to the Director of the .American
Museum of Safety Devices and Industrial Hygiene. 231
West Thirty-ninth street. New York.
Philadelphia County Medical Society.— The Central
Branch 01 tlii« society held a meeting on Wednesday even-
inpr, Ai)ril Kih. The general subject for consideration was life
insurance and medical practitioners, and papers were read
as follows : The Various Forms of Life Insurance and
Their Comparative Value 10 the Physician, bv Dr. Charles
M. Seltzer; The Rearing of the Recently Enacted New
York Law on the Fee for Medical Examination of Insur-
ance Applicants, by ;\Ir. J. Burnett Gibb. of the .American
Society of Actuaries ; The Five Dollar Minimum Fee for
the Medical Examination of a Life Insurance Applicant, by
Dr. J. Norman Henry ; Honor Roll of Life Insurance Com-
panies Paying the Five Dollar Minimum Fee for Medical
Examinations, by Dr. Ernest W. Kelsey. Among those
who took part in the discussion w ere Dr. William How-ard
King and Dr. J. Allison Scott.
Medical Society of the County of St. Lawrence, N. Y.
— The semiannual meeting of this society was held m
Gouverneur, N. Y., on the evening of April 7th. At the
close of the meeting a banquet was given by the members.
Dr. Grant C. Madill, of Ogdensburgh, presided as toast-
master, and among those who responded to toasts were
Dr. E. A. Nevin, Dr. H. J. Morgan, and Dr. S. W. Close.
The officers of the society are : President, Dr. James
Wiltse, of Benson Mines ; vice president, Dr. E. A. Nevin,
of Ogdensburgh ; secretary, Dr. S. W. Close, of Gouver-
neur; treasurer. Dr. A. H. Allen, of Gouverneur.
Charitable Bequests.— By the will of Benjamin Whit-
man, of Erie, Pa., who died in Mexico City, recently, the
Home for the Friendless and St. Joseph's Orphan Asylum,
Philadelphia, receive $1,000 each.
By the will of Miss Laura P. Willard, who died recently
in Prescott, Canada, the Brockville General Hospital and
the Toronto Hospital for Sick Children will each receive
$1,000.
By the will of Mr. William Wheeler Smith, who died
recently in New York, St. Luke's Hospital receives the
income from nearly $3,000,000 worth of property in New
York. On the death of Mrs. Smith the entire property
reverts to the hospital.
The Mortality of Chicago. — According to the report
of the Department of Health for the week ending April 4,
1908, there were during the week 637 deaths from all
causes, as compared with 686 during the corresponding
week in 1907. The annual death rate in 1,000 of population
was 15.33. Of the total number of deaths 364 were of males
and 273 of females. The principal causes of death were :
.Apoplexy, 19; Bright's disease, 51; bronchitis, 29; con-
sumption, 59; cancer, 30; convulsions, 7; diphtheria, 7;
heart diseases, 43 ; influenza, 8 ; intestinal diseases, acute,
32; measles, 3; nervous diseases, 24; pneumonia, 99; scar-
let fever, 8; suicide. 13; typhoid fever, 7; violence (other
than suicide), 31 ; whooping cough, 4; all other causes, 163.
Infectious Diseases in New York:
We are indebted to the Bureau I'f Reeords of the Depart-
ment of Health for the /"//nr^ ;;/.!,' statement of nezv cases
and deaths reported for the tn'o zueeks ending April 11, igo8:
■il 4- >
il 11. — ,
Cases.
Deatlis.
Deaths.
531
171
570
390
44
368
'65
37
1.877
48
52
985
54
166
Tvphoid fever
23
Whooping courIi
^9
I
Cerebrospinal meningitis . . .
9
12
329
4,015
390
The Health of the Canal Zone.— The report of the
Department of .Sanitaiion of the Isthmian Canal Commis-
sion for the month of Fchrnar\-, 1908, is at hand. During
the month the population of the Canal Zone, including the
cities of Colon and I'.in im.i. wns 113,269, atnong whom
there were 202 dc;i;li-, ,1 1 , mjinu to an annua! death
rate of 21.40 in t.oho 1 p, .pnl.-ni.-.n. There were 2 deaths
from typhoid fever, u; ironi .c-ti\ ciautumnal malaria. 20
from clinical malaria, i from liaemoglobinuric fever, 6 from
clinical dysentery, 4 from beriberi. 2 from septicaemia, 18
from pulmonary tuberculosis, 2 from other forms of tuber-
culosis. I from syphilis, 3 from cancer, 5 from tetanus, 4
from bronchopneumonia. iS from pneumonia, i from other
forms of pneumonococcus infection, and 14 from diarrhoea
and enteritis, under two years of age. Tlie death rate
among tlie white employees was 7.12 in 1,000. and among
the negroes it was 14.88 in i.ooo. The morbiditv rate
among the employees wai 17.86 in T.ooo; in February. 1907,
it was 24.73 in 1,000. Dr. Gorgas says at the end of his
letter of transmittal : "Taken as a whole, this is the most
favorable health report ihat the Sanitary Department has
been able to make since we have been on the Isthmus."
XEIVS ITEMS.
Personal. — Ur. Stephen J. Maher has been appointed
president of the l oard of health of New Haven, Conn.
Dr. Richard .Mills Pearce. Jr., of Albany, X. Y., has been
appointed professor of pathology and director of the labora-
tory of pathology at the University and Bellevue Hospital
Medical College, New York.
Dr. William H. Davis has been appointed a general medi-
cal inspector of the board of health of Boston. He will de-
vote most of his time to infectious diseases.
Vital Statistics of New York. — During the week end-
ing April 4, 1908, there were rcDorted to the Department ol
Health of the City i~^f New York 1,497 deaths from all
causes, corresponding to an annual death rate of 17.66 in
1,000 of population. Of the total number of deaths 830
were in the borough of Manhattan, 132 in the Bronx, 448 in
Brookhn, 69 in Queens, and 18 in Richmond. The prin-
cipal causes of death were : Contagious diseases, 142 ; pul-
monary tuberculosis, 171; pneumonia, 117; bronchopneu-
monia, 109; diarrhceal diseases, 94; Bright's disease and
nephritis, 115; organic heart diseases, 151 ; cancer, 63; apop-
lexy. There were 76 deaths from accidents, 4 from homi-
cide, and 18 from suicide. There were 743 marriages
recorded during the month, 2,724 births, and 143 stillbirths.
Medical Society of the County of Suffolk, N. Y.—
The semiannual meeting of this society will be held in Brent-
wood, N. Y., on Thursday, April 30th, at 11 o'clock. The
programme includes the following papers : Conduction
Aphasia, with the exhibition of the patient, by Dr. M. B.
Heyman, of Central Islip State Hospital : Measurement of
Blood Pressure, with demonstration of the apparatus, by
Dr. Roland Hazcn, of Brentwood ; Methods of Gastric
Diagnosis, with demonstrations of physical diagnosis and
laboratory examinations, by Dr. Dudley D. Roberts, of
Brooklyn. The officers of the society are : President. Dr.
Arthur H. Terry, of Patchogue ; vice president. Dr. Mar-
cus B. Heyman, of Central Islip; secretary. Dr. Frank
Overton, of Patchogue ; and treasurer. Dr. Barton D.
Skinner, of Greenpoint. ,
New York Pathological Society. — A regular meeting
of this society ^vas held at the New York Academy of
Medicine on Wednesday evening, April 8th. Dr. G. R.
Satterlee and Dr. S. O. Sabel reported a case of pernicious
anaemia with "hour glass" stomach treated by colon irriga-
tion. Dr. O. H. Schultze reported cases of septic throm-
bop|hlebitis of the longitudinal sinus and impetigo con-
tagiosa with septicaemia. Dr. H. Zinsser reported the fol-
lowing cases : Arteriosclerosis of the pulmonary arteries ;
metastatic sarcoma of the lungs with bone formation; and
typhoid infection of the gallbladder. Miss A. Oppenheimer
read a paper on Radial Fibres in Blood Vessels. Dr.
James Ewing read a paper on Myxoma of the Full Term
Placenta. Dr. E. Moschocowitz read a paper on Typhoid
Fever with Mixed Infection: Unusual Intestinal Lesions.
Dr. H. L. Celler read a paper on Lesions in a Case of Myas-
thenia Gravis.
A Dinner to Dr. Wiley.— The twenty-fifth anniver-
sary of the service of Dr. Harvey W. Wiley as chief chem-
ist of the LTnited States Department of Agriculture was
celebrated by a dinner given in his honor at the Hotel As-
tor on Thursday evening, April pth, by some two hundred
chemists of New York and vicinity. Dr. William Jay
Schieffelin presided at the dinner. Congratulatory ad-
dresses were made by Professor W. D. Bancroft, of Cornell
University; Professor Joseph P. Remington, of Philadel-
phia, chairman of the Committee of Revision of the United
States Pharmacopoeia; Professor M. T. Bogert, of Colum-
bia University: Mr. C. F. Cox. president of the New York
Academy of Sciences; Mr. Herman A. Metz, comptroller
of the city of New York; Mr. Walter H. Page, editor of
the World's Work; and others. The speakers lauded Dr.
Wiley tor his work in the fearless administration of the
national food and drugs act. He was referred to as stand-
ing' for the idea of pure, unadulterated truth, and as being
therefore essentially a scientist, as science means truth. On
the following evening, .\pril loth. the chemists of the city
of Washington also tendered Dr. Wiley a banquet in that
city in comtnernoration of his services to chemistry during
the period of his incumbency of office
American Paediatric Society.— The twentieth annual
meeting of this society will be held at the Water Gap
^House, Delaware Water Gap, Pa., on May 25th. 26th, and
27th. The committee is striving to make this meeting one
of unusual interest. On? session will be devoted to a dis-
cussion of the serum treatment of epidemic cerebrospinal
meningitis. Dr. Simon Flexner will open the discussion,
and Dr. Dunn will give a resume of the results of this
treatment as observed in the Children's Hospital in Boston.
Another session will be devoted to the subject of the in-
tiucnce of cold air in the treatment of disease, the disease
to which it is applicable, and the degrees of temperature
which should be used in the different types of disease. Dr.
Northrup and Dr. Graham will take part in the discussion.
Si'.fficient time will be devoted to poliomyelitis anterior,
especially as an epidemic, and Dr. Koplik and Dr. Le Fetra
have consented to discuss the subject. Dr. Holt has prom-
ised a paper on Recent Diagnostic Method* ni Tuberculosis
in Children. With four such interesting subjects for dis-
cussion, the committee feels warranted in asking the mem-
bers to prepare papers on the different phases of the ques-
tions. The committee is desirous of issuing the preliminary
programme as soon as possible, and members are therefore
requested to send the titles of their papers, at their earliest
con\cnience, to Dr. Samuel S. Adams, i Dupont Circle,
Washington, D. C.
Society Meetings for the Coming Week:
Monday, April 20th. — New York Academy of Medicine
(Section in Ophthalmology"); Aledical Association of
the Greater City of New York ; Hartford. Conn., Med-
^ ical Society.
i l Esn xY, April 21st. — New York Academy of Medicine
(Section in Medicine) ; Buffalo Academy of Medicine
(Section in Pathology) ; Tri-Professional Medical
Society of New York ; Medical Society of the County
of Kings, N. Y. ; Binghamton, N. Y.. Academy of
Medicine; Clinical Society of the Elizabeth, N. J.,
General Hospital; Syracuse, N. Y., .Academy ot Medi-
cine; Ogdensburgh, N. Y., Medical Association
Wednesd.w, April 32d. — New York Academy of Medicine
(Section in Laryngology and Rhinology) : New York
Surgical Society.
Thursd.ay, April 23d. — New York Academy of Medicine
(Section in Obstetrics and Gynaecology); Brooklyn
Pathological Society; Hospital Graduates' Club. New
York; New York Celtic ^Medical Society.
Frid.\y, April 24th. — New York Clinical Society : New
York Society of German Physicians ; Academy of
Pathological Sciences, New York.
S.\TURD.\Y, April 23tli. — West End Medical Society: New
York Medical and Surgical Society: Har\ard Medical
Society, New York; Lenox Medical and Sargicril So-
ciety, New York.
Meetings of Sections of the New York Academy of
Medicine. — The Section in Ophthalmology will meet
on Monday evening, April 20th. at 8:15 o clock. Dr. .Arnold
Knapp will present a specimen of inelanosarcoma of the
conjunctiva. Dr. E. B. Coburn will exhibit an apparatus
to measure ocular tension, and Dr. Arnold Knapp will ex-
liibit an apparatus to determine the enlargeinent of the
blind spot in Bjerrum's method of testing the field of
vision. The paper of the evening will be read by Dr. John
E. Weeks on Plastic Operations on the Lid? by Means of
Flaps without Pedicle.
The follov.ing programme has been arranged for a meet-
ing of the .Section in Medicine, to be held on Tuesday
evening, April 21st: Papers — The Association of Tubercu-
losis of the Lungs with Diabetes Mellitus, by Dr. Henry L.
Shively; Neuralgia: Its Specific Treatment with Chloro-
form Subcutaneously, by Dr. S. O. Goldan. Reports of
Cases — Pulmonary Arteriosclerosis, with specimen, by Dr.
Hrrlow Brooks ; Pulmonary Emphysema, operati\ e treat-
ment, by Dr. Charles Goodman ; Post Tvphoid Sepsis, by
Dr. F. R. McCreery.
l lie Section in Obstetrics and Gynecology will meet on
Thursday evening, April 23d, at 8:30 o'clock. The paper of
tlie evening will be read by Dr. Henry P. De Forest on
The Development and Malformations of the Female Geni-
talia, and the following reports of cases will be presented:
Strangulated "Dissecting" Hernia, simulating Peritubal
Suppuration, by Dr. A. Sturmdorf ; Nephritic Type of Tox-
aemia, Dead Foetus. Vaginal Caesarean Section, by Dr.
Le Roy Broun ; Drainage after Rupture of Recent Ovarian
Abscess while removing Culture Staphylococcus as opposed
to no Drainage, by Dr. Le Roy Broun; Two Cases of Frecal
Fistula, one Abdominal and the other Ileovaginal : Demon-
stration of a Manikin of the Pelvis, bv Dr. D mgall
Bissell.
752
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
April p, 1908.
1. On the Signiticance of Clinical Histories Before and
After Operative Demonstration of the Real Lesion,
By Maurice H. Richardson.
2. Observation Hospital or Wards for Early Cases of
Mental Uitturbance, By L. Vernon Briggs.
3. .\ Case of Infantik Pyloric Stenosis with Autopsy
Six and One Half Months After Successful Gastro-
enterostomy,
By John Lovett Morse, Fred T. Murphy, and
S. B. Wolbach.
4. A Case of Congenital Stenosis of the Pylorus,
By Charles W. Townsend.
5. I'he Scope of Therapeutic Inoculation,
By G. P. Sanborn.
3. A Case of Infantile Pyloric Stenosis. —
!Morse, Murphy, and Wolbach describe such a case.
'1 he cause of death was a general peritonitis with-
(;ut demonstrable anatomical cause. Special atten-
tion was given to the tissues about the gastroenter-
ostomy, both at the autopsy and afterward in going
over the hardened specimen. The condition of the
gallbladder, appendix, and gastrointestinal tract
ruled out infection from these sources. The nega-
tive findings in the dissection of the spermatic cords
and seminal vesicles made an infection from the
penis very improbable. Normal pleural and peri-
cardial cavities excluded these as sources of infec-
tion. Finally, the absence of any older localized
process, and the diffuse, even distribution of the
exudate forced the authors to the conclusion that
the infection took place through a vascular route.
The infecting organism, judging from the morphol-
ogy in sections, could be either the pneumococcus or
the streptococcus, probably the former. The micro-
scopical findings in the pylorus were surprising, be-
cause of absence of degenerative changes in the
smooth muscle, either in the form of atrophy or in
connective tissue overgrowth. The closed state of
the pylorus was proved by the mechanical tests ap-
plied and by the rigidity and thickness of the walls,
which were in striking contrast to the usual post
mortem condition of the pylorus in infants. The
flattening of the mucosa could hardly be considered
as an evidence of permanent closure. The cystic
dilatations of the glands were probably mechanical
in origin, though a few similar cysts have been seen
in the mucosa of the normal pylorus of infants. In
the case of an infant a few weeks old, operated
upon for pyloric stenosis and which died a few days
later, only slightly dilated pyloric glands were found.
This fact supports the belief that in the case our
authors reported the long continued closure of the
pylorus was the cause of the glandular dilatation.
The case is in so far interesting as it is the first one
reported where any one had had the opportunity of
studying the anatomical conditions in a case of in-
fantile pyloric stenosis at so long a time as six and
one half months after a successful gastroenteros-
tomy. This case, the authors conclude, proves that,
in some instances, at least, the stenosis is not due to
spasm, that medical treatment cannot be of any
avail, and that the only hope for relief and life lies
in surgical intervention. It also proves that an in-
fant can live and thrive for many months, although
all the food passes through the gastroenterostomy
opening and none through the pylorus. It suggests
that the condition of organic infantile pyloric steno-
sis is a permanent one, that there is no tendency
toward a restoration of normal conditions, and that
there is little hope of the pylorus ever resuming its
functions. It is not safe to draw conclusions from
these suggestions, remark the authors, as it is pos-
sible that, with the lapse of time and the growth of
the parts, changes may occur which will result in
the restoration of normal conditions and function.
These points can only be decided by the actual
observation of the anatomical conditions in cases
dead at longer intervals after successful operations.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
April II, igo8.
1. Pancreatitis Resulting from Gallstone Disease,
By William J. Mayo.
2. Detection of the Emotions by the Galvanometer,
By E. W. Scripture.
3. Plague Among Rats in San Francisco,
By William B. Wherry, Agnes Walker, and
Edgar H. Howell.
4. Ocular Rotations in Paresis, By Francis Valk.
5. The Treatment of Interstitial Keratitis,
By H. H. Martin.
6. Disturbance of Nitrogenous Metabolism in Epilepsy,
By A. J. RosANOFF.
7. Intussusception and Its Cause, By W. L. Wallace.
8. Passive Hypera;mia of the Lungs and Tuberculosis,
By Wilder Tileston.
3. Plague Among Rats in San Francisco. —
Wherry, Walker, and Howell agree with the last
Indian Commission that, with experience, the chances
of missing a plague* infected rat by the naked eye
method of examination alone are extremely small.
Recently the authors have abandoned the wholesale
preliminary microscopical examinations and substi-
tttted the anatomical dissections, followed by the
bacteriological and animal tests of anatomically sus-
picious rats. Of 14,184 rodents examined, 98.97
per cent, were M. decunianus ; 0.73 per cent. M. rat-
ius; 0.35 per cent. M. ratlns alexandrinus, and o.ii
per cent. musciiliis. By far the greater number
found infected were M. decunianus. The results of
animal inoculation experiments show that the bacil-
lus of natural rat plague in San Francisco is quite
as virulent as the strains tested in Bombay by the
last Indian Commission. Complete post mortem
notes on eighty-eight "positive" rats showed that
seventy-four of these had enlarged and congested
glands ; thirteen of the seventy-four showed a typical
primary bubo (six inguinal, one submaxillary, one
axillary). Only twenty-eight presented the charac-
teristic anatomical picture of general subcutaneous
congestion, enlarged and congested glands, splenic
tumor, and hydrothorax or hemothorax. The in-
guinal glands, either alone or along with other
glands, were enlarged and congested in forty-seven,
the axillary glands in thirty, and the submaxillary
glands in thirty-three instances. No single charac-
teristic abnormality invariably occurred in the rats
of this series. Most of the eighty-eight rats were
. fresh ; only seven showed much post mortem decom-
position, and in these typical bacilli were fairly
numerous, either in the spleen or in a gland.
4. Ocular Rotations in Paresis. — \"alk con-
cludes that all tests ior paresis must be made with
the look in complete infinity and wilii full acuity of
vision. We must have a standard of the field of
version for comparison of any deficiency of rotation.
April i8, 1908.]
FiTH OF CURREXT LIT ERA! U RE.
753
The straight muscles are capable of moving the eyes
in any part of the field of vision and from one part
of the field to another; in other words, in no part
of the field will the straight muscles fail to act ac-
cording to their usual function. The obliques take
no part or action in the rotation of the eyes in the
field of version ; in other words, the oblique muscles
do not elevate or depress the visual line. A distinct
line must be drawn between paresis and hetero-
phoria as shown by the diplopia ; in the first by
diplopia in infinity and in the second by the possible
diplopia with reduced vision. In the consideration
and diagnosis of paresis w e may exclude the condi-
tion of crossed or homonymous images and also the
tipping, except in a pathological condition of the
obliques. The individual muscles of the eyes are
not endowed with two distinct functions, as they
have but one nerve supply, except possibly "in the
action of convergence and inward rotation due to
two distinct nerve centres. The points of action V)f
the straight muscles of the eyes are the insertions
and the sheaths of the tendons as they are situated
in the orbit just behind the globe.
7. Intussusception and Its Cause. — Wallace
states that the typical symptoms of intussusception
are pain, shock, small, bloody mucous stools, with
tenesmus and characteristic tumor. In his case
pain was not a prominent symptom, and there was
no discharge from the bowels, no inclination to move
the bowels, and no tumor could be felt, even 'under
an anaesthetic. A child may have bloody mucous
stools without intussusception, and, on the other
hand, an intussusception may slough away without
the appearance of bloody stools. The usual ileocsecal
intussusception forms a palpable tumor, but an en-
teric intussusception may be so small or high that
a tumor cannot be appreciated. In his case an un-
usual symptom was present — frequent bloody vomit-
ing, in regard to the cause of intussusception,
observation and experiment show that invagination
is of frequent occurrence and is easily produced by
slight irritation of the normal intestine, the bowel
above rolling into the segment below and emptying
itself as in a movement of the bowels. Treves goes
so far as to hold that many attacks of indigestion
may be due to a temporary invagination of the
bowel, in which case the circular fibres below rapidly
contract and reduce the intussusception before adhe-
sions form between the layers. Whatever would
prevent the reduction of this physiological invagina-
tion would produce a true pathological intussus-
ception. There are two theories of the cause of
intussusception : spasm and paralysis. The first
theory holds that, for some reason, a local spasm is
set up in the bowel and a violent contraction takes
place, and this point is made the apex of an intus-
susception by passing into the intestine below or
having the bowel below drawn up outside. The
other theory is that of paralysis. .\ certain section
of bowel is paralyzed by interference with its nerve
or blood supply. It, therefore, becomes distended
and the bowel above is pushed into it.
8. Passive Hyperaemia of the Lungs and
Tuberculosis. — Tileston states that one hundred
and twenty-eight cases of mitral stenosis at autopsy
showed a much lower percentage of pulmonary
tuberculosis than the material from which they were
drawn. Those cases with a high degree of stenosis
were more free from tuberculosis than those with a
moderate stenosis, and were entirely exempt from
active tuberculosis. A person with mitral disease is
less liable than others to acquire tuberculosis of the
lungs, and if he does, the pulmonary disease usually
runs a mild course, with a strong tendency toward
cure. This relative immunity is to be ascribed to
passive hyperaemia of the lungs consequent on the
mitral lesion. There is a possibility that artificially
induced hyperasmia of the lungs may be a valuable
adjunct in the treatment of pulmonary tuberculosis.
MEDICAL RECORD
April II, igo8.
1. Diabetes and the Food Factor, By Henrv S. Stark.
2. Spontaneous Gangrene of the Foot Due to Endarteritis
Obliterans, By Isaac Levin.
3. The Relation of Appendicitis to Gj-nascological Pelvic
Diseases. By Samuel Wyllis Bandler.
4. Blood Pressure in the Practice of Medicine,
By W. Forest Duttox.
5. Health of Our High School Children,
By Elizabeth Jarrett.
6. The Solution of the Lodge and Society Problem of the
East Side, By Julius Weiss.
7. A Case of Cut Throat, By Charles L P.\ge.
I. Diabetes and the Food Factor. — Stark
states that as far as the dietetic treatment of dia-
betes is concerned, we should not lose sight of the
one cardinal fact, that total or partial failure to as-
similate carbohydrates is the salient phenomenon of
the disease. The principle involved in the treat-
ment, then, must be to lessen the carbohydrates in
the food, until the sugar disappears, if that is pos-
sible, and afterwards tentatively to replace them,
noting the effects of each addition on the urine, as
a guide to future dietary measures. In order to
carry this principle into effect it is necessary to as-
certain experimentally the patient's ability to as-
similate carbohydrates. For purposes of estimat-
ing, approximately, of course, this tolerance,
several methods are employed, the most familiar of
which is that known as von Xoorden's standard test
diet. This diet consists of three meals, carried out
for one or tw^o days, of articles free from carbo-
hydrates, except that a measured quantity of bread
is allowed for breakfast and lunch. The urine of
the next twenty-four hours is collected, that of the
day in a separate vessel from that of the. night, and
examined quantitatively for glucose, acetone, urea,
and other ingredients. Both the percentage of
sugar and the amount daily excreted are noted, and
cases classified as slight, moderately severe, and
grave, according to their degree of toleration. To
the first class belong to those diabetics in whom the
excretion of glucose is arrested on a starch free
diet. To the second class, the moderately severe,
belong those diabetics in whom the excretion of
sugar is not completely arrested, but markedly
diminished on a rigid starch free diet. To the third
class, the grave cases, belong those diabetics in
whom the excretion of glucose is not even dimin-
ished on a rigid starch free diet. In this last group
of cases sugar is formed from the proteid food ele-
ments. The m.ethod used by the author for the
toleration test is the following: On the test day
three meals consisting entirely of proteids, fats,
and water are given, but between breakfast and the
754
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
midday meal the patient is told to drink a mixture
of 50 c.c. of glucose dissolved in 250 c.c. of water.
The urine of the ne.xt twenty-four hours is exam-
ined quantitatively.
3. The Relation of Appendicitis to Gynaeco-
logical Pelvic Diseases. — ^Bandler concludes that
appendicitis in the form of an inflammation of the
mucous membrane does not result from inflamma-
tory diseases originating in the uterus or annexa.
Involvement of the appendix viewed as a peri-
toneally covered organ may take place as part of
a peritonitis, more or less localized or more or less
extensive, which has its origin in inflammatory
diseases of the anncxa. Severe inflammations of
the appendix, in so far as they cause a pelvic per-
itonitis or in so far as the accumulation of pus is
located in the pelvis, naturally involve the uterus
and annexa in adhesions, do not cause pyosalpinx,
but may cause tuboovarian cysts. A distinctive di-
agnosis as to original site of the infection, when the
appendix and right annexa are involved, is often
impossible except from the operative clinical stand-
point, and even then is not always certain. Mild
attacks of appendicitis, without the production of
well defined peritonitis, may involve the annexa
without adhesions, but especially by infection of the
Grafiian follicles, alterations of the stroma and the
production of varicocele of the broad ligament.
Such alterations in the annexa generally result
from processes extending from the cervix and
uterus into the broad ligaments, and a definite de-
cision as to the source of the trouble may be often
impossible.
4. Blood Pressure in the Practice of Medi-
cine.— Button says that in the study of abnormal
blood pressure we have the underh-ing cause or
sequence of over half the human ills, which makes
it one of the most profound subjects known to the
science of medicine. ]\Iuch is understood and
much is misunderstood. He thinks he has proved
by his own experiments and observations that the
life of the human organism, whether through
heredity or other causes prone to be aberated
blood pressure, may be prolonged ten to twenty
years. So long as normal blood pressure can be
maintained, the life of the organism will be sus-
tained until the natural sequences of decay result
in death.
6. The Solution of the Lodge and Society
Problem of the East Side. — Weiss speaks of the
so called east side of New York City. He observes
that the practice of medicine on the east side of New
York is unique. Seventy-five per cent, is lodge and
society practice. Three fourths of the physicians on
the east side accept this kind of practice. The lait\
is organized, the physicians are disorganized. To
gain contracts, physicians have to go through elec-
tions. To insure being elected, physicians make the
worst concessions and lower their professional dig-
nity. It is neccs.sary for the physicians to cooperate
to establish a uniform contract, and to raise the pro-
fessional standard on the east side. To accomplish
these reforms it is necessary to abolish the system of
election and to establish the system of selection. To
gain the good will and cooperation of the new and
less successful practitioners, it is necessary that the
older and more successful i>ractitioncrs allow the
former to examine candidates of the various lodges
and societies. There should be established offices
where the examining physicians should be assigned
in routine for the examination of candidates. The
income from these candidates should be divided in
equal shares quarterly among the examining physi-
cians.
BRITISH MEDICAL JOURNAL
March 38, 1908.
1. New Ideas on l''ractures of the Utmost Importance to
the Medical Profession and to the Lay Public in
Connection with Their Responsibilities and Possible
Legal Liabilities, By Lucas-Championniere.
2. Arthrodesis and Tendon Transplantation,
By R. Jones.
3. The Most Ancient Splints. By G. E. Smith.
4. The Post Mortem Staining of Bone Produced by the
Ante Mortem Shedding of Blood, By F. W. Jones.
5. Examination of the Bodies of One Hundred Men Ex-
ecuted in Nubia in Roman Times, By F. W. Jones.
6. Remarks Upon Excision of the Body of the Scapula,
with an Illustrative Case, By R. P. Rowlands.
7. Punch Fractures, By H. Burrows.
I. Fractures. — Lucas-Championniere for thirty
years has impressed the following precepts upon his
students: i. The accurate juxtaposition of the frac-
tured extremities of bones, in order to reproduce the
normal arrangement, is a laudable object. It is only
achieved in a minimal number of cases. 2. Never
tell a patient that you are going to obtain and that
you have obtained this exact result. 3. The books
teach you that this is the case, but clinically the
statement is false, and it will turn against you in
several ways. 4. The conditions that are necessary
in order that a limb should again become function-
ally perfect are far from demanding this exact jux-
taposition. There are a large number of conditions
which are more essential, and which you should be
more sure of satisfying. 5. Do not insist upon this
claim. 6. Give no credence whatever to the state-
ment that absolute lack of movement is the most
favorable condition for the repair of bone and for
the formation of callus. A certain amount of move-
ment favors and accelerates bone formation. 7. Do
not proclaim from the housetop that radiography
gives you an exact picture of the fragments. But
on the other hand never try to prevent the use of
radiography for a bony lesion. Whenever it is ma-
terially possible to employ it, have it employed ; but
never allow it to be interpreted in your absence, and
make a special point of explaining to the patient or
his friends in the clearest possible way the interpre-
tation of the photograph. The medical profession
should make the lay public understand the difficulties
involved in a study of fractures. They must know
that (a) radiographs have to be interpreted; (b)
the reduction of fractures is not an absolute rule and
is often not indispensable; (c) absolute rest is not
the necessary test of every sound treatment for frac-
tures; (d) a fracture is not a simple lesion, but in-
cludes complications owing to displacement, and
owing to rupture of tendons and muscles; and (e)
there is no mathematical solution for the repair of
fractures. It is always difficult to put the public on
its guard against the rooted belief that it knows and
can understand everything relating to medicine. But
in the case of fractures the doctor must be especially
on his guard, because nothing will uproot the con-
victi(>n of the public that it can unclusnnd every
April ,8. i9cs.] PITH OF CURRENT LITERATURE.
secret in connection with the treatment and repair
of bones.
2. Arthrodesis and Tendon Transplantation.
— ^Jones points out the causes of failure and the
essentials of success in the operations of arthrodesis
and tendon transplantation. By arthrodesis wc en-
deavor to ankylose a joint with the least possible
sacrifice of bone. The joint thus fixed is usually
perfectly healthy, but preternaturally mobile, and
the muscles which should govern it are either wholly
or partly paralyzed. The operation should be lim-
ited to those joints which are wholly dependent for
their usefulness on outside appliances and which
offer no opportunity for a successful tendon opera-
tion. The ankle joint is the one usually operated
on, but it is of the utmost importance that it should
not be fixed until we know: (a) That the paralysis
is complete, and depends on the destruction and not
on the temporary disorganization of motor cells.
(b) That at least two years have elapsed in the case
of muscles suspected to be completely paralyzed.
(c) That apparently paralyzed but really over-
stretched muscles have first undergone appropriate
treatment. Failure of the operation is generally due
to neglect of general principles. The operation
should not be performed on children under eight
years of age. It should not be performed until the
surgeon is satisfied that the muscles are paralyzed
beyond all hope. The preliminary preparation of
the foot by wrench and tenotome must correct all
deformity. The operation must be so planned that
at its completion the bones lie in opposition to the
foot, which should be placed in an overcorrected
position. This is effected by the exsection of skin
flaps, by the shortening of lengthened tendons, and
by the removal of graduated wedges of bone. The
wedge should never be taken from the tibia lest the
tibial epiphysis be injured. Splints should be ap-
plied and retained until union is complete. Tendon
transplantation is indicated: (a) To fortify a weak-
ened group of muscles, (b) To supplant a com-
pletely parah zed muscle or group of muscles, (c)
To obstruct an overacting spastic group, (d) To
deviate tendon action when perverted — as in trans-
ferrence of the tendo Achillis to the outer side of
the OS calcis in congenital clubfoot to prevent inver-
sion of the ankle, (e) As a help in partial arthro-
desis. In tendon transplantation one must insist on ;
I. The overcorrection of deformity as a preliminary
act. 2. The removal of skin flaps to secure the un-
interrupted continuity of the overcorrection. 3. The
direct and not angular deflection of the tendon. 4.
The free tunneling in one plane through the soft
tissues. 5. The firm suturing into periosteum or
bony groove. 6. The careful choice, tension, and
nursing of the transplanted tendon. 7. The mainte-
nance of a hypercorrected position until voluntary
power is assured to the tendon. 8. The deflection
of body weight during walking from the reinforcing
tendon.
6. Excision of the Scapula. — Rowland's con-
clusions regarding excision of the body of the scap-
ula are as follows: i. For suitable cases excision
of the body of the scapula, with preservation of the
processes and glenoid socket, is a much better oper-
ation than excision of the whole bone, because it
leaves a limb far more perfect from the functional
755
and the artistic points of view. 2. The operation is
especially suitable for innocent growths, which for-
tunately and frequently leave the processes and the
shoulder joint unaffected. 3. It may be adopted in
preference to complete excision of the scapula for
some small and slowly growing malignant growths
without increasing the immediate risk of death, and
probably without increasing the danger of either
local or general recurrence. 4. It may be occasion-
ally suitable for inflammatory diseases of the scap-
ula when the shoulder joint is unaffected. 5. It is
wise to tie the three main vessels as early as possi-
ble in the operation, and this can be easily done
through a suitably arranged posterior T shaped in-
cision. 6. The success of the operation largely de-
pends upon careful asepsis, the sewing of some of
the divided muscles together, and the early adoption
of systematic active and passive movements of the
shoulder.
LANCET
March .28, 1908.
1. The Pathology of Acid Intoxication (Arris and Gale
Lecture), By F. A. Bainbridge.
2. Tuberculosis of the Kidney and Malignant Disease of
the Caecum (Lettsomian Lectures, III),
By C. J. Symonds.
3. Observations on the Opsonins, with Special Regard to
Lupus Vulgaris,
By A. Reyer and R. Kjer-Petersen.
4. Modern Methods of Treating Infective Conditions of
the Throat, By M. Young.
5. Acquired Diverticula of the Sigmoid Flexure, Consid-
ered Especially in Relation to Secondary Pathologi-
cal Processes and Their Clinical Symptoms (Part
II), By W. H. M. Telling.
6. A Case of Diaphragmatic Hernia,
By H. O. Williams.
7. A Case of Metralgia Paraesthetica Successfully Treated
with the Constant Current, By E. R. Morton.
8. Perforation of the CEsophagus by a Rabbit Bone: Sep-
tic Inflammation of the Mediastinum: Ulceration
Into the Aorta ; Death from Haemorrhage,
By R. L. Knaggs.
9. The Method of Preparing "New Tuberculin" (Tuber-
culin T. R.) : A Correction, By W. G. Ruppel.
I. Acid Intoxication. — Bainbridge, in his Arris
and Gale lecture on acid intoxication, draws at the
outset a distinction between acidosis and acid intox-
ication. The essential feature of acidosis is the
occurrence of certain abnormal acids in abnormal
amount in the blood and the urine ; the most im-
portant of these acids are lactic and betaoxybutyric
acids, and their estimation in the urine furnishes
the most accurate means of measuring the intensity
of the acidosis. The term acid intoxication shotild
be limited to conditions in which, in addition to
acidosis, toxic symptoms referable to the organic
acids make their appearance. Acidosis may be ac-
companied by diminution of the alkalinity of the
blood, and the urinary excretion of ammonia is
usually increased. Even in acidosis, however, the
alkalinity of the blood remains remarkably con-
stant, though it may be temporarily disturbed by a
sudden production of acid ; andanormal alkalinity of
the blood may coexist with a considerable degree of
acidosis. And neither the total excretion of am-
monia in the urine nor the ammonia coefficient
(i. e., the proportion of the total nitrogen excreted
as ammonia) necessarily or even usually corre-
sponds to the degree of the acidosis. Lactic acid
is never the cause of acid intoxication in man, and
756
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
its appearance in the urine is either the result of
excessive production by the muscles or is secondary
to the failure of the liver to convert ammonia into
urea; its occurrence is not due to deficient oxida-
tion of lactic acid by the liver. It seems probable
that in diabetes there is a gradual depletion of the
alkalies in the tissues, and that a point is ultimately
reached when the alkali content of the tissues is
insufficient for normal metabolism and symptoms
of intoxication occur. It is possible, of course, that
the gradual loss of alkali simply lessens the amount
of base available for the neutralization of acid, and
that the ultimate result is an acid intoxication due
to the diminished alkalinity of the tissues. It is
also extremely probable that the lack of some or all
of the inorganic bases may primarily disturb the
course of the metabolism, quite independently of
the alkalinity of the tissues, which last does not de-
pend solely upon their inorganic constituents, since
the proteins can apparently act either as weak acids
or bases. On this view even the diminished alka-
linity of the blood in coma may be interpreted as
due to a final effort on the part of the tissues to
satisfy their need for base. It is not sufficient to
supply the body with sodium carbonate ; the
alkali treatment of diabetes might be of much
greater value if all the bases required by the body
were administered. Postanassthetic acetonuria is
the common form in children. In most cases ace-
tonuria is the only symptom, but occasionally toxic
S3-mptoms develop, and death may ensue. The most
characteristic symptoms are intense thirst, vomit-
ing, restlessness, and finally coma ; air hunger has
been observed in some cases. Post mortem the liver
shows constantly intense fatty infiltration, with
patches of necrosis. The interest of postanassthetic
acetonuria lies in the appearance of symptoms of
acute intoxication in certain cases and in its rela-
tion to other forms of acetonuria. The power of
anaesthetics to interfere with metabolism as a whole
and their toxic action upon protoplasm are well
known. The metabolic disturbance is usually
trivial, because the anaesthetic speedily leaves the
tissue when the anaesthesia comes to an end. The
severe toxic symptoms can only be explained by as-
suming that the anaesthetic remains in combination
with certain tissues. If this be admitted, then the
occurrence of acetonuria is the inevitable outcome
of the lessened oxidative capacity of the tissues.
Postanaesthetic acetonuria is closely analogous to
phosphorus poisoning, in which the oxidative ca-
pacity of the tissues is primarily damaged. The
inhibition of metabolism by anaesthetics results in
the incomplete combustion of fat, and betaoxy-
butyric acid and its products appear in the urine,
and the failure of the muscles to burn up fat leads
to its accumulation in both the muscles and the
liver. Fatty infiltration of the liver can occur with
remarkable rapidity, and there seems to be no rea-
son to believe that when symptoms of intoxication
occur after anaesthesia the liver was previously
diseased. Patients who take carbohydrate freely
both before and after operation seem less liable to
acetonuria, and it is probable that postanaesthetic
acetonuria may sometimes arise solely from carbo-
hydrate starvation, especially in those cases in
which, owing to vomiting, but little food has been
taken previous to operation.
LA PRESSE MEDICALE.
March 21, igo8.
1. Anaphylaxia, By Professor Ch. Richet.
2. Appendicitis and Chronic Ulcer of the Stomach,
By R. RoMME.
I. Anaphylaxia. — Richet applied this term in
1902 to a phenomenon he had discovered while
studying the action of certain poisons, namely, the
sensibility of the organism to a second injection of a
poison after recovery from the effects of the first
injection and apparently total elimination of the
toxic substance. The sensibility of the organism to
the second dose as compared with its sensibility to
the first may be either less, equal, or greater. The
author considers that anaphylaxia merits careful
study from the point of view of pathology and gen-
eral therapeusis, because he believes that through it
may be found an explanation of the peculiar phe-
nomenon called idiosyncrasy, which is the difference
of reaction in different individuals.
March 25, 1908.
1. The Course to Be . Pursued in the Treatment of a
Complicated Fracture, By P. Hardouin.
2. Disassociation and Antagonism of the Cutaneous and
Tendinous Refiexes, By Noica.
I. Treatment of Complicated Fractures. —
Hardouin gives, as the proper course to be pursued
in the treatment of a complicated fracture, cleansing
of the skin, an incision, or an enlargement of the ex-
ternal wound sufficient to obtain enough space for
the necessary manipulation, usually from four to
six centimetres long, resection of the parts of the
bone rhat should be removed, cleansing of the
wound, drainage, and the application of a dressing.
LA SEMAINE MEDICALE.
March 25, 1908.
Peripheric Rheumatismal Arteritis,
By M. RocH and R. Burnand.
Peripheric Rheumatismal Arteritis. — Roch and
Burnand report a case of rheumatism followed by
pain in certain parts of the limbs associated with
loss of pulse, which they are inclined to ascribe to a
local arteritis for the following reasons: i. The
progressive onset of the pain, which was preceded
by tingling and a feeling of weight in the limb, that
required two days to reach its maximum. 2, The
attacks of fever, which each time preceded the ap-
pearance of the arterial pains, which can be ex-
plained by nothing else than an infection. 3, The
nodulae of early periarteritis with painful cedcma-
tous infiltration along the course of the artery for a
considerable extent seems to accord with the idea of
an arteritis involving all the coats of the vessel
rather than with the idea of a mechanical obstruc-
tion by means of an embolus. 4, The transitory
character of the obliteration on the part of the artery
most affected. 5, The fact that the radial pulse was
at first wholly suppressed and that when pulsation
returned it was manifest during compression of the
artery above the pulse showed a temporary oblitera-
tion of the vessel throughout its length and not
merely an obliteration limited to a segment at its
upper extremity. 6, It has been noted that in the
phase just before obliteration in endarteritis the
pulse of the affected artery is stronger than that of
the corresponding artery. In this case it was noted
just before the onset of the symptoms that the pulse
of the left radial artery, which later was obliterated.
April 1 8, 1908.]
PITH OF CURRENT LITERATURE.
7o7
was stronger than that of the right. The only ob-
jections are that there was a cardiac lesion present
which might account for embolism, and that the in-
fection must be ascribed to the rheumatismal virus.
BERLINER KLINISCHE WOCHENSCHRIFT
March 16, 1908.
1. Concerning the Indications for Radical Operation in
Inflammatory Diseases of the Accessory Sinuses of
the Nose, By A. Kuttner.
2. Operation for Acute Haemorrhage from the Pancreas,
By F. Brewitt.
3. The Wave of the Phlebogram, By D. Pletnew.
4. The After Treatment of Carcinoma that Had Been
Operated on with Homogeneous Irradiation,
By Friedrich IDess.wer and Max KRiicER.
5. Concerning the Infectious Origin of Chronic Pancre-
atitis and Diabetes, By Felix Hirschfeld.
6. Studies of the Secretion of Pepsin in Healthy and Dis-
eased Infants. By J. Rosenstern.
7. The Cutaneous and Conjunctival Reaction to Tubercu-
lin in Animals. By Haxs Wildbolz.
8. Concerning the \'alue of Pirquet's and Wolff-Cal-
mette's Reactions in Childhood, By Robert Bing.
9. The Therapeutic Use of Radium Emanations,
By FrAXZ XAGELSCHMrOT.
ID. Concerning Puerperal Fever, By Erxst Ruxge.
1. Radical Operation in Diseases of the Ac-
cessory Sinuses of the Nose. — Kuttner protests
against too ready adoption of stirgical measures in
diseases of the accessory sinuses, because daily ex-
perience shows that the chances of recovery with-
out such intervention are much greater in both
acute and chronic forms than could theoretical-
ly be expected. Intranasal treatment should be
adopted in aH cases in which serious coinplications
are wanting.
2. Operation for Acute Haemorrhage from the
Pancreas. — Brewitt reports a case of haemorrhage
from the pancreas in a boy, sixteen years old. He
was seized twice within twenty-four hours with se-
vere abdominal pain, nausea, and vomiting. The
localization of the first appearance of the pain
could not be determined. Laparotomy was per-
formed, the pancreas found to be enlarged with a
swelling as large as an apple in its middle, that was
found to contain a bloody serous fluid. This was
incised and drained, the abdomen washed out with
salt solution, and the patient made a good recovery.
But for the operation the condition would in all
probability have proved fatal.
4. After Treatment of Carcinoma that Had
Been Operated on by Irradiation. — Dessauer and
Kriiger say they obtain a deep reaction in inopera-
ble carcinomata treated w'ith homogeneous irradia-
tion for a long time, but do not go so far as to say
that the x rays can destroy all large tumors in the
body without injury to the organism. They fear
not bums of the skin, but a weakening of the body
by the formation of toxines as the result of the
breaking down of tissue. As much as possible of
the malignant tumor should be removed b\' the
knife of the surgeon. As an after treatment di-
rectly following the operation the use of the x rays
is of great value, and makes it possible to prevent
a recurrence.
8. Value of Pirquet's and Wolff-Calmette's
Reactions in Childhood. — Bing reviews these
tests and concludes that Pirquet's cutaneous test
is absolutely without danger, while the same can-
not be said of the conjunctival reaction. Pirquet's
test also reveals latent tuberculosis, while a nega-
tive conjunctival reaction does not exclude it.
9, Therapeutic Use of Radium Emanations.
— Nagelschmidt reports ten cases in which he has
successfully employed radioactive water. The dis-
eases thus treated include articular rheumatism,
oza;na, crepitation of the scapula, muscular rheu-
matism, and chronic catarrh of the bladder.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT
March 24, 1908..
1. A Theory of the Natural Immunity of the Living
Tissue, By Holzixgek.
2. Concerning Wassermann's Serum Diagnosis in Syphilis,
By Fraxkel and Much.
3. The Actual Changes in Operative Obstetrics,
By Baisch.
4. Concerning Localization and Clinical Symptoms of In-
tracranial Extravasations of Blood in the Newly
Born, By Seitz.
5. Stasis Hyperaemia in Acute Inflammatory Diseases,
By CosiE.
6. Concerning the Connection Between Diseases of the
Stomach and of the Nose, By Hecht.
7. The Treatment of Malaria with Atoxyl,
By Georgopulos.
8. Concerning Three Rare Forms of Haemorrhage During
Delivery, together with Some Remarks on the
Preparation of Students for the Treatment of Pu-
erperal Haemorrhages, By Selxheim.
9. Temperatures of Opposite Sides of the Body in Appen-
dicitis, By WiDMER.
10. Concerning Diabetes and Psychosis, By Kauf.maxn.
11. Concerning the Life Saving Action of Infusions of
Adrenalin and Salt Solution in a Case of Peritoneal
Sepsis, By Rothschild.
12. A Case of True Cholesteatoma of the Ear,
By Hansen.
13. Concerning a Phlegmon of the Neck of Dental Origin
Which Presented the Clinical Picture of Angina
Ludovici and was Associated with a Retropharyn-
geal Abscess, By Trautmaxn.
14. The Postoperative Tetanus Cases of Zacharias. Cases
of Catgut Tet-nus, By Kuhn.
15. The Genesis of Gallstones, By Lichtwitz.
16. Obituary of Nicholas Senn, By Allemaxn.
I. Theory of the Natural Immunity of Living
Tissue. — Holzinger declares that a certain weak
degree of osmotic movement in a nutritive solution
restricts the growth of microorganisms, which grow
luxuriously in the same solutions when at rest, and
that with a greater degree of intensity of the osmotic
movement of a nutritive solution, which in a state
of rest furnishes good material for the proliferation
of microorganisms, will completely check such pro-
liferation. Hence he advances the theory that the
living tissue is immune because the osmotic processes
in the tissue prevent the development of micro-
organisms that penetrate into it. It is only when
there is a marked slackening of these processes and
a relative rest of the tissue fluids that these become
favorable nutritive material and render infection
possible.
4. Localization and Clinical Symptoms of
Intracranial Extravasations of Blood in the New-
ly Born. — ^Seitz has observed twenty-three cases
of intracranial haemorrhage in the newly born, eigh-
teen of which were fatal. These he examined patho-
logically by means of frozen sections, and found that
these haemorrhages, instead of being arterial, as is
usual in adults, were venous almost without excep-
tion, that they were almost always subdural, between
758
PROCEEDINGS OF SOCIETIES.
[New York
Medical Jovrnal,
the dura and the pia, ahnost never in the brain sub-
stance, and rarely in the ventricles. Ha;matomata
between the dura and the bone are rare, not exten-
sive because of the firm adherence of the dura to
the bone, and never cause symptoms of pressure on
the brain. The point of greatest clinical importance
is whether the haemorrhages are infratentorial, over
the cerebellum and medulla, or supratentorial, over
the cerebrum. The infratentorial haemorrhages are
particularly dangerous, and, so far as his observa-
tion goes, are always fatal. They come from small
lacerated veins which open into the transverse or
neighboring sinuses. The amount of blood is usu-
ally slight, little if any over a teaspoonful. When
the transverse itself is lacerated the haemorrhage is
much greater and death is immediate. The danger
from these little haemorrhages in this place is due to
the pressure on the medidla oblongata and the centre
of respiration. Only blood stained liuid, no pure
blood, can be obtained by lumbar puncture. The
symptoms of an infratentorial haemorrhage are said
to be typical, so that a diagnosis may be made with
tolerable certainty during life. The children are
born either slightly or not at all asphyxiated, cry
strongly and give the impression at first of perfectly
healthy children. After some hours symptoms refer-
able to the medulla oblongata appear, irregular,
choppy, accelerated respiration, occasionally marked
respiratory spasms with deep cyanosis. In the
meantime the skin has assumed a bluish yellow
pallor, and the tension of the large fontanelle is
greatly increased. The breathing grows worse or
the respiratory spasms become more frequent, until
death occurs from twenty-four to forty-eight hours
after birth. When death is somewhat longer de-
layed some cerebral symptoms may develop from the
setting back of the blood, and if the haemorrhage
takes place more in the spinal canal certain spinal
symptoms will be present. Supratentorial haemor-
rhages are almost always unilateral and situated over
the convexity of the brain. The quantity of blood
is usually greater, so that more pressure is exerted
upon the neighboring parts of the brain. The blood
comes from lacerated veins that empty into the
longitudinal sinus. The children may be born spon-
taneously, easily, and quickly of multipara, or they
may be forceps cases. They are not asphyxiated, or
revive with little difficulty and cry well. During the
first day nothing wrong is to be noted ; on the sec-
ond day they become very restless, cry continually,
and refuse to nurse. This hard crying apparently
without reason is a very characteristic symptom, and
in the author's experience is always present. It is
caused by the painful tearing of the dura. The great
fontanelle shows about this time a somewhat in-
creased tension, and the following symptoms gradu-
ally develop, dependent on the pressure on the brain :
Disturbances of respiration, especially spasms dur-
ing inspiration, increase of the blood pressure, un-
consciousness, and sometimes, though not as com-
monly as in adults, slowing of the pulse, from irri-
tation of the vagus. The chalky white appearance
of the children is very marked. In addition to these
general symptoms there are local symptoms from
which the scat of the haemorrhage can be determined
in .some cases. In all cases with marked progressive
symptoms of intracranial pressure, operatixc inter-
vention is indicated, which has been practised some-
times with success. The five children that recovered
were cases of cerebral haemorrhage. Three recov-
ered fully and later showed no trace of mental or
nervous disturbance. The fourth had nystagmus,
strabismus, and athetosis of the left hand. He died
when nine months old of gastroenteritis. Of the
fifth nothing certain could be learned.
AMERICAN SOCIETY OF TROPICAL MEDICINE„
Fifth Annual Meeting, Held in Baltimore on March
28, 1908.
The President, Dr. J.ames M. Anders, of Philadelphia,,
in the Chair.
A Review of the Year's Progress in Tropical
Medicine was the title of the president's address.
He referred to the work of the Indian Plague Com-
mission, which has resulted in the confirmation of
the suspicion that plague was transmitted from rat
to rat and from rat to man by the rat flea ( Pulex
chcopis). He referred to the results of the use of
Hafifkine's prophylactic in reducing the mortality
by about eighty-five per cent. He mentioned the
work of Strong in his attempt to produce artificial
immunity by the injection of attenuated living cul-
tures of Bacillus pesiis. He spoke of the work of
Ashburn and Craig on the relation of Culc.v fati-
gaiis to the distribution of Filaria philippiiiciisis,
and on the de^felopment of the embryos of this
nematode worm in the mosquito in question. He
also referred to the work of the same authors on
the transmission of dengue by the same mosquito,^
Culex fatigans. The paper by ?\Iusgrave on
paragonimus infection, the discovery of a body re-
sembling a spirochaeta in a kidney from a case of
yellow fever, the theory of the aetiology of beri-
beri advanced by Hewlett and DeKorte. with the
description of a protozoon parasite ; the treatment
of Malta fever with a bacterial vaccine prepared
from pure cultures of Micrococcus melitensis; the
occurrence of Entamaba coli in the stools of ap-
parently healthy men ; the comparative study of
dystenterylike bacilli by Fisher ; the reports of cases
of gangosa by Stitt and by Musgrave and Marshall
in the Philippines ; the work on human myiasis :
the work of the Puerto Rico anaemia commission on
uncinariasis and their good results during 1906,
when they treated more than 89,000 cases ; the In-
ternational Conference on Sleeping Sickness and
Koch's suggestion that the disease might be trans-
mitted by coitus ; the formation of the Interna-
tional Society of Tropical Medicine at the Four-
teenth International Congress of Hygiene and
Demography ; the establishment of the Amtals of
Tropical Medicine and Parasitology and of the
United Stales Naval Medical Bulletin, were all re-
ferred to.
Dw John M. Svv.\x, of Philadelphia, read the
report of the secretary and the report of the
treasurer.
A Memoir of the Late Dr. James Carroll was
April iS. 1 908. J
PROCEEDINGS OF SOCIETIES.
759
read by Dr. Josei-h McFaklaxd. of Philadelphia,
an honorary member of the society.
Dr. William S. Thayer, of Baltimore, de-
scribed the last illness of Dr. Carroll.
Soil Pollution in Hookworm Disease was the
title of a paper by Dr. Charles Wardell Stiles,
of the United States Public Health and Marine
Hospital Service. Dry skin, dry hair, winged
scapulae, and tibial ulcers were constant phenomena
in cases of hookworm infection. Dr. Stiles was of
the opinion that the worm was a blood sucker, and
said that if the worm was examined as soon as it
was expelled, blood would be found in its gastroin-
testinal tract. Hookworm disease was more fre-
quent in a country in which there was sandy soil
than in one in which the soil was composed of clay,
as illustrated in some of the southern United
States. The number of cases of infection rose in
districts in which there was a sandy soil, and fell
in districts in which there was a clay soil. Soil
pollution was the great cause for the spread of the
disease. The small farms were not provided with
proper privies, so that the result was a large
amount of soil pollution. Dr. Stiles was of the
opinion that the poor white in the South was the
product of hookworm disease to a great extent.
He showed a plan for a hygienic privy for small
farms.
Dr. William S. Thayer, of Baltimore, asked
what could be accomplished by having the people
wear shoes.
Dr. Stiles said that many of the people in the
rural districts of the South could not afford to buy
shoes. Eighty per cent, of the cases were pre-
ceded by ground itch, but he was of the opinion
that the educated people were infected through the
mouth.
Dr. Bailey K. Ashford, of the army, said that,
so far as Puerto Rico was concerned, there was no
distinction of frequency of infection as regarded
the soil. In that island the infection was so preva-
lent and the conditions were so favorable for the
development of the embryos that the character of
the soil made no difference. He had seen cases of
tibial ulcers which recovered following the use of
thymol. He gave it as. his opinion that the symp-
toms of uncinariasis were due to the liberation of
a haemolytic toxine. Dr. Stiles said that the popu-
lation of Puerto Rico was seven times as dense as
that of North Carolina, for example, and that the
chance for soil pollution and infection was much
greater.
Rat Extermination was the title of a paper by
Mr. D. E. La.xtz, of the United States Department
of Agriculture. He said there were some 300 spe-
cies of rats in the world, but there were only four
species which were cosmopolitan — Mus rat fits, the
black rat; Mus decumanus, the gray rat; Mus
alexandrimis, the roof rat; and Mus musculus, the
mouse. Ninety-eight per cent, of the rats in the
United States were of the species Mus decumanus,
and about two per cent, were of Mus rattus. Mus
decumanus was adaptable to all kinds of tempera-
tures ; it even bred in cold storage plants ; the fe-
male had from three to five pregnancies a year, with
an average of ten young at each pregnancy in the
latitude of Baltimore ; in the South the number in
each litter was less ; in India there was an average
of 8.1 to each litter. The fecundity of the rat was
increased by a plentiful supply of food. Mus de-
cumanus was the most destructive rodent in the
world. If each farmer in the United States had
one rat for every head of live stock on his place,
the grain bill would be $100,000,000 yearly. Mus
decumanus was omnivorous; it carried plague, and
disseminated trichiniasis and septic pnevunonia.
The latter disease he believed was often due to
drinking water in which a rat had died and in
which its body had decomposed. In San Francisco
the sanitary authorities were catching 10,000 rats
a week and expending about $42,000 a week.
About one per cent, of these rats were infected with
Bacillus pestis. In order to exterminate rats
their natural enemies must be spared — hawks,
owls, and skimks. The injury done by these ani-
mals to game was not nearly so great as that done
by the rats. Buildings might be kept free from rats
by employing rat proof construction and by screen-
ing low windows. The guillotine trap was the best
device for the destruction of the animals ; the best
bait was "wienerwurst." Poisons could not be
placed about inhabited buildings.
Puerto Rico as a Field for Research in Trop-
ical Medicine. — Dr. Ashford read a paper on this
subject. He had seen about 15,000 patients in hos-
pitals and dispensaries while on duty in the island,
and he supposed that at least 20,000 others had been
seen by his colleagues. Uncinariasis was by far the
most important disease. . Seven per cent, of the
strength of one battalion harbored Filaria nocturna.
Chyluria, varicose groin glands, and other filarial
diseases were common. Erysipelas bore a relation
to filarial disease, particularly when in the lower
limb ; it was sometimes confounded with malarial
disease. Bilharziosis was fairly common ; in one
district five per cent, of the rural population were
infected with Schistosomum Mansoni. This infec-
tion was not attended by eosinophilia. The ova
were never found in the urine. The infection seemed
to be on the increase, and in places it was epidemic.
The most common symptoms were bloody and nui-
cous stools with pain. Ascaris and oxyuris infec-
tions were common. In one case of the latter infec-
tion 418 worms were expelled after two doses of
beta naphthol of two drachms each. Strongyloides
and Tricoccphalus trichiuris infections were com-
mon ; cestodes were rare ; trematodes offered a fer-
tile field for original work. Abscess of the liver was
very rare ; amoebic dysentery was, consequently, not
common ; there was no kala azar and no trypano-
somiasis. Treponema pertenue must exist, although
the speaker had seen no cases of yaws. Malaria
was common in certain valleys and coast districts.
Typhoid fever was very fatal and was becoming a
cause for alarm. Puerto Rico offered a favorable
opportunity for the use of antityphoid vaccine. Ba-
cillary dysentery was not common at present, al-
though it might be epidemic at times. There was
no plague, no cholera, no yellow fever, and no Malta
fever. There was some leprosy, an occasional case
of glanders, tetanus in infancy, and sprue occasion-
ally. Tuberculosis was bad in the towns, but not in
the mountains ; beriberi might be confounded with
uncinariasis. There had been a great change in the
760
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
attitude of the people toward hygienic methods since
the successful work of the anaemia commission.
Dr. Stiles said that he had seen endemic cases of
bilharziosis in Florida. He was of the opinion that
the disease was much more common in this country
than was usually thought to be the case. He was
coming to believe that the separation of Schistoso-
miini Mansoni from Schistosomum hcematobimn
was justifiable. The fasciola found in Puerto Rico
was a new species. He said that the ordinary treat-
ment of oxyuris infection was wrong. The adult
worms lived in the small intestine and should bi^
driven into the large intestine by an anthelminthic
before local injections were given.
Dr. John M. Swan, of Philadelphia, said that
within the last month, through the kindness of Dr.
A. A. Eshner, he had had the opportunity of exam-
ining the blood of a stout African negro in whom
there was an infection with Schistosomum Mansoni.
The blood had shown only 4.2 per cent, of eosino-
phile cells. He said that he had succeeded on one
occasion in expelling four adult specimens of Tricho-
cephalus trichiuris, two males and two females, with
thymol, used as advised by the Puerto Rico ansemia
commission.
Dr. JuDSON Daland, of Philadelphia, said that
kala azar might in the future be imported into the
West Indies by the coolie laborers from India.
Vaccination Against Plague.— Dr. C. P. Emer-
son, of Baltimore, read this paper, by Dr. Richard
P. Strong, of Manila. He described the treatment
of persons exposed to plague by the injection of at-
tenuated living cultures of the Bacillus pestis. He
had vaccinated 200 persons. There was no severe
reaction. There was a little induration and redness,
with soreness on pressure, at the point of inocula-
tion. There had been no serious results so far. The
examination of tissues from apes after the inocula-
tions showed the presence of the organisms in the
tissues. The bacilli evidently reproduced for a time
and then died off. Vaccination should be done only
when the operator could guarantee the organism to
have lost all virulence. The stability of the viru-
lence of the Bacillus pestis necessitated the greatest
precautions and repeated testing on guinea pigs. A
higher degree of immunity was obtained by this
method than by any other.
Dr. William H. Welch, of Baltimore, said that
there was no instance of substantial protection from
disease by the injection of killed organisms. It was
only by the injection of living cultures that we could
expect to get the best results in protective vaccina-
tion. The vaccination against smallpox, anthrax,
rinderpest, and tuberculosis in cattle was all done
with living organisms. There seemed to be little
hope in the direction of vaccination with killed or-
ganisms.
Quinine Prophylaxis and Mechanical Prophy-
laxis of Malaria. — Dr. William S. Thayer, of
Baltimore, read this paper. Malarial prophylaxis
by mechanical appliances included the protection of
human beings from the bites of mosquitoes by
screening, burning pyrethrum powder in the houses
daily, and wearing protective articles of clothing on
(he head and hands while out of doors. These meth-
ods had been carried out best by the Italians, both
officially and through the efforts of private corpora-
tions. On the railways which ran through very ma-
larial districts, and on which these methods had been
employed, the incidence of the disease had been
much reduced. The method was expensive, trouble-
some, and often impracticable. The Italians had
done much work in the destruction of the malarial
parasite within the human host by the prophylactic
use of quinine. The spring relapses initiated the
regular malarial season. In every relapse, accord-
ing to certain methods of treatment, the patient re-
ceived one or two grammes of quinine daily until the
infection was eradicated. Then he received one
gramme every eighth or ninth day for two months.
There were many objections to this method of treat-
ment— that the patient forgot it was not the least of
these. Consequently, instead of this routine the pa-
tients were treated vigorously until the infection was
conquered, and then small doses of quinine, six
grains daily, were given for a prolonged period.
Also 'all the inhabitants of a malarial district re-
ceived this prophylactic dose of quinine, two grains
three times a day, throughout the malarial season.
The results of continuous treatment were much bet-
ter than those of intermittent treatment. The diffi-
culties in the way of the general adoption of this
form of treatment were the expense of the method
and the lack of appreciation of its value on the part
of the public. In order to adopt a system of quinine
prophylaxis, furthermore, it was necessary to fur-
nish the drug in a form not too unpleasant for both
adults and children. In Italy the government sold
quinine bisulphate or quinine dihydrochloride in
sugar coated tablets for adults, and as quinine tan-
nate made into a confection with chocolate for chil-
dren. These forms were readily absorbed, and the
children took the latter form of the drug readily.
The tannate confections were supplied by a private
corporation, because there is a member of the Italian
government who believes that quinine tannate was
not readily absorbed. Dr. Thayer exhibited tables
which showed that under this system of quinine pro-
phylaxis there was less malarial disease in Italy than
formerly, even in intensely malarial districts, and
which also showed that the death rate was much less.
The state made a profit on the sale of the quinine. If
the state would take up the sale of quinine tannate
for the children, the results would be better than
they were now. In the malarial districts of the
United States there was need of cooperation of the
municipal, county. State, and national governments
to establish some such system. In addition, the co-
operation of local boards of health and medical soci-
eties was required to educate the public to the neces-
sity for the adoption and continuation of such a
measure. The physician should be educated in the
modern methods of combating and recognizing the
disease, and an efficient and agreeable form of qui-
nine should be oft'ered for sale at a low rate.
Mosquito Extermination. — Dr. L. O. How.\rd,
of the Department of Agriculture, read a paper on
this subject. He said that the Italian method of
prophylaxis was by giving quinine ; the German
method was to prevent the mosquito from biting the
infected individual ; but the American method was
to destroy the breeding places of the mosquitoes. He
pointed out some of the fallacies that had so far
been discovered in the methods of working out the
April i8, 1908.]
PROCEEDIXGS OF SOCIETIES.
761
problem, and showed the necessity for studying the
habits of the insects and for discovering the varie-
ties of mosquitoes that were able to transmit the dis-
ease. He said that mosquitoes would breed in salt
water, in the bilge water in vessels, in holes in the
trunks of trees, and in other out of the way places.
He exhibited a number of lantern slides showing
mosquito breeding places and the methods adopted
in various parts of the United States to destroy
these breeding places.
A Tank in which Live Mosquito Larvae and
Pupae Might be Exhibited, by being thrown on the
screen by an ordinary projection apparatus, was
shown by Dr. William N. Hill, of Baltimore.
Dr. Edward R. Stitt, of the navy, called atten-
tion to the difficulties of drainage in the tropics, and
to the difficulties in inducing persons to use mos-
quito net constantly, on account of the climatic pe-
culiarities. In places in the Philippines it was neces-
sary to use oil after burning of¥ the tropical under-
growth. Tadpoles were of use in destroying larvae,
and their development should be encouraged in
places in which mosquitoes bred. When he was
serving as the medical officer of the Nicaragua Canal
Commission, he was told by a physician who had
had much experience in the tropics that quinine pro-
phylaxis was unsatisfactory, and that when persons
who had taken prophylactic doses of quinine became
infected their attacks were harder to cure, and that
relapses were more common and were difficult
to cure. He spoke of tw^o instances w^hich seemed
to show that the malarial parasite could acquire a
resistance to quinine.
Dr. \V. E. Robertson, of Philadelphia, said that
he had seen twenty cases of malarial disease w^hich
were contracted in Colon, in which the patients had
received quinine prophylactically. In these cases it
was difficult to demonstrate the organism, and it
was only after the use of quinine hypodermaticall}-
that a cure was obtained. One of the patients had
gangrene of the skin after this form of treatment,
and another had a severe attack of multiple neuritis.
Dr. Stiles said that we ought to say protection
against mosquitoes and not mosquito extermination
in speaking of malaria prophylaxis. The doctrine
of mosquito extermination was doing harm, because
it was such an expensive procedure that communi-
ties were staggered when they considered the neces-
sarv outlay. Mosquito extermination, for this rea-
son, was not practicable in many districts in the
South. In these districts, however, it was possible
to protect against mosquitoes.
Dr. HiLL said that it was practicable to eradicate
mosquitoes. It was an economic question. Drain-
age of land w^orth little increased its value several
hundred times. It required the cooperation of the
town, county. State, and national governments.
Dr. Welch thought that probably the chances of
infection might be diminished by taking quinine.
Dr. Hamilton Wright, of Washington, said
that he had been in charge of sanitary measures for
the eradication of malaria at Port Sweatenham. Fed-
erated IMalay States. Every form of prophylaxis
known was adopted, and in six weeks there was no
malaria in the port. This result was accomplished
at a cost of $50,000.
Dr. Thayer said that it was advisable to employ
every prophylactic measure. Quinine should be
used for at least a month after the malarial
paroxysms had ceased. It was well knowm that
relapses were less tractable than the original at-
tacks. He did not think that the previous admin-
istration of prophylactic doses of quinine lessened
the number of parasites in the peripheral blood in
cases of fresh infection.
Strongyloides Intestinalis in Philadelphia. — Dr.
Daland read this paper. He reported a case of
infection originating in a Philadelphian who had
spent six days in Mexico six years before. The
history of the case seemed to exclude water infec-
tion. The blood of this patient contained from
38.2 to 27 per cent, of eosinophile cells. The re-
duction in the number of eosinophile cells w^as co-
incident with improvement in the symptoms of the
infection. The author described experiments made
with the fseces of the patient, in which he succeed-
ed in developing both male and female adults from
proper culture materials, and from which he suc-
ceeded in infecting guinea pigs by the application
of the faeces to a shaved area of the abdomen. The
tail of the male worm was supplied wath a bursa,
and there were some other anatomical features
which seemed to show that the parasite was a new
species.
Dr. Stiles brought some theoretical objections
to the acceptance of this as a new parasite, the
chief of which was that the earth and water used
in making the cultures had not been sterilized.
Dr. TH.A.YER said that the frequency of the oc-
currence of ova in the stools of the patient and the
presence of such a high eosinophilia seemed to show
some differences from the ordinary strongyloides
infection.
Dr. Daland said that ova in which embryos
were about to escape were common in the stools at
the present time.
Dr. Allen J. Smith had reported to Dr. Daland
that the parasite seemed to be a new species.
The Comparative Morphology of the Spiro-
chastas of Syphilis and Yaws. — ^Dr. F. F. Russell,
of the army, read a paper thus entitled. The au-
thor said that there appeared to be differences in
morphology which were regular and constant, and
that the species were distinct.
The society then adjourned to the Laboratory of
Chinical Pathology, where Dr. Terry, of New
York, gave a demonstration of living spirochaetse
and trypanosomes.
The following papers were read by title : Report
of the Society's Representative at the Third Inter-
national Sanitary Convention of American Re-
publics. Dr. R. H. von Ezdorf, of the Public Health
and Marine Hospital Service; Twenty Years' Ex-
perience with the Hypodermic Use of Quinine
and Urea Hydrochloride in Malarial Infection,
with Remarks on the Thirteen to Fourteen Days'
Cycle of Freedom Produced by a Single Injection,
by Dr. S. Solis Cohen, of Philadelphia; A Bio-
graphical Note of Dr. Louis Beauperthuy, by Dr.
Aristides Agramonte, of Havana : Some Notes on
a Collection of Entozoa Made by Dr. F. Creighton
Wellman in Portuguese West Africa, by Dr. Henn,'
B. Ward, of Lincoln, Nebraska; The Pathogenesis
of Pernicious Malaria, by Dr. William H. Deader-
762
BOOK NOTICES.
[New York
Medical Journal.
ick, of Marianna, Arkansas; Clinical Charts of
Quartan Malarial Fever Observed in the West
Africa, with Commentary, by Dr. F. Creighton
Wellman, of Benguella, Angola, West Africa;
History of a Case of Malarial Fever, Algid Form,
Choleraic Type, by Dr. R. H. von Ezdorf ; The
Prevention of Tropical Abscess of the Liver by the
Early Diagnosis and Treatment of the Presup-
purative Stage of Amoebic Hepatitis, by Dr. Leon-
ard Rogers, of Bombay ; and A Review of the Re-
cent Work on Spirillar Fevers, by Dr. F. Percival
Mackie, of Bombay.
Officers for the Ensuing Year were elected as
follows: President, Dr. James M. Anders, of Phila-
delphia ; vice presidents. Dr. William S. Thayer, of
Baltimore, and Dr. Rudolph Matas, of New Or-
leans ; treasurer, Dr. Wharton Sinkler, of Phila-
delphia ; secretary, Dr. John M. Swan, of Phila-
delphia ; assistant secretary. Dr. Edward R. Stitt,
of the navy ; councillors, to serve for two years,
Dr. George Dock, of Ann Arbor, Mich., and Dr.
Joseph McFarland and Dr. Judson Daland, of
Philadelphia.
lawk |[0titfS.
[ IVe publish full lists of books received, but wc acknou'l-
cdgc no obligation to revieiv them all. Nevertheless, so
far as spaee permits, ive review those in ivhich zve think
our readers are likely to be interested.]
The Produetion and Handling of Clean Milk. By Kenelm
WiNSLow, M. D., M. D. v.. B. A. S. (Harv.), Formerly
Instructor in Bu.^sey Agricultural Institute and Assistant
Professor in the Veterinary School of Harvard Univer-
sity, etc. New York : William R. Jenkins Company, 1907.
Pp. 207. (Price, $2.50.)
A glance at the title page indicates clearly the
author's qualifications for the work he has under-
taken, and the finished product of his mind
often bears ample testimony to Dr. Winslow's
fitness for the task. There are three intro-
ductory chapters devoted to Germs in their Gen-
eral Relation to Milk ; Composition of Milk and
Cream and Their Products : and Milk Products ;
then four — Feeding for Milk ; Housing and Care
of Cows; Handling of Milk and' Cream; Cost of
Producing and Distributing Clean Milk. Chapters
viii and ix arc devoted to milk distribution and
inspection. These are followed by an appendix re-
lating to the construction of bams and milk houses
and their proper maintcnanc(> and care ; and lastly
we find a general outline of a scheme for the con-
trol, supervision, and inspection of a citv milk sup-
ply.
We have rarely laic down a book the perusal of
which has given us so much pleasure. It is simple,
instructive, and practical, and the physician who
masters its contents will be in a position to influence
the dairy farmer in his rural surroundings greatly
and aid the general present movetTient in the eflFort
to secure clean milk at its point of production. The
work is well illustrated with cuts of improved dairy
apparatus, etc.
We have but one fault to find — the price seems
too high. Two dollars would have been ample, and
would, we think, lead to a nnich larger sale, and
correspondingly increase its influence in the com-
munity.
Medical Lectures and Aphorisms. By Samuel Gee, M. D..
Fellow of the Royal College of Physicians, Honorarv
Physician to H. R. H. the Prince of Wales, and Consult-
ing Physician to St. Bartholomew's Hospital. London :
Henry Frowde (Oxford University Press) and Hodder
& Stoughton, 1908. Pp. viii-308.
"Samuel Gee" we read on the title page, and
"S. J. Gee" and "Samuel Jones Gee" on the cover.
Dr. Gee, whatever his full name may be, has given
us a charming little book. It is not one to which
the practitioner will resort to "read up," but it is
one which the scholarly physician may pick up at
any time, and, opening it at almost any page, find
profitable and entertaining reading.
Our author is evidently a man of erudition, and
his style is somewhat suggestive of the late Sir
Thomas Watson's, though he has not Watson's ele-
gance of diction. He is inclined to be aphoristic,
and this tendency occasionally leads him to make
statements that it might be difficult to prove. For
example (on page 15) he says: "Apoplexy signifies
deep coma coming on suddenly and lasting till
death." Of course, the coma does not last till death,
in cases of recovery, however temporary and incom-
plete, from an apoplectic stroke.
Dr. Gee's reasoning is always consonant with
plausibility, though it is not invariably convincing.
One of the best examples in the book is to be found
in his lecture on the nature of asthma (page 129).
Almost the whole of the book is good, and we advise
our readers to obtain it. If they once begin to read
it they will hardly let it alone till they have finished
it. The present edition is the third, though it is not
so stated on the title page.
The Sciuii)isanc and the Semiresponsible (Demifous et
Demirespcnsables). By Joseph Grasset, Professor of
Clinical Medicine at the University of Montpellier, etc.
Authorized American Edition, Translated by Smith Ely
Jelliffe, M. D., Ph. D., Clinical Professor of Mental
Diseases Fordhani University, New York. New York
and London : Funk & Wagnalls Companj', 1907. Pp.
XXV-415.
Dr. Grasset remarks in his preface : "Society
knows to-day that, if it has any rights in connection
with criminals, it has also duties toward the dis-
eased. And. further, in the presence of a misde-
meanor or a crime it ought to put the question,
Should the accused be punished or should he be
treated?" To this the author gives his answer,
which he demonstrates in his book thus : The ac-
cused may be entirely responsible, and ought to be
punished ; or he is entirely irresponsible, and ought
to be treated : or he has an attenuated responsibil-
ity, and ought to be first placed in prison and later
in a hospital.
This third group, that of the borderland type, is
the main subject of the book, and the author comes
to the conclusion that the semiinsane and the semi-
responsible have rights which should be taken into
consideration, legally as well as scientifically. They
are described as they appear in literature, on the
stage, and in history, and as they are met in daily
practice by the specialist. We find among them
persons of genius who have been of great benefit to
mankind, and, again, persons whose actions have
been of great detriment and danger to their fellow
men.
The book has been well translated and will cer-
tainly find a ready audience among physicians,
jurists, and laymen.
April .8. 1908.]
MISCELLANY.
763
Prostatic Enlargement. By Cuthbert S. Wallace, M. B.,
B. S. (London), F. R. C. S. (England), Surgeon to the
East London Hospital for Children, etc. Bacteriology.
By Leonard S. Dudgeon, M. R. C. P. (London), Bac-
teriologist to St. Thomas's Hospital, etc. London :
Henry Frowde and Hodder & Stoughton, 1907. Pp. vii-
215-
This monograph offers an interesting contribu-
tion to our knowledge of prostatic hypertrophy.
The anatomy, physiology, and pathology of the
gland are considered in a brief way. The bacte-
riology of enlarged prostates is next studied, the
conclusions being that infection is a secondar\- phe-
nomenon in prostatic hypertrophy, and that there
is no evidence that enlarged prostates are due to
gonorrhoeal infection. The rest of the book deals
with the astiolog}-, diagnosis, and treatment of en-
larged prostates. As regards the suprapubic opera-
tion, Freyer, of England, gets all the credit, while
the names of American surgeons, such as Fuller and
Guiteras, who practised the operation before
Freyer, are not mentioned. The work of Hugh
Young, of Baltimore, on perineal prostatectomy, is
mentioned in a nonpareil footnote. Studies on the
enucleation operation are presented, in which it is
shown that the ideal total prostatectomy consists in
the enucleation of the gland from within its capsule
formed from the expanded outer portion of the
prostate.
Jahresbericht iibcr die Fortschritte in der Lehre von den
pathogenen Mikroorgauismen umfasscnd Bakterien,
Pilse und Protosoen. Unter Mitwirkung von Fachge-
nossen bearbeitet und herausgegeben von Dr. med. P.
VON Baumgarxen, o. o. Professor der Pathologic an der
Universitat Tiibingen. und Dr. med. F. Tangl, o. o Pro-
fessor der allgemeinen und experimentellen Pathologic
an der Universitat Budapest. Einundwanzigster Jahr-
gang. 1905. Leipzig: S. Hirzel, 1907. Pp. 941.
We welcome this year book, now in its twenty-
first year. It is indispensable for workers in bac-
teriology, in protozoology, and in the study of path-
ogenic fungi. The present volume analyzes nearly
3,00a articles in this field, which appeared in 1905.
\Yt wish Baumgarten's Jahresbericht many years of
continued usefulness, and congratulate the editors
on the high quality that characterizes these careful
abstracts.
Transactions of the American Surgical Association. By
Richard H. Harte, M. D., Recorder of the Association.
Volume the Twenty-fifth. Philadelphia : William J.
Dornan, 1907.
This, the twenty-fifth volume, published by the
American Surgical Association, contains many valu-
able contributions. These essays are interesting for
their own sake as well as for the discussions which
follow them, and which are also included in the
book. The volume is not overcrowded with illus-
trations, but where these appear they are clear and
instructive.
BOOKS. PAMPHLETS, ETC.. RECEIVED.
Diets in Tuberculosis. Principles and Economics. By
Noel Dean Bardswell, M. D., R. C. P., F. R. S. (Edin.),
Medical Superintendent, King Edward VH Sanatorium,
and John Ellis Chapman, M R. C. S., L. R. C. P., Medical
Superintendent, Coppin's Green Sanatorium. London :
Henry Frowde (Oxford Universitv Press) and Hodder &
Stoughton, 1908. Pp. 184. (Price, $2.50.)
Nervcn und Scele. Von Dr. Paul Kronthal. Mit 139
Figuren im Text. Jena: Gnstav Fischer, 1908. Pp. 431.
Nervous and Mental Diseases. For Students and Prac-
titioners. By Charles S. Potts, M. D., Professor of Neu-
rology in the Medico-Chirurgical College of Philadelphia,
etc. Second Edition, Revised and Enlarged. Illustrated
with 133 Engravings and Nine Plates. Philadelphia and
New York: Lea & Febiger, 1908. Pp. vi-570.
Hygiene and Public Health. By Louis C. Parkes, AL D..
D. P. H. University of London, Consulting Sanitary Ad-
viser to H. M. Office Works, etc., and Henry R. Kenwood.
M. B. Edin., D. P. H. Lond., Professor of Hygiene and
Public Health at University College, London, etc. Third
Edition, with Illustrations. Philadelphia: P. Blakiston's
Son & Co., 1907. Pp. xi-620. (Price, $3.)
Le Cancer. Prophylaxic. etiologie, traitcment. Par le
Docteur C. Sobre-Casas, medccin de Thopital Rawson
(Buenos Aires). Paris: G. Stcinhcil, 1908. Pp. 224.
A Manual of the Diseases of Infants and Children. By
John Ruhrah, M. D., Clinical Professor of Diseases of
Children in the College of Physicians and Surgeons, Balti-
more. Second Edition, Thoroughly Revised. Philadelphia
and London : W. B. Saunders Company, 1908. Pp. 423.
(Price, $2.50.)
A Simple Method of Water Analysis. Especially De-
signed for the Use of Medical Officers of Health. Bv John
C. Thresh, M. D. (Vic), D. Sc. (Lond.). D. P. H.
(Camb.), Fellow of the Institute of Chemistry, Member of
the Society of Public Analvsts, etc. Sixth Edition. Lon-
don : J. & A. Churchill. 1908. (Through P. Blakiston's
Son & Co., Philadelphia). Pp. 61. (Price. $1.)
Cancer. Relief of Pain and Possible Cure. By Skene
Keith, M. B., F. R. C. S. (Ed.). Author of Introduction
to the Treatment of Disease bv Galzanisni, and George E.
Keith, M. B.. C. }^L. Author "of Tc.vthook of Abdominal
Surgery with Mr. Skene Keith. New York : The Macmil-
lan Company. 1908. Pp. 155. (Price. $1.25.)
Itisallang.
The Army Medical Bill. — The measure known
as Senate Bill 1424, providing for the reorganiza-
tion of the ^k ledical Department of the United States
Army, was passed by the Senate, amended by the
House of Representatives, referred to a joint com-
mittee, further amended in conference, and has
been favorably reported from the conference com-
mittee substantially in the form given below, in
which it will no doubt become a law :
To increase the efficiency of the Medical Department of
the U. S. Army. Be it enacted, etc.. that from and after
the approval of this act the Medical Department of the
U. S. Army shall consist of a Medical Corps and a Aledical
Reserve Corps, as hereinafter provided ; and the Hospital
Corps, the nurse corps, and dental surgeons, as now
authorized by law.
Section 2. That the Medical Corps shall consist of one
surgeon general, with rank of brigadier general, who shall
be chief of the Medical Department ; fourteen colonels,
twenty-four lieutenant colonels, one hundred and five ma-
jors, and three hundred captains or first lieutenants, who
shall have rank, pay and allowances of officers of corre-
sponding grades in the cavalry arm of the Service. Imme-
diately following the approval of this act all officers of the
Medical Department then in active service, other than the
surgeon general, shall be recommissioned in the corre-
sponding grades in the Medical Corps established by this
act in the order of their seniority and without loss of rela-
tive rank in the Army, as follows : Assistant surgeon*
general, with the rank of colonel, as colonels ; deputy sur-
geons general, with rank of lieutenant colonel, as lieutenant
colonels; surgeons, with the rank of major, as majors;
assistant surgeons, who at the time of the approval of this
act shall have served three years or more, as captains ; and
assistant surgeons, with the rank of first lieutenant, who
at the time of the approval of this act shall have served
less than three years as such, as first lieutenants ; and
hereafter first lieutenants shall be promoted to the grade
of captain after three years' service in the Medical Corps.
Section 3. That oromotions in the Medical Corps to fill
vacancies in the several grades created or caused by this act,
or hereafter occurring, shall be made according to senior-
ity, but all such promotions and all appointments to the
764
OFFICIAL NEWS.
[New York
Medical Jousnal.
grade of first lieutenant in said corps shall be subject to
examination as hereinafter provided: Provided, That the
increase in grades of colonel, lieutenant colonel, and major
provided for in this act shall be filled by promotion each
calendar year of not exceeding two lieutenant colonels to
be colonels, three majors to be lieutenant colonels, fourteen
captains to be majors, and of the increase in the grade of
first lieutenant of not more than twenty-five per centum of
the total of such increase shall be appointed in any one
calendar year: Provided further, That those assistant sur-
geons who at the time of the approval of this act shall have
attained their captaincy by reason of service in the volun-
teer forces under the provisions of the Act of February 2,
1901, Section 18, or who will receive their captaincy upon
the approval of this act by virtue of such service, shall take
rank among the officers in or subsequently promoted to
that grade, according to date of entrance into the Medical
department of the Army as commissioned officers.
Section 4. That no person shall receive an appointment
as first lieutenant in the Medical Corps unless he shall have
been examined and approved by an Army medical board
consisting of not less than three officers of the Medical
Corps, designated by the Secretary of War.
Section 5. That no officers of the Medical Corps below
the rank, of lieutenant colonel shall be promoted therein
tmtil he shall have successfully passed an examination be-
fore an Army medical board consisting of not less than
three officers of the Medical Corps, to be designated by the
Secretary of War and to be held at such time anterior to
the accruing of the right to promotion as may be for the
best interest of the Service : Provided, That should any
officer of the Medical Corps fail in his physical examina-
tion and be found incapacitated for service by reason ot
physical disability contracted in the line of duty, he shall
be retired with the rank to which his seniority entitled him
to be promoted ; but if he should be found disqualified for
promotion for any other reason, a second examination shall
not be allowed, but the Secretary of War shall appoint a
"board of review to consist of three officers of the Medical
Corps superior in rank to the officer examined, none of
whom shall have served as a member of the board which
examined him. If the unfavorable finding of the examining
board is concurred in by the board of review, the officer
reported disqualified for promotion shall, if a first lieuten-
ant or captain, be honorably discharged from the Service
with one year's pay; and, if a major or lieutenant colonel,
shall be debarred from promotion and the officer next in
rank found qualified shall be promoted to the vacancy. If
the action of the examining board is disapproved by the
■board of review, the officer shall be considered qualified
and shall be promoted.
Section 6. That nothing in this act shall be construed to
legislate out of the Service any officer now in the Medical
Department of the Army, nor to affect the relative rank on
promotion of any medical officer now in the Service, or
who may hereafter be appointed therein, as determined by
the date of his appointment or commission, except as
herein otherwise provided in Section 3.
Section 7. That for the purpose of securing a reserve
■corps of medical officers available for military service, the
President of the United States is authorized to issue com-
missions as first lieutenants therein to such graduates of
/ reputable schools of medicine, citizens of the United
States, as shall from time to time, upon examination to be
prescribed by the Secretary of War, be found physically,
mentally and morally qualified to hold such comrnissions,
the person.s so commissioned to constitute and be known
as the Medical Reserve Corps. The commissions so given
shall confer upon the holders all the authority, rights, and
f)rivileges of commissioned officers of the like grade in the
Medical Corps of the U. S. Army, except promotions, but
only when called into active duty, as hereinafter provided,
and during the period of such active duty. Officers of the
Medical Reserve Corps shall have rank in said corps ac-
cording to date of their commissions therein, and when
employed on active duty, as hereinafter provided, shall
Tank next below all other officers of like grade in the U. S.
Army: Provided, That contract surgeons now in the mili-
tary service who receive the favorable recommendation of
the Surgeon General of the Army shall be eligible for ap-
pomtment in said reserve corps without further examina-
tion, provided that they arc not less than twenty-seven
-years of ape.
Section 8. That in emergencies the Secretary of War
may order officers of the Medical Reserve Corps to active
duty in the service of the United States in such numbers as
the public interests may require, and may relieve them from
such duty when their services are no longer necessary:
Provided, That nothing in this act shall be construed as
authorizing an officer of the Medical Reserve Corps to be
ordered upon active duty as herein provided who is unwill-
ing to accept such service, nor to prohibit an officer of the
Medical Reserve Corps not designated for active duty from
service with the militia, or with the volunteer troops of the
United States, or in the service of the United States in any
other capacity, but when so serving with the militia or with
volunteer troops, or when employed in the service of the
United States in any other capacity, an officer of the Medi-
cal Reserve Corps shall not be subject to call for duty
under the terms of this section : And provided further.
That the President is authorized to honorably discharge
from the Medical Reserve Corps any officer thereof whose
services are no longer required : And provided further,
that officers of the Medical Reserve Corps who apply for
appointment in the Medical Corps of the Army may, upon
the recommendation of the Surgeon General, be placed on
active duty by the Secretary of War and ordered to the
Army Medical School for instruction and further exami-
nation to determine their fitness for commission in the
Medical Corps.
Section 9. That officers of the Medical Reserve Corps
when called upon active duty in the service of the United
States, as provided in Section 8 of this act, shall be sub-
ject to the laws, regulations, and orders for the govern-
ment of the Regular Arm}', and during the period of such
service shall be entitled to the pay and allowances of first
lieutenants of the Medical Corps with increase for length
of service now allowed by law, said increase to be com-
puted only for time of active duty : Provided, That no
officer of the Medical Reserve Corps shall be entitled to
retirement or retirement pay, nor shall he be entitled to
pension except for physical disability incurred in the line
of duty while in active duty: And provided further. That
nothing in this act shall be construed to prevent the ap-
pointment in time of war of medical officers of volunteers
in such numbers and with such rank and pay as may be
provided by law.
Section 10. That all acts and parts of acts in conflict with
the provisions of this act are hereby repealed.
Public Health and Marine Hospital Service
Health Reports:
The following cases of smallpox, yellow fever, cholera,
and plague have been reported to the surgeon general,
United States Public Health and Marine Hospital Service,
during the week ending April 10, 1908:
Smallpox— Utiited States.
Places. Date. Cases. Deaths.
California — Los Angeles March 14-21 p
California — San Bernadino County .M.Trch 19-20 6
California — San Francisco '..March 19-20 18
District of Columbia — Washington . March 14-28 23
Florida — Jacksonville March 21-28 i
Illinois — Rockford March 21-28 i
Illinois — Springfield March 19-26 4
Indiana — Elkhart March 21-28 i
Indiana — Evansville April i i
Indiana — Indianapolis...". March 22-29 4 i
Iowa — Ottumwa March 21-28 2
Iowa — Sioux City March 1-31 16
Kansas — Kansas City March 21-28 18
Louisiana — New Orleans March 21-28 10 2
Michigan — Detroit March 21-28 2
Michigan — Grand Rapids March 21-28 4
Michigan — Kalamazoo March 21-28 2
Minnesota — Winona March 21-28 2
Missouri— Kansas City March 14-28 16
Missouri — St. Tosenh March 14-21 30
Missouri — St. T.ouis March 21-28 2
Montana — State Feb. 1-29 58
Nebraska — Nebraska City March 21-28 4
Ohio — HoUoway Feb. 22-March 19... 15
Ohio— Toledo March 14-21 2
Texas— San Antonio March 21-28 14
Washington — Spokane March 15-21 15
Washington— Tacoma March 14-21 i
Wisconsin — Milwaukee March 21-28 2
Wisconsin — Racine March 21-28 5
West Virginia— Charleston March 1-31 2
April 1 8, 1908.]
OFFICIAL NEWS.
765
Smallpox — Foreign.
Brazil— Para Feb 29-March 7---- «
Canada— Toronto March 14-21 7 „
China— Amoy (Kulangsu) Jan. 25-Feb. 15 p"^^°f
China— Foochow Feb. 22-29 Present
China— Shanghai Feb. 9-16.... 4 7
Ecuador— Guayaquil Feb. 29-March 14- •• »
France— Paris March 1 7-24 ■ • 5
India— Bombay Feb. 26-March 3.... 50
India— Calcutta Feb. 8-15 »
Italy— Catania ^^^jrch 5-12 ^
Java— Batavia Feb. 8-15 3
Mexico— Aguas Calientes il^^'^Y ^'^^
Portugal— Lisbon March 7-i4- ■ • i
Spain— Denia Feb. 29-March 14... 10
Spain— Valencia March 8-15 |7
Turkey— Bagdad Feb. 1-13 89 20
Yellow Fezer — Foreign.
Barbadoes — Bridgetown, vicinity .. .March 7-i4- • ' '
Brazil— Para Feb. 29-March 7.... 8 7
Ecuador — Guayaquil Feb. 29-March 14- ■ • "
Cholera — Foreign.
India— Bombay Feb. 6-March 3 '
India— Calcutta Feb. 8-15- 129
India— Madras Feb. 22-28 9
India— Rangoon Feb. 15-22 i
Plague — Foreign.
Brazil— Para Feb. 29-March 7.... 1
India— Bombay Feb. 26-March 3 185
India— Calcutta Feb. 8-15 13
India— Rangoon Feb. i 5-22 27
Public Health and Marine Hospital Service :
OMcial list of changes in ihe stations and duties of com-
missioned and noncoininissioned officers of the United
States Public Health and .Marine Hospital Service for the
seven days ending April 8, lOoS:
Blue, Rupert, Passed Assistant Surgeon. Detailed to at-
tend the meetings of the State Health Officers of Cali-
fornia, at Coronado, Cal, April 20, ic»o8, and of the
State Medical Society, at the same place, April 21,
1908, and to attend the meeting of the City Board of
Health at San Diego, Cal.
Bryan, W. M., Assistant Surgeon. Bureau orders of
March 25, 1908, assigning to temporary duty at the
quarantine station, Quarantine, La., amended to read
"for duty and assignment to quarters."
C.VRMicHAEL, D. A., Surgeon. Leave of absence granted
for ten days from March 25, 1908, on account of sick-
ness, amended to read for six days.
Delgado, J. M., Acting Assistant Surgeon. Granted leave
of absence for twenty-three days from March 3, 1908,
on account of sickness.
Fauxtlerov. Ch.\rles M., Assistant Surgeon. Directed
to report to the medical officer in command. New Or-
leans, La., for duty and assignment to quarters.
Goldberger, Joseph, Passed Assistant Surgeon. Granted
leave of absence for five days from March 3, 190S,
under provisions of paragraph 191, Service Regulations.
Hamilton, Jamin H., Acting Assistant Surgeon. Granted
leave of absence for thirty days from February 22,
1908, on account of sickness.
Hart. Lasher, Assistant Surgeon. Directed to proceed to
Stapleton, N. Y., reporting to the medical officer in
command at thai port for duty and assignment to
quarters.
Hoi.T. E. M., Pharmacist. Directed to proceed to New
Orle.ms, La., for special temporary duty, upon com-
pletion of which to rejoin his station.
Keen. \\'. H., Pharmacist. Granted leave of absence for
two days from March 30, 1908, under paragraph 210,
Service Regulations.
Krulish, E., Assistant Surgeon. Granted leave of absence
for two days from March 24, 1908, under paragraph
191, Service Regulations.
Lanza, A. J., Assistant Surgeon. Relieved from duty at
the Marine Hospital in San Francisco, Cal., and di-
rected to report April 15, 1908, to the commanding
officer of the revenue cutter Manning.
McCoNNON, George H., Assistant Surgeon. Directed to
proceed to Port Townsend, Wash., reporting to the
commanding officer of the U. S. revenue cutter Rush
for duty.
Mathewson, H. S., Passed Assistant Surgeon. Directed
to visit charitable institutions within a radius of
seventy-five miles of Cleveland. Ohio, from time to
time, for the purpose of examining aliens reported to
be public charges.
Oakley, J. H., Passed Assistant Surgeon. Directed to
assume temporary charge of the Marine Hospital at
Port Townsend, Wash., during the absence of Surgeon
Stimpson on leave.
Olesen, Robert, Assistant Surgeon. Directed to proceed
to San Francisco, Cal, reporting to the medical officer
in command for duty and assignment to quarters.
Roberts, Norman, Assistant Surgeon. Directed to pro-
ceed to Baltimore, Md., from time to time, for special
temporary duty, upon completion of which to rejoin
his station.
Rucker, W. C, Passed Assistant Surgeon. Detailed to
attend the meetings of the State Health Officers of
California, at Coronado, Cal, April 20, 1908, and of
the State Medical Society, at the same place, April 21,
1908, and to attend the meeting of the City Board of
Health at San Diego, Cal.
Ryder, L. W., Pharmacist. Granted leave of absence for
three days from April 6, 1908, under paragraph 210,
Service Regulations.
SiMONSoN, G. T., Acting Assistant Surgeon. Leave of
absence granted for two days from March 31, 1908,
revoked.
Stearns, H. H., Acting Assistant Surgeon. Granted leave
of absence for one day, March 27, 1908, under para-
graph 210, Service Regulations.
Stimpson, W. G., Surgeon. Bureau order of March 11,
1908, directing to report to the commanding officer of
the revenue cutter Thetis for temporary duty, re-
voked; granted leave of absence for six days from
April 7, 1908.
Stoner, G. W., Surgeon Granted leave of absence for five
days from March 30, 1908, under paragraph 189, Ser-
vice Regulations.
Thomas, J. M., Acting Assistant Surgeon. Directed to
make inspection of certain stations in Cuba, returning
to New Orleans upon completion thereof.
Van Ness, George I., Pharmacist. Granted leave of ab-
sence for thirty days from April 3, igo8.
Walker, R. T., Acting Assistant Surgeon. Granted leave
of absence for twenty days from April 27, 1908.
Warner. H. J., Assistant Surgeon. Directed to proceed
to Baltimore, Md., reporting to the medical officer in
command at that port for duty and assignment to
quarters.
Wertenbaker, C. p.. Surgeon. Directed to proceed to
Cape Charles quarantine station for special temporary
dutv, upon completion of which to rejoin his station at
Norfolk. Va.
Wetmore, W. C, Acting Assistant Surgeon. Granted
leave of absence for one day from March 31, 1908,
under paragraph 210, Service Regulations.
Wightman. William M., Assistant Surgeon. Relieved
from duty at Callao, Peru, and directed to proceed to
Guayaquil, reporting to Passed Assistant Surgeon
Lloyd for duty.
Wilson, J. G., Acting Assistant Surgeon. Granted leave
of absence for two days from March 21, 1908, under
paragraph 210, Service Regulations.
Wood, Charles A., Assistant Surgeon. Directed to pro-
ceed to Baltimore, Md., reporting to the medical offi-
cer in command at that port for duty and assignment
to quarters.
Appointments.
Dr. H. J. Warner commissioned as .\ssistant Surgeon
in the Public Health and Marine Hospital Service, April
3, 1908.
Dr. Charles E. Wood commissioned as Assistant Sur-
geon in the Public Health and Marine Hospital Service,
April 2. 1908.
Dr. Charles M. Fauntleroy commissioned as Assistant
Surgeon in the Public Health and Marine Hospital Ser-
vice, April I, 1908.
Dr. Robert Olesen commissioned as Assistant Surgeon in
the Public Health and Marine Hospital Service, April
1, 1908.
Dr. George H. McConnon commissioned as Assistant
Surgeon in the Public Health and Marine Hospital Ser-
vice, April I, 1908.
Dr. Lasher Hart commissioned as Assistant Surgeon in
the Public Health and Marine Hospital Service. April
2, 1908.
766
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
Resignations.
Passed Assistant Surgeon H. A. Stansfield; resignation
accepted by direction of the President, to take ef¥ect March
23, 1908.
Acting Assistant Surgeon W. J. Linley resigned, to take
eflfect April i, 1908.
Boards Convened.
Boards of medical officers were convened to meet on
April 9, 1908, for the purpose of making physical exami-
nation of such officers of the U. S. Revenue Cutter Service
as should present themselves for that purpose, as follows :
New York, N. Y. : Passed Assistant Surgeon H. W.
Wickes, chairman ; Acting Assistant Surgeon, T.
Alahoney, recorder.
San Francisco, Cal. : Surgeon H. W. Austin, chairman ;
Passed Assistant Surgeon C. H. Gardner, recorder.
Baltimore, Md. : Surgeon L. L. Williams, chairman;
Passed Assistant Surgeon J. T. Burkhalter, recorder.
Wilmington, N. C. : Passed Assistant Surgeon C. H. Lav-
inder, chairman ; Acting Assistant Surgeon —
— , recorder.
Key West, Fla. : Surgeon C. E. Banks, chairman ; Acting
Assistant Surgeon S. W. Light, recorder.
Mobile, Ala. : Surgeon G. M. Guiteras, chairman ; Acting
Assistant Surgeon J. O. Rush, recorder.
Port Townsend, Wash. : Passed Assistant Surgeon J. H.
Oakley, chairman ; Acting Assistant Surgeon Robert
Lyall, recorder.
Army Intelligence:
Official list of changes in the stations and duties of
officers seri i>i>; in the medical department of the United
States Army far the i^'cek ending April 11, igo8:
Carter, W. F., Major and Surgeon. Appointed a member
of an examining board to meet at Fort Monroe. Va.,
for the examination of officers of the Coast Artillery
Corps for promotion.
Davis, W. R., Captain and Assistant Surgeon. Appointed
a member of an examining board to meet at Fort
Baker, Cal., for the examination of applicants for
commission in volunteer forces.
JuENEMANN. G. F., First Lieutenant and Assistant Sur-
geon. Appointed a member of an examining board to
meet at Fort Baker, Cal., for the examination of appli-
cants for commission in volunteer forces.
LaGarde, L. a., Lieutenant Colonel and Deputy Surgeon
General. Arrived at Denver, Col., for duty as Chief
Surgeon, Department of Colorado.
Ragan, C. a., First Lieutenant and Assistant Surgeon. Ap-
pointed a member of an examining board to meet at
Fort Monroe, Va., for the examination of officers of the
Coast Artillery Corps for promotion.
Navy Intelligence:
Official list of changes in the medical corps of the United
States Navy for the iceek ending March 14, igo8:
Abeken, G. F., Passed Assistant Surgeon. Detached from
the naval training station, San Francisco, Cal., and
ordered to the West Virginia.
Bacon, S., Acting Assistant Surgeon. Ordered to duty at
the Naval Hospital, New Fort Lyon, Col.
BiELLO, J. A., Acting Assistant Surgeon. Ordered to duty
at the Naval Hospital, Portsmouth, N. H.
Bishop, L. W., Passed Assistant Surgeon. Detached from
the naval training station, Newport, R. L, and ordered
to the Hancock.
Green, E. H., Medical In.spector. Detached from the Navy
Yard, New York, and ordered to command the Naval
Hospital, New York. N. Y.
Harmon, G. F:. H., Medical Director. Detached from
command of the Naval Ho.spital, New York, N. Y.,
and ordered home to await orders.
Hough, F. P. W., Acting Assistant Surgeon. Ordered to
the naval proving ground, Indian Head, Md.
Lung, G. A., Surgeon. Detached from the Hancock and
ordered to the Navy Yard, New York, N. Y.
McGuike, L. W.. Acting Assistant Surgeon. Ordered, to
duty at the Nrival Hospital, Charleston, S. C.
Mei.horn, K. C, Acting Assistant Surgeon. Ordered to
the Wabash.
Morgan, C. R., Acting Assistant Surgeon. Resignation
accepted, to take effect April 8, 1908.
Page, J. E., Surgeon. Retired from active service from
April 3, 1908, under the provisions of section 1453, Re-
vised Statutes.
Plummer, R. W., Passed Assistant Surgeon. Ordered to
the Idaho.
Rhoades, G. C, Acting Assistant Surgeon. Ordered to the
Franklin.
Richards, T. W., Surgeon. Ordered to the Kansas when
discharged from treatment at the Naval Hospital, Mare
Island, Cal.
St,\lnaker, P. R., Assistant Surgeon. Detached from the
West Virginia and ordered to instruction at the Naval
Medical School, Washington, D. C.
Stearne, Assistant Surgeon. Appointed assistant surgeon
from March 19, 1908.
Wickes, G. L., Passed Assistant Surgeon. Commissioned
a passed assistant surgeon from April 12, 1908.
ZiEGLER, J. Z., Acting Assistant Surgeon. Appointed an
acting assistant surgeon from April 6, 1908.
Married.
Brophy — Strawbridge. — In Moorestown, New Jersey,
on Tuesday, March 31st. Dr. Thomas W. Brophy, of Chi-
cago, and Mrs. Esther W. Strawbridge.
Douglass — Ellis. — In Rome. New York, on Saturday,
April 4th. Dr. Adelbert C. Douglass, of Ilion, and Miss
Frances H. Ellis.
Hayden — Howard. — In Washington. D. C, on Thurs-
day, April 2d, Dr. Reynolds Hayden, LTnited States Navy,
and Miss Belle Howard.
Wetzel — Whalev. — In Covington. Ohio, on Friday.
.A.pril 3d, Dr. Henry S. Wetzel, of Dayton, and Miss Mary
Whaley, of Osborne.
Died.
Bennett.— In Battle Creek. Michigan, on Wednesday.
.\pril 1st, Dr. C. T. Bennett, aged sixty-three years.
Black. — In Louis\ilIe, Kentucky, on Sunday, April 5th.
Dr. Edward Henry Black, aged eighty-eight years.
Cabanne. — In St. Louis. Missouri, on Tuesday. .-Kpril
7th. Dr. James Shcpard Cabanne. aged sixty-nine years.
Clagett. — In Baltimore. Maryland, on Saturday, .^pril
4th, Dr. Joseph K. Clagett, aged seventy-seven years.
Clapp. — In Gene\a, New York, on Saturday, .\pril
28th, Dr. Henry D. Clapp. aged thirty-four years.
Egert. — In Holland Patent. New York, on Wednesday.
.\pril 1st, Dr. Philip Merriman Egert. aged forty-four
years.
Griffiths. — In Louisville, Kentucky, on Friday. April
loth. Dr. George W. Griffiths, aged fifty years.
Harwood. — In Sandwich, Ontario. Canada, on Monday.
.-\pril 6th, Dr. Charles Harwood. aged sixty-three years.
HiCBEE. — In St. Paul. Alinnesota, on Friday, April 3d, Dr.
Chester Goss Higbee, aged se\ enty-three years.
LowENGRUND. — In Philadelphia, on Wednesday, .\pril 1st.
Dr. Lee Lowengrund. aged fifty-five years.
Martin. — In Mcndota. Washington County, Virginia, on
Friday, April 3d, Dr. J. T. Alartin. aged sixty-three years.
Molyneaux. — In Woodland. Illinois, on Friday. April
3d, Dr. James C. Molyneaux, aged fifty years.
O'Connell. — In Montclair, New Jersey, on Saturday,
.\pril 4th, Dr. Joseph Francis O'Connell, aged fifty years.
Peaker. — In Toronto, Canada, on Sunday, April 5th. Dr.
J. W. Peaker. aged forty-three years.
RorsE. — In York. Pennsylvania, on Friday, April loth.
Dr. Samuel J. Rouse, aged eighty years.
Selden. — In Hampton, Virginia, on Saturday, April 4th.
Dr. Charles Selden, aged seventy years.
Stebbins. — In Geneva, New York, on Wednesday, April
8th, Dr. James H. Stebbins. aged seventy-four years.
Thomson. — In Belchertow n. Massaciiusetts, on Sunday.
March 29th, Dr. Edmond Fanford Thomson, aged forty
years.
Westlake. — In Elizabeth, New Jersey, on Tuesday.
April 7th, Dr. Warren Carter Westlake, aged fifty-eight
years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal it Medical News
A Weekly Review of Medicine, Established 1843.
AYjl. LXXXVII, Xo. 17.
XEW YORK, APRIL 25, 1908.
Whole No. 1534.
AN ORIGIXAL METHOD OF OPERATING FOR
CONGENITAL DISLOCATION OF THE HIP*
A Preliminary Report of Cases.
By Russell A. Hibbs, M. D.,
New York,
Surgeon in Chief of the New York Orthopaedic Dispensary an-.l
Hospital, etc.
\\'ithout an anjesthetic in the average uncompli-
cated case of congenital dislocation of the hip in
a child up to the fourth year (Fig. 4), and under an
ansesthetic in those older, it is possible by flexing and
adducting the thigh on the abdomen, and extending
the leg on the thigh to force the head down, be-
low, and behind the acetabulum. The route which
the head follows in its course downward is behind
the acetabulum.
It seemed to me possible, therefore, that if in
extending and abducting the thigh in an attempt to
bring the leg -back to its former position, parallel
to its fellow, some means could be devised by
which the head could be forced to travel upwards
by a more anterior route, a reduction of the dislo-
cation could be secured, as the acetabulum would^
be directly in the way of the anterior route. As-
suming, of course, that the acetabulum was large
enough to receive the head, both of approximately
normal shape and size. Two things appeared in-
dispensable to the accomplishment of this result ;
first, absolute control of the pelvis, and, second, an
immovable trochanteric pad so shaped and held
against the trochanter as to direct the head upward
and forward. Such resistance.as the capsule or the
Y ligament might offer to the reduction would cer-
tainly not be increased by such a method and might
be diminished, while the muscular resistance, so
serious an obstruction to reduction by the Lorenz
method, would be entirely avoided, with the in-
juries not only to the muscles themselves, but often
to other important structures, consequent upon the
application of a force necessary to overcome that
resistance.
Figs. I and 2 show an instrument which I have
devised and used for this purpose. This consists
of a board two inches thick, six feet long, and two
feet wide, with two windlass pulleys on the under
surface. In the board there are two openings
made (Fig. 2), A and B, for the trochanteric pad.
At points C and D are attachments for the pelvic
straps, and at E is a roller over which the straps
run. The child is placed on the board with its
sacrum resting on the solid board between the two
openings, A and B. The two pelvic straps are at-
*Presented at the Sectio
Medicine, April 17. 19D8.
in Orthopaedics of the Acaden
tached at points C and D, which are widely enough
separated for the straps to pass just internal to the
crest of the ilium, down over the ramus of the
pubis running over the roller just in front of the
perinaeum, E, on the under surface of the board, to
be attached to the two windlass pulleys.
By means of the windlass sufficient pressure
may be made on these straps to hold the pelvis
in an absolutely immovable position, without the
slightest damage to the skin or any other part.
The force is exerted laterally against the sides of
the pelvis, as well as backward. In locating C
and D, the points of attachment for these straps,
it is important to have them separated sufficiently
to insure this lateral direction of the force, and the
distance will vary with the size of the pelvis. The
openings, A and B, in the board are sufficiently
large to allow the trochanteric pad, which is five
inches by one and one-half inches in size, triangular
in shape, and hollow, to pass through, upwards.
This pad is attached to the under surface of the
board by an adjustment which makes it easy to ap-
ply it to either side, and by means of a worm screw
mechanism it can be forced up by the operator
with ease against the trochanter to any point where
it remains immovable. The direction of the pad
in its immediate relation to the trochanter is de-
termined and fixed by a ball and socket adjust-
ment. This pad is made of highly polished steel,
as such a surface slides over the skin with the least
possible friction. This instrument may be attached
to any plain wooden table, and is simple and inex-
pensive in construction.
\\'ith this instrument, in its more or less incom-
plete form. I have operated on fourteen hips — in
thirteen patients with absoltite success in placing
the head in the acetabulum in each without trau-
matism. In regard to the stability of the reduc-
tion, since the integrity of all the muscles and
structures about the joint is not impaired, may
they not furnish such stability to the reduction, as
will make a redislocation less likely to occur? The
greater tension placed upon them by the increase
in the length of the limb would seem a distinct ad-
vantage. This same fact would shorten the dura-
tion of the after treatment and the wearing of a
fixed dressing, and enable an early resumption of
the normal function of the limb. Such has been
the experience in the cases herein reported.
May it not be possible that some of the failures
by the Lorenz method, which we have considered
as due to the shallowness of the acetabulum, were
really due to the destruction of the resistance of
those structures which hold the head in its proper
relation to the socket, done by the stretching neces-
Copyright. 1908. by A. R. Elliott Publishing Comrany
768
HI BBS: OPERATION FOR CONGENITAL DISLOCATION OF HIP. [New York
Medical Jourxal.
sary by that operation to secure a reduction? In
operating with this instrument there is no trau-
matism of any consequence. These children have
all walked, several the next day after the operation,
Fig. I. — Showing complete instrunent used in operation for con-
genital dislocation of the hip.
and all within three days. The older cases have
complained of slight pain at first. The only trau-
matism that suggests itself as possible, in the use
of such force as is here used, is a fracture of the
neck of the femur. This has not occurred in any
of the cases, and with ordinary judgment I think
the possibility remote, because the force exerted
upon the femur at all times is in two directions,
namely, abduction and extension, and by the op-
erator's hand.
It would seem possible to secure a reduction by
forcing the trochanteric pad upwards, but here you
have a force which cannot be measured by the op-
erator so accurately. '
Case I. — M. R., age three years. Both hips dislocated.
The right dislocation reduced April 30, 1907. Left
dislocation reduced June 3, 1907. Right hip in plaster
nineteen weeks. Left hip in plaster fourteen weeks. Re-
ond operation December 10, 1907. Plaster applied with leg
in 65° abduction and 50° flexion, changed every three weeks,
leg being gradually brought to straight line. On March
20, 1908, the plaster removed, limbs were equal, motion
free, head in the acetabulum. Leg brace with a hip band
applied as a precaution. April 17, 1908, the reduction seems
secure. Limbs equal, head in acetabulum, motion free.
C.\SE IV. — E. M., age three years, male. Left hip one
inch shortening. Operation August 13, 1907. In plaster
thirteen weeks. Four months since removal of plaster.
On April 17th the limbs were equal, motion free, head in
the acetabulum, and result perfect.
C.\SE V. — M. O'F., age two years si.x months. Left hip
one half inch shortening. Operation September 10, 1907.
In plaster thirteen weeks. Four months since removal of
plaster. Limbs equal, motion free, head in the acetabulum,
and result perfect.
C.\.SE VI.— M. McP., age two years. Both hips dislocated.
Operation September 13, 1907, on right hip only. Died on
November i, 1907, of empyema, following pneumonia. Re-
duction remained secure to time of death.
Case VII. — S. H., age five years nine months. Left hip
one and one half inches shortening. Operation November
14, 1907. In plaster eight weeks. Nearly three months
since removal of plaster. Limbs are equal, motion free,
head in the acetabulum, and result perfect. April 17, 1908.
Case VIII. — K. S., age eleven years. Right hip two
inches shortening. Operation December 12, 1907. Plaster
removed February 19, 1908. In plaster ten weeks. Walks
with limb slightly abducted, with slight flexion at the knee.
Reduction seems perfectly stable. April 17, 1908: Head in
the acetabulum , motion free, limbs equal.
Case IX. — F. R., age six and one half years. Left hip
one and one eighth inches shortening. Operation February
II, 1908. Plaster removed April 4, 1908. In plaster seven
weeks. April 17, 1908: Head in the acetabulum, limbs
equal, motion free. Reduction seems secure.
Case X. — M. M., age nine years nine months. Left hip
one and one half inches shortening. Operation February 18,
1908. Plaster removed March 28, 1908. In plaster a little
over five weeks. February 17, 1908: Limbs equal, head in
acetabulum, joint motion free, 10° fle.xion of knee, and
slight abduction of thigh. It may be of interest to add that
in this case the Lorenz method was attempted unsuccess-
fully in another hospital.
Case XI. — H. F., age eleven years. Left hip one and one
I If
i n;. 2. — Upper surface of instrument, showing jjelvic straps, openings for trochantcnc pad, do.
suit on April 17, 1908: Head of femur in the acetabulum in
each hip, limbs parallel and equal, motion free, result
perfect.
Case II.— .A. M., twenty-one months old. Left hip dis-
located, three quarter inch shortening. Operation July
5, 1907. In plaster fourteen weeks. Head in the acetab-
ulum, limbs equal, motion free, and result perfect, April
17. 1908.
Case TII.— M. W., age two years. Left hip dislocated,
one half inch shortening. Operation July 5. 1907. In plas-
ter fourteen weeks. Taken from hospital bv mother
against niy urgent advice, immediately after the removal of
the plaster. Was again admitted with redislocation. Sec-
half inches shortening. Operation February 18, 1908. This
operation was attempted in the face of the fact that the x
ray showed a very shallow acetabulum. The .x ray taken
after the operation shows the head in the acetal)ulum.
March 31, 1908, plaster removed : head in the acetabulum,
limbs equal ; knee slightly flexed, and thigh slightly ab-
ducted. April 17, 1908: Has walked without support since
removal of plaster. Reduction continues secure.
Case XII. — Jennie D., age four years and six months.
Right hip one and one quarter inches shortening. Opera-
tion March 6, 1908. before the Interurban (^rthop.xdic Club.
Plaster removed April 13, 190S. Head in acetabulum, limbs
equal, reduction seems secure. .April 17th.
April 25. >9o8.l HIBBS: OPERATIOX FOR CONGENITAL DISLOCATION OF HIP.
769
Fig. 3, A.-
step of operation.
Case XIII. — Jennie R., age eleven years. Left hip one
and seven eighths inches shortening. Operation March
17th. Limb put in plaster parallel with its fellow, including
knee. April 2, 1908 : Knee freed. Plaster removed April
13th. Head in acetabulum, limbs equal, reduction secure
April 17th.
In each instance the reduction has been con-
firmed by an x ray taken immediately after the
operation with the Hmb in plaster, and in every
case after its removal.
Thus we have fourteen hips in thirteen children
which we may consider as having the head in the
acetabulum, and in most cases a sufficient time has
elapsed to make it safe to say that the reduction is
stable. In one. Case III, the dislocation recurred ;
Fig. 4, A. — X ray of Case XII. ' Shows dislocation.
the limb now seems stable. In Case \'I the patient
died while in plaster. In Case XI the shallow
acetabulum makes it doubtful that reduction will
be secure. However, it is so now.
The steps of this operation are shown in the illus-
fiG. 3, C. — Third Step of operation.
Fig. 4, B. — X ray of Case XII. Shov
liead was placed, without an anaesthetic,
trations (Fig. 3, A, B, C) and are: First, the child
is placed upon the table, and the pelvic straps at-
tached, then the leg to be operated on is flexed on
the abdomen. At this point, by the windlass, the
pelvis is made immovable by tightening the straps.
Second, the leg is extended on the thigh, with
the thigh held in adduction and flexion on the ab-
770
HI BBS: OPERATION FOR CONGENITAL DISLOCATION OF HIP. [New York
Medical Journal.
domen, thus forcing the head below the acetabu-
lum. At this point the operator, by means of the
wheel and worm screw mechanism, forces the
trochanteric pad, it being so set by the ball and
socket adjustment as to direct the head upward and
forward, firmly against the trochanter, and then
the thigh is extended and abducted, forcing the
head to travel upward, anteriorly, into the acetabu-
lum. The degree of extension of the thigh
necessary before the head reaches the acetabu-
lum in its course upward will depend upon
the distance below the acetabulum at which
it rests when the thigh is in flexion and
adduction on the abdomen and the leg extended,
and will be less in the older cases. The lower the
will vary with the age of the patient, being greater
in those with most shortening. However, in some
cases, as in Case XIII, age eleven, the leg was
brought to a position of io° abduction and i8o°
6. — First plaster, Ca
ng degree
extension in the first plaster. The first plaster
should be changed at the end of two weeks, when
it will be found possible to place the limb nearer
the normal position, and the plaster should be
chanqed every two weeks until its removal. I
head is gotten the easier will be the reduction, as
when it is well below the acetabulum it is forced into
the anterior route more gradually. The angle of
departure from the posterior route, traveled in its
descent, is more acute. The sensation when the
reduction is accomplished can hardly be mistaken,
and the snap can often be heard. The muscles be-
come taut, and the leg flexed.
Third, plaster is then applied with the thigh in
abduction and flexion, so as to put considerable ten-
sion on the muscles, and the knee is included in the
plaster with the leg extended so the ham strings
are tense. The angles of abduction and flexion
April J5, 1908. J
BUCHANAN: SUDDEN BLINDNESS.
771
doubt the necessity of any case wearing plaster
more than two months, and at the most three, and
in many a shorter time.
The ages of the cases herein reported, varying as
they do from twenty-one months to eleven years,
suggests that cure may be effected more quickly in
all cases, than by the Lorenz method, for instance,
and that the upper age limit where perfect results
may be obtained may be increased.
Is it not possible also that the number of cases
in which an anterior transposition has been con-
sidered a good result may be smaller?
All these cases were treated in the New York
Orthopaedic Hospital and this instrument. was made
m its shop.
130 East Thirty-sixth Street.
SUDDEN BLINDNESS AND ITS VARIOUS
CAUSES.*
By Mary Buchanan, M. D.,
Philadelphia.
Sudden blindness : The words strike terror to the
hearts of the strongest of us ! Modern man's en-
joyment comes so largely through his sight that the
mere thought of such a fate being ours causes each
to cry instinctively, "Rather let me die !" Sudden
]oss of vision, however, like sudden death, spares its
victim the horror of anticipation.
Sudden blindness in both eves simultaneously is,
fortunately, rare ; in one eye it is not infrequent,
and partial loss of vision is quite common. Blind-
ness, more or less complete, whether monocular or
binocular, is often spoken of as "amaurosis," while
that of lesser degree, and generally without appar-
ent fundus or other lesion, is called "amblyopia."
We will consider briefly first, sudden binocular
blindness ; then monocular ; and third, partial blind-
Tiess, suddeni in its onset.
Sudden complete blindness in both eyes, barring
traumatism (gunshot injuries, lightning stroke, etc.)
suggests always a systemic origin. Among the more
important of these causes may be mentioned those
usually classed as toxaemias, notably uraemia ; ma-
laria ; anaemia, due, for instance, to a profuse gen-
eral haemorrhage ; drugs and poisons, such as qui-
nine, lead, and methyl alcohol.
In regard to gunshot wounds of the head causing
blindness, it is interesting to note that the would be
suicide who puts the revolver to the temple and
fires rarely succeeds in his purpose ; the bullet plows
through the orbit and severs the optic nerve, or at
times goes through the chiasm, and instead of sud-
den death sudden blindness is his portion.
Uraemic amaurosis is most frequent in the nephri-
tis of scarlatina and pregnancy. It is more common
in acute than in chronic nephritis. It is generally
preceded by headache, but develops suddenly, is
"bilateral and passes rapidly into complete blindness,
"which may remain permanent or mav be relieved,
depending upon the course of the nephritis.
The fundus picture is negative and the pupils re-
act to light, showing the cortical nature of the affec-
tion, as the reflex arc of the pupil is not connected
with the cortex directly. The secretion of urine
is diminished or suspended, the specific gravity is
♦Read before tlic West Philadelphia Braiich of tlie Philadelphia
•County Medical Society, February 14, 1908.
high, and the urine contains a large amount of al-
bumin. The usual symptoms of uraemia are present,
and the treatment is for this condition.
The restoration of sight is at times sudden and
occurs in from twenty-four to thirty-six hours, or,
as Knies states, "when the nephritis is capable of
recovery the blindness may also disappear, other-
wise it indicates the beginning of the end."
The blindness produced by methyl alcohol poi-
soning is bilateral and generally complete. It may
set in a few hours after ingestion of the poison
(for it is a poison), or it may be delayed several
days. There is subsequent improvement in vision,
but finally a relapse into permanent blindness.
Methyl alcohol, or wood alcohol poisoning, is be-
coming much more frequent of late because the
relative cheapness of the drug (50 cents per gallon
against $2.60 per gallon for ethyl alcohol) leads to
its use in cheap whiskeys, Jamaica ginger, lemon
extracts, bay rum, cologne water, Florida water,
Columbian spirits, Cologne spirits, standard spirits,
union spirits, eagle spirits, etc., and also because of
increase of local option and prohibition states, which
makes it impossible for men to purchase alcoholic
beverages for drinking purposes, so they resort to
subterfuge ; they buy it for external use, or drink
one of the above preparations. Dr. Frank Buller
and Dr. Casey Wood made an exhaustive study and
reported of these cases in 1904 for the Ophthalmic
Section of the American Medical Association, and
found that 153 cases of blindness and 122 deaths
had been traced to this poison ; they stated that the
total would reach 400 if a more thorough search
were made. I quote the following from their con-
clusions :
The symptoms are gastrointestinal disturbances, more or
less severe, with pain, general weakness, nausea, vomiting,
vertigo, headache, dilated pupils, and blindness. If recov
ery does not occur there is marked depression of the
heart's action, sighing respiration, cold sweats, delirium,
unconsciousness, coma, and death.
Acute abdominal distress followed by blindness should
always suggest methyl alcohol poisoning. The visual fields,
if blindness is not complete, are contracted and show a
central absolute scotoma, that is, there is no perception of
color or liglit in the area.
Individuals differ as to their susceptibility to the poison,
and toxic symptoms may even be produced by inhalation
or by methyl alcohol rubs. Treatment consists in the use of
the stomach pump and stimulants, especially ethyl alcohol,
strychnine, and coffee, and external heat. The treatment of
the blindness is unsatisfactory; pilocarpine and potassium
iodide may be given early, later strychnine.
Malarial poison acting upon the optic nerves and
retina may cause a loss of vision or complete blind-
ness, lasting from several hours to days or months.
It disappears under malarial treatment.
Quinine in large doses may produce total blind-
ness due to spasm of the vessels diminishing the
blood supply and causing, according to Ward
Holden. a degeneration of the ganglion cells and
nerve fibres of the retina and optic nerve. The
pupils are dilated and do not respond to light, and
there is also associated with this tinnitus and deaf-
ness. Central vision may be restored, but the periph-
eral field will remain cut. The treatment is with-
drawal of the drug, and the administration of amyi
nitrite and strychnine.
Lead poisoning has been known to cause sudden
binocular blindness, probably central in origin.
Excessive haemorrhages, particularly from the
772
BUCHANAN: SUDDEN BLINDNESS.
[New York
Medical Journal.
Stomach, may cause sudden loss of sight, which may
be only temporary or may end in optic atrophy and
permanent loss of vision. The ophthalmoscope
shows a pale disk and contracted arteries. The le-
sions in the unfavorable cases do not appear until
a week or more after the haemorrhage. Uterine
cases give the most favorable prognosis.
Transitory blindness sometimes occurs with brain
tumors, particularly, according to Bruin, with those
of the occipital lobes. Hirschberg denies that blind-
ness in these cases is a localizing symptom.
Malingerers sometimes feign sudden blindness of
both eyes for gain, or to escape military duty. These
people must be closely watched. Priestly Smith and
E. Jackson give the following test for feigned
blindness :
Place a lighted candle in front of the subject; now hold
a 6 degree prism base out before one eye ; if both eyes see,
the one behind the prism will move inward, and on remov-
ing the prism will move outward, the other eye remaining
fixed. The explanation of this is that the prism throws the
Fig. I. — Embolism of the central artery.
candle image inward, causing two candles to appear, but
the impulse for binocular vision makes the eye move in-
voluntarily so as to fuse the images into one.
It is not safe to depend upon the reaction of the
pupils to light, because if the lesion is behind the
corpora quadrigemina, the pupils will still react, al-
though the patient is blind.
Mind, psychic, or object blindness, may appear
suddenly. It is that condition in which the individ-
ual, because of cerebral lesion or disturbances, is un-
able to recognize familiar objects.
Burr reports a case in a woman sixty years of
age who, while sitting at the table, suddenly lost
vision. When he examined her she could not tell
a watch when placed in her hands, .and she could
not feed herself because she could not recognize
knife, fork, or spoon.
Before these cases are classified as mind blind-
ness they should be carefully studied to exclude all
peripheral causes.
Hysterical blindness is rarely bilateral.
Complete sudden loss of sight in one eye without
external signs of inflammation suggests immediately
embolism of the central artery, complete detachment
of the retina, or an extensive haemorrhage into the
vitreous chamber.
In embolism of the central artery the history iS'
a sudden blindness, coming on without warning,,
without exertion, often on awaking from a sound
sleep. We expect to find this in a patient with a
heart lesion, but this cannot always be demonstrated
cHnically. The diagnosis can readily be confirmed
with the ophthalmoscope, for the picture is unique.
(See Fig. i.) There is a cherry red spot in the
macula which stands out well against the white
background, the disk edges are not visible on ac-
count of the swelling, and the arteries are reduced
to threads. It is a tragic picture, for our only
chance is in dislodging the obstruction and that
immediately, for the ganglion cells, which depend
for their nourishment upon the retinal vessels, are
soon starved to death and rapidly degenerate. Very
few cases of embolism, if any, recover vision.
Complete detachment of the retina is not apt to
occur spontaneously in a previously healthy eye.
There is a history of a fall, a blow, or a nearsightied
or diseased eye. An eye that has a detached retina
is always soft on pressure. If you will recall the
anatomy of the eye for a moment you will remember
that the retina has firm attachment only at the optic
nerve entrance, and anteriorly in the ciliary region ;
hence it must be held in place by the vitreous body.
It can become detached by being pushed away by
an exudate or a tumor beneath, or through the lack
of support from a diseased or fluid vitreous body.
A nearsighted eye often has a fluid vitreous body,
and with its weakened and stretched coats is in
danger of detached retina.
In these cases you get a gray reflex by throwing
a strong light into the pupil, but it is deep, because
the clear lens is in front of it. Possibly there has
been a slight detachment before, to which the pa-
tient has paid no attention, but questioning will
bring out the fact that he had noticed a moving
cloud or curtain before his eyes. This is what the
patients with partial detachment complain of. De-
tachment generally begins above, and then the fluid
sinks gradually to the lower portion of the eye and
increases until there is a total separation and blind-
ness.
The prognosis of total detachment is absolutely
hopeless, and while we rarely have both eyes lost
through embolism, it is not unusual to have detach-
ment in both eyes, although not simultaneously, be-
cause the same predisposing causes are apt to be
present. These patients must be cautioned as to
their danger, for even with the best of care as to
correct glasses, avoidance of close work, violent
exercise, etc., detachment may occur.
Sudden profuse haemorrhage into the vitreous
chamber will cause complete loss of vision, and to
the ophthalmoscope presents a dark, impenetrable
mass. It is not apt to occur unless there has been
traumatism, or there is disease of the bloodvessels,
or a blood dyscrasia.
Thrombosis of the central retinal vein causes
almost complete loss of sight at the time of occur-
rence and may ultimately lead to permanent blind-
ness. The ophthalmoscopic picture is typical ; the
veins are engorged, the arteries are reduced to
April 25, 190S.J
BUCHAXAN: SUDDEN BLIXDXESS.
Ill
threads, the outline of the disk is obliterated, and
the fundus is covered with numerous haemorrhages.
(See Fig. 2.) This is most apt to occur in elderly
persons with atheromatous vessels, but may appear
as a complication of facial erysipelas. The infection
IS then carried into the orbit, and the septic throm-
bus extends from the orbital vein into the retinal
vessel. According to Knapp, "if, after the subsi-
dence of an erysipelas involving the orbit, the eye
is found to be blind, with optic atrophy and attenu-
ated vessels, we may conclude that there has been
a thrombosis of the central retinal vein."
Thrombosis of the retinal veins may be preceded
by transitory attacks of blindness, as a premonitory
symptom.
These four conditions give no pain, and the ex-
ternal appearance of the eye is normal, but acute
glaucoma, on the other hand, which must never be
forgotten, produces intense pain and does alter the
appearance. Here the eyeball is hard to the touch,
Tig. 2. — Thromosis of the c<;:.:i\i; ein.
the pupil dilated and immovable, the cornea very
hazy, like steamed glass, the iris is pushed against
the cornea, and there is pain through the ball and
over the brow.
The attack causes marked prostration, nausea, and
vomiting. These patients are generally middle aged
or past it, and their future e>^sight and usefulness
will depend upon the recognition of the condition
by the family physician and his promptness in send-
ing for skilled aid. This is one condition where the
ophthalmologist is a necessity.
Sudden unilateral blindness may follow a blow
over the orbit, in which case the optic nerve is
generally severed or compressed by a splinter of
bone. Here the histor\^ of traumatism is an aid.
and every case of "black eye" should be examined
carefully, with the possibilitv of fracture in mind.
An X ray should be taken at once if vision is reduced
or lost. Delay is fatal to the return of sight.
Haemorrhage into the sheath of the optic nerve
or into the orbit may cause blindness, but this may
disappear as the blood is absorbed.
A transitory form of monocular blindness has
been recorded in which the blindness lasted about
half an hour, and is supposed to be due to a spasm
of the vessels. These cases are rare.
Blindness of one eye is often feigned by malin-
gerers or observed in hysterical patients. In a paper
read by Dr. H. F. Hansell, before the Ophthalmic
Section, College of Physicians, on this subject, men-
tion is made of the difficulty of distinguishing be-
tween these two types, particularly where suit for
damages is made. Dr. de Schweinitz gave a simple
rule to follow, "The blind hysteric is consistent, the
patient who pretends to be blind but is not hyster-
ical is not consistent."
There are a number of tests for simulated blind-
ness. One of the commonest is to place a red glass
in a trial frame before the good eye and ask the
patient to read the red letters on a test card ; these
cannot be seen through the red glass. Another is
to place a strong glass before the good eye through
which the patient could not possibly see, and a plane
glass before the "blind" eye, and ask the patient to
read a distant chart.
Another consideration in these legal cases follow-
ing injury is that the eye may really be blind, but
the condition existed prior to the accident. These
patients may declare they saw well before the trau-
ma, and yet an ophthalmoscopic examination reveals
a well marked optic atrophy, or a large patch of
sclera shining through where smooth choroid and
retina should appear. These degenerative changes
take at least three weeks and often months before
they show up. and would make good vision impos-
sible at the time stated by the plaintiff.
Sudden partial loss of vision may arise from con-
ditions similar to those causing complete loss. Thus
an embolism of a branch of the central artery would
cause a blind area in the part supplied by that
vessel ; or partial detachment, a cutting down of the
field in the portion corresponding to the part in-
volved. If it is above the patient cannot see the
ground, or he notices a cloud waving in front of it.
Here again we have a soft eyeball, and generally a
prominent, nearsighted eye to aid in the diagnosis.
It requires considerable skill to recognize an early
detachment with the ophthalmoscope, and even older
ones when they are peripheral, and it is in the early
stage onlv that there is hope of replacement and
restoration of function.
Retinal haemorrhage causes more or less blind-
ness, according to its position. A large haemor-
rhagic area at the periphery may almost escape un-
noticed by the patient, while a tiny one right at the
macula may reduce vision to about 1/60 of normal
and make reading an impossibility. A blow on the
eyeball, diabetes, arteriosclerosis, or anaemia are all
liable to cause haemorrhagic retinitis.
An acute inflammation of the orbital portion of
the optic nerve will blot out central vision suddenly.
This may be caused by prolonged exposure to in-
tense cold, by pressure from the sphenoidal sinus, or
inflammation extending from it. A sudden reduc-
tion of vision coming on after a coryza, or after in-
fluenza, should ahvays suggest sinusitis as a possible
cause.
Methyl alcohol poisoning of a milder grade than
described before will cause sudden central blindness.
Prolonged gazing at the sun, as during an eclipse,
will produce a temporary central blind spot which
774
COLE: RADIODIAGNOSIS OF RENAL LESIONS.
[New York
Medical Journal.
may persist for several days. Improvement in
vision may take place, but complete recovery is not
common.
The so called "snow blindness" is produced by
exposure of the eyes for a long time to the glare of
the sun on a large area of snow. This is mosvly an
affection of the lids and conjunctiva. The lids are
red and swollen, there is lacrimation and photopho-
bia with blepharospasm. The condition generally
passes off in three or four days without leaving any
bad results.
Electric ophthalmia is a condition similar to snow
blindness, occurring in those engaged in electric
welding, and occasionally in those who use a strong-
arc light. It comes on within twenty-four hours
after exposure, and recovery occurs in a few days
with no bad results. Exposure to strong electric
light may cause the same effect on the retina as
blinding by the sun, that is, there is a central blind
spot ])rodiiced. These workers should wear colored
glasses, either yellow, ruby, or a combination of blue
and red.
Transitory hemianopsia or scintillating scotoma
is, as its name implies, a transient loss of sight in
symmetrical portions of the fields of vision which
may last from a few minutes to half an hour. The
blindness commences over a small area near the
macula, with zig zag flashes at its periphery, and
gradually spreads over the whole side of the field.
It is usually followed by migraine, and is generally
classed as a symptom of the latter, though either
the scintillation or the migraine may be absent.
These attacks usually occur in intellectual individ-
uals ; and fatigue, long reading, hunger, and anaemia
may produce them. They are probably due to some
cerebral circulatory disturbance.
Permanent blindness involving half of each field
may occur suddenly. This is known as hemianop-
sia, and is due to a lesion at the chiasm, at the centre
of vision in the cortex, or between these two places.
The term is not used when the disease is in the eye
itself. If you will recall the anatomy of the brain,
you will remember how the optic nerves leave the
orbit and join at the optic chiasm, and then pass on
as the optic tracts. The fibres from the outer half
of each retina do not cross at the chiasm, but con-
tinue to the cortex in the tract on their own side,
while the nasal fibres cross at the chiasm and join
the tract on the other side of the brain. Hence, a
lesion of one tract or one cortical centre would de-
stroy vision in the temporal half of one eye and the
nasal half of the other eye. If the lesion is in the
optic tract, optic radiations, internal capsule, or pul-
vinar, hemiplegia, motor aphasia, or paralysis of
central nerves, may be noted as direct symptoms.
Homonymous hemianopsia is the most common
form ; that is where the right half or the left half
of each field is wanting. In this variety the patient
with the left portion of each field cut off is much
more fortunate than the one with the right portion
gone, because in reading and writing English it is
necessary to see ahead to the right, hence a patient
with right hemianopsia can neither read nor write.
The fact that a certain ward patient's plate always
returned with the food remaining on one side of it
led to the discovery that he had homonymous
hemianopsia. He only ate what he saw.
Bitemporal hemianopsia is where the outer side
of each field is lost. This can only be caused by a
lesion at the chiasm, as it is only here that the nasal
fibres from each retina meet. Binasal and alti-
tudinal hemianopia are so rare, and so unlikely to
occur suddenly, that they need not be discussed here.
The chief diagnostic symptom of cortical hemian-
opsia is what is known as vision nulle, that is, al-
though the patient knows he has a blind area in each
field, he is unconscious of it. It does not bother him
any more than the blind spot does a healthy person.
There are also a number of cases in which the
clinical history is of sudden blindness in one eye,
and close questioning will elicit the fact that the
patient suddenly covered the good eye, and acci-
dentally discovered that he could not see. Ophthal-
moscopic examination will prove that the lesion is
a chronic one, and has been so gradual that the other
eye has done all the work and the defect has not
been noticed. Cataracts are often discovered this
way, and grave fundus lesions, because they are
painless, often work irreparable destruction on this
account.
A large area of chorioiditis may also destroy the
retina and chorioid without the knowledge of the
patient, and be suddenly discovered through some
temporary shutting off of vision of the fellow eye.
It is strange but true that a case of "pink eye,"
ordinary catarrhal conjunctivitis, will give a patient
much more alarm and cause him to seek medical aid
much quicker than the sudden discovery of im-
paired vision without external inflammation. It is
not unusual to get a history of poor sight discovered
in a supposedly healthy eye some ten days to six
weeks previously. The victims delay, thinking "it
will come all right again," and when it does not.
they seek the ophthalmalogist too late to be of any
use, but to be assured that nothing can repair the
loss. The retinal tissue is so highly specialized that
it rapidly degenerates under pressure, or inflamma-
tion. This is a point for the general practitioner to
remember, for it is the family doctor that is often
first consulted in these cases of sudden blindness.
Not infrequently we see eyes stone blind from acute
inflammatory glaucoma where the doctor had passed
it off with "You've taken cold ; bathe it in hot water
and it will come around all right." If you do not
know what the condition is, don't waste time, but
call in the ophthalmologist, just as you would the
surgeon in serious abdominal conditions.
324 South NiiXEteenth Street.
RADIOGRAPHIC DIAGNOSIS OF RENAL LESIONS.
By Lewis Gregory Cole, M. D.,
New York,
Consulting Rontgenologist to the Board of Healtli, Rontgenologist to
St. Mary's Hospital for Children.
Since the more general practice of nephrotomy
has demonstrated the difficulty of diagnosticating
cases of renal calculi with any degree of certainty,
the demand for a more positive method has been
apparent, and the discovery of Rontgen, twelve
years agoi was at once eagerly seized upon as fur-
nishing this method.
Radiographs of favorable subjects were made
showing these lesions, and reports of these cases
were heralded around the world, creating in the
ILLUSTRATING DR. COLE'S ARTICLE ON ROENTGENOLOGICAL DIAGXOSIS OF RENAL LESIONS.
Key to the illustrations: a, ribs; b, spine and transverse process; c. psoas muscle; d. kidnev: c\ spine of ischium; g, gas in intestines; h. calculus;
I, faecal concretions; k, calcified costal cartilages; /. calcified artery; ni, phleboliths or calcified bodies; ji. flaw in plate; o, tuberculous kidney; p, styletted ca-
theter in ureter. Fig. i, normal kidney; Fig. 2, two large calculi in kidnev; Fig. 3. large branching phosphatic calculi; Fig. 4, large vesical calculus: Fig.
5,. ureteral calculus; Fig. 6, small soft renal calculus; Fig. 7, renal calculu?; Fig. 8, faecal concretions" resembling calculus; Fig. 9, calcified costal cartilages:
l*ig. 10, phleboliths or small calcarous bodies resembling ureterocalculi; Fig. i:, calcified plaque in artery or vein; Fig. 12, flaw in plate resembling small cal-
April 25, 1 90S. J
COLE: RADIODIAGXOSIS OF REXAL LESIOXS.
775
minds of the oversanguine the erroneous impression
that the x ray furnished a simple and infallible solu-
tion of the problem. With the generally limited
knowledge of the science then possessed, physicians,
surgeons, and instrument makers at once provided
themselves with x ray equipments and undertook to
make radiographs of renal calculi with what would
now be regarded as crude apparatus.
As a result radiographs were made, giving shad-
ows which were interpreted as calculi, but which,
in many cases, were not sufficiently distinct to jus-
tify a positive diagnosis, and in none of these early
plates was there sufficient detail to warrant a nega-
tive diagnosis. Such diagnoses were, however, fre-
quently made, and in many cases proved erroneous,
with the result, that this method fell into disrepute,
and it is with considerable difficulty that it is be-
coming- reinstated in its proper place.
Three years ago this spring, after making a num-
ber of satisfactory radiographs of the renal and
ureteral region, I read a paper before the genito-
urinary section of the Xew York Academy on The
Negative and Positive Diagnosis of Renal and
Ureteral CalcuH by the Ray of Selective Absorp-
tion, and demonstrated some plates which showed
calculi distinctly where the diagnosis had been veri-
fied by operation, and others which showed the
psoas muscle and the tips of the spinous process
distinctly enough to justify a negative diagnosis.
In some of these cases the symptoms of renal cal-
culi were so characteristic that the operation was
performed, and in only one patient was a stone
found that \yas not shown in the radiograph, and
in that case the plate did not extend high enough up
to include the area of the pelvis of the kidney, where
the stone was found on operation.
This success continued until the two tubes I was
using gave out, and with new tubes the results were
not nearly so satisfactory, and for several months
it was with great difficulty that I obtained radio-
graphs showing sufficient detail to justify a negative
diagnosis.
During the winters of 1904 and 1905 I devoted
much time to experimental work on the ray of se-
lective absorption, and the results of this line of work
are fully described in the Archizrs of the Rdntgeii
Ray, May, 1905, and further experiments along the
same line in the Archives of Physiological Tlierapy,
December, 1906, or in the transactions of the Amer-
ican Rdiitgen Ray Society. In brief, this resulted in
the separation of the x ray into three distinct varie-
ties: I, The direct ray: 2, the indirect ray; and 3,
the secondary, or Sagnac, ray.
The purely direct ray when it can be obtained
gives, on a well timed and properly developed plate,
the greatest amount of detail, not only the structure
of the bones, but the muscles, fasciae, fat, and even
the blood in the veins show very distinctly.
The indirect rays from the average tube are
equally as powerful and abundant as the direct rays,
and their effect is simply to fog the plate and ob-
scure the detail of the direct rays. It has been
demonstrated by Professor J. J. Thomson that the
secondary, or Sagnac, rays are generated in and
emanate from all substances under the action of the
X ray in inverse proportion to the density of the
substance, and I am convinced by my own experi-
ments that they are produced to a greater extent
by the indirect than the direct rays, and the effect
upon the plate is detrimental in the same manner
as the indirect rays.
Compression Blend. — The use of a diaphragm or
compression blend cuts off the indirect rays to some
extent and helps very materially in obtaining good
radiographs of the renal and ureteral region, but
it does not convert any greater percentage of the
energy into direct rays.
With an apparatus so constructed that one has a
preponderance of direct rays and using a compres-
sion blend to eliminate the indirect rays and limit
the field in which the secondary rays are generated,
we can obtain enough detail to enable one to make
a negative or positive diagnosis of renal or ureteral
calculi of sufficient size to justify an operation.
Technique. — The patient should be prepared for
the radiograph by thorough catharsis the night pre-
vious and an enema just before the exposure is
made. This is especially important when the patient
is constipated and the stools are hard and dry. The
bladder should also be empty.
Diet. — It is desirable that only a light breakfast
should be eaten, and that the stomach should be
empty before the radiograph is made.
Clothing. — The clothing should be removed fr(3m
the part of the body to be radiographed, not that
the clothing interferes so much with the rays, but
they are likely to contain buttons, hooks and eyes, or
pins, that might lead to a misinterpretation of the
negative.
Position. — The patient then lies with his back flat
on the table and the thighs flexed so that the small
of the back is in contact with the plate. Raising the
head or shoulders sometimes assists in securing this
position.
Large Plate for Genitourinary Tract. — If one
large plate is to be used to include both kidneys, both
ureters, and bladder, the tube is placed vertically
over the umbilicus, twenty or twenty-two inches
from the plate.
Size of Plate. — An 11 x 14 inch plate is the small-
est size that will include both kidneys, ureters, and
bladder, and if the patient is tall this is not large
enough. Just previous to adjusting the plate under
the patient it is well to test the tube. As the kidney
moves from one half to two inches during respira-
tion, the patient should hold his breath during the
exposure, otherwise the shadow of a calculus will
appear ill defined and indistinct, and if very small
will appear as a blurred line.
Exposure.- — The time of exposure varies from
ten to thirty seconds, according to the size of the pa-
tient and condition of the tube. The radiograph
should include the eleventh and twelfth vertebrae and
ribs above, and extend about one inch beyond the tip
of the coccyx below.
Compression Blend. — ^Much more detail may be
shown when a compression blend or diaphragm is
used. The compression blend not only compresses
the parts and holds the patient quiet, but it also pre-
vents to a large degree abdominal breathing. At the
same time it so limits the area exposed that its use
requires five radiographs to show the entire genito-
776
COLE: RADIODIAGNOSIS OF RENAL LESIONS.
[New York
Medical Journal.
urinary tract, one for each kidney and the upper
])art of the ureter, one for each ureter, and one for
the bladder and lower part of each ureter.
Renal. — The radiograph of the kidney region
should show the eleventh and twelfth ribs, and the
first, second and third vertebrje (lumbar).
LTCteral. — The ureteral radiographs extend from
the third lumbar vertebra to the brim of the pelvis.
bladder. — The radiograph of the pelvis includes
the pubis below and extends up as far as possible.
I'ull Set of Plates. — The necessity of making a
full set of plates cannot be too strongly urged. An
oculist would not limit his examination to one eye,
or an aurist to one ear. nor would a diagnostician
make a physical examination nf one side of the chest,
even although all the pain was on that side. Why
should a radiographer make a radiograph of one
kidney?' In a number of cases, which I will men-
tion later, calculi have been shown on the opposite,
side from which the pain occurred, or calculi have
been present on both sides and only given symptoms
on one. If an opinion is desired as to the size, shape,
position, and density of the kidney, then surely a
radiograph of both kidneys is necessary for com-
parison.
Interpretation of Plates. — The interpretation of
the plate is more important and more difficult than
making it, and lack of care and experience in this
is the cause of most of the errors that have been
made in the diagnosis of renal and ureteral calculi
by the x ray.
A person unfamiliar with woodcraft is astonished
at the way an old hunter can follow the track of an
animal in the woods, yet when his attention is called
to the barking of a fallen log, the slight imprint in
the ground, the turned leaf, or broken twigs, etc.,
they are all apparent. It is nnich the same in read-
ing x ray plates — the shadows are there, and an\-
one can see them when they are pointed out.
It requires a careful study and comparison with
other plates b\' a trained eye to detect slight shad-
ows, and it requires experience to determine whether
they are due to calculi or one of many other things
which I will mention later. This has been especialK
impressed upon me during the preparation of this
paper, when I have studied nearly fifteen hundre l
plates, made during my practice, some of the earlier
ones showing shadows of what I then failed to rec-
ognize as possible calculi, requiring repeated ex-
])osures for verification.
It is unwise to make a diagnosis on a wet plate ;
drops of water and the glistening of the wet surface
interfere with the detail. The plate should be al-
lowed to dry slowly and the back of the plate' thor-
oughly cleansed and polished. It should then be
carefully studied and compared with other plates in
a good even light. Some prefer an illuminating box-
where the light can be controlled with a rhcost'it, but
personally I prefer a northern sky or daylight with
a ground glass, holding the plate in my hands so
that it may be tilted nt different angles to .show finer
gradations of the shadow.
One is not justified in making a negative diagno-
sis of renal or ureteral calculus, unless a plate of the
renal region shows the following detail, which is
shown in Fig. i : i. The spine and transverse pro-
cesses should show distinctl\ all the way to the tip.
2, The outer border of the psoas muscle must show.
In some very flabby, fat patients it may not show as
distinctly as the kidneys. 3, The eleventh and twelfth
ribs should show distinctly, and in many cases the
bony detail may be distinctly seen. 4, In about 75
per cent, of the cases the kidney may be seen more
or less distinctly, and if special care in technique is
used, it may be shown in nearlv everv case. 5. The
liver is frequently seen, and at times it interferes
with showing the convex surface of the upper pole
of the right kidney. 6, The spleen also may be seen',
especially if it is enlarged or congested. 7, Accu-
mulation of gases in the colon and small intestines
appear on circumscribed areas, and folds in the walls
of the intestines are often seen traversing these
areas. 8, Pieces in the intestines, especially in the
colon, show very distinctly, and interfere very ma-
terially with the diagnosis of renal lesions.
Ureteral. — The plate of the ureteral region should
include the third, fourth, and fifth lumbar vertebrae,
and part of the sacrum and ilium. The bony detail
should show distinctly, and the sacroiliac svnchon-
drosis should be well defined. The outer border of
the psoas muscle is clear, and the accumulation of
gas and fjeces are frequently seen in the coecum or
sigmoid. The course of the ureter is about on a
line with the tips of the transverse processes, and
at the sacroiliac synchondrosis. Calcified arteries
are sometimes seen in the plates.
Pelvis. — This plate shows the pubes, bony
structure of the spine of the ischium, sacrum, and
coccyx all the way to the tip. The bladder dis-
tended with urine is sometimes well marked, also
when injected.
Diaguo.'iis. — Up to the present time the radio-
graphic diagnosis of the genitourinary tract has
largely been limited to the negative or positive diag-
nosis of renal, ureteral, or vascular calculi. We
will therefore consider this subject first.
After having made and carefully studied about
fifteen hundred plates of the genitourinary tract in
about five hundred cases, I believe that a plate hav-
ing the described detail will show any variety of
renal, ureteral, or vascular calculi of sufficient size
to justify an operation — that is, one that is too large
to pass.
In view of the fact that some of the best authori-
ties disagree with me in this statement, it is with
reluctance that I make it, but after carefully ex-
perimenting with the softest calculi that I could ob-
tain, and in one case using the very stone it was
stated would not show, I am convinced that I am
justified in making this statement. I placed the
stone behind a patient and made an exposure, and
it showed very distinctly on a plate placed be-
hind him. Thi.s, of course, is much easier
than if it were in the kidney. I then placed it
on the abdomen of a large man. and it showed
distinctly. This was much more difficult than show-
ing it in the kidney, because the further the calculus
is from the plate the less distinct it is. Not satis-
fied with this, I imbedded this calculus in paraffin
and ])laced it behind a ])atient the same distance
from the plate that it would be if it were in the
kidney, and it showed distinctly. Fig. 23 shows a
cystine calculus, which is one of the varieties that
sonic authorities claim cannot be shown by x ray.
April 25, 1 908. J
COLE: RADIODIAGNOSIS OF REXAL LESIONS.
777
Differential Diagnosis. — In some cases. Figs. 2.
3, 4, 5, 14, 15, 19, 20, 21, 23, and 24. the calculi
are so distinct that there is no difficulty in mak-
ing the diagnosis. In others. Figs. 6 and 7.
on account of the size or indistinctness of the
shadows, it requires the careful study of sev-
eral confirmatory plates to make a positive diag-
nosis or to distinguish between calculi and the
following: i, Faecal concretions; 2, gallstones;
3, calcified costal cartilages of the eighth and
ninth ribs : 4, spiculae of the bone ; 5, small cal-
carious bodies or so called phleboliths ; 6, folds of
intestines ; 7, enteroliths ; 8, foreign bodies in in-
testines ; 9, calcified arteries ; 10. calcified lymph-
noids ; 11, prostatic calculi; 12, finger marks; 13.
developing stains from uneven flood of developer ;
14, flaws m plates; 15. tuberculous kidney ; 16. shot
in back; 17, unknown.
1. Faecal concretions. — We are most frequently
called upon to distinguish between the shadows of
calculi and those of faecal concretions, such as
shown in Fig. 8, and it is unwise to make this dis-
tinction on one plate.
Calculus. Fcccal Concretions.
If the patient has held his The edges of the shadows
breath, the edges of the cal- are iil defined, and the
cuius will appear clear cut shadows less dense than
and well defined. The shad- those of calculi of the same
ows are more dense for size. They are usually mul-
their size, and are only seen tiple and at least some are
in the region of the kidney not in the region of the kid-
or ureter, and the most im- ney or ureter, and if time is
portant thing is to give time allowed to elapse between
for faecal concretions lo exposures and a cathartic
move out of the field or and enema are given, the
change position, and if the concretion changes its place
shadow remains in the same or disappears entirely,
place it is not faecal concre-
tion.
2. Gallstones. — Gallstones may be shown with
patients on back, but are more clearly defined when
patient lies with abdomen flat on the plate. The
reverse is true of renal calculi. Shifting the tube
slightly changes the position of the shadow of the
gallstone more than it does the shadow of the kid-
ney stone.
3. Calcified costal cartilages of the eighth and
ninth ribs. — The calcified costal cartilages of the
eighth and ninth ribs resemble renal calculi very
closely. They may appear, as is shown in Fig. 9, in
the kidney in the same positions in repeated ex-
posures. There is usually more than one cos-
tal cartilage calcified, which gives the ai)ix ir-
ance of a calcarious deposit throughout the kid-
ney, more than an isolated calculus, or two or
three calculi, and are usually bilateral. They
may be definitely distinguished from calculi by
having the lip of the compression blend under
the free border of the ribs : therefore, when-
ever the shape of a person is such that the compres-
sion blend must be on top of the free border of the
ribs in order to include the renal region, these shad-
ows must be distinguished from calculi.
4. Osteoplaques or spicula of bone. — In cases
of osteoarthritis of the vertebrje, they resemble
ureteral calculi. They are a trifle nearer the spine
than the normal course of the ureter, and the other
changes of the spine, such as lipping and destruc-
tion of the cartilages, are always present.
^. Small calcareous bodies or so called phlebo-
liths.
Calculus. Calcified Bodies.
Usually single and only CalcUied bodie': near the
on one side. If multiple lower end of the ureter usu-
they are arranged in lines ally are multiple and on
which correspond with the both sides. When multiple
course of the ureter, usually they are arranged in a line
are irregular and have running in the opposite di-
rough edges. If they are rection to the course of the
round, or small with rough ureter. They are round
edges, they change position with smooth edges and so
between exposures with at- small that were they calculi
tacks of renal colic and they would pass or change
blood in urine. They must position between exposures,
be in line with the course of L'-^ually they are one-quar-
the ureter. ter to three-quarters of an
iiich to the outer side of the
ureter.
Ureteral catharization, v.hich is discussed later,
aids very materially in distinguishing between these
conditions.
6, Folds of intestines. — These are not as well de-
fined as calculi ; usually seen only accompanied by
accumulation of gas and appear as long, narrow
shadows instead of the shape of calculi. Unless the
fold is permanent and held in place by adhesions,
it does not appear in confirmatory plates.
7 and 8. Enteroliths and foreign bodies. — En-
teroliths and foreign bodies change their position.
A Murphy button in the stomach viewed edgewise
might readily be taken for a large calculus, but
sooner or later it would show the hole in the centre.
9. Calcified arteries. — Calcified arteries usually
are bilateral and show the tortuous course of the
arteries, and are not in the position of the kidney
or ureter. \\'hether the shadow shown in Fig. 12
is a single calcified plaque in an artery which shows
indistinctly, or a true phlebolith in a vein, is unde-
cided, but it is certain that it is not a calculus in the
ureter.
10. Calcified lymphoids. — Calcified lymph
glands, especially those in the pelvis, resemble cal-
culi very much. They usuall\', however, are multi-
ple and not in line with the normal course of the
ureter.
11. Prostatic calculi. — Prostatic calculi ' are fur-
ther down than ureteral or vascular calculi, and
more closely resemble phleboliths.
12. Finger marks. — Finger marks made during
the development of the plates might readily be mis-
taken for stone.
13. Developing stains from uneven flood of de-
veloper.— Irregular flooding of the plates during
developing may leave a small area that resembles
a stone.
14. Flaws in plates. — A slight flaw in a plate came
as near causing me to make an error as anything I
have seen. The case I have in mind, shown in Fig.
12, appeared as a small, well defined, round shadow
with clear cut edges, exactl}' in the region of the
kidney and about the place the patient had com-
plained of the greatest pain. Up to this time I had
only made confirmatory plates in doubtful cases,
and this did not appear to be a doubtful case, but,
fortunately, a confirmatory plate was made and the
spot had disappeared. On closer study one could
see it was a flaw in the plate.
15. Tuberculous kidney. — Some cases of tuber-
778
COLE: RADIODIAGNOSIS OF REXAL LESIOXS.
[Xew York
Medical Journal.
culous kidney may be very readily diagnosticated
by X ray, as shown in Fig. 13. In this case the en-
tire kidney was involved with an old, slow tuber-
culous process. A radiograph made two years pre-
vious to this one was the first in which I felt justi-
fied in making such a diagnosis. It was later con-
firmed by the finding of tubercle bacilli, but the pa-
tient refused operation, and we are thus able to
watch the development of the case by a series of
radiographs. In another case the process was so
distinct that it was difficult to distinguish between
it and calculus, but as the treatment for each was
the same the differential diagnosis was not so im-
portant.
16. Shot in back. — Shot in the muscles of the
back are more distinct and the edges more clear cut
than calculi.
17. Aside from these possible mistakes we find
well defined permanent lesions which I have been
unable to diagnosticate.'
X Ray versus Exploratory. — Anyone who has
hunted for a needle in a finger, even after a radio-
graph has shown its presence and apparently its
exact position, realizes how difficult it is to find a
foreign body. The finger is much smaller than the
kidney, there is nothing to prevent cutting in all di-
rections, haemorrhages may be prevented, and all the
circumstances are most favorable, yet few persons
except radiographers know how prolonged and un-
successful operations for foreign bodies frequently
are. How often you hear this phrase : "The x ray
showed a stone, but none was found on operation."
No one would question for a minute the fallacy of
the exploratory operation, especially if the kidney
was split and the calices explored with the finger.
The following cases would show the relative value
of x ray and exploratory incision :
The writer radiographed a patient, as shown in Fig. 14,
and made a diagnosis of six calculi, a large one in the
pelvis, and five small ones apparently in the calices. An
operation was performed b)- a very careful surgeon, the
kidney was split and the large stone was found. A thor-
ough search was made by the surgeon and his assistant
for the small ones. The calices were explored with the
finger of each of the operators. Assuming that the nodules
on the calculus were what I had interpreted as five small
calculi, they informed me that the radiographic diagnosis
of a large calculus was correct, but that there were no
small ones present. About six weeks later the patient had
a severe ittack of renal colic and passed five of the largest
calculi that could possibly pass. The large calculus was in
such a position that the small ones could not possibly have
slipped past into the ureter before or during the operation.
A number of cases are on record where the cal-
culus had been shown in radiographs and not found
on operation, but later the diagnosis has been veri-
fied by removal of the kidney, when the calculus
has been found. Are surgeons justified in say-
ing that the calculi are not present after an ex-
ploratory operation, when a satisfactory radio-
graphic examination and positive diagnosis have
been made?
Catheterization versus X Ray in the Diagnosis
of Renal and Ureteral Calculi. — Comi)aring the
relative value of catheterization and x ray, so much
depends on the technique of the one and the dex-
terity with which the other is performed that we
will only compare the results of the best of each.
Each has its dangers.
'Tlicfc arc rmt reproduced because of lack of space.
In X ray there is the danger of the so called burn,
but with the short exposures of thirty to fifty sec-
onds this is practically eliminated. The danger of
infection and shock from ureteral catheterization
you are in a position to know better than I am, and
the discomfort, to say the least, w^ell — the patient
is the best judge of that, and most of them have
very decided views on this subject.
As to their value, each has its place. !Many
things can be determined w-ith the catheter that
cannot be with the x ray, but in the diagnosis of
renal calculus, if you cannot find a stone in the
kidney when it is split open by examining each
calix with your finger, how do you expect to make
a negative diagnosis of calculus at the other end of a
catheter sixteen inches long? And with what cer-
tainty can one say that he touches a stone in the
pelvis of the kidney? In the diagnosis of ureteral
calculi the catheter is of more value than in renal,
as one can say with certainty that he meets with
an obstruction so far from the bladder, and with
wax tips or other devices, in some cases may be
reasonably sure it is a stone, but whether it is small
or large, smooth or rough, and whether it will move
or not, it is impossible to say.
A radiograph as reproduced in Fig. 15 will show
the size, shape, and position of a calculus, and with
a little experience one can tell whether it will pass
or not. A small, rough one will lodge, while a
smooth one of astonishing size will pass. On the
other hand, small calcified bodies near the lower
ends of the ureters, called by many phleboliths. are
frequently mistaken for calculi. The characteristic
difiFerences between these are described early in this
paper, but a combination of catheterization and x
ray, as shown in Fig. 16, is of greatest value, using
a styleted catheter and making a radiograph.
As I said, these phleboliths are usually about ont-
half to three quarters of an inch to the outer side
of the course of the ureter, but sometimes directly
in line with the ureters, and in the x ray appear to
lie against the catheter. It is wise to make two
radiographs at diflferent angles to prevent this
source of error. The following cases will show the
fallibility of making a negative diagnosis of ureteral
calculus', even though the catheter passes all the
way to the kidney with little or no obstruction.
Case I.— The first case of ureteral calculus that I radio-
graphed showed a well marked shadow at the lower end
of the ureter, oval in shape and about one centimetre long.
It appeared in several plates. Ureteral catheterization
showed no obstruction at this point. An exploratory op-
eration was performed and on palpation no calculus coulci
be felt. The ureter was opened and a catheter was passed
down into the bladder without meeting with an obstruc-
tion. Aa that time I was not familiar w ith so called phleb-
oliths, and insisted there must be a calculus, so just be-
fore the wound was closed a further search was made and
the calculus was found in a pocket it had formed in the
ureter just before it passes into the bladder. It was pushed
out of the pocket into the ureter and out of the opening
near the kidney.
Case II. — The second ca.^e was where a young woman
was catheterized by one of the most eminent genitourinary
surgeons in the country, with a wax tipped catheter, and
the catheter was passed up to the kidney without obstruc-
tion, but with a scratch on the wax tip. Preparations were
made for an operation, but an x ray failed to show the
calculus in the kidney. The ureter was again catlieterized
and there was no obstruction in the ureter, or scratch on
the wax tip of the catheter. The operation was indefinitely
postponed, and later the case was referred to me by
April 25, 1908.]
COLE: RADIODIAGXOSIS OF RENAL LESIOXS.
another surgeon. Fig. 5 shows very distinctly a calculus
about one half inch in diameter near the lower end of the
ureter. An operation verified the findings of' the radio-
graph. The surgeon says the calculus passed from the kid-
ney to the lower part of the ureter between the time of his
last examination and my first. This, of course, I cannot
disprove.
Considering the previous case and the following
case which I am about to describe, it seems possi-
ble, at least, that the calculus was in the ureter and
the catheter passed it with little or no obstruction.
Case III. — The third case was referred by Dr. Bangs and
Dr. Pederson, and their history of the case and record of
operative procedure is as follows :
First attack of renal colic took place on July 12, 1907. It
was severe on the ri?ht side; there was frequent vomiting;
the pain was confined to right kidney region : no radiations ;
no bladder symptoms. Hjematuria was not noted, perhaps
because the patient did not look for it.
Second attack occurred the following daj'. It persisted
for ?even days with varying severity, some vomiting dur-
ing first day. The pain remained localized as before.
For a month thereafter he suffered nagging pain every
few days, lasting from a few seconds up to a few minutes.
Third attack happened on December 21, 1907. Very se-
vere, no radiation.
Fourth attack took place on December 24; the pain
ceased suddenly.
Fifth attack happened December 26th, and lasted from
10 p. m. until 5 a. m. Again the pain ceased suddenly.
Cystoscopy, performed on December 27th, showed no
calculus in the bladder, and nothing distinctively pathologi-
cal in its appearance.
Radiographic examination, December 28, 1907. showed
two calculi (Fig. 17). one just below the brim of the pelvis
and the other opposite the transverse processes of the
fourth lumbar vertebra.
Cystoscopy and catheterization of right ureter was per-
formed on January 8. 1908. No obstruction was encoun-
tered, no grating sensation was perceived.
Second radiographic examination, January 11, 190S,
showed that the calculus, which was near the brim of the
pelvis had descended to the lower end of the ureter, but
that the upper one was in the same place, opposite the
transverse processes of the fourth lumbar vertebra.
The lower stone was passed from the bladder, 11 a. m.,
January 12, 1908.
Cystoscopy and catheterization of right ureter performed
on January 13th. Again no obstruction was felt. Patient
was now free from all pain and tenderness over the right
ureter.
Another attack of pain in the right kidney region, lasting
ten minutes, during the night of February 24" Patient passed
another almond shaped calculus similar in shape and size
to the first calculus on February nth. The patient when
last seen (February 24th) had been entirely free from
sxinptoms of any kind.
Radiographs of both calculi were made" after he passed
them, and these are reproduced in Fig. 17 with the first
radiograph made of him.
These cases demonstrate that it is unwise to
make a negative diagnosis of ureteral calculus, even
if there is no obstruction in the ureter.
Do Calculi Perforate or Migrate Through the
Walls of the Ureter? — The case just described,
where a stone was found in a pocket near the lower
end of the ureter and another case (Tig. 18),
where a calculus was found to be imbedded in the
walls of the ureter, seem to suggest this possibil-
ity and Dr. Keyes told me of a case where a stone
containing urinary salts was found in the abdom-
inal cavity. In another case the catheter met wath
an obstruction about one and one half inches from
the ureteral orifice. The case was radiographed at
the patient's request to ascertain the size and shape
of tlie stone and the possibiHty of its passing. No
calculus was shown at this point, but there was a
well defined one in the kidney, which was verified
on operating.
One of the most important points that the writer
has to make is, that many of the cases having
typical attacks of renal colic do not have a stone
in any part of the genitourinary tract, and when a
calculus is shown in this class of cases it is usually
so small that it will pass without an operation other
than ureteral catheterization.
On the other hand, most of the cases in which
renal calculi have been demonstrated by x ray have
had no symptoms that were sufficiently character-
istic to justify an operation, and only those that en-
gage in the ureter or obstruct the pelvis cause
typical renal coHc. They may have pain either in
the back or side, especially on jolting or riding in
a car, tenderness over the kidney, dull aching, or
especially what is described by them as a sense of
weight or heavy feeling in the back. Figs, ig and
20 demonstrate this class of cases very clearly.
Fig. 19 shows a large rectangular calculus in the
pelvis of the right kidney, and Fig. 20 shows a cal-
culus four inches long in the lower end of the right
ureter of the same patient (in process of reproduc-
tion the plates are reversed, which causes it to ap-
pear on the left side), and yet the symptoms were
not sufficient to designate which side the trouble
was on. The patient had been treated for many
months or a year for stomach trouble.
A great many of the cases diagnosticated as lum-
bago or rheumatism of the back have renal cal-
culi. Whether the calculus is the cause of the lum-
bago, or the lumbago the cause of the calculus, is
not for me to decide.
Calculi giving symptoms of chronic appendicitis
are very common. Several of the cases in which
calculi have been dem.onstrated were diagnosticated
as appendicitis, and radiographs have been made
just to eliminate the possibiHty of calculus. This
has occurred in so many cases that some physi-
cians are having nearly all cases of obscure ab-
dominal lesions radiographed. The wisdom of this
is particularly shown in the following cases:
Case IV. — A woman, fifty years, complained of symp-
toms which were diagnosticated as appendicitis (chronic).
She traveled a great deal both in this countrj' and abroad,
and her hobby was to get the opinion of the best authorities
in every country, and strange as it may seem, they nearly
all agreed that it was appendicitis in some form or another.
She finally came under the care of a physician who had
many of his obscure abdominal lesions radiographed, par-
ticularly those of appendicitis, to distinguish them from
renal calculi. This case, as shown in Fig. 7, had a stone
in the pelvis of the kidney, and repeated urinary analysis
had given no indication of stone.
Ten or eleven of Ihe fifty-four cases in which I
have demonstrated renal calculi have complained
of all the pain, or the most severe pain, on the op-
posite side from that on which the calculus was
found. Fig. 21 shows one of these cases. This is
such a peculiar fact, requiring a detailed history of
each case to make it cotnplete, that it seems unwise
to incorporate it in this paper ; I therefore rnerely
mention it here to show the necessity of making
radiographs of both sides.
Besides making a positive or negative diagnosis
of renal or ureteral calculi, much information may
78o
BURVILL-HOLMES: CHRONIC FIBRINOUS BRONCHITIS.
[New York
Medical Journal.
be gained by a radiograph having sufficient detail
to show the kidney distinctly. The density, shape,
size, and position may help very materially in mak-
ing the diagnosis of tuberculosis, new growth, pro-
lapse, and congestion of the kidney, and ascertain-
ing the presence of the kidney on the opposite side.
The kidney may be seen more or less distinctly
in about 75 per cent, of the cases, and if special
care in technique and selection of. tubes is used, it
may be shown in nearly every case. Strange as it
may seem, the size of the patient has very little in-
fluence— indeed, in large, fat persons it is more
frequently seen than in thin ones. This may be ac-
counted for by difference in density between the
kidney and fat it is imbedded in ; the more fat the
greater this difference is. The soft tissues of some
patients are much more dense to the rays than
others, and where this is so the kidney shows very
distinctly compared with the spine, which in these
cases shows indistinctly.
The repeated appearance of one kidney and not
the other, or the increased density of one compared
with the other, or with the psoas muscle, indicates
a change in the kidney, and if this density is uni-
form, and the kidney is not mottled, it is due, prob-
ably, to congestion of that organ, as shown in Fig.
22. If the kidney appears mottled, as shown in
Fig. 13. or of irregular density, it would indicate
tuberculosis or new growth, and if the contour of
the kidney is changed in addition to the irregulari-
ties of density and mottleness, it increases the prob-
ability of new growth. Seveial confirmatory plates
are necessary, and these shadows must be differ-
entiated from the same things calculi are, particu-
lary foecal accumulations.
Size. — The size of the kidney compared with the
opposite one may be fairly accurately determined,
but it must be remembered that it is slightly en-
larged in the radiographed. The amount of this
depends on the distance of the x ray tube from the
kidney, and the distance of the kidney from the
plate. In a person of ordinary size, with the tube
eighteen inches from the plate, the radiograph rep-
resents the kidney about one half to three quarters
of an inch larger than it really is. In some cases
the pelvis of the kidney and the ureter show dis-
tinctly, but it is doubtful if this is of any patho-
logical significance unless it is thickened and irreg-
ular, which would indicate tuberculosis (Fig. 13).
The position of the kidney at the time the radio-
graph is made may be demonstrated very accurate-
ly if the position of the tube is considered. If the
kidney is shown to be out of place, the diagnosis of
floating kidney is positive, but if it is shown to be
in its normal place it does not indicate that it is not
movable, as the position of the patient, and par-
ticularly the pressure of the compression blend,
tend to cause it to assume its normal position.
Resume. — The principal points that should be
remembered are :
With a limited knowledge of the science, radio-
graphs have been made which did not have suf-
ficient detail to justify a negative or positive diag-
nosis, and persons without sufficient experience
have made negative or positive diagnosis on these
plates.
The separation of the x ray into three varieties.
The value of the direct in radiography and the
detrimental effect of the indirect and secondary.
The interpretation of the plate is more important
and more difficult than making it.
The amount of detail necessary for a negative
diagnosis.
Technique, diet, clothing, catharsis, position, ex-
posure, etc.
Necessity of making full set of plates.
Reasons for believing that one is justified in mak-
ing a negative diagnosis of calculus when detail as
described is present.
Things calculi must be distinguished from.
X ray versus exploratory examination in the
diagnosis of calculi.
X ray versus ureteral catheterization in the diag-
nosis of calculi.
Most patients having typical attacks of renal
colic do not have stones, and, on the other hand,
only very few of the patients who have calculi
have symptoms sufficiently characteristic to justify
an operation.
Similarity of symptoms of chronic appendicitis
and renal or ureteral calculi.
About one quarter of the patients in whom cal-
culi are found have the most pain on the opposite
side.
Value of the x ray in the diagnosis of tubercu-
losis, new growths, and nephroptosis.
One cannot expect any great amount of success
in renal radiography when work requiring so much
attention to detail is turned over to hospital order-
lies, nurses, even physicians without any training or
experience along this line.
103 Park Avenue.
A CASE OF CHRONIC FIBRINOUS BRONCHITIS.*
By E. Burvill-Holmes, M. D.,
Philadelphia,
Ex-.Vssistant Chief Resident Physician of the Municipal Hospital;
Bacteriologist of the Henry Phipps Institute.
Acute or chronic inflammatory conditions of the
bronchial mucous membrane, accompanied by ex-
pectoration of casts of the bronchial tree, are of com-
parative infrequency, and in consequence such cases
are always of interest. In the past thirty-eight
years one hundred and eleven cases of this disease
have been recorded in the literature. Of this num-
ber one hundred — including two of his own cases^ — •
Bettman (i) in an exhaustive article thoroughly
analyzed. Since Bettman's treatise appeared up
until the end of the past year, eleven additional cases
have been reported, viz.: by Vassal (2), Rabe (3).
Shoyer (4), Moser (5), SchwarzkoflF (6), Dega-
nello (7>, Bosc (8), Bilina (9), Giglio (10), and
Dehon and Brasser (11). Contributions to the sub-
ject have been made by Eiselt (12). who enters
upon the aetiology of the disease, Milian (13). and
Rabe (14).
Vassal's case was one complicated with exophthal-
mic goitre in a woman of thirty-five years. Bron-
•Read. by invitation, before the College of Physicians, Philadel-
phia, I-ebruary lo, 1908.
April 25, 190S.J
BURVILL-HOLMES: CHRONIC FIBRINOUS BRONCHITIS.
781
chial casts showing arborescences were expecto-
rated. A man of thirty-seven years was the victim
in a case reported by Rabe. In this case it followed
closely in the wake of a pneumonia and terminated
fatally about three weeks subsequent to the initial
onset. In .Shoyer"s case the patient was a man of
seventy-four years, who, in early adolescence, had
had tuberculosis and who, five days after the onset
of what was diagnosticated influenza, coughed up a
complete cast of the bronchus 10.5 ctm. long. For
three weeks after, he expectorated great quantities
of ribbon like strips of fibrin. He was entirely well
in one month.
Moser believed syphilis to be the aetiological fac-
tor in his case, a man of forty-eight years who had
recurring attacks of severe coughing and dyspnoea.
The sputum was blood stained and in it casts of the
bronchi were noted. Fifteen years previously he
had had a chancre, and at the time of the attack
had syphilitic manifestations such as ocular palsy,
dermatitis, and mA^ocarditis.
Schwarzkoff reports a case of a girl, thirteen
years of age, whose mother was tuberculous. The
patient had undergone four attacks of acute rheu-
matism W'hich were followed by some cardiac dis-
turbance, but she had never had any severe bron-
chial or pulmonary disease. For three years she
had had a slight chronic cough, occasional haemopty-
sis, and subsequently typical attacks of fibrinous
bronchitis. Tuberculosis as an setiological factor
was absolutely excluded, and Schwarzkoff believes
the cause was mitral insufficiency.
The cases -of the remaining six authors I am un-
fortunately unable to recite owing to the fact that
the necessary journals were not available at the
library.
The case which was referred to me by Dr. Ross
T. Skillern and to whom I am indebted for the privi-
lege of reporting is as follows :
The patient was a young lady of twenty-six years, whose
family history was absolutely negative. Her past history
was good, as aside from measles, varicella, scarlet fever,
and pertussis in childhood she had always been well. Her
menstrual function was normal. The trouble which
prompted her to seek medical aid first made itself apparent
about eight weeks ago by a short, hacking, unproductive
cough, which was particularly troublesome at night and in
the morning upon rising. About one week after the onset
she was seized with a violent paroxysm of coughing and
of such a nature that she imagined she was again develop-
ing whooping cough. The paroxysm continued for several
minutes, and only ceased when a large "piece of phlegm,"
as she thought and expressed it, was dislodged and ex-
pectorated. Prior to this paroxysm there was no dyspnoea
and she was not in any sense of the word ill. A few days
later, just how many the patient did not recollect, and
again in the morning, a second paroxysm occurred and
another large piece of "phlegm" expectorated. A third and
a fourth occurred at intervals of from four to seven days,
always in the rnorning, and relief from it always brought
about by the dislodgement and expectoration of a large,
greyish white, solid piece of material. She stated that she
could always appreciate that there was something within
her lung that ought not to be there; that this something
was always felt in the same place, and that place just under
the clavicle of the right side. In her own words "she felt
as if by putting her two fingers in her throat she could
drag out the offending material."
After her last paroxysm she noticed that what she ex-
pectorated had some definite form and was undoubtedly
something more than mere bronchial secretion, so she pre-
served the specimen and with it visited her physician. As
the patient had at one time, to the physician's knowledge.
been a host for lumbricoids, he concluded upon superficial
examination of the specimen that she had vomited rather
than coughed up one of these parasites. Hsemoptysis had
never occurred, she never had night sweats, appetite
was and always had been fair, there had been no loss of
weight, and all her body functions had been regular. In-
deed, aside from the chronic dry cough, associated at inter-
vals with the paroxysms mentioned, she never felt the least
bit ill. As far as she knew she has never had an asthmatic
attack.
Physical examination of the patient showed a fairly well
nourished and developed girl of somewhat anaemic aspect,
and very nervous, her nervous state depending, however,
probably on the fact that it had been hinted to her that her
condition might be one of tuberculosis, a statement which
she was the more ready to accept since she appreciated how
closely she had associated during the summer with an
intimate girl friend who recently died at the Whitehaven
Sanatorium.
Careful examination of her chest showed a decided limi-
tation of movement in the upper right side anteriorly com-
pared with that of the left. Over this area. too. the breath
sounds were appreciably weaker than those of the opposite
side. There was apparently no impairment of resonance any-
where, and no rales could be heard. Her heart was nor-
mal, and the other organs apparently so.
A specimen of her sputum, which was difficult to obtain,
inasmuch as she expectorated but little, showed nothing of
moment. No tubercule bacilli were found. A bacteriologi-
cal study of a washed specimen showed the streptococcus
and the Staphylococcus aureus.
Milian, in a contribution on the subject of fibrinous bron-
chitis, divides bronchial casts into four classes, namely:
Bacterial casts, which are very rare and composed almost
entirely of organisms: mucous casts, also very rare; fibrino-
leucocytic casts, and lastly blood casts. The cast from this
patient was of the fibrinoleucocytic variety, but differing
from jMilian's description, who says in regard to the cellu-
lar elements, "bien colores, c'est-a-dire bien vivants, rare-
vient mortiUcs" — in that many of the cells show degenera-
tion. The most interesting histological feature, however,
was that the cellular elements were largely composed of
eosinophiles, which, according to most of the writers, are
found only in small numbers. On the other hand, mono-
neuclear leucocytes, which are as a general thing to be
noted in considerable numbers, were in this specimen con-
spicuous by their sparsity. Stained by Weigert's method,
the stratified anastomosing substance in the meshes of
which the leucocytes were, showed for the most part to be
composed probably of mucin, although a little fibrin was
present. Several sections stained for the ordinary patho-
genic bacteria showed none of these, which was again in-
teresting, since these can usually be identified, except, as
Rabe points out, in old exudates. A large number of sec-
tions were examined for the tubercle bacillus, but were, to
the exclusion of a single one, unfruitful of success. Thij
one section, however, did show what very strongly resem
bled three acid fast bacilli, but inasmuch as several were
examined without result, and as the sputum, as we have
seen, was negative, it would be unjust in view of this in-
definite ocular evidence to positively diagnosticate them as
5i;ch. Cultures from the cast were not made, as I thought
the results would be of little value, since the specimen had
hee:i kept for some time in an unsterile bottle.
Macroscopically the main trunk of the cast was about five
centimetres long by about four millimetres in diameter. It
terminated in two branches, each about twenty-five by three
millimetres. This is, of course, when compared to those
reported by other authors, which averaged ten to sixteen
centimetres, not a large one. No lumen could be recog-
nized in either the main trunk or its branches. The cast
was of a slate color.
Bettman, in analyzing a hundred cases, classified
them as follows: i, Chronic bronchitis with ex-
pectoration of branching casts : 2, acute bronchitis
with expectoration of branching casts ; 3, cases in
which branching casts were not expectorated but
found at autopsy ; 4, cases in which cast showed no
dichotomous branching: 5. expectoration of casts in
organic heart disease : 6, expectoration of casts in
pulmonary tuberculosis; 7. cases of small and non-
782
ZEMP: ACCIDENTS DURING ANAESTHESIA.
[New York
Medical Journal.
branching casts associated with asthma ; and 8,
formation of casts in bronchi, in cases of puhnonary
oedema following thoracentesis.
Accepting this classification then this case would
belong to either the category of group i, viz., the
expectoration of branching casts associated with
chronic bronchitis, or to cases in group 6, cases as-
sociated with pulmonary tuberculosis. If to the
latter the case is interesting because in the cases
recorded by Jacoud, Model, Duflocq, and Menetrier
the expectoration of casts did not occur until late
in the disease, and consequently with clinical symp-
toms well marked. However here, while we have
much to substantiate the inference of probable tuber-
culous trouble, namely the circumstantial evidence
of close association for three months with a rapidlv
dying case of consumption, suspicious physical
signs, the markedly diminished movement of the
upper right chest with weakened breath sounds over
the same area ; a lymphocytosis in the circulating
blood, and opsonic index of 0.7, and lastly the find-
mg in one of the sections what suspiciously resem-
bled acid fast bacilli, it is by no means definite. At
best the subjective and the objective symptoms are
such that if tuberculosis exists at all it is in its in-
cipiency, and hence if the ^etiological factor in this
case, the case is rare.
Comparing the case with those associated with
chronic bronchitis it presents one or two interesting
features. Usually these cases exhibit marked dysp-
noea preceding the expectoration of the cast. This
patient says that she never had dyspnoea, and hav-
ing none it is exceptional for the severe paroxysms
of coughing which she sufifered from, because ob-
servers have noted that in those cases in which
dyspnoea does not obtain, little or no coughing is
the rule. As is usually the case the casts were al-
ways formed in the one place, as is evidenced by the
patient's own appreciation of their location. The
not uncommon symptom of emaciation and loss of
strength is not present here. The patient weighed
136 pounds and she said that she never weighed
more than 140. No skin complications such as
pemphigus, impetigo, or herpes zoster, noted by
many authors in connection with these cases, existed,
or as far as I could ascertain had existed.
References.
1. American Journal of the Medical Sciences, Februarj',
1902.
2. Bulletins et m^moires de la Socicte anatomique de
Paris, l.xxviii, p. 834, 1903.
3. Ibidem, pp. 708 to 711.
4. British Medical Journal, 1906, ii, p. 1055.
5. Medical Record, Ixvi, p. 206, 1904.
6. Mtinchener medizinische IVuchenschrift, li, p. 343,
1904.
7. Rei-ista veneta di scienza medica, xl, pp. 241 to 262,
1904.
8. Montpellier Medical Journal, pp. 468 to 471, 1903.
9. Roussky Vratch, vi, pp. 1212 to 1216, 1906.
10. Cazzetla degli ospidale, xxvi, 1510, 1904.
11. Echo medical du Nord, xl, p. 80. Lille, 1906.
12. Casop lek cesk v. Pragc. xlv, pp. loio to 1014, 1906.
13. Bulletins ct mdmoires de la Sociite anatomique de
Paris, Ixxx, pp. 487 to 489, 1905.
14. Gazette des hopitaux dc Paris, Ixxxix, pp. 879 to 884.
2030 Chestnut Street.
ACCIDENTS DURING AN.ESTHESIA.
Their Recognition, Prevention, and Treatment.
By E. R. Zemp., B. S., M. D.,
Knoxville, Temi.,
Professor of Materia Medica, Therapeutics, Pediatrics, -^nd Clinical
Medicine, Tennessee Medical College.
Death from an anaesthetic is such an appalling
event, and carries with it such a stigma in the eyes
of the public, that any research that has for its
intention the lessening of the dangers pertaining to
this class of drugs should receive the careful atten-
tion of all who are called upon from time to time
to administer them. It is true that comparatively
few patients die from the direct effect of an anaes-
thetic, but this apparent safety makes anaesthesia
more dangerous. A physician does not need more
than one death from this cause to injure him seri-
ously in his community. The public seems to think
that all deaths from this cause are due to careless-
ness or ignorance, and in some cases, no doubt, this
is true. There seems to be an opinion among med-
ical men that anybody can give an anaesthetic, so
often we see the cone in the hands of medical stu-
dents, and even the laity are intrusted with it. The
mortality from anaesthesia will never be lowered by
putting its administration into the hands of inex-
perienced and ignorant persons, but this practice
will be the means of teaching some doctor some day
a very severe lesson.
There is so much to be said upon this subject that
one is at a loss where to begin, but believing that
an ounce of prevention is worth many times its
weight in cures, I will begin by briefly stating some
of the points we should observe, when it is possible,
in preparing the patient to receive the anaesthetic.
Some of these may seem very trifling to the dog-
matic, superficial eye, but each detail goes to make
up the whole ideal, and it is only by striving to
attain the ideal that we are able to obtain the best
results.
When it is practical, the patient should have sev-
eral days' attention before the operation ; better, a
week. Chemical and microscopical examinations of
the urine should be made. The bowels should be
emptied, which takes several days of careful purg-
ing. However, no purgative should be given later
than forty-eight hours before the operation, but an
enema should be given about twelve hours before
the appointed time. The free administration of
water bv the mouth is very beneficial, and both com-
bine to limit the formation of gas. thereby reducing
intraabdominal pressure. The food should be care-
fully regulated for several days, the most easily
digested food being selected. Nothing should be
given in the way of food twelve hours l^efore the
operation, as the nerv^ous state of the patient in-
hibits digestion. If conditions permit, a general
bath should be given the night before the operation,
and it is also highly important that the patient
should get a good night's sleep preceding the day
appointed for the operation. ITypnotics should be
used, if necessary, and there is perhaps none better
than trional (sulphonethylmethane). .\11 of the^e
points bear directly upon the patient's safety. When
carried out they give the patient the very best
chance of taking the anaesthetic quietly and .safely.
,\pril 25, 190S.J
ZLMF: ACCIDEXrS DURING AN/ESTHESIA.
7«3
for such preparation means that you have put the
system in the very best possible condition. In
minor operations it is, of course, unnecessary to go
into such an elaborate preparation of the patient,
especially where the anesthesia is to be of short
duration, but even in these cases such a preparation
could do no harm.
Before the patient is brought to the anaesthetizing
room a careful examination of the heart should be
made. Note the color of the skin, the character of
the pulse, the condition of the arteries, whether they
are hard or soft. The character of the respiration
should be noted, as should also the patient's general
temperament.
All rings having been removed from the fingers
and ears ; all loose teeth having been taken out ; all
constrictions of throat and chest having been cor-
rected, the patient is brought to the table and is
ready for the anaesthetic. It is a good plan to give,
a few minutes before the anaesthetic is begun, ^
grain of morphine and 1-150 grain of atropine. This
quiets the patient iv.vl reduces the excitability of the
respiratory tract, it does more than this. It lessens
the excitability of the inhibitory centre of the heart,
which centre is very wide awake during the early
stages of anaesthesia. It steadies up the vasomotor
system and thereby lessens the fall of arterial pres-
sure, so certain to occur under chloroform. It
diminishes the amount of mucus secreted under
ether, thereby lessening the chances of an infected
respiratory tract, pneumonia. The position of the
patient is important. He should be flat on his back,
with only a small pillow under his head and shoul-
ders. The arms at the beginning should be in such
a position so that the fingers can be clasped over
the abdomen. Do not be in too much of a hurry to
l)egin the anaesthetic. Converse with the patient
cheerfully. Allay his fright as far as possible.
Assure him th^it he v, ill be safely carried through
the trying ordeal. Death has occurred a number of
times from fright alone, even before a drop of the
anaesthetic had been given, so it is best to divert
the patient's mind from himself as much as possible.
The best way to do this is to have the patient put
the ends of his thumbs together and press firmly
upon them. I say to them: "The more queer you
feel the harder you press." This concentrates the
mind upon the thumbs and gives the patient some-
thing to do, which is much easier than trying to be
perfectly passive. Whatever you do, do not tell the
patient to take a deep breath. This is just what you
do not want him to do. You want him to be as
"natural" as it is possible to get him. Now begin
the anaesthetic — chloroform, we will say. Drop by
drop it should be added, not to one spot on the
mask, but all over it. The wire frame covered with
several layers of gauze is the best mask for either
chloroform or ether. Some authorities say, push
the anaesthetic as soon as the higher centres show
signs of incoordination, but it is best never to push
it, in the sense of adding a large amount of it to the
mask at one time. The continuous dropping will, in
the large majority of cases, silently and surely do
the work. So easily do many patients take chloro-
form in this way that if one is not careful the
surgical stage will be passed before one knows it,
and the patient will be in that stage of complete
relaxation that is hardly ever to be desired. No
matter how carefully the anaesthetic is given, very
frequently symptoms will arise that call for either
more anaesthetic or its immediate withdrawal ; con-
sequently it is important to understand all the
phenomena that may arise, that we may avoid
danger on the one hand or the needless allowing of
the patient to come from under the anaesthetic on
the other. No anaesthetizer can forget the disgust
that mounts the surgeon's face when a patient is
allowed to wake up in the midst of a difficult opera-
tion unnecessarily.
Generally the first difficulty we strike is some
abnormality in the breathing, commonly stertor.
There are three kinds of stertor : Palatine, mucous,
and phar\ngeal. The first two are not danger sig-
nals, but the last calls for the immediate removal
of the mask. It is caused by the tongue dropping
back against the posterior pharyngeal wall, and if
not attended to the patient may suddenly suck his
tongue tightly down into his throat, thus cutting of¥
the air entirely. It is a sign of marked relaxation,
which is always dangerous ground to be on. We
remedy this condition by temporarily removing the
anaesthetic and bringing the chin forward and up.
This pulls the tongue away from the posterior wall
and permits the air to enter. The palatine stertor
may be remedied in the same way. When lifting
the chin forward and up does not relieve the condi-
tion promptly, the tongue itself should be caught
with forceps or napkin covered fingers and gently
pulled forward and up, toward the nose. Pulling
the tongue straight out over the teeth only makes
the condition worse. After the tongue has been
pulled away from the posterior pharyngeal wall it
can generally be kept away by keeping the chin well
up and the patient's mouth shut, or by turning the
head to one side, so that gravity will carry the
tongue in this direction rather than backward.
After the stertor is relieved the anaesthetic may be
continued. Sometimes there appears quite early a
choking sensation, and the patient will try to re-
move the mask. This should be met by the adminis-
tration of a little air, after which the anaesthetic can
be dropped somewhat faster. The following condi-
tions indicate that the anaesthetic should be gradu-
ally increased : Marked lateral rolling of the eyes,
deep, sighing respiration, swallowing, hiccough,
and vomiting. During the last mentioned event the
patient's head should immediately turned to one
side, to prevent the vomited matter from being aspi-
rated into the lungs. It can be stated as a safe
rule to follow that if the respiration at any time
becomes irregular the anaesthetic should be sus-
pended, for it is by the respiration that we can best
judge the amount of anaesthetic the patient is get-
ting. Even m the early stages, where irregularity
in the respiration is known to be of reflex origin,
it is best, to admit a little air before increasing the
anaesthetic. When struggling, holding the breath,
or vomiting occurs, alarming symptoms may sud-
denly develop, so that one should deal gently with
these symptoms. Beware of the inspiratory "whoop."
On several occasions I have had patients to stop
breathing after giving this whoop, and they were
revived with the greatest difficulty. The mucous
stertor so frequently heard when ether is being ad-
784
ZEMP: ACCIDENTS DURING ANESTHESIA.
[New Vork.
Medical Journal.
ministered is due to an outpouring of mucus and
saliva. If very excessive it can be removed with a
piece of gauze wrapped around the finger, or, better
still, by turning the head to one side, thereby drain-
ing the patient's mouth. The so called "pumping
method" of getting rid of the mucus requires some
skill and will be used only by the expert anaesthetist.
In this method the patient's chin is pressed down-
ward and backward during expiration. This forces
rhe mucus out through the nose. During inspira-
tion the chin is held in ks usual position — forward
and upward.
Should the anaesthetist watch the pulse or the
respiration? I believe he should watch both, but he
should especially watch the respiration, noting the
pulse from time to time. If the patient is getting
too much anaesthetic, this fact will be reflected in
the respiration, either by change in rhythm or depth.
Under chloroform, with its accompanying low arte-
rial pressure, the temporal or even the radial pulse
is not a true index to the heart's action. The respi-
ratory centre is quick to notice any marked fall in
the pressure, because under such circumstances it is
not properly supplied with blood ; hence we will get
a disturbance of the respiration before we can appre-
ciate with the fingers on the pulse that there has
been a dangerous lowering of arterial pressure.
Another point to be remembered is that the amount
of anaesthetic a patient is getting cannot be judged
by the amount we pour upon the mask. It is the
amount that he inhales that regulates the effect.
A^hen the respiration becomes irregular the dose
becomes uncertain, and when the dose becomes un-
certain the patient is In danger. So we watch the
respiration to see if the patient is getting the anaes-
thetic in evenly distributed doses. It is the sudden
increase of the percentage of the anaesthetic in the
blood that usually kills the patient. It matters not
whether we watch the respiration or the heart, we
are unable to forecast these sudden deaths that
sometimes arise, especially from chloroform, but in
the ordinarily healthy heart watching the respiration
will enable us to judge how well the patient is stand-
ing the anaesthetic. The patient's face is a good
index to the respiratory movement. Marked cyanosis
means respiratory failure. Pallor indicates heart
failure.
A slight irregularity in the heart's rhythm has
no special significance. Neither do murmurs neces-
sarily contraindicate the administration of an anaes-
thetic. Especially is this true if there is no distinct
functional disorder. As Dr. Wood says, the key
to the situation is not found in the valvular lesion,
but in the condition of the heart muscle. Loud
murmurs do not more strongly contraindicate an
anaesthetic than do weak ones. The very loudness
of the murmur shows that the heart muscle is in a
fair condition. It is a safe statement to make, how-
ever, that anaesthetics should be avoided,, if possible,
in all diseased conditions of the heart, bearing in
mind that the shock of the operation without an
anaesthetic may be more dangerous to the patient
than the anaesthetic. Every anaesthetizer has noticed
how the weak, nervous heart is improved by the
anaesthetic. The vasomotor system being depressed,
a patient gets chilled if the proper care is not taken
to keep the temperature up, but it is doubtful
whether this chilling is ever a cause of the post-
operative pneumonia that follows the administration
of ether.
The wise selection of the anaesthetic will diminish
the liability to accidents. All forms of organic
brain diseases contraindicate the administration of
anaesthetics, especially if there is atheroma of the
vessels. In this case chloroform would be the anaes-
thetic of choice. Without atheroma, ether is safer.
In heart disease, without complications, ether is the
anaesthetic of choice. Where there is pulmonary
engorgement, all anaesthetics are very dangerous.
The combined use of chloroform and ether is per-
haps the best plan under these circumstances. In
chronic lung troubles chloroform is safer than ether.
In all acute pulmonary affections, especially if asso-
ciated with dyspnoea, anaesthetics are strongly con-
traindicated. The same is true in obstructive laryn-
geal diseases, but chloroform is less dangerous than
ether. In spasmodic laryngeal troubles chloroform
should be selected.
In kidney disease authorities differ in regard to
the selection of the anaesthetic, but I believe the
majority of them lean toward chloroform as the
anaesthetic of choice. Our selection, however, would
be influenced by the secondary effect of the disease.
If the heart was markedly affected, ether would be
our choice. If the lungs were engorged, chloroform
would be safer, as ether would increase the engorge-
ment.
The time of day would influence our choice.
Ether is inflammable, so it should be used cautiously
in the presence of a light other than the incandescent
electric. It should be remembered, however, that
while chloroform is not inflammable, it undergoes
degeneration in the presence of a flame and chlorine
is liberated, causing a severe irritation of the respi-
ratory tract to all in the room.
In spite of all the care we can bestow upon the
patient, alarming symptoms and sometimes death
will occur. There is no method known to man of
administering an anaesthetic that is entirely free
from danger. Beware of the anaesthetist whose own
peculiar method of administration has banished the
hypodermatic needle from the operating room and
reduced the mortality from anaesthesia to nothing !
Eternal vigilance should be the watchword, and the
minute the least suspicious symptom arises the anaes-
thetic should be suspended. Death may come sud-
denly. Alarming symptoms may arise at any time.
How can we tell when the patient is in danger?
First, by closely watching the respiration. Any
irregularity means trouble. Watch the face for
cyanosis or pallidit\^ Examine the pupils from
time to time ; their sudden dilatation without fluctua-
tion means stop the anaesthetic and give plenty of
fresh air. Note the pulse from time to time. A
weak, fast pulse calls for stimulation and the
momentary stopping of the anaesthetic.
Suppose, however, instead of any of these symp-
toms, the patient suddenly shows signs of impend-
ing death. What is to be done? First, don't get
excited. Have a systematic plan of treatment "at
your fingers' ends," then apply it speedily but thor-
oughly. Unless the heart is beating forcibly, which
_\liril 25, 1908. J
LE ROY: JETIOLOGY OF PSORIASIS.
785
is entirely unlikely, invert the patient's body to an
angle of forty-five degrees with the floor. Imme-
diately begin artificial respiration and see that the
tongue is held in such a position, by an assistant,
that the air can enter the lungs freely. This is lung
washing, and is the only way we can get the poison
(anaesthetic) out of the patient, just as we wash out
the stomach when the patient has swallowed a
poison. Artificial respiration should be faithfully
and persistently carried out. The patient must be
made to breathe. The rhythmical dilation of the
rectum is a powerful stimulant to the respiration.
It rarely fails to make the patient gasp. Pressure
over the abdomen while the patient is inverted will
help to send the blood to the brain, where it is so
badly needed at this time. As for drugs, only two
or three are of any value, and these should be given
hypodermatically : Strychnine sulphate, i/io grain,
and digitalis, 5 minims, should be administered by
an assistant. Ammonia may be inhaled, and a pint
of decinormal salt solution, containing fifteen or
twenty drops of adrenalin chloride solution, may be
given under the skin. This sometimes has a mark-
edly restorative effect. It should be borne in mind,
however, that absorption is exceedingly slow in
these cases, on account of the defective circulation,
so that in administering drugs toxic doses should
not be given, nor should the doses be repeated too
often or too close together, for drugs given under
these circumstances remain under the skin just
where they are injected until the circulation begins
to improve, at which time all of the doses may be
absorbed at once, kilhng the patient. Artificial
respiration stands first ; all other restorative meas-
ures are secondary. Be sure to provide plenty of
pure air and keep the patient warm. After the
patient has recovered he should be watched for sev-
eral hours. There are certain drugs that have been
used in treating impending death from anaesthesia
that I regard as of doubtful efficacy, if not actually
dangerous. Amyl nitrite is one of these. This drug
depresses in a powerful manner the entire central
nervous system, including all the higher centres.
It paralyzes the vasomotor system in large doses
and depresses the heart. I will admit that there is
a time in its action when it apparently stimulates
the heart, but this occurs only when the dose is
regulated to a nicety, and is exceedingly fleeting.
"The dominant action of amyl nitrite is that of a
powerful depressant to all higher forms of proto-
plasm,"' and especially is this effect noted upon the
vasomotor system. Alcohol in any form is also
contraindicated, for it only differs in that its action
is more prolonged. Especially is this true when
ether is the anresthetic. Hypodermatic injection of
brandy or whiskey should not be given. The
hvoodermatic iniection of ether is a physiolosfi-
cfll outrasre. Xitroglycerin acts similar to amvl
nitrite.
The writer hopes that this paper will aid those
physicians who are called upon from time to time to
administer anaesthetics. With a careful attention
to its details many of the unpleasant symptoms of
anaesthesia can be avoided and its dangers greatly
diminished.
617 Walnut Street.
ON THE .ETIOLOGY OF PSORIASIS.
By Bernard LeRoy, M. D.,
Athens, Ohio.
The causes of psoriasis are not known. This is
the gist of the writings of the authorities on skin
diseases, as it is the first statement of nearly all
lecturers when presenting cases of psoriasis to the
class.
It was while the writer was taking a prolonged
course of instruction in laboratory methods and
technique at the Philadelphia Polyclinic Labora-
tories that the idea first came to him to try out the
method which has proved successful in growing the
germ which, when the opsonins were made there-
from and used in treatment upon the patient, re-
sulted in a speedy and safe cure of the disease.
I had been attending the clinic of Professor
Schamberg for the purpose of gathering material
for laboratory use when he presented a very bad
case of psoriasis. During his lecture he spoke
of the aggravating effects that hot water and
soap had upon this disease. Perhaps it was because
of the way he put this information to the class,
nevertheless it impressed me forcibly and I became
determined to try out the method which came to my
mind during those moments. I intended to have
made the trial then and there, but was called home,
and it was not until this winter that an opportunity
presented in which I could do so.
But first let me quote from some authority on
skin diseases — and perhaps Hyde on the Diseases
of the Skin is as good as any — to show us the pres-
ent state of the bacteriological search for the cause
of this dreadful disease.
"Lang, of Innsbruck, attracted notice by his alleged dis-
covery of certain fungous elements in psoriasis that he as-
serted to be the cause of the disease. These fungi he finds
in the whitish pellicle beneath the superficial squamous
layer, to which Bulkley had already called attention. After
stripping the pellicle or a part of it from the surface, and
subjecting it to the action of a five per cent, solution of
caustic potash, the epithelium appears translucent, and upon
and beneath the epithelium double contoured and highly
refractive spores become visible. Lang considers this
fiingus to be of the lowest species, different from any pre-
viously recognized upon the skin, and he terms it
epidermorphyton. Weyl, who believes that psoriasis is due
to 'an inherited weakness of the nervous centres,' has seen
Lang's _ 'brood cells,' and he regards them as 'myelin like
exudations' ; but this position is disputed by both Wolfi
and Eklund. who confirm Lang's observations, and who
believe the disease to be of parasitic origin. Lassar suc-
ceeded in producing a disease of the skin in rabbits by
rubbing into various portions of their bodies scales, blood,
and lymph removed from psoriatic patches of a male
patient."
I could quote from other writers, but to the same
effect, that nothing definitely is known.
The case upon which I determined to carry out the
mental suggestion received during Professor Schamberg's
lecture was a man aged forty-eight, short and stolidly
built, in excellent health, other than being afflicted with
psoriasis in one of the worst form? I ever saw ; he was
ever careful and regular in all his habits, and he has never
been sick, nor had any disease since early childhood.
The patches were numerous and thick, extending from
the forehead, back to his heels, and covered completely both
upper and lower extremities, his hands and the lower part
of his face being the only parts of his body free from
the disease.
As I examined this man the words of Professor
Schamberg came to me with the same force and
780
rypHoiD I'ErER ]vithoui a nurse.
[New York
Medical Journal.
mental pictures received while at his clinic one year
ago.
I proceeded to work by removing the outer scales,
and when I had reached the lower stratum I pro-
ceeded with care and removed scales to a wet slide,
keeping the scales moist with soapy water and at a
temperature of 104° F., examining it at stated inter-
vals with the high power lens. At the end of twelve
hours I failed to detect any change whatever in the
scale, the "myelin like exudations" were in evidence
and seemed to so fill the scale that nothing else
could be seen.
I left it that night under arrangements whereby
the moisture and temperature would be retained at
even degree. The next morning I was surprised
to find that the temperature stood at 190.4° F.,
scales moist, and upon examination I was surprised
to find a growth of a very peculiar germ.; all the
"myelin like exudations" were in bloom, and the
growth was at or from one end of the spore, looking
for the world like a transparent, delicate, diminutive
stove pipe placed over one end of an egg.
In the hanging drop I found that while the
organism is in this state it will swim through the
iiuid, spore end first ; after the growth of the vege-
tative end has reached an almost fully developed
state the organism will swim or move through the
fluid vegetative end first. Now one may see the
germ making strong and rapid movements to rid
itself of the spore. Should it succeed it will move
away as an independent organism, but should it not
become free and not be disturbed it will develop
into as pretty growth of fungus as could be found.
The bottom growths; grown in a liquid medium
containing sodium nitrite, are of a long, slender,
delicate, transparent nature, containing compara-
tively few spores, while the top growth seems to
run to seed, so numerous are the sf>ores. In one
organism I was able to count over sixty spores.
I then made a liquid medium, slightly alkaline,
and containing o.i per cent, sodium nitrite, and
securing fresh scales, as before, I incubated at 159°
F. for two weeks in semidarkness. The growth
was heavy, and examinations from time to time
showed the same odd shaped and odd acting germ.
I at last succeeded in obtaining a pure culture,
from which I made the opsonins, and gave the pa-
tient his first treatment. The opsonic index was
taken several times, but proved nothing.
I have not finished my study of this organism,
but suffice it to say that it is a mould.
At the end of four days my patient reported at
my laboratory and seemed none the worse for the
treatment. The reaction, while quite severe for
about twelve hours, simulated rheumatism or a
slight cold settled throughout the muscular system ;
the patient never lost a meal nor an hour's time
during the course of the treatment. The only
change noticeable was a pitting of all the scales, as
if each scale was punctured with fine needles ; this
was noticed in every part of his body.
At the end of eight days he reported again. The
pitted condition of the scales was still in evidence,
with a decided lessening in the amount of the scales
formed on the inflamed patches of integument.
The second treatment was given : the reaction
proved to be of less severe character than the first.
In four davs he again reported. There was now
noted a decided change in the color of the inflamed
skin, changing from a bright red to a dull leaden
red, a decided shrinking in the elevation of the
inflamed integument, with numerous patches of
shrunken areas of smooth surface, which seemed
to be on a level with the normal integument. This
was the first noticeable change toward a return of
the psoriatic patches to a normal condition.
After the fifth dose the case progressed without
a stop or hitch in a smooth and even way toward
full recovery and a permanent cure ; at least, I have
good reasons to so state.
I have several milder cases under treatment at
this time, which I shall report later.
In conclusion it may be of interest to some to
know that in the examination of the saliva the
sulphocyanides were present, and that the content
of ammonia was above the normal, while the basic
salt of the saliva was potassium, and, as it is in all
inflammatory diseases, the secretions from the paro-
tid glands were in less amount than that from the
other salivary glands, causing the saliva to be of
a thick, stringy and frothy nature.
I have made a chemical study of this organism
and its opsonin, as I have of that germ which I
have made use of in my study of the epilepsies and
allied paralysis, and have found the same reaction
or substances which give the same reactions in both
germs, being found in greater quantities in the nidus
fluid, or liquid medium, in which the organism was
permitted to grow, until, from the accumulation of
a certain crystallizable substance (w'hich is an anti-
enzyme), prevents the organism from performing
its -normal function, thus causing its death. It is
this substance, and not pha,gocytososis, as is now
believed, that is the active agent in producing im-
munity.
There are found three distinct crystalizable sub-
stances, each forming distinct and different, though
beautiful, crystals, and an amorphous substance,
which I have reasons to believe is composed of two
different substances.
So far my laboratory studies have shown me
that each of these substances have distinct physio-
logical actions. One is the toxine which affects the
host, the second is the autogermicidal toxine which
I know will, W'hen in sufficient strength in the body,
kill the germ, and from laboratory experiments be-
lieve it to be an antiferment. The other substances,
as well as those just mentioned, are still being stud-
ied, with prospects of a full report within the year.
ON THE MANAGEMENT OF TYPHOID FEVER
WITHOUT A NURSE.
By L. C. Freeny, M. D.,
Pittsville, Md.
The average general practitioner is obliged to
treat probably three fourths of his cases without the
help of a trained nurse. Now and then one comes
in contact with people of good habits of observation
who make capital nurses, never having had any ex-
perience in the handling of the sick. On the other
hand, those you luight expect to do good work are
often the most disappointing.
.After some years of experience. I have made out
a sheet of instructions for the use of the family
April 25, 1908.]
MACMURROUGH : THYREOID EXTRACT IX CHLOROSIS.
when a competent nurse is not available. This sheet
I have typewritten, and order it to be tacked on the
wall. The family are told that when a question
arises, if they will read the sheet carefully they will
in all likelihood find in it just what they want to
know, as it covers a great deal of ground.
It may be as well to state that as soon as the di-
agnosis is made full directions as to the disposal
of f^eces, urine, and sputum are gone into thorough-
ly, once for all. Also the disinfection of the bed
linen. A solution for the disinfection of the hands
is kept in the room all the time, with the warning
that it must be used to prevent the disease being
communicated to those in attendance.
There are set aside for the patient's own use a suf-
ficient number of glasses. These are scalded after
being used each time, and once each day the whole
num.ber is boiled in a solution of sodium carbonate.
The same precautions are taken with the china,
spoons, etc., at a later time, i. e., when the patient
is convalescent.
A member of the family is shown how to take the
pulse, respiration, and temperature. These are put
down in a schedule, together with the number of
bowel movements and approximate amount of urine
day by day. From this data I fill out the chart my-
self for my own guidance in the case and for future
reference.
I sponge an arm to show how I want it done,
rubbing the part rather briskly with a dry cloth.
Then the arm is "slushed" with 95 per cent, alco-
hol. Some will not agree with this manner of
sponging, but it gives a more thorough refrigerant
eflfect than without friction. Not only that, but it
keeps the skin in good condition, stimulates the pa-
tient, and quiets the nervous system, the patient fall-
ing into a quiet and refreshing sleep.
If the family will carefully follow out the scheme,
and w^atch the patient closely, notifying the physi-
cian of any untoward symptoms, many of the acci-
dents in the management of this disease will be
avoided. To many that will read this it will seem
foolish or childish, but the patient's friends will not
think so. They fully understand that they are un-
dertaking something that they are unfamiliar with,
and anything that helps them in this self imposed
task will be gladly accepted.
Some Things to Remember.
Sponge the patient every three hours when the
temperature reaches 102.5° F. or over, unless he is
in a sweat. Use a watch to time yourself when
sponging, and make it take you at least thirty min-
utes to complete it.
Do not sponge the patient when he is in a sweat,
but wait, even if the temperature is high, until the
skin is dry and hot, before sponging.
Take the temperature every three hours.
Give the nourishment every three hours.
If you forget the medicine don't forget the nour-
ishment and the temp>erature.
Watch every bowel movement for any sign of
blood.
Report to me any complaint of pain in the bowels.
The nourishment ordered is enough. The patient
must not have anything else.
Keep quiet in the room and always encourage the
patient.
Give a warm soapsuds bath every morning at 9
o'clock, and an alcohol rub every evening at 9
o'clock.
Never rub the abdomen at all.
Write down anything of importance that you may
want to ask me ; then it will not be forgotten.
CHLOROSIS CURED BY THYREOID EXTR.\CT.
By F. K. MacMurrough, M. D.,
New York.
C.\SE. — B. H., aged twenty-two years, female, single,
occupation bookkeeper, suffered with symptoms of chloro-
sis since tirst menstruation. Fainting spells, heart flutter-
ings, constipation, scanty menstruation, and constant leu-
chorrhoea were the more prominent troubles m this case.
The blood count was deficient. The treatment consisted
of thyreoid extract, 3 grains after meals, a daily quart
clyster of normal salt solution, Blaud's pills, the practice of
deep breathing, and open air life. All the symptoms yielded
which had before been intractable to other modes of treat-
ment. The remedial measures employed were suggsted by
a cursory reading of the second volume of Sajous's
Internal Secretions and the Principles of Medicine.
If we are henceforth to ascribe many, if not all,
diseased conditions to overstimulation or depression
of the pituitary bodies and the consequent effect
upon the internal secretions of the ductless glands,
viz., the adrenals, thymus, parathyreoids, thyreoids,
and the spleen, medicine becomes at once an exact
and a simpUfied science. That such is the case
Sajous, in his exhaustive treatise on the Internal
Secretions, seems very strongly to establish. He
traces the nerve connection between these ductless
organs and the pituitaries so clearly, and shows the
control exercised by that portion of the brain over
the oxidation of tissue or tissue respiration, the
internal secretions acting and counteracting on the
blood through the "ferment of ferments,'" that the
vista at once gladdens the heart of the therapeutist
and brings an air of the fact accomplished which
becomes the most reassuring and convincing thing
in latter day medicine.
Following Sajous's line of medication, the two
contrasted conditions of exophthalmus and myx-
oedema would give the key to the whole subject.
Sajous says in the preface to his second volume that
he does not introduce any new theory or speculation
in medicine. He has simply followed such men as
Brown-Sequard, Langlois, and Ciliulski. He does
not even introduce a new serum. He simply intro-
duces order where there is a certain medical dis-
array. Mercur}-, iodine, quinine, strychnine, opium,
and the bromides have, through his good offices,
come into their rights, and rank higher than before
in the list of medicaments. Thyreoid extract is,
.perhaps, placed above them, but they are all con-
geners, and henceforth may become, in the hands
of the profession, weapons of as much point and
precision as the needle or the steriHzed blade. At
the same time he delivers a death blow to self medi-
cation at the hands of the laity, for when this new
step in medicine is realized and grasped by the
public mind, a proper dread should be felt by all
for the unscientific treatment of disease. Every man
should then not be his own physician any more than
even,' man is now his own surgeon.
100 Lafayette Street.
788
OUR READERS' DISCUSSIONS.
[New York
Medical Journal
dBur ^eaJiers' fiscussious.
A SERIES OF PRIZE ESSAYS.
Questions for discussion in this department are an-
nounced at frequent intervals. So far they have been
decided upon, the further questions are as follozvs:
LXXIll. How do you treat seasickness:' (Closed April
15, 1908.)
LXXIV. Hozv do you treat sunstroke? {Answers due
not later than May 15. igoS.)
LXXl'. How do you treat cholera infantumF (An-
szuers di:e not later than June 13. IQ08.)
Wlioeier answers one of these questions in the manner
most satisfactoi-y to the editors and their advisors will
rceeiz'e a prize of Xo importance zehatever will be at-
tached to literary style, but the aieard zeill be based solely
on the zalue of tlie substance of the anszeer. It is requested
(but not KEOuiRED) tJiat the anszeers be short; if practica-
ble, no one answer to contain more than si.v hundred
zsjords.
All persons zeill he entitled to compete for the price,
whether subscrwers m- not. This price zeill not be awarded
to any one person more than once within one year. Every
anszver must be accompanied by the zvriter's full name and
address, both of zeliieh zee must be at liberty to publish.
All papers contributed become the property of the Journal.
The prize of S-'i for the best essa\ submitted in anszver
to question LXX'lI has been awarded to Dr. J. Russell
Verbryeke. of Xeze York, zeh.ose article appears below.
PRIZE QUESTION NO. LXXII.
THE TREATMENT OF FRACTURE OF THE
PATELLA.
By J. Russell Verbrvcke, M. D.,
Xe\\- York,
House Physician to the Mt. Sinai Hos|iitaI (Private Pavilion).
Perhaps in no other injury does the future use-
fulness of the part depend so much upon proper
treatment as in fracture of the patella. In spite of
all our efforts, the result is often far from perfect,
and usually the patient has some weakness of the
leg, particularly in extension, though perhaps flex-
ion, also, may be restricted. ]\Iore unfavoralale out-
comes, such as nonunion or insufficient fibrous union
and bony anchylosis, are far too common.
The natural tendency of the fragments, because
of their usual wide separation, is to heal by fibrous
union. This must be prevented, and an attempt
made to obtain bony union, by more perfect coapta-
tion of the fragments. The separation is produced
by the retraction of the strong quadriceps muscle,
the collection of a large amount of fluid exudate and
])lood, which generally takes place speedily after the
injury, and the interposition between the fragments
of the torn periosteum or aponeurosis. The prog-
nosis is governed in great measure by the presence
or absence of these factors and the consequent treat-
ment employed.
Simple Fractures.
Eighty per cent, of simple fractures of the patella
are transverse. The aponeurosis covering the
patella is usually torn, while the capsule and rein-
forcing tendons of the vastus intcrnus to the inner
side and the prolongation of the fascia lata on the
outer side may also be injured to greater or less de-
gree. The extent to which these arc injured has
an important bearintj in the prognosis and treatment
of the case. There are two general methods of
treatment: (i) By mechanical means, and (2) by
open operation. In cases of transverse fracture, in
which there is not much injury to the surrounding
parts, no interposition of soft parts, not too great
swelling, and the fragments can be brought into
good apposition, the mechanical treatment may be
relied upon.
The best device is probably Agnew's. Use a
splint of board, about thirty inches long, five inches
wide at the top, and four inches at the lower end,
having two pegs projecting laterally from each
edge, the upper peg on each side to be above the
patella and the other two below. After padding
well apply it to the posterior surface of the thigh
and leg, and elevate the lower end. Bring the frag-
ments into position by strips of adhesive, of which
one passes from the upper peg on one side, down-
ward, under the lower fragment, thence to the
upper peg on the other side, while the other strip
is passed from the lower peg on one side, upward,
above the upper fragment, and thence to the lower
peg on the other side. By this means the frag-
ments are pulled toward each other, and by turning
the pegs more pressure may be exerted at will, so as
to keep them approximated.
Since, however, the mechanical treatment often
gives fibrous and incomplete union or the continued
immobility tends to produce bony anchylosis, me-
chanical treatment has its disadvantages. One can
never say when there is an interposition of soft parts
between the fragments, and cannot always esti-
mate the probable extent of the tear in the sur-
rounding structures.
So what appears the more ideal method of treat-
ment, now that nearly perfect asepsis can be ob-
tained, is the open operation and wiring. This is
the or.ly method b}' which bony union can usually be
obtained. A longitudinal or transverse incision is
made over the fracture, and the exudate, hjemor-
rhage, and tabs of tissue thoroughly cleaned out of
the joint. It is preferable to wash the joint out with
hot, sterile salt solution from a nozzle, and the fin-
gers should not touch the parts an}- more than is
positively necessary, all handling being done with
instruments as far as possible. The fragnnents are
brought together and held in position by two sil-
ver wire sutures passed through holes bored oblique-
ly through the dorsal surface and edge of each frag-
ment. The torn periosteum is united with heavy
catgut, the tear in the lateral expansion of the ten-
don with kangaroo tendon, and the wound closed.
A posterior splint is applied. As soon as the skin
wound l^as healed, and the sutures have been re-
moved, the knee is encased in a light plaster of
Paris cast. This is split in a few days, and removed
every day to allow light massage of the joint. In
three weeks the patient, still wearing the cast, may
walk with crutches, and in a month passive motion
should be practised. The cast should be worn dur-
ing the day for three months.
Good results with bony union are obtained by this
method in about ninety-five per cent, of the cases,
while the operation itself has scarcely any luortality
in the hands of good operators. It is the ideal
method of treatment, but should be employed only
April 25. 190S.J
CUR READERS' DISCUSSIOXS.
789
where the conditions are such that an absokitely
aseptic operation can be performed, and by a com-
petent surgeon.
Longitudinal fractures require little treatment.
The fragments do not tend to separate widely, and
may be held in place by adhesive strips and the use
of a posterior splint for two weeks, after which the
patient may walk with the knee in a light plaster
cast for several more weeks. The same may be said
of fissure fracture and most cases of oblique frac-
ture. If the fragments tend to separate in an oblique
fracture, treat as a transverse fracture. T shaped
fractures should be wired.
Compound Fractures.
Of course, it is evident that the open method,
with removal of small fragments, and thorough
cleansing of the joint, followed by approximation
with sutures, is the treatment which must be fol-
lowed in this class of cases. Temporary drainage
should be instituted. Heavy chromic gut is prefer-
able to silver wire in these cases for holding the
fragments in apposition, as, in the event of infection
taking place, the gut is absorbed, while the wire re-
mains as an irritant, preventing heaHng, until re-
moved.
Summary.
1 . In simple transverse fractures, when the proper
facilities are at hand, the results are more sure by
open method and wiring, with a consequent bony
union.
2. If the patient objects, or operation is not feasi-
ble, results from the Agnew splint are next most
satisfactory, though followed more often by fibrous
union.
3. In other varieties of simple fracture, the treat-
ment depends on the amount of separation, approxi-
mation being usually easily obtained by adhesive
plaster and the use oi' a splint.
4. All compound fractures should be treated by
approximation of fragments with heavy chromic gut
instead of silver wire, and the use of temporary
drainage.
Dr. Walter Ennis Hays, of Xciv York, ivrites:
We base our treatment of any condition requir-
ing medical or surgical attention on our understand-
ing of the morbid process presenting itself. The
usual thing in fracture of the patella is to find a
varying degree of separation of the fragments.
Especially is this the case when there has been quite
an extensive laceration of the soft tissues. The
fractured surface of the upper fragment is tilted
toward the cavity of the knee joint by the pull of the
fibres of the vastus externus and vastus internus in-
serted into the outer edge of the bone. The traction
exerted on the upper fragment by the tendon of the
quadriceps extensor and a counter pull on the lower
fragment by the patellar tendon serve to separate
the two fragments, the prepatellar tissues then fall-
ing over the edge of the upper fragment and inter-
feririg with direct apposition of the fractured sur-
facesT Effusion within the joint due to trauma of
the synovial membrane also separates the fragments,
the injured edge of the distal piece of bone being
usually tilted outward. There are cases of fracture
of the patella with little injury to the soft tissues
and but slight separation of the fragments. These
cases offer good results from conservative or non-
operative treatment. Fibrous union of the injured
bone, with its final crippling of the patient to a
greater or less degree, is so much to be dreaded,
however, that the radical treatment is always to be
preferred where a competent surgeon and the strict-
est aseptic technique can be assured.
The patient should be frankly informed as to the
dangers of sepsis with the risk to life and limb, as
well as the expected advantages to be derived by the
operative method. The probable results of the con-
servative treatment should also be laid before him.
The working man or any one else actively using his
legs can expect a shorter convalescence and a prob-
able better result by the operative than by the ex-
pectant treatment. Operation should never be at-
ternpted in individuals of over sixty years of age,
and is, of course, always necessary in compound
fractures. In multiple or comminuted fractures,
operation is also indicated, and wiring of the frag-
ments should be done. Amputation may have to
be considered in the latter class of cases. Prelim-
inary treatment of the joint to reduce swelling may
be necessary. The foot is elevated and the joint im-
mobilized. The ice bag and cooling lotions are ap-
plied to limit the inflammatory reaction. A flannel
roller bandage, reapplied as necessary, will greatly
aid in the absorption of the eff'usion. As soon as the
inflammation has subsided, operation may be at-
tempted with better result.
The operative treatment consists in careful cleans-
ing and sterilization of the area about the knee joint
with soap and water, alcohol, ether, and corrosive
sublimate solution (i in i.ooo). A transverse or
longitudinal incision is then made exposing the cav-
ity of the knee joint. All blood clots and shreds o£
tissue must be wiped away from the surfaces of
the fractured bone and the joint cavity sponged or
irrigated free of clots or other tissue debris. If the
joint is irrigated, sterile normal salt solution should
be used, except in an open fracture, where mercuric
chloride solution (i in 10,000) may be employed
and followed by the salt solution. Care must be
taken to reach all parts of the joint, especially pos-
teriorly, behind the condyles of the femur. It is
usually not necessar\- to fasten the bony fragments
unless the fracture is an old one or comminuted, as
mentioned before, and difficulty is experienced in re-
taining the injured bone in proper position. The
ligamentous tissue covering the patella is sutured
with chromicized catgut, after the fractured sur-
faces have been carefully approximated. The fascia
is also brought together with chromicized catgut,
while the skin is closed with a subcuticular suture of
silkworm gut. Xo drainage is necessary. The joint
is then immobilized in a posterior wire or plaster of
Paris splint. Massage may be begun after two
weeks. At the end of three weeks, passive move-
ments should be instituted. A week later the splint
should be removed, and a light stiff dressing applied
about the knee joint. The patient should then be
encouraged to attempt walking. At the end of the
sixth or eighth week the patient should be able to
fiex the knee, and will only need to wear a light
flannel bandage and use a cane. A month later the
joint should be as useful as before the accident.
7yo
OUR READERS' DISCUSSIONS.
[New York
Medical Journal.
In the conservative method of treatment the knee
joint should be immobilized by a posterior splint,
either of wire or board with side pieces, or of plas-
ter of Paris. The latter has seemed more satisfac-
tory, as it can be perfectly fitted about two thirds of
the circumference of the leg from the gluteal fur-
row to the foot. Several layers of canton flannel,
well rubbed up in cream of plaster of Paris, can be
applied posteriorly to the leg, and held in place by
a muslin roller bandage. It may be removed as nec-
essary and reapplied. Care should be taken that it
should fit snugly after the joint swelling has dis-
appeared. Adhesive plaster strips are used to ap-
proximate the two fragments in proper position.
One strip of the plaster is applied from above down-
ward obliquely about the joint, so that its lower
edge will pass over the upper border of the upper
fragment of bone, pulling it downward and pre-
venting the inward tilting of its lower edge. A sec-
ond strip is passed obliquely from below upward
and posteriorly over the lower fragment, so that
the 'outward tilting of its fractured edge will be ob-
viated. Occasionally it will be necessary to firmly
apply a strip of adhesive transversely about the
joint to prevent eversion of the fractured edges. By
traction and countertraction thus exerted to pro-
mote apposition of the fractured surfaces, firm
fibrous union can often be secured and a good result
follow. As the efifusion disappears, readjustment
of the adhesive plaster strips will be necessary.
After the first week, daily massage of the quadriceps
extensor should be done, without removing the
splint, to prevent atrophy through disuse. At the
expiration of three weeks the splint should be re-
moved daily, and massage and passive movements
practised. At the sixth week, a light stif¥ splint
should be applied and walking with crutches per-
mitted. After the eighth week, active motion may
be tried with care, the crutches discarded, and a
cane used. This light stifif splint about the joint
should be continued until the sixth month, when a
flannel bandage should be applied and employed for
three months longer. After the ninth month a sup-
port is not usually required.
Comparison of results from the two methods of
treatment shows to the credit of the radical or op-
erative in more perfect restoration of function, bet-
ter bony union, and a shorter invalidism. However,
the danger from sepsis must not be discounted, even
with complete facilities for cleanly work.
Dr. P. C. Hulton, of the United States Army, states:
In the treatment of a fractured patella we first
seek an accurate reduction and means to immobilize
the fragments. Accurate reduction is dependent
largely upon the time elapsing between receipt of in-
jury and the time the patient is seen by the surgeon.
If seen immediately, the swelling will not be such
as to prohibit approximation and retention of frag-
ments, but if seen after the efifusion has become
prominent steps must be taken to dissipate this ef-
fusion before reduction can be accomplished. An
elastic bandage, should other means not be at hand,
will ordinarily secure the desired results, if trau-
matism has not been very severe, in twenty-four
hours or less, but two flat sponges, about the size of
a nian''^ hand, arc ei|uall\ efficacious and more com-
fortable to the patient. These sponges should be ap-
plied after the joint is snugly wrapped in a flannel
bandage and in such a manner that the sides of the
sponges come together over the anterior surface of
the patella. After carefully applying the bandage,
which holds them in position, with such force as
may be consistent, hot water (115° F.) is slowly
poured over the whole until the sponges become sat-
urated. This process is repeated each hour until the
bandages and sponges are removed.
Having dissipated the efifusion, the leg is mas-
saged and the fragments approximated. The lower
fragment is drawn upward as far as practicable, and
there maintained by a strip of adhesive plaster, one
and one half inches wide, passing beneath the lower
border, encircliijg the leg obliquely, and overlapping
on the under surface in the popliteal space. The in-
jured member is now elevated by an assistant, and
the upper fragment brought downward into apposi-
tion in a similar manner, the adhesive plaster over-
lapping on the posterior surface at about the lower
border of the knee joint. A properly padded, long
posterior splint is atifixed and held firmly by straps,
preferably made of canvas, and attached to back of
splint with a buckle, so situated as not to infringe
upon the limb. Of these straps there should be four,
one at each extremity of the splint and one above
and one below the knee. In addition to fixation of
leg to splint these straps also serve to prohibit pow-
erful contraction of the extensor muscles. This pro-
hibition is more completely realized, however, when
coaptation splints are also applied over the lower
half or two thirds of the quadriceps, but before their
application a second strip of adhesive plaster is
passed above and below the respective fragments,
and- the extremities of the straps made fast to the
posterior surface of the splint in the oblique manner
as indicated. As the swelling subsides these straps
may have to be tightened. In this event the frag-
ment is held in position by an assistant while the
surgeon reapplies the strap. The limb is now band-
aged snugly to the splint, both above and below the
knee, the joint being left clear for inspection and
examination. The limb should then be elevated in
order to secure relaxation of the extensor muscles.
The treatment from this point onward is of the
greatest importance, and the result attained will de-
pend largely upon the manner in which the case is
handled after reduction is complete. Daily mas-
sage, beginning upon receipt of injury, must be
carefully and systematically employed. The external
bandaging having been removed, the masseur should
begin at the ankle and slowly work upward. In
massaging the joint care must be exercised that no
violent friction is developed. The tips of the fin-
gers only should be employed at this point. Union
takes place in from two to six weeks, depending
somewhat upon the age of the patient, and the splint
should not he removed until the latter time has
elapsed. In this statement I am not unmindful of
what certain books recommend on this subject, but
having once had a distasteful experience I am in no
position to advise the removal of the cast nor the
commencement of passive motion at the end of four
weeks. The only danger of waiting six weeks is
that of partial anchylosis, and this always clears un-
der massage and passive motion. It is nuich better
April 25, 190S.]
OUK READERS'
DISCUSSIONS.
791
to have a well united patella than to have one weak-
ened by passive motion practised upon fibrous
shreJs before union is complete. Therefore at the
end of six v;ceks ].assive motion is to be instituted
and the massagx' still continued. At this time, also,
a removable, light plaster cast may be employed,
and at the end of eight weeks the patient allowed
to walk on crutches. About the tenth week the
■crutches may be abandoned for a stout cane. The
h'ght splint is worn for four to six months, when it
gives way to a flannel bandage, and in the meantime
the massage is continued. It is best to continue the
flannel bandage for one or, perhaps, two months,
when it may be removed. At this time perfect func-
tion should obtain, but the patient is to be cautioned
to avoid quick movements and the sudden applica-
tion of weight to the injured limb for a period of
one to two years.
Dr. IValter Lathrop, of Hasletoii, Pa., says:
W'hile fractures of the patella are not common as
compared with those occurring in other bones, yet
the importance of correct treatment cannot be over-
estimated, as the correct or incorrect handling of
the case usually determines the usefulness of the
limb.
The cause of these injuries is usually direct vio-
lence, and in my experience has most frequently
happened to railroad brakemen, who have been
struck by a brake iron, while setting or releasing a
brake. Again, I have seen it due to a kick from the
point of a heavy shoe. It may also be caused by
sudden contraction of the muscles or flexing of knee.
Of course a fall against some solid material would
easily produce the injury.
iNIost of my own cases have been of the com-
minuted type, and I believe those produced by direct
violence are frequently of this order, while muscular
contraction would tend to give a single break, and
this is usually transverse, and below the middle.
The symptoms, while familiar to all, may be brief-
ly stated in order of importance as, sudden loss of
power, pain, great swelling about the parts, and dif-
ficulty in raising the limb from the bed. There is also
a characteristic hollow between the fragments when
the leg is bent, and often with no moving of limb we
can separate the parts easily.
In regard to treatment we have to consider the
conditions present in this class of cases. We have
a joint filled with blood ; we have the fragments
pulled apart, and kept so by the action of a powerful
muscle and tendon, and we have also the strong-
supposition that interposed between these fragments
are pieces of tissue or shreds of aponeurosis, which
will act against our getting bony union if allowed
to take a course of nonoperation. It is true that
in many cases nonoperative treatment will give, and
has given, good results so far as fairly good use of
the limb is secured, provided the treatment has been
most carefully and thoroughly applied when the in-
jury is first received.
In the nonoperative treatment we hope to achieve
several things: The removal of effusion in joint and
tissues, and to overcome muscular opposition are the
chief objects in view.
The application of cold compresses is most val-
. liable, accompanied by firm bandaging, or we may
remove fluid by aspiration or small incision, being
sure of having the parts surgically clean. After
removal by incision or tapping, the part should be
firmly bandaged, to prevent a return of the trouble.
The treatment of the fracture is best done, I believe,
by the use of the x-\gnew splint, with or without the
adjusting pegs; my preference is either a firm fig-
ure of 8 bandage, bringing the bones together as
well as possible, or else using strips of adhesive
plaster, carefully applied, and passing beneath the
splint.
Plaster of Paris for fixation I have abandoned en-
tirely in these cases until several weeks have passed,
when the limb may be put up in plaster, and patient
let up on crutches, and shortly after the cast ma>-
be removed, and massage, passive movements, and
gradual use of the knee be commenced.
In regard to operative treatment, I am convinced
by a fairly large experience that, under strict sur-
gical cleanliness, aseptic or antiseptic surroundings,
fair ability, and clean work on the part of the sur-
geon, this method offers the very best of all meas-
ures, in securing bony union, and a useful limb.
When a patient is elderly, or in poor health, I think
it better not to operate, although possibly a local
anaesthetic might be used, but I doubt its expediency.
We must remember also that opening the knee
joint is not a simple affair, but a formidable opera-
tion, to be undertaken with the same preparation
that would be used in opening the abdomen, and, in
fact, the after results are more often in doubt where
the knee is involved than where the abdomen is con-
cerned.
Stiffness of the limb, infection, and possible loss
of the leg are possibilities not to be ignored, and it
is therefore self evident that the chief element of
success in these cases is scrupulous cleanliness at
every stage of the operation. If we can place the in-
jured parts in practically the same position as they
were before the injury, then we should expect a
practical cure, and it can be secured by the method
which is described in this paper, and used by a good
many surgeons, and is most satisfactory in the re-
sults obtained.
The leg and knee are carefully prepared for op-
eration, and then an incision made either across the
joint from side to side, above the fracture (my cus-
tom), or a "U" shaped flap turned up, exposing the
parts beneath. The torn tissues about the fracture
are turned back, all clots and debris carefully and
thoroughly removed by sterile salt solution, aided by
forceps if necessary. The leg is then extended and
held firmly while the fragments are brought into
apposition (care being taken to prevent any foreign
matter from lodging between the bones), and
sutures of chromic gut passed through the ligaments
and tissues about the patella, as well as the peri-
osteum, which should be secured over the line of
fracture very carefully. The quadriceps tendon
should be sutured with care, and the skin wound
closed with silk worm gut or any suture of choice.
I do not believe in the use of wire or nonabsorbable
material, and my experience has proved it unneces-
sary. A loop of catgut may be passed entirely
around the patella if the surgeon deems it necessary,
but I seldom, if ever, use it. The after treatment
consists in putting the limb on an Agnew splint.
792
CORRESPONDENCE.— THERAPEUTICAL NOTES.
[New York
Medical Journal.
with absolute rest, for two weeks; then very gentle
manipulation of the patella only, and after four to
six weeks passive motion, massage, and the gradual
use of the limb, aided, of course, by crutches. Of
course at the time of operation a small drain of
gauze or horsehair may be inserted at the angles of
wound if deemed advisable, but where hjemorrhage
has been carefully arrested, and the suturing done
with great care, the use of drainage is not often re-
quired.
As to time of operation, my practice is to operate
at once if possible, before the advent of great swell-
ing and haemorrhage about the joint, but most of
the patients have been received from two to four
days after the accident, and I have always operated
upon them at once, carefully cleansing the joint as
before mentioned, and getting splendid results in ev-
ery case.
I have tried the direct suture by wire, through
holes drilled in the fragments, by passing wire
around the fragments, and by a combination of
methods, but none equal, or even approach, the
means I have advocated.
Summary.- — In elderly or feeble people the non-
operative method seems advisable, save in selected
cases. For the general practitioner the nonoperative
is best.
Where hospital facilities can be obtained the op-
erative method is much the better method.
W here good surgical skill is at hand this method
is to be chosen in most cases. The use of chromic
gut is better than nonabsorbent sutures. The great
secret of success is absolute cleanliness, careful
technique, perfect apposition, with all bleeding-
checked, absolute rest for ten days to two weeks,
gentle massage after two or three weeks, and then
passive motion, and gradual use of the leg.
{To be continued.)
Corrfspnknce.
LETTER FROM HAMILTON, CANADA.
The Ontario Medical Association
Hamilton, April 20. igo8.
The twenty-eighth annual meeting of the (Jntario
Medical Association will be held in the Normal Col-
lege Building, Hamilton, on the 26th, 27th, and
28th of May, 1908, under the presidency of Dr.
Ingersoll Olmsted, of that city, the general secre-
tary being Dr. Charles P. Lusk, of Toronto. A
programme of great scientific and practical interest
has been prepared ; in fact, it is one which has not
been surpassed by any medical organization in Can-
ada within recent years. The address in medicine
is to be delivered by Dr. Charles G. Stockton, of
Buflfalo; the address in surgery by Dr. Charles L.
Scudder, of Boston. In addition to these, papers
are to be presented by several eminent United States
and Canadian physicians and surgeons. Among
others are Dr. Virgil P. Gibney, of New York; Dr.
Harry C. Buswell, of Buffalo; Dr. Thomas McCrae,
of Baltimore ; Dr. Lewis G. Cole, of New York ; Dr.
Benson P. Cohoe, of Baltimore ; Dr. Harry P. Lyle,
of New York ; Dr. J. C. Meakins, of New York ;
Dr. Herman Sanderson, of Detroit; Dr. George E.
.Armstrong, of Montreal ; Dr. A. E. Garrow, of
Montreal; Dr. J. W. Stirling, of Montreal; Dr.
Campbell Howard, of Montreal ; Dr. Colin K. Rus-
sell, of Montreal ; Dr. Adam H. Wright, of Toronto ;
Dr. N. A. Powell, of Toronto ; Dr. L. W. Cockburn,
of Hamilton; Dr. J. C. Connell, of Kingston; Dr.
J. T. Fotheringham, Dr. A. Primrose, Dr. W. P.
Caven, and Dr. E. E. King, of Toronto. The meet-
ing will convene in the following sections : General
Medicine ; General Surgery ; Obstetrics and Paedi-
atrics ; Eye, Ear, Nose, and Throat ; and Preventive
Medicine. The evenings will be given over entirely
to the social side of the convention. On the first
evening there will be a smoking concert at the
Yacht Club at Hamilton Beach ; on the second the
annual dinner at the Royal Hotel, when the invited
visitors will be the guests of the Hamilton members
of the association. The entire afternoon of the
second day will be given over to the business of the
association, which is an exceptionally wise choice,
as there are matters of importance to be properly-
presented and discussed which will be far better
handled than if they were left to the last session,
which in former years has been the case. The prin-
cipal item of business at this session will be the
reception of the report of the special committee of
the association appointed to revise the constitution
and by-laws to conform with the national medical
body, the Canadian ]Medical Association, so as to
provide for affiliation with that body. The splendid
and attractive programme and the important items
of business, combined with the promising social
side, will be sure to induce many to attend, and the
meeting will most probably be a record breaker in
the history of the association. The Ontario Medical
Association in the past has not traveled much. Most
of its annual meetings have been held in Toronto.
This departure will be watched with interest, and it
is "up to" the profession throughout the province
to support Hamilton to an unlimited extent. The
popularity of the president and the hospitable inter-
provincial spirit displayed in inviting many Mon-
treal men to present papers to the meeting will con-
tribute a due quota to the success of the meeting.
f bcrapnttical |[otcs.
Lotion for Gouty Joints. —
Sodium carbonate 3iii;
Liniment of belladonna, .vi;
Tincture of opium, .sii ;
Distilled water, q. s. ad 'vin.
M.
A small portion of the lotion is mixed with an
equal quantity of hot water and applied on cotton to
the affected joint. Repeat every four hours.
Bismuth Subnitrate in Diseases of the Stomach.
— The ArcJiivcs dcs maladies de I'apparcil di^;cstif
contains a full account, by Gaston Lion, of the use
of bismuth for diseases of the stomach. He insists
upon the use of a very pure preparation in order to
avoid toxic symptoms. The heavy subnitrate is to
be preferred to the light, because the latter very
often contains impurities, such as the carbonate or
the oxides (The Practitioner, April, IQ08). Chem-
ically pure bismuth subnitrate is harmless, as much
as .^iiss having been taken daily. Its use is indicated
in gastric pain, whatever may be the cause, and is
April 23. 190S.]
THEk.-iPEUJICAL 1\0J ES.
793
equally successful in hypopepsia, apepsia, and hyper-
pepsia. It soothes gastric pains of all sorts, but is
ineffective in those due to nervous dyspepsia. The
sedative effects are produced from the second to the
sixth day. In simple ulcer, it relieves pain and
hastens healing. In cancer of the stomach, only
temporary relief is afforded. In bleeding from the
stomach. Lion confirms the good eft'ects alread\
noted by IMouneret and Fleiner. It acts as an anti-
septic in abnormal fermentations. There is only one
contraindication to the use of bismuth in large doses,
which is when, in some part of the alimentary canal,
stenosis exists. In these cases, bismuth accumulates
behind the obstruction forming a concretion with
the mucus. If used in cases presenting only a slight
degree of stenosis, it must be given in small doses,
and be watched very carefully. Constipation is no
bar to its use, for large doses make the motions more
regular, and may even produce diarrhoea. Lion is
of opinion that it has a double action on the stom-
ach ; physically, by coating the mucous membrane,
and thus shielding the glands and nerve endings
from the more or less irritating eff'ects of the gastric
contents, ulcers being protected in the same way and
healing promoted. Chemically, many believe that
the salt is not acted upon by the gastric juice, but
Lion, as the result of clinical examinations of gas-
tric chemistry, has come to the opposite conclusion.
He finds that bismuth, taken either before or with
a test meal, lessens hyperchlorhydria. decreases the
pepsin, and reduces the energetic action of the pro-
cess of digestion. When it is taken with a meal, di-
gestion goes on more quickly, and the stomach emp-
ties itself in a shorter time. Bismuth has no direct
action upon secretion. It may be given in the morn-
ing, after lavage, in a dose of oiiss to ov suspended
in §vj to o^iij of water. The patient should then
lie down on the side corresponding with the pre-
sumed site of the lesion. When the protective action
of bismuth is wanted, the dose should be given when
the stomach is empty, and may be administered by
the mouth. By giving a large dose five or six hours
after a meal, the contents of the stomach are
changed into a solution which is, though acid, not
irritant, and the stomach then empties itself with
ease.
Treatment of Symptomatic Urticaria in Infants.
— Scharff (Therapentische Moiiatshcfte ; The Prac-
iitioner, April, 1908 ), as the result of several years'
experience, finds that the way to relieve the pruritus
in strophulus or erythematous urticaria (which he
prefers to term symptomatic urticaria) is to apply
to the skin a five per cent, aqueous solution of
ichthyol, to which should be added five per cent, of
glycerin. This is applied twice a day, and covered
with starch powder. ]\Iore obstinate patches are
treated by a coating of the following preparation :
B Ichthyol,
Pulverized starch, aa 31;
White of egg j ;
Water, 3iiss.
M.
In the reflex forms, like that arising from irri-
tation of the erupting teeth, ichthyol may be given
internally, a young infant being able to take, three
times a day, ten drops of a ten per cent, aqueous
solution. There is not, as a rule, any distaste shown
for the drug by children, disagreeable as it appears
to adults.
Treatment of Morphine Addiction. — In the
Medical Record for April 11, 1908, C. C. Langsdorf
publishes a statement regarding the drugs used by
him in the treatment of morphine addiction. The
following are the formulae employed :
I.
R Compound extract of colocynth, gr. i;
Extract of liyoscyamus, gr ;
Extract of r.ux vomica, gr.
Extract of jalap gr. Yz ,
Podophyllin, gr. J/^ ;
Oleoresin of ginger, gr. ;
Calomel, gr. i.
Mix, and make one pill.
II.
B Pilocarpine hydrochloride, gr. i;
Fluid extract of hyoscyamus 3ii ;
Fluid extract of prickly ash, 3ii ;
Tincture of belladonna root 3iv.
Dose : Seven to twenty drops every hour.
Ill
B Tincture of gelsemium.
Dose : Five to twenty drops every two hours.
IV.
B Tincture of strophanthus. 5ss ;
Tincture of nux vomica, 3i ;
Tincture of convallaria 3ii ;
Tincture of cactus grandiflora, 3ii ;
Tincture of digitalis, 3iii.
Dose : Seven to eight drops every four or five hours.
Langsdorf lays stress on careful observance of
details in administration. The usual dose of the ac-
customed drug [the addiction] is to be given at bed-
time, along with three pills (Formula Xo. i). In
the morning, after free movement of the bowels,
give another dose of the accustomed drug. If the
bowels have failed to move, give a hot water enema
or a saline laxative. Within one hour after the
morning dose of the accustomed drug, give ten to
fifteen drops of Formula Xo. 2, and continue giving
No. 2 every hour. Twelve hours after commencing
X'o. 2 start giving Formula Xo. 3, about twelve
drops every two hours. When Xo. 2 has been given
for fourteen hours, give three pills (Formula X^o.
i) ; continue Xo. 2 and Xo. 3. After Xo. i has
acted freely, give a moderate dose of the accustomed
drug. Continue No. 2, but stop Xo. 3 for eight
hours after the last dose of the accustomed drug,
then resume Xo. 3 as before. Twelve hours after
the last dose of the accustomed drug give three pills
(Formula Xo. i) and when these have acted freely
and show greenish or yellowish discharges, discon-
tinue Xos. I, 2, and 3 and start with Formula Xo. 4,
about eight drops every four or five hours. Con-
tinue this for several da}s. When greenish or yel-
lowish discharges appear the cure is effected.
Should the patient become nervous or restless, give
twenty-five drops of Formula Xo. 3. If the bowels
are slow, assist with a saline, hot water enema, or
castor oil. If, about the time for the last dose of
Formula Xo. i to act, the patient becomes nause-
ated, give plenty of warm water and induce vomit-
ing; it will give relief. If aching of the bones oc-
curs, give a hot bath. If sleep does not come by the
second night, give bromides or trional. Watch the
pulse throughout the treatment.
794
EDITORIAL ARTICLES.
[New York
Medical Journal.
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Review of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M. D.
Irff/jcs.s all business communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Philadelphia Office : Chicago Office :
3713 Walnut Street. 160 Washington Street.
Subscription Price :
lender Domestic I'ostage Rates, .$5 : under Foreign Postage Rate,
$7 ; single copies, fifteen cents.
Remittances should be made bv New York Exchange or post
offk-p or express mone.v order pa.vable to the A. R. Elliott Pub-
lishing Co., or b.v registered mail, as the publishers are not
responsible for money sent by unregistered mail.
i:Titered at the Post Office at New York and admitted for
transportation through the mail as second class matter.
NEW YORK, S.'\TURDAY, APRIL 25, 1908.
CONSUMPTION IN THE TENEMENT
HOUSES.
The work of combating pulmonary tuberculous
disease among dwellers in the tenement houses of
New York has been materially aided by the Char-
ity Organization Society^ which has recently pub-
lished a summary of its twenty months' experience
in collaboration with the Health Department and
various city dispensaries. So far as the resources
of these organizations would allow, all possible
means of alleviating the condition of the sufferers
and their families have been resorted to. Natural-
ly, there has been but little expectation of actually
curing the disease, except in its incipiency, but even
in this respect the results have been such as to con-
tribute perceptibly toward lowering the death rate.
But it is not by the cure or arrest of consumption
in the individual case alone that we must estimate
the beneficence of the work undertaken by the so-
ciety and its coadjutors. It is a great thing to pre-
vent the spread of infection from the sick person to
the other members of the family, and this the so-
ciety has succeeded in doing in a ilotable number
of instances. Instruction as to the disposition of
sputum has, of course, been given, but this instruc-
tion has been most efficiently supplemented by mate-
rial aid; in many instances in which the sick per-
son was sharing his bed with another the society
has provided bedstead and bedding for his sole use.
Furthermore — and this is in the highest degree im-
portant— wages lost by reason of physical incapacity
for work, partial or complete, have been made good
in money; families have been moved from insalu-
brious tenements to improved quarters, the society
paymg the increase of rent, or even, in some in-
stances, the entire I'ent ; nutritious food, clothing,
and needed furniture have been supplied ; sufferers
have been sent into the country and maintained there
at the society's expense ; medical supervision, medi-
cines, and nursing have been furnished gratuitously ;
and light work has been secured for those whose
working capacity has been partly regained or not
yet wholly lost.
Encouraging statistical tables are given in the
pamphlet issued by the society, but mere figures can
give but a feeble idea of the amount of good it has
done, and it has all been accomplished with an ex-
penditure of only about $20,000 a year. This, how-
ever, consumed the whole fund which the society
had at its disposal for the purpose, all derived from
individual contributions. Such contributions ought
to be greatly magnified, for in no other way that
we can imagine is it now possible to fight urban
tuberculous disease more effectively than by just
such measures as the society has employed. It is a
substantial gain to the community whenever an af-
flicted family is rescued from the lapse into pauper-
ism and put in the way of retrieving its inde-
pendence, and these things have resulted from the
society's work in many an instance. We hope that
its resources will soon be so augmented as to enable
it to extend its beneficent activities to the utmost of
New York's needs.
THE PREVENTION OF THE ORIENTAL
PLAGUE.
Even for American readers the question of coin-
bating plague possesses more than academic inter-
est, for the disease has obtained a foothold in San
Francisco and has also recently been reported from
Seattle. It is, of course, well established that it is
spread through the agency of infected rats and the
fleas which infest these animals. When this fact
was discovered, it was believed to point the way for
the ready suppression of the disease, but these hopes
have not been realized. An interesting review of
the question is presented by Professor W. M. Haff-
kine in the February number of the Journal of the
Royal Institute of Public Health. According to this
observer, the part played by man in the causation of
plague seems to be subordinate to that of other
agents. When plague first broke out in Bombay, in
1896, it remained for a considerable time confined
to one quarter of the city inhabited by day laborers.
.Although these people spent considerable time in
close communion with other people, the cases con-
t.Dll UKIAL AkTlL LLi,
795
tinued to occur only among the laborers and their
families. Only subsequently and gradually did the
disease appear in other parts of the town. Haff-
kine cites a series of such instances, and concludes
that the plague is, in general, a disease of locality,
that it is contracted principally at night, and that
the part which man plays as a direct agent in its
propagation is a subordinate one. So far as con-
cerns seeking to combat plague by disinfecting or
destroying infected merchandise, furniture, houses,
etc., the item of expense and other difficulties are
very great.
In discussing the measures directed to the lower
animals, the following plans have been pursued: i.
Destruction or keeping away of rats by poisoning,
trapping, tar and sulphuric acid mixture, or the
agency of the domestic cat. 2. Improvements in
towns and villages with a view of reducing or keep-
ing out the rat population, viz., demolition of dwell-
ings, storehouses, and insanitary buildings, prompt
disposal of garbage, cleaning and draining of
streets, etc. 3. Destruction and dispersion of fleas
by petroleum or other insecticides. 4. Fumigation
of houses as a temporary protection against rats and
fleas. 5. Anchoring infected ships away from shore,
or providing mechanical arrangements for prevent-
ing the landing of rats along mooring cable? and
gangways. 6. Fumigation of ships arriving with
plague patients or plague rats on board.
Professor HafTkine gives a very interesting ac-
count of the campaign which has been waged
against rats and fleas in various countries. It is
admitted that such a campaign is the most rational
and best founded of all the measures suggested for
stamping out the plague, but it is important to esti-
mate the extent to which this is a promising direc-
tion. The experience of the health officer of Xew
South Wales is cited. This officer carefully organ-
ized a campaign against rats in Sydne}-. with the
object of protecting from plague a white popula-
tion of a high standard of intelligence and educa-
tion. During the campaign it was found that the
gross returns of rats and mice caught and destroyed
week by week were nearly uniform, and that there
was thus no evidence that the slaughter produced
such an impression on the general horde as would
have rendered collection progressively more diffi-
cult. The use of Danysz's rat virus also did not
succeed in appreciably diminishing the number of
rats in places where this agent was tried. From
Japan also come reports that give little encourage-
ment for the destruction of rats. In Tokyo alone
almost five millions of these animals were killed,
and it seemed as though the slaughter had only pre-
pared more favorable conditions for the multiplica-
tion of the survivors.
According to Hattkine, the ultimate plan of com-
bating the bubonic plague in the areas in which it
becomes endemic consists in conferring on the pop-
ulation immunity from the disease by means of an
artificial treatment. As a result of the work in India
in the past ten years, Haffkine draws the following
conclusions: i. In a native of India, who is more
susceptible to the disease than Africans, Europeans,
and some other races, the inoculation now in force
reduces the liability to attack to less than one third
of what it is in a noninoculated Indian. 2. In the
one third of cases which still occur the recovery
rate is at least double that in the noninoculated at-
tacked. The ultimate result is a reduction of plague
mortality by some eighty-five per cent. 3. In an
inoculated European an attack of plague, if it subse-
quently occurs, has so far always ended in recov-
ery. 4. The inoculation is applicable to persons al-
ready infected and incubating plague, and prevents
the appearance of symptoms or else mitigates the
attack. Some idea of the importance of the con-
trol of plague in India may be obtained from the re-
turns for 1907. The total cases of plague from No-
vember 24, 1906, to November 9, 1907, were 1,394,-
947, of which number 1,276,576 were fatal.
INJURIES AND THE PRE\ lOUS CONDI-
TION.
For one reason or another there often arises the
question of the influence of a person's previous state
of health upon the disability resulting from an in-
jury. A lecture on the subject was recently given
at the Hotel Dieu by ]M. Brissaud {Progres medical,
April nth). His special topic was the question of
whether or not the possibility of such an influence
should be considered in adjudicating suits for dam-
ages. He maintains that no hard and fast rule on
the point can justly be laid down and be regarded
by the courts as inviolable. He protests against the
French law which ordains that a pregnancy lasting
more than 300 days cannot be admitted, with the
consequence that a child born even two hours after
the expiration of that fixed time, the date of the
last marital coitus being known, has been declared
illegitimate. The arbitrary rule is adhered to, he
says, in spite of a known case in which a woman
was violated, became pregnant, and carried the child
for 317 days, although she had never had sexual
connection before or after the rape. This matter
he brings up in his introduction, to support the con-
tention that the law is unjust when it generalizes
without regard to exceptional occurrences.
Proceeding to his proper subject, M. Brissaud
cites the case of a girl, twenty years old. employed
796
EDITORIAL ARTICLES.
[Ni-w York
Medical Journal.
by a seamstress, who pricked her left thumb with
a needle in the course of her work. A very small
superficial abscess formed at the site of the punc-
ture, and M. Kirmisson extracted a fragment of the
needle through an incision not more than a third of
an inch long. A few days later the girl's left hand
became painful, and the fingers were in an attitude
of contracture in extension. Almost at the same
time a new abscess, quite like the first one, formed
in the left forearm, and again a piece of needle was
removed. A few weeks afterward, the pain and
contracture of the hand persisting, a third abscess
appeared in the upper part of the arm, and a third
piece of needle was cut out.
It was soon afterward that M. Brissaud saw the
girl, and found hyperassthesia and even slight
atrophy (from disuse) of the upper left limb. The
young woman protested, with tears in her eyes, that
she could no longer work, and was disabled for
life, and proceeded to enact a scene of violent
despair. Some days later she had an abscess of the
left breast, and a fourth piece of needle was ex-
tracted. It is added that the four fragments, taken
together, exceeded an ordinary needle in length.
The girl had purposely stuck herself with needles.
Her mother bewailed the young woman's hysterical
conduct, saying that she had always been "so rea-
sonable, so sweet, so industrious," etc. And, says
M. Brissaud, the mother spoke justly; the first
prick, accidental as it was, had roused into activity
a latent state of hysteria.
SOME POINTS CONCERNING SCARLET
FEVER.
In the April number of the Dublin Journal of
Medical Science there is published the graduation
thesis of Dr. G. Allan Crowley. It is entitled Some
Points on the Diagnosis of Scarlet Fever, but the
points given do not all relate particularly, certain-
ly not solely,' to diagnosis. What the author says
is founded on his personal observation of 1,005
cases ; he has, therefore, no lack of clinical data, and
his thesis reads like the work of a good observer.
Dr. Crowley follows Caiger's division of cases of
scarlet fever — somewhat arbitrary, he admits — into
three classes, the simple, the septic, and the toxic.
The simple cases are those that usually run a mild
course, though they are not free from the liability
to dangerous complications. The septic cases are
those in which some secondary infection takes place,
especially that with Staphylococcus pyogenes, and
is apt to prove more important than the scarlet fever
itself. The third, or toxic, class is made up of those
fulminating cases in which the fatal issue is "the
direct result of an overpowering and lethal dose of
the scarlet fever toxine per se."
Dr. Crowley properly insists upon the diagnostic
value of the disproportion between the excessive
rapidity of the pulse and the moderate amount of
elevation of the temperature in the simple cases,
though it is observed only in the early period of the
fever. It is common enough, he says, to find the
pulse from 140 to 160, while the temperature is only
between 101° and 102° F. The discrepancy need
not in itself give rise to anxiety, though it is a very
important aid to diagnosis. As regards the tempera-
ture, he thinks there is a tendency on the part of
American and Continental authors to record it too
high in cases of average severity. We do not re-
member that such a difl:'erence has been noticed be-
fore. If it turns out to be real, it may perhaps be
accounted for by some variation in the process of
taking the temperature ; many of our physicians, it
is well known, have been taught to seek by extraor-
dinary precautions to elicit the highest possible de-
gree of heat in the mouth. It is hardly to be sup-
posed that the temperature of scarlet fever patients
is lower in Great Britain than elsewhere, or that
there are geographical variations of the accuracy of
clinical records in so simple a matter as ther-
mometry.
The author gives an interesting account of the
process of desquamation, especially of the form
known as the "pinhole"' desquamation, and his de-
scription of the rash is minute and accurate. Soon
after the rash has faded, he remarks, the diagnosis
may be extremely difficult. In that case the fol-
lowing points are of importance : The peeled condi-
tion of the tongue, which has not yet had time to
renew its epithelium ; the appearance of the fauces,
which, if the attack has been at all severe, will still
show some degree of injection; roughness and dry-
ness of the skin, which is not infrequently of a dirty
yellowish color; the presence of enlarged and in-
jected papilla: on such parts as the legs, the outer
side of the thighs, and the posterior surface of the
arms ; and the existence of enlarged and tender
glands at the angles of the jaw.
At the height of the rash, says Dr. Crowley, there
is often present around the mouth "a pallor in strik-
ing contrast to the cheeks, where the flush attains
a marked degree." He adds that " the existence of
this circumoral ring bears no special significance."
There is, however, in rare instances, a milk white
pallor about the mouth, which is said to be of dead-
ly import and to occur early in the disease, but this
is evidently a different thing from the pallor men-
tioned by Dr. Crowley.
OBI TUAKY.—XL IV S ITEMS.
797
A NOVEL SOURCE OF LIGHT FOR
OPERATLXG.
The illumination usually available in a farm
house is wofully inadequate when it comes to per-
forming even a minor operation. This fact re-
cently led a physician in Rome, X. Y., to put to a
novel use the acetylene headlight from his motor
car. The car was run close to the window of the
room in which the patient lay, and one of the gas
lamps was taken ofif the carriage and into the op-
erating room, the supply of gas being furnished
through a long piece of drainage tube. The result
was entirely satisfactory, so we learn from the
Scientific American, as the improvised light made
possible an operation which would have been dif-
ficult, if not impossible, to perform in an entirely
satisfactory manner without the a<lditional illu-
mination furnished by it.
JAMES KING CROOK, M. D.,
of Xew York.
Dr. Crook died on Thursday, April i6th, aged
forty-nine vears. He was a graduate of the Medi-
cal "Department of the University of the City of
Xew York,-of the class of 1880. He was known as
an excellent clinical observer and as a writer pos-
sessed of a clear and attractive style.
|i£tos Items.
Mount Sinai Hospital, New York. — The George
Blnmeiitlia!, Jr., Fellowship in Patholog>' for the current
year has been awarded to Dr. Reuben Ottenberg, of
New York.
Syracuse, N. Y., Academy of Medicine. — At a meet-
ing held on Tuesday evening. April 21st. Dr. I. H. Levy
read a paper on the Diagn^i-i^ nf (lallstones.
The Frederick Dovglass Memorial Hospital of Phila-
delphia has contracted lor ilie erection of a new five
story hospital building on the xmth ^ide of Lombard street,
between Sixteenth and Scventeenih streets.
The Medical Jurisprudence Society of Philadelphia
held a stated meeting on Monday evening, April 20th.
Henr\- Leffman, Esq., delivered an address on The Bar as
Seen from the Witness Box.
Meetings of Canadian Medical Associations. — The
forty-first annual meeting of the Canadian Medical Asso-
ciation will be held in Ottawa on June gth, loth, and nth,
and the Ontario Medical As-ociation will hold its twenty-
eighth annual meeting in Hamilton on May 26th, 27th,
and 28th.
Physicians of St. Joseph's Hospital Organize. — The
present and former physicians of St. Joseph's Hospital,
Philadelphia, met on April I4tli and organized the Asso-
ciation of Resident and ex-Resident Physicians of the St.
Joseph's Hospital. It starts with a membership of
seventy-five.
Consolidation of Medical Journals. — Announcement
is made of the consolidation of the Carolina Medical Jour-
nal with the Charlotte Medical Journal. The new publica-
tion will be under the business and editorial management
of the latter journal, and the name. Charlotte Medical
Journal, has been retained for the consolidated journal.
A New Medical Society in Bessemer, Ala. — The
physicians of Bessemer, Ala., held a meeting on the even-
ing of April gth, and organized the Bessemer Aledical So-
ciety, with the following officers for the first year : Presi-
dent, Dr. Thomas C. Uon:'.ld; vice president. Dr. E. P.
Lacy ; secretary, Dr. T. 1. Conwell ; treasurer. Dr. E. V.
Colwell.
The Rock Island County, 111., Medical Society held
its annual meeting on April 14th and elected the following
officers: President, Dr. T. J. Lamping, of Moline; first vice
president. Dr. William H. Ludewig, of Rock Island; second
vice president. Dr. M. S. Dondanville, of Moline : secretary,
Dr. H. L. Yout^, of Moline ; treasurer, Dr. A. E. Williams,
of Rock Island.
Springfield, Mass., Academy of Medicine. — The sec-
ond annual meeting of this organization was held recently,
and officers for the ensuing year were elected as follows :
President, Dr. W. A. Smith ; first vice president. Dr. John
A. Houston, of Northampton ; second vice president, Dr.
Ralph H. Seelve ; secretary, Dr. Joel I. Butler ; treasurer,
Dr. H. W. Van Allen.
Medical Society of the County of Cumberland, N. J. —
The annual meeting of this society was held in Bridgeton
on Tuesday, April 14th. Professor J. C. Applegate de-
livered an address on Eclampsia. The officers for the en-
duing year are : Dr. J. C. Loper, of Bridgeton. president ;
Dr. C. W. W'ilson. r^i Vineland, vice president; and Dr. A.
J. Mander. of Milhille. secretary.
Buffalo Academy of Medicine. — A regular meeting
of the Section in Pathology was held in Tuesday evening.
April 2ist. Dr. James A. Gibson presented specimens of
variations seen in livers hardened in situ, and Dr. F. C.
Busch read a paper entitled Transplantation of the Supra-
renal Gland. Dr. Edwin A. Bowerman is chairman of the
section, and Dr. George A. Sloan is the secretary.
Saratoga Springs, N. Y., Medical Society. — At a
meeting of this society h.eld on Friday evening. April 17th,
the general subect for consideration was irreducible her-
nia. Dr. M. E. Van Aernem read a paper on Varieties
.md Symptoms of Irreducible Hernia, and Dr. D. C.
Moriarta read a paper on the Treatment of Irreducible
Hernia. The discussion was opened bv Dr. J. F.
Humphrey.
The Hospital Conference of the City of New York.
— The annual meeting will be held on Thursday, April
,^oth. at 8:15 p. m.. at the New York Academy of Medi-
cine. Mr. Riciiard H. Townley will read a paper on State
Inspection and Municipal Aid, and Dr. S. S. Goldwatcr
will read a paper entitled The Unfinished Business of
General Hospitals. Officers will be elected to serve for the
ensuing year.
Scientific Society Meetings in Philadelphia for the
Week Ending May 2, 1908. — Monday. April 27th. Min-
cralogical and Geological Section. Academy of Natural
Sciences; Society of Normal and Pathological Physiology,
University of Pennsylvania. Tuesday, April 28th, Medico-
legal Society ; .South Branch, Philadelphia County Medical
Society. Friday, May ist, American Philosophical So-
ciety; Kensington Branch, Philadelphia Coimty Medical
Society.
Improvements for Hudson Street Hospital. — Plans
have been filed for the remodeling of the New York Hos-
pital's House of Relief, at Hudson and Jay streets, to
provide better facilities for the treatment of patients. The
projected improvements include making the ambulance
room in the basement into an x ray room, with isolation
and sterilizing rooms adjoining, and remodeling the ma-
tron's room and the laundry into apartments for the ac-
commodation of patients.
The Medical Society of the Georgetowm University
held its annual meeting m Washington. D. C, on Tuesday,
April 14th, and elected the following officers : Honorary
president. Dr. Warwick Evans ; president, Dr. John F.
Moran ; vice presidents. Dr. Edwin B. Behrend, Dr. Thomas
F. Lowe. Dr. Loren B. T. Johnson. Dr. Llew-elh'n Eliot,
and Dr. G. W. Wood ; corresponding secretary. Dr. Roy D.
.Adams; recording secretary. Dr. R. A. Hamilton; treas-
urer. Dr. Prentiss Willson.
The New Hampshire Medical Society. — The one
hundred and seventeenth annual meeting of this society
will be held in Concord on Thursday and Friday, May
1.4th and 15th. A good programme has been prepared,
and the meeting promises to be one of interest and value.
The officers of the society are: President, Dr. John H.
Neal. of Portsmouth ; vice president. Dr. John M. Gile,
of Hanover ; secretary. Dr. D. E. Sullivan, of Concord ;
treasurer. Dr. D. M. Currier, of Newport.
■798
NEWS ITEMS.
[N£W VORK
Medical Journ
Rochester, N. Y., Academy of Medicine. — The regu-
lar monthly meeting of the Section in Public Health, which
embraces hygiene, climatology, physiology, pathology, bac-
teriology, and forensic medicine, was held on Wednesday
evening, April 226. Climatology was the general subject
for discussion, and Professor Fairchild delivered an illus-
trated address on the Superior Climate of Rochester.
Plymouth District, Mass., Medical Society. — The
annual meeting of this society was held in Brockton,
Mass., recenth'. Dr. Oilman Osgood, of Rockland, de-
livered an address on Hippocrates, the Father of Medicine,
and Professor William E. Cheney, of Tufts College, read
a paper on the Accessory Sinuses. Officers for the ensuing
year were elected as follows : President, Dr. F. J. Ripley,
of Brockton: vice president, Dr. C. S. Millet, of Brockton;
secretary and treasurer. Dr. Alfred C. Smith, of Brockton.
Lectures on the Psychoneuroses. — Dr. Tom .V. Wil-
liams, who has taken up his residence in \\"asIiingtou,
D. C, after having spent two years abroad m the study of
nervous diseases, has made arrangements for a course of lec-
tures on the diagnosis and treatment of the psychoneuroses,
dealing particularly with the recent researches of the French
school in this branch of medicine. In the mornings the
lectures will be on anatomopathology, and the afternoons
will be devoted to clinical work. The course will begin
on May 25th, and the number of lectures will be limited.
A Joint Meeting for the Discussion of Tuberculosis.
— A meeting of the Ontario County, N. Y., Sanitary Offi-
cers' Association, the ]\Iedical Society of the County of
Seneca, N. Y., and the physicians of Geneva and Ontario
County will be held in Geneva on Tuesday, April 28th, at
3 p. m., in conjunction with the tuberculosis exhibit of the
Stale Department of Health. Dr. H. D. Pease, of Albany,
and Dr. Lewis Gregory Cole, of New York, will deliver
addresses on the subject of tuberculosis, which will be il-
lustrated by lantern slides. All who are interested are
invited to attend.
The Medical Society of the County of New York. — A
stated meeting will b; held at the New York Academy of
Medicine on Monda>' evening, April 27th. The scientific
session will be de\otcd ta a "symposium"' on obstetric
prophylaxis, and papers will be read as follows : The Hy-
giene and Management of Pregnancy. Including the Exam-
mation of Pregnancy, by Dr. Austin Flint, Jr. ; The
Prevention of Maternal Dystocia, by Dr. Richard C. Norris,
of Philadelphia: The Prevention of Maternal Infection, by
Dr. Edwin B. Cragin : The Prevention of Fcetal Infection,
by Dr. J. Clifton Edgar.
A Consolidation of Medical Colleges. — It is an-
nounced that the Medic, il School of Indiana University
and the Purdue Sclmol of Medicine arc to be united in
one school which is to Ije under the control of the Indiana
University. The faculty of the new^ school will be selected
with due regard to the members of the present faculties.
A two years' course of medicine will be mamtained at
Bloomington in addition to the complete medical course
at the University of Indiana. The final plans and details
of the merger have not yet been arranged, but it is said
that the change will be made as soon as possible.
The Mortality of Baltimore. — .A.ccording to the re-
port of the lie.Tltli dcp;i.rtment of Baltimore for the week
ending .April iitli. there were during the \yeek 235 deaths
from all causes, as compared with 227 for the correspond-
ing period in 1907 The annual death rate in 1,000 of popu-
lation was 20.60; white, 18.77; colored, 30.29. The principal
causes of death were: Measles, 2; scarlet fever, i; diph-
theria, I ; membranous croup, i ; grippe, i ; consumption.
41 ; cancer, 12; apoplexy. 14; organic heart diseases, 12;
bronchitis, 7: pneumonia. 26; Bright's disease, ig: suicides.
3; homicides, 2; accidents. 9; all other causes, 25.
The Section in Laryngology and Rhinology of the
New York Academy of Medicine will meet on Wednes-
day evening, April 2Qth. Dr. P. Fridenbcrg will present a
patient with a congenital defect of the anterior faucial
pillars, and Dr. S. Oppenheimer will present a patient with
congenita] atresia of the larynx. Papers will be read as
follows : The Treatment of Fractures and Depressed De-
formities of the Nose by a New Method, by Dr. William
W. Carter; The Drainage Mechanism of the Normal Ac-
cessory Sinuses, by Dr. Sidney Yankauer: A Report of
Three Cases of Laryngeal Growth Removed by Direct
Laryngoscopy.
Dr. Koch Compliments New York Institutions.—
During his stay in New York Dr. Koch visited the offices
of the health department and was enthusiastic in his
praise of the antituberculosis work inaugurated in this city
by Dr. H. M. Biggs. He said that Berlin was about five
years behind New York in the organization of the tuber-
culosis crusade, and was Watching w^ith interest the prog-
ress of the work here. Dr. Koch also visited the quaran-
tine station, and was much interested in the organization
of that service. He was particularly impressed by the
successful campaign which Dr. Doty has waged against
mosquitoes in Staten Island.
Society Meetings for the Coming 'Week:
AIoNDAY, April 27th. — Medical Society of the County of
New York.
Tuesday, April 28th. — New York Dermatological Society;
New York Medical Union ; Metropolitan Medical So-
ciet}' of New York City ; Buffalo Academy of Medi-
cine (Section in Obstetrics and Gynaecology).
Thursday, April soth. — Brooklyn Society for Neurology.
Frid.\y, May ist. — New York Academy of Medicine (Sec-
tion in Surgery); New York Microscopical Society;
Gynaecological Society, Brooklyn, N. Y. ; Manhattan
Clinical Society, New York ; Practitioners' Society of
New York.
Canadian Antituberculosis Association. — The eighth
annual meeting of the Canadian association for the pre-
vention of tuberculosis was held in Ottawa on March i8th.
The report of the secretary showed that a sanatorium for
tuberculosis patients had been established in British Co-
lumbia ; that one would be established in Manitoba this
spring, and that plans were being made for the establish-
ment of sanatoria in Alberta and Saskatchewan. Dr. La-
berge, of Montreal, spoke on Some Civic Aspects of the
Tuberculosis Problem, and Dr. Bryce, of Ottawa, delivered
an address on the Tuberculous Immigrant. Officers were
elected for the ensuing year, and Hamilton was chosen as
the place for the next meeting.
The Undergraduate Medical Association of the Uni-
versity of Pennsylvania is an association of the stu-
dents of the University modeled on the organization of the
American Medical Association for promoting "the growth
of practical accomplishments in scientific medicine among
the undergraduates, to prepare them for future usefulness
in wider spheres of professional activities, and to unify the
interests of the various constituent societies." The first
annual meeting of the association was held on Wednes-
day, April 8th. There was a morning session at 10:30, a
luncheon at 1:00 an afternoon session at 2:30, after which
Dr. S. Weir Mitchell, the orator of the day, delivered an
address on the Conduct of the Medical Life, and a dinner
in the evening. The entire affair was very successful.
Michigan State Board of Health. — The regular quar-
ter!} meeting was held in Lansing on .\pril TOth, with the
following members present : Dr. Angus McLean, of De-
troit, president; Dr. Malcolm Sinclair, of Grand Rapids,
vice president; Dr. Frank W. Shumway. secretary: Mr.
Charles M. Ranger, of Battle Creek, and Dr. .Aaron R.
Wheeler, of St. Louis. A resolution was passed authoriz-
ing the secretary to have printed in several foreign lan-
guages pamphlets containing instructions regarding
contagious diseases, to be distributed free of charge among
the foreigners who do not understand English. The sec-
retary was also authorized to issue placards for posting in
public places regarding the danger of the spitting habit,
and the spread and prevention of tuberculosis.
Infectious Diseases in New York:
]\'c arc indebted to the Bureau of Records of the De-
parhneut of Health for the follozmng statement of new
cases <!)((/ deaths reported for the t7vo iveeks ending April
iS, 1908:
, .\pril II. , , 18. >
Cases. Deaths. Cases. Deaths.
Tuberculosis pulmonalis 570 211 444 189
Diphtheria ^6S 65 436 5'
Measles 1.877 48 1,640 46
Scarlet fever 985 54 1,005 66
.Smallpox . . 2
Varicella 166 .. 108
Typhoid fever 2.1 4 '9 $
WhoopiriR cough 12 i i,i .1
Cerebrospinal meningitis 14 7 r 7
Totals 4.015 ,ign ,i.fi74
April 25, 190S.J
XEJVS ITEMS.
799
New York Academy of Medicine. — A public meeting
will be held at the New York Academy of Medicine on
Thursday, April 30th, at 8:30 p. m. The Hon. Rufus B.
Cowing will deliver an address on The Value of Medical
Expert Testimony based upon an Experience of Twenty-
eight Years on the Bench. He will be introduced by Dr.
John A. Wyeth, president of the academy, who will make
a brief address. The entire bar association of New York
has been invited, and the evening promises to be one of
unusual interest.
Association of American Teachers of the Diseases
of Children.— The annual meeting of this society will
be held in Chicago on June ist. The preliniinary pro-
gramme has been issued, and contains a long list of papers
dealing with the study, teaching, and practice of paediatrics.
The officers of the association are as follows : President, Dr.
< Samuel W. Kelley, professor of diseases of children in the
Cleveland College of Physicians and Surgeons ; vice president,
Dr. Charles Douglas, professor of diseases of children in
the Detroit College of Medicine ; secretary, Dr. John C.
Cook, professor of diseases of children in the Post Grad-
uate Aledical School and Hospital, Chicago (deceased) ;
secretary pro tern.. Dr. Robert A. Black, of Chicago ;
treasurer, Dr. George G. Cattermole, professor of diseases
of children in the Colorado School of Medicine.
Charitable Bequests. — By the will of Miss Clemence
Stephens, St. Thomas's Episcopal Church, New York, re-
ceives $5,000 for the purchase of a free bed at St. Luke's
Hospital.
By the will of Henry Rothschild the Federation of Jew-
ish Charities receives $1,500.
B}' the will of Mrs. Jane B. Shain, who died recently in
Atlantic City, the Working Homes for Blind Men and
Blind Women, Philadelphia, receive $1,000 each ; the Phila-
delphia Baptist Home receives $4,000 : the Baptist Orphan-
age of West Philadelphia receives $5,000; the Atlantic City
Hospital, the Mercer Memorial Home, and the Children's
Seashore House receive $1,000 each.
By the will of Jane McHone the Home for Widows and
Single Women, at Thirty-sixth and Chestnut streets, Phila-
delphia, receives a residuary bequest.
Philadelphia County Medical Society. — At a meeting
of the Ceiiira! Branch of this society, held on April 22d,
the evening was devoted to demonstrations of taking the
opsonic index, sphygmograms, and the blood pressure.
The method of taking the opsonic index was demonstrated
by Dr. Harry A.^uncan, and a discussion of the clinical
value of the opsonic index was opened by Dr. Nathaniel
Bowditch Potter, of New York, Dr. Nathaniel Gildersleeve,
and Dr. G. Morton Illm?n. Dr. L. Napoleon read a paper
on The Microscopic Diagnosis of Diseases by Blood
Smears. Dr. George W. Norris demonstrated a method of
using the sphygmograph, and a discussion of the clinical
application of the sphygmograph was opened by Dr. Wil-
liam Pepper. Dr. W. B. Stanton demonstrated the method
of determining the blood pressure, and a discussion on the
clinical value of knowing the blood pressure was opened by
Dr. Joseph Sailer.
The Health of Philadelphia. — During the week end-
ing March 28, 1908, the following cases of transmissible
diseases were reported to the Bureau of Health of Phila-
delphia: Typhoid fever, 91 cases, 13 deaths; scarlet fever,
76 cases. 10 deaths; chickenpox, 38 cases, o deaths; diph-
theria, 81 cases. 9 deaths ; cerebrospinal meningitis, 5
cases, 3 deaths ; measles, 275 cases, 6 deaths ; whooping
cough, 25 cases, 2 deaths ; pulmonary tuberculosis. 144
cases, 70 deaths ; pneumonia, 82 cases, 65 deaths ; erysipelas,
J5 cases, 3 deaths; puerperal fever, 6 cases, 2 deaths;
tetanus, i case, o deaths ; mumps, 39 cases, o deaths ; can-
cer, 21 cases. 23 deaths ; anthrax, i case, i death. The fol-
lowing deaths were reported from other transmissible
diseases: Tuberculosis, other than tuberculosis of the lungs,
22 ; diarrhoea and enteritis, under two years of age. 17 ; ma-
larial fever, i ; dysentery, i. The total deaths numbered
555 in an estimated population of 1.532,738. corresponding
to an annual death rate ot 18.80 in 1,000 of population. The
total infant mortality was 130; under one >ear of age, 102;
between one and two years of age, 28. There were 23 still-
births; 19 males, and 4 females.
College of Physicians of Philadelphia.— A meeting of
the Section in General Medicine was held on Monday even-
- i'-'g. April 1.3th. Dr. H. R. M. Landis read a paper entitled
The Ccmplications and Seqiilje of Measles. Based on a
Study of Four Hundred and Sixty Cases, and Dr. George
W. Norris read a paper on Lobar Pneumonia, which was a
study of four hundred and forty-hve cases, with especial
reference to the decreased mortality since the institution
of the fresh air treatment.
At a meeting of the Section in Otologj- and Laryngology,
held on Wednesday evening, April 15th, the programme in-
cluded the following papers : Some L'nusual Middle Ear
Complications, by Dr. George C. Stout ; Fatal Sepsis with
Trauma of the Middle Ear and Skull, by Dr. B. Alexander
Randall ; Labyrinthitis Complicating Acute Middle Ear
Suppuration, by Dr. B. H. Potts.
The Section in Ophthalmology met on Thursday evening,
April i6th. Dr. S. D. Risley read a paper on Spontaneous
Rupture of a Reform Eye. Dr. Frederick Krauss read a
paper entitled The Ocular Symptoms of Ethmoidal Disease,
and exhibited two patients. Dr. William Campbell Posey
demonstrated an unusual case of congenital squint. Dr.
Howard F. Hansell exhibited a patient with gonorrhoeal
uveitis.
Personal. — Dr. William P. Spratling, medical super-
intendent of the Craig Colony for Epileptics, Sonyea,
N. Y., has returned to duty, after an extended vacation
spent in Bermuda.
Dr. John Warren has been promoted to the position of
assistant professor of anatomy at the Harvard University
Aledical School, and Dr. David Cheever has been ap-
pointed demonstrator of anatomy.
Dr. Hall Edwards, of Birmingham, England, who lost an
arm in the course of his researches in x ray work, has had
conferred upon him a civil service pension of $600 a \ear.
Dr. Hall discovered a method of treating cancer with riie
X rays.
Dr. L. A. Van Wagner has been appointed health officer
of the town of Sherburne, N. Y.. for a term of four years.
Dr. George Weinstein, of Philadelphia, has resigned
his position of resident physician at St. Joseph's Hospital
to take the position of head physician to St. Vincent's
Home.
Dr. August Martin, surgeon to Emperor William of Ger-
many, conducted a clinic at the Kentucky School of Aledi-
cine, Louisville, on Saturday, April i8th.
Dr. Norman E. Ditman. of New York, has been awarded
the Gibbs prize which was offered by the New York Acad-
emy of Medicine for the best original research work on the
kidneys.
The Health of the Canal Zone.— The Annual Report
of the Department of Sanitation of the Isthmian Canal
Commission for the Year 1907 has just been received.
During the year there were 3,435 deaths in the Canal Zone,
including the cities of Colon and Panama, in a population
of 102,133. corresponding to an annual death rate of 33.03
in 1,000 of population. These figures include deaths among
the natives as well as among the whites. There were 115
deaths from typhoid fever, i from relapsing fever, 4I5
from malarial fever, 68 from asstivoautumnal fever, 50 from
clinical malaria, 15 from malarial cachexia. 20 from hjema-
globinuric fever, i from smallpox, i from diphtheria, 55
from dysentery, i from bacillary d> sentery. 53 from amoebic
dj'sentery, 7 from clinical dysentery. S from leprosy, 53
from beriberi, 45 from septicsemia. 295 from tuberculosis of
the lungs, 57 from other forms of tuberculosis, 14 from
syphilis, 19 from cancer, 7 from epidemic cerebrospinal
meningitis, 36 from tetanus, 51 from bronchopneumonia,
530 from pneumonia, 18 from other forms of pneumonococ-
cus infection, 1.11 from diarrhoea and enteritis, under two
years of age, and 18 from puerperal septicaemia. In his
letter of transmittal Dr. Gorgas analyzes the general mor-
tality and shows that the death rate among the white em-
ployees was 16.71 in 1,000; that among the black employees
it was 33-^8 in 1,000. Amoi.g all employees the death
rate was 28.77 in 1,000, against 41.24 in 1,000 in 1906. In
the latter year the death rate among the general population
was 49.10 in i.ooo; while in 1907 it was 33.63 in 1,000. The
deaths from malaria have been reduced from 712 in igo6 to
568 in 1907, with 36,000 more population in the latter year.
The morbidity rate has also decreased from 21,739 cases
admitted to the hospitals in 1906. to 16,753 cases admitted
in 1907. This is among the employees of the Canal Com-
mission only. 243 cases of syphilis. 190 cases of gonorrhoea,
and 116 cases of alcoholism v.ere admitted to the hospitals
during the year, which, in so large a force of laborers and
other employees, is quite remarkable.
8oo
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
April i6, 1908.
1. Chronic Obstruction of the Duodenum by the Root of
the Mesentery, By E. A. Codman.
2. Acute Yellow Atrophy of the Liver. A Report of
Two Cases, One with Ascites,
By Wilder Tileston.
3. On the Significance of Clinical Histories Before and
After Operative Demonstration of the Real Lesion,
By Maurice H. Richardson.
I. Chronic Obstruction of the Duodenum by
the Root of the Mesentery. — Codman, in his pa-
per, wishes to prove his contention that in the
human being the transverse portion of the duo-
denum is more or less compressed by the root of the
mesentery. Shght anatomical deviations from the
normal or certain pathological conditions may in-
crease this pressure to a varying extent up to the
point of complete occlusion of the gut, and when
this pressure reaches a degree great enough to give
more resistance to the muscular efforts of the duo-
denum than the closed pylorus, the condition be-
comes of pathological significance. Thus anatomic-
ally the duodenal secretions are brought in contact
with mucous membranes unfitted physiologically to
withstand their corrosive action. The obstruction
favors stasis in the duodenum and thus bacterial in-
vasion of the tissues. He concludes that if these
propositions can be proved they will materially alter
the present conceptions of the aetiology and treat-
ment of a variety of pathological conditions, e. g.,
hyperchlorhydria, nervous dyspepsia, duodenal and
gastric ulcer, pancreatitis, cholelithiasis, persistent
vomiting after laparotomy and in pregnancy, and
excessive fluid drainage from wounds in the com-
mon duct and duodenum.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
April 18, 1908.
1. Malunion of Bones, By Carl Beck.
2. Malignant Degeneration of Warts and Moles,
By Edmund A. B abler.
3. Static Electricity. Its Physical Properties, Modalities,
Physiological Effects, and Therapeutic Indications,
By William Benham Snow.
4. Etiology and Treatment of Hypertrophy of the Pros-
tate, By A. J. Crowell.
5. Blood Depletion in Pernicious Anaemia, with Recov-
ery, By Willard J. Stone.
6. A Case of Transient Heart Block Due to Intestinal
Toxaemia, By Fielding Lewis Taylor.
7. How the Malarial Parasite Perpetuates Its Existence,
By Albert Woldert.
8. The Systematic Occupation and Entertainment of the
Insane in Public Institutions, By Eugen Cohn.
9. Diagnosis of Tumors and Other Lesions in the Cere-
bellopontile Angle, By T. H. Weisenburg.
10. General Anaesthesia, By Orval J. Cunningham.
I. Malunion of Bones, — Beck suggests the
following axioms : No bone injury should be treated
unless at least one reliable Rontgen ray picture is
taken. The Rontgen method, in combination with
the usual methods of examination, determines the
character of a suspected bone injury. If there is no
bone injury the usual treatment consists in massage,
followed bv temporary immobilization ; a movable
splint (piaster of Paris) being recommended for the
latter purpose. If there is a fissure or fracture, fol-
lowcfl by no displacement, manipulation of the in-
jured area must be avoided, and immobilization in
the most comfortable position applied. A plaster of
Paris dressing answers the purpose best, as it adapts
itself to the contours of the body in any shape de-
sired, and it olfers no obstacle to the control of the
Rontgen rays. After two or three weeks the dress-
ing is removed and massage begun. If a displace-
ment is present, the fracture must be looked on as
a most important injury. Reduction must then be
tried at once. This may be done under the control
of the screen, on a translucent table, a plaster of
Paris dressing being applied after reposition is per-
fect. This is a simple, short, and cheap method, but
the impressions on the fiuoroscope are by no means
so reliable as those made on a plate, and the latter
can be studied at leisure. If the facilities allow, a
plate should therefore be made before efforts at
reduction under the guidance of the fiuoroscope are
tried. Another method consists in taking two skia-
graphs, in different positions, generally in the lateral
as well as in the dorsal position. Under the guid-
ance of these plates the reposition is done and a
plaster of Paris dressing is applied. A Rontgen
picture is taken dirough it in order to ascertain
whether or not reposition is perfect. If it does not
seem to be, the dressing must be removed and an-
other attempt at reposition made. If the process of
reduction, as frequently happens in displaced frac-
tures, meets with difficulties, anaesthesia should be
employed.
2. Malignant Degeneration of Warts and
Moles. — Babler remarks that the laity should be
impressed with the danger of permitting warts and
moles to grow, and should be urged to have them
excised at once. The early excision of apparently
harmless warts and moles will save days of suffer-
ing ; in many instances the life of the individual will
be saved thereby. The moment that warts and
moles begin to grow they are almost invariably
already malignant growths and should be treated as
such.
3. Static Electricity. — Snow gives four rules
of dosage: i. The spark gap, when administering
the wave current, must not be made so long as to
produce too severe pain throughout the inflamma-
tory area, and the gap should be gradually length-
ened as it becomes possible ; 2, the spark gap should
not be so long as to produce spastic or too severe
muscular contractions ; 3, the static sparks should
be regulated in their length according to the depth
of the lesion or size of the part under treatment,
from one half inch to the fingers, to four inches over
the knees and thighs : 4. the convective discharges
should not be administered to the extent of local
irritation. The author gives a list of diseases in
which static electricity should be applied. '
5. Blood Depletion to 296,000 in Pernicious
Anaemia, with Recovery. — Stone reports such a
case, from which lie draws the following conclu-
sions : The immediate prognosis in certain cases of
pernicious anaemia, with blood depletion below 400.-
000, although serious, is not hopeless. The progno-
sis depends on the degree of red cell regeneration in
the bone marrow, the age of the individual, and the
potency of the haemolytic poison being important fac-
tors. Arsenic exerts a rapid .specific influence on
the degree of red cell regeneration in certain cases
April 25. 1908.]
PITH OF CURRENT LITERATURE.
801
of pernicious anaemia, but whether through direct
stimulation to bone marrow activity or through neu-
trahzation of the haemolytic poison, or both, is a
point that remains to be settled.
7. How the Malarial Parasite Perpetuates Its
Existence. — Woldert says that the length of time
a mosquito may live in temperate zones has not yet
been absolutely determined. In Philadelphia the
author kept one living in a glass jar and fed on
bananas, from October 28th to December 26th, or
sixty days. Some mosquitoes may live in the lati-
tude of Philadelphia during the months of December.
January, February, March, and, in fact, throughout
the entire year. In Tyler, Texas, he found larvje of
Anoplielcs living on the surface of water of a small
pond in midwinter, and after freezing weather. It
is undoubtedly true that mosquitoes may live and
propagate in regions near the Arctic zone. Rear
Admiral George Wallace [Melville informed the
writer that he had found mosquitoes within 500 miles
of the north pole, in latitude 65 to 78 degrees X.
Mosquitoes are said to be so numerous in regions
near the north pole that animals coming southward
during certain months of the year are driven back
north again by the swarms of mosquitoes infesting
that country. The determination of the length of
life of this insect is of special interest in the preven-
tion and prophylaxis not only of malarial fever, but
also of yellow fever. Woldert has stained specimens
of malarial parasites taken from cases of malarial
fever occurring in every month of the year. In every
instance but two the specimens were stained by his
modification ef the Xocht-Romanowski method, and
in these exceptions the carbolthionin and Wright
methods were used. The t}-pes of malarial para-
sites found in the peripheral blood were as follows :
January, tertian merozoites and a few rosettes. Feb-
ruary, estivoautumnal ring and signet ring forms.
March, tertian rosettes and many rings forms. April,
tertian rings and full grown forms." May, half grown
tertian forms. June, tertian forms. July, tertian
rosettes. August, estivoautumnal rings. Septem-
ber, estivoautumnal rings. October, swollen estivo-
autumnal rings. November, estivoautumnal rings and
full grown forms. December, crescents and estivo-
autumnal merozoites. Our author has taken the ma-
larial parasite from the peripheral circulation in cases
of malarial fever occurring in every month of the
year (during winter, when there are presumably no
mosquitoes, and also during the spring, summer, and
fall, w^hen they are abundant), therefore no one can
escape the conclusion that the malarial parasite may
live and thrive during the winter months, without
the existence of mosquitoes, and that man is its per-
manent host.
9. Diagnosis of Tumors and Other Lesions in
the Cerebellopontile Angle. — Weisenburg reports
five cases, in two of which a tumor growing from
the dura covering the petrus portion of the temporal
and the occipital bones gave some of the symptoms
of a lesion in the cerebellopontile angle to such an
extent that an operation was performed in one. In
the third case, there was entire absence of headache,
nausea, vomiting, vertigo, and choked disc, and yet
sufficient symptoms were present to indicate a lesion
in the cerebellopontile angle, to find at operation a
cyst, with the consequent, almost total, recovery of
the patient ; the report of a case of abscess of the pia
which stimulated the symptoms of a tumor in this
angle, and, lastly, the report of a case in which a
tumor of the fourth ventricle, compressing the in-
ferior vermis, indicated a lesion in the cerebellopon-
tile angle. The cerebellopontile angle is that area
between the lateral lobe of the cerebellum and the
medulla and pons in which are located the eighth,
seventh, sixth, and fifth cranial nerves. Tumors of
this area, as a rule, are fibromata, and grow princi-
pally from the eighth nerve, less frequently from the
fifth and seventh nerves. Such tumors, especially
those growing from the eighth and seventh nerves,
are favorable for operative removal. Lesions in this
area may be classified according to their nature and
origin. They may be fibromata, sarcomata, endo-
theliomata, fibrosarcomata, or they may be cystic.
According to the location, they may grow from the
eighth, fifth, or seventh cranial nerves ; secondly,
they may grow from the substance of the cerebellum
or pons, and secondarily involve the structures in
this angle, and, thirdly, they may grow either from
the dura covering the petrous portion of the tem-
poral or the occipital bones, or from both, and sec-
ondarily involve the structures in this angle. Inas-
much as tumors of this area, if sufiiciently large,
most involve the cerebellum, the motor fibres of the
pons and the cranial nerves situated there, it is of
the utmost importance to recognize the disease as
early as possible, and, therefore, the early symptoms
are of the greatest importance. These will depend
on the situation of the growth. If a tumor grows
from the eighth nerve, there will be, at first, diminu-
tion of hearing on the same side, with such irritating
phenomena as buzzing, rushing, singing noises, etc.
Later this will be replaced by total deafness. Very
often, however, little attention is paid to the diminu-
tion of hearing or the noises in the ear, and the first
symptom that the patient will complain of will be
that of incoordination as a result of the pressure ex-
erted on the lateral lobe of the cerebellum, or the
early symptoms may be those which are the result of
increased intracranial pressure, such as headache,
nausea, vomiting, vertigo, and choked disc. The
symptoms of lesions growing from the dura covering
the petrous portion of the temporal and occipital
bones and involving the cerebellopontile angle sec-
ondarily will be bilateral, the greater involvement
being on the side of the tumor. There should be
present implication of the cranial nerves on both
sides, with difficulty in eating, talking, and swallow-
ing, because of the involvement of the bulbar nerves,
incoordination in the limbs, depending on the side
of the cerebellum diseased, the general symptoms of
brain tumor, and, at times, spastic paresis of the op-
posite side of the body, because of pressure on the
pons, all of these coming on gradually.
MEDICAL RECORD
April 18, 1908.
1. Constructive Surgery After Extensive Gunshot Wound
of Abdomen, By \V. M. Polk.
2. A Phenomenal Aortic Aneurysm,
By W. GiLMAX Thompson.
3. A Case of Recurrent Jaundice ; Death in Third At-
tack from Carcinoma of Pancreas,
By George L. Peabody.
4. Bright's Disease and Its Treatment, By Otto Lerch^
802
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
5. Electromechanical and Thermic Removal of Local
Stasis, By William Benham Snow.
6. Integrity of Stereognostic Function and of all Forms
of Sensation in a Case with a Lesion of the Left
Parietal Lobe, By Alfred Gordon.
7. Fractures of the Tip of the Olecranon Process,
By Frank E. Peckham.
I. Constructive Surgery After Extensive Gun-
shot Wound of Abdomen. — Polk reports the his-
tory of a patient who was badly injured by the dis-
charge of both barrels of a shotgun, the muzzle be-
ing directly against the body, with three layers of
clothing intervening. The contents of the two bar-
rels struck the abdomen at and above the anterior
superior spinous process of the left ilium and came
out at and above the iliosacral joint, tearing away
all the soft tissue from the crest of the ilium and the
crest itself, above a line drawn from a point one
inch back of the anterior superior process, around
the outside of the bone to the upper limit of the
sacroiliac joint. The joint was not entered, but
the outer half of the transverse processes of the two
lower vertebras were torn of?. Many pieces of de-
tached and semidetached bone were scattered
throughout the entire field of the deeper parts of
the wound. The only portion of the crest that
escaped fracture was that in the immediate region of
the anterior superior process, but between it and
the inferior process this space was stripped of all
tissue but the periosteum. Four operations became
necessary. The last one is described thus : The first
step was the separation of the intestine from the
surrounding wall and then closing it. After being
separated, the openirig in the gut was spontaneously
lessened somewhat, but. still the large oval opening,
narrowing at its extremities and widening at the
middle, involved so much of the circumference of the
gut, particularly at its widest part, as to raise a doubt
as to the proper line of procedure. This doubt was
still further increased by the necessity for removing
the thickened cicatricized edges in case it should be
decided to close this opening, rather than resect.
There was ample room for resection had it not been
for the attachment at the point of anastomosis.
This reduced somewhat the amount of intestine be-
low the traumatic opening at disposal for such an
operation. It was concluded to close this opening.
Closing it longitudinally would have been unwise, as
the gut would have been too much narrowed at the
central portions of the opening. It was therefore
closed transversely, making thus an elbow in the
gut. widening it at that point. Through and
through primar}' sutures were used with the usual
peritoneal surface sutures all interrupted. The next
question was to provide adequate covering. Fortu-
nately the omentum was abundant and its displace-
ment to the left dependent upon the anastomosis
made it easy to draw it over the entire opening.
This had expanded after the intestine had been cut
out. so that its measurement was now increased
from one half to three quarters of an inch, the gen-
eral outline remaining oval as before. The first step
was to provide a parietal peritoneal covering for the
restored sigmoid ; to this end the omentum was
drawn over the intestine without tension, and
stitched to the under edge of the abdominal open-
ing throughout its entire circumference. This df-
fordctl ample parietal peritoneal covering. It was
out of the question to find either fascia or muscle
for the purpose, so Dr. Polk was compelled to rest
satisfied with a supercovering of fat and skin. Ver-
tical incisions were therefore made through the skin
and fat at either extremity of the opening, the long-
est arm being through the gluteal region, the skin
with the fat was then dissected from its under at-
tachment beginning at edges of wound, and drawn
together over the omentum. The major portion of
the flap was taken from the gluteal region. A small
piece of rtibber tissue drain was inserted at the an-
terior angle of the wound and dressings applied.
The patient was then returned to bed. Care was
taken by the frequent passage of the rectal tube to
keep down the accumulation of gas in the lower
bowel. A through and through movement was ob-
tained by a mild catharsis on the second day, and
from that time on the progress of the case was un-
eventful. The patient recovered entirely.
4. Bright's Disease and Its Treatment. — Lerch
states that if Bright's disease is recognized early
and proper treatment undertaken, it is curable.
Early symptoms, no matter how light, must be re-
garded as serious. If the favorable time is allowed
to pass, cure becomes more and more impossible,
relief of distressing symptoms more and more dif-
ficult, and the fatal issue is only a question of time.
Statistics are unreliable, because the patients are
usually carried off by intercurrent diseases ; dam-
aged kidneys provide a favorable soil for almost any
disease, and death follows, when with these organs
sound the patient would pass smoothly through the
attack. The treatment of acute nephritis is first of
all preventive. During an infectious disease and
after the disease has run its course, the kidneys have
to be watched and the urine has to be frequently
examined. Pure water, vichy, milk, and buttermilk
must be freely administered to flush the kidneys,
and drugs that irritate them should be given with
the greatest caution. Absolute rest in bed is the
treatment after the disease has been established, no
matter how mild the case. There is no drug known
that exercises a beneficial influence upon the pro-
cess. Thorough elimination by skin, bowels, lungs,
and kidney, and rest to the organ are the indications.
A flushing of the kidneys, freeing tubules and
glomeruli from debris, is desirable. However, the
oedema present and the state of the circulatory ap-
paratus must guide the administration of the liquids.
The tepid bath increases diuresis and effects a flush-
ing of the kidneys. The bowels have to be kept
freely open, sodium and zinc sulphocarbonate
given ; if diarrhoea is present betanaphthol or other
antiseptics may be administered to prevent fer-
mentation. For practical purposes it is sufiicient to
administer these antiseptics in doses large enough
to make the stools odorless or to add bismuth and
to continue to increase until salt is found white in
the dejections. If the nephritis is due to chilling of
surface, the treatment ought to be commenced with
a steam or hot air bath. Severe pain in the region
of the kidneys demands hot fomentation or a Pries-
nitz bandage. If oedema is excessive and does not
yield to the hygienic and dietetic treatment, the usual
measures have to be taken — saline laxatives to pro-
duce waterv stools — hot baths, hot packs, and hot
air baths. Of the diuretics only those that are not
April 25. 1 90S. I
I'iTH OF CURRENT LITERATURE.
803
irritating ought to be administered : the tartrates and
acetates of sodium and potassium, lemon juice, in-
fusion of juniper berries, infusion of digitalis, and
benzoate of sodium. During an acute attack all food
must be withdrawn. Chloroform inhalations and
hypodermatic injections of morphine to stop spasm :
venesection in suitable cases, and hot injections of
normal salt solution may be tried — pilocarpine if
the lungs are not seriously damaged. The treatment
of the chronic form does not materially differ,
though rest and diet must be modified to conform to
less vigorous demands.
BRITISH MEDICAL JOURNAL.
April 4, 1908.
1. The Phvsiolog^• of the Emotions (Lecture I).
By F. W. MoTT.
2. Vicious Circles Associated with Disorders of the Heart,
By J. B. Hurry.
3. Repor:, with Comment, of Six Cases of Heart Block,
with Tracings, and One Post Mortem Examination
of the Heart, By E. O. Jellixek and C. M. Cooper.
4. A Specific Treatment of Leprosy,
By Professor Deycke.
5. Electrolysis in Tic Douloreux and in Spinal Sclerosis,
By D. Turner.
2. Cardiac Disease. — Hurry states that the
term "vicious circle" in medical nomenclature indi-
cates a morbid condition in which cause and effect
act reciprocally on each other. Such vicious circles
are numerous and play an important part in the
processes of disease. Vicious circles associated with
disorders of the heart may be grouped as follows :
(a) Associated with the myocardium, (b) With
the endocardium, (c) With the pericardium, (d)
With neuroses, (e) With a fall in blood pressure.
All these vicious circles can be analyzed into two
or more factors which act and react on each other
to the progressive injury of the patient, and their
recognition is essential to rational treatment. Spe-
cial points as regards treatment are as follows :
I. The exciting cause must be sought. This may
be obvious, e. g., rheumatic fever, or pneumonia
and heart failure. But close investigation of de-
tail may be required ; thus an ill ventilated, gas lit
office or overindulgence in tobacco may so depress
the heart, even when organically sound, that the
pulse becomes feeble and intermittent and life mis-
erable and useless, the heart and general health de-
pressing each other. 2. It is frequently desirable to
actively treat each of the several factors concerned.
In pneumonia the heart must be watched as care-
fully as the lungs. The unsound heart of the laborer
must not be stimulated with digitalis and strychnia
if no steps are to be taken to lessen the hard work
that is preventing compensation. 3. Where there is
a choice of treatment, the physician must attack what
appears to him the point of least resistance. Hence
results a varying modus operandi for the same dis-
order— a variety which puzzles the patient. 4. The
close dependence of the heart on the central nervous
system is shown by the existence of several vicious
circles in nervous introspective patients. There is
often a baseless fear of sudden death, which a few
well chosen words from a trusted adviser may en-
tirely dissipate. 5. Many vicious circles associated
with the myocardium arise from the failure of com-
pensatory changes — e. g., when a salutary hyper-
trophy is followed by undue dilatation, caused either
by degeneration of the myocardium or by the ex-
cessive work thrown on the heart. Here treatment
may do much to increase the vigor of the myocar-
dium or to lighten its load. By one or both courses
the failing compensation may be so restored as to
render the heart once more equal to its task. Above
all. an ample supply of pure blood must be secured
to the mvocardium.
3. Heart Block. — Jellinek and Cooper report
six cases of heart block, with the results of the post
mortem examination in one case. Three of the pa-
tients were comparatively young, twenty-seven,
thirty, and thirty-one years respectively, and two of
these died, the third' being in the preparoxysmal
stage and recovering. All of the patients came un-
der observation complaining of attacks of the nature
of semifaints, the patients not quite losing conscious-
ness. Several of the patients complained of aura; or
preseizure sensations. These may be due to: i.
Extra systoles which, coincidently in some cases, in
others perhaps regularly, precede the seizure, the de-.
scription given being not unlike the so called "aurae"
in Adams-Stokes"s disease. 2. Slight, short seizures,
preceding more prolonged ones. 3. The pumping in
of blood into comparatively empty bloodvessels after
an extra systole has failed'to open the aortic valves :
this, for instance, causing an additional pulsation in
some of the vessels. The attacks seem to occur in
spells and are an indication of the temporary break-
ing down of the ventricular compensation. It is re-
markable from what seizures or series of seizures
people can recover and afterwards lead a useful life
for years. Pulsation of the veins of the neck can
only be detected during the shorter, milder attacks.
The sounds as heard over the auricles are shortened
miniature toneless imitations of the normal first and
second sounds as heard at the apex. In no case was
there any oedema. Clinically the hearts of four of
the six patients were greatly dilated and hypertro-
phied. Rest in bed was the most salutary factor in
treatment, drugs having but little or no influence.
4. Leprosy. — Deycke in his studies of leprosy
has not succeeded in cultivating the lepra bacillus as
seen in the leprous tissue. But he has isolated, how-
ever, from several severe cases of nodular leprosy a
characteristic microorganism which he terms the
Streptothrix leproides. The material from which
the cultures were made was obtained by throwing
back a flap of skin, including a nonulcerated recent
leproma, and taking fragments of lepra tissue from
the under surface of the leproma, every precaution
against outside infection being of course taken. The
tissue so obtained was placed in nonnal salt solution
and incubated for several weeks, when the filaments
of the streptothrix could be observed growing from
the mass in great profusion. Injection of a small
quantity of a living culture into a severe case of lep-
rosy at weekly intervals was followed by disappear-
ance of the fever and rapid retrogression of the lep-
rous symptoms, so that at the end of two months
recovery was apparently complete. Investigation of
the cultures showed that the active principle was
contained among the fatty substances. This sub-
stance, called "nastin," was found to be a genuine
neutral fat, the glycerin ester of a high molecular
fatty acid. When suitable doses of pure nastin are
8o4
Piri-I OF CURRENT LITERATURE.
[New York
Medical Journal.
given hypodermaticall}', there ensue more or less in-
tense reactive processes in the leprous tissue, con-
sisting in inflammatory swelling and saturation,
pulplike softening, true suppuration, and necrosis of
the leprous formations, the normal tissue remaining
unaffected. It was found that by combining nastin
and benzoylchloride the former was activated to a
great extent. The nastin is carried to the lepra ba-
cilli, to which, owing to its near chemical and phys-
ical relation, it attaches itself, and then the benzoyl
can fully display its well known antibacterial action
in removing the fat of the lepra bacilli. And when
deprived of fat the lepra bacilli seem to be doomed.
The human organism then effects with comparative
ease the further dissolution and ultimately the com-
plete destruction of the bacteria nuclei. The writer
sums up his conclusions in one short sentence : Ben-
zoyl nastin is an agent which acts directly on lepra
bacilli.
LANCET.
April 4, 1908.
1. The Pigmy and Negro Races in Africa (Hunterian
Lectures, I), By F. C. Shrubsall.
2. Tuberculosis of the Kidney and Malignant Disease of
the Cscum (Lettsomian Lectures, III),
By C. J. Symonds.
3. Delayed Chloroform Poisoning: Its Nature and Pre-
vention, By W. Hunter.
4. Observations on the Bacteriology of Scarlet Fever,
_ By H. Kerk.
5. Note Upon the i uberculoopsonic Index of the Urine
and Sweat in Health and in Tuberculous Disease,
By J. Miller.
6. Observations on the Opsonins, with Special Regard to
Lupus Vulgaris. Part II,
By A. Reyn and R. Kjer-Petersen.
7. Motoring Notes, By C. T. W. Hirsch.
2. Cancer of the Caecum. — Symonds in the
third of his Lettsomian lectures on the above named
subject points out the characters of early cancer of
the caecum, and shows the comparative safety of
operation in suitable cases and the degree of
mimunity from recurrence that may be secured.
The two main signs are the presence of a tumor
and the occurrence of early intestinal colic due
to obstruction of the ileocaecal orifice. The tu-
mor in its most typical form is unlike any other
morbid condition about the caecum. It is movable,
hard, and well defined, and so close to the abdominal
wall that it may be grasped by the hand and
even lifted from the posterior wall. It may be
moved downward and upward for quite a distance,
during which movement a gurgle is often felt from
air passing through the stricture. The discovery of
the tumor by the patient may be the first sign of dis-
ease. Intestinal colic is a common initial symptom,
and if the patient be taking food at the time of the
colic part pf the food may be rejected without nau-
sea, and lie may return to his meal. Colic may be
entirely absent where the disease begins in the pos-
terior wall or just above the orifice. Swellings in the
region of the caecum giving rise to questions of diag-
nosis may be classified as follows : i. The conditions
resulting from appendicitis. 2. Cancer of the pos-
terior wall with early perforation, fixation, and sup-
puration. Here the resemblance to subacute cases
of appendicitis is very close. 3. Glands in the angle
between the ileum and caecum. 4. Tuberculosis of
the caecum. This occurs in earlier life and fixation
arises sooner than in cancer. 5. Actinomycosis in
its early stages resembles more closely that form of
appendicular swelling due to a calcareous covered
concretion, in that the tumor is fixed and does not
disappear. In the later stages, when infiltration and
suppuration occur, there is a resemblance to cancer
beginning in the posterior wall. So mobile is the
tumor in cases of cancer of the caecum, that until the
abdomen is opened one cannot be certain whether
extirpation is possible or not. The presence of
ascites and of secondary deposits in the peritonaeum
or liver puts excision out of the question, as does
also adhesion to the posterior wall with infiltration
of the muscle or with a sinus. Infiltration of the
anterior abdominal wall, unless very limited, also
renders complete eradication impossible. Where the
disease is too expensive for removal, short circuiting
will sometimes relieve the symptoms. The writer
makes use of the ^lurphy button in almost all his
cases, but supplements it by a row of Lembert's
stitches all round.
3. Delayed Chloroform Poisoning. — Hunter
holds that to connect the symptom complex of post-
anaesthetic poisoning exclusively with disturbances
in fat metabolism is to exaggerate the importance
of this change and to underestimate the importance
of the other functional liver disturbances with which
disturbance in fat metabolism is associated. The
acidosis accompanying increased fat metabolism be-
comes of grave pathogenetic significance when com-
bined with diminished proteolytic activity, owing to
inanition, deprivation of food, or recurrent vomiting.
As the result of the diminished absorption of am-
monia in the portal blood catised by such conditions
the intracellular alkalinity of the liver cell is already
at a low level. There then results first of all a seri-
ous interference with the proteolytic, antitoxic, and
glycogenic functions of the liver (of which the post-
anaesthetic nausea is a symptom), and the transfer-
rence of fat to the liver in increased quantit\- from
its depots is a result. The acidosis which accompa-
nies this increased fat metabolism depresses still fur-
ther the intracellular alkalinity and proteolytic and
antitoxic powers to the point when they are almost
in abeyance. There tlTen ensue the characteristic
severe toxic cerebral symptoms of the condition
which rapidly prove fatal. So that the disturbances
in fat metabolism, evidenced by the fat changes after
death, and the acetonuria and acidosis during life,
are thus the results rather than the causes of the
preceding disturbances in the other functions of the
liver. The vomiting which occurs after tlie admin-
istration of anaesthetics is not of nervous origin, but
is essentially toxaemic, due to the profound depres-
sion of liver function, with consequent diminution in
its antitoxic function during the period of the ad-
ministration. This depression will be the greater if
a liver already weakened by disease or by poor nu-
trition be further unduly weakened by food having
been withheld for many hours before the administra-
tion. This enforced abstention from food before
administration of an an;esthetic may thus, in indi-
vidual cases, be carried too far, and it is largely re-
sponsible for the fatal effects of delayed chloroform
poisoning in exceptional cases. Such effects could,
in all probability, be completely prevented if, instead
of withholding food, particular care was taken that
the patient had always a very nutritious and easily
April 25, 1908.]
PITH OF CURRENT LITERATURE.
805
digestible meal, well sw eetened, two or three hours
before the operation.
4. Bacteriology of Scarlet Fever. — Kerr has
made a bacteriological investigation of the throats of
J 60 patients suffering from scarlet fever, and found
streptococci present in 84 per cent. But cultures
from forty healthy throats showed streptococci in 83
l^er cent. Streptococci in pure culture were founrl
frequently in the adenitis and mastoid infections,
showing that they play an important astiological part
in the complications of scarlet fever. All the strep-
tococci found were subjected to the well known Gor-
don tests, but no light was thrown on the aetiology
of the disease, as at least seven dift'erent strains were
found. That the infecting agent is present in the
pharyngeal and faucial mucus is absolutely all that
has been established for certain regarding the causa-
tion and source of the disease. If none of the strep-
tococci in the throat are causative of the primar\'
condition, some other agent must have made it pos-
sible for them to obtain entrance to the tissues in or-
der to produce the secondary complications.
BERLINER KLINISCHE WOCHENSCHRIFT
March 23, 1908.
1. Contribution to tiie Surgery of the Lower Segment of
the CEsophagus, By O. Hildebrand.
2. Contributions to the Surgery of the Brain and Spinal
Cord, By Herman Kuttner.
3. Diagnosis and Treatment of Puerperal Fever,
By J. Veit.
4. Gastric Disturbances in Masturbators,
By C. HiRSCH
5. The Decrease of Mortality from Tuberculosis and Its
Causes, . By B. Frankel.
6. The Operative Treatment of Chronic Obstipation,
By W. Arp.l'thnot Lane.
7. Homes for Lupus Patients and the Subjugation of the
Disease,
By Albert Neisser and E. Meirowsky.
8. What Should the Physician Do for Tumors of the
Bladder? By Posner.
1. Surgery of the Lower Segment of the
CEsophagus. — ^ Hildebrand considers operative
measures to remove carcinoma of the lower portion
of the oesophagus to be hopeless.
2. Surgery of the Brain and Spinal Cord. —
Kuttner reports thirteen cases in this portion of his
paper.* They are divided into congenital malforma-
tions, injuries, and inflammatory diseases. The
cases of congenital malformation were one of
cephalocele occipitalis inferior cured by operation,
one of spina bifida of the upper dorsal vertebra in
which death resulted from compression of the me-
dulla oblongata by a sarcoma of the plexus chori-
oideus of the fourth ventricle, one of spina bifida
occulta with defect of the lower segment of the
sacrum and of the coccyx, and one of spina bifida
occulta of the sacrum with the formation of a tu-
mor. The cases of injury were one of late haemor-
rhage in fracture of the base of the skull, one of
fracture of three cervical vertebrae with pure motor
paralysis of both arms by intramedullary haemor-
rhage followed by perfect recovery, one of fracture
of the spinous process of the fourth lumbar ver-
tebra by muscular violence, and one of tropheneu-
rotic gangrene of the foot after fracture of the
spine. The cases of inflammatory disease are di-
vided into two parts: i. Brain abscess and purulent
meningitis ; one of acute abscess of the brain after
complicated fracture of the skull with recovery after
operation, one of acute traumatic abscess of the
brain with an enormous prolapse of the brain that
recovered with a certain amount of spastic paresis,
one of chronic abscess of the left frontal lobe of the
brain which simulated a tumor of the cerebellum on
the left side, and one of purulent meningitis with
the formation of gas. 2, Myelitic processes. Only
one case is reported which was of congenital sym-
metrical paralysis and deformity, due perhaps to a
foetal poliomyelitis.
4. Gastric Disturbance in Masturbators. —
Hirsch reports a case of nervous dyspepsia met with
in a man, twenty years old, which was cured by the
stoppage of the habit of masturbation.
5. Decrease of Mortality from Tuberculosis.
Frankel states that in Prussia there died from tu-
berculosis 88,283 persons in 1886, 64,459 1906.
In terms of proportion in 1886, 31.14 to the 10,000;
in 1906, 17.26 to the 10,000. The steady decrease
in mortality from this disease during these twenty
years is excellently shown by a table prepared by
the author.
7. Homes for Lupus Patients. — Neisser and
Meirowsky urge the establishment of institutions in
which patients with lupus may be cared for, and
think that by this means the disease may become
stamped out.
AMERICAN JOURNAL OF THE MEDICAL SCIENCES.
April, 1908.
1. The Hygiene of Medical Cases, Particularly in Hos-
pital Wards, with Notes on Various Ward Infec-
tions, and Observations Relating to the Probable
Role of Secondary Gastrointestinal Infections in
Typhoid Fever, By D. L. Edsall.
2. The Nature and the Management of Diabetes Mellitus,
By O. T. Osborne.
3. The ImpoKtance of the Early Detection of Aneurysm
of the Aorta, By H. D. Arnold.
4. Carcinoma of the Mediastinum Simulating Aneurysm,
By J. Perkins.
5. Cardiac Arrhythmia Due to Extrasystoles Originating
in the Bundle of His,
6. Some of the Reasons Why Cholecystectomy Should
Not be Performed as Frequently as is Advocated
by Many Surgeons, By J. B. Deaver.
7. Perforation of the Gallbladder During Typhoid Fever;
Cholecystectomy ; Recovery ; with an Analysis of
Twenty-one Operations on the Gallbladder during
Typhoid Fever, By A. P. C. Ashhurst.
8. The Diagnosis and Treatment of Syphilitic Lesions of
the Nervous System, By T. H. Weisenberg.
9. The Neurasthenia of Autointoxication,
By T. J. Orbison.
10. The Indican Reaction as Evidence of Enterogenic In-
toxication, By H. A. Houghton.
11. The Treatment of Chronic Stenosis of the Larynx and
Trachea, By J. Rogers.
12. The Reaction of the Phagocytes of Elephant's Blood
on the Bacilli of Tuberculosis, By S. G. Dixon.
I. The Hygiene of Medical Cases, Particu-
larly in Hospital Wards. — Edsall believes that
infection is communicated in hospital wards much
more frequently than is usually suspected, and in
medical more frequently than in surgical wards.
The ordinary regulations are inadequate in two
ways; (i) they consider only a few of the infec-
tions, (2) they cover only a portion of the means
of conveyance. Isolation of cases is a very incom-
plete solution, for it can be applied to very few dis-
eases. Infection of the food, and especially of the
8o6
PITH OF CURRENT LITERATURE.
[New York
-Medical Journal.
milk, when the milk is not pasteurized, is a matter
requiring serious attention. The milk when re-
ceived at the ward should be under the care of a
particular nurse and protected from infection. The
rest of the food within the ward must also be pro-
tected from infection. The nurses and doctors may
transmit disease from one patient to another. The
patient's mouth must be kept free from infection,
hence it should frequently be swabbed out with cot-
ton and a suitable solution. Ward utensils must be
frequently boiled, and orderlies must be eliminated
from the care of patients as much as possible.
Both nurses and patients should be protected from
infecting themselves or others.
2. The Nature and Management of Diabetes
Mellitus. — Osborne states that this term should
be restricted to cases in which the sugar in the
urine cannot be removed by any dietetic or medici-
nal treatment. Clinically recurrent glycosuria is,
however, frequently a forerunner of diabetes mel-
litus. Temporary diabetes may be produced by
phosphoric, lactic, and hydrochloric acids, by
strychnine, arsenic, phosphorus, and carbonic
oxide. Glycosuria resulting from irritation of the
floor of the fourth ventricle or of the medulla
oblongata is well known. Disease of the islands
of Langerhans in the pancreas is present in many
cases of diabetes. The diabetic cats an excess of
proteid and fat in order to get the proper amount
of energy from his carbohydrates. His dry skin
is due to the great loss of water from the tissues,
and he shows predisposition to infections. Dia-
betic coma is preceded by headache, nervous irri-
tability, and an acid condition of the blood. In
treatment of this condition starches must not be too
rapidly withdrawn. The diet must be suited to the
individual case ; medicine is of secondary impor-
tance. A warm climate, especially an equable cli-
mate, is to be preferred, with freedom from worry,
and work that is not fatiguing. The pancreas and
suprarenal extracts are the only organic substances
which the writer has found serviceable.
3. The Importance of Early Detection of
Aneurysm of the Aorta. — .\rnold states that in
examining for this condition one should carefully
percuss the area of dullness of the great vessels,
note the conduction of the heart sounds in this area,
examine both radial pulses simultaneously, examine
for the tracheal tug, note all evidences obtained by
inspection or palpation, note carefully all the ana-
tomical relations of the aorta, and ever keep in
mind the possibility of aneurysm. The early symp-
toms are usually pain or disturbance with the
respiratory apparatus, the latter from pressure on
the air passages or the recurrent laryngeal nerve.
The symptoms often simulate those of heart dis-
ease. There are no pathognomonic signs ; the
features may be entirely (liffercnt in successive
cases. An x ray examination is useful for con-
firmatory evidence, for distinguishing ■ from solid
tumor, and for detecting aneurysms not discover-
able by ordinary methods of examination. While
the disease cannot be cured, it can be relieved. It
demands limitation of exertion and mental
quietude. The vasodilators are the most useful
drugs which can be given.
6. Cholecystectomy. — Deaver sounds a note
of warning against too frequent extirpation of the
gallbladder. The organ serves a useful purpose,
and should be retained unless hopelessly diseased.
From the standpoint of pathology it is most useful
as an avenue for drainage in septic conditions of
the liver and biliary passages. If chronic pan-
creatitis follows removal of the gallbladder, pro-
longed drainage will' be necessary. In such cases
cholecystoenterostomy is the procedure of choice.
If the gallbladder is removed in the presence of
infection of the bile passages, drainage of the
stump of the cysticus or of the choledochus with a
rubber tube is essential ; this is better than draining
into the duodenum. In doubtful cases drainage is
preferable to removal of the gallbladder, the dan-
gers in the latter operation being always far greater
than in the former. Cholecystectomy is always in-
dicated for dropsy, cancer, or other new growth,
calcareous degeneration or fibrosis of the- gallblad-
der. If the fundus alone is diseased it should be
resected and the remaining portion drained.
10. The Indican Reaction as Evidence of En-
terogenous Intoxication. — Houghton offers the
following working rules: i. Urinary indican is a
product of intestinal putrefaction. There may be
putrefaction without the production of indol, but
there can be no indicanuria without putrefaction.
2. A maximum excretion of indican, of 100 or
more on Frolin's scale, indicates excessive intes-
tinal putrefaction, and the consequent intoxication.
3. A maximum reaction with an index under 100
may be significant, but its interpretation should be
guarded by the oxidizing and excretory capacity of
the patient. 4. A heavy indican reaction which
subsides under treatment indicates intoxication to
a lesser degree, but minor variations in the color
index have no significance with our present knowl-
edge. 5. No interpretation can be placed upon a
negative reaction, as there are too many unsolved,
factors in the problem.
ANNALS OF SURGERY
April, 1908.
1. The Direction of the Jejunum in the Operation of
Gastroenterostomy. By B. G. A. Moynihax.
2. Transfusion and Arterial Anastomosis,
By R. OxfENBERG.
3. On the Thymus Gland Treatment of Cancer,
Bv F. GwvER.
4. The Parathyreoid Glands. By'N. P. Geis.
5. Acute Dilatation of the Stomach and Arteriomesenteric
Ileus, By W. B. L.^ffer.
6. The Removal of Gallstones from the Second and
Third Portions of the Common Bile Duct,
By F. G. CoxxELL.
7. The Reduction en Masse of Strangulated and Non-
strangulated Herniae,
By E. M. Corner and .\. B. Howitt.
8. Diagnosis of Renal Disease and Sufficiency,
By B. .A.. Thom.^s.
9. Multiple and Consecutive Operations on the Kidneys
for Calculi, By \V. \V. B.muoc k.
2. Transfusion and Arterial Anastomosis. —
Ottenberg suggests the following points in tech-
nique : I. The vessels must be handled gently, never
with toothed forceps. The best instrument is a fine
bent forceps. 2. The part to be cuffed back is
cleaned of its connective tissue by pulling the con-
nective tissue sheath over the cut end of the vessel
and cutting it off with scissors. On the end of the
other segment much connective tissue should Ix* re-
tained. 3. During the operation the vessels nuist he
April 25, 1908.1
PITH OF CURRENT LITERATURE.
807
kept moist with salt solution. 4. One should expose
one half inch of the vessel to be cuffed and a simi-
lar length of the vessel which is to be pulled over
the cuff. If the vessels have branches they must be
tied close to the vessel with fine silk. 5. The lumen
of the ring for clasping the vessels must be as large
as the outer diameter of the unopened vessel which
is to be cuffed back. The ring must be placed on the
smaller of the two vessels. 6. There must be no ten-
sion, as in all plastic operations. 7. The part oper-
ated on must be immobilized after operation. 8.
Temporary blood stasis is best obtained by Bill-
roth's harelip clamps covered with rubber tubing.
9. If the muscular sheath of the vessel contracts it
may be relaxed with hot saline solution, or dilated
with a small haemostatic forceps. 10. Absolute asep-
sis is necessary.
3. Thymus Gland Treatment of Cancer. —
Gwyer rhakes a second report on this method of
treatment. His cases, with one exception, were in
an advanced stage and inoperable. The following
points were noted : i . With the exception of two
or three patients they showed temporary improve-
ment, less pain, reduction in the growth, prompt im-
provement in the general condition. 2. Several of
the patients have died or will soon die. 3. In many of
the fatal cases there was no great loss in weight, no
pallor and cachexia, no local increase in the tumor.
Some of the cases showed marked improvement in
general appearance, with no evidence of metastases.
4. The deaths were attributed to progression of the
cancer, to the effects of the thymus treatment, or to
the effects of, some substance liberated by the in-
gested thymus which was not eliminated. Probably
no deaths were caused directly by the ingested thy-
mus, but its continued use may have caused the de-
velopment of an antibody of such toxicity, persist-
ency, and quantity as to produce the condition which
preceded death. The treatment consisted mainly in
the use of the dried gland in the form of a powder,
the usual dose being two drachms three times daily.
AMERICAN JOURNAL OF OBSTETRICS.
April, igoS.
1. The Significance of Pain in Pelvic Disease,
By E. Novak.
2. The Diagnosis of Nonpuerperal Pelvic Infections,
By H. J. BoLDT.
3. ^Etiology of Acute Nonpuerperal Pelvic Infection,
By C. R. Hyde.
4. The Treatment of Nonpuerperal Infections of the
Pelvis, By F. R. Oastler.
5. Report of a Case of Impacted Breech Presentation
Treated by Hebotomy, By B. H. Pomeroy.
6. Temporary or Apparent Disproportion Between the
Foetal Head and the Maternal Canal,
By M. McLean.
7. Disproportion Between the Foetal Head and the Ma-
ternal Pelvis and Its Management,
By J. D. VOORHEES.
8. Ectopic Pregnancy in the Stump of an Excised Tube
Causing Attacks of Intestinal Haemorrhage,
By H. N. ViNEBERG.
9. Ear Disease in Infancy and Childhood,
By J. A.'Kenefick.
10. The Use and Abuse of Salt Solution,
By E. A. Balloch.
11. Chloroform versus Ether at Columbia Hospital for
Women, By T. Abbe
I. The Significance of Pain in Pelvic Disease.
— Novak offers the following suggestions: i. A
careful physical examination is of first importance
in the diagnosis of pelvic disease, but interesting in-
formation will also be derived from the character
and distribution of the pelvic pain. 2. The exact
nature of the disease should be determined in a
given case, as nearly as possible, and not the advisa-
bility or inadvisability of an operation alone. 3.
Pain in the pelvic viscera is governed by the same
laws which apply to the causation of pain in the
other abdominal viscera. 4. Neurasthenia may de-
velop from neglected pelvic disease, with diffusion
of pain and characteristic symptoms in other parts
of the body. 5. Persistent neurasthenia following
pelvic operations is frequently responsible for the
continuance of unpleasant symptoms. 6. Hysteria
with pelvic symptoms has the same characteristics
as when associated with other diseases. 7. The re-
moval of normal ovaries for pelvic pain is now re-
garded as unjustifiable. 8. Fibrocystic ovaries are
often found in women who are in perfect health.
Operation on such organs should be conservative
9. Pain is the resultant of a lesion and a patient and
in order to understand its significance both these
factors must be carefully studied.
ID. The Use and Abuse of Salt Solution. —
Balloch reaches the following conclusions : i. Phys-
iological salt solution is a fluid which is isotonic
with the plasma of the blood. 2. Its field of thera-
peutic usefulness is in conditions which cause alter-
ations in the quantity or quality of the plasma. 3.
The quantitative alterations are chiefly those which
are caused by haemorrhage and obstruction of the
upper bowel. The qualitative alterations are caused
by the various toxaemias. 4. The exact percentage
of salt in the solution is important, and extempora-
neous solutions are to be condemned, owing to the
danger of haemolysis. 5. The subcutaneous tissue
forms the most useful avenue for the introduction
of the fluid. The intravenous route may be used in
emergencies, and Jor postoperative purposes the rec-
tum is most serviceable. 6. Its u?e for irrigating
purposes in abdominal surgery will not prevent the
formation of adhesions, and it is probable that its
use for washing away pus blood, and debris is no
more effective than dry sponging.
II. Chloroform versus Ether at Columbia
Hospital for Women. — Abbe thinks advances in
general and local anaesthesia in the past few years
have been as great as in any branch of medicine.
Local anaesthesia now suffices for many minor and
major operations, a weak solution of cocaine, with
one or more adjuvants, being entirely efficient.
Spinal anaesthesia has undergone improvements and
is satisfactory for operations on the legs and lower
portion of the abdomen. General anaesthesia, fol-
lowing.hypodermatic injection of morphine and hyo-
scin, requires very little of the inhalation anaesthetic.
In some conditions, especially in obstetrics, the hy-
podermatic injection takes the place of the inhalation
anaesthetic. New drugs have been proposed for in-
halation anaesthesia. Ether and chloroform are still
supreme, however, notwithstanding their disadvan-
tages. The features to be eliminated in anaesthesia
are: (i) The disagreeable features of administra-
tion. (2) Irritation of the mucous membrane of the
air passages and the dangers of inhibiting the re-
flexes of respiration and of cardiac action during
the anaesthesia. (3) Postanaesthetic poisoning as
shown by nausea, vomiting, suppression of urine, ne-
phritis, acidosis, and pneumonia.
8o8
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journau.
MEDICAL SOCIETY OF THE STATE OF
NEW YORK.
One Hundred and Second Annual Meeting, Held in
Albany, January 27, 28, 29, and 30, 1908.
The President, Dr. Frederic C. Curtis, of Albany, in the
Chair.
(Concluded from page 714.)
The Mosquito: Its Relation to Disease and
Its Extermination, was the title of a paper by Dr.
A. H. Doty. In addition to malaria and yellow
fever, he said, the mosquito was also charged with
the dissemination of elephantiasis, and to some ex-
tent bubonic plague, and still all the habits and his-
tory of this pest were but incompletely known. It
had been shown that they breed only in water, and
this they must have present for at least two weeks,
usually not in large bodies of water, but in small,
stagnant pools, tin cans, broken crockery, etc. The
mosquito did not wander far from its breeding
place, and one was capable of producing from one
hundred to two hundred eggs at a time. The larvae
were commonly known as "wigglers," and they had
to rise at intervals to the surface of the water in
order to obtain air. After about ten days they be-
came larger, particularly the head, and in a few days
more burst their envelope and became winged mos-
quitoes.
He believed petroleum to be the most effective
means of extermination, as it suffocated the larvje
by forming a film upon the water, which the air tube
could not penetrate. A pint of oil was advised for
every twenty-five square feet, and the application
was to be repeated every ten days or two weeks.
Bichloride of mercury, carbolic acid, and other such
agents were often used, but were pronounced dan-
gerous to both men and anim.als, and uncertain as
to result.
The Relationship Between Bovine and Human
Tuberculosis. — In this paper Dr. Stowell stated
that there were 120,000 deaths annually from tuber-
culosis; that sixteen per cent, of all cattle tested suf-
fered from it, and that cows were thought to be one
of the chief .sources of the disease. All animals, and
especially young children, were susceptible to it,
and it might enter through an abrasion, through the
respiratory passages, or through the intestinal tract.
He referred to a children's hospital which was
supplied with milk in part from the average New
York City milk and in part from a particular herd
of thirty cows, which were afterward found to be
suffering from tuberculosis. In the wards which
had been supplied by the farm milk there had de-
veloped no more cases of tuberculosis than in those
supplied by the ordinary city milk, and so he con-
cluded that tuberculosis was not so frequently trans-
mitted by milk as was ordinarily supposed.
Oxygen in Surgery. — In this paper Dr. Wii.-
Li.\M S. B.MNnRiDGi-: said he belicvecl that the pro-
fession had long overlooked the medical properties
of this valuable agent, and he hoped to stimulate in-
vestigation and place it upon its proper basis. In
surgery oxygen had its mo.st promising field, anrl
he recommended its use in wounds and injecting it
into the abdominal and pleural cavities, joints, etc.
It should first be warmed to 85° or 90° F. and
passed through a tube into the cavities mentioned. In
the pleural operation the tube should be attached to
the end of an aspirating needle. It stimulated the
pulse and respiration and gave to the blood a better
color.
He cited seventeen cases of infection, most of them
peritoneal, in all of which there had been marked im-
provement after its use. He believed the possible
fields of usefulness for oxygen to be as a stimulant
to muscular contractions in intestinal paresis; after
all laparotomy operations, especially with pus ; to
lessen pain; as a general stimulant; as a means of
lessening shock after the perforation of typhoid
fever ; to reduce to a minimum the danger of acute
dilatation of the stomach ; to be of value in shock,
asphyxia, haemorrhage, ascites, and peritonitis.
Dr. Goth MAY stated that this plan of treatment
certainly did straighten out the pulse, relieve nausea
and vomiting, and stimulate the patient generally.
A few days ago he tried to kill an animal by over-
distending the abdomen, but the pulse and respira-
tion remained in an even line and not depressed.
The animal came out of an anaesthesia of two hours
and fifteen minutes in five minutes. Thus he con-
cluded that there was no danger from overdisten-
tion.
Dr. Bainbridge said that in his talk he did not
mention the thoracic cavity, but that he had used it
in bleeding from the lung to compress and collapse
that organ, but he observed that the oxygen was
absorbed almost too quickly to act as an efficient
lung compressor.
The Significance of Uterine Bleeding. — In this
paper Dr. John A. Sampson asserted that the mod-
ern improved results in diphtheria and many other
conditions were due for the most part to more ac-
curate diagnoses. In no department of medicine
was an early diagnosis so essential as in gynaecolog)".
Uterine bleeding was often a symptom of ma-
lignancy, polypi, abortion, and many other conditions,
and the purpose of the paper was to show how these
various conditions might be recognized.
An early diagnosis saved the patient from the
symptoms resulting from the bleeding, such as
anaemia. In ectopic gestation the mucosa of
the uterus underwent the same changes as occurred
in normal pregnancy, and a decidua was formed.
At the sixth, eighth, or tenth week bleeding might
occur, and pieces of decidua were often found in
the discharge. From a lacerated cervix slight and
inconstant haemorrhage might occur, especially upon
straining or during the congested state of preg-
nancy.
He referred to the frequent association of retro-
flexed uterus and an hypertrophied condition of its
mucosa. Under such conditions the menses would
be prolonged, profuse, and possibly painful. The
type there was seen to be a inenorrhagia, character-
ized by slight bleeding in the intervals.
A polyp was defined as a localized hypertrophy
of the mucous membrane, which caused symptoms
quite similar to those of the previous condition.
When they formed in the cervical canal they were
April 25, 1908.]
PROCEEDINGS OF SOCIETIES.
seen to extend down into the vagina and bleed upon
straining, even in the interval. A subserous myoma
did not cause any haemorrhagic disturbances.
Inasmuch as cervical cancers were easily injured,
bleeding often occurred early. If it was of the in-
verted type, an ulcer was the common result, and
this was' very prone to haemorrhage. On the other
hand, bleeding might be slight and inconstant,
and not observed till late in the disease. This hst
type of cancer was seen to be much more malignant,
and when profuse bleeding did occur it was apt to
indicate metastasis.
Acute Flexures, Angulations, of the Sigmoid
and Colon was the title of a paper by Dr. J. P.
TuTTLE (see page 479).
Aerotherapy in Certain Toxaemias of Child-
hood.— Dr. F. W. LouGHRAN, in this paper,
quoted many textbooks on the treatment of different
conditions, all of which seemed to consider an even
temperature of from 60° to 70° F. indispensable.
The open air treatment had long been recognized as
a cure, especially in chronic diseases. He did not
believe this fresh air a "cure all," and thought that
drugs were often necessary in conjunction.
Vascular Crises. — In this paper Dr. H. L. Els-
NER Stated that arteriosclerosis might exist for years
and give rise to no symptoms whatever, or it might
cause marked symptoms of an acute nature.
These might subside and not return for years. In
young subjects he believed the disease to be due to
syphilis as a rule. A person apparently normal might
suddenly have an attack of angina pectoris, recover,
and never suffer a relapse, and arteriosclerosis was
usually discovered accidentally, especially in old peo-
ple.
By the vascular crises referred to he meant the
acute symptoms following a sudden spasm or possi-
bly sudden dilatation of the small bloodvessels. The
cause of it might be an extra tax upon the organ in-
volved, such as the unusual amount of work required
of the heart when a patient took a rapid walk after
a hearty meal. The closure of a coronary artery in
the heart did not, in his opinion, cause death, but if
both were obstructed a fatal result was inevitable.
He believed Adams-Stokes disease, or heart block,
due to arterial spasm which in some way influenced
the nutrition of the bundles of His, and the symp-
toms were due to a repeated shutting off of nutrition
to the heart muscle.
Angina of the heart might in some cases give rise
to symptoms below the diaphragm, and abdominal
angina and coronary angina might alternate witli
each other or be associated. A person might be ap-
parently in good health and suddenly be seized with
aphasia or even hemiplegia, and in four or five min-
utes recover slowly. Such a condition, in his opin-
ion, was due to vascular spasm. Such patients were
especially predisposed to cerebral haemorrhage, be-
cause spasm of the cerebral vessels was always found
to be associated with diseased arteries. Many pain-
ful affections of the limbs were seen to be due to
vascular spasm. In examinations of patients he ad-
vised an investigation of the arteries as well as of
the heart itself. The prognosis and treatment were
not given as satisfactory, but light, nutritious diet,
rest, and vasodilators would give the best result.
The Causes and Treatment of High Arterial
Tension. — Dr. L. F. Bishop, in this paper, took
up the diagnosis of high arterial tension, and said
that for this purpose no instrument could ever re-
place the fingers, but by this crude method low ten-
sion appeared lower than it really was. He described
an instrument of his own invention for the determi-
nation of blood pressure.
Dr. Jacobi said that he considered every one over
thirty-five years old more or less a sufferer from
arteriosclerosis. It often did not begin uniformly,
but in the kidneys, brain, periphery, or heart. When
it started in the heart it caused angina. He advised
the physician always to examine the urine and kid-
neys of a man or woman over forty years of age.
A slight trace of albumin was said to be normal, but
this was not so. Such patients should be examined
frequently and kept under observation ; they were
undoubtedly sufferers from high arterial tension, and
arteriosclerosis was seldom seen without Bright's
disease. He declared casts and epithelial cells to be
evidence of arteriosclerosis. The remissions he be-
lieved to be due to a wavering in the nutritive circu-
lation of the nerves, the sudden improvement that
took place after an attack to be due to the establish-
ment of a collateral circulation, and the temporary
aphasia described in the paper to be due to thrombo-
sis of the minute bloodvessels in that area of the
brain. As treatment for this condition, he recom-
mended regular light diet containing but little cal-
cium, hygiene, and alkalies, nitrites and lactates.
The Diagnosis of Pulmonary Tuberculosis by
Tuberculin and Other Methods. — Dr. L. Brown,
in this paper, stated that all to-day were agreed upon
the importance of an early diagnosis in tuberculosis,
because only in those cases where an early diagnosis
had been made could a favorable reaction to treat-
ment be hoped for.
He believed that the family history had been given
too mpch weight ; if positive it was of value, but if
negative it was of no weight, and a history of ex-
posure to the disease, of anxiety, overwork, debility,
anaemia, or excesses was of greater importance.
He had observed that symptoms often came on
before any definite physical signs could be made out,
such as a slight but constant rise of temperature,
persistent rapid pulse, increased nervousness, some
loss of weight and strength, cough, expectoration,
dyspnoea, haemoptysis, and fistula in ano. All these,
taken in connection with a history of exposure, were
most conclusive. In case of any suspicions the pa-
tient should be instructed to bring an early morning
specimen of sputum. If the tubercle bacilli were
found it denoted ulceration, and the disease was
then no longer in its early stage. The opsonic index
was not deemed practical. Examination of the faeces
might be important, especially in patients who would
persistently swallow the sputum. The injection of
the sputum into guinea pigs was given as a valuable
means of diagnosis.
In the physical examination of the patient he
should be instructed to breathe out, cough, and
breathe in. By this method rales could often be
heard at the apices of the lungs. Percussion was
not so important as auscultation. Patients concern-
ing whom there was any doubt should be reexam-
810
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
ined at frequent intervals. On the other hand, the
absence of physical signs did not conclusively prove
the absence of tuberculosis.
As a last resort tuberculin was used when other
means had failed. The first dose given was always
to be one of sterile salt solution to exclude any ner-
vous reaction. Other diseases had been said to react
to tuberculin, but this had yet to be proven.
The diagnosis from bronchitis, malarial disease,
nervous dyspepsia, etc., was said to be extremely
difificult at times. He emphasized the fact that tuber-
culosis was a widespread and contagious disease
from which our own friends and family were not
exempt.
CEsophagoscopy and Bronchoscopy. — Dr. Hal-
STED exhibited a case of instruments for the exam-
ination of the upper digestive and respiratory sys-
tems. Cocaine or general ansesthesia might be used.
The object of the paper was to show a means of di-
rectly examining the oesophagus, trachea, etc.
The Emmanuel Church Movement of Boston
and the Treatment of Psychoneuroses. — -This pa-
per, by W. C. Krauss, was read by title.
County Laboratories and Their Uses was the
title of a paper by Dr. Orlando Hallenbeck. He
referred to the inadecjuate means of information
available to practitioners remote from large centres,
and believed that if every county had its own bac-
teriologist and laboratory it would be a profitable in-
vestment for the people at large. He asked how
many cases of inflamed throat were diagnosticated
as diphtheria^ quarantined, etc, and vice versa, and
in how many cases of tuberculosis a similar mistake
occurred.
He thought, as the people were to derive the ben-
efit, that they should pay the expenses of the institu-
tion, when an individual alone would be benefited by
any examination of specimens, etc., that he should
pay a small fee in return, and that the entire enter-
prise could be carried out for $1,500 per annum. He
believed that the laboratory should be inspected at
regular intervals, and the bacteriologist in charge be
required to render reports, and stated that the cost
(if the building would' be about $1,000 and that of
the equipment about $400.
He asserted that many specimens would be exam-
ined that would never be sent to a State laboratory
or one at any great distance, and believed that these
laboratories should operate with the State Health
Department for the good of the general public.
Dr. liusH said that, following the example set,
the county of Chemung had started legislation
which would give the board of supervisors power to
establish a laboratory and emplov a bacteriologist.
And he thought that possibly a general bill should
be pushed which would give all the counties of the
State the same privilege. He asked the sentiment
of the meeting in regard to the matter.
Dr. Sci-IOON.MAKKR, of Clifton Springs, stated
that he had visited the laboratory referred to in the
paper, and that it was in every way complete and
efficient. He had ol)scrvcd a better and more scien-
tific tone in the general practice of the county.
Dr. J ACORi stated that every legislator in the State
should have a copy of Dr. Hallenbeck's paper, and
he did not believe that any one of them could resist
the suggestions and appeals embodied therein ; a
resolution should be framed to that eflfect.
Dr. W. R. TowNSEND, the secretary, replied that
he would frame the desired resolution.
Dr. Stranahan stated that in the course of a
conversation with Dr. Potter he had been shown a
bill that would shortly be introduced which will
meet all the requirements of Dr. Bush.
A resolution was framed by Dr. Townsend that
a committee be required to see that the paper of Dr.
Hallenbeck be printed at an early date and copies
sent to each member of the Senate and Assembly of
the State of New York, with resolutions endorsing
the paper.
Dr. Bush said that he did not think that the reso-
lution went far enough, that it should endorse a
general bill, that the society should take immediate
action, and that sentiment should be made in favor
of each county possessing its own laboratory. So
Dr. Bush moved the amendment, which Dr. Town-
send accepted, that the Committee on Legislation be
instructed to use its influence for the passage of a
law for the establishment of laboratories and the of-
fice of bacteriologist all over the State.
The President spoke of two things which had
impressed him during the reading of the paper:
That it was a pattern for all the counties of the State
to follow ; that a body of men had convened and
done something ; that there was nothing that a coun-
ty society or the State society could fail to accom-
plish provided it was sane and reasonable.
What New York Is Doing for Its Crippled
Children. — This paper, by Dr. N. M. Shaffer,
was read b}- title.
The Intracranial Complications of Middle Ear
Suppuration. — Dr. S. J. Kopetzky read a paper
in which he stated that the pus might reach the
cranial cavity either through natural anatomical
channels or bv passages formed pathologically by
necrosis, and that by extension might aflfect the jug-
ular vein or the semicircular canals. He believed
that complications occurred usually from one to five
years, more often in males than in females, between
the ages of four and six years. The course of the
acute disease was from two to four weeks ; of the
chronic, from fifteen months to seven years. Any
of the fossae at the base of the skull might be in-
volved, thus giving rise to symptoms referable to
each.
Meningitis of extradural origin was one of the
most common complications. In cases of abscess,
lumbar puncture did not always show the cerebro-
spinal fluid to be under tension.
Chronic Middle Ear Deafness. — In this paper
Dr. W. SoHiER liKVAXT rcfcrrcd to the importance
of the potency of the iuistachian tube and to the dif-
ference between middle ear suppuration and middle
car catarrh. He believed all forms of middle ear
disease but the congenital were amenable to treat-
ment, and the improvement following treatment in
all other cases justified the effort.
Medical Libraries for Small Centres. — Tn this
paper Dr. Smith Baker said that the scientific read-
ing of the average practitioner was very limited,
owing to routinisni. arrest of enterprise, or lack of
books. The establishment of libraries would be a
April .■■5, 190S.)
LtlTERS TO THE EDITORS.
Sii
source of benefit not only to the profession, but in-
directly to the public as well. He believed the pres-
ent system of even,- one's buying his own books to
be wasteful and ineflftcient, and instead of each man's
buying practically the same books, physicians should
assume a fraternal spirit and have a common library
which would avoid duplicates and thus have a great-
er degree of efficiency. He quoted Dr. William
Osier as saying: "It would be hard for me to speak
of libraries in terms which would not appear exag-
gerated."
He said that such libraries might be kept in the
offices of the physicians interested, each in turn, or
when it became too cumbersome, a part of a local
city or town library might be devoted to medical
books, and the State library at Albany might co-
operate with the smaller libraries for the distribution
of medical literature.
Dr. A. M.\'axder \'eer said that, as he understood
the paper, its purposes were threefold — to stimulate
among the practitioners of smaller towns and vil-
lages the desire to obtain the current medical litera-
ture; to establish in connection with local libraries
a medical department ; and to secure the cooperation
of the State library at Albany in the carrying out of
these purposes. The library at Albany was now in
a position to send out books as a circulating librar}-.
and many more volumes, now boxed up, would be
available as soon as the new library building, now
under construction, was completed.
Dr. Jacoei spoke of the existence of the Associa-
tion of ^ledical Librarians, and stated that it could
do more and better work with increased member-
ship ; that for a number of years the exchanges had
been copious, but that they could be more so. He
advised physicians in towns that had no library to
become members of that association.
Instruction in Physiology and Hygiene in the
Public Schools. — Dr. George Miles, in this pa-
per, said he believed that there was much printed
matter, and there were many confused ideas upon
just what should be taught in the public schools, but
that it was better to teach nothing at all than that
which was untrue. All physiological teaching
seemed to hinge upon the evil effects of alcohol and
narcotics upon the body. He believed that temper-
ance and self control should be taught, but also the
effects of heredity, exercises, sanitation, etc.. and
that such education should be honest and sound,
^[ost children got but ven.- little physical instruction
at home, so they should get it in school. Oral les-
sons should be given before the regular lessons, and
the teachers themselves should be taught to adapt
themselves to this method.
He criticised most school textbooks upon physi-
ology as giving too much space to the bones and
muscles and not enough to the special senses, and
said that children should be taught the care of the
eyes and what wholesome foods were and how to
see, hear, feel. talk. eat. and walk properly. What
was taught should have higher ends than the mere
accumulation of facts ; it should give knowledge of
how to keep well. He asked of what good were
Greek and Latin when the child knew nothing of the
laws of his own body, and of what value were sci-
ence and languages when the health was gone. He
advised teachers not to let the evils of alcohol and
narcotics overshadow instruction as to how to live
properly, and to instil one point at a time into the
minds of the children, so that when they grew up
they would be of value to them, and so that in after
years they might look back and call their teachers
blessed.
The Nature and Cause of Colic. — This paper,
by Dr. G. F. Schields. was read by title.
Closing Remarks by the President.— Before ad-
journing the meeting, the Presidext made a few
closing remarks. He said that he felt honored in
the position which he was about to vacate, because
of the illustrious men who had preceded him and
also because of his successor. Dr. Trudeau. He be-
lieved that the past year had been one of great value
to the society in fixing it along better ways than ever
before. He referred to his duties as grateful tasks,^
and wished to thank the various officers and commit-
tees for the cheerful and efficient assistance tendered
during the past year.
Dr. Jacobi said that while he was chairman of
the Committee on Prize Essays for the past few
years he had been kept very busy doing nothing, and
he urged men capable of writing essays to take up
this work. He believed, in fact, knew, that the
president was entirely too modest in giving credit to
various officers and committees when the greater
part of it really belonged to Dr. Curtis himself. He
spoke of the long, active, and valuable career of
the retiring president in the State society, and called
for a vote of thanks to him for his most successful
administration.
^rtlfrs to the (tbitors.
THE HAVERSTRAW COLONY.
319 East Twextv-third Street, Xew York,
April 10, 1908.
To the Editors-
The Senate Finance Committee has reported on
the bill for the purchase of the Haverstraw Colony
site with the appropriation cut nearly in two. The
site is a narrow valley protected by steep hills from
intrusion on three sides. The commission selected
only such plots as were indispensable to secure the
strategic control of the valley, the water supply, the
clay pits for brick making, and the railroad siding.
With the reduced amount now proposed (Sioo,-
000) the colony will be flanked by a fringe of
summer boarding houses, and along the railroad
directly in front of the administration group will
spring up a row of saloons, hovels, and the usual
surroundings of the brick making industry, which
even now is trying to acquire the clay pits.
Inmates could not be allowed to work or stay out-
side of buildings without close surveillance, which
means increased cost to the State for attendants and
curtailment of the happiness and industrial efficiency
of the patients. This is the unfortunate condition
now existing at the Newark Asylum, from which,
in spite of constant vigilance, several helpless women
inmates have been enticed away by intruders, against
whom the institution has not even adequate fence
protection. At Haverstraw the entire colony is
8l2
BOOK NOTICES.
[New York
Medical Journal.
safely isolated, or may be, if the whole site recom-
mended (costing $188,575) is purchased.
This argument is entirely aside from the fact that,
given ample land for tillage, the institution can raise
much of its own supplies, with great benefit to the
health of the inmates. There is every reason, both
of business economy and of humanity, why the full
site should be secured now. It will be next to im-
possible to get it piecemeal later.
The press all over the State has already co-
operated very generously with us in getting the facts
before the public. I hesitate to urge you to give
further space to a matter of relatively minor public
interest, but if we do not speak out for these broken
lives, and do it now, it may mean to thousands of
them the difference for life between being cooped
up in an overcrowded institution and living and
working out in the open, under conditions almost as
happy and natural as if they were normal citizens.
Surely the State can afford the little extra land
needed to accomplish the latter result.
Herbert S. Brown.
iofirk f fftias.
[ 14^6 publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, zve review those in which we think
our readers are likely to be interested.]
The Conquest of Cancer. A Plan of Campaign, being
an Account of the Principles and Practice Hitherto of
the Treatment of Malignant Growth by Specific or Can-
crotoxic Ferments. By C. W. Saleebv, M. D., F. R. S.
(Edin.). New York: Frederick A. Stokes Company,
1907. Pp. xxiv-361.
It is with some trepidation that one takes up for
notice this aggressive volume of Dr. Saleeby's. The
writer is so convinced of the importance of his mes-
sage, he is such a militant advocate, and he is so
cocksure of the efficacy of the trypsin treatment
that his attitude will hardly admit of questioning
■without bringing upon his hapless critics a storm of
indignant abuse. It is perhaps not without signifi-
cance that the book has been more favorably re-
ceived by the newspapers than by the profession and
the medical journals. We are convinced that, what-
ever may be the merits of the trypsin treatment, it
will be given a fair trial, and that Dr. Saleeby is un-
just in assuming that physicians generally are
prejudiced against the use of any measure which
promises relief for .so frightful a scourge as can-
cer. He certainly has not a monopoly of unselfish
and humane interest in this large subject, and it is
difficult for us to understand how a writer who has
had a medical education can so far forget the best
traditions of his profession as to directly charge
surgeons with indifference or hostility to the tryp-
sin treatment from interested motives. Dr. Saleeby
is fond of drawing a parallel between the struggle
of trypsin for recognition and the reception ac-
corded in the beginning to Christianity, the reforms
■of Savonarola, and the scientific truths of Giordano
Bruno and of Galileo. If this doughty champion
is really the herald of an important new truth he
will not in this age be either crucified, burned, or
imprisoned, but will, we believe, live to see it uni-
versally accepted if it has only half the value he
alleges for it. His judicious friends will, however,
regret the acrimonious and controversial tone he has
adopted in his advocacy of it.
An Introduction to the Study of the Infant's Stool. By
Paul Selter, M. D., Soligen, Germany ; Translated by
Herbert M. Rich. B. L., M. D., Detroit, Assistant in
Diseases of Children, Detroit College of Medicine. The
Detroit Medical Journal Company, Detroit, Mich, 1907.
This pamphlet presents in an easily accessible form
a systematic account of the study of the infant's
stools. It is a translation of a German monograph
which appeared in the beginning of 1905.
The author, Dr. Paul Selter, of Solingen, Ger-
many, intends to demonstrate that we are able to de-
termine some very important facts from the exam-
ination of the infant's stool ; we- can tell whether any
food element is properly digested and assim.ilated.
and in many cases we can decide which element is
not so disposed of. We then may correct the faulty
feeding and thus improve the general condition of
the infant.
The booklet is well translated and will certainly
appeal to every physician whose practice brings him
into contact with infants.
Kurzes Lehrbuch der organischen Chemie. Von William
A. NoYES, Professor der Chemie an der Universitat Illi-
nois. Mit Genehmigung des Verfassers ins Deutsche
iibertragen von Walter Ostwald, und mit einer Vor-
rede von Professor Wilhelm Ostwald. Leipzig:
Akademische Verlagsgesellschaft M. B. H., 1907. Pp.
xxiv-722.
Professor Noyes's standard textbook on organic
chemistry apeared for the first time about five years
ago. It was so well received that Professor Ost-
wald, of the University of Leipsic, proposed to the
author a German translation. This version now has
been published. The contents of the English orig-
inal are so well known that we shall not refer to
theiii. The translation leaves nothing to be desired ;
in fact, the book reads more like an original compo-
sition than like a translation. Some changes have
been made to adapt it to the use of German students.
Of great advantage is a full index.
A Textbook on Uric Acid and Its Congeners. With Spe-
cial Reference to its Physical and Chemical Properties
and Accumulation in the Organism. Together with the
Disease Processes Arising Therefrom and Their Etio-
logical Therapy. For Medical Students and Practition-
ers. By George Abner Gilbert, M. D., Member of
Local, County, and State Medical Societies of Connecti-
cut, etc. First Edition. Danbury, Conn: The Danbury
Medical Printing Company, 1907. Pp. 310.
The author has studied with great industry the
uric acid question as it appears to him and as it is
treated in the medical literature of to-day. He has
tlnis brought together from all available sources the
results of the experimental work of American,
English, French, German, Russian, and Swedish
investigators. He comes to the conclusion that uric
acid is one of the waste products of the human
organism most frequently retained and responsible
for many of the common ills. We should therefore
"endeavor to prevent the body from becoming
highly charged with uric acid," a dictum of Min-
kowski in Die Giclif. who suggests trying to eft'ect
this desirable object by decreasing the formation of
uric acid, l)y furtlicring its excretion, by hastening
April 25, 1908. J
OFFICIAL NEWS.
813
the further oxidation, and by increasing the solu-
bihty of uric acid in the blood and tissues. This
will be best achieved by the alkaline eliminant mode
of treatment.
BOOKS. PAMPHLETS, ETC., RECEIVED.
An Aid to Materia Medica. By Robert H. M. Daw-
barn, M. D., Professor of Surgery and of Surgical An-
atomy, New York Polyclinic Medical School, etc. Fourth
Edition, Revised and Enlarged, by Eden V. Delphey, M. D.
Kew York : The Macmillan Company, 1908. Pp. xi-338.
(Price, $1.75.)
Climate Considered Especially in Relation to Man. By
Robert DeCourcy Ward, Assistant Professor of Clima-
tology in Harvard University. Illustrated. New York:
G. P. Putnam's Sons. London: John Murray, 1908. Pp.
xiv-372.
Thirty-first Annual Report of the Board of Health of the
State of New Jersey for the Year 1907, and the Annual
Report of the Bureau of Vital Statistics. Pp. 432.
The Submucous Resection of the Nasal Saeptum. A De-
tailed Description of the Flap Method. By Otto T. Freer,
M. D., Professor of Rhinology and Laryngology, Chicago
Polyclinic, etc. With Twenty-four Original Illustrations.
Chicago: Journal of Ophthalmology' and Otolaryngology,
1908. Pp. 51. (Price, 50 cents.)
Die Hautkrankheiten. Von Prof. Dr. A. Jarisch.
Zweite, vermehrte und neubearbeitete Auflage. Mit 7 Ab-
bildungen im Texte. Bearbeitet von Prof. Dr. Rudolf
Matzenauer. I. Halfte (Vorwort, Inhalt und Bogen I-38).
II. Halfte (Bogen 39-69 und Register). Wien und Leip-
zig: Alfred Holder, 1908. Pp. mo.
— Foreign.
March 29
March 18-28 38
March 21-April 4... z
Cases. Deaths
• 50
Public Health and Marine Hospital Service
Health Reports:
The following cases of smallpox, yellon; fever, cholera,
and plague have been reported to the surgeon general,
United States Public Health and Marine Hospital Service,
during the iveek ending April 17, igo8:
Smallpox— United States.
Places. Date.
Alabama — Huntsville, vicinity. ... January-.April
California — Los Angeles. .March 21-28
California — San Francisco .March 21-28
District of Columbia— Washington . March 28- April 4. .
Ceorgia — Augusta March 24-31
Illinois — Chicago March 2i-.\pril 2S.
Illinois— Rock Island March 21-28
Illinois— Springfield March 26- .April 2..
Indiana— Elkhart March 28-April 4..
Indiana— Evansville March 28-.\priI 4..
Indiana — La Fayette March 30-April 6..
Indiana — Marion .March 1-31
Indiana — Muncie Feb. 29-March 7...
Iowa — Cedar Rapids March 1-31
Kansas — Karsas City March 28-April 4..
Kansas — Topeka ^March 21-28
Kentucky — Lewis County March 8-April 4...
Louisiana — Xew Orleans March 28-April 4..
Maine — Limestone April 3
Michigan — Detroit March'
Michigan— Grand Rapids March
Minnesota— Winona March
Montana — Butte March
Nebraska — Nebraska Citv March 28-April 4.
Xew York — Niagara Falls March 28-April 4.
North Carolina — Charlotte March 2i-.\pril 4.
Ohio — Cincinnati March 20-April 3.
Ohio — Dayton March 28-.\pril 4.
Ohio — Tippecanoe Jan. I5-March 14..
Ohio — Toledo .March 21-April 14
Ohio — Warren March 28-.\pril 4.
Ohio — Zanesville .March 1-31
Tennessee — Nashville March 28-.\pril 4.
Texas — Eagle Pass March 31
Texas — Galveston March 21-ApriI 3.
Texas — San Antonio March 28-April 4.
Washington — Spokane March 21-28
Washington — Tacoma March 21-28
Wisconsin — La Crosse March 2i-.\pril 4.
Wisconsin — Manitowoc March 21-28
Wisconsin — Racine March 28-April 4.
Wyoming — Laramie ilarch s-.^pril 4..
-Apri:
-Apn
-.\pril
Smallpt
Arabia — Aden
Brazil — Rio de Janeiro
Canada — Halifax
Canada — Hamilton March . „
China — Shanghai Feb. i6-March 8.... 5 foreign
and 23 deaths native.
Egypt — Cairo Feb. 27-March 4.... 4 1
Formosa Feb. 8-March i 5 i
France — Paris March 14-21 6
Great Britain^ — Edinburgh March 14-21 2
Great Britain — Leith March 14-21 i
India — Bombay March 3-10 42
India — Calcutta Feb. 15-22 9
India — Madras Feb. 29-March 6.... i
Italy — General March 19-26 17
Italy — Catania March 19-26 5 3
Japan — Kobe Feb. 29-March 7.... 79 47
Japan — Nagasaki Feb. 24-March 15... 8 i
Japan — Osaka Feb. 29-March 7.... 292 100
Java — Batavia Feb. 15-22 4
Mexico — Aguas Calientes March 22-29 7
Mexico — Matan'oras March 28-April 4... 4
Mexico — Citv '.f Mexico Feb. 15-22 6
Mexico — \"era Cruz March 14-21 3
Russia — Libau Feb. 14-21 2
Russia — MoscoNV Feb. 29-March 14... 56 24
Russia — Odessa March 14-21 3
Russia — Riga March 17-21 6
Russia — St. Petersburg Feb. 29-March 14... 44 11
Russia — Warsaw Jan. i8-Feb. i 23
Spain — Denia March 14-21 6 1
Spain — Valencia March 15-22 25 2
Straits Settlements — Penang Feb. 15-22 i
Turkey— Bagdad Feb. 15-22 42 9
Turkey — Constantinople March 8-15 3
Yellow Feier — Foreign.
Barbados — Bridgtown, vicinity ... .March 7-11 2 i
Brazil — Para March 7-21 14 10
Trinidad— Port of Spain Feb. 29-March 7 i 1
Cholera — Foteign.
India — Bombay March 8-10 2
India — Calcutta Feb. 15-22 112
India — Madras Feb. 29-March 6... 7
India — Rangoon Feb. 22-29 3
Plague — Foreign.
Brazil — Rio de Janeiro March 1-8 2
India— General Feb. 15-22 6,842 5,502
India — Bombay March 3-10 254
India— Calcutta Feb. 15-22 • 29
India — Rangoon Feb. 22-29 50
Japan — Osaka Feb. 29-^Iarch 7.... i i
Public Health and Marine Hospital Service:
Official list of changes of stations and duties of com-
missioned and noncommissioned officers of the United
States Public Health and Marine Hospital Service for the
seven days ending April 15, igoS:
C.A.RRIXGTON, P. M., Surgeon. Granted leave of absence
for four days, from April 8, 1908, under paragraph
189. Service Regulations.
Cobb, J. O., Surgeon. Relieved from duty at Cairo, 111.,
and directed to proceed to Milwaukee, Wis., assuming
charge of the service at that port.
GoLDBERGER, JosEPH, Passed Assistant Surgeon. Granted
leave of absence for seven days, from April 9, 1908.
GuiTER.AS, G. M., Surgeon. Directed to proceed to Pas-
cagoula, Miss., for special temporary duty, upon com-
pletion of which to rejoin his station, at Mobile, Ala.
Jackson, J. M., Acting Assistant Surgeon. Granted leave
of absence for ten days, from .\pril 4, 1908.
James, W. F., Acting Assistant Surgeon. Granted leave
of absence for thirty days, from July i, 1908.
McIntosh, W. p., Surgeon. Directed to proceed to Bo-
ton, Mass., for special temporary duty, upon comple-
tion of which to rejoin his station, at Portland, Me.
Mead. F. W., Surgeon. Granted leave of absence for ten
days, from April 12, 1908'.
Nyedegcer, J. A., Passed Assistant Surgeon. Granted
leave of absence for two days, from April 11, 1908,
under paragraph 191, Service Regulations.
O.AKLEV, J. A., Passed Assistant Surgeon. Granted leave
of absence for one month, from April 15, 1908.
Rice, W. E., Acting Assistant Surgeon. Granted leave of
absence for fourteen days, from May i, 1908.
Schereschewsky, J. W., Passed Assistant Surgeon. Di-
rected to report to the Bureau, Washington, D. C, for
special temporary duty, upon completion of which to
rejoin his station, in Baltimore, Md.
Scott, E. B., Pharmacist. Granted leave of absence for
two days, from April 14, 1908.
Stimpson, W. G, Surgeon. Directed to assume temporary
charge of Port Townsend Quarantine Station during
8i4 BIRTHS, MARRIAGES, AND DEATHS. ^, [N'e" York
" Medical Journal.
the absence of Passed Assistant Surgeon Oakley, on
leave for one month from April 15, 1908.
VVicKES, H. W., Passed Assistant Surgeon. Relieved
from duty at Stapl3ton, N. Y., and directed to pro
ceed to New Orleans, La., reporting to the medical
officer in command of the Marine Hospital, for duty
and assignment to quarters.
Wilson, R. L., Passed Assistant Surgeon. Relieved from
duty at New Orleans, La., and directed to proceed to
Cairo, 111., assuming command of the service at that
port.
Board Convened.
A board of medical officers was convened to meet at
Seattle, Wash., April 13, 1908, for the physical exam-
ination of an alien. Detail for the Board: Passed Assist-
ant Surgeon M. W. Glover, chairman; Assistant Surgeon
C. \V. Chapin ; Acting Assistant Surgeon F. R. Lender-
wood, recorder.
Army Intelligence:
Omdal list of changes in the stations and duties of
officers serjAng in the medical department of tlie United
States Army for the zveek ending April 18, igo8:
AsHFORD, B. K., Captain and Assistant Surgeon. Ordered
to report at Army Medical Museum Building, Wash-
ington, D. C, for examination for promotion.
C.\RSWELL, R. L., Captain and Assistant Surgeon. Left
Depot of Recruits and Casuals, Angel Island, Cal., on
leave of absence for two months.
Chamberlain, W. P., Captain and Assistant Surgeon.
Ordered to report at Army Medical Museum Building,
Washington, D. C, for examination for promotion ;
granted leave of absence for one month and ten days,
with permission to ask an extension of twenty days.
DeLoffre, S. M., Y'n.st Lieutenant and .Assistant Surgeon.
Ordered to report at the expiration of his leave of
absence at the Army Medical Museum Building,
Washington, D. C, for examination for advancement.
Ford, J. H., Captain and Assistant Surgeon. Ordered to
report at the Army General Hospital, San Francisco,
Cal., for examination- for promotion.
LaG \RDE, L. A., Lieutenant Colonel and Deputy Surgeon
General. Granted leave of absence for two months.
Page, Henry, Captain and Assistant Surgeon. Ordered
to report at the Army General Hospital, San Fran-
cisco, Cal.. for examination for promotion.
Powell, J. L., Lieutenant Colonel and Deputy Surgeon
General. Left Fort Ethan Allen, Vt., on leave of
absence for ten days.
ScHREiNER, E. R., Captain and Assistant Surgeon. Or-
dered to report at the Army General Hospital, San
Francisco. Cal.. for examination for promotion.
Truby, a. E.. Captain and Assistant Surgeon. Ordered
to report at the Army General Hospital, San Fran-
cisco, Cal.. for examination for promotion.
Whaley, a. M., First Lieutenant and .Assistant Surgeon.
Ordered to Jackson Barracks, La., for temporarj-
duty; on completion, to return to station.
WiL.soN, W. H., Major and Surgeon. Returned to Fort
Hamilton, N. Y., from accompanying troops to San
Francisco,' Cal,
Navy Intelligence:
Official list of changes in the medical corps of the United
States Navy for the iveek ending April 18, iqoS
Brown, H. L., Passed Assistant Surgeon. Detached from
the naval station, Cavite, P. I., sailing from San Fran-
cisco, Cal., about May 5th.
Ch.\mbers. W., Assistant .Surgeon. Ordered to the Naval
Hospital, Philadelphia, Pa.
Di( KSON, S. H., Medical Inspector. Detached from the
navy yard, Norfolk. Va., and ordered to the marine
barracks, Washington. D. C.
Ely, C, M., Passed .\ssistant Surgeon. Detached from
the naval recruiting station, Buffalo, N. Y., and or-
dered tb the Hartford when commissioned.
Haines, B. P., .Acting Assistant Surgeon. Resignation
accepted, to take effect April 15, 1008.
Langhorne, C. 1)., Surgeon. Detached from the marine
barracks. Washington, D. C, and ordered to the naval
station. Honolulu, fl. I., sailing from San Francisco,
Cal., about May 5th.
Leach, B., Surgeon. Ordered to the Hancock.
McDonell, W. X., Passed Assistant Surgeon. De-
tached from the Hancock and ordered to the naval
recruiting station, Buffalo, N. Y.
McLean, A. D., Passed Assistant Surgeon. Detached
from the navy yard, Portsmouth, N. H., and ordered
CO the Chester when' commissioned.
Shiffert. H. O., Passed Assistant Surgeon. Detached
from duty at marine at Camp Elliott, Isthmian Canal
Zone, and ordered home to wait orders.
Smith, C. G., Passed Assistant Surgeon. Detached from
the naval station, Honolulu. H. I., and ordered home
to wait orders.
Sterne, C. F., Assistant Surgeon. Ordered to the Naval
Hospital, New York.
Married.
Fellow s — Love. — In Des Moines, Iowa, on Wednesday,
April 8th, Dr. Joseph T. Fellows and Miss Estelle Love.
Geyser — Higbie. — In New York, on Wednesday, April
15th, Dr. Albert C. Geyser and Dr. Annie S. Higbie.
Hall — Page. — In Brookline, Massachusetts, on Wednes-
day, April 22d, Dr. Gardner Wells Hall and Miss Eliza-
beth Hancock Page.
Jones — Austin. — In Philadelphia, on Wednesday, April
22d, Dr. Isaac H. Jones and Miss Emily L. S. Austin.
Petty — Mellersh. — In Philadelphia, on Wednesday,
April 8th, Dr. Orlando H. Petty and Miss Marcie Mel-
lersh, daughter of Dr. A. H. Mellersh.
Savage — Ingersoll. — In New York, on Saturday, April*
nth, Dr. William B. Savage, of Central Islip, and Miss
.\dele L. Ingersoll.
Schultz — List. — In Philadelphia, on Wednesday, April
15th, Dr. Howard F. Schultz and Miss Maud List.
Straeten — Root.— In Washington, D. C, on Saturday,
.\pril II, Dr. Renier J. Straeten, United States Navy, and
Miss Emeretta Root.
Sykes — Bergan. — In Philadelphia, on Wednesday, April
15th, Dr. Henry Sykes and Miss Elizabeth M. C. Bergan.
Vogt — Nichols. — In New York, on Wednesda\". .April
8th, Dr. William H. Vogt. of St. Loins, Missouri, and
Miss Edna Jeanette Nichols.
Died.
Brown. — In ( ii in-Lietnw n. Kentucky, on Monday, April
r3th. Dr. Gcm-i ( ). llr'iwn, ,[ged sixty-seven years.
Clisi'.e. — 111 ( ildw ati-r. Michigan, on Tuesday, April
7th, Dr. Sicplien II. Clisbc, aged sixty-five years.
Crook. — In New York, on Thursday, April i6th, Dr.
James King Crook, aged forty-nine years.
Crumb. — In Norwich. New York, on Thursdav, April
i6th, Dr. De Witt Crumb.
Goodman. — Li .St. Ciilurines, Ontario, Canada, on
Tliursday, April gtli, Dr. Edwin Goodman, aged seventy-
live years.
Gore. — In Charlotte, North Carolina, on Thursdav, April
Qth, Dr. J. W. Gore.
Hubbard. — In Essex, Connecticut, on Sunday, April
r2th. Dr. Charles H. Hubbard, aged seventy-two years.
Kellar. — In Lexington, Kentucky, on Thursday, April
9th, Dr. David Kellar, aged eighty-nine years.
Kennedy. — In Springfield, Massachusetts, on Friday,
.April loth. Dr. Catherine M. Kennedy, aged sixty-four
years.
La Count. — In Wausau, Wisconsin, on Sunday, April
I2th, Dr. David La Count, aged seventy-nine years.
Lewis. — In Huntsville, .Alabama, on Saturday, April 4th,
Dr. P. H. Lewis, aged eighty-fiv eyears,
McDo\\'ELL.— In New York, on Wednesday, April I5:h,
Dr. Alexander B. McDowell, aged forty-four years.
Richards. — In Glastonbury, Connecticut, on Fridiy,
April loth. Dr. George C. Richards.
Robie. — In New York, on Wednesday, April 15th, Dr.
John Wilson Robie, aged seventy-one years.
Thompson. — In Boston, on Saturday. April nth, Dr,
George E. Thompson, aged fifty-nine years.
Wade. — In Danbury, Connecticut, on Saturday, .\pril
nth. Dr. J. .Alexander W'ade.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal rlt Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXVII, Xo. 18.
XEW YORK. ^lAY 2, 1908.
Whole No. 1535.
(Original Communitatioas.
A BRIEF CRITICAL REVIEW OF A YEAR'S
PROGRESS IX TROPICAL MEDICINE.*
Bv J.\.ME5 M. Anders. M. D.. LL. D.,
Philadelphia,
Professor of Medicine and Clinical Medicine in the Medico-Cliir-
urgical College; Consulting Physician to the Jewish Hos-
pital; Consulting Physician to the Widener Home
for Crippled Children, etc.
It has been an honor, highly appreciated, to serve
as the presiding officer of a bodv so distinguished
as that of the .\merican Society of Tropical ]\Iedi-
cine during the year just ended. Before taking up
the theme of my brief discourse, I desire to convey
to the officers, more particularly to the efficient sec-
retary, Dr. Swan, whose enterprise deserves un-
stinted praise, my grateful acknowledgment of the
singular zeal manifested in the executive work of
this society. - Especial commendation is also due the
members for increased activity and greater fruitful-
ness of results in the individual study of tropical af-
fections during the past year. The growing im-
portance of this special field of medicine is becom-
ing rapidly evident, and it is equally clear that a
thorough and systematic investigation of this class
of diseases in the immediate future is vital to the
progress of medical science and art in America ; and
to appreciate this truth it is only essential to grasp
the changed conditions — social, industrial, hygienic
— growing out of the acquisition of our new de-
pendencies.
The present state of affairs has already called
forth a practical rearrangement of the themes pur-
sued, and labors of, governmental officials, sani-
tarians, clinicians, and research workers. But the
present activities in the domain of tropical medicine
may be regarded as being but a feeble foretaste of
what the future inevitablv conceals. Tropical dis-
eases have been among the last to engage the serious
attention of trained scientific investigators, although
many members belonging to this extensive group
have been imperfectlv known and described from
the remotest antiquity. Among the influences that
will coimt for much in determining the extent and
nature of this work to be carried forward in the
immediate future for the better service of our sci-
ence and art. the American Society of Tropical
Medicine should, and doubtless will, take conspic-
uous rank. If I mistake not. this new society, with
the light of dawn still upon it, is gripped with a
'Address of the president delivered at the Annual Meeting of the
American Society of Tropical Medicine, held at Johns Hopkins Uni-
versity. March 28. 1908.
Copyright, 1908, by A. R.
high purpose, and destined to fulfil its great
promise.
In devoting attention to the elucidation of the
subject, the undertaking should have reference to
well defined points of view — e. g.. aetiological.
pathological, clinical, therapeutical. In order to
achieve satisfactory and permanent results, these
dift'erent phases should receive separate considera-
tion, although an intimate and practically important
interconnection between them must be recognized.
The earlier work should aim to obtain sure aetio-
logical and pathological facts or evidence, for in
the absence of a knov^ ledge of the necessary causes
of tropical diseases and a clue from their pathology
we shall continue to remain ignorant of, or, at all
events, incapable of interpreting their clinical be-
havior. On the other hand, svstematic. uniform, and
properly directed investigations cannot fail to
achieve much needed information available for prac-
tical uses.
In the case of the infective diseases, at all events,
the practical solution of the issues involved must
come from setiolog}- and pathology. Xo large meas-
ure of professional opinion, expressed or entertained
on any medical subject can receive adequate sup-
port either from clinical observation or therapeutical
tests alone. Considerable thought, therefore, should
be given to the order of development of the vast
field of research in question, and to the thread of
connection between the dift'erent aspects of the com-
plicated subject.
This. then, is the pathwav to be trodden, my
learned coworkers, if we wotild venture to hope to
bring this extensive field of investigation into that
state of forwardness which characterizes our posi-
tive knowledge of many nontropical diseases. Much
has hitherto been disco\ ered and announced to the
scientific world, but more is still enveloped in ob-
scurity, to be elucidated, as intimated before, by ap-
peals to bacteriology, parasitology', morbid anatomy,
and morbid physiology-, through the aid of which the
clinical symptoms manifested may be rationally in-
terpreted.
\Miilst the year just ended has witnessed but few.
if any, epoch making discoveries, the net gain may
be said to have been considerable, and is an augury
warranting the most favorable predictions for the
future. It is to be recollected that the magnitude
and complexity of the problems awaiting solution
can scarcelv be appreciated by an enlightened pro-
fession, as yet imperfectly acqttainted with the man-
ners, habits, and customs of the peoples of our new-
ly acquired territories.
To attem.pt to give a complete review of the pro-
Elliott Publishing Company.
8i6
ANDERS: TROPICAL MEDICINE.
I New York
Medical Journal.
grcss actually made during the previous year would
lead beyond the scope of this address ; I shall, there-
fore, be constrained to content myself with a brief
chronicle of the more important advances gained
during that short period of time. Mere theoretical
expressions, unsupported by proof, will be rigorous-
ly omitted.
Foremost among tropical affections comes plague,
and magnificent recent work has been done in rela-
tion to the aetiology, more especially the modes of
conveyance of the bacillus. The recognition of the
fact that the plague bacillus may be carried from
one rat to another by the rat flea resulted from the
labors of the British Plague Commission working in
India.' During 1907, the previous experiments of
the commission have been entirely confirmed, and
additional observations, which have contributed
much to systematic science, have been conducted."
It was conclusively shown that rats could be in-
fected by feeding them with the viscera of dead
plague rats, and that in such cases the site of the
bubo was the mesentery. Per contra, cervical bubo
is the rule in naturally infected rats, hence it is ob-
vious that natural intestinal infection rarely, if ever,
occurs. Evidence to show that the infected faeces
of the flea may carry the infection to the flea bite
sustained by man has been advanced.
It was proved that the Indian rat flea (Piilc.v cheopis),
under certain circumstances, will readily bite man — a fact
which has long been the subject of controversy. Roths-
child has pointed out that this species of flea is the com-
monest one foimd on house and port rats in many parts
of the world, and that it is identical with the Pulex pal-
lidus found in Australia and the Pule.v philippincnsis found
in Manila— localities where plague has repeatedly appeared.
The Pulc.v irntans and Ccratophyllus fasciatus were also
shown by experiment to be "capable of infecting animals in
a few instances, and it is of prime importance that their
exact influence in the transmission of plague from rat to
man should also be determined."
So strongly has the entire medical profession be-
come impressed with the truth of the view that the
principal, if not the onl}-, means of transmission has
been accurately determined to be the flea, that no
invincible obstacle to the serious business of the
United States Public Health and Marine Hospital
Service and .State and municipal authorities in ap-
plying antiplague measures will, it is hoped, be per-
mitted to exist in future, (iranted that every facil-
ity be provided for the operation of these organized
bodies, the impracticability of absolute prevention
must, owing to the peculiar mode of transmission,
appear evident. Finally, the necessity for united
action with a view to exterminating rats and fleas
in infected localities will be universally acknowl-
edged.
Tlafl^kine' has recently descril)ed the present posi-
tion of inoculation in an important address deliver-
ed to the I'^pidemiological Society of London on the
Present Methods of Combating Plague. His con-
clusions were :
I. Natives of India arc more suscc))til)lc to plague than
Africans, Europeans, and some other races, but the inocu-
lation treatment reduces the liability to attack to less than
one third of that in noninoculated. 2. In one third of the
'Journal of Hygiene, Cambridge Press, Extra Plague Number,
September. 1906!
'Journal nf Hygiene, Extra Plague Number, July, 1907.
•Editorial. Journal of the American Medical Association, Decem-
ber 28, 1907. Public Health Reports, December 13, 1907.
^Journal of the American Medical Association, January 4, 1908.
cases which occur in the inoculated the recovery rate is at
least double that in the noninoculated, the ultimate result
being a reduction in the plague mortality by about 85 per
cent. 3. All the cases of plague in inoculated Europeans
have ended in recovery. 4. Inoculation is applicable to
persons already infected and incubating the plague and pre-
vents the appearance of symptoms, or else mitigates the
attack. 5. In natives of India the degree of immunity con-
ferred by inoculation, though it gradually diminishes, lasts
during several outbreaks of the plague. 6. In Europeans
the effect has not yet been seen to disappear since its in-
troduction in 1897.
Reference should be made to the exhaustive
studies of Richard Strong' in plague immunity.
This observer doubts the protective value of Hafif-
kine's prophylactic, while certain Indian physicians
emphasize its great value in lessening plague inci-
dence and plague mortality. For example, W. J.
Simpson," in the Croonian Lectures on plague,
stated that one injection of three cubic centimetres
of Haffkine's prophylactic is sufficient to protect
during an existing epidemic :
Inoculation is powerless to arrest the disease in those
in whom the symptoms have already appeared or develop
in a few hours after inoculation. Inoculation mitigates or
aborts the disease in those who are in the incubation stage
or have been infected three or four days previously.
Strong advocates the injection of attenuated liv-
ing cultures of Bacillus pest is as a method of im-
munization. He found natural plague aggression
effective in animal experiments, but owing to the
great difficulties encountered in its preparation this
will probably not be generally adopted. Strong also
demonstrated the fact "that the development of the
immunizing substances is quite independent of that
of the agglutinins.'" Strong arrives at the conclu-
sion that in sera possessing immunizing power no
bactericidal action can be shown to exist. He insists
that inoculation against plague with suitable cul-
tures is not infallible on account of individual varia-
tions in susceptibility to infection and in natural re-
sistance. There is a consensus of opinion that in-
oculation is powerless to influence the general course
of the disease after it is well characterized clinically.
The work of Ashburn and Craig,' in connection
with Filaria philippinensis. is especially worthy of
notice, and among the conclusions reached are the
following: (a) That the complete development of
Filaria philippinensis, discovered by them in 1906.
has been followed in the mosquito, Culex fatigans;
(h) that the Filaria philippinensis is distinguishable
from other filarire "both in the blood and during the
developmental cycle within the mosquito"; (c) that
as regards the time of its occurrence in the blood,
this organism presents no periodicity. The same
observers have, by their persistent investigations into
the ;etiology of dengue, thrown an important side-
light upon that subject. Of their conclusions, a few
merit enumeration here:
(a) The specific cause is most probably ultrami-
croscopic in size, neither bacterium nor protozoon
being demonstrable in either fresh or stained speci-
mens of dengue blood by the microscope or in
bouillon blood culture; (b) the disease is character-
ized by a well marked leucopenia, the polymor-
phonuclear leucocytes being decreased, as a rule,
^Philippine Journal of Science, June, 1907.
'Journal of Tropical Medicine and Hvgiene, .\ugust, 1907.
^S'ew York Medical Journal. October jo, 1907.
'i\'e:c York Medical Journal, June 15, 1907.
May 2, 1908.]
ANDERS: TROPICAL MEDICINE.
8.7
while the small lymphocytes are decidedly in-
creased; (c) dengue can be transmitted by the mos-
quito, Culex fatigans, hence it is probably not con-
tagious, but infectious in the same manner as is
yellow fever and the malarial fevers. It should be
pointed out that Schaudinn, Novy, and others sus-
pect that both dengue and yellow fever are caused
by protozoon parasites.
Musgrave" has observed seventeen cases of para-
gonimiasis, eight of which came to necropsy, in Ma-
nila, during the year 1906 and the early part of
1907; he has contributed an exhaustive study of this
infection, based partly upon the post mortem find-
ings and partly upon close clinical studies of the
cases observed. The course of the disease is usual-
ly chronic, although an acute form is recognized
with secondary infection, as a rule. Again, the con-
dition may be either generalized or localized. An
assured diagnosis rests solely on the finding of the
ova of the trematode in the sputum, in the faeces,
the scraping from ulcers, or in fluids and tissues re-
moved at operations. Until more is known of the
life history of this parasite, satisfactory prophylac-
tic measures cannot be indicated. The subject is of
distinct importance to this body, since imported
cases have been met with in the United States and
will probably be more commonly found in the fu-
ture.
Concerning the fetiology of yellow fever, the re-
sults of recent investigations, while failing to dem-
onstrate the presence of any organism having
^etiological significance, are strongly suggestive that
the disease is due to a spirochasta. In the Public
Health Reports for May 3, 1907, Stimson describes
an organism which he observed in the kidney of a
yellow fever patient, following the method of Leva-
diti, its general appearance suggesting a spirochseta.
But though specificity cannot be assigned to this or-
ganism, without ample confirmation, it is undoubted
that the blood picture closely resembles that of dis-
eases known to be caused by protozoon parasites.
During August, 1907, a few cases of yellow fever
were reported from Cuba, but, as was to be expect-
ed, no widespread epidemic was kindled thereby. An
important lesson is taught the medical profession by
these recurring outbreaks of yellow fever and other
infectious diseases ; it is that the final eradication of
pestilential diseases is practically beyond human
power. Again, such visitations indicate clearly
enough the necessity for constant vigilance or the
constant application of active measures calculated
to serve as preventives, more particularly in the
warm months or period of the year during which
our territory is continually menaced.
Professional zeal, amounting to anxiety, to learn
the specific cause of that interesting form of multiple
neuritis, beriberi, has failed to receive an encour-
aging impetus within the past year; both the bacil-
lus of Hamilton Wright and the coccus of Okata
and Kokubo have been shown to bear no setiological
relation to the disease. The aetiological position of
the organism discovered by Tscizuki'" still lacks the
needed experimental proof.
Hewlett and de Korte" have advanced a new
'Philippine Journal of Science, B. Medical Science, March, 1907.
'"New York Medical Journal, August ii, 1906.
tentative hypothesis, namely, that beriberi is the re-
sult of a protozoon infection, the invasive agent be-
ing eliminated through the urine, which conveys the
contagion. In the urine of beriberi patients were
found three varieties of refractive cells, believed to
be degenerate cells, or protozoa. These observers
also carried out investigations bearing on the pathol-
ogy of beriberi. They found a disease in monkeys
showing marked similarity to beriberi; the animals
were anaemic, the knee jerks either exaggerated, di-
minished, or absent, with oedema of the face and
genitalia in some cases. The urine showed hyaline
casts and highly refractive cells (supposedly pro-
tozoa), but no albumin. The animals succumbed
to the disease, and post mortem section revealed
changes similar to those met with in the human kid-
neys in this disease.
In the recent past numerous excellent articles
concerning the aetiology and nature of beriberi have
appeared in medical literature. There are not a few
modern writers who contend that the disease is of
dietetic origin, more particularly from the ingestion
of rice and fresh fish. While the controversy as to
whether beriberi is a microorganismal disease or the
food theory is to be ultimately accepted, the balance
of testimony would appear to be favorable to the
infectious nature of the disease, although it must
be owned that the specific cause still remains in
doubt.
Among the advances in experimental thera-
peutics is to be mentioned the use of vaccine pre-
pared from cultures of Micrococcus melitensis
freshly isolated from the spleen during life. Bas-
sett-Smith'' reports two series of cases, the first
series consisting of twenty-two cases, with marked
improvement in fifteen, the second consisting of
twenty-three patients, with marked improvement in
sixteen. He restricted its use to the more chronic
condition, in which there was a mild, seesaw tem-
perature without marked hectic symptoms. Fortu-
nately, although Malta fever is regarded as an acute
infection, most cases pursue a chronic course. It is
important to recollect that the addition of further
quantities of artifically produced toxine to a patient
in the acute phases of an infectious process is like-
ly to act detrimentally. In view of the results thus
far obtained, the method of treatment under con-
sideration deserves more extended trial.
During the past year the bacteriologists have con-
tinued to bestow much attention upon the subject of
the aetiology of intestinal diseases, attended with the
symptom complex, known as dysentery. Ashburn
and Craig," in a study of tropical diseases as they
occur in the Philippine Islands, report, under date
of June 15, 1907, that they have examined one hun-
dred healthy men, of which seventy-two, or sevent}--
two per cent., have shown Entamoeba coli in their
faeces. These men were all American soldiers serv-
ing at the division hospital, Manila, P. I., with no
dystenteric symptoms since residing in the Philip-
pines. They contend that it is possible to distin-
guish Entamoeba coli, as they occur in the faeces of
^^Journal of Tropical Medicine and Hygiene, October, 1907.
^-Journal of Tropical Medicine and Hygiene, May 15, 1907.
i^Loc. cit.
8i8
ANDERS: TROPICAL MEDICINE.
[New York
Medical Journal
man, from the morphological appearance of the
amoeba, and cite two cases which were fully cor-
roborated by information concerning their previous
history, elicited subsequent to the bacteriological
examinations.
Dr. Jesse Weston Fisher" has recently made a
bacteriological study of normal and diarrhoeal stools
for the detection of organisms belonging to the
dysentery group; he employed thirty-seven patients.
Of these eighteen were healthy, and nineteen suf-
fered from mild diarrhoea. The evidence, as it stands
from these investigations, leaves little room for
doubting that diarrhoeal cases in which blood or
bloody mucus are found in the stool, all show the
presence of the Bacillus dysenterice of the Flexner
type. Thus but two exceptions of mild grade were
noted in Fisher's series ; one of these showed a bacil-
lus of the Shiga type and the other of the Duval
lactose fermenting type. It is worthy of notice that
the Shiga type may be the exciting cause of mild
diarrhoeas, but it is not found in normal stools. On
the other hand, a '"dystentery like organism" called
Bacillus F. was recovered from 44.4 per cent, of
normal stools, "from the stools of 10.5 per cent, of
cases of simple diarrhoea, and from the stools of o.oi
per cent, of cases of dysentery." This organism was
found to inhibit the growth of both the Shiga and
Flexner types of bacillus dysenteriae in test tube
cultures, and in agglutination and absorption ex-
periments the organism produced specific agglutins
for itself, but not for types of dysentery, colon or
typhoid.
Two cases of gangosa — a destructive ulceration
and gangrenous disease of the palate and nose —
have been reported wi-thin the past year, one by
Stitt," observed at a naval hospital at Canacoa, and
the other (a fatal case) by Musgrave and Mar-
shall," occurring in a male Filipino, who had never
been away from the island of Luzon. A bacterio-
logical examination of the scrapings from the
lesions proved negative in its results. Musgrave
and Marshall give the details of the histological ex-
amination of the tissues ; they regard the condition
as distinct from syphilis, yaws, and tuberculosis, al-
though finding themselves on difficult ground, owing
to the absence of any organism having aetiological
significance, a positive expression of opinion is wise-
ly withheld.
Since the recent publication of the article by
Yount and Sudler" on the subject of human myiasis
from the screw worm fly, considerable interest has
been awakened in the subject. The disease is be-
lieved to be not rare, and the twenty-three cases re-
ported by the authors occurred during a single sum-
mer. In man its results are always serious or
fatal if not early and properly treated. The disease
attacks many lower animals — e. g., horses, cattle,
sheep, hogs, and it has been observed in many coun-
tries, islands of America, North America, Cuba,
Mexico, Brazil, Venezuela, Chile, and New Hol-
land. According to Snow, it is common from
Argentine Republic to Canada. In the vast ma-
jority of cases, the site of the attack is the nasal
"Journal of Medical Research, May, 1907.
>»U. S. Naval Medical Bulletin, July, 1907.
''Philippine Journal of Science, August, 1907.
"Journal of the American Medical Association, December 7, 1907.
mucosa, where it produces ulceration often asso-
ciated with necrotic or gangrenous changes.
These observers point out that "a chronic rhinitis
or otitis or even uncleanliness attracts the female
fly, as does any exposed wound or ulcer." It is
also noteworthy that sleeping in the open air gives
the fly an opportunity to deposit its eggs, after which
the larvae are capable of boring into healthy as well
as diseased tissue. Yount and Sudler present the
symptomatology and diagnosis of the condition in
the article referred to, and it is interesting to ob-
serve that chloroform employed in the form of a
spray is counselled for diagnostic purposes, as it
serves to bring the parasites to light, and also as the
most effective measure of treatment.
Among the more important tropical and subtrop-
ical diseases stands uncinariasis, which has received
a large share of professional attention, and the re-
cent work of E. C. Shattuck," of Manila, on this
disease is worthy of elaborate mention. The hos-
pital system, consisting of Bilibid Prison, with 3.800
prisoners, a hospital of 150 beds for general pur-
poses, and a quarantine pavilion in which all re-
cent admissions to prison are kept for a period suf-
ficient to develop any latent infection, furnished'
ample opportunity and scope for systematic and sat-
isfactory observation. All new admissions were
regularly examined for intestinal parasites, and ap-
propriate treatment instituted in infected cases.
Approximately 1,000 examinations of quarantine
cases have been made to date. Of 530 prisoners
admitted to the hospital for treatment, there were
243 cases of uncinariasis, sixty-three of amoebic
dysentery, three of balantidium coli infection, 186
of ascaris infection, seven of taenia, and the re-
mainder acute dysentery.
There is a tangible basis for the belief that thor-
ough, careful observations on this broad line will
lead to the discovery of points of great interest and
importance for practical purposes. As Shattuck
pertinently remarks, however, the work on un-
cinariasis is hardly more than begun, although the
prompt recognition of the condition, from the mi-
croscopical examinations referred to before, has
doubtless already contributed materially to the
marked decrease in the death rate during the past
half year. Extended investigations have been car-
ried out simultaneously in connection with the
treatment, and as the result preference is given to
eucalyptus rather than thymol, which was formerly
the generally accepted remedy.
Authors are in agreement that prevention of un-
cinariasis must lie in two directions : First, personal
cleanliness, and, second, the prompt disinfection of
the faeces. Of less, though considerable import, is
the question of the prevention of faecal deposits in
moist places and near to dwellings.
In the recent work on Anmnia in Porto Rico, by
the Permanent Commission for the Suppression of
Uncinariasis, it is estimated that ninety per cent, of
the population suffers from this formidable scourge.
The Commission treated 89,233 patients with the
following result: Complete cure in 25.71 per cent.,
"American Medicine, December, 1907.
May 2, 1908.]
KNOPF: SOCIAL EVIL.
819
practical cure in 17.88 p>er cent., and 40 per cent, are
still under treatment. Of those treated, 0.21 per
cent. died. The treatment cons'sted in the repeated
administration of thymol and belanaphthol, preceded
and followed by a saline. Eucalyptol was tried, but
was not found efficacious. At autopsies renal de-
generation rather than inflammatory lesion was
found.
x\n International Conference on Sleeping Sick-
ness was held in London (June, 1907), and it is a
matter of deepest regret that its deliberations and
reflections can merely be touched upon in this place.
Among the conclusions arrived at, based on present
knowledge of the subject, is that sleeping sickness
is due to the Trypanosoma gainbiense, "propagated
in main by the Glossina palpalis, or tsetse fly, al-
though other species of flies, notably of the glossinge,
cannot be excluded. '"° Methods of prevention con-
cerning both the patient and the fly were suggested
and considered, and among the most noteworthy
are: Police sanitation of infected individuals in or-
der to prevent the transportation of the parasite, the
avoidance of the establishment of camps or habita-
tions in localities where the tsetse fly lives, particu-
larly to keep clear of infected localities, attention to
the borders of streams and lakes (clearing out the
brush, etc.), the places inhabited by the flies, and,
finally, the protection of houses, closets, etc., by me-
chanical means in order to keep out both glossinae
and various species of anopheles. From the thera-
peutic side, the conference approved the use of
arsenic, which, by diminishing the number of try-
panosomes in the blood, also diminishes the
chances of contagion. Koch^° has suggested that
trypanosomiasis may be transmitted by sexual in-
tercourse.
The formation of the International Society of
Tropical Medicine during the Fourteenth Interna-
tional Congress of Hygiene and Demography,
which was held in Berlin in September, 1907, was
an event well worthy the serious notice of this so-
ciety. The objects of the society are twofold :
First, to bring together the societies of tropical
medicine of different countries for the purpose of
an exchange of views, and, second, to hold a con-
gress of tropical medicine once in three years.
The affairs of the international society have been
in the hands of a committee of management, com-
posed of two representatives of each national so-
ciety of tropical medicine, and the authorized mem-
bers on said committee from the United States are
Dr. H. G. Beyer, of the Navy, and Dr. Richard P.
Strong, of the Government Biological Laboratories
at Manila.
Mention should also be made of the establishment
of two new journals, namely, The Annals of Trop-
ical Medicine and Parasitology, published by The
Liverpool School of Tropical Medicine, of which
the first number was issued under date of February
I, 1907, and The United States Naval Medical Bul-
letin, published in Washington, the first number ap-
pearing in April, 1907.
1605 Walnut Street.
"Editorial Article, New York Medical Journal, September 7, 1907.
-"Journal of Tropical Medicine and Hygiene, February 15, 1908.
SOME THOUGHTS ON THE ETIOLOGY,
PROPHYLAXIS, AND TREATMENT
OF THE SOCIAL ILL.*
By S. Adolphus Knopf, M. D.,
New York.
As the title of my paper indicates, I have no inten-
tion to present to you suggestions for the complete
solution of this momentous problem. All I expect or
can hope to do is to call the attention of this audi-
ence to a few perhaps less known aetiological factors
and point out some measures which, to my mind,
may be added to those already in vogue in the pre-
vention and treatment of this ill.
First, let me explain, not exactly as an apology
for, but rather in defense of the innovation of speak-
ing of the problem of prostitution ; not, as is usual-
ly done, as a social evil or social crime, but simply
as a social ill.
The general understanding of the word "evil" im-
plies that the perpetrator of the act which is sup-
posed to be an evil one is an evildoer or criminal.
I believe it is neither just, humane, nor even con-
sistent to call the offenders, male or female, crimi-
nals in every instance. Before an audience of this
kind I do not need to state that there are numerous
cases in which the unfortunate woman is really in-
nocent, if not before the laws made by man, at least
before the higher divine laws. That there are also
instances when the other sex, the innocent and un-
knowing youth, has fallen victim to the experienced,
unscrupulous courtesan, often old enough to be his
mother, is also too well known to need detailed men-
tion.
When not applied to physical conditions, the word
evil is usually understood as wicked conduct or
criminal disposition, while the word ill or illness,
when figuratively used, means a derangement and
an unwholesome condition. By rights we should
not even caH prostitution the social ill, but only a
social ill, as it is by no means the only one, for
surely alcoholic intemperance and gambling must
also be considered social ills responsible for fully
as much misery as prostitution.
Presuming, then, that you will grant me the priv-
ilege of substituting the name "social ill" for "so-
cial evil," what definition would I wish to give of
this term in order to convey in concise words my
reasons for the change? I would say the social ill
is an abnormal, or, figuratively speaking, a patho-
logical condition which results from disturbances or
failures of sociological functions of the individual,
for which in few instances the individual alone, but
in the majority of cases our social fabric, is respon-
sible.
Let us now trace for a few moments some of the
aetiological factors perhaps not usually or not suffi-
ciently thought of by reformers. I cannot nor will
I subscribe to the cruel statement made by some
sociologists and syphilographers that many women
are born prostitutes. There is no evidence for this
assumption. All physicians know, of course, that
just as there are boys born with an adherent pre-
puce, so are there girls born with an adherent
clitoris. When these trifling physical defects are not
*Read before the American Society of Sanitary and Moral Pro-
phylaxis, April 9, 1908.
820
KNOPF: SOC/AL EVIL.
[New York
Medical Journal.
corrected they may lead to the habit of masturba-
tion in both sexes. When operated upon, the ac-
quired pernicious habit usually ceases. But if, as is
asserted by some authorities, this physical defect
predisposes the female child to prostitution and the
male child to corresponding abnormalities, then by
all means let us make it a practice to have every
child, male or female, carefully examined and treat-
ed for such possible defects by a competent
physician.
Physicians of public nurseries, orphan asylums,
boarding schools, etc., should make it a rule to ex-
amine every child under their care for possible de-
fects or deformities which, when left uncorrected,
might destroy the moral conception of what is right
and wrong sexually.
We are educating in this country ever)' year a
goodly number of women physicians who should be
best fitted for such work in girls' institutions, par-
ticularly when it is extended, and it should be to all
public schools.
Hysteria is another disease, which, according to
some authors, is predisposing to prostitution. Le-
grand du SauUe observed that twelve per cent, of
hysterical women took to prostitution out of sheer
dilettantism, without any pressure from misery, and,
according to Tarnowsky, the percentage is as high
as fifteen per cent.' If that is true then let us ex-
amine every female child and treat it thoroughly
for whatever hysterical manifestations may show
themselves.
What other classes of children are there who, be-
cause they often enter the life of prostitution at the
age of puberty, if not before, are for that reason
classed by certain writers on the subject as born
prostitutes? They are the unfortunate little ones
born amid surroundings of ill repute or vice. While
in such instances it cannot be denied that a pre-
disposition to the social ill under consideration may
be acquired, one can and should not 'speak even
here of a born prostitute. This is shown by the
very fact that many a woman whose lot has been
cast among these unfortunate ones, on becoming a
mother has often worked and sacrificed herself so
that she might give to her offspring the chances of
a purer and better life by placing the child in an in-
stitution or a responsible private home. A great
many prostitutes are recruited among the children
of widows and deserted wives, and perhaps an
equally large number from children whose parents
are incapable, shiftless, or dead.
In New York city we have a number of local
charitable agencies intended to relieve misery
caused to wives and mothers by the death or deser-
tion of their husbands, but to find a truly far reach-
ing remedy for these conditions we must look to the
example of New South Wales. In that advanced
community there exists a State Children's Relief
Board, whose purpose it is to protect, first, the child
without a parent; secondly, the child with an irre-
sponsible, immoral, or wholly incapacitated parent.
With the aid of the Children's Relief Act. the fu-
ture citizens of New South Wales, male and female,
who are deprived of the benign influence of intelli-
gent and loving parents, are disposed of by being
Ijoarded with selected foster parents. If the mother
'I.ombroso, The Female Defender.
is a widow or a deseited wife she retains the chil-
dren as boarders, an allowance from the State en-
abling her to do so until they have become self sup-
porting.
I come now to ojie of the most painful subjects,,
which must be considered a strong aetiological fac-
tor of prostitution. I refer to that other horrible
social ill which 1 have not yet mentioned, child
labor. Permit me in regard to this to quote from
John Spargo's book. The Bitter Cry of the Children :
The moral ills resulting from child latK>r are numerous
and far reaching. When children become wage earners
and are thrown into constant association with adult work-
ers, they develop prematurely an adult consciousness and
view of life. About the first consequence of the employ-
ment is that they cease almost at once to be children. They
lose their respect for parental authority in many cases, and
become arrogant, wayward, and defiant. There is always
a tendency in their homes to regard them as men and
women as soon as they become wage earners. Discipline
is at once relaxed, at the very time when it is most neces-
sary. When children who have just entered upon that
most critical period of life, adolescence, are associated with
adults in factories, are driven to their tasks with curses,
and hear continually the unconstrained conversation, often
coarse and foul, of the adults, the psychological effect
cannot be other than bad.
In saying this I would not for a moment desire
to cause a reflection on the general character of the
working women or men within or without the fac-
tory. I believe their moral standard compares
favorably with that which we call society. But
with Mr. Spargo I say that for the plastic and im-
pressionable mind of a young girl between the ages
of ten and fifteen the moral atmosphere of the aver-
age factory is bad, and I know that none will more
readily agree with us than the men and women who
have worked in mills and factories.
But leaving aside the possible corruption of the
child's mind, let us- turn for a moment to the other
features of child labor. Take a little girl of ten
years of age, put her to work in a factory for ten
hours a day, and let her live this humdrum exist-
ence to the age when she develops into womanhood,
will she be able to resist the temptation of a life of
ease and plenty if it is offered to her? That parents
who make of their daughters slaves by enforcing
child labor at home, by depriving them of their
natural rights to play and recreation, compelling
them to mind for hours and hours the smaller chil-
dren, do house and kitchen work when not at
school, are equally responsible for many a young
girl becoming wayward and seeking freedom in
what she thinks is a happier and more joyful life.
Undue severity with children, especially with young
girls, is as much to be condemned as lack of all
discipline. ,
That great reformer and lover of children. Judge
Lindsay, of Denver, has told us what not to do with
children when they are seemingly in the wronp: :
"Do not punish a child at the time of offense ; wait
and cool down, otherwise you make yourself ridicu-
lous and the child will fail to get justice." "Do not
mistrust a boy or girl even if your confidence in him
or her is weak : faith will work wonders.'" "Do not
talk roughly or swear at a boy or girl; it is a trick
of a coward."
We must do away with child labor in factories as-
well as at home. The excuse of some advocates of
child labor, that the money the children earn is
^lay 2, 19C1S.]
KNOPF: SOCIAL EVIL.
821
needed to supplement the meagre earnings of the
father, is rarely well founded. In the few instances
where child labor seems to be necessary to help sup-
port the family our local Consumers' League comes
to the rescue by according scholarships to the chil-
dren."' On the other hand, in most communities
where there has been enforcement of child labor
Jaws, investigation has proved that in families where
the father was sober and industrious child labor was
not needed.' By saying this, however, I do not wish to
exclude the, alas, quite numerous instances where
the heads of families vvho are workers are under-
paid.. It is also true that if we could but convince
working men and women that the intemperate use
of alcoholic drinks is responsible for a great deal
of their misery, privation, and want, the laboring
man would be helped to make himself, his wife, his
:Sons, and daughters happier, better, and nobler citi-
zens.
It would lead too far to discuss here at length
the second social ill, "alcoholism," the curse of our
and so many other nations. We know that the ex-
pressive indulgence of alcohol dulls the moral senses
of man and woman, and the child of an alcohoHc
parent is apt to become itself an alcoholic and in-
herit other stigmata of a degenerate type. Thus
alcoholism indirectly predisposes to the social ill.
What remedy have I to suggest for the combat
of alcoholism in order to combat the social ill at the
same time?
Some time ago it was my privilege to read before
the Society of Medical Jurisprudence a paper on
the subject'of Medicine and Law in Relation to the
Alcohol. Venereal Disease and Tuberculosis Prob-
lems.' In it I suggested a few remedies to combat
alcoholism, such as a law preventing the habitual
drunkard from marrying, and the most rigid en-
forcement of the law which makes it a felony to
sell liquor to a minor or to administer strongly alco-
holic beverages to a child without the physician's
prescription. The law which obliges the manufac-
turer of patent medicines to put on the label the
exact alcoholic contents of the nostrum should be
enforced with equal vigor. Rational educational
movements instructing the people to be temperate
in all things should be encouraged. And last but
not least may I suggest an antitreating club, so that
when a drink must be taken in company with others,
it should not. because of the time honored American
custom, be Multiplied according to the number of
the company present.
I cannot help thinking that the establishment of
more comfort stations would greatly reduce the
necessity of many a man going into a saloon, where
he feels obliged to take a drink in order to avail
himself of the toilet facilities. There is no doubt
in my mind that numerous sanitarily constructed
and well kept comfort stations for both sexes
throughout the city would greatly add to the physi-
cal comfort of many people and indirectly prevent a
great deal of illness of all sorts. It is well known
^The amount of the scholarship is varied, equaling approximately
what the child would earn if at work, so far as these earnings are
essential to the family welfare. These scholarships may be given
for a period of from three to twenty months, and the weekly assist-
ance is given only on the receipt of a certificate of regular school
attendance from the school principal.
^Tohn Spargo, The Bitter Cry of the Children, p. 208.
'Medical Record, June 2, iqo6.
that even syphilis and gonorrhoea have been trans-
mitted to innocent adults and children because of
badly and unsanitarily kept public comfort stations.
There should be more play, more sleep, and less
work for our school children. I hold the highly
nervous state of our children, which is produced by
too much mental work at school and at home, and
not enough sleep nor enough out door life, largely
responsible for the readiness of our young people
to acquire the alcohol habit.
Of the nefarious influence of child labor on the
constitution of the growing girl and boy as a pre-
disposing factor to the social ill I have already
spoken. That a young man's or woman's nervous
system, after being wrecked by child labor, is more
ready to acquire the alcohol habit, with all its nefa-
farious consequences, must also be evident. The
seriousness of child labor in this country is, I am
afraid, not well enough understood and appreciated.
Let me hope that the gravity of the situation will
be better understood by you when I tell you that,
in spite of all the labors of many noble men and
women, there are still, according to Mrs. Florence
Kelly, the secretary of the National Consumers'
League, well known for her noble work in this
cause, no less than 2,000,000 children earning their
living in factories and workshops in the L'nited
States.
Rational lessons in temperance should be taught
in schools and adapted to the understanding of the
child.
I believe in the Gothenburger system, which con-
sists in the manufacture and sale of alcohol by the
government, and giving the dispenser of alcohol a
salary, so that no benefit shall accrue to him from
the amount of alcohol he sells, but I fear this system
is not as yet practicable in our country. Perhaps
even a law limiting the manufacture of alcoholic
beverages is not yet feasible, but I believe in the
possibility of limiting the number of licenses of
saloons and even elevate their standard by ehminat-
ing that type of saloons which police records show
to be centres of crime. There should be State insti-
tutions for the treatment of alcoholism to which the
habitual drunkard could be committed by law, and
to which the man desiring to free himself from the
craving for alcohol could commit himself volun-
tarily.
Bad housing, unsanitary and unclean, overcrowded
tenements, with no room for the children to play
or for young people to meet in innocent and whole-
some enjoyments, and with no place for recreation
for the adult, are factors in predisposing men and
women, young and old, to both alcoholism and the
social ill.
Who will dare to deny that the thin partition
walls and the often promiscuous mixing of the sexes
in the crowded quarters tend to the demoralization
of the young girl blossoming into womanhood? It
is my firm conviction that the building of more
model tenement houses, where commodious and
healthy quarters can be obtained at the same and
often more reasonable rates than are now demanded
for rooms hardly fit for human habitation, the re-
modeling of bad tenements, the making an open
playroom of the roofs of all tenements, old and new,
by fencing them in with strong wire netting, the
822
KNOPF: SOCIAL EVIL.
[New York
Medical Journal.
creation of more parks and playgrounds within the
most crowded sections of our city, and the establish-
ment of healthy places of amusement, open Sundays
and weekdays, where the laborer can partake of very
light or nonalcoholic drinks and enjoy the society
of his friends, will do more to do away with alco-
holism and diminish the social ill than anything
heretofore tried.
My studies in relation to tuberculosis and the
housing problems in large cities, and particularly in
our own, have, of course, convinced me that, with
the constant increase of our population, the building
of new tenements and the remodeling of old will
not suffice to do away with all the congestion, the
causes of tuberculosis, other diseases, and the social
ill. Something in the line of the work of the
Garden Cities Association of England and also of
this country will have to be done on a large scale.
For those who are not familiar with the object of
this movement I wish to say in brief that its object
is to advocate and to further the removal of families
and individuals, particularly of the industrial and
working classes, from overcrowded cities to the
country, where each family may have its own com-
fortable home in surroundings and under conditions
which shall unite, so far as possible, the attractions
both of the city and of the country. To obtain this
end, these associations work toward the founding
and developing of model industrial towns and vil;
lages, or so called "garden cities," wherein factories,
stores, and other forms of business may be estab-
lished, with space for air, beauty, convenience, and
room for growth.
To many of you this may seem a dream, but those
who have visited the Congestion Exhibit last month
and were privileged to listen on the opening even-
ing to our distinguished governor's address, will
grant me that I do not stand alone with this view
of the solution of the congestion problem with all
its attending evils and ills. If I understood Gov-
ernor Hughes correctly, he said that night that dis-
tribution of the people in more tenements on the isl-
and would not in itself suffice, but that there must
be also a large distribution of centres of work. Be-
sides improving existing tenements in accordance
with the tenement house law and building new model
tenement houses on the still unoccupied and health-
ful sections of Manhattan Island and the neighbor-
ing boroughs, we should do all we can to encourage
garden city movements. That even the city and
State would be the financial gainers if they would
come to assist in such enterprises, I hardly need to
dwell upon before an audience which has made the
study of social medicine its main object. The cost
of wretchedness as it now exists is greater than
would be the cost of prevention. To emphasize this
still more let me repeat to you the exact words of
the governor from that impressive address: "Who
pays the bill? The city and the State are paying
for the crime, for the disease, for the wretchedness
that comes from those congested conditions."
The social workers in the districts of the poor
will tell you that the disreputable dance halls are per-
haps one of the greatest sources of danger to the
young, unsophisticated girls of the tenement house
districts. We have learned recently through our
daily press that a vigorous crusade has been in-
augurated against these places, where many a young
girl, often while yet in short skirts, has been enticed
with fatal consequences.' All of us will endorse
this crusade against such dangerous resorts, but
must we not also think of the necessity of providing
in their stead places of amusement where the young
girl could safely go and be shielded from all dan-
ger? Young people love and need enjoyment; they
love to dance and love to be merry. Let some
philanthropist think of this, and by a munificent gift
help the social settlements, the People's Institute,
and similar institutions to enlarge their work in this
field or create new fields for legitimate enjoyment
and rational recreation for the young workers.
The next most important feature to be considered
is, of course, education as a prophylactic means. To
educate first the lawmakers where such education is
still needed would seem of prime importance. I
refer first to the wisdom of enacting laws such as
are already in vogue in Michigan, which forbid the
issuing of a marriage license to individuals afflicted
with venereal disease, and, secondly, to the neces-
sity of a federal law to make obligatory the instruc-
tion of recruits to the United States army and navy
and pupils of naval and military academies con-
cerning venereal disease, personal hygiene, etc. It
is for the purpose of educating the masses, the
young, the adolescent, and the adult regarding the
sexual problem and the prevention of venereal dis-
eases perhaps more than for any other reason that
the American Society of Sanitary and Moral
Prophylaxis has been founded.
You are all familiar with the fact that the prime
mover in the magnificent work is the distinguished
gentleman who presides over this assembly to-night.
Professor Prince A. Morrow. He has not only
■ given us the fruits of his lifelong experience as a
physician and teacher, but has favored us at the
very beginning of our career with a number of lec-
tures," here and elsewhere, which have been most
helpful in starting such associations in other cities.'
It is to be hoped that soon every city in the United
States, nay even every hamlet of any size, will have
such a society, or at least a centre from which lit-
erature, approved of by the society, could be dis-
tributed. Thus far three educational pamphlets
have been issued, and already thousand of copies of
them have been distributed. They are entitled ( i )
The Relation of Social Diseases with Marriage and
Their Prophylaxis, (2) Educational Pamphlet for
Teachers, (3) The Young Man's Problem."
I think the time has now come for the issuing of
an educational pamphlet entitled The Young Wo-
man's Problem. Perhaps one of our distinguished
lady members of the society will undertake this
task. I am willing to confess that the issuing of
'A bill to do away with some of the worst evils of the dancing
academies, dancing schools, and dance halls has been introduced by
Mr. Graubard and has already passed the assembly.
'The Control of Syphilis and Venereal Diseases. The Society of
Sanitary and Moral Prophvlaxis: Its Objects and Aims. Social
Disease and Marriage. Results of the Work Accomplished by the
American Society of Sanitary and Moral Prophyla.ris.
•Such societies have been founded or are in progress of forma-
tion in the following cities: Baltimore, Md.; Boston, Mass.; Brook-
lyn, N. Y.; Chicago, III.; Denver Col.; Detroit, Mich.; Jacksonville,
Fla*. ; Philadelphia, Pa., and the City of Mexico.
'This literature can be obtained by applying to our secretary. Dr.
Edw. Keyes, Jr., 109 East Thirty-fourth street, at the following
rates: . ^ . ,
(1) 72 pp., 25 cents; 5 copies $1; 25 copies $5.
(2) . 10 cents: 50 copies $3; 100 copies $5.
(3) 32 PP-- 10 cents; 50 copies $3; 100 copies $5.
KNOPF: SOCfAL EVIL.
823
such a pamphlet has already been under considera-
tion, but we who belong to the strong and fearless
sex have not yet had the courage to undertake it.
It is strange that nearly all of us hesitate to write
or speak plainly on one of the most vital subjects
which concern the human race. There exists an ex-
cellent article by Dr. Woods Hutchinson on the sub-
ject of The Economics of Prostitution.^ I have
read and reread it, but no passage has impressed
me so much as the following, which may well serve
as a guide to the author of the educational pamphlet
to be entitled The Young Woman's Problem:
The freedom of intelligent, refined conversation upon
sexual subjects ought to be broadened; it should no
longer be considered indecent to speak plainly. Most of
the flavor of obscenity which hangs about- the discussion
of sexual matters is due to this very restriction. No ex-
cuse or danger should be left for boys and girls on the
grounds of ignorance of this important function. In other
words, intelligence, altruism, true refinement, should be
promoted by every possible means, and Nature will con-
tinue to assist us by emphatically discouraging their oppo-
sites.
Besides the educational pamphlets which should
be carefully distributed, nothing is so valuable as
the carefully prepared popular lecture. But it is not
always easy to speak the language of science in the
language of the people, and to lecture on the subject
under consideration with the necessary force and
clearness will require much tact and skill. But I
have faith that the executive committee of our so-
city will choose the right men and women for that
purpose. When they are chosen I trust that our
supervisor of lectures, that great popular educator.
Professor Henry M. Leipziger. will realize the im-
portance of educating the adult population as well
as the younger generation regarding this great
problem, and will inaugurate a series of popular lec-
tures on the prevention of this ill, as he has done
for the prevention of other ills.
I cannot leave the subject of education without
saying a word as to what can be done in the line
■of educating the school child in regard to the sex
problem. We have had in this society from time to
time men and women who have told us that it is
■quite feasible to teach the children, according to
their age and understanding, what they should know
of this. At one of our recent meetings we had the
privilege to listen to Mr. Curtis, the superintendent
of the Curtis School, who has made it a practice
to educate children under his charge in all that is
necessary and useful to have them think and act
rightly in regard to this vital problem. From the
interesting literature he was good enough to send
me I will quote only a few sentences :
There is nothing in the world half so powerful as right
knowledge to suppress impurity of thought, word, and
deed. Whoever is responsible for the training of children
and is unwilling to instruct them about the meaning and
the sacred relations of sex takes an untenable position.
He practically confesses that ignorance is better than
knowledge. The child with its healthy instincts uncon-
sciously repudiates this assumption, and will forever con-
tinue to do so. The whole subject, rightly studied, is in
itself so essentially beautiful and so ennobling in all its
relations to character that one cannot unfold it step by step
to children without finding in it new impulse to delicacy
of thought and to elevation of purpose, , . . It was recently
written that it is a cardinal sin to allow a son to reach
manhood years without knowing all that pertains to good,
'American Medicosurgical Bulletin, .\ugust 15, 189;.
pure, refined womanhood — all that chastity, wifehood and
motherhood means to a woman.
But we may say that it is also a cardinal sin to
allow a daughter to grow up and blossom into wo-
manhood without knowing all that she should know
as a woman, as a prospective wife, and a future
mother. The home is the ideal source of such in-
formation, but as yet few homes give it. It is left
for the schools that dare to do so to instruct chil-
dren on these vital themes. Neither must the
teacher be satisfied with this partial performance of
his duty; he must reach out beyond the child, and
touch public sentiment in order to elevate it.
Those who have carefully studied the many
causes which make girls with a fair education and
a good home training enter the life of prostitutio;i
will know what a large contingent comes from the
workers employed by manufacturers of women's,
men's, and children's garments, in factories or tene-
ments, and that perhaps an equally large number
come from the underpaid girls working as clerks
or saleswomen. It is often said that their great love
for finery leads them to ruin. This may be so at
times, but surely this is not the most frequent cause.
For the girl without a home it is hard to live on $4
a week. With her it is want for bread and not
finery which drives her to despair.
This is not the place to discuss why women should
be paid so much less for their work than men. A
few weeks ago I saw, at the Congestion Exhibition,
various articles manufactured by the children, young
women and mothers of the tenements, as for ex-
ample: Infants' dresses, 6 cents a dozen; rate of
earning. 3 cents an hour, or 42 cents in 14 hours.
Glove finishing, 6 cents to 15 cents a dozen pairs;
3 persons work for 60 cents a day. Artificial flow-
ers, $1.25 a gross sprays; average, 3 persons one-
half gross a day. Small hot water bottles, i cent a
dozen ; 20 an hour by expert. Men's neckwear, 55
cents a dozen for lining and hand sewing ; average.
$4 per week.
You all know — and if you do not know you ought
to know — of the work of the Consumers' League of
the City of New York, which should have its coun-
terpart in every city of this fair land. You should
be familiar with what this league has termed a
"standard of a fair house." It means, in substance,
equal pay for work of equal value, irrespective of
sex, reasonably short hours, and sufficient attention
to the physical and moral comfort of the women
employed.
The Consumers' League publishes a white list
which the governing board recommends to its mem-
bers and to all others interested in the welfare of
working women and girls. In this white list all the
retail houses are mentioned which deal justly by
their employees and approach nearest to the stand-
ard of the league.
A little propaganda among men, or better yet, for
the stronger sex to join as active cooperators with
the ladies of the Consumers' League against the
sweatshop system would also seem to me timely.
I cannot leave this subject without also saying a
word to all the manufacturers and heads of depart-
ment stores and other large establishments, many
of whom are even philanthropically inclined. Let
all who have not yet complied with the standard of
824
KNOPF: SOCfAL EVIL.
[New Vokk
.Medical Journal.
the "fair house" remember one thing : it is a greater
pliilanthropy to pay the girls in their employ living
wages while they are still among the living, so that
the temptation to err will be removed, and to have
an active interest in their employees' physical and
moral Avelfare, than to leave millions in their last
will and testament to cathedrals, churches, hospitals,
and similar charities.
We must acknowledge that much has been done
of late hi various States to curtail the curse of sweat-
shop and child labor, but there is much more to do.
It would seem that all regulation of child labor,
woman and sweatshop labor in general in tenements
is futile, and that prohibition, direct or indirect, of
work in living rooms is the only rational solution
of the problem which is responsible for so much
disease, misery, and physical and moral deteriora-
tion of the laboring population, and particularly of
women and children.
The young girls who fall victims to the social ill
do not, however, come only from the cities. A large
contingent of them comes from the smaller towns
and villages. We all know that the attractions of
city life have led many a young girl and also young
man to leave the healthful home surroundings for
the complex and often dangerous city life. These
young people, tired of the humdrum existence in the
village, flee to the city, thinking that there they will
find joy and pleasure and much less work than they
are obliged to do at home. If the young man fails
to succeed, has indulged in pleasures in which he
would not dare to indulge at home, or ^ven if he has
done greater wrong, he may iievertheless return
home, be again respected and honored, and marry
a good, pure young woman.
How different with the girl ! She may have loved
but once, though not wisely, and upon her are sud-
denly thrust the responsibilities of motherhood, and
in this condition she may be alone in a strange city,
without friends or means. She does not dare to
return to her home. Though she may be innocent
in the eyes of a higher judge, she knows that human
society at large will condemn her, and often her
very family disown her. For the sake of being able
to support her child, whom she loves as all mothers
do, the girl thus abandoned finds it hard to find
honorable employment, and thus not infrequently
enters the ranks of what society is pleased to term
"fallen women." More of such work as is done by
the New York State Aid Charity Organization, pro-
viding homes' for mother and child and employment
for the former, is urgently needed in our own and
other American communities.
-■Mas ! woman herself not infrequently joins in
the denunciation of her unfortunate sister, and helps
to stamp the mark of an outcast upon her. A little
more humanity, a little more sisterly love, a little
more compassion is needed here. Let woman be
more womanly toward her sister who may have
fallen, but nine times out of ten through no fault
of her own. A helping hand stretched out to the
unfortunate child-mother will often prevent her from
becoming a prostitute.
What remedy have I to offer to combat the unfor-
tunate tendency of young people in villages and
small towns to migrate to large cities with an uncer-
tain prospect of being able to make an honest living?
Practical philanthropy cannot do the work alone
here. If we wish to stem the tide of migration from
village to city, and perhaps at the same time reverse
the tendency as far as is in our power, thus helping-
to relieve the congestion and tenement evils already
referred to, both practical philanthropy and practical
statesmanship must come to our aid. By judicious,
and wise laws farming should be made rnore profit-
able, and thus offer more attractions to the rising
generations than it has been doing during the last
few decades.
Philanthropists should aid the statesmen by en-
dowing institutions for instruction in scientific and
profitable agriculture, and also by providing health-
ful amusements, good libraries, and other educa-
tional institutions in country districts, thus making
living in the country more interesting and attractive
to the young people.
A large contingent of the unfortunate women iu
the larger cities, about which we are speaking, is
sent there by importation from the interior of the
country and from abroad. All social workers are
familiar with what is known as the "white slave traf-
fic." Our laws seem to be too elastic or their en-
forcement too lax to make any impression on this
disgrace to civilization. It was recently my privi-
lege to listen to an address on The Protective Work
of the Travelers' Aid Association by Miss Grace
Dodge. If there is any movement which needs
strengthening, co-operation, and support, it is this.
One of the most important features of the noble
work of those activeh- engaged in this movement is-
to meet the lonely woman traveler on her arrival in
a great city and protect her from falling into the
hands of the persons who may have enticed her to
come to the city under promise of lucrative employ-
ment, but whose interest is to make of the unfor-
tunate victim a slave.
We come now to that part of our subject which I
believe is the most difficult of all to discuss, namely,
treatment. How shall we deal with prostitution as
it exists to-day, with its widespread ill, known as
venereal disease? You all know that neither pros-
titution nor its concomitant physical diseases are a
product of modern times. Herodotus (484-424
B. C.) tells us of prostitution in ancient Babylon, and
venereal disease seems to be almost as old. Eman-
cipation of woman, which has been slow but sure,
has, in my humble opinion, certainly done something
in improving conditions, and when we compare the
history of prostitution of old with that of to-day we
can still say it is better now. Nevertheless, it exists,
and whether it still flourishes because of man's pa^
sion, or because of our social fabric, which only per-
mits too few and too late marriages, or because of
injustice of man to woman, or because of lack of the
divine in all of us, or because of all these causes
combined, I do not pretend to be able to say.
I have said in the beginning of my address that I
look upon the situation as a disease, which, after
everything has been done in the line of prevention,
must be treated. This is the attitude which every
physician takes when he is in the presence of illness.
In my humble opinion, the disease with which we
are confronted at this time can be treated in the pres-
ent state of civilization by three methods only, namc-
Iv. first, by repression ; secondly, by giving to all
May 2. iprS ]
KXOPF: SOCPAL EVIL.
825
those who are diseased the best, most thorough, and
scientific medical treatment ; thirdly, by offering to
all those who wish to leave the ranks of prostitution
shelter, protection, and work.
Let me, in conclusion, dwell for a few moments
on each of these three therapeutic topics. In refer-
ence to the first, let me defend my position, which is
for repression and not for oppression, and repeat
what I have said once before on the occasion of ad-
dressing the Society of Medical Jurisprudence : "I
doubt the wisdom of our lawmakers, city fathers,
and reformers in perpetually hounding the unfor-
tunate prostitute. These women are driven away
from one part of the city only to turn up in another,
and. instead of confining the evil to one section, it is
spread all over. I have the strongest doubts that the
social ill as such can be suppressed in a city like
Xew York by no matter how strict a police regula-
tion. It has been said by authorities who have
studied this subject very thoroughly that there is al-
wavs a natural tendency to segregation, just as there
is a tendency to segregate among other trades. It
certainly would seem that if some kind of segrega-
tion could be accomplished by passive or even by
active measures, so as to limit this social ill to some
portion of our city which could be properly con-
trolled by an efficient police, it would stop the con-
comitant thievery and robbery and greatly diminish
that still greater crime of having men live on the
shame of women. Remove by sensible and just laws
tile necessity of bribe giving, and the bribe giver will
cease to exist. I do not like this perpetual cry of
some against a corrupt police, an inefficient judi-
ciary, etc., etc.
"Let us make laws that can be enforced. Remove
the ridiculous character of some of the laws, and you
will find the vast majority of our policemen true
guardians of the peace and willing to perform their
duty, and our judiciary you will find as spotless as
any."
i have mentioned as the second part of my pro-
gram of dealing with the social ill the most thor-
ough, scientific medical treatment. There is not a
physician in Xew York, from our distinguished
president down to the young graduate serving in a
public dispensary, who will not tell you that, while
venereal disease must be considered one of the most
prevalent of all infectious, contagious, and commu-
nicable diseases, for its treatment there is an almost
total lack of facilities and system in this as well as in
most cities of the United States. From statistics
gathered by Dr. Armstrong and published by Dr.
Newborn in a paper read before this society, the
lamentable condition has only been too plainly dem-
onstrated. The City Hospital and the Metropolitan
Hospital are the only two institutions in this great
metropolis which have beds for the treatment of
venereal diseases. The combined capacity for this
purpose consists of one hundred and twenty beds
for male and thirty-three beds for female patients.
The evident need of many, many more hospital facil-
ities to treat this class of patients must be evident
even to laymen, especially when the physicians tell
them that hundreds and hundreds of cases of people,
and particularly women of the unfortunate class un-
der consideration, are now walking the streets of
Xew York knowingly or unknowingly spreading the
disease broadcast and causing untold misery and suf-
fering. If hospital facilities would be provided for
them I am quite sure a goodly number would avail
themselves of the opportunity to be cured. There
is. however, one condition on which I would insist
in providing such hospital facilities. There should
be no special hospital, but there should be special
pavilions or special wards attached to a general hos-
pital. If we wish to induce the afflicted to go there
we must avoid the stigma which would attach itself
to the name of a special venereal hospital. It has
been said by advocates of licensing and regula-
tion of prostitution that more cases would be treated
and cured under such a system. I have no evidence
that this statement is correct, but, if statistics are re-
liable, the disease vuider consideration would seem
as frequent in some countries where there is regu-
lation as where there is none. But it is difficult to
see why, among women suffering from venereal dis-
ease, a large number would not gladly avail them-
selves of the opportunity to be examined, treated,
and cured. To this end our dispensaries for the
treatment of venereal diseases should be multiplied
and they should be so managed that any woman or
man, fearing to be infected, could be assured of hu-
mane consideration and scientific and thorough treat-
ment. Who will dare to deny that much sorrow, and
much suffering would thereby be spared to the com-
munity at large?
Would it not be wise to offer to all these unfor-
tunates an opportunity to at least regain their phys-
ical health, and thus stop at the same time a source
of infection to others? If it was only to save the
lives of the innocent and prevent the blindness of
thousands of little children by saving them from
gonococcic infection, it would be a vast economy tu
a community to treat as many of the infected adults
as possible.
I come finally to the third and last of the remedial
agents I have to offer. It is a shelter to receive all
those who voluntarily wish to leave the life of pros-
titution and who fear to return home or are not able
to make an honest living, or, worse yet, fear that in-
dividual who does not deserve the name of man for
having lived on the shame of woman.
All those who have studied the problem without
bias and with only the view to help where help is
needed will realize the need of such an institution.
You may be pleased to learn that, owing to the in-
spiration and indefatigable energy of Miss Maude E.
.Miner, probation officer of the city magistrates'
courts, such a home has been started already on a
small scale. .Most gratifying to all those interested
in this work was the endorsement of the city magis-
trates. At a recent meeting they unanimously voted
their approval of the establishment of a home for
girls released from court on probation. Funds are
coming gradually, and those of us interested are full
of hope that ere long we may be able to put it on a
sound financial basis, and make this home large
enough to receive girls whom the probation officers
from all over the city courts may choose to bring
to it.
It was my privilege recently to spend the hours
from 9 p. m. to 3 a. m. at the side of the city magis-
trate of the night court. If I had not been converted
that night to the need of such an institution, the two
826
DE IRIES: PSYCHIC PHEXOMEXA OE IXTESTIXAL I OX JEM I AS. I^'e" Vork
Medical Jolrxai..
incidents related to me by Miss Miner would certain-
ly have convinced nie of the need of shelters and
homes for the unfortunate women who are seeking
to be freed from the life of shame. Let us use ]^liss
^liner's own words:
A young German girl was arrested recently for soliciting
on the streets and was placed in my care. Two months
before she had been working regularly and living a good,
honest life. With tears and sobs she told me her sad story
— how she had met the man who lured her from her work,
how she had gone to live with him. and then how he had
forced her. four weeks later, to go on the streets and sup-
port him by her immoral living. She declared that she
wanted to give up the wretched life and was willing to go
with me to any home to which I might take her. It was
with great difficulty that I succeeded in finding a place for
her.
Another girl was pregnant, and had been forced to
solicit because she had not a cent for food, had no home.
The institutions at whose doors I knocked refused to
admit her, so that my only solution was to take her with
me to my home.
It is Aliss ]\Iiner"s ambition, and it should be ours,
to have many such homes and in the various cities of
the United States, and thus by interchang-e facilitate
the reentrance into proper and honest spheres of life
any girl who voluntarily leaves the ranks of prosti-
tution.
I have endeavored in this feeble effort to point out
to you a few of the most urgent things which must be
done if we wish to deal with this all important prob-
lem intelligently. We must approach the subject of
prevention and treatment of this social evil with no
sentimentality, but practically, prepared even to be
disappointed now and then, yet remain charitable and
continue the work without fear and on the principles
of the broadest humanit>-.
To those who are afraid to deal with the subject
or think themselves above it, to those who fear to
touch it because it is too dark and too sad, as well as
to those who are willing to help their unfortunate
sisters, let the words of the Great Physician be their
inspiration and reward : "Inasmuch as ye have done
it unto one of the least of these ye have done it unto
me."
1 6 West Xinetv-fifth Street.
THE PSYCHIC PHEXOMEXA OF IXTESTIXAL
TOX.EMIAS AXD THEIR TREATMEXT.*
' By J. CARLISLE De Vries, M. D.,
New York.
The treatment of indigestion is of peculiar inter-
est to the members of the medical profession, espe-
cially in view of the fact that the profession is di-
vided as to the advocacy of surgical intervention in
these cases. Operative procedure is not as success-
ful in producing the ultimate end as sound, common
sense scientifically applied.
I have been placed for the past six months in an
adtnirablc position to study this class of cases, dur-
ing which time I have been in daily attendance upon
at least forty to fifty cases of some form of indiges-
tion either primarily or as an accompanying symp-
tom of some other disease.
I will cite at length one or two illustrative cases
of this character. The first one is that of a very
learned reverend gentleman, whose history I append
•Read before the Tri-Profe^sional Medical Society of New York.
January 20, 1908.
in his own language ; the next is that of a very prom-
inent physician, at the present time in practice in
Ltica.
C.\SE I : Rev. W. H. O., age thirty-four. — "The first at-
tack of intestinal to.xsemia from which I suftered occurred
about the middle of July in the year 1901. I had eaten
heartily of crab farci one day, and awoke the ne.xt morn-
ing sui¥ering from a most violent vertigo, which was
followed by diarrhoea and nausea which continued almost
incessantly for a period of nearly one half hour and ended
with the emission of bile of a dark, green color. As this
vertigo was typical of all the attacks which followed, I will
describe it in some detail. It was objective, and the things
around me — tables, chairs, pictures, and pattern on the
wall paper, etc. — rotated with extreme rapidity in circles
with a radius of about eighteen inches, in vertical planes.
For several days after this attack I was exceedingly un-
steady on my feet, and my head was heavy, although at
this time I did not experience that.subsequent trouble with
my vision which I had at a later period following these
attacks, and by which things appeared to me blurred and
indistinct, and I saw as if through a curtain of unreality.
"My second attack occurred in February of 1905 after
eating a club sandwich with rhine wine and soda. This
attack was comparatively light and of short duration and
with only slightly pronounced after effects. I did not suf-
fer again from the trouble until the 15th of June. 1906.
During the winter of 1906 I had been extremely busy and
also very nervous, suffering in addition to nervous anxiety
with a difficulty with my right ear. which has since been
oronounced to have been in no way an attack of Meniere's
disease. In April of 1906 I left Xew York and became
rector of a parish in one of the suburbs of the metropolis.
Here I was not only extremely busy, but had many things
of importance and difficulty to worry and annoy me. I ate
quite inordinately of everything that was set before me ;
with particular heartiness of strawberries and things made
of chocolate. I recollect, however, that I felt extremely
well on Sunday, the 17th of June. Early next morning I
awoke with a slight attack of vertigo such as I had had in
1901 and 1905. This soon passed off. and I fell into a pro-
found sleep such as in many cases followed later attacks. I
breakfasted that morning as usual, and suffered a slight
return of the vertigo after breakfast. I went to Xew
York, however, where I had some matters of pressing
business to attend to. All went well until I was within a
few blocks of the Grand Central Station, where I was
seized with a most violent attack of vertigo and fell in the
street as if I had been shot. A policeman with great
kindness and apparently sincere attention took me to a club
of which I was a member, in the neighborhood. Here I
was seized with nausea and diarrhoea, and experienced a
most profuse perspiration which struck completely through
to the back of my coat. I received medical attendance, and
was able to return to my home that night. The following
morning I again had a slight attack of vertigo, and follow-
ing that day tor nearly two weeks I was extremely ill.
having many and still more violent attacks of the vertigo,
a pulse of 46 for several days and temperature consid-
erably subnormal. It was almost impossible for me to
keep any food upon my stomach, and I began to be attacked
with very pronounced nervous symptoms. Those of my
family who were with nie said that I spoke and acted in a
very peculiar manner. The slightest unexpected move-
ment in the room or the sudden entrance of a person into
the room caused me to start as if I had heard the report
of a revolver. In course of time, however. I was able to
be about, and then began a sensation whach was hardest
of all for me to bear, and which has taken the greatest
while, nearly a year, for me to overcome. This sensation
I should describe as being similar to that experienced
when skating upon rotten ice or when on board a ship
which was rolling considerably. I cannot, however, tell if
it was objective or subjective. For many weeks it was
with difficulty that I could walk straight upon the side-
walk, and I felt under the necessity of dodging all the
lampposts and telegraph poles I saw.
The shock of my fall in the street was such that for
many months I was imable to .go about unaccompanied
without the strongest sensation of fear.
By September of 1906 I seemed to be quite well, and by
the Tst of October appeared to be enjoying >that good
health which had been practically unbroken for the pre-
May 2. .9C8.J DE I RIES: PSYCHIC PHEXOMEXA Of IXTESTIXAL TOX.EMUS.
827
vious seventeen jears. On tlie night of October lotli,
however, I ate heartily of fried panlish, and about one
half hour after supper 1 had a flight attack of vertigo,
which was followed by a pronounced renewal of the
dreaded unsteadiness. All of this wrought upon me so
that by the middle of November I seemed to be a com-
plete nervous and physical wreck, and was obliged to
withdraw from my work. I again experienced attacks of
vertigo followed by the usual conditions ; my temperature
reached a lower point than in any of the previous attacks,
and my pulse was still slower; the action of my heart
seemed to be extremely irregular, and I could not concen-
trate my thoughts nor use my mind without experiencing
sensations of pressure upon my head and ternples and
rushes of blood to my face. My ijervous condition was
deplorable; I could hardly speak or think, and yet, curi-
ously enough, 1 never once, either then, before, or since,
sut?ered in the smallest degree irom insomnia, ror sev-
eral wrecks I lay under a most painful sensation of dread ;
I was always expecting some awful calamity to occur, and
can only describe this sensation by saying that it was such
as 1 would imagine one to experience who saw a dear
friend advance unconsciously in front of an express train
going at full speed, and was the while utterly unable to
prevent the approaching tragedy.
"About the middle of January, 1907, I began to improve,
and my progress was most surprisingly rapid until March,
when I very foolishly ate heartily of some chocolate fudge,
and next morning woke up with the vertigo. 1 was very
ill tor nearly two wrecks and suffered from my old symp-
toms. Yet it is interesting to note that while these at-
tacks of toxremia were far less severe than those I had
previously experienced, the nervous after effects were, if
possible, even more violent.
"To make a long story short, it was absolutely necessary
for me to withdraw from the presence of my church and
church work. I went to England, hoping that quiet and
change would benefit me, but the result was quite the re-
verse. I returned to America in July, 1907, and while on
the steamer again suffere-d an attack of toxaemia, less vio-
lent, quite truly, than I had had before, but accompanied
by the same distressing symptoms.
"I am not writing at all for the sake of advertisement,
but I believe that the treatment which I have undergone
has been successful in relieving me of the dreaded toxaemia
with the after effects and in rebuilding a physical condition
greatly depleted, thereby enabling the weakened and
poisoned ganglia of my sympathetic nervous system to
resume their work, which is so necessary for the main-
tenance of the human organism."
Case II : Dr. E. V. D. G., age forty-one. — "It is almost
impossible for me to state positively exactly when my
peculiar physical ailment originated. As a boy I was of a
rather stocky build, rugged and hearty. I had the usual
diseases of childhood: but, to the best of my recollection,
I had no serious disease, with the exception of a light at-
tack of pneumonia, until I was about seventeen. During
that summer I was taken ill with what the medical men in
attendance called ,a 'spell of fever.' This is not a very
definite diagnosis from a medical standpoint, but it is the
best I can give, for the reason that this is all the said
medical men told mv family. All I remember of this ill-
ness is, that I had been feeling badly for some time, and
finally had to give in. I was in bed for about a month,
and It was another month before I was out of the house.
Severe frontal headaches, acute sensitiveness to light and
noise', fevers, and delirium follow^ed by extreme and pro-
longed lassitude, are all the symptoms which I now recall,
and there are none of my family at the present writing at
hand to refresh m.y memory. I do remember, however,
that on a few occasions when I was quite a child I suffered
from what my elders called 'fainting spells.' These spells
never lasted long and. to the best of my recollection, I
never actually lost consciousness.
"I did not attain my full growth until my twenty-first
year. My height is now six feet and three inches, and I
am about as slender as I am tall. Five or six years ago I
weighed 196 stripped. Two days ago I tipped the scale
at 147- .
"While these facts may not be of any special importance,
I mention them, as it has occurred to me that perhaps my
rather rapid growth between the ages of sixteen and
twenty-one may have undermined my general physical con-
ditions particularly as, during these years, instead of con-
tinuing my Studies 1 wa> clerking in a business which re-
quired of the employees of its wholesale department much
hard physical labor and Heavy lifting.
"At the age of twenty-one, I commenced the study of
medicine. There was no provision for the feeding or lodg-
ing of the students at that time at the institution of learn-
ing which it was my privilege to attend, so that the men
w ere obliged to obtain lodgings where they could find them
and eat when and where their means would allow them.
"I had a room near the college, but I obtained my meals
at first one place and then another, frequently changing,
for as we all know, the menu of even the best boarding
house soon palls upon one, and student boarding houses
are not particularly noted for being of the highest class.
Perhaps the irregular life I led during this time had its
influence upon m}' alimentary tract.
"With these preliminary statements, I will now en-
deavor to give an account of the (to say the least J un-
pleasant attacks to which 1 have been subjected for several
years pas;, and of my present physical condition.
"It was in the spring of the > ear 1889 that my attention was
first very forcibly called to my stale of health. The spring
term of the college year had closed, and I was visiting a
relative who lived in the same city in which the college was
located. There was to be a dinner of my class or fra-
ternity. I had dressed preparatory to going to the place
of meeting, and was about leaving this relative's home
when, without warning, a peculiar feeling came over me.
I cannot accurately describe this feeling even now after the
lapse of all these years, and after having gone through
many similar attacks of greater or less severity, few of
them greater, almost all of them less. Suffice it to say that
the very first sensation is one of dread, not fear, but dread
of something. Exactly what that something is I never have
been able to discover. Quickly following this feeling is a
condition in which my brain seems to be groping around
in semidarkness in a vain endeavor to grasp some very
faintly defined thought which constantly eludes the pursuit.
My pulse becomes rapid and irregular, and my heart seems
to come up as a lump in my throat and choke me. During
this period I am conscious of what is going on around me,
although I feel weak, my hearing is dulled, my sight is
dim, and it is only by the greatest effort that I can speak,
and then my speech is thick and jumbled. My instinct is
to lie down perfectly flat, loosen all my clothing, especially
about the chest and throat. I should also say that my.
breathing is somev.hat difficult.
"Now, if I can get some stimulant at the proper moment,
right at the start, the attack will almost invariably end at
this stage, in fact it will be cut short before it is neces-
sary for me to give up and lie down. I have tried aro-
matic ammonia, whiskej', etc., but whiskey taken straight
and followed by a little water seems to do the work best.
"If I had followed the treatment which I adopted (I
might say instinctively) upon the onset of my first attack.,
that is, had I laid down, or even kept quiet for a while,
probably what occurred would not have happened. But
I was new to this sort of trouble. I was young, and I was
anxious to get to that dinner and enjoy myself: so as soon
as I felt somewhat better I left the house. My destina-
tion was some distance away. I w-as already late for my
appointment, and my natural course of action would be tc
board a car, but I did not do so, w;hy, I cannot say, ex-
cept that I did not feel quite right, and I shrank from
coming in close contact with my fellow creatures. Right
here I might say that this feeling is and always has been
present at these times. I prefer being absolutely alone to
having any strangers with me. Later on, after some mem-
bers of my family had witnessed one or more of these
attacks, I did not object to their presence so much,
although even while I was suffering I have always sympa-
thized with their feelings ("have felt for them"), for I
have realized that it must be far from pleasant, especially
for a layman to stand by at these times, to witness another
suffer, and yet he able to do so little.
"I had not walked more than two or three blocks from
the house before the premonitory symptoms returned with
greater suddenness and strength than before. Being on
the street. I could not lie or even sit down, and I soon
found my gait becoming unsteady. My feet felt heavy
.ind dragged, and I commenced to stagger markedly. I
\^-as even con<;cious of this myself, yet I could not prevent
it. Seeing a car approaching, I went out in the street to
hoard it. This is the last I remember until some hours
828
DE VRIES: PSYCHIC PHENOMESA OP INTESTINAL TOXJEMIAS. UN'eu Vork
Medical Jolrnal.
later. It seems that just as I reached the car I lurched
forward and fell, striking my head upoii the car step and
cutting a gash in my forehead. A policeman was sum-
moned, who called an ambulance, and 1 was taken to a
hospital. In some ways it was fortunate for me that 1
had received the cut, as otherwise I doubtless would have
been treated as a plain drunk, for, as I afterward learned,
the odor of whiskey was very plain upon my breath.
"It was some hours later that I came to myself, and
then it was to find several physicians and nurses standing
around my bed. I was in evening dress and there was
nothing upon my person by which to identify me. The
doctor commenced to question me, but I was still
dazed and found speech very difficult, and it was some
time before I was able to give an account of myself. By
the time I was able to do so I had recovered my strength
to some degree, and I was put in a carriage and sent home.
The family were naturally very much frightened ; a physi-
cian was sent for at once, who gave me some sedative and
left. The next day he and two others examined 'and
questioned me, held a consultation, and decided that it
was a case of brain fag from overwork, and advised that
I should get out in the wild and live an open air life for
some months. Accordingly, I was sent into the mountains
of the south, where just at this time an attempt was being
made to open up some of the iron and manganese mines
w hich had been shut down since the civil w ar. In this region
I remained for about fifteen months, living a rugged out of
door life — in short, roughing it. During this time I grew
hearty and apparently well, and yet at intervals of varying
lengths I would suffer from these peculiar attacks, but not
nearly so frequently the latter part of the time as at first.
■'This brings me to the autumn of 1890, at which time I
returned north and again resumed my studies, being grad-
uated in the class of '92.
"Winning my appointment on the house stafT of a cer-
tain hospital, I served my term and started on the active
practice of my profession. To me it seemed a rather
strange fact that although during my last two years of col-
lege I suflfered from several severe attacks, during the eigh-
teen months of my hospital service I had only a few attacks,
and none of these severe. Not once were my duties inter-
fered with, and yet, as we all know, the life of a house
physician or surgeon is neither an easy nor a regular one.
Nor, for a while after I started in private practice was I
much troubled, but as my work and responsibilities in-
creased, especially the night work, I found that the curse
of my life was again being visited upon me, and the at-
tacks grew more frequent and more severe.
■'In May, 1903, I suffered a serious accident, being run
over by a cab and rendered unconscious. I was home
five weeks, the first three of which are a total blank. My
nights were the worst part of the twenty-four hours, as
then I was particularly restless and irritable. I had re-
ceived a blow on my head and the fifth and si.xth ribs on
my left side were fractured; I was a year getting well,
and during this time I was out of the city at a summer re-
sort, and did not even have the slightest suggestion of an
attack, and the following winter but few, and these of a
mild clipracter, but shortly after again taking up practice
their frequency and severity increased, and I became more
and more nervous, my appetite become poorer and poorer,
and my digestion even worse, with much flatulency. I
have never been a great sleeper, but insomnia became a
very marked symptom, and I would go for weeks with not
more than from three to five hours' sleep at night and very
frequently would pass the night with none at all. I found
it difficult to concentrate my mind, and seemed to be un-
able to grasp the meaning of what I read. My memory
became so poor that often I could not even recall events
of importance aftei*the lapse of a short period of time.
■'Being unconscious during an attack, I cannot describe
the symptoms and my actions during one, except that I fre-
quently vomit a great deal of bile and afterwards pass much
more from the bowels. An intensely severe headache in-
variably follows and lasts hours and sometimes days. Pain
in the abdomen, especially in the gastrohepatic region, is
another symptom always present, and the abdominal
muscles become rigid. If there has been a convulsion all
the voluntary muscles are lame and sore afterward, and
my right hand is found placed over the liver."
What cau.scs the awful depression, the dread, fear?
is it tlie undigested food that rcm?iins in the intes-
tinal canal, is it the toxines produced thereby, or is
it the lack or entire absence of peristalsis? I have
seen cases with perfect peristalsis and normal bowel
movements, and yet these same morbid symptoms
persist.
Take the suicide statistics. They either kill them-
selves because of financial reverses, broken hearts,
or other causes; yet the physician in attendance, it
questioned, will say that almost the last symptom or
the patient was constipation or indigestion.
I must now call your attention to a case in point ;
the main symptom in his history was chronic con-
stipation and indigestion. He said that he had not
had a normal bowel movement in twenty years,
thought he never would get well, had delusions, was
inordinately depressed, in constant fear of a twisted
gut, and thought the best way out of his misery was
suicide. It seemed his one thought.
Another case is that of a prominent lawyer of
Rochester, who was rapidly going insane, as he
termed it, because his bowels would not move, be-
cause he could not digest his food, because his in-
testines were dilated with gas during the night, and
at this time his morbidity was much increased. He
passed out of my hands, and has since made away
with himself.
Another case, the wife of a former State treasurer
of Pennsylvania, who, when her digestion was per-
fect and her bowels regular, coinplained of nothing,
notwithstanding the fact that she had Bright's dis-
ease and arteriosclerosis, and yet when she becaine
constipated in the slightest degree, or when any part
of her meal did not agree with her, her depression
was absolute, suicide being her only topic of conver-
sation.
The great indication in the treatment of this awful
condition is to remove -the cause.
Nervous anorexia, or a complete absence of the
sensation of hunger, associated with loss of appe-
tite, is a very difficult condition to combat. This
symptom of neurosis usually follows some great de-
pression, family troubles, or some other cause. The
onset of the symptoms is gradual, the patient first
discarding the heavier articles of food ; later almost
every form is refused. The diagnosis is not difficult
if one sees the patient at the very commencement of
the disturbance. On the other hand, if you see the
patient after emaciation has become marked and no
history can be obtained, diagnosis is obscure. It
may resemble tuberculosis, and the symptoms, no
appetite, anaemia, pallor, asthenia, may also resem-
ble cancer. However, loss of appetite from organic
disease of the stomach, whether due to catarrh or
cancer, is almost always accompanied by fear and
dread. In nervous anorexia the patient seems to be
totally indifferent to this as well as other changes in
his environment. In this condition food should be
given at frequent intervals and should be varied.
Some one of the bitter tonics given a half hour be-
fore meals is helpful. Later, after emaciation has
resulted and the condition is chronic, residence at a
health resort for several weeks is necessary. Depres-
sion of spirits is very marked. The high frequency
current, and occasional forced feeding and hydro-
therapy consisting of a salt rub. a needle bath,
C harcot douche, an electrothermal bath, with an oc-
casional massage, usually effects a cure in these
cases.
May 1908. J STEIX: RAPID PARAFFIX IMBEDDING. 829
The term neurasthenia gastrica. or nervous dys-
pepsia, impHes those vague, incompletely defined dis-
turbances which occur during the digestive act. The
patients show no demonstrable change in the stom-
ach. Many and varied clinical symptoms with no
organic lesions are present in this disease. This un-
balanced state may follow debilitating or chronic dis-
eases, sexual excesses, abnormal conditions of the
genitourinary organs, great and sudden nervous
shocks and breakdowns.
The patient experiences discomfort after food, a
sensation of fullness, slight burning, belching, drow-
siness, and fullness in the forehead. These symp-
toms often continue through the period of digestion
and are followed by sensations of dizziness and
weakness. In many cases the patient will be un-
comfortable at all times, whether the stomach is
empty or full. The intestines are not free from ap-
parent disturbance. The patient says that he feels
that his abdomen is filled with gas, and he is usually
constipated. Nutrition may become involved, and
the patient loses weight. \\'e are not justified in
diagnosticating nervous dyspepsia if we find food in
the stomach six hours after a dinner consisting of
mixed foods. The absence of blood is a strong point
favoring the existence of nervous dyspepsia.
Pain usuall}' disappears on pressure when due to
nervous dyspepsia, and is increased if due to ulcer.
If nervous dyspepsia is associated with neurasthenia
we find typical tender spots.
Where the diagnosis, is not certain, the patient
should be subjected to the rest cure, as the best re-
sults are brought about by this course. Cold baths,
shower baths, and occasionally a hot brine sponge
and the vibrator are very efficient.
Ichthyol in divided doses to be continued for an
indefinite period, or ichthalbin (ichthyol albuminate)
in combination with one of the valerianates is one of
the best mediums for the absolute relief of the neu-
rasthenic type of intestinal derangement.
How many of these cases report that they are feel-
ing fine, that their bowel evacuation was abnormally
large and satisfactory, and that the relief they ex-
perienced was perfect, and then within twenty-four
hours they experienced a return of all the old symp-
toms. Does not the toxjemia stimulate before it
prostrates? I have found this to be the case in
many patients. I have also found a very rapid pulse
in one attack and a slow pulse in another in the same
patient, all due to a variation in gas pressure on the
pneumogastric nerve.
1 96 Lexox AvExui:.
WHO ORIGINATED THE METHOD OF RAPID
•PARAFFIX IMBEDDING? A REPLY
TO DR. POND.
By Arthur Stein, M. D.,
New York.
On November 16, 1907. there appeared in this
journal among the original articles one by A. Pond
entitled Improved Rapid Method of Imbedding
Histopathological Specimens in Paraffin. Dr.
Pond describes a method by means of which it is
possible to make paraffin sections of fresh patho-
logical specimens in one and a half hours. As he
mentions no literature on the subject it would ap-
pear he was the originator of the method. Even
if he developed it independently of those who
worked along these lines, it would have been no
more than just to refer to their publications, espe-
cially as these date back several years. The latter
fact in itself goes to show that the method de-
scribed by Pond is not a "new or improved one."
Moreover, it would have been an easy matter to
obtain information of this kind in Schmorl's' book,
which is universallv acknowledged as one of the
best on the subject.
As I have been using the rapid method of pre-
paring paraffin sections for several years. I take the
liberty of summarizing what I wrote concerning
it in 1903.' At that time I stated that I had been
using the method for one and a half years and that
I followed the verbal directions of my teacher,
Lubarsch :
The fresh specimen is hrst fixed in a 10 per cent, for-
malin sokition for about five minutes, when it is put into
Q5 per cent, alcohol for another five minutes, and then trans-
ferred to absohite alcohol in which it remains ten minutes,
the a'bsolute alcohol being renewed once. After having
been in absolute alcohol it is immersed in perfectly clear
aniline oil until it has become entirely transparent, a process
taking on an average from fifteen to twenty minutes. From
the oil the specimen is brought into xylol, in which it re-
mams until the xylol no longer becomes discolored yellow
(this takes about fifteen minutes if the specimen is small).
Finally it is placed in melted paraffin for from ten to thirty
minutes at a temperature of from 58° C. to 60' C. I
wish to emphasize especially that the vessels containing
the various fluids arc kept in the incubator. In this zcay
the specimen is impregnated much more rapidly than if the
fluids Zi'cre kept at room temperature.
To recapitulate. Lubarsch's method of rapid
hardening and rapid imbedding ( under which
name I described it. and by which name it has since
been referred to in medical literature) consists of
the following steps: i. 10 per cent, formalin for
about five minutes : 2, 95 per cent, alcohol for
about five minutes; 3. absolute alcohol (renewed
once), ten minutes: 4, aniline oil until the specimen
is entirely transparent, fifteen to twenty minutes;
this is to be done in an incubator at 122° F. to
125.6° P.; 5, Xylol, changed two or three times,
about fifteen minutes ; 6. melted paraffin, from ten
to thirty minutes, depending upon the thickness of
the specimen. All this is to be done in an incubator
at 136.4° F. to 140° F. :
One can readily see that the entire process takes no
longer than one and a quarter or one and a half hours,
which is less time than Gutman's method (Schmorl's) re-
quires. Of course, it is only suitable for pieces of tissue
from one to three millimetres thick (Schmorl). thus being
especially adopted for curettings. Nevertheless, tissue from
any organ, as already pointed out by Gutman, can be thus
imbedded provided the piece has the required thinness.
.As regards the durability of the specimens pre-
pared in this way, I can confirm, after several
years' more experience, what I stated in 1903. after
a trial of only one and a half vears. Thev are
durable and in no way inferior to those prepared
by the slow imbedding process. My own experi-
'DiV patliologisch-histologischen V ntersucliungsmethoden , Leip-
zig. 1905.
-A. Stein. Ueber Schnellhartung und Schnelleinbettung. Deutsche
mcdizinische Wochenschrift, No. 44, 1903.
830
DRENNAN: CALCIUM SALTS AND DENTAL DISEASE.
[New York
Medical Journal.
ences have been similar to Schmorl's, who says
{he. cit., page 58) :
If we arc in a great hurry to examine pathological
specimens, i. e., in cases in which tissue is removed for
diagnostic purposes, we can use the method of rapid hard-
ening and imbedding, first suggested by Lubarsch, to great
advantage. Tt has recently been recommended by various
pathologists and has given excellent results in my own
experience.
Let me now quote from Pond's article':
The chief objection heretofore advanced against the use
of paraffin as imbedding material was the length of time
required to properly harden, dehydrate, and clear the tissue
in preparation for the impregnation of paraffin, this process
usually requiring from thirty-.six to seventy-two hours.
Then follow.s "Pond's method": i, 10 per cent,
formalin, five to fifteen minutes : 2, 95 per cent,
alcohol, five to fifteen minutes ; 3, absolute alco-
hol, not less than ten minutes, and no longer
than twent\' minutes ; 4, aniline oil, ten to twenty-
five minutes ; all four proceedings to be done in in-
cubator at 122° F. : 5. Xylol, fifteen minutes,
changed three times; 6, paraffin, ten to thirty inin-
utes, in incubator at 140° F.
On comparmg this "improved method" with
Lubarsch's, pubHshed by me in 1903, we cannot
help but notice a striking similarity not only as re-
gards the order of the separate fluids used, but
also with respect to the time which the specimen
has to remain in each fluid. With what wonder-
ful accuracy the directions of both correspond !
Pond's paper certainly invites one of two criticisins,
it either shows a deplorable ignorance of medical
literature or it represents an intentional plagiarism.
.-\ny one interested • in the different methods of
rapid hardening and imbedding may consult the
writings of Lubarsch''" and Pick, as well as a more
recent publication by Henke and Zeller."
I have already referred to Schmorl's opinion,
which practically confirms Lubarsch's favorable
experiences. As far back as 1903 the latter said:
"I can assure you that the specimens prepared in 1889,
when I first came to definite conclusions as regards my
rapid method, have undergone no change. After using
both the rapid and slow method of imbedding for almost
fourteen years J cannot detect the slightest difference as
regards stain or durability in the sections prepared by the
two methods."
I have been told that Weigert himself used
Lubarsch's niethofl frequently and successfullx .
This in itself is sufificient reason to recommend it
to Americans. It is especially adopted for patho-
logical laboratories where many specimens have to
be examined and where it is important not only to
make a rapid microscopical diagnosis, but also to
obtain durable sections.
My sole object in writing the foregoing has been
to set forth the truth and to give the credit to
whom it belongs, namely, to LubarscJi.
36 W'kst Fiftv-nixth Street.
'.\Va' York Medical Journal, November i6, 1907.
<l'i-b'.r nicine .Sclinellhartungv unri .Sclinellcinhfttiingsnn.tlio<l'j.
Deutsche ii-edhiitische Wochcn.<:chr{ft, 1903, p. 896.
"I.ubarsch iiml O.stcrtag: Ergchiti.ise der altgentciiieii Pathologic.
etc., 1805. part ii. p. 14.
•.\ccton Paraffin .Scliii-.llcinbcttung. Centralhlalt fiir allgcmeiiie
Palholo^ic, xvi, 1905.
THE ABSTRACTION OF CALCIUM SALTS FROM
THE MOTHER'S BLOOD BY THE FCETUS.
A Cause of Dental Disease in the Former.
By Jennie G. Drennan, M. D., C. M.,
St. Thomas, Ont., Can.
In an article published in the New York Medical
Journal of September 28, 1901, I stated that the
abstraction of calcium salts from the mother's blood
by the foetus would be a cause of osteomalacia in
the former, provided that the diet was poor in such
salts, as it would be among the ill fed mothers of
the peasant and slum classes ; for osteomalacia is a
disease the result of a poverty of calcium salts in
the blood of the mother, by which her osseous tis-
sues are deprived of this calcifying element. If her
diet had been rich in these salts there would be a
sufficiency for bofh mother and foetus. At the pres-
ent day, ainong the better class of patients, one finds
a condition analogous to osteoinalacia, only on a
lesser scale and affecting a tissue which may be arti-
ficially replaced by the dentist, viz., the noncalcifica-
tion or soft condition of the tooth, leading to caries
of the dentin and enamel and also to destruction of
the pulp. The foetus requiring calcium salts for the
development of its own osseous tissues, abstracts
from its mother's blood all the available calcium
salts — parasites usually fare better than their hosts
— and this leaves none or very little of this material
for the mother's organism to replace the wear and
tear in her osseous structures, the teeth being one
of the first to suffer, probably partly on account of
their position, where other deleterious factors are
at work — fermentation and putrefaction of parti-
cles of food, the presence of secretions which con-
tain germs, and the acid vomit from the stomach
coming in contact with them.
If the mother's diet was rich in calcium salts
there would be sufficient of this material for both
her child and herself ; but, as is too often the case,
her appetite is extremely capricious, and she does
not eat that which she should. At the present day.
with life in an apartment and its attending lessened
labor, the woman has not the same hearty appetite
as liad the woman of the forest or the plain ; food
is not so rich in calcium salts, for much of our prc-
jiared vegetable food — cereals — is adulterated, or.
at best, so refined as to have removed from it that
which is most necessary to the human organism.
Durim; [jregnancy and lactation the mother's food
slinuld be richer in calcium salts than at any other
time, because she is then to supply such salts to
two f)rganism,s — herself and her foetus or infant,
the latter being greedy for such material.
.\ certain degree of softening or noncalcification
in some of the mother's bones at the time of deliv-
ery is rather advantageous in aiding in the easy
delivery of the foetus, but faulty calcification of
tooth tissue is of no benefit; then, also, a certain
degree of noncalcification of bone tissue favors the
greater production of blood cells in the marrow of
bone, for unstable osseous cells readily break down
and are converted into blood cells. This to a cer-
tain extent is perfectly physiological, but becomes
pathological whcti the mother's osseous structures
May 2, 1908 ]
DUKEMAK: REMOVAL OE GRAVID UTERUS.
831
.-uft'er and become incapable of maintaining her in
a condition of health. Pregnancy is tending to be-
come a pathological condition.
Caries of the teeth of the mother is due to the
fact that they are deprived of their normal amount
of calcium salts by the foetus. The calcifica-
tion of tooth tissue should be normal, but it is
not so if the mother's blood is not rich in calcium
salts, for the foetus will have its share by depriving
the mother; this is then a pathological noncalcifica-
tion. In the dentine and enamel, as in all other
osseous structures, there is constant wear and tear,
which must be replaced, and for this replacement
calcium salts are needful. By a poor supply of this
material the dentine and enamel will lack their
normal degree of firmness, and will, in their state
of faulty calcification, be easily acted upon by the
secretions, fermented and putrefied food, acid diet
(of which pregnant women are so fond), and acid
vomit. Hard enamel protects the dentine, soft does
not. This decay oftener commences from within
the tooth — tooth tissue is formed from within out.
If the new cells formed in the interior of the tooth
for the replacement of worn out cells lack sufficient
calcium they break down easily and also tend to
approach a lower type of animal cell, one which
multiplies and dies more easily and forms putres-
cent dead matter in the tooth cavity ; this causes
pain and decay of contiguous tissue — dentin and
enamel.
Such a condition may be averted by giving the
pregnant woman a diet rich in calcium salts and
also b\- admrnistering to her these same salts in the
form of medicine — to-day pregnancy tends to patho-
logical conditions. The fruit diet fad for preg-
nancy has its drawbacks in that it produces soft
bones for mother and child, and the teeth being
really appendages, are the first osseous structures to
sufifer. Children produced on such a diet are prone
to late ertiption of their teeth and to walk late in
infancy. I have just such a case in my mind of a
child, seventeen months of age, who has only four
teeth and has just walked : otherwise apparently
healthy. The mother has poor osseous and muscular
development, and lives principally upon a fruit and
vegetable diet, not being fond of milk. A mixed
diet is necessary for human beings, for they are of
the omnivora; from this diet the mother prepares
nutriment for the foetus during pregnancy and the
infant during lactation. Milk and eggs are both
animal products and are rich in osseous forming-
elements.
Carelessness in the toilet of the mouth, along
with the other factors already mentioned, tends to
destroy the teeth, but the primary cause is the lack
of available calcium salts for her osseous tissties.
Dr. Branth, of New York, in the Xczc York
Medical Journal of August 10, 1901, wrote an
article entitled Cleft Palate and Its Association with
Harelip, in which he mentioned the fact that lion-
esses fed on flesh containing bones too large for
mastication, gave birth to offspring with cleft pal-
ates; but. he added, lack of a meat diet and insuffi-
cient calcium phosphate in the human mother's case
would not cause the same result in her offspring,
as the foetus would draw upon her tissues for its
calcium salts if there were not a sufficiency by
ingestion. From this statement the question oc-
curred to me — may not this very abstraction from
the mother's tissues be the cause of osteomalacia in
her? But the question to be first settled is, does
the foetus abstract calcium salts from her tissues,
or does it do so from her blood and thus appro-
priate what by rights should go to nourish her
osseous structures? This seems to me to be the
correct view.
HYSTERECTOMY OF A FIVE MONTH GRAVID
UTERUS FOR CARCINOMA UTERI.
RECOVERY.
By Willi.^m H. Dukeman, M. D.,
Los Angeles, Cal.
On March 26, 1907, I was consulted by Mrs. \V. H. L.,
of Yuma, Arizona, age thirty years, and a native of Peru,
South America.
She was a lean, wiry person, five feet in height, and
weighed ninety pounds. Her general appearance was one
of frailty, very ansemic, and of an e.xceedingly nervous
temperament. She was the mother of one child, a daughter
eleven years old, by her first husband. She had been married
to her present husband less than six months. Her men-
struation was regular up to five months ago, when she
missed for three months. For the past two months she has
noticed at frequent intervals, a menstrual discharge of a
darker color than formerly, and at times of a foul odor.
She complained of a dull burning pain in the vagina which
caused her to grow \ery nervous and restless, causing much
insomnia. Her appetite, however, was good, digestion nor-
mal, tongue clean, and bowels regular. Pulse 104, tem-
perature 99.5°, respirations 20. Her family history was
good, and her mother, a healthy Irish lady, aged sixty years,
accompanied her. Patient had been engaged as a concert
singer every night up to midnight or later for past several
years.
E.xaininaticn revealed the following condition : The ab-
domen presented the appearance of a pregnant woman at
about the sixth month. The foetus, however, could not be
distinctly outlined, and there were no fcetal movements
nor heart sounds perceptible. On bimanual examination
with fingers in the vagina, the cervix felt like one very ex-
tensively lacerated transversely, deeply excavated with a
cauliflower like surface, and bled very readily. The uterus
was enlarged, as noted before, quite fully movable, except
on the left where it was attached to a solid mass about the
size of an orange. The speculum was then inserted into
the vagina and the cervix presented the appearance as I
have described it.
Diagnosis: Carcinoma of a gravid uterus containing
dead ftetus of about five months growth, and a tumor in
left side of the pelvic cavity, in all probability an extension
iif the carcinomatous condition.
I advised operation by abdominal section and a removal
of the whole mass if possible, as the only chance to pro-
long life. The gravity of the case was presented to her
and family in every detail as to her chances of recovery
as well as to the seriou'^ness of so extensive an operation in
her present condition. The patient was very anxious to
recover so that she could resume her concert singing, and
she, as well as her family, were veVy desirous and anxious
that I proceed with the operation at the earliest possible
time. I assented to do so provided counsel were called
and my diagnosis confirmed. I then called in Dr. H. W.
Howard, who examined the case and confirmed my diag-
nosis. The vital organs were in good condition, and ex-
amination of the urine showed it to be practically normal.
The patient was sent to the Pacific Hospital and put in
the best possible condition for operation. She was very
anxious to ha\e the operation over with, asserting her
every confidence that she would recover. Four days later,
on the morning of March 30th, I operated upon her. Dr.
Howard and Dr. Godin assisting. An incision was made
from the umbilicus to the pubes, and on opening the abdo-
men, the pregnant uterus presented, and the foetus could
then be outlined, but no signs of life were discernible.
I did a total hysterectomy as speedily as possible without
832
SPENCE: ANGULATION OF SIGMOID.
[New York
Medical Journal.
encountering any great difficulty or mishap, and found
that the tumor in the left pelvic cavity was entirely separate
and not adherent to the uterus as supposed. After the
gravid uterus was removed in its entirety, I decided to
remove the tumor. It seemed to fill the deep posterior cavity
or hollow of the sacrum, apparently solid and immovable.
Dr. Howard suggested that I better not attempt to remove
it owing to its critical location, but I felt that the opera-
tion was not complete unless at least a very decided at-
tempt should be made before concluding the operation.
By carefully breaking up adhesions by blunt dissection
with my fingers I soon succeeded in loosening up the mass
sufficiently to get my left hand well under it, when my fore-
finger of a sudden slipped into a spongylike cavity and
about half a pint of creamy, cheesylike substance was com-
pressed out. The greater part of it found its way out
through the vaginal opening made by the hysterectomy.
The iliac and sacral glands were so extensively involved
that any further endeavors would have been fatal to the
patient. The parts were thoroughly cleansed and the cavity
packed with gauze, and drain carried down through the
vagina.
The operation was then concluded in the usual manner by
suturing the raw edges of the peritonaeum from side to
side, covering in all raw surfaces, the abdominal cavity
thereby being completely closed, leaving the glandular
cavity to drain through the vagina. The abdominal wound
was closed in the usual manner in layers. The patient was
under the anaesthetic two hours, but left the table in re-
markably good condition. She came out of the anaesthetic
with little or no shock and without any vomiting.
The foetus in the meantime had been extracted from the
uterus and it had apparently been dead for some days. It
was well nourished and in the sixth month development.
A section of the cervix as well as a specimen of the
broken down mass was sent to the pathologist who later re-
ported : Carcinoma of the cervix and broken down epi-
thelium of the large cell variety, showing the involvement
of the deep iliac and sacral lymph glands.
The patient at the first did exceedingly well. The ab-
dominal wound healed by immediate union, and the stitches
were removed on the twelfth day. The vaginal drainage
was quite profuse during this time. The patient continued
to have a good appetite and good digestion, but seemed to
be growing extremely nervous, when in the third week
she showed symptoms of derangement of her mind. She
became very talkative and insisted on getting up. She got
little or no sleep, and required constant watching day and
night up to the end of the fourth week, when her mental
derangement abated. Her appetite and digestion during
this time continued good ; secretion of urine was normal,
but bowels were loose; pulse varied from 130 to 100; tem-
perature 100° F. to normal iip to this time; and she was
entirely free from pain.
From this on she made a steady gain. She left the hos-
pital at the end of the fifth week and was removed to the
home of a friend. She continued to grow stronger, and by
the end of the sixth week she was up and around and her
mental faculties again normal. At the end of two months
she was allowed to go to the beach at Ocean Park, where,
with her little daughter and her attendant, she was en-
joying herself and in better health than she had been for
many months. '
The vaginal opening in the meantime had almost closed,
leaving a very small fistulous opening from which there was
an occasional slight bloody discharge. Fi\c months after
the operation, while lying in the sand on the beach, she had
a slight lijemorrhage from ihe vagina. She was taken to
her cottage, where it immediately stopped. Examination
revealed nothing but "a small fistulous opening leading
to the site of the tumor. Next day she was allowed to be
up and around again. One week later she was attacked
with a severe coughing paroxysm followed by a profuse
haemorrhage of the lungs, and succumbed in about one hour.
The drama of this case may be conci.«ely stated
as follows : Preg^nancy in a malignant uterus ; death
of foetus at five months ; operation, hysterectomy :
mental derangement for three weeks ; recovery,
great happiness and enjoyment of life for three
months : at the end of five months, pulinonarv
hjemurrhage, death.
410 Gr.nnt Ruilding.
ANGULATION OF THE SIGMOID.
By Thomas Bray Spence, M. D.,
Brooklyn, N. Y.,
Surgeon in Chief to the Methodist Episcopal Hospital.
Angulation of the sigmoid fle.xure, causing in-
testinal obstruction, partial or complete, has been
described by Dr. Delatour (Annals of Surgery,
November, 1905) and by Dr. Loroque (Annals of
Surgery, November, 1906). In an earlier paper
Dr. Ries (Annals of Surgery, October, 1904) re-
ported a case as volvulus of the sigmoid that, ac-
cording to his description, may possibly have been
the same as these later cases, some of which were
proved to be angulation, and his observations on
mesosigmoiditis throw some light on the aetiology
of the condition. So little has been written on the
subject that it seems justifiable and desirable to re-
port any additional cases and to remind the pro-
fession of the existence of a remediable condition
which is sometimes very distressing and sometimes
exceedingly dangerous.
Strictly speaking, the case which is here reported
does not correspond exactly with the condition de-
scribed by Dr. Delatour, but it was so manifestly
an angulation of the sigmoid that it will be neces-
sary to make his definition a little inore inclusive.
He says: '"By angulation at the sigmoid, we mean
that the intestine is so bent upon itself, at either the
upper or lower end of the sigmoid, that complete
or partial obstruction to the passage of the faecal
current is established." In my case the sigmoid
was bent upon itself at the middle of the loop, and
in this way three abnormal angles were made.
Angulation is therefore not confined to "either the
upper or lower end of the sigmoid," and there
seems to be no good reason for creating a new class
for angulation between these two points.
Case. — My patient was a man, thirty-nine years of age,
a policeman by occupation. He was well until two years
ago, when he began to have pain in his left side, at the
location of the 'descending colon. This pain was sometimes
intense, at other times it was a dull ache. At the begin-
ning of the trouble his bowels became constipated and con-
tinued so ; his faeces were either scybalous or fluid, never
normal in character, and the pain was more severe when
the constipation was most marked. There was a loss of
weight of twenty pounds during the first year, and very
little after that.
One year ago the patient was operated upon in a hospital
in New York for a suspected cancer of the bowel, but was
told that nothing abnormal had been found. He naturally
experienced no relief from the operation and continued
with precisely the same symptoms as before. At a later
date he was treated in the medical ward of the hospital,
and the question of a renal calculus was thoroughly investi-
gated, but uranalysis and the x ray failed to corroborate
a suspicion of stone.
The man was sent to me by Dr. Webster, who en-
countered him in his duties of police surgeon. After watch-
ing him for two weeks I agreed to perform an operation,
for it seemed certain there must be some condition causing
a partial obstruction of the intestine. .As the pathological
condition must have existed at the time of the first opera-
tion we felt that we could rule out tumors of any kind and
bands of adhesions caused by the operation. We both
had known of Dr. Delatour's cases, and angulation of the
sigmoid seemed to us the most probable cause of the trouble,
as well as the condition most likely to have been over-
looked by the surgeon at the time of the first operation.
A ventral hernia was present at the site of the original
operation, and it was found that pressure on the descend-
ing colon elicited the typical pain which had been com-
plained of for so long a time.
The incision included the .scar of the former operation,
and many adhesions were found in the left side of the ab-
May 2. 1908.]
OUR READERS' DISCUSSIONS.
833
domen. An angulation of the sigmoid, as described before,
was found, and a thorough search revealed no other lesions.
The loop of the sigmoid formed by the angulation was held
firmly by adhesions, and, even after the adhesions were
torn loose, the sigmoid immediately fell back into its faulty
position when it was dropped into the abdomen. Because
of the difficulty in overcoming the angulation, and because
of the possibility of further trouble from the numerous
dense adhesions along the course of the descending colon,
it was deemed wise to cut out the colon by a short circuit
between the small intestine and the sigmoid. An anasto-
mosis was accordingly done, connecting the lower limb of
the sigmoid to the ileum at a point about twelve inches
from the ileoc^ecal junction. Two rows of sutures were
inserted, the inner one being a through and through stitch.
'I he hernia was repaired by imbricating the layers of the
abdominal wall.
On the eighth day after operation the patient vomited
a small amount of blood and on the ninth day a much
larger quantity. On the tenth day a small enema brought
away a large amount of black faecal matter. The loss of
blood from the stomach and bowel affected the patient
markedly, but he soon reacted and was able to sit up on
the nineteenth day.
There has not been any of the old pain since the opera-
tion, and at the end of four months there is a complete re-
turn of health and strength.
The happy result in this case seems to justify
the operative procedure adopted, though it has
probably not been done for this condition before.
Loroque divided a short mesosigmoid for angula-
tion, and relieved the obstruction, but this seems to
me a procedure not wholly without risk to the in-
tegrity of the intestinal wall, because of the dimin-
ished blood supply. Delatour successfully treated
■some of his patients by fixing the sigmoid to the
abdominal wall, and that is without doubt the op-
eration best, adapted to angulation at the upper or
lower end of the sigmoid, but it would not have
been effective in the case here reported. ' An anas-
tomosis between the upper and lower limbs of the
sigmoid would probably have answered the pur-
pose, but the presence of so many adhesions along
the course of the descending colon determined the
operator in favor of a commimication between the
ileum and the lower part of the sigmoid.
139 Seventh Avenue.
Physicians in Politics.— Referring to a State
convention in Ohio of one of the leading parties,
to which one hundred and five physicians went as
•delegates, the Jotirnal of the American Medical
Association remarks editorially: If better condi-
tions are to be obtained in mttnicipal and State
government, it must be through an appreciation
of the fact that the proper work of govern-
ment is administration and not exploitation of
the public. With this in view, there is no reason
why the physician should not prove as good an ad-
ministrator as his brother the lawyer, to whom the
lion's, share of political duties and opportunities has
been awarded in the past. Three fourths of the
work of the average legislative body to-day has to
<lo with questions of administration. There is noth-
ing in the personality, training, or experience of the
successful physician that would render him less
effective in dealing with administrative problems
than the lawyer or the business man ; neither is there
any reason why a physician should not demand and
exercise his full rights as a citizen, especially since
he is far better fitted by education and experience
for dealing adequately with many of the problems
of modern legislation than is the average lawyer.
(But ^eabers' fistussions.
A SERIES OF PRIZE ESSAYS.
Questions for discussion in this department are an^
nounced at frequent intervals. So far they have been
decided upon, the further questions are as follows:
LXXIII. How do you treat seasickness? (Closed April
IS, 1908.)
LXXIV. How do you treat sunstroke? {Answers due
not later than May 15, 1908.)
LXXV. How do you treat cholera infantum? {An-
swers due not later than June 15, igo8.)
Whoever answers one of these questions in the manner
most satisfactory to the editors and their advisors will
receive a prize of $25. No importance whatever will be at-
tached to literary style, but the azvard will be based solely
on the value of the substance of the ansiver. It is requested
(but not required) that the ansivers be short; if practica-
ble, no one answer to contain more than six hundred
words.
All persons will be entitled to compete for the prize,
whether subscribers or not. This prize will not be awarded
to any one person more than once within one year. Every
answer must be accompanied by the writer's full name and
address, both of zvhich we must be at liberty to publish.
All papers contributed become the property of the Journal.
The prize of $25 for the best essay submitted in answer
to question LXXII has been awarded to Dr. J. Russell
Verbrvckc . of New York, ivhose article appeared on
page 788.
PRIZE QUESTION NO. LXXII.
THE TREATMENT OF FRACTURE OF THE
PATELLA.
{Continued from page 792.)
Dr. L. F. Barrier, of Louisville , Ky., observes:
The treatment of fractured patella may be con-
veniently described under two headings, viz. : Non-
operative and operative, each having distinct advan-
tages in selected cases.
When the fragments are easily replaced and sur-
roundings are such as to render technique question-
able, I prefer the nonoperative method, and treat
them after the following manner: If I see the case
before there is marked transudate into the joint I
seek to limit this transfusion by an elastic bandage
and cold packs. The rubber bandage may be used
for this, or dry sea sponges can be bound tightly
upon the knee while dry, and then the sponges are
wet with cold water. The swelling of the sponges
keeps an even pressure and limits transudation, and
at the same time applies the cold. This method is
also useful to promote absorption if transudation has
occurred. In cases with extreme transudation the
joint should be aspirated carefully.
xA.fter the swelling and fluid have been made to sub-
side, the permanent dressing is put on. The knee
is fully extended with a posterior splint and the
thigh moderately flexed to relax the quadriceps ex-
tensor tendon. The fragments are now accurately
adjusted and held firmly while the assistant tightly
adjusts two inch strips of adhesive plaster by fasten-
ing the middle above the upper fragment and then
attaches the ends spirally around to the calf of the
leg. Another is attached in the same manner be-
low the lower fragment and pulled upward, to be
attached spirally to the posterior aspect of the
thigh. After sufficient number of these strips have
been firmly applied, a strip of plaster is well fastened
over the top of the patella, so that tilting of the
fragments cannot take place.
834
OUR READERS' DISCUSSIONS.
[New York
Medical Journal.
The splint is held in place by straps so as to al-
low the limb to be exposed for massage twice or
three times daily for ten or fifteen minutes for the
first few weeks. At the end of three or four weeks
passive motion is begun. This must be very limited
at first and not sufficient to separate the fragments,
but just enough to prevent adhesions to the joint
surface. The range of motion must be very grad-
ually increased for several weeks, during which time
the patient should be up on crutches with the limb
encased in a plaster cast, which may be spHt and
sprung ot¥ for passive motion, or in some form of
splint that will permit easy removal.
At the end of eight or ten weeks the splint should
be removed and the limb well bandaged, and the
patient allowed to walk with a cane, but stair climb-
ing or any sort of lifting must be avoided for sev-
eral months.
This method gives good functional results in a
large percentage of cases, but it requires much
longer time for recovery than does the operative
method.
The operative method is always to be preferred
when surroundings are so that ideal technique can
be had. The great danger lies in infecting the large
serous sac of the knee joint.
In none save compound fractures should operative
procedures be instituted until the acute reaction has
been made to subside. Then with the most rigid
asepsis the joint should be opened and washed free
of blood clots with warm saline. The patella frag-
ments are pulled together by hooks and the peri-
osteal fringe removed from between them, and
sutures of chromic catgut introduced through the
fascia and tendinous structures and the periosteum,
and rarely through holes drilled in the bone, so as to
coapt the broken surfaces nicely. The method of
placing the sutures will, of course, depend upon the
line of fracture and the number of fragments. If
the bone is fractured into several pieces the frag-
ments can iisually be held best by encircling the en-
tire bone with the catgut.
The wound is now closed with catgut and the
limb put upon a posterior splint. It is also well to
put an adhesive plaster dressing on like the one de-
scribed above, so the fragments cannot be accidental-
ly torn apart.
Massage must be kept up, and at the end of two or
three weeks gentle passive motion instituted, and the
patient is allowed to be up on crutches with a light
splint.
If the fracture is compound the joint must be well
irrigated with i to 10,000 bichloride of mercury so-
lution, followed by saline. The small, ill fitting
fragments are removed and the others sutured in,
place and the joint drained for a time.
Occasionally the patella is so badly comminuted
by direct force that it is better to remove it entirely
than to attempt to unite the pieces. In a case of this
kind the fascia is saved so far as possible and a
tendinous flap made from a part of the tendon of
the quadriceps, which is turned down and sutured
to the ligamentum patella, and the fascia preserved
after removal of the bone.
In these cases it is well to surround this length-
ened tendon by fatty tissue, so as to form a sheath
as free from adhesions as possible.
Dr. G. H. Palmerlee, of Detroit, Mich., states:
In the treatment of fractures of the patella there
are three indications to be considered, no matter
whether the treatment is to be operative or nonop-
erative. The first thing to do is to stop the haemor-
rhage and effusion into and around the joint ; sec-
ond, secure the approximation of the fragments un-
til union occurs ; and. third, restore the function of
the joint and overcome atrophy of the quadriceps
extension muscle.
A good method to secure a quick absorption of
the effusion indicated, no matter whether the fur-
ther treatment is to be operative or nonoperative, is
to apply a well padded posterior splint, elevate the
foot, and bandage the knee from below upward with
a rubber bandage, making firm and even pressure,
but not tight enough to interfere with the circula-
tion, leaving the bandage on for two days, then
most of the blood or exudate will be absorbed. Mas-
saging the knee twice daily for five minutes will
often prove useful. Aspiration is sometimes em-
ployed, but does not prove altogether satisfactory 0x1
account of the blood clots present.
Various subcutaneous operations have been de-
vised, and since it must be admitted that they incur
some risk of infection without securing accurate ap-
position of the fragments, then it is obvious that if
any operative procedure is undertaken, the open
operation should be the one of choice, since by no
other method can the fragments be accurately ap-
proximated.
Operative treatment is absolutely contraindicated
unless the strictest aseptic technique can be carried
out ; and it is contraindicated in old people, or
where the skin is much bruised and there is some
doubt of not obtaining primary union of the skin
wound.
It seems to be the consensus of opinion among
surgeons who operate a good deal that the operative
treatment gives the best results, as the haemorrhage
is at once relieved ; the tear in the aponeurosis can
be repaired better, the displacement of the fragments
is overcome, and the chances for a bony union are
more favorable.
Some surgeons prefer to wait a few days before
operating, but it is safe to operate after the first
twenty-four hours. .\ curved incision is made, the
fascia cut through, and the fracture exposed. The
joint should then be thoroughly washed out with a
saline solution or sterile water ; or if antiseptics are
used they should be very weak, flushing the joint
after their use with sterile water.
The torn aponeurosis and periosteum, which are
turned over the edges of the fracture, are cut away
and retracted. The patellar fragments and the apo-
nuerosis may be united with silver wire, catgut, or
kangaroo tendon. The tendency now is to use an
absorbable suture, and it is of as great importance
to suture the aponeurosis as it is to suture the pa-
tella itself. Unite the aponeurosis and periosteum
in front of the patella with three sutures, and suture
the lateral tears with at least two sutures. Silver
wire inserted through holes drilled in the patella is
still extensively used. It is not necessary to use a
metal suture or unusually large catgut or kangaroo
tendon, as it does not require much to hold the
ifay 2. 1908.]
OCR READERS' DISCUSSIONS.
835
fragments together, since we depend on a splint
principally for immobilization.
Rubber gloves should be worn and the wound
handled as little as possible ; drainage is not used,
and the skin is closed with silkworm or catgut. The
leg should now be wrapped in sheet wadding from
the heel to the hip ; a plaster cast is then applied and
left on for six weeks ; at that time the fragments are
usually firmly united ; the cast should then be re-
moved, massage and passive motion may be safely
begun, and the patient allowed to go about on
crutches, bearing but little weight on the injured
leg, the injured joint being protected by a leather
knee cap or elastic bandage.
Old cases, where the knee cannot be flexed to a
right angle, or if it is impossible to extend the knee
or walk without limping, a much better functionat-
ing joint can be obtained by operating; the fibrous
tissue is dissected out, the edges of the fragments
freshened, and sutured with number four catgut or
kangaroo tendon, or it may be necessary to remove
the fragments and suture the patellar ligament to the
quadriceps extensor tendon ; occasionally the upper
fragment will have to be detached from the femur.
Perraresi's method consists in turning down a
square flap of the anterior fibres of the quadriceps
tendon over the broken patella, and suturing it to
the patellar ligament below; this prevents eversion
of the upper fragment.
The nonoperative treatment is indicated in very
elderly people, and when the fragments can be easily
approximated, and when circumstances do not per-
mit of strict asceptic precautions, or when the sur-
geon is not accustomed to doing much operating,
and not in the habit of daily asepsis. The injured
leg should be placed on a well padded (particularly
at the heel) posterior splint, extending from below
the heel to the hip and elevated about six inches ; the
next important thing is to reduce the swelling;
probably nothing will do this as readily as a rubber
bandage, applied firmly, but not tight enough to in-
terfere with the circulation. The application of an
ice bag is of some service, not only in reducing the
swelling, but relieving the pain. Massage is also of
service in getting rid of the exudate. In a few days
the swelling will have subsided, and not until then
should an attempt be made to approximate the frag-
ments. Do not apply a plaster cast until the frag-
ments have united, since the joint cannot be inspect-
ed, and the fragments may become widely sepa-
rated. The splint being applied, the upper fragment
is held down by a strip of zinc oxide adhesive plas-
ter passed just above the upper fragment, ex-
tending downward in such a manner as to pull the
upper fragment down, the ends fastened to the
splint ; the lower fragment is now held in a similar
manner, the adhesive strip placed below the frag-
ment, extending upward and backward, and fastened
to the splint; another strip is placed over the edges
of the fragments, which prevents them from tilting
outward after they are approximated; two or three
strips may be used instead of one, overlapping each
other a little ; the plaster strips need not be removed
until six weeks have passed. Union has usually
taken place in that time.
If a plaster cast is used it should be split down
the median line before it hardens in order that it
may be removed at intervals for massaging; at the
end of six weeks the patient may be allowed to bear
some weight on the limb, with the help of crutches,
while wearing a removable splint such as a knee
brace, or leather knee cap, and at the end of two
months the patient may be allowed to walk with a
cane. The knee should be protected by an elastic
bandage for another two months, and sudden move-
ments should be carefully avoided during this time,
since there is a liability of refracture.
Dr. Sidney J. Sondheim, of Reading, Pa., says:
Upon having made the diagnosis of fracture of
patella, two methods of treatment present them-
selves for consideration, operative and nonoperative.
What are the influencing factors which should de-
termine your decision?
1. Age and physical condition of patient. Opera-
tion unless open fracture of patella should never be
performed in person over sixty, and if not in good
health should not be performed at any age.
2. Environment as to modern hospital and expert
surgical skill. Since we are dealing with one of»the
largest joints of the body, with its numerous syn-
ovial sacks and consequent danger of infection, op-
eration in simple fracture should, as a rule not be
performed unless in a hospital with all modern
equipments and expert surgeon and assistant.
3. Occupation of patients. If a man's occupation
is such that full use of his leg is a necessity to him
for a livelihood, or if compelled to get back to work
in short time, operative procedure when successful
gives better and quicker results.
4. Character of fracture. All open fractures of
patella should be sutured at once. Simple fractures,
with wide separation of fragments and extensive
lacerations of capsule or when comminuted, give,
under favorable circumstances, better results when
sutured. Secondary fracture of patella, long
fibrous union in an old fracture, fracture healed so
as to prevent motion of leg, all indicate operative
procedure under favorable circumstances.
A decision should not result from consideration
of any one factor, but of all of them. It is always
to be remembered that with operative method, even
under the best of conditions, there is danger of in-
fection, with stiff joint, perhaps amputation, and
death. With nonoperative procedure, if a failure,
we can always resort to operative method at any
time, although perhaps with less favorable local con-
ditions.
Nonoperative method. — Whatever method of
treating fracture we adopt we have the following
indications to meet always: i. Removal and preven-
tion of swelling as far as possible. 2. Reduction and
apposition of fragments. 3. Complete immobiliza-
tion of fragments until union is secure. 4. Restora-
tion of functions of knee joint.
If seen early swelling can often be prevented b\-
equal pressure over joint by elastic rubber bandage
or by sponges beneath a bandage, which are then
saturated with water or lead water and laudanum,
which will cause the sponges to swell and give equal
pressure over joint. Elevation of leg and massage
two or three times daily are routine measures.
836 THERAPEUTICAL NOTES.
These measures also apply to reduction of swelling
when not seen early. If swelling is very persistent
and efYusion great, an incision or aspiration with
needle with most careful precautions to prevent in-
fection may be done.
The swelling having been reduced, we next con-
sider reduction and fixation of fragments. To se-
cure complete relaxation of quadriceps extensor
muscle we extend and elevate the leg. A posterior
or ham splint of plaster of Paris or wire extending
from about one decimetre above the heel to the up-
per part of the thigh, held in place by three or four
bands of adhesive, which go around the leg, and
prevent its flexion, is next applied. The upper
fragment is drawn down and held in place by trac-
tion of a strip of adhesive placed above the frag-
ment and running obliquely down the leg below the
fragment. The lower fragment is similarly fixed.
As the swelling subsides the upper adhesive strap
becomes loose and must be frequently adjusted. A
third strip of adhesive is placed directly across the
fracture and around the leg to prevent tilting of
fragments. To facilitate action of adhesive a splint
cart be placed above the quadriceps. Lateral splints
may now be applied and fastened and the leg ele-
vated. The splints, except the adhesives, should be
daily removed and the leg thoroughly massaged.
At the end of four to six weeks all dressings can
be removed, and plaster cast extending from below
fulness of calf to groin can be applied. This should
be slit, so as to be readily removed for massage and
bathing, and fastened again firmly after each such
treatment. Slight passive movements of leg may
now be adopted, and patient allowed to go about on
crutches. At end of eight to twelve weeks patient
may walk with cane, and passive movement should
be increased. At the end of five to six months splint
may be removed, bandages applied, and leg grad-
ually u.sed.
( )perative treatment. — I shall dwell very lightly
on this phase of the subject. There are two meth-
ods of fastening fragments by suture, subcutaneous
method and open method. Each has its indications,
advantages, and disadvantages. They are. briefly :
When we can obtain good apposition with fracture
transverse and in absence of most favorable oper-
able conditions, the subcutaneous method is to be
preferred. When we have wide separation or frag-
mentation and great swelling, with tearing of liga-
ments and modern hospital necessities, open method
is to be preferred.
Subcutaneous method. — Under strict asepsis
thrust a knife through the skin and ligamentum pa-
tellae just below middle of lower fragment. Pass
pedicle needle through this wound beneath patella,
above upper fragment, through insertion of quad-
riceps, and through incision made in skin at this
point. Thread with strong sterilized silk and draw
out through lower opening, unthreading the needle,
leaving the thread in place. Now pass needle
through the same lower opening, above patella, to
the upper opening, again thread needle, and draw
through the lower opening. We now have the liga-
ture looped about the patella. Displace any tissue
which lies between the fragments h\ briskly rub-
bing them together, and tie suture tightly. Close
wound, apply a jx)sterior splint, and preferably fig-
[New York
Medical Jovrnal.
ure of eight bandage, or adhesive plaster. Passive
movements may be begun in from ten to fourteen
days, and plaster of Paris dressing in three to four
weeks.
Open method. — Unless an open fracture, when
the joint should be widely opened, we mav use
three forms of incision — transverse, vertical, or oval
incision fCheyne). The latter two are preferable,
since *in former there is some danger due to flexion
of the leg bringing tension along the line of in-
cision, and certainty of opening prepatella bursa.
With most careful aseptic precautions, the joint is
opened by one of the methods cited. The clots are
removed by flushing the joint with sterilized normal
saline solution, or a i in 10,000 bichloride solution.
Loose particles of bone are removed, and holes are
bored in the patella from upper to fractured sur-
face, both superficial and deep. Blood and fibrous
tissue are now removed from the approximating
surface, and suture material is introduced. If silver
is used, after twisting and smoothing down, the
torn capsule is sewed and fibrous tissue over patella
is sewed. The skin suture is closed, and Post splint
is applied until the skin incision is healed : then the
knee is placed in plaster cast. Daily massage is em-
ployed, and patient can be about usually in three
weeks in plaster cast. Movement of patella may be
begun quite early to hasten the free use of the limb,
which can. as a rule, be freely used in a few months.
(To he concluded. )
Treatment of Red Nose. — In reply to an in-
quiry regarding the treatment of red nose several
contributors to The British Medical Journal for
April II. 1908. make suggestions. It is noted that
each case requires treatment for the cause. A lady
who had a very ugly red nose was treated with the
following, which acted well :
R Sulphur, praecip., calaminae aa gr. xxx ;
Ac. carbol, ^ vj ;
Lanolin, pur 5j.
.Sig. : After steaming the nose over boiling water, apply
this ointment at night.
R Fer. am. cit., 5j ;
Liq. arsenical ._3j ;
Aq. chlorof., ad 3vj.
Sig. : 3ss three times a day after food.
In another case the administration of laxative
doses of cascara sagrada every night, and the use
of the following lotion, proved effective :
H Calamine gr. x;
Bismuth trinitrate gr. x;
Acid, hydrocyanic, dil 3i.i ;
Pulv. tragacanth cc, 5j ;
Aq., ad 3j.
M. Sig. : For external use.
A little to be sponged over the nose every night at bed-
time and allowed to dry. .Another practical hint is always
to use the tragacanth powder for cosmetic lotions instead
of pulv. acacix.
The pernicious habit of passing the smoke
through the nostrils in cigarette smoking was blamed
for the appearance of a glaringly red nose in a
youth who was addicted to the habit.
THERAPEUTICAL XOTES.
837
Medication by Cataphoresis. — Tlic Prescriber
for April, 1908. gives a brief account of the cata-
phoretic method of introducing medicines into the
system. Many apphcations of the principle are
now in use. It is well known that when a current
of electricity is passed through a solution of a
chemical salt, the latter becomes decomposed or
electrolized. the base as a rule going to the nega-
tive pole and the radicle to the positive pole. This
is accounted for by the theory that the molecules
exist as ions, or electrified particles of matter, those
of the base and radicle carrying respectively their
negative and positive charge of electricity. These
ions are dissociated by the electric current which
appropriates them to the corresponding comple-
mentary poles of the circuit. Advantage is taken
of this principle to force medicinal substances in
the ionic state into the tissues of the body. If a so-
lution of, say, quinine sulphate be used to soak a
pad covering the positive pole of a battery, this pole
applied to the skin, and the negative pole so ar-
ranged that the current may pass through the tis-
sues, the quinine ions will seek the opposite pole,
and in so doing will pass through the tissues with
the current. The ions thus forced into the body
enter not only into the lymph spaces, but into the
cells themselves, becoming a part of the pro-
toplasm, and consequently their effects are much
more pronounced. The principle may be shown
experimentally by placing a piece of raw beef be-
tween the poles of a battery, the negative electrode
being covered with blotting paper soaked in a so-
lution of potassium iodide, and the positive elec-
trode similarly treated with starch solution. On
applying the current the iodine ions pass through
the beef to the positive pole, the paper on which
soon shows the blue color of starch iodide. This
process, described as cataphoresis or ionic medica-
tion, has been tried with considerable success in the
case of such drugs as break up into ions. Relief
of tabes dorsalis by cocaine ionization was de-
scribed in the British Medical Journal in January.
1905. and since then a number of cases have been
successfully treated by this method. Dr. Lewis
Jones {The Hospital, October 20, 1906) and Dr.
Dawson Turner (The Prescriber, September.
IQ07) have both reported on cases of rodent ulcer
cured by means of zinc ions. The process is ex-
tremely simple — a portable battery with wires has
a disc or rod of zinc attached to the positive pole.
The zinc is covered with a few layers of lint wetted
with a five per cent, solution of zinc sulphate and
applied to the ulcer previously cleaned. The nega-
tive electrode is either held in the patient's hand or
placed in a basin of salt water in which the hand is
immersed. The current is gradually raised to
40-60 milliamperes, or as much as the patient can
bear, and continued for thirty seconds. The sur-
face of the ulcer is now white and dry. and another
application may be made in a week or a fortnight,
two or three applications usually being sufficient.
A burning sensation like that of a mustard plaster
is felt, which in sensitive patients may be counter-
acted by means of cocaine. Other applications of
the ionic treatment are suggested. Copper ions
haA'e been found efficacious in destroying the para-
site of ringworm, and magnesium ions have cured
multiple warts on the hands. The chlorine ions
have proved useful in fibrous ankylosis and sclero-
sis, and a case of Dupuytren's contraction, which
had lasted fifteen years, was recently cured in the
same way. The salicylic ion has been found to re-
lieve tic doloureux which had proved refractory to
other remedies. Giovine {Rifor)iia Medico. No-
vember 2, 1907) records cases of gonorrhoeal
arthritis and tabetic arthropathy of the knee, in
which the idoine ions from potassium iodide gave
good results, also a case of sclerodactylia, which
was cured by application of chlorine ions. The
difficulty in the wa>- of treating lupus has so far
lain in the fact that the bacillus contains a large
proportion of fat, v.hich is a complete noncon-
ductor of electricity. In applying the ionic treat-
ment it should be borne in mind that basic ions
move from the positive to the negative pole, con-
sequently the medicament must be introduced at
the opposite pole. Acids move in the opposite di-
rection. The limitations of the method are that
the ions can be introduced only very slowly, and a
prolonged application, possibly under chloroform,
would be necessary to reach parts at great depth.
Prescription for Obstinate Hiccough. — The fol-
lowing prescription is recommended by The Hos-
pital as being successful in cases of obstinate hic-
cough :
B Spirit of nitroglycerin, viii ;
Spirit of chloroform 5iv;
Water q. s. ad o^w
M. Sig. : One fourth part for a do?e : to be repeated for
three or four doses.
Tannin in Postpartum Haemorrhage.— In the
\'aud. where the women lead very laborious lives
and have very large families, postpartum haemor-
rhage, due to uterine inertia, is of very frequent oc-
currence, and the country practitioner is at times at
his wits' end for an effective method of treatment,
the usual means — ergotin. massage of the uterus,
bimanual compression, ice, injections of hot water,
with or without tannin, and even plugging with
gauze or the fist — having failed him. In such a case
Renaud {Revue mcdicale de la Suisse romande ; The
Practitioner. April. 1908) tried the effect of gauze
powdered with tannin, and the effect was almost
immediate, although the uterine contractions re-
mained very weak. He thereupon had prepared
some gauze, impregnated with ten to fifteen per
cent, of tannin, which was cut into suitable lengths
for packing the uterus, and then sterilized by high
pressure steam. These are packed in parchment pa-
per, which keeps them aseptic, portable, and ready
for instant use. He has made an extensive use of
this haemostatic packing, and has always obtained a
successful result, with rapidity and certainty in cases
of postpartum hemorrhage, and also in cases of se-
vere metrorrhagia at the menopause, in which pack-
ine has been necessary. As the dressing is "haemo-
static" and not "'antiseptic," every care must be
taken in introduction to avoid soiling against the
labia and external parts of the genital region, and
the packing should not be allowed to remain in the
uterus for more than from twelve to twenty hours.
This allows ample time to insure firm coagulation
838
EDITORIAL ARTICLES.
[New York
Medical Journal.
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Review of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M. D.
idflicts all business communications to
A. R. ELLIOTT PUBLISHING COMPANY,
PiiblishcrSj
66 West Broadway, New York.
Philadelphia OFFirr. : Chicago Office:
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Subscription Price :
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Remittances should l)e made by New York Exchange or post
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lishing Co., or by registered mail, as the publishers are not
responsible for money sent by unregistered mail.
Entered :it the Post Office at New York and admitted for
transportation Ibrc.ush the mail as second class matter.
NEW YORK, SATURDAY, MAY 2, 1908.
THE ARMY MEDICAL CORPS BILL SIGNED.
On April 23d President Roosevelt signed the bill
enacted by Congress providing for the reorganiza-
tion of the Medical Department of the United States
Army. The measure wa-s printed in the Nczv York
Medical Journal for April i8th, on page 763, and
has already been commented on. The essential fea-
tures of the bill are the provisions for a material
increase in the number of officers — for a surgeon
general with the rank of brigadier general, fourteen
colonels, twenty lieutenant colonels, one hundred
majors, and three hundred captains or first lieuten-
ants, all of whom are to have rank, pay, and al-
lowances of officers of corresponding grade in the
cavalry arm of the service. Assistant surgeon gen-
erals are to be recommissioned, with the rank of
colonel ; deputy surgeon generals, with the rank "of
lieutenant colonel ; surgeons, with the rank of
major ; assistant surgeons as captains and first lieu-
tenants, the lieutenants to be promoted to the rank
of captain after three years' service.
The reserve corps which is provided for in the
measure is to be made up from surgeons in civil
life, who will be given the rank of lieutenant, but
without pay, save when assigned to active service.
The bill will make thirty-tw-o vacancies in the corps
in addition to the twcnty-.seven already existing.
I-lxaminations will be held on May 4th and on
.\ugust 3d to fill these vacancies. The bill pro-
viding for an increa.se in the pay of the officers
and enlisted men of the army, including the officers
(if the medical corps, has not yet been enacted, some
objection having been made to its passage, although
it seems probable that it will become a law before
the close of the present session of Congress.
THE CRAZE FOR NOVELTY IN BOOKS.
Le roi est wort, vive le roi! Hardly is the first
demand for copies of a new medical book satisfied
than its legitimately expected further sale is found
to be almost impossible. The cry is set up that it is
out of date, and many a copy that has been ordered
is returned to the publisher with the more or less in-
dignant comment by the person who ordered it that
he will not put up with an old book. And yet the
book may be a very recent one and quite abreast
with progress in the subject with which it deals.
The unreasonable purchaser demands that every-
thing shall be "hot ofif the griddle" ; he wishes to see
the current year designated on the title page. In
most instances the demand is utterly senseless. Ev-
ery year there are issued many medical books which
will never grow old in the sense of becoming use-
less. It is our own fault if we blink this fact and
virtually force the publishers into the issuance of
new editions, or what purport to be new editions, of
such books. It must be admitted, of course, that in
some of the departments of medicine a book really
does get out of date, however satisfactory and com-
plete it may originally have been, but the deficiencies
of such a book may always be supplemented by re-
course to the medical journals ; to make up for such
deficiencies is one of their chief functions.
So long as this demand for a new date on the
title page exists publishers will find it expedient to
resort to certain devices which are not always harm-
less. One of these is that of changing the date an-
nually, whence great injustice to the author often
results if he has not been allowed to revise the text.
Fancy, for example, a medical dictionary dated
1908, but really published in 1900. Between those
two dates multitudes of new words have come into^
use, and many fresh meanings have been given to
old ones. Necessarily these verbal novelties do not
appear in the book, and the unthinking revile the
author and despise his careful and really meritori-
ous work. A publishing house has been known to
defend this misbranding procedure by professing
that it had only desired to show that 'the book was
a "live" one, whereas it w-as the real purpose of the
house to galvanize a dying book into such a sem-
blance of vitality as might lead to its continued
sale.
C an we be censorious witli the publishers for re-
sorting to such a practice? Their fault, it seems to
us. lies chiefly in their resorting indiscriminatelx
to a device which, if applied only to certain books.
May 2, 1908.]
EDITORIAL ARTICLES.
839
would work no real injustice, whatever might be
thought of its abstract right or wrong. So called
"new editions" are often only fresh printings, and
the practice of printing the misleading announce-
ment on the title page is even more detrimental to
the author's reputation than the mere change of
date to which we have alluded. We are glad to
be able to say that publishers are resorting to these
devices less and less, and that there are not a few
houses which have never yielded to the temptation.
Let us assist them in resisting it by showing our-
selves permanently appreciative of good books, even
if they are a few years old, for, save in a few fields,
such as that of bacteriology and radiography, in
which progress at the moment is rapid, the differ-
ence of a few years in the date of the edition of a
book is not a serious matter.
SCHOOL CHILDREN'S EYES.
^^'e are glad to learn that the Association of
A'X'omen Principals of the Public Schools, of New
York, has taken up certain important questions con-
nected with the care of school children's eyes. Phy-
sicians have for years been convinced of the delete-
rious effects of the maddening glare given out by
the glazed paper which is used in books when it is
thought desirable to illustrate them with half tone
•engravings. In some foreign publications we find
half tones handsomely printed on paper which is al-
most if not quite unobjectionable so far as glare is
concerned. Our French and German exchanges,
for example, afford ample evidence of this. For
certain trade reasons, we suppose, such paper is not
to be obtained here at all or only at prohibitive
prices. So we imagine that the half tones will have
to go if we are to get rid of the highly glazed paper.
Many of the half tone engravings are in a high
•degree artistic, and they have the advantage of pre-
senting undeniable reproductions of photographic
pictures, with all their good points and all their bad
ones. For all that, however, we prefer woodcuts
for most purposes. Where are the half tones that
present such lucid depictions as are to be found, for
instance, in the old woodcuts of Sappey's Anatomy?
But the woodcuts must be of a high order of excel-
lence, and to whom shall we turn now for such
work in woodcutting as we were accustomed to a
few decades ago? Doubtless a few accomplished
wood engravers- still survive, but their numbers
must be steadily diminishing. Wood engraving,
alas, is almost a lost art. As a rule an engraving
on wood is more expensive than a half tone block,
and doubtless that fact will stand in the way of a
general return to the wood, but it ought not to pre-
-vent our taking all practicable steps to safeguard
the children's eyes. The semidiagrammatic is often
wonderfully effective in the art of illustration, and
it seems to be more readily attained by the wood
engraver than by the process worker — effective, we
mean, not solely from the artistic point of view, but
also from that of instructiveness. Surely that con-
sideration ought to weigh against the objection to
woodcuts on account of their cost.
Another point brought out by the association is
that of the strain on vision caused by following long
lines of type, even if the type is large. Short lines
with suitable leading permit of the use of compara-
tively small type with far less fatigue to the reader's
eyes ':han must result from the employment of long
lines. The difficulty comes in when the reader has
finished a line and seeks to retrace his course so as
to take up the next one ; it is almost as trying as that
of sighting a rifle fitted with a wind gauge. It is
unjust to impose such a difficulty on any reader;
in the case of a young child (studying, not reading
for amusement) it amounts to cruelty. Evidently
there are many of our school books which can be
materially improved from the mechanical point of
view, and we hope that the necessary improvement
will not long be deferred. The same may be said
with regard to medical books.
THE ETIOLOGY OF MYCETOMA.
Musgrave and Clegg (Philippine Journal of
Science, December) report a case of Madura foot
which they observed in Musgrave's clinic in St.
Paul's Hospital. They succeeded in isolating a
streptothrix from the tissues of the foot which has
some morphological and cultural differences from
actinomyces and from Streptothrix Madnrce (Vin-
cent), as well as from the streptothri.x isolated from
cattle in Guadaloupe by Fullerton, and from the
streptothri.x isolated from a brain abscess in man by
Fullerton. Musgrave and Clegg have named the
organism isolated by them Streptothrix Freeri, after
Dr. Paul Freer, director of the Bureau of Science
of Manila.
They have succeeded in killing monkeys, guinea
pigs, and dogs by intraperitoneal inoculation of the
pure cultures of the streptothrix. In monkeys a
tumor is produced at the site of the inoculation
which contains the organism. Death is apparently
due to a toxaemia. In guinea pigs metastatic ab-
scesses containing the streptothrix were found in
the liver, the diaphragm, the omentum, the mesen-
tery, and the spleen, from which the streptothrix
was obtained in pure culture. By inoculation of
pure cultures of the streptothrix, and by inoculating
material from the human foot, after amputation, into
the feet of monkeys, a disease was produced in the
EDITORIAL ARTICLES.
[New York
Medical Joirxal.
monkeys similar to that in the amputated foot. The
disease is distinct from actinomycosis, and it appears
from this report that the :Madura foot of the Philip-
pine Islands is due to an organism which differs in
some respects from that causing Madura foot in
India.
TRAU.MATIS.M AXD TABES DORSALIS.
In many cases of mechanical injury sustained by
a person in the performance of his work it is diffi-
cult to form a just estimate of what damages, if
any, the injured individual is entitled to; but per-
haps it will be Easier when we have accumulated
data concerning a large number of cases. One case
that seems to be of considerable interest is recorded
by M. Tourey-Piallat in La Clinique for April 17th.
On the 1st of March, 1906, a man employed by
a railway company at the Bourgoin station was
struck in the back by a piece of falling baggage,
but not knocked down. The second article fell
upon him and prostrated him. Then the third, a
heavy wicker hamper, fell on his right leg and broke
it. A surgeon in the employ of the company at-
tended the man. In the course of the ensuing July,
the injured limb being still rather weak and in-
capable of full power of motion, the man was sent
to the Zander mechanotherapeutic institute at Aix-
les-Bains. This was by the advice of the railwav
surgeon. In August "there appeared pronounced
signs of tabes. The patient was then taken back
■to Bourgoin, where the malady became more and
more decided, at last rendering him quite incapable
of work.
The victim, regarding his ataxia as the result of
the fall, sued for damages to the amount of two
thirds of his pay. The company, challenging his
ability to establish a connection of cause and effect
between the accident and the disease, estimated that
twenty per cent, only of his disability was attri-
butable to the injury, that being apparently the
amount which the traumatic lameness added to the
incapacity produced by the locomotor ataxia. A
medical expert appointed by the court coincided in
this estimate, and the court held accordingly. The
expert reported that tabes of purely traumatic origin
was not generally admitted, and that in the par-
ticular case under consideration the length of time
that had elapsed after the man was able to rise and
walk before the ataxia appeared showed that the
traumatic weakening of one lower limb had simply
somewhat aggravated the disabling effect of the
tabes.
M. Tourey-Piallat thinks that the decision was a
just one, and he intimates that it makes amends for
the failure of the law to take antecedent morbid
conditions into account. If, he says, the injured
person was previously affected with a latent disease
or infirmity, and an accident hastened its evolu-
tion, the injury would be held to be the sole cause
of the final condition. In the Bourgoin case the
tabes could not with certainty be held to have been
an antecedent morbid state, and its development
could not, therefore, be looked upon as due to the
injury. Thus, indeed, may the law secure some-
thing like, an equaHzation of right and wrong in a
general way, but it is not easy to see how it miti-
gates the sad lot of the poor Bourgoin emplo\ ee.
In this connection the reader may find it interesting
to refer to the article entitled Injuries and the Pre-
vious Condition in our issue for April 25th. on
page 795-
A XO\ EL MEW OF THE MEDICAL
LICENSE.
The Lancet, of London, puts forth the sugges-
tion that authority to treat disease by drugs or other-
wise be granted to unqualified persons upon pay-
ment of a license of 500 pounds. In defense of this
suggestion it is pointed out that brewers, publicans,
and tobacconists have to pay for a license now,
though the state does not guarantee the purity of
the articles sold by them. The Lancet despairs of
the suppression of unqualified practice and quack
medicines by law. offers the suggestion of a high
license fee as a partial solution of the problem of
regulating the practice of medicine by law, and
seems somewhat surprised that so simple and. to
the state, profitable a scheme has not been approved
of. The suggestion will strike American readers
as being both absurd and unwise. In fact it places
the state in the attitude of reaping a benefit from
the issue of licenses to do wrong and as being on
a par with the sale of indulgences. To the medical
profession on this side of the Atlantic the most sur-
prising feature of the suggestion is that it should
emanate from so sane and so conservative a source
as the Lancet.
THE LATE PROFESSOR CORNIL.
\ ictor Cornil, the great pathological histologist,
died on April 14th at Menton, whither he had be-
taken himself in the hope of regaining his strength
after a severe attack of bronchopneumonia. He
was a little more than seventy years old at the time
of his death. In this country we are accustomed to
thinking of him mainly in connection with the
.Manuel d' histologic patholoi^icjue. which he wrote
in conjunction with M. Ranvier. In the Presse
medicate for April i8th M. Maurice Letulle justly
May J. igoS I
XEIVS ITEMS.
speaks of him as a master of pathological anatomy,
a worthy successor of Cruveilhier. Lebert. Wilpian,
and Charcot, all of whom had been his teachers.
It was not in science alone that M. Cornil
achieved distinction. He was active in political life,
and at a critical period in the affairs of the French
nation Gambetta placed him at the head of a de-
partment. He served also in the Chamber of Depu-
ties and subsequentlv in the Senate. After years of
effort he and M. Brouardel had the satisfaction of
>eeing the Senate, in 1902. pass the public health
bill which the Chamber had already adopted. W ith
all his political activity. M. Letulle reminds us.
Cornil never ceased from his devotion to scientific
investigation. As a man renowned in medical
science and as a statesman, he may fittingly be
classed with \ irchow. There have been few such
men in the medical profession. There ought to be
many more, for there is no incompatibility between
the prosecution of science and the furtherance of
jxjlitical affairs.
Iletos Items.
Changes of Address. — Dr. Max Bernstein, to 2 East
One Hundred and Seventeenth street. New York : Dr. Julius
London, to 763 East One Hundred and Fifty-sixth street,
Xew York.
A Dinner to Professor Martin, of Berlin. — A sub-
scription dinner is to be given at the Hotel Astor on the
evening of June loth. as a farewell ceremony in honor of
Geheimrat Professor August Martin, of Berlin.
Medical Society of the George Washington Univer-
sity.— At a meeting of this societ}-, held on Thursday
evening. April 23d, Professor E. A. Schafer. of Edin-
hurgh, delivered a lecture on Internal Secretions.
Medicolegal Society of Philadelphia. — At a regular
meeting of this society, held on Tuesday evening. April 28,
Dr. F. X. Dercum read a paper on Expert Testimony.
The Boston Medical Society held its annual meeting
recently and elected the following officers : President, Dr.
William F. Gay : vice president. Dr. A. J. Hurwitz : treas-
urer. Dr. Rufus K. Xoyes : financial secretarj-. Dr. Fred-
crick J. Bailey; corresponding secretary. Dr. L. A. Herman.
Atlanta School of Medicine. — The annual commence-
ment was held on April 22d. and forty-nine young doctors,
representing twelve stales and two foreign countries, re-
ceived their diplomas. Dr. John C. Olmsted delivered
the annual address.
Vital Statistics of Minneapolis. — During the month
of March. 1908. there were reported to the Department of
Health of Slinneapolis 262 deaths from all causes. 154
males and 108 females. There were 22 still births. One
hundred and forty-four marriages were reported and 517
births.
The Kentucky State Association of Railway Sur-
geons.— The fourth annual meeting of this society will
be held in Louisville. Ky.. on May 12th and 13th. All who
are desirous of taking part in the discussions will please
notify Dr. Cuthbert Thompson, Broadway and Third street,
Louisville, Ky.
The Mercy Hospital of Canton, Ohio, will soon be
opened. It is to be a nonsectarian general hospital and
will occupy the site of the home of President William
McKinley. The property was purchased by Mrs. Rose
Klorer for $20,000 and made over to Bishop Horstman for
hospital purposes.
Connecticut River Valley Medical Association.— The
annual meeting of this association will be held at Bellows
Falls, Vt.. on Tuesdav, Mav 5th. Papers will be presented
by Dr. F. M. Dinsmoor. Dr. A. L. Miner, Dr. X. P. Wood,
and Dr. S. W. Hammond, which will be followed by discus-
sions and reports of cases.
Plague in Guayaquil, Ecuador. — According to news-
paper reports, plague has appeared in Guayaquil, and dur-
ing the four days ending April 22d twenty cases of the
disease, with nine deaths, were reported. Among those
who have died of the disease is Flores Ontaneda. a chem-
ist, who was engaged in preparing Hattkine's prophylactic.
Laying of Corner Stone of New College of Physi-
cians Building, Philadelphia. — The ceremonies of laying,
the comer ston.e of the new building of the College ol
Physicians took place on Wednesday afternoon. April 29th,
After prayer by Bishop Whitaker, the president. Dr. James
Tyson, delivered a short address, and the corner stone was
then laid by Dr. S. Weir Mitchell.
Buffalo, N. Y., Academy of Medicine. — A special
stated meeting of the academy was held on Tuesday even-
ing. April 28th. to cqnsidei the question of incorporating
the academy and of securing a permanent home for the
organization. The scientific programme of the evening was
furnished by the Section in Obstetrics and Gynjecolog>-.
The principal paper was entitled Mj- Obstetrical Experi-
ence, and was read by Dr. J. W. Grosvenor.
Richmond, Va., Academy of Medicine. — The follow-
ing papers were read at a meeting of this academy, held
on Tuesday evening. April 28th : Xature and Treatment of
Fever, by Dr. William S. Gordon : Diagnostic Significance
of Chills, by Dr. P. D. Lipscomb: Some Reflections ■■>n
.Scientific Mechanotherapy. So Called Osteopathy, by Dr.
V. L"lrich. Among those who took part in :he discussion
were Dr. J. X. Upshur and Dr. J. Garnett Xelson.
The Annual Report of the Library Committee of the
College of Physicians of Philadelphia for the year 1907
shows that there were 75.616 volumes in the the library at
■-he close of the year. There were also on the shelves 8,807
unbound reports and transactions: 21,733 theses and disser-
tations, and 62.300 unbound pamphlets. During the year
3,344 volumes. 17.138 pamphlets. 28.109 numbers of medical
periodicals, and S90 inaugural dissertations were received.
Association of American Physicians. — The twenty-
third annual meeting of this society will be held in the
Xew Willard Hotel. Washington. D. C. on May 12th and
13th. The programme contains a long list of papers, and
the meeting promises to be one of interest and value. The
officers of the society are : President. Dr. James Tyson, of
Philadelphia: vice president. Dr. Victor C. Vaughan, of
Ann Arbor; secretary. Dr. Henry Hun. of .\lbany; treas-
urer, Dr. J. P. Croze'r Griffith, of Philadelphia.
Notice to Members of Tulane Alumni Association. —
All graduates of the medical department of Tulane Uni-
versity who intend to be present at the meeting of the
American Medical Association in Chicago, on June 2d to
5th. are requested to write at once to Dr. Hugh B. Wil-
liams. 100 State street, Chicago, for information concerning
the gathering of the alumni on June 2d. The headquarters
for Tulane graduates will be at the Auditorium Hotel, and
alumni are urged to call upon their arrival for information.
Medical Association of Georgia. — The fifty-ninth an-
nual meeting of this society, which was held in Fitzgerald
on April 15th. i6th. and 17th. was one of the most satisfac-
tory in the history of the organization. Officers for the
ensuing year were elected as follows : President. Dr. T. D.
Coleman, of Augusta : first vice president. Dr. W. B. Arm-
strong, of Atlanta : second vice president. Dr. R. Lattimore,
of Savannah : secretary and treasurer. Dr. Claude A. Smith,
of Atlanta. Macon was selected as the place of meeting
for 1909.
The Medical Association of the Southwest. — This
association, which embraces the strtes of Kansas. Arkansas.
Oklahoma. Texas, and Missouri, will hold its next annual
meeting in Kansas Citv. Mo., on October 20th and 21st.
The secretary. Dr. F. H. Clark, of El Reno. Okla.. is
actively engaged in the preparation of an extensive pro-
gramme, and the committee cn arrangements is already
uiaking plans for the entertainment of those who attend.
Dr. Tohn Punton, 532 Altman Building, Kansas City. Mo.,
is chairman of the committee on arrangements, and will be
glad to answer all communications relative to the meeting.
842
Mil IS ITLMS.
Kansas Medical Society. — The forty-second annual
meeting of this society will he held at Klks Hall, lola,
Kan., nn May 6th, "th, and 8th. A splendid programme
has been prepared, and the meeting promises to be one of
great interest. The officers of the society are: President,
Dr. J. E. Sawtell. of Kansas City; vice presidents. Dr.
Thomas Kirkpatrick, of Garnett ; Dr. M. F. Jarrett, of
Fort Scott, and Dr. George M. Gray, of Kansas City ;
secretary. Dr. Charles S. Huffman, of Columbus; and treas-
urer. Dr. L. H. Munn, of Topeka.
The Canadian Hospital Association. — At the annual
meeting of this association, which was held in Toronto on
April 2ist, the following officers were elected for the en-
suing year : President, Dr. W. J. Dobbie, of Weston ; first
vice president. Dr. A. D. Maclntyre, of Kingston; second
vice president, H. E. Webster, of Montreal ; third vice
president, Miss I. C. Brent, of Toronto; fourth vice presi-
dent, W. \V. Kenny, of Halifax ; fifth vice president, L. L.
Cosgrove, of Winnipeg; secretary. Dr. J. N. E. Brown, of
Toronto; treasurer, Miss Patten, of Toronto.
The Society of Normal and Pathological Physiology,
Philadelphia. — .\ meeting of this society was held in
the new medical laboratory of the University of Pennsyl-
vania on Mnnday evening, April Jjtli. Dr. J. E. Sweet
read a pajier C(>\enng a report of the work accomplished
in experimciiial surgery. Dr. D. W. Fetterolf read a
paper dealing with the preliminary results of the analysis
of diabetic foods. Dr. N. Gildersleeve read a paper enti-
tled Streptothrix Infections. Dr. W. H. F. Addison read
a paper on the Structure of the Cerebellar Cortex, and
Dr. H. B. Wood read a paper on the Variability of the
Parathyreoid.
A Dinner to Professor Schafer, of Edinburgh. — A
dinner was gi\en in honor of Professor E. A. Schafer,
F. R. S., of the University of Edinburgh, on the evening
of April 22d, at the Shoreham Hotel. Washington, D. C.
Among those oresent were President Buell, of George-
town University; President Needham, of George Washing-
ton Univer.sitv ; Dr. Barchfcld. Member of Congress; Sur-
geon General Wyman, I'niied States Public Health and
Marine Hospital Service ; Dr. W. W. White, superinten-
dent of the Government Hospital for the Insane; Professor
Shields, of the Catholic University of .\nicrica. and Pro-
fessor Franz, of George Washington Uni\ersity.
The Mississippi Valley Medical Association. — The
thirty-fourth annual meeting of this society will be held in
Louisville. Ky., on October i.^tli. 14th, and 15th. An-
nouncement h.as just been made that iJr. George Dock,
professor of medicine in the l'ni\crMty of Michigan, Ann
Arhor, will deliver the address in medicine, and Dr. Arthur
Dean Bevan, professor of surgery in Ru^h Medical Col-
lege, Chicago, will deliver the address in surgery. The
officers of the society are as follovv s : President, Dr. Arthur
R. Elliott, of Chicago; first vice prcsidciit. Dr. Florus
Lawrence, of Columbus, Ohio; second xicc president. Dr.
Robert C. McChord, of Lebanon, K\ ; -< cretary, Dr. Henry
luios Tully, of Louisville, Ky. ; treaMU cr. Dr. S. C. Stanton,
of Chicago: chairman of the Committee on .\rrangement>.
Dr. Louis I'rank. of Louis\ille. Ky.
Scientific Society Meetings in Philadelphia for the
Week Ending May 9, iqo&.— Monday. May 4th., Phila-
deiphia .Academy of Surgery; Biological and Microscopical
Section, .\cadcmy of Natural Sciences ; West Philadelphia
Medical Association; Northwestern IV^edical Society.
Tuesday, May fith. Academy of Natural Sciences. IVedncs-
day, May 6th, College of Physicians; .Association of Clini-
cal .Assistants, Wills Hospital. Thursday, May 7th. .Ameri-
can Therapeutical Society: Obstetrical Society: Medical
Society of the Southern Dispensary ; Section Meeting,
Franklin Institute; Germantown Branch, Philadelphia
County Medical Society. Friday. May fith. .American
Therapeutic Society ; Northern Medical Association ;
West ]^.r;uich, Philadelphia County Medical Society. Sat-
urday. May (jih, .Americm Therapeutic Society.
The Health of Philadelphia.— During the week end-
ing .April II, 1908, the following cases of transmissible dis-
eases were reported to the Bureau of Health of Philadel-
phia: Typhoid fever. f>H cases, 15 deaths; scarlet fever, 76
cases, 0 deaths: chickenpox, J4 cases, o deaths; diphtheria,
75 cases. 14 deaths; cerebrospinal meningitis, 5 cases, 2
deaths; ineaslcs, 314 cases. 2 dcatlis; wiioo])ing cough, 32
cases, 1 ilr;itli-; iMihiion.ir;, tiilvrculoM^. lOQ cases, 62
deaths ; pneumonia, 7,? cases, 64 deaths ; erysipelas, 7 cases,
I death ; puerperal fever, 2 cases, 5 deaths ; anthrax, i case,
I death ; mumps, 37 cases, o deaths ; cancer, 20 cases, 23
deaths. The following deaths were reported from other
transmissible diseases : Tuberculosis, other than tubercu-
losis of the lungs, 9 cases ; diarrhoea and enteritis, under
two years of age, 11 cases. The total deaths numbered
534 in an estimated population of 1,532,738, corresponding
to an annual death rate - of 18.10 in 1,000 of population.
The total infant mortality was 123; under one year of age,
96; between one and two years of age, 27. There were 52
still births ; 35 males, and 17 females.
Infectious Diseases in New York:
iVc arc indebted to the Bureau of Keeords of the De-
partment of Health for the follozving statement of new
cases and deaths reported for the tzco zcccks ending April
2^, igo8:
Cases.'' Deaths? Cases.' Ueatlii.
Tuberculusis puliiionalis 444 i8g 439 i^o
IJiphtheria 43b 51 344 39
Measles 1,640 46 1,891 39
Scarlet fever 1.005 66 929 64
Smallpox
X'aricella 108 . . 153
Typhoid fever 19 5 33 11
Whooping cough 13 3 14 i
C erebrospinal meningitis 7 7 u 7
Totals 3.674 367 3.813 341
The Mortality of Chicago. — According to the weekly
bulletin of the Department of Health, during the week
ending April nth there were 600 deaths from all causes,
,is compared with 717 for the corresponding period in
1907. The annual death rate in i.ooo of population was
14.44. Of the total number of deaths, 344 were of males
and 256 of females. Under one year of age, 143 ; between
one and five years of age, 44; between five and twenty
years of age, 21 : between twenty and sixty years of age,
251 • over sixty years of age, 141. The principal causes of
death were: Apoplexy, 5; Bright's disease, 36; bronchitis.
19; consumption, 69; cancer, 28; convulsions, 3; diph-
theria, i; heart diseases, 58; influenza, 5: intestinal dis-
eases, acute, 39 ; measles, 4 ; nervous diseases, 18 : pneu-
monia, 97; scarlet fever, 5; suicide, 13; typhoid fever, 4:
violence other than suicide, 23; whooping cough, 3: all
other causes, 170.
Montgomery County, Md., Medical Association. —
The annual meeting of this association was held in Rock-
\ille on Tuesday, April 21st. Dr. James E. Deets, of
Clarksburg, the retiring president, presided, and Dr. John
L. Lewis, of Bethesda, acted as secretary. A committee,
consisting of Dr. J. W. Chappell, of Tenleytown, Dr. Otis
M. Linthicum, of Rockville, and Dr. Horace P. Haddox, of
Gaithersburg, was appointed by the association to consider
the feasibility of establishing a hospital in the county, to be
under the control of the association, and to devise ways
and means of financing the project. The principal feature
of the scientific programme was an address on tulierculosis
by Surgeon Ger.eral Sternburg, of the United States Army.
.An election of officers was held, which resulted as follows:
President, Dr. Charles Farquhar, of Olney ; vice president.
Dr. Otis Linthicum, of Rockville ; secretary and treasurer.
Dr. John L. Lewis, of Bethesda.
Personal.— Dr. G. M. F. Rogers, of Minneapolis.
Minn.; Dr. M. J. Lilly, of Switchback, W. Va. ; Dr. Ed-
ward D. Helfrisch, of Gallon, Ohio; and Dr. Elbin J. John-
son, of Wind Ridge, Pa,, are registered at the Philadelphia
Polyclinic and College for Graduates in Medicine.
Dr. J. Henry Carstens. of Detroit, has announced that
he will accept the Republican nomination for mayor.
Dr. Charles \l. Donlan has been elected superintendent
of the Boston almshouse and hospital on Long Island.
Dr. Herbert B. Howard, of Boston, has resigned his
position as resident physician of the Massachusetts General
Hospital, to become head of the new Peter Brighain Hos-
pital in Brookline.
Dr. L. M. Early, of Columbus, Ohio, has had his left
hand amputated as a result of x ray burns.
Dr. William G. McCallum, resident pathologist of the
Johns Hopkins Hospital, has been appointed head of the
pathological department of the City Hospital, Cincinnati,
and of the Cincimiati University.
Dr. Frederick .A, Hunt, of Jamesville, N. V., has been
appointed physician to tli<- Onondaga County Penitentiary
May 2. .908.1
XEIl'S ITEMS.
843
Vital Statistics of New York.— According to the re-
port of the Department of Health of the City ot New
York for the week ending April i8th, there were durmg
the week 1,544 deaths from all causes, correspondmg to
an annual death rate of 18.21 in 1,000 of population. Ot
the total number of deaths Box were m the Borough ot
Manhattan. 177 in the Borough of the Bron.x 404 "i
Brooklyn. 56 in Queens, and 16 m Richmond. Ihe Bor-
ough o'f the Bronx had a death rate of 28.19, which \vas
the highest for the live boroughs, but the death rate of this
borough is increased by the presence of several large in-
stitutions, the inmates of which are residents of the other
boroughs. There were 2,142 births, 387 marriages, and 127
stili births reported for the week.
American Pharmaceutical Association.— The Phila-
delphia branch of this society will hold a stated meeting
in the College oi Physicians on the evening of Tuesday.
May 5th, at 8 o'clock. The program for the evening in-
cludes a discussion of pharmaceutical associations and
their uses, and physicians are invited to give suggestions
or offer criticism of the -work that is now being done in
connection with the several pharmaceutical organizations.
Manv pharmacists appreciate that there is a need for active,
energetic work to advance the science of pharmacy in this
country, and are earnestly endeavoring to bring about a
reawakening on the part of others engaged in the same
calling The discussion will be opened by the following
contributions: The X. A. R. D. as a Factor in the Pro-
gress of Pharmacy, bv Mr. Thomas H. Potts; The Status
of Pharmacy and of Pharmacists in Europe, by Mr.
M. 1. Wilbert: The Reorganization of the American Phar-
maceutical .Association, by Professor Henrys Kraemer.
Society Meetings for the Coming Week:
Mo.VD.w, Max 4tli.— German Medical Society o^ the City
of New York : Utica, N. Y., Medical Library Associa-
tion : Niagara Falls, N. Y., Academy of Medicine
(annual): Practitioners' Club, Newark, N. J. (an-
nual) ; Hartford, Conn.. Medical Society.
Tlesu.w. May j//;.— New York Academy of Medicine
(Section in Dermatology): New York Neurological
Society : -Buffalo Academy of Medicine (Section in
Surgery): Ogdensburgh, N. Y., Medical Association:
Syracuse. N. Y., Academy of Medicine: Hudson
County. N. J., Medical .Association (Jersey City)
(annual) : Medical Association of Troy and Vicinity.
N. Y. : Hornellsville. N. Y.. Medical and Surgical
Association: Long Isliand. N. Y., Medical Society;
Bridgeport, Conn., Medical Association.
\\ EDXESD.'W, May 6th. — Psychiatrical Society of New York ;
Society of .\lumni of Bellevue Hospital, Ne\v York;
Harlem Medical Association, New York ; Elmira, N. Y..
Academy of Medicine.
Thursd.w, May ~tli. — New York Academy of Medicine;
Dansville, N. Y., Medical .Association.
Frid-sv, May 8th. — New York Society of Dermatology and
Genitourinary Surgery : New York Academy of Medi-
cine ( Section in Otology) ; Eastern Medical Society
of the City of New York; Saratoga Springs, N. Y.,
Medical Society.
Saturd.w, May ()t'h. — Therapeutic Club. New York.
Philadelphia Bureau of Health Statistics. — During
the month of February, 1908. in the Division of Medical
Inspection, .^,720 inspections were made, excluding schools:
601 fumigations were ordered ; 58 cases were referred for
special diagnosis: 5,021 visits were made to schools, and
657 children were excluded from school : 320 cultures were
taken; 160 injections of antitoxine were given; and 233
persons were vaccinated. In the Division of Vital Statis-
tics 2,373 deaths, 3,175 births, and 711 marriages we're re-
corded. In the Division of Milk Inspection 7,183 inspec-
tions were made of 169,768 quarts of milk, of which 250
quarts were condemned. Six specimens were examined
chemically and 841 microscopically. In the Division of
Meat and Cattle Inspection 3,695 inspections were made:
83 showed unsanitary features, and 214 carcasses were con-
demned ; 868 post mortem examinations were made, with
44 condemnations. In th.e Division of Disinfection i fumi-
gation was ordered for smallpox. 270 for scarlet fever. 340
for diphtheria. 165 for typhoid fever. 215 for tuberculosis,
and 436 for miscellaneous diseases. Twenty-eight schools
were disinfected. In the Bacteriological Laboratory 1,028
cultures were examined for the presence of bacillus diph-
theri;e; 431 specimens of blood were examined for the
serum diagnosis of typhoid fever ; S41 specimens of milk
and 180 specimens of sputum were examined ; 6 disinfec-
tion tests were made; and 3,913.850 units of antitoxine were
distributed. In the Clinical Laboratory 98 analyses were
made.
Meetings of State Medical Societies for the Month of
May, 1908:
Arkansas Medical Society, annual meeting at Little
Rock, May 13th, 14th, and 15th.
Connecticut Medical Society, annual meeting at New
Haven, May 27th and 28th.
Illinois State Medical Society, annual meeting at Peoria,
May 19th. 20th, and 21st.
Indiana State Medical Association, annual meeting at
French Lick, May 23d, 24th, and 25th,
Iowa State Medical Society, annual meeting at Des
Moines, May 20th, 21st, and 22d.
Kansas Medical Society, annual meeting at lola. May
6th, 7th, and 8th.
^lissouri State Medical Association, annual meeting at
Sedalia. Date not announced.
:\Iontana State Medical Association, annual meeting at
Butte, May 13th and 14th.
New Hampshire Medical Society, annual meeting at
Concord, May 14th and 15th.
Nebraska State Medical Association, annual meeting at
Lincoln, May 5th, 6th, and 7th.
Medical Society of the State of North Carolina, annual
meeting at Winston Salem. May 25th.
North Dakota Medical Associatoin, annual meeting at
Grand Forks, May 20th and 21st.
Ohio State Medical Association, annual meeting at Co-
lumbus, May 6th, 7th, and 8th.
Oklahoma State Medical Association, annual meeting
at Sulphur, May 14th, 15th, and i6th.
The State ^ledical Association of Texas, annual meet-
ing at Corpus Christi. May 12th.
Utah State Medical Association, annual meeting at Salt
Lake, May 12th and 13th.
The Fifth Pcm-American Medical Congress. — The
executive committee of this congress, wliich will be held
in Guatemala City, Guatemala, on .August 5 to 10,
1908, announce the following list of subjects for the
general discussions : General Medicine — Tropical .Anaemias ;
The Present Cause and Treatment of Cancer. Surgery —
Prostatectomy; Operations for Repairing the Ureters.
Hygiene and Demography — Should the Segregation of
Lepers be Enforced? Demographic Distribution of Tuber-
culosis in .America. Mental and Nervous Diseases — Classi-
fication of Mental Diseases; A Discussion of Dementia
Prsecox. Internal Medicine — Tropical Diseases the Char-
acter and Causes of Which Have Not Yet Been Deter-
mined: -Ankylostoma. Gynecology — Can Metritis be Con-
sidered as a Predisposing Cause of Cancer of the Uterus?
The Best -Means of Keeping the Uterus in Position in
Cases of Prolapse. Military Sanitation — First Aid to the
Injured on the Battlefield and the Organization of an .Ad-
vance Guard to Render .Assistance : The Hygienic Equip-
ment of the Soldier. Syphilis and Dermatologj- — Paresis
and the Locomotor Ataxia Syphilitic. Ophthalmology- —
What is the Best Method of Treating Pigmentary Retinitis
That We Have at Present? Discus-^ion of Trachoma. Ob-
stetrics— Post Partum Haemorrhage in Valvular Lesions
of the Heart. Children's Diseases — Infantile Meningitis.
Medicolegal — Psychical Causes That Attenuate or .Annul
the Responsibility; Civil Rights Relative to People's Mental
Condition. Laryngology and Rhinolopy — (Causes and
Treatment of Rhinoscleroma. Dental Surgery — Indica-
tions for the Extraction of Teeth. Radiography— Exact
Methods L'sed in Radiography. Bacteriology — Bacterio-
logical Study of Typhus Fever : Bacteriological Study of
Rhionscleroma ; Bacteriological Study of Leprosy ; Filaria
Sanguinas Hominis in Central .America : Diseases That Can
he fransmitted by Mosquito Bites. Materia Medica — Cen-
tral .American Quinine: Central .American Sarsaparilla ; .A
Stf.dv of the Myroxilon Pereirea Tree. Those who desire
to present papers on any of these subjects, or to take part
in the discussions, should send their names at once either
to Dr. .A;^urdia, General Secretary, Guatemala, or to Dr.
Ramon Guiieras, .American Secretary, 75 West Fifty-
fifth street. New York.
844
THE BOOKS OF SIX MONTHS.
[Ntu York
Medical Journai,.
THE BOOKS OF SIX MONTHS
THE PRINCIPAL MEDICAL BOUKS PUBLISHED SINCE OCTOBER I. mi
Nearly all the medical books that have been issued by American publishers during the year, as well as
many others of foreign production, have already been reviezved in our columns. These revieivs,
ho-cVdver, are scattered throughout the different numbers of the Journal for the entire year,
and are consequently not easily accessible to the reader. We feel confident, therefore,
that our readers will find that the list which zve have compiled here belozv zvill be of
great vahic as a guide to the selection of books for the library. In viezv of
I 1 the fact that the majority of the hooks have already received review notice,
^ ' zi'e insert only occasional brief comments. For convenience of refer-
ence, the titles of the publishing houses are arranged alphabetically.
ENGLISH.
D. APPLETON & COMPANY,
New York.
Anders.—.^ Te.vtbook of Physical Diagnosis. By Howard
S. Anders, A. M.. M. D., Aledico-Chirurgical College,
Philadelphia. Svo. Illustrated. Price, cloth, $3 net.
Its simplicity and e.xcelleiit scheme bring out the
essential features of diagnosis and furnish all ma-
terial desirable for a student previous to clinical ex-
perience.
Babcock.— Diseases of the Heart and Arterial System. By
Robert H. Babcock. A. M., M. D., Chicago. Second
Edition, Revised, w ith 3 Colored Plates and 139 Illus-
trations. 8vo. Price, cloth, $6 net.
Babcock.— Disrases of the Lungs. By Robert H. Babcock,
.\. M.. }vl. 1). .\ companion volume to Diseases of the
Heart and .\rterial System. With it Colored Plates
and 104 Illustrations. 8vo. Price, cloth, $6 net.
Baumanx. — Gonon-ha\i. Its Diagnosis and Treatment. By
Frederick BAU-MAXx/Ph. D., M. D., College of Phy-
sicians and Surgeons, Chicago.
This little book is especially valuable in omitting
many well known details, and giving clearly and
concisely the essential points in the diagnosis and
treatment of gonorrhoea and its surgical sequelae.
CuvRcn.— Diseases of llic Xerrous System. The fourth
volume .it .Modern CIniual .Mediaue. Edited by
Archibald Chlki h. M. D.. Northwestern University,
Chicago.
This book is characterized by a thoroughness and
comprehensiveness typical of German productions,
and will be found of the highest service to .students
and practitioners.
FooTE. — Minor Surgery. By Edward Milton Foote, A. M.
M. D., College of Physicians and Surgeons, Columbia
I'niversity, New York. 407 Illustrations. Price, cloth,
$5. net. ' ■
This book treats of the every day o])cralinns nf
surgical practice, those problems in surgcr\ which
are not adequately discussed in the works which
take cognizance of the more serious conditions.
I^OLT— 7/ir Diseases of Infancy and ChildJwod. By L.
Emmett Holt, M. D., Sc. D., LL. D., College of Phy-
sicians and Surgeons, Columbia University, New York.
Third Edition, Revised and Enlarged. With 245 Il-
lustrations, including 8 Colored Plates. Price, cloth.
$6 net.
Kelly.— -Wjt' Medical Gyncccology. By Howard h. Kbllv,
M, D., Johns Hopkins Hospital, Baltimore, Md. Over
100 Original Illustrations. Price, cloth, $6 net.
A work of great im])ortance, which, taken with
Kelly's Operative Gyncccology. gives you a complete
treatise bv the best authority.
PusEV. — the Princil^les and Practice of Dermatology. By
Wn.LiAM .'Xi.i.F.N PrsEV. University of Illinois. 356
Illustrations in the Text and one Colored Plate. 8vo.
Price, cloth, $6 net.
That the work is thoroughly up to date is evinced
by the description of meralgia paraesthetica and un-
cinariasis of the skin and by the discussion on the
Spirochccta pallida and on Wright's method of treat-
ment.
VViLiAMS. — Obstetrics. By J. Whitridge Williams, Johns
Hopkins University. Baltimore. Md. 8vo. 820 pages.
630 Illustrations, 8 Colored Plates. Price, cloth, $6
net.
This book is written in a clear and admirable
manner, it is comprehensive and exact, and last, but
not least, it is written in English.
Wynter. — Minor Medicine. By Walter Essex Wynter,
M. D., B. S., London. Price, cloth, $2 net.
This book is a treatment on the simpler disorders,
such as bilious attack, dyspepsia, stye, epista.xis, neu-
ralgia, chilblains, heartburn, constipation, corn cures,
syncope, cough, toothache, hiccough, baldness, ceph-
alalgia, seasickness, warts, enuresis, cold in the
head, etc.
P. BLAKISTON'S SON & COMPANY,
Philadelphia.
Allen.— 77u' Opsonic Method of Treatment. By Dr.
Richard W. Allen, .\. M.. M. B., Pathologist, Royal
Eye Hospital, London, etc. 8vo, Containing 16 Charts.
Price, cloth, $1.50 net.
.\n opportune book tliat has aroused so much in-
terest that two importations were exhausted imme-
diate! \ upon their receipt in this country.
Bartlev. — Physiological and Clinical Chemistry. The
Chemical Examination of the Saliva. Gastric Juice,
Fsces, Milk. I'rine. etc.. with Notes on LVinary Diag-
nosis, Volumetric .\nalysis. and Weights and Measures.
By E. H. I'.ARTi.KV, M. D.. Professor of Chemistry,
Toxicology, and P<-ediatrics in the Long Island College
Hospital, late Dean and Professor of Chemistry,
Brooklyn College of Pfiarmacy. etc. Third Edition.
With 51 Illustrations. i2mo. 202 pages. Cloth, $1 net.
Cuff. — Lectures on Medicine to Nurses. By Herbert E.
Ct'FF. M. D.. F. R. C. S.. Late Medical Superintendent,
Northeastern Fever Hospital. Tottenham. London.
Fifth Edition. Illustrated. i2mo. 269 pages. Cloth,
$1,25 net.
Daniels. — Laboratory Studies in Tropical Medicine. Bv
C, W. Daniels. M. R, C, S,. Late Medical Superinten-
dent of the London School of Tropical Medicine, etc.
With 4 Colored Plates, Containing 92 Figures, 6
IS. 8vo. Price, cloth,
4 net.
Charts, and 156 other Illustrations
Intended to serve as a guide for physicians en-
gaged in scientific nic'lictl w(^rk in tro]iicn1 countries.
May 2, 1908.]
THE BOOKS OF SIX MOXTHS.
845
DoMViLLE.— J Manual for Hospital Xurses and Others
Engaged in Attending on the Sick. By Edward J.
DoMviLLE. L. R. C. P. Lond.. M. R. C. S. Eng., Sur-
geon to the Royal Devon and Exeter Hospital, and to
the Exeter School ; Lecturer and Examiner to the St.
John's Ambulance Association. Ninth Edition. i2mo.
152 pages. Cloth. $0.75 net.
GowERS.—Lcititres on Diseases of the Xervous System.
By Sir Willi.am R. Cowers, M. D., F. R. S., Physician
to the National Hospital for the Paralyzed and Epilep-
tic, etc. The Borderland of Epilepsy. Faints, Vagal
and Vasovagal Attacks. Vertigo, Migraine, and Other
Seizures. 12010. Cloth, $1.25 net.
This is the third in Gowers's popular series of lec-
tures on Diseases of the Xervous System.
Groff.— Materia Medica for Xurses. With an Epitome of
Official Drugs, Preparations and Chemicals, giving
their Medicinal Uses and Doses: and Questions for
Self Examination. By Johx E. Groff. Ph. G., Apothe-
cary in the Rhode Island Hospital : Professor of Ma-
teria Medica in the Long Island College of Pharmacy.
Fourth Revised Edition. Rearranged by Lucv C.
Ayres, Superintendent of Nurses' .Training School.
Rhode Island Hospital. Sections on Therapeutics Re-
written by Herm.\x C. Pitts. M. D., Gynaecological
Surgeon, Rhode Island Hospital. i2mo. 221 pages.
Price, cloth. $1.25 net.
H.\rtridge. — The Ophthalmoscope. A Manual for Physi-
cians and Students. By GfST.wus H.xrtridge. F. R.
C. S.. Senior Surgeon, Royal Westminster Ophthalmic
Hospital ; Ophthalmic Surgeon to St. Bartholomew's
Hospital, etc. Fifth Edition, Revised. With 4 Colored
Plates and 68 Wood Cuts. i2mo. Price, cloth. $1.50
net.
Hewlett. — Pathologx, General and Special. By R. T.
Hewlett, >!. D." M. R. C. P.. Assistant Bacteriologist,
British Institute of Preventive Medicine, etc. Second
Edition, Revised. 31 Plates Containing 63 Figures,
and 13 other Illustrations. i2mo. viii-585 pages. Price,
cloth, $3.25 net.
HoRWiTZ. — Compend of Surgery. Including Minor Sur-
gery. Amputations. Bandaging. Fractures, Dislocations.
Surgical Diseases, etc.. with Differential Diagnosis and
Treatment. By Orville Horwitz. B. S.. M. D., Professor
of Genitourinary Surgery. Jeiferson Medical College:
Surgeon to the Jefferson Hospital : Consulting Surgeon
to the Jewish Hospital, etc. Sixth Edition, Thor-
oughly Revised, in Parts Rewritten. With 195 Illus-
• trations and 104 Formulae. i2mo. 334 pages. Blakis-
ton's (Quiz-Compend) Series. Price, cloth, $1: inter-
leaved for the addition of notes, $1.25 net.
J.\COBSON. — The Operations of Surgery. By W. H. A.
Jacoeson, F. R. C. S. (Eng.). Surgeon, Guy's Hospital,
etc.. and R. P. Rowlands. F. R. C. S.. Assistant Sur-
geon, Guy's Hospital, and Joint Teacher of Operative
Surgery in the Medical School. With 777 Illustrations.
Fifth Edition, Revised and Enlarged. 'Two Volumes.
Bvo. 2084 pages. Price, cloth, $12 half morocco, $14
net.
Jones. — Oufliues of Physiology. By Edward Groves Jones,
M. D.. Professor of Surgery, formerly Professor of
Physiology, Atlanta School of Medicine. Revised by
R. G. Stephens, Assistant in Physiology in the Atlanta
School of Medicine. Second Edition. With 107 Illus-
trations. i2mo. 383 pages. Price, cloth, $1.50 net.
Lindsay and Blakiston. — The Physician's Visiting List
for' 1908. Pocket and Pencil. Gilt Edges. Leather,
$1 to $2.25 net.
NoTTER. — The Theory and Practice of Hygiene. Second
Edition. A Complete Treatise bv J. Lane Notter.
M. A., M. D.. F. C. S.. Fellow and Member of Coun-
cil of the Sanitary Institute of Great Britain. Pro-
fessor of Hygiene, .\riny Medical School : Examiner
in Hygiene. University of Cambridge, etc.: and W. H.
Horrocks. M. D., B. Sc. (Lond.). .Assistant Professor
of Hygiene, Army Medical School, Netley. Illustrated
by 22 Lithographic Plates and 200 other Illustrations,
and including Many Useful Tables. Third Edition,
Carefully Revised. 8vo. 993 pages. Cloth. $7 net.
Earkes and Keswoov —Hygiene and Public Health. A
Practical Manual. By Louis C. Parkes. M. D.. D. P. M.
(Lond. Univ.), Lecturer on Public Health at St.
George's Hospital ; Medical Officer of Health and Pub-
lic Analyst, Borough of Chelsea, London, etc. ; and
Henrv Kenwood, M. B., F. C. S., Assistant Professor
of Public Health, University College, London, etc.
Third Edition, Enlarged and Revised. With 85 Il-
lustrations. i2mo. 763 pages. Cloth, $3 net.
Rodman.— Z^wca^fj of the Breast: zcith Special Reference
to Lancer. By William L. Rodman. M. D., LL. D..
Profosor of the Principles of Surgery and of Clinical
Surgery in the Medico-Chirurgical College : Professor
of the Principles of Surgery and of Clinical Surgery
in the Woman's Medical College of Pennsylvania.
8vo. With 69 Plates, 12 in Colors, and 42 other Illus-
trations. Price, cloth, $4 net.
A careful study covering twenty-five years' ex-
perience. It appeals to general practitioners as well
as surgeons.
Thorndike. — A Manual of Orthopcrdic Surgery. By
AuGL'STUs Thorndike, .A. B.. M. D. (Harv. ). As
sistant in Orthopaedics, Harvard Medical School : Vis-
iting Surgeon, House of the Good Samaritan ;
Assistant Orthopaedic Surgeon, Children's Hospital,
Boston : Member American Orthopaedic .Association.
191 Illustrations. The Leather Bound Series of Man-
uals. i2mo. 401 pages. Full morocco. Gilt Edges
and Rounded Corners. $2.50.
Covers its subject concisely and authoritatively
and in a manner that will prove to the general sur-
geon the advantages of a greater familiarity with
orthopaedic work.
Wilcox. — The Treatment of Disease. A Manual of Prac-
tical Medicine. By Reynold Webb Wilcox, M. A..
M. D.. LL. D., Professor of Medicine at the New York
Post Graduate Medical School and Attending Physi-
cian to the Hospital : Consulting Physician to the
Nassau Hospital : Visiting Physician to St. Mark's
Hospital: e.x-President of the American Therapeutic
Society: Vice-Chairman of the Revision Committee
of the United States Pharmacopoeia, etc. Second Edi-
tion. 8vo. 932 pages. Sold by Subscription. Cloth,
$6; half morocco, $7.
CLEVELAND PRESS,
Chicago.
Croftan. — Clinical Therapeutics. A Handbook on the
Special Treatment of Internal Disease. By Alfred
C. Croftan. M. D., Professor of Physical Diagnosis,
and Associate Professor of Medicine. Medical De-
partment University of Illinois: Physician in Chief
to St. Mary's Hospital: Author of Clinical Urinology.
etc. Second Edition. Over 600 pages. Price, cloth,
$5 : half morocco, $6.
Danforth. The Life of Xathan Smith Davis. A. M.,
M. D., LL. D.. i8t7-i904. By I. N. Danforth, A. M.,
M. D.. Chicago. About 200 pages. Illustrated. Price,
cloth, $2.
D.wis. Historx of Medicine. With the Code of Medical
Ethics. By Nathan S.mith Davis. A. M.. M. D.,
LL. I)., Late Emeritus Dean and Professor of Medi-
cine. Northwestern University Medical Sciiool. Chi-
cago. Second Edition. .About 200 pages. Price, cloth.
$2.
Ferguson. The Technic of Modern Operations for Her-
nia. Illustrated by Reproductions of Original Draw-
ings from the .Author's Collection. By" .Alexander
Hugh Ferguson. M. B.. M. D.. C. M..'F. T. M. S..
Commander order of Christ of Portugal : Professor of
Clinical Surgery. Medical Department of the Univer-
sity of Illinois: Professor of Surgery at the Chicago
Post Graduate Medical School : President of the Chi-
cago Hospital : Surgeon to the Chicago and Post
Graduate Hospitals : Fellow of the International Sur-
gical Association. Atnerican Surgical Association. Chi-
cago Surgical Society, etc. Second Edition. About
350 pages, and 70 illustrations. Price, cloth, $4: half
morocco. $5.
846
THE BOOKS OF SIX MONTHS.
[New York
Medical Journal.
Kreissl. a Treatise 011 the Practical Treatment of Dis-
eases of the Urinary and Genital Systems. By Filipp
Kreissl, M. D.. Professor of Genitourinary Diseases
in the Chicago Clinical School, late Attending Sur-
geon to Cook County Hospital. 500 pages. About 200
illustrations. Price, $5; half morocco, $6.
Levings. Everyday Surgery. A Practical Guidebook on
Everyday Surgery and Surgical Handicraft. By A.
Hamilton Levings, AI. D., Professor of the Prin-
ciples and Practice of Surgery in the Wisconsin Col-
lege of Physicians and Surgeons ; Surgeon to St.
Joseph's, Milwaukee County, and Mt. Sinai Hospitals ;
Consulting Surgeon to Johnston's Emergency Hospital
and to the Milwaukee County Hospitals for the Acute
and Chronic Insane. Over 900 pages. 500 Illustra-
tions. Price, cloth, $5; half morocco, $6.
OcHSNER AND Sturm. TJie Organization, Construction,
and Management of Hospitals. With Numerous Plans
and Details. By Albert J. Ochsner, B. S.,F. R. M. S.,
M. D., Surgeon in Chief, Augustana Hospital, and
Professor of Clinical Surgery, Medical Department
University of Illinois. And Meyer J. Stur.m, B. S..
Architect, Chicago. 600 pages. About 350 Illustra-
tions. Fricc. cloth, $7; half morocco, $8.
Patton. Anccsthesia and Ancestlietics, General and Local.
For Practitioners and Students of Medicine and
Dentistry. By Joseph M. Patton, M. D., Professor
of Internal Medicine, Chicago Policlinic; Clinical Pro-
fessor of Diseases of the Chest, Medical Department
University of Illinois. Over 200 pages. 60 Illustra-
tions. Price, cloth, $2.50.
THE CLINIC PUBLISHING COMPANY,
Chicago.
Caniiler. 'The Every Day Diseases of Children and Their
Proper Treatment. "Pertinent Points on Paediatrics;
Diseases of the Newborn; Diseases of the Nose,
ThrDUt. Mouth, and Ear; Diseases of Nutrition; Dis-
eases of the Stomach and Bowels; Diseases of the
l.iver; Diseases of the -Urogenital System; the Acute
Infectious Diseases; Diseases of the Nervous System,
etc. By Geo. H. Candler, AI. D., Chicago. 386 pages.
Price, cloth, $1.
L.vnphear. Surgical Therapeutics. Practical Suggestions
for the Management of Surgical Cases, Management
of I'Vactures, and Dislocations; Application of Band-
ages, Dressings, and Compress Preparations in the
Use of Anaesthetics; Preparation of Patients for
Operation and Postoperative Treatment ; also the
.Medicinal Treatment of the Surgical Diseases. By
ICmory Lanphear, M. D., LL. D., St. Louis, AIo. 396
pages. Price, cloth, $1.
THE GRAFTON PRESS,
New York.
Rav(k;li. Syphilis. In its Medical, Medicolegal and So-
ciological Aspects. By A. Ravogli, M. D., Professor
of Dermatology and Syphilology at the Medical College
of Ohio, Medical Department of Cincinnati University.
Octavo, about 520 pages. 21 Illustrations. Price, cloth,
$5 net; carriage extra.
THE ILLUSTRATED MEDICAL JOURNAL
COMPANY,
Detroit.
Leonard. Physicians' Office Day Book. By C. Henri
Leonard, M. D. Size. 6x9 inches, 136 pages. Leather
and cloth binding. I V'olume. Good for twenty-five
families daily for four years ; for fifty families daily
for two years. Price. $2.
Leonard. Physicians' Handy Ledger. By C. Henri Leon-
ard, M. I). Size. 7.XI0 inches, 250 pages. Leather and
doth binding. Good for four hundred families yearly
for Tive years. Price, $2.50.
WILLIAM R. JENKINS COMPANY,
New York.
Wi^iSLow'.— Production and Handling of Clean Milk.
A complete, plain, practical, and authoritative guide
to the production and distribution of clean milk
for farmers, health officers, milk inspectors, students
of agriculture and dairying country gentlemen, phy-
sicians, and others interested in matters pertaining to
dairymg and hygiene. By Kenelm Winslow, M. D.,
M. D. v., B. A. S. (Harv.), formerly Instructor in
Bussey Agricultural Institute and Assistant Professor
in the Veterinary School of Harvard University. Size,
65-4x9^. 207 pages, many illustrations, including i col-
ored and 15 full-page plates. Price, cloth, $2.50.
W. T. KEENER & COMPANY,
Chicago.
Ballantyne. — Seven Volumes of the Encyclopedia and
Dictionary of Medicine and Surgery and the Special-
ties. By the Most Eminent Authorities. Edited by
J. W. Ballantyne. In Ten Volumes. Price, $5 a
volume.
Bland-Sutton. — Tumors. Innocent and Malignant. Their
Clinical Characters and Appropriate Treatment. Bv
J. Bland-Sutton, F. R. C. S. Fourth Edition. With
355 Engravings. 675 Illustrations. Price, cloth, $5 net.
Bowlby. — Surgical Pathology and Morbid Anatomy. Bv
Anthony A. Bowlby, C. M. G., F. R. C. S. Fifth
Edition. Edited with the Assistance of Dr. F. W.
Andrewes. 632 pages. Price, cloth, $3.50 net.
Buchanan. — Manual of Anatomy, Systematic and Practi-
cal, Including Embryology. Bv A. M. Buchanan,
M. A., M. D., C. M.,'F. R. p. S. (Glas.). Two Vol-
umes. With 268 Illustrations, Mostly Original and in
Colors. Price, $2.75 a volume.
Cripps. — On Diseases of the Rectum and Anus. Including
the Fifth Edition of the Jacksonian Prize Essay on
Cancer. By Harrison Cripps, F. R. C. S. Third Edi-
tion. 538 Pages. Price, cloth, $4 net.
Eden. — Manual of Midieifery. Bv Thomas Watts Eden,
M. D., C. M. (Edin. I, F. R. C. P. (Lond.). With 26
Plates and 233 Illustrations in the Text. 518 pages.
Price, cloth, $3.50 net.
French. — Medical Laboratory Methods and Tests. Bv
Herbert French, M. A., M. D. (Oxon.), F. R. C. P.
(Lond.). Second Edition. 175 pages. Price. $1.50
net.
Grimsdale. — Textbook of Ophthalmic Operations. By
Harold Grimsdale, M. B., F. R. C. S., and Elmore
Brewerton, F. R. C. S. 349 pages. Price, cloth, $4.50
net.
Harris. — Electrical Treatment. By Wilfred Harris. M.D .
(Cantab.). 1'. R. C. P. (Lond.). Illustrated. 372
pages. Price, $2.25 net.
Laveran and Mesnil. — Trypanosomcs and Trypanoso-
miases. By A. Laveran and F. Mesnil. Translated
and Much Enlarged by David Navarro, M. D., B. Sc.,
D. P. H. (London). With Colored Plates and Si
Figures in the Text. 538 pages. Price, cloth. $7.50 net.
Meti hnikokf and Lankester. — The Nezv Hygiene. Three
Lectures on the Prevention of Infectious Diseases. By
Elie Metchnikoff. With a Preface by E. Ray Lan-
kester. 104 pages. Price, $1.
Morris and Dore. — Light and X Ray Treatment of Skin
Diseases. Bv Malcolm Morris," F. R. C. S. (Ed.),
and S. Ernest Dore. M. D. (Cantab.). With 12 Plates.
172 pages. Price, $1.50 net.
l\\c.E.— Elements of Physics for Medical Students. Bv
Frederic James M. P.m;e, B. Sc. (Lond.). F. I. C, Asso'-
ciate of the Royal School of Mines. With a Colored
I'rontispiece and 2.30 Figures in the Text. 288 pages.
Price, $1.25 net.
Paton. — Essentials of Physiology for Veterinary Students.
By 1). Noel Paton. M. D., B. Sc.. F. R. C. P. (F.din.).
Second Edition. Revised and Enlarged, 464 pages.
Price, cloth, $3 net.
May 2, 1908.]
THE BOOKS OF SIX MONTHS.
847
Robertson. — Meat and T'uod Inspection. By William
Robertson, M. D., D. P. H. F. P. S. With Regulations
Governing Meat Inspection in the United States. By
Maximilian Herzog, M. D. 8vo. Iliustrated. Price,
lioth. $3 50 net.
Savage and Goodall. — Insanity and Allied Xeuroses. A
Practical and Clinical Manual. By George H. Savage,
M D. F R. C. P. With the Assistance of Edwin
CIood.all, M. D. (Loud.), B. S., F. R. C. P. With 6
Colored Plates and 45 Illii>trations in the Text. New
and Enlarged Edition. 624 pages. Price, cloth, $2.75
net.
Starling. — Mercers' Company Lectures on Recent Ad-
vances in the Physiology of Digestion, Delivered in tlie
Michaelmas Term, 1905, in the Physiological Depart-
ment of Universitv College. London. By Ernest 11.
Starling, M. D., F. R. S. With 12 Illustrations. 156
pages. Price, cloth, $2 net.
VoN Xoorden. — Metabolism. The Physiology and Patho-
logy of Metabolism, With Its Applications to Practical
Medicine. By Cart. Von Xoorden. In Three Volumes.
1500 pages. Royal 8vo. Price, cloth. $16 a set.
Walsh. — The Hair and Its Diseases, Including Ringworm .
Grexness and Baldness. An Introductory Handbook.
By "David W.alsh, M. D. (Edin.). Second Editi..n.
94 pages. Price, $1 net.
Wood and Woodruff. — The Commoner Diseases of the
Eye. Hou! to Detect and Hon- to Treat Them. For
Students of Medicine. V\'ith 280 Illustrations (Many
Original) and 8 Colored Plates. By Casey A. Wood.
C. M., D. C. L.. and Thomas .A. Woodruff, M. D..
C. M., L. R. C. P. (London). Third Edition, Enlarged
and Improved, with Index. 598 pages. Price, $2.50
net.
LEA & FEBIGER.
Philadelphia.
Adami.— ^ Treatise on General Pathology. By J. George
.Adami, M. D., Professor of Pathology in McGill Uni-
versity, Slontreal. In one handsome octavo volume of
about 850 pages, with 265 engravings and 9 colored
plates.
A correct grasp of pathology, the actual phenom-
ena of disease conceived as an entity, must underlie
its recognition or diagnosi.s, and hence also its ra-
tional treatment. In this new work one of the
world's masters of the subject will develop the gen-
eral aspects with well rounded knowledge and in
clear and charming literary style. The volume will
equally answer the needs of students and practi-
tioners.
Ballenger. — A Treatise on Diseases of the Xose. Throat,
and Ear. By Willja.m Lix'cdln Ballenger. M. D.,
Professor of Laryngology, Rhinology, and Otology in the
College of Physicians and Surgeons. Chicago. Octavo,
about 1,000 pages with about 500 original engravings
and 9 colored plates.
This new w-ork by a leading American authority
will cover both the medical and surgical aspects of
diseases of the nose, throat, and ear. The skill of the
accomplished teacher is manifest in the clear and
sequential presentation of each subject. The book
will be particularly notable for its profuse series of
illustrations, which are entirely original and specially
drawn to emphasize important points, often being in
series in order to give the successive steps of oper-
ative procedures.
Dearborn. — A Textbook of Physiology. For Students and
Practitioners. By George V. N. Dearborn, M. D.
(Harvard), Professor of Physiology in Tufts Medical
College, Boston. Octavo. 550 pages, with about 300
engravings and 8 colored plates.
In a volume of moderate size Professor Dearborn
has succinctly covered tlic field of modern phvsiol-
og\\ and has. moreover, indicated its relations to
otiicr departments of medicine. He has accordingly
produced an excellent textbook for students and a
useful work of reference for practitioners. The
abundant engravings and plates are pertinent and
instructive.
Egbert. — A Manual of Hygiene and Sanitation. By Seneca
Egbert, ^I. D., Professor of Hygiene in the Medico-
Chirurgical College, Philadelphia. Fourth edition, thor-
oughly revised. i2mo., 498 pages, with 93 illustrations.
Price, cloth, $2.25, net.
H.\RDAWAV AND Grindon. — A Handbook of Cutaneous
Therapeutics. By W. A. Hardawav, A. M., M. D..
Professor of Diseases of the Skin and Syphilis, and
JosEi'H Grindon, Ph. B., .M. D., Professor of Clinical
Dermatology and Sjphilis, in the Washington Uni-
versitv, St. Louis. i2mo., 608 pages. Price, cloth.
$2.75, net.
By concentrating attention upon diagnosis and
treatment the two eminent authors have been able to
cover the whole practical side of dermatology in an
exceedingly comprehensive volume of moderate size.
They have written for the general practitioner, who
must treat a class of cases often considered difficult
and obstinate. The therapeutic sections are abun-
dant and place at the reader's command means and
methods easily accessible. At the end of manv of
ihe chapters are given carefully selected formulas ii;
addition to those in the text. The foregoing charac-
teristics will also render the volume particularly suit-
able as a textbook in the majority of college courses.
Hare. — A Textbook of Practical Diagnosis. The Use of
Symptoms in the EHagnosis of Disease. By Hobart
Amorv Hare, AI. D., Professor of Therapeutics and
Materia Medica in the Jefferson Medical College of
Philadelphia. New (6th) edition, thoroughly revised.
Octavo. 616 pages, with 203 engravings and 16 full-
page colored plates. Price, cloth, $4.50 net.
Osi-KR.—.\Iodern Medicine. Its Theory ind Practice in
Original Contributions by Eminent .American and For-
eign Authors. Edited by A\'i;i.l\.m Osler, M. D..
Regius Profesor of Medicine in Oxford University.
England; Honorary Professor of Medicine in Johns
Hopkins University. Baltimore ; formerly Professor in
the University of Pennsylvanqia, Philadelphia, and in
.McGill University, Montreal. .Assisted by Thomas
McCrae. M. D., .Associate Professor of Medicine and
Clinical Therapeutics in the Johns Hopkins University.
Baltimore. In seven octavo volumes of about 900 pages
each, illustrated. Price, per volume, cloth, $6, net:
leather. $7, net; half morocco. $7.50, net. Subscriptions
received only for the whole work.
The value of such a work, or, rather, the necessitv
for it at the present time, scarcely needs to be stated.
Of all the professions, that which grapples with the
problems of life and death most requires the fullest
know ledge which can be develojjed b\- human effort
and experience. Responding to this need, medicine
is the most active and fruitful of all professions in
developing new knowledge. As one advance begets
another, progress is self accelerating. The past cen-
tury was more productive than all prior time, and
years now outstrip former decades. Complete pres-
entations of medicine therefore become necessary at
more frequent intervals, and render a double service
by placing every member of the profession in com-
mand of the best collective knowledge of all. and
providing a new^ and higher plane for fresh ad-
vances. The one requisite is that such works shall
be authoritative and applicable to practical ends.
They must start under such auspices as will attract
the real leaders in the various subjects to present
their knowledge, the right man must be chosen for
each, and the assembled parts must cover the whole
848
THE BOOKS OF SIX MONTHS.
[New York
MiOJiCAL Journal.
realm. Only the broadest mind can view so vast a
field in its natural perspective, neither magnifying
nor neglecting anything. Only a man of the widest
knowledge and universally admitted eminence can
select the best writer for each chapter, whether in
America, Europe, or Asia, and secure his coopera-
tion. Dr. Osier combines all these requirements of
knowledge and position, and so is thoroughly fitted
to plan and edit such a work. The test of its value
is its acceptance by the profession for use in their
daily duties.
P\i<K. — The Principles and Practice of Modern Surgery.
By RoswELL P.MU-c, M. D., Professor of Surgery in
the University of Buffalo, hi one very handsome im-
perial octavo vohnne of 1074 pag^s, with 722 engrav-
ings and 00 full-page plates in colors and monochrome.
Price, cloth, $7, net ; leather, $8, net.
This new work from the individual pen of Dr.
Park furnishes an authoritative and comprehensive
exposition of the most modern surgery, both in its
principles and practice. By the adoption of a large
form the equivalent of fifteen hundred ordinary
pages has been brought into a convenient volume of
a thousand. It is a book of the widest utility and
importance to all classes of readers concerned in any
•way with surgery. It suffices the student during his
entire course by carrying him from the basic princi
pies through to the diagnosis and operative treat-
ment of all surgical afifections. The consecutivcness
and completeness of such a volume will appeal to
teachers as an advantage second only to the clear
presentation resulting from the author's long expe-
rience as a teacher himself. Practitioners requiring
a guide thoroughly abreast of the times and answer-
ing all needs will appreciate the mature and conser-
vative knowledge of one of the world's foremost sur-
geons. The author's surgical confreres will find
much of interest and value in its pages.
Potts. — Xcrvotts and Mental Diseases. A Manual for Stu-
dents and Practitioners. By Charles S. Potts, M. D.,
Professor of Neurology in the Medico-Chirurgical Col-
lege of Philadelphia. New (second) edition, thor-
oughly revised and greatly enlarged. In one i3mo
volume of about 550 pages, with 133 engravings and
9 full-page plates.
KciiDiMAN. — A Manual of Materia Medico. For Students
of Pharmacy. By E. A. RuDDi.\rAN, Ph. M., M. D.,
Professor of Pharmacy and Materia Medica in Van-
derbilt University. i2mo, 453 pages. Price, cloth,
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This textbook, written by an eminent teacher, suc-
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and thorough.
Simon. — A Textbook of Physiological Chemistry. For
Students of Medicine and Physicians. By Charles
H. Simon, M. D., Professor of Clinical Pathology in
the Baltimore Medical College; author of Simon's
Clinical Diagnosis, etc. Octavo, 490 pages. Price, cloth,
$3 25 net.
Treves. — Surgical Applied Auatoniv. By Sir Frederick
Treves, F. R. C. S.. Sergeant Surgeon to H. M. the
King, formerly Lecturer on Anatomy at the London
Hospital. New (fifth) edition. Revised by the Au-
thor, with the assistance of Arthur Keith, M. D..
F. R. C. S. i2mo, 640 pages, with 107 Illustrations,
of which 41 arc in Color. Price, cloth, $2.25 net.
Treves.— Manual of Operative Stirgerv. By Sir Fred-
erick Treves, F. R. C, S.. Sergeant Surgeon to H. M.
the King, Consulting Surgeon to the London Hospital.
New edition, revised liy the author and Jonathan
Hutchinson, Jr., F. R. C. S., Surgeon to the London
Hospital. In two octayo volumes.
J. B. LIPPINCOTT COMPANY,
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De Garmo. — Abdominal Hernia. By W. B. De Garnio,
M. D. Over 226 Illustrations. 8yo. 456 pages. Price,
cloth, $5 net. By subscription only.
DwiGHT.— / 'ariations of the Bones of the Hands and Feet.
By Thomas Dwight, M. U., LL. D. Illustrations and
Plates. 8vo. 108 pages. Price, cloth, $5 net. By-sub-
scription only.
FucHS and Duane.— Textbook of Ophthalmology. By
Ernst Fuchs, Professor of Ophthalmology in the
University of Vienna. Translated and Enlarged by
Alexander Duane, M. D., Surgeon to Ophthalmic and
Aural Institute, New York. 441 Illustrations in Colors
and in Black and White. Third Edition. Svo 877
pages. Price, cloth, $6 net. By subscription only.
Harvey Lectures. Second Series. Lecture- Delivered
Under the Auspices of the Harvey Society of New
York, 1906-1907. Illu.strated. Crown Svo. Price,
cloth, $2 net.
Ortner. — Treatment of Internal Diseases. By Dr. Norbert
Ortner. Svo. 600 pages. By subscription only. Price,
cloth, $5 net.
Pfaundler and Schlossman.— Diseases of Children.
Edited by Professor M. Pfaundler and Professor A.
Schlossman. English Translation Edited bv Henry
L. K. Shaw, M. D., of Albany, N. Y. ; L. La Fetka,
M. D., New York. With an Introduction by L.
Emmett Holt. M. D. Illustrated. Svo. Four Vol-
umes. By subscription only. Price, cloth, net, $5 a
volume.
PiERSOL. — Human Anatomy. Edited by George A. Pieksol,
M. D. Illustrated. Imperial 8vo. Price, cloth, $7.50
net; half leather, $9 net. In two volumes, by subscrip-
tion only, hah leather, $10 net.
Ramsey. — Practical Life Insurance Examinations. Bv
Murray E. Ramsey, M. D. A Handbook for Life
Insurance Examiners. i2mo. Price, cloth, $1.25 net.
Remington.— r/ie Practice of Pharmacy. Bv Joseph P.
Remington, Ph. M. New Fifth Ed"ition. Illustrated.
Price, cloth, $6; sheep, $6.50: half Russia, $7.50.
Schmidt, — Pain. By Dr. Rudolf Schmidt. An Accurate
and Thorough Analysis of the Various Painful Sensa
tions That Occur in Internal Diseases, Their Mode
of Causation, and Correct Interpretation. Illustrated.
Crown 8vo. Price, cloth, $3 net.
Thompson.— G7/);//'Jcj of Medical Europe. By R. L.
Thompson, M. D. An Account of a Summer's Visit
to the Prominent Medical Schools of Europe. With
Many Illustrations Reproduced from Pen and Ink
Drawings and Photographs. Illustrated. i2tTio. Price,
cloth, $2 net.
Thomson and A'Iiles. — Manual of Surgery. By Alexis
Thomson, F. R. C. S. (Ed.), and Ale".\ axder Miles,
F. R. C. S. (Ed.). Second Edition, Revised and En-
larged. Two Volumes. 515 Illustrations, Crown Svo.
Price, $5 net.
LONGMANS, GREEN & COMPANY,
New York.
Bose. — Comparative Electro/Physiology. By J.vc.adis Chux-
der Bose, M. A.. D. Sc., Professor, Presidency Col-
lege, Calcutta. Svo. Pp. xlvii-760. Price, $5.75,
Newman. — Movable Kidnex and Other Displacements and
Malformations. By D.wid Newman, ]\I. D„ F. F. P,
S. G., Surgeon to the Glasgow Royal Infirmary; ex-
President of Glasgow Medico-Chirurgical Society,
With 25 Illustrations. Svo. Pp. xii-233. Price, $1.75
net.
Rivers,— 77if Influence of Alcohol and Other Drugs on
Fatigue. By W. H, R. Rivers. M. D. F R. C. P,
Svo. (Nearly ready.)
May 2, 1908. 1
THE BOOKS OF SIX MOXTHS.
849
Russell— 77u' Reduction uf Cancer. By the Hon. Rollo
Russell. Crown 8vo. 62 pages. Price, $0.50.
This book consists of an examination of the view
strongly held by distinguished medical men that can-
cer is to a great extent a disease due to overfeeding,
to toxic beverages, and to worry. The results of a
comparison, by the author, of different countries,
communities, and occupations are found to support
this view very fully.
The Proceedings of the Royal Society of Medicine. Vol.
I. No. 3. Large square 8vo. Price, $2.00. The
Proceedings will be published monthly from November
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THE MACMILLAN COMPANY,
New York.
Barrus. — Nursing the Insane. By Clara Barrus. M. D.,
Woman Assistant Physician in the Aliddletown State
Homoeopathic Hospital, Aliddletown, N. Y.
Clark. — Neurological and Mental Diagnosis. A Manual
of Methods. B_\- L. Pierce Clark, M. D., Senior Vis-
iting Physician to the Hospital for Nervous Diseases,
New' York; Visiting Neurologist to the Randall's
Island Hospitals and Schools; Consulting Neurologist
to the Manhattan State Hospital, New York; Consult
ing Neurologist at the Craig Colony for Epileptics.
Sonyea. N. Y.. Assistant Neurologist at the Vanderbilt
Clinic (Columbia University'. And A. Ross Diefen-
DORF, M. D.. Lecturer in Psychiatry in Yale Univer-
sity; Member of the American Neurological Associa-
tion, of the New York Neurological Association, of
the New York Psychiatrical Society, and of the Amer-
ican Medicopsychological Association, etc.
Confessio Medici. By the Writer of "The Young People."
i2mo. Price, $1.25 net.
A collection of delightful essays by a physician
who has evidently read very extensively, and has
gathered from a wide experience a fund of informa-
tion which he draws upon with kindly humor and a
literary grace that make his writing extremely at-
tractive. The book is just the one which a weary
doctor would enjoy reading before his fire after the
day's work is done.
Dawbarn and Delphey. — An Aid to Materia Medico. By
Robert H. AI. Dawbarn. M. D., Professor of Surgery
and of Surgical Anatomy. New York Polyclinic
Medical School ; Professor of Surgery, Fordham
Medical College, New York ; Visiting Surgeon to the
City Hospital. New York. Fourth Edition. Revised
and Enlarged by Eden V. Delphev, M. D.
Keith. — Cancer. Relief of Pain and Possible Cure. By
Skene Keith, M. B.. F. R. C. S. (Ed.). Author of
Introduction to the Treatment of Disease by Galvan-
ism, Electricity in the Treatment of Uterine Tumors,
Gyncccologtcal Operations. And George E. Keith.
M. B., C. M., Author of Te.vtbook of Abdominal Sur-
gery, with Mr. Skene Keith.
Storring and Loxeday. —Mental Pathology in Its Relation
to Normal Psychology. A Course of Lectures deliv-
ered in the University of Leipsic. By Gustav Stor-
ring, Dr. Phil, et Med. Translated by Thomas Love-
day, j\L A. Bibliography and Index. 8vo. Pp. x-298.
Price, cloth, $2.75 net.
The author of these lectures, who is now pro-
fessor of philosophy in the University of Zurich, be-
lieves that the study of psychology heretofore has
been too metaphysical. He regards conscious pro-
cesses as deeply influenced by bodily conditions, and
holds that a study of abnormal mental conditions,
connected with known physical causes, will throw
most light on normal mental processes. The book,
in its fullness of discussion and illustration, becomes
a storehouse of facts in psychiatry, as well as im-
portant to the psychologist.
THE MIDLAND PUBLISHING COMPANY,
Columbus, Ohio.
Rutter. — Manual of Ijisaiiity. U'itli Especial Reference to
Criminal Responsibility. By H. C. Rutter, M. D.,
Medical Director, Mental and Ner\ous Department,
Ohio Sanatorium, Columbus, Ohio. Formerly con-
nected with the Hospital for the Insane at Dayton,
Ohio; the Hospital for the Insane. Athens, Ohio;
State Hospital for the Insane. Columbus, Ohio ; Ohio
Hospital for Epileptics, Gallipolis, Ohio. 295 pages.
Price, cloth. $2.50.
OXFORD UNIVERSITY PRESS,
London and New York.
The O.vford .Medical Manuals. Edited bv J. Keogh
Murphy. M. A., M. U., M. C. (Cantab.)," F. R. C. S.,
and G. A. Sutheklaxd. M. D.. F. R. C. P.
Abel.— .-J Laboratory Handbook of Bacteriology. By Dr.
Rudolf Ahel. Medical Privv Councillor. Berlin. Trans-
lated by Dr. M. H. Gordon, M. A., M. D. (O.xon.), B. Sc.
224 pages. Tenth Edition. Price, $1.50.
Adamson. — Skin Affections in Childhood. By H. G.
Adamson, M. D., M. R. C. p.. Physician tor Diseases
of the Skin, Paddington Green Children's Hospital, and
the North Eastern Hospital for Children. 284 pages.
Illustrated. Price, $1.50.
"Sound in information and practical in teaching."
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"Canot fail to be popular as it deserves to be." —
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Bardswf.ll and Chapman. — Diets in Tuberculosis. Prin-
ciples and Economics. By Noel D. Bardswell. M. D.,
Medical Superintendent, King Edward Mi's Sana-
torium, Midhurst. and J. E. Chapman, M. R. C. S.
A full account of the practical value and cost of
diets in general, and in every detail of the various
diets which may with advantage be used in the treat-
ment of tuberculosis.
Barwell. — Diseases of the Laryn.v. Bv Harold Barwell.
M. B. (Lond.) ; F. R. C. S. (Eng.) ; Surgeon for Dis-
eases of the Throat, St. George's Hospital : Larj ngol-
ogist. Mount Vernon Hospital for Diseases of the
Chest; Consulting Surgeon for Throat and Ear Dis-
eases. Cripples' Home for Girls. 266 pages. Illus-
trated. Price. $1.50.
"In the attempt to adapt it to the requirements of
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ful."— St. George's Hospital Gazette.
BoLm.— Trachoma. Bv Dr. J. Boldt. Translated bv J.
Herbert Parsons, D. Sc., F. R. C. S., and Thomas
Snowb.\ll. M. B., C. M., Burnley. With an Introduc-
tory Chapter by E. Treacher Collins. F. R. C. S.
232 pages. Royal 8vo. Price. $3.
"This interesting monograph is a library in itself
which (to use a hackneyed phrase) no ophthalmolo-
gist can afford to be without." — H ouia-opathic Eye,
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Boyle. — Practical Anccsthetics. By H. Edmund G. Boyle,
M. R. C. S., Anaesthetist to 'St. Bartholomew's Hos-
pital, etc.
"As a rule, it is better for a student to avoid the
larger books on anresthetics until he has sttidied the
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Bkockbank. — Life Insurance and General Practice. Bv
E. M. Brockbank, M. D.. F. R. C. P.. Assistant Physi-
cian, Manche-ter Royal Infirmary. 8vo. Price. $2.50.
An account of life insurance from the practition-
THE BOOKS OF SIX MONTHS.
[New York
Medical Journai,.
er'-s point of view, whether employed as an exam-
iner or consuked by a patient as to the prospects of
acceptance or not. The question of increased risks
for various causes is fully dealt with. The whole
will be found to be practical and complete.
CoKMK. — Diseases of the Male Generative Organs. By
EuRED M. Corner, M. C. (Cantab.). F. R. C. S., Assist-
ant Surgeon, St. Thomas's Hospital, and Senior Assist-
ant Surgeon, Great Ormond Street Hospital, etc. 279
pages. Illustrated. Price, $1.50.
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Corner and Pi^cuf.s.— Operations of General Practice. By
Edked M. Corner. M. C. (Cantab.), F. R. C. S., Assis-
tant Surgeon to St. Thomas's Hospital; Senior Assis-
tant Surgeon, Hospital for Sick Children, Great Ormond
Street, etc. ; and Henry Irving Pinches, M. A., M. B.
206 pages. Over 175 Illustrations. Price, $5.50 net;
postage 12 cents extra.
"The details of the many lesser operations in sur-
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etc.', which a medical man may elect to perform, have
been collected in this work. As the large textbooks
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one book should be a necessity for every busy gen-
eral practitioner. Many illustrations have been pre-
pared to illustrate the various points in their per-
formance. It is large without being too big. It is
clearly written, and gives just that amount of assist-
ance which is likely to be needed." — The Lancet.
Gv.E.— Auscultation and Pereitssion, zvith the other methods
of Physical Exaniination of the Chest. By Samuel
Jones Gee, M. D., F. R. C. P., Honorary Physician to
H. R. H. the Prince of Wales, Consulting Physician to
St. Bartholomew's Hospital, etc. Fifth Edition. 325
pages. Price, $1.50.
Gee. — Medical Lectures and Clinical Aphorisms. By
Samuel Gee. M. D., F. R. C. P., Honorary Physician
to H. R. H. the Prince of Wales, Consulting Physician
to St. Bartholomew's Hospital, etc. Price, $1.50.
"W'c cordially recommend this book to be "read,
marked, learne.d, and inwardly digested' by all prac-
titioners and students. It is small and easily car-
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repaid by the valuable hints which it contains." —
Practitioner.
CiuTHKiE. — Functional Nervous Disorders in Childhood.
By Leonard Guthrie, M. D.. F. R. C. P., Senior Physi-
cian to Paddington Green Children's Hospital ; Physi-
cian to the Hospital for Paralysis and Epilepsy, Maida
Vale, etc. Price, $3 net ; postage. 12 cents extra.
"We think. Dr. (iuthrie"s work is likely to take its
place as a standard work on the subject, and to be
one of the most popular of the Oxford medical pub-
lications."— The Practitioner.
Keo(;h. — A Manual of Venereal Disease. By Officers of
the Royal Army Medical Corps. Introduction by The
Director General of the Army, Sir Alfred Keogh.
K. C. B. ; History, Statistics, Invaliding, Effect in Cam-
paigns, etc., by Lieut. Colonel C. H. Melville, D. P.
IT., Secretary to the Advisory Board; Clinical Pathol-
ogy and Bacteriology, by Colonel Leishmann, F. R.
S.. R. A. M. C. ; Clinical Course and Treatment, by
Major C. E. Pollock, R. A. M. C. 282 pages. Illus-
trated. Price, $1.50.
"The amount of information the book contains is
very great. The pathology, diagnosis, and treat-
ment of syphilis are fully considered." — .S7. Barthol-
omew's Hospital Journal.
L(.iCKV\ooD. — Clinical Lectures and Addresses on Surgery.
By C. B. LocKWO(jD, Surgeon to St. Bartholomew's
Hospital; late Hunterian Professor, Royal College of
Surgeons, England ; late Surgeon to the Great North-
ern Hospital. 307 pages. Illustrated. Price, $1.50.
"Whatever Mr. Lockwoocl writes every thinking
surgeon is compelled to read." — British Medical
Journal.
"It is a work which every student should read be-
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that the same student will in the after years of his
own professional work read the book again with an
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The Medical Chronicle.
McCann. — Cancer of the IP'omb: Its Symptoms, Diagno-
sis, Prognosis, and Treatment. By Frederick J. Mc-
Cann, M. D. (Edin.), Fellow of. the Royal College of
Surgeons, England, Member of the Royal College of
Physicians, London, Physician to the Samaritan Hos-
pital for Women, London, Lecturer on Gynaecology,
Medical Graduates' College and Polyclinic, London.
Fully illustrated. Price, $7 net ; postage, 12 cents
extra.
"The book is one of great merit; it will be read
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PoYNTON. — Heart Disease, Including Thoracic Aneurysm.
By F. J. PoYNTON, M. D., F. R. C. P., Assistant Physi-
cian to University College Hospital ; late Sub-Dean to
the Medical Faculty of University College ; Physician
to Out-Patients, the Hospital for Sick Children, Great
Ormond street. 310 pages. Illustrated. Price, $1.50.
A handbook dealing with the principles of phys-
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and treatment of the more itnportant diseases of ti e
heart, including thoracic aneurysm. The aim of this
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Sargent. — Surgical Emergencies. By Percy Sargent, M.
B. (Contab.), F. R. C. S. (Eng.), Assistant Surgeon,
St. "Thomas's Hospital ; National Hospital for Paralysis
and Epilepsy, Queen's Sciuare ; and Senior Assistant
Surgeon, Victoria Hospital for Children. Price. $2 net.
'Tt is a book we can heartily recommend to the
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Sutherland. — Treatment of Disease in Children. By G.
A. Sutherland, M. D.. F. R. C. P., Physician Padding-
ton Green Children's Hospital, and North Western
Hospital, Late President of Section in Diseases of
Children. British Medical Association. 310 pages.
Price, $1.50.
"We commend it to those who require a small and
trustworthy work on the management of sick chil-
dren."— Lancet.
Tod. — Diseases of the Ear. By Hunter Tod, M. B., F. R.
C. S., Aural Surgeon to tlie London Hospital, etc. Il-
lustrated. Price, $2 net.
"Will certainly take its place among the very best
and most up to date works on the subject." — Journal
of Laryngology.
Tweedy and Wrench. — Rotunda Practical Midivifery. Bv
Erne.st Hastings Tweedy. M.' D., F. R. C. P. I., Mas-
ter of the Rotunda Hospital, Dublin ; and E, M.
Wrench, Assistant Master. 464 pages. Fully illus-
trated. Price, $6.
This is a practical book on midwifery, embodying
the teachings of the Rotunda School. It contains no
])athology or mechanics of obstetrics except where
May 2, 1908.]
THE BOOKS OF SIX MOXTHS.
either is essential for understanding the proposed
treatment. The conduct of normal labor is dealt
with, the closest attention given to every practical
detail, however small, and all possible complications
are treated in the same way. The authors devote the
closest attention to the management of the puerperal
state and the earliest disorders of the infant, also to
the causes and immediate treatment of fever occur-
.ring in the puerperium. The work is illustrated by
over one hundred drawings and original photo-
graphs.
Waggett. — Diseases of the Xose and Throat. By E. B.
Waggett, M. D. (Cambridge J, Surgeon for the Throat
and Ear Department of the Charing Cross Hospital;
Surgeon, London Throat Hospital, and Throat and Ear
Department Great Northern Hospital and Central Hos-
pital. Illustrated. Price, $2 net.
"Short, concise, and, above all, readable. The
illustrations are original and are very good." — St.
Bartholomeiv's Hospital Journal.
Wallace.— Eiilargemoit of the Prostate. By Cuthbert
Wallace, M. S., F. R. C. S., Assistant Surgeon to St.
Thomas's Hospital, etc. 215 pages. Fully illustrated.
Price, $4.50.
This is a full account of this affection and its vari-
ous consequences. The author first deals fully with
our present knowledge of the anatomy, physiology,
and pathology of the prostate, the work being copi-
ously illustrated throughout by original drawings
from specimens and photographs, also photomicro-
graphs. He then treats of the anatomical character-
istics of enlargement and its results, direct and indi-
rect. The various means of treatment are then dis-
cussed, the more recent operative treatment is fully
described, its results summarized, and the after treat-
ment carefully dealt with. The work is a complete
and exhaustive monograph, containing over one hun-
dred and fifty illustrations in the text and a colored
plate.
Wrench. — Rotunda Midwifery for Xiirscs and Midn'hrs.
By G. T. Wrench, M. D., Late Assistant Master of the
Rotunda Hospital ; with a Preface by the Master of the
Rotunda. Illustrated. Price, $2.
This is an entirely practical account of that part
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embody the teaching of the Rotunda, and is fully
illustrated, containing over one hundred illustra-
tions, all of which are original.
REBMAN COMPANY,
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Bakdeleuen and Haeckel.— .-J); Atlas of Applied (Typo-
graphical) Human Anatomy. For Students and Prac-
titioners. By Dr. Karl von Bardeleben (Jena) and
Professor Dr. Heinrich Haeckel (Stettin). Under
the collaboration of Dr. Fritz Frohse (Berlin), and
with contributions by Professor Dr. Theopor Ziehen.
Only authorized English adaptation from the third
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M. Ch. Oxon., F. R. C. S. England. One crown
quarto volume containing 204 woodcuts, most of which
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by Subscription only.
^TA.etvsow.— Synoptical Delineation of the Xeries of the
Human Body. By A. K. BELOfsow. Professor of
.\natomy at the University of Charkow (Russia).
Three large colored charts mounted on linen, with
rollers, accompanied by an explanatory text by Pro-
fessor Dr. R. Kr-\i PE. of Berlin. Explanatory text in
book form. Price, $30. Full descriptive circular with
4 illustrations (one in colors) will be sent on ap-
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These three "synoptical charts of the nerves of
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senting all the peripheral nerves with anatomical ac-
curac}- in a dummy has been solved by Belousow in
the most masterly fashion. Chart I shows the nerves
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enlarged. Thus the upper part of the Chart (head
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makes it possible to see all the details even at a con-
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deals with the lower one. The three charts are
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BocKENHEiMER AND Frohse. — An Atlas of Typical Opera-
tions in Surgery. Vor Practitioners and Students. By
Dr. Ph. Bockenheimer and Dr. Fritz Frohse. Adapted
(only authorized) English version by J. Howell
Evans, M. A., M. B., M. Ch. Oxon., F. R. C. S. Eng-
land. With 60 plates (12 in. by gYi in.) in three color
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surgical instruments and appliances to which reference
is made in the text. Handsomely bound in half leather.
Price, $16. Sold by subscription only.
Braddon. — The Cause and Prevention of Beriberi. By W.
Leonard Braddon. M. B., B. S., F. R. C. S., State Sur-
geon, Negri Sembilan, Federated Malay States. Royal,
8vo. Price, cloth, $6.
BuLKLEY. — On the Relations of Diseases of the Skin to
Internal Disorders. With observations on Diet, Hy-
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BuLKLEV, A. M., M. D., Physician to the New York
Skin and Cancer Hospital, Consulting Physician to the
New York Hospital, etc. Small 8vo. Price, $1.50.
BuLKLEV. — The Influence of the Menstrual Function on
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Bulklev. — Local Treatment in Diseases of the Skin. By
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Price, cloth, $1.
Carrington. — Vitality, Fasting, and Xutrition. A Physio-
logical Study of the Curative Power of Fasting, to-
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Human Vitality. By Herew.\rd Carrington, Member
of the Council of the American Institute for Scientific
Research, Member of the Society for Psychical Re-
search, London; Author of The Physical Phenomena
of Spiritualism, etc., with an introduction bv .\.
Rabagliati, M. a., i\. D.. F'. R. C. S., Hon. (iynje-
cologist and late Senior Hon. Surgeon. Bradford Royal
Infirmary. One 8vo. volume. Price, cloth, $5.
Conferences on the Moral Philosophy of Medicine. By an
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Dining and Its Amenities. By a Lover of Good Cheer.
Demy 8 vo. Price, cloth, $2.50.
Forel. — Hypnotism, or Suggestion and Psychotherapy. A
Study of the Psychological, Psychophysiological' and
Therapeutic Aspects of Hypnotism. Bv Dr. (Med.)
August Forel, Dr. Phil. (H. C.) et Jur. ( H. C),
Chigny. Switzerland : formerly Professor of Psychia-
852
THE BOOKS OF SIX MONTHS.
[New V<,kk
Medical Journal.
try and Director of the Provincial Limatic Asylum,
Zurich. Translated by H. W. Armit, M. R. C. S.,
L. R. C. P., from the fifth (German) edition. Amer-
ican cdilicin, revised and corrected. One 8vo volume.
Price, $3.
FoREL.— 77u' Sexual Question. By Dk. (Med.) August
[•OREL. Dr. Phil. (H. C.) et Jur. (H. C. ) Chigny, Swit-
er'.and : formerly Professor of Psychiatry and Di-
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FouRXiER. — Treatment and Prophyla.vis of Syphilis. By
Alfred Folrxier. Professor at the Faculty of Medi-
cine, Member of the Academy of Aledicine, Physician
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Royal 8vo. Price. $5. American edition, revised and
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Royal 8' n. Price, cloth, $5.
GouLEV.— ,b"i</.i;i/ v ,if Gcnitourinarv Organs. By J. W. S.
GouLEY, M. b. Demy 8vo. Price, cloth, $3.
GuiLLEAtiNOT. — Electricity in Medicine. By Dr. W. H.
GuiLLEMi.voi . Paris. A Textbook for Students and
Medical Practitioners. Only authorized translation by
VV. Deane Butcher, M. R. C. S. England, Surgeon
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Jacobl — .4 Portfolio of Dernioehromes. By Professor Dr.
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Klopstock .\xd Kowarsky. — A Manual of Clinical Chem-
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IV. The Sputum V. The Gastric Contents. VI.
The Fsces. VII. The Urine. VIII. The Urethral and
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The Usual Methods of Bacteriological Examination,
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Price. $2.25.
Krafft-Ebixg. — Psychopathia Sexualis. With special ref-
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fessor of Psychiatry and Neurology, University of
Vienna. Only authorized Translation from the Twelfth
enlarged and revised German Edition by F. J. Reb-
MAN. Royal Svo. Price, cloth. $4.
Luke. — .hiecslhesia in Denial Surgerv. Second Edition.
By Thomas D. Luke. M, B., F. R. C. S. E. Illus
tratcd. Crown 8vo. Price, $1.75.
Neissek .\xn .Ta(Oei. — Hionograpltia Dermatologica. An
Atlas of New and Rare Skin Diseases. Edited by
Professor Dr. .Albert Neisser (Brcslau) and Pro-
fessor Dr. EnuARi) Jacobi (Freiburg i. Br.), with the
collahoratif n of a large number of prominent special-
ists throughout the world. Crown 410. Published
twice a year. Price. $2.50 per issue.
Neustaetter.— i/fe/ajco/'.v. Phantoms and Diagrammatical
Models, in Colors, with a Guide to the Theory and
and Practice of Skiascopv. By Otto Neustaetter,
M. D., Munich, Price, $16.
Sabouraud. — Regional Dermatology. An Elementary
Manual of Regional Topographical Dermatology. By
R. Sabouraud, Director of the City of Paris Dermato-
logical Laboratory at the St. Louis Hospital. Only
authorized translation by C. F. Marshall, late As-
sistant Surgeon to the Hospital for Diseases of the
Skin, Blackfriars, London. Royal Svo. 231 photo en-
gravings in the text. Price, $5.
This is a new departure in dermatolog\-. The book
will strongly appeal to the practical mind of the busy
practitioner.
Schleip. — Hematological Atlas zvith a Description of the
Technic of Blood Examination. By Priv. Doz. Dr.
Karl Schleip, Scientific Assistant in the Medical
Clinic, University of Freiburg i/B. English adaptation
of text by Frederic E. Sqxderx, M. D., Professor of
Clinical Pathology, New York Post Graduate Medical
School and Hospital, Director Clinical Laboratory,
New York Lying-in Hospital. With 71 colored Illus-
trations, and many diagrams in the text. One quarto
vol. leather. Price, $10.
Schrotter. — The Hygiene of the Lungs. By Professor
Dr. L. vox Schrotter, Director of the Third Medical
Clinic in the University of Vienna. Translated by H.
W. Armit, M. R. C. S.. L. R. C. P, Crown Svo. Price,
cloth, $1.
The work is intended to lay before the uninitiated
reader (and also before the practitioner) the ana-
tomical and physiological characteristics of the or-
gans of respiration, and the best methods of protect-
ing these organs. It deals with the more common
ailments, and with the rational treatments, not onl\
of the aflfected parts, but also of the causal agents,
thus combining an elementary therapy with an ele-
mentary prophylaxis. In the most readable manner
possible, this little book tells a useful story of the
healthy and diseased lungs, a story which the practi-
tioner who reads it will not despise, and which he
will find of great value to give his patient to read.
Sexator-Kaminer. — Health and Disease in Relation to
Marriage and the Married State. A Manual Con-
tributed to by many authors. Edited by Geh. Medi-
zinalrat Professor Dr. H. Senator, and Dr. (Med.) S.
Kaminer, The only authorized translation from the
German into the English language by J. Dulberg,
M. D.. of Manchester. England. In one handsome
royal Svo volume of 1257 pages. Price, cloth, com-
plete, ,$6.
Stroxc;. — Modern. Electrotherapeutics. An Elementary
Textbook on the Scientific Use of Electricity and
Radiant Energy. By Frederick Finch Stroxg. M. D.,
Instructor in Electrotherapeutics at Tufts College Med-
ical School, Boston. Crown Svo. Price, $1.
Tibcles. — Food and Hygiene. An Elementary Treatise .on
Dietetics and Hygienic Treatment. By William Tib-
BLEs. LL D., L. R. C. P., M. R. C. S., L. S. A., Medi-
cal Officer of Health, Fellow of the Royal Institute of
Public Health, etc. Large crown Svo. Price, cloth, $3.
Wachexheim, — Climatic Treatment of Children. By
Frederick L. Wachexheim, M. D., Chief of Clinic,
Children's Department, Mount Sinai Hospital and Dis-
pensary. New York. Demy Svo. Price, cloth, $2.50.
THE SAALFIELD PUBLISHING CO.,
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The Doctor's Recreation Series, hi Tweke Volumes.
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Ames. — The Inn of Rest. Divers Episodes in Hospital
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Edited by Sheldon E. Ames. Volume VII. Four
Photogravure Illustrations. Large octavo. Price,
cloth. $2.50: half morocco, $4.
May z, 1908.]
THE BOOKS OF SIX MONTHS.
853
Davjes. — Tlic Doctor's Leisure Hour. Facts and Fancies
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Davies. — Doctors of the Old School. Being Curiosities of
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Jeaffkkson. — A Book About Doctors. By John Cordy
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Kellev. — /;; the Year 1800. Being the Relation of Sundry
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Year 1800. A novel by Samuel Walter Kellev,
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tavo. Four Illustrations in Photogravure. Price, cloth,
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KiXG. — The Doctor's Domicile. Concerning the Home Life
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AiKENs. — Hospital Training-School Methods and the Head
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Anders.— .4 Textbook of the Practice of Medicine. By
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Camac. — Epoch-Making Contributions ti> Medicine and
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Ca.mpbell. — Textbook of Surgical Anatomy. B_v W.m.
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oratory, Woods Hole, Mass. i2mo of 201 pages. Price,
cloth. $1.25 net.
Eisendrath. — A Textbook of Clinical Anatomy: For Stu-
dents and Practitioners. By Daniel N. Eisendrath,
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Eisendrath. — Surgical Diagnosis. By Daniel X. Eisen-
drath, M. D.. Adjunct Professor of Surgery in the
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pages, with 482 original illustrations. 15 in colors.
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Fowler. — The Operating Room and the Patient. By
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York. Second Edition, Enlarged. Octavo volume of
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(Ileason. — A Manual of Diseases of the Xose. Throat, and
Ear. By E. Baldwin Gleason, M. D., Clinical Pro-
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Goepp. — State Board Questions and Ansnrrs. By R. Max
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Greene and Brooks, — Diseases of tlic Genitourinary Or-
gans and the Kidney. By Robert H. Greene. M. D.,
Professor of Genitourinary Surgery at the Fordham
l'niversity, New York ; and Harlow Brl«3ks. M. D.,
Assistant Professor of Pathology, University and
854
THE BOOKS OF SIX MONTHS.
[New York
Medical Journal.
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Hecker, Trumpp and Abt. — Atlas and Epitome of Dis-
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Children in Rush Medical College, in affiliation with
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text. Price, cloth. $5 net.
Heislek. — A Textbook of Embryology. By John C.
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Howell.— /J Textbook of Physiology: for Medical Students
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Ho.xiE. — Practic£~of Medicine for Xtirscs: A Textbook for
X'urses and Students of Domestic Science, and a Hand-
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George Howard Hoxie, M. D., Professor of Internal
Medicine, University of Kansas. With a chapter on
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Keex. — Surgery: Its Principles and Practice. In five vol-
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Keen.— Swr^^ry; Its Principles and Practice. In five vol-
umes. By 65 eminent surgeons. Edited by W. W.
Keen, M. D.. LL. D., Hon. F. R. C. S., England and
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Kei.lv and Noble. — Gyncrcology and Abdominal Surgery.
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Kr.M.F.y.— Treatment of the Diseases of Children. By
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KEUri.—Diagnosliis of Diseases of Children. By Le-
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K\iy..~Diseasrs of the .\osc and Throat. By D.
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Fourth Edition, Thf)rouKhlv Revised and Enlarged.
Octavo volume of 725 pages, with 215 illustrations. 28
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McCoMBS. — Diseases of Children for Nurses. Including
Infant Feeding, Therapeutic Measures Employed in
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Hygiene, and Nursing. By Robert S. McCombs,
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structor of Nurses at the Children's Hospital of
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cloth, $2 net.
Meyer and Schmieden. — Bier's Hypercemic Treatment tn
Surgery, Medicine, and the Specialties. A Manual of
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tor Schmieden, First Clinical Assistant to Professor
Bier, University of Berlin, Germany. Octavo of 250
pages. Illustrated.
Nothnagel and Dock. — Diseases of the Heart. By Pro-
fessor Th. von Jukgensen, of Tubingen ; Professor
Dr. L. Krehl, of Greifswald; and Professor Dr. L.
voN Schrotter, of Vienna. Edited, with additions,
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Nothnagel and Rolleston. — Diseases of the Intestines and
Peritonceum. By Dr. Herrmann Nothnagel, of
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London, England. Second Edition. Octavo of 1059
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Paul. — A Textbook of Materia Medica for Nurses. In-
cluding Therapeutics and Toxicology. By George P.
Paul, M. D., Assistant Visiting Physician and Ad-
junct Radiographer to the Samaritan Hospital, Troy,
N. Y. i2mo of 240 pages. Price, cloth, $1.50 net.
Register. — Practical Fever Nursing. By Edward C. Reg-
ister, M. D., Professor of the Practice of Medicine in
the North Carolina Medical College. Octavo volume
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RoBSON AND Cammidge. — The Pancreas: Its Surgery and
Pathology. By A. W. Mayo Robson, D. Sc. (Leeds).
F. R. C. S. (England) of London, and P. J. Cam-
midge, M. D. (England) D. P. H. (Camb.), of Lon-
don. Octavo volume of 546 pages, fully illustrated.
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RuHRAH. — A Manual of Diseases of Infants and Children.
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eases of Children, College of Physicians and Surgeons,
Baltimore. Second Revised Edition. i2mo volume of
423 pages, fully illustrated. Price, flexible leather,
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ScuDDER.— r/ir Treatment of Fractures. With Notes on
a Fczi.' Common Dislocations. By Ch.\rles L. Scud-
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Hospital. Sixth Edition, Revised and Enlarged. Oc-
tavo volume of 635 pages, with 854 original illustra-
tions. Price, polished buckram, $5.50 net; half mo-
rocco, $7 net.
Soborra and McMurrich. — Atlas and Textbook of Human
.Inatoniy. By Professor J. Sobotta, of Wiirzburg.
Edited, with additions, by J. Plavfair McMi'rrich.
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of Toronto, Canada. Volume HI. Quarto of 342
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Stelwagon. — A Treatise on Diseases of the Skin. For the
use of advanced Students and Practitioners. By
Henry W. Stelwagon. M. D., Ph. D., Professor of
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Fifth Edition, Revised. Handsome octavo of 1150
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Todd. — Manual of Clinical Diagnosis. By Ja.mes C. Todd.
^^. D., .Associate Professor of Pathology, Denver and
Gross College of Mecticine, Denver. i2mo of 500
pages. Illustrated.
Wells. — Chemical Pathology. Being a Discussion of
General Patholog>- from the Standpoint of the Chem-
May 2, 1908.]
THE BOOKS Of SIX MOXTHS.
855
ical Processes Involved. By H. Gideon Wells, Ph. D.,
jM. D., Assistant Professor of Pathology in the Uni-
versity of Chicago and in Rush Medical College, Chi-
cago. Octavo of 549 pages. Price, cloth, $3.25 net.
Wilson. — A Reference Handbook of Obstetric .Xursing.
By W. Reynolds Wilson. M. D., Visiting Physician
to the Philadelphia Lying-in Charity; Member of the
American Psditaric Society. 32mo of 258 pages.
Illustrated. Price, flexible leather, $1.25 net.
CHARLES SCRIBNER'S SONS,
New York.
CuTTEN. — Psychology of Alcoholism. By George B. Cut-
ten, Ph. D., Yale. Illustrated. Crown 8vo. Price,
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A modern scientific treatment of the great ques-
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relation of alcohol to the mental state.
THE SCUDDER BROTHERS COMPANY,
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Stephens. — Essentials of Medical Gyncecology. By A. F.
Stephens, M. D., Professor of Medical Gynaecology in
the American Medical College. St. Louis, Mo. i2mo,
428 pages. Fully illustrated. Price, cloth, $3.
Thomas. — The Eclectic Practice of Medicine. By Rolla
L. Thomas, M. D.. Professor of the Principles and
Practice of Medicine in the Eclectic Medical Institute,
Cincinnati, O. ; Ex-President of the National Eclectic
Medical Association : Consulting Physician to the Seton
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E. B. TREAT & COMPANY,
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Abr.\ms. — The Blues (Splanchnic Xeurasthenia) . Causes
and Cure. By Albert Abrams, A. M., M. D. (Heidel-
berg). F. R. M. S., Late Professor of Pathology and
Director of the Medical Clinic, Cooper Medical College,
San Francisco, Cal. Third edition, revised and en-
larged. 8vo, 294 pages. Illustrated. Price, cloth,
$1.50 net.
Bishop.— Heart Disease and Blood Pressure. A Practical
Consideration of Theory and Treatment. By Louis
Faugeres Bishop. A. M., M. D., Clinical Professor of
Heart and Circulatory Diseases, Fordham University,
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Lincoln Hospital, etc. Second edition, revised and en-
larged. i2mo, 120 pages. Price, cloth. $1 net.
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International Medical Annual, 1908. A Year Book of
Treatment and Practitioner's Index. Edited by a staff
of 33 department editors. 26th year. Octavo, 700
pages. Illustrated. Price, cloth. $3.50 net.
All the medical books and periodicals of the world
for the past year are here reviewed. With this vol-
ume in his library a physician is alwavs abreast of
the times.
Marsden. — Hints on the Management of the Commoner
Infections. By R. W. M.\rsden, M D., M. R. C. P.,
Honorary Physician to the Ancoats Hospital, Manches-
ter; Honorary Assistant Physician to the Manchester
Hospital for Consumption : Formerly Medical Super-
intendent, Monsall Fever Hospital, and Clinical Lect-
urer in Infectious Diseases, Owens College. 8vo, 136
pages. Price, cloth, $1 net. .
The author has given much excellent advice on
the management of the every day infectious diseases.
It is an excellent manual for ready reference.
Scott.— The Sexual Instinct, Its Use and Dangers as Af-
fecting Heredity and Morals. Essentials to the Wel-
fare of the Individual and the Future of the Race. By
James Foster Scotp. B. A. (Yale), M. D., C. M.
(Edinburgh), Late Obstetrician to Columbia Hospital
for Women, and Lying-in Asylum, Washington, D. C.
Second edition, revised and enlarged. 8vo, 480 pages.
Illustrated. Price, cloth, $2 net.
VoN Neusser. — Dyspncca and Cyanosis. Part I. of a Series
of Monograph Translations from the German on the
Symptomatology and Diagnosis of Disorders of Res-
piration and Circulation. By Professor Dr. Edmund
VON Neusser, Professor of the Second Medical Clinic,
Vienna ; Associate Editor Nothnagel's Practice of
Medicine. Authorized English Translation by Andrew
MacFarlane, M. D., Professor of Medical Juris-
prudence and Physical Diagnosis, Albany Medical Col-
lege; Attending Physician to St. Peter's and Child's
Hospital and Albany Hospital for Incurables. 8vo. 203
pages. Price, cloth. $1.50 net.
The author is one of the great clinicians of our
time, and his volume is exhaustive of the sttbject
viewed from the clinical standpoint.
\^0N Neusser. — Bradycardia and Tachycardia. With com-
plete English .\bstracts and Foreign Bibliography.
Part II. of a Series of Monograph Translations from
the German on the Symptomatology and Diagnosis of
Disorders of Respiration and Circulation. By Profes-
sor Dr. Edmund von Neusser, Professor of the Sec-
ond Medical Clinic, Vienna : Associate Editor Noth-
nagel's Practice of Medicine. Authorized English
Translation by Andrew MacFarlane, M. D.. Profes-
sor of Medical Jurisprudence and Physical Diagnosis,
Albany Medical College ; Attending Physician to St
Peter's and Child's Hospitals and Albany Hospital for
Incurables. 8vo, 150 pages. Price, cloth, $1.25 net.
The study of cardiac phases is no unimportant
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Xeusser has brought together all the factors involved
in the decrease and increase of cardiac action. It is
final on the subject for some time to come.
JOHN WILEY & SONS,
New York.
BoLDUAN. — Immune Sera. By Charles Frederick Bol-
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Fischer. — The Physiology of Alimentation. By Martin
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figures. Price, cloth, $2 net.
Hammarsten. — A Textbook of Physiological Chemistry.
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York University and Bellevue Hospital Medical Col-
lege. 8vo. pages viii-845. Price, cloth. $4.
Whipple. — Typhoid Feier. Its Causation, Transmission
and Prevention. By George C. Whipple. Consulting
Engineer, with an Introductorj- Essay by William T.
Sedgwick, Professor of Biologj-, Massachusetts Insti-
tute of Technologv-. Large i2mo, pages xxxvi-407. 50
figures. Price, cloth. $3 net.
YEAR BOOK PUBLISHERS,
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Abt and Ridlon. — Ptediatrics and Orthopedic Surgery.
Paediatrics, by I. A. Abt. M. D., Assistant Professor
of Medicine (Psediatric Department), Rush Medical
College: Orthopaedic Surgery, by John Ridlon, A. M.,
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University, Medical School. \'olunie VII. about 2^0
pages. Price, $1.25.
856
THE BOOKS OF SIX MONTHS.
[New York
Medical Journal.
Balm a.nd Mover. — Skin and Venereal Diseases and Mis-
cellaneous Topies. Skin and Venereal Diseases, by
W. L. Baum, M. D.. Professor of Skin and Venereal
Uisea-ef. Chicago Post-Graduate Medical School; Mis-
cellaneiius. comprising topics not treated in the other
sections, by Harold N. Mover. M. D. Volume IX,
about 250 pages. Price, $1.25.
BiLLi.xcs AXD Salisbury. — General Medicine {Section i).
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cine. Rush Medical College, and J. H. Salisbury, A.
M., M. D., Professor of Medicine, Chicago Clinical
School. Volume I, about 350 pages. Price, $1.50.
Billings and Salisbury. — General Medicine (Section 2).
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Price. $1.50.
Butler. — Materia Medica and Therapeutics and Preven-
tive Medicine. Materia Medica and Therapeutics, by
G. F. Butler, Ph.G., M. D., Professor and Head of
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lege of Medicine and Surgery ; Climatology, by Nor-
man Bridge. A. M., M. D., LL. D., Emeritus Professor
of Medicine. Rush Medical College: Preventive Medi-
cine, by H. B. F.WILL. A. B., M. D., Professor of Thera-
peutics and Preventive Medicine, Rush Medical Col-
lege. Volume VIII, about 350 pages. Price, $1.50.
De Lze. -Obstetrics. By Joseph B. De Lee, A. M., M. D.,
Professor of Obstetrics, Northwestern University
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Dudley and Bachelle. — Gyncecology. By E. C. Dudley,
A. M., M. D., Professor of Gynaecology, Northwestern
University Medical School, and C. V. Bachelle, M.
S., M. D., Gynaecologist to the German Hospital, Chi-
cago. Volume IV, about 224 pages. Price, $1.25.
Murphy. — General Surgery. By John B. Murphy, A. M..
M. D., LL. D., Professor of Surgery, Rush Medical
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Patrick and Mix. — Nervous and Mental Diseases. By H.
T. Patrick. M. D., Professor of Clinical Neurology,
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Northwe-tern University Medical School. Volume X,
about 250 pages. Price, $1.25.
Wood, .Andrews, and Head. — Eve, Ear. Nose, and Throat.
The Eye, by Casey A. Wood, C. M., M. D., D. C. L.,
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Medical School ; The Nose and Throat, by Gust.wus
P. Head, M. D., Professor of Laryngology and Rhinol-
ogj', Chicago Post-Graduate Medical School. Volume
III, about 350 pages. Price, $1.50.
FRENCH.
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Achard et Ijw.per.— Precis d'anatomie pathologique. Par
Ac hard et LoEPER, professeurs agreges a la Faculte de
niedecine de Paris, i vol. in-8 de 525 pages, avec 312
figures et 2 planches coloriees.
Abadie et G\..m.\^d.— Guide de I'infirmiere et de I'in-
firmur. Par Abadie et Glatard. i vol. in-i8 de 270
pages, avec 115 figures.
Balland et LviZET.—Le chimiste Z. Ruussin. chiniie,
physiologic, expertises mcdico-legalcs. Par Balland
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portrait. (Prix, Fr. 5.)
Bf.sson.— 7 echnique niicrobiMogiquc et sdrolherapique.
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Brouardel— Lrj Accidents dtt travail, guide du medecin.
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medecin-expert pres le tribunal civil de la Seine.
2e edition, i vol. in-i6 de 96 pages. (Prix, cartonne,
Fr. I.) (Actualites medicales.)
Brouardel, Gilbert, et Thoinot. — Noiiveau traite de
niedecine. Ease. XX. Maladies des glandes sali-
vaires _ et du pancreas, par Paltl Carnot, professeui
agrege a la Faculte de medecine de Paris, medecin des
hopitaux. I vol. gr. in-8 de 350 pages, avec 60 figures.
(Prix, broche, Fr. 7: cartonne, Fr. 8.)
Chantemesse et Mosny.— rraiYt' d'hygiene. Fasc. XIV.
Approznsionnenient coinniunal. Eaux potables. Abat-
toirs. Marches, par les Drs. F. et E. Putzeys et M.
Piettre. I vol. gr. in-8 de 464 pages, avec 134 figures.
(Prix, broche, Fr. 10; cartonne, Fr. 11.50.)
Combe. — Le Traitement de I'enterite muco-niembraneuse.
Par A. Combe, professeur de clinique infantile a la
Faculte de medecine de Lausanne. Nouvelle edition.
I vol. in-i6 de 335 pages, avec figures et 4 planches
coloriees. (Prix, Fr. 3.50.)
CouLON. — La Communaute des chirurgiens-barbiers de
Cantbrai (1306-1795). Par H. Coulon. i vol. gr. in-8
de 281 pages, avec gravures. (Prix, Fr. 6.)
Cuyer et Fau. — Anatoniie artistique du corps huniain.
Par Cuyer et F"au. edition, i vol. in-8 de 208
pages, avec 41 figures et 17 planches. (Prix, Fr. 6.)
Gaultier. — Calculs des voies biliaires et pancreatites.
Par R. Gaultier. chef de laboratoire a la Faculte de
medecine de Paris, i vol. in-i6 de 96 pages, avec 16
figures. (Actualites medicales.) (Prix, cartonne,
Fr. 1.50.)
Grashey, Beclere, et J^ugeas. — Atlas de radiograpliie
de I'homme normal. "Par R. Grashey, Beclere, me-
decin de I'hopital Saint-Antoine, et F. Jaugeas, chef de
laboratoire. i vol. gr. in-8 de 108 pages, avec 97
planches. (Prix, cartonne, Fr. 20.)
Grasset. — Diagnostic des maladies de la moelle. Par
Grasset, professeur de clinique medicale a I'Universite
de Montpellier. 3^ edition, i vol. in-i6 de 96 pages,
avec figures. (Actualites medicales.) (Prix, cartonne.
Fr. 1.50.)
Grasset. — Diagnostic des maladies de lencephale. Par
Grasset. 2^ edition. 1 vol. in-i6 de 96 pages, avec
figures. (Actualites medicales.) (Prix, cartonne.
Fr. 1.50.)
HoRAND. — Syphilis et Cancer. Par Horand, chef de clin-
ique a la Faculte de medecine de Lyon, i vol. in-i6
de 96 pages, avec figures. (Actualites medicales.)
(Prix, cartonne, Fr. 1.50.)
Keim. — Les Medications nouvelles en obstetrique. Par G.
Keim, ancien interne des hopitaux de Paris, i vol.
in-i6 de 84 pages. (Actualites medicales.) (Prix,
cartonne, Fr. 1.50.)
Le Dentu et Delbet.— iVo!(T'r«i( traite de chirurgie. Par
A. Le Dentu et P. Delbet. Fasc. V. Maladies des
OS. Lesions infectieuses. parasitaires. trophiques. nco-
plasiques. Par H. Mauclaire. professeur agrege a la
Faculte de medecine de Paris, chirurgien des Hopi-
taux. I vol. gr. in-8 de 318 pages, avec 161 figures.
(Prix, broche, Fr. 6: cartonne, Fr. 7.50.) Fasc. VI.
Lesions traumatiques des articulations. Par le Dr. L.
Cahier, medecin principal de I'armee. i vol. gr. in-8
de 332 pages, avec 136 figures. (Prix, broche, Fr. 6:
cartonne, Fr. 7.50.) Fasc. VIII. Arthrites tuber-
culeuses. Par Michel Gangolphe, professeur agrege
a rUniversite de Lyon, i vol. gr. in-8 de 234 pages,
avec 76 figure?. (Prix, broche, Fr. 5: cartonne. Fr.
6.50.) Fasc. XX. Corps thyroide. goitre, cancer
thyroidien. Par L. Berard, professeur agrege a la
Faculte de medecin de Lyon, i vol. gr. in-8 de 407
pages, avec 112 figures. (Prix, broche, Fr. 8: car-
tonne, Fr. 9.50.) Fasc. XXV. Hemies. Par M,
Jaboulav, professeur de clinique chirurgicale a la
Faculte de medecine de Lyon, ct Maurice Patel. pro-
fesseur agrege a la Faculte de medecine de Lyon, i vol.
gr. in-8 de 426 pages, avec 128 figures. (Prix, broche.
Fr. 8: cartonne, Fr. 9.50.)
Parisot. — Prcssion arterieltc et glandes a secretion interne
(Foie. reins, surrenales. hypophyse). Par J. Pari-
May 2, 1908. J
THE BOOKS OF SIX MONTHS.
857
SOT, chef de clinique medicale a la Faculte de mede-
cine de Nancy. Preface du professeur H. Roger, i vol.
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Rvbznthaler.— Technique histologique et cytologique.
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858
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Vox Witn:KEL.— Handbuch der Geburtshiilfe. Unter
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May 2, 1908.]
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86o
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862
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ZwEiG (Walter). — Die Therapie der Magen- und Darm-
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Magen- und Darnikrankheiten in Wien. Mit 28 Abbild-
ungen. 402 Seiten. (Preis, in eleg. Halbfranzband
Mk. 12.50.)
May 2, 1908.]
THE BOOKS OF SIX MONTHS.
863
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50 Seiten. (Preis, broschiert Mk. 1.20.)
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406 Seiten. (Preis, broschiert Mk. 10; in Leinen Mk.
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864
PITH OF CURRENT LITERATURE.
[N York
Mt:;Mi.vL Journal.
|it^ fff UxxtxiX f ittratnre.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
April 23, 1908.
1. Orthopredic Heresies on Feet and Their Treatment,
By L. R. G. Crandon.
2. Rosenmiiller's Fossae and Their Importance in Relation
to the Middle Ear, By Francis P. Emerson.
3. A Periosteal Flap for Use in Primary and Radical
Mastoid Operations, with an Illustrative Case,
By George A. Leland.
I. Orthopaedic Heresies on Feet and Their
Treatment. — Crandon remarks that proper walk-
ing is the proper exercise for all the waking hotirs.
Proper walking will restore the stiffened feet, and
every minute of proper walking is a part of the
treatment. Special exercises to restore the feet give
the patient the wrong conception of his essential
trouble. The foot s\'mptoms are only a part of the
general laxity, lack of freedom, and lack of Ijal-
ance. The author analyzes proper walking thus :
I. As the foot goes forward, the weight comes on
the rounded heel. 2. As the sole comes to the
ground the rounded heel throws the weight along
the outer ridge of the plantar region to the distal
end of the fifth metatarsal. 3. The toes take the
ground in order, beginning with the little toe. 4.
As the toes take the ground, the weight leaves the
heel and the whole foot grasps the ground like a
hand. Heel and great toe approach each other and
every joint in the foot combines in "arching." Thus,
the walking foot is not a "hock, arch, and hoof," but
rather a hand with the heel a grasping talon. 5.
All weight lastly rests on a triangle bottnded by
great and little toe, "its apex behind at the ends of
the middle metartarsals. From this triangle the final
push is given as the foot leaves the ground. — The
education of a patient may be outlined thus : Proper
walking is made clear to the patient, lie is told to
get into the way of standing with the feet parallel,
spreading his toes out enough to get the requisite
broad base for balance, and to get Chinese slippers,
strawsoled slippers, with soft top -on the front, and
none on tlie heel, in which he walks about at all
convenient times. To keep this sandal on the foot
the foot must at each step flex on itself in a pre-
hensible fashion. He is encouraged, if it is feasible,
to walk barefoot on turf or sand. He is not told
to do toe and heel exercises, which tend only to
stretch the atrophied plantar structures, but rather
to practice standing on one foot, the other curled
round his standing leg. The eitort to balance in
this position works every muscle of the foot and
leg. He is told to stand, stockingfoot or barefoot,
on a rubber doormat, legs crossed, feet as far apart
as possible but parallel, witii soles firmly planted on
the mat. The leg which is behind is then swung
round in front and crossed over to its former posi-
tion, and so on, alternately crossing one leg in front
of the other in a standing position. He is then told
to walk in this cross legged fashion. These instruc-
tions are sufficiently specific to satisfy the patient.
These exercises are interesting to the patient and
will, therefore, be carried out. The patient thus
educating himself cannot alternate between his moc-
casins, or wi.se shoeing, which is superior to moc-
casins, and his old shoes. Moccasins, or their
equivalent, are "foot-wear." Shoes, as they are
made, are "hoof-wear."
2. Rosenmiiller's Fossae and Their Importance
in Relation to the Middle Ear.— Emerson ob-
serves that pathological amounts of lymphoid tissue
are present in Rosenmiiller's fossa; in a large num-
ber of cases of chronic secretory and suppurative
ears. This cannot be detected with certainty by
posterior rhinoscopy alone, even where a good view
of the vault is obtainable. In every chronic case
there should be a routine digital examination.
Where much tissue has been found and removed,
the process of healing should be watched that no
fibrous bands form. It is possible in a large ma-
jority of cases to predict the involved ear by the
condition of the corresponding fossa. Results,
where after treatment is followed, are particularly
good in removing abnormal sensations, restoring
uniform hearing without fluctuations in the partial
or complete relief of tinnitus, and in the prevention
of recurring salpingitis. If directions are given to
blow one side of the nose at a time and carefully,
the affected tube is no more apt to be infected later
than its fellow.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
April i>5, igoB.
1. A New and More Rational Method of Treatment of
Lenchfemia by the X Ray. Peliminary Report,
By .\i.FKED Stengel and Henry K. Pancoast.
2. Comparative Potency of Hyoscine and Scopolamine
Hydrobromide in Refraction Work.
By Wendell Reber.
3. Acute Pyelitis Due to Acute Appendicitis,
By Guv L. Hunner.
4. The Operation for Thrombus of the Sigmoid Sinus
and Internal Jugular Vein of Otitic Origin,
By Frank Allport.
5. Treatment of Chronic Trachoma, By A. E. Prince.
6. The Ocular Typhoid Reaction. Preliminary Report
of a Modfication of the Ocular Test of Chantemesse..
By Walter W. Hamburger.
I. A New and More Rational Method of Treat-
ment of Leuchaemia by the X Ray. — Stengel and
Pancoast report their results ..with x ray treatment
in leuchiemia. In any method of applying the treat-
ment to the bone marrow the body should first be
divided into definite regions, and each of these
should be exposed with regularity. The manner in
which they have mapped out the areas for exposure,
is as follows : ( i ) The feet, ankles, and lower
halves of the legs. (2) From the middle of the legs
to the middle of the thighs. (3) The right half of
the abdomen and pelvis and the upper half of the
right thigh. (4) The corresponding area on the left
side, carefully avoiding the spleen in the earlier ap-
plications, but including its lower half later on. (5 )
The right half of the thorax and the right shoulder,
including as much of the upper extremity as possi-
ble. (6) The corresponding area of the left side,
again avoiding the spleen early, but including its
upper half later on. (7) Later in the treatment the
entire thorax and both shoulders are often included
in one application, making the proper correction in
time for the increase in distance. In stout subjects
it may be advisable to treat this part of the body pos-
teriorly as well. (8) \\ hen it is safe to expose the
entire spleen it is advisable to approach it from the
back and thus include the lumbar spine and the pos-
terior a.'^])ect of the ])elvis. Fach of these regions is
May 2, 1908.]
FITH OF CURRENT LITERATURE.
865
treated in rotation and receives three successive ex-
posures. In direct contrast to the older method of
directly exposing the spleen from the start, their ex-
perience has demonstrated that this is an unwise pro-
cedure. This does not mean that the spleen should
never be exposed, for to avoid it at all times would
be almost impossible, and, besides, more or less ex-
posure is no doubt necessary, but should not be at-
tempted while the organ is still very large and the
leucocytosis is still high. It is best to wait until the
count is materially reduced and the patient's general
condition has improved considerably. This mass of
lymphatic tissue is far too susceptible to x ray in-
fluence, and the patient is not in a condition at first
to stand the strain imposed by its exposure. Al-
though this treatment requires a much longer period
of time, the misleading tendency of a comparatively
'quick symptomatic cure, such as follows direct
splenic exposures, is avoided. Applications confined
mainly to the spleen reduce the size of that organ,
destroy the leucocytes in the circulation, including
the myelocytes, and possibly have some inhibitory
influence, secondarily, on the cause, and hold the dis-
ease in check, leading to an impression that the case
is cured, whereas statistics show that this is seldom
the case. Applications to the bone marrow also re-
duce the size of the spleen and destroy the leucocytes
circulating in the blood, but, in addition, they are
more likely to reach and remove the cause of the dis-
ease. The spleen should be exposed at some time,
but never until it is considerably reduced in size and
the patient's general condition is markedly improved,
and even then it should be done with caution. The
proper time to stop treatment is still a somewhat un-
certain question. The frequency of the applications
should not be lessened until the general condition is
normal and the size of the spleen and the leucocyte
count nearly so. It would seem wiser to stop gradu-
ally rather than abruptly.
5. Treatment of Chronic Trachoma. — Prince
states that the principal considerations are : First,
select a germicide which is effective ; second, pre-
pare the infected surface in such a manner that the
germicide may act; third, combat corneal complica-
tions (pannus and ulcers) : fourth, correct the con-
dition of the lids, which may cause relapsing inflam-
mation (entropion, cysts, etc.). The remedies used
are copper sulphate, mercuric oxide, tannic acid, sil-
ver nitrate, boric acid, jequirity. In the empyrical
use of drugs to combat chronic trachoma, perhaps
no remedies have been so extensively used as copper
sulphate and silver nitrate, the former in the ab-
sence and the latter in the presence of secretion.
The removal of trachomatous material can be done
by squeezing out of the follicles. After squeezing,
scarifying, and milking out all the trachomatous ma-
terial, apply a 10 per cent, solution of copper sul-
phate in glycerin, and scrub with cotton, so as to
force it into the tissues. Rinse with water to remove
excess, and prevent corneal irritation. A Belgian
method, which has been popular in the army, has
been the rubbing on with the finger of powdered
boric acid. Ulcers occurring in conjunction with
trachoma show little tendency to heal until the tra-
chomatous infection has been brought under control
by the germicidal action of the blood, chemical reme-
dies, or actual cautery. Following this, a healing
tendency is usually rapidly established ; pannus pro-
ceeds and nutrition follows. The favorite cautery
in these cases is the Gruening platinum probe, which
is heated in the Eunsen flame, and applied to the
entire area. When the necrosis is shallow, rapid re-
covery usually follows, but when the layers of the
cornea are destroyed down to the membrane of Des-
cemet, it is usually found necessary to make a para-
centesis through the floor of the ulcer, and keep the
opening from closing by the repeated applications of
a probe until the healing tendenc\- has been est ib-
lished. The establishing of a fistula by cauterizing
the margin of a perforating ulcer will often bring
about a rapid change from a progressive destruction
to rapid reparation. As an aid te^ repair iodoform
has held first place, but argyrol in 25 per cent, solu-
tion every two hours is well tolerated, painless, and
efficient. Hypopion, in conjunction with trachoma,
is similarly treated. It is the aim to divide the floor
of the ulcer and carry the incision into the sound tis-
sue on both sides. The pus escapes with the aqueous
humor, and the anterior chamber is emptied twice
daily with a probe, when found necessary, until no
more pus is formed, after which the opening in the
cornea is allowed to heal. Of jequirity the author
says that he commences treatment with a verv \\eak
infusion, one fourth of i per cent. This is employed
twice a day for two days, during which time the tis-
sues stretch to accommodate the infiltration. In case
the eye is sensitive to the remedy, a solution of this
strength is usually sufficient to produce the desired
reaction. In case toleration exists the strength of
the solution may be increased to one half of i per
cent. The eye soon develops tolerance, and com-
mences to improve before the discontinuance of the
use of the remedy. It is desirable to secure a de-
cided membrane covering the surface of the tarsal
conjunctiva. It may extend over the retrotarsal fold,
in which case care will be necessary to separate the
surfaces which lie in contact or adhesion may take
place. Of the bean, the author says that it will be
found very difficult to remove the cortex of the bean
and reduce it to a powder unless one is provided
with the proper means. The suggestion is to get a
hand pepper grinder, with which many persons grind
pepper fresh while at table. The first turn breaks
the cortex. The beans are emptied out, the cortex
removed, and the kernels replaced in the grinder.
They are ground through several times until a mod-
erately fine powder results. Divide into one grain
powders. One powder in two drachms of a 2 per
cent, solution of boric acid will be the initiative
dose. It is ready for use in fifteen minutes, and
should be made fresh every day.
MEDICAL RECORD.
April J J, njoS.
1. The Physiological Mechanism of \'asoconstriction and
Vasodilatation, By George B. W.\llace.
2. Therapeutics of Vasoconstriction and \'asodilatation.
By Egbert Le Fevke.
3. The Treatment of Endometritis by Irrigation and
Drainage, By Augustix H. Goelet.
4. Sciatica, By M. L. Barshinger
5. Intramural Transplantation of the Round Ligaments
Versus Alexander's Operation or \'entrosuspensio
Fixation of the Uterus for Retroversio Flexion,
By CH.A.XNIXG W. Barrett.
6. Autointoxication and Indicanuria,
By Albert Abra.ms.
3. The Treatment of Endometritis by Irriga-
tion and Drainage. — Goelet remarks that the fun-
866 PITH OF CURRENT LITERATURE.
damental principle in the treatment of endometritis,
in whatever form encountered, is or should be
drainage, not of the cavity alone, but drainage of
the submucous glands as well. In conjunction with
drainage, cleanliness is likewise essential. This
should comprise removal of accumulated secretion
and debris from the cavity of the uterus, and ag-
glutinated, viscid secretion from the surface of the
mucous membrane of the cervix by copious irriga-
tion, repeated at least daily. This is accomplished
by means of a special double current or return flow
irrigator, made sufficiently small to permit intro-
duction through the canal without previous forcible
dilatation such as is required for curettage. Suffi-
cient dilatation for introducing this small irrigator
is secured, when necessary, by means of conical
electrode dilators, introduced through the canal
while connected with the negative pole of the gal-
vanic current. A moderate current of lo milliam-
peres will suffice and this does not irritate or
cauterize. Thus negative electrolysis is utilized to
free the canal for irrigation and subsequent drain-
age. As a rule this irrigator may be introduced
without the preliminary dilatation, or it may be con-
verted into an electrode by insulating it with a piece
of rubber tubing slipped over it, there being an at-
tachment for connecting it with the wire from the
battery. In this manner its introduction is facili-
tated. Throughout the irrigation the current should
be continued in force in the same moderate strength.
The solution used for irrigation will vary with the
individual condition under treatment. It may be
simple sterile water, normal salt solution, potas-
sium permanganate (i to 3,000 or 5,000), hydrogen
peroxide (i to 4), lysol (a drachm to 2 qts.),
which facilitates removal of the viscid secretion,
or iodine in the strength of one drachm of the tinc-
ture to three or four pints of water. When iodine
solution or other astringent or antiseptic solutions
are used in the uterus care must be observed to let
all of the solution escape before the irrigator is
withdrawn or contraction of the cervix may occur,
causing retention of the solution and provoking
severe pain. This is the most effective method of
cleansing the cavity and making application thereto.
5. Intramural Transplantation of the Round
Ligaments. — Barrett describes his operation. He
remarks that it occurred to him that by going
through the median line to do work in the abdo-
men and pick up the ligaments, he could then carry
them through the internal ring and fasten them at
some point without tedious dissection, as was done
by Edebohls' Alexander operation following celec-
tomy. After considering the many ways in which
the ligament could be dealt with such as a puncture
over the internal ring, tunneling over the aponeuro-
sis, etc., the most feasible plan seemed to be to pass
a curved ligature carrier under the aponeurosis to
the internal ring and there enter the abdomen and
secure the silk ligature which had been previously
placed upon the round ligament two thirds of the
distance from the uterus to the internal ring. The
forceps are then withdrawn and along with them
the silk loop, and with this the loop of round liga-
ment, which is sewed to the under side of the apon-
eurosis over the rectus muscle, and then if long
enough it is sewed to the loop on the opposite side.
We now have the ligament running from the uterus
[New York
Medical Journal.
to the internal ring, then under the aponeurosis over
the rectus muscle to or near the median line, where
it is sewed, then back to the internal ring, then
through its normal course to the labium. It is
shortened by the distance of its excursion inward
and back to the internal ring. In some cases the
author has made a two and one half inch incision
transversely down to the aponeurosis of the external
oblique, then a median longitudinal incision to do the
work in the abdomen, then the ligature carrier was
pushed through the aponeurosis at the outer ends
of this transverse incision, and was carried through
the internal ring to pick up the control silk on the
ground ligament. This, while it makes a splendid
operation, is only advisable when the complications
are slight. The median incision through all the
layers is preferable for severe complications. In
addition to the round ligament work it has seemed
best at times to shorten the sacrouterine ligaments.
We should remember that the work of ligaments
is to carry the uterus ; they are not intended to do
the work of the pelvic floor, and this latter structure
should be repaired if inefficient. This operation
makes the most anatomically perfect operation
which has yet been proposed which does not require
tedious dissection to find the ligament, and has the
distinctive feature of having the ligament leave the
abdomen at the proper place — the internal ring. We
cannot hope in our operative work to improve upon
the normal condition ; no operation can anchor the
ligament farther out or a less distance and be quite
as right. Alexander's operation fails because most
cases of retrodisplacement are complicated. An
operation to be widely useful must open the ab-
domen for inspection and correction of complica-
tions. It should be capable of being combined with
the best incision for doing work, it must not create
false ligaments which will not evolute during preg-
nancy and involute thereafter. There must be no
abnormal arrangement of natural ligaments which
allows them to run transperitoneally. When the
round ligaments are employed the inner, stronger
portion of the ligament should be chosen. An oper-
ation for retrodisplacement must often be per-
formed after much other operating, and so should
not offer any tedious technicality such as is found
in the external search for the ligaments.
BRITISH MEDICAL JOURNAL.
April II, 1908.
1. Remarks on the Treatment of Fracture of the Patella
of Long Standing, By Lord Lister.
2. Remarks on the Rational Treatment of Functional
Dyspepsia, By R. Hutchison.
1. Two Lectures on the Physiology of the Emotions,
By F. W. MoTT.
4. The Clinical Value of the Pancreatic Reaction in the
Urine, Based on over 250 Analyses,
By C. Watson.
The Therapeutic LTses of Normal Serums,
By E. C. HoRT.
6. Hy.sterectomy Performed upon a Patient with
Glycosuria, By J. D. Malcolm.
7. Some Remarks on the Irish Poor Law Medical Service,
By J. W. BoYCE.
8. The Attendance Prize System: Its Relation to the
Spread of Disease in Elementary Schools,
By R. P. Williams.
2. Treatment of Dyspepsia. — Hutchison states
that alterations in the functions of the stomach
which produce the symptoms termed "dyspepsia"
iMay 2, 1908.J
PITH OF CURRENT LITERATURE.
867
tend to be in the direction of either excess or defect.
The physiological functions of the stomach are :
Secretory ; motor ; sensor}- ; and absorptive. Taking
up these in order: I. Secretory functions. An ex-
cess of secretion may be manifested by a total in-
crease in the amount of gastric juice secreted (hy-
persecretion, gastrosuccorrhoca) or it may alTect the
hydrochloric acid alone (hyperchlorhydria). Con-
versely the total amount of gastric juice may be
deficient (hypochylia), or it may even be absent al-
together (achylia) or the hydrochloric acid may
alone be deficient (hypochlorhydria j . 2. Motor
functions. The more passive function of "tonicity"
must be distinguished from active "motility." De-
fect of these results in "hypotonicity" and "defec-
tive motility" respectively. Mere want of tone is
responsible for many cases of "splashing stomach" ;
if the active movements are also defective, there is
delay in the passage of the food, but no actual stag-
nation as in pyloric stenosis. Increase of the motor
functions is less important than defect, in the pro-
duction of dyspepsia, but "pyloric spasm" may be
regarded as an increased manifestation of the active
movements, usually induced by the presence of an
ulcer or fissure. 3. Sensory functions. Exagger-
ated sensibility of the stomach (hyperaesthesia) is
a common cause of gastric pain, and can be assumed
to exist when the secretion is normal and there is
no evidence of organic disease. Of defective sensi-
bility or anaesthesia of the stomach, nothing is
known. 4. Absorptive functions. The absorptive
power of the stomach is at best limited and, as far
as is known,- alterations in it play no part in the
production of functional dyspepsia. Of course any
of these disorders may exist alone, but usually two
or more coexist in the same cases. Treatment di-
rected to the nervous system is, of course, applicable
to all cases — e. g. rest, liberation from worry and
mental work, change of air and scene, hydrothera-
peutics, etc. Taking up the whole functional dis-
orders as classified before: i. Secretory disorders,
(a) Excess. Dietetic treatment. Articles acting as
stimulants of secretion must be avoided, such as salt,
meat extracts, and meat soups, alcohol, spices, and
condiments. Milk is a good food, in that it restrains
secretion, but except in very bad cases, good results
will be obtained with a diet of milk, eggs, meat, and
fish — the starchy foods being strictly limited. Medi-
cines. *rhe bromides are useful in excessive gastric
secretion, by lessening the activity of reflex pro-
cesses. In general drugs should be used to neutral-
ise the secretion after it has formed, rather than to
check it. (b) Defective secretion. Diet. Here
stimulating articles of diet should be given, such as
meat extracts and soups, alcohol, etc. The food
should be as well cooked and served as possible, so
as to stimulate the flow of "psychic" gastric juice.
Medicine. Drugs may be employed in these cases
either to stimulate the natural secretion or to replace
it artificially. The bitters are the chief stimulants
of secretion, and should be given in solution and
shortly before meals. Both hydrochloric acid and
pepsin can be replaced artificially, but their use in
actual practice has been disappointing. It is diffi-
cult to give enough hydrochloric acid to be of use,
while as regards pepsin it is difficult to obtain an
active preparation, and further it is inactive unless
the gastric contents be raised to their normal level
of acidity. Ferment therapeutics are almost worth-
less. 2. Motor disorders. (a) Excess (Pyloric
spasm). Diet. The diet here must be as bland as
possible, consisting mostly of milk, supplemented by
soft farinaceous foods. Medicine. The drugs to
be used are those which lessen the acidity of the
gastric juice, and which diminish the hyperaesthesia
of the stomach. Hydrotherapeutics. The most use-
ful measure is the local application of heat to the
epigastrium by means of fomentations or poultices,
(b) Motor defects (Atony). Diet. The most im-
portant rule is to avoid burdening the stomach with
a mass of heavy contents which tends to distend it
by its weight. Fluids are particularly harmful, and
all tough, hard, and indigestible articles should be
forbidden. The diet should be "dry." Medicine.
No drug is known which can be relied upon to in-
crease the tonicity and muscular efficiency of the
stomach. Strychnine and alcohol possess this power
in some degree, however. Physical treatment. Mas-
sage is sometimes of service, by increasing the ex-
ternal support of the stomach. Electric treatment
is of very doubtful value. 3. Sensory disorders.
Hyperaesthesia. Diet. This should be bland, but it
may be necessary to feed the patient up in spite of
the pain at first produced. Medicine. Bismuth is
an efficient gastric sedative, bromides, hydrocyanic
acid, hyoscyamus, chloral, and even opium may also
be used. Physical treatment. The local applica-
tion of heat is the most potent of all methods of re-
lieving oversensibility.
4. The Pancreatic Reaction in Urine. — Wat-
son has studied Cammidge's so called pancreatic re-
action in the urine of persons suffering from disease
of the pancreas. His results go to confirm the view
that there is a definite and important relationship
between the pancreatic reaction in the urine and
disease of the pancreas. He divides the cases in
which the pancreatic reaction is present into the
following groups: — i. Those in which there is def-
inite clinical or pathological evidence of serious or-
ganic disease of the pancreas — for example, acute
and chronic pancreatitis, usually associated with dis-
ease of the bile ducts. 2. Those in which the reac-
tion is associated with pronounced arteriosclerosis,
a condition usually accompanied by more or less
sclerosis in different glands. 3. Those in which the
reaction is dependent upon congestion and catarrhal
conditions of the gland ducts and substance, with
associated toxjemia — e. g., advanced heart disease,
appendicitis, pneumonia, malaria, and the like.
LANCET.
April I J, 1908.
1. Remarks on the Treatment of Fractures of the Patella
of Long Standing, By Lord Lister.
2. The Pygmy and Negro Races of Africa (Hunterian
Lectures, II), By F. C. Shrubsall.
3. The Diagnosis and Treatment of Malignant Disease of
the Prostate, By J. W. T. Walker.
4. A Report on Fifty Cases of Analgesia by the Intra-
spinal Injection of Stovaine, By L. H. McGavix.
5. Renal Haemorrhage in Chronic Interstitial Nephritis,
By J. T. McNab.
6. The Treatment of Disease and Deformity Due to Scar
Tissue, By J. Snowman.
7. Labor in a Case of Triple Pregnancy, with Observa-
tions Thereon, B. V. Z. Cope
868
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
8. Note on an Abnormality of the Liver Simulating a
Tlioracic Tumor,
By E. A. Elder and J. M. Postlethvvaite.
9. The Cell as a Factor in Phagocytosis,
By H. W. Bayly.
10. "Cures" for Asthma: Fatal Case from an Overdose of
Oil of Sage. By H. T. M. Whitling.
11. Motoring Note<, By C. T. W. Hirsch.
12. Peter of Albano, By C. E. A. Clayton.
3. Cancer of the Prostate. — Walker states that
sixteen per cent, of cases of enlarged prostate tmder-
going operation are due to malignant disease. Of
forty cases studied by him, the average age was
sixty-rive years. But malignant disease of the pros-
tate is. however, of slow growth and the symptoms
which it produces are due to urethral obstruction
and nerve pressure, so that the disease has spread
widely before they appear. It is probable that the
growth actually commences at a much earlier age,
so that age is of no great value in making a diagno-
sis except that an enlargement of the prostate which
commences much under fifty is more likely to be
malignant than simple. Difficult micturition is the
cardinal symptom, being most frequent, most proin-
inent, and usually the earliest. Next to difficult
micturition an increase in the frequency of the act is
the symptom oftenest complained of. It is not often
due to cystitis or to a septic condition of the tirine,
but the growth spreads outside the bladder along the
anterior and posterior walls and so fixes the urethra
that it acts as an immobile tube which drains off the
urine. Pain is of course often present, and is of
three types, (a) Pain connected with micturition
is usually along the urethra and in the penis, is
experienced either at the commencement or after
micturition, and is aching and not severe. (b)
Pain apart from micturition but due to urinary ob-
strtiction. This is aching in character and felt over
both kidneys, (c) Pain independent of micturition
or obstruction. This is felt in the penis, the rectum,
or the lower part of the back. The pain in these
cases is never agonizing ; its characteristics are that
it is constantly present, that it persists for months
or years, that there is no connection with micturi-
tion or movement, and that drug treattnent gives
no relief. Haematuria is usually absent, being noted
in only twelve per cent, (if the cases. This is due
to the fact that the growth is of the hard scirrhus
type, comparative!}- avascular, and not prone to ul-
cerate. Emaciation is not so marked as in other
forms of malignant disease. Intestinal obstruction
may complicate matters, being dtie to extensive in-
filtration of the rectal wall. The inguinal lymph
glands arc frequently the seat of secondary growths,
and arc enlarged, hard, and discrete. On examin-
ation the prostate is found to be hard, irregular,
and fixed. Many cases, when first seen, are too far
advanced for radical operation ; catheter life may
become necessary, and opium be required to relieve
the pain. The methods of operation open to choice
are the suprapubic and ])erineal. the writer prefer-
ring the latter. Digital enucleation from the blad-
der is often very difficult to perform. Perineal
operations may be either prostatectomy as usually
performed for the removal of benign enlargeinents
of the prostate, or more complete removal of the
prostate, j^ro.static urethra, .sheath of pelvic fascia,
portion of the bladder base o\ crlying the prostate,
and seminal vesicles.
4. Intraspinal Analgesia. — ^McGavin, from a
study of fifty cases of intraspinal analgesia, is con-
vinced that it is a method of the greatest value, and
in careful hands, perfectly safe. The opinion of
patients as to its merits is universally favorable, and
the after effects of the drug are really trivial in the
majority of cases, while in the remainder they bear
comparison very favorably with those of the various
general an;esthetics. The analgesia provided is, as
a rule, of the most perfect order, available to all
operations within the area involved. The excessive
rapidity of the pulse noticed in soine of the cases
subsequent to injection has probably nothing to do
with the drug itself; it is amply accourited for by
the excitement of the patient, and it rapidly sub-
sides on the discovery that the operation is really
painless. The frequent occurrence of tympanites
is clearly explicable on the supposition that the rami
communicantes of the sympathetic system of nerves
are equally affected by the injection, the bowels be-
coming for the time being partially paralyzed. The
effect of the drug is not exerted upon the spinal
cord itself, but upon the posterior, and to some ex-
tent upon the anterior nerve roots.
5. Renal Haemorrhage in Nephritis. — McNab's
article is based on a series of thirty-one cases of
renal hjcmorrhage occurring in chronic interstitial
nephritis. These thirty-one cases were selected
from ■A,22g cases of granular kidney, a frequency
of one in seventy-two, probably far too low. It
was at first thoughc that haemorrhage was always
a late complication, bitt of the cases here reported
the average age was 26.2 years, the youngest being
eight years and the oldest sixty-four years. In
twenty-one cases there were no signs of dis-
ease other than the state of the urine, hsematuria
being the first indication of a chronic nephritis and
calling attention to it at an early stage of the dis-
ease. In only six of the thirty-one cases were any
changes found in the fundi of the eyes. Sex had
little or no influence in the causation of haematuria.
twenty-nine cases being in men, and sixteen in
women — the usual proportion in granular kidney
Renal haemorrhage is usually recognized by the fact
that the blood is intimately mixed with the urine.
In doubtful cases cystoscopic examination is most
useful. The differences between sttbacute nephritis
and renal haemorrhage in chronic nephritis are that
in the latter there is little or no oedema, the amotmt
of blood and albtimin fluctuates from day to day.
and the course of the case is different. The haemor-
rhage may persist for weeks and months, and when
it does the urine is of low specific gravity and con-
tains casts with a trace of albumin. Haematuria
due to renal tuberculosis may be recognized by the
more marked nocturnal frequency, by the results
of cystoscopic examination, and by tubercle bacilli
lieing found in the urine. Renal calculi give a typi-
cal history and may be detected by the x rays. In
malignant disease of the kidney in the later stages
there is usually a unilateral tumor. The haematuria
of granular kidney does not seem to depend on
purely mechanical causes such as high arterial ten-
sion and deterioration of the vessel walls, but is
more probably due to local infiltration set up by
some toxin. Tlie prognosis depends almost entirely
on tlie degree of kidney change that is present.
May 2, 1908.]
1'11'h: of currext literature.
869
Rest in bed, purgatives, and a diet consisting chiefly
of milk, bread, and butter will, as a rule, be suffi-
cient to stop the bleeding. Haemostatics, such as
calcium lactate or calcium chloride, may be tried,
but are hardly necessary. Iron in some form is use-
ful during convalescence. Recurrence is extremely
probable, for the cause, the chronic nephritis, still
remains. Surgical treatment may be necessary in
rare cases of severe hsematuria occurring early in
the disease.
LA PRESSE MEDICALE.
March 28, 1908.
1. Aspiration by Water Power. Its Applications in Op-
erative Surgery, By V. Legueu.
2. Simple and Complicated Obesity, By Makcel L.xbbe.
3. Brudzinski's Sign, By R. Romme.
2. Simple and Complicated Obesity. — Labbe
says that there have always been distinguished two
types of obesity; in the one the people are florid,
vigorous, and looking well, in the other cachectic,
feeble, and pale. Physicians have been accustomed
to designate the former as sanguine and plethoric,
the second as anaemic and lymphatic, while popular
language has distinguished them as good fat and
bad fat. These two types are the results of differ-
ent pathological processes. The one is simple florid
obesity, in which the augmentation of weight is
due to the accumulation of fat in the organism ; the
other is complicated, and in it the augmentation of
weight is due in part to accumulation of fat, in part
to the retention of water. Complicated obesity is
a sequel to the simple form. The fatty infiltration
causes the heart excessive fatigue and diminishes
the resistance of the myocardium, the intoxication
produced by supraabimdant alimentation, especially
by supraalimentation with meat, gradually produces
changes in the kidney and brings about renal sclero-
sis. The alterations of the heart and kidnevs, the
fatal but slow result of habitual supraalimentation,
may form a complication if an intercurrent disease
causes a strain on the kidney or the heart. Pulmon-
ary emphysema, which is frequently observed in
these patients, is one of the causes that favor insuffi-
ciency of the myocardium. Hence in certain pa-
tients a florid obesity rapidly gives way to a com-
plicated, cachectic obesity, with its train of visceral
alterations and functional insufficiencies. The com-
bination of Bright's disease with myocardic insuffi-
ciency results in a retention of the chlorides with
the oedema.
April I, igo8.
1. The True Conception of the Antibody. Its Relation to
Immunity, By Foix and M.mlein.
2. Acute Enteritis and Appendicitis. Late Perforation of
the Intestinal Ulcerations, By A. Broca.
I. The True Conception of the Antibody. —
Foix and Mallein say that every antigenous sub-
stance introduced into the organism provokes the
appearance of another substance which is called
antibody. The number of substances to which these
terms might be applied is great, but the application
of the terms is restricted to the antigenous microbes
and their toxines and the antagonistic substances
called forth by them. The antitoxines are antagon-
istic to the toxines, the antibodies to the microbes
themselves. If one injects into an animal of the
species A blood from another animal of the species
B there are formed in the organism of the animal A
precipitating substances in opposition to the serum
B, agglutinants and haemolysants in opposition to
the blood corpuscles. The same formula can apply
to every microbic infection, whether spontaneous or
experimental. W e have then precipants, or precipi-
tins, agglutinants, or agglutins, cytoHsants, or
bacteriolysins. There is m addition a set 01 anti-
bodies that favor the phagocytic action of the white
blood corpuscles. I'hese arc the stimulins of
Metchnikofl^ and the opsonins of Wright and
Douglas. The author deals at some length with
each of these substances, and then enters into the
question of the nature and origin of the antibody
and briefly presents the theories of immunity.
2. Acute Enteritis and Appendicitis. — Broca
describes a case in which this puzzling complication
was present in a boy thirteen and a half years old.
LA SEMAINE MEDICALE
April I, 1908.
Diagnosis of Pancreatic Insufficiency,
By Professor R. Lepixe.
Diagnosis of Pancreatic Insufficiency. — Lepine
reviews the literature on this subject and finally
gives as the best signs of faulty external secre-
tion of the pancreas abundance of fat and rarity
of soap in the faeces, with diminution of the sulphur
products in the urine. The mydriasis provoked by
adrenalin is an index of a deficit of the internal
secretion. It is readily to be seen how much the
diagnosis of a functional insufficiency of the pan-
creas is to be desired.
MUENCHENER MEDIZINISC.HE WOCHENSCHRIFT
March 31, 1908.
1. The Crime of Drunkenness and Its Legal Penalty,
By Heilbronner.
2. Therapeutic Contributions to the Arc Light Treatment
of Skin Diseases, By Riedel.
3. Concerning a Rare Complication after Operations on
the Stomach, By Stieda.
4. Concerning Thymus Persistens and Apoplectiform
Thymus Death, Together with Remarks Concerning
the Relations between Persistence of the Thymus
and Exophthalmic Goitre, By Hakt.
5. The History and Technique of Orthodiagraphy,
By MoRiTz.
6. The Treatment of Spasm of the Cardiac Orifice,
By Geissler.
7. Concerning Tendinitis Ossificans Traumatica.
By HoRixG.
8. A Case of Dementia Postraumatica with Unusual Ac-
companying Symptoms, By Trespe.
9. The Treatment of Sore Throat, By Berliner.
ID. The Sterilization of Rubber Gloves, By Fl.\tau.
11. A Typical Case of Sudden Interruption of the Menses
with Sore Throat, By Sehlbach.
12. The Production of Instantaneous X Ray Pictures,
By Kastle, RiEDER, and Rosenthal.
2. Arc Light Treatment of Skin Diseases. —
Riedel reports twenty-five cases of skin disease, in-
cluding various forms of eczema, acne, sykosis,
pruritus ani, scrophuloderma, tuberculosis, and syp-
hilis, successfully treated with arc light.
3. Rare Complication After Operations on
the Stomach. — Stieda reports the case of a wo-
man fifty-five years of age on whom resection of
the pylorus was performed. The operation was fol-
lowed by persistent vomiting of a slightly bloody
fluid. Introduction of the stomach tube showed tliat
the stomach was empty. As the vomiting increased
and threatened the life of the patient another lapar-
otomy was performed, when the jejunum was
870
PROCEEDINGS OF SOCIETIES.
[New York
Medical Jolrnal.
Opened, the stomach found perfectly empty, and no
explanation of the vomiting was discovered. She
died two days later, and on autopsy the only objec-
tive conditions to be found were a stippling of the
gastric mucous membrane, a small ulcer near the
insertion of the sutures at the place of anastomosis,
and a haematoma at the occlusion suture of the
stomach. There was no peritonitis, or other condi-
tion to explain the vomiting. Hence the latter was
referred to an extraordinarily increased reflex ex-
citability in the region. He mentions also two other
patients who died of hiccough after operation, due
apparently to a nervous condition, as no cause was
revealed at the autopsies.
5. Orthodiagraphy. — Moritz describes the ap-
paratus employed in orthodiagraphy, with the man-
ner of its employment, and mentions as advantages
possessed by this method its quickness and simpli-
city, the cheapness of the measurements taken as
compared with photographs, the possibility of simul-
taneous observation of the processes in the thorax
of the patient while the measurement is being taken,
and the determination whether the patient breathes
quietly and in what phase of respiration the meas-
urement is taken. It is also possible to produce on
one and the same paper various cardiac measure-
ments in different respiratory phases.
6. Treatment of Spasm of the Cardiac Orifice
of the Stomach. — Geissler has devised a sound
with an india rubber bulb attachment to be passed
through the oesophagus until the empty bulb is in
the spasmodic stricture, which is then to be dilated
by inflation of the bulb.
7. Tendinitis Ossificans Traumatica. — Horing
describes a case of ossifying tendinitis met with in
a man fifty-six years "of age, of good health, who
had received a severe blow on the left tendo Achillis.
9. Treatment of Sore Throat. — Berliner rec-
ommends the use of a protargol ointment introduced
through the nose.
^xmtkm^s til ^mt\m,
MEDICAL .ASSOCIATION OF THE GREATER CITY
OF NEW YORK.
St>ecinl Meeting, Held on February 3, igo8, at the Staten
Island Academy, St. George, Borough of Richmond.
Dr Henry C. Johnston in the Chair.
Radium. — Dr. Rob ERT Abbe made an address
on radium and its use in the treatment of disease.
He said that for the past five years he had been ex-
perimenting practically with this agent, and that he
was now beginning to see daylight. When radium
was first exploited in the medical world, it was an-
nounced that it was a wonderful cure for cancer,
and, as was commonly the case with such premature
allegations, disappointment resulted. There was.
naturally, a great deal of "faking" in connection
with the subject, and charlatans everywhere vaunted
their ability to perform miracles with radium. To
Dr. Abbe it appeared that the real value of the agent,
if such it had, could be demonstrated only by per-
sons who were thoroughly conversant with regular
surgical procedures in the treatment of cancerous
and other growths, and he undertook to make an
extended scientific test of the matter. He recog-
nized that no dependence could be placed on photo-
graphs of the pathological conditions to be repre-
sented, and he therefore tried a new method of se-
curing a record of cases before, during, and after
treatment. This was by the making of casts from
life, which, when accurately colored, showed exact-
ly the existing conditions. No treatment other than
the radium applications was given.
The speaker then gave a resume of the history of
the discovery of radium, and some account of its
effects on cell and animal life. There appeared to
be no limit to its penetrating power, as was shown
by tests with the most opaque substances, such as
lead and other metals. When mice were subjected
to its influence they became affected with spinal men-
ingitis and were paralyzed in their hind legs. On
their skin, as well as on human skin, burns were
produced similar to those from the x ray. Its value
in cancerous and other neoplasms seemed to be due
to its destructive agency on new growing cell life.
Dr. Abbe then presented, with brief descriptions
of the cases and their treatment, a very large series
of the beautiful and accurate casts which he had
made. For ordinary warts (papillomata) , such as
were commonly met with on the hand, one applica-
tion of radium for fifteen minutes, he said, would
suffice for a perfect cure in almost all instances. The
radium was efficient in all stages of the change of
tissue between normal hypertrophic growth and ma-
lignant disease. Many cases of so called cancer of
the tongue, he believed, were simply papillomata of
the same kind seen on the cutaneous surface. There
were, of course, true cancers of the tongue, however,
and it was probable that these papillomata were
oftentimes the precursors of cancer. Leucoplakia
of the mouth was readily cured by means of radium,
and it seemed now to have been demonstrated that
cancerous growths were not malignant at first. Epi-
thelioma might go on for years without the occur-
rence of metastasis. The casts were shown of a very
severe case of this kind, which had been perfectly
cured by seven applications of radium for an hour
at a time. Three years had now elapsed, and there
had been no return whatever of the disease. A can-
cer of the nose had been cured by two applications,
and the same was true of one affecting the eyelid
and corner of the eye. Tuberculous lesions of the
hand and the heel, in the same patient, which had
existed for some years and resisted all other forms
of treatment, had been cured by seven applications
of radium of an hour each. An eroding epithelioma
of the cheek had been perfectly cured by three simi-
lar applications, and a cancer behind the ear and ex-
tending down the neck, by four applications. One
of the most interesting of the cases was an extensive
and most disfiguring sarcoma of the eyelid, which
had been cured by four applications. Here the de-
formity and loss of tissue appeared to have been
beautifully repaired by a reassembling of the nor-
mal cells through the agency of the radium — in fact,
forming the lid over again. In a mixed sarcoma of
the parotid region and a giant celled sarcoma of the
jaw, involving the bone, the result had been equallx
satisfactory. In the latter instance fifteen applica-
tions were required to effect the cure. The more
malignant and "juicy" a growth was, the more read-
ilv and quicklv it seemed to yield to the effect oi
radium. The casts of all these cases and many
May 2, 1908.]
LETTERS TO THE EDITORS.
871
others, showing the condition before, during, and
after treatment, were presented by Dr. Abbe.
He said that he did not care to speak of the use of
radium in internal cancer. He had not ventured into
this field to any great extent, and unfortunately most
of the cases which had been sent to him had been
too far advanced to be benefited by any treatment.
He did not believe, however, that these internal
growths differed materially from the superficial
ones. Like the latter, they appeared to consist of
cells growing wild, as it were. It seemed to him
that the results which he had obtained with radium
went to demonstrate that cancer could not be of bac-
terial origin.
The great objections to radium were its exceeding
rarity and high cost. The purest to be had was the
German radium bromide, which was the standard of
activity, and the commercial value of this was $1,000
a cell of 10 milligrammes. The supply of this was
extremely limited, for, while radium was found in
some other localities, the expense of mining was far
too great to render the supply available. The only
place from which it could be obtained was the one
mine in Bohemia where it existed in the pitchblend
from which the uranium was extracted for the man-
ufacture of the Bohemian glassware. On account
of the possibility that the supply of pitchblend might
become exhausted, and the large population engaged
in making glass might thus be deprived of their live-
lihood, the government now strictly limited the
amount of mineral to be mined each year to a certain
fixed quantity. Hence the pure radium bromide
which came from this mine could scarcely be ob-
tained at all at present. Before these regulations
were quite so strict Dr. Abbe had fortunately been
able to secure several specimens of radium, and he
had one tube containing six cells (or 60 milli-
grammes) of the pure bromide, which was valued
at $6,000. The risk of handling radium was also
very great. On two occasions in his experience (one
of them very recent) the little container had fallen,
and as it exploded the radium had been scattered
about in all directions. By the extraordinary power
of the radium, however, he had succeeded in obtain-
ing photographs showing every particle of it ; so
that he was able to recover it all from the floor. It
was of value to know that the less pure specimens of
radium were still of service in the treatment of dis-
ease. The only reliable test of the activity of such
specimens was the photographic one. By testing
them through a lead disc, in comparison with the
photographic power of the standard radium bro-
mide, the exact degree of their activity could be de-
termined. It had been shown that a weak specimen
could be used with good effect if its application was
maintained for a sufficient length of time. Thus, one
which the photographic test had demonstrated to be
ten times less energetic than the standard must be
applied for ten times as long as the latter at each
sitting.
During the evening Dr. Abbe made applications
of radium bromide, of fifteen minutes each, to warts
on the hands of two of the physicians present. One
of these had lasted for twenty years, persisting in
spite of various forms of treatment.
The Modem Treatment of Bone Tuberculosis.
Dr. Reginald H. Sayre read a paper on this sub-
ject. Having remarked that the scientific treatment
of any disease must rest upon a clear understanding
of its aetiology and pathology, he referred to the
complete eradication by operation of tuberculous foci
advocated by many surgeons before the natural his-
tory of tuberculosis was as well understood as at the
present day, and said that in still earlier times the
opinion had prevailed that noninterference was ad-
visable in bone tuberculosis. The proper mode of
treatment lay between these two extremes, for, while
the good results noted from this course had been ar-
rived at empirically, recent laboratory investigation
had shown the scientific basis for the facts which
were observed clinically.
The speaker dwelt for some time on the causation,
course, pathological characteristics, and clinical his-
tory of bone tuberculosis, and emphasized the prime
importance of early diagnosis. To this end it was
requisite that the patient should be stripped, and if
disease was suspected in the hip, knee, or ankle, both
sides should be examined thoroughly. If there was
any doubt as to the presence of disease in a joint, it
was a great mistake to resort to an anaesthetic in
making the examination, as this would take away
the most reliable guide we possessed for the diagno-
sis of early inflammation, namely, the involuntary
muscular spasm by which Xature protected the joints
from traumatism. Almost the first symptom to be
manifested in joint inflammation was spasm of the
muscles controlling the joint, and it was one of the
last symptoms to subside. In the course of his re-
marks on diagnosis he referred to the use of tuber-
culin, and said that as yet but little had been report-
ed as to the reliability of this test.
(_To be concluded.)
—
f ttttrs t0 \\t m\m.
AX IMPOSTOR.
234 Clinton Street, Brooklyn, N. Y., April 28, 1908.
To the Editors:
On Thursday of last week a young man of good
appearance called on me and made the following
statement: That he was a graduate in medicine of
Berne ; that he had come to this country to prac-
tise medicine, but without success, and that he was
in distress, having a wife and child to support ; that
through the efforts of Dr. Carl Beck, of Manhat-
tan, and Dr. Wunderlich. of Brooklyn, he was re-
ceiving some aid from the German Medical Society.
He gave his name as Eschenbach and begged me
to get him into a hospital in any capacity. I called
up the superintendent of the Kings County Hospital
and stated the case, and was told to send the man
to the hospital with a card of identification and he
would be given a place as orderly. He never ap-
plied for the place. He does not live at the address
he gave me. Dr. Beck and Dr. Wunderlich both
repudiate him, and he is evidently an impostor. I
.have been informed, however, that he is using the
card of identification from me as an introduction,
and on the strength of this and some stationery
which he stole from my office is gaining admission
to the offices of physicians for begging purposes.
I hereby repudiate him. A. T. Bristow.
872
BOOK NOTICES.
[New York
Medical Journal.
MICROORGANISMS OR ARTIFACTS?
256 West Fifty-seventh Street,
New York, April 25, 1908.
To the Editors'
In to-day's issue of the Journal Dr. LeRoy de-
scribes some forms that he considers to bear an aeti-
ological relation to psoriasis. In them I recognize
appearances described by me in the Journal in 1872
(June and July) as being found when vaccine crusts
and crusts from impetigo contagiosa were soaked in
an alkaline caustic solution, that of sodium hydrate,
six per cent., being perhaps the best. Later I veri-
fied Lang's observations in relation to psoriasis. At
first I considered these forms to be fungoid bodies,
but later became satisfied that they were simply arti-
facts and not bearing any aetiological relation to
psoriasis or any other disease.
HeXRV G. PiFFARD.
Soflk |i0tices.
[ JVe publish full lists of books received, but we acknowl-
edge HO obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
Principles and Application of Local Tycatinent in Diseases
of the Skin. By L. Duncan Bulklev. A. M., M. D..
Pliysician to the New York Skin and Cancer Hospital,
etc. New York : Rebman Company. Pp. xii-130.
(Price, $1.)
Dr. Bulkley's vast experience in dermatology and
his well known conservatism will cause this small
and convenient book to meet with an unusually cor-
dial welcome from the medical profession of the
English speaking world. In it the topical forms of
treatment recommended are fully reasoned out, but
the reader is not burdened with prolix essays. The
book is the product of Dr. Bulkley's personal obser-
vation, not a rehash of others' dicta, and that is al-
ways a great advantage in a work on such a practi-
cal subject as the treatment of disease. We car,
commend it without the slightest reservation.
Comparative Electrophysiology. A Physicophysiological
Study. By Jag.^dis Chunder Bose, M. A.. D. Sc., Pro-
fessor, Presidency College, Calcutta. With Illustrations.
New York, Bombay, and Calcutta : Lxjngmans, Green, &
Co., 1907. Pp. 760.
Since the appearance of Biedermann's monumental
work on electrical phenomena as manifested in liv-
ing organisms nothing has appeared in this field of
research that is so interesting or so fundamental as
the work before us.
The present volume, the author tells us, is the
conclusion of a line of investigation of responsive
phenomena, begun in 1900, to bear out the general
thesis that living and inorganic substances show sim-
ilarities of response, due to fundamental molecular
reactions common to all matter in general.
He tells us that "an interesting link between the
response given by inorganic substances and the ani-
mal tissues is that given by plant tissues." By meth-
ods which he has described in an earlier thesis he
has been able to obtain from plants strong electrical
responses to mechanical stimuli ; such responses are
known for the sensitive plants, but Bose shows them
to be universal. Effects of fatigue, of temperature,
of poisoning, and of stimulation of plants show their
electrical responses. Such findings as these have
been regarded as highly improbable, and numberless
controversial discussions were aroused at the time of
their earliest publication. They are now accepted as
facts. In this connection it may be recalled to the
minds of our readers that there are many doubting
Thomases in our ranks who are skeptical as to the
facts concerning electrical registration of emotional
states, etc., as recently studied by Jung and others.
The author was led to seek for the more intimate
nature of these responses in a later investigation,
published in 1906, where he found that the in-
ternal stiinulus was in reality derived from some ex-
ternal source which was immediate or held latent in
the plant tisues. Thus the blow of external stimulus
is conserved in the plant tissues, and our wonder at
the seeming disproportion of reaction to an apparent-
ly infinitesimal stimulus receives an explanation.
That this fact may have some bearing on the high
potential motor discharges in epilepsy, etc., is an in-
evitable association in the mind of the reviewer.
From this idea alone it becomes apparent that the
comparative method of study for the elucidation of
the complex biological problems of electrical energy
in living matter is of the highest value, and Bose's
work is worthy of a place in every investigator's
laboratory.
We cannot at this time analyze the contents of th.is
large work of over 700 pages. It is compact experi-
ment and deduction, but a few points on which the
author differs with current beliefs may be touched
upon. The reactions of diverse tissues have hereto-
fore been regarded as specifically different. A;
against this, a continuity has here been shown to ex-
ist between them. Thus, nerve was universally re-
garded as typically nonmotile ; its responses were be-
lieved to be characteristically different from those of
muscle. He has been able to show, however, that
nerve is not only indisputably motor, but also that
the investigation of its response by the mechanical
method is capable of greater delicacy and freedom
from error than the electrical. It has further been
thought that plants are devoid of the power to con-
duct true excitation. This Bose shows to be incor-
rect.
He further pays his coinpliments to Pfliiger's law
of the polar effects of currents. This law, which
has been held to be universal, Bose disputes, show-
ing that both below and above certain limits of elec-
tromotive intensity the polar eft'ects of currents are
precisely opposite to those enunciated by Pfliiger.
The work, as has been said, is one to be most high-
ly commended ; it is stimulating, profound, and full
of suggestions of great practical value for the stu-
dent of electrical phenomena as manifested in living
matter.
Hwtiiatological Atlas. With a Description of the Tech-
nique of Blood Examination. By Priv. Doz. Dr. Karl
Schleip, Scientific Assistant in the Medical Clinic Uni-
versity of Freiburg i/B. English Adaptation of the Text
by Frederic E. Sondern, M. D., Professor of Clinical
Pathology, New York Postgraduate Medical School and
Hospital, etc. With Seventy-one Colored Illustrations.
New York: Rebman Company, 1908. Pp. 256. (Price,
$10.)
This handsome volume is equally creditable to the
author, the translator, and the publisher. Its most
striking feature is the excellence and accuracy of
May 2, igoS- I
OFFICIAL NEIVS.
^73
the beautifully executed plates, drawn to scale and
faithfully reproducing in color the well stained
specimens which served as originals. Each illus-
tration is separately mounted. In the accompany-
ing text are fully described recent and practical
methods for making blood films, the examination
of fresh and dried specmiens, staining, the estima-
tion of haemoglobin and specific gravity, the enu-
meration of the red and white cells, and the diflfer-
ential count of leucocytes. Every type of the es-
sential blood diseases is adequately shown, also the
changes associated with tumors of the bone mar-
row and the parisitology of the blood, including
malarial disease and trypanosomiasis. An effort
has been made in every case to present a simple
technique which will serve as a reliable guide to
the physician interested in clinical pathology, as
well as for the more experienced laboratory work-
er. This atlas of haematology meets a real want
and will prove, we believe, as indispensable to the
clinical microscopist as are colored plates and wax
models in the study of dermatology. The work is
also notable as a fine specimen of artistic book-
making.
BOOKS. PAMPHLETS, ETC.. RECEIVED.
The Influence of Alcohol and Other Drugs on Disease.
The Croonian Lectures Delivered at the Royal College of
Physicians in 1906. By W. H. R. Rivers, M. D., F. R. C. P.,
Fellow of St. John's College, Cambridge. London : Ed-
ward Arnold, 1908. Pp. viii-136.
The Next Step in Evolution. By I. K. Funk, D. D.,
LL. D. New York and London: Funk & Wagnalls Com-
pany, 1908. Pp. vi-107.
Spezielle Diagnose der inneren Krankheiten. Ein Hand-
buch fur Aerzte und Studierende. Nach Vorlesungen
bearbeitet von Dr. Wilhelm v. Leube, Professor der
mediz. Klinik und Oberarzt am Juliusspital in Wiirzburg.
IL Band. Siebente collstandig umgearbeitete Auflage. Mit
78 Abbildungen. Leipzig: F. C. W. Vogel. 1908. Pp. xii-
69-'. (Price, 16 marks.)
Ikonographia Dermatologica Tabulae selectse
editse a Albert Neisser. Breslau, Eduard Jacobi,
Freiburg i. Br. Ease, iii., tab. .xvii-xxvi. Berlin und Wien :
Urban & Schwarzenberg : Paris: Masson & Cie ; New
York : Rebman Company ; London : Rebman Limited, 1908.
Quarto, pp. 77 to 125.
• Atlas of Typical Operations in Surgery. By Dr. Ph.
Bockenheimer und Dr. Fritz Frohse. Si.xty Illustrations
from Water Colors by Franz Frohse (Artist), Berlin.
Adapted English Version by J. Howell Evans, M. A.,
-M. B., M. Ch., Oxon. ; F. R. C. S., England ; Demonstrator
<i_t Operative Surgery at St. George's Hospital, London, etc.
Xew York : Rebman Company ; London : Rebman Limited.
Quarto, pp. 252.
Elements of Water Bacteriology. With Special Refer-
ence to Sanitary Water Analysis. By Samuel Cate Pres-
cott, Assistant Professor of Industrial Biology, and Charles
Edward Amory Winslow, Assistant Professor of Sanitary
Biology in the Massachusetts Institute of Technology.
Second Edition, Rewritten. First Thousand. New York:
John Wiley & Sons, 1908. Pp. xii-258. ( Price. $1.50.)
Die Erkrankungen der weiblichen Geschlechtsorgane.
Von Hofrat Prof. Dr. R. Chrobak und Hofrat Prof. Dr.
A. von Rosthorn in Wien. II. Teil. Die Missbildungen
der weiblichen Geschlechtsorgane. Mit 90 Abbildungen
und 2 Tafeln. Wien und Leipzig: Alfred Holder, 1908.
Pp. 272.
The Borderland of Epilepsy. Faints. Vagal Attacks,
Vertigo. Migraine, Sleep Symptoms, and Their Treatment.
By Sir William R. Cowers, M. D.. F. R. C. P., F. R. S.,
Hon. Fellow, Royal College of- Physicians, Ireland, etc.
Philadelphia: P. Blakiston's Son & Co., 1907. Pp. vi-121.
(Price. $1.25.)
Mortality Statistics for 1906. Sexenth Annual Report,
Department of Commerce and Labor. Bureau of the Cen-
sus. S. N. D. North, Director. Washington : Government
Printing Office, 1908. Pp. 480.
Public Health and Marine Hospital Service:
The folloiving cases of smallpox, yelloiu fever, cholera,
and plague were reported to the surgeon general, Public
Health and Marine Hospital Service, during the week end-
ing April 24, 1908:
Smallpox — United States.
Places. Date. Cases. Deaths.
California — Berkley March 28-April 4 i
California — Los Angeles .March 28-April 4.,.. 5
California — San Francisco March 28-April 4 7
District of Columbia — Wasliinston . .\pril 4-11 21
Illinois — Chicago Vpril 4-1 1 4
Illinois — Springfield Vpril 2-9 5
Indiana — Indianapolis .March 29-April u... 6
Indiana— South Bend \pril 4-" i
Iowa — Davenport Vpril 1-30 11
Iowa— New London March 28 i Imported
Iowa — Ottumwa Vpril 4-11 7
Kansas— Kansas City Vpril 4-1 1 12
Kansas — Topeka .March 28-April ji... 26
Kansas — Wichita \pril 4- 11 8
Kentuucky— Covington April 4-11 3
Louisiana — Hornbeck Dec. 20- April I3 - - 34
Louisiana — Lake Charles April 14 2
Louisiana — New Orleans April 4-11 14 -2
Imported
-Vlichigan — Port Huron March 28-.\pril 11... 5
.Michigan — Saginaw March 28-April 11... 4
Missouri — Kansas City March 28-.\pril 4.... 9
Missouri — Ozark.... Feb. is-.-kpril 13 17
Missouri — St. Joseph .larch 7-14 23 i
Minnesota — Winona Vpril 4-1 1 2
Nebraska — Fall City and vicinity .. .To April 9 13
Nebraska — Nebraska City ' Vpril 6-13 2
New York— Buffalo Vpril 4-" i
Xew York — Niagara l :ilK April 4-11 3
(Jhio— Chillicothe March 3-April 15 18
Ohio — Cincinnati .\pril 3-10 13 i
Ohio — Murray March i-.\pril 3 25
Pennsylvania — Sayre .March 14-Apiil 11... 2
Tennessee — Knoxville Vpril 4- 11 i
Tennessee— Memphis .March 28-April 12... 9
Texas — San Antonio \pril 4-n 20
Wisconsin — -La Crosse April 4-1 i 6
Wisconsin — Racine April 4-11 5
Wisconsin — Spokane March 28-April 4.... 12
Smallpox — Foreign.
.Arabia — .Vden March 16-23 2
i'razil — Manaos March 14-21 3
Brazil — Rio de Janeiro March 8-15 87 9
Lgypt — Cairo Marcli n-i8..... ... 5 i
France— Paris .Vlarcii 21-28 5
Italy — General March _'6-. Vpril 2.... 98
India — Bombay March 10-17 44
Java — Batavia Feb. 22-March 7.... 10
.Malta Feb. 29-March 21.... 23 i
Manchuria — Dalny eb. 9-15 i
Mexico — City of Mexico Feb. 22-March 7.... 11
Portugal — Lisbon March 21-28 4
Russia — Odessa March 21-28 5
Russia— Warsaw I'eb. i-8 9
Spain — Aimeira Feb. 1-29 6
.Spain — Vigo March 1-28 2
Turkey — Bagdad Feb. 22-29 40 8
Turkey — Constantinople March 15-22 3
Turkey — Smyrna Jan. 1-28 10
Feb. 1-29 6
Yellow Fever — Foreign.
Brazil — Manaos March 7-21 6 3
Brazil — Para March 21-28 2 2
Cholera — Foreign.
India — Madras March 7-13 4
India — Rangoon Feb. 29-March 7.... 2
Plague — Insular.
Hawaii — Hilo April 6 i
Plague — Foieign.
Africa— Gold Coast:
.\kkra Jan. 11 -March 3---- i'4
Brewa Jan. ii-March 3.... 19
Miknunyano Jan. ii-March 3.... 5
Tema Jan. ii-March 3.... 9
Australia— Brisbane ->b. 1-8 2
.\ustralia— Sydney Feb. 24-.March 2.... i
Brazil— Para March 21-28 i i
Brazil— Rio de Janeiro March 8-15 i 1
Ecuador — Guayaquil March 30 Present.
Ecuador — Quito, vicinity March 21 Present.
Lgypt — General March 10-17 19 7
Egypt — Alexandria March 10-17 i
India — General Feb. 22-29 7.403 5,94-
Feb. 29-March 7... 8, 1 03 6,854
March 7-14 8,048 6,739
India— Bombay .March 10-17 306
India — Rangoon Feb. 29-March 7.... ig
Peru — Callao March 4-1 1 3
Peru — Catacaos March 4-11 i
Peru — Chepen March 4-11 i 1
Peru — Chiclayo March 4-1 1 2 2
Peru— Eten March 4- 11 i 4
874
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
Peru — Ferrenhafe March 4-11 2
Peru— Lima March 4-1 1 4 3
Peru — Mollendo March 4-1 1 4 3
Peru — Troillo March 4-1 1 39 'j
Turkey in Asia — Kerbela March 13 2
Public Health and Marine Hospital Service:
Official Hst of changes of stations and duties of commis-
sioned officers of the United States Public Health and
Marine Hospital Service for the seven days ending April
22, 1908:
Altree, G. H., Acting Assistant Surgeon. Granted leave
of absence for thirty days, from May 5, 1908.
B.MLEY, C. A., Acting Assistant Surgeon. Directed to pro-
ceed from St. John, New Brunswick, to Quebec, Can-
ada, for duty.
Brooks, S. D., Surgeon. Granted leave of absence for
three days, from April 20, 1908.
Brown, S. E., Acting Assistant Surgeon. Leave of absence
granted for fourteen days, from March 15, 1908,
revoked.
Foster, S. B., Acting Assistant Surgeon. Leave of absence
granted for fifteen days, from April 6, 1908, revoked ;
granted leave of absence for seven days, from April
13, 1908.
Hamilton, J. H., Acting Assistant Surgeon. Granted
leave of absence for two days, from April 20, 1908.
Holt. J. M., Passed Assistant Surgeon. Granted leave of
absence for seven days, from Aprrl 21, 1908.
SiMONsoN, J. H., Acting Assistant Surgeon. Granted leave
of absence for two days, revoked.
Sm.^ll, E. M., Acting Assistant Surgeon. Granted leave
of absence for eight days, from April 18, 1908.
Boards Convened.
Boards of medical officers were convened to meet on
April 27, 1908, for the purpose of examining candidates for
the position of cadetship in the Revenue Cutter Service, as
follows :
Baltimore, Md. : Surgeon L. L. Williams, chairman; As-
sistant Surgeon H. H. Warner, recorder.
Boston, Mass. ; Surgeon R. M. Woodward, chairman ;
-Assistant Surgeon T. W. Salmon, recorder.
Chicago, 111. : Surgeon G. B. Young, chairman ; Passed
.Assistant Surgeon J. "S. Boggess, recorder.
Detroit, Mich.; Surgeon Fairfax Irwin, chairman;
Passed Assistant Surgeon M. J. White, recorder.
Galveston, Tex. : Passed Assistant Surgeon G. M. Cor-
put, chairman; Acting Assistant Surgeon W. H. Gammon,
recorder.
Mobile, Ala.: Surgeon G. M. Guiteras, chairman; Acting
-Assistant Surgeon J. O. Rush, recorder.
Newport News, Va. : -Assistant Surgeon G. L. Collins,
chairman ; Acting Assistant Surgeon A. C. Jones, recorder.
New York, N. Y. : Passed Assistant Surgeon J. -A
Hydegger, chairman ; Acting -Assistant Surgeon F.
Mahoney, recorder.
Philadelphia, Pa. : Surgeon J. M. Gassaw ay, chairman ;
Passed -Assistant Surgeon Taliaferro Clark, recorder.
Portland. Me.: Surgeon W. P. Mcintosh, chairman; Act-
ing -A-sisiant Surgeon -A. F, Stuart, recorder.
San I'Vancisco, Cal. : Surgeon H. W. Austin, chairman ;
Passed -Assistant Surgeon C. H. Gardner, recorder.
Seattle, Wash. : Passed .Assistant Surgeon M. W. Glover,
chairman ; Assistant Surgeon C. W. Chapin. recorder.
Washington, D. C. : Assistant Surgeon General W. J.
Pettus, chairman ; Passed Assistant Surgeon J. W. Trask,
recorder.
Army Intelligence:
Official list of changes in the stations and duties of
officers serving in the medical department of the United
States Army for the week ending April 25, igo8:
Clark, J. A., Captain and .Assistant Surgeon. Ordered to
Madison Barracks, N. Y., for temporary duty.
Davis. W. R., Captain and -Assistant Surgeon. Ordered
to accompany troops from San Francisco, Cal., to Fort
Thomas, Ky., and return ; granted leave of absence for
fifteen days.
DeLoffre, S. M.. Captain and Assistant Surgeon. Or-
dered to Columbus Barracks, Ohio, for duty ; ad-
vanced to grade of captain to rank from September
10, 1908.
Greenleaf, H. S., Captain and Assistant Surgeon. Or-
dered to duty at Madison Barracks, N. Y., at the ex-
piration of his present leave of absence.
Harris, H. S. T., Major and Surgeon. Granted an exten-
sion of one month to his leave of absence.
Kendall, W. B., Major and Surgeon. Granted leave of
absence for one month, about April 20.
Schreiner, E. R., Major and Surgeon. Returned to duty
at Army General Hospital, San Francisco, Cal., from
detached service to Madison Barracks. N. Y., and
leave of absence..
Navy Intelligence:
Official list of changes in the medical corps of the
United States Navy for the zueek ending April 26, jgo8:
Baker, M. D., Pharmacist. Appointed a pharmacist from
April 17, 1908.
FiSKE, C. N., Passed Assistant Surgeon. Orders to Wash-
ington, D. C, revoked ; to continue treatment at the
Naval Hospital. Mare Island, Cal. ; ordered home and
granted sick leave for two months, when discharged
from treatment at the Naval Hospital, Mare Island,
Cal.
Koltes, F. X.. -Assistant Surgeon. Detached from the navy
yard. Mare Island. Cal., and ordered to the Connecticut.
Ransdell, R. C, Assistant Surgeon. Detached from the
Connecticut and ordered to the second torpedo flotilla.
ZiEGLER, J. G., Acting -Assistant Surgeon. Ordered to duty
at the Naval Hospital. Portsmouth, N. H.
Born.
Usher. — In Camp Stotsenburg, Philippine Islands, on
Friday, January 17th, to Dr. Francis M. C. Usher, United
States' Army, and Mrs. Usher, a son.
Whaley. — In Fort Sam Houston, Texas, on Tuesday,
April 7th, to Dr. .Arthur M. Whaley, United States Army,
and Mrs. Whaley, a daughter.
M arried.
Buck — White. — In Camp McKinley, Philippine Islands,
on Friday, -April loth, Dr. Carroll D. Buck, United States
-Army, and Mrs. Ynez Shorb- White.
Hill — Clay.— In Atlantic City, New Jersey, on Wednes-
day, April 29th, Dr. Howard Kennedy Hill and Miss Ruth
Clay.
Mason — Strickland —In San Francisco, California, on
Wednesday, April 15th, Dr. William McPherson Mason
and Miss Geraldine Belle Strickland.
Robertson — Brown. — In Boulder, Colorado, on Tuesday.
-April 14th, Dr. Eugene H. Robertson and Miss Elinore
-A. Brown.
ScHUMAN— Peightol. — In Philadelphia, on Thursday.
April i6th. Dr. Frank L. Schuman, of Huntington, Pennsyl-
vania, and Miss Mary Peightol.
Died.
CoNOVEK. — In Port Townsend, Washington, on Sunda\-.
.April 19th, Dr. Simon B. Conover.
Gamble. — In Gastomille. Pennsylvania, on Tuesday,
-April 14th, Dr. William Jackson Gamble.
Legler. — In Oakland, California, on Tuesday, April I4tli.
Dr. Henry T. Legler, aged eighty-nine years.
MooRE.-^In San .Antonio. Texas, on Tuesday, April 14th.
Dr. Frank P. Moore, aged tifty-seveii years.
Patterson. — In Cincinnati, on Friday, April 17th, Dr
William G. Patterson, aged ninety-three years.
Ross.— In Miinster. Westphalia, Germany, on Wednes-
day, .April 15th, Dr. Joseph B. Ross, of St. Louis. Missouri,
aged fifty years.
Stansfield. — In San Francisco, California, on Wednes-
day, April 15th. Dr. Halstead A. Stansfield.
Stebhins. — In Omaha, Nebraska, on Sunday, .April iQtli.
Dr. Richard Stebbins. aged eighty-four years.
Stephenson.— In Iroquois, Ontario, Canada, on Monday.
April i.^th, Dr. James Stephenson, aged seventy-three
years.
Thomas. — In Cleveland. Ohio, on Saturday. April i8th.
Dr. William E. Thomas, aged eighty years.
TowNE. — In Essex, Massachusetts, on Thursday, April
i6th. Dr. Charles J. Towne.
Wilder. — In Mcdfield. Massachusetts, on Friday, April
17th, Dr. Ralph Wilder, aged thirty years.
WKiGHr.- In Montreal, Canada, on Friday. April 17th.
Dr. William Wright, aged eighty-one years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal tH Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXVII, No. 19. NEW YORK, MAY 9, 1908. Whole No. 1536.
(Original Communira'tifliis.
THE RESTORATION OF THE NORMAL BALANCE
OF THE FOOT.
L
A Preliminary Paper. The Anatomy and Functions of the
So Called Arch of the Foot, with Results of Experi-
ments on Both the Normal and the Weak Foot.
By E. G. Abbott, M. D., and H. A. Pingree, M. D.,
Portland, Me.
The term "arch," as appHed to that part of a
normal foot which does not come in contact with
the surface beneath it, when a person is standing,
appears to be a misnomer and most misleading.
"Dome" or "vault" would be a far more descriptive
word to use, and "arch" would be a better term to
apply to any line extending over the surface of the
dome from one point to another. Changes in an-
atomical nomenclature are, however, not readily ac-
cepted, therefore no attempt will be made to
substitute either of the terms suggested ; but the
reader is requested to bear in mind that wherever
"arch" occurs in the phraseology it represents that
part of the foot which as a whole is dome shaped.
In the description of the arch of the foot it has
been customary to consider it as half of an arch
Fig. 1.— Plaster cast of the arch of the skeletal foot,
l iG. 2. — Plaster cast of the arches of two skeletal feet held in
apposition.
formed by placing the inner borders of the feet in
apposition. It is also usual to regard a point sit-
uated on a line between the feet thus placed as the
highest part. If the skeleton of the foot is used for
this demonstration, and a plaster cast (Fig. i)
taken of this rather than of the living subject, it
would be readily seen that the usual impression is
erroneous, and that, when the two feet are placed
in apposition, it would be more correct to describe
the contour of the surfaces, which do not come in
contact with the floor beneath them, as two separate
arches (Fig. 2), or speaking more accurately, as a
segment of two arches ; and, if the space beneath
the skeletal feet held in this manner is filled with
plaster of Paris, instead of our having an object
similar in shape to one shallow bowl, w^e would
Fin. 3. — Diagranimatic cross lection of arches with skeletal fool
in api osition.
have an object which more closely resembles two
bowls (Fig. 3).
It would seem then more exact to describe the
arches of the feet separately, and to represent each
as a section of a shallow bowl, that portion being
cut of¥ which extends beyond the internal border of
the foot, but along a line, which by no means cor-
responds to its highest part. A plaster cast of the
skeleton of the foot would show that the highest
part of the model is not the inner border, but that
it is some distance external to it.
If, beginning at the distal end, we draw a line
(Fig. 4) longitudinally over the surface of the high-
est part of the arch of the skeletal foot, we shall
find that it passes over the third metatarsal bone, the
external cuneiform, outer part of the scaphoid, the
astragalus and the inner margin of the calcaneum ;
and that all parts internal to this line, consisting of
the first and second metatarsal bones, middle and
internal cuneiform, a large part of the scaphoid,
and a part of the astragalus, as well as those ex-
ternal, the fourth and fifth mata tarsal bones, cuboid
and caleneum, are placed on lower planes.
A cross section of the plaster cast near its centre
(Fig. 5) shows the arch well defined transversely,
its external end, however, on a much lower level
than its internal, and its crown at a point near the
junction of the middle and inner thirds. The other
parts of the foot usually mentioned in descriptions —
the anterior metatarsal arch, and the arch formed by
the internal border of the foot — are not of so much
importance, and their consideration is not so neces-
sary, if we throughly understand the arch of the foot
as dome or vault shaped, for, if this arch is main-
tained within its normal limits of motion, the other
parts will remain in their normal position.
When the foot is used as a support, the arch is
ConyriRht. 1908, by A. R. Elliott Publishing Company.
876
ABBOTT AND PINGREE: NORMAL BALANCE OF FOOT.
[New York
Medical Journal.
held in place by muscles, fascia, and ligaments ; but
there is very little strain on any of these parts, as
the arch is so constructed that in a normal condition
the balance of the foot is easily maintained. The
arch is normally
somewhat depressed,
when the foot is used
only as a support, but
this change is not
''S^fi great. It is simply a
fllffl^l relaxation from mus-
'H contraction, and
^ muscles then
^'PfmW § serve as strong liga-
il iMrm ments in conjunction
ak^H'iir ■ ^^^^'^ ligaments
, |f fldHi'^ ..^t proper to maintain
''imKmk* ■' ^'^^ ^^^^ °^
■'Im^f^mJ '^^'^'^ curve of the in-
ternal border of the
i./ ■■ ' ^^'^^ somewhat
n' >1b ' lessened by this relax-
y 'Ij . ation, but not to any
considerable extent.
I The usual eversion
j of the foot in this
state of support (Fig.
Fio. 4.— Line indicating high- 6 ) mUSt UOt be mis-
est part of arch at ditTerent taken for a prOUatcd
points. . ^ ^
foot m the sense of a
deformity, as this position is caused chiefly by
a rotation of the femur to relieve the strain
upon the hip structures : and all the normal de-
pression of the arch would take place just the
same if the foot was inverted. In some instances
it appears that the arch is normal in shape although
the foot is habitually abducted, and the inner border
is bulged (Fig. 7) ; yet the only way to change this
habitual abduction or pronation is to increase the
height of the arch, and, when this is done, the bulg-
ing of the inner border disappears and the foot re-
turns to a corrected position (Fig. 8); therefore,
what might seem to be a normal arch in a foot
which is habitually abducted is not so for that indi-
vidual, for, when it is raised, the deformity disap-
pears.
In activity the foot is controlled by muscles, and
as long as they are in a normal condition and noth-
Vic. s. — Cross section of plaster cast of tlie skeletal arch near it>
centre.
ing interferes with the joint motion, the foot per-
forms its functions in a normal manner. The prin-
cipal movements which may take place in the arch
of the foot are four, flexion, extension, adduction,
and abduction. The arch is raised and lowered
(flexed and extended) by muscular action to a cer-
tain extent in the normal foot, and, with this rais-
ing and lowering, the foot is changed from adduc-
tion to abduction and vice versa. It is a compound
Fig. 6.— Normal attitude of vest, showing outward rotation of
limbs without pronation.
movement, and must necessarily be so on account of
the shape and structure of the arch ; and the primary
changes, which have been mentioned, cannot take
place alone.
In the preservation of the normal arch movement
it is necessary to take into consideration only those
I'lG. — I'ronatcd foot with bulging of inner border. .\rch ap-
parently normal in height.
Fig. 8.— Same foot as Fig. -. arch raised to normal height by a
metal support. Pronation and bulging of inner border disappears.
May 9, 1908.]
ABBOTT AND PINGREE: NORMAL BALANCE OF FOOT.
^77
muscies which control these movements. The prin-
cipal muscles which raise the arch (flex and adduct)
are the anterior and posterior tibial, the latter hav-
ing the greater influence, as it is much more power-
FiG. 9. — Showing inability to raise arch by traction on tendon?
of anterior and posterior tibials when heel cord is short.
Fig. 10. — Same foot as in Fig. 9, arch easily raised after heel
cord has been severed.
ful. The chief ones which enter into any depres-
sion of it (extend and abduct) are the peroneus
longus, brevis. tertius, and gastrocnemius. All the
other muscles which participate in any way in these
movements are only adjuncts to these, and alone
exert very little control.
The following experiments, which were per-
formed upon recent amputations with the assistance
of Dr. F. A. Bartlett. illustrate the changes which
occur in the arch of the foot when the muscles are
severed, the amount of traction requisite to main-
tain the arch in a normal position, and the amount
necessary to raise it to a normal position, when
depressed : also an experiment upon the living sub-
ject showing the alterations in the arch of a weak
foot when it is changed from the position of rest to
that of pronation.
Experiment I. Cadaver. Showing the eflfect of
a much shortened heel cord upon the arch of the
foot. If a dissected weak foot, in which the heel
cord is shortened, is held in the same position as
that of the normal foot in use (all restriction except
the short heel cord being absent), it will be found
that it is impossible to raise the arch by traction
upon the anterior and posterior tibial muscles to a
normal position (Fig. 9) ; but, if the tendo Achillis
is divided, that the inner border of the foot is raised
easily to the desired height (Fig. 10).
Experiment II. Cadaver. Showing the efTect of
the peroneus longus and brevis, when they are short-
ened, upon habitual abduction of the weak foot. If
a weak foot, which is habitually abducted, is pre-
pared in the same manner as in Experiment I, and
if force is applied in an attempt to adduct it. it will
be found that there is no change in the altered arch,
and that it is impossible to bring the foot into a
normal position (Fig. it). If, however, a tenotome
is placed beneath the shortened tendons and the
same force applied, the foot will, when the tendons
are severed, readily assume the adducted position
(Fig. 12).
Experiment III. Cadaver. Showing the eflPecr
in a weak foot of dividing the tendo Achillis, the
Fig. II. — Unable to raise arch by traction on the tendons of the
anterior and posterior tibials, when the peronei are short.
Fig. 12.-— Same foot as in Fig. ii, showing arch easily raised by
same traction with the perDaei severed. .
tendons of the peroneus longus and brevis, and of
shortening the tendons of the anterior and posterior
tibial muscles. If, having dissected the skin and
subcutaneous tissues from the foot and ankle in a
case of weak foot with permanent pronation, we use
force in the direction of adduction, it will be found
impossible to bring the foot into a corrected position
(Fig. 13), but if the tendo Achillis and the tendons
of the peroneus longus and brevis are cut. the foot
swings readily into the desired position, and, if the
tendons of the anterior and posterior tibial muscles
878
ABBOTT AND PINGREE: NORMAL BALANCE OF FOOT.
[New York
Medical Journal.
are shortened, it remains in this position (Fig. 14). ^
Experiment IV. Cadaver. Showing the neces-
FlG. 13. — Arch held depresse'l by short heel cord and peronei.
sary amount of traction on the posterior tibial muscle
in order to maintain the arch of the foot when it is
in normal position. A normal foot, having been
Fig. 14. — Same fool as in Fig. 13; with pcronti and heel cord
cut, arch can be raised to normal height, and the foot brought to
a correct position.
prepared by removing the skin and subcutaneous
tissues, is placed in the position of weight bearing.
All the parts which hold the arch are divided so
that w hen a light weight is placed upon the leg the
foot will assume the pronated position, with the
internal border resting upon the surface beneath it
(Fig. 15). Now, if scales fastened to a pulley
overhead are hooked into the cut end of the pos-
terior tibial tendon, and if the arch is pulled into
normal position (Fig. i6), it will be found that a
traction oi twenty-four pounds will maintain a
normal arch when a weight of two hundred pounds
is placed on the upper end of the tibia. This ex-
periment would indicate that, in order to hold the
arch in position, the power applied to one of the
muscle tendons, which normally supports the greater
part of the strain in weight bearing, would need to
Fig. 15. — .\11 parts divided which hold the arch in normal posi-
tion, allowing the inner border of the foot to rest upon the surface
beneath it.
Fig. 16. — Same foo< as in Fig. 15, showing that a traction of 24
lbs. applied to the posterior tibial tendon, will maintain the arch in
normal position, when a weight of 200 lbs. is placed upon the leg.
be less than one eighth of the weight supported.
Therefore, if the arch is in normal position, it re-
quires very little muscular power to maintain it.
Experiment V. Cadaver. Showing the same ex-
periment with the tendon of the anterior tibial
muscle fastened to the scale in conjunction with the
posterior tibial (Fig. 17). In this experiment it
requires only nineteen pounds to hold the arch in
position. This shows the advantage in having the
two tendons pull together, in that the amount of
traction necessary is lessened about one fourth.
Experiiiirnt VI. Cadaver. Same sf)ecimen used
as in Experiments W and V. Showing the amount
of traction necessary to raise the depressed arch
when applied with the foot fully pronated. If the
leg is held erect and the foot allowed to pronate so
May 9, 1908.]
ABBOTT AND PINGREE: NORMAL BALANCE OF FOOT.
879
that the internal border will come in contact with
the surface beneath, and if traction is then applied
to the free ends of the anterior and posterior tibial
tendons (Fig. i8), it will be found that, in order to
lift the arch, an amount of force equal to the weight
borne upon the leg is required, and if two hundred
pounds are placed on the upper end of the tibia, it
will take a force equal to two hundred pounds on
the scales to raise the arch from the surface upon
which it rests, but that this amount of force lessens
proportionately as the foot approaches its normal
position.
Experimetit VII. Living subject. Showing the
change which takes place in the arch of the weak
foot at rest, when it is pulled by muscular action
into the pronated position. If a person with a weak
foot is placed in a sitting posture, with the legs
crossed, the foot being suspended free in front of
Fig. 17. — Same foot as in Fig. 16, with the addition of the an-
terior tibial the amount of traction is reduced to 19 lbs.
Fic. 18. — Same foot as in Fig. 17, 200 lbs. weight placed
upon the leg with arch depressed. 200 lbs. traction upon the an-
terior and posterior tibial tendons ^s required to start arch from
surface beneath it.
him, it will be seen that the arch of the foot is
apparently normal in height (Fig. 19). Now, if
the patient is requested to hold the foot in extreme
pronation, the arch will still seem to be of normal
height or even higher, but if a more careful ob-
servation is made, it will be seen that the arch is
not so high, but that it is twisted, and that the ap-
parent increase is due to the pulling of the peroneus
longus muscle upon the first metatarsal bone, which,
even in the normal foot, is freely movable, and may
be lowered easily one half an inch bv this action.
A more striking method of demonstrating this
twist is to fasten two strips of wood across the bot-
tom of the foot, one under the heel and the other
beneath the ball, so that they will both be on the
same plane when the foot is at rest (Fig. 20) : then
let the patient place the foot in a position of ex-
treme pronation, and it wiU be seen that there is
a marked difference between the planes of the two
pieces of wood (Fig. 21).
Any change from the normal in the structure and
Fig. 19. — Weak foot at rest, a, Arch apparently normal, b.
Same foot pronated with arch increased, due to action of peroneus
longus in lowering the first metatarsal bone.
function of the foot to the pathological of the weak
foot must come through a disturbance of the arch,
and as long as the arch is maintained such a condi-
tion as weak or flat foot cannot take place. There-
fore, in examining a weak or flat foot, it is neces-
sary to consider only the arch and those structures
which should control and maintain it, for, if the
arch is restored, and those parts which hold it in
position regain their functions, the foot will recover
its normal condition. The normal state of the arch
and the parts which maintain and control it are
then of primary importance, and any pathological
condition, like that found in weak foot, is due to
some change in these structures.
In looking at the anatomv of the weak or flat foot
Fig. 10. — W^ak foot at rest. Arch apparently normal with heel
and ball on same plane.
we find that the changes which have taken place are
many, but that those which prevent the normal
maintenance of the arch after all restriction to
passive motion has been removed are of the most
concern. The pathological alterations in the indi-
vidual ligaments, bones, and joints are of little im-
88o
XEIl'MAYER: DEFECTIVE VISIO.Y IN CHILDREN
[New Vork
Medical Journal.
portance in this connection, as they are only inci-
dental to the continued depression of the arch. It
matters not in what condition we find the foot, it
must first be brought to such a state that it is freely
movable in all directions, i. e., to a condition of
weak foot.
The next step or change from a weak to a normal
foot presents a far more difficult problem to solve ;
Fig. 21. — Weak foot pronated. Arch apparently normal, but twisted
by rction of peroneus longus on first metatarsal bone.
therefore, the changes which take place in the joints
and ligaments, in so far as they retard motion, may
be left out of consideration, and attention given to
those parts which, through their pathological
changes, prevent a weak foot from being a normal
one, namely, the ligaments and muscles. The liga-
ments are lax throughout the whole structure, and
those muscles which control certain motions are
lengthened, while others are shortened. On the
inner side of the foot the anterior and posterior
tibials are the principal muscles at fault. They are
stretched much beyond their normal limit : are pull-
ing at a great disadvantage whenever the foot is in
use, and give no support when the foot is at rest.
On the outer side of the foot the peronei are found
to be shortened and often displaced ; but. instead of
being weakened in their action, both as a support
and as a lever, they are strengthened through this
displacement, and work most advantageously in in-
creasing the deformity. It is not unusual to find the
heel cord shortened sufficiently to prevent the calca-
neum from being held at its normal angle, thereby
restraining the arch of the foot from preserving its
normal contour when the foot is flexed. The plantar
fascia, the principal truss of the arch, is stretched
and gives little aid in holding the foot in position.
DEFECTIVE VISION AND THE MENTALLY SUB-
NORMAL CHILD.*
By S. W. Newmayer, M. D.,
Philadelphia,
.Assistant Ophthalmologist to the Polyclinic Hospital.
This article has been written, not to enlighten the
ophthalmologist or that small part of the medical
profession who are acquainted with diseases of the
eyes, but to arouse in the general practitioner a
greater interest in his responsibility to school chil-
dren suffering from defective vision. I have tried
to express myself in terms which would make the
•Read be .'ere the XortI; Western Medical Society.
subject likewise clear to such laymen as teachers
and educational authorities, who should have a
knowledge of this subject. Another important ob-
ject of this article is to try to correct a dangerous
misuse or abuse of the "test card," not only by lay-
men but by some of the medical profession.
In recent years much has been writen and said
in reference to the relation of physical defects and
mentality. Several prominent physicians have as-
serted that physical defects have no influence on
mentality. This may ofttimes be considered correct
if they refer to that mental deficiency which is of
such a degree to classify the child as an idiot or
imbecile. It seems to me that the varied opinions
are due to the too loose use of the term "mental de-
fective." I believe this term should be reserved for
those graver cases which are due to congenital de-
fects of the brain and its functions, to those cases
which from birth show little or no development of
their mental faculties. To those minor cases which
exhibit an abnormality to a moderate degree,
whether inherited or acquired through physical de-
fects, the term "mentally subnormal" could be ap-
plied. The use of such a classification may facili-
tate a more systematic and uniform study of this
important medicopsychological subject. Consider-
ing the mentally subnormal, I am convinced that
physical defects are an important factor in their
study. It is true that not every child with a physi-
cal defect is mentally subnormal, because the ^ame
defect influences each child differently.
There should be an attempt to show the rela-
tion between cause and effect. In the study of each
individual case, it is not only necessary to isolate
if possible the causative factor, but the individual
reaction to such cause. One child may not be af-
fected by a moderate degree of defective vision,
and another child be seriously hampered by the
same amount of defect. Most physicians have seen
cases of decided change in mentality following an
acute disease such as grippe or typhoid fever. This
may or may not be due to the lowered vitality. It
may be due to the effect of the toxines directly on
the brain. There may be as a sequela a defect of
hearing or of vision. However, most physicians
will agree that some physical defects can cause an
altered condition in the mental state. The im-
portant problem is to recognize these defects, and
correct them.
The time is near when our public school authori-
ties will recognize and classify in a practical man-
ner the children with varying degrees of mentality.
At present the child with little physical vigor and
lessened mental capacity is placed in classes with
far brighter pupils, and is goaded on to keep the
pace with the most precocious child. These back-
wards are overlooked and misinterpreted, and
sooner or later are physical or mental wrecks. If
we could only follow these cases after school life
we would find some interesting statistics of termi-
nations. The majority of these cases leave the
schools, no matter to which grade they have
reached, as soon as they pass the age of thirteen
or fourteen years, and out of reach of the "Truant
Law." These are the children that must make un-
desirable citizens. They have not the education to
take skilled positions, the greater time idle, and
May 9, 1908.]
NEIVMAYER: DEFECTIJ-E VISIOX IN CHILDREN.
88l
easily led into a life of waywardness. The termi-
nation is ofttimes the prison or asylum. The noble
type of teacher is she who recognizes such un-
gent squint in a school cliild, due to
fortunates in her class, and makes every effort to
discover a cause, and attempt to have it corrected.
Let us consider the various physical defects
which may be found in children and study their
effect on the mentality. Acquired orthopaedic de-
fect, whether spinal curvature or hip disease, etc.,
have no direct action on the brain or its functions,
as likewise congenital defects unless accompanied
by a congenital or hereditary defect in the brain
itself. Lesions of the skin, nose, and throat (in-
cluding the much talked of adenoids) exercise no
retardation of the mental faculties, except in those
cases where these defects affect the general health
and nutrition of the child. These are sometimes
cases of fatigue or exhaustion, and from whatsoever
cause the existence of these symptoms may cause
a mental subnormality.
The nervous system with its allied diseases is an
important factor in causing mental subnormality.
til one lens on the
However, in most of these cases the nervous symp-
toms are secondary to another defect. Not infre-
quently in children this defect is in the eyes. The
eyes and ears are the remaining organs, defects of
which may cause mental retardation. Normal hear-
ing is important to normal mental faculties, but
when one considers that there are few impressions
dependent on the sense of hearing, that can not be
conveyed by the sense of sight, and also the relative
infrequency of defective hearing in comparison to
defects of vision, a study of the eye and its defects
is bv far the most important. I believe I .am not far
from correct when I make the assertion that more
than seventy-five per cent, of the cases of mental
retardation are
due to, I. disease
of the brain, with
a greater or less
degree of absent
or undeveloped,
untrained, latent
function ; and, 2.
defects and dis-
eases of the eyes.
When we con-
sider the practical
application of
these two great
classes with an
attempt at treat-
ment, the mentally
defective of the
type of imbecile
or idiot, and due
to inherited or
congenital ab-
sence of brain
function, is a
hopeless patient
and should be
placed where he
does the least
harm to society
and himself. The
patient with the
undeveloped, un-
trained, latent
faculties can oft-
times be benefited by a proper systematic train-
ing. The eye, defects of which cause a large
percentage of cases of mental subnormality, is
most often amenable to treatment, but often over-
looked as the offending organ. The chief reason for
not suspecting the eyes as the seat of trouble is that
the examiner always expects to find symptoms and
signs to point to the eyes, forgetting that ofttimes
gross changes may be present in these organs and no
outward signs noticeable. There may be no redness
or inflammation of the lids, no squint, no apparent
impairment of vision, possibly 'only an occasional
headache, twitching of the lids, or possibly a stye,
and considerable abnormality present. Never ex-
clude the eyes except in the proved absence of ocu-
lar disease, the most thorough and systematic ex-
amination for possible errors of refraction, or ab-
normality of binocular vision. It appears that much
of the deception is due to an abuse of the test card.
These cards seem to be used for absolute diag-
nosis of eye defects, instead of a valuable aid to con-
firm the findings by instruments of precision.
Much time and energy- have been wasted in gather-
FiG. 3. — Test card for children
iterates, designed by the autli-K.
882
NEW MAYER: DEFECTIVE VISION IN CHILDREN.
[New York
Medical Journal.
ing statistics of the number of cases of hyperopia
and myopia, and astigmatism. Most of these sta-
tistics are based on the abihty of children to see
clearly the letters of a test card, placed at a set dis-
tance from the pupil. The findings by these meth-
ods are inaccurate, because the child has a great
power to accommodate for near and distant objects.
With this quality, which is possessed to a greater or
less degree by all eyes, especially
prominent in children, one can
temporarily overcome an existing
defect and see objects at a dis-
tance distinctly. By this means
the examiner is noting only the
apparent or "manifest" errors,
and the important "latent" de-
fects are neglected. In exam-
ining eyes with a test card only,
if a child sees the letters of a
fifteen feet line distinctly at that
distance means that the child's
eyes are normal, or he is ac-
commodating sufficient to over-
come all defects. If he cannot
see this line distinctly at the re-
quired distance, one can say
with reasonable accuracy he has
defective vision. It may be
hvperopia, myopia, astigmatism,
or anv combination. The use
of the clock dial and various
other astigmatic charts may help
one to diagnosticate the case, but
more often fails. Because a
child can read further and
smaller type than the fifteen feet
line at that distance does not sig-
nify that the pupil is far sighted,
but he possesses very acute
vision. If we could eliminate
this power of accommodation, the
chances are the child may have
vision far below normal. This
power of accommodation or
ability to adjust the eyes to dis-
tinct vision at varying distances
is most prominent in children.
It is accomplished by a combined
action of the ciliary muscles,
lenses, and the pupils, through
which the- optical power (re-
fraction) of the eyes is altered
to meet the varying require-
ments. These facts can readily
be proved by placing in front of
a patient's eyes spherical lenses,
convex or concave, and note
to what extent the patient
can overcome these lenses
and still maintain distinct vision. The relaxing of
accommodation to obtain correct findings is accom-
plished by instilling into the eyes drugs such as
atropine. These drops relax accommodation and
dilate the pupils, and admit of a true refraction.
Of course this should be done only on the order of
a physician. Ophthalmologists rarelv attempt to
order necessary glasses in patients under the age of
fortv-five or fiftv vears, in whom there is no sus-
picion of glaucoma, without placing some such
drops in the eyes. Of course it is of value to know
the acuteness of vision without the mydriatic, but it
should be compared with the findings during its ac-
tion. The reason why I call attention to this abuse
of the test cards, especially by school teachers and
principals, is that I believe if the same amount of
time and energy that is expended in obtaining these
worthless statistics were used to urge the parents
of pupils with glaring defective vision to obtain
the necessary glasses far better and more practical
results would be obtained. It requires a competent
ophthalmologist with instruments of precision to
make the proper examinations and necessary deduc-
tions as to the necessary glasses to be worn. The
test card will in some cases enable the layman to
pick out a glaring case of defective vision, but I
May 9, .90S. J
XEir.MJVER: DEFECTIVE J'lSIOX IX CHILDREX.
883
believe there is no better method of detecting these
cases among school children than the observing and
interested teacher. She can tell more by her con-
tinuous close contact and watching the actions of
the chiklren than anyone who stands the child for
a few minutes before a test card. A child may at
that moment have acute vision, but at some time
while at work in the class room show the effects of
eyestrain.
Why do the same errors in different people not
produce the same signs, symptoms, and ultimate
effects? One is apparently unaffected, another suf-
fers from headache and a train of reflex symptoms
sufficient to cause invalidism. There may be violent
attacks of headache : dull or sharp pains in the
eyes ; sore and inflamed eyelids : twitchings of the
forehead or eyes resembling chorea ; a marked
squint ; there may be convulsions, and again there
may be few symptoms. Sometimes there may exist
only a continuous dulness and inabilit\- to work or
absorb any knowledge. These variations depend
much on the temperament of the individual : one is
phlegmatic, another is neurotic.
To obtain a normal education a child must ob-
tain correct impressions, and to this end normal
vision is necessary. Every child with errors of re-
fraction is not a mental defective, but the pupil who
suft'ers from defective vision remaining uncorrected
must be below the mental status of another child
of equal abilities who is not handicapped by such a
disability. The pupil with defective vision, espe-
cially if symptoms are present, must Ije below par.
and hence mentally subnormal. The true keenness
and intelligence of the pupil may still be evident,
but the education nevertheless is hindered in various
ways. Headaches may make the child restless and
inattentive, or there may be for the same reasons
repeated absence from school. Every child who
seems mentally subnormal, or who suft'ers from
headaches, nervousness, blurring or impaired vision,
facial twitchings, or frequently inflamed eyes,
should be thoroughly and systematically examined
by a competent ophthalmologist for possible re-
fractive errors, and deviations from normal binocu-
lar vision.
Beyond the correction of errors of refraction,
many physicians seem to place little importance on
the muscles attached to the eyes and keeping a per-
fect binocular vision. If a self evident squint is not
present, this important factor is ofttimes overlooked.
A muscle unbalance of these organs may give symp-
toms sufficient to disable a patient. As to the cases
of squint so often met in school children, they are
generally dependent on gross errors of refraction,
mainly hypermetropia and hypermetropic astigma-
tism. One can safely say most of these children
are greatly benefited if fitted. with the proper glasse.=
early enough. In some cases the eyes are com-
pletely straightened after wearing the proper cor-
• rection. Fig. i shows a characteristic case of squint
or strabismus found in a school child and due to
refractive errors. It is evident how the presence of
a squint mav aft'ect the education of a child.
How old should a child be to be examined for
glasses? This question is frequently asked. If a
child needs them badly, as shown by any prominent
-symptoms or a marked squint, I believe the child
should be examined and supplied with glasses as
soon as it is able to sit on a chair. It is in early
childhood before school days that the best results
are obtained.
Here I would off'er a word of advice to teachers.
Children who have been wearing glasses should be
watched, and if they come to school without them,
should be sent home to bring them. If the child
persists in not w^earing the glasses, possibly the
glasses are not suited, or the frames are so ill fit-
ting as to give discomfort. Again it seems criminal
to allow a child to sit in the class room wearing a
pair of glasses so out of adjustment that one lens
is on the forehead and the other upon the cheek.
An example of such a case is shown in Fig. 2.
When a physician writes a prescription for
glasses, and the lenses are supposed to contain cylin-
ders at a certain axis, to correct astigmatism, what
results can be expected from the glasses if the pa-
tient wears the lenses at anv axis? The patient has
poor results and the physician receives the blame.
Again the proper fitting of the frames is as neces-
sary as the proper lenses. Unless otherwise ordered
for a certain effect lenses should be so adjusted that
the centre of the lens is at the centre of the pupil.
A little attention by teachers to children wearing
glasses would result in giving considerable comfort.
Frequently a patient returns after a year or so and
asks wdiether they need to change their glasses, be-
cause they cannot see as clearly as they did at first,
and on adjusting the lenses the fault is easily
remedied.
Many parents pay little attention to their children
who have squint, because they believe it to be a con-
genital condition for which little can be done. It
may be well to impress on such parents that a con-
genital squint is rare. It ofttimes happens, however,
that a child inherits defective vision, and through
this defect the sciuint is manifested. When a squint
is congenital, there is ofttimes an accompanying-
asymmetry of the orbits and possibly of the skull.
It is stated by some that the asymmetry of the orbit
admits of the eye turning to adjust itself to the
shape of the orbit.
Teachers should aid the physicians in overci ming
the opinion that "children should not weaf glasses
because in that event they must wear them for-
ever." On the contrary- they can assure the par-
ents that ofttimes by correcting defects early in life,
in a few years the e\ es improve sufficiently to allow
the child to discard the glasses.
Camnaigns for improvements in questions of pub-
lic health ; if not backed by law, are a tedious and
ofttimes a fruitless task. I therefore believe that
"the State should not only protect its people from
their own ignorance and superstitions in questions
of public health, concerning contagious diseases like
smallpox and diphtheria, but it should likewise pass
a law which v. ould compel ever\ child before being
enrolled in o public school, not only to undergo a
physical examination, but any defect which would
greatly interfere with that child from obtaining a
normal education should be corrected before the
child is admitted to school." The examination should
include a thorough examination of the eyes, ears,
nose, and throat by specialists in these branches.
I have advocated for several years that a pro-
cedure such as this would make unnecessary an an-
nual examination of each child. This would also
884
NEWMAYER: DEFECTIVE VISION IN CHILDREN
[New York
Medical Journal.
allow the time of attending physicians free to be
devoted to examinations of new pupils, and all acute
cases which arise in the schools. A child with de-
fective vision or hearing most often has the defects
when it begins school life, and it is the exception
that these conditions arise during this period. A
child may have serious errors of vision, and the
parents and child not notice them until the work
at school makes apparent the defect. Sometimes
the conditions in these cases are blamed on too closc'
application in the school room, but it is not so.
It is interesting to note that recently the authori-
ties in London passed a law similar to the one cited,
and it went into effect January, igo8. F'arliament
has asked the Board of Education to present to
thtm an annual report of the findings and results
obtained. They intend later to create school dis-
pensaries for diseases of the eyes and ears, etc.
These chnics. besides a dental clinic, are already
in vogue in some of the larger European cities.
Such recognition by the authorities of large cities
is, in itself, sufficient proof of the views on rela-
tion of physical defects to mentality. A child in
early school days may. l^ecause of a defect of vision,
merely show an inability to acquire certain sub-
jects, especially reading and writing, but later the
child may. to a great extent, become incapacitated.
These pupils ofttimes manifest an unaccountable
stupidity, and their inattention and misconduct de-
prive both the teacher and the other pupils of con-
centration to work.
Modern scientific p^edagogy looks to the physician
to explain why this or that child is dull and men-
tally subnormal. Many physicians are content to
merely label the child as a congenital mental de-
fective. An exhaustive attempt to localize the
trouble is ignored, and the teacher accepts the diag-
nosis of inferior brain function, and a hopeless case.
This exonerates the tcaclier of all responsibility, and
covers up lier inal)ility to instruct a pupil, which is
not "an ordinarx , e\ er\- day, routine pupil."
It would be a great aid in the study of mentallv
subnormal children, if teachers would give us ac-
curate records of the school work of pupils mentally
subnormal and physically defective. The stud\
should include the psychological study of the cases,
the physiology of the child's various mental pro-
cesses. A close study of the kind of work the child
fails in, and any change in these branches after cor-
rection of defects, would aid in a study of relation-
ship between physical defects and mentality.
The results obtained from the correction of eye
defects are generally good, sometimes marvelous.
The best results are obtained in the earliest school
days. In older children, occasionallx , defects of
vision are found and corrected, and the results on
the mental condition are not immediately apparent.
Here the teacher or jiarent is too early discouraged.
One must not forget that prolonged eye strain sets
up pathological changes in the tissues of the eves,
and even after removal of the cause the results may
still remain for some time.
'i'he test card l)eing the only instrument available
for the examination of eyes by leacliers and others
ni>t possessing the scientific knowledge of a ])hysi-
cian. it may be well to explain how the best and most
])ractical results can be obtained from them. Re-
cently a principal of a public school published the re-
sults of an examination of about five hundred chil-
dren, using the ABC letter test card, and the illit-
erate E card, and compared the results. His method
consisted of placing the child sixteen feet from the
card ; if he saw correctly the letters of the sixteen
feet line, he was asked to step back two feet, and
if he still read the letters correctly he was designated
as farsighted. If he could not see distinctly every
letter at sixteen feet, he was advanced two feet at
a time until he accomplished the reading, and these
cases were all labeled as myopic or near sighted.
His results recorded were as follows : With ABC
card : Near sighted. 65.8 per cent. ; far sighted.
15.5 per cent. With the illiterate E card he found:
Near sighted, 8.1 per cent. ; far sighted. 82.2 p:."r
cent. Having obtained these directl}- opposite results,
he very ingeniously formulated a theory to prove
the illiterate E test card built wrong. It happens,
however, that the results he obtained with the ABC
card are nearer to being correct. Myopia in children
is rare in comparison to hypermetropia. even if one
does hear more about "the near sighted child." The
principal comments as follows: "I frequently found
it necessary in all grades, especially in the primary
grades, to allow the pupils to rest their eyes. . . .
Many eyes after reading- a half dozen letters were
filled with tears. ... It was not an uncommon
thing for a pupil to have to move up to twelve feet
in order to make out the direction of the E ; but hav-
ing once clearly seen it he could recognize the other
direcfions with apparent ease at twice the distance. '
It is not my intention to ridicule the work of this
gentleman, but rather to congratulate him on his
honesty in publishing such a full and concise report
after obtaining such extremely opposite results. His
comments spell most plainl\ accommodation. This
principal is not the only one w ho has made the error
of trying to tabulate the near and far sighted by
means of the test cards. I recently read the report
of a physician who examined one thousand schcoi
children and used the following method : The pupil
was placed five metres from a test card, and a con-
vex spherical lens of a half dioptre was placed in
front of the eye; if the child said he saw better with
this kns than with the naked eye he was registered
as hypermetropic. If he saw better with a concave
spherical lens of a half dioptre he was considered
near sighted, and all others were normal. These
statistics are worthless, as a child may easily over-
come even a nuich stronger lens and see distinctly.
The test card is a valuable subjective test, but to
a layman admits only of his diagnosticating bad
cases of defective vision. He can rarely with
accuracy distinguish hyperopia, myopia, and astig-
matism. He therefore can obtain most practical re-
sults by using the test card to choose the cases of
defective vision, and then refer the case to a com-
petent ophthalmologist to make an accurate diag-
nosis. After a case is examined the teacher would-
do well to follow the pupil, urging the parents t;)
obtain the glasses. The test card is worth little
more to the physician until he relaxes accommoda-
tion with a cycloplegic. Then the lenses which
bring the visual acuity to normal are the proper cor-
rection. If there is no astigmatism, or the astig-
matism is at an axis of ()0° or 180'' tlie physician
May 9, 1908.]
HERRI. \G: PSYCHOTHERAPY.
885
may be able to find the correcting lenses with no
further objective tests than the test card and lenses.
However, this method should only be used to con-
firm the findings by instruments of precision, the
retinoscope. ophthalmoscope, and ophthalmometer.
Many varieties of figures and letters have been
used for test types, but all are made on the same
principle, to represent normal visual acuity at defi-
nite distances. With pupils of higher grades the
ordinary test card after Snellen, and using the vari-
ous letters, answers every purpose. But for the
illiterate and very young it is sometimes a grave
problem to use a test card with any dependence.
With children cards with numbers seem to
be more reliable than those with letters. Some-
times the illiterate card with the letter E pointing
in various directions is satisfactory. For several
years I have tried several charts with a view of ob-
taining one which would serve the purpose equally
well for all cases. A chart composed of small words
as "cat," "man," was adapted to some pupils of the
primary grades. Pictures and silhouettes were un-
reliable. Having had occasion to refract the eyes
of a deaf and dumb child, necessity lead me to de-
sign a card composed of hands with various fingers
extended and in various directions. The fingers
were accurately measured to conform with the type
of Snellen. The success met with encouraged mt
to use the card on all cases, especially children. It
proved the most practical of all the charts. A child
not only can imitate the hands, but can be allowed to
count the fingers. I have reproduced here this chart
of hands, and also the chart of pictures.
The method of procedure with a test card is fa-
miliar to all. The child is placed sixteen feet from
a test card, placed in proper light and at the height
of the child's head. Each eye is tested separately,
covering one eye which the other is being examined.
In expressing the visual acuity, the distance at
which the patient is stationed becomes the numera-
tor, and the distance at which the test letters should
normally be seen the denominator of the fraction.
With the present system of medical inspection of
the public schools accomplishing much in the detec-
tion of cases of defective vision, and the addition
of trained nurses in those sections of the city where
parents are careless or because of poverty neglect
the necessary attention to obtain the glasses, we are
well equipped to attend to these unfortunates. Cases
which for various reason would receive no atten-
tion should be referred to a competent ophthal-
mologist employed by the city for these examina-
tions. Difiiculty in obtaining parents to take their
children to dispensaries situated at a distance from
their homes makes it imperative for this work to be
performed at school, after obtaining permission
from the parents. If it were possible the largest
school in each section should have for eye examina-
tions a closet fitted for dark room examinations, or
a portable arrangement could be used in the various
schools.
Finally, children who are too poor to obtain
glasses, when necessary, should be supplied with
them from a fund appropriated by the city. All
books are supplied, and sometimes the glasses are
more necessary than the books.
1300 Pine Street.
PSYCHOTHERAPY IN THE TREATMENT OF THE
FUNCTIONAL NEUROSES.
By Arthur P. Herring, M. D.,
Baltimore,
.Associate Professor of Neuropathology, College of Physicians and
Surgeons; Neurologist to St. Agnes' Hospital.
"Nervousness is a disease preeminently psychical,
and a psychical disease needs psychical treatment."
Mental therapeutics has been practised from the
earliest ages by physicians, at times for the patients'
benefit and nearly as often for their detriment. Ev-
ery physician employs "unconscious therapeutics" in
his daily practice, and it is only because so many
reputable practitioners neglect the importance of
"unconscious therapeutics" that it has not been gen-
erally used. We have been taught for so main-
years to deal with the physical that we look askance
when anything pertaining to the psychic is men-
tioned. Psychotherapy is a valuable therapeutic ad-
junct when used intelligently and by conscientious
physicians ; on the other hand, it is one that readily
lends itself to charlatanism and quackery in the
hands of the unscrupulous doctor and the gullible
patient. The success and rapid growth, especially
in this country, of the various faith cures. Christian
scientists, magnetic healers, etc.. is due to the mental
impression these people are able to make upon the
American public. That they cure a great many of
the functional neuroses most of us must admit, espe-
cially when we experience patients leaving us and
going over to the various faddists, after we have ex-
hausted our stock of drugs without any beneficial
effect. The time has come when we must seize upon
truth "wher'er 'tis found, on foe or friendly
ground," and use every available means to relieve
the misery and suffering of the nervous patients.
It is unfortunate that the subject of psychotherapy
is so frequently neglected in the medical curriculum,
and I fear that students go out from our schools
with the idea that anything psychic is shrouded in
mysticism and often charlatanism. That suggestion
often powerfully affects the progress of a case for
good or for ill everv experienced practitioner will
admit. It is a helpful adjunct in the treatment of
functional neuroses, and even in incurable cases it
often aids in keeping the patient comfortable. There
are, I fear, very few physicians in this coimtry who
rely entirely upon psychotherapy in treating the
nervous patient. \\'e have not the temerity of our
French confreres, Dubois, Dejerine, and others,
who isolate their patients and depend entirely upon
suggestion or persuasion to cure them. W^eir
Mitchell over thirty years -ago blazed the way for
our methods in psychotherapy in his Fat and Blood
and Hozc to Make Thciii. This little book has
probably done more to relieve the sufferings of neu-
rotic women than any other writing on the subject.
This work was taken up enthusiastically by W. S.
Playfair in England, and resulted in curing a great
many nervous cases. In France, Charcot and his
followers made use of hypnotism in treating cases
of hysteria. Liebeault and the "Xancy school" prac-
tised suggestion in waking state. Both methods,
however, have the objection of substituting the will
of another person instead of reinforcing and
strengthening the patient's own intelfigent will and
selfreliance.
886
HERRI \'G: PSYCHOTHERAPY.
[New York
Medical Journal.
Professor Dejerine, now in control of the Sal-
petriere, dispenses with massage and electricity, em-
ploys rest in bed, overfeeding when indicated, and
relies principall}- upon rigid isolation and per-
suasion. He explains the abnormal symptoms, and
appeals to the patient's higher reasoning faculties.
When this treatment is effective, and it very often
is. it has the effect of giving the patients a healthy
viewpoint of their condition and results in selfre-
liance and selfcontrol which they did not have be-
fore. The recent writings of Janet, Loewenfeld.
and Dubois has awakened a new interest in the sub-
ject of psychotherapy. Dubois's The Psychic
Trcaiiiiciif of Xeri'oiis Disorders has had an exten-
sive circulation in this country and served to place
psychotherapy on a scientific basis. Taking the
subject up as he does from a psychological stand-
point he shows clearly the mental processes at work
in the neurotic individual, and gives very definite
directions, with- illustrative cases, how to overcome
and correct the mental and moral orthopsedia. The
literature dealing with the psychic factor in disease
has been increasing in this country, as will be ap-
preciated by glancing over the files of the current
journals for the past five years.
In the practice of psychotherapy the personality
of the physician probably plays a more important
role than in anv other department of medicine.
Barker remarks in his recent article on Psycho-
therapy and Reeducation that "the psychothera-
ijeutist should be an honest man and an expert
clinician. He should recognize the horrible reality
of the misery of the psy choneurotic. He may be
more successful in understanding and treating his
patients if he has had himself, at least, some little
experience with the fatigues and fears of neuras-
thenia, provided he has made a good recovery. He
must be interested in functional disturbances and
not simply in anatomical lesions, and he must un-
derstand that hysteria and psychasthenia are as
much disease as are pneumonia or gonorrhoea, and
often incapacitate the suft'erer for a much longer
period of time. Pfe should be skilled in all the
modern refinements of diagnosis, and should ex-
haust them in the study of his case before begin-
ning his therapy." In addition to the foregoing the
physician to treat successfully the neurotic patient
must possess the attributes, patience, sympathy, and
tact. It is only those who know the tortures under-
gone by functional nerve suft'ercrs, the neurotic
derelicts of both friends and ph) sicians. and who ap-
preciate their suffering, that ran ims^ilily put up
with the trying nature of the patient and their mul-
titudinous and often incurable ailments. The lack
of these virtues among doctors fills the various
health resorts at home and abroad with patients
sent there because the physician could not stand the
strain at home, and realizing his inability to help
them, takes this as an easy way out. Tact is the
unconscious mental touch, the tactus eruditiis, by
which one mind feels another and can convey to it,
physically or psychically, skill, decision, and sym-
j)atliy. Psychic tact, if I may use the term, is the
sine qua non to success in treating the neurotic pa-
tient.
The foundation for most of the functional neu-
roses has been begun I)y a "nervous shock," and upon
this has been reared a superstructure of varied emo-
tional symptoms. In order to successfully raze this
neurotic temple it is essential first of all to get at
the underlying cause, remove this if possible, and
the subsequent treatment will be comparatively
easy. It is necessary to obtain the patient's full and
complete avowal, and to investigate the condition of
the mental background and determine the mobilit\-
or immobility of their ideas : in doing so the three
cardinal virtues, patience, sympathy, and tact, are
to be used.
Sir Dyce Duckworth has said : "Confidence may
be gained and is always strengthened by a close and
careful attention to the minutest details of the case
before us. All hesitation and appearance of uncer-
tainty is to be strenuously avoided. A medical man
who cannot keenly regard his patient eye to eye
with firmness and directness is hardly likely to suc-
ceed. Dogmatism founded on sound principles is as
good for patients and their friends as it is for stu-
dents in the lecture room. We mtist be definite and
we must be lucid."
After a thorough physical and mental examina-
tion of a patient the physician assures himself that
the case is entirely functional ; he can then institute
rational psychotherapy and use as adjuncts the nec-
essary physiological means to bring about a cure.
Using either persuasion or suggestion, or both, be-
cause it is a difficult matter to separate the two. he
will state plainly the facts of the case to the patient,
telling him what caused the trouble and explaining
how the different symptoms may be produced, the
part the mind plays in originating and fostering the
various fears and distressing symptoms. The fact
that these symptoms can be relieved and cured with
his cooperation, and how this is to be brought about,
are impressed upon him repeatedly. Patients of
average intelligence will listen to the explanation
with considerable interest, and in the majority of
cases enter into hearty cooperation with the doctor
to bring about a speedy recovery. It is surprising to
see (unless one has had the experience) how readily
the average patient accepts the statement of the doc-
tor and believes that they will get well, even after
months of suffering. After once carefully listening
to a recital of the patient's symptoms and explaining-
each one, it is much better at subsequent visits,
when possible, not to again refer or allow the pa-
tient to refer to them. Keep the one idea always in
view that the symptoms will disappear, and they will
get entirely well. As Preston aptly expresses it in
his book on Hysteria and Certain Allied Condi-
tions: ".\11 treatiuent. whether it be drug or hygienic
measure, should be made impressive, should be
tipped, as it were, with suggestion." When the case
requires treatment other than that which is purely
psychic we do not hesitate to use dietetics, electro-
therapv. hydrotherapy, pharmacotherapy, or any
physiological means to bring about a recovery.
Psychotherapy should not tend to make us thera-
peutic nihilists.
Svstcmatic treatment should be elastic and differ-
entlv adajited to meet the needs of dift'erent teiupera-
ments and circumstances in patients, no two of
whom are ever quite alike. What we want to se-
cure is a central will reassured, instructed, strength-
ened, and set free from worrying trammels, to play
its proper part as director general of the personality.
To assure tlie cure of the sick it is not enough to
May 9. i^oS.J
HERRIXG: PSYCHOTHERAPY.
SS7
correct their logical defects : one must also teach
them a philosophical conception of life, in the
stoical sense, so that they can adapt it to their case.
By physical methods we may give them a physio-
logical basis of personality, but by psychic means
we teach them to educate and assimilate their con-
scious material and maintain a condition of adaptive
stability in relation to their environment.
The ambulatory neurotic is rather difficult to
handle. It is far preferable when possible to remove
the patient from sympathizing friends and relatives
and place them in a hospital or sanatorium. Here
the patient is under close surveillance, and the many
necessary details can be successfully enforced. They
are free from the various annoyances associated
with their home or business environment, and real-
ize that the object in view is to get well, hence the
mind is more receptive to psychotherapeutic influ-
ences and recovery is often materially hastened.
So much for the immediate care of the nervous
patient. Of equal importance is the after care of
the psychasthenic or neurasthenic. It is often im-
possible for the average patient to remain in the
hospital until complete recovery ensues : with such
patients it is advisable to keep in touch for a while
until the last vestige of the neurosis disappears.
This can be satisfactorily carried out by means of
psychotherapeutic letters (Oppenheim). In addi-
tion to keeping in touch with the patient and try-
ing as far as possible to remove all exciting influ-
ences that would tend to cause a recurrence of the
malady, it has been our custom, especially with the
poorer class of patients, to have the district nurse of
the charity organization visit these patients in their
homes, and advise them how to live and manage their
affairs with the least amount of friction or worry.
It is manifestly useless to place a patient in the hos-
pital for six or eight weeks, cure them of neu-
rasthenia, then send them back again amid the same
uncongenial surroundings, and expect a continuance
of the good accomplished during their stay in the
hospital. See Cabot Methods at Massachusetts Gen-
eral Hospital.
I am not ignorant of the fact that a great many
of our so called cures often times relapse and drift
about from one physician to another, while we con-
gratulate ourselves that we have made a successful
cure.
"The nervous patient is on the path to recovery
as soon as he has the conviction that he is going to
be cured ; he is cured on the day when he believes
himself to be cured."" — Dubois.
Rational psychotherapy requires time to effect a
complete transformation of a mind that has been be-
set with doubts and fears for months. If we per-
sist in our efforts to reeducate the neurotic sufferers
we can at last hope for a permanent result.
A few illustrative cases have been selected from
the neurological wards at St. Agnes Hospital. The
histories are presented in brief abstract form, as
the details would occupy considerable space, and not
be specially interesting to the average reader.
C-\?E I. — P>>cha?tbei-'ia : fear of insanity; erotic hallu-
cinations ; insomnia ; cure.
Mrs. C, age twenty-eight, factory girl, was admitted to
the public ward of St. Agnes Hospital on May 6, 1907,
complaining of nervousness and loss of sleep.
Family history : Mother is subject to ner\ ous attacks.
Paternal aunt had "mental trouble." One brother died of
consumption.
Previous history : Had smallpox ten years ago, and
scarlet fever four years ago, which left her with nervous
trouble. Patient had had attacks of heartburn ; and felt
as though pins and needles were sticking in her; she also
had had "'electric shocks," and could not sleep well. Pa-
tient taught a country school for several years; on ac-
count of the nervousness increasing she left the country
and came to the city, where she worked in a wholesale
drug house for a while, but could not continue, as she was
getting worse all of the time.
Present condition : Onset of illness had been gradual.
Patient was very much depressed and could not sleep.
Had thought of committing suicide : had a fear of some-
thing dreadful going to happen. Memory was poor for
recent events. Easily frightened without cause. Thought
she was going to become insane. Would not talk about
her troubles unless urged. Had been losing weight. Ap-
petite poor, bowels constipated. Had no somatic symp-
toms. Physical condition showed no evidence of organic
disease.
Treatment: Patient put to bed and isolated. Milk diet
for the first week, and then three full meals with milk
between meals. She was told that there was no physical
Trouble and assured of the fact that recovery was bound
to come if she would only help. However, recovery was
not as rapid as it should have been, and one day after a
lengthy conversation the patient's "complete avowal" was
obtained and a thorough explanation of each symptom
given. After that the change was remarkable. The fears
and distressing symptoms rapidly disappeared, and the pa-
tient left the hospital very much better.
Unfortunately, she was allowed to go back to uncon-
genial surroundings, and the old anxiety and fear began
to return. She was put in touch with a district nurse, who
obtained a position for her amid surroundings that were
iielpful. and when last heard from she was feeling very
well, .\bstract from ?. letter received September 2 : "Yes,
I am feeling very much better : in fact, I have not been so
well for years. Life is really a pleasure now."
Case I'I. — Psychasthenia. Simple goitre ; morbid fears ;
latigability ; despondency; gain of twelve pounds; cure.
Mrs. B., age twenty-nine, entered private ward, St.
Agnes Hospital. July 9th, complaining of nervousness and
fear of walking.
Family history was negative.
Previous history : Patient had enjoyed good health until
pfter death of her husband, whom she nursed for nearly
two years almost constantly. Shortly after his death the
nervous breakdown occurred. Patient was unable to eat.
rould not walk any distance, was always tired, became very
despondent, lost weight rapidly, suffered from palpitation
of the heart and accumulation of gas on the stomach.
Present condition : Patient w as very w eak : Seemed to
have lost all hope of ever getting better, was quiet and
despondent. Took very little interest in her condition or
the surroundings. Said she was afraid to eat and afraid
to walk.
Physical examination : Patient was emaciated, mucous
membranes pale : pupils dilated and active : no exophthal-
mos ; slight bilateral enlargement of thyreoid gland ; no
bruit : no thrill ; heart rapid, soft blow ing systolic murmur
at ape.x : lungs clear ; reflexes normal. Examination of
abdomen was negative except for a slight enteroptosis.
Dermatographia was present. Muscle tone was fairly
good. Bowels were constipated. There were no delusions
or hallucinations, but a mild affect depression. She re-
plied normally to questions, but evinced loss of interest
and emotional tone.
Treatment: Rest and isolation; milk diet for a week and
then forced feeding. Persuasion. Cold baths and massage.
Rapid recovery. Gain in w-eight and mental condition
cleared up. Patient bright and self confident. The fol-
lowing is quoted verbatim from a letter received on Sep-
tember 13, 1907: "I am feeling so well that I hardly feel
like the same person of two months ago. Yesterday was
just one month since I left St. Agnes and in that time I
have gained about se\enteen pounds in weight. I am en-
joying plenty of pure milk and fresh country eggs, and de-
lightful country air. and everywhere is beautiful, and in a
few words. I feel like living and enjoying life."
C-\SE HI. — Neurasthenia; persistent vomiting; insomnia;
loss of weight : depression ; cure.
888
BLAIN: GENERAL AN^STHESTA.
[New York
Medical Journal.
Mrs. L., age thirty-one. Entered private ward, St. Agnes
Hospital, complaniing of nervousness and stomach trouble.
Family history was negative.
Previous history: Patient had been healthy until after
the death of her mother, when family trouble and worry
started the present nervous condition.
Present condition : For past eight months patient had
been fed almost constantly by rectal tube, as she had suf-
fered from persistent nervous vomiting. Had been very
emotional and irritable, at other times moody and de-
pressed, unable to sleep, and had resorted to hypnotics
almost constantly for the past eight months. There had
been rapid loss of weight. Complained of headache and
numbness and tingling of different parts of the body.
Easily fatigued. No desire or energy to go about.
Physical examination : A careful physical examination
revealed nothing abnormal, except pale mucous membrane
and some emaciation.
Treatment : Isolation ; complete rest ; milk diet for one
week, then overfeeding. After one thorough explanation
of patient's condition and forcibly impressing upon her the
fact that she would improve rapidly and get entirely well,
no further trouble was experienced. There was no nausea
or vomiting. Patient ate heartily and gained weight rap-
idly. Left hospital at end of four weeks, perfectly well.
Case IV. — Hysteroneurasthenia ; "stomach trouble" ;
scoliosis ; hysterical paraplegia ; parasthesia of legs ; crying
spells; improvement.
Mrs. H., age forty-two, entered private ward February
4th, complaining of indigestion and general weakness.
Family history was negative.
Previous history: Patient said she "had never known a
well day." Had usual diseases of childhood. When six-
teen years old a lateral curvature of the spine developed.
Had never been able to do any hard work. Had suffered
from severe attack of gastritis three years ago; following
this attack there was a paralysis of both legs for a month,
without any involvement of bladder or rectum. Patient
had had two other similar paraplegia attacks, which would
come on slowly and disappear rapidly under psychic stim-
ulation. When riding in an electric street car she stated
that she could feel the electricity through the floor of the
car. Her limbs always felt stronger after such an experi-
ence.
Present condition : Patient had been unable to digest any
solid food for some weeks, and had lost weight recently.
Great weakness. Easily exhausted. Complained of "in-
ternal twitching of nerves of stomach, feels like a dozen
children in stomach." Had frequent attacks of vertigo,
especially when sitting at the table.
Physical examination was negative except for the spinal
curvature.
Treatment : Isolation ; complete rest ; milk diet for one
week, and then overfeeding. Psychotherapy. The symp-
toms were explained, and the patient encouraged to believe
she would get well. Baths, massage, etc., given. Improve-
ment at first was slow. Gradually the patient was made to
realize that she could get well, and just as soon as she
felt in her own mind that good health was possible, she
began to improve. Daily encouragement by both doctor
and nurse was necessary, with the result that when the
patient left the hospital she reeducated her mind to a
healthy viewpoint.
330 North Ch.\rles Street.
A CLINICAL STUDY OF GENER.\L
ANESTHESIA.*
By Alexander W. Bi.ain, Jr., M. D.,
Detroit, Mich.,
Senior Resident Physician, Harper Hospital.
In this late day and age, when the administration
of an ana'.sthctic may truly be said to be the most
common procedure in surgery, it may appear to be
but rcj)etition to add still another contribution to
the already voluminous literature on the subject.
Extended observations during the pa.st three
years have, however, led me to believe that there
•Read at mreting of Wayne County (Mich.) Medical Society,
March t6, 1908.
is no subject in general medicine which is more
misunderstood, and few that cause more needless
deaths and suffering, owing to the misunderstand-
ings on the part of the profession, than the tech-
nique and selection of the anaesthetic.
It is not my purpose here to call attention to the
shortcomings of otir profession, and I have with-
held writing the following with the hope that some
more mature member of our society, with years of
experience and observation, would call attention to
some of the fallacies under which medical men are
now laboring. But as such a thesis is still forth-
coming, I will attempt the same, yet not having
forgotten that "fools rush in where angels fear to
tread."
The advent of anaesthesia marked the beginning
of modern surgery, of the marvelous achievements
we neeil not enumerate here. The startling tri-
umphs of the past century may not be reduplicated,
but there is still room for wonderful improvements
on the discoveries of the past ; especially is this true
in regard to clinical methods.
Modern instruments, chemical research, and a
better knowledge of physiology, pathology, et cetera,
have all aided in bettering our knowledge of dis-
ease and its treatment. But there is still a tendency
to overestimate laboratory methods, which often
have little bearing on practical results. Thus the
Hyderabad Commission in Europe found that
chloroform was safer as an anaisthetic than ether.
While the investigations of the cominission were
exhaustive, their results bear little relation to actual
results in human subjects, for anaesthesia in dogs
cannot be used as a criterion of results in the human
subject. I simply mention this instance in passing
to show how investigations are given to and ac-
cepted by the profession as final, where in reality
they are of but little clinical significance.
We have not tiine here for a complete resume
of general anaesthesia. Ether, chloroform, and
nitrous o.xide are the drugs in general use the world
over to-day. Various other agents have been
recommended from time to time and combinations
of the above, but most of them for various reasons
have been dropped by the wayside.
Of local and spinal anaesthesia we have little to
say here. The latter, however, bids fair as a future
method in a goodly number of cases. I fail to see
any advantage over general anaesthesia as a routine
procedure, though it doubtless will find a field of
usefulness. Local an;esthesia has a large range of
usefulness. While not coming within the scope of
this paper, I may be permitted to say but one word.
In infiltration anjesthesia the drug employed often
plays so small a part that the patient should not be
subjected to the possible toxic action of cocaine
when a o.i per cent, solution or sterile water will
often give as good results as a ten per cent, solu-
tion.
Morphine, hyoscine, and cactinc compound as a
general anaesthetic T mention simply to condemn. It
has no place in surgery.
The comparative safety of ether and chloroform
has long been a much mooted subject, not in this
country alone, but in Europe. Abroad, especially in
England, chloroform still holds sway. In this coun-
try ether is favored, and is rapidly gaining further
May 9, 1908.I
BLAIN: GENERAL AN^STHESfA.
889
ground. During my short period I have seen the
abohshnient of chloroform by a large number of
surgeons. But its use to-day is still too large, espe-
cially among the general practitioners and in cases
where it is supposed to be indicated. It is upon this
subject of indications which we wish to lay special
stress.
Most textbooks on surgery devote much atten-
tion to the indications and counterindications of
chloroform and ether, and it is upon this basis that
so many men select chloroform to the detriment of
their patient. That these classical indications are
not backed bv clinical experience I thoroughly be-
lieve, and that the many set indications are not well
grounded we shall attempt to show.
Statistics, especially medical, are unreliable, yet
there are some known facts which will bear con-
sideration. Over 100,000 ether administrations
have been given at one leading Eastern hospital'
without a death which could be attributed to that
agent alone, while in England in one year there
were no less than ninety-six published' deaths from
chloroform, and this probably is only a small pro-
portion of the fatalities in that country during that
period. If the fatalities from chloroform in this
city during the past few years could be compiled
the list would be appalling. I believe the ratio
would reach more than one death in each five hun-
dred administrations. Not a few deaths occur at
Harper Hospital each year as a result of the use of
this drug.
In the tropics and in the time of war, when the
subject of bulk is an important issue, chloroform fills
a role which is unexchangeable. In the Northern
States, such as Michigan, its use, except in child de-
livery, is, in my opinion, next to criminal.
The varying results of comparative safety of
these diflferent agents in the hands of operators are
different for several reasons. Thus the results of
so ardent an advocate of chloroform as Sir Victor
Horsley, who has his own an?esthetist — a trained
specialist — are not to be compared with the work of
a novice, often not even a nurse or medical stu-
dent. But one thing is certain, chloroform is ex-
tremely dangerous, even in the hands of an expert.
That deaths do occur from ether, I do believe, but
they are in all instances unnecessary deaths. They
are due to a lack of knowledge of the drug, its
physiological action, and the simple technique of its
adm.inistration.
There are many points aside from the mere giv-
ing of the drug which have much bearing on the
patient. The relation between the anesthetist and
the patient is unique. Often the latter has perfect
confidence in the surgeon, but a greater fear of the
ansesthetist. It is important in every case that the
anjesthetist should know his patient, and that he
should inspire confidence in his part of the work as
well as the surgeon. So often we see a patient
wheeled from his bed to the operating room in our
larger hospitals, a cone put over the face, and the
first words of the anaesthetist are: "Take a deep
breath."
It is impossible to enumerate here what routine is
to be followed with each patient, but there are a
'Ciuy. History of Boston City Hospital, 1906, p. 264.
-Waller, Britisi Medical Journal, April 23, 1898.
few points which bear consideration: i. A con-
versation regarding the patient's illness ; 2. An ex-
amination of the patient's heart and mouth with ref-
erence to the tongue, teeth, etc., and, third, a con-
versation on some subject having no bearing on the
patient's trouble, the latter to be started shortly be-
fore the administration of the ether. This, of
course, is not practical in every case, but in most
instances will accomplish the most charming of re-
sults ; thus, a farmer will talks of his crops, a sports-
man of hunting, a child on things at school, et ccetera.
This advice, when carried out with a little tact, con-
sumes no extra time and saves much time after the
auiissthetic is once begun. I can't dwell upon this
point too long, for it is a most neglected point, espe-
cially in our hospitals.
Another thing which is not considered is the re-
lation between the surgeon and the anaesthetist.
Usually the administration of the anaesthetic is des-
ignated to the younger members of the staff of resi-
dent physicians or to the externes. I believe that
a surgeon should be commander of his anaesthetist,
yet at the same time the anaesthetist should be given
more consideration than he often receives by some
of our local surgeons.
It is unfortunate that only a few of our surgeons
have any knowledge of the proper methods of ad-
ministration or of the physiological action of ether.
Thus the young anaesthetist is often scared out of
his wits by one he most fears — possibly his pro-
fessor at college — and often prevented from doing
good work by remarks on the part of the surgeon.
Too much has been claimed for the various com-
plicated cones ; in my experience none of the patent-
ed cones have any advantage over the simple Esh-
march or its modifications. As a general thing, the
smaller the cone the better, as it does not cover up
the face and eyes, and can be managed by one hand.
It, moreover, gives a chance to regulate the dosage.
Proper etherization has been more correctly
termed "ether air anaesthesia." We hear much
nowadays about the drop method, but, as a matter
of fact, it is not common to see it given that way.
As a rule it is literally poured on. The cone should
be placed on the face, and one drop of ether given,
about fifteen seconds later a second drop, and so on
until the patient becoms accustomed to the odor; it
can be then given a little faster, but always by drops.
The drug should, of course, be fresh, and should
be administered from a three or four ounce bottle,
through a small hole in the cork, and never from
the large cans in which it is packed, as in this way
it is impossible to regulate the dosage. The ether
should also be warmed to almost body temperature.
This can be usually accomplished by holding the
bottle in the hand for a few minutes.
From two to seven ounces may be given as the
dose of ether, and it should be given with the same
thought of physiological action as one would use in
giving digitalis, aconite, or any other drug. Of
course we expect that the patient has been proper-
ly prepared beforehand and that the man holding the
knife is a surgeon. In the average operation of
whatever sort it is seldom necessar\^ to give more.
Previous to operation, one eighth to one fourth
grain of morphine, hypodennatically, is often of
benefit and aids considerably. While not always
890
BLAJX: GENERAL AN^STHESl'A.
n^ecessary, except in drinkers,, ct ccetcra, who take
no anc'cstlx'tic well, it is a good routine practice.
Atropine is alsu of much value in some cases.
The importance of the operation versus the ana?s-
thetic as viewed by the surgeon was recently well il-
lustrated, and I relate it here to show the minor
importance placed by surgeons in methods of giv-
ing ether. The surgeon, an eminent Eastern spe-
cialist, was operating upon a patient for brain
tumor. The ansesthetist was placed under a cover
which extended over the patient's face, and allowed
to give the ether from a Squibb's can. It is of the
utmost importance to observe strict asepsis in sur-
gery, but never to the total exclusion of a proper
anaesthetic. It is needless to sa\- that the auxs-
thetist under such conditions, himself saturated and
working in the dark, could not do justice to the
patient.
Ltlier given as I have outlined is not unpleasant
to a large proportion of patients. Nitrous oxide as
a general anesthetic in minor operations is too fa-
miliar to all of us to dwell upon here. In major
surgery it is well suited in many cases, as in pro-
statectomies in old men, the drainage of an appen-
dicular abscess in much debilitated patients, etc.
But its use ends here. In the average appendec-
tomy, or any other abdominal operation, its use is
not good practice, regardless of the amount of skill
possessed by the antesthetist. Nitrous oxide as an
antecedent to etherization is advised by some sur-
geons. It has some points in its favor, but like-
wise its disadvantages. The apparatus necessary
for gas anaesthesia is often startling to a patient, and
the stage of excitement, which can be overcome in
the majority of cases by ether alone, as I have sug-
gested, is sometimes marked as the patient is
coming out of the gas and going under the ether.
Here the tendency again is to give too much ether.
The cone should not be satiu^ated, but the drug
should be given by drops.
Turck' has shown that the phenomenon of shock
can be produced in dogs by anaesthesia alone. Clin-
ically, however, the slight shock of ether given in its
physiological limit is of no significance, and in the
majority of cases the drug acts only as a slight
stimulant. On the other hand, the extreme de-
pression of chloroform is often marked, even with
a comparatively small dose. Extreme nausea and
vomiting following anaesthesia is unnecessary in the
great majority of cases. It is due usually to a toxic
dose. The stomach, as is well known, is one of the
main routes of excretion of the anaesthetic, ether or
chloroform. When the blood is saturated with
ether, the stomach is called upon to aid elimination,
and nausea and vomiting arc the natural conse-
quences.
The foolishness of giving drugs for this condition
can readily b^e seen. .A glass of lukewarm water
with ten grains of sodium bicarbonate or sodium
chloride will wash out the stomach and carry with
it the ofYending agent. Bismuth, charcoal, the car-
minatives, etc., are worse than useless.
The habit of washing the stomach by means of a
tube, immediately following aniesthcsia, is danger-
ous, and invariably harmful. .\ patient ordinarily
should waken up by the timi; the bandage is ])inned
■Voiirmi/ of llie AmcnnDi Mcilu iil Associiilimi . .May .•. 1903.
[New York
Medical Journal.
up. I have seen them sit up after a breast has
been amputated so as to allow the bandage to be
put on with more ease, and ask the surgeon regard-
ing his opinion of the possible malignancy of the
growth.
The patient is, or usually should be, awakened by
the time it is necessary to proceed with the stomach
washing. If this is insisted upon, it is necessarv to
give from one to three extra ounces of ether in or-
der to relax the patient sufficiently- to allow of open-
ing the mouth. The patient has thus so much more
ether to excrete, and thus nausea is far greater as
a rule. There are other dangers in connection with
this method which are obvious at. this time.
There are few points in connection with technique
which need emphasis here: First, do not use tongue
forceps ; they are cruel, and are not necessary in one
case out of a hundred ; second, do not touch the
conjunctiva with your finger. It is never neces-
sary, and sometimes it causes trouble afterwards.
At the same time it is important to see that the lids
are kept closed during the administration of the
anaesthetic, so that the conjunctiva will not become
dry ; third, do not use too much force in holding the
patient's jaw forward, for while it is occasionally
necessary to lift the jaw up and keep it there, too
much force will often cause the parts to become very
painful.
The idea that the patient's head should be lowered
is erroneous. As a rule the patient's head should
be raised on a pillow. This is contrary to the teach-
ings in most textbooks, but patients invariably do
better by this method.
Cyanosis, excessive mucus, after nausea, and vom-
iting are rare with the drop method, and the fault
rests with the anaesthetist, and should not be laid
to the drug employed. All these conditions are the
result of a too concentrated vapor or the toxic
action of an overdose. Much has been said regard-
ing the after effects of ether anaesthesia. Pneu-
monia, nephritis, fatty degeneration, and a multi-
plicity of conditions are given as the direct result of
ether. As a matter of fact, these conditions are very
rare ; moreover, the\- are fully as common witli
chloroform as with ether. It is sometimes forgot-
ten that these conditions occur as sequelae of the dis-
ease from which the patient is suffering, and thus
often the blame is laid to the anaesthetic, where it
probabh' bears no relation, exce])t that, together with
the ()])er;iti(iii, it aided in lowering the patient's vital-
ity, and thus increased his susceptibility.
That the extremes of age bear ether well is borne
out by a large series of cases. Here again chloro-
form is so often selected owing to the bugbear,
"ether pneumonia." which still lingers in the minds
of physicians, or "a few drops is all that is neces-
sarv" for the tonsilotomy or circumcision, with the
unfortunate result that a perfectly healthy individual
dies a martyr, together with others, which will final-
ly change tlie i)hysician's point of view.
Conclusions.
The following practical deductions may be drawn
from the present studies:
I. Chloroform is a dangerous drug, and should be
totally eliminated from the armamentarium of the
surgeon.
May 9. 1908.]
TAYLOR: CEREBRAL ABSCESS.
891
2. The so called ■'morphiiie-hyoscine anaesthesia''
is unscientific, and is equally as dangerous as chloro-
form alone. It has no place in surgery.
3. The comparative safety of ether and chloro-
form cannot be based on our present statistics, but
one point is certain : chloroform is always danger-
ous, while ether given with a comparative amount of
skill, is absolutely safe.
4. Nitrous oxide as a general anjesthetic is occa-
sionally of value, but its use is extremely limited, as
good results can be obtained in these cases where
gas is used by ether, if the latter is given with the
same amount of skill as iS' necessar}- is giving the
gas.
5. The anaesthetist should pay more attention to
his patient, and the surgeon give more consideration
to the duties of the anaesthetist.
6. The indications in a surgical operation are for
ether, and the counterindications are nil.
In conclusion I want to express my thanks to Dr.
W. A. Fenner. Dr. F. E. Bowman, and other mem-
bers of the resident staff for records, observations,
etc.. which have been material for deductions on no
small proportion of the past five thousand surgical
cases treated at Harper Hospital.
A CASE OF ABSCESS OF THE FROXTAL LOBE
OF TRAUMATIC ORIGIN/^
Bv Fielding Lewis Taylor, A.. 'M. D.,
New York.
Tliomas H.. aged twenty-seven years, was struck with
a brick above the right eye in a street fight in May, 1906,
about four months before I saw him. September 13th.
He was not rendered unconscious by the blow. The re-
sulting wound was sutured in a hospital in a New Eng-
land city, and he returned to his work as a railroad
section hand the following day.
After a month considerable inflammation about the
wound, which had healed, caused him to return to the
hospital, where a superficial abscess was opened and sev-
eral small pieces of brick and some spicula of bone were
removed by the attending surgeon. Although the wound
healed, the patient suffered from intense headache at
times, w hich w as most marked over the occiput ; he could
scarcely stand up. while he could move his legs fully
though feebly in bed. He was obstinately constipated and
vomited very frequentlx'. His intellect was sluggish, and
he could not sleep. His friends became dissatisfied and
removed him to his home in the country. Here he re-
mained most of the time in bed. suffering tortures with
headache and vomiting, until September 12, 1906. when
he was seen by Dr. A. B. Tucker, who brought him to a
sanatorium in this city. I saw him the afternoon of the
same day with Dr. Tucker.
The patient was terribly emaciated. He yawned every
few minutes. If his attention was attracted he would
answer questions sluggishly but intelligently. Otherwise
he was apathetic. His pupils were moderately dilated
and responded in a measure to light and distance. Vision
was decidedly diminished. Dr. Claiborne examined his
eyes and found bilateral optic neuritis more advanced on
the left side. There was slight paresis of the left side
of the face without ptosis. The tongue could be but par-
tially protruded, and deviated slightly to the left. There
was distinct weakness of grip in the left hand.
He could move his legs. The abdominal and cremas-
tetic rt hexes were well marked. The Babinski sign was
not present. Kernig"s sign was marked at 50° dorsi-
flexion. The patellar reflex was absent on both sides.
The muscles of the neck and back were verj- stiff, and
he complained of great pain in the occiput and down the
spine.
There was incontinence of urine and faeces and persist-
*Read before the Section in Surgery of the New York .\cademy of
Medicine. January, 1908.
ent vomiting. The pulse was 72, respiration 16, and rectal
temperature 98° F. The leucocyte count was 8,000. of
which seventy-nine per cent, were polymorphonuclear
neutrophiles. nineteen per cent, lymphocytes, one per cent,
eosinophiles, and one per cent, basophiles.
There was an irregular cicatrix crossing the right tem-
poral ridge about one inch above the external angular
process of the orbit and adherent to the bone, in which a
fissure could be felt. The skin in the neighborhood was
oedematous, and slight fluctuation and congestion were
present at the inner end of the scar. There was cedema
of the right upper eyelid. The whole anterior part of
the head on the right was tender on deep pressure. There
was a difference in the percussion note on the two sides,
but this I thought might be attributable to the oedema.
The patient's pulse fell to 53 during the night. He was
operated upon the next day. An incision was made in
the line of the old cicatrix. There was a drop of pus at
its inner end. The fissure was enlarged with a bone for-
ceps, and a round opeinng about an inch in diameter made
with its centre about an inch above the junction of the
middle and outer thirds of the supraorbital ridge. The
dura bulged into the wound and w as incised. There was
some inspissated pus inside, which was removed. The
anterior tip of the frontal lobe presented. It was very
hard and did not pulsate. A very large hypodermic
needle was pushed upward, backward, and inward, and
encountered pus at the depth of half an inch. Upwards
of two ounces of pus were evacuated with an artery
clamp. The cavity was simply drained with a piece of
rubber tubing and weak iodoform gauze without being
scraped or irrigated. A hernia cerebri developed a few-
days later, about half the size of a hen"s egg. which
sloughed off, after which the wound closed.
The patient recovered his intelligence at once, except
for the fact that for three days occasionally he would
spring suddenly o\er to the right edge of the bed to catch
hoid of a table or other object, under the impression that
the bed was falling over to the left : and that for more than
a week he could not be convinced that he was not ill at
his home in the country. The day after the operation
his slight hemiparesis disappeared, his patellar reflexes
returned, he retained his urine and faeces, and stopped
vomiting. He passed enormous quantities of urine of
low specific gravity without albumin or sugar, and soon
developed a ravenous appetite. The pain and stiffness in
the neck and uppir part of the spine caused him more
trouble than anything else, but gradually disappeared.
He returned home October 17th. apparently well, ex-
cept that he was nearly blind in his left eye and could see
but pooriy with his right. I last saw him on December 3.
1906. He stated that ten days after his discharge he had
some pain in the neighborhood of the wound during the
day ; the same night he aw oke with considerable pain in
the occiput and down the spine, and vomited. The pain
in the occiput lasted three days and ended with an attack
of vertigo. When I saw him his leucocyte count was
6,000; his pulse was 72, full, soft, and regular. His
patellar reflexes were normal, the wrist and elbow re-
flexes seemed slightly exaggerated; the strength of the
hands was normal ; he said that his legs seemed some-
what weak at times. There w^as no stiffness of the neck
and spine, and no tenderness about the wound. The right
eye was worse, he could only distinguish light. The
left he thought somewhat improved, as he could count
figures across a poorly lighted room.
He again returned to his home in a comparatively in-
accessible place, about 100 miles from Xew York. I heard
from him several times during last year that he was well,
except that his eyesight was not improving. He made ar-
rangements to come to town to be shown to this section
on November I, 1907, and was in excellent spirits when I
heard from him the latter part of September. I was dis-
appointed to learn from his employer on October 30th
that he had died on October 23d. On Thursday, October
17th, he comnlained of severe headache, which continued
Friday and Saturday. During the day Saturday he had
two convulsions, from which he recovered : during Sat-
urday night he had four, after each of which he recov-
ered consciousness. Sunday he had a fit every ten
minutes, and this continued until his death, on Monday
afternoon.
I regret that I was not sent for, as I think that he had
developed a secondary abscess by the evacuation of w-hich
his life might have been saved. (I could at least have
892
OSTHEIMER: INFECTIONS IN CHILDHOOD.
[New York
Medical Journal
done an autopsy.) That such was the case is not the
only explanation for the convulsions, as the scar result-
ing from the abscess and subsequent hernia cerebri was
very large.
I postponed reporting this case for a year, await-
ing the development of sequelae. That a secondary
abscess does develop in the neighborhood or even at
some distance from the first, and that, too, after a
considerable lapse of time, is amply proved by a re-
view of the literature of the subject, with which I
shall not burden you. This is a grave danger in
cases that have been operated on with apparent suc-
cess.
On the other hand, to show that a scar following
an abscess may give rise to epileptic convulsions
leading to status epilepticus and death, I shall cite
only the following case : In the Cincinnati Lancet
Clinic for 1906 ( New series, Ivi, p. 401), Dr. J. C.
Oliver reports the further history of a case of ab-
scess of the frontal lobe, which was operated on on
September 11, 1895, and reported as cured in the
Journal of the American Medical Association, of
May 30, 1896. Eleven months after the operation
the patient, a man twenty-one years of age, devel-
oped epilepsy, and had about one paroxysm a month
for five years. The interval between the paroxysms
gradually lengthened, until on February 19, 1904,
he had several convulsions in rapid succession. A
few days later he developed status epilepticus, and
died of exhaustion. The only lesion found on au-
topsy was the cicatrix of the abscess, which extended
into and involved the motor area.
173 West Seventy-third Street.
THE PREVALENCE OF INFECTIONS IN
CHILDHOOD.*
By Maurice Ostheimer, M. D.,
Philadelphia,
Instructor in Paediatrics, University of Pennsylvania.
The time is not very far off when you are likely
to be called to see sick children, and it may be dif-
ficult, in many cases, to make a diagnosis. You may
see an infant who continues to cry, and this con-
stant crying is the dominant symptom, with some
fretfulness possibly, and perhaps some fever and loss
of appetite; examination shows nothing beyond a
reddened throat and slightly coated tongue, and be-
fore you have exactly made up your mind what the
trouble is, the mother or nurse has discovered a
running ear! Here you had an infection which be-
came localized in the middle ear. Other children
may escape otitis media, yet develop corj'za, laryn-
gitis, amygdalitis, adenitis, parotitis, bronchitis,
pneumonia, or pleurisy as the result of the same or
similar infectious microorganisms.
Then you may see a larger child, coming with the
history of having had sore throat and fever, with-
out other disturbance. Some weeks later the attack
of amygdalitis seems to be repeated, this time with
signs of decided weakness, and your examination
shows slight irregularity in the heart's action. It is
then only a question of the number of recurrent at-
tacks, either with throat or joint symptoms, until
you discover the murmur of endocarditis, perhaps
with signs of myocarditis or even pericarditis. And
•AdclrcsK read before the lames Tyson Medical Society, Uni-
versity of IVnn*ylvania. .March 13, 1908.
probing into the antecedent history of some of these
children, you will find that there had been, years be-
fore, an attack of scarlet fever. And in the older
children, those approaching puberty, the previou.s.
occurrence of articular rheumatism or chorea may
be revealed, and your questions will bring to light
the history of numerous, repeated attacks of infec-
tion.
You should all know how very easily and rapidlx-
gastritis, gastroenteritis, or enteritis develops in a
young child. Generally the food, the heat, or ex-
posure to sudden change in temperature is blamed ;
but you will remember that there are always infec-
tious microbes present. Just which one plays the
role of predisposing cause and which that of ex-
citing cause is still in doubt, but microorganisms in
great quantity and variety are found on examina-
tion.
So far I have spoken of infection in general ; but
you have already learnect that one sort of coccus has
been considered the specific agent in epidemic men-
ingitis, another in pneumonia, another in gonor-
rhcea, and probably several groups, distinctive mor-
phologically, in erysipelas, scarlet fever, and rheu-
matism. Bacilli appear to be the cause of tuber-
culosis, typhoid fever, influenza, dysentery, and
diphtheria ; while protozoa are supposed to be t!ie
infecting agents in malaria, relapsing fever, small-
pox, and syphilis.
Your surgical experience has made you familiar
with the various wound and skin infections, pysemia.
and septicaemia, as well as the different forms of
genitourinary infections. And you have studied
how the blood and lymphatic streams spread the dis-
ease germs.
Yet our knowledge of disease is still so incom-
plete that, while we consider many diseases as in-
fectious in character, the infecting agents have not
SO' far been surely distinguished. Here we should
group scarlet fever, rheumatism, poliomyelitis,
whooping cough, measles, and chickenpox.
If we go over the diseases already mentioned, we
find remaining very few of the illnesses of child-
hood. Of course you will say "What of rickets and
infantile scurvy?" Well, who can tell how soon
they, too. may be classed among the infections !
Realizing, then, the very great role played by in-
fections in children, it is your place, as physicians,
to prevent their occurrence among your young i)a-
tients. Therefore a general prophylactic treat-
ment, for the prevention of infections, is of decided
value to keep the children well.
As most of the infections are believed to enter
the body through the lymphatic tissues of the naso-
pharvnx. the most important thing you can do is
to keep the nose and mouth clean. This should be
begun in infancy, and kept up regularly and con-
tinuously until later life. Nurses and mothers must
learn to clean noses, mouths, and throats early and
with regularity ; and signs of the presence of any
abnormality, such as adenoids, should necessitate an
immediate visit to the specialist.
Here I want to remind you once again, as I have
so often before, that all cases of cervical adenitis
are not tuberculous, the majority of such swellings
in children being the direct result of other infec-
tions.
See to it that all infants under your charge are
May 9. 1908.]
BRADDOCK: LEPROSY.
893
vaccinated between six weeks and three months of
age ; and order that all children be kept in the open
air as much as possible during infancy and child-
hood. Besides, care must be taken in the prepara-
tion of all food for children, to prevent infecting the
gastrointestinal tract.
If any child should come in contact with an in-
fectious disease, precautions should be taken at once,
such as the injection of an immunizing dose of arxti-
toxine in case of diphtheria. And the possibility of
treating all infections by the opsonic method seems
to offer better results than any one method thus
far advanced.
In closing, I beg of you to remember the great
prevalence of infections m childhood, and hope that
\"our good care will prevent man\" cases of infection
in the future.
225 South Twentieth Street.
SOME RANDOM XOTES ON LEPROSY IN THE
FAR EAST.
By Charles S. Br.\ddock, Jr.. Ph. G., M. D.,
Haddonfield. N. J.,
Late Chief Medical Inspector Royal Siamese Government.
Leprosy is a disease which is looked upon with
horror by the people of the Occident. In the Ori-
ent, however, through long association, it is looked
upon far differently and with more tolerance.
From personal observation my opinion is that lep-
rosy is not nearly as contagious as is usually consid-
ered by the -average man. In the Far East, and T
speak more particularly of Siam and the Malay pen-
insula, lepers mingle with the rest of the people,
travel in the same public conveyances, sit on the
corners of the streets near public bridges and meet-
ing places, and solicit alms in the midst of the great
population, and the disease, while prevalent, does
not seem to increase materially.
There is no segregation by the government of the
lepers, and they are free to come and go at their
own free will.
I notice, however, that the children of the lepers
also develop leprosy, and that seems to be the mode
of propagation of the disease. I never was able to
get a single history of any one having acquired the
disease directly from another, but had many chil-
dren brought to me showing the first signs of the
disease, usually manifested by a white patch slowly
spreading over some part of the body, most usually
the face, wrist, or ankle and usually anjesthetic, but
not always. In every case on inquiry I found there
was a history of leprosy in the family or collateral
relatives.
I believe that any one who wore the clothes of a
leper would acquire the disease, but it requires per-
sonal contact. Many persons associated with the
lepers for long periods without contracting the dis-
ease.
I well remember a tramcar conductor in Bangkok
who was a pronounced leper, and would probably be
collecting fares from the public yet if the Europeans
had not protested and had him removed from his
position.
The amount of alms given along the streets to the
lepers is enormous, and this money is passed on
from hand to hand. I always washed my hands
with an antiseptic after handling money.
At one time a row of buildings in Bangkok col-
lapsed, killing and injuring a large number of peo-
ple. One man helping to remove the injured was
covered with blood from a man who was crushed.
On bringing him into the street he was horrified to
see the man was a leper in the last stages of leprosy.
I made him change and destroy his clothing at once
and bathe with an antiseptic, and he was never af-
fected in any way. Xot a pleasant predicament,
however.
I have attended many patients sick with other dis-
eases, and have only found out after a physical ex-
amination that they were lepers ; also dressed their
sores, and have tried various medical means for
their relief, but outside of the general improvement
in health and surgical cleanliness have never seen
any result from medical treatment.
These cases are usually neglected ones, so that
when the leprous sores are cleaned and treated
antiseptically, and the patients given strong tonics,
their general health improves. I think that the best
results will be obtained in the future along the lines
of curative sera and antitoxines.
On a journey to the island of Puket, in the
Indian Ocean, lying between the west coast of the
]\Ialay peninsula and to the south of the Mergui
archipelago, mv attention was called by Prince
Damrong, minister of the interior of Siam, to a
body of people who had called to pay their respects
to him, and whom he called sea gypsies. These
people had a dialect of tiieir own, and lived in
boats, roaming about the islands, and were en-
gaged in procuring pearl shell and fishing for a liv-
ing. The prince called my attention to the fact
that these people, almost to a man. suffered from a
skin disease, a form of ichthyosis, as the skin look-
ed like the scales of a fish. It is a question whether
it is a skin disease purely or a form of leprosy. I
never saw it except in these people. It is unknown
among the dwellers on the mainland. From what
I could learn this disease was always known among
these people, who are clannish, and do not inter-
marry among the Siamese or ^lalavs.
A few months later, while traveling on another
expedition in the north of Siam. near the Indo-
Chinese frontier, my attention was called by the
authorities to a leper village of about one hundred
inhabitants. These people, all closely related by
blood, had by gradual selection and other causes
settled in a village together, where they lived and
tilled fhe soil. The village was some distance from
our camping place, but when getting ready to go
and visit it I was informed by an orderly tliat they
were waiting outside the camp. On going a few
hundred yards away I found about thirty-five men,
women, and children all squatting on the ground
and all showing, in a more or less degree, a curious
thickening of the tissues of the face, far more
marked in some than in others ; only three or four
had lost fingers or toes, but all had this face dis-
figurement, some to so great a degree that the poor
creatures looked like persons with an enormous
distorted false face. It was a sad and grotesque
sight. I had seen a few cases of this form
of leprosy before, but never so many at one
894
QVR READERS' DISCUSSIONS.
[New York
Medical Journal.
time. A large quantity of tonic medicine was
given them, for which they were very grateful.
Leprous sores were almost altogether absent in
these cases.
The Siamese government are contemplating
building a leper colony and hospital on an island
in the gulf of Siam, but it will be difficult to put
isolation into operation, owing to the fact that the
people have very little fear of the disease, and
therefore do not want harsh measures used in sep-
arating families and isolating patients.
In (;onclusion I would say that I think a mistake
is made in the hospital treatment in this part of
the world. In treating some of the contagious dis-
eases, such as leprosy, plague, smallpox, scarlet
fever, etc., as I think none of these cases should be
treated inside the four walls of a house. In the
summer thev shotild be treated in a pavilion open
to the four winds of heaven, with a roof to keep off
the rain and sun, and in the winter in tents to hold
not over two patients, and on the removal by death
of the patients the torch should be applied to the
pavilion or tent, and to everything contained there-
in, after the removal of the body. This applies
more particularly to plague. No plague case should
ever be put within the four walls of a house.
(©ur gobtrs' |iscu5Sious.
A SERIES OF PRIZE ESSAYS.
Questions for discussion in this department are an-
nounced at frequent intervals. So far they have been
decided upon, the further questions are as follows:
LXXIII. How do you treat seasickness? {Closed April
13, 1908.)
LXXIV. How do you treat sunstroke? {Answers due
not later than May 15, 1908.)
LXXV. Hoiv do you treat cholera infantum? {An-
swers due not later than June 15, 1908.)
Whoever ansivers one of these questions in the manner
most satisfactory to the editors and their advisors will
receive a prise of $25. No importance whatever will be at-
tached to literary style, but the award will he based solely
on the value of the substance of the answer. It is requested
{but not required) that the answers be short; if practica-
ble, no one answer to contain more than six hundred
words.
All persons will be entitled to compete for the prize,
whether subscribers or not. This prize tvill not be awarded
to any one person more than once within one year. Every
answer must be accompanied by the writer's full name and
address, both of ivhich we must be at liberty to publish.
All papers coiitributed become the property of the Journal.
The prize of $25 for the best essay submitted in answer
to question LXXII has been awarded to Dr. J. Russell
Verbrycke, of Nczv York, whose article appeared on
page 788.
PRIZE QUESTION NO. LXXII.
THE TREATMENT OF FRACTURE OF THE
PATELLA.
(Concluded from page 8^6.)
Dr. L. IV. Bagii, of Nezvark, N. J., remarks:
In order to decide upon the best treatment of
fracture of the patella, a few important facts must
be kept constantly in mind, viz., (i) the patella is
a sesamoid bone, located in one of the most power-
ful and useful muscular mechanisms of the body ;
(2) its location is immediate to one of the most
dreaded fields for surgical interference ; and (3) the
reflections of the aponeurosis are essential to the
strength and the functions of the knee joint : in-
jury to these reflections are almost always asso-
ciated with complete fracture of the patella. Bear-
ing in mind these thre,e points in treating such frac-
ture, we should make a careful estimate of the de-
gree of injury, age, occupation, and resisting power
of the individual, and proper regard for the means
at hand, in carrying out operative treatment, if this
course is indicated. The acute attention to detail
in carrying out whatever line of treatment is select-
ed, and a painstaking attitude towards patient and
injured part, until the final result is attained, are
essential.
Fractures of the patella may be divided into new,
transverse, comminuted, oblique, longitudinal, old or
refractures — that is, those generally occurring in the
line of union of previous fractures. Fractures oc-
curring in patellae, previously fractured, but in a
fresh location, are considered as new fractures.
Complete. Incouiplctc. Simple. Compound Frac-
tures.— Important associated conditions which may
accompany these fractures are : ( i ) Severe
abrasions of the skin and injury to adjacent tissues
of such a degree as to prevent primary union; (2)
wide separation of fragments; (3) tilting of frag-
ments; {4) tears or rents of lateral portions of the
aponeurosis, or lateral expansion of the quadriceps
tendon, with separation; (5) folding in of the peri-
osteum over the fragments, thus preventing good
approximation ; and ( 6) exudate and haemorrhage
into the knee joint.
In view of what I have stated, let us classify our
cases according to those which should be subjected
to operative treatment, and those which should be
treated by a retentive method.
In elderly patients operation should not be consid-
ered unless in cases of refracture, where the limb
is practically useless to the individual. Patients of
low power of resistance, due either to inheritance or
constitutional disease, should not be subjected to
operation. In comminuted fractures, when frag-
ments are in good apposition, in oblique and longi-
tudinal fractures, where there is no separation, do
not operate.
Where fractures are complicated by injury to the
skin of such a degree as to prevent primary union,
wait until the skin has regained itself before oper-
ating. In cases of transverse fracture, with sepa-
ration, operate. In compound fractures, with infec-
tion of the knee joint, this should be treated as any
septic wound.
Three steps in treatment should be our guide :
( I ) To reduce the swelling and hasten absorption
of the exudate and free blood; (2) to bring the
fragments into apposition, and maintain their ap-
proximation until union occurs; (3) to maintain, as
far as possible, the tone of quadriceps muscle, and
restore the function of the knee joint.
To reduce the swelling and to alleviate pain, apply
a rubber elastic bandage, from just below the knee,
upward to about eight inches above the joint. This
should be applied snugly, but not so as to impair
the circulation of the limb or increase the pain ; then
apply a well padded posterior splint, slightly wider
than the limb, padding well the heel. The splint
May 9, 1908. 1
OUR READERS' DISCUSSIOXS.
895
should be held in place by three pieces of zinc oxide,
adhesive, about two inches in width, placed one at
the ankle, one at the upper end of splint, one just
below knee; then apply a flannel roller bandage
from toes to groin ; each bandage about three inches
in width, applied snugl_\- and evenly. Elevate the
foot on pillows, about six inches, and apply ice con-
stantly to the knee. This dressing should be taken
down at the end of forty-eight hours ; reapply flan-
nel bandage, using ice until swelling is reduced. If
the patient is seen immediately following injury, in-
stead of an elastic bandage, apply a flannel bandage,
kept wet, with an official solution of lead and opium,
and also apply ice. This will give the patient much
relief from pain, and also tend to prevent swelling,
and check spasm of muscles. After six to ten days
the patient will have recovered from shock, due to
the injury, the injured tissues have regained them-
selves, and the healing process has started. This is
the best time for operative treatment, provided the
strictest aseptic methods can be obtained, as well
as proper surgical technique, never forgetting the
thovight which Lister advanced, when he wrote "no
man is justified in performing this operation unless
he could say with a clear conscience that he consid-
ers himself morally certain to avoid the entrance of
any septic mischief into the wound."
Xow, what do we accomplish by operation ? ( i )
By removing exudate and blood clots we help to
avoid troublesome adhesions. (2) We restore parts
to their proper anatomical relations. (3) Tilting of
the fragments is immediately overcome. (4) The
rents in the aponeurosis are brought into proper ap-
position and sutured, thus enabling us to begin early
our treatment of the quadriceps muscle and knee
joint, in preventing atrophy and retaining tone of
muscle and restoring function of the knee joint.
The patient is started on a more rapid road to re-
covery, thus avoiding the uncertainty and frequent
complications which result from adhesions of torn
and misplaced tissues.
Operation. Incision. — Circumlinear incisions with
convexity upward seem to give the best view of the
field, especially when there is a wide separation of
the fragments. The deep fascia is incised, or, if al-
ready torn, its edges are retracted.
Cleansing. — Irrigate the knee joint and tissues
thoroughly with normal salt solution, temperature
110° F., using it freely, so as to throroughly cleanse
parts. I have taken it for granted that rubber
gloves should be worn. The interior of the knee
joint should be let alone as far as possible from any
manipulation, either with the hand or gauze sponges,
The hot saline has a stimulating effect upon the in-
jured tissues. The edges of the periosteum and tags
of torn tissue are trimmed and retracted.
Suturing. — The fragments are held firmly and
two small holes drilled from above downward, about
half an inch back from fractured edge, coming out
equal distance from articular surface. These holes
should be equal distance as well from the centre
line. \Mien sutures are introduced and drawn taut,
the fragments should then be in perfect apposition.
The heavy chromacized catgut has given excellent
service. The periosteum and aponeurosis, which
are one layer over the patella, are brought into ap-
position and sutured with fine chromicized gut. It
is very important to suture the lateral portion of the
torn aponeurosis. This separation is the main
cause of the separation of the fragments : ii.< propei'
union is necessary to attain results. A silkworm
strand is passed into the joint, and another strand
down to the joint, placed at each angle of the
wound. The skin is now sutured either with fine
catgut or silk. Dry sterile dressing is applied, and
flannel bandage from the toes to the groin. Ele-
vating the foot six inches is essential. After forty-
eight hours remove dressing, and if there is no ele-
vation of temperature or other signs of suppura-
tion present, the silkworm strands are removed and
sterile dressing reapplied as before. If sepsis is
present, it will find free exit along the strands of the
silkworm, thus aiding ocir prevention of a more gen-
eral infection of the synovial membrane. At the
end of fourteen days passive lateral motion of the
patella should be begun, and continued daily, as well
as massage of the muscles of the leg and thigh to-
ward the knee joint for fifteen minutes twice daily.
At the end of five weeks begin passive motion of the
knee joint; allow patient to move around with
crutches, removing splint at night : at the end of
eight weeks remove all support to the knee, cau-
tioning the patient against any muscular exertion or
direct violence.
X onoperativc Treatment. — Treat the early stage
as indicated : where absorption is tardy it is a good
plan to aspirate joint. A small amount perhaps can
only be removed, due to clogging of the needle, but
even this will aid greatly the absorption and tend to
check the development of troublesome adhesions.
As soon as the swelling has been sufficiently reduced,
which is toward the end of the first week, the pos-
terior splint is applied, as before indicated : the limb
is then elevated so as to relax the quadriceps ex-
tensor muscle, the upper fragment is drawn down
and held by strip zinc oxide adhesive plaster in a
loop, passed downward diagonally, and fastened to
posterior surface of splint. A second piece is like-
wise adjusted to lower fragment, drawing it up-
ward. A third strip should be placed directly over
the line of fracture, drawn downward, and fastened
beneath splint. This aids greatly in preventing tilt-
ing. Three or four additional strips should rein-
force the strips first applied of the same width, and so
placed as to cover the preceding one by two thirds
of the width of the latter. The flannel bandage is
then applied, and elevation is maintained.
The adhesive strips should be left on for six
weeks : the muscles of the limb should be massaged
toward the knee for fifteen minutes twice daily. At
the end of six weeks remove splint and adhesives,
and apply to the limb from the ankle to the gluteal
fold a light posterior cast. This splint can be easily
removed and massaged, and passive and active mo-
tion of the knee joint easily obtained. From the
sixth to the eighth week, the patient is allowed up
and about, with the use of crutches, being very care-
ful to protect limb from any muscular exertion or
direct violence : a simple rubber bandage should
be worn for six months. Daily massage and passive
motion should be continued for some months.
Old or Recurrent Fractures. — The upper frag-
ment is often found adherent and many other trou-
blesome adhesions present. If the fragments can be
896
OUR READERS' DISCUSSIONS.
[New York
Medical Journal.
brought into apposition, they should be sutured as
a primary fracture, having first freshened the frac-
tured surfaces. If the fragments cannot be brought
into apposition, then the fragments are removed, and
a portion of the quadriceps tendon is brought down
and sutured to the patella tendon.
Incomplete Fractures. — In these we have no sepa-
ration of fragments or tears in the aponeurosis to
deal with ; these should be treated as complete frac-
tures without scjxiration.
Coiiiiiiiiinfed fractures. — Where there is no dis-
placement of fragments the aponeurosis is probably
intact. The retentive method gives us good results
in these cases. Cases in which there is a separation
of fragments are best treated by operation.
Dr. S. JV. IVyiiite, of Nezi.' )'ork, observes:
The treatment of fracture of the patella is gen-
eral and local. The former, although important, as
it is in all surgical conditions, need not be dwelt
upon here, as it (Iift'er^ in nowise from that indicated
in any kind of fractures.
The local treatment is conservative or nonopera-
tive, and radical or operative. ( )ur first duty should
be to conscientiously determine which course to fol-
low, and in -o deciding the following conditions are
to be considered :
1. The a\ailability of an experienced surgeon,
skilled assistants, and an operating room where
absolute antiseptic and ase])tic precaution can be ob-
served. W'itliout these adjuvants operation is never
justifiable. The dangers ot' oijening the knee are too
familiar to all to re([nire mention ; suffice to say
from a standpoint of mortality alone they are rela-
tively greater than those attending laparotomy.
2. The patient himself, who should ha healthy and
oi a suitable age. A thorough general examination,
including heart, lungs, urine, etc., is therefore in
order.
3. The local condition, when the separation is
three cjuarters of an inch or more, wdien the frag-
ments are comminuted, as in those fractures caused
by direct \iii!iiice. wlien there is much efifusion or
haemorrhage nitt/ the joint, when the anterior fibro-
j)eriosteal layer, blood clots, or bony spicules are in-
terposed between the fragments, operation is indi-
cated, provided the first two conditions can be con-
scientiously disposed of.
It is to be borne in mind that the nonoperative
method practically in nowise endangers the life of
the patient, neither does it exclude the possibility of
a successful operation at a later date, and, lastly,
that a good functional leg usually results and often
more rapidly than when many of the operative pro-
cedures are resorted to. However, in the case of
young adults in robust health, the operative treat-
ment is to be preferred in all ca.ses, provided, of
course, the facilities for its successful performance
are at hand. However, the facts in each individual
case should be carefully weighed before determining
upon the advice to be offered.
.Should one be called to attend the patient upon
the scene of the accident, further separation of the
fragments and tearing of the cajjsule and patellar
tendons, while he is being moved, is to be prevented
by placing the injured leg upon an improvised pos-
terior si)lint, having first hound the knee in a snug
figure 8 bandage to support the tissue, and thus con-
trol the amount of effusion, for when the capsule
becomes overdistended by effusion it loses its elas-
ticity, and absorption is slow.
The patient having been put to bed and the leg
bared, a more careful examination ma}- be made, and
the line of treatment determined upon, or we may
proceed with the nonoperative, wdiile more carefully
considering the advisability of an operation. Let us
therefore first take up the nonoperative treatment.
It is evident that in order to secure and main-
tain apposition of the fragments, the effusion must
first be reduced, antl to that end we must bend oiu"
first efforts. Apply a snug figure 8 bandage about
the knee over a moderately thick layer of cotton,
place the leg upon a long posterior splint extending
from the ankle to the upper one third of the thigh.
Agnew's splint is admirable for the purpose. The
splint is held in place by a bandage above and below
the knee. A pillow may be placed beneath the heel
to secure hyper extension. l""or the first day or two
apply Leiter ice coil or ice bags. Later intermittent
heat may be of benefit.
The bandage is removed and reapplied, when it
becomes loosened or inspection of the part is de-
sired.
If there is much effusion or haemorrhage into the
joint, aspiration under the most rigid observance of
asepsis ma}- be employed ( blood in the knee will not
clot for several days). After this procedure again
support the tissues to lessen further effusion.
When the eft"usion has receded sufficiently to al-
low of the fragments being brought into fair appo-
sition discard the first dressing, and with the leg .still
upon the splint draw the fragments together. The
absence of crepitus denotes the presence of an inter-
posing body ; gentle manipulation will often serve to
displace it. Carry a strip of adhesive plaster an inch
wide and several feet long over the upper border of
the upper fragment, pull the bone well down, and
fasten the ends of the plaster to posterior surface of
the splint below the lower level of the joint, rein-
force this with another strip; now carry a third strip
under the lower bonier of the lower fragment, draw
the bone up, and fasten the plaster securely to the
posterior surface of the splint above the uppermost
level of the knee; then to correct the tilting of the
fragments carry a strip of plaster transversely over
the line of fracture, and fasten to splint.
A bandage then holds the splint in place, and is
carried around the knee in figure 8 fashion. The
heel may be raised upon a pillow, to extend the leg
and semiflex the thigh.
J{ach day the bandage is removed, parts are in-
spected, straps tightened, and bandage reapplied. As
the more acute symptoms subside gentle massage
may be employed daily.
At the end of the second or third week remove
the splint, and with the leg in extension apply a
plaster cast from the ankle to the middle of the
thigh, and get the patient around on crutches. Be-
fore placing the le,g in the cast the fragments may
be secured by three strips of adhesive plaster. This
cast is worn until the ei.ghth week ; it is then re-
placed by a lighter and shorter one, to be worn four
to six weeks longer ; canes now replace the crutches.
I-^or the first year after removal of cast, a leather
May 9. -oos., OUR READERS' DISCUSSlOXS. 897
lacing knee cap is worn during the clay for protec-
tion, and daily massage employed in conjunction
with gentle active anci passive movements.
Although this prolonged immobilization renders
the joint more or less stifif, an almost certain oc-
currence, still the end result is better than the flail-
like joint, due to the wide separation of the frag-
ments that invariably follows early use of the joint.
When practicable it is well to cut down the cast so
as to permit of its daily removal for massage.
In alcoholic cases it is a wise precaution to imme-
diately put the leg up in a cast until all danger of
delirium tremens is past ; thus further injury of the
parts are guarded against.
Operation having been determined upon, the open
method alone should be considered, as it permits
of a thorough inspection of the parts, the removal
of blood clots, bony splinters, and of interposing tis-
sue, the repair of the capsule and patellar ligaments,
and such other damages of the joint structures as
may be present, and the perfect apposition of the
fragments. The closed methods defeat the very
ends for which an operation is performed.
The ligamentum patellx, with its lateral expan-
sions, is in realitv the continuation of the tendon of
the quadriceps, the patella being but a sesamoid bone
that has developed in its course. The poor blood
supply possessed by such bones accounts for their
comparative tardiness in uniting. The necessity of
repairing what is really the tendon of the quadri-
ceps is readily apparent. And, then, why use un-
absorbable suture material, as silver wire? They
possess no advantage over the absorbable ones, and
the objections to their use are many. Our purpose,
as in all fractures. Is simply to restore the parts to
their normal relationship, and to thus maintain them
until Nature can effect her own union, and when she
has it is time for us to vacate. For Nature, too, re-
sents permanent receiverships, and her resentment is
shown in sepsis, anchylosis, etc. Properly prepared
gut and kangaroo tendon fulfill every requirement.
The joint is opened by a U shaped incision, con-
vexity preferably upward. Blood clots, bony splin-
ters, etc. removed, the joint is flushed out with ster-
ile normal salt solution, the part brought into normal
relation, the torn edges trimmed up when neces-
sary, or freshened up in late operations, and the
tears of the capsule and lateral expansion of patella
ligament and the anterior fibroperiosteal layer su-
tured, and to insure perfect and firm apposition of
the bony fragments, especially when comminuted, a
purse string suture is thrown around the circum-
ference of the patella, drawn taut, and tied. The
objection that this suture interferes with the blood
supply is, I think, theoretical rather than practical.
Any other injuries of the joint structures are. of
course, repaired, special attention being paid per-
haps to the ligamentum mitcosum and the ligamenta
alaria, injuries of which Dr. Flint has demonstrated
so often give rise to the so called "foreign bodies"
of the knee,
In closing the wound a small strip of rubber tis-
sue is left in the joint, protruding from one of the
angles of the incision, to provide for drainage of the
serum that will accvunulate within the first and sec-
ond days. It is removed as soon as deemed advisa-
ble, usually at the end of the second or third day.
The wound is dressed in the usual fashion, and the
leg placed on a posterior splint.
Passive motion is begun about the third week, and
the patient allowed around on crutches.
To sum up. the treatment of fracture of the pa-
tella is operative and nonoperative. The latter sel-
dom results in bony union — in fact, fibrous union
under one half inch is considered a good result. It
is to be advised, however, when the conditions for
operation are unfavorable. The operative treatment
should always be by the open method, and in prop-
erlv selected cases good bony union should result.
Dr. George A. Hopp, of Philadelphia, writes:
In the treatment of fracture of the patella there
are several measures which are of value. One of
the most important is the functional result, also the
short period of recovery, which is of greatest im-
portance to the patient.
Fracture of the patella is a very common accident.
Eighty per cent, of all the fractures are the result of
direct violence ; fractures which were supposed to be
due to muscular contraction are comparatively rare
and can only occur when the knee is extended.
There are two methods of treating fractures of
the patella, the operative and nonoperative. The
open operative method is the best of the operative
methods, as it gives better functional results.
The operation is performed on the third or fourth
day after the accident, when the patient has been
more or less reconciled to bed and the swelling of
the joint has ceased to increase. A semicircular flap
is raised from over the fragments and all the clots
are carefully turned out. Each fragment is then
drilled, and they are brought in exact opposition
with kangaroo tendon, which is a reliable suture and
is absorbable. The objections to silver wire for su-
ture, which many surgeons use, are that it is non-
absorbable and acts as a foreign body which the
patella tries to expel : as the result of this it cau.-es
the failure of bony union and movable joint.
If an X ray is taken one can see that the wire
suture has been broken when passive motion was
made, and this causes a second operation. After the
fragments are brought together the torn fascia on
the cutaneous surface of the patella is then united
with sterile catgut, and one or two catgut sutures
are used to join together the aponeurosis on either
side if it has been extensively lacerated.
At the angle of the cutaneous incision there is left
a little opening in case there should be any oozing,
as no drain is inserted.
No antiseptic solution should be allowed to touch
the interior of the joint. There is no occasion to
wash it out, as the blood clot can be removed with
ease by means of sterilized gauze.
The wound is dressed with deep and superficial
dressings, with posterior splint, which immobilizes
the leg. The knee is firmly bandaged and the pa-
tient put to bed. On the fifth or sixth day the band-
ages and the superficial dressings are removed, and
the part is examined. The patient is encouraged to
flex and to extend the limb, the dressings are re-
placed, and each day passive motion is made more
and more. By the end of a few days it can be bent
to right angle.
Massage is begun as soon as the wound is healed.
898
OUR READERS' DISCUSSIONS.
[New Vork
Medical Jol-rxal.
The patient is allowed to get up before the end of
the third week, and by the end of the fourth week
he is able to walk.
If this method of treatment is carried out under
proper precautions, the result is infinitely better than
is that obtained by any other method, and there is
an enormous saving of time to the patient.
Dr. Richard L. Igel, Jr.. of Leazrin^'orfh, Kansas,
says:
In the treatment of patellar fracture the method
of procedure is largely dependent on the character
of the injury present. If due, as is most frequently
the case, to sudden, violent action of the quadriceps
extensor muscle, the line of division is transverse,
the aponeurotic covering is usually torn, and there
is considerable space intervening between the two
fragments. If occurring as the result of direct vio-
lence the fracture is more often vertical or star
shaped, the aponeurosis remains inlTact, and there is
but slight displacement, as a rule. The simple frac-
tures where the capsule remains unru].)ture(l are best
treated without operative interference. The most
satisfactory results can be secured by the use of a
long posterior splint, with attached foot rest. Above
and below the injured bone half inch strips of ad-
hesive plaster are attached, transversely, and to the
ends of these, on either side, pieces of strong elastic
webbing are fastened, the loose extremities of which
pass to sharp tongued buckles on the sides of the
splint. These elastics are so arranged as to exert
tension on the upper and lower fragments, bringing
them in apposition. The apparatus is a modification
of one devised by Alanning, and, in my experience,
has proved very efficient'.
Longitudinal and starred fractures with unbroken
capsule, and consequent slight separation, require
only the posterior splint for from two to five weeks,
coupled with massage, then passive movement, suc-
ceeded by careful exercise.
In transverse fractures of the more severe type,
unless operation is contraindicated by some inter-
current disease or the patient prefers an impaired
limb during the remainder of his life to the risk at-
tendant on instrumental interference, operative meas-
ures are invariably indicated. The date at wdiich the
operation should be undertaken depends on the con-
dition of the surrounding structures. If these are
considerablv involved, or a synovitis present, a wait
of from one to two weeks, with rest and the applica-
tion of cold, locally, is necessary.
If considerable serum has exuded into th'e joint
aspiration is indicated.
The bone is exposed by a transverse, semilunar
incision, extending about one inch above the upper
border of the superior fragment, and the Hap care-
fully dissected down. The blood clots are removed
with a spoon, all intervening ligamentious and
tendinous structures cleared away, and the frag-
ments coapted. Absolute asepsis is essential to suc-
cess. The use of strong, irritating antiseptics is to
be avoided. I prefer a solution of carbolic acid or
lysol. If there is much fragmentation the edges of
the capsule arc now drawn together, not too tightly,
with chromicized catgut sutures, and the outer
wound closed, .small gauze drains being inserted bi-
laterally, at the corners. ( )ftentimes a circumferen-
tial suture of small kangaroo tendon will prove of
value here, especially if there has been much com-
minution.
If the bone is divided into only two or three pieces
the most satisfactory results can be secured by using
two, or, at most, four, fine chromicized kangaroo or
medium catgut ligatures, and passing them through
slanting holes, drilled about one fourth of an inch
back from the fractured margin. These bind the
mass together efficientlw give rise to no irritation,
and never cause secondar_\- joint trouble. It is usu-
ally well, in all of these cases, to freshen the oppos-
ing edges of bone with a sharp curette before bring-
ing the parts together. The wound having been
covered wi^h a moist antiseptic dressing ( it is best to
take no chances of infection here), the limb is placed
on a long, straight posterior splint and kept ele-
vated. At the end of one week the dressing can be
changed, and the stitches and drainage wicks taken
out.
Later the splint should be frequently removed and
the part massaged. The support can be completely
discarded at the end of four weeks, and passive flex-
ion commenced.
Dr. G. Walthcr Otto, of Dresden, Germany, states:
The most satisfactory treatment of fracture of the
patella is the wiring of the broken bone. The physi-
cian who undertakes that operation must always bear
in mind that the opening of the injured knee joint is
a question of life and death to the patient. Only
those who master asepsis in every detail are com-
petent to perform this operation.
Besides the operator, two assistants are necessary,
one to give the narcotic, another one to assist during
the operation. Both operator as well as his assistant
must disinfect their hands very carefully and must
wear sterile rubber gloves during the operation. The
skin of the injured knee must be disinfected very
carefully. Sterile napkins cover the limb and are
fastened to the incision over the fracture with j\Iicu-
licz clamps to make the contact of the hands of the
operator and his instruments with the bare skin im-
possible.
The incision on the fracture should be vertical.
All bleeding must be arrested. Examination of the
opened joint w-ill be done now. But no fingers in
the joint ! The assistant helps w^ith sharp hooks.
Blood cjots are removed with sterile clamps or sterile
gauze sponges, small i)ieccs of the broken bone re-
moved, etc. Do the operation as dry as possible.
The operator helps himself to his well sterilized in-
struments and to the other utensils. The drilling of
the holes through the broken bone must be done
very carefully, to avoid splintering. The assistant
holds the bone with force])s. \W drawing the wire
close together bring the broken parts of the patella
as far as possible into their normal position. The
wire must not irritate the cartilage surface of the
articulation nor the skin. ()verla])ping fringes of
periosteum ought to be laid over tlie united bone.
.Vdapt the torn or cut ligaments and fascia by sutures
and unite the skin incision exactly.
By paying minute attention to the rules of asepsis
you will succeed. The slightly bent joint is dressed
and placed in a stifl' bandage from three to six
weeks.
May 9, igoS.]
THERAPEUTICAL NOTES.
The necessity of changing the aseptic dressings
and the condition of. the patient will decide whether
splints or plaster of Paris cast can be applied. At
each change of the aseptic dressings great care has
to be taken to avoid a secondary infection. Hands
must be well disinfected, sterile rubber gloves used,
and instruments and dressings sterilized.
After removal of the stift" bandages the phvsician
begins the passive movements of the joint. To re-
store active power and nutrition of the muscles of
the leg after the enforced quiescence, massage very
soon.
fbmpfutical Jotes.
Lotions for Seborrhoeic Eczema of the Scalp.
— Resorcin has been found remarkably efficacious
ui controlling seborrhoeic eczema of the scalp — the
condition of the scalp characterized by the appear-
ance of what is popularly termed "dandruff." In
the following lotion the resorcin is exhibited in an
agreeable form, the prescription being taken from
Die Praxis dcr Hautkrankhcitcn. a collection of the
teachings of Unna :
B Castor oil 5i .
Resorcin, 5iis5 :
Eau de cologne :
Alcohol (95 per cent) 5ix.
M. ft. lotio.
This may be used as a hair wash applied to the
scalp two or three times a week.
L. Duncan Bulkley uses a stronger solution of
resorcin in a "different menstruum, prescribing the
following :
B Resorcin, 5ii ;
Alcohol 5iii ;
Glycerin 5iv ;
Rose water, q. s. ad 3iv.
M. ft. lotio.
This is directed to be applied by means of a long
"hair dropper." and thoroughly rubbed in. with
shampooing every week or so.
Nitrite Poisoning Following Large Doses of
Bismuth Subnitrate. — Two recent cases of death
following the internal administration of bismuth
subnitrate in the large doses required for radioscopic
purposes prompt us to caution in the use of this
substance. It would seem that the salt is reduced
in the system by bacterial reaction, both nitric acid
and nitrites being formed in the blood in sufficient
quantity to cause death. In The Therapeutic Ga-
zette, for April, 1908, a citation is made from an
article by A. Bohme {ArcJiiv fiir experimciitcUc
Pathologie mid Pharmakologie. Ivii, 441. 1907) re-
porting the sudden death of an infant who had been
given a bismuth emulsion by mouth and later also
by rectum. Three hours after the rectal injection
she was seized with abdominal pains, vomiting and
diarrhoea, cyanosis, which steadily became more
marked, dyspnoea, collapse symptoms, and death
within thirty minutes of the onset. These it will be
noted are not the symptoms of bismuth poisoning
per se. which it is well known more nearly resemble
those of mercurial poisoning. In the other case re-
ported by Bennecke and Hoft'mann the drug had
been given in buttermilk and it was supposed that
death had been caused by the absorption of the salt
through its dissolution in the lactic acid of the milk,
but this did not explain the methsemoglobinjemia
found at the autopsy. In Bohme's case the most
evident post mortem finding was also methsemoglo-
binsemia, and he set himself the task of determining
experimentally if sufficient nitrites could be pro-
duced and absorbed from bismuth subnitrate to
endanger life. He seems to have established by
chemical means and by experiments on animals that
such is the case. He found that human faeces was
capable of reducing nitrates to nitrites, and the re-
action occurred more readily and frequently with
infant stools, than with the ffeces of adults. From
this he thinks it possible that the combination of a
large quantity of the bismuth salt with a pronounced
bacterial activity might produce sufficient amounts
of the nitrites to cause a methjemoglobinjemia. but,
at the same time, he believes that therapeutic doses
of bismuth subnitrate are not capable of producing
harm in human beings, even in the ver_\- }'oung.
The large doses which are required for radiography
should be used with some caution even in adults,
especially as the conditions favoring nitrite produc-
tion are not well understood. It has been proposed
to substitute bismuth hydroxide for the subnitrate,
a step which would exclude the possibility of nitrite
poisoning.
Gargles for Sore Throat. — W here there is only
a slight degree of inflammation a gentle astringent
preparation like the following is useful {Bulletin
general de thcrapeutique) :
B Sodium borate 5s# :
Tincture of benzoin 5ii ;
Syrup of mulberry 5i ;
Water 3vi.
yi. ft. gargarisma.
A ten per cent, solution of borax in glycerin used
as a mouth wash leaves a clean, soothing sensation.
As soon as the acute symptoms have subsided it
is recommended to employ a stronger topical ap-
plication and thus insure a good healthy condition
of the parts. ]M. Lermoyes (loc. eit.) prescribes the
following :
B Sodium borate gr. xlv:
Resorcin gr. xxx :
Glycerin, 5vss ;
Peppermint water Tli Ixxv.
M.
Injection for Multiple Sclerosis, — Boteano
{Journal de mcdecine de Paris April 4. 1908) gives
every second or third day a hypodermatic injection
of fifteen mitiims of the following solution :
B Scopolamine hydrobromide gr. 1/5;
Distilled water, 5v ;
Cherrv laurel water 5v.
M.
The treatment should be suspended if symptoms
of intolerance are shown, such as mydriasis, dryness
of the throat, sleeplessness, etc.
Pyelitis. — Robin prescribes the following pill
m inflammation of the mucous membrane of the
pelvis of the kidney :
B Venice turpentine, 5iiss;
Camphor, 3iss;
Extract of opium,- gr. iv;
Extract of aconite, gr. ii.
M. ft. pil. LX.
Sig. : One pill two or three times a day.
900
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Review of Medicine.
Edited by
FRANK P. FOSTER, AI. D.,
and SMITH ELY JELLIFFE, M. D.
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responsible for money sent by unregistered mail.
Entered at the Post OfBce at New York and admitted for
transportation through the mail as second class matter.
NEW YORK, SATURDAY, MAY 9. 1908.
TYPHOID FEVER IN MILITARY AND
INDUSTRIAL AGGREGATIONS.
The May number of the Military Surgeon con-
tains a number of valuable articles expository of
certain points in connection with typhoid fever as it
prevails among' men gathered together in close
quarters, whether for military or for industrial pur-
poses. It seems to have been due to some extent to
deference to the teachings of so excellent an observer
as Sir Patrick Manson (which teachings may have
been misunderstood) that in the Philippine Islands
some outbreaks of typhoid fever have for a time
failed of recognition, the disease being spoken of
as "simple" and "double" continued fever — "simple"
denoting cases without a relapse, and "double" be-
ing applied to those with a relapse. Another source
of error has. lain in undue importance being attached
to the absence of Widal's agglutination reaction be-
fore convalescence was established.
The first of the articles referred to is by Lieu-
tenant Henry J. Nichols, an assistant surgeon in
the army, most of whose observations were made
in the post hospital of Camp Bumpus, Tacloban.
Leyte. Dr. Nichols is of the opinion that typhoid
fever — popularly known in the Philippines simply as
a variety of calentiira — is much more prevalent
among the natives, especially the children, than is
generally supposed. In this opinion he has the sup-
port, by no means negligible, of the intelligent
Spanish father of one of his little patients. The
man declared, in answer to a question, that the
disease with which his child was afflicted was regii-
[New York
Medical Journ.^i.
kir y natural cn todos los pueblos y barrios of that
part of Leyte.
Dr. Nichols further concludes that cases resem-
bling the "simple" and "double" continued fever of
Crombie and Manson should not be regarded as
entities, but as examples of simple and relapsing
typhoid fever; that the Widal test cannot be de-
pended on for a diagnosis unless the reaction occurs,
for it may fail to show the expected result until the
fourth week or even until convalescence has set in ;
and that the mortality from typhoid fever among
white persons in the Philippines is not excessive.
The next article is by Lieutenant Earl H. Bruns.
an assistant surgeon in the army, on an epidemic of
typhoid fever in Iloilo. Dr. Bruiis's experience with
the Widal test coincides with that of Dr. Nichols.
He reports that the epidemic was confined to one
company of the Eighth Infantry, and to that part
of the company w-hich was lodged in a structure
that is supposed to have become infected, the sup-
position being supported by the subsidence of the
epidemic when the structure had been fumigated
and disinfected.
The third article is bv Lieutenant Colonel Louis
A. La Garde, deputy surgeon general, who, com-
menting on the epidemic described by Dr. Bruns
(the second one, it seems), says: "The laboratory
assistant had failed to obtain the Widal reaction.
Nevertheless, rose colored spots and enlargement of
the spleen were associated in the majority of cases.
These symptoms, with the fever, even in the absence
of the agglutination test, should have been sufficient
to warrant a diagnosis of typhoid fever; to wait
for confirmation by a delayed Widal reaction under
such circumstances was simply adding to the spread
of the disease."
Captain Louis C. Duncan, an assistant surgeon in
the army, contributes an interesting account of a
small typhoid epidemic in the county of Missoula.
Montana, in a succession of camps of laborers en-
gaged in railway construction. They were "laborers
of the lowe.st class, from all parts of the country,
living in tents and temporary houses, with no sani-
tary arrangements or control." Dr. Duncan says :
"The large contractors employed physicians to treat
the sick and injured, but no sanitary offlcers to pre-
vent sickness." "Here." he adds, "was to be seen
the working of the idea prevalent in the army until
recently, that medical men were employed to cure
sickness, not to prevent it." He thinks that the in-
fection was chiefly in the drinking water, which,
though originally pure, is contaminated in the irri-
gation ditches, which pass through "fields, pastures,
barnyards, hog lots, and other sources of filth and
infection." Flies are not numerous, and practicallv
there is no wind, and consequently but little dust in
the air.
EDITORIAL ARTICLES.
May 9, 1908.]
EDirORlAL ARTICLES.
901
GREAT MEDICAL LIBRARIES.
The librarian of the New York Academy of Medi-
cine has compiled a list of the considerable medical
libraries of the world, and it has been published by
the American Medical Association. In most in-
stances the size of the library is stated. Among the
larger collections are the following : The New York
State Medical Library, Albany, 18,912 books; the
Medical Library of the University of Michigan,
Ann Arbor, 19,165; the Library of the Medical and
Chirurgical Faculty of ^Maryland, Baltimore, 17,103;
the Library of the Kaiser Wilhelm Academy for
Military Medical Training, Berlin, 65,000; the
Library of the Berlin Medical Society, 30,000; the
Boston Medical Library, 57,493; the Bristol (Eng-
land) Medical Library, 21,000; the Library of the
Medical Society of the County of Kings, Brooklyn,
65,000; the Library of the x\cademy of Medicine of
Belgium, Brussels, 100,000; the Library of the
Royal Society of Physicians of Budapest, 20,528 ;
the Library of the Medical College of Bengal, Cal-
cutta, 50,000; the Medical Section of the John
Crerar Library, Chicago, 42,000; the Library of
Rush Medical College, University of Chicago,
16,000; the Cincinnati Hospital Library, 18,000; the
Library of the Royal College of Physicians of Ire-
land, Dublin, 15,000; the Library of the Royal Col-
lege of Surgeons in Ireland, Dublin, 30,000; the
Library of the Royal College of Physicians of Edin-
burgh, 80,000; the Library of the Royal College of
Surgeons, Edinburgh, 15,000; the Library of the
Royal Medical Society, Edinburgh, 30,000 ; the
Medical Library of the Scientific School, Florence,
30,000; the Library of the College of Physicians
and Surgeons of Glasgow, 50,000 ; the Medical Li-
brary of the Imperial University, Kyoto, 25,016;
the Librar}- oi the British Medical x\ssociation,
London, 20,000; the Library of the Medical Society
of London, 25,000; the Library of the Royal College
of Physicians, London, 25,000; the Library of the
Royal College of Surgeons of England, London,
60,000; the Library of the Royal Society of Medi-
cine, London, 70,000 ; the Library of the Manchester
(England) Medical Society, 37,310; the Library of
the Bureau of Science, Manila, 25,000; McGill Med-
ical Library, Montreal, 30,000; the Library of the
New York Academy of Medicine, 85,000; the Li-
brary of the Paris Academy of Medicine, 100,000;
the Library of the Faculty of Medicine of Paris,
175,000; the Library of the College of Physicians
of Philadelphia, 84,423 ; the Library of the Hahne-
mann Medical College, Philadelphia, 15,000; the
Medical Library of the Pennsylvania Hospital,
Philadelphia, 15,000; the Library of the Rhode
Island Medical Society, Providence, 22,000; the Li-
brary of the Imperial Academy of Medicine, St.
Petersburg, 170,000; the Lane Medical Library, San
Francisco, 33,000; the Caroline Institute Library,
Stockholm, 40,000; the Library of the Surgeon
General's Office, United States Army, Washington,
158,791; the Library of the United States Naval
Medical School, Washington, 16,000.
In our enumeration we have omitted mention of
libraries containing fewer than 15,000 books each.
It will be seen that the largest collection is in Paris.
Then come those in St. Petersburg, Washington,
Brussels, New York, Philadelphia, and Edinburgh.
Particularly noteworthy is the rapid growth of the
Library of the Bureau of Science, in Manila, which
must have been started less than ten years ago. The
Library of the Medical Society of the County of
Kings, too, has grown very rapidly within the last
few years. Such increments betoken a gratifying
appreciation of the value of libraries in the diffusion
of knowledge. There are, indeed, few agencies, if
any, on which greater dependence can be placed for
the spread of medical knowledge. The growth of
medical libraries should on all accounts be promoted
to the full ability of the profession.
THE DIAGNOSIS OF CANCER OF THE
TONGUE IN SYPHILITICS.
Far from being an exception, the coexistence of
lingual syphilis and cancer is not uncommon, and
probably syphilis is -ui im.portant predisposing cause
of malignant disease of the tongue, because it cre-
ates points of lessened resistance which favor the
development of the neoplasm. The diagnosis of
cancer should be made in syphilitic subjects by a
careful study of all the symptoms. The pronounced
induration of the ulceration, the appearance of a
hard, everted edge, the amout of lymphatic involve-
ment and pain, especially in the ears, when the case
is one of lingual carcinoma, are all symptoms which
should lead one to suspect cancer. On the other
hand, if one is dealing with a purely syphilitic ulcer-
ation, these important symptoms are lacking. In
the majority of cases carcinoma occurs in an old
syphilitic presenting a localized lingual leucoplakia.
The latter lesion remains for a considerable length
of time in the form of brilliant white patches with
a narrow red border, seated on the borders of the
tongue or on its upper aspect, but little by little thev
become cracked and ulcerated. Up to this time
there is nothing to call the patient's attention to it,
but sooner or later the surface of the patch becomes
irregular, and is covered by warty projections.
These papillomatous vegetations take on the aspect
of a cat's tongue, and are the indication of an im-
minent transformation of the leucoplakia into can-
cer. \\'hen this has taken place, a hard tumor will
902
EDITORIAL ARTICLES.
[\e\\ Vokk
.:l)ical Journai.
be found, usually on the point of ulcerating, and
from the very beginning of this transformation the
patient experiences sharp pain, extending toward the
ear. When salivation sets in, with fcetor of the
breath, the diagnosis can no longer be faulty. In
other cases the carcinoma occurs in a syphilitic in
the full tertiary period.
In gummatous glossitis the malignant growth be-
comes grafted on a gumma which has broken down,
and here its aspect is very typical. On a tongue
presenting rounded, hollow ulcers, with sharply cut
borders, in the midst of thickened tissues will be
seen on the dorsal aspect of the organ, usually to-
ward its centre, one of these ulcerations, bleeding
easily and secreting a bloody liquid. The borders
are only slightly undermined, but are not sharply
cut. The base of the ulcer is covered with a gray-
ish adherent membrane as in a gumma ; if the
growth is pres.sed, little fragments of tissue may be
sciueezed out, a most important symptom in favor of
carcinoma. The diagnosis may also be based on the
presence of enlarged glands, pain, and salivation.
If one is dealing with a sclerogummatous tongue,
the clinical picture changes. ' )nly infrequently does
the malignant growth precede the syphilitic mani-
festations in the tongue in this case, and should they
develop together the cancer will awaken the old
syphilitic process. But usually the sclerogum-
matous process and cancer are associated. The
tongue increases in size, presenting quite a large in-
duration at a given point. Then a cancerous ulcer-
ation is not long in appearing, while the condition of
the glands will give evidence of its malignancy.
Quite different is the evolution of carcinoma in a
syphilitic subject who is cured. In point of fact,
syphilis, by its sclerosing action on the tissues, pre-
pares a poor soil for the development of car-
cinoma.
ANCIENT HEPATOSCOPY.
In the twenty-ninth volume of the third series of
the Transactions of the College of Physicians of
Philadelphia — a volume which, like its predecessors,
is replete with valuable matter — we find an article
on a subject so unusual that it is likely to appeal
particularly to those who are interested in the his-
tory of medicine, including its connection with the
mysticism of times long gone by. It is entitled
The Liver in Antiquity and the Beginnings of
Anatomy, and its author is Morris Jastrow, Jr.,
Ph. D., professor of Semitic languages in the Uni-
versity of Pennsylvania.
Professor Jastrow deals largely with divination
by inspection of the liver of sacrificial animals, as
practised by the ancient Babylonians and other
peoples of remote antiquity. He traces a connection
between this ancient hepatoscopy, or hepatomancy,
which has met with oblivion, and palmistry, which,
though itself ancient, has survived and still figures
in the belief of many thousands of persons, some
of whom are intelligent and otherwise rational.
Moreover, this old form of divination by minute
observation of the hepatic fissures doubtless played
a part in leading to the subsequent scientific study
of the anatomy of the liver.
DEEP PERICARDITIS.
This term seems preferable to '"subpericarditis"
(soiis-f^cricardite) , under which name ]\I. Babes
made the affection the subject of certain remarks at
a recent meeting of the Paris Society of Biology
{Seinaine nicdicale, April ist). It is described as
an inflammation and degeneration of the deep por-
tions of the pericardium and of the superficial part
of the underlying muscular tissue of the heart, oc-
curring particularly as a complication of pulmonary
emphysema, chronic bronchitis, ulcerative pleuro-
pneumonia, etc. It is said to be rather frequent,
having been observed nineteen times in a hundred
and fifty post mortem examinations, and seven times
among thirty-five cases of such heart diseases as
endocarditis and myocarditis. The lesions are in-
contestable, though they are not very apparent to
the naked eye, and ]\I. Babes has no doubt that thev
count in the production of pericarditic and myocar-
ditic phenomena. He himself has seen four cases
of a grave character in which no other cardiac le-
sions were made out.
A NEW LARYNGOLOGICAL JOURNAL.
We have received the first number of the Zeit-
schrift filr Laryngologie, Rhinologie iind ihre
Grenzgebiete, edited by Dr. Felix Blumenfeld, of
Wiirzburg, and published by Curt Kabitzsch, of
Wiirzburg. it is announced that a volume will ap-
pear every year, in six parts, which will be pub-
lished about every second month. Under Grenz-
gebiete are tmderstood tracheoscop} , bronchoscopy,
(xsophagoscopy, diseases of the mouth, diseases of
the cavities of the head, including the orbit, the
external surgery of the throat, the pathology and
therapeutics of the voice, and diseases of the lungs
and skin, so far as all these affections have any
connection with those of the larynx and nose. The
first number contains articles by Dr. P. Heymann
and Dr. G. Ritter. of P.erlin ; Dr. \'oigt. of Wiirz-
Inirg : Dr. .Alexander Iwanoff, of Moscow ; Professor
Gerber, of Konigsberg; Professor Kan, of Leyden :
Dr. Hansberg. of Dortmund ; Dr. Moller. of Copen-
hagen ; Professor Starck, of Karlsruhe : Dr. Goris,
of Brussels: and Dr. Herman Gutzmann, of Berlin.
May 9, 1908. J
NEIVS ITEMS.
903
THE DOCTOR'S DUTY TO THE STATE.
Under this title a well known Philadelphia sur-
geon, Dr. John B. Roberts, has recently issued a
pamphlet in which are printed various addresses of
his dealing with certain matters of ethics. The col-
lection deserves to be studied by the medical pro-
fession. Some practices that meet with more or
less general toleration are clearly shown by Dr.
Roberts to be unworthy of a liberal profession and
detrimental to the welfare of the community. Even
those who already realize the truths which he enun-
ciates may gather from the pamphlet effective ar-
guments to use for the enlightenment of those who
do not as yet realize them.
Changes of Address. — Dr. Walter C. Gilday, to 44
West Thirty-seventh street, New York; Dr. Charles B.
Warden, to" 322 South Si.xteenth street, Philadelphia.
The Pennsylvania Red Cross Society sent six nurses
to the tornado district in the South on Friday, May ist.
The nurses were graduates of the Medico-Chirurgical Hos-
pital Training School, Philadelphia.
The Northwestern Medical Association of Philadel-
phia met on Friday evening. May 8th. The principal
paper of the evening was read by Dr. E. E. Montgomery
on Office Treatment of the Diseases of Women.
The Alumni Association of Carney Hospital, Boston,
held its annual meeting and banquet on the evening of
April 23d. Officers were elected as follows : President,
Dr. F. X. Crawford; vice president. Dr. John T. Sullivan;
and secretary, Dr. W. H. Burke.
American Gastroenterological Association. — The
eleventh annual meeting of this association will be held
in Chicago on Monday and Tuesday, June i and 2, 1908.
The sessions will be held at the .-Xuditorium Hotel, and all
members of the medical profession are cordially invited to
attend.
National Confederation of State Medical Examining
and Licensing Boards. — The annual meeting of this
organization will be held at the Lexington Hotel, Twenty-
second street and Michigan Boulevard, Chicago, on Mon-
day, June 1st. Thtrc will be three sessions, at 10 a. m., 2
p. ni., and 8 p. m., respectively.
The Mortality of New Orleans. — During the month
of March, 1908, there were 633 deaths reported from all
causes, 386 white and 247 colored. The annual death rate
in 1,000 of population was 17.91 for the white population,
31.87 for the colored, and 21.64 for the total white and
colored. There were 48 still births.
American Medical Editors' Association. — The annual
meeting of this society will be held at the Auditorium
Hotel, Chicago, on May 30th and June ist. An extensive
and interesting programme has been prepared, and every
member of the association is urged to be present. Editors
of medical publications who are not affiliated with the
society are also invited to attend.
The Buffalo Academy of Medicine. — .A. meeting of
the Section in Surgery was held on the evening of May
Sth. The principal feature of the programme was a paper
by Dr. Paul Thorndike, professor of genitourinary diseases
at the Harvard Medical School, on Patients with Enlarge-
ment of the Prostate Who Should Not be Operated upon by
Prostatectomy.
Contagious Diseases in Chicago. — During the week
ending April 25th there were reported to the Department of
Health 607 cases of communicable diseases. Of these 62
were diphtheria, 78 were scarlet fever, 7 were smallpox, 326
were measles. 28 were chickenpox, 25 were typhoid fever,
24 were whooping cough, 44 were tuberculosis, and 12 were
contagious diseases of minor importance.
National Association for the Study of Epilepsy and
the Care and Treatment of Epileptics. — The annual
meeting of this association will be held in Indianapolis,
Ind., on Tuesday and Wednesday, November 10 and 11,
1908. Those desiring to attend the meeting and present
papers should communicate with Dr. J. F. Munson, secre-
tary and treasurer, Craig Colony for Epileptics, Sonyea,
N. Y.
The Northwestern Medical Society, Philadelphia. — At
a meeting of this society, held on Monday, May 4th, the
general subject tor discussion was the rights of the unborn
child. The subject was dealt with from the standpoint of
the law by John M. Patterson, LL. B. : from the standpoint
of the church by the Rev. Joseph J. Murphy, D. D., J. C. D. ;
and from the standpoint of the physician In Dr. Wilmer
Krusen.
A Meeting of Officers of Hospitals for the Insane. —
The semiannual meeting of the trustees and superinten-
dents of the State and Incorporated Hospitals for the In-
sane and Feebleminded of Pennsylvania was held in
Philadelphia on Tuesday afternoon, May 5th. The pro-
gramme included a paper entitled Some Questions Relating
to the Insane, by Dr. Robert H. Chase, and a paper on the
Potentially Insane, by Dr. Frank Woodbury.
A Tuberculosis Sanatorium in Rensselaer County,
N. Y. — At the regular monthly meeting of the Medical
Society of the County of Rensselaer, N. Y., which was
held in Troy on Tuesday, April 14th, the following resolu-
tion was adopted: "Resolved, that it is the sense
of every member of the Medical Society of the County
of Rensselaer that a county sanatorium and hospital be
erected for the care of advanced tuberculosis cases."
Wills Hospital Ophthalmic Society, Philadelphia. —
The following papers were presented at a meeting of this
society, which was held on Monday afternoon. May 4th:
The Value of Photography in Ophthalmology, by Dr.
Frank C. Parker; A Case Illustrating the Results of Iri-
dotomy, b}' Dr. George Robinson ; Tenotomy of the In-
ferior Oblique, by Di . William Campbell Posey; Some Re-
sults of Gahanocautery Puncture, by Dr. S. Lewis Zeigler.
Syracuse, N. Y., Academy of Medicine. — A meeting
of this academy was held on the evening of Alay 5th. Dr.
I. H. Levy read a paper entitled The Diagnosis of Gall-
stones, and Dr. Clarence E. Coon read a paper on the X
Ray as an Aid in the Early Diagnosis of Pulmonary Tuber-
culosis, which was illustrated with lantern slides. Dr. A.
B. Miller opened the discussion on Dr. Levy's paper, and
Dr. .\. C. Mercer opened the discu^-sion on Dr. Coon's
paper.
Scientific Society Meetings in Philadelphia for the
Week Ending May i6, 1908. — Matiday. May jitii. Sec-
tion in General Medicine, College of Physicians; Wills
Hospital Ophthalnnc Society. Tuesday. May utb. Phila-
delphia Pediatric Society; Botanical Section, .\cademy of
Natural Sciences. Wednesday. May i^^tli. Philadelphia
County Medical Society. TIntrsday. May I4tli. Section
Meeting, Franklin Institute. Friday. May i^fli. American
Philosophical Society.
Appointments at the Northwestern University Medi-
cal School, Chicago.— Dr. John B. Murphy has resigned
as professor of surgery and co-head of the department in
Rush Medical College, and has accepted the position of
professor of surgery and head of the department in North-
western University Medical School. Dr. A. W. Meyer, of
the University of Minnesota, has accepted the professorship
of anatomy, and Dr. A. N. Richards, of the College rf
Physicians and Surgeons, New York, has been appointed
professor of pharmacology.
The Harvey Lectures.— The tenth and last lecture in
the Harvey Society course will be delivered at the New
York Academy of Medicine on Saturday, May 9th. at 8:30
p. m., by Professor A. E. Schafer, of the University of
Edinburgh. Tlie subject of the lecture is Artificial Respira-
tion in Man. Professor Schafer was chairman of a com-
mittee appointed by the Royal Medical and Chirurgical So-
ciety to investigate the phenomena attending death by
drowning and the means of promoting resuscitation in the
apparently drowned, and his lecture will embody the results
of much practical work on the subject of artificial respira-
tion. Professor Schafer came to the United States for the
purpose of giving the Herter lectures at the Johns Hop-
kins Medical School.
904
NEWS ITEMS.
[New York
Medical Journal.
American Laryngological Association.— The thirtieth
annual congress of this association will be held in Montreal,
Canada, on May ii, 12, and 13, 1908. The headquarters of
the association will be at the Windsor Hotel. An excellent
programme has been prepared and ample arrangements
have been made for the entertainment of the visitmg mem-
bers and their friends. The meeting promises to be one of
great interest, and all members of the medical profession
are cordially invited to attend.
New York Academy of Medicine.— At a stated meet-
ing of the academy, held on Thursday evening, May 7th,
under the auspices of the Section in Public Health, Dr.
Walter Bensel, sanitary superintendent of the New York
Department of Health, read a paper entitled Possible
Sources of Typhoid Fever in New York City. Among
those who took part in the discussion were Dr. E. G. Janc-
way. Dr. A. Seibert, Dr. J. M. Wainwright, Dr. William H.
Park, and Dr. John S. Thacher.
The Floyd County, Ga., Medical Society. — The Sev-
enth District Branch of this society met in Rome on
March nth and effected a permanent organization, with
the following officers for the ensuing year : President, Dr.
R. P. Cox, of Rome; vice president. Dr. C. F. McLaird,
of Calhoun ; secretary and treasurer. Dr. Harlan L. Erwin,
of Dalton. The society meets twice a year, on the second
Wednesday in October and March. The next meeting
will be held in Cartersville on October 14th.
Pennsylvania Society for the Prevention of Social
Disease. — A meeting of this society will be held at the
College of Physicians, Philadelphia, on May 22d, at which
Dr. Helen C. Putnam, of Providence, R. I., will deliver an
address outlining her experience in the teaching of hygiene
and morality in the public schools. Dr. Putnam is chair-
man of the Committee on the Teaching of Hygiene in the
Public Schools, appointed by the American Academy of
Medicine. The meeting will be open to the public.
American Laryngological, Rhinological, and Otologi-
cal Society. — The fourteenth annual meeting of this so-
ciety will be held in Pittsburgh, Pa., on May 28, 29, and 30,
1908. The headquarters of the society will be at the Hotel
Schenlcy, and the sessions will be held in the Carnegie
Library. The programme, which seems to be a particularly
good une. includes a "symposium" on the cosmetic and
plastic surgery of the nose, throat, and ear. The oration in
otology will be delivered by Dr. A. Jansen, of Berlin, Ger-
many. All members of the medical profession are invited,
and a good time is expected.
The Obstetrical Society of Philadelphia.— A stated
meetincr of this society was held on the evening of May
7th. The programme, which was a long one, included the
following papers : The Toxpemia of Pregnancy, by Dr.
Collin Foulkrod; A Case of Concealed Haemorrhage in
Pregnancy compared with a Case of Extrauterine Preg-
nancy, by Dr. George Erety Shoemaker : The Value of
Acetone in the Treatment of Inoperable Carcinoma Uteri,
by Dr. F. Hurst Maier; Drainage of the Pelvic Cavity
after Abdominal Section, by Dr. Ella B. Everitt ; Hyper-
nephroma, by Dr. L. J. Hammond.
College of Physicians of Philadelphia. — A stated
meeting was held on the evening of Alay 6th. Dr. Meyer
Solis-Cohen read a paper on a Simple and Accurate
Method for Testing the Clotting Time of the Blood. Dr.
Warren Walker read a paper on Myostitis Ossificans Pro-
gressiva, and exhibited a patient with the disease. Dr.
Gwilym G. Davis presented several patients with congenital
dislocation of the hip. A paper by Dr. John H. Jopson, Dr.
C. Y. White, and Dr. John Speese on Tumors of the
Breast in Childhood was presented, and Dr. Henry Tucker
read a paper on the Local Uses of Solutions of Magnesium
Sulphate in the Treatment of Erysipelas.
The Mortality of Chicago. — According to the report
of tlie Department of Health for the week ending April
25, 1908, there were during the week 623 deaths from all
CPMses, as compared with 678 for the corresponding period
in T907. The annual death rate in 1,000 of population was
15.00. The principal causes of death were: Apoplexy, 11;
Bright's disease, 48; bronchitis, iq; consumption, 78; can-
cer, 23; convulsions, 6; diphtheria. 8; heart diseases, 47;
influcn/a. 6; intestinal diseases, acute, 40; measles, 7;
nervous diseases, 19; pneumonia, 112; scarlet fever, 5;
suicide, 11 : typhoid fever. 3; violence, other than suicide,
36; whooping cough, i ; all other causes, 143.
Personal. — Dr. George H. Kirby has resigned as as-
sociate in clinical psychiatry at the Pathological Institute
of New York, and has accepted the position of director of
clinical psychiatry at the Manhattan State Hospital, Ward's
Island, N. Y.
Dr. Llewellys F. Barker, professor of medicine at the
Johns Hopkins Medical School, has received the honorary
degree of doctor of la\ys from Queen's University, Kings-
ton, Ontario.
Dr. William H. Warren has been chosen dean of the
Medical Department of Washington University, St. Louis,
to succeed Dr. Robert Luedeking, who died recently.
New York Pathological Society. — The regular meet-
ing of this society will be held at the Academy of Medicine
on Wednesday ev ening, May 13th, at 8 :30 o'clock. The
programme includes the following papers: Two Atypical
Kidney Tumors, by Dr. I. Strauss; A Case of Rhabdo-
myoma of the Tongue, by Dr. Horst Oertel ; Notes on
Blood Cultures in Glanders, by Dr. B. Crohn ; The Ag-
glutinating Action of Ricin on Erythrocytes in Isotonic
Sugar Solution, by Dr. Cyrus W. Field ; Report on a Series
of Tumors of the Rat and Mouse, with demonstrations. In
Dr. Simon Flexner and Dr. J. W. Jobling; Prevention bv
Atoxyl of Syphilis in Macacus Rhesus, by Dr. Simon
Flexner.
Mortality Statistics of New York. — During the week
ending April 25, 1908, there were reported to the Depart-
ment of Health of the City of New York 1,536 deaths from
all causes, as compared with 1,671 for the corresponding
period in 1907. The annual death rate was 18.12 in 1,000
of population. Of the total number of deaths 801 were in
Manhattan, 140 in the Bronx, 520 in Brooklyn, 57 in
Queens, and 18 in Richmond. The principal causes of
death were: Apoplexy, 58; Bright's disease and nephritis,
113; bronchitis, 32; cancer, 65; contagious diseases, 153;
diarrhneal diseases, 44 ; diarrhteal disease, under five years
of age, 43 ; pneumonia, 262 : organic heart diseases, 148 :
pulmonary tuberculosis, 180: tuberculosis, other than of the
lungs, 34; typhoid fever, 11: suicide, 24; homicide, 3; acci-
dents, 59. There were 119 still births.
Infectious Diseases in New York:
IVc ai\' indebted to the Bureau of Records of the Dc-
t>artiuent nf Health for fl'c fidlon'ing statement of new
cases and deaths repurted for the tzvo zveeks ending May
3. jgo8:
I April 25. ^ , May 2. ^
Cases. Deaths. Cases. Deaths.
Tuberculosis pulmonalis 439 180 ' 482 178
Diphtlieria ' 344 39 425 45
Measles 1.891 39 1,652 41
Scarlet fever 929 64 855 60
Smallpox . . I
Varicell,-i 153 ... 158
Typhoid fever 33 11 36 8
WhoopiuR cough 14 i 27
Cerehrospinal lueuingitis 12 7 12 14
Totals 3.815 341 3.648 346
Colleges and Hospitals Cooperating in Educational
Work. — .At a meeting of the Hospital Conference of the
City of New York, held at the Academy of Medicine on
.^pril 30th. a report of the sub-committee on medical or-
ganization and medical education was presented. The
committee reported that the faculties of Cornell University
Medical College, University and Bellevue Medical College,
and the College of Physicians and Surgeons had all agreed
that the time had arrived for the readjustment of the cur-
riculum of the medical schools so as to enable the fourth
year, or graduating class, to spend additional time in hos-
pital wards as clinical clerks and surgical dressers, or as
students participating in tlie work. At Cornell the faculty
has already ordered that the liours from 10 a. m. to 12 m.
shall be devoted to extramural teaching for as many stu-
dents as can be at liberty at that time.
The Annual Report of the Board of Trustees of the
Philadelphia Polyclinic and College for Graduates in
Medicine has just been received. During tlie twenty-
five years of the existence of the institution 15.500 patients
have been treated in the hospital and 325,000 patients have
Iieen treated in the dispensaries. Tlie following gifts were
received during the past year : $10,000 from the estate of
Mary C. Dulles, $5,000 from the estate of Louisa
Dietrich, and $2,400 from the Charity Rail Commit-
tee of 1907. Eiglit v-eight cases of typhoid fever were
treated, with 5 (ieath-i, a mortality of 5.65 per cent.; 59
May 9, 1908.]
NEWS ITEMS.
cases of pneumonia and bronchopneumonia were treated,
with 12 deaths, a mortality of 20.33 per cent.; 179 cases of
intraabdominal disease were treated, with 19 deaths, a
mortalitj- of 10.61 per cent. There is no list of operations
in the report, so that the mortality of operation cases can-
not be computed. The report of the dean shows that dur-
ing 1907, one hundred and hfty-eight students matriculated
in the college department of the institution. Eight nurses
were graduated from the training school during the year.
The trustees report the necessity of temporarily stopping
work on the new dispensary building, on account of lack
of funds.
Charitable Bequests. — By the will of Lewis P. Simp-
son the Methodist Hospital of Philadelphia becomes a re-
versionary legatee, the money received to be used for th^
endowment of free beds and for the maintenance of the
dispensary.
By the will of Charles H. Newhall, the Lynn, Mass., Hos-
pital receives $50,000, and the Old Ladies' Home and the
Old Men's Home in Lynn receive $15,000 each.
By the will of Sarah Reeves the Episcopal Hospital,
Philadelphia, receives $5,000 to endow a free bed in mem-
ory of Joel and Sarah P. Reeves, parents of the deceased.
By the same will the Philadelphia Home for Consumptives
receives $500.
By the will of Patrick Larkin, Carney Hospital, Bos-
ton, receives $5,000; Holy Ghost Hospital and Cambridge
Hospital each receive $1,000.
A New National Hospital for Cuba. — Hospital de Al-
fonso XHI, which was originally built in 1895, is to be re-
built on the heights of Principe Castle, just outside of the
city of Havana. Plans for a two story building have been
tiled, and the work will be begun as soon as Governor
Magoon issues the necessary financial decrees. The pres-
ent available fund consists of a balance in hand of $120,000
from tile fund granted by the Cuban congress and a grant
of $150,000 from Governor Magoon. The Cuban congress
also voted an annual subsidy of $150,000 until a total of
$750,000 had been collected. Governor Magoon will con-
firm this latter arrangement, thus giving the board an avail-
able fund of $1,000,000 for the building and equipment of
the hospital. It is the intention of the board to make this
hospital thoroughly modern in ever\- respect, and no effort
is being spared in the search for the latest and best surgi-
cal and pharmaceutical equipment. The question of having
a department for the study of tropical medicine connected
with the hospital is under advisement.
The Health of Philadelphia. — During the week end-
ing April 18, igoS, the following cases of transmissible dis-
eases were reported to the Bureau of Health of Philadel-
phia: Typhoid fever, 79 cases, 13 deaths; scarlet fever, 75
cases, 3 deaths; chickenpox, 36 cases, o deaths; diphtheria.
71 cases. 12 deaths ; cerebrospinal meningitis, 8 cases, 5
deaths : measles, 424 cases, 9 deaths ; whooping cough. 22
cases, 9 deaths ; pulmonary tuberculosis, 140 cases, 45
deaths ; pneumonia, 74 cqses, 65 deaths : erysipelas, 4 cases,
2 deaths ; puerperal fever, 4 cases. 3 deaths ; mumps, 37
cases, o deaths; cancer, t6 cases. 23 deaths; septicaemia, 2
cases, o deaths. The following deaths w^ere reported from
other transmissible diseases : Tuberculosis, other than
tuberculosis of the lungs. 11; diarrhoea and enteritis, under
two years of age, 13. The total deaths for the week num-
bered 496. in an estimated population of 1,532.738, corre-
spondmg to an annual death rate of 16.80 in 1,000 of popu-
lation. The total infant mortality was 117; under one year
of age. 87 : between one and two years of age. 30. There
were 53 still births: 34 males, and 19 females.
Changes in the Requirements for Admission to the
College of Physicians and Surgeons, New York.— The
forthcoming announcemtnt of this institution, which is
the medical department of Columbia University, will con-
tain notice of a change in the requirements for admission,
to take effect in September. 1909. All candidates for the
degree of doctor of medicine on entering the college will
then be required to present a certificate from the Regents
of the University of the State of New York, and must also
show evidence of the completion of not less than two full
years of study in an apprned college or scientific school;
or graduation from an approved college or scientific school ;
or a bachelor's degree or its equivalent from some ap-
proved European institution ; or. in lieu of either of these,
evidence of exceptional fitness to imdertake the study of
medicine. Candidates who have completed one or more
years of study in an approved medical school will be ad-
mitted to advanced standing on presentation of proper cer-
tificates, provided that before beginning the study of medi-
cine they have fulfilled the qualifications for admission re-
quired by the College of Physicians and Surgeons.
Meetings of Sections of the New York Academy of
Medicine. — The Section in Neurology- and Psychiatry-
will meet on Alonday evening. May iith, at 8:30 o'clock.
After the presentation of patients and the reports of cases,
Mr. Arthur Train, assistant district attorney, will read a
paper entitled Insanity as a Defense to Crime. Among
those who v. ill take part in the discussion are Judge Dike,
Bartow S. Weeks, Esq., Nathan A. Smvthe, Esq., Dr. C. L.
Dana, Dr. William Hirsch, Dr. William B. Pritchard, Dr.
Smith Ely Jelliffe, Dr. James J. Walsh, and Dr. Carlos F.
MacDonald.
The Section in Paediatrics will meet on Thursday even-
ing. May 14th, at 8:15 o'clock. Dr. Max G. Schlapp will
report a case of cerebral changes following scarlatina and
measles. Dr. Herman Schwarz will present a patient with
infantilism and will read a paper entitled Infantilism and
Allied Conditions, wliich will be followed by a general
discussion.
A special meeting of the Section in Otology will be held
on Tuesday, Alay 26th, to greet Mr. Arthur H. Cheatle,
F. R. C. S., of London. A buffet luncheon will l)e serAed
at 2 p. m., and at 8 130 p. m. a lantern slide demonstration of
Mr. Cheatle's collection of temporal bones will be given in
Hosack Hall. The collection will also be on exhibition on
the afternoons and evenings of May 22d, 23d, and 2Sth.
Prizes Offered for Members of the American Laryn-
gological, Rhinological, and Otological Society. — Four
prizes of $100 each have been ofifered by members of the
American Laryngological, Rhinological and Otological So-
ciety, as follows :
By Dr. J. E. Sheppard for the best classification of non-
suppurative affections of the middle ear, to be based as far
as possible on pathological research.
By Dr. Charles W. Richardson for the best essay on the
operative treatment which offers the best results for the
cure of chronic suppurative frontal sinusitis.
By Dr. Nerval H. Pierce for the best original work on
rarification of the labyrinthine capsule.
By Dr. Edward R. Dench for the best essay on chronic
nonsuppurative inflammation of the middle ear.
The competition is open to members of the society only,
and all essays must be in the hands of the secretary before
April 15, 1909. who will furnish full information regarding
the requirements. The council of the society also an-
nounces that the society holds a fund of $500 for the en-
couragement of original research work. The whole, or a
part, of this fund will be awarded, at the discretion of the
council, to the member of the society presenting the best
essay embodying original work in subjects relating to larvn-
gology, rhinology, or otology.
Society Meetings for the Coming 'Week:
MoxD.w. May nth.—'Kev.' York Academy of Medicine
(Section in Neurology- and Psychiatry) ; Society of
Medical Jurisprudence. New York; New York Oph-
thalmological Society: Corning, N. Y., Medical Asso-
ciation ; Watefbury, Conn., Medical Association.
Tuesday, May /i-f/;.— New York Academy of Medicine
(Section in Public Health): New York Obstetrical
Society; Newburgh Bay. N. Y., Medical Society; Buf-
falo Academy of Medicine (Section in Medicine") ;
Medical Society of the County of Rensselaer, N. Y. ;
Medical Societv of the County of Schenectady. N. Y. ;
Practitioners' Club of Jersey City, N. J. (annual).
Wednesday. May /j^/i.— New York Pathological Societv;
New York Surgical Society; Medical Society of the
Borough of the Bronx ; Alumni Association of the City
Hospital. New York: Brooklyn Medical and Pharma-
ceutical Association : Medical Society of the County of
Richmond. N. Y.
Thursday. May 14th.— New York Academy of Medicine
(Section in Paediatrics) ; Brooklyn Pathological So-
ciety: Blackwell Medical Society of Rochester, N. Y. ;
Jenkins Medical Association, Yonkers, N. Y.
Frid.\y, May 15th.— New York Academy of Medicine (Sec-
tion in Orthopaedic Surgery) : Clinical Societv of the
New York Post Graduate Medical School and Hos-
pital ; East Side Physicians' Association of the City of
New York: New York Microscopical Society; Brook-
lyn Medical Society.
goG
|it^ of Cumnt literature.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
April JO. J(,oS.
1. Some Urinarv Infections with a Variety of the Staphy-
lococcns A'lbus. By Akthl r L. Chute.
2. The Treatment of Abnormal Rigidity of the Cervix
Uteri bv Deep Incisions. A Report of Two Cases,
By N.\TH.\NIEL R. M.XSON.
3 Mattapan Dav Camp for Consumptives, Boston, Mass.,
By Daviu Townsend
4. The Plaster of Paris Bar or Rope,'
By Robert Soutter.
5. Some Observations on a "Figure of Eight" Plaster
Jacket, By John D. Ad.\ms.
2. The Treatment of Abnormal Rigidity of
the Cervix Uteri by Deep Incisions. — ^^iason re-
ports two such cases. FVoni his operations he con-
cludes that where immediate delivery is demanded
in tlic presence of an undilated and rigid cervix.
multi])le deep incisions from the border of the ex-
ternal OS to tlie uterovaginal junction furnish the
most rapid and safest method of emptying the
uterus. There is no danger of the incisions tearing
in cases under full term, or in cases at full term,
where the pelvis is normal and the foetus is of mod-
erate size, nnr risk of hasmorrhage when clamps are
employed before making the incisions. The chance
of septic infection is no greater than after the lacer-
ations occurring at the tiine of normal delivery, and
the scars in the cervix and vaginal vault will cause
no trouble in the course of subsequent pregnancies
and labors.
4. Plaster of Paris Bar or Rope. — Soutter re-
marks that ])laster of Paris bandages have been
strengthened by strips of wood, steel, iron, card-
board, wood pulp, etc., and by laying the plaster
gauze longitudinally instead of in a circular man-
ner. The latter is not as rapid a manner of apply-
ing reinforcement as by means of the plaster bar
or rope. To make a plaster bar, a very wet plaster
of Paris bandage is rapidly unwoun.d back and forth
to the desired length. Xo attempt is made to rub
it or to applv it to the partially aj^plied dressing.
When the roll is entirely unwound it is held at one
end 1)y one hand, while the other is grasped around
it and' slid down to the other end, moulding it into
a bar. It is then slapped into place and rubbed three
or four times. This method of reinforcement is
more rapid than the lime it takes to describe it, says
the author. • Plaster bars may be used in front and
behind on a plaster of Paris spica at the weak points,
or to strengthen a plaster jacket. In jackets for
forcible correction in cases of curvature of the spine
or bad round shoulders, it is often important to
apply the jacket very rapidly. By means of two or
four ropes a strong, light, and retentive ai)]>aratus
can l)e finished in a very short time.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
.l/<;v J. 190S.
1. Chemical Problems in Hospital Pr.iclice,
By Otto Foijn,
2. The Scientific and Practical Value of Hospital Interne-
ship, By the Late Nichol.vs Senn.
3. Tiibercnlin in Pulmonary Tuberculosis,
By P.wi. H. Ringer
4. Relationship between the Spinal Cord, the Sympathetic
System, and Therapeutic Measures.
Ry S. D. LuDLU.M.
|.\ ; V V .UK
.M.;|1IC.-\L JOVRNAL.
5. The Treatment of Placenta Previa,
By H. S. Crossen.
6. Practical Value of Modern Conceptions of Syphilis,
By Alfred Sch.\lek.
7. Treatment of Eclampsia, By John F. Mor.xn.
^. Some of the Motor Phenomena of Chorea Clinically
Considered, • By Frank R. Fry.
9. Eye Syndrome of Dementia Praecox,
By H. H. Tyson and L. Pierce Clark.
2. The Scientific and Practical Value of Hos-
pital Interneship. — This is the last paper pre-
pared by tlie late Nicholas Senn, which was read
for him. In it he said that one of the most valuable
practical advantages of an interneship is the asso-
ciation of his colleagues. A noble spirit of rivalry
reigns in the little circle, a healthy stimulus for
hard, honest work. Books and medical journals are
read and their contents discussed. Cases and opera-
tions are made the subject of conversation at table
and during hours of leisure, and this way each in-
terne receives, to a certain extent, the benefits of
the entire service, and such intercourse is the best
possible preparation for their future work in medi-
cal societies. It is conducive to the development
of the gift of debate and a wholesome spirit of criti-
cism. Internes are attracted by medical societies,
and often enrich the meetings by the presentation
of cases and pathological specimens, thus filling in
many gaps in the programme with valuable material.
In this way the interne becomes at the very thresh-
old a contributor to medical literature and learns
the value of postgraduate education through the
medium of medical societies.
3. Tuberculin in Pulmonary Tuberculosis. —
Ringer remarks that tuberculin may be employed
in: I. All incipient cases, cases of closed tubercu-
losis in which ulceration has not taken place and
bacilli are not to be demonstrated in the sputum.
2. Uncomplicated, nonfebrile, first and second stage
cases. 3. Fibroid cases not running a febrile tem-
perature. 4. P^ebrile cases in which the temperature
does not drop under treatment by rest, and where
fever is due to the tuberculotoxine alone and not to
mixed infection. In such cases tuberculin should
be administered with the greatest caution, in the
most infinitesimal doses, with long intervals between
successive doses. 5. Advanced, third stage cases.
Tuberculin can here occasionally be used, not as a
curative agent, but to aid in relieving distressing-
symptoms. It will often relieve the tight, harassing
cough that is so exhausting, render expectoration
easier, do away with thoracic pain, and help to make
the patient more comfortable. In such cases its ad-
ministration sliould be most guarded and the do.sage
ver\ minute. The contraindications are given as
follows : I . Greatly emaciated or greatly weakened
individuals. The general body strength mu.st first
be raisefl bv rest and proper diet before such patients
will be able to su])plv those defensive forces which
tuberculin .stinnilates to action. 2. Third stage cases
with mixed infection. Those cases constitute the
most ab.solute contraindications to the use of tuber-
culin. In them a hypersu.sceptibility is easily ex-
cited, violent reactions are prone to occur, a general
aggravation of the symi)tonis may set in, and great
harm result. 3. H.-emorrhage : Hc-emoptysis oc-
curring during the administration of tuberculin is a
signal not for the iiermanent withdrawal of the
run OF CURRENT LITERATURE.
PITH OF CURRENT LITERATURE.
drug-, but for its cessation at once and until some
time after subsidence of all haemorrhagic symptoms.
4. Heart disease : A contraindication only if it is
feared that owing to possibility of reactions com-
pensation may be lost. 5. Marked increase in pulse
frequency, beginning and persisting during admin-
istration of tuberculin. 6. Marked loss of weight,
beginning and persisting during the administration
of tuberculin. 7. Complications : Diabetes, nephri-
tis, hepatic cirrhosis, hysteria, neurasthenia, epilepsy.
Of the results the writer remarks that patients tol-
erating increasing doses are not so prone to the
exacerbations and relapses exhibited by those not
so treated. More permanent cures have resulted
when tuberculin has been used than where it has
been omitted ; many patients running a slow but
steadily downhill course, in spite of open air treat-
ment, improve and get well under tuberculin. Tu-
berculin has a favorable effect on the chronic
toxjemia of tuberculosis, ^\■hich disappears under its
use to an astonishing degree. Cough and sputum
frequently cease, or persist greatly lessened in
amount. The conclusions the author draws are that
tuberculin is the most valuable adjuvant to fresh
air, rest, good food, we possess in the treatment of
pulmonary tuberculosis. It is indicated in manv
types of cases, and in the hands of a competent ad-
ministrator will do no harm. Reactions are often
overlooked ; they are not to be desired, and when
frequent or violent are distinctly harmful to the pa-
tient. The dosage should at first be infinitesimal ;
increase should be very gradual. Time and toler-
ance bring success in the treatment by means of tu-
berculin. Tuberculin should never be used save in
conjunction with strict hygienic and dietetic meas-
ures.
5. The Treatment of Placenta Praevia. —
Crossen states that three points are to be kept in
mind in the delivery of placenta praevia. i. The
dilation of the cervix must be gradual because of
the danger of serious laceration ; 2, there must be
compression of the bleeding area during this gradu-
al dilatation, to prevent dangerous haemorrhage : 3.
that method of deliver}- is to be chosen wliich gives
the best chance of saving the foetus, provided it does
not unduly jeopardize the mother. The cervix
should be dilated sufficiently to admit two fingers
for more accurate examination. In manv cases, par-
ticularly in multiparc'e, this slight dilatation may be
accomplished with the fingers, while in other cases
a dilator will be needed. This procedure enables
us to decide whether the case is one that will prob-
ably require only minor assistance in the process
of delivery, or one that requires radical interference
at once because of imminent danger to the mother.
Delivery is a serious procedure in most of these
cases and is accompanied with the danger of sudden
fatal haemorrhage. Consequently, the physician
should take care to provide the required assistants,
instruments, and materials to meet emergencies that
may arise. Two assistants are advisable — one to
attend to the anaesthetic and the other to assist the
operator and attend to the intravenous administra-
tion of saline solution if necessary. If the patient
is near a hospital she should be moved there. If
the bleeding is not severe, or has been checked by
-firm packing, the removal to the hospital with the
patient perfectly quiet on a stretcher is less danger-
ous than an attempted delivery, with its possible
serious emergencies, at the home.
6. Practical Value of Modern Conception of
Syphilis. — Schalek says that, although it was al-
ways stated that one infection of syphilis conferred
an absolute and permanent immunity, this was
never accepted universally. But the few reports of
reinfections could never be confirmed. It is known
at present that there is a period during the existence
of a chancre when multiple autoinoculations occur,
and that, furthermore, there is a time limit to the
protection conferred on an individual by his first
attack of syphilis, after which reinfection may take
place again. The diagnostic feature of one single
initial lesion of syphilis, as distinguishing it from
the multiplicity of chancroids, should not be relied
on any more. [Multiple syphilitic chancres have
been reported lately by Taylor and others, appear-
ing simultaneously or successively and in different
stages of evolution. F"inger's explanatimi of this
recurrence seems most rational : Immunitv begins
and develops gradually with the first appearance of
the primary lesion. It grows in intensity during the
secondary stage, but never becomes absolute. Af-
ter reaching its climax it again decreases in its po-
tency until a virus which may have remained latent
for a time can produce new pathological changes,
or an infection from outside sources becomes a pos-
sibility.
7. Treatment of Eclampsia. — Aloran observes
that if, in spite of vigorous treatment, the volume
of the urine is not increased, and the excretion of
urea remains stationary or diminishes, together with
persistence of menacing constitutional symptoms, it
will be necessary, particularly if the f«tus is viable,
to terminate the pregnancy. \Miile the aetiology of
eclampsia is still unsolved, its clinical phenomena
and pathologv point to a probable intoxication of
maternal, fcetal. or combined origin. Therefore,
sedation, elimination, and evacuation of the uterus
are the chief indications in the treatment. The
sedatives are valuable for their tranquilizing influ-
ence, while the deliverv is being promoted or ef-
fected by other direct measures. The result in a
given case will depend on the severity of the attack,
the judgment and skill of the physician, and the
rigid observance of asepsis. Essential t(^ success is
a well thought out plan of prompt but not over-
zealous procedure based on the Narirr.i- phases of
the disease, combined with a knowledge nf the con-
dition of the cervix and the changes which it must
undergo before pregnancy can term.inate or be termi-
nated.
9. The Eye Syndrome of Dementia Prascox.
— Tyson and Clark have examined the pupils in
eighty-five cases. The result of their examinations
is as follows: The findings indicate that dementia
prascox is attended bv such an early and constant
syndrome of alteration and disc, visual field, pupil
and corneal sensibility as to materially aid in diag-
nosticating this psychosis. Consideration of the
syndrome will particularly aid in the distinctive
diagnosis of dementia praecox from the manic de-
pressive group, acquired neurasthenia, hysteria and
the various forms of imbecility and constitutional
inferiority. The syndrome is a distinct contribution
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
to the theory that dementia praecox is an autotoxic
disease, and that the poison is primarily vascular,
which finally induces neuronic degeneration. It
points to a toxine of some sort, which is either a
metabolic defect in the tissues (ductless gland
defect) or. what seems more probable, that the poi-
son is generated in the liver or in the gastrointesti-
nal tract itself. The syndrome is of prognostic
value, as the severer grades of eye changes are
found in the more rapidly deteriorating cases. The
optic nerve lesion is quite in accord with our best
knowledge of the pathological anatomy of dementia
praecox, in other tracts of the brain (than the optic
nerve which itself may be counted an analogue).
The early vascular changes in the brain ought to
receive more serious investigation.
MEDICAL RECORD
May 2. igoS.
1. The Cancer Problem, By Eugene Coleman Savidge.
2. The Effects of Urban Congestion on Italian Women
and Children. By Antonio Stella.
3. The Fifth Nerve in Relation to Ophthalmic Conditions,
By Samuel Horton Brown.
4. A Piece of Catheter Voided During Urination.
By Walter S. Reynolds.
5. The Inunction of Iodoform in Tuberculous Peritonitis,
By Sidney F. Wilcox.
I. The Cancer Problem. — Savidge in his pa-
per calls our attention to the fact that the yeast
plant ferment was found to act on the left isomer,
while the ferment of the mold acted upon the right
solution. Elemental carbon exists as coal and as
diamond. There is a difference between laboratory
products and the substance derived from organic
compounds, that is. the natural organic products
rotate the polarized light either to the right or left,
according to quality, but always one way, to the ex-
clusion of the other isomer. There is a force that
will cure some cancers and cause some cancers.
The radial action of sun and ray is probably in the
direction of a cure when it acts repressively on the
noxious bacterial life. It is probably acting in the
direction of heat when it destroys our assimilative
and protective ferment. The author cites a case of
a syphiletic who was attacked with smallpox. Re-
covery from smallpox left the patient permanently
cured of his tertiary syphilis ; the explanation was
that the smallpox germ had killed the syphilis germ.
When an item or an aggregate of items restores
glandular activity, replaces the disturbed ferment
protection, restores the isomeric inteorit\ , that item
thereby cures cancer. The author concludes in say-
ing: A certain known, but not understood, "radial"
force can act upon products containing the asym-
metrical carbon atom to change their isomeric qual-
ity as shown by polarized light. That one force
can so act presupposes that other forces may so act.
The natural ferments contained in the secretions of
the body, digestive and protective, "digest" one
series of i.somers and leave the opposite series un-
touched. Therefore, the action of this occult '"radi-
al" force — this assailing of isomeric integrity — can
change protoplasm from digestibility to indigesti-
bility to the natural ferments, and vice versa. The
local cancer products consists presumably of
changetl isomers allowed to grow instead of being
"digested." This is made all the more probable by
the disappearance of the opsonic ferments in the
blood in all such diseases as have been subjected to
controlled observation ; and, specifically in cancer,
by the gradual suppression of the enumerated fer-
ments. These ferments — presumably — begin to
modify long before transition from the preliminary
to the final state called cancer. Therefore, even if
there is no change in isomeric quality, the secretion
suppression would explain the growth of the cancer
weed cells that effective ferments would have re-
moved. If there is no flaw in these significances,
the cure for cancer, as well as its prevention, lies in
the realm of synthetical medicine.
2. The Effects of Urban Congestion on Ital-
ian Women and Children. — Stella gives a great
amount of statistical material, and concludes with
the following words : Let us arrange for a better
distribution of the immigrants not after they have
reached Ellis Island, but before they decide to leave
their motherland, b}- informing them of the wonder-
ful resources of this vast continent, outside and be-
yond the large cities ; let us educate them to the
principles of hygiene and life, when the}- are set-
tled here, and above all, let us distribute the work
in appropriate areas outside of the city limits, so
that proximity of the factory should not be as it is
now, in a large percentage of the cases, the chief
reason for their congesting the cities. Let us. final-
ly, promote the building of model tenements at a
low rent that will not absorb thirty-three per cent,
of their income, and stimulate the philanthropy of
the rich in this direction, and when we shall have
given the pleople clean, healthy homes, full of light
and sunshine, we shall have accomplished the physi-
cal and moral regeneration of the masses ; we shall
have given them that to which every human being
is entitled, health and happiness.
BRITISH MEDICAL JOURNAL.
April 18, 1908.
1. Some Observations on Bronchitis and Emphysema,
By Sir J. B.\rr.
2. The Physiological and Pathological Effects which Fol-
low Exposure to Compressed Air (Arris and Gale
Lectures), By Major Greenwood, Jr.
3. Primary Pneumococcic Peritonitis, By A. Curr.
4. Observations on the Rectal Temperature after Muscular
Exercise, By M. Fl.\ck.
5. Calmctte's Ophthalmoreaction. By T. H. Butlek.
6. A Note on the So Called Stimulating Effect of Alcohol
on Protoplasm, By W. H'. Kesteren.
I. Bronchitis and Emphysema. — liarr, after
discussing the aetiology and pathology of bronchitis
and emphysema, has the following to say as regards
treatment. R>-oi>chitis. The patient should be
hardened and protected against the injurious influ-
ences of cold, dust, microorganisms, irritating gases,
etc. He should live as far as possible in a pure, dry
atmosphere which, at least during the acute stage
of the disease, should be warm. Every person with
a liabilitN to bronchitis should for.swear the use of
alcohol in all its forms. It is one of the most fre-
quent causes of chronic bronchitis and is never use-
ful in treatment. When bronchitis is secondary to
other diseases, the treatment is chiefly symptomatic.
When it arises, as is frequently the ca.se. from di-
gestive disturbances, attention should be specially
devoted to the stomacii and bowels. As a rule the
carbohydrates and fats should be cut down, a liberal
allowance of nitrogenous food being granted. The
May 9, 1908.]
PITH OF CURRENT LITERATURE.
diet should not be too liquid, though a fair amount
of hot water may be given. If there is any defi-
ciency of lime salts in the blood, which is often the
case when the expectoration is free and albuminous,
a moderate amount of milk should be given, also
gelatine. But where the expectoration is scanty and
tough with bronchial spasm and rales, milk and
gelatine should be avoided, the lime salts being in
excess. Sodium chloride, which has a high osmotic
equivalent, should be restricted. A good emetic is
often an excellent preliminary treatment, and in all
cases the bowels should be well cleared out with
calomel or sodium sulphate. As a rule the fewer
drugs used the better. Ammonium carbonate is
certainly injurious in the early stages of the dis-
ease. Antimony and compound tincture of cam-
phor with ipecac, are excellent remedies. If there
is bronchial spasm and tough expectoration, decal-
cifying agents such as the citrates of potash and
soda should be used, while on the other hand, where
the expectoration is profuse and albuminous, cal-
cium lactate should be given. In bronchial spasm
the nitrites are very valuable, and potassium iodide
is an important adjunct. When the acute stage
has passed, tonics such as strychnine and quin-
ine should be given. Counterirritation is often ex-
tremely valuable, the writer preferring mustard
poultices. Emphysema. What has been said of
lironchitis applies largely to emphysema. The treat-
ment should be chiefly dietetic and hygienic, and
prevention is always better than cure. The patient's
appetite is frequently too good, he is stout and
plethoric, and thus there is a demand for more oxy-
gen than the lungs can supply. Moreover the ple-
thoric and cyanotic conditions lead to congestion
of the lungs,- greater respiratory eft'orts are made,
and the emphysema is increased. The patient should
be starved as much as possible. This is usually diffi-
cult, but at any rate the fats and carbohydrates
should be diminished. The thin, spare patient does
best. Too much table salt should be prohibited, but
plenty of fruit and a fair amount of green vege-
tables can be allowed. The patient should live in
a dry, warm atmosphere, and should practice respir-
atory gymnastics, being taught how to expire rather
than inspire. Comparatively few drugs are of any
value, the most generally useful being the iodides.
Thyreoid extract may be added if there is any defi-
ciency in metabolism. If there is much cough,
opium must be used.
3. Pneumococcic Peritonitis. — Cuff states that
it has been established beyond all doubt that cases
of peritonitis occur in which most careful search,
both ante and post mortem, fails to show any prim-
ary lesion in any abdominal viscus. The cause of
many such cases is the pneumococcus. Pneumo-
coccic peritonitis is at all times uncommon. It is
most often met with in children, being extremely
rare in adults. It may be dififuse or localized in the
form of an intraperitoneal abscess. Onset is sudden
with severe pain, the previous health having usual-
ly been good. The cour.se of the disease is very
rapid : free fluid in the abdominal cavity is an early
sign. The pus is peculiar in that it always con-
tains a larere quantity of coagulated lymph like
curdled milk. The writer reports a series of five
cases from which he draws the following conclu-
sions:— I. That an acute diffuse or localized peri-
tonitis may be the sole symptom of a pneumococcic
infection. 2. Such cases possibly form a consider-
able proportion of those anomalous cases of peri-
tonitis without visible lesions of any of the abdo-
minal viscera. 3. Their sudden onset after pre-
vious freedom from abdominal trouble, together
with the frequent accompaniment of diarrhoea, and
signs of early systemic poisoning, may perhaps
serve to assist in differentiating them from periton-
itis caused by other infection. 4. They may be fol-
lowed by pneumonococcic lesions in other organs of
the body. 5. Their prognosis is extremely grave.
5. Calmette's Reaction. — Butler has carefully
investigated the so called ophthalmoreaction for
tuberculosis as introduced by Calmette. He con-
cludes that it is a safe and simple practical test that
can be used by the general practitioner, and that
it does not inconvenience the patient. It is a very
useful aid to diagnosis, but occasionally the results
are equivocal. The patient's eyes must be carefully
examined and the condition noted in a book. It is
essential that there be no preexisting conjunctiv-
itis, for the reaction would then be masked. One
or two drops of the solution must be instilled into
the lower cul-de-sac and the eye held open for a few
seconds. If the subject is tuberculous the eye will
begin to redden in about three hours, and lacrima-
tion will be complained of. At about the sixth hour
the caruncle begins to swell, and there may be a
slight fibrous exudation which gathers in filaments
in the lower conjunctival sac. The reaction reaches
its maximum in from six to thirteen hours ; there is
no rise in temperature and no general malaise. The
inflammation may var}- in degree from slight lacri-
mation and an almost imperceptible enlargement of
the caruncle to a severe conjunctivitis which may
last for several days or even for weeks. But there
is little danger to the eye unless it be affected with
tuberculous disease — a rare condition. The inten-
sity of the reaction bears no relationship whatever
to the severity of the tuberculous process. Every
case of obvious tuberculosis tested by the writer
gave the reaction, and only one slight reaction was
observed in an apparently healthy mdividual.
LANCET,
April 18, igo8.
1. The Anatomy of the Long Bones Relative to Certain
Fractures (Hunterian Lectures, I),
By R. Thompson.
2. The Pygmy and Negro Races of Africa (Hunterian
Lectures, III), By F. C. Shrubsall.
3. Observations on Blood Pressure, Chlorine Retention
and Dechlorination, Hyperacidity, and Variations in
the Starch Ration, By H. Higgins.
4. The Epidemiolog\- of Diphtheria in the Light of a Pos-
sible Relationship between the Diphtheritic Affec-
tions of Man and Those of the Lower Animals,
By L. W. Sambon.
5. A Case of Cavity of the Lung Successfully Treated
with Ozone, By G. Stoker.
6. .A.nterior Dislocation of the Sternal Ends of the Clavi-
cles : Treatment by Fracture of the Clavicles with
Good Results, By T. H. Middlebro'.
I. Fractures of the Long Bones. — Thompson,
in the first of his Hunterian lectures, discusses frac-
tures of the neck of the thigh bone, dealing espe-
cially with the anatomy of the bone itself. In the
ends of the bones of an ordinary adtilt man there
9IO
PITH OF CURRENT LITERATURE.
are developed definite lamellc-e running in the main
direction along which pressure is iransmitted. Cer-
tain other lamellje are also developed, gradually
crossing these i)ressurc lamellje at right angles.
These are known tension lamellje. Their pres-
ence generally increases the elasticity and therefore
the strength of the bone. In the young person, as
well as in the old, these pressure lamelL-e are not
well seen, nor are the tension lamellae. In the
young person the cancellous tissue at the ends of
the long bones is so dense and the meshes are so
fine that the pressure and tension lamelte can hard-
ly be demonstrated. In the old person the bone
fibres are so obscured by the presence of fat that
they are \ ery difficult to discover. Relatively large
masses vt tat develop in the part of the bone which
is least subject to pressure. Fractures of the neck
of the thigh bone have perfectly definite causes, the
statement of which depends to a large extent upon
the knowledge of the internal structure of the ui)per
end r)f the femur. Xow, in addition to the two series
of lamelhe. tliere is a third series, which pass from
the upper surface of the head to the lower surface
of the neck, and thus to the compact layer on the
inner surface of the shaft of the femur. This layer
or spur of bone is known as the calcar femorale, or
MerkeKs or Adam's arc, is a nearly vertical ledge of
compact bone. It does not always disappear in old
age, but, on the other hand, it is not invariably
present, even in young people. The calcar in ex-
tracapsular fracture of the neck of the femur is re-
sponsible for the edge and lower end of the clusel.
whose other parts are represented by the head and
neck of the femur. -The calcar certainly produces
the vertical secondary fracture of the great tro-
chanter and upper part of the shaft of the femur,
and may be held partially responsible for the hori-
zontal secondary fracture near the base of the great
trochanter. In intracapsular fracture of the neck
of the femur the pressure starts from the front of
the upper part of the neck. If the patient is in
the flexed position when the accident happens, the
ligamentum teres is not strong enough to resist the
sudden force which is put upon it, and so it may
be eitlier stretched or ruptured. The anterior sur-
face of the neck of the femur then comes into forci-
ble contact with the corres])on<ling part of the
acetabulum, and the fracture is begun. The line of
fracture then passes for some distance in a trans-
verse direction along the neck until it meets with
the lamellc'e coming down from the anterior u])])L'r
surface of the head of the femur to the i)ostcrior
and under surface of the neck of the same bone, and
is by them deflected so as to form either a posterior
or an infericjr tongue of bone.
4. Epidemiology of Diphtheria. -- ."-"anibiMi
calls attention to the wides])rcad prevalence among
animals of diphtheria, or, at any rate, of a disease
resembling diphtheria, and caused bv microorgan-
isms apparently morphologically identical with the
Klebs-Lofller bacillus. That diphtheria may be
conveyed from the lower animals to man. and vice
versa, is a very old and general belief. The simul-
taneous occurrence of diphtheria ejjidemics in man
and of epizootics of a similar nature in animals has
been observed again and again in all ages and
places. Human diphtheria bacilli inoculated into
[New York
Medical Journal.
susceptible animals produce the disease, and our po-
sition is very much the same as in tuberculosis,
where two forms of tubercle bacilli ( the human and
the bovine) are recognized. And it is generally held
that bovine tuberculosis can be and is transmitted
to man, and humaii tuberculosis to animals. The
writer holds that the conveyance of diphtheria by
means of milk and eggs would explain the great
frequency of the disease in young children, because
their food consists almost entirely of these two arti-
cles given raw or almost raw. It is probably by
means of these foodstuffs that the disease is brought
into towns, although, of course, it may also be in-
troduced by infected human subjects or by infected
animals, especially birds, such as pigeons and spar-
rows. The pigeon is quite common in the parks
and squares of large cities, and it is quite conceiv-
able that horses and sparrows contract the disease
from them. The cat, a natural enemy of the spar-
row, mav contract diphtheria from that bird, which
is likely to fall an easy prey when paralyzed by the
disease. The role of the cat in connection with
diphtheria is of great importance. This animal,
after prowling in field and gutter, has access to the
bedroom and sleeps on the bed with and is fondled
by the children. Cats have been noticed to suffer
simultaneously with man in almost every outbreak
of diphtheria. But in diphtheria, as in plague, one
particular kind of animal seems especially concern-
ed in the wider spread of the disease. In plague
the rat, owing to its wide distribution, its great
numerical prevalence, its close association with
man, and, above all, its migratorial habits, is the
true cause of the great pandemics which at various
intervals desolate the world. In diphtheria proba-
bly a similar role is played by the pigeon.
BERLINER KLINISCHE WOCHENSCHRIFT
March 30, IQOS.
1. The Syniptomatology and Treatment of Tumors of the
Cerehellum. By E. Siemeklixg.
2. Concerning the Practical Importance of Opsonins,
By JURGENS.
3. The Efficiency of Pepsin and a Simple Method for hs
Estimation, By Oskar Gross.
4. The Action of the X Rays upon Ferments.
By P. F. RiCHTER and Gerh.\rtz.
5. Operatiyc Treatment of Diffuse Purulent Peritonitis,
By KOTZEXBEKG
6. Contrihutions to the Surgery of the Brain and Spinal
Cord { Cdiitinucd) . By Herm.\nn Kuttnek.
7. Insects and Ticks as Disease Carriers to Men and
Animals. By Moei.lers.
2. Practical Importance of Opsonins. — Jiir-
gens considers that the opsonic index must not be
relied on too much, but that when it is used carefully
and criticalh in the clinicoi^athological syndrome it
can give the observer ? great deal of help.
4. Action of the X Rays on Ferments. — Rich-
ter and (ierhartz have instituted a number of ex-
periments the results of which go to show that the
ferments are affected in no way by the x rays. Some
writers have ascribed an excitant, others a restric-
tive action on ferments to the x rays, but these
would seem to be erroneous observations, or at
least to rest on very insecure foimdations.
5. Operative Treatment of Diffuse Purulent
Peritonitis. — Kotzenberg includes inider diffuse
peritonitis only that form in which pus is present
May 9, igoS.]
PITH OF CURRENT UTERATL'RE.
911
throughout the entire abdomen, the serous covering
of the intestine exhibits evident signs of peritonitis,
and ihere are large accumulations of pus not only
in the pelvis but also below the liver and the spleen.
He considers that the principal points of the ration-
al treatment of such a condition are drainage by
means of the tampon drainage of Dreesmann. res-
toration of the intraabdominal tension by accurate
suturing of the abdominal walls in three layers, leav-
ing an opening exactly large enough for the glass
drain in the lower angle of the wound, thorough
irrigation of the abdominal cavity with salt solution
of the proper temperature, which is not removed
but allowed to remain in the cavity, and the main-
tenance of the patient in an oblique position. Par-
ticular care must be exercised in the renewal of the
tampons in the glass drain.
6. Contributions to the Surgery of the Brain
and Spinal Cord. — Kiittner in this number gives
the details of four cases. (3ne of myelitis and
myositis ossificans after measles, one of successful
removal of a round cell sarcoma from the left fron-
tal lobe, one of extirpation of a round cell sarcoma
from the anterior central convolution followed by
death, and an exploratory operation for a tumor of
the brain which was not found.
LA RIFORMA MEDICA,
March 23, jgo8.
1. On Experimental Typhoid Infection in Goats,
By Umberto G.\bbi.
2. On the Operative Treatment of Facial Neuralgia by
Tansini's "Method. By Stephano D'Este.
3. On Adenoma of the Liver. By O. D'Allocco.
4 On a Case of Anencephalus Caused by Dystocia,
By A. Bussi.
I. Experimental Typhoid in Goats. — Gabbi
studied typhoid infection experimentally in goats,
and reports his results in a preliminary communi-
cation. It has been known for some time that the
milk of tuberculous cows is capable of carrying tu-
berculosis to human beings, especially to children.
Malta fever is now known to be transmitted through
the milk of goats. Researches carried on bv the
author and his pupils in Sicily and Calabria have
shown that not only ^Maltese goats, but also goats
from the regions mentioned carry Malta fever
germs, and transmit the disease through their milk
Avithout showing any revealing sign which would
enable one to distingitish these goats clinically from
uninfected animals. The author furthermore noted
within the last three or four years that there were
many more typhoid patients admitted to the clinic
than patients with Malta fever, and it occurred to
him that, possibly, the milk of goats may transmit
typhoid infection. Fiorentino, a pupil of Gabbi.
who was looking for Malta fever in goats, found, in
the course of his investigation, that there was a
typhoid epidemic in a locality m which six per cent,
of the goats were found infected with typhoid. He
therefore believes that the milk of goats may be a
possible carrier of typhoid infection, and in order
to determine this he proposed to find out whether
goats are really susceptible to infection with the
t\ phoid bacilhis. whether in these mammals experi-
mental infection ma\ be transmitted through the
milk, and if so. whether the milk of goats may carry
the disease to himian beings. The restilts of the in-
vestigations thus far indicated that the injection of
virulent typhoid bacilli in goats produced a brief
rise of temperature, and that these bacilli were elim-
inated through the milk of the animal for several
days after the fever had disappeared. The VVidal
reaction was present in the goats, and could be
fotind on several days after the disappearance of the
fever. The goat, as in the case of Malta fever,
seems to remain indifferent, practically, to the
typhoid infection which passes through it. The milk
of these infected goats showed no change save the
presence of the bacilli.
March 30, 1908.
1. A Case of Acute Aortic Insufficiency of Traumatic
Origin, By Umberto Deganello.
2. Contribution to the Study of the Pathogenesis of
Cystic Kidneys {To be continued) ,
By DoMEMCo Taddei.
3. The Filtrability of Human Vaccine Virus.
By Oddo Cas.\grandi.
I. Traumatic Insufficiency of the Aorta. — The
case reported by Deganello was that of a man. aged
thirty-five, driver, who had been well until the day
of the accident, which consisted in a severe crush-
ing injury of the thorax, especially of the precor-
dial region. After the accident there were severe
cardiac symptoms for a time, but the patient lived,
and a month later presented the evident signs of a
cardiac lesion. There was dyspnoea, cyanosis, signs
of pulmonary congestion, slight palpitation, etc. On
examination there were found a noteworthy hyper-
trophy of the left ventricle and an intense diastolic
murmur, which had a musical quality and was heard
especiallv over the aortic region. The pulse was
bounding. The symptoms of loss of compensation
went on progressively and rapidly, and the patient
died five months after the accident. At the autopsy
it was found that the two anterior aortic valves were
tort! for a certain distance from their line of inser-
tion, so that they did not close completely. There
was also a dilatation of all the cardiac cavities, espe-
cially of the left ventricle, which was also hyper-
trophic. On histological examination of the valve it
was found that some new connective tissue had
formed in it in an attempt to heal the laceration.
The author urges the necessity of microscopical ex-
amination in such cases, as only by this means can
we prove the traumatic origin of the lesion.
ROUSSKY VRATCH
March 75. IQ08.
1. On the Presence of Sulphurous Add in Dried Fruil
from California, By S. .A. Przhibytek.
2. A New Method of Gastrointestinal Anastomosis,
By A. N. ZiMiNE.
3. On the Relation of .Addison's Disease to Chronic
Malaria. {To be concluded). By G. A. Lubenetski.
4. The Indications for and the Technique of Prostatectomy,
By B. N. Kholtsoff.
5. Hematoma of the Vagina and External Genitals,
By S. S. Kholmogoroff.
6. A Case of Meningitis of Otitic Origin.
By A. B. Kaplan.
7. Materials for the Pathology of Pityriasis Rubra
Pilaris {Concluded). By Z. V. Sovinski.
8. On Pseudoappendicitis {Concluded),
By B. P. Kester.
I. Sulphurous Acid in California Dried
Fruit. — Przhibytek examined fifty-three samples
912
PITH OF CURRENT LITERATURE.
[New York
Medical Journai..
of various dried fruit in which he found a consid-
erable quantity of sulphurous acid. These various
fruits had been imported to St. Petersburg from
California. There is no law in Russia preventing
the use of sulphurous acid for the preservation of
fruit products. There is such a law, however, in
Germany. The author advocates the passage of
such a law. The medical council of the Empire, on
February 26th, decided to forbid the entrance into
Russia and the sale of dried fruit from America.
AMERICAN JOURNAL OF SURGERY.
March, igo8.
1. The Significance of Abdominal Tenderness in Locating
Lesions of Viscera, By T. C. Witherspoon.
2. The Induction of Premature Labor in Amaurosis and
Amblyopia, in Connection with the Albuminuria of
Pregnancy, By Thomas R. PooLEy.
3. A Use of the Automobile in Surgical Practice, with
Report of an Illustrative Case, By W. B. Reid.
4. Postoperative Treatment of Adenoid Patients,
By Bryan de F. Sheedy.
5. Blood Examination in Surgical Diagnosis. A Practical
Study of Its Scope and Technique (Continued),
By Ira S. Wile.
6. A Case of Stricture of the CEsophagus Treated by Gas-
trostomy and Retrograde Dilatation by Ochsner's
Method, By F. W. Parham.
7. Report of a Case of Ununited Fracture of the Shaft of
the Humerus and Paralysis of the Musculospiral
Nerve, By Duncan Eve.
I. Abdominal Tenderness. — Witherspoon re-
marks that the location of tenderness undoubtedly
is a most valuable aid in arriving at a diagnosis. It
is a fact that a viscus usually lies directly under
that part of the abdominal wall which is innervated
by somatic nerve fibres coming off from the same
spinal seginent as the nerve fibres which supply the
viscus. This is due to developmental shifting, in
like degree, of the splanchnic and somatic struc-
tures. It may, therefore, be argued by one, that
the tenderness is located in the viscus, and by an-
other that it is in the parietes. The location, never-
theless, bears an important relation to the viscus
involved rcganlless of the actual seat of tender-
ness. One of five general conditions may be sig-
nified by abdominal tenderness: i, A lesion of an
abdominal viscus ; 2, a lesion of the wall ; 3, a lesion
of a viscus outside of the abdomen awakening ten-
derness in the abdominal wall ; 4, a central nervous
lesion or one which im])licates nerve trunks sup-
plying the abdominal wall ; and 5, a systematic
disorder accompanied by abdominal pain and ten-
derness. The degree of sensibility of different indi-
viduals varies greatly in the normal. One remains
practically comfortable under rough handling, while
another objects to the mildest pressure. It is al-
ways well to note the general sensibility of a pa-
tient before proceeding to obtain evidence of a local
increase of sensibility. It has probably happened
time and again that the first touch of the cxaininer
has called forth an expression of discomfort and
led to a premature announcement of "appendicitis,"
"gallstone disea.se." or "pelvic inflammation." In
commencing tf) i)alpate always begin upon an area
least susi)ected of harboring disease. This gives
an idea of the normal response; moreover, the pa-
tient is placed off guard and when the tender area
is approached the muscles are not fixed guarding
against |)ain.
4. Postoperative Treatment of Adeniod Pa-
tients.— Sheedy emphasizes the following points
in postoperative treatment of adenoid patients: i.
Keep children in bed for from two to three days
after operation, and away from other children. 2.
Keep parts clean by use of alkaline washes and
medicated mentholated oil solution. 3. Use con-
stitutional and reconstructive medication. 4. See
that thoracic gv'mnastics are practised for a long
period. 5. Zinc oxide plaster over the mouth at
night to keep the mouth closed until normal breath-
ing is established. 6. Watch for return of the
growths.
THE JOURNAL OF NERVOUS AND MENTAL DISEASE
April, 1908.
1. Hysteria in Children, By John Jenks Thomas.
2. A Contribution to the Pathogenesis of Some Epilepsies.
A Preliminary Contribution,
By Smith Ely Jelliffe.
2. A Contribution to the Pathogenesis of
Some Epilepsies. — Jelliffe remarks that it is prac-
tically conceded that there is more than one epilepsy.
Clinically we recognize the classical forms of grand
mal, petit mal,' psychical equivalents, etc. ; forms that
dement rapidly, which are in marked contrast with
those that do not. Pathologically a multiplicity of
alterations have been described, all tending to show
that different processes are active, ^tiologically a
similar variability of factors is observable. There
are the epilepsies following an acute poison of some
nature ; usually the toxine of an acute infectious dis-
ease. The epilepsies so prone to follow scarlet fever,
measles, diphtheria, whooping cough, streptococcus
infections, and influenza offer the most striking ex-
amples. While it is yet uncertain what are the affini-
ties or perhaps lack of affinities of the poisons of
these differing infectious diseases, and their relation
to other poisons, it has been amply demonstrated by
a number of workers in pathology that alterations in
the character of the blood and changes in the walls
of the bloodvessels throughout the body are very
characteristic, and it is not a far cry to apply the
knowledge of such study on vascular alterations to
such changes in the brain. Minute haemorrhages,
capillary thrombi from agglutination, endothelial al-
terations are the precursors of the more extensive
and permanent glia alterations, made necessary b\'
the general phagocytic activity of these connective
tissue elements. Having had under observation a
striking example of poisoning by santonin in a
yoimg child, with the production of a permanent epi-
leptic state, Jelliffe made some experimental studies
with this substance, in order to gain some informa-
tion concerning its action on the cortex of lower ani-
mals. He concludes that following santonin poison-
ing there results a definite cellular alteration in the
ganglionic areas of the psychomotor area, with death
and destruction. This accounts for the profound
functional disturbances resembling epileptiform con-
vulsions. That as a result of chronic poisoning by
the same substance a definite form of neuronophagia
is demonstrated, which by inference from the many
studies bearing on this subject, may be interpreted
as a forerunner of a glial infiltration. Whether this
latter will be found in his specimens the author can-
not yet say. Should such be the result, it would
afford excellent evidence for a more definite under-
standing of the cellular mechanisms which lead t(.
the gliosis of many chronic epilepsies.
May 9, 1908.]
PROCEEDINGS OF SOCIETIES.
MEDICAL ASSOCIATION OF THE GREATER CITY
OF NEW YORK.
Special Meeting, Held on February 3, 1908, at_ the Staten
Island Academy, St. George, Borough of Richmond.
Dr Henry C. Johnston in the Chair.
{Concluded from page 871.)
The diagnosis having been made, the most impor-
tant point in the treatment was rest. The securing
of this, he said, would depend upon the part affect-
ed, on the means at hand, and partly on the skill of
the surgeon in the use of different forms of treat-
ment. If the upper extremity was involved, a plas-
ter of Paris splint taking in the joint on each side of
the affected one would probably be the most efficient
device. In disease of the spine the great majority
of patients did better if allowed to go about, but if
an abscess was forming, the temperature running
high, the deformity increasing, or paralysis begin-
ning, the patient should be kept quiet and not al-
lowed to stand. In such cases the wire cuirass, with
a head support to exert traction on the spine in its
long axis, was the most suitable appliance. This
must be so shaped as to exert a corrective influence
on the curvature, if one was present, and, if the dis-
ease was in the upper dorsal region, an apparatus
such as Whitman's shoulder support should be em-
ployed to avoid the forward reaching of the shoul-
ders which tended to curve the spine. In the cuirass
the patient could be carried out of doors and receive
the benefits of fresh air, sunshine, and diversion. This
method of treatment was especially available in
young children. For ambulator}- cases the plaster of
Paris jacket (with a jury mast if the disease was
high seated) or the Taylor posterior support was
applicable.
In disease situated in the lower extremity a splint
combining traction with fixation was superior, ac-
cording to Dr. Sayre's experience, to either the plas-
ter of Paris splint or the Thomas splints for knee
and hip. The removal of weight bearing was essen-
tial, and the particular method employed to give rest
to the inflamed joint was not of much importance,
provided it actually did aftord rest, and not a pre-
tense of it, as was often the case when a loose and
short envelope of plaster of Paris was put around
the knee, and the patient allowed to walk about.
The second principle in combatting bone tubercu-
losis was to increase the vitality of the patient as
much as possible. Fresh air and sunshine were vital,
and one of the most powerful arguments in favor of
treatment by apparatus, as opposed to bed treat-
ment, was the opportunity which this aiforded for
these essentials while the patient was wholly or par-
tially ambulatory. Caged animals were prone to be
affected with tuberculosis, and the same was true of
caged human beings. While the necessity of fresh
air in abundant amount had long been recognized in
pulmonary tuberculosis, in tuberculosis of the bone
this had not been insisted upon as it should have been
until very lately. Fresh air, not merely for one or two
hours a day, but for the whole twenty-four, was the
proper quantity, and to secure this it was not always
necessary for the patient to go to a country resort.
Opening the windows was one way to get fresh air ;
yet most persons seemed to think that in order to
obtain it one must go out of doors. Many main-
tained that it was essential that the air should be
cold, but the speaker believed that its temperature
was not of special importance, and that excessive
cold was quite unnecessary. As sunlight was essen-
tial, as well as fresh air, the patient, if he could not
go out or be placed in the open air, should occupy a
room with a southern exposure. Feeding was an-
other essential, and, as the appetite was often capri-
cious in these cases, five or six meals a day might be
required in order that the proper amount of nourish-
ment should be received. As both the appetite and
digestion were greatly improved by diversion of
the mind, this was a point which should always re-
ceive attention. Overfeeding, however, was to be
guarded against, and a dose of calomel might be re-
quired from time to time to clean out the alimentary
canal. Many observers believed that by the long
continued use of guaiacol or guaiacol carbonate the
fermentation processes so often seen in the digestion
of tuberculous patients were lessened, and the nutri-
tion thereby improved.
In addition to these well recognized methods of
raising the vital resistance, it had been suggested
that the patients should be treated with an antibac-
terial serum, and for this purpose the new tuberculin
(T. R.) of Koch and the Marmoreck serum had
been employed. At the present time, however, our
knowledge of the possibilities of this treatment was
extremely small. A number of observers had re-
ported certain- effects, but they had not been con-
vincing, and up to the present time the results of
serum injection in bone tuberculosis were of more
academic interest than practical utility.
The treatment of the abscesses which occurred in
a large percentage of cases was most important, and
one measure which the speaker had found of great
value in properly selected cases was the use of the
actual cautery. Before opening one of these tuber-
culous abscesses it should be borne in mind that in
the vast majority of instances such an abscess led
up to a sequestrum somewhere in the bone, and that
it might be extremely difficult to follow it to its
source and thoroughl\- remove all the diseased tis-
sue. Unless this could be done the door would be
laid open for the infection which it was so impor-
tant to prevent. If the abscess did not interfere with
the application of an appropriate brace, it was better
not to interfere with it, certainly early in its history.
Later on, these collections of tuberculous matter
seemed to wall themselves off from the bone where
they originated, and in such old abscesses, or at an
earlier period if the abscess showed a tendency to
become infected, it might be wise to evacuate it
through a small incision. Care should be taken to
injure the abscess wall as little as possible, and after
a thorough washing out with sterile normal salt so-
lution the incision should be closed without drainage.
In some instances this incision would heal, but in
others it would break down later on, and in subse-
quent dressings very careful attention would be re-
quired to prevent the tract from becoming infected.
In the majority of cases the cavity left by the re-
moval of carious bone or a sequestrum, if thoroughly
cleansed, had better be left to fill with blood. If it
914
PROCEEDINGS OF SOCIETIES.
[\e\v Vork-
.Mf.DICAL loURNAL.
was clean, new bone would soon be organized, and
supplant the blood clot, while, if it was not clean,
suppuration would follow. It was advisable to avoid
resection of tuberculous joints, if possible, but in ex-
ceptional instances (as where the circumstances of
the patient rendered it impossible for him to submit
to a prolonged course of treatment — lasting perhaps
two years) this became necessary, and recovery took
place with a stifif joint. In speaking of the local
hyperremia treatment of Bier, designed to improve
the nutrition of the part. Dr. Sayre said that the
time required for treatment did not seem to be short-
ened by this procedure. If it was resorted to. he
thought that in connection with it proper mechanical
support should be employed. The whole aim in the
treatment of bone tuberculosis was to cut the disease
as short, and to cause as little destruction of tissue,
as possible.
Meeting of February 17, 1908.
The President, Dr. Tho.m.vs E. Satterthwaite, in the
Chair.
The Late Dr. Loomis. — The committee on the
death of Dr. H. P. Loomis (Charles H. Knight,
M. D., chairman) reported as follows:
The .Medical Association of the Greater City of
Xew York is called upon to record, with deep re-
gret, the loss of one of its early members and a fre-
quent contributor to its proceedings, Henry Patter-
son Loomis, who died at his home in this city on
December 22, 1907. He was born in New York in
1858, the son of a father well and widely known as
a medical author, practitioner, and consultant. He
in.herited many qualities of mind and heart which
endeared him to his friends and enabled him to
achieve distinction in his profession. He was grad-
uated from Princeton University in 1880, and took
his medical degree at the Medical Department of
the University of the City of New York in 1883.
He was an attending physician at Bellevue Hos-
pital and until recently at the New York Hospital.
For several years he held a professorship at the
University Medical College, and at the time of his
death was professor of materia medica, therapeu-
tics, and clinical medicine at Cornell Universit\-
Medical College. He was a facile writer, a success-
ful clinician, and an apt teacher. His death in the
l^rimc of life, and with many years of usefulness
before him, is a source of profound sorrow to a
wide circle.-
The Death of Dr. R. W. Taylor.— The commit-
tee on the death of Dr. Robert W. Taylor ( Edward
1). Bron.son, M. D., chairman) presented an elabor-
ate report, which was in part as follows:
It is wholly fitting that a halt should be called
in our proceedings to do reverence to the memory
of one of the most distinguished of our members.
To us was rendered what was probably his last pub-
lic service in that domain of medicine in which his
life work was mainly engaged. Even then, ham-
pered as he doubtless was, and with something of
his old time vigor abated, through the encroach-
ments of the fatal malady to which he shortly after
so suddenly succumbed, there was still in evidence
that sincerity of purpose, zeal, and earnestness which
had always characterized the si)irit of his work.
Though chiefly preeminent in the field of that most
intricate and absorbing of all the enigmas of medi-
cal research, syphilis. Taylor's name was also fam-
ous for signal services looking to the relief of those
other ills of erring flesh — the hideous progenv of
lust and folly. Through the welter of these afflic-
tions of humanitv. involving, as they do, the inno-
cent as well as the erring, he waged a lifelong com-
bat; seeking the roots and remedies of evil, and
bearing aloft the torch of hope. Nor did these
Augean labors limit the range of his activities. Be-
ginning at a time when more than now were asso-
ciated in a common specialty both venereal diseases
and the general aft"ections of the skin, his interest in
and contributions to dermatology were most valu-
able, and occupied him to the end. The list of his
published works in these fields of research is an ex-
tensive one. They have had great influence in the
medical world, and a considerable number of them
were translated and published in foreign tongues.
. . . Beside his literary labors should be placed
his long service at Charity (now the City) Hospital,
where he trod in the footsteps of those earlier mas-
ters, \'an Buren and Bumstead. together with his
public teachings as professor in the chair of either
venereal or skin diseases, first at the Woman's Medi-
cal College, later at the College of Physicians and
Surgeons and also at the University of X'ermont. In
all of these labors his work was indefatigable, thor-
ough, and conscientious. With a catholic spirit he
combined the temper of the conservative.
But, while acknowledging the intellectual achieve-
ments, let us not forget the amiable (jualities of the
man. By nature impetuous, while sometimes hasty
of speech and on occasion resentful of real or fan-
cied injuries, Taylor was a loyal friend and an agree-
able man to meet. In his manner, with its air of
cordiality, cheeriness, and bonhomie, there was a
something that savored of a personal compliment.
He liked to be liked, as in his home life he loved to
be loved. The pity of it is that in his home, where
all should have been hap]3iness and content, one deep
shadow of affliction succeeded another, 'till in his
latter days lonely grief tinged his life with sombre-
ness and doubtless accelerated its end. So. in our
acclaim over the triumphs of an accomplished
career, a successful life, there intrudes the note of
pathos, an undertone ot sympathetic regret. Peace
to his ashes ! Lasting honor to his shade !
Resolution on the Retirement of Dr. Satter-
thwaite. — The following preamble and resolu-
tion, presented by the recording secretary. Dr. P.
Brynberg Porter, were adopted:
The Medical Association of the Greater City of
New York desires to record its high appreciation of
the services rendered the society during the past
four years by Dr. Thomas E. Satterthwaite, now
retiring from the presidency. Dr. Satterthwaite has
by his self sacrificing and unremitting labors jilaced
this association on a level of scientific achievement
which it had not previously attained. He has suc-
cessfully carried out the plan of presenting in turn
the latest research and practical work in all the
various departments of medicine and surgery, and
this has been done by the ablest exponents of the
subjects treated of, not only in the different bor-
oughs of New York, but in I 'hiladeliiliia. Washing-
May 9. 1908. 1
PROCEEDINGS OF SOCIETIES.
ton, Baltimore, Boston, Albany, Buffalo, and other
cities. So admirably has the high aim sought been
accomplished that the programmes of our monthly
meetings have excited unusual attention and have
been universally admitted to be of a scientific excel-
lence and value seldom reached. In many other
ivays also has Dr. Satterthwaite worked faithfully
for the interests of the association, while he has won
the affection and esteem of all its fellows by his
geniality and urbanity and by the dignity and cour-
teousness with which he has presided.
Resolved, That the Medical Association of the
Greater City of New York tender to Dr. Satter-
thwaite its sincere thanks for all the noble work
he has done in its behalf, and express to him its
profound regret at his retirement, together with its
heartfelt wishes for his future welfare and happi-
ness.
The Opportunities of a Great Medical Society.
— On retiring from the presidency of the associa-
tion. Dr. Thomas E. Satterthwaite made an ad-
dress on this subject. There were, he said, four
large medical bodies in New York : the Academy of
Medicine, the New York and Kings County so-
cieties, and this association. Each of these assumed
certain functions, duties, and responsibilities, which
were their distinguishing features. After all. how-
ever, there were, he thought, some general prin-
ciples which underlay all other considerations, gov-
erning the activities of such organizations. Along
what lines, then, and in what manner was progress
to be most profitably made? From the programme
of the meeting of a county society in Kentucky
which he had recently seen it would seem that there
was a movement in that locality to have some sort
of postgraduate course for the members, with week-
ly meetings devoted to the consideration of special
subjects. This Kentucky society was undertaking
a campaign of education, and the plan might well
serve as an example for other large general socie-
ties. Supposing, however, that another course were
pursued, and that a society would, for instance,
undertake to "regulate the practice of medicine and
surgery," holding out that among its prime objects
were the prosecution of unlicensed or criminal prac-
titioners, unregistered midwives, and medical im-
postors in general : it might always be reasonably
objected that the crusade, though laudable in theory,
and also in practice if carried on with discretion and
good faith, would still be open to the imputation
that so called regulation did not invariably regulate.
Perhaps, too. some one might be bold enough to ask
within what limits the society was proposing to ex-
ercise legal functions. Certainly most members of
these large societies, if the choice were offered them,
would be apt to favor more medicine and less law
in their programmes.
For we must, first of all, in some way, keep
abreast of the advances in the various departments
of medicine and surgery, if we are to practice with
safety to our patients and satisfaction to ourselves.
No one of us had either the time or the ability to
cope successfully with even the chief problems
which confronted us, and it would seem as if our
larger medical bodies, representing as they did
every phase of our art, might easily be the most
important factors in disseminating this very im-
portant knowledge, and that in the most palatable
and digestive form. Who that valued his time
would not prefer to spend two hours in hearing some
vexed question threshed out by experts, rather than
to be forced to listen to a one sided presentment of
an unimportant topic, the exploitation of immature
ideas, or collections of ill assorted parts? Four
years ago this society, through its council, under-
took a campaign of education, and had kept it up
year by year, only halting its scheme when the gen-
eral public was looking for special information on
such live questions as pure milk, water supplies, dis-
posal of sewage, and the like, or when the oppor-
tunity was particularly favorable for discussing
more theoretical questions, such as nutrition, im-
munity, pathogenic protozoa, etc., in which the
medical profession in general was always profound-
ly interested. More than this, who would not be-
lieve that opportune discussions on such public
questions as those mentioned were instrumental in
shaping useful legislation, and that this society did
effective work thereby for the city. State, and nation
perhaps ?
Except for these occasional variations, the year
had been divided in such a way that the entire fields
of medicine and surgery had been systematically
touched upon at their most important points; more
time, of course, being devoted to general medicine
and surgery, and less, proportionately, to the smaller
specialties. For each session the best obtainable
expert talent was secured, whether in New York
or other cities. As indicative of the eft'orts made
to secure the services of the best men during these
four years, more than fifty nonmembers had been
invited to contribute to the programmes, and they
had represented a geographical area extending from
^Montreal to Savannah and from Boston to Buffalo.
This statement also illustrated the fact (constantly
becoming more evident) that many topics important
for medical men to be acquainted with could not be
discussed advantageously without the help of lay-
men, such as the chemist, the pharmacist, and the
civil engineer. Fortunately, the larger societies
operating on this basis attracted representative audi-
ences, so that the lay specialist had an incentive to
appear before them, particularly as reports of the
meetings were published in the prominent medical
journals. Under these circumstances also our gen-
eral societies should be more attractive to every kind
of specialist than they were at present, since meetings
such as those described necessarily enlarged his field
of view, which otherwise tended to gradually be-
come smaller and smaller. Medicine was both an
art and a science. It had abandoned the realm of
magic and mysticism, and was amenable to the same
general laws as governed in the world of physics.
It required the same sort of apparatus, the same
kind of reagents, and the same mental attitude and
training which are essential to the physicist.
In speaking of the importance of the social ele-
ment in a large society, Dr. Satterthwaite said that,
with some, friendly greetings stood for more than
the scientific programme; but whichever were
placed first in one's estimation, there was nothing
but good to be had from a kindly word and a hearty
grasp of the hand. This social side of the associa-
tion's meetings had been especially emphasized by
gi6
LETTERS TO THE EDITORS.
[New York
"sIedical Journal.
the two extra borough meetings recently held, where
the attendance was small enough to give each mem-
ber the opportunity to meet and greet his fellows
cordially, and yet large enough to encourage the
speakers to do good work. The large societies
ought also to provide some practical protection for
their members in the legitimate and proper dis-
charge of their professional duties. In closing, he
said that the association would have a president
possessing all the qualifications necessary for main-
taining a high standard of achievement, a member-
ship representative of the best medical men in the
city, and, lastly, a sufficient balance in the treasury.
He would venture the hope that the campaign of
education inaugurated by it would continue to be a
dominating feature, and that its teachings would
always be sound and its policies wisely aggressive.
(To be concluded.)
'gttttn ts%~kmm.
THE PALLIATIVE TREATMENT OF PROSTATIC
HYPERTROPHY.
126 East Thirty-fourth Street,
New York, April 22, jgo8.
To the Editors
Having read the most valuable article of Dr.
Frederic Bierhoff under this title, in your issue for
April 1 8th, I wish to be permitted to say a word
about the author's erroneous interpretation of the
term "palliative" in the sense of "nonoperative."
The more I admire Dr. Bierhofif's writings, the more
I regret that such a distinguished author should re-
peat an error made b-y others before him.
Pallium is a Latin word, and means a covering
garment, a cloak ; it was the Greek outer garment in
distinction from the Roman toga. The pallium was
given by the Roman emperors ( from the fourth cen-
tury) to the higher bishops. Pallium caritatis is the
cloak of Christian love. Palliatio is new Latin, and
means covering with a cloak in the meaning which
we figuratively express by the word "whitewashing."
Palliative, from the Latin palliatus, a, nm, means
covered with a cloak ; in medicine a palliativum, or
palliative remedy or treatment, is a remedy or treat-
ment which is employed to ameliorate symptoms, to
do for a while until a radical remedy (not neces-
sarily an operation) can be applied or in case a rad-
ical cure is out of the question. A palliative cure is
the opposite of a radical cure ; that is, palliative treat-
ment is directed against the symptoms only (not
against the disease itself). Eo ipso, even a surgical
operation may under certain circumstances be noth-
ing more than a palliative measure. A. Rose.
ANCIENT PHTHISIOTHERAPY.
1022 North Fifth Street,
Philadelphia, April 30, 1908.
T 0 the Editors:
In connection with an article entitled A Retrospect
in Phthisiotherapy, by Henry Farnum Stoll, M. D..
in the Journal of April i8th, I would say that Pliny,
in a letter to his friend Valerius Paulius (Book V,
Letter 19, Orey's Translation), stated that he was
going to send lo his (Valerius Paulinus's) estate his
freedman Zosimus, who was evidently suffering
with pulmonarv tuberculosis.
In the letter he says : 'Tt is now some years since
he was pronouncing a speech with great vehemence
and earnestness, when he spit blood, and, upon that
account, being sent by me into Egypt, after a long
stay in that country, he returned lately in a con-
firmed state of health ; since which, as he has exer-
cised his voice for many days together, he was
threatened with his old infirmity by a little cough
and afterward again spit blood. For which reason
I determined to send him to your estate in Foro-
julium, having often heard you say that the air
there was healthy, and the milk particularly preval-
ent in curing disorders of this kind."
From this it is evident that in the early days of
the Roman Empire there were some who believed
that cHmate and milk were useful in the treatment
of phthisis, and, moreover, it proves the truth of
the saying, "There is nothing new under the sun."
J. F. E. C0LG.\N.
§0ffk 'gatim.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
Vitality, Fasting and Nutrition. A Physiological Study of
the Curative Power of Fasting, Together with a New
Theory of the Relation of Food to Human Vitality. By
Hereward Carrington, Member of the Council of the
American Institute for Scientific Research, etc. With an
Introduction by A. Rabagli.\ti, M. A.,^M. D., F. R. C. S.,
Hon. Gynaecologist and Late Senior House Surgeon,
Bradford Royal Infirmary, etc. New York : Rebman
Company, 1908. Pp. 648. (Price, $5,)
The author as a result of much reading, and
fortified by many quotations, endeavors "to show
that what little the medical profession is supposed
to know of the nature of disease is totally wrong;
that their theories of the origin and nature of dis-
ease are erroneous ab initio; and that every new
discovery made, which they have considered an un-
mixed blessing and a sign of progress, has, in real-
ity, only led them further and further from the
truth, and away from an understanding of the real
cause and cure of disease." He asserts that there
are only two schools of healing in the world, the
hygienic and any other, which includes all others.
We are left somewhat at a loss as to what a hygien-
ist is, but his attitude toward disease is defined from
a book by Emmet Densmore, who regards it as a
"curative action on the part of the ruling (vital)
force." The author informs us that no one part
of the body can possibly be af¥ected without all
other parts being also involved, and we strive to
grasp the idea that all talk of local diseases is "non-
sense pure and simple, and implies either ignor-
ance or shortsightedness on the part of any man
who uses the term as to what constitutes the real
nature or essence of disease."
The author asserts that he takes "the broad stand,
and defends the philosophic principle," that the
supposed action of drugs on certain tissues, organs,
or localities is altogether mythical and does not exist
in reality, and if proof is wanted you are advised to
study the philosophicomedical writings of a Dr.
Trail, author of Water Cure for the Million, which
was published in New York in i860.
May 9, 1908.]
BOOK NOTICES.
917
Again, the ''broad stand" is taken against the
germ theory, of which the premises are wrong and
the teachings of medical science are erroneous ab
initio. As the cause of disease is the encumbrance
of the system with effete, malassimilated foreign
material, and personal susceptibility corresponds to
the amount of the morbid matter within the organ-
ism, therefore disease itself is merely the process of
the system to rid itself of these impurities, and it is
in a last analysis a curative crisis.
The second book discuses the physiology and phil-
osophy of fasting, the author inviting attention to
the venerable dictum that men eat too much, choke
and block the organic functions with food materials,
and should relieve such conditions by fasting so that
the system may have a chance to throw off impuri-
ties.
This gospel has been voiced by many. Burton
writes : "Fasting is an all sufficient remedy of it-
self; for, as Jason Pratensis holds, the bodies of
such persons that feed liberally, and live at ease,
'are full of bad spirits and devils, devilish thoughts ;
no better physic for such parties than to fast.'
Hildesheim to this of hunger, adds, 'often baths,
much exercise and sweat,' but hunger and fasting
he prescribes before the rest. ... As 'hunger,'
saith Ambrose, 'is a friend of virginity, so is it an
enemy to lasciviousness, but fulness overthrows
chastity, and fosterth all manner of provocations.' "
(Anatomy of Melancholy, pt. iii, sec. 2, mem. 5,
subs. I.)
The practical application of fasting is shown in
a chapter on- cases cured by this method, which has
the same scientific value as an account of cures at
Lourdes or of treatment by Christian Science. The
author herein submits a new cause of paralysis : "It
is the pressure over the nerves of unduly retained
effete material." The theory that the sole function
of food is the replacement of tissue, that it supplies
no heat and no energy whatever, and that energy
flows into the organism in some mysterious way
from some external though unknown source is
scarcely worth discussion in these columns. We
are told that "sleep is that physiological condition
of the organism in which the nervous system of the
individual (in precisely the same manner as the
electric storage battery) is being recharged from
without, by the external, all pervading cosmic en-
ergy." Tliose who are not adepts on cosmic energy
are incompetent to discuss this theory.
Anaemia is a curing process, we learn, because
it is caused by overfeeding. Cancer is due to "an
overplus of malassimilated material within the sys-
tem," and should be cured by fasting in the initial
stages. An unwonted conservatism is manifested
in the statement that "overeating may be and prob-
ably is one of the chief causes of insanity to-day."
though this mental attitude changes in his deduction
from Kraepelin's histories that it was obvious that
the forced feeding was the chief cause of the con-
dition.
The author is in error in assuming that fasting
does not appear absurd as a cure for all bodily com-
plaints, even though he concedes that it may have
its limitations, as in mental diseases or mechanical
obstruction or interference. He begs the question
in the statement that in deaths from starvation it
is not the fasting but the mental condition — fear.
etc. — that kills the individual. Throughout organic
life privation of nutriment will cause death, and
those pathologists who work in large cities are fa-
miliar with deaths due to starvation. Not only
should the histories of famine epidemics indicate
the influence of fasting in the causation of disease,
but the employment of such a method would in
many instances result in an exhaustion associated
with toxaemia or acidosis that will terminate fatally.
Studies in Laboratory Work. By C. W. Daniels, M. B.,
Camb., M. R. C. S. Eng., Director of the London School
of Tropical Medicine, etc., and A. T. Stanton, M. D.
Tor., M. R. C. S. Eng., D. T. M. and H. Camb., Demon-
strator, London School of Tropical Medicine. Second
Edition. Thoroughly Revised, with Many New and
Additional Illustrations. Philadelphia : P. Blakiston's
Son & Co., 1907. Pp. 491.
The first edition of Daniels's laboratory studies in
tropical medicine is well known to all students of
that branch as a good working guide for use in the
field. Since the publication of the first edition, in
1903, the advances made in tropical medicine have
been so marked that a new edition is most oppor-
tune. The activity in the line of tropical medicine,
however, continues, and there are some things in
the present edition that must be changed in the next.
This statement applies more particularly to zoolog-
ical nomenclature and the relation between the in-
sect transmitters of protozoon parasites and the par-
asites which they harbor.
The new edition contains admirable analytical ta-
bles for the determination of mosquitoes, ticks, bit-
ing flies, tsetse flies, lice, and fleas. The analytical
tables for the trematodes, cestodes, and nematodes
are about the same as those in the first edition of the
book.
The discussion of statistics has been given a spe-
cial chapter, in which there is a consideration of
the value of evidence of the existence of certain -dis-
eases when obtained from sources other than per-
sonal observation, the spleen test, the endemic index,
the preparation of charts, etc. Dr. H. B. G. New-
ham contributes a section on water analysis.
We think that possibly it would have been better
for the practitioner in the field had the authors tabu-
lated the methods of using the different staining
processes, giving a time limit for each step of the
procedure. It has been our experience that direc-
tions for using stains and for employing chemical
tests have to be very explicit if those using them for
the first time are to get good results.
It appears to us that there are too many typo-
graphical errors for the second edition of a work of
this kind.
The colored plates are the same as those in the
first edition, but the figures in the text are more nu-
merous and are very clear.
Traite clinique des maladies de I'estomac. Par le Dr.
LuciEN Pron (d' Alger). Paris: Jules Rousset, 1908.
After a surfeit of treatises on the stomach in
which an exaggerated prominence is given to the
chemical examination of the gastric secretions, it is
a relief to turn to this excellent work, written more
from the clinical standpoint — not, however, that the
more modern methods of diagnosis have been neg-
lected by Dr. Pron. They are given in sufficient de-
tail, but are properly subordinated to careful studv
of the symptomatology and the older methods of
9i8
BOOK NOTICES.
[New York
Medical Journal.
accurate bedside observation. These are now often
somewhat neglected for the more fashionable lab-
oratory methods, but are, we believe, of greater value
to most practising physicians than the difficult quan-
titative analyses which occupy so much space in
many recent books. Only a competent chemist is
capable of making such analyses, and there is a good
deal of cant and pretense in much of the assumed
familiarity with them. As might be expected from
a French author, the sections on diet are especially
good, and contain many useful hints and practical
suggestions as to the selection and cooking of food
for dyspeptics. The American victim of cold stor-
age processes and the queer commercial products
which come out of cans and boxes will read with
poignant interest these gastronomic chapters which
emanate from a land where the intelligent prepara-
tion of real food is an art understood and practised
in the humblest homes. Methods of treatment arc
considered with unusual fulness, there is a scholarly
article on the relation of the stomach to other or-
gans, and the book as a whole gives the impression
of a large personal experience supplemented by dili-
gent study of all the important special literature. If
a minor criticism is permissible where there is so
much to be commended, it may be said that the'
author's elaborate classification of functional disor-
ders of the stomach appears to be somewhat strained
and artificial. '
Die Funktiouen dcr Nervcncentra. Von Prof. Dr. W. v.
Bechterew^ 0. Akademiker, Direktor, der psychiatrischen
und Nervenklinik der medizinischen Akademie, Presi-
dent des psychoneurologischen Institutes in St. Peters-
Ijurg. Deutsche Ausgabe, in Verbindung mit dem Ver-
fasser redigiert durch Dr. Richard Weinberg. Professor
der Anatomie m St. Petersburg. Erstes Heft : Ein-
leitung, Untersuchungsmethoden, Ruckenmark und Ver-
langertes Mark. Mit 96 Abbildungen im Text. Jena :
Gustav Fischer, 1908. Pp. 691.
This first volume of the German edition of Bech-
terew's general treatise on the functions of the
nervous system is one of more than usual interest
in the vast horde of recent works on the nervous
.svstem and its functions. It deals with the methods
of investigation of the nervous system and the
physiology of the spinal cord and medulla oblong-
ata. It is almost a commonplace to state that ac-
tivity in the investigation of the nervous system
has never been more pronounced than during the
last fifteen years. The newer methods of micro-
scopical anatomy have given a definiteness and pre-
cision to physiological study that had before been
lacking, and the almost impenetrable maze of an-
atomical structure, thanks to the researches of
Weigert. Golgi, von Lenhossek, Cajal, Nissl, and
Bielschowsky, has been boldly entered, and the re-
sults have been dealt with by such eminent physiolo-
gists as Sherrington, Ferrier, Munes, Goetz, Flech-
sig, and Luciani. It is with these correlations that
this work deals.
W'e cannot enter into a detailed analysis of the
work. It is too monumental. We can only point
out its practical character, although deprecating its
excessive verbosity. In no other work of a similar
kind have there been brought together so many of
the facts concerning the nervous fimctions. Thus,
as an instance, the author, in treating of the tendon
reflexes, departs from the usual line of a general
description of what constitutes a reflex with a brief
schematic picture of the reflex arc, in that he dis-
cusses the actual nerve paths traveled in each re-
flex. The entire muscular and sensory physiology
is handled in the same detailed and thorough
manner.
This work is destined to be one of great import-
ance in the history of our knowledge of the nervous
system. It does not purport to be a work of orig-
inal research, but it is a valuable compilation, ad-
mirably conceived and well executed.
Syphilis. A Treatise for Practitioners. By Edward L.
Keyes, Jr., A. B., M. D.. Ph. D., Clinical Professor of
Genitourinary Surgery, New York Polyclinic Medical
School and Hospital, etc. With Sixty-nine Illustrations
in the Text and Nine Plates, Seven of which are Colored.
New York and London : D. Appleton & Co., 1908. Pp.
xxix-577.
The elder Keyes, who contributes a "foreword"
to this volume, has long been known for the admir-
able clearness of his writings, and the son is not in
the least his inferior in trenchant diction. The
style, indeed, is one of the great charms of the book.
The book is interesting throughout ; perhaps of par-
ticular interest to most readers will turn out to be
the section on tabes dorsalis and paresis. "Seeing
these diseases from a syphilitic point of view," says
the author, very frankly, "I naturally encounter
only those of manifest syphilitic origin, and, accord-
ingly, must side with those who believe tabes to be
almost always syphilitic in origin, paresis frequently
so." Further along he says: "Juvenile paresis and
tabes are exclusively syphilitic." He adds: "Most
authorities agree that syphilis is not the adequate
cause of either malady. 'Syphilis and civilization,'
says Krafft-Ebing. And this is the accepted doc-
trine." Evidently the author does not subscribe to
the daring dictum that all tabes is syphilis, and our
own belief is that he is right in declining to do so.
The initial chapter. Syphilis in Relation to Public
Health, is impressive and strengthens one's hope
that such agencies as the Society of Sanitary and
Moral Prophylaxis may in a few years accomplish
something substantial in the way of curbing the in-
roads of prostitution, whether professed or clandes-
tine, on the physical and moral health of the com-
munity. Running all through the book, indeed,
there is a wholesome undertone which will achieve
much more in that direction than police raids or
lofty legislation.
The book is very handsome in appearance, though
the text is luarred by an extreme of the "bobtailed"
spelling, which, we presume, is the work of the pub-
lishers, not of the authors. We heartily commend
Dr. Keyes's treatise.
.4(1 Introduction to Vegetable Phvsiology. By J. Reynolds
GiiEEN, Sc. D., F. L. S.. F. R". S., Fellow of Downing
College, Cambridge, Late Professor of Botany to the
Pharmaceutical Society of Great Britain, etc. Second
Edition. Philadelphia ; P. Blakiston's Son & Co., 1907.
Pp. xx-459.
As the study of human physiology and pathology
advances it becomes more and more evident that the
fundamental processes are extremely simple and ar-
rive at the complexity seen in human life only by
countless series of generations of growth in struc-
tural complexity. It seems only yesterday that the
animal physiologist became vitally interested in the
problems of physical chemistry, of electrical dissocia-
tion in cells, of the intricate nature of cellular fer-
May 9, 1908.]
BOOK NOTICES.
gig
mentation, and of related subjects, all of which in-
volve the most elementary forces of organic and in-
organic life.
There has been a tendency to exaggerate the dif-
ferences that exist in plant and animal life, which
the author of this work wishes to show are unessen-
tial. There is a fundamental unity of all living sub-
stance. Protoplasm, in short, is the same material,
whether we call it animal or vegetable. Its condi-
tions of life and its immediate necessities must be
practically the same, whatever its degree of differen-
tiation in either direction. Differences of behavior
and of structure are to be traced to differences of en-
vironment and habit of life more than to those of
constitution.
It is not only by reason of these essential similari-
ties that the study of plant physiology should consti-
tute an essential feature in the curriculum of a mod-
ern medical school, and a work on plant physiology,
one to be read by medical practitioners, but by virtue
of the further significant fact that in plants, for the
most part, the fundamental physiological processes,
because of the simplicity of structure, may be the
more readily comprehended and subjected to experi-
mentation.
A good short handbook on plant physiology has
not been attainable ; those of Pfeffer, Sach, Jost, and
Vines are too extensive, and MacDougall's is too
elementary. This work of Professor Green's, whose
work on fermentation is so well known to physiolo-
gists the world over, is admirably adapted to the
purposes, and deser\'es a wide circle of readers.
Atlas of Typical Operations in Surgery. By Dr. Ph.
BocKENHEiMER and Dr. Fritz Frohse. Sixty Illustra-
tions from Water Colors by Fraxz Frohse (Artist),
Berlin. Adapted English Version bv J. Howell Ev.axs,
M. A., M. B., M. Ch., Oxon., F. R. C. S., England, Demon-
strator of Operatiev Surgery at St. George's Hospital,
London, etc. New York : Rebman Company ; London :
Rebman Limited. Quarto, pp. 252.
These superb plates depict high tracheotomy
(three plates), hemicraniotomy (two plates), Bas-
sini's operation for the radical cure of inguinal her-
nia (five plates), ligation of the lingual artery, von
Bergmann's method of excision of the tongue (five
plates), gastrostomy (two plates), excision of the
larynx (five plates), resection of a rib, cellulitis of
the hand (its relations), excision of the kidney (two
plates), an operation for femoral hernia (two
plates), removal of the vermiform appendix, trans-
pleural laparotomy, urethrotomy and prostatectom\
(three plates), cellulitis of the neck (its relations),
suprapubic cystotoiny, laminectomy (two plates),
colostomy, enterostomy, anterior gastroenterostomy
(three plates), resection of intestine (two plates),
pericardiotomy, posterior gastroenterostomy, lateral
intestinal anastomosis, excision of the rectum (two
plates), operations on the biliary passages (three
plates), thyreoidectomy (two plates), cesophagoto-
my, removal of the breast, and operations on the tri-
geminal nerve and the Gasserian ganglion. In addi-
tion to the plates, there are numerous woodcuts of
the various instruments and appliances that have
been found useful in the operations. The explana-
tory text, though condensed, is clear and precise.
The book is handsomely and substantially bound,
and the typography is of the best. It seems to us
that no progressive surgeon would be willing to be
without it.
Les Homosc.vuels de Berlin. Par le Dr. Magnus Hirsch-
FELD. Paris : Jules Rousset, 1908. Pp. 103.
This short contribution to the literature of sexual
anomalies deals largely with the recent cause celebre
of Berlin, and in tone is a general defense of many
practices allowed in ancient times, but more or less
frowned upon in polite society, at least as regards
avowed attitude.
Practical An-asthetics. By H. Edmuxd G. Boyle. M. R.
C. S., L. R. C. P., Assistant Anaesthetist to St. Bar-
tholomew's Hospital, etc. London : Henry Frowde
(Oxford University Press) and Hodder & Stoughton,
1907. Pp. viii-178.
We have here another of the series of excellent
Oxford medical publications, several of which have
already been reviewed in these columns. In this issue
the entire subject of general anaesthesia is treated in
a thoroughly practical manner, detailed instructions
as to the best modern methods of administering ni-
trous oxide, ether, chloroform, and ethyl chloride,
with the different anaesthetic mixtures, their indica-
tions as to preference and dangers, being fully de-
scribed. Their author makes a point that ether is to
be preferred in inducing, chloroform in maintaining
anaesthesia. For prolonged surgical anaesthesia the
best method in general is the sequence of nitrous ox-
ide, ether, and chloroform. All directions are clearly
given, and the book should be of special interest to
the surgical hospital interne, who is too often lam-
entably deficient in his knowledge of the correct use
of anaesthetics. The value of the text is enhanced
by a number of very good illustrations.
Xerz'ous and Mental Diseases. For Students and Practi-
tioners. By Ch.xrles S. Potts, M. D.. Professor of
Neurolog}- in the Medico-Chirurgical College of Phila-
delphia, etc. Second Edition. Revised and Enlarged.
Illustrated with 133 Engravings and Nine Plates. Phila-
delphia and Xev. York : Lea & Febiger, 1908. Pp.
vi-570.
The second edition of this manual makes its ap-
pearance in a greatly enlarged and amended form.
To it has been added a chapter on mental diseases
which has been entirely rewritten, and about fifty
pages are devoted to mental troubles. In general
the teachings in the first portion of the book on
nervous diseases are in accord with those usually
held by neurologists the world over, and. presented
as they are in a very sketchy manner, they are par-
ticularly useful to beginners in this field of medi-
cine. It is because of this didactic mode of
presentation that the book has found considerable
favor and will continue to be of service.
At the same time we think that the author could
have improved his work considerabh- if a number
of his statements had been made less didactic and
more inclusive of the general biological point of
view. It is impossible to analyze at this time the
various features discussed and to point out some of
the slight mistakes that have been made : but in
general the latter have been few.
So far as the chapter on mental diseases is con-
cerned, we feel that the author's point of view is
strangely at variance with modern teachings. To
Dr. Potts, insanity is one disease which shows itself
imder various phases. This is a distinct reversion
to the idea almost, we might say. of Hippocratic
days, and tends to perpetuate the confusion that al-
ready exists, not only in the mind of the layman, but
in that of the physician, especially if he has had any
920
MISCELLANY.
[New York
Medical Journal.
experience in mental disorders. To say that mental
disorders are not diseases, but symptom groups
alone, means very little, for, after all, diseases are
nothing but symptom groups. Specific modes of re-
action on the part of functional disturbances are
just as truly diseases, if the proper concept of what
constitutes a disease is borne in mind. Because our
methods of analysis are as yet comparatively crude
in the field of mental derangement is certainly no
justification for relapsing into the laisses faire atti-
tude adopted by the author in the second part of
this otherwise very excellent manual. To maintain,
for instance, that hysteria is a definite disease,
whereas general paresis is only a symptom group, is
ridiculous. All in all, however, the manual will be
a very useful one for those for whom it is devised.
BOOKS, PAMPHLETS, ETC., RECEIVED
Heredity. By J. Arthur Thomson, M. A., Regius Pro-
fessor of Natuial History in the University of Aberdeen,
Author of The Study uf Animal Life, etc. 'With 49 Illus-
trations. New York : G. P. Putnam's Sons ; London : John
Murray, 1908. Pp. xvi-605.
Nursing the Insane. By Clara Barrus, M. D., Woman
Assistant Physician to the Middletovvn State Homoeopathic
Hospital, Middletown, N. Y. New York: The Macmillan
Company, 1908. Pp. x-409.
Immune Sera. A Concise Exposition of our Present
Knowledge Concerning the Constitution and Mode of Ac-
tion of Antitoxines, Agglutinins, Haemolysins, Bacterio-
lysins, Precipitins, Cytotoxines, and Opsonins. By. Dr.
Charles Frederick Bolduan, Bacteriologist, Research Lab-
oratory, Department of Health of the City of New York.
Second Edition, Rewritten. First Thousand. New York:
John Wiley & Sons ; London : Chapman & Hall, Limited.
1907. Pp. viii-154. (Price, $1.50.)
Typhoid Fever. Its Causation, Transmission, and Pre-
vention. By George C. Whipple, Consulting Engineer, with
an Introductory Essay by William T. Sedgwick, Professor
of Biology, Massachusetts Institute of Technology. First
Edition. First Thousand. New York: John Wiley &
Sons ; London : Chapman & Hall, Limited, 1908. Pp. xii-
407. (Price, $3.)
Diseases of the Nose, Throat, and Ear. Medical and
Surgical. By William Lincoln Ballenger, M. D., Professor
of Otology, Rhinology, and Laryngology, College of Physi-
cians and Surgeons, Department of Medicine. University
of Illinois, etc. Illustrated with 471 Engravings and 16
Plates. Philadelphia : Lea & Febiger, 1908. Pp. viii-17
to 905-
An Appeal to the Medical Profession. — The
Legislature has passed a bill. Senate Bill No. 1033,
creating a profession of optometrists, and it is up
to the Governor to sign or not to sign as the merits
of the case appeal to him.
It creates a board of examiners of "five persons
who shall possess sufficient knowledge of theoreti-
cal and practical optics to practice optometry, and
who shall have been residents of the State actually
engaged in the practice of optometry for at least
five years."
It provides that any person who has been en-
gaged in the practice of optometry for two years
next prior to the passage of the act may receive
a license without examination, upon recommenda-
tion of the board of examiners.
This bill is an invasion of the sphere of medicine
in one of its most important branches, and confers
privileges on certain people which, in accordance
with the wording of the act, they are utterly in-
competent to exercise.
The bill grants to opticians the right to adjust
lenses to people's eyes in need thereof, and denies
them the right to use drugs.
Without the use of drugs, in certain cases, even
the most competent physicians cannot properly ad-
just lenses to the eyes, especially in children, and
great harm can be produced by attempting such
practice without using drugs.
The knowledge of optics alone, however exten-
sive, does not render a person competent to do the
work this bill would give opticians the right to do.
To examine the eyes and adjust lenses one should
have a knowledge of anatomy and physiology at
least, but this bill provides only for a knowledge of
optics. The many diseased conditions which may
influence the eyes, and vision, are not considered at
all. The ability to make a diagnosis is necessary
to enable one to discriminate between visual defects
due to diseases and those due solely to optical er-
rors, both of which often exist at the same time, and
this ability requires more than a knowledge of
optics.
The passage of this act denotes gross and inex-
cusable ignorance on the part of members of the
legislature, or an utter disregard of the welfare of
the community.
It is a most vicious type of special legislation in
that it permits an examining board of five members
to discriminate between opticians who apply for cer-
tificates of exemption. The recommendation of this
board is necessary before these certificates can be
granted, and this board can limit its recommenda-
tions to a chosen few.
If the physicians of this State will go on record
with the Governor, opposing this bill, it will never
become a law. Will you write at once, urging the
Governor to withhold his approval?
Very truly yours,
Frank Van Fleet, M. D..
Chairman Committee on Legislation,
Medical Society of the County of New York.
Walter E. Lambert, M. D.,
Member Committee on Legislation,
Medical Society of the State of New York.
Resolution Adopted on the Death of Sister
Louis Gonzaga. — The medical board of St. Vin-
cent's Hospital adopted, at a recent meeting, the
following resolution :
After many fruitful years of continuous, abund-
ant, and merciful labor in the cause of the poor and
the suffering of the city, Sister Louis Gonzaga has
passed along from an honored post of earthly duty
to one of exalted station of reward in the world
above.
Those who, heretofore, have been cheered by her
gracious presence and genial smile, ever an earnest
of beneficent desire and of a pure and humble spirit,
will miss her benign presence and bountiful benev-
olence more and n1ore as time endures. Sister Gon-
zaga's devotion to duty was not limited by measure
nor modified by method : it was free and boundless.
Her activities were tireless, and the products of her
efforts were worthy of the emulation of those hav-
May 9, igoS.l
OFFICIAL NEWS.
921
ing the sincerest motives and the largest benevol-
ence.
Sister Gonzaga believed in friends implicity and
heeded their advice with discreet and trustful re-
liance. She resented wrong with vigor ; pardoned
error with joy ; and welcomed truth with open arms.
Sister Gonzaga"s devotion to duty should inspire
us all to broader efforts and higher aims in every
field of worthy opportunity, so that, like her, we
too can reap the rewards commensurate with right-
eous achievements in every path of duty.
CoxsTANTixE J. MacGuire, iM. D.,
Chairman.
E. L. ICeyes, Jr., M. D.,
Secretary.
Public Health and Marine Hospital Service
Health Reports :
The foUo'd'iiig cases of smallpox, yelloTij fever, cholera,
and plague have been reported to the surgeon general,
United States Public Health and Marine Hospital Service,
during the UTck ending May i, 1908:
Smallpox — United States.
Places. Date. Cases. Deaths.
California — Los Angeles April 4-11 2
District of Columbia — Washington.. April 11-18 5
Illinois — Chicago April 11-18 4
Illinois — Galesburg April 11-18 3
Illinois — Springfield April 9-16 6
Indiana — Indianapolis Aoril 12-19... 7
Indiana — La Fayette April 13-20 i
Kansas — Kansas City .\pril 11-18 20
Kansas — Wichita...., .\pril 11-18 9
Louisiana — Xew Orleans .\pri'
ilaryland — Baltimore April 11-18...
Michigan — Detroit .A.pril 4-1 1 ... .
Michigan — Grand Rapids April 4-1S....
^Michigan — Kalamazoo ilarih j8-Apri'
ilississippi — Greenville Feb. 1-29
March 1-31...
Missouri — Kansas City March 4-18...
Alissouri — St. Louis April 11-18...
^lontana — Butte March 31-April
Xebraska — Nebraska City April 11-18...
North Carolina — Charlotte April 4-18....
Ohio — Cincinnati \pril 10-17...
Ohio — Dayton \pril 11-18...
Tennessee — Nashville \pril 11-18. .
Te.xas — Fort Worth March 1-30...
\"ermont — Xew Bury March 12-18..
Washington — Spokanr April 4-1 1 ... .
AVashington — Toconia March 28-April
Wisconsin — La Crosse April 11-18...
Wisconsin — Milwaukee -April 4-18....
Wisconsin — Racine .\pril 11-18. . .
Smallpo.i- — Foreign.
Arabia — Aden March 23-30
Austria — \'ienna .March 28-.-\pril 4.... 1
Brazil — Bahia Feb. 29-March 28.... 80
Brazil — Pernambuco Feb. 1-29
Brazil — Para March 28-April 4. ... 195
Brazil — Rio de Janeiro March 28-April 4.... i
C^hina — Hongkong Feb. 22-March 62
China — Sihanghai March 8-15 2
Ecuador — Guayaquil March 14-28
Egypt — Cairo March 18-25 i
£gypt — Suez Feb. 18-March 18.... S
Formosa March 7-14 5
France — Marseilles March 1-21
France — Paris March 28-April 4.... 5
•Germanj' — General March 29-April 11... 43
Great Britain — Leith March 21-28
India — Bombay March 17-24
India — Calcutta Feb. 22-March 14....
Italy — General April 2 19
Italy — Catania March 26- April 9.... 5
Italy — Naples March 28-April 4 i
Japan — Kobe March 7-14 56
March 14-21 34
Japan — Xagasaki March 14-22 1
Japan — Osaka March 7-14 306
Me-xico — Aguas Calieines March 29-April 12..
Jle.xico — City of Me.xicc March 7-14 13
Portugal — Barreiro .March 28-April 4.... i
Portugal — Lisbon March 28-April 4 . . . . i
Russia — Moscow March 14-28 88
Russia — Riga March 28-April 4.... 5
Russia — St. Petersburg March 14-21 26
Russia — Warsaw Feb. 8-March 14....
Spain — Denia March 21-April 4..
Spain — Madrid JIarch 1-31
Spain — Valencia March 22-April 5..
Straits Settlements — Penang March 7-14
Straits Settlements — Singapore. . . . Feb. 27-March 7. .
Turkey — Smyrna Feb. 23-March 24.
Ycllo^i Fczet — Foreign.
Brazil — Para March 28-April 4..
Brazil — Rio de Janeiro March 15-22
Ecuador — Guayaquil March 14-28
CI., icr.i— Insular.
Philippine Islands — Manila Feb. 22-March 7..
Cholera — Foreign.
Cochin China — .Saigon Feb. 21-March 7..
India — Calcutta Feb. 22-March 14.
India — Madras March 14-20
India — Rangoon March 7-14
Plague — Foreign.
Feb. 2g-March 14.
March 15-22
Present.
399
China — Hongkong
Cochin China — Saigon . . . .
Ecuador — Guayaquil
Egypt — Assiout Province.
Egypt — Fayoum Province.
Egypt — Girgeh Province..
Xndia-
.reb. 22-29
Feb. 22-March
March 14-28...
.March 6-12....
March 6-12....
March 8-11
March
India — Calcutta .Feb. 22-March 14... 153
India— Rangoon March 7-14 32
Straits Settlements — Singapore .... Feb. 29-March 7.... 1
Public Health and Marine Hospital Service:
OfUcial list of changes of stations and duties of commis-
sioned and noncommissioned officers of the United States
Public Hcaltli and Marine Hospital Service for the seven
days ending April 29, 1908:
BoGGES, J. S.. Passed Assistant Surgeon. Relieved from
duty at Chicago, 111., and directed to proceed to Seattle,
Wash., reporting to the commanding officer of the
revenue cutter Perry not later than May 5, 1908, for
duty.
Brooks, S. D., Surgeon. Leave of absence granted for
three days, from April 20, 1908, revoked.
Foster, A. D., Passed Assistant Surgeon. Relieved from-
duty at Ellis Island and directed to proceed to Port
Townsend, Wash., reporting to the commanding officer
of the revenue cutter Thetis not later than May 5,
1908, for duty.
GoLDSBOROUGH. B. W., Acting Assistant Surgeon. Granted
leave of absence for three days, from April 28, 1908.
Green, E. S., Acting Assistant Surgeon. Granted leave of
absence for twelve days, from April 18, 1908 .
Gustetter, a. L., Acting Assistant Surgeon. Granted
leave of absence for three days, from April 27, 1908. _
Hurlev. J. R., Assistant Surgeon. Relieved from special
temporary duty at San Francisco and directed to re-
port to the commanding officer of the revenue cutter
Bear not later than May 5, 1908, for duty.
Jackson. J. M., Acting Assistant Surgeon. Leave of ab-
sence granted for ten days, from April 4, 1908,
amended so as to read for sixteen days, from April
4, 1908.
Me.^d, F. W., Surgeon. Leave of absence granted for ten
days, from April 12, 1908, amended to read leave on
account of sickness.
Oaklev, J. H., Passed Assistant Surgeon. Leave of ab-
sence granted for one month, from April 15, 190S,
amended so as to be effective April 17, 1908.
Olesex, Robert. Assistant Surgeon. Relieved from duty
at the Marine Hospital, San Francisco., Gal., and di-
rected to report to the commanding officer of the
revenue cutter McCulloch not later than May 5, 1908,
for duty.
Parker. H. B., Passed Assistant Surgeon. Granted leave
of absence for, nine days, from April 18, 1908, on ac-
count of sickness.
Scott, E. B., Pharmacist. Granted leave of absence for
eight days, from .April 24, 1908.
SiMONsoN. G. T., Acting Assistant Surgeon. Granted
leave of absence for four days, from April 30, 190S;
granted extension of lea'/e of absence for two days,
from May 5, I9C^.
Thomas, J. N., Acting Assistant Surgeon. Directed to
proceed to Puerto Barrios, Guatemala, for special tem-
porary duty.
Wasdin. E., Surgeon. Directed to proceed to certain
points in Mississippi for special temporary duty, upon
completion of which to rejoin his station.
922
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
Wood, C. E., Assistant Surgeon. Relieved from duty at
Stapleton, N. Y., and directed to proceed to Chicago,
111., reporting to the medical officer in command for
duty and assignment to quarters.
Board Convened.
A board of medical officers was convened to meet at
Seattle. Wash., April 24, 1908, for the purpose of making
physical examination of an alien immigrant. Detail for the
board : Passed Assistant Surgeon M. W. Glover, chair-
man ; Assistant Surgeon C. W. Chapin ; Acting Assistant
Surgeon F. R. Underwood, recorder.
Army Intelligence:
Official list of changes in the stations and duties of
officers serving in the medical department of the United
States Army for the rueek ending April 25, 1908:
Banta, W. p., First Lieutenant and Assistant Surgeon.
Granted leave of .absence for four months.
Carter, E. C, Major and Surgeon. Granted leave of ab-
sence for three months, to take effect about June ist.
Craig, C. F., First Lieutenant and Assistant Surgeon.
Granted lea\e of absence for two months, to take effect
about July 1st.
Davis, W. R. Captain and Assistant Surgeon. Granted
leave of absence for fifteen days.
Fischer, H. C, Major and Surgeon. Relieved from duty
at Fort Logan, Col. ; ordered to Washington. D. C,
for instructions; thence to Fort Slocum, N. Y., to
familiarize himself with certain methods pertaining to
the examination of recruits ; and thence to Columbus
Barracks, Ohio, for duty.
GosMAN, G. H. R., Captain and Assistant Surgeon. Re-
lieved from duty at Columbus Barracks, Ohio, and or-
dered to Fort Morgan, Ala., for duty.
LeWald, Leon L., Captain and Assistant Surgeon. Re-
lieved from- duty at Fort Slocum, N. Y., and ordered
to Columbus Barracks, Ohio, for duty.
Powell, J. L., Lieutenant Colonel and Deputy Surgeon
General. Granted an extension of eight days to leave
of absence.
Raymond. H. L, Major and Surgeon. Relieved from duty
at Columbus Barracks, Ohio, and ordered to Fort Sam
H&uston, Tex., for duty.
Rav.moxd, T. U., Major and Surgeon. Granted leave of
absence for one month ; order for Fort Sam Houston,
Tex., amended ; will proceed to Fort Logan, Col., for
duty.
RocKHiLL. E. P., Captain and Assistant Surgeon. Relieved
from observation and treatment at the General Hos-
pital, Fort Bayard, N. M., and from further duty in
the Philippines Division, and ordered to duty at that
hospital.
VoSE. W. E., Captain and Assistant Surgeon. Relieved
from duty at Columbus Barracks, Ohio, and ordered
to Fcrt Slocum, N. Y., for duty.
Williams, A. W., Captain and Assistant Surgeon. Granted
leave of absence for two months ; at the expiration,
ordered to proceed to Fort H. G. Wright, N. Y., for
duty.
Navy Intelligence:
Official list of changes in the medical corps of the United
States Navy for the week ending May 2, 1908:
Bacon, S., Assistant Surgeon. Appointed assistant sur-
geon from April 11, igo8.
Baker, M. D., Pharmacist. Ordered to duty at the Naval
Medical School Hospital, Washington, D. C.
Biello, a. Appointed an assistant surgeon from April 11,
1908.
Cook, F. C, Surgeon. Detached from the Naval Academy
and ordered to the North Carolina when commissioned.
Hough, F. P. W., Assistant Surgeon. Appointed an as-
sistant surgeon from April 11, 1908.
Plummer, R. W. Surgeon. Commissioned a surgeon
from February 23, 1908.
Rhodes, G. C, Assistant Surgeon. Appointed an assistant
surgeon from April 11, 1908.
RoTHGANGER, G., SurgeoH. Granted sick leave for three
months when discharged from treatment at the Naval
Hospital, New York.
Spear, D. A., Assistant Surgeon. Ordered to duty at the
Naval Hospital, Washington, D. C.
iirt^s, Itarriagts, anb itat^s.
Married.
Cook — Hare. — In Philadelphia, on Tuesday, April 28th,
Mr. Arthur B. Cook, United States Navy, and Miss Marie
Amory Hare, daughter of Dr. Hobart Amory Hare.
Egan — Gensler. — In Chicago, on Monday, April 20th,
Dr. J. J. Egan and Aliss Theckia Gensler.
Gkeenleaf — McClellan. — In Washington, D. C, on
Thursday, April 30th, Dr. Henry S. Greenleaf, Medical
Department of the United States Army, and Miss Carrie
McClellan.
HiGGtNBOTHAM — Phillips. — In Boston, on Tuesday,
.•\pril 2ist, Dr. PVed A. Higginbotham, of Cambridge, and
Miss Maud E. Phillips.
James — Jones.— In Utica, New York, on Wednesday,
.\pril 22d, Dr. F. W. James and Miss Lillian Mae Jones.
Lung — De Pevster. — In New York, on Tuesday, April
28th, Dr. George A. Lung, United States Navy, and Miss
Helen Van Cortlandt de Peyster.
Marter — West.— In Los Angeles, California, on Satur-
day, April 25th, Dr. Linnaeus Esher Marter and Miss
Emma Brown West.
O'Connor — De Witt. — In Roxbury, Massachusetts, on
Wednesday, .-\pril 22d, Dr. Victor F. O'Connor and Miss
Lila M. De Witt.
Zalesky — Dismukes. — In St. Augustine, Florida, on
Monday, April 27th. Dr. William John Zalesky, United
States Navy, and Miss Elizabeth Gibbs Dismukes.
Died.
Aldrich. — In Cleveland, Ohio, on Wednesday, April
29th, Dr. Charles J. Aldrich, aged forty-six years.
Cochrax. — In Brooklyn, N. Y., on Wednesday, April
29th, Dr. Alexander Cochran, aged seventy-six years.
Craig. — In Cincinnati, Ohio, on Thursday, April 23d, Dr.
A. G. Craig, of Vevay, Indiana.
DoDD.--In North Babylon, Long Island, New York, on
Tuesdav, April 28th, Dr. E. Dodd, aged sixty-nine years.
Earles. — In Milwaukee, Wisconsin, on Tuesday, April
28th, Dr. William Henry Earles, aged fifty-five years.
England. — In Winnipeg, Canada, on Friday, April 24th,.
Dr. W. S. England, aged forty years.
Farrington —In New York, on Monday, May 4th, Dr.
Joseph Oakley Farrington, aged seventy-eight years.
Gaskill. — In Bourbon, Indiana, on Tuesday, April 21st,
Dr. I. C. Gaskill.
Harris. — In Kansas City, Missouri, on Wednesday,
April 22d, Dr. E. B. Harris, aged seventy years.
Hay.— In Jamaica Plain, Massachusetts, on Sunday,
April 26th, Dr. Gustavus Hay, aged seventy-eight years.
Heidemann. — In St. Louis, Missouri, on Saturday,.
April 25th, Dr. J. H. Heidemann, aged sixty-three years.
Hutchinson. — In Wakefield, Massachusetts, on Tues-
day, April 2 1 St, Dr. Marcello Hutchinson, aged fifty-eight
years.
Lorenzo. — In Monroe, Michigan, on Wednesday, April
22d, Dr. Godfrey Lorenzo, aged seventy-nine years.
Miller. — In Harrisburg, Pennsylvania, on Monday,
April 27th, Dr. Jacob A. Miller, aged seventy-one years.
Morton.— In* Baltimore, Maryland, on Monday, April
27th, Dr. J. Cook Morton, aged forty-four years.
NiCKLES. — In Cincinnati, Ohio, on Tuesday. April 2ist„
Dr. Samuel Nickles, aged seventy-three years. •
Ralston. — In Pittsburgh, Pennsylvania, on Sunday,
.\pril 26th, Dr. Curtiss Ralston, aged thirty-two years.
Robinson. — In Monongahela, Pennsylvania, on Sunday,
April 26th, Dr. F. C. Robinson, aged eighty-eight years.
ScAMMELL. — In St. John, New Brunswick, Canada, on
Saturday, April 25th, Dr. J. Harris Scammell.
Shaw.— In Hoosick Falls, New York, on Thursday,
April 30th, Dr. J. C. Shaw, aged sixty years.
Smith. — In Hornell. New York, on Sunday, .'^pril 26th.
Dr. L. B. Smith, aged fifty-seven years.
Stiemer. — In Hillsdale, Michigan, on Saturday, .'\pril
2Sth, Dr. Alexander Stiemer.
Terhune. — In Brooklyn, on Thursday, April 30th. Dr.
James Jackson Terhune, aged sixty-four years.
Watson.— In Chicago, on Friday, April 24th, Dr. Harry
Watson, aged twenty-five years.
Wii.LouGHBY.- In Colhorne, Ontario. Canada, on Tues-
day, April 28th, Hon. Dr. William .\rmson Willoughby,
aged sixty-four years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal ^It Medical News
A Weekly Review of Medicine, Established 184J.
\ou LXXX\'II. Xo. 20. XEW YORK, MAY 16, 1908. Whole Xo. 1537.
(Original Communirations.
THE DIAGNOSTIC VALUE OF SYMPTOMS OF
THE LARYXX. PHARYNX, AND NOSE,
IN NERVOUS DISEASES.*
Bv Thomas J. Harris, M. D.,
New York.
Xo more interesting and timely subject could
have been selected for consideration to-night than
the diagnostic value in general medicine of symp-
toms referred to the upper air passages, especially
the diseases specified in this symposium. .\t the
same time the subject is so broad and far reaching
that any presentation of it in the comprehensive
way which is demanded will be prevented by the
time at our disposal. Particularly true is this in
the matter of nervous diseases. Certain phases of
the subject have served to provoke unending discus-
sion and debate in ihe early years of laryngology,
and the literature thereon is well nigh inex-
haustible.
Any attempt at entering at length upon a con-
sideration of these is neither desirable nor possible.
An intelligent appreciation, however, of the diag-
nostic value of such symptoms demands at least a
cursory review of what has been agreed upon after
all controversial questions are omitted. It may be
said at the outset that aftections of the nervous sys-
tem present symptoms of value and importance
from a diagnostic standpoint, in the throat and nose,
whether they be true organic affections or only
functional disorders such as the so called neuroses.
Of the two, the organic affections are much more
the important. They show themselves chiefly in the
lar\-nx and are in the form of either sensory or
motor disturbances. .\s is well known, the nerve
supply of the laryngeal muscles is derived from the
vagus, the inferior or recurrent laryngeal nerve
conveying motion to all except the cricothyreoid,
which is supplied by the superior laryngeal, which
is also the nerve of sensation. The only dispute
in this connection has been whether the spinal ac-
cessory shares in this function to a limited extent.
It has now generally been agreed that this is not
the case. It must further be remembered that these
nerves are called upon to perform a double func-
tion, first to open the glottis during respiration, and
second to bring the cords together for the purpose
of phonation. The first is accomplished through
the abductor muscles, the two cricoarytenoid
postici ; the second function, through the adductors,
*Read before the New York Academy of Medicine. April 2. 190S.
including the cricoarytenoid laterales. the trans-
versus and the thyreoarytaenoidii interni.
There can be little question that the centre for
respiration is in the medulla, in all probability on
the floor of the fourth ventricle, and is not under
the control of the will. That there is a second cen-
tre for phonation in the cerebrum is also now gen-
erally admitted. Indeed in 1884 Krause demon-
strated such a centre in the anterior lower extremity
of the anterior central convolution of each hemi-
sphere, irritation of which on either side produces
bilateral adduction. This observation has subse-
quently been confirmed b\- various investigators.
The important corollary is, however, to be noted
that a lesion involving one centre alone is not suffi-
cient to suspend movement in the larynx, though
this occurs when both centres are involved. And
in spite of the persistent and ardent attempts made
to prove such a direct relation between the cortex
and larynx, the summing up of \Vright made ten
\ears ago' represents the views of most scholars
to-day, viz., "there has been no case reported in man
of a cortical lesion accompanied by laryngeal par-
alysis in which the possibility, and few in which the
probability, of involvement of the nervous tract be-
low could be excluded. We must, therefore, in
view of the positive evidence in animals and the
negative evidence in man, admit that Semon's dec-
laration of the nonoccurrence of cortical laryngeal
paralysis in man is probably correct." We are ac-
cordingly forced to limit the scope of such laryn-
geal symptoms, from a diagnostic standpoint, to
lesions of the medulla or below. When such svmp-
toms are considered we at once find that the motor
manifestations are by far the most striking. These
may represent either excess or diminution of action.
Excess of action is seen in spasms which may be
tonic or clonic. Tonic spasms may take the form of
a. spasms of the larynx ; b. laryngeal crises : c. ictus
laryngis. Clonic spasms as a. rhythmic twitchings :
and b, tremors, ^\'he^e an organic nerve lesion is
present, it is most frequently one of diminished ac-
tion or paralysis. These paralyses may involve the
superior or the inferior laryngeal nerve. A par-
alysis of the former alone, causing a failure to
respond on the part of the cricothyreoid, is exceed-
ingly rare. Mygind has collected reports of thir-
teen cases, four of his own. Three of these latter
showed bulbar sy mptoms, and in one a degeneration
of both superior laryngeal muscles was found on
autopsy. A study of paralyses of the inferior
laryngeal will reveal that they almost without ex-
^American Textbook of the Eye, Ear, Nose, and Throat.
Copyright, 1908, by A. R. Elliott Publishing Company.
924
HARRIS: DIAGNOSIS OF NERVOUS DISEASES.
[New York
Medical Journal.
ception involve the cricoarytenoideus posticus at
the onset and only ai a late stage of the disease, if
ever, attack the adductors. This striking fact was
first set forth by Sir Felix Semon in an elaborate
paper on the subject, and has since been known as
Semon's law. Its clinical significance is at once
apparent. A posticus paralysis, which, with the
cords immobile in the median line and their free
borders taut, would mean, in all probability, a cen-
tral nerve lesion. If now the picture should in time
change to one showing the cords in the so called
cadaver position, that is, midway between inspira-
tion and expiration with concave borders, we
would know that the entire recurrent nerve has been
involved, pointing to the progressive character of the
lesion in the bulb. This dictum of Semon has been
productive of much independent research which
has, on the whole, served to establish its correct-
ness. Onodi has shown the presence of separate
fibres in the nerve. Frankel has demonstrated that
when the nerve is frozen, the abductors fibres first
succumb. Hooper has found a similar condition
when ether was used, and Massini, when he em-
ployed chromic acid. Krause endeavored to experi-
ment on animals to show that this apparent paralysis
may. under certain conditions, be due to a reflex
contraction of the laryngeal muscles. This theory
has, however, been abundantly disproved by the fact,
among others, that at least one case of posticus
paralysis has shown at the necropsy a true atrophy
of the cricoarytaenoideus posticus. Finally, Grabower
has discovered that the nerve endings in the abduc-
tors diifer morphologically from those in the ad-
ductors, pointing to a - difference in their function,
the one being concerned with phonation, while the
others has to do with respiration. Indeed, Semon
believes in a "reflex tonic spasm in the posticus
muscle constantly present under the influence of the
respiratory centre, which serves to keep the glottis
always open.'' The existence of such a reflex would
serve, in his opinion, to explain the failure, first,
of the abductor fibres in a central lesion in con-
formity with the "physiological law that irritability
of afferent nerves is exhibited earlier than of eft'er-
ent nerves." Much remains, however, to be done
to reconcile seeming discrepancies, as is evidenced
by the fact that cases of posticus paralysis have been
observed for years where no change in the position
of the cords took place.
With this- hasty summary of the present day
views on the innervation of the larynx, for which
we are largely indebted to Curtis's translation of
Fredrich's admirable work on RJiiiiology, Laryngol-
ogy, and Otology, and Their Significance in Gen-
eral Medicine, we shall proceed to consider briefly
how we may make use of them in a practical man-
ner in diagnosis. As has been previously stated,
this applies chiefly to affections of the medulla and
below, although it is true that cerebral haemorrhage,
tumors, abscess, gummata, and pseudobulbar palsy
may produce motor changes in the larynx when ex-
tensive enough or properly situated.
Tabes Dorsalis. — Of the affections, situated in the
cord, locomotor ataxia probably presents symptoms
more often than any other. These may at times
show themselves in the nose by disturbances of the
olfactory nerve, such as anosmia or parosmia, but
usually they are limited to the larynx. Of these,
some form of paralysis is comparatively common.
Gerhardt found seventeen cases 'in 122 tabetics. Of
these, eleven patients showed a posticus involve-
ment, five bilateral, while three had paralysis of the
entire recurrent. Semon's statistics are similar,
fourteen cases in 100, eleven of which involved the
postici, sljowing an overwhelming preponderance
of abductor palsies. In a word, unilateral or bi-
lateral posticus paralysis may be regarded as char-
acteristic of tabes, and from the table of Berger
of seventy-one cases of laryngeal palsies found in
tabes, the bilateral form is nearly as common as the
unilateral. The voice in the latter variety may not
show any change, and accordingly such a condition
is undoubtedly overlooked unless a systematic ex-
amination is made. Indeed, even in the bilateral
form, the one symptom is gradually increasing in-
spiratory dyspnoea, with expiration unaffected. As
is well known, this may lead to pronounced
asphyxia, in time demanding tracheotomy.
Even more interesting are the various forms of
laryngeal motor irritations in tabes. These include
(a) ataxia of the cords, a name applied to a con-
dition in which the cords execute irregular move-
ments during phonation and deep respiration, giving
rise to the characteristic scanning speech ; and ( b)
laryngeal crises. These, like the palsies, may oc-
cur very early in the disease, preceding even the
ocular manifestations. The laryngeal crisis is char-
acterized by the simultaneous involvement of all the
respiratory muscles, and so dift'ers from an ordinary
spasm of the larynx, where only the laryngeal mus-
cles that suffer. It may arise without cause or as
a result of a slight local stimulation, such as swal-
lowing or touching the throat. It begins with a
tickling or burning in the pharynx, followed by a
choking sensation. A loud strident inspiration is
heard, followed by a short puffing expiration. The
patient gives rise to a cough, which is said to re-
semble that of whooping cough. While attacks are
not usually regarded as dangerous, five fatal cases
have been reported. Sensory disturbances in con-
nection with tabes are rare.
Multiple Sclerosis. — Multiple sclerosis of the
brain and spinal cord will produce symptoms in the
larynx almost, if not quite, as frequently as tabes.
These have been exhaustively studied by Lori. who
followed several cases clinically for years. The
common symptom present was a delay in the mus-
cular action. This may take the form of a tremor
in phonation. \\'ith this goes an abnormal tendency
to voice fatigue. After a short use, the voice en-
tirely fails. There will be noted also a scanning
speech with frequent interruptions by high pitched
explosive sounds. Because, too, the adduction is
not complete, the voice is often raspy or hoarse.
Finally, we occasionally meet with true paralyses,
usually of the adductors. W'e have recently seen
a woman of seventy years, where a diagnosis of
laryngeal paralysis had been made because of the
weakness of the voice. There were here the symp-
toms just mentioned, of scanning speech, voice
fatigue, and hoarseness, all indicative of a dissemi-
nated sclerosis.
Sxringoinclia. — Laryngeal symptoms, also mo-
tor in nature, and rocluced refle.x irritability of the
May 1 6. 1908.]
HARRIS: DIAGNOSIS OF NERVOUS DISEASES.
925
posterior pharynx wall are not uncommon in
syringomyelia. Forty cases of paralysis have been
collected "by Iwanow up to 1907, usually involving
the posticus on one or both sides, and occasionally
the internus muscle as well. It was on account of
the associated paralysis of the trapezius muscle in
some of these cases that it was thought at one time
that the spinal accessory sent fibres to the larynx.
Progressive Bulbar Paralysis. — Progressive bul-
bar paralysis, often known as glossolabiolaryngeal
paralysis, is especially characterized, as the latter
name implies, by symptoms referable to the tongue,
lips, and larynx. While those of the tongue are
wont to be very constant and usually appear early,
producing difficulty in speech, increased later by an
associated atrophy of the lip muscles, laryngeal par-
alyses, though important when present, do not oc-
cur with any such constancy. They may be the re-
sult of paralysis, either of the postici or of the
entire recurrent, and may be unilateral or bilateral.
Any serious involvement of the muscles here taken,
especiallyin connection with aboHshing of thepharyn-
geal reflexes, may permit the entering of food into
the bronchi and so give rise to an inspiratory pneu-
monia.
Progressive Muscular Atrophy. — Progressive
muscular atrophy will very commonly show some
symptoms m the pharynx or larynx. These are
usually of the nature of a paralysis, either of the en-
tire throat and larynx or more often of the larynx.
Here a unilateral posticus paralysis is most fre-
quently met with. Occasionally an anaesthesia of
the pharynx is also present.
Xeuroses. — The functional nervous af¥ections
which show themselves in the upper air passages
are the various neuroses. Of these we shall briefly
consider only the two most commonly met with,
paralysis agitans and hysteria.
Paralysis Agitans — Paralysis agitans, in a con-
siderable number of cases (five out of twelve cases
in one series examined), gives rise to symptoms in
the larynx. These are wont to be motor in char-
acter. Twitching movements of the cords will be
noticed in phonation. and also as a rule in respira-
tion, thus being distinguished from the tremors of
multiple sclerosis. The epiglottis may share in the
involvement. The speech is also at times scanning,
and there is wont to be a sudden change from the
high to the low pitch.
Hysteria. — Hysteria, as is generally recognized,
will give rise to symptoms of one kind or another in
the nose and throat in not an inconsiderable num-
ber of cases. These may be either sensory or motor.
Sensation is often affected. Anaesthesia of the mu-
cous membrane of the nose and pharynx is frequent.
It is usually not general, affecting only certain defi-
nite areas. The saeptum is wont to escape as well
as the larynx. Hyperaesthesia and analgesia of the
pharynx are even more frequent and take the form
of a choking sensation, tickling, feeling of a for-
eign body, and the familiar globus hystericus.
These often result from some slight trauma, and of
themselves may cause by the coughing organic
changes in the throat. Hysterical motor svmptoms
are wont to affect particularly the muscles of the
larynx. The most important of these are:
(a) Laryngeal Spasm. — This is often the result
of a preceding catarrhal condition. It may be the
first and only sign of hysteria. The clinical picture
resembles the spasm which follows occasionally
applications to the larynx. There is a series of long
drawn out inspiratory whistles, followed by a short,
loud expiration, attended by more or less severe
dyspnoea, and complicated at times by general con-
vulsions. It differs from the spasm attending an
organic lesion by not involving any of the respiratory
muscles. The appearance of the cords in the mirror
during the attack suggests a posticus paralysis, but
when the attack is over they resume their normal
position.
(b) Nervous Laryngeal Cough. — Xervous laryn-
geal cough, often referred to as chorea of the larynx,
shows, as all the other laryngeal manifestations of
hvsteria, a lowered vitalit\", together w^ith heightened
nervous irritability. While more generally met with in
women, it occasionally occurs in young boys, as we
have seen at least twice. Gottstein distinguishes two
forms, I, periodic; 2, continuous, rhythmic. It may
persist for hours, or even at times days and weeks,
but usually ceases during sleep, eating, and drink-
ing; and only rarely seems to affect the general
health seriously. The sound of the cough is char-
acteristically unmelodious, resembling a bark. The
cords are seen in the laryngeal mirror to come to-
gether at the moment of cough, but different from
the picture in the usual cough, they appear very lax.
There is also wont to be more or less of a distinct
vibration on expiration. The glottis is not entirely
closed, as is shown by the absence of cyanosis. 3,
Disturbances of coordination are especially interest-
ing. These may affect either the function of i, res-
piration or that of 2, phonation, very rarely, if ever,
both. As in similar conditions depending on an or-
ganic lesion, thev take the character of either over
action — spasm — or under action — paresis. Cases
where respiration is afifected are very rare : Treupel
has collected seven. The picture, as described by him.
is one where the glottis opens on inspiration, suc-
ceeded by a pause when the cords are strongly ad-
ducted. There is then an expiratory opening of the
glottis, complicated by an initial closing, then a
pause when the cords resume their normal position.
The symptoms of the attack vary in their severity.
There is usually great inspiratory dyspnoea, often
accompanied by cough ; and the beginning is marked
by a long drawn, audible sound of inspiratory
spasm. The face shows anxiety and fear of suf-
focation. The attack ceases during sleep.
Disturbances of Coordination During Phonation.
— These are more common, (a) Dysphonia spas-
tica is a term employed to describe the spastic form
here. As long as the patient makes no attempt to
speak the larynx appears normal, but the moment
he tries to make any sound the adductor muscles
come spasmodically together and the chink of the
glottis is lost. The patient may be able to get out
a few words or utterly fail to produce a sound.
Much more frequently still we meet with the (b)
paretic manifestations of incoordination in phona-
tion, known as aphonia. This very common mani-
festation of hysteria is the result, as a usual thing,
of a paresis of all the adductors and tensions of the
larynx, occasionally of the transversus and rarely of
the transversus and interni muscles. The picture
926
JELLII'l'li: HYSTERIA AND REEDUCATION.
[New York
Medical Journal.
is often a changing one. The cords may for a brief
moment come together. The false cords meet en-
tirely in many cases.
To Conclude. — While in this hurried presentation
of the subject we do not pretend to have included
all the various nervous af¥ections showing them-
selves in the region under discussion, we feel that
enough has been said to show two things: i. That
pharyngolaryngeal symptoms in nervous diseases are
deserving of more attention on the part of the neu-
rologist than they have received up to the present
time. And 2, that no field offers greater opportu-
nity to the laryngologist for original study and re-
search than that which embraces the innervation t)f
the larynx.
117 East Fortieth Street.
HYSTERIA AXD THE REEDUCATION METHOD
OF DUBOIS.*
Bv S^[ITH Ely Jelliffe, M. D., Ph. D..
New York,
Visiting Xeurologist to the City Hospital; Clinical Professor of
Psychiatry, Fordham University.
I have been asked to discuss the subject of the
Dubois reeducation method in psychotherapy, as
applied to the psvchoneuroses, and I make this at-
tempt fully cognizant of the necessary shortcomings
that such a task will reveal. First, with reference
to the time that such an expose would require in
order to do the subject justice, which is all too short,
and secondly, recognizing my own deficiencies for
such a task.
The gradual grow.th oi the principle and appli-
cation of psychotherapy is a fit subject for the es-
sayist's art. The entire history of medicine is
closely interwoven with the development of what is
so often called the soul life and with its expressions
in religion, and the insufficiencies of thought have
l)een reflected in both. Superstition and faith are
twins, brothers of the same family, and as Magnus
has well said, both originate in a .sense of the in-
adequacy of human science in the face of natural
phenomena demanding an interpretation. The early
human mind, all human mind, in the attempt to
explain has created an ethical requirement reaching
out beyond the comprehension of the individual to a
firmer understanding which it has called faith.
Faith, in my opinion, is one of the corner stones
of psychotherapy, and hence the method of my in-
troduction : ".\ new faith, separated, however, from
superstition, with which it has too often been asso-
ciated, is in the simplest of terms the expression
of what it is desired to impart by the reeducation
method — a faith raised to the level of reason and
of knowledge, .so far as we may be able to see it,
and so far as the intelligence of the patient may be
able to grasp it, is the aim of the psychotherapist in
u.sing the reeducation method" — I speak at this time
in symbols only.
In the earlie.st phases of the so called temple sleep,
I take it we see one of the most primitive expres-
sions of a medicotheological therapeutic applica-
tion of the principles of psychotherapy. A careful
reading of the ancient theologies no doubt reveals
other procedures closely allied, but for our present
•Contribulion lo a Discussion on Psychotlierapy, New York Neu-
roloRical Sf)ciety, Kebruary, 1908.
purposes, the psychical side of the therapeutics of
the priests of the pre-Hippocratic era. in which sim-
ple, abiding, childlike, unreasoning faith was the
master key, and which has persisted in smaller and
smaller degree to our own times, suggests the open
door to the present day developments of an old, old
idea.
It would be impossible for me, in this short space
of time, to trace the course of the leading strings
down through the centuries, but I bring to' your
minds the fact that there have been such, since one
of the fundamental features in the therapeutic art
of the true mental scientist is the need for the recog-
nition of primitive features in the mind stuff of his
patients, who are in need of educating if a synthesis
is to be brought about sufficient in degree to meet
the demands of the situations in which they may be
placed.
Just what classes are in need of psychotherapy in
some of its forms, is not my province to discuss.
The breadth of the foundation laid do^yn by Dubois
precludes even the mention of the different forms
of disorder in which the mind disturbance is the
primary or contributory factor.
Recognizing the danger that I may beat all about
the bush and raise no game. I shall purposely limit
my remarks to the consideration of one particular
type of reaction which, although hampered by the
misinterpretation of ancient and even our own
times, must needs blindly grope about in its protean
and bizarre aspects as hysteria.
I am led to develop some of my own notions con-
cerning hysteria, l^ecause, although recognizing that
I shall express them in the most general of terms,
should such thought reflect a fairly accurate ap-
proximation of the situation, it may be at once ap-
preciated whv the psychotherapeutic principle of
education is the one best adapted to give results
which may be hopefully regarded as permanent.
At the outset I desire to state a position that does
not regard hysteria as a disease, or a malady, due
to a specific disease process. I regard it rather as
a collection, in an adult individual, of primitive
traits of psychological response to physicopsychical
factors. From the ontogenetic aspect one might ex-
press it that hysterical individuals are grown up
children ; from the standpoint of phylogeny, they
are educated, or better, instructed savages. Ac-
cording to the proportion of these childish, or ata-
vistic traits, which may be present in an individual,
we find the symptom picture of hysterical traits, of
the hysterical temperament, of minor hysteria, or of
major hysteria ; not that major hysteria represents
any greater proportion of these reactions than
others, but their manifestation in the psychomotor
zone makes them the more striking.
I feel that I am not alone in holding that all of
the efforts thus far put forth to make all of the in-
numerable troubles (jualified as hysteria to fit into
one category as a morbid entity have been fruitless.
Hysteria considered as an entity appears like a
gigantic F'roteus and escapes all definitions. Seek-
ing to define hysteria by the description of all its
manifestations, different authors have been led to
include the entire symptomatology of nervous dis-
eases in their definition.
Bernheim. Schnyder. I'.inswanger. Dubois, and
May 1 6, 1908.]
JELLIFFE: HYSTERIA AND REEDUCATION.
927
many others have protested against this nosological
conception, and the former reserves for the crises
alone the term hysterical, giving to all the other
troubles considered as characteristic of hysteria
(stigmata, sensory motor troubles, visceral, etc.)
the value of those manifestations having the general
character of the psychoneuroses.
W'e are at one with Bernheim when he says, "hys-
teria is not a morbid entity." but. in his opinion, the
crises constitute the abnormal psychical process to
which one cannot without inconvenience apply the
denomination hysterical. They can appear episodic-
ally in certain individuals ; they are often widelx
enough extended, and continuous enough to permit
of our speaking of them as the hysterization of the
mentality. All in all, hysteria is the psychopathic
manifestation par excellence, the most primitive ex-
pression, ijie most common of the inherent weak
nesses of the human personality.
Hysterical modifications appear in mentalities very
diii'erent one from another. They may be present in
the gay and careless infant, in the sensible and im-
pressionable woman, in the anxious and morose man
modeling themselves exactly on the habitual tem-
perament. These psychical characters may be
summarized more or less didactically as follows : In- x
stability is a primary hysterical trait. This instabil-
ity is particularly prominent in the field of the
emotions — emotional lability, Krapelin calls it ; de-
pressive states alternate rapidly with periods of ex-
altation ; at one moment the hysterical patient is irri-
table and over impressionable, the slightest cause
giving rise to a flow of tears ; again, they are cold,
indifferent, and cruel. At one moment intriguing,
putting everybody by the ears, accusing others,
then again overcome with self reproaches for their
own wickedness. In their activities the same varia-
bility is manifest. At one time they are filled with
an almost pathological (manic) energy; again they
show its antitype, an absolute inability to do any -
thing.
A second trait is the marked influence of sugges-
tion. Babinski believes that a marked pathological
alteration of this one factor is enough in itself to ex-
plain all the phenomena of the hysterical reaction.
A third trait, negativism, flows as a corollary from
the second. In the terms of Bleuler's interpretations
of negativism it is a necessity consequent on patho-
logical suggestibility.
The egocentric nature is a fourth feature. The
attention is fixed almost pathologically on the ego.
and the constant search for changes within the per-
son's own body on which to hang complaints is pur-
sued with a definite pleasure and refined meditation.
The slightest sensation is caught hold of and magni-
fied. The pains of others, however, are not felt at
all. and jealousy and envy arise if other pains are
considered of moment to the neglect of theirs. To
be sick and the centre of the stage becomes a life
work, and a theatrical apprenticeship, with masterly
training under the suggestive tutelage of many phy-
sicians, usually gives a finished artist in the end.
This pathological egocentricity leads to a number
of secondary attributes, all very primitive in their
nature. The strutting war chief, proud of his feath-
ers and paint, is showing in his wn\- the self same
features that the hysterical patient show? in her at-
tempts to create a sensation. Her romantic accusa-
tions, sensational confabulations, self mutilations,
and refined theatrical attempts at suicide, all have
their real motive power in this desire to be the ob-
served of all observers. Lies, disfigurations, slan-
derings. stealing, and other crimes are not too much
to brmg this about. Simulation, in all its various
aspects, becomes a useful adjunct in this mechanism
to make the limelight constantly play on the individ-
ual's acts.
Practically all physical signs result from the sec-
ond factor of suggestibility, but the more complete
analysis of these is apart from our subject. We are
confining ourselves to the mental mechanism of these
psychic children.
W'e should note the dift'erent characters oft'ered
by infantile, male, and female hysteria by the ex-
aggeration of certain psyxhical mechanisms existing
in a more or less marked degree in all individuals.
The mental make up of a person may show modifi-
cations of a hysterical character which, though often
transient and accidental, may sometimes be so pro-
nounced as to constitute a distinct clinical form of
a psychoneurosis.
Hysterical manifestations may moreover appear
in connection with the more frank insanities (de-
mentia pr:ecox. manic depressive, various degener-
ative psychoses) : they have even been noticed along
with general paresis. They may also be found as-
sociated with other organic aft'ections of the nervous
system — cerebral haemorrhages, tumors of the brain,
tumors of the cord — they may make part of the
clinical picture of certain intoxications (alcoholic,
carbon dioxide, sulphonal, bromides, analgassic ani-
line derivatives ; . Finally they impress upon cer-
tain purely neurasthenic conditions certain charac-
teristics which justify the term hysteroneurasthenia.
It is not difficult to perceive why such hysterical
manifestations should accompany physical disease:
indeed it is in strict accord with our hypothesis that
the superior inclividual is one who by intelligence
and by training has developed past his hysterical in-
fancy, or youth, but let intercurrent disease reduce
his resistance, or sink the level of his nervous ten-
sion, as Janet would express it, and a partial rever-
sion to primitive traits is to be expected. To be a
hysterical old woman is another way of say ing that
an advancing arteriosclerosis has broken down the
synthesis of strong manhood and left the disorderlv
n.ncontrolled connections of youth, or infancy.
In the normal mentality of a child, one may find
the ground plan as it were of most hysterical mani-
festations, and to speak of a physiological infantile
hysteria, while it does not explain, is yet tenable.
Hysteria in an adult is closely allied to certain
psychic conditions which represent, in .fact, a men-
tal retrogression toward the infantile type, of which
the chief characteristic is the lack of logical judg-
ment. The hysterical individual is led by the ini-
tial defect into a system of autosuggestions which
may end up in a profound disturbance of his ]ier-
sonality.
The importance of moral causes in the develo]>
ment of hysterical states cannot be overestimated.
From this point of view we may consider hvsteria
as a series of abnormal reactions of the individ'ial
to the exigencies of life. These abnormal modes
92S
JELLIFFE: HYSTERIA AND REEDUCATION.
[New Vokk
Medical Journ'al.
of reaction are often the consequence of the fetters,
or the obstacles which the moral and social order
imposes upon the expression of the natural tenden-
cies of man and show themselves the more strong-
ly the closer the man approaches the child view-
point.
In a general way, one may say then with Schny-
der that the hysterical modifications of the mental-
ity have as their starting point a defect of judgment,
or lack of mental synthesis, which leads to an er-
roneous conception of real situations, and a conse-
quent inability to adapt oneself to them. Hysteria
is, in the first place, a disease of the evolution of
the human mind. It represents a break in the de-
velopment of the mentality. Therefore, hysteria in
its pure form is a disease of youthful individuals,
just as it IS a disease of humanity in its infancy.
One rarely meets it in the adult whose mentality
has reached its full development. Its reappearance
in the years of involution is self evident.
With Schnyder, I believe that one can show that
from the phylogenetic point of view, hysteria may
be the attribute of evolutionary phases of human-
ity ; in history it appears to blossom each time that
the aspirations of the human mind have been held
back and repressed by the laws of the established
order of the age. Namely, in those periods which
have preceded the great moral, social, and political
revolutions. Schnyder asserts that the best example
of this is seen in the Middle Ages, which was the
classical period of "hysteria of the masses," or, as
Hellpach has expressed it, "the period of the in-
fancy of individualism," where all the forces of con-
servatism, with the. Church at their head, were
struggling in vain to withstand the ' inroads of
newer and better adapted, moral standards of in-
dividualism.
I do not feel at one entirely with Hellpach's state-
ment concerning the attitude of clericalism toward
the whole movement. What he sa^s is only a half
truth, too biased and perhaps prejudiced by the lit-
erature of anticlericalism. I prefer to see it in the
light of the upward impetuous striving of human
effort and culture apart from any preconceived no-
tions we might have regarding efforts at repression,
as coming from one side alone. The driving, for-
ward element was just as evident in ecclesiastical
as in nonecclesiastical circles, and the bonds of con-
servatism were not all of religious forging.
With Schnyder and Moebius, I believe that hys-
teria cannot be considered as the attribute of a peo-
ple whose civilization is too refined, unless it be
the expression of the decadent period of a people.
Empirically we find that certain classes of indi-
viduals possess mentalities which offer a favorable
soil for the growth of hysteria. There are, on the
one hand, the dwellers in rural communities, and on
the other the workmen of the proletariat. At the
present time it is among those coming from the
country that one actually meets the purest types of
hysterical conditions. There may still be found,
from time to time, in some remote village, an epi-
demic of hysteria which recalls the classic instances
of the kind described in the Middle Ages. We are
all familiar with such instances.
T need only remind you of Krapelin's researches
among the natives of Java, where he found hysteria
extremely abundant ; in fact it and dementia prsecox
were the most prevalent types of mental disorder.
Hysteria as seen clinically to-day is the morbid
psychic reaction of choice in individuals of simple
and naive minds who are transported into condi-
tions of existence to which they find difficulty in
adapting themselves. It has been held by many that
emigration from the country to the city, by reason
of the efforts at adaptation which are necessary to
individuals, constitutes an important cause of mod-
ern hysteria, in which connection Gaupp's interest-
ing comparisons of the psychoses in rural and
urban communities are illuminating.
We have already seen the important role which
social aspirations play in the hysteria of the prole-
tariat workman, which Hellpach considers to-dav
as the same thing as the hysteria of the masses of
the Middle Ages. "Hysteria is the ofdinary re-
sponse to the exigencies of life in all those people
whose roots have been torn up, or who have been
disenchanted with their ideas, but who still present
the simplicity of psychic reaction of a child."
So much for that aspect of hysteria seen in its
simplest phases as an expression of the naive child-
ish type of mind still engrossed with the Avondei
working of Nature.
There is still another type which has often been
written about, particularly by the French school,
whereby hysteria is regarded only as a manifesta-
tion of mental degeneracy. There is no question
that one may say that it is a manifestation of men-
tal insufliciency. But this term "insufficiency" is
by no means definite. One can only speak of the
mental insufficiency of an individual in regard to
the conditions under which such an individual is
called upon to live. Mental insufficiency indicates
disproportion between the mental aptitude of the
individual and the demands imposed upon him bv
life. There is a mental w-eakness which may be
purely physiological in itself as in the case of a
child and to a certain degree in woman ; in the same
way such mental weakness may be the attribute of
the average mentality of a race, of a people, and of
a class. According to the external conditions this
weakness will pass into insufficiency and will give
rise to pathological manifestations such as hysteria.
Following Schnyder I have laid considerable
stress upon that aspect of hysteria which may be
called cvohitizr. forming, in fact, only an accident
in the mental evolution of the individual or of the
species. There remains to be discussed very briefly
this second group developing not on a simple
healthy soil, but on that of a distinct neuropathic
heredity, a group which we have for some time
termed the degenerative hysterias.
The degeneracy may lead the mentality toward
an inferior type which it .corresponds to in some
particular, as the infantile type. The psychic change
is often partial. It may, for example, allow bril-
liant intellectual faculties to exist along with a loss
of the moral sense (superior deviate). It pre-
disposes to hysteria when it diminishes in the in-
dividual the qualities of judgment and of rational
criticism, permitting these individuals to flounder
into psychoneuroses according to the degree in
which the conditions of their existence arc unfavor-
able to them. It is in this group that we find the
May 16, 1 90S. I
JELLIFFE: HYSTERIA AXD REEDUCATION.
929
great disproportons in mental capacities. It is from
this mixture that the demifous of the world are
made.
To say that the hysterical forms of degeneracy
are met with most often in the superior classes of
modern society, in what might be called the bour-
geois classes — the newly rich, or springing from
those unions in which titles and dollars, or family
and wealth make an uneven mixture, only details
of course a fact of distribution. These forms more
rarely present the characteristics of pure, out and
cut hysteria. The mental degeneracy asserts itself
by combinations of hysterical symptoms, and by
symptoms belonging to other psychopathological
conditions. It is perhaps in this milieu that the
purer types of Janet's psychasthenia are encoun-
tered.
Finally a word as to a third broad subdivision,
not that these subdivisions are anything more than
of the most general scope — we find the purely symp-
fomatic hysterias. These have already been men-
tioned. They constitute one of the chief stumbling
blocks in the path of psychotherapy. Picture one's
attempts to try to reeducate a patient who is suffer-
ing from dementia prsecox. with an accompanying
symptomatic hysteria : or one in whom a carcinoma
of the stomach, or a multiple sclerosis, or a tumor
of the brain or spinal cord is overlooked. The case
reported by Dr. W. A. Timme last year before this
society of general spinal carcinosis which went the
rounds of many of our members as a hysteria, is
only one of jnany of this type, and I think that I am
not unduly critical in holding the opinion that some
opposition to psychotherapy is found in the minds
of those who have thought it inefficacious in cases of
this kind.
But to another phase of the problem of hysteria
and of psychotherapy. Does hysteria constitute a
morbid modification of mentality more frequently
seen at the present time than formerly? What is
the future of hysteria? Such questions interest
both the physician and the psychologist.
It is very difficult to solve the first question by
depending upon statistics, and almost impossible to
bring them together upon the subject. However.
I believe that the statistical study of hysteria per-
mits us to state that certain forms of hysteria have
diminished in frequency as the result of the pro-
gress of civilization. These are. first of all. the
collective hysterias affecting a whole population,
such as were described in the Middle Ages under
the various names, saltatory epidemics ; dancing
manias ; witchcraft ; inquisitions, etc. Then the in-
dividual forms growing out of religious mysticism
and the belief in spirits and demons. Manifesta-
tions of this kind are still seen to-day. but in a
manner isolated and of a more benign character
than hitherto. Whatever one may say of it the pro-
gress of education in the majority of civilized coun-
tries has made the limits of credulity recede. The
superstitions of the rustic become more and more
rare; but if naive credulity has lost ground, it has
given way to those qualities of healthy logic and
rational criticism which prevent the influence of
false auto suggestions and erroneous conceptions of
realities to rule the personality.
If we can believe that the mind of the masses is
becoming more and more free from the false doc-
trines of the past — from the manufactured ideals
meant for the good of certain classes and imposed
by all the power possible by these classes, call them
religion, or politics, or socialism, or what not ; if
liberty of thought meets fewer obstacles, and more
sympathy, even if the reach for happiness has taken
on a more rugged character, social revindication
and economic struggles constitute for the modern
man an ever renewing source of moral disturbance.
Abandoning more and more the hope of future
compensations, as preached by such moderns as-
Nietzsche, Ibsen, and others, man wishes to possess-
and to enjoy everything immediately. Impatience,
irritability, immoderate ambitions, the idea that hap-
piness consists only in accumulating material ad-
vantages, these are the disturbing features for the
modern individual. It is not at all astonishing,
therefore, that his nervousness bears the mark of
these various influences, and is distinguished from
a nervousness fed by characters which dift'er from
those of former times. Alodern nervousness is
translated into neurasthenic or psychasthenic forms
more than by purely hysterical forms. Hysterical
conditions are still strongly impregnated by mys-
ticism, imagination, fantasy, naivete, and puerility
which belongs so to speak to the golden age of
nervousness. Modern mentality in the upper levels
of culture is more complicated ; it lends to man an
imagination which is less replete with ideals ; it also
leads to morbid manifestations which are more ade-
quate to reality.
Hysteria stiil remains the appanage of primitive
mentalities. It will still constitute, for a long time,
the morbid manifestation of choice of the feminine
mentality, which submits more easily than that of
man to concerted influences. However, it is to be
foreseen that the contemporary feministic move-
ment, by exposing woman to social conditions anal-
agous to that to which man is submitted, will make
her share the risk of a common nervousness. In
woman the neurasthenic conditions will tend to sup-
plant hysterical conditions, and there are not want-
ing many who think this is so to-day.
I believe that the era of the grand manifestations
of collective hysteria may be considered as closed.
(The factors that have brought this about are be-
yond our present discussion.) Man possesses to-
day in the face of causes of intellectual, political,
and social oppression to false ideals means of re-
action which he did not formerly possess. Liberty
of the press, democratic political institutions, work-
men's organizations permit him to manifest his dis-
content otherwise than by hysteria. These are the
present day conversions for what in the past might
show themselves in general hysteria. On the other
hand, hysteria by reason of individual manifesta-
tion is not ready to disappear, for it would be rash
to hope that the faculties of logical and rational
criticism would so soon dominate the psychical ac-
tivities of man.
The moral education of man still rests in a large
degree on the principle of authority transmitted hy
the Church ; it makes the practice of duty depend
upon the fear of punishment and the hope of re-
ward. It does not incite man to seek for pure and
simple truth, or to disinterested culture of right;
930
KOYSTER: DUTY TO CHILDREX.
[New York
Medical Journal.
it does not develop sufificiently his judgment or
healthy logic, necessar)- qualities for the formation
of a high moral conception of life. It is this last
which will permit man to pursue with serenity the
end which he proposes in life, without selfish pre-
occupation and without discouragement ; it is in this
way that he will escape the depressing and dissolv-
ing action of the emotions, and that he will accept
the inevitable with a healthy philosophy of life, and
will not seek in the subterfuge of hysteria a remedy
for his insufificiency. or a compensation for his dis-
appointed hopes (Schnyder).
If I may here interpose a thought from Xietzsche
which expresses this truth in another form. "r^Ian's
shame of man. The weary pessimistic look, the
mistrust toward the riddle of life, the chilling Xo
of the surfeit of life — these are not the symptoms
of the most evil period of humanity. ( )n the con-
trary, being swamp plants, the}- appear only when
the swamp to which they belong has sprung into
existence. By that I mean the sickly eft'eminac\
and moralization by means of which the animal
man is taught to feel ashamed at last of all his in-
stincts. On the road to become an "angel.' man
(and particularly woman ) has reared for himself
that spoiled stomach and furred tongue, which ren-
dered obnoxious to him not only all the pleasure
and innocence of the animal, but made life itself
of ill taste to iiim. "
"A strong and well fashioned man will digest his
experiences (including deeds and misdeeds) as he
will his meals, even if he has to devour hard morsels.
In case he fails to get beyond an experience this
kind of indigestion is physiological no less than the
other, and, in many cases, merely one of the con-
sequences of the other.'" Xietzsche, Genealogy of
Morals, p. 78.
As may be seen, we have arrived at a moral con-
ception of hysteria, which seems to be the logical
termination of a study which has for its object path-
ological manifestations of the mind which are most
Ultimately bound up with the moral personality of
man. If psychology is absolutely indispensable for
the analysis of the mechanism of hysterical phenom-
ena, and here we have full justification for those
methods of study as outlined by Freud, Jung, Janet,
and others, it cannot in itself alone resolve the com-
plex problem of the origins of the hysterical modi-
fication of mentality. To all psychological concep-
tions of hysteria there must be associated a moral
conception of it. It is chiefly this moral conception
which ought to inspire all rational treatment of
hysteria, such as has been indicated by Dubois in
maintaining for the psychoneuroses a moral treat-
ment in the highest sense of the word. The psycho-
logical analysis alone is but a step in the process
toward reaching, from the therapeutic point of view,
anything but partial results and the suppression of
such and such s\-mptoms. To get at hysteria in
its very origin, one nnist penetrate more profoundly
into the personality of the patient. He must be
heli)e(l to reconstruct his mental synthesis on the
basis of good logic, and to reconstruct his moral
education, a complicated and often arduous task,
but in Dubois's terms it is a true treatment of the
.soul which no physician could repudiate to-day.
f->\ W icsr Imitv-sixth Strl;i:t.
THE AiEDICAL PROFESSION'S DUTY TO THE
CHILDREN OF AMERICA.*
By L. T. Rovster, M. D.,
Norfolk, Va.
Looking back over history many changes are ap-
parent. Xations have risen, waxed strong, pre-
vailed over lesser peoples and disappeared : kings
and rulers have appeared, triumphed for a space
and passed away ; war and pestilence have de-
vastated the land, pauperized nations and crushed
their rising hopes : all these are remembered to-day
by a page in history and are relegated alike to a
desolate immortality. Evil forces have not always
prevailed, however, for there has been a more
potent influence for good, and in the midst of
gloom and despair the dawn has broken upon events
notable for their uplifting influence on the human
race and the improvement of health and morals.
X'o changes have been more marked, either in
themselves or in their result, than those in the field
of medicine. These changes have been quiet and
unostentatiotts, characteristic of the lives of the men
through whose efl:orts they have come to pass ; men
who lived lives of self sacrifice, poverty, and even
persecution to serve their fellow creatures.
The evolution of medicine is pectiliarly interest-
ing. The incantations and gesttuTS of the "medi-
cine man" of the aboriginal tribes have given place
to the assayed drugs of the modern pharmacopoeia :
the terrible carnage of epidemic pestilence has been
checked by the simple application of isolation and
quarantine : "laudable pus" has disappeared and in
its stead we have a clean wotind healing by first
intention, as a result of cleanliness in the operating
room ; the ignorant and uncleanly "granny" has
been supplanted by the trained obstetrical nurse,
and yellow fever and malaria are fast disappearing
through the destruction of the mosquito. Through
the whole field of investigation, discovery, and im-
provement there has been a strong and marked ten-
dency toward prevention and this is imdoubtedly
the keynote of modern medical endeavor.
But while the world has been gradually aroused
to the importance of medical matters the most im-
portant part of the human race has been singularly
neglected. I refer to the children, for only during
the past fifteen years have the\- begun to receive
their just proportion of our attention, and to them
the physician owes his greatest duty. The affairs
of the nation will soon rest on the shoulders of the
children of to-day. and how many reach the years
of mattirity physically capable of coping with the
])roblems which confront them? On whom rests the
responsibility of improving the physical, mental, and
moral being of the nation ? Especially on the physi-
cian. Undoubtedly the greatest source of mortality
among infants is ignorance in their handling, the
correcting of which fact is obviously education, and
who alone can supplv the necessary instruction to
overcome this evil ? Manifestly the physician. How
then can the physician best do his duty to the chil-
dren of our nation ?
First by educating himself and second by edu-
cating the public. P.-ediatrics should be taught as
thoroughly in our medical colleges as is anatomy or
•.Addrfss bcf.irc the Tacultv and Graduating Class of the Uni-
versity of North Carolina at Raleigh. N. C, February 22. 1908.
May 16, 1908.]
ROVSTER: DUTY TO CHILDREN.
surgery, yet it is only within the past few years
that this branch has been given any attention what-
ever as a separate course in the curricuhim, with
the result that men have graduated and become
practising physicians knowing nothing concerning
this class of patients, consequently these patients
have been turned over to the tender mercies of old
women and superstition, usually synonymous terms.
The study of paediatrics is to-day in the class of
specialties, and when we consider the fact that out
of every one thousand children born into the world
two hundred and thirty die during the first twelve
months and 10 per cent, of the remainder before
the end of the fifth year, does it not seem imperative
that a larger proportion of our efforts should be
directed to the prevention of this terrible loss to
the race during infancy?' To this end not only
should paediatrics be taught in the curriculum of
our colleges bv thoroughly capable pasdiatrists. but
no course of clinical medicine should be considered
complete until a large amount of time shall have
been devoted to the study of children. Not every
practitioner is expected to acquire the knowledge
of a specialist, but every physician licensed to-day
must be expected to know enough about children
to appreciate his limitations, and when he does this
and is honest with his patients and himself he will
seek competent advice, when needed, just as he does
in surgery or conditions of the eye. Also in order
that he may do his duty by the children in his prac-
tice he must know the right and wrong in handling
them and so teach the parents that they in turn
may do their duty.
Every hospital should be supplied with properly
equipped children's wards where all conditions
peculiar to this class of patients may be given the
most approved treatment. In order that they may
receive the best treatment the convalescent ward
must be distinct from the sick ward, in order that the
little patients may be removed from depressing sur-
roundings and be given an opportunity to express
their feelings in play and laughter, signs of return-
ing health.
One of the most important matters concerning
children wliich demand the attention of the profes-
sion is the "secret nostrum" evil, which has become
not only a blot on our civilization, but is a menace
to health and even life. I believe that the admin-
istration of such substances is responsible for more
deaths than we realize, and it is imperative that
some definite measures be adopted which will con-
trol the distribution of such nostrums and the
criminally false statements asserted for them
through the medium of clever commercial advertis-
ing. If legislation can accomplish nothing, and it
seems that it cannot, then the profession must edu-
cate the public among whom it moves as to the
certain result of relying on the supposed benefit to
be derived from the use of articles absurdly alleged
to be curealls : and that a compound which may
do no positive harm may by delay place the patient
beyond the aid of intelligent treatment. It seems
that something might be done to prevent such
quackery from affecting innocent children at least.
^These statistics are an average compiled from a large number
and relate to the suburbs as well as the closely settled centres cf
population, both American and foreign.
And just here a word may be pertinent concerning
the so called "ethical proprietaries." These may be
made just as dangerous as the secret nostrum if the
statements of the manufacturers as to their scope
and power are not curtailed. The use of these
preparations arises from two sources : First, the
parents themselves get into the habit of prescribing
for their children in accordance with the printed
circular, and the second, which I am ashamed, al-
most, to admit, through the indifference and ignor-
ance of the profession itself. Physicians not know-
ing a great deal about children are only too apt
themselves to accept the statements of the circular
of information and prescribe in original packages —
as they are always advised by the manufacturer to
do — some proprietary preparation, or to advise the
mother to give the bab>' this or that cough mixture
or prepared food. Is it not time to call a halt?
Unfortunately, maternal feeding in this country is
fearfully on the decrea-^e and we all know that there
is no true substitute for mother's milk, but when
the necessitv for artificial feeding does arise the
greatest care and study on the part of both parent
and physician are absolutely essential to success. As
cooperation on the part of the mother is necessary,
it is our duty to instruct her carefully as to the
nature of feeding, the care necessary in the prepa-
ration of the meal, and the scrupulous cleanliness
which is essential in the handling of milk and uten-
sils, and on these points the average physician is
in many instances in as great need of having his
attention called to these things as the mother. The
busy practitioner with little time at his disposal is
too apt to overlook details and to fail to examine
the conditions surrounding the child, the character
of the stools, the sources from which milk and water
are being secured, and the necessities of the indi-
vidual child. Rules and formulas have been set
forth from time to time which are said to over-
come the various difficulties of infant feeding.
Each discovery or improvement has met with
marked success for a while only to fail in some
difficult case. All of these various ideas, however,
have served their purpose and will ultimately result
in a treatment based on rational application of well
imderstood conditions and principles.
The greatest number of failures must be ac-
counted to the fact that we too often lose sight of
the individuality of the patient. It is just as true
of children as of any other patient that what is one's
food is another's poison. When we are not suc-
ceeding in an individual case we are too prone to
shift responsibility, and unfortunately this is usually
done by telling the mother to administer some com-
mercial preparation "guaranteed to suit any case"
by following the directions of the circular. Thus
the mother is left helpless to rely upon her own
tmedticated judgment, and the child finally becomes
a monkey faced marantic or a fat. rickety or scor-
butic wreck ; if it does not die. Is this doing our
duty by this class of patients? If the physician has
not the time to study the difficult cases in his prac-
tice, he must do the honest part by his charge and
consult one who possesses special knowledge on the
subject, just as he would turn over to the surgeon
a case of gallstones or brain abscess. I have yet
to meet with a case of feeding which was not
932
ROYSTER: DUTY TO CHILDREN.
[New York
Medical Journal.
amenable to treatment by properly modified cows'
milk. Hence I do not consider the prepared foods
of commerce a necessity. Few communities are as
yet supplied with up to date laboratories for the
scientific and approved preparation of milk formu-
las, so in most instances the mother must be in-
structed in this preparation, which as a rule can be
done very well, and some of my very best results
have been obtained under such circumstances.
An intelligent mother is as great an aid to the
physician as the ignorant one is a drawback, hence
the importance of the physician personally instruct-
ing the mothers of his patients. In doing this we
have not only the most important but the most
difficult part of our task. As before suggested,
ignorance and superstition have played so important
a part in the handling of infants that their influence
is difficult to overcome. The idea that a teething
child must necessarily have green and undigested
stools or "inward fevers" is just as erroneous and
absurd as the "sun do move" theory, and the fact
that milk in some form of modification must form
the sole article of diet during the first year of life
cannot be too forcibly impressed on the public mind,
and a matter of just as great importance is that
every child artificially fed must at all times be un-
der the care of a physician.
The improvement and maintaining of a proper
milk supply of a community should be the constant
care of the medical profession, and in order that
this as well as all matters pertaining to the welfare
of children be properly attended to, this profession
should be represented on all controlling boards.
The value of fresh air in the treatment of all
ailments of children as well as its influence on the
healthy child cannot be too strongly emphasized.
It is not sufficient that the little ones have a daily
outing ; as near as possible the growing child should
live out of doors. High winds and damp atmos-
phere must, it is true, be avoided, but aside from
these two conditions we need not fear the result of
outdoor life. The best tonic for a physically sub-
normal child is fresh air and sunshine. I have re-
peatedly seen a child that did not seem to be improv-
ing on what appeared to be a proper milk formula at
once pick up and gain steadily when sent out of
doors for the greater part of the time. The old
superstition that a sick child must not be exposed
to the atmosphere of outdoors is deeply rooted in
the popular mind, and we frequently see the room
in which a sick child is lying close and stuffy to the
point of suffocation. I am now following an al-
most universal rule in using all the fresh air com-
patil)le with the condition of the individual case.
The school children of to-day are in vastly greater
need of our attention than those of former times.
The strenuous life reflects itself on the school
child ; further, it has extended itself into the very
school room. The temptation to overcrowd the
child with multitudinous duties and studies is great.
The standard of the grades is constantly being
raised, even though the children are probably less
prei)arcd physically than they were a generation
ago. The question is repeatedly asked why so many
men of prominence come from the rural districts;
the answer is plain. The quiet life of the country
or small town better prepares the nervous system
for the battle before it, while the active and irregu-
lar city life produces young adults with already
wasted energies almost devoid of that poise of de-
velopment which is so necessary in a calling of any
kind. The old saying, "early to bed, early to rise,"
etc., is to-day considered a relic of medievalism and
is too often laughed at as being out of date, but
if the average American mother would pay personal
attention to her off'spring and not leave them to de-
velop along lines of their own choosing rather than
those which are for their good, and not spend so
much time and thought in getting them into society,
or having them taught "accomplishments" which
are really drawbacks to their physical and moral de-
velopment, and dwell more on matters which tend
to develop character and health, we would have as
a result the sturdy manhood and womanhood for
which in this age the need is so great.
The choreic school child is an object of pity, and
the one who is suffering from adenoid vegetations
is noticeable at sight and is incapable of mental
activity, but nevertheless these creatures are forced
beyond their strength to keep up with a grade too
advanced for them. From such as these as well
as those suffering from eyestrain come many of our
laggards and defectives. These children are often
kept back in their class and in turn keep the class
from advancing, yet most of this could have been
overcome or prevented had the family physician ob-
served more carefully the children in his practice
and advised the proper measure of treatment in the
individual case. All children classed as backward
should be given the benefit of a thorough medical
examination and all physical defects corrected. Eye-
strain should be relieved and adenoids removed,
and by this procedure a large percentage of such
children will soon be among the average of their
class, if not at the head. It is surprising how much
the mentality of children is affected by physical
defects. The results of treatment in this direction
are little short of astonishing, as is clearly proven
by the report of the recent "adenoid crusade" of
New York city. Those children whose defection
is truly mental can be vastly improved in special
classes and schools devoted entirely to their instruc-
tion, where the difficulties of individual cases may
be met and overcome by proper training directed
to personal needs.
The fearful and shameful results of ophthalmia
neonatorum demand our most careful consideration
and the most stringent laws should be adopted and
enforced in all States, requiring prophylaxis at
birth by careful attention to the hygiene of the eyes
of the infant. The neglectful physician is, in large
measure, responsible for the baneful result in this
condition.
No discussion of this nature would be complete
without at least a reference to the inexorable law of
heredity. This law hangs over us as a dark shadow
and cannot be brushed aside, and until the time
arrives when national eugenics become more than
a theory the duty of correcting the evils incident
thereto lies largely at the door of the physician.
The care of the pregnant woman and prophylaxis
regarding venereal disease is the duty you owe the
generations yet unborn. The opportunity afforded
the family physician in uplifting the human race
May J 6, 1908.]
SHIVELY:
TUBERCULOSIS AND DIABETES.
933
is one which you should appreciate and grasp and
utiHze, and in tliis way better than in any other
can you be benefactors to humanity. As I have
already said, the health and morals of a nation are
always complementary, and the mothers of the land
are the powerful agency through which we must
accomplish the greatest good. Mothers are the di-
rectors of the lives and conduct of their offspring,
and from them should come the proper instruction
of the children, but from the medical profession
must come the instruction for the mother.
The mothers of this country are in appalling need
of instruction in the rearing of their children ; they
must be taught how to feed them ; that, as has been
said, milk in some form of modification is the only
food necessary during the first year of life, and
that any other substance during this period is not
only harmful, but exceedingly dangerous. That
few artificially fed children can digest whole milk
even at the twelfth month, hence the weaker formu-
las increased in total quantity are far better as a
rule and more easily digested than the smaller
amount of a strong solution. That the lunch of the
school child is more important than the home meal,
and that its preparation should be attended to with
great care. That sweets should form a very limited
proportion of the diet of the growing organism,
and that fancy dishes should give place to plain
but wholesome food.
The mother must be taught also how to direct
the child's exercise. This should be as far as pos-
sible in the open air and always of a definite char-
acter and preferably with a certain amount of sys-
tem. The associates of children should be care-
fully watched, and here the whole responsibility
must rest on the mother, but the physician must
tell her why this is of importance in protecting the
morals of the child, as the wrong sort of com-
panions may impart a very erroneous impression of
right and wrong. Above all, the mother must be
told how to inform the child who is about to change
from youth to young but mature physical adult life,
about matters pertaining to sex, on a correct un-
derstanding of which and on the proper care along
these lines depends the protection of the race from
the dread results of venereal disease, for one single
misstep may result in the acquirement of syphilis
and the ultimate production of that pitiable object,
a luetic oft'spring. These matters must be taught
by the mother, who, above all, should be the one to
instruct the children, and the mother in turn should
learn them from the family physician. I repeat,
therefore, unhesitatingly, that the medical profes-
sion has it within its opportunity to be the greatest
factor in the uplift of the nation.
Young men of the graduating class resolve, there-
fore, in leaving your alma mater that you will be of
service to your fellow men ; that you will be a force
to uplift the fallen, to cheer the despondent, and,
above all, to benefit the race; and to this latter end
heed the cry of the children who come under your
care, for upon them depends the future of our coun-
try and the human race; give the humblest child
whose habitation is a cottage the same gentle, pains-
taking care you give the more favored one whose
dwelling is a palace, for upon a physician such as
this was passed the encomium of the great philoso-
pher who said :
"But nothing is more estimable than a physician
who, having studied nature from his youth, knows
the properties of the human body, the diseases that
assail it, the remedies that will benefit it, exercises
his art with caution, and pays equal attention to the
rich and the poor."
Taylor Building.
THE ASSOCIATION OF TUBERCULOSIS OF THE
LUNGS WITH DIABETES MELLITUS.*
By Hexry L. Shively, M. D.,
New York.
For two diseases so essentially different in their
nature as are pulmonary tuberculosis and diabetes
mellitus, there are certain points of analog}- be-
tween them which are at once curious and striking.
Diabetes is to be considered a typical example of a
disease of metabolism, of disturbed function due to
the action of unknown toxines originating within
the body itself. The production of these toxines is
apparently related in some way to the internal
secretion of the islands of Langerhans, and there is
accumulating evidence, for which we are largely in-
debted to the investigations of von Mering and Min-
kowski and the recent researches of Hansemann,
Opis, Herter, and Bosanquet, that the pathological
basis of true diabetes is a congenital or acquired in-
sufficiency of these histological elements of the
pancreas. Hansemann found the pancreas diseased
in seventy per cent, of all of his cases which came
to autopsy. In nineteen cases Opie showed the gland
to be affected in fifteen, Bosanquet in seventeen out
of nineteen cases.
Tuberculosis of the lungs is perhaps the best
known and most carefully studied example of a
chronic, infectious disease due to a specific micro-
organism introduced from without the body. Both
diseases are usually progressive in their course and
are regularly attended by emaciation ; in both there
is impairment of the power to utilize carbohydrate
food ; both diseases are very fatal in early life, and
are, on the other hand, comparatively well with-
stood when they appear after middle age. Both have
strong racial affinities. The negro and Irishman,
who are extremely susceptible to tuberculosis, are
less so than most races to diabetes. Statistics
of the Johns Hopkins Hospital show that the negro
in Baltimore has only half the susceptibility to dia-
betes of the general white population. In Ireland
the mortality from diabetes is three per 100,000, as
compared with seven in 100.000 for England, and
five in 100,000 for the whole of Europe. The Tew,
who is generally believed to be especially resistant
to tuberculosis and in whom the disease certainly
often takes a more favorable course than in other
nationalities, is singularly prone to diabetes, as are
Hkewise the French and the native populations of
India, especially the Hindus. In Paris the mor-
tality from diabetes is fourteen per 100,000. \'on
Noorden states that at Frankfort the deaths from
diabetes among Jews are more than six times the
*Read before the West End Medical Society, February 22, 1908, and
before the Section in Medicine of the New York Academy of Medi-
cine, .'Xpril 21, 1908.
934
SHI r ELY: TUBERCULOSIS AND DIABETES.
[New York
Medical Journal.
proportion among non-Jews. Bouchardat considers
the frcquenc}- of diabetes among Hebrews to be due
to their fondness for sedentary occupations and dis-
incHnation for physical exercise. Von Noorden ad-
A'ances the theory that it is due to a physical degen-
eracy produced by many centuries of inbreeding.
Jloth tuberculosis and diabetes are more common in
cities than in the country, and in both hereditary
l)redisposition is of some account in the aetiology.
Fitz and Joslin found heredity to play a role in
23.8 per cent, of their cases of diabetes, Naunyn
in seventeen per cent, of the cases reported by him,
Bouchard in twenty-five per cent., and von Noorden
in 18.5 per cent. It has even been suggested that
tinder some circumstances diabetes, like tubercu-
losis, may be communicable, as in the so called cases
of conjugal diabetes reported by Reil and Henke,
Oppler, Kiilz, Schmitz, and others. Naunyn agrees
with Senator, however, that these cases are to be
explained as coincidences. In both diseases drug
treatment is of relatively little value, as compared
with the importance of cletailed attention to hygiene
and diet, and the intelligent cooperation of the pa-
tient himself is vitally necessary for any measure
of success in either. The prognosis in both is large-
ly dependent upon the social and financial status of
the patient, the unfavorable influence of poverty,
ignorance, and bad hygienic conditions being most
marked. Both diseases exercise a decided effect upon
the psychical attitude and morale of the patient.
The tendency of the diabetic is to melancholy and
a peevish hypochondria. The consumptive, on the
other hand, frequently .exhibits a blind and fatuous
optimism. Finally, both tuberculosis and diabetes
are often associated in the same person.
This association has long been a familiar clinical
fact. It v.-as first noted in literature by Richard
]\forton in i6(/j. his Latin treatise, entitled
PlitJiisinJo'^a , containing a chapter Dc Tahc a Dia-
bete. Diabetic phthisis was more fully studied by
John Rollo in 1798. Bardsley asserts that all dia-
betics are attacked with tuberculosi.s in the latter
stages of their disease. Gricsinger found tubercu-
losis to be present in forty-three per cent, of the
250 cases reported by him. Bouchardat found pul-
monary tuberculosis nineteen times in nineteen
autopsies. Some of the latter authorities give a
less proportion. Thus Germain See states that only
twenty-three, per cent, of diabetics die tuberculous.
Naunyn in fifty autopsies found tuberculosis in
forty-one per cent. Frerichs found the lungs tuber-
culous in twenty-five out of fifty autopsies. In most
cases the tuberculosis is secondary to the diabetes,
but this is not invariably the case. The tissues of
tlic diabetic, which are so vulnerable to eczemas,
carbuncles, ulceration of the skin and mucous mem-
branes, furunculosis, and gangrene show also a
peculiar su.sceptibilit> to tuberculous infection.
Bouchardat believed that the polyuria of diabetes
created a i)redispo.sition to tuberculosis in much the
same way as does the ])rolonged lactation of milch
cows and nursing mothers who bear numerous chil-
dren in quick succession. The tuberculous tendency
of diabetics is now, however, very generallv con-
sidered to be due to the hyperglyciemia and hyper-
glycosis of their tissues, for it is well known that
the tubercle bacillus has a sweet tooth, Nocard and
Roux having demonstrated that it in common with
many other microorganisms develops most luxuri-
antly in a culture medium to which sugar has been
added.
Before the tubercle bacillus was known diabetic
phthisis was often described as a disease sui generis.
but soon after Koch's discovery Immermann and
Riitimeyer demonstrated that the tubercle bacilli are
regularly present. There are, however, certain pe-
culiarities in the pathological conditions present in
the lungs in tuberculosis accompanying diabetes,
which have been well described by Naunyn. The
tuberculous cheesy infiltration is soft, and there is
a tendenc}- to the rapid formation of vomicae,
masses of tuberculous tissue surrounded by a puri-
form fluid being found in the recent cavities. Some
authorities still consider that in diabetes there may
be a destructive lesion of the lungs closely simulat-
ing tuberculosis without the presence of tubercle
bacilli. Such a case has been reported by Roque.
Von Noorden is authorit}' for the observation that
there frequently exists in the sputum of diabetics
a subtance which rapidly disintegrates and destroys
the tubercle bacillus. Among the curiosities of the
literature on the pathology of diabetic tuberculosis
is a case reported by Schindelka of a diabetic dog
with a complicating tuberculosis of the lungs. Ex-
amples of a similar association have been observed
in apes.
In view of the emphasis which has been attached
in recent years to the pancreatic origin of diabetes
it might be surmised perhaps that in the exceptional
cases in which tuberculosis precedes the develop-
ment of diabetes there might be found a tuberculous
lesion of the pancreas as a cause of the latter dis-
ease. Such, however, is not the case. Kudrewetski
found in a series of 128 cases of tuberculosis of the
lungs the pancreas was affected but fifteen times,
and in these cases diabetes is not noted as having
been present during life. Primary tuberculosis of
the pancreas, if it exists at all, is certainly ex-
tremely rare. Delafiold and Prudden do not men-
tion it as occurring. Cornet says that tuberculosis
of the pancreas is always secondary. The only
cases referred to in literature are two cited by Senn.
ono. of which was reported by Wilson in 1829, the
other by Aran in 1846. Both of these cases ante-
dated a time when an\- very exact or certain deter-
mination of the tuberculous nature of the lesions
was possible, and in neither case was diabetes pres-
ent. The usual lesions of the pancreas in diabetes
are an interstitial pancreatitis, atrophy of the
glands, a dift'use arteriosclerosis, or a hyaline de-
generation of the cells of the i.slands of Langerhan^.
Tuberculosis as a cause of diabetes may then be
dismissed.
Frequent as is the jissociation of the two diseases,
one or the other in its early stages is not infre-
quently overlooked. It is a safe rule in practice to
make repeated examinations of the chest in dia-
betics, and in tuberculosis the urine should be peri-
odically examined for glucose. Tuberculosis of the
lungs in diabetics, especially of the obese type, fre-
(|uently runs an atypical course. There is often ob-
served a somewhat characteristic, reddish cyanosis
of the face instead of the ordinary pallor or hectic
flush of tuberculosis. The cough is often slight
May 1 6, 1908.]
SHIVELY: TUBERCULOSIS AND DIABETES.
935
and attended by little or no expectoration. Sugar
may sometimes be demonstrated in the sputum, and
the pulmonary lesion may terminate in gangrene,
which is not attended by the characteristic foetor of
ordinary gangrene of the lungs. The appetite is
usually well preserved and may even be greater than
in health. The temperature may not be elevated,
and night sweats are often not present. Seegen and
von Leyden state that haemorrhages are of rare oc-
currence, on account of the higher specific gravity
and greater viscosity of the blood. Dieulafoy, how-
ever, does not consider haemorrhages infrequent in
diabetic consumptives. On the other hand, if the
tuberculosis is the prominent feature, the diabetes
may escape recognition. It has been frequently ob-
served where phthisis develops in a subject of dia-
betes there may be a marked diminution in the
quantity of urine and the percentage of sugar will
fall. These changes, however, are delusive signs
of improvement. The diabetes continues unchecked,
and is hastened in its progress by the complicating
tuberculosis. In the later stages the dry itching
skin of the diabetic becomes moist and there may be
profuse night sweats.
Gouty diabetics are said to seldom develop tu-
berculosis. Renon has reported at least one such
case, however, and others have been described by
Charcot, Brouardel, and Naunyn. Diabetics who
neglect their diet and thus invite an access of gly-
cosuria are more likely to become tuberculous than
careful, conscientious patients who observe a strict
regimen.
The recognition of the coexistence of diabetes
and tuberculosis has an important bearing upon the
prognosis and treatment of the patient. Not infre-
quently in examining tuberculous patients, cases
are discovered to be diabetic who have had no in-
struction as to diet and who have been receiving
a syrupy cough mixture and cod liver oil with ex-
tract of malt, the latter consisting of more than fifty
per cent, maltose, which is immediately converted
into grape sugar in the intestine. Some of these pa-
tients are found also to have a marked acidosis, evi-
denced by the presence of acetone, diacetic acid and
beta oxybutyric acid, with an excess of ammonia in
the urine. The presence of these acetone bodies,
which are to be regarded as a forerunner of the
danger of coma, makes it a question of more than
theoretical interest whether the administration of
large quantities of oils and fats, which is an im-
portant part of the dietetic treatment of tubercu-
losis, may not possibly in some cases hasten a fatal
termination in diabetic coma. Magnus Levy has
shown that beta oxybutyric acid is in part as least
derived from fats, and this is the parent substance
of the other acetone bodies, diacetic acid and
acetone, into which it is readily changed. In this
connection the experimental evidence of Grube is
interesting, that pork fat is peculiar in not being
a source of beta oxybutyric acid. It would seem
practical wisdom in cases showing strong reactions,
with the ferric chloride and sodium nitroprusside
tests with high dextrose percentage in the urine, to
limit the quantity of butter, cream, and oils — with
the possible exception of pork fat — and substitute
for such tuberculous diabetics alcohol, which At wa-
ter and Benedict have shown may take the place of
fats and carbohydrates as a source of energy, and
thus spare, in a measure, the excessive tissue waste
which is a conspicuous symptom of both diabetes
and tuberculosis. The combustion equivalent of
alcohol is seven calories, of fat 9.3 calories, and of
sugar four calories. Another indication for the ad-
ministration of alcohol in diabetes is the presence
of acetone substances in the urine. Langstein and
von Noorden agree that the effect of alcohol is to
diminish acetonuria, and patients taking alcohol in
moderate amount show no increase in the sugar
content of the urine. The quantity should not ex-
ceed two ounces daily, in the form of pure whisky,
gin, cognac, or a dry wine. A rational therapy in
the acidosis of diabetes also demands an additional
allowance of carbohydrate food and the exhibition
of alkalies to overcome the diminished alkalinity of
the blood. An excessive flesh diet is also con-
sidered to be favorable to the acid intoxication
which is believed to be a factor in producing dia-
betic coma. The difficulties in the prevention and
treatment of this grave condition are thus apparent.
These difficulties are not diminished by the fact
the von Noorden and other are now inclined to
doubt the entire theory of acidosis as promulgated
by Stadelmann and Naunyn. For those who be-
lieve that the acid toxaemia of the acetone sub-
stances is adequate to account for the phenomena of
diabetic coma, theoretically, all classes of food are
more or less contraindicated, carbohydrates on ac-
count of their failure to be oxidized and their ex-
cretion as sugar, fats on account of their splitting
up into fatty acids, and proteids because in excess
they also produce acidosis. The only escape from
this blind alley is to treat the patient without too
much regard for theory. No abstract considera-
tions should determine the diet. The patient's tol-
erance for carbohydrates must, in every case, be
carefully established, and as liberal and varied a
diet permitted as is possible. It is better for the
patient to gain in weight and improve in health
with an increased percentage of sugar than to lose
ground with a reduction in the glucose content of
the urine. The case is even more difficult with a
complicating tuberculosis present. Some authori-
ties advise ignoring the diabetes and treating only
the tuberculosis. Dieulafoy in these cases excludes
only sugar from the diet. Naunyn has shown, how-
ever, that great benefit may be derived by the tu-
berculous patient with diabetes from a carefully
regulated diet. Fortunately many of the indications
for treatment are the same" for both diseases. A
diet of meat, fat, cheese, and eggs is equally good
for both. Milk may often be permitted for dia-
betics, especially when sour or artificially fer-
mented. The drug of greatest value in diabetes,
opium, with its derivatives, codeine and heroin, is
also indicated for the cough, the haemorrhages, the
diarrhoeas, and to promote the euphoria of the ad-
vanced consumptive. The diabetic consumptive is
very often afebrile, and for such cases exercise in
moderation in the fresh air is not contraindicated.
Such exercise is distinctly useful for the diabetic,
as it has been shown that larger quantities of car-
bohydrates are tolerated on account of the increased
consumption of sugar by the muscles during exer-
cise. Creosote and guaiacol carbonate, which have
936
SHIVELY: TUBERCULOSIS AND DIABETES.
[New York
Medical Journal.
continued in favor for tuberculosis, are also be-
lieved to relieve the symptoms of diabetes, notably
the thirst and polyuria. Arsenic and strychnine,
which have their advocates in diabetes, are good
systemic tonics for the consumptive. Hydrothera-
peutics are valuable in both diseases, as are also the
alkaline mineral waters, woolen clothing next the
skin, abstinence from tobacco, freedom from worry
and care, and a quiet life in the country in a mild,
dry, and equable climate.
The prognosis in either disease is sufficiently
grave. A diabetic, however, after the age of fifty,
with careful dietetic management, may prolong his
life for many years and maintain a fair condition of
health. Tuberculosis also, developing after middle
age, often assumes a relatively benign and nonpro-
gressive character. The lesions in the lungs are
frequently of a fibroid type, tending to spontaneous
arrest. Such a consumptive with suitable hygiene,
diet, and careful regulation of his life may live out
all his days and die of some unrelated disease. But
usually when diabetes and tuberculosis are asso-
ciated in the same individual, the mortality is so
high as to make treatment of little avail. Naunyn,
however, has reported the case of a diabetic, aged
fifty-three, who was attacked with tuberculosis in
both lungs and a tuberculous ulceration of the
larynx, in whom the pulmonary process was ar-
rested, the ulcer of the vocal cord healed, and the
patient was in good health sixteen years later.
Fraenkel has reported a case of apparent cure in a
diabetic physician with well marked tuberculosis of
the lungs. Such cases, unfortunately, must be re-
garded as extremely rare. A practical conclusion
which cannot be too strongly urged is the import-
ance of safeguarding the diabetic from tuberculous
infection. Diabetics should be rigorously isolated
from members of their family who are tuberculous.
A recent case at the tuberculosis clinic of the Pres-
byterian Hospital well illustrates the danger of
household infection. A young Irishman, who has
been a diabetic for a year and a half, has lived in a
tenement with his married sister, who has for three
years been a consumptive of rather careless habits.
I'ive months ago he began to cough and has now a
well marked lesion of the right upper lobe. A simi-
lar case is related by Renon. A man of sixty, who
had been a diabetic for many years, but whose gen-
eral condition was excellent, had a daughter aged
twenty-one who became tuberculous. The father
was intimately associated with her while she was
taking- climatic treatment in the south of France.
The daughter died in a few months of acute
phthisis. The father also was attacked with tuber-
culosis of the lungs of a rapidly progressive type,
and died several months after the death of his
daughter. Obviously, diabetics should not be re-
ceived in hospital wards which harbor consump-
tives, nor should they frequent health resorts which
are visited by large numbers of tuberculous patients.
Of six cases of associated diabetes and tubercu-
losis, recently under observation at the tuberculosis
clinic of the Presbyterian Plospital, in all but one
the diabetes preceded the development of the pul-
monary disease. In this case the patient was un-
doubtedly tuberculous at least a year and a half be-
fore the appearance of any diabetic symptoms. Her
diabetes developed during pregnancy and she was
delivered of a seven months' child which lived eight
weeks. In four cases the tuberculosis developed
eighteen months, twelve months, seven months, and
two months, respectively, after the patients were
known to be diabetic : in the remaining case the
time could not be ascertained. This patient, a Hun-
garian Jewess, died seven months after the develop-
ment of her tuberculosis. Three of the six patients
were Hebrews. In four of the patients the family
history was negative, both as to diabetes and tuber-
culosis, in one case a maternal aunt had diabetes,
and in one, as already noted, the patient was prob-
ably infected with tuberculosis by a consumptive sis-
ter. Four of the cases were afebrile, and in the
other two the temperature at no time has been above
100° F. The cases were equally divided as to sex.
In the three women pruritus vuIvje was a marked
symptom. In four out of the six frequent and con-
siderable hfemoptyses were present. Tubercle ba-
cilli were found in the sputum of three and were
absent in three patients. In one patient it was pos-
sible to demonstrate the presence of glucose in the
sputum with the phenylhydrazin test. The urine
showed a strong reaction for acetone in all patients,
and in one diacetic acid was also present. A trace
of albumin was found in four of the six urines ex-
amined. The largest total quantity passed in twen-
ty-four hours was seven and a half quarts, the
highest specific gravity was 1.047, the greatest per-
centage of glucose noted was 7.2, estimated by the
polariscope. In one case glucose was present in a
urine of very low specific gravity, 1.009. The ap-
petite was excessive in one patient, good in two,
variable in two, and poor in one. Of five patients
in whom the patellar reflexes were tested, they were
abolished in but one. Bouchardat first directed at-
tention to the fact that in diabetes the knee jerk
is frequently absent. In one case a compHcating
laryngeal tuberculosis was present. In the case
showing the highest specific gravity and greatest
sugar content of the urine the patient several times
appeared to be threatened with coma, as evidenced
by great muscular prostration, irritability, sighing
dyspncea, drowsiness, and syncopal attacks. The
husband of this patient has recently been attacked
with tuberculosis of the lungs — apparently a clear
case of conjugal infection. In a case of combined
tuberculosis of the lungs and diabetes in a Cuban
at St. Joseph's Hospital there was an extreme de-
gree of ichthyosis of the skin of the entire trunk
and limbs. In this case, as in a similar one reported
by Lebcrt, the ichthyosis had existed for many years
prior to the diabetes and tuberculosis.
The majority of the cases of this association of
tuberculosis of the lungs with diabetes which I have
seen have been in dispensary practice, and it is felt
that as a rule in such practice insufficient care is
taken in supervising the details of treatment of the
diabetic element. In recent years, through the in-
stallation of nurses and better equipment of the out-
door departments of hospitals, there has been great
improvement in the dispensary care of tuberculous
patients, but the diabetic is still comparatively neg-
lected. His diet should be at least as carefully pre-
scribed as his medicines, and the ready made printed
diet sheet does not meet this indication. A valu-
May 1 6, 1908.]
MILLER: ASSOCIATION OF TUBERCULOSIS CLINICS.
937
able and seemingly practicable extension of the
work of district nurses and the diet kitchen, which
has been so helpful in the tuberculosis clinic, would
be instruction in the preparation and supervision of
food for the diabetic, which is now very imperfect-
ly attended to in the tenement home. This com-
parative neglect of diet is a difficulty which is also
experienced in the care of the well to do diabetic.
It is not possible in this country to send diabetics
to well managed institutions where there are the
modern facilities for dietetic treatment under ex-
pert supervision which exist abroad. It is probable
that the patient who does well at Xeuenahr, Carls-
bad, or Vichy is as much indebted for his improve-
ment to the painstaking attention to dietetic detail
of the local physicians, and to the intelligent co-
operation of the hotels and pensions in providing
an attractive, ample, and varied menu which makes
the dietetic cure a pleasure, as to the alkaline min-
eral waters which are drunk so seriously in these
places. To Kiilz is due the credit for having first
emphasized the importance of institutional treat-
ment for the diabetic. In both tuberculosis and dia-
betes the careful regulation of the patient's daily
life is the important factor, and this can, in most
cases, probably be most easily and most efficiently
carried out in a well conducted sanatorium. When
the two diseases coexist the care of such a case is
a dispiriting and usually fruitless task for the phy-
sician, but the unfortunate patient's condition may,
at least, be made more tolerable, his life may be pro-
longed, and in rare cases he may, perhaps, recover
through wisely directed and faithfully continued
adherence to the necessary hygienic and dietetic re-
quirements.
References.
Richard Morton. Opera Medica. Lugduni. 1696.
John Rollo. Cases of the Diabetes Mellitus. London.
1798.
E. Bertail. Etude sur la phthisie diabetique. Paris.
1873.
A. Bouchardat. De la glycosurie on diabete sucre, son
traitement hygietnique. Paris. 1875.
Immermann and Riitimeyer. Zentralblatt fur klinische
Medizin. IV.
Von Leyden. Zeitschrift fur klinische Medizin. IV.
Lebert. Traite d'anatomie pathologique. II., 1854.
Marsh. Strumous Diathesis and Diabetes. Dublin
Quarterly. XVII, 1854.
Schindelka. Diabetes beim Hunde. Monatshefte fUr
praktische Tierkunde. IV, p. 132.
Senn. Surgery of the Pancreas. Transactions of the
American Surgical Association. 1886.
Dieulafoy. Diabete sucre et tuberculose pulmonaire.
Clinique viedicale de I'Hotel Dieu. IV., 1901-2.
Poslin and Goodall. Boston Medical and Surgical Jour-
nal. February 20, 1908.
Naunyn. Der Diabetes Mellitus. Wien. 1906.
L. Renon. Conferences pratiques sur les maladies du
coeur et des poumons. Paris. 1906.
Robson and Cammidge. The Pancreas. Its Surgery and
Pathology. Philadelphia and London. 1907.
Von Noorden. Die Zuckerkrankheit und ihre Behand-
lung. Berlin. 1907.
Sauerbeck. Zeitschrift fiir klinische Medizin. XXVI.
Von Noorden. Metabolism and Practical Medicine.
Chicago. 1907.
K. Grube. Centralblatt fur die gesammte Therapie. Sep-
tember. 1902.
303 Amsterdam Avenue.
THE ASSOCIATION OF TUBERCULOSIS CLINICS
OF THE CITY OF NEW YORK.
By James Alexander Miller, M. D.,
New York,
President of the Association.
The tuberculosis clinic has taken its place as a
permanent institution in our community. This fact
is not as yet universally recognized, but I take it
that in a few more years every dispensary will have
discarded the old haphazard methods, and tubercu-
losis patients will everywhere receive treatment
based as much upon the social environment as upon
the physical condition of each case.
The study of these two factors in their relation to
each other is the distinguishing feature of special
tuberculosis clinics which mark the beginning of
organized social service in the practice of medicine.
Main Features of a Tuberculosis Clinic. — The
more evident advantages of the special tuberculosis
clinics may be summarized somewhat as follows:
First. Greater individual attention and study are
given to each patient by physicians who are more
interested and more skilled in their treatment.
Second. The control of the patients both in the
waiting and consultation rooms is more complete,
so that any danger of infection to other patients is
minimized.
Third. By means of visiting nurses, the social
conditions and home surroundings of each case are
studied and supervised in conjunction with the ad-
vice and treatment given at the clinic. A wide-
spread campaign of education is thus carried on in
the tenements.
Fourth. Extra diet in the form of milk and eggs
is given to such patients as are unable to supply
themselves. Such diet is dispensed upon the physi-
cian's prescription as a part of the treatment, and
not as charitable relief.
Fifth. Close association with charitable societies,
sanatoria, hospitals, and other institutions enables
the clinic physicians to know which of such facilities
are available for any patient, and to place any such
care or assistance at his disposal as may be neces-
sary.
Sixth. Patients who are discharged from hos-
pitals and sanatoria, upon returning to the city, are
supervised both at home and at the clinic, and the
danger of a relapse is consequently much dimin-
ished.
Seventh. An excellent opportunity is offered to
younger physicians to become skilled in the manage-
ment of pulmonary tuberculosis. The training in
early diagnosis is especially valuable and much
needed by many general practitioners.
It is thus evident that the tuberculosis clinic con-
stitutes a centre for accurate and reliable advice
upon all of the varied problems which this disease
presents, and should therefore become more and
more valuable as its advantages are more widely
known and more universally utilized.
The Development of the Special Clinic Idea in
New York. — The first of these clinics was organized
in 1903, and during each succeeding year one or
more new clinics have been established, until there
are now ten special tuberculosis clinics in the bor-
ough of Manhattan. They were each organized
independently, and have endeavored to work out the
938
MILLER: ASSOCIATION OF TUBERCULOSIS CLINICS.
[New York
Medical Journal.
general principles of the iTLanagement of their pa-
tients, each in its own way.
It very soon became evident, however, that even
these special classes left a good deal to be desired,
and that many evils and defects still remained. The
chief among these defects were a lack of uniformity
between the methods in operation at the different
clinics, an insufficient knowledge on the part of the
clinic physicians of the modern scientific principles
upon which the social portion of the work should be
conducted, and the waste of time and energy occa-
sioned by each clinic sending nurses to visit its pa-
tients in all parts of the city indiscriminately. It
was apparent, therefore, that some cooperation be-
tween the different clinics would be necessary to
insure truly efficient work.
The Beginnings; of Cooperation. — In the spring of
1906, an unusually fortunate opportunity to remedy
It very soon became evident that many other
things besides relief were bound to result from these
meetings. Work at cross purposes was everywhere
apparent. Relief was given or proposed regardless
of the medical aspects of the case. Many cases were
being visited by three or four different nurses or
agents, each representing a different organization
for giving aid, and each with a different notion of
what that aid should be.
We physicians had no uniform system of nomen-
clature ; in fact, absolutely contradictory medical re-
ports were often received from different clinics
upon the same case. We also knew little of even
the rudiments of the science of charity work, and
might recommend giving rent and food without re-
gard to the fact that a shiftless husband was prob-
ably the chief beneficiary of the airy rooms to be
provided for his consumptive wife, or was enjoying
Diagram of plan 0 f
EXPLANATION OF DIAGRAM.
men,L''Ah'in''^^ThI^^ ^ifi'^'" J^K show the Association of Tuberculosis Clinics with its component parts of active and associate
^r^e circlT^t t^P of tuberculosis in the homes be.ng the underlying factor in this whole scheme, the homes are represented by the
anvi^JarLi 1! '^■ki sized circles, one at each corner, show the hospitals for advanced cases, the sanatoria, the clinic
auxiliaries, and the charitable societies as chief factors in the scheme. Aiound each are grouped the component parts as smaller circles.
ith their relation to the scheme as a whole. The double lines connect the integral por-
irocaj relation between component parts. Single lines without darts con-
the antituberculosis campaign. (.Adapted'
Other smaller circles show less important factors
tions of the central organization. The double darts show the
nect affiliated mstitutions. The evident plan is to promote cooperation between all factors
trom a similar diagram by Dr. Edwin A. Locke of the work in Boston )
the situation presented itself. The committee on the
prevention of tuberculosis of the Charity Organi-
zation Society received gifts of over $20,000 to be
used for the benefit of persons suffering from tuber-
culosis.
To administer this fund a subcommittee was ap-
pointed, composed of representatives from the
Charity Organization Society, and from the various
tuberculosis clinics. Weekly conferences were held,
and the various problems of relief were studied from
the data furnished by the Charity Organization So-
ciety investigator, and by the clinic physicians and
nurses.
huge omelettes daily from the raw eggs furnished
to her by the clinic.
Other defects in our system also became manifest.
Chief among them was the visiting nurse problem.
We had at that time eight different clinics with pa
tients all over the city, each sending its nurse from
the Bronx to the Battery, with enormous expendi-
ture of time and energy, for which there was no
corresponding benefit in return. A very few of
such visits used up the nurse's day. In adidtion, the
Health Department was sending its inspectors and
nurses to these same patients, and to relief ca,>;es,
charity visitors were also going regularly. Those
May 1 6, 1 908. J
MILLER: ASSOCIATION OF TUBERCULOSIS CLINICS.
939
were truly reception days in the tenements ! It is
small wonder that patients sometimes moved away
to escape our multiplied ministrations. This picture
is not overdrawn, but represents fairly accurately
the conditions as they existed eighteen months ago.
Improvements in Methods. — The first step toward
improvement was the requirement of an accurate
medical report in each case as a basis of its con-
sideration for relief. To accomplish this the physi-
cians had to remodel their ideas to a more or less
uniform standard.
A card for such reports was carefully prepared,
based upon the classification of the National As-
sociation for the Study and Prevention of Tubercu-
losis, and for reference this classification was printed
in full upon the reverse of the card. This in itself
proved a fruitful source of elementary education.
The reports upon the social conditions were fur-
nished by the Charity Organization Society investi-
gators, and, as might be expected, were excellent.
They often opened the physician's eyes, and led to
many a change in the plan of management. The
Charity Organization Society agents on their side
learned the importance of relying on medical opin-
ion for diagnosis, and to modify the tendency to
which they were inclined, of keeping the families of
tuberculosis patients too near the border line of
need.
As the physicians began to see the necessity for
considering other factors in the treatment of the
family than the mere prescription for the sick per-
son, so the charity workers, on the other hand, came
to realize the necessity of finding some way for sup-
plying food, rest, air, and sunshine in plenty to the
tuberculosis patient, without disastrous moral ef-
fects ; for if it were not possible to supply these
essentials in abundance, it were far better to aban-
don home relief and bend all energies to getting the
patient into a suitable hospital.
In the proper disposition of cases, whether suit-
able for sanatoria, hospitals, country care, day
camp, or home treatment, we all — doctors and
nurses and charity workers — gradually came to
something approaching a uniform notion.
In the delicate question of milk and eggs distri-
bution from the clinics, that disputed territory of
charity and therapeutics, our ideas became clearer,
with the result of much more careful supervision,
and I may add considerable curtailment of its use.
Cooperation zvith the Health Department. — But
we were still laboring with the problem of unnec-
essary duplication of work. The first move towards
its solution was to obtain the consent of the Health
Department to consider the visits and reports of the
clinic nurses satisfactory substitutes for those of its
inspectors and nurses. The next was the closer
cooperation between clinic nurses and charity agents,
so that their visits supplemented rather than paral-
leled each other. These changes resulted in con-
siderable relief to the patients by eliminating many
unnecessary visits in their homes and also in a great
saving of unproductive and conflicting efifort.
The City Is Apportioned to the Clinics bv Dis-
tricts.^— The next step was a long one. It was un-
dertaken with trepidation, but the result has been
a great success.
'See map and directory.
The various clinics adopted the district system.
The advantages to be derived from such a system
are obvious and they have all been realized. The
patient no longer takes a long fatiguing journey to
the clinic, and he makes the shorter trip oftener ; the
nurses can visit more patients and each one more
frequently ; the physician can exercise better super-
vision of each case, and require more careful atten-
tion to details from both patient and nurse.- The
saving of time and labor is enormous.
Our method consists simply in referring each ap-
plicant at a clinic who does not live in the district
to the proper clinic, a reference card being used,
one half of which is given to the patient, and the
other mailed to the clinic. Should a patient so re-
ferred not appear within a week, he is looked up at
his home by the nurse from the clinic which his
received the notification of his transfer.
Explanation of map :
MANHATTAN.
Note. — ilanhattan applicants for examination
or treatment should apply at the dispensary in
the district in which they live. The dispen-
sary districts are shown on the map.
DISPENSARIES.
Department of Health, 55th St. and 6th
Ave., weekdavs. 10 a. m. to 4 p. m. Mon.,
Wed., Fri., 8 to 9 p. m.
Bellevue Hospital Dispensary, Foot of East
26th St., weekdays i to 3 p. m.
Gouverneur Hospital Dispensary, Gouver-
neur Slip, Mon., Wed., Fri., 2 to 4 p. ra.
Presbyterian Hospital Dispensary, 70th St.
and Madison Ave., Mon., Wed., Fri.,* 1.30 to
3.30 p. m.
Harlem Hospital Dispensary, 136th St. and
Leno.x Ave., weekdays 3 to 4 p. m.
Vanderbilt Clinic, 60th St. and
Amsterdam Ave., weekdays 2 to
3 p. m.. Mon., Wed., Fri., 9 to
10.30 a. m.
New York Dispensary, 137 Centre
St., weekdays 11 a. m. to 12.30 p.m.
New York Hospital Dispensary, 8
West 1 6th St.. weekdays 2 to 4 p. m.
Mt. Sinai Hospital Dispensary,
Madison Ave. and looth St., week-
days 10 to II a. m.
German Hospital Dispensary, 76th
St. and Park Ave., weekdays 2 to
4 p. m.
Health Department, Bronx, 3d
Ave. and St. Paul's Place, week-
days 2 to 4 p. m.
Theoretical Objections to
the District Plan.— The
chief objections that have
been raised to such a sys-
tem are: i. The reluctance
of the patients to give up
their free choice of physicians
or institutions ; 2, the un-
equal distribution of num-
bers among the clinics, and
3, the hesitation on the part
of teaching institutions to
part with their interesting
clinical material.
The District Plan a Com-
plete Success. — In experi-
ence, none of these an-
ticipated objections has
materialized. There have been practicallv no com-
plaints on the part of the patient ; the numbers at all
of the clinics have increased because of more efti-
cient visiting and the better care given to the pa-
tients; and a little adjustment of district boundaries
easily corrected the slightly unequal distribution that
940
MILLER: ASSOCIATION OF TUBERCULOSIS CLINICS.
[NEiV VuRK
Medical Journal.
resulted at first ; and as for teaching, all clinics have
had more material than ever before.
It would seem that this classification by districts
is much inore satisfactory than one upon any such
proposed basis as race, creed, or color. The indi-
vidual clinic can quickly adjust itself to the char-
acteristics of its own districts, and certainly, for
purposes of dispensary cooperation and consistent
social service this system is admirable. It also
checks the abuse of dispensaries by patients who are
able to pay.
Eventually we hope to have each district so com-
pact that every house in it will be familiar to the
clinic nurse. This will require the cooperation of a
much larger number of the dispensaries in the city,
but this does not appear impossible, and I know of
no other way to effectively control the spread of
tuberculosis in the tenements.
Clinics for Children Are Established. — A few
months ago the majority of the clinics established
a separate class for children. The main object was
to institute as a routine procedure the thorough ex-
amination of all children in the families of our pa-
tients and thus discover, if possible, latent and
unsuspected cases.
This has proved a most interesting and valuable
experiment. In a collective investigation we have
examined 431 such children, and found that sixty-
two of them, or somewhat over fourteen per cent.,
either had or were strongly suspected of having
pulmonary tuberculosis. The diagnosis in these
cases is more difficult even than in the adult, and
the various tuberculin tests have been of great value
in many doubtful cases.
It seems evident that, contrary to the usually ac-
cepted ideas, pulmonary tuberculosis is very fre-
quent in children, that they are infected in a large
proportion of cases from close association with ad-
vanced cases in their own families or homes, and
that the signs and symptoms of the disease remain
for a long time so obscure that they would escape
detection except for a most rigid examination by
a trained observer.
If this is so, it opens up a tremendous field for
productive prophylactic work in ferreting out these
children, and providing for their care, both before
and after they may have become infected.
The Formation of the Association of Tuhercidosis
Clinics. — All. of this work that I have endeavored to
describe was, as we have seen, developed largely
through the membership of the representatives of
the various clinics in the relief committee of the
Charity Organization Society.
When this fund was exhausted and our committee
disbanded a few months ago, it was our firm con-
viction that it would be most unfortunate to lose
the benefits that we had gained by cooperation, and
that, on the contrary, we should, if possible, form
a closer union between the various clinics to con-
tinue and enlarge the work already begun.
Such a union was consequently established by the
formation of the Association of Tuberculosis Clinics
of New York City.' This association is composed
"ORGANIZATION OF THE ASSOCIATION.
Officers. — James Alexander Miller, M. P., president; John H.
Huddleston, M. D., vice president; Frank 11. ^lann, secretary, No.
I OS East Twenty-second street.
Active Members.— John S. Billings, M. 1)., K. A. Frascr, M. D..
of active members, who are the representatives of
the various clinics, and of associate members, who
are selected as representing the different charitable,
religious, and social societies and institutions in the
city which are coming in contact with tuberculosis
as a constant social problem.
It is our aim to enlist the active cooperation of
all these agencies in such a way that in each district
of the city the tuberculosis clinic may become the
centre to which all workers among the poor will
naturally turn for expert advice upon all questions
and problems which may arise in regard to tuber-
culosis. To promote this end we are also planning
the organization of a women's auxiliary to the as-
sociation. This auxiliary would be composed of
charitable women of standing and influence in the
city, who would widen the interest in anti-tubercu-
losis work, and would take a personal interest in
many individual cases, thus helping to carry out
the physician's recommendations where otherwise
it might be impossible. It is planned that each clinic
should have its own separate auxiliary, the chairmen
of which shall be associate members of the main
association.''
The Cooperation of All Physicians Necessary. —
It is now our foremost aim, however, to interest
the physicians of the city in this movement. It
should appeal to them especially, because the whole
plan of organization is based upon the medical as-
pects of tuberculosis. We physicians have allowed
the laity to run beyond us sometimes in the now-
widespread campaign against preventable disease.
In this organization, however, it is proposed that
medical science shall lead the way, and in this we
need the help of all physicians.
This means more than simply referring poor pa-
tients to the clinic in the proper district. It means
especially a responsibility upon all physicians con-
nected with any medical dispensary to influence
their own institution to join in this work.
This may be done in one of two ways : First :
By the organization of a special tuberculosis clinic
with a visiting nurse, assuming the responsibility
for the care of a district of the city, and joining our
association ; or, secondly : If such a separate clinic
is not feasible, then the dispensary should refuse
to treat pulmonary tuberculosis, and refer all such
patients to the proper special clinic.
There are, at present, a total number of sixty-
nine dispensaries in the borough of Manhattan.
There is probably a need of twenty or twenty-five
John H. Huddleston, M. D., Abraham Jacobi, M. D., James C.
Greenway, M. D., Alfred Meyer, M. D., James Alexander Miller,
M. D., Henry S. Patterson, M. D., Henry L. Shively, M. D.,
Arthur M. Shrady, M. D., Bertram H. Waters, M. D.
Associate Members. — Robert \V. Bruere, Association for Improving
the Condition of the Poor; John J. Fitzgerald, the Society of St.
Vincent de Paul; Miss Jane Elizabeth Hitchcock, Nurses' Settle-
ment; Rev. Walter Laidlaw, the Federation of Churches; Miss
Anna Maxwell, Visiting Nurses' Association of the Presbyterian
Hospital and Vanderbilt Clinic; Dr. Walter Sands Mills, Department
of Public Charities; J. K. Paulding, trustee of Bellevue and .\1-
lied Hospitals; Lawrence Veiller, Charity Organization Society;
Gaylord S. White, Association of Settlement Workers; Dr. C. M.
Cauldwell, St. Joseph's Hospital; Mrs. J. Borden Harriman, Civic
l"edcration and chairman of Presbyterian Auxiliary; Mrs. Richard
irvin, Loomis Sanatorium; Mr. Henri Maillard, Societe frangaise
de bienfaisance; Mr. Celestino Piva, Italian Benevolent Association;
Miss Blanche Potter, Bellevue Clinic Auxiliary: Dr. Frederick L.
Wachenheim, United Hebrew Charities; Mrs. Henry V'illard, Diet
Kitchen Association
'Since this article was written three clinics have organized auxil-
iaries with a membership aggregating nearly 200. The idea has met
with unhoped for success, and been taken up with astonishing en-
thusiasm.
May 1 6, 1908 ]
DORRAXCE AXD GINSBURG: TRANSFUSION.
941
special tuberculosis clinics. A canvass is now being
made of all these dispensaries to ascertain their at-
titude toward this district plan, and physicians can
help very materially in determining what this
attitude shall be.
Complete Control of T nberculosis a Possibility —
For the first time in the history of this city, there
seems to some of us a possibility of adequately
supervising and subsequently controlling the spread
of tuberculosis.
All students of this problem have come to agree
that the breeding places of this plague are in the
homes of the poor. It is in these homes that we
plan to make our fight.
We ask the help and cooperation of all those
whose work or interests bring them in touch with
any of the varied aspects of tuberculosis.
18 West Fifty-first Street.
TRANSFUSION : HISTORY, DEVELOPMENT,
PRESENT STATUS. AND TECHNIQUE
OF OPERATION.
By George M. Dorraxce. M. D.,
and
Nate Ginsburg, M. D.,
Philadelphia.
There are few operations that deserve to be called
life preserving to such an eminent degree as trans-
fusion, and among these few there is hardly one that
is technically so simple and so devoid of danger in
its execution (Leisrink).
The possibiHty of saving life by the introduction
of healthy blood' into the circulation of one suffering
from sudden loss or gradual depreciation of the vital
fluid, naturally presented itself as a resource to the
minds of the physicians of the earliest periods.
Hebraic, Egyptian, and Syriac medical records all
tell of the practice of this procedure in the various
ages of which they speak; and steadily downward
through the times of Greece and of Rome can
traces, well marked and distinct, be discovered of
its occasional adoption as a therapeutical resource.
Nor was the operation lost sight of in the advance
of modern times, for in 1492 we learn that one of
the Roman pontiffs was submitted to it at the hands
of a Jewish physician; that in 1615 an essay was
written upon the subject by Libravius, of Halle;
that in 1652 Polli, of Italy, contrived an apparatus
for arteriovenous transfusion ; and that in 1664 the
process was fully described by Daniel, of Leipsic, as
one to which he was in the habit of resorting (T.
Gaellard Thomas). James R. Chadwick. of Bos-
ton, in an original communication in 1874 refers to
the employment of transfusion on the person of
"Naum," Prince of the Syrian army, who, when
stricken with leprosy, to effect a cure, removed the
blood from his veins and replaced it with other
blood. Medea is represented by Ovid as offering
to restore youth and strength to Pelias by replacing
his aged blood with that of a young man.
Without discussing the credibility of these and
similar statements, it was not until the year 1665
that Richard Lower, an Englishman, first published
a complete description of the procedure to be fol-
lowed in transfusion, and performed the operation
upon animals. Denys, of Paris, in 1667, stimulated
by accounts of Lower's success in England, experi-
mented on animals, and later in two instances suc-
cessfully transfused a lamb's blood into the human
circulation. The publication of Denys's results
gave rise to the most violent excitement in Paris.
One party laid claim to the discovery of a universal
remedy which would restore health, youth, and
vigor, quiet diseases of the mind, calm the most vio-
lent dispositions, and might even prolong Ufe be-
yond its natural term.
The opponents of this operation contended that
it was based on false premises, and sought to have
its performance stopped. Laury, for instance, an
eminent surgeon, maintained that certain particles
of the blood were distributed to nourish certain
parts of the body, and asked what would become
of those ingredients of the blood, which Nature in-
tended should produce the horns of a bull, if a bull's
blood were introduced into the human circulation.
He also thought that the stupidity and low instincts
of the animal would thus be transmitted to the man.
Through this writer's unfair efforts the operation
was interdicted in France, unless done with the ap-
proval of a member of the faculty of Paris. Thus
the operation of transfusion sank into oblivion not
only in France, but also in other countries.
Blundell in 1818 revived the operation in Eng-
land, and clearly demonstrated its beneficial eft'ect
on persons suft'ering from excessive haemorrhage
following childbirth. Following the three success-
ful cases of Blundell of transfusion with human
blood, Dumas and Prevost in France, and Dieffen-
bach and Panum in Germany, became very active in
experimental work bearing on transfusion of blood
from one individual into another. Panum showed
scientifically that for transfusion on man, only hu-
man blood should be used. Kuhne gave a consid-
erable extension to transfusion in his paper on car-
bonic oxide poisoning. Martin, in 1859, advocated
transfusion in haemorrhage of parturients. Neu-
dorfer employed it in chronic anaemia, consequent
upon purulent discharges ; Nussbaum in chlorosis.
Of the most important are the labors of Hiiter.
who first introduced arterial transfusion. Esmarch,
in a personal communication to Leisrink, stated that
he performed transfusion on a person during the
extirpation of a fibrocavemous tumor from the
base of the skull, where much blood was lost, by
pumping back new blood into the arm. Also in a
case of exarticulation of the femur, Esmarch
caught up the flowing blood, and drove it back di-
rectly into the femoral vein, following a procedure
first recommended by Volkmann in 1868.
Dr. ^^'alter Channing, of Boston, in a paper, pub-
lished in the Boston Medical and Surgical Journal.
at this time also strongly advocated the practice
of transfusion in properly selected cases. Follow-
ing these contributions the exponents of transfusion
became numerous. Milne-Edward, Dieffenbach.
Bischoft", Polli, and Nicholas all strove to elevate it
to a legitimate position, but it has only been during
the last twenty years that its claims have been ad-
mitted. Among later workers and writers on this
subject, whose efforts have assisted the adoption of
transfusion to save life, are : Ore, of France :
Gesellius, of Russia; Hasse and von Bergmann, of
Germany ; Roussel, of Geneva ; Avelling, Mc-
Dowell, and Higginson, of England ; and Crile,
Murphy, and others of this country.
DORRANCE AND GINSBURG: TRANSFUSION.
[New York
Medical Journal.
T. Lauder Brunton, in 1873, advocated trans-
fusion as a means of preserving life in cases of coal
gas poisoning. He states that in these cases the
only hope lies in removing the poisoned blood and
replacing it by healthy blood. This does not by any
means always succeed ; but occasionally the recov-
ery from impending death is almost miraculous, as
in a case where it was employed by Professor
Hiiter (Berliner Klinische Wochenschrift, 1870, p.
341). The patient, who was a strong, young man,
was living in a hotel, and one night had a fire light-
ed in the stove of his room. Next morning he was
found perfectly unconscious, his iris and cornea
quite insensible, and his pulse small and rapid. His
respiration was weak and intermitting. Just as ev-
erything was ready and transfusion of blood was
begun, his respiration failed altogether. Notwith-
standing this fresh blood was allowed to stream into
the patient's radial artery; the poisoned blood was
drawn from a vein, and respiration was kept up
artificially. Gradually the pulse became stronger,
spontaneous respiratory movements again began,
and the cornea became sensitive. In about five
hours consciousness returned, and in a few days
health was completely restored. After recital of
this remarkable case of recovery, Brunton was so
profoundly impressed with the efficacy of trans-
fusion as a means of preserving life that he also
advocated its adoption in treating cases of strych-
nine poisoning, by blood letting in addition to trans-
fusion. He also believed that the blood of lambs
and calves could be transfused into the human be-
ing in the event of failure to secure fresh human
blood, a procedure which has since been proved to
be not only contraindicated, based on physiological
grounds, but also fraught with great danger to the
recipient. He believed the objection raised by
Laury, two hundred years before his time, regard-
ing the transmission of animal characteristics along
with the blood of the donor, a theory untenable, and
totally disproved by the experiments of Galton on
rabbits.
Franz Gesellius, in a classical, historical, critical,
and physiological study of the transfusion of blood,
refers to the first case of recovery from carbon
monoxide poisoning, in which pure blood was used
in 1871. This distinguished scientist reviews the
literature relating to this procedure, dwelling at
length upon . the practicability of employing de-
fribinated blood, the apparatus for transfusion, and
a report of cases.
In reviewing the historical development of this
procedure we are next attracted to the paper of the
eminent physiologist, Bowditch, of Harvard Uni-
versity, published in 1876. Reference was made to
the works of Gesellius and Hasse in transfusing
blood of various species. In addition to these lat-
ter two experimenters, the work of Fiedler and
Birch-Hirschfeld were mentioned, mainly along the
same lines. The views held by Bowditch were
mainly those advanced by earlier workers in this
line of re.search, and are to be noted mainly for the
indications offered for performance of transfusion.
The notable monograph of T. Gaillard Thomas,
published in New York in 1878, is a treatise on the
intravenous injection of milk as a substitute for the
transfusion (A blood. While it is true that this in-
genious observer was inspired by the experiments
of Hodder, of Toronto, Canada, in 1850 on cases
of Asiatic cholera and also by the previous use of
blood for transfusion and the failures that attended
the operation, the record of his cases in which milk
was employed as a substitute can hardly stand as a
proof of the superiority of milk over blood. Wil-
liam Hunter, in 1889, based his opposition to trans-
fusion of blood in the human being on the deleteri-
ous eft'ects resulting from, the blood, which was sat-
urated with salt solution or a solution of sodium
phosphate.
Coincident with the struggle for the survival of
the operation of blood transfusion, the history ' of
the development of the apparatus for carrying out
the procedure offers an interesting tale. Conten-
tion over the advisability and practicability of em-
ploying defribrinated or undefribrinated blood was
waged along with the question of direct or indirect
transfusion and the employment of blood from the
same or varied species. Hunter, in spite of his
pronounced views against the regular employment
of transfusion as a routine procedure, admitted the
most positive indication for the performance of
transfusion, i. e., the sudden collapse from rapid
and severe loss of blood. This single statement in
a great measure offset his other arguments.
Blood of dissimilar species was proved to be im-
practicable and dangerous for purposes of introduce
tion into the human circulation. Magendie, Panum,
Ponfick, Landois, Hunter, Mittler, Wormmuller,
Ploz, and Gyorgyai opposed the transfusion of blood
of animals into the human circulation. They ascribed
their reasons to dissimilarity in the properties of the
different types of blood, and the resulting hjemoly-
sis which took place. Experiments in the hands of
a large number of workers in this field have proved
conclusively the dangers attendant upon introducing
blood of animals into the human circulation. Not
only was no improvement noted in those cases in
which it was done, but serious shock followed the
operation, and in no few instances sudden termina-
tion of life. Hasse first employed arteriovenous
transfusion in thirty-nine cases by introducing lambs'
blood into the human circulation. Like those of
others, his results were variable and in some in-
stances fatal.
The question of the employment of defibrinated
or of undefibrinated blood is one which took many
years to settle. Prevost, Bischoff, and Panum op-
posed the use of undefibrinated blood on the grounds
of the danger of thrombosis and embolism, which
was the cause ascribed to the unsuccessful cases.
Hunter believed that defibrinated blood was uncer-
tain in action, sometimes quite harmless, and at other
times highly dangerous, the result being entirely in-
dependent of the quantity injected or the care taken
in injecting it. Until i860 only thirteen cases had
been recorded of the use of defibrinated blood (Ma-
gendie). In addition to Hunter, Ponfick. Landois,
and Gesellius also experienced great difficulties in
the employment of defibrinated blood.
The long unsettled question concerning the supe-
riority of defibrinated or undefibrinated blood was
in a great measure dependent upon the type of in-
strument used to transfuse the blood. Those who
performed direct transfusion naturally opposed de-
May 1 6, 1908.]
DORRANCE A.\'D -GINSBURG: TRAXSfUSIOX.
943
fibrination, while others who were compelled to em-
ploy a syringe or tube attached to a reservoir fa-
vored defibrinated blood, because only in this state
could the blood be maintained in a fluid condition
for reintroduction into the circulation.
\'arious instruments and tubes were employed
for transfusion. Gesellius. Leisrink. and others em-
ployed a glass canula. Nicolas Duranty employed a
cold syringe ; [McDonnell, a slight modification of
Duranty 's instrument ; Higginson. a tube with a bulb
attached, and later Aveling employed two canula
attached with rubber tubing to a syringe, so that the
blood could be sucked from the veins of the donor
into the rubber bulb, and then by compression driven
into the vessels of the recipient. It was also alleged
that with this instrument the quantity of blood trans-
fused could be accurately measured. Chadwick also
employed Aveling's apparatus, first filling the bulb
and tubes with water to avoid introducing air into
the vessels.
It is obvious that with the development of direct
transfusion by end to end anastomosis between the
artery of the donor and the vein of the recipient
(either by a mechanical method or by direct suture)
that the questions of defibrination or undefibrination
of blood and the employment of complicated, uncer-
tain apparatus are swept aside. The procedure to-
day is one of sim.plicity and of certain success in the
presence of secure asepsis and good assistance. If
any factor contributed to the severe symptoms in
addition to the development of thrombosis and em-
bolism in former days, tending to cause failure in
its performance, the absence of sure asepsis was the
principal cause.
The Present Status of Transfusion.
The indications for transfusion inay be consid-
ered in two ways, from the physiological and clin-
ical standpoint. It is indicated physiologically
when the blood is greatly deficient in quantity or
quality; clinically when the blood cannot perform
its function of carrying materials from one point to
another, or is not able to nourish the blood forming
organs so that they can produce corpuscles. The
clinical indications are divided into four classes, i.
Acute grave anaemia due to haemorrhage ; 2, chem-
ical changes in the blood ; 3, deficient coagulability
of the blood ; 4, in certain blood diseases.
1. For anaemia due to acute grave haemorrhage,
as from an accident, ruptured extrauterine gestation,
or postpartum haemorrhage. In this variety the in-
dication is clear and the results have been excellent.
2. Where chemical changes have occurred in the
blood and the haemoglobin is not able to perform the
interchange of carbon dioxide and oxygen : as in
carbon monoxide poisoning and poisoning from syn-
thetic analine compounds. Here the indication is
positive and the results good if the operation is per-
formed early.
3. In haemorrhage where the coagulability of the
blood is deficient, as in haemophilia, cholaemia, and
in haemorrhage during typhoid fever. In haemo-
philia it v.-ill assist coagulation and with the other
methods of treatment stop the haemorrhage, but of
course will not cure the underlying cause. In cho-
laemia transfusion will increase the coagulability of
the blood and make it possible to operate without
excessive haemorrhage.
4. In certain blood diseases where the blood form-
ing organs are not sufficiently nourished to produce
corpuscles or where the blood corpuscles are defi-
cient in numbers ; as in extreme chlorosis, secondary
anasmias, unclassified anaemias of childhood, and in
pernicious anaemia. In these diseases the transfu-
sion should be repeated if marked improvement or
permanent results are to be expected. In pernicious
anaemia, if this method of treatment is contrasted
with the other methods in use, one should be per-
fectly satisfied with marked temporary benefit.
Methods of Performing Trausfusio)!. — The oper-
ation of direct transfusion from an artery to a vein,
which is the one that should be used, can be per-
formed in several ways ; but two factors must always
be considered. First, the method must be one that
will not cause the blood to coagulate while passing
from the donor to the recipient. Second, the method
must be simple and easy to perform if it is ever to
come into general use.
Method Xo. i. By means of the Crile tubes.
The tubes were first employed by von Ouirolo in
1895, and later modified by Payr, and still later by
Crile. In this method the vein is passed through the
tube of appropriate size and the free end t'urned
back over the end of the tube, thus forming a cuff,
which is tied in place with a fine linen ligature. The
artery is then drawn over the venous cufif and tied
in place. These tubes have the advantage of keep-
ing the blood stream within the vessels and not per-
mitting any foreign substance to come in contact
with it. The disadvantages are that the tubes can-
not be used by one not skilled in this work, and. sec-
ondly, it is very difficult and at times almost impos-
sible to use them when the patients are very restless.
^lethod Xo. 2. By means of tubes of various sub-
stances. The tubes are easily applied, but within a
very few minutes thrombosis occurs within them
even under the most careful application.
Method X'o. 3. End to end anastomosis bv direct
suture. This method possesses no advantage over
the other methods. Its disadvantages are: i, That
it is exceedingly difficult to perform ; 2, the vessels
contract ; and, 3, thrombosis occurs at the line of
suture after a few minutes.
Technique of Operation. — The forearm of the
donor and the recipient are sterilized and then anaes-
thetized by local infiltration. The arm of the recipi-
ent is constricted by an assistant to make the super-
ficial veins prominent. Usually the superficial radial
vein is the one selected, and if so should be exposed
near the wrist for about one inch and two linen lig-
atures placed beneath it. The radial artery of the
donor should be exposed at the wrist and two linen
ligatures placed beneath it. Then the forearms are
placed so that the hand of the donor is directed to-
ward the elbow of the recipient. Xow divide the
radial artery and ligate the distal end with one of the
ligatures, and control the haemorrhage from the
proximal end v.ith specially constructed forceps, digi-
tal pressure, or by placing a small piece of narrow
tape around the artery and clamping it near the
artery so as to compress the artery. Xow divide the
vein, ligate the proximal end, and applv the Crile
tube as described before : then draw the arterv over
^44
OPPENHEIMER: INCONGRUITIES IN THE MEDICAL PROFESSION. , [New York
Medical Journal,
the tube, ligate it in place, and remove the constric-
tion of the artery, and allow the blood to flow. If
the vessels are very small they may be dilated with
forceps or small haemostats. After the desired
amount has been transfused the artery and vein are
ligated, the tube removed, and the skin sutured. The
amount to be transfused will vary with the disease,
but it must always be remembered that too large an
amount will raise the blood pressure. The opera-
tion may be repeated without any bad effects.
Report of Cases.
Case I. — Pernicious ansemia. Patient of Dr. D. Riesman,
Polyclinic Hospital, Philadelphia. Transfusion by direct
suture. Life extended six months. Full report later.
Case II. — Pernicious anxmia. Patient of Dr. D. Ries-
man. Unsuccessful. Report later.
Case III. — Acute lymphatic leuchjemia. Patient of Dr.
Myers Solis-Cohen. Transfusion by suture method. Small
amount transfused. The vessels contracted after a short
time and very little flowed after that accident. No marked
change in condition of patient.
Case IV. — Shock and acute haemorrhage. Patient of Dr.
Levi J. Hamrnond, Methodist Hospital. Operation per-
formed after a partial resection of the stomach. Recovery
from shock and marked improvement in general condition.
Patient died later from complication of gastric operation.
Case V. — Extreme haemorrhage from stomach. Patient
of Dr. James Lloyd, Methodist Hospital, Philadelphia. On
account of extremely restless condition of the patient the
Crile tubes or suture method could not be used. The trans-
fusion was tried with glass tubes lined with petrolatum.
Operation was not a success. Patient died several hours
after the second attempt. A very small amount of haemo-
globin was found in the urine after the transfusion, but I
do not know if it was present before.
Case VI. — Hsemorrhage during typhoid fever. Patient
of Dr. Riesman, Jewish Hospital. Small amount transfused.
No after hjemorrhage. Recovery. Full report to be pub-
lished later.
All our patients were in moribund condition when
we were given permission to operate.
1 71 6 Locust Street.
SOME INCONGRUITIES IN THE MEDICAL
PROFESSION.*
By L. S. Oppenheimer, M. D.,
Tampa, Fla.,
President of the Association of Seaboard Air Line Railway Surgeons;
Major-Surgeon, Second Regiment, F. -S. T.
The title of this address may appear to some of
you a pessimistic dissertation on the practice of med-
icine. No, it is merely an expression of a few strik-
ing matters that have appealed to me from time to
time, in which I would enlist your interest.
No one denies our steady trend to betterment in
all directions. Nevertheless, progress in ethics and
our art is of course not in pace with the advance-
ment in the sciences.
Some of my admonitions will, I trust, be salutary ;
all of them are sincere. I do not flatter myself that
I have found solutions to these shortcomings ; I hope
to induce others better fitted to search for them. It
is the privilege of truth to upset the traditional false-
hoods that men cherish, but traditional contentment
dies hard. We will probably always be creatures of
custom and slaves of routine, for the laws of natural
selection grind slowly.
Local Ethics.
Since the abrogation of the old code of ethics of
the American Medical Association, State and county
'Read before the Association of Seaboard Air Line Surgeons, at
a meeting held on February 18, 1908.
medical societies have formed later ethical rules,
often restricted by conditions of local import, some-
times, as I have personally observed, at variance
with fundamental principles in ethics, of question-
able utility, and ultimately working disaster to the
body politic.
As an illustration : A county medical society-
adopted a law discountenancing all kinds of con-
tract practice as being unethical, but exempted rail-
way surgeons, military surgeons, and some others.
Now, I am fortunately or unfortunately both the one
and the other, but I cannot understand by what
method of induction in ethics a principle is permit-
ted to be violated arbitrarily. If the principle is cor-
rect the exception is immoral, and of course vitiates
the spirit of the whole fabric. Contract practice per
se is neither wrong nor undignified. The unethical
feature in it is the same as in private practice, viz. :
inadequate remuneration for the services, nothing
more, nothing less ; and a volume of hysterical pride
or resolutions cannot alter this basic law of political
economics.
Co)isultations.
Why does the consultant always get a larger fee
than the attending physician ? The latter has studied
the case more closely before, is to have the care of it
afterward ; bears all the worry, anxiety, responsibil-
ity, criticism, does more thinking, more work, than
the consultant.
Unless there are some special reasons for it, such
as pertains to acknowledged experts, etc., the fees
should be reversed, the responsible man getting the
larger share, the consultant being really entitled to
no more than a reasonable amount for actual ser
vices.
Fees.
Neither should we in every day practice be re-
stricted to the conventional inflexible fee bill sched-
ule. We should have a sliding scale according to
the financial ability of the patient and character of
services rendered ; not fixed and absolute like that
of the merchant. The opulent should pay according
to his income, while the middle class pays the cus-
tomary fee. Too many of these, like the indigent
poor, get their services free.
What other calling or class daily gives to the pub-
lic a considerable part of its time, skill, and means
without remuneration, without ostentation, often
enough without gratitude? Then why gauge our
methods by the tape measure of commerce ? I may be
pardoned for perpetrating this apothegm, without
fear of contradiction : The doctor's business is the
only business whose business it is to destroy its
business ; or, if we must be commercial, and really
we are by no means enough so for our own good,
why not be consistent with our changed conditions?
Commodities rise, house rents go up, labor is bet-
ter paid, riches become universal, yet the average
doctor's fee is probably the same as when, in the
embryonic period of our art, the priest, and later the
barber, honored the leech with an occasional "case."
"Men may come and men may go,"' but the doc-
tor's fossilized fees seem to go on forever, in more
senses than one. The world acknowledges that our
material emoluments are in no wise commensurate
with the intelligence, knowledge, and responsibility
required of every physician. Where is .so much con-
May 1 6, 1908. J
OPPEXHEIMER: IXCOXGRUITJES IN THE MEDICAL PROEESSIOX.
V45
summate skill expected, yes, demanded, as that
which deals with the first principles of existence it-
self, and the essentials which make that existence
tolerable ?
In Court.
When doctors are arrayed against each other in
giving expert testimony in the courts, the doctor as-
sumes, in spite of himself, a partisan attitude. He
prompts his attorneys to confuse and belittle the
testimony of his fellow physician on the witness
stand. The expert's statements on the opposing
side are discredited or made ridiculous, and the
medical profession in general becomes the laughing
stock of the jury, the press, and the public.
Xow, these invidious situations should be obvi-
ated, and would be, if the physician would insist
upon being true to himself first and last, and thus be
true to the profession he is supposed to adorn. Hon-
estly endeavor to meet and consult with the oppo-
nent's physician, and, so far as practicable, to har-
monize conflicting views. Refuse to be forced by
lawyers or employers into an unfair partisanship.
Lack of Harmony.
Through lack of harmony we have earned the
contempt of corporate powers and politicians. Our
weakness is as manifest as our boasts, and corpora-
tions are not slow to discover and take advantage of
it. Where one of us will resent an unfair proposi-
tion, another will greedily accept. \\'here one set of
medicos plead for the enactment of a just and
righteous law, another set seditiously or surrepti-
tiously opposes or tear^ it down. The pretense of
harmony is as transparent as the selfish impulse
which actuates it.
Military.
Speaking of military surgeons, I am reminded of
the common routine of promotions in all branches
of the service by reason of seniority. Thus, a sur-
geon with little or no special ability is promoted to a
rank in which he is the acknowledged inferior to
another whose commission dated one day or one
year later. Is it for the best interests of the service
to indefinitely continue this vicious precedent?
And here I shall call you to task for an apparent
indifference that the medical profession in this coun-
try has evinced in the afifairs of the army medical
corps. For a number of years past, efforts have
been made to increase the corps. Its insufficiency
even on a peace footing is a conspicuous feature of
our imperfect military organization. Twice has a
bill passed the senate and been reported favorably
to two congresses, still it has never become a law.
President Roosevelt in his annual message said.
"The medical corps should be much larger than the
needs of our regular army in war." Yet at present
it is smaller than the needs of the service demands
even in peace. The fault lies in our apathy, in our
failure to demonstrate our patriotism in our own
household. \\'e praise the achievements of the
Japanese military medical service, yet fail to lend
our influence toward the advancement of our own.
We surely have competent surgeons. We do not
need to be "damned with faint praise." Give us
enoueh trained men to do the work and we will
agree to be second to none when the occasion de-
mands. Urge your representatives to pass the law
promptly, and thus demonstrate at once your pa-
triotism and your professional pride.
Politics.
The exigencies of an active physician's Ufe usual-
ly preclude political aspirations. Besides, the suc-
cessful physician is the one who is devoted soul
and body to his art, hence, cares little for the bubble
of political fame. But in this the physician does
himself and the world a wrong. The public needs
just such men in power.
Who is so well qualified to know the public needs
as the ideal altruist, the ubiquitous friend, and con-
fidential adviser, the doctor? He makes a model
executive oflr'cer, and the public is not slow to recog-
nize his virtues. Xumerous examples of the suc-
cessful doctor politician might easily be cited. Enter
the arena if you feel convinced that you are needed
there.
Books.
The fast increasing tendency of men who have'
some original ideas to become inspired thereby to
write entire textbooks, is flooding our bookshelves,
our brains, and our reading hours. "A few modest
volumes would suffice to chronicle the real achieve-
ments of medicine ; a library is necessary to tell the
story of medical speculation and practice."
Prezentive Medicine.
Our American lawmakers have at last passed
essential health laws for the protection of the public
which have for decades past been in active opera-
tion in Eastern "benighted" countries ; but the rank
and file of the medical army are still sadly derelict
in the matter of public hygiene and preventive
medicine.
We may appreciate our positions as guardians of
the public health, but you will be told by health offi-
cers everywhere, that the average medical attend-
ant is not as rigid or reliable in his supervision of
infected houses or individuals as this responsibility
demands. Earlier and persistent disinfection of in-
fective excreta, and appreciation of the menace of
typhoid and other stools for some time after con-
valescence and more rigorous protection against the
milder tuberculous types are urgent needs.
To the failure of early diagnoses and consequent
preventive discipline is ascribable the persistence of
many preventable diseases.
Isms.
Many of us ridicule or attempt to obstruct or
destroy isms or patliies with which we are not in
accord, while at the same time our incredulity is
vanquished without an effort by a new ipse dixit
from otir authority, or insufficient data.
We accept at once Brown-Sequard's orchitic
elixir for perennial virility, or a new tuberculin cure
for tuberculosis, or the dictum that the Anopheles
claviger is the sole carrier of the malarial parasite,
or that the Eberth bacillus is only transmissible
through the stools, or that every appendix and
every diseased ovary should be removed or that op-
sonic indices or x ray radiographs are infallible, and
a horde of dogmatic doctrines that have not yet
passed through the crucible. Says Dr. Max Nor-
dau in his well known book Paradoxes : "State-
'ments hitherto considered unimpeachable because
946
FALIEli: PYLORIC IXSUfFlCIBXCY.
[New Vork
iI:;DicAL Journal.
no one has ever questioned their validity must sub-
mit to the demand for proofs, and it then frequent-
ly appears that they have none."
Now as a matter of fact there must be a germ of
truth in every ism. Those extraordinary or occult
fads are based upon some sound physiological or
pathological principle. \\'e are not defeating them
bv derision, we will not destroy them by persecu-
tion. How few of us really know any more about
them than do the most ignorant devotees that wor-
ship at their mystic shrines.
\\'ould it not be more effective for our colleges
to devote two or three hours each semester to an in-
telligent dispassionate study of each of them, free
from ridicule or levity?
Indeed, our illiberalism in medicine smacks
strongly of religious bigotry and intolerance.
Egoism.
The standard of the medical profession is almost
Utopian in its loftiness. We are the champions_ of
humanity, charitv, patience, self sacrifice, puritv.
knowledge, and wisdom. Hence, inconsistencies in
our theories and practices are more glaring, and
violations more flagrant than in any other sphere
of life.
How incongruous that jealousy, envy, egoism,
should enter such ennobling lives, whether actuated
by mercenary greed or selfish ambitions, and l^eget
.social and professional demoralization.
Is it not a travesty upon that classical honor
Avhich is a vital element in our profession, for a
physician who succeeds another in a case to inveigh
against the ability of his absent predecessor? Is
it not both undignified and cowardly?
Each one of you is the standard bearer and model
of the entire bodv : and it is but a logical inference
that the profession be held responsible for yoiir
shortcomings. W e are in very truth our brother's
;keeper.
And so, when we chasten ourselves we purify
.our environs. And the corollary follows:
As one lamp lights another nor grows less,
So nobleness enkindleth nobleness.
A CASE OF CHRONIC DIARRHCEA ACCOM-
PANIED BY PYLORIC INSUFFICIENCY:
Relieved by Hydrochloric .4cid.
Bv E. Palier, M. D.,
New York.
The following case is interesting from several
standpoints, and I believe it deserves to be reported :
Patient was a baker, thirty-five years old, born in Rus-
sia. He was somewhat above medium height and well
built. Family history was negative. Patient had had no
serious illness, except the one to be described. In .\pnl,
1907, he came to me at a dispensary because of a diarrhoea
which he said had lasted for the last five years, havmg had
from five to fifteen stiwls daily. The diarrluca was pam-
l;-ss, ,ind frequently came on soon after a meal, and the
patient had also often to get up several time at night to
evacuate the bowels. A flesh diet invariably aggravated
tl-c trouble, according to patient's statement. He could
not give any definite cause to account for his illness.
'l iic patient was- pale and anremic, but there was very
linle emaciation, contrarv to what might be expected. A
ph>-sical examination showed nothing abnormal, and no
points of tenderness cnnld be elucidated anywhere m the
abdomen.
Tile stoois were jeniiliquid and contained mucus and
big pieces of undigested food. What the patient had eaten
could be seen in the stools.
The patient was given a test ineal at 3 p. m., and in ad-
dition he had had a light meal in the morning: the stomach
tube was introduced at 4 p. m., i. e., one hour later ; but
absolutely nothing could be brought out of the stomach.
The same was repeated two days later with similar re-
sults ; the stomach was entirely empty. Then the tube was
introduced three quarters of an hour after a test meal, and
only a few cubiccentimetres of stomach contents were ob-
tained. The tube was again introduced half an hour after
a test meal, and about twenty cubic centimetres of stomach
contents were withdrawn. Two days later the same was
repeated w ith similar results.
The stomach contents were not well digested, but it was
not surprising in view of the fact that they were with-
drawn so soon afier the test meal. But there was a mod-
erate reaction on congo paper, and the hydrochloric acid
aciditj' amounted to about 20.
The patient had been put on a strict antidiarrhceal diet,
such as rice soup, boiled milk, very soft eggs, etc., and
numerous drugs, both singly and in various combinations,
had been given, but without any appreciably good results.
Opiates had a slight transitory effect only.
The patient was then given dilute hydrochloric acid, 10
drops in a tcaspoonful of water, after each meal, and in one
week the stools were reduced to two daily, and in another
week the patient had about one good evacuation of well
formed fseces daily, and he said that he felt perfectly well.
At first the hydrochloric acid was given together with
small doses of iDismuth subnitrate and pepsin. But the lat-
ter two had been prescribed previously without any effect,
consequently no great influence can be attributed to
them. Soon, however only the hydrochloric was given. As
impro\-ement continued the intervals of exhibiting this
drug were gradually increased, till the patient took it only
several times during the week. The stomach contents were
examined after the patient had improved, a;id an hour after
a test meal tlie normal amount, about forty to fifty cubic cen-
timetres, could be withdrawn. They were fairly well di-
gested, and the hydrochloric acidity amounted to about 30.
On the da> s wb.en the stomach contents were examined
the pan'cnc tnok no hydrochloric acid.
Now, this drug was given the patient at first because I
suspected he had some hypochlorhydria ; subsequent exami-
nations of the slonrich contents. howt\er, slinwed that the
acidity of the patient's stomach was about normal, or at
least there was not such a marked deficiency as to require
the administration of hydrochloric acid. Nevertheless, the
hydrochloric acid had an excellent effect. Whether or not
it had a favorable effect on the intestinal secretion, is a
question which we cannot answer with any degree of cer-
tainty. But there is one thing certain, and that is that the
evacuation of the patient's stomach at first was too rapid,
and that it became normal under the administration of
hydrochloric acid.
Was there pyloric insufficiency or simple hyper-
motility of the stomach? Sere, and afterwards Eb-
stein," have called attention to jiyloric insufficiency.
Some authors .seem to think, however, that this af-
fection cannot be demonstrated with certainty, and
that what is taken for pyloric insufficiency is simply
hvpermotility of the stomach. It seems to me,
however, that if the pylorus functioned well, hyper-
motility of the stomach alone could not cause the
rapid evacuation of the stomach contents, as the
pylorus would offer an effective barrier. If there
is accelerated evacuation, the pylorus evidently of-
fers an ineffective resistance. In my case the gas-
tric secretion was about normal, and there was no
pathological cause to account for a hypermotility of
the stomach.
It is very hazardous to draw conclusions from
the results of a certain treatment as to the diagnosis,
for we know how often such conclusions arc de-
'Qiioted hy A. Mathieii, Trait,' dcs nialiulit's de I'estomac cl de
I'infcstiv. Paris, 1901. p. no.
May 10, 1 90S.]
THERAPEUTICAL NOTES.
947
ceptive. But in my case it would be hard to explain
how the administration of hydrochloric acid could
inhibit the hvpermotility. But it seems rational to
explain that this drug 'acted on the pylorus as an
irritant, causing it to contract longer, and thus caus-
ing a longer retention of the food and a better di-
gestion in the stomach, and therefore less work for
the intestines.
Such a hypothesis, I am aware, is antagonistic to
conclusions recently reached by Cannon' from
radiographic researches. According to this inves-
tigator, the acidity of the stomach has a relaxing ef-
fect on the pylorus, and hastens the evacuation of
the stomach, whereas diminished acidity is acconi-
panied by retardation of gastric evacuation. This
statement is entirely at variance with what we daily
see in our patients. ' People with hypochlorhydria or
entire achlorhydria may have a normal or accel-
erated emptying of the stomach, whereas some who
have a high hyperacidity may have, and they fre-
quently do have, retarded evacuation.
A reviewer' of Cannon's work, indeed, raises ob-
jections to some of the latter's conclusions. These
conclusions are certainly in disaccord with our daily
experience.
In my case the passage of undigested food prob-
ably acted as an irritant on the intestines, and they
in "their turn became aftected. This case empha-
sizes the necessity of an examination of the
stomach contents in chronic disorders of the alimen-
tary canal. Furthermore, such patients must be
warned against taking any liberties with their di-
gestive apparatus, as relapses usually follow abuses.
Such patients are relieved, and can remain well as
long as they are careful, but they get unwell again
under indiscretion in regimen.
55 East Ninety-third Street.
f btrapeutital giotes.
Furunculosis. — In the case of a man aged
thirty-seven, afflicted with crops of furuncles mak-
ing their appearance on arms, neck, and body about
every two weeks, Shoemaker (Medical Bulletin.
April, 1908) prescribed rest for a week and an ab-
solute milk diet, beginning the treatment with a
thorough purging by means of calomel, gr. ij, in
divided doses, powder form, dry, on the tongue
every half hour, followed by a tablespoonful of
magnesium sulphate in the morning. The following
was then ordered to be taken regularly as pre-
scribed :
R Extract of mix vomica gr. y;
Arsenic trioxide gr. i;
Calcium sulphide gr. xx;
Quinine bisulphate, gr. xlv;
Extract of gentian, 5i-
M. ft. capsulre xxx.
Sig. : One capsule after each meal and at bedtime.
Ichthyol and Resorcin Mixture for Dysentery.
— Belbeze (Journal de mcdccine, de Paris. April 4.
1908) prescribes the following for the treatment of
dysentery :
'Cannon. The Acid Control of the Pylorus, American Journal of
Physiology. November, 1907. p. 284.
»J. P. Langlois, La Presse medicate, January 4, 1908.
B Ichthyol, gr. xlv.
Resorcin, 3i;
Glycerin, 3i;
Syrup of quince, ^v.
M. ft. mist.
Sig.: One tablespoonful three times a day.
(The patient should be instructed to wash out his
mouth with water containing a little lemon juice in
order to correct the disagreeable flavor of the medi-
cine.)
Treatment of Vulvovaginitis. — The various
methods of treating inflammation of the vulva and
the vagina in children and in adults are collated in
Pron's Formulaire synthctique de medecine, as fol-
lows : For children it is recommended to bathe the
vulva twice daily with a i in 2,000 solution of potas-
sium perinanganate and at the same time inject it into
the vagina under light pressure through a small
catheter of narrow calibre. At night introduce a
pencil shaped pessary of the following:
B Salol gr. iss;
Cacao butter gr. xv.
In the case of adults rest in bed should be im-
posed, and the patient put on a light diet ; cold com-
presses are applied to the vulva, and renewed every
two or three hours, tampons of cotton saturated
with a I in 2.000 solution of potassium permanganate
being placed between the labia pudendi majora.
Order a Sitz bath with the following:
R Belladonna leaves,
Hyoscyamus leaves, aa 3i ;
Poppy heads, No. 2.
\Mien the inflammation subsides use once or twice
a day at first an injection of boric acid water, and
later, potasssium permanganate solution (i in 2,000
to I in 1,000) ; solution of corrosive sublimate, i
in 5,000, or the following:
^ Copper sulphate, )
Ferrous sulphate, > aa gr. xv ;
Zinc sulphate, )
Gum acacia, gr. iii ;
Water, 5x.
M. ft. injectio.
Insert between the labia a tampon saturated with
an antiseptic or astringent solution, such as a i in
200 solution of lead acetate or a i in 40 solution
of glycerite of tannin.
Folliculitis is treated with a lotion applied lightly
as a paint, using either one of the following pre-
scriptions :
I.
R Silver nitrate, gr. xii ;
Distilled water ji.
Solve.
II.
B Zinc chloride gr. xii;
Distilled water, ji-
Solve.
As a dusting powder toward the end of the treat-
ment, use the following:
B Bismuth subgallate, 3ss;
Bismuth subnitrate, 3i;
Zinc oxide 3v.
M.
For chronic vulvovaginitis in children, in addi-
tion to the usual tonic treatment (cod liver oil,
syrup of iodide of iron, etc.), sea baths should be
prescribed, or a bath at home containing:
B Sodium chloride, lb. ii;
Sodium carbonate,
M.
948
THERAPEUTICAL NOTES.
LXe.v Vurk
Medical Journal.
Gargle in Diphtheria. — The following is cred-
ited to Heindl, of \ icnna, in Journal de mcdecine
de Paris, for April i8th:
B Iodine tribromide, gtt. xy;
Potassium iodide, gr. iji ;
Distilled water, 3x.
M. ft. gargarisma. Sig. : Use as a gargle every hour.
(This solution should be put up in an amber col-
ored glass bottle.)
Suppository for Fissure of the Anus. — The fol-
lowing suppository will relieve the pain in fissure
of the anus:
B Extract of rhatany, gr. vi ;
Extract of opium gr. ss ;
Extract of belladonna, gr. Yi ;
Cocaine hydrochloride, gr. Ys;
Cacao butter, gr. xlv.
M. ft. supposit. i.
Not more than two of these suppositories should
be given during twenty-four hours, the suscepti-
bility of some persons to belladonna being borne in
mind.
Treatment of Posttyphoid Alopecia. — Alfred
Martinet discusses in the Prcsse medicale, for
April 1 8th, the loss of hair in women which usual-
ly accompanies an attack of typhoid fever, and sug-
gests a course of treatment, remarking that in the
case of young girls the aesthetic result of neglect of
precautions to insure the regrowth of the hair may
prove disastrous to their prospects in life. He con-
siders the question of when the hair should be cut,
and advocates cutting it twice, once at the end of
the first week after the fever has abated and when
the patient is able to bear the exertion entailed by
the process, and again a month or six weeks later.
The hair should be washed once a week with soap
and water or with a decoction of quillaja, and the
new growth of hair stimulated by dry friction of the
scalp and the application of an invigorating lotion
of either of the following types :
I.
R Pilocarpine hydrochloride, gr. vi ;
Ammonia water, ^ Ixxv;
Spirit of lavender, S'^s ;
Compound spirit of ether
M.
II.
R Solution of formaldehyde, tt^ xv ;
Glacial acetic acid, ^3i ;
Tincture of jaborandi, aa 3vi ;
Acetone,
Alcohol, aa ^iv.
M.
The last preparation is very active and strongly
irritating, and so must be used with caution.
It is noted by Dr. Martinet that the hair is often
slow to regain its former vigor, and the patient
should be told that it may take six months to re-
store it, but that recovery is certain, and tlie new
growth will be full and lasting.
[It may be w^ll to repeat here what was said in
an editorial article in the issue of the Journal for
Jantiary 4, 1908. on page 29, regarding a prescrip-
tion of Sabouraud's for falling of the hair in wo-
men, in which it was remarked that the proportions
of the ingredients in the fortnula should be varied
to suit individual cases, it being observed that
"when a woman finds a particular prescription
proves beneficial in her case, she is very apt, in the
goodness of her heart, to pass it around among her
friends, but disappointment is almost sure to result,
because hardly any two cases in the circle of her ac-
quaintances are exactly alike, and it would be as
futile to order one prescription for indiscriininate
use as to prescribe the same eyeglasses for all per-
sons with visual errors."]
For Collicky Pain in the Stomach the following
mixture is recomended in Bulletin general de thera-
peutique:
B Cocaine hydrochloride gr. ;
Codeine, gr. 54;
Lime water, 5v;
Chloroform water, 3x.
M. Sig. : One tablespoonful every half hour, but not more
than four such doses to be administered in one day.
Mercurial Stomatitis. — Queyrat is of the opin-
ion that the disagreeable effects sometimes observed
to follow hypodermatic injections of mercurial oil
are the result of faulty technique. For his part he
never injects more than one grain of mercury a
week in a patient weighing 145 pounds. He pre-
scribes for use as an application to the teeth and
gums during the time the patient is under treat-
ment the following saponaceous dentifrice :
B Almond soap, .3x ;
Glycerin, 5vi ;
Extract of rhatany,
Sodium borate, aa gr. xx;
Oil of anise, ttj^ xx ;
Oil of peppermint, tt^ vi.
Queyrat insists that the treatment should be sus-
pended on the appearance of nodules at the site of
injection. In a case of very severe stomatitis fol-
lowing the careless administration of mercury hypo-
dermatically he was able to afford relief to the sub-
ject with irrigations of carbolic water and solution
of hydrogen dioxide, touching the spots with tinc-
ture of iodine and injections of colloidal platinum
and sea water.
Injection for Haemorrhoidal Pruritus. — Adler
{Journal de mcdecine de Paris, April i8th) uses
the following injection:
B Fluidextract of hamamelis, 3iv ;.
Fluidextract of ergot,
Fluidextract of hydrastis, aa 3ii ;
Carbolated olive oil (5 per cent.), 5v.
M. S. : After shaking well, inject one or two ounces into
the rectum.
Intestinal Antiseptic for Children. — For a
child, five years of age, the following is pre-
scribed :
B Bismuth subgallate, gr. -)4 ;
Sodium bicarbonate gr. iss ;
Prepared chalk, gr. iss.
M. Sig. : One powder every three hours.
Coryza. — One or two days' treatment with the
following will relieve a cold in the head, says the
Bulletin general de thcrapcutique, for April 8, 1908:
B .AlropiiiC sulphate, gr.
Pulverized Pulsatilla gr. iii;
Acetyl salicylic acid, )
Quinine hydrochloride, V aa gr. xxx.
Sugar of milk, )
M. In cachet xii req. div.
Sig. : One cachet three or four times a day, at least one
hour apart.
May 1 6. 1908. J
EDITORIAL ARTICLES.
949
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Review of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M. D.
Addresx ail business communications to
A. R. ELLIOTT PUBLISHING COMPAXY,
Puhlishersj
66 IVcst Broadway, New York.
Philadelphia Office : Chicago Office :
3713 Walnut Street. 160 ^^ ashington Street.
SuBSCBirxiox Price :
Under Domestic Postage Rates. : under Foreign Postage Rate.
$7 ; single copies, fifteen cents.
Remittances sliould be made by New York Exchange or post
office or express money order payable to tlie .\. R. Elliott Pub-
lisliing Co., or by registered mail, as the publishers are not
responsible for money sent by unregistered mail.
Entered at the Post Office at New York and admitted for
transportation through the mail as second class matter.
NEW YORK, SATURDAY, MAY 16, 190S.
THE HOME MANAGEMENT OF CONSUMP-
TION AMONG THE POOR.
The city of New York is commonly regarded as
furnishing an exceptional example of overcrowd-
ing of the poor in unsavory tenements, but perhaps
it is by reason of the great population of New York
that it has excited so much attention, for it certain-
ly seems as if some smaller municipalities might be
held up as at least proportionately equal to us in
neglect of domiciliary sanitation. The city of
Nantes, for instance, appears to be in very bad con-
dition, as we gather from articles by Dr. Becigneul
and Dr. Fargues, published in the Gazette mcdicale
de Nantes for April nth. Dr. Becigneul, who re-
ports upon the operations of the Dispensaire antitu-
berculeux for the year 1907, is able to record a
slightly diminished tuberculous mortality for the
year in proportion to the entire number of deaths,
though the actual mortality from tuberculous dis-
ease was greater than it had been before for more
than twenty years. In New York we have made a
better showing, but our tenement house population
is still atrociously housed.
\\'e suppose it may fairly be presumed that in
the matter of habitations for the poor Nantes is no
more negligent than many another town of moder-
ate size, though some .of the conditions set forth by
the authors whose names we have mentioned are
about as bad as they could be. For example, it was
found in the dispensary visitations that, of sixty-
seven families of four members each, one occupied
four rooms, six three rooms (one of them in three
instances without a window), thirty-two two rooms
(one without a window in four cases), and twenty-
eight but a single room. Filth, including excrement,
accumulated on the common staircase (which it
seemed to be nobody's business to clean), together
with repulsive drains sometimes regurgitating the
sewer contents to the very verge of a bed, added to
the horrors and dangers of the cramped air space.
\Mien the management of a case of pulmonary
tuberculous disease at the sufferer's own home is
undertaken, the work necessary is not confined to
ministering to the individual needs of the sick per-
son ; it includes the utmost endeavors to prevent the
conveyance of the disease to others. W hen these
efforts are hampered by such conditions as those of
Nantes, where often as many as four persons had
to sleep in one bed, there is scant hope of fore-
stalling infection. It must be evident to the most
superficial student of demography that the housing
of the poor needs radical improvement if we are to
better the public health in any considerable degree.
THE ••ADREXUTHYREOID CENTRE."
By this term, as used by Dr. Charles E. de AI.
Sajous, of Philadelphia, we understand the pitui-
tary body or some constituent part of that structure,
acting through direct nerve connections upon the
thyreoid and the suprarenal glands. A notable con-
tribution to our conceptions of its action is to be
found in a paper recently presented by Dr. Sajous
before the American Therapeutic Society and the
Philadelphia Branch of the American Pharma-
ceutical Association. It is entitled The Autopro-
tective Resources of the Body — A New Foundation
for Scientific Therapeutics. It is to appear in full
in the May number of the Monthly Cyclopcedia of
Practical Medicine, advance sheets of which have
been courteously sent to us.
The pituitary body, if we understand Dr. Sajous
aright, performs the twofold duty of a sentry (be-
ing in great part a sensory organ) and of an aide
de camp, calling the thyreoid or the suprarenals into
defensive action when it has scented danger to the
organism. It is on this associated function of de-
fense, fulfilled by what he terms the "adrenal sys-
tem," that Dr. Sajous thinks that the therapeutics
of the future — scientific therapeutics — must largely
be founded. The therapeutics of the present time
rests extensively on empiricism, and empirical
knowledge, as he, in common with many other
thoughtful writers, freely admits, always consti-
tutes the cornerstone of a science. It is doubtful,
indeed, whether we shall ever wholly escape from
empiricism : perhaps it is in no great degree desir-
950
EDITORIAL ARTICLES.
[New York
Medical Tol'rnaI.
able that we should do so, and certainly we ought
not to seek to break loose from it violently at the
expense of what is useful, even if not entirely ex-
plicable. This Dr. Sajous freely concedes, but he is
none the less mindful of the superiority of a system
of therapeutics founded on coordinated facts and
susceptible of a rational explanation.
Since Bichat, as it seems to us, there has been no
more fascinating projector of a philosophy in medi-
cine than Dr. Sajous. With an enthusiasm border-
ing on eagerness he leads us on through difficulties
at which, left to our own resources, many of us
might quail. What will it uhimately matter if he
is at length shown not to have paused to struggle
with every feature of detail that he encountered?
For our part, we prefer his ardent prosecution of a
grand idea to the sombre "platitudes of the thera-
peutic nihiHst, for it seems reasonably sure to lead
to something positive and to help powerfully in lift-
ing into an approach to certainty that feature of
medicine which most concerns the community at
large and upon the condition of which we must be
content to be rated.
THE SEASIDE FOR NEURASTHENICS.
In the Journal de mcdecine de - Bordeaux for
April 1 2th there is pubhshed a portion of a report
on this subject prepared by Dr. E. Regis for the
Biarritz Congress of Climatotherapy, including the
author's conclusions. He remarks that one must
take account of the individual's idiosyncrasies,
psychical and physical ; it is quite important that the
seaside should be attractive to the patient. Up to
the present time a marine climate has generally been
thought to be favorable to depressed persons and in-
jurious to those who are excited, but a reaction
against this traditional way of thinking seems now
to have set in, and the reverse opinion appears to
be justified by observed facts, so that neither excite-
ment nor depression is a formal indication or con-
traindication of seaside treatment. Apart from
idiosyncrasy and other considerations, purely ner-
vous excitation as a manifestation of the neuras-
thenic condition is benefited, or at least not aggra-
vated, by a marine climate, while seaside treatment
is injurious and even dangerous in cerebral excita-
tion due to organic lesions of the nervous system
underlying the neurasthenia. Depression, on the
other hand, must not be associated with too pro-
found debility.
Unless there is grave intolerance or some sub-
jacent morbid complication, neurasthenia occurring
in children and adolescents is notably ameliorated
by thalassotherapy, especially if, as is not infre-
quently the case, there is present retardation of
growth, rickets, lymphatism, or spermatorrhoea. All
forms of neurasthenia in females are especially re-
lieved by seaside treatment, preeminently those
supervening at puberty or at the menopause and
those accompanied by dysmenorrhsea, uterine and
ovarian aifections, visceral ptoses, anaemia, or gen-
eral debility. The only contraindications are super-
sensitiveness to barometric changes and profound
general weakness. Hysteria is no bar to the treat-
ment. Neurasthenia accompanying or closely pre-
ceding senility calls for the greatest prudence in
prescribing the seaside treatment, on account of the
circulatory cerebral derangements with which it is
most frequently associated; but there is no abso-
lute contraindication, for certain aged neuras-
thenics, especially men, are notably benefited by tlie
seaside.
The indications are more dependent on the pe-
culiarities of the individual than on the aetiology of
his nervous trouble, or, with certain exceptions, on.
its clinical form. The marine climate is best adapt-
ed to those forms of general neurasthenia in which,
the asthenic element predominates. Gastrointes-
tinal neurasthenia, especially if it is complicated
with mucomembranous enteritis, is injuriously in-
fluenced by such a climate. Psychic neurasthenia
is under no fixed rule as regards thalassotherapy ;
in it that treatment is not inadmissible, though de-
lirium, hallucinations, morbid impulses, and epilep-
tic manifestations are more or less prohibitive. The
symptomatic neurasthenias, especially the "preor-
ganic," such as those preceding tabes or paralysis,
do not usually allow the treatment to be well borne.
Opinions differ as to the effects of a marine climate
on the nervous system of tuberculous persons, some
considering them as sedative, others as excitant.
THE TREATMENT OF CANCER OF THE
TONGUE IN SYPHILITICS.
In our issue for May 9, 1908, we spoke of the
diagnosis of lingual cancer in syphilitic subjects.
As regards the treatment, it should be prophylactic,
and Hallopeau insisted last year, before the French
Academy of Medicine, on the fact that certain
types of syphilis should be more actively treated in
order to prevent the development of epithelioma. If
one is dealing with an initial syphiloma, the growth
should be cauterized with acid nitrate of mercury
after having been anjesthetized. For the leuco-
plakia, Gaucher and Trapenard advise frequent irri-
gation of the mouth with alkaline solutions where
ulceration is present, but if the latter is absent the
diseased structures may be cauterized with a weak
solution of potassium bichromate, the excess of the
latter being removed by careful irrigation. Cau-
terization of the fissures should be done with
chromic acid or the acid nitrate of mercury, and
May 16. 1908.]
EDITORIAL ARTICLES.
951
when the ulcerations are deep the galvanocautery
must be resorted to.
The treatment becomes more delicate when the
cpitheHoma has appeared. Horand is inclined to
treat the syphilis with mercury. The iodides may
produce oedema and a congestive attack in the can-
cerous ulceration. On the other hand, mercury has
given excellent results with Fournier. Mercury
should be administered in the form of subcutaneous
injections of calomel, given once a week, five centi-
grammes in each injection, or with the gray oil, the
dose of mercury not being more than seven centi-
grammes. As soon as the lesions become station-
ary, and the improvement which in the first place
showed itself ceases, the injections are to be stopped.
This treatment should not be continued too long,
otherwise the epithelioma will become aggravated,
and the proper surgical procedures will have to be
retarded.
Should a radical operation be declined or prove
impossible, medicinal treatment ofifers as a last resort
the use of the hydrobromide or hydrochloride of
quinine, in amounts of twenty to thirty grains daily
for from fifteen to twenty consecutive days, or in
hypodermic or intramuscular injections of a fifty
per cent, watery solution. Trypanroth may be given
subcutaneously, seven grains dissolved in ten
drachms of sterilized salt solution. Four or five
injections are to be given, and then one should wait
until decolorization of the integument occurs, when
one or two more are given. This treatment of car-
cinoma should always be combined with the use of
general tonics.
THE ASSOCIATION OF AMERICAN
PHYSICIANS.
This year's meeting of the association, held in
Washington on Tuesday and Wednesday of this
week, was among the most notable gatherings of the
organization. There was a large attendance of rep-
resentative men from various parts of the country,
the programme contained titles of many topics of
prime importance in the progress of medicine, and
the discussions were to the point and free of useless
talk. The association, now nearing the completion
of its first quarter of a century, has done much to
further advancement in our art, and its future course
may assuredly be looked to for further solid work.
FLIES AND MOSQUITOES.
The suburban householder is now engaged in
taking down his storm windows and putting up his
Venetian blinds, preparing to let in the warm airs
of summer and keep out the glare of the sun. It is
happily coming to be more and more recognized that
an important part of the spring attire of the house
is the installation of window screens for the exclu-
sion of flies and other insects. A study of statistics,
shows a rapid rise in the morbidity of infectious
febrile diseases coincident with the advent of the
fly and the mosquito, and the householder who ade-
quately protects his house against the visits of these
little pests goes a long way toward insuring himself
and his family against these infectious diseases. The
mosquito is so obnoxious for its immediate effect,
the annoyance of its song and of its sting, that much
more effort is put forth to destroy it or to protect
the household from its effects than is exerted for
the purpose of ridding the house of the fly. While
the mosquito is the bearer of at least two specific
infectious diseases, malarial fever and yellow fever,
the fly is known to be mechanically the bearer of a
wide variety of infectious diseases, one of the most
dangerous of which is typhoid fever. It is quite
probable that many of the cases of typhoid fever,
the origin of which cannot be traced, are due to
infection through the agency of flies, and the house-
keeper who keeps her house free from these pests
confers a double benefit on her household in pro-
moting cleanliness and the health of its members.
INCREASED PAY FOR THE ARMY
MEDICAL OFFICER.
The combination of advanced rank given under
the measure reorganizing the medical corps of the
Army, which was printed in our issue of April i8th.
and of increased pay under the Army appropriation
bill, which has just been agreed to by Congress, will,
it is hoped, make the medical corps so much more
attractive to the younger members of the profession
that it may be possible to fill the vacancies in the
corps and thus furnish a force more nearly commen-
surate with the tasks confronting this department
of the Army.
The increase in pay provided for in the appro-
priation bill is well deserved, and is far from being,
liberal when the increased cost of living is taken into
consideration. The present pay tables were adopted
many years ago, and a comparison of the cost of
living then and now would show an increase of
probably 335^ per cent. Recent studies prove that
during the past ten years alone there has been an
increase of 25 per cent, in the cost of living. In
order, therefore, to place the income of the Army
officer on a parity with that which he was receiving
ten years ago, taking the cost of living into consid-
eration, his pay should have been increased 25 per
cent. This has not been done in the appropriation
bill, save in the case of the first lieutenant, who is
therefore relatively better off than his superior offi-
952
NEIVS ITEMS.
[New \ork
Medical Journal.
cers. The increase provided in the appropriation
bill amounts approximately to 20 per cent, for the
captain and major, 16 per cent, for the lieutenant
colonel, 14 per cent, for the colonel, and 9 per cent,
for the brigadier general. It will thus be seen that,
taking the increased cost of living into consideration.
Congress has not been unduly liberal to Army offi-
cers in the matter of pay.
DERMATOLOGY AND KNIGHTHOOD.
We learn from an editorial article in the April
number of the British Journal of Dennatology that
on March 19th a complimentary dinner was given
in London to Sir Malcolm Morris, to congratulate
him on the honor recently conferred upon him by
the King. The chairman, Dr. H. Radcliffe-Crocker,
president of the Dermatological Section of the Royal
Society of J\Iedicine, the article goes on to say,
pointed out that this was the first time that a title
had been given to a dermatologist "in recognition
of services rendered in that special branch of medi-
cine." Would it not have been just as well to allow
certain people to keep on taking it for granted that
the late Sir Erasmus Wilson owed his title to his
achievements in dermatology?
Changes of Address. — Dr. William Rumfitt Lee, of
the New York Lying-in Hospital, New York, to 342 Sec-
ond street, Troy, N. Y. ; Dr. H. Greenstein, to 341 East
Fifty-second street, New York.
The Gloucester County, N. J., Medical Society will
meet in Woodbury, N. J., on Thursday, May 21st, at 2 :30
p. m. The principal feature of the programme will be a
paper by Professor Orville Horwitz.
A Department of Psychology at Chautauqua. — Ar-
rangements have been made for a department of psychology
at Chautaucjua, N. Y., this summer, and Professor Charles
H. Judd, of Yale, will be one of the lecturers.
The Portland, Me., Medical Club met on Thursday,
May 7. Dr. John F. Thompson was the host, and Dr.
George N. Turner was the essayist of the evening, the sub-
ject of his paper being Psoriasis.
Rochester, N. Y., Academy of Medicine.— At a regu-
ular meeting of this academy, which was held on the even-
ing of May 13th, Dr. E. Wood Ruggles read a paper en-
titled Honor to Whom Honor Is Due — a Tribute to the
Late Dr. Henry Koch.
New York Academy of Medicine. — At a meeting of the
Section in Laryngology, which will be held on Saturday,
May 23d. at 8:15 p. m.. Dr. Albert Jansen. of Berlin, Ger-
many, will read a paper on Frontal Sinus Disease. Mem-
T)ers of the academy and their guests are invited.
National Association for the Study and Prevention
of Tuberculosis. -The fourth annual meeting of this
association will be held at the .'\uflitorium Hotel, Chicago,
on June 5th and 6th. .'\n extensive program has been ar-
ranged, and the meeting promises to be both interesting
and profitable.
Medical Society of the County of Kings, N. Y.— A
meeting of the Section in Prediatrics was held on Friday
evening. May 15th. Dr. H. R. Wilcox, of Manhattan, read
a paper entitled Diabetes Mellitus in Infants and Young
Children, and Dr. G. F. Little, of Brooklyn, read a paper
on the Marantic Infant.
Summer Session of the University of Michigan. — The
annual summer session of the department of medicine and
surgery of the University of Michigan will open on June
22d and close on July 31st. The course is open to all per-
sons qualified to pursue it to advantage, and no formal
requirements for admission are exacted.
More Pay for the Naval Officer. — Naval surgeons will
be interested to learn that on May 12th the House of Repre-
sentatives adopted the conference report on the Senate
amendments to the naval appropriation bill, the effect of
which will be to increase the pay in the Navy and the
Marine Corps and of officers on the retired list.
The Birth Rate of France. — Vital statistics for the year
1907 show a marked decrease in the number of births in
France. During the year there were 774,000 births re-
corded, which was 33,000 less than for the preceding year,
while the average decrease for the past seven years has
been 12,000. There were 793,000 deaths during the year.
A Summer Course in Medicine at the St. Louis Uni-
versity.— A summer course in medicine, beginning May
25th and ending July 4th, has been arranged by the St.
Louis University. It is intended for both students and
practitioners of medicine, and instructors have been en-
gaged who will deliver lectures on the various branches of
medicine.
Contagious Diseases in Chicago. — During the week
ending May 2, 1908, there were reported to the Department
of Health 517 cases of contagious diseases, as follows:
Diphtheria, 59; scarlet fever, 75; smallpox, 4; measles,
281; chickenpo.x, 23; typhoid fever, 18; whooping cough,
11; tuberculosis, 39; minor contagious diseases, 7.
Connecticut River Valley Medical Association. — At
the annual meeting of this association, held in Bellows
Falls, Vt., on May 5th, the following officers were elected :
President, Dr. J. A. Stevenson, of Chester; vice president.
Dr. O. L. Corliss, of Walpole, N. H. ; secretary, Dr. J. S.
Hill, of Bellows Falls ; treasurer. Dr. Edward R. Campbell,
of Bellows Falls.
Medical Society of the Missouri Valley. — The annual
dinner of the society will be given at the Victoria Hotel,
Chicago, on Wednesday, June 3d, at 6 p. m. Tickets may
be obtained from the secretary at the hotel. Ladies are
invited. On June 5th there will be an excursion to Alil-
waukee, where the party will be entertained by Dr. C. O.
Thienhaus.
The Medical Society of Richmond County, N. Y.—
The regular monthly meeting of this society was held at
the Staten Island Acadamy of Medicine on the evening of
May 13th. Dr. W. R. Bastedo, of Manhattan, read a paper
entitled Gastrointestinal Diseases from an Everyday Stand-
point, which was discussed by Dr. George Mord and Dr.
Goodwin.
Buffalo Academy of Medicine. — At a meeting of the
Section in Medicine, which was held on May 12th, the gen-
eral subject for discussion was bacterial vaccines, papers
being read as follows : The Vaccines in Their Application
to the Ordinary Pyogenic Case, by Dr. Norman K. ]\Iac-
Leon ; The Vaccines in Their Relation to Erysipelas, bv
Dr. Thomas J. Walsh.
The Society of Medical Jurisprudence, New York. —
At the two hundred and fourteenth regular meeting of this
society, which was held at the New York Academy of
Medicine on the evening of May nth. Dr. Thomas Dar-
lington, Health Commissioner of the City of New York,
read a paper entitled Food and Drug Adulterations ; Their
Medical and Legal Significance.
Richmond, Va., Academy of Medicine and Surgery.—
.\ meeting of this academy was held on May 12th. Dr.
Edward McGuire read a paper on Prolapse of the Ovary,
which was discussed by Dr. R. D. Garcin. The Tech-
nique of Operations on the Mouth and Neck was the title
of a paper read by Dr. J. Shelton Horsley. The discussion
on this paper was opened by Dr. J. W. Henson.
The Bristol, Mass., South District Medical Society.—
The annual meeting of this society was held on Thursday
afternoon. May 14th. The general subject for considera-
tion was prostatic hypertrophy. Dr. H. C. .'\llen read a
paper on the pathology of the disease. Dr. A. I. Connell
dealt with the qucstidii of palliative treatment, and surgical
treatment was the sulijcct of a paper by Dr. G. de N.
Hough.
May i6, 1908.]
A'EIVS ITEMS.
953
A Special Number of the Women's Medical Journal
has been issued with the report of the annual meeting of
the Women's Medical Society of the State of New York.
The number "contains several interesting communications,
a handsome portrait of Dr. Sarah Adamson Dolley, of
Rochester, president of the Women's Medical Society of
the State of New York, and an appreciative editorial notice
of Dr. Dolley and her work.
Personal.— Dr. Frank K. Sanders, of Boston, has been
appointed president of Washburn College, Topeka, Kan.
Dr. George H. M. Rowe, for twenty-nine years superin-
tendent of the Boston City Hospital, has been obliged to
give up his position on account of ill health. The trustees
of the hospital have given him an indefinite leave of ab-
sence. Dr. J. H. McCullom has been appointed head of the
hospital during Dr. Rowe's absence.
On 'Slay 19th the alumni of the medical department of
Tulane University, New Orleans, will celebrate Dr. S. E.
Chaille's fiftieth anniversary as a teacher in the department.
The Medical Society of the Borough of the Bronx.—
At a stated meeting of this societj-, held on the evening of
May 13th, the following papers were read : Rupture of the
Kidney, by Dr. Joseph J. Higgins; Some Observations of
the Juvenile Delinquent from a Medical Standpoint, by
Dr. William G. Eynon ; The Management and Care of
Patients with Hemiplegia resulting from Cerebral Apo-
plexy, by Dr. William M. Leszynsky.
The Annual Meeting of the National Conference of
Jewish Charities was held in Richmond, Va., recently
On the last day of the conference the following officers
were elected for the ensuing year : President, Dr. Jacob H.
Hollander, of Baltimore; first vice president, Mr. Martin A.
Marks, of Cleveland; second vice president, Mrs. Max
Lowenberg, of New York; secretary, Mr. Louis Lavine, of
Baltimore; treasurer, Mr. Bernard Greensfleder, of St.
Louis.
American Surgical Association. — At the annual meet-
ing of this association, which was held recently in Rich-
mond, Va., the following officers were elected for the en-
suing year: President, Dr. C. B. G. Nancrede, of Ann
Arbor, Mich. ; vice presidents, Dr. A. P. Gerster, of New
York, and Dr. Leonard Freeman, of Denver; treasurer.
Dr. Charles A. Powers, of Denver; secretarys Dr. Robert
G. Leconte, of Philadelphia. The meeting in 1909 will be
held in Philadelphia.
Medical Society of the Woman's Hospital of Phila-
delphia.— At a meeting held on Monday evening, April
20th. the following programme was presented : Demonstra-
tion of the venous pulse, by Dr. Frances C. Van Gasken
and Dr. Anne H. Thomas ; a paper on Laryngeal Compli-
cations of Typhoid Fever, by Dr. Emma E. Musson ; the
report of Septic Cases following Childbirth, by Dr. Caroline
M. Purnell ; and a paper entitled Technique of the Ophthal-
motuberculin Reaction, by Dr. Mary C. McClellan.
College of Physicians, Philadelphia. — The following
programme was presented at a meeting of the Sec-
tion in Medical Historj-, which was held on Tuesday
evening. April 28th : Some Remarks about Dr. Lettsom,
by Dr. Charles J. Burr; The State of Medicine as Depicted
by Pepys in the Reign of Charles H ; Montaigne's Estimate
of the Medical Profession, by Dr. Francis B. Packard ; the
exhibition of a Pharmacopoeia formerly the property of
William Penn. by Professor Joseph P. Remington.
The Philadelphia Academy of Surgery. — At a meeting
of this society, held on Monday evening. ^Iay 4th, the fol-
lowing papers were read : A Case of Haemophilia Treated by
Transfusion, by Dr. Francis O. Allen ; Two Cases of Intes-
tinal Hasmorrliage following Abdominal Operation, by Dr.
Charles F. Mitchell ; A Case of Gastrointestinal Hjemor-
rhage following Radical Operation for Hernia: Exhibition
of Specimen of Large Fibrosarcoma of the Uterus Compli-
cated by a Three Months' Pregnancy, by Dr. Orville
Horwitz.
American Gsmaecological Society.— The thirty-third
annual meeting of this society will be held in Philadelphia
on May 26th, 27th. and 28th. All the sessions will be held
in the Assembly Hall of the College of Physicians. The
officers of the society are: President, Dr. j' Montgomery
Baldv. of Philadelphia: first vice president. Dr. I. S. Stone,
of Washington. D. C. : second vice president. Dr. Eugene
Boise, of Grand Rapids. Mich. ; treasurer. Dr. Charles P.
Noble, of Philadelphia; secretary. Dr. J. Riddle Goffe, of
New York.
Officers of the American Therapeutic Society. — At
the annual meeting of the society, which was held in Phila-
delphia last week, the following officers were elected :
President, Dr. Frederic H. Gerrish, of Portland. Me. ; first
vice president. Dr. Alexander D. Blackader. of Montreal,
Canada ; second vice president. Dr. Howard Van Rensse-
laer, of Albany, N. Y. ; third vice president, Dr. Robert T.
Morris, of New York; secretary, Dr. Noble P. Barnes, of
Washington, D. C. ; treasurer, Dr. A. Ernest Gallant, of
New Y^ork.
The Medical Society of Washington County, Md.,
met in regular session on Thursday, May 14th. Dr. E.
Tracy Bishop read a paper on Parasites, and Dr. Clara S.
Eirley presented the report of a clinical case. The reading
of the papers was followed by a general discussion of the
relations at present existing between the society and the
Washington County Hospital Association. The value of
the post graduate course was considered, and the question
of physicians" names appearing in the public press in con-
nection with notices of their cases was discussed.
The Medical Association of the Greater City of New
York. — A stated meeting of this association will be
held in Du Bois Hall, New Y'ork Academy of Medicine, on
Monday, ^May i8th, at 8 :30 p. m. The programme includes
the following : Remarks on the Ultraviolet Ray. High Fre-
quency Currents, and Tabes, suggested by the discussion at
the March meeting, by Dr. Henry G. PifTard ; a paper by
Dr. Edward F, Brush, entitled Dairy Dirt (.Harmful Dirt;
Harmless Dirt ; Pathological Dirt ; .Esthetic Dirt ; Some
New Points Relative to Typhoid Fever and ^lilk) ; a paper
on Diseases Conveyed by Insects, by Dr. John B. Huber.
Vital Statistics of the Philippines. — According to the
Quarterly Report of the Bureau of Health of the Philippine
Islands, during the last quarter of the year 1907 the num-
ber of deaths registered was 2,502, corresponding to an
annual death rate of 44.42 in 1,000 of population, which is
somewhat higher than that of the other three quarters of
the year. The report shows an increase in the number of
deaths from bronchitis, pneumonia, and cholera, but a
slight decrease in the number of deaths due to diseases of
the alimentary canal. There were 2,293 births registered
during the quarter, an increase of 310 over the preceding
quarter.
The Mortality of Chicago. — According to the bulletin
of the Department of Health for the week ending May 2,
1908, there were during the week 536 deaths from all
causes, as compared with 764 for the corresponding period
in 1907. The annual death rate in 1,000 of population was
12.90. The principal causes of death were: Apoplexy, 10;
Bright's disease, 28; bronchitis, 22; consumption, 67; can-
cer, 29; convulsions, 5; diphtheria, 10; heart diseases, 54;
influenza, 3; intestinal diseases, acute, 32; measles, 2;
nervous diseases. 20; pneumonia, 68; scarlet fever, 4;
suicide, 9; violence (other than suicide) ; whooping
cough, I ; all other causes, 141.
Vital Statistics of New York. — During the week end-
ing May 2, 1908, there were reported to the Department of
Health 1.500 deaths from all causes, corresponding to an
annual death rate of 17.69 in 1,000 of population. Of the
total number of deaths, 808 were in Manhattan, 128 in the
Bronx, 479 in Brooklyn, 65 in Queens, and 20 in Richmond.
The principal causes of death were : Contagious diseases.
154: pulmonary tuberculosis, 178; pneumonia. 271: organic
heart diseases. 145: cancer, 62; bronchitis. 21: diarrhceal
diseases (under five years of age), 54: suicide, 20: homi-
cide, 2; accidents, 73. There were 151 still births. The
number of births recorded during the week was 2,430, and
of marriages, 1,002. '
Infectious Diseases in New York:
]Ve are indebted to the Bureau of Records of the De-
partment of Health for the following statement of neiv
cases and deaths reported for the tzvo weeks ending May
9, 1908:
, May 2. , , May 9. ,
Cases. Deaths. Cases. Deaths.
Tuberculosis pulmonalis 482 178 518 185
Diphtheria 425 45 394 37
Measles 1,652 41 1,668 47
Scarlet fever 855 60 908 43
Smallpox I
Varicella 158 .. 136
Typhoid fever 36 8 32 8
Whooping cough 27 . 32 5
Cerebrospinal meningitis 12 14 8 7
Totals 3,648 346 3,696 332
954
NEJVS ITEMS.
[New York
Medical Journal.
Scientific Society Meetings in Philadelphia for the
Week Ending May 23, igoS-^Monday^ May iSth, North-
east Branch, Philadelphia County Medical Society. Tues-
day, May igth, Dermatological Society; Academy of Nat-
ural Sciences; North Branch, Philadelphia County Medical
Society. Wednesday, May 20th, Section in Otology and
Laryngology, College of Physicians; Association of Clini-
cal Assistants, Wills Hospital; Franklin Institute. Thurs-
day, May 2ist, Section in Gynaecology, College of Physi-
cians; Section meeting, Frankhn Institute; Medical So-
ciety, Woman's Hospital. Friday, May J2d, South Branch,
Philadelphia County Medical Society; Northern Medical
Association; Philadelphia Neurological Society.
Philadelphia Polyclinic and College for Graduates in
Medicine. — The following are registered at this college:
Dr. N. P. Wood, of Denver, Col. ; Dr. W. B. Kearney, of San
Francisco, Cal. ; Dr. G. C. Snyder, of Moxahala, Ohio ; Dr. T.
C. Bakes, of Raton, N. M. ; Dr. James M. Blackwood, of
New Castle, Pa. ; Dr. S. Ira McDowell, of Dallastown, Pa. ;
Dr. L. A. Larson, of Kane, Pa. ; Dr. E. H. Hickman, of
Kane, Pa.; Dr. Douglas P. A. Jacoby, of Newport, R. I.;
Dr. John Lear, of Allentown, Pa. ; Dr. Henry F. Schwartz,
of Reading, Pa.; Dr. J. C. McAllister, of Ridgway, Pa.;
Dr. Norman H. Goodenow, of North Yakima, Wash. ; Dr.
A. J. Hill, of Canton, Ohio; Dr. Herman D. Andrews, of
Buffalo, N. Y.; Dr. H. Wells Woodward, of Washington,
D. C; Dr. H. W. Cowper, of Buffalo, N. Y. ; Dr. W. E
McLoughlin, of Mimieapolis, Minn. ; Dr. Charles H. Brown,
of Franklin, Pa. ; Dr. J. H. Orbison, of Lahore, India, and
Dr. R. D. Nicholls, of Glassport, Pa.
The Health of the Canal Zone. — During the month of
March there were 198 deaths in the Canal Zone, including
the cities of Panama and Colon, in a population of 114,920,
corresponding to an annual death rate of 20.67 in 1,000 of
population. There was i death from typhoid fever, 6 from
;estivoautuninal malaria ; 18 from clinical malaria ; i from
malarial cachexia ; i from hjemoglobinuric fever ; 3 from
amoebic dysentery ; i from clinical dysentery ; 3 from beri-
beri; 2 from purulent infection and septicaemia; 17 from
tuberculosis of the lungs; 5 from other forms of tubercu-
losis; 3 from tetanus; 9 from bronchopneumonia; 13 from
pneumonia; and 11 from "diarrhoea and enteritis, under two
years of age. The death rate among the white employees
of the commission was 16.75 1,000; among the black
employees, 10.80 in 1,000; and among all the employees,
12.47 i'l 1. 000. The morbidity rate among all employees
was 18.23 in 1,000 of population.
Charitable Bequests and Donations. — By the will of
Joseph Channon the Bethesda Children's Home, the Chil-
dren's Hospital, the Episcopal Hospital, the Foster Home,
the German Hospital, the Germantown Hospital, the
Germantown Relief Society, the Orphan's Home and Asy-
lum for the Aged of the Lutheran Church, Germantown,
the Masonic Home of Pennsylvania, the Methodist Epis-
copal Home for the Aged, the Methodist Episcopal Hos-
pital, the Methodist Episcopal Orphanage, the Odd Fellows'
Home, the Samaritan Hospital, the Southern Home for
Destitute Children, and the Woman's Hospital, of Phila-
delphia, became reversionary legatees.
By the will of John A. Brill, the German Hospital, Hayes
Mechanics' Home, the Society for Organizing Charities,
and the Free Hospital for Poor Consumptives (Whitehaven
Sanitarium) receive $5,000 each; the Home for Incurables
receives $3,000, and the Home for Crippled Children re-
ceives $2,000.
Lord Strathcona and Lord Mount Stephen have each
donated the sum of $1,000 to the General Hospital of Win-
nipeg, Canada.
The estate of the late Mrs. Thomas T. Kinney has made
a gift of $10,000 to the Babies' Hospital, Newark, N. J., as
an endowment fund.
The board of directors of the Whitehaven Sanitarium
for consumptives announces the gift of a new cottage, with
a capacity of sixteen beds, by Mrs. Henry Phipps, of Pitts-
burgh.
The Health of Pittsburgh.— During the week ending
April 18, IQ08, the following cases of transmissible diseases
were reported to the Bureau of Health of Pittsburgh :
Chickcnpox, 12 cases, o deaths; typhoid fever, 26 cases, 6
deaths ; scarlet fever, 13 cases, i death ; diphtheria, 8 cases,
3 deaths: measles, 191 cases, to deaths; wliooping cough. 8
cases, I death; pulmonary tuberculosis, 20 cases. 11 deaths.
The total deaths for the week numbered 160 in an esti-
mated population of 403,330, corresponding to an annual
death rate of 20.62 in 1,000 of population. During the week
ending April 25, 1908, the following cases of transmissible
diseases were reported ; Chickenpox, 7 cases, o deaths ;
typhoid fever, 29 cases, 2 deaths ; scarlet fever, 21 cases, 2
deaths ; diphtheria, 8 cases, 3 deaths ; measles, 252 cases, 6
deaths ; whooping cough, 26 cases, 2 deaths ; pulmonary
tuberculosis, 10 cases, 10 deaths. The total deaths for the
week numbered 192, in an estimated population of 403,330,
corresponding to an annual death rate of 24.75 in 1,000 of
population.
The Health of Philadelphia. — During the week end-
ing, April 25, 1908, the following cases of transmissible
diseases were reported to the Bureau of Health of Phila-
phia : Typhoid fever, 95 cases, 13 deaths ; scarlet fever, 52
cases, 6 deaths; chickenpox, 41 cases, o deaths; diphtheria.
54 cases, 9 deaths ; cerebrospinal meningitis, i case, o
deaths ; measles, 508 cases, 10 deaths ; whooping cough, 38
cases, I death; pulmonary tuberculosis, 109 cases, 56
deaths ; pneumonia, 80 cases, 56 deaths ; erysipelas, 10 cases,
0 deaths ; puerperal fever, 5 cases, 2 deaths ; mumps, 33
cases, o deaths ; cancer, 23 cases, 25 deaths ; tetanus, i case.
1 death. The following deaths were reported from other
transmissible diseases : Tuberculosis, other than tubercu-
losis of the lungs, 14 ; diarrhoea and enteritis, under two years
of age, II. The total deaths for the week numbered 499
in an estimated population of 1,532,738, corresponding to
an annual death rate of 16.90 in 1,000 of population. The
total infant mortality was iii; under one year of age, 75:
between one and two years of age, 36. There were 39 still
births ; 20 males, and 19 females.
American Proctological Society.— The tenth annual
meeting of this society v.ill be held in Chicago, June 1st
and 2d. The preliminary programme, which we have just
received, includes a long list of papers by well known spe-
cialists in diseases of the rectum, among whom are the
following: Dr. William M. Beach, of Pittsburgh, Pa.; Dr.
John L. Jelks, of Memphis, Tenn. ; Dr. Samuel T. Earle,
of Baltimore; Dr. Samuel G. Gant, of New York; Dr.
Joseph M. Mathews, of Louisville, Ky. ; Dr. William L.
Dickinson, of Saginaw, Mich. ; Dr. Jerome M. Lynch, of
New York; Dr. J. A. MacMillan, of Detroit; Dr. T. C.
Hill, of Boston; Dr. Collier F. Martin, of Philadelphia;
Dr. George B. Evans, of Dayton, Ohio ; Dr. Dwight H.
Murray, of Syracuse, N. Y. ; Dr. James P. Tuttle, of New
York; Dr. Louis J. Hirschman, of Detroit; Dr. J. Ravviori
Pennington, of Chicago ; Dr. Louis J. Krouse, of Cincin-
nati; Dr. Edwin A. Hamilton, of Columbus, Ohio; Dr. B.
Merrill Ricketts, of Cincinnati ; Dr. Leon Straus, of St.
Louis ; and Dr. Lewis H. Adler, Jr., of Philadelphia. The
officers of the society are : President, Dr. A. Bennett Cooke,
of Nashville, Tenn. ; vice president. Dr. Louis J. Krouse,
of Cincinnati, Ohio; secretary and treasurer. Dr. Lewis H.
Adler, Jr., of Philadelphia.
The Army Pay Bill and the Officers of the Medical
Corps. — The Army appropriation bill w^hich provides
for the pay of officers and men of the Army has, after
various amendments, been at last agreed to by a conference
committee of the Senate and the House of Representatives.
The report of the conference committee has been accepted
and it is quite probable that the measure will be signed by
the President in the near future. In our issue of April i8th
we printed the text of the measure providing for the reor-
ganization of the Army Medical Department, which changes
the title of the department to Medical Corps, drops the titles
of surgeon, assistant surgeon, etc., and leaves the officers
of the corps to be designated simply by their military titles.
This measure also provides for a material increase in the
number of the officers in the corps and for the establish-
ment of a reserve medical corps. The appropriation bill as
finally adopted provides for a flat increase of $500 a year
in the salary of officers, save that the increase in the pay
of the first lieutenant and captain is only $400. The
measure also provides for an increase in the pay of enlisted
men and noncommissioned officers of the hospital corps,
and specifically provides against the use of this rate of pay
as a basis on which to compute the pay of naval officers.
Clinical Week at Boston University. — Tn response to
many requests from iihy^icians throughout New England,
the faculty of the Medical School of Boston l^iivcrsity
has arranged for a short course of general clinical instruc-
tion. This course will be held during commencement week.
June I to 6. iqpS. The sessions will begin daily at 9 a. m.
and continue till 4 p. m.. the entire time being fully occu-
pied by clinics, clinical lectures, lectures and demonstra-
May 1 6, 1^08.]
PROCEEDINGS OF SOCIETIES.
955
tions. More than thirty professors and lecturers will par-
ticipate, each dealing with the particular subject in his
own line that he considers of most general value. General
medicin?, surgery, gj'naecology, and the various specialties
will all be represented, as well as other miscellaneous sub-
jects. The course will be so arranged that each attendant
can be present at every exercise and can thus obtain a
survey of a large field in a comparatively short time. Ses-
sions will be held at the Medical School buildings, at the
Out Patient Department of the Hospital, and in the amphi-
theatre and the clinical lecture room of the main building
of the hospital. Free use will be made of the large amount
of clinical material available in these closely connected
institutions, as well as that from other sources. The course
will be open without fee to graduates of any reputable
medical college. The number admitted will be limited,
tickets being issued in the order of application. Further
information and tickets admitting to all sessions may be
obtained from the registrar. Dr. Frank C. Richardson, 80
East Concord street, Boston.
Philadelphia County Medical Society. — A meeting of
the West Branch of this society was held on Friday even-
ing, May 15th. The guest of the evening was Dr. Theo-
dore B. Appel, of Lancaster, Pa., who read a paper entitled
Lancaster County and Its People and the Practice of Medi-
cine Therein. The paper gave a historical sketch of the
people of the county, describing some of their character-
istics and the difficulties the medical man meets in prac-
tising among them. Dr. Julius F. Sachse also contributed
some historical notes on medical practice in Lancaster
County. Dr. A. B. Hirsh exhibited a copy of the manual
of practice of the hydropathic institution that existed at
Ephrata Springs early in the last century, and related
some of the experiences of medical students in Lancaster
County. Dr. Samuel Skillern read a paper entitled Remi-
niscences of the Practice of Medicine in the Early Days
of Western Philadelphia Dr. Charles W. Dulles opened
the discussion on this paper.
At a meeting of the Central Branch of this Society,
which was held on Wednesday. May 13th, the evening was
devoted to a "symposium" on lateral curvature. Dr.
James K. Young presented patients who had been cured of
lateral curvature by light gymnastics and selective exer-
cises. Dr. H. O. Feiss, of Cleveland, Ohio, read a paper
on the Mechanism of L-ateral Curvature. Dr. H. Augus-
tus Wilson exhibited lantern slides showing faulty postures
in school children which produce lateral curvature. Dr.
Harry Hudson demonstrated his new scoliometer. Among
those who took part in the discussion were Dr. de Forrest
Willard, Dr. James P. Mann, and Dr. J. Torrance Rugh.
Society Meetings for the Coming Week:
Monday, May iSth. — New York .Academy of Medicine
(Section in Ophthalmolog>-) ; Medical Association of
the Greater City of New York; Hartford, Conn., Med-
ical Society.
TuESD.w, May 19th. — New York Academy of Medicine
(Section in Medicine) ; Medical Society of the County
of Westchester, N. Y. ; Buffalo Academy of Medicine
(Section in Pathology) ; Tri-Professional Medical So-
ciety of New York : Medical Society of the County of
Kings, N. Y. : Binghamton, N. Y., Academy of Medi-
cine; Clinical Society of the Elizabeth, N. J., General
Hospital ; Syracuse, N. Y., Academy of Medicine ;
Ogdensburgh, N. Y., Medical Association.
Wednesd.w, May 20th. — New York Academy of -Medicine
(Section in Genitourinary Diseases) ; New York So-
ciety of Dermatology and Genitourinary Surgery ;
Woman's Medical Association of New York City
(New York Academy of Medicine, annual) ; Medico-
legal Societv. New York : New Jersey Academy of
Medicine (Jersey City) ; Buffalo Medical Club (an-
nual) ; New Haven, Conn., Medical Association; New
York Society of Internal Medicine ; Northwestern
Medical and Surgical Society of New York.
Thursday, May .?/jf.— New York .Academy of Medicine;
German Medical Society, Brooklyn ; Newark. N. J.,
Medical and Surgical Society: ^sculapian Club of
Buffalo, N. Y.
Friday, May 22d. — Academy of Pathological Science, New
York ; New York Society of German Physicians ; New
York Clinical Society.
Saturday. May .i-jrf.— West End Medical Society, New
York; New York Medical and Surgical Society; Har-
vard Medical Society, New York; Lenox Medical and
Surgical Society, New York.
THE ASSOCIATION OF AMERICAN PHYSICIANS.
Twenty-third Annual Meeting, Held in Washington, May
12 and 13, 1908.
The President, Dr. James Tyson, of Philadelphia, in the
Chair.
The President's Address. — Dr. Tyson referred
to tlie organization and development of the associa-
tion, and spoke of some of the eminent men who had
been members and officers in past years. He re-
ferred to the numerous papers of great scientific im-
portance that had been read at its meetings and that
were collected into the twenty-two volumes of its
Proceedings. During the year Dr. Charles Follen
Folsom, of Boston, and Dr. James Carroll, of the
United States Army, had been removed by death.
Experimental Ligation of the Coronary Arte-
ries of Dogs, and Its Bearing on the Treatment
of Angina Pectoris. — Dr. Joseph L. Miller and
Dr. S. A. Matthews, of Chicago, said in this paper
that it had been found that after ligation of the
main trunk of one of the coronary arteries the heart
stopped beating. According to some investigators,
both ventricles stopped at once ; according to others,
the ventricle which v/as supplied by the ligated ves-
sel ceased beating first. According to Spalteholz
and Hirsch, the coronary arteries were not terminal
arteries. The work undertaken by the writers of the
paper had had for its object the determination of
the relation of ligation of the coronan- arteries to
the symptom complex known as angina pectoris. It
was noted that after the operation clinical features
closely resembling those of angina pectoris devel-
oped. The animals used were divided into three
groups. One group was untreated ; one was treat-
ed with nitroglycerin after the operation ; and the
other group was treated with digitalis or strophan-
thus. Nitroglycerin apparently did the animals no
good after the operation, but strophanthus, on the
other hand, elevated the blood pressure and im-
proved the systole. These results appeared to con-
firm the statement that the digitalis group was bet-
ter for the treatment of angina pectoris than the
nitrites.
Dr. William H. Welch, of Baltimore, asked if
the investigation had added anything to our knowl-
edge of the terminations of the coronary arteries.
It was generally believed that the intramuscular
branches of the coronary arteries were terminal, and
that the epicardial branches had anastomoses. It
had always been held that anaemic necrosis was con-
stant after closure of the intramuscular vessels.
Dr. S. SoLis Cohen, of Philadelphia, said that
it was by no means sure that the post mortem le-
sions represented the conditions present in the early
stages of angina pectoris. These lesions repre-
sented the results of permanent interference with the
circulation. The paroxysm of angina pectoris was
a temporary condition, not a permanent one. Those
paroxysms which ended in death could not, of
course, be relieved with nitroglycerin. On the other
hand, the temporary attacks were relieved with nitro-
glycerin.
Dr. Robert W. Babcock, of Chicago, said that
it was his opinion that the blood pressure had much
to do with the attacks of angina pectoris and the
influence of the nitrites. If there was a high sys-
956
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
tolic blood pressure the nitrites relieved the attack;
if, on the contrary, the systolic pressure was low,
the nitrites failed to relieve.
Dr. Alexander McPhedran, of Toronto, said
that, in his experience, when the blood pressure was
high, the nitrites did not relieve the attack. He re-
ferred to a case in which the systolic pressure was
217 millimetres, in which no results were obtained
with nitroglycerin.
Dr. ]\IiLLER said that he had not studied the ef-
fects of the ligation of the intramuscular vessels. In
his experiments the left ventricle had always been
arrested first. He believed that the paroxysms of
angina pectoris were not due to a temporary condi-
tion, but that we were dealing with the permanent
occlusion of a vessel. The necessary feature of
treatment in such cases was to endeavor to improve
the condition of the heart muscle, not to relieve
peripheral tension.
Some Lesions of Experimental Nephritis. — Dr.
H. A. Christian, of Boston, presented the results
of a study of the pathological conditions found in
experimentally produced nephritis in dogs. He had
found, first, a glomerular lesion which presented the
appearance of droplets, of varying degrees of
coarseness, which stained blueblack with Mallory's
phosphotungstic acid, hsematoxylin method, in the
walls of the glomerular vessels. These droplets
were found in eleven out of thirteen animals in
which nephritis had been produced by uranium ni-
trate. In twelve control animals in which the ne-
phritis had been produced by other substances this
lesion was found but' twice, and then in relatively
small amount. Second, he had found hyaline drop-
lets in the renal epithelium lining the tubules in dogs
poisoned by uranium nitrate, in cases of acute ne-
phritis in man, and in the toxic nephritides of other
animals. Third, in some of the animals poisoned by
uranium nitrate he had found a change in the
epithelium lining the collecting tubules, and to a less
extent in that lining the convoluted tubules, which
was characterized by an increase in the thickness of
the hyaline layer at the base of the epithelial cells,
and a loss of nuclei and of the granules in the cyto-
plasm of the cells.
A Review of Theoretical Considerations and
Experimental Work Relative to Opsonins, with
Observations Made at the Saranac Laboratory.
— Dr. Edwin R. Baldwin, of Saranac Lake, N. Y.,
doubted the occurrence of specific opsonins in blood
serum. He believed them to be the same as the
body known as the amboceptor. At the Saranac
Laboratory he and his coworkers had found that
protective inoculations of weakly virulent opsonized
bacilli in guinea pigs provoked more extensive and
more severe local mflammation. After the use of
tuberculin for diagnostic purposes, no constant in-
fluence on the opsonic index was noted.
A Classification of Acidoses. — Dr. James
EwiNd, of New York, said that acid intoxication
occurred in dial)ctcs, starvation, phosphorus poison-
ing, the toxaemia of pregnancy, cyclic vomiting of
children, delayed chloroform poisoning, and other
morbid conditions, in each of which the ab.straction
of fixed alkalies or the direct toxic action of the
salts of the acid compounds was supposed to con-
tribute to or to dominate the symptoms. He sug-
gested the following division of these conditions :
I. Experimental type, hydrochloric acid poisoning;
clinical forms, diabetic acidosis and the acidosis of
starvation ; the acetone bodies were present and the
urinary ammonia was proportional to them ; there
were no characteristic pathological lesions in this
form. 2. Experimental type, extirpation of the liver
or Eck fistula ; clinical forms, phosphorus poisoning,
toxaemia of pregnancy, cyclic vomiting, chloroform
poisoning; lactic acid was formed in the urine and
urinary ammonia was in excess of the acetone
bodies ; pathologically, excessive fatty degeneration
was found. While the uninary ammonia was ac-
cepted as the measure of acidosis, there was reason
to believe that its significance was not the same in
the two types of acid intoxication. The marked
difference in the observed pathological changes in
the two types would seem to distinguish them still
further.
Dr. Lewellyn F. Barker, of Baltimore, referred
to cases of acidosis in which there was high urinary
organic acidity.
Dr. J. P. Crozer Griffith, of Philadelphia, re-
ferred to the cyclic vomiting which was said by
some observers to be due to acetonsem'a, but said
that he could not agree to that theory.
Dr. David L. Edsall, of Philadelphia, agi-eed that
there were two types of acidosis, but the whole sub-
ject was still very indefinite.
Dr. S. SoLis Cohen, of Philadelphia, said that
the acid excreted was certainly doing no harm, and
asked if there was not also acid retention. He could
conceive that acid intoxication might be due to the
excessive neutralization of alkalies.
Dr. Ewing said that it was doubtful if the acetone
in the blood was sufficient to account for the symp-
toms of cyclic vomiting in children. He was aware
of the uncertainty of the whole subject. The signifi-
cance of the formation of ammonia was not defi-
nitely known, but it was thought to be a compensa-
tory process. He, however, believed it to be more
than that. The estimation of acidosis by the urinary
ammonia was unsatisfactory.
Experiments with an Ash Free Diet. — Dr. E. P.
JosLiN and Dr. H. W. Goodall, of Boston, had
fed two healthy men on Taylor's ash free diet, com-
posed of the whites of eighteen eggs, 200 grammes
of crystallized sugar, and 120 grammes of olive oil
freed from salts, until the daily excretion of
chlorine was as low as 0.17 gramme. No symptoms
of acid intoxication appeared, and at no time was
acetone detected either on the breath or in the
urine. The two subjects experienced marked loss
of weight. In a first experiment the weight was
regained within four days after a return to an or-
dinary diet. In a second experiment the weight was
nearly all recovered in three days, when twelve
grammes of salt was added to the salt free diet daily.
The assimilation of food was excellent, although the
subjects had no appetite and were mentally de-
pressed. In one of the subjects 4.090 c.c. of urine
was passed four days after the return to a normal
diet in which there were twenty-five grammes of
chlorine. The urinary ammonia was increased
slightly toward the end of the experiment. In a
case of diabetes with moderate nephritis absolute
carbohydrate intolerance developed during an acute
May 1 6, 1908.]
PRQCEEDIXGS OF SOCIETIES.
957
illness. The chlorine in the urine gradually fell to
less than 0.4 gramme in twenty-four hours, but the
change in acidosis was insignificant. The experi-
ments did not confirm the observation that an ash
free diet produced acidosis. The withdrawal of
salts, on the other hand, caused no change in me-
tabolism, and produced no acidosis.
Dr. Edsall said that Dr. Taylor's experiments
had no bearing on diabetic acidosis or on the me-
tabolic changes of carbohydrates and fats. The re-
sults did show that there were two forms of
acidosis. As Taylor got an acidosis in himself on
this diet, it indicated that there was more than one
cause for the condition ; at times acidosis might fol-
low the administration of a salt free diet.
Dr. EwiXG said that he had drawn the same con-
clusion from Taylor's work that Dr. Joslin had.
The central point in the discussion was. How much
withdrawal of alkalies could be stood without the
production of symptoms?
Dr. JoSLix said that Dr. Taylor deserved great
credit for inaugurating a new form of diet, which
had led to interesting results.
On the Relation of the Parathyreoid Glands to
Calcium Metabolism and the Nature of Tetany.
— Dr. G. MacCallum and Dr. Carl \ oegtlix,
of Baltimore, pointed out that the convulsive and
other symptoms of tetany which resulted from the
extirpation of the parathyreoid glands might be rap-
idly benefited by the administration of a soluble salt
of calcium. Given by the mouth, it was not so rap-
idly curative as-by intravenous administration. Me-
tabolism studies on dogs with tetany had shown an
increased calcium elimination, while the blood and
the tissues were found to be deficient in calcium. It
appeared probable that the parathyreoid bodies had
a control over the calcium metabolism, and that loss
of calcium from the brain and the other tissues was
the cause of tetany.
Dr. John H. Musser, of Philadelphia, referred
to a case of adenocarcinom.a of the thyreoid body
and lymph nodes of the neck in which the parathy-
reoid bodies were probably removed with the dis-
eased tissues. Five days after the operation tetany
developed. Large doses of calcium lactate, in com-
bination with morphine, relieved the symptoms.
Forty-eight hours after the calcium lactate was
withdrawn the symptoms of tetany returned. Cal-
cium lactate was again given, and the symptoms dis-
appeared.
Dr. E. H. GooDMAX. of Philadelphia, had studied
the metabolism in Dr. Musser's patient. The cal-
cium balance was minus on one day of tetany and
plus on another day. He thought there was no re-
lation between calcium and tetany. The persistently
high urinary nitrogen excretion in this case made
one suspicious of an acidosis as responsible for the
symptoms. It was possible that calcium under such
circumstances acted as any base would act.
Dr. S. J. Meltzer, of New York, referred to a
case of tetany in the practice of Dr. Elsberg. Upon
the administration of calcium lactate the symptoms
subsided. When the calcium salt was omitted for
forty-eight hours the symptoms returned, to disap-
pear upon the readministration of calcium lactate.
It appeared to him that calcium was capable of cor-
recting the balance of inorganic salts; similar re-
sults would be produced by sodium, potassium, or
magnesium. In other words, it might act by pre-
serving the equilibrium of inorganic metabolism.
Dr. Edsall referred to a case of myasthenia
gravis, in which a study of the metabolism showed
an excess of calcium in the urine. Similar results
had been seen in his laboratory in acromegaly and
in cases of acidosis. He did not know whether there
was an excess or a diminution of calcium in the
blood. He had given calcium lactate to the patient
with myasthenia gravis with benefit.
Dr. IIacCallum had seen a case of tetany in a
woman which was relieved by calcium lactate and
recurred when the calcium salt was stopped. He
had also an idea that there was a relation betw^een
acidosis and tetany, as the amount of ammonia in
the blood was increased.
An Unusual Paroxysmal Syndrome Probably
Allied to Recurrent Vomiting, with a Study of
the Nitrogen Metabolism. — Dr. Theodore Jane-
way, of Xew York, reported the case of a girl, aged
sixteen years, who had had attacks characterized by
epigastric pain, general abdominal pain, pain in the
shoulder, hips, and other joints, loss of appetite and
salivation, fever to 104°, a rapid pulse to 140,
nausea, vomiting with retching, a heavy but not
sweet breath, rigidity and tenderness of the abdomen,
mostly in the right lower quadrant, polymorpho-
nuclear leucocytosis, and loss of weight. These at-
tacks had been experienced since birth at varying
intervals. After the attack there was leucopoenia,
with renewal of weight and strength. The saliva
was always acid ; the vomitus contained aliundant
free hydrochloric acid ; the stomach contents between
the attacks showed excessive hydrochloric acid ; the
urine usually showed a trace of albumin and acetone.
A study of the metabolism on a purin free diet
showed little deviation from the normal, except for
a marked decrease in the uric acid and a slight in-
crease in the urinary ammonia during two of the
attacks. The condition might be due to a recurring
infection, such as a small pancreatic calculus, with
inflammation, a recurring toxjemia, or a neurosis.
Dr. E. P. JosLix, of Boston : Dr. Walter B.
James, of Xew York, and Dr. David L. Edsall, of
Philadelphia, referred to similar cases. Dr. Edsall
had eliminated fats from the diet in his case, and
the patient had had no attacks for a year.
Dr. Jaxeway referred to the possibility of such
a patient being operated on for appendicitis.
Some Cases Presenting a Recurrent Syndrome
Apparently Due to Exposure to Heat. — Dr.
Edsall reported four cases which he had observed
in which, after exposure to intense heat, the patients
had exhibited a high degree of hyperniyotonia, re-
sembling tetany. There was no exaggeration of the
reflexes, no central nervous system symptoms, and
all indications pointed to a peripheral condition due
to heat. There were cramps in the legs. Blood
pressure observations, blood counts, and ordinary
routine urinary examinations indicated that the
condition was probably toxic. Since observing these
cases he had discovered by correspondence that in
the merchant marine, the United States Navy, and
the Pennsylvania Railroad ser\'ice the syndrome was
well known and was considered to be due to heat.
In the navy as many as 400 cases to a i.ooo rnen
have been observed annually.
(To be continued.)
958
PITH OF CURRENT LITERATURE.
[New Vork
-Medical Journal.
|it^ of Cttmnt f ittratttu.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
May 7, 1908.
To Reginald Heber Fitz, M. D., LL. D., in Honor of his
Sixty-fifth Birthday.
1. Reginald Heber Fitz.
2. Some Blood Pressure Observations in Eclampsia.
By George S. C. Badger.
3. Two Cases of Atypical Leuchaemia,
By WiLLisTON W. Barker.
4. On the Toxine of Eclampsia, By William F. Boos.
5. The Tent Ward at the Massachusetts General Hos-
pital, By L. H. BURLINGHAM.
6. The Histology of Multiple Myeloma. A Comparative
Study of Sixteen Cases, By Henry A. Christian.
7. The Use of Human Milk in Typhoid Fever to In-
crease the Bacteriolytic Power of the Blood,
By Francis P. Denny.
8. Bronchopneumonia: Its Clinical Types in Relation to
.Etiology. By Charles Hunter.
9. The Diagnosis of Circulatory Conditions by Tempera-
ture Measurements,
By Theodore Jewett Eastman.
10. On the Translation of Clinical Descriptive Terms into
their Histological Equivalents in Diseases of the
Nose and Throat, By J. L. Goodall.
11. The Clinical Value of the Estimation of Ammonia in
Diabetes,
By Harry W. Goodall and Elliott P. Joslin.
12. The Study of the Functions of the Alimentary Tract
for the Digestion and Absorption of Food by the
Examination of Fasces in Clinical Work,
By Henry F. Hewes and Herman W. Osler.
13. Blood Cultures in Typhoid Fever, with Comments
upon the Hospital Treatment,
By Elliott P. Joslin and Charles P. Overlander.
14. The Use of Tuberculin in the Treatment of Localized
Tuberculosis Excluding Pulmonary Tuberculosis,
By Roger I. Lee.
15. Hodgkin's Disease with Eosinophilia : Report of a
Case with Autopsy. By Merrick Lincoln.
16. Sahli's Butyrometric Test of Gastric Function,
By Francis W. Palfrey.
17. On the Occurrence of Steatorrhoea Unassociated with
Jaundice or Demonstrable Pancreatic Disease,
By Joseph H. Pratt and Royal Hatch.
18. Fact and Speculation Concerning the Nature of Typhoid
Fever, By Mark Wyman Richardson.
19. Primary Sarcoma of the Pleura,
By William B. Robbins.
20. General Streptococcus Infection through Unrecognized
Channels: A Report of Two Cases,
By Wilbur A. Sawyer.
21. The Origin of Urinary Casts ; An Experimental Studv,
By R. M. Smith.
22. Age in Its Relation to Arteriosclerosis and Death from
Arteri9sclerosis, By William H. Smith.
23. Tuberculous Peritonitis, . By Arthur K. Stone.
24. On the Early Diastolic Heart Sound (the so Called
Third Heart Sound), By William Sydney Thayer.
25. The Value of Lumbar Puncture in Syphilitic and Para-
syphilitic Diseases of the Nervous System,
By G. A. Waterman.
26. Acute Yellow Atrophy of the Liver,
By Franklin W. White.
2. Some Blood Pressure Observations in
Eclampsia. — Badger has studied this question
and oh.scrvcs that the blood pressure in eclampsia
IS high, and of diagnostic and prognostic impor-
tance. In spite of improvements in subjective symp-
toms and increase in the quantity of urine, the blood
pressure may remain high, in which case the prog-
nosis is grave, and labor ought to be induced. The
continuance of high blood pressure during the pucr-
pcrium warrants a grave prognosis as to complete
rec(ncry.
6. The Histology of Multiple Myeloma. —
Oiristian has observed eleven cases of multiple mye-
loma. The histological study of these cases shows
a striking similarity of cell structure with differ-
ences of minor degree. The common characteristics
of the cells are a tinely granular, slightly basophilic
cytoplasm, an eccentrically placed nucleus, a nucle-
olus, centrosomes, a nuclear membrane, and a tend-
ency to mural arrangement of the chromatin. Cer-
tahi nuclear changes, regarded as the results of'
degeneration, are commonly found. Mitotic figures
occur in most of the cases studied by him, though
absent in a few. Alyelomata are to be classed with
the tumors. They tend to remain localized in the
bone marrow, but almost all show evidence of in-
vasive growth into adjacent structures, and in a few-
metastasis has taken place. These tumors, then,
are malignant in the usual sense of the word, but
their malignant proix-rties are apt to appear rela-
tively late in many cases. With these characteristics
there is a greater resemblance of the tumor cells to
bone marrow plasma cells than to myelocytes. In
most of the cases reported by other observers the
cells show these characteristics and these tumors
from a group within which the cells of individual
cases show no greater variation than occurs in other
tumor groups.
9. The Diagnosis of Circulatory Conditions
by Temperature Measurements. — Eastman has
found that the variation in temperature between
rectum and hand in healthy persons averages 0.6°
to 1.3° C, and is greater in cases of cardiac disease,
except in aortic insufficiency. There is a character-
istic difference in the peripheral circulation in aortic
insufficiency as contrasted with other heart lesions.
Muscular exertion, even to fatigue, in a person with
a normal heart, causes a rise in temperature in the
extremities. Fatigue in a case of cardiac decom-
pensation causes a fall in the peripheral temperature.
Therefore this method of temperature measurement
is a simple and useful addition to the other methods
in use for the examination of cardiac cases, and for
the distinction of cardiac sufficiency or insuffi-
ciency. It is a means of determining the effect of
exercise, either active or passive, upon cardiac cases,
and furnishes us with a method of distinguishing
the cedema arising from passive congestion from
that due to nephritis.
II. The Clinical Value of the Estimation of
Ammonia in Diabetes.- — Goodall and Joslin find
that quantities of ammonia reaching 5 grammes in
twenty-four hours indicate an extremely severe form
of diabetes, which usually proves fatal within a year.
Patients under forty years of age tolerate an acidosis
estimated in terms of 4 to 5 grammes ammonia far
better than those above fifty years tolerate an
acidosis of 2.5 to 4 grammes ammonia. An acidosis
in an individual above fifty years of age is of a very
serious prognostic imjx>rt. A knowledge of the
ammonia excretion usually helps in the treatment
of a case of diabetes, and generally, but not always,
gives warning of impending danger. The value of
a knowledge of the ammonia excretion in the prog-
nosis of a diabetic patient is enhanced by a knowl-
edge of the quantity of albumin and carbohydrate
in the diet. A lowering of the carbohydrate intake
in a severe case of diabetes from a total of 80
grammes to 55 granmies in twenty-four hours pro-
duces little effect upon the acidosis.
21. The Origin of Urinary Casts. — .Smiili h;is
Way 16, J 908.]
PITH OF CURRENT LITERATURE.
959
made some experiments on rabbits in producing
nephritis, using uranium nitrate, potassium bichro-
mate, trjpan red, arsenic, and cantharides. He
found that it is possible by the injections of irri-
tants to produce in rabbits an albuminuria and
cylindruria dependent upon lesions of the kidney
simulating nephritis in man. Granular casts are the
lirst to appear in the urine when the kidney is at-
tacked by an irritant. Casts are more common in
the urine when the kidney lesion is primarily a
necrosis of the tubular epithelium, and arise from
the degeneration and necrosis of the cells of tlie
tubular epithelium of the kidney. Entire necrotic
cells may desquamate and at first remain distinct
from one another, then become massed together, and
finally formed into a definite plug, taking the shape
of the tubule in which it is formed. The same pro-
cess takes place with cell fragments and granular
material derived from disintegrated cells. The casts
are all granular at first and later become hyaline
as they pass down the tubule in the urinary stream.
22. Age in Its Relation to Arteriosclerosis and
Death from Arteriosclerosis. — Smith found that
in his series of 2,000 autopsies, 442 cases, or 22.1
per cent., showed more or less arteriosclerosis.
Arteriosclerosis was three times as common in the
male as in the female. It occurred no earlier in the
-colored race in this series. The average age of the
cardiorenal group was nearly fifty-five. The aver-
age age of the cerebral group was nearly sixty.
Fifty per cent, of the cases of cerebral haemorrhage
occurred in the fifth and sixth decades, and was
three times as common in the male as in the female.
All the cases of aneurysm were in males. The aver-
age age of death was nearly forty-five. Death from
gangrene and diabetes was incident to the last
decades — tlie sixth and seventh ; the average age
nearly sixty-five.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
il/(7v 9, igoS.
1. Paravertebral Triangle of Dulness (Grocco's Sign) in
a Case of Abdominal Multiocular Cystadenoma,
By Frank Smithies.
2. Distinction of Bacillus Coli Communis from Allied
Species in Water, By D. Rivas.
3. Psychotherapy, with Some of Its Results,
By Beatrice M. Hixkle.
4 Typhoid Fever, ' By J. H. Laxdis.
5. Intranasal Drainage of the Frontal Sinus,
By E. Fletcher Ixgalls.
6. Practical Cystoscopy; Its Scope and Limitations, with
a Review of the Prominent Cystoscopes of the Pres-
ent Day. By Braxsford Lewis.
7. Harelip and Cleft Palate,
By Alexaxder Hugh Fergcsox.
2. Distinction of Bacillus Coli Communis from
Allied Species in Water. — Rivas thinks that
the saccharolytic group represents not only one
but diflferent kinds of microorganisms commonly
found in nature, especially in water, character-
ized by its predominating action in splitting dex-
trose. The constant occurrence of this group in
water may prove to be a factor in itself which
may shed a new light on our vital problems of
the bacteriolog}- of water. The Bacillus coli coni-
mnnis must not be confounded with the colon
group, which he calls "saccharolytic group." hold-
ing that this group should have no relation to the
colon bacillus. Since the saccharolytic group is
shown to be more closely related to what at present
is regarded as the colon group, the substitution of
"saccharolytic group" for "colon group" is more
comprehensible, and he thinks will aid considerably,
not only in relieving the confusion which the colon
group presents, but especially in establishing the
colon bacillus as a distinct type of microorganism
and not an indefinite chain of them, as it is consid-
ered at present. Bacillus coli comniuuis, in addition
to the recognized characteristics, will fail to exhaust
the sugar in i per cent, dextrose bouillon at 37°
C. in forty-eight hours, while contrary to this, the
saccharolytic group may in many ways present char-
acteristics of the colon bacillus, but will always ex-
haust the sugar in forty-eight hours at 37° C. in
I per cent, dextrose bouillon. Bacillus coli com-
munis should be discarded as an agent for exhaust-
ing the sugar in the meat juice and one of the
saccharolytic group should be used instead.
3. Psychotherapy. — Hinkle understands under
psychotherapy all forms of mental treatment,
whether accompanied by hypnosis or without. The
hypnotic state is not primarily the result desired,
but the receptive condition induced by that state,
in order that the curative suggestion given may be
accepted without interference from the objective
self. Hypnosis of itself without suggestion never
accomplished anything ; the forceful directions given
the patient during the responsive state of hypnosis
achieve the lesults. The author has had six years
of experience with suggestive therapy, the last two
years exclusively, and she finds that the most intelli-
gent Americans yield more readily to mental treat-
ment than the foreign born clinical patients. There
are two distinct types of patients — the one who is
afraid he will go to sleep, and the other who is
afraid he will not. Both of these have to be met
and dealt with accordingly. The former, after a
few simple explanations, usually lose this feeling.
The latter class are perhaps a little more difficult,
because as a rule they have fixed ideas as to the
only way in which they can be helped, and if they
are not conscious of being asleep and amnesic they
will declare that they are not influenced at all, and
by their own strong autosuggestion in many cases
will counteract the physician's influence. In a few
of these cases, when reason could not be used, she
has employed hypnotic drugs for their quieting in-
fluence and to heighten the verbal suggestion. In
all she has used these drugs about six times, giving
either bromide or paraldehyde. The results have
been favorable in all the cases except one insom-
niac patient, and in that case she could neither influ-
ence the patient with drugs or without, and appar-
ently made no impression of any kind. It is not
wise to use drug therapy at the same time as sug-
gestive therapy, for the divided attention of the
patient seems to weaken the suggestive effect, and
for that reason he never combines the two unless
it is especially indicated, or is merely the prescribing
of a simple tonic.
6. Practical Cystoscopy: Its Scope and Lim-
itations.— Lewis remarks tliat the purposes of
ureteral catheterization are twofold, for diagnosis and
for treatment. For Diagnosis. — (A) To locate the
origin of pus, blood, tuberculous products or bacilli,
the various pyogenic infections, abnormally des-
quamated epithelium, etc.. as to whether they come
from (i) the bladder, (2) the right ureter, (3) the
960
PITH OF CURRENT LITERATURE.
[New York
Medical Journai.
left ureter, (4) the right kidney, (5) the left kid-
ney, (6) the right or (7) the left perirenal space,
communicating with the corresponding kidney or
ureter. (B) To recognize and locate obstructive
conditions in the right or left ureter from (l)
stricture, (2) stone, (3) adjacent tumor, (4) bend
or kink in the ureter from movable or dislocated
kidney, (5) valvular junction of the ureter with its
pelvis. (C) To determine (i) the number of kid-
neys present ; (2) if only one, which is absent. (D)
To determine the number of ureters present. (E)
To determine the functional activity of each kidney
separately and relatively, with respect to its excre-
tion of urea, albumin, quantity of urine, the specific
gravity, etc. (F) To determine the size and capa-
city of each kidney pelvis, with respect to (i)
hydronephrosis, (2) pyonephrosis, (3) total obliter-
ation of secreting tissue. (G) If there is kidney dis-
ease present, to determine (i) if only one kidney is
affected or both; (2) if only one, which is the af-
fected one; (3) if both, which is the one more af-
fected ; (4) if removal of the worse one be advisa-
ble, is the other one able to carry on kidney function-
ation sufficiently; (5) if removal of one be advisable
and the other is capable of supporting life, will the
operation remove the infection from the body, re-
moving the possibility of dissemination or recon-
tamination? For Treatment. — (A) To enlarge nar-
rowings or strictures at (l) the ureter openings, or
(2) in the channels at any point; (3) by facilitating
drainage through the increased ureter calibre thus
obtained, to assist in the improvement of pyelitis or
pyonephrosis, unilateral or bilateral. (B) To irri-
gate and medicate (i) the ureters, (2) the kidney
pelvis, of one or both sides. (C) To assist, by
anaesthetizing, lubricating, or enlarging a ureteral
orifice, the passage through it of a calculus or plug
of pus, blood, etc. (D) To use the ureter, after it
is catheterized, as a guide in certain abdominal and
pelvic operations. (E) By prolonged catheteriza-
tion and drainage of a ureter, to facilitate the cure
of ureteral fistula.
MEDICAL RECORD,
May g, igo8.
1. Darwinism and Diabetes, By R. G. Eccles.
2. Cerebellar Hjemorrhage ; Remarks on the Functions of
the Cerebellum. By Joseph Collins.
3. Report of Nine Cases of Fracture of the Carpal
Scaphoid, By Leon.\rd W. Ely.
4. The Pulse of the Nervous System, By J. Henry Dowd.
5. Some Considerations m the Management of Burns and
Scalds in Infants and Children, By Medvvin Leale.
6. A Report of Fifty Cases Tested by the Calmette Oph-
thalmoreaction Test for Tuberculosis,
By Charles Graef.
7. Success and Failure in Nauheim Cures,
By Paul C. Franze.
I. Darwinism and Diabetes. — Eccles remarks
that nothing in Nature is more closely associated
with every form of evolution than is disease. The
healing forces are as truly physiological as are those
of assimilation and growth. The processes of disease
are aimed not at the destruction of life, but at the
saving of it. If it were not for disease in the popu-
lar .sense the human race would soon be extinct.
These sentences the author has taken from a speech
of Sir Frederick Treves. For centuries there has
been presented the strange spectacle of men of sci-
ence struggling to the utmost to thwart, to curb, to
annihilate, a process of cure. Unfortunately for the
ailing, this strange spectacle is far from having
ceased, although in one or two instances it has been
checked. The author takes up one general reaction
of organisms toward adverse condition, hypergly-
chaemia and glycosuria. He states that the present
attitude of almost the entire profession toward it is
pre-Darwinian. Citing some clinical cases of the
influence of sugar, he says that these evidences haye
been confirmed by animal experiments. Exceed-
ingly large quantities, as compared with the amount
in normal blood, have been subcutaneously injected
into dogs, without the slightest signs of toxicity.
The experiments demonstrated that the animal body
has great power in utilizing dextrose when adminis-
tered in this way. The fear of sugar, as sugar, is
probably a vestige of the time when no one was al-
lowed to sell it but the dealer in poisons, and he
dared not dispose of it without a physician's pre-
scription. The ghosts of such antiquated notions
still continue to interfere with logical thinking even
among many who think themselves entirely eman-
cipated from them. If more evidence is still de-
manded in proof of the harmlessness of sugar the
geographical and social distribution of diabetes
ought to be sufficient. Find a place where sugar-
cane is grown, and sugar consumed in abundance,
and one is found in which diabetes is exceedingly
rare or else is unknown. Find a region where car-
bohydrate food constitutes the bulk of that con-
sumed and that place will be found to contain little
diabetes. Discover a race that subsists exclusively
on carbohydrate food and we discover one that
knows no diabetes. Find a religion whose votaries
must subsist exclusively on a vegetable diet and one
will be found that knows little or nothing about dia-
betes. Now, on the other hand, the discovery of
a class, people, or faith, where meats are largely
consumed is quite likely to be one in which the death
rate from diabetes is at its maximum. Such at
least has, so far, been the results reported by those
who have made a study of its geography. If we
turn to Europe and America what do we discover?
The very men and women whose daily food comes
most nearly up to the standard of diet prescribed
for diabetics are the very men and women in whom
the cases of diabetes are most numerous and most
fatal. They are the people whose daily ration is
filled with fish, flesh, and fowl, and in which but
little room is left for bread or potatoes. The plain
people who subsist on the more economical diet, a
diet chiefly carbohydrate, know but little of diabetes.
It is those who regale on table d'hote dimiers who
are the sufiferers. They fill up on chicken and tur-
key, quail and partridge, venison and mutton, beef
and oysters, fish and lobster, with only a minimum
of carbohydrates. With an increase in the wealth
of a nation comes an increase in the number of cases
of diabetes, and pari passu with this, an increase in
the consumption of proteid with a corresponding
decrease in the consumption of carbohydrates.
3. Fracture of the Carpal Scaphoid. — Ely
draws the following conclusion from nine cases:
Fracture of the scaphoid is comparatively frequent,
and is often mistaken for sprain of the wrist. It
often escapes detection and recovers without any
treatment. It is usually caused by a fall on the ex-
tended hand. It may be caused by punching with
May 16, 1 90S.]
PITH OF CURRENT LITERATURE.
961
the clenched fist., or rarely by superflexion of the
hand. The one important symptom is tenderness
over the scaphoid on the dorsum of the wrist in the
"tabatiere," or slightlv internal to this spot. All the
other classic symptoms of a fracture may be absent,
except pain on motion. If the fracture is accom-
panied by a dislocation of the semilunar, extension
of the fingers, especially of the middle finger, will
be limited and painful, and the disability will be
much greater. The prognosis of simple uncompli-
cated fracture of the scaphoid is good ; that of frac-
ture with dislocation is less favorable. A good
treatment of simple fracture is immediate immobili-
zation. If the semilunar is dislocated, a piece of the
scaphoid often goes with it. If a dislocation is pres-
ent, the dislocated bone must be replaced. If this
is not possible, then it should be removed. Rough-
ly speaking, sensitiveness over the scaphoid, with a
history of a fall on the extended hand, without much
disability or swelling, means simple fracture. If
great swelling and disability are present, and the
middle finger is held in rigid flexion, a dislocation
accompanies the fracture.
6. The Calmette Ophthalmoreaction Test for
Tuberculosis. — Graef has tested the tuberculin
ophthalmoreaction of Calmette in fifty cases. He
thinks that the test seems to be a fairly reliable one,
well worthy of wide and repeated trial at least. In
some advanced cases no reaction will occur, a mat-
ter of little moment if the test proves reliable in early
cases, whatever the reason for this peculiarity may
be. Some allowance should be made for possible
faults in the tuberculin as furnished at present.
From the observations made on these cases he re-
gards the ophthalmoreaction as good evidence of the
presence of tuberculosis. In one of the cases a diag-
nosis made in this way was afterward confirmed by
finding the bacilli in the sputum.
BRITISH MEDICAL JOURNAL.
April 2S, 1908.
1. The Cystic Forms Xanthelasma Palpebrarum,
By J. Hutchinson.
2. Notes on the Treatment of Puerperal Fever,
By A. K. Gordon.
3. The Diagnosis and Treatment of Renal Mobility,
By G. Barling.
4. A Case of Ureterotrigonal Anastomosis for Ectopia
Vesicae, By J. S. Riddell.
5. Prolapse of the Inverted Bladder through the Urethra,
By C. Leedham-Green.
6. "Solitary Kidney," with the Notes of a Rare Case,
By B. J. Ward.
7. Remarks on Traumatic Rupture of the Kidney,
By C. A. Griffiths.
8. Certain Infections of the Urinary Tract, with Special
Reference to Tubercle, Gonococcus, and Bacillus
Coli Communis, By G. L. Eastes.
9. The Diagnosis of Impacted Calculus in the Ureter.
By C. A. Ball.
10. The Physiological and Pathological Effects which
Follow Exposure to Compressed Air (Arris and
Gale Lectures, II), By ^laj. Greenwood, Jr.
I. Xanthelasma Palpebrarum. — Hutchinson
states that the usual site of xanthelasma palpebra-
rum— the wash leather patches on the eyelids — is in
crescentic grouping above and below the inner
canthus of the eyelids. They occur in adults or
middle aged persons who have 'usually accounted
themselves "bilious,"" and are more common in dark
complexioned persons than in the fair. After mid-
dle age they cease to develop and may disappear,
which suggests that the sexual system may have
something to say to the recurring attacks of liver
disturbance. Those who develop these wash leather
patches have almost always been liable to periodic
disturbances of pigmentation in the eyelids. Once a
month or oftener the thin skin of the eyeHds has
been prone to become dark by temporary increase
of pigment. In women they often reveal the men-
strual periods. It is from these attacks of tem-
porary, but often recurring, attacks of pigmentation
that the xanthelasma patches take their origin. They
result from the deposit of a fatty acid derived from
the bile and are to be regarded as a late result. They
are not the only consequence of the recurring nu-
tritional disturbances: The gland structures may
suffer also and now and then the papillae. The
writer classifies the several forms which occur as
follows: I. Xanthelasma planum or flavum, the
wash leather type described originally by Rayer.
2. Xanthelasma sebaceum, where comedones are
present. 3. Xanthelasma cysticum, when cysts are
present. 4. Xanthelasma pigmentosum, when dark
pigmentation is the only condition.
2. Puerperal Fever. — Gordon holds that puer-
peral fever is wound fever. The wound is present
after every labor at the placental site. When it be-
comes infected we may have: i. Rapidly general-
ized septicaemia, from passage of the organisms di-
rectly into the veins of the part. This form is usual-
ly fatal in from one to three days, and the circulat-
ing blood generally contains streptococci. 2. Direct
extension through the Falloppian tubes to the peri-
toneal cavity, and resulting general suppurative
peritonitis. 3. Extension as far as the Falloppian
tubes only, with formation of adhesions, shutting
off the general peritoneal cavity, resulting in the oc-
currence of pyosalpinx, pelvic peritonitis, or tubo-
ovarian abscess. 4. Lymphatic extension, causing
parametritis, which may go on to suppuration. The
infecting agent in all forms is usually a streptococ-
cus, but the colon bacillus is often found later. Oc-
casionally the whole system becomes invaded by this
bacillus as a terminal infection. The following
points must be observed in treatment: i. The avoid-
ance of anything that may interfere with the clos-
ing of the placental site, such as the retention of
placental tissue, etc. 2. Care should be taken that
no other wound be made, e. g., with the forceps.
3. Infection of the wound should be avoided by ab-
stention from^ too frequent vaginal examinations,
and by the wearing of rubber gloves. 4. Douching
the vagina is seldom necessary and always risky.
A rubber syringe should never be used. 5. The
vulva should be kept covered with an antiseptic pad.
There are two main modes of treatment : The pas-
sive and the active. The former is based on the
beHef that between the organisms and the host lies
a barrier of leucocytes which should be left intact
and not destroyed by any local disinfection. The
writer, however, believes in active treatment — cu-
retting and swabbing with strongly bactericidal
chemicals. In the treatment of the septicaemic con-
ditions themselves there is nothing equal to large
quantities of sterilized sahne solution given per
rectum or subcutaneously. With these may be com-
bined calomel and alcohol, both in fairly large doses.
Antipyretic drugs are usually harmful ; cold water
is the best treatment for pyrexia per se. Anti-
962
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
Streptococcic serum is useful in a limited number of
cases only, but is never harmful. The serum should
be polyvalent, /. e., prepared from many strains of
streptococci, some of which should have been ob-
tained from cases of puerperal fever. At least 50
c.c. should be given subcutaneously, and twice as
much is preferable. The dose should not be re-
peated, as joint pains and pyrexia are apt to result.
The type of case in which these bactericidal serums
are of benefit is that in which the streptococci are
present in the circulating blood. They probably do
not affect the local lesion at all, and their value in
checking absorption of toxins from the lesion is
problematical. They are not supposed to have any
antitoxic value.
6. Solitary Kidney. — ^\'ard reports a case ni
that rare condition known as "solitary kidney."
The term has been widely and loosely used, and in-
cludes the three following classes: i. Congenital
absence of development of one kidney, its vessels,
and the corresponding ureter. The remaining kid-
ney is hypertrophied and may occupy its nor-
mal position in the loin, the ureter opening into the
bladder in its normal position. 2. Fusion of the two
kidneys into one mass, the simplest and best known
form of which is the "horse shoe kidney," in which
two of the poles are united by a bridge of kidney
substance across the middle line. There are never
less than two ureters, and sometimes three or four.
3. Cases in which one kidney is either rudimentary,
degenerated, or so diseased as to be incapable
itself of carrying on the excretory needs of the body.
This is the class most frequently met with by sur-
geons. The methods of diagnosis at our command
are cystoscopy, segregation of the urine by separa-
tion of the bladder into two halves by a special in-
strument, and inspection of the two kidneys, this
last requiring a second operation.
LANCET.
April 25, igo8.
1. The Gresham Professors of Physic (Gresham Lecture),
By F. M. Landwith.
2. The Anatomy of the Long Bones Relative to Certain
Fractures (Hunterian Lectures, II),
By R. Thompson.
3. On So Called Rheumatic Iritis; By C. Higgens.
4. The Influenza Bacillus as a Cause of Fatal Endocar-
ditis after Eight Years (?) (An Influenza Carrier?),
By F. J. Smith.
5. The Accuracy of Opsonic Estimations,
By L. Noon and A. Fleming.
6. Chronic Polycythaemia, By E. Cantley.
2. Fractures of the Long Bones. — Thompson,
in the .second of his Hunterian lectures, discusses
fractures of the upper extremity and shoulder gir-
dle. In Colles's fracture the main pressure is trans-
mitted through the posterior part of the radius.
When a breaking strain is applied the anterior or
concave part of the radius, which really corresponds
to the convex side of the arm, is put upon the
stretch and smashes first, and then the line of frac-
ture is directed along the line of pressure lamellae,
i. e., along the grain of the bone. Hence the ob-
liquity of the line of fracture from below, oI)Hquelv
upwards and backwards. The transverse line of
fracture may be explained by the fact that in coronal
sections of the bone the lamellae are not nearly so
pronounced as in sagittal sections, and thei'efore will
not affect the line of fracture to any marked extent.
In fracture of the clavicle, no pressure, or very lit-
tle, is transmitted through the acromioclavicular
joint, even when blows are struck upon the outer
"edge of the acromion process. This absence of di-
rect pressure through the acromioclavicular joint
is explained by the presence of the trapezoid liga-
ment and its attachment to the coracoid process of
the scapula and the clavicle. The pressure which
passes through the coracoid process and the trap-
ezoid materially affects the internal structure of the
clavicle. The obliquity of the adjacent surfaces of
the acromio clavicular joint and the presence of the
triangtilar fibro cartilage still further diminish shock.
By direct impinging of the coracoid process against
the clavicle fractures of the clavicle between the
conoid and trapezoid ligaments are produced, and
with such fractures not only is displacement pos-
sible, but impaction may also take place. By bend-
ing of the clavicle over the coracoid process frac-
ture of the shaft of that bone may be produced.
3. Rheumatic Iritis. — Higgens states that iri-
tis dependent on rheumatism no doubt frequently
occurs, but a very large number of cases so called
are due to the poison of gonorrhoea, and the worst
cases almost always. The patients are almost al-
ways men, over thirt)' years of age, and give a his-
tory of gonorrhoea, often of repeated attacks. In
most cases an attack has not immediately preceded
the iritis. ]\Iore likely the last attack of gonorrhoea
was some years previously. In most cases there has
been no gonorrhoea! rheumatism. The iritis is
severe and all the usual symptoms are well marked.
It is painful, often severely so ; there is swelling
of the iris, generally much photophobia ; a strong
tendency for adhesions to form, though there is no
very great amount of exudation, with much ciliary
and conjunctival congestion. There are also a de-
cided inclination to contraction of the pupil, which
strongly resists the action of mydiatics, of which
there is often a marked intolerance ; a tendency to
increased tension ; a general intractability, rendering
treatment most difficult and its results most disap-
pointing; and an unlimited capacity for recurrences
continuing through any number of years. The lia-
bility continues through the whole of sexual life.
It is probable that in many men who have had
gonorrhoea severely and frequently there is left for
many years in some part of the urinogenital appara-
tus a very much attenuated virus which gives no
trouble locally, but from time to time becomes more
active, and though still setting up no local irrita-
tion IS capable after absorption of causing inflam-
mation in synovial membranes or in the iris. It
looks almost as if the iris becomes, on occasions,
an excretory organ and tries to eliminate the poison,
receiving considerable damage itself in the attempt.
There must also be a large personal element nr
idiosyncrasy. The results of gonorrhoeal iritis in-
clude all those consequent on iritis in its worst
forms : Synechiae, more or less extensive, occluded
and excluded pupil, complete adhesion of the pos-
terior surface of the iris lo the lens capsule, bombc
iris with its attendant evils, capsular cataract, glau-
coma, with changes in structure of the iris, and loss
of vision, varying from slight impairment to total
blindness. Treatment is most unsatisfactory. My-
driatics irritate, and rise of tension is very frequent,
so that they must bo used with caution. Heat is
verv usefnl, rspecially w here pain is a marked symp-
Jilay 16. 190S.J
PITH OF CURREXT LITERATURE.
963
toni or where the tension is markedly increased.
Blisters are not of much service, but leeches are
often very beneficial, acting almost like magic in re-
lieving pain. The writer sounds a note of warning
against the use of cocaine and adrenalin. They do
reduce vascularity and relieve pain, but their after
effects are positively harmful, for they cause par-
alysis of the blood vessels and thus add fuel to the
fire which they are intended to extinguish. None
of them should be used, except for local anjesthesia
in prevention of bleeding during an operation, or
for the examination of painful or sensitive parts.
Constitutional treatment should consist of free
purgation and washing out the system by copious
draughts of hot water : mercury, iodides, salicylates,
and quinine. Salicylates are rarely useful, but
aspirin relieves pain.
6. Chronic Polycythaemia. — Cantley reports
a case of chronic polycythfemia occurring in a man,
aged forty-seven years. Although any condition of
cyanosis induces polycythajmia.it does not follow that
the increase in the ntmiber of the red cells is due to
the cvanosis. More probably there is an acttial increase
in the production of red cells, and the cyanosis is
consequent on the increasing viscosity of the blood
and difficulty in its efficient aeration. The consider-
able increase in the number of leucocytes, especially
the polymorphonuclear forms, suggests that we
have to deal with an inflanmiatory afliection of the
blood forming organs, possibly the result of some
toxin, \ enesection in the case here reported re-
lieved the patielit considerably. The omission of
milk from the diet, and large doses of citrate of
soda did not appear to produce any beneficial effect.
LA PRESSE MEDICALE,
April 4. 190S.
1. The Treatment of Measles. By J. Halle.
2. Should We Use Ethyl Chloride Mixed with O.xygen for
Anaesthesia of Short Duration? By Llciex Camus.
3. Apropos of the Specificity of the Cutaneous Reactions,
By R. Rom ME.
I. The Treatment of Measles. — Halle remarks
that there is no specific treatment of measles, and.
as we are unacquainted with the germ responsil)le
for the disease, and the disease seems to atifect the
human race alone, that it is not likely that we shall
soon find a seropathic treatment with which to com-
bat it. Althougli measles is known to be rarely mortal,
yet under certain circumstances its fatality may be-
come very great, and Halle considers that careful
attention should be paid to children suffering from
it, either in its simple or complicated form. In sim-
ple measles the child should remain in a well ven-
tilated room kept at an even temperature, and proper
hygienic precautions should be observed. Attention
shotild be paid to the skin, the eyes, the nose, the
mouth, the genitals, the digestive and the respira-
tory apparatus. Special attention should be paid
to the dietary, into which the author enters ver\-
fully. In complicated measles the treatment given
simple measles is indicated, together with the addi-
tion of therapeutic measures directed actively
against the complications. The forms mentioned
are the dyspnoeic with absence of any physical signs
of lung trouble, the haemorrhagic. the hyperpyretic.
the ataxic, and the adynamic. The complicating
diseases mentioned are bronchopneumonia, laryn-
gitis, diphtheria, otitis, and stomatitis.
2. Ethyl Chloride for Anaesthesia. — Camus
considers that it is simpler and easier to give pure
eth} l chloride gradually than wheit it is mixed with
either oxygen or air, and that it produces anaesthesia
more regularly. He asserts that the ethyl chloride
should be given in known, small doses, so that it
may be absorbed slowly, and the nervous system
become gradually aft'ected.
April S, 1908.
1. The Reeducation of the False Gastropathies,
By J. Dejerixe and E. Gauckler.
2. The Phvsicochemical Properties of Radium.
By L. Matout.
I. Reeducation of the False Gastropathies. —
Dejerine and Gauckler allege that in very many of
the cases of gastric trouble that are met with the
trouble is purely psychic and there is no true gas-
tropathy. To correct these cases the atithors pre-
sent a set of rules covering the feeding of the pa-
tients for several weeks.
LA SEMAINE MEDICALE
April 8. 1908.
Cyclothymia, By M. G. Dexv.
Cyclothymia. — Deny states that this term was
first introduced by Kahlbaum in 1882 to indicate
circular insanity or neurasthenia, a condition which
has attracted the attention of some writers. Deny
finds that so many more \\omen than men are af-
fected that the female sex might be considere d a
predisposing cause of the disease. It may last all
one's life without resttlting in insanity. Its exacerba-
tions coincide in general with the epochs of puberty
and the menopause, and may be provoked by ex-
cesses, the emotions, severe hemorrhages, and re-
peated pregnancies.
BERLINER KLINISCHE WOCHENSCHRIFT.
April 6, 190S.
1. Simulation of a Condition of Idiocy Maintained for
Years, By Kxapp.
2. Syringomyelia, By R. Milchxer.
J. Contribution to the Antiferment Action of Human
Blood, By Marcl's.
4. The Forms of the Tubercle Bacillus Not Demonstra-
ble According to Ziehl's Method, By Haxs Much.
5. The Importance of Serum Diagnosis in the Patholog>-
and Treatment of Syphilis, By A. Blaschko.
6. Concerning the Influence of the Reaction Upon the
Accomplishment of Wassermann's Complement
Union in Syphilis, By K. Altmaxx.
7. Symptomatology and Treatment of Cerebellar Tumors
(Concluded), By E. Siemerlixg.
8. Contributions to the Surgery of the Brain and Spinal
Cord (Concluded). ' By Hermaxx Kuttxer.
1. Simulation of Idiocy. — Knapp reports an
interesting case in which a man maintained a simti-
lation of idiocy for years for the purpose of mulct-
ing the insurance companies in which he had taken
otit policies insuring his health. By this means he
had greatly increased his income during the time his
simulation remained undetected.
2. Syringomyelia. — Milchner describes a case
of this disease met with in a man thirty-two years
of age. It seemed to date back to a fall when the
patient was ten }-ears old. in which he struck on the
back of his head, but suft'ered no immediate ill
effects.
3. Antiferment Action of the Human Blood.
Marcus says that for the determination of the power
of the human blood to restrain the digestion of al-
bumin by the Miiller-Jochmann method a one per
964 ^'^TH OF CURRENT LITERATURE.
cent, solution of trypsin is a positive test substance.
The antitryptic strength of the blood serum corre-
sponds to the normal when it prevents the forma-
tion of dimples on the Loeffler plate of a threefold
volume of a one per cent, solution of trypsin. It
is therefore diminished when it renders inactive less
than a threefold volume of the trypsin solution, and
increased in strength when it renders inactive a
greater quantity. The antitryptic power of the
blood serum varies from the normal in various
pathological conditions. Further researches are
necessary to determine whether any valuable clini-
cal, diagnostic, or prognostic conclusions may be
derived from the weakened or strengthened power
of the blood serum to inhibit trypsin digestion.
7. Cerebellar Tumors. — Sienierling adds four
more carefully observed cases, and then reviews the
symptomatology presented in this condition.
8. Surgery of the Brain and Spinal Cord. —
Kiittner adds the following cases: One of pallia-
tive trepanation for a brain tumor, which was not
localized, with almost complete restoration ; one of
cyst of the surface of the brain after fracture with
depression productive of general traumatic epilepsy,
which was operated on with a good result ; one of
exploratory laminectomy for a suspected gliomato-
sis of the spinal cord ; one of tumor (psammon) of
the spinal cord successfully removed ; one of fibroma
of the caudia equina successfully removed.
Throughout this long and valuable paper comments
are made with regard to the individual cases, but
very little is added in the way of general comment.
GAZZETTA DEGLI OSPEDALI E DELLE CLINICHE,
March 22, 1908.
1. Yefimov's Test for the Diagnosis of Intestinal Worms,
By M. V. Carletti and L. Dozzi.
2. Eosinophilia and the Antibodies in the Serum,
By Bazzicalupo.
3. On Hernial Tumors of the Omentum,
By E. Arcoleo.
4. Hyperaemia in Acute Superficial Inguinal Adenitis,
By Ugo Groini.
5. A Case of Dorsal Dislocation of the Middle Carpal
Bone, By V. Scoccia.
I. Yefimov's Test in the Urine for Worms. —
Carletti and Dozzi say that Yefomiv's chemical and
microscopical tests for the presence of worms is of
no value. The chemical test which was suggested
by the Russian author mentioned was as follows :
From 5 to 10 cc. of recently voided urine were treat-
ed with five or ten drops of a solution of mercuric
nitrate. A precipitate formed. If the latter was
white, milky, the patient did not have any worms.
If, however, the precipitate was greyish or more
or less dirty, almost black, then the patient had in-
testinal worms. In order to avoid possible causes
of error, the autlior advises that the patient should
not take any medicine for several days before the
test, because alkalis, sulphates, and compounds of
lead, iron, etc., produce a greyish color in the pre-
cipitate. Albumin, glucose, indican, etc., do not
modify the reaction. Pus, on the other hand, will
cause it to color the precipitate a dark tint. The
second reaction recommended by Yefimov is more
important than the first, and not only indicates the
I)resence of worms, but even shows what variety of
worms is present. It consists in the microscopical
examination of the crystals, which are obtained by
evaporating a drop of the urine on a slide. Gran-
[New York
Medical Journal.
ular crystals indicate the presence of cestodes, while
crystals in the shape of crosses show the presence
of nematodes, or round worms. The simplicity of
this test led the authors to experiment with it. They
examined in a number of patients, some of whom
were tuberculous, while others suffered from a va-
riety of diseases, both the fseces and the urine. The
fjEces were examined in order to find out whether
the eggs of parasites were present ; the urine whether
Yefimov's test could be obtained. The conclusions
which the authors make as the result of the exam-
ination of eighty patients are : ( i ) The chemical re-
action with the acid nitrate of mercury does not
usually present the marked characteristics described
by Yefimov. The color of the precipitate varies
greatly without reference to the presence of worms.
In two cases, in which the fasces did not show the
presence of intestinal worms, there was a distinctly
dark precipitate. On the other hand, the precipi-
tate was white in three cases in which the faeces
showed the presence of worms. (2) The presence
of crystals in the urine of these patients did not
correspond to the presence of worms. The shape
of the crystals varied greatly in the same case at dif-
ferent times. In ten patients, who showed no eggs
of parasites in the faeces, only three showed crystals
in the urine.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT.
April 7, 1908.
1. Functional Diminution of the Heart, By Moritz.
2. Concerning the Alternating Pulse and Its Relations to-
the Bigeminal Pulse. By von Tabora.
3. Sudden Death in Patients with Heart Disease,
By KiscH.
4. Studies Concerning Tobacco Smoke, By Lehmanx.
5. Concerning a Simple Method of Demonstration of the
Function of the Pancreas in Healthy and Diseased
Persons, By Schlecht.
6. Demonstration of Pus by Millon's Reagent,
By Dreyer.
7. The Antiferments in Human Blood Serum,
By JocHMANX and Kantorowicz.
8. Concerning Skin Reactions after Inoculations with
Dead Typhoid, Paratyphus Bacillus, and Coli Cul-
tures, By Link.
9. The X Ray Demonstration of Ossification of the Car-
tilages of the Ribs. By Ckodel.
10. Perhydrasemilkagar, a New Nutrient Material for
Bacteria, By Frankel and Much.
11. A Simple Nutrient Material for Gonococci.
By PlORKOWSKI.
12. Concerning the Transmutation of Lymphosarcomatosis-
and Tuberculosis, together with a Contribution to
Experimental Cirrhosis of the Liver. By Brandts
13. Persistent Anrtsthesia in the Tuberculous Larynx,
By Hoffmann.
14. Fibrolysin in Croupous Pneumonia with Delayed
Resolution, By Kkl-singer.
r.s. Diagram of the Bodv. By Hii-DEBRAxdt.
16. Concerning Thymus Persistens and Apoplectiform-
Thymus Death, with Remarks Concerning the Rela-
tions of the Persistent Thymus to Exophthalmic
Goitre (Concluded). ' By Hart.
17. Obituary of Carl Binz, By Schmiz,
18. Japanese Women as Prostitutes and Prostitution in
Japan,
2. The Alternating Pulse and Its Relations to
the Bigeminal Pulse. — You Tabora means by al-
ternating |)uUe that form in which a stronger con-
traction of the heart alternates with a weaker one
so that the interval between the latter and the
former is as great or greater than that between the
weaker and the subsequent stronger contraction. In-
the bigeminal form the stronger contraction alter-
nates with the weaker but with an interval that is
May 16. 1908.1
XEIV INVENTIONS.
965
always less than that between the weaker and the
subsequent stronger contraction. Thus in the al-
ternating pulse the weaker contraction of the heart
takes place either at the right time or after the right
time, in the bigeminal always before. The alternat-
ing pulse seems to be comparatively rare and the
author reports a case.
3. Sudden Death in Heart Disease. — Kisch
finds from a study of 156 cases of sudden death in
patients with heart disease that prior to the age of
thirty there is very little tendency to sudden death
from cardiac lesions. Indeed where there is good
compensation sudden death is almost as rare as in
people without heart trouble. From thirty to fifty
the number of sudden deaths increased progressive-
ly, and after the age of fifty valvular lesions form
a factor which under certain pathological conditions
may cause sudden death. As regards the conditions
of the heart and vessels in these 156 cases thirty-
five were cases of cor adiposum. thirty-two of myo-
degeneratio cordis, fifty-nine of endarteritis chron-
ica, thirty-six of endarteritis aortae, seven of sclero-
sis of the coronary arteries, thirteen of mitral in-
sufficiency, nineteen of mitral and aortic insufficien-
cy, thirteen of aortic aneurysm, three of rupture of
the heart, thirty-six of chronic nephritis, twenty-one
of chronic emphysema of the lungs, and seven of
cerebral haemorrhage. It happened most often in
persons with very fatty hearts and in persons with
general arteriosclerosis. The immediately actuat-
ing cause is sometimes difficult to determine. Men-
tal excitement is sometimes sufficient, sometimes it
is caused by an increase of the blood pressure.
Hereditary and meteorological influences also seem
to take a part.
4. Tobacco Smoke. — Lehmann states that nic-
otine is an uneven mixture of a number of sub-
stances and a very strong poison. He does not
think nicotine responsible for all the toxic symp-
toms produced by smoking and questions why, if
nicotine is responsible, children exhibit symptoms of
apparent nicotine poisoning after smoking parts of
plants that are free from nicotine, why cigars that
contain an equal amount of nicotine dififer greatly
in their effects, why cigars that are rich in nicotine
are frequently milder than others that are markedly
poor in nicotine, and why cigar tobacco seems to be
so much stronger when smoked in a pipe.
II. A Simple Nutrient Material for Gono-
cocci. — Piorkowski prepares his nutrient material
in the following manner : A litre of fresh milk is
mixed with 5 ccm. of dilute hydrochloric acid (i
in 4) and kept at a temperature of 37° C. until the
casein has become separated. It is then filtered and
the filtrate neutralized with a ten per cent, solution
of soda. It is then cooked for two hours in a vapor
bath, neutralized again, and then filtered once more.
It is then placed in bulbs or test tubes and sterilized
for an hour at a temperature of 100° C.
HfW InDtntiflus.
A LARYNX KXIFE AND SILVER NITRATE
CARRIER.
By M11.TOX J. B.\LLiN. M. D.,
New York.
While working at Hajek's Clinic in Vienna about
six years ago I frequently met with intralaryngeal
conditions which necessitated the use of the larynx
knife. There were several knives in use at that
time, but for one reason or another they seemed
inadequate, and I therefore endeavored to devise
an instrument which would overcome these slight
deficiencies. The knife in the accompanying illus-
tration has proved most satisfactory. In addition
to the knife, there is a silver nitrate carrier which
allows one to apply the solid silver to the larynx.
A laryn.x knife and silver nitrate carrier.
without coming in contact with any other part of
the throat, owing to the fact that the sheath slides
ever the carrier containing the small silver pearl.
This knife is intended to give to the laryngologist
a practical and light instrument, which can be used
with perfect safety in all intralaryngeal work. The
instrument itself consists of four metallic parts
which can readily be taken apart, thus making it
simple and in no way cumbersome.
It has the advantages: i, That it is light in
weight ; 2. being all of metal, can be easily taken
apart and sterilized if desired; 3. the screw ar-
rangement at the upper part of the handle permits
one easily to regulate the length at which one de-
sires the knife to protrude from the sheath, that is,
if one wishes to make a deep incision or merely a
superficial scarification ; 4, the sheath moves back
while the knife remains stationary, which is con-
trary to other knives, thus allowing the knife to re-
main directly over the part to which it is intended
to be applied ; 5, the knife recovers itself owing to a
small spring on the handle; this is of great im-
portance, as the knife is always protected, except
when one pulls the sheath back, thereby overcoming
the danger of cutting the patient while the instru-
ment is being withdrawn ; and 6. the knife blade
itself, which is about an inch in length, can be made
o66 IJll TEKS TO THE EDITORS. LXevv York
Medical Journal.
to cut in any direction, o\vin<j to a small screw ar-
rangement at the lower part of tlu- sheatli.
57 East Fiftv-Eicuth Stref.t.
^lALARIA IN GREECE.
126 E.\ST Thirty-fourth Street,
Ne\\' York, April 25, 1908.
To the Editors:
In the issue for April iith of the New York
Medical Journal appeared my article under this
heading-. It was my intention to give a series of
papers on the work done by our Greek brethren un-
der the protection of the King of the Hellenes, and
in cooperation with the Greek people to exterminate
malaria in their country.
As stated in this paper, I took my information from
the reports of the Syllogos, founded by Dr. Car-
damatis to combat malaria in Greece, for the years
1905 and iyo6. (Jn reconsideration of the matter,
I find that nothing short of a complete translation
would do justice to the noble work presented in this
report. In fact, it is more than a report, for it pre-
sents the state of our knowledge of the present day
about malaria and the scientific measures against it,
as executed in all different countries. Everything
of scientific value that has been done and written
is collected in a masterly way.
Such a version in English would serve great pur-
poses ; it would draw attention to the state of medi-
cal science in Greece and would be a means of en-
listing our own people in the cause of exterminating
malaria ; it would aid in stimulating our authorities
to support our own boards of health in their attempt
to secure hygienic conditions, for instance, on
Staten Island, where an immense amount of work
has already been done, in order to make this beauti-
ful island an earthly paradise ; but, further, to stimu-
late the government and the legislators to assist in
one of the greatest and noblest tasks the medical
profession can suggest. A. Rose.
iffok |[atices.
If/V publish full lisis of books received, but zee ackninvl-
edge no obligotioi I" rcrieic them all. Nevertheless, so
far as space permits. <■ rrrie:,.' lliose in ivhich zve think
our readers arc likely t>i he iiilercsted.]
Eormuhiire synthctique dc medccine. Par le Dr. L. Pron.
Paris: Jules Roiisset, 1908. Pp. 601.
The arrangement of this formulary dififers from
that of most compilations of its kind, where the
formulas are grouped under the names of the drugs
and one principal drug is combined in dif¥ercnl
forms for use in the treatment of a given disease.
Dr. Pron's formulary prescriptions are grouped un-
der the names of the disea.ses. or the applications
for which they arc intended, and different remedial
agents are represented in the prescriptions. A good
selection for formulas is given, and accompanying
them are directions for administration, together
with the doses suitable for adults and children. In
addition to this there are chapters on diet, sero-
therapy, poisons and antidotes, uranalysis. mineral
waters, and incompatibilities, so that it is more than
a mere compilation of formulas. The volume is of
convenient pocket size, and should serve a useful
purpose as an aide-inciuoire for practitioners.
Verhandhnigen der deutschen laryngologischen Gesellschaft
auf der ii. Versammlung zu Dresden, vom. 15. — 18.
September, 1907. Herausgegeben im Auftrage des Vor-
standes vom Schriftfiihrer Dr. med. Georg Avellis.
Frankfurt a. M. Mit einem Titelbild und 2 Abbildungen
im Text. VVurzlmrg: Curt Kabitzsch (A. Stuber's Ver-
lag), T908. Pp. .\iii-176.
^ These transactions of the second meeting of the
German Laryngological Society, held in Dresden,
contain, besides the official report of the meeting,
man}' interesting essays. We find such names as
Kuttner. Frankel, Gerber, Heymann, Hoffmann.
Krebs, Avellis. Sanger, Senator, Barth, Hajek.
Pause, Kuhn, Rudloff, Rosenberg, Albrecht,
Scherer, Blumenfeld, Imhofer, Mann. Keigler, Fla-
tau, and Gutzmann among those of the authors. As
an introduction there appears a memorial of Moritz
Schmidt, the dean of German laryngology, who took
a leading part in the tragic malady of the German
Emperor Frederick III.
Die tierischen Parasiten des Menschen. Ein Handbuch fiir
Studierende und Aerzte. Von Dr. M.\x Braun, Pro-
fessor der Zoologie und vergl. Anatomie, etc. Mit 325
Abbildungen im Text. Vierte. vcrmehrte und verbes-
serte Auflage. Mit einem klinisch-therapeutischen An-
hang. Bearbeitet von Prof. Dr. Otto Seifert in Wiirz-
burg. Wurzburg: Curt Kabitzscb (A. Stuber), 1908.
Pp. 623. (Price, $4.)
The fourth edition of this standard work has been
so changed that it appears as an entirelv new book.
The author gives first a short introductory chapter
in which he speaks of the parasites generally, and to
which he adds a chronological list of the more im-
portant books on helminthologv (27 pages). This
he follows up with the description of animal para-
sites of men (326 pages) and a bibliography (70
pages), which is arranged according to the chapters
of the book. Finally we find an alphabetical index
of the parasites described in the text, with their syn-
onyms. Entirely new is the second part of this very
interesting book, written by Professor Seifert, and
containing a description of the' diseases resulting
from the parasites and their treatment (150 pages).
Although the book is rather larger, the arrange-
ment in one volume seems to be very advantageous.
The illustrations are very instructive. The German
is written in short, precise sentences, which make
the reading and unclerstanding not at all difficult,
while the price is not prohibitive. It is, in short, an
up to date standard textbook which can be well rec-
ommended.
Diseases of the Lungs. Designed to be a Practical Presen-
tation of the Subject for the Use of Students and Prac-
titioners of Medicine. By Robert H. B.vbcock. A. M.,
M. I)., until recently Professor of Clinical Medicine and
Diseases of the Ciicst. College of Physicians and Sur-
geons (Medical Department of the Illinois State Uni-
versity), Chicago, etc. With Twelve Colored Plates and
One Hundred and Four Text Illustrations. First Edi-
tion. New York and London : D. .Applcton & Co.. 1907.
Pp. xix-809.
The high respect in which Dr. Ilab^-O'rk is held
throughout the country will lead hosts of his profes-
sional brethren to rejoice that he has now supple-
mented his work on diseases of the heart by this one
on the lungs. It is well that the original scheme of
May 16, iyo&.]
BOOK NOTICES.
967
dealing with both subjects in one volume of about
1,000 pages was abandoned, for. as the author says,
such an arrangement would have proved unsatisfac-
tory, since it would have called for such condensa-
tion as to diminish the practical value of the work.
In the preface Dr. Babcock says that he "awaits
with considerable apprehension the criticisms to be
passed upon the chapters devoted to pneumonia and
pulmonary tuberculosis." We have examined those
chapters carefully, and. as we had expected, we have
found them exceedingly satisfactory, teeming with
originality and good sense. Aluch care has been be-
stowed on the treatment of the various forms of
pneumonia, and we would urge a careful reading of
what the author says concerning the use of calfeine,
camphor, musk, alcohol, nitroglycerin, oxygen, asa-
fcetida. adrenalin., and bloodletting. In the chapters
on pulmonary tuberculous disease equally sound
views are expressed about the sterilization of milk,
diet, climatic treatment, the employment of creosote
and its derivatives, and the therapeutic use of tuber-
culin. \'ery properly, as we think, influenza is not
treated of systematically, for it is not essentially or
even preponderatingly a disease that finds expres-
sion in pulmonary affections.
The book is written in Dr. Babcock's usual clear
style, a style to which we find few exceptions,
though he does use here and there the word "be-
fallen" in a sense that is at least unusual, saying that
a patient was or was not "befallen" with a disease.
We are glad to see that he has not suft'ered his book
to be disfigured with the "bobtailed" spelling; "hem-
orrhage" is haemorrhage, and "quinin" is quinine.
There seems to have been an omission of some ex-
planatory heading from the table beginning near the
foot of page 594 ; we guess that the numerals mean
calories, but we are not sure. In the same tnble it
is rather queer to find caviare listed under shell fish.
From the mechanical point of view the volume is
very praiseworthy, and in all respects it is most com-
mendable.
Mosqiiirti Life. The Habits and Life Cycles of the Known
Mosquitoes of the United States ; ^lethods for Their
Control; and Keys for Easy Identification of the Species
in Their Various Stages. An .Account Based on the In-
vestigations of the Late J.\mes WTlli.x.m Dupree, M. D.,
Surgeon General of Louisiana, and upon Original Ob-
servations bv the Writer. By Evelyn Gro.ssbeeck
Mitchell. A. B.. M. S. Illustrated. New York: G. P.
Putnam's Sons, 1907. Pp. 281.
The author is to be congratulated upon having
produced a volume which will interest the lover of
nature, and which also makes a direct practical ap-
peal in the important relations which the subject has
to preventive medicine. Much of the material is
based upon the unpublished labors of the late Dr. J.
W. Dupree. who found time, in connection with a
large general practice and the exercise of manv im-
portant functions as a ptiblic spirited citizen, to carrv
out numerous minute researches of value in entomol-
ogy and bacteriology. The life history of the mos-
quito is considered in all its phases, and there are
chapters on the relations of the mosquito to malaria,
yellow fever, filariasis, and other diseases. Append-
ed are identification keys and a systematic list which,
with the anatomical studies included, will enable the
reader to readily recognize the dififerent species.
Treatise on Diseases of the Skin. For the Use of Ad-
vanced Students and Practitioners. By Hexrv \V.
Stelwagox, M. D., Ph. D., Professor of Dermatology in
the Jefferson Medical College, Philadelphia, etc. Fifth
Edition, Thoroughly Revised. With 267 Illustrations in
the Text, and 34 Full Page Colored and Half Tone Plates.
Philadelphia and London : W. B. Saunders Company,
1907. Pp. 1 150. (Price. $6.)
]^luch new matter has been added in this edition
of Dr. Stelwagon's admirable treatise, but the size
of the volume has not been made appreciabh'
greater, for some material has been dropped from
the original work. There are thirteen new cuts
and two new plates. The changes in the text are
for the most part to be found in the articles on
framboesia. Oriental sore, verruga peruana, and
tinea imbricata. Several tropical skin diseases are
newly treated of. prominent among which are
"ground itch" (the dermatitis of uncinariasis) and
"dhobie itch." The book continues to merit high
commendation.
Darzciiiisiu To-day. A Discussion of Present Day Scien-
tific Criticism of the Darwinian Selection Theories, To-
gether with a Brief Account of the Principal Other
Proposed Auxiliary and Alternative Theories of Species
Forming. By Verxox L. Kellogg. Profe-sor in Leland
Stanford, Jr.. University. New York: Henry Holt &
Co., 1907. Pp. xii-403.
To those, and they are not few, who glibly tell
us that Darwinism is dead, that "the monkey theory"
has passed to its eternal rest, this work of Kellogg's
wdl come as a surprise, i. e.. if they read it. For in
it will be found a simple and concise account for stu-
dents of biology, and for general readers, as well, of
the present day standing of Darwinism in biological
science, and an outline of the various auxiliary and
alternative theories of species formation which have
been proposed to aid or to replace the selection the-
ories.
While no one doubts that the present time is one
of unprecedented activity and fertility, both in the
discovery of facts and in attempts to perceive their
significance in relation to the great problems of bio-
nomics, yet in the very wealth of acquirement it
often becomes difficult to decipher the understruc-
tures which support the more elaborate building.
The knowledge of the factors of organic evo! t on,
the hypotheses to which they have given rise, and the
gaps which have been filled in the past few \ears
have each and all been added to or modified, and only
the specialist [s able to keep clearly before the mind's
eye the essential as distinguished frona the trivial and
accidental.
It is such a quality that renders this volume so use-
ful and advantageous, and the reader who has been
confused by the pros and cons of a never ceasing
discussion may find in it some rest and satisfaction.
The author first points out very clearly that Dar-
winism and evolution are not the same. He then
explains what is meant by Darwinisnl. and subse-
quently discusses the attacks made upon the theories,
notably upon that of sexual selection. Chapters vi
and vii contain a defense of Darwinism, while Chap-
ters viii, ix, X, and xi discuss other theories of spe-
cies formation. In the final chapter of the book the
present standing of Darwinism is given.
■"The living stream of descent finds its never fail-
ing primal source in ever appearing variations : the
968
MISCELLANY.
[New York
Medical Journal.
eternal flux of Nature, coupled with this inevitable
primal variation, compels the stream to keep always
in motion, and selection guides it along the ways of
least resistance. The guardian of this course is nat-
ural selection. Selection will inexorably bar the for-
ward movement, will certainly extinguish the direc-
tion of any orthogenetic process which is not fit,
that is, nonadaptive. Darwinism, then, as the nat-
ural selection of the fit, the final arbiter in descent
control, stands unscathed, clear, and high above the
obscuring cloud of battle." This is the author's con-
tention. To determine how well it is supported, and
to get a full view of the battle as it is waging, one
should read the book. It is well worth while.
Heart Disease and Thoracic Aneuryism. By F. J. Poyn-
Tox, M. D., F. R. C. P., London, Assistant Physican to
University College Hospital and Physician to Out Pa-
tients at the Hospital for Sick Children, London, Late
Medical Tutor and Medical Registrar to St. Mary's
Hospital. London: Henry Frowde (Oxford University
Press) and Hodder & Stoughton, igoj. Pp. 310.
It would be difficult to comprise ini such a small
compass more valuable material than is contained
in this admirable little volume. The author, who is
equally well known as a research worker and care-
ful clinician, has sticceeded in impressing the stamp
of originality and new interpretation upon many
familiar facts. As might have been expected from
his collaboration witli Paine, the pathology of
rheumatic endocarditis is presented with special ful-
ness. Myocardial affections also receive the atten-
tion which their growing recognition demands, and
the newer subjects of the auriculoventricular bundle
of His, the Stokes-Adams syndrome, heart block,
and the different varieties of arteriosclerosis are
adequately treated. The book is a model of con-
densation, attractive arrangement, and sound teach-
ing, and may be warmly recommended as probably
the best recent work of its kind for both student and
practitioner.
The Theory and Practice of Hygiene (Xotter and Firth).
Revised and Largely Rewritten by R. H. Firth, Lieuten-
ant Colonel, Roval Armv Medical Corps, etc. Third
Edition. Philadelphia: P. Blakiston's Son & Co., 1908.
Pp. 993- (Price, $7.)
Colonel Firth, of England, has edited a third edi-
tion of Xotter and Firth's Hyi^iciic. which appeared
for the first time in 1896, based upon the late Dr.
Edmimd A. Parkes's work.
The changes made in this new edition are such as
to make it practically a new book. One of the prin-
cipal changes is the omission of the list of books of
reference which formerly followed each chapter ;
the bibliography is now to be found in footnotes, and
that arrangement we regard as a decided improve-
ment, while in the former editions .sanitary law
took up a separate chapter, it is now discussed as
far as possible at the end of each chapter. But two
new chapters have been added : Sanitary Adminis-
tration and Law (Chapter i), and Recent Sanitary
Legislation (Chapter xviii), taking up such subjects
of the law as would not l)c referred to in the general
chapters. The chapter on \'ital Statistics has also
been materially changed.
Besides these major alterations, the book has been
fully brought up to date, and is a worthy successor
to the well received former editions. .\s it is based
entirely upon sanitary law s and statistics in Great
Britain, it will not so much appeal on this account to
the American reader, but there are many other points
in it which are of general interest.
Medical Diagnosis. A Manual for Students and Practi-
tioners. By Charles Lymax Greene, M. D., Professor
of the Theory and Practice of Medicine in the Uni-
versity of Minnesota, etc. Second Edition, Revised,
whh Seven Colored Plates and Two Hundred and
Forty-one Illustration. Philadelphia : P. Blakiston's
Son & Co., 1907. Pp. 691.
Within the compass of some seven hundred pages
of a book of convenient size, well bound in limp mo-
rocco. Dr. Greene has presented a manual of med-
ical diagnosis which has many excellent features.
The typographical arrangement of the work is ad-
mirable from the student's point of view, accentu-
ating the important features in each of the state-
ments made. The work is supplied with several col-
ored plates, which add much to its value, showing
the effects of stains and reagents in a manner more
accurate and comprehensible than could possibly be
shown by words alone. The marginal notes add
much to the value of the work for ready reference.
On the whole, the volume is one which has much to
commend it, both as to the matter it contains and as
to the manner in which it is presented, and we are
by no means surprised to learn that a second edition
was demanded within seven months of the issue of
the first.
Surgery Before the Days of Anaesthesia. — Dr.
W. C. Wood, of Gloversville, N. Y., sends us the
following extract from Tlie Herald of tlie United
States, published by Nathaniel Phillips, at the Post
Office in Warren, State of Rhode Island, Saturday,
October 20th, 1792 :
Warrex, R. L, October 20, 1792.
On Sunday, the 8th inst.. Dr. Nathaniel Miller, of Frank-
lin, in Massachusetts, performed a chirurgical operation in
Barrington.
Mrs. Allen, the amiable Consort of Samuel Allen, Esq.,
having a Tumor on her left arm which had been collecting
upwards of 20 years. The excresence (by its bulk) had
become troublesome ; rational resolution stimulated her
submission to the operation which was performed by Dr.
Miller, in presence of Dr. Baylis of Dighton. and several
other gentlemen of the faculty. The tumor was extracted
by incision and weighed pounds. Before the operation
began, a pertinent prayer was made by the Rev. Mr. Town-
send, to the Author of Goodness for Divine countenance
in the operation: After it was performed, a grateful ac-
knowledgement was made to Heaven for its supporting
hand.
Mrs. Allen sustained a fortitude highly becoming the
principles of reason and decency.
Much credit is due to the skillful Gentleman in his chi-
rurgical performance as well as his attention in the healing
;irt — his patient is now out of danger from the extraction.
Appointments of Reserve Surgeons.— There
exists some misapprehension among contract sur-
geons in the army in re.gard to appointments as re-
.serve surgeons. It should be explained that there
is no provision in the new medical law for allow-
ances to contract surgeons who may become candi-
dates in the Army Medical School. Therefore con-
tract surgeons who wish to enter the school and
are of the eligible age and have qualified by pass-
May I 6, 1 90S. I
OFFICIAL NEWS.
969
ins: examination to enter it will be appointed to the
reserve " corps. Seventy-four candidates are en-
rolled for the examination to be begun May 4th
for appointments as surgeons in the army. Last
year at the similar examination there were but thir-
ty-four candidates. All applications coming in now
from intending candidates are placed on file for the
■examination arranged to take place beginning Aug-
ust 3d. The candidates who pass in either exam-
ination will be on the same footing, as all will be
regarded as one class. Those who apply now or
hereafter will need time to file their credentials and
make ready for the examination, so that there is no
material gain in being in the first examination. The
relative standing of all examined at both examina-
tions will determine seniority in appointment. There
are now fifty-nine vacancies and to these will be
added two more by retirements soon to occur.
There are now ten members of the class at the medi-
cal school and these will receive the first ten ap-
pointments. After that the vacancies will be sup-
plied from the successful candidates of the two
coming examinations. Of the existing vacancies
thirty-two were created by the new medical bill and
twenty-seven are due to retirements and resigna-
tions.— Army and Nai:y Journal.
A Great Society for Coping with the Emergen-
cies of Peace and War. — The National Volunteer
Emergency Service, instituted in 1900, has recently
been reorganized by the election of Dr. James Eve-
lyn Pilcher, the distinguished editor of The Military
Surgeon, as its director general, and Dr. F. Elbert
Davis, of New York, as its adjutant general. Its
work will be conducted along military lines, the de-
tails being worked out in three separate corps, a first
aid corps, a public health corps, and a medical corps
— the latter consisting of physicians, with rank from
lieutenant to colonel, according to length of ser-
vice, to whom are afforded special opportunities for
emergency training. It includes among its per-
sonnel a large number of notable personages, and
is rapidly extending its membership throughout the
country. Full details regarding the service and its
great work may be obtained by addressing Director
General Pilcher at Carlisle, Pa.
Medical Language. — D. H. Zimmerer, of Re-
gensburg, Germany, remarks in the Journal of the
American Medical Association that the writings
of Hippocrates, Aristotle, and Galen, as well as
of Celsus, Pliny, and X'egetius, are, and will
remain for all scientists, the basis and test for
correctness of language, and purity of Greek and
Latin terms in the domain of natural philosophy.
Pollux, in his Greek Onomasticon, has stored up the
existing supply of medical onomatology. It is by
this means that these sciences still bear to-day the
stamp of intercommunity, simplicity, and interna-
tionality, and this fact makes it an indispensable
duty for every physician and natural philosopher to
acquire a knowledge of these two languages. With-
out a knowledge of etymolog}- and the laws of word
construction a linguistic expression will not be re-
tained in the memory : it possesses neither sense nor
form, its relations and dififerentiations are unrecog-
nizable and obscure, throwing the door wide open
to arbitrary misconception and linguistic malforma-
tions.
^Bffirial liftos.
Public Health and Marine Hospital Service
Health Reports:
lite t<'ll"'^^'iiig cases of siiiallpox, \cl!ozc fever, cholera,
and piu:^iu- /u;:v been reported to 'the surgeon general.
United .States Public Health and Marine Hospital Service,
during the iveek ending May 8, 1908:
Smallpox — United States.
Vlaces. Date, Cases. Deaths.
California — San Francisco April 11-18 15
District of Columbia — Washington . April 15-25 2
Illinois — Chicago April 18-25 7
Illinois — Galesburg Anril i8-'^ 1
Illinois— Rock Island April 18-25'. . ! ! . . . i
Illinois — Springfield April 16-23 3
Indiana — Ft. Wayne April 18-25 i
Indiana — Indianapolis April 19-26 24
Ipwa — Ottumwa April 18-25 8
Kansas — Topeka Aoril 11-25 31
Louisiana — New Orleans Aoril 18-25 5 i
Michigan — Detroit Aoril 18-25 3
Michigan — Grand Rapids April 18-25 5
Michigan — Kalamazoo April 11-18 3
Michigan- — Port Huron April 11- 18 i
Missouri — Kansas City April 18-25 16
-Missouri — St. Joseph April 18-25 16
Missouri — St. Louis April 18-25 7
Montana — Butte .\pril 14-21 1
Nebraska — Nebraska City April 19-26 5
Ohio — Cincinnati ' .-\nril 17-24 13
Ohio — Toledo April 11- 18 i
Tennessee — Nashville April 18-25 3
Texas — Galveston .-Vpril 17-24 1
Te.xas — San .\ntonio April 11-25 21
Virginia — Richmond .\pril 18-25 i
Washington — Spokane April 11-18 12
Wisconsin — La Crosse .\pril 18-25 5
Wisconsin— Milwaukee April 11-25 3
Wisconsin — Racine April 18-25 4
Sinallpo.r — Foreign.
Algeria — Algiers March 1-3 1 2
Arabia— .■\den March 30-April 6... 1
Brazil— Manaos March 21-28. 2
Brazil — Para March 28-April 11... 2 i
Canada — Halifax .\pril 18-25 4
Canada — Toronto March 2i-.April 4.... 18
Canada — Winnipeg \pril 1-18 i
Ecuador — Guayaquil March 28-April 4... 2
Egypt — Cairo March 25-April 8... 12 4
France — Paris .\pri! 4-1 1 5
France — Toulon March 1-31 8
Great Britain — Leith \pril 4-11 i
India — Bombay March 24-31 67
Italy — General April g-i6 67
Italy — Catania ,\pril 9-16 i
Italy — Naples April 4-11 i Imported
Japan — Kobe March 21-28 23 13
Japan — Osaka March 21-28 238 06
Malta M.qrcli 2i-.\pril 4... 3 '1
Mexico — .Aguas Calientes \pril 12-19 3
Mexico — Monterey \pril 5-12 i
Mexico — Vera Cruz April 13.
Russia — Moscow March 28
Russia — Odessa March
Russia — St. Petersburg March
Spain— Almeira March
Spain — Cadiz March
Spain — Denia April 3-10
Spain — Valencia April 5-12
Spain — Vigo April 4-11
Straits Settlements — Penang March 11-21...
Straits Settlements — Singapore.... March 7-14....
Turkey — Constantinople March 22-April
Zanzibar March 7-14....
Yellozi' Fever — Foreign.
Barbados — Bridgetown April 18 ......
Brazil — Manaos March 2i-.-\pril
Brazil— Para March 28-April
Cuba — Santiago May 2
Ecuador — Guayaquil March 28-April
Clwlera — Foreign.
India— Bombay March 24-31 . . .
Plague — Foreign.
China — Amoy April 25
Ecuador — Guayaquil March 28-.\pril
Egypt — Provinces —
Assiout March 20-21...
Beni Souef March 21
Fayoum March 20-26...
Galyoobeeyah March 21
Garbieh March
Kena March
Minieh March
India— General Ma
India— Bombay March
India — Rangoon Marcli
Peru— Callao March
Peru— Catacaos March
Peru— Chepen March
Peru— Chiclavo March
.\pr
2S-Apr
2i-.\pr
iported
13
23-26.
23-26.
23
24-31
970
BIRTHS, MARRIAGES, AND DEATHS.
[New Vork
Medical Journai..
Peru — Chosika March 14-21 i i
Peru— Eten March m -'i >i 7
Peru— Lima March i4--'i 10 7
Peru- Mollendo March i4--'i 5 4
Peru — -Monsefu March 14-21 S 5
Peru — Pisco March 14-21 1 1
Peru— Trujillo March 14-21 3^
Public Health and Marine Hospital Service:
Ofhcutl list of changes in the stalioiis and duties of com-
iiiissioiicd and nnneoiiiinissioned officers of the United
States Public Health and Marine Hospital Service for the
seven days ending j\Iay 6, igoS:
Carmichael. D. a.. Surgeon. Granted leave of absence
for fourteen da\s. from May 27, 1908.
Drew. A. D.. Acting Assistant Surgeon. Granted leave of
absence for thirty days, from June 3, 1908.
Gardner. C. H., Passed Assistant Surgeon. Detailed as a
member of a Revenue Cutter Service Retiring Board,
to meet at San Francisco, Cal, May 12, 1908.
Fo-STER, A. D., Passed Assistant Surgeon. Granted leave
of absence for one day, April 16, 1908, under paragraph
191, Service Regulations.
HoBDV. W. C., Passed Assistant Surgeon. Detailed as a
member of a Revenue Cutter Service Retiring Board,
to meet at San Francisco. Cal., May 12, 1908.
Holland. D. J., .\cting Assistant Surgeon. Granted leave
ot absence for five days, from ^Nlay 4, 1908, under para-
graph 210, Service Regulations.
Keatlev, H. W'.. Acting Assistant Surgeon. Granted leave
of absence for one day, April 30, 1908, under paragraph
210, Service Regulations.
Kerr, J. W., Assistant Surgeon General. Detailed to repre-
sent the service at the meeting of the National Associa-
tion for the Prevention of Tuberculosis, to be held in
Chicago, 111., June 4 to 6, 1908. Also directed to at-
tend the meeting of the National Association of the
Milk Commission at Chicago, III, June i, i9aS.
McIntosh. W. p.. Surgeon. Directed to proceed to Vance-
boro and other points in ^Maine for special temporary
duty, upon completion of which to rejoin his station.
Ryder. L. W., Pharmacist. Granted leave of absence for
two days, from May 6, 1908, under paragraph 210,
Service Regulations.
Stanto.n. J. G., .Acting Assistant Surgeon. Granted leave
of absence for twenty-seven days on account of sick-
ness, from April 4, 1908.
Stuart. .\. ¥.. Acting Assistant Surgeon. Granted leave
of absence for twenty-one days, from May 15, 1908.
Walker. T. D., .\cting Assistant Surgeon. Granted leave
of absence for four days, from ]\Iay I. 1908.
Wetmore. \V. O.. Acting .Assistant Surgeon. Granted
leave of absence for one day, April 24, 1908. under
paragraph 210. Service Regulations.
Wilson, J. G.. Acting Assistant Surgeon. Order granting
leave of absence for two days in March. 1908, amended
to read for one day only.
Board Convened.
A board of medical officers wa- convened May 2. 1908.
to meet at Seattle, Wash., to make physical examination
of an officer of the Revenue Cutter Ser\ice. Detail for
the board: Passed .Assistant Surgeon M. W. Glover, chair
man; Assistant Surgeon C. W. Chapin. recorder.
Army Intelligence:
Official list of changes in the stations and duties of officers
scr-ving in the medical department of the United States
Army for the -week ending April ij. 1908:
Bkownlee, C. Y.. Captain and .Assi.stant Surgeon. Left Pa-
cific Branch, U. S. Military Prison, Alcatraz Island, Cal.,
for duty as surgeon of the transport Sheridan.
Gkissinoer. J. W.. Captain and .Assistant Surgeon. Left
Fort Ethan Allen Vt.. on leave of absence for two
months.
Williams. A. W.. Captain and Assistant Surgeon. Relin-
quished leave of absence and will proceed to duty at
Fort H. G. Wright. N. Y.
Navy Intelligence:
Official list nf changes in the medical corps of the United
States Navy for the -n'cek ending May 9. 1908:
Belknap. J. L., .Assistant Surgeon. Detached from the
naval training station, Newport, R. I., and resignation
accepted to take effect May 6, 1908.
Cook, F. C, Surgeon. Orders to the North Carolina re-
voked ; ordered to continue duty at the Naval:
Academy. Annapolis.
Jones, A. McK., Acting Assistant Surgeon. Detached
from the naval recruiting station, Des Moines. la., and
resignation accepted to take ef¥ect May i. 1908.
McGuiRE, L. W., Assistant Surgeon. Appointed an acting
assistant surgeon from April 15. 1908.
McMuRDO, H. B., Acting Assistant Surgeon. Appointed an
acting assistant surgeon from April 15, 1908.
Miller, J. T., Assistant Surgeon. Detached from the
tranklin and ordered to the North Carolina when
commissioned.
Strite, C. E., Assistant Surgeon. Ordered to the Franklin.
Warner, R. A., Assistant Surgeon. Detached from the
Naval Hospital, Pensacola, Fla., and ordered to Wash-
ington, D. C. May 7. for examination for promotion
and then to await orders.
Married.
Heil.nlvn — Kirk. — In Syracuse, New \"ork. on Thursday,.
.\pril 30th, Dr. Ralph Salem Heilman and Miss Laura
Burns Kirk.
Judy — Rairdon. — In Picjua, Ohio, on Friday, May ist,.
Dr. G. S. Judy, of Miami-burg, and Miss Ida E. Rairdon.
Died.
Calhoun. — In Philadelphia, on ^Monday, May 4th, Dr.
' -Oward Calhoun, aged thirty years.
Carmichael. — In Trinidad, Colorado, on Friday. May
.St, Dr. Ahab K. Carmichael, aged fifty-four years.
Cartledge. — In Louis\ille, Kentucky, on Monday, \lay
y.h, Dr. A. Alorgan Cartledge, aged forty-nine years.
Caswell. — In New York, on Sunday. ^lay 3d, Dr. Wil-
liam Halsted Caswell, aged si.xty-six years.
Christison. — In Chicago, on Friday. May 8th, Dr. John
Sanderson Christison.
Clark. — In Lakewood. Ohio, on Monday. May 4th. Dr.
William Clark, aged eighty-two years.
Draper. — In Kansas City, Missouri, on Tuesday, May
5th, Dr. James F. Draper, of Victor. New York, aged
eighty-two years.
G.XMBLE. — In St. Louis, Missouri, on Monday, May 4th,,
Dr. David Coalter Gamble, aged SLxty-four years.
Guild. — In \\'heaton, Illinois, on Saturday, April 25th,
Dr. Elias Cornelius Guild, aged seventy-six years.
Hall. — In Boston, on Wednesday, April 29th, Dr. Rufus
H. Hall, of Everett, Massachusetts.
Holmes. — In Adams, Massachusetts, on Sunday, May 3d,.
Or. Horace M. Holmes, aged eighty-two years.
KiRCHNEK. — In St. Louis. Missouri, on Sunday, May 3d,.
Dr. Henry Charles Albert Kirchner, aged eighty-seven
\ ears.
KuiiN. — In Brooklyn, New York, on Thursday, Ma\- 7th,
Dr. Louis Debarth Kuhn, aged seventy-nine j'ears.
Lewis. — In I-"armcr, North Carolina, on Thursday, April
23d, Dr. Claude H. Lewis.
Lyons. — In Fitchburg, ^lassachusetts, on Wednesday,
May 6th. Dr. Herbert H. Lyons, aged fifty-three years.
McCoy. — In Independence. Alissouri, on Wednesday,.
April 29th, Dr. Charles D. McCoy, aged fifty-six years.
.M< Nri.TY. — In New York, on Friday, May ist, Dr. John
Joseph McNult>'. aged forty-five years.
M.NDHix - In Nashville, Tennessee, on Monday May 4tli.
Dr. John W. .Maddin, aged forty-two years.
Maduin. — In. Nashville, Tennessee, on Monday, .April'
27th, Dr. Thomas L. Maddin.
Perry. — In Worcester, Massachusetts, on Friday, May
1st, Dr. Charles Homer Perry, aged sevent\ -three years.
ScHLERETH. — In Ncw Rochellc, New York, on Wednes-
day, May 6th, Dr. George Schlereth, aged sixty-four years.
Silbert. — In Roxbury, Massachusetts, on Saturday, May
2(1. Dr. Joseph J. Silbert, aged forty-three years.
Starrett. — In Chicago, on Friday, April ist. Dr. Carlton
E. Starrett, of Elgin, Illinois, aged forty-four years.
Tabor. — In Cassopolis; Michigan, on W'ednesday, .April'
29th, Dr. J. S. Talx)r, aged thirty-three years.
Warrington. — In Washington. New Jersey, on Thurs-
day, May 7th, Dr. Charles B. Warrington, -aged seventy-
four years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal rlt Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXMI, Xo. 21.
XEW YORK. MAY 23. itjoS.
W'unui Xo. 1538.
(Sriainal Communications.
THE SIGMOID.AL FACTOR IX PELVIC DISEASES *
Bv J. Ra\v.sox Pexxixgtox, M. D.,
Chicago,
Professor Rectal Diseases, Chicago Policlinic.
Relations and Isifliiences. — I was greatly im-
pressed, when making some observations concerning
the anatomy and physiology- of the sigmoid and
rectum in iSf/) and Kpo,' by the various lengths,
positions, and adhesions of the sigmoid and of its
relations to the pelvic viscera. In fact, I was so
much impressed with these various conditions that
I believed then, have taught since, and still contend,
that an adherent, extra long, overfilled, or loaded
sigmoid, particularlv when it has an extra lowj;
mesentery, is more frequently than usually consid-
ered a potent factor in the pwoduction of many dis-
eased conditions occurring in the pelvic viscera.
Especially was I impressed with the possible patho-
logical influences of such conditions on the uterus
and its annexa ; and, in this paper, shall confine my
remarks to these relations and influences. Later I
shall consider other phases of the subject. If the
foregoing premises are true, then the treatment of
cases of uteroovarian diseases caused by such con-
ditions, should, it seems to me, be directed primar-
ily to the sigmoid and rectum, and, secondarily, to
the uterus and its annexa. But, you ask, what per-
centage of uteroovarian diseases are due primarily
to sigmoid influences ? Xot being familiar with any
statistics bearing on this subject I shall state that it
is my opinion, based on the following clinical ob-
servations and autopsy findings, that quite a large
percentage of such cases, a much larger percentage
that you would imagine, are caused by conditions
emanating from the sigmoid and its mesentery.
Clinical Observations.
1. It has been my observation that more than
seventy-five per cent, of adult women whom I have
examined for some rectal or sigmoidal disease have
had, in .addition to the bowel trouble, more or less
uterine disorder.
2. In making proctosigmoidal examinations,
from one half to two hours after defaecation, of
young girls between the ages of sixteen and twenty-
two years, suffering from some form of uterine
disorder, such as leucorrhcea. dysmenorrhoea. etc.,
I have found the rectum and sigmoid more or less
filled with faeces.
*Read at the meeting of the Mississippi Valley Medical Associa-
tion, at Columbus. Ohio. October, 1907.
'Journal of the American Medical Associaiion, November 30, 1900.
3. That f^ari passu with the relief and improve-
ment of the rectal and sigmoidal conditions, in a
large percentage of these cases, there will also be
obser\-ed relief and improvement in the uterine
troubles.
4. That when the sigmoid and uterus sustain
normal physiological relations to each other and the
former is loaded and unloaded periodically, then
the effect of the sigmoid on the uterus is salutarv.
This is true, because the normal physiological po-
sition of the uterus is one of suspended mobility in
an anteverted state, and such functions are physio-
logical. But, on the contrarv, if the functions of
Fig. I. — The uterus, u. was retroverted and forced ri^wnwards in
the relvis. The sigmoid, s, which is suspended by a hook, h, was
twenty-t\yo inches lorg, filled with faeces; and, with this entire load,
was resting on the fundus of the uterus. It was also bound down
by adhesions, a, to the broad ligament and the parietal peritonaeum
on the left side. .-Xutorsy July '.=;. '907. (Pennington.)
the sigmoid are compromised by adhesions or some
other pathological or anomalous condition, then we
should expect it to have a detrimental rather than a
salutary effect on these organs, and that is what we
usually do find. Again you ask. and quite perti-
nently too : What percentage of these cases have ad-
hesions or some other pathological or anomalous
condition of the sigmoid : and. in what percentage
of the cases does the sigmoid fail to load and un-
load periodically ?
Byron Robinson (Medical Standard. IQ07) says
that in 800 adult autopsies ( 600 men and 200 wo-
men) of which he has a record, that adhesions of
the sigmoid were found in eighty per cent, of the
men and in eighty-five per cent, of the women.
Furthermore, every laparotomist and every prosec-
Copyrieht, 1908, by .\. R. Elliott Publisning Con any.
972
PEA'XINGTOX: SIGMOID AND PELVIC DISEASE.
INe.v York
.M:;dical Jolrnal.
tor knows of the frequency of such adhesions ; and
every physician and most laymen are familiar with
the prevalence of constipation.
Autopsy Findings. — The following- illustrations
(Figs. I to lo), made from autopsies, show that the
Fig. 2.— The Mmi,oi<l, ,v. -r,-i , M.b u 1- hnok-., It xvas twenty
inches long, partiallv tille^l >m ^.x^,<r,\ into tli,/ Irft -ulc or
the pelvis, forcms the uii ■ " '^ln .n .1 Iimmi; .t
there. The left oviduct. , - .u: iix. .1 h> a.llu mwh^.
doubled on itself, and hcu- , njar it- iiii.hlle by thi
weight of the sigmoid. M. L . age titty thi ee. .\utoi sy. .\ugust.
1907. (Penninijton.)
sigmoid may overlap, wind around, rest heneath or
on these org-ans, and thai il iiia\ Iv.' adherent at va-
rious points. .Sucli ci iiditii ins not onlv compro-
mise its functions, but those of the uterus and its
annexa.
The uterus, when sustaining such relations to a
chronicallv loaded sigmoid, may be disDlaced up-
Fir,. 3. — TIk- ..iKmoi.l, s. was twintyfour inches long. It <li-
scendcd to the holtoin of the cul-dc-sac in the left side of the pel-
■vis and in front of the uterus, «. It then extended upwards, back-
wards, and outwards crossing the right broad ligament and oviduct,
r o, and passing downwards behind these structures and the cervi.x,
terminated in the rectum, r. It was bound down by adhesions, a.
to the left psoas and parietal peritona;um. It compictcly filled the
right side of the pelvis, displacing and fixing the uterus in a posi
tion of left lateral retrodeviation. The right fimbriated extremity
was adherent to the parietal pcritona;um, a, on that side. The right
oviduct r o. was elongated aiul bent downwards by the weight of
the loaded bowel. I.. C, age forty. Autopsy, August, 1907. (Pen-
nington.)
wards, downwards, laterally, backwards, or forwards,
and held or fixed in that position. This interferes
with its mobility and functions, hence produces a
])athological state of that organ. If the uterus is
continuously held nr fixed in any relative position
whatsoever, be that position anteversion or other-
wise, and whether it be by tumors, an overloaded or
adherent bowel, or what not, it must sooner or later
become congested and the victim of infection.
The normal physiological position of one's hand,
for example, is likewise that of suspended mobility,
and when b\- his side is in a normal relative posi-
tion. Yet it cannot be gainsaid that, if it be con-
tinuously maintained in that position, either bv
t\ ing or an\- other means, it will, sooner or later, be-
come congested and in a pathological state; so will
the uterus if it be maintained permanently in any
relative position.
This compromisation of the mobility of the uterus
places it under stress, and an organ under stress
becomes turgescent, crippled, and is, therefore, not
in a good condition or the best position to defend
itself against the invasion of microbes, .\long with
Fig. 4. — The same case as Fig. Here the sigmoid, s, is held
up by a hook. h. This exposes the doubling up of the left oviduct,
/ 0. and tlie dci\vn,\ard bend and displacement of the right oviduct,
r o. It also -allows the position ot the uterus, u. in the left side of the
pelvis; r. ri-c.uni. 1 ( ;eciini. 1 l-tniuneton.)
this loaded and more or less fixed condition of the
sigmoid there may exist sigmoiditis, mesosigmoid-
itis, or perisigmoiditis with adhesions. This further
compromises tlu- functions of the sigmoid, and it in
turn tho.^c of the uterus. Such a compromised posi-
tion of the uterus and its appendages is pathologi-
cal and demands attention. But should that atten-
tion be directed primarily to the uterus and its an-
nexa, or to the structures causing the trouble, i. e.,
to the sigmoid and rectum?
Symptoms. — Doubtless you will have anticipated
that the symptoms arising from such complex con-
ditions would be primarily from the sigmoid ; and,
secondarily, from the uterus, ovaries, and oviducts.
But such is not the case. The man who steps on
your toe. for example, is not the one that usually
makes the first outcry. Yet he is the offender.
Neither is it the sigmoid that necessarily presents
the first symptoms, although it may be impinging
on the uterus. As regards the relative time of the
May 23, 1908.]
PEXXIXGTOX: SIGMOID AND PELVIC DISEASE.
973
manifestation of the symptoms, it is, in the ma-
jority of cases, the uterus and its annexa to which
complaints are first referred and for which reUef is
sought; and, frequently, not for a considerable
length of time, indeed sometimes not at all, is the
complaint referred to the organ that is the real
source of the mischief. Among those symptoms
emanating especially from the uterus may be men-
tioned leucorrhoea, dysmenorrhcea. metorrhagia,
and menorrhagia, while those pointing directly to
the bowel factor are constipation, an overloaded
bowel with daily evacuations, painful defsecation.
mucus in the stools, etc. Among those common to
all the organs considered are haemorrhage, nausea,
sensation of weight in pelvic region, especially at
the menstrual period, pain or pain and weight in the
left or right groin, dragging pains in the iliac and
lumbar regions, headache, lassitude, nervousness,
tired feeling, etc.
The foregoing are the same clinical symptoms
mentioned in our textbooks on gynaecology and
surgery, differing only in an attempt at classifica-
F:g. 5. — The sigmoid was eighteen inches long. It descended into
the left side of the pelvis and into the cul-de-sac between the
bladder, b, and uterus, i< ; then ascended upw ards, crossed over the
fundus of the uterus, u, and descended behind this organ to the
rectum. The uterus was in a position of right lateral retrodeviation
ar.d greatly displaced downwards in the pelvis. M. G., age fifty.
Autopsy, Jiay 5, 1907. (Pennington.)
tion. Patients with such symptoms usually seek
relief for the uterine and ovarian trouble only.
They regard the symptoms which are especially as-
sociated with the bowel factor as of little or no im-
portance. Even the consulted physician frequently
fails to realize the value of this factor. Why ? Be-
cause. I, he seems to forget the anatomical and
physiological relations existing between the rectum
and the sigmoid and the uterus and its annexa ;
2. he rarely, if ever, examines the rectum and sig-
moid in cases of uteroovarian diseases except in a
perfunctory manner. It is obvious, therefore, that
the conclusion reached by such an examination is
faulty.
To properly interpret the array of symptoms
arising from these closely related organs (the rec-
tum and sigmoid, and the uterus and its annexa)
necessitates a careful examination of each ; and if
the rt'ctum and sigmoid are found in a condition
that would modify or interfere with the functions
of the uterus and its annexa that condition should
be treated.
The following case emphasizes the importance of
this assertion :
C.A.SE I. — Miss W., of Princeton, 111., age twenty years,
was referred to me by a confrere in May, 190S, to be treated
for pruritus ani. Examination showed that she had proc-
tosigmoiditis, was constipated, had mucus in her stools,
pain in her left side on palpation, leucorrhoea, dysmenor-
rhea, a retroverted and very sensitive uterus, and great
tenderness over both ovaries and oviducts. Many weeks
of topical applications to the uteius had given her no relief.
Fig. 6. — Same as Fig. 5. Here the sighnioid, i. is elevated by a
hook. It. The meser.tery. iii. was six irches long. (Pennington.)
Part of my treatments consisted in colonic lavage com-
bined with manual massage. This produced quite a little
pain, especially on the left side. I repeatedly requested her
to consult a gyn?ecoiogist. because of her uteroovarian trou-
ble. Finally, of her own accord she consulted one of the lead-
ing internists and one of the most eminent gynaecologists
in the city. Each, according to her report, said her ovaries
would have to be removed. I then had another gynaecolo-
gist examine her. He confirmed their diagnosis and ad-
vised the same surgical procedure. She declined the opera-
tion. I continued my treatment. One day on leaving the
office she said she had a sensation as though something
broke loose within the abdominal cavity. From that day
on colonic lavage was painless, her bowels improved, and
her leucorrhoea soon became notably less. While there is
still some thickening of the broad ligaments and some
slight tenderness over the tubes and ovaries, yet she has
had no dysmenorrhcea nor leucorrhoea, and her bowels
move regularly daiK'. I have often thought since finding
Fig. 7. — Sagital view of the same case as Figs. 5 and 6. It
shows the sigmoid, .r. passing down into the cul-de-sac between the
bladder, b, and the uterus, ». Note how- closely the sigmoid hugs
the uterus and the shortness of the vagina, v, which is due to the
displacement downwards of the uterus, u, by the sigmoid. (Pen-
nington.)
974
PENNINGTON: SIGMOID AND PELVIC DISEASE.
[New York
Medical Journal.
the specimen shown in Fig. lo that she likewise had an
adherent appendix epiploic and that it was the breaking
of this band which she felt.
Diagnosis. — Here again we are confronted with
the same complicateci proposition as when we at-
tempted to write the symptomatology. To make a
diagnosis in a case of suspected uteroovarian dis-
ease, or in one presenting the foregoing symptoms,
it is as necessary to make a complete and thorough
rectal and sigmoidal examination as it is to make
Fig. 8. — The sigmoia.
down the left side ot the jm
front of the merus: thi n ac
right side of the pelvic, then
oviduct, then sliehtlv ujiwai
passed bevond the median li
wards behind the fundus, th
and passed bevcmd the left f
to the riglit and | assed acrn.
terminate in tin rectum, r.
the uterus: / ,^ th.^ n^hi '
a. adnesions t.i tlu vamtal i
oviducts were l un n~Jv omi
it inches long. It passed
jttom of the cul-de-sac m
of the uterus, u. to the
backwards over the right
ds the left side, until it
d to the riaht and down-
tlie left benind the uterus
organ, then crossed again
of Dnuslas s cul-de-sac to
1U4 piacticallv surrounded
:niHi,l : is the left loon:
rccinm. The ovaries and
-k, ich. R. P... age f^fty
a complete and thorough uterine examination. The
former, as a rule, should be made first. Especial-
ly is this true in the case of young girls and unmar-
ried women, as this examination may give sufficient
information without making the latter. If not, then
the uterine examination should be made bv the
usual "touch" bimanial and in.strumental means.
One of the object.^ in making a rectal and sig-
moidal examination is to ascertain whether or not
the sigmoid and rectum are emptied and refilled
periodically. An individual may defascate regu-
larly every day and yet have a continuously loaded
bowel. Such a condition may interfere with
rhythmic uterine action, and if not corrected cause
a pathological state of that organ. Hence the ne-
cessity and importance of proctoscopy, sigmoid-
oscopy, palpation, etc.. when making such examina-
tions. It is not necessary for the uterus to be
pushed to one side or down in the pelvis and held
there, as shown in some of the foregoing illustra-
tions, to become pathological. It is a movable or-
gan, and its position is one of suspended mobility.
.Anything, tlierefore, that immobilizes it continuous-
ly, it matters not wliat the relative position of the
uterus may be, compromises its functions with a
pathological sequence. A persistently loaded sig-
moid and rectuin may produce this pathological se-
quence. If the patient has fibrosis of the rectal
valves, chronic hyiK-rtrophic or atrophic proctosig-
moiditis, contractions, strictures, kinking, adhe-
sions, or an extra long sigmoid or mesentery or
other conditions interfering with the regular
rhythmic loading and unloading of the sigmoid and
rectum, she, in the course of time, is most likely to
have leucorrhoea, dysmenorrhoea, and other symp-
toms pointing to the beginning of a pathological
state in her genitalia.
The mere statement of a patient that she is not
constipated because her bowels move once or twice
daily is not to be accepted as conclusive evidence
that she has not an overloaded bowel. In fact,
when a patient states that her bowels move twice
daily and that both movements are close together,
I usually expect and do find a continuously filled or
diseased bowel. To illustrate:
Case II. — A lady was brought to my office in April, 1905,
by a former patient seeking, through me, the services of a
gynaecologist. Believing from her statement that her
bowels were more in need of treatment than her uterus, I
made a rectal examination after she had assured me that
she was not constipated, that her bowels had moved twice
that morning, and that she had never had any trouble of
any kind whatsoever w-ith them. On removing the obtura-
tor from the proctoscope I found her rectum loaded with
fa?ces. I requested her to return home, cleanse her bowels
with injections, and return the following morning for ex-
amination; this she did. She expressed great surprise on
entering my office the following day at the amount of ma-
terial she had passed as the result of the injection; but for
the same reason as on the previous day it was impossible
to examine her. This was repeated for three successive
mornings. On the fourth morning her husband accom-
panied her and assured me that her bowels were clean this
time because he had attended to the matter himself. On
removing the obturator from the speculum he was very
much chagrined to find that they were not as yet clean.
Fig. 9. — The same case as Fig. s I ii. M.:! i, id. s, is lifted up
by the hook, h. The uterus, ». is pulled ,l„unwards by the hook,
2; If is a white fibrous line in the mesentery over the |isoas
muscle; o p. adhesions binding the sigmoid to the psoas; a. adhes-
ions causing an angulation of the sigmoid; a a, adhesions between
the appendix and fimbriated extremity of the right oviduct, r
/ o, left oviduct; r, rectum. (Pennington.)
Vaginal examination in her case showed the uterus to be
slightly anteverted and very sensitive, and the ovaries and
tubes very tender.
I treated her with lavage of the colon combined with
manual massage, and throusfh these measures either
stretched or broke up some adhesions which I believed I
had detected. At least the pain in her left side, her leucor-
rhoea, dysmenorrhcea, nausea, and "tired feeling." etc., all
May 23. 1908.]
PEXXIXGTOX: SIGMOID AND PELVIC DISEASE.
975
disappeared, and her bowels became quite regular, moving
once daily.
Treatment. — Here again we are confronted with
very much the same difhcuhy that we were in at-
tempting to write the symptomatology and diag-
nosis, i. e., a dual proposition.
From the foregoing it would seem that the treat-
ment of many pelvic diseases should be directed pri-
marily and early to the sigmoid and rectum, and
secondarily to the uterus and its appendages.
To treat, for example, a uterine disorder due to
sigmoiditis, mesosignioiditis. or perisigmoiditis, or
to hypertrophic or atrophic proctosigmoiditis, fibro-
sis of the rectal valves, or to a continuously over-
loaded bowel, etc., by topical applications and vagi-
nal tampons is not only useless, but positwely hann-
ftil. Such treatment of this class of cases allows
the condition to advance and leads to the later stages
of pelvic disorders which necessitates more severe
and radical measures. Doubtless it was the result
of such treatment that caused Dudley to say in his
most excellent textbook on Gyncccology that "topical
applications should be consigned to the archives of
gvnascologv." In such cases topical treatment seems
to benefit the patient temporarily : but, as a matter
of fact, the condition continues to grow worse and
worse until finally hysterectom\-, oopherectomy, sal-
pingectomy, or hysterosalpingooopherectom\-, with
their deplorable sequences, have to be performed.
If the conditions causing these troubles have ad-
vanced to that stage where they can not be corrected
by simple methods and general tonic treatment, then
laparotomy should be performed ; not, however, for
the purpose of removing the tubes and ovaries, but
to apply such surgical measures to the offending sig-
moid, as may seem indicated. Incidentally, of
course, any requisite operative work on the uterus,
tubes, and ovaries should be done at the same time.
The following case (Fig. 11) serves to illustrate
the point in question.
Miss L., aged tvventy-tive, was referred to me
by Dr. Gratiot, of Mineral Point, Wis., ]May 2, 1905.
Fig. 10. — .-i-o. :i.-, tl:e adhesion of an appendix epiploic, ci. of the
sigmoid to the botiom of the pelvic floor, which caused an acute
flexure of the sigmoid at f, and prevented its rising out of the
pelvic cavity. Autopsy,. 1907. (Pennington.)
She gave a history of inflammation of the bowels the pre-
vious February. She was a typical neurasthenic, had lost
twenty pounds in weight, had fibrosis of the rectal valves,
proctosigmoiditis, and was constipated. Her left ovary
and oviduct was tender, and she suffered from leucorrhoea
and dysmenorrhoea. Proctovalvotomy, lavage with manual
massage, and general tonic treatment gave her some relief
only.
She returned December 14, 1905 : conditions about the
same as when she first consulted me. Laparotomy exposed
adhesions of the sigmoid to the broad ligament and parietal
peritonaeum on the left side, which confirmed my diagnosis.
These were severed and the raw surfaces covered. Her
improvement was ven' marked. Bowels became quite regu-
FiG. II. — r is 'the colon; the sigmoid which is elevated by a
hook; a. adhesions between the sigmoid and parietal peritonseum;
b I, adhesions between the broad ligament and the sigmoid; / o,
left ^oviduct slightly pulled down by a hook; u, uterus. (Penning-
lar, leticorrhoea, dysmenorrhoea. and tenderness over ovary
and oviduct disappeared. She has returned three different
times since the operation because of the beginning pain
in the left side. After a few treatments with lavage and
manual massage the pains disappeared and she returned
home feeling quite well again. She has had no leucorrhoea
or painful me!i5trual periods since the adhesions were
broken up. Her bowels have not improved so as to move
regularly every day without some little assistance : yet,
there is a marked improvement over her former condition
and the uterine and ovarian trouble have entirely
disappeared.
It seems to me that we are approaching a position
from which we can view the treatment of pelvic dis-
eases in a diflferent and broader light. In the treat-
ment of pelvic diseases early diagnosis and treatment
is quite as essential to permanent success as is early
diagnosis and treatment of cancer of the stomach, as
advocated by W. J. Mayo.
There is probably a period in many cases of this
class of pelvic disorder at which if taken they could
be easily managed and successfnllv treated without
surgical procedures. But if not properly handled
at that time then early surgical interference to break
up adhesions, straighten out kinks in the sigmoid,
especially the one that so frequently occurs at the
rectosigmoidal junction, shortening or hitching up
the mesentery, sigmoidopexy, "short circuiting" the
bowel current, by lateral anastomosis, and, if needs
976
ABBOTT AND PINGREE: NORMAL BALANCE Of FOOT.
[New York
Medical Journal.
be, resection of the sigmoid should be done with the
hope of preserving the genitaha and womanhood.
Should all of these measures fail, then, as a der-
nier ressort, hysterectomy, salpingectomy, oophorec-
tomy, or hysterosalpingooophorectomy may have to
be performed.
103 St.\te Street.
The use of a support or plate in a shoe for the
purpose of lifting the arch of a weak foot into a
normal position and holding it there is not unlike in
its effect that produced by the application of a brace
to any part of the anatomy, and atrophy of the soft
tissues with a corresponding weakness is the result.
As the muscles which should maintain the arch in
THE RESTORATION OF THE NORMAL BALANCE
OF THE FOOT.
H.
Second Patter. The Treatment of Weak or Flat Foot by
the I'.u- of a Meehanical Snffort.
By E. G. A];i;oit, AL D.. .\.\d H. A. Pingree, M. D.,
Portland, Me.
The term weak or flat foot is here employed to
designate that condition of the foot in which the
arch is depressed, but in which the joints are freely
movable in all directions. The complications of
Fig. 22. — Picture of di.ssected foot hat-
showing shape of arch.
formaldehyde.
rigidity and inflammation which frequently accom-
pany this deformity are not considered in this paper,
since, as already stated in the introductory article on
this subject (see Journal, p. 875), the treatment of
them is necessarily preliminary to that of restoring
the arch to its normal position, and a support, if of
any value, does not fully serve the purpose for which
it is intended until all restriction to motion is re-
moved.
Also all such treatment as strapping or braces is
not included, as thai likewise is a preparatory meas-
ure. The use of proper shoes is here indicated, just
the same as it is in the normal condition of the foot,
and has only a relative bearing upon this part of
the subject.
Fig. 23. — Plaster cast ut arch of skeletal foot, showing dome shape.
flat foot are already weak, it is very evident that
such treatment alone, if the result sought is com-
plete restoration of the normal, is not only inade-
quate, but unscientific.
The plate is useful during a certain stage in the
treatment of weak foot, but should only be used as
an agent in bringing the foot to a normal condition ;
and in order to do this it must be of such a shape
that it makes little or no pressure when the foot is
in activity, acts as a reminder to the patient to hold
the arch in a proper position when the foot is pas-
sive, but supports it when he is unable to do so
longer.
The best idea of what should be the correct form
of support can be obtained by an examination of
the contour of the arch in a dissected normal foot
(Fig. 22), by an analysis of the motion of the foot
when used in walking, and
also from the attitude in
weight bearing. A look at
the plaster model of the
skeletal foot will suffice to
show that the arch is not
an inclined plane, but that
it resembles a section of a
dome (Fig. 23), and there-
fore that, in order to main-
tain it in a normal position,
the support must he dome
shaped. The model also
shows that the highest part
of the support should not
be at its inner margin, but
at a point on it which cor-
responds with that part of
the foot beneath the sca-
phoid bone and situated at
some distance from its in- Fig. 24.— Footprint of a nor-
t-^...,^! 1,^^,1,,^ A ^..^^^^4. "la' foo<- showing weight be.ir-
ternal border. A support i„g surfaces,
of this form, then, with
slight allowance for the soft tissues, would just fit
the arch of the normal foot, when the patient is
standing, without making any considerable pressure.
The parts of the foot which would support the body
weight on the surface beneath it. rather than on the
May ^3, 1908. J
ABBOTT JXD PLXGREE: NORMAL BALASCE OF FOOT.
977
plate, would be the heel, the outer margin of the sole,
and the ball (Fig. 24). These would also be the
parts which would successively support the body in
walking, and such a plate would have no action
26
Fig. 25. — Plates ready made, such as are sold in shoe stores.
Fic. 26. — Uusual type of jlate made from a cast of the foot.
whatever on the normal foot either during motion
or at rest.
Now, if a support of this shape is placed beneath
a weak foot, it will be found that the arch is raised
to a normal position, and that it remains there with
very little pressure upon the plate even in those
cases where the relaxation is extreme, notwith-
standing that very little or no effort is made by the
28
Fig. 27. — Plates with the outer border turned up so that the foot
will not slide off from them.
Fig. 28. — Whitman plate as devised by Royal Whitman. New York.
patient, as soon as he tires, to hold the arch by
muscular power, for, as shown in the preceding
paper, it requires only one eighth as much force
to maintain the arch, when it is raised to a normal
position, as that necessary to lift the weight of the
body, and this in the cadaver, the most lax condition
obtainable.
In walking, this support has no more action in
the flat than in the normal foot, with the exception
that it does remind the patient to place the foot in
a correct position, so that the step may be properly
taken. It makes no difference in the action of a
plate of this shape whether it is placed in a shoe or
upon the floor, where all restrictions are removed,
the arch is maintained in its normal place and the
foot must assume the correct position.
The arch is such, then, in its contour that, if a
plate is so constructed that it conforms to it, it
needs nothing whatever to prevent the foot from
slipping oft' from it in any direction, it has very
little action as a direct support until the patient tires,
it acts as a reminder to the patient to hold the arch
in a normal position, and it prevents the foot from
assuming anyrhing but a normal attitude during the
successive movements of the step.
The dift'erent supports now in use all resemble
in a general way the inclined plane, but. as they
Fig. 29. — Position of a weak foot on the Whitman plate as soon
as muscular relaxation takes place.
diflfer somewhat in particulars, a brief description
of them will be necessary in order to understand
their action.
The one in most common use is that found in shoe
stores (Fig. 25). and it is a type familiar to all.
The highest part is the border which extends along
the inner margin of the foot, and the plate's upper
surface slopes concavely downward from this line
to it? ( pposite edge. It is made from a stock pat-
tern, and is practically worthless. It is needless to
mention the reasons why it does not accomplish its
purpose.
The next most frequent shape met with resembles
the ready-made plate with the exception that it is
fitted over a cast of the foot (Fig. 26), and there-
fore conforms much better to the surface beneath
which it is intended to be placed. The effect, how-
ever, is wholly to raise the inner border of the foot
near the centre by resting it upon an inclined plane.
The support cannot do this unaided, therefore the-
978
ABBOTT AYD PINGREE: NORMAL BALANCE OF FOOT.
[New York
Medical Journal.
boot must prevent the foot from sliding if the plate
is to be held in place. It is at its best only a prop
to the internal border of the arch, held in place by
the boot ; its action as a curative agent is practical-
ly nil. and it is probably more detrimental than use-
ful to a i)roper gait.
In some instances the outer border of the plate
l iG. 30. — I.iiu- f...llo\vc(l in making a j-late,
is turned up so that the foot is prevented from slid-
ing from it ( iMg. 27), and in this case the foot
rests in a curved trough with the inner border
higher than the outer.
The Whitman plate (Fig. 28). which is much
superior to the su])])orts described in the preceding.
Fic. 31. — Different vi
with flange for scaphoid
and wliich marks a periofl of pronounced advance-
ment in the mechanical treatment of weak foot, dif-
fers somewhat from the others both in its action
and shape. It covers less of the foot on its under
surface, but more on its inner, and has one outer
flange just below the external malleolus. It is,
however, an inclined plane, and apparently the
greater part of its action is due to this.
The so called positive action of this support is de-
scribed as follows: The patient is instructed to
throw the body weight on the outer side of the foot,
as by so doing the foot presses against the flange
on the outer side of the plate, tilting it. This causes
the internal border of the support to l)c raised and
pressed against the inner surface of the foot, which
IS instinctively drawn away from it.
It would seem from the description and from an
examination of the plate in use that this positive
action consists chiefly in causing the patient to walk
on the outer side of the foot,' provided he follows
mstructions. The lateral pressure voluntarily made
on the outer flange of the support certainly raises
Its mternal border, but by this action the border is
raised throughout its entire length and carries as a
whole the inner part of
the foot with it. If
the foot is placed
upon this support it
will be found that the
posterior part. or
heel, is held on an
inclined plane b\- the
outer flange, but that
the whole anterior
portion is free and
cannot be held in the
correct position un-
less the weight i?
thrown on the outer
side of the foot, and
then only through
considerable effort
upon the part of the
patient. That this
position cannot be,
maintained for any
considerable length
of time is evident,
for, as soon as the
patient tires and the
muscles relax, the
anterior part of the
foot slides from the plate (Fig. 29).
The statement made by the supporters of this
plate is that its action differs in principle from that
of other forms, first, in that it supports the arch by
lateral pressure over the inner surface of the foot,
thereby preventing bulging of the internal border,
which is the most important element of the deform-
ity; second, in that the foot is under much less
restriction and ci insi.'(|uently its action is more like
that of the n(a iiial toot.
It would seem from observations and exjx^riments
that the inner bulging of the foot, as already stated,
is due wholly to a depression of the arch, and in-
stead of being the most important element of the
deformity, that it is only a result of this depression,
and disappears at once as soon as the arch is re-
stored by a proper support (see Figs. 7 and 8). It
is possible for this plate through pressure along the
inner surface of the foot to cause the patient to hold
the foot for a time in a correct position by muscular
effort, but. as soon as relaxation takes place — and.
Fig. 32. — Showing position of a
wealv foot witli plate placed be-
neatli it.
May 23, 1908.]
ABBOTT AXD PINGREE
NORMAL BALANCE OF FOOT.
979
if it did not, there would, be no need of a support —
the problem is one of simple mechanics, and just
the same as that presented when an arch of similar
shape of any material needs support. In such a case
it would be necessary to do something besides secur-
ing one end of the arch and then making pressure
against one side of it, with the other end entirely
free.
The frequent assertion that the foot has more
freedom in this support appears to be open to dis-
cussion. In the normal foot the arch movement is
slight, and in all other motions which the foot has
it moves as a whole, and any plate should not restrict
these. It is a fact that this support covers less of
the under surface of the foot than any other, but
how much motion takes place in that part of the
normal foot which would be left by such a plate?
With this support the heel is firmly fixed and the
rest is free, but the freedom is all in the direction
of deformity, and it would seem that movements
normal to the foot are less restricted by the ordinary
plate.
In order to construct a support which shall meet
the requirements in weak foot it is a well recognized
fact that a model which conforms to the shape of
the skeletal foot, at least approximately, is neces-
sary. To obtain this by merely making a cast of
the foot is impossible, as the soft parts cover it
unevenly, and such a cast must necessarily be inac-
curate. It might seem that the support would hold
the bony framework in normal position if it con-
formed to the normal surface of the foot in the
living subject, but experiments show this conception
to be false, as some parts are covered with tissues
which are resistant, while others are yielding and
easily become absorbed under pressure. The best
that we can expect to obtain is a model which con-
forms to that part of the bon\" framework which
holds the body weight when the normal foot is used
as a support. The modelling of the arch must be
done with a knife, and the amount to be removed,
as well as the shape, must be determined by judg-
ment based unon experience.
There are several kinds of materials for making
models, wax. paraffin, dental gum. lead, and plaster
of Paris. The last named is most frequently used
and upon the whole is considered the most satis-
factory. The position in which the foot should be
placed when the model is made is a question some-
what in dispute, and the l^est way to arrive at any
conclusion as to the superiority of one over others
is to analyze, step by step, the methods employed
in taking the cast, of which there are two in com-
mon use, and compare the advantages alleged by
the supporters of each.
By one method the model is made with the foot
at rest. i. e.. without being subjected to muscular
action or weight bearing ; by the other it is made
with the foot approaching, if not quite in, the state
of active support.
If the first method is used. i. e., a model taken
with the foot at rest, the patient is seated with the
leg flexed and the thigh rotated outward, so that,
if the foot is put upon a chair in front of him, it will
rest upon its outer torder and external malleolus.
Plaster is then mixed to the proper consistencv and
poured upon a paper which is placed upon the chair,
and the foot is allowed to sink into it until about
one half of its surface is covered. As soon as the
plaster sets, its upper margin is smeared with a
lubricant and more plaster is spread over the re-
maining exposed part of the foot. This portion is
then allowed to harden, after which it is removed,
the foot taken out, the two parts placed in appo-
sition again and bound together with a bandage.
This mould, well oiled inside, is now filled with
plaster porridge, and, as soon as it sets, the outside
is re^noved and the model of the foot is the result.
A cast of the foot by the other method is made
as follows : The patient is seated in a chair which
is of just the right height, so that, when the legs
are flexed to a right angle with the thighs, the foot
will rest easily upon the floor. Some plaster having
been mixed in a shallow pan and placed in front of
the patient, the foot is grasped firmly around the
ankle by one hand and around the toes hy the other
and held in a correct position, while it is pressed
strongly against the bottom of the pan.
The foot is removed as soon as the plaster sets,
and, after lubricating the impression, it is filled with
plaster broth. The following day. or as soon as the
broth has hardened thoroughly, the outside is broken
away with a hammer, leaving the model.
As already stated, either method gives a model
which is inaccurate, and which, in order that a plate
may Ix- constructed from it which will be efficient,
must be carveci with a knife, as the judgment indi-
cates ; but, as these two processes are the best that
have so far been devised, it is necessar}' to choose
between the two.
It is asserted by those who use the model made
with the foot at rest that the arch is held by gravity
in the best position obtainable, and that therefore it
is the better method. If it is the purpose to get a
cast of the foot with the arch placed apparently in
the highest position possible, regardless of the
normal when in use, this would undoubtedly be the
method of choice. The arch in the normal foot,
however, assumes a shape, when at rest, very differ-
ent from that when it is used as a support, therefore
the normal position of the arch with the foot at
rest is not the normal position of it as a support,
consequently a plate made from such a jnodel will
not even allow the arch of the foot to assume a
normal position when in use.
Another disadvantage of this method is this, that
the ball of the. foot is quite likely to be on a diflferent
plane from that of the heel, and the arch is thereby
twisted.
^^'hen the model is taken with the arch held in the
normal position of support, and is subjected to
pressure similar to that when the foot is in use,
these difficulties are overcome and the cast approxi-
mates more closely the shape of a normal foot in
weight bearing.
It would seem reasonable to suppose, then, if a
plate is to be constructed for the purpose of correct-
ing the deformitv of weak foot, whether by sugges-
tion through its presence to the patient to hold the
foot in the correct position, or by direct pressure,
that it should be shaped over a model of that foot
taken in 3 normal position, and subjected to a pres-
sure like that of a normal foot when in use, rather
than from a model of the same foot at rest, with
the arch entirely changed, and in a position where
it cannot be supported.
98o
NEPPER: MUCOMEMBRANOUS ENTEROCOLITIS.
[New York
Medical Journal.
The usual objection raised to taking a cast by
holding the foot is this, that it cannot be held in a
normal position, and, therefore, that it is most inac-
curate. It is certainly not so difficult a procedure
to hold a foot in a normal position in a pan of
plaster as it is to hold a foot in a normal or over-
corrected position while it is being fixed by plaster
of Paris bandages, after breaking up adhesions of
the joints.
If the model of the foot is correctly taken and
afterward properly carved, a plate made over it
should hold the foot in a natural position, or in the
same position as the nonnal foot is held, when it is
used as a support, and the best test of the value of
a plate in the condition of weak foot is this, that,
when it is placed under the arch, it makes very little
if any pressure when the patient is standing, as
long as he is able to hold the foot in a normal posi-
tion, and none whatever when he is walking, but
does support the arch in normal position unaided
by a boot when the patient fails to do so by muscular
action.
The changes which are made by the knife should
commence with the impression before it is filled.
The skeleton shows that the first metatarsal bone
is freely movable and placed on a lower plane than
the second, therefore the impression should be cut
out along that part of it which corresponds to that
bone, for, by so doing, it will be possible to trim the
inner border of the cast more easily, so that it will
be on a lower plane than the middle. The model
should also be carved to correspond to the shape of
the skeletal foot, and the lines for the support
marked on its surface as follows : Beginning on the
inner side of the heel just in front of the tuberosities
of the calcaneum, a line is drawn curving backward
to a point near the outer margin of the cast, thence
along the outer border of the sole to 'a point just
behind the head of the fifth metatarsal bone, thence
over the ball of the foot to a point beneath the head
of the first metatarsal bone, thence backward beneath
this bone to the scaphoid where it curves inward
and upward for a short distance, then backward
and downward to the first mentioned point under
the heel (Fig. 30).
The plate, when made, should resemble in shape
the section of a dome, with the exception of the
slight extension which controls the scaphoid bone
(Fig- 30- .
If a plate is made over such a model as described
and along the lines indicated, it will be found upon
trial that the foot rests easily upon it without the
slightest tendency to slip from it, and this without
the aid of a shoe; that anything but a normal step
cannot be taken ; that the foot is held in the cor-
rected position, when used as a support, either
through muscular action, which is the most agree-
able method for the patient, and is maintained as
long as he is able, or, as soon as relaxation takes
place, by direct pressure (Fig. 32).
The whole action of such a support may be
summed up as follows : Whether the foot is used in
walking, or as a support in standing, it is not only
prevented from assuming anything but a normal
position, but there is a decided tendency for the
foot to assume this normal position through mu.'?-
cular effort.
MUCOMEMBRANOUS ENTEROCOLITIS. ITS
CAUSES AND MECHANISM.
By H. Nepper, M. D.,
Paris, France,
Assistant at the Department of Physiology-. Hautes Etudes, Coliege
de France.
The proper definition of mucomembranous en-
terocolitis is : A symptomatic complex of very slow
and chronic evolution characterized by constipation,
mucomembranous secretions, and pains. These
pains are of variable intensity and localization, and
are of no great import in the aetiology of the dis-
ease; they only indicate that the intestines are in a
state of irritation ; they are common to numerous
affections. Therefore only two signs remain of the
three symptoms : Faecal stasis and the presence of
coagulated mucus in the stools.
It is not my intention to speak of the symptoma-
tology of this disease ; I only wish to throw more
light upon its pathology by reporting the results of
some new experiments.
Aitiology — I shall simply enumerate the pre-
disposing causes, as they are usually stated :
Arthritis, both hereditary nervous and neuro-
arthritis ; social position ; adult age ; female sex, etc.
As occasional causes are cited : Defective alimenta-
tion ; sedentary life and its usual consequence, con-
stipation, etc. Other causes given are: Haemor-
rhoids ; intestinal polyps ; abdominal tumors ; utero-
ovarian lesions ; floating kidney ; and enteroptosis.
Finally, not to mention such causes as a chronic
cold, we must include cases where chronic colitis
was the sequela to acute colitis, dysentery, peri-
tonitis, and typhoid fever.
Pathology. — Persistency of the symptoms, pains,
faecal stasis, and mucomembranous stools does not
imply, or rather did not imply, a specific process to
be attributed to a casual agent which was always
the same. Different theories, therefore, have been
put forward which I shall shortly state: i. The
theory of infection ; superficial infection of the mu-
cous membrane attributed to the Bacillus coli, Ba-
cillus Huoresccns. Proteus vulgaris, and the Dip-
lococcus of Thicrcclin. the virulence of which is
very much increased b\- faecal stasis and mucous
oversecretion. 2. The theory based on nervousness.
The phenomenon of colitis is said to be due to pure-
ly nervous troubles. 3. ]Mathieu believes it to be a
reflex action of a short or a long circle, and at the
same time a superficial inflammation with mucous
oversecretion and cellular desquamation. 4. Final-
ly we must remember the theory of enteroptosis
proposed by Glenard, and the theory of Robin, who
declared it to be a syndrome subordinate to a gas-
trohyperassthetic condition.
I cite these theories without discussing them,
and wish to merely state that "although each of
these pathogenic theories enables us to explain a cer-
tain number of cases, we cannot any longer say that
a single one among them explains all these cases,
nor can we say that all neurasthenics, that everybody
whose intestinal nuicous membrane is the seat of
scarifying noxious substances, or that all women af-
fected with one of the many symptoms of ptoses or
with any other uterus or annexa lesions, are suf-
fering from mucomembranous enterocolitis." I.
furthermore, wish to call attention to the follow-
May 23. iQoS.J
XEPPER: MUCOMEMBRJXOUS EXTEROCOLITIS.
ing particularly : All the causes which were given
have one common point of action, all theories pro-
posed have the same basis, that is an action upon
the liver. Every noxious influence, indeed, on the
gastrointestinal apparatus reacts upon the liver. Let
us remember the vasoconstriction reflexes exerted
upon the liver by excitation of the general sensory
nerves, the visceral, the distribution of these reflexes,
their mechanical effects, their intervention, when
poisons of whatever origin pass through the liver,
and finally the analogous mechanism of psychic in-
fluences. All these causes have a tendency to di-
minish the functions of the hepatic gland.
After this remark let me close the discussion of
the various theories and again consider tlie two
principal symptoms : The fjecal stasis, and evacua-
tion of mucus ; and let us find out their causes.
First Part. — Evacuation of mucus. This excre-
tion must be preceded by two phenomena : i . secre-
tion and, 2. coagulation.
a. Secretion of mucus. — This secretion, or rather
oversecretion (because it is evident even when only
superficially examined), is dependent on the sym-
pathetic excitement which may result from many
causes : irritation through the presence of a f?ecal
mass ; elimination of toxic substances ; nephroptosis :
hepatoptosis : enteroptosis. which is very often over-
looked : salpingitis : psychical or any other cause.
It is. therefore, onlv a phenomenon of a small re-
flex.
But the fact of a mucous secretion does not nec-
essarily imply excretion, and, what is still more,
coagulation. "
b. Excretion of Mucus. — Xormally the mucus
necessary to digestion is secreted in great abun-
dance throughout the intestinal canal, and is then
absorbed in the large intestine, with the exception
of some small amount, which is found mixed in the
matter which escapes absorption. Pathologically
the excretion of the mucus is easily explained when
the digestive passage is much abbreviated, as is the
case in dysentery in the tropical countries, in which
disease the mucus has not the time to be absorbed.
On the contrary, in all cases of mucomembranous
enterocolitis, where the faecal stasis is the main char-
acteristic sign, the digestion is always slackened and
slower than in the average normal cases, according
to the case itself. The oft'hand explanation of
excretion in a case of dysentery is therefore of not
much account, and to be logical we must conclude
that the mucus is the better and the more complete-
ly absorbed the longer the faecal stasis lasts.
In order to prove the truth of this reasoning I
have made a number of experiments, of which the
following is typical. Take a healthy dog and make
sure that the animal has a normal digestion. To do
this let him swallow a colored powder (carbon or
carmine) and ascertain that his faeces do not con-
tain any mucus, coagulated or not. Some particles
of hyaline mucus are always found in the normal
stool. Make, then, a permanent fistula on a line
with the ileum as near as possible to the caecum lat-
erally, which opening will not interrupt the descent
of the faeces and will allow at any time the taking
out of the intestinal contents.' After the recovery
'The fistula is to be made with the help of the small cannula of
Laborde, fastened to skin outside of the wound on a level with a
special buttonhole according to the method described by Pawlow.
of the dog his digestion is again examined, and his
faeces are analyzed in order to ascertain whether
the intestines functionate normally. Through the
fistule a portion of the intestinal contents is taken
out at different times, when numerous particles of
hyaline mucus, more or less colored by the bile, will
be found. These particles are later absorbed in the
large intestines, as they are no longer found in the
stool. We then cause in this normal animal an abun-
dant oversecretion of mucus, to see what will be the
result. To accomplish this the dog was made to
swallow through a catheter a solution of silver ni-
trate. As soon as this solution comes in contact
with the mucous membrane it produces a great over-
production of the mucus. After five or ten minutes
^ ~.
i
4*. '
Jut let f:it^iti-e.nicn.is ci^^ J^U-'t-^' ^:^u
this secretion is to be neutralized by a physiological
salt solution. The mass taken from the fistule will
now show large mucous masses, the quantity of
which is much greater than that found in the nor-
mal mucus. If the treatment has been too violent
the animal will be attacked by a profuse diarrhoea
and discharge the mucus. When these phenomena
of reaction are missing, that is to say, when the
passage is not considerably accelerated, the exam-
ination of the faeces will not reveal more mucus
than under normal conditions.
As a result of this experiment we can suppose
that it is possible that there will be an oversecretion
of mucus when the passage is not accelerated, such
as is the case in mucomembranous colitis.
It may, therefore, be concluded that all pathogenic
theories, based solely on oversecretion of the mucus,
are at least incomplete. They do not give a satis-
982
y UPPER: MUCOMEMBRANOUS ENTEROCOLITIS.
[New York
Medical Journal.
factory explanation of the excretion, and do not ex-
plain coagulation.
c. Coagulation. — \\\\\ does mucus coagulat
Mathieu has advanced a very ingenious theory. He
says that after exudation from the mucus layer in
the intestine a portion of the liquid may be reab-
sorbed and the consistency of the mucus increase in
proportion to the reabsorption. This is the theory
of desiccation. But what is the reason for the elect-
ive reabsorption of the watery portion of the mucus?
Why does deh} dration take place instead of total re-
absorption, as is the case in normal condition and
was noted in our experiments? It must be surmised
that the mucus undergoes a change of phy sical con-
dition or of chemical constitution, which makes it
unfit for absorption, however large the quantity of
excretive mucus may be, and in whatever intestinal
segment the absorption takes place. Under this
condition the mechanism of desiccation would ap-
pear.
Experiments have corroborated this hypothesis.
Professor Roger"' has shown the coagulabilitv of
certain intestinal extracts wIku in contact with mu-
cus. This phenomenon can be reproduced /// I'itrn.
Roger attributes this action to a special ferment
which he calls mucinasc. I have myself pro-
duced this action of coagulation in vitro, without
differing in opinion as to the specific nature of this
action.'' I too have found this specific action in
the faeces of patients evidently afifected with entero-
colitis, and in such patients only. Conscqucntlv it
is both necessary and ^iiftici<.-nt fnr the mucus to
have been suljmitted to this action, so lliat it ma\- be
excreted ; desiccation takes place only to increase
its consistency, and overescretion to increase the
quantity. These latter two are only secondary phe-
nomena, coagulation is the primary.
But there exists in the intestine a liquid which
prevents coagulation. This is the bile. Dr. Roger
^Cours (le pathologic expcrimentale et comparee. Premiere Legon:
La coagulation, jocicti- de biologic, November 14, 1906, pp. 423,
424.
»H. Nepper — i ° — Pathogenic et trailement dc la colite muco-mein-
braneuse, 1907. 2° — Essai sur la pathogenic de I'enterite muco-
membraneuse. Gazette des hopitaux No. 70, June 20, 1^07. H. Nep-
per ct Uiva — Recherches sur les substances anticoagulantes dc la
bile dans leurs rapports avec la colite muco-niembraneuse et son
trailement. Sociitc de biologic, January 26, 1906, pp. 143, 144.
Idem — Recherches de la mucinasc dans les matieres fccales. 5or -
etc dc biologic, I'ebruary 17, 1906, p. 361.
has observed it and we also have proved its action by
numerous experiments. "The presence of bile always
delays coagulation and prevents it absolutely when
present in large enough proportion. This action
takes place vitro and can be proved in all evacu-
ations."
\\'& have thus ascertained two new facts of great
importance: I, The coagulative power of a tes-
tinal extracts ; and, 2, the anticoagulative action of
the bile. Summarizing shortly the results of our
labor, we can deduce the following conclusions from
our experiments: i. The mucus in grains of hyalin
changes into vellow from the bile, collected from an
ileac fistula, is entirely absorbable, and is proof
against coagulative action. This fact can now be
easil)- understood when we take into consideration
the anticoagulative action of the bile. 2. Over-
secretion does not necessitate excretion if the
digestive passage is not very much shortened.
It is necessary and sufficient that the mucus
should become coagulated in order to be also
excreted. Oversecretion and desiccation are
therefore secondary phenomena. It is un-
necessary to insist upon the importance of the
anticoagulative action of the bile.
Thus the symptoms indicating mucomem-
branous evacuation may now be well under-
stood. It is the consequence of a coagulation
of mucus which can no longer be reabsorbed.
Whatever be the duration of the digestive
passage it will be necessarily rejected.
Let us now look at the second symptom :
Delayed digestive passage of constipation,
which, as well as mucomembranous evacua-
tion, is the primary symptom, so much so in-
deed that it was rightly said that to make it
disappear would mean to cure the mucomembranous
enterocolitis.
I certainly do not take into consideration in
this definition any delay of evacuation due to some
obstacle situated more or less higher up, such as a
tumor in the intestine or a pressure by some other
organ. I consider exclusively what may be called
essential constipation.
Second Part. — Constipation. Whether we accept
tlie opinion of some authors that constipation is due
to atony ; or the opinion of others that it is due to a
more or less local spasm ; or the opinion of a great
number of authors that it is caused by the combined
action of spasm and atonv in elifferent segments, the
([uestion remains the same, because atony and spasm
are only signs of troubled intestinal activity, and do
not at all explain the cause of trouble in the action
of peristalsis. Why is this peristalsis deranged?
What are the causes of spasm and atony ? This is
the question in its true light.
I have often asked myself whether there does
not exist a correlation- between the causes of coagu-
lation and those of constipation, or, to be more defi-
nite, whether the anticoagulative function of the
bile is not accoiuijanied by some motor excitation
upon the intestinal fibre. If this hypothesis should
prove correct constipation and coagulation of the
mucus would be ])henomena of the same origin, that
is, of a diminished biliary secretion, coagulation
needing a second factor always, the presence of a
coagulatory stinutlant.
Ill
liy'.' Sc.i. 'B'Yc
May 23, 1908.]
XEPPER: MUCOMEMBRAXOUS EXTEROCOEITIS.
Let us now examine upon what basis this hypoth-
esis might be founded. 'Thus, for instance, consti-
pation would usually occur when the bile did not
flow into the intestine. On the other hand (Leyden
and Schiilein), digestion of biliary salts would pro-
duce diarrhoea and vomiting."*
These arguments, says l5astre, cannot be admit-
ted as having been proved. Eckard tries to solve the
question by experiments following the lead of Fu-
bini and Luzzati.^ The results were rather diver-
gent and did not prove much. The technique, ac-
cording to Eckard, left much to be desired. As I
also desired to solve this question I made some
researches with Mr. Hallion : first, whether the bile
exerts some motor exciting action upon the intes-
tinal fibres in general ; and, second, what variation
our experiments would show when made in differ-
ent segments when bile would be introduced into a
vein or would be brought into direct contact with
the intestinal mucus membrane.
I shall not report the technique of our experi-
ments ; it may be sufficient to say that an ampulla
was introduced into the intestine, which transmitted
the diflferent pressure to a registering drum of
Marey by the help of a water manometer. The de-
tails are described somewhere else." I shall only
say here that our researches were made in different
seginents of the intestinal canal, the conclusions of
which we shall publish later. I shall reproduce
here only a part of the tracing, which has already
been published. Fig. i represents the evolution of
intestinal peristalsis in the duodenum during f.irtv-
seven minutes with two interruptions, the first of
one minute, the second of seven minutes. It can be
seen that before the injection the intestinal contrac-
tions took place moderately often around a middle
tonus which was rather constant ; this was especially
the case during a long period before the tracing was
done, about three hours. An injection
was slowly made into the saphena, first
three c.c. and later seven c.c. of bile.
At first a marked degree of the peri-
stalsis and a slacking of the middle
tonus was observed. Soon after this
the contractions were seen to become
much longer. At the same time the
tonus was much increased. A hori-
zontal line shows the result.
Fig. 2 shows the same motor effect
produced by direct injection of bile
into the duodenum. Fig. 3 shows the local ef-
fects of the bile injection into the rectum.
The number of respirations is noted, and also
the time in seconds. During the first three
hours of this experiment no rectal contraction nor
defcecation is noted. Then 10 c.c. of bile are in-
jected into the rectum. After four minutes repeat-
ed defecation was noted during the following eight
minutes. The experiment was stopped for ten min-
utes, but during this period, which is partly repre-
sented in the left side in Fig. 3. a single rotation (a.
b, c) of the anal region was sufficient to produce
immediately a contraction of the perinseum alto-
gether similar to the one that accompanied the move-
*Article on Bile. Dictionnaire de physiologie, 1897.
Kentralblatt fiir Physiologie, No. 49, 1899.
'Comptes rendiis des seances de la Societe de biologic, July 26 and
27, 1907.
ments of defaecation represented in the tracing on
the right side of the figure.
These facts may well be compared with the re-r
suits of numerous experiments which I have made
on man. \Mien 50 c.c. of bile was introduced
through a catheter into the rectum about 15 centi-
metres above the anus one will always obtain de-
faecation in cases of the most stubborn constipa-
tion. After five minutes the patient usually feels
the imperious necessity to go to stool, sometimes re-
sulting in a colicky passage, which stops directly
after the expulsion of the fceces. It is therefore
evident that bile has a motory effect upon the rec-
tum, which can be and is utilized in therapeutics.
Following are the conclusions which we have
drawn from the experiment :
1. The bile when in contact with the mucus of
the intestine exercises locally a motory influence
upon the small intestine as well as in the rectum.
2. Introduced into the blood circulation, it gives
the same result.
3. The later action seems at least partly the result
of an exaggeration of bile secretion, due to the
cholagogical influence of the injected bile.
The experiments, therefore, prove absolutely an
indefinite action of the bile in the intestine, of its
exciting motor influence. Any decrease, therefore,
of biliary secretion will effectually diminish the
value of intestinal peristalsis — that is, it will length-
en the duration of the digestive passage, or, in other
words, bring about constipation, which will last un-
til this secretion is reestablished. One will under-
stand now why from the beginning we observe that
all of the causes taken into consideration to explain
the aetiology of enterocolitis point to one common
origin, action upon the liver. Intoxication, troubled
digestion, etc.. lead to overworking of the liver, re-
sulting into a tiring cut of the organ, which means
Fig. 3
a decrease of biliary secretion, thus producing en-
terocolitis.
Therefore, if I summarize the experiments re-
ported in this article I find that : To be constipated
means to have an insufficient biliary secretion, the re-
sult of innumerable causes. Suffering from entero-
colitis means constipation and evacuation of co-
agulated mucus — that is, to have an insufficient se-
cretion of bile. Consequently constipation and
enterocolitis have the same origin. They are both
varieties of the same phenomena, two states of the
same affection, enterocolitis differing from constipa-
tion only by the addition of a second factor, coagu-
latory power. The mechanism of enterocolitis and
constipation, therefore, seems to be well established.
As soon as the liver is overworked on account of
whatever cause (and this will happen, especially in
patients who easily suffer from oversecretion or
984
FREUDENTHAL: BRONCHOSCOPY.
[New York
Medical TouRNAt.
arthritis, in patients who have a sedentary occupa-
tion), bihary secretion will decrease, and, according
to the cases, result either in enterocolitis or in con-
stipation. When this becomes later chronic muco-
membranous evacuation will take place, possibly
complicated by all kinds of infections, either in the
liver ( angeiocholitis, cholecystitis, gallstones, or in
the intestines, appendicitis, etc.).
In certain cases mucomembranous evacuation
produces the emission of intestinal sand. In the
Biochemical Journal, II, 9, August 20, 1907, Owen
T. Williams shows that this sand contains eighty
per cent, of acids saturated with fat (stearitin and
palmitin), which form, so to say, the nucleus of these
sand grains. This phenomenon only becomes pos-
sible by diminished absorption of the fatty substance
— that is, by decreased biliary function. This is an
addition to the proof which we have furnished in
the course of this paper.
Finally the treatment which I have instituted
and described in detail elsewhere is based on these
experiments, and has given me very good results.
A very strict diet is to be prescribed after a trial
meal, which makes it possible to recognize the food
which is most easily digested, and to discover pan-
creatic oversecretion, which is often associated with
enteritis. The treatment consists in prescribing a
biliary extract, to be administered as described, part-
ly through the mouth and partly through the rec-
tum. My technique has enabled me to obtain the
best results where other treatments have failed.
With these facts before us I think I have a
right to formulate the following theory :
1. The false membrane is the agent which in-
creases coagulative power and diminishes biliary
secretion, which permits its beneficial function.
2. Mucomembranous enterocolitis is the result of
biliary oversecretion.
A PLEA FOR SYSTEMATIC USE OF BRONCHO-
SCOPY IN OUR ROUTINE WORK.
With Description of a Modified Bronchoscope.
By Wolff Freudenthal, M. D.,
New York.
At the time when Killian published his method
for the direct examination of the trachea and bron-
chi, it was mainly with the idea of utilizing it for
the removal of foreign bodies from these parts.
This method has since been extensively employed
and with excellent results, but as we are aware, it
still is in its infancy. The introduction of the
bronchoscope is not only difificult to learn and diffi-
cult to execute, but it is troublesome to the patient.
Often a good deal of pain is caused and general
anaesthesia has to be resorted to in quite a number
of instances. No one doubts the justifiability for
our taking all this trouble, since in cases of foreign
bcKlies there is a question of life and death, and
anv procedure is permissible that will save the pa-
tient.
But it appears to me that a method that enables
us to inspect these parts should be utilized for other
purposes as well and in a more systematic manner.
Parenthetically it may be added that bronchoscopy,
as might be expected, has been employed for the
diagnosis of tumors and aneurysms in or near the
trachea and bronchi, but of course these cases are
of rare occurrence. The field for investigations is
much larger. Some work has been done already in
other directions, as for example by A. Loewy and the
late H. von Schroetter in their studies of the cir-
culation of the blood through the bronchoscope.
But that is a mere beginning, and it would seem
that a great deal more can and will be accomplished.
First of all idiopathic diseases of the lower air pas-
sages should be studied /;/ vivo, their direct treat-
ment iattempted, etc. At first sight it would appear
that these affections are rare. But if we look for
them systematically, most likely the same will hap-
pen as with the laryngoscope ; many a hitherto ob-
scure afifection will be elucidated. Hence system-
atic examinations of the trachea and bronchi should
be made just as is customary in the larynx. But
how ?
With the instrumentarium at our disposal this is
well nigh impossible. Take for example the "sep-
arable or slide speculum" of Chevalier Jackson. It
is a strong instrument which enables the operator
to get a firm grasp and control over his patient, and
Jackson is justified in feeling proud of it. But for
routine work any such contrivance is out of the
question. Besides there are other drawbacks which
render bronchoscopy difficult and sometimes im-
possible, as a too fleshy tongue, large teeth, narrow-
ness of the fauces, inability to sufficiently separate
tlie jaws, a very low position of the larynx, etc.
Last but not least, I agree with von Schroetter. that
the dexterity and technical ability of the operator
himself play the most important role.
It is with the aim of overcoming at least some of
these difficulties that the "jointed bronchoscope"
has been devised by the writer.
From a historical point of view it must be men-
tioned that flexible instruments for examination of
the oesophagus were devised by Kelling. of Dresden.
Kelling's ingenious oesophagoscope was introduced,
bent, and afterward straightened by a scissor like
mechanism. Kolliker modified this by using an
elastic tube provided with a stylet (mandrin).
After the tube was in position he removed the stylet
and introduced in place of it a metallic tube. These
instruments for the oesophagus have nothing in com-
mon with my bronchoscope, but are mentioned here
for the sake of completeness.
When beginning my experiments in broncho-
scopy, it occurred to me that the bronchoscope
might be introduced m the same way as any laryn-
geal instrument, viz., with the aid of the laryngeal
mirror. As that could not be done with a straight
instrument, one capable of being bent had to be de-
vised. The flexible (csophagoscopes did not seem
suitable for this purpose, and a jointed instrument
was contrived. This bronchoscope consists of two
parts of about equal length, the distal portion (b. c)
ijeing narrower in order to fit in the other. The
joint (c) is exactly as shown in the cut. leaving
an opening in the upper portion when the tube is
bent. The patient is thereby enabled to breathe
through it even when it is at a right angle. There
is no openin<r at c when the tube is straightened.
May 23, igo8.]
KORSHET: MALNUTRITION.
985
It soon was noticed that the distal end (b, c) was
too long to be of much service, and consequently
it was gradually shortened so that its length in the
latest mstrument is two and one half inches.
Afterward another question came up. viz., that
of proper illumination. Different sources of light
have been utilized. The first instruments for auto-
scopy were provided with Casper's electroscope, as
used by him for cystoscopy. Rosenheim, of Ber-
lin, utilized it for cesophagoscopy, and Kirstein for
bronchoscopy. Better, however, was the headlight of
Kirstein or Killian. H. von Schroetter used a min-
iature osmium lamp and endeavored to place the light
where it is wanted, viz., at the distal end. He availed
himself of the well known phenomenon of the con-
duction of light m a glass rod. If a light is placed
at one end of a glass rod it will shine with the same
intensity at the other end, this being due to its con-
duction through the rod. Instead of the latter von
Schroetter used a glass tube which was introduced
into the bronchus. The inner surface of this tube
is blackened so that one looking into it sees only
the illuminated distant end.
I have not tried von Schroetter's method, but
have emploved Kirstein's and Killian's headlight. I
"
I
Freudenthal's modified bronchoscope.
must confess, however, that there are difificulties at-
tending the use of these headlights which I could
not overcome. First it is not always easy to focus
the lamp correctly. Secondly and of more import-
ance is the fact that even when the light is adjusted
properly the distal end is not satisfactorily illumin-
ated. For that reason the light carrier first used
b}' Max Einhorn for the cesophagoscope and then
adopted by Chevalier Jackson for the bronchoscope
was added. After the bronchoscope was in sitn.lh^
light carrier was inserted. But this prolonged the
whole procedure and was therefore discarded as
unsatisfactory for most cases. The next step was
the construction of a flexible light carrier instead
of the rigid one. This was accomplished in such
manner that the flexible part of the light carrier,
viz., the cable (d) fitted into the section (c) so that
it was easily bent during manipulations of the in-
strument, while at the same time it was sufficiently
rigid to be readily inserted.
The mode of procedure is as follows : The tube
is grasped, not by the handle, but by the longer end
(a, c) just like a penholder. The patient pulls
down his tongue. With the aid of a laryngeal mir-
ror, the light of the bronchoscope at b furnishing
the illumination, the instrument is introduced like
in any other intralaryngeal procedure. As soon as
it is in the larynx, the tube is straightened (see
dotted lines in figure), and we then proceed as
usual.
One of the important points in bronchoscopy is
the local anaesthesia. With a spray of cocaine
(four per cent.) the epiglottis, base of the tongue,
and the whole introitus of the larynx are anaesthet-
ized. After this a swab moistened in a ten to twen-
ty per cent, solution of cocaine is applied to the
lower parts. In order to do away with that dis-
agreeable feeling of thickness that is so objection-
able to many patients after the use of cocaine I
have lately employed alypin (twenty to thirty per
cent.) in a number of cases. The result was that
the patients did not experience the same degree of
unpleasant sensation in the throat.
\\'hile some colleagues, who have watched the in-
troduction of the tube, were surprised at the ease
with which it was done, two objections were raised.
Firstly it was suggested that while straightening
the tube the mucous membrane might be caught
at the upper end of the joint (c). Thus far this
has never happened, and I believe we may eliminate
its probability. The second objection was that the
distal end (b, c) might become bent during its in-
troduction. If that should happen it would be no-
ticed immediately, because the light would go out.
By drawing the tube up a short distance, or turning
the handle to one side or the other, this has been
always corrected in a few seconds. But should it
a happen in an exceptional case
rry that one is unsuccessful in
\ straightening the tube and
\ A\i* ^.^ns restoring the light, the
\ flexible light carrier should be
\\\ withdrawn and the rigid one
V\\ inserted,
f \ \ The writer has done con-
\J siderable work with this im-
proved bronchoscope, especially in cases of tuber-
culosis pulmonum, but is not yet prepared to pub-
lish the details of his experience.
It is my belief that this modification of Killian's
instrument will render bronchoscopy much easier
than before. As proof of how much its application
is facilitated it may be noted that we were able to
introduce the jointed bronchoscope in a case of bi-
lateral recurrent paralysis with the vocal cords in
the so called cadaveric position.
Whatever may be the experience of others, let us
at least try to extend the scope of the bronchoscope
to other lines of investigation.
1003 Madison Avenue.
AIALNUTRITIOX.
By Morris Korshet, M. D.,
Baltimore, Yvd.,
Late House Physician and Surgeon. St. Francis Hospital, Tren-
ton, N. J.
The Burlingham report, compiled by a board of
educators who investigated the health of the school
children in many of our large cities, states that out
of six hundred thousand school children in the city
of New York, four hundred and sixty-five thousand
eight hundred were physically defective. Of this
number two hundred and thirty thousand eight hun-
dred sufTered from defective breathing, one hundred
and eighty-seven thousand from enlarged glands, and
forty-eight thousand from malnutrition. The pro-
portion is as follows : Enlarged glands, 48.8 per
986
KORSHET: MALNUTRITION.
[New York
Medical Journal.
cent. ; bad teeth, 72.4 per cent. ; malnutrition, 12 per
cent. ; eye defects. 14.4 per cent. ; nose troubles, 27.7
per cent. ; and throat troubles, 29.9 per cent. Were
this percentage maintained throughout the United
States, since rural districts exhibit physical defects
similar to those of the urban, it would mean that
there are one million four hundred and fortv thou-
sand ill nourished children, five million six hundred
and fifteen thousand with enlarged glands, and six
million nine hundred and twentv-fivc thousand with
defective breathing — a total of thirteen million nine
hundred and eighty thousand children whose phys-
ical defects not only retard their mental develop-
ment but handicap them in the struggle for existence
with those whom the chance of birth favored with
vigorous constitutions.
As they stand, these figures are sufificiently alarm-
ing; but reduced to a scientific analysis they expose
a state of physical deterioration that is simply ap-
palling. Unfortunately the report, like all reports
emanating from charitable bureaus, terrifies but does
not teach. In such reports the symptoms of the so-
cial disease are so skillfully classified that the disease
is not only obscured, but the symptoms themselves
become of interest only to physicians or criminolo-
gists. To the masses, a statistical display of this
kind merely awakens the suspicion that the chil-
dren's eyes are weak as a result of excessive
study, or their teeth bad because of overindulgence
in sweets. Ami the children are taken to an oculist
to have their eyes tested, or to a dentist to have their
teeth repaired, while the underlying causative con-
dition is entirely overlooked.
The laity and many members of the medical pro-
fession fail to grasp the simple fact that the eyes,
ears, nose, hmgs — in short, all organs of the body —
act primaril}- for the benefit of the entire body and
only secondarily do they function for their individual .
development. Hence, an injury or disease of any
organ must disturb the entire system, and, converse-
ly, an injury or disease of the system afifects the in-
dividual organs, particularly the delicate organs of
special sen^t.• which recjuirc a large and varied
amount of nutriment for their maintenance and
growth.
The basis of life is nutrition. All living things,
from the simple unicellular amoeba to the complex
specialized organism — man — require nutriment in
some form or other. Food the tissue builder, air
the energy supplier, and sunshine that warms and
freshens germinating life into full bloom, are the
nutritive trio without which all life on this planet
would cease. A disturbance in the ([uantity or qual-
ity of any of these elements means a disturbance of
life. So long as the human being receives the
proper proportion of these substances he remains
healthy despite the millions of disease producing
bacteria which continually surround him. But let
this nutritive equilibrium be deranged and immedi-
ately some part of the body weakens ; the part, its
resistance lessened, becomes fertile soil for the im-
plantation of germ colonies, and thus nutrition is
further impaired by the diseases generated.
The Burlingham report arranges the pliysical de-
fects into diseases of the nose, throat, eyes, teeth, and
glands, but attributes to malnutrition only twelve per
cent, of the cases. The actual fact is that malnutri-
tion is the direct cause and the various diseases
specified are only symptoms of the poorly nourished
condition, just as fever, coated tongue, nose bleed,
vomiting, and purging are symptoms of typhoid fe-
ver. ^Malnutrition, the gaunt handmaid of poverty,
hisidiously invades the. body of its victim and, break-
ing down all protective barriers, leaves the body
defenseless to the ravages of disease.
Malnutrition does not begin the moment the child
starts, without any breakfast, to "creep like a snail
unwillingly to school." Its beginnings are at con-
ception, when the cells of an overworked and under-
fed male and female unite ; in utero, when the
mother, beside the drain of gestation, must perform
the arduous labor of a housewife or factory hand ;
and finally, after birth, when it must feed upOn
breast milk lacking nutritive qualities or cows' milk
obtained from tuberculous cattle or adulterated and
laden with poisonous preservatives.
The symptoms of malnutrition are loss of flesh,
delayed dentition, backward muscular development,
nervous excitability, poor circulation, and anjemia.
Enlargement of the lymphatic glands is common,
especially of the neck ; the inflammation of the
glands may start from a slight cold, but the glands
remain enlarged for months after the cold has sub-
sided. The children are seriously aftected, often
fatally, by all acute diseases, and especially suscepti-
ble to acute diseases of the stomach and intestines,
the so called summer complaint. A striking char-
acteristic is their vulnerability ; they "take" every-
thing. The nose, pharynx, and bronchi are easily
attacked by acute catarrhal inflammations which in-
variably become chronic. Thus malnutrition mani-
fests itself locally and generally, and by a process of
tissue starvation leaves the system an easy prey to
most pathological changes known to medicine.
An extreme and frequently fatal degree of mal-
nutrition, seen in the dispensaries of large cities and
especially common in institutions for infants, is
termed marasmus. Literally, it means infantile atro-
phy. The child simply wastes away, death resulting
from some acute disease.
Marasmus is essentially a disease of the poor.
While seen in premature children and in the illegiti-
mate offspring of young girls, the great majority of
cases are due to two things — the food and the sur-
roundings. The disease is rarely, if ever, found in
the country. Here the infant, though poorly fed
and neglected, receives an abundant supply of fresh
air and sunshine, and. as a rule, does well. In the
congested districts of the city, if the infant has an
adequate amount of good breast milk, it continues to
thrive in spite of its pernicious surroundings. But
woe to the infant brought up in a tenement and arti-
ficially fed ! It is doomed to an infancy of an intol-
erable suffering, a childhood of chronic torment, and
a vitiated maturity that will reproduce a race of
physical, mental, and moral defectives.
Overcrowding of infants in institutions is another
important cause of marasmus. In his experience in
four institutions. Dr. L. Emmett Holt, professor of
children's diseases in the College of Physicians and
Surgeons (Columbia University, New York), finds
that more than half the deaths under one year were
diVectly or indirectly from this cause. The deter-
mining factor in the fatal result is marasmus, but
May 23. 1908.]
KORSHET: MALXUTRITIOX.
987
the cause of death is usually reported under some
other name. Though fed by thoroughly scientific
methods, infants, who on admission were chubby
faced and lusty, lose bit by bit, until at the end of
three or four months become mere skeletons, incur-
able cases of marasmus, perishing of some mildly
acute disease such as indigestion or bronchitis, the
intrinsic cause nevertheless being marasmus. With
the very best ventilation, one thousand cubic feet of
air to each human being is absolutely essential to
health. In most institutions for infants only five
hundred cubic feet are allowed, and, in many in-
stances, where too many children are placed in one
ward, they receive considerably less.
The diseases of children that medicine distin-
guishes as due to faulty nutrition are scorbutis and
rachitis. An understanding of the symptomatology
of these diseases^, particularly rachitis, will throw
some light on the origin of many derangements
afflicting the school child and youth, and demonstrate
the absolute necessity of proper food and surround-
ings as the foundation stone for healthy growth and
physical and mental training.
Scorbutis or scurvy is an acute disease due to
some continued dietary error. It is characterized by
spong}-, bleeding gums, swellings and blood erup-
tions about the joints, hjemorrhages from the nose
and other mucous membranes, extreme sensitiveness
to pain, protrusion of the eyeball, pseudoparalysis
of the lower limbs, and marked general deteriora-
tion, with intense anaemia.
The age is an important index in this disease,
^lore than four fifths of the cases occur between
the sixth and fifteenth months and one half between
the seventh and tenth months, showing clearly that
it is a disease of infancy. The disease occasionally
manifests itself in children in evident good health
and excellent surroundings.
The diet is the direct cause of this disease. Many
theories have been advanced for the causation of
scurvy bv the diet, but so far nothing definite is
known, except that there is something lacking in the
food which is required for the nutrition of the body.
One fact that stands out clearly is that breast milk
and cows' milk give the smallest percentage of casts.
The following report of the American Paediatric So-
ciety's collective investigation of infantile scurvy in
1898, embracing 379 cases, reported by 138 ob-
servers, proves conclusively the kind of food that is
at fault:
Previous Food : Breast milk in twelve cases : raw
cows' milk in five cases : ])asteurized milk in twenty
cases ; condensed milk in sixty cases ; sterilized milk
in 107 cases; and proprietary infant foods in 214
cases. This establishes condensed milk, sterilized
milk, and the proprietary infant foods as the chief
causative factors of scurvy. The disproportion be-
tween pasteurized milk (heated at 167° F. for thir-
ty minutes) and sterilized milk (usually heated to
212° F. for one hour) is interesting. The large
number of cases due to sterilized milk confirms the
conclusion that the heating alone was the cause,
since prompt recovery followed the discontinuance
of heating. It also demonstrates the necessity of
properly testing and preparing cows' milk. Scor-
1)utic symptoms disappear rapidly when condensed
milk and the proprietary infant foods are discon-
tinued and good breast milk or properly modified
cows' milk resumed. The addition of "fresh fruit
juices aids recovery very materially.
Rachitis or rickets is a chronic disease of malnu-
trition. The quaint description of this disease by
the celebrated English chaplain, Thomas Fuller
(1608-1661), holds to this day: "There is a disease
of infants called the rickets, wherein the head
waxeth too great and the legs and lower parts wane
too little." The most prominent manifestation of
rickets is extensive, and usually permanent, changes
in the bony structure of the body. The head is ab-
normally large as compared with the face, the skin
is pale and thin, and the child has an old and wise
look far beyond its years. The bones are soft in
spots and the sutures remain open. The r\hs at about
an inch from the breastbone present beaded eleva-
tions known as the "rachitic rosary."' At this point,
also, owing to a falling in of the ribs, vertical and
transverse grooves of the chest are formed. The
breastbone is frequently depressed, producing the
"funnel chest" deformity, or it may be elevated, giv-
ing the "pigeon breast" effect. It is easy to under-
stand how such deformities, impairing the vigor and
vitality of the respiratory organs by compressing
them and restricting their movements, pave the way
for all acute pulmonary diseases, and that most
dreaded of all chronic diseases — tuberculosis. The
ankle and knee joints, by a process of softening in
one spot and overgrowth in another, present the
"bow legs" and "knock knees" so familiar to all.
The spine is sometimes curved inward or to the side,
and the pelvic diameter shortened, rendering labor,
in later life, extremely difficult and dangerous.
Dentition is delayed and difficult, and accompanied
by frequent attacks of indigestion. These attacks,
attended by iinperfect absorption, produce a condi-
tion known as autointoxication (literally, selfpoi-
soning). wherein the system is exposed to all man-
ner of infections from within and without. The
abdomen, protuberant from the persistent gas ac-
cumulation, is stretched tight as a drumhead, mak-
ing the child "pot bellied." An early symptom is
profuse sweating at night, especially of the head.
As a result, colds are easily contracted, and these
infants almost always suffer from some form of
nasal or bronchial catarrh. Rachitic infants are
highl}- susceptible to enlargement of the lymphatic
glands of the neck, enlarged tonsils, and adenoid
growths of the pharynx.
The coexistence of scurvy and rickets in the same
patient, as established by the society's investigation,
adds further proof to their dependence on deficient
nutrition. Of the 340 cases of scurvy, in which this
condition was noted, symptoms of rickets were
present in 152 cases, or 45 per cent. In seventy-two
children the symptoms were reported as slight ; in
sixty-four marked ; and in sixteen not specified. In
fifty of the rachitic patients it was recorded that
the rickets preceded the appearance of scurvy.
Rickets can be traced to two great causes, diet
and surroundings. Children reared on the pro-
prietary infant foods and sweetened condensed milk
generally suffer from rickets. These preparations
contain an excess of sugars and starches, but are
low in fats. This deficiency in fats causes the
rickety condition. Rickets have been produced ex-
988
KORSHET: MALNUTRITION.
[New York
Medical Journal.
perimentally in animals by withholding mother's
milk and feeding them on meats, vegetables, or
starches.
The influence of surroundings is proved by the
fact that rickets occurs principally in children who
live in crowded tenements. A few weeks' change
to the open country, where they can get plenty of
good food, fresh air, and sunshine works marvels
in these children.
The prolonged use of the proprietary infant foods
has so often resulted in scurvy and rickets that there
can be no doubt that they were the active cause.
Dr. Holt's experience, as indeed that of most intel-
ligent physicians, forces the conclusion that the in-
fant foods, as frequently used by the laity and even
the medical profession, are capable of doing and
have done much positive harm. They should only
be used like drugs in diseased conditions when tem-
porary stimulation of the body is required.
Wlien we consider that the practice of maternal
nursing is rapidly diminishing — among the wealthy
because of anxiety to preserve their forms and the
fear of losing a moment in the quest for pleasure,
and among the poor because the mill and factory
call the mother to assist in maintaining a semblance
of the cherished tradition "home," and that these
mothers, rich and poor, find in the proprietary infant
foods cheap and convenient substitutes for nursing
or cows' milk — we can readily realize the vast
amount of physical deterioration that follows in the
wake of such helpless, misguided, and vicious mal-
feeding.
The extreme cases of malnutrition are rarely met
in private practice because of inability to pay for
treatment which must necessarily extend over many
months and even years. It is in the dispensaries
and hospitals of the slum districts of large cities that
the most pitiable cases are seen. Some of them, in
all their squalor and rags, present such pathetic
pictures of abject poverty as to arrest the attention
of physicians and nurses accustomed to such sights
and bored by the helpless sameness of them.
In the Gouverneur Hospital Dispensary for Chil-
dren's Diseases of New York, the records show an
average of fifteen hundred cases a month. Through
the kindness of Dr. Tunick, in charge of this de-
partment, I was permitted during the summer of
1907 to examine three hundred children and to
closely question two hundred mothers. The exam-
ination into the social conditions and maternal hab-
its of the mothers developed the following facts :
Ninety-six lived in three room flats, sixty-two in
four room flats, and the remaining forty-two in five
room flats. These flats were in tenements in the
vicinity of the hospital, and fearfully lacking in
light, ventilation, and bath tubs. With few excep-
tions, the women admitted a lodger or two, some
keeping as high as three and four. One woman
with a severely rachitic child stated that she lived
in five rooms, had seven children, and kept six
lodgers. "What can one do," she naively asked,
"when the wages of one's husband are only six dol-
lars a week, hardly enough to pay for the food of
the family?"
About one half of the women nursed their chil-
dren, while the other half were fed on "baby food"
and "zwieback." Many of the children over one
year old, and some that had been weaned, were per-
mitted to eat at the table with the adults, and one
pale, anaemic little infant of six months was
brought in vigorously sucking a fig !
Fully ninety per .cent, of these children displayed
unmistakable evidences of malnutrition, and, as Dr.
Tunick informed me, this percentage was main-
tained throughout the year. A diagnosis in these
cases is hardly necessary. For purposes of con-
venience, the cases are arranged according to the
seasons. In the winter their sufi'erings are record-
ed as "colds" and in the summer as "indigestion."
These exhibit all degrees of acuteness and intensity,
but the possibility of a permanent cure, without a
radical change in the food and surroundings, is so
remote that they lose even scientific interest.
Besides derangements of the respiratory and di-
gestive tract, the majority of the children were af-
flicted with sore eyes, nasal and pharyngeal growths,
large tonsils, and swollen glands. It was a common
occurrence to meet the same children in the depart-
ments for diseases of the eye, ear, nose, and throat.
For instance, Dr. Grushlaw, in charge of the nose,
throat, and ear department, stated that more than
seventy per cent, of his cases are sent to him
through Dr. Tunick's department, and most of the
new cases must be sent there for general treatment.
And so the vicious circle is maintained. A faulty
supply of the life giving elements, food, air, and
sunshine, produces general diseases, with localized
symptoms in the eye, ear, nose, throat, teeth, and
glands, and a proper investigation into these special
manifestations leads one back to the primal cause —
malnutrition.
xA.s an illustration of the lack of maternal care
among the children of the poor and of the "home
preserving" tendencies of the present social system.
Dr. Tunick instanced the case of an old woman who
visits the dispensary regularly every two weeks with
eight to twelve children, claiming them as grand-
children, greatgrandchildren, or some other rela-
tives. The doctor is certain she is paid five or ten
cents a day to see that the children are taken care
of and receive medical treatment while the mothers
are out at work. He recalls seeing her at other dis-
pensaries in the interim of her visit to the Gouv-
erneur Hospital.
A physically defective child means a mentally de-
fective child. .\ cliild with a half starved weak
body is in no condition to perform the arduous tasks
of the modern classroom. I'liysically and mentally
defective children mean physically and mentally de-
fective men and women, which in turn means that
in one or two generations we will have a nation of
physical, mental, and moral degenerates. It is high
time that we bestir ourselves in behalf of the chil-
dren if we wish to save our race from the fate of
the Gneco-Roman civilizations.
What is the remedy? Unfortunately, medicine
has no answer, for it is as blind to the correction of
social conditions as are the other professions. Med-
icine, like law, which ])unishes the criminal while
crime hatching conditions remain untouched, bends
all its knowledge and skill to the suppression of dis-
eases and their symptoms, while social conditions
breeding disease are completely overlooked.
It is curious to note that the National Association
May 23. .908.1 SLUDER: MECKEL'S GANGLION IN NASAL HEADACHES.
for the Improvement of the Condition of the Poor,
under whose auspices the BurHngham Commission
carried on its investigations, has nothing better to
offer the physically defective children than a "tooth-
brush and a' cake of soap for every child. Which
means that if the negligent poor will only keep their
children's teeth clean and their hands and faces
spotless to delight the aesthetic tastes of certain char-
iably disposed ladies and gentlemen, their empty
stomachs could be entirely forgiven them. In short,
charitable bureaus and associations for "improving"
the poor do everything to soften the shocking fea-
tures of poverty, but absolutely nothing to remove it
entirely.
Modern hypnotism asserts that the hunger and
thirst of subjects can be satisfied, during deep hyp-
nosis, by the suggestion of food and drink. If char-
itable bureaus and associations were aware of this
fact, the perplexing problem of "improving the poor"
would be speedily solved. The establishment of a
class of hypnotism for the suggestion of food and
drink to the underfed school children would make
the children happy and contented, and relieve kind
hearted philanthropists and their agencies of heavy
responsibilities.
Conditions make the man, and only secondaril}-
does man react on his conditions. Social conditions
to-day deny to the laboring classes an opportunity
to procure for themselves and their children proper
food and surroundings, with the result that malnu-
trition swiftly enters to disable and kill. Personal
hvgiene and compulsory medical treatment may cor-
rect certain .physical defects, but not until faulty so-
cial conditions are removed will the basic cause of
these defects be eliminated. A change in social con-
ditions will not only assure to the working classes
an abundance of good food, fresh air, and sun-
shine, thus weeding out the ills of malnutrition, but
make of the physician a public officer working for
the prevention of disease for the general good in
place of an individual business man treating disease
as a means of private gain. Then, and only then,
will the school child, properly fed, clothed, and
housed, be in a fit physical and mental condition to
absorb what it is taught.
In the meantime, the vast number of poorl\- nour-
ished and physically defective children call for im-
mediate ameliorative measures. The city should
provide a wholesome free lunch for all school chil-
dren, and, in cases that require it, shoes and cloth-
ing. It should establish' numerous public play-
grounds and baths with trained gymnastic and
hygienic teachers in charge. A system of compul-
sory calisthenics in the schools, together with periodi-
cal medical examinations for the reparation of physi-
cal defects, should be instituted. Large tracts of
open country outside of the city limits should be set
aside as camping grounds for the children during the
summer. The city should organize milk depots
where properly modified cows' milk could be pro-
cured at small cost. It should also establish airy
and commodious nurseries, with skilled attendants
in charge, where women compelled to work can
leave their children. The health board physicians
should visit the tenements regularly and instruct
mothers in the nursing and feeding of infants and
have full powers to remedy unsanitary conditions.
989
In short, everything should be done, so far as pos-
sible, to obviate the evil effects of malnutrition, but
with the understanding that malnutrition itself is but
an effect, and can only be completely and perma-
nently eradicated when its fundamental cause — our
present social and economic system — is completely
transformed.
819 Park Avexuk.
THE ROLE OF THE SPHEXOPALATIXE (OR
MECKLE'S) GAXGLIOX IX -NASAL
HEADACHES.*
By Greenfield Sluder, 'SI. D.,
St. Louis, Mo.,
(.'linical Professor, Diseases of the Tliroat and Nose, Medical
Department, Washington University.
Occasionally it has been my lot to be consulted by
patients who were in every way healthy and normal,
but who suffered much of the time from headache
which did not follow any of the known rules. It
was irregular as to the time of its appearance, and
irregular as to the part of the head involved. Some-
times it was referred to behind the eyes, sometimes
to the upper jaw in front, and sometimes to the hard
or soft palate. Occasionally the nose was said to
ache in the back, or the teeth were described as sore,
or the pain was referred to the temple and to the
occiput or neck. This headache appeared most ir-
regularly, but was seldom absent for more than a
short time. It sometimes would become severe and
behave as a migraine. Sometimes an indefinite sense
of stiffness was described. These symptoms ap-
peared from day to day, alternating one with the
other, or associated two or three together. On one
occasion I had them all described at once.
^^'ithin the past six months I have seen some high
grade inflammatory troubles in the posterior eth-
moidal and sphenoidal sinuses, which have subsided
and healed, usually within a week or two, but have
left the train of symptoms, as described, in their
wake, and these have continued on more or less in-
definitely. This exceedingly irregular train of symp-
toms cannot be explained on a basis of inflammatorv
troubles in the accessory sinuses.
They seemed to me neuralgic and to have been
excited by the forerunning inflammatory process in
the nose. The coal tar products give transitorv re-
lief.
The position of the sphenopalatine (^Meckel's)
ganglion in such close relation to the accessory
sinuses and the external wall of the nose suggested
the possibility of its involvement secondary to in-
flammations in these parts. Furthermore, the distri-
bution of the nerve processes of this ganglion corre-
sponds closely with man}- of the regions to which
pain is referred by these patients. Sobotta' describes
the sphenopalatine ganglion as follows (Vol. Ill, p.
199) :
The sphenopalatine ganglion is a rounded, triangular
ganglion lying in th.j pterygopalatine fossa close to the
sphenopalatine forainen. It is suspended loosely from the
trunk of the maxillary nerve by the (second and third)
*Read before the Laryngological Section of tiie St. Louis Medical
Society, March 25, 1908.
'Dr. Tohannes Sobotta, Atlas and Te.rtbook of Human Anatomy.
Edited "by J. Playfair McMurrich, A. JI., Ph. D. \V. B. Saunders
& Co., 1907.
990
BRYANT: MIDDLE EAR DEAFNESS.
[New York
Medical Journai
sphenopalatine nerves, which form its sensory root. In
adthtiiin tn this main root it receives a second, the nerve
of t'lR iJti_ rygi lid canal (Vidian nerve), which passes
turon:ali tlu corrc-pcmding canal of the pterygoid process
of tlu splKiKiid and really consists of two nerves usually
very closely united in their course through the canal, one
of which is the motor, the other the sympathetic root of
the ganglion. The motor part of the nerve is the greater
superficial petrosal nerve, a branch of the geniculate gan-
glion (of the facial nerve). It courses through the grove
named after it in the anterior surface of the pyramid of
the temporal bone, then through the sphenopetrosal fissure
(or foramen lacerum), and then it crosses the internal
carotid artery and enters the posterior aperture of the
pterygoid canal. The second component of the nerve is
the sympathetic root of the ganglion and is known as the
deep petrosal nerve. It arises from the internal carotid
plexus and passes from the foramen lacerum to the ptery-
goid canal, in which it unites with the preceding to form
the nerve of the pterygoid canal.
The l-ranchcs of the sphenopalatine ganglion are,
1. Small orliital rami to the orbit, which enter through the
inferior orbital fissure ;iiid supply the smooth musculature
of the orbit and the periorbita. A longer branch unites
with the posterior ethmoidal nerve and helps in the supply
of the mucous membrane and of the sphenoidal sinus.
2. To the nasal cavity: (a) The posterior superior lateral
nasal rami enter through the sphenopalatine foramen and
pass to the mucous membrane of the superior nasal meatus
and of the superior and middle nasal conchas and also to
that of the siilKiioidal sinus and the posterior ethmoidal
cells. A few delicate libres also pass posteriorly to the
uppermost portion of the pharyngonasal cavity, (b) The
posterior superior medial nasal rami also enter through
the sphenopalatine foramen and ramify in the mucous
membrane of the posterior part of the nasal saeptum. A
longer l)r;iin!i known as the nasopalatine ner\c passes ob-
liquely- aci' tlu- nasal sa^ptum from above and behind,
downward and anteriorl>-, to the incisive canal, into which
it sends some slender lilaments which anastomose with the
corresponding nerve of the other side and also with the
terminals of the anterior palatine and superior alveolar
nerves, forming with them a small plexus through which it
takes part in the innervation of the pulp of the upper in-
cisors, (c) The posterior inferior nasal rami, which sup-
ply the posterior part of the lateral wall of the nose, do
not enter through the sphenopalatine foramen but course
with the palatine nerves for a short distance in the ptery-
gopalatine canal. They leave this canal at the middle of its
length through a lateral opening, and ramify in the middle
and especially in the inferior nasal conch.T and in the mid-
dle and inferior meatus, and also in the mucous membrane
of the maxillary sinus. Its branches also anastomose with
the superior dental plexus.
,3. To the palate. The branches from the sphenopalatine
ganglion going to the palate pass along with the descend-
ing palatine artery through tlic ptery,gopalatine canal. In
this they divide into several branches, invested by a com-
mon sheath, these making their exit from the canal through
the palatine foramina. These branches are: (a) The an-
terior palatine nerve, the strongest of the set, which passes
through the anterior palatine foramen and ramibes with
the greater palatine artery in the mucous membrane of the
hard palate, reaching the incisive canal, where it anasto-
moses with the nasopalatine nerve, (b) The middle pala-
tine nerve is much weaker than the preceding and passes
through one of the minor palatine foramina ; it ramifies
in the mucous membrane above the palatine tonsil and
partly in the velum of the palate, (c) The posterior pala-
tine nerve also passes through one of the small palatine
foramina, and in the palatine velum ramifies not only in
the mucous membrane but also in the levator vcli palatini
and musculus uvulre. It, therefore, contains motor fibres
for the muscles, which are supposed to enter the nerves by
way of the great superficial petrosal, originating, that is to
say, from the facial.
The connection of the sphenopalatine ganglion
with the seventh nerve, Sobotta described as fol-
lows :
At the first bend of the facial canal below the hiatus a
small triangular ganglion, the geniculate ganglion, occurs
in the course of the nerve, formed by the intermediate or
nerve of Wrisberg, which from this point onward courses
with the facial nerve. Since the facial nerve, as well as the
canal, makes a rectangular bend at the ganglion, this point
is termed the ( external ) geniculum of the facial nerve.
From the ganglion arises the greater superficial petrosal
nerve which passes to the sphenopalatine ganglion as de-
scribed above. Probably this nerve contains fibres passing
not only from the facial to the maxillary nerve, but also
reversely, and thus carries sensory fibres from the tri-
geminal to (the peripheral part of) the facial; it forms,
therefore, a mutual anastomosis. Also arising from the
geniculate ganglion there is an anastomitic ramus to the
tympanic plexus.
I have found the position of the sphenopalatine
ganglion to vary, sometimes being deeper and some-
times superficial in relation to the external wall oi
the nose ; sometimes in close relation to the apex of
the maxillary sinus : sometimes close to the sphe-
noidal sinus ; sometimes close to the post ethmoidal
labyrinth ; sometimes higher, sometimes lower.
I then began the experiment of anjesthetizing the
ganglion, or at least attempting it, by an applicator
tipped with a very small amount of cotton, such as
would be moistened by one drop of a twenty per
cent, cocaine solution, and placing it just over the
ganglion, that is, as a rule, just posterior to the
posterior tip of the middle turbinate. I found that
for some patients it relieved all the symptoms com-
pletely and invariably. For some others it relieved
all the symptoms except pain in the neck ; for some
it failed completely or helped very little. Where it
succeeded I have thought the ganglion was close to
the external wall of the nose, and where it failed it
probably laid deeper. The relief would last for
from fifteen minutes to an hour ; occasionally it
would abort the attack.
Of the ten cases I have observed none were of
sufficient severity to warrant operative interference.
Application of silver two per cent, or formaldehyde
one half per cent, to that area of the nose either
cured or helped the pain.
From the relation of the apex of the maxillary
sinus to the sphenopalatine ganglion the inflamma-
tory process might spread from this sinus to the
ganglion ; but I have not so far observed this.
3542 Washington Avenue.
MIDDLE EAR DEAFNESS.
By W. Sohier Bryant, A. M., M. D.,
New York.
Our grandfathers classified ear diseases in two
categories — those that got well without treatinent
and those that resisted all treatment. In our day
there are very few cases of chronic middle ear deaf-
ness that cannot be improved, and acute middle ear
deafness is very ainenable to treatment. The excep-
tions are the cases of malformation of the middle
ear, the cases of advanced stapes fixation, and those
of extremely advanced otosclerosis.
The amount of the possible improvement in hear-
ing is in inverse ratio to the pathological changes.
Chronic deafness from past or present suppuration
of the iniddle ear can. without exception, be helped
bv treatment. The amount of help depends upon
tlie power of the patient to make repair and to sub-
stitute parts which have been lost. Deafness follow-
ing middle ear catarrh is mure resistant.
When we realize that about ninety-eight per cent,
of the cases of chronic deafness are due in whole or
May
AM.- MIDDLE EAR DEAFXESS.
])->rt to middle ear disease, then we appreciate the
great frequency of chronic middle ear deafness.
About eightv-four per cent, of the cases of chronic
middle ear deafness are due to middle ear diseases
alone, while fourteen per cent, are due to middle
ear diseases combined with diseases of the inner ear.
Of the cases of chronic middle ear deafness, about
eightv-three per cent, are due to chronic middle ear
catarrh alone : fifteen per cent, are due to present or
past suppuration of the middle ear : one per cent, is
due to stapes fixation, and less than one per cent, to
congenital malformation of the middle ear. The
fifteen cases which are the result of suppuration are
often complicated by chronic middle ear catarrh.
We see, therefore, that ninety-eight per cent, of
chronic cases of middle ear deafness are due in
whole or in part to "chronic middle ear catarrh."
Chronic middle ear catarrh makes about sixty-
nine per cent, of all chronic deafness, while middle
ear suppuration causes about thirteen per cent, of
chronic deafness. The causes of chronic middle ear
catarrh arise in the nasopharynx and affect the mid-
dle ear bv interfering with the Eustachian tube. The
aim of treatment is first to restore the functions of
the Eustachian tube : and, second, to correct the de-
fects of the middle ear. By treatment of naso-
pharynx, prophylaxis of these defects is easily as-
sured.
The causes of stapes fixation are trophic disturb-
ances. Not only must these disturbances be checked,
but their recurrence must be prevented.
The chief difference between the aetiology of mid-
dle ear suppuration and chronic middle ear catarrh
is pyogenic bacterial infection. Suppuration occurs
almost never independent of nasopharyngeal disease.
Prophylaxis of chronic middle ear deafness due to
suppuration is secured by preventing purulent in-
flammation through care of the nasopharynx. But
if suppuration has already begun the hearing is pre-
served by immediately stopping the suppuration and
by treating the nasopharynx appropriately. If any
suppuration shouid exist in chronic middle ear deaf-
ness it must be immediately arrested. If perfora-
tions of the membrane exist they must be closed by
the growth of cicatrices. In order to compensate for
the important parts of the sound conducting mech-
anism which may have been lost, it is necessary to
adjust mechanical appliances. Adhesions of im-
portant parts must be loosened.
Besides showing the second stage of stapes fixa-
tion (Case X), the following cases also show the
three conditions caused by chronic middle ear sup-
puration, together with their nine methods of treat-
ment (Cases I to IX). The thirteen conditions of
chronic middle ear catarrh and their treatment are
also shown (Cases XI to XXR').
.Case I. — No. 12076. A man, aged thirty-four. Chronic
middle ear suppuration with impaired hearing for six
years. Perforation of Shrapnell's membrane. Politzer's
acoumeter heard less than three feet. Nine weeks later,
after cleansing treatment and cessation of suppuration,
acoumeter heard at thirty-five feet. Improvement has per-
sisted to the present time, covering a period of three
years.
C.\SE II. — No. 13016. A man, aged twenty-seven.
Chronic middle ear suppuration for four years; small
perforation of membrana vibrans and considerable loss
of hearing. Politzer's acoumeter heard at three feet.
Three months later, after cleansing treatment and ces-
sation of suppuration, acci-meter i-.tard at thirty feet. Im-
provement has continued over lliree \ears.
Case III. — Xo. 14212. A woman, aged fifty-three. Suf-
fered from eiifects of chronic middle ear suppuration;
large, dry posterior perforation of drum membrane.
PoUtzer"s acoumeter heard at twelve inches. The other
ear worthless. The perforation was caused to cicatrize
over by aid of paper dressings. Six weeks later, Politzer's
acoumeter heard at eight feet. Improvement has
continued.
Case IV. — No. 13000. A woman, aged twenty, who had
been rejected in a civil service examination. Effects of
chronic middle ear suppuration. Adhesion of malleus
iiandle to promontory. Perforation of drum head had
already closed. Watch heard at five inches. The other
ear worthless. Two and a half months later, after forci-
ble catheterization and relaxation of the bands of adhe-
sion, watch could be heard at seventeen inches, and
applicant passed a successful civil service examination.
Improvement retained.
Case V. — No. 13070. A doctor, aged forty-five. Long
standing suppuration and large perforation in membrana
vibrans. Politzer's acoumeter heard at ten inches. One
week later, after cleansing treatment and cessation of sup-
puration, the perforation was closed with paper dressings;
acoumeter heard at twelve feet.
Case \'I, — No. 14207. A woman, aged' twenty-four.
Suppuration since childhood : total loss of drum mem-
brane and the three ossicles. \\'atch heard at one inch.
Other ear of little use. One week later, after cleansing
treatment and cessation of suppuration, tympanic ballast
was adjusted, watch heard at thirty-six inches. Improve-
ment continues over three \ears.
Case VII. — No. 12077. A woman, aged twenty-seven.
Suppuration since childhood ; loss of drum head and cica-
tricial attachment of malleus to promontory ; early im-
pairment of hearing. Politzer's acoumeter heard at twelve
inches in right ear. Left ear absolutely deaf. Cleansing
treatment and cessation of suppuration. ■ Politzer's acou-
meter heard at four inches. Tympanic ballast then ad-
justed, acoumeter heard at eight feet. Ballast caused re-
turn of suppuration. A mastoid antrectomy was performed
in order to allow the use of the tympanic ballast. After
convalescence Politzer's acoumeter heard at thirteen inches.
Ballast adjusted, acoumeter then heard at nine feet. Watch
heard at tw-o inches. Condition remained the same. Func-
tional tests without tympanic ballast : Tone perception, high
limit, 16,800 single vibrations (Edelmann-Galton) ; low
limit fork 1,024 single vibrations. Bone conduction o.
With tympanic ballast in place : Tone perception, high
limit, 39,400 single vibrations : low limit fork, 128 single
vibrations. Bone conduction, fork 512 single vibrations
heard on mastoid. A tone gap existed for a time, fork
2,028 double vibrations not heard by air conduction while
other c forks were heard.
Case VIII. — No. 14478. A man, aged seventy-five.
Chronic middle ear suppuration of many years' duration
with poor hearing. Watch heard at four inches. My modi-
fied radical mastoid operation was performed. Cessation
of suppuration and watch heard at ten inches.
Case IX. — No. 13038. A woman, aged twent}'-four. Sup-
puration since infancy ; loss of all tympanic contents : tym-
panic caries. Watch heard at contact. Radical
(Schwartze-Stacke) mastoid operation performed. Con-
valescence complete in three weeks without skin grafts.
Cessation of suppuration and watch heard at ten inches.
The patient has retained the improvement now for four
years.
Case X. — No. 14229. .\ man, aged sixtj'-seven. Stapes
fixation in the second stage. Deafness commenced ^ght
years ago; hearing had been very bad for three years; this
condition was possibly aggravated by business failure. Hear-
ing variable. Drum membrane whitish and opaque. Posi-
tion, contour, and light reflex normal ; malleus movable.
Politzer's acoumeter heard in right ear at four inches ; left
ear, at three inches. Loud conversation heard in right ear
at si.x inches ; left ear. at thirty-two inches. Watch not
heard in either ear. Bone conduction much diminished.
Fork, 128 single vibration^, low limit for tone perception
bv bone. Fork, 256 single vibrations not heard by air.
High notes well heard. Treatment by general hygiene and
regulation of blood supply of the middle ear. Six months
later, Politzer's acoumeter heard in right ear at seven feet.
BRYANT: MIDDLE EAR DEAFNESS.
watch at twenty inches; in left ear, acoumeter at four and
one half feet, watch not heard at all. Improvement has
continued now for a period of four years.
C^^^. XI. — No. 13083. A man, aged forty-seven; had
noted (kliciency in hearing for eighteen years. Drum heads
good c idr, fair contour and position, light reflex very
small. Xares partially occluded by hypertrophies and
irrcgnlarilics. Foss;e of Rosenmuller partially closed by
adluvMon-. Tubal mouths slightly obstructed by thickened
mucosa. \\'atch heard in right ear at fifteen inches; in left
ear, at four inches. Astringents and irritants to naso-
pharynx. Three years later, wtitch heard at forty-eight
inches in left ear and eighty-four inches in right ear. Im-
provement maintained.
C.vsE XII.— Xo. 14528. A man prematurely old at forty-
seven. First noted impaired hearing thirty-four years ago;
losing ground ever since in spite of much treatment. Has
not heard watch in right ear for twenty-one years, and in
left, twenty-hve years. Flat, opaque, retracted drum mem-
branes; no light reflex, rigid. Xares hypertrophic; inflation
by Politzer's method or catheterization impossible. By air
conduction, right ear, low tone limit fork 1,024 single vibra-
tions ; high tone limit fork 2,048 single vibrations. Left
ear, low limit, 512 single vibrations; high limit 4.096 single
vibrations. Bone conduction decreased. Right ear, low
tone limit by bone conduction. ^.024 single vibrations; high
limit fork. 8.192 single vibrations. Left ear, low limit by
bone. fork. 1.024 single vibrations; high limit, 8.192 single
vibrations. Very loud voice heard at one foot in right ear ;
left ear, at eight inches. Bougies, local astringents, and
stimulation. Portions of lower turbinates removed. Eight
months later, low tone limit in left ear, fork, 256 single
vibrations; right ear, fork, 268 single vibrations; high
tone limit 40.000 single \-ibrations in both ears. Politzer's
acoumeter lieard in right ear at fifteen inches; in left ear
at twenty-seven inches. Watch heard light contact on both
ears. Loud conversation heard in right ear at five and a
half feet; left ear at four feet. Eustachian tubes patulous;
appearance of drum membrane much improved in every
respect ; good light reflex, color, position, and surface, still
somewhat opaque.
C.\SE XIII. — No. 14177. A woman, thirty-eight years
old. Had undergone much injudicious treatment. Eusta-
chian tubes used to be closed, now cannot close. Dimin-
ished hearing began fifteen yetirs ago. ^Nlembrana tympani
thin, flaccid, readily movable. Politzer's acoumeter heard
at twenty inches in right ear. Treated by rest, stimula-
tion, and collodion splints. After six months. Politzer's
acoumeter heard at four and a half feet; watch, at two and
one fourth inches. Improved function of Eustachian tube.
Case XIV. — A man. aged forty-three. For several years
the patient's hearing had been impaired; drum head re-
tracted; good color, contour, and reflex. Did not move on
inflation. Watch heard at one and a half inches; after
inflation heard at twenty-four inches. Treatment, infla-
tion and pharyngeal astringents; one month later, watch
heard ;it eighteen feet.
C.\SE X\'. — No. 1469(1 .-\ man, aged twenty-seven. Im-
paired hearing for ;i number of years; much deafness in
family. Dnmi membranes slightly congested along maller.s
handle and periphery, and depressed, small light reflexes,
inflation difficult. Nasal engorgement. Left ear, watch
heard at five inches ; right car, watch heard at nine inches.
Bone conduction slightly prolonged. Low notes well
heard. High limit, left ear, 39.000 single vibrations (Edel-
mann-Galton). Right car. 44,000 single vibrations. Treated
by inflation, removal of part of lower turbinates, and
astringents. Three days later, watch heard at twelve feet;
left ear, at ten inches. Improvement maintained.
C.\SE XVI. — No. 1.3012. A man. aged sixty-seven. Some
difficulty in hearing for a number of years. Membrane
very thick and white, with thinner areas. Large light re-
flexes. Inflation slow. Politzer's acoumeter heard in right
ear at twenty-five inches; in left ear, at seven inches. High
tone limit, left ear, 29,000 single vibrations (Edelmann-
Galton). Right ear, 20,000 single vibrations. Right ear,
low tone limit, 102 single vibrations. Treatment, astringent
to nasopharynx and aural stimulation ; two weeks later.
Politzer's acoumeter heard in right car at five feet; left
€ar. at fourteen feet.
C.xsE XVII. — No. 14649. A man. aged fifty-eight. Ex-
tremely deaf for two years; licaring difficult many years.
Thick, flat, contrnctefl drum heads; no light reflexes;
Eustachian tubes fairly patulous. Could hear nothing b_\
bone conduction. Could not hear his own voice or a slap
on tl'.e cheek. Heard very loud noise close to his ear.
Treated by nasal counter irritation and tympanic stimula-
tion. After se\eral treatments, acoumeter heard in right
ear at two inches ; left ear. at five inches. High tone limit,
right ear, 24,000 single \ibrations ( Edelmann-Galton) ; left
ear, 22,000 single \ ibrations. Low limit, left ear, fork, 250
single vibrations; right ear. fork. 1,096 single vibrations.
Eight months later, ordinary voice heard by air at four
feet. Low tone limit fork, 128 single vibrations, by air in
both ears.
Case XVIII. — Xo. 14160. A woman, aged fifty. Hear-
ing had been defective twenty-five years. Partial nasal ob-
struction. Drum head depressed, very thin, transparent,
and lax. Inflation not perfect ; watch not heard. Right
ear, the better ear. Politzer's acoumeter heard at five feet.
Low tone limit. 256 single vibrations. Treated by nasal
astringents, removal of part of lower turbinates, and aural
stimulation. Fifteen months later, watch heard at thirty-
six inches. Low tone limit, fork, 113 single vibrations.
High limit, 43,000 single vibrations (Edelmann-Galton).
Case XIX. — Xo. 14128. A man, aged forty-five. Im-
paired hearing many years. Right ear absolutely deaf;
left ear, relaxed drum membrane. Patulous Eustachian
tubes. Politzer's acoumeter heard at seven inches. Treat-
ment, paper splints and collodion. Si-x months later, left
ear heard watch at one and a half inches; acoumeter at
twelve feet. Resilienc\" of drum membrane restored. Im-
provement maintained.
Case XX. — No. 12099. A woman, aged thirty-nine. Had
long noted trouble in hearing. Right ear. the best ear. A
large part of the drum membrane calcified. The tube not
perfectly patulous. Politzer's acoumeter heard at two
inches. Treated by inflation, astringent to nasopharynx,
and tympanic stimulation. One moth later, right ear, watch
heard at eighteen inches. Mobility and elasticity of the
sound conducting mechanism improved.
Case XXI. — No. 14179. A man, aged forty-one. Had
been a little deaf for a number of years. Left ear showed
a somewhat depressed gra\- membrane with irregularly
depressed surface after inflation, indicating bands of adhe-
sions running to the inner tympanic wall. No history or
evidence of suppuration. Tympanic inflation difficult.
Acoumeter heard at three inches. Treatment, inflation and
tubal astringents. Four months later, Politzer's acoumeter
heard at four feet in left ear. Adhesions appear to be
entirely relaxed.
Case XXII. — No. 14177. A woman, aged thirty-eight.
Noted impairment in hearing fifteen years ago. Previously
tubal stricture, much injudicious treatment, now permanently
open tubes and abnormally mo\able left drum membrane
and malleus, less of elasticit\' of membrane and extreme
laxity of mallear ligaments. Bone conduction much in-
creased, low notes deficient, high note-; well heard. Left
ear. acoumeter heard at twenty-five inches. Treatment by
collodion splints, rest, and irritation of pharyngeal mouth
of tube. Five months later, watch heard in left ear at four
and three three fourths inches. Politzer's acoumeter heard
at ten feet.
Case XXIII. — Xo 14861. A woman, aged thirty-five.
Some difficulty in hearing for at least two years. Tym-
panic membrane fairly normal in appearance. Malleus
immovable. Right ear, watch heard at seventeen inches;
left ear, at three inches. High tone limit, left ear, 40.000
single vibrations (Edelmann-Galton) : right ear. 48.000
single vibrations. Gelle positive, low limit left ear fork,
134 single vibrations; right ear. 174 single vibrations. Bone
conduction, normal duration. Treated by tympanic and
tubal stimulation. Six weeks later, left ear. watch heard at
nine inches; right ear. at twenty-one inches. High tone
limit, right ear, 85.000 single vibrations ; left ear. 92.000
single vibrations. Low limit. 128 single vibrations both
ears.
Case XXIV. — .\ boy. aged thirteen. Patient had always
had slightly defective hearing. Watch heard at twenty
inches in both ears. Mastoiditis and operation treated with
my modified blood clot dressing. After convalescence from
Ih'e operation, the ear operated on for mastoiditis heard the
watch at twelve feet.
Summary. — We have seeti that all forms of mid-
dle ear deafness except the congenital cases are
amenable to treatment, and that tlie amount of im-
provement justifies the effort expended.
57 W'rCST FiFTY-TllIRI) Strkkt.
May 23, 1908.J
GRllU-lTH: SYNTHETIC ANATOMY.
993
A NEW METHOD OF ANATOMY STUDY.
By Frederic Griffith, M. D.,
Rome, Italy.
Introduction.
Of all the manifest difficulties encountered by
students of medicine at the very outset of profes-
sional school life the topic of anatomy looms
most stupendously before the mind's eye contemplat-
ing the stage of its coming mental activities. Con-
tinued thought of the beginner upon the matter
serves but to strengthen preconceived notion — ac-
centuated by wellnigh universally expressed opin-
ion of all other past and present medical tyros —
namely, that the subject of human anatomy is at
once the most intricate, hardest to fix in mind, and
easiest forgotten of any branch of medical
knowledge.
One desirous to discover the reasons for the per-
plexities overshadowing the way of him who would
become a skilled anatomist will not seek far before
becoming impressed by the very same thought
which, however imdiscerned, acted so overpower-
ingl}' upon the student himself. In a word, the real
cause for the hardness of anatomy lies in the very
essence of anatomy itself as commonly presented.
Ambiguity in this statement will be cleared if the
reader will momentarily allow his mind to dwell
upon the abstract aspect of the subject under dis-
cussion. Consider the term anatomy and what is
presented to consciousness. Is it not the body in its
entirety? This presentation of the whole crowding
the brain becomes the primal source of confusion
when localized disassociation of the subject is at-
tempted. Entering from the surface, the deeper one
delves the more complicated the structures, until the
inquirer becomes lost in a maze of contra relation-
ships of muscles, bones, vessels, nerves, and visceral
organs.
That -which serves to so confound the casual
glance acts similarly in the student's mind, and by
reason of the incompleteness of his study causes an-
atomical facts to remain but lightly fixed" in memory.
The monuments of Cheops have remained the
marvel and bewilderment of the centuries since the
secret of their construction slept after two or three
generations from the builders. Lately has come one
who suggests that the pyramids are cement. Proved
to be so, the mystery of those imperishable piles is
solved and the tradition of the "hundred thousand
straining backs" tugging quarried blocks of a size
not worked in our time becomes mere figure of lan-
guage. To reduce the anatomical stumbling block
and to render its grasp facile for the learner by
means eminently practical is the purpose of the
present writing.
To study a house without the aid of the architect's
plans, even though one may have the privilege of
tearing the building down, serves but to mystify and
is likely to leave the intrepid investigator exercising
the extreme prerogative standing finally amid a
wreck of thought and disjointed bricks. Markedly
similar is the result after the average dissector has
approached a human body in search of its secret
conformation.
Based upon the thought that a reconstructive pro-
cess logically should follow close after the analyzing
dissecting knife if the student is to gain proper
grasp of subject anatomy, the system to be presently
described is projected. Every sincere anatomy
teacher, mindful of dissecting room shortcomings,
has thought, if indeed he has not voiced, keen sor-
row at the constant waste of material caused by
thoughtless, untrained students. Too often parts
are merely rifled hastily, as footpads scour their vic-
tim's pockets.
Admittedly but little is ever gained from the dis-
section of a first part. To present anatomy from
the very beginning, recognized as being made up of
local and distinctive elements, the several factors
entering into the construction being as easy of re-
tention when once properly presented before the
mind as is the reassembling of a bony skeleton once
set up, is what is strived for by the method of syn-
thetic development described in this article. To be
able to replace the component materials entering into
a construction carries the individual possessed of
such power a long ways towards an understanding
of it, but to be enabled to create the parts in some
similitude, however crudely, first, if built upon a
sound foundation, is to accomplish far more.
By the aid of some plastic material and an assem-
bled bony skeleton the anatomy student will have at
hand the means of fixing facts upon his memory
after every part dissected in a manner inconceivably
valuable. By ordinary dissecting methods one gains
sight of existent relationships. If the common prac-
tice, however, is followed by a synthetic process the
student gains thereby a strengthened brain impres-
sion. Whereas, in the former he saw merely the
picture, by the latter means he duplicates the imprint,
for now he not only sees the bare fact, but is forcecl
to consider every concept by reason of the manual
effort in the reproduction.
Equipment.
The materials necessary for the development of
the sy nthetic method of anatomy study are :
(1) Provision for a skeleton of average size,
preferably that secured from the body of a muscu-
lar male adult. Thus is provided a sure control and
foundation for all the subsequent production, the
well marked bony ])roniinences serving as positive
guides for the building up of the soft parts. Such
a skeleton may be readily secured, selected, cleansed,
properly assembled, and wired, from the dissecting
room supply of material in the early fall at the be-
ginning of college work; or it may be obtained
from dealers in anatomical and surgical supplies at
a cost of thirty to sixty dollars. One such skeleton
may be adequate to serve the practical needs of a
group of four or even six students. AMiere there
are larger classes a number of the skeletons should
be provided.
While assured that if synthetic demonstrations
were instituted as regular supplemental procedures
at the close of anatomical courses much would be
gained, greatest good is obtainable when the student
himself prepares his own specimens. The actual
w^ork at modeling of the anatomical duplicate di-
rectly after completion of the dissection serves to
fasten the facts as nothing else can do.
(2) The modeling material may consist of any
one of the following : A recognized plastic substance
well fitted for the intended work having a founda-
tion of wax, being in general use by sculptors, is
u(u GRIFFITH: SYNTHETIC ANATOMY. . LNeu- Vur.
J -''^ Medical Jour:
known under the trade name of plastilina. It is
placed first upon the list of desirable shaping matter
for the reason that it is most practical and least
troublesome of all to use. The substance comes in
three consistencies, of which that termed medium
or hard will be found most satisfactory for present
purposes. Manufactured in several colors, and as it
is muscle relationships which will be particularly
studied and which are of greatest importance in fix-
ing nerve and bloodvessel locations, red should be
chosen as being nearest the natural tint. Put up in
one pound packages and selling for twenty-five
cents apiece ; ten cakes will be found amply sufficient
for carrying oiU compietest detail work. Ordinary
modelling clay costing at the rate of about three
cents a pound may be used. This clay has the dis-
advantage of it being necessar\- to keep it constantly
wetted to prevent crumbling. iMt'tecn or twtntv
pounds weight of clay may be provided, as it is
somewhat heavier in a given quantit}' than in the
case of the first mentioned material. The clay is
best kept in a stone crock or closed enamel vessel.
When obtained the mass should be broken up b\
the fingers into small pieces of about the size of
walnuts and spread in layers in the receptacle. Each
layer to be well sprinkled with water. Finally the
whole should be covered in with a dampened cloth
to prevent evaporation of the water. Very lately
has appeared a modified claye>- substance termed by
the inventor, a Norwegian sculptor, "classical clay,"
from its partaking of the nature of modelling ma-
terial used by ancient Greek and Roman artists.
This clay may be readily employed as a medium for
carrying out synthetic anatomy study, its cost being
but about twice that of ordinary modelling material.
Classical clay has distinct advantages in that the
finished work does not require to be kept wet during
the intervals of study : also from the fact that addi-
tions may be added without in any way disturbing
the original construction.
The implements required for the working of the
plastic materials are few. Two or three of the broad
and narrow ended wooden modelling tools, selling
for small cost at art material shops, or the student
may provide a spatula like tool whittled from a
piece of broom handle, finding it satisfactory for
every purpose. Chief reliance is to be placed upon
the student's own fingers for the carrying out of the
work, as it is the act of modelling the parts which
serves unconsciously to fix the anatomical fact being
Studied at the time firmly in mind.
7 " ■ The Body Surfaces.
The value of synthetic study of surface markings
becomes a])i)arent when it is recalled that ])hysical
anatomy depends upon the landmarks of the sub-
cutaneous bony prominences, muscular and facial
elevation and depression, for its basis. Not alone is
the surgeon dependent, but also the physician, upon
the fixed bodv points, in the determination of the
extent and character of surgical injury or internal
disease. The ease with which accurate knowledge
of what goes to make up surface prominences and
contiguous structures is evident by a mere cursory
eJtamination of any of the standard anatomy text-
books. A wealth of pictorial description shows the
bones o{ tlie skeleton carefully marked with origin
and insertion of all the muscles thus acting as ready
guides, but which hitherto without the connecting
link of plastic material and transfer to the bony
skeleton has been neglected.
The Head.
After completing the dissection of the head or
during the course of the work, with the skeleton
head set up beside that of the subject, duplication
may be commenced.
Aluscles of the Face and Cranium.— Beginning
with the temporal muscle, for convenience, its origin
and insertion are to be examined in the subject. Re-
production upon the skeleton head may then be car-
ried out, making frequent comparisons. Cutting
ofl: a piece of the modelling material in bulk similar
to the temporal muscle to be copied, the lump is to
be kneaded and moulded into a somewhat elongated
fan shape. By compressing the expanded edge to
the temporal fossa and ridges, external angular pro-
cess of the frontal bone to the mastoid portion of
the temporal behind, curved lines of the frontal and
parietal bones above to the pterygoid ridge upon the
greater wing of the sphenoid below, the origin of the
muscle will be traced. The insertion is set upon the
inner surface, apex, and anterior border of the coro-
noid process of the lower jaw. extending almost to
the last molar tooth.
The masseter, the remaining muscle entering the
temporomaxillary region, is to be copied in a simi-
lar manner. This muscle is found to arise from
the malar process of the superior maxillarv bone
and from the anterior two thirds of the lower border
of the zvgomatic arch ; a second, deeper portion
the muscle arising from the posterior third of the
lower border and from the whole inner surface of
the zygomatic arch. The common insertion being
set into the upper half of the ramus and outer sur-
face of the coronoid process of the inferior maxilla.
The relations of the paroti(l gland, fascial, masse-
teric, temporal, and buccal vessels and nerves may
be subsequently indicated.
Pterygomaxillary Region. — The pterygoid mus-
cles, by comparison with the w'orked out originals
ill the subject, are duplicated similarly upon the
skeleton. Modelling the external pterygoid muscle
in the shape of a short and somewhat conical form.
The origin is to be indicated by attachment of the
mass to the pter}g"oid ridge upon the greater wing
of the phenoid and from the osseous surface lying
between it and the base of the pterygoid process ;
also from the outer surface of the external pterygoid
plate. The insertion is set into the anterior depres-
sion lying just below the condyle of the lower jaw.
The internal pterygoid is formed to arise from the
inner surface of the external pterygoid plate and the
grooved surface of the tuberosity of the palate bone ;
also by an extension from the outer surface of the
tuberosity of the palate bone and the tuberosity of
the superior maxillary bone. The insertion is set
into the ramus and angle of the lower jaw, extend-
ing as high up as the dental foramen. The vessel
and nerve associations are to be carefully considered
and indicated.
In like manner the intermaxillary, superior, and
inferior maxillary regions are to be plotted. The
nasal region being limited uix)n the skeleton to bone
formation, must be prolonged by use of plastic sub-
stance to indicate the cartilaginous structure. In
May 23, 1908. J
CORRESPONDENCE.
995
all the work of reproduction the different muscular
structures must be actually built up, not merely-
drawn by indentation upon an adherent mass of
plastilina or clay. It is only by the student himself
locating and indicating positively the points of origin
and insertion of muscular structures that the great-
est good is obtainable.
In making a synthetic study of the orbital region
special provision by sawing through the frontal bone
in such a manner as to open this space sectionally
must be made.
The muscular structures entering into the neck
are to be duplicated upon the skeleton as found.
Beginning with the muscles of the soft palate, the
pharynx, anterior vertebral, lateral vertebral, lin-
gual, suprahyoid and infrahyoid, and superficial
cervical regions.
The Thorax.
The thorax, being for the most part made up of
more readily worked out structures, owing to their
greater size than in the case of the head and neck
regions, synthetic study of this portion of the body
is most satisfactory. The muscles of the back be-
ginning with the structures forming the fifth muscle
layer may perhaps be best built up after a careful
reading of the anatomy textbook. So close together
are the back muscles that a first dissection is very
apt to add confusion rather than clearness to the
understanding. This is due to the complicated in-
termuscular sasptal supports, whose removal disor-
ganizes the contained muscles.
In the building up process the student may possi-
bly distort somewhat the various layers upon the
skeleton model by lack of sufficient care in the pro-
portionment. but he will have at the end clear mental
pictures of the lay and action of the structures of the
region under consideration.
Upon the thorax the chest wall is to be built up
between the model ribs and sternum, beginning with
the levatores costarum, intercostales, infracostales,
and triangularis sterni muscles.
The Abdomen.
The wide expanded structural formation of the
abdominal walls likewise causes this portion of the
body to be peculiarly adapted for a synthetic study.
To prevent collapsing of the set up model muscles
employ a bundle of excelsior or crumpled news-
papers to take the place of the viscera. Begin the
process of leconstruction by first laying down the
transversalis and quadratus lumborum muscles ; fol-
low with the deep muscles of the abdomen, namely,
the psoas parvus and magnus, iliacus. Anteriorly fill
in the internal and external oblique, the rectus ab-
dominis, and pyramidalis muscles.
The visceral organs may be added and the pe-
rinaeum built up in conjunction with the develop-
ment of the thorax and abdomen or separately.
The Upper Extremities.
Reconstruction of the arm may commence with a
reproduction of the pectoralis minor muscle, costo-
coracoid membrane, pectoralis major and subclavius
muscles. Continue hy laying down the serratus
magnus, subscapularis, supraspinatus, infraspinatus,
teres minor, teres major, biceps, coracobrachialis,
brachialis anticus, deltoid, triceps and subanconeus
muscles in the order named. Upon the forearm the
deep flexors and extensors, pronator quadratus.
supinator longus, pronators, superficial flexors and
extensors, abductors, interossei, palmares and dor-
sales, and the lumbricales muscles.
The Lower Extremities.
In the sy nthetic study of the thigh commence with
the deep lying muscles of the anterior femoral
region, laying down the cureus, subcureus, vastus
externus, vastus internus. rectus femoris, and sar-
torius muscles, with the tensor vaginae femoris.
Upon the inner side of the thigh lay the abductor
longus, brevis. and magnus muscles, the gracilis and
pectineus muscles. About the hip and back of the
thigh first set the biceps semitendinosus and semi-
membranosus muscles ; continue with the quadratus
femoris, pyriformis. obturator externus, obturator
internus, gemellus inferior, gemellus superior, glu-
taeus minimus, glutaeus medius. and finally covering
in with the glutccus maximus muscle.
Descending to the region of the lower leg, fill in
the anterior tibiofibular region by laying down the
extensor longus digitorum, extensor proprius hallu-
cis, peroneus tertius, and tibialis anticus muscle.
Posteriorly set the flexoi- longus hallucis. flexor
longus digitorum. popliteus, tibialis posticus mus-
cles ; afterwards add the superfixial structures of the
region, namely, plantaris. soleus, and gastrochemius
muscles. Upon the outer side of the leg place the
peroneus longus and peroneus brevis muscles.
Continue to the foot, laying down the anterior,
internal, and external angular ligaments, indicating
the proper relationships of structures passing
through or beneath them.
Upon the dorsum of the foot set the extensor,
brevis digitorum. In the plantar region set the in-
terossei muscles : flexor iDrevis hallucis. adductor
obliquus hallucis. flexor brevis minimi digiti. ad-
ductor transversus hallucis ; abductor hallucis, flexor
brevis digitorum, ai)ductor minimi digiti.
It must be conceded that a thorough groundwork
of the muscles by use of the system indicated in the
previous pages founds the whole study of anatomy
upon securest basis in the student's mind. Further-
more, elaboration of the synthetic method by laying-
down nervc>. lib ■ iw^- 1^, and organs may be car-
ried out to rcn.MLv>-i detail. The synthetic method
as well lends itself readily as a means for determin-
ing a student's knowledge of anatomy by the
examiner.
(LoriTspouiirncc.
LETTER FROM LONDON.
The Research Defense Society. — IVonieii and the Royal
College of Surgeons. — Anccsthctics and the Hospitals. —
Charges to Hospital Out Patients. — The Finances of
the Hospitals.
LoxDON. May 3. 1908.
A society has been formed called the Research
Defense Society, whose objects are to point out to
the public, by means of pamphlets, lectures, and
debates, the value of experiments on animals to
science and medicine. The president is Lord
Cromer, and there are nearly a hundred vice presi-
dents, including some of the most distinguished
men in the kingdom. There are, among others, six
bishops and four deans. A society formed under
996
LETTERS TO THE EDITORS.
[New
Medical
York
Journal.
such distinguished patronage can scarcely fail to
have great influence, and the public will now have
the opportunity of hearing both sides of the ques-
tion regarding vivisection. Hitherto the antivivi-
sectors have been permitted to work their own will
without let or hindrance. The only exception to
this general statement was the recent libel action
against the Hon. Stephen Coleridge, the leading
spirit of the antivivisectors, with the result that he
was mulcted in heavy damages. With this excep-
tion, the misleading and calumnious statements of
the antivivisectors have been ignored by the medi-
cal world. It is thought that this passive attitude
is a mistake, and that the time has arrived when
more active measures are necessary to combat these
attacks. With this object the society has been
formed, and it wall give information to all in-
quirers who desire to examine the arguments in
favor of experiments on animals. It will also pub-
lish precis, articles, and leaflets, send speakers to
debates if re(|uired, and generally spread the
knowledge of the truth as regards vivisection.
The honorary secretan,- is Mr. Stephen Paget,
F.R.C.S., to whom the medical world owes a debt
of gratitude for his organizing such a powerful
and influential society.
Several important letters have appeared in the
Times and other daily journals on the subject, in-
cluding some from laymen, testifying to the interest
the society has aroused among the educated classes.
The society will no doubt be largely joined by
members of the medical profession.
The council of the Royal College of Surgeons of
England has lately been considering the advisa-
bility of admitting women to the examinations for
the membership and fellowship of the college.
With regard to the membership, there seems little
doubt that this privilege will be granted to women.
This examination, conjointly with that for the
licentiateship of the Royal College of Physicians
(AI.R.C.S., L.R.C.P.), is the standard qualifying
examination for English students, and the great
majorit}- of medical practitioners in England pos-
sess this diploma. As women are now admitted to
the examinations of most universities and licensing
bodies, there seems no reason why they should not
be admitted to the "conjoint" examination. As re-
gards the fellowship, however, opinions are not so
unanimous. Though most medical men are pre-
pared to discard their prejudices against the ad-
mission of women as physicians, they do not all
look with favor on the idea of women practising as
surgeons only.
The fellowship being a purely surgical diploma pos-
sessed by most of the hospital surgeons, it is thought
by some inadvisable to admit women. The opinion of
all the members and fellows of the college on these
questions has been sought, and they are being asked
to vote for or against the admission of women (a)
to the membershi]), {b) to the fcllowshi]). The
opinion having been expressed that, if women arc
admitted to the membership, they could not be
legally debarred from entering for the fellowship
and having a share in the management, govern-
ment, and proceedings of the college, the council
have taken legal advice on the subject, and find
that under their bylaws of incorporation thev can
admit women to the membership without admitting
them to the fellowship or giving them an}- right
in the management or government of the college.
The result of the ballot will be awaited with in-
terest as afifording an idea of the present day opin-
ions of medical practitioners as regards the admis-
sion of women to the profession.
The question of the administration of anaesthetics
in hospitals is likel}- to attract considerable attention
in the near future. A number of cases of death
under anaesthetics have been reported recently, Guy's
Hospital having been particularly unfortunate in
this respect. At a recent meeting of the Society of
Anaesthetists, Dr. F. Hewitt, the leading authority on
anaesthetics in the country, expressed the view that
most of the fatal cases were preventable and could
be avoided by more skill and care on the part of the
anaesthetist. Of course, this statement was vigor-
ously contested by most of the other speakers. Dr.
Waldo, coroner for the city of London, suggested
the appointment of a Royal Commission to inquire
into the w^hole question. So far, the result of the
recent discussions has been that extra anaesthetists
have been appointed at some of the larger hospitals,
two additional ones having been appointed at Guy's
Hospital. The great number of anaesthetizations
daily in some of the larger hospitals make it abso-
lutely impossible for each one to be -conducted by a
skilled anaesthetist or even by a qualified man, but
as far as possible, when a student gives an anaes-
thetic, he has previously had some preliminary train-
ing and is under skilled supervision. It is worthy
of note that most of the recent fatalities have oc-
curred with chloroform or the A. C. E. mixture. It
is true that ether is much less used in London than
chloroform, but in some of the large provincial hos-
pitals, where ether is principally used, such, for in-
stance, as the General Infirmary at Leeds, fatalities
are of \tv\ rare occurrence.
The recent proceedings at the Hospitals' Confer-
ence have been sharply criticised by general practi-
tioners. One of the motions, submitted by the Hon.
Sydney Holland, chairman of the London Hospital,
was to the eft'ect that out patients should be asked
to pay for food, medicine, and dressings if they could
afifor'd it. At the London Hospital the scheme has
been in operation for some time. In one year the
hospital got £2.000 from a charge of threepence a
patient for medicines or dressings. Those patients
who did not receive any medicine or dressing did not
have to pay, and those who were too poor were also
exempt. Mr. Holland considered that the charitable
work of a hospital should be restricted to providing
for the sick poor that help which they could not
possibly afiford to provide for themselves, but that a
good many could afford a small sum for medicine
and dressings. jMedical men in general practice
object to this scheme on the ground of unfair com-
petition. They say they would lose many patients
who could aflford to pay a small fee. The resolution
is also antagonistic to one of the model principles of
the British Medical Association, that "inability to
pay for adequate treatment shall be the considera-
tion for the admission of all patients for hospital
treatment." There is no doubt that the large hos-
pitals in London, which together treat several hun-
dred thousand patients per annum, already compete
May 2 J. 1 908. J
THERAPEUTICAL NOTES.
997
severely with the general practitioner, and the sug-
gested'payment by patients will tnake this competi-
tion worse. Doubtless the systein of small payments
by out patients would increase the funds of the
hospitals, but it would be at the expense of the
medical practitioner.
The financial state of most of the large hospitals
is not at all good ; several of them have a whole
ward empty owing to lack of funds. But the plight
of one of the smaller hospitals at present is still
worse. This is the Kensington General Hospital, in
Earl's Court. All the in patients departments have had
to be closed, and the cut patient work has had to be
carried on luider great dilliculty. The secretary has
received several writs from tradespeople for goods
supplied to the hospital, and now the climax has been
reached, the bailiff's man being in possession, and
iniless substantial relief is forthcoming, the hospital
furniture and effects will be sold. The publicity
which has been given to this distressing condition
will doubtless call foith a generous response from
the wealthy, so that the hospital will be able to con-
tinue its charitable work.
®I]cra{ieutital Botes.
The Treatment of Acute Bronchitis. — The
value of large doses of ammonium carbonate in the
treatment of acute bronchitis was. the St. Louis
Medical Review for April says, believed in by the
late Dr. Gustave Schorstein, who recommended as
much as fifteen to twenty grains to be prescribed
four times daily. If the pulse becomes weak and
respiration labored, solution of strychnine hydro-
chloride should be given hypodermatically. If the
symptoms are not very severe, one of the following
mixtures may be prescribed :
R Ipecacuanha wine tU vi ;
Solution of ammonium acetate 5iss ;
Spirit of nitrous ether njd xii ;
Syrup of tolu, 5ss;
Camphor water, ad ^i-
M. et Sig. : Two tablespoonfuls every four hours.
If the patient is a young adult, and the pulse full
and strong, antimonial wine may be substituted for
the wine of ipecacuanha in this prescription.
R Ipecacuanha wine tti. y :
Ammonium carbonate gr. iii ;
Spirit of chloroform n x;
Tincture of hyoscyamus tt), xii ;
Camphor water, ad 3i.
M. et Sig. : Two tablespoonfuls every four hours.
In some cases Dr. Schorstein recommended the
administration of belladonna in combination with
potassium iodide as follows :
R Tincture of belladonna illx;
Potassium iodide gr. iii;
Ammonium carbonate gr. iii:
Potassium carbonate gr. xv ;
Camphor water, ad 3i.
M. et Sig. : Two tablespoonfuls three or four times daily.
Treatment of Sciatica by Perineural Injections.
—According to the Journal of the American Med-
ical Association for February 29, 1908, A. Bum,
of \"ienna. is the author of a commiinication to the
Wiener mcdizinischc Prcssc for Xovember 17, 1907.
in which he states that he has found local injection
of a fluid extremely efliective in the cure of chronic
peripheral sciatica. He has occasion to treat frorn
fifty to sixty patients with sciatica every year, and
since 1904 has been systematically applying these
perineural injections. He ascribes the benefit to the
mechanical distention of the parts, and thinks it is
important to inject the fluid in a constant stream and
under considerable pressure. Physiological salt so-
lution is injected throitgh a needle cannula from 7
to 8 cm. long, inserted at the point of the inner
aspect of the thigh where the long head of the biceps
femoris is crossed by the gluteus maximus. The
patient must be in the knee elbow position ; the can-
nula is introduced for half its length, and is then
lowered a little and pushed in for 3 or 3.5 cm. far-
ther. This brings the tip to the sciatic nerve at the
point where it is most easily and safely reached
without fear of injury of the soft parts, as he learned
from experiments with colored fluids on the cadaver.
The injected fluid enters the perineurilemma. When
the needle reaches the sciatic nerve the leg twitches
or there is sharp pain or parassthesia in leg and foot.
The tube connected with the syringe holding just
100 c.c. is attached to the cannula and the fluid is
injected. The patient lies down for a half hour or
so, and then goes home and rests for the next day
or two. In a few cases the neuralgia recurs, re-
quiring from two to four injections before the pa-
tient is entirely cured. In 62.6 per cent, of 67 cases
the cure was complete ; in 20.8 per cent, there was
marked improvement, and in 8.9 per cent, no effect
was apparent.
The Administration of Magnesia in Gastric
Affections is discussed in the Journal of the Amer-
ican Medical Association for April 25. For gastritis
with constipation the following is prescribed :
R Bismuth subnitrate, 5v;
Magnesium oxide 5iiss
M. et fac chartulas xx.
Sig.: One powder three times a day Ijefore meals.
If there is hyperacidity of the stomach sodium
bicarbonate is added as follows :
R Bismuth suljgallate 5iiss :
ilagnesium oxide 5iss :
Sodium bicarbonate 5iiss.
M. et fac chartulas .xx.
Sig. : One powder three times a day before meals.
If there is much gastric flatulence wood charcoal
is substituted for the bicarbonate :
R Bismuth subnitrate 5v :
Magnesium oxide,
Wood charcoal, aa gr. Ixxv.
M. et fac chartulas xx.
Sig. : One powder three times a day after meals.
Lactic Lemonade for Arteriosclerosis. — In the
Journal de mcdecine dc Paris for ]\Iay 2 the follow-
ing formula is given for a drink to be taken by suf-
ferers from arteriosclerosis, several times a day, for
a month or two :
R Sodium carbonate 5iis3 ;
Lactic acid, enough to saturate the alkali, and in
addition 3iiss ;
Simple syrup 3iiss ;
Water %\'\.
M.
998
EDITORIAL ARTICLES.
[Neu-
Medical
York
Journal.
NEW YORK MEDICAL JOURNAL
IXCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Review of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M. D.
Adihcss all business communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 IVcst Broadway, New York.
■Philadelphia Office: Chicago Office:
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Subscription Price :
Under Domestic Postage Kates, .$5 : under Foreign Postage Rate,
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Remittances should be made by New York Exchange or post
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Entered at the Post OfBce at New York and admitted for
transportation through the mail as second class matter.
\1-:\V YORK. .SATURD.-XY, MAY J3, 1908. .
MERCURY IX THE TREATMENT OF
COXSUMPTIOX.
While there shouhl be no abatement of our pres-
ent ardor in the employment of hygienic agencies
in the treatment of inberculous disease — preventive
measures, pure air, sanitary homes, rest, nutritious
food, and the like — the cry of "throw physic to the
dogs" should not lead us to neglect all other re-
sources, including the use of drugs, that may be of
assistance in combating the disease. There are
thousands of instances, indeed, in which it is diffi-
cult if not almost impossible to carry out the
hygienic treatment in such a way as to give the pa-
tient even an approach to the benefit which ought
to result from a full and fair employment of it. If
in such cases there is a prospect of some benefit
from the administration of drugs, by all means let
us make use of them. More than ordinary inter-
est, therefore, attaches to an article by Surgeon Bar-
ton Lisle Wright, of the navy, published in the
April number of the United States Naval Medical
Bulletin, in which weighty evidence is to be found
of the efficacy of mercury in tuberculous disease.
It was by accident that Dr. Wright's attention
was first drawn to the possibility of benefiting tuber-
culous individuals by the use of mercury. He tells
us that three years ago, while he was on duty in a
temporary camp for the tuberculous established in
connection with the United States Naval Hospital
in Pensacola, he had under his care several patients
who were bf)th tuberculous and syphilitic, and that
under mercurial treatment their pulmonary lesions
improved much more rapidl}- than he had ever ob-
served in pure tuberculous infections treated under
similar or more advantageous climatic conditions,
so that he was led to believe that the improvement
was due to the antisyphilitic medication. With this
idea in view he placed about ten men on the "mixed
treatment." They all improved until the treatment
had to be discontinued bv reason of the occurrence
of gastrointestinal derangement, but before he could
continue the experiment further he was ordered to
sea. Earl}- in the autumn of 1907, when he had
gone on duty at the United States Naval Hospital,
New Fort Lyon, Las Animas, Colorado, his col-
league there. Passed Assistant Surgeon E. M.
Brown, in the light of Dr. Wright's experience, tried
the mercurial treatment on several pulmonary pa-
tients, but with only indififerent results. This, Dr.
Wright now believes, was due to the fact that the
doses of mercury given were not sufficiently large,
for the same patients showed immediate and decided
improvement under the use of larger doses.
Then, in about three months, Surgeon W. H.
Bucher reported for duty, and took up with Sur-
geon Wright's idea enthusiastically, and the plan
was promptly and heartily approved by Medical In-
spector C. T. Hibbett, the commanding officer. At
Dr. Bucher's suggestion it was determined to use
injections of mercur\- succinimide, that compound
having been found b\" him superior to other mer-
curials in the treatment of syphilis. About a month
later an abstract of an article by Dr. Wolters, in the
Dcnnatologische Zcitschrift for the preceding Sep-
tember, confirmed the confidence of our officers in
the efficiency of antisyphilitic medication in the
treatment of tuberculous disease. Intramuscular in-
jections of the succinimide were settled upon, and
the experiments proceeded. A few encouraging
case reports are given.
Dr. Wright invites special attention to the follow-
ing points brought out in his experiments and those
of his associates: i. The immediate improvement
of the patients' general condition, as shown by
slowing of the pulse, reduction of temperature, and
gain in weight. 2. A conclusive demonstration that
the treatment will cure extremely advanced tuber-
culous ulceration of the larynx and pharynx in a
remarkably short period of time. 3. The fact that
the treatment produces a decided improvement of
advanced pulmonary lesions and also has an evi-
dent beneficial action on tuberculous glands. He
notes that great care was taken to ascertain that
the subjects were not syphilitic. Stress is laid upon
the fact that large and increasing doses of mercury
are required, and the statement is made that tuber-
culous persons are extremely tolerant of the drug,
more so than sy])hilitics. When, however, the in-
May 23, 1908.]
EDITORIAL ARTICLES.
999
fection is slight the large doses are not so well
borne; in several cases an injection of 0.4 of a
grain of the snccinimide caused soreness of the
gums and the dose had to be reduced. The idea is
rather prevalent in the profession that the waters of
Hot Springs, Arkansas, enable syphilitics to bear
larger amounts of mercury than it would ordinarily
be prudent to administer. Our Hot Springs friends
may therefore find it advantageous to treat tuber-
culous patients with mercury and the waters.
THE BACTERIOLOGY OF GENERAL
PARESIS.
Of all the mental diseases, general paresis stands
out as the most distinct and the most hopeless.
From the days of Bayle to the present time steady
advance has marked the progress in our under-
standing of this disease process, and in the com-
paratively recent monumental work of Alzheimer
and Nissl it would appear that, from the pathologi-
cal standpoint at least, this disease has found a
firm underlying foundation and an anatomical in-
terpretation for all time, ^tiologically, however,
the view is still troubled. Notwithstanding the
general conviction — founded on the insecurities of
statistical analysis and the more thorough and ap-
parently definitive findings of Wassermann and
Plant relative to the presence of a syphilitic anti-
body in the cerebrospinal fluid of most paretics —
that syphilis is the fundamental aetiological factor,
there still remain difficulties in the way of interpret-
ing this disease solely in the light of its being a
syphilitic final product acting on nervous tissues.
It is for this reason that the studies of Ford
Robertson and the discovery of his so called Bacil-
lus paralyticans have aroused considerable interest
and given rise to protracted discussions, the latest
of which took place at a recent meeting of the
American Medicopsychological Association.
The scientific world has not accepted the Ford
Robertson findings, nor yet is it prepared to accept
the therapeutical results alleged by him and his fol-
lowers in this and other countries ; yet the conten-
tions are entitled to be heard and the evidence re-
viewed. At the meeting in question, Dr. John D.
O'Brien, of Massilon, Ohio, reported some further
observations on the aetiology and treatment of gen-
eral paresis, in which he reasserted his belief in the
causal relation of the pseudodiphtheroid Bacillus
paralyticans to paresis, and also reported some
measure of success in the treatment of this disease
by "vaccines" prepared from this organism. Work
done in the Cincinnati Sanatorium under the direc-
tion of Dr. F. W. Langdon, confirmatory of Dr.
O'Brien's position, was also brought forward. On
the other hand, in an exhaustive analysis of some
of the bacteriological findings, post mortem and
ante mortem, in one hundred cases of mental dis-
ease of various types. Dr. E. P. Gay, Dr. E. T.
Richards, and Dr. E. E. Southard, of Hathorne,
Mass., established the facts that terminal infections
were very frequent in mental disorders, and that
a vast variety of organisms might be found. ]More
particularly it was shown by their studies that
members of the pseudodiphtheria group, to which
Bacillus paralyticans belongs, are very frequent
saprophytes, being found in the skin, bronchial mu-
cous membrane, and genitourinary tract, and even
occurring in epidemic frequency in certain labora-
tories under diverse conditions. They were unable
to find this organism in the cerebrospinal fluid in
paretics, living or dead, and when found it could
be established that such findings resulted only as a
result of faulty technique.
In the discussion it developed that other workers
had come to the same conclusions — that, from per-
sonal observation, the work of the .Scotch bacteri-
ologist did not come up to the technical require-
ments of exact bacteriology, and the general con-
clusions drawn were that it was not proved that the
Bacillus paralyticans had any relation to general
paresis; that, if it had, it was a saprophyte that
perhaps played a part in causing a secondary sep-
tichsemia in paretics ; and that the therapeutical
deductions might have some value relative to the
treatment of such secondary infections, but had no
real relation to the underlying process. From this
latter standpoint further studies were thought to
be desirable.
THE EXPERIMENTAL TREATMENT OF
TRYPANOSOMIASIS IN RATS.
In the treatment of trypanosome infection in rats
it has been found that a number of substances will
cause the parasites to disappear from the peripheral
blood for a time, but that after a varying period of
freedom the blood will again be found to contain
numerous parasites. Certain arsenical preparations
gave the best results in quickly ridding the periph-
eral blood of the parasites and in keeping it free
from them for the greatest period of time. It was
subsequently found that the administration of a mer-
cury salt after the trypanosomes had disappeared
from the peripheral blood would in many cases
permanently cure the infection. In many of the ani-
mals, however, death took place from the organic
degenerations produced by the remedies. A com-
mittee of the Royal Society has been engaged in
studying the subject, and in the Proceedings of the
Royal Society, vol. Ixxx, No. B 536, Plimmer and
lOOO
EDITORIAL ARTICLES.
LXkw Vork
Medical Journal.
Thomson report for this committee. They have
foimd that the sahs of mercury have not given alto-
gether satisfactorv- results, on account of the chronic
kidney and liver lesions produced. Although they
say that in the more chronic form of trypanosomi-
asis, such as Tryt^anosoma gambicnsc infection, this
treatment might be more successful than in the more
acute infections with Trypanosoma Evaiisi and
Trypaitosouia Brucei.
Since treatment with arsenic compounds was only
partially successful, they turned their attention to
antimony compounds. The}' first used antimony
glycine without encouraging results ; then they em-
ployed potassium antimonyl tartrate, but it killed
the animals in a short time. They then used sodium
antimonyl tartrate in one per cent, solution. They
found that this substance had the most marked influ-
ence upon the trypanosomes in the living body of
any of the various substances so far used, including
the arsenical preparations which had given such
good results in the past e.xperiments. The injections
caused no pain and produced no inflammatory reac-
tion, and the trypanosomes disappeared from the
peripheral blood with great rapidit}-. Thirty-nine
rats infected with Trypanosoma Evansi and Try-
panosoma Brucci were treated with this compound.
Some of them died from other diseases than try-
panosome infection, and a satisfactory percentage
were living at periods varying from twenty-one to
fifty-two days after the beginning of the diseases.
THE FORTHCOMING ^lEETIXG OF THE
AM ERIC AX ^lEDICAL ASSOCIATION.
Hardly will this issue of the Journal have reached
our remote subscribers when it will be time for them
to start for Chicago to attend the approaching meet-
ing of the American Medical Association. We take
it for granted that a goodly proportion of them will
go, even irrespective of membership in the associa-
tion, for the profession at large is always interested
in the meetings and in the concomitant events.
Moreover, Chicago, "the Empress of the West," as
the late Dr. Gaillard Thomas called the city, could
not be seen to better advantage by medical men and
their families than on the occasion of such a great
gathering of their own solidarity.
The comparatively central situation of Chicago
and its ready accessibility invite a large attendance,
and the city is so large and so well provided with
hotels that nobody who goes to the meeting need be
at a loss to find suitable quarters. It is usually an
attractive place in the month of June, and we may
be sure that its hospitable inhabitants will exert
themselves to the utmost to provide entertainment
for their visitors. From the .-scientific |)()int of view.
apart from the proceedings of the various sections
of the association, the clinical work announced is on
an unusually large scale, and the pathological ex-
hibit will probably be more extensive than it has
been heretofore. Chicago is one of the great cen-
tres of activity in science as well as in trade, and it
is to be expected that much that is not formally an-
nounced in connection with the meeting will be
found inviting to visiting physicians. All things
considered, it will be seen that the Chicago meeting
promises to be exceptionally large and profitable.
PROSPERITY 13Y SUGGESTION.
The psychology of suggestion is undoubtedh- an
important factor in all the relations of life, and we
are interested to note that it is proposed to use it
systematicall}- with a view to improving the pres-
ent commercial and financial conditions. So far as
purely physical factors are concerned, the United
States is in a prosperous condition. As a result of
wildcat speculation, carried out in many instances
with other people's mone}', a financial crisis was
brought about in New York, requiring a readjust-
ment based on real and not inflated values of incor-
porated securities. Out of this readjustment,
however, there was developed a certain pessimistic
tendency which had a very real efifect on commer-
cial conditions, as can be testified to by many physi-
cians, who have felt it either directly, in their own
investments, or indirectly, through the influence
on the incomes of their patients. To counteract
this pessimistic attitude an organized movement has
been set on foot by various associations of commer-
cial travelers, who will hold an Interstate Pros-
perit}^ Congress in New York during next August.
In St. Louis an organization has also been formed
under the title of the National Prosperity Associa-
tion, the object of which is to restore confidence
among business men.
The movement has been treated lightly by some
of the newspapers, and in one particular paper has
been characterized as an effort of the commercial
world to lift itself by its own bootstraps. We do
not think that this characterization is justified. If
the substantial basis of prosperity exists, as is as-
serted by the officials of the prosperity crusade,
and if the only obstacle to a return of commercial
and financial prosperity is lack of confidence, such
organized efforts as are being put forth to restore
confidence hold out much promise of good.
Psychologists have come to recognize clearly the
importance of suggestion in the creation of mental
conditions, and the psychology of mass action as
seen in crowds is well known. It has been clearly
shown in these studies of the psychology of the
May 23, lyoS. I
NEWS ITEMS.
lOOI
crowd that there are action and interaction by sug-
gestion which make it possible for the individuals
in a crowd to reach a state of exaltation or fervor
which they would be incapable of reaching were
the same influences brought to bear on them as
isolated individuals. This idea is worked out with
considerable elaboration in an interesting drama
now on the New York stage, The Witching Hour.
In this play a wave of horror and repulsion which
sweeps over the entire community at the disclosure
of certain facts afifects the decision of a jury, the
members of which have no knowledge of the facts
bringing about this feeling of repulsion, though
they are unconsciously ai¥ected by it.
By all means, therefore, let the commercial
world make this essay in suggestion, for if confi-
dence is the only element of prosperity lacking, it
would seem well within the bounds of possibility
that through some concerted movement of this kind
confidence might be restored. While it will not be
possible for the psychologist to exercise that con-
trol over the various factors in the experiment re-
quired to place the results on a really scientific
basis, the results will still have a certain scientific
as well as a commercial interest.
A WELL DESERVED PENSION.
It is announced from Washington that the
House of Representatives has unanimously voted
a life annuity of $125 a month each to the widow
of the late Major James Carroll, of the Medical
Department of the United States Army, and to the
widow of the late Acting Assistant Surgeon Jesse
W. Lasear. Both those gentlemen, as our readers
are well aware, lost their lives in consequence of
experimental work that has proved of incalculable
value in the prevention of disease and added lustre
to the medical corps of the army.
^bititarg.
JOHN DUTTON STEELE, M. D.,
of Philadelphia.
Dr. Steele, who was born in Pottstown, Pa., on
February 21, 1868, died in Wayne, Delaware Coun-
ty, Pa., on Sunday, May 17th, aged forty years.
In 1888 he received the degree of A. B. from Wil-
liams College, and in 1893 he was graduated from
the Medical Department of the University of Penn-
sylvania. Dr. Steele, on the occasion of his grad-
uation from the latter institution, received the
alumni medal for the highest general average in the
examinations of the course. He went to the Phila-
delphia General Hospital as interne soon after his
graduation, and, after completing a full term in
that institution, spent some time in Germany and
Austria studying internal medicine and pathology.
Upon his return to this country, after his period of
European study, Dr. Steele engaged in the practice
of his profession. He became connected with the
Department of Medicine of the University of
Pennsylvania, where he was assistant demonstrator
of gross morbid anatomy, instructor in medicine,
and associate in medicine successively. He also
became associated with the Presbyterian Hospital,
in which institution he was clinical pathologist and
visiting physician successively. Dr. Steele was a
member of the Association of American Physi-
cians, a fellow of the College of Physicians of
Philadelphia, a member of the Philadelphia Patho-
logical Society, a member of the Philadelphia
County Medical Society, of the [Medical Society of
the State of Pennsylvania, and of the American
Medical Association.
Dr. Steele's writings were principally on subjects
pertaining to the diseases of the gastrointestinal
tract. He had contributed to many discussions at
the various medical societies to which he belonged
and to many medical journals. In association with
Dr. S. J. Repplier he presented a paper at the
meeting of the Association of American Physicians
in Washington on May 12th on the Value of Intes-
tinal Antiseptics, which was read by title owing to
his illness. Dr. Steele had many friends, whom he
made and held by his pleasant personality and en-
gaging manners, who will sincerely regret his un-
timely death.
Jiftos Items.
Changes of Address. — Dr. C. T. Graham Rogers,
from 104 East Ninety-sixth street to 1333 Lexington ave-
nue, New York ; Dr. H. Greenstein, from 341 East Fifty-
second street to 147 West One Hundred and Forty-third
street, New York.
Buffalo Academy of Medicine. — The Section in
Pathology met on the evening of Tuesday. May 19th. The
chief feature of the programme was a paper on the care
of the municipal milk supply, with a lantern slide demon-
stration, by Dr. George W. Goler, Commissioner of Health
of Rochester, N. Y.
Scientific Society Meetings in Philadelphia for the
Week Ending May 30, 1908.— .l/(;)i(/ay. May jjth. Min-
eralogical and Geological Section, Academy of Natural
Sciences. Wednesday. May s/th. Philadelphia County
Medical Society. Thursday, May 28th. Pathological So-
ciety; Section Meeting. Franklin Institute.
Contagious Diseases in Chicago. — During the week
eudnig May g, 1908, there were 576 cases of contagious
diseases reported to the Departm.ent of Health, of which
337 were of measles, 56 of scarlet fever. 46 of diphtheria,
38 of tuberculosis, 35 of typhoid fever, 26 of whooping
cough, 20 of chickenpox. and 4 of smallpox.
The Tricounty Medical Society of South Jersey will
hold its next regular meeting at the Schaefer House,
Salem, N. J., on Tuesday, May 26th. at i 130 p. m. This
society includes the counties of Gloucester, Salem, and
Cumberland. The officers are : President, Dr. W. H.
James, of Pennsville ; first vice president, Dr. J. H. Moore,
of Bridgeton ; second vice president. Dr. H. B. Diverty, of
Woodbury; secretary and treasurer. Dr. George Evans
Reading, of Woodbury.
Officers of Association of American Physicians. — At
the annual meeting of. this association, wjiich was held in
Washington last week, the following officers were elected
for the ensuing year : President, Dr. Victor C. Vaughan,
of Ann Arbor; vice president, Dr. Henry Hun. of
Albany, N. Y. ; secretary. Dr. George M. Kober, of Wash-
ington. D. C. ; recorder. Dr. S. Solis-Cohen, of Philadel-
phia; treasurer, Dr. J. P. Crozer Griffith, of Philadelphia;
councilor. Dr. S. J. Meltzer, of New York.
I002
NEIVS ITEMS.
[New York
Medical Journal.
Charitable Bequests.— The St. Louis Children's Hos-
pital receives $500 l)y the will of Mrs. Clara li. Curlis, and
$300 by the will of .Mrs. deorgiana C. Loudcrmann. The
latter bequest will be devoted to the equipment of a new
dispensary at the hospital, and the bequest of Mrs. Curtis
will be used to endow a bed for hve years.
By the will of IMrs. Lavinia Hunting, of Maiden, the
Manhattan Eye and Ear Infirmary, New York, and the
CuUis Consumptives' Home, Boston, receive $3,000 each.
The Silver Anniversary of the German Poliklinik.—
The twenty-lifth anniversary of the founding of the Ger-
man Poliklinik. 137 Second avenue, New York, was cele-
brated on the evening of May i6th with a dinner at the
Waldorf-Astoria. Dr. Samuel Kohn, Dr. H. J. Boldt, Dr.
A. H. von Ramdohr, and Dr. Ludwig Weiss, the four sur-
viving doctors of the original fifteen who established the
institution, were the guests of honor. In its twenty-five
jears of existence the Poliklinik has treated nearly a mil-
lion persons free of charge.
Plague in Venezuela. — According to press dispatches,
the plague situation in Venezuela has assumed an alarming
aspect. The city of La Guayra is under strict quarantine,
and quarantine regulations against Venezuelan ports have
been ordered by Colombia and Trinidad. Daily bulletins
are issued in Caracas purporting to give the number of
deaths, and it is reported that in La Guayra there are from
lift}- tn se\enty deaths a day. The authorities are doing
ever\ thing in their power to stamp out the plague, but their
eftorts so far seem to have had little effect.
The Harlem Eye, Ear, and Throat Infirmary. — Plans
iiave Ix-cn filed for a new two story and basement building
for this institution, which is to l)c erected at tlie corner of
Lexintiton aseiuie and One Hundr-jd and Twenty-seventh
-ticet. at a cost of $.25,000. Ground was broken on May
14th, .uid the work nn the new iiuilding will be pushed
forward as rapidly a> possible. The Harlem E\e, Ear. and
Throat Infirmary \\a-- founded in T(S8i by Dr. R. E. Swin-
burne. It treats about six thousand [jatients annually. Dr.
C. D. Meding is executi\-e surgeon of the institution.
The Mortality of Chicago. — During the week ending
Alay 9. 1908. there were 531 deaths from all causes re-
ported to the Department o"f Health, as compared with 717
for the corresponding period in 1907. Of the total number
of deaths, 312 were of males, and 219 of females. The
annual death rate in t,ooo of population was 12. -S. The
principal causes of death were: .Kpoplexy, 10; llnght's dis-
ease. 23: bronchitis. 14; ci:insunipti<in, 77: cancer 26; con-
vulsion-. 7: <li])lulicriri, 7; lirart disease--. 4S ; infiuenza, 5;
intestinal <li-e;i-es. .K'ute. 25: measies, 10 ; nervous dis-
eases, 20: pneumonia. 77: scarlet fe\er. 2; suicide. 13;
typhoid fever. 4; violence (other than suicide), 13;
whooping cough. 2 ; all other causes, 148.
Infectious Diseases in New York:
M'e are indebted to the Bureau of Records of the De-
partment of Health for the fallowing statement of nezi'
cases and deaths reported for flic two z^rebs ending May
16, i(/)S:
■ May g. , , May 16. ,
t r:s, Dcatlis. Cases. Death.-;.
Tuberculosis pulmoiialis 51S iS; 403 i5>i
IJiphthcria 394 37 409 36
Measles 1,668 47 1.513 35
Scarlet fever 908 43 1,173 4'
Smallnox .. I
Varicella 136 . . 134
Typhoid fever 32 8 25 6
Wliooi)ing cough 32 5 37 4
Cercbr.ispinal meningitis 8 7 13 11
Totals 3.696 332 3,708 291
The Society for the Study of Inebriety, Alcohol, and
Other Narcotics.— The thirty-eighth annual meeting of
ihis 'ocicty will be held in the .Xuditorium Hotel, Chicago,
on June 2d, 3d. and 4th. There will be one session each
day, from 9 a. m. to 12 m. The programme includes more
than twenty papers wliich will be read and discussed by
prominent members of the medical profession, and the
meclinij proniis.'s to be one of great interest. A "temper-
ance iinich" will be served at the hotel on Wednesday.
June 3d, at t : 30 p. m., wiiicb will be the occasion for an
informal discussion of the alcohol problem. Dr. T. D.
Crothcrs. of Hartford, Conn., secretary of the society, has
charge of this "lunch meeting," and will be glad to fur-
nish programmes and any information desired regarding
the meeting.
Philadelphia's Two Himdred and Twenty-fifth Anni-
versary celel)ration will include notable observances by
medical men, as \\\\\ be seen by the programme for "Medi-
cal Day" wdiich has just been issued. On Tuesday morning,
October 8th, at 11 o'clock, in the Academy of Music, the
following addresses will be delivered: The College and
Allied Institutions of Philadelphia, by Dr. George A. Pier-
sol ; The Great Hospitals of Philadelphia, by Dr. J. Chal-
mers Da Costa ; The Development of Practical Medicine in
Philadelphia, by Dr. James M. Anders.
Personal. — Dr. John M. Swan, of Philadelphia, has
been appointed secretary for the United States of the Section
in Tropical Medicine of the Fifth Pan-American Medical
Congress, which will be held in Guatemala City, Guate-
mala, August 5th to loth.
Dr. Louis Faugeres Bishop and Mrs. Bishop will sail for
Europe on June 17th. They intend to spend the summer
in Nauheim, Germany, returning to New York early in
September.
Dr. H. B. Roop, of Columbia. Pa., is registered at the
Philadelphia Polyclinic and College for Graduates in
Medicine.
On the afternoon of Tuesday, May 19th, Dr. Charles E.
Beevor, of London, delivered, by invitation, a lecture on
the Methods of Examining Muscular Movements, at the
Hospital of the University of Pennsylvania.
Society Meetings for the Coming Week:
MoND.vY, May jjtli. — ^Medical Society of the County of
New York.
TuESD.w, May j6tli. — New York Dermatological Society
■ (annual) ; New York Aledical Union: New York Oto-
logical Society: }iletropolitan Medical Society of New
York City; pHLiTalo Academy of ^^ledicine (Section in
Obstetrics and Gynaecology).
Wednesd.w. May jjth. — New York Academy of Medicine
(Section in Laryngology and Rhinoldgy) ; New York
Surgical Societ}-.
Thursi).\\\ .l/,!y 2.V//;. — New York Academy of Medicine
( Seciion m Oljstetrics and Gyna?cology) : Brooklyn
Pathological Society: Hospital Graduates' Club. New-
York ( anni\ ersary ) ; New York Celtic Medical So-
ciety ; Brooklyn Society for Neurology.
The Health of Pittsburgh. — During the w^eek ending
May 2, 190S. the following cases of transmissible diseases
were reported to the Bureau of Health of Pittsburgh:
Chickenpox, 7 cases. 0 deaths: typhoid fever. 38 cases. I
death; scarlet fever. 16 cases, i death; diphtheria, 12 cases.
3 deaths; measles. 175 cases. 8 deaths: whooping cough. 14
cases, o deaths ; pulmonary tuberculosis, 25 cases. 10
deaths. The total deaths for the week numbered 140 in
an estimated population of 403,330. corresponding to an
annual death rate of 18.04 in i.ooo of population.
During the week einling May 9, 1908, the following cases
of transini-sililL .liv,.;is,- i\ure reported: Chickenpox. 4
cases, o c!i_,iih-: iNpliMid fe\er. 26 cases, 2 deaths; scarlet
fe\er. ,^t ci-i o deaths; diphtheria. 7 cases, 3 deaths:
mea'~!i 200 ci^cs. 2 deaths; whooping cough. 6 cases, 2
. deaih-; pnl mary tuberculosis. 31 cases, 15 deaths. The
total deaths for the week numbered 160 in an estimated
population of 403,330, corresponding to an annual death
rate of 20.62 in 1,000 of population.
Increased Pay for Naval Officers. — \ bill has been
signed by the President providing for increased pay for
officers and men of the Navy, which, according to the
members of the Committee on Military Affairs, puts the
officers of the Na\^ on a parity with those of the .-^rmy
under the new army appropriation bill. The bill fixes the
remuneration of commissioned officers on the active list
at the following figures: Lieutenant, junior grade, $2,000:
lieutenant. $2,400; lieutenant commander. $3,000; com-
mander, $3,500; captain, $4,000; rear admiral, second
nine, or commodore. $6,000; rear admiral, first nine,
$8,000. Each officer below the rank of rear admiral
receives 10 per cent, of his current year's pay for
each term of five years' service in the Army, Navy, and
Marine Corps, in addition to his annual pay, provided that
the annual pay of a captain shall not exceed $5,000 per
annum; of a commander. $4,500 per annum; and of a lieu-
tenant commander, $4,000 per annum. Furthermore, officers
are to receive an allowance of 10 per cent, additional wdicu
on sea duty or on sliorc duty lieyond the continental limits
of the United States.
May 23, .90S.] PITH OF CURREXT LITERATURE.
Details of the Army Pay Bill. — The army appropria-
tion bill contains many features which are of interest to the
members of the medical corps. Among these are the
authorization of the secretary of war to contract for the
care, maintenance, and treatment, at any asylum in the
Philippine Islands, of insane natives serving in the Army.
The appropriation for the hospital corps amounts to $955,-
840, of which $100,000 is for length of service; for the
medical corps. ^16,300, of which $130,000 is for additional
pay; for miscellaneous hospital matrons, $9,000; superin-
tendent of the nurse corps, $1,800; female nurses, $55,020;
for hospitals, $545.366 ; for quarters for hospital stewards,
$75,000; for medical supplies, $700,000; for special ap-
paratus, $200,000; for museums and laboratories. $5,000;
and for the surgeon general's library. $10,000. The total
appropriation for the Army, including the items mentioned,
amounts to $95,382,246.61. The bill includes an appropria-
tion of $1,000,000 for heavy furniture for permanent use
in the officers' quarters.
The Health of Philadelphia.— During the week end-
ing May 2, 1908, the following cases of transmissible dis-
eases were reported to the Bureau of Health : Typhoid
fever, 68 cases, 14 deaths; scarlet fever, 61 cases. 5 deaths;
smallpox, 2 cases, o deaths; chickenpox. 31 cases. 0 deaths;
diphtheria. 79 cases, 9 deaths ; cerebrospinal meningitis, i
case, o deaths ; measles, 504 cases. 17 deaths ; whooping
cough, 25 cases, 5 deaths ; pulmonary tuberculosis. 125
cases, 64 deaths; pneumonia, 72 cases, 51 deaths; erj-sipe-
las, 6 cases, i death ; puerperal fever, 6 cases, 7 deaths ;
mumps, 34 cases, o deaths ; cancer. 20 cases, 21 deaths. The
following deaths were reported from other transmissible
diseases : Tuberculosis, other than tuberculosis of the
lungs. 10; diarrhcEa and enteritis, under two years of age,
15. The total deaths for the week numbered 513 in an
estimated population of 1.532,738. corresponding to 'an an-
nual death rate of 17.40 in i.ooo of population. The total
infant mortality was 107; under one year of age, 74; be-
tween one and two years of age, 33. There were 49 still
births, 24 males, and 25 females.
Meetings of Sections of the New York Academy of
Medicine. — The Section in Ophthalmology met on
^londav evening, ^lav i8th. After the presentation of
patients by Dr. J. E. Giles and Dr. H. H. Tyson, Dr. Ed-
win Torok read a paper entitled The Diagnostic and
Therapeutic Value of Tuberculin in Tuberculous Eye
Diseases.
The Section in ^Medicine met on Tuesday evening. May
19th. Among the cases presented for discussion were an
unusual case of diabetes mellitus, by Dr. T. C. Janeway,
and a case of myelogenous leucamia with unusual peri-
splenitis, by Dr. X. S. Patterson. Dr. C. A. McWilliams
read a paper on Acute Dilatation of the Stomach.
On Wednesday evening. May 20th, a meeting of the
Section in Genitourinary Surgery was held. Dr. Charles
Goodman reported a case of papilloma of the bladder. Dr.
John Van der Poel presented specimens of hydrocele sac
containing atrophic testis and of teratoma testis. Dr.
Hiram X. Vineberg read a paper entitled Pyelitis in Preg-
nancy and in the Puerperium, which was followed by a
general discussion.
A meeting of the Section in Laryngology and Rhinology
will be held on Saturday evening, ^lay 23d. at 8:15 o'clock.
The programme includes the following papers : Some Es-
sential Principles in the Surgery of the X'ormal Accessory
Sinuses, by Dr. John F. Barn'hill. of Indianapolis, Ind. ;
Frontal Sinus Diseases, by Dr. Albert Jansen, of Berlin.
Germany. Among those who will take part in the discus-
sion are Dr. Robert C. IMyles, Dr. T. P. Berens, and Dr.
Felix Cohen.
The Section in Orthopaedic Surgery will hold no meet-
ing this month.
A meeting of the Section in Obstetrics and Gynaecology
will be held on Thursday evening. May 28th. at 8:30
o'clock. Dr. Ralph Waldo Lobenstein will report a case
of ruptured uterus after two Cesarean sections. Dr.
Ralph Waldo will present a specimen of dermoid cyst
of the right ovary from a child of nine years. Dr. Herman
Grad will report a case of hyperemesis gravidarum in two
successive pregnancies. Dr. H. A. Miller, of Pittsburgh,
Pa., will read, by invitation, a paper entitled A X'ew
Method of Controlling Haemorrhage in Cases of Placenta
Praevia Centralis. Dr. J. E. Welch w-ill read a paper on
Postpartum Bacteriaemia, based on the report of forty cases.
|it^ at Cumnt f ittratm.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
May 14, 1908.
1. A Comparative Study of Tsutsugamushi Disease and
Spotted or Tick Fever of Montana,
By P. M. AsHBURN' and Charles F. Craig.
2. A Study of the Value of the Measurements of Chest
Expansion,
By Harry W. Goodall and J. Lyman Belkxap.
3. The Extraintestinal Origin of Hydrobilirubin,
By A. E. AuSTix and Mabel D. Ordway.
4. A Lipoma from the Brachial Plexus : A Review of
Some of the Rare Cases of this Tumor.
By W. P. Carus.
I. A Comparative Study of Tsutsugamushi
Disease and Spotted or Tick Fever of Montana.
— Ashburn and Craig come to the conclusion that a
con.sideration of the facts concerning the two dis-
eases as at present known justifies the opinion that
they are separate and distinct disease entities ; they
present many points of semblance, but not enough
of them to overbalance those of difference. Accord-
ing to Tanaka the name tsutsugamushi has been
known since the earliest historical times, while the
name sliashitsu occtirs in old Chinese writings of
more than a thousand years ago. A quotation from
one such writing mdicates that at that time the dis-
ease was recognized as a distinct affection and was
ascribed to the bite of a mite which occurred in sum-
mer time in certain districts that had been flooded
by the spring rains. The bite was described and the
statement made that after three days high fever de-
veloped and a ptistule appeared at the site of the in-
jury. It was also recognized that only certain
regions were infected, and that the disease only ap-
peared in persons entering them. The disease was
brought to the attention of the \\'estern world by
Palm, in 1878, and Balz, in 1879, and since that time
it has been the subject of much painstaking work
by Japanese medical men and of numerous articles
in Japanese and some in foreign jotirnals. Numer-
ous microorganisms, including cocci, bacilli, and
protozoa, have been described as the cause of the
disease, and several investigators are working at the
present time, each with what he thinks the causative
factor. It cannot be said that any of these workers
has yet established his allegations. Three hypotheses
at present divide the workers and rule the work of
investigation : i . That the disease is due to a bacteri-
um, a belief favored bv the workers of the Institute
for Infectious Diseases. 2. That it is a protozoal
infection. Professor Ogata is the leading exponent
of this idea. 3. Tanaka thinks the disease due to a
toxine contained in the body of the red mite. Shot-
ted fever of Montana has been recognized for only
a few years, twenty-five at the most, while the liter-
ature relating to it has practically all been made
since 1902. At that time Wilson and Chowning
published their first account of it and their ideas as
to its cause and method of transmission, in a pre-
liininary report to the ^lontana State Board of
Health. ]\Iajor Wood, in 1896, and ]Maxey. in 1899,
reported a similar, or the same, disease in Idaho, but
the form occurring there presents great points of
difterence, particularly in regard to mortality. It
occurs in very strictly limited areas, particularly in
a strip of country about four to ten miles wide and
t0O4
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
fifty miles long, l\ ing on the west side of the Bitter
Root River and the eastern side of the Bitter Root
Mountains, and partly on the slopes of these moun-
tains. The country in question has a considerable
snowfall and the snow remains on the mountains
until mid June and on the highest peaks two or three
weeks longer. The Bitter Root River is largely fed
from this snow, and, as it begins to melt in March
and continues to do so with increasing rapidity until
most of it has disappeared, the stream is in a state
of freshet during that time and does not again reach
"low water" until July. During the same period
ticks, Dermaccntor occidentalis, which before and
after it are infrequently seen, appear in great num-
bers, particularly in the woods, thickets, and un-
cultivated regions. Likewise, and, as a rule, dur-
ing the same period, cases of spotted or tick fever
appear, and in almost all cases there is a history
of a recent visit to, or residence in, the infected dis-
trict, and, in many cases, of tick bites received there.
It may be said that the disease is introduced by the
bite of Dermaccntor occidentalis. A consideration
of the aetiology of the two diseases shows many
points of resemblance, but also differences. Both
occur in small and usually strictly limited areas
along certain streams running through mountainous
country. The country in each instance is subject to
heavy snowfall in winter and the streams to spring
or summer floods. Along each infected stream the
dangerous spots are usually more or less unculti-
vated and the soil overgrown with underbrush, trees,
or weeds, while the immune spots are well culti-
vated. In each instance the disease is attributed to
the bite of an Acarina, and in each a supposed pro-
tozoan blood parasite has been described as the cause
and has not been confirmed as such. Contagion is
unknown in either disease. The differences in the
aetiology of the two are equally well marked. The
Acarina whose bite causes tsiitsugainiislii is always
a six legged, larval Tromhidium, whose adult form
is unknown. That causing spotted or tick fe-
ver of ^Montana is always Dermaccntor occidentalis.
and usually the adult. Tsiitsiigamiishi disease oc-
curs always after floods, and it is contracted on
ground which has actually been submerged by the
swollen river. Fields immediatel\- adjoining the in-
fected areas and but a few feet higher are consid-
ered safe. The Montana disease may precede the
flooding of the streams, or, more usually, accompa-
nies it. It is very commonly contracted on ground
which has not been submerged, but is on hillsides
high above the level of the river. The cases be»in
in March and rarely appear after the middle of July.
Tsiitsuf^amushi disease is beginning to appear at
that time and continues to do so into October.
3. The Extraintestinal Origin of Hydrobili-
rubin. — .\ustin and Ordway state that when no
bile enters the intestine (absence of urobilin in fjEces
and urine) urobilin may occasionally be found in
fistula bile. This is not due to the conversion of
bilirubin to urobilin by the blood ; what effect cells
actively may have upon it we do not know. It is evi-
dent that the liver does not form urobilin, or it would
•be oftener found when complete closure of the com-
mon duct occurs. If urobilin is ever regenerated to
bilirubin, it is probably not an oxidative process, as
so often .stated. As cholecystitis is often accompa-
nied by bacterial infection of the gallbladder, from
which these germs may easily make their way into
the liver and there exercise their functions as in the
intestines, the query appears a just one, if the for-
mation of urobilin other than in the intestine may
not be due to bacterial infection.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
May 16, 1908.
1. Ideas and Ideals in Medicine, By S. J. Meltzer.
2. A Resume of the Coagulation of the Blood, with
Especial Reference to the Therapeutic Efficacy of
the Alleged Coagulants,
By William Egbert Robertson, G. Morton Illman,
and Harry A. Duncan.
3. Milk and Its Relation to Human Tuberculosis,
By James T. Gorton.
4. Acute Glanders. Report of a Case, with a Review of
Recent Literature and a Complete Bacteriologic Re-
port, By Leo B. Meyer and Burrill B. Crohn.
5. Glanders in Man,
By Arthur Dean Bevan and Walter W. Hamburger.
6. The Successful Treatment of Catarrhal Deafness, with
Especial Reference to Conditions in the Fossae oi
Rosenmiiller, By J. W. Jervev.
7. Rapid and Aseptic Anastomosis of the Hollow Viscera
by a New Method, By E. Wyllys Andrews.
2. Coagulation of the Blood. — Robertson, Ill-
man, and Duncan find that during the febrile stage
of the infectious diseases coagulation is noticeably
retarded. The clinical employment of the calcium
salts has no direct or invariable effect on the coag-
ulation time of the blood, either in large doses one
hour after its administration or in small or large
doses at any subsequent period, even extending
over two or more weeks. In their hands the cal-
cium cpntent of the blood, as determined in terms
of ammonium oxalate, proved unreliable. They
were unable to show definite relationship between
leucocytosis and coagulation time. Nucleic acid
uniformly failed to produce an increase in the num-
ber of leucocytes and also failed to hasten coagula-
tion. But the reaction of the coagulation time to
haemorrhage was shown conclusively. Though not
as striking as some of their other results, they
have been able to show that citric acid prolongs the
coagulation time, and it seemed, even when the dif-
ference in time before and after its use was not a
very material one, that the viscosity of the blood
was lessened.
4. Acute Glanders in Man. — Meyer and Crohn
say that in a typical case, with a good history the
diagnosis should not be difficult, if one has the dis-
ease in mind. Acute glanders in man is seen so sel-
dom that it is usually not even thought of, especially
when there is little in the way of skin lesions. A
bad coryza, which may be the most marked local
sign of glanders, is, of course, often present in grip
or pneumonia. Many of the cases recorded in the
literature, in which mistaken diagnoses were made,
showed neither coryza nor skin lesions at the on-
set, this being often characterized by chill, followed
by typical symptoms of pneumonia or grip or by
joint symptoms simulating rheumatism. Onl\
after a variable time has elapsed does there appear
nasal symptoms or a skin eruption which suggests
the possibility of glanders in any case. When,
however, with a more or less septic condition,
there appear on the skin indurated painful redden-
ed areas with soft centres, with less tendency to
May 23, 190S.J
PITH OF CURRENT LITERATI RE.
1005
rupture than ordinary abscesses, and whicli, when
opened, discharge a thin, serosanguinous material,
the resulting ulcer having a necrotic base, usually
involving muscle, and with no tendency to heal,
glanders should be thought of, and all the means
at our disposal should be made use of in aiding us
to reach a' correct diagnosis. The injection of mal-
lein. which is employed in diagnosticating incipient
or latent glanders in horses, is of no service in an
attack of suspected acute glanders in man. as a
positive diagnosis depends mainly on a rise of tem-
perature (in addition to a local reaction), and this
is always present. They have heretofore depended
on finding the Bacillus wallei in the cultures, and in
the typical results obtained by inoculation. These
means will, in practically all cases, enable us to
reach a diagnosis, but they are time consuming, re-
quiring from one to three days to furnish results.
Recently a new method of arriving at a diagnosis
has been devised, one based on the phenomenon of
agglutination and precipitation, and. therefore,
similar to the Widal test in typhoid. This method,
according to the report, is used officially in the di-
agnosis of glanders in horses, in Austria and Prus-
sia, and is considered fairly accurate.
6. The Successful Treatment of Catarrhal
Deafness. — Jervey describes the method of treat-
ment which he uses: After thorough cocainization.
the operator, facing the patient and slightl\- to his
right, passes the right index finger (palm of the
hand up) through the mouth, behind the soft palate
and into the postnasal space. After locating the
landmarks of the space, the finger tip is placed over
the top of the cartilaginous ring of the tubal orifice
into the upper end of the crescentic fossa. Press-
ing the finger firmly and deeply into the fossa, it is
sw^ept backward and downward throughout the
fossa's length, breaking down all resisting tissues,
repeating the movement if necessary, and not fail-
ing to break up the mass of granulations which fre-
quently occupies the extreme lower end of the fossa
behind the posterior faucial pillar. By inclining
the finger to the opposite side it can then be treated
in the same fashion, thus attending to both sides
without withdrawing the finger. After the bleed-
ing, which is usually slight, has ceased a cotton
tipped, curved, postnasal probe, dipped in a five to
ten per cent, silver nitrate solution or a thirty per
cent, argyrol solution, is firmly swept through the
fossae. This application should be repeated every
forty-eight hours for ten days or two weeks. The
results are excellent, sometimes brilliant, even ap-
parently miraculous, and often immediate. The
author has several times seen the hearing of a pa-
tient improve from 200 to 300 per cent, within a
half hour of the operation. The improvement is a
permanent one, which usually improves still
further under persistent catheterization and routine
applications. The latter should always be carried
out faithfully in these cases. The diagnosis of the
condition is easy by means of the rhinoscopic mir-
ror. Occasionally, when the fossa; are almost or
quite filled with form.ations which happen to pre-
sent a more or less sm_ooth surface, the appearance
will be that of very shallow or absent fossae. A
mistake should not be made. The fossa is never
absent and never very shallow in the adult. At
least three eighths of an inch of natural depth is al-
ways present, and sometimes considerably more.
The granulations or glandular hypertrophies some-
times extend down below the end of the fossa, and
appear, on oral examination, as reddish elevations
or thickenings just behind the posterior faucial pil-
lar. This appearance is often given the name of
lateral pharyngitis, and its treatment by the ordi-
nary routine has heretofore been rather unsatisfac-
tory^ If the patient has a wide open nostril all the
wav through, anterior rhinoscopy will show a lim-
ited excursion of the tubal orifice during the act of
swallowing. Inspection of the tympanic mem-
branes will show a lessened or absent hght reflex,
a ground glass, lustreless appearance, with more or
less depression. The hearing will usually be per-
ceptibly dulled, and if the condition is of long stand-
ing it mav be almost lost. Bone conduction of
sounds will be good, while air conduction is seri-
ously impaired, showing that the disorder is of the
passages and not of the perceptive apparatus.
MEDICAL RECORD.
May 16, 1908.
1. The Occurrence of Epileptiform Attacks in Diabetes
Mellitus. By Lewis A. Conner.
2. The Surgical Treatment of A'lveolar Pulmonary
Emphysema,
By'CH.\RLES Goodman and Siegfried Wachsm.\xn.
3. A Plea for Stricter Prophylaxis and More Sciemitic
Management of Obstetrical Cases in Tenement
House Practice, By E. K. Brown.
4. Air Borne Infections, Their Mode of Entrance;
Preventive, Abortive, and Ameliorative Treatment,
By W. SoHiER Brvant.
5. The Problem Which Confronts "the Otologist in the
Treatment of Chronic Catarrhal Deafness,
By Carolus Cobb.
6. Nitroglycerin in the Treatment of Neuritis,
By H. Burton Stevenson.
1. The Occurrence of Epileptiform Attacks in
Diabetes Mellitus. — Conner remarks that, al-
though some of the epileptiform attacks wh'ch
occur in the course of diabetes are manifestly due
to other associated conditions ( uraemia, cerebral
softening, meningitis, etc.), a certain proportion of
them are unquestionably related directly to the dia-
betes itself, and are the expression of some form
of diabetic intoxication. Such attacks may simu-
late closely the general convulsions of true' epi-
lepsy, or they may be distinctly Jacksonian in
character and be limited to one side of the body or
to certain groups of muscles. These localized con-
vulsions are usually associated with transient
paralysis of the aftected muscles, aphasia, sensory
disturbances, or other symptoms suggestive of a
circumscribed brain lesion, and may thus lead to
serious errors in diagnosis. The convulsions ma\-
appear only during the terminal coma, or they may
be repeated at frequent intervals for days or weeks
before coma develops, or, finally, they may cease
with improvement of the diabetic symptoms. The
association of such epileptiform attacks with the
signs of acid intoxication is by no means constant.
It seems probable, therefore, that the cause of the
convulsive attacks must be sought for in some other
form of diabetic intoxication.
2. The Surgical Treatment of Alveolar Pul-
monary Emphysema. — Goodman and \\'achs-
mann have adapted Freund's mode of operation.
ioo6
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
The pathological finc!ino-s are that the costal car-
tilages are of a (li;t\ \cllo\v color, in a state, of
fibrillation and cysnc. sliDwing also calcareous de-
posits which cause llicni to become increased in
size ; they are hardened, brittle, and devoid of their
normal elasticity. In the presence of such
changes, the proper excursion or motion of the cor-
responding ribs is interfered with. The cartilages
of the second and third ribs of the right side are
most frequently involved, but these changes may
involve all the costal cartilages. The first cartilage,
however, is rarely, and then usually the last, to be
involved in this disease. With the degeneration of
the cartilages and the accompanying rigidity of the
ribs, the sternum is forced outwards and contrib-
utes eventually to the formation of the rigid barrel
shaped thorax, which retains the lung in a contin-
ued state of distention. With the increase in the
diameters of the chest, the normal function of the
diaphragm is interfered with, and the muscle shows
evidences of atrophy and fatty degeneration. By
removing or resecting the offending cartilages, the
proper functioning power of the chest may be re-
stored ; the ribs will be permitted to exercise their
proper range of motion, and the proper expiratory
efforts of the lungs will be facilitated. They have
found that Freund's operation is of great benefit in
emphysema with a rigid dilated condition of the
thorax. A most convincing feature of this treat-
ment is observed during operation ; when the costal
cartilage is resected the rib recedes immediately, at
times below the level of the sternum. The ribs
move so freely that the finger tip is distinctly
squeezed when inserted between the sternum and
rib. The lung visibly contracts. Relief may be
afforded by operating upon one side. The opera-
tion is not dangerous, and is not followed by
shock. Cardiac insufficiency, asthma, chronic
bronchitis, and albuminuria are not necessarily con-
traindications of the operation. The best results
are likely to follow, however, when the operation is
undertaken before complications have arisen. A
removal of, or a plastic operation on, the perichon-
drium of the resected cartilages seems imperative
in order to obtain lasting im])rovcment.
4. Air Borne Infections. — r>r\ant says that
the evidence accumulated for many years, proving
that air borne infections are the most imi)ortant. is
now at our disposal. While the infections con-
veyed in fluids or solids are less numerous and have
fewer victims, the diseases carried by the air are
very many, and the list is constantly growing.
Tuberculosis, scarlet fever, measles, pertussis,
chickenpox, variola, influenza, pneumonia of vari-
ous kinds, diphtheria, epidemic ccrcl)r()si)inal men-
ingitis, acute poliomyelitis, acute articular rheuma-
tism, pyogenic bacterial infections, arteriosclerosis,
acute nephritis, typhoid fever, etc., are now known
to be air borne infectious diseases. Where do
these infections gain entrance to the body? Prob-
ably at the spot where the first signs of disease are
detected, namely, in the nasoi)haryn.\'. It has been
proved beyond the shadow of a doubt that this is the
road of infection in the majority of the diseases that
have been named. Note the chronicity of the symp-
toms, primary local infection and later toxaemia,
and the seciuence of local and general bacterial find-
ings. Some of the best understood of the diseases
which show these relations clearly are influenza,
scarlet fever, epidemic cerebrospinal meningitis,
acute articular rheumatism, and diphtheria.
BRITISH ^/EDICAL JOURNAL.
May 2, iQoS.
1. The Influence of Pregnancy upon Certain Medical Dis-
eases and of Certain Medical Diseases upon Preg-
nancy (Goulstonian Lectures, I), By H. French.
2. The Treatment of Widespread Suppuration and Multi-
locular Abscesses, By W. G. Spencer.
3. A Consecutive Series of Thirty-four Cases of Excision
of a Portion of the Rectum for Carcinoma,
By C. A. Morton.
4. Case of Strangulated Femoral Hernia, complicated by
Prolapse of the Caecum and Adhesion of the Vermi-
form Appendix to the Sac,
By D. V. Maxwell Adams.
5. Acute Faecal Impaction in the Rectum,
By W. M. RoBSON.
6. A Case of Tubercular Leprosy. By M. Mackinnon.
7. Kala Azar in the Royal Navy, with Illustrative Cases,
By P. W. B. Smith.
I. Pregnancy in Its Relation to Disease. —
French, in the first of his Goulstonian lectures, states
that there are certain medical diseases for which
pregnancy itself seems directly responsible. One of
the most definite of these is herpes gestationis, a
disease apparently related to pemphigus, hydroa,
erythema bullosum, and to dermatitis herpetiformis.
The eruption varies as to the relative preponderance
of erythema, papules, and wheals, but the distinctive
lesion is vesicular or bullous. The vesicles are not
often confluent or crowded together as in herpes
zoster. They are preceded by an itching erythema,
rapidly becoming papular and then vesicular. The
chief clinical distinction between it and dermatitis
herpetiformis is the direct relationship of herpes
gestationis to pregnancy. Increased pigmentation
of the skin is apt to be left after each attack : this
may be generalized all over the body, but usually
it is most marked where the eruption has been the
worst. It is probably not allied in any way to
uterine chloasma, and the chief causes are the con-
stant scratching and rubbing, and also the arsenic
which is given in most cases. Herpes gestationis
agrees with the other bullous dermatoses in exhibit-
ing eosinophilia ; this is not confined to the blood
alone, but the eosiiinphile leucocytes are also found
in the interepithelial l\niphatic spaces, and in the
fluid of the blebs. But they are not increased in
the fluid of an artificial blister. The general opinion
is that the eosinophilia is the result of the skin
lesion, due, perhaps, to the absorption of something
from the skin, ju.st as in ankylostomiasis there is
eosinophilia, due to absorption of a toxine from the
bowel. It seems clear that the cause of herpes
gestationis arises within the body, and that the
lesion is not due to agents acting directly upon the
skin from without. Bacteriological investigations
have proved negative. Impetigo herpetiformis
seems to be a virulent degree of herpes gestationis,
dangerous to life. Fortunately, it is rare. The
eruption is pustular, and may spread over the entire
body. The pustules dry up with the formation of
scabby crusts, fresh ones appear in the adjacent
skin, and so the eruption spreads in a circinate man-
ner. There is no ulceration. The patient has con-
tinuous remittent fever, with an exacerbation with
Maj- 23, 1908.]
PITH OF CURRENT LITERATURE.
1007
each fresh crop of pustules. \'omiting and deUrium
are usual, and the patient generally dies in a few-
months. Labor does not prevent the fatal termina-
tion. Post mortem there is no evidence of pygemic
or septicaemic infection. The cause is probably an
internal toxaemia. Eczema and psoriasis are often
influenced by pregnancy. As a general rule, a pa-
tient's eczema will very likely be mitigated rather
than made worse during pregnancy. Pregnancy
either makes psoriasis worse or better — more often
the latter. On the other hand, the effect of lactation
upon psoriasis is almost invariably bad. Pregnancy
is an important factor in the causation of pyelo-
nephritis. The sequence of events probably is as
follows : Enlargement of the uterus ; compression
of the ureter against the brim of the true pelvis ;
consequent difficulty in the ejection of urine secreted
by the corresponding kidney ; infection of the urine
retained in the partially obstructed ureter and renal
pelvis ; and subsequent spread of the kidnev sub-
stance itself. And just as in pyelonephritis in man,
due to prostatic enlargement, removal of the ob-
struction by the birth of the child tends to cure the
renal mischief. In nearly every case the right kid-
ney is very much more affected than the left. This
is probably due to the fact that the uterus develops
much more to the right than to the left ; it also in-
clines and is rotated to the right. The bacteriology
of the condition is very constant ; in all but a few
of the cases the Bacillus coli communis is the causa-
tive microorganism. It is nearl\- always in pure
culture. The pyelonephritis of pregnancy is often
mistaken for something else — c. g., lumbago, in-
fluenza, pneumonia, pleurisy, appendicitis, etc. The
main symptoms are backache and pyrexia, with or
without headache, vomiting, or rigors. Examina-
tion of the urine wilt of course, show pus and
microorganisms.
3. Excision of the Rectum for Cancer. — Mor-
ton's article is based on a series of thirty-four con-
secutive cases of rectal cancer treated by excision.
There were four deaths, a mortality of twelve per
cent. Two deaths were due to shock, one to peri-
tonitis, and one to acute mania. Eight cases have
remained free from recurrence after one to three
years. In all the recurrent cases the disease was
extensive. In fifteen cases the coccyx was not re-
moved, and the peritonaeum was not opened. Where
the growth is low down, yet far enough above the
anus to leave a healthy segment of bowel, by re-
moving the coccyx a circular union can be made,
sphincter action preserved, and yet the peritoneal
cavity not have to be opened at all. It is usually
stated that if the growth is fixed to the tissues out-
side the rectum the case is inoperable. But this
does not hold good always. Growths may be fixed
to the prostate and yet not infiltrate it. Fixation
to the lower end of the sacrum or the coccyx need
not contraindicate operation, for that portion of the
bone can be removed. If the posterior vaginal wall
is involved, it can also be removed. As a rule,
there is no great amount of shock after the opera-
tion. If it is done with the patient almost prone
very little blood is lost. The best position for drain-
age is on the back. But pressure must be taken off
the wound by proper arrangement of the pillows.
After the first twenty-four hours the back and
lateral positions should be alternated. As regards
the amount of control over evacuation of the bowel
after the operation, the result is generally about the
same as after a colotomy on the left side. The
bowels act once or twice a day, and leaking is slight
or absent. After circular union the action of the
bowels may be normal. Half the patients here re-
ported were from sixty to seventy years of age.
In two very extensive cases the ages were only
twenty-six and twenty-eight years. In conclusion,
the author's study of these thirty-four cases shows
that, even including the cases of growth high up.
the excision of which necessitates removal of a part
of the sacrum and a free opening of the peritoneal
cavity, the mortality is not very high. There may
be no recurrence in quite a number of the cases, and
life will be much prolonged and made much more
comfortable in a large number.
LANCET.
May 2, igo8.
1. The Influence of Pregriancy upon Certain Medical Dis-
eases, and of Certain !NIedical Diseases upon Preg-
nancy (Goulstonian Lectures, I). By H. Frenxh.
2. The Special Psychologj- of \\'omen. By T. C. Shaw.
3. Ophthalmia Neonatorum; an Experiment in Treatment.
By A. N. Walker and A. A. Mussen.
4. The Treatment of Trachomatous Dacryocystitis,
By T. H. Butler.
5. On the Pathology and Treatment of Inguinal Hernia
in Children, By C. H. F.xgge.
6. Disseminated Sclerosis, commencing with Failure of
Vision, By R. T. Williamsox.
7. On the Rectal Administration of Antitoxic Sera.
By J. P. Parkixsok.
8. Motoring Notes, By C. T. W. Hirsch.
3. Ophthalmia Neonatorum. — Walker calls
attention to the unsatisfactory results of treatment
of cases of ophthalmia neonatorum among the poor,
due to the cases being seen late and not being con-
tinuously treated. He is satisfied that the disease is
very amenable to treatment if attacked vigorously
at the outset. But this is the very treatment which
the average case does not receive, owing to the im-
possibility of carrying out, in the homes of the poor,
frequent and thorough irrigation both by day and
by night. The indication then is the admission of
cases occurring among the poor, as soon as possible
after the beginning of the disease, into an ophthal-
mic hospital, where vigorous treatment can be car-
ried out. A separate ward must be provided and
a special nurse appointed who must not be allowed
to touch clean cases. In order not to interfere with
the feeding and nutrition of the infant, its mother
should be admitted to the hospital also.
5. Inguinal Hernia in Children. — Fagge ac-
cepts the view of Russell that hernia is primarily
a developmental defect owing to either partial or
complete persistence of the embryonal processus
vaginalis. As regards the diagnosis of inguinal
hernia in children, the only other inguinoscrotal
swelling likely to cause difficulty is a patent pro-
cessus vaginalis containing fluid — a "congenital"
hydrocele. This is usually irreducible, though the
fluid spontaneously returns to the abdornen after
the child has been lying down for a short time.
\Mien the fluid returns into the vaginal process it
does so slowly, and this is in itself quite sufficient
to distinguish it frotn a hernia. As regards treat-
ment, the writer has never seen circumcision have
ioo8
PITH Of CURRENT LITERATURE.
LN'ew York
Medical Journal.
the slightest effect, either in aiding the cure or even
in preventing tlie enlargement of a hernia. The
woolen skein is absolute as a truss. When truss
treatment is adopted it must begin as soon as the
rupture appears. A well fitting spring truss cov-
ered with rubber must be applied daily before the
child is lifted from its cot, while the hernial con-
tents are still within the abdomen. In many cases
where the hernia tends to come down at night a
light truss must be worn at night also. The diffi-
culty of efficiently carrying out this line of pro-
cedure is enormous. A truss must be worn for
several years before we can hope that the hernia
will not return if it is omitted, and during this time
attention must be paid to changing the truss in ac-
cordance with the growth of the child. The writer
thinks it is the duty of every medical man to im-
press upon parents that trusses hold out no pros-
pect of permanent cure, and that the time has cer-
tainly arrived when cure can be more easily and
almost certainly obtained by operative means,
which, in themselves, are practically devoid of risk.
The following are absolute indications for opera-
tion. I. Hernije which cannot be kept up by trusses,
or which are painful when a truss is worn. 2. Large
scrotal hernise which have stretched the inguinal
canal considerably and therefore render trusses
necessary throughout life. 3. The association of
an undescended testis with an inguinal hernia. 4. A
hernia which has been irreducible on a previous
occasion. This does not, of course, include strangu-
lated herniae, which must be dealt with at once. In
the writer's opinion, taxis should never be at-
tempted.
6. Disseminated Sclerosis. — Williamson re-
ports a series of cases of disseminated sclerosis in
which failure of vision, in one or both eyes, was
the first symptom of the disease. Other symptoms
may not appear or may be very slight for a long
period, even for many years. Signs of optic atrophy
may or may not be present. At first these cases are
usually diagnosticated as primary optic atrophy, or
as retrobulbar neuritis of "imknown origin." In
this form of disseminated sclerosis, pain, and anaes-
thesia are very rare. The signs of chief diagnostic
value in the early stage are : ( i ) Unilateral or
bilateral visual failure, with central scotoma in
some cases, and often with pallor of the optic disc,
especially of the temporal half; (2) the Babinski
type of plantar reflex on one or both sides; (3) the
irregular and shaky character of the handwriting,
even when the tremor is so slight that it can hardly
be detected; and (4) the age of the patient, under
forty years. The absence of any cause for the affec-
tion and of any history of syphilis, the absence of
any pain and anaesthesia, and the presence of the
knee jerks, tendo Achillis reflexes, and pupillary
reflexes are points of diagnostic value in favor of
dis.seminated sclerosis. In many cases, after the
visual defect has become marked there is a decided
improvement or almost complete recovery of vision.
Even when the visual defect does progress it rarely
advances to complete blindness, differing in this
respect from the optic atrophy of tabes dorsalis.
Though the prognosis of disseminated sclerosis is
usually unfavorable and the termination fatal, yet
in many cases the disease is very chronic.
LA PRESSE MEDICALE.
April II, 1908.
1. The Suture of Vessels, By Albert Frouin.
2. Facial Hemispasm, with Motor Troubles of the Limbs
of the Opposite Side,
By Brissaud and J. A. Sicard.
3. The Treponema Pallidum. Diagnosis of Syphilis with.
the Ultramicroscope, By Paul Gastou.
4. The Midday Diarrhcea, By R. Rom me.
1. The Suture of Vessels. — Frouin describes
with illustrations the technique of uniting the ends
of a divided artery, and of joining an artery and a
vein.
2. Facial Hemispasm with Motor Troubles of
the Limbs of the Opposite Side. — Brissaud and
Sicard report three cases. The first, a man forty-
six years old. syphilitic, with facial hemispasm on
the right side, hemiparesis of the upper and low-er
limbs of the left side, and a facial paralysis on the
left side of a peripheric type ; the second, a general
paralytic, fifty-two years of age, who had total
facial hemispasm of the right side, ten to twenty
spasms an hour, with hemiparesis of the upper and
lower limbs ; the third, a tabetic, of forty-eight
years, with left facial hemispasm and hemiparesis,
and trembling of the right upper and lower limbs.
3. Diagnosis of Syphilis with the Ultramicro-
scope. — Gastou describes the principle of the
ultramicroscope, the mechanism of the Leitz-Cogit
instrument, the manner in which it is used, and the
appearance of the Treponema pallidum when thus
seen. Finally, he gives a distinctive diagnosis be-
tween the spirochaeta and spirillae as seen with the
ultramicroscope.
April 75, jg)08.
The Scientific Contest \\ith Typhoid Fever,
By Robert Debre.
LA SEMAINE MEDICALE.
April ij, igoS.
Twenty-fifth German Congress of Internal Medicine, held
at Vienna, April 6 to 9, 1908.
1. The Female Genital Organs and Internal Diseases.
2. Actual State of Our Knowledge Concerning the Pathol-
ogy and Treatment of Syphilis.
3. The New Methods of Clinical Investigation of Intes-
tinal Functions.
BERLINER KLINISCHE WOCHENSCHRIFT
April 13. 1908.
1. The Treatment of Phlegmon of the Sheath of a Ten-
don, By R. Klapp.
2. Concerning Special Nervous Symptoms in Addison's
Disease, By L. Wagner.
3. Wassermann's Syphillis Reaction, By R. Beneke.
4. Concerning the Role of the Lipoid in Wassermann's
Syphilis Reaction,
By O. PoRGES and Georg Meier.
5. The Pathogenesis of Salivation, By H. Roder.
6 The Symptomatologj' of Chorionepithelioma, Particu-
larly of the Pulmonary Metastases,
By E. Scheidemandel.
7. The Indications Discoverable with the X Rays of Gas-
trectasia and Ptosis of the Pylorus,
By Franz M. Grodel.
8. Concerning iMyosis in Reflex Immobility of the Pupil,
By Levinsohn.
9. Concernmg Sigmoiditis and Perisigmoiditis Puerperalis,
By F. Lehmann.
10. Concerning a Hitherto Undescribed Symptom Observed
in Chronic Strictures of the CEsophagus,
By P. M. REwinzoFF.
IT. The Leuchxmic and Pscudoleuchnemic Diseases of the
Skin, By .\rthur .Alexander.
I. Treatment of Phlegmon of the Sheath of a
Tendon. — Klapp incises the phlegmon not from
May ^3. 'QoS.J
PITH OF CURRENT LITERATURE.
1009
the tiexor side, but always from the lateral side.
In the fingers the incisions are made on either side
to the palmar side of the arteries, so that there is
no danger of wounding them, leaving a portion of
the skin unwounded at each joint. By these inci-
sions the pu§ is freely evacuated and the sheaths are
then washed out with a warm physiological salt
solution. A dressing is then applied and changed
daily. He has used this method in nineteen cases
which he divides into four groups: i, Ten cases of
pure phlegmon of the sheath of a tendon, nine cured,
one became partially necrotic. 2, Two cases with
large subcutaneous panaritium over the tendon in
which the latter had been exposed for a long time
through extensive necrosis of the skin, one cured,
one partly necrotic. 3, Six cases of panaritium
tendinosum complicated with changes in the bones
(infected fracture of the phalanx by a bite, gunshot
injury with laceration of the sheath of the tendon,
panaritium ossale), two cured, four partially or
wholl}- necrotic. 4, One case which resulted in
death from sepsis on the twelfth day after the in-
fection, in spite of the most careful evacuation of
the pus.
4. The role of the Lipoid in Wassermann's
Syphilis Reaction. — Porges and Aleier say that it
is certain that the materials demonstrated in the
serum and other body fluids by Wassermann's reac-
tion should not be designated as antibodies in the
sense in which that term has hitherto been used,
i. e., to denote substances connected with the heal-
ing process. They are rather materials which pos-
sess a great power of elimination of certain lipoid
substances of "exceeding importance to the normal
cells of the organism, particularly of lecithin. While
they state that it is their desire not to draw conclu-
sions, but rather to simply report experimental facts,
they nevertheless point out that further conclusions
might be drawn from the knowledge thus discovered
in regard to the details in syphilitic infection and in
postsyphilitic diseases, especially as literature al-
ready contains a great number of facts and observa-
tions which indicate the role played by lecithin ni
certain syphilitic affections.
5. Pathogenesis of Salivation. — Roder con-
cludes from the results of his experiments on dogs
that the salivary secretion is altected by three differ-
ent kinds of reflexes: i, the involuntary reflexes of
the oral cavity ; 2, the voluntary reflexes ; 3, the
reaction from the sensory motor zone of the cere-
bral cortex when simultaneous movements are exe-
cuted.
6. Chorionepithelioma: — Scheidemandel says
that the chorionepithelioma is the form of tumor
which is most frequently productive of pulmonary
metastases. The symptoms are sudden haemoptysis,
dyspncea, cyanosis, chills, and pain in the breast,
which form the first and only indications of the
presence of this form of tumor in persons previously
with healthy lungs. The history of the former ex-
istence of a hydatid or cystic mole is of great im-
portance in the diagnosis. Further confirmation can
be obtained from a gynaecological examination, espe-
cially an inspection of the vagina for the varix like
tumor nodules. In men chorionepitheliomata of the
lungs may appear in association with teratoid neo-
plasms of the testicle. Treatment must be operative
with demonstrable disease of the uterus ; the pres-
ence of pulmonary metastases does not form a con-
traindication to the operative procedure.
7. Indications Discoverable with the X Rays
of Gastrectasia and Ptosis of the Pylorus. — Gro-
del delineates the conditions in a number of patients
examined by him and compares them with the de-
lineation of the picture presented by the normal
stomach. The pathological conditions were those
of atonic ectasia and hereditary ectasia of the stom-
ach, with or without ptosis of the pylorus.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT
April 14, igo8.
1. Accidental Cardiac Sounds in Pregnancy, By Link.
2. The Practical Value of the Opsonic Index,
By Saathoff.
3. Tuberculin and Antituberculin, By Ludke.
4. The Treatment of Surgical Tuberculosis with the Anti-
tuberculosis Serum of Marmorek, By Hohmeier.
5. Contributions to the Epidemiology and Bacteriology of
Epidemic Cerebrospinal Meningitis,
By Trautmanit.
6. Serum Reaction in Scarlet Fever and Aleasles,
By SCHERESCHEWSKY.
7. The Composition of Whale's Milk. By Scheibe.
8. Border Line Cases in Gynaecology, By Brewitt.
9. The Treatment of Cardiac Diseases, By Freund.
10. Concerning Intermittent Lameness (Dysbasia Angio-
sclerotica, Erb), By Grube.
11. The Phosphatometer, with Some Remarks Concerning
Phosphoric Acid in the Urine and Phosphaturia,
By Friedmann.
12. Eye Disease Caused by Working with an Artificial Fer-
tilizer, By Bond.
13. Concerning a Rare Case of Extensive Destruction of
Bone Resulting from a Tuberculous Suppuration of
the Jkliddle Ear in a Child Two Years of Age,
By Muhlenkamp.
14. A Clamp for the Umbilical Cord, By Muller.
15. Obituary of Friedrich von Esmarch, By W.mtz.
2. Practical Value of the Opsonic Index. —
Saathoff concludes that on account of the compli-
cated nature and extremely difficult technique, the
method of determination of the opsonic index can
be practised only in certain institutes w^hich are able
to employ an investigator for this purpose. This
detracts greatly from the value of the method. On
accotmt of the great and incalculable sources of
error which appertain to the determination of the
opsonic index the method is of value only in the
rare cases in which the eruptions are very great.
For these reasons the opsonic index is unreliable for
therapeutic application. The value and the further
development of active immunization remains un-
touched.
4. Treatment of Surgical Tuberculosis with
the Antituberculous Serum of Marmorek. — Hoh-
meier states as the result of his experience that he
has not observed any serious disturbance or injury
of the organism from the use of the serum, that he
considers it possible that in very mild cases of bony
tuberculosis Marmorek's serum may accelerate a
cure, but cannot ascribe a positive effect upon quite
fresh and slight tuberculous diseases of the bones or
joints to the serum ; that he thinks he has observed
an effect of the serum upon granulations which, be-
fore the treatment, were gra}- and sluggish, and af-
terward assumed a bright red appearance : that he
did not obtain a cure in cases of tuberculosis of the
bones of moderate severity, though in one case he
PITH OF CURRENT LITERATURE.
succeeded in closing obstinate fistulre : that in severe
cases of tuberculosis of the bones he did not observe
the least improvement as the result of the serum,
either immediately or. so far as he had opportunity
to observe, subsequently, and that he did not obtain
an improvement of the general condition which he
could ascribe to the serum.
6. Serum Reaction in Scarlet Fever and Mea-
sles.— Schereschewsky says that, although no
definite conclusions in regard to the relations of the
streptococcus to scarlet fever can be drawn from
his experiments, yet the latter show the presence of
materials in the serum of scarlet fever patients which
have the power to precipitate each other, and that
these sul)stances. scarlet fever precipitin and pre-
cipitogen, are not to be replaced by the streptococ-
cus precipitinogen of the streptococcus pyogenes of
his stock.
10. Intermittent Lameness. — Grube reports
four typical cases of dysbasia angeiosclerotica with
absence of the foot pulse. All the patients were
men, aged sixty-six, fifty-four, seventy, and fifty-
nine. Three were suffering from dialx'tcs or glyco-
suria, one had contracted kidne}-s. Erb ascribes a
certain :etiological value to the misuse of tobacco,
and this had formerly been present in two of the
cases. One case gave no historv of the mistise of
either alcohol or tolxacco, or of syphilis.
AMERICAN JOURNAL OF SURGERY.
April, 1908.
1. A Point in the Technique of Appendicectomy,
By Howard Lilienthal.
2. An Original Observation as to the Nature of Colic;
and Remarks Concerning Its Diagnostic Value,
By George Franklin Shiels.
3. Uterine Fibroids Complicating Pregnancy,
By C. C. Barrows.
4. Blood Examination in Surgical Diagiidsis. A Practical
Study of Its Scope and Technique ( Cinitiinicd ) .
By Ika S. Wile.
5. The Early Restoration of Function After Excision of
the TubercuknH FJlinw Joint,
P.y GiLCERT Geoffrey Cottam.
6. Treatment of the Bladder After Suprapuliic Cystotomy
f' r Stiiiie. By Willlam A- Goldsmith.
7. Ga •irfi( iiiri (i-,toniy, By John D.\ri<ington.
8. .Maia--'- Operation. Report of Four Cases,
By Craig Barrow.
9. Caesarean Section ; Report of Two Cases,
By E. J. Johnson.
10. Two Cases of Cnnipli'-aicd r;rrine Prolapsus: Com-
plete Prolapsii- . .t l/ii rim i'ihroid: Ovarian Cyst
Complicating Secion! De.uree Prolapse,
By Wn.MEK Kkusen.
11. Frecal Fistula Following Appendicectomy, with Report
of Three Cases, By JoskVii B. Bissell.
12. Remarks on the Treatment of iMMetnn ,<( die Hip.
with Especial Reference to Wlniman's .Method.
r.\ .\. COWDEN.
I. A Point in the Technique of Appendicec-
tomy.—Lilienthal remarks that the handling of the
intestines, and even iheir exposure to the air, is one
of the mcst potent causes of shock after abdominal
operations. To lessen this element of danger in
appendicectomy, he has used the following method,
whicli can be j)erformcd in most of the cases, espe-
cially in interval cases and in the early stage of the
actite form of perityphlitis. Through a small in-
cision marie in the locality preferred by the operator,
a gloved finger is insertcfl, locating the ca;cum ; a
portion of this viscus is withdrawn with dressing
forrcy)s, and landmarks followed in the usual way
[New York
Medical Journal.
to locate the base of the appendix. During this
procedure there will be a little unavoidable handling
of intestine outside of the abdomen. Having
exposed the base of the appendix, a ligature is
passed through the mesenteriolum, to be used sub-
sequently for ligating the organ ; the 'ends of this
ligature are left long, and are tied together or held
with a clamp. The exposed part of the appendix
and all other intestines are now returned to the ab-
dominal cavity. When traction upon the ligature
is made the base of the appendi.x and nothing more
is brought into the wound. In the majority of cases
it will then be found extreiaiely simple to deliver the
entire appendix even though a considerable number
of adhesions should be encountered. During the
procedure of freeing and removing the appendix,
this organ only is in the field.
THE PRACTITIONER.
April, igo8.
1. The Treatment of Acute Pneumonia, By L. West.
2. Polycytluemia in Diseases of the Heart and Lungs and
Durmg Residence at High Altitudes,
By F. P. Weber.
3. Injuries to the Head in Young Children,
By D. Drew.
4. The Importance of Accurate Diagnosis and the Treat-
ment of Fractures in the Vicinity of Joirits,
By C. H. Fagge.
5. The Relation Between Sciatica and Disease of the Hip
Joint, By W. I. Bruce.
6. Some Important Points in Connection with Infant
Feeding, By J. Burnet.
7. Chronic Colitis and Its Surgical Treatment,
By P. L. Mummery.
8. The Ambulatory Treatment of Fractures as Applied
to Osteotoiny, By G. B. Buchanan.
9. Some Recent Literature Upon Arthritis. A Review
and Commentary, By F. J. Povnton.
10. A Review of Otology, By R. Lake.
2. Polycythaemia in Diseases of the Heart and
Lungs and During Residence in High Altitudes.
— West observes that an abnormal number of red
corpuscles may be absolute or relative. The lat-
ter is due to concentration of the blood, as from
choleraic diarrhoea ; the former is due to an actual
increase in the volume of blood in the body. Cases
of the former may be due (i) to imperfect oxy-
genation of the blood and tissues resulting from
circulatory disturbance in chronic cardiac and pul-
monary disease, or (2) to residence at a high alti-
tude, with diminished oxygen tension in the in-
spired air, or (3) to splenomegalia. In the first
class of these cases, deficiency of oxygen stimulates
the function of the red bone marrow and causes in-
creased production of red cells, being thus a con-
servative or compensatory reaction. In the second
class there is al.so a conservative vital reaction of
the bone marrow, compensating for the difficulty in
oxygenation at the high altitudes. In the third class
nothing further is known than that here also is an
increased activity of the bone marrow. True poly-
cythaemia is usually associated with a condition of
true plethora. The viscosity of the blood is in-
creased in all of the varieties of polycythaemia, and
this is a factor of importance in chronic disease of
the heart and lungs. It is an indication for vene-
section, with consequent relief to the right side of
the heart and dilution of the blood current.
3. Injuries to the Head in Young Children. —
Drew states that these injuries dilYer from similar
May 23, 1908.]
FITH OF CURRENT LITERATURE.
lOll
ones received in, later years, the skull being less re-
sisting, the bones flexible, the dura more adherent,
and the sutures ununited. Fractures rarely occur,
but may result from abnormality in the maternal
pelvis, precipitate labor, or the use of forceps. De-
pressions may be slight, with indentation which
gradually disappears, or they may be extensive and
demand operation. The depression may destroy life
in utero, or such a result may be deferred for hours
or days after birth. Injury to the brain may be
quite out of proportion to the apparent injury to the
skull. If the dura is torn the subdural space will
be opened, the cerebrospinal fluid will escape, and
a cephalhydrocele ma\- result. If such a tumor in-
creases in size the prognosis will be unfavorable,
meningitis or hydrocephalus being the probable se-
quence. The most frequent injury to the head in
the newborn is haematoma. If unassociated with
fracture it is usually absorbed in three or four
week's. In fracture, with or without depression, the
-question of operation becomes an important one for
consideration.
4. The Importance of Accurate Diagnosis and
the Treatment of Fractures in the Vicinity of
Joints. — Fagge justlv remarks that immediately
after a fracture a correct diagnosis is often impos-
sible. The diminished mobility often suggests dislo-
cation, especially in those fractures which extend
from a joint surface into the shaft of a bone. Even
radiography may not reveal such lesions. It must
not be forgotten that dislocation is frequently asso-
ciated with fractures. Following Cheyne, these frac-
tures are of three forms, i. Those which do not
involve the articular ends of the bone and are out-
side the capsule. 2. Those which extend into the
joint cavity, as a linear split involving one of the
condyles of the humerus or a T shaped fracture or
comminution of the articular extremity. 3. Those
which do not extend into joints, but are typically
associated with displacement of the adjacent artic-
ular surfaces. A diagnosis may be confirmed by
radiography, but one must be able to make a diag-
nosis W'ithout such aid. The deformity should be
reduced under a general anaesthetic, and an x ray
picture may be taken after the application of the
splint. If the fragments do not remain in appo-
sition an open operation will be required within five
or ten days from the reception of the injury. The
aim of treatment should lie not onlv the replacement
of the normal outline of the bone, but restoration
of the movements of the adjacent joint and muscles.
6. Some Important Points in Connection with
Infant Feeding. — Burnet assumes that there is
no perfect substitute for mother's milk. Diluted
cow's milk is the best substitute there is. h"t the
tendency is to make the dihition too complicated.
Sterilized milk is dangerous. A child may gain in
weight under its use, but soon it will become an-
aemic, constipated, and perhaps rachitic. Milk
depots should not be managed bv nurses and lay-
men, but by a physician who knows the supreme
value of breast feeding. Sterilized milk, after re-
peated handling, is no longer sterile, and that is the
condition with much of the supplv in milk depots.
Pure cow's milk is not more likely to cause diar-
rhoea than the average breast milk. Sterilized milk,
it must be remembered, has been deprived of some
of its most useful properties. As to the matter of
weight in infants, too much stress has been laid
upon this subject. Gain in weight does not neces-
sarily indicate gain in health and strength ; it may
even be associated with rachitis. Loss of weight,
however, does indicate retrogression. Infant foods
are not essential to the rearing of healthy children.
7. Chronic Colitis and Its Surgical Treatment.
— flummery classifies this disease as chronic mucous
colitis, membranous colitis, chronic ulcerative colitis,
and follicular ulcerative colitis. The electric sig-
moidoscope has greatly extended our knowledge of
this disease, for the sigmoid is the portion of the
colon most frequentl>- afifected. The first two of
these forms are quite similar; their cause must be
discovered, and if this should be appendicitis, cancer,
or local lesion, the cause must be removed surgi-
cally. One of the suggested measures of treatment
is appendicostomy, after which the colon can be
regularly washed' out with appropriate solutions.
Another suggestion is ileosigmoidostomy, by which
the ileum is drained directly into the rectum.
Chronic ulcerative and follicular ulcerative colitis
are also two forms of the same disease, the ulcers
being small and punched out, with red, raised edges ;
diarrhoea and bloody stools are usually present. Or
the ulcers may be large, irregular, and extend
around the bowel, the condition being serious and
often fatal. Medical treatment having failed in such
cases, a right lumbar colotomy should be performed.
This will often turn the scale in the patient's favor.
ARCHIVES OF P/CDIATRICS.
April, JO08.
r. The Relation of the Bacilli Belonging to the So Called
Dysentery Group to the Diarrhoeal Affections of
Infants, By J. H. M. Knox, Jr.
2. The Need of Greater Accuracy in Prescribing Starch
in Infant Feeding, By M. L.\dd.
3. Specimens and Photograph of Resected Ribs.
By F. HuBER.
4. A Case of Articular Rheumatism in an Infant,
By J. P. C. Griffith.
5. Congenital Malformation of the Oisophagus, with Re-
port of a Case, By J. Phillips.
6. Sarcoma of the Kidney in Infancy,
By W. F. Cheney.
7. The Pathology of Fuberculosis in Children.
By J. McCrae.
8. Laboratory Aids to the Diagnosis of Tuberculosis in
Infants, By T. H. Coffin.
9. Channels of Communication in Tuberculosis,
By S. McC. H.^MiLL.
2. The Need of Greater Accuracy in Prescrib-
ing Starch in Infant Feeding. — Ladd states that
his plea is neither for nor against the use of starches
in the first year of life, but for a more scientific
basis of administering them when thev mav be
needed. Starch should be prescribed in percentages,
the same as fats, sugar, and proteid. Infants being
unable to digest starch at birth, the logical way of
using it, barley w-ater, for example, is to begin with
a small percentage and gradually increase it. In
a series of analyses of cereal decoctions it was ob-
served : ( I ) That the barley and oat preparations
made after the manner described have the same
composition. (2) That two ounces of either flour
to a quart give a 3 per cent, starch solution. (3)
That three ounces of either flour to a quart give
4.5 per cent, starch solution. (4) That the per-
centage of fat added to a mixture by the cereal is
1012
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal^
practically nothing. (5) That the percentage of
proteids added to a mixture by the cereal is small.
The general formula for the cereal decoction to be
added to modified milk to obtain any percentage of
starch is starch percentage desired, multipHed by
total ounces mixture and divided by 3.5.
6. Sarcoma of the Kidney in Infancy. — Che-
nev is presented with three questions in the study
of' this subject: (i) How frequent is sarcoma of
the kidnev in infancy? The answer is it is exceed-
ingly rare. (2) How are we to recognize so rare
a disease when confronted with it? The answer
is that it is a tumor of very rapid growth, that it
does not cause cachexia until it is very large, that
it causes little or no pain or disturbance of the gen-
eral health, and that it is usually first discovered by
accident on account of change in the contour of the
abdomen. Hyematuria may or may not be present.
Such tumors lie behind the colon ; they begin at one
side, but grow downward and inward, other abdom-
inal tumors being more centrally located from the
start. Such tumors are also hard, firm, and fixed.
(3) Is operation justifiable? The mortality from
operation is high, and recurrence is not infrequent,
but as it is the only treatment which of¥ers a shadow
of hope, it is the treatment which the author ad-
vises.
9. Channels of Communication in Tuberculo-
sis.—Hamill draws the following conclusions:
I. That it is impossible to gain knowledge concern-
ing the point of entrance either from the location or
the degree of the tuberculous lesions. 2. Foetal in-
fection has been proved, but is not common. 3. In-
fection through the mouth, tonsils, and pharynx is
frequent, and may be produced by inhalation or in-
gestion. 4. Primary inhalation infection through
the lungs does occur. 5. Infection through the in-
testinal tract is definitely proved. 6. The bronchial
glands and lungs may be infected through the in-
testinal tract as well as through the lower respira-
tory tract. 7. The relative significance of the vari-
ous' modes of infection is difficult to determine, for
it has been clearly shown that from whatever point
the tubercle bacilli may be introduced they may
eventually reach the bronchial glands and lungs
without leaving any evidence as to the mode of en-
trance.
|rflt«bings at Sirrittiw.
NEW YORK ACADEMY OF MEDICINE.
Meeting of February 20, jgo8.
Dr. Abr.'iHam Jacobi, Chairman pro tern.
The meeting was held under the auspices of the Section in Neu-
rology and Psychiatry.
The Development of the Modem Care and
Treatment of the Insane, as Illustrated by the
State Hospital System of New York. — Dr. Car-
los F. MacDo.wald read this paper. He said he
had entered upon the work of caring for the insane
in 1870. Since that time he had witnessed and par-
ticipated in the efforts made to improve the meth-
ods of caring for the insane, especially as regarded
the disuse of mechanical restraints and punish-
ments of various kinds, and the abolition of the bar-
barous system of so called "county care" and the
substitution therefor of the modern hospital for the
insane. Cupidity and self interest should have no
sway where suffering humanity was concerned.
Insanity, of all diseases, was by far the most fre-
quent, most widely prevalent, and most far reach-
ing in its effects, and the commonwealth was in
duty bound to provide these dependent sufferers
with suitable shelter, food, and raiment, together
with means of occuoation and diversion, competent
medical care, and supervision. To-day in the State
of New York alone there were more than 29,000
certified lunatics, not to mention the large number
of border line cases which were at any time likely
to require medical care and attention. The aver-
age life of the insane was twelve years, and the
annual per capita cost of maintenance was $200;
therefore, each person who failed to recover dur-
ing this period represented a loss to the State of
$2,400 ; whereas a sane person for a like period
would represent a gain of $2,400. To-day there
were in the State of New York fifteen State hos-
pitals for the insane (two for insane criminals)
and twenty-two licensed private institutions for the
insane. The whole number of committed insane
in the public and private hospitals of the State at
the end of the fiscal year, September 30, 1907, was
29,093 (13,927 men and 15,166 women). The
whole number of insane in licensed private insti-
tutions was 977. The net increase for the fiscal
year in all institutions was 791 ; in the State hos-
pitals, including the criminal asylums, the net in-
crease was 799. The number of resident medical
officers in State hospitals was about 150, and at-
tendants, nurses, and other employees, -5,000. The
cost of the State hospitals represented an invest-
ment of more than $26,000,000, while the average
annual expenditure for their maintenance was.
about $5,000,000. The average weekly per capita
cost of maintenance for the last fiscal year was-
$3.53. This weekly rate was somewhat higher than
the average for the whole United States, in which
the number of insane was roughly estimated at
200,000. The first attempt on the part of the State
to provide State care for her insane was made
nearly sixty years ago, when, in 1836, the legisla-
ture created the State Lunatic Asylum at Utica,
now the Utica State Hospital. This institution,
however, was not opened for the reception of pa-
tients until January, 1843. Prior to that time the
insane poor, in both acute and chronic cases, were
mostly cared for in county or town poorliouses or
in jails. Provision was made whereby patients who
failed to recover after a certain length of time, or
who were pronounced incurable, might be removed
to the county poorhouse. This was a most in-
humane provision, and it continued in operation,
with certain modifications, though with practically
the same results, until the creation of the Sate Com-
mission in Lunacy, in 1889, and the subsequent pas-
sage of the State Care .\ct in 1890. The standard of
care and the resultant conditions were graphically
portrayed in the following extract from a report
made to the legislature in 1864 by the late Dr. Syl-
vester D. Willard, who personally investigated the
condition of the insane in the various poorliouses.
May 23, i9c«.l
PROCEEDINGS OF SOCIETIES.
1015
county insane asylums, and other institutions
wliere tlie insane poor were kept :
\r. some of these buildings the insane are kept in cages
and cells, dark and prisonlike, as if they were convicts, in-
stead of the life weary, deprived of reason. They are in
numerous mstances left to sleep on straw, like animals,
without other bedding, and there are scores \yho endure
the piercing cold and frost of winter without either shoes
or stockings being provided for them ; they are pauper
lunatics and shut out from the charity of the world, where
they could at least beg shoes. Insane, in a narrow cell,
perhaps without clothing, sleeping on straw or in a bunk,
receiving air and light only through a rough, prisonlike
door, bereft of sympathy and of social life, except it be
with a fellow Umatic, without a cheering influence or a
bright hope of the future I The violent have only to rave
and become more violent, and pace in madness their miser-
able apartments. These institutions afford no possible
means for the various grades of the insane ; the old and the
young, the timid and the brazen, the sick, the feeble, and
the violent, are herded together without distinction as to
the character or degree of their madness, and the natural
tendency is for all to become irretrievably worse. In some
violent cases the clothing is torn and strewn about the
apartments, and the lunatics continue to exist in wretched
nakedness, having no clothing and sleeping upon straw
filthy with excrement and unchanged for several days. Can
any picture be more dismal? And yet it is not overdrawn.
The publication of the report aroused public senti-
ment and resulted in a second spasmodic effort to
provide for State care of the chronic insane by the
establishment, in 1865, of the Willard Asylum for
the Chronic Insane, now the Willard State Ho.spi-
tal, and subsequently an institution at Binghamton.
This second era in lunacy legislation for State care
largely failed of its object through delay on the part
of the State to provide sufficient accommodations
for this class fowing to this lack of accommodation,
the State asylums for the acute insane were per-
mitted by law to continue the pernicious practice
of returning their unrecovered patients to the county
poorhouses, some of which were called "county
asylums." This inhuman practice continued until
the creation of the State Commission in Lunacy, in
1889, and the enactment of the State Care Law in
1890. This commission, the creation of w^hich gave
a powerful impetus to the State care movement,
promptly joined hands with the State Charities Aid
Association and others in their efforts in behalf of
State care. In the first year of its existence (1889)
it made a thorough examination of the twenty-one
county institutions for the insane, in many of which
the conditions were found to be nearly as bad as
those portrayed in Dr. Willard's report. In its first
report to the legislature the commission disclosed
the wretched condition of these institutions and
their inmates, and recommended the abolition of the
county care system and the transfer of all the in-
mates of such institutions to State hospitals. This
report gave the death blow to county care of the
insane in the State of New York. Dr. MacDonald
then called attention to the important features of
the State Care Act (Chap. 126, Laws of 1890) and
of the acts supplementary thereto.
Among the more important improvements that
had accrued for the insane and their government,
under the new order of things, might be mentioned
the following: i, A codification of the laws of the
State relative to the insane into one comprehensive
statute, known as the Insanity Law. 2, A complete
- registration of all qualified examiners in lunacy.
3, A complete registration of all persons committed
to institutions for the insane, both public and priv-
ate. 4, Provision for the transfer of patients from
one institution to another without recommitment.
5, The removal of patients from their homes or else-
where, by trained nurses sent from the hospitals
and, if necessary, a medical officer. 6, Removal of
the legal distinction between acute and chronic in-
sanity by designating each State institution for the
insane as "hospitar' instead of "asylum," and incul-
cating the hospital idea. 7, A regulation regarding
the correspondence of the insane, which provided
that any patient who desired might write at least
once in two weeks, etc. 8, Provision for paroling
patients for a period of thirty days, with a return
to the hospital without recommitment. 9, A regula-
tion requiring that patients on admission shall be
informed of the nature of the institution. 10, Af-
fordmg to all patients the legal right of a hearing.
II, A rule restricting the issuing of licenses to con-
duct private establishments for the insane to reputa-
ble physicians. 12, A general adoption of a uniform
dress for nurses' and attendants' wear. 13, Pro-
vision for the clinical teaching of psychiatry in the
State hospitals. 14, Provision for the appointment
of medical internes in addition to the regular medi-
cal staff. 15, A regulation requiring competitive
civil service examinations for appointments as resi-
dent officers. 16, A material increase in the aver-
age rates of salaries and wages of all grades of
service. 17, The introduction of women nurses in
the men's wards. 18, A material extension of ac-
commodations for attendants and nurses in de-
tached buildings. 19, The establishment of training
schools for nurses in all the hospitals. 20, Provision
for the employment of dentists for patients, also for
ophthalmological examinations by eye specialists.
21, An annual allowance to each hospital for the
purchase of medical books and journals and other
periodicals. 22, The employment of a chef in each
hospital. 23, The adoption of a schedule of food
supplies. 24, A marked improvement in the meth-
ods of bathing. 25, A requirement that the hospi-
tals shall enter into joint contracts for the purchase
of staple articles of supply through competitive bids.
26, The abolition of mechanical restraints in all the
hospitals, and the substitution therefor of useful oc-
cupations, diversions, and amusements of various
kinds. 27, The introduction, in 1901, of tent Hfe
for the care of the tuberculous patients. Dr. Mabon,
superintendent of the Manhattan State Hospital on
Ward's Island, stated that the recovery rate of pa-
tients cared for in the open air was as high as forty
per cent., whereas the death rate was "extremely
low." 28, The systematic employment of patients
at useful occupations. 29, The establishment of a
pathological institute. Prior to October i, 1893,
at which time the commission was given supervision
and control of the hospital finances, the average
annual per capita cost of maintenance was $222 ;
the commission reduced this to $184, and at the
same time materially raised the standard of care,
thus effecting, in a single year, a saving of hun-
dreds of thousands of dollars.
Dr. William Mabon, superintendent of the Man-
hattan State Hospital, called attention to the insti-
^ tute work and to the uniform methods of clinical
study and laboratory research. The methods now
IOI4
BOOK NOTICES.
[New York
Medical Journal.
used at the Manhattan State Hospital were as fol-
lows: The division for men, as well as that for
women, had a reception service; in each there was
a staff of from four to five physicians who worked
under the direction of an assistant. Physical ex-
aminations were made at first ; afterward the mental
symptoms were studied. Dr. Adolf Meyer was the
director of the pathological institute, and he had
formulated a very valuable classification. Meetings
of the staff were "held in the two divisions each week
day morning to give them an opportunity to express
an opinion as to the advisability of discharging a
patient, etc. Every third Tuesday night was held
a staff meeting, and original papers were presented
and discussed. The results of this method had
shown the great value to be obtained by members
of the staff.
Dr. Frederick Peterson, ex-president of the
New York State Commission in Lunacy, said that
a book might be filled with praise for what they had
accomplished ; they could also fill a book with what
they had not accomplished. Nearly twenty per cent,
of the insane owed their insanity to a preventable
cause, alcohol ; through alcoholic insanity there was
a loss to the State of about $2,400,000. People
should be taught that insanity was a preventable
and curable illness. Insanity was a disease ; an in-
sane person was sick. The responsibility of over-
crowding, which the Lunacy Commission reported,
was due to neglect by the legislature ; only one hos-
pital for the insane had been built in eighteen years.
On October 1,1 906, the Lunacy Commission reported
that the excess of patients in the hospitals over the
estimated capacity was 1,812; more money should
be appropriated for the building of more asylums.
It was an interesting fact that the admissions of
people between sixty and one hundred years old
amounted to some sixteen per cent, to seventeen per
cent., physiologically senile or dotards. There was
also an inadequate supply of physicians ; the pro-
portion should be not less than one physician to
150 patients.
Dr. Charles W. Pilgrim, of Poughkeepsie,
president of the State Commission in Lunacy, told
of the many obstacles the commission had to over-
come, and believed that when the history of the in-
sane in the State of New York was written, two
names would appear very prominently, those of Dr.
Carlos F. MacDonald and the Hon. Goodwin
Brown.
Dr. Albert' Warren Ferris, member of the New
York State Commission in Lunacy, said that li-
censed private houses for the care and treatment
of the insane were allowed to receive voluntary pa-
tients, as well as those committed under the In-
sanity Act, a very reprehensible condition. No
actual ruling as to these voluntary patients was
made until 1891, when the new commission formu-
lated a special document. Attention was called to
Section 445 of the Penal Code, under the title Main-
taining Private Insane Asylums, and to Section 47
of the Insanity Law, and the amended chapter 497.
Laws of 1905. There seemed to be a desire among
a certain class of physicians to quietly and secretly
place patients in the custody of unskilled and im-
proper persons. The question as to when a patient
was properly a voluntary one was a vexed one, but
he believed such a person to be one who understood
to some extent his ailment in so far that he knew
he was ill, and also understood that the house to
which he was taken was for the treatment of ailing
people and that he was willing to stay. Voluntary
patients should have every possible facility to pre-
vent the graver forms of mental disturbance. Ef-
forts that were now being made to prevent insanity
by studying conditions, food, occupations, educa-
tion, environment, etc., would lead to the saving of
many valuable lives, as well as to the early restora-
tion of many hundreds of shattered individuals to
their position in the community, to enjoy life, lib-
erty, and the pursuit of happiness.
The Hon. Goodwin Brown said that up to i88()
the world for the insane was in chaos ; they lived
to be cured by chance, or else were treated as crimi-
nals. Efforts made to alleviate the condition of
these unfortunates were futile. In all great crises
men were brought forth when most needed, such as
Hannibal, Csesar, Cromwell, and Napoleon, and in
this crisis the man most needed was forthcoming,
Dr. Carlos F. MacDonald.
[We publish full lists of books received, but we acknowl-
edge no obligation to review' them all. Nevertheless, so
far as space permits, zve review those in which we think
our readers are likely to be interested.']
Nerven und Seclc. Von Dr. Paul Kronth.al. Mit 139
Figuren im Text. Jena : Gustav Fischer, 1908. Pp. 431.
Goethe has said that "all professional men labor
under the disadvantage of not bemg able to neglect
what is useless," and there certainly is no profession
to which this applies with more force than the med-
ical profession. At the same time we cannot resist
the conviction that in the wisdom of the ancients all
is not useless, for it may be recalled that Gom-
precht, one of the ablest of modern historians, has
said that, if the wisdom of the Greeks had left us
nothing more than an outline of the atomic theory,
it had made its lasting contribution to the develop-
ment of human culture. The philosophy engen-
dered by the Greeks has continued to the present
time, and it is with much pleasure that, as medical
disciples, we note that the physician has always re-
mained a philosopher.
In the volume before us we find one of the most
recent attempts to solve the physiological relations
which exist between the nervous system and the
soul, this time from the pen of a well known neu-
rologist. It would be natural that the mode of ap-
proach should be more or less anatomical, and fully
one half of the volume before us is devoted to a
critical analysis of the structure of the neurone,
which, we may say in passing, seems entirely too
detailed in its anatomical features for any philo-
sophical correlation. Certainly all the facts which
have been patiently dug out in the historical labora-
tories of the world are here collected. An attempt
has been made to show wherein anatomical
structure underlies physiological function. The at-
tempt has been too rigidly limited to cytological de-
tails, and the much more fascinating features of
neurone linking have been neglected.
May 23, 1 908. J
BOOK NOTICES.
In attacking the second portion of his problem,
namely, the soul, the author first justifies himself by
maintaining that the study of the nature of the soul
is a natural science idea. The psyche is really the
reaction phase only of all external stimuli making an
impress on nervous structures. It is the sum of the
reflexes due to peripheral stimulation. He there-
fore discusses in detail more or less what these
peripheral reactions are, and endeavors to show how
sleep, memory, will, feeling, and reflex are integers
in the problem. Kronthal, in a certain sense, de-
parts from most works of a similar character in pay-
ing attention to the pathology- of the psyche bv a
full consideration of the insane mental reactions,
and through them attempts some explanation of
what have been called the soul processes. In this
respect it v.-ould seem that a fruitful avenue has
been traversed, for in the study of the biological
sciences it has been demonstrated over and over
again that a true knowledge of the physiology of
function has only been arrived at through the path
of its pathology".
The author's point of view is naturally material-
istic. He discusses nerve cells, nerve paths, and
nerve impulses, and shows us how far the material-
istic point of view may be traveled without difficulty.
That he has solved the unsolvable problem of
psychophysical parallelism is hardly to be expected.
Xevertheless, it -is interesting reading, well put to-
gether, and remarkably simple so far as the German
construction is concerned.
The Borderland -of Epilepsy. Faints, Vagal Attacks, Ver-
tigo, Migraine, Sleep Symptoms, and their Treatment.
By Sir WILLI.^M R. Gowers, M. D.. F. R. C. P., F. R. S.,
Hon. Fellow, Royal College of Physicians, Ireland, etc.
Philadelphia: P. Blakiston's Son & Co., 1907. Pp. vi-121.
(Price, $1.25.)
To the narrow student of nervous phenomena this
work will come as a shock. All too prone are many
physicians to accept a diagnosis of a condition as
a finality. Their therapeutics is hypnotized by a
word, and an all too prevalent nihilism in the field of
treatment renders them powerless before the magic
word epilepsy.
But there are epilepsies and epilepsies ; those due
to irremediable and incorrigible defects of structure
— no fewer than fifty pathological defects are known
to be the exciting causes of that general symptom
picture which, for too many, diagnosticated as epi-
lepsy, fails to awaken any desire to discover a cause
and seek for a remedy.
Gowers has done well to call attention to a large
group of epilepsies in which the irremediable causes
are not present, and in which, with proper care,
treatment may be instituted which will give endur-
ing benefit. Tonics of this kind are like draughts
of cold water : they stimulate and invigorate, and we
feel that many are in need of the very excitation that
this excellent work will produce.
Confessio Medici. By the Writer of The Young People.
New York: The Macmillan Company, 1908. Pp. ix-158.
(Price. $1.25.)
This is a book worthy to be placed in the hands of
every student of medicine on the day he is gradu-
ated. Its conception is loftv, and the literary stvle
^of the author has a compelling charm, so that the
reader is held captive to the volume until it is read
from beginning to end. All through the ten essays
which make up the book there runs a vein of exquis-
ite sensibility which reveals the writer as one who
is a lover of his calling, and who, moreover, has the
right idea of a calling as distinguished from an avo-
cation. In fact, the first essay in the book is a dis-
sertation on the meaning of the word vocation, the
conclusion being reached that, "if a doctor's life may
not be a divine vocation, then no life is a vocation
and nothing is divine." There is food for thought
in every chapter, and the sentiments to which the
author gives expression will be relished as much by
the old and experienced doctor in practice as by the
young man who has just been graduated and has
started to make a name for himself. There is much
good counsel in the book and plenty of helpful sug-
gestion, all combined with much practical philoso-
phy, bound up in instances with noble examples from
the lives of men whose names are writ large in the
history of medicine. The chapter on Ambroise Pare
will be at the same time a revelation and a well-
spring of inspiration for many an ambitious young
surgeon, and that not less by the fine moral tone of
the writing than by its easy charm of diction and its
uplift. It is not a book that lends itself well to quo-
tation ; it must be read as a whole and in the spirit
of the author, whose Confession is not a confession
of sins, but a confession of devotion and loyalty to his
own profession. Although published anonymously,
"by The Writer of The Young People," it is easy to
guess at the identity of the author, who cannot be
other than Dr. Stephen Paget, son of the late Sir
James Paget, who is known to be the author of Our
Voitiig People.
Xursing the Insane. By Cl.\r.\ B.\rrus, M. D., Woman
Assistant Physician in the Middletown State Homoe-
opathic Hospital, Middletown, N. Y. New York: The
Alacmillan Company. 1908. Pp. x-409.
In taking from the preface of this work some of
the ideas expressed by the author we feel that we
can best represent the spirit that animates it. This
spirit is one with which we are in cordial sympathy,
and we are desirous that it should be more wide-
spread among workers in this most perplexing field.
W ithin the memory of the passing generation our
institutions have been evolved from mere places of
detention and custody into modern hospitals, which
aim to provide comfortable, pleasant, and hygienic
surroundings for the patients, scientific treatment di-
rected to the cure of the curable, and judicious and
humane care for all. But even with this highly de-
sirable evolution there are still too many dark places,
not peculiar to hospitals for mental disorders alone,
but which, when found in such, are all the more de-
plorable, since so many of the patients are unable by
the very disorders from which they sufiFer to ob-
tain redress.
The inmates of a hospital for mental disorders are
for the most part peculiar and tr\ ing to treat — pe-
culiar and trying, however, only so long as the old
fashioned ideas regarding mental disorders are held
to. "To deal with them wisely and kindly requires
exceptional qualities of mind and character," writes
Dr. Barrus, and we might raise the query. How are
such exceptional qualities to be obtained for the
miserable pittance which State legislators dole out
to the physicians, nurses, and attendants?
ioi6
BOOK NOTICES.
[New York
Medical Journal.
To train nurses and attendants in this special
branch of work is the object of this book, and we
know of no similar one that approaches the subject
in the broad, comprehensive spirit which is so de-
sirable. It is well written, specific, and adequate,
and we can commend it most cordially. It is not
alone of value to nurses ; physicians should read it,
as it reflects the proper attitude of mind that is nec-
essary in order to deal adequately with the problems.
Such an attitude of mind the physicians of this coun-
try themselves are in need of acquiring, and in the
volume before us are set forth principles which have
been the fruit of a ripe and sympathetic experience.
Movable Kidneys and Other Displacements and Mal-
formations. By David Newman, M. D., F. F. P. S. G.,
Surgeon to the Glasgow Royal Infirmary, etc. New
York, Bombay and Calcutta: Longmans, Green, & Co.,
1907- Pp- 233.
It is an evidence of the great accumulation of
knowledge on special subjects in medical science
that there should be material for a fair sized vol-
ume on a subject the scope of which, to ordinary
observation, is not broad. The author's classifica-
tion into movable and floating kidney, according as
the organ is not or is in the peritoneal cavity, is not
very exact, for a floating kidney is certainly a mov-
able one.
Extraperitoneal and intraperitoneal might be more
accurate. The latter is rarely seen, and the former
frequently causes no symptoms. The author is in
favor of nephrorrhaphy whenever the symptoms
from the displacement are at all severe. He is
rather more radical in this respect than Treves,
whose experience is certainly as great, and who be-
lieves that an operatioii is seldom required.
A large number of illustrative cases are reported
in detail, and various anomalous conditions of the
kidney are represented by very good illustrations.
We fail to find anything new, however, in the au-
thor's consideration of his subject.
A Te.rtbook of Minor Surgery. By Edward Mn.TON Foote,
A. M., M. D.. Instructor in Surgery, College of Physicians
and Surgeons (Columbia University ), etc. Illustrated by
407 Engravings from Original Drawings and Photographs.
New York and London: D. Appleton & Co., 1908. Pp.
xxvi-752.
When we first saw this substantial volume, our
first thought was one of wonder that so big a book
had been written on the subject, for we called to
mind the little minor surgeries of the past. But ex-
amination of the work shows that the author classes
as "minor" the greater part of surgical practice —
all of it, we may say, that is not of heroic magnitude.
He gives what we must admit is a good reason for
doing so, namely, that the authors of the more pre-
tentious recent textbooks of surgery have to a great
extent rather slighted those portions of their subject
which fall .short of the supreme degree of impressive-
ness. Just this kind of book, therefore, has been
needed, and Dr. Foote has given us a good one. His
teachings are such as a rather careful examination
of the contents does not allow us to find fault with,
further than to remark that the regional division
has necessarily led to some repetition. The dedica-
tion is particularly good : "This book is dedicated
to the man at tlie point of the knife, for his grit and
patience, and especially for his willingness to be pho-
tographed that others may profit by his misfortune."
The mechanical quality of the volume — in print, pa-
per, pictures, and binding — is most creditable to the
publishers.
Healthy Boyhood. By Arthur Trewby, M. A. With an
Introduction by Sir Dyce Duckworth, M. D., LL. D.,
Consulting Physician t,o St. Bartholomew's Hospital, etc.,
and a Foreword by Field Marshal Earl Roberts,
K. G., K. P., V. C, O. M., P. C, G. C. B., G. C. S. I.,
G. C. I. E., D. C. L., LL. D. New York: Longmans,
Green, & Co., 1907. Pp. 63.
In the lay press, as well as in our professional
journals, we find the question discussed very often:
What should a boy know who is entering upon man-
hood, and who should instruct him ; or should this
theme be left untouched? Our author thinks that
a boy at such a period should be made acquainted
with the mysteries of life in a scientific, fatherly
way; the introduction into the knowledge of man-
hood should not be left to chance, but the knowledge
should be well expoimded to adolescents.
The book may be given to the boy to read, and
will thus take the place of verbal instructions by
parent or teacher. It can be well recommended to
any household, as its language and expression are
so guardedly written that nobody can object to it,
and only good can come from reading it.
Rotunda Midwifery for Nurses and Midlives. By G. P.
Wrench, M. D., Late Assistant Master, Rotunda Hos-
pital. With an Introduction by the Master of the Ro-
tunda Hospital. London: Henry Frowde (Oxford Uni-
versity Press) and Hodder & Stoughton, 1908. Pp.
xiv-324.
There are those who think that too many books
have been written for the purpose of teaching nurses
how to practise medicine more or less, and we admit
that our own tendency is toward that opinion. How-
ever, the thought would hardly arise if such books
were always written so judiciously as this one of Dr.
Wrench's. The Dublin Rotunda has always stood
high as a source of instruction in obstetrics, and its
medical officers may be relied upon to present the
subject in a conservative manner.
Dr. Wrench teaches in a most practical way in
this book, and he does it in simple and easily intel-
ligible language, though the statement that " 'white
leg' causes morbidity" (page 252) is perhaps more
sententious than lucid, and the following statement
(page 139) docs not seem quite consistent: "Our
hospital patients get up on the evening of the sev-
enth and go out on the eighth day. A woman may
sit up nil the fifth day. She may go out after she
has been up for five or six days."
Dr. Wrench sa\ s nf "(luict rupture of the uterus"
(a phrase with w hirh we arc not familiar) : "This
is a form of rupture which occurs without previous
signs of threatening rupture. It is not uncommon
in Ireland." In such matters as this, as in many
others, this little book may be of service to young
physicians as well as to nurses and midwives. It
is deserving of high commendation.
Clinical Lectures and Addresses on Surgery. By C. B.
LocKWOoD. Surgeon to St. Bartholomew's Hospital.
London: Henry Frowde (Oxford University Press) and
Hodder & Stoughton, 1907. Pp. viii-307.
The volume before us is a second edition, thou.gh
that is not stated on the title page. The fact of its
appearing in the same year with the first edition
shows the acceptability of the took. The chapter
May 23. 1908.]
MISCELLANY.
headings are as follows : An Introduction to the
Study of Clinical Surgery ; Clinical Reasoning ;
The Course of Intraabdominal Inflammation ; On
the Recognition and Management of Intestinal Ob-
struction ; The Essentials of a Diagnosis ; Secondary
Infection of the Lymphatic Glands in Malignant
Disease of the Tongue ; Carcinoma of the Breast
and its Spread into the Lymphatics ; Varicose Veins ;
Swellings Above, Below, and Within the Neck of
the Scrotum, particularly Inguinal \"aricocele and
Hydrocele ; Exploratory Laparotomy, especially in
Cases of Malignant Disease ; F2ecal Leaks and Fis-
tulae ; The Immediate Microscopical Diagnosis of
Tumors during the Course of Operations ; Clinical
Pathology in its Relation to Diagnosis and Treat-
ment ; and Salivary Calculi.
So slight a connection is there among most of
these subjects that the lectures may fairly be called
disjecta membra, but they are exceedingly practical
and the teachino- given in them is wise. The author
gives many useful hints that one might look for in
vain in a formal textbook. Mr. Lockwood's style is
colloquial to an unusual degree, but there is never
any doubt as to his meaning. \\q commend the
book without reserve.
The Influence of Alcohol and Other Drugs on Disease.
The Croonian Lectures Delivered at the Roval College
of Physicians in 1906. By W. H. R. Rivers, M. D.,
F. R. C. P., Fellow of St. John's College. Cambridge.
London: Edward Arnold, 1908. Pp. viii-136.
The lectures printed in this book are those deliv-
ered at the Royal College of Phvsicians. entitled the
Croonian Lectiires for 1906. differing in their print-
ed form somewhat in details of arrangement and in
the addition of new matter from their first presenta-
tion, which for the most part took place in the Jour-
nal of Physiology.
The author first takes up the methods followed in
his experiments, dealing with the double problem of
individual muscle fatigue and the more psychical
factor of general fatigue. He then takes up in de-
tail the drugs studied, caffeine, alcohol, cocaine,
strychnine, and tobacco being chosen.
The problems dealt with by Rivers have all re-
ceived considerable attention from the eflforts of
physiologists, pharmacologists, and psychiatrists,
and in the main his results are confirmatory of those
arrived at by the more advanced workers in these
fields. To the worker in psychiatry the results are
of special interest in that the author confirms in
large part the observations of Kraepelin, the psychi-
atrist, whose researches have given in the past
decade the greatest impetus to the forward study of
mental disorders.
Itistdlans.
German Comment on Dr. Rose's Ideas of
Medical Language. — Dr. Herman Triepel. pro-
fessor of anatomy at the L^iiversity of Breslau,
submitted to the German Anatomical Society at
the twenty-second annual convention in Berlin, a
memorial on anatomical nomenclature (Deiik-
schrift iiher die anatomische Nomenclatur der
_auatomischen Gesellschaft auf ihrer 22. Versamm-
luiig in Berlin, vorgelegt am 22 April, ipo8), en-
dorsing the views and suggestions put forward by
Dr. Achilles Rose since 1894. Thus, he also confirms
Rose's statement that the work of the Commission
on Nomenclature of the German Anatomical So-
ciet}-, now known by the designation of B. N. A., is
not perfect, that it is defective in regard to lan-
guage, and that a thorough revision of the B. N. A.
is indicated. During the last few years quite an ap-
preciable number of books have been published,
notably also in America, which have adopted the
Basle nomenclature, and Triepel is of the opinion
that the unopposed dissemination of the imperfec-
tions in medical onomatology should be checked.
In agreement with Rose, Triepel considers it an im-
portant requisite to secure the assistance of Greek
colleagues for the linguistic revision of the B. N. A.
He points out that the value and position of mod-
ern Greek has up to the present time been frequent-
ly misunderstood. The Greek written language has
preserved to the present day, and with great
tenacity, the material features of ancient Greek. In
spite of its conservative character, however, it is not
dead ; it lives in the national consciousness, not only
as a written, but also a spoken language. This is
the idea to which Rose has given expression in
numerous writings, calling attention to the fact that
the thesaurus of modern Greek is particularly
adapted to supply the technical terms of medical sci-
ence. Rose is confirmed in saying that only an edu-
cated Greek could command the linguistic feeling
which is a prerequisite in the formation of new
words from the elements of the existing treasure.
Of particular importance is the following passage:
'Tf we are in doubt as to the validity of an anatom-
ical name, taken from the Greek language, we shall
probably obtain satisfactory information by con-
sulting a Greek textbook of anatomy. For our pur-
poses the most commendable of all Greek textbooks
is the one by Papaioannou. the most extensive one
in existence. ( Sclavuno's textbook is not yet com-
pleted.) In order to be able to employ in his work
a nomenclature free from objections, Papaioannou
studied, as stated in the preface, the writings of the
ancient Greek philosophers and physicians. Some
of the names he encountered had to be first remod-
eled, in so far as they did not conform to the strict
requirements of the laws of Greek word construc-
tion. In many designations which had been misun-
derstood or mistranslated by European nations, and
had been taken over without criticism by modem
Greek authors, he had to establish their true mean-
ing in order to find a proper place for them. Other
words again have undergone an entirely new forma-
tion at his hands, keeping strictly to the applicable
linguistic rules. Papaioannou's nomenclature "is
to-day generally employed in Greece in scientific
works, lectures, etc.." as his son, Professor Theo-
dore Papaioannou. states. Triepel believes that it is
reserved to just that book of Papaioannou to render
the most important services in the construction of
an improved nomenclature. It is also interesting
that on April 14, 1907, the iNIedical Society of
Athens appointed a committee for the purpose of
undertaking a reform of the entire medical nomen-
clature.
ioi8
OFFICIAL NEWS.— BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
Affinal getos.
Public Health and Marine Hospital Service
Health Reports:
The folhwi)ig cases of sniallpo.v, yelloiv fever, cholera,
and pla:4uc hare been reported to the surgeon general,
United States Piiblie Health and Marine Hospital Service,
during the z<.rck ending May 13, igo8:
Smallpo.v — United States.
Places. Date. Cases. Deaths.
L.nty....\pril ,-3" 17
25-Mav
25- May
23-30- ■
-'3-30 • •
26- .May
-■7-Mav
4-.Mav' -
25-May
Alabama — Mobile, city and cc
California — Los Angeks....
California — San Francisc.i i
District of Columbia— W yOiiiiKt.M, . Apn
Illinois — Danville \|iri
Illinois — Galesburg Xjiri
Illinois— Rockford \pri
Illinois — Springfield Apri
Indiana — Anderson \pri
Indiana — Indianapolis \iiri
Indiana — La Fayette \l)ri
Indiana — Muncie \pril
Iowa— Ottumwa Apri
Iowa — Sioux City Apri
Kansas — Kansas City Apri
Kansas — Topeka \pri:
Kansas— Wichita \pi il
Kentucky — Henderson \|iii
Louisiana — New Orlean>^ \pril
Michigan — Kalamazoo \pril
Michigan — Port Huron \pril
Michigan — Saginaw \pril
Minnesota — Stillwater \pril
Mississippi — Gulfport \|irii
Missouri — Kansas City V] rii
Missouri — St. Louis .\pril 25-M
New- York — New York \pril 25-May 2
New York — Niagara Falls April 25-May 2.
North Carolina — Charlotte April 25-May 2.
Ohio— Bucvrus. April 18-25
Ohio — Cincinnati April 24-May i
Tennessee — Knoxville April 25-May 2
Tennessee — Nashville April 25-May 2
Texas — San Antonio April 25-May 2
\'irginia — Newport News April 1-30
Washington — Spokane April 18-25. - - •
Wisconsin — Beloit April 23-May 7
25-May 2.
-May
SimiUpo
Africa — East London.
Arabia — Aden
Austria — Trieste
Belgium— Ghe
lada — Halifax .April
China — Foochow March
China — Hongkong March
China — Shanghai March
Kcuador — Guayaquil .\pril
France— Paris \pril
Germany — General % .'\pril
Great Britain— Leith .-Xnril
India — Btimbay March
India — Calcutta March
India — .Madras March
Indo Cliina — Cholan March
Italy — Catania -April
Italy — Genoa .March
Japan — Kobe March
Japan — Nagasaki March
lapan — Osaka March
Java— Batavia March
.Mexico — .'\guas Calientef April
Mexico — City of Mexico March
Persia — Chiraz .April
Persia — Kirmanshah April
Portugal — Lisbon .April
Russia— Libau March
Russia — Moscow April
Russia — Odessa April
Russia — Riga .April
Russia — Warsaw March
Switzerland — Zurich .April
Turkey — Bagdad Feb. i
—Foreign.
March 21-28 2
April 6-13
April 4-1 1 I
Apr-
May 2 3
3 1 -.April
14-28. . .
28-April
Epidemic
Epidemic
Brazil — Manaos. . . .
P>razi1 — Para
Kcuador — Guayaqui
Apr
Yellow Fcier- — Foreign.
.April
-18.
April 1 1
.-Vnril 4- 1 1
Cholera — / nsular.
Philippine Islands— .Manila March 7-14
Cholera — Foreign.
India — Bombay \'arch ji-.Anril 7.
India— Calcutta March 21-28
India — Madras March 2i-A|>ril 3.
India — Rangoon March 21-28
China — Hongkong . . .
Kcuador — Guayaf|uil. .
'■-ftyi'' — f icncral
Kgypt — Alexandr
Foreign.
. .March 7-14. . . .
. April 4-'i
..Jan. i-.April 23
.Jan. I April
Japan March i8-.Apri
India — Bombay March 31-April 7... 491
India — Calcutta March 14-28 219
India — Rangoon March 21-28 27
Japan — Osaka .\larch 21-28 i 1
Peru — Genera! March 28-ApriI 4... 53 27
Peru — Callao .March 28-April 4... 2 i
Peru — Lima March 28-April 4... 3 1
Army Intelligence :
Official list of changes in the stations and duties of
officers of the Medical Corps of the United States Army
for the week ending May i6, igo8:
AsHFORD, B. K., Captain. Relieved from duty at Wash-
ington Barracks, D. C, about July ist, and ordered to
San Juan, P. R., for duty.
Baker, F. C, Captain. Ordered to Fort Moultrie, S. C,
for temporary duty during army and militia defence
exercises, June i8th to 28th.
Deshon, G. D., Major. Relieved from duty and station at
Fort Des Moines, la., and assigned to station and duty
at the Army and Navy General Hospital, Hot Springs,.
Ark.
KoERPER, C. E., Captain. Granted leave of absence with
permission to visit the United States, to sail^ from
Havana, May 22d, and to sail from Newport News,
returning, June 15th.
Rafferty, O., Major. When relieved from duty at San
Juan, P. R., ordered to Fort Wayne, Mich., for
duty.
Raymond, H. I., Alajor. Ordered to Washington Barracks,
D. C, for treatment at the General Hospital.
Vedder, E. B., Captain. Granted leave of absence for four
months.
Navy Intelligence:
Official list of changes in the stations and duties of,
officers in f!ir Medical Corps of the United States Navy
for the iK'ccI: cmlin:^ May 16, jgo8 :
De.x.ms, J. B., Surgenn. Detached from the South Dakota
and ordered to the Virginia.
Lowndes, C. H. T., Surgeon. Detached from the Virginia
and ordered to the South Dakota.
Born.
Lyster. — In Ancon, Canal Zone, Panama, on Sunday,
April 26th, to Dr. Theodore C. Lyster, L'nited States
Army, and Mrs. Lyster, a son.
Porter. — In Key West, Florida, on Thursday, May 7th,
to Dr. Joseph Porter, Jr., United States Marine Hospital
Service, and Mrs. Porter, a son.
Married.
Graham — H.xcker. — In St. Louis, Missouri, on Tues-
day, May 5th, Dr. Thomas E. Graham and Miss Julia E.
Hacker.
Little — Tadd. — In Philadelphia, on Monday, May lith,
Dr. John Forsyth Little and Miss Edith Jane Tadd.
Died.
C.\MER0N. — In Westmoreland, Maryland, on Sunday,
May 3d, Dr. Martin F. J. Cameron, aged forty years.
Heintz. — In Marion, .-Xrkansas, on Sunday, May lOth,
Dr. Louis Ferdinand Heintz, aged thirty-eight years.
HiTT. — In Los .'\ngcles. California, on Sunday, May lOth,
Dr. S. Merritt Hitt, aged forty years.
Hopkins. — In Philadelphia, on Tuesday, May 12th, Dr.
Elhvood E. Hopkins.
McCandi.ish. — In Emporia, Kansas, on Tuesday, May
5th, Dr. Robert McCandlish, aged eighty-two years.
McCarthy. — In Barric, Ontario, on ^londay. May nth.
Dr. John Leigh Goldic McCarthy, aged sixty-three years.
Murray. — In St. Louis, Missouri, on Thursday. May 7tli,.
Dr. S. J. Murray, aged forty-two years.
St.\nton. — In Bridgeport, Connecticut, on Friday, May
8th, Dr. Thomas F. Stanton, aged forty-four years.
Steele. — In Wayne. Pennsylvania, on Simday, May 17th,
Dr. John Dutfon Steele, of Philadelphia, aged forty years.
Thomas. — In Cmnhcrland. Maryland, on Tuesday, May
5th, Dr. William George Thomas.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal The Medical News
A Weekly Review of Medicine, Established 184J.
\'0L. LXXXVII, No. 22. XEW YORK, MAY 30, 1908. Whole No. 1539.
^Brigmal Communicatiuns.
THE MANAGEMENT OF SELF LIMITED DISEASE.=*
By W. B. Konkle, M. D.,
Montoursville, Pa.
The partridge rummaging through brushwood or
scratching in forest Htter in quest of bug or berry ;
the heron at the .stream, sentinel Hke, patiently, per-
sistently peering into the shallows for a sign and
glimpse of a craved prize ; the owl, with impelling
hunger, ranging among the mystic shadows of the
night ; these are the medical specialist in laboratory,
or in clinic, or in private practice investigating, ob-
serving, exploring. The haw^k soaring above house
top and tree top and hill top, sailing in unimpeded
flight the upper airs, commanding the landscape be-
low from horizon to horizon, that is the medical
philosopher, analyzing, classifying, correlating,
reconciling the gross findings of the del vers. If
placed somewhat at disadvantage as to discernment
of facts in their minutia and detail, yet is the general
practitioner peculiarly adapted by position and pur-
suits to the inter\'aluation and interadjustment and
interharmonization of general ideas and general
truths. And self evident is it that to orientate is as
vitally requisite as to advance.
In a domain only partially explored are the results
of exploration, by reason of their patchy, incomplete,
disconnected character, liable to appear contradicton,'
or antgonistic. In the field of therapeutics is this
found to be notoriously the case. Here, indeed, are
the Doles of thought and advocacy widely separated,
with sons of Anak stoutly holding each antipodal
standpoint. On the one side we have a von Le\ den
oracularly announcing ^'Dic Zciten des Nihilistiius
in der Klinik mid dcs Pcssiinismiis in der Praxis
sind iibem-iinden, sie licgcii hinter uns." ("The times
of nihilism in the clinic and of pessimism in prac-
tice are surmounted, they lie behind us.") On the
other side we find a scholarly and experienced
leader courageously attacking even the time ce-
mented stronghold of quinine, and otherwise out-
Sangradoing Sangrado in the paucity of his reme-
dial measures, still further narrowing and simplify-
ing the famous formula, "La saignce ct lean
chande" of the \'alladolid doctor by replacing its
"la saignce" with "I'eau froide" — water, the alpha
and the omega, "water, water everywhere." On one
shore of the Atlantic a distinguished teacher firmly
maintains that "he is the best doctor who knows the
worth of medicines." On the opposite shore a silver
*Read before the Lycoming County Medical Society, at W^illiams-
-poTt, Pennsylvania, April lo, 1908.
tongue declares that "he is the best doctor who
knows the zcorthlessness of medicines." Extremes,
however, are in a sense not irreconcilable. Ordi-
narily antithetic doctrines are neither all right nor
all wrong — they mutually look toward a common
intermediate truth. Ask "A," who is viewing a
given point from the east, what is the direction of
approach toward that point, and he will reply west-
ward. Ask '"B," who is Aaewing the same point
from the west, what is the direction of approach
toward that point, and he ^vill reply, eastward. The
function of disinterested criticism is to find between
conceptions thus at variance the juste inilieu. So in
the province of therapeutics it will be manifest that
between scornful nihilism and arrogant absolutism
there should move a discriminating common sense;
between sullen pessimism and ecstatic optimism
there should operate a progressiveness at once alert
and active ; between stolid unbelief and frenzied
credulity there should reign a reasonable and reason-
ing scepticism.
Restricting discussion to the confines of our pro-
posed subject, the management of self limited dis-
ease, we would apply therein the aforestated theses
as criteria. The phraseology, self limited disease,
is inaccurate, but so sanctioned by use that in pro-
priety it may not be arbitrarily rejected. It is mis-
leading, however, and needs to be defined, ^"entur-
ing a definition, we submit that so called "self lim-
ited" disease is disease which, with more or less
certainty, with more or less safety, with more or less
promptness, the natural forces eliminate.
The term "management" is advisedly employed.
It is meant to indicate direction rather than coercion ;
influence rather than usurpation ; promotion of re-
covery rather than cure. The term is not exclusive
of the idea of specific treatment of disease — indeed,
it is entirely compatible with such idea. A specific
is, simply, an agent which directly and causally
accelerates and safeguards Nature's movement
toward health along her own course. The only pity
is that we have at our command so few of these
agents.
Neither does the method implied in the word
"management" debar drugs as remedies. The re-
quirement for modification of some certain physical
process does not necessarily carry with it an indi-
cation of the exact character and form of the instru-
ment to be selected. Other things being equal, con-
siderations of effectiveness and availability very
properly are determinative at this point. If no
special contraindication exists, what reason or wis-
dom can there be in ignoring the claims of a drug
simply because it is a drug? Why is it not logical
Copyright, 1908 by A. R. Elliott Publishing Company.
I020
KONKLE: SELF LIMITED DISEASE.
[New York
Medical Journal.
and scientific to attain salutary results by extraor-
dinary means where ordinary measures fail or are
lacking?
Arriving at the immediate and intimate discussion
of our subject, I would submit first of all and most
prominently that the primary and fundamental
factor in the management of self limited disease is
the thorough, the exhaustive, the lucid, the com-
manding comprehension of the natural course of
such disease. We must know clearly and fully the
features of the typical case, and we must know the
safe and permissible deviations therefrom. We
must be familiar with the symmetry of symptoms,
and we must be able to recognize the bounds of un-
essential asymmetry of the same. Just so far as we
do not knozv are we bound to keep our hands ofif.
Merest hazard even is as safe a guide as ignorance ;
certainly a usually benign natural order will be im-
measurably more trustworthy than sightless eyes.
"God moves in a mysterious way his wonders to
perform." Nature to the doctor is divine. If he
be not initiated into her mysteries he must not pre-
sume to assist at her offices. The doctor who is
keenly, humbly conscious of what he does not know
will refrain from positive action beyond the limits
of his knowledge. He will prefer the risk of nega-
tive error. He will choose not to do rather than to
do by chance. In assuming this position he will, of
course, bring himself within the range of the thrust
of La Bruyere where, in his Characters, he satirizes
our profession thus: "La temerite des charlatans, et
leurs tristes succes, qui en sont les suites, font
valoir la medecine et les medecins ; car ceux-ci lais-
sent mourir, les autres tuent." ("The temerity of
quacks, and their sad successes which are the conse-
quences of it, make for the reputation of medicine
and of physicians ; for the latter simply let people
die, while the former kill them.")
But far better is it to render ourselves liable to
such shafts of irony as aimed at a conservative nega-
tivism than to incur just criticism of the kind em-
bodied in his epigram on "The Physician" by the
German fabulist, Nicolay, which I beg leave to
quote :
"Wenn Uebel und Natur in einein Korper streiten,
So kommt ein blinder Arct und Iiaut nach beiden
Sett en;
Wenn er das Uebel trifft, so stellt er wieder her;
Wcnn die Natur, so todtet er."
This may be translated as follows : "When a dis-
order and Nature are battling in a human body,
there comes a blind doctor and slashes toward either
side ; if he chances to hit the disorder, he restores
to health again ; if he chances to hit Nature he
kills."
Truly he charges himself with an awful responsi-
bility who dares to supplant Nature — to censor and
alter her plans of operation — to halt or modify her
processes and procedures. It is a very serious mat-
ter to administer a really active dose of a potent
drug; to do it intelligently is eminently proper; to
do it at random is altogether reprehensible. In al-
luding to certain desperate conditions, where one
sick is at the very last extremity, Celsus coined the
■dictum, "Melius est anceps reniediiim qtiam nullum"
— "Better a hazardous remedy than none." This
proposition of the Cicero of medicine his com-
mentators have quite generally reprobated. Bouchut
apologizes for it only on the ground that it zvas ap-
plied by its famous author solely to cases practically
devoid of hope except as hope might remain in the
caprice of some heroic intervention.
In the management of self limited disease imme-
diately after the requirement of adequate acquaint-
ance with the natural history of such disease comes
the obligation to see that this natural history be nor-
mally developed. The single but solemn duty of
the doctor here is to have the disease keep its due
course, or maintain its symmetry. He can do no
more than that ; he should try to do no more. His
province includes no less than that; he should aim
at no less. As a corollary of his obligation to see
that these diseases hold their course stands the fur-
ther obligation to not interfere when that course is
being followed. Symptom tinkering is extremely
pernicious, can do naught but harm, where a proper
balance or proportion between the symptoms already
exists. In illustration take temperature. Not so
long ago it was thought good practice to depress
exalted temperature, regardless of its relationships;
now it is coming to be considered a useful factor,
and its deficiency within bounds is deplored.
Thus far our discussion has been general. Let us
now briefly touch a few points in particular. And
first it may be mentioned that in self limited dis-
ease, as, indeed, also in every other condition of
disease, the problems of heredity and habit and
environment and idiosyncrasy — in fact, all those
elements which make an individual an in-
dividual and render every case a case by
itself, all this should be taken into the
reckoning. Sir Dyce Duckworth has recently en-
tered protest against the tendency of medicine to
neglect the personal. It would seem that it has
l)een peculiarly Osier's mission t(j champion the
claims of man to be dealt with even in a medical
way as a human being unique and unduplicated,
rather than as an animate lump of matter of distinct-
ly generic mould.
In every case of self limited disease rest and
sleep should be given careful attention. To this end
pain of a degree that is distressing and exhausting
should be controlled. Of course the heart
should be assiduously, untiringly watched. A con-
sideration of vital importance is the efficient per-
formance of their functions by the emunctories —
this cannot be overemphasized. Nutrition should
be looked after; but here again natural indications
should be closely studied — we should be careful not
to say cat, when Nature says fast. Water will be
the indispensable food.
Many of us are quite familiar with river rafting.
The management of self limited disease, it seems to
the writer, is like unto that. Is the raft duly in
its channel? On the bosom of the current undis-
turbed let it float — the river will strongly, securely
bear it forward — the motionless oars will be the
certain sign that all is well. Has the raft drifted out
of its channel ? Let there be no hesitation or delay ;
let a "long pull and a strong pull and a pull all to-
gether" bring it back where rafts are wont to go.
Yonder is the pilot — mostly standing with folded
arms, his eyes bent on stream and shore ahead.
May 30, 1908.]
I'AN SLYKE: FAT AND PROTEINS IN COIV'S MILK.
I02I
Now he directs a slight adjustment this way and
now that way, and again he urges a mighty, a reso-
lute effort against a power drawing his raft toward
rock or shoal. He does not have things done only
later to have them undone. Never does he lose his
head ; if he should he would lose his raft. He knows
where he is and whither he is going; if he did not
he would not be a pilot. Probably he will arrive
dov/n river without loss. Should his raft ground or
"stove" he will not be at fault.
Yes, the medical man is the counterpart of the
riverman. Like him he has a charge to guide down
the angry current of a flood from which there is no
escape except in the quiet waters below. Similar
knowledge should be his, and similar principles
should govern him. He can do no more than the riv-
erman, albeit his trust is incomparably momentous.
To know the courses, and to wisely, skilfully strive
to hold them is the measure of possible competency.
Let him, then, simply be another captain of a raft.
In failure he, too, will be faultless. But if at last
his raft glides out upon a serene expanse beneath
sunny skies, even though the oars have been most
of the time idle, for what he did not do as much as
for what he did do he will be a victor — he will be a
pilot — he will be a doctor.
CONDITIONS AFFECTING THE PROPORTIONS
OF FAT AND PROTEINS IN COW'S MILK.
By L. L. Van Slyke, Ph. D.,
Geneva, N. Y.,
Chemist of the New York Agricultural Experiment Station.
In the utilization of cow's milk in infant feeding
a knowledge of the proportion of fat and proteins is
of fundamental importance. The assumption, so
common in works on infant feeding and in practice,
that fat and proteins in cows' milk are present in
fairlv uniform percentages, is not supported by the
actual facts.
The accumulation of extensive data in the records
of this station bearing on the subject of this paper
furnish abundant material for a somewhat detailed
discussion. Briefly stated, these records include the
following data : ( i ) Analyses of the mixed milk of
numerous herds of cows, as obtained at cheese fac-
tories in this State. We have over three hundred
such analyses, representing results of work done
during several different factory seasons (April to
November). (2) Analyses of the milk of each of
fifty different herds of cows, whose milk was taken
to one cheese factory, analysis being made every
other week from April through October. This work
furnished about 650 analyses of herd milk, such as
is common in the dairy regions of this State. (3)
Analyses of milk of individual cows, representing a
systematic investigation covering entire periods of
lactation. Seven different breeds are represented,
each with three to six individuals, the results cover-
ing for each individual one to eight periods of lacta-
tion. This work has furnished several thousand
analyses of milk. The extent of our data is such
that in the limits of this article they can be used only
in the digested form of summaries or in illustration
of specific details.
It is the purpose of this article to present data
showing, (i) the range of variation in the amounts
of fat and proteins in milk; (2) the conditions
which influence variation of these constituents; (3)
the variations in the relation of fat to proteins ; and
(4) some of the practical applications of the facts
presented.
General Range of Variation in the Percentages of
Fat and Proteins in Milk.
The extreme variation possible in cow's milk is a
matter of general rather than practical interest. As
such, we first present the results furnished by our
records. As would be expected and as is well
known, the variations in the percentages of constitu-
ents are much greater in the case of single milkings
of individual cows than in the case of averages for
entire periods of lactation, or than in the case of the
mixed milk of a herd of cows, or than in the case
where the milk of several different herds is mixed.
Of course, practically all the milk handled in com-
merce is either the milk of individual herds or the
mixed milk of numerous herds.
(i) Fat. — Taking all the results in our records
for the single complete milkings of individual cows,
the lowest percentage of fat found is 2.25 and the
highest 9 ; the minimum amount being found in the
milk of a Holstein-Friesian cow, the maximum in
that of a Jersey cow that was far along in lactation.
During a period of lactation (usually ten to twelve
months) the fat in the milk of an individual cow
may vary, in the case of single milkings, more than
three per cent., from lowest to highest. The ex-
treme variation of fat between two successive milk-
ings (night and morning) may be as much as two
per cent, in the case of the same animal.
The percentage of fat in the milk of individual
cows for an entire period of lactation, according to
our records, is a minimum of 2.79 (Holstein-Fries-
ian) and a maximum of 6.30 (Jersey).
In the case of individual herds of cows, such as
are common in the dairy regions of this State, the
minimum percentage of fat on any one day was
found to be 2.90 ; the maximum, 5.50, which oc-
curred late in the season (October). The lowest
season average for any one herd was 3.31 per cent. ;
the highest, 4.31 per cent.
In the case of milk consisting of a mixture of the
milk of different herds, the lowest percentage of fat
found was 3.04 and the highest 4.60.
Proteins. — For the purpose of this article we can
consider the proteins of milk as consisting of casein
and albumin.
In the single milkings of individual cows we have
found as low as 2.19 per cent, of total proteins and
as high as 8.56 per cent., the casein varying from
1.59 to 4.49 per cent., and albumin from 0.31 to 5.32.
per cent. The highest percentages were found in
the case of cows far along in lactation and giving
only small amounts of milk. Such milk is, of course,
not normal from a commercial standpoint and pos-
sesses interest mainly in showing what the secretion
may become under certain known conditions.
The percentage of proteins in the milk of indi-
vidual cows for an entire period of lactation varies
from 2.37 to 4.44; of casein, from 1.90 to 3.55 ; and
of albumin, from 0.47 to i.oo.
In the case of individual herds of cows, the per-
1022
VAN SLYKE: FAT AND PROTEINS IN COW'S MILK.
[New York
Medical Journal.
centage of proteins ranged from 2.31 to 3.71 ; of
casein, from 1.79 to 3.02 ; and of albumin, from 0.41
to 0.97.
In the case of milk consisting of a mixture of the
milk of dififerent herds of cows, the percentage of
proteins varied from 2.53 to 3.76; of casein, from
1.93 to 3.00; and of albumin, from 0.47 to 0.88.
Conditions Affecting Variations of Fat and Pro-
teins in Milk.
The conditions of the marked variations observed
in the amounts of constituents in cow's milk have
received considerable study, and many of our data
are available, with special reference to this phase
of the subject, which will be discussed under the
following headings: (i) Individuality, (2) breed,
(3) stage of lactation, (4) food, (5) season, (6)
manner and time of feeding.
(1) Individuality. — In examining the results of
analysis of single milkings in the case of two or
more individual cows, one is first impressed with the
marked differences usually existing. If one carries
on the study of individuals for prolonged periods of
time, it will be noticed that, while the composition
of the milk of each may vary quite widely in single
milkings at different times, each possesses certain
characteristics that serve to distinguish it in a man-
ner more or less marked. To change the composi-
tion of the milk of a cow to such an extent that it
loses its individual characteristics requires extreme
and abnormal conditions ; and even when such
changes are effected, they are usually only tempo-
rary. Probably no question in animal nutrition has
attracted so much attention along practical lines as
that of changing the percentage of fat in milk by
means of feeding, or, to state it in another form, the
problem of overcoming through food the influence
of individuality. The problem has not yet been
solved, at least not in an economical form, and it is
generally regarded by students of animal nutrition
as a dairyman's will-o'-the-wisp. A few analyses
are given in Table II, illustrating individuality in a
general way.
(2) Breed. — The influence of what is known as
breed upon the composition of cow's milk has been
recognized and extensively studied. The following
figures, representing in the case of each of seven
different breeds averages of three to six individuals
of each breed for an aggregate of four to twenty
periods of lactation, will illustrate the point under
consideration.
Table I. Fai
Name of breed:
1. Holstein-Friesian
2. Ayrsire
3. American Holderness.
4. Shorthorn
5. Devon
6. Guernsey
7- Jersey
Proteins in Milk of Different
Cows.
Proteins, Casein,
per cent, per cent.
Fat,
per cent.
3.26
3.76
Albumin,
per cent.
4.28
5.38
5.78
Z.84
2.20
0.64
307
2.46
0.61
332
2.63
0.69
3-43
2.79
0.64
3-93
3.10
0.83
3-56
2.91
0.65
3-68
303
0.65
The characteristics of a breed are, of course, more
or less modified in the case of individuals, so that
we may have quite wide variations in the per-
centages of fat and proteins in the milk of dififerent
individuals of the same breed ; but it is extremely
rare that the individual characteristics overcome
those of breed to such an extent that we should, for
example, not be able to distinguish normal Guernsey
or Jersey milk from Holstein or Ayrshire milk, even
in the case of single milkings. While extreme varia-
tions in the case of individuals of the same breed
can be thoroughly studied only with single milkings,
the average differences for entire periods of lacta-
tion are very marked, as is illustrated in the case
of two breeds by the following figures.
Table II. Differences in Percentage of Fat and Proteins in
Individual Jerseys:
Individual Holstein-Friesians:
Fat.
Proteins.
Casein.
Albumin
5-49
3-57
2.91
0.66
S.61
3-44
2.83
0.61
5-77
3-69
2.91
0.78
6.04
3.87
319
0.68
6.15
396
3-42
0.54
3.05
2.97
2.29
0.68
3-II
2.60
2. 1 I
0.49
3-i6
2.96
0.55
3-19
2.92
Z.27
0.6s
3-53
3-34
2.70
0.64
(3) Stage of Lactation. — From the time a cow
"comes fresh in milk" up to the time when she be-
comes "dry," the composition of the milk undergoes
a gradual process of change, quite independent of
other conditions. The period of lactation varies in
length with different individual cows, but, for prac-
tical purposes, lasts about ten to twelve months. The
changes in the percentages of fat and of proteins
observed during the progress of the lactation period
are quite marked and fairly regular, without refer-
ence to individual or breed. The colostrum, the se-
cretion produced by a cow soon after calving, is very
different in composition from normal milk, and is
not considered at all in our discussion. The figures
presented in the following table represent the month-
ly averages of nearly 100 different lactation periods.
Table III. Influence of Lactation on Percentages of Fat 'and
Proteins in Milk.
Month of lactation.
Fat.
Proteins.
Casein.
Albumin.
4-30
3.16
2.54
0.62
4.1 1
2.99
2.42
0.S7
4.21
304
2.46
0.58
425
3-13
2.52
0.61
4.38
3-25
2.61
0.64
4-53
3-33
2.68
0.65
4-57
3-40
2.74
0.66
4-59
3-47
2.80
0.67
4.67
3-57
2.90
0.67
4.90
3-79
3.01
0.78
5-07
4.04
313
0.91
In studying this table, we notice that the percent-
ages of fat and proteins drop in the second month
of lactation, as compared with the first, and then
begin to increase, continuing to increase from month
to month during the entire period of lactation.
Such behavior appears to be the general rule. Oc-
casionally, an individual may, for a single period
of lactation, depart quite widely from the general
tendency. Individuals usually, but not always, show
much of the uniformity observed in the results
shown in Table III. The occasional variations from
the general tendency are due to special, temporary
causes in each case, usually connected with such con-
ditions as weather, health, care, etc.
In the tenth and eleventh months of lactation, the
increase of fat and proteins is more marked than
during the preceding months. In the case of cows
whose lactation period is prolonged for one and a
half or two years, with a good flow of milk, the
percentages of fat and of proteins may not continue
to increase, but may even decrease.
In this connection, it will be a matter of interest
May 30, 1908.]
VAN SLYKE: FAT AND PROTEINS IN COW'S MILK.
1023
to consider the influence of advancing lactation upon
the percentages of fat and of proteins, as observed
by us in the case of milk used at cheese factories in
this State; because this milk represents the condi-
tion present in the large milk producing sections of
the State. In general, dairymen have their cows
"come fresh in milk" in March and April, so that
the milk taken to a cheese factory (or sent to the
city markets) represents during the season (April
to November) stages of the lactation period extend-
ing from about the second to the eighth months.
Cows kept under ordinary farm conditions are sub-
ject to greater variation of external influences than
in the case of the cows used in our station investiga-
tion. The following figures give the results of our
work with cheese factory milk.
Table IV. Influence of Lactation on Percentages of Fat and
Proteins in Case of Cheese Factory Milk.
Month. Fat. Proteins. Casein. Albumin.
April 3.43 2.81 2.29 0.52
May 3.58 3.02 2.34 0.68
June 3.64 3.24 2.47 0.77
July 3-62 3.07 2.43 0.64
August 3.84 3.02 2.39 0.63
September 3.92 3.20 2.55 0.65
October 4.23 3.55 2.81 0.74
These results show, in general, an increase in the
percentages of fat and of proteins similar to that
observed in Table III. The irregularities shown in
July and August, especially by a decrease in pro-
teins, will be considered later.
(4) Food. — It has been stated already that, under
normal conditions, the percentage composition of
milk is little influenced by variations in food. In
the course of our studies of cheese factory milk,
it was noticed that, under certain conditions,
marked changes in composition take place. Each
year of our studies it was observed that about the
middle of May there was a marked increase of fat
and proteins. Thus the difference in composition
of milk between the first half and the second half
of May in one season is shown by the following
figures :
Fat, Proteins, Casein, Albumin,
per cent, per cent, per cent, per cent.
First half of May 3.46 2.85 2.25 0.60
Second half of May 3.70 3.17 2.45 0.72
A careful study of all the available facts justifies
the explanation that these changes were largely due
to a marked change in the character of the food and
environment of the cows, since they were turned
into pasture about the middle of May. Under the
known existing conditions, there was thus a change
from dry food of an indifferent character, mainly
straw or poor hay without grain, to a highly succu-
lent food of a most palatable and nutritious char-
acter. It is probable that the change of environment
of the cows from confinement in barn and yard to
the freedom of the pasture exercised a beneficial
physiological influence.
In Table IV it is noticed that there is a marked
decrease of proteins in July arfd August. Similar
changes were always observed in the case of cows
kept at pasture without supplementary sources of
food whenever there was a period of drouth suffi-
ciently severe to cause a drying up of pastures.
Under such circumstances the main food supply
was seriously affected. The changes in composition
of milk were accompanied by severe shrinkage in
yield of milk. Accompanying this impaired condi-
tion of food supply, the animals were subjected to
the unfavorable effects coming from excessive heat,
combined with annoyance of flies. Such changes in
composition and yield of milk do not occur in times
of drouth in the case of cows which are protected
from the effects of extreme weather and whose food
supply is kept normal.
(5) Season. — The influence of season upon varia-
tions in the composition of milk, apart from the ef-
fect of advancing lactation, is, to a considerable ex-
tent, associated with that of food supply, as indi-
cated by the discussion preceding. When conditions
are normal or when cows are properly protected
from the effects of abnormal weather conditions,
variations in the composition of milk appear to be
quite independent of seasonal influences.
(6) Time and Manner of Milking. — The composi-
tion of the milk given by an individual cow may be
much influenced by the conditions under which milk-
ing is done. We shall consider three conditions :
(a) Time between milkings ; (b) fractional milking
of the whole udder; and (c) milking different quar-
ters of udder separately.
(a) Time Between Milkings. — In general, when
the time between successive milkings is the same,
the composition of the milk varies little in the ab-
sence of any special, disturbing influence. Averag-
ing about 500 analyses, each, of morning's and even-
ing's milk, representing 15 cows, we find the morn-
ing's milk to contain 100 parts of fat, as compared
with 99.06 parts in the evening's milk, and 100 parts
of proteins for 98.34, the time between the milkings
being as nearly uniform as possible. However, if
we consider single milkings of an individual cow,
we may, in special instances, find considerable varia-
tion, in illustration of which the following figures
are given :
Table V. Percentages of Fat and of Proteins in Morning's and
Evening's Milk.
Date. Fat. Proteins. Casein. Albumin.
Dec. 13th, a. m 5.60 4.16 3.52 0.64
Dec. 13th, p. m 6.00 4-23 3-55 0.68
Dec. 20th, a. m 6.00 4.11 3.26 0.85
Dec. 20th, p. m 6.00 3.93 3.19 0-74
Dec. 27th, a. m 5.80 4.19 3.51 0.68
Dec. 27th, p. m 6.45 3.98 3.30 0.68
Jan. 4th, a. m 6.20 4-37 3-52 0.85
Jan. 4lh, p. m 6.40 4.23 3.38 0.85
(b) Fractional Milkings of Whole Udder.— The
first portions of milk drawn from a cow's udder are
very unlike normal milk in composition, showing
a marked deficiency of fat. Each successive por-
tion of milk drawn increases in fat content and the
last portions drawn usually contain twice as much
fat as normal milk. In illustration of these state-
ments, we give analyses of the milk of a Guernsey
cow, representing milk drawn successively from the
whole udder in four fractions.
Table VI. Variation of Fat and of Proteins of Milk in Frac-
tional Milkings.
Fraction Pounds of Fat, Proteins, Casein, Albumin,
drawn. milk. per cent, per cent, per cent, per cent.
First 3.2 0.76 3.29 2.67 0.62
Second 4.1 2.60 3.21 2.57 0.64
Third 4.6 5.35 3.10 2.49 0.61
Fourth 5.3 9.80 2.97 2.39 0.58
Whole milk of
same cow .. .. 5.34 3.12 2.51 0.61
While the fat increases rapidly with each suc-
cessive portion of milk drawn from the udder, the
proteins decrease slightly, as would be expected
I024
VAN SLYKE: FAT AND PROTEINS IN COlV'S MILK.
[New York
Medical Journal.
from the mere presence of increase of fat. The
work was repeated by us with several different cows
and the several sets of corresponding analyses show
similar results.
(c) Milking Dififerent Quarters of Udder. — As
the result of a large number of analyses of milk
drawn separate!}- from each quarter of the udder, it
appears that the milk in each quarter possesses in-
dividual characteristics of composition, the extent
of difTerence between the quarters varying in the
case of different cows. The following figures fur-
nish an illustration :
Table Percentages of Fat and Proteins in Milk from Dif-
ferent Quarters of Udder.
Quarter of udder. Fat. Proteins. Casein. Albumin.
Left hind quarter 415 2-97 2-33 o-64
Left forward quarter 4.60 2.94 2.32 0.62
Right hind quarter 5.05 2.89 2.31 0.58
Right forward quarter 5.20 2.96 2.38 0.58
The variations in percentage of fat are much
greater than in the case of proteins.
Not only does the composition of the milk in one
quarter of the udder differ from that in other quar-
ters, but the composition in the same quarter varies
according to the order, relative to the other quar-
ters, in which the milk is drawn, as shown by the
following example :
Table VIII. PERCENTAri-; of Fat and of Proteins in Milk of
Same Quarter of Udder When Drawn in Different Order
Kel.'VTIVe to Other Quarters.
Left forward quarter of udder. Fat. Proteins. Casein. Albumin.
When milked first 5.10 2.85 2.30 0.55
When milked second 4.85 3.00 2.40 0.60
W'lien milked third 4.60 2.96 2.36 0.60
When milked fourth 3.95 2.91 2.35 0.56
Variations in the Relation of Fat to Proteins in
CoK's Milk.
We have thus far corrsidered the conditions which
affect the percentages of fat and of proteins in milk,
without paying attention to the relative variations
of these constituents. It now remains to study the
effect of various conditions upon (i) the relation
of fat to total proteins, (2) the relation of fat to
casein, and (3) the relation of casein to albumin.
Conditions Affecting the Relation of Fat to Total
Proteins and to Casein in Milk. — This phase of our
subject will be briefly considered under the head-
ings already used in discussing the general subject
preceding and the figures already presented in the
foregoing tables will be utilized in furnishing de-
sired data.
(a) Breed. — The influence of breed in affecting
the relation of fat to proteins is shown in the fol-
lowing table, the data of which are derived from
Table I :
Table IX. Influence of Breed Upon Relation of Fat to
Proteins.
Parts of Parts of
Fat, Proteins, proteins for Casein, casein for
Name of Tireed. per per i part of fat. per i part of fat.
cent. cent. Fat : Proteins. cent. Fat : Casein.
1. Holstein-
I'ricsian ... 3.26 2.S4 i 10.87 2.20 i : 0.67
2. Ayrshire . . . 3.76 3.07 i : 0.82 2.46 i : 0.65
3. American
Holderness . 4.01 3.32 i : 0.83 2.63 i : 0.66
4. Shorthorn . 4.28 3.43 1 : 0.80 2.79 i : 0.65
5. Devon 4.89 3.93 I : 0.80 3.10 i : 0.63
6. Guernsey.... 5 38 3 56 J : 0.66 2.91 i : 0.54
7. Jersey 5.78 3.68 i : 0.64 3.03 i : 0.52
It is seen that the different breeds represented
separate into two general groups in relation to the
ratio of fat to total proteins and to casein in milk.
In the case of the first five breeds, the ratio of fat
to proteins or to casein does not vary widely. The
milk of the Holstein-Friesian breed contains least
fat and most proteins in relation to fat. In the case
of the next four breeds in the list the fat varies
from 3.76 to 4.89 per cent., but the proteins also
vary in very nearly the same ratio as the fat. The
Guernsey and Jersey breeds constitute the second
group, the fat being high in amount, but the pro-
teins relatively low. These two breeds vary com-
paratively little in reference to the ratio of fat,
either to the proteins or to casein.
(b) Individuality. — We will notice briefly the
variations that occur in case of different individuals
of the same breed. The figures in the following
table are derived from Table II and represent the
averages for an entire period of lactation in the case
of several different individuals of two breeds. More
marked dift'erences could be obtained, of course, by
taking single milkings or monthly averages.
Table \. Influence of Individuality Upon the Relation of
F.\T to Proteins.
Parts of Parts of
Fat, Proteins, proteins for Casein, casein for
per per i part of fat. per t part of fat.
cent. cent. Fat : Proteins, cent. Fat : Casein.
Individual Jerseys:
1 5-49 3-57 I : 0.64 2.91 i : 0,56
2 5-6i 3-44 I : 0.64 2.83 i : 0.53
3 5-77 3-69 I ; 0.64 2.91 I : 0.50
4 6.04 3.87 I : 0.61 3.19 I : 0.50
5 6.15 3.96 I : 0.65 3.43 I : 0.53
Individual Holstein-Friesians:
1 3-05 2.97 I : 0.97 2.29 I : 0.75
2 3. II 2.60 I : 0.84 2. 1 1 I : 0.68
3 3.16 2.96 I ; 0.94 2.41 1 10.76
4 319 2.92 I : 0.91 2.27 1 : 0.71
5 3-53 3-34 i : 0.95 2.70 i : 0.77
Whether we take the ratio of fat to proteins or
of fat to casein, there would be very little difficulty
in identifying any individual in the list with its
proper breed, even though there is some range of
variation between the individuals of each breed.
(c) Stage of Lactation. — We have previously
noticed that during the period of lactation the fat
and proteins increase gradually and quite regularly.
We will now consider the question as to whether
these constituents increase in the same ratio. The
data in the following table are derived from the fig-
ures given in Table III.
Tablf XL Influence of Stage of Lactation Upon the Relation
of Fat to Proteins.
Parts of Parts of
Fat, Proteins, proteins for Casein, casein for
Month of per per i part of fat. per i part of fat.
lactation: cent. cent. Fat : Proteins, cent. Fat : Casein.
1 4-3° 316 I : 0-74 2.54 I : 0.59
2 411 2.99 1 : 0.73 2.42 I : 0.59
3 4-21 3.04 I : 0.72 2.46 I : 0.58
4 4 25 3.13 1 : 0.74 2.52 I : 0.59
5 4 38 3.25 I : 0.74 2.61 I : 0.60
6 4-53 3-33 1 : o 74 2.68 i : 0.59
7 4-57 3-40 I : 0.74 2.74 i : o.6o-
8 4 59 3-47 I : 0.75 2.84 I : 0.61
9 4-67 3-57 I : 0.76 2.90 I : 0.62
4 90 3-79 1 : 0.77 3.01 I : 0.62
II S-07 4 04 I : 0.80 3.13 I : 0.62
An examination of the fourth and of the last
columns in the above table shows a remarkable uni-
formity in the ratio of fat to total proteins and to
casein throughout most of the period of lactation.
During the first three months a very slight tendency
appears for the fat to increase with reference to
proteins, qr, stated another way, for the proteins to
decrease in proportion to fat. After this there is
very close uniformity in the ratio of fat to proteins
up to the eighth month, after which the total pro-
teins increase gradually in relation to fat to the end
May 30, 1908.]
VAX SLYKE: FAT AND PROTEINS J.\ COIV'S MILK.
1025
of the lactation period. During the last three
months of lactation, the fat increases quite rapidly,
but the proteins increase even more rapidy in rela-
tion to fat. During this period the casein increases m
exact proportion to fat, maintaining a uniform ratio
that is very striking. The close uniformity observed
in Table XI is not always so marked, of course, in
every individual case, but the tendency shown is a
very general one.
In this connection, we will use the data embodied
in Table IV to illustrate the relations under con-
sideration in the case of the mixed milk of many
herds of cows, as obtained at cheese factories.
Table XII. Influe.nce of Stage of Lactation Upon the Relation
OF Fat to Protei.vs in Cheese Factory Milk.
Parts of Parts of
Fat, Proteins, proteins for Casein, casein for
Month. i.ci- per 1 part of fat. per i part of fat.
cent. cent. Fat : Proteins, cent. Fat : Casein.
April 3.43 2.81 I : 0.82 2.29 i : 0.67
May 3.58 3.02 I : 0.84 2.34 i : 0.65
June 3.64 3.24 1 : 0.89 2.47 i : 0.68
July 3.62 3.07 1 ; 0.85 2.43 I : 0.67
August 3.84 3.02 I : 0.79 2.39 I : 0.62
September .... 3.92 3.20 i : 0.82 2.55 i : 0.65
October 4.23 3.55 i : 0.84 2.81 1 : 0.6b
The amount of total proteins shows a tendency
to increase relative to fat for a few months, when
a decrease occurs, which is followed by a later in-
crease. The casein maintains a fairly uniform re-
lation to fat during the whole season, except during
August, when a decrease was caused by the effect
of drouth upon pasturage and attendant unfavorable
conditions.
(d) Food and Season. — Attention has previously
been called to the effect of turning cows into pas-
ture, as manifested by changes in the composition
of milk in the first and second half of the month of
May. We will now notice whether the relation of
fat and proteins is changed.
Parts of Parts of
Fat, Proteins, proteins for Casein, casein for
per per i part of fat. per i part of fat.
cent. cent. Fat : Proteins, cent. Fat : Casein.
First half of May 3.46 2.85 i : 0.82 2.25 i : 0.65
Second half of
May 3.70 3.17 I : 0.86 2.45 i : 0.66
It is seen that while total proteins increased with
reference to fat, the ratio of casein to fat changed
only slightly,
(e) Conditions of Milking. — An inspection of
Tables V, VI, VII, and VIII indicates that the total
proteins and the casein also remain fairly uniform
while the fat may vary greatly in the case of milk
drawn from the udder in fractional portions, in the
case of milk drawn from dift'erent quarters of the
udder, etc.
Conditions Affecting the Relation of Casein to
Albumin in Milk.
The general statement has been prominently cur-
rent in medical literature to the effect that casein
and albumin are present in cow's milk in very con-
stant relative proportions, the amount of casein be-
ing five times that of albumin. Taking herd milks,
we have found the casein varying all the way from
2.6 to 5.6 parts for one part of albumin. In single
milkings of individual cows, the variations are con-
siderably wider. The data already presented en-
able us to study this question under a variety of
conditions.
(a) Breed. — The variation of albumin in relation
to casein in the case of different breeds of cows is
shown in the following table, the data of which are
derived from Table I :
Name of breed.
« M E
1. Ilolstein-Friesian ... 2.84 2.20 0.64 i .3.4 77.5 22.5
2. Ayrshire 3.07 2.46 0.61 i 14.0 80.1 19.9
3. American Holderness 3.32 2.63 0.69 i : 3.8 79.2 20.8
4. Shorthorn 3.43 2.79 0.64 i : 4.5 81.3 18.7
5. Devon 3.93 3.10 0.83 I : 3.7 78.9 21.1
6. Guernsey 3.56 2.91 0.65 1 : 4.5 81.7 18.3
7. Jersey 3.68 3.03 0.65 i : 4.7 82.3 17.7
In Studying the results embodied in Table XIII,
it is noticeable that the casein and albumin vary
more or less in their relative proportions in the case
of different breeds of cows, and in no case is the
proportion of casein to albumin as high as is ordi-
narily stated (five to one). It is also noticeable
that, in general, the albumin forms a larger pro-
portion, and the casein a smaller proportion, of the
proteins in milk that contains a low percentage of
fat than in case of milk containing a high percent-
age of fat, when we compare the milk of dift'erent
breeds of cows. Thus, in the milk of Holstein-
Friesian cows, we have the least amount of fat, and
the albumin forms a larger part (22.5 per cent.)
of the proteins than in case of any other breed un-
der discussion. In the case of Guernsey and Jer-
sey milk, in which the fat content is highest, the
proportion of albumin with reference to total pro-
teins or to casein is least (17.7 and 18.3 per cent,
of total proteins).
(b) Individuality. — For illustration of the rela-
tive proportions of casein and albumin in the case
of the milk of different individuals of the same
breed, we take the data embodied in the following
table from Table II :
Table \IV. Influence of Individuality Upon Re
Casein to Albumin in Milk.
Individual Jerseys:
0
•1 1
0 'u
< K
Perc
prot
of a
3-57
2.91
0.66
3-44
2.83
0.61
I : 4-6
ll'-t
369
2.91
0.78
1 : 3-7
78.8
2 1 .2
3-87
3- 19
0,68
I : 4.7
82.4
17.6.
396
342
0.54
1 : 6.3
86.4
13.6.
2-97
2.29
0.68
I : 3-2
22.9.
2. II
0.49
1 : 4-3
11.1
18.S
2.41
0-55
I : 4.4
81.4
18.5
0.65
I : 3-5
77-7
22.3
2.70
0.64
1 : 4.2
80.9
19.1
We see marked variation in the relation of casein
to albumin in the case of the milk of different in-
dividuals of the same breed, the ratio varying in
case of the Jerseys from 3.7 to 6.3 parts of casein
I026
rAN SLVKE: FAT AND PROTEINS IN COW'S MILK.
[New York
Medical Journal.
for one of albumin, and in case of the Holstein-
Friesians, from 3.2 to 4.4.
(c) Stage of Lactation. — Making use of the data
given in Table III, we are able to prepare the fol-
lowing table :
Upon Relation of Casein
Table XVII.
Table XV. Influenci
Monfli of lactatioi'
OF Lactatio:
TO Albumi
CLi a. O =. < o. C-(>So< Phco C-ao
I 3.16 2.54 0.62 I : 4.1 80.4 19.6
2 2.99 2.42 0.57 I : 4.2 80.9 19. 1
3 3-04 2.46 0.58 I : 4.2 80.9 19.1
4 3-13 2-52 0.61 I : 4-1 80.5 ig-S
5 3-25 2.51 0.64 I :4.i 80.3 19.7
6 3.33 2.68 0.65 I : 4-1 80.5 19-5
7 3 40 2.74 0.66 I : 4.2 80.6 19.4
8 3-47 2.80 0.67 I : 4-2 80.7 i9-3
9 3-57 2-90 0-67 I : 4-3 81.2 18.8
10 3.79 3 01 0.78 I : 3-9 79-4 20.6
II 4-04 313 0.91 I ; 3-4 77-5 22.5
The relation of casein and albumin, as shown bv
the foregoing data, is remarkably uniform during
the first eight months of lactation, varying between
4.1 and 4.2 parts of casein for one part of albumin ;
or, stated in another way, the percentage of total
proteins in the form of albumin varied from 19. i
to 19.7 and, in the form of casein, from 80.3 to 80.9.
After the ninth month, the casein decreases relative
to albumin, or the albumin increases in relation to
casein ; and the change is quite marked and rapid
during the tenth and eleventh months, constituting
the closing months of the lactation period studied.
In the case of the mixed milk of numerous herds
of cows whose milk was used in cheese making, we
have the following results, derived from Table IV:
Table XVI. Influence of Stage of Lactation Upon Relation of
Casein to Albumin in Case of Milk Used for Cheese Making.
.SS =•§•=§ °-|s g.s| g.ii
Is Is Is i^ii sf: t^l
April 2.81 2.29 0.52 I -.4.4 81.5 18.5
May 3.02 2.34 0.68 I : 3.4 77.5 22.5
June 3.24 2.47 0.77 I : 3.2 76.2 23.8
July • 3 07 2.43 0.64 I : 3.8 79.2 20.8
August 3.02 2.39 0.63 I : 3.9 79.1 20.9
September 3.20 2.55 0.65 i : 3.8 79.7 20.3
October 3.55 --.81 0.74 i : 3.S 79.2 20.8
The proportion of casein in relation to albumin
decreases until July, when it makes a marked in-
crease and then remains quite uniform during the
remainder of the season, which extends approxi-
mately through the seventh or eighth month of
lactation.
(d) Time and Manner of Milking. — Variation in
time and manner of milking may, as we have seen,
profoundly affect the fat in relation to proteins, the
percentage of proteins remaining fairly constant,
while the fat may vary greatly. It remains now to
see whether such variation of conditions of milking
affects at all the relation of casein to albumin. The
data in the tables following are derived from Tables
V, VI, VII, and VIII.
(i) Morning's and Evening's Milk — The follow-
ing data are given as a mere illustration :
Dec. 13th,
Dec. 13th,
Dec. 20th,
Dec. 20th,
Dec. 28th,
Dec. 28th,
Jan. 4th,
Jan. 4th,
° II'e
? ■- "-^
6 0.
< 1
m
... 4.16
352
0.64
I : 5.5
ra
• • 4.23
3-55
0.68
I : 5-2
3.26
0.85
I : 3-8
3-93
319
0.74
I : 4-3
... 4.19
3-51
0.68
I : 5-2
m
. .. 3-98
3-30
0.68
I : 4.9
4-37
0.85
I : 4.1
• • • 4-23
0.85
I : 4.0
84.6
83.9
79-3
81.2
83.8
R2.9
80.6
80.0
" w E
20.7
18.8
16.2
These data indicate that there may be quite
marked variation in the relation of casein to albu-
min in the milk of morning and evening in the case
of the milk of the same animal.
(2) Fractional Milkings of Whole Udder.— We
have previously seen that the percentage of fat
varies greatly in different portions of milk drawn
from the same udder, while the total proteins re-
main fairly constant. Below we present data to il-
lustrate to what extent the casein and albumin may
varv relatively under such conditions.
Fraction drawn. eg £ ° "-^g g.S'i |.S.o
2^- i"- £ '~ Ml-.!! ^o" ^o"*
(Co. Ua. < c. pH.£n< o. o C^o.'o
First 3.29 2.67 0.62 I : 4.3 81. i 18.9
Second 3.21 2.57 0.64 i : 4.0 80.0 20.0
Third 3.10 2.49 0.61 i : 4.1 80.3 19.7
Fourth 2.07 2.39 0.58 I :4.i 80.5 19.5
Whole milk of same cow.. 3.12 2.31 0.61 I : 4.1 80.4 19.6
These results indicate that under conditions which
may very greatl}- affect the relation of fat to pro-
teins, the relation of casein to albumin may be in-
fluenced very little.
(3) Milking Separately Different Quarters of
Udder. — We have previously seen milk from dif-
ferent quarters of the udder vary in fat content,
with little change in percentage of proteins.
Table XIX. Relation of Casein to .\lbumin in Milk from Dif-
ferent Quarters of Udder.
Left hind quarter 2.97
Left forward quarter.. 2.94
Right hind quarter 2.89
Right forward quarter. 2.96
0.64
0.62
0.58
0.58
I :3-6
I : 3-7
I : 4.0
Bh So
78.4
The relation of casein to albumin differs in the
right and left halves of the udder, but, in this par-
ticular case, is practically constant in the two quar-
ters of each half.
(4) Milking Same Quarter of Udder in Different
Orders Relative to Other Quarters. — The data be-
low illustrate variation of the relation of casein to
albumin as the result of milking the same quarter
of the rudder in different orders with reference to
the other (|uarters.
May 30, 1908.]
VAX SLYKE: FAT AND PROTEIXS IN COJV'S MILK.
1027
Table XX. Relation of Casein to Albumin as Influenced by
Milking One Quarter of Udder in Different Orders.
Left forward
quarter of uddei
When milked first 2.85 2.30 0.55 i : 4-2 80.7 19.3
When milked second.. 3.00 2.40 0.60 i 14.0 80.0 20.0
When milked third.... 2.96 2.36 0.60 i : 3.9 79-7 20.3
When milked fourth... 2.91 2.35 0.56 i : 4.2 81.0 19.0
The results show simply that in this particular
case there is some slight variation of casein in rela-
tion to albumin in milk when the same quarter of
the udder is milked in different order relative to
other quarters.
Methods for Calculating Total Proteins and
Casein in Milk.
While the relation of fat to casein in cow's milk
is a variable one, a relation exists in the case of
mixed milk which can be utilized in calculating- the
amount of casein approximately when the per cent,
of fat is known. As a result of the writer's stud}-
of the milk of each of fifty different herds of cows
during one season ( ^lay to October, inclusive), a
general relation was noticed between the fat and
casein content. In general, it was found that when
fat in milk increases i.o per cent., casein increases
0.4 per cent. This was found to hold quite satis-
factorily when applied in case of ordinary herd milk
varying in fat content from 3.0 to 4.5 per cent. In
milk with less than 3.0 per cent, of fat. the casein
content is usually higher in relation to fat than in
milk with more than 3.0 per cent of fat ; while in
the case of milk containing more than 4.5 per cent,
of fat, the ratio of casein to fat is usually some-
what less than in milk containing less than 4.5 per
cent, of fat. Starting with milk containing an aver-
age of 3 per cent, of fat and a casein content of 2.1
per cent., milk with 4 per cent, of fat was found
usually to contain about 2.5 per cent, of casein. On
the basis of these observed general relations, the
following rule was worked out : From the number
representing the per cent, of fat in milk subtract 3,
multiply the remainder by 0.4 and to the result add
2.1. Expressed as a formula, we have:
(F — 3) X 0.4 - 2.1 = per cent, of casein (F equals
number representing the per cent, of fat in milk).
This formula may give somewhat low results in
the case of milk produced after the eighth or ninth
month of the lactation period, when the casein is
usually greater in relation to fat than during the
previous stage of the lactation period.
Applied to samples of herd milk, this formula is
capable of giving very satisfactory results, as shown
by the following dara :
Table XXI. Calculation of Per Cf.-^t. of Casein in Cow's Milk
Per cent, of casein
in cow-s milk.
t. of fat in milk.
Determined by
Calculated b;
chemical method.
formula.
2.42
4.07
2.42
2-52
3-67
2.45
2-37
3-55
2.34
2-32
3-90
2.41
2.46
403
2.40
2.50
3-45
2.23
2.28
4-27
2.38
2.60
3.88
2.46
2.46
4.22
2.48
2.58
342
2.27
For ordinary purposes, where strict accuracy is
not required the rule can be used quite satisfactorily
when applied to herd milk within the limits specified,
and comparatively little commercial milk goes out-
side cf these lim.iis.
This method of ascertaining the amount of casein
in cow's milk can be found especially useful in con-
nection with infant feeding in cases' where it is de-
sired to know approximately the amount of casein
in cow's milk. In connection with the feeding of
top milk, the following use can be made of the
method: Before the cream is allowed to rise, the
milk to be used can be sampled and examined for
fat by the Babcock test. From the percentage of fat
thus found the amount of casein can be calculated.
And very nearly this percentage of casein will be
present in the top milk. Then, if the relation of fat
to casein in the top milk is desired, the fat can be
determined directly by the Babcock test. This sim-
ple procedure, involving a fat test of the whole
milk before creaming and of the top milk after
creaming, will enable the specialist in infant feeding
to obtain a control over his work which he cannot
otherwise have.
Suni)uar\.
1. Extent of Data. — The study of the conditions
aft'ecting the proportions cf fat and proteins in
cow's milk, as embodied in the preceding article, is
based upon the following data : ( i ) ^00 analyses
of the mixed milk of numerous herds, obtained at
cheese factories, such as is common in the dairy
regions of New York State. (2) 650 analyses of
milk of 50 separate herds of cows, covering a period
of about six months. (3) Several thousand analyses
of milk of individual cows, representing seven 'dif-
ferent breeds of cows (American "^Holderness,
Ayrshire, Devon, Guernsey, Holstein-Friesian, Jer-
sey, Shorthorn), covering for each individual sev-
eral lactation periods and an aggregate of about 100
periods of lactation.
2. General Range of \'ariation in the Percentages
of Fat and Proteins in Milk — ( i ) In single milkings
of individual cows, the fat varied from 2.25 to 9.0
per cent. : the total proteins, from 2.19 to 8.56 per
cent.; the casein, from 1.59 to 4.49 per cent.; and
the albumin, from 0.31 to 5.32 per cent. The high-
est percentages are found in the case of cows far
along in lactation. (2) In the case of individual herds
of cows, such as are common in this State, the fat
varied from 2.90 to 5.50 per cent. : the total pro-
teins, from 2.31 to 3.71 per cent.: the casein, from
1.79 to 3.02 per cent.: and the albumin, from 0.41
to 0.97 per cent. (3) In the case of milk consist-
ing of a mixture of the milk of many different herds
of cows, the fat varied from 3.04 to 4.60 per cent. ;
total proteins, from 2.53 to 3.76 per cent. ; casein,
from 1.93 to 3.00 per cent.: and albumin from 0.47
to 0.88 per cent.
3. Conditions Aft'ecting A^ariations of Fat and
Proteins in ^lilk. — The following conditions are
discussed as those of special prominence in causing
variations of percentages of fat and proteins in
milk: (i) Individuality. (2) breed, (3) stage of
lactation, (4) food, (5) season. (6) time and man-
ner of milking, including fractional milkings, milk
from different quarters of udder, and relative order
of milking a quarter of udder.
I028
FULLER: GOXORRHCEAL RHEUMATISM.
[New Vokk
ilsiTCAL Journal.
4- Conditions Affecting the Relation of Fat to
Total Proteins and to Casein in Milk. — (i) The
breeds studied fall into two general groups : in one
case, the ratio of fat to proteins is relatively high
(Guernsey and Jersey) : in the other, relatively lower.
Individuals of the same breed may vary consider-
ably in this respect. (2) The ratio of fat to pro-
teins is very uniform through the lactation period,
until about the ninth month, when the total proteins
increase quite rapidly in relation to fat. The ratio
of fat to casein is very uniform throughout the en-
tire period of lactation, there being a slight increase
of casein in relation to fat about the ninth month.
(3) \*ariations in composition of milk due to man-
ner of milking affect the fat more or less extensively,
but the proteins very little.
5. Conditions Affecting the Relation of Casein to
Albumin. — Albumin in milk varies quite widelv in
relation to casein. The ratio varies (i) with differ-
ent breeds, (2) with different individuals of the
same breed, (3) with time and manner of milking.
(4) The relation is quite uniform during the first
eight or nine months of lactation, after which the
albumin increases relatively more than the casein.
6. Method for Calculating Amount of Casein in
Normal ^lilk. — In the case of herd milk containing
3.00 to 4.50 per cent, of fat, the following formula
for calculating the amount of casein has been found
to give m most cases quite satisfactory results :
(F — 3) X 0.4 - 2.1 = per cent, of casein in milk
(F equals number representing the per cent, of fat
in milk).
GONORRHCEAL RHEUMATISM CURED BY SEMI-
NAL VESICULOTOMY.
By Eugene Fuller, M. D.,
New York.
Visiting Surgeon. Genitourinary Division of tlic City llo'^pital. etc.
In December, 1904, I originated the idea of try-
ing to cure gonorrhoeal rheumatism in the male
through, the employment of the operation I had de-
vised of seminal vesiculotomy, and the fir.st gonor-
rhoeal rheumatic patient I operated upon was at the
City Hospital in December, 1904. The result in the
first and experimental case was a brilliant success.
In February, 1905, I operated upon my second Citv
Hospital case of gonorrhoeal rheumatism, the result
being a complete cure.
In an article entitled The Relation of Gonorrheal
Rheumatism to Seminal Vesiculitis and Its Cure by
Seminal Vesiculotomy, published in the Annals of
Surgery, June, 1905, those two City Hospital cases
were reported, together with two other cases from
my service at the Postgraduate Hospital, making in
all four cures out of the four cases so far operated
on. In explanation of my early study of this sub-
ject I will quote from my opening remarks in the
article just alluded to in the Annals of Surgery:
As it was but five months ago, namely, in December,
1904, that the idea occurred to me to try to cure gonor-
rhoeal rheumatism by the operative method I am now re-
porting, it is only since then that I have been actively in-
vestigating tlicse cases from the standpoint of the male
subject ; and my special clinical study has been to try to
determine whether the systemic infection in these cases
seemed to enter from any special focus, or from the gen-
eral mucous surface. I am as a result strongly of the
opinion that the systemic infection in the male usually
enters from a special focus, and that that special focus is
represented by a seminal vesiculitis. In support of this
assertion, I have investigated fifteen cases of gonorrhoeal
rheumatism in the male. Six of these cases are from my
private practice and nine from my practice at the City and
Fostgraduate Hospitals. In twelve of these the only ex-
isting genitourinary lesion was in the seminal vesicles,
namelv, seminal vesiculitis. In one there was a marked
seminal vesiculitis and a subsiding inflammation of the
mucous urethral surface. In two, although the seminal
vesicles were not free from some involvement, still, the
urethral inflammation seemed to be the chief feature. To
further prove my contention, I have been able to subject
to my operation of seminal vesiculotomy four out of the
twelve cases showing seminal vesiculitis to be the only ex-
isting genitourinary lesion. By means of this surgical pro-
i^edure, all systemic absorption from the seminal vesiculitis
h.as been immediately checked and a resolution of the geni-
tal lesion has promptly followed. Almost immediately in
all these cases the active symptoms of gonorrhoeal rheuma-
tism have wholly disappeared.
Up to date, February i. 1908, I have performed
the operation of seminal vesiculotomv one hundred
and one times without a death. Out of this number
the operation has been undertaken twentv-three
times for the relief of gonorrhoeal rheumatism.
In all the twenty-three patients the operation has
had a profoundlv beneficial effect on the rheuma-
tism. All have left the hospital in a well or greativ
improved condition. In all these patients there was
of course a .seminal vesiculitis to account for the
focus from which the sv^temic absorption origi-
nated. Out of the twenty-three cases seventeen pa-
tients were cured as a direct result of the operation
and were well when last seen. Of the remaining six
patients, two got well after the operation and re-
mained so till about a year ago, when each of them
contracted gonorrhoea afresh. Rheumatic symptoms
then reappeared. Both of these patients were then
seen but once with moderate rheumatism, after
which all trace of them was lost. Two more pa-
tients, after leaving the hospital in a very satisfac-
tory condition, immediately resorted to sexual inter-
course. The sexual exercise during the convalescent
stage from the operation naturallv reinflamed the
seminal vesicles, and there was a relapse of the rheu-
matism. In both these cases, however, the rheuma-
tism again disappeared after the eft'cts of the prema-
ture sexual exercise had passed off, and these pa-
tients are now well. Two very chronic cases re-
lapsed, one after being well eight months after op-
eration, and one after being relieved three months.
In both these cases there was a recrudescence of the
tenderness and inflammation in the seminal vesicles.
They were destitute individuals, and probably ex-
posure and poor living were to blame for the relapse.
In the acute bedridden cases the effect of the op-
eration is most marked. In twenty-four to thirty-
six hours the pain in the joints disappears, and by
the fourth day the swelling. Some stiffness and
some atrophy of the muscles are of course left after
the rheumatic process has disappeared in these acute
cases, requiring massage and passive movement.
In the chronic cases pain disappears in a week or
ten days, and at the end of two weeks massage can
be prescribed. In the very chronic cases it may take
two to three months of massage and exercise to lim-
ber up the joints which have been robbed of their
function. In fact, one has the same problem in
these cases which the surgeon has after resolution
from a fracture of long standing. It is well known
that in chronic gonorrhoeal rheumatism inassage and
May 30, 1908.]
I-LLLER: GOXORRHCEAL RH ILU M Al ! s .
1029
manipulation make matters worse, whereas in these
cases convalescent after seminal vesiculotomy such
treatment is beneficial, because there is no longer the
systemic absorption of the toxine.
In many of the chronic cases the preceding gonor-
rhoea was so remote an aflfair that the existing rheu-
matism had supposedly had no connection with it.
In these cases the diagnoses of uric acid, chronic
rheumatism allied to the so called inflammatory form,
arthritis deformans, gout, neuritis, and neuralgia
had been made to account for existing conditions.
The physician or orthopaedic surgeon rather than
the genitourinary surgeon had been consulted by
most of these sufferers.
One point I have noticed after operation in quite
a number of these cases is that in the third week
after operation there may be a mild and temporary
recrudescence of the rheumatic symptoms, whereas
in the two weeks immediately after operation there
had been a complete recessation of all such symp-
toms. Such recrudescence, I take it, is due to a
somewhat premature closure of the tract of the in-
cision before a complete elimination by drainage of
all the toxines has taken place. In all such cases I
have been able to demonstrate, by palpation, with
the finger tip introduced at the rectum, considerable
remaining tenderness and tumefaction in the region
of one or both seminal vesicles. By further rest, to-
gether with tonics and attention to nutrition, such
remaining tenderness and tumefaction will sponta-
neously disappear in most instances, provided the
seminal vesiculotomy has been thoroughly per-
formed. In case there should not be a spontaneous
disappearance it may be necessary to open the tract
of the wound and reintroduce the drainage tubes,
keeping these same reintroduced tubes in place till
all question of their necessity has disappeared. I
have never found it necessary to reintroduce the
drainage tubes in any of my cases of gonorrhoeal
rheumatism, although on two or three occasions I
have had to do so in connection with my seminal
vesiculotomies, undertaken for the relief of other
ailments.
During my December, 1907, and January, 1908,
service at the City Hospital I have successfully per-
formed seminal vesiculotomy eight times for the
cure of gonorrhceal rheumatism. For the collection
of this large amount of material in so short a space
of time I am under much obligation to Dr. Mitchell,
who was my house surgeon for that period. A brief
detail of the histories of these cases is as follows :
Case I. — H. L., age twenty-two; December, 1907, help-
less and bedridden, owing to gonorrhceal rheumatism in-
volving left leg, hip, and thigh. The symptoms were acute
and severe. He had been confined to bed four months
following a gonorrhcea which he had contracted five
months before. There was a marked seminal vesicuUtis,
but no other genitourinary lesion. Seminal vesciculotomv
was performed. In this case there was some bleeding
twenty-four hours after the operation, for which the in-
cision was partially reopened and repacked. Following
this reopening there was some urinarj' leakage through the
wound. This case now, seven weeks after the operation, is
entirely well of all trace of rheumatism. There is a slight
stiffened state of the hip, but this is rapidly disappearing
as a result of massage and of walking about. The resolu-
tion in this case was somewhat tardy, probably due to the
repacking of the wound and the temporary urinary leak-
age. Patient is now ready to be discharged.
Case II. — P. L., age twenty-three ; December. 1907, very
acute febrile case of gonorrhceal rheumatism involving
both wrists, left hip and right knee. These joints were
verj- much swollen and very tender. Patient was in bed
and unable to move, and had been suffering from this acute
attack about one month. This was his second attack. His
first one, which had been very tedious, had been three years
ago, following a gonorrhoea. Previous to the present attack
he had had a urethral discharge, but whether this was a
reinfection or relapsing in character was not clear. Exam-
ination showed the present lesion to be a seminal vesi-
culitis. Seminal vesiculotomy was performed, followed by
a very quick subsidence of all his rheumatic symptoms.
In three days all active evidence of the rheumatism had
disappeared. Four weeks after the operation the patient
left the hospital to . sail for Europe. He was completely
well except for a slight stiffness of the right wrist. This
was rapidly disappearing as the result of active use of the
part.
Case III. — V. A., forty-five years of age; December,
1907. This patient entered the hospital owing to trouble
in connection with his left knee; which he had had ap-
parently for four months. The knee was the seat of a
hard, inflammatory tumefaction consisting of an exuda-
tion. This exudate had caused complete ankylosis. The
joint was tender to deep pressure, and much pain and ten-
derness resulted when the weight of the body was put on
the joint. The patient gave a past history of several
gonorrhoeas or relapsing urethral discharges. His sexual
function was also impaired. At the time he entered the
hospital he felt that he had no gonorrhoea or urinary in-
flammation. Medical and orthopaedic form of treatment
had been tried with no beneficial effect, and the patient
was transferred to my service. Examination showed that
he had a chronic seminal vesiculitis, especially in connec-
tion with the right sac, the lower portion of which was
enveloped in a sclerous infiltration. Seminal vesiculotomy
was performed, the sclerous infiltration cut through, and
the sacs freed from adhesions and freely incised. Painful
sensations quickly left the joint after the operation, fol-
lowed more slowly and gradually by a resolution of the
hard exudate. With the disappearance of the exudate the
joint motion has gradually returned. Now the patient
walks about without pain and with much movement in the
joint, and this movement is increasing rapidly.
Case IV. — J. S.. thirty years of age. Operated on early
in January. Chronic gonorrhoeal rheumatism of eight
years' standing. Both knees, hips, spine, and neck were
involved. Back was bent, no mobility to spine, and but
very little motion to neck. He had been on crutches for a
year before operation. Got his first gonorrhoea nine years
ago and a second attack four years ago. Both seminal
vesicles were thickened and embedded in a periseminal
vesicular sclerosis. Seminal vesiculotomy was performed
five weeks ago. The thickened sclerosed tissue surround-
ing the seminal vesicles was cut through on each side and
the seminal vesicles were freed from surrounding ad-
hesions, after which both sacs were freely incised, packed
with gauze, and drainage tubes adjusted. In this case,
owing to the chronicity of the lesion, there was no active
intraseminal vesicular catarrh, the sac walls being in fact
compressed and somewhat atrophic. A few intracellular
diplococci were found in a smear taken from the region
of the sac cavity. One week after operation patient could
move his back and neck quite freely without pain. He is
now walking abo-it easilv and quickly without crutch or
cane. The affected joints are still somewhat stiff and the
muscles have not yet recovered wholly from their atony,
but those symptoms are rapidly disappearing as the result
of massage and exercise.'
Case V. — T., December 29. 1907. This case presented
an instance of acute gonorrhoeal rheumatism of six weeks'
standing. Patient was confined to bed. Both knees and thighs,
right wrist, and back were involved. The knees and
wrist were very much swollen. Patient was thoroughly
helpless and in great pain. He gave a historj- of gonor-
rhoea eleven years ago, three years ago, and three months
ago. The seminal vesicles were markedly sclerosed and
evidently recently reinfected. This was his first attack of
rheumatism. Seminal vesiculotomy was performed. Three
days after the operation patient was wholly free from pain,
and by the end of four days all swelling had disappeared.
He could then move his back and legs and wrist without
discomfort. In this case at the end of two weeks after the
operation there was a slight recrudesence o.f the pain in
'Cases III and IV I exhibited at the Section in Surgery of the
Academy of Medicine, February 7, 1908.
I030
HUBER: KIDNEY IN ACUTE INFECTIONS.
[New York
Medical Journal.
the joints due to the premature closing of the outside
wound, thus checking all drainage. Before the fourth
week, however, this recrudesence had disappeared, leaving
the patient in good order and free from his rheumatism.
Case VI.— J. L., twenty-three years of age; January,
1908. Patient presented a very acute synovitis of the right
knee. The joint was greatly distended and there was
marked surface redness and tenderness. No movement of
the joint was possible. This condition had persisted for
si.v weeks arjd had been uninfluenced by rest or antirheu-
matic treatment. Had had gonorrha-a five months before
affection in joint appeared. The gonorrhoea had apparently
gotten well in three weeks and so had not been connected
in a causative way with the following joint involvement.
There was no urethral discharge and the urine was clear.
Rectal examination, however, showed seminal vesiculitis,
the inflammatory involvement being chiefly in connection
\vith the right seminal vesicle. I did not at first wish to
operate in this case, bemg fearful, owing to the rather
slight extent of the seminal vesiculitis, lest the operation
would fail to relieve the joint. The patient having seen
the benefits of the operation in the preceding cases, begged
for the operation, and I accordingly performed seminal
vesiculotomy. In three days all pain, swelling, and inflam-
matory evidence had disappeared from the knee. In fact,
on inspection the right knee looked exactly as the left. In
this case also at the end of two weeks there was a slight
and temporary recrudesence of the rheumatism, the right
wrist becoming a little stiff. This, however, shortly dis-
appeared, leaving the patient well.
Case VII. — J. S.. age thirty-one; January, 1908. This
case was to me one of the most interesting of the series.
For three months the man had been unable to move his legs
or thighs. He lay perfectly helpless on his back. He had
first felt liis rheumatism one year before, and from that
time it had been gradually getting worse. Two years ago
he had had gonorrhcea, but stated that he had gotten
wholly over the disease in two months and had never after
had occasion to think of it. He had taken all sorts of anti-
rheumatic remedies, and had been treated by orthopaedic
surgeons, all to no avail. Rectal examination showed a
marked old seminal vesiculftis with much periseminal vesicu-
lar inflammatory involvement. Seminal vesiculotomy was
performed, and in three days he could move his legs and
thighs freely. At the end of three weeks, on being let out
of bed, he ran about the ward briskly with no discomfort.
This was remarkable, as in most such cases the joints are
left stiff for a time after the rhemuatism has disappeared,
necessitating massage.
Case Vfll. — V. L., twenty-seven years of age; January,
1908. This patient had gonorrhoeal rheumatism in both
ankles and knees. He was not bedridden, but walked with
great difficulty with a stick. Both ankles were somewhat
swollen. He had been so aff^ected one month. Two
months before he had contracted gonorrhoea. This was
apparently his third attack of gonorrhoea. The urethral
discharge still persi'-tcd at this time. A chronic seminal
vesiculitis existed wliifli sli.'wrd evidence of recent rein-
fection. Seminal \ r ,i.-ul. itnm\- w as performed, followed
by a quick disappcar.nuc nf die rheumatic symptoms. This
patient at the time ni ilns n p.irt is ready to leave his bed.
Before performing Miniiial vesiculotomy on any
of these patients I liavc t^'ii'lcavorcd to excltuie ttiber-
ciilosis as a complicating- clement tlirous^h the em-
ployment of the Calmelle and tuberculin tests. Had
these tests in any instance indicated tuberculosis I
would have refrained from operation.
From the results obtained in the comparative!)
larc^c number of cases operated on I now feel that the
■efficacy of this form of treatment is establi.shed.
My preceding articles bearing on seminal vesicu-
lotomy are as follows :
A Xew Operative Method to Expose the Seminal
Vesicles and I'ro.state for Purposes of Extiri^ation
and Drainage. A Preliminary Report. — Journal of
the American Medical Association. May 4, 1901.
Operative Surgery Applied to the Seminal Vesi-
-cles. A Demonstration of Some New Principles. —
Medical Record, May 21, 1904.
Seminal \ esicuIotomy. The Author's Operation.
— The Posli^radiKite. ( )ctol)er, 1904.
The Relation of Gonorrhoeal Rheumatism to Sem-
inal \'esiculitis and Its Cure by Seminal Vesiculot-
omy.— Annals of Surgery, June, 1905.
A Further Report on the Cure of Gonorrhoeal
Rheumatism through Seminal Vesiculotomy. —
American Journal of Dermatology and Genitouri-
nary Surgery, x, No. 3.
A Plea for the Sexual Protection of Young Boys.
— Ibidem, xi, No. 9.
Operative Cure for a Hitherto Unrelieved Class
of Cystites. — The American Jour)ial of Urology,
December, 1906.
252 Lexington A\-exue.
THE KIDNEY IN ACUTE INFECTIONS.*
By John B. Huber, A. M., M. D.,
New York,
Visiting Physician to St. Josepli's Hospital for Consumptives, New
York City, etc.
An incomplete list of the diseases with which the
kidney may be related in infectious processes would
include scarlet fever, typhus and typhoid fevers,
malaria, pneumonia, diphtheria, influenza, acute
rheumatism ulcerative endocarditis, septichaemia.
erysipelas, intense and difftise erythemata, small-
pox, measles, varicella, parotitis, tonsillitis, menin-
gitis, acute tuberctilosis, dysentery, yellow fever,
and bubonic plague. It is not possible, in a brief
paper, to consider these affections in detail ; I can
but prepare in some sort a composite picture. And
in doing so I must paint with a broad brush.
To begin with, the kidneys are more subject than
are some other organs to pathological influences.
Becattse of their anatomical position they must bear
an enormous amottnt of punishment ; and they have
comparatively little means of efl:ective rebellion.
Their texture is unusually intricate and delicate ;
and therefore so much the more in danger of break-
ing down under great and undue pressure. When
the lungs are diseased they have a fairly large vent
through which pathological material may be emit-
ted ; an outraged stomach may easily enough empty
itself; any abuse of the aliinentary tract may be
very thoroughly purged away. But the kidneys
cannot so easily meet the strains put tipon them.
They are imbedded in a mass of fat, in a region
so shut ofif that examination of them by the clinician
is most difficult and oftentimes impossible. We
cannot directly examine them as we can the blood,
the laryn.x, or the bladder; we caniKU. in most cases,
apply to them the phy sical tests we use in examin-
ing the heart and the lungs. Their only vent is
the ureters ; the urine which they excrete should
and does give us nnich diagnostic information. Yet
we are being surprised and not a little mortified
when Cabot and others demonstrate the very wide
iliscrepancy there had been between the diagnoses
based upon urinary findings during life and the evi-
dences revealed on the autopsy table.
The function of the kidneys under normal con-
ditions is to eliminate from the blood substances
which have been excreted elsewhere throughout the
organism in the processes of metabolism. In the
infections the products of inflammation are for the
most i)art existent in the blood before they reach
the kidneys. In addition to the heavy work of dis-
♦Read in a Symposium before the New York Urological Society.
May 30, 1908.]
HUBER: KIDNEY IN ACUTE INFECTIONS.
posing of these, these suffer, as must all the others,
either from bacterial invasion or from the eft'ects
of the toxines evolved by the bacteria. The degree
of degeneration or destruction of kidney tissue will
also vary according to the biological characteristics
of the given specific agency. The tubercle bacillus
seems comparatively innocuous w^ith regard to this
organ; the streptococcus, on the other hand, works
extensive necrotic changes.
The internal secretion of the kidney (which con-
tains the renal juice) should be considered. The
field of internal secretions is a new one; and the
near future may prove it to be very broad and fer-
tile. The point here is that under abnormal condi-
tions the kidney either does not secrete the renal
juice, or the secretion of the latter is modified ; and
thus the organism suffers from the deprivation of
whatever benefits the juice exerts. We are not at
all sure in what matter uraemia comes about. The
prevailing belief has been that it is due to the re-
tention of excrementitious matters in the blood,
which the diseased kidney cannot eliminate. Yet
there are many objections to this belief. And von
Noorden, though he does not maintain the view,
thinks it possible that uraemia really supervenes when
this kidney function of internal secretion is held
in abeyance. (Xephrectomized dogs died sooner
than when the ureters were ligated; the kidney se-
cretion could nevertheless, in the latter case, get into
the blood. And the nephrectomized dogs lived
longer when renal juice was injected into them.)
The symptomatolog}^ of kidney involvement is
classic : Chilliness and rigors ; pain in the back :
fever, sometimes absent, sometimes high, especially
in children ; a high tension pulse ; the aortic second
sound accentuated (evidences of a heart hard at
work). A dry, pale skin; no sweat; possibly acute
uraemia ; convulsions sometimes in children ; hsemor-
rhagic retinitis and papillitis : puff'y eyelids ; cedema
of the extremities and perhaps of the lungs and the
glottis ; pleural effusion, possibly dropsy.
The specific gravity of the urine will vary in-
versely with the quantity passed ; generally it is
high, in the beginning at least. This fluid is highly
colored, from a smoky hue to that of deep porter ;
it may be bloody. The sediment is abundant ; albu-
min, epithelial, hyaline, renal tube casts and pus
cells are to be found. Bacteria may be present.
The acidity is high ; the urea is at first abundant
and later reduced. There may be suppressed or
scanty urine. Such, in general terms, are the evi-
dences of a kidney suffering from an acute infec-
tion. The symptoms may be very marked, without
indicating great danger to the organ ; on the other
hand grave lesions will result, it would seem, with
very few signs to manifest them. In certain infec-
tions characteristic things are found : In typhoid
fever, for instance, the bacillus may be abundant in
the urine, even for years after the attack ; the diazo
recation may manifest the disease. In septichaemia
pus and necrotic detritus may be forthcoming ; on
the other hand, there may be extensive necrosis
which will not be evident, for the reason that the
broken down tissue will find no outlet in the pelvis.
A. bloody urine is found even in grippe : it is not
aincommon even in scarlet fever, smallpox, and yel-
low fever. We may, from urinary examination, in-
fer pyaemic infarcts in erysipelas. A diphtheritic
membrane may develop in the pelvis. In acute
dysentery the colon bacillus, which ordinarily seems
innocuous (except, as Metchnikoff thinks, to hasten
senility), may take on virulent properties. Like the
typhoid bacillus, it may be found abundantly in the
urine.
The pathological changes wrought in the kidney
in infectious diseases may be slight and evanescent ;
or they may be extensive and permanent. The
glomeruli become swollen and congested ; and thus
the circulation in them is obstructed. Detritus ex-
tends Bowman's capsule. The nutrition of these
most delicate structures is interfered with. Yet the
convoluted tubules seem to suff'er most, since the
tufts eliminate fluids, leaving the tubules to cope
with the more concentrated blood which afterward
passes through them. In these tubules the epithe-
lial cells suffer granular or fatty degeneration.
There may be such interstitial changes as cellular
infiltration in and about the parenchymatous struc-
tures. The general organ suft'ers because of reten-
tion in the blood current of waste products and the
infective material which the affected kidney does
not eliminate.
Our ideas of diagnosis in renal disease have of
recent years been not a little disturbed. A decade
ago Councilman observed that "the chemical and
microscopical examination of the urine, important
as it is, does not give any sure indication as to the
character of the renal lesions."' Upon this hint
Cabot investigated ; Emerson, of Johns Hopkins
University, and others also worked upon the same
lines. Cabot holds that albumin and casts alone
never prove the presence of nephritis ; that by their
appearance in the urine we can never estimate the
anatomical condition of the kidney. Moreover,
most estimates of urinary solids, phosphates, chlor-
ides, sulphates, and especially urea, are a waste of
time. The most reliable data about the urine are
those most quickly obtained — the twenty-four hour
quantity, the specific gravity, and the color. The
iconoclastic Cabot divides disturbances of renal
function into three sorts ; renal irritation, renal in-
sufficiency, and nephritis. He submits that the term
irritation is vague ; it means, no doubt, the equiva-
lent of a mild inflammation. Many things, includ-
ing fevers, may bring it about : it may be evidenced
by albumin, casts, blood, pus, and renal epithelium,
just as those things are held to indicate an acute
nephritis. But Cabot's distinction is that if these
urinar}- abnormalities disappear in a few days we
have simple irritation; and that such a temporary
change in the urine is perfectly consistent with
normal kidneys, according to autopsy findings. And
we should add that urinary examinations should be
continued during weeks ; that the search for bac-
teria should not be neglected ; and that if the ab-
normalities persist through a number of weeks the
meaning is that pathological changes have super-
vened in the kidney structure.
In renal insufficiency the kidney cannot excrete
the products of nitrogenous metabolism, water, and
inorganic salts ; the urine is suppressed and visceral
phenomena, dropsy and heightened vascular tension
(leading to cardiac hypertrophy and dilatation)
supervene. Cabot here likens the heart and the kid-
ney to a team ; and he declares that a strong heart
will triumphantly help through a badly damaged
I032
SILKIVORTH: JUNGLE PLANT.
[New York
JIedical Journal.
kidney. The harm done by a diseased kidney, he
declares, will depend upon how well the heart can
make up for the damage by increased work. If a
lair amount of urine is passed we know that the
heart is doing well ; when the heart and the kidney
are both failing the amount of the urine begins to
decrease ; and then we have evidences of renal in-
sufficiency. I think, however, it is a mistake to rely
too much on the heart in infectious fevers ; the ef-
fect of bacterial and toxic invasion upon the myo-
cardium (as in diphtheria and grippe), is such that
sudden death has during the present season been not
at all rare.
In acute nephritis, as in certain chronic forms, we
must rely more than formerly on the history, the
general condition, and the physical signs of all the
organs ; and less on urinary findings. It were a mis-
take to consider the kidney as a thing apart in the
economy. Cabot declares that thirteen out of one
hundred cases of acute nephritis were recognized
first on autopsy ; one in four were wrongly diagnos-
ticated. Eleven were clinically called acute ne-
phritis; but the autopsies showed no corresponding
lesion. Emerson's conclusions were much like
Cabot's ; they were reached from a consideration of
over i,ooo cases, with 500 autopsies.
Osier observes that persons rarely die of the
serious diseases which they have suffered during
life ; terminal infections carry ofif many incurable
cases. Such is certainly the experience in hospital
wards. He cites Flexner's analysis of 255 cases of
chronic renal and cardiac disease, in which com-
plete bacteriological examinations were made at
autopsy; excluding tuberculous infection, 213 gave
positive and forty-two negative results. Local in-
tercurrent affections are very common ; and the
majority of cases of advanced arteriosclerosis and
Bright's disease evidence at autopsy such bacteria
as the Streptococcus pyogenes, the Staphylococcus
aureus, the Bacillus proteus, and the gonococcus.
Of eighty-five cases of chronic renal disease in
which Flexner found bacteria, thirty-eight ex-
hibited general infections.
In my own desultory experience as a coroner's
physician a decade ago, I oftentimes had occasion
to wonder how the lives of the subjects examined
could have continued so long as they did, notwith-
standing the extensive destruction of organic tissue
which was revealed. I have understood this a great
deal better since I heard Dr. S. J. Meltzer's paper
on the Factors of Safety, which he read before the
Harvey Society. With regard to the renal func-
tion we know that life is lived very comfortably
after the surgeon removes one kidney. In animals
at least two thirds of both kidneys can be removed
without serious detriment to life or to the renal
function. Moreover, the average quantity of the
urine, as well as the normal quantities of its vari-
ous constituents, may be greatly reduced without
any visible detriment. With regard to human be-
ings Meltzer observes: "For a score of years or
more, in many of us the kidney is gradually losing
some of its valuable material from one cause or
another without any symptom, without a reminder
sufficient to spoil our pleasure of life or to hamper
our activities. Not until that luxurious sur|)lus is
approaching its exhaustion do we get a warning.
But then our work is mostly done and our time
limit nearly reached."
I shall not outline the familiar treatment when
the kidney is involved in infectious fevers, but
shall submit but one observation : We are, or at
least we have until recently been advised to direct
the drinking of as much water as possible ; water in
unlimited amounts, "gallons of water. The patient
can't get too much of it," the idea being to flush
the kidneys and thus wash the debris from their
tubes, an idea rather fanciful than scientific. Cer-
tainly the patient should drink as much fluid as he
desired and as he can comfortably dispose of ; but
to force fluid upon him in unlimited quantities is
certainly a mistake. For thus extra and often un-
nuecessary work is laid upon the kidney and espe-
cially upon the heart; no doubt the latter has fre-
quently broken down under such a strain. It were
better to ease the labor these organs have to do by
diaphoresis and hydrotherapy ; we had best put as
much of the work as possible upon other emunc-
tories. This consideration should hold, I think, ex-
cept in extensive erythemata, when the skin can-
not perform its functions. It were oftentimes well
to complement the drinking of water with procto-
clysis ; though, of course, this would not materially
lessen the cardiac and renal strain.
44 East Sixty-Fourth Street.
NOTES OF THE JUNGLE PLANT (COMBRETUM
SUNDIACUM).*
Exhibit of Cases.
By W. Duncan Silkworth, M. D.,
New York,
Member of the Medical Society of the County of New York.
The various manifestations of chronic morphine
and opium poisoning are conditions so well known
that further reference to them is not necessary in
calling attention to the antiopiuin plant which has
been used with apparent success in the Far East.
In passing, however, I should like briefly to allude
to the term morphinomania, as commonly used and
placed in the same category with dipsomania, which
as a disease is almost universally considered uncur-
able. The vast majority of those addicted to mor-
phine would, beyond doubt, discontinue its use
promptly were it not for the physical torture which
would almost immediately supervene. They use the
drug from necessity, not from desire. There are
unfortunate cases where neurasthenia or some pe-
culiarity of constitution renders a permanent with-
drawal of the drug almost impossible, and to this
limited class may be attributed the origin of the
term morphinomania, a morbid craving for mor-
phine. In opium smoking, the pipe itself, the lamp,
and associations are powerful factors in considering
the possibilities of a permanent cure. There are
many who, long after they have discontinued the
drug, will continue to light each night the small
lamp used in preparing the opium for smoking, so
that after a few years' use of the drug these are the
habits they crave possibly more than the opium
itself. A more healthy and humane conception by
•Read before the New York County Medical Society, February 24,
1908.
May 30, 1908.]
SILKWORTH: JUNGLE PLANT.
physicians of drug addiction will do much toward
eliminating the habit and will turn to legitimate
channels the thousands of dollars which now fill the
pockets of advertising frauds.
A party of Chinese wood cutters were presumedly
the first to discover the properties of the drug which
is now used extensively as a cure for the opium
smoking habit in the Federated Malay States. The
plant is a large climber, with a long woody stem
often reaching a height of one hundred or. more
feet. In the Materials for a Flora of the Malayan
Peninsula it is described botanically by Lieutenant
Colonel Sir George King and is shown to belong
to the order Coinbretum sundiacum. Sir George
Watt, in a dictionary of the economic products of
India, mentions two species of the genus as being
used in native Indian medicine, but with no details
as to their uses or properties.
In preparing the drug, the branches and leaves
are chopped into pieces about one and a half inches
in length; after drying, the woody portions are sep-
arated from the leaves, and both the bark and the
leaves roasted, the leaves to a less extent than the
bark. Upon compIeticJn of this process the two por-
tions are mixed together again.
The infusion is prepared by taking, for example,
ten ounces avoirdupois of the roasted drug and mix-
ing with about four gallons of water. This solution
is kept boiling for three hours, being loosely covered
to prevent too rapid evaporation. The liquid is then
strained and is ready for use. I do not believe that
a fixed rule for prescribing can be laid down, but
m general the method of administration to an opium
smoker would be as follows :
Whatever the daily amount of opium the person
habitually smokes, that amount is to be mixed with
the infusion. The average allowance would be from
sixty to one hundred and twenty grains, although
beyond doubt a considerable quantity of the alka-
loids are not absorbed into the system of the smoker.
If, for example, one hundred and twenty grains had
been the daily allowance, then two twenty-five ounce
bottles of the infusion A and B are used. Into A
is put one hundred and twenty grains of burnt
opium (that is prepared the same as if for smok-
ing). From the bottle A one and a half ounces is
given to the patient and one and a half ounces
from bottle B is put into bottle A. This is repeated
each time a dose is taken, usually three times a day.
Bottle A maintains its bulk, although continually
decreasing in its opium contents until bottle B is ex-
hausted. At the end of this course a second treat-
ment is given, beginning with about one third the
initial amount of opium used, and upon completion
-of this the patient should be cured. With twenty-
five ounces in the bottle and one and a half ounces
at each dose, there would be about sixteen doses in
each bottle. Each dose would represent a decrease
of one sixteenth of the total amount of opium left
from each succeeding dose up to the seventeenth
dose on the sixth day, or until bottle B is exhausted.
There would then be no further change to the
thirty-second dose, when the entire one hundred
and twenty grains would have been taken and the
.contents of the two bottles exhausted.
The remedy, while not a panacea, seems to ofifer
the best medium of reduction thus far given to the
profession, and while my experiments have been
confined solely to the practical demonstration of the
plant, I am led to believe that there may be present
in the remedy an active ingredient, antiopium in its
properties. The burnt opium in gradually de-
creasing doses certainly plays an important role in
the treatment, but this alone, or in combination with
any other form of medication heretofore known, has
been, on the whole, unsatisfactory.
Both physician and patient must work together in
harmony, and the suffering incident to the discon-
tinuance of a powerful drug must be mitigated as
much as possible, if permanent results are to be ob-
tained.
I wish to acknowledge the great assistance which
was given by the Rev. W. E. Horley, of the Metho-
dist Episcopal Mission at Kuala Lumpur, and L.
Wray, Esq., I. S. O., whose paper in The Journal
Federated Malay States Museums has formed the
basis of my investigations. The Rev. Mr. Horley
writes me that "thousands have been cured, but.
alas, many have returned to the drug. Will power
and the grace of God are needed in conjunction with
the remedy."
C.\SE I. — Mrs. AI. had used the drug continuously for
sixteen years, the habit having been acquired at the age of
fifteen ; the daily amount of opium taken by the patient
varied from sixty to one hundred and twenty grains. No
other drug or stimulant had been used.
The condition of the patient was critical, melancholia
was pronounced, accompanied by a state of mental and
physical collapse. Not being acquainted with the action
of the new remedy, it was considered best to first improve
the general condition of the patient, and a short prelimi-
nary treatment under the asual methods was given, during
which the daily amount of the drug was somewhat reduced.
The remedy was then prepared and administered as
follows :
The initial amount of the solution prepared was equiva-
lent to fifty ounces ; with twenty-five ounces of this was
dissolved one hundred grains of burnt opium; three doses
were given a day, about one and one half ounces at each
dose, the remaining twenty-five ounces being used to
dilute the first solution in like proportion as each dose was
taken. The reduction of the opium during the first five
days amounted to about one sixteenth of the total amount
at each dose. From the fifth to the seventh day the reduc-
tion remained constant. During the eighth day the dose
was slightly increased, this change of administration
hemg necessary to relieve headache, accompanied by rest-
lessness and to frequent attacks of sneezing; the distress-
ing gastrointestinal symptoms so often connected with the
withdrawal of opium or morphine not occurring during
the entire treatment. Improvement in condition on the
ninth day being apparent, the initial dose was again re-
sumed and the course completed on the tenth day. The
symptoms, however, not having sufficiently abated, a sec-
ond course was commenced, beginning with one third of
the initial amount of opium. The reduction was then
continued without interruption to the eighth day of the
second course, when the remedy was discontinued without
further inconvenience.
In connection with this case, it may be of interest to
add that in investigating the past history of the patient, it
was found that James McKally, a one time famous green
goods man and now in the New York City Almshouse, was
the first to initiate Mrs. M. in the use of the drug at the
earlv age of fifteen, and that practically from that time
until the treatment was given she was an absolute slave to
the liabit, devoting almose her entire tim.e to its use or as
attendant to other users of the drug, to many of whom she
is well known.
C.\SE II. — Miss F., a trained nurse, apparently very de-
sirous of being cured, had used morphine, ten grains sub-
cutaneously for ten years. Accomplished three quarters
I034
MARPLE: EXTRACTION OF CATARACT.
[New York
Medical Journal.
of the treatment with apparent success, but for reasons not
clear to me, relapsed, although stoutly denying the same.
Case III. — Mr. M. first acquired the opium smoking
habit in Boston, fourteen years ago. After two years of
smoking shifted to morphine subcutaneously, which has
since been used continuously in amounts varying from fif-
teen to sixty grains in twenty-four hours. A preliminary
treatment was given and with the intelligent cooperation
of the patient, the drug was reduced from fifteen grains
subcutaneously to four grains internally. One hundred
and twenty grains of burnt opium were then dissolved
with twenty-five ounces of the solution and three doses
were given a day, following closely the procedure of the
first case. Three courses were given and the treatment
voluntarily discontinued.'
Case IV. — Mr. H. L. Opium smoking habit of fourteen
years' duration. General condition fair for this class of
case. Some emaciation and quite marked nervous twitch-
ing. Patient used about eighty grains of opium in twenty-
four hours. Under a short preliminary treatment the drug
was reduced slightly and the general condition somewhat
improved. Sixty grains of burnt opium were then dis-
solved with twenty-five ounces of the solution. Three
doses were given a day, one and a half ounces at each
dose, with no variation in the regular scale of reduction up
to the sixth day. The number and amount of the doses
were then voluntarily decreased by the patient and finally
discontinued on the twelfth day. During the entire treat-
ment no other drug or stimulant was used. As in the
former cases, attention to hygiene and diet were insisted
upon.
Case V. — Mr. E. W. Morphine habit of seven years'
duration. Daily amount nine grains internally. Regular
toxaemic symptoms with very pronounced pallor and ema-
ciation. Tonics were given, and with the earnest coopera-
tion of the patient the drug was reduced from nine grains
to four grains a day. The treatment was administered as
in the previous cases, two courses completing the cure, cov-
ering a period of twenty-one days.
Case VI. — Mr. E. M. Morphine habit of eight years'
duration. Daily amount eight grains internally. Condition
fair. The regular course of treatment was followed and
the drug reduced to two grains in twenty-four hours. Two
courses of the treatment completed the cure, which has
just been accomplished within the past few days.
124 E.^ST Sixteenth Street.
EXTRACTION OF CATARACT IN THE CAPSULE.*
By Wilbur B. Marple, M. D.,
New York,
Ophthalmic Surgeon, New York Eye and Ear Infirmary, etc.
If any one supposes that the writer accepted the
invitation to present the following paper becatise
he poses as an advocate of the extraction of cataract
in the capsule as a routine practice, he wishes to
correct the misapprehension at once. He never has
done it, and doubts if he ever will, except in cases
in which it was plainly indicated in the manner to
be brought out below.
It is now thirty years since Pagenstecher advo-
cated the extraction of cataract in the capsule in
selected cases, and more recently Major Smith, of
Julltindur. India, has done a similar operation as a
routine procedure.
The technique of Pagenstecher's operation is a.^
follows : Strict attention to asepsis is given and
cocaine is employed. He syringes out the lachrymal
canal with a sublimate solution, i in 5,000, before
the operation, and, being ambidextrous, operates on
the right eye with the right hand and on the left
eye with the left, standing at the head of the patient.
>Mr. M. here reported his own story to the society.
•Read, hy request, in a Symposium on "Cataract Extraction" be-
fore the Section in Ophthalmology of the New York Academy of
Medicine.
who is lying in bed. The section is made upwards
in the sclerocorneal margin, so that it lies wholly
in corneal tissue, with more or less of a conjuctival
fiap. The position of the section in the cornea
favors rapid healing, and the conjunctival flap tends
to bring about early closing of the wound. As
Pagenstecher says, however, it is of more import-
ance that the section is made with a steady hand
and a sharp knife, and that it shall not become in-
fected than that its location is accurately adjusted.
The section should be large enough in each in-
dividual case to allow the easy extraction of the lens.
When the lens is extracted in the capsule, the sec-
tion, above all, must not be too small, yet it should
never be larger than one third of the corneal cir-
cumference. (The writer generally makes the sec-
tion two fifths of the corneal circumference.) Mor-
gagnian cataracts, of course, slip out through
smaller sections. Pagenstecher operates with a
sinall knife, selecting one with the back not too
thick. He thinks that a knife with too thick a back
bruises the tissues at the points of puncture and
counterpuncture, and that this may delay healing
and predispose to infection. 'He uses a Weiss knife
with double edge, but admits that it bends easily.
He always does an iridectomy, since the vision is
practically the same whether or not there is a colo-
boma, and he would rather excise the iris than ex-
pose a single case to the danger of a prolapse. Af-
ter fleeing the pillars of the coloboma, an attempt
is made to expel the lens by making pressure
through the lower lid against the cornea below,
while the scleral margin of the wound above is
gently pressed backwards with the spoon. Some-
times this manoettvre sitcceeds in expelling the lens.
If it does not, he introduces the spoon rather steep-
ly behind the upper border of the lens ; the handle
is then depressed and the spoon is gently advanced,
but not beyond the posterior pole of the lens. The
assistant now makes gentle pressure upon the lower
corneal margin with a specially constructed glass
spoon or pusher, sliding this upward over the cornea
with light continuous pressure, thereby pushing the
lens upward into the wound. In this manner the
spoon in the operator's hands serves more the pur-
pose of an inclined plane upon which the lens is
pushed out, than of a traction instrument ; at the
same time it holds back the vitreous humor and
prevents it from escaping. Only when the zonula
is pretty firm and when the lens by moderate pres-
sure from without cannot be entirely delivered
should the operator push the spoon further to the
lower border of the lens, seize the latter from be-
hind, and extract the cataract, while the assistant
makes gentle pressure upon the cornea.
Pagenstecher thinks that when correctly done, in
a proper case, it is a more conservative operation
than when the capsule is opened and pressure is
made upon the globe, expelling the nucleus and re-
moving the cortex.
He flushes the conjunctival sac with a sublimate
solution. I in 5,000, before and after the operation,
covers the eye with sublimate gauze, then with cot-
ton wet in the sublimate solution, and finally with
a bandage. When there is chronic conjunctivitis
or a recently cured dacryocystitis, he employs a
modified "open treatment." He covers the eye with
a moist sublimate compress, which is changed every
two hours, or three times a day ; at the same time
he washes out the eye with the above mentioned
solution. ]\Iost ophthalmologists have, of course,
long since given up the use of sublimate solutions
for irrigating the conjunctival sac before and after
cataract extraction. I have used for a good many
years a sterile normal salt solution.
He has been surprised at the very slight irrita-
tion which attends the healing in these cases. When
the eye is bandaged he uses a form of coquille, as
we do the mask, and as soon as the wound is closed
he keeps on the coquille alone. (I myself have
found in not a few cases that removal of the band-
age within three or four days after the wound has
closed, leaving the eye protected simply by the mask,
has been followed by a more rapid clearing up of
the redness of the eye.)
It may be instructive to bring out the indications
for extraction in capsules by briefly referring to
one or two cases which have come under my ob-
servation.
Case I. — August 19, 1902, I operated at the New York
Eye and Ear Infirmary upon an old lady who had an
hypermature cataract in the right eye. Careful examina-
tion previously showed that there was no sign of luxation
of the lens. When an attempt was made to do a capsu-
lotomy, the cystotome merely pulled the lens bodily after
it, but did not lacerate the capsule. At the same time,
vitreous presented in the wound. An iridectomy was made,
the spoon was introduced, and a large brown lens was
extracted with the loss of scarcely any vitreous. The
result was excellent, and the patient was discharged in
ten days. I thought at the time that the reason for the
complication was a dull cystotome, but the same accident
happened to me again in a similar case when the cystotome
was known to be in perfect order. It was evident that the lens
was so hard, its capsule so adherent, and the zonula so
atrophied, that the cystotome merely dug into the hard
lens and pulled it along after it.
These lenses may not infrequently be removed in
the capsule without the introduction of a cystotome
or spoon into the eye, and a cautious attempt to do
this should generally be made. In several cases I
have succeeded in extracting the lens in this manner.
C.\SE II. — On June 23, 1905, I operated at the Xew York
Eye and Ear Infirmary on the right eye of an adult male
for shrunken cataract. After a small section, an unsuc-
cessful attempt was made to express the cataract. I then
endeavored to seize it with capsule forceps, but this at-
tempt also failed. A small iridectomy was then done,
and pressure and the forceps again failing, I cut through
the zonula with a Graefe knife. The spoon was then
introduced, and the cataract was extracted after one or two
unsuccessful attempts, with the loss of a very little vitre-
ous. The reaction was slight, and the patient was dis-
charged in two weeks with a good result.
These two cases illustrate one of the indications
for Pagenstecher's operation, viz., hypermature cata-
racts. Under hypermature cataracts belong, of
course. Morgagnian cataracts, and those that are
shrunken and chalky, as in Case II.
C.'^SE III. — On June 30, 1904, I operated at the Infirmary
on the left eye of a man. This patient had made several
trips to a Western city to consult a quack who cured cata-
racts without operation. This person had given him a
"massage apparatus" to use, which was nothing more than
an electric bell without the bell. He would hold this up
to his face so that the tapper would pound on his eye
through the closed lids when the current from six cells
was turned on. This was the "massage," and a brief ex-
perience demonstrated to me that it was quite painful.
So far from curing the condition, it ripened both cataracts
in a surorisingly short time, for ten days before he had
been able to attend to his business, but now had to be led
to my ofiice. Both lenses were opaque and swollen; he
saw fingers at five feet m one eye and at one foot in the
other. In addition, the left lens was partially dislocated
and there was a tremulous iris. It is easy to imagine the
force with which this instrument "massaged" the eye.
Operation. — Left eye. After the section and iridectomy,
vitreous presented. I then introduced a wire loop back
of the lens and almost lifted it out, but it slipped back.
This necessitated a second introduction of the loop, and
this time the lens was extracted without the loss of vitre-
ous. His vision with correction was finally 20/15, though
on the fifth day I had to cauterize a portion of the wound.
The anterior chamber was slow in closing.
This case illustrates another indication for ex-
traction in the capsule, viz., dislocated cataracts,
and presentation of vitreous after section or iri-
dectomy. A further indication for the operation,
according to Pagenstecher, is furnished by cataracts
which have formed in eyes that have had chronic
iridochoroiditis with occlusion of the pupil. I have
recently, however, operated in such a case satis-
factorily with capsulotomy and subsequent needling.
Con train die at ions :
1. Even when from its character a cataract is
suitable for this operation, it is contraindicated if,
after section and iridectomy, the tension of the
vitreous is high or the patient is unruly.
2. In cataracts which have been ripened by
Forster's method, it is best not to attempt to extract
in the capsule, since the latter is very tightly
stretched by the swelling of the lens masses and is
apt to rupture if such an attempt is made.
3. Cataracts which have been ripe only a short
time, and have ripened quickly, as in the course of
a few months, should not be operated on after this
method, as the capsule has not attained sufficient
strength compared to that of the zonula. These
cataracts are swollen, and are said to be in the stage
of imbibition.
Pagenstecher says he regrets that he cannot oper-
ate on all cataracts in this manner, and that the only
reason he does not is on accotmt of his conviction
that the majority of cases are not suitable for it,
inasmuch as the capsule is apt to rupture and part
of it remain behind in the eye.
Advantages of the Operation:
The vision secured in this manner is perrnanent,
for there is no capsule left behind to subseqttently
wrinkle and cause deterioration of sight. The pupil
is clean, the best possible vision is secured, and a
secondary operation is not necessary.
Disadvantages:
There can be no doubt that loss of vitreous oc-
curs by this method far more frequently than when
the capsule is left behind. Pagenstecher operated
on seventy-four cases in which the cataract in one
eye was hypermature, and in the other eye simply
mature. He extracted the first seventy-four with
the capsule and the last seventy-four without the
capsule.
(In passing, it might be noted that of these
seventy-four cases Pagenstecher operated fifty-six
times on both eyes at one sitting — a practice as to the
wisdom of which opinions dift'er. I have never
operated on both eyes at one sitting, and it has al-
ways seemed to me that Dr. Knapp's position in
reference to this was correct. If we operate on both
eyes at the same time, the conditions are alike, and
1036
MARI'LE: EXTRACTION OF CATARACT.
[New York
Medical Journal.
if there should happen to be a break in our chain of
asepsis, and infection should take place, both eyes
would be lost — an appalling calamity which every
operator seeks to avoid. Moreover, during the
treatment, we learn a great many peculiarities of
the bodily and mental conditions of our patients,
which it is of advantage to know at the second
operation. If there are any particular circum-
stances making it desirable to have the two eyes
operated on at about the same time, a good compro-
mise is operate on the second eye a week or two
after the successful operation on the first.)
Of the seventy-four cases extracted in the capsule
there was loss of vitreous in thirty-nine, or in nearly
53 per cent. ; v/hile in the seventy-four cases ex-
tracted without the capsule this complication oc-
curred in only five, or 6.5 per cent. While he pre-
fers not to lose vitreous, his experience has led him
to look upon such loss in extraction in the capsule
as an unimportant complication, attended by no
further danger to the eye, so long as strict asepsis
is observed. There are few observers, however,
who agree with Pagenstecher, that this accident is
of such trifling significance.
Ray, of Louisviile, read at Atlantic City, in 1907,
before the Section in Ophthalmology of the Ameri-
can Medical Association, a paper on The Immediate
and Remote Effect of Loss of Vitreous in the
Operation for Extraction of Cataract. In this pa-
per he has collated the views of a number of opera-
tors of skill and experience upon the question
whether loss of vitreous at the time of extraction
increases the danger of infection. Most operators
consider that the vitreous is a perfect culture for
microorganisms, and that the probability of infec-
tion is greater when the hyaloid is ruptured and
vitreous is lost. Ray concludes that loss of vitreous
at the time of extraction adds to the danger of
primary infection, this danger being irrespective of
the quantity of vitreous lost, but dependent largely
on the care used in the preparation of the field of
operation.
With this opinion the writer agrees in the main,
and considers that it is of the utmost importance
to observe the strictest aseptic precautions when
vitreous is lost. I confess that I am much relieved
when, on changing the dressing, I find everything
in a satisfactory condition in a case in which I have
lost vitreouS:
While most operators consider that loss of vit-
reous predisposes to subsequent detachment of the
retina, it must be admitted that Pagenstecher's re-
sults do not support such a view. Out of six hun-
dred extractions in the capsule, done by himself and
his brother, he met with only one case of detach-
ment of the retina, and this in a myopic eye with
extensive choroiditis and fluid vitreous — surely a
most excellent showing, according to any method.
Moreover, there is some force in what Pagenstecher
says, viz., that, as so often ha])pens, one here con-
founds cause and cft'cct. If an operator happens
to do an extraction with lo.ss of vitreous in one or
several eyes in which subsequent detachment occurs,
he immediately concludes that the loss of vitreous
is the cause of the complication, whereas the real
cause lies in certain pathological changes in the
eye with predispose to retinal detachment, and
this, together with the fluid vitreous or detachment
of the vitreous present, at the same time, causes
the loss of vitreous during the operation. More-
over, when this complication occurs, the pillars of
the coloboma are much displaced and the coloboma
thereby is widened. This does uot improve either
the cosmetic or visual results.
Another disadvantage attending extraction in the
capsule is that the resulting astigmatism is greater.
Rupture of the capsule very seldom happens in
the ordinary method of operating or when the ex-
traction in the capsule is limited to those cases in
which Pagenstecher considers that it is indicated.
In one hundred seventeen cases operated on by him,^
rupture of the capsule occurred only four times.
Management of Prolapse, or Loss of Vitreous:
If merely a bulging of the vitreous occurs with-
out any actual loss, Pagenstecher says that this
usually returns under the pressure of the lids. Un-
til quite recently my own experience agreed with
this observation. Some weeks ago I extracted a
hypermature cataract in the capsule with iridectomy.
There was a small hernia of the vitreous, but no
loss. I bandaged the eye, hoping that the vitreous
would return, as I had seen it do before. On ac-
count of my own subsequent illness, I did not see
the patient again for ten days. A condition had
arisen which is well described by Czermak: "Af-
ter the rupture of the zonula the hyaloid yields and
the vitreous bulges forward and presses against the
wound, causing it to gape. The iris is thus folded
between the lips of the wound and incarcerated,
whether or not there has been an iridectomy. The
coloboma is thus made surprisingly broader and its
pillars can be released only with the greatest diffi-
culty, or not at all." This is exactly what had taken
place in this case, and the condition was not at all
satisfactory. The wound did not close for fuUv a
month. So that if I had a similar case and still
found bulging of the vitreous when I changed the
dressing, I should excise it.
When there is actual loss of vitreous, Pagen-
stecher cuts it off close to the wound with scissors
curved on the flat. My own observation has been
that when vitreous is excised more follows, so that
I have usually left the vitreous tags untouched,
and generally at the first or second dressing I have
found the wound closed.
Sometimes after the loss of fluid vitreous, some-
times when no vitreous has been lost, the eye col-
lapses and presents what Knapp used to call a
"squeezed lemon" appearance. In these cases it is
always well to gently inject sterile normal salt solu-
tion, so as to restore the shape of the globe and
thus bring the edges of the wound into apposition.
Knapp reported (in his Archives. 1899, p. 308)
cases treated in this manner, and Andrews also re-
ported cases treated in a similar manner (Knapp's
Archives. 1900, p. 50).
The writer has a great deal of respect for the
conservatism of Czermak, and agrees with his con-
clusions as to the value of Pagenstecher's work.
Czermak says : "In these eases an accurate diag-
nosis is of the first importance, as Becker has al-
ready emphasized in his work on The Pathology of
the Lens System. But it is in just this direction
May 30, 1908.]
TRACY.
ECTOPIC GESTATIOS AND FIBROMYOMATA.
1037
that the untiring work of Pagenstecher has accom-
pHshed so much. Where he has succeeded in estab-
lishing the diagnosis as to the nature of the cataract
and its appendages to such a degree of accuracy
that of 117 cases extracted with the capsule, the
latter ruptured only four times, he has attained as
high a degree of accuracy as one could desire. This
much we must admit unhesitatingly."
With the operation of Major Smith (routine ex-
traction of all cases in the capsule), the writer has
no personal experience, and therefore will refer to
it in only a few words. It should be said, how-
ever, that the visual result in Major Smith's cases
is almost an unknown quantity, for in many in-
stances the patients are discharged in a few days
and lost sight of before any accurate visual tests are
made. After doing ten of these operations, Cheney,
of Boston, an exceptionally skillful operator and
astute observer, concludes his report as follows:
''While I am inclined to believe that a small per
cent, of lenses may, with advantage to the patient,
be extracted in the capsule, I shall do very little
more pioneer work in attempting to determine the
cases best adapted to this operation. There is one
sentiment of Alajor Smith's, in his article in the
Archives of Ophthalmology, that expresses so ad-
mirably my feeling on this subject that, although
the application is a very different one, I will take
the liberty of quoting it in concluding this paper:
"There is virtue in knowing when to quit and in
letting 'well enough' alone."
46 West Fjfty-third Street.
REPORT OF A CASE OPERATED OX FOR AD-
VAXXED ECTOPIC GESTATION ASSOCIATED
V\'ITH FIBROMYOMATA UTERI.*
By Stephen E. Tracy, M. D.,
Philadelphia,
Gynecologist to the Stetson Hospital.
Operation for the usual case of ectopic gestation
offers no special difficulties for the experienced ab-
dominal surgeon. When, however, the gestation
develops beyond the third month and the sac be-
comes adherent to and receives a liberal blood sup-
ply from neighboring structures the operation is not
only difficult but dangerous, and the patient may
succumb before haemorrhage can be controlled.
In operating on a case of advanced ectopic gesta-
tion the surgeon may carry out one of two pro-
cedures: I. To open sac, remove the foetus, suture
the sac to the edge of the abdominal incision, and
drain the cavity; or, 2, to make a complete enuclea-
tion. Should the surgeon doubt his ability to con-
trol the haemorrhage an enucleation should not be
undertaken. \\'hile the latter is the more complete
surgical procedure, the former is no doubt the safer.
In this case complete enucleation was carried out :
Case. — The history of the case is as follows : Mrs. W.,
aged thirty-seven years; nullipara; began to menstruate at
the age of seventeen years. The menstrual periods oc-
curred from twenty-nine to thirty-four days, lasted from
five to seven days, and were always painful. On two oc-
casions the intramenstrual period was six weeks, and at
those times she supposed she was pregnant. During the
last twelve years she had been confined to bed many times
*Read before the Philadelphia Obstetrical Society, April 2, 1908.
with attacks of pelvic peritonitis. The last menstrual
period prior to this illness was in September, 1907. The
menstruation beginning on October 20th was scanty, and
the period lasted about half the usual time. On the even-
ing of December 20Lh, after being upon her feet a greater
part of the day, she had discomfort in the pelvis and sup-
posed she was about to develop another attack of peri-
tonitis. She started to take a hot douche to relieve the
discomfort, and almost immediately after the fluid began
to run into the vagina she was seized with agonizing pain
across the lower abdomen, became nauseated, and vomited.
Two days later I saw the patient in consultation. At that
time the pain was dull in character, and there was decided
tenderness over the lower abdomen. Upon vaginal exami-
nation the pelvis was found filled with a hard conglomerate
mass and nothing definite could be made out. Operation
was recommended and refused. The following day the
patient passed six or seven drops of blood from the vagina.
The pain subsided gradually and the patient left her bed
about three weeks after the beginning of the attack. From
then on, although suffering with some discomfort in the
left side of the pelvis, she was able to be up and about the
house. In the early morning of March i, 1908, she was
seized with severe pain in the lower abdomen, after which
she vomited and had diarrhoea. The following day the
temperature was 101° F. and the pulse rate 120 per minute.
After this attack of pain she consented to operation and
was admitted to the Stetson Hospital the afternoon of
March 3d.
Upon admisison she had a temperature of 99° F. and
a pulse rate of 80 per minute ; the lower abdomen was ten-
der, and there was a mass on the left side. Upon vaginal
examination a mass was found which filled the pelvis and
extended up the left side of the abdomen above the anterior
superior spine of the ilium. The pelvic portion of the mass
was hard, while the abdominal portion was soft. With the
exception of a few drops of blood passed after the begin-
ning of the attack in December, there had been no bleeding
from the vagina; at times there was a slight, pinkish leu-
corrhoeal discharge.
Operation was performed under ether anaesthesia. When
the abdomen was opened it was found that the gestation
sac filled the left side of the pelvis and the lower portion
of the abdomen, and was almost completely surrounded by
adhesions. After placing gauze pads to protect the general
peritoneal cavity, the hand was passed gently behind the
sac to determine the anatomical relations. Scarcely had
the sac been touched when the pelvic and lower abdominal
cavities were flooded with blood. The sac was quickly
enucleated and brought to the surface, and the portion at-
tached to the left broad ligament clamped, cut, and removed.
An attempt was made to temporarily control the bleeding
by packing with gauze, but this was not successful until a
large vessel, fully as large as any uterine artery I have
ever seen, at the fundus of the bladder was ligated. By
careful manipulation it was found that the uterus con-
tained many fibroid tumors which were adherent in the bot-
tom of the pelvis and could not be enucleated in the usual
manner because the adhesions were very dense, and there
was no room to work, as the pelvis was packed with gauze
to control the bleeding. The bladder was then pushed
down, the broad ligaments were clamped, the uterus was
amputated at the internal os, and by making traction
upwards on the uterus the fibroids were cut free by scissor^
and the bleeding points controlled by forceps from below
upwards. After the uterus was removed, ligatures were
applied and the forceps removed, and the toilet of the pelvis
completed as after the ordinary hysterectomy. The bleed-
ing from the omentum and along the edge of the bowel,
which had been controlled by gauze pressure, was then
controlled by ligatures. A few other bleeding points were
then controlled, and the abdomen was closed w^ithout
drainage.
Although this was a case of abdominal gestation,
I believe it originated in tne left Falloppian tube and
was expelled through the side of the tube probablv
at the time the patient suffered with the first attack
of pain, and that it continued to develop until the
time of the operation. \\^hether the patient became
pregnant after the normal menstrual period in Sep-
tember and the foetus ceased to develop some days
SQUIER: BLADDER IN TABES.
[New York
Medical Journal.
before operation, or whether she became pregnant
after the atypical menstruation in October it is im-
possible to say. It is probable that pregnancy fol-
lowed the menstrual period in October and advanced
until the time of operation. The time from the
atypical menstrual period in October until the date
of the operation was 137 days, or nearly twenty full
weeks. One interesting feature about the specimen
is that a portion of the placenta is entirely around
the neck of the child.
The gestation sac in this case was attached to
the distal end of the left Falloppian tube, the left
broad ligament, the fundus of the uterus, and the
bladder, the fibroid tumors adherent in the pelvis,
the sigmoid and ileum and the great omentum. The
of the bladder and from the ileum. An attempt was
made to control the bleeding from the ileum by a
continuous suture, but the haemorrhage was so pro-
fuse that it was necessary to clamp along the edge
of the bowel for several inches and then to apply
ligatures.
The patient, although badly shocked from the loss
of blood, reacted promptly, and with the exception
of a phlebitis in the left leg the convalescence was
uneventful.
Such an experience teaches but one thing, and
that is the value of early operation in all cases of
ectopic gestation. The ideal time for operation is
before rupture takes place. Unfortunately, the sur-
geon seldom sees these patients until after rupture
has occurred. Had this patient submitted to opera-
tion when advised to do so by the family physician,
the operation would have been a simple afifair, and
her life would not have-been jeopardized.
1429 Spruce Street.
THE BLADDER IN TABES.*
By J. Bentley Squier, M. D.,
New York.
The importance of a thorough appreciation of
the role which motor or sensory irregularities of the
urinary vesical function play in the diagnosis,
course, and termination of posterior spinal sclerosis
cannot be overestimated. A certain percentage of
tabetic patients have their attention directed to dis-
turbances in their urinary function as the primary
discomfort. The percentage is not particularly
great, but it is sufficiently large to emphasize the
fact that the possibility of tabes should be kept in
mind in diagnosticating any case of unusual func-
tional disturbance of the bladder.
If in eighty per cent. (Starr) of tabetic patients
bladder symptoms arc present, and in thirty per cent.
(Erb) of these they form the initial symptoms, the
value of this statement is manifest. Tabes, like the
acute infection which is probably its only origin, has
been divided, for ease of description, into the stages
of paresthesias, of ataxia, and of paralysis. This di-
vision, as in dividing syphilis into primary, second-
ary, and tertiary stages, is misleading, because any
symptom or train of symptoms may be the initial
one. Thus it is not an uncommon experience for
the genitourinary surgeon to have a case of tabes
brought to him for diagnosis or treatment where
*Read before the Medical Association of Greater New York.
from the symptoms only an organic bladder or pro-
static lesion has been suspected. The distinctive
diagnosis being often difficult, this error is easily ex-
plained, the difficulty being that even though the
patient has tabes he may also have a real local lesion
which is in part or wholly responsible for the blad-
der symptoms and not the cord degeneration. Vice
versa, if the cord lesion is present and its presence
is not recognized one may inadvertently propose
some radical surgical measure for the rehef of the
urinary symptoms, presumably due to local causes,
which are in reality due to a central lesion, thus leav-
ing the patient in a more distressing condition than
he would have been if no operation had been per-
formed.
I have recently seen a patient whose prostate was
removed for the relief of complete retention of
urine, there simply being some enlargement of the
prostate present. As the result of the operation the
patient was left with complete incontinence, requir-
ing the constant wearing of a urinal, and it was only
after operation and the development of other signs
of tabes that the spinal cord disease was recognized
and the futility of operation recognized.
Two cases which I have already reported (see
New York Medical Journal, March 16, 1907) were
considered to be tabetic until multiple calculi were
diagnosticated and removed from the bladder with
an immediate cessation of the bladder symptoms and
lightning pains in the legs, which had been the
salient points upon which the diagnosis had been
made.
To go further, tabes is not in itself fatal. It ren-
ders the patient a chronic invalid, but does not kill.
He dies from some intercurrent disease, the most
common of which, from the surgical standpoint, are
complicating cystitis or pyelonephritis. To guard
against these sequelae makes the knowledge of how
to deal with any urinary difficulties occurring in the
course of tabes imperative.
Bladder symptoms when present usually present
themselves as (a) varying degrees of retention of
urine, or (b) varying degrees, of incontinence of
urine, in accordance with the degree of interference
in reception of sensation to the mucous membrane
or of the muscle of the bladder. For example, the
vesical symptoms may be so slight as to escape the
patient's notice, or the patient may have hesitancy in
commencing micturition. When the desire to uri-
nate occurs he may be unable to control it, and a few
drops may escape before he can reach the toilet. In
laughing, coughing, or in sleep there may be slight
incontinence, or he may have absolute incontinence,
or absolute retention. Any of these symptoms may
be wholly due to the central lesion. On the other
hand, if infection of the urinary tract takes place
from septic instrumentation or autoinoculation, all
the other symptoms of cystitis, prostatetis, vesical
calculi, and pyelitis may be added. By autoinocula-
tion is meant that condition ever present in tabes of
trophic disturbances which renders the patient pe-
culiarly susceptible to infection of the bladder or
kidneys. A colon bacillus infection taking place
through the lymphatics or from a direct extension
through the rectal walls may be the cause of a fatal
termination of the disease. This lack of resistance
to bacterial invasion is forcibly shown in the fre-
May 30, 1908.]
SQVIER: BLADDER IX TABES.
1039
quency with which perforating ulcer of the loot fol-
lows a corn, a bunion, or a boil.
To illustrate I have selected a few cases of tabes
which are at present under observation, each of
w^hich teaches an important lesson, and each shows
different aspects of the manner in which the blad-
der involvement may present itself.
Case I. — The first patient, a male, thirty-five years of
age, developed his primary symptoms of tabes in August,
1907. The initial symptoms presented themselves in an
attack of gastric crisis. After this, with considerable
rapidity, stiffness of gait, dizziness when walking, lightning
pains in legs, and other classical signs, subjective and
objective, developed. He had acquired syphilis when
twentj'-five years of age. No bladder disturbances devel-
oped until a few days ago, when complete retention sud-
denly took place. At no time during the past eight months
in which he had been under observation had there been
any bladder disturbance.
Case IL — The second case, a male, sixty-one years of
age. consulted me September last, suffering from complete
retention of urine of eight years" duration, requiring the
constant use of the catheter. He had been a sufferer from
tabes for fifteen years. The bladder symptoms in his case
had been slow in their manifestation, commencing with
increased difficulty in urination. This became gradually
worse imtil complete inability to void urine took place.
During this period of eight years he had had probably a
dozen attacks of violent cystitis due to infection from his
catheter. He had never been properly instructed in the
care of the instrum.ent.
Case HI. — Another patient who has been under observa-
tion for the past five years, whose tabes have been present
tor fifteen years, when first seen was suffering from symp-
toms due to a large vesical calculus in addition to bladder
changes produced by his tabes. Removal of the calculus
cleared up most of his bladder symptoms except a little
hesitancy and at times a few ounces of residual urine. It
has been this- patient's custom for the past four or five
years to take a number of courses of antispecific treatment
two or three times a year. During these periods of treat-
ment he takes large doses of potassium iodide, and at these
times his bladder symptoms are always aggravated. The
congestion of the mucous membrane of the bladder and
urethra caused by the iodide adds just enough extra ob-
struction so as to interfere with the act of urination, there-
fore during these courses of treatment he has to make use
of the catheter frequently to relieve the hesitancy thus
produced.
_ Case IV. — The next case shows the symptom of incon-
tinence as the most prominent urinary factor. The patient
was attacked with tabes when thirty-six years of age. six-
teen years after he had acquired syphilis. The initial symp-
toms were frequency of urination and ataxic gait. He was
compelled to urinate four to six times at night with more
or less incontinence. During the day it was necessary for
him to wear a urinal continually. The bladder always con-
tained eight to ten ounces of residual urine.
These cases show the usual ways the bladder
symptoms appear. Xow the most important ques-
tion arises, \\'hat can be done for the relief of these
distressing conditions? Tabes is a disease the
treatment of which is one of absolute attention to
detail, and it is therefore necessarv, if one expects
any improvement whatsoever, to seek out every fac-
tor which may contribute any peripheral irritation
to the already degenerated centres. I mean by this
that it is not sufficient to simply teach the patient
the use of the catheter to relieve the symptoms of re-
tention or the incontinence of overdistention or mus-
cular insufficiency, but it is necessary to go into the
care of his urinary apparatus minutely. In exam-
ining the patient with tabes in which urinary symp-
toms are present, one should be absolutely certain
that no local lesion of the urinary tract is over-
looked. The congenital abnormally tight meatus if
present, should be divided, the possibility of stricture
due to gonorrhoea should be considered, chronic
congestion of the deep urethra or prostate, or any
possible source of peripheral irritation should be in-
quired into and treated. This is necessar)- before
one can tell how much of the patient's discom-
fort is due to tabes and how much to contributory
irritation fromi outside sources.
Having eliminated all other pathological condi-
tions which might be present in a tabetic bladder or
annexa, the question of treatment resolves itself into'
a twofold proposition : First, and most vital, to keep
the viscus in an absolutely sterile condition ; second,
to reestablish, by motor reeducation, its lost func-
tion. The first proposition is a surgical probability,
the second an experimental possibility. In the
motor training in ataxia we are often astonished by
the amount of improvement which has taken place
in many patients when we consider the amount of
disturbance of the posterior sensory tracts which
must be present. The reason need not concern us.
Tabes is at present a necessarily symptomatically
treated disease, and we have to be governed accord-
ingly. Therefore, to take up the second possibility
of treatment, as soon as the patient shows any hesi-
tancy or incontinence the bladder instruction should
begin, the technique of which is simple. After uri-
nation a catheter should be passed, the residual
urine, if present, drawn, and a measured quantity
of a mildly irritating fluid (silver nitrate, i in 1,000)
injected into the bladder, and the patient required
then to make efforts to void it. He should be taught
the value of making his efforts of urination at stated
times, and always to try to evacuate the bladder to
the last drop. Sometimes a stronger solution of silver
(grain I or II to the ounce) may be instilled into the
prostatic urethra with beneficial results. It will ex-
cite a condition of mild vesical tenesmus, thereby
stimulating the contractile power of the bladder.
The vesical spasm of tabes is best relieved by the
passage of a cold sound. If it becomes necessary
to put the patient on catheter life no detail in his in-
struction in sterile catheterization should be over-
looked, as upon this may depend the extent of his.
lease of life.
20 East Fortv-sixth Street,
Neue Wege (Modern Ways). Baumbach, the
well known German author, has written a drama in
three acts, which is published by Friedrich Gutsch,
of Karlsruhe. In the play the son, a young gradu-
ate of medicine, returns from the university to the
home of his father, a well known physician, where
he meets his early sweetheart. The young girl falls
suddenly ill, and the elder physician, deciding to
try a new remedy of his own discovery which he
has not yet tested clinically, administers it to her,
and she dies. At her death he is made aware for
the first time that she was engaged to his son. The
son is prostrated with grief "^over the death of his
fiancee, and decides to leave his father's house, and
in bidding farewell he thus interrogates his father:
"Would you have treated ^laria as vou did, if you
had known she was my affianced wife, your future
daughter ?"
1040
OUR READERS' DISCUSSIONS.
[Ne«- York
Medical Journal.
(©nr f ta^im' iiscussions.
A SERIES OF PRIZE ESSAYS.
Questions for discussion in this department are an-
nounced at frequent intervals. So far as they have been
decided upon, the further questions are as follows:
LXXIV. How do you treat sunstroke? {Closed May
15, 1908.)
LXXV. How do you treat cholera infantum? {An-
swers due not later than June 15, igoS.)
LXXJ'I. Hoit' do you treat acute articular rheumatism?
(Anszcrrs liiic ii'it later than July 15, 1908.)
Whoi i cr onswcvs one of these questions in the manner
most satisfactory to the editors and their advisors will
receive a prize of $25. No importance whatever will be at-
tached to literary style, but the azvard will be based solely
on the z'alue of the substance of the ansiver. It is requested
{but not required) that the anszvers be short; if practica-
ble, no one anszver to contain more than six hundred
words.
All persons will be entitled to compete for the prize,
whether subscribers or not. This prize will not be awarded
to any one person more than once zvithin one year. Every
answer must be accompanied by the zvriter's full name and
address, both of ivhich xve must be at liberty to publish.
All papers contributed become the property of the Journal.
The prize of $2^ for the best essay submitted in answer
to question LXXIII has been azvarded to Passed Assistant
Surgeon Charles .S". Butler, United States Navy, whose
article appears belozv.
PRIZE QUESTION NO. LXXIII.
HOW DO YOU TREAT SEASICKNESS?
By Charles S. Butler, M. D.,
United States Navy.
It may be stated at the start that there is no spe-
cific for seasickness. The psychic attitude toward
a given drug influences so markedly its efifect upon
the patient in this particular complaint that we find
the apparent paradox of a single drug seeming to
intensify in one person those symptoms which it
relieves in another. Thtis it happens that almost
every known drug has been tried and recommended
in seasickness. _ Promiscuous drugging in seasick-
ness is pernicious rather than beneficial.
I think that the efifort of the physician should be
to lead his patient up to the acquirement of an im-
munity— to use this term in its broad sense — rather
than to be content with simply mitigating existing
symptoms. No immunity begotten purely of drugs
can long endure ; it passes with the drug.
Immunity to seasickness is only relative. Under
unusual stress of weather the hardiest sailor may
fall victim to the complaint. But it should be the
earnest desire of every one who goes to sea to
acquire such a degree of immunity as will furnish
a reasonable return in comfort during the ordinary
conditions on the ocean.
Bromides, alcohol, or opium can never give this
"something," which, like the knack of swimming,
once acquired, lasts for life. What these drugs give
is a temporary and imperfect imitation of the real
thing. People who are not used to going to sea are
wont to forget, amid the unusual surroundings
aboard ship, the daily routine which, on shore, gives
them the best returns in wcllbcing. They lose sight
of the fact that to sleep in a stuffy stateroom, to
neglect the daily exercise or cold dip. will have ex-
actly the same effect upon them as if they were on
shore. To off set seasickness they need all that well-
being and hold on the will which a well regulated
routine will give them. It would seem that the
quickest way out of seasickness is not by the drug
route, but by the immunity route, and to this end
I may divide travelers into three classes :
1. Those who naturally have a comparative im-
munity to the complaint, suffering with slight
nausea in the beginning of a sea voyage, which
quickly passes off. This class requires no treat-
ment.
2. Those showing more persistent symptoms, psy-
chic (depression of spirits) and cerebral (headache
and vertigo), as well as gastrointestinal (anorexia,
nausea, vomiting, and constipation), but who, with
proper care, ultimately acquire an immunity.
3. Those who can never become used to the oscil-
lation of a ship, however long or often subjected
to it.
It is the exception to find an individual who prop-
erly belongs in this last class, by far the majority
of people falling into one of the first two classes.
It is only to this last class that the usual sedative
treatment with bromides, or chloral, or atropine,
should be applied, and then only after we are
assured that the individual is one of those rare un-
fortunates. The only thing to do for him is to make
him as comfortable as possible, and support his
strength until the voyage is completed. How to do
this is a matter to decide for each individual case,
but generally speaking, a reclining or recumbent
position (on deck, whenever possible), an easily
digested diet taken at frequent intervals, as much
reading as is consistent with pleasure, and the avoid-
ance of sleep until night, will give the best results.
To these general measures special measures as re-
quired may be added. The sipping of a sparkling
laxative water, well iced, is often beneficial, and, as
a general rule, the application of a snug abdominal
binder, from chest to hips, will prove of service. In
women this, of course, should displace the corset,
which does not give proper distribution of the pres-
sure.
To return to the second class, which embraces the
great majority: The pathology of seasickness has
never been written. To this assertion the multi-
plicity of hypotheses to explain it attest. Not know-
ing its cause our treatment then becomes empirical,
and hence not ideal. Disregarding personal handi-
caps, such, for instance, as an already existing gas-
tritis, a naturally torpid liver or other complaint
which may predispose one to seasickness, those indi-
viduals fare best whose secretions are most active,
who early acquire the knack of orientation, and
whose dispositions are most optimistic. To aid and
encourage these three things in the patient offers
the best chance for early acquiring the immunity
of which I speak. To this end it is well to have the
person, before sailing, if time permits, take a thor-
ough course of catharsis. If the individual knows
when he is to sail, it is well to have him take a chola-
gogue cathartic atout a week beforehand, and then
keep the bowels in an open condition with some
saline cathartic. During this time the diet should
be light and largely composed of vegetables. The
meal immediatclv i)efore sailing should be a full
one. It is best to leave alcohol entirely alone.
May 30, 1908.]
OUR READERS' DISCUSSIONS.
Nothing will so surely precipitate seasickness as a
little too much alcohol the night before. So, too,
with coffee, tea, and tobacco. The two first named
not only tend to constipate, but also disturb the rest
and so produce a certain ennui, tlie wtry reverse of
what should exist at the sailing time. W ith a good
start the battle is half won. During the voyage it is
well to avoid coffee, tea, and tobacco until one is
assured he can take them without undue detriment.
When indulged in they should be taken in the early
part of the da}-, not toward evening. Plenty of
sleep and an active condition of the bowels should
be the rule throughout the voyage. Sleep during
the day should be discouraged. It is calculated to
make the regular sleeping hours less refreshing.
To promote laxity of the bowels, three measures
may be employed in case the individual is inclined
to be costive, and such is usually the case with those
who are seasick. At night, after turning in, and
when drowsiness has come on, administer one of
the stomachic and laxative pills containing aolin,
strychnine, belladonna, and ipecac, a combination
which most manufacturing pharmacists prepare.
This usually acts well the following morning, and
"if administered as directed, is rarely vomited. Or
before turning out in the morning have the patient
take a glass of a purgative mineral w^ater, and
remain quiet for a time. In case these preferred
measures should fail, then recourse should be had
to enemata. Every traveler should be provided with
one of the little soft rubber bulb syringes with a
capacity of four to six ounces. By injecting cold
water (five ounces) when one arises — a procedure
recjuiring but half a minute — the desired effect will
usually be attained by the time the patient is ready
to go for his bath.
The next question after guarding the welfare
of the gastrointestinal tract is that of orientation.
When the novice starts on a voyage, his first pleas-
urable sensations at the slighter motions of the
vessel soon give place to that disagreeable feeling
which one experiences in a rapidly descending ele-
vator. Of the several motions of a ship, the one on
the thwart-ship's axis (the pitch) is by far the most
eft'ective in producing this sensation. This is attrib-
uted to the fact that we anticipate the roll, but not
the pitch. It seems to me that there is something
other than anticipation needed to explain this, for
the seasoned sailor can no more anticipate it than
the novice, and yet he is not affected by it. He has
taught his equilibratory apparatus to disregard it.
He goes with the ship and does not resist going
where she goes. He is, in a certain sense, passive,
w-hereas the novice keeps his equilibratory apparatus
in a constant state of insult by trying to draw back,
much as one imagines a man would who was being
shoved over a precipice. It is this constant tendency
to try and right the ship rather than to be a part
of her which must be overcome, and I think when
one has accomplished this he has gone far towards
becoming a good sailor. To accomplish this is
largely a matter of inhibition, and is accomplished
by the will. Practice may be acquired in this inhi-
bition by using vigorously one of the old time
swings known to us as children. It may be aided
by deep inspiration at the time of descent, repeated
regularly until this kind of respiration becomes a
habit.
The third element making for immunity, the
cheerfulness, is rather contributory than essential.
It is difficult to further a determination to resist to
the last when one feels that awful goneness at the
pit of the stomach, but it is certain that the capacity
for optimism aids the will at the time when it most
needs it.
Coiicliisio)! ' We may summarize the treatment of
seasickness thus: i. Avoid sources of depression,
such as tea, coff'ee, alcohol, and tobacco.
2. Keep the secretions active.
3. Learn to be a part of the ship.
4. Cultivate a good daily routine as to meals,
baths, exercise, etc.
5. Stay on deck and amidships as much as pos-
sible.
6. Never take sedatives until compelled to.
7. Cultivate cheerfulness.
Dr. B. R. O'Reilly, of Toronto, Canada, remarks:
There is no disease which will tax the "ship
surgeon's" resources to such an extent as a severe
case of nial dc mcr, for not only has he to deal with
the physical manifestations, .but added to these are
those mental symptoms of apprehension, etc., from
which frequently the patient suffers far more than
from the nausea and vomiting itself.
Seasickness declares itself in several distinct ways.
In my experience none can compare, from the pa-
tient's standpoint, wath that nervous type showing
itself in intense occipital headache, severe spinal neu-
ralgic pains, mental trepidation, etc. (frequently un-
accompanied by vomiting), and, although a certain
amount of relief may be afforded, these patients can
seldom be given any permanent degree of comfort.
One can divide cases of mal de mer into two classes,
for the purpose of laving down certain general rules
as to their management, i. e., the "gastric" and
"nervous." In the former group we meet with every
degree of suffering from simple vomiting unaccom-
panied by nausea to uncontrollable emesis, with the
serious problem, during a long voyage, of the main-
tenance of nutrition before us.
Prophylaxis may be of great service, especially
in this form, and it is here that on the second night
before embarking a full dose of calomel, followed
the next morning b\- a saline draught, or large warm
water enema, has its place ; minor points, such as a
cup of hot tea or coff'ee before rising, abstinence
from the time honored tramp before breakfast, a
somewhat hasty plain meal, and immediate recourse
to a lounge chair on deck, should never be forgot-
ten. Some individuals experience excellent results
from a dose of eft'ervescent saline on waking, or a
full tumbler of sea water, in the latter case the in-
duced emesis apparently acting as a gastric seda-
tive, and this is the favorite method adopted bv Chi-
nese sailors in the Orient.
Occasionally a firm abdominal pad or binder, or
a belladonna plaster over the epigastrium, wall add
not only to the patient's comfort, but in certain indi-
viduals may even ward off an expected attack.
The patient should be w^armly and comfortably
clad ; nothing adds more to the misery than sensa-
1042
OUR READERS'
DISCUSSIONS.
[New York
Medical Journal.
tions of cold. Encourage the sufferers to take a
moderate amount of nourishment, the stomach beins^
less impressionable during the process of digestion.
For the relief of nausea uncontrolled by simple
remedies such as have been suggested, one must
have recourse to more active measures, and fore-
most among these comes the application of sina-
pisms to the epigastrium ; gastric lavage is often
eminently successful, and this opportunity may be
used for the introduction of such drugs as bismuth,
carbonate, creosote, hydrocyanic acid, or cocaine (in
doses of i/8 grain), into the stomach ; drachm doses
of gl\cerin have also been recommended. These
having failed, we have still several means at our dis-
posal for relieving the depression, even if we cannot
control the active emesis, and it is in these cases
that the use of the hypodermatic syringe finds its
place. In individuals who know by experience that
severe nausea and vomiting are inevitable, a pro-
phylactic injection of i/ioo grain of atropine sul-
phate combined with 1/50 grain of strychnine sul-
phate will do much to inhibit its onset. The drug on
which I place greatest faith is nitroglycerin, in doses
of i/ioo grain, the subjective symptoms of depres-
sion frequently being ameliorated, even though vom-
iting persists.
The use of champagne and the sucking of ice may
Tdc allowed, although it is doubtful if much value
can be attached to their action, beyond the mental
impression they produce, and in the same category
I place the use of brown paper over the abdomen
and many other similar expediencies. Lastly, it may
be necessary to relieve thirst with sa.line injections
and employ nutrient enema to support nutrition.
Turning now to the nervous type of the malady,
one's advice and procedure as to prophylaxis is sim-
ilar, but following this a different course of treat-
ment is usually found to be advantageous. Theoret-
icall}', the nausea and vomiting being ascribed tO' a
central reflex disturbance (possibly due to an alter-
ation in the normal conditions of the endolymph and
perilymph of the semicircular canals), the setiolog-
ical factor being the same, one's treatment of the
two forms should be similar.
Experience teaches us that it is here the sedatives
are of greatest value, and probably none are more
useful than the bromides (given in doses of 20
grains every six hours for at least two days before
embarking, preferably the strontium salt), or chlore-
tonc in 5 grain gelatin capsules or paraffin wafers,
and repeated every four to six hours (it is officially
known as trichlortertiary butyl alcohol, is a crys-
talline salt, nearly insoluble in water, volatilizes at
low temperatures, and should therefore be kept in
glass stoppered bottles).
One may, especially in cases of headache and
spinal pains, get marked relief from the "'coal tar"
l)roducts, and of these phenalgin (which contains
ammonia) is the safest and least depressant, and in
my experience is the most reliable. Hyoscine has
been u.sed extensively, but cases have been reported
in which mania lasting for several days has been the
outcome ; lastly, and never to be used except in the
most extreme forms, comes morphine.
In concluding let me emphasize the fact that, while
seasickness is seldom in itself a menace to the life
of the patient, it may. and not infrequently does,
precipitate serious complications, such as cerebral
haemorrhage or the rupture of a previously existing
gastric ulcer, and that the treatment of even the ap-
parently mild cases should receive more than a pass-
ing thought ; finally, the future holds out to us the
hope that in the "gyroscope" we may find an anti-
dote which will displace entirely our present system
of therapeusis, and that ultimately mal dc iiicr will
be a disease of the past.
Dr. Robert A. Bachinann, of the United States
Navy, writes:
If possible the treatment of seasickness should be
begun before the attack. A subject of the disease
prior to embarking on a voyage should be prepared
by dietary regulations and a thorough catharsis two
days before. The former means simply a restriction
in diet as to quantity, particularly in the reduction
of meats and fats, eliminating everything but pos-
sibly a small amount of light meat once a day, and
the latter is best accomplished by fractional doses
of calomel (o.i grain for ten doses as an average
dosage), followed by a Seidlitz powder or magne-
sium citrate in the morning. Whether the modus
o/yeraiidi of the calomel is to increase peristalsis or
stimulate the liver, the object — to get rid of as much
bile as possible in the intestines — is accomplished.
The day before sailing, small doses of potassium
bromide are useful in quieting the vomiting centre
as well as the sensibility of the semicircular canals
and lessening the irritability of the stomach. Ten
grains three times a day are sufficient for this pur-
pose.
The treatment on the ship demands two most im-
portant conditions — fresh air and the recHning posi-
tion. Frequently these accomplish a cure without
medication or diet. Senseless advice to "fight it
ofif," not to "give up,"' but to spite your stomach
and eat in the face of nausea or walk around when
the semicircular canals should be at repose, is not
only bereft of good reasoning, but positively plagues
your patient.
With the beginning of rough weather inject atro-
pine sulphate o.oi grain, and hyoscine sulphate 0.005
grain, ever_\- three hours until two or three doses
produce dryness of mouth, cessation of nausea, and
a desire to sleep.
The patient is placed on deck amidships, where
motion is least, in a steamer chair or cot, head on a
soft pillow, and well blanketed. The absence of
odors, especially of tobacco smoke, is greatly appre-
ciated by your patient. If symptoms of seasickness
develop in spite of the treatment, or in late cases, if
they do not abate, I add a twenty grain dose of
potassium bromide in fruit juice and aerated water,
and follow it with ten grain doses every three hours.
Women are often benefited by warm applications
to the epigastrium and abdomen, and severe cases
of retching and vomiting in either sex are improved
hy this as well as hot applications to the head.
The most delectable nourishments are fruits and
fruit juices, light broths, crisp crackers, toast well
baked, zwieback, and later the lighter meats, eggs,
egg desserts, etc. Champagne, cracked ice. and
aerated waters are the best drinks. The sucking of
an orange or lemon is pleasant to some. Personal
tastes must l)e considered.
May 30, 1908.]
OUR READERS' DISCUSSIONS.
1043
After the patient has improved do not risk a re-
lapse by letting him be too active. Keep him in the
open air, reclining, and further his recovery by giv-
ing strjxhnine 1/20 grain three times daily, or five
drop doses of tincture of nux vomica in water ever}'
three hours. The natural tendency most people have
to become constipated at sea is best corrected by
a morning dose of fluidextract of cascara sagrada.
The three main considerations to obtain are a
normal digestive tract, fresh air. and the reclining
position. With these to work on such medication
as has been mentioned will hardly fail to give at
least relief.
Dr. Irving Wilson Voorhees, of Xezc York, says:
At the outset it should be thoroughly understood
that this condition is dependent upon no singlo
cause, but upon a variety of causes operating local-
ly to influence the abdominal organs and constitu-
tionally to disturb the equilibrium of the central
nervous system. Without going into the alleged
causes of mal de mer in detail there are two the-
ories which are supported by an overwhelming
amount of clinical evidence. The first of these
argues that the abdominal organs are pulled in va-
rious directions by the swaying of the ship and thus
set up a reflex irritation of the sympathetic gan-
glionic system, with its attendant results ; the other
avers that there is a disturbance of the pneumo-
gastric nerve, either mechanical, thermal, psychic,
or toxic, and that this is responsible for the dis-
tressing symptoms. That there is some (but not
all) truth in each of these hypotheses is beyond
question, but they do not cover the actual condi-
tions in every case, as our therapeutic eflforts prove.
Stomach washing and catharsis have proved to
be of value in my experience. As soon as nausea
begins the stomach is washed with water at 90^ F.
containing 10 minims of nux vomica, which is con-
tinued until the water comes away absolutely clear.
Unless the bowels are already very active, physo-
stigmine sulphate, grain o.oi, is given hypoder-
matically. I prefer this to the use of the internal
cathartics, because it acts quickly and does not irri-
tate the mucous coat of the gastrointestinal tract.
Ergot by mouth is useful in a limited number of
cases, particularly those of a neurotic type, with
congestion of the gastric mucosa. I give to adults
J/2 drachm in a little water every four hours.
The bromides have been in use for years, and are
highly recommended by some writers. Personall}-
they have given me poor satisfaction.
Hyoscine, atropine,, strxxhnine. — A combination
of hyoscine hydrobromide. grain 1/ 100 ; atropine
sulphate, grain i/ioo; and strychnine sulphate. grain
1/60, by hypodermatic injections, not oftener than
every four hours, is sometimes useful.
^Morphine, atropine, caffeine citrate. — This is
the best method of controlling obstinate seasick-
ness, with which I am familiar. As soon as nausea
begins the patient is given an gram of morphine
with a i/ioo of atropine in 15 drops of sterile water
by hypo. If nausea is still present one hour later,
give caffeine citrate, grain iv, in 25 drops of sterile
water by hypodermatic injection. The atropine
should not be repeated within four hours. Occa-
sionally atropine must be given on the following
day if the sea is very rough.
Essentials. — The patient should make sure before
sailing, in so far as possible, that his nervous and
gastrointestinal systems are in prime condition.
This is, of course, impossible with many patients
who must sail at once, but the use of phosphogly-
cerates of lime and soda or the syrup of hypophos-
phites with stryclinine is very helpful when given for
one month before sailing.
The patient should be kept in the open air, pre-
ferably on deck, lying flat on his back in a swinging
hammock. \\'hen the port holes are all closed and
the patient is tossed about in his berth in a foul at-
mosphere and surrounded by the noises and odors
of other sick people he is not in the best possible en-
vironment for an immediate recovery.
A broad belt, extending from nipples to pubes,
tightly applied gives much relief. I have seen it
help when all other measures accomplished very
little.
It is best to abstain from all food and drink.
Even water will sometimes start a new attack of
vomiting, and if given at all it should be by tea-
spoon. If the patient is in immediate danger of
starvation, one has recourse to rectal enemata.
Dr. Frederic H. Wilson, of New York, observes:
In dealing with the affection known as seasick-
ness or mul de mer, it is necessary to take into con-
sideration two things, namely, whether the sea trip
is to be of long duration, as a transatlantic voyage,
or merely a day's outing on a pleasure craft. In
either case, prophylaxis is a most important factor
in the treatment, but is seldom possible in the latter
case. }iIost patients who anticipate a lengthy voy-
age are deluged by well meaning friends with vari-
ous suggestions for eliminating the bugaboo of the
trip, varying from sucking a lemon to an almost con-
stant sojourn on deck. The writer uses two courses
of treatment, both of \\hich are successful in the
majority of cases and which have stood the final test
of any treatment by a physician, namely, using them
on himself.
The patient who is going on a pleasure excursion,
as a short yachting trip, and who comes to me for
advice as to how to avoid being seasick, is given, on
the evening before sailing, a hypodermatic injection
of strychnine hydrochlorate, grain 1/60, and atro-
pine sulphate, grain 1/150. The majority of those
who ask for advice are ladies, who are somewhat
dubious when the hypodermatic is suggested, and I
therefore am frequently obliged to medicate by
mouth. On the morning of the journey another
dose is given, this time by mouth in all cases, using
the strychnine in a dose of grain 1/30, and the atro-
pine, grain i/ioo. The patient is advised to refrain
from rich food and copious drinking during the day,
and freedom from the dreaded nausea is the result
in almost all cases.
On the other hand, the treatment for a proposed
long voyage is necessarily much more thorough and
should cover a longer space of time. The patient
is told to take every morning, for five days previous
to embarking, a Seidlitz powder. On the afternoon
of the day before sailing the patient is given calo-
I044
CORRESPONDENCE.
[New York
Medical Journal.
mel, grain 1/5, for five doses, followed by another
Seidlitz powder on the morning of departure. By
this prophylaxis the entire intestinal tract is cleared
and the liver put into good functionating condition.
The absorption of toxic material from the lower
bowel becomes greatly increased by the rolling of a
vessel, and the described treatment eliminates a large
part of the toxins arising from intestinal putrefac-
tion.
The patient should occupy an "outside" stateroom
and keep the window or porthole open as much as
possible, especially at night. He should be particu-
larly cautioned to spend as little time as possible in
his stateroom or in the cabins. During the first days
of the voyage only light meals should be eaten,
whether seasick or not, as the appetite, stimulated
by the sea air, will invariably cause a voyager to
overtax his digestive organs unless strict care is
maintained.
A very valuable point is the following: After
the first few days the patient will find no inclination
to seasickness except on arising. When this occurs
he should dress as expeditiously as possible and im-
mediately go on deck instead of to the dining saloon.
While in the chair on deck he should have the deck
steward serve to him an iced grapefruit, slightly
sugared, which should be eaten, together with sev-
eral -pieces of the ice served with it. The lumps of
ice should be swallowed whole. The bracing effect
of the bitter (cinchona) of the grape fruit is imme-
diately noticeable, and within a few minutes a hearty
breakfast can be eaten in the saloon. I have known
this routine of treatment to enable the most acute
sufiferer from mal dc mcr to pass through a nine chy
voyage, including a two day storm, with no more
serious inconvenience than a slight nausea and gid-
diness on arising in the morning and lasting less
than a half hour daily.
( To be concluded.)
LETTER FROM OTTAWA.
The Forty-first Annual Meeting of the Canadian Medical
Association. — The Eighth Annual Meeting of the Can-
adian Medical Protective Association. — The Second
Annual Meeting of the Association of Medical Officers
(if the Militia of Canada.
Ottawa, May 16, 1908.
The forty-first annual meeting of the Canadian
Medical Association will be held in the Capitol,
Ottawa, on the 9th, 10th, and nth of June, under
the presidency of Dr. F. Montizambert, of Ottawa,
director general of public health. Dr. R. W.
Powell, of Ottawa, is the chairman of the Commit-
tee of Arrangements. Delegates to this meeting-
will travel from every province in Canada on the
standard certificate plan. During the course of the
meeting, as usual, the annual meeting of the Cana-
dian Medical Protective Association will take
place, when the president of that lusty organiza-
tion, Dr. R. W. Powell, of Ottawa, will have a
splendid report to make. This organization came
into existence at the Winnipeg meeting of the
Canadian Medical Association in 1901. Every
year it has prospered both in numbers and in
finance. During that time it has defended a num-
ber of its members in suits for alleged malpractice.
and in no instance where it undertook a defense has
it been other than successful. Indeed, its power
and strength are becoming known to the ex-
tent that year by year there are fewer actions of
this character all over Canada. The Military Sur-
geons this year, under the presidency of Dr. George
Stirling Ryerson, of Toronto, meet as a section of
the Canadian Medical Association. The social side
of these meetings promises this year to be more
than ordinarily interesting. There are to be a re-
ception at the Ottawa Golf Club, an excursion to
Caledonia Springs, an excursion to the Experi-
mental Farm, and a smoking concert, besides
numerous private functions. This is the first ineet-
ing under the new constitution, and the provincial
societies are sending delegates to represent them on
the business body of the association, the Executive
Council.
The l^residential Address will ]:)e given by Dr.
F. Montizambert, of Ottawa ; the x\ddress in Medi-
cine by Dr. Risien Russell, of London, England ;
and the Address in Surgery, The Surgical Rights
of the Public, by Dr. John C. Munro, of Boston,
Mass.
A Bath for Urticaria. — In La Clinique for May
15th G. Bardet is credited with the following for-
mula for a powder to be added to the bath water in
the treatment of urticaria :
R Potassium carbonate, 5iii ;
Sodium carbonate 5ii ;
Sodium borate, },\;
Pulverized starch, liiiss to 5vii.
M. .
After the bath it is recommended to rub the skin
lightly with glycerite of starch containing one per
cent, of carbolic acid.
Enema in Intestinal Tuberculosis. — Soubeyran
and Ardin Delteil ( Journal de mcdccinc de Paris.
April 24th) use the following as an enema in the
treatment of tuberculosis of the intestines :
R Methylene blue, gr. i to gr. ii ;
Distilled water, ^xvi to ixxxii .
M.
Or,
Naphthol camphor 5ss ;
Yolk of egg, No. i ;
Distilled water, with milk 5x ;
Wine of opium gtt. vi.
M.
[Naphthol camphor consists of a mixture of beta-
naphthol, 100 parts, and camphor. 150 parts.]
Solution of Formaldehyde for the Destruction
of Flies and Mosquitoes.— In the Archives dc
iiu'diciite ct dc plioDiiacic iiiilitaires for April, igo8,
M. Delamare, chief of the military wards of the
h(jspital of Saint-Denis, describes a method of de-
stroying flies and mosquitoes in apartments by the
use of a ten per cent, solution of commercial formal-
dehyde. Saucers containing the solution arc placed
on the window sills and on tables in proximity to
the places infested by the flies. The .solution is said
to be very effective, flies and mosquitoes being ar-
rested and killed in their flight as they pass over
the vessels containing it. Saucerfulls of the solu-
May 30, 1908.)
THERAPEI TICAL XOTES.
1045
tion, placed at the heads of the beds in the hospital
wards, protect the patients from attacks. The author
had the curiosity to count the number of insects
killed, and found that, during the period from
August I to August 7 the daily average was 4.000
flies. The saucers should be emptied of dead flies
and replenished with fresh solution once a day.
Application for Toothache. — After the cavit\
has been thoroughly cleansed and dried, J. O. Hart
{The Virginia Medical Semi-Monthly, May 22d,
1908) applies the following on a pledget of cotton:
R Chloroform,
Oil of cloves.
Creosote, aa 5s 5;
Morphine sulphate, gr. i.
M.
To reduce periosteal inflammation, the surround-
ing gums should be painted with equal parts of
tincture of iodine and tincture of aconite.
Injection for Foetid Bronchitis. — Rabe {Journal
de mcdecine de Paris. April 24th) injects hypoder-
matically two to four cubic centimetres of the fol-
lowing preparation during the twenty-four hours :
B Guaiacol gr. Ixxv;
Iodoform. gr. xv ;
Sterilized oil.
Liquid petrolatum aa q. s. ad Jiii.
M.
Styptic Powder. — The composition of a styptic
powder used b}- Professor P. G. Unna is as follows :
B Tannic acid, "j
, -
Rosin, I
The ingredients, finely pulverized, are intimately mixed
together.
Metchnikoff's Mercurial Inunction. — The oint-
ment .employed by Metchiiikoff at the Institut Pas-
teur for the prevention of inoculation by syphilis is
composed as follows :
B Calomel 33 parts;
Petrolatum, 10 parts ;
Anhvdrous wool fat, 67 parts.
M.
It is important in preparing this ointment to avoid
the slightest contamination with water, and care
should be taken to insure the use of perfectly anhy-
drous petrolatum and wool fat.
Tonic and Reconstructive Cachet. — The fol-
lowing combination, credited to [Nlilian in Journal
de medecine de Paris, is said to be useful in weak-
ened conditions marked by alopecia :
B Sodium chloride gr. xii;
Quinine sulphate, gr. iss;
Calcium glycerophosphate gr. iiiss.
M. ft. cachet i.
Sig. : One cachet twice daily at meal time.
Gout Treated with Hydrochloric Acid. — Fal-
kenstein. of Berlin, having observed that the major-
ity of gouty patients suffered from hydrochlorhydria.
arrived at the conclusion that the gout was the result
of trouble with the gastric mucosa, characterized by
an insufficiency of hydrochloric acid, this poverty of
the organism in hydrochloric acid preventing the
formation of alkali chlorides, and, as a consequence,
their elimination by the kidneys. When hydro-
chloric acid is lacking in the system the alkalies
enter into combination with the uric acid, and as
urates do not pass through the kidneys, they remain
in the blood, where they cause all the troubles with
which we are familiar. The internal administration
of hydrochloric acid in doses of fifty drops a day
favors the elimination of alkalies by the kidneys and
so prevents the formation of deposits of urates in
the joints. The treatment is said to be well tole-
rated, and there is reason to hope that recent cases
of gout are curable by this method of treatment.
Hiccough in Children. — Teaspoonful doses of
the following are given at intervals until the hic-
cough stops:
B Syrup of poppy, 5v ;
Chloroform gft. xx;
Syrup of peppermint 5iiss ;
Oil of sweet almond 3ii.
M.
Bulletin general de thcrapeutique, April 8, 1908.
Inhalation for Bronchitis in Children. — The in-
halation three or four times a day of the vapor from
a teaspoonful of the following mixture added to a
quart of water heated in a teapot or kettle is recom-
mended for the treatment of bronchitis in children :
B Wood creosote, 'i> Ixxv ;
Tmcture of benzoin 5iiss;
Oil of turpentine >iis^ .
M.
. Intravenous Injections in Infectious Diseases.
— Bacelli, of Rome {Journal de mcdecine de Paris,
April 24th), has effected cures in malarial subjects
by the intravenous injection of quinine hydrochloride
dissolved m physiological salt solution, of the fol-
lowing strength :
B Quinine hydrochloride, gr. x;
Physiological salt solution ti]^ xv.
M.
The injection is made preferably with a glass
syringe, the part of the body selected being first
made aseptic, and if the bend of the arm is chosen
as the site of the injection, an elastic band is first
applied. It is of the utmost importance to avoid the
introduction of bubbles of air in making the injec-
tion. Twenty-four hours after fifteen grains of qui-
nine are administered in this way the blood is found
to be free from the malarial parasites.
In the treatment of syphilis he uses the following
formula :
B Corrosive sublimate gr. xv ;
Sodium chloride, 5ii ;
Distilled water, sxxxii.
U.
He begins by injecting fifteen minims of this solu-
tion, and increases the dose until he reaches a maxi-
mum of ten times this quantity as the daily dose.
The injections are considered equally serviceable in
the treatment of puerperal infection, cerebrospinal
meningitis, acute articular rheumatism, and en^sip-
elas.
Ointment for Psoriasis. — The following oint-
ment, credited to Saalfeld in Journal de mcdecine de
Paris, is applied once a day, bathing being interdict-
ed during the treatment :
B Salicylic acid,
Chrysarobin, aa 3iiss ;
Green soap,
Petrolatum aa 3vi.
M.
1046
EDITORIAL ARTICLES.
[New York
Medical Journal.
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
S A Weekly Review of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M. D.
Addrcsn all business communications to
A. R. ELLIOTT PUBLISHING COMPANY,
riiblisticrs,
66 IVest Broadway, New York.
Philadelphia Office : Chicago Office :
3713 Walnut Street. 160 Washington Street.
SuBSORiPTiox Price :
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$7 : single copies, fifteen cents.
Remittances should be made bv New York Exchange or post
office or express mone.v order payable to the -V. R. Elliott Pub-
lishing Co., or by registered mail, as the publishers are not
responsible for money sent by unregistered mail.
Entered at the Post Office at New York and admitted for
transportation through the mail as second class matter.
NEW YORK, .S.^TURDAY, MAY 30, 1908.
THE CHAILLE JUBILEE.
"Our fair city of New Orleans has ever been rich
in the genius and achievements of her medical fac-
ulty," said Dr. Beverley Warner; ''Stanford E.
Chaille, doctor of medicine, doctor of laws, doctor —
the degree is unknown, the power is acknowledged
— doctor of men," said the same speaker; "I have
never seen any one so impressive in the classroom
or who imparted so much knowledge to his pupils
as did Dr. Chaille," said Dr. Lewis S. McMurtry,
of Louisville — all in the course of remarks made m
the celebration of Dr. Chaille's completion of fifty
years' service in the Medical Department of Tulane
University, held in New Orleans on May 19th. Not
one of these saying was vainglorious. New Orleans
has indeed borne an exalted part in the progress of
American medicine, with Dr. Chaille as magna pars.
From the - year 1858 up to the present time Dr.
Chaille has served the ]\Iedical Department of Tu-
lane University continuously, one might say, for his
absence on military duty, whether in the field or on
hospital work, also reflected lustre on the university,
and his service has been of the most distinguished
order. Universities are getting to recognize more
and more that their professors' achievements outside
the collegiate precincts redound to their renown, and
in centuries yet to come Tulane University will plant
Chaille's name higher and higher on its roll of those
by whose benefactions it has profited.
It is eminently fitting that Dr. Chaille's efforts in
the .service of Tulane University, in the sanitary
interests of Ix)uisiana. for the prestige of .Xmerican
medicine, and for the glory of our profession all
over the world, should be commemorated perma-
nently, and it is the intention on the part of the
alumni of the Medical Department and their friends
that such a commemoration should take the form of
a chair endowed in his name. It is to be hoped and
confidently expected that this worthy ambition will
speedily be realized. At the celebration Dr. AIc-
Murtry was introduced as "a distinguished son of
Tulane," and we are sure that he could never wish
for a more august denomination. The country waits
loyally on the triumph of New Orleans, as shown in
the general recognition of Dr. Chaille's career. His
declining years are sure to be devoted to the still
further advance of medicine. May they also be hal-
lowed by repose and by reports of continued high
achievements by his successors.
THE MECHANICAL FACTORS IN
LYMPHOCYTOSIS.
F. Peyton Rous {Journal of Experimental Medi-
cine, INIarch) contributes an interesting and impor-
tant paper on the manner of production of lympho-
cytosis. He finds, from experiments on dogs, that
the lymph of the thoracic duct furnishes a large
proportion of the lymphocytes to the circulating
blood. The number supplied to the peripheral blood
through the thoracic duct in the healthy dog is
practically constant from hour to hour, if the physio-
logical conditions remain the same. Muscular activ-
ity is the most important altered physiological con-
dition affecting the number of lymphocytes. It is
accompanied by a prompt increase in the output of
lymphocytes through the thoracic duct. This is
shown by an increased number of cells in each cubic
millimetre of lymph and by an increased amount of
lymph voided through a fistula in the thoracic duct.
The number of lymphocytes leaving the thoracic
duct may be tripled or quadrupled during a long
continued struggle, and following this struggle the
output of lymphocytes is less for a short time than
it was previous to the exertion.
A lympiiagogue, such as glucose, also produces
an increased flow of lymph and an increased output
of lymphocytes through the thoracic duct. While
the number of cells to the cubic millimetre of lymph
is often low, the total number of cells transported
is large. This fact supports the theory of Ehrlich,
that a rapidly appearing lymphocytosis may be pro-
duced by the flushing effect of an increased flow of
lymph. In comparing the lymphocytosis produced
by muscular activity and that due to glucose, it is
evident that there is some undetermined factor in
addition to the increased flow of lymph to be con-
sidered in the former.
May 30. "QcS l
EDITORIAL ARTICLES.
104T
THE EMMANUEL CHURCH MO\'EMEXT
IX BOSTON.
The Emmanuel Church movement in Boston,
which has resulted in establishing a clinic for the
treatment of functional nervous and mental disor-
ders, under the directorship of an able pastor. Dr.
Worcester, has assumed such proportions and been
so widely exploited that it behooves the medical
profession to pause, take an account of stock, and
make a careful survey of its objects and methods
before concluding as to its worth. This is espe-
cially so as many of the leading physicians, both in
Boston and elsewhere, have lent the weight of their
influence to the movement, and the earnestness,
energ}-, and convincingness of its founder bid fair
to make many proselytes.
The rationale of this movement must be based
upon the distinction between mind and body, for it
is hardly to be supposed that even so great an en-
thusiast as Dr. Worcester would presume to- deal
therapeutically with bodily diseases. Even he
would probably hesitate to treat a broken hip or a
case of typhoid fever. Aside from the ven- ob-
vious legal objections to such a course, he specifi-
cally disavows any intention of dealing with or-
ganic disorders, and the physicians who are asso-
ciated with the movement carefully exclude such,
sending him only the so called functional cases.
The priest-phvsician is not new ; he dates back
to the primitive social conditions when disease was
supposed to emanate from the gods or from evil
spirits, and its treatment was therefore closely
wrapped up in the current theology. But for the
past two thousand years and more the priest, on
the one hand, and the physician, on the other, have
been gradually differentiated from this early proto-
type, and by slow increments of change along the
line of development of each have become, biologi-
cally speaking, distinct varieties. Incidentally, too.
it must not be forgotten that the greatest good that
has come to the mentally deranged during this time
has come from considering them as sick persons,
and not as possessed of evil spirits, that the great
advances which have taken place in their care and
treatment have taken place under the guidance of
medicine and not of theolog}-; although only the
shortsighted will forget that it was under the in-
fluence of the Church that the large humanitarian
movements which culminated in the hospitals for
the mentally disordered were conceived and carried
into execution.
But we are now confronted with another phase
of this same type of humanitarian rnovement, much
more restricted in its general scope than were sim-
ilar movements in the past centuries. The hos-
pitals for the treatment of the sick of body and mind
have passed over almost entirely into purely medi-
cal hands. But there are many sufferers from mild
and severe functional derangements that need more
than the comfort that religion has heretofore given ;
it must have a dash of science in it, in the form of
psychotherapy. Once again, and largely, we be-
lieve, on economic grounds, the priest is called
upon to enlarge the scope of his work and take
upon himself certain attributes of the physician,
thus far, without any preparation, save that nat-
ural endowment he possesses for influencing the
minds of men through emotional agencies — a not to
be derided power, let it be understood, particular-
ly in the application of this special feature of the
physician's work.
In this Emmanuel movement the clergy are seek-
ing newer fields, and what more promising than the
extension of a field in which they have worked for
years, but solely as spiritual advisers and com-
forters? But the flock, becoming immune to the
eflorts so unceasingly practised, force their leaders
to more practical issues, and they turn doctors.
One is tempted to draw an analogy, somewhat dis-
torted though it may be. If the water pipe were
leaking, would an electrician be sent for to repair
it? Perhaps the electrician might be one of those
"handy men" who can do anything, and perhaps he
would do a good job on the water pipe. But, on
general principles, would it not have been the part
of wisdom to send for a plumber? Perhaps Dr.
Worcester is one of those "handy men," capable,
broad gauged, deep of sympathy, who can turn
their hands to any task, shoulder any responsibil-
ity. Assume that he is, and he really gives that
impression, yet he is a priest, and the priest and the
physician are as far apart as the aforementioned
plumber and electrician. They are two different
types of men, their outlook upon life is from dif-
ferent standpoints, their thoughts travel in differ-
ent paths, their sympathies, ambitions, and aims are
different. It is true that at times their paths may
cross, that at points their fields of interest may
touch, but the principle is not on that account
changed.
And herein lies the crux of the situation. Dr.
\\'orcester is not undertaking a strictly personal
work, confined by the four walls of his study; he
is at the head of a movement, the sponsor for a
doctrine which he proclaims from city to city, and
as he goes he invites others to take up the work.
Is it inherently any more probable that the priests
as a class will be any better able to take up the
work of the physicians than the electricians as a
class are able to do the work of the plumbers?
Perhaps Boston is suckling another child which,
though sweet and innocent looking now, may
EDITORIAL ARTICLES.
[New York
Medical Journal.
grow to be a terrible ogre, demanding its human
sacrifice through the length and breadth of the
land.
We regret that we already know of many at-
tempts which are being made by clergymen, in dif-
ferent parts of this country, men who are no more
able to carry out the ideas of Dr. Worcester, much
less understand them, than a journeyman plumber
can work out the complicated mathematical calcu-
lations of an hydraulic problem. The intricacies of
the superior psychical mechanisms which consti-
tute the thought processes are not for the untrained
mind of the average clerg\man as we now know
him.
Whatever results may flow from this movement,
one of them, it is to be hoped, will be that of arous-
ing the medical profession to a fuller appreciation
of its opportunities and responsibilities. The class
of patients to whom the Emmanuel Church appeals
want help. They have tried in several quarters to
get it and failed. They have sought advice of
many physicians to little avail. These people will
go where help is offered. They had rather get it
from legitimate sources, but if not from them,
from such as can he obtained. Let the physician
see that he himself is equipped to "deliver the
goods." If he is not, he cannot complain if his
patient goes elsewhere.
It often takes such side stepping from the con-
ventional as this movement is to emphasize certain
situations by providing a new setting. The lesson
learned, the reason for the movement ceases, and
matters move on again in their old accustomed way.
For a time the credulous will be misled, but in the
end, let us hope, good will result. The way to this
result is, not by opposition — martyrdom is a stim-
ulus to growth, bad as well as good — but by taking
up the indicated task and by doing it well fulfilling
the highest functions of our calling.
THE AMERICAN TETANUS ANTI-
TOXINE UNIT.
The Standardization of Tetanus Antitoxine is the
title of a pamphlet, by Surgeon Milton J. Rosenau
and Passed Assistant Surgeon John F. Anderson,
of the United States Public Health and Marine
Hospital Service, recently issued by the bureau. Of
the four methods of measuring the strength of
tetanus antitoxine — the German, the French, the
Italian, and the American — the authors describe the
American as the most satisfactory and the simplest
of execution. Its application by legal authorization
insures identical antitoxic strength in the products
of the five American producing establishments, a
condition of prime importance in securing uniform-
ity of prophylactic and curative action. The pam-
phlet furnishes much interesting information con-
cerning many points connected with tetanus, but a
satisfactory abstract of it cannot well be given with-
in the space now at our command. It is a very
scholarly production, and we commend it to our
readers.
THE MILK SUPPLY OF NEW YORK.
The New York City Board of Health has recently
announced that hereafter only certain specified terms
will be allowed to be used in the local milk traffic,
and each term will have a definite meaning. Prac-
tically, three grades are recognized — certified, in-
spected, and ordinary milk. Instead of leaving the
definition of the first two terms entirely to the milk
commissions of the county medical societies, the
board has — wisely, we think — laid down a minimum
of requirements to be met. The use of- the term
"pasteurized" is also regulated by the board, and
this, it is to be hoped, will do away with a lot of
tradino; under false pretenses. It is notorious that
a great deal of "pasteurized" milk is merely milk
several days old heated to 150° F. for several sec-
onds to prevent it from souring. Such milk, how-
ever, has frequently been put forward by dealers as
something superior because "pasteurized."
The board has also legalized the sale of skimmed
milk, but under restrictions. It is generally recog-
nized that skimmed milk possesses considerable nu-
tritive value, and the only objection to its sale is the
ease with which deception can be practised, skimmed
milk being sold for whole milk or being mixed with
whole milk. BerHn recognizes whole milk, half
milk, and skimmed milk. It is hard to say just how
well this works, even in that city. Certainly the
general quality of the Berlin milk is far below that
of the milk sold in New York.
CHEYNE-STOKES RESPIRATION.
Since the time when Cheyne and Stokes described
the peculiar phenomenon which has since gone by
their combined names, from patients suffering with
fatty degeneration of the heart, much physiological
and pathological interest has been taken in this type
of breathing, and a gradual modification of the sig-
nificance to be attached to it has taken place. It is
now well known that Cheyne-Stokes respiration is
not necessarily a pathological type of breathing.
Not only do cold blooded animals show it regularly
as a physiological type, but there is present in many
mammals under certain normal conditions a type of
respiration which cannot be distinguished from the
Cheyne-Stokes respiration known to the clinician.
May 30, 1908.]
NEIVS ITEMS.
1049
This periodic type of breathing is seen in the winter
sleep of the marmot, the hedgehog, and the dor-
mouse, and in many mammals, when great diminu-
tion of nervous excitability takes place, typical
Cheyne- Stokes breathing supervenes. In young and
healthy sleeping infants a periodic type of breath-
ing of a similar order is frequently observed, and
even in many healthy adults Cheyne-Stokes respira-
tion is present in deep sleep. In all these conditions
a marked diminution in nervous excitability is nat-
urally present.
The changes in the activity of the respiratory cen-
tres have been ascribed to the composition of the
blood, and it is to a combination of these two condi-
tions that modern physiologists have attributed the
phenomenon. All the cases of Cheyne-Stokes re-
spiration, physiological as well as pathological, are
accompanied by a decrease in the excitability of the
nervous system. The phenomenon in pathological
cases is not characteristic of any particular disease,
and it is not necessarily a fatal omen ; it is a sign
of diminished nervous excitability, and is very fre-
quently associated with a defective supply of arterial
blood to the brain. The different phases of Cheyne-
Stokes respiration appear to arise in the following
manner: The carbon dioxide accumulates and the
oxygen diminishes until the depressed nerve cells
are stimulated ; the first respirations are shallow and
inefficient, and, owing to the delay necessary for the
renewal of the air in the lungs and the passage of
blood from the lungs to the brain, the carbon diox-
ide still increases and the oxygen decreases. Thus
arises the waxing respiration, which culminates in
deep dyspnoeic breathing; carbon dioxide is re-
moved in great quantities from the blood, and suffi-
cient oxygen is taken in ; the stimulation becomes
less and less and respiration wanes. Then follows
apnoea, due apparently to the absence of sufficient
carbon dioxide to excite the respiratory centre. On
account of the latency already mentioned, the most
arterial blood will reach the medulla at the end of
the breathing period, and at the same time the blood
pressure will have been raised by the pumping effect
of the deep respiration.
getos Items.
Changes of Address.— Dr. Matthias Lanckton Foster,
to 211 Centre Avenue, New Rochelle, N. Y. ; Dr. Edward
A. Schumann, to 348 South Fifteenth Street, Philadelphia;
Dr. Collier L. Bower, to the Dardinelle, Broad and Locust
Streets, Philadelphia.
The Philadelphia Medical Club will hold a reception
nt the Bellevue-Stratford Hotel on the evening of June
I2th. The guests of honor will be Dr. William L. Estes,
of South Bethlehem, Pa., president of the Medical .Society
of the State of Pennsylvania, and Dr. Albert M. Eaton, of
Philadelphia, president of the Philadelphia County Medical
Society.
Vacancies in the Medical Corps of the Navy.— There
are fifty-four vacancies in the grade of assistant surgeon in
the Navy and sixteen vacancies in the grade of acting as-
sistant surgeon. The board will meet on June 1st for
the examination of candidates.
A Chair in Phthisiotherapy at the Postgraduate.—
A chair in phthisiotherapy has been created at the New
York Postgraduate Medical School and Hospital, and Dr.
S. Adolphus Knopf, of New York, has been appointed pro-
fessor of phthisiotherapy to fill the chair.
Medical Society of Otsego County, N. Y. — The semi-
annual meeting of this society will be held in Cooperstown
on Tuesday, June 9th. The programme will include a
"symposium" on adenoids and throat tumors, and a general
discussion of hyoscine, morphine, and cactin in surgery.
The Lawrence, Mass., Medical Club held its regular
nionthiy meeting at the residence of Dr. Burnham on the
evening of May 25tli. The general subject for considera-
tion was scarlet fever, and after the usual half hour talk
on miscellaneous medical topics, the discussion was opened
by the chairman, Dr. Allen. At the close of the meeting
refreshments were served.
Appointments at Albany Medical College. — Dr. An-
drew McFarlane has been appointed professor of physical
diagnosis and medical jurisprudence at this college; Dr.
Arthur G. Root has been appointed professor of diseases
of throat and nose ; and Dr. Leo H. Neumann has been
appointed professor of gastroenteric diseases and clinical
professor of the theory and practice of medicine.
The Red Cross to be Taken from Ambulances. — The
Red Cross Society objects to the use of the red cross on
city ambulances, on the ground that the society has the
exclusive right to the use of the emblem, having copy-
righted it in all civilized countries. Consequently the red
cross will be removed from all the ambulances of the hos-
pitals, and a green symbol will be used in its place.
Richmond, Va., Academy of Medicine and Surgery. —
A regular meeting of this academy was held on Tuesday
evennig. May 26th. Dr. Edward McGuire read a paper
on Prolapse of the Ovary, and Dr. J. Shelton Horsley read
a paper entitled Technique of Operations on the Mouth
and Neck. Dr. Ramon D. Garcin opened the discussion
on Dr. McGuire's paper, and Dr. J. W. Henson opened the
discussion on Dr. Horsley's paper.
American Medical Editors' Association. — The pro-
gramme for the thirty-ninth annual meeting of this asso-
ciation, which is to be held at the Auditorium Hotel, Chi-
cago, May 30th and June ist, has just been received. It con-
tains twenty-two papers by well known medical editors, and
a list of subjects which will be announced for discussion if
time permits. The annual banquet of the society will be
held at the hotel on Monday evening, June 1st.
Personal. — Dr. John H. McCollum has been ap-
pointed professor of contagious diseases at the Har\ard
Medical School. Dr. McCollum was city physician for
Boston for many years and superintendent of the con-
tagious disease department of the Boston City Hospital.
Dr. J. C. Nicholls, of Braddock, Pa.; Dr. W. M. Jones,
of Omaha, Neb., and Dr. Robert B. Knight, of Couders-
port. Pa., are registered at the Philadelphia Polyclinic and
College for Graduates in Medicine.
Vacancies in the Army Medical Corps. — Examina-
tions were recently held in various parts of the country of
candidates for appointment as assistant surgeon to fill the
sixty-eight vacancies now existing in the corps. Seventy-
two candidates applied for the examination, sixteen failed
to appear, eighteen were found to be physically unfit, and
the papers of the remaining thirty-eight applicants are now
being examined. Examinations will be held again in Octo-
ber to fill such vacancies as may then exist.
Philadelphia County Medical Society.— The Central
Branch of this society held a meeting on the evening of
Wednesday, May 27th. Mrs. L B. Oakley presented a
shorty communication on the plan of establishing "zones of
quiet" in the neighborhood of hospitals, and among those
who took part in the discussion of the subject was Miss
Maud Banfield, superintendent of the Polyclinic Hospital,
and Dr. W. M. L. Cnplin, medical director of Jefferson
Hospital. Dr. W. N. Bradley read a paper on Diphtheria
Quarantine, raid Dr. James W. Walk read a paper on'
Avoidable Mistakes in Medical Testimony.
I050
NEWS ITEMS.
[New York
Medical Journal.
A Department of Mechanicotherapeutics at Vander-
bilt Clinic. — As a memorial to her late husband, Airs.
Ray Matshak has given the money necessary to equip a
department for surgical mechanicotherapeutics at the Van-
derbilt Clinic of the College of Physicians and Surgeons.
Columbia will be the first university in the United States
to have such an equipment. Dr. Charles H. Jaeger, in-
structor in orthopredic surgery at Columbia University, will
have charge of the department.
Officers of the American Neurological Association. —
At the annual meeting of this association, which was held
in Philadelphia on May 21st, 22d, and 23d, the following
oiifiicers were elected : President, Dr. S. Weir Mitchell, of
Philadelphia ; first vice president, Dr. Pierce Bailey, of
New York ;- second vice president. Dr. F. W. Langdon, of
Cincinnati ; secretary and treasurer, Dr. Graeme Hammond,
of New York ; councilors. Dr. H. W. Thomas and Dr.
Charles W. Burr, of Philadelphia.
Alumni Association of Jefferson Medical College. —
The annual meeting of this association will be held in the
college building at 12 o'clock on June 6th, and the annual
banquet will be given in the ballroom of the Bellevue-
Stratford Hotel in the evening, of the same day. The
balcony of the banquet room has been reserved for ladies.
A grand rally of graduates of the college will be held in
Chicago during the meeting of the American Medical As-
sociation on the evening of June 2d at the new Chicago
Automobile Club.
Samaritan Hospital, Philadelphia, Medical Society. —
At a meeting of this society, which will be held on Satur-
day evening. May ^oth. at 9 p. m., the programme will
include the following papers : Ocular Signs of To.xxmia in
Diabetes, by Dr. Wendell Reber; The Theory and Applica-
tion of Bier's Hyperjemic Treatment, by Dr. William A.
Steel ; A Study in Anaesthetics, and a Demonstration of
the Surgical Pathology of the Gallbladder, by Dr. W.
Wayne Babcock ; Benign Strictures of the Rectum, by Dr.
C. Howard Pratt ; Report of the Work of the Genito-
urinary Department of the Hospital, by Dr. H. G. Fretz ;
Report of a Year's Work by the Surgical Staff, by Dr.
John Leedon.
Vital Statistics of New 'York. — During the week end-
ing May 16, 1908. there were reported to the Department
of Health 1,465 deaths from all causes, as compared with
1. 471 for the corresponding period in 1907. Of the total
number of deaths 762 were in Manhattan, 134 in the
Bronx, 475 in Brooklyn, 66 in Queens, and 28 in Rich-
mond. The annual death rate in 1,000 of population was
17.28 for the whole city, 17.62 for Manhattan, 19.47 for
the Bronx, 18.12 for Brooklyn, 16.77 for Queens, and 19.37
for Richmond. The total infant mortality for the week
was 384; under one year of age. 300: between one and two
years of age, 84. There were 143 still births. There were
406 marriages recorded during the week and 2,287 births.
Scientific Society Meetings in Philadelphia for the
Week Ending June 6, 1908:
MoND.w, June 1st. — Philadelphia Academy of Surgery;
Biological and Microscopical Section, Academy of Nat-
ural Sciences ; West Philadelphia Medical Association ;
Northwestern Medical Society.
Wednesd.w, .Tune 3d. — College of Physicians; Association
of Clinical Assistants, Wills Hospital.
Thursday, June ^ih. — Obstetrical Society ; Section Meeting,
Franklin Institute ; Germantown Branch, Philadelphia
County Medical Society.
Friday, June 5th. — Kensington Branch, Philadelphia Coun-
ty Medical Society.
New York Academy of Medicine. — At a stated meet-
ing of the academy, which was held on Thursday evening.
May 2ist. the following papers were read: The Hospital
and the Professional Anjesthetist, by Dr. .\. T. Bristow ;
General An.Tsthesia on the Basis of the Principle of Adapt-
ing the Boiling Point of the .Anaesthetic to the Tempera-
ture of the Body, by Dr. Willy Meyer; The .A.n,-Bsthetic
at the Hospital for the Ruptured and Crippled, by Dr.
Virgil P. Gibney; Anaesthesia at St. Luke's, by Dr. Robert
Abbe ; The Scope of Local Ansesthesia in General Surgery,
by Dr. J. A. Bodine ; The Administration of .An.-esthetics
at Mt. Sinai Hospital, by Dr. Howard Lilienthal : Rectal
Anaesthesia at Roosevelt Hospital, by Dr. J. A. Blake and
Dr. George E. Brewer; Anaesthesia at the Harlem Hos-
pital, by Dr. William H. Luckett ; Anaesthesia at Bellevue
Hospital, by Dr. George Woolsey; Nitrous Oxide and
Oxygen as an Anaesthetic Agent, with Notes on the Value
of Warming the Vapors of Ether and Chloroform, by Dr.
James T. Gwathmey.
The Mortality of Chicago.— According to the weekly
report of the Department of Health, during the week end-
ing ilay 16, 1908, there were reported to the department
635 deaths from all causes, as compared with 531 for the
preceding' week, and 707 for the corresponding period in
1907. The annual death rate, in an estimated population
of 2.166,055, \\'as 15.29 in 1,000 of population. The prin-
cipal causes of death were: Apoplexy, 23; Bright's dis-
ease, 42; bronchitis, 18; consumption, 63; cancer, 42; con-
vulsions, 8; diphtheria, 3; heart diseases, 57; influenza, 5;
intestinal diseases, acute, 35 ; measles, 5 ; nervous diseases,
19; pneumonia, 74; scarlet fever, 10; smallpox, o; suicide.
8; typhoid fever, 11; violence (other than suicide), 46;
whooping cough, 8; all other causes, 158.
Secretaries of Sections of the Fifth Pan-American
Medical Congress. — Secretaries for the United States
of the various sections of this congress, which is to be held
in Guatemala City, Guatemala, on August 5th to loth, in-
clusive, have been appointed as follows : General Medicine,
Dr. Judson Daland, of Philadelphia; General Surgery, Dr.
Emmett Rixford, of San Francisco ; Hygiene, Demography,
and Epidemiology, Dr. T. Darlington, of New York;
Nervous and Mental Diseases, Dr. Charles Hughes, of St.
Louis, Mo. ; Tropical Medicine, Dr. John M. Swan,, of Phil-
adelphia ; Military Sanitation, Dr. L. L. Seaman, of New
York; Ophthalmology, Dr. Bert Ellis, of Los Angeles,
Cal. ; Nose, Throat, and Ear, Dr. W. S. Bryant, of New
York; Pathologj- and Bacteriology, Dr. Walter Chase, of
Boston; Gynjecology, Abdominal Surgery, and Obstetrics,
Dr. H. P. Newman, of Chicago ; Children's Diseases, Dr.
C. G. Kerley, of New York.
Infectious Diseases in New York:
We are indebted to the Bureau of Records of the De
partment of Health for the following statement of nezi'
cases and deaths reported for the two weeks ending May
-'?. 1908:
, May 16. V , May 23. v
Cases. Deaths. Cases. Deaths.
Tuberculosis pulmonalis 403 158 420 201
Diphtheria 409 36 397 37
Measles 1,513 35 1,555 33
Scarlet fever 1,173 41 i,o53 4°
.Smallpox I
Varicella 134 .. 144
Typhoid fever 25 6 32 4
Whooping cough 37 4 24 4
Cerebrospinal meningitis 13 11 12 9
Totals 3.708 291 3.637 328
The Harvey Society. — At the annual meeting of this
society, which was held on Friday evening. May 15th, the
following officers were elected : President, Dr. James
Ewing; vice president. Dr. Simon Flexner; treasurer, Dr.
Edward K. Dunham ; secretary, Dr. F. C. Wood ; council.
Dr. Graham Lusk, Dr. S. J. Meltzer, and Dr. Adolph
Meyer. The following resolution was adopted by the so-
ciety :
Resolved, That, in the desire of Dr. Graham Lusk not to under-
take again the duties of president of the Harvey Society, its mem-
bers express to him their cordial appreciation of the great value of
his services to the medical scienors in ihis country in founding the
society, in successfully adniinivK-riiv.; its affairs during its early
growth, and in placing it upon a substantial basis. The place now
occupied by it abundantly demonstrates the wisdom of Dr, Lusk in
organizing a medium of communication between the laboratory
and the medical practitioners; and whatever the society shall ac-
complish in the future will be due in no small part to the worthy
example which he has set.
International Congress on Tuberculosis. — President
Roosevelt has accepted the presidency of the International
Congress on Tuberculosis, which is to be held in Washing-
ton, September 21st to October 12th. Dr. Edward L.
Trudeau, of Saranac, N. Y., has been elected honorary
president of the congress, and among those who have
agreed to serve in the capacity of vice presidents arc
Vice President Fairbanks. Speaker Cannon, and the Gov-
ernors of the States of California. Colorado. Connecticut,
Illinois, Indiana. Iowa, Kansas, Kentucky, Maine. Mary-
land, Michigan, Minnesota. Mississippi, Missouri, New
Hampshire, New Jersey, New York, North Carolina, North
Dakota, Ohio, Oregon. Pennsylvania, South Carolina, Ten-
nes.see, Vermont. Virginia, and West Virginia, The Ger-
man committee of arrangements for the congress has a
membership of over one hundred and fifty, and the names
of some of the highest dignitaries in the Empire appear
May 30, 1908.]
NEWS ITEMS.
105 1
on the list which has been forwarded to the Secretarj-
General. A committee of sixty-four members has been
appointed to arrange for the part Belgium will take in the
congress.
The Medical Inspectors of the Department of Health
of the State of Pennsylvania met in Philadelphia on Mon-
day and Tuesday, May iith and 12th. for the purpose of re-
ceiving instruction in their duties and for illustrative talks on
the affairs with which they are in daily contact. There was a
meeting at the Academy of Natural Sciences, at which
Dr. Samuel G. Dixon, the Commissioner of Health, ad-
dressed the inspectors. Clinics were held at the ^Medical
Department of the Universitj' of Pennsylvania, the Phila-
delphia General Hospital, the Medicochirurgical College,
and the Jefferson Medical College, and a visit was made
to the gardens of the Zoological Society of Philadelphia,
where Dr. Herbert Fox described some experiments on
the treatment of tuberculosis in monkeys. The inspectors
also visited the new Municipal Hospital of Philadelphia.
The Health of Philadelphia. — During the week end-
ing May 9, 1908, the following cases of transmissible dis-
eases were reported to the Bureau of Health: Typhoid
fever, 62 cases, 10 deaths; scarlet fever, 45 cases, 3 deaths;
chickenpox, 36 cases, o deaths ; diphtheria, 68 cases, 5
deaths ; measles, 564 cases, 14 deaths ; whooping cough, 24
cases, 6 deaths ; pulmonarv- tuberculosis, 135 cases, 71
deaths ; pneumonia. 49 cases, 59 deaths ; erysipelas, 9 cases,
I death ; puerperal fever, 2 cases, i death ; mumps, 23 cases,
0 deaths ; cancer. 19 cases. 23 deaths : hydrophobia, i case,
1 death. The following deaths were reported from other
transmissible diseases : Tuberculosis, other than tuberculosis
of the lungs, 7 cases : diarrhoea and enteritis, under two
years of age. 9 cases ; dysentery, 3 cases ; malarial fever, i
case. The total deaths for the week numbered 451, in an
estimated population of 1,532.738, corresponding to an an-
nual death rate of 15.30 in 1,000 of population. The total
infant mortality was 103 ; under one year of age, 75 ; be-
tween one and two years of age, 28. There was 36 still
births. 19 males and 17 females.
Society Meetings for the Coming Week:
MoxDAY, June 'ist. — German Medical Society of the City
of Xew York: Utica, X. Y., Medical Librarj- Associa-
tion ; Niagara Falls. N. Y., Academy of Medicine ;
Practitioners* Club. Newark, N. J. ; Hartford, Conn.,
Medical Society.
TuESD.w, June 2d. — New York Academy of Medicine
(Section in Dermatology-); New York Neurological
Society ; Buffalo Academy of ^Medicine ( Section in
Surgery) ; Ogdensburgh, N. Y.. Medical Association :
Syracuse, N. Y., Academj' of Medicine ; Hudson
County. N. 'J., Medical Association (Jersey City) ;
Hornellsville, N. Y.. Medical and Surgical Association ;
Bridgeport, Conn.. Medical Association.
Wednesday, June 3d. — Society of Alumni of Bellevue Hos-
pital, New York: Harlem Medical Association. New
York; Elmira. N. Y., Academy of Medicine.
Thursday. June 4th. — Xew York Academy of Medicine ;
Dansville, N. Y., Medical Association.
Friday, June 5th. — New York Academy of Medicine (Sec-
tion in Surgery): New York Microscopical Society;
Gynsecological Society, Brooklyn, N. Y. ; Manhattan
Clinical Society. New York.
The Annual Report of the Bureau of Health of the
Philippine Islands. — The annual report of the Bureau of
Health of the Philippine Islands for the fiscal year ending
June 30. 1907. has just been received at this office. We find
that the following deaths occurred in ^lanila from various
transmissible diseases : Typhoid fever, 66 cases : relapsing
fever, 2 cases : intermittent fever and malarial cachexia. 191
cases : smallpox, i case : whooping cough, 2 cases ; diph-
theria and croup, 9 cases: influenza. 27 cases: Asiatic
cholera, 625 cases: dysentery, 356 cases: leprosy. 61 cases;
erysipelas, 2 cases : beriberi. 423 cases : purulent infection
and septicemia. 43 cases : malignant pustule, 2 cases : rabies.
I case: pulmonary tuberculosis, 1,187 cases: other forms of
tuberculosis. 157 cases ; syphilis. 10 cases : cancer, 57 cases ;
acute articular rheumatism. 10 cases; chronic rheumatism
and gout. 34 cases ; scurvj'. 7 cases ; diabetes. 4 cases ; ex-
ophthalmic goitre. 2 cases : Addison's disease, i case : leu-
cjemia. t case ; chlorosis. 16 cases ; tetanus. 97 cases : acute
endocarditis, 19 cases ; bronchopneumonia. 37 cases ; pneu-
monia, 33 cases : diarrhcea and enteritis, under two years of
age, 496 cases ; diarrhcea and enteritis, over two years of
age, 368 cases ; puerperal septicjemia, 47 cases. The popu-
lation of the citj- of Manila was 223.542; there were 8,251
deaths reported, corresponding to an annual death rate of
36.91 in 1,000 of population. Seven thousand one hundred
and thirty-six births were reported, an annual average of
31.92 births in i.ooo of population.
Medical Internes for the Government Hospital for the
Insane. — The United States Civil Service Commission
announces that an examination will be held on June 17th
to secure eligibles from which to make certification to till
two, and' possibly three, vacancies in the position of medi-
cal interne (male), and one vacancy in the position of
medical interne (female), at S600 per annum each, with
maintenance, in the Government Hospital for the Insane.
Washington, D. C, and vacancies requiring similar qualifi-
cations as they may occur. Right is reserved to terminate
the appointments at the end of one year's service, if it is
deemed advisable to do so. The examination is for both
men and women, and the age limit is twenty years or over
on the date of the exa.nination. Applicants must be citi-
zens of the United States, must be unmarried, and must
be graduates of a reputable medical college. Applicants
should apply at once to the United States Civil Service
Commission, Washington. D. C. for application form
1312, or for any further information regarding the exami-
nation.
Chicago Meeting of the American Medical Associa-
tion.— Elaborate preparations have been made for the
fifty-ninth annual session of the American Medical Asso-
ciation, which is to be held in Chicago on June 2d to 5th.
The first general meeting of the association will be con-
vened at the Auditorium at 10:30 a. m. Tuesday, bj" the
president. Dr. Joseph D. Bryant, of New York. The an-
nual address of the president and the formal address of
welcome will be delivered on this occasion. The second
general meeting will be devoted to the oration in medi-
cine, by Dr. William S. Thayer, of Baltimore, and tlie
oration in surgerj-, by Dr. George W. Crile, of Cleveland,
and will be held at Orchestra Hall, 165 Michigan Avenue,
on Tuesday evening, at 7 :30 o'clock. On Wednesday even-
ing, at 7 :30, the third general meeting will be held at the
same place, when Dr. Charles Harrington, of Boston, will
deliver the oration in State medicine. The registration
department will be on the main floor of the First Regiment
Armor>', ^lichigan Avenue and Sixteenth Street. Members
and visitors will be expected to register here, as no one
wnll be admitted to the entertainments unless provided
w^ith a badge. A bureau of information will be maintained
at the same place, where full details can be obtained re-
garding the meeting places of the various sections and of
the several societies which meet in Chicago during the
v.eek. An elaborate programme of entertainments has
been prepared, and special clinics will be held in all the
leading hospitals, to which members of the association are
invited.
Queens-Nassau Medical Society. — The annual meeting
of this society was held in Jamaica. Long Island, on the
evening of Saturday, May 23d. It was one of the most suc-
cessful meetings ever held by the society. There were
about eighty members in attendance, and the papers, which
were all of a high order, were listened to with much inter-
est. Dr. T. D. Crothers. of Hartford, Conn., read a paper
entitled Home and Office Treatment of Spirit and Drug
Takers, after which a "sj^mposium" on midwifery was
presented as follows : The Conduct of Normal Labor, by
Dr. Charles Jewett. of Brooklyn : Eclampsia, by Dr. J.
Clifton Edgar, of ^Manhattan ; The Action of Forceps, by
Dr. James D. Trask, of Highlands. N. J. ; Version — When
Shall We Prefer it to Forceps ? by Dr. W. G. Frey. of
Long Island City : The Art of Pelvimetry, by Dr. Sidney
D. Jacobson. of ^lanhattan ; Caisarean Section, by Dr. John
O. Polak, of Brooklyn: Post Partum Plastic Repair, by
Dr. Grant Baldwin, of Brookh-n : Morbidity and ^lortality
as Sequlae of Labor, by Dr. Walter B. Chase, of Brookljai.
A committee w-as appointed to consider the matter of sep-
arate societies for the two counties. Officers to serve for
the year commencing January- i, 1909. were elected as fol-
lows : President, Dr. C. M. Niesley, of Manhasset : vice
president, Dr. P. ^I. Wood, of Jamaica ; secretary- and
treasurer. Dr. James S. Cooley. of Glen Cove; historian,
Dr. Walter Lindsay, of Huntington : board of censors.
Dr. ■\\". G. Frey. of Long Island City ; Dr. A. J. Blanchard,
of Jamaica: Dr. A. W. Jagger. of Flushing: Dr. F. T.
De Cano, of Rockville Centre: and Dr. Guy F. Cleghom.
of Mineola.
I052
FITH OF CURRENT LITERATURE.
[New York
Medical Journal.
|itt flf Ctimnt f iUratm.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
. May 21, 1908.
1. Socia' Legislation in Germany and Its Relation to the
Practice of Medicine, By Friedrich Muller.
2. Certain Common Disorders Frequently Misinterpreted,
By George L. Walton.
3. Medical Notes on Northern Alaska,
By S. P. Howe.
4. Varicose Veins of the Papilla of the Kidney. A Cause
for Persistent Haematuria,
By William F. Whitney.
3. Medical Notes on Northern Alaska. — Howe
lias spent a year on the north coast of Alaska. He
makes some interesting notes : The Eskimo race in
Alaska has greatly diminished in numbers in the
past twenty years, in a large part because of dis-
ease inevitably introduced by the whites. Whether
the race will acquire sufficient immunity to with-
stand this sort of thing time alone wiU tell. He
thinks the outlook for the Eskimo in his natural
condition is better than that of the North American
Indian, because the Eskimo is industrially valuable
to the whites in the extreme north. The Eskimo,
while useless for steady day labor, is docile and
satisfactory as a hunter and trapper. He makes a
good sailor on a whale ship, and is practically neces-
sary to the men engaged in floe whaling. Tubercu-
losis is the great plague of the country. It was
present, so he was told, when white men first came
into the country. In summer the patients with pul-
monary disease improve markedly while living out
of doors, only to relapse again in winter. Venereal
disease is less common now than formerly, as the
natives come in somewhat less contact with the
crews of the whale ships. Very soon after the set-
tlement of Nome an epidemic of measles swept up
the coast with frightful mortality. Many who re-
covered fell victims to pneumonia and phthisis.
This epidemic carried off nearly half the inhabi-
tants of some of the villages. A disease, similar to,
if not identical with, influenza, is endemic at Point
Barrow. Formerly, at the time of childbirth, a
woman retired to a separate house or tent to have
her child. No one entered the house or offered any
assistance. Now, frequently, other women are pres-
ent, and, if there is any trouble, the help of a white
man is welcomed. When twins are born, if it seems
feasible, both are raised, if not, one is exposed to
die. The natives are sorry to do it, but take it calm-
ly as a matter of course. A woman nurses her child
as long as she is able, or till another child is born.
This is rather necessary, as native food is not very
satisfactory for weaning a young child. It is not
an uncommon thing to see children three and four
years old nursing. A large infant mortality, due to
improper feeding, makes large families the excep-
tion. A child is allowed to eat anything its parents
■do. Abortion is occasionally practised, by means of
violent abdominal massage, but is not common, as,
generally speaking, children are desirable assets.
The staple food of the coast Eskimo is seal meat,
summer and winter, though whale, deer, bear, fish,
and ducks arc important in their seasons. Though
the primitive Eskimo diet was almost entirely ani-
mal, at present most reasonably prosperous natives
get considerable tea, flour, sugar, and tobacco. In
fact, the children suft'er considerably if deprived of
flour and sugar now.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
May 25, 1908.
1. The Prevalence of Cancer in the Philippine Islands,
By F. W. Dudley.
2. The Cause of Milksickness or Trembles,
By Edwin O. Jordan and N. M. Harris.
3. Surgery of the Prostate. A Plea for Early Prostatec-
tomy in Hypertrophy of the Prostate,
By Miles F. Porter.
4. Hypertrophy of the Synovial Fringes of the Knee
Joint, By Edville Gerhardt Abbott.
5. Hip Joint Tuberculosis : Its Earlier Symptoms and
Treatment, By Willam Thompson Berry.
6. Serum Treatment of Gonorrhcea, with Report of Cases,
By Robert H. Herbst.
7. Spinal Sprain : Its Complications and Consequences,
with Report of Cases, By Prescott Le Breton.
8. Are There Valid Objections to the Quinine Prophy-
laxis of Malaria? By E. R. Stitt.
9. Psychic Treatment of Spirit and Drug Neuroses,
By T. D. Crothers.
10. Pathological Results of Operations on the Turbinates,
By Francis R. Packard.
1. The Prevalence of Cancer in the Philippine
Islands. — Dudley concludes from his observa-
tions that cancer is not confined to temperate cli-
mates. It is believed that cancer exists in the Phil-
ippine Islands to a greater extent than in the United
States. The measures now being taken in other
more enlightened countries to warn the people of the
necessity of early diagnosis, and early radical sur-
gical treatment in this disease, should be adopted in
the Philippine Islands, where it is of sufficient im-
portance to warrant an effort being made to obtain
better statistics in the future.
2. The Cause of Milksickness or Trembles. —
Jordan and Harris describe a peculiar disease, now
all but forgotten both by physicians and the general
public, which prevailed extensively in certain sec-
tions of the United States during the years of
pioneer settlement. This disorder was known under
a great variety of names, but was most commonly
referred to as milksickness, from its apparent con-
nection with the use of milk and milk products. A
singular feature of the disease was its geographic
limitation, the States of Ohio, Indiana, Illinois, Ken-
tucky, and Tennessee covering the area chiefly af-
fected. The medical journals of the western States,
in the period of from 1840 to i860, contain numer-
ous articles on the disease, but coincident with the
clearing and cultivation of the land milksickness has
tended to disappear, and except for its sporadic ap-
pearance in certain localities, has become practically
extinct in those States in which it was once a bar-
rier to settlement. Cases, however, have occurred
in Illinois as recently as 1904, and six deaths were
reported from this cause in Macon County, Ten-
nessee, in April and May, 1907. The chief symp-
toms of the disease are usually persistent nausea
and vomiting, which led to the use of the name "sick
stomach" in some localities. Obstinate constipation
is an almost invariable accompaniment of the mal-
ady. A peculiar odor of the breath, usually de-
scribed as "sweetish," is commonly noted and is
regarded as highly characteristic by those having
May 30, 1908.1
PITH OF CURRENT LITERATURE.
most experience with the disease. Muscular weak-
ness, abdominal pain, and other symptoms are more
or less frequently reported. In the more severe
cases great prostration occurs. As a rule, little or
no fever is present, and the temperature is said
sometimes to be subnormal. The authors discovered,
in November, 1907, a new form of milksickness in
the valley of the Pecos river, New Mexico; the
death of cattle was generally attributed to alkali
poisoning. The authors have made many observa-
tions and autopsies on cattle and received from local
physicians the reports of thirty-eight cases in man.
They found a bacillus in cattle which they desig-
nated Bacillus lactimorhi. It is a little smaller than
the anthrax bacillus, larger and more slender than
the colon bacillus, and stains unevenly with methy-
lene blue ; spore formation was seen, which was sim-
ilar to the eflfect of the tetanus bacillus ; the organ-
ism is motile, is possessed of ten or fifteen flagella.
the flagellum measuring about five times the length
of the bacillus itself. Some conjectures have been
made as to aetiology, but nothing definite can be
said.
6. Serum Treatment in Gonorrhcea. — Herbst
thinks that the serum has absolutely no efi'ect on
acute gonorrhoeal infections, whether they exist in
the lower urinary tract or in any other part of the
body. Its value in subacute and chronic cases is
very doubtful, although he found a few isolated
cases in wh.ich the results were somewhat better than
seen with local treatment, but its value in the treat-
ment of chronic gonorrhceal joints is without ques-
tion. In the past, these painful joints accompanying
and following gonorrhcea have been most resistant
to treatment, both local and general, and he thinks
that we now have a remedy which will give rapid
and permanent relief. The antigonococcus sera
used by Herbst were made according to the method
described by Rogers and Torrey. Cultures are
grown for from eighteen to twenty-four hours on
large slants of ascitic agar. Culture tubes average
one inch in diameter. It is essential to obtain a
luxuriant growth. This is best accomplished by
planting from an eighteen to twenty-four hour stock
culture to medium of the following composition :
Meat peptone 2 per cent, agar is prepared in the
usual way and triturated 1.5 per cent, acid to phe-
nolphthalein. One part of rich sterile ascetic fluid
is then added to two parts of the agar. The full
grown uncastrated male sheep (the ram) only is
used. In immunizing these animals it has been
found advantageous to pursue the following plan :
The first inoculation may consist of the twenty-four
hour surface growth, from eighteen square inches of
solid culture medium, emulsified in about 30 c.c. of
normal saline solution and heated for about one half
hour at 65° C. In immunizing rabbits and goats, a
potent serum was obtained, but it was found that the
serum itself is decidedly toxic for some individuals
and produced rather alarming reactions ; hence, only
rams are used. The immunization of the ram re-
quires ten weeks, one injection being given weekly.
The animal is bled to death from the carotid and
the serum collected, filtered, and tested for sterility.
The serum is polyvalent. The method of adminis-
tration is by subcutaneous injection, the skin being
prepared as for other subcutaneous injections. The
abdominal wall was used in all his cases, because the
reaction which follows almost every injection is
better tolerated in this part of the body. The amount
given at each injection varied from 2 to 6 c.c. The
injections were given from forty-eight hours to
seven days apart, depending on the severity of the
reaction. A reaction followed almost every injec-
tion, appearing sometimes in the form of a slight
urticaria at the site of the injection, at other times
in a more severe form accompanied by a dermatitis,
enlargement of the inguinal glands, rising of tem-
perature from one to two degrees, and an increase
in the pulse rate. Most of these symptoms disap-
peared in from twenty-four to forty-eight hours. In
one case, however, the urticaria and dermatitis ex-
tended over the entire body, with a high temperature
and rapid pulse, and continued for nearly five days.
The absorption of the serum was rapid ; the tumor
which followed the injection disappeared in about
fifteen minutes.
7. Spinal Sprain. — Le Breton remarks that rest
in bed, with counterirritation to the spine, is eflfectual
in the severe types of sprain. A plaster jacket for
several weeks is the most comfortable and rigid
splint, to be followed by a removable leather or cel-
luloid jacket. It is most strongly indicated where
there is spasm, but also is often indicated where
there is only pain on motion, or in cases where there
is no pain but where cord symptoms are developing.
In neurotic cases a light temporary support acts
favorably. There is not the same danger of pro-
longed stiflfness following, such as may result from
fixation of a sprained ankle. Massage, exercises,
and avoidance of lifting, bending, and riding in cars
are in order later on. The support is left ofif at
night, and a small pillow is placed under the small
of the back to fix the lumbar cur\-e. For spasm of
the neck muscles, head traction in bed, followed by
a jacket with a head support, brings prompt results.
The injur}- that originates a true sprain of the spine
is more often indirect than direct. In seventeen of
his twenty-six cases the cause was a fall on the but-
tocks, a fall on the feet, prolonged lifting, or a vio-
lent wrench of the body, causing sudden flexion of
the spine. In nine of the cases the cause was direct
violence to the back itself. The site of trouble is
more often at the lumbodorsal region than at that
other movable section, the lower part of the neck.
In nineteen of the cases the lumbar portion of the
spine was affected, and in seven the lower cervical.
Brush, in a collection of forty-three cases, found the
condition located in the lumbar region in thirty-eight
of them. The outlook for recovery is much better
if the diagnosis is prompt and treatment is instituted
early. When fixation by jacket is indicated by great
pain or spasm, it is most unwise to defer it. Brush
states that in fourteen cases in which the diagnosis
was made at once and proper treatment begun, there
were eight full recoveries. \\'hereas in twenty-nine
cases with delayed diagnosis and treatment, there
were but two recoveries. In general, it is much
better to settle an impending suit rather than to wait
for trial, but settlement should be deferred until one
can feel sure about the future condition of the
patient.
!io54
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
MEDICAL RECORD.
May 23, 1908.
■I. A Clinical Study of a Case of Brain Tumor; Opera-
tion; Complete Recovery, By William W. Graves.
2. Pneumothorax and Posture ; the Importance of the
Abdominal Posture in Operations on the Pleura and
Lungs, ' By Charles A. Elsberg.
3. A Report of Thirty-one Cases of Congenital Disloca-
tion of the riip Joint Reduced by Manipulation,
By Edville Gerhardt Abbott.
4. Sources of Error in Gastric Diagnosis,
By Charles Sumner Fischer.
5. Prevention and Treatment of Cystitis,
By Paul Pilcher.
1. A Clinical Study of a Case of Brain Tumor.
— Graves observes that brain tumor is usually local-
izable ; therefore, an early and localizing diagnosis
is always desirable if complete restoration is to be
hoped for. If palliation alone is to be expected,
precise localization is not absolutely necessary
though always desirable. It may be stated, how-
ever, that tumor of the brain giving rise to symp-
toms indicating palliation will usually present un-
mistakable localizing symptoms. The presence of
brain tumor, its location, its probable nature, and
the surgical indications, whether extirpation or
mere palliation, are problems the surgeon has a
right to expect — the neurologist to attempt to solve.
On the other hand, the neurologist expects, and the
interest of the patient requires, the surgeon to be
possessed of a degree of technical skill commensur-
ate with the difficulties constantly met with in this
field of work. The ideal would be a surgeon who
is at the same time a neurologist. The difficulties
encountered in surgery of the nervous system are
so great that it is rapidly becoming, and justly so,
a special department of surgery. He who would do
this work should have had some special training — ■
not only special technical training, but also in the
physiology, anatomy, and pathology of the central
nervous system — in other words, he should have
given the whole subject his earnest consideration
before invading the brain or spinal cord with the
same degree of assurance that he would the ab-
dominal cavity. The surgeon and the neurologist
are indispensable to each other at the present time
in surgery of the nervous system. It is a field
wherein they should both work shoulder to shoulder,
and when it is tilled with earnestness and mutual
consideration, their joint labor can only have the
result of saving or prolonging many lives.
2. Pneumothorax and Posture. — Elsberg says
that the danger of the stidden entrance of air into
the normal pleural cavity has, more than anything
else, impeded the progress of the surgery of the
lung and of the other intrathoracic viscera. There
are other dangers, such as that of great susceptibil-
ity to infection, but the grave symptoms from acute
pneumothorax are those that have to be most con-
sidered. Much careful experimental and clinical
work has been done to overcome and guard against
the dangerous respiratory embarrassment which is
apt to ensue. He reports the experiments made by
others and by himself. His results were then ap-
plied on patients. All of these patients upon whom
operations were performed which required the open-
ing of the pleura, were operated upon lying flat on
the abdomen. Care was taken that the patients were
•deeply innler the an.-esthetic at the moment when
the pleura was opened. Operations on the lateral
or posterior aspects of the thorax could be done
with ease. The patient was laid flat on the belly
with the head turned to one side or supported be-
yond the end of the operating table so that the
ana;sthesia could be given without trouble. The po-
sition did not interfere with the operator or assist-
ants. In this posture he has operated upon a large
number of patients with empyema, upon two pa-
tients with abscess of the liver, upon three with sub-
phrenic abscess, and upon one with a bronchiectatic
cavity in the left lung. In all of the last named
patients the pleura had to be opened. The patients
in whom a normal pleura had to be opened showed
unusually few untoward symptoms when the open-
mg was made and air was allowed to enter the
pleural cavity. In the patients upon whom an opera-
tion for empyema was done, it was noted that with
only one exception the coughing and interference
with breathing, regularly observed when the open-
ing in the pleura is made for this affection, were en-
tirely absent. While these cases are too few to be
conclusive, remarks the author, they seem to demon-
strate that what is true for dogs is also true in this
respect for the human being, and that there are de-
cided advantages in operating upon these patients
in the abdominal posture. He believes that those
who try this simple procedure will soon appreciate
its manifest advantages. It is a very simple method
of safeguarding our patients a little more in our in-
trathoracic operations, and may be used in conjunc-
tion with other methods.
BRITISH MEDICAL JOURNAL.
May p, 1908.
1. The Diagnosis and Operative Treatment of Diseases
of the Stomach, By B. Dawson.
2. Gastroenterostomy and After,
By B. G. A. Moynihan.
3. Erythrocythsemia and Cyanosis,
By W. P. Herrixgham.
4. The Recognition and Training of Congenital Mental
Defectives, By W. A. Potts.
5. An Outbreak of Beriberi on Board a i\ierchant Vessel.
By S. Roach.
6. Treatment of Bronchial Catarrh by Alkalies,
By A. Haig.
7. The Influence of Pregnancy upon Certain Medical Dis-
eases and of Certain Medical Diseases upon Preg-
nancy (Goulstonian Lectures, II), By H. French.
I. Surgery of the Stomach. — Daw^son dis-
cusses the diagnosis and surgical treatment of vari-
ous affections of the stomach. In malignant disease
of the oesophagus gastrostomy may prolong life, but
will prolong misery also. Unless and until there is
some definite urgent symptom like thirst calling for
relief, the operation should be avoided. In most
cases the body is able to obtain enough water and
enough nourishment. The operative treatment of
cancer of the stomach comprises excision and
gastroenterostom}". Where the disease is discovered
early enough, the results of excision are promising.
Gastroenterostomy docs palliate suffering where
there is pyloric obstruction, but the immediate mor-
tality is not less than twenty-five per cent., and in
prolonging life the suffering is prolonged. Evai
where an exploratory operation has been done,
gastroenterostomy should be advised against unless
there is some (Icfinitc object to be gained. Rut
where the pylorus is obstructed by a hard, circum-
May 30, 1908.]
PITH OF CURRENT LITERATURE.
scribed growth, the advantage of providing an exit
for the food outweighs the risk. But even then
lavage often gives better results. Pain is often not
a prominent early feature of cancer ; in contrast to
this, absence of actual pain in gastric ulcer is almost
unknown, and if there is vomiting it follows this
pain. Stomach discomfort in an adult over thirty
who has previously had a good digestion, and with-
out obvious cause, calls for further investigation,
consisting of : ( i ) Inflation of the stomach with gas
to see if it is enlarged or prolapsed; (2) passage of
a tube eight hours after an ordinary meal to see if
the stomach is empty; (3) analysis of the gastric
contents after a test meal; and (4) microscopical
examination of the fasting stomach contents. Acute
perforation of a gastric ulcer calls for immediate
operation. The operative treatment of subacute and
chronic ulcer resolves itself into a study of the bene-
fits to be expected from gastroenterostomy. These
benefits are: (a) Diminished acidity when the stom-
ach is quiet in the intervals of digestion; (b) the
evils of pyloric spasm are eliminated; (c) the intra-
gastric pressure is kept lower, and therefore the
movements and tension of the stomach wall are less.
The diagnosis of gastric ulcer is often made only
with the greatest difficulty. ^Nlany cases, previously
thought to be ulcer, are now recognised not to be
ulcer at all. Such cases fall into two main groups.
First, the cases of pain and vomiting after food,
occurring exclusively in anaemic young women.
The symptoms improve rapidly when the patients
are put to bed, and solid food and iron are tolerated
from the first. " Another group of cases is called by
the writer "haemorrhagic gastralgia. ' Here the
clinical symptoms are identical with those of ulcer.
As regards operation in cases of haematemesis, in
order to ligate the bleeding points, the writer puts
forward an emphatic negative. The operation is
necessarily severe, involving traction on the stomach,
and this at a time when the patient is exhausted by
loss of blood. There may be and often are multiple
points of haemorrhage, and to place sutures around
such points is almost futile. Finally, medical treat-
ment of haematemesis is successful, and the mortal-
ity is but little more than three per cent. In cases
of atonic or nonobstructive dilatation of the stomach,
gastroenterostomy is rarely necessary or desirable ;
failure of motor power is usually responsible for
nonsuccess. In a few cases where there is marked
gastroptosis, with almost kinking of the stomach,
gastroenterostomy might conceivably be of service.
But medical treatment is usually satisfactor\-. It
should consist of careful dieting to make the work
of the stomach as light as possible, of careful mas-
sage, of keeping the patient in as good condition as
possible, of drugs like strychnine, "and of periods of
rest on a bed or couch the foot of which is elevated.
2. Gastroenterostomy. — :\Ioynihan's conclu-
sions are as follows: i. Gastroenterostomv is a
short circuiting operations, and like all such proced-
ures, acts best when a gross mechanical obstruction
exists in the normal path of the intestinal contents.
2. Experiment shows that when the pylorus is nor-
mal, and there is no impediment to the passage of
food through it, the opening made in the operation
-of gastroenterostomy does not allow of the escape
of any of the gastric contents into the intestine. 3.
The operation therefore gives the best results in
cases where there is organic disease in the pre-
pyloric or pyloric regions of the stomach or duo-
denum, or when performed on the cardiac side of
a stenosis in the body of the stomach. 4. When an
ulcer is found on the lesser curvature toward the
cardia it should be excised if possible ; gastrotenter-
ostoniy is not necessary, and if performed is either
almost useless or entirely harmful. 5. When there
is a suspicion of malignancy in an ulcer or ulcers
in the pyloric region, Rodman's operation should be
performed. 6. Under no circumstances, and in
compliance with no persuasion, however insistent, is
gastroenterostomy to be done in the absence of
demonstrable organic disease. 7. Regurgitant vom-
iting, formerly the most troublesome of all compli-
cations, is dependent upon faults in the operation
which result in some mechanical obstruction to the
intestine. These faults are chiefly dependent upon
the presence of a '"loop" in the jejunum, but may
also be caused by a twist in the intestine around its
longitudinal axis at the time of its application to the
stomach. 8. The posterior no loop operation with
the vertical application of the bowel to the stomach
is the best procedure.
LANCET.
May g, 1908.
1. The Influence of Pregnancj- upon Certain Medical Dis
eases nnd of Certain Aledical Diseases upon Preg-
nancy (Goulstonian Lectures, II), By H. Frexch.
2. The School and Its Part in the Prevention of Tuber-
culosis, By J. Hay.
3. The Experimental Production of Gastric Ulceration
by Injection of Gastrotoxine, By C. Bolton.
4. Leprosy: Some Notes on Its Causation, Symptoms,
and Treatment, Based on an Experience of 152
Lepers in the Leper Jail of the United Provinces,
India, By T. Huxter.
5. Aortic Aneurysms; Sudden Deaths; The Capacity of
the Pericardium, By H. A. Smith.
6. The Precipitin Reaction in Hydatid Disease,
By D. A. Welsh and H. G. Ch.^pman.
7. The Operative Surgery of Labyrinthitis,
By C. E. West and S. Scon.
8. The Nursing Difficulty in France, By J. Dardel.
I. Pregnancy in its Relation to Diseases. —
French, in the second of his Goulstonian lectures,
considers the influence of suppurative calculous
and tuberculous affections of the kidney on preg-
nancy. He reports one case in which the sequence
of events was renal calculi, hydronephroses, preg-
nancy, microbial infection of the kidneys, pyo-
nephroses, suppurative pyelonephritis, cystitis, urae-
mia, and death. Tuberculosis of the kidney and
pregnancy are practically never associated. As
regards nonsuppurative renal affections, it is clear
that pregnancy will have a deleterious effect upon
the kidneys of women suffering from nephritis,
and that such women should not marn,-. There
are two groups of cases in which the renal dis-
ease is directly attributable to pregnancy, those
in which renal oedema is developed in the middle
months and those terminating with eclampsia. In
most cases albumin and tube casts disappear from
the urine soon after the pregnancy has terminated.
The writer ranges himself with those authorities
who regard these kidney changes in pregnancy as
essentially similar in kind to those which may occur
1056
FITH OF CURRENT LITERATURE.
[New York
Medical Journal.
in scarlet fever, and holds that there is no intrinsic
difference, but only one of degree and acuteness,
between the renal changes in eclampsia cases, and
those in cases where renal oedema is a prominent
symptom less late in the pregnancy. Albuminuric
retinitis is more common in pregnancy kidney cases
than in other forms of nephritis. The deleterious
effect of twin pregnancy upon the kidneys is more
marked in the eclampsia cases than in those of gen-
eral oedema without eclampsia. All statistics show
a high mortality amongst the children of nephritic
mothers. The treatment of an eclamptic case lies
mainly with the obstetrician. The nephritis of the
earlier months, however, calls for obstetric meas-
ures in but few cases. Rest in bed, with suitable
medication and diet, ameliorates the renal symptoms
in many cases. Pregnancy seems to be one of the
causes of tetany, differing in no essential way from
adult tetany due to other causes. The affection de-
velops during the later months of pregnancy, as a
rule, but the spasms are rarely met with during
labor. They may occur for the first time during
lactation. Pregnancy does not predispose to a
primary attack of appendicitis, but may light up
another attack in a person who has previously suf-
fered from the disease. This last it probably does
by stretching or breaking down old inflammatory
adhesions as the uterus enlarges and rises out of the
pelvis. It is not at present possible to state whether
the coexistence of pregnancy makes an attack of
appendicitis more severe than the average. Yet
pregnancy does increase the risks and dangers ; even
after drainage of the abscess a septic salpingitis or
endometritis may be set up. The foetus is born dead
in ninety per cent, of the cases. On the whole,
operative measures should be accelerated rather
than postponed in cases of appendicitis complicated
by pregnancy. It is in the last degree undesirable
that obstetric measures for terminating the preg-
nancy artificially should be resorted to, for fear of
breaking down adhesions that are helping to localize
the inflammation. Early operation is the best
chance of saving both the mother and the child.
3. Experimental Gastric Ulceration. — Bolton,
by injecting rabbits with an emulsion of the stom-
ach cells of guinea pigs, has succeeded in preparing
a gastrotoxic serum active against the gastric cells
of the guinea pig. Injection of the serum into an-
other rabbit produces no effect, but in half an hour
after intraperitoneal injection of the serum into a
guinea pig the symptoms of intoxication are well
marked, and death occurs within twenty-four hours.
The post mortem lesions are limited to the stomach
and always occur within the first twenty-four hours
after injection. If the animal survive, no further
symptoms or lesions occur. This limitation of the
lesions to the stomach does not indicate that the
serum is specific in its action ; other tissues are also
affected, as is shown by the symptoms and death of
the animal. The lesions consist of patches of necro-
sis in the mucous membrane, stained black by
altered blood pigment. They are usually multiple
and often nearly the whole mucous membrane is
affected. After from twenty-four to forty-eight
hours the black tissue has completely disappeared,
leaving perfectly clean and sharply punched out
ulcers. The ulcers heal in from fourteen to twenty-
eight days, but may perforate on the third or fourth
day, causing death' or a local abscess. The gastro-
toxine itself is unable to produce necrosis and ulcera-
tion of the mucous membrane of the stomach ; these
are brought about by the gastric juice. If this be
put out of action by alkalies, etc., no lesion can be
found. The serum is capable of bringing about two
well defined reactions in the test tube — it is haemo-
lytic and contains several precipitins. From the
above observations it seems possible that not only
certam endogenous but also certain exogenous poi-
sons may be capable of initiating self digestion,
through the blood stream, and that the production
of such lesions may be facilitated not only by hyper-
acidity of the gastric juice, but also by other bodies
intorduced with the food. It is possible that the
chronicity and refusal to heal of the human gastric
ulcer may depend on a secondary bacterial infection
of the ulcer largely owing to muscular insufffciency.
6. Precipitins in Hydatid Disease. — Welsh
and Chapman's conclusions are as follows: i. The
interaction between selected hydatid fluids and a
sufficiencv of the serum of a patient affected witli
hydatid disease has, in their experience of nine
cases, never failed to give a positive precipitin reac-
tion when tested before operation. 2. Not all hy-
datid fluids are capable of eliciting this reaction,
and their failure is not associated with any notice-
able diminution of their protein content. 3. Persist-
ence of a marked reaction some weeks after opera-
tion probably indicates the continued presence of
the parasite, but the disappearance of the reaction
does not necessarily indicate complete removal of
the cysts. 4. A positive reaction is independent of
the si*^e of the hydatid cyst (hepatic, peritoneal,
muscular) and independent also of the nature of its
contents (clear, turbid, or purulent).
LA PRESSE MEDICALE.
April 22, 1908.
1. The Fiftieth Anniversary of I-aryngolog>-,
By Marcel Lermoyez.
2. Contribution to the Study of Muscular Atrophy of the
Aran-Duchenne Type,
By .A.POSTOLOS G. Apostolides, Jr.
2. Muscular Atrophy of the Aran-Duchenne
Type. — Apostolides reports a case of progressive
spinal muscular atropliy of the Aran-Duchenne type
met with in a man. thirty-eight years of age. The
observations seem to have been made carefully and
to form a valuable contribution to the literature on
the subject.
April 23, 1908.
1. Applied Physiology. The Antibody in Experimental
Practice. The Deviation of the Complement,
By L. H.\LLioN.
2. Cholera in Constantinople. The Search for the Vibrio
of Cholera in Molluscs and in Sea Water,
By Ferid Ibrahim.
3. Mikulicz's Disease, By R. Romme.
I. The Antibody in Experimental Practice. —
Hallion devotes considerable space to the definition
of such terms as antibody, amboceptor, etc., and
tries to make his definitions clear by means of sche-
matic diagrams. He deals with the difl'erent classes
of antibodies, the sensibilitrices or amboceptors, and
the alexin or complement, and then passes to the
May 30. 1 90S.]
FITH OF CURRENT LITERATURE.
1057
reciprocal reactions of these upon each other,
which he presents in mathematical form as five
propositions. He then presents problems to be
solved by means of the antibody, the mode of pro-
curing each of the substances mentioned, the efTects
produced by the combination of the alexin with the
antibody, and the solution of problems in practice.
2. Cholera in Constantinople. — Search for the
vibrio of cholera in molluscs and sea water. Ibra-
him reports failure to find the cholera vibrio in the
molluscs examined or in the sea water.
LA SEMAINE MEDICALE.
April so, 1908.
Apraxia of the Cephalic Muscles, By Felix Rose.
Apraxia of the Cephalic Muscles. — Rose pre-
sents a fair resume of the literature on this subject.
BERLINER KLINISCHE WOCHENSCHRIFT
April 20, 1908.
1. Contributions to the Normal Histology of the Cortex
of the Suprarenal Capsule, By Oskar Storck.
2. Primary Carcinoma of the Vermiform Appendix.
By S. Isaac.
3. Concerning the Disinfection Value of the New Kresol
Soap of the Ministerial Decree of October 19, 1907,
By E. Seligmann.
4. Myoma of the Uterus in Young People,
By L. Laxdau.
5. Concerning Narcosis by Suggestion,
By Bexno Hallauer.
6. Concerning the Treatment of Bartholinitis with Bier's
Hyperaemia. By Theodor Plass.
7. The Idiopathic Gangrene of the Skin in Infancy.
By Paul Heim.
8. The Theory of the Action of Sulphur, By Diesixg.
9. The Oxidation of Sugar. By Georg Rosexfeld.
10. .Etiology of Tuberculosis. By ^^AZYCK P. Ra\-exel.
11. Urine Gelatin with the Addition of Bile,
By Robert Gueterbock.
12. The Important Part Played by Near Work in the
Origin of Myopia, By W.\lter Thorxer.
13. Electrolysis in Cicatricial Stricture of the (Esophagus,
By A. W. Zuberbuhler.
14. Blood Conditions by the North Sea, By Haberlix.
1. Normal Histology of the Cortex of the Su-
prarenal Capsules. — Storck says that a number
of recent writers in the description of tumors of the
cortex of the suprarenal capsules have mentioned
glandular tubes within the parenchyma of the
tumors, but declares as the result of his observations
on the suprarenal capsules of both men and animals
that a true glandular tube formation is never pres-
ent, either physiologically or pathologically, in the
cortex of the suprarenal capsule.
2. Primary Carcinoma of the Appendix. —
Isaac gives a full account of the findings at autopsy
on a man, twenty-five years of age, whose appendix
was found to have been totally destroyed by a carci-
noma. The principal other pathological conditions
noted were an extraperitoneal paravesical abscess,
multiple abscesses of the liver, an ichorous abscess
in the right lower lobe of the lungs, multiple pru-
rient pulmonary emboli, multiple infarcts and ab-
scesses of the lungs, purulent thrombus of the vena
cava inferior, endocarditis of the tricuspid valve,
empyema of the pleura on each side, chronic en-
largement of the spleen, abscess of the brain, and
fatty degeneration of the heart and of the liver.
4. Myoma of the Uterus in Young People. —
Landau states that among the last four hundred
cases operated on by him for myoma of the uterus
there were forty-two women between the ages of
twenty and thirty.
5. Narcosis by Suggestion. — Hallauer advo-
cates the practice of narcosis by suggestion in cases
where slight operations are to be performed or for
the purpose of making examinations.
7. Idiopathic Gangrene of the Skin in Infancy.
— Heim reports three cases of this nature met with
in children three weeks, six months, and nine
months old. In each there was a circumscribed
gangrene of the skin of the leg which did not appear
to be due to traumatism. \"ery few such cases are
on record.
10. .ffitiology of Tuberculosis. — Ravenel is of
the opinion that the digestive tract is a very frequent
place of entrance for the tubercle bacillus ; that the
tubercle bacillus is able to penetrate the uninjured
mucous membrane of the digestive canal without
leaving a trace of its entrance, and does this most
readily during the digestion of fat ; that the bacilli
pass with the chyle through the lymph vessels and
the thoracic duct into the blood, which carries
them to the lungs, where they are in great part
caught in the tissue ; that infection by way of the
intestine is particularly frequent in children ; that
the milk of tuberculous cows is in many cases the
source of the infection (the exact proportion cannot
yet be determined, but it is probably great) ; that
tuberculosis can be carried by kissing, by touching
with soiled hands, by injuries during autopsies, by
cleansing of vessels used by consumptives, but these
forms of infection play a comparatively slight part
in the spread of the disease.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT.
April 21, igo8.
1. Concerning Pneumonia Caused by the Friedlaender
Bacillus, By Apelt.
2. Concerning the Serum Therapy of Streptococcus Infec-
tions, By Zangemeister.
3. Concerning Karell's Treatment of Serious Circulatory
Disturbances and the Treatment of Obesity,
By Jacob.
4. Concerning the Demonstration of a Satiable Toxine in
the Urine and Stools of Infants, By Cellhorx.
5. Concerning Biological Distinction of Milk, By Bauer.
6. Concerning an Epidemic of Pruritus /Estivus Caused
by the Lepttts Autumnalis, By vox Notthafft.
7. A Contribution to the Treatment of Acute and Chronic
Gonorrhoea by the Internal Administration of Arho-
vin. By Knauth.
8. Contribution to the ^tiologj' of Congenital Asphyxia
of the New Born, By Feuchtwaxger.
9. Casuistics of Fibroma Molle, By Dobrowolsky.
10. Suction Occlusion of the Urethra, By Lob.
11. The Keating-Hart Method of Treatment of Cancer,
By Dessauer.
12. Tuberculin and Antituberculin, By Ll'dke.
13. Compilations from the Field of Experimental Psychol-
ogy and Psychopathology-. By Isserlix.
I. Pnevunonia Caused by Friedlaender's Ba-
cillus.— Apelt states that of seventy-seven cases
of pneumonia bacteriologically investigated during
1907 he found in sixty the Lanceolatus pncnmonice,
in ten the Streptococcus mucosus, and in seven the
Diplobacill'.is capsulatiis. But of these seven four
were cases of mixed infection with the lanceolatus
and one with the coli, so that among the entire
seventy-seven cases there were only two which were
of pure Friedlaender infection. His conclusions
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
are that there are pneumonias which are caused by
the Diplohacilhis capsulatus, discovered by Fried-
laender in 1883, as: i, Proved by the presence of
this bacilhis in the blood and also in the sputum dur-
ing life, and in one reported case in the secretion
from an open wound in a patient with pneumonia
and the same bacillus in the sputum ; 2, indicated
by the agreement between the clinical picture of the
cases, absence of herpes and chill, with a severe
course, the macroscopic and microscopic characteris-
tics of the sputum, and the pathological preparations
made from these pneumonias ; 3, the diagnosis of a
Friedlaender pneumonia can be made from the mu-
cous sputum microscopically rich in capsulated ba-
cilli : 4, in regard to the prognosis, which is apt to
be very bad, it is well to be guided by the result
of the bacteriological examination of the blood ; 5,
treatment does not differ from that of the pneu-
monia due to the lanceolatus.
2. Serum Treatment of Streptococcus Infec-
tions. — Zangemeister asserts that his experi-
ments show that the antistreptococcus sera ob-
tained to-day from the horse are totally ineffective
on monkeys, which renders it very probable that
they are equally so for men ; that monkeys can be
passively immunized against streptococci, the same
as other animals, as long as the serum of one of
their own kind of animals is used ; that antistrepto-
coccus sera, so far as they cannot be tested directly
on men, should be tried on monkeys ; that, aside
from the fact that horse immune serum is worth-
less, it may be directly injurious to monkeys, and
cause the death of the animal experimented upon.
3. Karell's Treatment.- — ^Jacob reports a num-
ber of cases of serious, cardiac disease which he has
treated with excellent results along the lines laid
down in 1868 by a Russian physician named Karell,
the patient to drink 200 c.c. of milk four times a
day, the milk to be raw or scalded according to
taste and at such a temperature as may be agreeable.
Aside from this, the patients get neither solid nor
liquid food during the first five or seven days, after
that other food is gradually added ; at first, one egg
about 10 o'clock, and some zwieback about 6 o'clock,
then two eggs, some black or white bread, then
other additions are made until, some twelve days
after the commencement of the treatment, the pa-
tient has returned to full mixed diet.
7. Treatment of Gonorrhoea with Arhovin. —
Knauth speaks very highly of the internal admin-
istration of -arhovin as a remedy for gonorrhoea in
both the acute and chronic stages. In taking the
place of the method of treatment by injections, it
avoids the dangers of the latter, such as injuries
of the urethra, and carrying the gnnnrrlireal poison
into the posterior part of the urethra willi its im-
desirable consequences of provoking inllammation
of the bladder or of the epididymis. During the
past year he has thus treated eleven patients with
acute, eleven patients with subacute or chronic
gonorrhfEa, and seven patients with epididymitis,
giving from four to six capsules containing 0.25
gramme of arhovin by the mouth. In the most
acute stage the diet is restricted mainly to milk, the
patient is kcjjt in bed, and ice applied locally.
Wlicn the discliarge assumes a more watery, mu-
cous character the patient is allowed up and given
his usual diet without alcoholic beverages.
AMERICAN JOURNAL OF THE MEDICAL SCIENCES.
May I, igo8.
1. An Analysis of One Hundred and Forty Operations
on the Kidneys and Uterus, By G. E. Brewer.
2. The Epidemiology of Acute Poliomyelitis. A Study
of Thirty-five Epidemics,
By L. E. Holt and F. H. Bartlett.
3. Suppurative Phlegmonous Gastritis, with the Report of
a Successful Laparotomy (Probably the First) in
the Treatment of a Case, By J. W. Bovee.
4. Gallop Rhythm of the Heart, By G. C. Robinson.
5. Toxffimia from the Standpoint of Perverted Meta-
bolism, By R. W. Webster.
6. The Relaxed Knee Joint, By A. H. Freiberg.
7. Primary Colloid Carcinoma of the Vermiform Appen-
dix, By E. H. White.
8. The Management of Labor in Minor Degrees of Pelvic
Contraction, with Special Reference to the Relative
Indications for Abdominal Cassarean Section. A Tab-
ulated Report of Eighteen Cesarean Sections,
By H. D. Fry.
9. The Clinical and Pathological Aspects of Rodent Ulcer,
By G. McCoNNELL.
10. Erysipiloid of Rosenbach. A Note on Its Occurrence
in Laboratory Workers, By J. H. Jopson.
11. The Symptom Complex of Transverse Lesion of the
Spinal Cord and Its Relation to Structural Changes
Therein, By A. R. Allen.
2. The Epidemiology of Acute Poliomyelitis.
— Holt and Bartlett drav,' the following conclu-
sions : The occurrence of epidemics and the rela-
tion of certain groups of cases to one another in
these epidemics place beyond question the statement
that acute poliomyelitis is an infectious disease.
Whether we can go farther and state that the dis-
ease is communicable is an open question. After
carefully considering all the evidence brought to-
gether in this paper the authors cannot resist the
conclusion that the disease is communicable, al-
though only to a slight degree, one of the most
striking facts being the development of the second
cases within ten days after possible exposure. Posi-
tive statements must be deferred until the discovery
of the infectious agent. A table is given collating"
the principal facts regarding the epidemics, together
with the references to the literature.
3. Suppurative Phlegmonous Gastritis. — Bo-
vee thinks it is evident that until the report of his
case no case of phlegmonous gastritis had been
operated on. In four cases, which are cited, there
is a very strong relation to the suppurative form of
the disease. It would seem, and particularly from
these four cases, that opportunity for drainage by
abdominal section and external drainage, with or
without gastric incision, is necessary. Gastrostomy
or gastroenterostomy seems to be strongly indicated,
particularly as the pyloric end of the stomach is
usually most involved. In the author's case the
pylorus was completely obstructed. Gastroenter-
ostomy would afford drainage of the stomach into
the intestine, and incision into the submucous coat,
with adequate technique, would afford exit for pus
and relieve tension. Robson and Moynihan recom-
mend in moderate terms gastrostomy or gastro-
enterostomy in acute phlegmonous gastritis, and in
the circumscribed form th.cy remark that opening
and drainage of the abscess would be advisable.
4. Gallop Rhythm of the Heart. — Robinson
believes this is a clinical phenomenon of consider-
able frequency and consists of three cardiac tones,
none of them being murnnirs, occurring under vari-
able clinical conditions. The form which is heard
May 30, 1908.]
PITH OF CURRENT LITERATURE.
1059
over the apex or the central part of the praecordium
may be divided into presystoHc, protodiastoHc, and
mesodiastolic types, as the extra tone falls at the
end, beginning, or middle of the diastole. Each
form is associated with a characteristic cardiogram
and is produced by a combination of factors. The
presystolic form may be heard in strongly acting
hearts, the tone being caused by an hypertrophied
auricle, and also in weak, rapid hearts at the height
of acute febrile diseases, the extra tone being pro-
duced in the auricle rather than in the ventricle.
The protodiastolic and mesodiastolic forms are
caused by the production of an extra tone in the
ventricles, the factors being an increase in the
amount and velocity of the blood flow from the
auricles to the empty ventricles, and a loss of tone
of the heart muscle of the ventricles. The longer
silent period with gallop rhythm is usually systolic.
5. Toxaemia from the Standpoint of Pervert-
ed Metabolism. — Webster defines toxaemia as a
condition characterized by the overloading of the
blood with normal or abnormal products of food
or tissue metabolism. It is purely endogenous and
distmct from toxaemia due to exogenous products
or from toxaemic states arising in the course of
infectious disease. Abnormal activity of any organ
may result in the overloading of the blood with
products which lead to various toxaemic symptoms
or may so influence the activity of other organs that
abnormal results will follow. Such may be the in-
fluence of the thyreoid, the ovary, the testicle, the
pancreas, the suprarenal, and the hypophysis on the
general functions of the body. The author then
discusses in succession intestinal, hepatic, renal, and
thyreoid toxaemias, and concludes that toxaemia,
apart from that which follows acute or chronic
bacterial processes, is always of metabolic origin.
The toxaemias discussed are more the effects of a
general metabolic perversion than of a direct or-
ganic disorder.
6. The Relaxed Knee Joint. — Freiberg sum-
marizes his paper in the following propositions :
I. Many cases of so called functional knee symp-
toms are due to reflex atrophy of the quadriceps
extensor muscle resulting from injury. 2. The term
relaxed knee joint should be reserved for such cases.
3. The injury may be so slight that its aetiological
relation may be overlooked. 4. The atrophy follow-
ing in many cases cannot be explained as a conse-
quence of inactivity. 5. A cure in this condition
will be accomplished only when the quadriceps ex-
tensor muscle is restored to its normal volume and
strength. 6. Recovery is so protracted in some of
the cases as to suggest serious injury to the central
nervous system. 7. Though the treatment of these
prolonged cases is necessarily limited to the peri-
phery, they will ultimately recover with persever-
ing and w ell directed efforts.
THE JOURNAL OF NERVOUS AND MENTAL DISEASE
May, igo8.
1. A Case of Meningeal Tumor Compressing the Cere-
bellum, By Helen Baldwin.
2. Melancholia with Delusions of Negation : Three Cases
with Autopsy.
By H. W. Mitchell and E. E. Southard.
3. Spinal Cord Tumor and Trauma; A Report of Two
Cases, By Pearce Bailey.
1. A Case of Meningeal Tumor Compressing
the Cerebellum. — Baldwin reports a case of slowly
growing brain tumor. The first symptom of the
disease appeared ten years before death. The tumor
grew to such a size that it would seem that it
must have given characteristic symptoms, yet optic
neuritis never developed, there were only a few at-
tacks of vomiting throughout the illness, and these
were evidently due to acute indigestion, and, while
headaches occurred for short periods daily in the
early years of the disease, during the three years
before the patient's death they did not recur. Dur-
ing the course of the illness the symptoms so closely
simulated those of Parkinson's disease, of arterio-
sclerosis of the vessels in the cerebrum and cerebel-
lum, and of cyst of the cerebellum, that, while the
question of brain tumor was always considered, the
symptoms at no time seemed to justify an explora-
tory operation. In reviewing the history of this case,
says the author, it will be seen that, while the symp-
toms of brain tumor were not distinctive, those due
to cerebellar involvement were marked throughout
the course of the disease. These include the attacks
of suboccipital headaches, the cerebellar ataxia, the
cerebellar seizures — sudden relaxation and falling
with no vertigo or unconsciousness — and the tend-
ency when sitting to drop the head toward the left
shoulder. The symptoms of involvement of cranial
nerves also pointed to a localization of the disease at
the base of the brain — the nerve deafness in the
right ear, dysphagia, and anaesthesia of the tongue.
But, while the involvement of the cerebellum was
evident, the lesion seemed to be one of degenera-
tion rather than of compression from an extracere-
bellar growth.
2. Melancholia with Delusions of Negation:
Three Cases with Autopsy. — Mitchell and South-
ard describe the history of three such cases, the ana-
tomical side of which present several common as-
pects, but little which promises to explain the dis-
ease. Arteriosclerosis, when confined to the large
branches of the circle of Willis, can scarcely be in-
voked as underlying symptoms of such specialized
character as those under consideration. Just as the
patients showed strikingly little in alterations of re-
flexes, so the brains showed strikingly little in the
shape of gross or focal alterations. jNIoreover, the
brains gave little evidence of general or focal atro-
phy. No striking alterations in cortical topography
and arrangement of layers could be detected on mi-
croscopical examination. Pigment bearing cells in
perivascular spaces were constantly found ; and, in
default of any suspicious localization of these, they
should "oe attributed rather to the results of ad-
vancing years than to a special factor. Neuroglia
cell pigmentation was also quite constantly found ;
but this was not so universal in distribution as was
the case with the perivascular cell pigmentation.
Common to all three cases was a neuroglia cell pig-
mentation in the intermediate layers of the areas of
cortex examined. The relation of the neuroglia cell
pigmentation to cortical activity could not be made
out. Satellite cell pigmentation was not constant.
Nerve cell pigmentation was constantly found in the
elements of moderate size in all parts of the cortex
examined. This pigmentation was strikingly brought
out by the use of iron haematoxylin.
io6o
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
^xmtVmp at Btstittm.
MEDICAL ASSOCIATION OF THE GREATER CITY
OF NEW YORK.
Meeting of February 17, jgo8.
The President, Dr. Thoma.s E. S.-\tterth\vaite, in the
Chair.
{Concluded from page 916.)
Metaplasia of the Appendix Vermiformis and
a New Diagnostic Point. — This was the title of
the address made by the president-elect, Dr. Robert
T. Morris. The time had now come, he said, to
classify appendicitis cases under four separate and
distinct kinds: i. Normal involution, beginning
with a metaplasia of the lymphoid and submucous
coat and ending with connective tissue replacement
of all coats. During a part of the involution process
the patient suffered from local and reflex disturb-
ances, and this class of cases included probably the
larger proportion of all patients affected with dis-
ease of the appendix. Although this was by far the
most common variety of appendicitis, it was the one
most seldom recognized. 2, Infective appendicitis,
the form most often recognized. 3, Congestive ap-
pendicitis, accompanying, for instance, ascites or
pressure from a floating kidney. 4, Appendicitis
secondary to some external affection, like cancer or
tuberculosis, of slow development. If it was asked.
Do these four types merge one into another? he
would answer, Not often, in his opinion. Much
confusion had existed in his own mind in regard to
this subject until recently, but now he believed that
some, at least, of the perplexities with which it was
attended had been cleared away. The reason why
we did not have normal involution merging into in-
fective appendicitis was because, as a result of the
involution, there was a disappearance of those ele-
ments in the appendix which were most necessary to
an infectious process. The third and fourth types,
in consequence of the slow character of the swell-
ing, seemed to call out the elements of protection
against infection. It was his belief that the chief
cause for the disasters in appendicitis was to be
found in rapid swelling. The tension produced by
this gave rise to compression anaemia, and in this
way the tissues were rendered vulnerable to bac-
terial invasion.
In normal involution the metaplasia might go on
for years. The patient very rarely had to take to
his bed. In exceptional instances, however, the oc-
currence of spasm of the intestine at times might
necessitate this. But such patients suffered not a
little from intestinal dyspepsia, and it was un-
doubtedly true that metaplasia of the appendix oc-
casioned more intestinal dyspepsia than any other
one cause. Defective metabolism was a result, and
the patients suffered from a long train of secondary
effects, including, in many instances, various local
neuralgias due to irritation of nerve filaments en-
trapped in the new connective tissue. This form of
appendicitis was not likely to explode ; the chief mis-
chief resulting from it was the discomfort and nag-
ging described, lasting for years. In it, therefore,
it was not necessary to remove the appendix, on
account of existing or threatened danger, but re-
moval was often highly desirable for the comfort
of the patient. Dr. Morris here presented three
specimens showing the process of involution in dif-
ferent stages. In the third and most advanced
specimen there was nothing left but peritonaeum.
It was worthy of note, he said, that throughout the
process, however, the nerve fibres remained.
As an aid to the diagnosis, he had found a cer-
tain point of value. This was in the course of the
line drawn from the right anterior spinous process
of the ilium to the utnbilicus, upon which McBur-
ney's point was located; but, while the latter was
an inch and a half from the spinous process, the
new point was situated an inch and a half from
the umbilicus. This point had reference to tender-
ness, elicited by finger pressure, of the right lumbar
ganglia of the sympathetic system, and in cases of
normal involution of the appendix there was per-
sistent tenderness at the point. In irritations of
pelvic origin, both right and left lumbar ganglia
were tender. In making differential diagnoses,
therefore, this was a point of great value. For in-
stance, if, in a case in which the appendix and the
right Falloppian tube were bound together by ad-
hesions, we wished to decide whether certain symp-
toms proceeded from the appendix or from the ovi-
duct, the point described would alone be tender if
the symptoms came from the appendix, while, if
they came from the tube, both right and left lumbar
ganglia would be tender.
Dr. Robert F. Weir said that Dr. Morris had
originated many new ideas, and, while he was not
invariably right, it had often proved the case that
the surgeons had come to adopt them. He could
not see how the process described prohibited in-
fectious invasion. The smaller the lumen of the
appendix, the less chance there would be of such
invasion, but unless there was complete obliteration,
it seemed to Iiim that there was always the possi-
bility of this taking place. Nor could he see ex-
actly how the line between the two forms of appen-
dicitis could be drawn so finely as the speaker would
have us believe. If, however, the experience of
other observers confirmed the position taken, it
would certainly be a great point gained. It would
be on a par with the achievement of McBurney in
appendicitis. While many surgeons were now dis-
posed to attach less significance to McBurney's point
than formerly, he personally still regarded it as of
the greatest significance, provided proper methods
are employed in the examination. His own experi-
ence with finger point pressure in the location indi-
cated by Dr. Morris had been very limited, but in
two cases of the character described, which he had
recently examined, there had been no pain eHcited
at this point. Since this new proposition had been
brought to his attention he had made a study of the
anatomical rekitions of the parts involved, and from
this it appeared to him that the pain would naturally
emanate from the lower dorsal, rather than the lum-
bar, ganglia. It had then occurred to him that the
condition might possibly be due to an infection by
means of the lymphatics. Perhaps a larger e.xperi-
ence would bring all observers into full accord as
to the points at issue.
Dr. Algernon T. Bristow, of Brooklyn, said
that the normal involution of an organ was not
measured by the life of any man. It was a matter
May 30, 1908.]
FROCEEDJNGS OF SOCIETIES.
1061
of a very long period, even thousands of years. As
illustrating this, he referred to the development of
the intestinal canal in successive generations of ani-
mals, requiring many centuries for its completion.
He strongly objected to having chronic appendicitis
designated as a normal involution. It was no more
this than cirrhosis of the kidney was a normal in-
volution. In the latter there was a strangulation
of the glandular structure of the organ, and the
process in the appendix was entirely analogous. The
relatively poor blood supply of the appendix was
one of the factors which favored inflammation ; an-
other was the poor drainage of the organ. If, noWj
infective material was added, we had the triad which
was necessary for the production of appendicitis.
Although the first two of these were constantly
present, without the addition of the third factor,
infection, there could be no appendicitis. With the
exception of the use of terms, the speaker said that
he was, in the main, in accord with Dr. Morris,
though he would go further than the latter in re-
gard to some points. The condition in the cases
described was not one simply of discomfort, but
amounted to really one of chronic ill health. He
v/ould no say that this kind of cases never exploded,
for he had found that they did occasionally ex-
plode. As a rule, however, the operations in such
cases were not life saving operations, like those in
acute appendicitis. The happiest results generally
followed the operation, so that patients who before
were suffering a miserable existence were complete-
ly restored to health.
Dr. Alexander B. Johnson said that only a few
years ago a surgeon would have been laughed at
if he maintained that an inch and a half for the
incision and a week and a half's confinement were
all that were required for an appendectomy. Yet
in interval operations these were now quite suffi-
cient. He thought that we should not form too
hasty opinions in regard to Dr. Morris's conten-
tions. The matter should be thoroughly sifted bv
surgeons generally, and he for one would be glad
to give the new diagnostic sign a thorough practi-
cal test. The term normal involution seemed to
him a proper one. Evolution and involution went
on in the individual, just as they did in the race.
It was possible to have an appendix which in one
part was undergoing involution, while another part
was the seat of infection. In exceptional instances,
he had also seen rupture in cases of tuberculosis
of the appendix, and even of cancer. In the class
of cases described by Dr. Morris it was advisable to
operate when the symptoms became sufficiently
troublesome, and in a fairly large proportion of such
cases, in his experience, the appendix appeared to
be undergoing normal involution. He was much
interested in the question of whether it was possible
in certain instances to distinguish between disease
in the appendix and in the right Falloppian tube,
and if the Morris sign enabled us to determine this
point it would prove exceedingly useful.
Dr. Franz Torek said that for a number of
years he had observed that a tender point was apt
to be found in the location indicated by Dr. Morris.
He could not, however, subscribe to the opinion that
it was present only in normal involution, as he had
certainly met with it in ordinary cases of appendi-
citis. It would not do to be too exact in placing the
position of the point of tenderness, since it might
be a little more or a little less than an inch and a
half from the umbilicus. The distance between the
latter and the anterior superior spinous process of
the ilium was usually set down as seven or eight
inches, but he had repeatedly seen instances in which
this line measured only four inches. In such cases
the McBurney point and the Morris point would
be very close together, and it was conceivable, with
the variations in the seat of tenderness which must
be taken into consideration, that the two points
might even be identical. On the whole, it seemed
that the exact point might be a little difficult to
find. In one young lady whose ovaries and tubes
were normal he had elicited pain on pressure at
Morris's point, and yet this could not have been due
to appendicits, because he had removed the appen-
dix four years before.
Dr. John B. Walker said that, like Dr. John-
son, he had seen a number of cases in which a large
part of the appendix had become obHterated, and
yet in which abscess was associated with the con-
dition.
Dr. Charles H. Peck said that several times he
had been much puzzled in trying to distinguish be-
tween disease of the appendix and of the right
Falloppian tube, and he argued with Dr. Johnson
that, if the Morris sign could be well established,
it would prove of special value in such cases. He
had found it difficult also to distinguish betweerr
obliterative appendicitis and the milder attacks of
inflammatory appendicitis, and thought it very de-
sirable that the distinction between the two should
be more clearly defined.
Dr. Albert A. Berg said that at times the mean-
ing of pain located in the lower right quadrant of
the abdomen was very difficult to determine. If the
appendix alone was in this situation there would
be no trouble about the matter ; but there were also
many other structures here which might be the seat
of disease, the recognition of which was most im-
portant. It was the experience of all hospital sur-
geons that without any inflammation of the appendix
whatever there might be localized pain in this quad-
rant. Thus, it might be due to stone in the right
ureter or other abnormal condition in the ureter,
or to a colitis. To make a diagnosis only on pain
seemed to him a step backward. Still, in the way
of corroborative evidence, the Morris sign, if sub-
stantiated, would be of great assistance. As to the
liability to explosion in appendices which were some-
what obliterated, he thought there was little dan-
ger of this if the normal involution was taking
place regularly. In some instances, however, stric-
ture formation was met with, and in these he be-
lieved there was greater liability to infection (in
consequence of the presence of stricture) than in
the normal appendix in which no involution had
occurred.
Dr. Morris said that he had devoted much care-
ful study to the subject before making known the
conclusions at which he had arrived, and he was
much pleased to have had such a full and intelligent
discussion of the points at issue. He would en-
deavor to reply to the various criticisms and in-
quiries in turn. In cases where we had infective
appendicitis and also the presence of hyperplastic
conective tissue, we had a history of active attacks
I062
LETTERS TO THE EDITORS.
[New York
Medical Journal.
of acute appendicitis. Wherever we had scar tis-
sue from previous infective appendicitis, such at-
tacks were apt to be met with; but in such cases
we did not meet with the persistent discomfort and
repeated attacks of a few hours' duration which
were characteristic of normal involution. As to Dr.
Weir's anatomical studies, the lymphatic connection
between the appendix and the lumbar ganglia was
not direct, and the condition was not one secondary
to an infection carried by the lymphatics. Dr. Bris-
tow thought the nomenclature wrong. He (Dr.
Morris) had found much difficulty in getting a
proper nomenclature, and he was by no means sat-
isfied with the results thus far attained in this di-
rection. For want of a better term, he had sug-
gested "metaplasia." He believed that in rare in-
stances we did have inflammatory processes asso-
ciated with normal involution, but such an occur-
rence was accidental, rather than a natural sequence.
He entirely agreed with Dr. Bristow as to the happy
results usually following an operation. We not in-
frequently heard of appendices which, after being
taken out, were found to be normal. While they
might appear to be normal, he did not believe they
were so, for if they are examined microscopically
it would be seen that they were in process of in-
volution. Dr. Johnson was correct in asserting that
perforation might occur in tuberculous or cancer-
ous cases, but when this was the case it was not an
acute phenomenon. The matter of the oviduct and
the appendix was one which he had worked out
very carefully. In reply to Dr. Torek, he would
say that the measurement of an inch and a half was
not meant to be absolute ; this distance was rather a
bull's eye at which to' aim, and which it would be
well to keep in mind. As to the existence of pain
at the inch and a half point in the case in which the
appendix had been removed, he believed that this
was due to the presence of adhesions at the site of
the removed appendix. Coming to the remarks of
Dr. Berg, Dr. Morris said that he himself had seen
a number of instances of inflamed ureter which
might possibly have been mistaken for appendicitis,
but in making the diagnosis of these he had de-
pended rather on the collateral symptoms and the
clinical history. The localized point of tenderness
which he had described was a sign characteristic of
normal involution, but not peculiar to it. He would
never think of operating unless the corroborative
evidence afforded by palpation was present. As to
the stricture formation referred to, even here he
had felt that potection from infection was called
out by the leucocytosis developed.
fttttxs ta t\t mtm.
THE WORD "PALLIATIVE."
S3 East Fifty-eighth Street,
New York, May ii, 1908.
To the Editors:
I have read the criticism by Dr. A. Rose of my
use of the term "palliative" in the title of my paper,
which was published in the Journal of April i8th,
and have noted the fact that Dr. Rose asserts that
my interpretation of this term was erroneous. Had
this criticism been made by one less scholarly than
Dr. Rose, I should have felt impelled to ignore it;
under the circumstances, however, I feel compelled
to answer.
My justification for the use of the word "palli-
ative," in the sense in which I employed it, rests
upon authority which is good enough for me. If
the doctor will turn to Foster's Medical Dictionary
he will find the adjective palliative upon page 2508,
as follows: "Palliative, adj. Lat., palliativus. Fr.,
palliatif. Ger., lindernd (adj.). Palliativ (n.).
Tending to moderate a morbid condition \vithout
curing it; as a n., a p. agent." If the doctor will
carefully read the article in question, he will find
that its entire sense is exactly in the spirit of this
definition, i. e., the moderating of a morbid condition
without curing it. Nowhere in the article is there
any claim made to curing prostatic hypertrophy by
these measures, but simply the amelioration of the
symptoms dependent upon or resulting from the dis-
ease of the gland. In view of the measures advo-
cated, I should not have been justified in using the
term "nonoperative," since I have frequently re-
ferred to the use of the catheter and cystoscope,
which, in the eyes of surgeons, is an operative pro-
cedure.
Dr. Rose, in his communication, states: "Palli-
ative, from Latin palliatus, a, um, means covered
with a cloak ; in medicine palliativum, or palliative
remedy or treatment, is a remedy or treatment
which is employed to ameliorate symptoms, to do
for a while, until a radical remedy (not necessarily
operative) can be applied or in case a radical cure is
out of the question." The entire article is in the
sense of the doctor's definition of the term "pallia-
tive," as quoted above, which must become clear at
once to any one carefully reading it.
In /view of these facts — that is, my justification
for the use of the term in the sense in which it was
employed, first by Foster's Dictionary and, secondly,
by the definition given by Dr. Rose himself — I must
insist that my use of the word was correct.
F. BlERHOFF.
ABOUT DR. PALIER'S ARTICLE ON PYLORIC
INSUFFICIENCY.
616 Madison Avenue,
New York, May 18, 1908.
To the Editors:
Glancing over the table of contents of the last
issue, for May i6th, I noticed the heading of Dr.
E. Palier's article, A Case of Chronic Diarrhoea
Accompanied by Pyloric Insufficiency. I confess
that I felt quite pleasantly over the fact of having
gained another convert to my teachings. At least
I thought so after glancing over the title. In look-
ing over the article I read with delight the history
of the case and the method by which Dr. Palier
made the diagnosis. Very properly does Dr.
Palier deny the possibility of dealing with hyper-
motility of the stomach, instead of with insuffi-
ciency of the pylorus. Very properly also does Dr.
Palier assert that the passage of undigested food
probably acted as an irritant on the intestines.
But how painful did I feel when at the end of his
article I saw no mention of my name at all ! Had
May 30, 1908.]
BOOK NOTICES.
1063
Dr. Palier abstained entirely from quoting any one
— well, it would have been different. But he did
mention Ser^ and Ebstein, whom (the latter one
only) I also mentioned in my first monograph. In
this article, Insufficientia Pylori, a Sequela of
Chronic Gastritis, with Reports of Fourteen Cases
Successfully Treated (Philadelpli^a Medical Jour-
nal, May 24, 1902), he wnll find, right after my
quoting an abstract from Ebstein, one sentence
reads thus : "Why must hypertony of the stomach
be accepted to explain the absence of food in the
stomiach at too early a time?" In this article, as
in the subsequent ones, the symptom, diarrhoea, is
mentioned quite prominently, besides explaining its
cause and effectual treatment. If Dr. Palier wishes
to consult my works on this subject, I will give
him here a partial list of additional publications in
which he can read of insufficiency of the pylorus :
Further Remarks on Insufficientia Pylori, Xezi'
York Medical Jonrnal, October 4, 1902 ; Journal of
the American Medical Association, April 16, 1904;
Medical Record, April 30, 1904; Transactions of
the Medical Society of the State of New York,
1904; A Few Remarks on the Prospect of the
Chronic Dyspeptic, Nen' Albany Medical Herald.
January, 1906; The Outlook for the Chronic Dys-
peptic. American Medicine, March 10, 1906. I
have referred to and made short mention of this
very frequent disease in many other articles, but I
think these will suffice for reference. I wish to
bring out here these facts : That insufficiency of the
pylorus, not a very occasional and nervous phenom-
enon, but as - the usual and natural sequel of
chronic pyloritis, was first described by me in May,
1902 ; that insufficiency of the pylorus is a very
frequent condition — I have seen, treated, and cured
dozens of cases ; that insufficiency of the pylorus is
the true condition, and not achylia gastrica, so
mistakenly, as I believe, taught by Einhorn ; that
the method of diagnosticating it is the repeated
giving of test meals and aspirating them at inter-
vals of less than one hour after the Ewald's test
breakfast ; that one of the symptoms of insufficiency
is chronic diarrhoea, which can be checked in from
two to three days, and absolutely cured in about as
many weeks. I have reported the cure of chronic
diarrhoeas which had persisted for from five to nine
years. Boardman Reed, in his book. Diseases of
the Stomach and Intestines (1904), has this to say
on page 868: "When pyloric incontinence exists,
in the absence of any mechanical cause for it, the
more plausible explanation seems to be the one
championed by Knapp," and on the following page
he says : "Knapp insists that insufficiency of the
pylorus is quite frequent, and that it is the natural
result of a prolonged condition of hypertonicity of
the part, the overtaxed muscle finally becoming ex-
hausted and weak. He maintains . . . that a too
rapid emptying of the stomach is evidence rather
of an exhausted and relaxed pylorus than of hyper-
motility of the gastric walls, . . . and it would
follow further that . . . diarrhoea may be produced
... by pyloric incontinence."
It is rather strange, although perfectly possible,
that Dr. Palier came to the same results and
through the same channels of reasoning apparently
as I did six years ago. without knowing anything
of my many contributions on this highly interesting
subject which have appeared since my first article.
But the fact is that I have been teaching the exist-
ence of that disease and the method of diagnosti-
cating and curing it for the last six years, besides
taking part in discussions in societies. Knowing
Dr. Palier quite well, I am sure that this letter will
cause him to hunt up the literature and that at his
earliest opportunity he will hasten to rectify the
omission after convincing himself of the truth of
the purport of this letter. I am glad, however, that
there is another believer in insufficiency of the
pylorus, and that possibly in the near future we
may be able to demonstrate by concerted action the
utter fallibility and the inherent fallacy of Ein-
horn's teaching about "achylia gastrica." Let me
pray, for the betterment of mankind, that we may
soon succeed in unmasking that diabolical disease
"achylia gastrica," even if we have to throw over-
board all of the cherished teachings of Einhorn.
Mark I. Knapp.
].We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
Ikonographia Dermatologica. . . . Tabulae selects . . .
editse a Albert Neisser, Breslau, Eduard Jacobi, Frei-
burg i. Br. Fasc. iii. Berlin and Vienna : Urban &
Schwarzenberg ; Paris : Masson & Cie ; New York :
Rebman Company ; London : Rebman Limited. Pp.
(text) 79 to 125; plates 20 to 32.
This fasciculus of Neisser and Jacobi's Atlas of
Nezc and Rare Skin Diseases (one of the subtitles
of the work) quite maintains the degree of excel-
lence shown in the preceding fasciculi in both text
and illustrations. The atlas as a whole cannot fail
to be exceedingly useful to the general practitioner
as well as to the specialist in dermatology.
The Functional Inertia of Living Matter. A Contribution
to the Physiological Theory of Life. By David Fraser
Harris, M. B.. M. D., B. Sc., F. R. S. E., Lecturer on
Physiologj- and Normal Histologv- in the University of
St. Andrews, etc. London : J. & A. Churchill, 1908.
(Through P. Blakiston's Son & Co., Philadelphia.) Pp.
136. (Price, $2.)
Two hundred and thirty years ago Francis Glis-
son, M. D., of Cambridge, gave to the science of
his day the conception of the irritability of living
matter. The astonishing growth of biology' wit-
nessed since that time is due in an exceptional de-
gree to the potentiality for advancement conferred
by the recognition of this property of affectibility
in living matter. But the ultimate processes under-
lying what is called life can scarcely be conceived
of as wholly made up of irritability, or affectibility,
as some prefer to call it. To rest here would be
tantamount to an admission that life is but unin-
terrupted response, ceaseless activity, endless un-
rest. This is contrary to what we know of the
capacity and physiological wants of the human or-
ganism or, indeed, of any organism. Nowhere
among living things is affectibility, continuous, un-
restricted, and unopposed, to be met with. Conse-
quently, if we would conform theory to the exac-
tions of biological fact, we are obliged to ascribe a
further quality to protoplasm — that of insuscepti-
bility. As Dr. Harris observes, the results of the
1064
BOOK NOTICES.
[New York
Medical Journal.
possession of this second attribute have been, to a
certain extent, appreciated by philosophical biolo-
gists ; but, so far as he is aware, no one has till now
"formally asserted that livingness consists in the
simultaneous possession by protoplasm of two physi-
ologically opposed properties — affectibility and in-
susceptibility— or, as I prefer to call the latter, func-
tional inertia."
These, then, are the essential or fundamental
properties of protoplasm as Dr. Harris conceives
of them. From his point of view, however, irrit-
ability (affectibility) is not of the same order as
movement, secretion, etc. On the contrary, it is
more fundamental — "a property of living matter,
in fact, while the other things are results of its ex-
istence." Of "functional inertia" he observes that it
is that "property of protoplasm whereby the living
matter contrives to remain in a functional status
quo ante, notwithstanding that it has received a
stimulus, or, having responded to the stimulus, it
•continues to exhibit its functional activity for a cer-
tain time after the stimulus as a form of energy has
•ceased to exist."
Assimilation, certain aspects of metabolism,
movement, secretion, and reproduction the author
would regard as vital manifestations or results of
affectibility ; while from functional inertia he would
derive automatic molecular changes and certain
other aspects of metabolism, e. g., reproduction and
rhythmic movements. As to the physiological sig-
nificance of functional ineria, Harris is inclined to
believe that, in many cases, it is destined to preserve
the protoplasm from excessive activity (pages 126-
127).
Finally, while the results of the possession by
protoplasm of such a property as functional inertia
had been perceived with clarity more or less by
Hobbes and Faraday, and in our own day by
Adami, Cattell, Guyau, Mercier, Mosso, Robertson,
Woller, Ribot, Sharkey, Sherrington, Strottan, and
Schaeffer — while even the term inertia was used by
some or all of them — Harris found that, to ade-
quately explain certain phenomena, he was obliged
to ascribe to protoplasm a certain real or positive
property, functional inertia, mere diminution or ab-
sence of affectibility being inadequate rationally to
account for the occurrences. Functional inertia, in
this sense, Harris attributes to the biogens, or living
molecular constituents of protoplasm.
This, if we have read him aright, is a brief but
true statement of the author's position with regard
to one of the most complex questions in the whole
range of biological science — a question which he has
treated at every point with lucidity and logical acu-
men. Our author, in truth, is not one of those
wizard prophets of Lilliput, who, mounting upon a
stilt scaffolding of many syllables, would win to a
fictitious altitude in the world of thought. His is
no mumbojumbo of contorted eloquence. Rarely,
indeed, have we met, in a work at once so abstruse
and highly technical, with such a store of simple,
sturdy English. It is hard to predict, perhaps we
never can predict, the ultimate fate of such a bio-
logical subtlety as that which constitutes the burden
of this writing. Only a churlish captiousness, how-
ever, could withhold commendation, in view of an
argument so obviously sincere, of an imagination
working as far as may be under the guidance of ex-
periment; of a judgment buttressed always by a
strict observance of the laws of inference — a judg-
ment finding, moreover, in elegance and simplicity
its most congenial and convincing utterance.
Immune Sera. A Concise Exposition of our Present
Knowledge concerning the Constitution and Mode of
Action of Antitoxines, Agglutinins, Hsemolysins, Bacterio-
lysins, Precipitins, Cytotoxines, and Opsonins. By Dr.
Charles Fkederick Bolduan, Bacteriologist, Research
Laboratory, Department of Health, City of New York.
Second Edition, Rewritten, First Thousand. New York:
John Wiley & Sons ; London : Chapman & Hall, Limited,
1907. Pp. viii-154. (Price. $1.50.)
The cordial reception given immediately by the
profession to the first edition of this book of Dr.
Bolduan's is to be ascribed in great measure, we
think, to his happy faculty of treating of difficult
matters in language readily understood by the reader.
The same felicity of expression will be found in the
material added in the second edition, including short
accounts of snake venoms and their antisera, agglu-
tinins, opsonins, and serum sickness. The practical
character of the book is well shown in the follow-
ing passage from the chapter on opsonins (page
134) : "There is little doubt that the opsonic indices
do measure a certain fraction or phase of the im-
munity reaction ; we do not believe that they g-eplace
clinical observations in measuring the effect of im-
munizing injections." We have nothing but com-
mendation for this handsome little book.
La Liitte contre les microbes. Cancer, tuberculose, maladie
du sommeil, tetanos, enterite et microbes intestinaux,
variole et vaccine: L'CEuvre de Jenner. Par Dr. Etienne
Burnet, de I'lnstitut Pasteur, chef du service de la vac-
cination de la Ville de Paris. Paris : Armand Colin, 1908.
Pp. 318.
We have here an entertaining volume by an as-
sistant and disciple of Metchnikoff, who discusses
in a popular and discursive fashion numerous prob-
lems relating to various infectious diseases, includ-
ing cancer, tuberculous disease, African sleeping
sickness, tetanus, and intestinal putrefaction. There
is also an historical retrospect and study of vaccina-
tion and the work of Jenner. The use of uncooked
fruits and vegetables, especially those growing near
the ground, is condemned as a probable source of
many cases of obscure infection. Cultures of the
Bulgarian lactic acid bacillus are recommended as
an eff.cient means of combating pathogenic micro-
organisms in the intestine. In his essay on cancer
the author commits himself more ftilly to the par-
asitic theory than, in our opinion, is justifiable in the
present state of our knowledge.
BOOKS. PAMPHLETS, ETC.. RECEIVED
The Opsonic Method of Treatment. A Short Compen-
dium for General Practitioners, Students, and Others. By
R. W. Allen, M. B., B. S. (Lond.), Pathologist to the Royal
Eye Hospital, London, S. E., etc. Philadelphia : P. Blakis
ton's Son & Co., 1Q08. Pp. 138. (Price, $1.50.)
The Development of Ophthalmology in America. 1800
to 1870. A Contribution to Ophthalmological History and
Biography. An address delivered in Abstract before tlic
Section in Ophthaniology of the American Medical Asso-
ciation, June 4, 1907. Revised and Enlarged. Ilhistrnted
by Selected Portraits and Cuts. By .\\\'m A. Hubbell,
M. D., Ph. D., Professor of Clinical Ophthalmology in the
University of Buffalo, etc. Chicago: W. T. Keener & Co.,
1908. Pp. 197- (Price, $1.75.)
An Index of Treatment. By Various Writers. Edited by
Robert Hutchison, M. D., F. R. C. P.. Physician to the
May 30, 1908.]
OFFICIAL NEWS.
London Hospital, etc., and H. Stansfield Collier, F. R. C. S.,
Surgeon to St. Mary's Hospital, etc. Revised to Conform
with American Usage by Warren Coleman, M. D., Pro-
fessor of Clinical Medicine and Instructor in Therapeutics
in Cornell University Medical College, etc. New York:
William Wood & Co., 1908. Pp. 888.
A Textbook of the Practice of Medicine. For Students
md Practitioners. By James Magoffin French. A. M., M. D.,
Formerly Lecturer on the Theory and Practice of Medi-
cine, Medical College of Ohio. Third, Revised Edition.
Illustrated by One Hundred and Ten Engravings in the
Text and Twenty-five Full Page Plates in Tints and
Colors. New York : William Wood & Co., 1907. Pp. xxii-
1253-
Abdominal Tuberculosis. By A. Ernest Maylard, M. B.,
B. S. (Lond.). Surgeon to the Victoria Infirmary, Glas-
gow, etc. Philadelphia : P. Blakiston's Son & Co., 1908.
Pp. xvi-360. (Price, $4.)
The Principles and Practice of Hydrotherapy. A Guide
to the Application of Water in Disease. For Students and
Practitioners of Medicine. By Simon Baruch, M. D., Pro-
fessor of Hydrotherapy in Columbia University (College
of Physicians and Surgeons), New York, etc. Third Edi-
tion, Revised and Enlarged. With Numerous Illustrations.
New York : William Wood & Co., 1908. Pp. 544.
Cancer. Relief of Pain and Possible Cure. By Skene
Kehh, M. B., F. R. C. S. (Ed.), Author of Introduction to
the Treatment of Disease by Galvanism, etc., and George
F. Keith, M. B., C. M., Author of Textbook of Abdominal
Surgery ^\ ith Mr. Skene Keith. London : Adam and
Charles Black, 1908. Pp. 155.
Scientific Nutrition Simplified, A Condensed Statement
and E.xplanation for Everybody of the Discoveries of Chit-
tenden, Fletcher, and Others. By Goodwin Brown, A. M.
New York : Frederick A. Stokes Company, 1908, Pp, 200,
Tascheribuch der Physiologic. Von Prof. Dr. med. H.
Boruttau in Berlin. Heft i und Heft 2, Leipzig: Dr.
Werner Klinkhardt, 1908. Pp. 243.
La Diathese urique. Par Henri Labbe, chef de labora-
toire a la Faculte de medecine de Paris. Paris : J. B. Bail-
liere et Fils, 1908." Pp. 95.
Lehrbuch der Ohrenheilkunde. Fiir Studierende und
Aerzte. Von Dr. Georg Boenninghaus, Priv. Doz. fiir
Ohrenheilkunde. Ohrenarzt am St. Georgs-Krankenhaus zn
Breslau. Mit 139 Textabbildnngen und i Tafel farbiger
Trommelfellbilder. Berlin : S. Karger, 1908. Pp. viii-376.
(Price, M. 9.80.)
Beitrage zur allgemeinen Kolloidchemie. Von Dr. B.
Szilard, Paris. Dresden : Theodor SteinkopfT, 1908. Pp.
41. (Price. M. 1.50.)
Untersuchungen zur Kenntnis der psychomotorischen
Bewegungsstorungen bei Geisteskranken. Von Dr. Karl
Kleist. Assistenzarzt der Klinik fiir Nerven- und Geistes-
krankheiten zu Halle a. S. Leipzig : Dr. Werner Klink-
hardt. 1908. Pp. viii-171. (Price, M. 6.)
Traite de I'alimentation et de la nutrition a I'etat normal
et pathologique. Par le Dr. E. Maurel, medecin principal
de Reserve de la Marine, professeur a Faculte de medecine
de Toulouse. Deuxieme volume. Les rations a I'etat nor-
mal. Ration moyenne d'entretien de I'adulte. Ration de
croissance et apres I'age adulte. Paris : O. Doin, 1908. Pp.
xv-666.
Die nervosen Erkrankungen des Geschmackes und
Geruches. Von Prof. Dr. L. v. Frankl-Hochwart. Zweite,
ganzlich umgearbeitete Auflage. Mit 14 Abbildungen.
Wien und Leipzig: Alfred Holder, 1908. Pp. iv-96.
Die Lehre von der Intubation. Von Prof. Dr. J. von
Bokay, Direktor des Stefanie Kinderspitals zu Budapest,
etc. Mit 113 Abbildungen und 2 Tabellen im Text, Leip-
zig: F. C, W, Vogel, 1908, Pp, 250. (Price, M. 10,)
Fourth Annual Messa,ge of John Weaver, Mayor of the
City of Philadelphia, With the Annual Reports of the
Director of the Department of Public Health and Charities
and Superintendent of the Bureau of Charities, For the
Year ending December 31, 1906. Issued by the City of
Philadelphia, 1907,
A Manual of Fever Nursing. By Reynold Webb Wilcox,
M. A., M. D., LL. D., Professor of Medicine at the New
York Postgraduate Medical School and Hospital, etc. Sec-
ond Edition, Revised. Illustrated, Philadelphia : P. Blakis-
ton's Son & Co., 1908, Pp, 229, (Price, $1.)
Transactions of the Obstetrical Society of London. Vol-
ume xlix. For the Year 1907. With a List of Officers,
Fellows, etc., and General Index to Vols, i to xlix. Part
III. For June and July. Edited by Herbert B. Spencer,
M. D., and Robert Boxall, M. D., Senior Secretary. Lon-
don : Published by the Society, 1907.
Forty-third Annual Report of the Trustees of the Boston
City Hospital, Including the Report of the Superintendent.
Official gm.
Public Health and Marine Hospital Service
Health Reports:
The folloiving cases of smallpox, yellow fever, cholera,
and plague have been reported to the surgeon general,
United States Public Health and Marine Hospital Service,
during the week ending May 22, 1908:
Smallpox — United States. .
Places. Date. Cases. Deaths.
Alabama — Mobile May 9-16 6
California — Los Angeles April 25-May 2 3
California — San Diego and vicinity May 1-8 7
California — San Francisco '..April 25-May 2 5
District of Columbia — Wasington . . May 2-9 5
Illinois — Chicago May 2 9 4
Illinois— Danville May 3-10 2
Illinois — ^Jacksonville May 2-9 i
Illinois — Springfield April 3o-May 7 3
Indiana — Fort Wayne May 2-9 4
Indiana — Indianapolis May 3-10 8
Indiana — La Fayette ilay 5-1 1 2
Iowa — Albion Jan. 1-31 10
Iowa — Ottumwa May 2-9 ^
Kansas — Kansas City ilay 2-9
Kansas — Topeka May 2-9
Kentucky — Covington May 2-9
Louisiana — New Orleans May 2-9
Michigan — Grand Rapids May 2-9
Michigan — Kalamazoo May 2-9
Michigan — Saginaw May 2-9
Missouri — St. Joseph March 21-May 9...
Missouri — St. Louis May 2-9
Nebraska — South Omaha May 2-9
North Carolina — Charlotte May 1-8
Ohio — Cincinnati ilay i-8
Ohio — Toledo April 25-May 2....
Tennessee — Nashville Mav 2-9
Texas — Galveston May 1-8 2
Texas — San .Antonio May 2-9 6
Washington — Spokane April 25-May 2 9
Washington — Tacoma May 2-9 2
Wisconsin — La Crosse April 25-May 9 12
Smallpo.v — Insular.
Philippine Islands — Manilla March 21-28 7
Smallpox — Fo re ign .
Austria — Trieste April 18-25 i
Belgium — Ghent A nl 18-25 i
Brazil — Rio de Janeiro March 30-April 12... 240
China — Amoy Feb, 15-April 4
China — Hongkong March 14-28 51
China — Shanghai April 4-12 i
Egypt — Cairo April 8-22 8
France — Paris April 18-25 2
India — Bombay Auril 7-14
India — Calcutta March 28-April 4...
India — Rangoon Marcn 3o-.April 4....
Italy — General April 16-30 63
Italy — Catania April 23-30
Japan — Kobe April 4-1 1 6
Japan — Osaka March 28-April 4... 145
Mexico — .Aguascalientes April 26-May 3
Russia — Odessa \pril 2330 i
Russia — St. Petersburg April 4-18 53
Spain — Denia April 11-25 15
Spain — Valencia April 12-26 46
Straits Settlements — Singapore. . . . March 21-28
Transvaal— Pretoria March 28- .April 4
Turkey in Asia — Bagdad March 28-April 11... 65
Turkey in Europe — Constantinople . April 12-26
Yellow Fever — Foreign.
Barbadoes — Bridgetown and vi-
cinity Anril 14 i
Costa Rica— Punta Arenas May 7 i
Cuba — Santiago May 18 i
Cholera — Insular.
Philippine Islands — Las Pinas March 21-28
Philippine Islands — Pangasinian
Province March 21-28
Cholera — Foreign.
Ceylon — Colombo March i8-April 4,..,
China — Hongkong Nov. 24-28 6
India — Bombay April 7-14... _
India — Calcutta March 28-April 4....
India — Madras April 4-10
India — Rangoon March 28-April 4. . . .
Plague — Foreign.
Australia — Brisbane Feb. 29-March 14... 3
Australia — Kempsey May 2-9 i
Brazil — Rio de Janeiro March 31-April 12... i
io66
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Jouenau
China — Hongkong March 14-28 8 7
India — Bombay April 7-14 393
India — Calcutta March 28-April 4.... 151
India — Rangoon March 28-April 4.... 32
Straits Settlements — Singapore. ... March 21-28 2
Public Health and Marine Hospital Service:
Official list of changes of stations and duties of commis-
sioned and noncommissioned oMcers of the United States
Public Health and Marine Hospital Service for the seven
days ending May .20, igo8:
AsHFORD, F. A., Assistant Surgeon. Granted leave of ab-
sence for four days, from April 12, 1908, on account of
sickness.
Bowie, R. I., Sanitary Inspector. Granted leave of absence
for thirty days, from July i, 1908, and extension of
leave without pay for fourteen days, from August
I, 1908.
BuRKHALTER, J. T., Passcd Assistant Surgeon. Granted
leave of absence for one month, from June 3, 1908.
Carrington, p. M., Surgeon. Granted leave of absence for
five days, from May 19. 1908, under paragraph 189,
Service Regulations.
Frost, W. H., Assistant Surgeon. Granted leave of absence
for two days. May 2 and 3, 1908, under paragraph 210,
Service Regulations.
Lanza, A. J., Assistant Surgeon. Relieved from duty on
the revenue cutter Manning, and directed to proceed
to Port Townsend, Wash., reporting to the command-
ing officer of the revenue cutter Rush for duty.
Mason, W. C., Acting Assistant Surgeon. Granted leave
of absence for two days, from May 28, 1908.
McLarty, a. a., Acting Assistant Surgeon. Granted leave
of absence for fourteen days, from May 15, 1908.
RosELLO, M. M., Acting Assistant Surgeon. Granted leave
of absence for four days, from April 25, 1908.
VoGEL, C. W., Passed Assistant Surgeon. Relieved from
special temporary duty at San Francisco, Gal., and
directed to proceed to San Juan and other quarantine
stations in the island of Porto Rico, and also to cer-
tain places in Venezuela, for special temporary duty.
Warren, B. S., Passed Assistant Surgeon. Granted leave
of absence for two rnonths, from June 5, 1908.
Young, G. B., Surgeon. Detailed to represent the Service
at the meeting of the American Medical Association,
Chicago, 111., June 2 to 6, 1908.
Boards Convened.
A board of medical officers was convened to meet in
New Orleans, La., for the purpose of making a physical
examination of Passed Assistant Surgeon T. D. Berry, in
accordance with paragraph 50 of the Service Regulations.
Detail for the board : Surgeon J. H. White, chairman ;
Passed Assistant Surgeon H. .W. Wickes ; Assistant Sur-
geon C. M. Fauntleroy, recorder.
A board of medical officers was convened to meet in
Chicago, 111., May 22, 1908, for the purpose of examining
applicants for the position of cadetship in the Revenue
Cutter Service. Detail for the board: Surgeon G. B.
Young, chairman ; Assistant Surgeon C. E. Wood, recorder.
A board of medical officers was convened to meet in
St. Louis, Mo., May 23, 1908, for the purpose of examining
an applicant for the position of cadetship in the Revenue
Cutter Service. Detail for the board : Passed Assistant
Surgeon B. S. Warren, chairman; Acting Assistant Sur-
geon H. C. Wakefield, recorder.
Army Intelligence:
Official list of changes in the stations and duties of
officers of the medical corps of the United States Army
for the weeli ending May 23, rgoS-
Cole, C. L., First Lieutenant. Ordered from Ft. Thomas,
Ky., to Ft. Benjamin Harrison, Ind., for duty.
DuTCHER, B. H., Major. Relieved from duty in the Philip-
pines Division in time to sail for the United States
about July 15th; granted two months' leave of absence.
Ei'.ERT, R. G.. Major. Arrived at San Francisco from tour
of the Philippine Service.
Ireland, M. W., Major. Detailed to represent the Medical
Department of the United States Army at the meeting
of American Medical Association, at Chicago, June 2
to 5, 1908.
Lynch, Charles, Major. Granted leave of absence to
June 30, 1908.
Navy Intelligence:
Official list of changes in the stations and duties of
officers of the medical corps of the United States Navy
for the weefi ending May 16, igo8:
Baker, M. C, Assistant Surgeon. Detached from the
navy yard, Mare Island, Cal., June ist, and ordered
to the Ohio.
Baker, M. W., Passed Assistant Surgeon. Detached from
the Colorado and ordered to the Nebraska.
Gather, D. C, Assistant Surgeon. Detached from the
Lancaster and ordered to the naval recruiting station,
Kansas City, Mo.
Dunn, H. A., Passed Assistant Surgeon. Detached from
the NebrasJ^a and ordered to the Colorado.
Farenholt, A., Surgeon. Detached from the Independence
and ordered to the Maryland.
Garrison, H. A., Assistant Surgeon. Detached from the
Naval Hospital, Philadelphia, June 20th, and ordered
to the naval station.
Kennedy, J. T., Surgeon. Detached from the naval re-
cruiting station, Dallas. Tex., and ordered to the
Independence.
Mayers, G. M., Passed Assistant Surgeon. Ordered to the
navy yard, Mare Island, Cal.
Moran, C. L., Assistant Surgeon. Detached from the
Naval Hospital, Norfolk, Va., and ordered to the naval
recruiting station, Dallas, Tex.
Shipp, E. M., Surgeon. Detached from the Illinois and'
ordered to the Pennsylvania.
Urie, J. F., Surgeon. Detached from the Pennsylvania
and ordered to the Illinois.
Married.
Astley — Casselberry.- — In Philadelphia, on Sunday,
May 17th, Dr. George Mason Astley and Dr. Clara Melvia
Casselberry.
Collins — Hendershot. — In Platteville, Wisconsin, on^
Thursday, May 14th, Dr. W. P. Collins and Miss Mae
Hendershot.
Dowd — Grote. — In Indianapolis, Indiana, on Tuesday,
May I2th, Dr. Francis Tobias Dowd and Miss Nannette
Grote.
Huggins — CoLLADAY.^ — In Washington, D. C, on Thurs-
day, May 14th, Dr. John B. Huggins, Medical Corps,
United States Army, and Mrs. Rose Loretto Colladay.
Died.
Alling. — In Dunkirk, New York, on Friday, May 8th,
Dr. Charles P. Alling, aged seventy years.
Beach. — In Hartford, Connecticut, on Friday, May 15th,
Dr. Oliver J. Beach, aged thirty-five years.
Behm. — In Chicago, on Saturday, May i6th, Dr. Charles
E. Behm, aged thirty-eight years.
Carrington. — In Farmington, Connecticut, on Wednes-
day, May 20th, Charles Carrington, aged sixty-nine years.
Cuddy. — In Baltimore, Maryland, on Thursday, Mav •
14th, Dr. J. W. C. Cuddy.
Harman. — In Wakefield, Nebraska, on Tuesday, May
I2th. Dr. B. T. Harman, aged sixty-five years.
Long.— In Somerville, New Jersey, on Wednesday, May
20th, Dr. William H. Long.
Marcour. — In New Orleans. Louisiana, on Sunday, May
17th, Dr. Raphael O. Marcour, aged thirty-four years.
Pear.son.— In Toronto, Canada, on Sunday, May 17th..
Dr. B. F. Pearson, aged sixty-eight years.
Petpis. — In West Branch. Michi,gan. on Monday, May
T8th, Dr. A. J. Petpis, aged thirty-eight years.
Salesman.— In Jersey City, New Jersey, on Monday.
May i8th. Dr. E. .\. G. Salesman.
Stillman. — In New London, Connecticut, on Thursday,
May 2ist, Dr. Martha Rose Stillman, of Plainfield.
New Jersey.
Stritthers. — In Sudbury, Canada, on Thursday, May
14th. Dr. R. B. Struthers. aged forty-nine years.
Tweedy.— In Buffalo. New York, on Wednesday, May
1,3th, Dr. Edward H. Tweedy, aged forty-three years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal rlt Medical News
A Weekly Review of Medicine, Established 184J.
\'oL. LXXXMI. Xo. 23.
XEW YORK, JUNE 6. 1908.
Whole Xo. 1540.
(Brigmal Cflmmunications.
EXPERT TESTIMONY.*
By Judge Rufus B. Cow ing,
New York.
Some days ago I was invited by the worthy presi-
dent of the Xew York Academy of Medicine to
attend this meeting and make some remarks on the
value of medical expert testimony, based upon my
experience and observation on the criminal bench
of this county. It can hardly be expected that I
shall be able before such a bod-*" of medical scien-
tists to present many new ideas, for my subject has
frequently been a matter of discussion between phy-
sicians and lawyers. It may be said, however, that
I am here to-night as a sort of expert to address
you on the value of medical expert testimony, as
during my twent3"-eight years on the bench in the
court of general sessions of this county I presided
over many criminal trials where medical experts
were called upon to give their opinions.
The safeguards provided by the criminal law to
protect the innocent are many, and after a long
experience and much observation I have come to
the conclusion that it is practically impossible to con-
vict an innocent person of crime when all these safe-
guards are invoked and observed in a criminal pros-
ecution against him.
Ever}- person charged with the commission of a
crime: i. Is presumed to be innocent until he is
proved guilty. 2. Has the right to be defended by
his own counsel, and to call witnesses in his defense.
3. Has the right to assist in selecting his own jury.
4, Has the right to challenge, with or without cause,
any juryman whom, for any reason, he considers
imfavorable to him. 5. Has the right to see and
examine the indictment against him. and make such
objection to it as his counsel may suggest. 6, Has
the right to face his accusers in an open and public
court. 7. Has the right, through his counsel, to
thorotighly and rigidly cross examine the witnesses
against him in order to determine the truthfulness
of their testimony. 8. Has the right to object to the
admission or exclusion of any evidence which his
counsel may think is unfavorable or favorable to his
side of the case. 9, Has the right to object to any-
thing said or done during the progress of the trial
which he considers prejudicial to him or his case.
10, Cannot be convicted upon a preponderance of
evidence, but can only be convicted upon such evi-
dence as satisfies the consciences of twelve men.
*Read before a meeting of the Xew York Academy of Medicine.
'The author here alluded to the Tiilniage case.
Copyright. igoS. by A. R.
whom he has himself assisted in selecting, beyond all
reasonable doubt. 1 1. Has the rigiit of appeal, either
with or without exceptions, if the verdict is against
him, so that practically his whole case may be retried
by an appellate court, and a new trial granted him
if the appellate court, after a review of the whole
case, comes to the conclusion that justice demands
it. 12. Has the right to take the witness stand in
his own behalf, if he elects to do so ; and if he re-
fuses to do so the jury have no right on that account
to draw any unfavorable inferences against him.
All these safeguards and many others are un-
doubtedly provided for the protection of the inno-
cent, and not of the guilty, and, as I said before,
make it practically impossible to convict an innocent
person of a crime.
^M^en a person kills another under such circum-
stances that the only possible defense is that he was
insane at the time of the killing, he calls as wit-
nesses all persons acquainted with his past life, who
narrate to the jury all the strange, odd. and eccen-
tric things which he has ever done or said, and, if
possible, testify that one or more of his lineal ances-
tors were insane, and that the defendant has suffered
from diseases which would be likely to disturb his
equilibrium. The people controvert the defense by
putting in all attainable evidence to show that the
defendant at the time of the killing was not only
sane, but criminally liable.
Both sides then produce medical experts to sus-
tain their respective contentions, and it is a remark-
able fact that both sides can generally obtain as
many experts as they are willing to pay for.
Both sides then proceed to draw up a long hypo-
thetical question, based, as a rule, not upon the
whole evidence, but only upon so much of it as seems
to sustain their theory, and from their respective
experts obtain answers so contradictory that the iur\-
is often obliged to discard the whole of it and decide
the case upon the evidence and its own unaided judg-
ment.
I have never heard of a case in which the sole
defense was insanity, where the defendant was put
upon the witness stand, and I have often wondered
what the result would be if he should be called as
a witness in his own behalf, and on cross examina-
tion be asked a few relevant and material questions,
such as :
Are you in the habit of carrving a revolver loaded
with powder and ball? Do you remember the time
when and the place where you shot and killed the
deceased? Did you know at the time you shot the
deceased that if you shot him in the heart or any
vital part of his body it would probably kill him?
E:iiott Publishing Company.
io68
COIVING: EXPERT TESTIMONY.
[New York
Medical Journal.
Did you know that in shooting the deceased you were
doini; an unlawful act? And other similar questions
whicli niiglit he put to him by a skilled cross exam-
iner.
Legal evidence is that which is properly submitted
to a competent tribunal as a means of ascertaining
the truth of any alleged matter of fact under investi-
gation before it. Tersely put, it is a means to an
end, the end being th.c ascertainment of the truth.
While opinions of experts are not facts, yet under
certain circumstances they are admitted in evidence
as aids to the court and jury in the ascertainment of
facts.
Our present judicial procedure, instituted for the
purpose of administering the civil and criminal jus-
tice in our courts, is constantly undergoing change,
and it cannot justly be claimed that the same is in
all respects perfect.
It is believed b\- many that our present jury sys-
tem very inadequately answers the purpose for
which it was mstituted, and that trial by jury should
be superseded by some other more certain and reli-
able method for the ascertainment of the truth.
While I don't think tliat our present method is
perfect, I do think that it is the best system; which
has yet been suggested or devised, and from my ex-
perience and observation I believe that the jury
generallv arrive at a just conclusion on the facts in
any given case and commit less errors than some
judges in determining questions of law in the same
case.
It is a fundamental principle of the criminal law
that every sane person who has arrived at the age
of discretion is conclusively presumed to know the
law. I onl\' know of one exception where this rule
docs not apply, and that is to our able judges, and
for that reason the State provides appellate courts
to review their decisions and correct their mistakes
of law.
From my observation and experience I am of the
opinion that a competent, honest, and impartial
medical exuert may and often does aid a jury mate-
rially in determining the facts in a case on trial, but
I am al-^o of the o|)inion that the practice now in
vogut' in reference t<i medical ex])ert testimony must
be radically changed before it will receive from
courts, juries, and the general public that considera-
tion to which it is justly entitled.
A medical expert is a doctor of medicine or sur-
gery who, by special study and experience, has ac-
quired skill and a peculiar knowledge upon certain
subjects pertaining to his profession, which qualify
him as an expert and render him competent to give
his opinion in a judicial proceeding upon such sub-
jects.
The o])inions of experts are not, however, admis-
sil)lc u])on matters of common knowledge. As these
arc within ccjmmon observation and experience the
jurors are deemed (|ualificd to judge without expert
aid.
Besides being an expert it luust not be forgotten
that he is al.so a witness, and. in fact, is only dist n-
guishal)lc from a nonexpert or lay witness in that
he is permitted to give his opinion in answer to a
hypothetical (juestion basetl upon assumed facts in
evidence which are i\ot within his own personal
knowledge, while a nonexpert or lay witness can
only base his opinion upon facts within his own per-
sonal knowledge, which have first been disclosed to
the jury by Iiim.
Neither the opinion of the expert or nonexpert
witness is conclusive upon the jury, wYio- are the
sole judges of the facts, but is to be weighed like all
other evidence, and the jury should always consider
quality as well as quantity ; in fact, the jury may
come to a conclusion against the greater number of
opinions and in favor of the lesser.
The opinion of one competent expert may, on ac-
count of his greater knowledge and experience of
the subject, or from his giving a fuller detail of the
facts or more probable reasons, be of greater value
to the jury than the opposite opinions of several.
We sometimes hear lawyers seriously argue to the
jury that quantity should have as nuich weight with
them as quality. I call to mind a case which was
tried before me in which the lawyer for the defend-
ant, after the close of the people's case, informed his
client that he must be on hand the next morning
at the opening of court with at least seven witnesses,
he having ascertained after counting up that the
people had called six.
In propounding a hypothetical question to a med-
ical expert, as the law now stands, the counsel has
the right lo assume, within tb.e limits of the evi-
dence, any state of facts which he thinks the evi-
dence justifies, and ask the witness to give his opin-
ion upon the facts thus assumed, which facts are
assumed only for the purpose of the question, and
for no other purpose. If the jur}- find that the facts
stated in the hypothetical question are not proved,
the opinion goes for nothing. The counsel may em-
brace in his hypothetical question such facts as he
may deem established by the evidence, and if the
opposing counsel does not think that all of the rele-
vant facts in evidence are contained in such ques-
tion, he may include them in a ((uestion propounded
bv him on cross examination.
The principal defects in medical expert testimony
are as follows: i. Its partisan character. 2, The in-
sufficiency of the present standard of qualification.
3, The excessive number of experts examined. _],
The right given to experts to give their opinions
based upon facts or alleged facts not within their
own ijersouai km i\\ ledge.
1. \'ery nuich of the just and harsh criticism
which has from time to time been made bv om^
courts against expert testimony and which has
brought such testimony into disrespect and dis-
repute among the public generally is its partisan
character, which is invariably shown from the fact
that an expert always gives his opinion in the inter-
est of the party by whom he is called and paid, and
the further fact that he very frecpiently participates
in the trial in the double capacity of witness and
adviser to counsel trying the case. How to over-
come these objections so as to make experts more
fair and impartial is one of the (luestions to be deter-
mined. I will later discuss this phase of the (|ues-
tion more in detail.
2. In a criminal case where the insanity of the
defendant is the defense, besides the usual ques-
tions put to the proposed expert witness as to tlie
extent of his study of medicine and surgery, an;I
COIJ'IXG: EXPERT TESTIMONY.
1069
his experience in treating diseases of the mind, he
should be asked whether he has made a special
study of psychology, and whether he is familiar
with the law's definition of insanity, and whether he
believes that law just and right.
A medical expert should be versed in psychology
as well as physiology, particularly in these days,
when it is bein.g recognized more and more that both
form a part of the science of healing.
In the colloquy between Macbeth and his wife's
physician, Shakespeare showed that in his day the
medical profession was not as far advanced in this
resf>ect as in our time.
Macbeth: How does your patient, doctor?
Doctor: Not so sick, my lord, as she is troubled with
thick coming fancies
That keep her from her rest.
Macheth : Cure her of that.
Canst thou not minister to a mind diseased?
Pluck from the memory a rooted sorrow.
Raze out the written trouble of the brain.
And with seme sweet oblivious antidote
Cleanse the stuff'd bosom of that perilous grief
which weighs upon the heart?
Doctor : Therein the patient must minister unto himself.
Macbeth: Throw physic to the dogs; I'll none of it.
The mere fact that a witness is a practising phy-
sician should in no case render him a competent
expert witness in cases , where insanity is the issue.
He may be a competent expert in diseases of the
eye, the ear, the heart, the kidneys, or any other
part of the human anatomy, but an incompetent
expert witness in diseases of the mind.
I have heard medical experts say that they did
not believe that the law's definition of insanity is
either just or right. By the law of this State a
person is not excused from criminal liability as an
insane person except upon proof that at the time
of committing the alleged criminal act he w-as labor-
ing under such a defect of reason as either not to
know the nature and quality of the act he was doing,
or did not know the act was wrong. It is very read-
ily seen that every degree of insanity will not excuse
a criminal act, but onlv such degree as comes within
the law's definition. A person, to establish his de-
fense of insanity as an excuse for an otherwise
criminal act, must be able to show that his mind
was so diseased at the time of committing the act
tliat he did not have sufficient mental capacitv' to
form a criminal intent, and that he did not know
the nature and quality of his act or that the act was
wrong.
3. With reference to the number of experts to
be called by the respective sides, it should never be
left to the discretion of counsel, but to the discretion
of the court, and, as a rale, never more than two
for each side should be allowed. This would com-
pel the respective parties to produce the best experts
obtainable, and would save time and much confu-
sion to the jury, which often results from a multi-
plicity of experts.
4. In my judgment the practice of allowing a
medical expert to give his opinion upon a hypo-
thetical question based upon assumed facts not with-
in his personal knowledge should be done awav
with.
Every witness who is permitted to give an opin-
ion should be compelled to first give the facts with-
in his own personal knowled.ge and observation upon
which his opmion is predicated, which would enable
the jury to determine whether the disclosed facts
justify his conclusion.
These long drawn out hypothetical questions,
which are based only upon a portion of the evidence
and usually upon that portion only which is most
favorable to the party asking the question, which
sometimes contain two or three thousand words and
require an hour or more to read, and which as a
rule are unfair and misleading, in my opinion, in-
stead of aiding the jury in coming to a correct con-
clusion, mystify and confuse them to such an extent
as sometimes to cause a miscarriage of justice.
It must be remembered that in criminal cases the
defense of insanity is often manufactured and is
the only conceivable defense which can be made.
An expert who is not possessed of sufficient abil-
ity to personally examine the defendant and ascer-
tain for himself the facts upon which he predicates
his opinion should not be allowed to give it.
The rule regulating the admissibility of the opin-
ions of nonexpert or lay witnesses upon questions
affecting the mental condition of a person should be
applied to expert witnesses. We find the rule laid
down in the case of "People vs. Conroy." decided
in the Court of Appeals in 1884, as follows :
"When a layman is examined as to facts within
his own knowledge and observation tending to show
the soundness or unsoundness of the defendant's
mind, he may characterize as rational or irrational
the acts and declarations to which he testifies. But
to render his opinion admissible even to this extent,
it must be limited to his conclusion from the specific
facts he discloses."
To revert to the question of allowing medical ex-
perts to act in the dual capacity of counsel and wit-
ness. There has grown up a practice in the courts
of calling medical experts to aid the respective
counsel in conducting the trial by suggesting ques-
tions to be put to medical expert witnesses, thus
making them practically counsel in the case, and
afterwards calling them as witnesses to sustain the
side of the case for which they have been acting in
the capacity of counsel. All this is done in the pres-
ence and hearing of the jury, and has the effect of
convincing them that experts are not fair and im-
partial witnesses, but are prejudiced in favor of the
party calling and paying them.
This practice has had much to do in bringing
medical expert testimony into disrepute, and should
be done away with.
There can be no valid objection for either side
in a criminal case to employ able medical experts
to assist counsel in conducting the trial, but having
so acted they should never be permitted to go upon
the witness stand ss experts. In other words, they
should never act in the double capacity of witness
and coimsel.
\'arious means have been suggested by lawyers
and doctors for minimizing the evil which attends
the reception of medical expert testimony at the
present time.
Among such remedies are : i , The appointment
by som.e competent power of medical expert wit-
nesses, who must qualify themsleves to give opinion
evidence in the case without consultation with the
litigants or their counsel, and whose services must
lO/O
ABBOTT AND PINGREE: NORMAL BALANCE OF FOOT.
TNew York
Medical Journal
be paid for by the county in which the trial takes
place. 2, A statutory prohibition against receiving
any expert evidence from a witness who has been
paid or expects to be paid anything by either party,
which is practically going back to the old rule of
evidence, which disqualified a witness who had any
pecuniary interest in the result of the trial. 3, The
appointment of a commission of experts in insanity
cases to examine the person alleged to be insane
before trial and make a report to be read at the trial,
where all the members of the commission must
attend to be examined and cross examined, as either
part} ma}- desire, \vithout compensation except a
fee to be fixed and paid by the State.
For many years the law of England and this State
made any one who had a pecuniary interest in the
result of a lawsuit an incompetent witness to testify
in such suit.
While this rule of evidence has been relaxed so
that pecuniary interest no longer disqualifies, yet
juries and courts have a right and should consider
such interest in determining the credibility of the
witness.
The reason of the old rule rendering such a wit-
ness incompetent was that his testimony was consid-
ered to be so prejudiced as to render it unreliable
for the jury to consider in coming to a conclusion,
and it seems to me that the reason of this old rule
applies with great force to medical experts, and how
to change the present system of obtaining and pay-
ing such experts, so as to render their testimony
less liable to be discredited, is the question which
the medical and legal professions are now trying to
determine.
The proposed plan of having some disinterested
power select and pay such experts is not unattended
with difficulties, but one thing is certain : This soci-
ety and other similar liodies can formulate wise
rules of medical ethics, which shall bind all their
members and materially aid in solving the questiou.
THE RESTORATION OF THE NORMAL BALANCE
OF THE FOOT.
HE
Third Paper. Operative Measures in JVeak or Flat Fool
Upon the Tendons of Tliose Muscles ]Vhich Normally
Control the Arch Movements, for the Purpose of
Correctino tlte Deformity.
By E. G. Abbott, D., .\xd H. A. Pingree. ]\L D.,
Portland, Me.
The use of a mechanical support alone for the
cure of weak or flat foot is ineffective, as stated in
the preceding paper (see Jonural, p. 976), since it
tends to weaken the already overstretched structures
which, when in a normal condition, hold the foot in
a correct position.
The use of a support simply as a means of relief
is objectionable, as patients are not only averse to
wearing such a cumbersome apparatus over
a long period, but the expense and troulile are fac-
tors to be considered. The orthopaedic surgeon also
realizes that the result obtained is only palliative,
as the gait is never normal, although the plate may
be an excellent fit, and there is a prompt return of
the deformity as soon as its use is discontinued.
In order, then, to effect a cure with the use of a
support it is necessary to supplement it with a long
continued course in muscular exercises, as the arch
can be maintained in a normal position, if unsup-
ported, by muscular development only.
The restoration to a normal condition as a result
from this combined method of treatment need not
Fig. 33. — Showing hypertropliy of anterior and posterior tibial
tendons in weak foot.
be expected in all cases, even under the direction
of the most skilled surgeon and with the assistance
of the patient, as conditions are such in many in-
stances that the parts at fault fail to respond to the
treatment, and the result too often is a foot which
remains in a normal position only so long as the
support is used.
There are a large number of patients for whom
it is useless to prescribe muscular exercises for any
considerable period, as many are so busily engaged
that they neglect them, many are too indolent, while
Fig. 34. — Showing shortened peronei tendons which prevent the
arch from being raised to a normal position.
June 6. 1 908. J
ABBOTT AXD PINGREE
NORMAL BALANCE OF FOOT
IO71
a greater number are so ignorant and poor that they
cannot be kept under the necessary observation dur-
ing such a course of treatment.
In consideration of the foregoing it would seem
best, if possible, that some method should be adopted
for the treatment of these cases which would be
effective, would be adapted to the conditions met
Fig. 35. — a. Arch flattened and held by peronei. b, Arch in nor-
mal position as soon as tendons are divided.
in the majority of patients, would not involve the
expenditure of a considerable length of time, and
would insure a larger percentage of cures than that
obtained under our present plan of treatment.
A review of the literature upon conservative
measures shows that almost all conceivable methods
and agents have been utilized, either alone or in
combination, with about the same results, and the
question naturally arises, is not the operative plan
of treatment the only one which offers a solution
of the difficulties which are so apparent?
Several operations for the relief of this deform-
ity have been devised which have been more or less
successful in a certain class of cases, but none has
been generally adopted, and at the present time
there does not seem to be any surgical procedure
which will successfully overcome the condition me',
with in a majority of these patients.
A brief reference to the description in the pre-
ceding paper of the structural changes which have
taken place in a weak foot, and a consideration of
36 a 56 2r
Fir. 36. — a. .^rch flattened and held by tendo Achillis. b. \tq\\
corrected as soon as tendo Achilles is severed.
what might be done in the way of operative work
to bring the foot to a normal condition, will help
us in determining whether such measures would be
feasible.
As already stated, the complications in weak foot
must be overcome before curative measures of any
kind can be successfully carried out ; therefore, the
analysis of its struijtures sh(juld begin with the foot
in a state where it is freely movable in all directions,
i. e., as far as interjoint motion is concerned. The
only abnormal condition then would be the patient's
inability to maintain unaided the foot in a normal
position, and this disability would be due either to
weakness and overstretching of those structures
that support a normal arch, which would prevent
the foot from being held in the correct position, or,
together with this, to shortening of those muscles
which depress the arch, which would make it im-
possible to even bring the foot into a correct posi-
tion.
The foot is found to be everted, the bones are
displaced and often misshapen, the ligaments are
stretched and attenuated, and some muscles are
lengthened, although they usually show marked
hypertrophy of their tendons (Fig. 33), while
others are often shortened (Fig. 34).
From our present knowledge it would seem, from
the before mentioned examination, that the only
Fig. 37. — Tendon elevator, showing manner of sliortening tendon
before dividing.
part wliich would admit of anv surgical interference
would be the muscles, since the bones cannot be
changed in shape by operative measures, as it would
destroy the ioint surfaces, and the ligaments are so
situated and are so numerous that any attempt to
alter them in this manner would be futile. The
only change, then, that could be made surgically to
better this condition, with a reasonable hope for a
return to the normal as a result, would be in the
muscles or their tendons, and this change can be
brought about only by shortening these which nor-
mally maintain the arch, and lengthening those
which prevent it from assuming the normal position.
The preliminary paper on this subject (see Jour-
nal, p. 875) showed, in the experiments described,
that the anterior and posterior til^ials are the muscles
which hold the arch in place, and that the peronei
muscles and the tendo Achillis prevent it from being
1072
ABBOTT AND PINGREE: NORMAL BALANCE OF FOOT.
LNew York
Medical Journal.
brought into a normal position readily if they are
shortened. It also showed that it reciuires only a
small amount of power, in comparison with that
necessary to lift the wcisi^ht of the body, upon the
anterior and posterior til)ial muscles to hold the arch
Fio. 38. — Position of limb in plaster of Paris after operation.
in place, when the patient bears his whole weight
upon the foot, provided that the peronei tendons
and the tendo Achillis are divided, so that, when
the experiment is made, the arch can be brought into
a normal position.
It would not seem unreasonable, then, to suppose
that this deformity may be corrected by a division
of those structures which resist the restoring of
the arch to a normal position, and a shortening of
those which normally maintain it in place.
It was from conclusions drawn from such an
analysis of these experiments that the following
briefly described operation was undertaken, and the
results so far obtained have given the operators
reason to believe tliat the work justifies further
consideration.
After the usual preparation, the foot is grasped
by the operator, with an assistant holding the leg.
and inverted with a moderate degree of force. With
the foot in this position the peronei tendons, wdiich
are upon the stretch, are severed sulunilanediisly at
a point about half way between the external malle-
olus and the- sole. This pmcedure allows the foot
to be inverted to its fullest extent by the surgeon,
and the arch assumes the highest position possible
(Fig. 35). The tendo Achillis is now divided, so
that the foot is hypcrflexed when force in this
direction is brought to bear upon it f iMg. 36). By
this means the calcancum is permitted to slide for-
ward upon the astragalus, thus elevating its anterior
extremity, relaxing the i)lantar ligament, and bring-
ing the tubercles to their normal position of weight
bearing. A short oblique incision is made over the
tendon of the anterior tibial muscle, iust in front
of the internal malleolus, at a point where it com-
mences to turn over the internal border of the foot.
The sheath of the tendon is opened, and a grooved
director — f-r. better, an instrument devised for pick-
ing up tendons — is pas.sed beneath the tendon, and
it is lifted abcjve the surrounding tissues. The
grooved director or tendon elevator supporting the
tendon is twisted in a circular manner until the de-
sired amount of shortening is made (Fig. 37), when
the contiguous parts of the proximal and distal ends
of the tendon are securely fastened together by
means of a linen suture. By this method just the
proper amount of tension upon the tendon can be
made, and the difficulty usually experienced in try-
ing to hold the cut ends in place while a suture is
passed and tied is avoided. The loop of the tendon
is severed, and the free ends are trimmed to a suit-
able length and sutured to the tendon. The sheath
is carefully stitched together, and the skin prefer-
ably closed by buried sutures. The tendon of the
posterior tibial is treated in a manner similar to the
one described, the incision being at a point where
it passes beneath the inner malleolus. The foot is
held in the position of flexion and extreme inver-
sion, the leg is flexed, and the limb enveloped in
plaster of Paris, including the foot, leg, and lower
part of the thigh (Fig. 38). The plaster dressing
remains in place for four weeks ; then it is removed,
and massage and passive motion commenced. A
week later the patient is allowed to walk with the
arch supported until the tendons are firmly united,
and the muscles sufficiently developed to hold the
foot in the corrected position.
The most important step of the operation is the
division of the peronei tendons and the heel cord;
for the arch in a large number of cases undoubt-
edly would return to a normal position without any
further surgical interference, since there is a strong
tendency for the foot to assume the correct position,
in most instances, as soon as^ these structures are
divided, for the opposing muscles no longer exert
any force, and without this opposing force the mus-
cles which hold up the arch wouUl in a brief time
shorten to their normal length.
The question which naturally confronts one at
this point is. Will these shortened tendons remain
so and hold the arch in a normal i:)osition when
Fig. 39. — Case immediately before opernlioii.
they are subjected to strain, or will they stretch
and allow the foot to flatten again? If tlie condi-
tions after the operation are the same as before
the deformity occurred, and the .same factors which
caused it in the first place arc present, it would
June 6, 1908.]
ABBOTT AND PINGREE: NORMAL BALANCE OF FOOT.
1073
seem that a recurrence would take place, as the ten-
dons are no stronger, and the ligaments weaker.
From observations made thus far, however, this
reasoning does not seem to be verified clinically, and
might be explained by these facts : First, that those
Fig. 40.- — Same case as in l"ig. 39. tliree weeks after operation.
factors which prin:arily caused the deformity are
eliminated, in that proper attention is given to the
foot wear, and the patient is instructed as to the
care of the feet, so that improper postures are
guarded against, and muscular exercises are encour-
aged ; second, that, although the condition after the
operation is similar, it is not the same as when the
deformity commenced, since the normal balance has
been restored-, therefore the arch is easily main-
tained in a normal position, as the muscles act to a
better advantage, in that the leverage is improved,
and in consequence of this the required muscular
power is much lessened.
It is not uncommon to find deformities in which
the condition at a certain stage is nearly analogous
to that found in the foot after this operation, which
will illustrate the point in question. For instance,
in acquired clubfoot, when the deformity first be-
gins, it is due to the shortening of the anterior and
posterior tibial muscles, which rre not only able to
Fig. 41. — Same case as in Fig. 39. twelve weeks after operation,
the I atient having walked for nine weeks.
increase the arch and invert the foot, but will turn
it bottom side up in a comparatively short time. To
those who have had experience in correcting this
deformity of clubfoot, even in those cases just be-
ginning, it is very apparent that these two muscles
are well able to maintain the arch of the foot in
place, if they can work to an advantage.
It does not seem unreasonable to believe, then,
that these muscles (tibialis anticus and posticus)
will not only hold the arch in position, but will con-
tinue to shorten after the operation until they are
sufficiently opposed by the lengthened peronei mus-
cles, since the normal balance in any segment of the
body is maintained only in this manner.
From the results so far obtained in this operation
there does not appear to be any tendency toward
a return of the deformity, but. instead, the im-
provement has been constant, and it seems possible
to correct this distortion by this method. At this
time, however, there has not been a sufficient num-
ber of cases operated in, nor has there been suf-
ficient time since the operations to warrant positive
statements as to the final outcome (Figs. 39, 40,
41).
In all patients who have submitted to the opera-
tion there has been a marked change for the bet-
ter, and in those cases where the result has not fully
met the expectations of a complete restoration of a
normal arch, the fault was an error in judgment as
to just how much of the tendon should be removed,
rather than any defect in the operation as a whole.
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Antonelli. Zeitschrift fiir orthoplidische Chirurgie, 1904.
Arnaiid. La Tarsectomie interne, etc. These de Mout-
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1905-
Bilhaus. Annales de chirurgie et d'orthopedie, 1907.
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I074
PIFFARD: ACTION OF MERCURY IN SYPHILIS.
[New-
Medical
York
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de Paris. 1906.
Joachimsthal. Deutsche inedicinische Wochenschrift,
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Jones. A f a' York Medical Journal, 1903.
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Kofmann. I'ciitsclic .Icrztc-Zcitung, 1907.
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Idem. Sirassburgcr inedi-znuschc Zeitung, 1906.
Ledderhose. Deutsche nicdicinische Wochenschrift, 1906.
Legg-. Boston Medical and Surgical Journal, 1907.
Lengfellner. Miincliener nicdicinische Wochenschrift,
1907.
Lovett. American Journal for Orthopcedic Surgery,
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Lucas. Illinois Medical Journal, 1906.
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Idem. Aerztliche Rundschau, 1906.
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Nicoladoni. Deutsche Zeitsclirift fiir Chirurgie, Ixiii.
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Palzer. Uebcr Schncn-T ransplantafioii hei statischeiii
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Poncet. Lyon medical. 1905.
Renton. (Aasgozc Medical Journal. 1903.
Roederer. La Cliniquc. Paris, 1907.
Sachs. Therapie der Gegcnicart. 1904.
Schultze. Zeitsclirift fiir ortliopcedische Chirurgie, 1904 ;
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Semeleder. iricncr klinische W ochenschrift, 1907.
Shands. International Clinics. 1903.
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Taylor. American Journal for Orthopccdic Surgery. 1905.
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Wilkins. 7 ransactions of the Xczc Hampshire Medical
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Wilson, H. .•\. .Annals of Surgery. 1906.
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Wilson and Patterson. American Medicine. 1905.
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THE SPECIFIC ACTION OF MERCURY IN
SYPHILIS.
Bv Henry G. Piffard, M, D.. LL. D.,
New York,
Professor Emeritus of Dermatology, New York University; Con.
suiting Surgeon, City Hospital, etc.
For several years Roux and Metchnikoff have
carrier! on a series of experiments at the Pasteur
Institute in the attempt to inoculate the anthropoid
apes and some of the lesser memhers of tlie simian
family with syphilis. In these experiments they
have obtained positive results. The ultimate aim of
these researches was to find, if possible, some means
whereby the effects of the inoculation could be pre-
vented l)eforc the virus pfained entrance to the £jen-
cral system. In this way they have apparently suc-
ceeded by the application of a mercurial ointment
composed of one part of calomel and two parts of
lanolin. This should be applied within twelve or
eighteen hours of the time of inoculation, and when
properly carried out general infection does not
occur. In other words, the mercury applied locally
destroys the spirochaetae.
During the progress of the investigation notices
thereof have appeared in Annalcs de riiistitiit Pas-
teur, and the general results have been embodied in
a These by Paul Maissonneuve. This has been
translated by de V'erteuil under the title, The E.v-
periinental Prophylaxis of Syphilis. From this little
work I quote a number of paragraphs ;
"The use of mercury applied locally in syphilis
has been advocated by eminent authorities on syphi-
lis, such as Deday, and more recently by Fournier."
Concerning mercury, Roux and Metchnikoff
quote Hallopeau (1906) as saying: "I systematic-
ally employ this local treatment in every syphilitic
lesion accessible to its influence. . . . Unless I
am mistaken, this systematic use of local mercurial
treatment, which I have already advocated on sev-
eral occasions, should not be looked upon as being
of little importance. I personally consider it to be
of great practical value" (p. 36).
Speaking for themselves, Roux and Metchnikoll
declare that "Mercury is even a greater specific
against the local disease than against the general)
disease" (p. 55).
Concerning the relation of potassium iodide to
the treatment of syphilis, I quote the following
(p. 29) : "It is, however, a matter of common
knowledge that it has no influence on the chancre
and on secondary lesions ; it has never been consid-
ered as an antimicrobic agent. We must not, there-
fore, expect to find in this drug an antidote against
the poison of syphilis.''
While these views as to the local action of mer-
cury and of the influence of the iodide in the treat-
ment of syphilis will be new to many, they are not
altogether novel, as will be seen by reference to my
own writings of more than thirty years ago (An
Elementary Treatise on Diseases of the Skin, 1876).
from which I quote the following :
"How does mercury cure the syphilides? Is it
by some alteration of the constitution of the blood,
and the consequent induction of nutritional changes,
or is it by direct local action of the drug upon the
lesion itself? The former is the more prevalent
belief, but the latter, I think, is nearer the truth.
J\lercury cures the lesions by the particles being
brought in direct contact with them, and ceteris
paribus, the larger the quantity of mercury that can
be made thus to act, the sooner the cure, provided
the remedy be used in such a way as not to exhibit
its own peculiar effects" (p. 69).
In a later writing (Cutaneous and J'enereal
Memoranda, 1877), ^ again referred to the local
effects of mercury as follows: "If there be mucous
patches or other lesions about the mouth, the tritu-
ration" (of mercury) "is to be preferred to the pill,
insomuch as the finely divided drug is thus bnnight
into immediate contact with the lesions themselves,
and by its local action hastens their removal." Still
later (Practical Treatise on Diseases of the Skin.
1891), I wrote concerning mercury as follows: "My
own practice is to use this agent both internally and
externally, believing as I do that the drug acts by
I line 6, 1908. J
LVXCH: IXTUSSUSCEPTIOX Ol- SIGMOID.
virtue of its particles being brought into direct con-
tact with the lesions, externally by means of lotions,
salves, or other applications ; internally, through the
medium of the blood and circulation" (p. 56).
Concerning the iodide, I wrote (1876) as fol-
lows : "Let us now consider the uses of the iodide
in connection with the treatment of syphilis. Mer-
cury removes symptoms and cures the disease, but
sometimes does so slowly. The iodide does not
cure the disease, but may remove certain symptoms
with wonderful promptness" (p. 73).
It is certainly gratifying to know that the views
as to the action of these drugs, presented more than
thirty years ago as the result of observation and
ratii cination, have been so amply confirmed by the
recent experimental laboratory work of the Pasteur
Institute.
256 West Fifty-sevexth Street.
IXTL'SSUSCEPTION OF THE SIGMOID.*
By Jerome M. Lynch, M. D.,
New York,
Lecturer on Rectal Surgery. New York Polyclinic and St. Bar-
tholomew's Clinic.
Intussusception of the sigmoid is a condition
which is much more frequent than we are aware,
and has such an important relation to constipation,
autointoxication, hjemorrhoids. mucous and mem-
branous colitis, that a short paper on the subject,
with a brief review of cases, may be of interest. By
the sigmoid I mean that portion of the intestine be-
tween the bifurcation of the common iliac arterv
and the perioneal reflection of the cul-de-sac of thl-
rectum. In other words, the iliac S of the French.
^^tiology. — When the mesentery of this organ is
abnormally long, it may be congenital or acquired.
As the sigmoid is the storehouse, or fa;cal retainer,
we can readily see how a long mesentery will, if the
calls of nature are not promptly heeded, cause em-
barrassment to the sigmoid. Inflammation, infec-
tion, and ulceration are very apt to follow under
pressure of hard fjecal matter on the mucous mem-
brane, when it is allowed to accumulate for anv
length of time. In order to evacuate the bowels
drastic cathartics are given, and, when these f-il to
give relief, enemas in abnormal quantities are re-
sorted to; as a result, straining at stool occurs,
bringing the abdominal muscles and diaphragm into
pla}-, which, owing to the pressure from above and
the relaxed state of the organ, eventually brings on
intussusception.
It is naturally trivial at first ; but when once start-
ed the difficulty of expulsion and the demands on
the abdominal muscles and diaphragm for extra
force are increased. The mesentery may become
elongated from constant dragging, due to' disphce-
ment of the surrounding organs, following child-
birth, or from inflammation. Acute diarrhoeal con-
ditions, due to constitutional disease or infection,
following amoebic dysentery, are astiological factors
to be considered. Also growths, like poh-pi, bv
causing straining and a frequent desire to evacuate
tlie bowels, are contributory factors.
*Read before the West Side Clinical Society, April 9, 1908.
Pathology. — liyron Robinson tells us that in these
conditions the submesosigmoidal tissues, vessels, and
veins are elongated and attenuated. Interference
with the circulation causes disturbed secretion and
peristalsis. There is an increase in the number of
goblet cells, infiltration with round cells, infection,
ulceration ; also, a thickening of the mucosa and
submucosa. When these conditions have existed
for any length of time, very extensive ulceration of
the sigmoid occurs, and sigmoiditis or perisigmoid-
itis is the result.
Symptoms. — A feeling of unfinished stool, follow-
ing a movement of the bowels, aching pain in the
sacrum, a passage of mucus or membrane, a drag-
ging sensation in the left iliac region, with a feeling
of heat across the lower portion of the abdomen and
back, periodical attacks of haemorrhage from the
bowels, colicky pains before the bowels move, pain
on sitting or standing for any length of time, head-
ache, vertigo, nausea, vomiting, frequent and pain-
ful urination, pain down the back of the legs. The
symptoms vary with the degree of intussusception,
Intussusception of lower portion of sigmoid into rectum.
length of time it has existed, and the involvement
of other organs.
The feeling of unfinished stool, following a move-
ment of the bowels, is the most constant and typical
symptom, and when present should lead to digital
and proctoscopic examination of the rectum. It is
described as a feeling of something in the rectum
that should come awa>-. In a short time after the
movement there is a desire to go to the toilet again,
when very little is accomplished, unless an enema is
taken. Assuming the knee chest posture will verv
often give relief.
Aching pain in the sacrum and pain down the
back of the legs are other symptoms which are pres-
ent in all cases, and are. no doubt, due to conges-
tion, pulling on the mesentery, and pressure in the
sacroplexus.
The feeling of heat in the ileopubic region and in
the sacrum is not present in all cases : but when it
manifests itself it causes a great deal of distress.
This symptom is due to congestion, because patients.
1076
LYNCH: INTUSSUSCEPTION OF SIGMOID.
[New York
Medical Journal.
as a rule, feel relief after a haemorrhage from the
bowels.
Passage of mucus or membrane depends a good
deal on" the degree of intussusception; if this is
marked, membrane is passed ; if not, only mucus.
Periodical attacks of hc-emorrhage usually occur
in cases in which the intussusception is severe, and
in which either constipation, or diarrhoea are marked
features. It is due, I presume, to the intense con-
gestion caused by the obstruction to the return cir-
culation. It also occurs when ulceration exists, and
I have seen ulceration of the entire circumference
of the bowel in these cases.
Colicky pains, before the bowels move, are due to
an effort on the part of nature to get rid of the ac-
cumulated gas and fjecal matter; the pulling of the
intestine on its mesentery in an effort to straighten
itself. Adhesions of the sigmoid, or some other
neighboring organ, may also cause it.
Pain, on sitting or standing, only occurs in a small
percentage of cases ; this is due to pressure and con-
gestion in the anal region.
Frecjuent and painful urination is no doubt a re-
flex s\ niptoni, due to the sympathy existing between
the urinar\- and rectal sphincters.
Trcatinciit. — The treatment may be divided into
palliative and operative.
Palliative treatment is indicated in those cases
where, owing to age or some constitutional disease,
operative treatment is contraindicated. The general
constitutional condition of the patient must always
be considered and' a suitable diet prescribed ; the
bowels moved every day with a mild laxative, and
an enema of olive oil or" saline solution employed to
wash the lower bowel and prevent straining. When
the condition is exaggerated, the patient should be
instructed to move the bowels when lying either on
the side or back, and a bed pan used. If there is
discomfort and pain after the movement, rest should
be advised, with the hips slightly elevated for an
hour or two. The patient can be taught how to
rephuT tile iiiti-^tiiK' ])as>ing a Xo. 3 Wales bou-
gie, to th(_ end of which is attached an inflating
bulb; when the bougie meets with any resistance, a
little air is introduced, and in this manner the bowel
is gradually rei^laced. After this four ounces of oil,
or some medicated solution, is introduced through
the bougie in position, and the patient directed to
rest for an hour, with hips elevated.
Office treatment, once or twice a week, is indi-
cated in most of these cases, for by this means we
are able to see if ulcerations exist, and, if so, to trrai
them locally ; also, the act of passing tlie tube and
the massage incident to the air pressure seems to
have a decidedly beneficial effect. If this procedure
is followed, impaction never takes place. And as
we cannot always depend on the patient to carry out
the treatment intelligently at home, it is well to
keep him under our supervision until we are satis-
fied that there is material improvement.
Openilk'c Treatment.' — The patient is prepared
in the usual way. as for any laparotomy. Beginning
about two and a half inches above the pubis an inci-
sion s«)me three inches long is made on the outer
side of the left rectus mu.scle. The sigmoid is easi-
ly reached through this incision, and brought into
'Tuttic wa» the hrst to suggest suturing the sigmoid to the
transvalis fascia.
view. Three or four Pegenstecher sutures are now
passed through the inverted transvalis fascia, on one
side, through the muscular wall of the intestine, and
again through the inverted edge of the transvalis
fascia on the other side,. In this way the intestine is
suspended from the fascia, instead of from the peri-
tonaeum. (This point should be borne in mind, be-
cause if the sigmoid is suspended from the perito-
naeum, instead of from the transvalis fascia, it grad-
ually relapses, with the result that a suspensatory
ligament is formed, and a return of the old condi-
tion inevitable.) The fascia is then closed by means
of interrupted sutures, and the skin with a continu-
ous plain catgut. The patient should be confined to
his bed for at least two weeks, and the bowels moved
about the fourth or fifth day.
Case I. — C. D., age twenty-three ; occupation laborer.
Family history: Father and mother both living and well.
Personal history : Has always suffered from constipation.
Present illness : About two or three years ago, he began to
have pain before the bowels moved ; the movements were
never satisfactory, and he had a feeling as if there was
something more to come away. He passed mucus and
blood occasionally, and suffered from severe pain in his
back and left iliac region, which was so severe at times as
to prevent his working. He felt better when he rested
awhile, but was hardly ever free from backache. Appetite
was poor, and he suffered from indigestion. He had lost
about ten pounds in the last six months.
The examination showed a normal heart and lungs. Ab-
domen was flaccid; there was slight tenderness over
descending colon and sigmoid ; and patient complained of
occasional pain over splenic flexure. Digital examination
revealed a protrusion into the rectum which felt like an
OS uteri, and was surrounded by sulcus. Proctoscopic ex-
amination showed hypertrophic catarrh of rectum ; some
mucus, and faecal matter ; sigmoidal mucous tnembrane was
congested ; bled easily, and was covered by a mucus
resembling the white of an egg.
Diagnosis: Prolapse of sigmoid.
Case H. — E. F., twenty-four years, nurse.
Family history : Mother had typhoid fever several years
ago, which was followed by colitis and constipation,
bather died of pneumonia.
Personal history : Several years ago patient had cellulitis
of the right leg ; diphtheria ; mastoiditis ; and typhoid fever.
She had suffered occasionally from muscular rheumatism,
and had had a pain in the rectum and left side since she
was thirteen years old. Pain was worse when she was
constipated.
Present illness : About two years ago she had a severe
diarrhoea which lasted four months ; following this, she
suffered from cnnstip;ition up to the time she was operated
upon for appendicitis: after this, her stools were fairly reg-
ular for a time. She suffered occasionally frotn diarrhcea ;
had had two attacks last week, and since then had been
constipated. Had distress and eruct^itions an hour and a
half after eating. About once in one or two weeks she had
attacks of severe gripino or twisting pains, which lasted
where in ni iwi Kr to fnurtecn hours, and were followed
1)\ the ])assase (if lar-e (|uaiitities of nnicus and membrane.
She njver had a satisfactory movement of the bowels;
always the feeling of unfinished business; but was relieved
when she took an enema.
Diagnosis : Extensive adhesions between omentum anJ
caecum ; the omentum was also adherent to the descending
colon or sigmoid. Cystic ovary about the size of an egg
adherent to the sigmoid, which was prolapsed. Mass could
be felt through the anterior vail of the rectum.
Case IH. — Mrs. C, thirty-two years, widow, appearance
healthy.
Family iiistory: Patient had menstruated at the age of
fifteen, and had always been regular. Was thirty years old
when she gave birth to a child, and at that time was badly
lacerated. It was necessary to perform upon her a perinc-
orriiaphy and tracliclorrhaphy. She had always had trou-
ble with her bowels; griping pains all her life; never, as
long as she could remember, had slie had a satisfactory
movement; troubled with gas and cramps in the lower part
of the abdomen and a feeling as though there were a lump
June 6, 1908.J
ALBEE: OSTEOMYELITIS.
in the rectum. Since her child was born all her trouble had
increased, and she had a feeling of heat across the lower part
of the abdomen, and a dull aching pain in the back. When
walking or going up stairs she had a pain in the left in-
guinal region. Had flashes of different colors before the
eyes; and had a feeling as if the top of her head were
being lifted off. Soreness all over the abdomen. About
two hours after eating, had acid eructations, sometimes
very bitter. She suffered from nausea, and vomited oc-
casionally. Had a floating kidney on the right side, and
movable on the left. Had about three movements daily.
Diagnosis : Prolapse of the sigmoid.
36 West Thirty-fifth Street.
OSTEOMYELITIS.*
Bv Fred H. Albee, M. D.,
New York,
Assistant in Orthopaedic Surgery. College of Physicians and Si'.r
geons (Columbia University); Instructor in Orthopjedic
Surgery. Postgraduate iledical School and Hospi-
tal: Clinical -\ssistant. Hos ital for the
Ruptured and Crippled.
Acute infectious osteomyelitis is a pyogenic in-
fection of bone, occurring most frequently in early
life. Trendel. from an analysis of 1.058 cases at
Brun's clinic, states that it is most common from
the thirteenth to the seventeenth year. In one half
the cases the femur was involved, in one third the
tibia. Others state that 50 per cent, of cases occur
during these years. It is due generally to the
Staphylococcus aureus. However, other organisms,
such as streptococci, pneumococci, and typhoid
bacilli, are sometimes the cause. Certain factors
also predispose to this disease, such as exposure to
cold, trauma, fatigue, acute infectious diseases, and
typhoid fever.
In most cases complicating the infectious dis-
eases, it is a secondary infection, but occasionally
it is said to be primary, as typhoid osteomyelitis.
In a certain number of fractures the ends of the
bones become infected and a traumatic variety re-
sults. Here the process is almost invariably con-
fined to the immediate locality of the fracture.
The ustial location of acute osteomyelitis is either
at a point of injury or in the extremities of shafts
of long bones, near the epiphyseal cartilage, and
beyond which line it rarely extends because of the
marked resistance cartilage bears to infection and
the dififerent blood supply of the epiphysis. In
some cases, especially in adults, in whom the epiphy-
seal cartilage has ossified and no longer persists
as a bearer, the infection may extend through the
epiphyseal line and involve the epiphysis and joint.
The beginning foctis is always in the marrow, the
trabeculas and cortex being attacked secondarily.
Its location is an important point clinically, because
tuberculosis practically always begins in the epiphy-
sis. Xow since the marrow cells communicate very
freely with each other the toxic material, retained
in this dense shell, spreads rapidlv, and large areas
may become necrosed before infiltration with exu-
date is even marked. The process may extend along
these spaces and the entire marrow of the shaft
be involved in a very short time. The extent to
which cortical necrosis occurs depends upon tw'o
things: On the extent of destruction of the end-
osteuin and the amount of separation of the peri-
osteum (Nichols). Since these two factors vary
*Read before the West Side Clinical Society. March 12. igo8.
greatly in individuals, it is easily understood thit
the amount of necrosis of the cortex must var_\-
within wide limits. If the endostetun remains
viable, the internal layer of the cortical bone will
retain its vitality. If the perioste).im is intact, the
Fig. I. — Regenerated lower end of fibula after removal of the dead
osteomyelitic shaft in a young child.
outer layer retains its vitalitv. The marrow has
considerable power of repair. Dense cortical bone
has practically no reparative power.
The overlying soft tissues, in time, usiially be-
1078
ALBEE: OSTEOMYELITIS.
[New York
Medical Journal.
come infiltrated, and in certain instances an ab-
scess connecting with tiie bony focus forms. The
periosteum is often separated from the cortex and
elevated from the bone over a large area. In this
event the space is filled with a purulent exudate.
Finally such an abscess may perforate the skin
through one or more openings, leaving sinuses
which lead down to bare necrotic bone.
S\mpto}}is. — The disease commonly begins with
a sharp onset and the symptoms are definitely lo-
calized pain and sensitiveness, as well as all the con-
stitutional symptoms of an acute infection, with the
absorption of infectious material. The temperature
is usually elevated to about 103" to 104° F. and the
pulse is usually greatly accelerated. The tongue
is dry and coated. The face is often drawn and
flushed. The leucocyte count is usually very high —
Fig. 2.— Localized osteomyelitis of the great trochanter. The
symptoms in this case simulated very closely those of tuberculosis
of the hip joint. After the removal of the sequestrum, which ap-
pears in the skiagraph, the convalcct nce was rapid.
20,000 or 30,000. The course of the disease varies
with the virulence of the organism and the extent
and the situation of the process. The pain is usual-
ly inten.se, and if the bone is superficial, swelling
can usually be detected early. The skin may become
red or livid. In a few days either pitting on pres-
sure or fluctuation appears. When the bone is
more deeply situated, or when the process has not
extended beyond the medullary cavity the swelling
and redness may not appear until late.
In young children, who are usually not apt to
localize pain well, it may be only after very care-
ful study that the particular bone afi^ected is found,
especially when the patient is in a state of stupor.
However. y)ain is usually elicited by pressure over
the focus or by jarring the sensitive bone, such as
lapping on the foot in a case of involvement of the
tibia or femur. The diagnosis of early cases in
older children is sometimes difficult even to experi-
enced men who have the lesion in mind. The pain
is frequently referred to a neighboring joint, in
which no evidence of involvement can be made out,
or the swelling of such a joint may come on so
early as to distract attention from the disease in
the bone until an abscess appears. In severe cases
the symp'toms may be very grave, and the patient
may die in a few days of septicaemia, while in other
instances the patient may survive the local disease,
but subsequently die of pyaemia, ulcerative endo-
carditis, exhaustion, etc.
If suppurative arthritis occurs in the neighboring
joint the case is a very grave one. The prognosis,
however, depends to a great extent on early and
vigorous treatment, so much so that even the grav-
est cases may be saved. Under any circumstances,
the prognosis should be very guarded as to im-
mediate and remote results, the certainty being that
at best the illness will be long, and that the neigh-
boring joint may be involved, or that a deficiency
in growth, with its resulting deformity, may follow.
The diseases which are most liable to be con-
founded with this disease are tuberculous arthritis,
gonorrhceal arthritis, typhoid fever, acute rheuma-
tism, and abscess of soft parts. Tuberculosis of
the joints nearly always begins in the epiphysis of
ihe long bones, while osteomyelitis, as stated before,
almost always begins in the diaphvsis. In cases of
epiphyseal osteomyelitis, the sudden onset, intense
pain, early involvement of joint, marked leucocyto-
sis, in contrast with its absence in tuberculosis, and
the presence of constitutional symptoms, should al-
low a diagnosis.
Acute articular rheumatism generally affects more
than one joint and the symptoms are much milder.
The constitutional disturbance, the leucocyte count,
and the temperature, are all very much less. The
reaction to salicylates may help. The pain and
s\-mptoms in osteomyelitis are in the bone and not
in the joint.
Gonorrhceal rheumatism may at¥ect but one joint,
and in some cases the early symptoms are severe.
The history of a previous attack of gonorrhoea can
usually be elicited and the bone tenderness is want-
ing. The constitutional symptoms are much less
severe. The detection of gonococci in the joint
fluid would be conclusive evidence.
The high leucocytosis, the pain and local symp-
toms, sudden onset, and absence of W'idal reaction,
usually permit a distinctive diagnosis from typhoid
fever. Any severe pain in bone, with or without
swelling, should always recall the possibility of acute
osteomyelitis.
Treatment. — The treatment of acute osteomyelitis
consists of two operative steps, the first for drain-
age, the second for removal of dead bone. The first
()])eration consists in cutting down to and turning
aside the periosteum, and then in trephining or
chiselling away enough cortex to thoroughly ex-
pose the whole extent of the disease. In cases
where the whole diaphysis is affected it may be
preferable to make several openings in the bone and
to scrape out as much of the medullary cavity as is
filled with purulent material, between them, rather
than to make one large gutter the whole length of
June 6, 1908.1
ALBEE: OSTEOMYELITIS.
shaft. It is extremely desirable to leave all the
marrow possible, even if it is somewhat infiltrated,
because the curetting of the marrow causes a de-
struction and removal of the endosteum upon which
the integrity of the internal layer of the cortex de-
pends. As a large part of the bone will die any-
way in the severe cases, there is no harm in remov-
ing a considerable amount of bone for thorough
drainage.
The medullary cavity should then be carefully
cleaned out with the curette as far as the diseased
marrow extends, and the cavity sponged with crude
carbolic acid, followed by alcohol. A large drain-
age tube with, gauze packing about it should be then
packed into the cavity thus left and the limb placed
in a splint.
If, in exceptional cases, at the end of three or
four days the process seems to have been well lo-
calized, the necrotic bone to have been entirely re-
moved, and the wound appears aseptic, then the
gauze and tubes may be left out and only one small
drainage tube retained at the ends of the wound,
\vhich can be drawn together in its centre, or the
bone cavity may be dried and filled with iodoform
bone plugging material of the late Mosetig-Moor-
hof, of Vienna. This mixture consists of iodoform,
60 parts ; spermaceti, 40 parts, and oil of sesame, 40
parts. This is heated until it becomes fluid, and is
then poured into the bony cavity, which it hermeti-
cally seals by hardening at the body temperature.
In this event the skin may be entirely closed by
suture.
In rare instances, cases brought to the surgeon
early may be operated on before the destruction of
the endosteum or cortex takes place, and the mar-
row will regenerate from the endosteum. Com-
plete regeneration of the bone will then take place,
with no formation of a sequestrum, and the wound
will heal by granulation.
Where joint s\ mptoms do not subside after thor-
ough drainage of the diseased bone, it is well to
aspirate the jomt for the purpose of a bacterio-
logical examination. If infection is found, then the
joint should be treated as a case of infectious
arthritis, irrespective of the associated lesion.
In all instances where the whole or part of the
diaphysis is dead and becomes separated at the epi-
physeal line the operative treatment should be in
two steps. First, continued thorough drainage
should be maintained, after* the operation described
before, until the sequestrum separates well and the
periosteum thickens about the dead diaphysis suffi-
ciently (;. e., to about one sixteenth to one tenth
inch thick). This is the so called involucrum. The
time required will be between eight and twelve
weeks, providing an accessory bone is present which
may act as a splint and maintain the length of the
limb during the process of bone regeneration, e. g.,
the fibula may act as a splint bone during the re-
generation of the tibia. In cases where there is
only one bone in a limb, as the humerus, in the
arm. the danger of deformity from muscular con-
traction is great if the necrotic shaft is removed
before the periosteum becomes rigid. However, if
we wait too long the periosteal shell will begin to
ossify and will have no power to proliferate cen-
trally and fill up the cavity left by the removal of
the sequestrum. At tiie end of about fourteen
weeks the involucrum. although it is quite rigid and
capable of acting as a splint, still retains much of
its power of central growth. At this time it is about
one half the diameter of the normal humeral shaft.
The second part of the operative treatment con-
sists in incising the mvolucrum both ways to the
extreme ends of tlie sequestrum, in separating it by
Fig. 3. — Localized osteomyeliti? of the middle third of the tibia
in a child of seven years. The wound was healed in three weed's
after the removal of the sequestrum.
blunt dissection from the underlying dead bone,
and in shelling the latter out, as a banana from its
peel. In order to do this, healthy bone, which may
overlie the sequestrum, often has to be chiselled
away before the dead bone can be reached or en-
tirely removed. It is best to extract the sequestrum
in toto if practical, thus insuring its entire removal.
io8o
A LBEE : OSTEOMYELITIS.
[New York
Medical Journai
In all instances the epiphyseal cartilage should be
interfered with as little as possible. The gutter
left should then be thoroughly scraped and cleaned,
being ever mindful also not to injure the involu-
crum upon which we are so flepcndent for the new
bone formation. The cavity ma\- then be packed
with gauze and drainage tubes as described before,
or it may be filled with iodoform bone plugging
material, and the skin brought together and sutured
over it. I'lie latter procedure is feasible only where
the infection has well subsided.
In cases where a part only of the circumference
of the cortex dies and the sequestrum lies deep.
Fig. 4. — SiKcinicns of osteomyelitis from th(
of Columbia University. The bone to the left
myelitis of the lower end of the femur.
The sequestrum (n), tlirec inches long, was never removed and
the involucrum (&) formed about it; the bone to the right is a
specimen of osteomyelitis of the lower end of the tibia (the bone is
reversed); (r) holes in the involucrum which nature has left for the
drainage of the sequestrum pocket beneath; (rf) sequestrum (dead
shaft) in situ; (<?) involucrum.
and approximately one half of the healthy cortex
remains vial)le. the involucrum with the attached
skin and s(jft tissues may be turned into cavity and
nailed to remaining plate of cortex with sterile
tacks (Neuber). In this way the whole wound may
be closed. 'I'his i)roccdure is likewise possible in
cases of mild infection, anrl nnlv when it is fairh-
certain that all infective material has been removed.
The limb should in all cases be firmly held either
in a plaster of Paris splint with a large window for
dressings, or by a wire splint. And, in either case,
some splint should be retained until sufficient bone
foundation has taken place to give a weight bearing
stability. ,Jf bone in an adequate amount does not
develop, bone grafting should be subsequently em-
ployed. However, it should be understood that it
may require many months for complete ossification
to take place.
In a recent case where two thirds of the lower
part of the tibia was removed by the writer, it was'
fourteen months before the brace could be discard-
ed. The appearance of osteoid tissue of about the
consistency of an early external fracture callus is
usually rapid, but its transformation into bone is
much slower.
In addition to the acute forms of inflammation of
bone there exists a more chronic type which is more
apt to be multiple in its manifestations. The amount
of bone involved is often very extensive, and there-
fore furnishes very difficult operative problems.
The sequestra lie in large bone cavities whose walls
are very dense. If the process is of very long dura-
tion the periosteum will be much thickened. For-
tunately this type of case often quiets down from
careful rest, hygienic, and brace treatment. The
operative indications are the same as those of the
more acute variety.
A third type is a definitely circumscribed process
to which the names of bone furuncle or Brodie's
abscess have been applied. The pyogenic cocci are
usually the infective agent. It is occasionally
chronic in its course, and gives little clinical evi-
dence of its presence. Frequently the process is lo-
cated near a joint or even at the epiphyseal carti-
lage and is thus liable to be confounded with joint
disease. Its thickened wall stands out very distinct-
ly in the radiograph.
The pperative principles laid down before are of
e(|ual importance here. The curette should never
l)e used as a subterranean instrument for scrapins:
blindl}' about either in this condition or in that of
old hone sinuses, but should always be used under
the direction of the eyesight. This is an important
precept and one that is often violated, which is, I
am led to believe, one of the reasons for the exist-
ence of many persistent osteoniyelitic sinuses.
The operative indications are to remove the dead
bone which is likely to lie beneath newly formed
periosteal bone, through which a hole always per-
sists for the drainage of the sequestrum pocket be-
neath. Now in order to get a thorough exposure
of the sequestrum, it is often necessary to make a
considerable skin incision and remove with chisel
and mallet a considerable amount of overlying bone,
either old or newly formed. This new bone forms
very rapidly on account of the irritative stimulation
of the periosteum by the presence of the dead bone.
If possible the sequestrum should be removed in
ioto. When all particles of dead bone are removed
the sinus will immediately clo.se and close perma-
nently, providing .sufficient endosteum remains in-
tact.
125 Wkst I''i1'TV-eu;iith Stricet.
June 6, 1908.1
TUBBY: SIMPLE ''AIR HOUSE."
1081
A SIMPLE "AIR HOUSE."
By J. T. Tubby, Jr.,
Xew York.
The qviestion of open air bungalows and sleeping
quarters is no longer restricted to building for tuber-
culous persons. It is admitted that sleeping out of
doors is as beneficial for the so called "weir" as for
the sick. Hence the prediction is well founded that
the community will shortly demand of its architects
first, the design of second story loggias, then of
temporar}^ free standing bungalows, and finally open
buildings of a type to supply an abundance of fresh
air under the least artificial conditions. Already the
It is desirable to select a dry, well drained site
for the structure, in a position having a free circula-
tion of air. It may stand alone or in juxtaposition
to a sheltering house. Connection to a house piazza
is a convenient arrangement. A site well shaded
with tall trees trimmed up to ten or twelve feet
from the ground would be excellent.
The air house shown in the accompanying sketch
has a room abovit eight feet by thirteen feet, with
an ample porch. The roof has a wide overhang at
every point.
The house is raised three feet from the ground
upon three inch locust, cedar, or chestnut posts set
three feet into the ground. Sills and beams are of
Fig. I.— '•.\ir House.
evidence pointing to such a conclusion is strong.
Our architectural periodicals show in greater num-
bers designs for cottages of very open type.
In the present state of popular opinion, from the
point of view of that sane lieing, "the average man,"
the question of the use of outdoor sleeping quarters
is considered a question of luxury. Such need not
be the case. Sleeping quarters of the type shown in
this article can be built inexpensively and can be
used to advantage as additional veranda space or
for a children's playroom in the daytime.
hemlock, spruce, or pine. The flooring is crowned
one inch at centre to throw out water. The window
openings, and, in fact, the whole house wall above
three feet six inches, is closed with shutters of roof-
ing paper, waterproofed canvas, or some similar
material, stretched over a light wooden framework.
The shutters are manipulated precisely like an ordi-
nary window sash, and allow the closing of the
entire structure or the opening of any part of it to
the window^ sill level. Wire netting may be tacked
fiat on outside casing in a region infested bv mos-
io82
ALGER: MIGRAINE.
[New York
.Medical Journal.
quitoes. Light is afforded, in the rare case of clos-
ing the shutters, by two window sashes in rear wall
and two sashes in the front doors.
The color treatment should harmonize with exist-
ing conditions of site. The temperature inside, how-
ever, is affected by a light outside color. Dull colors
for interior finish and underside of eaves will prove
restful.
The furnishing will be dictated by the taste or
convenience of the occupant.
The cost of such a structure will depend on the
cost of lumber and of labor at the place of erection.
3" a"
z'o'
subject to eyestrain. In the discussion which fol-
lowed, Patrick, of Chicago, voiced the prevailing
opinion among neurologists when he said that he re-
ferred such patients to a competent oculist as a mat-
ter of routine, unless they had already consulted
one, but that the cases in which migraine had been
cured were of extreme rarity in his experience.
Some neurologists go even further and consider the
connection between eyestrain and migraine to be so
improbable that it is a waste of time to have the
eyes examined at all in such cases, while some oph-
thalmologists go to the other extreme and state that
20-
DOWAI
-4
LATTICE.
Porch
R.A 11-
RAIL
To HOUSE
•977
JLATTICE ^RAI
-Plan of "Air House.
In the neighborhood of New York it could be built
for about $150.
If a dozen or more of uniform design were
erected for sanatorium use, etc., the individual cost
would be materially decreased.
81 Fulton Street.
TO \VH.\T EXTENT IS MIGRAINE AMENABLE TO
TREATMENT OF THE EYES?
By Ellice M. .a.lger, M. D.,
New York.
At the last meeting of the American Medical As-
sociation Coggeshall and McCoy, of Boston, pre-
sented to the neurological .section a singularly con-
servative and temperate joint paper on headache,
which they concluded with the broad statement that
their experience had led them to consider the vari-
ety known as nngraine or sick headache in the
great majority of cases as the reaction of a neurotic
they are able to cure practically every case under
their care.
Like most dis]:)utes between honest men the pres-
ent one probabl) depends in large part on lack of
understanding to start with, first as to what consti-
tutes competent e\ c treatment ; second, what is to
be considered a cure, and, finally, most important of
all, exactly what is meant by the term migraine.
Coggeshall and McCoy have given in the paper
referred to a definition of what they understand by
competent eye treatment, and conclude : "We ven-
ture to say that most neurologists who are sceptical
about the eyes as a factor in migraine and other less
severe forms of headache have failed to give this
much consideration to the details of the oculist's
treatment, but if we do not pay unremitting and ex-
act attention to all these minutia* we shall continue
to see cases of migraine that are not due to the eyes."
Most men place their confidence in a competent ocu-
list, which is not the same by any means. Just as a
man mav be a perfectly competent general surgeon
June 6, 1908.]
ALGER: MIGRAINE.
and yet do the most ragged kind of special surgery,
so there is a vast number of oculists skilful and gen-
erally competent, but who lack the interest or the
time or even the skill to do good refraction work.
I will not enter into a discussion of methods, the
use of cycloplegics, the value of the ophthalmometer,
the investigation of muscular imbalances, and other
questions over which oculists are divided, but it
seems only reasonable to argue that competent treat-
ment means treatment by some one who habitually
gets results at least approximating the most success-
ful by whatever methods of work he deems most
suitable in a given case. Judged by this standard,
many oculists cannot be considered competent when
it comes to the treatment of migraine and many
other nervous affections, which, it is admitted, they
seldom treat successfully.
The term "cure" also needs explanation. Even
supposing for the moment that eyestrain is admitted
as the chief exciting cause, every migraine patient
also has an underlying nerve instability often hered-
itary, without which no amount of excitation would
be effective in producing an attack. This instability
may be so great that even overuse of normal eyes is
disastrous, or, on the other hand, the irritability may
be slight while the exciting eyestrain is relatively
large. The first case we should hardly expect to
benefit short of stopping entirely the use of the eyes,
while the second would cease to have trouble as soon
as we have enabled him to use his eyes economically.
The majority of cases fall between these extremes,
but it seems to me that we are hardly justified in
using the word "cure." We do indeed often re-
move the exciting cause and the attacks cease, but
the underlying instability is still present, perhaps
modified to some extent, but still capable of reacting
to a sufficient excitation.
Then, too, we are not all agreed as to just what
the term "migraine" means. Many general practi-
tioners and not a few oculists base their diagnosis
on the severity of the attack and consider every vio-
lent headache as a migraine, especially if it is one
sided, and, on the other hand, overlook many typical
cases in which the head symptoms are not very se-
vere. Migraine is defined in the textbooks as an ex-
plosive paroxysmal psychoneurosis developing in
certain neurotic individuals. It is in a sense a fam-
ily disease, being often traceable in the direct line
for generations. Patients may be unaware of this,
but questioning will often elicit a history which is
suspicious, to say the least, of "sick headache," "bil-
ious headache," "neuralgic headache," in various an-
cestors. In the same families this nerve instability
is sometimes evidenced by cases of insanity and epi-
lepsy, and indeed between the latter and migraine
there are so many analogies that many authorities
consider the one a sensory form of the other. A long
list of exciting causes is usually given, which may
precipitate at attack from time to time, such as low-
ered health, constipation, autotoxgemia, gout, fatigue,
worry, and strong emotions. A few years ago none
of the textbooks mentioned the abuse of the eyes as
an exciting cause. Recent editions are now almost
unanimous in putting it among the possibilities, and
we may hope that in course of time it may be in-
cluded in the long list of probabilities.
The symptoms in a typical case are unmistak-
able, consisting of an aura, followed by sensory
disturbances generally involving the eyes, head-
ache, nausea and vomiting, and, finally, by sleep
which precedes recovery. But not one of these
symptoms taken singly is pathognomonic, so that in
atypical cases it is often difficult to establish the
diagnosis beyond cavil. The premonitory symp-
toms, for instance, are often wanting. They often
consist of a feeling of dulness and apathy, or pos-
sibly of unusual exhilaration, which in this indi-
vidual leads him to expect an attack, but they are
not in any sense diagnostic, and are not invariably
followed by migraine. The sensory phenomena are
the most constant and characteristic, and are usual-
ly confined to the eyes. They often consist of spark-
ling lights, near the fixation point, which widen and
assume the most changing and fantastic shapes, and
at the same time there is disturbance of vision,
varying from photophobia to absolute blindness of
corresponding halves of each retina. The headache
comes on at once, sometimes one sided, but not al-
ways so by any means. In some patients it is regu-
larly very slight, and is not allowed to interfere
with usual duties, but in others it is an excruciat-
ing jumping pain, which lasts perhaps several days
and causes utter prostation. In most cases there
follows an intense nausea, often accompanied by
vomiting. There is a complete arrest of digestion,
but the vomiting persists long after the stomach is
empty, and only serves to increase the headache.
These are so often associated in the minds of
both patient and physician that the indigestion is
considered the exciting cause of the attack, which
is spoken of as a bilious headache. But there are
many cases in which the nausea is hardly noticeable,
and the vomiting does not occur at all. It is a nota-
ble fact that for a variable time after an attack the
usual exciting cause seems incapable of precipi-
tating another attack.
Recent authorities are beginning to agree that
faulty eyes may be a factor in migraine, but there
are many reasons which suggest a far closer con-
nection than is generally admitted. For instance,
migraine begins in thirty per cent, of the cases be-
tween the ages of five and ten years, or just at the
period when school life is beginning to put the first
serious strain on the eyes. Of the balance most
begin in the second decade, and only in the rarest
instances does it begin after thirty. It is said to
gradually subside after the menopause, and this
has been considered significant, but it must be re-
membered that it also begins to abate in men at the
same age. But this same period in both sexes
marks the onset of that great change in the eyes
which we call presbyopia, during which the patient
is gradually compelled to admit that even straining
his eyes no longer results in satisfactory near vision
and that glasses have at last become a necessity.
But among those who deny the presbyopia and put
off as long as possible the wearing of glasses, at-
tacks of migraine are notably increased both in fre-
quency and severity. In old age, when the accom-
modative power has practically disappeared, attacks
practically never occur. The very fact that the in-
dividual symptoms of migraine often appear in
other patients as the result of abuse of the eyes is
suggestive. In many cases patients have noticed
1084
ALGER: MIGRAINE.
[New York
Medical Journal.
tliat attacks are much more frequent when they
are doing work that involves unusual use of the
eyes, while conversely when leading an outdoor life
thev are practically free. Careful questioning will
elicit the same history in many others.
There are three ocular conditions which are con-
ceivably concerned in attacks of migraine. First
and most important, over use of the ciliary muscle
in accommodation, which may exceptionally occiir
in normal eyes by reason of immoderate use, but is
almost invariable in hyperopia and especially in
astigmatism, since it is only by accommodation that
clear vision is secured ; second come conditions in
which binocular vision is impossible v/ithout undue
strain of the extrinsic ocular muscles ; and, third,
the cerebral fatigue that comes from the constant
interpretation of distorted or unequal retinal images,
as in astigmatism and anisometropia. It can readi-
ly be seen that the relief of these conditions may
often be a very complicated problem, an exact solu-
tion of which is sometimes impossible. In most
people Nature herself has compensatory powers,
and if we can bring the error within the limits of
those powers we shall have given all the relief nec-
essary. This is the reason why inexpert work is so
often perfectly satisfactory to patients in ordinary
conditions. Ijut it must be remembered that in
migraine and many other nervous conditions it is
this very attempt at compensation that causes the
trouble, and a much closer correction is called for.
The one great defect in the evidence is the wide-
spread failure of ocular therapeutics to afford re-
lief, even when applied by men whose reputations
are of the highest. This may be due to two causes,
nrst, that the ocular treatment is seldom as patient
and painstaking as it should be ; and, second, be-
cause there may be cases in which eyestrain is not
the chief cause and perhaps not a cause at all. So
far as my own experience goes, I believe both to
be true. Many of the patients whose histories are
here recorded had received from reputable men pre-
scriptions very different from the ones which final-
ly proved beneficial. On the other hand, there are
many patients whose hereditary instability is so
great that an explosion may occur from any one of
several exciting causes. Suitable eye treatment
might prevent some of these attacks, but could not
possibly prevent them all. Other cases are pure
eyestrain cases, and are completely relieved.
I believe a thorough examination of the eyes
should be made in every case, not only once, but
several times, by different men if the first is not
successful. This may seem an extreme position to
take, but when one considers the alternative plan
of treatment as outlined in our standard textbooks :
the long continued use of drugs, ranging from
bromides to cannibis indica, with analgesics for the
attack ranging from acetanilid to morphine, very
possibly combined with a rigid diet, intestinal anti-
septics, and continued abstinence from nearly every
interest or occupation that makes life worth living
to a normal man or woman, and when, after all
this, we are obliged to tell our patient that these
measures are only occasionally productive of per-
manent good, but that, at the very worst, his old
age will be a happy one, the ophthalmological po-
sition does not seem so extreme.
Many oculists have recorded their success in the
relief of migraine, but the term is used so indis-
criminately that I have thought it wise to append
the histories of a few illustrative cases, which, it
will be noted, were not all successfully treated.
Some of them seem f rpm the very history to be pure
eyestrain cases, and were invariably relieved. In
others, notably Case X, the nerve instabihty is the
predominant factor, while still others occupy an in-
termediate ground. One or two of them date back
to a time when I thought I could do sufficiently ac-
curate work without a cycloplegic, a practice which
I have given up in all cases of any moment. I am
sure it was the cause of my being compelled to
write "benefited" instead of "cured" at the end of
many a case record.
Case I. — Male, aged twenty-eight, bookkeeper. Family
history not noted. For several years he had had attacks
of migraine at frequent intervals which he had supposed
were due to indigestion and for which he had had much
treatment by various physicians without any result. For
some time past he had been having an attack every other
day, generally in the afternoon, beginning with scotoma
scintillans, followed by nausea and vomiting, the whole
lasting a couple of hours. He had noticed that he rarely
or never had an attack while on vacation. He had never
had any trouble with his eyes, and only came to satisfy the
wi.--li of his physician. His static refraction was
R. E. -1- 62 -I- 37 ax. 105 ; L. E. -I- 75 + 50 ax. 105. A
month later lie complained that his glasses fogged things
except when he looked straight at them, but that he had
had absolutely no headache, though there had been no
change in the kind or condition of his work. This has con-
tinued since.
Case H. — Female, aged twenty-two, housewife. Patient
could remember that her mother had frequent severe head-
aches sometimes lasting several days, but could recall no
details. She herself as a schoolgirl had severe headaches
with nausea, which were ascribed to biliousness. These
became less frequent after she finished school, but during the
last five years recurred every two or three weeks, being so
dependent on the use of her eyes that she had to give up
reading and sewing to a great extent. They generally be-
gan with a "flimmering of light," followed by hemianopsi;;
and a headache which was usually onesided at first. She
has no nausea now, but used to have. The duration of an
attack was about twelve hours. Her static refraction was
R. E. + 1.75 + 25 ax. 120; L. E. + 1.50 + .25 ax. 60.
A month later she reported that she had been reading all she
wished and doing much of the sewing for four children,
and had had no headache of any kind except one night
at the theatre, when she had left her glasses at home. Up
to the present time, a period of five months, the same free-
dom from migraine has persisted.
Case HI. — Female, aged twenty-nine, occupation house-
wife. Family history negative, did not suffer from school
headaches and remembered no abnormality as a girl. At
age of twenty-two began to have attacks of migraine, espe-
cially at menstrual periods and when subjected to excite-
ment. Married at twenty-six, no children. A year ago
lost her husband, since when she had been having attacks
much more often, every week or so. The attacks began
with a heavy feeling, followed by "white specks" before
the eyes and a severe frontal headache, getting worse till
she went to bed. She had nausea and sometimes vomit-
ing, which last afforded some relief. Otherwise she was
perfectly well and had never been conscious of any eye
trouble. Her refraction under atrophine was R. E. — I.
—4.50 ax. IS =20/50; L. E. — 5.25 = 20/30. She had a
divergent squint in relaxation. Maddox rod showing an
exophoria of 10° with a left hyperphoria of 4''. I supposed
this would have to be corrected, but she reported three
weeks later that at her menstrual period she had had no
headache for the first time in years, and this has been the
case to the time of writing, a period of five months, so
that I ha\'c thought it advisable to let well enough alone.
Case IV. — School girl, aged fourteen. Family histor>
negative. Patient had had no serious illnesses, but was
rather anjemic and delicate. She was of a nervous temper-
ament, and had been subject to headaches for several years.
June 6, 1908.]
ALGER: MIGRAINE.
sometimes having them several times a week, especially in
school time. Frequently, but not always, they were pre-
ceded by flashes of light and followed by nausea. She first
noticed failing vision about two years ago, and a glass of
No. — I. D. was prescribed by a well known oculist. This
had no appreciable effect on her headaches, and she thought
her eyes were getting worse all the time. Her refraction
under atropine was at this time R. E. — 1.25 — 75 ax.
105; L. E. — 125 — 75 ax. 75. The corneal radius was
7.65. Eighteen months later she reported that she did not
remember having any headaches. Under homatropine she
required a half diopter increase in the sphere to give her
normal vision.
Case V. — Female, aged twenty-two, occupation machine
operator. Family history not noted. Patient had always
been nervous and as a schoolgirl was of the opinion that
she had headaches nearly every day. She was otherwise
healthy and never had her eyes examined till four years
ago, when an optician prescribed some concave cylinders,
though she had never been near sighted. These glasses
helped her only for a short time, but had been worn stead-
ily even since, though the headaches were now typical
migraine attacks, occurring about once a week and fol-
lowed by nausea and vomiting. Her eyes called for a
convex cylinder instead of a concave, her refraction being
R. E. + 75 ax. 45 ; L. E. -j- 1.25 ax. 135. A month later
she complained that she had had a hard time in getting
used to her glasses but had had no headaches. I have not
seen her since, but in writing for a copy of her prescrip-
tion, two years later, she reported that her glasses were all
right and that she was having no trouble.
Case VI. — Female, aged thirty-one. housewife. Very
fond of sewing aiid embroidering. Family history nega-
tive. Always healthy except for two attacks of rheuma-
tism, which had left a heart complication. Married eight
years without children, and was said to have a retrover-
sion. She was of a nervous temperament, but was not
hysterical. Her eyes had troubled her all her life, being,
as she said, "near sighted." She received glasses from an
optician in childhood which improved her vision, and she
did not remember being troubled with headaches while in
school. During the last year or so had been having many
headaches which she thought depended almost entirely on
the use of her eyes, as she was almost entirely free in the
summer, when she was out of doors most of the time. Her
eyes became tired, her sight blurred, and shortly she had a
severe headache, generally right sided, which was soon
followed by nausea and vomiting. A year ago she was
examined under atropine by one of our most experienced
oculists, who prescribed R. E. -|- 2.25 ax. 75 ; L. E. + 2.25
ax. 105. These gave her no appreciable relief and, indeed,
in her opinion, were not as helpful as the previous glasses
by the optician. Her true correction was R. E. +2 + 150
ax. 120; L. E. + 250 -r 150 ax. 60. Her husband reported
four months later : "Glasses thoroughly satisfactory ; can
read and sew a great deal, and has not been troubled with
headaches, though she is obliged to wear her glasses con-
stantly. She cannot work comfortably by lamplight." Two
months more have now elapsed without an attack of
migraine.
Case VU. — Male, aged thirty-four, occupation business
man. Father and grandfather had typical migraine. Pa-
tient had headaches all his life, beginning with luminous
flashes and settling in left eye. Nausea and vomiting not
invariable. Had been free at times for three weeks, and
once had no attack for six months while taking what he
thought was strychnine. Thought he would have attacks
several times a week, but took acetanilid in 10 grain doses
when he felt them coming and often aborted them. At-
tacks sometimes lasted for several days and even a week.
His occupation at times placed great strain on his eyes
and he had always been a very heavy smoker. Otherwise
he was healthy and did an unusual amount of work. De-
clined to have a cycloplegic examination at present. His
refraction without cycloplegia was R. E. -1- 75 ; L. E. -f-
75 -f I ax. 10. which was ordered for constant use. I
am certain that this was not by any means his full correc-
tion, but he complained constantly that his distant vision
was fogged, though it made his near work much easier.
A month later he reported that his headaches had been
both fewer and milder, but complained so much of the
fogging that I reduced the strength of his glass a half
dioptre. A month later he reported headaches worse and
went back to stronger glass. The next month "was threat-
ened with headache many times but had only one," which
he thought was due to something he ate, as it was accom-
panied by gastroenteritis. He had stopped the use of
tobacco. Nine months after his first visit he reported that
he had been entirely free from headache till recently he
had to do "over 100 columns of fractional figuring" and
had had trouble ever since. He had begun smoking again.
Case VHI. — Male, aged thirty-six, minister, who did
much literary work. The family history was negative. As
a child he was delicate and had frequent sick headaches
characterized by "quivering of the eyes," severe headache
and vomiting. Could remember rolling on the floor in his
attacks, which lasted usually half a day. He was cured for
ten years by an irregular nerve doctor, who gave him a
syrup which tasted like peach pits. As sophomore in col-
lege had scarlatina, which was followed by migraine, often
twice a week. This had continued more or less ever since,
the headaches being much more frequent when he was
studying and writing steadily. Had always been near-
sighted and worn glasses, sometimes ordered by opticians
and sometimes by physicians. They never had any ef-
fect on his migraine, the last by a well known oculist being
R. E. — 1.75 — 50 ax. 180; L. E. — i — 50 ax. 180. Vision
is equally good in both eyes, but he had a divergent squint
with a left hyperphoria which was alternating. His refrac-
tion under atropine was R. E. — 1.50 — 50 ax. 45 = 20/20;
L. E. — 1.75 — 50 ax. 105 = 20/20, which was very different
from the preceding correction. Nothing w^as done about
his squint, as it was not a cosmetic defect and he had
learned to suppress the image in the nonfixing eye. He
reported a month later that he had been able to use his
eyes more comfortably than he could remember and had
not had a suspicion of a headache. An interesting feature
of this case was a habit of tilting his head to the right,
presumably due to the oblique axis of his astigmatism.
Case IX. — Female, aged thirty-five, occupied chiefly in
looking after her health. Family history negative. Was
brought up by an ambitious aunt who pushed her educa-
tion. Between the ages of six and seven she began to have
headaches so severe and frequent that she was allowed to
give up study and run wild. Found she could wear her
mother's glasses but was seldom allowed, for fear of in-
juring her eyes with such strong glasses. Never had a
pair of her own till fifteen, since which time they have
been changed often, always by opticians, except the last
pair by an oculist (3.25), with a stronger pair for near
work. She had had five children in the last eight years,
was greatly run down, and had come north to recuperate.
A well known internist said she had a mild anaemia with
enteroptosis, but was otherwise sound. He advised iron and
tonics with rest. An equally well known neurologist said
it w-as a pure neurosis and advised bromides and no tonics.
Just which plan the family physician adopted I do not
know. The patient appeared a nervous wreck, was irri-
tated by everything; was very hysterical at times and again
was very melancholic. She was in great fear of death and
complained of a band sensation about her head. Her
digestion was bad, her heart irregular, and she was often
troubled with insomnia. She said her headaches were
often preceded by musc?e volitantes and characterized by a
"fireball" and one «ided blindness. The right lid drooped
and the right eye diverged slightly. Under atropine her
correction was R. E. -t- 5 -|- 50 ax. 105 ; L. E. -i- 5 -|- 50
ax. 75. Both before and after atropine she had a marked
cross diplopia with a red glass. Two w-eeks later I in-
creased the strength of her glass a dioptre for near work
as her accommodation was subnormal, a condition which
was in my experience very common in patients of Spanish
descent. Four months later she was very much better in
every way; had no more need for a nurse; had had little
or no headache and very infrequent attacks of hysteria and
depression. She had been doing a great deal of continuous
shopping without undue fatigue and could use her eyes for
reading and sewing with comfort for the first time in years.
The drooping of the lid was now hardly perceptible, and
the diplopia with the red glass had disappeared, though
she still had some exophoria. Of course, I do not say that
the entire improvement was due to the relief of her eye-
strain, but the head symptoms certainly improved steadily
from the time of the first installation of atropine. She
has now returned to her home, but her husband writes
that her condition remains satisfactorj- after a lapse of nine
months.
Case X. — Mr. S., aged forty-four, single, publisher.
io86
TUCKER: EPILEPSY.
(New York
jNIkdical Journal.
There was a a. history of typical migraine on his mother's
side for two generations. Patient was undersized, badly
developed, anaemic, and of a decidedly neurotic type. He
had never been very strong nor suffered from any severe
illness. He had had attacks of migraine on the average
once a month ever since he could remember, though some-
times they were more frequent. They often began with a
capricious appetite or a mental exhilaration, followed
shortly by scotoma scintillans and then a violent pain, be-
ginning in one eye and finally spreading over the whole
side of the head, with the most distressing nausea and
vomiting. Sometimes the attacks lasted only twenty-four
hours, but often the pain after leaving one side went over
to the other, and such attacks sometimes lasted three or
four days, during which he was absolutely confined to his
bed. Coal tar products were of no use, but occasionally
an attack could be aborted by a half grain of morphine
hypodermatically. The pain was so severe that it could be
controlled by nothing but morphine, and I was frequently
obliged to give him a grain a day without by any means
affording complete relief. He was my bete noir for several
years. The exciting cause of his attacks seemed numer-
ous ; one could be confidently expected after any worry or
business misfortune, of which he suffered many, and some-
times they seemed to follow dining out and sometimes
overuse of his eyes. I once apparently caused an attack
shortly after a severe one which should have conferred
temporary immunity by testing his eyes with prisms in my
office. One attack I succeeded in aborting by instillation
of homatropine after it was fairly started, but this invari-
ably failed in subsequent attacks. His static refraction
was R. E. + 75 + 175 ax. 90; L. E. + 75 -|- 1.75 ax. 90,
with the addition of a -f- i, sphere for near work. He
regularly had an esophoria of about 2° between the attacks,
but which increased during them so that he often had a
perceptible squint with diplopia. In other words, he was
affected with a spasm of the interni, which might have
been either the cause or the effect of his attack. A full
correction of his refraction apparently modified somewhat
both the frequency and severity of his attacks during sev-
eral months. He then had an operation on first one ex-
ternus and then the other, which finally secured a normal
balance of the extrinsic muscles, both as measured by the
tropometer and prisms. This resulted in complete freedom
for three months. About this time he failed completely in
business and took a position as a clerk, and whether from
the worry or increased work the attacks recurred. At first,
however, they were notably less severe, as he was able to
keep at his desk and do without any morphine at all.
Eventually, how^ever, they became about as severe as when
I first saw him. During a period of emplovment in Phila-
delphia he had his glasses reduced slightly in strength, and
since then I have no record of his eye condition. That
winter he spent as a clerk in a country store, absolutely
free from all worry and overwork, and the next summer as
watchman in a summer hotel, leading an outdoor life, but
under such conditions he said the migraine remained as
when I first saw him.
55 E.\ST FiFTY-.sixTii Street.
EPILEPSY.*
The So Called Idiopathic Form.
By Beverley R. Tucker, M. D.,
Richmond, Va.,
Instructor in Nervous and Mental Diseases, Medical College of
Xirginia.
In presenting a paper upon so complex a disease
as e;)ilepsy T realize tlie limitation of the time al-
lotted me and hence I shall only attempt to briefly
condense what I consider mo.st important. The
Jacksonian type of the disease will not he con-
sidercfl, hut only the so called idiopathic form.
T"-])ilepsy is one of the most interesting, most dis-
tressing, and. until recently, most neglected of dis-
eases. It has been known from time iinmemorial.
•Read before the Tri-Statc Medical Association, at Charlotte.
Ti. C, February ig. igo8.
It affects every race, is found in every clime, and
no age nor state of society is iinmune to this dis-
ease. Attacking its victim at the most unexpected
moment, sometimes with and sometimes without
warning, it has led to many unfortunate accidents,
and is a constant source of danger to the patient and
of extreme anxiety to the family and friends. It is
a spectre that cannot be hid in the family closet,
and its convulsions are only too often food for the
morbid amusement of the curious and jeering in-
human element of human society. The jails and
insane asylums can testify to the extreme effects of
epilepsy ; but the outlook is brighter now, for, in the
last decade or two, the epileptic colonies are hu-
manely and scientifically looking after many of
these unfortunates. Our chief aim, however, should
be to check the process before its ravages make in-
stitutional care taking necessary, and I shall at-
tempt to show that with patience, knowledge, and
projer management the disease can be frequently
arrested and often cured.
The derivation of the name epilepsy implies
"being seized upon." It has been called "falling
sickness." Many superstitions have been connected
with the disease and its victims have been con-
sidered as possessed with devils, or, on the other
hand, it has been considered a sacred disease, inor-
bus sacer, and more recently its manifestations have
been thought to be due to an explosion of some sort
of an electrical force. Some of the world's greatest
men are said to have been epileptics, notably, Julius
Ca;sar and Napoleon. Some of the most vicious
criminals and most profound idiots have also been
epileptics.
Hippocrates and Lucretius have well described
the convulsions, and from their time to nearly the
nineteenth century the study of the disease has con-
sisted almost entirely in simply noting the fit.
It is said that there is a fraction more than one
epileptic to every four hundred of the population
of this country. The probability is, however, that
the proportion is even greater, as many cases, espe-
cially of petit mal, would not be reported for sta-
tistics. Sex has no marked influence upon the
aetiology. The most frequent age of onset of the
disease is the first year of life, about ten per cent,
beginnmg at this time. Between eleven and twenty
years about 46.5 per cent, begin, jlccording to
Turner. From twenty years on as age advances the
frequency of the onset of epilepsy decreases.
Race has but little influence, except that it is
rather rare in the negro. The hereditary factor
has been the stibject of much discussion, and sta-
tistics vary according to what the observer thinks
heredity should embrace. In cases beginning
early in life its influence is traced more frequently
than in those beginning late. Epilepsy, alcoholism,
and insanity are the chief hereditary factors. Af-
ter reviewing a large number of statistics I conclude
that these cannot be traced in more than forty per
cent, of the cases. We must also bear in mind that
many other individuals would present family his-
tories of one or more of these diseases.
Intrauterine developmental conditions as mal-
formations, hydrocephalus, and microcephalus. or
birth trauma causing intracranial cysts, local com-
l)ressi()iis. or hemiplegias are sometimes seen, while
June 6, 1908.]
TUCKER: EPILEPSY.
1087
rickets, scurvy, malnutrition, and other conditions
infrequently seem to have some causative relation
to idiopathic epilepsy.
After considering all of these there is still a larger
class in which no clinically demonstrable cause can
be elicited, but I purpose to point out later on that
there is enough evidence in the latest pathological
investigations to make us believe that every case of
epilepsy has a definite histological and pathological
basis. I believe I am justified in saying that the
immediate cause of a convulsion or a series of con-
vulsions has but little to do with the cause of the
disease ; that the convulsion is simply a manifesta-
tion of an underlying pathological condition ; and
that autointoxication and reflex irritations bear the
relation of exciting causes only. These exciting
causes may be shock, excitement, fear, overeating,
improper diet, too violent exercise, mental and
physical, overheating, masturbation, alcohol, reflex
states from trauma, defective eyesight, adherent
prepuce, ovarian or uterine disease, menstruation,
pharyngitis or any irritative condition.
There are many clinical forms and types of epi-
lepsy which must be distinguished and separately
considered and treated if we hope to cope scien-
tifically or successfully with the disease. The fol-
lowing classification is a modification from that of
several authorities, especially Turner :
1. Petit mal. a. Complete attacks, usually with-
out aura or marked convulsions, and with brief loss
of consciousness, b. Incomplete attacks, consisting
of aura only or brief periods of distracted attention
without loss of consciousness.
2. Gra>id mal. a. Complete attacks with or with-
out aura. Consciousness is lost and the patient may
fall. Then there is a stage of tonic, then clonic
muscular spasm which is followed by a period of
more or less stupor, b. Incomplete attacks, consist-
ing of aura, slight muscular paroxysm, and with or
without loss of consciousness.
3. The combined type, consisting of sometimes
major and sometimes minor seizures.
4. Nocturnal, a. Either major or minor attacks
occurring only during sleep or in the predormant
or postdormant stage, b. ^Nlixed day and night at-
tacks.
5. Serial. Attacks, either major or minor, occur-
ring in a series of fits with periods of freedom or
comparative freedom.
6. Status epilepticus, major or minor fits with one
attack following another so closely that conscious-
ness is hardly regained, or not regained, between
the convulsions.
7. Psychical epileptic equivalents, which, if we
follow Turner rather closely, consist of : a. True
psychical epilepsy, as automatic movements, like
undressing without realizing it, etc. b. Epileptic am-
bulatory autoniatisin, in which, sometimes for days,
a patient may travel and then suddenly find himself
in a strange community without knowing how he
got there, c. Epileptic mania, including impulsions,
d. Dream states, consisting of a feeling of nonex-
istence and doubts as to reality of surrounding
things. These feelings recur at intervals and may
be preceded by an aura. e. Transitory delusional
states in which the patient may be pugnacious and
hard to manage, f. Catatonic stuporous conditions.
These also occur in nonepileptic patients and are
usually marked by a blank expression and rigidity,
g. Cephalic sensations occurring in epileptics which
seem to replace the seizure. Headache is an ex-
ample when it takes the place of an attack, h. Aura.
This is present in about half the cases and may oc-
cur without the convulsion following. This aure,
or warning, may have a motor manifestation, as
localized muscle spasm, or a sensory, as a sick sen-
sation in the stomach, or may be purely psychical,
as fear. I have a' patient who has aura of all three
varieties, i. Miscellaneous equivalents, as narco-
lepsy, paroxysmal laughter, or sneezing, which, un-
less they occur in known epileptics and seem to take
the place of attacks, cannot be considered at all as
equivalents.
Diagnosis-' , The diagnosis consists in the recog-
nition of the types just outlined and in noting the
result of long standing epilepsy, for example, the
facies epilepticus, changes in disposition, and the
insanities and criminal states that may follow. The
description of the convulsions of the various types
are so familiar that I shall not detail them here, ex-
cept as a matter of interest to quote from Lucretius
his word picture of a major fit, penned over 2,000
years ago.
Oft, too, some wretch, before our startled sight,
Struck as with lightning, by some keen disease
Drops sudden : By the dread attack o'erpowered
He foams, he groans, he trembles, and he faints ;
Now rigid, now convulsed, his laboring lungs
Heave quick, and quivers each exhausted limb.
Spread through the frame, so deep the dire disease
Perturbs his spirit ; as the briny main
Foams through each v,ave beneath the tempest's ire.
He groans since every member smarts with pain
And from his inmost breast, with wontless toil
Confused and harsh, articulation springs
But when at last the morbid cause declined,
And the fermenting humors from the heart
Flow back, with staggering foot first treads,
Led gradual on to intellect and strength. (1)
Having noted the especial type of an attack, we
must watch for its recurfence to confirm our diagno-
sis. I believe, however, that many of the convulsions
of infants and some so called fainting attacks of
adults are cases of epilepsy with a single manifesta-
tion in which the convulsive habit is never formed.
The chief consideration in the distinctive diagnosis
of idiopathic epilepsy is to separate the disease from
hysteria. The unfortunate term hysteroepilepsy,
frequently taken to mean a combination of the two
diseases, has been a dumping ground for both and
has kept physicians from attempting to separate the
forms of either. Cowers doubts the existence of
hysteroepilepsy, while the last editions of Church
and Peterson and Purves Stewart ignore it in their
indices. It no more exists than does typhomalaria.
The two conditions may exist independently in the
same individual, but, through some wise provision
of Nature, this is rare. The very type of an hysteri-
cal personality is frequently at the opposite pole
from an epileptic disposition.
In hysterical convulsions the patients fall, if they
fall at all, without injury, and they often talk and
scream during the attack. The eyelids usually
quiver, the pupils react to light, the movements of
their extremities are wide and purposive, they may
fight, or beat at surrounding objects or people, their
io88
TUCKER: EPILEPSY.
[New York
Medical Journal.
position takes the character of a pose, and there is
usually no after stage of stupor, while various anaes-
thesias and other hysterical stigmata may usually
be found. The tonic then clonic stage of convul-
sion, biting of the tongue, foaming at the mouth,
and other symptoms of epilepsy are absent.
I happened to have had the pleasure in London of
hearing Sir William Gowers read his recent paper
on Vagal Attacks which are due to disturbance of
the vagus nerve. These have a sense of gas and
fullness in the stomach, dyspnoea, inability to con-
centrate attention, and a sense of coldness or rigor.
Consciousness is not lost. This condition has been
mistaken for epilepsy.
Pathology. — Coming to pathology, only a few of
the main points can be considered here, but they are
the new ones and are of greatest importance. That
there is a pathology to the so called i'diopathic epi-
lepsy has been denied, but the work of the last few
years, and especially that of Dr. John Turner, of
England, from whom I largely quote, has done much
to clear the field and to put epilepsy in the class of or-
ganic nervous diseases and upon a very fair patho-
logical basis. The changes in the brain tissue pre-
viously noted as taking place are those supposed to
result from the effect of many convulsions, and con-
sist of dilated bloodvessels, increase in the neuroglia
elements, and atrophy of the convolutions. I be-
lieve with Dr. Turner that there is a congenital de-
velopmental defect in most cases, and this conclu-
sion has been reached from his many examinations
of epileptic brains. He says : "The occurrence of
epilepsy in persons who are sane is not necessarily
an objection to this view^ as congenital, structural
defect may coexist with average intelligence." He
has found changes indicative of cerebral congenital
defect, such as diminution of the number of nerve
cells in cortical areas, changes in these cells and
their nuclei, and changes in the nucleoli, especially
of the Betz cells. The changes which occur as the
immediate cause of an attack are intravascular clot-
ting, either formed by masses lying free in the ves-
sels (which are probably an amalgamation of blood
plates), or hyaline material formation, or finely
granulated debris, or fibrin threads. These changes
were found in over eighty per cent, of a large num-
ber of epileptic brains examined. From these and
similar investigations he reaches the conclusion that
"there are two factors whose cooperation is neces-
sary before a fit can result : a. A brain hereditarily
and structurally predisposed to instability and con-
vulsion ; b. A sudden deprivation of the normal blood
supply." The immediate cause being "cortical stasis
resulting from obstruction of the blood supply by
intravascular clots." (2)
Hulings Jackson advocated the latter point of this
view in 1864, but could not prove it and did not in-
clude the congenital structual defect which Turner
believes to be essential.
Chemical examination and microscopical analysis
and estimation of the blood elements have proved of
no conclusive value. In view, however, of the in-
travascular clotting found, the blood coagulation
time was found to be greatly reduced in nineteen
out of twenty-three cases examined by Turner just
before, during, and shortly after the convulsive
seizure. It is a well known clinical fact that the
wounds of epileptics heal quickly, showing a tend-
ency to rapid blood coagulation. (3)
It is believed that some cases of autointoxication
thicken the blood and may cause a convulsion in a
person with a congenital structural cerebral defect.
Dr. William J. Taylor, of Philadelphia, called my
attention some time ago to the fact that thyreoid ex-
tract given internally would decrease the coagula-
tion time of the blood. This was tested successfully
at the Orthopaedic Hospital and Infirmary for Ner-
vous Diseases of Philadelphia in cases of haemo-
philia. (4) Such being the case, thyreoid extract
given to epileptics should increase the frequency of
the convulsions. This, of course, is a line of inves-
tigation which we hesitate to explore.
The testimony of examiners of the urine, sweat,
and cerebrospinal fluid of epileptics has been con-
flicting and uninstructive.
Prognosis. — The prognosis of the disease under
consideration depends much upon the type to which
the case belongs. It has been considered an almost
hopeless disease to cure or ameliorate. However,
statistics show that from seven to ten per cent, of
all cases are really cured, while in a larger percent-
age the attacks are arrested for a time and the con-
dition improved. It must be remembered in estimat-
ing the seven to ten per cent, cured that the worst
and most chronic, forms of epilepsy in colonies and
asylums are included, and that many cases seen in
private practice of the milder forms have not been
considered, hence the conclusions are entirely too
pessimistic.
Various authorities estimate that an arrest of
seizures from three to nine years should constitute
a cure. The writer believes that after five years
without an attack we are justified in calling the pa-
tient cured. An opinion based upon the recent lit-
erature of the subject and observations in clinics
leads me to believe that the prognosis as to cure, in
all cases outside of the insane class, provided the
best treatment and regulation of life is strictly ad-
hered to, is from twenty to twenty-five per cent., and
that from sixty to seventy-five per cent, can be
greatly improved with the same proviso.
Cases treated between ten and twenty-five years
of age seem to have the brightest prospect of cure.
The more frequent the attacks and more long stand-
ing the manifestations of the disease the worse the
prognosis. The diurnal is said to have a better
prognosis than the nocturnal, major better than the
minor or combined type of attacks, while in psychic,
serial, and status epilepticus the prognosis is worst
of all. The curability seems to depend upon whether
or not we are able to arrest the convulsive habit in
these congenitally defective brains, and upon our
ability to get the blood in such a condition that local
or general cerebral stasis does not occur. ,
Treatment. — The treatment of epilepsy would be
subject matter enough for quite a long paper and
can only be outlined here.
In each case we must bear in mind the following :
First — and this I wish to insist upon — the case miist
be classified as to which especial ty-pe of the disease-
it belongs. Second, the treatment must include the
search for and the correction of all reflex causes.
Third, each individual case must be managed with
reference to habits, diet, occupation, education, rest,
June 6, 1908.]
KARFELES: MULTIPLE CONCEPTION.
etc. Fourth, the patient must continue under obser-
vation at regular intervals for years, and an exact
list kept of the occurrence and character of convul-
sions. Fifth, patients having frequent, uncontrolla-
ble convulsions, or who are dangerous to themselves
or to others, or who cannot receive supervision and
care at home, or who develop insanity, should be
sent to colonies or institutions for treatment.
Every conceivable drug has been used in epilepsy,
and during the last fifty years the bromine salts more
than all others. They have not proved specific by
any means, and at times the end result of bromism,
acne, lassitude, stupidity, etc., have been almost as
distressing as the disease.
The sodium and potassium salts are upon the
whole the best, and thirty to forty-five grains daily
is the usual dose. Much larger doses may be given
in conjunction with purgatives, massage, and hot
baths. The action of the bromides is aided by a
"salt free diet," and this procedure, even when the
bromides are not used, gives marked beneficial re-
sults. The method was introduced by Toulouse and
Richet. To keep the patient from becoming demin-
eralized, sodium phosphate was given. (5)
Turner highly recommends a "purin free diet."
The base of purin substance is ON*. Dr. Walker
Hall gives the following articles as purin free: Milk,
eggs, cheese, butter, sugar, white bread, rice, tapi-
oca, cabbage, cauliflower, lettuce, macaroni, straw-
berries, and olive oil, and another list, including po-
tatoes, onions, oatmeal, beans, carrots, kale, spinach,
dates, figs, asparagus, and codfish, as being purin
poor ; and salmon, halibut, beef, pork, mutton,
chicken, veal, liver, and sweetbread as purin rich
foods. (6.)
At Chalfont Colony in England the decreased
purin diet is said to have proved very eft'ective.
The patient should be very moderate in the use of
cofifee and tobacco. Pastries, candies, and alcohol
should be practically excluded. All forms of excite-
ment should be avoided. Baths, hot or cool, should
be regularly given, and the bowels should be kept
open. Convulsions may often be aborted by con-
trolling the aura if present. This may be done if an
aura begins locally in an accessible part, by sudden
compression, or, in any case of psychic or sensory
aura, by the administration of nitroglycerin one hun-
dredth to one twenty-fifth of a grain (7), or by the
inhalation of minims five of amylnitrite. In attacks
known to come on at regular times sodium bromide,
grains twenty, should be given two hours before the
fit is due.
In petit mal or in nocturnal epilepsy chlorotone,
grains three, morning and night, should be given.
I have seen brilliant results from this remedy. Tri-
onal often has a good effect in the nocturnal form.
In grand mal, and combined grand mal and petit
mal, the bromides, sodium biborate, or fluid extract
of Solanum carolinense, are our best drugs. Often it
is advisable to change from one of these remedies
to the other. If the convulsions are close together
bromides may be increased quickly to as high as two
hundred grains a day, and after they are controlled
for a few days, reduced quickly to the ordinary dose.
It is important in administering this drug in ascend-
ing doses to give massage, hot baths, and purgation
at the same time to prevent bromism.
In serial epilepsy chloral in small doses in addition
to other medication, and rest in bed, may cut short
the series. Chloral is also indicated in status epi-
lepticus if the patient is strong. In the stupor fol-
lowing status epilepticus give liquid food by mouth
or bowel, and do not hesitate to stimulate with whis-
key or strychnine if there are any signs of collapse.
For psychical epilepsy hyoscine or duboisine should
be added in small doses to the bromides. As ma-
laria in some cases seems to aggravate or to be the
exciting cause of epilepsy, it should be borne in mind
that quinine is of supreme value in these cases.
Conclusion. — In conclusion, allow me to submit
that we should look upon epilepsy as an organic
nervous disease with a pathology of its own, that
we should admit the majority of all cases to be help-
able, and a goodly percentage curable, and that, if
we will turn from the apathy of the past and adopt
the more modern methods of diagnosis and treat-
ment, we may aid in the inauguration of a new and
optimistic era for this much dreaded malady.
References.
1. Translated by Mason Good, quoted by Peterson, Na-
tional Association Transactions, 1901, p. 11 ; and by Turner,
Epilepsy, p. i.
2. Aldren Turner. Epilepsy. Chapter on Patholog}'.
3. Aldren Turner. Epilepsy, p. 194.
4. William J. Taylor. Surgery, Gynecology, and Ob-
stetrics, iii, No. 2, p. 219.
5. Hugh M. Cox. New York Postgraduate, August,
1905.
6. Aldren Turner. Epilepsy. Appendix.
7. Allen McLean Hamilton. Handbook of the Medical
Sciences, iii, p. 852.
402 West Grace Street.
MULTIPLE CONCEPTION.
Bv M. J. Karpeles, M. D.,
Germantown, Philadelphia.
'J'he birth of triplets, according to statistics, oc-
curs once in 7,910 births. This infrequency, there-
fore, warrants the report of this case. I have at-
tended women who have given birth to twins, and
this as a surprise, but when a retail engagement
becomes a wholesale one, the surprise is all the
greater.
Multiple conceptions may result in the birth of
twins, triplets, and quadruplets. A number of in-
stances of five children at one time are recorded,
and even an apparently trustworthy case of the birth
of six — four boys and two girls — has been reported
by Vessalli. The most extensive statistics examined
with a view of determining the relative frequency
of multiple conceptions is that studied by G. Veit,
which included the records of 13,000,000 births in
Prussia. According to this report, twins occur once
in eighty-eight births, and, as stated before, triplets
once in 7,910, and quadruplets once in 371,126.
Recent statistics by the Boards of Health of New
York and Philadelphia place the frequency of twin
births in these cities at one in every 120 births.
Twins are more frequent in multiparae than in prima-
parse. Individual and hereditary tendencies seem to
be factors in the occurrence of multiple conceptions,
as will be shown in the case I am reporting, and
female twins often give birth to twins. Triplets
may originate from a single ovum, from two or
I090 OUR READERS' DISCUSSIONS.
three distinct eggs, a frequent arrangement being
that one child is derived from a distinct ovum and
two from a single ovum. Upon the manner of their
origin depend the arrangement and relation of the
placenta and membranes.
Plural conceptions may result from a single coitus
whereby are impregnated ova which have simul-
taneously been discharged from the sexual gland,
prepared for the reception of the male elements.
On the other hand, repeated impregnations may
occur after different though closely following sexual
acts, these resulting in the fcECundation of different
ova which have been liberated at slightly different
moments, but which belong to the same ovulation.
This possibility received recognition in the term
"superfoecundation," by which is understood the
foecundation of two ova belonging to the same
period by different sexual acts. Conspicuous exam-
ples of such occurrences are afforded by instances
where a negress gave birth to a white and a black
child. The only rational explanation is that in each
case each child shows a different paternity.
A mare may be covered by a stallion and at an
interval following from a few hours to fifteen days
is covered by an ass ; she has twins, one a horse, the
other a mule.
A bitch in heat is covered by different dogs, and
in her litter the puppies may indicate different
fathers. I might add here, to avoid any suspicion
of multiple racial paternity, that all three of these
babies reported are white.
Tarnier's statistics show that in more than two
thirds of multiple pregnancies the labor is prema-
ture ; the reason for this fact is the great distention
of the uterus.
The case is as follows :
E. O., age thirty-one, married six years. Had first
child eleven months after marriage, female ; second child
fifteen months later, also female; one and a half years
later, miscarriage of twins, male and female. Fifteen
months later, another female child. Two years later,
triplets. Aunt on mother's side had ten children, which in-
cluded both twins and triplets.
The beginning of February I was called to see the patient
at 6 a. m. This was three and one half weeks before the
date of her expected confinement. On examination I found
the bag of waters ruptured, position left occipitoanterior.
Labor was well advanced, true labor pain every ten minutes,
which rate continued about an hour. The pain after that
came every three or four minutes, and by 7 o'clock she
was delivered of this baby, which weighed five and one
quarter pounds. The cord was so short that it was neces-
sary to clamp with two hsemostats and sever before the
child could be fully expelled.
Placing my hand over the uterus, it seemed as large as
before the delivery, and on examination I found a breech
presenting and this bag unruptured. I anesthetized the
patient with chloroform, ruptured one sac, and brought
down the feet and delivered with very little difficulty. The
uterus still was large, and on examination, to my great
surprise, I found another with the head presenting. The
patient was allowed to recover from the influence of the
anresthetic, and in course of fifteen minutes later pains set
in at intervals of three minutes, which continued for twenty
minutes, and the third child was delivered.
The second child weighed five pounds and the third four
pounds, making a total of fourteen and one quarter pounds.
All three were females, this making six female heirs and
a twin miscarriage during her married life of six years. I
was careful not to make traction on the cords until the
triplets were bom. I had little trouble in delivering the
placenta, which was of course very large, giving the ap-
pearance of three placenta coalesced into one with three
cords and three distinct attachments to the placenta.
While I had attended this patient during previous con-
[New York
Medical Journal.
finements, I did not see her during this last pregnancy until
after labor had begun.
The babies were weighed today, April 2d, and recorded,
respectively, five pounds eleven ounces, six pounds five
ounces, and six pounds seven ounces. They are artificially
fed.
60 West Chelten Avenue.
A SERIES OF PRIZE ESSAYS.
Questions for discussion in this department are an-
nounced at frequent intervals. So far as they have been
decided upon, the further questions are as follows:
LXXIV. How do you treat sunstroke? {Closed May
15, 1908.)
LXXV. How do you treat cholera infantum? (An-
sivers due not later than June 15, 1908.)
LXXVI. How do you treat acute articular rheumatism?
{Answers due not later than July 15, igo8.)
Whoever answers one of these questions in the manner
most satisfactory to the editors and their advisors will
receive a prize of $25. No importance whatever will be at-
tached to literary style, but the award will be based solely
on the value of the substance of the answer. It is requested
{but not required) that the answers be short; if practica-
ble, no one answer to contain more than six hundred
words.
All persons will be entitled to compete for the prize,
whether subscribers or not. This prise zmll not be awarded
to any one person more than once within one year. Every
answer must be accompanied by the writer's full name and
address, both of which we must be at liberty to publish.
All papers contributed become the property of the Journal.
The prise of $25 for the best essay submitted in answer
to question LXXIII has been awarded to Passed Assistant
Surgeon Charles S. Butler, United States Navy, whose
article appeared on page 1040.
PRIZE QUESTION NO. LXXIII.
HOW DO YOU TREAT SEASICKNESS?
{Concluded front page 1044.)
Dr. William C. Griggs, of Philadelphia, states-'
Whenever the textbooks recommend a large
number of drugs for the treatment of a disease, the
student is pretty safe in believing that not one of
them is absolutely satisfactory, and that the longer
the list is the less satisfactory are the remedies. This
is at least true in the case of seasickness, where they
range all the way from calomel to chloroform. In
fact, just as "more pure air and less drugs" is be-
coming the rule in treating tuberculosis, so I believe
"larger and better ships and less 'dope' " will prove
the best preventative of seasickness.
It cannot be too strongly urged that many patients
are sent to sea who should be kept ashore. If a
patient can afford an ocean trip it is an easy way
for a physician to shift the responsibility of an un-
desirable case upon the surgeon of a transatlantic
liner, especially if that physician has not personally
suffered the horrors of seasickness. Many a patient
would be a good deal better off at the shore or on
the motmtains than in a twelve by eight stateroom
on a steamer. Since globe trotting, however, has
become such a fad, there are few physicians prob-
ably who are not called upon to give advice at least
once during the summer.
Amongst these may be a man who has just been
planning a trip to Europe. The night before sailing
June 6, 1908.]
OUR READERS' DISCUSSIONS.
IO91
his friends give him a sendoff ; probably they attend
a theatre and afterwards adjourn to a restaurant
for supper, and going upon the principle that "a
man might as well hang for a sheep as a lamb," the
prospective sailor eats heartily, maybe finishing up
with a Welsh rabbit and champagne, and comes
aboard the ship next day like a bomb with the fuse
lit.
Here is another man: He has made up his mind
that he will be seasick in the most orthodox fashion,
and therefore prepares himself for the ordeal. For
weeks he has been reading up on the subject, and
in addition to a starvation diet, has purged himself
and then taken all sorts and conditions of patent
medicines, which, in spite of the fact that half of
them have names which appear to have been taken
out of a Chinese grammar and the other half stolen
bodily from the outside of a Pullman car, rely for
their effect upon practically nothing but chloral and
bromides. That man would be seasick if he had a
total gastrectomy performed upon him before sail-
ing.
About midway between these two extremes, how-
ever, the vast majority of travelers will come, most
of them nervous, especially if the trip be the first
they have taken ; and while in a great many cases it
is impossible to entirely prevent the unpleasant ex-
perience they dread, it is without doubt possible to
shorten it and make it more bearable.
First of all, the traveler should for a day or two
before sailing prepare himself by not taking any
rich foods or anything which he knows "disagrees
with him." The day previous to sailing let him
take 0.1 grain tablets of calomel every hour for ten
doses or until the bowels have moved freely, and
then, last thing before going aboard, eat a good,
plain substantial meal.
Tell your friend to keep on deck as much as pos-
sible, have a good comfortable cane (not canvas,
that gets wet and is difficult to dry) steamer chair,
long enough to lie full length in, and a warm
steamer rug or blanket ; the latter is very impor-
tant, for seasickness almost always makes a person
feel chilly.
The first meal on the steamer is usually a hurried
affair, everybody wanting to get on deck again as
soon as possible, so as not to miss seeing the harbor,
etc., and passengers are liable to "bolt" their food;
under the circumstances a very bad thing to do. A
little cold boiled ham or a sandwich or two is best ;
nothing hot or greasy should be taken ; then on deck
again. Do not omit this meal or the stomach be-
comes "empty" before the next one is ready, a con-
dition which greatly predisposes to an attack of sea-
sickness.
Personally I do not believe it is a good thing to
"fight oflf" the nausea when it comes. Most people
greatly dread to be the first to show the white
feather, and hang on till the last possible moment.
Better go to the rail and get it over and not pro-
long the misery ; then, when the stomach has emp-
tied itself, lie down with a soda cracker and munch
it dry. These soda crackers are better than all the
drugs ever used.
Retiring the first night and getting up the next
morning are two dark, dark spots in most first voy-
ages, but "keep your head down when you once get
it on the pillow" is a good rule, never mind how
suggestive the unpleasant sounds from the next
cabin may be. Call the steward to bring a little hot
tea and more soda crackers twenty minutes before
you try to get up next morning, then jump into
your clothes as fast as you can and get on deck,
and don't go into your stuffy cabin again before you
have to.
Always go to the dining saloon at meal times,
even though you have to beat a hasty retreat imme-
diately after. It may not be a very Christianlike
sentiment to feel good when looking at the rows of
empty seats and the idle stewards, but the fact re-
mains it will help you a lot. Take a few more soda
crackers with you when you return on deck and
munch them dry, and when the deck steward comes
around with the beef tea at "eight bells" you will
probably find you can not only retain a cupful, but
will really enjoy it.
There are practically no drugs here, it may be
noted, because in a simple case such as I have out-
lined I do not believe they are of any practical
benefit. Of course, there are cases which demand
them. Some persons become dangerously ill ; one
case I recall of a woman in the second month of
pregnancy who alm.ost died during a trip across the
Atlantic in November, and another similar case in
the Mediterranean Sea, the latter aborting on the
fourth or fifth day. Here iced brandy, very small
doses of malted milk at frequent intervals, with suffi-
cient morphine, given hypodermatically, is the most
satisfactory treatment.
Dr. Charles Haase, of Elmira, N. F., remarks:
Nothing is of more value in treating those subject
to seasickness than a preparatory treatment. Get
the digestive tract in good condition by excluding
from the diet for one week previous to sailing the
following: Nuts, salads, pastry, condiments, fats,
bonbons, fried foods, and farewell dinners. On the
second night before sailing, one grain of calomel in
divided doses is taken, to be followed in the morn-
ing by a Seidlitz powder. The Seidlitz powder to
be repeated every morning for four or five days.
For weak individuals strychnine sulphate 1/60
grain, and fluidextract of ergot TIP v are given three
times a day after meals. This dose to be doubled
on the voyage. For robust individuals sodium
bromides in 20 grain doses three times a day, after
each meal, is of more value. It is to be given three
days previous to and the first three days of sailing.
On board ship it is important that small quantities
of easily digested food be taken at short intervals,
at least every three hours. Liquids in small quan-
tities should only be taken at meal times, as the
rolling around of fluids in the stomach tends to
produce nausea. Remain on deck as much as pos-
sible. Do not neglect taking exercise, and there is
none better than walking. Avoid thinking and talk-
ing about seasickness. Have your stateroom thor-
oughly ventilated, as ship odors are a factor in the
causation of seasickness.
In mild attacks of seasickness, with headache, the
application of the constricting bandage to the neck
and a reclining position in a deck chair, with the
1092
OUR READERS' DISCUSSIOXS.
I New York
Medical Journal.
eyes closed, is usually all that is necessary. The
bandage relieves the anaemia of the brain and the
closing of the eyes prevents optic vertigo.
In more severe cases, where nausea and vomiting
are present, a glass of lukewarm water or some
weak emetic is given to clean out the stomach. The
patient is placed in bed, with the head low, eyes
closed, and the constricting band applied to his neck.
A large dose of magnesium citrate is given by the
mouth, and if this is not retained an enema is given.
Then a hypodermatic injection of atropine sulphate
i/ioo grain, and strychnine sulphate 1/60 grain, is
injected into the epigastrium.
A mustard plaster over the epigastrium and an
ice bag to the nape of the neck often adds greatly
to the patient's comfort.
In cases where the blood pressure is low, and it
is so in mose cases, strychnine sulphate 1/30 grain,
and fluidextract of ergot tlj'x should be given every
three to six hours, as indicated.
In exceptional cases it may be necessary to give
a hypodermatic injection of morphine to control
vomiting.
Clam broth, strong black cofifee. beef juice, pep-
tonized milk, grape fruit juice, lemon juice, dry
toast, and salted crackers are some of the foods most
easily retained. The individual's liking or longing
for certain food is usually a good indicator of what
the stomach will take care of.
Dr. Samuel Stalhcri^. of Philadelphia, says:
The passenger should put himself in the best
physical condition before, coming on board ship. He
should avoid the fatigue and irregular meals usual-
ly attending the preparations for the departure.
Only easily digestible food should be taken for a
few days preceding the voyage. One quarter grain
calomel for eight closes, followed by a bottle of so-
lution of magnesium citrate, should be taken on the
day of sailing. In the bilious this may be replaced
by a few pills containing calomel and podophyllin.
The berth selected should be as near amidships as
possible, well ventilated, and free from odors. The
larger, steadier, and slower going boats should be
selected. Straining of the eyes and looking at the
water should be avoided. For the first few days the
meals should be light, taken often.
When the first symptoms of the attack present
themselves, such as lightheadedness, dizziness, head-
ache, and epigastric uneasiness, the passenger
should assume a horizontal position in bed, or in a
sailor's hammock on deck, well protected against di-
rect sunlight and a view of the ocean. A bowl of
hot soup or cup of coffee should be taken, and in
cases that do not go beyond this stage, this will be
sufficient to restore the disturbed equilibrium and
relieve cerebral hyperaemia, sending the patient on
his way to recovery.
In the majority of cases, however, these symp-
toms are but the beginning, and nausea, vomiting,
vertigo, faintncss, ' and mental depression follow.
These patients should maintain the horizontal posi-
tion, and keep their bowels open by the effervescent
magnesium citrate, Seidlitz powder, or some mineral
water. The diet should consist of clam juice, nu-
tritions soup, and pasteurized milk, which can be
pancreatized or diluted with equal parts of vichy or
lime water, or.it may be taken with ten grains of
sodium bicarbonate and three grains of cerium
oxalate to the tumblerful, and kumyss and matzoon.
In some patients solid food is better than liquids for
the vomiting, and they should try soda crackers,
zwieback, lemon ginger snaps, and chipped smoked
beef. All of these, as well as bottled milk and clam
broth, should be taken along when going on board.
Fresh lemons, oranges, and lime water tablets are
often gratifying. Daily baths of cold water, or hot
water followed by friction or by a cold douche,
should be taken. The patient should be made as
cheerful as possible.
In patients in whom nausea and vomiting are per-
sistent, and exhaustion is marked, strychnine sul-
phate, grain 1/48, and atropine sulphate, grain
1/240, should be given hypodermatically, three or
four times daily, until recovery sets in. The atro-
pine and strychnine solutions should be kept sepa-
rately, but given together, so as to better regulate
their administration in accordance with their effect.
They may be given by mouth, if retained, in the
form of tablets, but these tablets should never be
entrusted to the patients themselves. Where there
is marked headache, potassium bromide, grain xxx^
three times a day, should be given.
Cerium oxalate, grain iii ; bismuth subnitrate,
grain x, and codeine sulphate, grain may be tried
if the vomiting is persistent. If nausea is constant
and vomiting does not follow, it is well to unload
the stomach by a light emetic, such as a glass of
lukewarm water to which is added salt, or a few tea-
spoonfuls of the wine of ipecac. Hot water bags
and mustard leaves or plasters to the epigastrium
should be applied. When patients crave sour arti-
cles to relieve the bad taste in the mouth, such as
sour pickles, lime juice tablets, etc., these may be
cautiously allowed. Small pieces of cracked ice may
be swallowed.
Few persons will go beyond this stage, but those
that do are alarmingly ill, and the prostration is
marked. In these cases, hot water bottles should be
kept along the limbs, and the latter rubbed briskly
with alcohol. The stimulating and supporting treat-
ment mentioned before should be carried out. .A.
hot compress to the forehead, and a broad rubber
band tied around the neck with a moderate
amount of pressure, on the principle of Bier's
hyperasmia method, should be tried. An ice bag to
the spine may be tried. It is in these cases that the
various mechanical devices calculated to lessen the
effects of the movements of the boats, though usual-
ly useless, may be tried. These are the swinging
staterooms, "berths, and bunks, the Bessemer sus-
pended saloons, and the electrically vibrating chair.
Schlick, a Hamburg naval engineer, has recently
invented an apparatus which may prove of real value
in limiting the rolling motions of the boat. This
apparatus is designed at the same time to increase
considerably the period of oscillation of the rolling
movements and to diminish the amplitude of the
oscillation. This is based on the gjTOScopic effect of
a fiv wheel mounted on board a steamer and caused
to rotate rapidly. The vertical axis of the appa-
ratus is so located as to be able to move pendulum-
June 6, 1908.]
CORRESPONDENCE.
1093
like in the central plane of the ship. The rapid
oscillations of the wheel will result in rendering the
patient insensible to the effects of the wave motion,
the rolling- movements being practically eliminated.
The underlying principle of the apparatus is the fact
that a rotating body will oppose to any inclination
of its axis a resistance higher, as its rotation is more
rapid and its weight more considerable.
Those affected with acute disease, and those with
diseases like aneurysm and hernia, in which the me-
chanical effect of the vomiting might be disastrous,
should abstain from undertaking a sea voyage.
While a treatment, as stated, is in the main symp-
tomatic and aiming at rationality, still it was at-
tempted to recognize that seasickness is primarily a
neurosis, the movements of the vessel causing dis-
turbances of equilibrium in the brain centers, the
visual and aural disturbance probably also contrib-
uting their stimuli. This disturbance causes vertigo,
malaise, etc., and the sympathetic being involved,
nausea, vomiting, and prostration following. Due
to vasomotor disturbance, anaemia of the centres
follows, and heart weakness results. Therefore
stimulating rather than depressant treatment is
recommended.
Correspnbence.
LETTER FROM LONDON.
Mr. Moynihm on Gastroenterostomy. — The Proposed Re-
moval of King's College Hospital. — The Registration
of Nurses Bill. — An Antivwisectionist Meeting. — The
Royal Academy Pictures. — The Franco-British Ex-
hibition.
London, May 18, igo8.
At a recent meeting of the Sunderland Branch
of the British Medical Association, Mr. Moynihan,
the well known Leeds surgeon, gave an address on
the operation of gastroenterostomy. As a leading
exponent of gastric surgery in England, Mr. Moyni-
han was an ardent advocate of this operation. With
the improvements in method and technique the
operation mortality has gradually fallen and in the
hands of some surgeons is now less than two per
cent. It was therefore, he said, scarcely surprising
that this operation should be performed with in-
creasing frequency, the indications for its perform-
ance growing more numerous from time to time.
Mr. Moynihan's teaching has been generally ac-
cepted, and many surgeons hold the view that if
laparotomy is performed for supposed organic dis-
ease of the stomach and none is found it is advisable
to proceed to the performance of gastroenterostomy,
apparently on a similar principle to that of those sur-
geons who remove the appendix whenever they
operate in that region, whether it is diseased or not.
Out of 205 patients upon whom this operation had
been performed by Mr. ]\Ioynihan, there were
eleven in whom no organic disease was found. Now
that he has had a further opportunity of studying
the after results of his cases, Mr. Moynihan ex-
presses himself as being distinctly antagonistic to
the performance of this operation except when
demonstrable organic disease is present. In func-
tional stomach conditions the after results are al-
most invariably bad, the patients either remaining
in the same condition or their symptoms being ag-
gravated by regurgitant bilious vomiting. No im-
provement is to be expected in those cases in which
the pylorus remains patent. Experimental work has
shown that if gastroenterostomy is performed on
healthy animals, all the stomach contents continue
to pass out by the natural opening, the artificial one
not being used at all. Thus in cases of an ulcer
on the lesser curvature, near the cardiac end, the
pylorus remaining normal, gastroenterostomy not
only is useless, but may be harmful, and the best
treatment in such cases is excision of the ulcer.
Mr. Moynihan's conclusions are of considerable in-
terest and will, no doubt, have some influence in
producing a reaction in favor of conservatism in
this operation.
Considerable interest is being aroused in the pro-
posed removal of King's College Hospital, one of
the large metropolitan teaching hospitals, to Den-
mark Hill, in South London. The general practi-
tioners of the South London district, who will be
most affected by the change, have held a large meet-
ing to discuss various matters in connection with the
hospital. Several resolutions were proposed and ac-
cepted relating to the methods of managing the hos-
pital, and it was intended to place these resolutions
before the hospital committee. They related chiefly
to the question of hospital abuse, one of the most
important being that out patients should not be seen
at the hospital, except on production of a cerificatc
from a medical practitioner stating that the patient
was a suitable person for hospital treatment. These
certificates would be given by the general practi-
tioners free of charge. Another resolution pro-
posed was to the effect that the out patient depart-
ment should only be consultative. A medical man
wanting a specialist's opinion on a case where the
patient could not afford to pay a consultant's fee
should be able to send this patient to the hospital
with a letter, and after seeing the patient the con-
sultant should outline the treatment to be adoped in
a letter to the medical practitioner, who would con-
tinue in attendance. At the Bolingbroke Hospital,
Wandsworth, one of the smaller hospitals, this sys-
tem has now been in vogue for some time and is
very successful. The question of the admission of
paying patients to the hospital was next considered,
and a resolution was carried unanimously to the
efifect that in a hospital supported b>' charitable con-
tributions this was a mistake. Doubtless the gen-
eral practitioners in the district will be adversely
affected to some extent by the advent of a large hos-
pital. The decentralization of a large teaching hos-
pital is certainly an innovation. We have got used
to the idea of having all our large hospitals in the
heart of the city. But the increasing growth of the
suburbs affords plenty of scope now for the exist-
ence of large hospitals outside the central area, and
the example of King's College may possibly be imi-
tated by another large hospital.
Medical opinion in England . is divided on the
question of the state registration of nurses. The
British Medical Association had the subject under
consideration for two years, and it was fully de-
I094
THERAPEUTICAL NOTES.
[New York
Medical Journal.
bated in all its aspects. Finally, at the annual gen-
eral meeting in 1906 the principle was approved of.
The General Medical Council, the body controlling
medical registration, was also in favor of the prin-
ciple. Yet on Wednesday last, May 6th, the second
reading by Lord Balfour of Burleigh's Official Di-
rectory of Nurses' Bill, which requires "that an offi-
cial directory be kept on which shall be entered the
names of all nurses who have received an adequate
training," was rejected in the House of Lords by
53 votes to 20. The debate on the bill showed that,
although most of the speakers were in favor of some
form of state control over the nursing profession,
the present bill did not supply an adequate method
of dealing with the question. It did not provide
proper representation of the nursing and medical
professions, neither would it guarantee the effi-
ciency of those registered.
The Antivivisectors have not been long in re-
taliating upon the Research Defense Society. On
Tuesday, May 12th, they held a large meeting at
the Caxton Hall, Westminster, with the object of
"making a demonstration against vivisection and
the principles, tactics, and misleading title of the
newly formed Research Defense Society." It was
stated that this society lacked courage to send a
speaker to debate with them. They had written to
Mr. Stephen Paget, the honorary secretary, asking
him to send a speaker to meet one of the Antivivi-
sectors in a public debate, the question to be dis-
cussed being Is Vivisection Morally Justifiable and
Scientifically Necessary? but their challenge was
not accepted. This is scarcely surprising in view
of the insults and extravagant statements of some
of the Antivivisectors, but the presence of Mr.
Paget at the meeting and his very effective speech
showed that he did not lack the courage to beard
the lion in his den. It would not serve any useful
purpose to make further comments on the proceed-
ings at the meeting, but a comparison of the names
of those constituting the Research Defense Society
with the names of the leading Antivivisectors will
at once show thinking men which side to follow.
Some of the pictures at the Royal Academy this
year have a decided medical interest. There is one
by the Hon. John Collier, entitled The Death Sen-
tence. It portrays an intellectual looking physician
giving advice to a young man who is obviously suf-
fering from some severe illness. His malady may
be open to speculation by physicians, but the aspect
of the patient is most like one afifected with tuber-
culous disease. The picture displays realism and
the situation is dramatic, but it is not a very un-
usual occurrence in the busy physician's life. There
is also a good portrait of Dr. Pridgin Teale, and
among the sculptures is a bust of Hughlings Jack-
son.
The opening of the Franco-British Exhibition at
Shepherd's Bush took place on Thursday, May 14th.
The wretchedness of the weather and the general
state of unprcparedness combined to mar the open-
ing function somewhat. None of the medical or
scientific exhibits, of which there will be quite a
large number, were ready for inspection, and it will
be some time before the various exhibits reach the
stage of completion.
Treatment of Pain from Biliary Calculus. — A
paper by Robin on the treatment of biliary calculus,
published in the Bulletin medical, is summarized in
the Journal de medicine et de chirurgie pratiques.
For the relief of pain he does not use morphine
hypodermatically, except in particularly painful
cases and such as do not respond to a sedative like
the following:
R Potassium bromide, 3iss;
Morphine hydrochloride.
Aqueous extract of belladonna aa gr. 54;
Syrup of ether, ^i;
Cherry laurel water, Siiss ;
Valerian water, 3iiiss.
M. et sig. : One tablespoonful every half hour until three
or four doses have been taken.
While this medicine is being taken apply over the
region of the liver a piece of flannel soaked in the
following liniment :
R Compound oil of hyoscyamus, N. F 5x;
Extract of opium,
Extract of belladonna,
Extract of hyoscyamus, aa 5ss;
Chloroform, 3iiss.
M. ft. liniment.
The third thing to be done is to evacuate the in-
testine. During an attack of biliary colic, the intes-
tine, like the biliary duct, is in a state of spasm, and
the mildest form of enema must be used. This con-
sists of water which has been boiled and allowed to
cool to the temperature of the room ; such an enema
exerts a cholagogue and evacuant action on the
liver.
In cases where the foregoing means of overcoming
the pain prove insufficient, recourse must be had to
hypodermatic injections of morphine, hot sedative
baths, or to a sedative mixture of chloral, chloro-
form, and glycerin, according to the following for-
mula of Manquat :
B Syrup of chloral,
Glycerin, aa
Chloroform water.
Cinnamon water aa ^iss.
M. et sig. : One tablespoonful every fifteen minutes until
the pain is relieved.
The vomiting which is reflex in its nature is read-
ily controlled by the administration of six drops of
the following mixture, given in a little warm water :
R Picrotoxine gr. 3/4;
Alcohol, enough to dissolve the picrotoxine,
Morphine hydrochloride, gr. 3/4;
Atropine sulphate, gr. 3/20;
Vyon's ergotine, gr. xv;
Cherry laurel water, 3iii.
M.
Five or more doses of this are given during the
twenty-four hours, but the vomiting will usually
cease after the second dose.
As medicine to be taken regularly during the day
the following powders are prescribed with which to
make phosphobenzoated water:
R Sodium bicarbonate 3ii;.
Dried sodium sulphate,
Dried sodium phosphate, aa gr. xlv;
Sodium benzoate gr. xv.
M. ft. chart. No. i.
Sig. : One powder to be dissolved in a quart of boiling
water. Take a wincglassful on rising: and one and one
half glassfuls (three ounces) at 10 o'clock a. m., and at 5
and 10 o'clock p. m.
June 6, 1908.]
EDITORIAL ARTICLES.
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Refien' of Medkine.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M. D.
AdflKSs ail business communications to
A. R. ELLIOTT PUBLISHIXG COMPAXV,
riitlishcrs,
66 West Broadway, A'ctx' York.
Philadelphia Office : Chicago Office :
3713 Walnut Street. 160 \A ashington Street.
Subscription Pricl ;
Under Domestic Postage Rates .?■"> : under Foreign Postage Rate.
%'i ; single copies, fifteen cents.
Remittances should be made by New York Exchange or post
office or express money order payable to the A. R. Elliott Pub-
lishing Co., or by registered mail, as the publishers are not
responsible for money sent by unregistered mail.
Entered at the Post Office at New York and admitted for
transportation through the mail as second class matter.
NEW YORK, SATURDAY, JUNE 6, 1908.
THE MEDICAL RESERX'E CORPS OF THE
ARMY.
The Act to Increase the Efficiency of the Medical
Department, United States Army, approved April
23d, contains a feature which must be of great in-
terest to the medical profession of the country . The
institution of a reserve corps of officers available for
military service in war or other great emergency is
distinctly a new departure in the military history of
the United States, and if the attempt is a success
there is reason to believe the principle of maintain-
ing reserve forces may be extended along other and
nonmedical lines, much to the advantage of the na-
tion.
The immediate aid to the military medical service
afforded by this provision of the recent act is that
the contract surgeons now in service will receive
commissions and enjoy the positions and emolu-
ments of regular officers, instead of the unsatisfac-
tory half military, half civil status heretofore occu-
pied by them. The recent increase in army pay
makes the new position also better worth having.
The necessity for a considerable number of medical
officers additional to those of the IMedical Corps
will continue for some years at least, as the increase
in the regular force cannot under the act be fully
obtained for four years, and unless much greater
success than heretofore is had in securing properly
qualified men, the corps is not likely to be entirely
filled even in that time.
Candidates for the permanent corps wilj, after
passing the preliminary examinations, be also com-
missioned in the Reserve Corps and placed on active
duty until they have gone through a course of in-
strv.ction at the Army ^Medical School, thus insuring
them against loss of pay or future loss of rank in
the Medical Corps when they are finally admitted.
The present advantages of this section of the act
are, therefore, so manifest that the Medical Depart-
ment may well be congratulated upon its passage^
but it is hoped the ]\Iedical Reserve Corps of the
future will be much more than a small band of as-
sistants temporarily helping out the medical service
of our little regular army. The President is au-
thorized to commission as first lieutenants of the
Reserve Corps properl\- qualified graduates in medi-
cine who are citizens of the United States. The
holders of these commissions, although not on act-
ive duty, will form a body of men available for ser-
vice in emergency all over the land. They will be
considered as having pledged themselves to serve
the country professionally in time of war when
called upon, although by no means necessarily as
first lieutenants of the Reserve. Service to the na-
tion in any capacity will be considered as carrying
out the agreement.
The number of the Reserve Corps is not limited
by law, and it is probable that the age limits will be
so fixed that some of the older men of acknowledged
eminence may be induced to enter and put a proper
"cachet" upon the new corps from the beginning.
We take for granted that physical soundness, good
standing in the community, and legal qualification
to practise will be required of all applicants.
The success of the scheme will depend entirely
upon the interest taken in it by the best physicians
and surgeons throughout the land. If, from mo-
tives of patriotism and national pride, representa-
tive men, and no others are wanted, enter the Re-
serve Corps, the War Department will be enabkd to
maintain contact with the medical profession of the
country that will insure our soldiers, regular and
volunteer, in future wars an adequate and efficient
medical service. Except for the few who are em-
ployed on active service in time of peace, and the
candidates for life careers in the army undergoing
instruction at the school, positions in the Reserve
Corps carry no emoluments of any sort. We be-
lieve, however, that the possession of the President's
commission and the knowledge that one's name is
registered among those willing to serve the country
in her time of need will be sufficient attraction for
the class of men particularly desired.
THE EDUCATION OF THE PUBLIC IN:
MEDICINE.
Dr. Herbert L. Burrell. of Boston, the new presi-
dent of the American Medical Association, chose a.
timely theme for his inaugural address before the
annual meeting of the association, held in ChicagO'
this week. We are indebted to the general secretary
1096
for advance proofs of that and the other formal ad-
dresses. The title of Dr. Burrell's discourse was A
New Duty of the Medical Profession : the Educa-
tion of the Public in Scientific Medicine. Having
paid a graceful tribute to the memory of the late
Dr. Nicholas Senn and traced the progress of medi-
cine from the condition of a satellite of theology to
that of biological science applied to the prevention
and relief of disease, the president proceeded to his
subject proper.
Dr. Burrell is in thorough accord with the present
feeling of the profession that the general public
needs medical instruction from the best sources, not
the self seekers and the covert advertisers, whom,
he is quite si.ire, the people would not be slow to
detect. He specifies four agencies by which the
public may be educated in medicine. The first of
tliem is newspaper articles authorized by a respon-
sible board of medical men. "These articles," he
says, "should be signed and published under the
authority of the Board of Public Instruction. That
these articles should be judiciously edited must be
a])parent to all. No statement issued by the Board
of Public Instruction should fail to be the absolute
truth. Irreparable damage to the medical profes-
sion and to the public might be done by unwisely
exploiting mooted subjects." \\'e presume it may
be taken for granted that authoritative boards would
be less likely to fall into the errors alluded to than
enthusiastic individuals would.
The next agency mentioned is magazine articles
written by skilled lav writers inspired by medical
men of sound knowledge and discretion. This
strikes us as an exceedingly hopeful means, only we
may first have to disabuse the public of the extrava-
gant appreciation which it has been taught to en-
tertain of "the commercial value of a name," for
that overappreciation is a real obstacle. The man
who has done things and who knows things is not
usually the one who can best expound them. Julius
Caesar was a shining exception, but our Caesars are
few and far between. We presume that the source
of the lay writer's inspiration ought always to be
mdicated, but the intervention of the skilled writer
is highly necessary.
The next agency mentioned is that of free public
lectures. In regard to their efficiency. Dr. Burrell
says :
These lectures sliould be given l)y men who are au-
thorities in their subjects; and the experiment as it has
been tried in vaiious .parts of the country, particularly in
Chicago and at Harvard, has been a success. At Harvard
(luring this last winter the lectures have been so popular
tlial at times a hundred or more people have been turned
away, being unable to gain admission. A wide range
of subjects has been covered in these lectures. Many
factors influenced the attendance: First, the subject se-
lected; second, the individual who gave the lecture; and
[New York
Medical Journal.
third, the condition of the weather. Sunday afternoon
lectures were better attended than Saturday evening lec-
tures. Inclement weather markedly diminished the at-
tendance. The most conspicuous factor that influenced
the attendance at the lectures was the cooperation of the
press. For example, when a lecture was given on a sub-
ject of great public interest, then if the press devoted
from a half column to three columns to noticing it, the
stimulus to the attendance at succeeding lectures was
marked.
But Dr. Burrell is convinced that the most potent
agency of all is individual teaching by the physician
in the family, and we believe that the profession will
cordially agree with him in this. He thinks that in
public instruction it will be well to avoid attempts
to cover too wide a field ; we should rather seek to
make the instruction thorough in a limited range,
such as that of the infectious diseases, and notably,
as is now being done, with regard to tuberculous
disease. The address as a whole was replete with
wisdom.
OUR RELATIONS WITH THE PUBLIC.
The association is to be congratulated on having
selected so scholarly and broad minded a man as
Dr. William Sydney Thayer, of Baltimore, to deliver
the address in medicine this year. Dr. Thayer
touches luminously on a number of points covered
by the title of his address, On Some Relations of
the Physician to the Public ; Duties and Opportuni-
ties. We can mention only the more notable of
them. The subject of malaria receives considerable
attention. The Hellenic Peninsula, Dr. Trayer re-
minds us, is still cursed with the prevalance of
malarial disease, and he implies that the decadence
of the Greeks of ancient times may be traced to the
sapping of general liealth among them by that in-
fection. In Italy, on the other hand, malaria is well
on the road to suppression as a result of vigorous
sanitation. In our own country we ma}- take a les-
son from what has been accomplished in some of our
dependencies, particularly in the Panama Canal
Zone, in the prevention of disease. Of the work on
the canal, "one of the greatest undertakings that
man has ever essayed," Dr. Thayer says :
The French, with unexcelled mechanical skill and energy,
had failed — failed largely because of the dreadful and
continued mortality among the workmen. The United
States took up the work. In the mean time there had come
the great discoveries of Ross and Grassi and Bignami
and Bastianelli, completing those of Laveran, concerning
malaria, and the vital and illuminating contributions of
our own Reed, Lazear. Carroll, and .'Xgiamonte. with re-
gard to yellow fever. And to-day the Panama Zone com-
pares favorably, as to sanitary conditions, with the more
iiealthy parts of this country. Yellow fever, though on all
sides, is here unknown. It is the greatest triumph of
preventive medicine that the world has ever known.
Dr. Thajer depicts vividly the difiicultics too fre-
(|ucntl\ met with b\ physicians in inducing person;;
EDITORIAL ARTICLES.
June 6, 1908.1
liDITORIAL ARTICLES.
1097
in authority to listen to arguments in favor of hy-
gienic precautions, instancing "an eastern city"
whose authorities suftered an engineer to stifle the
pleadings of medical men who insisted on proper
measures for insuring the salubrity of the water
supply. It would have done no harm, we think,
if he had mentioned the city by name ; municipalities
are in great need of having such blunders brought
home to them specifically.
Frankness with patients, as a part of the public,
is another of the great duties which Dr. Thayer
msisted upon — frankness associated with optimism.
The mysterious, the impressive, the oracular, he said,
should be discarded in our intercourse with the sick.
"Truth," he reminded us, "is as sacred a duty in
medicme as anywhere else in life," and he forcibly
cited Cabot as having said: "The doctor's lie is
always detected."
THE CANCER PROBLEM.
This was the title of the address in surgery by Dr.
George W. Crile, of Cleveland, delivered before the
meeting of the American Medical Association in Chi-
cago. Not only, in our opinion, was it the gem of all
the formal discourses, but also such a pronouncement
as cannot fail to remain a landmark, and a bright
one, in the history of the present worldwide endeavor
to solve the problems of malignant disease. It is no
wonder that those who heard it were profoundly
impressed. There is no circumlocution about Dr.
Crile's way of putting things, no shadow of uncer-
tainty as to his meaning or as to the depth of con-
viction from which he speaks ; his incisiveness, in-
deed, reminds us of the late Dr. Henry B. Sands,
and there is often observable in his style a verbal
felicity that but few medical writers have ever pos-
sessed. The following expressions, for example,
are worthy to be ranked with the late Dr. Roberts
Bartholow's "therapeutic nihilism" : "Cellular can-
nibalism" (referring to the destructive action of
cancer) and "There is no tie of sentiment between
a man and his cancer" (apropos of the feasibility
of inducing a patient to consent readily to excision
of a precancerous lesion).
Dr. Crile is optimistic in the matter of cancer, but
his optimism is abundantly justified. Though he
gives solid reasons for hopefulness as to the ulti-
mate triumph of other means, he regards the knife
as still practically the sole resource in rescuing the
subjects of cancer. He presents an encouraging
contrast between the "ghastly" statistics of oper-
ative results collected by Butlin twenty-one years
ago and the brilliant consequences witnessed at the
present day. But, he insists, the operation must be
an early one. done in the precancerous stage if pos-
sible, and he justly scores those doubters in the pro-
fession who dally with a growth of yet uncertain
nature until the period of hopefulness has been
passed. "I have often thought," he says, "that,
pending a more general enlightenment, it would be
a great boon to mankind if the words 'glandular en-
largement and cachexia' as denoting symptoms of
cancer were stricken from every textbook of medi-
cine. These are terminal symptoms, and indicate
that the surgical opportunity is forever lost."
Early and thorough excision, under proper tech-
nique, having been demonstrated to be practically
curative of readily accessible growths. Dr. Crile
turns his attention to internal cancers. In common
with many others, he is convinced that these tumors
also have a precancerous stage, gastric cancer, for
example, following upon a simple ulcer. Hence
these possibly precancerous lesions should be re-
moved. In the early diagnosis of internal cancer
much dependence may be placed upon blood exam-
inations turning upon the presence or absence of
hsemolytic action. In cases that appear inoperable
on account of the patient's bad condition, substantial
assistance is to be derived from a properly conduct-
ed transfusion of whole blood or an infusion of
serum, and there is good ground for expecting the
establishment before long of immunization by serum
treatment. We know of nothing in all our litera-
ture which is so encouraging in the struggle against
cancer as this address of Dr. Crile's.
THE AMERICAN .AIEDICOPSYCHOLOGI-
CAL ASSOCIATION.
The sixty-fourth annual meeting of this organiza-
tion, the oldest national medical association in the
country, took place recently in Cincinnati, with an
average attendance of over two hundred members.
The meeting was marked by many pleasant social
features, as members from all parts of the United
States and Canada were in attendance ; the hospital-
ity of the State, the city, and the medical profession
was most cordial, and the scientific programme was
rich in records of earnest and progressive work in
the special field of psychiatry.
In his opening address. Dr. Charles P. Bancroft,
of Concord, New Hampshire, speaking of the hope-
ful and discouraging aspects of the psychiatric out-
look, reviewed the progress of the past few years,
showing how rapidly the science of psychiatry had
been advancing, far more rapidly, in fact, than most
of the members of the profession Avere aware, and
this progress, he said, had been no less marked in
the sphere of the therapeutics of mental disease than
in that of its more exact diagnosis. He emphasized
the necessity for a broader outlook on the part of
alienists if they were to discharge a fuller measure
1098
111)110 RIAL ARTICLES.
[New York
Medical Journal.
of their responsibility to the social body, and spoke
of the discouraging features implicated in the polit-
ical management of many of our hospitals for the
insane.
In Dr. Henry J. Berkley's paper, read by Dr.
Hurd, on Thyreoidectomy and the Thyreolecithin
Treatment of Catatonia, the definite report of thera-
peutic advance was made with reference to this
group of mental disorders. In well marked catatonic
praecox cases, characterized by much motor disturb-
ance, in the form of command automatism, nega-
tivism, stereotypy, catalepsy, etc., by the removal of
part of the thyreoid gland, done under certain sur-
gical precautions, a definite and distinct ameliora-
tion had taken place in a fairly large number of pa-
tients. In some instances the change had been so
marked and had occurred in so short a time that the
eflfects seemed almost magical. The author, how-
ever, gave a very guarded estimate of the perma-
nent value of the procedure, and expressed the opin-
ion that the number of reported cases was still too
small to permit of generalizations. In view of the
active discussion that brought out the facts of the
relatively good prognosis in this particular form of
disturbance, the difficulties in diagnosis, especially
of certain hysterical admixtures, the absence of defi-
nite biological concepts interpretative of the results,
the general feeling shown was that of a hopeful pro-
ductive conservatism thai counseled further trials
under rigid analysis of results.
The vexed problem of the presenile mental affec-
tions was attacked with hopeful results by Dr. E. E.
Southard and Dr. H. W. Mitchell, of Hathorne,
Mass. The coordination of clinical and pathological
material in an analysis of some 400 cases was too
exhaustive to permit of more than a brief note in
this place. The author showed, however, that in
some twenty insanities occurring in the sixth and
seventh decades, which were studied post mortem,
there was no need of regarding them as different in
type, from the clinical or pathological point of view,
from the insanities known to occur in other decades.
Thus, one patient of over sixty, in the absence of
any arteriosclerosis, showed the typical clinical pic-
ture of a dementia prjecox ; others were classical
"manic depressives," the attacks occurring apparent-
ly for the first time in these decades. The paper
was extremely suggestive in many directions and
offered considerable light in a field much in need of
investigation. A spirited discussion was held on
the general subject of the bacteriology of general
paresis, which wc have presented in a separate edi-
torial note. The paper of Dr. Henry M. Hurd, of
Baltimore, was a masterly one — Psychiatry as a Part
•of Preventive Medicine. We shall comment upon
it at a future time.
Speaking of the proper size of hospitals for the
insane, Dr. Charles W. Pilgrim, of Poughkeepsie,
made a searching analysis of this entire question.
He traced the gradual growth of our hospital sys-
tem from the days when, 300 inmates were regarded
as sufficient in number for one superintendent to
care for properly, to the enormous piles in which 5,000
are domiciled. He showed that we now had had
experience enough to determine the proper size for
a hospital for mental disease, from the standpoint of
economical administration and maximum efficiencv
in the treatment of the individual.
We have been able only to pick out here and there
some of the interesting papers given before this as-
sociation— there were many others equally important
that space does not admit of our discussing.
INSTRUCTION IN HYGIENE AT WEST
POINT.
The recent appropriation bill for the Military
Academy at West Point provides that the Secretary
of War may appoint a medical officer of the army
as "instructor" of hygiene for the Corps of Cadets.
The use of the word "instructor" instead of "pro-
fessor," as heretofore, is most unfortunate and con-
stitutes a step backward in the teaching of hygiene
to the line of the army. A West Point "professor"
is a personage with distinct rights and privileges.
He has the rank of lieutenant colonel or colonel,
and his assistants detailed from the army are "in-
structors." Professors are also members of the
Academic Board. The professor of hygiene at the
academy has enjoyed like privileges and, although
a major in the Medical Corps, has been carried on
the register with the temporary rank of lieutenant
colonel. The position carried with it extra pay to
the extent of five hundred dollars a year (the dif-
ference between the pay of a professor at the Mili-
tary Academy and a major in the army). It ap-
pears that Congress objects only to the extra pay,
and so substituted the word "instructor." The loss
of pay to the officer in question, although it seems
unfair to him. is not a tiiatter of national import-
ance, but the change of title is really a serious mat-
ter, as it tnininiizes the chair of hygiene and may
possibly operate as a technical obstacle to the teach-
er of that branch serving on the Academic Board.
The actual daily practice of military hygiene is
necessarily in the hands of the officers who com-
mand men. and its foundation is discipline. The
instruction, therefore, of future ofincers of the army
in all that constitutes "care of troops" is of supreme
importance, and the relegation of hygiene to an in-
ferior place in the curriculum at West Point is
much to be regretted.
Tune 6, 1908.] CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
1099
The American Medical Association,
Fifty-ninth Annual Meeting, Chicago, June 2, 3, 4, 5, 1908.
With a registered attendance of six thousand
four hundred members the fifty - ninth annual
meeting of the American Medical Association
establishes a new record for gatherings of medical
men, for it can be safely asserted that never be-
fore were there so many physicians gathered to-
gether on- one occasion. The central situation of
the place of meeting, its accessibility, and the ex-
cellence of the programme all combined to make
possible so large an attendance.
Although the scientific meeting was not called
until Tuesday, the House of Delegates began its
sessions on Monday, the ist, at lo a. m. A full re-
port of the business of the House of Delegates will
be found after this article.
The General Meetings. — The first general
meeting was called to order at 10:30 a. m. on the
2d by the president. Dr. Joseph D. Bryant, of
New York. After an invocation by the Right Rev-
erend Charles Edward Cheney, D.D., bishop of the
Reformed Episcopal Church, addresses of welcome
were made by the Honorable Charles S. Deneen,
governor of Illinois ; the Honorable Fred A. Busse,
mayor of Chicago; and Dr. H. B. Favill, the presi-
dent of the Chicago Aledical Society.
After the report of the local committee of ar-
rangements was presented by Dr. M. L. Harris, of
Chicago, Dr. Herbert L. Burrell, of Boston, was in -
troduced and conducted to the chair. Dr. Burrel!
then delivered the address of the president (see
page 1095).
The second general meeting was called to order
at 7 :30 p. m. on the 2d, by the president, Dr. Her-
bert L. Burrell, of Boston. The oration on med-
icine was delivered by Dr. William S. Thayer, of
Baltimore. The oration on surgery was delivered
by Dr. George W. Crile, of Cleveland, in the section
on Surgery and Anatomy. Both of these orations
have been treated in our editorial columns in this
issue. At the third general meeting, which was
held on V/ednesday, June 3d, at 2 p. m.. Dr. Charles
Harrington, of Boston, delivered the oration on
State medicine.
The Scientific Business. — The scientific busi-
ness of the meeting as conducted in the various
sections was up to the average of excellence so long-
maintained by this association. Lack of space pre-
vents us from giving the gist of each paper read,
but the reader will find abstracts of several impor-
tant communications in proper sequence in the de-
scription of the meetings.
Guests. — Among the distinguished foreigners
who were present as guests of the association may
be mentioned Professor J. Hannenstiel, of Kiel,
Germany, who spoke upon Abdominal Cervical
Cesarean Section at the symposium on Csesarean
section at the Tuesday afternoon meeting of the
Section in Obstetrics and Diseases of Women;
Professor A. Martin, of Greifswald, Germany, who
spoke on Genital Tuberculosis at the Wednesday
afternoon meeting of the Section in Obstetrics and
Diseases of Women ; Professor L. Brauer, of Mar-
burg, Germany, who took part in the symposium on
the surgery of the vascular system and read a pa-
per on Positive Pressure in the Surgery of the
Chest ; Professor Jensen, of Berlin ; Dr. Arthur
Bahr, of London, who read a paper on the
Surgery of the Abdomen; Professor Edward A.
Schaefer, of Edinburgh, Scotland, who read a pa-
per on Artificial Respiration in Its Physiological
Aspects, and another paper on the Pituitary Bod}
at the meetings of the section in Pathology and
Physiology; Dr. F. Sauerbruch, of Marburg, Ger-
many, who read a paper on the Present Status of
Surgery of the Thoracic Cavity and the Signifi-
cance of the Author's Method of Preventing Pneu-
mothorax, in the section in Surgery and Anatomy ;
Dr. E. Treacher Collins, of London, who read a
paper on the Developmental Deformities of the
Crystalline Lens, and took part in the discussion on
the treatment of simple glaucoma in the section in
Ophthalmolog)- ; Dr. Charles E. Beevor, of London,
who addressed the section in Nervous and Mental
Diseases on Associated Movements.
The Entertainments. — The social features of
the meetings of the American Medical Association
are among its most important proceedings. The
president's reception and the ball, which were held
on Wednesday evening, were, of course, the lead-
ing social functions, and it was a great pleasure to
watch the gay scene m which such a large number
of physicians and their guests took such evident en-
joyment. The Art Institute, on Michigan avenue,
was open daily to those who wore the official badge
of the association. Automobiles left from the Art
Institute hourly from 10 o'clock every day, in
which those who desired to see the city were taken
to the various points of interest. There was an in-
formal gathering of the ladies in the rooms of the
Fortnightly Club, the Chicago Woman's Club, and
the Chicago College Club on Tuesday afternoon;
a reception in honor of Mrs. Herbert L. Burrell at
the South Shore Country Club on Wednesday
1 100 CHICAGO MEETING OF AMEh
afternoon ; a reception and a musicale by members
of the Theodore Thomas Orchestra in the Art In-
stitute on Thursday afternoon. There was a con-
cert an4 smoker at the CoHseum for the men on
Thursday evening.
Tuesday evening was given over to section din-
ners and entertainments and alumni reunions. Dur-
ing the past few years the latter have taken on
great and increasing importance as an attraction for
those contemplating attending the meetings of the
association. This year the following alumni had re-
unions, all of which were well attended.
Alumni College Reunions. — Albany Medical
College, Dartmouth Medical College, Detroit Col-
lege of Medicine, Harvard Medical School, Jeffer-
son Medical College, Johns Hopkins University
Medical School, Kentucky School of Medicine,
Long Island College Hospital, McGill University,
University of Maryland, University of Michigan,
University of Nebraska School of Medicine, North-
western University Medical School, Medical Col-
lege of Ohio, University of Pennsylvania Medical
Department, College of Physicians and Surgeons,
Chicago, College of Physicians and Surgeons, New
York City, Rush Medical College, Tulane Uni-
versity Medical Department, Western Peimsylvania
Medical College, Women Alumnae, Woman's Medi-
cal Society of Illinois, Medical Woman's Club of
Chicago.
On Friday evening the Wiener Studenten 1906-07
enjoyed a Dutch lunch at the Tom Jones Restaurant.
The Phi Rho Sigma Fraternity held a smoker on
Monday evening at the Beta chapter house.
Opportunities were offered for members of the
association to visit the plant of the Illinois Steel
Company at South Chicago. Armour and Company,
Swift and Company, and Libby, McNeill, and Libby
arranged a demonstration of government inspection
of meat and of the killing of cattle on Saturday
morning, June 6th.
The Scientific and Commercial Exhibits. — The
scientific exhibit, under the direction of Frank B.
Wynn, of Indiana, was possibly not quite so large
as that in Atlantic City, but was quite as interesting.
Mention should be especially made of the exhibition
of anatomical specimens from Tulane University
and of the life history of the tick, Dermacentor occi-
dentalis, and the pathology of Rocky Mountain
fever.
The commercial exhibit was of the usual char-
acter.
There had been some doubt in the minds of some,
in the East particularly, as to the possibility of hotel
accommodations holding out ; but no one, .so far as
we know, had any difficulty in securing satisfactory
CAN MEDICAL ASSOCIATION. [New Vcrk
Medical Journal.
quarters. The Chicago hotels which are opposite
Grant Park on Michigan avenue have a site which
is quite picturesque and is very interesting. To look
out of one's window at night and to see three light-
houses on guard at the entrance to the Chicago
River, at the south end of the government pier, and
at the crib for the intake of the Chicago water,
one would easily imagine himself at the seashore.
The Illinois Central Railroad is depressed so as not
to spoil the view from the street, and wdien the road
is equipped with electric locomotives there will be
no telltale smoke to indicate its presence.
The meeting was a large one ; up to Thursday at
4 o'clock 6,389 members had registered. The
weather was all that could be desired.
l^roceetJinsfii of tf)t l^ousfe of Belegated.
The House of Delegates met on Monday, June
1st, at 10 a. m., the president. Dr. Joseph D.
Bryant, of New York, in the chair.
After the adoption of the minutes of the fifty-
eighth annual meeting the president delivered his
annual address.
The Retiring President's Address to the House
of Delegates. — Dr. Bryant spoke as follows :
Gentlemen : The period of my official connection with the
high station to which I was chosen is drawing to a close,
and in a feu hours what yet remains will become a part of
that already passed, when the whole will have been regis-
tered in the annals of the affairs of the organization, there
to remain as evidence in the estimate of my official deserts.
For the expression of confidence and respect so generously
bestowed I again bow in most humble acknowledgment.
The practical wisdom of those who conceived and gave
birth to the system of government of the association did
not seriously contemplate that the transient advent of a
president need much disturb the ordinary tide of its con-
cerns. Whether or not this conception of presidential
utility be wise or otherwise cannot yet be considered as set-
tled. And, whether it be wise or not can better be deter-
mined by a broad spirit of statesmanship than by one of
restricted policy. It might safely be regarded as possible
that a transient judicious executive would exercise a whole-
some influence in the control of affairs. Be this as it may.
the comparative differences of the governing affairs of the
association and those of the government on which they are
fashioned become less apparent as one reaches the sources
of authority, and they practically disappear at the port cf
the official head of this organization.
I am not finding fault because of this anomaly, but am
simply pointing out what is recognized and gravely re-
garded by many thoughtful and devoted men, whose view^.
are not limited by the horizon of the present time. In my
judgment the well being of the association would be more
securely fixed and correspondingly enhanced by requiring
that the president cooperate with his colleagues in official
labors, the same as is done in other corporate bodies of
established significance.
The problem which for long has periodically perplexed
our Federal government and its gracious and sympathetic
people, viz., "What to do with the former presidents," now
appears to be knocking at the door of expediency of our
organization, and inquiring "What to do with the former
presidents" of its own? In this connection, I would say
that the degree of wisdom which our former presidents
have acquired because of established official contact with
their colleagues in the control of affairs cannot be seriously
regarded as profoundly fitting them for much special con-
sideration. With this important feature thus qualified, I
am inclined to caution you to think carefully and act slowlv
in a matter which, while disturbing the equilibrium of con
June 6, iQoS.l
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
IIOI
stituted State representation, seems not to contribute a
commensurate gain.
I am aware it is often thought wise or expedient by
some persons that the coordinating requirernents of an or-
ganization be not too explicitly stated in its constitution
and bylaws, but I am none the less of the opinion that
these of ours could be improved in forms of expression and
in scope and requirement by comparatively brief efforts
of judicious character.
The fact of whether or not the provision relating to the
calling of meetings is sufficiently amplified for the purposes
of duly authorized action might well be determined.
The clause of the constitution providing that "no mem-
ber of the House of Delegates shall be eligible to the office
of president or vice president" is a wise and healthy meas-
ure, for men thus disposed should not be active constituents
of a legislative body vested with the power of conferring
official station, nor should one be thus connected whose re-
muneration for special services can come before the legis-
lative body for consideration, for plainly obvious reasons.
The selection of the members constituting the special and
reference committees of the session have been made, as far
as practicable, in accordance with the numerical representa-
tion in the association of the respective parts of the coun-
try and as estimated for the purpose of selection by Mr.
Hoffman, of Newark, a distinguished statistician and ac-
tuary. Therefore, if any disappointment should happen be-
cause of less representation than before, the difference is
due more to the verdict of impartial figures than to the
exercise of individual desire.
I have thus far on all occasions taken pleasure in com-
mending the purpose and the work of the Council on Phar-
macy and Chemistry. I again wish to renew this approval,
and also to express the self evident fact that, if medical
therapy is to be of reliable worth, then, indeed, the con-
structive purity of its agents and their physiological action
must be scrupulously guarded.
I have been not a little disturbed by the assertions of
persons who are engaged in the enterprises of pharmacy,
related to certain wrongs which they qlaim to have sus-
tained because of unfair and ungentlemanly treatment at
the hands of responsible officials of the association. In one
instance it was asserted that oppressive and illegal hardship
had been inflicted which resulted in mental distress and in
pecuniary loss. In this instance I expressed the belief to
the complainant that he was in error, and predicted that the
courts would so determine, were a test made, and advised
that it be made at once. The complainant declined to ac-
cept this advice, saying that were his contentions w-ell
founded, and even sustained by the courts, still his business
would be destroyed by retaliatory cooperativee action of the
members of the American Medical Association ! Was ever
an upright and independent body of men more misjudged
than this? Could one impelled with childish imaginings be
more mistaken than he? It were better far for the honor
of the medical profession that this association resolve into
thin air or into the sediment of a stagnant pool than thus
attempt to smother established justice with the fumes of
revengeful disorder. Already too much of this kind of
spirit is abroad in the land for the comfort and security
of law abiding people. And we, the members of a
learned profession, should be ever actuated by the spirit of
citizenship, which promotes good order in all things and
invites the infliction of the penalties that foster obedience.
Bitter complaints have come to my notice which appear
to embrace the practical question of whether or not those
who are opposed to the policy of government which stands
for the securing of trustworthy medicinal agents are en-
titled to the same consideration as are those who approve of
and support the purpose. And, as a corollary of the pre-
ceding, whether or not those who actively give or passively
lend support to a policy impairing or making uncertain the
curative virtues of medicinal measures, or lowering in
other ways the station of scientific medicine, are entitled
for long to patient consideration at the hands of those who.
in this regard, are striving for the best of things? I do
not understand how it is that this question can be answered
in the affirmative. However, the unusual and novel ques-
tions which readily come to the front in these circum-
stances should be kindly though firmly met, and with a
spirit which, though striving for higher thought and action,
soothes instead of needlessly provoking opposition.
T am convinced of the need, and commend to your ap-
proval the importance of the work being done by Dr.
McCormack in elevating the tone and the standard of the
medical profession. A service of this kind is in order, and
will enhance the station of medicine accordingly as the
facts are wisely selected and judiciously expressed.
Some of the discreditable vagaries of thought and action
that are noted in business relations are threatening to enter
much into professional relations as well. In fact, tangible
evidence is not lacking that practices of unethical recipro-
cal nature too frequently exist for the credit and honor of
our calling. I regard it of special importance that _ stu-
dents in medicine should have their ideas of professional
conduct carefully moulded aright, while yet in the plastic
state of development. The principles of moral philosophy
as related to medicine are not apt to be decidedly catching
in the instances of physicians whose thoughts and habits
of action are already quite well established. And, also, the
active and passive obstruction to coordinating within de-
cent bounds certain questionable and convenient products
of pharmaceutical skill are an earnest of the need for a
proper bending of those who may be regarded as the
"twigs" of our profession, so that as "trees" they later may
be rightfully "inclined."
It would seem to me as wise that a standing committee
on principles of moral philosophy as applied to medicine
be constituted, with the view of elaborating still further
ethical principles, and so far as practicable establishing in
this respect uniformity between the medical profession of
this and other countries. Also, I would suggest that un-
dergraduate and postgraduate general instruction in ethical
medicine be a part of the requirements of institutions en-
gaged in medical teaching. I should expect greater, earlier,
and more durable results, and without friction, from this
plan than can come from any quasi-insistent method of en-
deavor. The incident of the insistent master, the abundant
trough, and the unwilling horse well typifies the present
situation in many instances. In any event, it would be well
to properly develop the roots of our profession while
busily trimming the branches.
I should signally fail in my duty at this time were I to
omit telling you that plausible measures directed to the
regulation of animal experimentation are abroad in the
land, which are drawn so adroitly and presented so cleverly
as to conceal, on confiding inspection, special factors of
grave possibilities. Consequently, medical men who are
loyal to the spirit of scientific endeavor are thoughtlessly
giving strength to the stealthy foes of scientific medicine.
It should not be possible to thus easily introduce into the
ranks of our calling a wedge which, when driven home,
would split our organization asunder on the policy of ani-
mal experimentation. Medical men should refuse to give
assent to strange policies of a professional kind until after
thoughtful and judicious consideration shall have deter-
mined the wisdom of the propositions. If organization in
medicine stands for aught, it should stand for unity of pur-
pose in all scientific matters relating to it. Since "fore-
warned is forearmed," each of you should keep in mind the
possibility of besetting dangers, and in no instance fail to
sound the alarm long in advance of parley or of impossi-
ble capitulation. I would respectfully urge that the House
of Delegates take decided and far reaching action in this
important matter.
Whether the constitution or the flag should take prece-
dence in the outlying parts of our country need not con-
cern this association as much as how soon can the medical
profession of those accessions properly become integral
parts of the organization. It seems to me that this ques-
tion should be answered at the earliest practical moment.
The claim of the medical profession of Alaska for similar
action is one of substantial moment, and may be of superior
importance to those of recent birth and of less development.
The moral effect, on the tone of the profession of these
communities, of the sympathy, approval, and support of
this association, in the furtherance of proper methods of
control of their affairs, would be encouraging to them and
creditable to the organization. And no doubt the sooner
the supporting hand is extended the easier and more com-
plete will be their task.
In as brief manner as possible I have called your atten-
tion to certain things relating to matters of the organiza-
tion which, in my judgment, should be better adjusted in
order to comport more nearly with the conduct of the af-
fairs of organizations whose wisdom of government one
cannot gainsay. The question before the house is not how
best to please a few, but how best to satisfy the many.
Therefore, the policy of government should be broad
and uniform and in conformity with the judgment of the
II02
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
[New York
ilEDicAL Journal.
majority. Its conduct should be characterized by the in-
herent power of discriminating justice, patiently and tem-
peratelv dispensed. The official servants of the organiza-
tion should regard themselves as such, and not the masters
of it. They should exercise discretion and patience, and
consequently should be vigilant and gracious under all cir-
cumstances. And in this connection it should be remem-
bered that our country is broad, and that its people are
independent and honest ; also that those of different parts
of the country do not always think and judge alike in sim-
ilar matters, and what is of special significance at this time
is that the medical profession is an influential part of the
people, and, therefore, of significant importance in its re-
spective environments. I earnestly utter these words and
without bias, because of the known recognized temptations
to inconsistency of thought and action which the exercise
of power so often begets. I would remind you that the
wise exercise of power oftener requires greater skill and
courage than does the achieving of power. And also that
the absence of wisdom in control not infrequently destroys
the highest governing conception of men.
Although it has been said that "those who think must
govern those who toil," it should not be overlooked that, in
a profession, those who toil must also think, and because
of thought are competent to govern while yet they toil.
That too much government is apt to be harmful is an ac
cepted fact, and, therefore, that those who govern least
may govern best cannot be gainsaid.
I should regard it as a misfortune were the duties of the
House of Delegates of this association to become so on-
erus and perplexing as to eliminate from its councils nien
whose ceaseless toil makes for higher station in medicine.
Consequently, I regard it as very important that the duties
of this body be abridged and simplified as much as possible,
and that judicious expedition in the conduct of its affairs
be promoted and that hindering cavil be abrogated. When
it shall appear that the uncertain products of legislative de-
sire are of more concern than those of positive scientific
endeavor, then the ennobling functions of the association
will have been mortally hurt.
That "death has many doors to let life out" is the history
of all bodies of men. And it is a matter of profound con-
gratulation to us that, of the many doors in this organiza-
tion, but few, indeed, came ajar during the last year.
Through one, however, out into the unknown has recently
passed a conspicuous member of the association and the
profession — one whose indefatigable energy and ceaseless
activity contributed enduring abundance to the honor and
glory of our calling. In his profession, the paths which he
hewed wi'-.h consummate wisdom and patient care, often
through obstacles akin to those of pious endeavor, still lead
onward and upward and toward the terrestrial Mecca of
cure and comfort of the human race. In other undertak-
ings his footsteps were firm, consecutive, and direct, and
his successes were indelibly impressed on the fields of his
toil. And, as an example for emulation in all that relates
to breadth of effort and height of success in the paths to
which he clung, the memory of the late Dr. Nicholas Senn
should be revered and ever regarded as a precious heritage
of our profession.
An unprecedented incident of unusual significance and
full of beneficent possibihties happened when, in March
last, the President of the United States extended an in-
vitation to the medical profession to take part in the con-
ference on the conservation of natural resources. The
President, in this regard, expressed himself as follows:
"I wish to invite the cooperation of the .'\merican Medical
Association in bringing this matter before the people; and
it gives me added pleasure to invite you, as President of
the association, to take part in the conference." It should
not be necessary to say that I was present and that, on
behalf of the American Medical Association, I thanked the
President profoundly for the invitation, and pledged to his
support in the conservation, not only the members of the
American Medical Association, but the entire profession of
the land. I would urge that prompt, appropriate, and de-
cided action be taken by this body, thus showing appre-
ciation of the invitation and determination to aid in every
possible manner.
I should be negligent of a plain duty and the promptings
of a keen sense of satisfaction were I to omit on this oc-
casion to express my appreciation of the uniform courtesy
which has been shown me by the members of this body and
by the officers of the organization. The charm of official
association is greatly enhanced by the unanimity of purpose
and the attention to duty which characterize those invested
with responsibility. In this connection it can be truly said
that criticisms visited on the officers of the association
rarely include those of delay or indifference in the conduct
of official business. And to have to do with the activity of
an organization blessed with the chance of bringing the
medical profession of this country into judicial unity, for
the promotion of wise and beneficent purposes, is the dis-
tinction of a lieftime, and one which those who are thus
favored should honor, as long as opportunity and effort
can add to the glory and station of medicine.
Finally, the comforting optimism of my nature leads me
to regard as certain the final success of all our contentions
which are based on the capacity to gladden and to cure the
afflicted of our kind.
The president appointed the following commit-
tees :
Reference Committee on Medical Education. — H.
D. Arnold, Massachusetts (chairman) ; Frank Bill-
ings, Illinois; A. Vander Veer, New York; L. S.
McMurtry, Kentucky; W. M. L. Coplin, Penn-
sylvania (Committee on Medical Education ex
officio). Reference Conintittee on Amendment
to Constitution and By-Laws. — George W. Guthrie,
Pennsylvania (chairman) ; Charles E. Cantrell,
Texas ; G. L. Taneyhill, Maryland ; C. H. Cook,
Massachusetts ; G. L. Strader, Wyoming. Refer-
ence Committee on Section and Section Work. —
Leartus Connor, Michigan (chairman) ; S. W.
Woodyard, Tennessee; Michael Hoke, Georgia;
Julius Bierwirth, New York; Charles McVea,
Louisiana. Reference Committee on Rules and
Order of Business. — W. H. Sanders, Alabama
(chairman) ; V. H. Stickney, North Dakota; J. F.
Highsmith, North Carolina; J. N. Jenne, Vermont;
Hugh F. Lorimer, Ohio. Reference Committee on
Legislation and Political Action. — C. S. Bacon,
Illinois (chairman); J. N. Hall, Colorado; S.
Bailey, Iowa ; Colonel H. G. Beyer. Navy ; Major
W. W. Ireland, Army (Committee on Medical
Legislation, ex officio). Reference Committee on
Miscellaneous Business. — Stuart McGuire, Virginia
(chairman) ; J. B. McGaughey, Minnesota; H. H.
McCarthy, Washington ; J. T. Wilson, Texas ; J-
H. Pierpont, Florida. Judicial Council. — C. E.
Cantrell, Texas (chairman) ; C. J. Kipp, New Jer-
sey ; J. F. Percy, Illinois ; George Dock, Michigan ;
H. L. Alkire, Kansas. Reference Committee on
Reports of Officers.- — Wisner R. Townsend, New
York (chairman) ; Donald Campbell, Montana; W.
T. Williamson, Oregon ; \\'. T. Sarles, Wisconsin ;
Frank Paschal, Texas. Reference Committee on
Hygiene and Public Health. — W. N. Wishard,
Indiana (chairman) ; A. R. Craig, Pennsylvania; G.
B. Young, U. S. P. H. and M.-H. S. ; J. D. Griffith,
Missouri. Committee on Credentials. — H. B. Ellis.
California (chairman); Horace Bonner, Ohio; C.
M. Nicholson, Missouri; D. C. Brown, Connecticut;
Adam Guthrie, Arkansas.
Report of the General Secretary. — Dr. George
H. Simmons reported that on May i, 1907, the
membership in the American Medical Association
was 27,515. During the year there had been a total
loss of 2,344 members and a total gain of 6,172
members, so that on May i, 1908, the total mem-
bership was 31,343, a net gain of 3,828. In Sep-
tember, 1907, the president appointed the following
Committee on Nomenclature and Classification of
Diseases : Dr. Frank P. Foster, of New York,
June 6, 1908.]
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
chairman ; Dr. W. A. N. Dorland, of Pennsylvania ;
Dr. Victor C. Vaughan, of Michigan ; Dr. Alexan-
der Duane, of New York, and Dr. J. Chalmers Da
Costa, of Pennsylvania.
Dr. William H. Welch resigned as a member of
the Committee on Medical Legislation, and Dr. John
B. Roberts, of Pennsylvania, was appointed by the
president to fill his unexpired term.
Delaware and Maryland voted in favor of estab-
lishing branch associations; Colorado, Idaho, Mas-
sachusetts, New York, Rhode Island, Ohio, and
Pennsylvania voted against their establishment ; and
twenty-five States have not yet voted on the ques-
tion.
The secretary recommended that the entire mat-
ter of uniform regulations regarding membership
be referred to a committee of three, at least two of
whom should be secretaries of constituent State asso-
ciations, with instructions to secure data regarding
the present provision of the constitution and by-laws
of various State associations on these points — as
well as the procedure followed by State and county
secretaries, and to report its findings and recom-
mendations at the next annual session.
A number of communications had been received
concerning the establishment of constituent associ-
ations in Puerto Rico and Alaska ; but no such asso-
ciation had yet been organized.
The American Medical Association Bulletin was
the continuation of the Councillors' Bulletin. It had
been used for the distribution of the outline of post-
graduate study, for information issued by the Com-
mittee on Medical Legislation, and a number would
soon be issued containing the minutes of the confer-
ence on Medical Education, held in Chicago in
April.
An invitation had been received for the American
Medical Association to appoint two of its members
to represent it in the council of the American Asso-
ciation for the Advancement of Science.
The past year had been one of increasing and un-
precedented activity. Much good had resulted from
the work of Dr. J. N. McCormack, of Kentucky, in
the systematic organization of county and State so-
cieties.
Report of the Board of Trustees for the Year
1907. — The Board of Trustees presented the re-
port of the Investors' Audit Company, of Chicago,
which had audited the books of the various officers
and committees of the association, This report
showed an excess of $301,650.15 over liabilities.
The treasurer had a total of $89,118.84 in his
hands on January i, 1908.
The percentage of physicians receiving the Jour-
nal of the American Medical Association varied ni
the different States from 75.1 in North Dakota, the
highest, to 21.5 in Georgia, the lowest. In New
York only 39.5 per cent, of the physicians belong
to the association, while in Pennsylvania the per-
centage was 40.6.
The work on the Directory had consisted in keep-
ing up the records relative to the graduates of indi-
vidual medical colleges ; the compilation of a bio-
graphical card index of all physicians ; revision
and corrections of the first edition material, and a
circular letter inviting criticisms and suggestions.
The first edition of the Directory was issued at a
net loss of $18,427.14.
The trustees appropriated a sum not to exceed
$225 to secure certificates of awards and medals in
addition to the customary appropriation for the
Committee on Scientific Exhibit.
The Board of Public Instruction on Medical Sub-
jects received $1,800. Dr. McCormack received
$7,500 for his travelling and other expenses, $600 of
which was for the purpose of establishing the post-
graduate course of study. The Anaesthesia Com-
mission was awarded $200.
The resolution of Dr. Peterson, of Michigan, au-
thorizing that free copies of the Journal of the
American Medical Association be sent to the mem-
bers of the Association of Medical Librarians was
not allowed, because the libraries to which these
librarians are attached already received free copies
of the Journal.
The suggestion of Dr. Marcy, of Boston, that
$5,000 be appropriated for the erection of a monu-
ment to Dr. N. S. Davis was respectfully declined
on the ground that such a precedent should never
be established.
The increase of clerical help for the Bureau of
Medical Legislation would be supplied from the
office of the Journal.
The trustees felt that the American Medical As-
sociation owed a debt of gratitude to Dr. J. N. Mc-
Cormack for the great work that he had done in his
special department.
The fifty-eighth annual meeting of the Associa-
tion, held in Atlantic City, cost $4,499.98.
The trustees commended the work of the Com-
mittee on Pharmacy and Chemistry, and the work
done in the chemical laboratory.
Dr. Reid Hunt, of Washington ; Dr. E. E. Hyde,
of Chicago; Dr. George Dock, of Ann Arbor; Dr.
Robert A. Hatcher, of New York; Dr. W. S.
Thayer, of Baltimore, and Dr. S. Solis-Cohen, of
Philadelphia, were selected as the committee to rep-
resent the Association at the next revision of the
pharmacopoeia, and $100 was appropriated for its
expenses.
Dr. David L. Edsall, of Philadelphia; Dr. J. A.
Capps, of Chicago; Dr. R. A. Hatcher, of New
York, and Dr. Otto Folin, of Waverley, were elect-
ed new members of the Council on Pharmacy and
Chemistry.
Dr. Alexander Lambert, of New York ; Dr. C. F.
Hoover, of Cleveland ; Dr. A. S. Taussig, of Den-
ver ; Dr. Charles G. Stockton, of Buffalo ; Dr. John
A. Witherspoon, of Nashville ; Dr. John T. Halsey,
of New Orleans; Dr. Alfred Stengel, of Philadel-
phia ; Dr. George E. de Schweinitz, of Philadelphia ;
Dr. Henry A. Christian, of Boston ; Dr. George
Dock, of Ann Arbor; Dr. LeRoy Crummer, of
Omaha; Dr. H. C. Moffitt, of San Francisco; Dr.
J. L. Miller, of Chicago ; Dr. A. T. McCormack, of
Bowling Green, and Dr. L. F. Barker, of Baltimore,
were elected members of a staff of clinical consult-
ants to the Council on Pharmacy and Chemistry.
The business affairs of the Journal office were
in satisfactory condition, so that the office had no
part in the "financial maelstrom."
The trustees suggested the advisability of making
1 104
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION. IN^w York
Medical Journal.
an annual appropriation of $500 for an essay on
subjects relating to internal medicine; that this be
awarded as a single prize, or as a first and second
prize of, say, $300 jmd $200. They further sug-
gested that, if this should be adopted, the editorial
board of the Archives of Internal Medicine should
have the management of the award of this prize or
prizes.
They recommended the following amendment to
the by-laws:
Amend Book I, Chapter III, of the By-laws by adding
the following as Section 9: "Retired members": "Any one
who has been a member in good standing of the American
Medical Association for twenty years, and who has been
placed on the retired list of his State association, shall, on
his request, be placed by the secretary of the A. M. A. on
the retired list of the members of this association. Retired
members shall be exempt from the payment of dues."
Report of the Committee on Medical Legisla-
tion.— Dr. C. A. L. Reed, of Ohio, said that the
Committee on Medical Legislation had endorsed
the bill for the reorganization of the Army
Medical Department, which became a law on
April 23, 1908. The committee cooperated in ev-
ery possible wav with the Medical Department of
the United States Army. It endorsed a bill reor-
ganizing and increasing the efficiency of the hos-
pital corps of the United States Navy; a bill au-
thorizing the appointment of dental surgeons in the
United States Navy ; and a bill authorizing the
establishment and organization of a corps of
trained women nurses. None of these bills passed.
It endorsed the bill for increasing the pensions of
Mrs. James Carroll and Mrs. Jesse W. Lazear,
which passed.
The question of uniform and adequate State
legislation on subjecis pertaining to the practice of
medicine and preservation of public health became
more important each year. The policy of the com-
mittee was to cooperate with various State associa-
tions and the State legislative committees appointed
by them ; to outline uniform policies regarding the
various questions in\olved: to draft and perfect
model laws for the use of State associations ; to ac-
cumulate, tabulate, and distribute necessary in-
formation regarding legislation in the various
States, as well as in foreign countries, and to con-
stantlv aid the various State associatit)ns by ad-
vice and cooperation. The actual work of securing
the adoption of desired laws should devolve on the
State association and its legislative committee. In
accordance with this plan, the committee had been
working along three different lines, viz. : ( i ) The
accumulation of data regarding medical practice
acts; (2) the formulation of a model bill regulat-
ing vital statistics; (3) the collection of material
regarding pure food and drug acts.
In order to accuiriulate data regarding medical
practice acts the committee was engaged in making
a comparison and analysis of the existing medical
practice acts ; in compiling a history of medical
legislation ; in compiling and comparing the medical
practice acts of foreign countries; and compiling,
collating, and comparing the decisions of all courts
of final jurisdiction, both State and I'^cdcral. so far
as they related to the constitutionality, interpreta-
tion, and enforcement of medical practice acts. It.
was obviously useless to attempt to draft a satisfac-
tory law for adoption by the different States with-
out first knowing what the decisions of our courts
had been on previous laws, and what rulings and
interpretations would be sustained by the courts in
future.
By the time the various State legislatures assem-
bled in the fall, it was hoped to have a vital statis-
tics bill ready for submission, which would have
the endorsement of all the authorities on this sub-
ject as well as of all recognized organizations in-
terested in this matter.
The committee had endorsed the pure food laws
of Kentucky and Tennessee, two of the best State
laws yet adopted, and with the national Food and
Drugs Act and the Iowa law, comprised the best
examples of pure food legislation.
During the past year the legislature had been in
session in fifteen States. Through the Bureau of
Medical Legislation the committee had endeavored
to cooperate with the legislative committees of the
various States and to afford them every possible as-
sistance in securing the passage of good laws and
the defeating of pernicious ones. The results had
been most gratifying and encouraging. With the
exception of the New York optometry law, which
was now in the hands of the governor, not a single
objectionable bill had been passed. On the other
hand, the medical practice act of Kansas had been
strengthened by the adoption of an amendment de-
fining the practice of medicine, the legislature of
Kentucky had passed one of the best pure food laws
yet enacted by any State ; a new board of health
law was adopted in New Jersey; an important
amendment to the medical practice act was passed
in South Carolina, while in Ohio a record for a suc-
cessful legislative campaign was established bv the
passage of a pure food and drug bill, a bill provid-
ing for county tuberculosis hospitals, a vital sta-
tistics bill, and a number of others. Bills intended
to hamper animal experimentation had been de-
feated in New York- and New Jersey. An excellent
law establishing a Board of Health had been passed
in Virginia.
At the Conference on Medical Legislation the
resolution on the control of rabies, submitted at the
last meeting by Dr. R. C. Cabot, of Massachusetts,
was discussed. Resolutions were adopted favoring
the increase of the scope and power of the United
States Public Health and .Marine Hospital Service,
in order that the question of rabies and similar ques-
tions affecting the public health might be taken up
by this service. The committee asked that the House
of Delegates recommend to the various State asso-
ciations that a State committee on legislation and
public policy be established, if this had not already
been done, and that the chairman of such commit-
tee be appointed by the president as the memlier of
the National Council on Legislation for that State ;
that the House of Delegates further recommend that
each association provide for an auxiliary legislative
committee, consisting of one member from each
county society, this member also to be appointed the
member of the National Auxiliary Legislative Com-
mittee for that county.
It further recommended that S.ection 5, Chapter
X. Book 3. page 20, of the Bylaws be amended by
substituting the title "National .Auxiliary Legis-
June o, iQc.S ]
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
1 105
lative Committee," in place of '"Xational Auxiliary
Congressional Committee,"" as at present.
Report of the Council on Medical Education. —
Dr. A. D. Bevan, of Illinois, reported that the third
annual conference of the Council for ]\Iedical Edu-
cation was held in Chicago. April 13, 1908. This
council was the instrument of the association in mat-
ters pertaining to medical education ; its functions
were those of a national bureau of information : ii
sought to collect the facts in regard to medical edu-
cation in this country and abroad, and to give pub-
licity to these facts. During the past year the work
of the council had been continued along these lines,
and the accumulation of data seemed to point to the
following basic principles for a model medical prac-
tice act which should be agreed upon and adopted vi
each State : ( i ) A single licensing board made up
of members irrespective of schools, the only require-
ment being that the men should be qualified practi-
tioners of modern scientific medicine. (2) This
board should have the power to determine the mat-
ter of preliminary education and medical curriculum
and should have the power to refuse recognition to
disreputable medical schools. (3) The preliminar.
education should be a standard four year high school
education, to which should be added in each State,
as soon as conditions warrant, a thorough training
in physics, chemistry, and biology, including labora-
tory work. (4j A four }ear medical curriculum
should be required, each annual session consisting
of thirty weeks, thirty hours a week, the first two
\ears to be spent in well equipped laboratories of
?!natomy, physiology, bacteriology, pathology, and
pharmacology, officered by trained teachers ; the sec-
ond two years devoted to medicine, surgery, obstet-
rics, and the specialties, largely in clinical work in
well equipped laboratories, dispensaries, and hospi-
tals. (5) When conditions warranted, there should
be added to this a compulsory year as a hospital in-
terne. (6) The State boards of each State should
inspect its schools and refuse recognition to those
which were not teaching scientific medicine.
Then there should be a single association of State
licensing boards organized, which should consist of
delegates who were active members of State boards,
representing every State in the Union. In order to
secure better conditions there should be an active,
earnest cooperation in each State between the State
licensing board and the organized medical profes-
sion : and the profession must see to it that the
necessary laws were secured and that efficient men
were appointed to see that they were enforced. The
report then took up the conditions now existing in
each State, from the viewpoint of the ideal law
above indicated. Then the defects were indicated,
and the remedy, higher preliminan- requirements,
was pointed out. The report then gave an interest-
ing collation of facts about medical standards
abroad. Several diagrams and maps were shown
which illustrated graphically the differences in
standard of educational requirements in different
countries and different States : both preliminarv
educational requirements and professional educa-
tional necessities. The recognition of medical col-
leges was taken up, together with reciprocity, pro-
gress toward uniformity, inspection of medical col-
leges, medical college mergers, and several other
important points which had a bearing on the sub-
ject of medical education. A special committee,
composed of Dr. \ ictor C. \''aughan, of Ann
Arbor ; Dr. ^^'illiam J. Means, of Columbus ; and
Dr. George W. \\'ebster, of Chicago, had been at
work on an outline of what should constitute a med-
ical college in good standing or a medical college
which, in the light of present day medicine, should
be considered as doing satisfactory work. The re-
port of the committee outlined a schedule of mini-
mum requirements, laboratory facilities, and clinical
facilities which should obtain in a medical college
before it could be considered to give a satisfac-
tor}- course or be determined to be a medical col-
lege in good standing. This included requirements
for matriculation, acceptable credentials, require-
ments for the course and for graduation, equipment
and teaching facilities, and the conduct of the col-
lege.
The Report of the Board of Public Instruction
on Medical Subjects. — Dr. Johx G. Clark, of
Philadelphia, presented the report of the newlv con-
stituted Board of Public Instruction. The 'board
had decided that the first articles that should ap-
pear under its auspices should be devoted to prelim-
inary education. The public was to be instructed
on the history of our present knowledge of infec-
tious diseases. The board had decided that gynaeco-
logical subjects and matters pertaining to sexual
questions could best be taken up through circtilar
letters to physicians or by carefully prepared mono-
graphs by some first class authori't\- in the medical
profession. In order to avoid the imputation of
advertising, no allusion to the details of treatment
should be included in these articles. The board had
not decided whether such articles should be
signed.
Dr« R. Max Goepi', of Philadelphia, had been se-
lected as the salaried secretary of the board. The
board recommended two lecture systems, one under
the direct authority of the American Medical Asso-
ciation, which should be national in character, and
one under the auspices of county medical societies.
The board further advised the establishment of
State boards of public instruction under the auspices
of the various State m.edical societies. Both the
State boards and the county boards should, of
course, \\ork in harmony with the national board.
It was suggested that a brief epitome of articles be
sent to the medical profession, either through the
Journal of the American Medical Association or
through a separate leaflet accompanying that jour-
nal. A provisional programme was 'submitted with
titles of proposed articles under the head of medi-
cine, including bacteriology, nervous diseases, sur-
gery, hygiene, and the history of medicine.
Report of the Committee on Organization. —
Dr. J- X. McCoRMACK, of Kentucky, outlined the
work of the year, which had been devoted princi-
pally to the making of addresses before audiences
composed of laymen and physicians. He asked to
be relieved of further duty on the Committee on
Organization. The organization was so far com-
pleted that he deemed it unnecessary to devote his
entire time to it; but he recommended that suitable
men be kept in the field and that these men be in-
creased in number as the necessity occurs.
iio6
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION. [New York
Medical Journal.
Report of the Director of Postgraduate Work.
— Dr. John H. Blackburn, of Kentucky, said that
an outline of study which was submitted to the
American Medical Association at its Atlantic City
meeting in 1907 had been sent out to selected work-
ers in the profession all over the country for sug-
gestions and criticisms. In the answers received
particular attention was called to the necessity for
instruction in materia medica and therapeutics. The
first year's outline was published in two parts, each
covering the work of six months. He had corre-
sponded with the county society officers and with
individuals in thirty-nine States regarding the
course, and he had been notified of its formal adop-
tion by ninety county societies. Five physicians had
been following the outline as a reading course of
home study because they were unable to meet with
others as a club. The first year's programme con-
sisted of twelve general subjects, but the second
year's outline would consist of ten only. It was
suggested that all societies intending to take up the
course for the coming year should begin work the
first week in September, so that the courses all over
the country should be uniform. This second year's
outline would be ready for distribution by August
1st. The committee had in view regular quarterly
examinations, with proper credits and a certificate
or a diploma on the completion of the four years'
course. The object of the course in postgraduate
study was the perpetuation of the county society and
its active cooperation with the national society.
The Report of the Committee on the Section
in Tropical Medicine. — Dr. L. Hektoen, of Chi-
cago, reported that the committee regarded the for-
mation of a section in tropical medicine by the Amer-
ican Aledical Association as unnecessary at the pres-
ent time. Papers and discussions on subjects con-
nected with tropical medicine might be very well
presented in the already existing sections. The re-
port was adopted.
The Report of the Committee on Scientific Re-
search.— Dr. Alfred Stengel, of Philadelphia,
said that the following grants had been made by the
committee for the encouragement of scientific re-
search. The papers resulting from these grants
were to be presented at the present meeting in Chi-
cago:
Dr. D. J. McCarthy and Dr. M. K. Myers, of
Philadelphia, An Experimental Study of Cerebral
Thrombosis. Dr. Karl Voegtlin, of Baltimore, Chem-
istry of the Parathyreoid Glands. Dr. Isabel Herb,
of Chicago, A Study of the Etiology of Mumps.
Dr. R. M. Pearce, of Albany, Dr. H. C. Jackson, and
Dr. A. W. Elting, A Study of the Elimination of
Inorganic Salts in a Case of Chronic Universal
CEdema of Unknown Etiology with Apparent Re-
covery. Dr. H. C. Jackson, Dr. C. B. Hawn, and Dr.
H. P. Sawyer, A Comparative Study of the Phys-
ical Changes in the Blood in Relation to Opsonic
and Phagocytic Indices and Cell Contents under
Normal Conditions. Dr. H. T. Ricketts, of Chicago,
An Investigation of the Identity of the Rocky Moun-
tain Fever of Idaho with That Found in Western
Montana.
The amount of the grant in each case had been
fixed at $200. The committee requested that its ap-
propriation be increased to $1,000 a year.
Report of the Committee on the Davis Memo-
rial.— Dr. Henry O. Marcy, of Boston, reported
slow progress. Massachusetts had collected over
$700, but beyond this subscriptions had not been re-
ceived. A number of the members of the committee
had resigned, and the committee requested that it
be given power to fill vacancies.
Report of the Committee on Nomenclature and
Classification of Diseases. — Dr. Frank P. Fos-
ter, of New York, said that he had communicated
with Dr. Cressy L. Wilbur, chief statistician of the
Division of Vital Statistics of the Bureau of the
Census ; with Dr. A. T. Bristow, of New York ;
with Dr. Wilmer R. Batt, of Harrisburg, represent-
ing the American Public Health Association, and
with Dr. Robert L. Dickinson, of Brooklyn, repre-
senting the American GynEecological Society. As a
result they recommended the adoption of the fol-
lowing resolutions :
1. Resolved, That the Nomenclature of Diseases of the
Royal College of Physicians of London be recommended
for the present use of American physicians in naming dis-
eases and injuries in clinical reports and papers, morbidity
and hospital returns, and for certificates of cause of death.
2. Resolved, That the International Classification of Dis-
eases and Causes of Death be recommended for all official
mortality and morbidity statistical reports.
3. Resolved, That the Committee on Nomenclature and
Classification of Diseases present a report on the London
nomenclature to the association at its meeting in 1909, with
such recommendations as may seem advisable for Ameri-
can usage, and with the assignment of each term indicated
according to the International Classification.
4. Resolved, That a tentative reconstruction of the Inter-
national Classification be framed on the basis of the fore-
going report, and recommendations be drafted for submis-
sion to the International Commission of Revision.
5. Resolved, That inquiry be made as to the possibility
of holding the next Decennial Revision of the International
Classification at Washington in 1910 in connection with the
International Congress of Hygiene and Demography.
6. Resolved, That after the revision of the International
Classification in 1910. the Nomenclature of Diseases be re-
cast in corresponding form, so that there will be available
under a uniform arrangement and with precise agreement
in the meaning of terms :
(1) International Classification of Causes of Death.
(2) International Classification of Sickness and Dis-
ability.
(3) International Nomenclature of Diseases and Injuries.
Report of the Committee on Ophthalmia Neona-
torum.— Dr. F. Park Lewis, of New York, said
that three things appeared to be necessary. ( i ) Ex-
act data concerning the incidence of the disease and
its results should be secured in every State. (2) The
control of the disease rested with the State through
its department of public health. (3) The securing
of united and concurrent action for its control on the
part of all those who know what to do and were
willing to aid in stamping out the disorder. A cir-
cular letter had been addressed to the president and
secretary of each State medical society asking that
these three things be done. Gratifying answers had
been received. The subject had been presented be-
fore a number of national societies. It was suggest-
ed that midwives be registered and that the disease
be made reportable. An outline of the manner in
which the problem might receive solution was ap-
pended to the report.
June 6, 1908.]
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
1 107
Reports of Committees on Referred Business.
■ — It was deemed advisable that the services of Dr.
J. X. McCormack be not entirely dispensed with,
but that he remain as the directing officer of organ-
ization, even if he did not give his entire time to
the work.
The report of the Board of Public Instruction
was adopted, and the board was given power to
have the articles that it intended to publish signed
at its discretion.
The report of the Committee on Ophthalmia
Xeonatorum was adopted, and the committee was
continued.
The report of the Committee on Scientific Re-
search was adopted.
The report of the Committee on Xomenclature
and the Classification of Diseases was adopted, and
the committee was continued.
The report of the director of Postgraduate
Study was adopted.
• Changes in the constitution and by-laws. — The
orations were made not mandatory, and authority
was given that they might be delivered at section
meetings if considered advisable.
Report of the Reference Committee on
Amendments to the Constitution and By-Laws.
—The conmiittee reported adversely on the amend-
ment to the constitution offered by Dr. J. N. Mc-
Cormack, of Kentucky, to make the ex-presidents
of the association members of the House of Dele-
gates.
Report of the Committee on Awards. — The
Committee on Awards, composed of Dr. William
M. L. Coplin, of Philadelphia ; Dr. George Dock, of
Ann Arbor; and Dr. George W. Crile, of Cleveland,
made the fcUowmg awards to those exhibiting in
the Scientific Department: The gold medal for a
research exhibit of tick fever to Dr. H. T. Ricketts,
of Chicago ; a diploma for an exhibit illustrating the
pathology of peptic ulcer, to Dr. Fenton B. Turck,
of Chicago ; a diploma for a teaching exhibit illus-
trating morbid anatomy, to the Northwestern Uni-
versity Medical Department ; a diploma for a teach-
ing exhibit illustrating morbid anatomy, to the
Rush Medical College ; a diploma for an exhibit of
drawings of the human eyeground, to Dr. Charles
H. Beard; a -diploma for the exhibit illustrating
early human embryolog}', to Dr. Maxmillian Her-
zog, of Chicago ; a diploma for a clinical and patho-
logical exhibit of stereoscopic photographs, to St.
Mary's Hospital, Rochester, Minn. ; a diploma for
an improved method for the preservation and ex-
hibition of anatomical specimens, to Dr. Edmond
Souchon, of New Orleans ; a diploma for an ex-
hibit illustrating blastomycosis, to Dr. A. M. Stober,
of Chicago; a diploma for an exhibit of drawings
and photomicrographs illustrating the classification
of tumors, to Dr. Mallory and Dr. Woolbach, of
Harvard University. Honorable mention was made
of the following exhibits: That of the United
States Public Health and Marine Hospital Service,
illustrating the investigations of Dr. C. W. Stiles,
on hookwom disease ; to the Iowa State University,
for an instructive tuberculosis exhibit; to the Cin-
cinnati Hospital, for a creditable group of speci-
mens : to* the Philadelphia Polyclinic and College
for Graduates in ^ledicine, for a creditable exhibit
of a group of teaching specimens ; to the Lying-in
Hospital, of New York, for a creditable exhibit.
Election of Officers. — The following officers
were elected for the coming year: President, Dr.
William C. Gorgas, of the United States Armv.
Mce-presidents, Dr. T. J. iNIurrav, of Butte, Mont. ;
Dr. John A. Hatchett, of El Reno. Oklahoma: Dr.
Thomas A. Woodruff, of Chicago ; Dr. E. N. Hall,
of Woodbum, Kentuck}-. General secretary. Dr.
George H. Simmons, of Chicago. Treasurer, Dr.
Frank Billings, of Chicago. Trustees to serve until
191 1, Dr. Wisner R. Townsend, of New York; Dr.
Philip Mills Jones, of San Francisco; Dr. W. T.
Sarles, of Wisconsin. Chairman of the Committee
on Transportation and Place of Session, to serve
three years, Dr. ]\I, L. Harris, of Chicago. The
following honorary members were elected : Pro-
fessor E. A. Schaefer, of Edinburgh, Scotland ; Dr.
August Martin, of Greifswald, Germany; and Dr.
E. Treacher Collins, of London. The president ap-
pointed Dr. Charles Harrington, of Boston, a mem-
ber of the Committee on Legislation, to serve until
191 1, and Dr. Victor C 'Vaughan, of Ann Arbor,
to be a member of the Council on Medical Educa-
tion, to serve until 1913.
The next meeting will be held in Atlantic City.
Officers of the sections. — Section in Practice of
Medicine: Chairman, Dr. Jospeh L. Miller, of Chi-
cago; secretary, Dr. Wilbur Tileston, of Boston;
delegate. Dr. George Dock, of Ann Arbor ; orator
in medicine, Dr. John B. McElroy, of Memphis.
Section in Obstetrics and Diseases of Women:
Chairman, Dr. Walter T. Manton, of Detroit ; secre-
tar)-. Dr. C. Jess Miller, of New Orleans ; delegate,
Dr. J. H. Carstens, of Detroit. Section in Surgery
and Anatomy: Chairman, Dr. John C. Munro, of
Boston; secretarj'. Dr. John F. Binnie, of Kansas
City; delegate, Dr. Edward Ochsner, of Chicago;
orator in surgery. Dr. Harvey Gushing, of Balti-
more. Section in Ophthalmology: Chairman, Dr.
Alvin A. Hubbell, of Baltimore; secretary. Dr. A.
E. Bulsom, Jr., of Fort Wayne; delegate. Dr.
Thomas A. Woodruff, of Chicago. Section in
Laryngology and Otology: Chairman, Dr. W.
Sohier Bryant, of New York; secretarv-, Dr. G. £.
Shambaugh, of Chicago ; delegate, Dr. H. W. Loeb,
of St. Louis. Section in Nervous and Mental Dis-
eases: Chairman, Dr. D. M. Allen Starr, of New
York; secretary, Dr. W. A. Jones, of Minneapolis;
delegate, Dr. T. H. Weisenburg, of Philadelphia.
Section in Diseases of Children: Chairman, Dr.
Thomas S. Southworth, of New York; secretary.
Dr. W. W. Butterworth, of New Orleans ; delegate,
Dr. R. B. Gilbert, of Louisville. Section in Hy-
giene and Sanitary Science: Chairman, Dr. J. H.
White, of the United States Public Health and
Marine Hospital Service ; secretary, Dr. S. T. Arm-
strong, of New York; delegate. Dr. Charles Har-
rington, of Boston. Section in Pharmacology and
Therapeutics: Chairman, Dr. Reid Hunt, of Wash-
ington ; secretar}-. Dr. C. S. N. Halberg, of Chi-
cago; delegate, Dr. M. Howard Tussell, of Phila-
delphia.
iio8
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
[New York
Medical Journal.
iHeettngs; of ^tttioni.
SECTION IN PRACTICE OF MEDICINE.
Chairm.\x. C. F. Hoover, Clevel.\nd, Ohio; Secret.\ry,
Joseph L. Miller, Chicago.
Chairman's Address : Paroxysmal Hsematuria,
By C. F. Hoover.
A Case of Syphilitic Infection of Fourteen Years' Duration
with Protracted and Unusual Febrile Symptoms,
By Henry C. Buswell.
• Endarteritic Gangrene in Early Life, By David Riesman.
Modification of Typhoid during Menstruation, and the Suc-
cessive Menstrual Epochs ; Treatment,
By Alfred Stengel.
The Pathology, Diagnosis, and Treatment of So Called
Hodgkin's Disease, By Hugo A. Freund.
Absolutely Irregular Hearts, By A. W. Hewlett.
Factors in Estimation of Blood Pressure, the Tonometer
of von Recklinghausen, By Joseph Eichberg.
Serotherapy of Meningitis, By L. W. Ladd.
Experiments on a Salt Free Diet, with Especial Reference
to Diabetes Mellitus,
By E. P. JosLiN and H. W. Goodall.
Physics of Physical Signs, By H. D. Arnold.
Diagnostic Value of Cutaneous and Conjunctival Tubercu-
lin Reactions,
By W. Engelbach and J. W. Shankland.
Clinical Manifestations of Cardiovascular Disease,
By Frank A. Jones.
Disguised Starvation, By Nathan Rosewater.
Viscosity of the Blood in Its Clinical Application,
By George W. McCaskey.
Causes of High Arterial Tension. By L. F. Bishop.
Cardiac Aneurysm, with Report of a Case Associated with
Mediastinopericarditis, By Ja.mes B. McElroy.
Temporary Periods of Improvement in Pernicious Anaemia,
By Walter L. Biereing.
.\ Clinical Method of Determining the Chlorid Content of
the Blood, By Douglas Vander Hoof.
Cliiiical Aspects of A-Iediastinal Tumors,
By Frank Smithies.
The Influence on Practice of Recent Studies of the Circu-
lation, By A. D. Hirschfelder.
An Epidemic of Trichiniasis, By S. Marx White.
The Clinical Value of the Quantitative Estimation of Pep-
sin, By C. B. Farr and E. H. Goodman.
Epidemic of Pellagra, By R. H. Bellamy.
Tlic Value of Nitrogen Insufflation into the Pleura in the
Treatment of Severe Forms of Unilateral Pul-
monary Tuberculosis, By Lltdolph Brauer.
Pliases of Duodenal Ulcer, By C. Graham.
Compensatory Diarrhoea, By Heinrich Stern.
Tuberculin Therapy. By H. B. Weaver.
"symposium" on TVI'HOIll FEVER.
Conditions Similating Perforation in Typhoid,
By David L. Edsall,
Channels of Infection in Relation to Suppression of
Typhoid, By M. J, Rosenau.
Treatment of Typhoid, By Thomas McCrae.
COMniNED MEETING OF THE SECTION IN PRACTICE Ol'
MEDICINE .\ND THE SECTION IN P.VTHOLOGY
.\XD PHYSIOLOGY.
"Symposium" on Typhoid Fever,
The Channels of Infection in Relation to the
Suppression of Typhoid Fever. — Dr. M. J. Rosi:-
.\.\u, of Washington, said that there was more ty-
I)lioicl fever in the country than there was in the
city. The infection came to the city in the water, in
the milk, in other varieties of food, and in the bodies
of certain persons who were now known as typhoid
fever carriers. The city returned the compliment to
the country, but to a less extent. The water was
the principal vehicle of infection, but not to such an
extent as used to he imagined. There were two
kinds of epidemics due to polluted water — the great
epidemics, which were due to high pollution, and
epidemics of less intensity, due to a diluted or at-
tenuated infection. In addition, there were the cases
of residual typhoid lever which were due to other
sources of infection. In Washington, in 1907, with
a very good sanitary water supply, there were thirty-
five deaths from typhoid fever to the 100,000 popu-
lation. The author thought that probably twenty-
five per cent, of these cases were due to milk and
probably more than thirty per cent, to direct con-
tagion. Typhoid fever might be uniformly distrib-
uted through a community without being due to any
single cause, such as water. In a community in
which typhoid fever was prevalent the normal curve
of case incidence showed the greatest number of
cases in the late summer and early autumn. In
places in which t\ phoid fever was due to an infect-
ive water supply, the greatest number of cases oc-
curred in the late winter and early spring. Milk
was the second great channel of infection. In Wash-
ington, in 1906, eleven per cent, of the cases were
traced to milk, and in 1907 nine per cent, of the
cases were due to milk. The author considered that
these figures were too low, because the only cases
that could be traced were those that occurred in
localized outbreaks. In a study of the dairies in
Washington it was found that the number of cases
of typhoid fever occurring in the families supplied
by the different dairymen (the case incidence of
typhoid fever to 100,000 gallons of milk supplied)
varied from 6.7 among the customers of a man who
sterilized his bottles and pasteurized his milk, to
52.5 among the customers supplied by a man who
did neither. What the result would have been if all
bottles had been sterilized and all the milk kept as
clean as possible could only be imagined. In Glas-
gow, Liverpool, and London, however, there was a
reduction of fifty per cent, in the case incidence of
typhoid fever with the establishment of pasteuriza-
tion of milk. All this reduction, however, could not
be credited to this factor, because sanitary measures
and filtration of the water supply were established
at the same time. In order to secure a clean milk
supply for a given community, it would be neces-
sary to educate the farmers in methods of producing
a clean milk, and it would be necessary to pasteurize
the milk in addition. The third great source of in-
fection was the so called typhoid carriers. In W ash-
ington, in 1906, six per cent, of the cases, and in
1907 nineteen per cent, of the cases, were shown to
be due to contact. These figures were too low, be-
cause it was difficult to trace contacts. Typhoid
fever was a contagious disease and should be iso-
lated, and typhoid suspects should be isolated and
thorough disinfection should be carried out. The
investigations of Reed, X'aughan, and Shakespeare
showed that typhoid fever was spread by actual con-
tact. Children probably played an important part
in the transmission of the disease, because the dis-
ease in children was very often atypical and abort-
ive. In America the things to be desired for the
prevention of typhoid fever were a clean water sup-
ply and an uninfected milk supply, isolation of the
patients, and early diagnosis.
The Value of Blood Culture in Typhoid Fever.
— Dr. 1<"rancis \\'. Pk.\I!oi)v, of Boston, said that
the earl\- diagnosis of typhoid fever was of great
juneb, igoB.i CHICAGO MEETISG OF AMERICAN MEDICAL ASSOCIATIOX.
1 109
importance on account of the possibility of spread-
ing the disease by contact with the patient and by
contact with the convalescent for a varying period
after the disease was supposed to be cured. He re-
ferred to the obvious objections to the ordinary
methods of making blood cultures. He mentioned
the employment of ox bile as a culture medium for
the Bacillus typhosus, and described a method of
making a blood culture with blood obtained by the
ordinary method of puncture. Two cubic centime-
tres of blood were inoculated into a small quantity
of pure sterile ox bile, which was incubated for
twenty-four hours. A portion of this culture was
then transferred to Loffler's blood serum medium
and incubated for another twenty-four hours. The
isolation of a motile bacillus was presumptive evi-
dence of the existence of typhoid fever, but, of
course, further culture experiments were necessary
to establish the identity of the organism. In the
Massachusetts General Hospital fifty-five out of
eighty-two cases of suspected typhoid fever were
diagnosticated by this method. The drawbacks to
the Widal reaction, as an early diagnostic method,
were the fact that the reaction was sometimes late
in appearing and that it was not absolutely specific.
As a supplement to a blqod culture, however, the
Widal reaction was very valuable, because the latter
occurred late, and the former occulred early in the
course of the disease.
Typhoid Bacillus Carriers. — A paper with this
title, by Dr. William H. Park, of New York, was
read by Dr. W.- B. Cannon, of Boston, in the un-
avoidable absence of Dr. Park. After an attack of
typhoid fever it was known that persons passed ty-
phoid bacilli in the urine and in the faeces for a vary-
ing period of time, sometimes for many years. The
typhoid bacilli that were passed in the faeces proba-
bly came from the gallbladder, although they might
be multiplying in the folds of the mucous membrane
of the intestine and in the glands of the intestine.
Large numbers of cases had been traced to these ba-
cillus carriers. Women were more frequently ba-
cillus carriers than men. A cook who had lived in
eight families in New York city, in seven of which
cases of typhoid fever had developed after she had
entered the service of the family, was referred to
the laboratory of the New York City Department
of Health. In these seven families twenty-six cases
of typhoid fever had developed, with one death.
Thirty per cent, of the bacilli in the faeces of this
woman were found to be Bacillus typhosus. The
woman denied that she had ever had typhoid fever.
The stools from fifty-two persons who had had ty-
phoid fever in an epidemic in the Xew Jersey State
Insane Asylum were examined, and two of them
were found to contain Bacillus typhosus. The stools
from sixteen persons in a Long Island village who
had recovered from typhoid fever were examined,
and two of them were found to contain Bacillus
typhosus. In other words, six per cent, of the pa-
tients examined were foimd to have typhoid bacilli
in their faeces. There were numerous cases of ty-
phoid bacillus carriers who had never had typhoid
fever, but who had been exposed to the infection.
Isolation in these cases was not always possible, al-
though the woman first referred to was being de-
tained by the Department of Health.
Some Conditions Simulating Perforation in
Typhoid Fever. — Dr. David L. Edsall, of Phil-
adelphia, said that he did not wish any of the re-
marks he was about to make to be construed as un-
dervaluing the necessity for operation in cases of
typhoid perforation, but he wished to point out that
the tendency of the surgeon was to operate in any
case in which a perforation was suspected. He
thought that an operation during the course of ty-
phoid fever was not a harmless procedure, and that
every case should be carefully studied clinically be-
fore an operation was undertaken. Among the dis-
eases which simulated perforation in typhoid fever
was, first, acute, sudden, lobar pneumonia. He re-
ferred to three cases of this character which had
occurred in his wards in the Episcopal Hospital in
Philadelphia. Second, there was typhoid spine,
which occurred during convalescence and might
simulate typhoid perforation. Third came throm-
bosis of one of the iliac veins. Fourth, there was a
marked, severe, stormy crisis, which was, of course,
uncommon. He said that he thought that the sur-
geon had more faith in rigidity of the abdominal
muscles as a sign of perforative peritonitis than was
proper. If rigidity of the abdominal muscles was
associated with a general muscular rigidity of equal
intensity, the sign would lose much of its value as a
symptom of typhoid perforation. A sharp and sud-
den fall of temperature near the end of a case of
typhoid fever was likely to be followed by a relapse.
A careful, complete physical examination, includ-
ing the chest and the vertebral column, should be
made in every case in which typhoid perforation
was suspected. One should consider the general
features of the case, and if the abdominal symptoms
were not prominent enough, the patient should not
be operated upon.
The Metabolism of Typhoid Fever. — Dr. P. A.
Shaffer, of Xew York, said that during" an attack
of typhoid fever the patient lost from ten to sixty
pounds of his tissue. This loss was felt particular-
ly in the fats and proteins. The excretion of ace-
tone lx)dies in the urine in cases of typhoid fever
ought not to occur if the patient received plenty of
carbohydrate food. The loss of nitrogen was com-
mon in typhoid fever, and accounted for the wast-
ing and the weakness. These symptoms were due
in part to the destruction of tissue and in part to an
autointoxication, not to a bacterial endotoxine. The
causes for the loss of protein, during typhoid fever,
were partial starvation, pyrexia, and the action of
the toxines produced by the typhoid bacilli. The
author described certain metaljolism experiments
which he had carried out in Bellevue Hospital. As
a result of these experiments they were able to re-
tard the loss of nitrogen by prescribing a diet which
contained a moderate amount of protein and a large
amount of carbohydrate, so that the caloric value
of the food was kept high. The loss of protein
might be compensated for only when 3,000 to 4,000
calories were given daily. It was quite possible to
give with benefit liberal diets to patients suft'ering
from typhoid fever. \\'hen such a diet was given,
the patient had little or no tympanites and little
fermentation in the intestines. The ordinary milk
diet in typhoid fever deprived the patient of fifty
per cent, of his normal nutriment.
IIIO
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
[New York
Medical Journal.
The Treatment of Typhoid Fever.— Dr.
Thomas McCrea, of Baltimore, said that it was
necessary to study the individual patient with care,
and to give him such a diet as would be suitable for
him. He thought that the simpler the diet the bet-
ter, and was inclined to adhere to the common milk
diet. He said that there was need for large amounts
of Avater in the treatment of typhoid fever, and it
was his custom to give an amount that would cause
the patient to excrete from one hundred to one hun-
dred and fifty ounces of urine daily. This internal
hydrotherapy, combined with external hydro-
therapy, had been very useful. The composition of
predigested foods should be investigated before
they were used. The initial purge, he thought,
gave a higher incidence of diarrhoea than when the
bowels were let alone. Opium was rarely justifiable;
in the majority of cases it caused harm. If restless-
ness must be treated, it was better to use morphine
by the hypodermatic route. If diarrhoea was trou-
blesome and required opium, it was better to use
the starch and laudanum enema. In haemorrhage in
typhoid fever, the lead and opium pill ordinarily ad-
vised did harm. It favored distention and conceal-
ed the signs of perforation. Haemorrhage was best
treated with hypodermatic injections of morphine, a
reduction in the diet, the local application of an ice
bag, and the administration of calcium lactate in
doses of thirty grains a day. In cases of perfora-
tion a more careful study of the signs and symp-
toms ought to be made. There should be more fre-
quent and earlier consultations between the physi-
cian and the surgeon. As between the opinion of
a surgeon who had seen a patient once and that of
the physician who had carefully studied the case for
a long period of time, the latter was the more val-
uable. In order to relieve gaseous distention of the
stomach, the passage of the stomach tube was the
method to be preferred. Urotropin was valuable in
preventing bacilluria, and, if given in large enough
doses, it \\«ould be found in all the fluids of the body.
Thus it might kill any bacilli that were inhabiting
the gallbladder. For this purpose he used as much
as seventy-five grains a day, watching the urine for
any sign of haematuria. The prevention of infec-
tion was as important as the treatment of the dis-
ease. In order to accomplish this, isolation of the
patient, personal cleanliness of the physician, the
nurse, and the orderly, the use of rubber gloves by
the nurse, if she had to handle bed pans, urinals, and
soiled bedclothing, were necessary. The nurse who
handled typhoid fever patients ought not to handle
other patients. The family should be instructed in
these methods by written direction. The supply of
bacilli in a patient who had had typhoid fever
should be exhausted before he was discharged.
Dr. William S. Thayer, of Baltimore, said that
he agreed that typhoid fever was a contagious dis-
ease and that the sooner we realized it the better.
Dr. James M. Anders, of Philadelphia, said that
Dr. Roscnau had laid down a very important prin-
ciple when he said that we should endeavor to dis-
cover the channel of infection in typhoid fever epi-
demics in each individual community.
Dr. John A. Wn iikkspoon, of Nashville, said
that the physician should instruct the people in the
methods of preventing infection with typhoid fever.
Dr. MuNSON, of Springfield, 111., asked how long
the typhoid bacillus would live in the ground.
Dr. Alexander Lambert, of New York, said
that it was important for county medical societies to
undertake to certify the milk used in the districts
over which they had surveillance.
Dr. Rosenau said that it was difficult to take all
the measures to prevent the occurrence of infection
in a given individual, but that it was comparatively
easy to diminish the amount of typhoid fever in a
community.
Dr. Jones asked whether the color of the bile used
for making blood cultures made any difference, and
he also wished to know how fresh the bile should be.
Dr. Peabody said that he had found no variation
in the results when he had used dark green or golden
yellow bile. After sterilizing, the bile kept indefi-
nitely. He had obtained the same results by using
pig's bile.
Dr. Henry Albert, of Iowa City, referred to an
epidemic of typhoid fever in Cedar Falls, Iowa,
which had been traced to a bacillus carrier.
Dr. Philip Marvel, of Atlantic City, spoke of
the advisability of draining the gallbladder in the
case of a bacillus carrier.
Dr. LiTTERER, of Nashville, reported a case in
which he had obtained a pure culture of Bacillus
typhosus in the pus of a periosteal abscess three
months after the abscess had been opened. He
thought that such a patient should be considered a
bacillus carrier. A typhoid vaccine had cured the
abscess. He thought that a typhoid vaccine might
be used in cases of infected gallbladder.
Dr. Rosenau said that the gallbladder was not
the only source of the appearance of typhoid bacilli
in the faeces, and that draining of the gallbladder
was probably not justifiable.
Dr. John A. Lichty, of Pittsburgh, said that
stone in the ureter and appendicitis might resemble
typhoid perforation.
Dr. Anders said that in perforation of the intes-
tine the temperature did not always fall. On the
other hand, it frequently rose. Dulness in the flanks
was not always due to perforative peritonitis. He
did not base his diagnosis on any single symptom,
but only on the combination of symptoms. The
most common condition simulating typhoid perfora-
tion was excessive tympanites. This condition was
frequently accompanied by movable dulness in the
flanks.
Dr. Edsall said that the absence of liver dulness
and movable dulness in the flanks were not very
valuable signs of intestinal perforation.
Dr. Alexander Lambert, of New York, said that
a liberal diet in typhoid fever prevented meteorism,
delirium, and great losses of weight.
Dr. Elliot P. Joslin did not approve of giving
typhoid patients such large quantities of water, nor
did he think it was necessary to have the patient
pass such large quantities of urine. He referred to
the possibility of favoring the development of arte-
riosclerosis by this procedure.
Dr. Thayer said that the physician should have
the surgeon see the patient when he first thought
that an operation for perforative peritonitis might
be necessary.
June 6, 1908.] CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
nil
Dr. Litchfield said that he approved of the ini-
tial purge.
Dr. H. P. Favill, of Chicago, said that he object-
ed to lead and opium in the treatment of typhoid
haemorrhage, because they produced meteorism, ob-
scured the symptoms of perforation, and locked up
a large amount of blood in the bowels, where it had
a tendency to decompose.
Dr. George Dock, of Ann Arbor, said that he
approved of the initial purge.
SECTION IN SURGERY AND ANATOMY.
Chairman, Rudolph Matas, New Orleans; Secretary,
WiLLARD BaRTLETT, St. LOUIS.
SYMPOSIUM ON SURGERY OF VASCULAR SYSTEM.
Observations, Clinical and Experimental, on Occlusion of
the Abdominal and Thoracic Aortas,
By W. S. Halsted.
Physiological Aspects of Blood Vessel Surgery with Dem-
onstrations, By C. C. Guthrie.
Results of the Transplantation of Blood Vessels and Or-
gans (Lantern Slides), By A. Carrel.
A Statistical Summary of the Surgical Treatment of
Aneurysm by the Intrasacular Method (Endoaneu-
rysmorraphy). By Rudolph Matas.
SYMPOSIUM ON the TECHNIQUE OF CRANIAL SURGERY.
The Surgery of the Base of the Skull,
By Professor Chipault.
Lantern Slide Demonstrations on Cranial Technique,
By Harvey Cushing, Frank Hartley, and
C. H. Frazier.
Intracranial Complications of Ear and Nose Diseases,
By J. F. McKernon and C. G. Coakley.
SYMPOSIUM ON artificial RESPIRATION.
Artificial Respiration in Its Physiological Aspects,
By Professor Schaefer.
Positive Pressure in the Surgery of the Chest,
By Professor Brauer.
Negative Pressure in the Surgery of the Chest,
By Sauerbruch.
Artificial Intrapulmonary Positive Pressure. Experimental
Applications in Surgery of the Lung,
By Samuel Robinson and N. W. Green.
Local Applications in Surgery. By James E. Moore.
Atavism in Facial Contours (Lantern), By V. P. Blair.
Bier's Hyperaemia, By J. F. Binnie.
Observations on the Thyreoid and ParathyTeoid,
By Herman Tuholske.
The Surgical Importance of Cervical Ribs,
By John B. Roberts.
A Study of Anterior Poliomyelitis, with an Analysis of
647 Cases, from the Children's Hospital. Boston,
By R. W. LovETT.
A Successful Ligation of the Innominate Artery, with
Presentation of Patient, By William Britt Burns.
Surgery of the Upper Abdomen, By B. G. A. Moynihan.
The Diagnosis at Operation between Chronic Ulcer and
Cancer of the Stomach, By F. B. Lund.
Ulcer of the Duodenum, By William J. Mayo.
The Surgical Diseases of the Pancreas.
By John B. Deaver.
Pancreatitis in Its Relation to Gallstone Disease,
By W. D. Haggard.
The Cause of Death in High Intestinal Obstruction, as
Demonstrated by Surgical Experimentation.
By J. W. D. Maury.
Intestinal Anastomosis. Presentation of a New. Simple,
and Aseptic Method, By Frank B. Walker.
A Report on a Series of Abdominal Gunshot Wounds,
By Cunningham Wilson.
Invagination of Limited Annular Gangrene of the Small
Bowel versus Resection, Bv J. E. Summers.
Gas Cysts of the Intestine, By J. M. T. Finney.
The Reports of a Case of Chronic Peritonitis with Com-
plete Obstruction Caused by Numerous Transverse
Constrictions of a Previously Undescribed Character
throughout the Intestine, By Miles F. Porter.
The Effects of Normal and Abnormal Variations in Peris-
talsis on Peritoneal Absorption, By J. L. Yates.
My Present Position on Appendix Questions.
By Robert T. Morris.
A Case of Acute Diverticulitis of the Sigmoid Operated
on before Rupture Had Taken Place,
By George Emerson.
Cancer of the Rectum. Deductions Derived from One
Hundred Personal Experiences in Extirpation of the
Rectum and Sigmoid, By James P. Tuttle.
Enterovesical Fistula, with Especial Reference to Its Sur-
gical Treatment,
By F. W. Parham and Joseph Hume.
A New and Rapid Method of Perineal Drainage in Supra-
pubic Cystotomy, By Joseph Ransohoff.
The Preservation of Anatomical Dissections with Perma-
nent Color of Muscles, Vessels, and Organs by
a New Method. Preliminary Note,
By Edmond Souchon.
Demonstration of Patients Operated upon for Cleft Palate,
By T. W. Brophy.
Abstracted Report of the Anaesthesia Commisison,
By J. G. MuMFORD.
Some New Facts Regarding Calculi and Tumors of the
Bladder, ^ By Carl Beck.
COMBINED MEETING OF THE SECTION IN SURGERY
AND ANATOMY .AND THE SECTION IN LARYN-
GOLOGY AND OTOLOGY.
The Lantern Slide Demonstration of Cranial
Technique. — Dr. Harvey Cushing, of Baltimore,
exhibited a number of lantern slides showing the
details of the methods employed in his clinic in in-
tracranial operations. He said that the surgeon
who wished to do brain surgery should endeavor
to perfect himself in neurology, and that the neu-
rologist who intended to direct intracranial opera-
tions should learn something about surgical tech-
nique. One of the most important questions
connected with intracranial surgery was that of the
administration of the anaesthetic. Disregard of the
risks of the administration of anaesthetics had been
well pointed out by Dr. John B. Roberts. These
risks were particularly prominent in brain surgery,
where the anjesthetist came in contact with the field
of operation and in which the induction of anaes-
thesia was particularly diflficult. He made a hood
for the anaesthetist with a sheet, and administered
the anaesthetic by the ordinary method of inhala-
tion. The anaesthetist listened to the patient's heart
continuously during the operation. He shaved the
scalp just before the operation, and arranged the
sheets and the towels, which were sometimes pinned
to the scalp itself, so as to expose as little beyond
the field of operation as possible. After the shav-
ing, the line of incision was scratched on the scalp.
He described the tourniquet and the forceps used
in his own operation. He then showed photographs
of the method and the results of decompressing op-
erations. H a decompression operation was fol-
lowed by internal hydrocephalus, that operation was
inefificient, and this complication was particularly
likely to develop in cases of cerebellar tumor. In
these cases, also, lumbar puncture was particularly
dangerous, because the pressure was exerted in such
a way that the medulla and the cerebellum were
forced down into the foramen magnum. After a
decompression operation the tumor sometimes be-
came localizable. A tumor which could not be lo-
calized was the most favorable for a decompression
operation. He said that he had done one hundred
decompression operations in three years. Decom-
pression was also of value in cases of urasmia and
in cases of fracture at the base of the skull. He
then reported seventy-five cases of operation on the
Gasserian ganglion, with two deaths.
I1I2
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
[New York
Medical Journal.
Dr. Frank Hartley, of New York, exhibited a
number of lantern slides illustrating the instruments
used, the method of preparing the field of operation,
the method of making the flaps, and the method of
craniocerebral topography for operation on the va-
rious regions of the brain.
Dr. Charles H. Frazier, of Philadelphia, de-
scribed his method of operating upon tumors of the
brain. He said that he had operated in a number
of cases of epilepsy within the last few years, and
that a decompressing operation had given relief in
many cases. On opening the skull in these cases
he found that the dura matter was thickened, that
it was adherent to the underlying membranes, and
that there were lines of thickening along the cere-
bral vessels.
Intracranial Cpmplications of Diseases of the
Eye. — Dr. James F. McKernon, of New York,
said that pachymeningitis was indicated as a com-
plication of a disease of the eye by the existence of
headache which corresponded to the area of inflamed
dura mater. This headache was aggravated by ex-
ercise and was frequently accompanied by delirium.
The diagnosis of the condition was not usually made
prior to the operation. When the existence of the
disease was suspected, it was because of the charac-
ter of the pain. In such a case every vestige of dis-
eased bone should be removed at the operation.
Epidural abscess was usually found around the
sigmoid sinus. It was indicated by headache and
continuous high temperature, followed by stupor,
chills, and an irregular temperature. If the diagno-
sis was made before the operation, it was made on
account of the occurrence of tenderness on pressure
and on percussion over the collection of pus and
oedema of the soft parts over that collection. The
polymorphonuclear leucocytes were found increased
in number. In such cases all diseased bone should
be removed. Thrombosis of the lateral or of the
sigmoid sinus might be partial or complete. The
cases might be typical or atypical, or they might oc-
cur as primary lesions of the bulb without disease of
the mastoid. These cases were characterized by high
and fluctuating temperature, chills in fifty per cent,
of the cases, and chilly sensations in many of the
others, a rapid pulse, corresponding to the tempera-
ture, pain along the course of the internal jugular
vein, intraocular symptoms in one third of the cases,
oedema over the mastoid bone, and stiffening and
rigidity of . the muscles of the neck. Except in ad-
vanced cases, the cerebral functions were normal.
The vein would have a hard and cordlike feel. Bac-
teriological examinations of the discharge from the
eye were of value ; a distinctive blood count in
which the polymorphonuclears were over eighty per
cent., also, blood cultures were of importance in
arriving at a proper diagnosis. The only treatment
for this condition was a complete excision of the
sinus.
Intracranial Complications of Diseases of the
Nose. — Dr. C. G. Coakf-ev, of New York, said
liiat few rhinologists had had experience with intra-
cranial disease complicating disease of the nose.
When intracranial lesions did occur, the organisms
entered the cranium along the lymph spaces or
through the bloodvessels which drained into the
ct rebral sinuses, and a complete nasal examination
was often very unsatisfactory because of the com-
mon occurrence of nasal and nasopharyngeal ca-
tarrhs and other nasal lesions, such as polypi. When
it was necessary to explore the accessory nasal
sinuses, he preferred the ethmoidal route.
Dr. John B. Murfhy, of Chicago, recommended
ligation of the external carotid artery for hjemor-
rhage from the middle meningeal artery and other
haemorrhages about the skull. He exhibited an in-
strument for opening the skull and a probe pointed
needle for exploring the brain after the skull had
been opened. He pointed out the value of the cis-
terna magna for purposes of drainage, and referred
to the necessity for lemoving a V shaped piece of
velum for the purpose of preventing occlusion of
the foramen of INIagendie.
Professor Jensen, of Berlin, said that purulent
troubles within the skull were rare after disease
within the nose ; he had seen but three out of twelve
hundred cases of nasal disease that developed men-
ingitis as a complication ; all of these patients died.
He had had no deaths from abscess of the brain.
He had seen patients with serous meningitis recover
after the removal of pus from the labyrinth. An
auditory tumor gave the symptoms of labyrinthine
disturbance, and cerebellar abscess gave similar
symptoms in some cases.
SECTION IN OBSTETRICS AND DISEASES OF
WOMEN.
Chaiu.max, Walter B. Dorsett, St. Louis; Secretary,
W. P. Manton, Detroit.
Chairman's Address : Criminal Abortion in Its Broadest
Sense, By Walter B. Dorsett.
Three Procedures for Entering the Abdominal Cavity :
the Vaginal, the Vertical Abdominal, and the Pfan-
nenstiel ; the Indications for, and Their Relative Ad-
vantages and Disadvantages,
By E. E. Montgomery.
The Preparation and After Treatment of Abdominal Sec-
tion, By Henry T. Byford.
The Care of Patients after Abdominal Section, with Espe-
cial Reference to the Period of Time They Should
be Kept Recumbent, By C. C. Frederick.
A Study of the After Condition of Median Abdominal
Wounds Healing Primarily, Which Were Closed in
Layers by Absorbable Sutures; with Special Refer-
ence to the Strength of Union of the Fascia and the
Uncertainty of the Staying Qualities of Ordinary
Catgut, By Le Roy Broun.
Abdominal Cervical Cesarean Section.
By Johannes Pfannenstiel.
Caesarean Section, with Report of Two Cases,
By J. M. Trigg.
Vaginal Caesarean Section and Its Place in Obstetric Sur-
gery. Report of Five Cases,
By Reuben Peterson.
Some Experiences with Extrauterine Pregnancy and Re-
port of Cases, By H. E. Hayd.
Ruptured Tubal Pregnancy. When Shall We Operate?
By Hunter Robb.
Obstetric. Septic, and .'\nsesthetic Toxaemias,
By H. G. Wetherill.
Diphtheritic Genital Infection Simulating Puerperal Fever.
By William Cuthbertson.
•Genital Tuberculosis. By A. Martin.
The Development of Malignancy in Operation Wounds.
By I. S. Stone.
The Serum Treatment of Carcinoma. By S. Strauss.
Uterus and Stomach : Their Anatomical, Physiological, and
Pathological Relationship, By Fred J. Taussig.
.A.cute Dilatation nf the Stomacli as a Postoperative Com-
plication in Gynaecological Surgery.
By Lewis S. McMurtrv.
Bowel Complications Following Gynaecological and Ob
stetric Operations. By Channing W. Barrett.
June 6, 1908.]
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
II13
The Expectant Treatment of Ureteral Calculus, Its Indi-
cations and Results, By Charles Lester Leonard.
The Treatment of Ureteral and Renal Pelvic Inflammation
by Means of Antiseptic Injections,
By Edgar Garceau.
The Corset for Movable Kidney and Associated Visceral
Ptoses, By A. E. Gallant.
The Suture ; Its Place in Surgery, By Henry O. Marcy.
The Female Perinaeum from a Physiological Standpoint,
By J. Riddle Goffe.
The Treatment of Uterine Fibromyomata Associated with
Marked Anaemia, By Benjamin R. Schenck.
The Conservative Surgeon and the Symptomless Uterine
Fibroid, By Thomas B. Eastman.
The Nonsurgical Treatment of Uterine Displacements,
By H. J. BoLDT.
The Advisability of Prompt Evacuation of the Uterus in
the Treatment of Eclampsia, By Henry D. Fry.
Report of a Case of Traumatic Rupture of the Uterus and
Bladder During Labor at Full Term. Hysterectomy,
Repair of Bladder, Recovery,
By John Young Brown and Percy H. Swahlan.
Abnormal Secretion from Mammary Glands in Nonpreg-
nant Women. By George Gellhorn.
The Menopause, By Daniel H. Craig.
Ablatio Placentae. (Premature Detachment of the Nor-
mally Situated Placenta),
By Rudolph Wieser Holmes.
Prolapse of the Rectum and Sigmoid Flexure Following
Hysterectomy, By L. J. Hirschman.
The Adjustable Canvas Chair as an Aid in the Murphy
Treatment of Diffuse Suppurative Peritonitis,
By D. Todd Gilliam.
Criminal Abortion in Its Broadest Sense. — Dr.
Walter B. Dorsett, of St. Louis, used the above
title for the address of the chairman of the section.
He gave the results of the answers to the following
questions submitted to a lawyer in St. Louis : First,
in a case of criminal abortion is the woman guilty
of any crime? In nine States the woman is guilty
of felony ; in seven States she is guilty of a misde-
meanor ; and in thirty-five States she is guilty of no
crime. Second, what is the charge and what is the
penalty for giving, selling, or ofifering for sale
abortifacient drugs or instruments for the pre-
vention of conception? In twelve States these con-
stitute a felony, and the penalty varies from im-
prisonment to a fine ranging from $50 to $5,000;
in twenty States it is a misdemeanor ; and in thirty
States there are no laws covering the subject.
Third, what is the charge, and is the penalty de-
pendent on the age of the foetus? In four fifths of
the States the age of the foetus is immaterial.
Fourth, what is the effect of the death of the wo-
man as to the charge and the penalty after the pro-
duction of a criminal abortion ? In eighteen States
the charge is murder, and the penalty is death or
imprisonment for life ; in six States the charge is
murder in the second degree and the penalty is im-
prisonment for life or for not less than three years.
Fifth, can the license of the offender be revoked
after the production of a criminal abortion? In fif-
teen States it can be revoked; in thirty-two States
there is no law. Sixth, can the physician who gives
subsequent treatment in a case of criminal abortion
be allowed to testify, or is his information regarded
as a professional secret? In one State only is he
allowed to testify. Dr. Dorsett called attention to
the fact that the laws were insufficient or inade-
quate, and he advised the appointment of a commit-
tee by the House of Delegates, to be known as the
Committee on Criminal Abortion, which should un-
dertake to secure the passage of suitable laws after
having studied the conditions from all points of
view.
Dr. Wathen, of Louisville, said that abortion
was offensive to every honest doctor and every hon-
est citizen. He considered that the offense was no
worse for the woman than for the man who com-
mitted it. In his opinion the offense was just as
great four weeks after conception as eight months
after.
Dr. Carstens, of Detroit, said that in this coun-
try people had not grown morally as they had
financially. The question of the prevention of
abortion was a question of education of the people
in their moral responsibility. It was also a ques-
tion of the education of girls in the meaning of life
and the duty of maternity. It was the duty of the
medical profession to teach, in so far as the oppor-
tunity lay with them, this moral responsibility, and
also to teach the necessity of love for children.
Dr. Helen Putnam, of Providence, said that for
the last year she had been investigating the teach-
ing of physiology and hygiene in the public schools,
and incidentally she had been inquiring into the
method, if any, by which the question of sex was
treated. She for.nd that many teachers, particular-
ly those who had had a training in biology, were
doing admirable work in teaching the phenomena of
life, especially as illustrated by plants and the lower
animals. They compared the facts thus presented
to their pupils with the facts of the development of
human beings, and finally gave their pupils a talk
on sexual matters. She was of the opinion that in
this manner the young people of the country might
be brought in time to have a proper idea of the sex
problem, and thus the tendency to the production
of criminal abortion would gradually be checked.
Dr. R. W. Holmes, of Chicago, said that for the
last year or two he had been the chairman of the
committee of the Chicago Medical Society which
had had the question of criminal abortion under
consideration. This committee found that the pub-
lic did not want a campaign against criminal abor-
tion. In IlHnois legislation was not needed ; the
necessary endeavor was toward the enforcement of
the existing law. He said that we must go back and
educate the boy and the girl in the meaning of con-
ception.
Dr. Abrams, of Michigan, said that he had been
a member of the Michigan legislature and the
chairman of its Committee on Public Health. He
said that there was no more prolific cause of the
production of abortion than making the woman a
party to it, because it was then imjxDssible to obtain
evidence.
Dr. Henry said that it was necessar>' to instruct
the people in the physical evils of abortion and to
teach the moral side of the question.
Dr. Denslow Lewis, of Chicago, emphasized the
need of education of the young concerning the sex
relationship.
Dr. A. Martin, of Greifswald, Germany, con-
demned criminal abortion, but said that any law-
passed to control it would fail.
Dr. Darrow, of Chicago, said that it was easy to
get a law, but difficult to enforce it. Among the
poor there was no need for preaching about the sub-
ject. Among the rich, childbirth was frequently in-
III4
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
[New York
Medical Journal.
convenient, and it was necessary that these and the
moderately well to do should be educated on all
sides of the question. She thought that the man
should be made equally to blame with the woman
whenever blame was to be placed. She thought it
was very important to teach the people the respon-
sibility that they bore to the unborn.
Dr. Lawrence, of Cincinnati, said that, in his
opinion, it was necessary to teach the meaning of the
term viability. He ofifered a resolution asking the
House of Delegates to begin to educate the people
concerning these matters. The resolution was car-
ried.
Dr. DoRSETT agreed that the education of the
laity was important, but he emphasized the necessity
for the passage of uniform laws covering criminal
abortion in all of the States and Territories.
Dr. Frederick, of Buffalo, offered a resolution
referring the entire matter to the House of Dele-
gates, and requesting them to appoint a National
Committee on Criminal x^bortion. The resolution
was carried.
SECTION IN DISEASES OF CHILDREN.
Chairman, Edwin E. Graham, Philadelphia ; Secre-
T.\RY, Samuel J. Walker, Chicago.
Chairman's Address : Infant Mortality,
By Edwin E. Graham.
Haemorrhage of the Suprarenal Capsules in the Newly
Born, with Report of Two Cases Due to Infection,
By Jennings C. Litzenberg and S. Marx White.
Haemorrhages of the Newborn, By Henry E. Tuley.
Cerebellar Symptoms in Hydrocephalus, with a Pathologi-
cal Report of a Case Associated with Syringomyelia,
By John H. W. Rhein.
Circulatory Disturbances in Diphtheria,
By John Howland.
The Spasmodic Disorders of the Respiratory Tract in
Children, By Charles G. Kerley.
Chronological and Anatomical Age,
By Thomas Morgan Rotch.
The Clinical Value of Blood Examination in Children,
By Louis Fischer.
A Study of the Anaemias of Infancy,
By John Lovett Morse.
Opsonic Work in Children, with Special Reference to the
Gonococcus, By F. S. Churchill and A. C. Soper.
The Vaccine and Serum Treatment of Gonorrhoea in Fe-
male Children,
By William J. Butler and J. P. Long.
Hydrotherapy in Scarlatina, with Special Reference to Tub
Baths at Water Temperature of 90° F. for Relief of
Nervous Symptoms in Early Stages of the Disease,
By D. S. Hanson.
An Epidemic of Haemorrhagic Nephritis Following Scarlet
Fever, • By C. F. Wahrer.
The Development of the Infantile Stomach,
By D. E. English.
A Study of the Quantity and Quality of Breast Milk Dur-
ing the First Two Weeks of the Puerperium,
By Effa V. Davis.
The Problem of Breast Feeding, By J. Ross Snyder.
The Character of the Stools in Infancy as Related to the
Intestinal Findings, By J. H. Mason Knox.
Studies in Infantile Indigestion, By Alfred Friedlander.
A Summer Camp for Treatment of Sick Babies,
By Walter Graham Murphy.
Adaptation of the Fresh Air Treatment of Tuberculosis
to Paediatric Practice, By Alexander McAlister.
The Ideal Intestinal .Antiseptic in Diseases of Children,
By G. E. Robbins.
Hyperpyrexia in Children: Causes and Treatment,
By Philip Marvel.
Paralytic Dementia in Childhood, with Report of a Case
and the Brain Changes, By Arthur W. Fairbanks.
A Consideration of Some Fallacious Standards Employed
in .Artificial Infant Feeding.
By Godfrey Roger Pisek.
The Use of Whey in Infant Feeding,
By Henry L. K. Shaw.
Present Status of Buttermilk in Infant Feeding,
By H. Lowenburg.
Feeding of Fat, By A. Jacobi.
High Fat Percentages • in Infant Feeding, Their Causes
and Effects, By Thomas S. Southworth.
The Prephysical Signs of Tuberculosis,
By W. C. HOLLOPETER.
Rachitic Erosions of the Permanent Teeth Associated with
Visual Defects, By I. A. Abt.
The Ambulatory Treatment of Pneumonia in Infants and
Young Children, By T. W. Kilmer.
Curative Effect of Rest in Children with Persistent
Loss of Appetite, By Irving M. Snow.
The Prephysical Signs of Tuberculosis. — Wil-
liam C. HoLLOPETER, of Philadelphia, called atten-
tion to the insidious onset of tuberculosis in chil-
dren, many cases resulting from a previous acute
infection, such as pneumonia, measles, or whooping
cough. The mediastinal lymphnodes were fre-
quently the earliest involved of all the lymphnodes,
and a recognition of the existence of these enlarged
nodes was an important point in early diagnosis.
The signs of pressure on the veins, dulness over the
first piece of the sternum, and paroxysmal cough
were important symptoms of this condition. The
development of a venous hum heard over the first
part of the sternum when the child's head is bent
back so that its face was almost horizontal was an
important physical sign of enlargement of the medi-
astinal lymphnodes and of early tuberculosis. The
detection of enlarged mesenteric lymphnodes and
the demonstration of tubercle bacilli in the rectal
mucus were two other important methods of deter-
mining the existence of latent tuberculosis.
Chronological and Anatomical Age. — Dr.
Thomas Morgan Rotch, of Boston, said that the
age of a child in years did not give a proper idea of
the anatomical development of that child. For the
past several years he had been studying the anatomy
of children by the aid of skiagraphs, and he found
that the development of children was very fre-
quently six months or a year behind the degree that
was considered by most authorities to be normal.
He showed the bearing that these facts would have
upon school work, athletics, and child labor. He di-
vided his cases into a number of groups, depend-
ing upon the degree of development of the centres
of ossification in the bones of the hands and wrists.
The paper called forth considerable interesting dis-
cussion by a number of well known paediatrists.
A Study of the Anaemias of Infancy. — Dr.
John Lovett Morse, of Boston, described the
characteristics of the blood in infancy, and the
changes in the blood picture dependent upon the
age of the patient. In children the haemoglobin
was relatively low and the lymphocytes were in-
creased in numbers. He said that chlorosis did not
exist in infancy, although anaemias of the chlorotic
type were common. He said that pernicious auc-emia
was very rare in childhood, but that when it did
occur it was almost always of the metaplastic type.
Secondary anaemias were very common and were
frequently associated with enlargement of the
spleen. He thought that there was no justification
for placing cases of anaemias with splenic tumor in
a class by themselves with a special name. Lou-
chaemia was very rare during childhood, but when
it did occur, almost all of the cases were acute, and
the majority of them were of the lymphatic type.
June 6, i9o8.] CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
1114a
SECTION IN NERVOUS AND MENTAL DISEASES.
Chairman, T. H. Weisenburg, Philadelphia; Secretary,
W. A. Jones, Minneapolis.
Chairman's Address, By T. H. Wf.isenburg.
Associated Movements, By Charles E. Beevor.
Epidemic Infantile Paralysis, By M. Allen Starr.
The Cortical Centres for Taste and Smell, Illustrated by
the Study of a Case of Brain Tumor with Necropsy,
By Charles K. Mills.
A Case of Cerebellar Tumor, By Wharton Sinkler.
Traumatic Cervical Myelomalacia. Report of a Case with
Necropsy, By Carl D. Camp.
Myotonia Atrophica, By J. Ramsay Hunt.
The Symptom Complex of Central Neuritis,
By Isadore H. Coriat.
Significance of Pupillary Changes in Tabes,
By Edward D. Fisher.
Cerebral Thrombosis, Venous and Arterial : A Clinical,
Pathological, and Experimental Study,
By D. J. McCarthy and Miltox K. Meyers.
Disease of the Cerebral Vessels with Its Problems in Diag-
nosis, By W. A. Jones.
A Study of Certain Nutritional Phenomena of Hysteria,
By James J. Putnam.
Certain Affections in Children Commonly Classed as
Hysteria, By William N. Bullard.
A Study of Three Cases of Hysterical Ocular Phenomena
Studied from the Standpoint of Dissociation,
By Sidney I. Schwab.
A Study of the Eye in Mental Defectives,
By L. Pierce Clark and Martin Cohen.
Injuries of Cranial Nerves from Fractures of the Skull,
By John J. Thomas.
Cerebral Inhibition, as Illustrated in General Pathological
Conditions in the Nervous System,
By H. A. ToMLiNSON.
Haemorrhage into the Ventricles; Its Relation to Con-
vulsions and Rigidity in Apoplectiform Hemiplegia,
By Alfred Reginald Allen.
Experiments in - Psychogalvanic Reactions from Cocon-
scious (Subconscious) Ideas in a Case of Multiple
Personality,
By Morton Prince and Frederick Peterson.
Elements of Psychiatric Prognosis, By F. X. Dercum.
Some Disorders of Attention and Their Treatment,
By Howell T. Pershing.
Pathological Report of the Nervous System in a Case of
Spondylose Rhizomelique, By John H. W. Rhein.
Traumatic Disfigurement, Depression, Suicidal Attempts.
Delusions of Negation : Bronchiectatic Abscesses of
Lungs, Abscesses of Brain, Chronic Meningitis,
By E. E. Southard and J. B. Ayer, Jr.
Cerebral Rheumatism, By Herman H. Hoppe.
Two Cases of Multiple Neuritis. ' By Philip Zenner.
The Attitude of Neurologists Toward Electrotherapy.
By Frank R. Fry.
The Respiratory Signs of Chorea Minor,
By William W. Graves.
Insanities Caused by Acute and Chronic Intoxications with
Opium and Cocaine; \ Study of 171 Cases,
By Alfred Gordon.
The Wild Duck. A Study in Psychopathologjs
Bv Smith Ely Jelliffe.
Psychotheraphy, By M. A. Bliss.
Neuromuscular Coordinations Having Eucational Value.
By Luther H. Gulick.
The Use of Physical Measures in the Therapeutics of the
Nervous System, By William Benham Snow.
Rontgenology in Neurology, By Mihran K. Kassabian.
Chairman's Address: Neurological Teaching
in America. — Dr. T. H. ^^'EISE^•BUR^,. of Phila-
delphia, traced the development of neurological and
psychiatrical teachings in America from the time of
Rush's lectures in Philadelphia in 1791. No lec-
tures on the subject of neurology were given until
1867, when Dr. William A. Hammond, one of the
former editors of the New York Medical Journal,
began his course on the diseases of the nervous sys-
tem in the Bellevue ^Vledical College in New York.
In 1 87 1 Dr. Hammond's book on Nervous Diseases
appeared. Dr. Weisenburg then referred to the lec-
tures given by E. C. Seguin in New York ; the work
of Mitchell, Moorehouse, and Keen in Philadelphia ;
of Putnam, Bowditch, and James in Boston ; of H.
C. Wood in Philadelphia ; of J. S. Jewell in Chi-
cago. He referred to the first course of lectures in
electrotherapeutics, which was given in New York
as a department of neurology in 1875 by Neftell,
Beard, and Rockwell, followed by the course given
by Mills, in Philadelphia, in 1877.
In psychiatry, after the lectures of Rush, no
course was given until in 1867, when Dr. William
A. Hammond began to give a course of lectures on
insanity in the Bellevue Hospital Medical College.
Dr. Isaac Ray was appointed lecturer on insanity in
the Jefferson Medical College in Philadelphia, an
appointment which was preceded by the publication
of the Medical Jurisprudence of Insanity in 1838.
In discussing the methods employed at the pres-
ent time in the teaching of neurology" in the medical
schools of America, the courses at Harvard, Cornell,
Pennsylvania, and Northwestern were compared as
four examples out of the many excellent courses
given. In comparing the methods employed in
teaching in this country with those in use in the
leading schools of Europe, the American schools
were far ahead of the latter in their undergraduate
courses in neurology and psychiatry.
The author then discussed the postgraduate teach-
ing of these subjects, beginning with the foundation
of the New York Polyclinic, in 1881, and the Phila-
delphia Polyclinic and College for Graduates in
Medicine, in 1882. He then outlined a course par-
ticularly fitted for the needs of the American med-
ical student, in which he advocated as thorough a
course in these subjects as is given in the other
specialties, as, for instance, ophthalmology.
SECTION IN PATHOLOGY AND PHYSIOLOGY.
Chairman, W. B. Cannon, Boston; Secretary, M. J.
Rosenau, Washington, D. C.
Chairman's Address, By Walter B. Cannon.
A Critic of Some of the More Recent Work and Ideas on
Nutrition, By L. Breisacher.
Some Observations on (a) Growth of Hen, (b) Egg Pro-
duction, (c) Weight of Eggs, (d) Fertility of Eggs,
and (e) Size of Chicks After Extirpation and Trans-
plantation of Ovaries in Chickens,
By C. C. Guthrie.
Experiments Toward a Physiologically Isotonic Solution
of Salts, By Herman M. Adlek.
Chloroform Necrosis of the Liver, By H. Gideon Wells.
Safeguards of the Heart, By Henry Sewall.
Some New Statistics on Blood Plates and Some New
Practical Points on Counting Them,
By George T. Kemp, with the collaboration of C. W.
Yeck and Carl Ten Broeck.
The Cleavage of Bacterial Proteids by Exposure to Direct
Sunlight, By Victor C. Vaughan.
Anaphvlaxis Induced bv Bacterial Proteids,
By D. H. Bergey.
Therapeutic Immunization in Mixed Infections,
By A. P. Ohlmacher.
Serum Diagnosis of Syphilis, By William J. Butler.
Histoplasma Capsulatum, By Samuel T. Darling.
Some Phases of Mycotic Diseases, By L. H. Pammel.
Demonstration of Diseased Conditions of the Appendix.
By E. R. Le Count,
"symposium" on typhoid.
Treatment of Typhoid, By Thomas McCrae.
Symptoms Resembling Perforation in Typhoid,
By D. L. Edsall.
Typhoid Bacillus Carriers, By William H. Park.
The Value of Blood Cultures, By Francis W. Peabody.
1 114b
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
The Metabolism of Typhoid Fever, By P. A. Shaffer.
The Channels of Infection, with Special Reference to Sup-
pression of Typhoid Fever, By M. J. Rosenau.
The Alleged Urinary Manifestations of Disease of the
Pancreas, By J. Henry Schroeder.
Some Observations on the Diuretic Action of Adrenalin
and the Active Principle of the Pituitary Gland,
By E. M. Houghton.
Further Results in Suprarenal Transplantation,
By F. C. BuscH.
The Nature and Cause of CEdema, By Martin H. Fischer.
Some New Points in the Physiology of Lymph and Lymph
Formation, By A. J. Carlson.
Multiple Hernias of the Cerebrum and Cerebellum Due to
Intracranial Pressue (Second communication) ,
By S. Burt.
JOINT MEETING WITH SCIENTIFIC SECTION.
How Is the Activity of Phagocytes Affected by Elec-
trolytes, by Nonelectrolytes and Changes in Osmotic
Tension? By Oliver Harry Brown.
Physiomechanical Causes of Pathological Conditions,
By R. C. Falconer.
Some Points on the Relation of the Intestinal Flora to
Peptic Ulcer, By Fenton B. Turck.
Tubercle Bacilli in Sputum of Acute Colds, with Disap-
pearance of Bacilli during Convalescence,
By L. Napoleon Boston.
SECTION IN OPHTHALMOLOGY.
Chairman, William H. Wilder, Chicago; Secretary,
Albert E. Bulson, Jr., Fort Wayne, Ind.
Chairman's Address, By William H. Wilder.
Address by Special Invitation. Developmental Deformi-
ties of the Crystalline Lens,
By E. Treacher Collins.
A Further Contribution to the Possible Relationship of
Autointoxication to Certain Diseases of the Cornea
and Uveal Tract (Special Investigation),
By G. E. de Schweinitz and Charles A. Fife.
The Eye as a Contributory Factor in Tuberculosis,
By F. P. Lewis.
The Calmette Ocular Reaction to Tuberculin,
By H. C. Parker.
Ocular Complications of Pregnancy (Special Investiga-
tion), By Hiram Woods.
The Relation of Ocular and Cardiovascular Disease,
By Melville Black.
Unilateral Voluntary Nystagmus, with Report of a Case.
By Walter L. Pyle.
Zonular Opacity of the Cornea, By F. C. Heath.
Diffuse Interstitial Keratitis in Acquired Syphilis,
By A. E. Davis.
Opacification of the Cornea Following Cataract Extraction,
By Vard H. Hulen.
The Surgical Treatment of Orbital Complications in Dis-
ease of the Nasal Accessory Sinuses.
By -Arnold Knapp.
.\n Infrequent Type of Optic Nerve Atrophy,
By H. F. Hansell.
Some Clinical Aspects of Lenticular Astigmatism,
By Edgar S. Thomson.
A Study of One Hundred Refraction Cases in Indians
Fresh from the Plains, By Clarence Porter Jones.
The .Association of Lens Opacity with Normal and Patho-
logical Blood Pressures, By D. W. Greene.
rhe Treatment of Some Forms of Lens Displacement
Other Than Those of Traumatic Origin,
By L. D. Brose.
History of Iridotomy. Knife Needle versus Scissors. De-
scription of Author's V Shaped Method,
By S. L. Ziegler.
.Miotics versus Iridectomy in the Treatment of Simple
Chronic Glaucoma. An Analytical Study of Sixty-
five Cases Treated by Miotics over a Series of
Years (Special Investigation), By W. C. Posey.
A Better Prognosis in Penetrating Wounds of the Eyeball,
By J. A. Donovan.
The Treatment of Strictures of the Nasal Duct with Lead
Styles, By H. Moulton.
Impcrforation of the Lachrymonasal Duct in the Newborn
and Its Clinical Manifestations,
By William Zentmeyer.
Motais Operation for Ptosis By Henry Dickson Bruns.
Principles Underlying the Operative Treatment of Strabis-
mus (Special Investigation), By Edward Jackson.
The Treatment of Recurrent Pterygium, By H. Gifford.
The Relation of So Called Ophthalmic Migraine to Epi-
lepsy, By A. A. HuBBELL.
Restoration of the Conjunctival Cul-de-Sac for the Inser-
tion of an Artificial Eye, By M. Wiener.
Palliative Operations for Choked Disc,
By William G. Spiller.
Decompression Operations, with Especial Reference to
Changes in the Eye Grounds,
By Harvey Gushing and James G. Bordlev.
The Optic Nerve Changes in Multiple Sclerosis, with Re-
marks on the Causation of Nontoxic Retrobulbar
Neuritis in General, By Ward A. Holden.
Migraine: An Occupation Neurosis, By G. L. Walton.
Distinctive Diagnosis of Affections of the Optic Nerve,
By Harry Friedenwald.
[The last five papers will be presented in the joint ses-
sion with the Section on Nervous and Mental Diseases.]
SECTION IN LARYNGOLOGY AND OTOLOGY.
Chairman, H. W. Loeb, St. Louis; Secretary. W. Sohier
Bryant, New York City.
Chairman's Address, By H. W. Loeb.
■"symposium." differential diagnosis of luetic tubercu-
lous and malignant diseases of the larynx.
Histological Diagnosis, By D. Braden Kyle.
Laryngoscopic Diagnosis, By Chevalier Jackson.
Systemic Tests, By John W. Boyce.
Laryngeal Manifestations Occurring in Locomotor Ataxia
and Multiple Sclerosis, By Wolf Freudenthal.
Tonsillectomy in Children Under Ether Anaesthesia. A
Hospital Operation, By Edwin Pynchon.
Laryngeal Manifestations Occurring in Locomotor Ataxia.
A Contribution to the Study of Streptococcic Infec-
tions of the Adenoid in Adults,
By Alice G. Bryant,
joint session with section in surgery.
Intracranial Complications of Ear Disease,
By James F. McKernon.
Intracranial Complications of Nasal Disease,
By C. G. Coakley.
"symposium" on correction of nasal deformities.
Submucous Resection of the Lateral Nasal Wall in
Chronic Empyema of the Antrum. Ethmoid, and
Sphenoid, ' By R. Bishop Canfield.
A Study of the Sphenoidal Sinus, By Joseph A. Gibson.
The Present Status of the Radical Operation for Empyema
of the Sphenoid Sinus, with Demonstration of a New-
Instrument, By Ross H. Skillern.
The Treatment of Hypertrophic Rhinitis (Hay Fever),
Especially with Reference to Injections with Alcohol,
By Otto G. Stein.
Faciohypoglossal Anastomosis. By George F. Cott.
Ear Symptoms of Cardiovascular Disease,
By Louis F. Bishof.
Middle Ear Sclerosis, or .Atrophic Middle Ear Catarrh,
By W. SoHiER Bryant.
Diagnosis of Functional Ear Disease, By Hermann Stolte.
Analgesia of the Nasal Mucous Membrane as a Prognosis
in the Treatment of So Called Dry Catarrhal Deaf-
ness, By Dunbar Roy.
Middle Ear Surgery. By Philip Hammond.
Meatomastoid Operation for Chronic Mastoiditis,
By William L. Ballenger.
Resection of the Labyrinth and Their Significance in the
Diagnosis of Suppurative Labyrinthitis,
By George E. Davis.
A Case of Acute Mania Following Ligation of thte Jugu-
lar for Otitic Symptoms, By Eugene A. Crockett.
SECTION IN HYGIENE AND SANITARY SCIENCE.
Chairman, Colonel W. C. Gorgas, U. S. A., .\ncon,
Panama; Secretary, S. T. Armstrong. New York.
Chairman's Address. By Colonel W. C. Gorgas.
Measures to Prevent Malaria on the Isthmus of Panama,
By Henry R. Carter.
Mosquito Work and Yellow Fever, By J. H. White.
• Mosquito Extermination in the Tropics,
By J. A. Le Prince.
Tropical Sanitation, By V. G. Reiser.
June 6, 1908.] CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
1114c
•"svmposium' on the necessity for uniformity in vital
statistics.
Prophylaxis and Management of Leprosy, By L. E. Cofer.
lylunicipal Sanitation, By Charles V. Chapin.
Milk as a Carrier of Infection. By John W. Trash.
Tlie Necessity of Obtaining Negative Cultures from All
the Inmates before Disinfecting a House for Diph-
theria, By Myer Solis-Cohen.
The Ocular' Tuberculin Reaction as a Means of Diagnosis
and Control, By Frank Smithies.
Early Diagnosis of Consumption as a Measure of Control.
Especially the Relation of Tuberculin thereto,
By W. A. Evans.
The Control of Smallpox. By H. M. Bracken.
The Responsibility of Municipalities in the Ohio Valley
for the Epidemics of Typhoid Fever.
By W. Forest Dutton.
Choleriform Diarrhoea of Cold Weather— Winter Cholera,
By O. C. Breitexbach.
Prophylaxis in Communicable Diseases, By M. J. Rosexau.
Examination to Establish whether a Gonorrhoea is Cured,
By F. C. Valentine,
SECTION IN STOMATOLOGY.
■Chairman, E. A. Bogue, New York; Secretary, Eugexe
S. Talbot, Chicago.
Chairman's Address, By E. A. Bogue.
Dental Education, By M. L. Rhein.
Pathology as Taught in Dental Schools, By L. G. Noel.
State Reciprocity in Dental Practice Licensing,
By Adelbert H. Peck.
Some Practical Considerations Concerning Inflammation.
By James E. Power.
Interstitial Gingivitis, By Edward C. Briggs.
Prophylaxis of the Mouth. By M. H. Fletcher.
.Etiology of Face, Nose, Jaw, and Tooth Deformities.
By ErcEXE S. T.\lbot.
Bone Pathology of Tooth Movement.
By EcGEXE S. Talbot.
The Influence on the Nose by Widening the Palatal Arch.
By Lee W.xllace Deax.
The Relation between Deviation of the Nasal Sreptum and
Dental and Jaw Deformities from the Rhinologist's
Standpoint, By Nelson M. Bl.\ck.
Diagnostic Value of Microscopical Examinations during
Operations on Patholgical Tissue.
By ViDA A. L.vtham.
The Surgerv of Harelip and Cleft Palate.
By George \'. I. Brown.
Tumors Involving the Alveolar Process.
By Stewart L. McCurdy.
Some of the Diseases of the Salivary Glands and Their
Ducts, By Thomas L. Gilmer.
Treatment of Mandibular Fractures, By Robert T. 0li\t:r.
Peripheral Causes of Facial Pains. Including Tic Dou-
loureux, By Morris I. Schamberg.
Nitrous Oxide and Oxygen Anaesthesia in Dental and Gen-
eral Surgery, By Fred K. Ream.
SECTION IN CUTANEOUS MEDICINE AND
SURGERY.
Chairman, M. B. Hartzell, Philadelphi.v ; Secretary,
M. L. Heidingsfeld, Cincinn.\ti.
Chairman's Address: The Nature and Causes of Eczema,
By M. B. Hartzell.
Nutritive and Neurotic Disturbances of the Hair,
By L. D. BuLKLEY and H. H. Janeway.
A Deceptive Case of Leprosy,
By Charles J. White and O. Richardson.
N Ray Uses, Dangers, and Abuses, By W. S. Gottheil.
The Treatment of Epithelioma by the Rontgen Rays,
• By G. E. Pfahler
Increasing Tendency to Recognize a Systemic .Etiolog\-
and Systemic Treatment of Skin Disease. The Old
and New in Cutaneous Therapy, By Ludwig Weiss,
lantern session.
Pemphigus, a Study of Some Cases Personally Observed,
By J. M. Winfield.
Pemphigus Foliaceus and Its Status among the Bullous
Dermatoses. By W. T. Corlett.
Tlie Pathology of Pemphigus Foliaceus.
By Oscar T. Schultz.
A Case of Acnitis (Barthelemy"). or Acne Agminata
(Crocker), By J. F. Schamberg.
Some Unusual Forms of Epithelioma of the Skin,
By J. A. Fordyce.
A Further Contribution to the Histopathology of Epider-
molysis Bullosa. By M. F. Engman and M. H. Hook.
Paraffin Prosthesis. A Further Contribution on its Histo-
pathology, By M. L. Heidingsfeld.
Multiple Haemorrhage Sarcoma (Kaposi),
By David Lieberthal.
Exhibition of Clinical Cases, By Joseph Zeisler.
The Pigmentations of the Mucous Membrane of the
Mouth, By H. G. Anthony.
Erythema Figurata Persians, By Grover W. Wende.
Cheilitis Exfoliativa, By L. M. R.witch.
Mercurial Treatment for Late Manifestations of Syphilis,
By Herman G. Klo-^z.
The Influence of the Discovery of the Pale Spirochaeta or.
the Treatment of Sj-philis, By W. F. Breakev.
The Relation of the Character of the Syphilitic Initial
Lesion to the Secondary Constitutional Period,
By A. Ravogli.
SECTION IN PHARMACOLOGY AND THERA-
PEUTICS.
Chairman, M. H. Fussell. Philadelphia : Secretary,
C. S. N. Hallberg, Chic.\go.
Chairman's Address : Simplicity in Prescribing,
By M. H. Fussell
.\ddre5s of Chairman of Delegation from American Phar-
maceutical Association, By Joseph P. Remington.
Report of Secretary, By C. S. N. Hallberg.
Trend of Pharmacology and Therapeutics in Relation to
Chemical Research, By W. J. K. Kline.
Osteopathic versus Drug Treatment,
By M. Clay'ton Thrush.
Work Cure. By Addison Thayer.
Physiological Assay of Some Commonly Used Drugs,
By Charles W. Edmunds.
Sodium Cacodylate : Its Therapeutic Uses.
By Frank Billings.
Arsenic in the Treatment of Diseases of the Skin,
By Milton B. Hartzell.
The Specific Chemical Therapy of TrA'panosomiases and
Spirilloses, By Benjamin T. Terry
Organotherapy, By Reid Hunt
General and Topical .\pplications in Advanced Laryngeal
Tuberculosis, By S. Solis-Cohen.
Pneumotherapy in Pulmonary Tuberculosis,
By S. Solis-Cohen.
The Use of Digitalis in Pneumonia,
By Thomas F. Reilly.
The Effects of Quebracho on the Respiration.
By H. C. Wood, Jr.
Tincture Strophanthus and Strophanthin, with Especial
Reference to Dosage. By R. A. Hatcher.
Coincibcnt iHcEtings.
American ^Medical Editors' Associ.a.tiox.
The thirty-ninth annual meeting of the American
[Medical Editors' Association was held in the Audi-
torium Hotel, Chicago, on Saturday, May 30th, and
Monday, June ist. The president. Dr. Charles F.
Taylor, of Philadelphia, editor of the Medical
World, in the chair. An interesting programme
was carried out.
The following officers were elected for the com-
ing year: President, Dr. T. D. Crothers, of Hart-
ford, Conn., editor of the Quarterly Journal of Ine-
briety; first vice-president. Dr. W. A. Young, of
Toronto, Canada, editor of the Canadian Journal of
Medicine and Stirgcry; second vice-president, Dr.
E. W. Taylor, of Boston, of the Boston Medical and
Surgical Journal; secretary and treasurer, Dr. Jo-
seph ]\IacDonald, Jr., of New York, of the Ameri-
can Journal of Surgery; members of the executive
committee. Dr. J. J. Taylor, of Philadelphia, editor
of the Medical Council; Dr. W. C. x\bbott, of Chi-
cago, editor of the Journal of Clinical Medicine, and
Dr. W. A. Jones, of Minneapolis, editor of the Jour-
nal of the Minneapolis Medical Society.
Iii4d
CHICAGO MEETING OF AMERICAN MEDICAL ASSOCIATION.
[New York
Medical Journal.
The banquet, which was held on the evening of
Monday, June ist, was well attended. Toasts were
responded to by Surgeon General Wyman, of the
United States Public Health and Marine Hospital
Service ; Colonel W. C. Gorgas, of the Isthmian
Canal Commission ; Dr. Charles A. L. Reed, of Cin-
cinnati ; Dr. W. A. Young, of Toronto ; Dr. Henry
O. Marcy, of Boston, and Dr. Wallace, of Chatta-
nooga.
THE ASSOCIATION OF AMERICAN TEACHERS OF THE
DISEASES OF CHILDREN.
The association held its annual meeting in the
Great Northern Hotel, Chicago, 111., on Monday,
June 1st, at 2 p. m.
The following programme was presented :
Address of welcome, delivered by Arthur D.
Bevan, of Chicago, chairman Council on Education
of the American Medical Association.
Address of the president, by Dr. Samuel W. Kel-
ley, of Cleveland, Ohio.
The Teaching of Paediatrics as Seen by an In-
spector of Medical Colleges, by Dr. Frederick C.
Zapfife, of Chicago, 111.
The Teaching of Pjediatrics in the European
Schools, by Dr. H. M. McClanahan, of Omaha.
The Teaching of Paediatrics in the Medicochirur-
gical College of Philadelphia, by Dr. W. C. Hollo-
peter, of Philadelphia.
Case Teaching in Paediatrics, by Dr. William W.
Butterworth, of New Orleans, La.
The Doctrine of Difficult Dentition, by Dr. Theo-
dore J. Elterich, of Pittsburgh, Pa.
Anatomical Peculiarities of Infants and Children,
by Richard B. Gilbert, -of Louisville, Ky.
The discussion was opened by Dr. Philip F. Bar-
bour, of Louisville, Ky.
What Conditions Demand Total Weaning and
What Demand Partial Weaning of Infants during
the First Two Weeks of Life ? by Dr. Charles Doug-
las, of Detroit, Mich.
Some Points on Infants' Clothing, by Dr. Alfred
C. Cotton, of Chicago.
The Urinary Infections in Children, by Dr. John
Zahorsky, of St. Louis, Mo.
The discussion was opened by Dr. Isaac A. Abt,
of Chicago.
Chorea in Its Relation to Tonsolitis, Rheumatism
and Endocarditis, by Dr. William J. Butler, of Chi-
cago.
Some Phases of the School Child, by Dr. J. W.
Van Derslice, of Oak Park, 111.
The discussion was opened by Dr. A. C. Cotton,
of Chicago.
Uncinariasis in the Southern States, by Dr. J.
Ross Snyder, of Birmingham, Ala.
The discussion was opened by H. M. Folkes, of
Biloxi, Miss.
Treatment of Pneumonia in Children by the Out-
door Air Method, by Dr. Frederic W. Loughran,
of New York.
The following officers were elected for the com-
ing year: President, Dr. Charles Douglas, of De-
troit; Secretary, Dr. Samuel W. Kclley, of Cleve-
land ; Treasurer, Dr. George H. Cattermole, of
Boulder, Col. Executive Committee, Dr. W. C.
Hollopcter, of Philadelphia; Dr. H. M. McClana-
han, of Omaha; and Dr. R. B. Gilbert, of Louis-
ville.
THE AMERICAN ACADEMY OF MEDICINE.
The thirty-third annual meeting of the American
Academy of [Medicine was held in the Lexington
Hotel, Chicago, on Saturday, May 30th, and Mon-
day, June 1st. The president. Dr. Thomas D. Davis,
of Pittsburgh, in the chair. The following pro-
gramme was carried out :
I. Report of the Committee on the Best Means
for the Medical Profession to Take Part in the Edu-
cation of the General Public in Medical Matters
through Publications, etc., by Dr. Edward Jackson,
of Denver, Chairman.
II. Report of the Committee to Investigate the
Teaching of Hygiene in the Public Schools ; and
III. Report of the Delegate to the Second Inter-
national Congress on School Hygiene, London,
1907, by Dr. Helen C. Putnam, of Providence, R. I.
IV. Report of the Committee on Conference with
Educational Institutions on Medical Education, by
Dr. Charles Mclntire, of Easton, Pa., Chairman.
V. Report of a Special Committee to Formulate
Conclusions from the Conference at Pittsburgh,
January 2, 3, 1908, by Dr. John L. Heffron, of
Syracuse, N. Y., Chairman.
VI. Report of the Delegate to the Annual Con-
ference of the Council on Medical Education of the
American Medical Association, Chicago, April 13,
1908, by Dr. Charles S. Sheldon, of Madison, Wis.
VII. Some Considerations of the Necessity for
a Rational Curriculum for the Doctorate, by Dr.
Henrv Beates, Jr., of Philadelphia.
VIII. Annual Address. The Doctor and School
Advice. This address was delivered by the presi-
dent of the Academy, Dr. Thomas D. Davis, of
Pittsburgh, Pa.
IX. Report of the Committee to Collect Data as
to the Amount of Damage Done by Alcohol in
Moderate Drinkers, by Dr. Woods Hutchinson, of
New York, Chairman.
X. Report of the Committee to Prepare a Draft
of an Act to Create a State Board of Medical Ex-
aminers, by Dr. Charles Mclntire, of Easton, Pa.,
Chairman.
"symposium" ox the place of women in the
modern business world as affecting home
life, the marital relation, piealth,
morality, and the future of the race.
1. As Afifecting the Home Life and the Marital
Relation, by Dr. A. Stewart Lobinger, of Los-
Angeles.
2. As Af¥ecting Health, by Dr. L. Duncan Bulk-
ley, of New York.
3. As Affecting Health and Morals, by Dr. Nor-
man Bridge, of Los Angeles.
4. As Affecting the Future of the Race, by Dr.
Otto Juettner, of Cincinnati, Ohio.
5. As Aft'ectino; the Future Welfare of the Race,
by' Dr. Edward B. Heckel, of Pittsburgh.
6. Female Labor as a Factor in Social Life, by
Dr. A. L. Benedict, of Buffalo.
The following officers were elected: President,
Dr. Helen C. Putnam, of Providence. Vice presi-
dents, Dr. Charles S. Sheldon, of Madison, Wis. ;
Dr. Mettler ; Dr. J. K. Weaver, of Norristown, Pa. ;
Dr. Norman Bridge, of Los Angeles. Secretan-
and treasurer, Dr. Charles Mclntire, of Easton, Pa.
Assistant secretary. Dr. Alex. R. Craig, of Phila-
delphia.
June 6, 1908.]
\EWS ITEMS.
gt\as |Ums.
Chanj^e of Address.— Dr. D. J. .Milton Miller, to 1700
Pacific A\'en;ie. Atlantic City.
Women Physicians of Colorado Form an Association.
The Woman's Colorado State Medical Association was
lecently incorporated, and every regular woman physician
in the State will be asked to become a member.
Buffalo Academy of Medicine. — The regular meeting
■of the Section in Obstetrics and Gynecology was held on the
evening of Mav 28th. The programme included a paper on
The Conservation of Nervous Energy^ in the Parturient, b>
Dr. Peter W. Van Peyma. and a paper on The Treatment of
Threatening and Inevitable Abortion, by Dr. William G.
Taylor.
St. John's Guild Opens Seaside Hospital. — St. John's
Guild opened the Seaside Hospital at >sew Dorp, Staten
Jsland, on June ist, when two parties of babies and little
children, with their mothers, were sent to the hospital on
the Staten Island ferryboats. The guild will continue to
convey patients to the hospital by boat twice daily, except
Sundays, until the Floating Hospital begins its trips, which
will be about July 6th.
Scientific Society Meetings in Philadelphia for the
■Week Ending June 13, 1908. — Monday, June 8th, Wills
Hospital Ophthalmic Society. Tuesday. June gth. Phila-
delphia Paediatric Society: Botanical Section, Academy of
Natural Sciences. ]V c'dnesday , June JOth, Philadelphia
County ?>Iedical Society. Thursday. June nth, Pathological
Society: Section Meeting, Franklin Institute. Friday. June
1 2th. Northern Medical Association: West Branch. Phila-
delphia County }vledical Society.
The Japanese Red Cross Society. — The sixteenth an-
niversary of the founding of this society was held in
Hiblya Park. 1 okio. on June ist. The society now ha> a
membership of 1.414,225, including 504 Americans. 590
Coreans, and 6,440 Chinese. The value of its property ex-
ceeds $7,000,000. Connected with its medical staff are 212 doc-
tors, 143 pharmacists, and 3,369 nurses. 668 male and 2.701
female. Since the Russo-Japanese war the society has put
into commission two large hospital ships, in addition to the
two already in use.
Charitable Bequests. — By the will of Frederick Roem-
mele the German Hospital, Brooklyn, receives S500, and
the German Home for the Aged receives S250.
By the will of Mary Ann Astor Woodcock the Meth-
odist Episcopal Hospital, Brooklyn, receives $5,000.
By the will of Annie Cohen the Jewish Hospital. Brook-
lyn, receives $1,000.
By the will of James Henry Smith St. Luke's H-r'Spital.
New York, receives $100,000, and the New York Orthopae-
dic Hospital and Dispensary receives $100,000.
American Gynaecological Society. — The twenty-third
annual meeting of this society was held in Philadelphia on
May 25th. 26th. and 27th. Dr. August Martin, of Berlin,
and Dr. F. Pfannenstiel. of Kiel, were guests of the
society. The following officers were elected to serve for
the year 1909: President. Dr. J. Riddle Goffe. of New
York: first vice president. Dr. Howard Kell\-. of Balti-
more: second vice president. Dr. M. McLean, of New York:
secretary. Dr. Le Roy Broun, of New York : treasurer, Dr.
J. Wesley Bovee. of ^^'ashingtnn. D. C. The next meeting
will be held in New York in May, 1909.
Cases of Tuberculosis Must Be Reported in New
York. — A bill has been enacted in the New York legis-
lature providing that physicians attending cases of tuber-
culosis shall make a report of such cases to the local health
authorities, and shall put into effect such precautions as
may be prescribed by the local authorities to prevent the
spread of the disease. The bill provides that a fee of $1
shall be paid out of the funds of the local government to
each physician who carries out the precautions specified by
the authorities. The measure resembles in many particu-
lars a law which has been in force for the past four years
in Maryland.
Appointments and Promotions at the Rockefeller In-
stitute for Medical Research. — The following appoint-
ments have been made to the staff of this institution : Dr.
P. A. Lewis, assistant in pathology : Dr. A. I. Kendall, as-
sistant in bacteriology : Dr. A. R. Dochez. fellow in oathol-
Dgy; Dr. A. O. Shaklee, fellow in physiolog>- and pharma-
cology. Promotions have been made as follows : Dr. John
Auer, associate in physiology and pharmacology : Dr. Don
R. Joseph, assistant in physiology and pharmacology : Dr.
Alexis Carrel, associate in surgery : Dr. J. W. Jobling, as-
sociate in pathology; Dr. Benjamin T. Terry, assistant in
protozoology- : Dr. Donald D. Van Slyke, assistant in bio-
logical chemistry; Dr. Walter A. Jacobs, assistant in
biological chemistry; Dr. Bertha I. Barker, fellow in
patholog}' : Dr. R. V. Lamar, fellow in pathology.
The Mortality of Chicago. — According to the report
of the Department of Health, during the week ending May
23, 1908. there were reported to the department 495 deaths
from all causes, as compared with 635 for the preceding
week, and 641 for the corresponding period in 1907. The
annual death rate in 1,000 of population was 11.92. The
principal causes of death were : Apople.xy. 8 : Bright's dis-
ease, 43; bronchitis. 13; consumption, 54: cancer, 26: con-
vulsions. 5: diphtheria, 6; heart diseases, 53: influenza. 2;
intestinal diseases, acute, 23: measles. 11: nervous diseases,
16; pneumonia. 57; scarlet fever. 6: suicide. 5; typhoid
fever. 2: violence (other than suicide), 22; whooping
cough. 2; all other causes, 141.
Meetings of State Medical Societies for the Month of
June:
Michigan State Medical Society, annual meeting at
Manistee, Mich., on June 24th and 25th.
Maine Medical Association, annual meeting at Bangor,
Me., on June loth and nth.
Massachusetts Medical Society, annual meeting at Bos-
ton on June loth and nth.
Medical Society of New Jersey, annual meeting at Cape
May. N. J., on June i8th. 19th, and 20th.
State ^ledical Society of Wisconsin, annual meeting at
Milwaukee on June 24th. 25th, and 26th.
Philadelphia Academy of Surgery. — A stated meeting
of this Academy was held on the evening of June ist. Dr.
James K. Ycung reported a case of exploratory arthrec-
tomy. Dr. John Price reported four cases of Ludwig's
angina. A paper on the End Results of Fractures of the
Femur Treated Conservatively was presented by Dr. A. P.
C. Ashhurst and Dr. William A. Newell. Dr. G. G. Davis
read two papers, one describing an operation for the cure
of enuresis, and the other giving the details of a method
of anastomosing the divided vas deferens. Dr. W. Estell
Lee read a paper entitled The Use of Ethyl Chloride as a
General -\n<-esthetic at the Pennsjlvania Hospital, with a
Report of Five Thousand Cases.
A Hospital for the Rockefeller Institute for Medical
Research. — The board of directors of this institution an-
nounce the receipt of a gift of $500,000 from Mr. John D.
Rockefeller, to be used for the erection and equipment of
a hospital in connection with the institute. The hospital
will be small compared with many others in the city, as its
purpose is not so much to provide accommodations for the
many as to furnish the means of studying the nature and
treatment of individual cases, and thus develop new and
more exact methods which may be applied elsewhere upon
a larger scale. The hospital will contain certain elaborate
provisions for the fresh air treatment of patients, and spe-
cial departments of hydrotherapy, and electrotherapeutics.
It will contain private rooms, as well as public wards, and a
special diet kitchen.
Personal. — Dr. Carl Beck, of New York, has been
decorated with the Order of the North Star by the King of
Sweden.
Dr. H. Sheridan Baketel. of New York, has been
awarded the honorary degree of Master of Arts by Hols-
ton College.
Dr. W. C. Jones, of Mobile. Ala., is registered at the
Philadelphia Polyclinic and College for Graduates in
Medicine.
Dr. Elmer E. Brown, of Philadelphia, has been ap-
pointed vice president of Temple L'niversity.
Dr. Robert Koch, the German bacteriologist, while in
Honolulu recently, on his trip around the world, visited the
famous leper settlement on the Island of Molokai. where
he went to investigate the method of treating leprosy.
Dr. G. A. De Santos Saxe. of New York, has been ap-
pointed instructor in genitourinary diseases at the New
York Postgraduate :Medical Sch(X)l and Hospital. Dr. Saxe
will be attached to the clinic of Dr. Ramon Guiteras, and
will deliver a course of lectures on genitourinarv diseases
during the summer months.
HID
NEIV yOKK MEDICAL JOURNAL
[New \uRi<
Medical Journal.
Vital Statistics of New York.— During the week end-
ing May 23, 1908, there were reported to the Department
of Health 1,463 deaths from all causes, as compared with
1,465 tor the precedmg week, and 1,447 for the correspond-
ing period in 1907. Of the total number of deaths 740 were
in Manhattan, 130 in the Bronx, 507 in Brooklyn, 57 in
tjuecns, and 29 in Richmond. The annual death rate in
rooo of population was 16.84 i'l Manhattan, 20.70 in the
iJron.x. 17.72 111 Brooklyn, 12.78 in Queens, 19.73 Rich-
mond. ,-uid in the whole city, 17.20. The total infant mor-
tality w as 3OO ; mider one year of age, 268; between one
and twi> years of age, 98. 'There were 156 still births.
Six iuindred and sixty-two marriages and 2,239 births were
recorded during the week.
Infectious Diseases in New York:
ll'c- arc- indebted to the lUireaii of Records of the De-
partment of Health for the folloi^'ing statement of nezv
cases and deaths reported for the tiw i^'eeks ending May
JO, i(jOcS:
, May J3. , , May 30. ,
Cases. Deaths. Cases. Deaths.
Tuberculosis puliimtialis 420 201 332 165
Diphtheria 397 37 .144 2,
.Measles 1..S55 33 i.-^3« 33
Scarlet fever 1,053 40 63.1 4A
Small|,..x
X'aric.lla 144 •• ^'3
Tyiihoiil fever 3-^ 4 32 12
Whooping cough 24 4 20 b
Cerebros|)inal meningitis 12 y y ^>
Tnlals 3.637 32« 2,829 297
Examination for Technical Assistant in Pharma-
cology.— The United States Civil Service Commission
announces an examination on July i, 190S. to secure eligi-
bles from winch to make certilication to lill a vacancy ui
the p.'silion of technical assistant, L)i\ision of Pharma-
cology, llygienic Lal)orUory, Public Health and Alarinc
Hospit.-il .Sci-Mce, at $150 a month, and vacancies re^iuiring
similar (|ualilicaliiins as they nia> occur in any branch of the
service. .Vpplic.ints nnist have received either the degree of
M. 1) n- Ph. I), from institutions of high standing, and
must M'hnm e\i<knce ol ahdUv to .lo research work. They
must ;iUo he ahh to read h'rench and (jerman. .\4)plicants
^houhl apiii.\ to tltc United States Civil Service Commis-
sion. Wasliingion, 1). C, for ai.)plication P'orm 304 and spe-
cial form, and for any further information regarding the
examination.
The Health of Pittsburgh.— During tin week ending
May 16, 1908, the following cases of tranMiii-MMe diseases
were repijrted to the Bureau of Health: t'hickeiipox, i
case, O deaths; typhoid fever, 2() easc•^. 2 deaths; scarlet
fe\er, 32 cases, 1 death; <lipluheri;i. o ca^es, o <leaths ;
measles, 20t cases, 7 deaths; pulmonarv tuberculosis, 21
cases, 13 deaths. The total <leaths for the week numbered
143. in an estimated nopulatioii of 403,3.^0, corresponding
to' an annual death r;ite of 18.43 111 i.ooo of population.
During the week ending Ma\ 23. lonS. the following cases
of transmissible diseases were reported: ( 'hickeiipox, .s
cases, o deaths; typhoid fewr. 2_| cases. 3 deaths; scarlet
fever. i8 cases, i death; dipluhena, 3 c:ims. o deaths;
measles. 248 ca.scs, 5 deaths; whooping cough, 10 cases, 2
deaths; pulmonary tuberculosis. ,54 cases, ,S (K:iths. The
tf)tal deaths for the w eek luimbeia <1 14,1, corresp mding lo
an annual death date of 18.43 in '-iio" "f po])ulation.
Philadelphia Bureau of Health Statistics. — During the
month of April, 1908, in the Div ision of .\1. I usin ction,
3,420 inspections were mad-, excbisivr -if schools; 520
fumigations were ordered; 28 cases were reft ria d for spc
cial diagnosis; 6,335 visits were made to school ; 00^ chil
dren were excluded from school: 215 cultures were taken;
114 injections of antitoxine were given; and nto persons
were vaccinated. In the Division of Vital Statistics, 2,042
deaths. 2.880 births, and 1,180 marria,ges were reported. In
the Division of Milk Inspection 9,789 ins])ections were made
of 2.^0.420 (|uarts of milk, of which 885 cpiarts were con-
demned. 'I'welve specimens were examined cliemically and
1,105 microscopically. Tn the Division of Meat and Cat-
tle Inspection 3,488 inspections were made: 94 were fomid
unsanitary: 102 pieces of dressed meats were condenmed,
and t,028 post mortem examinations were made, of which
72 were condemned. In the Division of Disinfection 4
fiinilKalifins were done for smallpox, 335 for scarlet fever,
T/X) for diphlluTia, 85 for tyiiboid fever. 218 for tubercu-
losis. 463 for miscellaneous diseases, and 46 schools were
fumiKalecl. In tlie RacteriojoKical Lahoratorv 950 cultures
were examined ff)r the presence of bacillus diphtherire; 376
specimens of blood were examined for the serum diagnosis
of typhoid fever; 1,105 specimens of milk were examined,
174 specimens of sputum were examined; 8 disinfection
tests were made; and 3,771,100 units of aiUhoxiiie were dis-
tributed. In the Chemical Laboratory 134 analyses were
made.
Maine Medical Association. — The fifty-sixth annual
meeting of this society will be held in the City Building,
Bangor, on Wednesday and Thursd.ay. June loth and iitn.
Sessions will be held at 9 a. 111. and at 2 p. 111. on both
days. A splendid programme has been arranged, which
includes eighteen papers on practical subjects by prominent
members of the medical profession. The annual oration
will be delivered on Thursday evening at 7 :30 o'clock by
Dr. Hobart .\mory Hare, of Philadelphia. His subject
will be Hold Fast to that which is Good in Diagnosis and
Therapeutics. After the oration the annual dinner will be
served at the Bangor House. The officers of the society,
are: President, Dr. B. B. Foster, of Portland: first vice
president. Dr. Alfred D. Sawyer, of Fort Fairfield: second
vice president, Dr. O. C. S. Davis, of Augusta ; seeretar\ ,
Dr. Walter E. Tobie, of Portland; treasurer, Dr .Arthur
S. Gilson, of Portland.
The Massachusetts Medical Society. — The one hun-
dred and twenty-seventh annual meeting of this society
will be held in the Mechanics Building. Boston, on Tues-
day and Wednesday, June 9th and lotli. Tuesday after-
noon will be devoted to the reading of scientific papers,
and on Tuesday evening the Shaituck lecture w ill be deliv-
ered m Paul Revere Hall. On Wednesdav inorning the
annual oration will be given, and at i p. 111. the annual
dinner will be served. TlKre will be pathological .and com-
mercial exliil>its on fjoth dav s, and the Soeietv for the Re-
lief and Control of Tuberculosis will have a large exhibi-
tion of appliances usefl ir. the oiitdc;)nr treatment of
tuberculosis. The District Committee for the Prevention
and Control of Ttilierculosis will meet in Paul Revere Hall
at 3 p. ni. on Tuesday. .Additional information regard-
ing the meeting may he itbiaiiied by raldressing Dr. George
S. C. Badger, cliairniaii of the committee of arrangements,
48 Hereford Street, F.oston.
The Northwestern Medical Society of Philadelphia. —
The members of this sni-ietv held a i,liiiic:il eonteri_iice on
the evening of June 1st. Dr. S. W .\'e\\ in;i\ , r read a
paper entitled Defective Visi(,in and thv Mentally Subiior-
iiial Child. Dr. Wendell Reber opened ilu disctissi, ,n. Di.
J. O. .Arnold reported a case of rectirreiit [isi ii<Iopyosis.
Dr. Nathan McMaiius rep<jrted twd iiiti restiiii,; cast. -, of
tvphoid fever. Dr. William AlcKe.ige reported :i e.isc of
tonsillitis followed bv sudden de;illi. Dr. I-.. 1. W . (dvcii
read a p:i|ier (iititled A Ple:i for a .Morr Ld.rr.d Diet in
Tvnlioid I'.-vrr. Dr. C. S, r.,arnes ]iresfnted a ]ireliminarv
reiiort of a rasr of hv drophobia. Dr. H II 11, Don read a
pa]icr oil All L'luisnal Series of Hi]i Joint Diseases in One
Family. Dr. Carl Lee l'\lt exhibited sdine interesting nose
and throat cases. Dr. Luther C. Peter exhiltited patients
shovviiig the res'ill of C'almelt'e oplithalmoreaelion, and
patients with iiiterestiii',; eve sym|)toms in multiple sclerosis
:md hysteria. Dr. J. I liompson Scbell exhibited a patient
w ith ;i dislocated tnbercnl. >ns shoulder, and reported a case
of C;esarean section with a doulile indication.
Society Meetings for the Coming Week:
.Mo.\'i>.\v, June <S'//;.— .\e\v York .Academy of Medicine
(Section in Neurology and Psychiatry): Society of
Medical Jurisprudence, New York: New York Oph-
tlialinological Society; Corning, N. Y., Medical As-
soci;iiion; W.ateibury, Conn.. Medical .Association.
I ricsnw, !\i)\e <)lli. — New York Academy of Medicine
(Section in Public Health): Medical Society of the
County of Schenectady. N. Y. : Practitioners" Club of
Jersey City, N. J. : Medical Society of the County of
Rensselaer, N. Y. ; Buffalo .Academy of Medicine (Sec-
tion in Medicine).
Wkdnesd.w, June joth. — New York Pathological Society :
Medical Society of the Borough of the Bronx: Brook-
lyn Medical and Pharmaceutical Association ; Rich-
mond County. N. Y., Medical Society.
TiifR.sD.w, June nth. — New York .Academv of Medicini
("Section in P;ediatrics) : Brooklyn Pathological So
c ietv (annual) : RIackwell Medical Societv of Roches-
ter.'N. Y.
I'"i<ii).\v. June j.?tli. — New York .Academy of Medicine
(Section in Otology) : F.astcrn Medical Society of the
City of .N^ew York.
June 6, 1908.]
PITH OF CURREXT LITERATURE.
III7
|itfe of Cnmnt f iUraturt
THE BOSTON MEDICAL AND SURGICAL JOURNAL,
.l/(7.\' j8. 1908.
1. The Hospital in Relation to the Community.
By Abxer Post.
2. A Case of Intravesical Cyst of the Ureter: Dilatation
of the Ureter with very Slight Dilatation of the
Renal Pelvis and Containing Twenty-eight Movable
Calculi ; Bactcriuria ; Alkalmuria ; Phosphaturia.
By E. A. CoDM.\x.
THE JOURNAL OF THE AMERICAN M EDICAL ASSOCIATION .
May 30. IQOS.
1. Incomplete ^Ivxoedema (Hypothyreoidea).
By Arthur R. Elliott.
2. An Analysis of Five Himdred Cases of Spinal Infan-
tile Paralysis,
Bv Jo.sEPH Collins and Theodore H. Romeiser.
3. Spondylitis Deformans : With Clinical Reports of Five
Cases, Bv Theodore Diller and George Wright.
4. A Visit to Stirling Asylum. By Jult.^ C. Uxthrop.
5. How a Great State is Handling the Tuberculosis Prob-
lem, By Albert Philip Fr.xxci.ve.
6. The White Man in the Tropics, By C. L. G. Axdekson.
7. Use of Gonococcic Vaccine in Twenty-six Patients,
By Edg.\r G. B.vllexger.
8. Beriberi without a Definite Rice Factor,
By JoHX Xivisox Force.
9. Hypernephroma of the Kidnev,
By Augl-stl s A. Ephxek.
I. Incomplete Myxoedema (Hypothyreoidea).
— Elliott says that the diagnosis of a well marked,
fully developed case of myxoedema is readily made
owing to the striking character of the symptoms.
The appearance of the patient is so peculiar that the
disease can be recognized at a glance, it is quite
otherwise when the disease is encountered in its
early stages or in atypical form. Slight evidences
of the condition may readily be overlooked. The
profound nutritional changes, which are so striking
in cases of more complete development, are absent,
or present only in modified degree. Most of the
cases of hypothyreoidea are encountered in women
at, or approaching, the climacteric, and the symp-
toms are usually ascriljed to the menopause. The
predominance of myxa?dematous states in the female
is well attested by statistics, the ratio being 7 to i.
This undoubtedly is due in great measure to the re-
peated hyperfunction and irritation of the thyreoid
resulting from the vicissitudes of woman's repro-
ductive life. A history of hyperthyreoidea in earlier
life is not without value from the a?tiological stand-
point. Hun and Prudden point out tliat the great
majority of women who suf¥er from m>x(Dedcma
have borne children, and onlvasmall proportion are
unmarried. This may point to a secondary atrophy
following puerperal hyperthyreoidea. In no other
way can the great dispro])()rtion in frequency be-
twen the two sexes be explained than by interpret-
ing many of the cases in the female as due to sec-
ondary atrophy induced by the thyreoid hyperfunc-
tion of pregnancy and lactation. A few cases both
of the fully developed and modified forms of myxoe-
dema have been reported in which the apparent
starting point was an acute infection. It is very
doubtful whether such cases are true instances of
postinfective myxoedema, although such a possibil-
ity cannot be denied. It is more probable that the
disease had previously existed in a latent form and
that the acute infective toxaemia provoked an ex-
acerbation. H>-poth\reoidea and myxoedema may
develop following (iraves's disease, sometimes years
afterward. Glandular hyperaemia and hyperfunc-
tion have here passed over into a state of secondary
atrophy with hypofunction.
2. Spinal infantile Paralysis. — Collins and
Romeiser remark that the epidemic occurrence of
anterior poliomyelitis i* firmly established. The
dependence of the disease on infection may there-
fore be legitimately assumed. The epidemic that
prevailed in Xew York in the summer and autumn
of 1907 afforded the authors unusual opportunity to
studv the disease, and present in tabulated form the
analvsis of 327 cases from that epidemic and 173
cases observed previous to that time. The figures
relative to the age arc very striking : 95 per cent, of
the patients were under 3 years, 70 per cent, were
between i and 3 -. e.irs, and 33 per cent, during the
second vear. The vulnerable age is, therefore, from
I to 3 years. In regard to paralysis that accompa-
nies lesion of the epidemic cases of 1907, it was
most frequently of the lumbar enlargement, next
often of the cervical and dorsal cord, but not infre-
quently bulbar. There were all possible degrees and
combinations. Two isolated facial ""nuclear" para-
lyses were observed during the height of the epi-
demic. Paralysis of the diaphragm was observed in
one instance only, accompanying forced inspiratory
efforts of the intercostal muscles. Xo definite or
constant relation was observed between the degree
or duration of fever and the severity or extent of
the paralysis, but it was distinctly made out that in
all quadriplegias there had been a distinct febrile
stage, whereas it was chiefly in the monoplegias
that a history of ""no fever" or "slight" was ob-
tained. Trauma, such as a fall, or physical exhaus-
tion is sometimes, though not often, a definite ante-
cedent. One child fell out of the window. An-
other, two years old, walked the unusual distance of
three miles just previous to the onset of the fever,
and in several instances there was a history of pro-
found fatigue. In general, physical shock or over-
exertion plays a minor role in the setiology and is
at most a predisposing factor. OccasionaH\- a fall
w hile walking is the first indication of a preexistent
paralysis. A striking feature is the fact that bv far
the greater number of children were in the best of
health at the time of onset, many of them without
previous illness of any moment. In regard to the
onset it may be said that the disease develops with
and without warning, but usually with vomiting and
fever. In many instances the child had gone to
sleep apparently well. ^Sometimes the paralysis was
evident the next morning, but usually from two to
four days afterward. In few cases only was it noted
that the fever continued after the appearance of the
paralysis. As the somnolence, pain, and hyperaes-
thesia (especially marked on active or passive move-
ments) are accompanied in many cases by immobil-
ity, it is often days and sometimes a week before the
paralysis is noted. The definite time and order of
onset and even initial distribution of the paralysis is
not often determinable with the exactness which the
statistician requires for reliable conclusions. Both
the ascending and the descending Landry types of
paralysis were observed in a few instances.
iii8
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
3. Spondylitis Deformans. — Diller and Wright
sav that the jetiology of spondyHtis deformans has
not yet been fully determined. The disease is about
three times as common in men as in women, and it
occurs most frequently between the ages of twenty -
five and forty-five. Habits involving exposure to
changes in temperature, hard work, and poor hy-
giene generally are important predisposing causes.
Heredity and trauma appear to play a role in some
cases. Finally it seems probable that some toxic or
infectious agent acts as an important factor in many
cases. As regards the symptoms, these are refera-
ble, as would be expected, to the spine, and to other
joints involved in the same osteoarthritic process, to
the spinal nerves. The onset is gradual and insidi-
ous, ver^• rarely acute, though this may occur. The
first sxmptoms noted are pain and stiffness in the
spine, m the earHer stages, most noticeable after a
period of rest, as when the individual is getting out
of bed or out of a chair. At times this may be felt
only on nodding the head or on stooping. The pain
mav be in the spine itself or referred to the nerve
distribution, accompanied also by anesthesias, par-
jesthcsias, hvpera^sthesias, and trophic disturbances.
Pains early in the disease are characteristic ; later
as movement in the spine is limited or lost, and there
has been a contraction and ossification of the exosto-
sis, pressure on the nerve roots is relieved and pain
may practically disappear. Wit): the gradual exten-
sion of the process, movement in the spine becomes
more and more limited and finally nil, so that the
sufferer is unable to move his spine at all or even
nod his head, a condition well meriting the oft ap-
plied term "poker back." Depending on the seat of
onset this stiffness may be limited to the cervical,
thoracic, or lumbar region, and progress no further.
Beside the spine, any other joints may be involved,
more especially those of the shoulder and pelvic gir-
dle. The ribs by reason of ossification of the costo-
vertebral articulations may lose their normal range
of motion, which is noticed early by the patient on
attempting a deep inspiration. Oi the treatment the
authors observe that once the diagnosis is made they
believe that the patient should be put into the hands
of a competent orthopaedic surgeon. The patient
needs most painstaking care, both as to his general
and local condition. The general health should be
improved to the highest possible degree and tlie
faulty action of any organ in the body corrected.
Any possible source of infection should be removed,
and to this end a careful examination should be
made of the nasopharynx, the gastrointestinal, and
genitourinary tracts, and the skin. On account of
the danger of upsetting the stomach, there is little
place for drugs. Tonics, fresh air, sunlight, good
nutritious food, rest, and restfulness should com-
prise the armamentarium. As regards the local
treatment, in the early stages some method of fixa-
tion for the spine should be used, cither of plaster
or steel. This prevents the irritation of the diseased
vertebrae and relieves pain and stiffness. Later, as
the process has subsided, passive motion and mas-
sage may be used with benefit. . The spine in old
ca.ses should not be fixed, for here our object should
be to ward off by massage and movements the tend-
ency to complete ankylosis. The authors conclude
that an infection of some kind, apparent or hidden.
plays an important role in the aetiology of this dis-
ease. Except for clinical purposes, we are not yet
warranted in classifying this disease into two sepa-
rate and distinct types. The probability is that
spondylitis deformans is not a distinct entity, but a
clinical term covering many perhaps aetiologically
and pathologically distinct diseases in which spinal
stiffness is the most prominent symptom. Proper
treatment in early cases, as a rule, brings good re-
sults ; in later cases it relieves distressing symptoms.
There is need of clinical records covering the subse-
quent history of these cases, for further develop-
ments may throw new light on the aetiology and ex-
act diagnosis. There is great need of additional
evidence from the postmortem table.
MEDICAL RECORD.
May 30, 1908.
1. Melsena Neonatorum, with Report of a Case Cured by
Transfusion, By Samuel W. Lambert.
2. The Distinctive Diagnosis of Meningococcus Cerebro-
spinal Meningitis from Other Types of Cerebrospinal
Meningitis, By Henry W. Berg.
3. A Plan for Reducing Infant Mortality in New York
City. By Wilbur C. Phillips.
4. The Correlation of Eyestrain and the Functional Neu-
roses. By Homer E. Smith.
5. Disturbances of Gastric Secretion ; a Practical Study,
By M. Gross.
6. Drainage of Wounds, By R. W. Kxox.
7. Some Observations on the Ophthalmotuberculin Reac-
tion, By Theodore B. Sachs.
I. Melaena Neonatorum. — Lambert reports
such a case. The 1)aby was a girl, born of healthy
parents. Subcutaneous bleeding extended down the
neck over the muscles, across the median line to the
other ear across the coronal suture over the frontal
bone, and forward tmder the left ear to the angle of
the jaw. The bleeding from the nose was continti-
ous and quite profuse. A dark meconium stool
gave a very positive reaction for blood, but the urine
was of normal color. The baby was of waxen pal-
lor. The diagnosis of melaena was made, and treat-
ment instituted upon the theory of its being an in-
testinal infection. One dose of thirty minims of
castor oil and two grain doses of calcium lactate
every two hours was given during the night. The
scalp haematoma increased in size and tenseness, and
the paleness of the skin increased, but the tempera-
ture gradually fell from the maximimi of the attack
at 104.4° F.till it readied 97.4° F.,the nasal bleeding
became less constant, and the baby nursed regulaily.
Adrenalin was tried in the nose, but without eft'cct.
It was decided to attempt a direct transfusion of
blood from the father of the infant by end to end
anastomosis of the two bloodvessels after the man-
ner devised by Dr. Carrel, of the Rockefeller Insti-
tute. This was done. The right popliteal vein of
the baby was sutured to the left radial artery of the
child's father, without anaesthetic to either patient,
and enough blood was allowed to flow into the baby
to change her skin from a pale transparent white-
ness to a brilliant red color. No measure of the
amount of blood was possible, but the evidences of a
sufficient quantity were manifold. She began to
cry lustily and to struggle against the bandages,
which held her strapped to an ironing board. The
wound in the leg up to this time had oozed a slight
amotint of pale, watcrv blood, which did not clot
well. It began to bleed freely and the blood prompt-
Tune 6, 1908.]
PITH OF CURRENT LITERATURE.
1119
Iv clotted. The nosebleed stopped instantly. The
pulse became full and strong and slowed down, and
the respirations were deep and full. As soon as the ■
wound was sutured and dressed, the bab}- was fed
an ounce of milk, which she took ravenously and
retained, and immediately went to sleep. Conva-
lescence from the operation was uninterrupted ex-
cept for a slight infection of the wound. There was
no evidence of haemolytic action at any time, and all
the symptoms of melaena ceased at once. The haema-
toma' w^as absorbed rapidly, except for a slight dis-
coloration of the upper lid of the right eye. The
stools became of normal character two days after
the operation. The wound is healed, and the child
appears to be a normal child of its age to-day.
2. Distinctive Diagnosis of Meningococcus
Cerebrospinal Meningitis from Other Types of
Cerebrospinal Meningitis. — Berg observes that
in a general way the microscopic appearance of the
fluid yields some indications as to the bacteriological
character of the meningeal process. Thus a puru-
lent turbid fluid speaks for meningococcus cerebro-
spinal meningitis; a comparatively limpid, clear
fluid containing flocculi or fibrinous shreds or a
slender white coagulated column, branching out at
the top and base like a slender pillar supporting a
capital in a test tube half filled with clear cerebro-
spinal fluid indicates tuberculous meningitis. The
diagnosis resting upon such macroscopic appear-
ances, however, rests upon but a slender reed, and
to clinch it the bacteria should be found by staining
or culture. In almost all cases of cerebrospinal
meningitis, as distinguished from toxic pseudomen-
ingitis, the normal tension of the fluid in the sub-
arachnoid space is increased, and the fluid issues
through the trocar under increased pressure ; while
this rule is not uniform, it is safe to state that in-
creased pressure indicates an abnormal and not a
sterile cerebrospinal fluid. For the purpose of bac-
teriological diagnosis of the disease during life, the
meningococcus must be sought for in the cerebro-
spinal fluid obtained by lumbar puncture. It can be
demonstrated by culture and microscopically. Cul-
tures made from fluid obtained by lumbar puncture
early in the disease will give positive results in a
very large proportion of cases. Whether the ag-
glutinating reaction will be found to be sufficiently
reliable and exclusive to use the method for diag-
nostic purposes after the manner of the Widal reac-
tion in typhoid fever, remains to be seen. The
diplococcus can also be found in the nasal discharges
of patients suflfering from the disease, both mi:ro-
scopically and by culture. If lumbar puncture is
done early in the disease, a cloudy fluid will be ob-
tained, containing pus cells in which the organisms
are found ; later in the disease, w'ith a clearer cere-
brospinal fluid, the result may be negative. Diplo-
cocci are more apt to be found in fluid obtained dur-
ing the acute stage or during an exacerbation.
When the case is one of toxic pseudomeningitis, the
fluid obtained by lumbar puncture is sterile and
clear. This, then, is the one reliable and decisive
factor in the distinctive diagnosis of these two con-
ditions. When, however, a cerebrospinal meningi-
tis of the meningococcus type is to be distinguished
from a cerebrospinal meningitis of other bacterio-
logical types mentioned, subjective and objective,
symptomatology is frequently not a decisive aid in
the differential diagnosis. In cerebrospinal menin-
gitis of the tuberculous type, there is generally a
longer prodromal period ; there is no leucocytosis
unless suppurating processes are complicating the
tuberculous meningitis ; there are more frequently
signs of chronic basilar meningitis, resulting in para-
lysis of the third, fourth, seventh, and bulbar nerves
in tuberculous meningitis, while in meningococcus
meningitis the opisthotonos is apt to be more
marked and more frequent, and yet after all in these
various types of meningitis the conclusive distin-
guishing factor will be the finding of the bacterio-
logical organism which is the causative factor in the
given case of meningitis.
4. The Correlation of Eyestrain and the
Functional Neuroses. — Smith says that the ocu-
lar conditions which give rise to eyestrain may be
refractional, accommodative, or muscular. The re-
sult is loss of neuricity. The effects are remote and
reflex, and may be expended upon any organ, group
of organs, the nervous system as a whole, or its
separate division's. It is the little refractional errors
which give rise to the greatest trouble : poor vision
and eyestrain are not concomitant conditions, but
exactly the reverse. It is imperative to have the eyes
of all children of school age examined under atro-
pine ; not only may health and comfort be conserved,
but their whole future may rest upon this simple
thing. Refractional errors of high degree should
be corrected, not because of any reflex disturbances,
but to save the eyes from disease and to give their
possessor better vision. The investigation of all
obscure nervous phenomena should begin with the
eyes ; often it will be necessary to go no further.
Typical sick headache is pathognomonic of ey e-
strain; if it is not cured in 99 per cent, it is the
fault of the refractionist.
BRITISH MEDICAL JOURNAL.
May 16, 1908.
1. The Anatomy of the Pancreas in Relation to Its Dis-
eases (Banks Lecture), By A. W. M. Robsox.
2. Fracture of the Patella Treated by Mobilising the
Lower Fragment, By J. L. Thom.\s.
3. A Case of Ectopic Gestation with Unusually Early
Symptoms, By E. A. Searle.
4. A Method of Obtaining Rapid Healing of Acute
Abscesses, By J. Phillips.
5. T'-i.mor of the Orbit Removed without Enucleation
and without Loss of Sight, By G. Apthomas.
6. Appendicitis Complicated by Hepatic Abscesses,
By G. P. Bletchlev.
7. The Influence of Pregnancy upon Certain Medical
Diseases and of Certain Medical Diseases upon
Pregnancy (Goulstonian Lectures, III),
By H. French.
I. Diseases of the Pancreas. — Robson states
that pathological changes in the pancreas may orig-
inate in any of its constituent parts. Inflammation
starting in the ducts is at first of a catarrhal nature
analogous to cholangitis, with which it is frequently
associated. If the infective catarrhal condition is
acute in character it may go on to diffuse suppu-
rative catarrh or to a localized suppuration ending
in abscess. If the infection is less virulent, it may
not assume the more immediately dangerous suppu-
rative form : but a chronic inflammation may extend
to the parenchyma of the gland, leading to an in-
crease of the connective tissue, eventually resulting
in a condition resembling that seen in cirrhosis of
U20 • Pll'H OF CURRENT LITERATURE.
the liver. An increase of fibrous tissue may occur
primarily around the bloodvessels as the result of
chanj^vs in them or in their contents, and give rise to
a cirrhotic c< mdition. In some instances it is proba-
ble that, as a result of toxic substances circulating in
the bl(j(xl, the islands of Langerhans become first
aflfected. as in amyloid disease of the gland. On the
other hand, the acute infective parenchymatous in-
flammations known as acute haemorrhagic, suppu-
rative, or gangrenous pancreatitis, give rise to the
most terrible and rapidly fatal diseases that the sur-
geon can be called on to treat. The various inflam-
matory conditions may be classified as follows: i.
Catarrhal inflammations, (a) Simple catarrh, acute
and chronic, (b) Suppurative catarrh, (c) Pancreo-
lithic catarrh. 2. [Parenchymatous inflammations.
AcHti\ (a) I hemorrhagic pancreatitis, (i) Ultra-
acute, in which the haemorrhage precedes the inflam-
mation, the bleeding being profuse and within and
outside the gland. (2) Acute, in which inflam-
mation precedes the hjemorrhage, which is less pro-
fuse and is distributed in patches throughout the
gland, ( b) Gangrenous pancreatitis, (c) Suppu-
rative ]iancreatitis (diffuse suppuration ) . Subacute.
Abscess of the pancreas (not diffuse suppuration).
Chronic, (a) Interstitial pancreatitis, (i) Inter-
lobular. (2) Interacinar. (b) Cirrhosis of the pan-
creas. Pancreatic calculi are rare and are apparent-
ly the result of catarrh of the ducts with stagnation
of secretion, and instead of calculi being formed the
ducts may be actually lined with calcareous material.
The presence of lime salts renders pancreatic calculi
opaque to the x rays, a valuable point in diagnosis.
The ultimate effect of pancreatic lithiasis is toward
complete destruction of the gland by a process of
interstitial pancreatitis ending in fibrosis. Surgery
offers a reasonable chance of cure if operation is
done early. • Cancer of the pancreas is much more
common than was previously supposed ; formerly
secondary growths in the liver were thought to be
primary. In most cases cancer of the pancreas is
painless, especially in its early stages. When the
body or tail of the gland is affected the only evi-
dence of disease may be failure of health and loss of
strength, together with signs of disturbed metabo-
lism, as revealed by examinations of the faeces and
urine ; for obstruction of the ducts by a neoplasm
brings about chronic inflammatory changes in the
gland beyond the obstruction. When the head of
the gland is affected the common bile duct becomes
obstructed, and jaundice, rapidly becoming inten.se
and absolute, manifests itself, producing character-
istic signs of the disease — rapid loss of flesh and
jaimdice of painless onset, with distention of the
gallbladder — conditions which may be simulated b\-
chronic interstitial pancreatitis. In the latter case
the pancreatic reaction in the urine will be of assist-
ance in diagnosis. Cancer or sarcoma of the head of
the gland is necessarily rapidly fatal, and incapable
of marked relief. Even palliative operations of
short circuiting the obstruction by cholecy.stenteros-
tomy are peculiarly fatal in malignant cases.
4. Treatment of Acute Abscesses. — Phillips
contends that in almost every case of acute abscess
there neerl not be left any source of irritation to con-
tinue to act for a considerable time, and that, unless
field bi.ne or some other irremovable irritant is pres-
LNew York
Medic.iiL Journal.
ent, something not unlike primary union is obtained.
Method. I. Cleanse the skin as in operating on ster-
ile tissues. 2. Make an incision long enough to per-
mit of the pus being freely evacuated and the pyo-
genic membrane rubbed clean and smooth with
gauze wrapped around the finger. 3. Having emp-
tied the abscess cavity as completely as possible, pack
it tightly with gauze (i to I, GOD mercury bichloride
gauze, dry) and apply a wool dressing and bandage
as firmly as possible. 4. At the end of forty-eight
hours remove the packing and dress the wound as if
it were a simple incision ; that is, do not pack or
drain at all, but simply fix a gauze and wool dressing
firmly in place with a bandage. This dressing will
require changing only once in three or four da\ s un-
til the incision is soundly healed, and it will be found
that the sides of the abscess cavity unite promptly
and that there is no outpouring of pus from it.
From the time when the packing is removed it is
practically a simple incised wound that is being
treated. The writer asserts for this method that it
results in rapid healing ; that the constitutional symp-
toms are gotten rid of almost at once ; that as the
dressing requires doing so seldom the doctor can do
it himself and so avoid the risk of a secondary mixed
infection ; and, finally, it effects quite a marked econ-
omy in dressings.
LANCET,
May 16, igoS.
1. The Connective Tissue in Carcinoma and in Certain
Inflammatory States that Precede Its Onset (Hun-
terian Lectures, I), By V. Bonney.
2. The Influence of Pregnancy upon Certain Medical
Diseases and of Certain Medical Diseases upon
Pregnancy (Goulstonian Lectures, III),
By H. French.
3. Juvenile Tabes Dorsalis : Notes of Five Cases,
By S. Stephenson.
4. A New Method of Restoring the Continuity of the
Bo\\.cI in Cases of Excision of a Growth Low Down
in the Sigmoid Flexure, By J. P. L. Mummery.
5. The Diagnosis of Perforating and of Chronic Duo-
denal Ulcer, By Sir J. F. H. Broadbext.
6. A Method of Administering Solids in Cases of Gas-
trostomy, By A. E. Mayl.\rd.
7. The Electrical Treatment of Atonic Conditions of the
Digestive System. By R. Morton.
8. Note on Two Cases of Chronic Dysentery Treated with
Forster's Antidysenteric Vaccine,
By E. A. R. Newman.
g. Note on a Case of Functional Paraplegia with .Asso-
ciated Paralysis of the Bladder. By A. Rose.
I. Connective Tissue and Cancer.^Bonney in
the first of his Hunterian lectures on connective tis-
sue and cancer makes a general survey of the con-
nective tissue changes in primary carcinomata.
Lymphocytes are a conspicuous feature of the cell
proliferation surrounding an early carcinoma, being
specially aggregated at the tips of the epithelial pro-
cesses. Their origin is very difficult to decide, and
they certainly take no part in the formation of the
.stroma of the growth. There is no increase in the
lymphocytes in the blood until a late stage of the
(iisease. Plasma cells are the most .striking objects
seen in the connective tisue around a cancer. They
are rarely in contact with the epithelial cells. The
writer thinks they originate from certain elongated
small nuclei, found in resting connective tissue. It
is probable that the plasma cells, together with the
fixed coimective tissue cells, constitute the frame-
work of the stroma on which a collagenous deposit
June 6, 1908.] PITH OF CURRENT LITERATURE.
subsequently occurs. Endothelial cells (those lining-
blood and lymph vessels) play but a small part in
carcinoma. Polynuclear leucocytes and giant cells
are also only slightly in evidence. Elastic tissue dis-
appears in all areas of connective tissue cell prolifer-
ation, whether this is associated with a definite in-
flammatory state or with the connective tissue
changes that are going on in a carcinomatous area.
This disappearance is permanent — i. e., there is no
regeneration of the elastic fibres when the cell pro-
liferation has departed and fibrosis has supervened.
This applies equally to the older parts of the stroma
of primary carcinoma and the fibrotic stage of
chronic granulomatous inflammation. In certain
conditions, however, of chronic irritation which fall
short of producing cell proliferation in the connect-
ive tissues, yellow elastic tissue may be increased by
the deposition of a granular elastin around the old
fibres. This is seen in some simple irritative states
as well as in isolated areas in the stroma of carci-
noma.
2. Pregnancy and Certain Medical Diseases.
— French, in the third of his Goulstonian lectures,
takes up the influence of pregnancy on the com-
moner fevers. Generally speaking, the pregnant
state seems to confer some degree of immunit}-. the
reverse being true of the puerperium. Typhoid fe-
ver may begin at any period of the pregnancy, and
its course is precisely similar to its course in other
cases. Pregnancy has no influence on the severit}
of the illness, nor upon the prognosis as regards the
mother. Premature ending of the pregnancy may
occur at any time, this depending more on the month
of the pregnancy than on the day of the fever. The
mother seems to suflfer very little from labor ; the
additional strain does not make her worse, and she
experiences considerable relief. The uterus involutes
just as usual, and the fever runs its ordinary course.
Turning now to the foetus, it has been definitely
shown that typhoid bacilli can cross the placenta,
reach the child, and be recovered from the child's
tissues after birth. It is not yet known whether the
child produces its own agglutinins or receives them
from the mother. In a few cases definite ulceration
of the fcetal Peyer's patches has been noted, but such
macroscopic lesions are quite the exception. It is
impossible to say if the child will have a natural im-
munity to typhoid fever if it lives, but there is con-
siderable evidence that such a child will suller in
other ways. If the child's life is a material consid-
eration it is very risky to allow it to remain in utero
beyond three weeks from the beginning of the ty-
phoid fever. With each week of the fever the
chances that the child will become infected with ty-
phoid bacilli rapidly increase. Smallpox is trans-
missible from the mother to the fcetus. The degree
to which the latter is aft'ected is very variable. The
stage of the eruption in the child may be almost
identical with that in the mother. The eruption goes
through a pustular stage in the unborn child just as
it does in the adult, and the lesions are even larger.
The duration of the eruption on the skin of the child
may be much longer than usual. The father may
have smallpox at the time of conception, the mother
may show no sign of the disease, and yet the child
may have it in utero. Cases of foetal scarlet fever,
measles, mumps, whooping cough, cholera, malaria.
1 121
and even cerebrospinal meningitis have been record-
ed. Diphtheria is particularly virulent in pregnant
women. The laryngeal form of the disease is very
common, and the mortality is great if antitoxine is
not used. Plague is no worse in pregnancy than in
ordinary cases, except that it usually terminates the
pregnancy. If lobar pneumonia develops early in
the pregnancy, the prognosis is about the same as
regards the mother as for other patients of the same
age. But if the pneumonia develops during the sec-
ond half of pregnancy, the probability is that the lat-
ter will be terminated in two thirds of the cases, and
the chances of the mother surviving will be greatly
diminished. Diabetes mellitus is by no means incom-
patible with pregnancy, and there is seldom any rea-
son for interference.
5. Duodenal Ulcer. — ^ Broadbent states that
duodenal ulcer may be distinguished from gastric
ulcer by the seat and character of the pain, the in-
definite relation of both pain and vomiting when this
occurs to ingestion of food, and the absence of h^em-
atemesis. Mel?ena in association with pain in the
right hypochondriac region is very significant. A
history of chronic indigestion occurring after middle
life may suggest malignant disease of the stomach,
but the chronicity and intermittency of the symp-
toms which may have lasted some years, and absence
of severe emaciation and cachexia, usually enable a
correct diagnosis to be made. In doubtful cases a
test meal is of great value ; in duodenal ulcer there
is often excess and seldom absence of free hydro-
chloric acid. In all cases, before considering opera-
tion, care should be taken to exclude the possibility
of gastric crises from locomotor ataxia.
LA PRESSE MEDICALE
April 29, 1908.
1. Prophylaxis of Xeryous Diseases of the Dietetic Foun-
dation, By P. LoNDE.
2. Epidemic of Paratyplioid Fever,
By Collin and L. Fortine.\u.
1. Prophylaxis of Nervous Diseases. — Londe
declares that there are four sorts of fetiological fac-
tors in the production of mental and nervous dis-
eases: I, Heredity : 2. accidental causes, including
emotions. traumatisn-iS, physical and mtntal over-
work: 3, specific diseases: and 4, digestive troubles
or non-specific diseases. In the fourth class of cases,
which includes a large variety of different diseases,
attention to the diet has proved of marked prophy-
lactic value.
2. Paratyphoid Fever. — Collin and Fortineau
use the term paratyphoid fever to denote an infec-
tion distinct from that of enteric fever, produced by
paratyphcbacilli.
LA SEMAINE MEDICALE.
April 29, 190S.
Pahidal Addison's Disease.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT
April 28, 1908.
1. Parallel Physiological Experiments on Wen and Ani-
mals, By Weber.
2. New Points of View in the Treatment of Purulent
Processes, By jMuller and Peiser.
3. Concerning Recent Efforts Toward the Improvement
and Sirriplification of Disinfection of the Skin.
By yox Bruxx.
1122
PITH OF CURRENT LITERATURE.
4. The Sjniptomatology and .Etiology of Barlow's Dis-
ease, By EssER.
5. The Question of Metatyphus, By Nieter.
6. Dietetic Nutrient Preparations Before the Forum of
the Specific Precipitation, By Horiuchi.
7. The Meat Juice "Pure," By Gerei.
8. 1 he Treatment of Perityphlitis, By Albu.
9. The (Juestion of Sanatorium Treatment and the Indi-
cation:, for the Same, By Frankexburger.
10. A Case of Poisoning After the Use of Thiosinamin,
By Grosse.
11. The Direct Inspection of the Mucous Membrane of the
Stomach, By Riehl.
12. A New Test for the Comparison of Sources of Actinic
Rays, By Axmann.
13. Technique of X Ray Photography, By Daviusohn.
14. A Simple Aid to Comfort During Labor,
By Herzberg.
15. An Improved Hypodennatic Syringe, By Faulhaber.
16. Concerning Karell's Treatment of Serious Circulatory
Disturbances and the Treatment of Obesity (Con-
cluded), By Jacob.
17. The Genesis of Gallstones, By Bacmeister.
18. Obituary of Professor Gustav von Hiifner,
By Burker.
2. Treatment of Purulent Processes. — ]\Iuller
deals witli the theoretical and experimental part of
the subject of controlling purulent processes by the
addition of large quantities of blood serum and
fluids rich in antiferments to the focus of suppura-
tion, while Peiser speaks of the clinical aspects of
the same subject. They allege that this method is
a simple, effective increase of the physiological pro-
tective powers of the organism.
5. The Question of Metatyphus. — Nieter is
convinced by the result of his researches that the
typhus and metatyphus bacilli that have been de-
scribed are accidental and that there is no real dif-
ference between them.
8. Treatment of Perityphlitis. — Albu deals
with the medical treatment of acute perityphlitis,
and then of the chronic form. In the treatment of
acute perityplilitis he considers that, in the hands of
the exiarienced pliysician, opium is certainly less
dangemus than castor oil, but the traditional dogma
of the textbooks that perityphlitis should be treated
with opium he considers obsolete.
9. Sanatorium Treatment. — • Frankenburger
refers entirely to the treatment of tuberculosis in
this paper.
II. Direct Inspection of the Mucous Mem-
brane of the Stomach. — Riehl remarks that, by
means of the gastroscope, with the stomach filled
with water, it is possible : 1 , To see clearlv the
greater part of the mucous membrane of the healthy
stomach, and study the normal coloring, the folds,
and the movements of the walls of the stomacli :
2, to illuminate the greater part of the lesser curva-
ture and the region of the pylorus ; and 3, to ob-
.servc the appearance of cancer, which, in a carci-
noma of the lesser curvature, presents a greenish
surface. An examination of the stomach should be
preceded by an application of a ten per cent, solu-
tion of cocaine to the throat.
16. Karell's Treatment. — Jacob, after report-
ing a series of cases of obesity treated in the way
described last week, says that this method is contra-
indicated only in cases in which there is degenera-
tion of the cardiac muscle, whether from coronary
sclerosis, arteriosclerosis of the bulb of the aorta, or
chronic inflammatory processes in the cardiac
muscle, or fat, so far advanced that even under the
most favorable conditions the heart cannot recover.
BERLINER KLINISCHE WOCHENSCHRIFT.
April 27, 1908.
I. Pericardial Friction Sounds with Synechia of the Peri-
cardium, By Erich Richter.
-'. Concerning the Results of Modern Investigations into
Sympathetic Ophthalmia, By Georg Lenz.
3. Interference with Respiration and with the Introduc-
tion of Food by a Large Thymus in a Child Ten
Weeks Old. Operation. Recovery,
By Willy Hinrichs.
4. O.xidation of Sugar, By Georg Rosenfelu.
5. The Care of Tuberculosis (Sanatoria?),
By AUFRECHT.
6. Rc-rarding the Question of the Permanent Results of
San.Uoria, By B. Frankel.
7 Wassermann's Syphilis Reaction, By J. Bauer.
8. Concerning Local Sensitiveness of the Conjunctiva to
Tuberculin, By Sigismund Cohn.
1. Pericardial Friction Sounds with Synechias
of the Pericardium. — Richter reports a case in
which a diagnosis during life of fresh pericarditis
was made because of the appearance and disappear-
ance of pericardial friction sounds, but on autopsv
the pericardial sac was found to have been totally
obliterated by adhesions which showed no signs of
recent inflammation.
2. Sympathetic Ophthalmia. — Lenz says that
recent anatomical studies of sympathetic ophthalmia
have demt^nstrated that there is a specific anatom-
ical picture which renders possible a distinction of
this from other forms of chronic uveitis, that oniy
such eyes as present this specific picture are sympa-
thetic, that the specific infiltration of the first dis-
eased eye is identical with that of the second eye to
be involved. Finally he states that, while import int
advances have been made in the knowledge of s\m-
pathetic ophthalmia, much still remains obscure, and
with many an injured eye we are in doubt whether
there is danger of sympathetic inflammation or not.
4. Oxidation of Sugar. — Rosenfeld in this con-
tribution considers the liver as the central organ of
metabolism.
8. Local Sensitiveness of the Conjunctiva to
Tuberculin. — Cohn states that a single instilla-
tion of a one per cent, solution of old tuberculin
while it does not induce a visible reaction does cause
a hypersensibility which is manifested in two ways :
1. By an ability to react to a second instillation of a
one per cent, solution of tuberculin with evident
signs of inflammation ; 2, by an ability to draw tu-
berculin frorn the circulating blood and then to re-
act to this. These peculiarities are strong locally and
confined to the conjunctiva which has been used for
instillation. A lapse of at least five days is usually
necessary for the development of these peculiarities.
The maximum of the hypersensitivencss is reached
about the beginning of the third week. It is possi-
ble, but not proved, that the artificial hypersensitive-
ness is a sign of latent tuberculosis.
LA RIFORMA MEDICA,
April 6, 1908.
I On Very Light Forms of Malta I-'cver in Naples,
By .\rnaldo Cantani.
2. On the Therapeutic Uses of Viscum,
By Carlo Fedeli.
3. Contribution to the Study of the Pathogenesis of Cystic
Kidney (Concluded). By Domenico Taddei.
PITH OF CURRENT LITERATURE.
1. Mild Form of Malta Fever in Naples. —
Cantani studies the very mild cases of Malta fever
which came under his observation recently in
Naples. Shaw was the first to describe in detail
an ambulant form of Malta fever. This author ex-
amined 525 dock laborers on the island of Malta
and found that seventy-nine showed a positive ag-
glutination reaction. In twenty-two of these la-
borers, Shaw found the micrococcus of Malta fever
in the blood and the urine. The ambulant form of
Malta fever has been prevalent in Naples for some
time, and Cantani urges the necessity of bacterio-
logical examinations in suspicious cases, although
he realizes that in the mild cases the patient will
rarely submit to medical treatment. Most cases
which he had under observation occurred in several
members of one family. Thus he reports five cases
in one family, of which three were of medium grav-
ity, and one was fairly severe. In another family,
a young woman was attacked first, her fever last-
ing forty days ; then followed two sisters, then a
brother. Several other similar examples are re-
ported by the author, the total cases numbering thir-
teen, and in each case the bacteriological examina-
tion of the blood showed the agglutination reaction.
Ambulant cases of Malta fever are much more fre-
quent than many physicians suppose. As we receive
annually a large number of immigrants from
Naples, some of them may import Malta fever, even
in this attentuated form, and it might be well for
the health authorities in the various ports to be on
the lookout for these cases.
2. Therapeutic Uses of Mistletoe. — Fedeli re-
views the literature which has recently been pub-
lished concerning the revival of mistletoe as a thera-
peutic agent. A number of articles have been pub-
lished on this subject, particularly that of Gaulthier
{Gazette dcs Hopitaux, October 17, 1907). The
preparations used by Gaulthier were an aqueous
extract of mistletoe in doses of from 20 to 30 c.c.
in twenty-four hours; a syrup, in doses of from 10
to 15 teaspoonfuls in twenty-four hours, etc. Vis-
CHin album has been found by Chevalier and Gaul-
thier to lower the blood pressure, to accelerate the
pulse, and in large doses to kill by paralyzing the
heart and causing hemorrhages in the gastroin-
testinal tract, the endocardium, etc. Gaulthier
recommends mistletoe in arteriosclerosis with high
tension pulse. Fedeli, in the present article, reports
an interesting case of severe acute nephritis in a
physician, in whom he used the extract of mistletoe,
beginning with 6 c.c and increasing to 30 c.c daily.
The efifect was excellent, the albumin diminishing
rapidly until, at the end of the month, there was
but a trace. It does not appear clearly, however,
whether the recovery was due to the mistletoe or to
the milk diet which the patient maintained. In an-
other case, with a history of uraemic attacks, the
extract of mistletoe was administered with good
results. In a third case of very severe nephritis
in . a young man who had slight arteriosclerosis,
hypertrophy of the left ventricle, oedema, scanty
urine, rich in albumin and casts, the extract of mis-
tletoe was given in increasing doses, with the re-
salt that the albuminuria rapidly diminished. This
patient died of uraemia. While the number of
cases in which mistletoe was used was small, the
author thinks that in selected cases I'isciiiii albnin
will give good results in the treatment of nephritis.
The remedy acts best in cases in which there is a
certain degree of increased arterial pressure and of
arterial spasm. In some cases, in which the lesions
are too far advanced, especially in cases of chronic
acute nephritis, not much benefit can be expected.
On the other hand, in ca.ses in which parenchyma-
tous lesions predominate, Visciim albiini will be
found to have a favorable efifect.
Ai^ril 13, 1908.
1. Observations on an- Involution Form and on Cultures
of Trypanosoma Brucei, By Ge.nxaro Fusco.
2. Syphilitic Fever? By Angelo Ceconi.
3. A Case of Dupytren's Disease, By A. B. Gianasse.
I. Cultivation of Trypanosoma. — According
to Fusco, the best medium for the cultivation of
trypanosoma is a mixture of three parts of blood
and one part of a two per cent, solution of sodium
oxalate. In this medium, the red blood corpuscles
remain unaltered for a long time at a temperature
of 22° C. The trypanosoma in this medium pre-
serves its characteristic shape for some time and
rarely shows the rounded involution forms which
are so frequently seen in other culture media. Some
involution forms, however, with a large and a small
nucleus each, and with a long filament, are noted
in these cultures. Here and there isolated macro-
nuclei are found. In a mixture of one part of a
two per cent, solution of ammonium oxalate and of
three parts of guinea pig's or white rat's blood, the
trypanosoma develops in rounded forms with a
large and small nucleus and a very long filament,
while the protoplasm is but faintly staining and the
large nucleus appears fragmented. In this medium
the red blood corpuscles remain unaltered for a long
time. If these involution forms of trypanosoma,
which are met with in the blood and the organs of
animals that died of trypanosoma infection, and in
these various culture media be compared with the
])odies studied by Leishman in kala-azar, it will
appear clearly that there is no difiference between
them. Under the name of kala-azar or dumdum
fever, there is a disease which flourishes in India,
especially in the neighborhood of Calcutta, and is
characterized by severe emaciation, an irregular re-
mittent fever, and an enormous enlargement of the
spleen. At first these cases are taken for malaria,
yet no parasites of malaria can be found, nor does
quinine relieve the symptoms. The patients suffer
from a progressive muscular atrophy and a blackish
pigmentation of the skin, as well as from occasional
oedemas of the feet and lungs. Leishman found
in the spleens of the patients that had died from
this disease a large number of bodies bearing char-
acteristics of the trypanosoma, but which he named
the piroplasma of Donovan, which name was later
changed to Lcishmania Donorani. The exact na-
ture of this body has not yet been determined, but
Rogers was able to transform Leishman's bodies
into trypanosomas in the course of cultivation for
ninety-six hours. From these studies it appears very
probable that Leishman's bodies are involution
forms of trypanosoma. The present author proves
that identical bodies exist in the blood and the
splenic pulp of animals that died of tryapnosoma
infection, and also in various culture media in
which trypanosoma grows. In other words, Leish-
man's bodies, under special culture conditions, may
1 1 24
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
assume the appearances of trypanosoma, and vice
versa.
THE ASSOCIATION OF AMERICAN PHYSICIANS.
Twenty-third Annual Meeting, Held in irashington. May
1.2 and 13, J908.
The President, Dr. J.vmes Tyson, of Philadelphia, in the
Chair.
(Continued from page 937.)
Nonfatal Coma in the Course of Diabetes. — Dr.
C. X. 11. C\M.\c, of Xew York, re])orte(l a case of
well marked diabetes in an adult who had been un-
der observation for six montlis. The patient be-
came irascible, and accompanying this phenomenon
the lu-ine became lower in specific gravity and the
quantity of glucose excreted was somewhat lessened.
Diacetic acid disappeared and oxybutyric acid did
not appear : but tlie coma, which was fullv devel-
oped, was not accompanied bv an increase of the uri-
nary ammonia until the consciousness was return-
ing ; then it increased quite decidedly. Later the pa-
tient became hemiplegic, the blood pressure rose to
between 170 and 180 mm., and death ensued. At
the necropsy interacinous pancreatitis, chronic ne-
phritis, cerebral softening, and general arterioscle-
rosis were the important lesions discovered.
Dr. S. SoLis-CoiiF.x. of Philadelphia, referred to
a case in which the ]iatient recovered from coma and
lived twenty \ears. Six years before death glucose
disappeared from the- urine and was replaced by al-
bumin. He referred to several cases in which recov-
ery from coma had occurred.
Dr. l.\>ri's luvixG, of Xew York, said that he in-
terpreted the case reported by Dr. Camac as one of
genuine diabetic coma without acidosis.
Dr. TiiizoDORK C. J.vxKw.w, of Xew York, said
that it was difficult to judge whether the case was
one of coma from diabetes, from unemia, or from
gross cerebral disease.
The Atrioventricular Bundle, with a Report of
a Case of Acute Ulcer on the Interventricular
Saeptum. — Dr. \\'.\lti;r li. J.vme.s, of Xew York,
exhil)ite(l a specimen in which there was a good
sized ulcer involving the heart muscle in the region
of the interventricular w-all, which would involve the
bundle of His. The patient was a man, aged sixty
years, who had suffered from malignant endocardi-
tis. He had a slow pulse, and simultaneous jugular
and carotid tracings showed dissociation ; the ven-
tricles were beating at a rate of 50 a minute and
the auricles at a rate of 100. There was at no
time a Stokes-Adams .syndrome. The speaker was
of the opinion that many cases were reported as
exaini)lcs of heart block which, on critical analy-
sis. ai)peared to be cases of extra .systole. Redupli-
cation of the first sound of the heart was the first in-
dication of myocardial disease or of endocardial dis-
ea.se, or of both, in such diseases as acute rhiuma-
ti.sm, for example.
Intraventricular Systole. — Dr. II. .\. Stkwart,
of llaUimore, exhil)ited an instrument designed to
give tracings of the events taking place at the valve
orifices during their closure. I'.y the use of this in-
strument he had been able to record some tracings
in dogs, and the\ showed that the aortic orifice was
closed during diastole, at least in part, by muscular
action. It was further found by careful dissection
that the aortic valve leaflets were attached to the
ventricular muscle, and that this muscle was active
in closing the aortic opening. He described the de-
velopment of an aortic diastolic murmur in the
course of certain diseases, such as typhoid fever and
exophthalmic goitre, which disappeared as the con-
valescence of the patient progressed. Such a mur-
nuir he would interpret as depending upon the fail-
ure of the muscle to properly occlude the aortic
opening during diastole.
Heart Sounds Heard Early in Diastole. — Dr.
William S. Thayer, of Baltimore, described a
sound which he had often heard in early diastole
while listening to the hearts of dogs which w^ere be-
ing experimented upon. He had also heard similar
sounds in examining children, and in quite normal
individuals. The sound was soft and was associated
with a visible shock, and sometimes with a palpable
shock ; it was increased by turning the patient on
the left side. In five out of six cases the aortic mur-
mur was accompanied by an "h" wave on the jugu-
lar tracing. The murmur described was similar in
character to a murmur heard early in diastole in
cases of mitral stenosis and in cases of galop rhythm.
It was probablv an event closely associated with the
rapid entrance of the blood into the ventricle early
in diastole. Dr. Thayer considered that the best hy-
pothesis for the explanation of the sound was that
during the first inrush of blood through the mitral
and tricuspid orifices the valves were suddenly
brought into tension, thus giving rise to the sound
described. It was not unconmion in the normal
heart or in the hearts of young individuals in early
diastole after the second sound occurred.
Dr. A. A. EsiixKR, of Philadelphia, said that he
had heard such a sound as that described by Dr.
Tha\er. He had thought that the condition of the
entrance of the blood into the ventricles during dias-
tole was proper for the production of such a sound.
Dr. Tn.wF.R said that an analogous sound could
be heard in cases of aortic insufficiency.
Anaemia in Children. — Dr. M. H. Fussell, of
Philadelphia, reported the case of a boy, aged thir-
teen months, who had had a severe intestinal dis-
turbance at the age of eight months. He was pal-
lid and had an abdominal tumor, which was proved
to be an enlarged spleen, enlarged lymph nodes, with
myelocytes in the blood. The patient died. He con-
sidered the case to be one of the anaemia infantum
pseudoleuchsemia of von Jaksch. He reported the
case of a girl, aged seven years, who vomited blood.
She was anaemic, and had an enlarged heart with a
mitral presystolic and a mitral systolic murmur. The
child died after a large h?emorrhage from the stom-
ach. The examination of the blood showed 1.275.-
000 erythrocytes, 6.000 leucocytes, and twenty per
cent, of hjemoglobin. At the necropsy the liver was
found enlargecl, pale, and pink in color ; there was
thrombosis of the hepatic vein ; the .spleen was en-
larged ; there were dilated oesophageal veins, from
which the lu-emorriiage had occurred. In this cis,'
the diagnosis was that of splenic an;cmia dependent
upon sei)sis. The third ])atient was very an.-emic,
June 6, 1 908. 1
PROCEEDINGS OF SOCIETIES.
1 125
presented a lemon yellow color, and suffered from
rhachitis. There was an enlarged liver with an en-
larged spleen. The blood examination showed
1,600,000 erythrocytes, 24,160 leucocytes, and twen-
ty-four per cent, of haemoglobin. There were forty
per cent, of polymorphonuclear neutrophiles, 40.1
per cent, of lymphocytes, and two per cent, of mye-
locytes in the circulating blood. The patient died of
right apical pneumonia. The examination of the
bone marrow showed a marked increase in the
lymphocytes. This case was looked upon as an ex-
ample of anaemia infantum p.seudoleuchaemia.
Dr. J. P. Crozer Griffith, of Philadelphia, said
that in his opinion the so called von Jaksch's anaemia
was infantile leuchasmia.
Splenic Anaemia, Splenectomy, Recovery. — Dr.
Morris J. Lewis, of Philadelphia, reported a case
of splenic anaemia in which splenectomy had been
done with recovery, and in which he had had the
opportunity of studying the blood for seven years,
four years before the removal of the spleen and three
■years after the operation. The patient had had a
moderate anaemia, with continuous symptoms of
dyspepsia. There was a sudden profuse haemor-
rhage, for which gastroenterostomy was done with
benefit on the theory that an ulcer had caused the
bleeding. Later, splenectomy was done and the op-
eration was followed by pleural effusion, pericardi-
tis, and abscess in the wound. These inflammatory
complications interfered with the accurate study of
the blood, but there was marked eosinophilia, which
persisted three years after the removal of the spleen.
There was but little change in the percentage of
lymphocytes in the blood.
Dr. James B. Herrick, of Chicago, and Dr. A. B.
Black.'XDER, of Montreal, referred to cases of sple-
nectomy.
The Relation of Urobilinuria to the Presence
of Bile Pigment in the Blood. — Dr. Lewis A.
Conner and Dr. J. C. Roper, of New York, had
found that as a rule the amount of urobilin in the
urine corresponded to the amount of bile pigment in
the blood serum. In order to determine the amount
of bile pigment in the blood, they employed a modi-
fied Gmelin's test as recommended by Gilliert and
Herscher. They found that in certain cases very
high amounts of bile pigment in the blood were not
accompanied by any urobilin in the urine. In cer-
tain cases of pneumonia there was urobilin in the
blood serum without bile pigment. This phenome-
non might be due to some action of the pneumo-
coccus.
Dr. James Ewing, of New York, said that in
puerperal eclampsia urobilin was found in the blood
serum. He "attributed the occurrence to a disordt r
of the hepatic function.
The Relation of the Auditory Centre to Apha-
sia.— Dr. Adolph Meyer, of New York, demon-
strated the lesions found in the auditory centre in
the superior temporal convolution of the cerebrum
in certain cases of aphasia with the aid of admirable
lantern slides and photographs of reconstructions.
The specimens showed that in certain cases of apha-
sia there was an extensive lesion in the cortical audi-
tory centre.
The Pathology of Exophthalmic Goitre as Re-
lated to Clinical Symptoms, Being a Study of
Nearly 300 Cases Operated on by Dr. C. H.
Mayo. — Dr. Louis B. Wilson, of Rochester,
Minn., exhibited numerous lantern slides showing
the gross and microscopical appearance of the thy-
reoid body, and the appearance of the patient suffer-
ing from exophthalmic goitre of varying degrees of
severity. He divided the operative cases into the
following groups: i, A small intraalveolar paren-
chyma increase, with a small amount of thin secre-
tion. 2, A large amount of intraalveolar increase,
with a large amount of thin secretion. 3, A large
amount of intraalveolar parenchyma increase, with
a large amount of thin secretion and beginning de-
generation. 4, Old intraalveolar parenchyma in-
crease, with a large amount of thick secretion and
advanced degeneration. 5, A small amount of mul-
tialveolar parenchyma increase, with a small amount
of thin secretion. 6, A large amount of multialveo-
lar increase, with a large amount of thin secretion.
7, A large amount of multialveolar parenchyma in-
crease, with a large amount of thin secretion and
beginning degeneration. 8, Old multialveolar par-
enchyma increase, with a large amount of thick se-
cretion and advanced degeneration.
Dr. William H. Thomson, of New York, said
that Graves's disease and exophthalmic goitre were
not synonymous.
Dr. William H. Welch, of Baltimore, said that
it was well known that the dogs in the Great Lake
region showed parenchymatous changes in their thy-
reoid glands, which disappeared on feeding the ani-
mals with iodine. In the neighborhood of Balti-
more such changes were rarely met with.
Dr. J. G. Adami, of Montreal, said that the paper
was an admirable one from the point of view of cor-
relating the clinical with the pathological manifesta-
tions of enlargement of the thyreoid gland with ex-
ophthalmos and tachycardia.
Dr. Wilson said he hoped that in time we should
get away from the terms exophthalmic goitre and
(iraves's disease, and should designate all cases pre-
senting the symptoms of enlarged thyreoid, exaph-
thalmos, and tachycardia as cases of hyperthyreoid-
ism.
Erythromelalgia, Raynaud's Disease, and Al-
lied Conditions- in Their Relation to Vascular
Diseases of the Extremities. — Dr. B. Sachs and
Dr. L. Buerger, of New York, exhibited lantern
slides to illustrate the opinion that Raynaud's dis-
ease and erythromelalgia were due to thrombosis of
the veins of the lower extremities. The proper name
for the condition, according to the writers, was
thromboangeitis obliterans. The two diseases were
closely related to each other and to gangrene and in-
termittent claudication. There were, furthermore,
some cases of loss of muscular power in old per-
sons, which were diagnosticated as cases of senile
paraplegia, which were due to interference with the
circulation in senile bloodvessels. The process was
an ascending obliterative one, which began in the
tributaries and the branches of the dorsalis pedis
and plantar vessels and ascended until all the arttries
and veins become occluded. In many of the vessels
the histological preparations showed that the central
clot was tunneled by small new vessels, which pre-
vented the occurrence of gangrene. There was, in
addition to the thrombotic process, periarteritis with
1 1 26
LETTERS TO THE EDITORS.
[New York
Medical Journal.
proliferation of the connective tissue, matting ves-
sels and nerves together. In other cases there was
associated atheroma.
(To be continued.)
f etttrs to tfee m\m.
THE WHITMAN BRACE.
126 E.\.-;t Thirty-fourth Street,
New York, May 23. 1908.
To the Editors:
In an article entitled The Restoration of the Nor-
mal Balance of the Foot, by Dr. Abbott and Dr.
Pingree, which appeared in the last issue of the
Journal, an illustration of a Whitman brace is pre-
sented showing how, when unsupported hy the shoe,
it permits the front of the foot to slide away from it.
As this brace can only be used in a shoe, the perti-
nence of the illustration is not apparent. Dr. Whit-
man has always insisted upon a proper shoe as an
essential adjunct of the brace, and that the foot
does not fall away from the brace when properly
applied m?L\ be demonstrated by observation, more
particularly by the imprint which is made by it on
the inner margin of the entire foot.
The brace advocated by Dr. Abbott and Dr.
Pingree is, from the Whitman standpoint, defective
in that it does not provide lateral support : thus it
cannot control the inward bulging significant of
abduction, which is the characteristic of all grades
of weak foot. The writers say that, if the sole plate
is sufficiently arched and if the foot may be so bal-
anced upon it that it does not slide away, abduction
is prevented. Granting this, for the sake of argu-
ment, it is prevented indirectly by pressure on the
soft tissues of the sole. It seems far more reason-
able to prevent abduction directlx , by lateral sup-
port, and thus to relieve the sole from abnormal
pressure of the arch of the brace. Thus both lateral
and direct support may be utilized to check de-
formity. Lateral pressure has another great ad-
vantage in that, on the one hand, it prevents the
toeing out which is one of the principal predispos-
ing causes of the weak foot, and, on the other hand,
it induces the instinctive drawing away of the foot
from this pressure toward a better attitude. This
attitude, which, when confirmed by posture and by
exercise, assures the cure, is aided by the slight
leverage action of the brace, if properly adjusted.
The lateral support and the leverage action are the
distinguishing features of the Whitman brace, and
that it is superior to those of the simple or nega-
tive type favored by the writers is confirmed, not
onl\- by observation of its ef¥ects, but by the testi-
mony of intelligent wearers of the brace as well.
The advantage of taking the cast by the Whit-
man method is that the entire foot is reproduced in-
stead of the irregular fragment illustrated in the arti-
cle. Thus the changes to be made in the cast,
upon which its fit and efficiency in .some degree
depend, may be made more intelligently. ( )vercor-
rection of the deformed foot, objected to by the
writers, is, as in the treatment of any other de-
formity, considered an essential step in functional
cure. It may be assumed that the majority of those
who use the Whitman brace have the advantage of
having learned the details of its application by actual
demonstration, after which the principles of treat-
ment, of which it is an essential part, may be much
better appreciated. John Carlixg.
iaok gotitfs.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
The Bacteriology of Diphtheria. Including Sections on
the Histor.v, Epidemiolog\-, and Pathology of the Dis-
ease, the Mortality Caused by It, the Toxines and Anti-
toxines, and the Serum Disease. By F. Loeffler. M. D.,
LL. D. ; Arthur Newsholme. M. D., F. R. C. P. ; F. B.
M.\LL0RY, M. A., M. D. : G. S. Grah.\m-Smith, M. A.,
M. D., D. P. H. : George Deax, M. D. ; William H.
Park, M. D., and Charles F. Bolduax. M. D. Edited
by G. H. F. Nutt.all, M. D., Ph. D.. Sc. D., F. R. S.,
Quick Professor of Biology in the University of Cam-
bridge, Fellow of Christ's College, and G. S.' Graham-
Smith, M. A.. M. D., University Lecturer in Hygiene,
Cambridge. Cambridge: University Press, 1908: Lon-
don : H. K. Lewis ; Leipzig : F. A. Brockhaus ; New
York : G. P. Putnam's Sons ; Bombav and Calcutta :
Macmillan & Co., Ltd. Pp. xx-718. ( Price, $7.50.)
This comprehensive treatise opens with several
single page biographical sketches of the men whose
names are so intimately associated with the history
of diphtheria, namely, Bretonneau. Loeffler, Behring.
and Roux. The text proper is divided into six sec-
tions, each written by an accepted authority, as fol-
lows : History of the disease, Professor Loeffler ;
epidemiology, Arthur Xewsholme : pathology.
Frank Mallory ; the diphtheria bacillus, G, S. Gra-
ham-Smith ; immunity, George Dean : mortality and
serum treatment, William H. Park and Charles F.
Bolduan.
The historical account, by Loeffler, quickly brings
the reader to that wonderful epoch in medicine sig-
nalized by the discovery of the diphtheria bacillus,
its toxine, and its antitoxine. The logical develop-
ment of this phase of the subject is well set forth,
and the important work done in this country is duly
credited.
Xewsholme, in his study on the epidemiology,
concludes that "diphtheria is relativelv more a con-
tinental than an insular disease," a statement which
the reviewer believes is open to question. The au-
thor also gives interesting data on the epidemic and
pandemic outbreaks of the disease, and then inquires
into the reason for these occurrences. He finds this
in the relation of the disease to rainfall, and says
that "diphtheria only becomes epidemic in years in
which the rainfall is deficient, and the epidemics are
on the largest scale when three or more years of
deficient rainfall immediately follow each other."'
It is interesting to note that Park and Bolduan. in
discussing the same point, are rather skeptical con-
cerning such a connection.
The section on the patliology of diphtheria, b\
Profes.sor Mallory, is very complete, and is based
on a studv of 251 cases of the disease which came
to autopsy in the Boston City Hospital. The gen-
eral distribution of the local lesion was about tlie
same as in other large series of cases. It is remark-
able that a definite membrane occurred in but 14S
June 6, igoS. I
BOOK NOTICES.
1 127
of the 251 cases. Diphtheria bacilli could almost
al\va\ s be found microscopically in early cases when
a definite membrane was present. They were not
found in living tissue or on the surface of normal
epithelium or even m those places which would be
regarded as the primary lesion of the disease. Mal-
lory therefore believes that the beginning of the
lesion is probably due to the toxic action of bacilli
growing in the fluids of the mouth or throat. When
necrosis is once produced, the necrotic tissue and
the membrane on its surface form a suitable culture
medium. In this series of cases it was found that
eighty per cent, of the patients who had been in-
tubated showed bronchopneumonia. In cultures
made from the lungs, streptococci were just about
as frequent as diphtheria bacilli.
The section on the diphtheria bacillus,, by G. S.
Graham-Smith, is a veritable mine of information,
and constitutes a welcome discussion of our present
knowledge of the subject. The author points out
the difficulties which have arisen in consequence of
the loose nomenclature, and particularly owing to
the indiscriminate use of the term "pseudodiphtheria
bacillus." He then gives a minute description of
the diphtheria bacillus and of HofTmann"s bacillus,
and their relation to one another. In a special chap-
ter on the diagnosis he also considers other diph-
therialike organisms, among them the xerosis bacil-
lus. Hoffmann's bacillus is held to be a distinct
species, and not merely a nonvirulent variety of the
diphtheria bacillus. There is an instructive table
showing the action of diphtheria bacilli from vari-
ous sources on dift'erent sugars and carbohydrates
in the serum water medium of His and in broth.
Space does not permit of even a mention of all the
other excellences of this section.
Dean gives a scholarly account of immunity in
diphtheria, first tracing the development of the sub-
ject to the time of the discovery of the diphtheria
toxine. He then discusses the toxine in detail, and
gives a clear picture of Ehrlich's conceptions of the
nature of the diphtheria poison. The production of
antitoxine is discussed very fully, and mention is
made of Gibson's method of concentrating the anti-
toxic globulins. Ehrlich's theory concerning the
toxine-antitoxine reaction receives considerable at-
tention, and the conflicting views of Ehrlich,
Arrhenius. and Bordet are clearly set forth. Dean
wisely refrains from expressing an opinion as to
which is nearest the truth.
The final section, by Park and Bolduan, gives a
scientific and clear exposition of the manner in
which statistics may be used to stud\- the influence
of treatment on the mortality from diphtheria. The
various sources of error in previous compilations
are pointed out and avoided in the present study.
This is based on the mortality returns from nine-
teen large cities, both here and abroad, and com-
prises statistics embracing a total population, in
1905, of over 23,000,000. One of the curves is par-
ticularly interesting. It shows the ■sudden drop in
mortality which occurred in 1895. when antitoxine
had just been introduced. The same authors have
a chapter on serum sickness, and report excellent
results following the use of concentrated and puri-
fied antitoxine made according to the Gibson pro-
cess. In their discussion on the theory of the serum
rashes the\' refer to the work of Pirquet and Schick.
The book closes with an excellent bibliography,
extending over more than sixty pages and well ar-
ranged typographically. Altogether this volume
presents a convenient storehouse of authoritative in-
formation on diphtheria, and should accordingly be
heartily welcomed by scientific workers everywhere.
The reviewer recommends the book to all who wish
to obtain accurate data on this important stibje^t.
Bier's Hyperccmic Treatment in Surgery, Medicine, and the
Specialties. A Manual of Its Practical Application. B3'
Willy Me\-er. ^l. D., Professor of Surgery at the Xew
York Postgraduate Medical School and Hospital, etc.,
and Professor Dr. Victor Schmiedex, Assistant to Pro-
fessor Bier, University of Berlin. Germany. Illustrated.
Philadelphia and London : W. B. Saunders Company,
1908. Pp. 209. (Price, $3.)
Although many essays have appeared in our medi-
cal periodicals, and still many more papers on this
subject have been read before medical societies,
treating of Bier's StamDigshxpcriimie — hyperaemic
treatment, as translated ustially : dammed circula-
tion, as proposed by Ewart, of England — there has
not been published so far an authoritative full ac-
count of the treatment. The profession will cer-
tainly welcome this addition to our literature.
Bier stated some years ago: ""Hyperaemic treat-
ment, used by Nature so extensively in combating
all kinds of lesions, is destined to be far more em-
ployed than has hitherto been done." Our authors
say rightly that it should not be assumed that the
millennium has been introduced with this treatment.
The physician must strictly follow the directions as
laid down by Bier and his school, must be absolutely
sure of the pro and contra indications, and must
be thoroughly familiar with the technique. Then,
and then alone, good results will be achieved. Hy-
peraemic treatment is not a panacea, and because
it has been accepted as such by many, failures have
been so often reported.
The profession will now have the means of try-
ing this method of treatment exactly, and may ac-
cept or decline it.
Surgery. Its Principles .ind Practice. By \"arious Au-
thors. Edited by \\'illiam \Villi.\ms Keex, M. D..
LL. D., Emeritus Professor of the Principles of Surgery
and of Clinical Surgerv. Jefferson Medical College,
Philadelphia. Volume HI. With 562 Text Illustrations
and 10 Colored Plates. Philadelphia and London : W.
B. Saunders Company, 1908 Pp. 1132.
The first chapter in the present volume is on the
surgery of the head, by Dr. Harvey Gushing, who
gives an admirable presentation of the subject and
states most truly that the prevailing impression in
regard to the dangers and general futility of cere-
bral surgery, which hampers its advance, is due. in
large measure, to the unsuccessful attempts of the
untrained and inexpert.
The surgery of the neck is described by Dr. E.
W'yllys Andrews, who favors Crile's method in
operating in this region.
Albert Kocher reviews the diseases of the thy-
reoid gland, and believes that surgical is superior
to any other form of treatment in exophthalmic
goitre, his own experience giving eighty-five per
cent, of recoveries, while in simple goitre the larg-
est share of treatment belongs to the internist.
The surgery of the nose and its accessory sinuses
1128
BOOK NOTICES.
[New York
Medical Jourwl.
is described by Dr. Harmon Smith in a brief and
practical manner.
Dr. George E. Brewer has written the chapters
on the surgery of the larynx and trachea and of the
thorax.
The surgery of the breast is described by Dr.
John '\\. T. Finney, who advises the complete ex-
tirpation of benign tumors, cysts, and malignant
growths.
Air. Edmund Owen is the author of the chapter
on the surgery of the mouth, teeth, and jaws.
The surgery of the tongue is reviewed by Dr.
John C. Da Costa in a somewhat brief fashion.
Dr. John C. Munro is the author of the chapters
on the technic|ue of abdominal surgery, on the sur-
gery of the abdominal wall, and on the surgery of
the peritonaeum and retroperitoneal space. Neces-
sarily these subjects are treated with brevity.
The surgery of the oesophagus is described b\
Dr. George Gottstein, who gives some interesting
illustrations of findings of the cesophagoscope.
The chapter on the surgery of the stomach, by
Mr. A. W. Mayo Robson, is one of the most satis-
factory in the volume.
The chapter on the surgery of the liver, the gall-
bladder, and the biliary duct is by Dr. William J.
Mayo and Dr. Charles H. Mayo, and is a succinct
presentation of the subject.
Mr. B. (i. A. Aloynihan is the author of the chap-
ters on the surgery of the pancreas and of the
spleen.
Diseases of the Nose, Tliroat, and Ear. Medical and Sur-
gical. By WiLLi.\M Lincoln Ballencer, M. D., Pro-
fessor of Otology, Rhiiiology, and Laryngology, College
of Physicians and Surgeons, Department of Medicine,
University of Illinois, etc. Tllustrated with 471 Engrav-
ings and 16 Plates. Philadelphia : Lea & Febiger, 1908.
Pp. viii-17 to 905.
This work, which includes also the relation of the
accessory sinuses to diseases of the eye, is thorough ■
ly abreast of the times in taking into consideration
the latest advances of medical science, especially in
pathology and surgical technique, almost encyclo-
paedic in scope, and, if any criticism was to be made,
rather more than necessarily full in detail. Th's
completeness is welcome and valual)le in the chap-
ters on treatment and operations, and the work will
be found an excellent reference handbook for this
rea.son. There is rather too much theorv and a
tendency to generalizing in the chapters on' ;etiology.
pathology, and principles of treatment, which some-
what lessens its value for the student and its useful-
ness as a textbook. The practical chapters are by
far the best, and it is to be noted that Ballengcr has
given us an excellent account of major (ii)eralions in
this .special field, such as extirpaln m t ,\ the larynx,
excision of the external carotid, ostco])lastic resec-
tion of the upper jaw, and the external operation for
pharyngeal abscess, which are often relegated to
general surgeons by specialists who are not fully
sure of themselves. The illu.strations are very nu-
merous and some of them are excellent.
This applies particularly to the diagrams
and instructive schemata, and to the half tone cuts.
Others, notably the many woodcuts from rather
mediocre line drawings, are uniformly on too small
a scale, and must, if judged by the present high
standard of medical illustrations, be said to be
inferior.
Christian Science, the Faith and Its Founder. By Lyman-
P. Powell, Rector of St. John's Church, Northampton;
Massachusetts. New York and London: G. P. Putnam's
Sons, 1907. Pp. xviii-261.
The author's purpose has been to write a book in
which the average man who is not a Christian Sci-
entist can find the things he wants to know about
its theory and practice. He concludes that the good
in that cult is the good in other religions, and needs
therefore no special emphasis ; that the evil is dis-
tinctive and needs analysis and publicity to make it
evident ; and, finally, that it is perilous for people to
commit themselves to this crude faith, that is "re-
pudiated with indignation by historic Christianity
and with contempt by science, without a clearer un-
derstanding than is common of its insecure founda-
tions and its inevitable implications." The author
has made a most painstaking and comprehensive
study of the subject, and his presentation of the facts
is cogent and forceful.
Gonorrhea. Its Diagnosis and Treatment. By Frederick
Baumann, Ph. D., M. D., Professor of Genitourinary
Diseases in the Reliance Medical College and Instructor
in Dermatology and Venereal Diseases in the College of
Physicians and Surgeons, Chicago. Fifty-two Illustra-
tions in the Text. New York and London : D. Appleton
& Co., 1908. Pp. .xii-206.
This book is a very good manual of the diagnosis
and treatment of the gonorrhoeal infections of the
genitourinary tract of the male. The subject is
treated of in a concise and clear manner. Gonor-
rhoea in the female is only so far taken into con-
sideration as it affects the urethra (Chapter xiv).
A very short chapter treats also of the "vaccination"
therapy of gonorrhoea.
On page 125 is reproduced an illustration tal en
from the ( lernian, which still contains ( ierman
nomenclature. Could not this be changed into Eng-
lish in future editions?
Die Pra.vis dcr Hautkrankheiten. Unna's Lehren fiir
Studierendr and .\(.Tzte, /.usannncngefa>st and dargestellt
von IwAN liLoui. licrlin. Mit eincni \'orwort von Dr.
P. G. LInxa in Hamburg. Mit 92 .Kbbildungen. Berlin
and Wien : Urlian & .Schw arzcnberg. igo8. Pp. 698.
(Price, 18 marks. )
This volume represents, as its title indicates, a col-
lection of the teachings of Professor P. G. Unna in
the field of dermatology, and the field is covered
very thoroughly. The work is prefaced with an his-
torical review ctf tlte recognition and treatment of
af¥ections of the skin from the earliest times, the
author making a brief reference to conditions in the
different epochs in history. The physiological
anatomy of the skin and hair is treated of concisely,
yet comprehensively, in the opening chapter, the text
being illustrated with numerous excellent engrav-
ings. The morphology, biology, and pathogeny of
the skin and tissues are considered in the o])ening
chapters, practically the rest of the book being de-
voted to diagnosis and treatment. For those who
are familiar with the (ierman language and who de-
sire to inform themselves regarding approved mod-
ern methods of treatment, this encyclopredic work
should prove especially helpful. It is particularlv
rich in formulas, as might be expected when the
mimber of both internal and external applications
June 6, 1908.]
OFFICIAL NEWS.
1 129
,for the treatment of skin diseases is considered. It
is a book which can be unhesitatingly commended
to the general practitioner as well as to the spe-
cialist.
Geschichte der Laryngologie itu W'iirzburg. Von Professor
Dr. Otto Seifert, Wiirzburg: A. Stuber, 1908. Pp.
68. (Price, 3.50 marks.)
This little book is an interesting historical sketch
of the development of the study of laryngology at
the University of W'iirzburg, and it may well be
applied to all German universities.
Die Erkraiikuugen der Zi.'eiblichen Geschlectsorgane. Von
Hofrath Prof. Dr. R. Chrob.ak und Hofrath Prof. Dr.
A. vox RosTHORX in Wien. II. Theil Die Missbildungen
der weiblichen Geschechtsorgane. Mit 90 Abbildungen
und 2 Tafeln. Wien und Leipzig: Alfred Holder.
Pp. 272.
This section of the author's extensive work on
gynaecology is devoted, as the title indicates, to the
deformities and anomalies of the sexual organs,
both external and internal. It is very copiously il-
lustrated, and some of the illustrations are ver\
good. The surgical methods for remedying these
abnormities are also given, and at the end of each
chapter is a very extensive bibliography which
shows the enormous literature which is available
upon this subject.
BOOKS PAMPHLETS. ETC.. RECEIVED
Linne's Dietetik. Pa Grundvalen af dels bans eget Origi-
nalutkast till Forelasningar : Lachesis Xaturalis Quae Tradit
Dietam Xaturalem. Och dels Larjungeanteckningar eftcr
dess bans Forelasningar: Collegium Diteteicum. Pa Lpp-
drag af Medicinska Fakulteten i Uppsala. Ordnad ocb
utgifven af A. O" Lindfors. Uppsala : Akademiska Bok-
bandeln (C. J. Lundstrom), 1907. Pp. 248.
Bref och Sknfvelser af och till Carl von Linne. ]\Ied
Understod af Svenska Staten utgifna af Upsala Universi-
tet. Forsta Afdelningen. Del. i. Stockholm: Aktiebola-
get Ljus. 1907. Pp. 341.
Experimentella Undersokningar af Ledningens Natur i
den hvita Xervsubstansen. Akademisk Afhandling af Gustaf
Fr. Gothlin. Uppsala : Almqvist & Wiksells Boktryckeri-
A. B., 1907. Pp. 406.
Beitrage zur E;istehung der Geschwulste. Dritte Engan-
zungzur ■"Geschwulstlehre fiir Aerzte und Studierende." Von
Hugo Ribbert, ordentlicher Professor der allgemeinen
Pathologic und pathologischen Anatomic. Direktor des
pathologischen Institutes in Bonn. Mit 19 Abbildungen.
Sechs beginnende Karzinome der Gesichtshaut eines
Mannes. Bonn : Friedrich Cohen, 1908. Pp. 31.
Zur DifTerentialdiagnose der Poliomyelitis anterior acuta
(Myaionia congenita lOppenheim) und Polyneuritis). In-
augural-Dis-crtation zur Erlangung der Doktorwiirde an
der Fricdrich-W'ilhelms-Universitat zu Berlin. Von J.
\'ictor Haberman, A. B., M. D.. ehemals vol. A?sistent an
dem Eppendorfer Krankenhaus zu Hamburg und an der
koniglichen Charite zu Berlin. Berlin : S. Karger. 1908.
Pp. 48.
Der Tod aus Altersschwache. Von Dr. Hugo Ribbert.
ordentlicher Professor der allgemeinen Pathologic und
pathologischen Anatomic, Direktor des pathologischen In-
stitutes der Universitat Bonn. Bonn : Friedrich Cohen,
1908. Pp. 85.
Medizinisclies Literatur-u. Schriftsteller-Vademecum,
1907-1908. Herausgeber: H. Albert. Bibliograph. Ham-
burg; Franke & Scheibe. 1908. Pp. 648.
Thirty-second Annual Report of the Managers and Offi-
cers of the Xew Jersey State Hospital at Morris Plains.
For the Year Ending October 31. 1907.
Report of the State Board of Managers of Reforma-
tories. Thirty-second Annual Report of the Xew York
State Reformatory at Elmira, and the Seventh Annual Re-
port of the Eastern New York Reformatory at Xapanoch.
For the Fiscal Year Ending September 30, 1907.
The Harvey Lectures. Delivered under the Auspices of
the Harvev Society of Xew York 1906-7. By Professor
A. E. Wright, Professor C. A. Herter. Professor W. T.
Porter, Professor J. G. Adami. Dr. S. J. Meltzer, Pro-
fessor F. G. Benedict, Professor E. B. Wilson, Professor
George S. Huntington. Professor W. T. Councilman, and
Professor Friedrick Miiller. Philadelphia and London:
J. B. Lippincott, 1908. Pp. 314.
The Sanitation of Recreation Camps and Parks. By Dr.
Harvey B. Bashore, Medical Inspector for the Pennsyl-
vania Department of Health. First Edition. First Thou-
sand. Xew York : John Wiley & Sons. London : Chap-
man & Hall, 1908. Pp. xi-109.
State Board Questions and Answers. By R. Max Goepp.
M. D., Professor of Clinincal Medicine at the Philadelphia
Polyclinic ; Assistant Visiting Physician to the Philadelphia
General Hospital. Philadelphia and London : W. B. Saun-
ders Company, 1908. Pp. 684. (Price, $4.)
Adenomyoma of the Uterus. By Thomas Stephen Cul-
len. Associate Professor of Gynecology in the Johns Hop-
kins University, Associate in Gynaecology in the Johns
Hopkins Hospital. Illustrated by Hermann Becker and
August Horn. Philadelphia and London : W. B. Saunders
Company, 1908. Pp. 270. (Price. $5.)
Public Health and Marine Hospital Service
Health Reports :
Tlic folloicing cases of smallpox, yello-jj fever, cholera,
and plague haze been reported to the surgeon general.
United States Public Health and Marine Hospital Ser-
z-ice, during the z<.'eek 'ending May 2g, 1908:
Smallpox— United States.
Places. Date. ' Cases. Deaths.
California — Los Angeles May 2-9 7
California — San Krancisco May 2-9 6
District of Columbia — Washington . May 9-16 8
Illinois — Chicago .Mav 9-16 i
Illinois— Danville .May 10-17 i
Indiana — Fort Wayne May 9-16 2
Indiana — Indianapolis May 10-17 3
Indiana — La Fayette May 11-18 2
Iowa — Cass Count v To -May 16 12
Iowa — Ottumwa May 9-16 i
Kansas — Kansas City May 9-16 4
Kansas — Topeka May 9-16 3
Kentucky — Covington May 9-16 2
Louisiana — Minden To May 11 19
Louisiana — Xew - Orleans May 9-16 7
Michigan — Grand Rapids May 9-16 i
Michigan — Port Huron ilay 2-16 5
Michigan — Saginaw May 9-16 3 i
Minnesota — Winona May 2-9 i
Missouri — Kansas City May 2-16 18
Montana — Butte .May 5-1J 3
Nebraska — South Omaha May 9-16 i
Xew York — Xew York May 9-16 i
North Carolina — Charlotte Mav 9-16 1
Ohio— P>owerston Apfil 23-May 25 i
Ohio — Cincinnati -May 8-15 9
Ohio — Dayton Mav 9-16 1
Ohio— Newark May 2-9 ■
Ohio — Sherrodsville Feb. 21-iIay 18 90
Tennessee — Kno.xville May 9-16 1
Texas — Galveston May S-15 i
Washington — Spokai e -May 2-9 17
West Virginia — Parkersburg May 1-13 3
Wisconsin — La Cro.sse ilay 9-16 6
Wisconsin — Milwaukee May 9-16 2
Sniallt>f.v — Foreign.
.\rabia — Aden April 13-27 3
Hrazil — Manaos .\pril 11-18 i
Brazil — Rio de Janeiro April 12-19 ii(> 43
Canada — Halifax May 9-16 3
Canada — Montreal Feb. 22-29 i
Canada — Winnipeg ilay 9-16 1
Cape Colony — Cape Town .\pril 4- 11 i
China — Hongkong March 2S-.\pril 1 1 . . . 53 39
France — Paris .\pril 24-May 2 4
Germany — General .\pril 26-May 2 22
Great Britain — London .\i ril 18-25 i !
India — Bombay .\pril 14-21 52
India — Calcutta -■Vpril 4- 11 24
India — Madras .\pril 11-17 i
India — Rangoon April 4-11 i
Italy —Catania .Anril 30-May 7 1
apan — Kobe April 4-n 2 2
apan — Osaka April 4-11 126 114
.Xpril 11-16 73 43
Japan — Y'okohama \iril 11-25 4
Mexico — City of Mexico March 2i-.\pril 4... 12
Portugal — Lisbon .-Kpril 25-May — .... 7
Russia — Moscow .\pril 11-18 39 10
Spain — Denia Vpril 25-May 2 4
Spain — Valencia April 25-May 2 22 i
Spain — Vigo .April 25-May 2 i
Straits Settlements — Singapore ... .March 23-April 4... 2
Venezuela — La Guiara May 7 Present.
BIRTHS, MARRIAGES, AND DEATHS.
1130
Yclljw Fever — Foreign.^
Brazil — Manaos April 11-18 i i
Brazil— Para April 19-26 3 3
Mexico — Laguna May 18 i
Cholcro-ForcgH.
French Indo Cliina — tholen March 28-April 12.. 26 26
India — Bombay Ajiril 14-21 3
India — Calcutta April 4-1 1 221
India — iladras \pril 11-17 3
India — Rangoon \pril 4-11 i
f'la^nc -Insiilcu:
Philippine Islands— Manila \pril 411 4
Pliigiir— Foreign.
Brazil — Rio de Janeiro April 12-19 1
Chile — Antofagasta April 11-18 20 3
Chile— Arica April 11-18 Present,
Chile — Iquique \l>ril 11-18 12 4
China— Hongkong March 28-April 11.. 19 18
India — General \pril 4-11 10,099 8,490
India — Bombay \, ril 14--'! 379
India — Calcutta \pnl 4-11 142
India — Rangoon \pril 4-11 16
lapan — Osaka \pril 4-18 5 4
Peru— General \pril 11-18 87 30
N'cnezuela — La Guiara Mzrch i-May 7 80
Estimated.
Army Intelligence:
OfRcial list (if changes in the stations and duties of
officers of the medical corf^s of the United States Army for
the Zi'eek ending May ih. /vOiV.-
Chamberlain, P., Cai)tain. Granted an extension of
twenty days to his leave of absence.
Church, J. R.. Captain. Granted leave of absence for one
month, about June 1st.
Grubbs, R. B., Captain. Ordered to Fort Mcintosh. Tex..
for duty, at the expiration of his present leave of
absence.
Harvev, p. F., Colonel. Detailed to represent the Medical
Department of the United States Army at the meeting
of the American Medical Association, Chicago, 111.,
June 2d to 5th.
MuNSON, E. L., Major. Detailed to represent the Medical
Department of the United States Army at the meeting
of the American Medical Association, Chicago, 111.,
June 2d to 5tli.
Powell, W. A., Captain. Relieved from duty at Jef¥erson
Ranks. Mo., in time to sail July 5th from San Fran-
cisco. Cal, for the Philippine service.
Raymond. T, I'., ^lajor. Ordered to perform the duties
of chief sur.Kc-on, Department of Colorado, during the
absence on leave of Lieutenant L. A. LaGarde, in addi-
tion to duty as surgeon. Fort Logan, Col,
Ru.ssELL. F. F.. Captain. Ordered to London, England, for
a course of study in the British Army Medical School
on tlie treatment of typhoid fever,
SiLER, J. F., Captain. Relieved from duty at Fort Des
Moines, la,, and ordered to Fort Slocum, N, Y., for
duty.
VosE. W. E., Captain. When relieved from duty at Fort
Slocum, N. Y., ordered to Fort Des Moines, la., for
duty.
The following officers of the medical corps are detailed
as chief surgeons at the respective mana m n, ramps:
Chief Surgeon. Department of Califoi ni.i. ai Atascadero
Ranch. Cal.
Chief Surgeon, Department of Colorado, at American
Lake. Wash.
Chief Surgeon. Department of East, at Pine Camp, Jeffer-
son County, N. Y.
Chief Surgeon. Department of Gulf, at Chickamauga
Park, Ga.
Chief Surgeon. Department of Lakes, at Fort Benjamin
Harrison. Ind.
Lieutenant Colonel J. M. Banister, at Fort Riley, Kan.
Lieutenant Colonel A. H. Appel, at h'ort D. A. Rus-
sell, Wyo.
Chief Surgeon. Department of Texas, at Leon Springs, Tex.
The following officers of the medical corps arc ordered
to accompany troops from their respective posts to duty at
the manoeuvre camp, Pine Camp, Jefferson County, N. Y.,
June 15 to Julv 15, 1008:
Kf.ndaIx, W. p.. Major. Fort Ethan Alien. Vt.
Peed, G. P., Captain. Fort Ontario, N. Y.
PiERSON, R. II., Captain. Fort Niagara. N. Y.
Weed. F, W., Captain. Plattsbnrg. N. Y.
Navy Intelligence:
Official list of elianges in the stations and duties of
officers of the medical eorf<s of the United States Navy for
the 'iccek ending May 30, 1908:
Casto,' D. H., Assistant Surgeon. Detached from the
Maine and ordered to the naval station, Guam, L, I.
Gather, D. C, Passed Assistant Surgeon. Commissioned
a passed assistant sm-geon from July 9, 1907.
Holeman, C. J., Assistant Surgeon. Detached from the
naval training station, San Francisco, Cal., and ordered
to the Charleston.
Lane, H. H.. Assistant Surgeon. Appointed an assistant
surgeon from ]\Iay 5, 1908.
McMurdo, H. B., Acting Assistant Surgeon. Ordered to
the na\-al training station at San Francisco, Cal.
Mayers, G. M.. Passed Assistant Surgeon. Ordered to
continue treatment at the Naval Hospital, Mare
Island, Cal.
Munger, C. B., Assistant Surgeon. Detached from the
Supply and ordered to the Maine.
Old, E. H. H., Assistant Surgeon, Detached from the
Naval Hospital. Canacao, P. I., and ordered to Wash-
ington, D. C.
Reed, E. M,. Assistant Surgeon. Detached from the
Charleston and ordered to the navy yard. Mare Island,
Cal.
Warner, R. A., Passed Assistant Surgeon. Commissioned
a passed assistant surgeon from May 3, 1908.
girths, Itarriaps, ani gtat^s.
Born.
Crump. — In Pittsheld, Alassachusetts, on Tuesda\-, May
I2th, to Dr. Irving Crump and Mrs. Crump, a son.
Married.
Bottomley — Kenney. — In Boston, on Wednesday, June
3d, Dr. John Taylor Bottomley and Miss Mary Agnes
Kenney.
Emerson — Skilton. — In Boston, on Wednesday. May
27th, Dr. William Robie Patten Emerson and Miss Edna
Skilton.
Kanar — Ryder. — In Albany, New York, on Tuesday,
May 19th, Dr. William P. Kanar and Miss Margaret
Edythe Ryder.
TowNSEND — Adee. — In Westchester County, New York,.
on Wednesday. June 3d. Dr. Raynham Townsend and Miss
Julia Stanton Adee.
Died.
.Archibald. — In Slaughtersville. Webster County. Ken-
tucky, on Monday, May 25th, Dr. L. A. Archibald,
Bell. — In Hampton, Virginia, on Sunday, May 17th, Dr.
William S. Bell, aged eighty-four years.
Corey. — In Fredonia, New- York, on Monday, May 25th,,
Dr. M. S. Corey, aged eighty-one years.
Davis. — In West Edmeston. New York, on Tuesday,
May 26th, Dr. A. C. Davis.
D-Wis. — In Chicago, on Tuesday, May 19th, Dr. Wilson
H. Davis, aged sixty-five years.
Galvin. — In Louisville, Kentucky, on Monday. May 25th,
Dr. Robert Eninutt (^ahin. aged forty-one years.
Hazard. — In Cincinnati, on Sunday, May 24th, Dr. James
Henry Hazard, aged sixt\-two years.
Hopkins, — In Brooklyn, on Saturday, May 23d. Dr.
George Gallagh.er Hopkins, aged sixty-live years.
Horton. — In Hnmniondsport, New ^'ork, on Sunday,
May 24th, Dr. John T. liorton, aged hfty-one years.
Hyland. — In New .Amsterdam, New York, on Tuesday,
May 26th, Dr. Thomas G. Hyland. aged fifty-one years.
LvoN. — In WTieaton. Illinois, on Sunday, May 24th, Dr.
Ellen Hancock Lyon, wife of Dr. H. N. Lyon.
McGiNLEY. — In Chicago, on Tuesday. May 19th. Dr.
James B. McGinley. aped forty-eight years.
Petti.s. — In Detioit. Michigan, on Friday. May 22d. Dr.
.\. J. Pettis, aged thirty-eight years.
Ravnek— In Philadelphia, on Thursday. May 21st. Dr.
Tliomas Buckley Rayner. aged seventy-four years.
Trowbridoe. — In Buffalo. New York, on Wednesday,
.May 20th. Dr. Grosvenor R. Tr iwbridge. aged forty-five
years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal rlt Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXMI, No. 24.
XEW YORK. JUXE 13, 1908.
Whole Xo. 1541.
^rtainal Cammunitations.
HYGIENE AND MAXAGEMEXT OF PREGXAXCY.*
Bv Austin- Flint, Jr.. M. D.,
Xew York.
That part of the subject which has been assigned
me by the president is a large one. if considered in
detail. I shall therefore take it up in a general
M-ay from the standpoint of the general practitioner
and tr\- to emphasize those points which, in my ex-
perience, are often neglected.
In recent years many important advances have
been made in the management of pregnancy which
are far reaching in their results, for the welfare of
both mother and child. It is not too much to say
that most of the complications of labor and the
puerperium can be forestalled and the dangers ma-
terially lessened by proper prophylaxis.
The first point to impress on physicians general-
ly and on patients is the wisdom of assuming
charge of the patient as soon as the diagnosis of
pregnancy is made. Too often the patient post-
pones the employment of a physician until preg-
nancy is well advanced.
It will be more convenient to consider the man-
agement by dividing pregnancy into three periods
of three months each. The first period comprises
the time from the beginning of pregnancy until
the end of the third month. I am accustomed to
explain to patients that during this time it is nec-
essary to observe the ordinary rules of health. The
changes in the maternal organism are so manifold
and the dividing line between health and disease is
so ill defined that derangements, which in the non-
pregnant condition are unimportant, may in the
pregnant state give rise to pathological conditions
which scriouslv affect the health of the mother and
child.
Under ordinar\- circumstances a patient may be
allowed to lead her usual life without restriction.
She should be encouraged to take exercise in the
open air, limited to walking; eat regularly, but only
of plain food, and keep regular and early hours.
As a rule, a pelvic examination is not necessary
during this period.
\'omiting is the only symptom which needs care-
ful investigation. WTien slight and limited to the
morning, no treatment is necessar\' beyond some
care in diet and perhaps some of the simple tonics.
When vomiting is marked and persistent, an at-
*Read before the Medical Societj' of the County of New York,
in a "Symposium" on Obstetric Prophylaxis.
tempt should always be made to discover its origin.
A convenient working rule is to recognize three
distinct types, neurotic, reflex, and toxaemic.
The neurotic is the most frequent and ordinary'
type, and may be distinguished by the exclusion of
reflex irritation and toxaemia. It ordinarily begins
at about the sixth week and continues until the be-
ginning of the fourth month. Regulation of diet
and removal of constipation, with the administra-
tion of five grain doses of cerium oxalate, will or-
dinarily improve the condition. In some cases
pepsin, bismuth, or small doses of cocaine will pro-
duce excellent results. If vomiting is persistent, a
pelvic examination and an examination of the urine
should always be made.
The reflex type of vomiting is due to some
pathological condition of the pelvic organs, a back-
ward displacement of the uterus being the most
common. Corrections of this condition and hold-
ing the uterus up by a suitable pessary is followed
by a prompt cure. I am one of those who believes
in the good eflfects of dilatation of the cervix, origi-
nally recommended by Copeman. although it is said
that the good eflfects are often due to suggestion.
The results of local treatment in cases where there
is erosion and laceration of the cervix are often
most satisfactory. Ovarian cysts demand removal,
and an early operation should be advised.
If no pathological condition can be found on ex-
amination the case probably belongs to the toxaemic
type.
Toxaemic Type. — Here the condition is properly
called pernicious vomiting. It must be recognized
that pernicious vomiting often begins as an ordi-
nary neurotic or hysterical vomiting, and the pa-
tient may become toxaemic secondarily.
The recent work of Stone, Ewing, and Whit-
ridge Williams has marked the most important ad-
vances in our knowledge of the management of
pregnancy. Until then we knew very little about
the pathology of pregnancy and what pernicious
vomiting really meant. The diagnosis is made by
the results of a chemical examination of a twenty-
four hour specimen of urine. The presence of al-
bumin and casts is significant of renal irritation
only. In toxaemia of pregnancy, there is a pro-
found disturbance of metabolism, indicated by a
diminution of the total nitrogen and a relative in-
crease of ammonia nitrogen. Williams has shown
that the "ammonia coeflBcient in the first half of
jjregnancy varies between four and five per cent.,
but in toxaemic vomiting it rises to ten, twenty, or
even thirt}- per cent."
As soon as the diagnosis of toxaemic vomiting is
Copyright. 1908, by A. R. Elliott Pi.blishing Company.
1132
FLINT: HYGIENE OF PREGNANCY.
[New York
Medical Journal.
made the uterus should be emptied. In hyper-
emesis it is better to interfere too early than too
late. The indication is based as much on the clin-
ical picture as on the urinary findings. I have long
taught that when vomiting is accompanied by
weekly loss of weight, progressive exhaustion, and
failure of the usual medicinal measures no time
should be lost in emptying the uterus.
The change in the nitrogen distribution in the
urine is an absolute indication for early abortion.
The operation should be followed by copious ene-
mata of saline solution, and Httle if any food given
by mouth. Gastric lavage sometimes gives great
relief.
In the second period of pregnancy I consider
regular systematic examination of the urine as the
most important part of the management. This
shoukl be done every second week up to the last
month, when the interval should be every week.
The danger of the occurrence of eclampsia in-
creases as pregnancy advances, and the only way
that we can be forewarned of danger is to insist
upon regular examinations. It is not necessary to
go into details of management under abnormal
conditions.
Diet. — During this period a full diet may be al-
lowed, interdicting only wines and the more indi-
gestible and richly flavored articles of food.
The patient should be instructed in regard to the
value of beginning regular walking exercise, so
that it can be continued without fatigue during the
next period.
Third Period. — This is the time when prophy-
laxis is productive of best results. The points to
be considered are: i. Pelvic mensuration; 2, physi-
cal examination ; 3, diet ; 4, exercise ; 5, care of the
breasts ; 6, examination of the urine.
First.^ — Pelvic examination is now the routine,
almost as much in private practice as in hospitals.
It is the only way that a diagnosis of pelvic con-
traction can be made. When we remember that
contraction occurs in from twelve to fourteen per
cent, of all cases the importance of careful meas-
urements can be appreciated.
About six weeks before the date of confinement
the patient should be instructed to stay in bed, and
a physical examination, including the pelvic meas-
urements, should be made.
I have found that there is seldom any objection
on the part of the patient when its importance is
explained. In cases where the pelvic measure-
ments are small, six weeks allows ample time for
interference.
A diagnosis of position and presentation can
easily be made at this time and confirmed by sub-
sequent examinations made from time to time, up
to the beginning of labor. The size of the uterus,
quantity of amniotic fluid, and the size of the child
should be estimated. In primipara especially, and
in all cases where the child seems large, good re-
sults follow a restricticMi of diet. In ordinary
cases the restriction need be merely general, the
patient being cautioned not to overeat. When real
dystocia is feared the diet may be cut down to the
smallest possible quantity in twenty-four hours.
As pregnancy advances the relative size of the head
and the pelvic brim should be tested from time to
time by trying to push the head down by external
pressure. (Muller's test.)
For many years occasional mention has been
made in obstetric literature in regard to the value
of regulating the diet in pregnant women, with the
object of preventing the overgrowth or full devel-
opment of the child, and so preventing difficult
labor.
This regulation was formerly limited to a reduc-
tion of the proteids, and I have unquestionably ob-
tained good results by this method. A year or two
ago my attention was brought to the results of the
more scientific regulation of the diet, as recom-
mended by Prochownik. Recognizing the high
mortality in premature children when labor was in-
duced for pelvic contraction, Prochownik applied
the principles of dieting, which he had previously
used for reduction of weight in adults, for the pur-
pose of reducing the weight of children born at
term. This procedure was employed as a substi-
tute for the induction of premature labor in cases
of moderate pelvic contraction. The results were
favorable in all instances.
In cases of moderate pelvic contraction, or when
dystocia from other causes is anticipated, Pro-
chownik's diet should have a wider use. Contrar}'
to previous ideas, this diet eliminates as far as
possible all fluids and carbohydrates, allowing pro-
teids and green vegetables, but these only in lim-
ited amounts. Then to fourteen ounces of fluids
during the twenty-four hours was the original al-
lowance. This is a diet which I have never strict-
ly carried out, but have often approximated in
cases where I have feared a difiicult delivery. I
can speak well of its value in preventing oversized
children, and so far have never seen any ill effects.
I have always been extremely careful to watch the
urine closely, and increase the fluids whenever
there seemed to be any kidney irritation. I have
occasionally found a trace of albumin in the urine,
but it has always been transitory, and disappeared
after a temporary increase in the amount of fluids
taken by mouth.
The general health of patients should be care-
fully supervised. An abundance of fresh air and
walking exercise is of the greatest value. Begin-
ning with a walk of at least half a mile during the
middle third of pregnancy, the daily walks should
be increased to two miles during the last two
months, and this can usually be accomplished with-
out fatigue. Nothing will favor preliminary soft-
ening of the lower uterine segment and allow the
head to sink down through the pelvic brim as well
as these daily walks. It is not unusual to find the
head in the excavation of the pelvis and the cervix
soft and partially dilated a week or ten days before
the onset of labor, even in primipara.
During the last third of pregnancy the patient
should be instructed in regard to proper clothing.
An abdominal binder or corset should be worn, so
as to hold the uterus up. and hold the long axis of
the child in the axis of the pelvic inlet.
The corset or abdominal supporter not only con-
tributes materially to the woman's comfort, but its
use is almost necessary during the time of exercise
June 13, 1908.1
FLINT: HYGIENE OF PREGNANCY.
II35
if we wish to produce a preliminary softening of
the lower uterine segment. In cases in which this
softening is marked a short first stage may confi-
dently be expected.
A factor in labor which can never be definitely
prognosticated is the quality of the labor pains. In
a vigorous woman, with good muscular developn
ment and in good health, nothing need be done in
the nature of trying to improve the strength of
uterine contractions. On the other hand, if the
health is below par, if the patient says that she tires
easily and cannot walk as far as she should, and
especially if the pulse is weak, moderate doses of
strychnine, with small doses of quinine, should be
given regularly three times a day for the last six
or eight weeks. This plan has been used by many
observers with results that seem variable. There
is no doubt that, in suitable cases, it is a most val-
uable aid. I have made use of it in a number of
multipara, with histories of prolonged labor, and
have invariably found that it caused stronger pains,
a shorter labor, and guarded against the danger of
postpartum haemorrhage, or a relaxed flabby uterus
after the birth of the child.
Care of the Breasts. — At the time when the reg-
ular physical examination is made the condition of
the breasts and nipples should always be ascer-
tained.
The old saying that "every healthy woman
should nurse her own child" is as true now as it
was years ago. When no attention is paid to the
preparation of the nipples nursing is an ordeal
which is justly dreaded by a woman about to be-
come a mother. When properly prepared for.
nursing should not only be painless, but usually
proves to be a source of intense satisfaction to all
concerned.
Beginning about six weeks before the calculated
date of confinement, the nipples should be painted
over with a solution of tannic acid in glycerin ev-
^ry night and at the same time be manipulated and
drawn out for a few minutes at a time. It is said
that manipulation of the nipples may cause prema-
ture uterine contractions, but I have not seen this
in any of my cases. The patient should be in-
structed to so arrange the clothing that the nipples
are not pressed upon. The recommendation that
the nipples should be bathed occasionally in some
astringent, such as alcohol or bay rum, is also of
value.
Examination of the Urine. — It is especially im-
portant that regular examination of the urine
should be made. This should be done at least once
a week for the last six weeks, in order to be fore-
warned as much as possible in regard to the ever
increasing danger of eclampsia.
A physician does not perform his duty to his pa-
tient who does not make it a rule to personally see
her at frequent intervals during the entire period
of pregnancy. It is impossible to treat the preg-
nant condition in any other way.
Every one who has had even a moderate ob-
stetrical experience knows that a large number of
cases which were formerly regarded as physiolog-
ical really are pathological. As an example, it is
only necessary- to remember that toxaemia is now
known to- be the cause of the vomiting in many
cases which were formerly regarded as physiolog-
ical "vomiting of pregnancv."'
As an illustration that a woman may suddenly,
with hardly any waming, develop a serious condi-
tion in pregnancy, the following unusual case is
briefly reported :
C.\SE. — K M. was admitted to Bellevue Hospital on
April 28, 1905. She was a primipara at term and apparently
in her usual health and had had no previous illness. Two
days after admission, she complained of slight pains in the
abdomen, but it was considered to be of trifling moment.
She was given free catharsis and felt considerably better.
May 3d (three days later), she again began to complam of
pain in the abdomen and back, and in addition vomited
after meals. She was put to bed on a milk diet and a twentj -
four hour specimen of urine examined with negative re-
sults. She then developed headache, slight vertigo, vomit-
ing, and pain in abdomen, which continued until May 9th,
when she v.as transferred to my service at the Emergency
Hospital. The urine on examination on May 7th showed
a faint trace of albumin, specific gravity 1.013, total quan-
tity thirty-eight ounces, and urea 4.5 grains to the ounce;
no casts. Pulse was 80, regular, of good quality and nor-
mal tension. On the day she was transferred, it was
noticed for the first time that she was slightly jaundiced.
Physical examination was negative, excepting that "liver
percussion showed dullness in sixth space, and dull tym-
pany to free border of ribs ; edge not felt," whereas on ad-
mission it was noted as "dull in fourth space, flat in fifth
space." This showed a distinct diminution in the size of
the liver, which was significant of a possible acute yellow
atrophy.
She was put under chloroform and the cervi.x dilated. In
the afternoon, although there were moderately strong
pams, she did not progress rapidly, and in the evening the
cervix was again manually dilated, followed by immediate
version and delivery of a female child. After delivery, the
general condition was good, but she did not sleep, and four
hours later vomited some dark brown material. On May
loth (the next day), condition was fair, she complained of
headache through the day ; was given a calomel series and
saline irrigations of colon. On the iith, vomiting con-
tinued. In the afternoon phlebotomy was performed, and
six ounces of blood withdrawn, followed by a saline in-
fusion of 1.200 c.c, which improved her condition markedh.
She slept quietly, pulse 96. regular, full, of good force and
size. During the evening she had a sudden attack of syn-
cope and became pulseless, with shallow and rapid respira-
tion. She was given oxygen, stimulation, etc. No cyan-
osis. Colon was again irrigated with six gallons of saline
and she improved slightly. She was conscious and rational,
but the jaundice deepened rapidly. During the night she
had muscular twitching of the face and extremities, and
early in the morning became mildly delirious, and com-
plamed incessantly of thirst and pain in the abdomen. Her
condition became gradually weaker during the day; pupils
contracted and pulse almost imperceptible. The jaundice
became more marked and there was a distinct uraemic
odor. She died about 3 p. m.
The diagnosis of acute yellow atrophy of the liver was
confirmed by a careful autopsy by Dr. Norris, the report
of which is too long to be quoted.
The urine examinations on May loth were characteristic.
Amount 1. 000 c.c. specific gravity 1.019; highly colored,
with a heavy sediment of urate? and epithelial cells. The
total nitrogen w as 7.22 grammes : ammonia nitrogen. 0.72S
gramme : urea. 4.32 grammes ; and uric acid, 0.52 gramme.
"Considerable leucin and tyrosin. which forms a large part
of the rest of the nitrogen."
This case was studied by Dr. Ewing and Dr.
Beebe, and the pathological findings incorporated
in papers by them, but so far has not been reported
clinically.
The lesson it teaches, namely, the necessity of
careful urinarv- and physical examinations in all
cases of pregnancy, is obvious.
34 East Fifty-fourth Street.
1 1 34
IJLIENTHAL: SUPRAPUBIC PROSTATECTOMY.
[New York
Medical Journal.
SUPRAPUBIC PROSTATECTOMY IN TWO
STAGES.
By Howard Lilienthal, M. D.,
New York,
Attending Surgeon to the Mount Sinai Hospital.
The operation described in the title has given me
such a sense of security in dealing radically with sn
called bad operative risks that I wish to describe the
method in detail and to illustrate its enormous ad-
vantages with the aid of a few histories. No matter
how feeble the patient, or how desperate the emer-
gency, one may feel sure that by operating in two
stages by the suprapubic route our patient is incui-
ring the absolute minimum of hazard.
As in the modern teaching of mathematics the stu-
dent is made to deduce the rule after having worked
out the problem, so it may be instructive here to re-
count .some typical histories and to deduce from
them the principles which shall govern us in the
treatment of similar cases.
Case I. — J. M., fifty-nine years old, had been suffering
for many years with symptoms of prostatic obstruction.
There were periods of acute prostatism during which the
frequent use of the catheter was necessary, but for months
at a time he would worry along with occasional catheter-
ization and urination by overflow. I'inally he set the day
for operation, but twenty-four hours before the time ap-
pointed a rather severe bleeding began. His physician
tried every means at his command to relieve him, iDut acute
haemorrhage resulting in prostration with great pallor and
small pulse threatened his life, and operation with incom-
plete preparation had to be perform.ed.
Under light chloroform narcosis a suprapubic cystotomy
easily emptied the distended bladder' of its contents — urine
and a large quantity of blood clot. In Trendelenburg's
posture, a bleeding vessel at the most prominent part of
an enlarged middle lobe was easily seen and touched with
the actual cautery. A few gauze packings and tube siphon-
age completed the procedure. There was no more bleed-
ing. The patient soon recovered from the shock of the
rapid depletion, and in four days was once more lightly
anesthetized, and the prostate enucleated through the
original wound.
The man had been told that the second anaesthesia
was for the purpose of removing the gauze packings
from his^ bladder, and not, until he was well on to-
ward recovery did he learn that the operation had
not been completed at the first sitting.
It seems probable that prostatectomy at the tinr^'
of the first operation during the shock of the recent
haemorrhage would have proved fatal.
C.\SE IT. — W. S., sixty-three years old, had for two years
complained of symptoms of obstruction due to enlarged
prostate. The urine had been cleared by urotropin and
there was no history of haemorrhage. Sexeral attacks of
retention. Suprapubic cystotomy under local anaesthesia
was followed by the usual relief which drainage of the
bladder affords, the patient being out of bed on the second
day and wr.lkiug about after the third day. One week
later, in eh! nofoim anaesthesia, the prostate was enucle-
ated. Hacmorhage was very slight. Packings and tube as
usual. The patient sat up out of bed the next day. and in
three days was permitted to walk a little. The urine did
not become clear of l)lood, however, a considerable oozing
gradually going on, so that at the end of another week he
had become quite anaemic and liad to go to bed again.
Astringent washes and efforts to secure haemostasis by the
more usual means were unsuccessfid, so two weeks after
the prostatectomy it was necessary to anaesthetize once
more, elevate the pelvis of the patient and look into the
bladder. The picture was an extremely interesting one.
The prostatic wound seemed to have completely healed, a
deep and wide sulcus having taken the place of the bulging
organ at the base of the bladder. The bleeding came from
an arteriole in the mucous mcmiiranc of the right side of
the bladder, close to the depression where the prostate had
been. This arteriole vvas not in a part of the mucosa which
had been wounded during operation, but lay in an other-
wise healthy fold at least an inch to the right. It is possi-
ble that the tube had ca,used the abrasion. The point was
touched with the Paquelin. Haemorrhage was instantly
checked, and the patient was sent to bed without any in-
travesical packing, and with the tube so short that it barely
entered the suprapubic wound in the bladder. Recovery
was now rapid and uneventful.
The beautiful and perfect exposure with the su-
prapubic incision, aided by Trendelenburg's posture,
made it possible to save this man's life.
Case III. — I was called to see Isaac W., seventy-five
years old, his bladder distended to his umbilicus, his pulse
hard, tongue dry, and his arteries degenerated. He was
cyanotic, and his sensorium was clouded. Catheterization
was difficult, and the surroundings of the patient were such
that instead of emptying the bladder and then partly filling
it with salt solution, I adopted the more ancient custom
of leaving one half the urine within the viscus, advising
an immediate removal to the hospital for operation.
This man's condition was truly alarming, and confidence
in his resisting power was still further lessened by his
gaunt and hollow eyed appearance. On arrival at the hos-
pital he was stimulated with strophanthus and judiciously
catheterized until the next day, when cystotomy, under local
anaesthesia, was performed. Haemorrhage was practically
absent. No vessel had to be tied. After even this slight
operation his condition became so critical that for several
days his death might have been hourly expected. Grad-
ually, however, he improved, and by the end of the second
week he was out of bed and on his feet. T attribute much
of his weakness to the fact that he had been bedridden for two
v. ceks before he came under my observation, a serious error
in the treatment of this disease in the aged.
After the expiration of two weeks the second stage of
prostatectomy was performed under short general anaes-
thesia. Forty-eight hours afterward he was out of bed and
made an uninterrupted though rather slow recovery, the
wound being entirely healed in four weeks from the time
of the second Operation.
Had this man succumbed after the first opera-
tion, the cystotomy, the prostate not having been
touched, it seems reasonably certain that his death
would all the more have been inevitable had the en-
tire operation been performed at one time. Death
after the first operation could certainly not have been
ascribed to suprapubic prostatectomy.
It is hardly necessary to multiply histories of this
kind. They are so similar that little is to be learned
from the repetition, except that each succeeding case
may be approached with greater and greater confi-
dence. The patient is taking his risk in instaltnents.
as it were, and, instead of being put once in great
jeopardy, he has been put twice in comparatively lit-
tle danger.
The advantages of the operation may be summed
up about as follows :
1. The dangers of serious haemorrhage are min-
imized, both on account of the lapse of time between
the two stages, and also because the functional rest
of the bladder after cystotomy greatly reduces the
congestion of the nnicous membrane.
2. The total time of operation, including both
stages, is considerably shortened, the time of general
aufesthesia being reduced not one half, but probably
three quarters. The combined time of the actual
operative procedures is rarely more than seven min-
utes and often less than five. Shock, which is a
combination of the effects of haemorrhage and lengtli
of operation, is therefore greatly reduced, Patients
who succumb after the cystotomy would almost cer-
tainly have died following cystotomy plus prostatec-
June 13, 1908.]
LILIEXTHAL: SUPRAPUBIC PROSTATECTOMY.
I135
tomy ; in fact, a death following cystotomy could not
be ascribed to prostatectomy in two stages.
3. The exploration of the bladder by sight and
touch at the time of the cystotomy is most perfect,
and the surgeon has time between operations to lay
out his plan of attack and to get his patient in excel-
lent physical condition. The suprapubic incision and
the Trendelenburg posture permit of the most care-
ful scrutiny of every part of the interior of the blad-
der, and the operator is given an opportunity of ob-
serving from within the actual conditions and causes
of the obstruction. Preliminary cystoscopy is not
only unnecessary, but extremely ill advised, for cys-
toscopy in the class of individuals under discussion
is by no means without danger. To show how un-
necessary and even misleading cystoscopy may be in
these cases I present :
Case IV. — A. W.. aged sevent>'-six. had hasmaturia and
dysuria for a number of months. Cystoscopy by another
surgeon demonstrated rather doubtfully the presence of
an enlarged prostate, the left lobe being principally in-
volved. I planned a two stage prostatectomy, but at the
preliminary cystotomy an isolated, ulcerated tumor of the
vesical wall was clearly demonstrated and was recognized
as a malignant growth. The tumor was the size of a
silver quarter and occupied a position in the left lower part
of the bladder, above and anterior to the ureteral opening.
I made a wide e.xcision of the tumor through all the
coats of the viscus, reuniting the bladder walls with sutures
of catgut within and silk without. The suprapubic wound
was permitted to drain. The prostate was not enlarged.
The histological report by Dr. Mandlebaum, pathologist
to the hospital, was "squamous celled carcinoma."
The patient rnade a good recovery, dying of a relapse
about a year and a half later. This relapse' did not show
itself for more than a year, during which the patient re-
mained well.
It will be noted that cystoscopy, though performed
by a competent man, was of little value, while cys-
totomy, the pelvis of -the patient being well elevated
and the interior of the viscus exposed with blunt re-
tractors, left no room for error.
4. Preexisting cystitis is cured by drainage and
urinary antiseptics before the prostatectomy proper.
Days or weeks may be required, but we shall have
gained two important factors of safety, a compara-
tively aseptic field and a comparatively healthy man.
The haemorrhagic cystitis following the sudden re-
lief of an over distended bladder has also usually
disappeared by the time we are ready for our second
step.
5. Relief of back pressure on the kidney s with re-
adjustment to normal conditions before prostatec-
tomy.
6. When the operation is performed at one sitting
there is necessarily a considerable pushing away of
the bladder from the abdominal wall, sometimes
opening up the space of Retzius. This is unneces-
sary if a simple cystotomy is perfonned. and at the
end of five or six days firm adhesions have taken
place, sealing the space and avoiding infection.
7. Injury to the rectum is practically unknown. I
have never caused such injury in performing supra-
pubic enucleation of the prostate, nor do I know of
any surgeon who has been unfortunate enough to
meet with this accident. It is comparatively com-
mon in the perineal operation.
'I use the word "relapse" instead of "recurrence" advisedly, be-
cause I believe that the reappearance of the tumor in the cicatri.x
at its original site signifies that its removal has not been complete.
I would suggest that this distinction should be more generally ac-
cepted.
8. The power of performing the sexual act is
rarely interfered with in suprapubic operations upon
the prostate, while it is often lost after even slight
operations in the perinseum. I have several cases in
which sexual — not reproductive — power has even
been increased after the operation.
One disadvantage of suprapubic prostatectomy,
whether in one or two stages, is that, although it
is an extremely safe operation, the convalescence is
apt to be rather slow, the patients usually remaining
in the hospital about four weeks.
I have never seen a permanent suprapubic fistula
after this method of prostatectomy. One case, how-
ever, gave me considerable trouble.
Case V. — T. A., sixty years old, had been operated upon
some years before by a surgeon who had performed a
suprapubic cystotomy by a transverse incision, severing a
considerable portion of the recti. At this time the prostate,
though enlarged, was merely cauterized. The fistula closed
very slowly. Temporary relief was followed by a return
of his prostatism with almost complete retention and con-
siderable cystitis.
I operated by a median sagittal incision, removing the
prostate in the usual way. The fistula at the crossing of
the two cicatrices did not close for several months, but
eventually there was final and complete recovery.
Description of the Method.
If the case is not an urgent one, two days of prep-
aration are advisable. In addition to the usual ca-
tharsis and general preparation it is well to give ten
minims of tincture of strophanthus every six hours
and ten grains of salol three times a day. If cathe-
terization is easy the bladder should be completely
emptied every three hours, day and night, for the
two days. The patient's bladder is emptied on the
operating table and the catheter left in place.
Under local anaesthesia a median incision of from
two to three inches through the skin and aponeu-
rosis is made, the recti are retracted and the bladder
distended with air through the catheter by means of
an ordinary atomizer bulb worked by an assistant.
The finger of the operator detects with ease the
tense, elastic wall of the bladder, and with a blunt
instrument or with the finger the reflection of the
peritonaeum is easily stripped upward and held there
by a blunt retractor. There is little, if any, likeli-
hood of dangerous pneumatic pressure, first, because
the patient will give the alarm, and, second, because
the air leaks out in considerable quantity alongside
of the catheter, so that from time to time the pump-
ing up will have to be repeated. With a sharply
curved needle with silk, the entire thickness of the
bladder is caught in a temporary traction suture,
first on one side and then on the other. A short
sagittal incision between these two ligatures, held
taut by an assistant, opens the viscus and permits of
digital exploration. This opening may then be
stretched with the fingers and the patient placed in
Trendelenburg's posture. Retraction completely ex-
poses the interior. The catheter at once indicates
the location of the internal urethral opening. The
time consumed, without the slightest haste, will not
be more than two or three minutes, and I have fre-
quently entered the bladder by this method in one
minute without hurrying. The operation is extreme-
ly easy. Usually no bloodvessels require ligation.
After the exploration and the removal of calculi
if any are present, a rather large drainage tube is
inserted, the silk traction ligatures are left in place.
1176 GREGORY: PARANOIA. [New York
•J Medical Journai
the space of Retzius is walled of¥ by packings, a
snug bandage is applied, and the patient is sent back
to bed. The next day he should be made to sit up
in a chair. If much c\ stitis is present the bladder
should be washed out through the tube two or three
times a day. In four or five days urotropin or some
similar formaldehyde preparation should be given
instead of the salol : cardiac stimulants as needed.
In three days the patient may be permitted to walk
about, still securely bandaged. He will probably be
wet and uncomfortable, but happy in his relief from
the burden of the catheter.
In from five to ten days, rarely longer, the second
step of the operation may be performed. Complete
relaxing anassthesia for live or six minutes is re-
quired. If the abdominal muscles of the patient are
not relaxed the operation is difficult; if they are re-
laxed, it is easy. Trendelenburg's position is not
essential. If the opening has become small by gran-
ulation it should be quickly stretched digitally. With
a pair of blunt pointed scissors, in the most promi-
nent part of the prostate, on the posterior lower wall
of the bladder, over the middle lobe, if there is one,
a rather deep incision is made. The finger of either
hand searches for the planes of cleavage, and the
tumor is shelled out. This is rather easily accom-
plished. The absence of distinct cleavage is sug-
gestive of carcinoma. This part of the operation
can best be performed with the ungloved finger. If
one finger cannot do the work properly, use two ; if
one hand becomes tired, use the other. The assist-
ant should raise the prostate through the rectum to-
ward the operator. Considerable force may be nec-
essary in detaching the prostatic tumor from its bed.
When working near the deep urethra the exercise of
a little care and the avoidance of undue haste will
prevent injury to the urethra. In those cases in
which the entire mass comes away in one piece, tun-
neled by the urethra, it will be seen on microscopical
examination that the lining of the urethra has been
drawn out of the opening in such a way that no mu-
cosa will be found. If the diseased prostate consists
of a number of adenomatous masses it may be neces-
sary to remove them separately. One should be
pretty sure to remove the greater part or as much as
possible of the enlargement. At times it happens
that the prostate is too large to be extracted through
the suprapubic wound in one piece, although it may
have been detached and lies loose within the blad-
der. It should then be divided and taken away in
several pieces rather than to enlarge the vesical
incision.'
The bladder should now be flushed out with hot
water and the prostatic portion packed with gauze
outside the mucosa in such a way as to obliterate as
far as possible the opening from which the prostate
came. A considerable portion of the mucosa will
at once become adherent to the walls of the depres-
sion, leaving only a small part to be filled in by granu-
lations. This is much better than to pack the raw
prostatic cavity, as was formerly practised. A few
more packings of gauze, carefully distinguished
for future identification from those which go to the
prostatic region, are now placed in the bladder, and
the patient sent to bed with a heavy sand pad over
the lower adbomen. The next day the upper vesical
'This advice would seem superfluous. It has, however, been found
to be necessary.
packings are taken out and a tube put in. In forty-
eight hours the remaining packings may be removed.
During convalescence from the second stage of
the operation the testicles should be well supported,
but in a certain number of these patients epididy-
mitis develops, and it seems to be impossible to avoid
this complication. At the end of forty-eight hours
the patient may sit up in bed, and in three days may
be out of bed. The urine contains blood for several
days after the operation. The first urine by the nat-
ural passages will probably be passed in from ten
days to two weeks after the prostatectomy ; occa-
sionally, when the suprapubic wound was rather
large, urination may not occur for a longer time.
It should not be necessary to pass any instrument
into the bladder by way of the urethra, but it is of
great importance that the viscus be thoroughly
flushed out twice a day through the wound for the
first week after the prostatectomy.'
115 East Seventy-third Street.
PRESENT DAY LIMITATIONS OF OUR CONCEP-
TION OF PARANOIA.*
By M. S. Gregory, M. D.,
New York,
Resident Alienist, Bellevue Hospital.
In opening the discussion this evening I desire
to present to you certain clinical view points
which in my experience have helped me in this
complicated question of the paranoid states. At the
outset let it be understood that I make no pretense
of trying to solve the paranoia problem. We all
know that the origins of paranoid delusion forma-
tion are extremely complicated, and it is not my in-
tention to attempt a complete psychological analy-
sis', notwithstanding its great importance, and in
spite of the fact that it is probably only through
such complete psychic analyses that we may ulti-
mately come to understand some of the more sub-
tle distinctions in this field of psychiatry.
I shall not attempt a complete historical resume
of the paranoia problem, interesting and instructive
though it may be, but shall consider only those later
day conceptions which are still subjects of contro-
versy.
Terms are often idle subjects of discussion, for,
were we to confine our ideas of the term to its
earliest application, we would find that in the
original Hippocratic form the word paranoia was
used both as synonymous with dementia and with
the entire subject of insanity; just as, in the times
of Pinel, works on psychiatry were called treatises
on mania.
But it is not so much with the word paranoia
that we would deal as it is with the later day con-
ceptions of what groups of cases we are to place
in this class, allowing for the gradual modifications
which have came about in later interpretations.
The modern conceptions of paranoia, as I shall
•Dr. Folkn Cabot, professor of genitourinary surgery in the New
York Postgraduate Hospital, and Dr. H. Goldenberg, genitourinary
surgeon to Mount Sinai Hos]iital, have both assured me of their
great satisfaction with this method and both of these gentlcmr-i
have been able to test its merits in comparison to those of other
operations.
•Read before the New York Neurological Society, May 5. >9o8,
in opening the discussion on the subject.
June 13, 1908. J
GREGORY: PARANOIA.
1137
speak of them, have clustered about the under-
standing of what English psychiatrists termed for
many years partial insanities, or moral insanities,
or monomanias ; the French as partial or systema-
tized delusions ; and the Germans under the general
term Verrilckthcit, and Wahnsinn. Esquirol, as
early as 1820, gave us the term monomania, but
Lasegue, in 1852, under the title delire de persecu-
tion, was perhaps the first to fairly set in motion
the more detailed study of this general group of
cases, which, culminating with the classical study
of Magnan in 1882 (Le Delire chronique a evolu-
tion systematiqiic ; gcncrale et partielle) , received,
so far as the French school is concerned, its final
definite form. Arnaud's treatment of the group in
Ballet's monumental treatise does not go beyond
the conceptions of Magnan.
In Germany we can go as far back as 1818,
when Heinroth utilized the term paranoia, but his
psychiatry is so mingled with ecclesiastical meta-
physics that it is impossible to pick out just what
he did mean. Snell in 1865 and Griesinger in
1868, working along similar lines to the French ob-
servers, described the types of Wahnsinn and pri-
mary Vcrriicktheit, while Sanders in 1868 also
described an original V erriicktheit, in which we see
the general beginning of the crystallization of our
present day idea of paranoial form of dementia
prsecox and paranoia cases, out of the mass of delu-
sional patients with relatively unimpaired intelli-
gence. Krafift-Ebing in 1879 again took up the old
Greek term paranoia, applying it to the systematized
delusions in general and following Magnan closely,
and was an adherent of the view that the disease ex-
isted only in a chronic form. Mendel, on the other
hand, in 1893, assumed a more general position, and
described acute 'and chronic paranoias, which, as I
believe, is responsible for most of the confusion in
our interpretations of what should be understood
by paranoia.
(3f the modern students of psychiatry, Cramer
and Ziehen represent the same tendency, and, like
Mendel, they regard the superficial symptom pic-
ture, instead of applying the severe clinical criteria,
which have contributed to establish the ideas of
Kraepelin on a much broader foundation. It
is this same attitude, namely, the overvalua-
tion of certain symptom groups, which re-
gards depression as the equivalent of melan-
cholia, excitement, as synonymous with mania,
and therefore delusional formation and hallucina-
tions are deemed sufficient to establish the group of
paranoia. Thus, from this point of view, a nar-
row, symptomatic test, we have acute and chronic
paranoias, paranoias with and without hallucina-
tions, primary and secondary paranoias, curable
and incurable paranoias, in all of which the chief
criterion is the presence of ideas of influence, of
ideas of observation, of ideas of persecution, etc.,
which become united into a delusional system,
more or less consistent and stable, according to the
type under observation. We thus have such diverse
conditions as postalcohoUc delusional states called
acute paranoias, and if the alcoholic hallucinations
persist, acute hallucinatory paranoias. A similar
interpretation exists for posttyphoid delusional
states ; for postinfluenzal toxaemias, and throughout
the long list of toxic and infectious diseases, in
which mental involvement appears, as it frequent-
ly does, as a disorder in the elaboration of ideas,
leading to delusional interpretations of the sur-
roundings.
Further, in the manic depressive group of insani-
ties, particularly in the hypomanic phases, we may
find at times a well marked delusional system,
which is fairly stable. These are classed by the
followers of Mendel and Ziehen as acute, or as
periodic paranoias, and contribute to the class of
paranoias which recover.
In the same category one must bear in mind
cases of early paresis, of epileptic insanity, of hys-
terical insanity, of senile deterioration, etc., which
may show a picture, at some time in their course,
of delusional formation in which ideas of refer-
ence, of observation, of persecution, are the most
striking features. V^iewed from the narrow stand-
point of symptom picture alone, these patients are
classed, by the authors mentioned, as acute or
chronic paranoias, whereas the fundamental and
essential disorder is something quite different and
the paranoid complex merely an episode.
On the other hand, we have seen the ideas of
Kraepelin develop along an entirely different line.
"The symptom picture of to-day," he says,
"changes slightly to-morrow." Therefore delu-
sions and hallucinations are not to be regarded as
pathognomonic of any one mental disorder; no
one symptom, or small group of symptoms, can be
so regarded ; and he insists on the full considera-
tion of all the facts of the case ; a true clinical sum-
ming up of the whole situation in terms of onset,
course, and termination before we are in a position
to satisfactorily classify our patients. Thus, at
least ten years ago, at one bold stroke, he demol-
ished the artificial barrier that was supposed to sep-
arate the so called intellectual disorders from those
involving the emotions, and distributed the acute
delusional and hallucinatory patients, with rela-
tively intact intelligence, into more natural groups,
as determined by aetiolog}-, course, and outcome.
Paranoia almost disappeared.
"Of what use to us," he says, "is the analysis of
the whole group of disorders of intelligence, with
its finest variations, if through it we cannot at the
same time learn whether the patient will get well,
whether he will be periodic, or simply demented,
or whether he will become crazy in the old sense ?"
"Concerning these important matters we must
come to definite diagnostic conclusions which sat-
isfy us and clear our conceptions." "There is no
doubt that no advance steps can be made if the
universal disease paranoia, which, according to
many alienists, includes seventy to eighty per cent,
of all the insane, is regarded in this manner."
"We know very well that delusion formation and
hallucinations occur in the recoverable and irrecov-
erable cases, in the acute and in the chronic forms,
in the simple and the periodic forms of insanity,
and of themselves, oflfer no definite key to the pro-
gress of any single case."
Kraepelin's application of this idea reduced the
paranoia group in the old sense, as he himself
GREGORY: PARANOIA.
[New York
Medical Journal.
States, from seventy to eighty per cent, of all in-
sanities in asylums to about ten per cent. — which
seem to have fundamental characteristics in common.
However, he even went further and excluded
from this group those cases which terminated, in the
great majority of patients, in a rapidly progressive
dementia, and in whom hallucinations played a
prominent part, thus reducing paranoia as de-
scribed by him to less than one per cent, of the
cases, found in hospitals for the insane.
Whether Kraepelin is justified or not in his
grouping of the large bulk of these cases under de-
mentia prjecox future observation and experience
alone will determine. It is very likely that it com-
prises several groups of closely allied disease pro-
cesses which in the present state of our knowledge
we are unable to distinguish.
Thus summing up the position assumed by
Kraepelin, we are reduced to the consideration of
two groups of cases, the one a comparatively large
assemblage of so called secondary paranoias or
paranoid forms of dementia prsecox, showing the
typical intellectual deterioration, the disorder of
attention, and blunting of the emotional tone with
more or less systematized delusional formation ;
and a still narrower and numerically smaller group
in which the delusional formation is unaccom-
panied by the other attributes of intellectual impair-
ment. So far as the acute cases are concerned
we have seen that they can be excluded, for the
most part, and apportioned to their fundamental
groups as indicated.
It appears to me that this restricted group of
paranoial forms, making up perhaps about ten per
cent, of our cases, can be regarded to clinical ad-
vantage as some of the French writers, especially
Magnan has done, but with slight modifications ;
not that it is any more scientific, but rather be-
cause it possesses certain clinical advantages. This
class may be divided into two general groups with
transition forms — first, those cases in which there
is progressive mental deterioration and in which
hallucinations play a prominent role, and, secondly,
a nondeteriorating group in which hallucinations
are not characteristic, and heredity plays a strong
part.
Within this first group certain further forms
stand out clinically, and I see certain subdivisions
which are fairly clear, as follows: (a) Chronic de-
lusional insanity as described by Magnan. This
is a well known type, and by many alienists and
writers is taken as a model for the description of
paranoia in general, and other forms arc given as
slight modifications. It was first described in a
masterly fashion by Magnan, who in.sisted that this
form must not be confounded with apparently sim-
ilar states and must not be taken as the rei)resenta-
tive of the whole group. He taught that in diag-
nosticating this form, not only certain symptoms,
but the whole clinical picture — its development,
regular characteristic course, and termination —
must be taken into consideration. He divided it
into the well known stages of development, de-
lusional formation, transformation of personality,
and dementia. It is gradual in onset and slowly
progressive. Hallucinations are always present at
some stage of the disease, and play a fairly impor-
tant role. Into this type fall the kings, emperors,
and prophets of the insane asylums who fantas-
tically decorate themselves.
(b) A second group is closely allied to the
former, but differs from it in that it shows many of
the characteristic symptoms of dementia prsecox.
The onset is acute, the delusions are shifting, fan-
tastic, and bizarre, and lack logical formation.
Mental reduction soon supervenes, especially in the
affective sphere. Transfomiation of personality,
if it appears at all, comes on soon and at times very
suddenly. In addition, many dementia praecox
symptoms appear, such as mannerisms, negativism,
stereotypy, etc. Hallucinations are commonly
present, and play a strong part in the disease.
(c) A small group might be made of those cases
in whom the delusional state is circumscribed and
apparently wholly dependent upon hallucinations
and somatic, false perceptions. I refer to a group
of persons who apparently are able to go through
life for many years occupying responsible positions
without suffering any marked mental reduction.
The delusional system is very limited ; the patient
apparently pays little or no attention to it, except
episodically, when he is stimulated by the halluci-
nations and false perceptions.
A brief summary of the following case might be
taken as illustration of this last group :
C.\SE 1. — Miss R., forty years old; unmarried; from
rather neurotic stock. One brother is said to be "nervous, '
probably insane. She is a refined and cultured woman
and for the past fifteen years has been able to support her-
self without much outside assistance. For the past few
years she has been a teacher in the public schools of this
city, which calling she has followed with apparent success.
About fifteen years ago she experienced strange sensa-
tions in her back and about her sexual organs, as well as
in her abdomen. She describes these strange sensations as
being similar to shocks of electricity passing through her
body, especially up and down her "nerve trunk," as she
terms it. This strange feeling would at times take the
form of internal language or words. She at first supposed
she was suffering from a physical disorder, but when she
■began to hear words and this inteinal language, she be-
came somewhat apprehensive and consulting a specialist,
endeavored to get an explanation. She states that she
could get no satisfactory explanation from the professional
man. At the same time her attention was attracted by her
reading to spiritualism and other mystic influences. She
at once decided to investigate these cults, hoping that
they would perhaps throw some light on her trouble. She
consulted spiritualists and others who concern themselves
with occult matters. These authorities gave her a ready
explanation of her condition, stating that spirits were hav-
ing communion with her to some purpose and that her ex-
perience was not in any way out of the ordinary. It was
also explained to her that perhaps evil spirits were working
to carry out the designs of some persons who were un-
friendly to her. After considerable thought she accepted
this, as it seemed to satisfy her more than any other
explanation she could find, .^t any rate, she formed the
circumscribed and limited delusion that perhaps some one
who was unfriendly to her for some reason, and who
possessed power in this mysterious sphere, had been an-
noying her. She states, however, that although she was
very much concerned and worried about the affair at first,
she soon regarded it lightly and did not permit it to inter-
fere with her daily routine life, except when these mys-
terious influences would become very marked, when it was
impossible for her not to take notice of them. This state
•of affairs continued for from fifteen to eighteen years,
during which, as has already been stated, she taught school
and was able to get along without assistance. She is an
intelligent, refined, cultured woman, a good conversation-
alist, and shows a good deal of ability and knowledge in
discussing current topics, and unless she chooses to speak
June 13, 190S.J
GREGORY: PARANOIA.
1 139
about her delusional ideas she shows no symptoms of men-
tal trouble, but impresses those with whom she comes in
contact as of more than average intelligence. When she
talks of her delusions in her endeavor to explain her ex-
perience, she becomes excited and almost incoherent.
However, as soon as the subject is changed, she calms
down and again becomes rational and reasonable. Her
delusional system has not shown any tendency to spread,
is limited and circumscribed, and has remained so for many
years. Her false ideas appear very fantastic when re-
garded in a superficial way, but really, it is a plausible ex-
planation when measured by the doctrine of the cult, which
in itself is fantastic.
This class of patients may be regarded the same
as those in the first group. Perhaps the general
progress of the disease was checked in some iin-
known way, and this diseased condition remains in-
tact without having spread further. The only rea-
son for grouping these patients as a separate one is
for clinical and therapeutic convenience.
2. The second large group comprises the so
called nondeteriorating or degenerative insanities
of the French writers. They differ from the former
group in that they do not terminate in dementia,
hallucinations are not present, and they invariably
show marked hereditary taint. The subdivisions of
this group are:
(a) Chronic progressive paranoia as described
bv Kraepelin, which comprises less than one per cent,
of asylum cases, although represented in a much
larger proportion in the general population. The
salient features of this group given by him are that
the delusional system is "enduring," '"unshakable,"
and "increasingly progressive with complete reten-
tion of the order of thought process." The delu-
sions are reasonable and logical, and are based in
part on facts which are distorted and incompletely
observed. No distinct hallucinations occur — at
least I have never personally met with them in my
exf)erience. False perceptions and misinterpreta-
tions of the environment with retrospective memory
disorder are the basis of the delusional concepts.
After many years some slight mental weakness may
supervene, but there is never any marked deteriora-
tion. Many are capable of carrying out business
and professional undertakings with a certain de-
gree of success. IMany paranoiac reformers, liti-
gants, platonic lovers, and regicides fall into this
group.
(b) A second subgroup can be made of those in-
dividuals who have a psychopathic constitution and
who under adverse conditions develop a paranoid
complex. These persons are eccentric, one sided,
imstable individuals, and might be termed potential
paranoiacs. Occasionally they may be brilliant and
talented in some one direction. A person of this
type, after some disappointment or failure or after
some occurrence which intensifies his natural ten-
dencies and weaknesses, readily develops the para-
noid complex in a typical psychogenetic manner, as
has been so ably demonstrated bv Dr. Mever and
Dr. Hoch.
Their system of delusions, however, unlike the
preceding group, is not broad, progressive, and
comprehensive, but is limited to a particular sub-
ject and its immediate ramifications. They readily
misinterpret and misconstrue ordinary facts in the
light of their delusions, but never show hallucina-
tions. If any hallucinations are present they are
due to extraneous influences, such as alcohol or in-
tercurrent disease, etc. The main deviations of
this type, then, from those of the true paranoia
group are such that the delusional system is Hm-
ited and is the outgrowth of the patient's former
tendencies, intensified by adverse conditions,
which, when removed, permit of a symptomatic re-
covery. The following case is typical of this
group :
Case H. — Male, forty-one years of age; married; tailor;
of neurotic laint ; mother had slight attacks of depression;
fathers sister had a psychosis for many years ; one brother
was eccentric. The patient was a good student, but was erratic,
unstable, and lacked application. He graduated from the
public school. He states that he had been highly sensitive
and unduly suspicious ; that frequently while at school he
thought his friends and schoolmates were against him on
the least provocation, but he would soon discover his mis-
take and correct it. At twenty-two he fell in love, but his
affections were not reciprocated because of a rival. Later,
the patient married the girl in question and they lived
together for nineteen years. His wife was loyal and af-
fectionate. After marriage, on the slightest provocation,
he would involuntarily, as he himself says, become jealous
and suspicious of her, and imagined that she loved his
former rival more than him. He frequently misinterpreted
her statements, but after some remonstrance on her part
he would admit that he was mistaken. At times he would
be sullen and quiet. However, with a great deal of tact
on the part of the wife, they got along fairly well
until four years ago. when his wife developed some
uterine disease and could not perform her marital duties
as often as her husband desired. She appeared, moreover,
to have developed an aversion in this matter, which caused
many quarrels. The name of the former rival would be
repeatedly mentioned, and on some occasions the wife
would unwisely refer to the rival in a commendatory way.
Thus the suspicion and fear that had lain dormant in his
mind for many years began to shape itself into delusions.
The wife, because of incompatibility, left him to live at her
mother's home, which happened to be in the neighborhood
where her former suitor lived. Such a coincidence con-
firmed his fears that something was going on between his
wife and former rival. He engaged detectives to follow
her and this man. On many evenings he would conceal
himself in the neighborhood and spy upon them. He never
obtained any evidence beyond the fact that the man once
or twice passed the house in which his wife lived. But
this was enough to confirm his suspicions. He wrote many
threatening letters to the man, accusing him of improper
conduct, adducing, in proof of the fact, the passing of his
wife's house and other facts equally insignificant and ir-
relevant. A reconciliation with his wife was effected with
many promises on his part, but the condition gradually
became worse. He would come home unexpectedly at dif-
ferent hours, search the house, accuse his wife because the
furniture was slight!}- disarranged, became suspicious of
his food, misinterpreted every movement of his wife, how-
ever insignificant, as being indicative of her guilt.
He was brought to the hospital after a violent outbreak.
He had a fixed delusional system regarding the infidelity
of his wife which he endeavored to support with facts
which were as absurd and insignificant as those just cited.
There was no alcoholic history and no hallucinations were
present. He was an excessive smoker. His friends inter-
fered, and it was arranged that he was to live apart from
his wife, and with some advice he was discharged from the
hospital with the understanding that he was to report from
time to time. .Soon after this his wife underwent a gynae-
cological operation for the uterine disease, in which the
patient had never believed. This seemed to arouse him
and gave the first blow to the integrity of his delusional
system. His enforced absence from his wife and home
led to the gradual disintegration of his delusional system,
and he finally developed insight and has since remained
apparently well.
(c) The third subgrouping includes those indi-
viduals who are constitutionally inferior, who. un-
der the stress of adverse conditions as here out-
1 140
GREGORY: PARANOIA.
[New York
Meuical Journal.
lined, are attacked with a paranoid complex. Con-
stitutional inferiority is here considered as a lack
of full mental development rather than the condi-
tion of disequilibrium, which is present in the
psychopath. These patients, owing to limited in-
telligence and education, when placed in an envi-
ronment favorable to the development of paranoid
ideas, form a delusional system of a very limited
type, due to their lack of full critical power.
These delusions are based on actual facts and oc-
currences which are misinterpreted, and the rela-
tions of the different occurrences are misjudged.
No hallucinations occur unless due to extraneous
influences.
They differ from the preceding group in that
they make no successful effort at explanation when
confronted with the inconsistency of their ideas,
but simply make the positive statement that such
are the facts. Their delusional system is more lim-
ited, and shows no tendency to further progress.
They are more amenable to treatment, and with
proper preventive measures their false ideas can
be made to disappear. As a type of this group the
history of the following case may be given :
Case III. — Male, twenty-four years old; colored; limited
education and intelligence. His mother had given birth to
an illegitimate son, whom she left in the care of her parents
in a southern State when she came to New York. Later
she married, and the patient is the first fruit of the mar-
riage. A few years after her marriage the husband dis-
covered her early history, and after considerable friction
became reconciled to take the child from his grand-
parents and care for him at home. He was brought up as
the elder brother of the patient, and turned out to be a
rather unruly and reckless boy. His conduct, in addition
to the friction between his father and mother, prompted
llie mother to put him into a home, where he was kept
rntil he was eleven years old. He was then left to shift
for himself, and naturally bore considerable enmity towards
her. The patient frequently met his halfbrother, who was
above the average in intelligence, and they became quite
friendly. The elder brother, taking advantage of his
brother's simplicity, poisoned his mind against their
mother, stating that she was cruel and had abused and
abandoned him to an institution ; he also told his younger
brother that he was treated in this manner because the
patient's father was not his father, and his mother, to con-
ceal her shame, had taken steps to dispose of him.
The patient then became quite unruly himself, worked
irregularly, stayed away from home a great deal, so that
his mother thought it necessary to discipline him. Her
action was misinterpreted by the patient, who, remembering
the case of his halfbrother, begpn to become very sus-
picious, and conceived the idea that his mother was trying
to do to hirh what she had done to the brother. Unfor-
tunately, by way of intimidation, she declared that unless
he behaved she would be compelled to place him in an in-
stitution. During his interviews with his halfbrother, who
lived away from home, he narrated his experiences at home
and w'as assured by his halfbrother that he was about to
receive the same kind of treatment that he had. This fact
intensified his suspicion still more, until he I)cgan to mis-
interpret every action made by his father and mother as
being unfriendly toward him. He naturally became more
unruly and disobedient. Matters went so far that it was
impossible to get along with him at home, and his parents
placed him in an institution. This unfortunate step more
firmly fixed the ideas of persecution which were already
forming. In the light of the experience of his halfbrother
he finally came to the conclusion that his mother was not
his right mother. Thus, he formed a delusional trend,
fairly well systematized but v ery limited. While in the in-
stitution he was a model inmate, worked regularly, and was
very obedient and careful in his observance of the rules of
the institirtion. As soon as he was taken home, however,
he immediately began to show his suspicions, misinter-
preting every act on the part of his mother, father, and
little brothers, distorting the facts in the light of his de-
lusions. This condition was intensified by the conduct of
the family, which, of course, was one of resentment and
severity. His suspicions increased, until he would not eat
with the family, and sometimes he would wait until some
one else had tasted the food before he would partake of it.
As his mother thought he was probably mentally un-
balanced, the patient was first brought to the hospital for
examination four years ago. At that time he showed a
limited system of delusions, that his mother was mistreat-
ing him, that she was trying to get rid of him and place
him in an institution ; that he was not treated like the other
children in the family ; and that he overheard many con-
versations between his father and mother relative to him-
self which convinced him that they were about to do away
with him. He stated that ne had taken precautions to pro-
tect himself and tl:at he had at times refused to eat. He
firmly believed that his mother was not his own mother
and that this was the reason he was being treated in this
manner, and as a proof of his contention he cited the case
of the elder halfbrother. When his ideas were attacked,
his defense was extremely weak ; he made no intelligent
attempt to defend his mode of reasoning, simply asserting
that these things were so. He was sent home with some
advice, but shortly returned, as it was impossible for him
to get along at home. Finally an arrangement was made
whereby he was to stay away from home, and not to com-
municate with his family in any way whatever. A place
was found for him where he worked for over a year with-
out having any trouble whatever, and he gave perfect
satisfaction. His employers were much pleased with his
work and could see no sign of mental derangement or even
peculiarity. At this time his mother, thinking that he was
quite well, wished to take him home, forgetting her former
promises. She induced him to go back and live with the
family. For several months he seemed to get along, but
his ideas of injury again took possession of him and so
dominated him that during one of his excited periods he
attacked his mother, for which he was committed to the
Work House. He re_rnained there six months and proved
to be a model inmate; but upon examining him there, I
found that his delusions were not only intact, but much
more fixed and intensified. After he left the Work House
his mother again induced him to live with them. Withm
a few weeks he became excited again, reacted to his for-
mer false ideas, and had to be committed to the hospital.
At this examination his delusional trend had not
only increased, but he was more convinced than
ever that his mother was not his right mother, be-
cause she had committed him to the Work House. He
again agreed to live entirely away from his family, and for
several months has been working, perfectly contented and
happy. His employers are much pleased with the work he
is doing. He has kept away from his home and has not
shown any animosity toward his parents.
The tentative groupings here suggested have
been of great aid to me in clinical work, especially
in the question of prognosis and treatment. To the
layman paranoia is the most widely known of the
insanities, and likewise with it, is associated the
idea of incurability. Physicians are also convinced
of its hopelessness, and we alf share this precon-
ceived idea of certain cases in the paranoia group,
so that we pay comparatively little attention to
them in a therapeutic way. They are usually im-
mediately sent to hospitals for the insane, where
they form a large part of the permanent population
and receive scant medical care. It is usually con-
sidered a waste of time to pay much attention to
this class of cases. There is no doubt that for
most of the groups of cases herein noted a chronic
progressive process is at work, but are not some of
those afflicted amenable to treatment, and cannot
their condition at least be ameliorated? Or can
we not by prophylactic measures in one predisposed
to the disease prevent an outbreak?
For example, the group of psychopathic para-
noiacs where the delusional formation is psycho-
genetic, or endogenous in the sense of Friedman,
June 13, 1908.]
GOLDAN: CHLOROFORM IN NEURALGIA.
1 141
can undoubtedly be benefited by treatment in the
way of judicious regulation of the patient's life,
looking particularly toward the removal of the
causes of irritation, which have given rise to his
false ideas. In some of these cases sanatorium
treatment is advisable, whereas in others it would
only intensify and aggravate the condition.
In the case of the young colored man here re-
ported, hospital treatment, I am certain, would
have settled and fixed the ideas, just as his remain-
ing in the midst of the irritating conditions at
home would have aggravated them. His condi-
tion, while at the workliouse, clearly demonstrated
this.
The same applies to the case of the jealous tailor
who was a psychopath and who was attacked
with a delusional system in close relation to his
former life and personal traits. It is possible that
incarceration in a hospital would have intensified
and fixed his ideas more firmly.
The same holds true in a restricted way of the
deteriorating group to which the case of the school
teacher belongs. She will perhaps eventually de-
teriorate so that it will be necessary to care for
her in an institution. However, she has been get-
ting along fairly well for many years, except at in-
tervals, when her somatic false perceptions, upon
which her delusions seem dependent, become
stronger. Under supervision, at the time of her
periodic outbreaks, it might be possible for her to
get along outside of an asylum for many years.
In other words, in the clinical grouping, as here
suggested, an attempt is made to distinguish those
cases for which, perhaps, something can be done,
and avoid the mistake on our part of regarding the
whole group as made up entirely of the severer and
more hopeless forms.
What is the relation of the genuine chronic
paranoia in the Kraepelian sense to these milder
types? Is it possible that they differ only in de-
gree? Can anything be done for the so called
chronic progressive paranoia in the early stages
and before it has made much progress? These are
questions that recur to me ver\' frequently. I
cannot recall one single case of this type of para-
noia, in which psychoanalysis of the delusional sys-
tem did not show, that at its very inception condi-
tions most favorable to the development of the dis-
ease were present. One can almost invariably
find that most of the unfortunate occurrences fol-
lowed in rapid sucession, and that the patient was
treated by his friends in the very way he should
not have been for the amelioration of the abnormal
ideas in their formative stage.
A grouping of this kind has another advantage
from the medicolegal standpoint. Most of the in-
sane patients who come in conflict with the law
present paranoid ideas. As there seems to be much
difference of opinion among alienists as to what
the term paranoia stands for. for the reasons al-
ready discussed, there are apt to be decided dif-
ferences of opinion expressed from the witness
stand. For one the term paranoia means the whole
group, for the other only one subdivision of the
group. One who has one of the milder types in
mind, which at times recovers, contends that a pa-
tient suffering from paranoia may recover; where-
as the other, having in view the chronic form, in-
sists that it never recovers and is progressive.
Some have in mind the paranoid ideas expressed by
a senile alcoholic, and term it paranoia ; others ob-
served paranoid ideas in a manic depressive and
call it paranoia ; while still others, observing a pa-
tient suffering from mild alcoholic hallucinosis
with paranoid ideas, term it an acute hallucinatory
paranoia, in the Mendelian sense^ and so the con-
fusion goes on. Thus, for lack of a proper agree-
ment as to what each alienist means, when he uses
the term paranoia, there results the confusion of
the court and jury, to the discredit of the medical
expert in general.
In summarizing it may be said :
First — That the grouping of paranoia from only
a symptomatic point of view is unscientific and un-
tenable.
Second — That when measured by complete clin-
ical criteria the paranoia group is reduced to about
ten per cent, of all insanities which seem to have
some fundamental characteristics in common.
Third — That this restricted group is composed
of two essentially dift'erent types, namely, dete-
riorating and nondeteriorating or degenerative,
which should not be confounded.
Fourth — That these two general groupings,
owing to our present limited knowledge, may only
empirically and arbitrarily be divided into other
subgroups: (a) For clinical and therapeutic con-
venience, (b) To bring about an understanding
among the alienists in order to avoid confusion in
medicolegal questions.
NEURALGIA.
Its Specific Treatment with Chloroform Subcutaneoiisly.*
By S. Ormoxd Goldan", M. D.,
New York,
Fellow Academy of Medicine, New York City. etc.
The importance and scope of the subject of neu-
ralgia is so extensive that with the limited time at
my command I wish to bring to your attention espe-
cially the method employed by me for the past ten
years in the treatment of this painful malady. The
great variety of neuralgias treated and the technique
employed make the method practically original. It
is a fact, however, that isolated cases of neuralgia
have been previously treated with chloroform,
though generally at present it has fallen into disuse.
While the subcutaneous injection of chloroform
is exceedingly easy of application, all patients will
not submit to it. The method produces certain re-
actions, such as redness, swelling, etc.. which seem
alarming to some. In acute neuralgia, where the
cause is easily determined, general medical treat-
ment will usually prove eft'ective. Where, however,
after all palliative methods have been unsuccessful,
the patient will be willing to submit to almost any
treatment which will relieve him of his suffering —
in these cases the treatment with chloroform will
prove almost always successful, in fact magical. It
is for this reason I have termed the method specific.
*Read before the Section in Medicine of the New York Academy
of Medicine, April 21, 1908.
1 142
GOLDAN: CHLOROFORM IN NEURALGIA.
[New-
Medical
York
Journal.
Fig. I. — A, Deep injection
In considering the setiological factors in neuralgia
we may mention anaemia ; exposure to cold and wet ;
change of seasons ; vitiated atmosphere ; periodic,
malarial and nonmalarial ; inhalation of irritating
gases ; inhalation of anaesthetics ; neuritis ; organic
and inorganic poisons, alcohol, lead, etc. ; autotox-
aemia ; syphilis.
I wish to direct attention to a frequent type of
neuralgia, "the periodic." Quinine will cure many
of these cases, others will respond to the coal tar
remedies. Where these attacks, instead of appear-
ing at the same time every day, seem to be deferred
to a time later and later each day, we can assure the
patient his neuralgia will quickly cease ; these are
the cases where the coal tar remedies prove more
successful than does quinine.
Autotoxaemia, particularly of the intestinal- type,
is one of the most prevalent causes of not only neu-
ralgia, but rheumatism, and frequently we find both
diseases coexistent. Fortunately in these cases the
same remedies prove equally efficient in both dis-
eases.
Some of my cases treated with chloroform can
hardly be classed as pure neuralgia, as lumbago,
which more properly is a muscular rheumatism and
neuralgia combined. Some of the most brilliant
results with the method of chloroform injection have
been secured in lumbago.
The classes of neuralgia subjected to the chloro-
form treatment may be stated as follows : Trifacial
neuralgia ; supraorbital neuralgia, first branch ; in-
Fic. J— Infraorbital and maxillary branches involv
Fig. 3. — Tortico
fraorbital neuralgia, second branch : mandibular
neuralgia, third branch. Torticollis. Brachial neu-
ralgia. Intercostal neuralgia. Sciatica. Lumbago.
Inguinal neuralgia. Coccygodynia. Plantar neural-
gia. Tendinous neuralgia.
Technique. — This consists in injecting pure
chloroform, in quantity varying from two to ten
minims, into the site of the neuralgic area with an
ordinary sterilized hypodennatic syringe with asep-
tic precautions.
Results.
Facial neuralgia. — In general practice one does
not see facial neuralgia every day. It is about the
most distressing sight one is called upon to witness.
My experience covers seven cases treated with
chloroform ; of these three were of the supraorbital
nerve, one infraorbital branch, and three of the in-
fraorbital and maxillary branches combined. The
treatment resulted instantlv in almost absolute ces-
June 13, 1908.]
GOLDAN: CHLOROFORM IX XEURALGIA.
Fig. 4. — Intercostal neuralgia.
sation of pain. One patient, who has kindly pre-
sented himself for demonstration, had received some
months previously injections with osmic acid. An-
other patient, wlio left the city before I had fully
applied the treatment, wrote me from a r^Iediterra-
nean city that all pain ceased from the first injec-
tion (infraorbital), the second injection (maxillary)
caused some pain when chewing, which lasted only
a few days. The procedure in all of these cases was
to inject two to five drops in five or six sites about
one half to one inch apart in the painful area. Xeu-
ralgia of the fifth pair has always been difficult to
account for ; the teeth have always been looked upon
as an aetiological factor, the patients having one or
more teeth removed, only to find the pain still per-
sist. The probable explanation is, while the teeth
may at times be the cause of pathological changes in
the nerve filaments, the neuritis progresses long after
the original cause has ceased. In the cutaneous
cases it seems to me that only small parts of nerve
filaments are the seat of neuritis and reflexly cause
involvement in large sections of contiguous nerves,
out of all proportion to the extent of the filament in-
volved. The fact that chloroform acts as a curative
agent would indicate that the above explanation is
the correct one. and how it acts I will presently state.
TorticolHs is an exceedingly painful condition.
Five injections were made in each of my two cases,
with rapid but not instantaneous recovery in each
case.
Brachial neuralgia. — I have treated three patients
with complete relief immediately after fairly deep
as w^ell as superficial injections.
• Intercostal neuralgia. — I have had seven patients :
all these were reheved immediately. Injections w^ere
made into the skin, as well as deep between ribs,
with needle of syringe pointing from behind forward
and upw^ard, or from before, backward and upward.
Sciatica. — I have treated five patients with this
Fig. 6. — Inguinal neuralgia.
method; three of these required repeated injections,
with perfect cure. ( )ne patient, while greatly ben-
efited, refused to have subsequent injections. One
patient received no benefit — in fact, was temporarily
worse ; it is interesting to note that this patient had
not solely sciatica, but a phlebitis, involving both
limbs and including the veins of the pelvis. Sciatica
was greatly improved as a result of improvement of
the phlebitis with the treatment with the waters at
Bagnole del Orne., France.
Lumbago. — I have had patients come to my office
almost creeping, to leave within a half hour perfect-
ly free from pain and perfectly erect; these had no
recurrence of lumbago. Up to the present time
fourteen patients have been treated by me with
chloroform, eleven had but one series of injections.
One I am unable to locate ; he was improved at the
time; and one was a somewhat peculiar case. This
patient had not a typical lumbago, but muscular
!I44
■MTULLAGH: MODIFIED CLOT IM MASTOID SURGERY.
(New York
MtDicAL Journal.
pains over the entire back; he was injected repeat-
edly, with more improvement than he had received
in sixteen years, as he stated. His treatment took
about a month; for obvious reasons he did not re-
turn. I concluded he had the lumbago habit.
Inguinal neuralgia. — Two patients ; superficial in-
jections, with perfect results.
Coccygodynia. — I have treated three patients
with this method ; one of these cases was a male.
This patient could not sit, and from his history he
must have injured himself while riding a bicycle;
his symptoms indicated a true coccygodynia. A deep
injection in the region of the coccyx relieved the
condition completely and permanently. Both fe-
male patients required more than one injection; in
one two, in the other six injections were made, with
no return of the trouble.
Plantar neuralgia. — This is an exceedingly pain-
ful condition in the sole of the foot. I have seen
several of these patients, but have had the oppor-
tunity of applying the injection method in but one.
The patient was considerably benefited. He left
the city, but. I subsequently heard from him that
while he remained as free from pain as at the time
the treatment was applied, his condition was at a
standstill. The injections made in this patient were
subcutaneous. I believe had it been possible to
make several injections, some deep, this patient
would have been completely cured.
Tendinous neuralgia. — A fairly large number of
patients recovering from attacks of acute rheu-
matism, with absence of elevation of temperature,
■complain of pain and stiffness about the joints. As
near as I could determine, this pain is located in the
tendons about the joints ; it persists for a variable
time. Small injections of chloroform are made into
the tendons as near as possible, with generally bene-
ficial results ; the patients all became well ; no doubt
with time they would have done so without the in-
jections. This procedure was employed by me in
thirty-two patients.
Explanation of the effects produced. — Neuralgia
is said to be a cry of the nerves for blood. If this
is so, chloroform, by causing an inflammation (I
might say a reparative inflammation), evidenced bv
redness and swelling, determines a new supply of
blood to the nerve filaments through the formation
of new capillaries. W hile other agents have been
used for injection in certain neuralgias, my results
have been universall_\- satisfactory with chloroform.
Any persistent pain which has not yielded to other
medication, chloroform is recommended with almost
certainty as proving efficacious.
Conclusions.
The nearest approach to a specific in neuralgia is,
in my opinion, chloroform.
Tlie method has in my hands proved to be devoid
of any untoward efifects, both immediate and re-
mote.
Chloroform injected locally has no systemic ef-
fects. It has a local anaesthetic efifect, which is de-
sirable.
Superficial injections often act with certainty,
.even when the pain seems to be deep seated.
50 West Seve.vtv-fourtii Street.
THE MODIFIED BLOOD CLOT IN MASTOID
SURGERY.*
By S-'^muel McCullagh, M. D.,
New York.
Although the value of the blood clot method of
healing wounds has been proved both in general
and mastoid surgery, it is strange how little atten-
tion has been paid to it by aural surgeons if an opin-
ion may be formed from published reports, or rather
the lack of them. Undoubtedly the explanation is
not far to seek. At first thought, to a surgeon, per-
haps nothing could seem more irrational and fore-
doomed to failure than the proposal to sew up the
wound made in the Schwartze operation and expect
healing by what is practically first intention. The
approach to so radical a departure from surgical
principles is usually made in a spirit of doubt and
with the expectation of failure. Should such be the
outcome no feeling of surprise is experienced, the
expected having happened, but rather a feeling of
relief that no untoward result has followed, and a
hasty return is made to the old method. The writer
feels that with care in the application of technique
and selection of cases the mastoid wound should
be perfectly healed within a week to ten days in at
least seventy-five per cent, of cases so treated. Fal-
lacious as most prophecies in the field of medicine
have been, except those as to its progress, it seems
as though the ideal mastoid operation has been at-
tained. Doubtless, improvements in the method of
exenterating the bone will come, and, doubtless,
fewer cases will come to operation, but for those
cases which do it is hard to see where, with the ex-
ception noted, further advance is possible.
The writer will confine his remarks in this pa-
per to a consideration of this method as applied to
the Schwartze operation only. He has nothing new
to suggest. His object is merely to reiterate and
emphasize the points already made by those who
have discussed this subject. In rather a cursory
examination of the literature so few authors have
reported cases treated by this method and the papers
of those who have used it are so highly eulogistic
that it is a cause of great wonder that a method
that will shorten the convalesence from a mastoid
operation from four to even twenty weeks and dis-
pense with the necessity of dressings should not
have been more eagerly tried out thoroughly and
given its true standing in aural surgery.
The factor militating most against a more ex-
tended trial is, undoubtedly, the knowledge that it
is impossible to render the wound aseptic and that
blood serum is a very good culture medium. We
seem here to have ideal conditions for the propa-
gation of bacteria — heat, moisture, a good medium,
and bacteria. Every surgeon has seen so many
wounds break down, where the prospect for heal-
ing by first intention was so bright, and experience
had taught him to expect it, that it is not to be won-
dered at that he looks askance at the proposition
under consideration. Reik (i) has thoroughly
discussed this phase of the subject in his paper on
The lilood Clot Dressing in Mastoidectomy,
Physiologically Considered. He says: "The nor-
•Presentcd as a candidate's thesis to the .American Laryngological,
Rhinological and Otological Society.
June .3. I908-J
MrULLAGtl: MODlllED CLOT IX MASTiHD .bL'J<uhR\
1 145
mal human blood possesses bactericidal power, vary-
ing in degree in its antagonism to different micro-
organisms ; this property of the blood is greater
after it is drawn from the vessels than while cir-
culating intravascularly ; the microbe destroying
substance is found in the serum, but is produced
by the leucocytes ; certain chemical changes in the
blood may be induced either to increase or diminish
its bactericidal power, and this property of the
blood naturally diminishes after the clot is forty-
eight hours old.
This microbe destroying substance, according to
X'aughn and McClintock, is nuclein. The bacteri-
cidal power seems to be present in freshly drawn
blood only when it is alkaline in reaction. The
nuclein acts only in an alkaline serum. If alcohol
be added to the blood, the bactericidal property is
destroyed through the precipitation of the albumi-
noid constituent. Bichloride of mercury likewise
has a deleterious influence on the bactericidal prop-
erty of the blood serum. '
The fact of this bactericidal action of freshly
drawn blood being recognized, it is easy to under-
stand how absolute asepsis is not a sine qua non
for the successful outcome of the blood clot method.
This statement should not be taken to indicate that
the slightest lapse from the strictest antiseptic pre-
cautions should be allowed either before, during, or
after the operation. In fact, they should be re-
doubled.
Regarding the manner of healing, Reik further
says : "The -blood flowing into the wound cavity
rapidly clots and the fibrinous framework of this
clot constitutes the scaffolding on which the new
tissue is built. Fresh granulations spring from the
wall of the cavity and grow out into the clot, form-
ing new fibrous connective tissue, the nature of
which is further altered to accord with the char-
acter of the surrounding cavity walls ; that is, if
the wound is made in bone, osteoblasts are sent out
from the bony walls or periosteum to convert the
fibrous substance into osseous tissue. Just how
early this osteoblastic activity commences is not
known, but such cells have been observed to form
within forty-eight hours after the operation, and it
is certain that granulation tissue grows more rapidly
into a healthy blood clot than into space. It is plain
then that Nature may be greatly aided in the re-
construction of destroyed tissue by providing an ex-
cellent framework on which to build, and leaving
her only the task of furnishing vascularity and new
tissue cells."
Technique. — The writer will omit any reference
to the preliminary preparation of the patient, as it
dift'ers in no way from that usually employed.
Neither will anything be said of the operation itself,
except that this method of after treatment obviates
the neecessiy for the removal of any healthy bone
from the posterior wall of the canal. It mav be
well here to urge the necessity for gentle treatment
of the periosteum, care being exercised that the in-
cision through it shall be a clean one and that it is
not maltreated by rough dissection. The use of
the hoe shaped periosteotome is indicated for this
step of the operation. All ragged edges should be
trimmed off before the insertion of the suture.
Marked infiltration of the soft tissues overlying the
bone is no contraindication to suturing, as union by
first intention will take place when this is present.
Xo antiseptics should be used at any stage of the
operation on the bone. If moist sponges are de-
sired they should be wrung out of normal salt solu-
tion.
-Silver wire and silk worm gut are the materials
of choice for suturing. The writer has used the
latter entirely; A heav}' grade is not necessary, as.
w-ith the method of suturing employed there is very
little strain on the stitch. A medium sized Hage-
dorn needle curved through an arc of 180° will be
found most convenient for the insertion of the
suture.
Before the mastoid operation it is well, in every
case, to make a free incision in the drum membrane.
This incision should include the mucous membrane
on the internal wall of the tympanum. The ear is
then irrigated thoroughly with a solution of bi-
chloride of mercury, followed by normal salt solu-
tion.
When the removal of bone is completed the cavity
should be flushed out with a normal salt solution
and sponged dry. A running subcutaneous suture
is then introduced. This is started at the most con-
venient angle and the wound is laced to the other
angle, the stitches not exceeding a half inch in
length. If larger stiches are taken the edges of the
wound cannot be approximated accurately. The
ends of the suture are left long. A piece of rubber
tissue about an inch long, that has been folded four
to six times to a breadth of one eighth to one fourth
of an inch, is now placed between the last two
stitches at the lower angle of the wound so that it
projects about a half an inch into the wound cavity
and the incision is closed by traction on the ends
of the suture. The edges of the wound are coapted
as accurately as possible and the ends of the suture
knotted together loosely in such a manner that there
is no strain on the wound. This is merely for con-
venience of removal. The^ can be cut off, provided
a sulficient length is left for grasping at the time
of removal. A second drain of rubber tissue is in-
serted in the canal and a dressing applied.
The drain that is inserted into the wound cavit\-
is not placed at the bottom of the wound, but very
superficially under the line of suturing. Its object
is merely to allow escape to the excess of serum
expressed from the clot and it remains in place onlv
twenty-four to forty-eight hours. The writer can
see no necessity for the inclusion of gauze in the
rubber tissue — the so called cigarette drain — as per-
fect drainage occurs along the plain rubber tissue
and the danger of the gauze acting as a cork is ob-
viated. For the same reason the middle ear is
drained in a similar manner.
One last word about the introduction of the
suture. \'ery great care should be exercised in this
step to be sure that none of the layers of the skin:
are included, as infection would be liable to occur,,
due to the bacteria resident in the deeper layers of
the skin. This has, doubtless, been the cause of
failure in many unsuccessful cases. Allowing a
factor of safety, the suture should be introduced as
close to the skin as possible, in order that coapta-
tion of the edges may be accurate and the resulting
scar as inconspicuous as possible.
1 146
M-'CULLAGH: MODIFIED CLOT IN MASTOID SURGERY
After Treatment. — At the end of twenty- four
hours the outer dressing is removed and will be
found to have absorbed quite a little serum. The
drain is removed and is allowed to stay out unless
there is a suspicion that the discharge is in any de-
gree purulent, in which case it is reinserted, though
this time only through the lips of the wound. If
the secretion is frankly purulent, the lips of the
wound are separated for a short distance with a
probe, the cavity wiped out with dry cotton and the
drain reinserted. In all cases the drain is removed
from tlie canal, which is wiped dry with cotton and
the drain reinserted.
At the end of forty-eight hours the wound is
again dressed. If the drain has been removed at
the end of twenty-four hours and all is well the
skin wound may be found entirely healed and the
stitch is removed. This should be done by first
withdrawing it a short distance from the tissues,
cutting it as close to the skin as possible and then
making gentle traction upon the other end. The
canal is treated as before and the patient is well, ex-
cept for a daily cleansing of the canal with dry cot-
ton until the discharge has ceased, which should be
wdthin a week or ten days. The wound should be
protected with a dressing and bandage for several
days. The writer has thought it unnecessary to
reiterate his statement that the most minute anti-
septic precautions should be observed ni every step.
Antiseptic solutions can be used as freely as fancy
dictates after the first twenty-four hours, provided
that they are not introduced mto the wound cavity
or canal.
If the drain has been reinserted through the lips
of the wound on the first day on the suspicion that
all is not going well and that suspicion has not been
justified it should be removed permanently and the
patient treated as indicated for an uncomplicated
case, the suture being allowed to remain in place
twenty-four hours longer.
In those cases where infection has occurred both
ends of the suture are cut off, as already described,
and it is removed by traction from the point where
the drain was inserted. By this manoeuvre the
chance of the extension of the infection to any part
of the clot that has held is lessened. If the whole
clot has broken down this precaution is unnecessary.
The wound is opened with a probe as freely as de-
sired, wiped dry, and drainage inserted if any of the
clot remains. Otherwise, the wound is treated so
as to encourage healing by granulation in the usual
way.
A sudden rise of temperature after the operation
should not be taken, per sc. as a cause for the im-
mediate removal of the suture and reopening of the
wound. Unless there is local evidence, such as red-
ness, pouting of the lips of the wound, or frank
purulent secretion, it is well to wait for a time to see
that no other condition is responsible for the tem-
perature curve. A reference to Case II will illus-
trate this point very well.
Indications and Contraindications. — Perhaps the
quickest way to reach the class of cases in which
this method is indicated will be to eliminate those
cases in which it is contraindicated, as even its
u.niiM-t ridvocates will not contend tiiat its applica-
bility is universal. Success cannot, be anticipated in
diabetes, but the writer can see no reason why it
should not be attempted in other constitutional dis-
eases. Sprauge (2) gives as contraindications acute
infectious diseases, tuberculosis, diabetes, and other
chronic constitutional diseases. The writer would
have no hesitancy in striving for primary healing in
all cases suffering from the diseases enumerated,
except diabetes. Even if the vitality is at such a low
ebb that there seemed no probability of success,
should healing by first intention, or even partial
healing, occur, the drain of a large suppurating area
is eliminated or diminished, and a further tax on the
already low vitality is avoided. Should the attempt
fail nothing is lost, but the very painful and ex-
liausting first dressing is dispensed with. Regard-
ing the partial healing of the wound Blake (3) says :
"Later experience has shown that it is perfectly
possible for a blood clot to remain intact in one part
of the evacuated mastoid and to become septic in
another, this forming a basis for primary external
healing in one portion, and in another, breaking
down and necessitating the establishment of drain-
age for the region involved, the healing of this por-
tion of the mastoid cavity being eft'ected by the
slower process of the formation of granulomata."
The great contraindication is, of course, intra-
cranial involvement. Leaving out of consideration
brain abscess and leptomeningitis, the question as to
whether intracranial complications are an absolute
contraindication is still an open one, and one that
will demand more experience with this method be-
fore a definite answer can be given. Sprague re-
ports three cases of sinus thrombosis in which the
blood clot method was used after the thrombus had
been removed with healing in about two weeks, and
Bryant (4) one of epidural abscess with the sami-
result. The writer admits that he would have a great
deal of hesitancy in thus dealing with a case of lat-
eral sinus thrombosis. In cases where a localized
meningitis is the complicating factor, if the condi-
tion appears to have existed for a comparativel\-
long time and the process is localized he would sew
the wound up. Otherwise he would resort to pack-
mg. In view of the results of the writers quoted
above the absolute contraindication is not intracra-
nial, but intradural, complications. In cases in whicli
the dura or sinus have been exposed there should be
hesitancy in adopting this line of treatment.
In discussing contraindications Sprague in hi;-
paper says: "If streptococcus is present in pure
culture and operation is demanded before the op-
sonic index of the blood is sufficiently high to resist
the infection, or nature has not had time to throw-
up her fortifications around the local process, the
l)lood clot should not be attempted, as not only the
clot becomes infected, but the virulence of the or-
ganism is so great that the whole wound suffers
more or less. The stitch holes and along the line
of incision and every freshly opened area is in forty-
eight hours covered with a fibrinous exudate. If we
have no bacteriological examination to help us out.
the duration of the disease from the primary otiti.'-
will be a safe guide, and, all things considered, is
probably the most reliable, even when laboratory
aid is available. It seems to require on the average
June 13, 1908.1
yrCULLAGH: MODIFIED CLOT /.V MASTOID SURGTRY.
1 147
about ten days from the onset of the middle ear
trouble for nature to do her work of fortification.
In my experience all these wounds do better after
this period, and really the cases which have gone on
three weeks do the best of all."
With the exceptions already no.ted the blood clot
method is indicated in all cases of acute mastoiditis.
Let us consider a little more at length the advan-
tages of the blood clot and why it is indicated. The
first and most important is the shortening of the
time of convalescence and the elimination of the
pain and distress of postoperative packing of the
wound. This advantage is particularly gratifying
in the management of nervous patients and children.
The writer ventures to say that there is an element
of selfcomniiseration mingled with the pity the sur-
geon feels for the child upon the operating table as
he thinks of the troublous times in store for them
both during the after treatment. To one who has
had a successful result with the blood clot the result
is so gratifying that there would be a tendency to
overstep the bounds of conservatism were not the
contraindications so sharply defined. The only
thing attended with the slightest degree of pain in
the whole after treatment is the removal of the stitch,
and that is so slight that it can be disregarded. Even
in those cases in which the success of the clot is
only partial, much time and discomfort, if not actual
suffering, are saved. Lastly, in those cases in which
the failure is complete no time has been lost, no un-
toward eft'ects have been experienced, and the very
painful first dressing has been dispensed with.
The element of the length of time required for
healing has already been referred to several times,
and the saving is so tremendous that it seems unnec-
essary to urge it further, but it would seem impossi-
ble to lay too much stress on the reduction of a con-
valescence from a minimum of three to four weeks
and a maximum of several months to forty-eight to
ninety-six hours, exclusive of the middle ear con-
dition.
The gam from a cosmetic standpoint is also very
great. There is no displacement of the auricle and
no unsightly depression back of it. The cavity in
the bone is entirely tilled up, the contour restored,
and all that remains to show that the operation has
been performed is a faint linear scar. Reik says
that in such a comparatively small cavity as the
mastoid it is probable that in some cases the fibrous
tissue is entirely converted into bone by the osteo-
blasts. ,
Illustrative Cases. — The writer cannot present a
large number of cases in which this method has been
used, but in those cases in which it has the results
have been so gratifying that he feels that too much
cannot be said in favor of a trial of the method.
There is no need of giving the history of those cases
in which primary union was obtained, as nothing is
to be said beyond what has already been noted.
However, three of his cases have presented points
of interest which it may be interesting to note as
illustrating some of the contingencies that may arise.
Case I. — W. G., age two and one half years. At the time
of operation the soft parts over the mastoid were inhltrated
to a thickness of at least half an inch. At the tirst dressing
the seriini seemed slightly purulent and drainage was re-
inserted. This character of the discharge persisted, and
although about ninety per cent, of the, wound healed by
first intention a small sinus persisted. This sinus was just
large enough to admit a probe and at its bottom bare bone
was detected. Local treatment and drainage were persisted
in for about two months, r.o packing being used at any time,
with ultimate closure of the wound. Cosmetic result
excellent. Middle ear dry in two weeks. While there was
no saving of time in this case there w as a marked saving of
pain and discomfort, and the writer considers it a success-
ful result in that sense.
Case H. — A. L., age six years. This case was a very
puzzling one. The patient came to the hospital with a his-
tory of an acute otitis media of a week's duration, for
which a paracentesis had been performed the day before
admission. The discharge from the middle ear was free.
The patient was under observation for two days before
operation. On the day of admission the temperature rose
to 104.4° F. and fell, the next day, to 99.2° F. The next day it
rose to 103.4° and four hours later w-as 98° F. There was
no chill or sweat accompanying these fluctuations of tem-
perature. The operation w as performed on the second day
after admission, when the sinus was exposed and found
apparently normal. The mastoid contained pus and gran-
ulation tissue. During the week following the operation
the temperature was very irregular, ranging between
104.4° F- arid normal. The wound was examined daily, but
seemed to be healing so nicely, there being no pus and no
redness of the edges, that, although drainage was allowed
to remain, the wound was not opened up. The main thing
that caused this course to be pursued was the general ap-
pearance and condition of the child, who had not the slight-
est appearance of sepsis. Malaria was thought to be the
cause of the irregular temperature, but there was no en-
largement of the spleen and examinations of the blood for
the Plasmodium were negative. A distinctive count gave
no clue. About ten days after the operation the patient
complained of severe pain in the left side of the chest, ac-
companied by a hard, dry cough, and a sudden rise of tem-
perature to above 104° F. A larval pneumonia was sus-
pected, but all symptoms passed off in a few days and the
temperature gradually returned to normal, where it re-
mained until the patient's discharge. The drain was left
in place for two weeks, and in less than three w-eeks the
wound was entirely healed and the middle ear dry.
In this case the temptation to reopen the wound
and seek the cause of the irregular temperature there
was naturally very great, and had the patient not
been under observation for forty-eight hours prior
to the operation this would undoubtedly have been
done. The general appearance of the child argued
so strongly against a septic condition that this, for-
tunately, was not done. This aptly illustrates the
fact that a postoperative rise of temperature should
not be attributed too hurriedly to the sewing up of
the mastoid wound unless local svmptoms are pres-
ent.
Case III. — -A. G., adult. Primary union occurred in this
case, but the patient continued to complain so much of pain
in the temporal bone that the wound was partially re-
opened. The findings were negative, and the edges of the
wound were allowed to fall together. Prompt healing
again took place, the nnddle ear being dry before the end
of two weeks.
In conclusion the writer would contend that this
method has passed the experimental stage, and
would make a plea for its more extended trial and
a report of results obtained, especially unfavorable
ones, so that the limits of its application may be
more clearly defined. There is still room for ex-
periment in this particular, but the writer feels that
within a very short time packing of the mastoid
wound in imcompHcated cases will be considered as
poor surgery as a mere opening of the antrum with-
out removal of all diseased tissue, and as justlv so.
He would strongly urge that one or two failures be
not allowed to deter from a repetition of the trial, as
SPRINGER: ANESTHESIA.
[New York
Medical Journal.
there is no reason why results identical with those
reported should not be obtained by any surgeon who
attends with care to his technique.
References.
1. Reik, H. O. The Blood Clot Dressing in Mastoidec-
tomy. Physinlngically Considered. Journal of the Ameri-
can Medical Association, March 31, 1906.
2. Sprague, F. B. The Blood Clot Method of Wound
Repair in Aural Surgery. Laryngoscope, September, 1906.
3. Blakf, C. J. P.lood Clot in Mastoid Operation, Fur-
ther Observations on. Transactions of the American Oto-
logical Society, viii, p. 146.
4. Bryant, W. S. Modified Blood Clot in Mastoid Sur-
gery. Annals of Otology, Laryngology, and Rhinology,
September, 1906.
35 Park Avenue.
AN ANALYTICAL STUDY OF SIX HUNDRED
CASES OF ANAESTHESIA.
By Harold L. Springer, M. D.,
Wilmington, Del.,
.Surgeon to the Delaware Hospital.
In presenting for your consideration a review
of this series of cases, I shall not attempt a sys-
tematic study of this subject for various reasons, but
shall confine my remarks to those points that have
impressed me as being of greater interest and im-
portance in the administration of anaesthetics, par-
ticularly ether and chloroform.
Ether was given in eighty-eight per cent, of cases
and chloroform in twelve per cent. Of those given
ether, two per cent, were begun with chloroform.
Never more than a drachm of chloroform was used
and often less, ether being substituted as soon as the
patient became quiet.
Ether was preferred in cases of organic disease of
the brain, heart, and bloodvessels, and chloroform in
cases of lung or throat disease, alcoholic, and ner-
vous persons, and where great rapidity was desired.
The average time to produce anaesthesia was ten
minutes, varying from three minutes in several in-
stances in children to twenty minutes in more diffi-
cult cases. The patient was considered anaesthetized
when complete relaxation was obtained. The pupils
were not used as an index at this stage, for in some
cases they remained responsive to light during the
entire operation. As a rule, however, moderate sec-
ondary dilation of the pupils is the best guide to
complete unconsciousness, and my experience leads
me to believe that the interval of safety between the
loss of the corneal reflex and failure of perspiration
and the heart, is greater than ordinarily supposed.
I agree with Thomas, who says that the corneal re-
flex is not to be depended upon at any stage, espe-
cially if muscular relaxation is desired, for this re-
flex varies so much in different individuals that, on
the whole, I think it is safer to ignore it altogether.
The total time that each patient was under the in-
fluence of the anaesthetic varied from fifteen minutes
to four hours, the average being one liour and fifteen
mimites.
The average patient gave the first definite sign of
return to consciousness in five minutes after the
anaesthetic was stopped. Children seemed to re-
cover sometimes almost as soon as the inhaler was
removed. Cases in which the patient is several
hours recovering are due to careless methods and to
an overdose of the anaesthetic.
The average total amount of ether used was eight
ounces, two and one half to produce and five and
one half to maintain the narcosis. The average
amount of ether used during the first hour was six
ounces, and during the second hour was three
ounces, and the quantity became less for each suc-
cessive hour. In one case of this series the opera-
tion was of four hours' duration, and the quantity of
ether used was five and one half ounces for the first
hour, two and one half for the second, and one half
ounce for the third and the fourth, making a total of
a little over nine ounces for the four hours. In an-
other instance thirty ounces were used in an opera-
tion of only one hour duration. The patient was an
alcoholic and had taken ether twice before. It re-
quired more ether to produce narcosis in alcoholics
and individuals who had taken it before. In several
instances it was impossible to secure relaxation with-
out the aid of chloroform. An extremely nervous
person always required more of the drug than a less
apprehensive one.
One of the greatest sources of annoyance to both
patient and anaesthetizer is the vomiting that occurs
from ether or chloroform". It does not occur in
every case, and it was this difference in behavior
on the part of the patients that induced the writer to
commence this record.
In this series of cases twenty-five per cent, of the
total number of patients vomited at some time dur-
ing the narcosis, and nearly all toward the end of it.
Often it was the first sign of returning conscious-
ness. A few times it occurred 'at the beginning.
Vomiting rarely occurred after the use of chloro-
form or after ether when chloroform was used to
start the anaesthesia, and when it did occur there
was always noticeable an unusually large quantity
of mucus. This hypersecretion was more marked
when nervousness or excitement was present, and
sometimes interfered seriously with breathing.
Choking and struggling followed, and more ether
was given. Thus, saturated saliva and mucus was
swallowed in large quantities, and from these rec-
ords the mucus would seem to be the cause of the
trouble. In other words, the mucus and ether, by
its irritant action on the stomach, caused vomiting.
The figures are very suggestive. Twenty-six per
cent, of the cases were associated with an excessive
amount of mucus, and every one of the patients vom-
ited. Twenty-four per cent, of the ^otal number of
patients vomited ; the remaining two per cent, vom-
ited from some other cause.
Vomiting may be prevented in some cases by di-
recting the patient to drink one or two glasses of
water about an hour before the operation, and pro-
longed vomiting may be stopped in certain cases by
drinking one or two glasses after the operation. The
latter acts the same as lavage, and lavage is a sure
cure for uncontrollable vomiting.
r-'or these reasons there .seems to bo strong cause
to believe that in the large majority of cases vomit-
ing is due to the irritant action of ether on the stom-
ach, and that, while many patients will vomit in
spite of all that can be done, the slow, cartful ad-
ministration of ether, drop by drop, will prevent it
in many instances.
^i=/</A G£i? : AX^STHESJA.
1 149
That form of vomiting that occurs sometimes at
the beginning of the narcosis in cases of intestinal
obstruction is a very serious comphcation. and it be-
hooves the anaesthetizer to be on his guard. It is
really a regurgitation, and the patient literally
drowns in his own vomitus. In cases of this sort
the patient should be anaesthetized in the Fowler po-
sition and the stomach washed out before the anaes-
thetic is given.
Aspirative pneumonia is a serious sequel of vom-
iting, although fortunately very rare. It is not, how-
ever, the usual type that follows the administration
of an anaesthetic. Pneumonia practically never oc-
curs after the use of chloroform, and very rarely
after ether. In the majority of cases it is not a true
pneumonia, but is, as Murrell notes, a catarrhal
bronchorrhcea followed by oedema of the lungs.
True pneumonia does occur, however, and is due to
the irritation of ether or unnecessary exposure and
chilling of the patient. It is especially liable to follow
the use of ether in a patient that has a bronchitis. It
rarely occurs in private as compared with hospital
practice, and may be guarded against by having the
mouth cleansed and the inhaler clean, by having the
head turned to one side in order that fluids may
escape from the mouth, and by using pure ether and
as little of it as possible.
Oxygen was administered in four per cent, of all
the cases as a necessity, and in 100 cases routinely,
to note the effects. The results in every instance
were very satisfactory-, and when chloroform was
used, oxygen was often indispensable. The return
to consciousness was undoubtedly more rapid than
when oxygen was not used, and in cases of respira-
tory embarrassment, • the change of color from
bad to good was often truly miraculous. I have
come to regard oxygen of so much importance that
I would rather be without drugs than without oxy-
gen. The value of the anaesthetic is increased as
regards safety to life without decreasing the anaes-
thetic eflfect. Gwathmey proved this by his experi-
ments on cats. His figures show that, regardless
of the air used., animals lived twice as long wuth
oxygen as when air alone was used. The same ex-
periments show that a mixture of chloroform and
oxygen was more than twice as safe as a mixture of
chloroform and air. This seems to indicate that
chloroform is safer than usually believed, and, in
fact, some authorities assert, as safe as ether, unless
g^ven by the inexperienced. At any rate, the use
of oxygen with ether, and particularly chloroform,
eliminates a large element of danger.
Struggling and extreme excitement during the
fir-st stage of anaesthesia may be avoided in ninety-
five per cent, of cases, according to my statistics, by
the drop method of administration and careful man-
agement. Thus one, if not the greatest, objection to
ether on the part of the patient can be eliminated in
this manner. Alcoholics will usually be an excep-
tion to this rule, as will persons who have taken
ether before. In these cases if chloroform is used
to commence the anaesthesia, the trouble will be
overcome.
Eight and two tenths per cent, of the patients had
taken ether before, varying from one to tive times.
They were all without exception more difficult to
get under the influence of the anaesthetic. Engel-
hart"s belief that the red blood cells assume an in-
creased resistance to ether in the same manner that
they do to other haemolytic agents, such as toxines,
is to my mind an untenable one.
The operations performed were of all varieties.
Seventy-five per cent, were major operations, and
eleven per cent, were fatal cases, death occurring
within the next forty-eight hours. The fatal termi-
nation may have been hastened somewhat in a few
cases, but death from the anaesthetic alone occurred
in only one case. This was a man aged sixty years,
who, after a long operation, died of oedema of the
lungs.
The patient's general condition was carefully
noted before and after the operation. The heart and
lungs were gone over, the urine examined, and the
pulse counted just before the operation. Ten per
cent, had heart murmurs, although not one of the
patients experienced any difficulty. Seven per cent,
had a more or less severe bronchitis, and only two
of them were attacked with pneumonia.
Eighteen per cent, of the patients required treat-
ment during the operation or within an hour after it.
Two and three tenths per cent, of those anaesthetized
were alcoholics, and gave trouble from start to finish.
A peculiar erythema of the face, neck, and upper
part of the chest was present in three and seven
tenths per cent, of the cases. It appeared only after
the use of ether and always during the first stage
of the narcosis. It persisted for from five to thirty
minutes and gradually faded as the anaesthesia pro-
gressed, until it had completely disappeared.
The method of administration was the drop one,
and the AUis inhaler was used in the large majority
of cases. Sterile gauze will answer almost as well,
but it is impossible to prevent the ether from coming
in direct contact with the face, and there is greater
danger of the ether getting into the patient's eyes.
Before starting the anaesthesia foreign bodies
were removed from the mouth, all persons that
were not absolutely essential were asked to leave the
room, and everything made ready for any emer-
gency that might arise. The inhaler was then placed
over the face without any ether upon it, and the
patient instructed to breathe deeply. In a few mo-
ments he became more or less composed, and then
the ether was poured on, drop by drop, very slowly
at first, gradually increasing the amount as the
patient became accustomed to the vapor. At this
stage choking and strangling indicated that the
anaesthetic was being pushed too rapidly. When
relaxation of the upper extremities was obtained the
patient was taken to the operating room. The fol-
lowing may be regarded as the most reliable signs
of surgical anaesthesia :
1. Deep, regular respirations, often accompanied
by snoring, and var\'ing in rate from 20 to 40 per
minute. A change in the character of the breathing
means usually that more ether is needed, and a long
sigh always means the same thing.
2. Absence of swallowing movements is a sign
that the patient is sufficiently under the influence of
the anaesthetic.
3. The pupils should be moderately contracted and
frequently will respond to light slightly during the
entire narcosis. In my experience it has never been
necessary to have the pupil completely paralyzed.
1150
SPRINGER: ANESTHESIA.
[New York
Medical Journal.
A sign which is of great importance in this connec-
tion is a pecLiHar jerking or nystagmus of the eye-
balls. It may be described as an irregular tremor
of both eyeballs that occurs during anaesthesia.
Sometimes it is only a rolling of the eyes. It is
present if the patient is not too deeply anaesthetized,
and is lost when the pupil becomes paralyzed to light.
This sign is a very good one to depend upon, both
to indicate the degree of anaesthesia and the limit
of safety. It was present in every case of this series.
4. Complete muscular relaxation is perhaps the
most constant and reliable sign of surgical anaes-
thesia, the masseter being the last to relax. Occa-
sionally the patient will fail to relax, although every
other sign of deep narcosis is present, and more
anaesthetic has no efifect. If under such circum-
stances the inhaler is removed and he is allowed to
breathe air for a few seconds, and then continue the
anaesthetic, relaxation will usually occur promptly.
The average time to produce anaesthesia from
chloroform was three minutes, and the average
amount required was thirty drops to a drachm.
Vomiting after its use was rare, and there was prac-
tically no stage of excitement. Chloroform was
never used unless there was a special indication for
its use, and never routinely, as in the South. The
color of the skin and the pulse were considered the
best guides to safety.
In a review of the comparative dangers of ether
and chloroform, we find that they produce anaes-
thesia in the same way, but their secondary actions
are dififerent and distinct. Chloroform depresses
markedly the heart and respiration and lowers blood
pressure, while ether has no such effect until the
toxic limit is reached. The working limits of chlo-
roform are much less than ether, hence accidents due
to an excess of the former are more to be feared,
and, moreover, prolonged anaesthesia is better borne
with ether than with chloroform.
Lull's statistics showed one death in 2,948 cases
of chloroform anaesthesia to one in 13,986 of ether,
making ether about five times as safe as chloroform.
Fatal terminations from chloroform usually occur
suddenly from circulatory failure, but sometimes
death does not occur until hours afterward. Autopsy
shows a fatty degeneration of all the organs.
Most observers agree, and they are borne out by
clinical experience, that ether undoubtedly has many
advantages .over chloroform which justify the in-
creased favor that it enjoys, and that while chloro-
form is the more nearly ideal anaesthetic except from
the standpoint of safety, it is much more dangerous
than ether, and particularly so in the hands of the
inexperienced.
In anticipation of trouble, a well matured plan
of action should be in mind and everything in readi-
ness to meet any emergency that may arise, for acci-
dents often happen without warning, and delay at
this time would be fatal. The anaesthetic should be
taken away and the patient given proper stimulation.
In my hands the most satisfactory results were ob-
tained with ammonia and oxygen, but others should
be used. The difficulty often is that before any
active measures can be instituted the patient is in
collapse, and there being no arterial pressure, the
drugs are not absorbed. Cold to the abdomen and
neck, and electricity, may be tried, as may dilation
of the sphincter ani. Tongue forceps and mouth
gag are rarely necessary, and the use of the former
is not often justifiable, on account of the severe
laceration of the tongue which it produces. Turn-
ing the head to one side and pushing the jaw for-
ward with the thumbs behind the angles will usu-
ally be all that is necessary. Efforts at resuscitation
by mechanical means should be tried, but should
never be so violent as to cause physical injury.
Recent contributions prove that cardiac massage has
a most useful field, and one which appears to have
been of value mostly in cases of syncope following
chloroform anaesthesia. While not having had any
experience with it personally, I think that, in a case
of last resort and after all other measures have
proved ineffectual, massage of the heart should cer-
tainly be attempted.
That the life of the patient in many cases rests
with the ansesthetizer is a fact not generally appre-
ciated. He should remember that he holds the life
of the patient in his hands, and should allow nothing
to hurry him, not even an impatient surgeon. All
of his thoughts should be concentrated upon his
task, but too often he is more interested in the details
of the operation than in the anaesthetic.
The administration of the anaesthetic is a task usu-
ally relegated to the least experienced resident phy-
sician in hospitals, or in private practice to the
family physician out of courtesy, often the very
person least capable, the reason being that these
persons are usually out of experience. To be a good
anaesthetist one must give ether or chloroform con-
stantly. The administration of these two drugs is
really a specialty in itself, and a successful anaes-
thetist must be fitted for his task, which can be
accomplished in one way only, by experience. He
should have sufficient tact and sympathy to give the
patient confidence and be able to allay the natural
apprehension and fear of the anaesthetic. A careless
anaesthetist often allows his patient to come partly
out of the influence of the drug, and then crowds
it at the command of the surgeon to prevent the
complete return of consciousness. The patient is
sure to give trouble under such conditions. On the
other hand, the skillful etherizer keeps his patient
constantly under, and avoids the mouth gag and
other troubles, with the result that there is quietness
and complete relaxation throughout the entire opera-
tion.
Therefore, in conclusion, let me urge that the im-
portance of this subject be given more recognition
by medical colleges, and each student receive more
individual instruction and experience. Furthermore,
let me urge that in hospitals the anaesthetizer be the
most experienced man on the interne staff instead
of the least experienced.
ConclHsio)is.
1. Ether and chloroform are apparently the most
satisfactory anaesthetics.
2. Ether is safer than chloroform, l)ut under cer-
tain circumstances, when chloroform is desired, the
risk may be materially lessened by giving oxygen
with it.
3. The average patient was ten minutes I)cconiing
anaesthetized and it required two and (.no half ounces
of ether to obtain this condition.
June 13, 1908.]
MASOX: PRURITUS AM.
4. The average length of time of the operation
was one hour and a quarter, and it required five and
one half ounces for this time, or. in other words,
about six ounces were used during the first hour,
and about three ounces for the second hour.
5. While most of the evidence at hand points in
favor of A'omiting being due to a centric disturbance
in ether anaesthesia, these records show a close rela-
tionship between excessive secretion of mucus and
vomiting.
6. In the treatment of accidents most dependence
may be placed upon ammonia in the form of inhala-
tion, and oxygen.
7. The more remote consequences of anaesthesia,
such as status lymphaticus, acetonuria, acidosis,
hepatic toxaemia, etc., must not be lost sight of, and
general anaesthesia should be preceded by a thor-
ough examination of the heart, lungs, and kidneys,
1013 Washixgtox Street.
PRURITUS AXI.
Its Cause and Treatment, with Especial Reference to the
Use cf the Ron t gen Rays.
By R. D. Mason, M. D.,
Omaha, Neb.,
Professor of Rectal and Pelvic Suigery in the John A. Creighton
Medical College; Surgeon to St. Joseph's Hospital.
This is the most intractable disease that the rectal
surgeon is called upon to treat. It is often spoken
of as a trivial matter, yet I have had patients who
were almost physical wrecks, due to the loss of
sleep, worry, and nervous irritation. I believe that
in its early stages it always has some well defined
cause which, if searched for and removed, will cure
the disease. A little later, however, the terminal
nerve filaments become affected, and. even though
the cause be removed, or has long since passed away,
the itching will still remain.
The skin becomes thickened and parchment like
and the nerve endings seem to be pressed upon and
constantly irritated. In these cases nothing will give
permanent relief except the destruction of this al-
tered tissue and the formation of new skin. There
are several ways of doing this, all differing in meth-
ods, but aiming at the same end ; of course, if there
is any cause that is keeping up the irritation, it
should be removed. It would be very unwise to try
to cure a pruritus due to eczema, pin worms, fistula,
haemorrhoids, rectal catarrh, ulceration, etc., with-
out first removing these.
Dr. Bulls, writing in the British Medical Journal,
says : "At a recent meeting of the British Medical
Association, at Oxford, an interesting discussion
took place, in the section on dermatology, on the
causation and treatment of pruritus ani ; any one
reading that debate cannot fail to be impressed with
the numerous numbers of distinct diseased condi-
tions to which this annoying symptom was attributed
by the various speakers, and, large as the number of
supposed causes assigned were, the various plans of
treatment advocated were still greater."
This disease is characterized by the most intense
itching, which is worse when the patient gets into a
warm bed. Patients have told me that pain would
be a relief and would be willingly borne in prefer-
ence to the pruritus. Many patients do not consult
the physician until the disease has become chronic,
and it is then most difficult to tell what may have
been the cause, as the symptoms may remain, even
after the cause has long since passed away.
They will usually try all sorts of remedies before
consulting a physician, and when they finally do, the
relief is often so transient and unsatisfactory that
they drift from one to another with but little bene-
fit from any treatment advised. They are likely to
think that but little interest is taken in their case,
and go from bad to worse, until, by the time thev get
ino the hands of a rectal specialist, they are often in
a serious condition.
In my opinion the disease is caused in the great
majority of instances by an unnatural discharge of
moisture about the parts ; this may be brought about
in various ways and by so many different conditions
that a most careful search should be made to deter-
mine its source before any treatment is started.
As before stated, in chronic cases the cause may
have disappeared, or if present its removal may not
end the trouble, as the skin has become so thickened
and thrown into folds that only its destruction or
removal will effect a cure. The irritation that causes
the catarrhal discharge may be internal or external
haemorrhoids, chronic proctitis, ulceration, fistulas,
especially the small submucous variety with no ex-
ternal opening, pin worms, hard dry faeces which
irritates the parts, the lodging of irritating matter
in the so called rectal pockets, the growth of small
polyps, or in fact anything that will cause an irrita-
tion.
Some of the patients who come for treatment are
afflicted for the first time, and the cause may be
some error of diet, excessive smoking or drinking,
and but little treatment is necessary to effect its re-
moval. After many years of study of this disease
I have arrived at about the same conclusion as Wal-
lis, of London, who attributes it to a small, shallow
ulcer just between the sphincters. He says:
In over ninety per cent, of the cases so examined the
shallow ulcer mentioned was found situated, usually be-
tween the two sphincters, more often in the posterior half
than in the anterior, and generally in the dorsal midline;
in some cases there is more than one ulcer, and. again in
others there are various clefts which occasionally almost
surround the bowel. This ulcer is not easy to recognize
by the touch, and it requires a certain amount of practice
to appreciate its presence. In the first place, it must be
remembered that it is only just within the anal margin, and
always below the internal sphincter. The smooth feeling
of the healthy lining membrane will be recognized, but
when the finger comes onto this abraded or ulcerated sur-
face the smooth feeling disappears, and a slightlv raised
margin can be felt around the rough surface, there is
sometimes pain, but more often none, associated with the
examination. When the speculum is introduced, it must
be remembered that the tissues are pushed in, some little
way, by the instrument, and therefore the ulcer will appear
higher up than it really is. If after its introduction the
speculum is opened to its fullest extent, the inexperienced
observer will probably not recognize the ulcer; but if the
speculum is only slightly opened and, when possible, a care-
ful view with a headlight is obtained, the ulcer can be
clearly seen as a shallow oval, livid abrasion, differing
markedly, and mainly in color, from the normal mucous
membrane. Here, then, is a definite lesion, in a so far in-
definite disease, and it seemed reasonable to believe that it
might be the cause of the irritation.
I have spoken of this little ulcer in my book on
1 152
MASON: PRURITUS ANI.
[New York
Medical Tolrnal.
rectal diseases,' and further experience only confirms
my opinion of its importance. It should be under-
stood, however, that it is not the uker itself that
itches, but it is the discharge flowing over the parts
that causes the trouble. The skin becomes thick-
ened and infiltrated, and loses its vitality. The nerve
endings are compressed by the pressure made on
them causing an irritation, and itching is the result.
Symptoms and Diagnosis. — These are so evident
that the patient will have arrived at a diagnosis be-
fore consulting the physician. He will probably
say that he has "itching piles," as he is unable to
recognize the cause of the trouble. His whole
thought is how to get rid of the intolerable itching,
which is simply wearing his life out.
Upon examination the first thing that will be no-
ticed is that the skin about the anal margin is thrown
into folds or ridges, and that it looks unnaturally
sodden and dead ; also in most cases there will be
seen an unusual amount of moisture coming from
the bowel above. This roughness and moisture are
often the lurking place for dirt and lint from the
clothing, which collects here and irritates the parts ;
even those of cleanly habits are unable to avoid this.
An eczema is generally present, often extending
over a large area, and the marks of finger nails may
oe seen, showing the results of scratching. This
chronic eczema is very hard to heal, and does not
respond to the ordinary remedies used for this dis-
ease.
Careful search should be made for some of these
conditions which I have mentioned, in order to ar-
rive at some conclusion as to the cause of the trou-
ble. This should in all circumstances be removed,
although, as before stated, it may not cure the dis-
ease.
Treatment. — The most important thing is to find
the exciting cause and remove it ; this in recent cases
will effect a cure. If the skin has become thickened
and rough, some method must be adopted to bring
it back to as near its normal condition as possible.
In some cases this seems to be beyond the reach of
drugs, and only to be accomplished by the destruc-
tion or removal of the skin. A plan that has given
me good results is the application of a ninety-five
per cent, solution of carbolic acid to the affected
skin ; I sometimes use a saturated solution of silver
nitrate instead of the acid, as suggested by Adler.
The epidermis peels off in a few days, leaving a
somewhat tender surface, that should be treated
with soothing ointments, such as the ointment of
zinc oxide.
After an interval of two or three weeks the acid
should be put on again. This may have to be put
on several times before the skin becomes natural.
Sometimes there are large, warty ridges almost re-
sembling piles. I never waste time with these, but
simply cut them off and let the space fill in by gran-
ulation. The intervening and all surrounding tissue
is treated with the acid.
This seems like rough treatment, and so it is, but
it should not be forgotten that we are dealing with
a most stubborn disease, and decisive measures must
be adopted to bring about a cure. Some patients
object, but the majority are willing to submit to
anything that promises relief. After all, it is not so
'The Office Treatment of Rectal Diseases, by R. D. Mason.
painful, as the acid acts as a local anaesthetic, and,
while it burns somewhat, it is a comfort, as it stops
the terrible itching.
The following case illustrates the benefit? of this
method of treatment.
Case. — Mr. W., age forty, treasurer of an eastern Iowa
county, and a man of more than ordinary intelligence, came
to my office complaining of pruritus that was simply mak-
ing life unbearable. The disease had troubled him for a
long time, but was much worse at present than ever before.
Examination showed the skin to be thick, parchment like,
and lifeless, with several heavy folds that radiated from
the anal aperture. I explained to him that as he could not
remain for treatment, anything that I did must necessarily
be quite severe; also that it would have to be kept up at
home for a long time. He replied that he "did not care
what I put on, as it would be a relief to what he was now
suffering. I cut off all the redundant tissue and applied
acid to the surrounding skin. I gave him the zinc oxide
ointment to use until the soreness had left, and told him
to have his wife apply the acid and to keep it up as long
as seemed necessary. I also gave him the following
injection :
B Dist. ext. hamamelis 5x;
Monsel's solution, 3ij ;
Sodium carbolate, N. F. 5vj ;
Glycerin 3iv.
M. Sig. : Inject one half teaspoonful in starch water at
bedtime.
He was warned against scratching, and told to forego all
alcoholic drmks. excessive use of tobacco, rich meats,
highly seasoned food, etc. He continued this treatment for
a long time and was rewarded with a complete cure. After
six years there has been no return of the disease.
In cases that are caused by a vegetable parasite
I have made use of pure sulphurous acid with good
results. It is generally used in solution, but I have
found that it is better to use it full strength. It is
quite painful, but one application is all that need be
made, as it will destroy any living parasite that may
be present.
The application of ver}- hot water, followed by
citrine unguentum applied freely on gauze, over
which is tightly bound a pad with considerable pres-
sure, will often give relief, so that the sufferer may
obtain a good night's rest. In fact, the citrine oint-
ment is the best single agent with which I am
familiar to bring about a permanent cure. When
used persistently for a long time it will in many
instances bring about permanent relief.
It is said that French surgeons use a sharp curette
and scrape away all of the diseased skin, thus bring-
ing about the same condition that we do by remov-
ing it surgically and bringing the edges together
with sutures. The carbolic acid does the same thing,
only in a slower manner.
Kelsey uses the white hot cautery, passing it
lightly over all the affected parts. This, of course,
is only another method of destroying the superficial
layer of skin and allowing healthy tissue to take its
place. It matters not what may have been the orig-
inal cause of the disease or how long since this
cause may have passed away, there comes a time
when the terminal nerve filaments are bound down
by the deposit of fibrous matter produced by the irri-
tation of scratching, and nothing short of its com-
plete destruction or removal will bring about a cure.
As before stated. I believe that most of these
cases originate from a catarrhal condition of the
bowel, and that if seen early enough, treatment
directed to this condition, if carefully carried out.
would cure the pruritus. Tuttle says :
June 13. 190S.J
MASON: PRURITUS ANl.
Catarrhal disease of the rectum and anus are among
the most frequent causes; whether it be the atrophic or the
hypertrophic form, pruritus is one of the commonest symp-
toins. The dry, brittle condition of the mucocutaneous
membrane about the anus, described as a symptom of pru-
ritus ani, is nothing more or less than a part of the atrophic
catarrh of the rectum and anus; and that moist, sodden,
whitish condition seen in chronic cases is the result of the
hypertrophic type.
It is well known by all who do rectal surgery
that after hsemorrhoid operations or any condition
where there is a wotmd that discharges pus as it
heals, there is a constant pruritus on all the sur-
rounding tissue owing to its being constantly irri-
tated by the discharge.
Other causes that should be searched for are con-
stitutional diseases, especially diabetes, rheumatism,
gout, and all the conditions that go under the name
of uricsemia. There seems to be an irritant in the
blood that causes cracks and fissures at all the muco-
cutaneous junctions and pruritus ani and vulvi
which are very troublesome.
These people are generally affected with eczema
and the skin seems dry and scaly, especially about
the scrotum, on the breast, and about the ears and
hair.
Certain errors of digestion as well as certain arti-
cles of food may start an attack of pruritus. Coffee
has seemed to me to be more harmful than any other
article of diet, and will alone produce the disease in
certain persons. All of these things should be
searched for, and, if found, given careful attention.
I absolutely refuse to treat a person who is in the
habit of drinking any form of alcohol.
As a rule, the treatment must be long and tedious,
and unless the patient will make every effort to assist
in bringing about a cure I refuse to treat him.
There are many formulas that are used with more
or less success, a few of which are here given.
Tuttle speaks highly of the following:
R Ac. carbolici 3ij ;
Ac. salicylici, 3j ;
Glycerini, 3j.
M. Sig. : Apply with camel's hair brush after bathing
with hot water.
Mathews recommends :
R Camphor and phenol, 3j ;
Glycerin, 3j-
M. Sig. : Apply after using hot water, and repeat fre-
quently if necessary.
In cases where there are fissure like cracks at the
junction of the skin and mucotis membrane. Cripps
recommends the following:
R Ext. conii, 5j ;
01. ricini 3j ;
Lanolini, 3j.
M. Sig. : Apply frequently.
An ointinent of chloroform as follows acts nicely
in many cases :
R Chloroform! 3j ;
Petrolati, 5i.
M. Sig. : Apply frequently.
This must be put up in a wide topped bottle and
kept tightly corked, as otherwise the chloroform will
soon evaporate.
Where the parts are too moist the treatment is
often assisted by the use of powders that will absorb
the moisttire. Plain starch has given good results in
^ many cases. Dry calomel many times is very use-
ful. The following has given good results :
i> Camphor, 5ij ;
Carbolic acid, gtt. 15;
Precipitated chalk (Eng.) 5ij ;
Zinc oxide, pulv. 5ij ;
Perfume, q. s.
M. Reduce the campiior with alcohol and mix the others
through bolting cloth of one hundred meshes to the inch.
I have operated under chloroform three times by
removing a section of the skin for about aii inch
on each side of the anus, and then undermining the
surrounding skin and drawing it together to cover
the denuded surface and stitched it to the mucous
membrane of the bowel.
In two cases I secured good results, while the
third patient was lost sight of. This procedure was
suggested to me by my friend, Dr. Hamilton, of this
city, and as a means of last resort I believe it to be
very valuable. I intend to make further use of it
as opportunity arises.
Patients should always be told not to scratch the
parts, although this warning is seldom heeded. If
the itching is so severe as to interfere with sleep,
have them use hot water, gradually increasing the
temperature, until it is nearly scalding. In case this
is not sufficient to give relief, an ointment of chloro-
form, one drachm to one ounce of petrolatum, may
be applied. A weak solution of carbolic acid in
water and glycerin will often give relief when all
else fails. The following mixture is a most excellent
one :
^ Sodium hyposulphate, 5;;
Carbolic acid 3ss;
Glycerin 5) I
Distilled water 5iij-
M. Sig. : Apply frequently on compresses.
Also:
^ Cocaine, 2^/2 gr. ;
Ex. rhatany, 15 gr. ;
Ext. hamamelis 75^ gr. ;
Petrolatum, 3v.
M. Sig. : Apply freely.
Dr. Buckley recommends the following, and L
can testify to its merits :
B Ungt. picis, 5iif,
Ungt. belladonnse, 3ij ;
Tr. aconit. rad., 3ss;
Zinci oxidi, 3j ;
Ungt. aquae tosx 5iij.
M. Sig. : Apply freely.
I have cured several patients by injecting cocaine
under a small portion of the skin where it is thick-
ened and then cauterizing it with the actual cautery.
After healing has taken place, another area is treated
in the same way. This makes the parts quite sore,
but not more than is bearable, and most patients are
willing to put up with it if it is likely to cure them.
While the principal attention should be paid to the
skin in order to get relief from the itching, yet meas-
ures should be taken to cure the catarrh in the bowel
above. I have the patient wash out the bowel with
solutions of boracic acid and then inject a twenty-
five per cent, mixture of glycerite of hydrastis (not
fluid extract). Other antiseptic astringent solutions
mav be used, such as would be beneficial in catarrhal
conditions m other parts of the body.
Owing to the difficulty experienced in effecting a
cure in some of the chronic cases that have come to
me for treatment, and being anxious to tn.' anything
that held out any hope of cure. I was led to tn- the
Rontgen rays. While my experience has not been.
1 154
FILES: PRURITUS ANI. CORRESPONDENCE.
LNew Vokk
Medical Journal.
great in the number of patients treated it has been
so satisfactory that not only myself but my patients
have l)een delighted with the result.
Tliis method is only useful in old chronic cases
where the skin is eczematous and thickened. Just
what the action is that brings about a cure 1 will not
attempt to say, but that the eczema disappears and
the skin returns to its normal condition or nearly so
is beyond question. It is too soon to say positively
how permanent the results are going to be, but I
think from the appearance of the skin that there will
be no return if the bowel above is put in a healthy
condition.
My technique is as follows : With a soft tube I
give an exposure of ten minutes" duration twice a
week, until I learn how the skin is going to stand
it. If there is no irritation I give three treatments
a week until a brown discoloration appears. All
treatment is then stopped until this goes away, when
treatment is resumed until it reappears. This is
usually enough, but, if possible, I think it is well to
give an occasional treatment after this as a matter
of precaution.
I hope to make a further report on the use of the
Rontgen rays in the near future, after there has
been more time to test its merits.
I know of no disease that will so tax the skill and
ingenuity of the physician as pruritus ani, and in
all cases the patient should be made to understand
that in order to be cured he must be willing to do
all in his power to aid the treatment. Matiy times
the cure seems to be accomplished when a relapse
will occur which is very discouraging to both the
patient and physician.
I 402 Brandeis Buill^hnc.
PRURITUS ANI.
By Ch.\rles O. Files, M. D.,
Portland, Me.
In the discussion of pruritus ani, in the Journal
about a year ago, many good and many true things
were written, but the final conclusions w ere peculiar-
ly unsatisfactory to some of the readers of the dif-
ferent communications. When all the customs,
habits, and appetites supposed to be inimical to gen-
eral health are given as direct causes of this sim-
ple, yet exasperating, malady, the real, immediate
cause seems buried beyond hope of recovery or
resurrection.
Constipation, from whatever source, is surely an
accessory or antecedent cause of this trouble. It
is possible, however, to come much nearer to the im-
mediate or exciting cause, if we investigate more
closely. There are two important factors which
ought to be studied. These are an analysis of the
contents of the rectum, and the physical condition
and mechanical efficiency of the sphincter ani mus-
cles, external and internal. The normal fasces con-
tain about seventy-three per cent, of water. This
water holds in solution various volatile, fatty acids
and probably other irritating excrementitious sub-
stances. During the retention of the fasces in the
rectum a considerable portion of the water disap-
pears. In prolonged constipation the faeces become
hard and dry. Some of this lluid i)asscs by (-)smosis
into the cellular tissues about the anus, and thence
to the skin. The liquid faeces are often very irri-
tating to the mucous membrane of the anus, and
cause an intense burning sensation. When this
acid, acrid solution is absorbed into the cellular tis-
sues it causes an irritation of the skin, and we call
that irritation pruritus ani. The sphincter muscle,
as long as it remains in a normal condition, prevents
the passage of any appreciable amount of fluid
through it. When, liowever. it is made somewhat
irregular by the presence of a h?emorrhoidal condi-
tion, some of the fluid leaks through the sphincter
and causes the pruritus by direct contact. The skin
about the anus is often found to be moist in per-
sons having haemorrhoids.
The treatment of this affection may be easily de-
duced from this statement of its causes. The pa-
tient should be directed to take only those kinds of
food that are easily digested, that are not consti-
pating, and that are not irritating. The bowels must
be kept open by the use of saline cathartics. Local-
ly, any soothing applications will allay the irritation
temporarily. Castile soap, boric acid, cold cream
will serve as well as anything.
195 High Street.
^
CorrespnJieutr.
LETTER FROM HAMILTON, CANADA.
The Ontario Medical Association. — Infanticide. — Teaching
in Psychiatry.
Hamilton, June i, igo8.
The Ontario Medical Association met here on the
26th, 27th, and 28th of May, under the presidency
of Dr. Ingers(Ml ( )lmstead. of Hamilton. It was
the largest meeting- nf the association ever held, the
attendance amounting to 317. From the standpoint
of scientific matter produced, it was about the best.
Dr. Charles G. Stockton, of the University of Buf-
falo, delivered the address in medicine, and Dr.
Charles Scudder, of Boston, the address in surgery.
Several members of the profession in Montreal were
present and contributed to the papers and discus-
sions. Speaking at the annual banquet, on the even-
ing of the 27th. Dr. Roddick, of Montreal, strongly
urged that interprovincial legislation be secured and
that the barriers keeping doctors in the dif¥erent
provinces from practising their profession in an ad-
joining province be taken down. He believed that
the government of the medical profession should be
in the hands of the Federal Government, and that it
was intended so by the British North .\merica Act..
It was the opinion of Dr. R(xidick that as soon as
Ontario strongly urged this measure other provinces
would soon fall into line.
The meeting unanimously adojited the following
resolution : ''That, whereas the destruction of chil-
dren for any other cause than that of the preserva-
tion of the life of the mother; and whereas the
perpetration of this act by a member of the medical
profession not only incriminates the physician him-
self, but also brings discredit on an honoraiile pro-
fession, we, members of the (Ontario Medical .Asso-
ciation, take this opportunity of stating that the as-
sociation has always C(Midemned in the strongest
possible terms this criminal practice."
.\nother res(iluti(~)n passed road as follows: "That
the r)ntario .Medical \ssociation desires to give ex-
June 13, looS.] T HER A PEL!
pression to its hearty approval of tlie ]jroposicion '>f
ihe Ontario government to establish psychiatric
clinics to work in conjunction with the hospitals
for the insane of the province : that the association
also respectfully request the government to have a
lunacy commission or a board of alienists, who
alone shall give expert evidence in a court of law as
to the sanity or insanity, and also to institute re-
forms in the civil service, in connection with the
hospitals for the insane, wherein- jiromotion for
merit shall take place, and especially to make a rule
that no one shall be appointed superintendent of
any hospital for the insane unless iic has had some
years of training in the serA'ice."
It was decided to meet in Toronto next year with
the following officers: President, Dr. H. j. Hamil-
ton, of Toronto; vice-presidents, Dr. R. R. Wallace,
of Hamilton; Dr. A. M. AlcFaul. of Collingwood :
Dr. A. Dalton Smith, of Mitchell ; and Dr. George
H. Field, of Coburg; general secretary, Dr. E. Stan-
ley Ryerson, of Toronto; assistant secretary. Dr. J.
E. Davey, of Hamilton: treasurer. Dr. j. H. Mullin,
of Hamilton.
LETTER FROM TORONTO.
The Uiiiz crsity of Toronto and the Toronto General
Hospital.
ToKONTO, May 30, igoS.
A pamphlet entitled The General Hospital z ersits
Unizersity of Toronto, embracing a series of articles
dealing with the supposed unfair action of the board
of governors of the Toronto General Hospital, in
their recent reorganization of their staff scheme,
toward the Medical Department of the university,
has been freely distributed among the medical pro-
fession in this city, and probably to some extent
among the public at large. These articles have been
appearing regularly for a month pa.>t in one of To-
ronto's evening papers. As the stand is taken by
some one favorable to the university, and probably
by some one whose ox has been gored, your cor-
respondent has taken the liberty of placing the Uni-
versity of Toronto in the position of plaintiff and
the Toronto General Hospital in that of defendant.
The complaint is made that in the recent reorganiza-
tion of the staff of the hospital the understanding
on which the university contributed $300,000 toward
the erection of a new hospital, designated as the
most important factor in the new scheme, was that,
so far as possible and practicable, the hospital was to
be made a university hospital, and that that under-
standing had been totally disregarded by the board
of governors of the hospital in making these ap-
pointments. The cliarge is made that the hospital
authorities did not intend to and did not recognize
the university in the working out of their plans for
reorganization, and do not propose to do so. To
those who have read these letters and have care-
fully perused the pamphlet, it is difficult to under-
stand wherein anv very strong "kick" can eman-ite
from any member of the Medical Department of the
University of Toronto. As a matter of fact, the
heads of all the departments or services in the hos-
pital, as well as all their assistants except two. are
members of the Medical Department, and there are
mighty few of the juniors under these but who are
associated with the Medical Department of the uni-
versitv as teachers, demonstrators, or instructors.
/C.'.l. XOTES. 1 155
Looking at the matter altogether apart from the
standpoint of medical education, and just from its
financial aspect and the point of view of the medical
practitioner in Toronto at large, it would appear
that the Toronto General Hospital is, practically
speaking, a university hospital. Not a single prac-
titioner from outside the Medical Department of
the university received an appointment as head of
any service in the hospital, and only two of the
senior assistants are beyond the pale of the Medical
Department of the university. The University of
Toronto contributed $300,000 toward this proposed
new hospital ; the city of Toronto. $200,000 ; sub-
scribers. $700,000 : and the old hospital board hand-
ed over a million dollars of assets. It will strike
most people that the University of Toronto for its
donation of $300,000 has done exceedingly well in
the matter of appointments. If one cared to carry
the matter further, the questions might be asked.
Where were the five representatives of the city of
Toronto on the board of governors of the hospital?
Where were the seven representatives on that board
of the subscribers ?— Yes, where were the eight rep-
resentatives of the Province of Ontario on that
board when the scheme .was going through? Did
the five representatives of the university on the
board, which represented a $300,000 donation,
"jockey" the others? In the face of these palpable
facts, one of the board of governors in his reply
to these newspaper articles states it is not a um-
versit\- hospital — "the university is but one of sev-
eral parties in its welfare." The "one of several
parties" seems to have done pretty well.
It has been admitted by one of the board of
governors of the hospital that, had that institution
been made a university hospital out and out, some
of the subscribers of the $700,000 would not have
come forward with their checks. This looks verv
much like an admission of fear of financial loss, oil
the one hand, but a latent feeling that it should
have been a university hospital, on the other. It is
doubtful if, provided the hospital had been made a
university hospital pure and simple, very much of
this $700,000 would have been lost to the institu-
tion : it is doubtful if there would have been very
much objection to making it such. It would have
been far better in man\' ways if the five representa-
tives of the university had carried the day outright,
rather than have the one sided arrangement as at
present.
Ilunpeutiral ^otes.
Iodine in the Treatment of Ulcers.— In a com-
munication to the Tourual of the American Medical
Association, for May 30. 1908. I. W. Roop, of
.\pache, Okla.. says he has found the application of
a saturated solution of iodine in alcohol to give ex-
cellent results in the treatment of ulcers. He began
by painting the skin up to the edge of the ulcer, and
this produced such good results that he ventured to
use it on the surface of the ulcer itself. He has
found that iodine used in this way is an efficient
means of converting a septic ulcer into a clean,
granulating wound which heals readily. He applies
the iodine, either in "a concentrated form or a
saturated solution in alcohol," everv dav or as often
THERAPEUTICAL NOTES.
[New York
Medical Jocrnal.
as is required until the slougii separates, when an
ordinary dusting powder and gauze may be appHed.
The iodine should then be discontinued, but if any
unhealthy or superfluous granulations appear, it
should be again applied. He says it quickly changes
a phagedenic ulceration into a healthy condition,
and speaks of other indications in which it has been
serviceable, as in mouth and throat troubles, by
painting it over the surface. It will arrest and cure
pyorrhoea alveolaris. The application is usually
painless.
Treatment of Severe Burns. — Having had oc-
casion to treat extensive burns on workmen in the
sugar works, glass factories, and mines in the dis-
trict of Douai, l^r. Galand, of Cambrai, recommends
the use of the following paint, which is applied with
a camel's hair pencil over the entire surface of the
injured parts. The application produces a sensation
of coolness and relieves the pain, forming at the same
time a varnish coating which serves to replace the
denuded skin {BiiUetin general dc thcrapcutiqiic.
May 8, 1908) :
R Carbolic acid, gtt. xxv;
Pulverized dextrin, 5iy;
Tincture of aloes 5ii !
Spirit of camphor 3i ;
Lead nitrate, gr. xlv ;
Tannic acid gr. xv;
Cherrj' laurel water, ^v.
M.
To make a perfectly homogeneous mixture it is
necessary to have the dextrin in a state of impalp-
ably fine powder. To this is added little by little
the mixture of tincture of aloes and spirit of cam-
phor, rubbing up until thoroughly incorporated.
The cherry laurel water containing the lead nitrate
and tannic and carbolic acid is then added.
Apply with a brush, and after the first coating has
dried apply a second or third coating to the more
severely injured parts.
Adrenalin in Acute Eczema. — .\ccording- to N.
E. Aronstam (Central States Medieal Monitor) a
solution of the active principle of the suprarenal
gland is astringent and soothing in acute eczema-
tous conditions and dermatitis. He recommends its
use in the following combination :
R Boric acid gr. \ ;
Solution of adrenalin (i in 1000), 5i;
Camphor water, 3ii ;
Distilled water ad Si-
M.
A piece of sterile gauze is saturated with the solu-
tion and applied to the inflamed or af¥ected parts,
the application being renewed when the dressing is
dry.
Treatment of Mushroom Poisoning. — Maheu,
in La cUniquc. summarizes the treatment of mush-
room poisoning. The first thing to do is to evacuate
the stomach by an emetic and then administer a
purgative. In cases where there is contraction of
the jaw, apomorphine should be given hypodermat-
ically in a dose of one twelfth of a grain for adults.
After the stomach has been emptied of the poison-
ous matter, administer dennilcent drinks, such as
milk, albumen water, etc. Apply a sedative applica-
tion of camphorated liniment and chloroform to the
abdomen ; to overcome the tainting condition sina-
pisms may be applied, or hot coffee given internally,
or hypodermatic injections of ether, or caflfeine.
The Treatment of Earache. — Earache of the
most intense variety is generally caused bv the for-
mation of a furuncle in the auditory passage. The
treatment should consist, according to Molinie
{Journal de medicine et dc cliinirgie pratiques,
March, IQ08), of overcoming the pain and evacu-
ating the boil. The parts should be made strictly
aseptic, and after cleaning them minutely, the pain-
ful spot should be touched with the following solu-
tion, applied wath a pledget of cotton :
R Cocaine hydrochloride,
Carbolic acid.
Menthol aa gr. xv.
M.
This application will deaden the pain and some-
times abort the furuncle. If the inflammation per-
sists the boil should be opened under an anaesthetic,
either local or general. Otitis of the middle ear,
which causes a most violent pain, is treated either by
palliative means or by operation. As a means of
relieving the pain the following solution may be
employed by dropping a few drops of it warmed
into the ear :
R Cocaine hydrochloride gr. xii ;
Morphine hydrochloride, gr. iv;
Carbolic acid, gr. iiss;
Glycerin,
Water, aa gr. Ixxv;
Soirit of peoperniint gtt. i.
M.
Applications in Galactorrhoea. — The application
of a solution of cocaine hydrochloride is recom-
mended by Dr. Comby and b\- Dr. Joire : the formula
used by the first named is as follows, according to
Journal de mcdccinc dc Paris for May 9, 1908:
R Cocaine hydrochloride gr. iii ;
Distilled water 5iiss.
M.
Dr. Joire's prescription is:
R Cocaine hydrochloride gr. Ixxv;
Gljcerin, Biss;
Distilled water 5iss.
M.
The mammae and areolae are painted with the
solution by means of a camel's hair pencil, or with
a w-ad of absorbent cotton. The efficacy of cocaine
in this application is due to its vasoconstrictive
action.
Injection for Internal Haemorrhage. — Huciiard
prescribes the following for hypodermatic use in in-
ternal haemorrhage :
R Ergotin, gr. 1/7;
Lactic icid, gr. 1/3;
Cherrv laurel water 3iiss.
M.
A Liniment for Engorged Lymphatic Glands.
— Heindl, of Vienna, treats engorged lymphatic
glands by the alternate application of compresses
wet with solution of aluminum acetate and rubbing
with the following liniment :
R Vcratrine gr. viiss;
Chloroform 3.'.'
Olcohalsamic mixture, N. F Mi.
M.
June 13, I'
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Jl'eekly Revicn' of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M. D.
Addics.i all business communications to
A. R. ELLIOTT Pl'BLISHIXG COMPAXY,
rublishers,
66 West Broadii-ay, Xeic York.
Phii^elphia Office : Chicago Office :
3713 Walnut Street. 160 Washington Street.
SuBscKiPTiox Price :
I'nder Jjomcstic Postage Rates ?."> : under Foreign Postage Rate.
$7 ; single copies, fifteen cents.
Remittances should be made by New York Exchange or post
office or express money order payable to the A. R. Elliott Pub-
lishing Co.. or by registered mail, as the publishers are not
responsible for money sent by unregistered mail.
Kntered .it the Post Office at New Vork and admitted for
transportation through the mail as second class matter.
XEW YORK. ?.\TURDAY. TUNE 13. !9oS.
THE XEW PRESIDENT OF THE AMERICAN
MEDICAL ASSOCIATION.
\\"e congratulate the association on its choice of
Colonel William C. Gorgas. of the Medical Corps
of the United States Army, of whom we present a
portrait in this issue, as its next president. Colonel
Gorgas's achievements in sanitation have won for
him the admiration of the nation, and his per-
sonal qualities have endeared him. to those whose
privilege it has ever been to come within the gentle
charm of his presence. He did not need strengthen-
ing before the public by any such specific support
as is proclaimed by his election to the presidency of
the great representative association of the medical
profession of the country, but it was none the less
a most graceful act for the association to signify
its appreciation of the man and of his services by
making him its chief officer.
The Medical Corps of the United States Army,
the Bureau of Medicine and Surgery of the United
States Navy, and the United States Public Health
and Marine Hospital Service are organizations of
which the medical profession is proud, and we hope
that it will often take occasion to signify its pride
in them by designating their members as chiefs
among its representatives. Though it is but a few-
years ago that Surgeon General Sternberg, of the
army, was the president of the American Medical
Association, it was high time for the association to
attest anew its appreciation of the various medical
corps of the national service. Not only has their
service training a decided tendency to fit the mem-
bers of those corps for the duties and responsibiH-
1157
ties of a presiding officer, but their purely profes-
sional attainments entitle them to the highest recog-
nition. We predict for Colonel Gorgas a memor-
able record as president of the American Medical
Association.
ALUMNI REUNIONS IN CHICAGO.
The difficulty of assembling alumni resident in
all parts of a country so large as ours is ordinarily
very great, but it was to a large extent overcome
in Chicago last week It is true that the Chicago
meeting of the American Medical Association was
large beyond precedent and. we imagine, beyond all
expectation, for more than six thousand members
were registered, and there was the usual attend-
ance, perhaps more, of visiting phvsicians who were
not registered. It was this influx, of course, that
brought with it a vast number of persons inclined
to take part in alumni reunions ; but any annual
meetin.g of the association, even one not half so
large as that of Chicago, may be counted upon to
bring together more alumni of an individual medi-
cal school than could well be gathered together on
a different occasion. Several of the school organi-
zations took advantage of the certainty that the
great meeting would enable them to assemble their
members in multitudes, and consequently their re-
unions, all held on one evening, were numerically
much superior to the common run of such gather-
ings. The element of entertainmicnt was in the as-
cendant, very properly, and banquets, smoking con-
certs, and the like made the assemblies festive as
w-ell as promotive of college spirit.
It must be confessed that our Western friends
manage such a thing as a large banquet much better
than we of the East generally do it. There is an
initial heartiness about them that makes a stranger
feel at home at once, and joy does not lag until the
wine has begun to work. In the Atlantic States it
is too apt to be the case that a man of little or no
prominence arrives on the scene of a dinner with
nobody particularly disposed to beguile for him the
w earisome waiting period. Jovialit}- and community
of feeling do, indeed, come at last, but, like the flavor
of the persimmon, not until after a frost has been
encountered. It was the privilege of a representa-
tive of this journal to be seated in the lobby of the
Illinois Athletic Club while the alumni of the Medi-
cal Department of the Northwestern University
were gathering for their banquet, and he could not
help admiring the conduct displayed. For the time
being, he regretted that he himself was not a North-
western alumnus. An energetic and hearty recep-
tion committee stood at the doorway of the great
building ; its members were not seated in solemn and
frigid dignity in a room more or less difficult to
EDITORL4L ARTICLES.
EDITORIAL ARTICLES.
[New York
Medical Journal,
find and ready to play the snob when at last they
were found. No sooner had a man stepped inside
than he was cordially grasped by the hand and, in
case he was not personally known to any member
of the committee, asked if he had come to join in
the banquet. On his answering in the affirmative,
he was led ( not directed) to the place where he
could divest himself of his hat and overcoat, and
from that inoment the fraternal feeling had full
plav. One could not but admire, also, the skill with
which the great throng was handled ; 789 men ar-
rived to attend the banquet, about 250 more than
had been expected, but the excess worked no serious
inconvenience, such was the capability of the club's
manager, and with an insignificant minimum of
waiting, spent in kindly frivolity of speech, ever}-
body was comfortably seated. Surely the manage-
ment of a banquet is among the many things in
which we might to our advantage take lessons of
our W estern friends.
PALMAR PROJECTION OF THE ULNA
AFTER COLLES'S FRACTURE.
In the May number of the Providence Medical
Journal. Dr. Franklin C. Clark, of Providence, pre-
sents a practical and very interesting subject for
consideration, that of a projection of the lower end
of the ulna "forwapd" (toward the palmar aspect
of the wristj after Colles's fracture, manifesting
itself secondarily, i. e., coming on at a comparatively
late period, after the fragments of the radius have
united. The occurrence seems to be rather rare, as
Dr. Clark has met with only two instances of it in
a practice of over thirty years. He gives the his-
tories of these cas^s. In one of them he might have
been inclined to attribute the abnormity to the very
extensive injury to the parts sustained by a woman,
forty years old, in a backward fall down the entire
length of a flight of stairs of seventeen steps. In the
other case, however, the injury seems to have been
caused by a simple fall forward, the weight of the
patient, a woman of sixty, coming upon the palm
of the hand.
This complication appears to detract decidedly
from the utility of the wrist joint, no matter in what
perfect apposition the fragments of the radius may
have united, and it is apt to lead to a conviction on
the part of the patient that the fracture was im-
properly set in the beginning. It occurs in cases
treated exactly like other cases of Colles's fracture
in which the ultimate result is in every way satis-
factory. Dr. Clark lost sight of both his patients
soon after tlu- complication had been recognized,
apparently withf.ut his having advised any second-
ary treatment, and it is difficult, indeed, to see that
much benefit could be derived from any treatment
beyond the support that might be given by a band.
Dr. Clark thinks that this untoward sequel of
Colles's fracture has not received enough attention
at the hands of surgical authors, though he finds
material more or less bearing upon it in the writings
of the late Dr. Frank H. Hamilton, the late Dr.
E. M. Moore, Dr. John B. Roberts, Dr. F. J. Bowen,
and Dr. Vertner Kenerson.
PSYCHIATRY AS A PART OF PRE\'ENTIVE
MEDICINE.
At the recent meeting of the American ]\Iedico-
psychological Association, held in Cincinnati, Dr.
Henry M. Hurd, of Baltimore, read a paper with
this title. Coming, as it did, shortly after the presi-
dent's address, in which the relation of psychiatry
to preventive medicine was also discussed, it was
most timely. It is only necessary to look back over
the history of mental medicine in this country for
the past quarter of a century to appreciate the many
changes which have occurred in the methods of car-
ing for and treating the insane. Housing facilities
and means of recreation and employment have been
improved and mtiltiplied, while the profession has
had placed at its disposal many therapeutic agents
which were before unheard of. When, however,
we look at the results, to see what effect all this
activity has had. we are chagrined to find that ap-
parently there has been hardly an adequate return
for the energy put forth.
Dr. Hurd, therefore, felt impelled to speak of
psychiatry in the role of preventive medicine, as it
is in this direction that he feels that we must labor
in the future if we are to accomplish aught to stem
the tide of mental disorder. He properly laid special
stress upon supervision of the life of the child, with
a view to detecting the earliest appearance of ab-
normal mental tendencies, so that the individual
could be put right before it was too late. Our
schools employ phvsicians to look after the eyes,
the ears, the noses, and the chests of the children,
and surely it is equally if not more important that
their mental condition should be studied with a
view, not only of detecting the earliest signs of ab-
normity, but also of preventing the stress of school
life and prescribing, to some extent at least, the
character of the studies best suited to the individual.
Dr. Hurd's paper was very favorably received
and freely discussed. A significant feature of the
discussion was the remarks of Dr. William A.
White, of Washington, who sounded a note that
rings true when he said that the association, instead
of meeting year after year and dining together and
exchanging the compliments of the season, ought
LDIIORIAL ARTICLES.
1 159
to rise to the great public issues, such as those dis-
cussed in Dr. Hurd's paper, and express itself as
an organization composed of the representative men
of the country engaged in the practice of mental
medicine. We fully agree with Dr. White in this
particular. The profession of the country has al-
ways had the profoundest respect for their confreres
of the Medicopsychological Association, and t ) at-
tain even a higher position they have only to rise to
the fuller measure of their responsibilities in ad-
vancing as a body the domain of psychiatry in its
preventive aspects. No single class of specialists
is so well fitted for the work; we believe that they
will not lack the energy to accomplish it.
WHAT IS HYSTERIA?
The "pain child of neurology" is the apt name
given to hysteria by Binswanger in his recent monu-
mental monograph. Wrapped in swaddling clothes,
hidden in the disjointed fragments of other disor-
ders of body and mind, it was reserved for the all
seeing eye of Charcot to discover that in this mass
there were those whose paralysis was not like that
due to a lesion of the brain, of the fibre tracts of
the cord, or of the peripheral nerves — those whose
disturbances of sensation did not agree with the pic-
ture seen resulting from a disorder of the sensory
nerves of the periphery, of the spinal cord, or of the
brain, and looking through the new lens of hypnosis
he read an answer to the riddle which, from the days
of the Greeks to the present time, has demanded an
explanation and been given thousands.
Charcot's answer to the question was that "hys-
terical are those physical and mental processes of
extraordinary character and strength which may be
brought into being by ideas." Many noted neurolo-
gists have been content with this general concep-
tion, Mobius accepting it bodily; while in more re-
cent times Babinski has extended the idea, and indi-
cates that "hysteria is a special psychic state mani-
festing itself principally in disturbances which may
be called primary and subsequently in secondary
disturbances." The primary disturbances are dis-
tinguished by the fact that it is possible to reproduce
them by suggestion in certain cases with rigorous
exactitude, and to cause them to disappear under the
exclusive influence of persuasion. The secondary
disturbances are distinguished by the fact that they
are immediately subordinate to the primary disturb-
ances.
Babinski lays a heavy weight of responsibility on
the physician, and by implication would make him
responsible for much that he himself would try to
treat. How much stomach washing, bowel cleans-
ing, massage, and electricity have done to perpetu-
ate the maladies sought to be alleviated thereb}' will
never be known, and the different outlook of alien-
ist and internist will continue to breed dissension
between brothers in the same profession, with simi-
lar therapeutic desires, so long as they see these
features from such diverse viewpoints.
The views of Janet, of Vogt, and of Breur and
Freud, expressed with much subtlet)' of analysis
and wealth of metaphor, are but finer architectural
stylistic efiforts reared on the foundations and fash-
ioned after the lines of the ground plan laid down
by Charcot. When Janet postulates the cause of
hysteria as a splitting of certain elements of con-
sciousness from the consciousness of self — the per-
sonality— thus giving rise to a sleeping, somnam-
bulistic self alongside of the ego ; and Sollier pos-
tulates a local sleep area ; and Vogt assumes a
dissociated condition, giving rise to a localiztd sleepy
retardation on the basis of a pathologically increased
affectivity, they all assume the essential relation of
the phenomena of hypnosis tii h\steria, just as
Forel's' phrase "increased autosuggestibility" or
Alobius's "pathologically increased suggestibility"
points out that in hypnosis we have an artificial
production of what takes place in hysteria naturally.
The hypnotized person realizes the relation of an
outside influence, the hysterical the will of an un-
known ego, which unknown, unconscious, and hid-
den ego, according to the narrower conceptions of
Breur and Freud, has arisen in times long gone by,
in childhood, on the basis of sexual experiences, but
lying dormant, so far as consciousness is concerned,
is still able to bring forth action sufiicient in in-
tensity to modify the conscious personality.
Dubois, Schnyder, and Hellpach, attacking the
problem from the genetic point of view, see in hys-
teria types of reaction to environmental factors
which Hellpach has developed along the psycholog-
ical path. Experience has taught that, whereas a
large number of individuals grow out of or adjust
themselves completely to a number of disturbing
causes in their environment, or, if reacting abnor-
mally for a time, later reach a satisfactory adjust-
ment, still a number do not, and in this latter group
he sees two classes with what he calls "a reactive
and a productive abnormity." The latter proceed to
the formation of frank mental diseases ; the product
is a definite failure of adjustment, as in dementia
praicox, paranoid dementia, paranoia, etc. The
former make up a group of unstable, labile individu-
als of lessened resistance to external stimuli. In this
group are to be found the individuals of the hyster-
ical reaction type. This is the fundamental rudi-
ment. It is the generalized mentality of a former
age, through which man has developed. The hys-
teria of the masses of the Middle Ages has passed.
ii6o
NEWS ITEMS.
[New York
Medical Journal.
Its modern descendants for the masses are the
psychoneuroses. Atavisms there are in plenty, hys-
teria in children of either sex in about equal propor-
tions ; hysteria in adult women more than in adult
men : in men hysteria being more common among
the lower and undeveloped classes, but generalized
hysterical reactions only here and there in certain
religious sects that recruit their members from such
atavistic individual reaction types, or under certain
paralyzing emotional stresses that reduce the tension
in the mass to the low water mark of preceding gen-
erations.
In Helpach's view we see a healthy breaking
away from the mysteries of the "unconscious," the
"subconscious." How can a disorder involving
psychical factors be understood in the mystifying
phrases of "unconsciousness"? How will such
psychical processes be analyzed if lost in the myste-
rious gray substance of mind? That the way opened
by him will be productive of light we feel assured ;
but that the problem is solved is a premature belief.
gttos Items.
Changes of Address. — Dr. Charles S. James, to 624
Lexington Avenue, New York, where he will resume
practice.
The Inauguration of Columbus Hospital, Buffalo,
N. Y., took place on Sunday afternoon. June 7th.
The First Spanish Congress on Tuberculosis will be
held in Zaragoza, Spain, on October 2d to 6th, 1908.
The Croonian Lectures will be delivered at the Royal
Colk-ge of Physicians of London on June i8th to 30th, by
Dr. .A. E. Garrod on Inborn Errors in Metabolism.
The Commencement Exercises of the Maryland
Medical College were held on the evening of June 2d.
Twenty young men received the degree of doctor of
medicine.
Donation to the St. Louis Skin and Cancer Hospital.
—It i« announced that a gift of $100,000 in cash and the
site for a new building has been made to this institution.
The donor's name is withheld.
Personal. — Dr. Isadore Dyer has been appointed dean
of the Medical Department of Tulane University, to suc-
ceed Dr. Chaille, who recently resigned, 'it is said that
Dr. Dyer is the youngest dean in America.
Richmond, Va., Academy of Medicine and Surgery. —
.^t :i meeting of this academy which was held on Tues-
day. Jime 9th, Dr. C. M. Hazen read a paper on Electro-
therapeutics, and papers on Cataphoresis were read by Dr.
M. W. Peyser and Dr. F. K. T. Warwick.
The Northwestern Medical Association of Philadel-
phia.— M a stated meeting i.f this society, held on Fri-
day evening, June 12th. Dr. William Egbert Robertson
read a paper on the Diagnosis and Treatment of Diseases
of the Heart, which was illustrated with lantern slide
picliires.
Buffalo Academy of Medicine. — The annual meeting
of this academy was held on Tuesday evening, June gth.
Officers for the ensuing year were elected, and reports were
presented of the commiss-ons on milk supply, on food sup-
ply, on inspection of schools and school children, and on
smoke and noise nuisance.
St. Gregory's Hospital. New York. — .\t a special
meeting of the board of directors of this hospital, which
was lieid on June 2d, Mr. John W. Thomas, of New York,
was i-Iected treasurer. Owing to the enforced absence of
the -iuperintcndent, on account of illness, Mr. Thomas is at
present acting superintendent of the institution.
The Medical Club of Philadelphia held a reception at
the Bellevue-Stratford Hotel on the evening of June 12th.
Dr. William L. Estes, of South Bethlehem, Pa., president
of Lhe Medical Society of the State of Pennsylvania, and
Dr. Albert M. Eaton, of Philadelphia, president of the Phil-
adelphia County Medical Society, were the guests of honor.
Franklin District, Mass., Medical Society.— At the
annual meeting of this organization, which was held in
Springfield recently, the old officers were reelected without
change, as follows : President, Dr. J. W. Cram, of Colrain ;
vice president. Dr. C. L. Upton, of Shelburne Falls ; secre-
tary and treasurer, Dr. Clara M. Greenough, of Greenfield.
Women Nurses in French Military Hospitals.— It is
reported thit women nurses are to be given a trial in the
military hospitals in France. The hospital connected with
the military medical school at Val-de-Grace, near Paris,
has made the experiment, and if it proves to be successful
other military hospitals will be supplied with women nurses.
Medical Society of the County of Richmond, N. Y.—
At the regular monthly meeting of this society, which was
held in the Staten Island Academy of Medicine on the
evening of June loth. Dr. Walker Washington read a paper
entitled The Differential Diagnosis of Typhoid Fever. The
discussion was opened by Dr. A. T. Wood and Dr. H.
Patterson.
The Medical Society of the Borough of the Bronx. —
.■\ stated meeting of this society was held on the evening
of Wednesday, June loth. The meeting was largely clini-
cal, the evening being devoted principally to the presenta-
tion of patients and the reports of interesting and unusual
cases. The paper of the evening was read by Dr. Charles
Herrman on Scarlet Fever Carriers.
A Research Fellowship at George Washington Uni-
versity.— The graduating class of the Department of
Medicine of George Washington L'niversity have an-
nounced to the university authorities the establishment by
the class of a research fellowship at the university. The
fellowship will be known as the Class of '08 Fellowship,
and will have an annual fund of not less than $300.
Contagious Diseases in Chicago. — During the week
ending May 23, 1908, there were reported to the Depart-
ment of Health 660 cases of contagious diseases, an in-
crease of 107 over the preceding week. Of the total num-
ber 353 were of measles ; 88 of scarlet fever ; 70 of diph-
theria ; 57 of tuberculosis ; 39 of chickenpox ; 23 of whoop-
ing cough ; 20 of typhoid fever ; i of smallpox ; and 9 of
less important diseases.
Connecticut State Medical Society.— At the one hun-
dred and sixteenth annual meeting of this society, which
was held in New Haven recently, the following officers
were elected for the ensuing year: President, Dr. Selden
B. Overlook, of Ponifret; first vice president, Dr. Irving
L. Hamant, of Norfolk: second vice president, Dr. W. L.
Barber, of Waterbury: secretary. Dr. W. R. Steiner, of
Hartford: and treasurer. Dr. Joseph H. Townsend, of
New Ha\en.
American Association of Medical Examiners. — The
ninth annual meeting of this association was held in Chi-
cago during the week of the meeting of the American Med-
ical .Association Officers for the ensuing year were elected
as follows: President. Dr. Frank E. Allard, of Boston:
vice presidents. Dr. L. H. Montgomery, of Chicago. Dr.
Allison Maxwell, of Indianapolis, Ind., Dr. W. J. Means,
of Columbus, Ohio, and Dr. E. O. Kinne. of Syracuse,
N. Y. : secretary and treasurer. Dr. J. G. Monilian of
New York.
American Association for the Advancement of
Science. — A special summer meeting of this association
will be held in the buildings of Dartinouth College, Han-
over, N. H., on Jime 29th to July 3d. Information relating
to the presentation of papers tnay be obtained from the
secretary, Mr. L. O. Howard, Smithsonian Institution,
Washington, D. C, and information on matters relating to
local arrangements may be obtained from Professor H. H.
Horne. Dartmouth College. Hanover, N. H.
The Mortality of New Jersey. — ^During the month
ending May 15, 1908. there were reported to the Bureau of
Vital Statistics of the State of New Jersey 2,602 deaths
from all causes, a decrease of 532 from tlic preceding
month, and a decrease of 386 from tlie corresponding
period in 1907. The causes of death were : Typhoid fevci .
28; measles, 27; scarlet fever, 46; whooping cough, 23;
diphtheria, 41 : malarial fever. 3 ; tulicrculosis of the lungs.
June 13, igoS.] NEWS ITEMS. I161
J48; tuberculosis other than that of the lungs, 60; cancer,
112; cerebrospinal meningitis, 24; diseases of the nervous
system, 319; diseases of the circulatory system, 214; dis-
eases of respiratorj- system (pneumonia and tuberculosis
excepted), 176; pneumonia, 253: infantile diarrhoea. 52;
diseases of digestive system, 143 ; Bright's disease, 202 ; sui-
•cide, 46; all other causes. -1S5.
The Alumni Association of the Woman's Medical
College of Pennsylvania iield its annual election on
May 2 1 sr. and elected the following officers for the ensuing
year: President, Dr. Margaret F. Butler; vice presidents,
JDr. Lida S. Cogill and Dr. Miriam M. Butt ; recording sec-
retary. Dr. M. Louise Diez ; corresponding secretary, Dr.
]Mary Buchanan : treasurer, Dr. Florence H. Richards : and
directors. Dr. Kate W. Baldwin. Dr. Matilda Beaver. Dr.
Caroline Smith, and Dr. Blanch Hillman.
The Springfield, Mass., Association for the Preven-
tion of Tuberculosis will establish a day camp for the
•open air treatment of tuberculosis in the near future. The
land has been rented, and many contributions have been
received, but about $i,coo more is needed to carry on the
work during the year. Patients will be received at any
time after 7 o'clock in the morning, and will be provided
with a morning and afternoon luncheon, a dinner, and
medical supervision free of charge. Dr. H. C. Emerson
will have charge of the camp.
National Association for the Study and Prevention of
Tuberculosis. — The fourth annual meeting of this or-
ganization was held in Chicago on June 5th and 6th. The
■meeting was largely attended and much interest was shown
in the papers presented. Officers for the ensuing j'ear were
elected as follows : President. Dr. V. Y. Bowditch. of Bos-
ton; vice presidents, Mr. Homer Folks, of Xew York, and
Dr. C. L. Minor, of Asheville. X. C. : secretary. Dr. H. B.
Jacobs, of Baltimore; treasurer. General George M. Stem-
"berg, of Washington ; executive secretary, Mr. Livingston
Farrand, of Xew York. ^
The Health of Pittsburgh. — During the week ending
May 30, 1908. the following cases of transmissible diseases
were reported to the Bureau of Health : Chickenpox, 9
cases, 0 deaths ; typhoid fever. 26 cases, 5 deaths ; scarlet
fever, 15 cases, 3 deaths; diphtheria. 9 cases, i death;
-measles, 184 cases, 4 deaths ; whooping cough, 5 cases, i
death ; pulmonary tuberculosis, 25 cases, 14 deaths. The
total deaths for the week numbered 150. in an estimated
population of 403,380, corresponding to an annual death
rate of 16.85 in 1,000 of population.
The Archives of Diagnosis is the title of a quarterly
journal devoted to the study and progress of diagnosis
which has been established by Dr. Heinrich Stern, of Xew
York. The second number, which recently appeared, con-
tains twelve special articles by well known authors ; a gen-
eral review of the recent literature of the diagnosis of
general paresis and the early dia,gno;is of uterine cancer;
abstracts of current literature in the field of diagnosis and
prognosis ; and a review of four recently published books
on diagnosis. The number contains a very handsome col-
ored plate and several excellent half tone illustrations.
Scientific Society Meetings in Philadelphia for the
Week Ending June 20, 1908. — Monday. June 15th. X^'orth-
-east Branch. Philadelphin CLaint\- Medical Society. Tues-
day. June i6th, Dermatcilogical Society; Xorth Branch,
Philadelphia County Medical Society. Wednesday. June
17th. Philadelphia County Medical Society (business meet-
ing open to members only ) ; Association of Clinical As-
sistants, Wills Hospital: Franklin Institute. Thursday.
June i8th. Section Meeting. Franklin Institute; Medical
Society, Woman's Hospital. Friday, June 19th, American
Philosophical Society.
Philadelphia Paediatric Society. — A meeting of this
■society was held on Tuesday, June 9th. Dr. Howard Childs
Carpenter exhibited a patient, a boy. with contractures
following epidemic cerebrospinal meningitis. Dr. B. t.
Royer showed a child with atrophy of one eye following
•epidemic cerebrospinal meningitis. Dr. Eleanor C. Jones
reported two cases of f?tal \-omiting. Dr. Charles A. Fife
reported a series of cases showing the results of buttermilk
feeding. Dr. J. Claxton Gittings read the report of a case
of tuberculous enteritis complicated by the presence of a
foreign body. Dr. B. F. Royer reported a case of diph-
theria in a child two weeks old. Dr. J. P. Crozer Griffith
reported a case of recurrence of scarlet fever in combina-
tion with measles.
The Health of Portland, Me.— During the four weeks
ending May 2. 1908. there were reported to the Board of
Health 89 deaths from all causes, in an estimated popula-
tion of 60.000, corresponding to an annual death rate of
19.28 in 1,000 of population. Of the total number of deaths
4 were from accident, 8 from apoplexy, 4 from cancer, 9
from heart disease, 7 from nephritis, 14 from pneumonia,
and 9 from tuberculosis. There were 8 cases of diphtheria
reported during the month, and no deaths; 5 cases of
typhoid fever, and i death ; 3 cases of scarlet fever, and
no deaths. The total infant mortality was 8, under one
year of age. There were 6 still births.
The Mortality of Chicago. — According to the report
of the Department of Health of the City of Chicago for
the week ending May 30, 1908, there were during the week
578 deaths from all causes, as compared with 495 for the
previous week and 643 for the corresponding period in 1907.
The annual death rate in an estimated population of
2,166.055 was 13.91 in 1,000 of population. The principal
causes of death were : Apoplexy. 8 ; Bright's disease, 40 ;
bronchitis, 13 ; consumption, 72 ; cancer, 27 ; convulsions.
8; diphtheria, 8; heart diseases, 50; intestinal diseases,
acute. 39 ; measles. 10 ; nervous diseases, 17 ; pneumonia,
61; scarlet fever, 10; suicide. 13; typhoid fever, 5; violence
(other tiian suicide). 37; whooping cough. 4; all othet
causes, 156.
Medical Alumni Association of the University of
Buffalo. — The thirty-third annual reunion of the Medi-
cal Department of the University of Buffalo was held re-
cently. AW the classes of the last sixty years which have
surviving members were represented. Among those who
made addresses w-ere Vice Chancellor Xorton. Dr. Allen A.
Jones, retiring president of the association ; Dr. Earl P.
Lathrop. and Dr. Frederick C. Busch. The following
officers were elected for the ensuing year: President, Dr.
Albert T. Lytle ; tirst vice president. Dr. Fitch H. \'an
Orsdale ; second vice president. Dr. Charles L. Presich, of
Lockport ; third vice president. Dr. W. H. Knickerbocker,
of Geneva ; fourth vice president. Dr. Alice Bennett ; fifth
vice president. Dr. Ross J. Loop, of Elmira; treasurer. Dr.
Herman K. De Groat ; secretary. Dr. Franklin W. Burrows.
Infectious Diseases in New York:
We are indebted to the Bureau of Records of the De-
partment of Health for the following statement of new
cases and deaths -reported for tlie tzvo zveeks ending June
6, 1908:
, .Ma>
Jur
le 6.— •^
Cases.
Deaths.
Cases.
Deaths.
• ■ • ■ 33-'
165
440
161
Diphtheria
344
268
25
Measles
.... ..238
33
1.322
17
Scarlet fever
.... 635
46
498
22
213
12
43
7
6
9
8
Totals
. . . . j.Sjq
297
242
Society Meetings for the Coming Week:
MoxDAV, June i^tli. — •Xew York Academy of Medicine
(Section in Ophthalmology); Medical Association of
the Greater City of Xew York ; Hartford, Conn., Medi-
cal Society.
Tuesday, June i6th. — New York Academy of Medicine
(Section in Medicine) ; Triprofessional Medical So-
ciety of Xew York ; Medical Society of the County ot
Kings. Xevv York ; Binghamton. X. Y.. Academy of
Medicine ; Clinical Society of Elizabeth, X. J., Gen-
eral Hospital ; Syracuse, X. Y.. Academy of Medicine ;
Ogdensburgh, X. Y., Medical Association.
Wednesday, June i/th. — Xew York Academy of Medicine
(Section in Genitourinary Diseases) ; Xew York Medi-
colegal Society ; Xew Jersey Academy of Medicine ;
Buffalo Medical Club ; Xew Haven. Conn., Medical
Association ; Xorthwestern Jkledical and Surgical So-
ciety of Xew York.
Ihursday. June iStli. — Xew York Academy of Medicine;
German Medical Society, Brooklyn: Newark, N. J.,
Medical and Surgical Society.
Friday. June 19th. — Xew York Academy of Medicine
(Section in Orthopaedic Surgery); Clmical Society of
the Xew York Postgraduate Medical School and Hos-
pital ; Xew York Microscopical Society ; Brooklyn
Medical Society.
1 162
XEJVS ITEMS.
[New York
Medical Journal.
Vital Statistics of New York. -During the week end-
ing Alay 30, 1908, there were reported to the Department
of Health 1,335 deaths from all causes, in an estimated
population of 4,422,685, corresponding to an annual death
rate of 1575 in 1,000 of population. Of the total number of
deaths 693 were in Manhattan, 123 in the Bronx, 437 in
Brooklyn, 56 in Queens, and 26 in Richmond. The total in-
fant mortality was 350; 270 under one year of age, and 80
between one and two years of age. There were 124 still
births. Three hundred and sixty-three marriages and 1,879
births were recorded during the week.
Ferryboats as Open Air Hospitals for the Tubercu-
lous.— Bellevue Hospital has acquired the old Staten
Island ferryboat Soiithftcld and turned it into an open air
hospital for incipient cases of tuberculosis. The value of
this work was demonstrated by the Charity Organization
Society, who used the Soutlificfd for a similar purpose last
year. The boat, which ha';
been entirely refitted, is
under the supervision of Dr.
James A. Miller, chief 01
the tuberculosis clinic of
Bellevue Hospital. It was
placed in commission and
formally opened for patients
on June 3d. It is said that
Gouvtrneur Hospital and
the Presbyterian Hospital
have obtained old ferry-
boats, which will be proper-
ly equipped and used as
open air hospitals for tuber-
culosis patients.
The American Hospital
Association. — The tenth
annual conference of this
association will be held in
Toronto on September 22d
to 25th. The purpose of this
organization is the propio-
tion of economy and effi-
ciency in hospital manage-
ment. It has a total mem-
bership of four hundred,
which includes more than a
hundred hospitals not pre-
viously identified with the
association, and it is antici-
pated that the gathering of
hospital workers in Toronto
will be unprecedented in
number, character, and en-
thusiasm. The programme
will include papers on the
varied interests of hospitals,
large and small, not only by
members of the association,
but by guests who have
been invited to participate
in the meeting on account
of their peculiar fitness for
dealing with some phase of
the problem of hospital
management.
Medical Society of the County of Kings, N. Y.— The
first clinical meeting of the Section in Paediatrics was held
on Friday afternoon, June 12th. The programme included
a symposium on heart disease in children, patients being
exhibited by Dr. Archibald D. Smith, Dr. L. C. Ager. Dr.
F. B. Van Wart, Dr. Le Grand Kerr, Dr. Alexander Spin-
garn, and Dr. Lester W. Volk. The following reports of
cases were presented : A case of sporadic cretinism, by Dr.
George F. Little : cases illustrating the late deformities of
acute anterior poliomyelitis, by Dr. F. B. Cross; a case ot
transposition of the viscera, by Dr. L. C. Ager; a case ol
cerebellar tumor, and a case of tuberculous dactylitis, by
Dr. .'\rchibald D. Smith ; two cases of hereditary spinal
spastic paraplegia, by Dr. .-Mexandcr Spingarn : a case of
chronic Ivmphangeitis. and a case of purnura hpemorrhagica,
by Dr. F. R. Van Wart. Dr. Archi))ald D. Smith is the
chairman of the section. Dr. John W Parrish is vice chair-
man, and Dr. Williatn H. Woglom is secretary and
treasurer.
The Medical Society of New Jersey. — The one hun-
dred and forty-second annual meeting of this society will
be held at the Hotel Cape Alay, Cape May City, on June
i8th, 19th, and 20th. The first session of the house of dele-
gates will be held at the hotel at 10:30 a. m., Thursday,
when the reports of the various committees will be pre-
-sented. The first general session will be opened on Thurs-
day afternoon with the oration in medicine by Dr. William
K. Newton, of Paterson. The last general session will be
held on Saturday morning. The annual banquet will be
held on Friday evening, Dr. Stephen Pierson, of Morris-
town; Dr. Hobart A. Hare, of Philadelphia, and the Hon.
Joseph S. Frelinghuysen, of Raritan, being among the
speakers. The officers of the society are : Dr. Edw ard J.
Ill, of Newark, president; Dr. David St. John, of Hacken-
sack, Dr. Benjamin A. Waddington, of Salem, and Dr.
Thomas H. MacKenzie,
Dr.
Assi;
COLONEL WILLIAM CRAWFORD GORGAS,
NT Surgeon General, United States Army; President-
ELECT OF THE AMERICAN MeDICAL AsSOCT AT TO \ .
Born in Mobile, Ala., October 3, 1854; A. B., University
of the South, Sewanee, Tenn., 1875; M. D., Bellevue Hos-
pital Medical College, New York, 1879; now Chief Sanitary
Officer of the Canal Zone, Panama.
Trenton, vice presidents ;
William J. Chandler, of
•South Orange. recordmg
secretary ; Dr. Daniel Strock.
of Camden, corresponding
.secretary ; and Dr. .\rchiba!d
Alercer, of Newark, treas-
urfr.
Bombay Medical Con-
gress.— .A medical congress
will be held in Bombay in
February, 1909, under the
presidency, of His Excel-
lency tlte Governor of Bom-
bay. The Central Coinmit-
tee, which is composed ot
representatives of the dif-
ferent branches of the medi-
cal profession, official and
unofficial, invites original
contributions from promi-
nent authorities on subjects-
relating to tropical medicine
and sanitation as applied to
India, and is also prepared
to consider voluntary com-
munications from any one
desirous of contributing.
There will be an e.xhibition
of pathological and micro-
scopical specimens of medi-
cal, surgical, and sanitary
appliances, and a series of
lantern slide demonstrations.
The sessions will extend
o\ er four days, and the sub-
jects will be considered in
six sections as follows : Sec-
tion I — Cholera, dysentery,,
enteric fever, and tropical
diarrhcea. Section II — Ma-
larial fever. Plague, Leish-
man-Donovan body inva-
sion, and relapsing fever.
Section III — Parasitic in-
sects, snake venom, beri-
beri, tnycetoma, elephan-
tiasis, and leprosy. Sec-
tion IV — Systems of disposal of sewage in India,
water supplies, (measures necessary to ensure purity,
etc.l. disinfection (methods applicable to India houses, in-
cluding methods of destroying vermin), and miscellaneous
nap( i s cem ral sanitation. Section V — Ophthalmic sur-
ger\. m ill ir\ cilculi, .and miscellaneous papers on tropical
sm gi ly Sii ii'.n VI — Exhibition and lantern slide demon-
strations. Special consideration will be given to the part
played by parasitic insects in the dissemination of diseases
peculiar to the tropics, the geographical distribution of.
those insects, and suggestions as to the best means of ob-
viating their attacks ; the .netiology, pathology, prophylaxis,
and treatment of beriberi and plague; the bacteriology of
and special methods of trealincnt of leprosy; the differen-
tial diagnosis of the \arious types of malarial fever and
dysentery. .-Ml coinnnuiications should be addressed to the
general secretary of the congress, W. E. Jennings. M. D.,
D. 1*. 11.. Lieutenant Colonel. I. M. S., care of Messrs.
Kiu'v, King & Co., Piankers and .\gents, Bombay. India.
June 13, 1 90S.]
PITH OF CURRENT LITERATURE.
THE BOSTON MEDICAL AND SURGICAL JOURNAL
June 4, 1908.
1. New Duty of the Medical Profession: The Education
of the Public in Scientific Medicine. President's
Address Before the American Medical Association.
By Herbert L. Burrell.
2. The Use of Silk Ligaments in Addition to Muscle and
Tendon Transference in Infantile Paralysis,
By Robert Soutter.
3. A Report of Some Atypical Cases of Tonsillar and
Peritonsillar Inflammations with One Unusual Com-
plication. By W. H. Merrill.
4. The Early Diagnosis of Typhoid Fever by Blood Cul-
tures from the Ear,
By O. R. Mabee and A. E. Taft.
5. Antityphoid Inoculation, By G. P. Sanborn.
2. The Use of Silk Ligaments in Addition to
Muscle and Tendon Transference in Infantile
Paralysis. — Soutter describes his procedure as
follows : In attaching the ligament to the tibia, the
periosteum is slit longitudinally. No. 14 or 16 or
20 silk is quilted up the everted edge on one side
and down the everted edge of the other side of the
slit. This gives a very strong attachment, which
cannot be pulled out. Three or four stitches are
taken on either side. The everted edges of the
periosteum are sufficiently loose to answer in the
same way as any soft tissue in stretching down with
the growth of a child, while in an adult it makes a
very strong attachment. The double silk is then
carried down and inserted well under the perios-
teum and superficial portion of the bone by means
of a blunt pointed, short curved needle with a han-
dle, somewhat similar to a Cleveland needle in shape.
The needle does not, however, open. \\'hen it has
been passed through the bone the eye is brought to
the surface. The two ends of a piece of silkworm
gut are passed through this e\'e, then the needle is
withdrawn and pulls the silkworm gut doubled
through the hole in the bone. This leaves two ends
of the silkworm gut protruding from the bone at
one hole and a loop from the other. ( )ne end of the
silk tendon is passed through the loop of the silk-
worm gut. Then the silkworm gut is pulled out,
bringing with it one end of the silk tendon. This
method is used in order not to enlarge unnecessarily
the hole in the bone. In tying the knot the ends are
left a little long, so that they will bend down. The
fascia is brought over the silk and knot by means
of interrupted catgut sutures, subcutaneous tissue,
and skin by means of interrupted catgut or horse
hair sutures. Plaster of Paris bandage is worn from
eight to ten weeks, then a brace to limit the ex-
tremes of motion. This is removed at niglit and
during the day for muscle training and exercise.
After four months a small brace inside the shoe is
worn for long walks only. The correction and pre-
vention of distortion is immediate. Some patients
have good motion from the transplanted maiscle,
some starting motion, but in all the foot is main-
tained firmly in a position of greatest usefulness.
4. The Early Diagnosis of Typhoid Fever by
Blood Cultures from the Ear. — Mabee and Taft
observe, that blood cultures in earlv cases of typhoid
fever (that is, within the first week) give an accur-
ate diagnosis in 90 per cent, to 100 per cent. The
information obtained in this way is, therefore, ex-
tremely valuable, because the \Mdal reaction is
rarely obtained before the ninth or tenth day of the
disease. The simplicity of the method of obtaining
blood from the ear for blood cultures warrants its
general use by practitioners. In early cases i c.c.
of blood is sufficient for each culture. In cases of
two and three weeks* duration a larger quantity of
blood gives a higher per cent, of positive cultures.
In febrile conditions of a few days' duration with
symptoms simulating typhoid fever a negative blood
culture probably excludes typhoid fever. In septicae-
mias due to the Staphylococcus pyogenes aureus, it
is possible to recover this organism from the blood
by the ear method with the use of ox bile as a cul-
ture medium.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
June 6, 1908.
1. A New Duty of the Medical Profession : The Educa-
tion of the Public in .Scientific Medicine. President's
Address at the Fifty-ninth Annual Session of the
American Medical Association,
By Herbert L. Burrell.
2. Relations of the Physician to the Public. Duties and
Opportunities. Oration on Medicine at the Fifty-
ninth Annual Session of the American Medical As-
sociation, By William Sidney Thayer.
3. The Cancer Problem. Address on Surgery at the Fifty-
ninth Annual Session of the American Medical As-
sociation, By George W. Chile.
4. Varicocele and Its Treatment, By Frank K. Boland.
5. Meaningless Diagnoses, By Harry I. Wiel.
6. Comatose Pernicious Malaria,
By Charles Sumner Neer.
7. Psychotherapy. By B. Onuf (Onufrowicz) .
8. The Production of Deciduomata, By Leo Loeb.
I, 2, 3. Addresses and Orations at the Fifty-
ninth Annual Session of the American Medical
Association. — See Xci^' York Medical Journal.
June 6th.
4. Varicocele and Its Treatment. — Boland re-
marks that varicocele is a common condition, being
found in ten per cent, of all men between the ages
of fifteen and thirty. Unsatisfied sexual desire and
excessive intercourse have been ascribed as causes.
The former must influence the trouble, since it some-
times disappears in young men after marriage. Xo
doubt a predisposition may be inherited. Occupa-
tion plays a part in the causation, since varicocele
is common among men who stand a great deal, such
as clerks, bookkeepers, etc. ]\Iore than ninety per
cent, of cases occur on the left side, the explanation
of which is on anatomical grounds. The veins in
the left cord are larger, the testicle hangs lower, and
the left vein empties into the renal vein at a right
angle, while the right vein empties into the vena
cava at an acute angle. Again, the left spermatic
vein, as it runs behind the sigmoid flexure, is con-
stantly subjected to pressure from the accumulation
of faeces in the bowel. It is said that the modern
habit of "dressing" on the left side tends to increase
varicocele on that side, and that mild cases some-
times are improved b> changing to the right side. A
very large varicocele may produce no symptoms,
while a small one often gives rise to pronounced
symptoms, depending largely on the effect on the
patient's mind. In a large number of cases the men-
tal elfect is the main feature of the disease and re-
quires an operation for its relief. This is particu-
larly true when the condition is associated with mas-
turbation, the patient then being fearful of impo-
tence. There is no proof that masturbation is con-
Ii64 PITH OF CURRENT LITERATURE.
nected with the cause of varicocele. Operative
treatment is best and can be carried out under local
anjesthesia, but a general anaesthetic is more satis-
factory. The textbooks recommend ablation of part
of the scrotum as being occasionally indicated, but
in the south, where the pendulous scrotum is so
common, it is generally indicated. Cures by this
procedure alone have been reported. Certainly it
is one of the most important steps in the operation.
The shortened scrotum affords a natural and per-
manent support for the cord and testicle. But the
best methodj in the author's opinion, is the open
method. By this procedure two incisions are avoid-
ed, as the veins may be removed through the same
opening. Inspection of the testicle and tunica vagi-
nalis is afforded, which in a large proportion of
cases will reveal a hydrocele. It is well to give at-
tention to small details in the operation, because so
often it is performed on neurotic patients on whom
the neglect of such details will have considerable
mental effect. For instance, in ablating the scrotum
a curved clamp should be used, or the ends of a
straight incision rounded off in order not to leave
any little elevations of tissue. These would absorb
in a short time, but their presence will annoy some
neurasthenic individuals while they remain. A
curved scrotal clamp or two curved long jawed for-
ceps are employed to hold the scrotum while the re-
dundant portion is being removed. The clamp is
pressed hard against the testicles, in a longitudinal
direction, and as much subcutaneous tissue as possi-
ble pressed out before cutting. This lessens the
number of vessels that will be cut. After severing
the scrotum with knife or scissors the clamp is taken
off and all bleeding points are carefully caught and
tied with fine catgut. The varicosed pampiniform
plexus is now exposed as far away from the testicle
as possible and separated from the vas deferens with
its artery and veins. The plexus lies with the sperm-
atic artery in a separate sheath which need not be
split. Sometimes the separation is difficult on ac-
count of adhesions which exist as a result of inflam-
mation. Ligation of the spermatic artery does not
impair the nutrition of the testicle. The vas defer-
ens is easily recognized by its cordlike feel. It must
not be handled unnecessarily, and is held aside with
its vessels while a double chromicized catgut liga-
ture is passed around the veins. This is separated
and the veins firmly tied in two places two inches
apart, the lower ligature being tied first. The inter-
vening section is now removed, care being observed
to leave the stumps long enough to prevent slipping.
The ends of the ligatures may be left long and the
cord shortened by tying them together. This saves
time, but leaves a lump which will persist for sev-
eral weeks to vex a nervous patient. It is better to
approximate the ends of the veins and stitch them
together. The wound is closed longitudinally with
interrupted silkworm sutures, the ends of which are
left long and tied together, as short ends will irritate
the sensitive scrotum. Drainage usually is not nec-
essary. Rubber tissue or oiled silk is placed over the
dressing to prevent the possibility of contamination
by urine. The dressing is held in place by a figure
of eight roller bandage which supports the testicles.
After a few days it is convenient to use a smaller
dressing and a large suspensory bandage. The pa-
[New York
Medical Journal.
tient is kept in bed for ten days, and a. suspensory
worn only until the wound is thoroughly healed,
then discarded.
6. Comatose Pernicious Malaria. — Neer says
that the main points to be considered in distinguish-
ing it from apoplexy are the age and general ap-
pearance of the patient, the splenic enlargement, the
higher temperature in malaria (though this is not
constant), and, of course, the examination of the
blood. Malarial coma sometimes quite closely re-
sembles sunstroke, and the heat may aggravate or
precipitate a severe malarial paroxysm. In such
cases an examination of the blood is often the only
means of determining the presence or absence of
malarial infection. From the urinary examination
alone it would be impossible to distinguish comatose
malaria from uraemia. Albuminuria and cylindruria
exist in both conditions ; therefore, it is necessary to
rely on other data. Quinine should be given hypo-
dermatically. It may be given in the form of the
hydrochlorate, the bisulphate, or quinine hydro-
chlorate, and urea. Regarding the dosage there is
some difference of opinion. Osier advises 30 grains
of the bisulphate hypodermatically with 5 grains of
tartaric acid every two or three hours, or 10 grain to
20 grain doses of the quinine and urea hydrochlorate.
Craig thinks 8 grains of the hydrochlorate, repeated
until 24 grains have been mjected, is sufficient in
most cases, but admits that in very severe infections
more of the drug may be needed. Bacelli first rec-
ommended the intravenous injection of quinine, and
tlhis method may be used in the presence of very
grave symptoms. Aside from specific therapy, treat-
ment must be symptomatic. Stimulants, especiallv
strychnine, are often useful.
MEDICAL RECORD
June 6, 190S.
1. A New Duty of the Medical Profession : The Educa-
tion of the Public in Scientific Medicine,
By Herbert L. Burrell.
2. The Cancer Problem, By George W. Crile.
3. Comments upon an Unusual Case Requiring Cjesarean
Section, By Walter T. Dannreuthek.
4. A Report of Three Cases Operated on for Large Ab-
dominal Tumors, By W. P. Harbin.
5. The Art of Surgical Knot Tying,
By Charles H. Duncan.
6. Urticaria Following the Second Administration of
Diphtheria Antitoxine, By Alexander W. Blain.
7. The Convalescent Period, and Its Successful Manage-
ment. By W. Parker Worster.
I, 2. Orations. — See Nezn' York Medical Jour-
nal, June 6, 1908.
3. Comments Upon an Unusual Case Requir-
ing Caesarean Section. — Dannreuther describes
this case as follows : The patient, eighteen years of
age, belonged to a troup of midgets. She had had
rickets when six months old. She was well nourished,
and apparently in excellent general health ; height
three feet eight inches ; had no perceptible enlarge-
ment of the thyreoid gland, and no pressure symp-
toms. Abdomen measured three feet six inches in
circumference. No cardiac murmurs. Lungs clear.
The diaphyses of the long bones were underdevel-
oped, while the epiphyses seemed almost normal in
size. Pelvic measurements were : Interspinous.
seven inches ; intcrcristal, eight and one half inches :
external anteroposterior, five and one half inches :
June 13, 1908.]
PITH OF CL'RREXT LITERATURE.
right external oblique, six and one half inchtes : left
external oblique, six and one half inches: internal
conjugate, one and one quarter inches ; internal an-
teroposterior, one and one half inches. An incision
was made through the abdominal wall in the linea
alba, extending t'rom. one and one half inches below
tlie ensiform cartilage to the symphysis pubis. Sec-
ond incision through the uterus in situ, in the middle
third of the median line. Time, thirteen seconds. Xo
attempt was made to control the bleeding from the
abdominal wound, which was inconsiderable. The
child was quickly seized, the cord being clamped
and cut, and was taken to another room. Artificial
respiration was unnecessary, as the child cried lust-
ih- immediately after extraction. The child deliv-
ered, a nurse began pouring a continuous stream
of normal saline solution, at a temperature of 120°
F.. directly upon the uterus. This promoted rhyth-
mical contractions, facilitating the removal of the
secundines. and controlling haemorrhage. Three
layers of continuous catgut sutures were introduced
into the uterine wound ; two into the musculature,
and one into the peritonaeum. One operator com-
pleted the first suture while the other began the sec-
ond, etc. No attempt was made to sponge out the
abdomen, the saline solution being purposely al-
lowed to remain. The abdominal wound was closed
by a continuous through and through chromic cat-
gtit suture, reinforced by silkworm gut interrupted
skin sutures. Time, from the first incision to the
late suture, thirteen minutes. The anaesthetic used
was chloroform,, followed by ether, which the patient
took well. The pulse did not rise above 88. and was
of good quality throughout. The baby was well
nourished and developed in all respects, weight,
seven and one half pounds. ]\Iother rallied well
after operation. Recovery was uneventful, the ab-
dominal wound healing by first intention. Sutures
were removed on the tenth day. The cervical canal
being well open, dilatation for drainage was un-
necessary. Lochia norm.al. The mother secreted
but a minimum quantity of milk, so the baby had to
be fed artificially. Both were discharged from the
hospital in excellent condition four weeks after the
operation.
5. The Art of Surgical Knot Tying. — Duncan
describes a new system of knot tying, introduced
by Dr. R. E. Brennan from Germany. It comprises
two dififerent knots, each of which may be tied with
either hand, the square sailor's or reef knot, and
the double surgeon's knot. It is impossible to de-
scribe it without giving illustrations.
6. Urticaria Following the Second Adminis-
tration of Diphtheria Antitoxine. — Blain observes
that the second immunizing dose of antitoxine
should be given with caution, especially to individ-
uals of the blond type, regardless of how long pre-
vious the first was administered. Should an indi-
vidual who has at some previous time received anti-
toxine become exposed to diphtheria, it is better, in
my opinion, if facilities are such that the exposed
person can be kept under obserA-ation. to delay the
administration until symptoms of diphtheria appear.
Further, in cases of direct exposure to diphtheria,
the possibility of contracting the disease is compara-
tively small. In persons in whom an immunizing
dose of antitoxine has been given, and who later
contract diphtheria, an attempt should be made to
regulate the dosage in comp :arison with the severity
of'the infection, and not to push the serum too far,
and thus overneutralize the toxine, possibly produc-
ing this distressing condition. A positive clinical
diagnosis of diphtheria is often utterly impossible,
regardless of the amount of experience possessed by
the clinician, and consequently all suspicious cases
should be treated as diphtheria, and as diphtheria by
antitoxine, until proved otherwise, since the possi-
bilit}- of trouble caused by the antitoxine is not to
be compared with that of the danger from diph-
theria.
BRITISH MEDICAL JOURNAL.
May .23, 1908.
1. An Experimental Inquiry into the Relationship of Ac-
tion to Dose, Especially with Reference to Repeated
Admigistration of Indaconitine,
By J. T. Cash.
2. Remarks on the Internal Use of the Oil of Turpentine,
By E. Smith.
3. Puerperal Eclampsia, with Special Reference to its
Treatment with Nitroglycerin,
By J. M. McCarthy.
4. On the Causes of Inversion of the Uterus,
By L. Atthill.
5. The Absorption of Ointments, By R. L. Sutton.
6. On Recent Advances in the Surgical Treatment of
Syphilis, By W. A. Power.
7. A Case of Ochronosis,
By L. C. E. Harstox and A. B. Soltau.
8. Satinwood Dermatitis, with a Suggestion as to Treat-
ment, By F. Gardiner.
2. Oil of Turpentine. — Smith states that oil
of turpentine has been tmdeservedly neglected. Pos-
sible irritation of the kidneys is usually apprehend-
ed, but small doses such as five or ten minims have
no such effect, and in large aperient doses (two
drachms to half an ounce) the action of the oil is
entirely upon the bowels, and but little is absorbed.
It is only the moderate dose of from one half to one
drachm that is to be feared. In cases of haemor-
rhagic purpura the oil of turpentine is of the greatest
value as a haemostatic. It should be given as an
aperient with castor oil, and in sufficiently large
dose. For children of from ten to twelve years
of age, as much as half an ounce each of the
two oils should be given every morning or ev-
ery other morning. The best time for admin-
istration is an hour after food. In most cases
of purpura recovery takes place within a week.
Even should haematuria take place, there is no cause
for alarm, as it quickly stops when the drug is dis-
continued. Other forms of haemorrhage may also
be quickly checked by the use of turpentine — in
haemophilia a large aperient dose may check the
bleeding when all other measures have failed. Local
bleedings, such as haemoptysis and the haemorrhage
from typhoid ulcers, may be checked in the same
way. smaller doses being used. One of the most
valuable uses of oil of turpentine is its internal ad-
ministration in small doses as an antiseptic and
sedative in cases of flatulent colic and unhealthy
states of the intestinal mucous membrane. This is
especially true in the aggravated flatulence and colic
occurring in hand fed infants. In cases of hic-
coughs ten drops of oil of turpentine with thirty
drops of nitrous ether often has a striking effect.
The curative value of oil of turpentine when given
by the mouth may often be supplemented and in-
.1166
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
forced by its internal use in enema. In cases of
thread worms its vermicidal action is strikingly
manifested.
3. Puerperal Eclampsia. — McCarthy's article
is based on a series of eighteen cases of puerperal
eclampsia. The convulsions are very similar to
uraemic convulsions- — in both the convulsions are
probably brought about by a toxine the origin of
which is faulty elimination on the part of the kid-
ney. The stage at which the convulsions threaten or
occur will indicate the nature of the treatment. In
the premonitory stage, where they threaten before
labor occurs, the treatment should tend to avert tox-
aemia. All the care in treatment that would be given
to an early case of nephritis, especially that relating
to diet, should be carried out. Nitroglycerin may be
very useful. The period of labor itself may be di-
vided into two stages: (a) Where the convulsions
are slight and the labor slow, the object should be
to avert convulsions. The subcutaneous administra-
tion of morphine and nitroglycerin, used alternately,
is beneficial in this stage. With a rigid os and in-
creasing convulsions, Caesarean section might have
to be considered, (b) When convulsions are in-
creasing and labor advancing — even if the os is di-
lating well — all energies should be devoted to ex-
pediting labor. This is the stage where chloroform
is essential and a drug of the greatest utility. When
labor is over the treatment should aim at the resto-
ration of the function of the kidneys and the recov-
ery of the nervous system from the shock it has sus-
tained. The writer was led to the use of nitroglyc-
erin in puerperal eclampsia, because of the favor-
able results following "its use in cases of contracted
kidney. Of five cases of puerperal eclampsia treat-
ed without nitroglycerin, three died. Of two cases
in which it was given internally only, one died. Of
eight cases in which it was given hypodermatically.
only one died. The mortality among infants was
four out of fifteen, or about 26.7 per cent.
5. Absorption of Ointments. — Sutton has test-
ed the relative absorption of the various ointments
by means of aniline dyes. Guinea pigs and white
rabbits were used, the ointment with the dye being
applied to a bare place on the skin. After a certain
time the patch was excised under anaesthesia, and
sections cut and examined. He found that lard, sim-
ple or benzoinated, and pure goose grease were the
most quickly absorbed of all the substances tested.
Petrolatum is a poor penetrant unless applied with
friction. Lanolin, alone, is absorbed very slowly ;
mixed with a more fluid material, as olive oil, it
readily enters the skin. The addition of a small
amount of cedarwood oil to an ointnicnt considerably
increases the rapidity of absorption.
6. Treatment of Syphilis. — Power discusses
the latest advances that have Ixien made in the treat-
ment of syphilis, and reaches the following conclu-
sions: I. Experimental evidence has shown that
syphilis is due to infection with Spiroclucta pallida,
an organism which lingers for a short time at the
scat of inoculation and then rapidly spreads through-
out the body. This organism, transmitted from
father to child, is the cause of inherited syphilis. 2.
Many forms of arthritis formerly classed as syphi-
litic are due to other infective agents acting upon
tissues modified by the action of the syphilitic virus.
3. Syphilitic changes in the bones, joints, tongue,
and other parts may occur as a result of inherited
syphihs much later in life than is usually recognized.
They are then the result of accidental causes, and
they are often the only evidence of the inherited
taint. 4. The modern treatment of syphilis consists
(a) in the more careful administration of mercury,
which is now given to cure the disease itself and not
merely to relieve the symptoms, as has hitherto been
the case; (b) in a recognition of the limitations of
the absorptive power of the iodides ; (c) in a freer
use of surgical methods to remove the products of
syphilitic inflammation before the iodides are ad-
ministered.
LANCET
May 23, 1908.
1. The Use of the X Rays in the Diagnosis of Appen-
dicitis and some other Abdominal Conditions,
By Sir W. H. Bennett.
2. The Connective Tissue in Carcinoma and in Certain
Inflammatory States that Precede its Onset (Hun-
terian Lectures, II), By V. Bonney.
3. Prophylaxis in the Care of Children in Hospitals,
By H. KoPLiK.
4. Malarial Cirrhosis of the Liver. By E. F. G. Tucker.
5. The .'\cute Suffocative Catarrh of Laennec and other
Conditions from which it Should be Distinguished,
By S. West.
6. Brief Notes of Interesting Cases of Cranial Surgery,
By H. Curtis.
7. A Method of Suturing the Lateral Recti to Insure
Greater Mobility of the Stump after Enucleation of
the Eyeball, By E. Clarke.
I. X Rays in Appendicitis. — Bennett calls at-
tention to the fact that the diagnosis of appendicitis
is neither easy nor sure. This is shown by the fact
that in many cases the appendix is found to be
normal after removal, while in other cases the
(operation fails to relieve the symptoms. Various
conditions give rise to symptoms so closely resem-
bling those of chronic appendicitis that the distinc-
tive diagnosis is extremely difficult. The prin-
cipal of these conditions are : Inflammation about
the ovaries and pubes ; tuberculous glands in the
iliac region; stone in the ureter; gallstone in the
cystic duct ; stone in the movable kidney : and malig-
nant disease of the iliac bone. In some of the de-
ceptive cases the cardinal sign of chronic appen-
dicitis— swelling or induration — may be absent.
But in the dangerous pelvic type of appendicitis
there may be no objective abdominal symptoms,
and in the j^resence of other indications the mere
absence of swelling or of abdominal rigidity is no
iustification for setting aside this possibility of or-
ganic appendix disease. Failing some objective
sign in cases like these, only two methods are avail-
able for clearing the matter up — an exploratory
operation on the one hand, and the use of the x rays
on the other. The operation may do no harm, the
X rays cannot. The result with the rays may be
nil, but they may disclose a .stone in the ureter, a
mass of tuberculous glands, a growth in the pelvic
l,ones — any of which might cause the symptoms of
which the patient complains. So that, in a case of
abdominal pain of any but an obvious kind, all
diagnostic resources have not been exhausted until
the result of an x ray examination has been seen.
There is still far too strong a tendency to decline
the aid of x ray examination because it is unlikely
June ij .yo8.| ['[IH OF CURRL
to give positive information, yet if made by a com-
petent person it will invariably show stones in the
kidney, ureter, and bladder, caseous tuberculous
glands, new growths of bone, concretions in the
appendix, sometimes stone in the gallbladder and
tuberculous disease of organs, and, of course,
metallic and bony foreign bodies. Under favorable
circumstances even the existence of a diaphragmatic
abscess can sometimes be shown.
4. Malarial Cirrhosis of the Liver. — Tucker
states that cirrhosis of the liver, due to chronic
malarial poisoning, is not of infrequent occur-
rence in Bombay, and that, too, in young children,
where all the possible contributory causes except
malaria can be eliminated. Besides the liver, the
stomach, spleen, and kidneys are severely affected.
There is a history of ill health and enlargement of
the spleen for some years, with repeated attacks of
intermittent fever. The enlargement of the spleen
becomes marked, and there is a profound secondary
anaemia. Later there is great emaciation and dis-
tention of the abdomen from collection of fluid in
the peritoneal cavity. The fluid is not very abun-
dant as a rule, and in many cases it does not recur
after tapping. After weeks of treatment with iron,
quinine, and arsenic the patient may improve great-
ly, and the spleen diminish in size. In the last stages
there is profound debility and emaciation with the
late toxaemic symptoms seen in other forms of cir-
rhosis. On opening the abdomen the most promi-
nent object is the enormous spleen. The capsule is
thickened and often adherent to one of the neigh-
boring organs. The liver is somewhat small, but
not as much so as in alcoholic cirrhosis. The red
corpuscles may be reduced to 1,500,000 to the cubic
millimetre. The malarial parasite present in the
peripheral blood is usually the benign tertian. To
sum up, therefore, we have in malarial cirrhosis
a complex condition, of which the hepatic disease is
the terminal event. Ascites is late. ' The finely
granular surface of the liver is quite distinct from
hobnail liver. The cirrhosis results from repeated
attacks of malarial hepatitis and capsulitis, associ-
ated with perisplenitis and a plastic peritonitis. The
adhesions resulting from the latter, along with the
dragging of the enlarged spleen, produce extreme
deformities of the stomach. Plastic peritonitis varies
in amount, but is always a feature in the case.
5. Acute SufTocative Catarrh. — ^West reports
a case of acute sufi^ocative catarrh of Laennec, oc-
curring in a man aged twenty-three years. It is a
rare but characteristic disease, being an acute ca-
tarrh affecting the whole or a portion of the lungs,
causing an acute suffocation. It lasts from twenty -
four to forty-eight hours, at the end of which time
either the patient dies or expectoration commences
and puts an end to the suffocation, after which the
disease goes on as an ordinary catarrh. The respi-
rations are not very lapid, and the temperature and
pulse are only moderately elevated. The clinical
condition is unlike asthma or pneumonia, and there
is no laryngeal obstruction. Examination of the
chest shows nothing beyond coarse bronchi. In the
case here reported, examination of the sputum
showed pneumococci, and a diphtheroid bacillus.
The condition has to be distinguished from capil-
lary bronchitis and disseminated, postbronchitic —
NT LITERATURE. n^y-
i. e., secondary — bronchopneumonia; more closely
resembling it are primary bronchopneumonia — i. e.,
disseminated pneumococcal pneumonia and possibly
an acute pneumococcal or other bacterial bronchitis.
In association with it may be placed ( i) cases of
acute pulmonary oedema, which develop in the
course of chronic heart obstruction or of acute heart
failure; (2) cases of collateral fluxion or of pulmo-
nary failure; and (3) cases of pneumonia which
commence with widespread pulmonary congestion.
A careful bacteriological examination of the sputum
should be made in all cases of suffocative catarrh
as being likely to throw light upon the true nature
of the affection.
LA PRESSE MEDICALE.
May 2, 1908.
1. General Pathology. Organic Reactions in Infection
with the Trypanosoma of Equine Syphilis,
By Henri Claude and Maurice Renaud.
2. The Principle of High Frequency Currents,
By A. Zimmern.
3. Abortive Treatment of Syphilis, By R. Rom me.
I. Organic Reactions in Infection with the
Trypanosoma of Equine Syphilis. — Claude and
Renaud present a very careful study of these micro-
organisms and state that the organic reactions pro-
duced by them are very analogous to those provoked
by bacteria, that the mechanism of infection is in a
general way the same as that of bacterial infections,
and that the details can be explained through a study
of the morphology and dissemination of the parasite.
May 6, igoB.
Treatment of Facial Neuralgia by Local Alcoholization,
By J. A. Sicard.
Treatment of Facial Neuralgia by Local Alco-
holization.— Sicard asserts that the treatment of
facial neuralgia by the injection of alcohol is the
method of choice. He does not confine his injections
to the foramen rotundum and foramen ovale, but
finds that they are useful when made at other points
of emergence. These foramina, or canals, of emerg-
ence, at which injections may be successfidly made,
he divides into three groups — the peripheral group,,
composed of the supraorbital, infraorbital, and in-
ferior dental foramina ; the median group, composed
of the canals of the diploe in the inferior and supe-
rior maxillae, the inferior dental canal at the process
of Spix, and the posterior palatine canal ; and the
deep group, composed of the round and oval fora-
mina. The sphenoorbital fissure is purposely omit-
ted because it is dangerous of access. The point of"
a fine platinum needle is carried down to one of
these points, and a mixture of eighty per cent, alco-
hol with twenty per cent, distilled water is injected
into the tissues. Stovaine may be added if desired,
but not chloroform, because the latter sometimes ex-
cites a very considerable degree of inflammation.
May g, igo8.
1. Diagnosis of Painless Affections of the Hip in the
Child, By Desfosses and Ducroquet.
2. Karell's Treatment of Cardiac Disease, By R. Romme.
I. Painless Affections of the Hip. — Desfosses
and Ducroquet declare that the lameness caused bv
painless affections of the hip depends upon a partial
or total incapacity of the glutaeus medius, and dem-
onstrates his point with several clinical and anatom-
Il68 PITH OF CURRENT LITERATURE.
ical pictures. He then discusses in turn paralysis of
the glutaeus medius, coxa valga, coxa vara, and con-
genital luxation of the hip, anterior and posterior.
LA SEMAINE MEDICALE.
May 6, 1908.
Technique of the Various Processes Employed in the
Serodiagnosis of Syphilis, By Fornet.
May 13, 1908.
Modern War and Military Surgery According to the
Russo-Japanese Campaign, By F. Lejars.
Modern War and Military Surgery. — Lejars
deals with the statistics of wounds and deaths in
their relative proportions, and compares them with
the figures of the Franco-Prussian war of 1870 and
the war in the Transvaal. He then discusses the
wounds of the abdomen, chest, brain, and spine.
BERLINER KLINISCHE WOCHENSCHRIFT
May 4, 1908.
1. Concerning the Stokes-Adams Disease,
By E. DE Renzi.
2. Pains About the Sternum, By P. Hampeln.
3. Concerning Idiopathic Osteopsathyrosis,
By Alexander Lipschutz.
4. Sarcoma of the Prostate, By Wolfgang Veil.
5. Concerning the Specificity of the Precipitate Reaction
in Syphilis and Paralysis,
By W. Fornet and J. Schereschewsky.
6. The Serum Diagnosis of Syphilis in Ophthalmology,
By Curt Cohen.
7. Concerning the Haemolytic Reaction of the Blood
Serum in Malignant Tumors, By Walter Fischel.
8. Studies Concerning the Guaiac Blood Test,
By Julius Rothschild.
9. Contribution to the Conjunctiva Reaction,
By Friedrich Rosenbach.
10. Histological Demonstration of Acidose in Children,
By G. Tugendreich.
11. Concerning the Value of Molliere's Methyl Violet Re-
action in the Demonstration of Free Hydrochloric
Acid in the Stomach, By Wasserthal.
12. Telephone for the Deaf, By P. Lebram.
I. Stokes- Adams's Disease. — De Renzi says
that two characteristic signs have been ascribed to
Stokes-Adams's disease — a permanently infrequent
pulse and nervous attacks, syncope or epileptiform.
But he thinks that the disease has a complex symp-
tomatology and that there are other phenomena
which are just as important, if not more so, than
these two. First is an apparently infrequent pulse, in
which there is a double contraction of the auricles
to each systole of the ventricles. This is shown in
several ways : i , Radioscopy shows an alternate
contraction of the auricle and of the whole heart.
2, In many cases the pulsation of the jugular is twice
as strong as the arterial. 3, By a careful examina-
tion an alternation between a strong and a weak
arterial pulsation can be detected. 4, In some sphyg-
mograms a slight elevation can be detected between
the two curves of the radial pulse. Second, are
•nervous attacks, dizziness, syncopal or apoplectiform
in character, proportioned to and the direct conse-
quence of the infrequence of the pulse. Third, the
infrequency of the pulse is scarcely influenced by
psychic influences, muscular movements, changes
of position, or drugs which accelerate the pulse.
Fourth, slight dyspnoea. In contrast to the puLse
which is constant the respiration changes easily and
is productive of dyspnoea. Fifth, notable increase
•of the blood pressure. Sixth, alternation of the
[New York
Medical Journal.
rhythm of the heart. Seventh, renal changes and
albuminuria.
3. Idiopathic Osteopsathyrosis, — Lipschiitz
reports a case of this disease, which is otherwise
known as idiopathic, brittleness of the bones, met
with in a man, forty-one years of age. He discusses
the symptomatology, the nature of the disease, for-
mer theories, the results of microscopical examina-
tions and of the x ray examination of his own case,
and the relations of idiopathic osteopsathyrosis to
such diseases of the foetal skeleton as foetal chondro-
dystrophia and osteogenesis imperfecta. The latter
he believes to differ from the disease under consid-
eration only in the time of its onset.
7. Haemolytic Reaction of Blood Serum in
Malignant Tumors. — Fischel says that in many
cases of malignant tumors the blood serum shows a
hjemolytic reaction with the blood corpuscles of dif-
ferent kinds of animals. The haemolytic reaction is
not specific for the blood corpuscles of one kind of
animal, as stated by Kelling. The haemolytic reac-
tion is not specific for malignant tumors, but is mei
with in some other diseases, particularly perniciou;
anaemia and tuberculosis.
8. Guaiac Blood Test. — Rothschild assert.s
that his experiments show that the idea of Schroder
that for the bringing out of the maximal stain by the
tincture of guaiac a certain quantity of the tincture
of a certain concentration is necessary, is correct in
principle. With weaker concentrations of blood, foi
which the guaiac test is chiefly used in clinical in-
vestigations, he is convinced that the use of such a
single guaiac tincture in such strength as is most
suitable is best, and one makes no mistake if he un-
dertakes the guaiac test with only a single solution
of guaiac resin.
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT.
May 5, 1908.
1. The Eye of the Obstetrician, By Sellheim.
2. Little Technical Points in the Practice of Uhlenhuth's
Examination of the Blood, By Merkel.
3. Acute Overexertion of the Heart, By Schott.
4. Contribution to the Proteolytic Action of Sterile Pus,
By Hertz.
5. Diabetes Mellitus as an Indication for the Induction of
Premature Labor in Pregnancy, By Schottelius.
6. .^itiology. Anatomy, and Diagnosis of Acute Atrophy
of the Liver, By Reichmann.
7. The Origin and Treatment of Intestinal Hernia,
By Koch
8. The Treatment of Venereal Ulcers With Hot Irriga-
tions, By Zinsser.
9. Lysol Poisoning After Washing Out the Uterus,
By Pilitz.
10. Abscess of the Kidney After Gonorrhoea. Nephrotomy.
Recovery, By Weisswange.
11. Treatment of Intestinal Haemorrhages in Typhoid
Fever by Injections of Gelatin and Salt Water,
By Witthauer.
12. A Practical Instrument for Physical Examination,
By Kretschmar.
13. The Question of Sanatorium Treatment and the In-
dications for the Same (Concluded),
By Frankenburger.
14. New Points of View in the Treatment of Suppurative
Processes, By Moro and Mandelbaum.
15. Obituary of Franz von Leydig. By Schultze.
16. The Physician and the Duty of Reporting Typhoid,
By Hillenberg.
3. Acute Overexertion of the Heart. — Schott
finds as the result of his experiments, commenced
in 1890. that bodily overexertions which arc carried
June 13, 1 908. J
PITH OF CURRENT LITERATURE.
so far as to produce a palpitation of the heart that
can be felt, together with a severe dyspnoea, will
finally result in acute dilatation of the heart.
5. Diabetes Mellitus as an Indication for the
Induction of Premature Labor. — Schottelius con-
siders that the prognosis for the life of either the
mother or the child is pretty bad when pregnancy is
complicated by diabetes mellitus, and therefore rec-
ommends that, when no visible result is obtained by
the internal and dietetic treatment of the diabetes,
premature labor should be induced.
6. Acute Atrophy of the Liver. — Reichmann
reports a case of this nature with the anatomical
findings at autopsy. A point in regard to the fetiol-
ogy is interesting. S>T)hilis was particularly sus-
pected to be the cause because the patient suffered
also from a parenchymatous keratitis, but not only
was infection of this nature denied by the patient
and by his father, but no stigmata whatever of syph-
ilis could be detected, aside from the keratitis, while
living, or in the tissues after death. The cause of
the atrophy of the liver remained obscure.
ID. Abscess of the Kidney After Gonorrhcea.
— Weisswange reports the case of a woman, thirty-
four years of age, who was attacked with an ab-
scess in the kidney six years after infection with
gonorrhcea. Virulent gonococci were found in the
pus.
II. Treatment of Intestinal Haemorrhages in
Typhoid Fever by Injections of Gelatin and Salt
Water. — Witthauer declares that the subcutane-
ous injections of solutions of gelatin and of salt are
remarkably effective. The injections of gelatin
should be made every day or every other day, those
of salt solution should be made more frequently, ac-
cording to circumstances, until the haemorrhage has
stopped certainly a couple of days.
13. Sanatorium Treatment. — Frankenburger
concludes that sanatoria form an important factor in
the measures adopted for the stamping out of tuber-
culosis, that in the admission of patients to the sana-
t:i;ria consideration should not be given to the statis-
tics of results, but only to the benefits to be expected
in each individual case. Patients in the first stage
of the disease, persons suspected of having tubercu-
losis, and those with a latent form of the disease
should be excluded from sanatorium treatment, be-
cause they can be treated equally as well outside by
hygienic regulation of their lives, and by thus re-
ducing the cost many more needy can be helped.
The sanatoria are particularly for patients in the sec-
ond stage of the disease. Admission to a sanatori-
um should not be permitted after a single examina-
tion, but only after previous observation at a hospi-
tal or elsewhere.
ROUSSKY VRATCH.
March 22, 1908.
1. Lipogenin in Eye Diseases, By A. G. Agabavoff.
2. On the Diagnostic Value of the Digestive Property of
Pus, By N. I. Spassokukotzaya.
,^ Materials for the Study of the Chemical Composition
of the Grey Matter of the Brain,
By G. G. Fleischer.
4. On Addison's Disease and Its Relation to Chronic
Malaria (Concluded), By G. A. Lubenetzky.
5. Experimental Polyuria as a Method of Diagnosis of
the Functional Capacity of the Kidney,
By D. P. KouzNETZKi.
6. A New Method of Employing Malachite Green for the
Cultivation of Typhoid Bacilli, By L. V. Padlefski.
7. On the Serum Reaction of Syphilis,
By M. H. TCHLENOFF.
8. Stenosis of the Larynx (Continued),
By M. F. TsiTOViTCH.
I. Lipogenin in Ophthalmology. — According
to Agabavofif, lipogenin is a colorless, transparent
liquid, neutral in reaction, which does not become
altered on exposure to air. It is soluble in ninety-
five per cent, alcohol, but not in glycerin and in
water. It is a mixture of the ether of palmitic and
isooleic acid. Lipogenin is made at a Russian soap
factory in Kazan, and is prepared in the form of a
liquid and in a crystallized solid form. Professor
Agabavoff, of Kazan, in this article, recommends
it as a solvent for alkaloids, as well as for a vehicle
for iodoform in ophthalmology. Aqueous solutions
of^ alkaloids used in eye diseases very readily de-
compose. The use of such decomposed solutions
gives rise to conjunctivitis, etc. Carbolic acid and
other antiseptics have been added to solutions of
this sort to prevent decomposition. But these are
either inefficient or injurious. It is not always pos-
sible to prepare the solution freshly with sterile
water. Olive oil has been recommended for the
preparation of these alkaloidal solutions as early as
1897 by Panas. It is very difficult to obtain pure
olive oil which does not decompose, and the oil must
be specially purified and sterilized. Lipogenin is a
substitute for olive oil, which, according to Agaba-
voff, is superior to it. The author employed it as
a dressing after plastic operations on the eye. He
covered the wound with a disk of sterile gauze,
soaked in sterile lipogenin, then with a layer of
waxed paper, with a thick layer of cotton, and a
bandage. The results were excellent. Lipogenin
does not dry or adhere to the wound and dissolves
iodoform, robbing the latter of its odor. Solutions
of iodoform or of iodine are very useful in eye sur-
gery: Iodine solutions have proved effective in the
treatment of trachoma, the strength being from one
half to two thirds per cent. Lipogenin dissolves
atropine, eserine, pilocarpine, strychnine, etc., in
considerable proportion, and the solutions are stable
and nonirritating.
6. Malachite Green in Culture Media for
Typhoid. — Padlefski recommends the following
medium for the diagnostic culture of typhoid bacilli.
The advantage of this medium is that the colonies
of typhoid bacilli can be distinguished by the green,
bright color. The medium is especially valuable
because it prevents the growth of other intestinal
microbes and promotes the growth of the typhoid
bacillus. The medium consists of agar mixed with
malachite green which has been rendered colorless
with sodium sulphite. The addition of bile to this
mixture, as well as of milk sugar, produces a
culture medium in which the typhoid bacillus grows
abimdantly in the form of green colonies, while
all other bacilli of the typhoid group grow at first
in colorless and then yellowish colonies. Other ad-
mixtures of germs do not grow at all, or in colorless
colonies. The typhoid bacillus, during its growth,
decomposes lactose and forms an acid which neu-
tralizes the action of the sodium sulphite and brings
out the green color of the malachite. The medium
is prepared as follows: To a three per cent.
1 IJO
PROCEEDINGS OF SOCIETIES.
[New Vukk
Medical Journal.
meat agar, with two per cent, peptone, having
a slightly alkaline reaction (to litmus), is add-
ed one per cent, of chemically pure milk sugar
and three per cent, of natural ox bile which
has been previously boiled and filtered. The
agar is poured into flasks holding lOO c.c,
which are sterilized in streaming steam for half
an hour on three successive days. A one per cent,
aqueous solution of chemically pure malachite green
is prepared {Malachit grime Zinkdoppclsals Kris-
talle). Next a solution of ten per cent, sodium sul-
phite is prepared. To each loo c.c. of the sterilized
and cooled agar are added 0.5 of the malachite solu-
tion and 0.5 c.c. of bile and 0.75 to i.o c.c. of the
sodium sulphite solution. The mixture should be
pale green in color and transparent. The agar is
then poured in a very thin layer (about 3 mm.)
into Petri dishes, which are allowed to remain open
until they dry, then are turned upside down and
dried from 10 to 15 minutes in a thermostat. When
cool, the agar should be transparent and yellowish,
without any greenish tint. The material to be ex-
amined should be spread by means of a curved glass
spatula, without undue pressure over the agar. The
agar need not be sterilized after the addition of the
malachite solution. The solution of malachite keeps
only for about a week. After the addition of bile
and sugar, the agar should be tested and should be
slightly alkaline. A slight excess of alkali does
not harm. It is very easy to isolate typhoid bacilli
with this method.
AMERICAN JOURNAL OF SURGERY.
May, 1908.
1. Some of the Modern Aspects of the Cancer Problem,
By RoswELL Park.
2. Simplified Equipment and Management for the Operat-
ing Room, By W. S. Schley.
3. The X Ray in Dermatology; or Truth and Fallacy
Concerning X Ray Dermatitis,
By Albert C. Geyser.
4. The Submucous Operation of the Nasal Saeptum, with
a Plea for a More Rapid Technique,
By J. E. Mackenty.
5. Blood Examination in Surgical Diagnosis. A Practical
Study of Its Scope and Technique (Concluded),
By Ira S. Wile.
6. Rectal "Don'ts," By Jerome M. Lynch.
I. Some of the Modern Aspects of the Cancer
Problem. — Park remarks that if there is anything
peculiar that cannot be alleged of this disease it is
that the cancer cell is its own parasite. It makes
for some a pretty and attractive statement, but it is
perfectly impossible. There is no other place in the
body, nor other circumstances under which the body's
own cells act as parasites. It lias been held that the
cells break up or degenerate and some portion of the
degenerative product is capable of acting as a para-
site. This is entirely undemonstrablc and incredible.
The author remarks to such statements that from
this and many other evidences that might be pro-
duced il c.'in easily be made to appear that the theory
by which the cancer cell is erected into being its own
parasite is far more revolutionary, and taxes the im-
agination far more, than the theory which seeks to
find the cxjjlanation in .some extrinsic agency, and
which is already receiving such striking corrobora-
tion from both clinical experience and the experi-
mental laboratory. He believes absolutely in the
statement that cancer begins as a result of local con-
ditions. Cancer, with all its local characteristics and
its fatal termination, is a disease without a symp-
tomatology of its own. It is a disease without a dis-
tinctive or definite symptomatology. Regarding the
curability of cancer, he states that he feels that if
a case is recognized early, and if it is located in an
accessible portion of the body, and if it were com-
pletely extirpated at that time, there would be a
great probability of cure and with a much lower
mortality. These "ifs," remarks the author, are tre-
mendous in size, and yet he does believe in the cura-
bility of cancer. As Behla says : 'Tf cancer is to
be regarded as a constitutional disease there is but
very little use in operating, since in that case there
would be almost as much reason for amputating the
foot of a gouty patient."
3. The X Ray in Dermatology. — Geyser con-
cludes that the so called x ray burn is no more the
direct result of the x ray than the same reaction
when the part has been exposed to the utlra violet x
ray, radium, or similar agents, and is, therefore, en-
titled to the name of radiodermatitis. The x ray
when brought into direct contact with the tissues is
far more active than radium and furnishes clinically
better results. There is no accurate- means at pres-
ent whereby the effect of the x ra}- can be measured ;
the reaction is largely due to conditions existing
within the body of the patient. The x ray is not a
cure all, but has its indication in certain selected
cases ; whenever possible malignant growths should
receive the benefit of radical removal by knife, cau-
tery, or paste.
MEDICAL ASSOCIATION OF THE GREATER CITY
OF NEW YORK.
Special Meeting, Held in Brooklyn, March 2, igo8.
Dr. J. Scott Wood in the Chair.
The Comparative Therapeutic Value of the
Compounds of Iron. — This paper, by Dr. R.\NS-
FORD E. Van Gieson, the vice president, has been
published in the Journal of April iith, on pages
687 et seq.
Dr. Reynold Webb Wilcox said that the iron
question was in many respects an enormous one,
though in its practical aspect it was comparatively
simple. He had in his possession a copy of the
Bdinburgh Phanuacopocia of 1808, and in this iron
appeared in four forms: (i) iron dust; (2) iron
filings; (3) iron muriate (the chloride); (4) iron
vitriol (the sulphate). Since then the preparations,
both official and nonofficial, had multiplied very
greatly. In the last revision of the United States
Pharmacopoeia, iron had been dealt with at consid-
erable length. Eveiy drug and preparation coming
before the committee had to be considered from two
points of view — the pharmaceutical side and the
medical side. As regarded the latter, no article was
admitted unless there were sound scientific reasons
for its employment. With the hundreds of iron
preparations brought forward they had done the
best they could. Although the preparations were so
numerous, the use of this remedy in practice was a
simple affair. The points requisite for success with
June 13, 1908.]
PROCEEDIXGS OF SOCIETIES.
II71
it were, first, careful observation of the particular
case to be treated, and, second, observation of the
effects of the preparation, to see whether definite
results were being produced by it. It should not be
forgotten that the red corpuscles of the blood could
be greatly increased in number without the use of
medicinal iron. Thus, a milk diet would have this
effect, although milk contained very little iron.
Massage, static electricity, and other agencies, as
well as ordinary wholesome food, also tended to
produce the same result. As Dr. George B. Wood
had said long ago, the best results w"ere obtained
when you simned your patient. The use of such
means cured secondary anaemia, because the effect
was to call into plav the reserve store of iron in the
liver. It was a ver}- easy matter to find out whether
the condition of a patient's blood was improving.
It was not necessary to count the corpuscles (a
very tedious and troublesome undertaking), since
the percentage of red corpuscles was as a rule quite
closely paralleled by that of the haemoglobin, and
this could be readily and quickly estimated by means
of the haemoglobinometer. During some years past
he and his assistants had made more than twenty
thousand haemoglobin estimates. Physical signs
(such as the different haemic murmurs) also indi-
cated quite closely the amount of haemoglobin pres-
ent. The quantity of nonsense which we heard
about iron was appalling, and in this talk there was
also a great deal always said about manganese.
Having said that manganese was practically useless
in improving the condition of the blood (as he had
proved by some three thousand haemoglobin esti-
mates), Dr. Wilcox said that the only reasonable
and scientific way to use iron was to select a single
preparation, which seemed best adapted for the
parricular case, and then observe whether it had the
desired effect, as show'n by the actual increase of
haemoglobin. Any preparation of iron which did
not add as much as 10 per cent, to the amount of
this each week was not accomplishing what we
ought to expect from this remedy.
Dr. H. A. Fairbairx said it would be an advan-
tage if nine tenths of the iron preparations should
be cut out of the Phwmacopocia. The large doses
formerly advised were entirely unnecessary, as
small doses were quite sufficient to accomplish the
desired purpose. There was one preparation on
which he was accustomed to rely almost exclusively,
and that was the syrup of the iodide. As had been
remarked, however, medicinal iron was not the only
thing needed by anaemic patients. It was true that
they required iron, but God had provided this in
the sunshine and in good food.
Dr. Van Gieson said that in his paper he had not
referred tn the iodide, because this was not com-
monly used for simple anaemia, although it was
most excellent in strumous conditions.
The Early Diagnosis of Cancer of the Uterus.
— Dr. Albert Martin Judd read this paper. Al-
though the subject, he said, had been brought to the
attention of the profession very frequentlv during
the last decade, his experience had taught him that
the question of an early diagnosis could not be too
frequently brought to the notice of the general prac-
titioner. In order to make an earlv diagnosis, the
physician, wholly ignoring the climacteric as an
entit}-, should insist upon a digital and speculum
examination whenever his patient complained of
any untoward or unwonted pelvic symptom. More
was learned by the finger than by the speculum. If
the cervix was sound, and the discharges, whether
bloody or leucorrhoeal, came from the uterine cavit\%
the curette should be used as an aid to diagnosis.
In all cases the microscope was to be called into
requisition. While much was still to be desired in
this regard, an early diagnosis was made more fre-
quently at present than formerly, and, consequently,
a less serious view of the disease must now be enter-
tained ; for many series of cases had been reported
by the wisest and most respected surgeons in which
a large percentage of cures were effected. By com-
plete cure he meant with no recurrence after five
years. Our operative treatment of cancer had taken
a long step forward when the modern theor>^ that it
began as a local disease was established. There
were certain types of uterine cancer which ran a
more malignant course than certain others, and two
cases illustrating this aspect of the disease were
cited by the speaker.
The classical symptoms of cancer of the uterus
were hjemorrhage, oft'ensive discharge, and pain.
Unfortunately, when these were all present, the dis-
ease was but too often no longer localized in the
uterine tissues. When the symptoms of cancer
were analyzed, therefore, it was seen that the early
diagnosis must depend upon other than the classical
signs. Very often women would complain of pelvic
symptoms common to several diseases, and the
diagnosis had to be made by the physical findings,
aided perhaps by a microscopical study of a portion
of the suspected tissue. It was his opinion that one
should not say that a given case was inoperable
until the patient was examined under an anaesthetic,
the uterus drawn down by a volsella, and a thor-
ough curetting done, unless (and this was ver}' im-
portant) there was unmistakable evidence of the
existence of secondary cancerous growths in other
portions of the body. The ordinar}- appearance of
the symptoms of carcinoma of the uterus was in
the following order: Ichorous leucorrhoea, pelvic
pain, foetid discharges, and general cachexia. But
while these symptoms were characteristic, some of
them might be absent, or their sequence might be
variable. Thus, pain might not be present. In other
instances haemorrhage would be the first symptom,
and again, loss of weight and general cachexia,
ordinarily the final manifestations, might be the first
to attract attention. As had been stated, a digital
examination, supplemented by the microscope, was
the only method of arriving at any conclusion. This
should never be neglected in any case of painful
coition, stubborn pelvic pain or backache, leucor-
rhoea, and especially metrorrhagia or menorrhagia.
A show of blood, however slight, following sexual
intercourse, should always awaken suspicion.
Having spoken of the technique in obtaining a
specimen for examination, Dr. Judd called attention
to a condition which the general practitioner saw
and treated, namely, erosions or ulcerations of the
cer\-ix, as they w^ere commonly called. An erosion,
he said, was never a disease; it was only a symp-
tom. Generally speaking, it was caused by some
irritating discharge from the cervix or uterus. This
1 172
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
latter might be produced by an inflammatory change
in the mucosa of the cervix or of the body of the
uterus, or might be an expression of some constitu-
tional trouble. It seemed but logical that the cure
of an erosion was to be accomplished only by the
cure of its cause, but we still saw many cases which
had been treated by local applications to the erosion
itself. The protracted course of such treatment led
to unavoidable delay in diagnosis, and delays were
sometimes fatal to the patient. Many of these cases
could be cured by office treatment. He did not hesi-
tate, in a case of so called endotrachelitis, to curette
the cervix in his office, though patients whose dis-
charge came from higher up had to be curetted
under an anaesthetic. Constitutional causes should
be treated constitutionally. The diagnosis of cancer
having been made, only one course was left to the
conscientious physician, and that was operative
treatment — removal, if possible; if not, curetting or
cauterization.
Following the paper there was a prolonged dis-
cussion, only the more important points of which
can be here given.
Dr. George McNaughton said that one great
difficulty in making an early diagnosis was the fact
that so many patients concealed their symptoms
until the disease had made fatal progress. It was,
therefore, a matter of the greatest importance that
a campaign of education should be carried on, so
that women might be brought to understand that
certain troubles which they supposed were due to
the menopause had nothing to do with this,, and
required the immediate attention of their physician.
Ninety per cent, of the cases of uterine cancer were
in the cervix, and, therefore, readily amenable to
operation, if this was undertaken in time. The
microscope would decide the matter in any case of
doubt. The scrapings from the body of the uterus
usually gave the pathologist the means of making
a satisfactory examination, but the curettings of the
cervix were not satisfactory. He had therefore de-
vised an instrument for obtaining specimens from
the cervix which was a slight modification of the
adenoid forceps. The importance of early diagnosis
was a point which could not be too strongly urged.
It should be reiterated again and again, and when
it had become more generally recognized, a fair pro-
portion of the patients could undoubtedly be saved.
Dr. L. Grant Baldwin having also spoken of
the importance of a campaign of education for
women, said that, as regarded di liferent degrees of
malignity, he believed much depended upon the age
of the patient. If she was above fifty, the disease
would be apt to recur less frequently and to be less
malignant than in a younger woman, in whom all
the functions of the economy were more active.
Loss of blood was the great sign of all others, and
every case of haemorrhage should be carefully in-
vestigated. The spottings between periods were
particularly significant, and with the haemorrhage
there was often associated a thin, watery discharge.
In some cases, however, there were absolutely no
symptoms until the disease had made fatal progress.
There was nothing distinctive about the odor of
cancer, and also the cachexia from sloughing
fibroids was very much the same as that from
•cancer.
Dr. R. H. PoMEROY said that, while Icucorrhoea
was by no means pathognomonic of cancer, it was
almost invariably one of the early signs of this dis-
ease. All the ordinary cases of leucorrhoea were
curable, and if in any instance the cause of the dis-
charge could not be found and treated, it was fair
to suspect the presence of cancer. A test that had
been proposed for determining the existence of
cancer when there was erosion of the cervix was
the application of a ten per cent, solution of copper
sulphate. If the granulations healed under this
treatment it would show that there was no cancer,
while the reverse of this would be true if they did
not heal.
Dr. A. Ernest Gallant said it was natural that
we should fail to recognize the early signs of cancer,
because there really were no symptoms which could
properly be called early. As to what are generally
known as erosions of the cervix, he had never seen
a case of this in which the condition was followed
by cancer. He had found that these erosions were
best treated by means of the application of pyro-
ligneous acid, repeated until they healed, and as an
adjuvant to this he employed douches of ordinary
vinegar. If there were a cancerous condition of the
cervix, however, this treatment would have no
effect. Women frequently had cancer long before
the menopause, and he had seen a patient of thirty
with enormous cauliflower growths. He believed
there was great danger of the cancerous degenera-
tion of fibroids. It would not do, therefore, to tell
patients with fibroids that they would get well when
they reached the menopause. There was a cachexia
from fibroid, and he was opposed to letting a patient
with such a tumor go on to this third stage. He
would operate early, for the prevention of future
trouble, just as he would in appendicitis. While no
one had greater respect for the work of the patholo-
gists than himself, he had found that they some-
times made mistakes, and he knew of three cases
where the uterus, which had been pronounced can-
cerous, had been taken out, when syphilis was really
at the bottom of the trouble. He therefore always
gave his patients a thorough course of antisyphilitic
treatment before he consented to operate. He did
not believe there was a pathologist living who could
always decide correctly in a case of suspected cancer,
and where the disease was located in the body of
the uterus, it was manifestly unfair to expect the
examiner to make the diagnosis from a few scrap-
ings from the lining of the cavity. To afford a
proper opportunity for decision, the curetting should
be deep.
Dr. Archibald Murray, having referred to some
of the difficulties with which the pathologist had to
contend, said that in any case, where the disease was
in the body of the uterus, he thought that in secur-
ing a specimen for examination the uterus should
be thoroughly curetted, and, if possible, some of the
underlying tissue obtained, as well as .some of the
sound tissue on either side also. He did not think it
fair to ask a diagnosis from a little mucus on a
tampon. If the specimen was kept in water or pre-
sented dry on gauze, not much could be done with
it. The surgeon was apt to expect too much of the
pathologist, and in many instances the early diag-
nosis of cancer was just as difficult for the latter
as it was for the surgeon.
Dr. Jt'DD said that personally he had never seen
June 13, 1908.]
BOOK NOTICES.
a case of cancerous degeneration of fibroids, al-
though for years he had been on the lookout for
this.
Experiences in the Field of CEsophagoscopy. —
The last paper of the evening was by Dr. Joseph
Mersbach, on this subject. He said that he had
no original views to present, but simply desired to
speak of the results of some of his examinations,
and to consider to what extent these investigations
had supplemented clinical observations. The instru-
ment employed was the Alikulicz cesophagoscope,
and the patient examined was placed in the horizontal
position. Except in one instance, local anaesthesia
was used ; at first a twenty per cent, solution of co-
caine, and afterward (as poisoning was once caused)
a ten per cent, solution. At his last examination he
employed general anaesthesia, and as the result of
this experience he now believed that, in making the
examination, this should always preferably be re-
sorted to. In two cases previously he had failed to
introduce the instrument because of his inability to
overcome the nervous irritability of the patient. The
speaker then proceeded to give a condensed report
of cases, each one of which was illustrative of one
of the four groups in which he had made examina-
tions. The first was a case of carcinoma, the second
one of idiopathic dilatation of the oesophagus, the
third one of syphilytic tumor, and the fourth one
of foreign body. By way of comment, he said it
was doubtful whether the limited number of his
cases entitled him to form any conclusions as to the
value of CEsophagoscopy, but, so far as he had been
able to form any opinion from his personal experi-
ence, it would be in the direction of not attaching
too much importance to the diagnostic significance
of such inspection. In malignant growths the diag-
nosis could usually be made by other methods, and
the diagnosis between a diverticulum and a dilata-
tion could also be arrived at by other means. In the
extraction of foreign bodies, however, the cesopha-
goscope was undoubtedly far superior to the method
of probing in the dark, and even to the removal by
the aid of the x ray, which was. of course, not
applicable to all foreign bodies. Here the cesopha-
goscope was the only rational instrument, and it
ought to be considered indispensable. If he had
succeeded in establishing the diagnosis of syphilis
in one instance, the value of this discover}- could
not be exaggerated, since it afforded the inspiration
to institute antisyphilitic treatment in the otherwise
hopeless cases of oesophageal tumor.
Dr. ;M.\x Eixhorx said that, in December. 1901,
he had had the honor of first demonstrating his new»
cesophagoscope before this association. In the older
instruments the source of the illumination was out-
side of the oesophageal tube, while in his own a
better illumination was secured by placing the lamp
at the lower end of the tube, near the area to be
examined. In examinations with the cesophagoscope
he thought that neither cocaine nor general anaes-
thesia should be resorted to. When insensibility
was present it was impossible to say what might not
happen. With all these instruments the introduc-
tion involved, under any circumstances, a consid-
erable amount of danger to the patient. In the case
of his own cesophagoscope, at least, the sitting pos-
ture was preferable to the recumbent for the intro-
duction, though later the patient might lie down
with the instrument in place. In some instances the
horizontal position afforded a better opportunity for
the observations required. In his opinion the
cesophagoscope as a diagnostic means was of very
great value. As an illustration of this, Dr. Einhorn
cited the case of a lady who had a small tumor of
the stomach. On account of the difficulty she had
in swallowing, it was suggested that an operation
should be performed. Before consenting to such a
procedure he thought it would be well to make an
oesophageal examination, and when this was done it
showed ver\- distinctly that there was a continuation
of the tumor into the oesophagus, a condition which
rendered an operation entirely unadvisable. Again,
there were certain cases in which there were ver\^
grave symptoms, and yet when the oesophagus was
inspected nothing was found. Here the instrument
was of service in excluding dangerous conditions,
and such patients were benefited by medicines. In
one case that he had observed there was a redden-
ing or perhaps inflarmnation of the oesophageal mu-
cous membrane, but no obstruction whatever. With-
out the cesophagoscope it would have been difiicult
to make a correct diagnosis, and under appropriate
treatment this patient got entirely well.
iffok gotiffs.
[IVe publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, n-e review those in which we think
our readers are likely to be interested.]
Diseases of the Heart. By Professor Th. von Jurgensen, of
Tubingen; Professor Dr. L. Krehl, of Greifswald; and
Professor Dr. L. vox Schrotter, of Vienna. Edited,
with Additions, by George Dock, M. D., Professor of
Medicine, Universitj- of Michigan. Illustrated. Phila-
delphia and London : W. B. Saunders Company, 1908.
Pp. 848. (Price, cloth, $5; half morocco, $6.)
In the collaboration on this well known volume
of Xothnagel's Practice. Professor Krehl has beerr
assigned the subjects in which the advances have,
perhaps, been greatest in recent years. As he is
equally esteemed as a pathologist, a brilliant investi-
gator, and a clinician, his discussion of diseases of
the myocardium, the cardiac neuroses, arteriosclero-
sis, and coronary disease are marked by the origi-
nality of view, scientific caution, and soundness of
deduction which would be expected by the student
familiar with his Pathological Physiology. The
American reader will be struck by the significance
attributed by the newer school of German observers
to the influence of alcohol and tobacco as causes of
the chronic degenerative changes in the heart and
bloodvessels. In the sections on treatment a con-
servative, but, on the whole, favorable opinion is
expressed as to the value of the Xauheim system
of baths and resistance exercises. The sodiosali-
cylate of the bromine is praised as a diuretic.
There is a masterly review by Krehl of the action
of digitalis, from which we cannot refrain from
quoting the following: "The physician must make
himself thoroughly familiar with the properties and
uses of this drug, for it is not enough for him to
knozL' that digitalis is the remedy to give; he must
also knozc how, u'hen, and hozv much of it to ad~
1 174
BOOK NOTICES.
LNew York
Medical Journal.
minister. It is my belief that an adequate knowl-
edge of this one substance would enable a physician
to dispense with all other 'heart remedies' ; but all
other remedies taken together, without digitalis, are
inadequate." The subjects of cardiac insufficiency,
endocarditis, and valvular lesions are dealt with in
an adequate and scholarly manner by von Jiirgen-
sen, who cites numerous illustrative case histories
from his own wide experience, and makes frequent
references to the important literature. In a work
so complete it would seem to be an omission that
in the discussion of rheumatic endocarditis there
should be no mention of the recent contributions of
Poynton and Paine. In the concluding chapters dis-
eases of the pericardium, including syphilis and new
growths, are well described by von Schrotter. \'alu-
able addenda in brackets by the editor round out
and complete the work for the reader in this coun-
try by giving all the references to important Ameri-
can literature. This fine volume will doubtless long
remain a standard reference work on diseases of the
heart.
Surgical Emergencies. By Percy Sargent, M. A., M. B.,
B. C. (Cantab.). F. R. C. S., Surgeon to Out Patients,
Sr. Thomas's Hospital, etc. London : Henry Frowde
(Oxford University Press) and Hodder & Stoughton,
1907. Pp. 256.
The author has availed himself of some eight
years' experience in St. Thomas's Hospital to pre-
pare this account of the methods to be employed in
the treatment of haemorrhages, burns and scalds,
fractures, pus infections, abdominal injuries, hernia,
and injuries of the neck, chest, nervous system, ear,
and eye. The directions are brief and practical and
the manual is handy in size.
Heredity. By J. .Arthur Thomson, M. A., Regius Pro-
fessor of Natural History in the University of Aberdeen,
Author of The Study of Animal Life, etc. With 49
Illustrations. New York : G. P. Putnam's Sons ; London :
John Murray, 1908. Pp. xvi-605.
That the subject matter of this work concerns
itself with facts and fancies which are not only fas-
cinating in their interest, but of great practical im-
portance, few will dispute. But, unfortunately for
the busy man or woman, either in the world of cotr.-
merce or in that of science, the specialistic point of
view has been reached so quickly, and the intricacies
of the subject are so multiplied, and scattered in the
transactions of learned bodies the world over, that
there is need for just such a work as we now have
before us, namely, an introduction to the study of
heredity, from the nonpartisan point of view, by a
student of biology whose equipment for the task is
undoubtedly ample.
The evidences derived from the microscopical
study of cell growth, pushed forward by Van Bene-
den, and in this country by Wilson ; from the statis-
tical data so well collected by Galten, Pearson,
Davenport, and others in Bionietrica and similar
publications, and the results of experimental re-
search have all been made use of to present to the
reader the present day concepts of the general laws
of heredity.
There is much loose thought and looser talk con-
cerning the subject of heredity in di-sease. We are
almost entirely in the dark so far as positive knowl-
edge is concerned, and it must be confessed that
our author contributes little new to the discussion ;
but, fortunately, his chapter on heredity and disease,
while not exhaustive, is sound, and the foolish talk
about the heredity of diabetes, of insanity, of epil-
epsy, etc., concerning which too much is written, is
largely omitted.. The general attitude of the book
is cautious and sound. It is a valuable addition in
the form of a well digested summary, and as such
commends itself to the thinking physician.
Vorlesungen iiber Didtbehandlung innerer Krankheiten vor
reiferen Studierenden und Aerzten. Von Professor Dr.
H. Str.\uss in Berlin. Mit einem Anhang, "Winke fiir
die diatetische Kiiche," von Elise Hannemann. Berlin ;
S. Karger, 1908. Pp. 340.
Professor Strauss has laid down in this book his
ideas about special dietetics in sickness. Questions
relating to general dietetics are only touched upon
in Chapter xv, and then in so far as they have refer-
ence to clinical problems. The dietetic treatment of
diseases of childhood is also omitted, as the author
thinks that should be the subject of a separate book.
Our book is divided into fifteen lectures, three
being introductory and the twelve others treating
of the object proper. Following his practical point
of view, to be as condensed and concise as possible,
the author does not give a special lecture to the dis-
eases of the lungs and to infectious diseases, as the
dietetics in these ills have been treated of under
forced alimentation and under diet in fever.
The book contains a great amount of valuable
material, based upon clinical experience extending
over a long period. The arrangement of the lec-
tures is exceedingly good, which arrangement, su]v
ported by a good index, makes the searching for a
certain diet an easy matter, and assists in the en-
joyment of the reading of the book.
Attached to the book are Hints for Dietetic Cook-
ing, by Miss Hannemann, a well known author in
this field. As the book is written for physicians, the
introduction the author gives to her hints is very
practical. She explains specific cooking expressions
which are so foreign to every one not connected
with the kitchen. The hints contain a rich store of
good recipes under well arranged headings.
Practice of Medicine for Nurses. A Textbook for Nurses
and Students of Domestic Science, and a Handbook for
all Those Who Care for the Sick. By George Howard
HoxiE, A. M., M. D., Professor of Internal Medicine in
the University of Kansas, etc. With a Chapter on tlie
Technique of Nursing, by Pearl L. Laptad, Principal of
the Training School for Nurses of the University of
Kansas. Philadelphia and London: W. B. Saunders
Company, 1908. Pp. 284.
As the title indicates, the purpose of this book
is to provide a manual for those who care for the
sick, either as a professionally educated nurse or as
a voluntary iiome .Samaritan. The book gives such
information as is most helpful in following the
directions of the attending physician.
It contains three introductory chapters, and the
subsequent matter is divided into thirty-nine chap-
ters, each treating of a couplet of diseases or one
disease alone, such as typhoid fever (chapter iv),
pneumonia (chapter v), scarlet fever (chapter vi),
blood poisoning (chapter xvi), coughs and colds
(chapter xx), blood disorders (chapter xxiv). dis-
eases of the eye (chapters xxxv and xxxvi), etc.
Miss Laptad has written an interesting chapter
on the care of patient and the sick room ; while
June 13, 1908.]
BOOK NOTICES.
1175
emergencies, such as acute poisoning and antidotes,
etc., are dealt with in the last chapter.
The book should find its place on every mother's
table, as it contains many a valuable hint, and a
physician can well recommend it to the families
whose medical cares are placed in his hands. But
why introduce -such a book with such an illustra-
tion as is given in Fig. i, opposite the title page?
Woman. A Treatise on the Normal and Pathological
Emotions of Feminme Love. By Bernard S. Talmey,
M.' D., Gynaecologist to the Yorkville Hospital and Dis-
pensary, etc.. New York. For Physicians and Students
of Medicine and Jurisprudence. With Twenty-three
Drawings in the Text. Second, Enlarged and Improved
Edition. New York : Practitioners' Publishing Com-
pany, 1908. Pp. 258.
This second edition appears only a few months
after the book came out for the first time. We re-
viewed it thoroughly (see the New York Medical
Journal, Ixxxv, p. 286), and to that notice we refer
our readers. The new edition has been somewhat
enlarged.
The Correction of Featural Imperfections. By Charles
C. Miller, M. D. Chicago: Published by the Author,
1907. Pp. 134-
The usual textbooks on surgery find but little
space for cosmetic operations, and yet the distress
that is caused, both in men and in women, by im-
perfections in feature — a distress that may influence
greatly the life of the individual — makes some
guide for operative procedures to remedy such con-
ditions a desideratum. The operations are described
briefly and illustrated by cuts, and the little volume
may be of use to many surgeons.
AtJas der pathologisch-anatomischen Sektionstechnik. Von
Prof. Dr. M. Westenhoeffer. Mit 34 Abbildungen. Ber-
lin: August Hirschwald, 1908. Pp. 53.
The many forms and modes of procedure in post
mortem examinations as tanght at the German uni-
versities have induced Professor Westenhoeffer to
place before his confreres a guide for necropsies
which could be generally accepted. Over thirty
years ago (in 1875) Virchow wrote a manual on
autopsies for the Prussian coroners' physicians, to
make the proceedings and their reports uniform, an
English translation of which appeared from the
fourth German edition in 1885. Johann Orth, who
now occupies Virchow's chair as professor of pathol-
ogy in the Berlin University, published a similar
compendium in 1905.
Our author has founded his rules upon a topo-
graphical anatomical basis, and treats the subject in
a very condensed, scientific way, illustrating his text
with well executed drawings. The language is
plain and to the point, and Professor Westenhoeffer
avoids the complicated sentences with which the
English reader so often has to struggle in German
medical books.
Bcricht iibcr den XIV. internationalen Kongress fur
Hygiene und Demographie, Berlin, 23-29 September,
1907. Band i. Berlin: August Hirschfeld, 1908. Pp.
314-
This is the first volume of the Report of the
Fourteenth International Congress of Hygiene and
Demography, held in Berlin, September 23 to 29,
IQ07. It is interesting to note that the contents of
the book pertaining to official proceedings appear
in three languages, German, French, and English,
while the papers and speeches are given in the
language in which they were presented.
The book contains the reports on the organization
of the congress and on the plenary meeting, the
protocol of the session of the permanent interna-
tional commission of the congress, and also a list
of the members. Of essays there appear three:
Chantemesse, Serotherapie de la fievre typhoide ;
Haldane, Some Recent Investigations in the Hy-
giene and Subterranean and Subaqueous Work ; and
Schattenfroh, Die Grundlagen der hygienischen
Wasserbegutachtung. We are to expect three more
volumes.
Transactions of the American Gyncecological Society. Vol-
ume xxxii. For the Year 1907. Philadelphia: W. J.
Dornan, Printer. Pp. 568.
This volume of transactions is more portly than
usual, owing to the addition of a number of papers
by members of the American Surgical Society and
American Ophthalmological Society in the "sympo-
sia" in which these kindred societies were especially
interested.
The same high quality which has characterized
the work of this society from the beginning is ob-
servable in this volume. The scope of its work, as
intimated above, is broader than in any previous
year.
A number of the papers are very brief, and this
is a decided improvement upon earlier custom. There
are very few subjects which cannot be treated in
this busy age, with its superabundant literature, with
comprehensive brevity. The art of luminous and
informing writing is at its best when controlled by
terseness and condensation, notwithstanding some
noteworthy exceptions to this rule in very high
places.
Die Schuppcnfiechtc (Psoriasis vulgaris) vnd ihre Behand-
lung. Von Dr. S. Jessner, Konigsberg i. Pr. Zweite
Auflage. Wiirzburg: A. Stuber, 1908. Pp. 39. (Price,
0.70 mark.)
This little pami)hlcl is the second edition of No.
13 of Dr. Jessner's collection of dermatological hints
for the general practitioner, in which the author
speaks of psoriasis vulgaris. Like all Dr. Jessner's
handbooks, it contains many valuable hints and a
num.ber of good prescriptions.
Cancer. Relief of Pain and Possible Cure. By Skene
Keith, M. B., F. R. C. S., Ed., Author of Introduction
to the Treatment of Disease by Galvanism, and George
E. Keith, M. B., C. M.. Author of Textbook of Ab-
dominal Surgery, with Mr. Skene Keith. New York:
The Macmillan Company, 1908. Pp. 155. (Price, $1.25.)
This volume is offered as a contribution of five
years' experiments in the treatment of cancer by
means of an injection method. An emulsion is
made of iodipin, iron arsenate, iron cacodylate,
and sodium cinnamate, which is given in doses
of from two to five cubic centimetres every other
day. There are records of thirty-six cases of car-
cinoma and five of sarcoma ; these histories are not
so detailed as might be wished, and they are not
summarized. While the authors state that in many
cases there was relief of pain, further data are nec-
essary to indicate the value of the preparation as a
cure.
MISCELLANY.
[New York
Medical Journal.
BOOKS. PAMPHLETS. ETC., RECEIVED.
The Sexual Question. A Scientific, Psychological, Hy-
genic, and Sociological Study for the Cultured Classes.
By August Forel, M. D., Ph. D., LL. D., Formerly Pro-
fessor of Psychiatry at and Director of the Insane Asylum
in Zurich (Switzerland). English Adaptation by C. F.
Marshall, M. D.. F. R. C. S., late Assistant Surgeon to the
Hospital for Diseases of the Skin, London. Illustrated.
New York: Rebman Company, 1908. Pp. 536.
Transactions of the American Pediatric Society. Nine-
teenth Session. Held at the Arlington Hotel, Washington,
D. C, May 7, 8, and 9, 1907.' Edited by Linnaeus Edford
La Fetra, M. D. Volume xix. New York : E. B. Treat
& Co., 1908. Pp. 220.
lli$ctll;uii|.
The Medical Centre of the World.— Dr. Osier
in his letter from Vienna in the Journal of the
American Medical Association remarks:
As a medical centre Vienna has had a remarkable career
and her influence, particularly on American medicine, has
been very great. What was known as the first Vienna
school in the eighteenth century was really a transference
by van Swieten of the school of Boerhaave from Leyden.
The new Vienna school, which we know, dates from Roki-
tansky and Skoda, who really made Vienna the successor
of the great Paris school of the early days of the nine-
teenth century. But Vienna's influence on American medi-
cine has not been so much through Skoda and Rokitansky
as through the group of brilliant specialists — Hebra, Sig-
mund, and Neumann in dermatology ; Arlt and Jaeger in
ophthalmology ; Schnitzler and von Schrotter in laryn-
gology ; Gruber and Politzer in otology. These are the
men who have been more than others responsible for the
successful development of these specialties in the United
States. Austria may well be proud of what Vienna's
school has done for the world, and she still maintains a
great reputation, though it can not be denied, I think, that
the /Esculapian centre has moved from the Danube to the
Spree. But this is what has happened in all ages. Minerva
Medica has never had her chief temples in any one country
for more than a generation or two. For a long period
at the Renaissance she dwelt in northern Italy, and from
all parts of the world men flocked to Padua and to Bo-
logna. Then for seme reason of her own she went to Hol-
land, where she set up her chief temple at Leyden with
Boerhaave as her high priest. Uncertain for a time, she
stayed here with Boerhaave's pupils, van Swieten and de
Haen, and could she have come to terms about a temple,
she doubtless would have stayed permanenttly in London,
where she found in John Hunter a great high priest. In
the first four decades of the nineteenth century she lived
in France, where she built a glorious temple to which all
flocked. Why she left Paris, who can say? But suddenly
she appeared here, and Rokitansky and Skoda rebuilt for
her the temple of the new Vienna school, but she did not
stay long. She had never settled in northern Germany,
for though she loves art and science she hates with a
deadly hatred philosophy and all philosophical systems
applied to her favorite study. Her stately Grecian shrines,
her beautiful Alexandrian home, her noble Roman tem-
disciples did she move to Germany, where she stays in
Johannes Miillcr and in Rudolph Virchow true and loyal
disciples did she move to Germany, where she stays in
spite of the tempting offers from France, from Italy, from
England, and from Austria.
In an interview most graciously granted to me, as a
votary of long standing, she expressed herself very well
satisfied with her present home, where she has much honor
and is everywhere appreciated. I boldly suggested that it
was perhaps time to think of crossing the Atlantic and
setting up her temple in the new world for a generation or
two. I spoke of the many advantages, of the absence of
tradition— here she visibly weakened, as she has sufTered
so much from this poison — the greater freedom, the en-
thusiasm, and then I spoke of missionary work. At these
words she turned on me sharply and said : "That is not for
me. We gods have hut one motto — those that honor us we
honor. Give me the temples, give me the priests, give me
the true worship, the old Hippocratic service of the art and
of the science of ministering to man, and I will come.
By the eternal laws under which we gods live I would have to
come. I did not wish to leave Paris, where I was so happy
and where I was served so faithfully by Bichat, by Laennec,
and by Louis" — and tears filled her eyes and her voice
trembled with emotion — "but where the worshippers are the
most devoted, not, mark you, where they are the most
numerous; where the clouds of incense rise highest, there
must my chief temple be, and to it from all quarters will
the faithful flock. As it was in Greece, in Alexandria, in
Rome, in northern Italy, in France, so it is now in Ger-
many, and so it may be in the new world I long to see.''
Doubtless she will come, but not until the present crude or-
ganization of our medical clinics is changed, not until there
is a fuller realization of internal medicine as a science as
well as an art.
The White Man in the Tropics. — Anderson
observes that when a species is well adapted to
the conditions which environ it, it flourishes : when
imperfectly adapted, it decays ; when ill adapted, it
becomes extinct. When a white man, native of a
temperate zone, goes to the tropics, there occurs a
biological reaction of his system to the new environ-
ment, and a readjustment of coordination between
his vital processes. In the tropics, the white man,
individually, can exist ; racially, he cannot persist.
Acclimatization is not possible. No superior race
can successfully govern an inferior race, superior in
numbers, with equality before the law. Only by
partial enslavement of the colored natives, superior
in numbers, can the white man rule and govern th,-
tropics, and it is only by relays of fresh representa-
tives he can continue his sovereignty. No colony of
northern origin has ever been able to lead a perma-
nent and independent existence in the tropics. — The
Journal of the American Medical Association.
The Millwheel. — At the dinner of the Edinburgh
branch of the British Medical Association Dr.
Charles Kennedy delighted the company with the
following original song:
Tune — The Millwheel.
My opsonic index is negative,
I greatly fear I must die,
I often require a restorative
Of Scotch or Irish or rye ;
My leucocytes are not digestive
Of staphylococci.
I've a boil no bigger than half a crown.
Though it feels as big as a .score.
It makes me sit up when I try to sit down,
It is so devilish sore ;
It's hotter than hell, and I've tried to drown
My sorrows in nips galore.
A bacteriologist came one day
With sterilized lancet and all.
He pricked it, and he carried away
Some matter from that boil ;
A little matter, I heard him say.
To grow on another soil.
He planted it in a jelly dish,
It flourished under his eye ;
Said he, when I asked him, "What is this?"
"They're staphylococci !
Yes, yes," he murmured, "What more can one wish
Than staphylococci !"
My germs, in strange scrum, with nicely washed leu-
Cocytes he now incubated,
And with oil immersion lens brought into view
The fact that each polymorph fed
On three or four cocci, and so one drew
An index opsonic, he said.
Then serum from me, for his leucos he asked,
A meal of my germs to prepare;
But they smiled at him, as in sunshine they basked.
For not one opsonin was there!
The cocci smiled blandly as polymorphs passed
With stolid, amoeboid stare !
With the ghost of a chuckle, he gazed on the sight,
Then took up a Pravas syringe
To dose me with cocci cream cooked a la Wright,
And told me my welfare would hinge
On whether my leucocytes still took fright
At cocci of golden tinge.
My wretched opsonins will not revive I
No matter how often we try:
The boil is much better, but can I survive
If the man with the cocci reply,
"You can only get well, if your leucocytes thrive
On staphylococci !"
And now, I could do with a drop of Scotch,
I like it much better than hy-
Podermic injections of coccal hotch potch.
And fain with my boil would I fly
To regions obscure, where there's no one to tort-
Ure me with pickled cocci.
-Through, the Scottish Medical and Surgical Journal,
March, 1908.
Public Health and Marine Hospital Service
Health Reports:
The fuUow'iig cases of smallpox, yellotu fever, cholera,
and plague have been reported to the surgeon general,
United States Public Health and Marine Hospital Service,
during the week ending June 5, 1908:
Smallpox — United States.
Places. Date. Cases. Deaths.
California — Los Angeles Ma 9-16 i
California — San Francisco May 9-16 4
Florida — Jacksonville May 16-23 1
Illinois — Chicago May 16-23 '
Illinois — SpringfielJ May 14-21 2
Indiana — Fort Wayne May 18-25 i
Indiana — La Fayette May 18-25 3
Indiana — Terre Haute May 16-23 •<>
Kansas — Kansas City ...May 16-23 7
Kansas — Wichita April 18-25 6
Kentucky — Covington May 16-23 5
Louisiana — New Orleans May 16-23 4
Michigan — Detroit May 16-23 i
Minnesota — Winona May
Missouri — Kansas City May
Missouri — St. Joseph May
Misouri — St. Louis May
Montana — Butte May i
North Carolina — Charlotte May ib-23
Ohio — Cincinnati May 16-23
Ohio — Dayton May 16-23
Texas — Galveston May 15-22
Virginia — Richmond May 16-23
Washington — Spokane May 9-16.
Wisconsin — La Crosse May 16-23
Wisconsin — Racine May 16-23
Smallpox — Foreign.
Brazil — Manaos April 18-2.
Brazil — Rio de Janeiro April i9-2(
Canada — Hamilton April 1-30
China — Hongkong April
China — Shanghai April
Egypt — Cairo April
France — Paris May 2-9..
Great Britain — Glasgow May 8-15.
Great Britain — London May 2-9..
India — Bombay April 1-28
India — Calcutta April ii-i!
Italy — General May 2-9..
Java — Batavia April 4-1 1
Mexico — Aguas Calientes May 10-17
Mexico- — Mexico City May 4- 11.
16-23.
16-23.
19-26.
16-23.
19-
1- 18....
2- 26
!-Mav 6.
-30-
Portugal — Lisbon .' . May 2-9
Russia — Moscow April 18-May 2.
Russia — Odessa April 18-May 9.
Russia — Riga April 25-May 9.
Russia— St. Petersburg April 18-25
Russia — Warsaw March 28-April 18..
Spain — Denia May 2-9
Spain — Madrid April 1-30
Spain — Seville .\pril 1-30
Spain — Valencia May 2-9
Transvaal — Pretoria April 1 1-18
Turkey — Bagdad April 11-18
Turkey — Constantinople April 26-May 10
Yellow fever — Foreign.
Brazil — Manaos April 25-May 2
Brazil — Para April 25-May 2
Mexico — Laguna de Terminos May 30 — June 2
on Russian
Cholera — Foreign.
India — Bombay April 21-28
India — Calcutta April 11- 18
India— Madrid April 18-24
India — Rangoon April 11-18
Plague — Foreign.
China — Foochow . . .
China — Hongkong. .
Egypt — General
Egj'pt — Alexandria .
India — General. . . .
India — Bombay. . . .
India — Calcutta
India — Rangoon. . . .
Turkey— Bagdad. . .
.AprU
April
.April
.April
, April
. April
.April
April
.June
Public Health and Marine Hospital Service:
Official list of changes in the stations and duties of com-
missioned and noncommissioned officers of the United
States Public Health and Marine Hospital Service for the
fourteen days ending June 3, 1908:
Bexl, J. M., Pharmacist. Granted leave of absence for five
days, from May 19, 1908, under paragraph 210, Service
Regulations.
Carter, P. I.. Acting Assistant Surgeon. Granted leave of
absence tor three days, from May 19, 1908, under para-
graph 210, Ser\-ice Regulations.
Cleaves, F. H., Acting Assistant Surgeon. Granted leave
of absence for ten days, from May 26, 1908.
Cobb. J. O., Surgeon. Granted leave of absence for seven
days.
EicHELBERGER, W. W.. Acting Assistant Surgeon. Granted
leave of absence for fifteen days, from June 10. 1908.
Fahev. E. W., Acting Assistant Surgeon. Granted leave
of absence for ten days, from May 26, 1908.
Gardner, C. H., Passed Assistant Surgeon. Granted leave
of absence for one month, from May 31, 1908.
Holt, J. M., Passed Assistant Surgeon. Granted leave of
absence for five days, from June 2. 1908.
HuxT, Reid, Chief of Division of Pharmacolog>-. Detailed
to attend the Council of Pharmacologv' and Chemistry,
in Chicago. 111.. June 2, 1908, upon the completion of
which duty to rejoin his station.
Hunter, R., Acting Assistant Surgeon. Granted leave
of absence for four days, from June 4, 1908.
Keatley. H. W., Acting Assistant Surgeon. Granted leave
of absence for three days, from May 13, 1908, on ac-
count of sickness.
King, W. W.. Passed Assistant Surgeon. Relieved from
duty at San Francisco. Quarantine station, and directed
to report to the medical officer in command of the
^Marine Hospital at San Francisco, for duty and as-
signment to quarters.
Naulty, C. W., Jr., Acting Assistant Surgeon. Granted
leave of absence for five days, from June 17. 1908.
Pearse, H. E., Acting Assistant Surgeon. Granted leave
of absence for three months without pav, from June
15. 1908.
Roberts. Xorman, Assistant Surgeon. Granted leave of
absence for three days, from May 25, 1908, under para-
graph 191, Service Regulations ; granted leave of ab-
sence for one month, from June i, 1908.
RoSENAU, M. J., Surgeon. Granted leave of absence for
one month.
Smith, A. C, Surgeon. Granted leave of absence for one
month and fifteen days, from July 6, 1908.
Thornton, M. J., Acting Assistant Surgeon. Granted leave
of absence for one month, from June 5, 1908.
Trask, J. W., Passed Assistant Surgeon. Granted leave of
absence for five days, from June 2, 1908.
BIRTHS, MARRIAGES, AXD DEATHS.
I New Vork
Medical Jourxax..
Wakefield, H. C. Acting Assistant Surgeon. Granted
leave of absence for five days, from May 21, 1908,
under paragraph 210, Service Regulations.
White, M. J.. Passed Assistant Surgeon. Granted leave of
absence for one month, from June i, 1908.
Young, G. B., Surgeon. Detailed to attend the meeting of
the Lake Michigan Water Commission, at Grand
Rapids, Midi., May 27, 1908.
Appointment.
Dr. Nathanael L. A. K. Slamberg appointed as Acting
Assistant Surgeon, for duty at Eastport. Idaho.
Army Intelligence:
Official list of changes in the stations and duties of
officers of the medical corps of the United States Army for
the zccek ending June 6, 1908:
AsHFORD, B. K.. Captain. When no longer needed at Hat-
tiesburg, Miss., ordered to return to Washington
Barracks.
Baily, H. H., Captain. When no longer needed at Hat-
tiesburg, Miss., ordered to return to W^ashington Bar-
racks; returned to Fort Myer, Va., from detached
service at Hattiesburg, Miss.
Banister. J. M., Lieutenant Colonel. Appointed a member
of a board of review to meet at Washington, D. C,
to review proceedings and findings of medical examin-
ing boards in the case of medical officers found dis-
qualified for promotion.
Crampton, L. W'., Colonel. Appointed a member of a
board of review to meet at Washington, D. C, to re-
view proceedings and findings of medical examining
boards in the case of medical officers found disquali-
fied for promotion.
Ebert, R. G., IMajor. Ordered to Vancouver Barracks,
Wash., for duty as chief surgeon. Department of the
Columbia.
Hutton, p. C, Captain. Ordered to return to Fort Wil-
liam H. Seward, Alaska, from Fort Benjamin Harri-
son, Ind.
La Garde, L. A., Lieutenant Colonel. Granted an exten-
sion of his leave of absence to include June 24th ; ap-
pointed a member of a board of review to meet at
Washington, D. C, to review proceedings and findings
of medical examining boards in the case of medical
officers found disqualified for promotion.
LvxcH, Ch.\rles, Major. Ordered to temporary duty in
the surgeon general's office, and on its completion to
revert to status of leave.
MuNSON, E. L., Major. Granted leave of absence for one
month.
Reynolds, C. R.. Captain. Arrived in New York from the
Philippines Di^■ision, on leave of absence.
Stone, J. H., Major. Relieved from duty with the Army
of Cuban Pacification, and ordered to Newport News,
Va., for further orders.
Straub. P. F., Major. Ordered to report to the President
of the .\rmy War College for duty pertaining to the
staff ride over the battlefields of Virginia.
Torney. G. H., Colonel. Granted leave of absence for fif-
teen days.
Navy Intelligence:
Official list of changes in the stations and duties of
officers of the medical corps of the United States Navy for
the zceeli ending June 6. IQ08:
.Allen, A. H., .Assistant Surgeon. Detached from duty in
connection with the Cape Cruz-Casilda survey expedi-
tion and ordered to duty with the Marines at Havana,
Cuba.
BiELi.n, J. A., -Assistant Surgeon. Detached from the Naval
Hospital. Portsmouth, N. H., and ordered to the
Solace.
Bishop. L. W., Passed Assistant Surgeon. Detached from
the Hancock and ordered to the Naval Recruiting Sta-
tion, Indianapolis. Ind.
Brister, J. M., Passed Assistant Surgeon. Detached from
the Naval Hospital. Puget Sound, Wash., and
ordered to continue other duties.
Cook, F. C, Surgeon. Detached from the Naval Academy,
and ordered to the North Carolina. June 6, 1908.
Holeman, C. J., Assistant Surgeon. Orders of May 26th
modified ; detached from the Naval Training Station,
San Francirco, Cal., and ordered to the Arelhusa.
McDonell, W. N., Passed Assistant Surgeon. Detached
from the Xaval Recruiting Station, Buffalo, N. Y., and
ordered to the Severn, for duty in connection with the
Navy Rifle Team.
Schaller, VV. F.. Assistant Surgeon. Resignation accepted,
to take effect June i, 1908.
S.mith, C. G., Passed Assistant Surgeon. Ordered to the
Naval Hospital, Portsmouth, N. H.
White, E. C, Assistant Surgeon. Detached from duty
with Marines at Havana, Cuba, and ordered home to
wait orders.
iirt|s, Parriages, anb itat^s.
Born.
Brechemin. — In Fort McKinley. Philippine Islands, on
Tuesday, March 17th, to Dr. Louis Brechemin, Jr., Medical
Corps, United States Army, and Mrs. Brechemin, a son.
Elliott. — In Philadelphia, on Tuesday, June 2d, to Dr.
John Denn Elliott and Mrs. Elliott, a daughter.
Gillespie. — In New York, on Sunlay, May 24th. to Dr.
H. M. Gillespie and Mrs. Gillespie, a daughter.
Married.
Alexander — Maltby. — In New York, on Saturday, June
6th, Mr. Ludwell T. Alexander, son of Dr. Welcome T.
Alexander, and Miss Mary Breckenridge Maltby.
DuNLOP — Schaeffer. — In Washington, D. C, on Tues-
daj-, June 2d, Dr. John Dunlop and Miss Gertrude King
Schuyler Schaeffer.
Flowers — Rose. — In Harrisburg. Pennsylvania, on Tues-
day, June 2d. Dr. Claude J. B. Flowers and Miss Augusta
Karoline Frederica Rose.
Gilbert — Stamper. — In Cincinnati, Ohio, on Thursday,
May 28th, Dr. J. T. Gilbert and Miss Blanche Stamper.
Hazen — Ross. — In Maiden. Massachusetts, on Monday,
June 1st, Dr. Henry Honeyman Hazen and Miss Laura
May Ross.
Miller — Foltz. — In Harrisburg, Pennsylvania, on Tues-
day. June 2d, Dr. David I. Miller and Miss Mary Frances
Foltz.
SwAYNE — Paramore. — In Philadelphia, on Wednesday.
June 3d, Dr. Eugene Swayne and Miss Ida M. Paramore.
Thompson — Nagle.— In Philadelphia, on Monday, June
1st, Dr. Louis L. Thompson and Miss Elsie May Nagle.
Van Wort — Dixon. — In Brooklyn, New York, on Tues-
day. June 2d, Dr. Clarence Tliorn Van Wort and Miss May
Louise Dixon.
White — Williams. — In Alexandria, Virginia, on Mon-
day, June 1st, Dr. W. E. White, of Harrisburg, Pennsyl-
vania, and Dr. Mary B. Williams.
Winsmorf. — BuHRE. — In Philadelphia, on Tuesdaj-, June
2d, Dr. Henry Davis Winsmore and Miss Bell Buhre.
Died.
Bell.— In Omaha. Nebraska, on Thursday. May 28th, Dr.
Joseph Bell, aged sixty-five years.
Gate. — In Medford, Massachusetts, on Thursday. May
28th. Dr. Isaac Wallace Gate.
Christie. — In Omaha, Nebraska, on Thursday, May 28th,
Dr. William H. Christie, aged sixty-four years.
CuLBERTSON. — In Cincinnati, Ohio, on Thursday, June
4th, Dr. J. C. Culbcrtson, aged seventy-five years.
Deane. — In Montague Centre, Massachusetts, on Sun-
day, May 31st, Dr. Ebenezer A. Deane, aged eighty-three
years.
Foster. — In Concord, New Hampshire, on Saturday,
June 6th, Mr. William P. Foster, father of Dr. Frank P.
Foster, of New York, aged ninety years.
Irish. — In Lowell. Massachusetts, on Friday, May 29th,
Dr. John Carroll Irish, aged sixty-five years.
Miller. — In Camden, Maine, on Friday, May 29th, Dr.
Horace George Miller, aged sixty-eight years.
Ronan. — In Albany, New York, on Monday. May 25th,
Dr. .Andrew J. Ronan.
Schadle. — In St. Paul. Minnesota, on Friday. May 29th,
Dr. Jacob E. Schadle, aged fifty-nine years.
Taber.— In Elmira. New York, Friday, May 2Qth, Dr.
Alfred B. Taber. aged seventy-six years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal it Medical News
A Weekly Review of Medicine, Established 184J.
Vol. LXXXVII, No. 25.
NEW YORK, JUNE 20, 1908.
Whole No. 1542.
(iBriginnl Comminutations.
A NEW METHOD OF ESTIMATING THE PERME-
ABILITY OF THE PYLORUS AND AN AT-
TEMPT AT TESTING THE PANCREATIC
FUNCTION DIRECTLY*
Bv Max Einhorn, M. D.,
New York,
Professor of Internal Medicine at the Postgraduate Medical School.
/. — Permeability of the Pylorus.
The methods ordinarily used for estimatin,^ the
permeability of the pylorus are based principally
upon examinations of the motor function, or rather
prochoresis, of the stomach, as, for instance, the
oil test of Klemperer and the examination for food
remnants of the day previous in the fasting condi-
tion. Neither test decides whether the trouble is
caused by abnormal weakness of the gastric mus-
culature or by a narrowing of the pylorus. The
rice test meal recommended by myself and the cur-
rant test of Strauss take the condition of the
F:g. I. — Smear of a piece of thymus (proximal piece) which had
been kept in patient McK.'s stomach for five and a half hours
(May 4, 1908). The nuclei are unchanged and visible as regularly
oval or rounded bodies.
pylorus a little more into account. The rice test
will, however, be positive only in advanced cases,
•Read before the meeting of the American Gastroenterological
Association, held at Chicago, 111., on June i, 1908.
and the currant test sutTers from the drawback that
frequently the currants will not pass the stomach
tube.
The direct introduction of rubber tubes into the
pylorus has been tried by Hemmeter and Kuhn,
but not with very marked success.
The idea presented itself of having beads of dif-
i
been keiit in patient McK.'s digestive tract for five and a half
hours (May 4. 1908). The nuclei have almost all disappeared, and
broken up debris are visible.
ferent sizes attached to a silk thread and having
them swallowed in order to see whether they pass
the pylorus or not. In normal conditions they will
pass ; in stenosis they will remain in the stomach.
As the length of the thread in itself is not a suffi-
cient guide to decide whether the bead was in the
duodenum or not we must look for a dii¥erent in-
dicator for this purpose. In the beginning I used
beads coated with mutton tallow, later beads filled
with methylene blue and coated with mutton tal-
low. In as far as the fat is dissolved mainly in the
duodenum, a green or blue color of the urine would
show that the bead had already passed the pylorus.
This usually occurs in from three to five hours. If
we then withdraw the bead we will find that it is
empty, i. e., contains neither fat nor methvlene
blue. In order to be sure, however, that the pro-
cess (disappearance of fat and methylene blue)
reallv occurred in the duodenum and not in the
Copyright, 1908, by A. R. Elliott Publishing Company.
ii8o
EIXHORX: PERMEABILITY OF PYLORUS, ETC.
[New York
Medical Jouknai.
are empty we can naturally not say whether the
lower bead passed the pylorus or not.
It was therefore necessary to look for other in-
dicators. At first I used pieces of thymus in gauze
and tied to the bead. In the small intestine the
nuclei will disappear, whereas in the stomach they
are not changed. If we allow the beads with the
thymus for four to six hours to remain in the di-
gestive tract, we find in most cases that the result
will be as indicated before. (See Figs, i to 4.)'
If, however, we leave the beads in the intestinal
tract for a longer time, as over night (for about
eleven to twelve hours), it happens occasionally
that the nuclei will also disappear in the stomach.
* ' ^\ ■ - ft, ^
KiG. 3. — Section of a thymus piece (proximal piece), which had
been kept in patient O.'s stomach for six hours (April 20, 190-$).
The nuclei are visible as rounded or slightly oval bodies of a regu-
lar shape.
stomach, I tied another similar bead for control
purposes to the thread at a distance of fifty centi-
metres from the lips.- This bead can only remain
in the stomach, whereas the original bead was tied
at a distance of seventy-five centimetres from the
lips, and could thus pass the pylorus and travel for
a distance in the duodenum, if, therefore, the dis-
tant bead is empty, whereas the proximal bead is
still filled, it would prove that the lower bead had
passed the pylorus.
In some cases of pyloric stenosis both beads re-
mained full.
In doing this test on a large number of patients
without pyloric stenosis at the German Hospital, it
was shown that frequently the stomach bead was
empty, i. e.. the fat can disappear from the bead
in the stomach (perhaps mechanically), and
methvlene blue can thus be liberated. If both beads
'A
41
Fig. 4. — Section of a piece of thymus (distal piece), which had
been kept in patient O.'s digestive tract for six hours (April 20,
1908). The nuclei are partlj* destroyed. In some places they show
distinctly irregular shapes.
Why this should happen, whether there is re-
gurgitation of the pancreatic juice into the stom-
ach, or whether it is due to other circumstances, I
am at present unable to
state. At all events, the
thymus was not sufficiently
reliable for our purpose.
Instead of thymus I used
pieces of agar that had been
saturated with tincture of lit-
mus and later with dimethyl-
amidoazobenzol. They were
placed in gauze and tied
to the beads. By means
of the litmus agar we deter-
mined that the duodenal
juice (or duodenal chyme)
is usually acid, because
the distal agar pieces
were colored red just like
the proximal stomachpieces.
'I am gr-atly indebted to Miss
Katharine Foot and Miss E. C. Stro-
bell for taking these excellent micro-
scopical photographs.
\7c: B. larger size: C, porci-
June 20
ELXHORN: PER-MEABILITY OF PYLORUS. ETC.
The dimethylagar, however, proved useful. It
was colored red in the stomach if it was removed
at a time when free hydrochloric acid was present,
whereas the duodenal piece usually remained col-
orless. It may, of course, occur that the proximal
piece also remains uncolored, particularly in cases
of achylia or marked subacidity ; on the other
hand, the duodenal piece may be red, if it has not
remained long enough in the duodenum to lose its
color, or where the duodenal chyme, for some dis-
tance, still contains free hydrochloric acid. In
these cases the test has to be done with a different
indicator.
It would be advisable to always use two indi-
cators at the same time, as, for in-
stance, fat and dimethyl or fat and
thymus, in order to decide more
accurately.
For in all cases in which one of
the indicators shows a diflference
Ijetween stomach and duodenum,
we can be sure that the lower bead
has passed the pylorus.
centimetres from the lips then we can often obtain
duodenal chyme.
I proceed as follows : The duodenal bucket,
tied to a long string of braided silk, with a mark at
seventy-five centimetres, is placed in a gelatin cap-
sule and given about one hour after a small meal.
It is left in the digestive tract for three hours with-
out taking any more food. The thread is tied to
the ear or fastened in another manner, so that it
cannot go beyond the seventy-five centimetre mark.
After three hours the thread is slowly drawn up.
In many cases we could feel a slight resistance
when the bucket passed the pylorus, the cardiac end
usually offering no resistance. At the entrance of
■Testing the Pancreatic Func-
tio)i.
Examination of the fjeces has up
till now furnished the best means
for judging the pancreatic func-
tion. The nuclein test of Schmidt
seems thus far to be the best pro-
cedure. The disadvantage, how-
ever, lies in the fact that at least
twenty-four hours are needed for
the completion of the test ; second-
ly, that if they disappear later the
possibility of their destruction by
microorganisms cannot be excluded.
I have already mentioned that
pieces of thymus attached to the
thread and swallowed lose the nu-
clei for the greater part in the duo-
denum. This may, of course, be
utilized for testing the pancreatic
function. I proceed as described
before, and have the result in five
hours.
Instead of observing the change
in test substances due to the action
of the pancreatic juice it would nat-
urally be better to get the juice di-
rectly. Boas tried this by intro-
ducing a tube into the empty stom-
ach, massaging the region of the
liver, and then obtaining the gastric contents. In
some cases Boas succeeded in demonstrating pancre-
atic juice in this fluid. This method is, however,
successful only in a fraction of the cases. The same
may be said of the methods of Hemmeter and Kuhn,
to obtain the juice by direct sounding of the duo-
denum.
On the same principle as the stomach bucket I
have constructed a much smaller duodenal bucket
(Fig. 5). If we have the patient swallow this
bucket on a thread for a distance of seventv-five
Fig. 6. — X ray ph
hirty grammes of bis
the oesophagus the resistance is o\ ercome by having
patient swallow once before withdrawing the
bucket. It is still better to have patient swallow
the bucket before retiring and withdraw it in the
morning in the fasting condition.
Usually the bucket returns filled. The contents
may be removed by means of a pipette and placed
in a small porcelain dish. The contents usually
look yellowish (owing to the admixture of bile),
and yield a neutral or faintly acid reaction without
the presence of free hvdrochloric acid.
Il82
STOUT: FAVUS.
[New York
M^icAL Journal.
Only in one case of grave hyperchlorhydria,
after an old ulcer of the stomach, free hydro-
chloric acid was found in the yellowish fluid. In
this case the string showed a distinctly brownish
coloration at the portion 52 to 64 cm., while the rest
was not colored. The brown part gave positive
reaction for blood. The colored string marked
most probably the position of the ulcer in the
pvlorus and duodenum.
That the duodenal bucket really gets into the
duodenum may be seen, first, from the contents,
secondly, from a Rontgen ray picture taken before
removing the bucket. Such an x ray picture from
patient H.. three and a half hours after swallowing
Fig. 7.— .\ ray plictograpli of the alxlomcn of ilu- >aiiK-
later, showinR tlic position of the colon and the iluodtiial luuki t. w
swallowed about tlirt-c hours previous to this e.xposurc tn i1m
B, hepatic flexure; C, splenic flexure; E, duodenal bucket, i Umi i
7 it can easily be seen that the bucket is lodged beyond ihi -i iin.u
the bucket is here re])ro(luccd. ( Figs. 6. 7, and 8.)"
The duodenal bucket can, of course, also be used
for testing tlie i)ermeability of the jjylorus. For
when it returns with the duodenal contents it cer-
tainly must have passed the pylorus. The tests de-
scribed here, however, will be of benefit principal-
ly in those cases in which there is any doubt
whether regurgitation has taken place from the
duodenum int<j the stomach.
20 Ea.ST Sl.XTV-THIRD StRKET.
'Dr. L. O. Cole was kind enough to lake these x ray photo-
graphs.
FAVUS, WITH REPORTS OF TWO INDIGENOUS
CASES.
By Emanuel J. Stout, M. D.,
Philadelphia,
Associate in Dermatology in the Jefferson Medical College.
Favus (literally a honeycomb) is of rare occur-
rence among natives of the United States, and is
usually met with in this country among the flotsam
from foreign lands, notably Russia, Poland, and
Italy. Both cases, to be referred to later, are ex-
amples of the disease in individuals born of Amer-
ican parents. Usually the afifection is located on the
scalp ( favus capitis or tinea favosa capitis, but any
part of the body, even the mucous
membranes, may be attacked.
Favus of the nails, also known as
onychomycosis favosa (from ovu'^,
nail; and a fimgus) is ex-
ceedingly rare, and the fungus is,
as a rule, introduced under the nail
by the latter scratching the scalp.
Lack of cleanliness and unfavorable
hygienic surroundings are regarded
as favoring its spread — one of the
synonyma used by the French,
tcignc dii pauvrc, being quite sug-
gestive, although the disease is oc-
casionally seen in individuals be-
longing to the better class. This
may be explained by the fact that
tinea favosa may be transmitted by
animals, such as cats, dogs, rats,
mice, rabbits, fowls, cattle, and
horses, and numerous cases have
been recorded in which the disease
has been conveyed from animals to
human beings. The writer is in-
clined to regard barber shops and
other public places, where combs
and l)rushes' are used promiscu-
ously, with considerable suspicion,
although he cannot recall these
articles being mentioned in dermat-
ological textbooks as causative fac-
tors. Some time ago, while rest-
ing after a Turkish bath, the writer
observed an Armenian rubber, em-
j^loyed in the establishment, who
exhibited typical favus of the scalp,
deliberately use the brush and
comb, intended for customers, and
I'h" ^'iiTnt'Tad arrange the few locks the achorion
!V ''\," "eci'm; had Icft uutouched.
r^iii.M!>~i,i 'i'n)'""' ( )bstupui, steteruntque comae et
vox faucibus haesit ! (Vergil). .Al-
though favus has been placed on the list of con-
tagious diseases by the t'nited States government,
and is regarded as sufficient cause for refusing ad-
mission to immigrants, nevertheless its not infre-
{|uent occurrence — principally among the foreign
population — bears evidence to the fact that the sup-
posed .Argus eyed ins])ectors at the various immi-
grant stations either fail to recognize the condition
or overlook it. From personal observation the
'Rayer, in Diseases of the Skii
readily communicated among chi
comb and brush.
STOUT: FAVUS.
1 183
writer has been impressed with the tendency among
a certain class of patients, when being treated
for some cutaneous afYection, to deny that they
are affected with favus, although the pres-
ence of scutula and loss of hair, often associated
with extensive atrophy of the skin or the scalp, will
frequently point to the true character of the dis-
ease. Although much less contagious than ring-
worm, its appearance in public institutions, homes,
and schools is much to be dreaded. This is another
excellent reason why medical inspection of school
children should be entrusted to competent hands
only, and carried out thoroughly. How often, how-
ever, are those who are expected to make a correct
diagnosis of cutaneous affections
among school children unable to
recognize the true state of affairs,
and how frequently we meet with
the stereotyped phrase on certifi-
cates, "disease of the scalp" (sic),
forcibly reminding one of that other
threadbare expression, "heart fail-
ure," which in former times played
quite an important role in death
certificates. Owing to its chronic
character and rebelliousness to
treatment, when on the scalp or
aft'ecting the nails (favus of the
cutaneous surface, tinea favosa epi-
dermidis, being much more amen-
able to treatment), it has proved a
veritable bete noire to the derma-
tologist. The modern treatment of
favus capitis with the x ray, strictly
observing the technique and rules
laid down by Sabouraud and Noire
{La Prcsse medicalc, 1904, p. 825,
and Annalcs de dcnnatologie et de
syphilis, 1904, p. 80), in conjunc-
tion with local applications, has
helped very materially in shorten-
ing the time required to affect a
cure. Under the old method of
treatment the time necessary to
bring about lasting and favorable
results ranged from six months to
two years ; now, however, it has
been reduced to three months.
Even under these much more fa-
vorable circumstances, "an ounce
of prevention is worth more than a
pound of cure"' fully applies to
favus.
The first case to be described
bears a resemblance in some re-
spects to the one reported in 1894 by
Cantrell and Stout ("A Case of Favus of the Head
and Body," Journal of Cutaneous and Genito-
urinary Diseases, pp. 375 and 419; article contains
review of similar cases and bibliography).
Case I. — John L., fourteen years of age, born in New
York City, came under the writer's care the latter part of
July, 1907.
Family History : Both parents are living ; father is a na-
tive of Boston, mother was born in New England. Two
brothers and one sister are living. According to state-
ments made by his aunt, quite an intelligent and neat
looking woman, h* is the only member of the family
having this eruption,
Previous History: Patient had measles and scarlatina.
His aunt stated that the disease began on the scalp two
years ago, while her nephew was in a home, and appeared
on the body and nails six months later.
Present Condition : The lad presented an anaemic appear-
ance, the muscles were flabby and the panniculus adiposus
was poorly developed. He was 5 feet 3 inches in height,
weighed 85 pounds, and had dark blue eyes and dark
hair. Scrotal hernia on right side. He complained of
itching on the scalp, more or less severe at times.
Examination of Urine : Reaction acid, specific gravity
1.022, no trace of albumin or sugar.
Scalp : On examination the entire scalp was found to be
involved, with the exception of an area in both temporal
regions about two inches wide and 3 inches long. The
postauricular lymphatic glands were visibly enlarged ;
pediculi or ova could not be found. Innumerable scutula
Fig. 8. — Same as Fig. 7, taken a few minutes later after injecting t
of bismuth subnitrate into the bowel. The outlines of the colon are
There is marked angulation of the sigmoid flexure. The bucket is se
denum in a slightly different position from Fig. 7. .V, cfficum; B, 1:
C. splenic fle-xure; D, sigmoid flexure and its angulation; E, duodena
horn, I'ermeability of Pylorus, etc.)
rty grammes
lore distinct.
. in the duo-
of various size were situated on the anterior and pos-
terior part of the scalp ; toward the temporal regions they
were more or less confluent and some of the cups showed
a .t^^triated concentric arrangement. When removed from
their bed they presented the typical cup shaped appearance
characteristic of the favus scutulum (scutulum, diminutive
of scutum, a shield), being convex in shape on their lower
and concave on their upper surface. The skin beneath
some of the small crusts was smooth, inflamed, and de-
pressed, and under some of the larger ones distinct atrophy
was noticeable. The removal of soine of the favi was
accompanied by slight liaemorrhage. A few of the smaller
lesions were pierced by hairs ; when rubbed between
the fingers the crusts crumbled readily. Some of the more
STOUT: FAVUS.
York
Medical Journal.
recent favi showed the sulphur yellow color ; where they
had become confluent they looked brownish yellow. The
characteristic odor — suggesting the odor of mice or musty
Fic. 1. — Tinea favosa capitis, epidcrmidis et unguium.
Straw — was very pronounced. The hairs showed decided
change and had lost their lustre, were dry and brittle, some
exhibited longitudinal splitting, and could be readily ex-
tracted with forceps. Midway of the scalp there were
several atrophic areas, almost entirely devoid of hair, vary-
ing in size, the largest being about two inches by two
inches in extent. The eruption extende'd anteriorly slightly
beyond the hairy margin of the scalp and posteriorly about
one half inch beyond the hair line. Owing to the hair
being rather long, it was impossible to obtain a satisfac-
tory photograph showing the full extent of the disease.
Face : Two typical, sulphur yellow, cup shaped lesions,
of the size of a split pea, were visible on the face below the
processus zygomaticus ; one similar, smaller, lesion was
situated on ihe upper part of the left ear and one pinpoint
scutulum on the lower part of the left ear lobe, and three
lesions, the size of a pea, were located near the left com-
misure of the lower lip, below the mucocutaneous junction.
Nails: The thumb nail of right hand had lost its glossy
appearance and was brittle, and slightly fissured; the
greater part of the nail from its distal end to lunula, and
laterally from the nail fold to corresponding side, was
implicated. The nails on the middle and index finger of
the same hand were of a grayish yellow color and slightly
raised from the nail bed. They were involved principally
at the lateral and anterior margins, and only about one.
fourth of the nail substance appeared to be diseased.
On the left hand the nails of the thumb, index, and ring
fingers were slightly affected and did not differ much in
appearance from those of the right hand. The toe nails
did not show any deviation from the normal.
The existence of favus on the body was discovered by
accident. The writer's hand happening to come in contact
with the lad's arm, and he being clad with a thin alpaca
coat, the weather being quite warm, it was possible to de-
tect decided irregularities through the coat sleeve. The
patient did not refer to any eruption on the body and ap
peared to be anxious to conceal the exact state of affairs
and merely called attention to his head and face. After
considerable persuasion he allowed a thorough examina-
tion to be made, which revealed the following conditions:
Arms : On extensor surface of upper part of right arm
there were eight scutula, varying in size from a pea to thai
of a quarter of a dollar. Above the external condyle the
lesions had become confluent and had formed a patch,
measuring about two inches in width and five inches in
length, situated on the external surface of the ulna. About
the middle of the elbow joint and on the internal condyle of
the humerus there were present two favus cups. Numerous
smaller scutula, exhibiting a tendency to become confluent,
were distributed on the inner surface of the radius, and
eight to ten isolated favus cups were scattered over the
extensor surface of the forearm, terminating one and one
half inches above the wrist.
Left Arm : Beginning at the acromion a patch, measuring
about one inch in width at the starting point and grad-
ually growing wider, reached about three inches down-
ward to a point on a level with the left nipple. From this
point an almost continuous sheet of scutula extended to
within two inches of the left wrist.
Trunk : The anterior part of the chest, abdomen, and
pubic region were not involved.
Legs: The scutula were quite plentiful on the upper part
and outer margins of the thighs ; a few were discrete, and
some had coalesced. On the lower part of the thighs the
eruption was very abundant, and extended downward, be-
coming narrower at the condylus externus of the femur
and gradually broadening out, terminated three inches
above the condylus externus of the tibia. On the inner sur-
face of the tibia a patch, several inches in length, was sit-
uated below the knee joint. The patellae were free from
eruption, with the exception of a few isolated lesions on
the left. On the left leg almost the same areas were in-
vaded, except the anterior upper surfi.ce of the tibia. The
eruption on the lower extremities showed considerable sym-
metry. On the left scapula were two large circinate lesions
the size of fifty cent pieces, the one near the upper margin
and the other about midway. Near its lower liorder were
located one lesion, the size of a dollar, and another, the
size of a quarter of a dollar, the latter becoming confluent
with the former. The posterior surface of the left arm
and outer margin of the left scapula were covered with
abundant confluent scutula, and the entire arm from the
June 20, 1908.)
STOUT: FAVUS.
shoulder to within a few inches of the capitulum ulnae was
literally strewn with favi.
On the right arm posteriorly there was a collection of
lesions, beginning about four inches below acromion and
extending to a point below internal condyle of the humerus
A large patch was situated below the olecranon and on
the outer margin of the forearm, and a number of isolated
scutula were visible on the inner margin of the arm.
Near the waist line on the left side of the spinal column
a large scutulum, the size of a quarter of a dollar, pre-
sented, and a pea sized favus cup was situated in right
lumbar region. Two larger lesions, about one inch by one
and one half inches in size, were noticeable in left lumbar
region, near upper margin of the pelvis.
Glutaeal Region: The left buttock was covered with the
eruption, and only a few small areas remained intact ; the
right gluta^l region was similarly affected, although in
a lesser degree. The eruption on the thighs was continu-
ous with that on the buttocks and covered large areas;
the popliteal spaces showed only a few scattered favi. The
posterior parts of both legs were the seat of a large num-
ber of patches and discrete scutula, the eruption being
especially abundant on the left leg.
The smaller scutula exhibited the cup shape very typi-
cally; where the favus cups had become confluent, they
bore a resemblance to fungi as seen on decaying stumps.
Quite a number of the larger lesions were arranged in
concentric rings. Where the scutula had been removed
accidentally, distinct atrophy was noticeable.
The boy remained under the writer's care for six weeks,
and after four weeks' treatment the lesions on the face
and body had entirely disappeared. Numerous atrophic
areas scattered over different parts of the body remained.
The patient complained of itching, more or less severe at
times, and owing to the skin being tense over the articu-
lations and glutaeal regions, movements of the body prav<*
rise to considerable pain.
Although favus over a Hmited space does not af-
fect the general health, generaHzed favus undoubt-
edly has a depressing efifect on the system. It is in-
teresting to note that the patient gained ten pounds
in weight after the disappearance of the eruption
and that his general physical condition improved
very materially.
The time required for the eruption of favus to
make its advent after experimental inoculations ap-
pears to vary somewhat. Thus in Van Harlingen's
experiment upon his left arm a scutulum developed
after ten days. Faljrv observed favus cups appear
on forearm after nineteen days, and they were pre-
ceded by an erytliematous circle and herpetic
lesions. In Bulkley's case three or four scutula
showed on the arm of one of his assistants after six
weeks, and were surrounded by a scaly, erythema-
tous halo. Peyritsch observed favi four days after
experimental inoculation and in another instance
after four weeks. Wishing to make personal ob-
servations and to study the evolution of the scutula,
the writer secured two mice and rubbed particles of
favus crust on the temporal region. The first at-
tempt resulted in disappointment, and proved nega-
tive after a period of five weeks had elapsed. A
second effort proved successful. Following as near-
ly as possible Peyritsch's method, several drops of
water, in which particles of favus crusts had been
soaked for several hours, were deposited in the tem-
poral regions of both mice, after the skin had been
scarified. Four weeks later three to four pinhead
sized scutula had developed in one mouse at the site
of the inoculation. It was possible to observe the
presence of small vesicles, arranged in the form of
circles i herpetischcs Vorstadium oi Kobner). which
were noticeable before the scutula appeared. Th'j
skin in the temporal region of the other mouse did
Fig. 2. — Tinea favosa capitis, epidermidis et unguiun;.
not show any change with the exception of slight
swelling.
ii8C
KEPPLER: INFANTILE PARALYSIS.
[New York
Mepical Journal
Report of Dr. R. C. Rosenberger, assistant pro-
fessor of bacteriology, Jefferson Medical College:
Specimen, sent by Dr. Stout, consisted of crusts from
the scalp, face, arms, legs, and scrapings from the finger
nails. Some of these were treated with a ten per cent,
solution of caustic soda and examined immediately ;
others were inoculated upon culture media, as bouillon
and agar.
The crusts, treated with this solution, showed the char-
acteristic hypae and spores of the achorion, and the scrap-
ings from the finger nails also contained the fungus.
The inoculations upon agar and bouillon developed a
mi.xed growth, consisting of the Micrococcus pyogenes
aureus and mould fungus. (Inoculation of white mice
was intended, but had to be abandoned, as no white mice
were procurable at the time.)
From the appearance of the hypha. the arrangement of
the hyphse and spores, as well as the morphology of the
growth upon culture media, it seemed beyond doubt that
the parasite was the one recognized as the cause of favus,
the Achorion Schoenleinii.
Fig. 3. — .\chorion Sclionleinii ; a, spores; b, liyplise.
The second case to be reported, briefly, furnishes
an example of favus occurring upon the body sur-
face alone.
Case II. — J. R., a young girl, aged thirteen, the daughter
of respectable and intelligent parents, both Americans,
came to the writer's office during the summer of 1907.
The parents consulted the author for an eruption on the
arm of three' weeks' duration and slightly itching in char-
acter. They stated that their family consisted of two
children, one boy and one girl, and that no other member
of the household had any cutaneous disease.
On inspection a group of sulphur yellow scutula, about
ten to twelve in number, varying in size from a pinhead
to that of a split pea, were seen on the flexor surface of
the right forearm, three inches above the wrist joint, and
occupying an area about four inches in diameter. 'Viewed
through a lens they appeared to be located around fine
lanugo hairs and were surrounded by a slight erythe-
matous halo. The most careful search failed to elicit the
presence of favus on the scalp or on any other part of the
body. Bearing in mind the possibility of the disease being
conveyed by animals, the writer after careful questioning
elicited the information that a pet cat, belonging to the
family and with which their daughter played quite fre-
quently, had several patches on its body devoid of hair,
and concluded that in all probability the cat had trans-
mitted the disease to the girl. Microscopical examination
showed the Achorion Schoenleinii to be present in scrap-
ings taken from the arm.
1^38 XoKi H Fifteenth Street.
THE TREATMENT OF INFANTILE PARALYSIS.*
By Carl R. Keppler, M. D.,
New York,
Orthopaedic Surgeon to the Out Patient Department of Harlem and
Fordham Hospital: -Associate Orthopaedic .Surgeon,
Red Cross Hospital.
Since it was the misfortune of the children popu-
lation of New York and its near vicinity to have
gone through a severe epidemic of anterior polio-
inyelitis during the last year, general interest in
this disease has been greatly awakened. Infantile
paralysis, which until then, on accoimt of its com-
parative rarity, was observed and treated only by a
selected few, now became a menace, and the cry for
further information as to its jetiology, pathology,
and treatment has been a universal one both in the
medical and lay press.
It will be my endeavor to rapidly outline the treat-
ment of the condition following the acute attack ;
but before doing so I wish to einphasize our present
general opinion, that during the first six weeks all
of these cases should be left alone, being kept ab-
solutely quiet in the recumbent position. This is
done so as to allow all inflammation and congestion
m the spinal cord to disappear : the products of dis-
ease to become absorbed. The best means at our
command for this purpose is a li^ht. portable gas-
pipe frame, to which the child is attached by an
apron ; this allows, without disturbance, easy trans-
portation from room to room, or outside into the
fresh air. The food administered should be light
and nourishing; the child's general health carefully
observed. Over the spine itself counterirritation by
means of the cautery might be practised at inter-
vals, and the limbs kept straight and warm in flan-
nel bandages.
Passing over to the treatment of the chronic
stage, that is, of established paralysis, a different
phase presents itself. It is our duty now to help
Nature in its reparative efforts, both at the seat of
the disease as well as in the aft'ected limbs, to pre-
vent these eft'orts from becoming vicious in effect,
and to gradually teach the child in protective ap-
paratus the lost art of locomotion. An absolutely
paralyzed muscle can probably not come to life
again, it is true, but mucli can be done to strengthen;
those partially paralyzed or frequently only weak-
ened. I believe, directed by observations of re-
sults obtained, that the treatment should be one of
active assistance, not only of passive indifference.
The procedures to be employed I will therefore
categorize as: i, active treatment; a, by the use of
pendulum inachines ; b, by the use of massage and
electricity ; c. by the use of hydrotherapy ; 2, brace
treatment : ^, operative treatment.
I, a. Treatment by the Use of the Pendulum Ma-
chines.— After the acute attack the lower (distal)
part of the body is cut off from the brain by means-
of the changes in the spinal cord ; the centres in the
brain therefore not having to work any more, that
is, to send out controlling impulses to these parts,
return in a sense to their infant stage, in so far
as to forget to frame and send out these complex
impulses. But at the diseased area of the spinal
cord not all — in fact, generally, not even the major
•Read before the Medical Society of the County of Richmond,
N. Y., Maich 11, 1908.
June 20. 1908.
KEPPLER: IX FAX TILE PARALYSIS.
1 187
Fig. I.— Pendulum machine.
portion — of the nerve tissue is absolutely degen-
erated, as one mig-ht be led to believe from the
changes in the limbs. ^lany of the cells are still
patent, having been simply put out of action and
dormant following the intense acute inflammation
of the affected area. If now we passively and
rhythmically move the paralyzed limbs, using for this
the basic principle of all motion, that is. the pendu-
lum movement or swing, we send at equal intervals
new impulses to the controlling brain centres — both
through the medium of the still existing nerve fila-
ments in the spinal cord, as well as through the
medium of the child's eyes. The brain is thus
called into activit}' and starts to imitate these sim-
ple pendulum movements ; the impulses thus gen-
erated pass down to (and through) the partly de-
generated, partly latent area in the spinal cord, caus-
ing renewed activity in the latter and possiblv some
regeneration in the former. All this time the effect
of motion in the atfected muscles of the limbs be-
ing exercised, is active in two ways : Firstlv. from
here impulses pass up through the peripheral nerves
to their centres along the cord ; these active im-
pulses meet and mutually aid those coming: from
the brain, causing a two fold activity of repair in
the diseased area. Secondly, the rhythmic expansion
and contraction of the muscles increases the flow
of blood in the limb, thus giving locally to the mus-
cles and tissues added nutrition and consequent tis-
sue change.
Passing now from theory to practice I can assure
you that in a relatively short space of time the good
results following the careful use of these machines
will become apparent in the children themselves.
They are admonished to try and work the machine
as soon as they appear to grasp its fundamental
principle and have recovered from the first few
frights anything new imparts. In this way they
learn to use actively whatever muscular power is
remaining — let us sav alive — in the limb, increas-
ing it ; and thus bring the frequently only dormant
fibres of apparently dead muscles into rhythmic play,
soon becoming active. The effect is nearly magic.
The flabbv, thin, cold limb increases in size and
solidity, and becomes pink and warm ; contractures
of the joints, if present, are gradually and painlessly
overcome, in fact, can be prevented if they have not
as yet occurred. The child's mind brightens, it
loses its sickly stoicism consequent to long confine-
ment, takes interest in its own progress, and will
soon try to work its limbs activelv without being
urged. Furthermore, the general health of the child
makes rapid strides forward, and there is an in-
crease in its appetite and general body weight. No
passive exercise manually done, no free exercise
could so well accomplish this desired result : for in
the first place the exercises w^ould and could not be
executed rhythmically and graded, and secondly,
the child's brain cannot formulate any distinct
movement independently and execute it. The funda-
mental principle upon which the pendulum machine
is built is simple : L'pon one end of a revolving
axle a weight and pendulum are attached, at the
other end by means of removable sandals or leg
cups the limb or part to be exercised. The pendu-
lum is now set in motion, either passively by the
attendant or actively by the patient, and swinging
to and fro gently and rhythmically exercises the part
Fig. 2. — Pendulum machine.
iiS8
KEPPLER: INFANTILE PARALYSIS.
[New York
Medical Journal.
of the body attached at the other end. One ad-
vantage to note is that the pendulum can be attached
at any plane to the axle so that one can stretch
any group of muscles desired.'
At first the child spends about five minutes ex-
ercising each part, and, as the work becomes more
active, this time is gradually increased to fifteen
minutes, never up to the point of fatigue.
I, b, Massage and Electricity. — Massage I con-
sider one of our main adjuvants to the successful
treatment of infantile paralysis. The manipulations
consequent to it are apparently so easily mastered
that, unhappily, its professional standard in this
country has been lowered by its promulgation in
the hands of charlatans and fakirs. In fact, I have
had to hear that it lowers the dignity of our pro-
fessional standing to make use of it personally. I
disagree with this, for it seems to me that what one
Fig. 3.— Pendiihnu macljiiu-.
wishes to teach correctly, one has to have a thor-
ough knowledge of. and I apply it, where possible,
myself in every case until T have sufificiently in-
structed the parent or nurse to know that it is thor-
oughly done. I usually advise massage for both legs
at the beginning of treatment in all cases — even in
those where only one limb apparently remained
paralyzed ; and in the more severe forms also in-
clude the muscles of the buttocks and back, the ab-
dominal muscles, and the arms if afifected. Each
individual group of muscles receives its share of
.stroking, kneading, striking, and vibration, as de-
manded, starting upward from the toes and follow-
ing its defined anatomical distribution ; the act be-
coming more severe as the hypersensitiveness of
the parts dccrej^ges. Lack of knowledge of or care-
lessness in the ^employment of massage I warn is
•Sec Kr|.i>lcr. Wtak Toot and Its Treatment. New York Medical
Journal, hinc x. 190; pp. 1066, et seq.
harmful and dangerous ; correctly administered it
is of marked benefit. Rubbing the limb, as so fre-
quently done by parents, up and down more or less
rapidly, is but misguided energy wasted.
Electricity can, in my opinion, hardly be placed
in the same category with pendulum machine and
massage treatment. The intermittent galvanic cur-
rent is useful in that it momentarily excites the
muscle fibres, thus causing frequent slight contrac-
tions and expansions of them, but the local and gen-
eral toning nutritive effect before mentioned is lack-
ing. It also cannot prevent contractures, nor over-
come them when present. The faradic current, I
think, only unduly excites and frightens the child,
without much benefit ; but I suppose on account of
its wholesome, buzzing sound, pleases the parents.
1, c, Hydrotherapy. — The manner in which I ad-
vise it is the following: Into a basin, pail, or tub
large enough to hold the affected limb, hot water
of about 100° F. is poured. To this is added sea
salt (one handful to about two gallons of water),
and the limb is then allowed to soak in this for
about five minutes. Upon withdrawal it is well
dried with a coarse towel, and immediately encased
in flannel bandages. This procedure is especially
effective when the limb is blue and cold, as after
long neglect, but I also advise its use in the lighter
cases, as an adjuvant to the other treatments just
described, where the parents' intelligence promises
its careful execution.
2, Brace Treatment. — The application of a brace
to a child suffering from infantile paralysis is an
absolute necessity, just as soon as it begins to use
its limbs in trying to stand or walk. The brace is
put on to keep the efforts of the still active muscles
within normal bounds — aiding the weaker, restrain-
ing the stronger; to protect the weakened joints
from injurious overstrain and stretching, and to
hold the parts of the limb in their correct relation-
ship to one another. The varieties of braces em-
ployed by their authors, and those indicated in each
individual case, are too numerous to mention here,
suffice it to say that in constructing the brace we
must always bear in mind that it should be a help-
mate, not a curse. It must therefore be as light as
possible, extend no further than really necessary,
and fit the limb correctly and snugly without caus-
ing undue constriction or discomfort.
But applying a brace is not the end of treatment,
nor can an occasional visit for a new buckle or
strap hardly be recommended. For if active rem-
edial measures, such as just described, are not
faithfully carried out during this time, regeneratiou
may easily become degeneration, the limb getting
miserably thin, hypersensitive, and the trophic
changes in it marked.
3, Operative Treatment. — Under this heading
many interesting treatises have been written and
much progress made since Stromeyer's first epoch
making tenotomy. The indications, in short, for
operation are: a. To overcome those deformities
resultant to the disease, not otherwise amenable to
treatment, b, To restitute the limb and its parts to
as nearly normal a relationship to one another as
possible, c. To aid and increase the useful work of
the still active muscles, d. If a limb is absolutely
paralyzed and all joints are flabby (Schlatter-
GRAEF: UNUSUAL EYE CASES. 1189
gelenke) to make of it a useful, supporting, al-
though stiff, member.
The modes of operation followed are: i, Ten-
otomy: This is the severing of shortened tendons
where they cause marked deformity and delay re-
covery of opponent muscles ; performed either with
or without suturing of the severed ends after sep-
aration. Two procedures are commonly followed,
subcutaneous and open.
2, Tendon Transplantation : The tendon of a still
active muscle either in whole or in part is intro-
duced into that of a paralyzed one, thus in time
shouldering its function.
Under this heading can also be mentioned muscle
transplantation, periostial tendon implantation; at
present mostly executed, as its effects are better and
more lasting than those of the other methods ; and
the introduction of silk, etc., in place of too short
or too weak a tendon. Care must be used, if pos-
sible, not to substitute an opponent muscle for the
paralyzed one. an exception being the knee joint,
where active hamstring muscles, attached to the
patella, can well substitute the paralyzed quadriceps
extensor.
3, Nerve Transplantation-: A procedure only re-
cently developed, rather questionable in result and
attended with great difficulties.
4, Arthrodesis : The substitution of a stif? sup-
porting for a useless flail joint by means of joint
resection.
In closing, I wish to state that with sufficient
care and the 'rational use of the treatments herein
tabulated — but especially the active pendulum ma-
chine and massage treatment, combined with the
application of a correct brace — we can in most cases
of infantile paralysis be quite optimistic in regard
to the recovery of usefulness of and restitution of
muscular power in the affected limbs.
Certainly it seems plausible to me that we can
hope to attain much better functional results if we
actively teach the child to help itself, instead of
leaving it in ignorance of its capabilities ; without
even considering the remarkable local regeneration,
and immediate gain in general health and strength,
it has been my pleasure to note so frequently, fol-
lowing the systematic use of pendulum machine
and massage treatment.
129 West One Hundred and Eighteenth
Street.
SOME UNUSUAL CASES FROM THE EYE SER-
VICE OF FORDHAM HOSPITAL.
By Charles Graef, M. D.,
New York,
Oculist and Aurist to Fordham Hospital; Clinical Professor of Oph-
thalmology, Fordham Medical College.
The following cases, which have recentl\- been
under my care, seem of sufficient importance and
interest to warrant reporting in some detail :
Case I. — H. S., a man, fifty-two years of age, came to
see about a change in his glasses — presbyopic— and in-
cidentally asked me to look at the stump of his left eye,
over which he was wearing a glass shell. Something more
than twenty-six years ago (December 25, 1881), in Ger-
many, he was struck in the left eye with a beer glass. The
eye was so badly injured that it was removed next day by
an ophthalmologist. No attempt was made to wear a glass
eye over the stump until 1884. The patient had then ar-
rived in New York, and after an operation on the stump
Fragments of a broken beer
glass, removed from the stump
of an injured eye after lying
embedded over twenty-six
years. A glass shell had been
worn over the stump for nearly
the full period after enuclea-
tion. The photograph is a little
less than the actual size of the
pieces.
at the Ophthalmic Institute in Twelfth street, to prepare it
for the reception of an artificial eye, a glass shell was worn
continuously until the present time.
He called my attention to it because he had lately noted
occasional twinges of pam in the stump and for a month
or more the upper lid, especially the inner half, was no-
ticeably swelled. Examination of the stump showed a
pouting opening of small size at one point, and feeling in
this with a probe I struck a hard substance which gave the
impression of glass. The patient was positive that nothing
had happened to the stump since the original injury, but as
I could plainly make out with the probe that a piece of
glass of considerable size was embedded, I cocainized the
tissues and dissected it out.
It proved to be a large fragment of the beer glass. It is
shown in the accompanying photograph.
I could not feel any other
pieces at the time, but I kept
the wound open with a small
gauze drain and several
days later secured the
smaller fragment also
shown in the photograph.
Careful search and observa-
tion of the wound failed to
reveal more ; the wound
closed and the lid swelling
disappeared.
The patient has never had
any irritation of the right
eye or any suggestion of dif-
ficulty with the stump in the
long period during which
the glass lay there. He has
been under the care of sev-
eral ophthalmologists in
New York at various times,
chiefly for attention to his
glasses. They examined the stump from time to time, but
found nothing amiss. He had some power of movement
with the stump at first, but this disappeared about six years
ago. A considerable measure of this has returned since the
removal of .the glass. An x ray examination of the part
failed to reveal any more pieces in the tissue of the orbit,
which seems fairly conclusive, since the glass fragments
show up clearly when held in the closed hand under the
fluoroscope.
Case II. — E. J., a lad of ten years, was struck in the
left eye by a bullet fired with an air rifle by a playmate
from a distance of about twelve feet. He did not come to
the hospital until two weeks after the injury, at which time
little evidence of external injury was to be seen at first
glance. There was some photophobia with haziness of the
cornea, but little or no injection of the conjunctiva. The
boy explained that he and his friends were able to see the
bullet still in the eye, however, and on drawing down the
lower lid it was found lying under the deepest part of the
bulbar conjunctiva. It was easily removed from its ap-
parently sterile resting place by snipping through the con-
junctiva over it. It had evidently struck the bulb a little
below the corneal margin with force enough to penetrate
the conjunctiva. The tough sclera had resisted and de-
flected it, much as a rib does a musket ball, to the point
where it was found.
The eye was badly injured by the blow. Fissured opaci-
ties traversed the lens in several directions, and the cornea
had likewise numerous fissures running in various direc-
tions and giving it the appearance of cracked mica, the
result of disturbed nutrition. The fundus showed a wide
area of chorioretinitis with exudate and hasmorrhages scat-
tered over the lower and outer part of the field. Vision
was reduced to counting fingers at two metres. This has
improved under treatment one sixth.
Case III. — J. F., a yoimg man of thirty-one, was sud-
denly attacked while on his way to work in the morning
with fainting, nausea, and vomiting. He had been in his
usual good health previously and had no idea what could
have brought on the condition. He was unconscious when
brought to the hospital in the ambulance and remained so
for nearly forty-eight hours. He vomited several times
and complained of headache when recovering consciousness.
Examination of the chest proved negative except for a
diastolic heart murmur, heard loudest in the fourth left
intercostal space. Abdominal and repeated urine ex-
aminations were also negative.
IlCfO
RUBER: BOTHRIOCEPH ALUS LATUS.
[New York
Medical Journal.
Eyes : Complete temporal hemianopia with an excellent
example of Wernicke's hemiopic pupillary reaction, that
is, the pupils reacted to light when this was thrown on the
temporal half of the retina of each eye, but did not react
when the light was directed to the nasal or blind half of
either retina, showing an interference with the nerves m
the chiasm, where the nasal portions of each nerve cross
to the opposite side.
There was some blurring of the disc edges, but the eye
grounds were otherwise normal. He had a convergent
squint of about 20 degrees, but this had been present from
early childhood.
There was absolutely no history of, nor any evidence
pointing to, specific disease. The ears were normal. The
left side of his nose was badly occluded by a marked deflec-
tion of the sseptum to that side with thickening. He had
some postnasal dropping and evidence of disease in the
posterior ethmoid cells and sphenoid sinus of the left side.
The case cleared up completely with rest in bed. While
it looked like a condition due to hjemorrhage the age and
general state of the patient were against such a diagnosis,
and the presence of the nasal faults made it likely that con-
ditions in the sphenoid sinus were responsible for the
trouble.
Case IV. — W. J., a young man, was struck in the left eye
with the prickly husk of a chestnut while looking upward
into a tree on a nutting expedition. When he presented
himself next day for treatment, the cornea and conjunctiva
were literally peppered with the barbed spicules from the
burr and a severe inflammation had set in.
Something more than twenty of the small thorns were
removed at the first visit. A number had to be left, as they
were broken off in the tissue and an excessive amount of
digging would have been required to remove them. Unless
one has had to deal with such a case it is difficult to appre-
ciate how troublesome the removal of such slender spicules,
deeply embedded in the cornea, may be. There happened to
be attending the clinic at the same time a patient who had
suffered a similar accident some years ago. The vigorous
effort made in his case to clear out all the spicules was
followed by reaction so se-vere that the eye bcame of lit-
tle use for visual purposes.
Careful watching of the injured eye, with the use of
atropine, warm bathing, and suitable coUyria, made it pos-
sible to remove the embedded spicules one by one as they
betrayed their presence. The oedema and softening of the
cells immediately about them rendered this comparatively
easy. In this way all were finally disposed of with excel-
lent results.
1076 Boston Ro.\d.
BOTHRIOCEPHALUS LATUS.
{Abnormal Segments.)
By Fr.ancis Huber, M. D.,
New York.
Thoucrh not indigenous in the United States, the
occurrence of Bothrioccphalus latiis h not uncom-
mon in our immigrant population. The geograph-
ical distribution of this variety is peculiar ; it ap-
pears to have spread from certain points into the
neighboring countries. In some places in Europe
where it was formerly rare it is now becoming
common. Common in Paris in the last century, it
is now only seen in the imported cases.
The scolices, or plerocercoids, occur, especially
in the pike, carp, salmon, etc. They are not killed
by slight smoking, salting, or freezing. The mode
of infection of fish is not known. The embryos of
the bothrioccphalus may be introduced through
eating lettuce, as is stated to be the case in Switzer-
land. This is .sometimes raised under irrigation
from lake water, thus carrying eggs or measles to
the plant, and thus explaining its occurrence in per-
sons not fish eaters.
Stiles in Osier's Modem Medicine writes:
"About thirty cases of infection with this parasite
have been recognized for the United States, chief-
ly among foreigners. Very probably it will be-
come more commonly known in the United States,
for now that special attention has been recently di-
rected to it in several American medical journals, it
will be more frequently recognized, and, further, it
is highly probable that immigrants will infect the
fish of some of our lake regions."
Nickerson {Journal of the American Medical
Association, March 10, 1906), in speaking of the
broad tapeworm in Minnesota, reports a case of in-
fection acquired in the State. The latter occurred
in a child of Finnish parentage, who was born in
Minnesota, and had never been out of the State.
This demonstrates the fact that the species has ob-
.\iuimnloii5 variations of section of Bothrioccphalus latus.
tained a foothold, at least locally, in this countr}-.
The author states that he has found the larvre in
.American fish, caught in the Great Lakes. He at-
tributes or explains the general freedom from in-
fection enjoyed bv .Americans to the fact that our
method of preparing fish for food tends to destroy
the larvfe.
Some years ago, while still engaged in active
practice, it was mv fortune to run across seven
instances in about as many years. These cases all
occurred in people who had emigrated to this coun-
try from the Polish countries. The interesting
specimen, the photographs of which are herewith
presented, was passed by a woman about twenty-
eight vears old. who had been in this country some
seven vears. She was a neurasthenic creature, pre-
June ::f. igo8.J
HIRSHBERG: CHOLERA INFANTUM.
I igr
senting a high grade of aiicemia. After the usual
treatment with male fern, etc., a large quantity of
the parasite, filling a large teacup about two-thirds,
was expelled. Unfortunately no measurements
were made. In examining the specimen, certain
peculiarities were noted, which are brought out
distinctly in the photographs. The best parts were
preserved ; the rest of the specimen, kept in another
jar, was inadvertently thrown away. A careful
examination of the separate portion shows the dif-
ferent stages of the anomalous variations of the
different segments and sections.
As cases of bothriocephalus are infrequent in
America, occurring only in immigrants, the topic
is referred to in a superficial manner in most of the
American textbooks. The abnormal appearance of
the individual segment or series is not even re-
ferred to.
The subject of Bothriocephalus latns, particu-
larly its relation to primary and secondary anaemia,
has been thoroughly discussed by Dr. Robert X.
Willson {American Journal of the Medical Sci-
ences, August, 1902).
In describing the characteristics of the various
parts he says : "Each segment contains at its centre
a dark, bluish gray spot, which, on examination,
appears in the form of an irregular rosette, mark-
ing the recurrence of the segments. This rosette
never fails of appearance, though the segments, as
already stated, may run together, be partially di-
vided, or shown no demarcation whatsoever. The
frequent occurrence of imperfect and abortive
types of twin segments may be considered an al-
most distinctive feature of the bothriocephalus
family, although seldom or never mentioned in the
textbook descriptions. The segments may also be
split, either at the free edge or in the parenchyma-
tous lateral portion of the body. I do not look
upon these irregularities as always due to trau-
matism or pressure, but consider them, esix-cially
the imperfect and twin segment formations, as
typical malformations."
A more plausible explanation is given by Jacobi,
and is as follows: "Sometimes they appear fenes-
trated in consequence of the btirsting of the sexual
apertures. Thus a genuine fissure may occur,
which yields the impression of a double develop-
ment'' (Jacobi. Intestinal Diseases, etc., page
251)-
209 E.\ST Seventeenth Street.
CHOLERA INFANTUM.
An Avoidable Plague whicli Annually Kills Fifty Thou-
sand Babies in the United States.
By Leonard K. Hirshberg, A. B.. j\L D.,
Baltimore.
Assistant, Johns Hopkins Hospital.
Cholera infantum is a name loosely applied to a
whole group of infantile maladies, which differ
greatly in important particulars, though they have
many characteristics in common. All are disorders
of the digestive tract; all are caused by unclean or
improper food, rarely by direct contagion ; all are
most prevalent in summer. A familiar synonym
for cholera infantum, in fact, is "summer com-
plaint." But this name is far from accurate, for
cholera infantum, while most common and most
dangerous in the hot months, is by no means con-
fined to the summer.
When cholera infantum appears in its true form
— that is to say, as an infectious dysentery — it is an.
exceedingly fatal disease. Several authorities say-
that the death rate is more than 60 per cent., which
means that two thirds of the children attacked hy
it die. In all large cities it is epidemic throughout
the year, and in Xew York, where the dwellings of
the poor are peculiarly crowded and insanitary, it
causes approximately 12.000 deaths each summer.
During the census year 1904, when the last mortality
statistics were gathered bv the federal government,
there were 37,000 deaths from cholera infantum in
the comparatively few cities and towns that made
returns. In the whole country, the mortality was
undoubtedly well above 50,000.
The most virulent and dangerous form of the
malady is caused by a minute organism now believed
to be identical with the germ which causes the ter-
rible adult dysentery of the tropics. The germ was
discovered by a Japanese scientist, Shiga, in 1898,
and bacteriologists have, therefore, called it the
Bacillus dysentcruc of Shiga. Two years later, the
eminent American biologist, Dr. Simon Flexner,
discovered an organism of similar appearance in the
tissues of a patient named Harris, at Alanila, and
this was given the name of Bacillus dysentericc of
Flexner, or Flexner-Harris. It was soon noted that
the two bacilli were practically identical, and since
then it has been found that, besides causing tropi-
cal dysentery, they also cause cholera infantum.
Many able men are now studying cholera in-
fantum and its organism, particularly at the Rocke-
feller Institute in New York, at the Johns Hopkins
Hospital, and at some of the German universities.
As yet no certain cure for the disease has been dis-
covered, but there is good reason to believe that,
within a few years, a protective vaccine will be per-
fected. When that is accomplished, it will be pos-
sible to vaccinate children againt cholera infantum
just as they are now vaccinated against smallpox.
It is evident that this will mean a great reduction in
infant mortality — a most important matter for the
human race as a whole.
The cholera infantum bacillus, like that of typhoid
fever, practically always enters the body through
the stomach, and by the medium of bad milk or con
taminated food. It lives and breeds in the intes-
tinal tract, and manufactures powerful toxines or
poisons which cause most of the familiar symptoms
of the disease — the vomiting, the acute diarrhoea, the
fever, the abdominal pains, and the rapid wasting of
strength. The onslaught is so severe that the little
patient sometimes dies within a week, and even
when recovery follows an attack, convalesence is al-
ways slow and precarious, and the danger of sud-
den relapse and collapse is always great.
In its war upon this terrible malady modern med-
icine must depend, as yet, on weapons that are nec-
essarily crude. An effort is made to remove the
bacilli and their toxines from the intestines by irri-
gation, and stimulants are employed to combat the
distressing exhaustion. In addition, the fever and
other symptoms are combated in the manner that
seems least harmful, and an effort is made to admin-
ister nourishment. Further than that some aid from
drugs and baths may be obtaiaed„ and it is there-
HIRSHBERG : CHOLERA INEANTUM.
lXi:w V,,RK
Medical Julrnal.
fore not remarkable that two tliirds of the children
who develop true cholera infantum die of it.
In many cases indeed, though the physician is
practically impotent, hope must never yield to
despair, and every ctiort must be made to keep the
child comfortable and to prevent the spread of the
disease to other children in the household. For
cholera infantum, as has been mentioned, is decided-
ly infectious, and every case is apt to be followed
by other cases. Therefore, when the disease ap-
pears in a house, it is well to employ the same safe-
guards against its spread as would be employed in
a case of typhoid. All the bedclothes and other
fabrics in use in the sick room should be well soaked
in a mild solution of some efifective germicide — car-
bolic acid or corrosive sublimate, for instance— be-
fore they are sent to the family laundry, and care
should be exercised in disposing of the water used
to wash the patient. Other appropriate precautions
will suggest themselves when it is remembered that
the intestines of the patient and their secretions are
fairly alive with virulent bacilli.
To prevent cholera infantum it is necessary, first,
to reduce the risk of direct infection to the mini-
mum, and, secondly, to keep the child in good gen-
eral health, so that in case of chance infection it
may be in a good condition to make a successful
fight against the disease. It must have fresh air,
proper clothing, and nourishing food. Both results
may be attained by1i proper supervision of its food
supply. It must be fed intelligently, and it must
get pure food, which means, not food which merely
looks good and smells good, but food which is
nourishing, easily digested, and absolutely free of all
deleterious organism. The child must also be kept
clean by frequent bathing.
Volumes may be inscribed with rules for hygienic
and dietetic prophylaxis of infantile dysentery. The
opportunities for the greatest of modern philanthro-
pies hovers about this important matter.
Calomel and castor oil are the cathartics of choice
which act on the small bowel, but they must often
give place to stomach lavage and colon irrigation;
the latter are quicker and safer methods late in the
attack.
The aid and importance of most drugs, except
opium, resorcin, and bismuth, and their allied and
analogous chemicals, is much overestimated.
Lime water, sodium bicarbonate, magnesium, and
the alkalies help in the vomiting of the acute stage.
In later stages, a few drops of a dilute acid help.
Astringents usually do harm. In cases of severe
prostration mustard baths, hot packs, and saline in-
fusions may be employed. One half ounce of old
brandy in twenty-four hours will be well borne by
an infant ten months old.
It is a lamentable fact, but one which no ob-
servant physician will deny, that mother love causes
almost as many deaths among babies as neglect.
About the business of "raising" babies — certainly
the most important profession in all the world —
there has been grouped a mass of traditions and
superstitions whose practical effect is a needless and
enormous increase in the infantile death rate. An-
cient grandmothers, intrenched behind the fact that
they have "raised a dozen children and lost none,"
appear with all sorts of ridiculous lore regarding
baby food and baby dressing, and it takes a great
deal of firmness and ingenuity on the part of the
physician to combat them and put them to rout.
Too often he is put to rout himself, and has to con-
tent himself with rectifying the damage they have
worked.
For instance, I was called in to ease the last mo-
ments of a poor little child whose life was ending at
four months. The baby had cholera infantum, and
was dying of it, and nothing could be done but
make its death painless. And why was it dying?
Simply because its grandmother — a presumably sane
and intelligent woman — had insisted that it be given
a "taste" of every dish eaten by its mother, on the
theory that it would thus progress most easily and
safely from a diet of milk to one of adult food. The
poor child's digestive apparatus was broken down
entirely by this incredible barbarity, and stray germs
of cholera infantum found it an easy victim. Yet
if the grandmother had been told that she was di-
rectly and unmistakably responsible for the baby's
death, she would have protested violently, and, in all
probability, would have instituted an action for
criminal slander.
Superstitions such as this are by no means few,
nor are they confined to the ignorant. Many a
mother of undoubted intelligence provides her baby
with one of the rubber or ivory nipples called "com-
forters" or "pacifiers." The theory of this is that
the "pacifier" will keep the baby quiet, divert it from
sucking its thumbs, and, by giving it something to
employ its gums on, help it to cut its teeth. This
is the theory. In sober reality, the pacifier merely
serves to make the baby querulous and peevish, to
teach it bad habits, and to fill its mouth and body
with the germs of half a dozn diseases — from
cholera infantum to diphtheria and from chicken-
pox to meningitis.
The baby is dumped into its perambulator, with a
pacifier in its chubby fist, and a nurse girl is told off
to take care of it. In a moment it drops the pacifier,
and the nurse rescues the deadly implement from the
sidewalk. If she is careful she wipes it with her
apron or handkerchief; if not she jams it into the
baby's mouth without wiping. In either case there
are ten chances to one that it is fairly alive with
germs. Wiping a thing with an apron or dusting
it with a brush or washing it with soap does not
rid it of the organisms of disease. The only way
to do that effectively is to boil it steadily for at least
half an hour. And whoever heard of a nurse girl
who boiled her charge's pacifier for half an hour be-
fore putting it to its disgusting and nefarious uses?
In pacifiers, rubber rings, and things of that sort
cholera infantum lies. One authority estimates that
from 5 to 10 per cent, of all deaths among infants
less than two years old are due to infections by such
or similar 'means. The average child, luckily
enough, has an almost uncanny power for resisting
virulent organisms. Its hold on life, despite its
physical weakness, is strong, and it has a wonderful
capacity for recovery. If that were not true, the av-
erage child, in the face of its almost constant ex-
posure, would die.
There is no truth whatever in the common super-
stition that children must have something to exercise
their gums on. The baby's liking for such things is
June 20, igol ]
HERZIG: COXJUXCTIVAL AND CORNEAL DISEASE.'^.
1
a habit, pure and simple, and a bad habit at that. It
is just as easy to teach it to do without its rubber
ring — just as easy and a great deal more humane
and sensible.
Ten days after they are born babies begin to ac-
quire habits. These may be bad habits or good
ones, according as the mothers act sensibly or the
reverse. If the mother of an infant — or its grand-
mother or aunt or nurse — rocks, bounces, or nurses
it every time it cries, it almost immediately notices
the connection between the two things, and so a bad
habit is formed. If, on the contrary, a deliberate
effort is made to teach it good habits, it will acquire
them just as quickly and cling to them just as
tenaciously.
During its first few months a healthy infant
should be fed regularly every two hours from day-
light until eleven p. m. Then it should be put to
bed and kept there, vvithout food, until five o'clock
the next morning. In the case of a baby who has
been fed every time it cries, the inauguration of this
regime will almost certainly bring forth heart
breaking protests. The first night, for instance, it
will yell most piteously, and so, too, the second and
third nights. But after that it will go to sleep when
it is put to bed, and sleep without interruption un-
til daylight. And when it does that, it will have
acquired a habit that is healthful and normal and
one that will conduce to its good health to the end
of its life.
The baby which sleeps by fits and starts and must
be walked up and down the floor is a baby with
an unwise mother. Any one who does not believe
this should pay a visit some night to an up to date
maternity hospital, wherein skilled nurses take the
place of meddlesome grandmothers. There may be
fifty babies in the place, but except among those
who are violently ill not a sound will be heard be-
tween midnight and dawn.
The connection between bad habits and illness is
obvious. The baby which frets and fumes is con-
stantly wasting its energy and losing its proper -rest.
Its power of resistance is thus lowered, and when
the germs of disease assail it. it falls an easy vic-
tim. The serene and good tempered child, which
has been taught to eat and sleep with regularity, is
almost invariably healthy. And the child who has a
mother sensible enough to teach it good habits, al-
most always has a mother sensible enough, too, to
protect it from pacifiers and to feed it upon appro-
priate and clean food.
The best of all food for the baby is that provided
by Nature. When unavoidable conditions put this
out of its reach, its mainstay should be pure or mod-
ified cows' milk. In all large cities there are com-
panies which sell this milk, so prepared that it con-
tains, in exact proportions, the ingredients recom-
mended by the family physician. To feed the milk
sold by the average neighborhood milk dealer to the
baby, particularly if that milk be unboiled, is little
short of assassination. There was no need for
President Roosevelt to point out this fact. The
mortality tables had revealed it long before it was
brought to his attention.
Often it is difficult to inquire closely into the
source of the family milk supply, but in all cases it
pays to take the trouble. The milk given to infants
should be absolutely free of germs, and this freedom
can only be obtained by proper pasteurizing. There-
fore, the family physician should be consulted and
his advice followed. He should be consulted, too,
when it is proposed to feed the baby on any one of
the many artificial foods on the market. Many of
these are most excellent, but it is necessary that the
peculiar needs and idiosyncrasies of each baby be
properly studied and understood before they are ad-
ministered.
Next to pure food, the most important thing for
infants is fresh air. The atmosphere of the aver-
age house in the average city is heavy with the
waste products of respiration, dried germs of all
sorts, and various other things. A child breathing
it day after day is almost certain to lose in vigor.
Fortunately, however, parks are plentiful, and their
air is always comparatively clean. Therefore, the
baby should spend much time in its perambulator
and under the trees, particularly in summer.
A great many children are made ill, in winter as
well as in summer, by too much coddling. Infants,
it should be remembered, are far more sensitive to
heat than adults, and their skin, when the air
does not reach it, is very liable to painful and per-
sistent eruptions. A baby born during the warm
weather should be put into short clothes at once —
despite the ancient and powerful belief that the vir-
tue and intelligence of a mother is to be measured
by the length of her baby's clothes. After the sec-
ond month, in the hot season, the child should be
practically naked, day and night.
1937 Madison Avenue.
A SHORT RESUME OF THE COMMON CONJUNC-
TIVAL AND CORNEAL DISEASES.*
Bv A. J. Herzig, M. D.,
New York.
Before proceeding with the description of the va-
rious eye diseases thus enumerated, I will give a
method of examining the conjunctiva and cornea.
Exposure of the lower conjunctival sack is per-
formed by pulling the lower lid downward with the
thumb and telling your patient to look up. Ex-
posure of the upper lid is as follows : Grasp the cen-
tral lashes between the thumb and index finger,
draw the lid forward, downward, and outward,
while with the other hand press with the finger or
toothpick at the upper margin of the tarsus, at the
same time directing your patient to look downward.
Pay special attention to the transition fold as to
ulceration and granulations. Inspection of the
cornea is as follows : Use a strong convex lens and
concentrate the light from the window or any other
artificial illumination on to the cornea. In exam-
ining children it is better to have them placed in an
attendant's or parent's lap with the child's head be-
tween your knees.
Foreign Bodies in the Conjunctiva.
A foreign body in the conjunctiva is usually
found under the upper lid and easily seen and re-
moved. A hair often finds its way into the upper
canaliculus, and this often escapes the observation
*Read at the March, 1908, meeting of the Eastern Medical Society.
1194
HERZIG: CONJUNCTIVAL AND CORNEAL DISEASES.
[New York
Medical Journal.
of the physician, who tells the patient there is noth-
ing in the eye. When seen, it is easily removed by
being- pulled out with a small forceps.
Injiij-ies.
Injuries to the conjunctiva are common, such as
contusions, burns, wounds, insect bites. Contusion
(black eye) is easily diagnosticated. Treatment
consists of ice applications and later massage.
Should an abscess result, it should be incised and
<lrainc(). \\'ounds should be dealt with surgically.
Insect bites cause a great deal of swelling some-
times, but this is easily reduced by iced compresses.
Burns pre best treated by some bland ointment such
as a one per cent, ointment of yellow oxide of mer-
cury. In extensive burns, skin grafts are required
after a proper treatment.
Catarrhal Coiijiinctk'itis.
This is subdivided into acute, chronic, and fol-
licular. Acute catarrhal conjunctivitis is usually
accompanied by a mucoid or mucopurulent dis-
charge; conjunctiva" red and swollen. There is a
congesfion of the bulbar conjunctiva. In severe
cases oedema of the bulbar conjunctiva (chemosis)
is present. Secretion also appears as scales ad-
hering to the margins of the lids. The patient
complains of an itching or burning sensation of the
lids, which feel hot and heavy, as though there was
a foreign body in the eye. There is more or less
photophobia present, according to the degree of in-
flammation. This condition may affect one or both
eyes. Treatment consists in applying hot or cold
compresses. I usually find heat the best. The con-
junctiva should be touched up daily until the acute
symptoms have subsided with a one per cent, solu-
tion of silver nitrate. The patient is to use a mild
astringent, such as a one half per cent, solution of
iinc sulphate in camphor water, at his home every
three hours and later three times a day.
Chronic Catarrhal Conjunctivitis.
This has similar symptoms to those of the acute
form, but a great deal milder in severity. The se-
cretion is slightly altered and more profuse in
quantitv. It is more mucoid in character. Treat-
ment consists in the regular applications of a one
per cent, solution of silver nitrate to the conjunc-
tiva every two or three days, as is necessar\ . I
usually give the patient a mild astringent to use
at home. These remedies may have to be changed
from time to 'time.
Follicular Conjunctivitis.
Follicular conjunctivitis is divided into two forms,
namely, fine granules and those that have large
lymphoi(i granules. Examination reveals in the
former fine sandpaperlike granules, which appear on
the upper conjunctiva and transition fold. These may
be associated with large lymphoid granules so com-
monly met with and so often mistaken for trachoma.
( Some authors state that this condition is a primary
stage of trachoma). These lymphoid granules are
found more commonly on the lower than on the
upper lid, but are commonly present on both.
Symptoms are those of catarrhal conjunctivitis, with
a feeling of a foreign body in the eye and profuse
discliarge. although in .some cases the discharge is
absent. in the sandpaper like granular form, with
little secretion, I prefer to use a one per cent, yel-
low oxide of mercury ointment to be applied into
the lower conjunctival sack three times a day and
then gently massaged. It is a practice with me to
treat these granular conditions with blue stone, as
the large lymphoid variety succumbs to this treat-
ment in very short order. These large lymphoid
granules are easily expressed by a roller forceps,
and cases have been credited to a cure of trachoma
instead of granular conjunctivitis.
Acute Epidemic Conjunctivitis, or Pink Eye.
This disease occurs most frequently in the spring
or fall season. It is generally bilateral and has all
the symptoms of an acute conjunctivitis, with all
the symptoms exaggerated, and a very profuse
mucopurulent discharge. Treatment consists in
giving the patient an astringent wash to use at home
and to keep the eye free from irritation, such as
dust and tobacco smoke. I treat these patients
daily at first, and later as the condition gets bet-
ter, less and less. I use a one per cent, silver solu-
tion in all these cases. Bathing the eyes with very
hot water night and morning is of great benefit to
these patients. It is well to keep these patients away
from other children, as the disease is highly con-
tagious, and also to caution them about being par-
ticular in avoiding to use other towels, napkins, etc.,
than their own.
Trachoma.
Trachoma is an infectious disease attacking the
conjunctiva of the transition fold of the upper lid
primarily, and firstly manifests itself by minute
ulcerations along the transition fold with fine sand-
paper like granules. These are very easily demon-
strated by everting the upper lid and placing the
margin of the lower lid under the transition fold.
These ulcers are minute, and appear as a series of
white spots in contradistinction to the red tissue in-
tervening. The other of the granular forms of con-
junctivitis may or may not accompany the trachoma.
In the examination of trachoma I have been able
to see and demonstrate this condition in every case
of beginning or incipient trachoma. This was first
brought to notice by Dr. R. O. Born in 1901, under
whom I have had the opportunity of seeing and
studying many cases. In the later stages these
ulcers disappear, to be replaced by cicatricial tissue.
In a hundred scrapings taken from these patients I
have not been able to demonstrate any special or-
ganism, the staphyococcus being present in fourteen
cases and the gonococcus in one case. Other ex-
aminations were negative. Treatment is nonop-
erative, as trachoma, being a nongranular disease,
there is nothing to squeeze out. Truly, the large
l}inpboiil granules are readily squeezed out and
easily cured, but not the trachoma. The proof of
this is that in a great number of cases where the
patients have been operated upon for trachoma,
these same patients come back after operation with
the trachoma remaining. Trachoma is curable in
the primary and secondary stages (hypertrophic)
hy the careful application of blue stone. The ter-
tiary (or scar) stage is incurable as regards to cur-
ing the scars, although these patients are relieved
from time to time by the use and application of blue
stone and silver. The diagnosis of trachoma can
)U,W jr. ,908.1
HERZIG: COXJUNCTIVAL AXD CORNEAL DLSEASES.
1 195
never be made without examining the transition
fold for these ulcerations — that is, the incipient
stage. Also, cases of trachoma should not be sub-
jected to a squeezing operation, as the resulting
scars of this method are worse than those of a
trachoma. I have never seen a case of genuine
trachoma successfully operated on and cured, while
1 have seen hundreds of cases cured by the
application of the blue stone. W hy operate when
vou can cure these patients by the applications of
blue stone? In cases of so called trachoma I have,
after eight to fifteen applications, found a good,
clean, smooth conjunctiva resulting. In cases
where there is an underlying trachoma, the trachoma
will remain after the granules have disappeared.
A word of advice as to the application of blue
stone. Never apply blue stone to the upper portion
of the everted lid, only under it and along the edge
of the transition fold. The injudicious use of blue
stone upon the upper tarsal folds causes scar tissue
after long use. The home treatment of these cases
is the same as that of conjunctivitis.
Blennorrhoca (Adnlfonnii).
After a period of incubation the lids swell and
become cedematous. hot, and red. The conjunctiva
is intensely swollen, very red, and often so intense
as to prevent opening the lids to inspect the cornea.
The secretion is often reddened like blood juice
mixed with flakes of pus. The preauricular glands
are often swollen and sensitive to the touch. The
positive diagnosis is made by examining the secre-
tion and the finding of Neisser's bacillus. It or-
dinarily takes from two to three days for the dis-
ease to reach its height, then the secretion becomes
purulent. A memlirane may often be seen super-
ficially ; small infiltrations may make their appear-
ance now. This is the stage when the cornea is
usually involved unless precautions are taken. The
treatment consists in protecting the other eye by
means of a shield C'f isinglass, and frequent cleans-
ing of the aft'ected eye with a i in 3,000 bichloride
solution and the daily application of a two per cent,
silver nitrate solution. I have these patients apply
iced compresses continually day and night. This
is best done by placing a small piece of ice in a
basin, surrounding it with sterile gauze, and having
quite a number of small cut squares of gauze about
an inch square laid on this gauze. The gauze is
changed every minute or so, so that the patient has
the constant effect of the cold. After using these
compresses for a time I advise them to be burnt.
When the swelling has gone down considerably I
substitute blue stone for the nitrate of silver solu-
tion.
Blennorrhoca Neonatorum.
Blennorrhoea neonatorum occurs in newly born in-
fants as a result of an infection of the eyes during
the passage of the head through an infected vagina.
The symptoms rvm the same as those in adults, only
much less severe. The danger of suppuration of
the cornea is not as great as in adults. The treat-
ment is the same. In cases where the suppuration
is profuse I apply the two per cent, silver nitrate
solution twice daily. Prophylactic treatment should
be more strongly advocated than it is. A two per
cent, solution of silver nitrate should be dropj^ed
into the baby's eyes immediately after birth.
Conjuncth'itis Diphtheritica.
This is an infectious disease of the eyelids caused
by the Klebs-Loeffler bacillus, and resembles blen-
orrhoea in its symptoms and course. The infiltra-
tion in these cases is more marked than the blen-
orrhoeal form, and the induration is greater. A
membrane is seen which bleeds easily upon removal.
This appeacance with a positive culture concludes
our diagnosis. Treatment consists in the injection
of antitoxine. in keeping the eye clean with a mild
antiseptic, and. lastly, in the application of cold.
Croupous Mcuibrnnes.
The} mav also be seen in severe conjunctival
catarrh or as a resuk of burns. Bacteriological ex-
.?mination will settle all doubt as to the cause of the
membrane, and the treatment is symptom.atic.
Phlyctenular Conjunctivitis and Keratitis.
These aflfections occur so frequently together that
1 will enumerate them under one heading. Some
writers group these forms imder those of conjunc
tivitis eczematosa. Xo real eczema occurs in these
cases, for these so called eczematous symptoms dis-
appear under proper treatment of the eye. These
conditions occur most frequently in children who
belong to that class designated lymphoid diathesis.
They have the enlarged glands adenoids, tonsillar
hypertrophies, and sometimes the large lymphoid
granules of the conjunctiva. These conditions are
diagnosticated by small elevations being seen upon
the conjunctiva or cornea followed by a streak of
bloodvessels, which usually range themselves in the
shape of a pyramid having the phlyctenule at the
apex of the pyramid. Circumcorneal injection in
these cases is marked, and blepharitis is often pres-
ent. I treat these cases firstly by giving the patient
calomel internally to use at home arid also yellow
oxide of mercury to be put into the lower con-
junctival sack two or three times daily. Apply a
one per cent, solution of silver to the phlyctenules
direct ; at first daily, and later as the condition im-
proves two or three times weekly, etc. These
phlyctenules usually disappear in from ten to twen-
ty-one days under this treatment. If there is any
coexisting condition of the lids treat it with castile
soap and water.
Ulcers.
Ulcers of the conjunctiva sometimes occur after
a severe conjunctivitis, but most commonly follow^
a burn by heat or caustics. These ulcers also occur
during the various exanthemata, but the commoner
forms are those of a chalazion breaking through the
conjunctival wall. Acute ulcers of the conjunctiva
are rare, and when seen are accompanied by a
swelling of the lids, considerable pain, enlargement
of the preauricular glands, and purulent secretion.
Ulcers occurring as a result of degeneration of an
epithelioma of the conjunctiva and specific ulcers
from degeneration of a gumma are one of our great-
est rarities. The treatment of ulcers is the treat-
ment of the cause.
Injuries.
Injuries of the conjunctiva are such as wounds
and burns. Wounds should receive proper surgical
treatment ; such burns are produced by hot water,
steam, caustics, hot cigar ashes, molten metal, elec-
tric flashes, exploding powder, and flames striking
1 196
HERZIG: CONJUNCTIVAL AND CORNEAL DISEASES.
[New York
Medical Journal.
the eye. Burns by caustics, especially lime in the
form of mortar, cause eshcars. These spots stand
out as gray or white patches in a sea of swollen con-
junctiva. These ulcers sometimes suppurate, and
are always followed by a scar. Symblepharon often
follows an extreme burn. Treatment consists in the
use of a one per cent, solution of atropine sulphate
everv three or four hours, cold compresses, and a
bland wash for the eye, such as a dilute sokition of
a concentrated solution of sugar, as that forms an
insoluble compound with the lime. After a separa-
tion of the eshcars, our aim is to draw the lids away
from the eyeball to prevent adhesions. To enumerate
these various methods would occupy too much time,
and I only wish to suggest the use of the yellow
ointment of mercury thoroughly applied into the
upper conjunctival sack, as this has proved success-
ful in my hands. In cases of burns by caustic alka-
lies do not use water, but use milk.
A Pterygium.
This is a triangular fold of mucous membrane
which extends from the ocular conjunctiva to the
cornea, either to the inner or outer side of the latter.
A pterv'gium of recent origin is succulent, and is
plentifully supplied with bloodvessels. We have
two varieties of pterygium — a stationary and pro-
gressive variety. The progressive form keeps on
growing until it reaches the centre of the cornea
or crosses the centre. Its greatest danger lies in
obstructing the vision. The stationary form re-
mains stationary, but does not progress, as its name
implies. The treatment of these conditions is en-
tirely operative. We have numerous operations of
this condition, but I will only describe the one which
has proved most successful in my hands. I prefer
the method of splitting the pterygium in the hori-
zontal plane after having separated it from its
corneal attachment and turning the lower flap down-
wards and backwards. I then fasten this flap into
its position by several silk sutures. The same is
done with the upper flap, only upwards.
Symblepharon.
S\ nihlepharon occurs after wounds of the con-
junctiva or cornea, by burns, etc. We have sev-
eral degrees of symblepharon which I will not go
into. Let it suffice to mention that the treatment
consists of a plastic operation. Various varieties
and positions of the symblepharon require different
procedures, and to describe any of them in prefer-
ence to the other would be great injustice, hence I
leave this subject to your own individual experi-
ence.
Subcon janctival H ceinorrhage.
Such a haemorrhage is easily diagnosticated by a
bright red patch of blood seen under the conjunc-
tiva, usually under the bulbar. This condition de-
velops after injuries (after squint operations) in se-
vere inflammations of the eyeball, such as glaucoma
or very commonly after a blow. Spontaneous ef-
fusions occur in old people, whose bloodvessels have
brittle walls, or may be occasioned by any extreme
exertion, such as sneezing, coughing, vomiting, or
great .straining. In children whoo])ing cough is a
great factor as a causative agent in ])roducing sub-
conjunctival h.-emorrhage. The treatment, provided
that glaucoma be excluded as a causative factor, is
nil. .\pplication of iced compresses hastens absorp-
tion of the clotted blood and reduces the swelling.
I have used adrenalin chloride in various strengths
in these conditions without satisfactory results. I
will next endeavor to point out and describe the va-
rious affections of the lid and lid margins. I will
only briefly mention the local skin disorders one
meets with in clinical and private practice. We see
the various exanthemata, herpeszoster, eczema,
erysipelas, etc. The treatment for these conditions
must be sought for elsewhere. Phlegmons of the
lids are easily recognized, and should be treated by
incision and drainage. Ulcers of the lids are caused
by injuries such as burns, contusions, or occur
spontaneously. We also have ulcers due to lupus
and syphiHs. The treatment for these conditions
will be to treat the cause.
Qideiiia.
CEdema of the lids: is a symptom and not a dis-
ease ; it is of such great diagnostic importance that
I mention it here and go into it in some detail, ^^'e
see it in erysipelas, infection of an operative wound,
such as iridectomy or cataract extraction, acute
glaucoma, iridocyclitis, insect bites, ivy poisoning,
severe blepharitis, infections from an abscess — e. g.,
hordeolum, gonorrhoeal ophthalmia, traumatism,
panophthalmitis, tumors of the orbit, thrombosis of
the cavernous sinus, angeioneurotic oedema, tenon-
itis, and phlegmon of the orbit. It also occurs with
a severe ethmoiditis.
Distinctive Diagnosis.
Erysipelas. — The redness and swelling of the lid
are uniform, circumscribed infiltration being absent.
The skin of the lid when grasped between the fin-
gers feels thicker and harder than the other varie-
ties of oedema. The swelling extends to both lids
and also extends to neighboring parts. In post-
operative infections the oedema usually presents it-
self on the upper lid. The appearance of the op-
erative wound will give us our diagnosis — that is,
an amount of retained lachrymal secretion is pres-
ent and a grayish discoloration is seen about the
corneal wound. CEdema accompanying acute
glaucoma is diagnosticated by the symptoms of
glaucoma — e. g., foggy cornea, pain, increased ten-
sion during attack, dull iris, etc. CEdema as a pre-
cursor of a severe iridocyclitis occurs along the
upper lid usually. Diagnosis of iridocyclitis is made
by its characteristic symptoms, which will define
your cause of the oedema. Insect bites causing
reck'ma arc casil}- diagnosticated by the small point
which is seen where the insect has bitten. Ivy poi-
soning oedema is shown by the characteristic skin
lesion and the terrible pruritis. A severe blepharitis,
whose diagnostic signs have already been pointed
out, also causes ccdema. This is usually on the
upper and lower lids, more so on the upper. Under
this heading also comes hordeolum accompanied by
oedema of the upper lid. In palpating the swollen
parts we find the (edema close to the edge of the
lid, and on looking at the lid margin see a yellow
pinpoint between the cilia: we can be sure we are
dealing with a hordeolum. CEdema is also caused
bv an acute dacryocystitis, and is diagnosticated b}
the character and situation of the swelling and the
expression of secretion from the lacrymal duct l)\
pressure. .Another rtdema occurring during the
treatment of an acute dacryocystitis is due to faultv
June 20, 1908.]
HERZIG: CONJUNCTIVAL AND CORNEAL DISEASES.
1 107
handling of the lacrymal spring, causing the medi-
cated sokition to enter the tissues surrounding the
eye instead of the duct. CEdema caused by gonor-
rhoeal ophthalmia is severe and great in amount, in-
volving the upper and lower lids. In some cases
it is very difficult to inspect the cornea. When pos-
sible, a smear should be taken, the bacteriological
finding of which will settle the diagnosis. QEdema
caused by traumatism, the most common form be-
ing that of a black eye, is easily diagnosticated by
its history and appearance. Panophthalmitis hav-
ing cedema as one of its signs is easily diagnosti-
cated by the previous course of the case, chemosis
being present in these cases and the exudate puru-
lent. Protusion of the eyeball takes place early.
Tumors of the orbit, causing cedema, speak for
themselves as to their diagnosis. Thrombosis of the
cavernous sinus is distinguished by the fact that the
oedema also shows itself behind the ear of the af-
fected side and that cerebral symptoms are present.
Angeioneurotic oedema is rare in this country, and
occurs and disappears spontaneously ; it occurs
mostly in women. CEdema in other parts of the
body are common in this condition. Absence of any
infiam.matory signs in the eyeball will also assist
towards a correct diagnosis. Tenonitis and
phlegmon of the orbit show similar symptoms,
hence I mention both of them under the same head-
ing. GEdema is present in both, as is chemosis,
protrusion of the eyeball, and immobility of the eye-
ball. In tenonitis the protrusion of the eyeball is
comparatively slight, while the oedema is marked ;
while in phlegmon of the orbit the oedema is less
and the protrusion of the eyeball is very marked.
Sometimes it is difficult to make a distinctive diag-
nosis till you see the pus breaking through. But,
in all events, do not wait until this occurs.
Ethmoiditis causes oedema of the upper lid when
it is pointing to an external opening. The diagnosis
is made by an intranasal examination.
Hyperceiitia
of the lid margin is seen in light complexioned
people more readily than in those of darker coun-
tenances. It follows great weeping, late hours, bad
dustry air, inveterate cigarette smoking, etc.
PJi fhiriasis Palpebrarum
This is due to the crab louse, which is very often
found adhering to the hairs of the lids. The nits are
adherent to the middle of the eyelashes in contra-
distinction to the scales of blepharitis, which are
adherent to the roots of the eyelashes.
Blepharitis.
This is subdivided by some authors into an ulcer-
ative and a nonulcerative form. I take it only as
one form ; the nonulcerative form being the primary
stage of a blepharitis when the hairs have been at-
tacked and loosened, the ulceration being the later
stage of the disease. The diagnosis is made by ex-
cluding the crab louse, the scales being attached to
the roots and not to the middle of the hairs, as pre-
viously mentioned. Removing the scales by means
of castile soap and warm water will reveal brittle
and stubby hairs, which fall out easily. In the latter
stages small ulcerations are seen at the base of the
hair follicles, which bleed easily. Treatment for
hyper;emia of the lids is to remove the cause. The
.same holds true with the next subject, namely, the
crab louse. A three to five per cent, yellow oxide
of mercury ointment applied to the lids will destroy
the louse. Scrubbing the lashes with vinegar will
greatly assist in removing the nits, which are most
difficult to remove. In blepharitis I personally scrub
the lids the first time with castile soap and water,
in order to show the parents how to do this. I
then apply a one per cent, solution of silver to the
margin of the lids. Home treatment consists in
giving these patients a one per cent, yellow oxide
of mercury ointment to rub into the margins of the
lids three times daily after thoroughly scrubbing the
lids with castile soap and warm water and remov-
ing all the crusts. This latter operation is most im-
portant. The general system in these cases ought
to be looked after and inquired into, as a great many
of these little patients suffering from blepharitis
have large glands, adenoids, etc. The administra-
tion of calomel in these cases is often of great ad-
vantage.
A liordeohun is an acute inflammatory condition
of the glands of the lids, and may be external or in-
ternal in variety. Hordeolum externum is due to an
infection of Zeiss's glands, while the internal va-
riety, which is rarer than the former, is due to sup-
puration of the Meibomian glands. Diagnosis of
the external hordeolum is made by palpating the lid
and noting the proximity of the swollen tumor to
the edge of the lids and its sensitiveness to the
touch. Pain is present, and is often extreme. Pull-
ing out a proximal eyelash will often reveal a drop
of oozing pus. Hordeolum externum usually
breaks through the skin ; hordeolum internum hardly
ever, as the tissue of the gland is denser and the
root of exit of the pus is through the conjunctiva
or through the only opening of the gland. Treat-
ment of an external hordeolum is as follows : When
I see a case not too far advanced I remove a hair,
and this often drains the gland, in the meantime ap-
plying heat to the lids. Wlien large or not re-
sponding to this treatment within forty-eight hours
I advise incision. I incise the hordeolum along the
edge of the lids preferably and thoroughly curette
the cavity. In the internal variety I usually open
and curette them at once. Yellow ointment may
also be used, but I ver\' seldom have seen its usj
abort a hordeolum as alleged by others.
Chaladon is a chronic affection of the Meibomian
glands, and manifests itself by a hard swelling,
which slowly increases in size. Inflammatory
symptoms are very rare, but may be seen to occur
should the chalazion become affected. The skin is
perfectly movable over this variety of tumor, while
it is not so over a hordeolum. This tumor can be
felt attached to the underlying tissue. A chalazion
does not lead to suppuration as a general rule, but
keeps on enlarging from month to month until it
reaches the size of a large pea.
Treatment. — Small tumors should not be touched.
When larger and causing some interference with
vision, or the patient's complaining of an unsightly
appearance for which he consults you, they should
be enucleated and not merely incised. This may be
done externally through the skin, internally through
the conjunctiva, or through the edge of the lid.
Personally, I prefer the external incision, as it is
the easiest and most satisfactory. The scar is so
small as to be hardly noticeable if the incision be
HERZIG: CONJUNCTIVAL AND CORNEAL DISEASES.
[New York
Medical Jovrsal.
made horizontally. It is well to remove these
tumors with their capsule, although often it is im-
possible to do so without cutting into them. The
underlying necrotic tarsus should be thoroughly
curetted. One or two silk sutures are put into the
external wound and the eye bandaged.
Trichiasis and Distichiasis. '
Trichiasis is a distortion of the cilia, which, in-
stead of looking forward, look backward, so as to
come in contact with the cornea. This condition
occurs most frequently as a result of the cicatricial
stage of trachoma. The contact of the eyelashes on
the cornea finally causes ulcers and later blindness
due to opacities. Distichiasis is where some cilia
look forward and others backward, and in reality
is a stage of trichiasis and need only be mentioned.
Treatment is epilation. If this does not suffice I do
plastic operation, which I will describe under treat-
ment for entropion. Electrolysis has been used with
fair success.
Entropion.
This denotes a rolling inward of the margin of the
lids. The edge of the lid is inverted inwardly to vari-
ous degrees, and, in fact, is a greater degree and later
stages of trichiasis. The posterior margin of the lid
is smoothed off, and the cilia brush up against the
cornea. This is commonly caused by the later
stages of trachomj;. We have a spastic entropion,
which is a spasm of the orbicularis palpebrarum and
the cicatricial entropion, the latter of which I shall
only take into consideration. The treatment is en-
tirely surgical. The flap operation which I per-
form is as follows: The patient being properly pre-
pared under cocaine anaesthesia (local) and an en-
tropion clamp applied, I make an incision the whole
lengtli of the lid margin. I then excise the hair
bearing portion of the tarsus with a scissor. My
second step in the operation is to take a small nar-
row strip of skin from about the middle of the
upper lid and place it in the excised portion, along
the lid margin, where it is fastened with two end
sutures of silk. The upper wound is closed by four
to five sutures, the ends of which are drawn above
the eyebrows and fastened there by strips of plaster,
thus everting the lid margin and keeping it in this
position until complete healing has taken place. The
skin graft usually attaches itself within forty-eight
to seventy-two hours. The patient is put to bed and
kept there until the graft has attached itself. Xo
other dressing except a clean piece of sterile gauze
over the eye is necessarj^
Ectropio)i.
This occurs as spastic, paralytic, senile, and cica-
tricial forms. Spastic ectropion occurs mostly in chil-
dren, and affects both upper and lower lids, and is
easily .seen by pulling the lids apart, when the lids
readily evert themselves. Paralytic ectropion occurs
as a result of paralysis of the orbicularis palpebral
and mo.stly affects the lower lid. The palpebral fis-
sure cannot be perfectly shut. This condition is called
lagophthalmus. Senile ectropion occurs in the aged,
and involves only the lower lid. The giving
of the elastic fibres in the tisues causes this condi-
tion. Cicatricial ectropion, which is due to burns or
wounds, is the last of the varieties described here
that is due to contraction of the lids by scar tissue.
Treatment is only nonopcrativc in spastic ectropion.
It consists in applying a well fitting bandage over
the weak tissues, so keeping the lids in place until
the condition is cured. Electricity is used in the
paralytic variety. If this fails operation is neces-
sary. Senile ectropion is treated the same way as
the spastic variety in its earlier and milder stage.
In the extreme or later stage operation is indicated.
Various plastic operations are in vogue, and to pre-
fer one to the other would be foolishness. I use
whichever operation suits my case.
Injuries and Tumors
of the lids must be treated surgically.
Dacryocystitis.
This may be acute and chronic. The diagnosis is
made by the expression of mucopurulent or puru-
lent secretion by pressure over the sack. Lachry-
mation is a constant symptom. In the acute form
all the symptoms of an acute condition are present,
namely, pain, tenderness, heat, and redness. Ex-
treme swelling and oedema of the lid are frequently
present. The chronic form gives a history of several
years' standing, the acute symptoms being absent.
The main symptoms being the purulent exudate
which is easily expressed by pressure on the gland
and intense lacrymation. Treatment of the acute
condition is the same as that of any abscess, namely,
drainage and relief of pain. This is often arrived
at by the timely application of heat and passing a
lacrymal probe through the duct, or at least at-
tempting to pass it may open a way for drainage.
This is often impossible. I give the patient a nasal
spray of adrenalin chloride, i to 3,000. This helps
a little in trying to open the lower end for drainage.
When these measures fail, I make an external in-
cision in the lacrymal sac and pass a large blunt
probe through the incision to the nasal end of
the duct, cleanse my wound, and drain it. I make
daily applications of one to two per cent, solution of
silver nitrate on a cotton swab to the interior of the
abscess cavity. This will usually result in a cure.
Should a fistula remain, proper measures must lie
taken for this condition. This will not be described
here. Chronic dacryocystitis, in many instances, can
be cured by probing the canaliculus and duct and
having the patient constantly squeeze out the secre-
tion at home. The office treatment consists of
syringing the duct with a one per cent, solution of
silver nitrate two to three times weekly, as is neces-
sary. This has ])roved a cure in my hands in a
great many cases. If after a thorough trial, say ten
to twenty treatments with this method, I find no im-
provement, I advise enucleation of the sac. This
may be done under local anaesthesia, using fifteen
minims of a one half per cent, solution of sterilized
cocaine and ten to fifteen minims of i to 1,000 adre-
nalin chloride injected around the field of operation.
This an.-esthesia usually lasts from thirty to forty
minutes.
Keratitis.
Keratitis can be divided into suppurative and non-
suppurative keratitis. Suppurative keratitis is sub-
divided as follows : Phlyctenular keratitis, ulcers 01
the cornea, keratitis due to lagophthalmus, neuro-
paralytic keratitis, and xerotic keratitis. The non-
suppurative forms are interstitial keratitis, pannus.
vesicular keratitis, keratitis profunda, sclerosing
keratitis, and ri])bon shaped keratitis.
HERZia : COX J UXC Til 'AL
AXD LURXEAL Dl^^EASES
1 19 J
Phlyctenular Keratitis.
This has been described under phlyctenular
conjunctivitis. Its treatment is the same. Symp-
toms of ulcers of the cornea are the same,
with different intensities, namely, pain, photo-
phobia, blepharo-spasm, lacrymation, and interfer-
ence with vision. Circumcorneal injection is in-
tense. Neighboring parts are often involved, caus-
ing iritis, etc. Infiltration of the cornea is always
present. Ulcer of the cornea shows itself as a gray-
ish infiltration. This may extend, as an ulcus ser-
pens, or remain stationary. It ma}- advance around
the corneal margin until crescent shaped as a ca-
tarrhal ulcer, or may appear as minute separate in-
filtrations along various portions of the corneal sur-
face. These ulcers may be extensive, with great de-
struction of the superficial epithelium or even per-
forate. In the latter condition the irritation of the
posterior endothelium of the cornea and the endo-
thelium of the iris give off an exudate which settles
in the anterior chamber as a hypopyon. In perfora-
tion we sometimes see Descemet's membrane bulging
through the opening, forming a keratocele. Pro-
lapse of the iris may take place at this stage.
Abscess of the Cornea.
This occurs as a circumscribed yellow mass
seen in the meshes of the cornea, and when
seen must be incised and kept open. The cru-
cial incision is the best. Symptoms of the above are
severe, as those of an acute inflammation. Kera-
titis due to imperfect closure of the lids shows no
different symptoms than those of any other form
except the lagophthalmus is present.
Neuroparalytic Keratitis.
This is observed after paralysis of the trigeminus.
The keratitis may be trophic or due to exposure to
foreign bodies and irritation on an insensitive
cornea.
Xerotic Keratitis, or Keratomalacia.
This is the result of malnutrition of the cornea.
It is a rare disease and occurs mainly in greatly
debilitated children. The diagnosis of ulcers of the
cornea is aided by dropping two or three drops of a
solution of fluorescin into the eye (fluorescin. r.o:
sodium carbonate, 1.5: distilled water, 30.0). The
ulcers are stained green and are easily outlined in
this way.
Treatment of Ulcers of the Cornea. — If the ulcer
is small it will cleanse itself, which is shown by the
appearance of sprouts of fine superficial bloodves-
sels running from the bulbar conjunctiva to the
ulcer. In cases where the ulcer spreads, it is im-
perative to cauterize same. This may be done with
the electrocautery or acids, tincture of iodine, or the
actual cautery. The latter is done by heating a stra-
bismus hook in an alcohol flame to red heat and
cauterizing the ulcer and an area surrounding it, to
prevent its spreading. This method is the safest, as
the danger of burning deeply is done away with, for
the iron cools readily. Should the ulcer perforate, a
well fitting bandage is applied and complete rest or-
dered. Atropine sulphate, one per cent., should be
instilled every four or five hours in all cases of ulcer
of the cornea that have a tendency to extend or
perforate. If the iris is seen protruding from the
wound, it should be grasped with an iris forceps
and excised. Samsich's method of splitting an ulcer
with a Graefe knife is of value in severe forms of
mdolent ulcers that perforate. In these cases th
wound is probed daily and the anterior chamber is
relieved of any secretion. In the other fomis treat
the cause. Ulcers after healing always leave scars
in the shape of corneal opacities of varying intensi-
ties.
Interstitial Keratitis.
This is seen first as a grayish infiltration,
which is central and extending to the periphery.
This infiltration is uniform in its distribution.
Acute symptoms are present, such as pain,
photophobia, lacrymation, and interference with
vision. These latter symptoms gradually subside
as the inflammation runs its course. This disease
is usually bilateral, and usually occurs between the
ages of fifteen and thirty, generally due to heredi-
tary svphilis, although it may occur in acquired
syphilis or tuberculosis or idiopathically ; the three
latter instances are extremely rare. Treatment is
to treat the cause, namely, antispecific treatment.
Local treatment consists in the use of atropine and
protection of the eye from light by means of
smoked glasses or shields.
PaMUus.
This should have been described with tra-
choma, but as I wish to describe the various forms
I will place it among the forms of keratitis. \\'e
have pannus due to trachoma, and pannus due to
corneal ulcer. Pannus due to trachoma is a condi-
tion where the bloodvessels grown down and ex-
tend to the upper portion of the cornea and later
cover it. These appearances, namely, broad ex-
panses of vessels coming down from above with
the appearance of ulcers along the transition fold
(trachoma), completes your diagnosis. Pannus
from corneal ulcer is demonstrated by the blood-
vessels coming from any portion of the bulbar con-
junctiva at the limbus and running to the ulcer.
The bloodvessels range themselves fan shaped, hav-
ing the ulcer at the apex. Both forms of pannus
may be present in the same case. Treatment con-
sists in treating the cause. If the vessels persist
in spite of treatment of the cause, they may be
scarified with a scalpel. Some cases resist all
treatment. Pannus from corneal ulcer will usual-
ly clear up when the ulcer is cured.
Vesicular Keratitis.
Large vesicles, such as buboes etc., occur
under this head of vesicular keratitis, but as
they are very rare, I will only name the com-
mon type, namely, herpes of the cornea. Herpes
of the cornea is distinguished by a group of
small, clear vesicles on the cornea. These are
very painful and irritating, and cause considerable
circumcorneal injection and lacrymation. This
condition appears most frequently during febrile
conditions — e. g., epidemic influenza, pneumonia,
etc. Treatment consists in the local application of one
per cent, of silver nitrate solution, applied directly
to these vesicles and an astringent wash for the pa-
tient to use at home.
Keratitis Profunda.
This is a deep seated grayish infiltration of the cor-
nea, usually occupying the centre of the cornea, in
contradistinction to the ir.terstiliai k>-ralitis, whicli ;s
more extensive, and usually extends more towards
the periphery. This condition usually disappears
ROSENBERG: PREMATURE SEPARATION OF PLACENTA.
spontaneously. Treatment consists of atropine and
protecting the eyes from light and the underlying
causes. Arlt gives rheumatism, intermittent fevers,
and colds as common causes of the above named
condition.
Sc I c rosin g Kcrai ilis.
This accompanies scleritis, and is a corneal mani-
festation of the latter. It is seen as a triangular
opacity near the periphery of the cornea, having
limbus as the basis of the triangle. Treatment is
that of the scleritis.
Ribbon Shaped Keratitis.
This occurs as a gray film running as a band over
the cornea. It occurs in old people, where the eyes
have been injured by some intraocular af¥ection.
Treatment consists in removing this band and giv-
ing these patients an alkaline wash to use at home.
Striped Keratitis.
This occurs often after corneal section — e. g.,
cataract operations most frequently. Where the in-
cision has been too small for the easy delivery of the
opaque lens, this condition often occurs. It is of
little moment, disappearing spontaneously in from
eighteen to forty-eight hours, and requires no spe-
cial treatment. This condition is seen as small
parallel bands running up and down the posterior
surface of the cornea.
Foreign Bodies in the Cornea.
They are easily seen by throwing a concen-
trated light on the cornea. They should be
immediately removed, after dropping two or
three drops of a four per cent, solution of co-
caine into the eye. A spear shaped instrument
which is made for this jntrpose is the best to use.
If pigment or grayish ulceration accompany a for-
eign bodv in the cornea it should be scraped away,
for, when left, it usually remains permanent. Very
often ulcers form where the cornea has become in-
fected, and it should be treated as such, after the
foreign body has been removed. Warm com-
presses and a mild antiseptic, such as i in 5,000
bichloride solution, can be used after extraction of
foreign body.
Wounds of the Cornea.
These should be treated by cleanliness, and if
prolapse of the iris occurs it should be excised.
Atropine should be used in both the above con-
ditions, the eye bandaged and kept at complete rest.
I)Urns by acids or alkalies have been fully described
in burns of the conjunctiva, and usually affect both
cornea and conjunctiva.
In conclusion I wish to state that 1 did not write
this paper with an idea of giving a complete resume
of the subject, but rather a brief resume, as the
title of my paper states.
2040 Skvkntii Avenue.
CAUSE OF PREMATURE SEPARATION OF THE
PLACENTA.
By Lionel Rosenberg, M. D.,
Brooklyn, N. Y.
I have come across some discussion in the medical
journals about tlxe cause of premature separation of
the placenta, and among the cau.scs mentioned I
have found in the New York Medical Journal of
March 14, 1908, that trauma is one of the causes.
[New York .
Mepical Journal.
This statement was made by Dr. Samuel Robbin-
ovitz. I would like to call the doctor's attention
that the cause given by him as trauma cannot act
without a predisposing cause ; and, furthermore, I
would like to remark that the cause given by him
is not original, as it is found among the exciting
causes mentioned by Professor Jewett, given in the
second edition of his well known work.
To state my opinion (that is, as far as my experi-
ence goes) of the causes of premature separation of
the placenta, I would say that, in the cases I have
had, I have found that metritis due to gonorrhoeal
infection acted as a predisposing cause, and the least
trauma caused h\ the midwife or physician in at-
tendance acted as an exciting cause. To prove my
statement I will cite the following case :
Case. — Mrs. M. M., an Italian, age twenty-eight, multi-
para, came under my observation in September, 1907, and
gave me a history of pain on urination, frequent urination,
and a profuse vaginal discharge foul in odor. Upon exam-
ination I have found her to sufifer from a gonorrhoeal infec-
tion probably due to her husband. Upon microscopical ex-
amination I found the gonococcus of Neisser in the vaginal
discharge. I placed her under the usual treatment of
gonorrhoea.
At the time she came to me she was about the end of the
eighth month of pregnancy, and as she engaged me to de-
liver her infant, I inquired into her previous history, and
found that she never had had any miscarriages or any
complicated labors at all. She was healthy otherwise, and
had no lacerations or injuries to any of the pelvic organs.
Three weeks later she was confined, and as I could not
come at the time of the delivery a midwife was called in to
attend the case. The midwife, noticing some haemorrhage,
understood that the case was a complicated one and sent
for me. I came and examined her, and found that the
haemorrhage was due to the premature separation of the
placenta. After delivering the child, I injected a two per
cent, solution of silver nitrate into the eyes of the child, as
I knew that this was a gonorrhceal case and was afraid for
ophthalmia neonatorum.
I inquired of the midwife as to her procedure before I
came, and she told me that she had applied friction over
the abdomen in order to stimulate the pain, had also applied
forcible pressure from above so as to help expulsion of the
child.
Upon repeated examination I foimd that the patient had
gonorrhoeal inflammation in its severest form, and so I
came to the conclusion that premature separation of the
placenta is due to the metritis set up by the gonorrhceal
infection, which acted as a predisposing cause, and that the
manipulation of the midwife acted as an exciting cause.
I have had two more cases like this.
171 pLovt) .Street.
IS IDIOPATHIC EPILEPSY WITH ASSOCIATED
PARALYSIS DUE TO THE ACTION OF
A GERM?
Bv Bi;KN.\t<D R. Le Roy, M. D.,
.\thens, Ohio,
Member of the Cleveland -Academy of Medicine.
For some ten years the writer has suffered from
the effects of paralysis of the lower bowels, follow-
ing an operation for haemorrhoids. Having been
forced to give up practice because of the results of
the paralysis and suffering want because of this re-
striction, the writer became interested in the studv
of paralysis, and after a careful preparation of sev-
eral years' study began a laboratory study of al!
germs which would be possible to have any bearing
upon such conditions, and this report is the first to
l)e made public. After thousands of experiments I
settled upon one genu, a spore bearing bacillus,.
June 20, 1908. 1
LE ROY: EPILEPSY AXD GERMS.
I20I
which in the normal state is about one to three micra
in length by one half to two thirds in width, acid
fast, motile, intensely so in certain media; is killed
when grown on agar at 194° F., but when grown
in media which have a small content of the silicates
of calcium and magnesium it cannot be killed with
prolonged boiling of the media : specimens living
that have undergone fractional boiling of the me-
dia for over two hundred hours.
Growths taken from this specimen and grown as
follows give peculiar results : In a faintly alkaline
gelatine bouillon at 98.6° F. it resembles, when full
grown, the Bacillus typhosus; transplanted to agar
made less alkaline, and grown at 98.6° F., it resem-
bles the Bacillus tctani; transfer to a faintly acid
silicate lime, magnesia media, and grow to full size,
then boil media and set aside for a few weeks, and
the germ will resemble tubercle bacillus ; now wash
germs off and place in faintly acid gelatine media
and grow for several weeks, and the germs will re-
semble Bacillus diphlhericp.
Throughout all of these changes the germs will
take the stain of the germ which it simulates, and
can be distinguished with some difficulty ; under
certain conditions of growth the germ becomes
ultramicroscopic in form, and after weeks of cul-
ture at 98.6° F. it reappears.
Clinical Use.
During the past summer it was my good fortune,
through the courtesy of Dr. Hansen, the superin-
tendent, to receive the privilege of studying for sev-
eral months at the State Hospital for the Insane at
this place, where, because of the more perfect con-
ditions existing, the oposonins derived from these
germs were first put into practical use.
In all cases no other remedial agent was or is be-
ing used except the opsonins. The opsonins were
autogenous, and were made, as indeed all the work
done, under strict laboratory methods and tech-
nique.
Case I. — W. P., age twenty-eight, epileptic since child-
hood, was having many attacks daily, presented the typical
appearance of such unfortunates. His mentality was
clouded and he lived in ihat subconscious life which is so
characteristic of these cases.
The germ was found in the discharge from the ear and
in the upper nasal sinuses, was grown on agar until the
germ was fully matured, then opsonins were made and a
dose given ; decided reaction resulted, and within twelve
hours he commenced to feel better and more lively.
On the third day he was free from depressive effects
and the attacks were much lighter in character and were
not coming so often ; by the fifth day his fits had vanished
and vvas having aurze only. On the eleventh day his fits
returned, and another dose was given him (one cubic cen-
timetre) ; he then went nineteen days without an attack,
p.urse growing lighter, and improvement noticed generally:
most ir.teresting being the clearing away of the mental
cloud and the peeping through of his normal mind.
Having no data to guide me, the index proving useless.
I watched him until the spells or fits returned, when
another dose of the opsonins was given, but during the
next five days his fits came often but not very heavy : I
then gave him a dose of the opsonins every four or five
days thereafter, the reaction growing lighter with each
dose, and at last did not even cause any remarks from the
patient. After this he went nearly one month without
spell or aurae, and was making fast improvement other-
wise, especially in the clearing of his mentality.
Case H.— J. v. R, aged forty-eight, inmate, suicidal homi-
cide, been confined within institutions for many years, was
considered dangerous and an epileptic of severe form.
First dose was given in .August and every four days
thereafter, reaction severe, but gradually passing away as
in Case I. This patient responded to the treatment slowly
but steadily, and the fits died away, leaving aurse of a
nervous type, which in turn faded away in much the same
manner, but which hnd not entirely disappeared when 1
was compelled to stop all treatment on these two patients.
Since then the fits have returned, but not so severe as be-
fore treatment.
Case HI, aged forty. — Wishing to try this treatment on
a paralytic, I selected a case of hemiplegia (luetic), and
found the germ in the nasal cavity and in the groin.
A dose was given, and on the third day, after resting a
while on a couch, he called to the attendant and asked if
he were moving his fingers ; he was doing so, opening and
closing his fingers of the paralyzed hand, being hitherto
unable to do' so ; five days after this he could move his
arm and lift his hand into his lap; a second dose was given
at the end of the second week, and within the next few
days he was able to lift his hand up to his waist. Circum-
stances over which I had no control caused me to stop all
work at this hospital ; and I have not treated the patient
since, and he has remained at a standstill since the last
opsonic treatment was given, in spite of much medical
treatment given him since.
Case IV. — L. B.. aged twenty, a private case. Epilepsy
since early childhood, two to five fits daily; I found germs
in the nasal cavity and in anal fold. I was at fault for
some weeks in this case, and having discovered the fault
I corrected it and at once obtained the usual good results,
but along similar lines as described in Case XL
I hope to carry this case to a conclusion, it being still
under treatment.
Case V. — C. C, girl, aged nine, infantile paralysis, both
lower limbs from waist down. I found germs in the nasal
cavity and in anal fold. This child was a hopeless cripple,
unable to move except to crawl m a peculiar fashion.
Treatments have been given once a week for several
months, and the most decided improvement has resulted
With the aid of simple straight support to the knees, and
crutches, she is able to travel about the house at will.
The muscles are increasing in strength and in size, show-
ing improved nutrition and action. I hope to carry this
case out to a conclusion.
Thinking that there may l)e some other method
of gauging the dose than b\ the index, which has
proved useless, I made a careful analysis of the
saliva in all my cases several times each day ; the
results jjroved to be quite intere.sting. I soon dis-
covered that ammonia predominated in the saliva,
with the chlorides .second, an entire absence of the
sulphocyanides. They may appear for a time, to
again disappear before the fit and to be replaced by
excess of ammonia.
Potassium as basic salt of the saliva is seldom
found in cases of epilepsy, the base being sodium
united with urea more often than with any other
chemical.
Noticing the absence of the sulphocyanides from
the saliva, I made use of the sodium sulphocvanide
by the mouth and hypodermatically, and intend to
write of my experiment later.
I also watched the effect upon epilepsy when the
sulphocyanides were kept present in the saliva at
all times.
I also found that when normal saliva was inject-
ed hypodermatically under proper precautions that
it had a decided action upon the nerves, and may
come into daily use as a therapeutic agent; it will
stop mild cases of epileptic fits in young persons,
but needs more study.
I am making a careful study of the germ, spoken
of in this article, in all its forms, and hope to be able
to make a more full and complete report within the
near future.
I202
CORRESPONDENCE.
[New Yokk
Medical Journal.
LETTER FROM LONDON.
A Slccl^ing Sickness Bureau. — The Royal Society of Medi-
cine.— Tuberculin, etc., Administered by the Mouth. —
IVrigiit's Of sonic Method. — King Edward's Hospital
Fund. — The General Medical Council. — The Death of
Dr. CuWngxvorth.
London, June .2, igo8.
The liritish government has taken a very proper
step to combat the alarming spread of sleeping sick-
ness in Uganda and other districts. It will be re-
membered that a short time ago an international
commission assembled in London to consider the
question of a combined organization to deal with
this problem. Unfortunately, owing to the disa-
greement between the delegates as to the locality of
the central bureau, the commission dissolved with-
out having accomplished anything definite. As the
question is of pressing importance, the British gov-
ernment have now decided, without any further loss
of time, to establish a central bureau in London with
the object of collecting and distributing information
with regard to sleeping sickness. The government
of the Soudan will contribute one fourth of the cost
of the maintenance of the bureau, and the Royal
Society are allowing the use of Burlington House
to provide the necessary accommodation. The
bureau will be under the management of a commit-
tee consisting, among others, of Sir Patrick Man-
son, Sir Robert Boyce, Dr. Rose Bradford, and
Colonel David Bruce. The main function of the
bureau, which will be administered by a paid di-
rector, will be to collect from all sources information
regarding sleeping sickness and to distribute this in-
formation as widely and as quickly as possible
among those who are engaged in combating the dis-
ease. The publications of the bureau will consist ot
scientific works intended for those engaged in carry-
ing on medical work in infected districts, and also
publications of a less technical character for the
use of government officials, missionaries, and others
whose duties involve residence in those districts.
At a meeting of the Royal Society of Medicine
held last Tuesday a discussion took place on the ad-
ministration of vaccines and sera by the mouth. Dr.
Latham made a communication on the treatment of
phthisis by administering Koch's tuberculin "R." by
the mouth, together with normal horse serum,
1/2,000 of a milligramme of tuberculin and 10 cubic
centimetres of horse serum being given at intervals
of a week. The temperature of the patient, which
had previously been high, was reduced to normal
and the general condition improved decidedly.
Dr. E. C. Hort said he had used normal horse
serum with great benefit in various conditions. It
was most valuable in ha;morrhagic diseases and in
conditions associated with internal or external ul-
cerations. In bacterial lesions it seemed to stimu-
laite repair of the tissues and inhibit the growth oi
the bacteria. The serum was administered by the
mouth. He also referred to twenty ca.ses, chiefly
staphylococcal infections, which were treated by vac-
cines given by the mouth, and the results so far were
encouraging. Dr. RoUeston also describid a case of
tuberculosis in which tuberculin was given by the
mouth, considerable improvement resulting. Dr.
Hector MacKenzie said he was quite satisfied that
staphylococcal vaccines could be administered by the
mouth with good results, but he was still in doubt as
to the value of the administration of tuberculin in
that way. He also stated that in his opinion opsonic
index estimations were, not feasible as a routine con-
trol in actual medical practice.
The programme of the seventy-sixth annual mtCL-
ing of the liritish Medical Association has now been
issued. The meeting will take place in Sheffield
from July 24th to July 31st, under the presidency of
Dr. Henry Davy, physician to the Royal Devon and
Exeter Hospital. The address in medicine will be
delivered by Dr. Kingston Fowler, that in surgery by
Dr. Pye-Smith, and Mr. Edmund Owen will deliver
the popular lecture on Dust and Disease. The sci-
entific business of the meeting will be conducted in
seventeen sections. There will also be several so:ial
functions, including a reception of the members b\
the Lord Mayor. The annual dinner will be givai
on July 30th, and the programme includes also the-
atrical performances for the ladies and excursions
into the countrv. The honorary local secretary is
Mr. Sinclair White, F. R. C. S., Ranmoor, Sheffield.
The Practitioner for May has a very important
series of articles on the Opsonic Index and Vaccine
Therapy. Sir A. E. Wright, in a long paper, very
ably defends his theory, which has been subjected t >
considerable criticism lately. He maintains that
clinical observations alone are uncertain guides to
the administration of vaccines. The opsonic index,
taken from time to time, gives the most reliable in-
formation as to the progress of immunization and as
to the amount and frequency of inoculation of vac-
cines. He points out the service that opsonic index
estimations have rendered to vaccine therapy, saying
that all our present knowledge of the proper dofe^
of vaccines, of the laws which govern the immuniz-
ing responses evoked by bacterial vaccines, and all
our knowledge of the phenomena of autoinoculatioii
have been derived from the opsonic index. The
other papers in the Practitioner are all more or less
in favor of Wright's theory. As there has been a
growing tendency in England to dispense with op-
sonic index estimations during a course of thera-
peutic immunization by vaccines, owing to the diffi-
culty in the technic |ue, etc., this collection of articles
in favor of Wriglit's method will perhaps result in
further investigations on the opsonic index, so that a
final verdict may be given as to its utility. For his
work on o])sonins, Sir A. E. Wright was presented
with the h'othergillian gold medal by the Medical
Society of London on May i8th.
King Edward's Hospital Fund has been enriched
by a further nuuiificent gift from Lord Mount Ste-
phen. The same donor had previtnisly given £400,-
000 to the endowment fund, yielding an income of
about £23,000 a year, and the later gift will increase
the annual income by over £7,000. The total income
of the fund from investments is £60,000 per annum,
so that over half the total income is derived from
Lord Mount Stephen's gifts. It is suggested that
an effort should be made to collect a further sum of
£300,000 for investment purposes.
On Tuesd'iv last the eigiUv-seventh session of the
June 211, 1908.1
THER. iPEUTICAL XOTES.
1203
( ieneral Medical Council was opened by the presi-
dent. Dr. Donald AlacAlister. In the business trans-
acted was the adoption of a reciprocit\- agreement
with the province of Quebec, whereby medical grad-
uates of the ]\IcGill University, of Alontreal, and of
the Laval University, of Quebec, will be admitted to
the Colonial List of the Medical Register. It was
hoped that similar relations might soon be estab-
lished with other provinces of the Dominion of Can-
ada. It was also stated at the meeting that steps '
had been taken to secure a copyright of the British
Pharmacopoeia, to prevent unauthorized reprints.
In November, 1908, the Medical Council will just
liave completed the first fifty years of its existence,
and it is proposed to celebrate the jubilee by a
friendly reunion to which all the survivors of the
past members of the council should be invited.
Dr. Charles James Cullingworth, consulting ob-
stetric physician to St. Thomas's Hospital, died last
week at the age of sixty-seven. He was a general
practitioner for some years after qualification. He
then obtained an appointment at St. Mar\-"s Hospi-
tal for Women, Manchester, and gradually gave up
general practice and took up gynaecology. He rap-
idly gained for himself a commanding position and
was offered the post of obstetric physician at St.
Thomas's Hospital, which he accepted. He took an
active part in the promotion of those attempts at
legislation which ended in the passing of the Mid-
wives' Act of 1902. He was also editor in chief of
the Journal of Obstetrics and Gyjuccology of the
British Empire. He was the author of several arti-
cles and papers, the best known being his mono-
graph on Diseases of the Falloppian Tubes and his
article on Pelvic Inflammation, in Albutt and Play-
fair's System of Gyncccology.
The Desmoid Reaction. — An ingenious method
of ascertaining the actual digestive power of the
gastric secretion, suggested by Sahli, of Berne, was
described in a recent issue of the Bulletin des
sciences pharmacoiogiques, from which it is ab-
stracted in The Prescriber, for June, 1908. The
method is termed the "desmoid reaction" (Greek,
osf7!J.oi, a tendon or band), and consists in admin-
istering after the midday meal a pilule of methylene
blue over which is stretched a piece of caoutchouc
tied with catgut. Under the action of the gastric
juice the catgut is dissolved, the caoutchouc con-
tracts and sets free the methylene blue, which short-
ly afterwards appears in the urine. If the gastric
juice be normal in composition the color appears
in the urine in from five and one-half to seven and
one-half hours after administration ; a longer or
shorter period indicates deficiency or excess of di-
gestive power. The process is criticised l)y Meimier
on the ground that the condition of the kidneys ma\'
affect the time of excretion ; moreover, in the event
of the gastric juice having no action on the catgut,
the latter will dissolve in the intestine and fallacious
results ensue. He therefore substitutes .for the
meth3'lene blue a perle of ether, coated with talc to
prevent its floating, and tied up in caoutchouc as
already described. The sac is administered after
an Ewald's test meal, and the exact time of solution
is indicated by a characteristic ertictation. In nor-
mal cases this occurs abcjut an hour and a half after
swallowing. The desmoid reaction is ingenious, but
it is not exactly new. Giinzberg, some fifteen years
ago, suggested testing the stomach contents by ad-
mmistering a rubber capsule containing potassium
iodide, and plugged with fibrin, and awaiting the
appearance of iodine in the excretions.
Laxative Preparations of Euonymus. — In the
Journal of the American Medical Association for
]\Iay 2, 1908, a note is published on the therapy of
euonymus or wahoo. The bark of the root is the
most active part of the plant. It contains a bitter
resin called euonymin, a crystalline glucoside termed
atropurpurin, and citric, malic, and tartaric acids.
The bitter j^rinciple euonymin is supposed to cause
the laxative or purgative action of wahoo. Euony-
mus is a mild laxative, somewhat resembling podo-
phyllum and rhubarb, only its action is weaker. It
increases the secretion of the mucous membrane of
the bowel, does not ordinarily cause griping, and
as it acts but slowly, for laxative eft'ects should be
given from twelve to fifteen hours before its action
is desired. It has been stated to have a slight tonic
action on the circulation, slight expectorant and di-
uretic action, and to be a stomachic. Xone of these
activities is of any importance. Some of its active
principles are excreted by the kidneys, but probably
it is mostly excreted by the intestines.
This drug is best used in combination, and mav
be combined with any other laxative to increase its
action, as :
R Aloin, gr. iii ;
Extract of euonymus gr. xv ;
Extract of belladonna leaves gr. iii.
M. et fac pilulas 20.
Sig. : One pill after supper.
Or:
R Aloin, gr. iss ;
Tpecacuanha gr. iii;
Extract of euon\'mus gr.xv ,
Resin of podopin Hum, gr. i.
^I. et fac pilulas 20.
Sig. : One pill after supper.
Or:
^« Euonymin gr. iii ;
Extract of cascara sagrada, gr. xlv ;
Extract of belladonna leaves gr. iiss ;
Extract of nux vomica.
Oleoresin of capsicum aa gr. iii.
et fac pilulas 20.
Sig. : One pill after supper.
A Normal Saline "Bomb," consisting of a
cylindrical glass vessel having sealed tapering ends,
is described by Dr. Brenner, in a recent number of
the Miinchcner medizinische Wochenschrift (1908,
p. 458). This vessel has a capacity of 350 c. c. and
is filled with sterile 0.6 per cent, salt solution, suit-
able for external or hypodermatic use. The
"bomb" is of such a shape that it is easily packed
for transportation, and may be heated to the proper
temperature for use by placing it in hot water, the
temperature being controlled by means of a bath
thermometer. Other fluids intended for infusion
ma>- be put up in the same manner.
I204
EDITORIAL ARTICLES.
[New York
MebICAL JoLRNAt..
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Review of Medicine.
Edited by
FRANK P. FOSTER, M. D.,
and SMITH ELY JELLIFFE, M. D.
Addresfi all business commnnicaliotis to
A. R. ELLIOTT PUBLISHING COMPANY,
Puhlishers,
66 West Broadzvay, Nezv York.
Philadelphia Office : Chicago Office :
3713 Walnut Street. 160 Washington Street.
Subscription Price :
Under Jjomestic Postage Rates, $.") ; under Foreign Postage Rate,
$7 ; single copies, fifteen cents.
Remittances should he made by New York Exchange or post
oflice or express money order jiayable to the A, R, Klliott Pub-
lishing Co., or by registered mail, as the jiiiblishers are not
responsible for money sent by unregistered mail.
Entered .it the Post Office at New Y'ork and ndraitted for
tiansiiortation through the mail as second class matter.
NEW YORK, SATURDAY, JUNE 20, 1908.
THE MEDICAL SERVICE OF THE NAVY.
In our department of- Miscellany we publish this
week almost the entire official circular of informa-
tion for persons desirous of entering the Medical
Corps of the United States Navy. We do so for
the purpose of informing the younger of our read-
ers concerning a most honorable career which is
open to those of them who prove themselves
worthy of entering upon it, because we are con-
vinced that for the most part they must have over-
looked its advantages. It is amazing that there
should, in spite of those manifest advantages, still
be fifty-four vacancies in the corps, though it is
gratifying to know that the num.bcr is less than it
was but a fe.w months ago.
The surgeon general of the navy, Admiral Rixc} ,
has, in his zeal for the welfare of the service and
out of regard for the interests of our younger pro-
fessional brethren, given out a printed statement of
the attractiveness of life as a naval surgeon, and it
is a "plain, unvarnished tale." The recent expan-
sion of the navy and its prominence in the thoughts
of the pul)lic, says Admiral Rixey, may or may not
have stirred young medical graduates to think of
the naval service as an opening for their profes-
sional career ; but, whether they have or have not, it
seems to him certain that such graduates are not
fully apprised of the facts. He says of the medical
officer of the navy that he "is vested with proper au-
thf>rity. receives unstinted praise and admiration, as
in civil life, wherever and wlicnevrr merited, and
fills a position socially, professionally, and officially
which self respect approves." He is a ward room
officer, he continues, as soon as he enters the ser-
vice, and his personal accommodations are as good
as those of any of his brother officers, and repre-
sent comfort.
The naval medical officer's professional oppor-
tunities, says the surgeon general, are liberal, af-
fording him time for following the practice of the
great civil hospitals and clinics when his station is
favorable, also liberty to engage in private practice
to any extent not inconsistent with the perform-
ance of his official duties, and in this field manv
naval surgeons have added considerably to their in-
come and to their reputation. In the great ports
of the world, moreover, naval medical officers are
freely received in the highest circles of society and
view civilization from standpoints unattainable at
home, and they have facilities denied to others for
studying diseases and sanitary conditions which the
civilian is debarred from observing.
In civil life the young graduate, already often al-
most impoverished by the cost of his professional
education, has to make a considerable additional
outlay for quarters and appliances at his very en-
trance on the tedious period of waiting for patron-
age. All this he escapes in the public service, where
everything necessary is furnished by the govern-
ment. At an age when his faculties and his capacitv
for enjoying life arc still as a rule not sensibly im-
paired he is retired for the rest of his existence on
remuneration reduced by only a quarter of his high-
est pay. Surely one would think that the career
of a naval surgeon would prove alluring to a great
ntiniher of yoimg medical men.
A NEW OPPORTUNITY FOR PSYCHIATRY.
TpiAf most baffling of all branches of medicine,
])syc]iiatry, dealing with the disorders of the most
highly evolved and most imfKJrtant organ of the
l)()dv, the brain, has finally come to its own. The
all wise Greeks clearly grasped the essential fact
that mental disorders were brain disorders, but for
a thousand years or so' the cobwebs of metaphysics
have been spinning and obscuring men's minds to
the obvious truths of cerebral mechanisms.
The extreme complexity of anatomical formation
of the as yet incompletely analyzed brain structure
has lieen an important factor in preventing psychi-
atry from assuming an authoritative position
among its many sister l)ranches, but it would seem
that with the advances made by such anatomists as
Ciolgi, Cajal, Van Gehuchten, Dcjerine, Nissl, Alz-
heimer, Dozicl. and IWelschowsky, such clinicians
as Wernicke, /iehen. Kraepelin. Tanzi. Head. lii-
June 20, 1908.]
EDITORIAL ARTICLES.
anchi, Jackson, Freud. Magnan. and ]\Ieyer, and
such physiologists as Wundt, ^lunk, Luciani,
Flechsig, Sherrington, Bechterew, and Lewandow-
sky, not to mention scores of others, psychiatry had
reached a point when fundamental correlations are
a reality and will remain for all time. It is there-
fore a welcome sign that this advanced position has
been appreciated by men of enlightenment and pub-
lic spirit, and embodied in a tangible gift to one of
our foremost universities.
The gift of $750,000 by Mr. Henrj- Phipps to
Johns Hopkins University, for the foundation of a
psychiatric clinic, will serve a threefold interest. In
the first place, it will be the mental ward of the
general hospital, in which patients may be received
for treatment without the formality of commitment,
and without the stigma that attaches itself to
patients with mental trouble, a relict of the days of
superstition and idolatry, when the mentally ill
needed to have devils cast out of them; secondly,
it will afford opportunities for instruction in this
vast and much neglected field of medicine ; and
finally, by reason of the rich endowment, labora-
tories for research will aflford unusual opportunities
for the carr>-ing out of the extremely technical
studies that work in this field requires.
• It is a subject for much congratulation that
through such a gift the importance of mental dis-
orders is emphasized. There is no field of preven-
tive medicine that can reap such fruit as that of
psychiatry. We have struggled for years to save
legs, to patch up internal organs, to keep out and
subdue infections ; now is the time to reap a rich
harvest in saving the mental powers of mankind.
Is there a way to lessen crime, to limit the outlay
of the public money in caring for the thousands of
dependents, the idiots, imbeciles, demented, and
chronic mentally ill? If there is, it will come about
only by the better recognition of the mental factors
which bring about such conditions. The new
psychiatric clinic will sen^e as a useful beginning in
this line, and we confidently look forward to the
time when others will see the needs as Mr. Phipps
has seen tliem, and respond to the call.
THE HEALTH OF THE PHILIPPINE
ISLANDS.
In our news columns we recently published some
figures taken from the annual report of the Bureau
of Health of the Philippine Islands. The report,
made by Dr. Victor G. Heiser, the director of
health, contains some interesting statements outside
of the purely statistical portion from which our fig-
ures were taken. These figures apply, as would be
supposed, to the city of Manila, the agricultural and
mountainous districts of the archipelago not yet
having been sufficiently organized to furnish reliable
statistics. The report shows that, while the death
rate to a thousand of population was 36.91, the san-
itar}- reforms inaugurated in the city and carried
out for the past few years are beginning to show
results. The public health was more satisfactory
(luring 1907 than at any previous time during the
American occupation. In 1906 the death rate was.
40.9 in a thousand. But the death rate for Amer-
icans shows even more gratifying figures; in 1906
it was 9.34; in 1907, 5.59 to a thousand of the pop-
ulation.
There has not been a single case of plague in the
islands ; there has not been one death from small-
pox in ^lanila; cholera in recognizable form has dis-
appeared ; provinces in which formerly there had
been 6,000 deaths annually from smallpox have not
reported a single death from the disease, and this
is the result of over 2,000.000 vaccinations. The
number of lepers on September i, 1905, was 3.58b;;
the number on June 30, 1907, was 2,282.
The report takes up the various epidemic diseases -
in detail and describes the methods adopted by the
Bureau of Health for their elimination. The small-
pox campaign really shows the most striking results,
although the cholera work is worthy of some com-
ment and of sincere congratulation to those en-
gaged in its conduct. At the time that the last an-
nual report was sent to the press the authorities
were engaged in handling an epidemic of cholera
which threatened to assume serious prof>ortions.-
The epidemic spread principally by land, both north
and south. The measures adopted for the sup-
pression of the epidemic were strict outgoing mari-
time quarantine, prompt isolation of the sick, and
disinfection of premises, with no attempt at land
quarantine. The discontinuance of a land quaran-
tine is a feature that the health authorities of }>ta-
nila are to be congratulated upon having courage to
adopt. We are strongly of the opinion that land,
quarantine is of no value in preventing the spread
of transmissible diseases, and that the important
thing is to isolate tlie infected individual. In re-
gard to this feature of the cholera campaign, Dr.
Heiser says: "Tt is hardly possible to describe the-
feeliiig of secnrit}- which seemed to pervade the pub-
lic. W'itli tile exception of the comparatively small
increase in the freight and passenger rates that was
imposed upon interisland vessels leaving Manila, no
large financial loss resulted. The regular machiner)-
of the Bureau of Flealth worked so smoothly that
it was able to meet all demands with practically no
increased outlay above routine expenditures. If it
had not been for the leports published daily the peo-
ple would scarcely have known that cholera was in;
1 206
their midst, except in so far as they or their friends
were flirectly affected by the disease. The feeling
of security was directly responsible for the preserva-
tion of many lives, and, on account of there having
l)een practically no disturbance to business, thou-
sands of dollars were saved."
At the San Lazaro Hospital twenty-nine cases of
leprosy have been treated with the x ravs. Eight
patients were very decidedly improved, thirteen
were considerably improved, seven showed no
change, and one died. The officials of the hospital
intend to continue the experiments with this form
of energy in the treatment of leprosy.
POPULAR INSTRUCTION IX XURSI.VG.
The Chautauqua School of Nursing, an institu-
tion which has its headquarters in Jamestown, N. Y.,
is undoubtedly doing a most excellent work, that of
fitting young women for the profession of nursing
in greater numbers than could be accommodated in
the regular hospital training schools and without
subjecting them to conditions which many of them
might find onerous. The teaching is chiefly by
means of printed lectures issued to the pupils. We
have examined these lectures, which cover the whole
range of medical, surgical, and obstetrical nursing,
and they seem to us admirably adapted to their pur-
pose. The necessary lack of personal demonstra-
tions is in a great degree compensated for by in-
genious engravings. The school does not content
itself with furnishing this literature to its pupils,
but recfuires them to fill out examination blanks
which are so devised as to afford practical tests of
the pupils' comprehension of the lectures. The
school also prints for the use of the }oung women
a number of narratives of the experiences of then-
predecessors who have completed the course, writ-
ten by themselves. These also we have examined,
and they have appealed to us as the productions of
very intelligent and conscientious women, women
who do not disdain to serve among the lowly and
at rates of compensation which the j^oor can for the
most part afford, or even wholly as a work of char-
ity in case of need, in remote rural places. Such
nurses are sorely needed In' the overworked country
practitioner and his patients, and it w^as this need
that was the special incentive to the establishment
of the school.
PRC )\ ()KK1) ERUCTATION AS A REME-
niAL MEASURE.
In the Scimiinc mcdicalc for June 3d we read that
-,in .\ustrian physician. Dr. Max Ikrz, of X'iennn.
has succeeded in mitigating the painful attacks in-
cident to cardiac disease, such as angina pect' ris,
[New Vokk
Medical Journal.
also paroxysms of tachycardia, by the expedient of
causing the patient to belch up wind from the stom-
ach. He has even prevented these attacks when
the eructation w^as brought about early enough, at
the time of the premonitory sensations. He attrib-
utes the efficiency of the procedure to the fact that
the heart and the stomach are both innervated by
the pneumogastric nerve.
Eructation is produced by the following proce-
dure : The patient, seated, takes a small drink of
water and holds it in his mouth. He then throws
his head as far backward as possible and swallows
the water. The posture is such as to stretch the
oesophagus and induce in the pharynx a sensation
which causes eructation, provided that result is not
voluntarily prevented b)- the patient. It is well to
warn the person that an eructation is desired ; other-
wise he may restrain it out of a sense of decency.
Herz had observed the relief afforded by spontane-
ous belching, but it is not explained how he was led
to devise the manoeuvre for imitating it.
A PROPOSED SCHOOL OF SANITARY
SCIENCE.
The Columbia University Quarterly has issued a
supplement of seventy pages devoted entirely to an
essay entitled Education and its Economic Value in
the Field of Preventive Medicine; the Need for a
School of Sanitary Science and Public Health, by
Dr. Norman Edwarci Ditman. Dr. Ditman depicts
very graphically the ravages of preventable disease
and their mitigation by preventive measures. One
need not agree to all that is said in the essay to join
with the author in his main contention that there is
great need in this country of a school, one at least,
for the diffusion of knowledge in regard to sanitar\-
problems and their solution.
Dr. Ditman would have a school of preventive
medicine planned to give instruction to students
preparing for the practice of medicine, for offices
of health boards and as sanitary inspectors, for san-
itary engineering (civil, military, and naval), for
work as school and college teachers, school nurses,
or school insi)cctors, for work as officers of charity
societies antl institutions, visiting nurses, and '"so-
cial workers," for the ministry, and for legislative
W'Ork, also to the public. He specifies more than
thirty subjects which he would have taught, men-
tioning also the groups of persons to whom the
branches should be taught. There are at present
courses in nearly halt these branches in Columbia
University. He would have medical students in-
structed in all these branches save the last, domestic
science, which, indeed, as we iniderstand his tabular
statement, he does not recommend for anybody, al-
EDITORIAL ARTICLES.
June 20. 1908.1
XEIVS ITEMS.
1207
though it is set down among those already taught
in Columbia. We fancy that in this particular the
table has been incorrectly printed.
There can be no doubt that all the subjects men-
tioned should be taught to various classes of the
community, especially to medical students, but it is
questionable whether the teaching should be done
in a special institution or in a department of a uni-
versit}-. It would be in the interest of economy, it
ma}- be supposed, to have it done in a university,
not as an integral part of the medical curriculum,
but with all the students of the medical school priv-
ileged to attend the courses.
Bftos Items.
Changes of Address. — Dr. Isaac H. Jones, to 4501
Spruce Street, Philadelphia.
The Hampden District, Mass., Medical Society held
its annua! meeting in Springfield recently and elected the
following officers : President, Dr. George L. Woods, of
Springfield ; vice president. Dr. C. W. Jackson, of Monson :
secretary and treasurer. Dr. R. S. Benner, of Springfield.
Society Meetings for the Coming Week:
TuESD.AY, June 33. — Buftalo Academy of ^Medicine (Sec-
tion in Obstetrics and Gynaecology).
Thcrsd.av, June 2}. — New York Celtic Medical Society:
Brooklyn Society for Neurology . .
5. VTURD.w, Jnne .'/f/i — Harvard Medical Society.
Contagious' Diseases in Chicago. — The following
cases of commiinicaMe diseases were reported to the Bu-
reau of Contagious Diseases during the week ending June
6. 1908: Measles, 269: scarlet fever. 63: diphtheria. 61:
chickenpo.K, 36; tuberculosis. 21: whooping cough. 20:
typhoid fever, 16: smallpo.x. i: diseases of minor impor-
tance. 4: total. 491.
Officers of the Massachusetts Medical Society. — .\t
the annual meeting of this society, which was held in Bos-
ton during the week of June 8th. the following officers
were elected : President, Dr. Silas D. Presbrey, of Taun-
ton: vice president. Dr. D. E. Keefe, of Springfield: secre-
tary. Dr. F. W. Goss, of Roxhury ; treasurer. Dr. G. M.
Buckingham, of Boston.
L'Association des Medecins de langue frangaise de
I'Amerique du Nord. — The annual meeting of the a^-
sociation of French speaking physicians of North America
will be held in the city of Quebec on the occasion of the
tercentennial anniversary of the founding of the city. The
sessions will be held in the buildings of Laval University
on July 20lh. 21st, and 22d.
Scientific Society Meetings in Philadelphia for the
Week Ending June 27, itio'&.—Wcdncsday. June 24th.
Philadelphia County Medical Society. Thursday, June
2StU. Patholoffical Society: Entomological Section, .Acad-
emy of Natural Sciences ; Section Meeting. Franklin Insti-
tute. Friday. June 26th. South Branch, Philadelphia County
Medical Society: Northern Medical Association: Philadel-
phia Neurological Society.
A Campaign Against Bovine Tuberculosis. — Gov-
ernor Hughes has signed the Allds bill, which aids the
New York State Department of Agriculture in its cam-
paign against bovine tuberculosis. Appropriations ag-
gregating $145,000 are available for the work. Included
in this sum is an appropriation of 875,000. made at the
recent session of the legislature, to be used in payment
for cattle condemned by the department.
The Medicochirurgical College of Philadelphia held
its annual commencement exerci-es on Saturday. June 6th.
The degree of doctor of medicine was awarded to one
hundred and fifty-five men. Dr. Henry C. Dooliiig re-
ceived the Dr. Snencer Morris prize and the faculty gold
medal for the highest general average in the graduating
class. Dr. Judson Perry Welch, vice president of the
Pennsylvania State College, delivered the oration.
Elmira, N. Y., Academy of Medicine. — At a meeting
of this academy, held on \\'ednesday evening, June 3d, Dr.
R. P. Bush, of Horseheads. N. Y., read a paper on Endo-
carditis, and Dr. Alexander Mark, of Elmira, N. Y., read
a paper on Diagnosis of Children's Diseases.
Association of Ex-Resident Physicians of St. Joseph's
Hospital, Philadelphia. — At a recent meeting of this
association permanent organization was effected, and offi
cers for the ensuing year elected as follows : President, Dr.
George Morley Marshall ; vice president. Dr. David Moy-
lan; historian. Dr. Joseph Roberts; secretary and treasurer.
Dr. Joseph M. Spellis.sy.
American Urological Association. — .\ stated meeting
of the New York Society was held in the New York Acad-
emy of Medicine on the evening of Wednesday. May 27th.
The paper of the evening was read by Dr. G. Morgan
Muren on Real Conservatism in the Treatment of the
Prostate. Among those who took part in the discussion
were Dr. Eugene Fuller. Dr. L. Bolton Bangs, and Dr.
Follen Cabot.
Medicochirurgical Society of Central New York.--
.\t the annual meeting of this organization, which was
held ill Syracuse recently, the following officers were
elected for the ensuing year : President. Dr. C. T. Haines,
of Utica: first vice president. Dr. W. H. Sweeting, of
Savannah. : second vice president. Dr. C. W. Radway. of
Medico: secretary and trea^^urer. Dr. George J. Gannette.
of Syracuse.
Obstetrical Society of Philadelphia. — At a stated
of this society, which was held on Thursday evening, June
4th, the programme included the following papers: Un-
controllable Haemorrhage .Associated with Diseases of the
Uterine Wall, by Dr. Brooke SI. Anspach : The Early Di-
agnosis of the Cancer of the Uterus, by Dr. R. F. Woods ;
Rupture of the Uterus, with Report of Two Cases, by Dr.
Frank C. Hammond.
Southwestern Kentucky Medical Society. — At the an
nual meeting of this society, which was held in Paducah
recentlv. the following officers were elected for the ensuing
vear: President. Dr. Vernon Blythe. of Paducah: first vice
president. Dr. H. T. Crouch, of Bardwell : second vice
president. Dr. L. W. Ogilvie, of Birmingham : secretary.
Dr. C. E. Purcell, of Paducah : treasurer. Dr. C. H.
Brothers, of Paducah : and hi-torian. Dr. R. T. Hocker. of
Arlington.
Missouri State Medical Society. — At the annual meet-
ing of this society, which was held in Springfield recently,
the following officers were elected for the ensuing year :
President, Dr. .\. R. Kieffer. of St. Louis: secretary. Dr.
A. W. McAllister. Jr., of Kaii^a< City: treasurer. Dr. J. F.
Walsh, of Salisbury. Dr. R. L. Goodier. of Hannibal, was
elected orator in medicine, and Dr. F. J. Lutz, of St. Louis,
orator in surgery. Jefferson City was chosen as the next
meeting place.
The West Virginia State Medical Association.— At
the annual meeting of this society, which was held recently
at Clarksburg, the following ofticers were elected : Presi-
dent. Dr. Fleming Howell, of Clarksburg : president elect.
Dr. V. T. Churchman, of Charleston : first vice president.
Dr. R. J. Reed, of Wheeling: second vice president. Dr.
R. S. Powell, of Grafton: third vice president. Dr. H. D.
Hatfield, of Echman : secretary. Dr. T. C. Moore, of Hun-
tington: treasurer. Dr. T. L. Barber, of Charleston.
Gift to the Garfield Memorial Hospital, Washington,
D. C. — Dr. Loren B. T. Johnson, of Washington, has
donated to this institution the sum of $50,000. to be use \
for the erection of an annex to the hospital as a rnemoriai
to his wife. The annex is to be devoted exclusively to the
care of afflicted children, and the donor is to be permitted
to place a tablet in some suitable place in the br.ilding to
i:idicate his purpose in erecting it. The proposed annex
will be called the Johnson Building.
Officers of the Tennessee State Medical Association.
— At the annual meeting of this organization, which was
held recently, the following officers were elected to serve
for the ensuing year: President. Dr. B. D. Bosworth. of
Knoxville: vice president for East Tennessee. Dr. C. T.
Carroll, of Cleveland : vice or ?sident for West Tennessee.
Dr. M. A. Blajiton. of Union Citv , vice president for Mid-
dle Tennessee. Dr. J. W. BrAndau, of Clarksville : secre-
tary. Dr. George H. Price, of Nashville : treasurer, Dr. W.
C. Bilbro, of Murfreesboro.
I208
NEWS ITEMS.
INew York
Medical Journal.
The Health of Pittsburgh. — During the week ending
June 6. 1908, the following cases of transmissible diseases
were reported to the Bureau of Health : Chickenpox, 5
cases, 0 deaths ; typhoid fever, 26 cases, 4 deaths ; scarlet
fever, 12 cases, o deaths ; diphtheria, 8 cases, o deaths ;
measles, 230 cases, 7 deaths; whooping cough, 7 cases, i-
death ; pulmonary tuberculosis, 30 cases, 10 deaths. The
total deaths for the ^veek numbered 144, in an estimated
population of 403,330, corresponding to an annual death
rate of 18.56 in i,0'.x> of population.
Medical Society of the Woman's Hospital of Phila-
delphia.— At a regular meeting of this societ}', held on
Monday '.'vcniug, June isth, the following papers were
read: Review nf Our Present Knowledge of the Physi-
ology of Digestion, by Dr. Martha Tracy; Acute Dilata-
tion of the Stomach asrociated with Operation, by Dr.
Ellen C. F'citer; Perforation of the Uterus, with a Report
of Two Cases, by Dr. Sarah H. Lockrey ; Report of the
190S meeting of the International Congress of Laryngolo-
gists, by Dr. Margaret F. Butler.
Philadelphia County Medical Society. — At a meeting
of the Central Branch of this society, which was held on
the evening of Wednesday, June loth, Dr. F. A. Faught and
Dr. J. F. Dever gave a demonstration of a device for facili-
tating test meal removal and gastric lavage. A paper en-
titled Fibroid Tumors of the Uterus Complicating Preg-
nancy was read by Dr. Wilmer Krusen and discussed by
Dr. Barton Cooke Hirst, Dr. Charles P. Noble. Dr. J. M.
Baldy, and Dr. Switnin Chandler. Dr. E. J. Gillespie
Beardsley read a paper on the Anamnesis of Subjects of
Exophthalmic Goitre.
The Jefferson Medical College of Philadelphia held
its eighty-third annual commencement on Monday, June
8th. One hundred and seventy men received the degree
of doctor of medicine. Dr. William H. Howell, dean of
the medical faculty and professor of physiology in the
Johns Hopkins University, delivered the oration. Two
prizes of $75 each, awarded upon recommendation of the
professor of medicine and of the prnfcisor of surgery
to the student in each branch considered the most worthy,
were awarded to Dr. Joseph Lloyd Warne and to Dr.
George Elmer Krout, respectively.
Charitable Bequests. — By the will of Mr-. Jerome
H. Jones, the Brookline, Mass.. Free Hospital for Women re-
ceives $[o.0'..n: tlic Industrial School for Crippled and
Deformed Children, Boston, receives $10,000; the Chil-
dren's Hospital, Boston, receives $10,000; and the Home
for Aged Couples, Boston, recei\'es $5,000.
By i!io Villi (if George Bliss Griggs, the Springiield,
Mass., !: iMiii il receives $10,000.
By tliL- (if Letitia Bentz the Little Sisters of the
Poor receive $250. and St. John's Orphan Asylum and St.
Agnes"s Hospital, Philadelphia, receive $ioo each.
The Annual Convocation of the Medical Faculty of
McGill University, Montreal, was held on the after-
noon of Jtme I2th. Eightv--ix students received the de-
gree of M. !)., C. M. The degree of LL. D. was conferred
upon Dr. r-ldward .\lhcrt Schafer. professur of ])liysiology
at the University of ICdinburgh, v ho made a lirief address.
The annual address to the graduates was delivered by
Professor T. A. Starkey, M. B.. D. P. H., Fellow of the
Royal Sanitary Institute, and the class valedictory was
read by Dr. Donald F. Macdonell. Dr. 'I'homas G. Rod
dick -'unounced his resignation as dean of the faculty, and
the appointment of Professor F. J. Shepherd as his
successor.
The Burlington County, New Jersey, Medical Society.
— 'i'he reguhir meeting of the Burlington County Medical
Sr)ciety was held at Morristown, N. J., on Wednesday,
Jiuic loth. Dr. Ernest Laplace, of the Medicochirurgical
College, read a paper on the Significance of Pain in Ab-
dominal Diagnosis. Dr. John M. Swan, of the Philadel-
phia Polyclinic, read a paper on the Diagnostic Signifi-
cance of Lcucocytosis. Dr. L. Napoleon Boston, of the
Medicochirurgical College, read a paper on Bacteriremia
following Surgical Conditions and in Acute I'evcrs. There
was a short discussion on Hydrophobia. /\ dinner fol-
lowed the scientific business of the meeting. -.Miout twenty-
five member'; ami guests were present.
Cornell University Medical College held its tenth
animal conunencement on June loth. The degree of doc-
tor of medicine was conferred on fifty-eight graduates,
among whom was one woman. Miss Phoebe Lott Du Bois,
of Freehold, N. J. The prize winners were Dr. Willis
Gaylord Graves, of Binghamton, N. Y. ; Dr. Rodney Ralph
Williams, of Fredonia, N. Y. ; Dr. Harry Clifton Luke, of
Salamanca, N. Y. ; Dr. Harold Elmore Santee, of Hor-
nellsville, N. Y. ; and Dr. Harold de Wolf, of Bristol,
R. I. Dr. J. G. Schurman, president of Cornell University,
delivered the address. The commencement exercises were
followed by the annual bantpiet of the Cornell Medical
Alumni Association at the Hotel Manhattan.
Infectious Diseases in New York:
IVe arc indebted to the Bureau of Records of the De-
partment of Health for the following statement of new
rases and deaths reported for the two weeks ending June
13, 1908:
, June 6. , , June 13.
Cases. Deaths. Cases. Deaths.
Tuberculosis puhiionalis 440 161 400 180
Diphtheria 268 25 353 37
Measles 1,322 17 1,031 21
Scarlet fever 498 22 513 27
Smallpox
Varicella 171 .. 122
Typhoid fever 45 7 35 5
Whooping cougli 25 5 25 4
Cerebrospinal meningitis 7 5 7 4
Totals 2,776 242 2,486 278
School of Instruction for Health Officers.— The
tenth annual course of instruction for the health officers
of the State of Vermont will be held in Burlington on
June 29th to July 2d, inclusive. All health officers of the
State are required to attend the sessions of this school,
and no one will" be excused for nonattendance except in
case of illness. The public are invited to attend. Ac-
cording to the provisional programme, which we have just
received, the first session wiW be held on Monday. June
29th, at 8 p. m., when addresses will be delivered by Dr.
Charles S. Caverly, president of the State Board of
Health; the Hon. F. D. Proctor, Governor of the State:
the Hon. Walter J. Bigelow, Mayor of Burlington, and
Judge Edward C. Mower, of Burlington. There will
be three sessions daily on Tuesday and Wednesday, at
9:30 a. m., at 2 p. m., and at 8 p. m., and the final session
will be held on Thursday morning at 9 o'clock.
A Psychiatric Clinic for Johns Hopkins Hospital. —
Dr. W'illiam LI. Welch, of Johns Hopkins University, an
nounces that Mr. Henry Phipps, of Pittsburgh, has ar-
ranged for a large gift to the Johns Hopkins Hospital and
University for the founding of a psychiatric clinic on the
lines of well known similar institutions in Europe. The
total amount of the gift is withheld in accordance with the
wishes of Mr. Phipps. but it is understood that it will ex-
ceed half a million dollars. The funds provide for the
erection of a four story building, vvith accommodations for
si.xty patients, with rooms for private patients. The building
will be equipped with all the most modern appliances and
app:iratus for use in the treatment of patients, and labora-
tories for scientific investigation of the nature, cure, and
prevention of mental diseases. Provision has also been
made for the establishment of a professorship of'psj'chia-
try at the university, the professor to be the director of
the clinic.
The American Academy of Ophthalmology and Oto-
Laryngology. — The thirteenth annual meeting of this
organization will be held in Cleveland, Ohio, on Thursday.
I'riday, and Saturday, August 27, 28. and 29. 1908. The
preliminary programme of the Oto-Larj'ugological Sec-
tion includes sixteen papers on subjects relating to dis-
eases of the throat and ear, and a symposium on the past,
present, .and future of oto-laryngological teaching. More
than twenty papers have been promised for the Section in
Ophthalmology, exclusive of a symposium on ophthalmic
pedagogy. The officers of the society are: President, Dr
Derrick T. Vail, of Cincinnati ; first vice president. Dr.
Joseph C. Beck, of Chicago; second vice president. Dr.
Theodore B. .Scheideman, of Philadelphia; third vice presi-
dent, Dr. F. S. Owen, of Omaha; treasurer. Dr. Otto J.
Stein, of Chicago; secretary. Dr. George F. Suker, of
Chicago; chairman of the committee on arrangements. Dr.
Secord H. Large, of Cleveland.
June 20, 1908.]
PITH OF CURRENT LITERATURE.
1209
The Mortality of Chicago. — During the week ending
June 6, 1908, there were reported to the Department of
HeaUh of the City of Chicago 483 deaths from all causes,
as compared with 578 lor the previous week and 574 for
the corresponding period in 1907. The annual death rate
in 1,000 of population was 11.63, which comes close to the
lowest rate ever recorded in Chicago at this time of the
year. The principal causes of death were : Apoplexy, S ;
Bright's disease, 35 ; bronchitis, 13 ; consumption, 63 ; can-
cer, 26 ; convulsions, i ; diphtheria, 7 ; heart diseases, 40 ;
influenza, 2; intestinal diseases, acute, 29; measles, 5;
nervous diseases, 19 ; pneumonia, 42 ; scarlet fever, 5 :
suicide, 10; violence (other than suicide), 52; whooping
cough, I ; all other causes. 125.
Vital Statistics of New York. — During the week
ending June 6, 190S, there were reported to the Depart-
ment of Health of the City of New York 1,222 deaths
from all causes, as compared with 1,434 for the corre-
sponding period in 1907. The annual death rate in 1,000
of population was 14.41, in an estimated population of
4,422,685. Of the five boroughs, Manhattan had the high-
est death rate, 15.20 in 1,000 of population, while the Bronx
came second with a death rate of 14.81. The death rate
of Brooklyn for the week was 13.49. that of Queens was
12. 1 1, the lowest for the five boroughs, and of Richmond,
14.29. Of the total number of deaths 668 were in Manhat-
tan, 93 in the Bronx, 386 in Brooklyn, 54 in Queens, and
21 in Richmond. The total infant mortality was 307; 242
under one year of age. and 65 between one and two years
of age. There were 144 still births. Seven hundred and
thirty-five marriages and 3,008 births were recorded dur-
ing the week.
American Climatological Association. — The twenty-
liith annual meeting of this organization took place in
Boston on June 9th, loth, and nth. The attendance was
large, members being present from all parts of the United
States, and all agreed that the meeting was one of the
best ever held by the association. The scientific pro-
gramme, which- was one of unusual interest, included a
number of papers dealing with the treatment of tubercu-
losis. The newly elected officers are : President, Dr.
Charles E. Quiniby, of New York; first vice president, Dr.
Edward R. Baldwin, of Saranac Lake. N. Y. ; second vice
president. Dr. Carroll E. Edson. of Denver, Col. : secre-
tary and treasurer. Dr. Guy Hinsdale, of Hot Springs.
Va. ; council. Dr. James C. Wilson, of Philadelphia ; Dr.
W. F. R. Phillips, of Washington, D. C. : Dr. E. L. Shurly.
of Detroit ; Dr. Thomas Darlington, of New York ; and
Dr. Thomas D. Coleman, of Augusta, Ga. ; delegate to the
council of the congress at Washington in 1910. Dr. Fred-
erick T. Knight, of Boston, with Dr. Roland G. Curtin, of
Philadelphia, alternate.
Rules Governing the Use of the Library of the New
York Academy of Medicine. — We present herewith
extracts frc:n the rule- governing the use of the library
of the New York Academy of Medicine by others than
members of *he academy.
Bylaw Xni. Section 7. Candidates for fellowship,
after announcement by the committee on admission, may
be granted the privileges of the library on the pa>Tnent of
a fee of $20 a calendar year or pro rata in advance. The
ainount so paid in a gi\en calendar year shall be deducted
from the candidate's admission fee if he be elected to fel-
lowship in a calendar year for which the fee was paid.
Section S. Any person approved by the library commit-
tee and by the council may become an annual subscriber on
such conditions as the council may impose. Annual sub-
scribers shall be entitled to a card giving the privileges of
the library, good for one year from the date of their
acceptance.
Section 10. The privilege of consulting the library, but
not of taking out books, may be granted for one month,
when authorized by a card signed by the executive
librarian or his representative, on written request by the
applicant, to accredited representatives of fellows of the
academy on application by the latter. No one shall be in-
troduced under the provision of this section more than
once in six months, except by special permission of the
council.
Section /J. The library shall be open to the public from
9 a. m. to 2 p. m. Fellows and persons included in Sec-
tions 7, 8, and 10 shall have access to the library from 9
a. m. to 10:30 p. m.
The fee of annual subscribers is now fixed at $20 a year.
|it^ at (Lviimi f iuratnu.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
June II, 1908.
1. On Some Relations of the Physician to the Public.
Duties and Opportunities,
By William Sydney Thayer.
2. Modern Medicine and Surgery in the Orient (<o be
continued). By J. Ewing Mears.
3. Modes of Infection in Tuberculosis,
By Silvio von Ruck.
4. Composition of Large Curds in Infants' Stools,
By Fritz B. Talbot.
5. Camphoric Acid, Its Action and Uses,
By Maurice Vejux Tyrode.
3. Modes of Infection in Tuberculosis. — Von
Ruck reviews our present knowledge of the modes
of infection in tuberculosis : As concerns the tuber-
culosis of animals as a source of infection, it is with
food products that we have chiefly to deal, especially
with meat and milk. The possibility of such infec-
tion has at no time been denied, but the question of
its frequency has given rise to varied opinions, and
in recent years has become of renewed interest as
the result of Professor Koch's announcement, at the
London Congress, of the nonidentity of the human
and bovine type of bacillus, and of his conviction
that the tuberculosis of these respective species is
not readily communicated from the one to the other.
The question has not been settled, and we have to
wait until more accurate study in the isolation of
cultures and experimental proof of their respective
virulence affords reliable data. Since 1902 such in-
vestigations at Koch"s suggestion have been vigor-
ously prosecuted at the German Imperial Health
Bureau and also by ethers. Up to the present time
the cases in which bovine infection has been proved
to have occurred in man are but thirty-three in num-
ber, eighteen of \\ hich have been examined at the
German Imperial Health Bureau, while fifteen are
reported by other obserA-ers. There are three groups
of infections : Infections of directly accessible sur-
faces, which may be termed local or contact infec-
tion ; infection through the air by inhalation ; and
infection through food by ingestion. To the group
of local infections belong all cases of skin tubercu
losis and the majority of the primary cases of tuber-
culosis of the mucosa of the several orifices of the
body. In these cases the tendency is for the disease
to remain localized unless in young children, in whom
the contrary is true, as is shown by cases of tuberc-
ulous infection during ritual circumcision, when gen-
eralization appears to be frequent. Occasional cases
of accidental infection of the hands at autopsies of
tuberculous sttbjects are known. Cases of local infec-
tion after piercing the lobule of the ear for earrings,
after the use of an infected hypodermatic syringe,
after tattooing, and after similar slight wottnds are
to be found in the literature. Occasional tubercu-
lous infection of surgical wounds occurs. It has
frequently been both asserted and denied that tuber-
culosis may be conveyed by vaccination, but vaccine,
the lymph from tuberculous cattle, and the contents
of vesicles in the arms of human subjects have been
repeatedly examined for the presence of tubercle
bacili with negative results. Even in arm to
arm vaccination, if the person furnishing the lymph
was tuberculosis, the tubercle bacilli must be pres-
ent in the blood before they can pass into the con-
r2io
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
tents of the vaccine ])ustn!e, and even llicn the proh-
abihties would stiH he against infeetion, unless pres-
ent in considerable numbers. The mode of infection
by inhalation is the one in which all the older authors
believed, who held consumption to be contagious.
Especially is this the case with sputum droplets.
The distance to which such droplets are projected '\>
usually stated to be about three feet, although Engel-
mann found it one and a half metres, while Bing
found bacilli at a distance as great as three metres,
and Muegge found that under artificial conditions
they could be projected even as far as ten metres.
The degree of danger attaching to droplet infection
has thus been variously estimated, but the writer is
not inclined to consider suspended droplets as the
most important source of infection. Such droplets
do not remain suspended indefinitely, and most of
them must gravitate immediately. It is when de-
posited in the form of dust or from dust containing
tubercle bacilli that the greatest danger exists, al-
though the danger is not to be minimized. The
third group is the most important one, the infection
of the digestive tract by ingestion of tubercle bacilli.
It is possible that food may serve as a medium for
infection with the bacillus of human type, but the
probability that enough bacilli are introduced by its
contamination with infectious dust or droplets in its
preparation by consumptives, or that flies are likeh
to play an important part by transferring tubercle
bacilli from sputum to food, would seem slight, and
especially so if alimentary infection of the human
subject conforms to the experience we have with the
lower animals, in which enormous ([uanlities of tu-
bercle bacilli must be fed to produce a positive re-
sult. That the human subject is not an exception
in this respect is indicated by the infrequency of
primary infections of the intestine, and, moreover,
l)y the clinical fact that the autoinfection of the di-
gestive tract is, as a rule, an occurrence deferred lo
the advanced stages of pulmonary phthisis. i )f
greater importance for primary infection of the di-
gestive tract appears the inhalation of infectious
(lust and its deposit in the pharynx or the mouth,
whence it is swallowed with mucus and saliva, and
with food and drink. It undoubtedly occurs,
it is more frequent in children than in adults,
and the origin of tuberculosis in the abdominal
cavity appears to be less frequent than it is
in that of the chest. The author also mentions the
contention of Behring that ])racticall\ all tubercu-
lous infections in man are due to fi^diuL; the milk
of tul)erculous cows to nurslings as ;i --ubslitute for
mother's milk. Behring has even gone so far as to
anounce that not a single case of epidemiological hu-
man infection has been proved.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION .
June 15, igo8.
1. State's Rights and tlic National Health. Oration on
State Medicine at the I'"ifty-ninth Annual Session of
the American Medical Association, at Chicago, June
2-5, 1908, By Ch.\RI,ES H.XRRINGTON.
2. Indolaccturia. By C. A. Hkrter.
Streptococcic Infections of the Pharyngeal .Adenoid
'l isstie in Adults. By .Xi.ke G. Bryant.
4. Laryngeal Manifestations in Locomotor Ataxia and
Multiple Sclerosis, By Woi.fk Frf.udenth.\l,
5 The I'hloridzin Test, with Special Reference to the In
fluence Exerted by a Diseased Kidney on the E.xcre-
tory Work of the Second Organ. By Edwin Beek.
6. An Epidemic of Cerebrospinal Meningitis. Successful
LTse of Elexner's Antiserum,
By Austin Miller and'S. A. Barber.
7. .Arthritis Deformans of the Hip. Preliminary Report
of a New Operation, By Fred H. Albee.
8. The Eye as a Contributing Factor in Tuberculosis,
By F. Park Lewis.
9. Ocular Reaction to Tuberculin, By Frederick Tice.
2. Indolaceturia. — Herter points out that it
appears probable that the excessive feeding of
proteins may be concerned with the development of
indolaceturia. lUu indolaceturia appears also in
persons who are taking no excess of protein food.
Moreover, in pathological cases of indolaceturia, in
which the protein food has been restricted, the in-
dolaceturia may be still persistent. It is thus clear
that, while the intake of a large amount of protein
is a factor highly favorable to the development of
indolaceturia. the occurrence of this condition must
be regarded as depending rather on delayed absorp-
tion of tryptophan and suitable bacterial conditions
than on mere over feeding with proteins. Assuming
that both inclolacetic acid and the indol formed in
the intestinal tract are derived from tryptophan
through the action of bacteria, the fact remains still
to be accounted for that sometinus the decomposi-
tion of tryptophan yields mainl\ indolacetic acid
and at other times mainlv indol. As is well known,
bacteria of the BacilUis coli group are capable of
clearing tryptfiplian to iiulcl and that these organ-
isms are able to form inclolacetic acid from trypto-
phan. It is doubtless true that in tlie intestinal tract
the bacteria associated with the colon bacilli play a
part in determining the direction of the main cleav-
age of tryptophan, and I think it possible that
through the careful studv of the symbiotic action of
bacteria on this substance it will be possible to gain
an insight into the different bacterial conditions that
determine the production of indolacetic acid rather
than indol.
4. Laryngeal Manifestations in Locomotor
Ataxia and Multiple Sclerosis. — I'reudenthal con-
cludes that the lar\nx is frecjuently the seat of seri-
ous afi'cctions in tabetics. Laryngeal crises are met
with so often that tliev are almost of pathognomonic
significance. L'nilateral and bilateral paralysis of
the postici muscles are the aflfections par excellence
in tabetics, but a unilateral paralysis of the recur-
rent nerve, often with the vocal cord in a hyper-
abducted ])osition, as mentioned by Harland, is
nothing uncommon. The abductor fibres of the re-
current laryngeal nerve are affected primarily in
tabes as well as in multiple sclerosis. The voice in
tabetics is often not changed, in spite of advanced
lesions. In order to reach a positive diagnosis all
these cases have to be observed during a consider-
able period. In multiple .sclerosis there is frequently
])resent a subjective dyspnoea that can not be ex-
l^laincd bv the objective signs.
7. Arthritis Deformans of the Hip. — .\lbee
describes his method of opera' ion. which he has
used in five ca.ses: The hi|) joint is reached
by an anterior incision five inches long,
throu.gh skin and sulKUtaneous tissues, start-
ing from just below and inside of anterior
suiK-rior spine of the ilium, and extending
June 20, 1908.]
PITH OF CURRENT LITERATURE.
I2H
downward along the inner border of the sartorius
muscle, which is retracted outward. The muscles
and the deep structures are separated by blunt dis-
section and the iliacus and the rectus femoris
muscles are retracted inward. A part of a large
ring of osteophytes about the rim of the acetabulum
is turned upward with the soft tissues adherent to
them. W ith the head of the femur ;';/ sitii about
one half of its upper hemisphere is removed with a
large chisel, through a plane nearly parallel to the
long axis of the neck of the femur, i'hcn with the
sam.e instrument the acetabulum is transformed into
a flat surfaced roof against which the fresh surface
of the head is tinally brought into firm contact by
abduction of the thigh. The bone is removed from
the acetabulum so that the flat surface is tilted
somewhat upward internally in order to produce, in
a way, locking of the fragments and also to prevent
any possibility of dislocation. Further abduction is
impossible on account of the shortened abductors
and an open tenotomy of these tendons and muscles,
at their origins, is found necessary before the leg
can be brought into proper position. The plain sur-
faces of the head and acetabulum are brought to-
gether by simply abducting the thigh. The capsule
and soft tissues are then sutured. Access to the
joint is much facilitated by a position of extreme
adduction of thejitnb. For purposes of orientation
an assistant is kept in constant readiness to rotate
the femur when desired. The leg in strong abduc-
tion is finally put in a spica from axilla to toes.
The patient upon whom this operation was per-
formed made an uneventful recovery and was walk-
ing about with crutches at the end of four weeks. A
short spica bandage was applied at the end of five
weeks. At the end of nine weeks he was able to
walk without cane or crutch and he went back to
work as patrolman in four months. He states that
he has not sutTered any pain since operation. The
leg has remained well in corrected f)osition and only
an extra lift of leather has been worn on the heel.
His occupation since the operation vouches for his
locomotive abilities. He has continued as a patrol-
man, working nine hours a day, and has not lost a
day on account of his hip since he went back to
work in September. 1907.
9. Ocular Reaction to Tuberculin. — Tice finds
that as a diagnostic method Calmette"s test is by
no means positive or even specific. In a varying
proportion of tuberculous cases of various forms a
positive reaction will occur, but not in all. In dis-
tinctive diagnosis it can be of but limited service as
it appears, apparentlv. in nontuberculous affections.
When the subcutaneous use of tuberculin in doubt-
ful cases of tuberculosis is not possible on account
of fever the ocular test may be employed. In his
incipient cases in which an early positive diagnosis
was most desired it was of no service. In a review
of the literature no reference is made to the thera-
peutic possibilities in this method of administering
tuberculin. The absorption by the conjunctiva is
rapid and considerable, as can be demonstrated in
the use of other drugs. Just what effect ocular ad-
ministration of tuberculin has on the powers of re-
sistance as indicated by the opsonic index has not
been determined. If the ocular reaction is ana-
logous to the local or general reaction produced by
subcutaneous injections of tuberculin, and it is
found feasible to administer it in this manner, it
may be found necessary to avoid the pronounced
and severe reactions. As the reaction occurs ap-
parently in patients in whom no tuberculosis can be
demonstrated it may, like the reaction from sub-
cutaneous use of tuberculin, belong to the ""group
reactions." From all we can now judge, the ocular
reaction to tuberculin must be considered simply as
confirmatory, and must always be considered sec-
ondary to the findings as determined b}- a careful
physical examination.
MEDICAL RECORD
June 13, igo8.
1. The Winning Fight Against Consumption,
By JoHX B. HuBER.
2. The Unfinished Business of General Hospitals,
By S. S. GOLDWATER.
3. Recurrent Vomiting, By Herbert Swift C.\RTER.
4. The New School Hygiene, By George \V. V.\ndegrift.
5. A Preliminary Note en the Disinfection of Body Cavi-
ties by Injection of Suspensions of Living Non-
pathogenic Bacteria, By Charles E. North.
4. The New School Hygiene. — \'andergrift
states that a subdepartment of hygiene in the de-
partment af health or education might be established,
not only in cities, but in every rural district, under
the sole authority of an associate superintendent,
who shall be a physician, and have full charge not
only of the discovery and correction of physical de-
fects, but of all school matters pertaining to the wel-
fare of school children, embodying questions of
properly constructed buildings, of playgrounds, of
books, curriculum, home study, and physical train-
ing. Under such a regime there will be no division
of authority, the single aim being the physical wel-
fare of the school children. Special appropriations
should be made by the board of estimate for its fur-
therance, and this appropriation should be used for
no other purpose. The department should not be.
as the board of health now is, forced to live from
hand to mouth, borrowing in advance to pay for
work done in the past. To earn the confidence of
the people, to do its work efficiently, this new depart-
ment should show clearly what the needs of these
defective children are, and should place squarely
upon the fiscal authorities the responsibility for suc-
cess or failure in this labor of "new school hygiene."
5. Preliminary Note on the Disinfection of
Body Cavities by Nonpathologenic Bacteria. —
Xorth deducts from the action of the lactic acid
bacteria and other nonpathologenic bacteria, from
the killing of the boll weevil by another insect, etc.,
that the judicious administration of properly se-
lected nonpathogenic bacteria as a means of oppos-
ing infections has a basis in reason. If the immun-
itv of any body cavity is largely dependent upon the
integritv of its garrison of nonpathogenic bacteria,
the question arises whether this integrity cannot be
maintained and the personnel of the garrison even
improved by trained reinforcements administered by
the bacteriologist. Metchnikoff and his followers
have already made a beginning. They recommend
the drinking of milk soured by selected lactic acid
bacteria for the purpose of inoculating the intestines
1212
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
with these bacteria. The spraying of any infected
parts with antiseptics is at best only a superficial
method of disinfection. In some of the body cav-
ities— the middle ear, the vagina, and the urethra,
and in sinuses and abscesses — it may be that the
natural antagonisms which exist between nonpatho-
genic bacteria and pathogenic forms can be of thera-
peutic use. The suspensions of lactic acid bacteria
may prove to be of service in these cavities, espe-
cially where putrefactive processes are causing the
irritation.
BRITISH MEDICAL JOURNAL.
May 30, 1908.
1. The Present Condition of Our Knowledge Regarding
the Functions of the Suprarenal Capsules (Oliver-
Sharpey Lectures, I), By E. A. Schafer.
2. Recent Progress in the Serum Therapy of Plague,
By K. B. N. H. Choksy.
3. Cats as Plague Preventers, By A. Buchanan.
4. Sporadic Kala Azar in Calcutta, with Notes of a Case
Treated with Atoxyl, By U. N Brahmachari.
5. On Measles, By E. Ward.
6. The Use of Serum in Scarlet Fever, By H. Cumpston.
7. Horsepox Directly Transmitted to Man,
By A. F. Cameron.
8. Primary Pneumococcic Peritonitis, By A. Smith.
1. The Suprarenal Capsules. — Schafer, in the
first of the Oliver-Sharpey lectures, begins by giv-
ing the history of the investigation of the supra-
renal capsules, and also a brief account of their
structure and development. The work of many ob-
servers, beginning with Ohver, has shown that the
suprarenal capsules, and to a less extent the pitui-
tary body, yield to glycerin and to water and saline
solutions, principles which have an extraordinary
effect upon the tone of the heart and arteries, tran-
scending that of any known drug. The active prin-
ciple is a substance of relatively simple constitution :
It may be boiled for a short time without deteriora-
tion, is dialysable and insoluble in absolute alcohol,
and is not destroyed by acids or gastric juice. For
this substance the author suggests the name "adre-
nin" in preference to the proprietary term "adrena-
lin." Nothing is known as to the substances from
which adrenin is formed in the organism, but it has
been suggested that one of these may be tyrosin,
which undergoes transformation into adrenin under
the influence of a ferment in the suprarenal.
2. Serum Therapy of Plague. — Choksy's pa-
per is based on the results obtained during the last
two and a half years by thirty observers in different
parts of India. The main conclusion deduced is that
in the Yersin-Roux antiplague serum we possess a
useful and efficacious remedy against the plague.
The absence of all antitoxic action is responsible for
its limited utility. It must, however, be pointed out
that a disease like plague, with a mortality of 89.9
per cent., is not likely to yield to serum therapeutics
as well as diphtheria has done. The whole secret
of the treatnicnt lies in applying the serum very
early. Among patients subjected to this treatment
within the first few or even twenty-four hours, it is
noticed that the whole course of the disease becomes
altered, the normal duration of eight or ten days is
reduced to four or five, seriouKcomplications of the
nervous, circulatory, and other systems are averted,
the buboes become absorbed, anfl. convalescence is
rapid. If the serum is given between twenty-four
and forty-eight hours after the onset of the disease
Its action is not so well marked and after the-expira-
tion of forty-eight hours it does not appear to influ-
ence the course of the disease perceptibly. Small as
these gains appear, they are not to be despised in a
disease so virulent as plague.
3- Cats and Plague.— Buchanan is firmly of
the belief that the best way to prevent plague is to
keep cats. Plague is spread by rats, and without
rats there will be no epidemic. Inoculation against
the disease in order to prevent its spread is efffcient
only for a few months ; it does not strike at the root
of the trouble, and, further, is not an absolute pre-
ventive. It causes sore arms, fever, and absence
from work, is greatly objected to by the people, and
is not favored by tradition or religion. It is very
expensive, a large establishment being required, as
it is necessary to inoculate every member of every
household. The extensive keeping of cats as pre-
ventive of the disease is, on the other hand, of per-
manent efficiency. The root of the trouble is de-
stroyed, and once the number of cats is sufficient and
all rats killed, then all risk of plague is abolished.
The cost is nil, as no establishment is required — one
cat protects a household. And finally there is a verv
strong tradition in favor of keeping cats, the onl}-
exception being the Parsees and Bhowani Dhers.
Shotgun quarantines and disinfection are useless,
and will continue to be so until proper steps arc
taken to destroy the rats.
4. Kala Azar. — Brahmachari defines kala azar
as the disease caused by the Leishmann-Donovan
bodies. Plindus are more frequently affected by the
disease than Mohammedans, the proportion being
about four to one. About one third of the cases are
under twenty years of age. Most of the cases are
chronic when first seen, with a history of illness for
several months, and a spleen extending below the
ribs. In many the liver is also moderately enlarged.
Our knowledge of the early symptoms of the dis-
ease is limited. In one class of cases there is a his-
tory of intermittent attacks of fever, lasting for
some months, and not benefited by quinine. In an-
other class there is a steady enlargement of the
spleen, with only a few attacks of fever. In a third
there is a history of attacks of low fever, with pro-
gressive enlargement of the spleen. In a fourth the
history suggests that of one or two attacks of ty-
phoid fever. In a fifth class there is a history of
gastrointestinal troubles, with dysenteric or diar-
rhoeic attacks, followed by oedema of the lower ex-
tremities, and aguelike attacks of fever. Other
symptoms are progressive emaciation, with anaemia,
cachexia, oedema, diarrhoea, dysentery, and haemor-
rhages from the skin and mucous membranes.
CEdema may appear very early or not until the last.
There may be fever of the pyaemic type, with two or
more remissions in the twenty-four hours. Among
the complications may be mentioned pneumonia, pul-
monary tuberculosis, cancrum oris, delirium or coma,
splenaigia due to infarcts in the spleen, haemorrhoids
which may bleed obstinately and profusely, and large
abscesses. The prognosis is always grave. Forty
per cent, of the author's hospital cases died, the
most frequent cause of death being intractable diar-
rhoea or dysentery. No drug can kill the parasites.
June 2'-. iQoS.]
I'lTH OF CURRENT LITERATURE.
1213
A prolonged and thorough trial was given to atoxyl
in one case, the drug being given for almost six
months. The patient improved in general health,
there were no symptoms of arsenic poisoning, and
no local action of the drug; but the parasites were
still to be found in the splenic blood in large num-
bers. A characteristic feature of the disease is the
reduction in number of the leucocytes — this leuco-
penia may be extreme, and in many cases the pro-
portion of white to red corpuscles is less than one to
one thousand. Such a count is almost diagnostic of
kala azar. In order that atoxyl may do any good in
these cases it must be given in very large doses (gr.
x\') every seven to ten days by injection, continued
for several months. Splenic puncture for diagnosis
is a safe procedure if one uses a hypodermatic needle
and does not draw more than one or two drops of
blood.
LANCET.
May 30, 1908.
1. The Present Condition of Our Knowledge Regarding
the Functions of the Suprarenal Capsules (Oliver-
Sharpey Lectures, I). By E. A. Schafer.
2. The Connective Tissue in Carcinoma and in Certain
Inflammatory States that Precede its Onset (Hun-
terian Lectures, III), By V. Bonney.
3. Analgesia vs. Anaesthesia in Obstetrics and Gynaecology,
By Sir W. J. Sinclair.
4. Hemiatrophia Facialis Progressiva, or Facial Hemi-
atrophy (Prosopodismorphoea : Aplasie Lamineuse
Progressive), By J. R. Williamson.
5. The Treatment of Pulmonary Tuberculosis by a Pos-
tural Method, Encouraging Drainage of the Lung
and Inducing Artificial Hyperaemia of the Apex,
By A. T. T. Wise.
6. A Case of Enteric Intussusception.
By F. DeH. Hall.
7. A Case of Pemphigus Vegetans, By C. W. Young.
8. Motoring Notes, By C. T. W. Hirsch.
2. Connective Tissue in Cancer. — Bonney in
the third of his Hunterian lectures summarizes the
results of his observations on the connective tissue
in cancer. The changes in the connective tissue in
cancer are identical with those met with in precar-
cinomatous states. And these precarcinomatous
states can be attained by many different routes,
starting in inflammatory conditions which histologic-
ally are at first quite distinct from each other and
which are initially due to entirely different forms of
irritant. In short, it is conceivable that the immedi-
ate agent of the precarcinomatous states may be
identical in them all, although the initial changes in
the tissues were due to totally different causes. The
carcinoma cell does not act as a specific irritant —
indeed, it is probable that it does not act as a tissue
exTcitant at all per se. Tumor cells often penetrate
beyond the area of tissue cell proliferation, and lie
between the tissue elements without exciting any
action in them whatsoever. The tissue cell prolifer-
ation accompanying a primary carcinoma cannot be
regarded as protective, for the following reasons :
(a) There is no evidence of any destruction of the
active carcinoma cell by the tissue cells comparable
to those seen in areas of bone necrosis or experi-
mental tissue implantations. (b) The infiltrative
character of the primary tumor is in marked con-
trast to the circumscription that obtains in perme-
ated lymphatics and to a lesser extent in metastatic
nodules, in both of which latter conditions no tissue
cell proliferation occurs, (c) The tissue cell prolif-
eration results in a rarefaction of the connective tis-
sue in front of the advancing carcinoma cells, in the
course of which mechanically resistant structures
such as fibrous tissue and elastic fibres become soft-
ened and destroyed. On the other hand, while there
is no evidence of active destruction of the carcinoma
cells by the proliferating tissue cells, neither are
there indications of any active destruction of the in-
flammatory tissue cells by the carcinoma cells. In the
older parts of the growth degenerating stroma may
be seen, but the epithelial cells are also coincidently
degenerative. Vigor of cancer cells accompanies
vigor of tissue cells, and vice versa. The author's
final conclusions are: i. The onset of the ordinary
forms of carcinoma is always preceded by a condi-
tion characterized by epithelial hypertrophy and cer-
tain constant changes in the subepithelial tissue.
2. This precarcinomatous state may be attained
through various inflammatory processes, at first
quite distinct from one another, but culminating in
the same histological picture. 3. The tissue cell pro-
liferation occurring round a primary carcinoma is
part of the precarcinomatous process, and materially
assists the progress of the growth. 4. There is no
histological evidence of a protective reaction on the
part of the tissues to the carcinoma cell. 5. Though
changes in the adjoining connective tissue bear some
very close relation to the cause of epithelial in-
growth, yet, malignanc}' having been established, the
further spread of the tumor is independent of such
assistance.
5. Postural Treatment of Pulmonary Tuber-
culosis.— Wise has devised a lying-out chair for
patients suffering from pulmonary tuberculosis
which they have used with great benefit. This chair
consists of two parts — a downward inclined plane,
on which the upper part of the body rests, and a
lower portion, which supports the knees and feet.
In this way a double inclined plane is thus formed,
and while the patient gets all the benefit of gravity —
drainage of the cavities, etc.. in the lung — yet ex-
cessive blood pressure in the cerebral vessels is obvi-
ated, as the lower extremities of the patient are not
raised above the level of the head. In all other pre-
vious attempts to invert a patient, congestion of the
head has proved a great obstacle to maintaining the
position for any length of time. The patient at first
uses the inclined plane for only half an hour, three
times a day. Later some hours may be spent in
this position, either waking or sleeping. In addi-
tion to using the force of gravitation for the drain-
age of corrupt accumulations in the lung, an impor-
tant modification of the pulmonary circulation is
brought about b)- the forward inclination of the
thorax. The apices of the lungs, now in a more de-
pendent situation, have at once a fuller blood sup-
ply, and some parts of the pulmonary tissue become
relieved from the weight of the heart, which falls
forward to be supported by the sternum. Of equal
or greater consequence is the increased diffusion of
blood which supervenes in the upper and more con-
fined parts of the lungs. This mechanical plethora
will be at its limit some time after the prone position
is assumed, when a partial readjustment of the cir-
culation will subsequently ensue, influenced by the
I2I4
PITH OF CURRENT LITERATURE.
[New York
Medical Journal.
nervous centres which control the puhnonary ves-
sels, and on the individual rising from the prone
position the blood supply to the lungs and other or-
gans will gradually resume its ordinary condition.
This go and come of blood surplusage or recurrent
hypercemia is, to the deteriorating apex, what takes
place in the normal being under conditions of rest,
alternating with healthy plethora caused by vigorous
muscular effort. The bactericidal power of the blood
circulating actively in a part has been demonstrated,
and artificial hyperaemia as a remedial measure has
been attempted in various ways. Cases of pulmo-
nary tuberculosis which should not undergo this
mode of treatment are those with a tendency to
haemorrhage, those with disease of a pronounced
pneumonic type, or with fluid in the pleural cavity.
LA PRESSE MEDICALE.
May 13, 1908.
1. The Functions of the Liver and of the Spleen in Their
Relations to Hremolytic Icterus, By L. Hallion.
2. Accidents Following the Injection of Quinine,
By R. DE Gaulejac.
1. The Functions of the Liver and of the
Spleen in Their Relations to Haemolytic Icterus.
— Hallion asserts that the spleen intervenes more or
less in the three varieties of haemolytic jaundice. In
the first variety the haemolysis is caused by a fault
of haematopoiesis. The spleen is perhaps one of the
organs of haematopoiesis and can intervene as such.
But it is rather as a destroyer than as a generator
of the red blood corpuscles that it appears capable of
acting as a cause ; an excessive number of destructi-
ble red blood corpuscle's influence the increase of its
work. In another variety of hemolytic jaundice it
is the plasma that destroys the elsewhere normal
globules. The spleen receives an excess of haemo-
globin set at liberty, which is stored up and remains
in the tissue. There remains the possibility of a
third variety in which the spleen is primarily over-
w(jrked.
2. Accidents Following the Injection of Qui-
nine.— Gaulejac says that the sloughs that follow
a very superficial subcutaneous injection can always
be avoided if the general condition of the patient is
not bad. An abscess almost always follows an in-
tramuscular injection in a patient formerly infected
or intoxicated. It follows then that ever}- intramus-
cular injection of quinine should be given b}' prefer-
ence with slowness, in small doses, at a point un-
affected by previous treatment, in the gluteal or
abdominal regions, and the patient remain quiet
and limit as far as possible the number and force
of the contractions of the muscles affected during
the day following the intervention.
May 16, jgo8.
1. The Surgical Treatment of Cancer of the Neck of the
Uterus. By Faure.
2. Cardiac Asthenia and its Treatment with Injections of
Serum in the Right Dorsal Region,
By Albert Deschamps.
3. Diabetes Mellitus in Infants, By R. Rom me.
2. Cardiac Asthenia and Its Treatment with
Injections of Serum. — Deschamps says that the
proper use of injections of scrum in minimum dose
gives adequate results in the treatment of cardiac
asthenia. The injections should be given in the
right dorsal region. This treatment does not ex-
clude the means ordinarily employed of cardiac
hygiene or cardiac tonic, but it contributes to the
direct stimulation of the pneumogastric and cervical
sympathetic nerves and their centres, to sustain the
nutrition of the myocardium, and thus to prolong
the resistance of the heart, the aim of all thera-
peutics.
BERLINER KLINISCHE WOCHENSCHRIFT.
May II, 1908.
1. Acute Yellow Atrophy of the Liver in Syphilis,
By W. Fischer.
2. Contributions to the Normal Histology of the Cortex
of the Suprarenal Capsule, By Oskar Storck.
3. Some Remarks on Touch Percussion,
By WiLHELM Ebstein.
4. An Atypical Case of Disturbance of Conduction of
Stimulation in the Cardiac Muscle,
By G. Joachim.
5. Contribution to the Pathology of Metabolism in Gout,
By W. Laqueur.
6. Connection between Diseases of the Nose and of the
Nasopharyngeal Space with those of the Eye,
By A. Onodi.
7. Concerning the Haemolysis of the Streptococci,
By T. Heynemann.
8. Critical Review of the Action of the Lactobacillus and
the Yoghurt Milk, By J. Leva.
9. Sarcoma of the Prostate {Concluded),
By Wolfgang Veil.
10. Difficulties in the Diagnosis of Cerebral Tumors,
By Edmund Forster.
2. Histology of the Cortex of the Suprarenal
Capsule. — Storck says that the overwhelming
majority of the so called adenomata of the cortex
of the suprarenal capsule have in fact no right to
such a designation. The formations of this kind
situated at a greater or less distance outside the
suprarenal capsule originate in fcetal processes of
detachment of the cortex, which later in life might
be looked upon as hypertrophic new formations of
tissue. Similarly there arise foetal and postfoetal
formations within the suprarenal capsule, on the
inner surface of the cortex and extending beyond
its limits. Only circumscribed formations of thi?
kind which present the criterion of continual growth
are entitled to the designation adenoma. A distinc-
tive histological diagnosis of the adenoma from the
appearance of the ceils, perhaps from peculiarities
in the size, form, and constitution of the cells and
cell bands in contrast to the picture of the physio-
logical paradigm seems to the author scarcely pos-
sible.
7. Haemolysis of Streptococci. — Heynemann
alleges that the highh virulent streptococci, such as
those productive of i)uer])eral fever, produce on a
contain blood agar plate, 5 c.c. agar and 2 c.c. blood,
a characteristic clear haemolytic areola about each
colony, and that by this peculiarity virulent strep-
tococci mav be distinguished from those which are
little if at all pathogenic.
9. Sarcoma of the Prostate. — Veil reports and
discusses a case of primary sarcoma of the pros-
tate with metastases in the liver. The sarcoma was
spindlecelled and contained al.so a highly distinctive
form of cell, very large, rich in protoplasm, some-
times multinuclear, in the form of long fibres which
resembled contractile elements. These cells were
not found in the metastases.
June 20, 1908.] PITH OF CURRENT LITERATURE. 121 5
MUENCHENER MEDIZINISCHE WOCHENSCHRIFT.
May 12, 1908.
1. Concerning Focal Symptoms in Diffuse Diseases of the
Brain, By Sanger.
2. Advances in the Diagnosis of Tumors of the Brain.
By Knapp.
3. Concerning the Use of Gum Arabic as an Addition to
the Anaesthetic in Lumbar Anaesthesia,
By Erhardt.
4. Concerning the Demonstration of Typhobacilli in the
Cerebrospinal Fluid in Typhoid Fever, By Xietek.
5. Concerning the Signification of Soapy Stools in Infancy.
By Hecht.
6. Concerning the Operative Treatment of Hernia in Chil-
dren, By Grossmaxn.
7. Concerning the Signification of the Reflex of the Tendo
Achillis, By Coxzen.
8. Remarks Concerning the Pathogenic Microorganisms
"Chlamydozoa," By Prowazek.
9. Experiences with and Studies of Lumiere"s Three Color
Photography, By Sievers.
10. Treatment of Fractures of the Forearm. By Kafer.
11. Treatment of the Decubitus, By Teller.
12. A Congenital Hairy Pharyngeal Polyp,
By Levinger.
13. Concerning Gastroscopy. By Loxing and Stieda.
14. Cataplasma Redivivum. By Paull.
15. Obituary of Geh. Medizinalrat Dr. Baer. By Hoppe.
I. Focal Symptoms in Diffuse Diseases of the
Brain. — Sanger .states that in multiple sclerosis
and progressive paralysis focal symptoms play a
great part, as they do also in the obscure cases which
have been termed by Xonne pseudotumors of the
cerebrum. He reports several cases, among them
that of a man, sixt\ -t\vo years of age, who was sud-
denly attacked Avitli a right sided hemiparesis and
disturbance of speech associated with a bilateral
choked disc. Xothing wrong could be found with
the brain, either macroscopically or microscopically.
3. Addition of Gum Arabic in Lumbar Anaes-
thesia.— Erhardt recommends the addition of
three per cent, gum Arabic to a one per cent, solu-
tion of tropacocaine for use in lumbar anaesthesia.
He does not consider the combination with other
narcotics to be advisable.
4. Typhobacilli in the Cerebrospinal Fluid
in Typhoid Fever. — Xieter alleges that in certai^i
doubtful cases the diagnosis of typhoid fever mav be
determined bv an examination of the cerebrospinal
fluid.
5. Soapy Stools in Children. — Hecht says that
the fat dyspeptic stools of the artificiallv and breast
fed children contain abundant mucus, while on the
contrary the soapy stools contain no mucus, as
the mucus prevents the soapy appearance. His
conclusions concerning the semeiology of the soapy
stools are: i, A moderate degree of disturbance of
the resorption of fat must be present ; 2, there can
be no hindrance to the subdivision of the fat ; 3,
much acidity must be absent ; 4, peristalsis cannot
be greatly accelerated ; and, 5, much catarrhal irri-
tation cannot be present.
7. Reflex of the Tendo Achillis. — Conzen
states that he has examined 3,290 cases, and found
the reflex of the tendo Achillis lost or reduced only
when something pathological could be demonstrated
in the nervous or muscular system. Examination of
this reflex should never be omitted, because it is as
constant a symptom as the patellar reflex, it re-
acts at least just as sensitively as the patellar reflex
to diseases of the nervous system, and frequent-
ly a difference in the tendon reflex may indicate
pathological processes in the nervous system.
12. Congenital Hairy Pharyngeal Polyp. —
Levinger removed from the pharynx of a child six
and a half months old a polyp measuring six by one
and a half centimetres, covered with skin and nu-
merous fine hairs.
ANNALS OF SURGERY
May, jgo8.
1. Subtemporal Decompressive Operations for the Intra-
cranial Complications Associated with Bursting
Fractures of the Skull. By A. Gushing.
2. Osteoplastic Resection of the Skull, with Description
of a Modification of Stelhvagen's Instrument for
Performing this Operation. By H. C. Wood.
3. Atlodecipital Dislocation. A Case of Fracture of the
Atlas and Axis, and Forward Dislocation of the
Occiput on the Spinal Column, Life being Main-
tained for Thirty-four Hours and Forty Minutes by
Artificial Respiration, during which a Laminectomy
\\as Performed upon the Third Cervical Vertebra,
By N. J. Blackwood.
4. Fracture through the Anatomical Is'eck of the
Humerus with Dislocation of the Head,
By J. J. Buchanan.
5. The Treatment of Dislocation of the Shoulder Joint
Complicated by Fracture of the Upper Extremity of
the Humerus, with an Analysis of Sixty-three Cases
with Fracture at the Neck of the Humerus and
Twenty-one Cases with Fracture of the Greater
Tuberosity Reported since 1894. By J. M. Mason.
6. A Treatment of Epiphysaal Displacements and Frac-
tures of the upper Extremity of the Humerus De-
signed to Assure Definite Adjustment and Fixation,
of the Fragments, By R. Whitman.
7. Traumatic Subluxation of the Humerus.
By F. P. Vale.
8. Occluding Pulmonary Embolism, By W. Bartlett.
9. Primary Carcinoma of the Hepatic Ducts. The Re-
port of a Case with the Autopsy,
By C. L. Scudder.
10. The Operative Treatment of Intractable Vomiting, not
due to Pyloric Obstruction. Neurosis of the
Stomach, By W. Meyer.
11. The Value of Enterostomy and Conservative Operative
Methods in the Surgical Treatment of Acute Intes-
tinal Obstruction, with Remarks on the Importance
of Operations in Two Stages, By C. A. Elsberg.
12. The Nonabsorbable Suture and Ligature.
By O. H. Allis.
13. Report of Saturday Surgical Clinics for Students held
at the German Hospital, Philadelphia, 1906 and 1907,
By J. B. Dea\t:k.
I. Subtemporal Decompressive Operations for
the Intracranial Complications Associated with
Bursting Fractures of the Skull. — Gushing finds
the following advantages from this procedure: i.
The approach is made through the thinnest available
part of the skull. 2. The opening is made under
the temporal muscle. When the split fibres of the
muscle are closed there is little tendency to bulging
of the brain, or to subsequent obtrusive depression.
A subsequent defect in this situation is harmless.
3. With rupture of the meningeal or its branches
the extradural clot is brought into view and the
vessel can be easily ligated. 4. In bursting frac-
tures, with laceration of the brain, the tips of the
temporal and base of the frontal lobes suffer most
frequently, and subdural extravasation from this
source can be most easily handled through an open-
ing in this situation. 5. Since the lines of fracture
in these accidents usually seek the midcranial fossa,
bleeding from the base can be easily drained from
under the temporal lobes through the temporal
I2l6
I'lTH 01- CURRENT LITERATURE.
[New York
Medical Journal.
fossa. 6. Subsequent oedema of the brain can be best
met with by an opening in this situation, under the
muscle. 7. In addition to promoting subsidence of
acute symptoms, these operations also lessen many
of the unpleasant signals, such as traumatic neu-
roses.
2. Osteoplastic Resection of the -Skull. — Wood
notes the great advantage of this method of enter-
ing the skull. The instrument devised by Stell-
wagen marked a great advance in this department
of surgery. Its objections were the fatigue which
its use entailed to the forearm muscles, the inse-
curity of the plate upon which the shaft of the in-
strument revolved, and the free haemorrhage from
the scalp while the bone was being sawn. These
objections have been effectively remedied in the
author's instrument, \\hich he has used with satis-
faction in a number of instances. He asserts for it
the following advantages: i. It enables one to cut
an osteoplastic flap quickly and safely. 2. No in-
jury can be done, even if the instrument is used
carelessly or clumsily. 3. Every part can be steril-
ized by boiling. 4. It is always ready for use, and
there are no complicated parts to get out of order.
5. It is complete in itself and does not depend upon
electric currents, motors, assistants, or anything, but
the operator's hands.
5. The Treatment of Dislocation of the Shoul-
der Joint Complicated by Fracture of the Upper
Extremity of the Humerus. — Mason offers the
folowing conclusions: i. Every dislocation of the
shoulder, associated with fracture of the upper ex-
tremity of the humerus, is a grave injury, and is
likely to result in serious impairment of function,
if not promptly treated. 2. Every such injury
should be subjected to x ray examination. 3. All
manipulative efforts at reduction should be gentle,
and should never bruise or lacerate the tissues.
4. Excision should be practised only after failure
to reduce with open arthrotomy, or when there is
extensive comminution of the upper extremity of
the humerus, or when, in fracture of the anatomi-
cal neck, it is improbable that the upper fragment
will unite with the lower. 5. After reduction, the
broken tuberosity should be nailed into position, or
should be removed, if necessary. 6. Manipulation
failing to produce reduction, immediate arthrotomy,
and reduction, with suitable treatment of the frac-
ture, are indicated. 7. Rigid asepsis is essential, and
the operations should not be undertaken if asepsis
is impossible.
AMERICAN JOURNAL OF OBSTETRICS.
May, JU08.
1. The Crime of Gyiijccology, By C. W. Barrett.
2. Preservation of the Ovaries Entire or in Part in Supra-
vaginal or Panhysterectomy, By R. Peterson.
3. Rupture of the Uterus through the Cesarean Cicatrix,
By G. L. Brodhead.
4. Report of Two Cases. (A) Myxosarcoma of the Round
Ligament. (B) Fibroma of the Anterior Ahdoniinal
Wall, By W. Kru.sen.
5. The Necessity for the .Artificial Feeding of Infants,
By L. Johnson.
6. Menorrhagia and Metrorrhagia (Uterine Hjemorrhage),
By T. KuBO.
I. The Crime of Gynaecology. — Barrett's con-
clusions arc the following ones: i. Charity patients
in hospitals do not generally have the privilege of
chwsing their physicians. 2. They should there-
fore be attended by men trained in the care of their
particular diseases. 3. One fourth or more of the
charity surgical beds arc occupied by gynaecological
patients. 4. Many gynaecological diseases are not sur-
gical. 5. Gynaecologists are prepared and trained to
treat pelvic disease. 6. General surgery has other
problems for its proper field. 7. Gynaecology should
be recognized in order that the pelvic diseases of
women be efficiently treated. 8. Gynaecology is a
special department of knowledge. 9. Its clinical
teaching should be in the hands of those who are
informed on such matters. 10. The Cook County
hospital should have a large gynaecological clinic.
II. Many gynaecological cases require both vaginal
and abdominal work. The gynaecologist should have
the choice of either. 12. If this is not conceded,
inefficiency will be the result. 13. The crime of
gynaecology is that it stands in the way of the sur-
geon's economic interest. 14. The crime of general
surgery is that it encroaches upon other specialties.
15. This results in less efficient work. 16. The
question should be, what is best for the patient?
17. Reforms are necessary in the direction referred
to to obtain the best results.
2. Preservation of the Ovaries Entire or in
Part in Supravaginal or Panhysterectomy. — Pe-
terson's conclusions are as follows: i. Ten per cent,
of those who are still menstruating at the time the
uterus and ovaries are removed will not be troubled
by the artificial menopause. 2. This percentage
will be more than doubled if a jx)rtion of ovarian
tissue is retained. 3. Symptoms due to the artificial
menopause are not severe when the ovaries are not
removed with the uterus. 4. A young woman from
whom uterus and ovaries are removed does not
necessarily have a troublesome menopause. Those
who are operated upon between the ages of forty
and forty-four suffer the most. 5. It should not be
the rule to remove the ovaries with the uterus in
those who have i^assed forty. 6. The severity of
the artificial menopause is by the variety of hysterec-
tomy, whether the ovaries are removed or not. 7.
The severity of the artificial menopause is uninflu
enced whether the uterus and ovaries are removed
for fibroid or inflammatory disease. 8. If a portion
of the ovaries is retained after hysterectomy, the
period of bad symptoms from the menopause will be
shortened. 9. The larger the portion of the ovaries
retained, the less severe will the menopause symp-
toms be.
3. Rupture of the Uterus Through the Caesa-
rean Cicatrix. — Brodhead draws the following
conclusions, i. Rupture of the uterus through the
C;csarean cicatrix is of rare occurrence. 2. With
prompt operative methods the mortality is compara-
tively low. 3. When pregnancy follows Caesarean
section the patient can usually be again delivered
with safety by the same method. 4. In repeating a
section labor should be anticipated by a week or ten
days. 5. If section is to be repeated and labor sets
in prior to the time elected for operation, the Cae-
•sarcan should be performed as soon as possible after
the onset of labor pains. 6. Sterilization may be
done at the time of section if the patient so desires.
7. Suture of the laceration has proved successful,
but in some instances hysterectomy will be the
method of choice.
PITH OF CURRENT LITERATURE.
1217
THE PRACTITIONER.
May, 1908.
1. On Some Points in Connection with Vaccine Therapy
and Therapeutic Immunization Generally,
By Sir A. E. Wright.
2. Some Observations on the Opsonic Index, with Special
Reference to the Accuracy of the Method and to
Some of the Sources of Error, By A. Fleming.
^ Observations on the Opsonic Index in Infants,
By J. H. Wells.
4. Note on the Experimental Error in the Method of De-
termining the Tuberculoopsonic Index of the Blood,
By A. H. White.
5. Statistical Considerations Relative to the Opsonic
Index, By M. Greenwood.
6. Treatment by Bacterial Vaccines, By A. B. Harris.
7. The Value of the Opsonic Index in the Treatment of
Pulmonary Tuberculosis, By A. C. Inman.
8. The Treatment of Pulmonary Affections by the Inocu-
lation of Vaccines Controlled by the Opsonic Index,
By J. C. Briscoe and E. U. Williams.
Q. A Surgical View of the Opsonic Method,
By H. S. Collier.
10. On the Treatment of Skin Diseases by Inoculation
after the Opsonic Method, By A. Whitfield.
11. The Treatment of Lupus and Tuberculous Disease of
the Ear, Nose, and Throat by Inoculation,
By H. F. ToD and G. T. Western.
12. Ulcerative Endocarditis and Its Treatment by Vaccine
Therapy, By T. J. Horder.
13. The Tuberculin (T. R.) Treatment of Tuberculosis of
the Genitourinary Organs, By J. W. T. Walker.
14. The Opsonic Method and Vaccine Therapy in Relation
to Diseases of the Eye, By R. W. Allen.
2. Some Observations on the Opsonic Index.
— Fleming summarizes his paper as follows, i. The
variation in the tuberculoopsonic index of healtliy
individuals is very small, normal serum furnishing
a good standard for the comparison of infected per-
sons from day to day. 2. With a diminution of the
number of washed corpuscles in the opsonic mixture
there is an increase in the amount of phagocytosis.
3. Agglutination of the washed red corpuscles in-
creases the amount of phagocytosis. 4. The tuber-
culoopsonic index is the same whether washed cor-
puscles are used from a healthy or tuberculous indi-
vidual. 5. If red corpuscles are taken up with
seram, the amount of phagocytosis is reduced.
6. Serum sealed in a capsule at room temperature
retains its full power in healthy blood for a week,
and in pathological blood for a day or two less. 7.
Blood capsules left open for several hours give un-
trustworthy readings. 8. Two practised observers
counting the same slides can obtain results varying
not more than ten per cent. 9. Duplicate estima-
tions of the tuberculoopsonic index of tuberculous
patients can be performed, the results rarely differ-
ing from each other by less than twenty per cent.
3. Opsonic Index in Infants. — Wells draws
the following conclusions: i. A low opsonic index
is not diagnostic in children under one year of age.
2. In infants a low opsonic index is not inponsistent
with health, and a child may be thriving well with a
declining index. 3. Wliere the opsonic index is low
it will rise in response to the stimulus of an inocula-
tion with bacterial vaccine. 4. Inspection of the
results tabulated by the author seems to show that
the healthy breast fed infant possesses no advan-
tages over the healthy artificially fed child. 5. The
antibacterial defense in children cannot depend upon
the opsonic content of the serum.
4. The Experimental Error in the Method of
Determining the Tuberculoopsonic Index of the
Blood. — White refers to recent attempts to im-
pugn the accuracy of the method of determining the
opsonic index of the blood. Of course, no method
is free from error, and the error must vary with the
worker. This is especially true in a complicated
process like this, in which every step is a possible
pitfall. If one has imperfectly mastered the details
of the procedure the error in determining the op-
sonic index may be very great. When these details
are mastered the experimental error will be insig-
nificant. The author gives a table in which the
variations between the counts of the different nor-
mals employed on the same day and incubated with
different batches are only from four to eight per
cent. With increased experience the author beheves
that this error can be still further lowered.
5. Statistical Considerations Relative to the
Opsonic Index. — Greenwood thinks that in the
present state of the question we can say: i. There
is no valid evidence that the limits of error do not
exceed twenty per cent, of the mean value. 2. The
skewness of the distributions thus far examined is
so great that, in the case of low emulsions, errors
in excess are more frequent than errors in defect of
the mean. 3. There is reason to hope that with high
emulsions the variation may become more sym-
metrical. The practical suggestions are that (a)
high indices should be more carefully scrutinized
than low values; (b) that it is better to work with
rather thick emulsion, giving an average for the
normal serum of not less than three bacilh per cell.
7. The Value of the Opsonic Index in the
Treatment of Pulmonary Tuberculosis. — Inman
finds that: i. Early or febrile cases of pulmonary
tuberculosis may be treated with advantage by
means of pure air and graduated exercise. If such
treatment is used it must be remembered that tuber-
culin by autoinoculation is being employed. 2. The
opsonic index is a valuable guide to such treatment
and also gives useful information if inoculations of
Koch's tuberculin are employed. 3. Rest is essential
in febrile cases of consumption, and in these cases
injections of tuberculin, using as a guide the opsonic
index, is the proper treatment. The latest methods
of treating consumption are those which . cooperate
with the natural methods employed by the body
itself for its own protection and defense. Both in
febrile and afebrile cases a watch is kept over the
blood by the opsonic index.
9. A Surgical View of the Opsonic Method. —
Collier states that he was formerly opposed to this
method for diagnostic and prognostic purposes, but
that he was converted by several cases in which the
opsonic method was successful as compared with
methods previously in use. It must be remembered
tliat with opsonins, if such substances really exist,
there is no such accuracy of treatment as is obtained
by chemistry. In eleven specimens of blood from
a patient with tuberculous cystitis which were sent
to ten laboratories, the results varied between 84
and 1.7. A vaccine can be depended upon in suit-
able cases to raise the opsonic index to the given
organism. A rise from a low to a normal opsonic
index has signified improvement in all the author's
I2l8
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
■cases. If an operation is contemplated, a period of
low opsonic index will usually ofifer the best results.
The author recommends that surgeons be clinically
:associated with opsonists.
ARCHIVES OF P/EDIATRICS
May, 1908.
.1. A Case of Anorexia Nervosa in an Infant,
By J. P. C. Griffith.
2. Kidney Lesions in the Infant. Pathological Aspects,
By R. L. Thompson.
3. Kidney Lesions in the Infant. Chnical Aspects,
By J. M. Brady.
4. The Calculation of Milk Percentages with Rules and
Examples, By H. E. Hale.
5. Empyema and Gangrene of the Lung Complicating
Typhoid Fever, By D. J. M. Miller.
6. The Indication for Stimulants in Pasdiatric Practice,
By Sara Welt Kakels.
7. Hydrotherapy in Childhood, By F. Grosse.
.8. The Use of Analgesics in Paediatric Practice,
By Le Grand Kerr.
2, 3. Kidney Lesions in tJie Infant. — Patho-
.logical Aspects. Thompson states that literature on
the infant kidney is scanty. Pathologically kidney
lesions may be acute or chronic ; they may also be
degenerative, exudative, or proliferative. The au-
thor analyzes the kidney conditions in fifty autopsies
upon infants as follows : In one case there was con-
genital narrowing of the ureter at its vesical inser-
tion. In one case there was abnormal hyperplasia
of the pyramidal portion of a foetal lobule in one
kidney. Uric acid infarcts were frequent in those
who had died within three weeks from birth. Three
•calculi were found in the pelvis of one kidney, com-
posed of acid urate of ammonium. Small cysts con-
nected with the tubules and glomeruli were found
in five cases. Congestion was frequently observed
in the capillaries between the convoluted tubules, the
glomeruli and their interspaces being filled with
blood. Thrombi of fibrin were found in the junc-
tional veins. Severe exudative and proliferative
lesions were not found, but degenerative changes
resulting in albumin and casts were frequent.
Microscopically there were frequent examples of
cloudy swelling of the tubular epithelium. In
many of the glomerular tufts there was an in-
crease in cells, but not so as to constitute
glomerular nephritis. The conclusion is that
marked disturbances of circulation and slight or
moderate degenerative processes are very common
in the infant kidney. Clinical Aspects. Brady quotes
Baginsky as to the importance of kidney lesions in
infants in diarrhoea. The convulsions which so often
■end such cases are frequently uraemic. Morse thinks
true nephritis a rare complication of dysentery, but
that degenerative changes of the epithelium due to
bacteria and their toxines are not infrequent. Vac-
cinia, pneumonia, and malaria are mentioned as
forerunners of nephritis. Nephritis is often compli-
cated with congenital syphilis, again it may be ex-
cited by potassium chlorate,. salicylic acid, and car-
bolic acid, and the irritating action of metabolic
products may cause it in connection with marasmus
and rickets. With albuminuria, which is almost con-
stantly present in infants, are often found hyaline
and epithelial casts. Haematuria may be present as
the result of scorbutus, purpura, uric acid infarcts
and calculi, pyelitis, tumors of the kidney, and acute
nephritis. Holt states that acute nephritis in infants
is not so rare as might be supposed. Neither casts
and albumin nor oedema and anasarca are necessari-
ly evidences of nephritis in infants. The disease
usually tends to complete recovery.
THE ASSOCIATION OF AMERICAN PHYSICIANS.
Tiventy-third Annual Meeting, Held in Washington, May
12 and 13, 1908.
The President, Dr. James Tyson, of Philadelphia, in the
Chair.
( Concluded from page 1126.)
Cases of Relapsing Fever, with Demonstra-
tions of the Spirochaetas in the Blood of Patients
and of Inoculated Rats.— Dr. John W. Huxter
and Dr. Thomas A. Cope, of Philadelphia, reported
two cases of relapsing fever. Both patients were
natives of Turkey; the first patient had arrived in
Philadelphia from France and had slept with the sec-
ond patient ; on three of the nights he had had fever.
Ten days after the patient was exposed to infection
from the first patient he was admitted to the hospi-
tal. In one of the patients the leucocyte count was
normal ; in the other there was a leucocytosis of
15,000. The authors believed that the spirochaetae
belonged to the bacteria. They had not succeeded
in demonstrating cilia on them, or in cultivating them
except for a short time in rats, where a few organ-
isms were seen ; they had been unable to inaugurate
bedbug experiments. The organisms disappeared
from the peripheral blood in both cases when the
crisis occurred.
The Action of Purgatin on the Kidneys. — Dr.
Franz Pfaff, of Boston, said that purgatin had
been alleged to be the best of all the organic purga-
tive compounds synthetically prepared. It was said
that it did not produce griping, and, although ex-
creted by the urine, that it did not cause renal irrita-
tion. Pfaf¥ had studied the action of purgatin on
dogs, cats, rabbits, and guinea pigs. Dogs and cats
were not affected by it ; rabbits and guinea pigs, on
the other hand, were affected by the drug. The in-
testines and the other internal organs were discol-
ored at autopsy, after the animals had lost weight
and died of exhaustion. In nine out of ten rabbits
there was marked acute nephritis. In dogs there
was no acute nephritis. The experiments showed
that purgatin did cause acute Bright's disease and
death in certain animals. It might cause irritation
of the kidneys in certain hinnan beings and ought
not to be used in therapeutics.
Therapeutics.
The Therapeutics of Self Repair.— Dr. S. J.
Meltzer, of New York, said that millions of men
have meddled with the phenomena of life for hun-
dreds of years without the proper knowledge of the
organism or its physiology ; but no serious results
had followed, because of the power of the organism
to recover from its own disorders. The power of
automatic repair was not even now thoroughly appre-
ciated. Therapeutics was the most important part of
June 20, 1908.]
PROCEEDIXGS OF SOCIETIES.
1219
medicine, and contempt for treatment was an anom-
aly. It was the duty of the physician to discover
artificial remedies ; not to depend entirely upon the
fact that self repair was possible. Therapeutics might
be divided into, first, rational therapeutics, which
was inactive ; and, second, empirical therapeutics,
which was active but unreliable. The attempt to
produce immunity was the most rational of the
therapeutic procedures. The signs of inflammation
were considered as attempts at self repair, and all
these signs were employed in therapeutics as aids in
the correction of inflammatory conditions — for ex-
ample, Bier's method of artificial hypersemia, the
artificial production of leucocytosis. the artificial pro-
duction of fever, and the artificial injection of sterile
pus. The methods followed by Nature for the re-
pair of injuries to the organism should not be fol-
lowed strictl}- by the therapeutist, however, but they
should be improved upon if possible. We should not
make the patient uncomfortable for mere theories,
but we should attempt to make life bearable as well
as to save life. The phenomena of disease should be
treated even if they belonged to the phenomena of
self repair, provided they made the patient misera-
ble. The fact of continuous recoveries was an argu-
ment in favor of rational therapeutics, both physio-
logical and pathological.
Dietetic and Hygienic Therapeutics. — Dr. Da-
vid L. Edsall. of Philadelphia, said that there was
a growing tendency to condemn drug treatment and
to laud hygiene and diet as therapeutic measures.
The majority of young men, however, got better
results from drugs than from diet and hygiene, be-
cause they used drugs more rationally. This was
due to the point of view of the student, who was in-
structed systematically in drug therapeutics, but not
in the rationale of hygiene and diet. The student
overlooked the importance of the commonplace, par-
ticularly the things that occurred in relation to occu-
pation. He was unable to correlate his scientific and
practical knowledge. In dietetics the great fault was
that of treating the name of the disease rather than
the disturbance of function, and foods were often
used without a knowledge of their nutritive value.
Organotherapeutics. — Dr. Reid Hunt, of
Washington, said that organotherapy was the utili-
zation of the internal secretions. The present tend-
ency was to study the rrjle of the hormones in the
body, to attempt to obtain them in a suitable form
for therapeutic purposes, and to try to influence them
as they occurred in the body. The secretion of the
suprarenal body was the typical e.xample of a hor-
mone. There had not recently been much advance
in thyreoid therapw but the discovery of the inde-
pendent function of the parathyreoids was of great
importance. The recognition of the uses of a typical
waste product, such as carbon dioxide : the role of
the internal secretion of the organs of reproduction ;
and the discovery that embryos produced an internal
secretion which appeared to exercise a restraining
influence on malignant growths were of great im-
portance. The substances offered for therapeutic
purposes were about the same as they had been one
hundred years ago, and they were advertised in
much the same language as was used a centurv ago.
Many hormones might in the future be made syn-
thetically, and the synthetic product would probably
be better than the natural hormone. The only func-
tion of certain organs was to produce hormones ; in
other cases the organ also destroyed poisons. As
an example of the possibility of influencing the pro-
duction of hormones in the body the author referred'
to the ef¥ect of hydrochloric acid on the mucous
membrane of the duodenum, the influence of the x
rays on the internal secretion of the ovary, and the
influence of iodine on the secretion of the thyreoid
body. The activity of extracts of the thyreoid body
depended upon the iodine contained in them. In-
vestigations conducted by the author had shown that
"protonuclein" was, to all intents and purposes, des-
iccated thyreoids, and so unsafe.
Serum Therapeutics, Including Treatment with
Specific Vaccines. — Dr. Mark W. Richardson,
of Boston, reviewed the results with the various sera
that were in common use at the present time. He
spoke of the use of fresh normal serum in doses of
fifteen to tvventy cubic centimetres in the treatment
of hjemorrhage and of the haemorrhagic diathesis.
He referred to the serum treatment of actinomyco-
sis, anthrax, carcinoma, cerebrospinal meningitis,
cholera, colon infections, diphtheria, bacillary dysen-
tery, erysipelas, gonorrhoea, plague, pneumonia, sar-
coma, snake poisoning, tuberculosis, etc. He spoke
of the treatment of cerebrospinal meningitis, colon
infections, gonorrhoea, staphylococcus and strepto-
coccus infections, tetanus, and tuberculosis with bac-
terial vaccines. In Dr. Richardson's own service, in
Boston, the treatment of 132 cases of typhoid fever
with typhoid products had reduced the relapses from
twenty to five per cent. He thought that the deter-
mination of the opsonic index was unreliable as a
guide to the administration of bacterial vaccines.
Psychotherapeutics. — Dr. Lewellys F. Bar-
ker, of Baltimore, read a paper on this phase of the
therapeutic art. He reviewed the psychotherapeutic
methods, both the conscious and the unconscious
ones, practised in the past, as well as those practised
at the present time. He described those methods
that were used in a legitimate way as well as those
that were used illegitimately. He said that psycho-
therapy was also physical therapy, and probably
psychophysical therapeutics would be a better name
for the collection of methods which made up the
subdivision of therapeutics under consideration.
]\Iesmerism, hypnotism, isolation, suggestion, per-
suasion, and inspiration of authority all belonged to
the class of measures referred to. The use of psycho-
therapeutic means should always be preceded by an
accurate diagnosis.
The Radical Cure of Constipation by Psycho-
therapy.—Dr. Irving P. Lyon, of Buffalo, de-
scribed his method of treating chronic constipation.
He considered the disorder to be, generally, a sim-
ple psychoneurosis which altered or obstructed the
normal innervation of the intestine. The faulty
nerve control was further intensified by dependence
upon cathartics, so that there were two bad habits to
correct instead of one. Drugs he regarded as un-
necessary in the treatment of the disorder, if not
positively harmful, and the attention of the physi-
cian should be given to instructing the patient how
to get himself into the habit of having a regular
stool daily. Dr. Lyon reported sixty-seven cures
out of sixty-nine attempts.
I220
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
Physical Therapeutics.— Dr. R. Tait McKen-
ziE, of Philadelphia, said that exercise as a thera-
peutic agent should include all means by which the
body might be acted upon by movements, active or
passive, vi^ith or without the aid of apparatus. Active
exercise included games which preserved and culti-
vated the old coordinations of throwing, catching,
striking, climbing, running, and leaping necessary
for complete development of the individual, difficult
to get naturally under city conditions. This form of
exercise might be subdivided into exercises of effort
and exercises of endurance. Exercises of effort were
contraindicated in cases of arteriosclerosis, advanc-
ing age, valvular heart lesions, and active tubercu-
losis of the lungs. Exercises of endurance were
contraindicated in cases of anaemia or cachexia from
any cause. In sound young men exercises combin-
ing both effort and endurance were productive of no
evil after effects. In duplicate movements the direc-
tion of the movement was controlled and the resist-
ance was prescribed ; in other words, the dose was
measured. The advantages of this method were its
accuracy, the possibility of specializing on isolated
muscle groups, and the possibility of stretching con-
tracted parts beyond what was possible by the volun-
tary power of the patients. In passive movements no
will power was required, and the action on muscular
nutrition was mechanical. These movements, as was
well known, came under the heads of massage and
mechanotherapy. The speaker then took up the vari-
ous diseases in which the different methods of exer-
cise were applicable. In conclusion, he said that ex-
ercise in its application"to pathological conditions of
posture, circulation, nutrition, and the nervous sys-
tem must depend for success on accuracy of dose,
persistence in following out the treatment pre-
scribed, and the careful observation of the patient
by a competent observer during the course of the
treatment.
Dr. HoBART A. Hare, of Philadelphia, said that
there was a wide breach between experimental phar-
macology and bedside experience, and that the
greater success of the older man depended upon this
experience. The ability of the body to adjust itself
to the onslaught of disease and the active medication
of disease could but be apparent to any one who was
at all observant. The accepted pharmacological ac-
tion of a drug might not be its true physiological ac-
tion. Some drugs must influence the metabolic pro-
cesses. The administration of antitoxines and bac-
terial vaccines converted the patient into a battlefield
between the invading organisms and the antitoxines,
and they should be used with great care. The adop-
tion of psychotherapeutic measures should not lead
to the exclusion of other satisfactory methods. Pic
would urge that, in addition to the encouragement
of research to produce new drugs, we should not
give up methods of- treatment which had been uni-
formly successful in the hands of our forefathers.
Dr. M. J. RosENAU, of Washington, said that the
administration of ether, referred to by Dr. Meltzer.
did not save life when life was imperiled by the phe-
nomenon of anaphylaxis.
The Clinical Value of the Tests of von Pirquet
and Calmette, Based upon Personal Observa-
tions.— Dr. Charles L. Greene and Dr. Frank E.
BuRCii, of St. Paul, gave an account of the prac-
tical utility of the cutaneous and ophthalmic tuber-
culin tests, based upon their experience in eighty-
three cases. The patients were all over eight years
of age. The authors concluded that the reactions
were comparable to that of the old injection test
with tuberculin ; that the two tests ran parallel ;
that both tests were active, but that the subcutane-
ous test was the more reliable ; that all patients with
tuberculosis reacted ; that the late reaction was more
common in cases of arrested tuberculosis; that ad-
vanced cases with a low resisting power gave a
slight reaction ; that a failure to react was of
great clinical value ; that the tests were of genuine
clinical service ; that the reported bad results fol-
lowing the ophthalmic test indicated the necessity
for caution in its application ; and that relatively few
persons reacted who did not show tuberculosis on
careful examination.
A Comparison of the von Pirquet, Calmette,
and More Tuberculin Tests and their Diagnostic
Value, — Dr. Samuel McC. Hamill, Dr. Howard
Childs Carpenter, and Dr. Thomas A. Cope, of
Philadelphia, reported the- results obtained in 134
cases in children under complete control, in one of
the orphan asylums in Philadelphia. The tubercu-
lin was prepared in one laboratory, by a uniform
method, the doses were uniform, and all the pa-
tients were subjected to a careful physical examina-
tion after the tests were made. All the patients
were under eight years of age. They had found
uniformity of reaction with all three methods. The
conjunctival test was sometime'S followed by seri-
ous inflammations of the eye with subsequent loss
of vision. The cutaneous and the ointment tests
were both better than the ophthalmic test. The
ointment test offered the further advantage that it
did not furnish a portal of entry for secondary in-
fections through abraded surfaces. They consid-
ered that all these methods were of less value than
it had been hoped they would be for the diagnosis
of the irregular forms of tuberculosis ; that a nega-
tive reaction was of more value than a positive one;
and that the type of the reaction bore no relation
to the type of the disease.
The Ophthalmotuberculin Reaction; A Warn-
ing.— Dr. M. J. RosENAU and Dr. John F. An-
derson, of Washington, said that the normal con-
junctiva might be sensitized by the instillation of
tuberculin. After fifty-one days a second instilla-
tion in one case was followed by a rapid and severe
reaction. Such a reaction had no clinical signifi-
cance, because a tissue which responded to ordinary
irritants so quickly as the conjunctiva would con-
centrate the immunizing forces upon the spot at
which the material was applied.
Dr. W. P. NoK i iiRri'. of New York, said that he
considered the ophthalmotuberculin reaction dan-
gerous, but believed that the cutaneous test was
reliable.
Dr. Hamill said that in his tests he had used
three points of inoculation ; one for the Moro test,
one for the von Pirquet test, and the third for salt
solution as a control.
Dr. W. R. Baldwin, of Saranac Lake, N. Y..
said that the amount of tuberculin used in the test
should be as small as possible, so as to prevent the
June 20, 1908.]
PROCEEDINGS OF SOCIETIES.
I22I
reaction of nontuberculous patients. The tests did
not appear to offer any prognostic aid.
Tronchin. A Sketch of His Life.— Dr. F. C.
Shattuck, of Boston, read a sketch of Tronchin,
whom he described as a great practitioner, who
never wrote a book, and who was, consequently, al-
most unknown.
Fatigue in School Children as Tested by the
Ergograph. — Dr. R. G. Freeman, of New York,
said that the theory as usually stated was that school
children possessed a power for increased work from
morning till noon, that the working power lessened
during the noon hour, and that it was lowest when
the children left school in the afternoon. In chil-
dren whom he had tested in the New York public
schools, he had not found evidences of fatigue with
the ergograph. He said that the Crampton test was
of no value and neither was the Storey ergograph
in testing for fatigue in school children. He thought
that an ergograph might be of some value in "tr} -
ing out" children so that the day might be modified
for those who did show fatigue.
Ascitic Exudate in Typhoid Fever. — Dr. Alex-
ander McPhedran, of Toronto, reported six cases
of typhoid fever in which ascites occurred without
demonstrable peritonitis. All the patients recovered.
Further Observations on the Pleural Reflexes.
— -Dr. Joseph A. Capps and Dr. D. D. Lewis, of
Chicago, described further experiments on the in-
fluence of mechanical and chemical irritants on the
blood pressure of dogs when they were applied to
the pleurae. In" a series of dogs with normal pleurje
and in a second series with artificially induced pleu-
risies, the pleural cavities were washed out with
various solutions. Fifty cubic centimetres of fluid
were used in each case. If this solution was very
irritating, it was subsequently washed out with ster-
ile water. Hot water alone was used in eight cases
of normal pleurae,with no fall in the blood pressure,
and in five cases of empyema, with no fall ; cold wa-
ter was used in four normal pleurae, with one fall of
pressure, and in four cases of pleurisy, with two
falls ; formalin and glycerin were used in eleven nor-
mal pleurae, with four falls, and in eleven cases of
pleurisy, with six falls ; a one per cent, solution of
iodine (Lugol's solution) was used in six normal
pleurae, with one fall, and in nine cases of pleurisy,
with two falls ; hydrogen peroxide was used in nine
cases of normal pleurae, with one fall, and in eleven
cases of pleurisy, with six falls. The pleura seemed
to be supplied with nerves that communicated with
the depressor nerves of the heart. In cases of pleu-
risy the action of these nerves was increased, so that
it was not altogether safe to use these solutions on
the human subjects.
Dr. F. C. Shattuck, of Boston, asked if the au-
thors had used a solution of chlorinated soda in their
experiments, a solution used by some surgeons for
irrigating the pleural cavity in cases of empyema.
Dr. S. J. Meltzer, of New York, said that it was
an interesting fact that the nerve fibres distributed
to a surface covered with fibrin had a more pro-
nounced action than the fibres distributed to a nor-
mal pleura.
Dr. Capps said that in some of their experiments
there had been a rise of blood pressure ; but the im-
portant point in their studies was the development
of the fact that in some cases the blood pressure did
fall. It was in these cases that there was danger.
Acute Pancreatitis. — Dr. Joseph Sailer, of
Philadelphia, described some experiments that he
had conducted, in conjunction with Dr. C. B. Farr
and Dr. John Speese, in order to produce pancreati-
tis. He suggested that in acute pancreatitis certain
ferments might escape from the pancreas and exert
their fat splitting function on the neighboring tis-
sues. The method of the production of this result
was not understood. Almost any foreign substance
injected into the duct of Wirsung. with ligation of
the duct, would produce it, and. in some cases, liga-
tion of the duct alone was followed by it. In a case
of acute pancreatitis, produced by the injection of
oil and the ligation of the duct, which was followed
by death in twelve hours, the necrotic pancreas was
emulsified and injected into guinea pigs. Four of
these animals died, but there were no toxic effects.
Dogs were injected with this emulsified pancreas,
and when they were moribund they were bled and
their blood serum was injected into guinea pigs.
The guinea pigs died. There was no evidence of
bacterial infection. The necrosis of the pancreas
was most marked near the bloodvessels. Normal
blood serum did not produce the same results. It
appeared that a partial immunization could be pro-
duced after two or three injections of small amounts
of the dog serum. The serum of the dogs injected
with emulsified pancreas was more toxic than the
serum of normal dogs. The lesions produced were
not like any others described.
Some Clinical Features of Pancreatitis, — Dr.
John H. ]\Ilsser, of Philadelphia, described the
clinical findings in nine cases of acute pancreatitis.
Trauma was an aetiological factor in one, gallbladder
disease in eight. There was epigastric tumor in
seven, diarrhoea in six, acute anjemia in five, leucocy-
tosis in the six cases in which a blood count was
made, shock in six, dyspnoea in eight, and a rapid
pulse in all. Cammidge's test was positive in the
last four cases.
Dr. Reginald Fitz, of Boston, said that not much
had been added to the methods of diagnosis in cases
of pancreatitis in recent years. The work of Dr.
Sailer was suggestive because the injection of ani-
mals with the serum of a suspected patient might be
developed into a diagnostic method.
Dr. William H. Welch, of Baltimore, asked
whether Dr. Sailer had tested the toxic action of the
serum of his dogs on other dogs. Dog serum was
normally toxic for guinea pigs, and it was possible
that the results obtained by Dr. Sailer might be
those of any alien serum. He would be inclined to
doubt the diagnostic value of injection of human
serum into animals in suspected cases.
Dr. S. J. INIeltzer, of New York, referred to the
report of the autopsy on Professor von Bergmann,
which seemed to point to acute pancreatitis as the
cause of von Bergmann's death.
Hypernephroma vnth Metastasis to the Ster-
num Simulating Aneurysm of the Aorta. — Dr.
Augustus A. Eshner, of Philadelphia, reported
the case of a woman, aged sixt\ > ears, who died of
uraemia, and in whom a diagnosis of arteriosclero-
sis, myocarditis, and nephritis had been made. There
was a pulsatile, elastic tumor of the first piece of the
1222
BOOK NOTICES.
[New York
Medical Journal.
Sternum, in the Tine of the aorta, which gave a sys-
■toHc murmur on auscultation. After death this tu-
mor was found to involve the sternum and ribs and
was seen to be a metastatic growth secondary to a
hypernephroma. There were other secondary
■growths in the lungs, the uterus, and the liver.
Dr. Charles G. Stockton, of Buflfalo, referred
to a case of hypernephroma in which there was in-
termittent fever. The symptoms of hypernephroma
were not unlike those of other malignant tumors.
The Importance of the Consideration of Nega-
tive Results in Blood Cultures. — Dr. E. Libman.
of New York, described the results of systematic
blood cultures in 1,500 cases of fever made in the
Mount Sinai Hospital in New York. In cases in
which the blood culture was negative the disease
might be due to an organism not easily cultivated ;
the organism might not be present in the blood when
the culture was made ; the organism might not be
demonstrable ; or the organism might have disap-
peared from the circulation after the local lesion had
been operated upon. In local infections of various
kinds, when the local lesion was out of the general
blood current, there might be no bacterisemia. In
-cases of suspected typhoid fever a negative culture
should lead to the suspicion of another disease. A
negative blood culture was valuable in the diagnosis
•of acute articular rheumatism. In a case of local
infection with severe constitutional disturbance a
negative blood culture indicated that there was no
general infection. There was a general infection
only when bacteria were found in the blood. A
negative blood culture 'excluded acute ulcerative en-
docarditis. In chronic endocarditis with fever a
negative blood culture was of value in excluding a
fresh infection. A negative culture was of value in
the diagnosis of infective thrombosis of the veins.
Dr. WiLLiAiM H. Welch, of Baltimore, said that
when bacteria were found in the blood in the human
subject their significance was not the same as when
they were found in the blood of the lower animals
suffering from septicaemia. In the latter instance
the organisms were actually multiplying in the blood
stream. In human pathology, on the other hand,
the organisms were usually swept into the blood cur-
rent and were not actively multiplying there.
Dr. LiBMAX said that he had reaclicd the conclu-
sion from his studies that bacteria were found in the
blood only when the original focus of Un int. etion
ruptured into the blood stream. The ors^anisnis w «, re
found in the blood all the time in cases n\ acute ul-
cerative endocarditis.
Obstruction of the Superior Vena Cava in
Graves's Disease. — Dr. Charles G. Stockton
and Dr. Albert E. Woehnert, of Buffalo, report-
•ed the case (to be published).
Dr. WiLLLAM H. Welch, of Baltimore, asked
whether the patient had shown tricuspid regurgita-
tion.
Dr. Abraham Jacobi.oI Xcw York, asked whether
the enlarged thyreoid body had interfered with the
A^enous circulation.
Dr. Stockton said that there had been no tricus-
pid lesion found at the autopsy. The thyreoid ap-
parently did not obstruct the veins. The process
was not, strictly speaking, a terminal one.
The Relation of Anaphylaxis to the Toxaemia
-of Pregnancy. — Dr. M. J. Rosenau, of Washing-
ton, said that in his experiments on the phenomenon
of anaphylaxis he had found that the guinea pig
could not be sensitized with the blood of foetal
guinea pigs. The placental juice of the guinea pig,
however, when injected into the mother, would sen-
sitize the animal to the placental juice. In man it
might be that the toxaemia of pregnancy was due to
poisoning with placental cells.
Dr. Victor C. Vaughan, of Ann Arbor, Mich.,
said that he had been struck with the resemblance
between anaphylaxis and eclampsia.
Eight other papers were read by title.
The following active members were elected • Dr.
E. R. Baldwin, of Saranac Lake, N. Y. ; Dr. J. A.
Capps, of Chicago; Dr. Theodore C. Janeway, of
New York ; Dr. L. A. Conner, of New York ; Dr. R.
G. Freeman, of New York ; Dr. J. Dutton Steele, of
Philadelphia ; Dr. Joseph Sailer, of Philadelphia ;
Dr. H. C. Moffitt, of San Francisco, and Dr. W. F.
Hamilton, of Montreal.
The following associate members were elected :
Dr. Harlow Brooks, of New York ; Dr. J. Alison
Scott, of Philadelphia ; Dr. W. T. Longcope, of
Philadelphia ; Dr. J. C. DaCosta, of Philadelphia ;
Dr. Rufus I. Cole, of Baltimore ; Dr. T. A. Claytor.
of Washington ; Dr. L. Brown, of Saranac Lake,
N. Y. ; Dr. Victor C. Vaughan, Jr., of Detroit ; Dr.
J. T. Halsey, of New Orleans, and Dr. C. H. Bun-
ting, of Madison, Wis.
The following officers were elected for the com-
ing 3'ear : President, Dr. Victor C. \'aughan, of
Ann Arbor, Mich. ; vice-president. Dr. Henry Hun,
of Albany ; secretary. Dr. George M. Kober, of
Washington ; recorder. Dr. S. Solis-Cohen. of Phila-
delphia ; treasurer. Dr. J. P. Crozer Griffith, of Phil-
adelphia ; councillor. Dr. S. J. Meltzer, of New
York ; representative on the executive committee of
the Congress of American Physicians and Surgeons.
Dr. F. H. Williams, of Boston (alternate. Dr. \\'. S.
Thayer, of Baltimore).
iaok llota.
[PVe publish full lists of books received, but zve acknowl-
edge no obligation to reviezv them all. Nevertheless, so
far as space permits, ive review those in which we think
our readers are likely to be interested.]
The Priiu-ith-s and Praclirr e/ H\'droihrrot\\ A Guide to
tlu' Applicati.'ii of W'-.tirv ,n Ui-oa-^r. t Siiidents and
rraclili.iiKTs of Al>-du-inr S:mmn IInkimi, M. D.,
J'n.fess.ir of llydruiluTMpx m L . .hinil.ia I'niversity (Col-
lege of Pl^ysici;m^ ,in.l Siir-roii-), Xcw York. etc. Third
Edition, Revised .uid I'nlavu.-d. With Numerous Ilhis-
trations. New York: William Wood & Co., 190S. Pp.
544-
Scientific hydrothcra]xnitics has rapidly come to
the foreground during tiie last twenty-five years,
and its representative in America is Dr. Simon Ba-
ruch, of Xew York. A book on hydrotherapy from
his pen is therefore a well authenticated report on
this branch of therapeutics, which is now represent-
ed by a department of the Vanderbilt Clinic of the
College of Physicians and Surgeons. Columbia I'ni-
versitv. ])re)bablv the hrst school of medicine in
America to make hydrotherapy an o!)ligatory study
in its curriculum.
Although the bo()k lietore us is the third edition,
we deem it proper to review it at some lengtii. a.-
wc have not done so before.
June 20, 1908.]
MISCELLANY.
1223
It is divided into two parts, the first part treating,
in ninety-five pages, of the physical properties of
water and its mode of action in health. The second
part deals, in 422 pages, with the practice of hydro-
therapy. It contains descriptions and rules of ap-
plying water in disease, and then goes into fuller de-
tail as to treatment of diseases, giving the reason
for each procedure and its therapeutic indications,
with reports of cases. We thus find that Baruch
■discusses water in the treatment of typhoid fever,
measles, scarlatina, pneumonia, enterocolitis, Asiatic
cholera, sunstroke, anaemia and chlorosis, phthisis,
diabetes, malarial diseases, neurasthenia, neuralgia,
hysteria, rheumatism and gout, dyspepsia, and in-
sanity. A full chapter is devoted to hydriatic pre-
scriptions. The last chapter of the book gives an
historical sketch of hydrotherapeutics. The book
may well be recommended to every practitioner.
"The Sexual Question. A Scientific, Psjxhological. Hy-
gienic, and Sociological Study for the Cultured Classes.
By August Forel. M. D., Ph" D.. LL. D.,, Formerly Pro-
fessor of Psychiatry at and Director of the Insane Asy-
lum in Zurich (Switzerland). English Adaptation bv
C. F. Marsh.all, M. D.. F. R. C. S., Late Assistant Sur-
geon to the Hospital for Diseases of the Skin. London.
Illustrated. New York : Rebman Companv. 1908. Pp.
536.
Dr. ^larshall has produced a very valuable trans-
lation of Forel's Question sexuellc, which we re-
viewed in our issue of July 6. 1907, page 46. The
translator as well as the publishers is to be congrat-
ulated on having made, through this English ver-
sion, the French work accessible to a much wider
circle of readers. The book is such that, although
Ave may not agree to all of Forel's conclusions, it
should be read by every one interested in not only
the scientific but also the sociological side of the
sexual question.
The Operations of General Practice. Bv Edred M. Corner,
M. A.. M. C. M. B. (Cantab.), 'B. Sc. (London),
F. R. C. S. (England), Surgeon in Charge of Out Pa-
tients at St. Thomas's Hospital and to the Children's
Hospital, etc.. and H. Irvixg Pinches, M. A., ]NL B.. B. C.
(Cantab.). M. R. C. S.. L. R. C. P. (London), Clinical
Assistant to the Children's Hospital, etc. London :
Henry Frowde (Oxford University Press) and Hodder
& Stoughton. 1907. Pp. xii-296. (Price, $5.50.)
The authors have presented in this volume an ex-
cellent manual of the minor surgery that the general
practitioner is called on to perform and that he is
too frequently imfamiliar with, because it Avas so
insignificant that it was not brought into his sur-
gical course when he was in college. The operations
are described imder the several anatomical regions.
■and the book will serve a very practical purpose.
How to Enter the Naval Medical Corps. — \\'e
quote the following froin the official circular for the
information of persons desiring to enter the Med-
ical Corps of the United States Navy : —
A candidate for appointment in the Medical Corps of the
na\y must be a citizen of the United States between
twenty-one and thirty years of age. and must apply to the
Honorable Secretary of the Xavy for permission to appear
before a naval m.edical examining board. The application must
be in the haudzcritiug of the applicant, stating age and place
of birth ; also the place and State of which he is a perma-
nent resident, and must be accompanied by letters or cer-
tificates from two or more persons of repute, testifying
from personal knowledge to his good habits and moral
character, and that he is a citizen of the United States.
(Thi.
FORM OF APPLICATION,
is not to be filled in here, but copied on a separate
sheet.)
190
Sir — I request permission to be e.xamined for an ap
assistant surgeon in the United States Navy.
I was born at and was years of age on the
day of , 190 , and am a citizen of the United States, re-
siding in county of in the State of
I inclose herewith certificates as to moral character, habits, and
citizenship.
Very respectfully.
The Honorable Secretary of the Navy,
Navy Department, Washington. D. C.
If, in reply, the candidate receives a permit, he will
notify the president of the naval medical examining board
at the U. S. Naval Medical School, Washington. D. C. or
at the L". S. Xaval Hospital, Mare Island. Cal., the only
places where the examinations are held, stating approxi-
mately the time at which he desires to be examined and
requesting that a date be fi.xed for his examination.
THE EX.\MIXATIOX.
When a candidate presents himself for examination on
the date fixed by the president of the board, he must bring
with him testimonials as to character and professional fit-
ness, diplomas, and a certificate that he is a citizen of the
L'nited States. While it is not essential, it is desirable that
candidates should have had hospital experience or at least a
year's practice in their profession. The examination usually
occupies about nine days, and is conducted in the following
order: I. — Physical. II. — Professional. III. — Collateral.
I.— PHYSICAL EXAMIXATION.
The physical examination is thorough, and the candi-
date is required to certify, on oath, that he is free from all
mental, physical, and constitutional defects. Acuteness of
vision, 12/20 for each eye. unaided by glasses, but capable
of correction by aid of lenses to 20/20. is obligatory.
Color perception must be normal and the teeth good. If
the candidate is fornd to be physically disqualified his ex-
a.Tiination is concluded: if found to be physically qualified
his examination is continued as follows: (i) Letter to the
hoard descrihi:ig in detail his general and professional ed-
ucation.
II.— PROFESSIOXAL EXAMIXATION.
Written Percentages
Subjects. questions. required.
Anatomv (2) and phvsiology (i) 3 80
S-urgery (2) " . 3 80
.Medicine (2) 3 80
Pathologv (i) 2 70
Obstetrics (i) and medical jurispru-
dence (1) 2 60
Materia niedica and physiological action of
drugs 2 80
Chemistry {i) and clinical microscopy (i) 2 60
Hygiene (i) and quarantine (i) 2 80
General aptitude . . 80
l iterary and scientific branches . . 80
Required aggregate .. 730
Bandaging: tourniquets: four operations on cadaver;
clinical cases (a written report being made in one
case giving history, diagnosis, prognosis, treatment, one
prescription, at least, being written out in full, in
Latin) : uranalysis (chemical and microscopical examina-
tion of one specimen of urine) : practical microscopy and
recognition of five mounted specimens (histological, patho-
logical, and bacteriological) : recognition of surgical
instruments.
OR.\L E.K.^MIN.ATION.
This follows the written work in each branch, and the
required percentage is made up from the combined results
of the written and the oral examinations. The percentages
given are not absolute, however, as losses in some branches
may be made good in others, provided the standard is
reached in the cardinal subjects of anatomy, physiology,
medicine, and surgery.
1224
MISCELLANY.
[Ne^v York
Medical Journal.
III.— COLLATERAL EXAMINATION.
This embraces spelling, punctuation, the use of capital
letters, grammar, arithmetic, geography (descriptive and
physical), languages, history, general literature, elementary
botany, geology, and zoology. While due credit is given
for a knowledge of languages and the sciences it is not
essential except in the case of physics, but a knowledge of
the common school branches is essential. This e.xamina-
tion will be omitted, in the discretion of the naval medical
examining board, in the case of applicants holding diplo-
mas or certificates from reputable literary or scientific col-
leges, normal schools, or high schools, or of graduates of
medical schools which require an entrance examination
satisfactory to the naval medical examining board.
The boards are required, under oath, to report on the
physical, mental, moral, and professional qualifications of
the candidate, so that the examinations are necessarily
comprehensive, though simple and practical, and not be-
yond the attainments of any well educated physician. The
oral and written questions are similar to those asked by the
best medical colleges in examinations for graduation. A
successful candidate, upon completion of his examination,
will be notified by the president of the board that he has
been found qualified. With the consent of the board, a
candidate may withdraw at any period from further ex-
amination, and may at a future time present himself for
reexamination. The board may conclude the examination
(writen, oral, and practical) at any time, and may deviate
from this general plan as it may deem best for the interests
of the naval service. No allowances will be made for the
expenses of pirsons appearing for examination. The
tenure of office in the Medical Corps of the Navy is for
life, unless sooner terminated by removal, resignation, dis-
ability, or other casualty. All conmiissioned officers of the
n.ivy, including the Medical Corps, are retired from active
service at the age of sixty-two years, and when so retired
(or when retired from active service for disability or other
casualty contracted in line of duty before that age) receive
an annual pay for life amounting to three fourths of the
highest pay of their grade. at the time of retirement. When
any officer of the navy, including medical officers, has been
thirty years in the service, he may, upon his own applica-
tion, in the discretion of the President, be retired from
active service and placed upon the retired list with an an-
nual pay for life amounting to three fourths of the highest
pay of his grade at the time of retirement. Upon the
death from wounds or disease contracted in line of duty
of any officer, including medical officers (and immediately
upon official notification thereof, there will be paid to the
widow of such officer, or any person previously designated
by him, an amount equal to six months' pay at the rate
received by such officers at the date of his death, less $75
to defray expenses of interment ; but the residue, if any,
of the amount so reserved will be paid subsequently to
the widow or other designated beneficiary. When travel-
ing in the United States under orders, officers of the navy,
including medical officers, receive 8 cents a mile to defray
the expenses incident thereto, and when traveling by other
than public conveyance at sea or outside the continental
limits of the United States, such officers are allowed actual
expenses, estimated on a liberal basis and in accord with
the position of an officer, both as regards admissible items
of expense and the cost of such items.
On entering the naval service medical officers are cred-
ited with five years' service (in recognition of the fact that
they have been at their own expense in preparing them-
selves for government service) for the purpose of estab-
lishing their date of precedence as regards rank and for
calculating their increase of pay for length of service, as
follows: For every five years' service the pay of officers is
increased lo per cent, (though not to exceed 40 per cent.),
calculated on the annual base pay of their grade, as shown
in the appended table; but the pay of medical director is
limited to $S,ooo; that of medical inspector to $4,500; and
that of surgeon to $4,000 When an officer goes to sea or
leaves the continental limits of the United States under
assignment to stations or for the performance of other
duties beyond the seas, his pay is increased 10 per cent.,
and this increase is calculated upon the pay, including in-
creases for lentjth of service, which, said officer may be re-
ceiving at the time of entering upon such duty or to which
he may succeed by virtue of promotion or length of ser-
vice during the performance of such duty, as shown in the
appended tabic. This increase for sea duty or service be-
yond the continental limits of the United States does not
fall under the statutory restrictions above mentioned, which
control the increase of pay for length of service in the
grades above passed assistant surgeon, and the operation
of this benefit is shown, in the second column of the ap-
pended table. The officers of the medical corps of the
navy, and their respective base pays, upon which the fig-
ures of the appended table have been calculated, are as
follows: Medical directors, $4,000; medical inspectors,
$3i5oo; surgeons, $3,000; passed assistant surgeons, $2,400;
and assistant surgeons, $2,000. Assistant surgeons are ex-
amined at the expiration of three years' service for pro-
motion, and if successful, become passed assistant sur-
geons. Promotions to the higher grades are made in the
order of seniority to fill vacancies as they are created (by
resignation, retirement, death, and the operation of the
thirty year retirement privilege), and for each promotion
a physical and professional examination is required by law.
The examination for appointment is noncompetitive, but if
two or more candidates are examined at the same time
their appointments will be in the order of merit reported by
the board.
For further information address the president of the
naval medical examining board, U. S. Naval Medical
School, corner Twenty-third and E streets, N.W., Wash-
ington, D. C, or the president of the naval medical exam-
ining board, U. S. Naval Hospital, Mare Island, Cal.
PAY AND ALLOWANCE TABLE.
Rank and Length of Service.
p. o C-i " < rt ii
.\ssjstant surgeons, rank of lieutenant
(junior grade) $2,200 $2,420 $432
Passed assistant surgeons, rank of lieu-
tenant 2,640 2,904 576
After 5 jears in the service 2,880 3,168 576
After 10 years in the service 3,120 3,432 576
Surgeons, rank of lieutenant commander 3,600 3,960 720
After 10 years in the service 3.900 4,290 720
After 15 years in the service 4,000 4,400 720
Medical inspectors, rank of commander:
After IS years in the service 4,500 4,950 864
Medical directors, rank of captain:
After 15 years in the service 5,000 5,500 1,008
Surgeon general, rank of rear admiral.. 6,000 6,600 1,152
Note. — There are also liberal allowances for fuel and light when
on shore, at home, and beyond the continental limits of the United
.States, the amount varying according to rank, season, and the lati-
tude of the station at which the officer is serving.
'Both within and (on shore duty) beyond the continental limits
of the United States, but only when quarters are not furnished by
the Government.
The requirements are stibstantially the same in
the case of applicants for appointment as acting as-
sistant surgeon, and they may at any time subse-
quent to their appointment be ordered for examin-
ation for the grade of regular assistant surgeon.
Resolutions Adopted at the Death of Dr. Far-
rington. — .At a meeting of the Harlem Medical As-
sociation, held June 3, 1908. the following minutes
and resolutions were adopted :
Whereas, Death has removed from among us a
former president and one of the founders of this
association, Dr. Joseph Oakley Farrington, unusu-
ally long and favorably known, and highly respected
by us, therefore, be it
Resolved, That we deeply regret the loss the as-
sociation has sustained in the death o*' its second
president, who enjoyed the fruits of his profession
for over half a century ;
Resolved, That the association extends its sym-
pathy to the family of the deceased, and that a copy
of these resolutions be spread in full upon the
minutes of this association ; that they be forwarded
June ao. 1908.]
OFFICIAL NEWS.
1225
to his family, and also be sent for publication to
the medical journals of this city.
Joseph E. Lumbard, M. D.,
Michael C. O'Brien, M. D.,
Edmund L. Cooks, M. D.,
Former Presidents of the Harlem Medical Asso-
ciation.
(Official Sftos.
Public Health and Marine Hospital Service
Health Reports :
The follozving cases of smallpox, yellow fever, cholera,
and plague have been reported to the surgeon general,
United States Public Health and Marine Hospital Service,
during the week ending June 12, igo8:
Smallpox— 'United Stales.
Places. Date. Cases. Deaths.
California — Los Angeles May
California — San Francisco Maj-
District of Columbia — W ashington . May
Illinois — Chicago May
Indiana — Indianapolis May
Indiana — La l-'ayette May
Indiana — South Bend May
Indiana — Terre Haute May
Iowa — Ottumwa May
Kansas — Topeka M
Kansas — Wichita
Kentucky — Covington
16-23 I
16-23 2
16-30 7
23-30 I
^+-3' 2
^5-June I I
2330 2
^3-3" '
23-30 3
. 16-30 8
May 23-30 3
May 23-30
Kentucky — Lexington May 23-30
Louisiana — New Orleans May 23-30 11
Maryland — Baltimore May 22-30 i
Massachusetts — Lowell May 22-29 '
Michigan — Saginaw May 16-30 26
Missouri — St. Joseph May 16-23 '. ... 11
Montana — Butte May 19-26 2
Tennessee — Nashville May 23-30 i
Ohio — Dayton May 23-30 6
Texas; — San Antonio May 16-30 9
Washington — Spokane May 16-23 7
Washington — Tacoma May 17-24 i
Wisconsin — La Crosse May 24-31 2
Virginia — Richmond May 22 30 i
Smallpox — Foreign.
Brazil — Rio de Janeiro April 26-May 3 123
Canada — Halifax May 23-30 4
Canada — Winnipeg May 23-30 2
China — Hongkong April 18-25
Egypt — Cairo May 6-13 6
Egypt — Suez April 1 5-May 6 2
Ecuador — Guayaquil April i8-May 2 S
France — Paris May 9- 16...' 3
Great Britain — Leith May 9-16 1
Great Britain — .Southamj ton May 9-16 i
India — Bombay .\pril 28-May 5
India — Calcutta .\pril 18-25..."
Japan — Kobe April 24-May 2 i
Japan — Nagasaki ^Iay 3-10 i
Japan — Osaka April 18-25 44
Japan. — Shimonoseki May 12
Italy — Catania May 14-21
^Mexico — Aguascalientes May 17-24 3
Mexico — Mexico City May 11-18
Russia — Moscow May 2-9 32
Russia — Odessa May 9-16 i
Russia — St. Petersburg May 2-9 31
Spain — Denia May 9-16 2
Spain — Valencia May 9-16 28
Straits Settlements — Penang April 18-25 >
Turkey — Constantinople May 10-17
Turkey — Smyrna March 24- April 7...
Yellow Fever — Foreign.
Brazil — Para May 9-16 2
Ecuador — Guayaquil April i8-May 2
Plague — Foreign.
China^ — Hongkong April 18-25 29
Ecuador — Guayaquil April 18-May
Formosa April 18-May 2 167
India — General March 28-April 4.10,665
India — Bombay April 24-May 5
India — Calcutta April 18-25. t •
India — Rangoon April 18-25
Japan — Osaka April 18-25 3
Mauritius Feb. 1-29 3
Peru — General April 25-May 2 30
Straits Settlements — Singapore... April 18-25
Trinidad May 31...
Venezuela — Caracas May 25
Venezuela — La Guaira May 22 2
May 31
Chole ra — Foreign.
India — Bombay .\pril 27-Mav 5
India — Calcutta April 18-25.". ."
India — Rangoon April 18-25
Japan — Yokosuka May 12 i
Public Health and Marine Hospital Service:
Official list of changes in the stations and duties of
commissioned and noncommissioned officers of the United
States Public Health and Marine Hospital Service for the
seven days ending June 10, 1908:
Bahreneurg, L. p. H., Passed Assistant Surgeon. Granted
leave of absence for two days from May 21, 1908,
under paragraph 191, Service Regulations.
BiERMAN, C. H., Pharmacist. Granted leave of absence
for thirty days from July 3, 1908.
Bowers, P. E., Acting Assistant Surgeon. Granted leave
of absence for seven days from June 6, 1908, and ex-
cused without pay for eight days from June 13, 1908.
Brown, B. W., Surgeon. Granted leave of absence for
one month and six days from June 25, 1908.
Fisher, C. £., .Acting Assistant Surgeon. Granted leave
of absence for ten days from June 2, 1908.
Foster, J. P. C., Actmg Assistant Surgeon. Granted leave
of absence for eight days from June 2, 1908.
Frissell, C M., Acting Assistant Surgeon. Granted leave
of absence for twenty cays from June 6, 190S.
Gibson, L. P., Acting Assistant Surgeon. Granted leave
of absence for eight days from June i, 1908.
GoLDSP.OROUGH. B. W.. Acting Assistant Surgeon. Granted
leave of absence for one day, June 18, 1908.
Herring. R. A., Assistant Surgeon. Relieved from duty
at Ellis Island, N. Y., and directed to proceed to
Reedy Island Quarantine Station, reporting to the
medical officer in command for duty and assignment
to quarters.
HicK-s, \V. R., Acting Assistant Surgeon. Granted leave
of absence lor fourteen days from June i, 1908.
Keatlev, H. \V., Acting Assistant Surgeon. Granted
leave of absence for two days from May 9, 1908, under
paragraph 210, Service Regulations.
Magruder, G. M., Surgeon. Granted leave of absence for
one -month from July 2, 1908.
Mason, W. C., Acting Assistant Surgeon. Granted leave
of absence for five days from June 22, 1908.
Mathewson, H. S., Passed Assistant Surgeon. Granted
extension of leave of absence for fifteen days from
June 15. 1908.
Parker, T. F., Acting Assistant Surgeon. Granted leave
of absence for ten days from June I, 1908.
Porter, J. Y.. Sanitary Inspector. Directed to inspect
Florida quarantine stations from time to time during
the present season.
Ramus, C., Passed Assistant Surgeon. Relieved from
duty in Honolulu, Hawaii, and directed to report to
the chief medical officer, Ellis Island, N. Y., for duty.
Roiii.vsoN. D. E., Passed Assistant Surgeon. Granted
leave of absence for two days from May 10, 1908,
under paragraph 191, Service Regulations.
Ryder, L. W., Pharmacist. Granted leave of absence for
two days from June 12. 1908, under paragraph 210,
Service Regulations.
Stearns, H. H., Acting Assistant Surgeon. Granted leave
of absence for one day. May 24, 1908, under paragraph
210, Service Regulations.
Stiles, Charles W.. Chief of Division of Zoology (Hy-
gienic Laboratory). Detailed to represent the service
at North Carolina State Medical Society meeting,
Winston-Salem. N. C, June 17. 1908.
STii\rpsoN, W. G.. Surgeon. Granted leave of absence for
eleven days from June 7, 1908.
Stoner, G. W.. Surgeon. Granted leave of absence for
four days from May 31, 1908, under paragraph 189,
Service Regulations.
Ward, W. K., Passed Assistant Surgeon. Granted leave
of absence for one day from May 10, 1908, under para-
graph 191, Service Regulations.
Appoint)nent.
Dr. W. D. Bell appointed Acting Assistant Surgeon for
duty at St. John's River Quarantine Station, Florida, June
6, 1908.
Army Intelligence:
Official list of changes in the stations and duties of
officers of the medical corps of the United States Army
for the iveck ending June /j, ig>o8:
Appel, D. M., Lieutenant Colonel. Left San Francisco,
Cal., for witness duty in Washington, D. C.
Darnall, C. R.. Major. Granted leave of absence for
two months.
1226
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
Field, P. C, Captain. Ordered to accompany Seventh In-
fantry to duty at manoeuvre camp, Chickamauga
Park, Ga.
Raymond, H. L, Major. Ordered to return from treat-
ment at Washington, D. C, to Columbus Barracks,
Ohio.
ScHREiNER, E. R., Captain. Assigned to temporary charge
of San Francisco Medical Supply Depot, during the
absence of Lieutenant Colonel D. M. Appel, medical
corps.
Navy Intelligence:
Official list of changes in the stations and duties of
oUiccrs of the medical corps of the United States Navy
for till? zi'cek ending June 13, igoS:
Barber, G. H., Surgeon. Detached from course of instruc-
tion at the naval medical school, Washington, D. C,
and ordered to the Naval Hospital, Boston, Mass.
Blackwell, E. Passed Assistant Surgeon. Detached
from course of instruction at the naval medical school,
VN'ashmgton, D. C, and ordered to report in that city
on June 15th for examination for promotion, and then
to await orders.
BoGERT, E. S.. Surgeon. Detached from course of instruc-
tion at the naval medical school, Washington, D. C,
and ordered to the navaJ war college. Newport, R. I.
Brown,_E. M., Assistant Surgeon. Detached from course
of instruction at the naval medical school, Washing-
ton, D. C, and ordered to the Naval Hospital, Nor-
folk, Va.
Bunker. C. W. O., Assistant Surgeon. Detached from the
naval academy and ordered to the Arkansas.
Clark. G. F., Acting Assistant Surgeon. Appointed an
acting assistant surgeon from June 6, 1908.
Cole, H. W., Jr., Assistant Surgeon. Detached from
course of instruction at the naval medical school,
Washington, D. C, ordered home, and granted leave
for one month.
DoNELsoN, M., Assistant, Surgeon. Detached from the
Porter, and ordered to the Biddle.
DuHiGG, J. T.. .Assistant Surgeon. Ordered to the naval
recruiting station. Los Angeles, Cal.
Fauxtlerov, a. M., Passed Assistant Surgeon. Detached
from course of instruction at the naval medical school,
Washington, D. C, and ordered to the naval medical
school hospital, Washington, D. C.
Freeman, G. F, Passed Assistant Surgeon. Detached
from course of instruction at the naval medical school,
Washington, D. C, and ordered to the navy yard,
Boston, Mass.
Lane. H. H.. Assistant Surgeon. Ordered to duty in the
department of government and sanitation, Canal Zone,
Panama.
McDowell. R. W., Assistant Surgeon. Ordered to the
Naval Hospital. Philadelphia, Pa.
Melhorn, K. C. Assistant Surgeon. Detached from the
IVahash and ordered to the Yankee.
Peck, A. E., Passed .Assistant Surgeon. Detached from
the naval ' station, Cavite. P. I., and ordered home.
Sellers, F. E.. Assistant Surgeon. Detached from the
naval academy and ordered to the Nevada.
Smith, G. T., Surgeon. Detached from course of instruc-
tion at the naval medical school, Washington, D. C,
and ordered to the Naval Hospital. New York, N. Y.,
July I.
Snyder. J. J., Passed Assistant Surgeon. Detached from
course of instruction at the naval medical school,
Washington, D. C, and ordered to report in that city
June 15th, for examination for promotion, and then to
await orders.
Stalnaker, P. R., Assistant Surgeon. Detached from
course of instruction at the naval medical school,
Washington, D. C, and ordered to report in that city
Jtme 15th. for examination for promotion, and then to
await orders.
Ta'slor. J. L., Assistant Surgeon. Detached from course
of instruction at the naval medical school, Washing-
ton. D. C. and ordered to report in that city, June
i.Sth. for exammation for promotion, and then to awaii
orders.
Verner. W. W., Passed Assistant Surgeon. Resignation
accepted from June 10, 1908.
Wilson, G. B., Surgeon. Detached from the course of in-
struction at the naval medical school, Washington,
D. C, and ordered to the Wabash.
Born.
Shook.- — In Pinar del Rio, Cuba, on Saturday, May 30th,
to Dr. J. Ralph Shook, United States Army, and Mrs.
Shook, a daughter.
M arried.
Albee— SuMMEY. — In Philadelphia, on Saturday, June
6th, Dr. William Albee and Miss Nellie Summey.
Atwell — MuRDOCK. — In Fly Creek, New York, on
Wednesday, June 3d, Dr. Floyd Jerome Atwell and Miss
Helen Williams Murdock.
Carlton — Win stead. — In Rocky IMount, North Carolina,
on Tuesday, June 9th, Dr. J. Lane Carlton, of Salisbury,
and Miss Meta May Winstead.
Coultes — Brigham. — In Philadelphia, on Wednesday,
June loth. Dr. J. F. Coultes and Miss Imogene Brigham.
Crofutt — Lape. — In Chicago, on Thursday, June 4th,
Dr. Edward F. Crofutt, of New York, and Miss Janet D.
Lape.
DoLiGHEKTY — Merklee. — In Philadelphia, on Wednesday,
June 17th. Dr. Clarence C. Dougherty and Miss Florence
Lillian Merklee.
Gage — Morley. — In Troy, N. Y., on Wednesday, June
3d, Dr. George Henry Gage and Miss Ethel Morley.
Good — Munder. — In Philadelphia, on Wednesday, June
loth. Dr. William Harmar Good and Miss Helen Agnes
Munder.
IvEKSEN — Smith. — In Palmyra, Nebraska, on Saturday,
June 6th, Dr. John C. Iversen and Miss Catherine Smith.
Jackson- — Stevens. — In Madison, Wisconsin, on Thurs-
day. June 4th, Dr. Reginald Harry Jackson and Miss Eliz-
abeth Breese Stevens.
Porter — MacMahon. — In Washington, D. C, on
Wednesday, June loth. Dr. Frederick E. Porter, United
States Navy, and Miss Lillian B. MacMahon.
WoRSLEY — Musselman. — In Bethlehem, Pennsylvania,,
on Thursday, June 4th, Dr. A. Sweden Worsley, of Phila-
delphia, and Miss Bertha M. Musselman.
ZoLLER — Hoffman — In St. Louis. Missouri, on Tuesday,
June 2d, Dr. C. H. Zoller and Miss Philippine Hoffman.
Died.
Aldrich. — In Fall River, Massachusetts, on Saturday,
June 6th, Dr. Nathaniel Borden Aldrich, aged forty-two
years.
Anderson. — In Grosse Isle, Michigan, on Monday, June
8th, Dr. Frederick Pope Anderson, aged sixtv-six years.
Ashley. — In Machias, New York, on Friday June 5th,
Dt. Harmon J. Ashley.
AusHTZ. — In New York, on Sunday, June 7th, Dr. Mar-
tin W. Auspitz, aged thirty-five year*;.
Blackford. — In Middletown, Ohio, on Monday, June
8th, Dr. Harry Blackford, aged forty-two years.
Clough. — In Honduras, Central America, on Saturday..
May 30th, Dr. A. A. Clough, of Denver, Colorado.
Davie. — In Boston, on Thursday, June 4th, Dr. Charles
H. Davie, of Scitnate. Maine, aged' 'iixty-five years.
FoLTZ. — In Cincinnati. Ohio, on Saturday. June 6th. Dr.
Kent Oscanyan Foltz. aged fifty-one years.
Galt. — In Richmond, \'ii t:inia. on Monday, June 8th. Dr.
T. A. D. Gait, agcil M vciU\ -four years.
Gardner. — In \\ .inIhiii^i. in, D. C. on Wednesday. June
3d. Lieutenant ("m](i>uI William TT. Gardner. Medical
Corps. I'liiud Stat','< Arnn'. aucd sc\(nt\- one years.
Mi;i«Rk.— In Piti^-iKld, Mas^aclnisctf;. on Thursday,
June nth. Dr. William M. Mercer, aged sixty-five years.
Naittze. — In St. Louis, Missouri, on Sunday, June 7th.
Dr. Gustave Nautze, aged tliirtv-eight years.
PospisiEL. — In Wasliington. D. C. on Sunday, June 7th.
Dr. Joseph Pospisiel. aged forty-five years.
Regent.— In Chicago, on Friday. June 5th, Dr. Michael
N. Regent, aged forty-four vears.
Stoddard. — In Rocliester. New York, on Saturday. June
6th. Dr. Enoch Vine Stoddard, aged sixty-eight years.
Sherman. — In Yonkers. N. Y.. on Thursday, June nth.
Dr. William H. Sherman, aged forty-nine years.
Si'ooR. — In Schenectady, New York, on Friday, May
29lh, Dr. David E. Spoor, aged sixty-two years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal tH Medical News
A Weekly Review of Medicine, Established 184J.
You LXXXVIL No. 26.
NEW YORK, JUNE 27, 1908.
Whole No. 1543.
(Original Cffmmwnitations.
REVIEW OF THEORETICAL CONSIDERATIONS
AND EXPERBIENTAL WORK RELATIVE TO
OPSONINS WITH OBSERVATIONS AT
THE SARA N AC LABORATORY.*
[Abstract.]
By E. R. Baldwin, M. D.,
Saranac Lake, N. Y.
The writer first drew attention to the fact that the
view at first held, that opsonic substances were dis-
tinct from other ingredients of serum, is now doubt-
ed. Dean, Cowie, and Chapin, Sleeswijk, and Leva-
diti have shown that the normal serum has opsonic
functions associated with the normal amboceptor
and complement which cannot be separated from
them. Heat and absorption afifect them to the same
degree as the opsonic activity. The substance favor-
ing phagocytosis need not be assumed to be wholly
distinct, because chemical and physical differences
in bacteria may account for varying manifestations,
sometimes phagocytic, at others bactericidal or ag-
glutinating. The opsonic and complement functions
are regarded as indistinguishable bv Muir and Leva-
diti. There is more reason to think that immune or
specific opsonic functions are due to separate sub-
stances. Their presence may be demonstrated when
corresponding lysins and agglutinins are absent or
removed, as shown by Neufeld and Topfer and Hek-
toen.
Even here differences in the chemical or physical
affinities or experimental limitations may obscure the
relations of these antifunctions due to a single sub-
stance. In most immune sera removal of immune
amboceptors by absorption is accompanied by a sim-
ultaneous loss of lytic, agglutinative, and opsonic
functions. The general result of such experiments
has been to class the specific opsonins with the am-
boceptors, whether identical or not with the lysins,
etc., is difficult to prove.
The subject is of importance because of the use
of the opsonic index as a standard of resistance, and
in diagnosis. The practical value in this clinical ap-
plication has lessened, as further study reveals it?
limitations. If it is the best it is yet a very imper-
fect standard, and other factors must be reckoned of
considerable importance. The majority of clinical
-Read at the annual meeting of the Association of American
Physicians, W^ashington, D. C, May 12, 1908.
Studies published will not bear criticism for accu-
rac}-, as shown by mathematical calculations ( see
Cambridge Committee Report). In some local in-
fections with tubercle bacillus and cocci the opsonic
estimations have appeared useful in diagnosis and
treatment. In progressive or generalized infections
the results have been of doubtful value. C. P.
Ritchie has sucessfully applied the method of ab-
sorption followed by opsonic estimations for diagno-
sis. It is analogous to that of Bordet and Gengou
recently employed by Wassermann in lues diagnosis,
except that the phagocytic test is substituted for the
haemolytic one.
Experiments at the Saranac Laboratory reported
last year on the effect of opsonized tubercle bacilli
have been confirmed and extended. Mrulent tuber-
cle bacilli treated with the fresh serum of an im-
munized cow produce more decided reactive inflam-
mation when inoculated into rabbits' corneae, in com-
parison with controls, and weak virulent bacilli treat-
ed in like manner appeared to be slightly more pro-
tective to guinea pigs subsequently inoculated to test
their immunitv.
The reaction described is characterized by an in-
creased leucocytosis, whether beneficial or not to the
animal is undetermined, but presumably it is con-
servative. Morphological changes in the bacilli were
not demonstrated by staining.
Dr. Kinghorn and Dr. Twichell have made clinical
studies with the tuberculoopsonic index in sixty-
three supposedly healthy persons and in thirty-six
tuberculous patients, controlling their technique fre-
quently by duplicate tests of four to six preparations
of the same serum.
The}- found a range from 0.92 to 1.94 in the
health)- sera, and from 0.26 to 2.26 in the tubercu-
lous.
They also made daily estimations of the sera of
seven persons six or seven days before and after the
subcutaneous tuberculin test for diagnosis. No reg-
ular reaction curve was detected, though after a tu-
berculin reaction the index was generally higher.
Likewise in eleven patients undergoing tuberculin
treatnient withoiit reference to the index, no char-
acteristic or uniform curve was manifest. Their
ascertained average technical error was + 4 per cent,
as determined from duplicate tests. Their results
do not encourage the expectation of much practical
use of the index in pulmonary tuberculosis in the
usual method of its application.
Copyright,
by A. R. Elliott Publishing Company.
1228
ILLMAN AND DUNCAN:
OPSONIC TREATMENT.
[New York
MliUICAL JOURNAU
THE OPSONIC TREATMENT OF DISEASE.
With a Report of Thirty Cases*
By G. Morton Illman, M. D.,
Philadelphia,
Lecturer on Clinical Medicine, Temple University; and Associate
Physician to the Garretson Hospital;
AND Harry A. Duncan, A. B., M. D.,
Philadelphia,
Director of the Clinical Laboratory, Samaritan Hospital.
In reporting the following cases treated by vac-
cine therapy we do so with the full appreciation of
the fact that at the present time the prognosis in the
cases considered cured can only be problematical,
and that time only will decide whether the results
obtained will be permanent.
Certain it is, however that at present prompt
beneficial results can be produced in many condi-
tions that have in the past been considered almost
hopeless as regards a complete cure.
Some of the cases here submitted were treated
nearly one year ago, and it is indeed gratifying to
note that in the majority of them there is absolutely
no tendency to a return at the present time. This
article, therefore, is not a review of the massive
quantity of literature on this subject, which is at
present attracting so much attention, nor is it to be
considered in the light of a criticism of the many
excellent methods or modifications of Wright's
opsonic technic^ue as originally advised by him, but
rather as an honest report of our experiences in the
treatment of any and all the cases that are from time
to time referred to us for treatment. Our tech-
nique, with but few modifications, has been essen-
tially the same as that advised by W^right. Many
of the cases were exceedingly resistant to all other
forms of treatment, and for this reason we have
endeavored to reduce the treatment by vaccines to
a more definite clinical basis, employing in each
case the minimum amount of technique necessary
to obtain a good result.
Taking an average of the frequency of doses and
strength of vaccine used by other investigators and
reported by them from time to time (and adhering
to the suggestions given by Wright), we admin-
istered our vaccine every seventh to fourteenth day,
depending upon the clinical condition, or opsonic
index, or both, of the patient at the time of the
treatment.
Many times the clinical condition of the patient
would be excellent, but the index low, and invaria-
bly when the patient returned to the clinic there
would be a renewal of a discharge from a sinus
which would have been impossible to forecast from
the clinical symptoms alone the week previous.
It is the better plan, therefore, in doubtful cases
to first make a study of the "opsonic" condition of
the patient before instituting any form of vaccine
injections. Our experience with a case in which
no opsonic index was taken and a large initial in-
jection given purely upon the clinical evidence pres-
ent was somewhat as follows :
The case was that of a colored woman : age thirty-nine
years. She had been operated upon for an empyema
eighteen years ago, with a negative result. Five subsequent
operations had also failed to give relief. The outlet of the con-
*Read before the Samaritan Hospital Medical Society, March 28,
1908.
stantly discharging sinus was just below and to the left
of the right scapula. A culture showed the presence of
the Staphylococcus aureus (the empyema was probably
tuberculous in origin). Clinically the patient was in the
best of health, and the sinus seemed to be the only thing
that prevented the free use of the right shoulder and arm.
She was given an injection of 200 million Staphylococci
aurei. This was followed by a severe reaction within the
following six hours, which made it necessary for the pa-
tient to go to bed. where she remained for seven days.
She complained at first of a chill, followed by vertigo and
severe rheumatic pains in the right shoulder and arm. Ten
days later, however, her improvement was so marked that
she was led to exclaim that "she had not felt so well in the
past ten years." An examination of the sinus at this time
showed the discharge from the sinus to have almost stopped
(one or two drops on a dressing in twenty-four hours),
and no pain whatever in the arm or shoulder.
That a fatal result did not follow the first injec-
tion given in this case was due more to good for-
tune than good management, and our experience
with other cases simulating this one has taught us
that in treating cases from the clinical standpoint
one should begin with very small doses of any and
all vaccines and gradually enlarge the dose with
each subsequent injection. More especially should
this routine be observed in cases where the lesion
is of very long standing. To suddenly arouse a
sleeping infection of eighteen years' standing with
a large initial dose of vaccine as was done in this
case is the very thing to be avoided if a favorable
result is to be finally obtained.
It is our practice at present to study the "phase" of
the patient, especially in cases where the lesion has
existed over a very long period. This we think is the
better policy to pursue until opsonic treatment has
more firmly established itself favorably in the opin-
ion of the profession, or to that place in therapeu-
tics which it so well deserves, for with such definite
scientific means at hand for determining before-
hand the possible effect of treatment the death rate
should practically be negative. It was the inabil-
ity to determine the opsonic condition of a patient in
former years that caused such a revulsion of feel-
ing toward Koch's tuberculin. The very same ad-
ministered now always under favorable circum-
stances is productive of nothing but good results
when tuberculin is indicated.
The number of diseases in which opsonic treat-
ment is curative or beneficial is already large, but
the present indications are that opsonic work will
not only be used more and more extensively in the
treatment of disease, but also in the diagnosis, as is
now seen in the treatment and diagnosis of tuber-
culous conditions.
Of the entire group of cases herein reported thir-
teen were tuberculous ; the remainder were as fol-
lows : Gonorrhoeal, five ; colonic, one ; staphylococcic,
six; streptococcic, three: staphylococcic and strep-
tococcic, one ; typhoid fever, one.
The one case of typhoid fever is reported because
it is typical of the negative results obtained in all
other cases that we have attempted to abort with
vaccine injections. The case reported was one in
which everything seemed clinically to favor vac-
cine treatment. We could not sec any improve-
ment, however, that could not have taken place in
any other typhoid case without vaccine treatment.
Our technique, briefly, is as follows: We first
make a thorough physical examination of the pa-
June 27, 1906.] ILLMAN AND DUNCAN: OPSONIC TREATMENT. 1229
tient and study carefully the personal and family
histor>-. The finger or lobe of the ear is then punc-
tured and the blood allowed to flow freely into a
Wright's tube. This is then conveyed quickly to
the laboratory and centrifuged. The serum thus
obtained is kept at 37° C. and used as promptly as
possible. The opsonic index for tuberculosis,
staphylococci and streptococci infections, etc., is
then determined (in the manner now so familiar to
all clinicians and laboratory workers), depending
upon the diagnosis of the condition when possible
by means of cultures and clinical phenomena. As
before stated, the index itself is often most helpful
in making a correct diagnosis. If the index is low
and is stationary, say 0.6 or 0.7. and the clinical
symptoms warrant it, without a repeated series of
more than two or three index observations being
made, we give the patient the first injection.
A point on the left arm about four inches above
the elbow is usually selected, and the skin thorough-
ly cleaned with sterile water, followed by alcohol
and again by sterile water. A drop of pure car-
bolic acid is then applied for a moment or two. This
acts both as an anaesthetic and antiseptic. The
needle is then thrust well into the subcutaneous
tissue, the injection slowly given, and the needle
quickly withdrawn, a piece of sterile cotton being
held at the point of puncture until the vaccine is
completely absorbed.
Our reason for selecting the arm in the region
usually employed for vaccination purposes is be-
cause of the fact that the patient becomes less sus-
picious and alarmed should there be any local urti-
caria or irritation following the injection, the pa-
tient being more apt to consider the local trouble
as a natural sequel to a process which he usually
believes to be nothing more or less than a form of
vaccination.
In our treatment of ' tuberculous cases we have
had more uniform results with tuberculin T. R.
than with the other forms of tuberculin when using
stock vaccines. The average dose employed in
adults is 0.001 milligramme, and we have seldom
had to change this dose in order to get good results
and cause a gradual rise in the index. One one
thousandth of a milligramme has never given any
disagreeable reaction, and we think that a course of
treatment which is never productive of a reaction
produces better and more prompt results than when
the reverse is the case.
In our treatment a year ago we used very large
doses of vaccine (one or two of the cases are in-
cluded in the appended list), which were productive
often of a very severe reaction, but followed
promptly in many cases by a fall of temperature and
improvement of syn^ptoms. The results, however,
were not alwavs permanent, so that we now feel
convinced that small initial doses at least should
always be employed ; but that in some cases doses
much larger than those recommended by Wright
must be used to bring about a good, permanent re-
sult.
We have employed the following minimum and
maximum doses:
Bacilli coli, 5,000,000 to 40,000 million ; gono-
cocci, 5,000,000 to 50 million ; staphylococci, 5,000,-
000 to 10,000 million ; streptococci, 5,000,000 to 12,-
000 million ; tubercle bacilli, 5,000,000 to 15,000 mil-
lion; typhoid bacilli, 5,000,000 to 1,000 million.
In all of the cases here reported, except Nos.
IV, XXI, XXIV, XXIX, and XXX, we used "stock
vaccines," and for the supply of the same we are
greatly indebted to Parke, Davis & Co. and the H.
K, Mulford Company. By using stock vaccines the
work is made much less complicated and greatly
facilitated, as it takes considerable time to accurate-
ly produce autogenous vaccine^.
We feel that in the majority of instances the
stock vaccines are in every respect just as efifective
as autogenous vaccines, and we make it a rule to
put all cases at first on stock vaccines. This fail-
ing, as it does now and then in complicated cases,
we put the patient on vaccines made from his own
cultures.
We must not, however, in these complicated cases
condemn our stock vaccines too quickly merely be-
cause we do not get a prompt response to treat-
ment, for in many cases our failure to get results is
not because of the fact that we are using a stock
vaccine, but because we have failed to employ that
vaccine or mixture of vaccines which corresponds
to the variety of infection to be treated. For ex-
ample, given a profuse discharge from a sinus
which cultures show us contains streptococci and
staphylococci — if the streptococcus is the pre-
dominant organism in the production of the con-
dition, staphylococcic vaccine given indefinitely would
raise the staphvlococcic opsonic index, but give little
or no result, or only in proportion to the activity
displayed by the staphylococcus in the aetiology of
the sinus. Study carefully the index and its rela-
tion to a mixed infection, and then use a stock vac-
cine corresponding to the infection, and usually a
prompt improvement is noted.
Again, in other cases we may get a histor}^ in a
given case which is decidedly tuberculous in detail,
and we give repeatedly tuberculin, or tubercle
bacilli, which produces a prompt rise in the tuber-
culoopsonic index, but no clinical improvement. An
osteomyelitis, tuberculous in character, may be con-
tinued for years by being contaminated with a sec-
ond or third infection (usually staphylococcus)
which finally becomes the predominating infection,
and a change to staphylococcic vaccine, or a mixture
of the same with tuberculin, causes a prompt, satis-
factory result.
Summary of the Cases Reported.
13 tuberculous cured 5 .... improved 4.... no result.. 4
5 gonorrhoeal " i.... " 4.... " .. o
6 staphylococcic " 4.... " o " ..2
3 streptococcic " 2.... " i
(erysipelas 2).
I mixed " o.... " 0.... " .. i
I colon infection " ' ,
I typhoid infection " 0.... " 0.... " .. 1
30 cases. 13 9 8
Total number of opsonic observations made 109
Total number of vaccine injections given 123
Conclusions.
That vaccine therapy offers a chance of cure in
many cases of disease heretofore regarded as in-
curable.
That in the large majority of cases stock vac-
cines are just as efficient as autogenous vaccines.
1230
ILLMAN AND DUNCAN: OPSONIC TREATMENT.
INew Vork-
MeDICAL JOVRN'AI.
That cases can be treated with fewer actual index
observations than was at first supposed.
That cases treated with the clinical phenomena
alone as a guide should only be so treated by some
one well versed in vaccine therapy, and then only
after having been under previous observation for
a period long enough to have determined "the
phase" the patient is in.
That very small initial doses should be employed
when the opsonic index has not been previously de-
termined.
That the best results at the present time are ob-
tained in ttiberculous conditions and staphylococcic
or streptococcic infections, as in acne, etc.
That to get the best results vaccine treatment
must be instituted as soon as the diagnosis is made.
Case I. — J. P., male, age sixteen years.
Family and personal history were negative.
Present illness : Osteomyelitis of right femur. Had been
treated for seven years locally by incisions, curetting, and
drainage. Five injections of tuberculin T. R., 0.001 mg.
at each dose, extending over a period of five weeks, caused
a complete cessation of the discharge and an apparent cure.
The tuberculoopsonic index during this time was • raised
from 0.7 to 1.4. A sudden drop of the index was promptly
followed by a small abscess a short distance from the
original sinus. This promptly healed after one more in-
jection of the tuberculin T. R., and the patient to-day is
in the best of health and has again resumed active work.
Case II. — F. M., colored, female, age twenty-six years.
Family and personal history were negative.
Present illness: Pott's disease with a discharging sinus.
May 28. 1907 — Tuberculoopsonic index, 0.8; given O.OOI
mg. tuberculin T. R.
June I, 1907 — Tuberculoopsonic index, 0.85 ; given o.OOi
mg. tuberculin T. R.
June 18, 1907 — ^Tuberculoopsonic index, 0.95 ; given 0.001
mg. tuberculin T. R.
July 9, 1907 — Patient better, discharge less ; given 0.001
mg. tuberculin T. R.
July 24, 1907 — Very little discharge noticed ; given 0.001
mg. tuberculin T. R.
August 30, 1907 — Sinus closed, had gained twenty pounds
in weight. The cure in this case was very gradual and
progressive. The final result to date is perfect.
Case III. — B. H., age four years, female.
Family history was negative.
Personal history : Had tonsils removed one year ago.
Present illness : Cervical adenitis.
May 29, 1907 — Tuberculoopsonic index, 0.65 ; given 0.001
mg. tuberculin T. R.
The first mjection was followed by marked improvement
clinically.
June I, 1907 — Tuberculoopsonic index, 0.75; given 0.001
mg. tuberculin T. R.
June II. 1907 — Reported to be in excellent condition and
has had no return to date.
Case IV. — E. T., female, age twenty-two years, colored.
Admitted to Samaritan Hospital April 2.3, 1907.
Family and persona! historj* were negative.
Present illness Tuljcrculous peritonitis.
May 2. 1907 — Tuberculoopsonic index, 0.5; given 15.000
million tubercle bacilli.
May 10. 1907 — Tuberculoopsonic index, 0.55 ; given 15,000
million tubercle bacilli.
May 12. 1907 — Tuberculoopsonic index, 0.65.
May 16. 1907 — Tuberculoopsonic index, 0.85.
May 17, 1907— Given 15,000 million tubercle bacilli. Dis-
charged from the hospital.
May 27, 1907 — Slight recurrence of symptoms. Tuber-
culoopsonic index. 0.75.
May 28, 1907 — Given 7,000 million tubercle bacilli.
March 20, 1908 — The patient's physician says she has
been practically well for the past ten months and has gone
.=outh to live.
Average temperature on admission. 10.3° F. After start-
ing treatment, average temperature. 99° to 100° F.
Cask V. — E. H., female, age nine years.
Family and personal history were negative.
Present illness : Began to notice swelling on left side of
neck six months ago, following a toothache. Tooth was
extracted. Gland finally broke down and began to dis-
charge three months after extraction of the tooth. Patient
was treated with various ointments and dressings for sev-
eral weeks with a negative result. She was then given a
course of x ray treatment with negative results. When we
first saw her the broken down area was constantly enlarg-
ing and discharging profusely.
November 11, 1907 — Tuberculoopsonic index 0.8; given
0.001 mg. tuberculin T. R.
November 23, 1907 — Tuberculoopsonic index, 0.8; given
0.001 mg. tuberculin T. R.
November 30, 1907 — Tuberculoopsonic index, 1.5; given
O.ooi mg. tuberculin T. R.
December 7, 1907 — Tuberculoopsonic index. 1.9; given
0.001 mg. tuberculin T. R.
December 14, 1907 — Tuberculoopsonic index, 1.6; gixen
0.001 mg. tuberculin T. R.
January 11. 1908 — Tuberculoopsonic index, 2.0; given
0.001 mg. tuberculin T. R.
Januery 25, 1908 — Tuberculoopsonic index, 2.0; given
0.001 mg. tuberculin T. R.
February i, 1908 — Tuberculoopsonic index. 2.1 ; given
0.001 mg. tuberculin T. R.
February 8, 1908 — Tuberculoopsonic index. 0.9; given
0.001 mg. tuberculin T. R.
February 15, 1908 — Tuberculoopsonic index, 0.8; given
0.001 mg. tuberculin T. R.
February 29, 1908 — Given 0.001 mg. tuberculin T. R.
In this case injections were given more according to the
clinical symptoms than according to the index, and al-
though the index fell decidedly toward the last the gland
had healed completely and left scarcely a mark to show
from where the discharge had taken place.
Case VI. — M. S., male, age seventeen years.
Family and personal history were negative.
Present illness: Was attacked with tuberculosis of li'ith
tibia nine years ago. Both legs operated on : right leg re-
covered, but left tibia still discharged. It was red. painful,
swollen, and discharged freely.
November 11, 1907 — Tuberculoopsonic index. 0.7; given
0.001 mg. tuberculin T. R.
November 16. 1907 — Tuberculoopsonic index, i.i.
November 20, 1907 — Tuberculoopsonic index, i.i ; given
0.001 mg. tuberculin T. R.
November 30. 1907 — Tuberculoopsonic index. 1.5; given
0.001 mg. tuberculin T. R.
December 7, 1907 — Tuberculoopsonic index, 0.7.
December 21. 1907 — Tulierculoopsonic index, 1.5; given
0.001 mg. tuberculin T. R.
January 4. 1908 — Tuberculoopsonic index, 0.9: given
0.001 mg. tuberculin T. R.
February i. 1908 — Tuberculoopsonic index, i.i : given
0.001 mg. tuberculin T. R.
February 15, 1908 — Tuberculnopsonic inde.x, 1. 2; given
O.OOI mg. tuberculin T. R.
Recovery complete.
Case VII. — J. R.. age fourteen years.
Family history was ne.gative.
Personal history and present illness : Four years ago
four ribs on the right side were removed ; cause, tubercu-
losis of ribs and plcurr.. He had a profuse, offensive
discharge from a large persistent sinus.
May 27, 1907 — Tuberculoopsonic index, 0.75 : given 0.001
mg. tuberculin T. R.
IMay 28. T907 — Tuberculoopsonic index, 0.7.
June 3. 1907 — Tuberculoopsonic index, 0.7; given o.oor
m.g. tuberculin T. R.
June 10, 1907 — Tuberculoopsonic index. 0.8: given o.OOi
mg. tuberculin T. R.
June 21, 1907 — Tuberculoopsonic index, 0.85; given o.ooi
mg. tuberculin T. R.
June 21. 1907^ — Gained four pounds in weight: marked
general improvement.
.August 23. 1907 — Condition very much improved.
.August 23. 1907 — Given o.ooi mg. tuberculin T. R.
December 14, 1907 — Tuberculoopsonic index. 1.5: gi\en
0.001 mg. tuberculin T. R.
December 21, 1907 — Had attack of influenza. Tubcrculo
index. 0.7.
December 21. IQ07 — Given 400 million mixed staph\
lococcic vaccine.
June -'7, 1908.]
ILLMAN AND DUNCAN: OPSONIC TREATMENT.
December 28, 1907 — Tuberculo index and staphylococcic
index, 1.5.
December 28, 1907— Given 0.001 mg. tuberculin T. R.
December 31, 1907 — Given 100 million staphylococci
mixed.
January 11, 1908 — Tuberculo index, 1.2.
January 8, 1908 — Given 100 million staphylococci mixed.
January 11, 1908 — Staphylococcic index, 1.9.
January 16, 1908 — Given 0.001 mg, tuberculin T. R.
January 25, 1908 — Tuberculo index, 0.9. Still consider-
able discharge noticed.
To be put on autogenous vaccine.
Case VIII.— G. C, male, age fifty-four years, colored
janitor.
Admitted to hospital October 22, 1907.
Diagnosis : Tuberculous laryngitis.
Family history was negative.
Previous personal history : Had rheumatism ten years
ago One year ago "took cold," severe cough and dyspnoea.
Present illness, cough, dyspncea. and pain in the back.
Physical examination : Impaired resonance at right apex.
Right side posterior, sibilant and bubling rales. Heart, apex
diffuse, accentuated second pulmonic. Throat, tuberculous
infiltration between the arytenoid cartilages, bases, and
epiglottis.
Average temperature. 99° F. ; highest temperature,
101.6' F.
Xo\ ember 3, 1907 — Tuberculoopsonic index, 0.6 ; given
0.001 mg. tuberculin T. R.
Xovember 28, 1907 — Tuberculoopsonic index, 0.85 ; given
0.001 mg. tuberculin T. R.
December 7, 1907 — Tuberculoopsonic index. 0.95 ; given
D.ooi mg. tuberculin T. R.
Left the hospital. While in the institution his improve-
ment was consistent with the gradual rise in the index.
The aphonia had disappeared.
Case IX. — N. B., age sixty-two years, male.
History was negative.
Present illness : Tuberculosis of lower third of ulna for
four years. Had had several operations. Two sinuses
were present, one discharging to outside of forearm, and
the other to the inside.
November 23. 1907 — Tuberculoopsonic index. 0.8; given
O.ooi mg. tuberculin T. R.
Xovember 30, 1907— Tuberculoopsonic index. 0.9 ; given
0.001 mg. tuberculin T. R.
December 7, 1907 — Tuberculoopsonic index, i.o; given
0.001 mg. tuberculin T. R.
December 14, 1907 — Tuberculoopsonic index. 1.2; given
400 million Staphylococcus aureus.
December 28, 1907 — Tuberculoopsonic index, i.o; given
0.001 mg. tuberculin T. R.
January 11, 1908 — Tuberculoopsonic index, 1.5: given
0.001 mg. tuberculin T. R.
February 22, 1908 — Tuberculoopsonic index, 1.2; given
400 million Staphylococcus aureus.
February 29, 1908 — Tuberculoopsonic index. 1.2: given
0.001 mg. tuberculin T. R.
March 7, 1908 — Given 0.001 mg. tuberculin T. R.
March 14. IQ08 — Given o.ooi mg. tuberculin T. R.
Responded to treatment but was not cured.
C-\SE X. — W. J., male, age twenty-one years, machinist.
Admitted to the Samaritan Hospital November 13, 1907.
Family and previous medical history were negative.
Diagnosis : Tuberculous peritonitis.
Present illness began one year ago with a pain in the
left side ; made worse by motion. Now had night sweats
and severe pain just below the epigastrium when coughing.
Temperature on admission. 101° F. Average temperature,
100° to T03° F. Tubercle bacilli could not be found in the
sputum ; white blood corpuscles, 7,600.
Xovember 28. 1907 — Tuberculoopsonic index. 0.85 ; raised
to I.I by January- 6, 1908.
X'ovember 29, 1907 — Given 0.001 mg. tuberculin T. R.
Some reaction noticed after the injection and fall of
temperature from 102.4° F. to 100.6° F. The average tem-
perature after the injections, however, was not afTected.
The result was negative. Patient left the hospital with
a temperature of 100° F.
C.\SE XI. — R. J., female, age twenty-four years.
Tamily and personal history were negative.
Pre-ent illness : Had had pain in right hip joint for past
two years ; some shortening ; general health good. No
local symptoms of inflammation.
Diagnosis: Tuberculosis of the hip joint.
Tuberculoopsonic index, 0.6.
Patient was given four injections of tuberculin T. R.,
0.001 mg.. at intervals of seven days. Opsonic index after
the fourth treatment, 1.2. The patient stopped coming for
treatment because she said that after each injection she
had severe pain for twenty-four hours in the affected joint.
Result negative.
C.vsE XII. — H. S., female, age two and one half years.
History was negative.
Present illness : Tuberculosis of lower maxilla.
Xovember 10, 1907 — Tuberculoopsonic index, 0.8; given
0.005 nig- tuberculin T. R.
Xovember 17, 1907 — Tuberculoopsonic index, 0.8; given
O.OOI mg. tuberculin T. R.
Xovember 23, 1907 — Tuberculoopsonic index, 0.9.
The child cried and opposed the injections to such an
extent that we stopped treatment.
C.\SE XIII. — W. S., male, age eleven years.
History was negative. Diagnosis : Tuberculosis of the
hip.
Present illness began five years ago after a fall on the
hip, with excessive discharge, and he has been wearing a
cast for five years.
November 15, 1907 — Tuberculoopsonic index, 0.9; given
0.001 mg. tuberculin T. R.
, November 30, 1907 — Tuberculoopsonic index, 0.95 ; given
0.001 mg. tuberculin T. R.
December 7, 1907 — Tuberculoopsonic index, 0.7.
December 21, 1907 — Tuberculoopsonic index, i.i ; given
400 million Staphylococci aurei.
December 28, 1908 — Tuberculoopsonic index, 1.2; given
O.OOI mg. tuberculin T. R.
January 4, 1908 — Given 300 million Staphylococci aurei.
January 11, 1908— Tuberculoopsonic index, I.7; given
O.OOI mg. tuberculin T. R.
February 8, 1908 — Tuberculoopsonic index, i.i ; given
O.OOI mg. tuberculin T. R.
February 22, 1908 — Tuberculoopsonic index, 1.4; given
300 million Staphylococci aurei.
February 29, 1908 — Given 0.001 mg. tuberculin T. R.
March 14, 1908 — Given o.ooi mg. tuberculin T. R.
IMarked improvement, but still had a slight discharge.
Will be put on treatment with autogenous vaccine.
C.\SE XIV. — A., age thirty years.
Family and personal history were negative.
Present illness : Patient had gonorrhoeal arthritis of both
ankle joints and both knee joints.
Two injections at intervals of seven days caused a com-
plete amelioration of the symptoms and a marked general
improvement, so much so that the patient said he did not
want any more treatment, and if he should have a relapse,
he said he would return.
Case XV. — Mr. G., male, age forty-two years. Diag-
nosis : Chronic gonorrhoea.
Family and personal history were negative.
He was treated locally from time to time and persistently
for the past six months with a negative result. All the
various astringents and combinations of the same gave no
result.
January 7. 1908 — Given 50 million gonococci.
January 21. 1908 — Marked improvement as regards the
quantity of the discharge.
January 21, 1908 — Given 50 million gonococci.
Januar\' 28. 1908 — Discharge decidedly less : given 50
million gonococci. When last seen no discharge was no-
ticeable except at intervals of three to four days.
Patient did not return for further treatment.
Case XVI. — E. M., male, age twenty years.
Family history and previous medical history were nega-
tive. Present illness : For the past two years patient suf-
fered with a severe pain in the rectum, accompanied with a
purulent, bloody discharge, which was at times very pro-
fuse. Shreds of mucous membrane, two to four inches in
length, were frequently passed.
Diagnosis: Gonorrhceal proctitis (clinically and micro-
scopically).
February 2, 1908 — Opsonic index, 0.7 ; 50 million gon-
ococci injected into the arm.
The index improved gradually until it reached i.i. The
discharge became less in quantity, but did not stop.
12.32
ILLMAN AND DUNCAN
OPSONIC TREATMENT.
[New York
Medical Jckrnal.
March 7. 1908 — We have stopped giving stock vaccine
and he will now be given autogenous vaccine.
Case XVII. — Mr. M., age forty years.
Family history was negative.
Previous medical history was one of exposure and
infection.
Present illness : Suffering for twenty years with a pos-
terior urethritis, prostatic abscess, and gonorrhoeal arthritis.
Had to use crutches for a long time and local treatment
gave only temporary relief. Ohlmacher gave him two in-
iections of gonococci, which was followed by immediate
and decided improvement. Business changes compelled
him to corne to Philadelphia.
With treatments that were very irregular as to time (pa-
tient was a traveling salesman), the improvement was very
--teady, the joint symptoms especially were clearing up, so
much so that he now travels to a considerable extent for a
mercantile house. The urethral discharge was less than
when we first saw him.
C.\SE XVIII.— H. S., age forty years, male.
Family and personal history were negative.
Contracted gonorrhoea in July, 1907 ; was given the usual
course of treatment for this condition for six months.
When we finally saw the patient he had a marked posterior
urethritis.
January 4, 1908 — Gonorrhoeal opsonic index was i.i. He
was given 50 million gonococci every seventh day, followed
by a steady improvement, but no cure effected. Index,
March i, 1908, 1.5. A careful culture study of the case will
now be instituted and the stock vaccine replaced by auto-
genous vaccine.
Case XIX. — Mrs. S., age thirty-eight years.
Family and personal history and previous medical his-
tory were negative.
Present illness : Had suffered with pustular acne of the
face and neck for twenty-three years, and had been treated
almost constantly during that time. High frequency cur-
rent, ultra violet rays, and x rays had all been given a
thorough trial with a negative result.
February i, 1908 — When -the patient presented herself for
treatment the pustules were very numerous and many of
them one half inch in diameter, containing much pus. Upon
this clinical evidence she was given an injection of 300
million Staphylococci citrei. This was repeated in seven
days, after which every papule and pustule on the face and
many on the neck disappeared, leaving a smooth, nonindu-
rated surface. She has now had six treatments. The face
is perfectly normal and not a single new lesion has
appeared.
C.^SE XX. — Mr. G.. age twenty-one years.
Family and personal history were negative.
Present illness : Had been afflicted with a pustular acne
of the face for the past three years.
December 11, 1907 — Given 300 million Staphylococci
citrei.
December 18. 1907 — Given 300 million Staphylococci
citrei.
December 25, 1907 — Given 300 million Staphylococci
citrei.
January 2, 1908 — Given 300 million Staphylococci citrei.
January 6, 1908 — Given 300 million Staphylococci citrei.
January 9, 190S — Cure complete.
Case XXI. — Mr. A., age twenty-four years.
Family and personal history were negative.
Present illness : Pustular acne of the face of six years-
duration.
June 4. 1907 — Staphylococcic index. 0.7; culture showed
staphylococci. Given 10,000 million staphylococci (auto-
genous).
June 10, 1907 — Given 10,000 million staphylococci. Some
improvement noted.
June 17, 1907— Given 10,000 million staphylococci (auto-
genous).
June 24, 1907 — Given 10,000 million staphylococci.
Result negative.
Case XXII. — Mr. D., age twenty-two years.
Family and previous medical history were negative.
Present illness: For five years had had acne pustulosa of
the face. Many hard, infiltrated areas were noted. Was
given three injections at intervals of seven days of 300
million Staphylococci citrei. The . condition rapidly
cleared up and the induration greatly improved when the
patient was attacked with pleurisy. For a period of three
weeks he was confined to the house. At the end of this
time a few papules again appeared on the neck. The injec-
tion was repeated and no new lesions appeared up to the
present time.
Case XXIII. — G. K., male, age twenty years.
History was negative.
Present illness : Infection of right side of the face and
neck following the opening of a pimple. Culture showed
Staphylococcii.i albus and aureus.
November 21, 1907 — Staphylococcoopsonic index, 0.8;
given 400 million mixed staphylococci.
November 23, 1907 — Staphylococcoopsonic index, 0.9.
December 7, 1907 — Staphylococcoopsonic index, 1.3.
Complete recovery.
Case XXIV. — A. M., female, age twelve years.
Family history was negative.
Present illness : Osteomyelitis with metastatic abscesses.
Temperature on admission to hospital was 105° F. Aver-
age temperature was 105° F. to subnormal.
Two days after admission tibia was scraped and drained.
Temperature became normal for a period of two days, then
began to rise and remit again.
Eighteenth day — Hsmoglobin, 70 ; white blood corpuscles,
26,000; red blood corpuscles, 3,250,000.
Thirty- fourth day — Patient became delirious.
Thirty-sixth day — We were asked to see the patient. We
made a culture which showed a mixed infection of Staphy-
lococcus aureus and streptococcus.
Thirty-seventh day — Patient was given 6,000 million
mixed staphylococci and streptococci (autogenous).
Thirty-eighth day — Rise of temperature from 99° to
103° F.
Thirty-ninth day — Patient much better, slept well and
took nourishment better.
Forty-second day — Mental condition very good ; tempera-
ture again falling to normal.
Forty-fourth day — Autog:enous vaccine again given. 12,000
million mixed staphylococci and streptococci, followed by a
rise of temperature from 98.8° to 106.6° F.
Fiftieth day — Temperature normal and remaining so for
ten days; improvement of all symptoms.
Sixty-first day — Temperature subnormal, 96° F. Physi-
cal examination showed enlarged liver, probably amyloid.
Temperature for seven days 96° to 97°F.
Sixty-ninth day — Patient died.
Case XXV.— H., male, age eighteen years.
Family and personal history were negative. Diagnosis:
Erysipelas.
Present illness : Patient had been treated for five days for
typhoid fever when the case was referred to us. The face
was greatly swollen, red, and oedematous on both sides and
extended into the scalp. Temperature, 101° F.
November 15, 1907 — Patient was given 50 million
streotococci.
Tlie temperature remained at 101° F. for twenty-four
hours, then fell to normal. The patient insisted on leaving
the hospital and going home. The improvement was very
decided, but we have been unable to locate the patient,
which necessitates the record of the case as "improved" in-
stead of "cured."
Case XXVI.— Mrs. B., age twenty-eight years.
Family history was negative.
Personal history : Had an attack of erysipelas when thr'»e
years of age.
Present illness : On fifth day of her puerperium the pa-
tient had a chill and some fever, with abdominal tenderness
over the uterine region. A pelvic examination revealed an
enlarged, tender uterus, and she was sent to the hospital
and a curcttement done. The day following the operation
the patient was attacked with facial erysipelas.^
January 15. 1908— Patient was given 50 million strep-
tococci.
The temperature, which was 102° F., fell to normal
within twenty-four hours, and it was found to be unneces-
sary to repeat the injection. A quick recovery followed
and no further rise in temperature was noted after the first
injection.
Case XXVII.— Mr. T.. age sixty-two years.
Family and personal history were negative.
Present illness consisted in a sinus following an operation
for ischiorectal abscess.
.\ culture showed the predominance of the Slaphylococ-
June 27, 1908.]
MORO: TUBERCULIN INUNCTION TEST.
1233
cus aureus, and mixed staphylococci vaccine injections
every seven days for four weeks raised the index from
07 to 1.4.
Not much improvement followed; autogenous vaccine is
now being administered with improvement.
C.\.-E XX\'III. — D. G., age five years, male.
History was negative.
Present illness : General infection of the arm following
a puncture wound.
November 21, 1907 — Streptococcic index, i.i.
November 23, 1907 — Given 25 million streptococci; fol-
lowed by complete recovery.
C.\SE XXIX. — C. R., female, age thirty-six years.
Family history was negative.
Previous medical history: Had had a difficult labor
eleven years ago ; the pelvis was justominor.
Present illness : Eighteen months ago began to show-
symptoms of cystitis. Had an operation done for repair
of a tear resulting from the difficult labor referred to ; at
the same time, the bladder was irrigated, which was con-
tinued for some weeks. This was followed by improvement
for a short time.
We now saw her for the first time. A retroverted uterus
was replaced and the bladder carefully explored with the
cystoscope and washed out with solution of silver nitrate.
No relief was noted from this or subsequent irrigations.
A culture from the urine showed the presence of colon
bacilli.
May I, 1907 — Colonopsonic index, 0.7.
■ May 2. 1907 — Given 40,000 million colon bacilli. (Auto-
genous).
May 3, 1907 — Index, 0.5 ; severe reaction followed this
injection ; the arm around the point of injection was
swollen and inflammatory in character; cleared up with
wet dressings ; no pus.
May 9, 1907 — Index, i.i. Given 5,000 million colon
bacilli.
^lay 21, 1907 — Given 10.000 million colon bacilli.
June 10. i907^Given 10,000 million colon bacilli.
Symptoms completely cleared up. Patient has remained
absolutely healthy to the present time. March 15, 1908.
C.xsE XXX,— D., age twenty-seven years. T)phoid
fever. Admitted to the Samaritan Hospital April 17, 1907,
the ninth day of the disease. Temperature, 103° F.
April 20. 1907 — Given 1,000 million typhoid bacilli ; fol-
lowed by a severe reaction, prolonged chill, and a rise of
temperature, from iot° to 103.6° F. Had no apparent ef-
fect on the course of the disease. Temperature reached
normal on the 21st day of the disease.
3235 XORTH FiFTEEXTH S i REET.
2721 \\'est Lehigh Avexue.
THE TUBERCULIN INUNCTION:
A Diasiiostic Measure zvithout Rupture of Continuity of
the Skill.
By Ernst Moro. M. D.,
Munich,
Privatdocent in the University of Munich.
I rul) into the skin of the chest or abdomen, over
an area of 4 cubic inches, *a piece of the fcllowing
ointment of the size of a pea for about half a minute,
and permit the ointment to remain on the surface of
the skin to spontaneously absorb. The effect of this
inunction is obser\-ed on the following day or later.'
The ointment is prescribed thus :
R Koch's old tuberrulin, 5 c.c. ;
Anhydrous wool fat, 5 grammes.
The result is positive when small papules appear
over the area of the inunction or in its immediate
vicinity ; negative when the skin shows no changes
of any kind. With the positive reaction one often
observes only a few very pale papules. Occasionally
the paptiles are very numerous and red, and only
exceptionally the skin in the region of the inunction
is very much reddened and itches. The papules
'Ohservation is usually best on the second day.
usually disappear at the end of a week. Other local
or general symptoms have not been observed.
A positive result obtained by this method is as
conclusive for a present or previous tuberculous in-
fection as is that obtained by the conjunctival reac-
tion or cutaneous method of von Pirquet.
By comparing the efifects of my method and that
of von Pirquet upon a large number of patients, the
following differences were seen: (i) In advanced
cases of tuberculosis the skin loses earlier its reac-
tionary power to the inunction. (2) In cases show-
ing no clinical signs of tuberculosis the percentage
of positive results is much smaller in the inunction
method.
As opposed to the conjunctival and subcutaneous
applications the inunction is entirely harmless. The
patients never object to its use.
]My investigations have been only upon children.
In tlie Munich medical clinics of Professor Friedrich
von Miiller and Professor Josef von Bauer, however,
the efficiency of my method has been proved on
adults.
23 Moz.artstrasse.
THE OPHTHALMIC TUBERCULIN TEST.
Bv A. L. Benedict, M. D.,
Buffalo.
So many thorough discussions of this method
have recently appeared that I merely wish to record
a few clinical data :
Case I. — Tuberculous tibia, moderate conjunctivitis in each
eye, reaction doubtful.
Case 11. — Acne, very marked, in chronic alcoholic, de-
layed and probably adventitious conjunctivitis in eye op-
posite to that into which the tuberculin was instilled.
Case III. — Typhoid, sixteenth day, nearly nonfebrile, no
reaction.
Cases IV to XII. — -Miscellaneous cases, mainly surgical,
no suspicion of tuberculosis, no reaction.
Case XIII. — Young woman, tuberculous since 1905.
bacilli and cavity in summer of 1906, treated with Smith
lymph, diet, etc., lungs let alone, no fever for some time,
good general health, some moisture in region of cavity
which I can no longer detect, practically no sputum; very
marked but not serious reaction.
Case XI\'. — Young woman said to have had weak lungs,
been "threatened with phthisis," and advised to give up dusty
work on that account. I had not been able to find any
lesion. Reaction negative.
Case XV. — Young woman with acute exudative pleurisy,
without assignable cause, in November. Apparently com-
plete recovery after tapping. Reaction doubtful.
Cases n and XV illustrate a possible fallacy
which I have not happened to see mentioned, name-
ly, the occurrence of an adventitious conjunctivitis
from dust, coryza, etc. Such causes may act so as
to simulate not only a positive reaction, but. bv af-
fecting the uninstilled eye. to vitiate the contrast
and thus perhaps lead to the recording of a negative
or doubtful result. I do not overlook the fact that
very circumstantial descriptions have been given of
the appearances to be looked for. but it seems doubt-
ful whether tliese are sufficiently characteristic to
be distinguished from a conjunctivitis of ordinarv
cause, especially when the latter occurs coinci-
dentally.
The patient in Case XV took cold on the dav of
the instillation. Thus, while there was slightly
more redness in the instilled eye. it was impossible
to say whether this was due to the tuberculin or to
a greater degree of extrinsic inflammation, such as
1234
BENEDICT: OPHTHALMIC TUBERCULIX TEST.
[New York
Medical Journal.
is very frequently noted. The nostril correspond-
ing also discharged slightly more. This suggests
the query as to whether tuberculin, in the case of
positive reactions, produces a corresponding uni-
lateral rhinitis and even as to whether we may not
apply the test nasally. If, as some state, "idio-
pathic" pleurisy is always tuberculous, we should
certainly expect a marked reaction in this case.
156 West Chippewa Street.
THE OPHTHALMIC REACTION IN THE DIAG-
NOSIS OF TUBERCULOUS CONDITIONS.
With Special Reference to the Lungs and Skin.
By Henry Hubbard Pelton, A. M., M. D.,
New York,
.\djunct Assistant Atteiidin" Physician to Bellevue Hospital; Chief
of the Medical Clinic, Presbyterian Hospital, Out
Patient Department.
Since Calmette's original papers' the ophthalmic
reaction to tuberculin has become too familiar to
the profession to need full description here. It is
sufficient to state that, in general, when a small
amount of sterilized one-half to one per cent, solu-
tion of dry tuberculin in normal saline solution is
instilled into the conjunctiva of a patient who is
the subject of tuberculous disease a local reaction
takes place. In most instances where this positive
reaction is obtained within three to forty-eight
hours after the instillation, the semilunar fold and
caruncle become reddened and the conjunctiva be-
comes congested, the general appearance being that
of an acute infectious conjunctivitis. The reaction
reaches its. height in from six to ten hours, and, as
a rule, disappears in from eighteen to thirty-six
hours. There may be slight lachrymation and the
eyelids may be gummed together when the patient
awakes in the morning, but the discomfort is very
slight. The positive reaction varies in degree from
a moderate congestion of the caruncle and conjunc-
tiva to marked oedema of these structures with
fribrinopurulent secretion and photophobia. The
local reaction is apparently accompanied by no con-
stitutional disturbance nor is the local tuberculous
process influenced in any degree. Diseases of the
eye contraindicate the employment of the test. For
a more detailed description of the types in which
the reaction may manifest itself the reader is re-
ferred to the paper of Smithies and Walker.'
A number of instances in which untoward re-
sults have followed the use of the test have been
reported. These have varied from persistent con-
junctivitis' to interstitial keratitis'; one instance of
destruction of the eye has also been reported." In
the writer's cases there were but two instances of
marked conjunctivitis (cases xx and xxiii) ; these
persisted for from ten days to two weeks ; one case
of persistent phlyctenular conjunctivitis has been
observed in a patient who underwent the test in the
wards of the Presbyterian Hospital.
In most of the patients reported in this paper a
one per cent, solution of tuberculin was used, but
'La Presse medicate, June 19 and July 13, 1907.
'■'Journal of the American Medical Association, January 25, 1908.
•Barbicr: Bulletin et Memoircs de la Sociite mfaicale des hdpitau.r
de Paris, December, 12, 1907; Renon, ibidem, December 12, 1907;
Mackay, Boston Medical and Surgical Journal, March 12, 1908;
Butler, British Medical Journal, April 25, 1908.
*Knapp: Archives of Ophthalmology, March. 1908.
•Gulland and Williamson: Scottish Medical and Surgical Journal,
April, 1908.
in a few a solution of one-half per cent, strength
was employed. The amount instilled in each in-
stance was 0.025 c.c. which was measured in a
graduated throttle pipette, this instrument being
sterilized by boiling before use. The technique
employed in the instillations was that described by
Baldwin.*'
It has been stated that the tuberculin solutions
are not stable but the one per cent, solution used
by the writer remained potent for aj; least two
months. \\'hen not in use it was kept tightly corked
at an ordinary temperature. The tuberculin em-
ployed was furnished to the Presbyterian Hospital
by the Rockefeller Institute of New York city.
When this study was undertaken it was intended
to embrace only patients sufifering from or suspect-
ed of being subjects of pulmonary tuberculosis, but
owing to the kindness and interest of Dr. Jerome
Kingsbury, class head in dermatology at the Pres-
byterian Hospital, Out Patient Department, a num-
ber of dermatological cases became available, and
the results obtained in these are incorporated in
this report. Most of the patients tested were se-
lected from those applying for treatment at the
Presbyterian Hospital, Out Patient Department,
but two are from the writer's private practice, and
several of the dermatological cases are from the
service of Dr. Kingsbury at the New York Skin
and Cancer Hospital. In recording the results ob-
tained the following scheme', which is practically
that of Baldwin, has been adopted: o, No differ-
ence in either conjunctiva. ?, Slight difference, es-
pecially in caruncle. +, Distinct redness of caruncle
and palpebral conjunctiva. ++, Distinct redness of
palpebral and bulbar conjunctiva with lachrymation
and formation of fibrin. CEdema of lids and
photophobia ( chemosis ) .
Case I. — L. B., female, fourteen years of age. Clinical
diagnosis: Pulmonary tuberculosis (second stage). Bacilli
found in sputum. On January 31, 1908, one half per cent,
tuberculin in right eye. Result, H — h.
Case II.— A. H., female, thirty-six years of age. Clini-
cal diagnosis : Probable pulmonary tuberculosis, incipient.
No bacilli found in sputum. In this patient the physical
signs were hardly sufficient to assure the diagnosis, and it
is in such cases, in-the writer's opinion, that the ophthalmic
test will find its greatest field of use in the diagnosis of
pulmonary tuberculosis. April i, 1908, one per cent, tuber-
culin in right eye. Result, O. April 13, 1908, one per cent,
tuberculin in left eye. Result, +.
Case III. — E. R., female, twentj^-two years of age. Clin-
ical diagnosis : Pulmonary tuberculosis, first stage. No
bacilli found in sputum. January 31, 1908, one half per
cent, tuberculin in right eye. Result, O. March 27, 1908,
one per cent, tuberculin in right eye. Result, -f-.
Case IV. — B. F.. female, thirty years of age. Clinical
diagnosis: Pulmonary tuberculosis, second stage. Bacilli
found in sputum. February 7, 1908. one half per cent,
tuberculin in right eye. Result, +.
Case V. — F. McP.. male, sixty years of age. Clinical
diagnosis : Pulmonary tuberculosis, third stage : Bacilli
found in sputum. AprW 10, 1908. one per cent, tuberculin
in right eye. Result, -|-.
Ca.'^e VI.— L. L'., male, forty years of age. Clinical diag-
nosis : Pulmonary tuberculosis, third stage : Potts' Disease.
No bacilli found in sputum. March 11, 1908. one per cent,
tuberculin in right eye. Result, O. March 25, 1908. one
per cent, tuberculin in right eye. Result, -|-.
Case VIT — J. F., male, forty-one years of age. Clinical
diagnosis : Pulmonary tuberculosis, second stage. Bacilli
found in sputum. March 29, 1908, one per cent, tuberculin
in right eye. Result. +.
^Journal of the .inicrican Medical Association, December 14. '907.
•Campbell, McKee, and White: Montreal Medical Journal, .\pril,
1908.
June J/, 1908.]
PELTON: OPHTHALMIC TUBERCULIN TEST.
1235
Case VIII. — G. H., male, thirty-fuur years of age. Clin-
ical diagnosis : Pulmonary tuberculosis, quiescent. This
patient applied at the dispensary some two years ago in
the second stage of the disease; bacilli were present in his
sputum. He has done well under treatment and has gained
twe'ity pounds. The signs of his old lesion are still dem-
onstrable. February 10, 1908, one half per cent, tuberculin
in right ' eye. Result, -r -f .
C.^SE IX. — ^J. R., male, forty-four years of age. Clinical
diagnosis : Pulmonary tuberculosis. The history of this
patient is very similar to that of Case VIII. Bacilli were
formerly present in his sputum, but have now disappeared.
March 20, 1908, one per cent, tuberculin in right eye. Re-
sult. O. April 10, 1908, one per cent, tuberculin in right
eye. Result, +.
Case X. — C. J., female, twenty. Clinical diagnosis :
Pulmonary tuberculosis, incipient. This patient has been
under the writer's care at intervals for about four years.
During the summer of 1907 she underwent an attack of
pleurisy with serous effusion; this was treated by means
of thoracocentesis. Recovery took place, but the clinical
symptoms since her pleurisy led to the belief that there was
a tuberculous lesion m the lungs, although no very definite
signs could be demonstrated, nor were tubercle bacilli
found in the sputum. It is in such patients that the oph-
thalmic test will prove extremely useful if further experi-
ence shows that it is reliable. March 7. 1908, one per cent,
tuberculin in right eye. Result, +.
Case XL — M. 0"B., male. Clinical diagnosis : Bronchiec-
tasis ; pnimonar\ tuberculosis, third stage. Bacilli found
in sputum. February 7, 1908. one half per cent, tuberculin
in right ej-e. Result, O. February 18. 1908, one per cent,
tuberculin in right eye. Result, O. March 14, 1908, one
per cent, tuberculin in left eye. Result, O. April 4, 1908.
one per cent, tuberculin in right eye. Result, +.
Case XII. — M. L. M., female, forty-one ye^s of age.
Clinical diagnosis : Pulmonary tuberculosis, first stage ;
surgical kidney. -March 5, 1908, one per cent, tuberculin
in right eye. Reaction, +. This patient was referred to
the writer by Dr. George B. Campbell. Her family history
was tuberculous, and she had been suffering from a bladder
disorder for twelve years. The urine contained pus. and
three times during the past three years a tumor appeared
just above the left groin. Each time the tumor disappeared
suddenly, without, how ever, any associated sudden increase
in the flow of urine. Physical examination revealed the
presence of a small tuberculous infiltration in the right
lung and of two palpable kidneys, the left larger than the
right and tender. A diagnosis of pulmonary tuberculosis
and left pyonephrosis, possibly tuberculous, was made. Xo
tubercle bacilli were found in the urine. The patient was
sent to the Presbyterian Hospital, where the diagnosis of
surgical kidney was confirmed by cystoscopy and ureteral
catheterization, the pus from the affected kidney contain-
ing Bacilli coli in pure culture. Subsequently nephrectomy
was performed by Dr. Ellsworth Eliot, Jr. The patient
made an uneventful recovery.
Case XIII. — J. C, male, tw enty-five years of ^e. Clinical
diagnosis : Cerebral syphiHs( ?) ; tuberculous brain lesion( ?).
February 24, 1908. one per cent, tuberculin in right eye.
Reaction, O. This patient was seen at the Manhattan Eye
and Ear Hospital by the courtesy of Dr. Frank J. Parker.
The facts that the symptoms rapidly disappeared under the
administration of potassium iodide in large doses and that
the ophthalmic reaction was negative would seem to rule
out tuberculosis as a factor in the condition.
Case XIV. — Female, twenty years of age. Clinical diag-
nosis : Probable incipient pulmonary tuberculosis. Feb-
ruary 17, 1908, one per cent, tuberculin in right eye. Reac-
tion, O. April 21. 1908, one per cent, tuberculin in left eye.
Reaction. O.
Case XV. — D. L.. female, sixteen years of age. Clinical
diagnosis (chiefly on history) : Possible incipient pul-
monary tuberculosis. Xo bacilli found in sputum. Feb-
ruary 14. 1908, one per cent, tuberculin in right eye. Reac-
tion. O. May I. 1908. one per cent, tuberculin in left eye.
Reaction, O.
Case XVI. — C. K., male, thirty-seven years of age.
(Control test.) Clinical diagnosis: Alcoholic gastritis.
^March 16, 1908, one per cent, tuberculin in right eye.
Reaction, O. April 21, 1908, one per cent, tuberculin in left
eye. Reaction. O.
Case XVII. — W. N., male, thirty-seven years of age.
(Control test.) Clinical diagnosis: Anaeitiia; possible car-
cinoma of stomach. March 9, 1908, one per cent, tuberculin
in right eye. Reaction, O.
Case XVIII.— L. M., female, thirty-five years of age.
Clinical diagnosis: Necrotic granuloma (folliclis). No evi-
dence of other tuberculous lesion. April 13, 1908, one per
cent tuberculin in right eye. Reaction, -|-.
Case XIX. — R. G.. female, twenty-three years of age.
Clinical diagnosis: Necrotic granuloma (folliclis). This
patient, several years ago, suffered from an attack of
erythema indurata (Bazin) and now has enlarged cervical
glands, which probably are tuberculous. April 17. 1908,
one per cent, tuberculin in right eye. Reaction, -|-.
Case XX. — H. H., female, twenty years of age. Clinical
diagnosis: Necrotic granuloma (folliclis). No evidence of
other tuberculous lesion. April 13, 1908, one per cent,
tuberculin in right eye. Reaction, +
Case XXI. — N. M., female, fifteen years of age. Clinical
diagnosis: Lupus vulgaris. No evidence of other tubercu-
lous lesion except slight dulness and diminution of the
breath sounds at the apex of the right lung. April 13, 1908,
one per cent, tuberculin in right eye. Reaction, -(-.
Case XXII. — B. M., female, thirty-three years of age.
Clinical diagnosis : Lupus vulgaris. No evidence of other
tuberculous lesion. March 26, 1908, one per cent, tubercu-
lin in right eye. Reaction, -|-.
Case XXIII. — G. M., male, thirty-one years of age. Clin-
cal diagnosis : Lupus vulgaris. No evidence of other
tuberculous lesion. February 18, 1908, one per cent, tuber
culin in right eye. Reaction, -|-
Case XXIV. — K. K., female, thirty-six years of age.
Clinical diagnosis : Lupus erythematosus. No evidence of
tuberculous lesion. February 28, 1908, one per cent, tuber-
culin in right eye. Reaction, O. April 20, 1908. one per
cent, tuberculin in left eye. Reaction O,
C.^SE XXV, — E, G„ male, twenty-six years of age. Clini-
cal diagnosis : Lepra. No evidence of any tuberculous
lesion. April 17, 1908, one per cent, tuberculin in right
eye. Reaction, O. April 23. 1908, one per cent, tuberculin
in left eye. Reaction, O. This patient was tested as a
matter of interest, since it is known that in leprosy injec-
tions of tuberculin under the skin may be followed by a
constitutional reaction.
Since the ophthalmic test may be positive in
txphoid fever it ma\' be well to state that none of
the patients who exhibited a positive reaction had
suffered irom a recent attack of this disease.
Summary. In summarizing the results it seems
be.st to deal with the dermatological cases separate-
ly. Of the other patients, all those in whom the
diagnosis was assured, either by the presence of
distinct physical signs or by the demonstration of
the presence of the tubercle bacillus in the sputum,
a positive reaction was obtained, although in some
instances two or more trials were necessary. The
two patients (Cases XR' and' XV) in whom a
tentative diagnosis of pulmonary tiiberculosis wa,":
made reacted negatively; the control cases (X\7
and XVII) also gave negative results.
Of the dermatological cases, in all those, six in
number, in \\hom the affection was one of tuber-
culous nature — for while necrotic granuloma is not
of itself a tuberculous lesion according to the der-
matologists, it seems to bear a constant relation to
tuberculosis — an undoubted positive reaction was
obtained, while, in the case of erythematous lupus
(XXR") the reaction was negative.
Conclusions: If one can deduce conclusions of
value from the results obtained in so few cases, it
would seem that the following might be justifiable :
I. The ophthalmic test is an aid of some value
in the diagnosis of tuberculous conditions of the
lungs, but in many instances is unnecessary since
the diagnosis may be assured by the examination
of the sputuin and by physical examination of the
chest. However, in incipient cases with equivocal
signs the test mav be of distinct assistance provided
1236
BERNART: MERCURY AND TUBERCULOSIS.
[New York
Medical Journal.
its results can be relied upon. Whether reliance
is to be placed upon it or not further study of the
reaction will show.
2. In lupus vulgaris and tuberculides of the type
of necrotic granuloma (follicles) the ophthalmic
reaction seems to afford a very material help in the
diagnosis of the condition.
The writer wishes to express his sincere thanks
to Dr. F. P. Kinnicut, attending physician to the
Presbyterian Hospital ; to Dr. E. F. DuBois, of the
interne stafif of the hospital ; to Dr. F. J. Parker,
ophthalomologist ; and to Dr. Jerome Kingsbury,
dermatologist to the dispensary, as well as to his
other associates of the dispensary staff, whose aid
and interest have made possible the writing of this
paper.
87 T Park Avenue.
MERCURY AND TUBERCULOSIS.
By William F. Bernart, M. D.,
Chicago, 111.
The editorial in the May 22d issue of the Nczv
York Medical Journal on Mercury in the Treatment
of Consumption, based upon the experiments of B.
L. Wright, Surgeon, U. S. N., and published in the
U. S. Naval Medical Bidleiin, has assisted in ad-
vancing a topic of considerable interest and mag-
nitude. I say advancing, as the subject has been
generally dealt with in articles upon the action of
mercury, in which it is usually stated that this metal
is contraindicated in certain wasting diseases, of
which tuberculosis is one. It is barely possible that
such deductions, in at least some varieties of tuber-
culous infections, were prompted by a faulty admin-
istration of the drug.
There is but little doubt that mercury adminis-
tered so as to gain an intensive action without the
production of toxic symptoms exerts a beneficial
influence over some varieties of tuberculous infec-
tions; just what conditions are the most favorably
influenced remain to be decided. It has been my
practice for some years to use mercury intravenously
for the routine treatment of syphilis, so possibly I
can add a mite to an interesting subject. A survey
of my statistics some months ago (preparatory to
the publishing of an article on syphilis, not tuber-
culosis) showed that I had treated 422 syphilitics
by the intravenous method, and had given 9,838 in-
jections, of which 944^) were of mercuric chloride,
327 of mercuric cyanide, thirty-two of sublamine
(ethylenediamine mercury sulphate), and thirty-
three of mercuric iodide. The average dose of mer-
curic chloride was 0.02 gramme (3^ grain).
Among the 327 patients treated with mercuric
chloride were several with tuberculosis and from
whom general observations were made. These ob-
servations at the time were not made for specific
publication, as they apparently were foreign to my
subject in view, but the rehabilitation of the topic
of mercury in tuberculosis prompts this informal
report.
Before citing the .influence of mercury injections
upon the tuberculous cases it might be of advantage
to show that mercury, when given by injections,
pos.scsses certain actions exclusive of its antisyphilitic
ones: this especially applies to the mercuric chloride.
This drug when injected in full doses has a decided
antithermic action in nearly all cases where the fever
is the result of some germ invasion. Besides this,
it also exerts what might be termed a sedative in-
fluence, that is, it decreases the nervous tension, or,
as the patient expresses it, it makes him lazy and
indolent. This latter action might be the result of
a mild metallic poisoning. In view of this, it is not
at all surprising that certain tuberculous patients
at first seem to be favorably influenced by this meth-
od of treatment.
The general observations made on the syphilo-
tuberculous patients of this series were as follows:
1. That the control of the active syphilis in many
of the tuberculous patients seemed for the time to
benefit the tuberculosis also.
2. That in patients with pulmonary tuberculosis,
after the first control of the syphilis and if the treat-
ment was continuously pushed, a few months would
show a gradual aggravation of the tuberculosis.
3. That the genitourinary tuberculous patients,
outside of the benefit to their syphilis, showed no
improvement in their tuberculosis.
4. That two patients with tuberculous eye trouble
were benefited, one markedly so and the other but
moderately so. This is not surprising, as the in-
travenous injections of mercuric chloride exert a
decided and beneficial influence over infections and
ulcerations of the eye.
5. That the patients with pulmonary tuberculosis,
evidently suffering from the absorption of septic
materials, probably due to a secondary germ infec-
tion, were decidedly benefited up to a certain point,
after which, if the mercurial treatment was con-
tinued, their retrogression was rapid.
Regarding the sending of tuberculous patients,
as suggested editorially, to the various spas, such
as Hot Springs, Ark., for the reason that they can
probably tolerate larger doses of mercury there than
elsewhere, I can only say that after five years of
practice at that same resort I became imbued with
the general impression in vogue, and this impression
undoubtedly emanated from experience that, so far
as the tuberculosis is concerned, syphilotuberculous
patients do not do well under the treatment at that
place. This impression may not be due to the use
of mercury, but to the overdosing with the iodides,
a habit nearly universally prevalent at the Springs.
42 !\Iadison Street.
PUERTO RICO .AS A FIELD FOR RESE.\RCH IN
TROPICAL MEDICINE.*
By Bailey K. Ashford. M. D., U. S. Army,
Washington, D. C,
Honorary Member, Puerto Rico An:eniia Commission.
{Under the Imprimatur of the Society of Tropical
Medicine.)
There are a few remarks which may be made
concerning certain diseases classed as "tropical"
to be found in the island of Puerto Rico which may.
perhaps, interest the members of this society in a
nearby and very inviting field of study.
I was for some years in a position to see a large
number of current dispensary ca.ses as well as to fol-
low up some special cases in the hospital. Prob-
•Read at the fifth annual niet-tinK of the American Society of
Tropical Medicine, h Id n. i;.-.lln....n . M.uili .-8. lO.-S
June zy, igo8.] ASHFORD. FIELD FOR RESEARCH IX FROPICAL MEDlLlXE.
ably about 15.000 were thus personally seen, and
fully 20,000 more were observed by colleagues work-
ing similarly in other parts of the island. These
patients represent fairly the average clinic among
the Puerto Rican laboring class, numerically large,
as it constitutes the vast majority of the inhabitants
of the country.
The society will, perhaps, be able to reach some
conclusion concerning the value of Puerto Rico as a
point of observation of some, at least, of the affec-
tions more or less foreign to our temperate zone.
Uncinariasis. — This is without doubt the most
serious of all diseases in Puerto Rico, not only in
point of numbers infected, but also in morbidity and
mortality. It is not probable that in any other
coimtry it is really the leading affection. Its char-
acteristics are well known, and no extended com-
ment is necessary, save to remind you that it is
estimated that not far from 800,000 of its i.ooo.-
000 of population harbored this parasite at the be-
ginning of the American domination, and that from
5,000 to 7,000 died annually from its effects. De-
spite the approximate 150,000 to 175.000 persons
treated by the Puerto Rico Anjemia Commission it
still remains the distinguishing feature of Puerto
Rican pathology, although now clearly understood
and properly treated by practically all insular phy-
sicians. Although what has been elucidated by
divers authors is common knowledge, there is no
point at which profound anaemias and their effects
can be better, observed. Despite faithful attempts,
no adequate explanation has yet been given of just
how this anaemia is brought about. Many believe
that it is a haemolysis due to some product of the
worm. This remains to be established by actual
proof, and constitutes a scientific problem of great
interest which can possibly be best worked out in
this island.
Microfilaria noctnrna. — This parasite is common-
ly encountered. Twelve per cent, of the second bat-
talion of the Puerto Rican provisional regiment of
infantry, stationed at Cayey. were found to be hosts
of this parasite, and while nearly all the infected
were apparently healthy men, their military medical
histories displayed from time to time the capacity
of this worm of evil. Whether this is a fair pro-
portion of infected among the civil population is
problematical. Suffice it to say that filariasis was
frequently seen among our patients in Ponce, and
chyluria, varicose groin glands, lymph scrotum, and
other manifestations were constantly in evidence.
Many were also found who suft'ered no symptoms.
Cases of elephantiasis were by no means in propor-
tion to the number of persons in whose blood mi-
crofilariae were circulating.
One of the most interesting phases of the disease
is the so called "erisipela" or erysipelas. This is
a most common condition and seems to bear rela-
tion to filarial disease, in most instances, when af-
fecting a lower extremity without other apparent
cause. It was our custom to suspect such cases of
filarial infection, and a search through the blood at
night was often rewarded by finding the embryo
worm. This "erisipela" is. of course, a complica-
tion with the usual sharp reaction of a lymphangei-
tis and is not at all fatal, as a rule, although I have
seen it result in death ; it is apt to end in elephantoid
swellings of the limbs, if not in elephantiasis.
As will be seen from the remarks on this, as well
as on the succeeding diseases, we were unable to
give our time to a thorough study of these cases as
uncinariasis was claiming most of our attention.
There seems to be, however, a decided tendency for
lymphangeitis of the lower extremity to recur again
and again in filarial infectious. Can there be a re-
duced resistance to the invasion of the streptococcus
and other pyogenic organisms? Our experience
with the affection would seem to indicate it. It is
needless to say that filariasis could be made a most
absorbing, perhaps very profitable study in the in-
terest of the large number of persons of all stations
of life who are victims of the disease, for it is not
alone confined to the poor. It is certainly much more
common in the mosquito plagued coast regions than
m the highlands of the interior, as may be imagined,
and is not rarely confounded with malaria if the in-
dispensable microscope is not called into service.
This is especially true in those cases where the chill,
high fever, and sweat are all the symptoms to be
elicited, a not uncommon picture in filariasis.
Other varieties of microfilariae were not observed,
although from reports from neighboring islands it
is not unreasonable to suppose that they are to be
found.
Bilharziosis. — This is not at all infrequent, the
first announcement of the disease in Puerto Rico
having been made by Gonzalez Martinez to the
Puerto Rican Medical Association earlv in 1904.
Thirty cases v.ere disclosed in the routine examina-
tion of the faeces of uncinaria patients by the com-
mission, but these were not all that were seen by
me. Others have made reports on bilharzia disease
in the island, notably Gonzalez Martinez, of IMaya-
guez. who tells me that in 5 per cent, at least of
the rural population of his district the eggs can be
demonstrated in the faeces. Great interest attaches
to this affection because of its exclusive limitation
to the rectal mucous membrane. It is due, almost
certainly, to the Schistosoma iiia)isoni of recent de-
scription and is not Scliistosoma hcciiiafobiinn as
first believed.
Members of the commission repeatedly asserted
their belief, based on the appearance of the ovum,
that it was not identical with previously described
schistosomata. Ova have never been found, to my
knowledge, in the urine; the parasites were large,
oval, and always provided with lateral spine. Ap-
parently no symptoms are usually elicited, but that
it can give rise to a serious affection is seen in the
death of one of our patients, a child of twelve, in
whom it was at least a contributory cause. During
the long stay of this child in our field hospital, the
infection was evidenced clinically by ulcerative
proctitis and prolapsus recti, and the autopsy re-
vealed many adult worms in the splenic and portal
veins. The worms and tissues were unfortunately
damaged in preservation by an assistant. Exam-
ination showed that the parasite was tuberculated.
The presence of the worm in Puerto Rico is be-
lieved by Stiles to constitute a serious menace to the
island, a view borne out by the fact that cases of
bilharziosis are apparently increasing in numbers.
ASH FORD: FIELD FOR RESEARCH IN TROPICAL MEDIC J XE. L>>'e" York
Medical Journal.
At one point, Mayaguez, the infection seems to be
deeply rooted in endemic form. Opportunities for
infection are never lacking among a large propor-
tion of the population, as the people go barefoot,
and there are no features of successful invasion to
alarm a patient, until extensive changes are wrought
and widespread dissemination of the ova has been
accomplished.
As a rule, the effects are simply those of the local
manifestation which, in aggravated form, with
bloody and mucous stools, tenesmus, and pain,
sorely tax the patience and strength of the host.
No high eosinophilia has been observed by us. In-
deed we question the eosinophilia of bilharziosis, but
a fair test of many cases has not as yet been pre-
sented, as it is so very difficult to find a patient suf-
fering from the disease, who is not at the same time
the host of Necator americaniis, a potent cause, as is
well known, of a eosinophilia, even, for a consider-
able period after expulsion of all worms.
Ascaris lumbric aides. — This is a very common
parasite of man in the island and is mentioned
merely because it is so extremely frequent.
Oxyuris vcrmicularis is common. In connection
with this worm, we stumbled upon what may be
a valuable point in its treatment : As is known,
the use every day or two of rectal enemata of salt
and water, infusion of quassia, etc., for four to six
weeks is recommended to effect a cure, as the fe-
male resides in the caecum and only goes to the
rectum after her eggs have matured, where, of
course, she would be reached by the remedies above
mentioned. In one of our cases 418 oxyurides were
expelled, all the patient harbored, by two doses of
betanaphthol of two grammes each ; the second dose
was administered one week after the first. This is
a simpler and prompter method of treatment than
the old one.
Strongyloidcs stercoralis is not infrequent.
Tricoccplia'its trichmris is very common, but,
while rebellious to anthelminthics, large numbers
have been expelled by thymol and beta napththol, in
spite of statements in medical literature, to the ef-
fect that the}- are insusceptible to its action. This
worm may not usuall\- cause ansemia, but we have
seen cases in which it seemed to have done so. It
occasions a moderate eosinophilia.
Trichiiielliasis was never seen.
Filaria medinensis was not observed, and no evi-
dence of its ever having been seen on the island can
be obtained.
Ccstodes are not at all frequent, and although
Hyincnolcpsis iiaiui was especially looked for it was
not found.
Tremaicdes offer a fertile field for original work.
Stiles reports in Osier's Modern Medicine upon a
fasciola, sent him from one of the cases of the
Anaemia Commission, and states that it is a new
species. I have still another from another case
found in Aibonito which is under consideration.
Faragonimns Westermanni cannot be frequent if it
exists in Puerto Rico. For several years I have
searched for it, as have others, and as yet without
result.
PROTOZO.XN DISE.^SES.
Amoebic dysentery is not common, relatively
speaking. Indirect testimony as to this statement
may be oft'ered in the well known fact that abscess
of the liver is exceedingly rare. I saw but one
case while in Puerto Rico. A few cases of patho-
genic amoebae were demonstrated in dysenteric
stools.
Trypanosomiasis does not exist in the island.
Treponema pertcnnc must exist, although I have
not seen it personally. There is clear and undis-
puted evidence of epidemic yaws, occurring in at
least two districts some twenty years ago. It was
typical from the description given by many who
witnessed the cases, and it is not unreasonable to
suppose that it will come to the fore again.
All care and diligence has failed to reveal kala
azar and, while the suspicious of some workers must
be respected, I have to record that all evidence is
as yet utterly insufficient to warrant serious atten-
tion. Of the hgemosporidia only the Plasmodia
claim attention. Statements concerning malaria in
Puerto Rico must be accepted with great reserve.
Positive evidence can be oft'ered for certain val-
leys and for some coast districts. A remarkable
feature of such foci, as were uncovered by the
Puerto Rico Anxmia Commission, is the limitation
of separate species to separate districts topographic-
ally distinct. For instance, while working in Aibo-
nito with a district of about 8,500 population, about
4,000 came under our care for uncinariasis. It soon
developed that in the large tobacco plantations of
the valley of the river Plata, there was a focus where
practically all cases were quartans, on the other
side of us in another punch bowl valley, tertian pre-
vailed, while from the sugar plantations of Aguirre
nearly all cases which reach.ed us were estivoautum-
nal. Thus within a few miles, in any one of three
directions, we could enter three distinct foci, each
populated by mosquitoes, bearing in one Plasmo-
dium vivax, in another Plasniodiitiii inalarice, and in
a third Plasmodium iinmaculatuni. This curious
condition may, and probably does, obtain in other
parts of the island, but the well known fact that
there is, as in the early days of Greece, compara-
tively little migration of peasantry from one to an-
other natural division of land will in part explain
this curious distribution.
B.A.CILL.\RY DISE.A.SES.
Typhoid fever, while not a tropical disease, is ap-
parently influenced by its tropical habitat. It is very
fatal, and Manson's statement that it is twice as
fatal in India among Europeans, as in the home
country, can be applied not onl>- to continentals but
to Puerto Ricans in the island under consideration.
This disease is gradually becoming a cause of alarm,
and while it existed sporadically before, its rapid
strides since our occupation are causing universal
comment. Recently I am informed that the large
town of Caguas has been visited by a severe epi-
demic. One such epidemic was observed in Cayey.
a mountain town of the interior, and one in Coamo ;
later a similar one invaded the town of -Aibonito.
where the commission was working, but it did not
reach serious proportions as in the other towns
mentioned. Our observation led us to the conclu-
sion that these outbreaks were often by contact in-
fection.
.\ rich o])portmiity for the application of antity-
phoid v;\ccines is here presented, at a critical jieriod,
June -^7. 190S.I ASHFOKD: FIELD FOR RESEARCH IX TROPICAL MEDICIXE
1239
when such aid might be truly appreciated. It would
be the only feasible \va_\- to put an end to what is
already seemingly a serious condition, should the
prophylactic value of the vaccine be established.
Bacillary dysentery. — At present the disease is
not epidemic, nor was it during the existence of the
Puerto Rico Anaemia Commission. \\'e were in-
formed that most severe epidemics are wont to fall
upon the island at times. It seems to be the pre-
vailing form of dysentery in Puerto Rico, and its
character has been studied and reported upon by
American investigators.
Plague has never been reported.
Cholera visited the island, during our own epi-
demic in this country.
Leprosy is not a common disease, but there is a
colony at San Juan of perhaps fifty patients. I saw-
one case, suspected of this disease in Ponce by its
health officer, in consultation with Dr. Joseph Gold-
berger. U. S. Public Health and Marine Hospital
Service. This patient, whose nature was promptly
revealed by scrapings from an incision into the an-
aesthetic lobe of the ear, was in hiding, and it is not
improbable that there may be others of a similar
nature, but such were not seen by any members of
the commission. It may be of interest to know that
all or nearly all cases are in native Puerto Ricans.
Vellozi.- Fever. — Since the advent of the Ameri-
cans, yellow fever, which, in the seven years pre-
ceding our arrival, gave an annual mortality of 161.
has not been seen. Stcgoiiiyia fasciata are very
abundant, however, and >et. in spite of this fact,
there is much to confirm the general boast among
the Puerto Ricans that the disease never really be-
came endemic as in Cuba. Cases developed in cer-
tain towns open to commerce from that cotmtry
and other infected posts, and usually in them only,
but soon died out to be revived by fresh importa-
tions.
Glanders. — Several cases of glanders have been
seen, and it has been not infrequent in horses, whose
care is very poor.
Tetanus has been another serious question as a
cause of infant mortality, but the responsibility for
this state of affairs cannot be laid at the door of in-
stilar physicians. Dr. Francisco del \ alle Atiles
states, in an interesting thesis on the Puerto Rican
peasant, in 1899 : ■■ . . . but of all diseases that an
infant contracts shortly after birth, tetanus causes
a higher mortality than any other. It can be said
that the affection is endemic in Puerto Rico." I
saw several true cases, and have heard of a large
number of others, but the rate of 3.41 per cent, of
the total mortality, given for the first seven months
of our occupation of the island, and said to be about
that for the ten years preceding, is certainly not due
to the bacillus of tetanus. Many convulsions of in-
fancy are wrongly attribttted to it and so swell the
reported mortahty. It is. however, not at all un-
common even among adults.
Tuberculosis cannot be discussed here, but its
ravages in towns are as great as its rarity among
the people of the mountains.
OTHER DISEASES.
Beriberi is not a disease of Puerto Rico. It has
been described in the island, but the reasonable
doubt that uncinariasis was the trtie aft'ection can-
not be overcome, in the absence of examination of
the faeces. The genuine danger of confounding cer-
tain cases of uncinariasis with beriberi is not to be
lightly passed over. Of course, they are separated
clinicallx in the vast majority of cases, but I have in
mind now a case which would puzzle anyone with-
out close study and, especially, in absence of a re-
port on the examination of the faeces.
Sprue is not very rare ; it occurs in foreigners to
the soil and in some Puerto Ricans.
Malta fcz-ers. — \"ery -careful search for Malta
fever was made during several years but none was
foimd.
Pellagra. — The writer has seen one case which
appeared to be genuine pellagra.
Heat stroke is indeed rare, as Puerto Rico can
hardly be considered a very hot country. This leads
to the suggestion that the climatic effects of the
tropics on our race be studied in this island. Even
at high altitudes where it is cool and pleasant prac-
tically all of the time, "tropical neurasthenia'" is in
evidence. The nervous system certainly suft'ers in
a manner not yet clearly worked out. where heat
cannot be considered a potent factor.
I believe, that this climatic effect is not alone
seen in strangers unaccustomed to this latitude.
Mai dc pelea. ataques. mal de corasoii are popular
names for a very common nervous manifestation
which is really hysteria. This is the nearest ap-
proach to a true brain storm I have ever witnessed.
It is frequently am.ong some women of the poorer
classes, and its name, "the fighting disease." is net
belied, as anyone who has seen it can testify.
The subject is not exhausted, but nothing has
been said about certain fevers which after some
study do not fit into any classification, simply be-
cause they have probably not been sufficiently stud-
ied. There is room for some valuable original
work, to clear up such as are still an enigma to
many pain.staking men in the island.
This rapid review of the tropical diseases of
Puerto Rico will indicate the importance of this
country as a centre for research. A few words may
not be amiss concerning the facilities for such in-
vestigations.
In the past few years a great change has been
noticed in the attitude of the people with regard to
problems of hygiene. The eradication of smallpox
and yellow fever, and the attack on the prevalent
and dreaded anaemia, have had their effect in deep-
ening respect for the advance of modern preven-
tive medicine. There is truly a remarkable faith in
all that tends to combat disease with scientific
weapons, and this among the most lowly class. On
the other hand physicians have been brought to a
full realization of their power, when efficient means
are taken to diagnosticate by methods which include
judicious use of microscope and approved instru-
ments of recent adoption, to treat causes, not eft'ects.
and to relegate to proper obscurity ancient and un-
reasonable drugs, which do little more than salve
the conscience with empty promises of cure of
symptoms. These physicians are generally grad-
uates of foreign schools and their classical knowl-
edge has been often acquired at some of the most
I240
BALLAGI: ACUTE SYPHILITIC NEPHRITIS.
[New York
Medical Journal.
famous European centres. Many of the recent
graduates come equipped from excellent schools,
both here and abroad, and have well supplemented
the conservatism of practitioners, whose experience
is of greatest value, by advanced ideas of medical
thought and technique. The Puerto Rican Medical
Association is a body of whom the island has reason
to feel satisfied, and their tolerance and their desire
for investigation of the problems affecting the health
of their country are marked and worthy of the high-
est respect.
In such an island, isolated from extraneous influ-
ence, no better opportunity can present itself to
demonstrate how modern conceptions of communi-
cable disease can influence the health of a tropical
country; and it is all the more of importance, when
America can point to such satisfactory results in
one of her new territorial acquisitions, in a group
of islands, famous for years as points from which
our knowledge of tropical pathology has been
greatly enriched. We are, as it were, in competition
with other powerful nations in the Antilles and we
must "make good."
Scientific working parties may gradually develop
a valuable centre for research. Puerto Rico ofl^ers
special advantages for the undertaking of such a
labor. It is a small island, densely populated with
about 260 inhabitants to the square mile ; 90 per
cent, of its population can be classed as rural ; it has
good roads ; and is within four or five days of New
York by good steamers ; it has a most beautiful and
varied picture of mountain, valley, and level coast,
and comfortable accommodations, and the ever at-
tractive environment of new customs and people.
Laboratory facilities are to be had, but there is
no large laboratory. The board of health has been
very generous in the past, and aids scientific work
in every possible manner. Besides this several phy-
sicians have at heavy personal cost developed small
laboratories.
It is hoped that interest in this island may be
aroused among the scientific men of our country,
and, through this society, may make an effort to
draw up some organized plan for coming into closer
touch with the workers in this promising field for
research.
ACUTE SYPHILITIC NEPHRITIS.
With Report of a Case.
By John Ballagi, M. D.,
Homestead, Pa.
No part, organ, or tissue of the human body is
exempt from the ravages of syphilis. S ) then- is
no reason to doubt the existence of syphilitic nephri-
tis, acute or chronic, just as we grant the existence
(T scarlatinal, malarial, alcoholic, etc., nephritides.
The difference is that the former seems to occur
rather seldom. According to Bamberger's statistics,
fjuoted by Fischer ( i ). out of fifty cases of nephritis
m luetic persons, syphilis as an ietiological factor
could be accepted by four only. Prager (2) com-
plains that his cases are not convincing, because the
patients were exposed to other causes too, first of
all, to the effect of mercury. That is why sn many
are inclined to place the responsibility on mercury
and not on syphilis.
Newer textbooks on syphilology do not give
much enlightenment about the question, either. I
just cite, for example, that of the late Robert W.
Taylor. He says, in his excellent textbook (3),
under the heading Albuminuria and Ephemera!
Nephritis : "There can no longer be a doubt that
early and sometimes rather late in the secondary
stage, a mild or more severe form of nephritis may
occur. . . . It is a glomerulonephritis, compar-
able to that of scarlatina. Some authors claim that
mercurial treatment causes the kidney clmnges, hut
zve have no definite knowledge on the subject"
(italics mine). Osier (4), talking of the aetiology of
acute nephritides, enumerates scarlet fever, typhoid,
etc., as direct possible causes. But regarding syphi-
lis he says only ; "Acute nephritis may be associated
with syphilis." Leube does not mention syphilis at
all.
An editorial of this journal (5) bearing the title
The Dangerous Action of Mercury on the Kidneys
is practically discussing the same question, namely,
whether nephritides occurring together with lues
are caused by the syphilitic virus or by mercury?
Admitting that "there certainly exists a syphilitic
nephritis in both the secondary and tertiary period,"
on the whole, the uncertain nature of this "syphilitic
nephritis" is plainly expressed through the caution
with which it is recommended to give mercury to
syphilitic patients with albuminuria. The main
points are also given how to distinguish and enable
oneself to know when mercury is indicated and
when it is dangerous. Among these diagnostic
points I missed just one, but one which in many
cases could do much more to enlighten the situation
than anything else. That is a trustworthy history
of the case. A patient with chronic nephritis, hav-
ing acquired syphilis later, is hardly a fit subject to
a protracted mercurial treatment. But when it is
possible to decide with certainty that syphilitic in-
fection occurred before the appearing of any symp-
toms of nephritis, and that the patient did not take
any mercury at all, then we are justified to suspect
the nephritis to be of luetic origin, and we would
not make a mistake in introducing a mercurial treat-
ment. When no history is obtainable, chemical
analvsis of the urine, saliva, blood, etc., may decide
the question. Mercury can be detected in the organ-
ismus months after it was incorporated, and with
so much more certainty when recent mercurial poi-
soning— that is, mercurial nephritis — is present.
According to the same editorial, kidney changes
due to syphilis or mercury may be slight. Other
authors, too, speak simply of "syphilitic albu-
minuria." Plain albuminuria, I supjxise, is not
equal to nephritis. Plain albuminurias, due either
to lues or mercury, may be more common and easily
avoid our attention. Real syphilitic nephritis is
rather seldom met with. Regarding these slight
albuminurias, our knowledge is not sufficient at pres-
ent to classify them either as luetic or mercurial.
The kidneys are very sensitive to any toxic matter
I)assing through them, and when they are exposed
to several of them simultaneously, so much harder
wiM it be tn tell which is the guilty one.
June 27, 1908.J
BALLACI: ACUTE SYPHILITIC NEPHRITIS.
1 241
Concerning mercury, I do not think its action on
the kidneys is sufficiently cleared up. Mercurial
poisoning- (stomatitis) is a very common occurrence,
so we ought to see more of its effects on the kidneys.
But cases of mercurial nephritis are so rare as to
be worth publishing. So does Wilson (6), re-
porting a case ending fatally after administering
eighty-four grains of calomel in fourteen days. But
his case is not instructive, the dose of mercury being
far over the limit. Almost any kidney would be
deranged when the patient was taking such enor-
mous doses of any active drug. And what more,
Wilson's patient was suffering with pericarditis and
insufficiency of the mitral, aortic, and tricuspidal
valves, consequently with a very much impeded
circulation and metabolism. Wilson's other cited
cases would weigh more, too, if they were not ex-
amples of exceptional idiosyncrasy against mercury.
What we need to know is whether regular doses of
mercury are capable of exciting albuminuria or
nephritis. As to my experience with syphilitic
patients, I never had occasion to restrict or stop
mercury on account of urinary troubles. Maybe
some of my patients did have a slight albuminuria
in the course of the disease, but the every day
general practice is not the field where such cases
can be easily detected if not accompanied by some
special complaint or symptom.
The closing remarks made by W'ilson I partly
concur with. The first one is a good suggestion,
that in every case when mercury is to be adminis-
tered for a longer period, a careful uranalysis
should be made. But when nephritis complicates an
existing syphilis I am of a different opinion. I
would "except those cases in which it is p>ossible to
trace the renal disability to a syphilitic infection."
Then I think no one needs to be afraid to employ
an energetic antisyphylitic cure with mercury, sup-
posing that is otherwise indicated, too. What a
good dose of mercury can do, the case I shall report
clearly shows.
Much depends on the mode of administering and
the preparations used. Internal administration and
inunctions are more dangerous. Wilson and Heller
prefer the injection of soluble salts, particularly the
liichloride. .So do I. The insoluble preparations —
metallic mercury, mercury salicylate, calomel, etc. — •
are either too slowly working or their effect is apt
to be cumulative. Gottheil (7) sets off as a great
advantage of the insoluble salts the following: "By
the injection of a dose of the insoluble compounds a
medicinal depot, as it were, is established into the
tissues." This sounds well, but is rather a disad-
vantage. We do not give drugs to remain in the
body an incalculable and unlimited period. On the
contrary, medicines, after having developed their
specific action on the tissues, are expected to leave
the organismus, the sooner the better. Welander
(8), of Stockholm, calls special attention to the
danger of producing "depots" by injecting insoluble
mercury in the tissues, and relates several cases
from his practice, with very bad complications. He
admits the relative harmlessness of the salicylate,
on account of its earlier elimination.
I would warn everybody against the injection of
calomel or gray oil. In a paper read before the
Homestead Branch of the Allegheny County Med-
ical Society in January, 1906, I reported a case from
my own practice of a young woman -who had eight
such "medicinal depots" of calomel in her body.
They did not trouble her until after the eighth injec-
tion, but then, all of a sudden, such toxic symptom.s
developed that all these depots had to be surgically
removed to save her life. Fortunately, the injec-
tions were made in the muscles of the back. Since
that time (it happened in 1894) I never used calomel
for injections. With the corrosive (five per cent,
solution) I never had any unpleasant experience.
The following case is very instructive in many
respects. Its history is precise, the symptoms clear
and distinct, the effect of the mercury so prompt and
decisive that the whole might easily pass for an ex-
periment in pharmacology :
C.\SE. — Michael G, thirty-five years old, a native of Hun-
gary, mill worker, married, but living separated from his
wife, she being in the old country.' I used to know him
for the last three years, attending to some minor acci-
dents. He was of a healthy family, strongly built, broad
shouldered, a man of temperate habits. The only sickness
he had was smallpox when about three years old.
On March 5, 1906, he came to my office very sick, but
with the sole complaint of an incessant cough and dyspnoea
about five or six days' standing. He was hardly able to
walk. Upon examination, I found a general dropsy ; the
face puffed, lips cyanotic, moderate ascites, heavy anasarca
of the under extremities and of the scrotum. The scrotal
sac was as large as a child's head, the prseputium hard and
phimotic. Qidema of both lungs with considerable dysp-
noea, and continuous cough, with thin, abundant sputum,
mostly mucus. Percussion showed slight dulness on the
bases, auscultation weak breath sounds, large and small
moist rales. Heart sounds were feeble on account of the
noisy rales, but clear. There was no detectable pleural
effusion. Temperature was normal, pulse 100 and over,
strong and full. Digestive organs were normal, upper
limit of liver dullness was normal, spleen not palpable. He
was passing very little urine lately and he could not pass
any in my presence, but in a few hours he sent to my office
about 40 c.c. dirty brown looking fluid containing albumin,
blood, epithelial, and blood casts. The daily amount did
not reach more than about 300 c.c.
On visiting him at his house the same evening I tried to
get the previous history of his sickness. But he was not
very communicative about it this time. Except that he
noticed the swelling of his feet about eight days ago, he
did not (or would not) rememl)er anything. Anyhow, the
uranalysis, together with the clinical symptoms, was
more than enough to make the diagnosis of acute nephritis
certain. I gave my orders accordingly: Rest in bed, milk
diet, sweating procedures, and prescribed Hunyadi Janos
water in moderate quantities. To allay the distressing
cough, I had to give a little opiate, in the form of Dover's
powder, with quinine in small doses.
Before leaving, he asked me to look at and give medicme
for some excoriations between the scrotal and femoral
surfaces. He supposed they were caused by sweating and
the continuous rubbing of the cedematous skin. In fact, I
myself expected to see a common erythema intertrigo.
But uistead of the reddened and chafed epidermis of ery-
thema there were quite a number of moist, slightly elevated
papuljE, some of them ulcerated, with a reddened circum-
ference. Around the anus were quite a number, too. The
appearance of these ulcerations were so characteristic that
anxbody would have declared them to be syphilitic without
further examination. The finding of slightly enlarged
glands in both groins gave more support to the real
diagnosis.
'Syphilis and venereal diseases are very frequent among the for-
eigners who left their wives behind in the old country. Jlostly
younger men strong and healthy and used to regular sexual prac-
tice; no wonder that they look to gratify their desire somewhere, cs
a rule, in the cheapest dives in and around Pittsburgh. Living in
crowded quarters, sleeping two, sometimes four in one bed (one
pair by day, the other by nightl, and using the same household
utensils, cases of extragenital infection are not very seldom.
1242
IVODEHOUSE: DIPHTHERIA ANTITOXINE.
[New York
Medical Journal.
Upon closer quesiioning he admitted to having in-
dulged in extramarital coitus some seven to eight weeks
before in a cheap dive. He never saw anything like a
primary sore, but imticed a few weeks after the coitus a
small hardening in tlie -ulcu^ coronse on the right side next
to the frenulum. It did not hurt him, so he did not care
much about it. much the less because his praeputium was
a little tight r.Iways and he was not able to push it back
easily. I could not retract it either, but after compressing
it and squeezing the serum out of the swollen prepuce the
sclerosis still could be felt.
It was evident and plain enough that the patient was
suffering, besides the acute parenchymatous nephritis, with
active syphilis in the secondary stage. The question was,
Did the syphilitic infection cause the nephritis, or was the
presence of both merely accidental ? Since the patient so
forcibly and repeatedly asserted that the dropsy, urinary
troubles, etc., came on rather suddenly and not more than
eight days ago, since no other aetiological factor could be
considered, 1 accepted the first alternative. Still, I hesitated
a little to give mercury, in face of the \ery much lessened
climinati\-e ability of the acutel\ diseased kidneys. I waited
two days more, hut -eeing the patient's condition turning
from bad to worse, 1 made up my mind and gave an in-
jection of a five per cent, corrosive sublimate solution on
March 8th. For local applicatinn to the ulcerations I used
rdcoholic solution of corrosive sublimate and du;,ting with
boric acid. Frequent rinsing of the mouth, hot packs to
stimulate sweating, restricted, mostly liquid diet, etc., were
ordered also.
The result of the injections was indeed very satisfactory.
The fourth day after the first injection, March I2th, the
amount of urme was doubled, the oedematous skin became
softer, the djspnaa and cough much easier. The sixth
day he passed nearly 1,500 c.c urine; there was much less
albumin in it. no blood, and very few casts. Qidema and
dyspncea almost disappeared. The eighth day, March i6th,
I gave another injection, and in a few days the mucous
patches began to dry up. Urir.e was normal, quantity and
([uality, on March 21st, and he felt so much improved that
he went to work. This happened without m}' consent,
though ; knowing my customer, ] told him again and again
the necessity of a prolonged treatment, and particularly
that the attained improvement would be lasting in case only
when he was to receive at least six to eight injections.
Notwithstanding this advice, he failed to appear for a third
injection, and went away to Beaver Falls, where he was
promised a more lucrative job. He did not stay very long.
.After three weeks, in April, he came back again, very
nnich scared, noticing tl^e swelling of his feet and new
|i;iteiies in his mouth. This time he had more common
sense, and patiently went through one series of injections
and stayed under my care till January, 1908, when he re-
turned to the old country, to his wife. No luetic symptoms
were visible then. During this time, from May, 1906, to
January, 1907, he was kept on progressing doses of potas-
sium iodide with intervals of two weeks every other month.
January, 1907, I admim'stered four injections again, and
after them prescribed potassium iodide again, now in con-
stant doses of a gramme daily. He never showed symp-
toms of renal trouble .uiy more >ince May, 1906. Before he
left. I instructed him to consult a reliable physician in the
old country upon arriving there.
References.
t. Adolph Fischer. Chronic Briglit's Disease. Buda-
pest, 1880.
2. Prager. Traitc drs uuiladics dcs reins. Paris, 1840.
.V _R. W. Taylor. Practical Treatise on
Syl>hiUs. p. 535. Third edition.
4. Osier. Practice of Medicine, p. 869. Fifth edition.
5. Sciv York Medical Journal, December 29, 1906.
6. Wilson. Mercurial Nephritis with Urjemia. Neiv
York Medical Journal. May 19, 1906.
7. Gottheil. Intramuscular Injections for Syphilis.
Nc'iV York Medical Journal, June 30, 1906.
■S. Welander. Treatment of Syphilis with Injections.
Hyi^iea. No. 7, 1907.
0 I- E. Lane. Intramuscular Injections in Syphilis.
Jhitisli Medical Journal. March 21, 1908.
438 Fifth Avenuk.
RESULTS OBTAINED FROM USE OF DIPHTHERIA
ANTITOXINE REFINED AND CONCEN-
TRATED BY GIBSON'S METHOD.
By Robert E. Wodehouse, M. D.,
New York,
-Member of the Toronto Academy of Medicine; Former iledical
Superintendent, Isolation Hospital, Toronto; Former House
Surgeon to Hospital for Sick Children, Toronto, etc.
The experience which I have had in the use of
diphtheria antitoxine, both prophylactic and thera-
peutic, prompts this brief note :
The prophylactic experience was gained chiefly
while house surgeon in the Hospital for Sick Chil-
dren, Toronto, and in the Lake Side Home for
Little Children, Toronto Island. The board of
trustees, at the suggestion of Dr. \A'illiam Goldie,
visiting physician in charge of infectious diseases,
issued a standing order that each patient, when ad-
mitted to either institution, must receive 1,000 units
of diphtheria antitoxine, and 500 units ever}- two
weeks thereafter so long as the child remained.
This routine, practised in a service embracing nearly
175 children under fourteen years of age, brought
out all the good and bad features associated with
the injection of antitoxine. The marked idiosyn-
crasies of some of the patients and absolute non-
tolerance of others was evident. The injections
were discontinued in three cases, one a rheumatoid
arthritic case and two tuberculous hip cases. The
numerous forms of skin rashes and the frequency
of their occurrence were constantly before us ; also
the terror some of the smaller patients had for the
second and succeeding injections. The antitoxine
used was of the ordinary, nonconcentrated, entire
.serum form, running 500 units to the c.c.
In the baby ward, to overcome the pain associated
with the distending of the tissues due to the injec-
tion, I used an antitoxine of a potency of 1,000
units to c.c. Only 0.25 of a c.c. was required to
give each baby the necessary injection of 250 units.
This small dose could be administered with an ordi-
nary hypodermatic needle, almost without pain. This
was actually proven in two cases where the injec-
tions were given in the buttocks without the knowl-
edge of the child, partially overcoming one of the
objectionable features in connection with the admin-
istration of the antitoxine. The troublesome urti-
caria and also erythema, resembling scarlatina, and
sometimes measles, were not materially changed.
L'pon the completion of my services in these in-
stitutions I accepted the appointment of medical
superintendent of the Isolation Hospital. Toronto,
tendered to me by Dr. Charles Sheard. medical
health officer. At this time a refined and concen-
trated antitoxine, prepared after Gibson's' method,
was offered in Toronto. The antitoxine was con-
centrated to a potency of 1,500 units to the c.c. and
this at once appealed to me as highly advantageous
where large therapeutic doses of 15.000 units and
upward were necessary, as in the Isolation Hospital.
It was suggested that the intensity and frequency
of skin rashes and in-ticarias were ver\- much re-
>Dr. Robert B. Gibson, assistant to William H. Park. M. D.,
director of the Research Laboratories of New York City Department
of Health, developed the work of Atkinson and found a method of
concentrating and lefining diphtheria antitoxic horse serum by the
elimination of the nonantitoxic substances. See Journal of Biologi-
cal Cheinislrv. I, Nos. 2 and 3, January, 1906.
Tune 1 908. J
IVODEHOUSE: DIPHTHERIA ANTITOXIXE.
duced by the use of this form of antitoxiiie. A sam-
ple consignment was forwarded and tried. The
therapeutic effect was naturally equal to the old
form of antitoxine, as a unit of antitoxine is an
international standard. With Dr. Sheard's permis-
sion we procured a supply of this refined and con-
centrated antitoxine, altogether 1.560.000 units, ex-
clusive of the primary sample.
The following table shows how this antitoxine
was used in 345 cases :
169 mild cases received a total of 591,500 units, average 3,500 units;
96 moderate cases received a total of 721,000 units, average 7.500
units;
37 severe cases received a total of 409,000 units, average 11,000
25 mixed (scarlet fever and diphtheria) cases received a total of
120,000 units, average 4,800 units;
iS negative swab cases received a total of 71,000 units, average
3,933 units.
In addition to this list, some poor patients not
admitted to the hospital received antitoxine on appli-
cation of the attending physician. (A commendable
practice was instituted by Dr. Sheard of providing
antitoxine to the poor from the Isolation Hospital,
whenever requested by a physician. In all, over
2,000,000 units were used in five months, 440,000
units of this being made up of whole serum of dif-
ferent makes, testing about 500 units to i c.c. When
a patient received antitoxine the time, amount, kind,
and the name of the administrator were recorded,
also any systemic effects or skin rashes following
its injection.
Of the 345 patients observed in the hospital, only
four receiving refined and concentrated antitoxine
developed an urticaria covering a larger area than
ten centimetres in diameter, surrounding the point
of injection. In two the affected area remained
confined to the thigh and buttock. In one case the
abdomen and extremities were involved. In the
fourth case, one of the three most marked cases I
have seen, diphtheria developed in the third week
of scarlet fever. The patient — nine years old, ver\-
fat. having an appearance of slight degeneracy and
also a status lymphaticus condition — was attacked
with general oedema, very marked about the eyes,
lips, and face. Urticaria was extreme and very
itchy. Urine was suppressed, temperature above
103° F., and myalgia and stift'ness in the joints of
the extremities marked. Catharsis and calcium lac-
tate treatment were instituted on the suggestion of
Dr. Wilson, a private physician in charge of the
case. The condition persisted four days. In sev-
eral cases painful myalgia developed. This was also
present with some degree of severity in two patients
who received no antitoxine and in other cases re-
ceiving ordinarily prepared antitoxine.
With these exceptions no symptoms traceable to
the use of refined serum were found, erythema be-
ing entirely absent. In the same wards, ordinary
serum (products of three different manufacturers
using other than Gibson method of concentration)
being used at the request of visiting physicians on
private patients, produced the usual ten to thirty
per cent.' of cases showing erythematous and urti--
carial rashes.
Upon further investigation, to satisfy myself as
to the possibility of our results being due to an
-Figures published by Binford Throne, M. D., American Journal
of the Medical SciencSs, Xovember, 1907.
extra good lot of serum produced from one horse,
we obtained from Dr. Lederle, in whose laboratories
the antitoxine was prepared, the following facts :
96 vials (S.ooo units each), received September 21, 1907, were
laboratory Xo. 40.
60 vials (5,000 units each), received Xovember 16, 1907, were
laboratory Xos. 47, 40, 13, and 61.
60 vials (5,000 units each), received Xovember 16, 1907, \Vere
laboratory Xo. 61.
96 vials (5,000 units each), received January 2, 1908, were labora-
tory No. 61.
Laboratory "No. 40 represented antitoxine obtained from Horse N.
Laboratory X'o. 47 represented antitoxine obtained from Horses X
and A (mixture).
Laboratory Xo. 13 represented antitoxine obtained from Horse .\.
Laboratory Xo. 61 represented antitoxine obtained from Horse N
(later bleeding).
This shows serum from two different horses;
serum from two horses mixed ; and serum from a
second bleeding of the first horse, at an interval of
some weeks.
This would lead one to believe, as Dr. William H.
Park, of the Research Laboratories of the New-
York City Department of Health has found to be
the case,' that the Gibson method of refinement and
concentration is the constant factor in the produc-
tion of the better results.
Aly reasons for asking Dr. Sheard's permission
to continue the use of this serum refined and con-
centrated by the Gibson method are :
1. In therapeutic use, often 10,000 to 15,000
units of antitoxine are indicated for one injection.
If concentrated to a potency of 1.500 units to i c.c.
10 c.c. only are necessar\- for latter dose, whereas
in using the old form of antitoxine, with a potency
of 5(X) units to I c.c, the tissues are necessarily dis-
tended three times as much by the injection of
30 c.c.
2. The much smaller sized syringe and needle
necessary were very potent factors in dealing with
neurasthenic, frightened patients, who ahvays see
every detail.
3. The systemic affections were markedly re-
duced.
4. In a hospital where both diphtheria and scarlet
fever are treated, the early recognition and isolation
of scarlet fever or measles, developing in the diph-
theria ward, is most important. When refined and
concentrated antitoxine has been used, there is no
necessity of retaining patients with er}thematous
rashes under observation for several days, as we
know these rashes rarely follow its use. whereas
under the old methods, using the unrefined horse
serum, with its accompanying rashes, the early diag-
nosis was always doubtful.
Thirst After Abdominal Operations. — The dis-
tressing thirst after abdominal operations, where
fluid by mouth produces vomiting, is best relieved
by subcutaneous infusions of normal salt solutions ;
or by the insertion of a tube into the rectum con-
nected with a bag of saline solution placed just
above the level of the patient's hips, allowing the
injection of water drop by drop and so slowly that
no irritation of the rectum is set up. The patient
may in this manner receive small quantities of water
for hours. — American Journal of Surgery.
'Journal of Biological Chemistry, I, Nos. 2 and 3, January, 191)6.
1244
OUR READERS' DISCUSSIONS.
[New York
Medical Journal.
A SERIES OF PRIZE ESSAYS.
Qiicsti'ins for discussion in this department are an-
nounced at frequent intervals. So far as they have been
decided upon, the further questions arc as follows:
LXXI'. //cec do you treat cholera infantum? (Closed
June /5, ii)oS.)
LXXri. llo'W di< \"u treat acute articular rheumatism.''
(.Uiszccrs due not later than July 13. igoS.)
LXXI' II. Ihnc do you treat varicose ulcer? (Answers
due not later than .lugust 13, igo8.)
JVhoever anszvers one of these questions in the manner
most satisfactory to the editors and their advisors will
receive a prize of No importance whatever zvill be at-
tached to literary style, but the award zvill be based solely
on the value of the substance of the anszver. It is requested
(but not REQUIRED^ that the anszvers be short; if practica-
ble, no one anszver to contain more than six hundred
zvords.
All persons zvill be entitled to compete for the prize,
zvhcther subscribers or not. This prize zvill not be awarded
to any one person more than once zvithin one year. Every
answer must be accompanied by the zvriter's full name and
address, both of zvhich zve must be at liberty to publish.
All papers contributed become the property of the JovR't^AL.
The prise of $35 for the best essay submitted in anszver
to question LXXIV has been awarded to Dr. Henry C.
Decker, of New York, whose article appears below.
PRIZE QUESTION NO. LXXIV.
THE TREATMENT OF SUNSTROKE.
By Henry C. Becker, M. D.,
New York.
In a consideration of the treatment of insolation
we take cog'nizance of two forms, the hypcrpyrex-
ial, where the temperature is the important point
at issue, and the other where an exhaustion or pros-
tration is the important feature ; the latter variety,
known as heat exhaustion, may be mild, moderate,
or severe.
In the hyperpyrcxial form the vital point in the
treatment is the rapid reduction of the temperature ;
the prognosis is fair in direct proportion to the
rapidity with which the temperature is reduced,
and in inverse proportion to the length of time it
has endured. In an emergency place the patient in
the coolest and shadiest place available, loosen the
clothing, and dash cold water over head and body ;
with better facilities to hand place the patient in a
bathtnl:) of col.d water, adding to it pieces of ice ;
the extremities and Ixidy should be constantly and
vigorously rubbed while thus immersed. In those
favorable cases where the temperature falls it is
accompanied by an improvement in the pulse and
respiration, and a clearing of the mind : it is well
then to take the temperature per rectum every
fifteen minutes, and remove the patient from the
cold bath when the thermometer registers 102° F.
The temperature often falls 2° every fifteen min-
utes, and may keep on falling even when the
patient is removed from the bath ; to obviate a sub-
normal temperature and a collapse, it is well to
observe this rule. When the patient has been re-
moved from the cold bath there ma\ be a relxnmd
of the temperature four or five hours after, particu-
larly in tho.se cases whose temperature has been
above 106° F. This can be controlled by cold
packs or cold sponging. Cold water enemas are in-
effectual unless ice cold, when they become too
dangerous for use, the patient being liable to go into
collapse. Antipyretics should not be used as a rou-
tine method, although in the tropics the hypo-
dermatic use of quinine is highly spoken of. If
there is much struggling or delirium a hypo-
dermatic injection of one fourth grain of morphine
may be given. The sudden shock from the cold
water may produce a tonic muscular spasm includ-
ing the diaphragm ; in these cases five minims of
amyl nitrite as an inhalation with an increase in the
temperature of the water employed in bathing along
with artificial respiration, if necessary, will tend to
overcome the spasm ; keep up the artificial respira-
tion half an hour if need be.
There is a strong tendency to congestion and
oedema of the lungs ; this condition should be met
by dry cupping and hypodermatic injections of
atropine and strychnine. Strong, robust, plethoric
individuals with full bounding pulses require
one fiftieth of a grain of nitroglycerin ; leeches to
the temples and behind the ears are also helpful.
.\fter the reduction of the temperature the bowels
should be emptied with a stimulating enema.
The after treatment consists in keeping the
patient in bed for several days on a light and easily
digestible diet ; there is often a subsequent inter-
mittent fever lasting several days ; this is best
treated by means of cold sponging and tablespoon-
ful doses of spirits of mindererus given every four
hours. For the headache small doses of acetphene-
tidin with citrated caffeine may be given. Special
attention should be given to the bowel and kidnev
functions ; any resulting sequelae should receive ap-
propriate treatment and care.
In the treatment of heat exhaustion stimulants
are primarily indicated, and in severe cases, to in-
sure their certain and prompt effect, they should be
given hypodermatically.
The slightest manifestation as headache, vertigo,
and faintness should be heeded, and the patient im-
mediately removed to some cool and shady room or
place. A teaspoonful of aromatic spirits of am-
monia in a glass of cold water will suffice in the
milder form of cases ; if somewhat feverish cold
sponging with alcohol and water is indicated. It
is in the more pronounced and severer forms of heat
exhaustion that heroic means are often necessary
to save life ; when there is respiratory failure
strychnine, T-30 to 1-15 gr. is to l)c iniLCted. oxy-
gen gas and artificial respiration may l)e required
and resorted to ; in acute heart failure camphor, i
gr. dissolved in sweet almond oil, 6 m. : or a solu-
tion of citrated caffeine, i to 2 sfrs., injected ; if
pulse is soft and feeble di^italin, T/200 gr., repeated
in an hour if necessary; if pulse is full and bound-
ing, t/ioo to 1/50 gr. nitroglycerin. For reflexly
stinndating the nerve centres mustard paste or the
douche may be employed.
The after treatment is rest in bed, with tonic and
stimulating medicines and treatment of any result-
ing seciueljE.
Prophylaxis. — This consists in the prevention of
exposure to the direct rays of the sun. moderation
in the amount of physical and mental work, the
wearing of light and cool clothincr during a pro-
tracted spell of hot and humid weather. The diet
June 27, .908.]
OUR READERS' DISCUSSIONS.
1245
should consist of little meat with plenty of vege-
tables and fruit; strong alcoholic liquors should be
eschewed. Water externally and internally so that
bowels, kidneys, and skin may be kept active, for
as a general rule a patient who sweats does not
sufifer sunstroke.
112 West One Hundred and Fourth Street.
Dr. B. B. Scarlett, of Philadelphia, says:
The treatment of sunstroke by the writer consists
in the removal of the patient to a shady spot, the
loosening of the clothes, the application of cold to
the head, and the administration of a stimulant
hypodermatically, if necessary, ^^'hen conditions
permit more radical treatment, the patient should
be stripped, covered with a sheet, placed in a tub of
ice water with an ice cap to the head, and the body
gently rubbed with a large piece of ice. The bath
should be discontinued, and the patient put to bed
when the temperature reaches 104° F. ; for beyond
this point the temperature usually continues down-
ward on its own accord ; whereas, if the patient
is kept in the tub until 99° or 100° F. is reached
the temperature will invariably become subnormal.
The ice cap should be kept to the head until the
patient has completely recovered from the attack.
If doubt exists as to the physical ability of the
patient to stand the tubbing, the body should be
covered with a sheet, upon which are placed small
pieces of ice, while quantities are laid loosely about
the head. Enemata of ice water of about a quart
should be given every ten or fifteen minutes until
the axillary temperature reaches 102° F. These
injections not only assist in reducing the tempera-
ture, but they supply to the body fluid that has been
lost by excessive sweating. The dashing of ice
water upon the patient from a distance of five or
ten feet often hurries the return of consciousness.
In cases where the temperature is not extreme, I
simply wrap the patient in a large muslin sheet
wrung out of cold water, and cover all with a
blanket. As soon as the sheet becomes warm, it is
to be replaced by another that has meanwhile been
cooling in the water. This is continued until the
temperature reaches normal. The depression in
temperature by this method is not a rapid one, but
there is seldom, if ever, a secondary rise.
In extreme cases where everything else has failed
to restore the patient to consciousness, the most
efficacious stimulant is the pouring, from an eleva-
tion, of a fine stream of ice water upon the fore-
head. As this treatment is very radical, it is con-
tinued for only one or two minutes at a time. In
conjunction, a full dose of the tincture of digitalis
should be given hypodermatically. except in ple-
thoric patients, with great arterial tension. In such
cases venesection should be practised and should be
followed by smaller doses of digitalis. The patient
should be put to bed and warmly covered when the
temperature reaches 104° F.
The m.ilder forms of sunstroke in infants should
be treated by sponging the body with hvdrant
water and administerine more water internally. In
the severe forms, a bath, the temperature of which
is not below 60° F., should be used. At the same
time friction should be vigorously applied to keep
the peripheral arterioles dilated.
In all cases stimulants should be administered
when indicated. Whiskey should be given by the
bowel except in those cases where the patient was
under its influence at the onset of the attack. Hypo-
dermatic injections of ether, followed by caffeine,
should be given in cases of collapse. Camphor and
nitroglycerm are also useful drugs in emergency.
Convulsions should be relieved by inhalations of
chlorofonn. \'enesection should be resorted to in
cases of convulsions and much syanosis, and should
be free and copious. The bleeding should be fol-
lowed by injections of salt solution. This provides
for the loss of fluid during the days of sweating,
dilutes the waste products in the blood, and is espe-
cially beneficial where the blood is thick and tarry.
After the reduction of the temperature the treat-
ment should consist of light diet, fresh air, perhaps
an ice cap to the head, and the administration of
stimulants, if necessary.
To prevent subsequent attacks the patient should
be advised to avoid, on hot days, violent exercise,
beverages containing alcohol, and excesses in the
use of animal foods.
Dr. Alexander Rozins, of Nev.' York, remarks:
Prophylaxis being of utmost importance I make
it a rule with the advent of hot weather to instruct
those of my patients whose occupations expose them
to great heat, whether artificial or that of the rays
of the sun, such as bakers, laundrymen, workers in
sugar refineries, foundries, and the like, as well as
drivers, peddlers, etc., especially if they are addicted
to alcohol, or inclined to be plethoric or obese, — to
avoid excess of any kind, particularly as regards
spirits, to dress lightly, not to overload the stomach,
especially with solid food, not to overwork, — in a
word to "take things easy" ; in addition to this
drink plenty of cool water so as to perspire freely,
bathe frequently, or at least sponge yourself with
cool water twice or three times a day. I impress it
upon them that heat stroke is especially liable to
attack them during the hot, damp days, or while
they work in an atmosphere surcharged with mois-
ture, and that as long as they keep on sweatinsr
more or less profuselv the danger of being "struck"
is practically reduced to a minimum. The moment
perspiration ceases, and they begin to feel uneasy,
slight or throbbing headache, dizziness, etc.. to eive
up the work at once, and seek rest and shelter in a
cool and airy place. In an hour or so they may
cautiously resume and continue their work. These
instructions are simple and easilv remembered, and
as I find from experience, usually willingly carried
out.
When called to a case of sunstroke make sure
of your diagnosis, and as lack of space forbids anv
discussion of the distinctive diagnosis between this
and other conditions that may simulate it. I will
only mention some of the latter to serve as a sort
of reminder: Uraemie coma (both sunstroke and
unemie coma may occur in the same individual ;
also the next condition) ; alcoholic stupor ; menin-
2:itis : epileptic coma; also be sure to distinguish
between heat stroke and heat exhaustion, as the
treatment of the latter condition is quite diflferent
from that of the former. Havinsf established the
diagnosis you enter upon the treatment of your
1246
OUR READERS' DISCUSSIONS.
[New York
Medical Journal.
case, and that promptly and vigorously in one of
more or less decided severity, with two aims in
view: i. The reduction of the temperature, and
that as quickly as possible before tissue changes
consequent on prolonged high temperature have
resulted ; 2. the stimulation of the nervous centres
that haA-e been overwhelmed by the high tempera-
ture.
For a mild case it may be sufficient to remove the
patient from the noxious surroundings to a . cool,
well ventilated, airy place, loosen his clothing, and
<illow him to rest in a recumbent posture for a few
liours, when he may be allowed to go home to take
a prolonged rest of two to three days, and then
cautiously return to his occupation. An attack of
this kind may be followed by no deleterious results ;
but in some cases there is established in the indi-
vidual an intolerance of heat, and a predisposition
to heat stroke ; and it often becomes advisable to
warn such patients against even slight exposures to
heat.
In the severe cases with flushed, hot, and dry
skin, with pulse rapid and full (or quick and jerk-
in), complete or semiconsciousness, stertorous,
sighing breathing, congested face and neck with
throbbing carotids, etc., energetic treatment is
called for. Remove patient to a cool, airy place,
strip him of his clothing, and place him into a bath
or bathtub of cold water which may still further be
cooled by adding some ice to it. While in bath rub
him vigorously, as this tends to reduce the conges-
tion of the internal organs, and drives the blood
therefrom to the surface of the body. If a bath is
not at hand, place the patient on a mattress covered
with a mackintosh or a piece of oilcloth, and rub
him all over his body with lumps of ice. Dash cold
water over him ; enemata of ice water tend to re-
duce the temperature very decidedly, and so does
an ice pack (sheets wrung out in ice cold water).
An ice bag or cloths wrung out in ice cold water
should be placed on the patient's head all the time.
While thus treated the patient's temperature should
be taken at short intervals (preferably by the rec-
tum), and the hydriatic treatment should be de-
sisted from as soon as the thermometer registers
101'' F., otherwise there is the danger of the tem-
perature nmning down to the subnormal, thus plac-
ing the patient in the imminent danger of collapse.
The patient is now made as comfortable as possible,
cathartics are administered, and, if necessary, he is
catheterizcd. Subsequent rises of temperature are
controlled either by cool spongings, or, if the con-
dition of the heart permits it, by the cautious ad-
ministration of antipyretics (acctphenetidin, anti-
pyrine, quinine). Convulsions accompanying an at-
tack are controlled by hypodermatic injections of
morphine (gr. ^), and inhalations of chloroform;
30 grains of sodium bromide and 20 grains of
chloral hydrate injected into the rectum are also
good for convulsions. If the circulation shows any
signs of failing, a hypodermatic injection of strych-
nine, digitalin, or Hoffmann's anodyne will brace
it up. This is especially to be looked for after the
reduction of temperature, when symptoms of col-
lapse and exhaustion that demand energetic stimu-
lation may make their appearance.
Recovery is conditioned on ab.solute rest, removal
of all disturbing intluences, a light and nourishing
diet, regulation of the bowels, etc. Convalescence
demands close attention, as intracranial mischief is
apt to manifest itself at this period. This may varv
from secondary meningitis down to increased irrita-
bility of temper. In addition to medication removal
to a cooler climate and the strict regulation of the
mode of living may conduce to making the patient
as comfortable as possible under the circumstances.
Dr. Albert Kaufman^ of Wilkcs-Barre, Pa., zoritcs:
In treating a case of heat stroke or sunstroke, we
must bear in mind that this malady manifests itself
in two forms : ( i ) the asphyxial or apoplectical form
in which there is heat exhaustion, this form is
rather of a rare occurrence; and (2) the hyperpyrex-
ia! form, or thermic fever, which is the most com-
mon form. The treatment, therefore, will differ in
the two forms accordingly.
When the patient has thermic fever, the reduc-
tion of the high temperature is a vital indication, —
the temperature usually being from 108° F. to 112°
F., at which temperature life may be destroyed.
The patient should be immediately removed to a
cool, well ventilated room ; his clothing should be
loosened or removed entirely if possible. Place him
upon a cot or bed, which is covered with a rubber
sheet, so that the water may drain into a pail or
trough. Ice should be used freely; an ice cap
should be placed immediately upon his head, and
an ice cold bath (ice floating in a tub of water) ad-
ministered. Rub the surface of the body with ice
in order to bring the hot blood to the cooled skin.
Douching with ice water is very good, or an ice
pack may be used advantageously.
The temperature should be taken very frequently
by the rectum in order to watch carefully that the
temperature does not fall beyond 100° F. If you
should find such a fall in, temperature, you should
recognize this as a signal for the cessation of the
ice applications, and the application of heat instead
of ice may be called for. Great care should be
taken in such cases, as collapse may threaten.
Should the latter show any sign of existing, it may
call for cardiac and respiratory stimulants, such as
strychnine, digitalin, alcohol, camphor, ether, atro-
pine, and nitroglycerin, hypodermatically, and in
some cases artificial respiration must be resorted to ;
also the use of oxygen gas by inhalation is valuable.
If the pulse is bounding, the face cyanotic, and
the heart laboring, it shows that the right heart is
much dilated and venesection is to be resorted to,
but this is to be used for this condition only, for
if used indiscriminately, it does great harm.
In many cases asphyxia is a very troublesome and
yet a dangerous complication, and it may be so
urgent upon the life as to necessitate bleeding the
patient. If venesection is used, you may at the same
time also use subcutaneous or intravenous injec-
tion of normal salt solution.
If the temperature should still remain high, the
application of ice and of the cold bath may be re-
sorted to. Mustard may be applied over the prse-
cordium. and if the temperature should go down
below 100° F.. it may call for heat in the form of
hot water bottles, which should be applied to the
lower extremities.
June 27, igoS.J
OUR READERS' DISCUSSIONS.
1247
If the temperature regains its normal condition,
let the patient remain quietly in bed. Give him
cracked ice by mouth to settle the irritability of his
stomach. Open his bowels with small doses of
calomel. Food should be given of the most nutri-
tious form and which is easily digestible, such as
milk, buttermilk, and some very light broths. Keep
him in bed for a few days until you are sure that
it is safe for him to resume his duties, as in many
cases there are dangerous complications and se-
quelae, which may prove fatal.
A case of ordinary heat exhaustion does not re-
quire much skilled treatment beyond the removal
of the patient to a cool and shady place. Loosen
all his clothing, and take his temperature by rec-
tum, as the thermometer is a sure guide in such
cases, and you will find that it may be below nor-
mal, in which case you will have to use heat instead
of ice applications as in the case of thermic fever.
In order to restore the bodily temperature in this
case you place the patient in a bath at 105° F. to
110° F., or use hot water bottles or hot bricks or
hot packs. Such a case may call for cardiac and
respiratory stimulants, such as the inhalation of
ammonia, amyl nitrite, aromatic spirit of ammonia,
or spirit of nitroglycerin by the mouth or hypo-
dermatically.
If the heart is laboring hard and cyanosis shows
and collapse threatens, lower his head, apply heat
to his lower extremities, and give him a hot bath
if convenient, and cardiac and respiratory stimu-
lants by the jnouth, by hypodermatic injection, and
by inhalation as in any other case of collapse.
Strychnine and digitalin may be used for a short
time to combat the neuromuscular weakness.
The patient should be kept quiet and remain in
ted and given highly nutritious food, including
milk and broths. Open his bowels with small doses
of calomel, and keep him in bed for a couple of days
itntil he feels able to resume his duties.
Dr Joseph W. Walsh, of Brooklyn, N. Y., rcinrks:
The successful treatment of sunstroke depends
upon our ability to lower the temperature. The
basis of the treatment should be the use of the cold
bath. Place the patient in a dry sheet and lift him
into a tub of water at a temperature of 80° F. and
adding ice freely to lower the temperature of the
water to its lowest possible point, using at the same
time friction on the arms, legs, body, and head
upon which you should simultaneously pour water
at a temperature of 60° F. Before subjecting the
patient to this treatment it will be helpful to give
him spiritus frumenti, one ounce, and tincture of
digitalis, m xx, fifteen minutes before the bath.
As a rule following the bath we get a lowering of
the temperature, a reduction of the pulse and respi-
ration, and a refreshing sleep. The bath should
last thirty to forty-five minutes, depending upon its
efifect, when the patient may be lifted from the bath
to a blanket and gently dried. The bath should be
given in a warm room in which there are no cur-
rents of air blowing upon the patient. Ice water
enemata in addition are ef¥ective in many cases, and
the ice cap is indicated in all cases of sunstroke.
The temperature sliould be frequently taken by
mouth or rectum, and the treatment regulated by
the temperature index. We must remember that
this treatment is powerful and capable if used too
long of doing harm. Croton oil, three minims, may
be given early with good effect in these cases, and a
free state of the bowels maintained by the use of sa-
lines for some days after the absence of the fever.
Should convulsions occur give morphine sulphate,
gr. 1/4 to gr. 1/2, with or without atropine sulphate,
gr. i/ioo, by hypodermatic injection. If convul-
sions persist anesthetize patient, using chloroform,
and if necessary keep the patient under the anaes-
thetic while giving the bath and watch the rectal
temperature while so doing. The use of drugs to
reduce the temperature is unwise, especially the
more depressing coal tar antipyretics. The bath
may be repeated every four hours if necessary, but
with the temperature only moderately high, 101°
F. to 103° F., the ice or alcohol bath should be
repeated every two and one half hours. This will
result in favorable symptoms which are : — A reduc-
tion in surface heat, a stronger pulse, a lessened
axillary and rectal temperature, an increased depth
of respirations, and a return of the conscious state.
For heart failure strychnine sulphate, gr. 1/32 to
gr. 1/20, every half hour ; tincture of digitalis, m xx
to m XXX, every half hour or hour ; sparteine sul-
phate, gr. 1/2, every hour, all to be most judiciously
used, until cardiac reaction is produced.
With the appearance of sthenic, apoplectic symp-
toms following the reduction of temperature or a
condition of asphyxia presenting, — venesection
should be seriously considered.
The sequelae of sunstroke are headache, vertigo,
insomnia, epilepsy, mental enfeeblement, mono-
plegia, paraplegia, and hemiplegia : and they should
all be treated symptomatically.
(To be continued.)
LETTER FROM OTTAWA.
Tlie Annual Meeting of the Canadian Medical Associa-
tion.— The Question of an Official Journal. — The
Canadian Medical Protective Association. — The En-
tertainments.
Ott.\wa, June 15, 1908.
The forty-first annual meeting of the Canadian
Medical Association, the first under the new consti-
tution, was held at the Capitol, in Ottawa, on the
9th, loth, and iith of June, under the presidency
of Dr. F. Montizambert, of Ottawa, director gen-
eral of public health, Dr. George Elliott, of Toronto,
acting as general secretary. The meeting was a
pronounced success. It was amply demonstrated
that sectional meetings were satisfactorj^ and that,
barring a few alterations, the new constitution pro-
vided for facilitating the work of the meeting. The
scientific programme was of the first order, while
the entertainments proved that the Ottawa men
were not going to be outdone, and so had presented
a "capital" programme. Dr. Risien Russell, of
Lx)ndon, England, delivered the address in medi-
cine. It was illustrated with lantern demonstra-
tions, and dwelt upon the reflexes. The Surgical
Rights of the Public was the title of the address in
surgery, delivered by Dr. John C. Munro, of Bos-
CORRESPONDENCE.
LNew York
Medical Juiknal.
ton. Dr. John 15. Deaver, of Philadelphia, read a
very favorably received paper on gallstones and
gallbladder surgery. There was held a very in-
teresting "symposium" on peritonitis. This was
opened by Dr. C. W. Duval, of Montreal, with a
paper entitled The Bacteriology of the Peritoneal
Cavity, with Special Regard to Peritonitis. Dr. J.
T. Fotheringham, of Toronto, followed, with a
paper on the diagnosis and general medical treat-
ment of the disease, stating that the malady really
had no medical treatment, and that as soon as a
physician found a case developing he should hand
the patient over to the surgeon. The surgical treat-
ment was dealt with in papers by Dr. J. F. W. Ross,
of Toronto, who advocated closure of the wound
without drainage, and by Dr. Murray Maclaren, of
St. John, N. B., Dr. L. C. Prevost, of Ottawa, and
Dr. George E. Armstrong, of Montreal. The spe-
cial committee on the establishment of an official
journal reported favorably on the project and asked
that the Finance Committee be instructed to go on
with the project. The Finance Committee, ap-
pointed by the Executive Council, were Dr. J. F.
Fotheringham, of Toronto, convener ; Dr. F. N. G.
Starr, of Toronto; Dr. R. W. Powell, of Ottawa;
Dr. George E. Armstrong, of Montreal, and Dr.
James Bell, of Montreal. A special committee to
be known as the Milk Commission of the Canadian
Medical Association was appointed, with Dr. C. J.
Hastings, of Toronto, as chairman, with members
in every province of the Dominion. Dr. A. T.
Shillington, of Ottawa, was appointed chairman of
the Committee on Medical Legislation ; Dr. R. A.
Reeve, of Toronto, chairman of the Committee on
Medical Education ; Dr. C. J. Hastings, of Toronto,
chairman of the Committee on Public Health ; Dr.
H. B. Small, of Ottawa, chairman of the Commit-
tee on Amendments to the Constitution and By-
laws; Dr. F. A. L. Lockhart, of Montreal, chair-
man of the Committee on Reports of Officers ; and
Dr. J. H. Elliott, of Toronto, chairman of the Com-
mittee on Necrology. On motion of Dr. H. A.
Bruce, of Toronto, Dr. Risien Russell, of London,
England, Dr. John C. Munro, of Boston, and Dr.
John B. Deaver, of Philadelphia, were elected hon-
orary members. Winnipeg was decided upon as the
place of meeting in 1909, with Dr. R. J. Blanchard
as president, the presidents of the provincial med-
ical societies as the vice-presidents, and the secre-
taries of the' provincial medical societies as the local
secretaries, with the exception of the province of
Quebec, which has no provincial medical society.
For that province Dr. F. A. L. Lockhart, of Mont-
real, was elected vice-president and Dr. C. A. Peters
local secretary. Dr. George Elliott, of Toronto, was
reelected general secretary and Dr. H. B. Small,
treasurer.
Dr. R. W. Powell, of Ottawa, the jjrcsident, oc-
cupied the chair at the seventh annual meeting of
the Canadian Medical Protective Association, which
was held in Ottawa on the 9th of June. He re-
ported that since the association was organized, in
Winnipeg, in T901, not a single case which they
had undertaken to defend had been lost ; that the
fact, becoming known among the public at large,
that the medical men of Canada had at their back
an organization of this character was acting as a
deterring influence against causeless litigation, and
that year by year there were fewer cases than in
the previous year which they had to defend. Dur-
ing the seven years the association has accumulated
nearly three thousand dollars. The fee for meiu-
bership is three dollars. Dr. Powell was reelected
president and Dr. J. Fenton Argue, of Ottawa,
secretary. The new dean of the Medical Depart-
ment of McGill University, Montreal, Dr. Francis
J. Shepherd, was present, and on every hand was
receiving congratulations. Dr. Roddick, the retir-
ing dean, was also present.
The entertainments took the form of a reception
at the Ottawa Golf Club on the evening of the first
day, an excursion to Caledonia Springs on the after-
noon of the second day, and a smoking concert on
the evening of the third day, besides numerous
private functions. Sir Wilfrid Laurier, Canada's
Prime Minister, and the mayor of Ottawa delivered
addresses of welcome.
Solvent for Uric Acid. — Fiessanger (Journal de
incdiciiie de Paris, May 9th) prescribes the follow-
ing' powder to be taken as directed :
R Dried sodium phosphate,
Sodium sulphate aa 5ss ;
Sodium bicarbonate, gr. xlv.
M.
Dissolve the mixed powder in a quart of boiling
water, and take one wineglassful in the morning on
an empty stomach; half a wineglassful at 11 o'clock
a. m., at 4 o'clock p. m., and on retiring for the
night.
Carminative Mixture in Flatulent Dyspepsia,
—A. F. Plicque (Le Bulletin medical, May 16, 1908)
advises the use of the following mixture for the re-
lief of the spasms of pain accoinpanying flatulent
dyspepsia :
B Oil of anise gtt. xU
'i'incture of ^•alerian, 31;
Tincture of opium xlv;
Magnesium carbonate, 5i to 5iss ;
Peppermint water, jiiss.
M. et Sig. : One teaspoon ful every hour, or every half
hour, until relieved.
Diabetic Coma. — After the withdrawal of a cer-
tain amount of blood in diabetic coma of acidjemia
it is advisable to inject into the veins solutions that
approximate normal blood plasma rather than either
physiological saline solution or saline solution with
a large amount of sodium bicarbonate. The follow-
ing is Ringer's solution, which may be used for this
purpose :
R Sodium chloride gr. cxxxv;
Calcium chloride. gr. iv;
Potassium chloride gr. viss;
Sodium l)icarbonate, gr. iii.
M. Fiat chartula i.
Sig. To be added to a quart of distilled water.
This solution may be made into sterilized tablets
and kept ready for use. — Journal of the Auierican
Medical Association.
June 2-. 1908.1
EDITORIAL ARTICLES.
1249
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and The Medical News.
A Weekly Review of Medicine.
Edited by
FRANK P. FOSTER, M. D,
and SMITH ELY JELLIFFE, M. D.
Addicsfi all business commitnications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, Xew York.
Philadelphia Office : Chicago Office •
3713 Walnut Street. IGO Washington Street.
SuBSCKiPTiox Price :
Under Domestic Postage Rates, ; under Foreign Postage Rate.
$7 ; single copies, fifteen cents.
Remittances should be made by New York Exchange or post
office or express money order payable to the A. R. Elliott Pub-
lishing Co., or by registered mail, as the publishers are not
responsible for money sent by unregistered mail.
Entered .it the Post Office at New York and admitted for
transportation through the mail as second class matter.
NEW YORK, SATURDAY, JUNE 27. 1908.
THE MEDICAL SERVICE OF THE ARMY.
We would call the attention of our readers to the
announcements which we publish in our depart-
ment of Miscellany this week, under the heading
of Army Medical Department Examinations, 1908.
Copies of the circulars of information reached us
when it was too late for their insertion in full in
this issue. In view of the fact that formal applica-
tions for permission to undergo the preliminary ex-
amination for admission into the Medical Corps
should be in the possession of the adjutant general of
the army before July ist. we hasten to publish the
condensed statements in question, and shall give our
readers further information in our next number.
An appointment as a medical officer of the army
or navy has always been coveted by the )oung
graduate, for there is no higher stamp of his merit.
If until recently certain conditions of the service
have operated to cause many promising and ambi-
tious young physicians to refrain from seeking for
this mark of distinction, to the great embarrassment
of the service, it is evident that recent legislation
has so remedied those deterrent features as to in-
sure a more general determination among eligible
men to take the examinations and enter upon a
career in the arm.y or navy. And yet, so large is
the number of vacancies created by the new law in
the Medical Corps of the Army, for several years
to come all candidates who pass the examinations
acceptably will be practically sure of succeeding in
-entering the corps ; so the heightened attractiveness
of the career need cause no competent man to fear
that increased competition will lessen his chances
of success.
A notable feature of the recent action of Con-
gress is the creation of the Medical Reserve Corps,
such a body as the army has always stood in need
of. Heretofore, whenever the emergency of war
has made a rapid increase of the number of medical
officers absolutely necessary, the personal prefer-
ences of civil officials and politicians have led to the
appointment of many persons whose unfitness soon
became manifest to everybody but themselves. The
flower of our profession have now the opportunity
of guarding against any further repetition of such
an unfortunate state of things, and at the same time
of letting their patriotism be known. Some sacri-
fices on their part will be needed when they are
called upon for active service, but they are such
sacrifices as every good citizen is ready to make, and,
as a class, physicians have never been backward in
endeavors to promote the public welfare at any cost
to their personal interests. It will soon come to be
recognized, we believe, that membership in the
^Medical Reserve Corps, even in times of peace, will
be accounted noble by the people, for whoever
stands ready to do a good deed when he is called
itpon is as meritorious as he who, having the oppor-
tunity, actually does it. ^^'e are very hopeful,
therefore, of the personnel of the new corps, for
we look to see it made up of the best men that the
profession includes, men who have made their mark
in civil life solely by their own fitness and the beauty
of their lives — surely a legion of honor.
CHARITY ORGANIZATIONS TO JOIN IN
RED CROSS WORK.
In the selection of Mr. Ernest P. Bicknell as
national director the American National Red Cross
seems to have chosen wisely. His selection as
director carries with it the adoption of the policies
which Mr. Bicknell has earnestly and ably advo-
cated. The essential idea of the reorganization of
the work of the Red Cross Society as outlined by
'Mr. Bicknell is that all the organized charities in
the United States are to be enrolled as auxiliaries
to the Red Cross, each organization agreeing to
send a certain number of trained agents and nurses
to the scene of need at the call of the society. This
would give a nucleus of experienced workers whose
eflforts would be much more eflfectual than those of
persons not trained in charity organization work.
Under this plan experienced investigators, visitors,
nurses, organizers, and administrators, trained to
work systematically and effectively, could be assem-
bled at any point in the United States within a few-
hours, ready to give skilled assistance in the relief
1250
EDITORIAL ARTICLES.
[New York
Medical Journal.
of suffering from any great disaster and to handle
and distribute supplies of any kind which might be
needed.
The skeleton organization of the society as out-
lined by Mr. Bicknell provides for the appointment
of local representatives in various sections who
would at once assume charge of relief measures
wherever the services of the society were required,
and to this representative the assistants from the
various auxiliary organizations will report as soon
as they are notified that their services are required.
The acts of the local representative will be subject
t(i the approval of the emergency relief board and
of the national director, who in cases of grave im-
portance will proceed to the spot himself and as-
sume immediate charge of the work. The plan as
set forth by Mr. Bicknell is an excellent one and,
as it is based on his experience in San Francisco,
we have no doubt that it will prove eminently satis-
factory in operation.
THE LIMTfATIONS OF DISINFECTION.
We often hear grave doubts expressed concerning
the value of disinfection of sick rooms after conta-
gious diseases, and are told that results would be
equally good if this were entirely omitted. Further-
more, bacteriologists teach us that practically all the
tests of the efificacy of disinfection now in use are
subject to wide error, and that no standard has yet
been discovered by. which to make comparative meas-
urements. The difference between tests on naked
germs and on germs in the presence of even three
per cent, of some form of organic matter may ex-
ceed fifty per cent. Hewlett and Kenwood, therefore,
prefer to obtain the carbolic acid coefficients of the
particular disinfectants to be compared by adding
varying dilutions of the disinfectants to a definite
quantity of faeces, and, after half an hour's exposure,
testing for the survival of Bacillus coli communis.
At the Lister Institute carbolic acid and Bacillus
typhosus are the standard chemical and germ em-
ployed for ordinary purposes. The organic matter
is supplied in the form of a sterilized three per cent,
emulsion of human faeces. This is made by drying
faeces at 102"' C. (215.6° F.), grinding in an agate
mortar, suspending the powder in water, and then
sterilizing in the autoclave. Blyth advocates the use
of milk of a given composition in place of the faeces
suspension.
So far as the advisability of disinfecting sick
rooms is concerned, a discussion reproduced in a
recent number of Public Health reflects the prevail-
ing opinions in England. Kenwood is a thorough
believer in such disinfection, and urges the frequent
disinfection also of school rooms. If possible, these
should be cleaned and disinfected at the end of each
week. Colonel Firth, who has had considerable ex-
perience with disinfection in the army, boldly advo-
cates omitting disinfection of sick rooms entirely.
Even after scarlet fever he makes it a practice not
to disinfect the rooms, but disinfects by steam all
personal clothing, and trusts to fresh air and soap
and water to cleanse the room. Rideal believes this
is going too far, and urges the value of disinfection,
especially in killing tubercle germs. Defries believes
that until we know the precise vehicle of infection
in any given case it will be best to disinfect the
rooms in order to be on the safe side. It certainly
is not well to create a false sense of security by
going through an elaborate disinfection and then
omitting careful cleansing with soap and water. As
a rule, however, the moral effect is just the reverse;
the family is impressed with the importance of
cleansing, ventilating, and renovating. In this moral
effect a great many health officers see the most im-
portant role of the disinfection of sick rooms.
Several observers spoke of the use of disinfectants
to kill vermin. Kenwood had made comparative
tests with formaldehyde, chlorine, nitrous acid, and
sulphurous acid, and found that fleas were killed
only by exposure to the last named. The results
with bedbugs were practically the same, so that,
for the killing of such vermin, the old sulphur dis-
infection is to be preferred. In killing lice on the
clothing of soldiers. Firth found that a three hours'
exposure to formaldehyde produced the best results.
The disinfection was carried out in a steam disin-
fector with just sufficient steam inside to keep the
air moist.
MASTURBATION AND ITS CONSE-
QUENCES.
But ver\- few physicians, we fear, have formed a
correct estimate of the influence of masturbation on
the physical and mental health of those who prac-
tise it. The quacks, of course, depict its alleged
direful effects in frightful terms, and, unfortunately,
there are some of our textbooks that are not far be-
hind them. The consequence is that many impressi-
ble persons, conscious of having been more or less
addicted to the practice in their youth, fall victims to
tormenting remorse, accusing themselves of vicious-
ness and of having brought upon them.selves an end-
less succession of physical and mental abnormities.
They feel convinced that they are rapidly drifting
into impotence or that they are doomed to end their
days in a madhouse.
However clearly wc may discern the fallacious-
ness of the teaching that has given rise to all this
unnecessary misery, most of us, in our intercourse
with the laity, hesitate to combat it, lest we should
be misunderstood as in some way countenancing a
June 2y, 1908.]
EDITORIAL ARTICLES.
habit which is certainly degrading and is popularly
reputed to be vicious and disastrous — so reputed in
spite of the fact that it is generally known to be al-
most universal among young persons. Is it not wise,
we are apt to argue, to let the popular impression
alone for the sake of some modicum of wholesome
effect which it may exert upon masturbators who
are in danger of carrying the practice to excess ? It
must be conceded that the question is a delicate one ;
however, we believe that more good is likely to come
from telling the truth than from refraining.
A remarkable contribution to the true statement
of the case was made in our issue for October g,
1897, in an article entitled An Investigation Into the
Effects of Masturbation, by Dr. A. C. McClanahan,
of Red Lodge, Montana. Dr. McClanahan gave
brief accounts of the subsequent careers of a number
of men known by him to have been masturbators in
their youth, and the narration speaks pointedly in
favor of the innocuousness of the habit. It is well
worth our readers' while to turn back to the article.
Quite recently, in the Progrcs medical for June 6th,
Dr. Maurice Royer has gone over the ground again,
and he comes substantially to Dr. McClanahan's
conclusions, though he admits that, when carried to
excess, masturbation is injurious, but no more so, he
implies, than excessive coitus. Incidentally, it is in-
teresting to note that M. Rover, not believing in the
syphilitic origin of tabes dorsalis, agrees with those
who ascribe that affection to excessive indulgence in
sexual intercourse. Its frequent occurrence in syph-
ilitic subjects, he thinks, is but a coincidence, de-
pending on the fact that libertines are particularly
prone to contract syphilis. He thinks, also, that pre-
cocious masturbation, the form sometimes noticed in
very young children, may create a locus minoris re-
sistentice in the spinal cord and thus pave the way
for tabes. Such children, as he remarks, are in-
capable of producing a '"terminal spasm" and an
ejaculation, but find satisfaction in a partial erection
of the penis which they keep up by manipulations
continued for hours at a time. It is this protracted
sexual excitement, he thinks, which does the harm.
Nobody can accuse these infants of viciousness ; they
generally learn the habit from their nurses' hand-
ling, carried out ignorantly or by design, for some
unscrupulous nurses do not hesitate to pacify a tur-
bulent child by titillating its genitals.
As to the part supposed to be played by masturba-
tion in the production of insanity, if all young mas-
turbators are destined to end in an asylum, asks Mr.
Royer, will it be possible to find enough keepers for
them? Masturbation has figured prominently in
the aetiological tables published in asylum reports,
and occasionally an alienist seems to think that he
has probed the aetiology of a case to the bottom when
he has elicited from an insane patient the admission
(sometimes unfounded) that he or she has been a
masturbator. In many an asylum, it is true, we may
see a poor inmate almost constantly executing move-
ments which can only be masturbatory, but surely
the revolting propensity may quite as well be the re-
sult as the cause of mental disease. We have no
more right to afflict the friends of an insane person
by saying that he or she masturbated himself or
herself into insanity than we have to declare that a
man drank himself crazy, whereas his insanity,
though incipient and latent, may have urged him to
drink.
THE FRENCH ^lEDICAL MEETING IN
QUEBEC.
As we have already noted in our news columns,
the Association des medecins de langue francaise
de I'Amerique du Nord will hold its fourth meeting
in Quebec on July 20th, to continue until the 22d.
The elaborate celebration of the tercentenar>- of the
historic and picturesque old city is sure to attract
a great number of physicians from various parts of
Canada and the United States, including many
whose native tongue is not French, and they will
naturally be interested in the meeting. So great a
concourse of visitors is expected, indeed, that the
hotels are not making reservations of rooms on
order. While this fact is proving decidedly em-
barrassing to the committee on quarters, the\- are
able to announce that 400 rooms, with or without
partial or complete board, have been placed at their
disposal, at charges ranging from $2 to $5 a day.
The secretary of the committee is Dr. Emile
Nadeau. It appears to be decided, the committee
say, that there will be a city of tents, with all the
necessary conveniences, including running water,
drainage, electric lights, service, police, and restau-
rants, which will also be open to physicians attend-
ing the meeting. The Canadian transportation com-
panies have arranged for half rates, and a similar
action has been taken by the railway companies of
the eastern part of New England. It is altogether
probable, therefore, that medical men who visit
Quebec for the occasion will be able to make the
trip comfortably and economically, and it seems to
us that the association may count on a very large
and satisfactory meeting.
A CONSOLIDATION OF SCOTCH
JOURNALS.
It is announced in the June number of the Scot-
tish Medical and Surgical Journal that there will be
no further issues under that name, for it is to be
consolidated with the old Edinburgh Medical Jour-
nal. For the eleven years of its existence the jour-
nal first mentioned has been justly held in high
1252
NEWS ITEMS.
[New York
Medical Journal.
esteem for its excellence, and it cannot be doubted
that the consolidation will give Edinburgh a journal
of heightened usefulness and influence. It was con-
sequent upon the acquirement of the Edinburgh
Medical Journal by members of the profession. The
new journal will be edited jointly by the senior ed-
itors of the constituent journals.
JUSTICE TO THE CONVICT.
In Charities and the Commons for May 9th
there appears a letter written by Dr. Beverley Rob-
inson, who has long shown a most philanthropic
interest in the inmates of our penal institutions.
Dr. Robinson mentions two ways in which com-
plaints by prisoners might be listened to without
hindrance and with some chance of avail. The
first one is by frequent visits by authorized persons
at unexpected hours, and the other is by allowing
prisoners to write to the State Prison Commission
as often as once a month without the knowledge of
the prison officials, or, at all events, without the
letters being opened before they are mailed. When
we remember that insanitary conditions often form
the burden of complaints, it will be realized that
the medical profession ought to cooperate with Dr.
Robinson.
Stray Dogs Condemned. — In view of the occurrence
of several cases of rabies recently, the Board of Health of
the City of New York has adopted an ordinance providing
for the destruction of all stray dogs.
The Medical Department of the Temple University,
Philadelphia, held its commencement exercises on the
evening of Wednesday, June 3d. The degree of doctor of
medicine was awarded to eight candidates.
The Antituberculosis League of New Orleans has
organized a branch league at Winnfield, La., with the fol-
lowing officers: President, Dr. J. J. Peters; vice president.
Dr. I. \i. Siess; secretary. Miss Georgia Prothro, and treas-
urer, Air. .S. G. Fittz.
Jewish Hospital, Philadelphia, Home for Nurses. —
The corner .stone for a home for nurses and a surgical
ward, to be known as the Pennsylvania Building, was laid
with api)ropriate ceremonies on the grounds of the Jewish
Hospital, Philadelphia, on Tuesday, June 2d.
Donation to the Syracuse, N. Y., Hospital for
Women and Children. — Mrs. Mead Belden has given
$5,000 to thi'^ institution, to endow a bed in the Holden
pavilion for children. This gift in perpetuity is to be a
memorial to Mrs. Bcldcn's son, Edward Mead Belden.
An Annex to Roosevelt Hospital. — Plans have been
filed for a two story pavilion which is to he erected as an
addition to Roosevelt Hospital. The pavilion will be fitted
as a pathological annex, with apparatus for microscopical
work. It has been presented to the hospital by Mr. James
W. McLane.
Contagious Diseases in Chicago. — Tlie following
cases of conmiunicable diseases were reported to the De-
partment of Health during the week ending June T3, 1008:
Measles, 227: diphtheria, 04; scarlet fever, 67; whooping
cough, 41; tuberculosis, 40; chickenpox, 17; typhoid fever,
•g; diseases of minor importance, 4; total, 497.
The Hartford Celtic Medical Research Society is the
name of an organization recently formed in Hartford,
Conn., with the following officers for the first year : Presi-
dent, Dr. D. F. Sullivan ; vice presidents. Dr. Edward J.
Thurbert, and. Dr. Thomas F. Welch; treasurer, Dr. P. R.
McPartland ; secretary. Dr. J. F. Rooney.
The Northwestern Medical Association of Philadel-
phia held a stated meeting on Friday evening, June
26th, which was the last meeting of the association until
the second Friday in September. The principal feature
of the programme was a paper by Dr. Moses Bel'msnd on
the Diagnosis and Treatment of the Enlarged Prostate
Gland.
Philadelphia County Medical Society. — A meeting of
the Central Branch of this society was held on the even-
ing of June 24th. Dr. James W. Walk presented a com-
munication on Avoidable Mistakes in Medical Testimony,
and Dr. Henry LefTmann delivered an address on Naturali-
7ation and Socialization of Medical Education the Only
Method of .Suppressing Quackery and Illicit Practice.
Tufts Medical College held its fifty-second annual
commencement exercises on Jime 17th. Two hundred and
forty-seven degrees were conferred, which breaks all previ-
ous records. At the annual dinner of the alumni associa-
tion Dr. Morton Prince delivered an address in which he
made a plea for donations for laboratories and endowment
to enable Tufts to take the lead in establishing a course
in psychotherapeutics.
Night Camps for the Tuberculous — Dr. Livingston
Farrand, secretary of the National Association for the
Prevention of Tuberculosis, says (Charities and the Com-
mons, June 20, 1908) that night camps are needed for
tuberculous patients who are still well enough to continue
their work. These night camps should provide the patient
with dinner, a place to sleep out of doors, and a good
breakfast before going to work.
Appointments at Cornell University, Ithaca, N. Y. —
Dr. Sutherland Simpson, of the University of Edinburgh,
has been appointed professor of physiology, and Dr.
.Andrew Hunter, of Leeds University, has been appointed
first professor of biochemistry. Dr. Dennie Hammond
Udall, professor of veterinary medicine in Ohio State Uni-
versity, has been appointed acting professor of veterinary
medicine, to succeed Dr. James Law.
Tuberculosis Camps. — The idea of tuberculosis day
camps for patients suffering from tuberculosis, which
originated in Germany, was first introduced into this
country in Boston by the Boston Association for the Re-
lief and Control of Tuberculosis, which established a camp
on Parker Hill, maintaining it from May until November.
The movement has spread rapidly throughout Massachu-
setts, and excellent results have been reported.
The Associated Physicians of Long Island held their
summer meeting at the Pcnataquet Corinthian Yacht Club,
Babylon, on Saturday, June lotli. .\bout seventy-five mem-
bers were present. Among those who presented papers
were Dr. Louis Nott Lanehart, of Hempstead ; Dr. Rus-
sell S. Fowler, of Brooklyn ; Dr. Arthur H. Bogart. of
Brooklyn; Dr. Archibald Murray, of Brooklj'n; Dr. Walter
Truslow, of Brooklyn, and Dr. Frederick Tilney, of
Brooklyn.
The Upper Cumberland Medical Society, Tennessee,
held its annual meeting recently in Sparta, Tenn. Officers
for the ensuing year were elected as follows: President,
Dr. B. S. Rhea, of Bon Air ; first vice president, Dr. J. T.
Moon, of Algood; second vice president. Dr. T. J. Potter,
of Smithville; third vice president. Dr. W. M. Breeing,
of Livingston ; secretary. Dr. V. L. Lewis, of Crossville ;
treasurer. Dr. R. E. Lee Smith. The next annual meeting
will be held in Cooksville.
An Antituberculosis Society in Newfoundland. —
society for the prevention of the spread of tuberculosis
has been org.i.nized in the colony of Xewfoundland, whose
special province will be to instruct the general public as
to the best methods of preventing the spread of this dis-
ease, which is the cause of a very large proportion of the
deaths of the colony. The various missionary societies are
taking an active part in the work, having provided trained
nurses for settlements where the inhabitants agree to pay
the expenses of the nurses.
Tune 2-, 1908.]
NEWS ITEMS.
1253
The Alumni of the Medical Department of the Uni-
versity of Pennsylvania elected the following officers
at the annual meeting held on Tuesday, June i6th : Presi-
dent. Dr. Charles K. Mills: vice presidents, Dr. Wharton
Sinkler, Dr. Allen J. Smith, Dr. H. H. Whitcomb, Dr.
Augustus S. Thayer, Dr. Theodore Diller, Dr. Dewitt
Sherman, and Dr. Alonzo E. Taylor; historian, Dr. Roland
G, Curtin; secretary and treasurer, Dr. Edward A. Shum-
way.
The Medical Department of the University of Penn-
sylvania held its commencement exercises, in common
with those of the other departments of the university, on
\\'ednesday. Tune 17th. One hundred and forty-two men
received the degree of doctor of medicine. The alumni
medal was awarded to Dr. James H. Austin. During com-
mencement week numerous clinics and demonstrations
were given in the medical school for the benefit of the
old graduates who were in Philadelphia for the exercises.
The Health of Pittsburgh. — During the week ending
June 13, 1908, the following cases of transmissible diseases
were reported to the Bureau of Health : Chickenpox, 6
cases, o deaths ; typhoid fever, 36 cases, i death ; scarlet
fever, 26 cases, i death ; diphtheria, 8 cases, o deaths ;
measles, 123 cases, 6 deaths ; whooping cough, 13 cases, 2
deaths ; pulmonary tuberculosis, 35 cases, 7 deaths. The
total deaths for the week numbered 125 in an estimated
population of 403,330, corresponding to an annual death
rate of 16.11 in 1,000 of population.
Hartford, Conn., Medical Society. — The regular meet-
ing of the Section in Surgery was held on the evening
of June 22d. Dr. Oliver C. Smith presented a patient with
renal calculus showing unusual features. Dr. J. B. Boucher
reported a case of renal tuberculosis with intestinal in-
volvement. Dr. H. G. Howe reported four knee joint
operations. Reports of the meetings of the American
Medical Association, the American Orthopsdic Associa-
tion, and the American Urological Association were pre-
sented by local physicians who attended the meetings of
these organizations in Chicago.
The Mortality of Chicago. — According to the report
of the Department of Health of the City of Chicago, dur-
ing the week ending June 13, 1908, there were reported to
the department 509 deaths from all causes, as compared
with 483 for the preceding week and 571 for the corre-
sponding period in 1907. The annual death rate in i.ooo
of population was 12.25. The principal cau-es of death
were: Apoplexy, 11; Bright's disease, 31: bronchitis, 12;
consumption, 79; cancer, 24; convulsions. 5: diphtheria, 6;
heart diseases, 36; intestinal diseases, acute, 32; measles,
8: nervous diseases, 22; pneumonia, 36: scarlet fever, 4;
suicide, 10: typhoid fever. 7; violence (other than suicide),
40: whooping cough, 5; all other causes. 141.
The Annual Dinner of the Medical Society of the
Missouri Valley was given at the Victoria Hotel, Chi-
cago, on the evening of June 4th. Covers were laid for
one hundred and fourteen guests, including a number of
ladies. Among the guests of the society were ; Dr. Hugh
H, Young, of Baltimore : Dr. C. M. Echols, of Milwaukee :
Or. Edwin Leonard, of New York: Dr. H. J, Boldt, of New
York : Dr. Thomas E. Holland, of Hot Springs. Ark. ; Dr.
A. W. McAIester. Jr., of Kansas City: Dr. F. E. Murphy,
of Kansas City: Dr. L. M. Crafts, of Minneapolis: Dr. J. J.
Taylor, and Dr. C. F. Taylor, of Philadelphia. On the
following Friday twenty-five members of the society spent
a delightful day in Milwaukee, the guests of Dr. C. O.
Thienhaus.
Vital Statistics of New York. — During the week end-
ing June 13, 1908, there were reported to the Department
of Health 1. 219 deaths from all causes, as compared with
I, 222 for the preceding week, and 1.343 for the correspond-
ing period in 1907. Of the total number of deaths 663
were in Manhattan, 98 in the Bronx, 370 in Brooklyn, 56
in Queens, and 32 in Richmond. The annual death rate
in I.ooo of population was 15.08 in ]\Tanhattan, 15.61 in
the Bronx, 12.93 in Brooklyn. 12.34 in Queens. 21.77 in
Richmond, and 14.38 in the whole city. The total infant
mortality for the week was 307 ; 228 under one year of age,
and 79 between one and two years of age. There were
127 still births. Nine hundred and forty-four marriages
and 2.250 births were reported during the week.
Personals. — Dr. A. H. Henderson, of Taunggyi, Bur-
mah, and Dr. Ross H. Jones, of Little Marsh, Pa., are
registered at the Philadelphia Polyclinic and College for
Graduates in Medicine.
Dr. Charles F. W. McClnre, professor of comparative
anatomy at Columbia University, has had conferred upon
him the degree of Doctor of Science by the university.
Dr. Charles E. Nammack, of New York, has had con-
ferred upon him the honorary degree of Doctor of Laws
by Fordham University.
Dr. Robert Luther Willis, of Lexington, Ky., has been
appointed superintendent of the Flastern Kentucky Asylum
for the Insane in Lexington, to succeed Dr. John S. Red-
wine. He will take charge on July ist.
Routes to the Pan-American Medical Congress. — Dr.
Ramon Guiteras, 75 West Fifty-fifth street. New York,
secretary of the International Executive Committee of the
Fifth Pan-American Medical Congress, has issued a cir-
cular of information regarding the cost of transportation
and the methods of reaching the place of meeting, Guate-
mala City. Central America, where the congress is to take
place from August 5 to 10, 1908. The cost of a ticket
from New York to Guatemala City will be $56 by rail to
New Orleans, steamer to Puerto Barrios, and rail to
Guatemala City. If desired the return may be made by
San Jose and the City of Mexico at a considerable in-
crease in the cost. The city of Guatemala is situated on a
plateau a mile above sea level and the weather is always
delightful there during August.
Infectious Diseases in New York.
We are indebted to the Bureau of Records of the De-
partment of Health for the folloiving statement of neiv
cases and deaths reported for the two weeks ending June
20, 1908:
r June
13. V
, Jun,
e 20. ,
Cases.
Deaths.
Cases.
Deaths.
180
428
143
37
377
30
-ML-asles
21
841
21
Scarlet fever
27
410
I
108
35
5
38
9
48
3
Cerebrospinal meningitis
7
7
7
Totals
278
2,258
238
The Blackwell Medical Society of Rochester, N. Y.—
The annual meeting of this society, which is the local or-
ganization of women physicians, was held at the residence
of Dr. Hurlburt White, of Fairport. It was also the
annual outing of the society, so the meeting took the form
of an outdoor picnic. The topic for discussion was the
feasibility and advantage of a national and international
medical organization for women. There are at present six
state societies — Iowa. Illinois, Colorado, Michigan, Massa-
chusetts, and New York, and it is hoped that eventually
every state will have its society, and that one national
women's medical society may be organized. Officers for
the ensuing year were elected as follows: President, Dr.
Sarah Pierson ; vice president. Dr. Mary Slaight : secre-
tary. Dr. Harriet Turner; treasurer. Dr. Mary Dickinson;
councillors. Dr. Sarah Dolley, Dr. Loretta Woodruff, and
Dr. M. Louise Hurrell.
The Medical Society of the State of New Jersey.—
The annual meeting of this society was held at Cape May
on Thursday, Friday, and Saturday, June i8th, 19th, and
20th. Three hundred members and guests were present,
and the meeting was one of the largest and most success-
ful in the history of the organization. The papers were
unusually good, and both the members and their guests
were delightfully entertained. The following officers were
elected for the coming year : President, Dr. David St.
John, of Hackensack; vice presidents, Dr. Benjamin A.
Waddington, of Salem ; Dr. Thomas H. Mackenzie, of
Trenton, and Dr. Daniel Strock, of Camden ; correspond-
ing secretary. Dr. Harry .Stout, of Wenonah ; recording
secretary. Dr. Wiliam J. Chandler, of South Orange ; treas-
urer. Dr. Archibald jNIercer, of Newark. The Committee
on Prize Essays awarded the prizes for the best essays
to Dr. Thomas W. Gray, of East Orange, and Dr. Floyd
McEwan, of Newark.
1254
PITH OF CURRENT LITERATURE.
[New York
Medical Tovrnai
Dr. Meyer Director of the Henry Phipps Psychiatric
Clinic. — The trustees of Johns Hopkins Hospital and
University have elected Dr. Adolph Meyer, of New York,
professor of psychiatry and director of the iienry Phipps
psychiatric clinic, which is to be erected and maintained out
of the fund donated for that purpose by Mr. Henry Phipps,
of Pittsburgh. Dr. Meyer will spend the summer abroad
with the architect who is to erect the buildings making
a study of similar institutions at Munich, Berlin, and Brcs-
lau, and will take up his residence in Baltimore in the fall
of 1909. Dr. Meyer has served as director of the clinic
at the Hospital for the Insane in Worcester, Mass., di-
rector of the pathological institute of the New York State
flospital on Ward's Island, since 1904 has been pro-
fessor of psychiatry at the Medical Department of Cornell
University, and is now president of the New York
Psychiatrical Society.
Oregon State Medical Association.— The thirty-
fourth annual meeting of this association will be held in
Portland on Wednesday, Thursday, and Fridaj', July ist,
2d, and 3d. A splendid programme consisting of over
twenty papers has been prepared, and ample arrangements
have been made for the entertainment of the visiting mem-
bers and their guests. The general sessions will be held
in the Assembly Hall of the Commercial Club, and the
meeting of the House of Delegates will also be held at
this ])lace. A public meeting under the auspices of the
Oregon State Board of Health will be held On Friday
afternoon. The officers of the association are as follows:
President, Dr. R. C. Cofifey, of Portland; first vice presi-
dent, Dr. Nicholas Molitor, of La Grande; second vice
president. Dr. J. H. Rosenberg, of Prineville ; third vice
president. Dr. A. C. Seeley, of Roseburg; treasurer, Dr.
Edna Timms, of Portland ; secretary. Dr. William House,
of Portland.
New Head for the Red Cross Society.— Ernest P.
Bicknell, who has been appointed national director of the
.'\merican National Red Cross Society, served for five years
as secretary of the Indiana State Board of Charities, dur-
ing which time he brought about several important re-
forms, both in the charity. work and in the penal system
of the Stale, intrndiicing the indeterminate sentence and
ilu- p.irole. \lr. Bicknell also had charge of the Chicago
liunau oi Charities for some years, taking acti\c part m
the in\ esligations of the County Hospital and ser\ing as
a member of the present commission charged with the
building of a new Cook County Infirmary and Tubercu-
losis Hospital. Mr. Bicknell showed distinguished ability
in work of relief at San Francisco, where he went to rep-
resent the Chicago Relief Committee, which contributed
$700,000 to the relief fund, and it was while there that
he evolved the idea of making charity organizations gen-
erally auxiliary members of the American National Red
Cross Society, with the view to giving a nucleus of trained
relief workers who could be called upon for iinmediate
ser\ice in case of emergencies, it is announced that this
plan will at once be put into effect.
The Health of the Canal Zone.— During the month
of April, 1908, the following deaths from transmissible
diseases occurred in the Canal Zone: Typhoid fever, i;
.•estivoautumnal' malaria, 2; clinical malaria, 20; dysentery,
5; amcfibic dysentery, i; l)eribcri, ; purulent infection and
septicEEmia, 4: tuberculosis of the lungs, 26; general tu-
berculosis, 3; cancer and other malignant tumors, 4; acute
articular rheumatism, i; elephantiasis, i; tetanus, 3;
l)ronchopneumonia, 3; pneumonia, 16; diarrhoe;i and en-
teritis, under two years of age, 15. The total deaths for
I he month nmnbered 194 in a population of 116,178. corre-
sponding to an annual cleath rate of 20.04 in 1,000 of pop-
ulation. The health 'of the employees of the canal com-
mission was exceptionally good. There were no deaths
Irom typhoid fever among them, and only one death from
malaria. In 1907 there were 816 cases of malaria treated
in the various hospitals, with 10 deaths ; in 1908 there
were 407 cases of malaria treated, with no deaths. The
decrease in the number of cases of malaria was accom-
l»anied by a decrease in the severity of the type of the
disease. The sick rate among the employees made quite
as good a showing as the death rate. In 1907 the rate
was 21.52 in 1,000; in 1908 it was 17.OQ in 1,000. Plague is
present at (jiiayaquil and at La Guayra, but no case has
been discoxered on the isthnnis. No case of yellow fever
has occurred on the isthmus since May, ^')o(^.
THE BOSTON MEDICAL AND SURGICAL JOURNAL.
June 18, 1908.
1. An Account of Dr. Louis IDaniel Beauperthuy, a Pio-
neer in Yellow Fever Research,
By Aristides Agramonte.
2. .Suture of the Patellar Tendon: Report of Three Cases,
By Charles F. Painter.
3. Notes on X Light. Note 208. The Resistance of an
X Light Tube Is not an Accurate Indication of the
Degree of the Vaciuun, By William Rollins.
4. Modern Medicine and Surgery in the Orient,
By J. EwiNG Mears.
2. Suture of the Patellar Tendon. — Painter de-
scribes his method as follo\\s: The incision is a
straight one directly over the patellar tendon, begin-
ning at the tibial tubercle and extending up over the
lower half of the patella. The sheath of the patellar
tendon is fully three quarters of an inch in breadth,
and at its attachment to the patella is separated from
the synovial membrane by quite a thick layer of sub-
serous fat. In elderly patients this fat may l)e so
atrophied that the sy novial membrane is practically
a part of the posterior surface of the patellar tendon.
If the rupture has been of long standing there is
likely to be considerable contraction of the divided
tendon, and in these cases it is necessary to employ
the method of Lange, devised for the purpose of
transmitting the power of a mtiscle at a distance
where there is no intervening tendon of sttfficient
length. In one case the writer used braided pedicle
silk, bridging over the entire distance between the
tibial tubercle and the patella. Four strands of this
silk were placed parallel to each other, being at-
tached above to the marginal cartilage of the patella
by threading through holes drilled in the cartilage,
and below they were quilted through the patellar
tendon. A fascia was then closed over these sutures
with interrupted catgut, and the skin united with a
Iniried silkvvoriu gut. In two cases where there had
Ijeen but little retraction it was possible to approxi-
mate the cut ends of the tendon quite closely to the
lower border of the patella. It was always necessary
to drill holes in the margin of the patella. The leg
w as then put up in plaster of Paris in complete ex-
tension and was not again disturbed, except for the
removal of the skin suture, until six weeks had
elapsed. The plaster was then split and taken off
each day to permit of passive motion. During the
next two weeks the patients were allowed to bear
weight on the leg, protected by the plaster. At the
end of a month, or ten weeks after the operation,
motion was possible to nearly a right angle, and
walking was then periuitted without the protection
of any splint. Crutches were used for the first six
weeks and then a cane for the next month. Protec-
tion by a flannel bandage was urged for two or three
months after the omission of the plaster. The func-
tional results have been entirely satisfactory. There
has been a loss of not over 5 degrees of extension in
any case, and this has not seemed to materially inter-
fere with function. In one of his cases where Langc's
method was employed one strand of the silk used to
i)ridge over the hiatus worked its way to the surface,
after being in place six months. This required a
careful dissection in order to avoid the removal of
the entire network. It also gave opportunity to oh-
June ^7, 1908.J
PITH OF CURRENT LITERATURE.
serve the way in which a new tendon was being
formed, fibrous tissue having enveloped these strands
throughout their entire extent.
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
/«;)(- X, 190S.
1. The Treatment bv Rest, Seclusion. Etc., in Relation to
Psychotherapy, ' By S. Weir Mitchell.
2. Cooperative Scientific Investigation. Address of the
Chairman of the Section on Ophthalmologj".
By William H. Wilder.
3. Autointoxication,
By G. E. DE ScHWEixiTZ and Charles A. Fife.
4. Tonsillaectomy in Children Under General Anaesthesia
— a Hospital Operation. By Edward Pvxchox.
5. Marriage and Intermarriage of Tuberculosis Subjects,
By I. A. :McS\vaix.
6. Thymic Asthma, with Report of a Case of Thymectomy
and Resection of Enlarged Thyroid in Child Twenty-
three Days Old, " By J. Schwinx.
7. The Conjimctival Tuberculin Reaction,
By Charles Pattox Cl.\rk.
5. Marriage and Intermarriage of Tubercu-
lous Subjects. — McSwain thinks the public should
be informed by distributing circulars written in lan-
guage that can be understood of the danger of inter-
marriage and marriage of tuberculous subjects.
Public exhibitions have a large influence on the pub-
lic mind ; school and home training is important, and
public lectures create interest as perhaps nothing else
can. Physicians in their close contact with the home
should certainly impress the young people of the
danger of the marriage of consumptives and strong-
1\ oppose it. Then, some time in the future, when the
beneficial effects of education are manifest and sani-
tary laws properly executed have curtailed the ravages
of the disease, for the incorrigible ones who will not
be governed by reason, the dignity and majesty of the
law should be invoked. Thus can we teach them that
it were better for a few to practise selfdenial than
that many should suffer for their indulgence. Tu-
berculous subjects should be taught in the most im-
pressive way that to marry and intermarry will in-
evitably bring much sorrow to the household, that
they will but hasten themselves into untimely graves
to leave behind them, perchance, a sickly posterity
that will be liable to succumb to the disease. Let
us instill high ideals in the minds of the young peo-
ple. That their purposes in life should be to bless
and elevate mankind, that the temporary joys of the
marriage of diseased persons are soon to be over-
shadowed by thick clouds of sorrow and disappoint-
ment. Better endure the loneliness, and even the
stigma, of single life than to behold the destructive
sequel that follows in the wake of marriage in such
cases.
6. Thymic Asthma. — Schwinn states that in
well developed cases of thymic asthma we find the
symptoms of a stenosis of the air tract somewhere
between the larynx and the bifurcation of the
trachea ; inspiratory and expiratory stridor, as a
more or less audible whistling respiration ; refraction
of the supraclavicular, infraclavicular, and intercos-
tal spaces during inspiration ; inspiratory dilation of
the nostrils, and more or less cyanosis and restless-
ness. Most any time these symptoms may assume a
most dangerous character, the respiration becoming
extremely labored, the patient becoming blue or al-
most black. Consciousness is lost, convulsion may
set in. and, with a rapid, weak pulse, death may fol-
low in the course of a few minutes. Potts reports
four cases where children died with the symptoms of
suft'ocation within two minutes after the insertion of
a tongue depressor. A child may show very slight
symptoms of difficult respiration, and suddenly in
the midst of a crying spell or during an exciting
play become cyanosed and perish with symptoms of
suffocation. Inspection and palpation are as a rule
negative in thymic enlargement, except where the
gland is quite large and forms a visible and palpable
swelling in the suprasternal notch. Percussion often
brings out an abnormal dulness over the upper part
of the sternum, while auscultation may show dimin-
ished breathing and abnormal tracheal sounds. The
voice is generally unchanged, except that it may be
weak. The fact that in a case of obstruction to res-
piration the usual intubation gives no relief, while
the intubation with the use of a long tube removes
the stenotic symptoms, would point to the thymus
as the cause of the obstruction. Chevalier Jackson
was enabled, by the use of a bronchoscopic tube in-
troduced by tracheotomy, to see directly the narrow
slit to which the trachea was reduced by the pres-
sure of the enlarged gland ; but of all the diagnostic
means the radiogram is the most trustworthy. The
enlarged gland throws a shadow different from that
of the normal gland in that it reaches farther to the
side of the vertebrae and merges into the shadow of
the heart in a convex line instead of in a rather
straight line. The condition being such that a child
with a large thymus may suft'ocate at any moment,
it is very plain that surgery, and prompt surgery at
that, is the only rational procedure. The medical
treatment may bring down a syphilitic enlargement
in time, but it surely will not reduce a simple hyper-
trophy far enough to keep the patient safe until this
reduction is accomplished. Some authors advise us
to keep a child of this kind quiet, see that it does not
throw the head back, keep it from crying and excite-
ment, keep away infectious diseases, etc. All of this
is very nice, but who can watch an otherwise healthy
child day and night for years in its every movement ?
Operation with the view of removing the offending
organ seems to the author the only treatment to be
thought of, and in the few cases where this was car-
ried out the results certainly have been all that could
be expected. But there is still that class of cases
left in which there are no s}Tnptoms whatever, until
suddenly and without warning a child is seized with
a suffocating attack and expires before help can be
had. In a considerably greater number of cases of
sudden death in children than we imagine at present
the thymus is in all probability to blame. In cases
of this kind we are utterl}- in the dark until after the
catastrophe, and the only way to prevent such deaths
would be a systematic radiographic examination of
children. The operation should be performed as
soon as a diagnosis is made, the radiographic method
being the most reliable of our diagnostic means. A
tracheotomy should be provided for in every case,
but avoided if possible on account of the danger of
infecting the mediastinum. The upper chest aper-
ture should be temporarily enlarged b)- the splitting
of the sternum, if during the operation the dyspnoea
is increasing at all ; in this way it will be possible to
PITH OF CURRENT LITERATURE.
1256
avoid tracheotomy in a number of cases. General
anaesthesia should be used, as it is very difficult to
operate upon a struggling child.
MEDICAL RECORD.
June 20, igo8.
1. Milk Free Fluid Diet, and Rectal Irrigations in Ty-
phoid Fever — A Further Report, By A. Seibert.
2. A Milk Free Diet in Typhoid Fever,
By Cyrus J. Strong.
3. Remarks on Milk Free Fluid Diet and Rectal Irriga-
tions in Typhoid Fever, By Robert C. Kemp.
4. Clinical Charts of a Case of Quartan Malarial Fever
Observed in West Africa, with Commentary,
By F. Creighton Wellman.
5. The Relation of Tuberculous Cows to Tuberculosis in
Children, By William Leland Stowell.
6. The Treatment of Diseases Due to Respiratory Catarrh,
By William Martin Richards.
7. The Injurious Habits and Practices of Childhood;
Their Detection and Correction,
By Karl H. Goldstone.
I, ,2, 3. Milk Free Fluid Diet, and Rectal Irri-
gations in Typhoid Fever. — Seibert has used plain
warm water in irrigating the colon in typhoid fever.
He observes the following rules : If nausea is pres-
ent on admission, the stomach is washed out. Then
two doses of calomel, each containing two grains,
are given within two hours. Rectal irrigations with
three pints of warm water are begun at once. In
severe cases every three, in milder ones every six,
and in mild cases every twelve hours. Bowel haem-
orrhage, appendicitis, and perforations are the only
contraindications. During the first day of treatment
nothing but cold water is given. From the second
day on, one half pint of strained rice, oatmeal, or
barley soup, containing the extract of half a pound
of meat and the yoke of a fresh egg, well spiced, are
given every three hours, five times daily. During
the night cold water alone is offered. During the
first three days of treatment the patients are not
urged to swallow all of their soup, but are persuaded
to drink cold water every hour by day and by night.
From the fourth day on, strained pea, lentil, potato,
and tomato soup, with rice, are added to the menu.
The desire for more food, coming in uncomplicated
cases not seldom on the fifth or sixth day, is met by
giving the soups thickly made. The lower the fever
and the more marked the hunger, the thicker the soup.
To very hungry patients two or three zwiebacks are
given with their soup at the end of the first week.
Orange juice is given in water three times daily.
Egg albumen' is not given, on account of the possi-
bility of forming toxines. Before each meal fifteen
to twenty-five drops of hydrochloric acid arc given
in one half ounce of water. Alcohol is given only to
topers. Cold baths are never employed, even in hy-
perpyrexia. Opium is used only in bowel haemor-
rhage. During complicating pneumonia sixty to
one hundred and twenty drops of 20 per cent, cam-
phorated oil are injected hypodermatically, twice
daily. No other medication is used. The results of
this plan of treatment have been the following : Nau-
sea, headache, delirium, insomnia, tympanites, and
diarrhoea disappeared in mo.st cases after two or three
days, and did not recur later on. In uncomplicated
cases the temperature began to drop after twenty-
four to forty-eight hours daily by 3/2° to 1° F., and
reached 99° F. in the rectum on the morning of the
ninth, tenth, eleventh, or twelfth day of treatment,
irrespective of the duration of the attack before ad-
mission. In a smaller number of cases this occurred
within the first week of treatment. In cases admit-
ted with complications (like pneumonia, nephritis,
and phlebitis) the intestinal symptoms (tympanites
and diarrhoea), as well as those of systemic infection
of the nervous system (delirium, headache, and in-
somnia), usually disappeared as readily as in uncom-
plicated cases, while the temperature, the pulse rate,
and the respirations remained at the height charac-
teristic of the local processes. The complications
disappeared more readily than under the former milk
diet. Later complications very seldom developed in
cases admitted without complications. The author
thinks that it abbreviates the attack and ameliorates
the symptoms by the constant reduction of infectious
material ; it prevents complications, and it reduces
the mortality. — Strong has treated seventeen cases
with the milk free diet, and speaks very favorably of
it. — Kemp is also in favor of Seibert's method. His
only modification of this method is in cases of compli-
cating nephritis of active type, where beef broths are
omitted ; but the strained farinaceous gruels are kept
up, and occasionally he uses malted milk made up
with hot water. [Moreover, he has been employing
of late in his gastrointestinal cases a sterilized milk
albumin product containing glycerophosphoric acid,
which is soluble in water and has been demonstrated
by Ewald to have considerable nutritive value and
to be readily absorbed in typhoid fever. In such
cases the author believes it would be of considerable
ralue. Strong remarks that the use of rectal irriga-
tions is one of the most important features in the
treatment of typhoid fever. He has generally em-
ployed the short recurrent tube and normal saline
solution. The only contraindications are haemor-
rhage and peritonitis. By the irrigations the small
intestine is emptied out into the large intestine, and
this in turn cleared out ; absorption from accumula-
tion in the rectum is prevented, and hence toxaemia
is lessened and the temperature is reduced ; gas, if
present, is removed from the bowel ; the large intes-
tine is kept clean, and elimination of the toxines,
through the diuretic action of the injections on the
kidneys, is promoted.
5. The Relation of Tuberculous Cows to Tu-
berculosis in Children. — Stowell says that fresh,
clean milk, when obtainable, is wholesome and more
readily digested than when pasteurized. The danger
of tul'ierculous infection from milk must be very
slight, for, in tracing the history of the children
and tlie diagnosis on admission to the institution,
there is no evidence of tuberculosis developing more
often among those having the farm milk than
among those in other wards having the pasteurized
supply from the city. Less than 10 per cent, of
the mortality was due to tuberculosis, and that,
according to the United States Census of 1900, is
the ratio" for the nation. We cannot deny the pres-
ence of a tuberculous dairy and the presence of
tuberculous children ; but a careful analysis fails to
show that one depended nn the other.
7. The Injurious Habits and Practices of
Childhood. — Among other injurious habits. Gold-
stone mentions the pacifier. He believes it to be
one of the most pernicious and harmful habits of
infancy. It is found among all classes of people.
June 27, 1908.]
PITH OF CURRENT LITERATURE.
1257
The good influence that it is supposed to exert — im-
aginary, as can be seen — is to quiet the child, stop its
crying, take the place of feeding, and allay the symp-
toms of teething (?). The pacifier can be said
to quiet the child only in the same sense as body
sucking and masturbation quiet ur rather satisfy
the child, but onlv to be replaced b\ the reaction of
a mental explosion, the result of high nervous ten-
sion. It takes the place of feeding only if one were
to consider swallowing of dirt and germs as feeding.
The sucking of the pacifier produces in infants (i )
the formation of adenoids by causing a congestion
of the postpharyngeal wall, and consequent hyper-
trophy of the lymphoid tissue situated between the
two Eustachian tubes and known as the pharyngeal
tonsil ; if adenoids are already present, they increase
in size and extent for the very same reasons. (2)
Deformities of the mouth and palate by the presence
of adenoids, whose growth it incites, and by the
repeated twisting and distorting caused in sucking.
Children who are subject to the habit have a high
arched palate, diseased and deformed teeth, and
thickened lips. (3) Colic and flatulence, by the
sucking in of air. (4) Ulcerative stomatitis and
sprue, by the sucking of dirty particles that always
collect on the pacifier. (5) Hypertrophied tonsils,
due to congestion as mentioned in adenoids.
BRITISH MEDICAL JOURNAL.
June 6, 190S.
1. Cerebral Influenza, By R. Sauxdbv.
2. Hemiplegia -with Unilateral Optic Atropln'.
By R. T. WlI.LIA.MSOX.
3. The Present Condition of Our Knowledge Regarding
the Functions of the Suprarenal Capsules (Oliver-
Sharpey Lectures, II), By E. A. Sch.a.fer.
4. An Unusual Case of Appendicitis, By R. Parker.
5. A Case of Compound Follicular Odontoma,
By J. W. Cousins.
6. Three Years' Experience of Butlin"s Operation for
Cancer of the Tongue, By F. T. Paul.
7. .Remarks on Cancer of the Mouth in Southern India,
with an Anal\ <is of Two Hundred and Nine Opera-
tions, By A. Fells.
8. On the Treatment of Fracture of the Femur in the
Newly Born, By R. Jones.
g. Plastic Resection of the Breast and its Bearing on the
Preliminary Incision of Breast Tumors.
By C. H. Whiteford.
I. Cerebral Influenza. — Saundby discusses the
chief clinical features of cerebral influenza and the
nature of the morbid processes to which it is related.
After citing a number of illustrative cases, he takes
up the pathology of the disease, and summarizes
the post mortem findings as follows : — in some cases
there is only congestion, in others meningitis of the
vertex or base, in others again acute hasmorrhagic
encephalitis, associated in certain instances with
haemorrhage or red softening. Bacteriological ex-
amination either reveals no organism, or strepto-
cocci, Pfeiffer's bacilli, or pneumococci. It is not
improbable that the meningococcus may cause some
of the cases, for there is evidence to show that the
effect of the influenza poison is to rouse into activity
any latent organisms and to diminish constitutional
resistance to their attacks. So that there may be
recognized a series of cases of purely influenzal
origin, and, secondly, one in which influenza forms
merely the soil where other disease germs find the
conditions favorable to their development. True
cerebral influenza may cause, first, a state of cere-
bral imoxication which passes off without doing
serious damage. Next there are cases in which the
poison causes intense and fatal congestion with
minute meningeal haemorrhages. Beyond these the
disease passes on to inflammation of the meninges,
and lastly we have acute hsemorrhagic encephalitis
with luemorrhage or red softening. The symptoms
of cerebral influenza are these : Usually after a
short period, ranging from one to four days, during
which the patient shows signs only of catarrh (and
this may be wanting in some cases), he is seized
with intense headache, with or without vomiting, or
neuralgia or an epileptic or apoplectic fit or aphasia,
or there may be facial paralysis, monoplegia, or
hemiplegia, for the cerebral symptoms may be
ushered in by any one of these symptoms. There
may be a preliminary period of restlessness, with or
without delirium : in others stupor or unconscious-
ness develops gradually or suddenly. There is usu-
ally fever, varying in amount. The muscles are
often rigid : stiffness of the neck, opisthotonos, as
especially contraction of the masseters and trismus,
have been frequently tioted. There may be twitch-
ings of the limbs, or clonic spasms of the head or
extremities, disturbances of vision, inequality or
irregularity of the pupils, paralysis of the sphincters,
and tachc ccrcbralc. The reflexes are generally pre-
served, and Kerig's sign is never mentioned as hav-
ing been present. Optic neuritis is occasionally seen.
Albuminuria is of infrequent occurrence. Chevne-
.Stokes breathing sometimes is present. The prog-
nosis should always be guarded, but not hopeless.
The gravest condition appears to be complete coma,
general relaxation of the limbs, rising temperature,
and Cheyne-.'~tokes breathing. The presence of ear
trouble, of organic disease of other nvz",''?,, of arte-
riosclerosis, or advanced age are bad features, while
youth, previous good health, and a sound constitu-
tion afford a basis for hope. The duration of the
fatal cases varies from two to fourteen days ; usu-
ally it is about a week. As regards treatment, we
are to a large extent powerless. If the patient can
take medicine by the mouth, small doses of quinine
should be given. The diet should consist of inilk,
beaten up eggs, and weak coffee with milk ; if there
is inability to swallow, rectal feeding should be tried,
and, if the sphincters are relaxed, subcutaneous in-
jections of salt solution should be given.
2. Hemiplegia and Unilateral Optic Atrophy.
— Williamson reports a series of cases of a peculiar
combination of symptoms — optic atrophy on one
side, with hemiplegia (or hemiparesis) on the oppo-
site side. Such symptoms could be produced by an
obstruction ( thrombosis) of the internal carotid and
middle cerebral, with occlusion of the central artery
of the retina by thrombosis or embolism.
9. Preliminary Incision of Breast Tumors. —
Whiteford's conclusions are as follows: i. Every
breast tumor should be incised prior to its removal.
The surgeon who, in performing a radical operation
for supposed malignant disease of the breast, neg-
lects the elementary precaution of incising the tumor
as a means of either confirming or disproving the
diagnosis, runs the risk of finding himself in the
unenviable position of having performed Halsted's
or some equally extensive operation for a simple tu-
mor such as an adenoma or abscess. 2. The explora-
PITH OF CURRENT LITERATURE.
[New York
Medical Journ\l.
tory incision should not be made through the skin
which overhes the tumor. An incision made into
the tumor through the overlying skin, in the event
of the tumor proving nonmalignant and needing
only local removal, results to a certainty in a scar
and probably in a depression. This scar, or scar
plus depression, if situated in the upper half of the
breast, interferes with the wearing of a low necked
dress. 3. For exploration of, and, if innocent, for
removal of, tumors situated in the upper hemisphere,
of the breast the incision and method of Collins-
Warren should be employed, because, in the event
of the tumor proving innocent and needing simply
local removal, this method prevents a disfigurement
whi^h, to a sensitive patient, is distressing, and, sur-
gicdly, is unnecessary.
LANCET
June 6, IQ08.
1. The Dangers and Treatment of Myoma of the Uterus
(Ingleby Lectures, I), By C. Martin.
2. The Present Condition of Our Knowledge Regarding
the Functions of the Suprarenal Capsules (Oliver-
Sharpey Lectures, II), By E. A. Schafer.
3. On the Preparation and Use of Antirabic Serum, and
on the Rabicidal Properties of the Serum of Patients
after Undergoing Antirabic Treatment ; also a Note
on the Blood of a Patient Suffering from Hydro-
phobia, By D. Semple.
4. Some Recent Cases of Csesarean Section.
By J. B. Hellier.
5. The Protracted Use of Digitahs, By R. E. Achert.
6. Suprarenal Haemorrhage in an Infant : Its Relation
to Haemophilia, By B. G. Morison,
7. A Case of Indicanuria, By G. N. Montgomery.
8. A Case of Appendix Rupturing during an Operation
and an Analysis of the Meaning of the Symptoms,
By F. R. B. BissHOPP and J. D. Malcolm.
9. -America's Triumph in Panama: Three Years' Medical
and Sanitary Record in the Canal Zone,
By J. G. Leigh.
I. Myoma of the Uterus. — Martin, in the first
of the Ingleby lectures, discusses certain of the dan-
gers connected with myoma of the uterus. Haemor-
rhage from the uterus is the commonest symptom of
myoma and is present in the great majority of in-
stances. It varies much in different cases. The
nearer the tumor to the cavity of the uterus, the
more severe the flooding. Thus in the subserous
growths it is slight, in the interstitial it is profuse,
and in the submucous and polypi it is excessive. In
some cases there is constant dribbling of watery
blood stained fluid. It is rare for a patient to actu-
ally bleed to death from myoma. There usually de-
velops a condition of marked chronic anjemia,
which is the chief cause of the brown atrophy and
fatty degeneration of the heart muscle, which occurs
in many cases of neglected fibroid. It is also the
main factor in producing thrombosis and phlebitis
of the veins of the pelvis and lower limbs, and sec-
ondary embolism of the pulmonary artery. Uncom-
plicated myomata do not, as a rule, give rise to much
pain — never anything approaching the agonies of
cancer. Most patients complain only of discomfort
and uneasiness. But other complicating lesions,
such as adherent and inflamed ovaries and tubes,
may cause severe pain. The pressure symptoms arc
numerous and may call for surgical treatment.
Among them may be mentioned constipation, haem-
orrhoids, varicose veins of the legs and vulva, neu-
ralgia, sciatica, and even retroflexion or complete
prolapse of tlie uterus. But the more serious and
distressing group of symptoms are those due to pres-
sure on the urinary organs. Retention of urine,
either sudden or of gradual onset, is quite common.
It is generally due to a fibroid on the posterior wall
of the uterus, retroverting the uterus, and pushing
the cervix forwards against the pubes. Cystitis sel-
dom occurs as a result of myoma, except by infection
through a dirty catheter. Pressure on the uterus is
most apt to develop where the tumor is developing
in the broad ligament. Disease of the uterine ap-
pendages frequently complicates myoma. Myomata
are peculiarly liable to various kinds of degenera-
tion, secondary changes being found in about twenty
per cent, of the cases. The}- may be divided into
three groups: (i) Nonmalignant degenerations
without necrosis, occurring in about fourteen per
cent, of myomata; (2) nonmalignant degenerations
with necrosis, occurring in about four per cent. ; and
(3) malignant degenerations and complications, also
occurring in about four per cent. There are three
modes by which a "natural" cure of a myoma may
take place: i. A submucous fibroid may necrose or
slough away, or it may be extended through the cer-
vix as a polypus and drop of¥. The risks are of
course much greater than the most formidable of the
modern operations for fibroids. 2. A myoma may
participate in the involution of the puerperium and
disappear. This is very uncertain and is more ap-
parent than real. 3. A natural cure may occur by
the absorption and disappearance of a fibroid at the
menopause. At one time this was looked on as a
certainty, but as a matter of fact the presence of a
fibroid delays the natural change of life, and instead
of the haemorrhages ceasing at forty-five they may
go on until the patient is well over fifty. Further, it
is just at this period of life that the most serious
forms of degeneration are apt to occur. Considering
the safety and the certainty of cure offered by mod-
ern surgical operation, we are not now justified in
advising a patient with a troublesome fibroid to wait
for the menopause.
2. The Suprarenal Capsules. — Schafer, in the
second of the Oliver-Sharpey lectures, sums up the
results of his observations as follows : There is lit-
tle doubt but that the suprarenal capsules are re-
lated in some way to metabolic changes in the tissues
and organs. This is indicated by the symptoms of
Addison's disease. Some of these symptoms can be
referred to absence of medullary secretion. But
others, such as the wasting and the malnutrition ex-
pressed by the abnormal pigmentation of the skin
and mucous membrane, cannot be referred to the
medulla, and are probably the result of disease of
the cortex. In assuming that the cortex of the or-
gan subserves through its internal secretion certain
functions connected with metabolism, there is an
analogy to the pituitary body. In this we have an
instance of a small ductless gland, partly epithelio-
nervous and partly purely epithelial in structure and
origin, the two parts having diflferent functions,
though bound up together into a single organ. Of the
two parts, the nervous part, as in the suprarenals.
produces a substance or substances known as "hor-
mones," which influence the circulatory organs and
certain externally secreting glands — in the case of
the suprarenals it is the salivary glands, in that ot
June 27, 1908. J
PITH OF CURRENT LITERATURE.
125.;
the pituitary it is tlie kidne> s which are speciallv
stimulated. ' The purely epithelial part of the pitui-
tary, however, is closely connected with the growth
and nutrition of certain of the connective tissues, and
especially of the bones, hyperplasia of the organ be-
ing accompanied by. symptoms of gigantism and ac-
romegaly. So that there is some justification for in-
ferring that the cortex of the suprarenals may x ield
a hormone which influences the growth and nutri-
tion of certain tissues and organs — it may be that
the integumentary tissues and the generative organs
— with the relative development of which it is mani-
festlv correlated — are directly under its influence.
THE MILITARY SURGEON.
June, 1908.
1. Antitvphoid Inoculation in the British Army.
By William B. Leishmax.
2. Operation for the Radical Cure of Hydrocele by the
Inversion of the Tunica Vaginalis,
By Powell C. Fauxtleroy.
J. Gallstones. Report of a Case.
By Hexkv a. M.\thewsox.
4. Classification of the Effects o'f the Sun's Rays and of
.\rtificial Heat, By H-\rold D. Corbusier.
5. Diseases and Sanitary Conditions among Alaskan In-
dians. By Paul C. Huttox.
6. Ethyl Chloride as a General Anesthetic in Minor
Surgery. By E. M. Blackwell.
I. Antityphoid Inoculation in the British
Army. — Leishman observes that question of the in-
oculation of large bodies of soldiers, at a few days
notice, on the outbreak of war appears to be one
for the grave consideration of all who are responsi-
ble for the liealth of the troops. Tht objections and
difficulties of such a proceeding are obvious and
should be anticipated and. if possible, avoided. In
modern warfare little time is given for preparation,
and the moment of mobilization is not the moment
for the carrying out of an operation which may re-
sult in the incapacitating of the soldier for twenty-
four or forty-eight hours, to say nothing of the pos-
sible dangers of a negative phase. Compulsory in-
oculation, in time of peace, renewed perhaps from
time to time, appears to be the ideal to be aimed at ;
but before this could be carried out. it would be
necessary to have the protective value of the inocu-
lations proved beyond doubt and universally con-
ceded. However hopeful some <if us mav be as
to the fttture. it cannot be said that that moment
has yet arrived.
4. Classification of the Effects of the Sun's
Rays and of Artificial Heat. — Corbusier classifies
attacks from the sun's rays and from artificial heat
thus: I. Siriasis (insolation) — that pathological
condition in which the actinic rays are the predom-
inating factor : characterized by violent headache :
vomiting ; dryness of mucous membranes : very high
fever, from 105' to iio'' F. : rapid pulse, often ir-
regular and intermittent ; cyanosis ; intensely hot
skin, first moist then dry ; deep or stertorous breath-
ing : absence of corneal and other reflexes ; sub-
sultus tendinum and convulsions ; unconsciousness ;
contracted or irregular pupils ; scanty urine : coma
or sudden death. Dr. W'arthin, Professor of Path-
ology of the University of Michigan, states the
pathological findings in cases affected by the ultra-
violet rays to be chiefly exudative meningitis with
marked hyperemia and scattered haemorrhages
throufth the cortex. These findings account* for
many of the symptoms just mentioned and particu-
larly distinguish this disease from the eflfects of heat
alone. These symptoms may occur while the pa-
tient is in the sun or may not manifest themselves
until many hours after exposure. 2. Sunstroke
( suntraumatism j — cases due chiefly to sun heat
but in which the actinic effect may play some part ;
characterized b}' sudden fainting and quick recov-
ery ; or else mental and physical fatigue ; thirst ;
headache; vertigo; confusion; photophobia; pain
in the limbs ; injected cornea ; skin moist and cool ;
perhaps nausea and vomiting ; rapid, shallow respir-
ation, never stertorous; small, compressible pulse;
normal or subnonnal temperature ; pupils normal
or dilated ; no complete loss of consciousness ; re-
flexes present ; perhaps irritable bladder ; more rapid
recovery than in siriasis. These cases occur when
the stibject has been exposed to the sun, particularly
while undergoing physical exertion. This condi-
tion is often a precursor to a more severe attack
developing into true siriasis. 3. Heat exhaustion
(heat stroke) — effects of artificial heat alone;
characterized by symptoms quite similar to those
just mentioned; headache; vertigo; moist, cool
skin ; shallow respirations ; small pulse ; subnormal
temperature, being characteristic.
AMERICAN JOURNAL OF SURGERY.
June, 190S.
1. Operative Indications in Dislocation of the Humerus
with Fracture. By Carleton P. Flint.
2. Nephropexy, with Special Reference to an Improved
Technique, By F. G. Du Bose.
3. Cases of Ischochymia Simulating Gallstone Disease,
By Max Eixhorx.
4. Nonpenetrating Abdominal Wounds. A Further Con-
tribution and Report of Cases.
By Hugh Wilkinson.
5. Lymphatic and Portal Infections following Appen-
dicitis, with Report of a Unique Case,
By Roland Hill.
6. The Diagnostic Value of Tenderness in the Ciliary
Region. By Edgar S. Thompson.
7. Report of a Case of C\st of the Brain and a Case of
Brain Tumor, with Operation in Both Cases,
By Max G. Schlapp and Raymond Hoobler.
8. Some Remarks on the Surgical Treatment of Trachoma,
By W. il. Carhart.
9. Tuberculosis of the Testicle. By Hugh Wilkinson".
10. Remarks on an Artificial Synovial Fluid.
By Robert T. Morris.
11. A Case of Fracture of the Tibial Spine.
By Sigmund Epstein.
3. Cases of Ischochymia Simulating Gallstone
Disease. — Einhorn reports tliree sucli cases: from
these it can be seen how the benign ischochymia
simulates gallstone disease. The author gives the
distinctive diagnosis in the following way: In be-
nign ischochymia the attack does not come abrupt-
ly, it usually lasts a week or more. Pain in upper
abdomen is diffuse, intense, but frequently endur-
able without the use of morphine. There is vomit-
ing of large quantities of food, containing usually
food from day previous. This brings relief, pain
.sometimes ceases after it. The stomach is usually
much dilated : peristaltic restlessness is at times vis-
ible. Examination of stomach contents in the fast-
ing condition shows presence of food remnants
from day previous. The liver is not enlarged,
icterus not found, fever usually absent. The attack
is more frequent in men. Gallstone disease : Attack
comes suddenly and ends abruptly. Pain in upper
l26o PITH OF CURRENT LITERATURE.
abdomen is usually more to right side over liver and
radiating to right shoulder, very intense, frequently
necessitating relief by morphine. Vomiting is not
usually present ; if present the vomit contains the last
meal but no food from the day before ; the vomiting
usually is without much influence on the attack.
The stomach is usually not especially dilated. Gastric
peristalsis not visible. Examination of stomach in
fasting condition shows that the organ is empty or
contains only a small amount of gastric juice with
or without bile. The liver is usually enlarged, both
upward and downward. Icterus is present at times,
fever is usually present. The attack is more fre-
quent in women.
8. Trachoma. — Carhart observes that the sur-
gical treatment of trachoma is the most effective
way of combating the disease. Expression is safe
and effective, it shortens the duration of treatment
in a marked degree. The operation can be per-
formed under cocaine, but in severe cases and in
intractable children ether and gas are preferable.
Adhesions in the lids should be separated with the
probe daily until the tissues of the lids have healed.
The reaction caused by the operation yields readily
to ice cloths applied to the lids, and the resulting
traumatic conjunctivitis can be controlled in a few
days with a silver salt. The after treatment is most
important to attam complete cure and to prevent
recurrence, and should continue some weeks.
THE JOURNAL OF NERVOUS AND MENTAL DISEASE
June, igo8.
1. Presidential Address :. The Mental State in Cliorea and
Choreiform Affections, By Chakles \V. Burr.
2. The Symptom Complex of Occlusion of the Posterior
Inferior Cerebellar Artery: Two Cases with Ne-
cropsy, By Wn.LiAM G. Spiller.
I. The Mental State in Chorea and Chorei-
form Affections. — Burr says that it is often stated
and has been put in many textbooks that everyone
suffering from Sydenham's chorea presents mental
symptoms. This is true in so far that patients suf-
fering from even mild attacks show peevishness,
fretfulness. some loss of the power of fixed atten-
tion, and increased selfishness, but it is not true thai
every case presents mental symptoms of such mo-
ment as to raise doubt of the patient's sanity. The
majority of the patients are entirely sane through-
out the course of the disease. The severity of the
mental symptoms varies greatly in different cases,
and a series can be made showing each case a little
more severe than the preceding and a little less
severe than the succeeding one. Patients in whom
the motor disturbance is very slight rarely if ever
present serious mental symptoms, but the converse
is not true, for even though the motor symptoms
are very severe, the mental upset may be relatively
.slight. He has never seen a patient with so called
paralytic ciiorea, in whom severe or permanent men-
tal .symptoms occurred. Though there are no sharp
lines dividing the cases they may be .separated, so
far as the mental symptoms are concerned, into the
following groups: (""irst (and this includes a large
majority), patients in whom there is peevishness,
fretfulness, some loss of the power of fixing the at-
tention, and a slight loss of the moral sense shown
by disobedience and selfishness. Second, those
[New York
Medical Journal.
showing in addition to the above symptoms night
terrors and transitory visual, auditory, or other
hallucinations. Third, those with distinct delirium,
wild or mild, accompanied with fever. Fourth, and
this group is very small when we remember how
common chorea is, those showing stupor or rather
stupidity and an acute dementia which may follow
the condition described under three or appear with-
out any preceding mental symptoms at all severe,
and which is usually accompanied with trouble in
articulation not caused by choreic movements of the
lips and tongue but the result of mental hebetude.
Fever is usually present for a time at least. Pa-
tients of the first and second groups almost always
recover mentally and physically; those of the third
group frequently die, and those of the fourth usual-
ly either die or, recovering from the chorea, remain
demented. Though the chorea of childhood is an
acute disease lasting only a few months, sometimes
we see patients whose symptoms are at the begin-
ning indistinguishable from chorea but who continue
ill for several years or indeed for life without in-
termission. In these chronic cases severe mental
degradation does not always follow, but frequently
there are marked and permanent mental and emo-
tional disturbances. Sometimes the movements
cease entirely withotit mental improvement. They
may be classed as instances of the chorea of degen-
erates. Though Sydenham's chorea is ordinarily a
disease of childhood and adolescence, cases occa-
sionally occur even in the aged. More frequently,
however, than true chorea in old people is the ap-
pearance of localized choreic movements caused by
focal brain disease. Thus before or after an attack
of apoplexy there may be in the paralyzed part or
the part later paralyzed choreic jerkings. These
when typical differ from athetoid movements, but
sometimes it is hard to decide which to call them.
The lesion is usually immediately behind or in front
of the motor tract in the internal capsule or else
involves the optic thalamus. Sometimes the move-
ments become general.
ZENTRALBLATT FUR CHIRURGIE.
May 2. 1908.
1. The History of Ether .^n.Testhesia. By AI. Hirsch.
2. A New Method for the Diagnosis and Treatment of
Fistulc-e, By E. G. Beck.
2. Treatment of Fistulas. — ?>eck has found
that by the injection into a sinus or fistula of a liquid
paste of bismuth and petrolatum every part of the
sinus will become distinctly visible under the Ront-
gen ray. The best results are achieved if stereo-
scopic pictures are taken. Operative intervention
becomes certain and positive in its results. Bv the
u.se of a second paste, the sinus or fistula often hea!s
without further treatment. The formula of the "di'ig-
nostic paste" is :
Bismuth suhnitrale, 1 ounce;
White petrolatum 2 ounces.
The formula of the ])aste for treatment is:
Bismuth suhnitrate I ounce;
White petrolatum 2 ounces;
Soft piiraffin '/,', of an ounce :
Lard, of an ounce.
May 9, jgoS.
I. Hie Temporary Opening of Both l^pper Jaws
, (Kochir), By T. C. Reinhariit.
June 27, 1908.]
PROCEEDIXGS OF SOCIETIES.
2. The Treatment of Bony Ankylosis of the Elbow Joint
by the Transplantation of an Entire Joint,
By P. BUCHMANN.
2. Transplantation of Joints. — Buchmann, in
two cases of bony ankylosis of the elbow joint, re-
sected the joint and transplanted the first metatarso-
phalangeal joint, which he selected on account of
its powers of extension and flexion with practically
no lateral movement. He concludes that joints can
be transplanted as easily as the long bones. The
resection of the elbow joint must be quite broad be-
tween the head of the radius and the condyles of the
humerus. Suture of the bone is unnecessary. The
motions of the new joint are painless to as great an
extent as the contracted muscles permit. Xo bad
results to the foot follow the extirpation of the first
metatarsophalangeal joint. In the two cases oper-
ated on, the results were good.
ZENTRALBLATT FUR INNERE MEDIZIN.
May g, 1908.
I. The Treatment of Infectious Meningitis,
By V. Arxold.
1. Treatment of Meningitis. — Arnold con-
cludes a lengthy paper as follows : In the treatment
of continuous vomiting in protracted cases of menin-
gitis, he found that the administration of hydro
chloric acid was exceedingly beneficial, while the
giving of morphine usually caused the vomiting to
increase, as it brings about a stagnation of the gis-
tric contents and delays the emptying of the stom-
ach. In several cases of the infectious type of men-
ingitis, .the epidermatic employment of guiacal
brought about a diminution of the meningeal symp-
toms in a few days and in a short time apparently
cured the disease.
ZENTRALBLATT FUR GYNAEKOLOGI E.
May 2, 1908.
1. New Modification in the Operative Treatment of Some
Rectovaginal Fistula;. By D. vox Ott.
2. Spirochaeta Pallida in Congenital Syphilis.
By C. Grouven.
3. Diagnosis of Embryonal Ovarian Teratomata from
Anal Discharges. By F. Uxterberger.
4. Antithvreoidin (.Mabius) in Osteomalacia.
By R. HoFFM.^xx.
5. Fatal Gangrenous Appendicitis in Pregnancy,
By F. Fromm.
2. Spirochaeta Pallida. — Grouven has had pos-
itive results in the examination of the organs, mu-
cous and skin lesions, and ascitic fluid in nineteen
infants suffering from congenital syphilis. He found
the organisms in the pemphigus lesions of the hand,
in papules on the cheeks and scrotum, in rhagades
at the angle of the mouth, in the liver and lungs, and
in sections of most of the internal organs.
4. Antithyreoidin in Osteomalacia. — Hofifmann
draws attention to the many similar features exist-
ing in Graves's disease and osteomalacia. Starting
from this premise, he gave a patient sutTering from
the latter disease injections of iMoebius's antithyre-
oidin serum with almost magical results. Up to the
present time the patient has remained well. The
author says that if intravenous injections are not
considered judicious, intramuscular injections of
]Moebius's serum or of an artificial suprarenin may
be given, Meltzer having shown that the intramuscu-
lar method is equally efficacious with the intra-
venous.
^ratn&ings of Sonetits.
AMERICAN GYNAECOLOGICAL SOCIETY.
Thirty-third Ainiual Meeting, Held in Philadelphia on
May 26 and 28, igo8.
The President, Dr. J. Moxtgomerv B.aldy, of Philadelphia,
in the Chair.
Immedi.xte zcrsiis Deferred Operatiox for Ix-
TR.\.\BDOMIXAL H.EMORRHAGE DuE TO TuBAL
Ge.statiox.
Dr. Floriax Krug, of Xew York, remarked that
the truth was usually to be found in the moot points
of surgical practice, as in other matters, in the mid-
dle course, when opinions were diametrically op-
posed to each other. This was also true with refer-
ence to all that might relate to the welfare of the
patient in such cases. From this proposition it fol-
lowed that in a given case of ectopic gestation we
could not say that an operation might be almost in-
definitely deferred, nor, on the other hand, should we
assert magisterially that a patient should be sub-
jected to an immediate operation in everv case, even
though the diagnosis had been established beyond
any reasonable doubt. The severity of the shock
was not always proportionate to the quantitv of
blood lost. In fact, there was only a small percentage
of cases in which death actually occurred from hem-
orrhage. Xot infrequently the injurv which might
be due to haemorrhage was intensified by curetting,
by forcible palpation of the abdominal wall and by
other unjustifiable violence. In general it might be
remarked that, if a case had resulted fatally, it might
be due to the fact, either that suitable surgical aid
had been wanting, that it had been inefifective, how-
ever skilful, or that it was ineffective because proper
preparations had not been made.
Dr. F. F. Snipsox. of Pittsburgh, remarked that
the usual experience in these cases was that the first
haemorrhage was seldom alarming. It was at this
time that a diagnosis should be made, followed by
an operation as expeditiously as circumstances would
permit, under favorable elective conditions. The
teaching that rupture occurred infrequently with the
primary haemorrhage was harmful from the fact that
those who were inexperienced were apt, on account
of such teaching, to minimize the danger of the sit-
uation until a second or third haemorrhage had
brought the patient almost to death's door. With a
patient in such a condition, there was of course lit-
tle vitality remaining to sustain a severe or pro-
longed operation.
Haemorrhage from rupture should rarel}- be fatal
if the treatment was prompt and fairly intelligent.
Such treatment was followed by low mortality, and
such a result should be expected with a reasonable
degree of confidence if precautions suitable to the
situation were not overlooked.
Dr. H. X. Vineberg, of Xew York, believed that
there was great variation in the quantity of blood
which was effused within the peritoneal cavity. In
the large majority of cases it was not suflicient to be
a direct menace to the patient's life. The question
of operation should be governed by the circum-
stances in each individual case, and the operation
should be immediate or deferred, as the condition of
1262
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
the patient demanded. In the cataclysmic cases in
wliich the outpouring of blood was sudden and co-
lossal, the abdominal cavity would quicklv become
filled with blood, and death from anaemia would be
threatened. In addition, there was the unfavorable
influence of pressure upon the diaphragm, with re-
sulting compression of the heart and lungs. Not-
withstanding the condition of shock in such cases,
an immediate operation was absolutely imperative,
and if the operation was reinforced by the intra-
venous infusion of saline solution, suitably admin-
istered, an impending fatal result might occasion-
ally be averted. In cases of this character the haem-
orrhage and shock could not be considered as con-
traindicating the operation any more than the sec-
ondary haemorrhage which might have followed any
serious surgical procedure. The indication was for
action of the most prompt and intelligent nature.
Dr. E. E. Montgomery, of Philadelphia, observed
that haemorrhage might result from rupture of the
tube, from perforation of its wall by the develop-
ment of the chorionic villi, or by partial detachment
of the foetal sac, with haemorrhage into the perito-
neal cavity through the abdominal end of the tube,
with haemorrhage into the uterus, or retention of the
blood within the tube. Or the foetus and its sac
might escape intact into the abdomen in the well
known condition of tubal abortion. In all these con-
ditions haemorrhage was an essential factor, but it
did not follow that a fatal result would ensue even
if an operation was not performed. In the cases
which were treated with electricity a generation ago,
and in which the diagnosis was not made until after
rupture had taken place, it was supposed that the
clot which had formed underwent absorption as the
result of the electrical current. It was not improb-
able that the same result would have taken place if
the electricity had been omitted. The formation of
the clot was' Nature's method of relieving the situ-
ation, the diminished arterial tension being a further
assistant to this conclusion. In cases which did not
receive surgical attention, and in which a clot did
not form, death necessarily resulted from excessive
loss of blood, and coroners' physicians in large cities
had reported many cases of this character. It was
just as important in the cases of severe haemorrhage
to ligate the bleeding vessel securely as it was in
cases in which the haemorrhage was upon the sur-
face or in any other portion of the body. Stimulants
must not be used in such cases unless the bleeding
vessel had been secured, as increase of cardiac and
arterial tension would be followed by recurrence of
the bleeding.
Dr. C. C. Frederick, of Buffalo, considered that
the necessity for aii immediate operation was rarely
present. The diagnosis in the majority of cases of
tubal haemorrhage was made days or weeks after the
primary rupture, and in only a minority of the cases
was the loss of blood really dangerous to life. In
most of the ca.ses the bleeding stopped after a short
time, but recurred, with manifestations of shock, at
more or less frequent intervals, h^xamination of the
haemoglobin index at frequent intervals and red
blood counts were the most effective measures for
determining whether the bleeding was progressive.
If the manifestations of shock continued and the ex-
amination of the blood showed progressive anaemia,
an immediate operation should be performed, the
circulation being stimulated with normal salt solu-
tion, adrenalin, etc. If the haemorrhage had ceased,
it would be safe to wait, the patient being stimu-
lated in the meantime and effectively prepared for a
suitable operation.
Dr. George T. H.\rrjson, of New York, believed
that the general surgical principle to ligate any ves-
sel which was sufficiently large to cause free haem-
orrhage when divided should obtain in this condi-
tion. Even though the patient was in profound col-
lapse, it would be necessary to operate, for if this
was not done the chance might be forever lost. The
dangers which were associated with delay were also
of such magnitude that we were never safe in ex-
posing a patient to such chances.
Dr. Egbert H. Grandin, of New York, was of
the opinion that this condition was surpassed in ma-
lignancy only by carcinoma. The longer one waited
the more dangerous it was likely to become. It was
illogical as well as unsafe to wait and see whether
haemorrhage would or would not recur. If, how-
ever, the patient was in collapse, it was probable
that active -haemorrhage had ceased, in which case
it was well to wait until she rallied and then operate
at once, and always by the abdominal route. It was
not advisable to stimulate the patient until after the
abdomen had been opened and the bleeding arrested.
Intravenous injection of saline solution, while it
might stimulate the patient, would also increase the
blood pressure and thereby increase the danger of
haemorrhage. The longer the delay after haemor-
rhage had ceased the greater the risk of severe com-
pHcations, and consequently the higher the mortality
rate. In the cases in which haematocele had formed,
it was permissible to operate by vaginal incision and
remove the clots. The abdomen might then be
opened if the condition of the patient would war-
rant it, and the injured broad ligament exsected.
Dr. W. P. Manton, of Detroit, advised that in
every case the condition of the patient and the sur-
roundings and facilities for an operation be carefully
considered. No fixed rule could be laid down, each
case being governed by the conditions present. Judg-
ment fortified by experience was imperative in every
case before attempting to interfere surgically.
Dr. A. Lapthorn Smith, of Monreal, had had an
experience of forty-one cases, with two deaths. He
believed that no case was too desperate for an at-
tempt to relieve it by surgical measures. He Ixe-
lieved that the diagnosis of tubal gestation could in
some instances be made l^efore rupture had taken
place. Even if the patient was unconscious from
loss of blood, it was proper to operate without wait-
ing for rallying, for that might mean a renewal of
the haemorrhage. It was far preferable to open the
abdomen, tie the bleeding vessel, and replace the lost
blood with normal salt solution.
Dr. B. F. Baer, of Philadelphia, accepted the sur-
gical principle that it was always imperative to se-
cure a bleeding vessel wherever located. This rule
was entirely ai)i)licablc in the luemorrhage from a
ruptured tubal gestation sac. If a patient was in
profound collapse, there might be a doubt as to
whether bleeding was still in progress, and in such a
case it might be wise to devote a few hours to the
application of restorative measures.
June 27, 1908.]
FROCEEDINGS OF SOCIETIES.
1263
Dr. Herman J. Boldt, of New York, thought
that much would depend upon the judgment of the
physician in the management of each individual case.
It was very important to distinguish between the
primary and the secondary haemorrhage in the
choice of the procedure to be followed. As a rule,
the sooner an operation was performed in a case of
tubal abortion the better, remembering, however,
that it was generally regarded as unsafe to inflict ad-
ditional injury while a patient was still sufifering
from shock. If the patient was improving, he
thought it better to wait and carefully observe the
situation. If there was any evidence of renewed
haemorrhage an operation should be performed at
once and concluded as quickly as possible. In these
extreme cases intravenous injections of saline solu-
tion should be given, and a tourniquet used upon
the lower extremities. Saline solution should also
be poured into the peritoneal cavity, and no time
lost in trying to find the embryo. The patient should
be operated upon at her home, if possible, to avoid
the danger of transportation. If a patient was ral-
lying, it did not mean that the necessity for an opera-
tion was passed. The only cases in which postpone-
ment was permissible were those in which an hasm-
atocele had manifestly formed. In general, if symp-
toms of haemorrhage were present, it was wise to
operate at once.
Dr. A. Martin, of Berlin, Germany, thought that
the bleeding in this condition should be treated on
surgical principles, dilatory tactics being entirely in-
admissible. Whether the operation should be done
immediately at the patient's home or after removal
to a hospital would be governed by the condition of
the patient at the moment she was seen. The ab-
dominal route was to be preferred for the operation.
Dr. Seth C. Gordon,, of Portland, Me., had per-
formed his first operation in 1887, twelve hours after
rupture had occurred, and the patient recovered. He
had operated by the vaginal route, but thought the
abdominal route preferable. If the symptoms in a
given case were ameliorating, he was disposed to
wait, keeping the patient under careful observation.
Shock and haemorrhage in these cases he considered
synonymous.
Dr. E. C. Gushing, of Boston, recognized that
there were some cases in which severe symptoms
were wanting. The diagnosis in such cases was de-
pendent upon the presence of an haematocele. If
severe symptoms were absent, temporizing was al-
lowable,, and some cases would do well if nothing at
all was done. Recent experiments had shown that
the hypodermatic injection of rabbit's serum might
be very effective in cases in which the haemorrhage
had been profuse.
Dr. Hunter Robb, of Cleveland, advocated mure
conservatism in the treatment of this disease. Even
if one was .satisfied that the diagnosis of internal
haemorrhage was correct, an operation could fre-
quently be deferred. This was certainly desirable in
cases in which shock was present. In many in-
stances the haemorrhage was not of a dangerous
character.
Dr. Wesley M. Boree, of Washington, thought
that every case of this condition was a surgical one
and required surgical treatment. This was empha-
sized by the difficulties and complications. Even if
the h;eniurrhage ceased, the possibility of its recur-
rence must be remembered.
Dr. Andrew F. Currier, of Mt. Vernon, N. Y.,
thought any further statement could only be a repe-
tition of w hat had already been said, pro or con.
Men usually grew conservative as they became
older, but he felt that for this condition the radical
position was the proper one. Being a surgical con-
dition, it demanded surgical treatment. The diag-
nosis of internal haemorrhage being made in any
case, we were bound to know the cause and remove
it if possible. The abdominal route seemed to him
the only safe one. His only experience with the
vaginal route had been in cases in which an in-
effectual attempt had been made by others to relieve
the situation by that procedure, greatly increasing
the difiiculties and complications which already ex-
isted.
Dr. H. Ehrenfest, of St. Louis, expressed his
preference for an immediate operation in all cases
m which the diagnosis was clear.
Dr. F. Pfannenstiel, of Kiel, Germany, thought
this condition should be treated in accordance with
the general surgical law and with as little delay as
possible. As soon as the diagnosis was made,
preparations for an operation should be begun and
the patient placed under conditions which would
most conduce to her recovery.
Dr. Brooks H. Wells, of New York, believed
in an immediate operation if possible, otherwise
with the slightest amount of delay.
Dr. J. Taber Johnson, of Washington, supposed
that this was a settled question and could only re-
gard its reopening as a step backward. If this
society gave out an uncertain note, its effect would
be disconcerting upon the profession at large. He
did not think an argument upon a matter o£ this
kind could be based upon experiments upon dogs.
As to unruptured tubal gestation sacs, the diagnosis
was difficult, but could be made, and he believed
that when it had been made an operation should be
performed at once. A waiting policy was too often
fatal. One could never predict the complications
which might arise. It was unwise to assume that
haemorrhage had ceased. Even if it had ceased, an
haematocele was by no means a desirable condition.
Dr. Gardiner, of Montreal, admitted that he was
of the number who had formerly made use of elec-
tricity for this condition, and as he then believed,
with good results. We should not forget those who
had done the pioneer work leading up to the present
situation. He was free to say that he leaned to the
conservative side of this question. The rule was a
safe one that we should be guided by the circum-
stances which were present in each particular case.
The Heart in Shock. — Dr. E. Boise, of Grand
Rapids, Mich., stated that it was generally conceded
that the danger in connection with shock arose from
the very low blood pressure, which was supposed
to be due to vasomotor paralysis. This was the
theory of Crile, but his conclusion was erroneous.
Howell thought that the low blood pressure in car-
diac shock was due to cardioinhibitory exhaustion.
Henderson thought that it was due to deficiency of
carbon dioxide in the blood, and that when death
occurred suddenly in shock the heart was tetanically
contracted. The author had demonstrated experi-
PROCEEDINGS OF SOCIETIES.
[Nkw York
Medical Journal.
iiKutalh- that the heart in a state i)f shock was in
ionic contraction, xaryin^;^- in decree with the degree
of tlie shock, the veins lacing hlled and the arteries
in spasm'. \'eratrum, when given in such cases,
irritated the peripheral nerves and caused toxic
SNinptonis. Adrenahn, when intro(hiced into a vein,
lela.xed the heart ;ind so reheved the overfilled
veins. The dogs upon which these experiments
were performed were partially antesthetized with
chloretone, no ether heing given.
Pernicious Anaemia of Pregnancy. — Dr. P.
FiM)i.i-:v, of ( imaha, stated that this rare disease
was first described in 1842, then at intervals until
187J, when five cases were carefully reported, all
of which ended fatally. Most of them were well
prior to pregnane}' : abortion occurred in some of
the cases, hut all the women who went to term died
shortly afterward. Xo explanation had been found
for its occurrence during that period. It was usu-
ally announced by hfemorrhage and shock during
the second half of pregnancy. Some of its symp-
toms were constipation, vertigo, loss of reflexes,
and diminution in the red cells. There was no
diminution in the haemoglobin, and the lympho-
cytes were not increased in number. At the autopsy
the organs were all found to be anremic. with
haemorrhage into their tissues. In some of the
cases there was improvement for a time, and labor
sometimes came normally, but the child, usually died
;';/. iitcro and the mother a few hours or days after
dcliverv. The diagnosis was made by the examina-
tion of the blood.
Dr. R. C. NoRRis, of Philadelphia, had seen but
one, case in 3.000 labors. In this case the blood did
not clot and persistently oozed through the uterine
packing. Death occurred after forty-eight liours.
Adrenalin was administered, but without benefit.
Suggestions in Teaching Gynaecology, with the
Demonstration of Special (Mechanical) Charts
as an Aid in this Work. — Dr. J. A. Sampson, of
Albany, X. Y., observed that three phases in the
study of any of the clinical branches of medicine
naturally suggested themselves: T. The studv of
each disease as a science, including its aetiology, the
anatomical changes in its different stages, and the
elucidation of its svmptomatology. 2. The classifi-
cation of symptoms and the study of their various
causes, with the modes of distinction. 3. The art
or technique of the clinical branch of medicine, in-
cluding the taking of histories, physical examina-
tion, diagnosis, and treatment, also practical experi-
ence gained in dispensaries, hospital wards, and the
private practice of instructors. The student should
attempt to solve the problems associated with each
disease from his knowledge of the normal anatomy
and physiology, rather than by memorizing data ob-
tained from lectures or textbooks. In the solution
of such problems questions were asked, and the stu-
dents' answers were corrected when necessary and
supplemented by information which they could not
he cxpcctcfl to rea.son out. Various apparatuses
might be employed, including drawings, models, or
specimens obtained by operation or at autopsy, ac-
cording to the rc(|uircments of the given lesson.
Medical charts had been found of great value in this
\\( rk b\- flic author, and a large number were ex-
hibited graphically depicting the various pelvic
organs and their functions.
Dr. M.VKTix was in favor of all methods of teach-
ing which brought out the subject inatter with
vividness. He had been accustomed to have his
students make sketches of that which they found
by clinical examination, and this habit was often
continued with great value through their profes-
sional life. Pie had always found the touch clinics,
which were not so common in this country as in
Europe, of the greatest value to students. He
called attention to his manikin, made from the
human pelvis and provided with various anatomical
preparations, as a useful means of teaching the
anatomical portion of gynaecology.
Dr. J. Riddle Goi^fe, of New York, was of the
opinion that correct principles of teaching had been
brought forward by Dr. Sampson. The important
point for the student was to obtain an indelible
mental picture of the organs and tissues which he
might be examining. As aids in acquiring informa-
tion the manikin, the chart, and the blackboard were
all useful.
Dr. MiER, of Philadelphia, described the method
of clinical instruction at Jefiferson College and re-
ferred in particular to the half hour before each
gynaecological operation, which was devoted to
examination of the patient to be operated upon by
a suitable number of students.
Hospital Gynaecology. — Dr. Robert L. Dick-
LNsox, of Brooklyn, spoke of the gynaecological
service as a separate department in a hospital, and
believed that in every hospital of any considerable
size this distinction should be made. The obstetric
cases and the cases of pelvic disease should in such
hospitals l)c entirely under the care of one who was
distinctly a gyncTCologist. The list of diseases
should include all the urinary bladder diseases and
those of the rectum as they occurred in women.
Gynaecological patients should be isolated as far as
possible, and unnecessary exposure and examina-
tions avoided. The hospital internes should be al-
lowed the greatest amount of practical work con-
sistent with the efficiency of the service. The best
results would be o])taincd when the chief of the
hospital internes was paid for his services and his
position made more or less permanent. The ordi-
nary hospital histories were too complicated and
deficient in system. The written history should be
simple, though comprehensive, its object being an
aid to treatment, not a scientific dissertation upon
the given disease. Hospital - regulations should all
be in print, clearly displayed, and rigidly adhered
to without exception.
The Surgical Treatment of Prolapse of the
Uterus and Bladder.— Dr. ]. S. Stone, of Wash-
ington, remarked that the first to develop the prin-
ciples upon which this treatment was based was
Simon. It was also associated with the principles
enunciated by Tait in his flap splitting method.
Hadra, too, had dcvi.sed a method by wliich the
vagina was dissected and attached at about the level
of the OS internum. The influence of Sanger in this
field had also been verv important, and the same
was true of Stoltz and ATackenrrKlt. The work of
Sims, Emmet, and Martin had been significant in
LETTERS TO THE EDITORS.
the evolution of the problem. An operation for.
cystocele was seldom complete without a simul-
taneous operation on the perinseum. It was seldom
necessary to amputate the portio vaginalis. The
older methods of operating by removing strips of
tissue from the anterior wall were entirely ineffi-
cient. The entire relations of the vagina to the pro-
lapsed uterus must be changed and brought back
as nearly as possible to the normal. In extreme
cases it would be necessary to open the peritonaeum,
bring forward the broad ligaments, and attach them
to the anterior wall of the uterus.
Dr. Pfannenstiel emphasized the great impor-
tance of this method of treatment and described by
means of drawings the method which he was accus-
tomed to use. He did not favor the methods in
which the round ligaments were instrumental in
relieving the prolapsus, believing that the support
which they gave was insufficient.
Dr. GoFFE believed that the organs of the pelvis
were sustained by ligaments, the same as other
viscera, and that any method for relieving prolapsus
must take into account this fundamental principle.
In the relief of cystocele it would therefore be
essential to operate directly upon the ligaments by
which the uterus and bladder were sustained. Thus,
the round and uterosacral ligaments should be
shortened and the bladder then hung by three
sutures to the top of the uterus. Of course the
pelvic floor was also to be reconstructed.
Dr. Martin described the evolution of his work
upon this problem during the past thirty years. The
recent suggestions, including Pfannenstiel's, relat-
ing to the support of the bladder, were ver)' impor-
tant ; also the method by which the uterus was
brought forward and secured under the bladder.
In order to get a permanent result in this condition,
all the organs in the pelvis must be corrected.
Treatment in some cases must be continued six or
seven years. A point which was often overlooked
was the proper treatment of the general nutrition.
If the tissues were all in bad condition, permanent
results from operations could hardly be expected.
In very aged women who suffered with this condi-
tion the uterus and annexa should all be removed.
Dr. Charles P. Noble, of Philadelphia, stated
that the condition of cystocele was but a small part
of the problem involved in prolapsus as stated by
Martin. Only by vers- free detachment of the
bladder and uterus from their surroundings could
effectual repair be accomplished. The problem was
a complex one in almost every case and demanded
a series of procedures.
Endometritis Exfoliativa. — Dr. H. Ehrenfest,
of St. Louis, stated that this condition had been
carefully studied and described bv Engelmann.
The membrane which was discharged was quite dif-
ferent from a decidua, and was not at all influenced
by coition or impending abortion. It occurred only
with menstruation, and must be regarded as an
epithelial tubal hjematoma containing many blood
cells. The extrusion of the membrane was painful
and it contained much glandular and interglandular
tissue. It was merely an exaggeration of the
normal menstrual membrane. The separation of
the membrane was accomplished by the effusion of
blood beneath it and by the contractions of the
uterus. There was no inflammatory process, but
there was a rich development of spongy inter-
glandular material.
Operations for the Relief of Pelvic Disease in
Insane Women. — Dr. L. Browx reported the op-
erations which he had performed during the past
five years at the Manhattan State Hospital. The
existing pathological conditions alone were consid-
ered, the mental condition being disregarded. The
character of the mental condition in the majority
of cases was unfavorable to recovery. It was be-
lieved that such patients had a right to relief when
they were the subjects of pelvic disease. The class
of patients in which there was stimulus to mental
recovery had that type of insanity which was known
as "manie depressive." The best results were ob-
tained in cases in which the mental disturbance had
not become a fixed habit. The character of the
operation did not appear to bear any relation to the
resulting mental improvement. Thirty-two patients
showed great improvement mentally after the per-
formance of an operation and were ultimately cured.
The mental improvement following the operation
was believed to be due to improvement in the physi-
cal condition.
Dr. \W. P. Manton, of Detroit, had worked in
the field covered by the paper for twenty years, and
was still an investigator. The good results which
had been obtained were not due to the operation
alone, that being but a single factor. It must be
admitted that in many of the cases the improvement
had been only temporary.
Dr. Dickinson reported three cases of nympho-
mania which had been cured after the performance
of hysterectomy and ovariotomy.
{To he continued.)
ftmrs tff \\t mwm.
THE "JUNGLE PLANT."
Bakerstown, Va., June i, igo8.
To the Editors:
Referring to the notes of Dr. Silkworth, page
1032 of the Journal, on the "jungle plant" (Com-
bretum siindiacnm) , it will be of service to know if
in any of the six reported cures the subjects relapsed
to their former condition in the near future.
This new opium cure is not yet two years old, but
it has been used very extensively throughout Malay-
sia, among Chinese, Malavs, and others, in some in-
stances with apparently very gratifying results.
Thousands are reported to have been cured, with
many relapses.
How much the drug helps toward a cure can
hardly be definitely determined at present. It is
probable that the process of roasting deprives the
plant of much of its medicinal value, and the burnt
residue may act only as an astringent, relieving the
sufferer of his violent diarrhoea, while the burnt
opium, coupled with the determination to quit its
use, really effects a cure.
Here is a good field for investigation. The cost
of 13,^/3 pounds (i pikul) of the green plant is
only one or two dollars (gold) in Kuala Lumpur,
Federated I\Ialay States.
W. T. Kensett.
[266
NEIV INVEXTIONS.—BOOK NOTICES.
[New York
Medical Journa
|l£to IniJtntions.
A NEW PLIABLE SUBMUCOUS ELEVATOR.
By Hugh Burke Blackwell, M. D.,
New York.
The instrument here illustrated is eight inches
long and silver plated throughout. It is composed
of a solid steel, octagonal handle, tapering at the
sides towards the extremities. Attached to each
end of the handle, or middle piece, is a partially
hardened copper blade, one blade being used as a
sharp elevator, the other as a dull one.
The blades of the instrument are pliable and may
be bent at any angle according to the degree of
saeptal deviation, and yet . they possess a sufficient
amount of rigidity to hold that angle while the
operator elevates the mucoperichondrium beyond
the point of deviation.
In shape the blades of the instrument resemble
those of the Killian elevator, but differ in being
pliable and somewhat heavier. The silver plating
e.TJEMANN a CO
prevents the formation of cracks in the smooth sur-
face of the blades, and in no way interferes with
its proper sterilization. It is made by George Tie-
mann & Co.
The value of the instrument in diminishing the
danger of perforations is at once apparent, especial-
ly while elevating the mucoperichondrium and
mucoperiosteum immediately behind a sharp angle
of deviation.
The blades of the elevator can be readily bent to
conform with the surface of any deviated sseptum,
and yet retain rigidity sufficient to hold the curve
imparted to them by the hand of the operator, while
he elevates the mucoperichondrium or mucoperios-
teum. Its continued use slightly increases the rigid-
ity of the blades.
I have used the instrument in operating on the
past thirty-one cases of submucous resection of the
saeptum, and have found it to be of practical value
in mv hands.
Iffak foticrs.
[ll^e publish full lists of books received, but we acknoivl-
edge no obligation to reviezu them all. Nevertheless, so
far as space permits, zve review those in zvhich ivc think
our readers are likely to be interested.]
Medical Gyncccology. By Howard A. Kelly, A. B., M. D.,
LL. p., F. R. C. S. (Hon. Edinb.), Professor of Gynae-
cological Surgery in the Johns Hopkins University and
GynjEcologist to the Johns Hopkins Hospital, Baltimore,
etc. With One Hundred and Sixty-three Illustrations.
New York and London : D. Appleton & Co., 1908. Pp.
xiv-662.
Dr. Kelly treats extensively of retiology in this
work, and we think he is to be commended for doing
so, for not all the diseases peculiar to women arc to
be traced to parturition, gonorrhoea, or traumatism.
In particular, we would direct attention to the chap-
ter on acute infectious diseases as causes of pelvic
disease, beginning on page 247. Deserved promi-
nence is accorded also to the eliciting and recording
of case histories and to the details of diagnosis. The
author is for the most part very clear in his state-
ments, but the following sentence (page 303) seems
rather defective : "The, cervix in such cases is at a
much lower point in the vagina than is normal, in
fact that conditions seem almost reversed." We
fancy that that is not what he meant to write.
In the matter of displacements of the uterus, we
think that an unnecessary distinction is made be-
tween descensus and prolapse, and we regret to see
that Dr. Kelly has such a poor opinion of the use of
pessaries. There are many signs that a reaction has
set in in their favor^ but we must add that in our
judgment most of the pessaries in use are exceeding-
ly faulty. A remarkable feature of the book is its
inclusion of an extensive essay on syphilis, covering
more than fifty pages.
We find some verbal peculiarities that rather grate
on us — for example, "deferinitis" (page 334) and
"col tapiroides" (page 343). In the latter instance
one is at a loss to know whether the author is using
a Latin adjective to qualify a French noun, or
whether both words are French, one in the singular
and the other in the plural. These are small mat-
ters, but they appear to us to be blemishes all the
same.
From the mechanical point of view, the volume
has the excellent feature of lying open without the
necessity of manual intervention, but we think the
page is too wide (the lines too long) to be read easi-
ly. The paper, the print, and many of the illustra-
tions are fine.
Elements of Water Bacteriology. With Special Reference
to Sanitary Water Analysis. By Samuel Cate Pres-
COTT, Assistant Professor of Industrial Biology, and
Charles Edward Amory Winslow, Assistant Professor
of Sanitary Biology, in the Massachusetts Institute of
Technology. Second Edition, Rewritten. First Thou-
sand. New York : John Wiley & Sons, 1908. Pp. xii-258.
(Price, $1.50.)
As the authors truly state, the most direct, accu-
rate, and practical method of water examination at
the disposal of the sanitarian is a bacteriological
test. In this new edition they have included the
advances that have been made in the past four years
that bear on the practical investigation of sanitary
questions connected with water supply, and notable
additions have been made to the chapters on self
purification, on the isolation of the typhoid bacillus,
on the interpretation of the colon bacillus test, and
on the significance of intestinal bacteria other than
the Bacillus coli. A chapter has been added on the
bacteriology of sewage and sewage effluents. The
book is terse, practical, and of value to all health
officers, sanitarians, and physicians engaged in prac-
tice in localities in which they must make their own
examinations.
A Manual of Venereal Diseases. By the Officers of tiie
Royal Army Medical Corps. Introduction by Sir .Al-
fred Keogh, K. C. B., Director General of the .Army
Medical Service; History, Statistics, Invaliding, etc., by
Lieut. Colonel C. H. Melvh.le, R. A. M. C, Secretary to
the Advisory Board ; Clinical Pathology and Bacteriology,
by Colonel Leishman, R. A. M. C. ; Clinical Course and
Treatment, by Major C. E. Pollock, R. .\. M. C. Lon-
don: llcnrv Frowde (Oxford University Press) and
Hoddcr & Stonghton, 1907. Pp. x-282.
This little volume sutnniarizes the chief features of
the report of the subcommittee of the .^rmy Medical
June 27, 1908.]
BOOK NOTICES.
1267
Advisory Board on the treatment of venereal dis-
eases in the British Army. The original report is
too bulky and contains too many details to be useful
to the average medical officer. The essential points
in the diagnosis and treatment of venereal affections
have therefore been included in the present work. In
the introduction, by Sir Alfred Keogh. emphasis is
laid on the need of administrative control and of
personal prophylaxis in the prevention of venereal
diseases in the army. In speaking of prophylaxis.
Lieutenant Colonel IMelville does not mention such
measures as the use of prophylactic injections, in-
unctions, etc., but mentions the disciplinary meas-
ures which are suggested as the best preventives of
venereal infection among soldiers. In this he is, we
think, on the wrong tack, for, w^hile discipline may
keep some men continent, it will not have much
effect on most enlisted men, and will lead only to
the concealment of their maladies.
The methods of examining secretions for the Spi-
roclicrfa pallida are briefly described by Leishman in
a very interesting and practical chapter, in which
there is also included a short sketch of the Wasser-
mann serum reaction in syphilis. In the section on
diagnosis Major Pollock gives a practical table of
'Values" of the dift'erent symptoms and manifesta-
tions. The values are arranged in order according
to the number of "points"' (as in bridge playing).
The chapter on treatment includes the methods used
in the British Army, with numerous tables and
schemes for the treatment of men through the entire
course of the disease. Mercurial cream is the favor-
ite preparation for injections. The diagnosis and
treatment of gonorrhoea and of soft chancre occupy
very brief chapters at the end of the volume. There
are a number of tables of statistics of venereal dis-
eases in the British Army, a list of authorities con-
sulted, and a formulary, together with forms, etc.,
for recording cases and keeping statistical returns
for the use of the Advisory Board.
The book will prove useful to army surgeons as a
gfuide to diagnosis and treatment, and might form
the basis of a similar work for our own army and
navy, modified to suit the methods in vogue in this
country.
Untersuchungen zur Kenntnis der psychomotorischen
Bewegungsstdriingen bet Geistcskrankeii. Von Dr. Karl
KxEiST, Assistentarzt der Klinik fiir Xerven- und Geistes-
krankheiten zu Halle a. S. Leipzig: Dr. Werner Klink-
hardt, 1908. Pp. viii-iyi. (Price, M. 6.)
It is a pleasure to review this small book, for one
finds in it, as it were, the spirit of the dead master
to whom the author has dedicated it, Wernicke. An
attempt is here made to analyze the disturbances in
the motor functions in mental disorders in terms of
the cerebral mechanisms. Psychomotor acinesia as
seen in mutism, psychomotor apraxia, and psycho-
motor aphasia and tonic and hypotonic muscular
symptoms are discussed in the light of mixed dis-
turbances based on factors of modified innervation
as influenced by psychical factors. External obser-
vations of psychomotor disturbances, of muscular
coordination, show them to be conditioned by a type
of altered innervation which, however, vary from
similar modifications which have a basis in lesions
of the sensorimotor areas, such as motor paralyses
and ataxias, and in the cortical and transcortical
apraxias and aphasias. Such modifications are in-
terpreted b}' the author as probably conditioned by
disorder in the connections of the frontal lobes and
the cerebellum, either in the terminal stations of
such connections, in the coordinating fibre tracts
themselves, or in the intermediate ganglia. In or-
ganic disorders of these structures, tonic muscular
tension, prolonged contractual states, and hypotonia
may also occur.
So far as the ps\chomotor symptoms of mental
disease are concerned, the author predicts the prob-
ability that the disease process does not involve ex-
clusively, or only in small degree, the cerebellofron-
tal system itself in its frontal portions, but that in-
volvement takes place between the frontal and other
brain areas in their transcortical connections. Two
types of such transcortical disturbances are con-
ceivable. Either a dissociation may take place be-
tween the cerebellofrontal system and the sensori-
motor system of the central lobe, or there results a
cutting oft' of the compound, complex motor apf>a-
ratus of the sensorimotor and cerebellofrontal sys-
tems from its relations to other portions of the
brain. In view of the wide dift'usion of the mental
disturbances, it is impossible to decide as to the more
important of these two conceptions. In this modi-
fied manner we find Wernicke's sej unction hx pothe-
sis again made prominent. The monograph oft'ers
interesting hypotheses and is worthy of the atten-
tion of psychiatrists.
La Diathcse urique. Par Henri Labbe, chef de laboratoire
a la Faculte de medecine de Paris. Paris : J. B. Bail-
liere et Fils, 1908. Pp. 95.
The author presents a review of the recent discov-
eries in physiology and biological chemistry which
have added to our knowledge of the production and
excretion of uric acid. He shows the latter in the
purin group and its close relationship with xanthin,
hypoxanthin, and caft'eine. The agents that have an
action on uric acid are classed as precipitants, that
is, those that prevent its solution, and the solvents,
that is, those that facilitate the acid's solution and
excretion. Among the first are cold, acids, some
metals and their salts, and the many substances that
increase acidity or form insoluble compounds with
uric acid. The solvents include sodium salicylate,
piperazine, lycetol, aspirin, urotropin, and thymic
acid.
The dietetic factors that augment or lessen uric
acid formation are described, and the author believes
that a dietary free from meats and those vegetables
that contain purin will give the most favorable re-
sults in those who have migraine, gravel, or other
uric acid disease.
Die Entziindung ; eine monographische Skizze aus dem
Gcbiet der pathologischen Physiologic. Von Dr. Rudolf
Klemexsiewicz, o. 6. Professor u. Vorstand des Institute
fiir allgemeine Pathologic an der Universitiit in Graz,
etc. Festschrift der k. k. Karl-Franzens-Universitat in
Graz aus Anlass der Jahresfeier am 15. November 1905.
Jena: Gustav Fischer. 1908. Pp. vii-120.
This "Festschrift" was written for the celebra-
tion of the anniversary of the University of Graz in
1905. The preface is signed "September, 1907";
and the essay is finally published in 1908.
The author gives us a short historical review of
the development of our knowledge of inflammation,
in which he places Cohnheim's name very rightly in
the foreground. This is followed by a description.
1268
MISCELLANY.
[New York
Medical Journal.
of the principal symptoms of inflammation, a review
of the leading theories, such as have been ex-
pounded by Cohnheim, Strieker, von Reckling-
hausen, Weigert and Ziegler, Marchand, Metch-
nikoff, and others. The succeeding chapters deal
with the causes and effects of inflammation, the
physiological and pathological action of the blood,
the leucocytes, etc., during inflammation, and the
physical laws which influence inflammation, resorp-
tion, etc. Chapter X reviews otir present knowl-
edge of inflammation.
Sul processo di riparasione delle perdite di sostanza nelle
cartilagini e pericondrio. Per il Prof. Dott. Giulio An-
ziLOTTi, aiuto e libero di patologia chirurgica. Pisa : Or-
soIini-Prosperi, 1907. Pp. 38.
This experimental research upon the process of
repair going on in cartilage, beginning in the peri-
chondrium, demonstrates the proliferation of carti-
lage cells. Active caryocinesis goes on in those cells
around the new cartilaginous "centres" which con-
stitute the reparative material. Proliferation was
noted especially in the groups of cells immediately
imderlying the perichondrium, but also in the deeper
layers and in cartilaginous fragments adhering to
the wounded perichondrium. The matrix also pro-
liferates by hypertrophy of its fibrillar components,
and thus the multiplying cartilage cells are gradu-
ally separated from one another. The author has
not observed the transformation of connective tissue
into cartilage directly, but in some instances fibro-
cartilage was first formed. And he has not found
any ossification or calcification in the process of re-
pair in cartilage. He emphasizes the low resistance
of cartilage against traumatism and infection and
its slow tendency to repair. These facts should teach
the surgeon to remove diseased or necrotic cartilage
widely to secure the best conditions for a reparative
process.
Morfologia delle arterie dell'estremitd addominale. G.
Salvi. Parte I. Origine e significato delle arterie chc
vanno all' estremita (selaci, anfibi, retilli, uccelli). Sup-
pleniento agli studi Sassaresi, anno v, 1907, sez, ii. Sas-
sari : G. Dessi, 1907. Pp. 53.
Salvi publishes in this pamphlet the result of ten
years of study on the comparative anatomy of the
arteries of the lower extremity at the Anatomical
Institute of Sassari. The work does not offer any-
thing of special interest to practising physicians, and
consists of an analysis of the structure of the arteries
of the lower limbs in reptiles, amphibia, etc.
BOOKS. PAMPHLETS. ETC.. RECEIVED
Die arztliche Begiitaclitimg in Invaliden- und Kranken-
versichcrungssachen. Zum praktischen Gebrauch fiir
Acrztc, Krankenkassen und Verwaltungsbeliorden. Von
Assessor Seelmann, Mitglied und stellv. Vorsitzenden des
Vorstandes dcr Landesversichcrungsanstalt Oldenburg.
Leipzig: F. C. W. Vogel, 1908. Pp. 64.
Mikroscopie und Chemie am Krankenbett. Fiir Studic-
rende und Aerzte bearbeitet. Von Professor Dr. H. Lcn-
barzt, Direktor des Eppcndorfcr Krankcniiauses in Ham-
burg. Fiinfte, wesentlich umgearbeitetc .'\uflage. Mit 85
Textliguren und 4 Tafeln in Farbendruck. Berlin : Julius
Springer, 1907. (Through G. E. Stcchcrt & Co., New
York.) Pp. 405. (Price, $2.25.)
Nierendiagnostik und Nierenchirurgie. Von Dr. G. Kap-
sammcr. I. Teil. Mit 29 Abbildungen im Tcxte. Pp.
xii-432. II. Teil. Mit 34 Abbildungen im Texte. Pp.
xi-567. Wicn und Leipzig: Wilhelm Braumiiller, 1907.
(Price. $5.)
First Annual Rjeport of the Commissioner of Health of
the Commonwealth of Pennsylvania, 1905-6. Presented by
the Commissioner, Samuel G. Dixon, M. D. Pp. 519.
Seventh Annual Report of the Metropolitan Water and
Sewerage Board, Boston. For the Year 1907. Pp. 253.
Das Ohrlabyrinth als Organ der mathematischen Sinne
fiir Raum und Zeit. Von E. von Cyon. Mit 45 Textfig-
uren, 5 Tafeln und dem Bildnisse des Verfassers. Berlin:
Juiius Springer, 1908. Pp. 432. (Price, $3.50.)
A Manual of the Practice of Medicine. By Frederick
Taylor, M. D., F. R. C. P., Consulting Physician to Guy's
Hospiltal, etc. Eighth Edition. London : J. & A. Churchill,
1908. Pp. xvi-iiii. (Through P. Blakiston's Son & Co.,
Philadelphia.) (Price, $6.40.)
lti.$tfllana.
Army Medical Department Examinations, 1908.
— The act of April 23, 1908, reorganizing the Med-
ical Corps of the Army, gives an increase in that
corps of six colonels, twelve lieutenant colonels,
forty-five majors, and sixty captains or first lieuten-
ants, and establishes a Medical Reserve Corps as an
adjunct to the Medical Corps. Under this recent
act, the lieutenants of the Medical Corps are pro-
moted to the rank of captain after three years' ser-
vice instead of five, and the increase in the higher
grades insures promotion at a reasonable rate all
through an officer's military career. Furthermore,
applicants who are found qualified in the prelim-
inary examination are appointed first lieutenants of
the Medical Reserve Corps and ordered to the Army
Medical School, in Washington, D. C, for eight
months' instruction.
The Medical Corps.
A preliminary examination for appointment in
the Medical Corps will be held on August 3, 1908,
and formal applications should be in possession of
the War Department prior to July ist. The ap-
plicant must be a citizen of the United States, be-
tween .twenty-two and thirty years of age, a grad-
uate of a medical school legally authorized to con-
fer the degree of doctor of medicine, of good moral
character and habits, and have had at least one
year's hospital training or its equivalent in practice.
The examination will be held concurrently through-
out the country at points where boards can con-
veniently be assembled, and due consideration will
be given to the localities from whicli applications
are received, in order to lessen the traveling ex-
penses of applicants as much as possible. The ex-
mination in subjects of general preliminary educa-
tion may be omitted in the case of applicants hold-
ing diplomas from reputable literary or scientific
coHeges, normal schools, or high schools, or in that
of graduates of medical schools which require an
entrance examination satisfactory to the faculty of
the Army Medical School. The large number of
vacancies created in the Medical Corps by recent
legislation makes it certain that all successful can-
didates will be recommended for a commission for
several years to come.
The Medic.xl Reserve Cori'S.
It is desired to obtain and maintain a list of qual-
ified medical men all over the country who are
willing to serve as medical officers in time of emer-
gency, and to such men the President is authorized
to issue commissions as first lieutenants, Medical
Reserve Corps. It is recognized that it will be nec-
essary to place only a limited number of these officers
on the active list in time of peace, and it is hoped
June 21, 1908.]
MISCELLANY.
that voung medical men throughout the country
and medical officers of the militia of the various
States may be sufficiently interested to secure posi-
tions on the Medical Reserve Corps list. An ap-
plicant must be between t\vent_\-t\vo and forty-five
years of age, a citizen of the United States, a grad-
uate of a reputable medical school legally author-
ized to confer the degree of doctor of medicine, and
have qualified to practice medicine in the State in
which he resides. Examinations will be held in the
near future and will embrace the practical medical
subjects. Full information concerning the Medical
Corps and the Medical Reserve Corps may be pro-
cured upon application to the surgeon general, U.
S. Army, Washington, D. C.
The Production of Deciduomata. — Loeb points
out a certain analogy which exists between
these artificially produced deciduomata and a variety
of multiple tumors that are limited to certain or-
gans, as, for instance, multiple fibroneuromata, en-
chondromata, symmetric lipomata, or adenomata of
the intestinal mucosa ; they might be called multiple
systemic tumors. The deciduomata represent a type
of new formations which he designated "transitory
tumors." If the substance were secreted by the
ovaries continuously, instead of intermittently, the
tumors would lose their transitory character and
would become permanent new grow ths. In the case
of the systemic tumors and of the deciduomata we
have to deal with multiple benign tumors of a more
or less transitory character aflfecting one organ or
one tissue. We know that the origin of the decidu-
omata depends on two sets of conditions : (a) That
a predisposing chemical substance be produced by a
certain organ ; and (b) that such a substance having
been produced, indifferent stimuli, for instance, trau-
matisms, are sufficient to produce the tumors. Clin-
ical observation makes it likely that certain tumors,
as, for instance, sarcomata, have at times been caused
by traumatisms. Experimentally, attempts to pro-
duce tumors through traumatism or through long
continued irritation have never been successful. It
may be suggested that such attempts could have been
successful only if the necessary "preparatory" sub-
stance had been secreted prior to the action of the
indifferent stimuli. Loeb states that he has found
the definite cause for the formation ofdeciduoma, and
he remarks that it is very desirable to emphasize
certain similarities betwen the deciduoma and vari-
ous other tumors in order to indicate the possible
presence of predisposing "preparing" substances, as
the unknown cause of certain tumors. Given such a
"preparing" substance, otherwise indift'erent stimuli
would be sufficient to excite the potential prolifer-
ative energy of the tissues. The fact that the decid-
uomata degenerate as soon as the "preparing" sub-
stance ceases to be active is no valid reason for de-
nying the designation "tumor" to these new forma-
tions. In order to indicate the ephemeral character
of such new formations they may be called "transi-
tory tumors." Even carcinomata may retrogress
spontaneously. The presence of "preparing" sub-
stance can only explain the formation of a "transi-
tory tumor," or, at the best, of a tumor that grows
indefinitely in the same individual in which it origi-
nated, but it cannot explain the growth of a tumor
which can be transplanted into many other individu-
als in which such a "growth" substance is not likely
to be present. In order to explain on such a basis
the inoculability of tumors we should have to assume
the hereditary transmission of an increased energy
of growth to the following generations of tumor
cells, which thus would be able to continue to
proliferate without the further presence of the
growth substance in the inoculated animal. The
possibility of such a transmission into later gen-
erations has not yet been established. Until
such a proof has been given we must assume
that transplantable tumors carry with them in
the tumor cells or in their direct neighborhood the
stimulus which enables them to proliferate in a new
host. But it is quite possible that a nontransplanta-
ble tumor which originated through the action of a
"preparing" substance may grow very rapidly and
be, therefore, malignant. Transplantable tumors, on
the other hand, do not need to be very malignant.
The degree of inoculability and energy of tumor
growth are two distinct properties which do not need
to be associated in the same tumor. But the trans-
plantability of tumors depends, in all probability, not
only on the presence of a permanent stimulus in or
near the tumor cells, but on some other factors, as
yet unknown. The presence or absence of such sec-
ondary factors might determine the inoculability or
noninoculability of a tumor, even if the essential
cause in the tumor formation was the same in both
cases. — Journal of the American Medical Associa-
tion.
The Survival of Typhoid Bacilli in Soil.— As
far back as 1889 it was shown by Grancher and
Deschamps that from soil inoculated with a bouillon
emulsion of typhoid bacilli the living organisms
could be recovered after a period of five and a half
months. Robertson, by the frequent addition of cul-
ture medium, was able to keep them alive in the soil
for ten months. More recently, Lorrain Smith tried
inoculating soil with an aqueous emulsion of the or-
ganisms, and found that, lacking the presence of the
artificial culture medium, they lived a much shorter
period. In his experiments twenty-one days proved
the longest period that they were shown to exist.
W. Mair has recently conducted some investigations
which bear on this subject, although the object of
his study was primarily to determine the effect on
the soil as a habitat for certain organisms of steril-
izing it by steam under pressure. The earth which
he utilized was taken at a depth of three or four
inches below the sod from the grounds of Queen's
College, Belfast. It was inoculated with aqueous
emulsions of the organisms and was kept under con-
ditions of temperature, light, and moisture as close-
ly simulating its natural surroundings as possible.
Under these conditions, the Bacillus typhosus was
shown to be present in a living state after eighty
days, though there was no evidence that it was capa-
ble of multiplying and leading a saprophytic exist-
ence. The Bacillus colt communis was found after
much longer periods. Some of his samples of soil
were shown to be rendered much less hospitable to
the bacilli if they were previously sterilized in an
autoclave. This he attributed to the development
of some bactericidal substance. Of course different
soils vary greatly in their suitability for the growth
of various organisms, but the fact that it is possible
12/0
O FFl ClAL NE WS.— BIRTHS ,
MARRIAGES. AXD DEATHS.
[Nsvv VORK
JIedical Journal.
for the typhoid bacillus to live for eighty days in any
soil under normal conditions is suggestive of the
extent of the danger from certain methods of sew-
age disposal. — Journal of the American Medical As-
sociation.
mtml fms.
Public Health and Marine Hospital Service
Health Reports :
I'he follozving cases of smallpox, yellow fever, cholera,
and plague have been reported to the surgeon general.
United States Public Health and Marine Hospital Service,
during the zvcek ending June 19, 1908:
Smallpox — United States.
Places. Date. Cases. Deaths.
.Mabama— Mobile .May 23-30 i
California — Los .Angeles May 23-30 i
Californio — San Francisco .May 23-30 15
Illinois — Chicago .May 30-June 6 i
Illinois— Springfield .May 2 S- Tune 4 3
Indiana— Indianapolis .May i8-June 7 17
Indiana — Fort Wayne May 23-.Tune 6 8
Indiana — Terre Haute .May 30-June 6 i
Iowa — Ottumwa May 30-June 6 i
Kansas — Kansas City .May 30-June 6 5
Kentucky — Covington ..May 30-June 6 1
Michigan — Grand Rapids May 30-June 6 i
Michigan — Kalamazoo Alay 30-June 6 2
Michigan — Saginaw May 30-June 6 i
Minnesota — VVinona May 30-June 6 4
Missouri — Kansas City May 23-June 6 10
Missouri — St. Joseph May 23-30 8
Missouri — St. Louis May 30-June 6 i
Nebraska — South Carolina May 22-29 2
New York — Bingharaton June 1-8 i
New York — Niagara Falls May 30-June 6 i
Ohio — Cincinnati May 22-29 7
Ohio — Dayton May 30-June 6 2
Tennessee — Kno.xvil!e May 30-June 6 2
Washington — Taconia May 23-30 2
Wisconsin— La Crosse May 30-June 6 i
Wisconsin— Milwaukee May 23-30 6
Wisconsin — Racine May 23-30 2
Snuul/'o.v — Foreign.
-Arabia — .^den .\pril 27-May 18 10
Brazil — Rio de Janeiro May 3-10 141 50
Canada — Halifax May 31-June 6 6
Cape Colony — East London April 18-25 i i
Ecuador — Guayaquil May 9-16 2
Egypt— Cairo May 13-20 11 3
France — Paris May 16-23 3
India — Bombay May 5-12 54
India — Calcutta \pril 25-May 2 15
Italy — General May 17-24 41
Japan — Osaka .May 2-9 52 29
Java — Batavia .\'iril 25-May 2 3
Peru — Lima May 2-9 2
RusSa — Batoum March 1-31 17
Russia — Moscow May 9-16 26 ii
Russia — Riga May 9-16 5
.Siberia — Vladivostok April 28-May 5 i
Spain — Valencia .May 16-23 '7 3
Turkey— Bagdad .April 25-May 2 29 3
Turkey — Smyrna .\pril 14-May 5 7
yellow Fever — Foreign.
Cuba — Santiago June 11 i
Ecuador — Guayaquil May 9-16 2
Cholera — Foreign.
Ceylon — Colombo May 14-21 i
India — Bombay May 5-12 2
India — Calcutta .\pril 2S-May 2 230
India — Rangoon April 25-May 2 7
Plague — Foreign.
Chile — Valparaiso March 21-28 5 3
Ecuador — Guayaquil May 9-16 10
India — Bombay May 5-12 260
India — Calcutta April 25-May 2 73
India — Rangoon April 25-May 2 37
Ja|)an — Nara To May 14 7
Japan — Osaka May 17-24 2 2
Peru — General May 2-9 39 19
Straits Settlements — Singapore. .. .'\pril 25-May 2 i
Venezuela — Caracas June 4 5 3 i
Venezuela — La Guayra .May 3<)-Tunc i 8 4
Army Intelligence:
OfHfial list of changes in the stations and duties of
officers of the Medical Corps of the United States Army
for the 7veek ending June zo, igoS:
Lewi.s, W. p., Major. Left Fort Sill, Okla., for duty at
I.con Springs, Texas.
Miller, R. B., Captain. Granted leave of absence for two
months in the United States.
Perlev, H. O.. Lieutenant Colonel. Relieved from duty
in the Philippines Division ; will sail for the United
States on October 15, 1908.
Stone, J. H.. .Viajor. Relieved from duty with the Army
of Cuban Pacification; will sail on June 22, 1908, .for
Newport News, Va.
Truby, a. E., Captain. Ordered to accompany one-half
of Co. B. H. S. from San Francisco, Cal., to AJurray,
Washington, for camp duty.
Whaley, a. J\I., Captain. Granted leave of absence for
three months, on completion of the manoeuvres; left
Jackson Barracks. La., for his proper station, Fort Sam
Houston, Te.xas.
Navy Intelligence:
Official list of changes in the stations and duties of
officers of the Medical Corps of the United States Navy
for the iveek ending May 16, i<)o8:
.A.LLEN, D. G., Assistant Surgeon. Appointed an assistant
surgeon from June 15, 1908.
Englander, S., Pharmacist. Retired from the active serv-
ice on June 15, 1908, on completion of thirty years'
service, in accordance with a provision of the naval
appropriation of May 13, 1908.
Farwell, W. G., Passed Assistant Surgeon. Detached
from the Lancaster and ordered to duty with Marines
at Camp Ellicott, Isthmian Canal Zone.
Haywood, A. B., Assistant Surgeon. Detached from the
naval recruiting station, Chicago, 111., and ordered to
duty 'with Marines at Camp Ellicott, Isthmian Canal
Zone.
Kerr, W. M., .Acting .\ssistant Surgeon, .\ppointed an
acting assistant surgeon from June 12, 1908.
Mayers, G. M., Passed .\ssistant Surgeon. Ordered to
the Naval Medical School Hospital, Washington, D.
for treatment.
Mink, O. J., Passed Assistant Surgeon. Detached from
the Naval Medical School, Washington, D. C, and
ordered to the naval recruiting station, Chicago, 111.
Smith, G. W., Assistant Surgeon. Appointed an assistant
surgeon from June 15, 1908.
Snyder, J. J., Passed Assistant Surgeon. Ordered to the
AVtc Hampshire.
Tho.mas, G. C, Assistant Surgeon. Appointed an assistant
surgeon from June 15, 1908.
Whiteside, L. C. Assistant Surgeon. Appointed an as-
sistant surgeon from June 15, 1908.
Ziecler, J. C, Acting Assistant Surgeon. Detached fronii
the Naval Hospital, Portsmouth, N. J., and ordered to
the Naval Hospital, Pensacola, Fla.
Married.
Cheetha.m — Robinson. — In Cleveland, on Thursday,
June i8th. Dr. .\rthur M. Cheetham and Miss Agnes May
Robinson.
Dougherty — Merklee. — In Philadelphia, on Wednesday,
June 17th, Dr. Clarence C. Dougherty and Miss Florence
Lillian Merklee.
Gill — Dunham. — In Alloway, New Jersey, on Tuesday,
June i6th. Dr. WaUer W. Gill, of Westfield. New Jersey,
and Miss Mary Claire Dunham.
McCallum-^Thomas. — In Philadelphia, on Monday. June
15th, Dr. Chester .\. McCallum, of Erie, Pennsylvania, and
Miss Helen Ramsey Thomas.
Died.
Barrows.— In Hackensack, New Jersey, on Thursday.
June 7th. Dr. Arthur A. Barrows, aged sixty-eight years.
Bush. — In Warren, Pennsylvania, on Saturday, June 13th,
Dr. John Bush, of Wahot). Nebraska, aged fifty-two years.
Cari.f.ton. — In Waterloo, New York, on Friday, June
19th, Dr John F. Carleton. aged sixty-four years.
Colby. — In Cadillac. Michigan, on Wednesday, May 27th>
Dr. Winfield S. Colby, aged thirty-one years.
HiRLEV. — In Norwood, Massachusetts, on Sunday. May
.^Lst. Dr. Daniel M. Hurley, aged forty-four years.
KuNSTLiCH. — In Passaic, New Jersey, on Siuiday. June
21 St, Dr. .Mexander .^. Kmistlich. aged sixty-four years.
INDEX TO VOLUME LXXXVII.
Pa..:
ABUOTT, E. G.. and rmgite, H. A.
The restoi^tion of the normal balance
of the foot 875. 976. lor '
Abdomen, gunshot wound of 186, 892
punctured wound of 5*>5
Abdominal contusions, avuUioti of mesen-
tery in 661
incision 4".'
section, enema after '"jo
for trauma of uterus S6
surgery, postoperative complications in.
tenderness. significance of 474. 9'-'
tumors, pseudomalignant
Abortion and labor, febrile conditions
after 3oo
.\bscess and liimatoma, septal, treatment
of 561
appendicular 39
cerebellar, symptoms of "57
cerebral, with masked symptoms 691
of frontal lobe of traumatic origin 891
of kidney after gonorrhiia 1169
perinephritic. following parturition..... 87
subphrenic, a complication of appendi-
citis 5" 3
surgical aspects of 5' 5
tropical, of liver -275
Abscesses, acute, treatment of 1120
use of thymol camphor in treatment of. j6c
Accidents, dependency arising from 121
following injections of quinine 1214
medicolegal considerations of 129
relation of, to nervous diseases and
psychoses •■ • • '29
Acetonuria, postoperative, significance of. 224
with vomiting •••• 183
Acid, glycuronic, in conditions of dimin-
ished o.xidation 2. '4
hydrochloric, in gout 1045
in pyloric insufiSciency with diarrhoea. 946
uneven distribution" of, in the gastric
contents I77
iodic, antiseptic value of 21O
iodoformic. in treatment of phthisis.... 27^
into-xication 755
lactic, for alopecia 648
picric, for plantar hyperidrosis 27
pyroligneous, for arthritis deformans... 408
salicylic, excretion of 230
method of administering 5S1
sulphurous, in California dried fruit... 911
tannic, in treatment of dermatitis vene-
uric. formation, elimination, and effect
on general svstem of 246
solvent for '. 124S
Acidoses, classification of 95t>
Acne, applications for 119
Adams-Stokes syndrome without blocking. 132
Adenectomy during middle ear disease.. 37s
Adenoid patients, postoperative treatment
of 9'-
Adenoids and tonsils 271
Adcnomyoma of uterus i2'6
Adhesions, perigastric, fibrolvsin treatment
of 132
Adiposis tuberosa simplex 613
Adrenalin in eczema 115O
Aerotherapy in toxaemias of childhood.... 809
Agatston, S. A. Treatment of post partum
haemorrhage 263
.\ir, compressed, tor dilating Eustachian
tube 33 >
house, a simi>]e 1081
passages, upper, inhalations of saponin
in diseases of 612
.\laska, medical notes on 105?
-Mbee. Fred II. Osteomyelitis 1077
Albumin, smallest necessary supply of 84
.Mbuminuria 230
and itch, connection between 459
calcium chloride in 457
orthotic, in children 323
.'Mcohol, effect of, upon secretions 569
injections for facial neuralgia 178
Alcoholic stupor, diagnosis of 404. 45'
postdelirious 154
Alcoholism and inebriety, literature of... 620
chronic, treatment of 632
Alger. EUice M. To wliat extent is mi-
graine amenable to treatment of the
eyes? loS;
Alimentary intoxication, treatment of. . . . 7.
Alkaline earth?, haemostatic action of.... 22^
Allen. A. H. Notes on dengue in Cuba.. 35.-:
Alopecia, lactic acid for 64.S
P.\GE.
.\iopecia. lotions and pomade for 119
posttyphoid, treatment of 948
Alumni reunions in Chicago ii5"
Anaemia in children 1121
pernicious, blood depletion in 80"
of pregnancy ....1264
splenic, splenectomy in treatment of... 1125
Anaesthesia, accidents during 782
analjtical study of six hundred cases
of 1 148
by nitrous oxide, nitrous o.xide and ogy-
gen. nitrous oxide and ether, chloro-
form and oxygen, and ether adminis-
tered per rectum 196
chloroform, studies concerning 30
ether 467
ethyl chloride for 963
fatalities : 4/2
general, clinical study of 888
with sequestration of a portion of the
circulation 26S
lumbar 374, 121 5
scopolamine morphine, in gynaecology.. 421
surgery before the days of 965
Anaesthetics, deaths under 705
Analgesia, intraspinal 86!5
spinal, clinical experiences with 371
.\naphylaxia 756
Anaphylaxis and anaphylaxines 74
relation of. to the toxaemia of pregnancy. 1222
.\nastomosi5. arterial, and transfusion.... 806
Anatomy and physiolog>- among the Chi-
nese 363
study, a new method of 993
Anders, James M. A brief critical review
of a" year's progress in tropical medi-
cine 815
Aneurysm of aorta, importance of early
detection ot 3o6
of ascending aorta 660
Angina. Ludwig"s 566
pectoris, ligation of coronary arteries in
treatment of 955
Angulation of the sigmoid 832
Angulations of sigmoid and color. 479
Anilines, poisoning by 123
Animal therapy, influence of, upon the op-
sonic index in tuberculosis 587
Antaphrodisiacs, formulas for 457
Antibody in ex. erimental practice 1056
true co!:ception of 869
Antimony as a hepatic stimulant 600
I'lea for 562
\ah:e of. in bronchial catarrh 551
Antiseptic, intestinal, for children 948
.\ntithyreoidin in osteomalacia 1261
.Antitoxic function and albumin 230
-\ntitoxine. diphtheria, refined and con-
centrated by Gibson's method, results
obtained from 1242
urticaria after administration of ii6?
tetanus, the American unit of 104.S
Antityphoid inoculation 1259
-\ntrum of Highmore, carcinoma of 417
Anus, fissure of, suppository for 94?
Aorta, aneurysm of, detection of So'S
spontaneous rupture of 181
traumatic insufficiency of 911
Aortic incompetence in later life 70S
regurgitation and floating liver 400
Aphasia, relation of auditory centre to..ii25
Aphrodisiacs, formulas for 457
Appendicectomy, technique of loio
Appendicitis, association of, with other dis-
eases in female pelvis 521
causes of 66
due to presence of oxyuris vermicularis. 36
early operation in 469
in children 39
infections following 521
one hundred consecutive operations for. 320
reflex troubles of the pulse in 228
relation of, to gynaecological pelvic dis-
eases 753
subphrenic abscess as a complication of 513
surgical treatment of 6gi
symptoms of 70S
traumatic 660
treatment of 3SI
with acute enteritis 869
X rajjs in diagnosis of n66
Appendix, abscess of 39
carcinoma of . . . . : 1057
harmful involution of 187
vermiform, diverticulum of
metaplasia of 1060
Apraxia of cephalic muscles 1057
.Aran-Duchenne type of muscular atrophy . lose
.\rc light treatment of skin diseases 869
Page.
.Arhovin in treatment of gonorrhoea 105S
Armstrong, Alfred W. The causes of ap-
pendicitis 66
Armstrong. Samuel T. The need of care
for the convalescent from the hospital
standpoint 437
Army Medical Bill 763
Department examinations 1268
necessity of important changes in or-
ganization of ^ 335
rank and pay of officers of 745
ofiicers, increased pay for 951
reser\-e corps of 1095
service of 1249
Arterial anastomosis and transfusion 806
tension, high, causes and treatment of.. 809
Arteries, coronary, ligation of, in treatment
of angina pectoris 955
Arteriosclerosis 177
lactic lemonade for 997
local 513
nervous manifestations of 421
relation of age to 959
studies on, with special reference to the
radial artery 8;
Arteritis obliterans 275
peripheric rheumatismal 756
Arthritis deformans of the hip 1210
pyroligneous acid for 408
infectious, strain as a causative factor
, • ■ 34
rheumatoid 375
Arthrodesis and tendon transfer in paraly-
tic club feet .'. 473
and tendon transplantation 753
value of , 517
.■\scaris, treatment of 693
Ascites associated w^ith hepatic cirrhosis. . 40
Ashford, Bailey K. Puerto Rico as a
field for research in tropical medi-
cine 1236
Aspiration diseases, artificial pneumothorax
in 84
Association of American Physicians g^r
of Tuberculosis Clinics of the City of
New York 9,7
State Charities .\id 284
Asthma, bronchial, mixture for 45S
.Asthenia, cardiac, injections of serum in
treatment of 1214
powders for inhalation in 27
spray for attacks of 64S
typhic 1255
-Vtaxia. locomotor 704
laryngeal manifestations in 121 o
.\tresia. acquired, of common duct, due to
gallstone 327
.Vutoinfection. bronchointestinal, in the
newly born 613
.\xilla and rectum, importance of differ-
ence in temperatures of 660
BACHMANN, Robert A. Treatment of
seasickness 1042
Bacilli, influenza, in the bronchi 517
parattphic 373
tubercle, essential identity of 555
Bacilluria in childhood.....' 227
Bacillus coli communis, distinction of, from
allied species in water 959
Friedlander's, a cause of pneumonia ... 10S7
Bacteria as incitants of malignant endo-
carditis 35
nonpathogenic, disinfection of body cavi-
ties by '. i2ti
pathogenic forms of. opsonins as a
means of distinction and identification
of 612
Bacterial disease, specific vaccines in treat-
ment of 70
vaccines and curative sera 41
Bagg, L. W. Treatment of fracture of
patella 894
Baldwin, E. R. Review of theoretical
considerations and experimental work
relative to opsonins 1227
Ballagi, John. .Acute syphilitic nephritis .. 1240
Ballin, Milton J. A larynx knife and silver
nitrate carrier 965
The removal of adenoids 293
Baltimore milk supply, chemical examina-
tion and inspection of 69
Barbour. Max. Indications for water in
childhood 253
Barrier, L. F. Treatment of fracture of
patella 833
Battlefield, illumination of. for search of
wounded 476
1272
JMDEX TO VOLUME LXXXVII.
Page.
Bates, W. M. Metchnikoff soured milk. 330
Bath for urticaria 1044
tub, treatment of cystitis 45
Baths, mud, influence of, upon organs
of circulation 3^4
Beardsley, John Gillespie. A unique case
of infectious orchitis 162
Beck, Carl. Urethroplastic operations.... 2^7
Becker, Henry C. Treatment of sun-
stroke 1244
Bedsores, application for prevention of... 094
Benedict, A. L. The ophthalmic tubercu-
lin test 1233
Benzol vapor, acute poisoning by 30
Beriberi, aetiology of 123, 281
Bernart, William F. Mercury and tubercu-
losis 1236
Bier clinic in Berlin, observations made at 70
Bierhoff, Frederic. Hysterical retention of
urine 163
The abortive treatment of gonorrhcea in
the female 6'>
The newer methods of examining the
bladder 588
The palliative treatment of prostatic hy-
pertrophy 73'
The word "palliative" 1062
Bier's hypersemia in inflammation 374
in treatment of metritis 83
in tuberculosis of bones and joints.. 374
stasis, action of 47^'
Bile changes in infective diseases 4'^
ducts, relation of typhus and paratyphus
fevers to i-j
pigment in the blood, relation of uro-
bilinuria to 112--,
Biliary calculus, treatment of pam from. . 1094
passages, diagnosis, and treatment of in-
fections of 2-6
Birth rate in New York, an improved.... 602
Bismuth subnitrate in diseases of the
stomach 79^
nitrate poisoning following large doses
of 8g
Blackwell, Hugh Burke. A new pliable
submucous elevator 1266
Bladder and urethra, overtreatment of.. 711
in tabes 00^°^^
newer methods of examinmg ...588, 71 '
prolapse of, surgical treatment of 1264
treatment of, after suprapubic cystotomy
for stone ■ ■ • 88
tumors of, transperitoneal removal of.. 88
urinary, primary carcinoma of 86
Rlain, Alexander W. A clinical study of
general anaesthesia 888
Bleeding, uterine, significance of 8o3
Blepharoplasty by means of pedicled flap
taken from the neck 013
Blindness, night 5i6
sudden, and its various causes 77'
Blood, bile pigment m ii--5
cells, red, relation of cobra poison to.. 612
clot, destruction of 707
modified, in mastoid surgery 1144
coagulability in the puerperal state.... 228
coagulation '"°4
clinical aspects of 232
condition of, in poisoning by anilines.. 123
conservatism of neurotic individuals.... 593
cultures from the ear in diagnosis of
typhoid fever "63
negative results in 1222
depletion in pernicious anaemia 800
human, antiferment action of 963
influence of electrical stimulus upon dis-
tribution of 324
intracranial extravasations of, in newly
born .• 757
plaques, bactericide and haemolytic effi-
ciency of material in 660
opsonic index of, accuracy of method of
determining 1217
destruction of 707
pressure, effects of hydrastis and its al-
kaloids on 79
graphic registration of 612
high, the organic factor in 320
in the practice of medicine 754
observations in eclampsia 958
reactions of inflammation 41
serum, haemolytic reaction in malignant
tumors 1 168
test, the guaiac 1168
Bodies, foreign, in larynx 635
in upper jaw the cause of conjunctivi-
tis 85
swallowing of 23'
Body cavities, disinfection of, by nonpatho-
genic bacteria
chemical control of 559
foreign, in left bronchus 181
in the nose 85
Boldt, H. J. Progress in gynicology from
a clinical viewpoint 527
Riiliis treatment of diarrhoea 39
I'.omh. a normal salirc 1203
Bone disease, tuberculous 3'o
Page.
Bone tumors, conservative operations on.. 271
Bones, long, fractures of 909, 962
malunion of 800
BOOK NOTICES:
Abel's Laboratory Handbook of Bacteri-
ology 571
Adamson, H. G. Skin Affections in
Childhood 667
Aikens, Charlotte A. Hospital Training
School Methods and the Head Nurse. 571
Anders, James M. A Textbook on the
Practice of Medicine 282
Annales de la Societe royale des sci-
ences medicales et naturelles de
Bruxelles 93
Anziolotti, Prof. Dott. Giulio. Sul pro-
cesso di riparazione delle perdite di
sostanza nedde cartilagni e pericon-
drio 1268
Avellis, Dr. med. Georg. Verhandlungen
der deutschen laryngologischen Gesell-
schaft 966
Babcock, Robert H. Diseases of the
Lungs 966
Ballenger, William Lincoln. Diseases of
the Nose, Throat, and Ear 1128
Bandelier, Dr. Lehrbuch der spezi-
fischen Diagnostik und Therapie der
Tuberkulose 716
Barnhill, John F., and Wales, Ernest
de Wolfe. Principles and Practices of
Modern Otology 44
Barrus, Clara. Nursing the Insane .... loi 5
Bartley, Elias. H. Manual of Physio-
logical and Clinical Chemistry 332
Baruch. Simon. The Principles and
Practice of Hydrotherapy 1222
Barwell, Harold. Diseases of the
Larynx 282
Baumann, Frederick. Gonorrhoea 1128
Baumgarten, Dr. med. P. von. Jahres-
bericht iiber die Fortschritte in der
Lehre von den pathogenen Microor-
ganismen unfassend Bakterien, Pilze,
und Protozoen 763
Bechterew, Dr. W. v. Die Funktionen
der Nervencentra 91S
Beers, C. W. A Mind that Found
Itself 601
Bericht iiber den XIV internationalen
Kongress fiir Hygiene und Demo-
graphie, Berlin 11 75
Bezold, Fr. Textbook of Otology for
Physicians and Students 619
Blair, Vilray Papin. Laboratory Guide
for the Modelling of the Human
Bones in Clay 57 1
Bloch, Iwan. Die Praxis der Haut-
krankheiten 1128
Blyth, Alexander Wynter. Poisons 42S
Bockenheimer, Dr. Ph., and F'rohse,
Dr. Fritz. Atlas of Typical Operations
in Surgery 919
Bolduan, Charles Frederick. Immune
Sera 1064
Bonnet, M. Geraud. Traite pratique
d'hypnotisme et de suggestion thera-
peutiques 429
Bose, Jagadis Chunder. Comparative
Electrophysiology 872
Bovee, J. Wesley. The Practice of
Gynaecology 667
Boyle. H. Edmund G. Practical Anjes-
thetics 91 y
Braun. Dr. Heinrich. Die Lokalanas-
thesie 139
Braun, Dr. Max. Die tierischen Para-
siten des Menschen 965
Bulkley, L. Duncan. Principles and Ap-
plication of Local Treatment in Dis-
eases of the Skin 872
Burnet, Dr. Etienne. La Lutte contre les
microbes 1064
Campbell. William Francis. A Textbook
of Surgical Anatomy 714
Carrington, Hereward. Vitality, Fast-
ing, and Nutrition 9ifi
Chrohak, Prof. Dr. R.. und von Rost-
horn. Dr. A. Die Erkrankungen der
weiblichen Geschlechtsorgane 1129
Confessio Medici 1015
Corner, Edred M. Diseases of the Male
Generative Organs 715
Corner, Edred M., and Pinches. H.
Irving. The Operations of General
Practice i.!23
Croftan, Alfred C. Clinical Therapeu-
tics > 7'5
Daniels, C. W. Studies in Laboratory
Work 9»7
De Mendoza, Alberto Suarez. Oiagnos-
tico y Tratamiento de las Enfermeda-
des de las Vias Urinaris 57i
Dupree, James William. Mosquito Life 967
Eiscndrath. Daniel. A Textbook of
Clinical Anatomy 44
Page.
BOOK NOTICES:
Fantus, Bernard. A Textbook on Pre-
scription Writing and Pharmacy 666
Fick, Dr. Johannes. Synonymik der
Dermatologie 93
Foote, Edward Milton. A Textbook of
Minor Surgery 1016
Forel, August. The Sexual Question. . 1223
Fothergill, Claude F. Blood Examina-
tion and Its Value in Tropical Dis-
ease 4^8
Fowler, Russell S. Operating Room and
the Patient 4;,
Fry, Harry D. Maternity 523
Gee, Samuel. Auscultation and Percus-
sion 5-1
Medical Lectures and Aphorisms 76 j
Gilbert, George Abner. A Textbook on
Uric Acid and Its Congeners 812
Gordon, H. M. Abel's Laboratory Hand-
book of Bacteriology 571
Gowers, Sir William R. The Border-
land of Epilepsy 1015
Grasset, Joseph. The Semiinsane and
the Semiresponsible (Demifous et
Demirespcnsables) 762
Green, Charles Lyman. Medical Diag-
nosis g68
Green, J. Reyonlds. An Introduction to
Vegetable Physiology 918
Greene, Robert Holmes. Diseases of the
Genitourinary Organs and the Kid-
neys 619
Guthrie, Leonard G. Functional Nerv-
ous Disorders in Childhood 188
Harris, David Eraser. The Functional
Inertia of Living Matter 1063
Hellpach, Willy. Technischer Fortschritt
und seelische Gesundheit 139
Hildebrandt, Dr. W. Schema des
Rumpfes 667
Hirschfeld, Dr. Magnus. Les Homo-
sexuals de Berlin 919
Hoche, Dr. A. Notwendige Reformen
der Unfallversicherungsgesetze 524
Hoxie, George Howard. Practice of
iledicine for Nurses 1174
Jessner, Dr. S. Die Schuppenflechte
(Psoriasis vulgaris) und ihre liehand-
lung 1 175
Jewett, Charles. Essentials of Ob-
stetrics 715
Jones. Robert. A Textbook of Mental
and Sick Nursing 92
Jurgensen, Prof. Th. von. Diseases of
the Heart 1173
Kabrhel, Dr. Gustav. Der Abstinentis-
mus und seine Bedeutung fiir das
Individuum und fiir die Gesellschaft . 620
Kanga, Prestonjee M. Reflections on
the Plague and the Methods of Check-
ing It 4,8
Keen, William Williams. Surgery.. 92, 1127
Keith, Skene. Cancer 1175
Kellogg, Vernon L. Darwinism To-
day 967
Kelly, Howard A. Medical Gyna;coIo.?y.i266
Keogh, Sir Alfred. A Manual of Ven-
ereal Diseases 1266
Keyes, Edward L., Jr. Syphilis 918
Kleist, Dr. Karl. Untersuchungen zur
Kenntnis der psychomotorischen Bewe-
gungsstorungen bei Geisteskranken . . . 1267
Klemensiewicz, Dr. Rudolph. Die Ent-
zungung 1267
Krehl, Dr. Ludolf. Pathologische Physi-
^ologie 138
Kronthal, Dr. Paul. Nerven und Seele.io.'4
Kyle, D. Braden. A Textbook of Dis-
eases of the Nose and Throat 475
Labbe. Henri. La Diathese urique 1267
Leo. Dr. Hans. Die Salzsauretherapie
auf theoretischer und praktischer
Grundlage 282
Loefiler, F., Newsholme. Arthur, etc.
The Bacteriology of Diphtheria 1126
Lockwood, C. B. Clinical Lectures and
Addresses on Surgery 1016
McCann, Frederick John. Cancer of the
Womb 570
Manz, Dr. Otto. Die chirurgischen
Untersuchungsartcn 667
Metchnikoff, Elie. The Prolongation of
Life : 33'
Meyer, Willy. Bier's Hypera:mic Treat-
ment in Surgery, Medicine, and the
Specialties 1127
Moore. Norman. The History of the
Study of Medicine in the British Isles 714
Morris. Malcolm. Light and X Ray
Treatment of Skin Diseases 380
McCombs, Robert S. Diseases of Chil-
dren for Nurses 47S
Miller, Charles C. The Correction of
Featural Imperfections H7.S
Muthmann. Dr. Arthur. Zur Psycholo-
gic und Therapie neurotischer Symp-
tome 138
INDEX TO VOLUME LXXXVII.
Pace.
BOOK NOTICES:
Neisser, Albert, and Jacobi, Eduard.
Ikonographia Dermatologica 1063
Newman, David. Movable Kidneys and
Other Displacements and Malforma-
tions 1016
Nichols, John Benjamin. Fiske Fund
Prize Dissertation. No. i. Diet in
Typhoid Fever 92
Nitze, Dr. M., and Jacoby, Dr. S.
Jahresbericht iiber die Leistungen und
Fortschritte auf dem Gebiete der Er-
krankungen des Urogenitalapparates . . 715
Noorden, Carl von. Metabolism and
Practical Medicine 235
Notter and Firth. The Theory and Prac-
tice of Hygiene 968
Noyes, William A. Kurzes Lehrbuch
der organischen Chemie 812
Nuttall, G. H. F. The Bacteriology of
Diphtheria 1126
Osier, William. Modern Medicine 379
Parsons, J. Inglis. The Operative
Treatment of Prolapse and Retrover-
sion of the Uterus 715
Pincus, Dr. Ludwig. Atmokausis und
Zestokausis 667
Pottenger, Francis M. The Diagnosis
and Treatment of Pulmonary Tuber-
culosis 618
Potts, Charles S. Nervous and Mental
Diseases 919
Powell, Lyman P. Christian Science,
the Faith, and Its Founder 1128
Poynton, F. J. Heart Disease and Thor-
acic Aneurysm 968
Prescott, Samuel Cate. Elements of Water
Bacteriology 1266
Pron, Dr. Lucien. Formulaire synthet-
ique de medecine 966
Traite clinique des maladies de I'es-
tomac 917
Putzel, Charles. Commercial Prece-
dents 235
Rivers, W. H. R. The Influence of Al-
cohol and Other Drugs on Disease. .. 1017
Robin, Albert. Les Ferments metal-
liques et leur emploi en therapeutique. 619
Robin, Albert. The Metallic Ferments in
Therapeutics 266
Russell, Hon. RoHo. The Reduction of
Cancer 92
Saleeby, C. W. The Conquest of Cancer 812
Salvi, G. Morfologia delle arterie dell-es-
tremita addominale 1268
Sargent, Percy. Surgical Emergencies. . 1 174
Schleif, William. Materia Medica,
Therapeutics, Pharmacology, and Phar-
macognosy 332
Schleip. Priv. Doz. Dr. Karl. Hsemato-
logical Atlas 872
Scripture, E. W. Thinking, Feeling,
Doing 236
Scudder, Charles Locke. The Treatment
of Fractures 571
Seifert, Dr. Otto. Geschicte der Laryng-
ologie in Wiirzburg 1 129
Selter, Paul. An Introduction to the
Study of the Infant's Stool 812
Simon, Charles E. A Manual of Clinical
Diagnosis by Means of Microscopical
and Chemical Methods 92
Smith, Fred J. Lectures on Medical
Jurisprudence and Toxicology 666
Sobotta, Dr. Johannes. Atlas and Text-
book of Human Anatomy 139
Starling, Ernest H. Elements of Human
Physiology 139
Stelwagon, Henry W. Treatise on Dis-
eases of the Skin 967
Stephenson, Sydney. Ophthalmia Neona-
torum 283
Stevens, A. A. Manual of the Practice
of Medicine 570
Strauss. Prof. Dr. H. Vorlesungen fiber
Diatbehandlung innerer Krankheiten. . 1174
Strong, Frederick Finch. Essentials of
Modern Electrotherapeutics 714
Talmey. Bernard S. Woman 1175
Thomson, J. Arthur. Heredity 1174
Thorndike, Augustus. A Manual of
Orthopaedic Surgery 283
Tod, Hunter. Diseases of the Ear...... 282
Transactions of American Gynscological
Society. Volume xxxii 1175
Transactions of American Surgical Asso-
ciation 763
Treves, Sir Frederick, and Keith. Arthur.
Surgical Applied Anatomy 572
Trewby, Arthur. Healthy Boyhood 1016
Von Bunge, G. Textbook of Organic
Chemistry for Medical Students 475
Waggett, E. B. Diseases of the Nose.. 282
Wallace, Cuthbert S. Prostatic Enlarge-
ment 763
Westenhoeffer, Prof. Dr. JI. Atlas der
pathologischanatomischen Sektionstech-
nik 1175
^\■hite, William A. Outlines of Psychia-
try 523
P.-\GE.
BOOK NOTICES:
Wilcox, Reynold Webb. Pharmacology
and Therapeutics 44
Winslow, Kenelm. The Production and
Handling of Clean Milk 762
Wrench, G. P. Rotunda Midwifery for
Nurses and Midwives 1016
Books, craze for novelty in 838
of six months 844
Bothriocephalus latus • 1190
Brace, the Whitman 1126
Braddock, Charles S. Leprosy in the Far
East 893
Vaccination in the Far East 304
Brain, abscesses of frontal lobe of 891
and spinal cord, surgery of 805
focal symptoms in diffuse diseases of 1215
substance, injections of extract of, in
tetanus 408
surgery of 911, 964
tumor, clinical study of a case of 1054
tumors, symptomatology of 229
Brav, Aaron. The rational treatment of
iritis 353
Brav, H. A. Diagnosis and treatment of
benign tumors of the rectum 446
Breast, cancer of, Tausini's method in 564
technique of operation 566
cysts, carcinomatous degeneration of 357
female, diagnosis of diseases of 420
tumors, preliminary incision of 1257
Breath as an aid to diagnosis 306
Breathing apparatus, diseases of, which af-
fect the breath 306
llreech presentation at end of pregnancy in
a uterus bicornis 565
I'.right's disease, treatment of 802
Bristow. A. T. An impostor 871
Bromides, a clinical study of 178
Bromine, antimicrobic action of 272
Bromopncea due to gingivitis, treatment of. 217
Bronchiectasis, artificial pneumothorax in. 84
Bronchitis, acute, treatment of 647, 997
aetiology, pathology, and treatment of.. 908
chronic, cause and treatment of 468
fibrinous, case of 780
foetid, injection for 1045
inhalation for i045
Bronchoscope, modified, description of 984
Bronschoscopy 810
systematic use of, in routine work 984
Bromoform, danger from 31
I5rothers, Abram. The management of
febrile conditions after abortion and
labor 300
Brown, Herbert S. The Haverstraw Col-
ony 811
Brown, Mary Hess. Observations made at
the Bier clinic in Berlin 70
Bryant, Joseph D., and Curtis, John G.
Vivisection in the State of New York. 188
Bryant, W. Sohier. Middle ear deafness.. 990
Bubo, chancroidal, treatment of 226
Buboes, treatment of, with hypersemia 39
Buccopharyngeal mucous membrane, spor-
otrichosis of 706
Buchanan, Mary. Sudden blindness and
its various causes 7/1
Bundle, the atrioventricular 1124
Bunion with hallux valgus, surgical treat-
ment of 330
Bureau of publicity, medical 615
Burns, extensive, application for 31'
treatment of 1156
Butler. Charles S. Treatment of seasick-
ness 1040
/^ABOT, Follen. Conservative prostatec-
^ toniy 384
Cachexia, striae atrophicae due to S^''
Cade ointment, adherent, for skin dis-
eases 119
Caecum, cancer of 804
Ca:sarean section, abdominal 13b
in an unusual case 11 64
rupture of uterus through cicatrix of 1216
vaginal 5'7
111 treatment of placenta praevia... 61 j
Calcium chlorate confounded with calx
chlorinata 71
chloride in albuminuria 457
lactate, administration of 744
metabolism and the parathyreoids 506
relation of parathyreoid glands to.... 957
salts, abstraction of, from the blood, a
cause of dental disease 83U
Calculi, renal and ureteral, complicating
or stimulating appendicitis 561
urinary, x ray diagnosis of 224. .ti6
Calculus, biliary, treatment of...... 360. 1094
ureteral, transperitoneal ureterotomy for 1S6
Calmette's ophthalmoreaction 225, 909
reaction in diagnosis of tuberculosis .... 1 234
test for tuberculosis 961. 1220
Calomel, injections of, for syphilis 71
Calx chlorinata confounded with calcium
chlorate 71
Cammidge's reaction in pancreatic dis-
ease 682
Page.
Campbell, William Francis. Some unusual
effects of gonococcus infections 356
Canal, genital, rupture of 708
Cancer 32a
aetiology and treatment of 227
causation and infectivity of 228
caused by x rays 322
clinical study of 72
connective tissue in 1120, 1213
difference in effect produced by injec-
tions of trypsin and glycolytic ferments
in 564
electric treatment of 470
endemic occurrence of, in Fisherville,
Va 608
excision of rectum for 1007
in Philippine Islands, prevention of... 1052
of breast, Tausini's method in 564
technique of operation for 566
of caecum 804
of large bowel 370
of ovary 180
of pancreas causing jaundice 231
of prostate, treatment of 471, 868
of stomach 615
gastroenterostomy in 617, 628
remedy for the vomiting in 217
of tongue in syphilitics 901, 950
of uterus, early diagnosis of 1171
our present knowledge of 650
problem 908. 1097
modern as|;ects of 1170
recovery from 232
thymus gland treatment of 807
treatment of 273
Cannaday, John Egerton. The surgical
treatment of appendicitis 691
Capsule, suprarenal, histology of cortex of.1214
our present knowledge regardinsi the
function of 12 12
Carcinoma, connective tissue in 11 20
of appendix 1057
of breast cysts 357
of nasal cavity and antrum of High-
more '. . 417
primary, of urinary bladder 86
splenectomy for 277
treatment of, after operation bv irradia-
/'O", • 757
uteri, hysterectomy ot gravid uterus for 83:
Carcinomata, squamous celled, of (e-o|)ha-
gus 289
Carcinomatosis of the meninges 191
Cardiac asthenia, injections of serum in
treatment of 1214
Cardiovascular renal disease, diagnosis and
treatment of 276
Caries, dental 655
Carling, John. The Whitman brace 1120
Carroll, Dr. James, a memoir of 758
Carter. Charles Edgerton. Laclacid milk
in infant feeding 042
Cataphoresis, medication by 837
Cataract, extraction in capsule of 1034
Catarrh, acute suffocative 1167
bronchial, value of antimony in 551
of upper air passages, treatment of.... 217
Catgut, chromic. Lord Lister's formula
for 458
for surgical purposes, preparation of... 274
Catheter scale, a uniform 268
Catheterism, ureteral 709
Cats as plague preventers 1212
Cauda equina, tumors of 614
Cerebellum, compressed by meningeal tu-
mor 1059
Cerebral abscess, a case of, with masked
symptoms 691
contusion 62
cedema, alcoholic 154
influenza 1257
Cerebrospinal fluid, typhobacilli in, in ty-
phoid fever 121 5
Cervix uteri, rigid, treatment of, by deep
incisions 906
Chance, Burton. Accessory sinus disease,
with symptoms of osseous tumor of
orbit 499
Attempts to repair the effects of great
destruction of lids and orbital tissues
caused by disease of antrum 735
Chincre, soft, paste for 552
Charlatanry, philosophy of 409
Cheyne-Stokes respiration 1048
Chilblains, treatment of 170. 311, 361
ulcerated, liniment for 217
Child, mentally subnormal, defective vision
in 880
Childhood, injurious practices and habits
of 1256
Children, crippled and deformed, care of. 507
what New York is doing for 810
medical profession's duty to 930
Chinese, anatomy and physiology among. . 363
college of medicine, the proposed 259
Chloroform, anaesthesia, studies concern-
ing 30
faradization in syncope from 38
LXDJiX TO VOLUME LXXXI II.
Chlorufc.v
Mihcut;
ralgi;
ellu
1 . . . . 56,!, 659, 804
1141
il<.s|.ital for
ChloroMs cured hv iliyrroul
iron ill
tuberculous, treatment of
Cholecystectomy
Cholecystitis, diagnosis and
medical treatment of
paratypliosa
Cholelithiasis, diagnosis aiul
13"
medical treatment of
treatment of
Cholera in Constantinople
infantum
Cholesie.nioma, a case of
t hole-ti rinc in pleural exudates
.pe
t horioepitlielioma loog
malignum 117
present significance of 66_'
( horioid, sarcoma of 674
Circulation conditions, di.i-n^ -1^ ni, hy
temjierature measurenimi - 958
influence of mud baths ii],mii .nLianv of.. 3_;4
Cirrhosis of liver 4.'j
ascites associated with 40
neurites in course of 2j6
Climatic treatment of children, principles
Ancient phthis
of"'
937
jlherapy. 916
594. 644
ulna
C linic*. liuropean surgical. iK
tuberculosis, in New ^'ork..
Close, Dr. Seth D., memorial
Coal ash. anthracite, as a surgical dressing. 560
Cobra poison, relation of. to red blood
cells 612
Cocaine in ointments 360
Cohn, l*'eli.N. Indications for surgical in-
tervention in suppurating middle ear
diseases 388
Cold in the head, treatment of 308
Cole. Lewis (.iregory. Radiographic diag-
nosis of renal lesions 774
Colgan, I. I". I
c:olic, gallstone
nature and c
Colitis, chronic,
Colles's fracture
after 11 58
Collins, Josejih. Psychasthenia 297
Collinsonia canadensis, physiological action
of 216
Colon and sigmoid, angulations of 479
infection of urinary tract 563
radiological investigation of 612
Colony, a new New York .State 460
Color photography. Lamijiere's 661
(."oma, diabetic, injection in 1249
Comedones, treatment of 120
Complements, forensic value and knowl-
edge of the joining of the 84
Conceptions, multiple 1089
Congestion, urban, efltects of, on Italian
women and children 908
Conjunctiva, diseases of 1193
miliary tuberculosis of 500
sensitiveness of, to tuberculin 1122
Conjunctivitis, foreign bodies in upper jaw
the cause of 85
Conklin, \V. 1.. The relation of mental at-
titude to bodily' function 582
Constipation, cure of. by psychotherapy 121Q
Consumption among the poor, home man-
agement i'l 949
dried sputum in the spread of 651
in tenement houses 754
mercury in treatment of 998
< onsumptives. sanatoria for 661
Contusion, cerebral 62
Convalescents, need of care for 437
Cornea, disea-cs of 1193
Corning, J. Lecmard. Letter on vivisection 573
Corpora striata, functions of 472
( ORRKSPONDENCE:
Letter from Hamilton, Canada 792, 1154
Letter from Kingston, Ontario 169
Letter from I^ndon 995, 1093, 1202
Letter from Ottawa 504, 1044, 1247
Letter from Toronto 359, 1155
( orson, Eugene R. Treatment of the vom-
iting of iiregnancy 24
l orycll. C. C. Treatment of post partum
hxmorrhage 214
Coryz.T, treatment of 7T, 948
Coughlin, Robert Emmet. A case of cere-
bral ab«ce«s with masked symptoms. . 691
Cowinfr. Julgc Rufus B. Expert testi-
mony 1067
Cow*, tuberculous, relation of. to tubercu-
lo>ii» in children 1256
Page.
trispin, Antonio il. Chorioepithelioma
malignum 117
"Cruise of the U. S, S. .Esculapius,"' an
opera in one act 285
C ulture media for typhoid, malachite green
in 1169
I ultures, blood from the ear in the diag-
nosis of typhoid fever 1163
C uminins, W. Taylor. Squamous celled
carclnoinata of the cesophagus 289
Cupar water supply, a study of 231
(. urrent. galvanic, response to, in children
with tetany , 83
Lurtis, John C, and IJrvant. loscijli U,
\'ivisection in the State of New York. 188
Custodial Institution at Haverstraw, X. Y.,
the proposed 668
Cyanosis, changes in terminal phalanges
in 38
Cyclothymia 963
Cyst of pancreas 185
Cystitis, application for 408
suppurative, treatment and prognosis of. 425
tub bath treatment of 4;
Cystoscopy, practical 959
Cystotomy, suprapubic, treatment of blad-
der following 88
Cysts, breast, carcinomatous degeneration
of 357
of liver, nonparasitic 568
Cvtodiagnosis in practical medicine, value
of 372
Czerny's exudative diathesis 183
DANA, Charles L. Melancholia 234
Darwinism and diabetes 960
Deafness, catarrhal, treatment of 1005
chronic middle ear 810
middle ear 990
Death, cause of 706
rate of New York City, eft'ect of cos-
mopolitan character of population on.. 226
sudden and unexpected 562
in heart disease 965
Deaths of physicians in 1907 332
Deciduomata, production of 1269
Defectives, mental and physical 140
Deformity, oral, relation of upper respira-
tory obstruction to 477
Delivery, forcible, fracture of femur in 134
Dementia prascox, eye syndrome of 907
psychology of 178
Dengue in Cuba 35S
Dental disease, abstraction of calcium salts
from the iilood a cause of 830
pregnancy an etiological factor in.... 368
Dentistrv and medicine, common ground
of .". 513
Dermatology, .\ ray in 1170
De X'ries, J. Carlisle. The psychic phe-
nomena of intestinal toxaemias and
their treatment 826
Dermatitis venenata, tannic acid in treat-
ment of 458
Dermatology and knighthood 95-^
teaching of, in medical schools
Desmoid reaction 1203
Dextrocardia, aci|uiied. associated with
phthisis 236
Diabetes, clinical value of estimation of
ammonia in 95'^
coma of, injection in 1249
dietetic treatment of 75.)
mellitus, association of. with tubercu-
losis of lungs 93.:
complicating i,ves:iancy 1160
epilt:ptiform attacks in 1005
nature and management of 8o(-
oatmeal diet in 560
two fatal cases of.. 181
nonfatal coma in the course of ii2,t
Liaphragm. relations of. as revealed by the
X ray 46^.
Diarrhoea, bolus treatment of 3y
chronic, accompanied by pyloric insuffi-
ciency, relieved by hydrochloric acid.. 94.)
Diarrhccas, winter, in infant feeding 499
Diastole, heart sounds heard early in 1124
Diet and hj'giene as therapeutic measures. 1219
ash free, experiments with g.so
milk free fluid, in typhoid fever \2$(i
of oatiiieal in diabetes 560
vegetarian, in i)Soriasis 416
Dietary, purin free 81
Dietetics, hospital 6.^
Dilatation, acute, of stomach, as a post-
operative complication 8-
Diphtheria antitoxinc refined and concen-
trated hy Gibson's method, results ob-
taitied from 1242
urticaria after administration of ii6.i
epidemiology of 910
gargle for 94S
nonspecific treatment of .S99
toxine. skin reaction after inoculation
with 660
treatment of 69;
value of stained smears in the diagnosis
"f 53 1
Page.
Disease, malignant, of testis 40
X ray treatment of 422
personal factor in 564
self limited, management of 1019
treatment of, by conversion 420
Diseases, acute infectious, clinical observa-
tions in 35
infectious, intravenous injections for.. 1045
infective, bile changes in 40
medical, influence of pregnancy on.... 1 121
vascular, of the extremities 11 25
Disinfection, limitations of 1256
of body cavities by nonpathogenic
bacteria 1211
Dislocation of shoulder joint, treatment of.1216
1 )ispensary patients, value of social worker
and visiting nurse to 143
Diverticula of sigmoid 70 j
diverticulum of cesophagus. radical opera-
tion for 182
of vermiform apiiendix 3t
Dorrance. George iL. and (iinsburg.
.Nate. Transfusion: History, devel-
o|iment, present status, and techni(iue
of operation 941
1 loirance. George Morris. Biliary tistula
u itii stone in hei atic duct 1404
Drainage, a prophylactic measure against
postoperative phlebitis 707
in acute middle ear suppuration,
evacuation and depletion of tympanic
cavity as aids to 80
Drcnnan, Jennie (j. The abstraction of
calcium salts from the mother's blood
by the fcetus a cause of dental disease
in the former 83a
The blood conservatism of neurotic in-
dividuals 593
Diessing, surgical, anthracite coal ash as. 560
Drugs and nihilism 281
Dubois reeducation method in hysteria.... 926
Dukeman, William 11. Hysterectomy of a
five month gravid uterus for carcinoma
uteri S3 1
Duncan, Harry A., and lUman, G. Morton.
The opsonic treatment of disease .... 1 228
Dunton. William Rush, Jr. Nervous and
mental manifestations incident to
school life 258
Duodenal ulcer 1121
Duodenum, acute perforating ulcer of 36S
injury of, by contusion 374
obstruction of, by root of mesentery.. 800
I )ysentery. ichthyol and resorcin mixture
fo"- 947
Dysmenorrhtea, su|i| ository for 600
Dyspepsia, asthenic, bitter tonic for, 552
flatulent, remedy for 1249
in tuberculous patier.ts. treatment of.. 71
treatment of 866
Dystocia, contracted pelvis a cause of.... 256
E.\R. middle, adenectomy during dis-
ease of 375
an instrument for inflating 693
chronic suppuration of, ossiculectomy
deafness 810". 990
infection, leucocyte examination in
suppurativ e conditions arising from 325
Rosennniller s foss;e in relation to 864
suppuration, gastrointestinal symptoms
?f ■•■ ■. 386
indications for surgical intervention
. 388
intracrarial complications of 810
evacuation and depletion of tym-
panic cavity as aids to drainage in 80
suppurations, significant features of.. 467
voice an index to diseases of 47
Earache, treatment of 1156
F-cIampsia, blood pressure observations in 958
decapsulation of kidney in 133
puerperal, treatment of. with nitro-
glycerin 1 166
treatment of 907
Eczema, erythematous, treatment of 4-,7
in infants and young children, treatment
of S30
seborrhoeic, of the face, Unna's powder
for 217
EDITORL\LS:
.•\ccidents, industrial, and dependency.. 121
.\denothyrcoid centre 949
.\crostatherapy 411
.Mbuminuria and the itch 459
.\Umini reunions in Chicago 1157
.\merican Medical .Association, forth-
coming meeting of 1000
Mcdicopsychological .Association 1097
Museum of Safety Devices, the estab-
lishment of 362
Society of Tropical Medicine 605
.\n.TSthesia, general, with sequestration
of a portion of circulation 2S8
JXDEX TO VOLUME LXXXI'Jl.
1275
Page.
iDITOKi.ti-s;
Anaijhylaxis and anaphylaxines 74
Anatomy and physiology in China 36.;
Army Medical Department, rank and nay
of officers of 745, 95 . 1^49
reserve corps 109.S
Association of American Physiciai s . . . . 951
Baby's bedclothes 3'4
Bacilli, tubercle, essential identity of.... 555
Beriberi, aetiology of 123
Birth marks, Mongolian 315
rate in New York, an improved 602
Books, craze for novelty in 83S
Bromoform, danger from 31
Bureau of Animal Industry 3*>5
annual report of 508
Calcium metabolism and the 1 arathy-
reoids 506
Cancer, clinical study of 72
of tongue in syphilitics 901, 950
present knowledge of 650, 1097
Catheter scale, a uniform 268
Chaille, Dr. Stanford E., jubilee of. .698, 1046
Charlatanry, philosophy of 409
Chloroform anaesthesia, studies of ,;o
Colles's fracture, palmar projection of
ulna after 1158
Colony, a New York State 460
Consumption among the poor, home
inanagement of 949
drie'd sputum in the spread of 651
in tenement houses 794
mercury in treatment of 998
Convict, justice to 1252
Cornil, the late Professor 840
Dermatology and general practice 312
and knighthood 952
Disgrace, a national ^ 265
Doctor's duty to the State 903
Emmanuel Church movement in Bos-
ton 1047
Eructation, provoked, as a remedial
measure ..120G
Eyes of school children 839
Fads, hyg.enic 410
Fermtnts. metallic, in therapeutics 266
Ferry boat, the passing of 461
Flies and mosquitcres 951
Food preservatives 122
Forests, preservation of 746
Freaks, circus and museum, pathology of 313
French medical meeting in Quebec 1251
Ciolitzyn Hospital in Moscow 696
Hair, falling of, in women 29
Henbane, spurious 30
Hepatoscopy, ancient 902
Hospital for the care of crippled and
deformed children J07
patient, diet of the 265
ships, command of 28. 21S
Hospitals, a phobia of 123
Humor, a puerile attempt at 508
Hygiene, instruction in, at West Point. 1098
Hysteria , 1159
Injuries and the previous condition 795
Iron in chlorosis 554
Koch. Robert, New York's tribute to.. 746
Laryngology, a new journal of 902
Libraries, great medical 901
Loco poisoning 364
Longevity, and the medical profession.. 219
Lymphocytosis, mechanical factors in.. 1046
Magnum. Dr 556
Malarial parasites, carriers of 696
Medical license, a novel view of 840
Medical Service of the Navy 1204
Medicine, American, the genesis of 312
education of the public in 1095
preventive, and the government 649
Meningitis, epidemic cerebrospinal, se-
rum treatment of 172
Mercury in the treatment of consump-
tion 998
Midwifery, minor 219
Milk and the public health 505
question in Chicago 171
supply of New York 1048
Mind that Found itself 600
Mycetoma, Ktiology of 839
Navy, medical service of 1204
Neurasthenics, the seaside for 950
Neurone doctrine, present status of 364
New England and the South shoulder to
shoulder 746
New York State colony, a new 460
Nursing, modern, the mother of 650
popular instruction in 1206
Ointment, white precipitate 411
Operating, novel source of light for 797
Operations, compulsory surgical 172
Ozsna derived from the dog 411
Paresis, general, bacteriology of 999
Pension, a well deserved 100:
Pericarditis, deep 902
Pharmacopoeial names, abbreviations of 26-
Philipriine I-l.inds. the health of 1205
Plague investigations in India 555
Oriental, prevention of 794
Pace,
Editorials;
Poisoning by anilines, condition of ^
blood in 123
Population, congestion of, in New York 507
Prosperity by suggestion 1000
Psychiatry as a part of preventive
medicine 1158
New opportunitv for 1204
Public Health and Marine Hospital Ser-
vice, annual report of 459
bills affecting 649
Public, our relations with 1096
Rabies 313
Red Cross, the Grand Legion of 553
work, charity organizations to join in. 12.19
Royal Society of Medicine 461
Sanitary science, a proposed school of.. 1206
Scarlet fever, points concerning 796
Sclerodermia, ocular symptoms of 747
Scotch journals, consolidation of 1251
Stuttering, melody cure for 267
.Subway, temperature of 461
.Suprarenal preparations in dermatologi-
cal diagnosis 362
Surgeons, two great, of Edinburgh 73
Syphilitics, cancer of the tongue in.. 901, 950
Tachycardia of tuberculous disease 602
Teaching, a valuable mode of 553
Tetanus antitoxine unit, the American. . 1048
Traumatism and tabes dorsalis 840
Trypanosomiasis in rats, experimental
treatment of 999
Tubercle bacilli, intracellular, in spu-
tum, significance of 747
bacillus and sunlight 171
Tuberculin, accidents of ocular reaction
to 220
Tuberculosis, the State Charities Aid
Association's work in the campaign
against 695
Tumors, malignant, transmissibilty and
heredity of 173
of mice, inoculable 220
spontaneous, in mice 173
Typhoid fever in military and industrial
aggregations 900
transmissibilitv of 410
Uncinariasis in Puerto Rico 460
Valvular lesions, experimental 697
V'ivisection in the State of New York. 29, 73
Voice sign, the epileptic 266
Yaws, ietiology of 603
papules, histology of 604
Eczema, seborrhoeic, of the scalp, lotions
for 899
use of adrenalin in 1156
vesiculosum, tannic acid in treatment of 458
Egbert, J. Hobart. Trachoma 548
Einhorn, Max. A new method of estimat-
ing the permeability of the pylorus
and an attempt at testing the pan -
creatic function directly ii79
Elbow, excision of, restoration of func-
tion after, in tuberculous cases 330
Electricity in treatment of cancer 470
static, therapeutical uses of 800
Electrolysis in treatment of angeiomata.. 612
Elevator, a new pliable submucous i26(y
Embolism, pulmonary 136
Emergencies of peace and war, society
for coping with 696
Emerson, Haven. Carious teeth in the
tenement population of New York
City 636
Therapeutic use of soured milk 245
Emmanuel Church movement in Boston,
810, 1047
Emphysema, aetiology, pathology, and
treatment of 908
alveolar pulmonary, surgical treatment
of 1005
treated by operative mobilization of
the thorax 39
following pleural puncture 375
pulmonary, surgical treatment of 39
Empyema, remarks on 614
Endocarditis, malignant, bacteria as inci-
tants of 35
Endometritis exfoliativa 1265
treatment of 656, 865
zinc chloride in treatment of 39
English, Japanned 717
Enteritis, acute, with appendicitis 869
Enterocolitis, mucomembranous, causes
and mechanism of 980
Enuresis following prostatectomy 369
Environment in relation to tuberculosis... 370
Epididymitis and orchitis complicating
typhoid .■ 655
erotica 133
treatment of, with hyperaemia 39
Epilepsies, pathogenesis of 912
Epilepsy, acute pulmonary, oedema a com-
plication of 54
idiopathic, due to germs I20>
so called idiopathic form of 1086
traumatic 184
treatment of 120
Epileptic seizure, heart's action preceding. 466
Page.
Epileptic voice sign 266
Epileptiform attacks in diabetes niellitus. . 1005
Epithelioma, aetiology of 319, 474
study of 427
treatment of 608
Epitheliomata, cystic, of ovary 420
Ergograph in testing fatigue in school
children 1221
Eructation, nervous, cure for 182
provoked, as a remedial measure 1206
Erythema annulare, treatment of 648
Erythraemia 275
Erythromelalgia, in relation to vascular
diseases of the extremities 1125
Etherization, postoperative complications
after 133
Ethics, applied, a problem in 618
Euonymus, laxative preparations of 1203
European surgical clinics, notes on 203
Eustachian tube, compressed air for dilat-
ing the 331
stricture of, due to adhesions in fossa
of Rosenmiiller 319
Exclusion, intestinal, as a surgical pro-
cedure 184
Expert evidence, psychiatric, in criminal
proceedings 431
Exudates, pleural, cholesterine in 661
E.xudative diathesis, Czerny's 183
Eye, dangers to, in ophthalmoreaction 83
diseases of conjunctiva and cornea of.. 1193
service of Fordham hospital, unusual
cases from 1189
syndrome of dementia praecox 907
Eyelids, lower, tongue and lower jaw, syn-
chronomous movements of in certain
diseases 37
Eyestrain and functional neuroses, corre-
lation of 1 119
FACE, hemispasm of, with motor trou-
bles of limbs 1008
Fads, hygienic 410
Fasces, significance of tubercule bacilli in. 85
Fscula. action of gastric and pancreatic
juices upon 131
Faradization in syncope from chloroform.. 38
Faringer, H, R. Riding astride by women 91
Farrington, Dr. Joseph Oakley, resolu-
tions on the death of 1224
Fatigue in school children tested by ergo-
graph 1 22 1
Favus II 82
Feeding of infants, lactacid milk in 642
important points in connection with..ioii
starch in loii
use of fat free milk in 607
winter diarrhoeas in 499
Feet and their treatment, orthopaedic
heresies on 864
paralytic club, arthrodesis and tendon
transfer in 473
Fermentations, abnormal digestive 408
Ferments, action of x rays on 910
metallic, in therapeutics 266
Ferments, mode of action of 228
Fever, acute glandular 613
paratyphoid 1121
puerperal 300
Fibromyomata uteri in ectopic gestation. . 1037
Files, Charles O. Pruritus ani 1154
Fischer. Louis. Gastrointestinal symp-
toms of middle ear suppuration 386
Fissure of anus, suppository for 948
palpebral, of both eyes, rhythmical
changes in width of 118
Fistula, biliary, between gallbladder and
stomach 404
Fistulas, treatment of 1260
Fitzgerald, R. S. Treatment of gallstone
colic 646
Flatulence, intestinal, treatment of 170
Fletcher, Frederick. Treatment of gall-
stone colic 597
Flexures or angulations of sigmoid and
colcJn 479
Flies and mosquitoes 95':
formaldehyde for the destruction of.. 1044
Flint, Austin, Jr. Hygiene and manage-
ment of pregnancy 1131
Fluor albus, pathogenesis of 324
Fluoroform for whooping cough 600
Food factor in diabetes 753
passage of, through pylorus 274
preservatives, sulphurous acid and the
sulphites as 122
Foot, Mendel-Becterew's reflex of dorsum
of 132
restoration of normal balance of,
875. 976. 1070
weak, the Whitman lirace for 1126
Fracture. Bennett, of metacarpal bone.... 465
Colles's, palmar projection of ulna
after 11 58
of carpal scaphoid 960
of femur in forcible delivery 134
treatment of i^e
1276
INDEX TO VOLUME LXXXVII.
Page.
Tracture of humerus, method of obtain-
ing extension for 127
of patella, treatment of 788, 833, 894
of thigh, results of Hodgen splint treat-
ment of, shown by x ray 134
of upper extremity of humerus compli-
cating dislocation of shoulder joint... 90
Fractures, complicated, treatment of 756
in vicinity of joints ion
new ideas on 754
of long bones 909, 962
of skull, operations for intracranial
complications of 1215
Franze, Paul C. How to estimate the
functional power of the heart 550
Freaks, circus and museum, pathology of. 313
Freeny, L. C. The management of typhoid
fever without a nurse 786
French speaking physicians of North
America 745
Freudenthal, Wolff. A plea for the sys-
tematic use of bronchoscopy in routine
work, with description of a modified
bronchoscope 984
Friedlander's bacillus a cause of pneu-
monia 1057
Friedman, G. A. Cammidge's reaction in
pancreatic disease 682
Fuller, Eugene. Gonorrhoeal rheumatism
cured by seminal vesiculotomy 1028
Function, bodily, relation of mental atti-
tude to 582
modern conception regarding chemical
regulation of 569
Furunculosis, treatment of 947
GAG and tongue depressor 22&
Galactorrhcea, treatment of 11 56
Gallant, A. Ernest. Treatment of vomit-
ing of pregnancy 25
Gallbladder, the pathological 326
surgery of 567
Gallstone, atresia of common duct due to. 327
colic, treatment of 594, 644
diagnosis of duodenal ulcer from 326
disease, ischochymia simulating 1259
surgical aspect of 444
in co.mmon duct, removal of 3J9
Gangrene of cornea, infantile 130
of scrotum after applications of iodine.. 183
of skin, idiopathic 1057
Gastrectasia and ptosis of pylorus,- x rays
in diagnosis of 1009
Gastric conditions in wasted infants 37
contents, distribution of hydrochloric
acid in 177
diseases, modern methods in the treat-
ment of 95
haemorrhage and ulcer 82
hyperasthenia, prescription for 634
neuroses 568
diagnosis and treatment of 276
secretion, method of ascertaining di-
gestive power of 1203
study of 372
surgery, present status of 187
ulcer, diagnosis and treatment of 568
early and late cases of 319
experimental 1056
medical treatment of 85
Gastritis, phlegmonous 35, 186, 1058
use of magnesia in 997
Gastroenterostomy 516, 1055
in cancer of the stomach 617, 628
physiological aspects of 274
relation of mesocolic band to 277
Gastrointestinal symptoms of middle ear
suppuration ' 386
Gastropathies, false, reeducation of 963
Gauze pack, inconsistencies of 186
Gelatin, saline solution of, for hypoder-
matic injections 216
Genital canal, rupture of 708
Genitourinary organs, tuberculosis of 37
Germs and epilepsy 1200
Gestation, ectopic 226
associated with fibromyomata uteri 1037
diagnosis and treatment of ' 609
tubal 418, i26>
Gibson's method of refining and concen-
trating diphtheria antitoxine 1242
Gilbride, John J., Gastroenterostomy in
cancer of the stomach 628
Gingivitis, treatment of the bromopnoea
due to 217
Ginsburg, Nate, and Dorrance, George M.
Transfusion: History, development,
present status, and technique of opera-
tion 941
Glanders, acute, in man 1004
Pirquct's method for diagnosis of 660
Glands, engorged lymphatic, liniment for.. 1156
Glaucoma in the young 31
Glycerophosphates, uses of 27
Glycolytic ferments, action of 564
Goitre, exophthalmic, and the sexual life.
132, 182
diagnosis and treatment of 559
Paok.
Goitre, pathology of 1125
removal of thyreoid gland in 564
• study of cases operated on by Dr. C.
H. Mayo 1125
Gold, therapy of 27
Goldan, S. Ormond. Neuralgia: Its spe-
cific treatment with chloroform sub-
cutaneously 1141
Goler, George W. Milk and education 207
(jonococci, a simple nutrient material for 965
Gonococcus in disease, the role of J78
Gonorrhoea, abscess of kidney after ii6g
acute, treatment of 279
complications in 182
curability of 43g
in the female, abortive treatment of 60
serum treatment in 1053
treatment of, with arhovin 1058
Gonzaga, Sister Louis, resolution adopted
on the death of 920
Gordon, Alfred. Pathogenesis of stump
hallucination 17
Gout accompanied with gastric disorders,
enema in 27
treated with hydrochloric acid 1045
Gouty joints, lotion for 792
Graef, Charles. Unusual cases from the
eye service of Fordham Hospital 1189
Graves's disease, medicinal treatment of.. 457
treatment of 613
obstruction of superior vena cava in.. 1222
Gregory, M. S. Present day limitations
of our conception of paranoia 11 36
Griffith, Frederic. A new method of
anatomy study 993
Griggs, William C. Treatment of seasick-
ness 1090
Guaiac blood test 11 68
Guaiacol and iodine injection for tuber-
culosis 310
Gunshot wounds 643
Gynaecology, hospital 1264
progress in, from a clinical viewpoint.. 527
recent advances in 663
teaching of 1264
IJAASE, Charles. Treatment of seasick-
ness 1091
Haemolysis of streptococci 1214
Haematoma and abscess, saeptal treatment
of 561
Haematuria in haemophiliacs, treatment of 361
in pregnancy 185
Haemoconia 82
Haemophiliacs, ha:maturia in 361
Haemoptysis, treatment of 552
Haemorrhage from pancreas, operation for. 757
gastric 82
internal, injection for 11 56
intestinal, in typhoid fever 27
into fatty capsule of the kidney 84
intraabdominal, due to tubal gestation. . 1261
post partum, tannin in treatment of 837
treatment of 164, 210, 260
renal, in nephritis 868
Haemorrhages, intestinal, in typhoid fever,
injections of gelatin and salt water in
treatment of 1169
uterine, influence of central nervous sys-
Hsmorrhoids, cautery clamp for 501
haemorrhage nine days after operation
for, complicated with sciatica 160
injection for pruritus iti 948
Haini, T.eon. The question of sour milk. .544
Hair, falling of, in women 29
loss of, following typhoid fever 948
pastes for the removal of 170
Hallucination, the physiopsychology of 133
stump, pathogenesis of 17
Hallux valgus with bunion, surgical treat-
ment of 330
Hand as a therapeutic agent 239
Hansen, Howard F. .\cute double miliary
tuberculosis of conjunctiva 500
Harrington's antiseptic solution. .329, 458, 552
Harris, Thomas J. The diagnostic value
of symptoms of the larynx, pharynx,
and nose, in nervous diseases 923
Harrogate salts, formula for 600
Haverstraw colony 811
Hawes, Alfred T. Treatment of post par-
tum haemorrhage 261
Hawkes, Forbes. Gallstone disease and
its surgical aspect 444
Hays, W. E. Diagnosis of alcoholic
stupor 406
Hays, Walter Ennis. Treatment of frac-
ture of patella 789
Treatment of gallstone colic 598
Head, cold in, treatment of 308
injuries to loio
Headaches, nasal, role of Meckel's gang-
lion in 989
neuralgic, application for 744
Heart, action of, preceding an epileptic
seizure 46'>
Page.
Heart, affections of, in acute rheumatism 512
and kidney, diagnosis and treatment of
diseases of 276
automatic rhythm of 130
block 803
condition of, after wheeling 660
diagnosis of diseases of 486
disease, new facts regarding 513
sudden death in 965
Karell's treatment of 1058
experimental lesions of 697
functional power of 550
gallop rhythm of 1058
in shock 1263
murmurs, multiplicity of 229
newer aspects of pathology of 518
overexertion of , 11 68
polycythaemia in diseases of loio
position of valves of 659
reduplication of first sound of 565
spontaneous rupture of 198
sounds in early diastole 1124
surgery of 187
ulcer on interventricular saeplum of 1124
use of drugs in diseases of 519
valvular disease of 708
Heat, artificial, and sun's rays, effects of.. 1259
recurrent syndrome due to exposure
to 957
Hemiplegia and unilateral optic atrophy .. 1257
Hepatoscopy, ancient 902
Hernia, congenital umbilical 707
femoral, the appendix in 474
inguinal, in children 1007
of iliac colon 611
umbilical and ventral 471
Herring, Arthur P. Psychotherapy in
treatment of functional neuroses 885
Herzig, Arthur J., Acute purulent otitis
media in infants and young children 502
The common conjunctival and corneal
diseases 1193
Sarcoma of the chorioid 674
Hibbs, Russell A. An original method of
operating for congenital dislocation of
the hip 767
Hiccough, obstinate, prescription for 837
treatment of 1045
Hip, arthritis deformans of 1210
congenital dislocation of. an original
method of operating for 767
joint disease, ambulatory treatment of.. 319
painless affections of 1167
Hirshberg, I^eonard K. Cholera infantum. 1 igi
Hodgen splint treatment of fractures of
thigh, results of, shown by x ray 134
Hoffman. William E. The inspection and
chemical examination of the Balti-
more milk supply 69
Holmes, E. Burville. Chronic fibrinous
bronchitis 780
Value of stained smears in the diagnosis
of diphtheria 534
Hookworm disease soil pollution in 759
Hopp, George A. Treatment of fracture
of patella 897
Hospital dietetics 65
interneship, scientific and practical value
of 906
patient, diet of the 265
ships, command of, by medical officers. 2 18. 281
wards, hygiene of medical cases in 805
Hospitals, neurological 91
phobia of 123
Huber, John B. The kidney in acute in-
fections 1030
Huber, Francis. Bothriocephalus latus 1190
Humerus, removal of 329
Hutton, Paul C. Treatment of fracture of
the patella 790
Hydatid diseases, precipitins in 1056
Hydrastis and its alkaloids, effects on
blood pressure of 79
Hydrobilirubin. extraintestinal origin of.. 1004
Hydrocele and thrombosis in inguinal
canal 184
Hydrops of pregnancy, withdrawal of com-
mon salt in 230
Hygiene and diet as therapeutic measures. 1219
and physiology, instruction in 311
new school of 12 11
instruction in, at West Point 1098
Hyiison, Lawrence M. Treatment of gall-
stone colic 646
Hyperaimia. Bier's, in tuberculosis of
hones and joints 374
in inflammation 374
treatment of epididymitis and buboes.. 39
Hypcridrosis, plantar, picric acid (or 27
Hypernephroma 1221
Hyperphonia, treatment of 609
Hypertrophy and organ correlation 565
prostatic 52:;
palliative treatment of 731, 916
Hypothyreoidea 11 17
Hyskell, W. Emory. Treatment of gall-
stone colic 596
IXDEX TO VOLUME LXXXVII.
1277
Hysterectomy
noma . . .
preservation
Pag-.
gravid uterus for carci-
831
ovaries in i ^ f'
total abdominal 322
Hvsteria "59
and the reeducation method of Dubois 926
nature and relationships of 661
genesis and nature of 559
in children 47i
in relation to 1214
Idiocy, amurotic family 276
simulation of 9^3
Igel, Richard L., Jr. Treatment of frac-
ture of patella 898
Iliac colon, hernia of 6"
lUman, G. Morton, and Duncan, Harry
A. The opsonic treatment of dis
ease
Immunity, natural, of living tissue
806
607
56
655
37
228
, „ 757
specific, and x ray therapeutics 614
to disease 6i4
Immunization by mouth 470
Indican reaction as evidence of entero-
genous intoxication
Indicanuria: aetiology, diagnosis, patho-
geny, and treatment 49
Indolaceturia 121
Infant feeding, important pomts in con-
nection with lot
lactacid milk in ' 64
standard of proteid in 18
starch in
use of fat free milk m
life, concerning the first week of.
mortality in summer
Infants, wasted, gastric conditions li
Infection, extragenital 231
modes of, in tuberculosis 120Q
with trypanosoma of equine syphilis, or-
ganic reactions in 11 67
Infections, acute, the kidney in 1030
air borne 1006
alimentary, and paratyphus 373
in childhood, prevalence of 892
Ivmphatic and portal, following appen-
dicitis - 522
of biliary passages, diagnosis and treat-
ment of 276
streptococcus, serum treatment of.. 1058
Infectious diseases, intravenous injections
in 104s
Inflammation, blood reactions of 41
suboccipital 229
Influenza bacilli in the bronchi 5I7
of nose, throat, and larynx 128
cerebral 1257
Injuries and the previous condition 795
Inoculation, antityphoid, in British Army. 1259
Insane, after care of 383
care of 623
development of modem care and treat-
ment of 1012
what we have not done for 623
women, pelvic disease in 1265
Insanity, potassium iodide in 19
Insomnia 419
Inspection of schools, medical, with
trained nurses 637
Insufficiency, pancreatic, diagnosis of 869
pyloric. Dr. Palier's article on 1062
with diarrhoea 946
traumatic, of aorta 911
Intertrigo, lotions for 170
Intestinal antiseptic for children 948
exclusion, value of, as a surgical pro-
cedure 184
obstruction 522
toxsmias, psychic phenomena of. and
their treatment 826
tuberculosis, enema in 1044
Intestine, high occlusion of 373
Intoxication, acid 755
alcoholic, draught for 600
alimentary 702
enterogenous, indican reaction as evi-
dence of 806
Intussusception 85, 611. 701, 753, 1075
Involution of appendix, harmful 187
lodates, antiseptic value of 216
Iodine and guaiacol injection for tuber-
culosis 310
application of. in the dark 311
formic acid solution in phthisis 264
in the treatment of ulcers 115?
Iodoform, fluid, medicinal uses of 311
Iritis, rational treatment of 353. 701
rheumatic 962
Iron, comparative therapeutical value of
the compounds of 687, 1170
in chlorosis SS4
stains on the teeth, application for 311
Isochymia simulating gallstone disease 1259
Itch and albuminuria, connection be-
tween 459
JACOBV, George W. A colony sana-
torium for the nervous and neuras-
thenic; a much needed work for phil-
anthropy
Psychiatric expert evidence in criminal
proceedings — its imperfection and rem-
edy
Japanned English
Jaundice caused by cancer of pancreas. . . .
haeraolytic, functions of spleen and liver
in relation to -.1
Jaw, lower, tongue, and lower eyelids,
synchronous movements of
Jejunum, peptic ulcer of
Telliffe, Smith Ely. Hysteria and the re-
education method of Dubois
Jennings. Walter B. Delayed labor
Joints, gouty, lotion for
transplantation of i
Tones. Glenn I. Treatment of post partum
haemorrhage
Jones, St. Clair. Treatment of post partum
haemorrhage 168. 1
Jungle plant, notes on 1
KALA AZAR. sporadic... 121:?
Kallak, description of 415
Karell's treatment of cardiac disease .... 105S
of obesity 1122
Karpas, Morris J. General paralysis in
the senile period I57
Karpeles, M. J. Multiple conceptions 1089
Kaufman, Albert. Treatment of sun-
stroke 1247
Keating. Emmet. The early diagnosis of
pulmonary tuberculosis 528
Kensett, W. T. The jungle plant 1205
Keppler. Carl R. The treatment of infan-
tile paralysis 11 Sri
Keratitis, neuropathic, bacteriology of 227
Kidney, abscess of, after gonorrhoea 1 169
decapsulation of, in eclampsia 133
haemorrhage into fatty capsule of 84
in acute infections 1030
lesions in infants 12 iS
movable 40
rupture of 277
106. 1012
solitary 962
tuberculosis of, treated with x rays 182
Kidneys, action of purgatin on 121S
liver m disease of 659
transplantation of 565
Kinch, Charles A. Teaching of derma-
tology in medical schools 309
Kirby. Frank B. Treatment of gallstone
colic 594
Kiylin, C. F. Varicose veins 103
Klingmann. Theophil. Spontaneous rup-
ture of the heart 198
Klotz, J. E. A catechism for physicians. 714
Diseases ot the breathing apparatus.... 300
Knapp, Mark I. About Dr. Palier's arti-
cle on plyoric insufficiency 1062
Knee joint injuries 179
relaxed 135, 1059
suppurative inflammation of 329
Knopf. S. .-\doIphus. The aetiology, pro-
phylaxis, and treatment of the social
ill 819
Knot, surgical, art of tying 1165
Koch. Dr. Robert, a dinner to 748
Xew York's tribute to 746
KoUe-W'assermann's meningococcus serum
in meningitis 229
Konkle. W. B. The management of self
limited disease 1019
Korshet. Morris. Malnutrition 985
Kraske's operation, technique of 181
Kummerf eld's lotion for acne 119
LABOR and abortion, febrile conditions
after
delayed
premature, induction of i
Laboratories, county, and their uses
Laboratory, clinical, of general practi-
tioner
Lactacid milk in infant feeding
Lameness, intermittent t
Landry's paralysis, recovery in
Language, medical
German comment on Dr. Rose's ideas
of
La Pierre, L. F. A case of sarcoma of
the kidney
Laryngology, a new journal of
Laryngostomy
Larynx, foreign bodies in
knife and silver nitrate carrier
value of symptoms of
Lathrop. Walter. Treatment of fracture of
patella
Laxative preparations of euonymus 1
Le Breton. Prescott. Ansesthesia bv ni-
P.^GE.
trous oxide, nitrous oxide and oxygen,
nitrous oxide and ether, chloroform
and oxygen, and ether administered
per rectum 196
Lemonade, lactic, for arteriosclerosis.... 997
Leprosy in the Far East 893
treatment of 803
Le Roy, Bernard. The aetiology of psori-
asis 785
Colorimetric analyses of saliva 448
Le Roy, Bernard R. Idiopathic epilepsy
with associated paralysis 1200
LETTERS TO THE EDITORS:
Applied ethics, a problem in 618
Bates, W. M. Metchniko£f soured milk 330
Bierhotf, Frederic. The word "palli-
ative" 1062
Bristow, A. T. An impostor S71
Brown, Herbert S. The Haverstraw
colony 811
Brvant, Joseph D., and Curtis. John G.,
Vivisection in the State of New York 188
Carling, John. The Whitman brace 1126
Colgan, J. F. EL Ancient phthisio-
therapy 9^6
Dana, Charles L. Melancholia 234
Faringer, H. R. Riding astride by
women 91
Kensett, W. T. The Jungle plant .... 1 265
Klotz, J. E. A catechism for physi-
Knapp, Mark I. About Dr. Palier's
article on pyloric insufficiency lof^j
Mettler, L. Harrison. Practical and
scientific neurology 90
Mills, Charles K. Neurological hos-
pitals 91
Packard, Horace. Recoverv from can-
cer 232
Piffard, Henry G. Microorganisms or
artifacts? 872
Porcher, W. Peyre. Compressed air for
dilating tne Eustachian tube 331
Rose, A. Malaria in Greece 966
The palliative treatment of prostatic
hypertrophy 916
Smith, A. C. The aetiology of beriberi 281
Spear, Edmund D. Acute poliomyelitis 281
Taylor, J. Madison. Manual thera-
peutics 66s
Leuchasmia, acute lymphatic, spirochaeta in 9
treatment of. by the x ray 864
Leucocyte examination in suppurative con-
ditions arising from middle ear infec-
tion 325
Leucocytes, bactericide and haemolytic effi-
ciency of material in 660
Leucorrhcea, douche for 170
Libraries, great medical 901
medical, for small centres 810
Lice and relapsing fever 36
Lickly. Iva M. Treatment of post partum
haemorrhage 212
Lids and orbital tissue, repair of 735
Life, first week of 56
insurance, medical aspects of 371
Ligament, sensitive short uterosacral,
treatment of 185
Ligaments, round, intramural transplanta-
tion of 866
silk, use of. in infantile paralysis 1163
Ligatures and sutures, buried 525
Light, arc, in treatment of skin diseases.. 869
Lightburn, Richard. Treatment of gall-
stone colic 644
Lilienthal. Howard. Suprapubic prosta-
tectom.y in two stages 1134
Lipogenin in ophthalmology 1169
Lister's formula for chromic catgut 458
Liver and gallbladder, surgery of 567
and spleen in relation to haemolytic ic-
terus 1214
atrophy of 1169
cirrhosis of 422
congenital cystic 568
fatty metamorphosis of 183
floating, and aortic regurgitation 400
in disease of kidneys 659
malarial cirrhosis of 11 67
nonparasitic cysts of 568
stimulant, antimony a 600
tropical, abscess of 275
Localization, tactile, and symbolia 324
Locomotor ataxia, diagnosis and treatment
of 130
laryngeal manifestations in 1210
relation of syphilis to 180
Lodge and society practice in New York 754
Lofton, Lucien. Dislocation of the neck,
with recovery 736
Longenecker, G. W. Treatment of sun-
stroke ■24&
Longevity and the medical profession 219
of physicians 232
127?^
INDEX TO VOLUME LXXXVIl.
Loomis, Ur. Uemy 1'., report ut tlic
committee on the death of 914
resolutions on the death of 14". 333
Ludwig's angina 5^6
Luke the physician 285
Lumiere's color photography 661
Lungs and pleura, abdominal posture in
operations on 1054
polycythemia in diseases of loio
Lupus patients, homes for 805
Lymph, bactericide and haemolytic effi-
ciency of material in 660
Lymphangeioplasty
Lymphatic glands, engorged, hniment for. 11 56
Lymphocytosis, mechanical factors in 1046
Lymphosarcoma, spirochaeta in 9
Lynch, Jerome M. Intussusception of the
sigmoid lO/S
Lyons. H. Tucker. Treatment of vomit-
ing of pregnancy 26
Lysol poisoning, treatment of 324
McBURNEY'S point, clinical signifi-
cance of 108
McCarthy. D. J., and Meyers, Milton K.
Carcinomatosis of the meninges 191
McCaskey, G. \V. Internal medicine 250
McCormick, William S. Treatment of
gallstone colic 646
McCullagh, Samuel. The modified blood
clot in mastoid surgery 1144
Mcintosh. W. ['. Treatment of post
parlum lucmorrhage 165
MacKee. (ic-urge M. IncUcanuria : etiol-
ogy, diagnosis, pathogeny, and treat-
ment 491
Mackay, Malcolm. The clinical laboratory
of the general practitioner 639
MacMurrough. F. K. Chlorosis cured
by thryeoid e.Ntract 787
Magnesia in gastric affections 997
Magruder, E. P. Aortic regurgitation and
floating liver 400
Makuen, G. Hudson. The voice an index
to diseases of the throat, nose, and
ear 47
Malachite green in culture media for
typhoid "69
Malaria, comatose, pernicious 1164
in Greece 680, 966
parasite; how it perpetuates its ex-
istence 801
parasites, carriers of 696
pernicious 671
prophylaxis of 760
Malignant degeneration of warts and
moles • 800
disease of skin 427
X ray treatment of 422
Malnutrition 985
Malta fever in Naples 1123
Mania, symptoms and setiology of 325
Manual therapeutics 665
therapy 239
Marmorek's serum in surgical tuber-
culosis 1009
Marple, Wilbur B. Extraction of cataract
in the capsule 1034
Marriage arid intermarriage of the tuber-
culous 1255
Mason, R. D. Pruritus ani 1151
Massage 239
Mastoid surgery, modified blood clot in... 1 144
Masturbation and its consequences.. 1250
Mastnrbators. gastric disturbance in 805
Measles, serum reaction in loio
treatment of 9^3
Meckel's ganglion in nasal headaches 989
Medical Bureau of Publicity, wanted 615
cases, hygiene of 805
centre of the world 1176
education considered from the stand-
point of the student 80
language 9^9
(ierman, comment on Dr. Rose's ideas
of 1017
libraries for small centres 810
profession, an appeal to 920
incongruities in 944
duty of, to children 93°
.Medicine and dentistry, common ground
of S13
art and science in the practice of 343
in Alaska 1052
internal 25°
practice of, in a Mexican mining camp 127
preventive, and the government 649
psychiatry a part of 1158
scientific, some of the triumphs of, in
peace and war in foreign lands 335
tropical, Puerto Rico a field for re-
search in 759
review of the year's progress in.
758, 815, 1236
Mcdicinci. glass for ndmin.mration of 661
>Ic1.Tna nfonatnrum 1 1 18
Melancholia 234
with (lcltisi'jn« of negation I0S9
Pagk
.Melody cure for stuttering 267
Mendei-Becterew's reflex of dorsum of
foot 132
.Meninges, carcinomatosis of 191
-Meningitis, cerebrospinal, meningococcus
serum in 229
serum treatment of 46S
epidemic cerebrospinal 84
serum treatment of 172. 607
meningococcus cerebrospinal, distinctive
diagnosis of 1 1 ig
.\lL-ntal attitude, relation of to bodily
function 582
diseases, potassium iodide in ig
disorders incident to school life, pre-
vention of Ill
manifestations incident to school life 25S
Mercury in syphilis, specific action of 1074
in the treatment of consumption. .998, 1236
Merrill. G. V . R. Typhoid fever and
tetanu- 21
.Mcsocolic band, relation of, to gastro-
enterostomy 277
.Metabolism, perverted, a cause of tox-
aemia 1059
.Metaplasia of appendi.x vcrmiforniis 1060
■Metatyphus 1122
.MetchnikofF soured milk 330
.VIetchnikofif's mercurial inunction 1045
.Metritis, treatment of. by Bier's method.. 8.?
.Mettler. L. Harrison. Art and science
as applied to the practice of medi-
cine 343
I'ractical and scientific neurology 90
Meyers, Milton K.. and .M cCarthy,' D. J.
Carcinomatosis of the meninges igi
-Mexican mining iiractice for the tuber-
• culous 129
Michaelis, L. M. Occipitoposterior ]io-
sitions 591
Microorganisms or artifacts? 8-i
Midwifery, minor 219
Migraine 419
treatment of the eyes in 1082
Milk and education 207
and the public health 505
cow's, conditions affecting the propor-
tions of fat and proteins in 1021
fat free, in infant feeding 607
ferruginous cow's, feeding with 83
free fluid diet in typhoid fever 1256
lactacid, in infant feeding 642
Metchnikof? soured 330
production, a method of 370
question in Chicago 171
sickness, cause of 1052
sour, the question of 544
soured, therapeutic use of 245
-terilized, as a food for infants 243
supply of BaTtimore, inspection and
chemical examination of 69
of New York 1048
to increase the How of 361
.Milks, sour, a studv of i
•\M>'<y "••''>■ ' 237
.Miller, lames .Mcxander. The Associa-
tion of Tuberculosis Clinics of the
City of Nc-u' ^■ork 937
Mills, Charles K. Neurological hospitals. 91
Millwheel, the 1176
Mineral waters. American 560
Mistletoe, medicinal uses of 169
therapeutic uses of 1123
Mistura ferri acida, formula for 648
aperlens 694
Moles and warts, malignant degenera-
tion of 800
Moore, J. Lytle. Treatment of post
partum haemorrhage 213
Mosquitoes and flies, formaldehyde for the
destruction of 1044
Morgenstern. Adolph. Treatment of post
partum haemorrhage Z15
Moro, Ernst. The tuberculin inunction... 1233
.Moro's test, diagnostic value of 1220
Morphine addiction, treatment of 793
Morse, John Lovett. The management
and treatment of tuberculosis in in-
fants and children 350
Mosquito extermination 760
relation to disease and extermination of 808
.Mosquitoes and flies 951
Mouth wash, antiseptic 408
Mumps, metastatic affection of pancreas in 472
Murray, Dwight IT. Cautery clamp for
haemorrhoids 501
Secondary haemorrhage nine days after
hacmorrhoidal operation. Sciatica
complications 160
Muscle and tendon transference in infan-
tile paralysis 11 63
clot, destruction of 707
Muscles, alroiihy of, of Aran-Duchenne
type io.<;6
cephalic, apraxia of 1057
.Musliroiini poisoning, treatment of 1156
Page.
Mycetoma, aetiology of
.Myeloma, multiple, histology of 958
Myoma of uterus 1057
Myxoedema 374, 1258
incomplete 1117
TRAILS, pigmentation of, in syphilis 133
■•■^ Narcosis by suggestion 1057
Xasal headaches, role of Meckel's eaii^lion
in 989
Navy, medical corps of, how to enter 1223
medical service of 1204
Neck, dislocation of, with recovery 736
gymnastics of 228
Nephritis, acute syphilitic 1240
experimental, lesions of 956
parenchymatous, renal decapsulation for 137
renal haemorrhage in 868
symptomatology and. diagnosis of 537
Nephrocystitis. unilateral tubercoulous.
diagnosis of 13
Nephropexy, new operation for 180
Nepper. H. Mucomembranous enteroco-
litis, its causes and mechanism 980
Nerve bridging 656
lesions, trophic, treatment of "465
optic, changes in, significance of 127
right ulnar, traumatic luxation r.f 612
Nervous and mental mainfi^tatini!, inci-
dent to school life 258
colony sanatorium for the 719
diseases, diagnostic value symptom- of
the larynx, jiharynx. and nose in gj3
functional, relation of accidents to 129
treatment of 420
prophylaxis of 1121
psychic treatment of, from a practi-
cal standpoint 115
disorders incident to school life, pre-
vention of Ill
manifestations of arteriosclerosis 42!
system, central, influence of, in uterine
hsmorrha.sjes 421
relation of syphilis to diseases of iSo
tuberculosis of igi
Neue Wege 103S
Neuralgia, facial, Schlosser's alcohol in-
jections for 178
treatment of, by local alcoholization 1167
intercostal, application for 744
of rectum 1S2
specific treatment of 1141
Neurasthenia in relation to pelvic symp-
toms in women 422
in the young 421
mental origin of 1 2g
Neurasthenic, colony sanatorium for 719
Neurasthenics, the seaside for 950
Neurites in cirrhosis of liver.... 276
Neurology, practical and scientific 90
Neurone doctrine, present status of 364
Neuroses, functional, and eyestrain, cor-
relation of 1119
psychotherapy in treatment of 885
gastric 568
diagnosis and treatment of 276
.Neurotic individuals, blood conservatism
of 593
NEW INVENTIONS:
Ballin. Milton J. A larynx knife and
silver nitrate " carrier. . .'. 965
Blackwell. Hugh Burke. A new pliable
submucous elevator 1266
Newly born, bronchointestinal autoinfec-
tion in 613
intracranial extravasations of blood in 757
Newniaver. S. W. Defective vision and
the' mentally subnormal child SSo
.\ practical system of medical inspec-
tion of schools with trained nurses.. 637
Nightingale, Miss Florence, the mother of
modern nursing 650
Nihilism and drugs 281
Nitrogen metabolism 957
Nitroglycerin in puerperal eclampsia 1166
Noma, a bacteriological study of 200
Nose, abnormities of, as.sociated with
tuberculosis 13'
accessory sinuses of .'"s
interesting case of foreign body in 8s
red, treatment of • 836
value of symptoms of. in nervous dis-
eases 923
voice, an index to diseases of 47
Nuclei caudati, gummatous disease of 660
Nutmeg poisoning 599
Nutt. John Joseph. Orthopaedic therapy
during early stages of anterior polio-
myelitis 400
O'RETI-LY. B. R. Treatment of sea-
sickness 1041
O'Sullivan, J. J. Diagnosis of alcoholic
stupor 4."!'
Oatmeal diet in diabetes 560
( 'bcrndorfer. Dr. Isidor Pierce, resolu-
tions on the death of 333
JXDEX TO VOLUME LXXXl'lI.
1279
OBIITAKV:
Appleton. Mr. Daniel Sidney. of
London 556
Crook, Tames King. M. D., of Xew
York ■ 797
Esmarch, Friedrich von, M. 1)., 01 Kitl.
Germany 4'-
Heineman. Henrv Newton, M. I)., of
I'aris 315
Iloffa, .\lbert, M. P.. of Berlin, ( .er-
many 76
Roosa, Daniel B. St. John, M. D.,
LL. D.. of New York 508
Senn, Nicholas, M, D., of Chicago 75
Steele. John Dutt-n. M. D., of Phila-
delphia lOOI
Stratford. William. .M. D.. of Ncnv ^ ork.
Taylor, Robert Wiiliam, M. D.. of
New Y'ork 75
Voit, Car! von, M. D.. of .Munich.
Germany 268
Wyman. Hal C. M. D. of Detroit.... 508
Obesity, Karell's treatment of 1122
simple and complicated 869
Obstetrics, operative tendencies in 441
practical application of recent knowl-
edge of 663
recent advances in 662. 707
Obstruction. upper respiratory, relation
of. to oral deformity 477
t)ccipitoposterior positions 59 1
( )ccipui: and atlas, inflammation of articu-
lation between 182
Qiderra, acute pulmonary, as a complica-
tion of epileptic seizures 54
alcoholic cerebral i54
(Esophagoscopy ^''^
diagnostic and therapeutic value of 470
experiences in the field of 11 73
CEsophagus. squamous celled carcinomata
of 289
surgery of lower segment of 805
< )intment, glyceroboric 600
white precipitate 4"
Ointments, absorption of 1166
cocaine in 360
Omentum, intraabdominal torsion of 86
torsion of 521
( )noniatology. medical 381
Operations, compulsory surgical 172
novel source of light for 797
preparatory and postoperative treat-
ment of 474
vaginal methods of 374
Ophthalmia neonatorum 472, 1007
sympathetic 11 22
Ophthalmoreaction in tuberculosis 324
to tuberculin 83, 121 1
dangers to eye in 83
Ophthalmotuberculin reaction ; a warning. . 1220
Opotherapy, hypophyseal (147
Oppenheimer. L. .S. Some incongruities
in the medical profession 944
Opsonic inde.x, accuracy of method of
obtaining 1217
in infants 121 7
in treatment of tuberculosis 587. 1217
of blood, accuracy of method of de-
termining 12 1 7
practical value of 1009
statistical considerations relative to 121 7
value of, in controlling use of vac-
cines 4-'4
in orthopa;dic surgery uS
method, surgical view of 1217
treatment, A. E. Wright's method of.. 423
of disease 1228
Opsonins as • a means of distinction and
identification of pathogenic forms of
bacteria 612
practical importance of 910
theoretical considerations and experi-
mental work relative to 956. 1227
< )ptic atrophy, unilateral, and hemiplegia, . 1 257
thalamus, >vndromc produced bv a
lesion of : 323
Optometry, the bill relating to 380
Orchitis a complication of typhoid 635
local applications for 552
unique case of 162
Organotherapy 121 9
Orthodiagraphy, history and technique of 870
( Ossiculectomy in chronic middle ear sup-
puration 35
Ossification penis, partial 83
I )3teomalaci.n. .^ntithyreoidin in 1261
Osteomyelitis 1077
Osteopsathyrosis, idiopathic 1168
Ostheimer, Maurice. Prevalence of infec-
tions in childhood 892
Otitis, external, in a telephone operator.. 22c,
media, acute purulent 502
boric acid instillation in treatment of. 120
purulent, indications for surgical in-
tervention in .iSS
Otto, G. Walther. Treatment of fracture
of patella 898
Ovaries and tubes, conservative surgerv
of 416
P.\GE.
Ovaries and tubes, preservation of. in
hy ste rectomy 1 2 1 6
Ovary, cancer of 180
cystic epitheliomata of 420
Oxidation of sugar 1122
Oxygen in surgery 808
Oxvuris vermicularis, appendicitis due to
the presence of 36
Ozaena derived from the dog 411
PALIER, E. Chronic diarrhoea accom-
panied by pyloric insufficiency re-
lieved by hydrochloric acid 946
Palmerlee, G. H. Treatment of fracture
of patella S34
Palpitation, nervous, sedative for 457
Pancreas, cancer of. causing jaundice 231
cyst of 185
diseases of 566, 11 19
Cammidge reaction in 682
function of. an attempt at testing .179
haemorrhage from, operation for 757
Pancreatitis, acute 1221
clinical features of 1221
Pancreon 230
Parabiosis 374
Paraffin imbedding. ra|)id 829
injection of. into subcutaneous tissues.. 373
Paralysis, general, a menace to public
safety in transportation 318
in the senile period 157
infantile 47'
treatment of 1 186
use of silk ligaments in 1162
Landry's 420
specific precipitate reaction in 324
spinal infantile tii7
Paranoia, present day limitations of our
conception of 1136
Parasites, malarial, carriers of 696
Parasitology, an annual of 652
Parathyreoid glands, relation 01. to calcium
metabolism joO, 957
Paratyphic bacilli 373
Paratyphoid diseases, diagnosis of 373
fever 1121
Paratyphus and alimentary infections 373
fever, relation of bile ducts to 323
Paresis, general, bacteriology of 999
ocular rotations in 752
Parturition, perinephritic abscc-.- following 87
Patella, fracture of, treatment of 788, 894
Peck, Charles H, Cholelithi.iMs 148
Pedersen, Victor C. Vivisection from a
student's standpoint 675
Pediculosis, treatment of 64S
Pelton, Henry H. Treatment of -'cold in
the head" 308
The ophthalmic reaction in diagnosis of
tuberculous condition^ 1231
Pelvic disease in insane women i2t,-~
significance of pain in 80-
sigmoidal factor in 971
Pelvis, contracted, a cause of dystocia 256
Pendulum machine in treatment of infan-
tile paralysis i iSd
Penis, partial ossification of 83
Pennington. J. Rawson. Tlie signioidal
factor in pelvis diseases 971
Penrose. Clement A. Psychic treatment
of nervous diseases from a practical
standpoint 115
Pericarditis 902. 112:
Pericardium, surgery of 187
synechia; of 1 1 22
Peritonitis, appendicular. pathological
changes in 425
diffuse, in women 426
purulent, operative treatment of 910
postoperative complications of 87
primary pneumococcic 909
suppurative, treatment of 136. 656
Perityphlitis, treatment of 1122
Perspiration of hands, permanent cure of,. 132
Peterson, Frederick. The after care of the
insane 383
What we ha\e not done fur the- infant.. 6.'.;
Pettey. George E. Chronic alcoholism 632
Phalanges, terminal changes in, in cyanosis 38
Pharyngitis, gargle for 694
Pharynx, suppuration in region of 40
value of symptoms of 923
Philippine Islands, the health of 1205
Phlebitis, postoperative, drainage a prophy-
lactic measure against 707
Phlegmon of sheath of a tendon 1008
Phosphaturia and treatment of disease by
conver-ion 420
Photography, Lumiere's color 661
Phthisiolherapy, ancient 916
a retrospect in 738
Phthisis, acquired dextrocardia with 236
in outdoor and indoor life 370
iodoformic acid in treatment of 264. 272
manual labor in 321
pulmonary, treated by operative mobiliz-
ation of the thorax 39
Physicians, a catechism for 714
diseases of 232
great, of the past, diseases of 232
Physicians in politics 833
longevity of 232
relations to the public of 1096
Physiology and hygiene, instruction in, in
the public schools 8t i
Piffard, Henry G. Microorganisms or ar-
■ tifacts? S72
The specific action of mercury in syphilis. 107 ^
A study of sour milks ' 1
Pingree, H. A., and Abbott, E, G, The
restoration of the normal balance of
the foot 875. 976, 1070
Pirquet's method for diagnosis of glanders 660
reaction, value of, in childhood 757
test, value of 1220
Placenta praevia, dangers and treatment of 38
frequency, mortality, and treatment of 79
treatment of 907, 612
premature separation of 501, 1201
Plague among rats in San Francisco". 732
cats as preventers of 1212
I"^'? ■ 517. 555, 794
serum therapy of 1212
vaccination against 760
Plaster of Paris bar or rope 906
Pleasants, J. Hall. Prevention of nervous
disorders incident to school life 11 1
Pleura and lungs, abdominal posture in
operations on 1054
Pleural reflexes 1221
Pleuritis. exudative, symptomatology of. . . 374
Plummer's pill 60 1
Pneumohydrothorax 470
Pneumonia, acute lobar 360, 702
catarrhal, inhalation for 600
caused by Friedlander's bacillus 1057
external use of guaiacol in 310
treatment of, by outdoor air 276
Pneumothorax and posture 1054
artificial, in tuberculosis, bronchiectasis,
and aspiration diseases 84
Poison, cobra, relation of, to red blood
. cells 612
Poisoning by anilines, condition of blood
by benzoi vapor '39
chloroform 659
, delayed 563, 804
loco 364
lysol, treatment of 324
meat, Widal's reaction in 374
mushroom, treatment of 1156
nitrite, following large doses of bismuth
subnitrate 899
nutmeg jgg
with tansy 686
Polak. John Osborne. Contracted pelvis
as a cause of dystocia 256
Polioencephalitis superior 369
Poliomyelitis, acute 281, 469
epidemiology of ,058
anterior as an epidemic disease 42
orthopaedic therapy during 400
Polycythaemia 470
chronic gg^
in diseases of heart and lungs loio
Polymyositis, subacute, pathology of 177
Polyp, congenital hairv pharyngeal 1215
Population, congestion of, in New York,. 507
Porcher, W. Peyre. Compressed air for
dilating the Eustachian tube 331
Porter, William Henry. Diagnosis of dis-
eases of the heart 486
Positions, occipitoposterior 591
Postoperative complications §7
Posture, abdominal, importance of, in
operations on pleura and lungs 1054
Potassium iodide in mental diseases 19
Pottenger, F. M. The advantages of sana-
torium regime in tuberculosis 49
Practitioner, general, clinical laboratory of 639
Precipitins in hydatid disease 1056
Pregnancies, morbid, hospital treatment of 226
Pregnancy an aetiological factor in dental
disease 368
complicated bv diabetes mellitus 1169
by fibroid tumors of ii;. ru> Sg
diagnosis of 707
extrauterine and intrauterine 136, 522
hematuria in 185
hydrops of, withdrawal of common salt
in 230
hygiene and management of 1131
influence of, on certain diseases 1121
in relation to disease 1055, 1096
in uterus bicornis 505
pernicious ansmia uf 1264
surgical treatment of conditions in-
fluenced by S12
toxaemia of. rtlation of anaphylaxis to. 1222
tubal twin 34
value of ocular examinations in 616
Prescribing and dispensing, faulty, physi-
sician and pharmacist fined for .... 45
Pressures, sphygmomanometric 369
Priest, Howard. Treatment of gallstone
colic S98
i28o
I.XDliX TO VOLUME LXXXVIl.
Pace.
Proescher, F., and White, William Charles.
The presence of spirochasta in pseudo-
leuc:emia, acute lymphatic leucaemia,
and lymphosarcoma 9
Prostate, cancer of 471, 868
hypertrophied, x ray treatment of 277
sarcoma of 12 14
with reference to curability of gonorrhoea 439
Prostatectomy, conservative 384, 711
enuresis following 369
suprapubic, in two stages H34
Prostatic hypertrophy, palliative treatment
of 731. 916
sexual perversion an accompaniment
of 522
Proteid in infant feeding, standard of 183
Pruritus ani 694, 11 54
cause and treatment of, with special
reference to the use of the x rays 11 51
haemorrhoidal, injection for 948
Pseudoleucaemia, spirocha^ta in 9
Psoriasis, adherent cade ointment for 119
stiology of 785
ointment for 1045
value of a vegetarian diet in 416
Psychasthenia 297
Psychiatric expert evidence in criminal
proceedings 43'
Psychiatry as a part of preventive medi-
cine 1 1 58
new opportunity lui uv-t
Psychic treatment ot nervous di-eases 115
Psychoneuroses, treatment of 810
Psychoses, relation of accidents to 129
Psychotherapeutical movement, attitude of
the medical profession toward 34
Psychotherapy 959, 12 19
in treatment of functional neuroses 885
radical cure ot CDUstipatiun by i-'i9
Ptosis and atonic dilatation of the stomach 322
of pylorus, x rays in diagnosis of 1009
Pubiotomy 39
Puerperal fever, treatment of 961
Puerperium, care ot the patient 111 278
coagulability of biood during 228
Puerto Kico as a hclil tor icbcaicli m tropi-
Pulse, alternating, and its relation to the
bigeminal pulse 9&4
i}\ appendicitis 228
Punn free dietary ■. 81
Purpura rheumatica and erythema exuda-
tion multitorme Hebr;e, alternating ap-
pearance of 230
Purulent processes ...11 22
Pyelonephritis, nontuberculous, an m-
sidious type of 271
Pyloric insufficiency with diarrhoea relieved
by hydrochloric acid 94^
Purgatin, action of, on kidneys.. 1218
Pyocyanasis, subcutaneous injection of... 374
Pylorus, new method of estimating perme-
ability of 11/9
jitosis of, X rays in diagnosis of 1009
QUININE, injections of, accidents fol-
lowing 1214
RA1!IES 313
Radiographic diagnosis of renal lesions 77.1
Radiography of pneumatic sinuses of the
face 579
Radium emanations, therapeutic use of 757
in cutaneous tuberculosis, action of 564
in treatment of disease 870
Railroad accident^, previous conditions of
victims r>f 612
Randle, Willinm II. 'I'rcatmont of post
Rat extermination 759
Raynaud's disease in relation to vascular
disease of the extremities 1125
Reaction, Calmettc's ophthalmo 909, 961
to tuberculin 225, 121 1
Cammidge's, in pancreatic disease 682
desmoid 1 203
indican, as evidence of enterogenous in-
toxication 806
ocular, to tuberculin, accidents of 220
of Bordet and Gengou in respect to the
streptococcus in scarlet fever 38
ophthalmotuberculin, a warning 1220
pancreatic, in urine 867
scrum, in scarlet (ever and measles loio
Wassermann's, in syphilis 182
role of lipoid in 1009
Wolff-Eisner conjunctival and Moro
ointment, comparative studies with 707
Reactions, blood, of inflammation 41
cutaneous and eye, to tuberculin 229
organic, in infection \vith the trypano-
soma of equine syphilis 1167
Pirquet's and Wolfl-Calmette's, value of 757
READERS' DISCUSSIONS:
Alcoholic stupor, diagnosis of 404, 451
Fracture of the patella, treatment of,
788, 833. 894
P.\GE.
Gallstone colic, treatment of 594, 644
Haemorrhage, post partum, treatment of,
164, 210, 260
Seasickness, treatment of 1040, 1090
Sunstroke, treatment of 1244
Vomiting of pregnancy, treatment of 23
Itectocele, high, after perineal repair 708
Rectum and axilla, differences between
temperatures in 660
benign tumors of, diagnosis and treat-
ment of 446
neuralgia of 182
Reeducation method of Dubois in hysteria 926
Reflex, excessive patellar, cause of 180
Mendel-Becterew's, of dorsum of foot.. 132
of tendo Achillis 1215
Regurgitation, aortic, and floating liver.. 400
Relapsing fever and lice 36
Renal haemorrhage in nephritis 868
lesions, radiographic diagnosis of 774
Resection, osteoplastic, of skull 1216
Resorcin in skin diseases 264
Respiration, Cheyne-Stokes 104S
Retention of urine, hysterical 163
Rheumatic iritis 962
Rheumatism, acute, cardiac complications of 512
applications for 120
articular, symptomatology and diagnosis 512
gonorrhoeal, cured by seminal vesicu-
lotomy 1028
tuberculous 565
I'Jhinitis, membranous 279
purulent, treatment of 310
Riding astride by women 91
Robbinovitz, Samuel. Premature separa-
tion of the placenta 501
Roberts, Dudley. Hos|iital dietetics 65
Rontgen rays (See x rays).
Rosacea of face, Unna's powder for 217
Rosenberg, Lionel. Cause of premature
separation of the jilacenta 1200
Kosenberger, Randle C. Noma 200
the present status of the a;tiology of
syphilis 391
Rosewater, Nathan. Treatment of gall-
stone colic 594
Robinson, W. F. Precautions to be taken
in coming South 351
Rose, Dr. Achilles, ideas of, on medical
language 1017
Malaria in Greece 680, 960
The palliative treatment of prostatic
hypertrophy 916
Koseninullcr's fossae, importance of, in re-
lation to the middle ear 86.(
Rovins, .Mexander. Treatment of sun-
stroke 1245
Rowan, Joseph J. Diagnosis of alcoholic
stupor 451
Royster, L. T. The medical profession's
duty to the children of America 930
Ryon, E. William. Treatment of post par-
tum haemorrhage 261
SEPTUM, intraventricular, ulcer on... 11 24
Saliva, colorimetric analysis of 448
Saline bomb, a normal 1203
Salivation, pathogenesis of 1009
Salpingitis, conservative medical treatment
of 86
Salt solution, use and abuse of 807
Sanatoria for consumptives, value of 661
Sanatorium for the nervous and neuras-
thenic, a colony 7'9
regime in tuberculosis, advantages of... 49
treatment -1122
of tuberculosis "69
Sand, George, and her lovers 716
Sanitary science, a proposed school of.... 1206
Saponin, inhalations of, in diseases of
upper air passages 612
Sarcoma in a stump '.. 661
of clioritiiil 674
of kidiuv 106, 1012
of .i.ck,'ino,..,.,hlc......^ 138
Sate
Savitz, Sannu : \ h .niiKtit of gallstone
colic 645
Scabies, trcainH m -1 648
Scalp, seborrlidii n/niia of, lotions for... 899
Scaphoid, carpal, fracture of 960
Scapula, excision of 755
Scarlatina without eruption 563
Scarlet fever and measles, serum reaction in 1010
bacteriology of 805
points concerning 796
return cases of 36
streptococcus in, reaction of Bordet and
Gingou in respect to 38
Scarlett, B. If. Treatment of sunstroke .. 1 245
School children, fatigue in. tested by
crgograph 1221
.School children's eyes 839
life, nervous and mental manifestations
incident to ili, 258
fAGE.
Schools, medical inspection of, with trained
nurses 637
Sciatica a complication of haemorrhoids... 160
treatment of 997
Sclerodermia, ocular symptoms of 747
Sclerosis, disseminated 1008
multiple igi
injection for 899
laryngeal manifestations in 1210
.Scopolamine morphine anaisthesia in gyn-
a;cology '. .. 421
Scrotum, gangrene of, after applications of
iodine 183
.Seaman, Louis Livingston. Some of the
triumphs of scientific medicine in
peace and war in foreign lands 335
Sears, Mark H. Treatment of gallstone
colic 644
Seasickness, treatment of 1040, 1090
Sea water in medicine 264
Secretions, effect of alcohol upon 569
Section, abdominal, enema after 600
for trauma of uterus 86
Ctesarean 1 30, 517
Self repair, therapeutics of 1218
.Septica;mia 81
relation of chorea to 656
Sera, iirtificial, formulas for 217
curative, and bacterial vaccines 41
Serositis, multiple 562
Serum, blood, haemolytic reaction in ma-
lignant tumors 1 1 68
diagnosis of syphilis 182
injections of, in treatment of cardiac
asthenia 1214
Marmorek's, in surgical tuberculosis. ... 10 )9
normal, therapeutics of 469
reaction in scarlet fever and measles loio
therapeutics 1219
therapy of plague 1212
treatment of epidemic cerebrospinal
meningitis 172, 607
of gonorrhoea 1053
of streptococcus infections 1058
Sexual factor in tuberculosis, management
of 608
life and exophthalmic goitre, relation
between 182
perversion an accompaniment of pros-
tatic hypertrophy 522
Shanahan, William T. Acute pulmonary
oedema as a complication of epileptic
seizures 54
Shelmerdine, E. Kirkland. Winter diar-
rhoeas in infant feeding 499
Sherman, De Witt H. Concerning the
first week of infant life 56
Shively, Henry L. Association of tuber-
culosis of lungs with diabetes mellitus 933
Shock, the heart in 1263
.Shoemaker, Harlan. Bacterial vaccines of
staphylococci stains: A technique for
their preparation 584
Shoulder joint, dislocation of 90, 1216
.Sigler, C. L. Treatment of post partmum
haemorrhage 167
Sigmoid, acquired diverticula of 704
and colon, angulations of 479
angulation of 832
in pelvic diseases 971
intussusception of I075
.Sigmoiditis, chronic 466, 504
Sigmoperisigmoiditis, occlusion form of... 132
Silkworth, W. Duncan. Notes on the
jungle plant 1032
Sill, E. Mather. Is sterilized milk a safe
food for infants? 243
Silver nitrate carrier and larynx knife 963
Sinus, accessory, disease of, w'ith symp-
toms of osseous tumor of orbit 499
Sinuses, accessory, of the nose, from an
operative standpoint 575
radical operation in diseases of 757
pneumatic, radiography of 579
Skin applications, formulas for 119, 647
diseases, arc light treatment of 869
suprarenal preparations in the diag-
nosis of 362
electricity and magnetism of 470
idiopathic gangrene of 1057
malignant disease of 427
reaction after inoculation with diph-
theria toxine 660
Skull, fractures of, operations (or intra-
cranial complications of 1215
osteoplastic resection of 1216
Sluder, Greenfield. The role o( the spheno-
palatine ganglion in nasal headaches.. 989
Smith, A. C. Tlie etiology o( beriberi... 281
Smith, E. E. Uric acid 246
Smith. F. H. Diagnosis o( alcoholic
stupor 454
Smith, Harmon. The accessory sinuses
o( the nose (rom an operative stand-
point 575
Smith. Oliver C. Notes on European sur-
gical clinics 303
Social ill, aetiology, prophylaxis, and
worker, value of, to dispensary patient.. 143
INDEX TO VOLUME LXXXVIl.
1281
Page.
SOCIETIES, PROCEEDINGS OF:
American Gvnscological Society 1261
American Medical Association.... 1099
American Medicopsychological Associa-
tion ...1097
American Society of Tropical Medicine.
695. 75°
Association of American Physicians.
955, 1124, I2lb
College of Physicians of Philadelphia. 231
Medical Association of the Greater City
of New York.
40, 518, 709, 870. 913, 1060. "7°
Medical Society of the State of New
York 267, 279, 422, 566, 713, 80S
New York Academy of Medicine,
375, 662, 1012
Philadelphia County Medical Society.
232, 615
Southern Surgical and Gynaecological
Association 87, 134^ 184
Western Surgical and Gynzecological
Association 326, 472, 521
Sodium nitrite in therapeutics 693
salicylate, method of administering 55i
Soldier's ration, sugar in /lo
Sondheim, Sidney J. Treatment of frac-
ture of patella 83 5
Soup, nutritive, for infants ; 27
South, precautions to be taken in going.. 351
Southwick, Parker F. Treatment of post
partum haemorrhage 214
Spear, Edmund D. Acute poliomyelitis 281
Specialty, the most useful ••• 728
Speese. John. Carcinomatous degeneration
of breast cysts 33 >
Spence, Thomas Bray. Angulation of sig-
moid S32
Spinal cord, surgery of.. 610, 658, 805, 911, 964
sprain '°53
Spine, cur\-ature of, apparatus for the cor-
rection of ■ 415
Spirochaeta pallida; biology and aetio-
logical relation to syphilis 39i> 1261
in pseudoleucaemia, acute lymphatic leu-
ciemia and lymphosarcoma 9
Spirochstae in blood of patients with re-
lapsing fever ...121 8
of syphilis and ySws, comparative
morphology of 76"
Spleen and liver in relation to haemolytic
icterus '^^"^
traumatic rupture of 561
Splenectomy for carcinoma 277
in splenic anaemia "2;
Splenic infection, by Leishmann-Donovan
bodies 469
Spondylitis deformans
Sporotrichosis of the buccopharyngeal mu-
cous membrane 706
Spotted fever, a study of 1003
Sprain, spinal I053
Springer. Harold L. An analytical study
of si.x hundred cases of anaesthesia. . 1 148
Squier, J. Bentley. The bladder in tabes. 103S
Stalberg, Samuel. Treatment of seasick-
ness loy-
Stammering and stuttering, treatment of. 6oy
Staphylococci stains, bacterial vaccines of. 58)
Starch in infant feeding 101 1
Status lymphaticus ■•• 321
Stauungshyperamie 80, 516
Stein. Arthur. The operative tendencies
in modern obstetrics 44i
Who originated the method of rapid
paraffin imbedding? 829
Stenoses, congenital, of urethra 132
Stenosis, pyloric 752
operation in 613
Sterilization apparatus for laboratory work 39
Stethoscope, a new 707
Stillman, Charles K. Postdelirious alco-
holic stupor 154
Stillborn, rigor mortis in 418
Stokes-.'\dams's disease 11 63
Stoll, Henry Farnum. retrospect in
phthisiotherapy 738
Stomach, acute dilatation of 87
bismuth subnitrate in diseases of 132
cancer of 615
gastroenterostomy in 617, 62S
colicky pain in 948
complications after operations on 869
diseases of, bismuth subnitrate in treat-
ment of 792
emptying of 324
examination of, with x rays S3
function of 516
functional action of aperture of 131
inspection of mucous membrane of....ii2L
ptosis and atonic dilatation of 32.:
spasm of cardiac orifice of 870
surgery of 1054
vomiting in cancer of, a remedy for.... ZI7
Stomatitis, mercurial 94S
Stone, common duct, the largest on record 326
in hepatic duct 40 1
Stools, soapy, in children 1215
Page.
Stout, E. J. A case of poisoning with
tansy ^86
Favus, with reports of indigenous cases. 1 102
Streptococci, haemolysis of 1214
Streptococcus infections, serum treatment . 1050
in scarlet fever, reaction of Bordet and
Gengou in respect to 3?
Striffi atrophicae, cachetic • • 503
Stricture of Eustachian tube due to ad-
hesions in fossa of Rosenmiiller 319
urethral, causes and varieties of 278
treatment of by bougie ......... 27b
Strongyloides intestinalis in Philadelphia.. 701
Styles, William A. L. Diagnosis of alco-
holic stupor 453
Styptic, potassium permanganate as a.... 170
powder, formula for • i045
Stump hallucination, pathogenesis of 17
Stupor, alcoholic, diagnosis of 404, 45i
postdelirious alcoholic .• • I54
Sturmdorf, Arnold. The clinical signifi-
cance of ilcBurney's point 108
Stuttering, melody cure for 267
Sugar in the soldier's ration 710
Suggestion, narcosis by i057
Summers, J. W. Treatment of post partum
haemorrhage
Sunlight, action of, on tubercle bacillus.. 171
Sun's rays and artificial heat, effects of 1259
Sunstroke, treatment of • -1244
Suppuration of middle ear, chronic, ossi-
culectomy in 35
middle ear, evacuation and depletion of
tympanic cavity as aids to drainage in 80
in region of pharynx 40
Suprarenal capsules, normal histology ol
cortex of ^°57, 1214
capsules, functions of 1212, 125s
Surgery before the days of anaestheisa 96S
intracranial • °2
mastoid, modified blood clot in 11 44
military, and modern war noS
of gastric diseases 95
orthopedic, value of opsonic index in... 12S
practice of 473
Sutton, John McGruder. Diagnosis of al-
coholic stupor 405
Suture of vessels 1008
Sutures and ligatures, buried.... • 5-5
Sweeney, Gilliford B. The influence of
animal therapy upon the opsonic in-
dex in tuberculosis S*'?
Syncope from chloroform, faradization in. 38
Syndrome, paroxysmal, allied to recurrent
vomiting
produced by a lesion of optic thalamus.. 323
recurrent, due to exposure to heat...... 957
Syphilis, acquired, clinical and historical
features of • 427
aetiology of, present status of ■ <39i
and yaws, comparative morphology of
spirochjetae of 761
congenital, spirochaeta pallida in 1261
corrosive sublimate in pill form for 457
diagnosis of, with the ultramicroscope. . 1008
equine, organic reaction in infection with
the trypanosoma of
inherited • 37i. 420
intramuscular injections in . - 744
intraocular lesions of infantile inherited 702
mercurous bromide in treatment of.... 647
Metchnikoff's mercurial inunction for.. 1045
microbiological examination in 181
modern conception of 907
pigmentation of finger nails in. ........ . i33
reaction, Wassermann's. role of lipoid in. 1009
relation of. to diseases of nervous sys-
tem ■•• 180
serum diagnosis in 182, 706
specific action of mercury in 1074
precipitate reaction in 324
spirochaeta pallida, in relation to 39 1
tardy inherited > ■ "02
treatment of 1 1 66
Wassermann's reaction in 182
Syphilitics, cancer of the tongue in.. 901, 950
Syringomyelia 963
Systole, intraventricular 1124
TABES, the bladder in 1038
Tabes dorsalis and traumatism 840
Tachycardia of tuberculous disease 602
Taenia solium, formula for 600
Tansy, a case of poisoning with 686
Tapeworm infection, multiple 743
Tausini's method in cancer of the breast.. 564
Taylor, Fielding Lewis. Abscess of frontal
lobe of traumatic origin 891
Taylor. J. Madison. The hand as a thera-
peutic agent 239
Manual therapeutics 665
The most useful specialty 728
Taylor. Dr. Robert W.. report of commit-
tee on the death of 914
resolutions on death of 476
Teeth, carious, in tenement population of
New York 636
diseased, a cause of other diseases...... 65;
Temperattire measurements, diagnosis of
circulatory conditions by 938
Tendinitis ossificans traumatica 870
Tendo Achillis, leflex of 12 15
Tendon and muscle transference in infan-
tile paralysis 1163
patellar, suture of 1254
transfer in paralytic club feet 473
transplantation 755
Tension, high arterial 809
Testimony, expert 1067
Testis, malignant disease of 40
Tests of von Pirquet and Calmette, clini-
cal value of 1220
von Pirquet, Calmette, and Moro, di-
agnostic value of 1220
Tetanus and typhoid fever 21
antitoxine unit, the American 1048
injections of extract of brain substance
in treatment of 408
Tetany, nature of 957
response to galvanic current in children
with 83
Therapeutics, best things in 415
dietetic and hygienic 1218
of self repair 12 18
physical 12x9
Thigh, shortening of 181
Thorax, operative mobilization of 39
Throat, sore, gargles for 899^
treatment of 870
ulcerative typhoid inflammation of 323
voice an index to diseases of 47
Thrombosis and hydrocele in inguinal ca-
nal 184
Thymus gland treatment of cancer 807
Thyreoid extract in treatment of chlorosis 787
gland, removal of, in exophthalmic goi-
tre 564
Tinea tonsurans, ointment for 64S
Tissue, living, natural immunity of 757
Tobacco in surgical practice, effect of 561
smoke, studies concerning. 965
Tongue, cancer of, in syphilitics 901, 950
depressor and gag 228
neurology of 373
Tonic and reconstructive cachet 1045
mixture, formula for 744
Tonsilitis, follicular, treatment of 120
Tonsils and adenoids 271
Toothache, application for 1045
Torek. Franz. Modern methods in the
treatment of gastric diseases 95
Torsion, intraabdominal, of omentum 86
Torticollis, congenital 232
Tousey, Sinclair. The radiographic topog-
raphy of the frontal sinus and other
pneumatic sinuses of the face 579
Toxaemia from standpoint of perverted
metabolism 1059
of pregna.ncy. relation of anaphylaxis
signs of, in pregnant women, value of
ocular examinations in 616
Toxaemias, intestinal, psychic phenom.ena
of, and their treatment 826
of childhood, aerotherapy in 809
Tracheobronchoscopy 566
Trachoma, chronic, treatment of 865
clinical aspects and successful treatment
of 548
surgical treatment of i26'i
Tract, urinary, bacterial infections of 227
Tracy, Stephen E. Ectopic gestation asso-
ciated with fibromyomata uteri. 1037
Transfusion and arterial anastomosis 806
history, development, present status,
and technique of operations of 941
Transplantation, intramural, of round liga-
ments 866
Trauma of uterus, abdominal section for.. 86
Traumatism and tabes dorsalis 840
Tronchin, sketch of the life of I2ji
Tropical medicine, a review of a year's
progress in 815
Puerto Rico as a field for research in. 1236
Tropics, white man of 11 76
Trv-panosoma, cultivation of 1123
Trypanosomiasis, experimental treatment
of 999
Trypsin and glycolytic ferments in cancer,
difference in effect produced by 564
Tsutsugamushi disease, a study of 1003
Tubby, J. T., Jr. A simple "air house".. 1081
Tubercle bacilli, essential identity of 555
in faeces, significance of 85
intracellular, in sputum, significance
of 747
and sunlight 171
which cannot be stained with Ziehl-
Xeelsen stain 129
Tuberculin, accidents of ocular reaction to 220
Calmette's ophthalmic reaction to 223
in pulmonary tuberculosis 906
inunction 1233
ocular reaction to 12 11
ophthalmoreaction to 83
reactions, comparative valuation of 566
sensitiveness of conjunctiva to 1122
test, cutaneous, in children 323
1262
L\JJl:X JU t OLLME LXXXi'JJ.
PAcn.
Tuberculin, test, ophtl;alniio 1233. 1234
treatment of tuberculosis 468
vaccination in diagnosis of tuberculosis. 273
Tuberculosis, advantages of sanatorium
regime in
etiology of , 1057
among medical students, prevention of.. 209
artificial pneumothorax in 84
association of nasal abnormalities with 131
bone, modern treatment of !>7i
Calmette's ophthalmoreacticu in... 961. jjh
channels of communication of 378, 1012
clinics of New York, as-ociation of 937
cutaneous 373
radium in 564
tuberculin vaccination in diagnosis of 273
decrease of mortality from 805
experimental diagnosis 01 517
frequency of, in infancy 517
genitourinary 37
human and bovine, relationfliip between 808
report of the Royal Coniniissum on bi-i
importance of examination after ex-
posure to 4-4
in children 81
n^anagcnici.t iiid tn.:i:.t-it .'t .i5"
relation of tuberculous cows to i-^!'
in infants and children 375. 3/8
in Ireland 3^i
in outdoor .and indoor 37"
in the T. >. Navy. study of 183
incipiencv in. from the standpoint of
s.-<.nat..ri.-. : • 3^0
influence 01 animal therapv on opsonic
index in '. S8-
Imernationa: Conpres? on 236
intestinal, enema in 104 »
iodine and guaiacol injection for 310
iodotannin mixture for 744
joint and bone • (>2^
laboratorv aids to the diagnosis of 377
laryngeal" •
management of sexual inctor in oo!>
mercury in treatment of iJio
miliary, of conjunctiva 5°°
modes' of infection m 1 -:09
new treatment of 407
of bones and joints. Bier's hypersemia in 374
of nervous system 191
ophthalmic reaction in diagnosis of....iJ.!|
pathological findings in •. 375
patients, dyspepsia in, treatment of 71
plan of campaign against 524
prevention of 468
pulmonary, associatior: -i. with diabetes 933
diagnosis of 528, 809
home treatment oi 60;
in children 6"9
postural treatment of
tuberculin in ')<i<'
value of opsonic index in i-'i;
recent diagnostic method^ in 376
relation of environment to 37°
renal 79
diagnosis of 277
X ray treatment of 182
revealed, in children 131
sanatorium treatment of . .1122, 1169
subjects, marriage and intermarriage of. 1253
surgical, treated with Marmorek's serum. 1009
treatment of 610
tachycardia of 602
value of ophthalmoreaction in the diag-
nosis of 324
work of the State Charities Aid Associa-
tion in the campaign against 695
Tuberculous chlo'rosis, treatment of 130
fever, acute 468
jihysicians. Mexican mining practice for 129
Tubes and ovaries, conservative surgery of 416
Tucker, I'.everlcy R. Diagnosis of alco-
holic stupor 404
Epilepsy: the so called idiopathic form.. 1086
Tumor, brain, clinical study of a case of.. 1054
meningeal, compressing cerebellum 1059
osseous, of orbit 499
paraffin 525
I umors and other lesions in cerebellopon-
tile angle 801
breast, preliminary incision of 1257
bone, conscn'ative operations on 271
cerebellar 964
fibroid, of uterus comiilicated by preg-
nancy 89
malignant, hemolytic reaction of blood
scrum in 11 6'^
transmissibilitv and heredity of 173
of bladder, transixritoneal removal of.. ««
of brain, symptomatology of 220
of Cauda equina and Inwcr vcrtebrje. . . . 614
of mice, inoculable 220
of rectum, benign 44f>
pscudomalignant abdominal 51*
spontaneous, in mice '73
Turpcn-ine, oil of, internal use of ii6<;
Tuttlc. James P. Acute flexures or angu-
lation!! of the sigmoid and colon 470
Typhoid and colon bacilli, value of mala-
chite green in distirEui'hing between, 36,^
P
Tyiihoid bacilli, survival of, in soil 1
ex|.eiiniental, in goats
iuvKv and tetanus.
ascitic exudate in 1
complicated by epididymitis and or-
cliitis
diagnosis of
liy blood cultures from the ear )
in military and industrial aggregations
intestinal haemorrhage in 27, i
larvngeal complications of
milk free fluid diet in 1
loss of hair accompanying
rectal irrigations in 1
transmissibility of
typhobacllli in cerebrospinal fluid in..i
ulcerations of throat m
without a nurse
malachite green in culture media for..i
Typhus fever, relation of, to bile ducts..
ULCER, duodenal 1
diagnosis of, from gallstones
gastric, treatment of 5-', 85,
early and late cases of
experimental 1
of duodenum, acute perforating
of leg, ointment for
on interventricular sieptum 1
peptic, of jejunum
Llcers, duodenal and gastric
iodine in treatment of 1
Ulna, palmar projection of, after Colles's
Ulnar nerve, lesion of .
Cultrainicroscope in diagnosis of syphilis.)
L'ncinariasis in Puerto Rico
I nna's powder for eczema and rosacea
formula for ■
Ursmia, |)ills to promote diuresis in
I'rcter, stone in, transperitoneal ureterot-
omy for removal of
Lrcthra and bladder, overtreatment of....
congenital stenosis of
L'rethrojjlastic operations
I'rinary casts, origin of
tract, colon infection of
L'rine, hysterical retention of
pancreatic reaction in
retention of, urethrotomy for
suppression of ^ .... ........ .
N'isccral disease, signs of
\ ision, defective, and the mentally sub-
normal child
Pacr.
703
bl<:
rticana, treatment ot..
'terine bleeding, signiflcance
'terus, adenomyonia of.....
bicornis, breech presentation
cancer of, early diagnosis t
displacements of
fibroid tumors of. coniplica
•793.
1057.
prolapse of. surgical trcaliiunl .if 1264
rurturo of. thiough Cesarean cicatrix .. 1 2 1 (,
trauma of. abdominal section for 8f.
V.\CCIN.\TION against plague 7<">
cutaneous tuberculin, in diagnosis of
tuberculosis -73
in the Far East 3" 4
N'accine treatment of gonorrhieal vulvo-
vaginitis 513
\'accines, bacterial, and curative, sera.
41. 79. 423, 4-'4
bacterial, of staphylococci stains; tech-
ni(|ue for their preparation .=184
\'an Gieson, R. E. The comiiarative thera-
peutical value of iron compounds 687
Van-Slyke, L. L. Conditions affecting the
proportions of fat and proteins in
cow's milk 1021
N'andcr IToof, Douglas. Symptomatology
and diagnosis of nephritis ;?7
Varicocele, treatment of 1 1 f'3
X'ascular crises 800
diseases of extremities 112.';
Vasodilator, the choice of a 4b'>
Vasomotor relations 17''
Veascy, C. A. Glaucoma in the young.... 21
Rhythmical alterations in width of pal-
pebral fissure of both eyes probably
liroduced by spasm of levator palpa-
brsc muscles 1 1
X'cgetarian diet in psoriasis 4if>
Wins, varicose, treatment of. by multiple
incisions n>i
Vcrbrycke, J. Russell. Treatment of frac-
ture of' patella 788
Vcrtebrsc, lower, tumors of 614
Vertigo of gastric origin 263
Vesiculotomy, seminal, in gonorrlural rheu-
matism 102>i
\'ienna, the medical centre of the world,, 11 70
X'isccra, lesions of. significance of abdomi-
nal tenderness in locating 474, 912
ion
573
bills relating to 380
from a student's standpoint 675
in the State of New York 29, 73, 188
\'oice an index to diseases of throat, nose,
and ear 47
sign, the epileptic 266
\ omiting in cancer of stomach, a remedy
for 217
of pregcaiicy, treatment of 23
recurreirt. paroxvsmal syndrome allied to 957
with acetonuria 183
N'oorhees, Irving Wilson. Treatment of
seasickness 1043
\ ulvovaginitis, gonorrhoeal, vaccine- treat-
ment of 513
treatment of 947
WACHENHEIM, F. L. The Principles
ot the climatic treatment of children 737
War, modern, and military surgery 1168
Warts, treatment of 599
Walker, J. M. Potassium iodide in mental
diseases 19
Walker, Maurice A. Treatment of jiost-
partum haemorrhages 164
Ware, Martin W. Diagnosis of unilateral
tuberculous nephrocystitis 13
Warts and moles, malignant degeneration... 800
Wassermann's reaction in syphilis 182
role of lipoid in 1009
Water, drinking, puritication of 744
in childhood, indications for 253
sea, in medicine 263
Waters, American mineral 560
Wells, William H. Treatment of the vom-
Cerebral contusion....
White, William Charles, and Proescher, F.
The presence of spirochaeta in pseudo-
Icuc.-emia, acute lymphatic leucaemia,
and lymphosarcoma
Whitman brace for weak foot i
Whooping cough, conveyance of
treatment of 361, 600,
Widal's reaction in meat poisoning
Wiener, Joseiih. General surgical consid-
erations of joint and bone tubercu-
Wile, Udo J. Tuberculosis among medical
students and its jiossible prevention. .
Williams, Linsly R. Value of the social
worker and the visiting nurse to dis-
pensary patients
\\ ilson. P.. W. Treatment of vomiting of
Wilson, Frederic II. Treatment of sea-
sick.icss
Wilson. K. I.. Multiple tapeworm infec-
Winfield, James M. Treatment of eczema
in infants and young children
Wodehouse, Robert E. Diphtheria anti-
toxine refined hv Gibson's method
Wolbarst. A. L. The prostate with refer-
ence to the curabilitv of goiiorrh(ca. .
Wolflf-Calmette's reaction value of. in
childhood
Wolff-Eisner conjunctival reaction and
Moro ointment reaction .
Woodbury, Frank T. Urethrotomy for re-
tention of urine
Worms, intestinal, Yefimov's test for....
Wound, .gunshot, of abdomen, constructive
surgery after
Wounds, gunshot 180, 372, .=;65,
Writers' cramp, treatment of...-
Wynne, S. W. Treatment of fracture of
patella
VAXTHELASMA Palpebrarum
X ray diagnosis of urinary calculi, 24,
in dermatology
in diagnosis of renal lesions
in treatment of leucxmia
momentary exposures
therapeutics and specific immunity
treatment of hypertrophied prostate,...
treatment of malignant disease
in diagnosis of appendicitis
gastrcctasia and ptosis of pylorus.
in examination of stomach..
in treatment of pruritis ani
renal tuberculosis
. 322
. 910
.1166
. 1 009
• 83
.1151
182
and syphilis, comparative morphol-
ogy of spirochiEtJC of 761
papules, histology of 604
Yefimov's test in urine for worms QC14
thesia 782
Ziehl-Neclsen method of staining tubercle
bacilli 129
Zlltmann's decoction, formula for 693
I
i
1
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